Advantages of using 3D virtual reality based training in persons with Parkinson's disease: a parallel study

Imre Cikajlo, Karmen Peterlin Potisk, Imre Cikajlo, Karmen Peterlin Potisk

Abstract

Background: Parkinson's disease (PD) is a slowly progressive neurodegenerative disease. There are mixed reports on success of physiotherapy in patients with PD. Our objective was to investigate the functional improvements, motivation aspects and clinical effectiveness when using immersive 3D virtual reality versus non-immersive 2D exergaming.

Methods: We designed a randomized parallel study with 97 patients, but only 20 eligible participants were randomized in 2 groups; the one using 3D Oculus Rift CV1 and the other using a laptop. Both groups participated in the 10-session 3 weeks training with a pick and place task in the virtual world requiring precise hand movement to manipulate the virtual cubes. The kinematics of the hand was traced with Leap motion controller, motivation effect was assessed with modified Intrinsic Motivation Inventory and clinical effectiveness was evaluated with Box & Blocks Test (BBT) and shortened Unified Parkinson's disease rating scale (UPDRS) before and after the training. Mack-Skilling non-parametrical statistical test was used to identify statistically significant differences (p < 0.05) and Cohen's U3 test to find the effect sizes.

Results: Participants in the 3D group demonstrated statistically significant and substantially better performance in average time of manipulation (group x time, p = 0.009), number of successfully placed cubes (group x time, p = 0.028), average tremor (group x time, p = 0.002) and UPDRS for upper limb (U3 = 0.35). The LCD and 3D groups substantially improved their BBT score with training (U3 = 0.7, U3 = 0.6, respectively). However, there were no statistically significant differences in clinical tests between the groups (group x time, p = 0.2189, p = 0.2850, respectively). In addition the LCD group significantly decreased the pressure/tension (U3 = 0.3), the 3D did not show changes (U3 = 0.5) and the differences between the groups were statistically different (p = 0.037). The 3D group demonstrated important increase in effort (U3 = 0.75) and perceived competences (U3 = 0.9).

Conclusions: The outcomes of the study demonstrated that the immersive 3D technology may bring increased interests/enjoyment score resulting in faster and more efficient functional performance. But the 2D technology demonstrated lower pressure/tension score providing similar clinical progress. A study with much larger sample size may also confirm the clinical effectiveness of the approaches.

Trial registration: The small scale randomized pilot study has been registered at ClinicalTrials.gov Identifier: NCT03515746 , 4 May 2018.

Keywords: Exergaming; Intrinsic motivation inventory; Rehabilitation; Telerehabilitation; Upper extremities; Virtual reality.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
10Cubes system with an infrared camera (Leap Motion Controller) for tracking of hand and finger motion was installed on the laptop computer. The LCD group used such system
Fig. 2
Fig. 2
The participants in the 3D group used the 10Cubes settings with the 3D VR Oculus Rift CV1 head mounted device
Fig. 3
Fig. 3
CONSORT Flow Diagram for the parallel randomized study
Fig. 4
Fig. 4
The spatio-temporal parameters of the training performance in the LCD and the 3D group calculated for each of the 10 sessions. The differences between the means of the 1st and last session are presented by the Cohen’s U3 index
Fig. 5
Fig. 5
The changes in IMI measure scales in the LCD and the 3D group for each of the 10 sessions. Interpolation with smoothing spline polynomials is presented. The differences between the means of the 1st and 10th session are presented by the Cohen’s U3 index. The polar plot demonstrates that the changes of the IMI measure scales in the LCD group were negative and the in 3D group positive or remain equal
Fig. 6
Fig. 6
The relationship between the IMI measure scales and the kinematic and game parameters for each of the 10 sessions. The arrows present the change from the 1st to the final session. The lower pressure/tension score in the LCD group resulted in the slower virtual cube manipulations, but fewer attempts resulted in more accurate movements with a lower tremor index
Fig. 7
Fig. 7
Median values, 25th and 75th percentile and 1.5 times whiskers of the BBT (upper) and UPDRS III for lower limb (lower) data for LCD and 3D groups before and after the virtual environment sessions. Both clinical tests demonstrated improvement in terms of mean values. The effect sizes are presented by the Cohen’s U3 index

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