Virtual reality therapy (VRT) is an interactive intervention that induces neuroplasticity. The aim was to evaluate the effects of VRT associated with conventional rehabilitation for an upper limb after stroke, and the neuroimaging predictors of a better response to VRT.
Patients with stroke were selected, and clinical neurological, upper limb function, and quality of life were evaluated. Statistical analysis was performed using a linear model comparing pre- and post-VRT. Lesions were segmented in the post-stroke computed tomography. A voxel-based lesion-symptom mapping approach was used to investigate the relationship between the lesion and upper limb function.
Eighteen patients were studied (55.5 ± 13.9 years of age). Quality of life, functional independence, and dexterity of the upper limb showed improvement after VRT (p < 0.001). Neuroimaging analysis showed negative correlations between the internal capsule lesion and functional recovery.
VRT showed benefits for patients with stroke, but when there was an internal capsule lesion, a worse response was observed.
Stroke can be defined as a neurological deficit resulting from focal and acute central nervous system injury. It is considered a major cause of mortality and disability worldwide1. Stroke is the second leading cause of death in Brazil and the leading cause of chronic disability in adults, resulting in socioeconomic consequences and reduced quality of life. Therefore, it is an important public health problem, particularly because of long-term dependence on public health services2,3.
Cerebrovascular injury may damage the cells of the cortex and emerging axons, generating dysfunction of the upper motor neurons. Motor function can be impaired, reducing functional capacity, particularly that of the upper limbs4. Approximately 85% of individuals experience hemiparesis immediately after the stroke, particularly in an upper limb, and 55%–75% of these individuals have persistence of motor deficits, making it difficult to return to work and leisure, consequently worsening their quality of life5.
Epidemiological clinical studies have suggested that 33%–66% of stroke patients had no motor recovery after six months. Several techniques aiming to improve upper limb function are still being developed. However, the implementation of these techniques requires great team work, a high degree of specialization, and requires more time5,6. Currently, there are new approaches to rehabilitation, and virtual reality is still developing, with the objective of restoring the functional capacity of individuals after stroke as an easy, interactive, and low-cost intervention7,8.
The objective of stroke rehabilitation is to provide maximal physical, functional, and psychosocial recovery for the patients9. Comprehensive rehabilitation initiated early after stroke (within the first 24 hours) is generally accepted as being associated with better motor outcomes for these patients9. Strength training is an important part of the therapeutic process for upper-limb motor impairment after stroke10.
Virtual reality is defined as any hardware or software system that provides a simulated environment with real or imagined conditions that allow participating individuals to interact with the environment. The interaction is made by body movements using motion capture technology or by manipulating a device11. This interaction generates information necessary for proper understanding of the movement with particular emphasis on the upper limbs12. The technique consists of an avatar (graphic representation of the person) generated by the video game, where the individual manages a wireless control, directing the movement during the practice of different activities5. This is a good option for rehabilitation for individuals with stroke due to the variety of nonimmersive video game systems developed by the entertainment industry for home use.
This wide availability makes virtual reality an accessible and inexpensive rehabilitation method for rehabilitation centers13. Despite the ease of application, virtual reality therapy (VRT), added to conventional physical therapy has not been associated with a better outcome than recreational activity13. Adverse events usually are mild and the main effects described are transient dizziness and headache, pain and numbness13,14. Time since the onset of stroke, severity of impairment, and the type of device (commercial or customized) usually do not influence the outcome14. However, the variable methodology is an important bias for these investigations14. Therefore, virtual reality is still a promising tool. Some authors have reported that VRT can be combined with conventional rehabilitation to improve upper limb function after stroke15,16. The clinical situations wherein VRT may best be used have not yet been established in the literature. Also, the exact mechanism of action of this treatment modality is not yet fully understood.
The objectives of this study were to evaluate the effects of VRT combined with conventional rehabilitation for upper limb function in the recovery of individuals after stroke. Neuroimaging characteristics that could be used as predictors of a better response to VRT were also investigated.[…]