Effectiveness of virtual reality on balance ability in individuals with incomplete spinal cord injury: A systematic review

BackgroundBalance dysfunctions are one of the most prevalent impairments post incomplete spinal cord injury (SCI). The evidence has proposed that the rehabilitation can be efficacious in treating balance dysfunctions in patients with SCI. Virtual reality (VR) is a computer technology designate 3-D setting which provides immersed users to generate numerous feedbacks such as visual, audio, and haptic.ObjectiveTo investigate the effects of VR on balance ability in individuals with incomplete SCI and to identify efficient training protocol.MethodsWe searched in SCOPUS, PEDro, PUBMED, REHABDATA, EMBASE, and web of science for experimental trials studying impacts of VR training on balance in patients with incomplete SCI that published in English. Physiotherapy Evidence Database (PEDro) scale was used to evaluate the methodological quality for selected studies.ResultsFive pilot studies were met the inclusion criteria. The PEDro scores ranged from 2 to 3, with a median of 2. All selected studies enrolled less than 20 patients. The findings showed beneficial effects of VR in improving balance ability in patients with incomplete SCI.ConclusionsThe preliminary findings showed that the influence of VR training on the balance ability in patients with incomplete SCI is promising. Applying 12 to 20 sessions of 30 to 60 min of VR training may show meaningful effects. Further randomized controlled trials strongly needed.     

Effects of virtual reality for stroke individuals based on the International Classification of Functioning and Health: a systematic review

Objective: This review determines the effects of virtual reality interventions for stroke subjects based on the International Classification of Functioning, Disability,and Health (ICF) framework. Virtual reality is a promising tool for therapy for stroke rehabilitation, but the effects of virtual reality interventions on post-stroke patients based on the specific ICF domains (Body Structures, Body Functions, Activity, and Participation) have not been investigated.

Method: A systematic review was conducted, including trials with adults with a clinical diagnosis of a chronic, subacute, or acute stroke. Eligible trials had to include studies with an intervention protocol and follow-up, with a focus on upper limbs and/or lower limbs and/or balance. The Physiotherapy Evidence Database (PEDro) was used to assess the methodological quality of randomized controlled trials. Each trial was separated according to methodological quality into a high-quality trial (PEDro ≥ 6) and a low-quality trial (PEDro ≤ 6). Only high-quality trials were analyzed specifically based on the outcome of these trials.

Results: In total, 54 trials involving 1811 participants were included. Of the papers included and considered high quality, 14 trials evaluated areas of the Body Structures component, 20 trials of the Body Functions domain, 17 trials of the Activity component, and 8 trials of the Participation domain. In relation to ICF Part 2, four trials evaluated areas of the Personal Factors component and one trial evaluated domains of the Environmental Factors component.

Discussion: The effects of virtual reality on stroke rehabilitation based on the ICF framework are positive in Body Function and Body Structure. However, the results in the domains Activity and Participation are inconclusive. More high-quality clinical trials are needed to confirm the effectiveness of virtual reality in the domains of Activity and Participation.     

The efficacy of treadmill training on balance dysfunction in individuals with chronic stroke: a systematic review

Background: Physical activity and exercise interventions are useful in facilitating the functional recovery of those with chronic stroke and, routinely, are gait-specific. While treadmill training has proven useful in gait performance recovery post-stroke, its efficacy on balance dysfunction has not been systematically reviewed.

Objectives: The purpose of this systematic review was to determine the effect of treadmill training (TT) interventions on balance dysfunction in individuals with chronic stroke.

Methods: A systematic literature search of PubMed, EMBASE, and CINAHL was performed. Eligible randomized controlled trials were published between 2007 and 2016. Selected trials investigated TT interventions in persons with chronic stroke and implemented at least one objective balance measure. Methodological quality was assessed using PEDro criteria.

Results: Eight studies met eligibility criteria and were included in the qualitative analysis. Studies differed in TT implementation and use of adjunctive treatments; however, all trials demonstrated improvements in balance measures that were as effective, if not more so, than conventional physical therapy treatments, including targeted balance training.

Conclusions: This review recognized moderate evidence in favor of TT interventions in balance and stroke rehabilitation programs. With TT, intensity may be a more critical factor than specificity and may offer additional carryover to recovery parameters of postural control and balance, beyond gait performance. It is recommended that clinicians utilizing TT incorporate objective measures of balance to assess the potential for skill transference and improvements in balance. Higher quality studies and additional research are needed to denote critical parameters by which improvements in balance may be optimized.     

Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: a meta-analysis

Virtual reality exposure therapy (VRET) is an increasingly common treatment for anxiety and specific phobias. Lacking is a quantitative meta-analysis that enhances understanding of the variability and clinical significance of anxiety reduction outcomes after VRET. Searches of electronic databases yielded 52 studies, and of these, 21 studies (300 subjects) met inclusion criteria. Although meta-analysis revealed large declines in anxiety symptoms following VRET, moderator analyses were limited due to inconsistent reporting in the VRET literature. This highlights the need for future research studies that report uniform and detailed information regarding presence, immersion, anxiety and/or phobia duration, and demographics.     

焦虑障碍虚拟现实暴露治疗的效果研究进展

本文目的是对虚拟现实暴露疗法治疗焦虑障碍各亚型效果的研究进展进行综述,以期为临床应用提供参考。虚拟现实技术的日益普及与发展,为焦虑障碍的治疗提供了新的有效方法。近年来,大量研究表明虚拟现实暴露疗法治疗焦虑障碍有一定的效果。本文探讨了虚拟现实暴露疗法治疗焦虑障碍各亚型的效果以及药物对虚拟现实暴露治疗的增效作用,并总结了虚拟现实暴露疗法的优点及不足。     

Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials

Trials of virtual reality exposure therapy (VRET) for anxiety-related disorders have proliferated in number and diversity since our previous meta-analysis that examined 13 total trials, most of which were for specific phobias (Powers & Emmelkamp, 2008). Since then, new trials have compared VRET to more diverse anxiety and related disorders including social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), and panic disorder (PD) with and without agoraphobia. With the availability of this data, it is imperative to re-examine the efficacy of VRET for anxiety. A literature search for randomized controlled trials of VRET versus control or in vivo exposure yielded 30 studies with 1057 participants. Fourteen studies tested VRET for specific phobias, 8 for SAD or performance anxiety, 5 for PTSD, and 3 for PD. A random effects analysis estimated a large effect size for VRET versus waitlist (g = 0.90) and a medium to large effect size for VRET versus psychological placebo conditions (g = 0.78). A comparison of VRET and in vivo conditions did not show significantly different effect sizes (g = −0.07). These findings were relatively consistent across disorders. A meta-regression analysis revealed that larger sample sizes were associated with lower effect sizes in VRET versus control comparisons (β = −0.007, p < 0.05). These results indicate that VRET is an effective and equal medium for exposure therapy.     

Validation of a low-cost virtual reality system for training street-crossing. A comparative study in healthy,neglected and non-neglected stroke individuals

Unilateral spatial neglect is a common consequence of stroke that directly affects the performance of activities of daily living. This impairment is traditionally assessed with paper-and-pencil tests that can lack correspondence to real life and are easily compensated. Virtual reality can immerse patients in more ecological scenarios, thus providing therapists with new tools to assess and train the effects of this impairment in simulated real tasks. This paper presents the clinical validation and convergent validity of a low-cost virtual reality system for training street-crossing in stroke patients with and without neglect. The performance of neglect patients was significantly worse than the performance of non-neglect and healthy participants. In addition, several correlations between the scores in the system and in the traditional scales were detected.     

虚拟现实康复技术在脑卒中后上肢运动障碍中的应用进展

虚拟现实康复技术是计算机模拟真实环境的集成技术,具有沉浸、交互和想象三大特点,广泛应用于脑卒中后上肢运动功能康复。本文简要阐述虚拟现实康复技术在脑卒中后上肢运动障碍中的应用进展。     

The feasibility of verbal and virtual reality exposure for youth with academic performance worry

With exposure emerging as a key ingredient in anxiety treatment for childhood anxiety disorders (CADs), expansion of exposure techniques is a promising avenue for improving treatment efficacy. The present study examined use of imaginal exposure (IE), a technique understudied in the treatment of CADs. Specifically, the study tested whether two forms of exposure to worries (verbal IE and virtual reality exposure therapy, VRET) would be effective and acceptable forms of exposure with youth. Twenty youth with fears of academic failure completed both types of worry exposure, presented in randomized order. Regardless of order of presentation, both verbal IE and VRET elicited moderate anxiety that decreased to mild over the span of the exposures. Both were found to be acceptable by youth and neither was associated with negative side effects. Youth found VRET to be slightly more interesting and novel, but noted that verbal IE was more realistic and individualized. The present study supports the use of standalone worry exposure as an effective and acceptable treatment for general worries in youth and suggests VRET could be more effective with improved realism.     

The relationship between posttraumatic and depressive symptoms during virtual reality exposure therapy with a cognitive enhancer

Two studies suggest that reductions in posttraumatic symptoms (Aderka et al., 2013) and cognitions (Zalta et al., 2014) precede reductions in depressive symptoms during prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) in female assault survivors. The present study explored the temporal relationship between posttraumatic and depressive symptoms in a randomized trial of D-Cycloserine (DCS) versus placebo augmented virtual reality exposure (VRE) therapy for chronic World Trade Center-related PTSD following the September 11, 2001 terrorist attacks. Twenty-five male and female participants were randomly assigned to receive either 100 mg DCS (N = 13) or placebo (N = 12) 90 min before 12 weekly VRE sessions. Participants contributed a total of 280 weekly PTSD Checklist (PCL; Weathers et al., 1993) and Beck Depression Inventory-second edition (BDI-II; Beck et al., 1996) symptom scores. Two sets of mediation analyses for longitudinal mixed models assessed the effects of 1) lagged PCL on BDI-II (Model 1), and 2) lagged BDI-II on PCL (Model 2) in the VRE-DCS and VRE-Placebo treatment groups, respectively. Results revealed reciprocal relations between posttraumatic and depressive symptoms during VRE treatment, although reductions in posttraumatic symptoms led to subsequent reductions in depressive symptoms to a greater extent than the converse. These effects were stronger in the DCS-enhanced group. Findings suggest that VRE primarily decreases posttraumatic symptoms, which in turn leads to decreased depressive symptoms, and that DCS may strengthen these effects.     

What is the effect of additional physiotherapy on sitting balance following stroke compared to standard physiotherapy treatment: a systematic review

Background: Sitting balance dysfunction is commonly experienced following stroke. Physiotherapists utilize interventions to address this problem but it is unclear whether treatment type, target or practice intensity may affect outcomes.

Objective: To compare the effects of standard physiotherapy to standard physiotherapy plus an additional physiotherapy treatment after stroke.

Data Sources: The databases of Cochrane Library, CINAHL, Embase, Ovid Medline, AMED, and the Physiotherapy Evidence Database (PEDro) up to December 2014 were searched.

Study Selection: Randomized controlled trials in English reported in peer-reviewed journals regarding the effect of additional physiotherapy on sitting balance were retrieved.

Data Extraction: The PEDro scale was used to assess study quality.

Results: Eleven studies met inclusion criteria. Nine targeted the ICF (International Classification of Function, Disability and Health) domain of Activity. The Trunk control test (TCT) was used as a primary outcome measure in five studies, and the Trunk Impairment Scale (TIS) was used in four. There was a significant effect (mean difference?=?1.67, 95% CI?=?0.54–2.80) favoring intervention, as measured by the TIS. There was no evidence to support the effect of additional treatment on sitting balance as measured by the TCT (mean difference?=???1.53, 95% CI?=???9.37 to 6.32).

Conclusion:The current evidence supports strategies that target deficits at the activity level and increase total treatment time. The TIS is most responsive as a measure of treatment efficacy. Further research is required using recommended outcome measures to facilitate generation of a minimum data set and data pooling.     

Evaluation of a virtual reality prospective memory task for use with individuals with severe traumatic brain injury

The current study aimed to evaluate the sensitivity, convergent validity and ecological validity of a newly developed virtual reality prospective memory (PM) task (i.e., the Virtual Reality Shopping Task; VRST) for use with individuals with traumatic brain injury (TBI). Thirty individuals with severe TBI and 24 uninjured adults matched on age, gender and education level were administered the VRST, a lexical decision PM task (LDPMT), an index of task-friendliness and a cognitive assessment battery. Significant others rated disruptions in the TBI participants' occupational activities, interpersonal relationships and independent living skills. The performance of the TBI group was significantly poorer than that of controls on event-based PM as measured by the LDPMT, and on time- and event-based PM as measured by the VRST. Performance on the VRST significantly predicted significant others' ratings of patients' occupational activities and independent living skills. The VRST was rated as significantly more reflective of an everyday activity, interesting and was afforded a higher recommendation than the LDPMT. For the TBI group, event and total PM performance on the VRST significantly correlated with performance on measures of mental flexibility and verbal fluency, and total PM performance correlated with verbal memory. These results provide preliminary but promising evidence of the sensitivity, as well as the convergent and ecological validity of the VRST.     

Effect of home-based virtual reality training and telerehabilitation on balance in individuals with Parkinson disease,multiple sclerosis,and stroke: a systematic review and meta-analysis

Neurological Sciences - In the last decade, there is a growing interest in the use of virtual reality for rehabilitation in clinical and home settings. The aim of this systematic review is to do a...     

A dance program to improve gait and balance in individuals with chronic stroke: a feasibility study

Background and Objective Despite gains made with rehabilitation, gait and balance remain limited post-stroke. Dance is a fun and motivating activity which has shown benefits in individuals with Parkinson’s disease. The purpose of this article is to investigate the feasibility of a dance program for individuals with chronic stroke.

Methods Pre-post intervention feasibility study where twenty individuals with chronic stroke participated in a dance class twice a week for 10 weeks. Feasibility measures included interest, enrollment, attendance, adverse events, and participant satisfaction. Outcomes of interest were spatiotemporal gait parameters and balance assessed with the MiniBESTest before and after the dance program. Pre and post measures were compared with paired t-tests.

Results Of the 33 individuals approached, 30 (90.9%) were interested in participating; however, scheduling conflicts were a common barrier. Ultimately, 22 individuals consented and 20 individuals completed the dance program without adverse events. The mean age was 62.3 (10.4) years, time post-stroke was 6.4 (6.0) years and National Institutes of Health Stroke Scale score was 3.1 (2.0). Average attendance was 92.5% with 10 classes missed across 8 participants and satisfaction ratings were high (e.g. 17/20 strongly agreed they enjoyed the program). No significant differences in spatiotemporal gait parameters were found; however, MiniBESTest scores significantly increased from 16.5 (6.0) to 18.6 (4.9) (p = 0.0005).

Discussion and Conclusions A dance program is safe and feasible post-stroke. Attendance and satisfaction were high and participants perceived walking and balance benefits. Future work will include a randomized controlled trial.     

Validation of an immersive virtual reality system for training near and far space neglect in individuals with stroke: a pilot study

Background: Unilateral spatial neglect (USN) is defined as impaired ability to attend and see on one side, and when present, it interferes seriously with daily life. These symptoms can exist for near and far spaces combined or independently, and it is important to provide effective intervention for near and far space neglect.

Objective: The purpose of this pilot study was to propose an immersive virtual reality (VR) rehabilitation program using a head-mounted display that is able to train both near and far space neglect, and to validate the immediate effect of the VR program in both near and far space neglect.

Methods: Ten USN patients underwent the VR program with a pre–post design and no control. In the virtual environment, we developed visual searching and reaching tasks using an immersive VR system. Behavioral inattention test (BIT) scores obtained pre- and immediate post-VR program were compared.

Results: BIT scores obtained pre- and post-VR program revealed that far space neglect but not near space neglect improved promptly after the VR program. This effect for far space neglect was observed in the cancelation task, but not in the line bisection task.

Conclusions: Positive effects of the immersive VR program for far space neglect are suggested by the results of the present pilot study. However, further studies with rigorous designs are needed to validate its clinical effectiveness.     

Efficacy of virtual reality exposure therapy to treat driving phobia: a case report

An AB case design was used to examine the efficacy of virtual reality exposure therapy (VRET) in treating driving phobia. After a one week baseline, the patient received three treatment sessions over a ten day period. Treatment included practice of four VR driving scenarios. Peak anxiety decreased within and across sessions. Ratings of anxiety and avoidance declined from pre-treatment and post-treatment, with gains maintained at seven month followup. Phobia-related interference in daily functioning similarly decreased. The results suggest that it would be useful to further evaluate the efficacy of VRET for driving phobia in controlled clinical trials.     

Virtual reality exposure therapy in anxiety disorders: a systematic review of process‐and‐outcome studies

In recent years, virtual reality exposure therapy (VRET) has become an interesting alternative for the treatment of anxiety disorders. Research has focused on the efficacy of VRET in treating anxiety disorders: phobias, panic disorder, and posttraumatic stress disorder. In this systematic review, strict methodological criteria are used to give an overview of the controlled trials regarding the efficacy of VRET in patients with anxiety disorders. Furthermore, research into process variables such as the therapeutic alliance and cognitions and enhancement of therapy effects through cognitive enhancers is discussed. The implications for implementation into clinical practice are considered. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

A virtual shopping task for the assessment of executive functions: Validity for people with stroke

The importance of assessing executive functions (EF) using ecologically valid assessments has been discussed extensively. Due to the difficulty of carrying out such assessments in real-world settings on a regular basis, virtual reality has been proposed as a technique to provide complex functional tasks under a variety of differing conditions while measuring various aspects of performance and controlling for stimuli. The main goal of this study was to examine the discriminant, construct-convergent and ecological validity of the Adapted Four-Item Shopping Task, an assessment of the Instrumental Activity of Daily Living (IADL) of shopping. Nineteen people with stroke, aged 50–85 years, and 20 age- and gender-matched healthy participants performed the shopping task in both the SeeMe Virtual Interactive Shopping environment and a real shopping environment (the hospital cafeteria) in a counterbalanced order. The shopping task outcomes were compared to clinical measures of EF. The findings provided good initial support for the validity of the Adapted Four-Item Shopping Task as an IADL assessment that requires the use of EF for people with stroke. Further studies should examine this task with a larger sample of people with stroke as well as with other populations who have deficits in EF.     

Leap motion controlled videogame-based therapy for rehabilitation of elderly patients with subacute stroke: a feasibility pilot study

Abstract

Background:

The leap motion controller (LMC) is a new optoelectronic system for capturing motion of both hands and controlling a virtual environment. Differently from previous devices, it optoelectronically tracks the fine movements of fingers neither using glows nor markers.

Objective:

This pilot study explored the feasibility of adapting the LMC, developed for videogames, to neurorehabilitation of elderly with subacute stroke.

Methods:

Four elderly patients (71.50?±?4.51 years old) affected by stroke in subacute phase were enrolled and tested in a cross-over pilot trial in which six sessions of 30 minutes of LMC videogame-based therapy were added on conventional therapy. Measurements involved participation to the sessions, evaluated by means of the Pittsburgh Rehabilitation Participation Scale, hand ability and grasp force evaluated respectively by means of the Abilhand Scale and by means of the dynamometer.

Results:

Neither adverse effects nor spasticity increments were observed during LMC training. Participation to the sessions was excellent in three patients and very good in one patient during the LMC trial. In this period, patients showed a significantly higher improvement in hand abilities (P?=?0.028) and grasp force (P?=?0.006).

Conclusions:

This feasibility pilot study was the first one using leap motion controller for conducting a videogame-based therapy. This study provided a proof of concept that LMC can be a suitable tool even for elderly patients with subacute stroke. LMC training was in fact performed with a high level of active participation, without adverse effects, and contributed to increase the recovery of hand abilities.     

Effects of virtual reality in post-stroke aphasia: a systematic review and meta-analysis

Neurological Sciences - To investigate whether virtual reality (VR) interventions have beneficial effects on the functional communication and language function of patients with post-stroke aphasia...