Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial Motor Learning Principles for Rehabilitation: A Pilot Randomized Controlled Study in Poststroke Patients Efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST): a randomised, multicentre, single-blind, controlled trial Addition of a non-immersive virtual reality component to treadmill training to reduce fall risk in older adults (V-TIME): a randomised controlled trial Reliability of the PEDro scale for rating quality of randomized controlled trials. Virtual reality-based cognitive-motor training for middle-aged adults at high Alzheimer's disease risk: A randomized controlled trial Virtual reality exercise intradialysis to improve physical function: A feasibility randomized trial What About the Role of Virtual Reality in Parkinson Disease’s Cognitive Rehabilitation? Preliminary Findings From a Randomized Clinical Trial Efficacy of different interaction devices using non-immersive virtual tasks in individuals with Amyotrophic Lateral Sclerosis: a cross-sectional randomized trial Three-Dimensional Augmented Reality System for Balance and Mobility Rehabilitation in the Elderly: A Randomized Controlled Trial A multimodal training modulates short-afferent inhibition and improves complex walking in a cohort of faller older adults with an increased prevalence of Parkinson's disease. Intensive virtual reality and robotic based upper limb training compared to usual care, and associated cortical reorganization, in the acute and early sub-acute periods post-stroke: a feasibility study
Background Recent evidence has demonstrated the efficacy of Virtual Reality ( VR ) for stroke rehabilitation nonetheless its benefits and limitations in large population of patients have not yet been studied . Objectives To evaluate the effectiveness of non-immersive VR treatment for the restoration of the upper limb motor function and its impact on the activities of daily living capacities in post-stroke patients . Methods A pragmatic clinical trial was conducted among post-stroke patients admitted to our rehabilitation hospital . We enrolled 376 subjects who had a motor arm subscore on the Italian version of the National Institutes of Health Stroke Scale ( It-NIHSS ) between 1 and 3 and without severe neuropsychological impairments interfering with recovery . Patients were allocated to two treatments groups , receiving combined VR and upper limb conventional ( ULC ) therapy or ULC therapy alone . The treatment programs consisted of 2 hours of daily therapy , delivered 5 days per week , for 4 weeks . The outcome measures were the Fugl-Meyer Upper Extremity ( F-M UE ) and Functional Independence Measure ( FIM ) scales . Results Both treatments significantly improved F-M UE and FIM scores , but the improvement obtained with VR rehabilitation was significantly greater than that achieved with ULC therapy alone . The estimated effect size of the minimal difference between groups in F-M UE and FIM scores was 2.5 ± 0.5 ( P < 0.001 ) pts and 3.2 ± 1.2 ( P = 0.007 ) pts , respectively . Conclusions VR rehabilitation in post-stroke patients seems more effective than conventional interventions in restoring upper limb motor impairments and motor related functional abilities . Trial registration Italian Ministry of Health IRCCS Research Programme Background . Six months after a stroke , the hemiplegic arm often remains compromised . More innovative approaches to motor rehabilitation are needed . Objective . The authors compared a motor learning — based approach in a virtual environment with more conventional upper extremity therapy in a pilot trial . Methods . This prospect i ve , single-blinded , r and omized controlled trial compared reinforced feedback in a virtual environment ( RFVE ; n = 27 ) with a control intervention ( n = 20 ) of progressive therapy for the affected upper extremity . Both treatments were provided for 4 weeks , 5 days per week , with 1-hour treatment sessions daily . The primary outcomes were the Fugl-Meyer Upper Extremity ( F-M UE ) and Functional Independence Measure ( FIM ) scores . Kinematic outcomes included mean duration ( MD ) , mean linear velocity ( MLV ) , and number of submovements to measure the motor performance . Analyses of the primary outcomes were performed per protocol and by intention to treat . Results . F-M UE scores improved significantly in the RFVE group compared with the conventional therapy group ( “ intention to treat ” = 5.10 points , P = .004 ; ANCOVA = 4.26 points , P < .01 ) . Several of the kinematic parameters improved in the RFVE group ( MD , P < .01 ; MLV , P < .01 ) . FIM improvements did not differ . Conclusions . Both rehabilitation therapies improved arm motor performance and functional activity , but the RFVE therapy induced more robust results in patients exposed to late rehabilitation treatment BACKGROUND Non-immersive virtual reality is an emerging strategy to enhance motor performance for stroke rehabilitation . There has been rapid adoption of non-immersive virtual reality as a rehabilitation strategy despite the limited evidence about its safety and effectiveness . Our aim was to compare the safety and efficacy of virtual reality with recreational therapy on motor recovery in patients after an acute ischaemic stroke . METHODS In this r and omised , controlled , single-blind , parallel-group trial we enrolled adults ( aged 18 - 85 years ) who had a first-ever ischaemic stroke and a motor deficit of the upper extremity score of 3 or more ( measured with the Chedoke-McMaster scale ) within 3 months of r and omisation from 14 in-patient stroke rehabilitation units from four countries ( Canada [ 11 ] , Argentina [ 1 ] , Peru [ 1 ] , and Thail and [ 1 ] ) . Participants were r and omly allocated ( 1:1 ) by a computer-generated assignment at enrolment to receive a programme of structured , task-oriented , upper extremity sessions ( ten sessions , 60 min each ) of either non-immersive virtual reality using the Nintendo Wii gaming system ( VRWii ) or simple recreational activities ( playing cards , bingo , Jenga , or ball game ) as add-on therapies to conventional rehabilitation over a 2 week period . All investigators assessing outcomes were masked to treatment assignment . The primary outcome was upper extremity motor performance measured by total time to complete the Wolf Motor Function Test ( WMFT ) at the end of the 2 week intervention period , analysed in the intention-to-treat population . This trial is registered with Clinical Trials.gov , number NTC01406912 . FINDINGS The study was done between May 12 , 2012 , and Oct 1 , 2015 . We r and omly assigned 141 patients : 71 received VRWii therapy and 70 received recreational activity . 121 ( 86 % ) patients ( 59 in the VRWii group and 62 in the recreational activity group ) completed the final assessment and were included in the primary analysis . Each group improved WMFT performance time relative to baseline ( decrease in median time from 43·7 s [ IQR 26·1 - 68·0 ] to 29·7 s [ 21·4 - 45·2 ] , 32·0 % reduction for VRWii vs 38·0 s [ IQR 28·0 - 64·1 ] to 27·1 s [ 21·2 - 45·5 ] , 28·7 % reduction for recreational activity ) . Mean time of conventional rehabilitation during the trial was similar between groups ( VRWii , 373 min [ SD 322 ] vs recreational activity , 397 min [ 345 ] ; p=0·70 ) as was the total duration of study intervention ( VRWii , 528 min [ SD 155 ] vs recreational activity , 541 min [ 142 ] ; p=0·60 ) . Multivariable analysis adjusted for baseline WMFT score , age , sex , baseline Chedoke-McMaster , and stroke severity revealed no significant difference between groups in the primary outcome ( adjusted mean estimate of difference in WMFT : 4·1 s , 95 % CI -14·4 to 22·6 ) . There were three serious adverse events during the trial , all deemed to be unrelated to the interventions ( seizure after discharge and intracerebral haemorrhage in the recreational activity group and heart attack in the VRWii group ) . Overall incidences of adverse events and serious adverse events were similar between treatment groups . INTERPRETATION In patients who had a stroke within the 3 months before enrolment and had mild-to-moderate upper extremity motor impairment , non-immersive virtual reality as an add-on therapy to conventional rehabilitation was not superior to a recreational activity intervention in improving motor function , as measured by WMFT . Our study suggests that the type of task used in motor rehabilitation post-stroke might be less relevant , as long as it is intensive enough and task-specific . Simple , low-cost , and widely available recreational activities might be as effective as innovative non-immersive virtual reality technologies . FUNDING Heart and Stroke Foundation of Canada and Ontario Ministry of Health BACKGROUND Age-associated motor and cognitive deficits increase the risk of falls , a major cause of morbidity and mortality . Because of the significant ramifications of falls , many interventions have been proposed , but few have aim ed to prevent falls via an integrated approach targeting both motor and cognitive function . We aim ed to test the hypothesis that an intervention combining treadmill training with non-immersive virtual reality ( VR ) to target both cognitive aspects of safe ambulation and mobility would lead to fewer falls than would treadmill training alone . METHODS We carried out this r and omised controlled trial at five clinical centres across five countries ( Belgium , Israel , Italy , the Netherl and s , and the UK ) . Adults aged 60 - 90 years with a high risk of falls based on a history of two or more falls in the 6 months before the study and with varied motor and cognitive deficits were r and omly assigned by use of computer-based allocation to receive 6 weeks of either treadmill training plus VR or treadmill training alone . R and omisation was stratified by subgroups of patients ( those with a history of idiopathic falls , those with mild cognitive impairment , and those with Parkinson 's disease ) and sex , with stratification per clinical site . Group allocation was done by a third party not involved in onsite study procedures . Both groups aim ed to train three times per week for 6 weeks , with each session lasting about 45 min and structured training progression individualised to the participant 's level of performance . The VR system consisted of a motion-capture camera and a computer-generated simulation projected on to a large screen , which was specifically design ed to reduce fall risk in older adults by including real-life challenges such as obstacles , multiple pathways , and distracters that required continual adjustment of steps . The primary outcome was the incident rate of falls during the 6 months after the end of training , which was assessed in a modified intention-to-treat population . Safety was assessed in all patients who were assigned a treatment . This study is registered with Clinical Trials.gov , NCT01732653 . FINDINGS Between Jan 6 , 2013 , and April 3 , 2015 , 302 adults were r and omly assigned to either the treadmill training plus VR group ( n=154 ) or treadmill training alone group ( n=148 ) . Data from 282 ( 93 % ) participants were included in the prespecified , modified intention-to-treat analysis . Before training , the incident rate of falls was similar in both groups ( 10·7 [ SD 35·6 ] falls per 6 months for treadmill training alone vs 11·9 [ 39·5 ] falls per 6 months for treadmill training plus VR ) . In the 6 months after training , the incident rate was significantly lower in the treadmill training plus VR group than it had been before training ( 6·00 [ 95 % CI 4·36 - 8·25 ] falls per 6 months ; p<0·0001 vs before training ) , whereas the incident rate did not decrease significantly in the treadmill training alone group ( 8·27 [ 5·55 - 12·31 ] falls per 6 months ; p=0·49 ) . 6 months after the end of training , the incident rate of falls was also significantly lower in the treadmill training plus VR group than in the treadmill training group ( incident rate ratio 0·58 , 95 % CI 0·36 - 0·96 ; p=0·033 ) . No serious training-related adverse events occurred . INTERPRETATION In a diverse group of older adults at high risk for falls , treadmill training plus VR led to reduced fall rates  compared with treadmill training alone . FUNDING European Commission BACKGROUND AND PURPOSE Assessment of the quality of r and omized controlled trials ( RCTs ) is common practice in systematic review s. However , the reliability of data obtained with most quality assessment scales has not been established . This report describes 2 studies design ed to investigate the reliability of data obtained with the Physiotherapy Evidence Data base ( PEDro ) scale developed to rate the quality of RCTs evaluating physical therapist interventions . METHOD In the first study , 11 raters independently rated 25 RCTs r and omly selected from the PEDro data base . In the second study , 2 raters rated 120 RCTs r and omly selected from the PEDro data base , and disagreements were resolved by a third rater ; this generated a set of individual rater and consensus ratings . The process was repeated by independent raters to create a second set of individual and consensus ratings . Reliability of ratings of PEDro scale items was calculated using multirater kappas , and reliability of the total ( summed ) score was calculated using intraclass correlation coefficients ( ICC [ 1,1 ] ) . RESULTS The kappa value for each of the 11 items ranged from.36 to.80 for individual assessors and from.50 to.79 for consensus ratings generated by groups of 2 or 3 raters . The ICC for the total score was.56 ( 95 % confidence interval=.47-.65 ) for ratings by individuals , and the ICC for consensus ratings was.68 ( 95 % confidence interval=.57-.76 ) . DISCUSSION AND CONCLUSION The reliability of ratings of PEDro scale items varied from " fair " to " substantial , " and the reliability of the total PEDro score was " fair " to " good . Introduction Ubiquity of Alzheimer 's disease ( AD ) coupled with relatively ineffectual pharmacologic treatments has spurred interest in nonpharmacologic lifestyle interventions for prevention or risk reduction . However , evidence of neuroplasticity notwithst and ing , there are few scientifically rigorous , ecologically relevant brain training studies focused on building cognitive reserve in middle age to protect against cognitive decline . This pilot study will examine the ability of virtual reality ( VR ) cognitive training to improve cognition and cerebral blood flow ( CBF ) in middle-aged individuals at high AD risk due to parental history . Methods The design is an assessor-blind , parallel group , r and omized controlled trial of VR cognitive-motor training in middle-aged adults with AD family history . The experimental group will be trained with adaptive “ real-world ” VR tasks targeting sustained and selective attention , working memory , covert rule deduction , and planning , while walking on a treadmill . One active control group will perform the VR tasks without treadmill walking ; another will walk on a treadmill while watching scientific documentaries ( nonspecific cognitive stimulation ) . A passive ( waitlist ) control group will not receive training . Training sessions will be 45 minutes , twice/week for 12 weeks . Primary outcomes are global cognition and CBF ( from arterial spin labeling [ ASL ] ) at baseline , immediately after training ( training gain ) , and 3 months post-training ( maintenance gain ) . We aim to recruit 125 participants , including 20 passive controls and 35 in the other groups . Discussion Current pharmacologic therapies are for symptomatic AD patients , whereas nonpharmacologic training is administrable before symptom onset . Emerging evidence suggests that cognitive training improves cognitive function . However , a more ecologically valid cognitive-motor VR setting that better mimics complex daily activities may augment transfer of trained skills . VR training has benefited clinical cohorts , but benefit in asymptomatic high-risk individuals is unknown . If effective , this trial may help define a prophylactic regimen for AD , adaptable for home-based application in high-risk individuals OBJECTIVE The main objective of this investigation was to assess feasibility of conducting a future RCT with an intradialysis non-immersive virtual reality exercise intervention . The secondary aim was to explore the impact of either conventional or VR exercise on physical function . DESIGN Feasibility r and omized trial . PARTICIPANTS Eighteen subjects who participated in a 16-week intradialysis combined exercise program .  INTERVENTIONS The program lasted four additional weeks of either combined exercise or virtual reality exercise . MAIN OUTCOME MEASURES Physical function was measured through several reliable tests ( sit-to-st and -to-sit tests 10 and 60 , gait speed , one-leg heel-rise tests , and 6-minute walk test ) at baseline , after 16 weeks of intradialysis combined exercise and by the end of four additional weeks of exercise .  Adherence to the exercise programs was registered . RESULTS There was a significant time effect , so that physical function improved in both groups . By the end of the 20 weeks , function improved as measured through the sit-to-st and -to-sit tests 10 and 60 , gait speed , one-leg heel-rise left leg , and the 6-minute walk test . Changes that did not occur due to error in the test were seen after 20 weeks were achieved in the sit-to-st and -to-sit test 60 , gait speed , one-leg heel-rise test for the left leg , and 6-minute walking test . CONCLUSION Virtual reality was a feasible intervention . Both interventions improved physical function . Adherence was not significantly different between groups Background : The purpose of this study is to evaluate the effects of a virtual reality training with BTS Nirvana ( BTS-N ) system in the cognitive and behavioral recovery in patients with Parkinson disease ( PD ) . The BTS-N is a semi-immersive therapy system used for motor and cognitive rehabilitation of patients with neurological diseases , by creating virtual scenarios with which the patient may interact . Methods : We enrolled 20 patients with PD undergoing neurorehabilitation . All the patients were r and omized into 2 groups : experimental group performing semi-immersive virtual reality training with BTS-N and control group undergoing traditional cognitive training . Each participant was evaluated before and immediately after the end of the training . Each cognitive training consisted of 3 sessions a week , each lasting 60 minutes , for 8 weeks , for a total of 24 sessions in each group . Results : Experimental group showed a greater improvement in cognitive functioning , with regard to executive and visuospatial abilities , as compared with the control group . Conclusion : Our findings suggest that rehabilitation through a new virtual reality instrument could be a valuable tool in improving cognitive and behavioral outcomes of patients with PD Background Amyotrophic Lateral Sclerosis ( ALS ) is a rapid progressive neurodegenerative disease , characterized by a selective loss of motor neurons , brain stem and spinal cord which leads to deterioration of motor abilities . Devices that promote interaction with tasks on computers can enhance performance and lead to greater independence and utilization of technology . Objective To evaluate performance on a computer task in individuals with ALS using three different commonly used non-immersive devices . Method Thirty individuals with ALS ( 18 men and 12 women , mean age 59 years , range 44–74 years ) with a mean score of 26 , ( minimum score of 14 and maximum 41 ) on the Revised Amyotrophic Lateral Sclerosis Functional Rating Scale ( ALSFRS-R ) and 30 healthy controls matched for age and gender , participated . All participants were r and omly divided into three groups , each using a different device system ( motion tracking , finger motion control or touchscreen ) to perform three task phases ( acquisition , retention and transfer ) . Results Both the ALS and control group ( CG ) showed better performance on the computer task when using the touchscreen device , but there was limited transfer of performance onto the task performed on the Finger Motion control or motion tracking . However , we found that using the motion tracking device led to transfer of performance to the touchscreen . Conclusion This study presents novel and important findings when selecting interaction devices for individuals with ALS to access technology by demonstrating immediate performance benefits of using a touchscreen device , such as improvement of motor skills . There were possible transferable skills obtained when using virtual systems which may allow flexibility and enable individuals to maintain performance overtime . Trial registration Registration name : Virtual Task in Amyotrophic Lateral Sclerosis ; Registration number : NCT03113630 ; retrospectively registered on 04/13/2017 . Date of enrolment of the first participant to the trial : 02/02/2016 We attempted to evaluate the clinical efficiency of a novel three-dimensional interactive augmented reality system ( 3D-ARS ) for balance and mobility rehabilitation . This system enables participant training with a realistic 3D interactive balance exercise and assessing movement parameters and joint angles by using a kinetic sensor system . We performed a r and omized controlled trial in a general hospital . Thirty-six participants ( age , 56 - 76 years ) who could independently walk and st and on one leg were recruited . The participants were r and omly assigned to either group . The control group ( n = 18 ) underwent a conventional physical fitness program such as lower-extremity strengthening and balance training thrice per week for 1 month . The experimental group ( n = 18 ) experienced 3D-ARS training thrice per week ( 1 session = 30 minutes ) for 4 weeks . Training comprised a balloon game for hip exercise , cave game for knee exercise , and rhythm game for one-leg balance exercise . Lower-extremity clinical scale scores , fall index , and automatic balance score were measured by using Tetrax ® posturography before , during , and after training . Significant group ( 3D-ARS vs. control ) × time ( before and after exercise ) interaction effect was observed for Berg balance scale ( BBS ) scores ( p = 0.04 ) and timed-up- and -go ( TUG ; p < 0.001 ) . Overall improvements occurred in stability index , weight distribution index , fall risk index , and Fourier transformations index of posturography for both groups . However , score changes were significantly greater in the 3D-ARS group . Significant group × time interaction effect was observed for the fall risk index . This demonstrates that the 3D-ARS system can improve balance in the elderly more effectively BACKGROUND Falls are frequent in Parkinson 's disease and ageing . Impairments in the cholinergic-mediated attentional supervision of gait may contribute to increased fall risk , especially when obstacles challenge gait . Interventions combining motor-cognitive approaches have been shown to improve motor performance , cognitive skills and falls number . Here , we hypothesized that an intervention simulating an attention-dem and ing walking condition could impact not only complex gait performance and fall risk but also short-latency afferent inhibition ( SAI ) , as a marker of cholinergic activity . METHODS Thirty-nine participants at falls risk ( 24 Parkinson 's disease subjects and 15 older adults ) were recruited in a r and omized controlled trial . Participants were assigned to treadmill training or treadmill training with non-immersive virtual reality intervention and trained 3 times a week for 6 weeks . SAI , a transcranial magnetic stimulation paradigm , was used to assess cholinergic activity . Gait kinematics was measured during usual walking and while negotiating physical obstacles . Transcranial magnetic stimulation and gait assessment s were performed pre , post , and 6 months post intervention . RESULTS Treadmill training combined with non-immersive virtual reality induced an increase in inhibition of the SAI protocol on cortical excitability , improved obstacle negotiation performance and induced a reduction of the number of falls compared to treadmill training . Furthermore , the more SAI increased after training , the more the obstacle negotiation performance improved and fall rate decreased There is conflict regarding the benefits of greater amounts of intensive upper limb rehabilitation in the early period post-stroke . This study was conducted to test the feasibility of providing intensive therapy during the early period post-stroke and to develop a r and omized control trial that is currently in process . Specifically , the study investigated whether an additional 8 h of specialized , intensive ( 200–300 separate h and or arm movements per hour ) virtual reality (VR)/robotic based upper limb training introduced within 1-month post-stroke result ed in greater improvement in impairment and behavior , and distinct changes in cortical reorganization measured via Transcranial Magnetic Stimulation ( TMS ) , compared to that of a control group . Seven subjects received 8–1 h sessions of upper limb VR/robotic training in addition to their inpatient therapy ( PT , OT , ST ) . Six subjects only received their inpatient therapy .  All were tested on measures of impairment [ Upper Extremity Fugl-Meyer Assessment ( UEFMA ) , Wrist AROM , Maximum Pinch Force ] , behavior [ Wolf Motor Function Test ( WMFT ) ] , and also received TMS mapping until 6 months post training . ANOVAs were conducted to measure differences between groups across time for all outcome measures . Associations between changes in ipsilesional cortical maps during the early period of enhanced neuroplasticity and long-term changes in upper limb impairment and behavior measures were evaluated . The VR/robotic group made significantly greater improvements on UEFMA and Wrist AROM scores compared to the usual care group . There was also less variability in the association between changes in the First Dorsal Interosseus ( FDI ) muscle map area and WMFT and Maximum Force change scores for the VR/robotic group . An additional 8 h of intensive VR/robotic based upper limb training initiated within the first month post-stroke may promote greater gains in impairment compared to usual care alone . Importantly , the data presented demonstrated the feasibility of conducting this intervention and multiple outcome measures ( impairment , behavioral , neurophysiological ) in the early period post-stroke
: Objective : the objective of this review is to analyze the advances in the field of rehabilitation through virtual reality , while taking into account non-immersive systems , as evidence have them shown to be highly accepted by older people , due to the lowest " cibersikness " symptomatology .
DATA SYNTHESIS VR ( Virtual Reality ) creates artificial environments with the possibility of a patient interaction .