Virtual Reality Training Using Nintendo Wii Games for Patients With Stroke: Randomized Controlled Trial

Naveed Anwar, Hossein Karimi, Ashfaq Ahmad, Syed Amir Gilani, Kehkshan Khalid, Ahmed Sohaib Aslam, Asif Hanif, Naveed Anwar, Hossein Karimi, Ashfaq Ahmad, Syed Amir Gilani, Kehkshan Khalid, Ahmed Sohaib Aslam, Asif Hanif

Abstract

Background: Stroke is a leading cause of disability. It is difficult to devise an optimal rehabilitation plan once stroke survivors are back home. Conventional rehabilitative therapies are extensively used in patients with stroke to recover motor functioning and disability, but these are arduous and expensive. Virtual reality (VR) video games inspire patients to get involved in their therapeutic exercise routine in a fun way. VR in the form of games provides a fruitful, secure, and challenging learning environment for motor control and neural plasticity development in rehabilitation. The effects of upper limb sensorimotor functioning and balance are the main focus of this trial.

Objective: The aim of this study is to compare the effects of VR training and routine physical therapy on balance and upper extremity sensorimotor function in patients with stroke.

Methods: It was a single assessor-blinded randomized clinical trial. A total of 74 participants with their first chronic stroke were included and rehabilitated in a clinical setting. The lottery method was used to randomly assign patients to either the VR group (n=37) or the routine physical therapy group (n=37). The VR group received a 1-hour session of VR training for 3 weekdays over 6 weeks, and the routine physical therapy group received different stretching and strengthening exercises. The outcome measuring tools were the Berg Balance Scale for balance and the Fugl-Meyer Assessment (upper extremity) scale for sensorimotor, joint pain, and range assessment. The assessment was done at the start of treatment and after the 6 weeks of intervention. Data analysis was done using SPSS 22.

Results: The trial was completed by 68 patients. A significant difference between the two groups was found in the Berg Balance Scale score (P<.001), Fugl-Meyer Assessment for motor function (P=.03), and Fugl-Meyer Assessment for joint pain and joint range (P<.001); however, no significant difference (P=.19) in the Fugl-Meyer Assessment for upper extremity sensation was noted.

Conclusions: VR training is helpful for improving balance and function of the upper extremities in the routine life of patients with stroke; although, it was not found to be better than conventional training in improving upper limb sensation. VR training can be a better option in a rehabilitation plan designed to increase functional capability.

Trial registration: Iranian Registry of Clinical Trials RCT20190715044216N1; https://www.irct.ir/user/trial/40898/view.

Keywords: Fugl-Meyer score; balance; function; physical therapy; randomized controlled trial; rehabilitation; stroke; therapy; training; virtual reality.

Conflict of interest statement

Conflicts of Interest: None declared.

©Naveed Anwar, Hossein Karimi, Ashfaq Ahmad, Syed Amir Gilani, Kehkshan Khalid, Ahmed Sohaib Aslam, Asif Hanif. Originally published in JMIR Serious Games (https://games.jmir.org), 13.06.2022.

Figures

Figure 1
Figure 1
CONSORT (Consolidated Standards of Reporting Trials) flow diagram.

References

    1. Charles D, Holmes D, Charles T, McDonough S. Virtual reality design for stroke rehabilitation. In: Rea PM, editor. Biomedical Visualisation: Volume 6. Cham: Springer; 2020. pp. 53–87.
    1. Singh V, Prabhakaran S, Chaturvedi S, Singhal A, Pandian J. An examination of stroke risk and burden in South Asians. J Stroke Cerebrovasc Dis. 2017 Oct;26(10):2145–2153. doi: 10.1016/j.jstrokecerebrovasdis.2017.04.036.S1052-3057(17)30210-0
    1. Saposnik G, Teasell R, Mamdani M, Hall J, McIlroy W, Cheung D, Thorpe KE, Cohen LG, Bayley M, Stroke Outcome Research Canada (SORCan) Working Group Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: a pilot randomized clinical trial and proof of principle. Stroke. 2010 Jul;41(7):1477–84. doi: 10.1161/STROKEAHA.110.584979. STROKEAHA.110.584979
    1. Williams EI, Betterton RD, Davis TP, Ronaldson PT. Transporter-mediated delivery of small molecule drugs to the brain: a critical mechanism that can advance therapeutic development for ischemic stroke. Pharmaceutics. 2020 Feb 14;12(2):154. doi: 10.3390/pharmaceutics12020154. pharmaceutics12020154
    1. Glegg SMN, Levac DE. Barriers, facilitators and interventions to support virtual reality implementation in rehabilitation: a scoping review. PM R. 2018 Nov;10(11):1237–1251.e1. doi: 10.1016/j.pmrj.2018.07.004. S1934-1482(18)30381-2
    1. Patel BM, Reinert NJ, Al-Robaidi K, Gao X, Fabio A, Esper SA, Muluk V, Jadhav A, Thirumala PD. Independent predictors of perioperative stroke-related mortality after cardiac surgery. J Stroke Cerebrovasc Dis. 2020 May;29(5):104711. doi: 10.1016/j.jstrokecerebrovasdis.2020.104711.S1052-3057(20)30087-2
    1. Long Y, Ouyang R, Zhang J. Effects of virtual reality training on occupational performance and self-efficacy of patients with stroke: a randomized controlled trial. J Neuroeng Rehabil. 2020 Nov 13;17(1):150. doi: 10.1186/s12984-020-00783-2. 10.1186/s12984-020-00783-2
    1. Stinear CM, Lang CE, Zeiler S, Byblow WD. Advances and challenges in stroke rehabilitation. Lancet Neurol. 2020 Apr;19(4):348–360. doi: 10.1016/S1474-4422(19)30415-6.S1474-4422(19)30415-6
    1. Cortes M, Elder J, Rykman A, Murray L, Avedissian M, Stampas A, Thickbroom GW, Pascual-Leone A, Krebs HI, Valls-Sole J, Edwards DJ. Improved motor performance in chronic spinal cord injury following upper-limb robotic training. NeuroRehabilitation. 2013;33(1):57–65. doi: 10.3233/NRE-130928.9U573632U5534044
    1. Van der Loos M. Virtual reality video games make rehab fun for younger patients. Vancouver Coastal Health Research Institute. 2019. Sep 23, [2022-06-08]. .
    1. Aramaki AL, Sampaio RF, Cavalcanti A, Dutra FCMSE. Use of client-centered virtual reality in rehabilitation after stroke: a feasibility study. Arq Neuropsiquiatr. 2019;77(9):622–631. doi: 10.1590/0004-282X20190103. S0004-282X2019000900622
    1. Levin MF, Demers M. Motor learning in neurological rehabilitation. Disabil Rehabil. 2021 Dec;43(24):3445–3453. doi: 10.1080/09638288.2020.1752317.
    1. Demers M, Fung K, Subramanian SK, Lemay M, Robert MT. Integration of motor learning principles into virtual reality interventions for individuals with cerebral palsy: systematic review. JMIR Serious Games. 2021 Apr 07;9(2):e23822. doi: 10.2196/23822. v9i2e23822
    1. Nomani AZ, Iqbal M, Jamil U, Nabi S, Mughal S, Badshah M, Majeed H, Yasin Khan RS. Etiology of stroke in young pakistani adults; results of a single center study. Pakistan J Neurol Sci. 2015;10(4):18–22.
    1. Hashmi M, Khan M, Wasay M. Growing burden of stroke in Pakistan: a review of progress and limitations. Int J Stroke. 2013 Oct;8(7):575–81. doi: 10.1111/j.1747-4949.2012.00827.x.
    1. Anwar N, Karimi H, Ahmad A, Mumtaz N, Saqulain G, Gilani SA. A novel virtual reality training strategy for poststroke patients: a randomized clinical trial. J Healthc Eng. 2021;2021:6598726. doi: 10.1155/2021/6598726.
    1. Yeh S, Lee S, Chan R, Wu Y, Zheng L, Flynn S. The efficacy of a haptic-enhanced virtual reality system for precision grasp acquisition in stroke rehabilitation. J Healthc Eng. 2017;2017:9840273. doi: 10.1155/2017/9840273.
    1. Gladstone DJ, Danells CJ, Black SE. The fugl-meyer assessment of motor recovery after stroke: a critical review of its measurement properties. Neurorehabil Neural Repair. 2002 Sep;16(3):232–40. doi: 10.1177/154596802401105171.
    1. Downs S, Marquez J, Chiarelli P. The Berg Balance Scale has high intra- and inter-rater reliability but absolute reliability varies across the scale: a systematic review. J Physiother. 2013 Jun;59(2):93–9. doi: 10.1016/S1836-9553(13)70161-9. S1836-9553(13)70161-9
    1. Holden MK, Dyar T. Virtual environment training: a new tool for neurorehabilitation. Neurol Rep. 2002;26(2):62–71. doi: 10.1097/01253086-200226020-00003.
    1. Sample size for before-after study (Paired T-test) Sample Size Calculators. [2017-07-18].
    1. Yoon J, Chun MH, Lee SJ, Kim BR. Effect of virtual reality-based rehabilitation on upper-extremity function in patients with brain tumor: controlled trial. Am J Phys Med Rehabil. 2015 Jun;94(6):449–59. doi: 10.1097/PHM.0000000000000192.
    1. Jeon M, Moon J, Cho H. Effects of virtual reality combined with balance training on upper limb function, balance, and activities of daily living in persons with acute stroke: a preliminary study. Phys Ther Rehabil Sci. 2019 Dec 30;8(4):187–193. doi: 10.14474/ptrs.2019.8.4.187.
    1. Aramaki AL, Sampaio RF, Reis ACS, Cavalcanti A, Dutra FCMSE. Virtual reality in the rehabilitation of patients with stroke: an integrative review. Arq Neuropsiquiatr. 2019 May 13;77(4):268–278. doi: 10.1590/0004-282X20190025. S0004-282X2019000400268
    1. Lee HS, Park YJ, Park SW. The effects of virtual reality training on function in chronic stroke patients: a systematic review and meta-analysis. Biomed Res Int. 2019;2019:7595639. doi: 10.1155/2019/7595639.
    1. Noveletto F, Soares AV, Mello BA, Sevegnani CN, Eichinger FLF, Hounsell MDS, Bertemes-Filho P. Biomedical serious game system for balance rehabilitation of hemiparetic stroke patients. IEEE Trans Neural Syst Rehabil Eng. 2018 Nov;26(11):2179–2188. doi: 10.1109/TNSRE.2018.2876670.
    1. Kim N, Park Y, Lee B. Effects of community-based virtual reality treadmill training on balance ability in patients with chronic stroke. J Phys Ther Sci. 2015 Mar;27(3):655–8. doi: 10.1589/jpts.27.655. jpts-2014-536
    1. Maier M, Rubio Ballester B, Duff A, Duarte Oller E, Verschure PFMJ. Effect of specific over nonspecific VR-based rehabilitation on poststroke motor recovery: a systematic meta-analysis. Neurorehabil Neural Repair. 2019 Feb;33(2):112–129. doi: 10.1177/1545968318820169.
    1. Huang Q, Wu W, Chen X, Wu B, Wu L, Huang X, Jiang S, Huang L. Evaluating the effect and mechanism of upper limb motor function recovery induced by immersive virtual-reality-based rehabilitation for subacute stroke subjects: study protocol for a randomized controlled trial. Trials. 2019 Feb 06;20(1):104. doi: 10.1186/s13063-019-3177-y. 10.1186/s13063-019-3177-y
    1. Serrada I, Hordacre B, Hillier SL. Does sensory retraining improve sensation and sensorimotor function following stroke: a systematic review and meta-analysis. Front Neurosci. 2019;13:402. doi: 10.3389/fnins.2019.00402.
    1. Aşkın A, Atar E, Koçyiğit H, Tosun A. Effects of Kinect-based virtual reality game training on upper extremity motor recovery in chronic stroke. Somatosens Mot Res. 2018 Mar;35(1):25–32. doi: 10.1080/08990220.2018.1444599.
    1. Huang X, Naghdy F, Naghdy G, Du H, Todd C. The combined effects of adaptive control and virtual reality on robot-assisted fine hand motion rehabilitation in chronic stroke patients: a case study. J Stroke Cerebrovasc Dis. 2018 Jan;27(1):221–228. doi: 10.1016/j.jstrokecerebrovasdis.2017.08.027.S1052-3057(17)30437-8
    1. Choi Y, Paik N. Mobile game-based virtual reality program for upper extremity stroke rehabilitation. J Vis Exp. 2018 Mar 08;133:56241. doi: 10.3791/56241.
    1. Shahrbanian S, Ma X, Aghaei N, Korner-Bitensky N, Moshiri K, Simmonds MJ. Use of virtual reality (immersive vs. non immersive) for pain management in children and adults: a systematic review of evidence from randomized controlled trials. Eur J Exp Biol. 2012:1408–1422.
    1. Powell W, Simmonds MJ. Virtual reality and musculoskeletal pain: manipulating sensory cues to improve motor performance during walking. Cyberpsychol Behav Soc Netw. 2014 Jun;17(6):390–6. doi: 10.1089/cyber.2014.0061.
    1. Triberti S, Repetto C, Riva G. Psychological factors influencing the effectiveness of virtual reality-based analgesia: a systematic review. Cyberpsychol Behav Soc Netw. 2014 Jun;17(6):335–45. doi: 10.1089/cyber.2014.0054.
    1. Georgiev D, Georgieva I, Gong Z, Nanjappan V, Georgiev G. Virtual reality for neurorehabilitation and cognitive enhancement. Brain Sci. 2021 Feb 11;11(2):221. doi: 10.3390/brainsci11020221. brainsci11020221
    1. Pintado-Izquierdo S, Cano-de-la-Cuerda R, Ortiz-Gutiérrez RM. Video game-based therapy on balance and gait of patients with stroke: a systematic review. Appl Sci. 2020 Sep 15;10(18):6426. doi: 10.3390/app10186426.

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner