Virtual Reality-based Balance Training Research Articles

Interventions to Improve Standing Balance in Individuals With Incomplete Spinal Cord Injury: A Systematic Review and Meta-Analysis.

Incomplete spinal cord injury (iSCI) often results in impaired balance leading to functional impairments. Recovery of standing balance ability is an important aim of rehabilitative programs. However, limited information is available on effective balance training protocols for individuals with iSCI. To assess the methodological quality and effectiveness of various rehabilitation interventions for improving standing balance in individuals with iSCI. A systematic search was performed in SCOPUS, PEDro, PubMed, and Web of Science from inception until March 2021. Two independent reviewers screened articles for inclusion, extracted data, and evaluated methodological quality of the trials. PEDro Scale was used to assess the quality of randomized controlled trials (RCT) and crossover studies while pre-post trials were assessed using the modified Downs and Black tool. A meta-analysis was performed to quantitatively describe the results. The random effects model was applied to present the pooled effect. Ten RCTs with a total of 222 participants and 15 pre-post trials with 967 participants were analyzed. The mean PEDro score and modified Downs and Black score was 7/10 and 6/9, respectively. The pooled standardized mean difference (SMD) for controlled and uncontrolled trials of body weight-supported training (BWST) interventions was -0.26 (95% CI, -0.70 to 0.18; p = .25) and 0.46 (95% CI, 0.33 to 0.59; p < .001), respectively. The pooled effect size of -0.98 (95% CI, -1.93 to -0.03; p = .04) indicated significant improvements in balance after a combination of BWST and stimulation. Pre-post studies analyzing the effect of virtual reality (VR) training interventions on Berg Balance Scale (BBS) scores in individuals with iSCI reported a mean difference (MD) of 4.22 (95% CI, 1.78 to 6.66; p = .0007). Small effect sizes were seen in pre-post studies of VR+stimulation and aerobic exercise training interventions indicating no significant improvements after training on standing balance measures. This study demonstrated weak evidence to support the use of BWST interventions for overground training for balance rehabilitation in individuals with iSCI. A combination of BWST with stimulation however showed promising results. There is a need for further RCTs in this field to generalize findings. Virtual reality-based balance training has shown significant improvement in standing balance post iSCI. However, these results are based on single group pre-post trials and lack appropriately powered RCTs involving a larger sample size to support this intervention. Given the importance of balance control underpinning all aspects of daily activities, there is a need for further well-designed and appropriately powered RCTs to evaluate specific features of training interventions to improve standing balance function in iSCI.

Portable neuroimaging and biped multi-task battery to study the effects of non-invasive cerebellar stimulation: a case series on hemiplegic patients with and without basal ganglia lesion

Abstract Introduction: The cerebello-thalamo-cortical(CTC) pathway plays a crucial role in postural control and balance. CTC pathway can be facilitated with cerebellar transcranial Direct Current Stimulation(ctDCS) while cortical responses can be measured with portable neuroimaging[1] that was investigated on stroke survivors with and without basal ganglia infarction. Methods: Twelve stroke survivors participated in a single-blind randomized-order crossover study on bipolar ctDCS targeting bilateral dentate nuclei and motor region of cerebellum(details in [1]). Current study investigated two subjects with basal ganglia(BG) lesions based on ctDCS effects on their performance during multi-task battery of overground/treadmill walking, standing weight-shifting(virtual reality-based balance training(VBaT)[2]) as-well-as brain activation at prefrontal cortex(PFC) and sensorimotor cortex(SMC) based on functional near-infrared spectroscopy(fNIRS) and electroencephalogram(EEG). Results: VBaT system identified directional weight-shifting dysfunction(measured by irregularity/sway in center of pressure trajectory) and dynamic variability(measured by coefficient of variation of step time and stride time characterizing walking). The ctDCS intervention did not affect performance in BG-lesion cases(when compared to others[1]). BG-lesioned cases did not fit general linear model well that putatively associated lobular electric field strength with changes in fNIRS-EEG measures at ipsilesional and contra-lesional PFC and SMC[1]. Furthermore, post-ctDCS cerebrovascular reactivity to ctDCS[3] was not significant in BG-lesioned cases while they were significantly(p<0.05) different between the hemispheres in other subjects. Conclusion: Deterioration in biped multi-task performance is postulated to be related to reduced error-correction ability because of BG infarction. Here, cerebrovascular reactivity to ctDCS[3] is postulated to identify responders where BG infarction may affected cerebello-cortical pathway[4] that needs investigation in a larger cohort.

Feasibility of combining functional near-infrared spectroscopy with electroencephalography to identify chronic stroke responders to cerebellar transcranial direct current stimulation-a computational modeling and portable neuroimaging methodological study.

Feasibility of portable neuroimaging of cerebellar transcranial direct current stimulation (ctDCS) effects on the cerebral cortex has not been investigated vis-à-vis cerebellar lobular electric field strength. We studied functional near-infrared spectroscopy (fNIRS) in conjunction with electroencephalography (EEG) to measure changes in the brain activation at the prefrontal cortex (PFC) and the sensorimotor cortex (SMC) following ctDCS as well as virtual reality-based balance training (VBaT) before and after ctDCS treatment in 12 hemiparetic chronic stroke survivors. We performed general linear modeling (GLM) that putatively associated the lobular electric field strength with the changes in the fNIRS-EEG measures at the ipsilesional and contra-lesional PFC and SMC. Here, fNIRS-EEG measures were found in the latent space from canonical correlation analysis (CCA) between the changes in total hemoglobin (tHb) concentrations (0.01-0.07Hz and 0.07-0.13Hz bands) and log10-transformed EEG bandpower within 1-45 Hz where significant (Wilks' lambda>0.95) canonical correlations were found only for the 0.07-0.13-Hz band. Also, the first principal component (97.5% variance accounted for) of the mean lobular electric field strength was a good predictor of the latent variables of oxy-hemoglobin (O2Hb) concentrations and log10-transformed EEG bandpower. GLM also provided insights into non-responders to ctDCS who also performed poorly in the VBaT due to ideomotor apraxia. Future studies should investigate fNIRS-EEG joint-imaging in a larger cohort to identify non-responders based on GLM fitting to the fNIRS-EEG data.

Exer-gaming reduces fall risk and improves mobility after stroke.

The current study evaluated the effect of virtual reality based balance training in 30 stroke patients recruited via purposive sampling technique for a clinical trial. Sealed envelope method was used to randomly allocate patients into two groups, i.e. Exer-gaming group (EGG) (n=15) and traditional training (TBT) group (n=15). Patients ranging in age from 50 to 60 years were included using Modified Rankin Scale (MRS). Patients with cognitive deficits, severe physical impairments, contractures, inability to perform tasks, complications of the joint that affected movement, history of recent fracture, arthritis and those on drugs that could affect their physical function were excluded. Data was collected using Berg Balance Scale (BBS) and Timed Up & Go Test (TUG). Significant improvement was observed in the exer-gaming training group after completing intervention (P<0.001). Exer-gaming appears to be more effective in improving functional level, mobility and balance in stroke patients. The study also suggests that exer-gaming further provides dynamic environment for stroke patients, thereby improving dynamic balance and mobility.

Efficacy of Electrical Stimulation-Augmented Virtual Reality Training in Improving Balance in Individuals with Incomplete Spinal Cord Injury: Study Protocol of a Randomized Controlled Trial.

Study DesignThis study is a single-blind, parallel, three-group, and randomized controlled trial.PurposeThis study aimed to investigate the effectiveness of electrical stimulation-augmented virtual reality training in improving balance in individuals with incomplete spinal cord injury (iSCI).Overview of LiteratureIndividuals with iSCI often face significant balance and mobility impairments affecting their quality of life. Scientific studies focusing on standing balance training in the iSCI population are limited. Virtual reality-based balance training has shown positive results in several neurological populations. Electrical stimulation has also proved to be effective in improving voluntary muscle strength in partially paralyzed muscles after iSCI as well as promoting neuroplasticity.MethodsForty-eight iSCI participants will be recruited based on the inclusion criteria. The participants will be randomly assigned to any of the three groups: virtual reality-based balance training along with the electrical stimulation group, virtual reality-based balance training along with sham stimulation group, or virtual reality-based balance training group. The intervention will be delivered as 60-minute sessions, thrice a week for 4 weeks.ResultsThe performance of the participants will be assessed using the lower extremity motor score, static and dynamic balance assessment using TechnoBody ProKin tilting platform and Berg Balance Scale, Walking Index for Spinal Cord Injury, and World Health Organization Quality of Life-BREF at pre-intervention, after 4 weeks post-intervention, and at 1-month follow-up.ConclusionsThe trial will provide new knowledge about the effectiveness of electrical stimulation-augmented virtual reality training in improving balance in individuals with iSCI. The study results will contribute to the design of better rehabilitation programs for individuals with iSCI.

Feasibility of a Short-Term Virtual Reality Balance Intervention to Improve Mobility Smoothness in Parkinson's Disease

Parkinson’s disease (PD) is a neurodegenerative condition often associated with reduced balance and gait control. Virtual reality (VR) is a promising intervention for enhancing rehabilitation efficiency and may assist in overcoming functional limitations. The objective of this study was to evaluate the feasibility, safety and efficacy of a 5-weeks VR intervention in increasing mobility smoothness in participants with PD. Participants were assessed using functional mobility tasks - Timed Up and Go (TUG) and 10-meter walking test (10MWT) and cognitive function tests. A total of 23 participants with a diagnosis of PD were randomly assigned to groups of VR or control interventions. In the VR group, for each session, participants received a VR–based balance training, for 20 minutes, preceded by 8 minutes of total body warm-up (total of 10 sessions over five weeks). Participants in the control group received 20 minutes of psychoeducation without a structured exercise program (twice a week). All screened participants engaged and completed a total of 10 VR-based intervention sessions. VR-based balance training caused no significant improvement in mobility smoothness for TUG or 10MWT (p > 0.05). Similarly, cognitive function was not affected by the VR intervention (p > 0.05). The outcomes of this study suggest that ten-twenty minutes of VR-based intervention is a feasible and safe rehabilitation activity. However, it was insufficient to promote improvement in mobility smoothness and cognitive function in participants with PD. A combination of task-specific training in the virtual and physical environments is warranted for future study designs.

Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury.

Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses. A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit. Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy. As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance. The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury. These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.

Virtual reality-based balance training system augmented with operant conditioning paradigm

BackgroundStroke-related sensory and motor deficits often steal away the independent mobility and balance from stroke survivors. Often, this compels the stroke survivors to rely heavily on their non-paretic leg during weight shifting to execute activities of daily living (ADL), with reduced usage of the paretic leg. Increased reliance on non-paretic leg often leads to learned nonuse of the paretic leg. Therefore, it is necessary to measure the contribution of individual legs toward one’s overall balance. In turn, techniques can be developed to condition the usage of both the legs during one’s balance training, thereby encouraging the hemiplegic patients for increased use of their paretic leg. The aim of this study is to (1) develop a virtual reality (VR)-based balance training platform that can estimate the contribution of each leg during VR-based weight-shifting tasks in an individualized manner and (2) understand the implication of operant conditioning paradigm during balance training on the overall balance of hemiplegic stroke patients.ResultTwenty-nine hemiplegic patients participated in a single session of VR-based balance training. The participants maneuvered virtual objects in the virtual environment using two Wii Balance Boards that measured displacement in the center of pressure (CoP) due to each leg when one performed weight-shifting tasks. For operant conditioning, the weight distribution across both the legs was conditioned (during normal trial) to reward participants for increased usage of the paretic leg during the weight-shifting task. The participants were offered multiple levels of normal trials with intermediate catch trial (with equal weight distribution between both legs) in an individualized manner. The effect of operant conditioning during the normal trials was measured in the following catch trials. The participants showed significantly improved performance in the final catch trial compared to their initial catch trial task. Also, the enhancement in CoP displacement of the paretic leg was significant in the final catch trial compared to the initial catch trial.ConclusionThe developed system was able to encourage participants for improved usage of their paretic leg during weight-shifting tasks. Such an approach has the potential to address the issue of learned nonuse of the paretic leg in stroke patients.

The effect of virtual reality-based balance training on motor learning and postural control in healthy adults: a randomized preliminary study

BackgroundAdults with sedentary lifestyles seem to face a higher risk of falling in their later years. Several causes, such as impairment of strength, coordination, and cognitive function, influence worsening health conditions, including balancing ability. Many modalities can be applied to improve the balance function and prevent falling. Several studies have also recorded the effects of balance training in elderly adults for fall prevention. Accordingly, the aim of this study is to define the effect of virtual reality-based balance training on motor learning and postural control abilities in healthy adults.MethodsFor this study, ten subjects were randomly allocated into either the conventional exercise (CON) or the virtual reality (VR) group. The CON group underwent physical balance training, while the VR group used the virtual reality system 4 weeks. In the VR group, the scores from three game modes were utilized to describe the effect of motor learning and define the learning curves that were derived with the power law function. Wilcoxon Signed Ranks Test was performed to analyze the postural control in five standing tasks, and data were collected with the help of a force plate.ResultsThe average score was used to describe the effect of motor learning by deriving the mathematical models for determining the learning curve. Additionally, the models were classified into two exponential functions that relied on the aim and requirement skills. A negative exponential function was observed in the game mode, which requires the cognitive-motor function. In contrast, a positive exponential function was found in the game with use of only the motor skill. Moreover, this curve and its model were also used to describe the effect of learning in the long term and the ratio of difficulty in each game. In the balance performance, there was a significant decrease in the center of pressure parameters in the VR group, while in the CON group, there was a significant increase in the parameters during some foot placements, especially in the medio-lateral direction.ConclusionThe proposed VR-based training relies on the effect of motor learning in long-term training though different kinds of task training. In postural analysis, both exercise programs are emphasized to improve the balance ability in healthy adults. However, the virtual reality system can promote better outcomes to improve postural control post exercising.Trial registration Retrospectively registered on 25 April 2018. Trial number TCTR20180430005

Efficacy of virtual reality-based balance training versus the Biodex balance system training on the body balance of adults.

[Purpose] This study investigated efficacy of virtual reality (VR)-based balance training on enhancing balance and postural reactions of adults as a low-cost new modality compared to the established Biodex Balance System (BBS). [Subjects] Thirty normal adults of both genders were divided randomly into two equal-sized experimental groups of 15: BBS balance training and VR balance training. [Methods] The training programmes were conducted in 12 sessions, three 15-min sessions per week. The Nintendo® Wii Fit Plus (NWFP) and its balance board were used to train of the VR group. Each participant answered a questionnaire concerning usability, enjoyment, balance improvement, and fatigue at the end of the training programs. [Results] The study found a significant increase the measure of mean overall balance (OLB) in both groups. No significant difference was found between the groups, but a significant decrease in the mean balance-test time was found for both groups, with no significant difference between the two training methods. The VR programme was rated highly enjoyable by 81.8% of the group. [Conclusion] The Wii Fit Plus system with the balance board as a new VR balance-training technique, can be considered an effective and enjoyable tool for the training of adults’ body balance.

Effect of virtual reality-based balance training in multiple sclerosis

Objectives:Balance and mobility impairments are common life-altering complications in patients with multiple sclerosis (MS). In this study, we aimed to investigate the efficacy of a short-term virtual reality (VR)-based balance training program on the balance ability of patients with MS.Methods:In this randomized controlled trial, 30 patients with relapsing–remitting or secondary-progressive MS were randomly assigned to an intervention or a control group. The intervention group performed a balance training program [postural stability training program (PST)] using the Biodex Balance System SD. Subjects in both groups were assessed using the manual muscle test (MMT), timed ‘up and go’ (TUG) test, the modified Ashworth scale, the Romberg test, the Berg balance scale (BBS), and the fall risk and postural stability tests, at baseline and after 12 weeks.Results:The TUG, fall risk index (FRi), and overall stability index (OSI) were significantly improved in the intervention group after 24 sessions of balance training. The changes in TUG, Fri, and OSi indices in the intervention group were significantly higher than the control group.Discussion:According to the fall risk and postural stability tests results, the VR-based balance training program could improve the balance ability of the patients with MS.

The Effects of Virtual Reality-based Balance Training on Balance of the Elderly.

[Purpose] The objective of this study was to determine the effects of virtual reality-based balance training on balance of the elderly. [Methods] The subjects were 32 healthy elderly people aged between 65 and 80, who were divided into a VR (virtual reality) training group (n=17) and a control group (n=15). The VR training group engaged in a 30-minute exercise session using Wii Fit three times a week for eight weeks, while the control group received no intervention. The balance of the two groups was measured before and after the intervention. [Results] According to the Romberg Test conducted to examine the effects of the training on balance, both the area covered by the body’s center of pressure movement, and movement distances per unit area of the body’s center of pressure envelope significantly decreased in the VR training group. Moreover, the two groups showed significant differences in balance. [Conclusion] Virtual reality training is effective at improving the balance of the healthy elderly. Thus, virtual reality training can be proposed as a form of fall prevention exercise for the elderly.

The Effect of Virtual Reality-based Balance Training in Multiple Sclerosis

To investigate the short term effects of 12 week balance training on postural stability in persons with Multiple Sclerosis (MS). A randomized controlled trial. Rehabilitation education and research hospital. Thirty MS patients (22 female, 8 male) were assigned randomly to training (n=15) or control group (n=15). No participant withdrew. Participants stood over a dual force platform (Biodex Balance System) and performed visually guided weight-shifting movements. The task required subjects to gradually transfer weight between sides during a 12-week training period (2 training sessions per week), and the control group maintained their usual lifestyle. Berg Balance scale (BBS), Postural Stability test, Falling Risk, Timed up and go test (TUG) and Modified Ashworth Scale. All outcomes were measured before and after intervention. After 24 training sessions the mean BBS, Postural stability, Falling risk and TUG improvements were 0.20±0.4, 0.44±0.51, 1.48±1.10 and 0.66±0.72 in the training group and 0.26±0.7, 0.08±0.4, 0.26±1.16 and 0.20±1.08 in the control group (P=0.018, P=0.007, P= 0.004, P=0.21 respectively). This study demonstrated that this type of 12 weeks balance training could improve the outcomes in terms of BBS, fall risk and postural stability in MS population in short term. Long term follow ups before recommending this kind of balance training are needed.

Locomotor Training and Virtual Reality-based Balance Training for an Individual with Multiple Sclerosis

Impaired walking ability, balance, and fatigue are common problems for people with multiple sclerosis (MS). The purpose of this case report is to describe the use of plan of care that included locomotor training using both a body weight support (BWS) with a treadmill (TM) and overground walking as well as a virtual reality (VR)-based balance intervention to improve walking ability, balance, and endurance for an individual with MS. The client was a 48-year-old female with a 10-year history of MS. Her main goals were to improve walking ability, balance, and endurance. She presented with impaired gait, balance, motor function, and increased fatigue. Locomotor training using a BWS/TM system and overground and VR-based balance interventions were implemented 2 days a week for 12 weeks. The client demonstrated improvements in gait speed, gait endurance, and balance postintervention and maintained the improvements at a 2-month follow up. This case report is the first to report on the use of locomotor training with BWS/TM system and overground and VR-based balance interventions for a client with MS. The plan of care was formulated based on the patient's goals and the available literature on the use of the interventions with other patients with neurologic conditions to provide an intervention that was task-oriented, skilled, and intensive.