Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial

Abstract

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 2590412.

Figure 1

Motor exercises in the virtual environment. The two scenarios (VRRS® Khymeia Group, Ltd. Noventa Padovana. Italy) represent: A) a simple reaching movement: the patient has to raise the red glass and place it among the blue glasses on the shelf, according to a pre-recorded path (yellow line); B) a complex movement of increasing difficulty: the patient has to move the blue ball through the orange circles. The green box represents the start zone, while the yellow box represents the end zone to reach, following the circular-like displayed path.

Figure 2

Scatter plot of the Fugl - Meyer Upper Extremity scores before and after treatment. Fitted models in the RFVE and ULC groups are displayed in dashed and dotted line, respectively. The plot shows the better score at F-M UE scale after RFVE compared with ULC therapy, adjusted for the severity of pre treatment motor impairment. Empty circle (о) represents individual F-M UE score of the RFVE patients group, cross symbol (+) represents individual F-M UE score of the ULC patients group.

Figure 3

Scatter plot of the Functional Independence Measure scores before and after treatment. Fitted models in the RFVE and ULC groups are displayed in dashed and dotted line, respectively. The plot shows the better score at FIM scale after RFVE compared with ULC therapy, adjusted for the severity of pre treatment motor impairment. Empty circle (о) represents individual FIM score of the RFVE patients group, cross symbol (+) represents individual FIM score of the UCL patients group.