Savonia Article: Virtual Reality and Exergames in Rehabilitation of Neurological Patients
In 20 – 25.2.2023, Blended Intensive program in Neurological rehabilitation ran. More than 30 physiotherapy students and teachers from three universities (Savonia University of Applied Sciences, Finland, Third Faculty of Medicine, Charles University, Czech Republic and University of Thessaly, Greece) actively participated. Students worked together and wrote articles devoted to on the following themes: stroke and rehabilitation, multiple sclerosis and rehabilitation, Parkinson’s disease and rehabilitation, children with neurological disorders and rehabilitation, spinal cord injury and rehabilitation and virtual reality and exergames in rehabilitation of neurological patients. We are going to present their great work here. (Äijö et al 2022.)
What is virtual reality and exergames?
VR is a technology that allows a user to simulate a situation or experience of interest, using a VR headset, within an interactive but computer-generated environment. Exergaming is defined as technology-driven physical activities, such as video game play, that requires participants to be physically active or exercise to play the game.
Pros and cons
The main advantages of the VR are that it optimizes motor learning in a safe environment with feedback on the performance. It keeps patients motivated for repetitive movement and endurance practice. Virtual reality has beneficial results to the strength, the dynamic postural control, balance, and sensory-gross motor function. Moreover, VR reduces pain through keeping the patience focus away. Also, it can help with daily basis living tasks.
The main con is that VR equipment and systems are expensive and not so available. It can also give the patience headache, make them feel dizzy and cause epileptic seizure. In our opinion not everyone is open to modern technology and rather choose convent rehabilitation.
We found systematic reviews, meta-analysis and RCTs that shows that VR can be used in rehabilitation of stroke, Parkinson disease, Multiple sclerosis, chronical pain, down syndrome, and cerebral palsy. (Truijen et al., 2021; Cho et al., 2016; Lopes et al., 2020; Afzal et al., 2022).
The use of VR technology in the rehabilitation of Parkinson’s disease has several potential benefits, such as improving balance, gait, reducing falls, and increasing mobility. The results have been proved by many meta-analyses. Virtual reality environments can be designed to simulate real-life situations that may be challenging for individuals with Parkinson’s disease, such as walking on uneven surfaces or navigating crowded spaces. (Dockx et al., 2016; Truijen et al., 2021)
In one study they aimed to investigate the effects of a virtual reality-based exercise program on balance and gait in individuals with Parkinson’s disease. The study included 28 participants who were selected based on similar stage of the disease, age act. and randomly assigned to either a virtual reality group or a control group. The virtual reality group participated in a twelve-week (45 min session, 5 times a week). The control group attempted same amount of therapy but in traditional way. The conclusion was that both groups got better in gait and balance based on the Berg Balance Scale, Timed Up and go scale and Functional Gait Assessment. (Feng etal., 2019)
Most of patients with multiple sclerosis have difficulties connected to mobility, geography location or both, that prevent them from receiving proper treatment at rehabilitation center. And that is perfect opportunity to use telerehabilitation using VR as an alternative to physical therapy. (Ortiz-Gutiérrez et al., 2013) found out, that rehabilitation using distance VR shows same improvement in general balance as conventional physical therapy. Telerehabilitation using VR describes optimization of processing of sensory information.
A Randomized Controlled Trial analyzed the effects of treadmill training with virtual reality. This research used eighteen children with spastic CP for sample and were divided into 2 groups. For the first group (n=9) they used treadmill with VR and for the second one (n=9), they used only treadmill training. The study lasted for 8 weeks (3 times/week). They examined muscle strength, gross motor function, balance and gait. The change in the muscular strength of right and left knee extension after training was significantly better in the VRTT group than the TT group. Right knee flexion strength was not significantly different between groups. As for the differences in clinical functional measures of the participants, there was an intense difference in 2-minute walk test and on standing. However, about walking, running, jumping and pediatric balance scale it was a small improvement to the children with VRTT compared to TT group. Problems of this research: 1) The number of participants was low so, more studies must take place 2) it was only for spastic CP therefore, more research is important for other types of CP such as ataxia and dyskinesia. Outcome: Intervention with treadmill training using VR has beneficial results to the strength, the dynamic postural control, the endurance, and the gross motor function. (Cho etal. 2016.)
Results of the research of VR rehabilitation on stroke patients have shown that rehabilitation with VR has improved patients balance and upper limb function. Of these two the effects of VR rehabilitation on upper limb function needs more research. For example, the research has not been able to show enough proof that VR would improve upper limb grip strength, gait speed or global motor function. Results with upper limb VR rehabilitation has also showed considerable heterogeneity and thus, may need to be treated with caution (Wu et al. 2021).
Meta-analysis shows that VR therapy can significantly reduce pain intensity and kinesiophobia in patients with chronic low back pain. There is great heterogeneity in the studies, which may affect the consistency of the results. So, we need more research with VR therapy and chronic low back pain. Also, one RCT-study shows that Virtual Reality exercises with routine physical therapy reduce pain intensity and functional disability more than only routine physical therapy (Afzal et al.2021; Brea-Gomez et al. 2022.).
In conlcusion, the main question remains. Is virtual reality useful? We find scientific articles that support that VR and exergames can offer more benefits to the physiotherapy treatment for a variety of neurological problems. However, it must be utilized as a complementary intervention and not exclusevely.
Johanna Hyvärinen, Physiotherapy students, Savonia University of Applied Sciences, Kuopio, Finland
Jenni Pentti, Physiotherapy students, Savonia University of Applied Sciences, Kuopio, Finland
Alena Marsalkova, Physiotherapy students, Third Faculty of Medicine, Charles University, Czech Republic
Sara Hukaufova, Physiotherapy students, Third Faculty of Medicine, Charles University, Czech Republic
Julie Soukenikova, Physiotherapy students, Third Faculty of Medicine, Charles University, Czech Republic
Eleni Maria Kalligeri, Physiotherapy students, Department School of Health Sciences, University of Thessaly, Greece
Dr. Marja Äijö, PhD, Principal lecturer of gerontology and rehabilitation, Savonia University of Applied Sciences, Kuopio, Finland
Dr. Kamila Řasová, Ph.D., Associative professor of Physiotherapy, Third Faculty of Medicine, Charles University, Czech Republic
Dr. Thomas Besios, Assistant Professor, Department School of Health Sciences, University of Thessaly, Greece
Afzal MW, Ahmad A, Mohseni Bandpei MA, Gilani SA, Hanif A, Waqas MS. 2022. Effects of virtual reality exercises and routine physical therapy on pain intensity and functional disability in patients with chronic low back pain. J Pak Med Assoc. 72(3):413-417. doi: 10.47391/JPMA.3424.
Brea-Gómez B, Torres-Sánchez I, Ortiz-Rubio A, Calvache-Mateo A, Cabrera-Martos I, López-López L, Valenza MC. 2021. Virtual Reality in the Treatment of Adults with Chronic Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Int J Environ Res Public Health. 11;18(22):11806. doi: 10.3390/ijerph182211806.
Cho C, Hwang W, Hwang S, Chung Y. 2016. Treadmill Training with Virtual Reality Improves Gait, Balance, and Muscle Strength in Children with Cerebral Palsy. Tohoku J Exp Med. 2016 Mar;238(3):213-8. doi: 10.1620/tjem.238.213.
Dockx K, Bekkers EM, Van den Bergh V, Ginis P, Rochester L, Hausdorff JM, Mirelman A, Nieuwboer A. 2016. Virtual reality for rehabilitation in Parkinson’s disease. Cochrane Database Syst Rev. 21;12(12):CD010760. doi: 10.1002/14651858.CD010760.pub2.
Feng H, Li C, Liu J, Wang L, Ma J, Li G, Gan L, Shang X, Wu Z. 2019. Virtual Reality Rehabilitation Versus Conventional Physical Therapy for Improving Balance and Gait in Parkinson’s Disease Patients: A Randomized Controlled Trial. Med Sci Monit. 5;25:4186-4192. doi: 10.12659/MSM.916455.
Healthysd.gov 2023. What is Exergaming? Read: 23.2.2023. In available: https://healthysd.gov/what-is-exergaming/
Liji T. 2021. Applications of Virtual Reality in Medicine. Read: 23.2.2023 In available: https://www.news-medical.net/health/Applications-of-Virtual-Reality-in-Medicine.aspx
Lopes JBP, Duarte NAC, Lazzari RD, Oliveira CS. 2020. Virtual reality in the rehabilitation process for individuals with cerebral palsy and Down syndrome: A systematic review. J Bodyw Mov Ther. 24(4):479-483. doi: 10.1016/j.jbmt.2018.06.006. Epub 2018 Jun 28.
Ortiz-Gutiérrez R, Cano-de-la-Cuerda R, Galán-del-Río F, Alguacil-Diego IM, Palacios-Ceña D, Miangolarra-Page JC. 2013. A telerehabilitation program improves postural control in multiple sclerosis patients: a Spanish preliminary study. Int J Environ Res Public Health. 31;10(11):5697-710. doi: 10.3390/ijerph10115697.
Truijen S, Abdullahi A, Bijsterbosch D, van Zoest E, Conijn M, Wang Y, Struyf N, Saeys W. 2022. 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. Neurol Sci. 43(5):2995-3006. doi: 10.1007/s10072-021-05855-2. Epub 2022 Feb 17.
Wu J, Zeng A, Chen Z, Wei Y, Huang K, Chen J, Ren Z. 2021. Effects of Virtual Reality Training on Upper Limb Function and Balance in Stroke Patients: Systematic Review and Meta-Meta-Analysis. J Med Internet Res. 12;23(10):e31051. doi: 10.2196/31051.
Äijö M, Řasová K & Besios T. 2022. Neurological rehabilitation, Blended Intensive program has started. Savonia Article, Savonia-ammattikorkeakoulu. In available: https://www.savonia.fi/en/articles/savonia-article-neurological-rehabilitation-blended-intensive-program-has-started/