Effect of virtual reality on balance and gait ability in patients with Parkinson's disease: a systematic review and meta-analysis

Can virtual reality have effects on cardiac rehabilitation? An overview of systematic reviews

OBJECTIVE

This paper aims to provide a review of the use of virtual reality in cardiac rehabilitation.

BACKGROUND

Can virtual reality technology improve outcomes in patients with cardiovascular disease? The question is still open.

DESIGN

Systematic review and meta-analyses.

METHODS

A literature search was conducted in the Embase, the Cochrane Library, PubMed, Web of Science, China National Knowledge Infrastructure Database, Wanfang Database, and China Biological Medicine Database. Databases were searched to July 2023. The inclusion criteria were as follows: the nature of the studies was set as a systematic review; the research participants were patients with cardiovascular diseases undergoing cardiac rehabilitation; the research content was a comparison of virtual reality effects between other care approaches. A Measurement Tool to Assess Systematic Reviews was employed to evaluate the quality of included studies and judge the overall certainty of evidence by using the Grading of Recommendations, Assessment, Development, and Evaluation methodology. When there were differences between the outcomes, we used the RevMan 5.3 to recalculate.

RESULTS

A total of 7 reviews were included in our synthesis, including 3 low-quality articles and 4 very low-quality articles. Virtual reality was effective in improving patients' depression symptoms, anxiety, stress, and improving athletic ability, but it remains unknown whether virtual reality is effective for other outcomes or not.

CONCLUSIONS

Virtual reality can effectively improve the mental health of patients with cardiovascular disease. However, its role in improving other health indicators such as adherence, satisfaction, and quality of life has not been shown.

Home-based exergaming to treat gait and balance disorders in patients with Parkinson's disease: A phase II randomized controlled trial

BACKGROUND

Exergaming has been proposed to improve gait and balance disorders in Parkinson's disease (PD) patients. We aimed to assess the efficacy of a home-based, tailored, exergaming training system designed for PD patients with dopa-resistant gait and/or balance disorders in a controlled randomized trial.

METHODS

We recruited PD patients with dopa-resistant gait and/or balance disorders. Patients were randomly assigned (1:1 ratio) to receive 18 training sessions at home by playing a tailored exergame with full-body movements using a motion capture system (Active group), or by playing the same game with the computer's keyboard (Control group). The primary endpoint was the between-group difference in the Stand-Walk-Sit Test (SWST) duration change after training. Secondary outcomes included parkinsonian clinical scales, gait recordings, and safety.

RESULTS

Fifty PD patients were enrolled and randomized. After training, no significant difference in SWST change was found between groups (mean change SWST duration [SD] -3.71 [18.06] s after Active versus -0.71 [3.41] s after Control training, p = 0.61). Some 32% of patients in the Active and 8% in the Control group were considered responders to the training program (e.g., SWST duration change ≥2 s, p = 0.03). The clinical severity of gait and balance disorders also significantly decreased after Active training, with a between-group difference in favor of the Active training (p = 0.0082). Home-based training induced no serious adverse events.

CONCLUSIONS

Home-based training using a tailored exergame can be performed safely by PD patients and could improve gait and balance disorders. Future research is needed to investigate the potential of exergaming.

The impact of virtual reality on manual dexterity of Parkinson's disease subjects: a systematic review

PURPOSE

To present the latest available evidence on the effects of a VR-based therapy on the manual dexterity of PD subjects.

MATERIALS AND METHODS

The search was conducted in PubMed, EMBASE, and PEDro databases. Were included in the systematic review Randomized Clinical Trials, Pilot and Feasibility studies published up to December 2020. The studies should include at least one of the following assessments: Box and Blocks Test, 9-Hole Peg Test; Purdue Pegboard Test. PEDro Scale was used to assess the methodological quality of the included studies.

RESULTS

Eight studies were included in the review. Most studies have shown an improvement in outcomes for manual dexterity, but most of them presented a high risk of bias with low methodological quality. A high heterogeneity was observed in the protocols used for each study.

CONCLUSION

The results suggest that VR-based therapy has great potential and feasibility to be used as a manual dexterity rehabilitation protocol in PD subjects. However, these results must be interpreted carefully and studies with greater methodological rigor must be conducted.Implications For RehabilitationRehabilitation programs using virtual reality seem to have greater adherence to the user.Immersive virtual reality systems seem to do better in manual dexterity than non-immersive systems.It is plausible to use virtual reality systems in telerehabilitation for manual dexterity training in subjects with Parkinson's' Disease.The use of Virtual Reality by the therapist in a rehabilitation program allows him to modulate the exercises, enabling a wide variety of therapeutic options.

Efficacy of virtual reality training on motor performance, activity of daily living, and quality of life in patients with Parkinson's disease: an umbrella review comprising meta-analyses of randomized controlled trials

OBJECTIVE

There are several meta-analyses of randomized controlled trials (RCTs) demonstrating the benefits of virtual reality (VR) training as an intervention for motor performance, activity of daily living (ADL) and quality of life (QoL) outcomes in patients with Parkinson's disease (PD). However, the aggregate evidence collected to date has not been thoroughly evaluated for strength, quality, and reproducibility. An umbrella review from published meta-analyses of RCTs was conducted to evaluate the strength and quality of existing evidence regarding the efficacy of VR training in improving the motor performance, ADL and QoL outcomes of patients with PD.

METHODS

PubMed, PsychInfo, Web of Science, and Scopus were searched to identify relevant meta-analysis of RCTs examining the effects of VR training on motor performance and quality of life outcomes in PD patients. We recalculated the effect sizes (Hedges'g) for VR training using DerSimonian and Laird (DL) random effects models. We further assessed between-study heterogeneity, prediction interval (PI), publication bias, small-size studies, and whether the results of the observed positive studies were better than would be expected by chance. Based on these calculations, the quality of evidence for each outcome was assessed by using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria.

RESULTS

Four meta-analysis with eight outcomes included in the umbrella review was recalculated effect size. Pooled results found VR training can large improve the basic balance ability, moderate improve the overall balance capacity and moderate improve the stride length in PD patients. For ADL and QoL, the effect sizes were pooled that suggested VR training can moderate improve ADL and QoL for PD patients. However, no statistically clear evidence was found in walking speed, motor function and gait function during VR training. The analyzed meta-analyses showed low-to-moderate methodological quality (AMSTAR2) as well as presented evidence of moderate-to-very low quality (GRADE). Tow adverse reactions were reported in the included meta-analyses.

CONCLUSIONS

In this umbrella review, a beneficial correlation between VR and balance ability, stride length, ADL and QoL in PD patients was discovered, especially for the very positive effect of VR on balance because of two of the eight outcomes related to balance ability showed large effect size. The observations were accompanied by moderate- to very low-quality rating evidence, supporting VR training as a practical approach to rehabilitation.

The effects of virtual reality-based exercise in adults receiving haemodialysis treatment: A systematic review and meta-analysis of randomized controlled studies

This meta-analysis aimed to synthesize the effects of virtual reality-based exercise on physical function, depression symptoms and quality of life in adults receiving haemodialysis. Data were analysed using Comprehensive Meta-Analysis Version 3. The random-effects meta-analysis was performed to pool intervention effects. A total of five studies were included. The majority of included studies compared intervention with passive control group. This meta-analysis showed with a moderate to high quality of evidence that virtual reality-based exercise has positive medium effect on improving physical function such as gait speed (g = .40, 95% CI 0.00 to 0.81), sit to stand 10 times (g = -.41, 95% CI -0.825 to -0.009), sit to stand in 60 s (g = .56, 95% CI 0.151 to 0.974), 6-min walk test (g = .66, 95% CI 0.247 to 1.079), not affect time up and go and sit to stand five times. The study indicated with moderate quality of evidence that virtual reality-based exercise had no effect on depression symptoms. The study also showed with a moderate quality of evidence that the intervention had a positive medium effect on improving physical function (g = .64, 95% CI 0.20 to 1.09). In conclusion, virtual reality-based exercise can be performed to improve physical function and quality of life of adults receiving haemodialysis for health professionals.

Virtual reality augments effectiveness of treadmill walking training in patients with walking and balance impairments: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To systematically summarize and examine current evidence regarding the combination of virtual reality and treadmill training in patients with walking and balance impairments.

DATA SOURCES

English language randomized controlled trials, participants with walking and balance impairments, intervention group used virtual reality and treadmill, control group only used treadmill with the same training frequency and number of sessions. Six bioscience and engineering databases were searched.

METHODS

Two independent reviewers conducted study selection, data extraction, and quality assessment. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Sixteen randomized controlled trials including 829 participants were identified. Compared to treadmill-only training, virtual reality augmented treadmill training induced significantly faster walking (p < 0.001; standardized mean difference (SMD) = 0.55, 95%CI: 0.30 to 0.81), longer step length (p < 0.001; SMD = 0.74, 95%CI: 0.42 to 1.06), narrower step width (p = 0.03; SMD = -0.52, 95%CI: -0.97 to -0.06), longer single leg stance period (p = 0.003; SMD = 0.77, 95%CI: 0.27 to 1.27), better functional mobility (p = 0.003; SMD = -0.44, 95%CI: - 0.74 to -0.15), improved balance function (p = 0.04; SMD = 0.24, 95%CI: 0.01 to 0.47), and enhanced balance confidence (p = 0.03; SMD = 0.73, 95%CI: 0.08 to 1.37). Walking endurance did not differ significantly between groups (p = 0.21; SMD = 0.13, 95%CI: -0.07 to 0.34).

CONCLUSIONS

Virtual reality augmented treadmill walking training enhances outcomes compared to treadmill-only training in patients with walking and balance impairments. The results of this review support the clinical significance of combining virtual reality with treadmill training with level 1A empirical evidence.

Immersive Virtual Reality in Post-Stroke Rehabilitation: A Systematic Review

In recent years, next to conventional rehabilitation's techniques, new technologies have been applied in stroke rehabilitation. In this context, fully immersive virtual reality (FIVR) has showed interesting results thanks to the level of immersion of the subject in the illusional world, with the feeling of being a real part of the virtual environment. This study aims to investigate the efficacy of FIVR in stroke rehabilitation. PubMed, Web of Science and Scopus were screened up to November 2022 to identify eligible randomized controlled trials (RCTs). Out of 4623, we included 12 RCTs involving post-acute and chronic stroke survivors, with a total of 350 patients (234 men and 115 women; mean age 58.36 years). High heterogeneity of the outcomes considered, the results showed that FIVR provides additional benefits, in comparison with standard rehabilitation. In particular, results showed an improvement in upper limb dexterity, gait performance and dynamic balance, influencing patient independence. Therefore, FIVR represents an adaptable, multi-faceted rehabilitation tool that can be considered in post-stroke rehabilitation, improving the compliance of the patients to the treatment and increasing the level of functioning and quality of life of stroke survivors.

Proprioceptive Focal Stimulation (Equistasi®) for gait and postural balance rehabilitation in patients with Parkinson's disease: A systematic review

Gait and postural deficits are the most common impairments in patients with Parkinson's Disease (PD). These impairments often reduce patients' quality of life. Equistasi^® is a wearable proprioceptive stabilizer that converts body thermic energy into mechanical vibration. No systematic reviews have been published investigating the influences of Equistasi^® on gait and postural control in patients with PD. This review aimed to examine the effects of proprioceptive focal stimulation (Equistasi^®) on gait deficits and postural instability in patients with PD. PubMed, Scopus, PEDro, REHABDATA, web of science, CHAINAL, EMBASE, and MEDLINE were searched from inception to July 2021. The methodological quality of the selected studies was evaluated using the Physiotherapy Evidence Database (PEDro) scale. Five studies met the eligibility criteria. The scores on the PEDro scale ranged from 3 to 8, with a median score of 8. The results showed evidence for the benefits of the proprioceptive focal stimulation (Equistasi^®) on gait and postural stability in individuals with PD. Proprioceptive focal stimulation (Equistasi^®) appears to be safe and well-tolerated in patients with PD. Proprioceptive focal stimulation (Equistasi^®) may improve gait ability and postural stability in patients with PD. Further high-quality studies with long-term follow-ups are strongly needed to clarify the long-term effects of proprioceptive focal stimulation (Equistasi^®) in patients with PD.

Virtual Reality for Motor and Cognitive Rehabilitation

Virtual Reality (VR) affords clinicians the ability to deliver safe, controlled, task-specific customised interventions that are enjoyable, motivating and engaging. Elements of training in VR comply with principles of learning implicated in new skill acquisition and re-learning skills post-neurological disorders. However, heterogeneity in the description of VR systems and the description and control of 'active' ingredients of interventions (like dosage, type of feedback, task specificity, etc.) have led to inconsistency in the synthesis and interpretation of evidence related to the effectiveness of VR-based interventions, particularly in post-stroke and Parkinson's Disease (PD) rehabilitation. This chapter attempts to describe VR interventions with respect to their compliance with principles of neurorehabilitation, with the goal of optimising interventions for effective training and facilitation of maximum functional recovery. This chapter also advocates using a uniform framework to describe VR systems to promote homogeneity in literature in order to help in the synthesis of evidence. An overview of the evidence revealed that VR systems are effective in mediating deficits in upper extremity, posture and gait function seen in people post-stroke and PD. Generally, interventions were more effective when they were delivered as an adjunct to conventional therapy and were customised for rehabilitation purposes, in addition to complying with principles of learning and neurorehabilitation. Although recent studies imply that their VR intervention is compliant with principles of learning, only a few explicitly describe how these principles are incorporated as 'active ingredients' of the intervention. Finally, VR interventions targeting community ambulation and cognitive rehabilitation are yet limited and therefore warrant attention.

Effect of Longitudinal Practice in Real and Virtual Environments on Motor Performance, Physical Activity and Enjoyment in People with Autism Spectrum Disorder: A Prospective Randomized Crossover Controlled Trial

(1) Background: People with ASD commonly present difficulty performing motor skills and a decline in physical activity (PA) level and low enjoyment of PA. We aimed to evaluate whether longitudinal practice of an activity in virtual and real environments improves motor performance and whether this improvement is transferred to a subsequent practice when changing the environment, promoting PA and providing enjoyment; (2) Methods: People with ASD, aged between 10 and 16 years, were included and distributed randomly into two opposite sequences. The participants performed a 10 session protocol, with five sessions practicing in each environment (virtual or real). Heart rate measurement was carried out and an enjoyment scale was applied; (3) Results: 22 participants concluded the protocol. Sequence A (virtual first) presented an improvement in accuracy and precision and transferred this when changing environment; they also had a greater change in heart rate reserve. The majority of participants reported "fun" and "great fun" levels for enjoyment; (4) Conclusions: The virtual reality activity presented a higher level of difficulty, with greater gains in terms of transference to the real environment. Considering PA, our task provided very light to light activity and the majority of participants enjoyed the task.

Effects of Non-Immersive Virtual Reality and Video Games on Walking Speed in Parkinson Disease: A Systematic Review and Meta-Analysis

People with Parkinson disease suffer from a loss of dopaminergic neurons, which are involved in walking speed. Currently, virtual reality (VR) has emerged as a useful tool for the rehabilitation of people with neurological diseases, optimizing results in balance and gait. This review aimed to evaluate the effectiveness of VR or video games (through face-to-face sessions and not telerehabilitation) in improving walking speed and other spatio-temporal parameters of gait, balance, and quality of life in patients with Parkinson disease. A bibliographic search was carried out in the MEDLINE, Web of Science, Scopus, and PEDro databases. This systematic review adhered to the PRISMA guideline statement and was registered in PROSPERO (CRD42020180836). From a total of 119 records, 5 studies met the inclusion criteria for qualitative analysis, of which 3 contributed to the meta-analysis; inconclusive findings were found on gait speed, balance, and quality of life after the use of non-immersive VR systems face-to-face. A greater number of studies are necessary, with a greater number of participants, to differentiate between those VR specific systems (specifically designed for rehabilitation) from commercial video games, including immersive systems, and obtain more conclusive evidence. Furthermore, it would be interesting to compare the administration of this treatment in person versus its administration via telerehabilitation, which will help plan treatment programs.

Assessment Tasks and Virtual Exergames for Remote Monitoring of Parkinson's Disease: An Integrated Approach Based on Azure Kinect

Motor impairments are among the most relevant, evident, and disabling symptoms of Parkinson’s disease that adversely affect quality of life, resulting in limited autonomy, independence, and safety. Recent studies have demonstrated the benefits of physiotherapy and rehabilitation programs specifically targeted to the needs of Parkinsonian patients in supporting drug treatments and improving motor control and coordination. However, due to the expected increase in patients in the coming years, traditional rehabilitation pathways in healthcare facilities could become unsustainable. Consequently, new strategies are needed, in which technologies play a key role in enabling more frequent, comprehensive, and out-of-hospital follow-up. The paper proposes a vision-based solution using the new Azure Kinect DK sensor to implement an integrated approach for remote assessment, monitoring, and rehabilitation of Parkinsonian patients, exploiting non-invasive 3D tracking of body movements to objectively and automatically characterize both standard evaluative motor tasks and virtual exergames. An experimental test involving 20 parkinsonian subjects and 15 healthy controls was organized. Preliminary results show the system’s ability to quantify specific and statistically significant (p < 0.05) features of motor performance, easily monitor changes as the disease progresses over time, and at the same time permit the use of exergames in virtual reality both for training and as a support for motor condition assessment (for example, detecting an average reduction in arm swing asymmetry of about 14% after arm training). The main innovation relies precisely on the integration of evaluative and rehabilitative aspects, which could be used as a closed loop to design new protocols for remote management of patients tailored to their actual conditions.

Effectiveness of Nintendo Wii on Balance in People with Parkinson's Disease: A Systematic Review

The use of exergaming exercises is increasingly becoming accepted as an alternative to surgical and medical therapies for Parkinson's disease (PD). Although the area has attracted some results, there is still no conclusive evidence on the benefit of exergaming exercises in improving PD patients' body balance. The current study is a systematic review aiming at examining the effectiveness of the Nintendo Wii Fit ("Wii Fit") game on improving the balance in people with Parkinson's disease. A total of 200 articles were selected online after conducting an extensive search on PubMed, Cochrane, PEDro, CAPES Periodic, ResearchGate, Web of Science, and ProQuest. Upon reviewing the identified sources, ten articles were included, of which four were randomized control trials. The results show that at least five weeks of Wii Fit exercises effectively enhance PD patients' body balance and life outcomes. However, better results occur when patients combine Wii Fit with other conventional exercises.

Virtual reality for balance and mobility rehabilitation following traumatic brain injury: A systematic review of randomized controlled trials

BACKGROUND

Balance and mobility deficits are most prevalent impairments in patients with traumatic brain injury (TBI). The evidence has proposed that rehabilitation plays an important role in improving balance and mobility post-TBI. Virtual reality (VR) is a computer technology that provides immersed users to generate feedback such as visual, audio, and haptic.

OBJECTIVE

This review aimed to examine the effects of the VR treatment intervention on balance and mobility in patients with TBI and to define the most effective VR treatment protocol.

METHODS

SCOPUS, PEDro, PubMed, REHABDATA, EMBASE, and the web of science were searched for experimental trials examining the impacts of VR training on balance and mobility in patients with TBI from inception until July 2022. Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the selected studies.

RESULTS

Five randomized controlled trials (RCTs) met the inclusion criteria. The PEDro scores ranged from 6 to 8, with a median of 6. A total of 157 patients with TBI were included in this review, 31.2% of whom were females. The findings showed that VR intervention is not superior to traditional physiotherapy interventions in improving balance and mobility post- TBI.

CONCLUSIONS

The preliminary findings showed that the influence of VR on the balance and mobility ability in patients with TBI is promising. Combining VR with other concurrent rehabilitation interventions may show more significant improvements in balance and mobility compared to VR interventions alone. The optimal VR treatment protocol remains unclear. Further randomized controlled trials are strongly needed.

Effectiveness of exergaming-based interventions for mobility and balance performance in older adults with Parkinson's disease: systematic review and meta-analysis of randomised controlled trials

BACKGROUND

exergaming-based interventions (EbIs) have been proposed to improve older adults' mobility and balance performance. However, the effectiveness of such interventions for older adults with Parkinson's disease (OAPD) remains unclear.

METHODS

seven databases (Web of Science, Medline, Academic Search Premier, CINAHL Complete, PsycINFO, PsychARTICLE and PubMed) were searched up to 7 April 2022. We assessed mobility and balance performance between EbIs groups and control groups or traditional physical training interventions (TPTIs) groups by comparing the outcomes of the Timed Up and Go (TUG), 6-Minute Walk Test (6MWT), Berg Balance Scale (BBS), gait velocity, stride length and Functional Gait Assessment (FGA).

RESULTS

we scanned 1,190 articles and meta-analysed 19 trials (sample size = 781). In general, the results revealed statistical differences between EbIs groups and TPTIs groups in the TUG [mean difference (MD) = -1.030 s; 95% confidence interval (CI) = -2.029 to -0.031; P = 0.043; high quality of evidence], 6MWT (MD = 63.483 m; 95% CI = 9.542 to 117.425; P = 0.021; moderate quality of evidence), BBS (MD = 2.129; 95% CI = -1.293 to 2.965; P < 0.001; high quality of evidence) and FGA (MD = 2.099 95% CI = -0.306 to 3.893; P = 0.022; moderate quality of evidence). No significant difference was discovered between EbIs groups and TPTIs groups in enhancing gait velocity and stride length.

CONCLUSIONS

EbIs are statistically better than TPTIs in improving OAPD's performance in TUG, 6MWT, BBS and FGA, whereas only the change between EbIs and TPTIs in 6MWT can reach the value of minimal clinically important difference. Further studies are needed to better assess the effectiveness of exergaming-based interventions.

Effect of virtual reality rehabilitation on functional outcomes for return-to-work patients with Parkinson's disease: An umbrella review of systematic reviews

BACKGROUND

Parkinson's disease (PD) is a neurodegenerative disease characterized by loss of substantia nigra neurons with deficiency of dopamine. The main symptoms are tremor, rigidity and bradykinesia. Rehabilitation has an important role in the treatment of this condition and virtual reality (VR) is one of the most recent tools.

OBJECTIVE

The purpose of this umbrella review is to evaluate the effectiveness of VR systems on gait control for return to work in patients with PD.

METHODS

The electronic search, for reviews and meta-analysis studies that investigated the effectiveness of VR on gait control in PD patients, was performed through December 2021 using the following databases: PubMed, Scopus, PEDro, and Google Scholar. Mesh terms used were: Job integration/reintegration OR return-to-work AND Parkinson's disease AND virtual reality OR exergame. No limit on the year of publication of the article was used.

CONCLUSIONS

A total of 14 articles were included in our analysis. The included evidence shows a stride length improvement in patients treated with VR compared to conventional active treatments. No difference was found in walking speed. Also, the included articles show an improvement on various measures of balance, motor function and severity of PD motor symptoms. In addition, the literature shows an improvement in the quality of life and neuropsychiatric symptoms in patients undergoing VR rehabilitation training.

RESULTS

he results of our study suggest that VR rehabilitation improves gait performance, particularly stride length, thus being able to provide an improvement in the quality of life and a more effective return to work training in patients with PD.

Wearable Immersive Virtual Reality Device for Promoting Physical Activity in Parkinson's Disease Patients

Parkinson’s disease (PD) is a neurological disorder that usually appears in the 6th decade of life and affects up to 2% of older people (65 years and older). Its therapeutic management is complex and includes not only pharmacological therapies but also physiotherapy. Exercise therapies have shown good results in disease management in terms of rehabilitation and/or maintenance of physical and functional capacities, which is important in PD. Virtual reality (VR) could promote physical activity in this population. We explore whether a commercial wearable head-mounted display (HMD) and the selected VR exergame could be suitable for people with mild–moderate PD. In all, 32 patients (78.1% men; 71.50 ± 11.80 years) were a part of the study. Outcomes were evaluated using the Simulator Sickness Questionnaire (SSQ), the System Usability Scale (SUS), the Game Experience Questionnaire (GEQ post-game module), an ad hoc satisfaction questionnaire, and perceived effort. A total of 60 sessions were completed safely (without adverse effects (no SSQ symptoms) and with low scores in the negative experiences of the GEQ (0.01–0.09/4)), satisfaction opinions were positive (88% considered the training “good” or “very good”), and the average usability of the wearable HMD was good (75.16/100). Our outcomes support the feasibility of a boxing exergame combined with a wearable commercial HMD as a suitable physical activity for PD and its applicability in different environments due to its safety, usability, low cost, and small size. Future research is needed focusing on postural instability, because it seems to be a symptom that could have an impact on the success of exergaming programs aimed at PD.

Virtual reality is a promising therapy tool for walking activities in pediatric neurorehabilitation: Evaluation of usability and user experience (Preprint)

Background

Objective

Methods

Results

Conclusions

The effectiveness of virtual reality for rehabilitation of Parkinson disease: an overview of systematic reviews with meta-analyses

BACKGROUND

An increasing number of systematic reviews (SRs) and meta-analyses (MAs) of clinical trials have begun to investigate the effects of virtual reality (VR) in patients with Parkinson disease (PD). The aim of this overview was to systematically summarize the current best evidence for the effectiveness of VR therapy for the rehabilitation of people with PD.

METHODS

We searched SR-MAs based on randomized controlled trials (RCTs) for relevant literature in PubMed, Embase, and Cochrane library databases for systematic reviews from inception to December 5, 2020, and updated to January 26, 2022. The methodological quality of included SR-MAs was evaluated with the Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR-2), and the certainty of evidence for outcomes with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). We created an evidence map using a bubble plot format to represent the evidence base in 5 dimensions: effect size of VR therapy versus active intervention (AT), clinical outcome area, number of trials, statistical significance, and certainty of evidence.

RESULTS

From a total of 585 reports, 12 reviews were identified, of which only one was rated moderate quality, three were rated low quality, and eight were rated critically low quality by AMSTAR 2. Compared with AT, VR therapy induced increased benefits on stride/step length, balance, and neuropsychiatric symptoms. Compared with passive intervention (PT), VR therapy had greater effects on gait speed, stride/step length, balance, activities of daily living, and postural control in people with PD. Certainty of evidence varied from very low to moderate.

CONCLUSIONS

We found the methodological quality of the reviews was poor, and certainty of the most evidence within them was low to very low. We were therefore unable to conclude with any confidence that, in people with PD, VR therapy is harmful or beneficial for gait, balance, motor function, quality of life, activities of daily living, cognitive function, neuropsychiatric symptoms, and postural control. In the future, rigorous-designed, high-quality RCTs with larger sample sizes are needed to further verify the effectiveness of VR therapy in the treatment of PD.

Augmented Reality in Physical Therapy: Systematic Review and Meta-analysis

Background

Augmented reality (AR) is a rapidly expanding technology; it comprises the generation of new images from digital information in the real physical environment of a person, which simulates an environment where the artificial and real are mixed. The use of AR in physiotherapy has shown benefits in certain areas of patient health. However, these benefits have not been studied as a whole.

Objective

This study aims to ascertain the current scientific evidence on AR therapy as a complement to physiotherapy and to determine the areas in which it has been used the most and which variables and methods have been most effective.

Methods

A systematic review registered in PROSPERO (International Prospective Register of Systematic Reviews) was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) recommendations. The search was conducted from July to August 2021 in the PubMed, PEDro, Web of Science, Scopus, and Cochrane Library scientific databases using the keywords augmented reality, physiotherapy, physical therapy, exercise therapy, rehabilitation, physical medicine, fitness, and occupational therapy. The methodological quality was evaluated using the PEDro scale and the Scottish Intercollegiate Guidelines Network scale to determine the degree of recommendation. The Cochrane Collaboration tool was used to evaluate the risk of bias.

Results

In total, 11 articles were included in the systematic review. Of the 11 articles, 4 (36%) contributed information to the meta-analysis. Overall, 64% (7/11) obtained a good level of evidence, and most had a B degree of recommendation of evidence. A total of 308 participants were analyzed. Favorable results were found for the Berg Balance Scale (standardized mean change 0.473, 95% CI −0.0877 to 1.0338; z=1.65; P=.10) and the Timed Up and Go test (standardized mean change −1.211, 95% CI −3.2005 to 0.7768; z=−1.194; P=.23).

Conclusions

AR, in combination with conventional therapy, has been used for the treatment of balance and fall prevention in geriatrics, lower and upper limb functionality in stroke, pain in phantom pain syndrome, and turning in place in patients with Parkinson disease with freezing of gait. AR is effective for the improvement of balance; however, given the small size of the samples and the high heterogeneity of the studies, the results were not conclusive. Future studies using larger sample sizes and with greater homogeneity in terms of the devices used and the frequency and intensity of the interventions are needed.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020180766; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=180766

Virtual reality balance training to improve balance and mobility in Parkinson's disease: a systematic review and meta-analysis

BACKGROUND

In the last few years, virtual reality (VR) has been increasingly used to strengthen the effect of balance training (BT) in Parkinson's disease (PD).

OBJECTIVE

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the effects of VR-BT relative to BT alone for improving balance and mobility PD subjects with balance/mobility difficulties.

METHODS

Four electronic databases were searched: two reviewers independently selected RCTs, extracted data, and applied the Cochrane risk-of-bias tool for randomized trials (version 2) and the GRADE framework for assessing the certainty of evidence. Primary outcomes were balanced (Berg Balance Scale-BBS), mobility (Timed Up and Go-TUG) and walking speed. Secondary outcomes were falls, walking distance and stability, spatial gait parameters, balance confidence, sensory integration ability, motor signs and quality of life.

RESULTS

We included 22 studies (901 patients). Meta-analysis on fourteen trials (430 patients) showed a mean difference (MD) of 2.09 points (95% confidence interval [CI] 0.86-3.33) on BBS favoring VR-BT compared to BT (low certainty evidence). Subgroup analyses showed higher balance improvement in most affected subjects (moderate certainty evidence) and using VR rehabilitation-specific systems vs. VR non-specific systems. Eight trials (236 patients) assessing mobility showed a MD of 1.55 s (95% CI 0.04-3.06) on TUG favoring VR-BT (very low certainty evidence). No differences were observed in walking speed. Estimated effects were not maintained for any outcome at follow-up.

CONCLUSIONS

This review suggests that VR-BT is more effective than BT to improve balance in PD subjects immediately after training, particularly in individuals with higher postural instability at baseline.

Sequential motor learning transfers from real to virtual environment

Background

Skill acquisition of motor learning between virtual environments (VEs) and real environments (REs) may be related. Although studies have previously examined the transfer of motor learning in VEs and REs through the same tasks, only a small number of studies have focused on studying the transfer of motor learning in VEs and REs by using different tasks. Thus, detailed effects of the transfer of motor skills between VEs and REs remain controversial. Here, we investigated the transfer of sequential motor learning between VEs and REs conditions.

Methods

Twenty-seven healthy volunteers performed two types of sequential motor learning tasks; a visually cued button-press task in RE (RE task) and a virtual reaching task in VE (VE task). Participants were randomly assigned to two groups in the task order; the first group was RE task followed by VE task and the second group was VE task followed by RE task. Subsequently, the response time in RE task and VE task was compared between the two groups respectively.

Results

The results showed that the sequential reaching task in VEs was facilitated after the sequential finger task in REs.

Conclusions

These findings suggested that the sequential reaching task in VEs can be facilitated by a motor learning task comprising the same sequential finger task in REs, even when a different task is applied.

Biomechanical measures of balance after balance-based exergaming training dedicated for patients with Parkinson's disease

INTRODUCTION

Although previous studies have contributed to our understanding of the effects of implementing the virtual reality as a rehabilitation tool in patients with Parkinson's disease (PD), additional research is needed to examine the effects of applying balance-based exergaming training on quantitative biomechanical measures of balance.

RESEARCH QUESTION

To investigate the effects of balance-based conventional and exergaming training on posture parameters.

METHODS

The study involved 24 patients with PD (Hoehn and Yahr stages II-III).Participants underwent twelve training sessions during the 4-week training period. The experimental group (n=12) was trained with a custom-made exergaming balance based training system, the control group (n=12) underwent a conventional balance training. All objective outcomes were measured before intervention and the day after completion of training program. Postural stability was assessed using the quiet standing test, dynamic balance was assessed using limits of stability (LOS) and functional balance (FBT) tests.

RESULTS

After training, participants in both groups showed significantly better results in static balance performance. However, only exergaming training significantly improved LOS performance (higher values of Range of forward lean (p = 0.039, d_z = 0.67) and leaning rate (p=0.007, d_z=0.96). Also FBT test improved significantly only in experimental group (decrease in time to target hit (p=0.02, d_z=0.76) and significant increase of average COP velocity (p=0.008, d_z=0.93).

CONCLUSION

This study found that exergaming training created for patients with PD enhanced static and dynamic balance whereas conventional balance training improved static balance. Posturography is sensitive enough to reveal differential effects of training for both groups. These findings support the inclusion of our exergaming training in the exercise program for participants with PD.

Effect of virtual reality therapy, combined with physiotherapy for improving motor proficiency in individuals with Down syndrome: A systematic review

Background

Individuals with Down syndrome may struggle with anticipatory postural adjustments, and adapt slower to motor tasks and environmental changes, due to decreased motor proficiency.

Objectives

To determine the effectiveness of virtual reality therapy (VRT), specifically Nintendo Wii, combined with physiotherapy or occupational therapy (OT) for improving motor proficiency in individuals with Down syndrome, compared to standard physiotherapy, OT or no intervention.

Method

Nine computerised databases were searched from inception to July 2020. Methodological quality of randomised controlled trials and quasi-experimental studies was appraised using the physiotherapy evidence database (PEDro) scale and the Joanna Briggs Institute Critical Appraisal Checklist for Case Reports.

Results

Two randomised controlled trials and four quasi-experimental studies were included, with an average PEDro score of 7.3. One included case study scored 5. This review included 345 participants. Motor proficiency includes balance, coordination, strength and agility. Agility showed a significant improvement after 5 (p = 0.01) or 24 (p < 0.01) weeks. Strength showed a significant improvement after a 6- (p = 0.000) or 24-week intervention (p < 0.05). Balance showed inconclusive results for adults, and significant improvement in children after 6 (p = 0.000), 8 (p < 0.05) or 24 (p < 0.003) weeks. One study (n = 155) showed that upper limb and bilateral coordination improved significantly after 24 weeks (p < 0.003).

Conclusion

Level II, III-1 and IV evidence suggested that VRT may be valuable to improve agility and strength in individuals with Down syndrome, and balance and coordination in children with Down syndrome.

Clinical implications

It may be beneficial to use VRT in addition to standard physiotherapy or OT interventions for improving motor proficiency in individuals with Down syndrome.

Evaluating the Accuracy of Virtual Reality Trackers for Computing Spatiotemporal Gait Parameters

Ageing, disease, and injuries result in movement defects that affect daily life. Gait analysis is a vital tool for understanding and evaluating these movement dysfunctions. In recent years, the use of virtual reality (VR) to observe motion and offer augmented clinical care has increased. Although VR-based methodologies have shown benefits in improving gait functions, their validity against more traditional methods (e.g., cameras or instrumented walkways) is yet to be established. In this work, we propose a procedure aimed at testing the accuracy and viability of a VIVE Virtual Reality system for gait analysis. Seven young healthy subjects were asked to walk along an instrumented walkway while wearing VR trackers. Heel strike (HS) and toe off (TO) events were assessed using the VIVE system and the instrumented walkway, along with stride length (SL), stride time (ST), stride width (SW), stride velocity (SV), and stance/swing percentage (STC, SWC%). Results from the VR were compared with the instrumented walkway in terms of detection offset for time events and root mean square error (RMSE) for gait features. An absolute offset between VR- and walkway-based data of (15.3 ± 12.8) ms for HS, (17.6 ± 14.8) ms for TOs and an RMSE of 2.6 cm for SW, 2.0 cm for SL, 17.4 ms for ST, 2.2 m/s for SV, and 2.1% for stance and swing percentage were obtained. Our findings show VR-based systems can accurately monitor gait while also offering new perspectives for VR augmented analysis.

Virtual reality for limb motor function, balance, gait, cognition and daily function of stroke patients: A systematic review and meta-analysis

AIMS

To explore the beneficial effects of virtual reality (VR) interventions on upper- and lower-limb motor function, balance, gait, cognition and daily function outcomes in stroke patients.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

DATA SOURCES

English databases (PubMed, EMBASE, the Cochrane Library, CINAHL, Web of Science, Physiotherapy Evidence Database, ProQuest Dissertations and Theses) and Chinese databases (Chinese BioMedical Literature Service System, WANFANG, CNKI) and the Clinical Trial Registry Platform were systematically searched from inception until December 2019. Additionally, reference lists of the included studies were manually searched.

REVIEW METHODS

The methodological quality of studies was scored with the Cochrane 'risk-of-bias tool' and PEDro scale from the Physiotherapy Evidence Database by two independent evaluators.

RESULTS

In total, 87 studies with 3540 participants were included. Stroke patients receiving VR interventions showed significant improvements in Fugl-Meyer assessment of Upper Extremity, Action Research Arm Test, Wolf Motor Function Test, Fugl-Meyer Assessment of Lower Extremity, Functional Ambulation Classification, Berg Balance Scale, Time Up and Go, Velocity, Cadence, Modified Barthel Index and Functional Independence Measure. However, differences between VR intervention and traditional rehabilitation groups were not significant for Box-Block Test, 10 m Walk Test, Auditory Continuous Performance Test, Mini-Mental State Examination and Visual Continuous Performance Test.

CONCLUSION

This review suggests that VR interventions effectively improve upper- and lower-limb motor function, balance, gait and daily function of stroke patients, but have no benefits on cognition.

IMPACT

This review identified the positive effects of VR-assisted rehabilitation on upper- and lower-limb motor function, balance, gait and daily function of stroke patients. And, we verified the duration of VR intervention affects some health benefits. The benefit of VR on cognitive function requires further investigation through large-scale multicentre RCTs.

Parkinson's disease and virtual reality rehabilitation: cognitive reserve influences the walking and balance outcome

INTRODUCTION

Parkinson's disease (PD) is a neurodegenerative pathology characterized by motor and non-motor symptoms that often lead to several impairments. Many studies show the efficacy of different rehabilitation protocols aimed to improve balance and gait functions in PD patients. However, multiple factors may influence rehabilitation outcome. Recently, it has been observed as the cognitive reserve (CR) may influence the rehabilitation outcome, helping to address the patient toward technological or conventional rehabilitation. Our study investigated how CR may affect motor rehabilitation outcomes in PD patients who undergo virtual reality (VR) rehabilitation, aimed at improving walking and balance.

MATERIALS AND METHODS

Thirty patients affected by idiopathic PD were enrolled. Patients underwent 12 sessions VR training, over 6 weeks (45 min). Six-Minute Walk Test (6MWT) and Berg Balance Scale (BBS) were used to assess walking and balance, respectively. CR was assessed by Cognitive Reserve Index questionnaire (CRIq).

RESULTS

Significant correlations between CR and change from baseline in walking and balance measures were found, with a significant positive correlation between CRIq and 6MWT (r=0.50, p=0.01) and between CRIq and BBS (r=0.41, p=0.04).

DISCUSSION

Our results showed that PD patients with higher CR treated with VR improved significantly more in their balance and walking distance than those with lower CR. The current study suggests that VR when aimed to improve balance and walking in PD patients is more effective in patients with higher CR.

The Effects of Exergaming Training on Balance in Healthy Elderly Women-A Pilot Study

Our aim was to observe, through objective testing using an assessment module incorporated in a new exergaming system, whether elderly people's static and functional balance is improved by a balance exergaming training program based on movements performed in everyday life. Thirteen healthy elderly women participated in 12 sessions of balance-based exergaming training (three times a week, 30 min per session). All objective outcomes, the quiet standing test, functional balance test (FBT), and limit of stability (LOS) test, were measured on three occasions: before intervention, after six training sessions, and after the completion of the four-week program. The results showed a significant improvement in LOS performance after the intervention. In FBT, participants exhibited a significant decrease (p < 0.01; Kendall's W = 0.5) in the average time to target hit after six trainings. The average center of pressure velocity increased after six and 12 sessions, however did not reach significance (p = 0.053); nevertheless the size of the effect was large (η_p2 = 0.22). The parameters of the quiet standing test were not significantly affected by the training. The results support the need for more definite and objective studies assessing exergaming for balance in elderly.

Effect of Virtual Reality on Balance in Individuals With Parkinson Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Virtual reality (VR) is a frequently used intervention for the rehabilitation of individuals with neurological disorders.

PURPOSE

The aims of this review were to identify the short-term effect of VR on balance and to compare it with the effect of active interventions in individuals with Parkinson disease (PD).

DATA SOURCES

Searches for relevant articles available in English were conducted using the MEDLINE (via PubMed), EMBASE, CENTRAL, CINAHL, PsycINFO, and Physiotherapy Evidence Database databases from inception until March 2019.

STUDY SELECTION

All randomized controlled trials comparing the effect of training with VR and the effect of training without VR on balance in individuals with PD were included.

DATA EXTRACTION

Two authors independently extracted data, assessed the methodological quality, and evaluated the evidence quality of the studies.

DATA SYNTHESIS

Fourteen randomized controlled trials including 574 individuals were eligible for qualitative analyses, and 12 of the studies involving 481 individuals were identified as being eligible for meta-analyses. Compared with active interventions, the use of VR improved the Berg Balance Scale score (mean difference = 1.23; 95% CI = 0.15 to 2.31; I2 = 56%). The Dynamic Gait Index and Functional Gait Assessment results were also significant after the sensitivity analyses (mean difference = 0.69; 95% CI = 0.12 to 1.26; I2 = 0%). Both provided moderate statistical evidence. However, the Timed "Up & Go" Test and the Activities-Specific Balance Confidence Scale did not differ significantly.

LIMITATIONS

Publication bias and diversity in the interventions were the main limitations.

CONCLUSIONS

Existing moderate evidence of the effectiveness of VR with the Berg Balance Scale, Dynamic Gait Index, and Functional Gait Assessment for individuals with PD was promising. Although the differences did not reach the clinically important change threshold, VR was comparable to active interventions and could be considered an adjuvant therapy for balance rehabilitation in individuals with PD.

Effects of Virtual Reality Therapy on Gait and Balance Among Individuals With Spinal Cord Injury: A Systematic Review and Meta-analysis

Background and Purpose. The use of virtual reality (VR) therapy among individuals with spinal cord injury (SCI) is a relatively new rehabilitation approach replicating real-life scenarios. The aim of this study was to evaluate the effectiveness of VR therapy for improving gait and balance in individuals with SCI. Methods. Databases of PubMed, Web of Science, Scopus, SportDiscuss, and CINHAL were searched from inception until September 2019. Two independent reviewers screened articles for inclusion, extracted data, and evaluated methodological quality of the trials. Results. Ten trials, including 3 randomized clinical trials (RCTs) and 7 pre-post trials, with a total of 149 participants were analyzed. Meta-analysis of RCTs demonstrated significant improvement in sitting balance (standardized mean difference [SMD] = 1.65; 95% CI 1.21-2.09; P < .01) after VR therapy with conventional rehabilitation compared with only conventional rehabilitation. Also, pre-post studies using VR therapy without a control group showed improvement in standing balance (Berg Balance Scale, MD = 4.22; 95% CI 1.78-6.66; P < .01 and Activities-specific Balance Confidence scale, MD = 8.53; 95% CI 2.52-14.53; P = .01) and a trend for improvement in gait (SMD = 0.34; 95% CI 0.02-0.66; P = .04). Conclusion. This study demonstrated the beneficial effects of VR therapy to enhance sitting and standing balance and showed a trend of gait improvement in individuals with SCI. This conclusion is based on mainly preliminary data and therefore, more RCTs are needed to confirm the effects of the use of VR in individuals with SCI.

Current approaches to modeling the virtual reality in rodents for the assessment of brain plasticity and behavior

Virtual reality (VR) and augmented reality (AR) have become valuable tools to study brains and behaviors resulting in development of new methods of diagnostics and treatment. Neurodegenerаtion is one of the best examples demonstrating efficacy of VR/АR technologies in modern neurology. Development of novel VR systems for rodents and combination of VR tools with up-to-date imaging techniques (i.e. MRI, imaging of neural networks etc.), brain electrophysiology (EEG, patch-clamp), precise analytics (microdialysis) allowed implementing of VR protocols into the animal neurobiology to study brain plasticity, sensorimotor integration, spatial navigation, memory, and decision-making. VR/AR for rodents is а young field of experimental neuroscience and has already provided more consistent testing conditions, less human-animal interaction, opportunities to use a wider variety of experimental parameters. Here we discuss present and future perspectives of using VR/AR to assess brain plasticity, neurogenesis and complex behavior in rodent and human study, and their advantages for translational neuroscience.

Gait Disorders Questionnaire-Promising Tool for Virtual Reality Designing in Patients With Parkinson's Disease

Background: Gait disorders (GD) are frequent and disabling symptoms in patients with Parkinson's disease, mostly because they significantly limit mobility and often lead to fear of falls or actual falls. Nowadays, rehabilitation is considered to be the most effective nonpharmacological approach to reduce risk of falls. Using paradigms in virtual reality (VR) is a promising tool in neurorehabilitation because of the potential improvement in motor learning and improvement in daily functioning by replicating everyday real-life scenarios. Objective: To identify the most prevalent everyday situations which impair gait in PD that could be simulated in virtual reality (VR) environment. Methods: A newly developed self-report questionnaire consisting of 15 binary response items (YES/NO) encompassing everyday walking situations was administered to 62 patients diagnosed with idiopathic PD according to MDS Clinical Diagnostic Criteria. We included patients able to walk unassisted for at least 10 min and without significant cognitive impairment. Mokken Scale Analysis was used to evaluate psychometric properties of the scale. Results: Questionnaires from 58 patients were analyzed (31 men, age = 63 ± 9.9 y, disease duration = 7.02 ± 4.03 y, LEDD = 1115 ± 549.4 mg, H&Y = 2.4 ± 0.6). Only 10 items (out of 15) were identified as scalable and these were included in Gait Disorders Questionnaire (GDQ). The most prevalent trigger of gait disorders was walking under time pressure, followed by gait in crowded places and walking while dual-tasking. The total score of GDQ significantly correlated with the disease duration (r _s = 0.347, p = 0.008) and modified H&Y staging (r _s = 0.288, p = 0.028). Conclusion: With the use of GDQ we identified the most prevalent everyday transition activities that provoke gait disorders in patients with PD. The results may be useful for further development and systematic application of VR paradigms for physiotherapy of PD patients.

Societal Burden and Persisting Unmet Needs of Parkinson’s Disease

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