Advanced virtual reality-based rehabilitation of balance and gait in clinical practice

Abstract

Background: Extensive research shows that virtual reality (VR) enhances motor learning and has advantages in balance and gait rehabilitation of neurological patients. There is still uncertainty, however, as for the practicality and efficacy of VR in long-term clinical routine. The objective of this study was to report on 3 years of clinical practice conducting VR-based rehabilitation of balance and gait in a large medical center.

Methods: This retrospective study systematically analyzed clinical records of patients who received VR-based rehabilitation in a large rehabilitation center during 3 years. We evaluated the effect of VR-based rehabilitation treatments on balance and gait, cognitive dual-task load, patient's balance confidence (ABC-scale) and perception of suitability. Patients were either neurological patients, allocated to five groups: Parkinson's disease (PD), poststroke (PS), multiple sclerosis, traumatic brain injury, and 'other conditions', or non-neurological patients.

Results: Records of 167 patients were analyzed. The availability of multiple VR systems and environments contributed to highly personalized interventions that tailored specific deficits with therapeutic goals. VR-based rehabilitation significantly improved balance and gait (measured by 10-Meter Walk Test, Timed-Up-and-Go, Berg Balance Scale, and Mini BESTest). Patients with PD and PS decreased dual-task cost while walking. Patients increased balance confidence and deemed VR suitable for rehabilitation.

Conclusions: Our results suggest that VR-based rehabilitation is practicable and effective in clinical routine. Functional measures of balance and gait show significant improvements following VR-based interventions. Clinical approaches should exploit VR advantages for promoting motor learning and motivation. This study serves to aid transition to long-term clinical implementation of VR.

Keywords: Parkinson’s disease; brain injury; multiple sclerosis; posture; rehabilitation; stroke; virtual reality; walking.

Figure 1.

Flow diagram showing treatment steps as part of the routine health service. Each session starts and progresses from the point and achievement of any previous recorded session in each patient. Patients sit or stand when they need to rest during the session. Subjective assessment consists of chart review for medical history, interview patient/family: social history, level of functioning and personal needs, patient’s goals and concerns. Objective assessment comprises observation and examination, functional tests and questionnaires, identifying impairments contributing to loss of function and movement. ICF: International Classification of Functioning, Disability and Health.

Figure 2.

Flow diagram showing medical record inclusion/exclusion for analysis. Of the 263 initially eligible persons, 44 did not proceed to treatment and 11 received additional treatments. Thus, only 208 patients initiated VR treatments, 41 of which were excluded because they did not complete at least one treatment.

Figure 3.

Treatment effects on balance and gait. Boxplots represent subgroup data. The central red line in each box indicates the median, and the upper and lower edges third and first quartile, respectively. Horizontal dashed lines indicate clinical thresholds, that is, MCID or MDC. Thresholds were taken from references published in the literature for each measure, and were found only for some measures and only for PD, PS, and TBI (for threshold values and references see Table e2). Percentages accompanying boxplots indicate the number of patients that, over completing the first treatment, successfully surpassed clinical thresholds. Values >0 indicate improvements for 10MWT, BBS, and miniBEST. Values <0 indicate improvements for TUG and FSST. 10MWT, 10 Meter Walk Test; BBS, Berg Balance Scale; FSST, Four Square Step Test; MiniBESTest, Mini Balance Evaluation Systems Test; MDC, minimal detectable change; MCID, minimal clinically important difference; MS, Multiple Sclerosis; NN, non-neurological conditions; ON, other neurological; PD, Parkinson Disease; PS, Poststroke; TBI, Traumatic Brain Injury; TUG, Timed Up and Go.

Figure 4.

Treatment effects on the Activities-Specific Balance Confidence (ABC) Scale. The central red line in each box indicates the median, and the upper and lower edges third and first quartile, respectively. Subgroups include MS, multiple sclerosis; NN, non-neurological conditions; ON, other neurological; PD, Parkinson disease; PS, poststroke; TBI, traumatic brain injury. The horizontal dashed line represents the minimal detectable change (MDC) in PD. Percentages accompanying PD boxplot indicate patients that, over completing the first treatment, successfully surpassed clinical threshold (MDC); 29% of PD patients surpassed the clinical threshold of 13% (for cohorts with known MCID/MDC, for published values see Table e2).