Posts Tagged Acquired Brain Injury
[ARTICLE] The Use of Therapeutic Music Training to Remediate Cognitive Impairment Following an Acquired Brain Injury: The Theoretical Basis and a Case Study – Full Text
Cognitive impairment is the most common sequelae following an acquired brain injury (ABI) and can have profound impact on the life and rehabilitation potential for the individual. The literature demonstrates that music training results in a musician’s increased cognitive control, attention, and executive functioning when compared to non-musicians. Therapeutic Music Training (TMT) is a music therapy model which uses the learning to play an instrument, specifically the piano, to engage and place demands on cognitive networks in order to remediate and improve these processes following an acquired brain injury. The underlying theory for the efficacy of TMT as a cognitive rehabilitation intervention is grounded in the literature of cognition, neuroplasticity, and of the increased attention and cognitive control of musicians. This single-subject case study is an investigation into the potential cognitive benefit of TMT and can be used to inform a future more rigorous study. The participant was an adult male diagnosed with cognitive impairment as a result of a severe brain injury following an automobile accident. Pre- and post-tests used standardized neuropsychological measures of attention: Trail Making A and B, Digit Symbol, and the Brown– Peterson Task. The treatment period was twelve months. The results of Trail Making Test reveal improved attention with a large decrease in test time on both Trail Making A (−26.88 s) and Trail Making B (−20.33 s) when compared to normative data on Trail Making A (−0.96 s) and Trail Making B (−3.86 s). Digit Symbol results did not reveal any gains and indicated a reduction (−2) in free recall of symbols. The results of the Brown–Peterson Task reveal improved attention with large increases in the correct number of responses in the 18-s delay (+6) and the 36-s delay (+7) when compared with normative data for the 18-s delay (+0.44) and the 36-s delay (−0.1). There is sparse literature regarding music based cognitive rehabilitation and a gap in the literature between experimental research and clinical work. The purpose of this paper is to present the theory for Therapeutic Music Training (TMT) and to provide a pilot case study investigating the potential efficacy of TMT to remediate cognitive impairment following an ABI.
An acquired brain injury (ABI) can result in impairment in a variety of domains including motor, speech, emotional, and cognitive. Cognitive impairment is the most common sequelae following an ABI [1,2,3,4] and is a result of deficit in one or more areas of cognition such as the various forms of attention, working memory, memory, executive function, or processing speed [5,6,7,8,9,10,11]. An individual with cognitive impairment may experience challenge to suppress distraction, remain on task, shift between tasks, follow directions, organize and initiate a response, or have difficulties with memory. Cognitive impairment can impact participation and progress in rehabilitation therapies for any of the above domains due to reduced attention, poor executive functioning, or impaired memory. The inability to attend to instructions of the therapist, to cognitively plan and organize a response, or to remember rehabilitation objectives outside the therapy session can potentially disqualify an individual from participation in rehabilitative programs or may impede progress in them. Furthermore, cognitive impairment is reported by family and caregivers as a significant source of stress [8,12,13,14]. Addressing cognitive impairment should be a priority in patient treatment following an acquired brain injury. Therefore, it is important to have on-going research into potentially effective cognitive rehabilitation tools.Music training has been noted in the literature to impact areas of non-musical functioning including phonological awareness , speech processing , listening skills , perceiving speech in noise  and reading [19,20]. Of significance to the theory of Therapeutic Music Training, the literature demonstrates the impact of music training on cognitive abilities including attention and executive functioning [21,22,23,24,25,26,27].Therapeutic Music Training (TMT) is a music therapy model in which the use of music training, specifically learning to play the piano, is used to address and remediate cognitive impairment following an acquired brain injury . TMT is informed by clinical work and is grounded in literature. The hypothesis of the efficacy of TMT to remediate cognitive impairment is supported by literature regarding the influence of music training on cognition [23,24,25,29], musician’s enhanced abilities in attention, working memory, and cognitive control , theories of attention [30,31,32,33,34,35] and the neuroplasticity of the brain, including following injury [36,37,38,39,40]. Because of the engagement of the prefrontal cortex and the demands placed on working memory and attention during TMT, it can be an effective tool to address cognitive impairment. Although functionally interconnected, specific aspects of cognition such as working memory, attention, executive function, and memory are targeted in TMT tasks. TMT is a remedial approach to cognitive rehabilitation, that is, the goal is to drive, strengthen, and improve the underlying neural processes involved in the target cognitive areas. This is in contrast to a compensatory approach to cognitive rehabilitation, in which the goal is to provide the individual with strategies and accommodations to deal with the outcomes of cognitive impairment. The tangible outcome of producing a song provides motivation for the client to engage in cognitive rehabilitation and to remain in the rehabilitative process for an extended period of time as is required to stimulate a neuroplastic response and for the remediation of neural processing to take place.TMT is distinct from modified music education in that the goal of TMT is the remediation of cognitive processes rather than music performance. Tasks involved in learning to play the piano are designed with the goal of placing demands on the various components of cognition. The sequencing and pacing of tasks are determined by the cognitive goals with consideration to target cognitive processes and the time required to drive and strengthen the networks involved. Novelty and the gradual increase in complexity of tasks are utilized to place on-going demands on attention networks and to gradually benefit higher cognitive processes. This is in contrast to modified music education, in which the primary goal is the acquisition of musical abilities and performance.TMT is distinct from other models of music therapy in that it uses music training as the intervention for rehabilitative purposes. TMT contrasts from other music therapy models which use music primarily for expressive purposes, lack corrective feedback from the therapist, or use isolated music tasks which are not intended as music training. TMT is distinct from Neurologic Music Therapy (NMT)  in addressing cognitive goals as NMT does not use music training in its music-based rehabilitative interventions. Bruscia highlighted the importance of the music therapist’s “non-judgemental acceptance of what the client does musically”  (p. 3). While the TMT therapist would express empathy and support to the client, s/he would also provide constructive and corrective feedback as required in the learning to play an instrument. As in other models of music therapy, the therapist’s use-of-self and the role of the client–therapist relationship are important contributors to the success of the therapy.Remarkably, much of cognitive rehabilitation is not grounded in the literature [36,43,44,45]. This may be due in part to the fact that rehabilitation therapy used to address cognitive impairment is most often based on a compensatory approach, accommodating or supporting the impairment, rather than attempting to remediate the cognitive processes that have been impaired. While the use of music and instrument playing for motor rehabilitation has been widely investigated [41,46,47,48], there is sparse literature investigating the potential efficacy of music-based cognitive rehabilitation interventions. This paper provides a brief introduction to the theory for TMT. This case study investigates the hypothesis of the potential effectiveness of therapeutic music training, TMT, to remediate cognitive impairment and serves as a pilot project to inform future, more rigorous studies. This investigation can contribute to the literature regarding music-based cognitive rehabilitation and inform clinical practice. There is a gap between cognitive experimental research and treatment applications . The hypothesis for TMT has been informed by clinical work and this study can help fill in the gap between experimental research and clinical application. […]
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[ARTICLE] Virtual reality-based treatment for regaining upper extremity function induces cortex grey matter changes in persons with acquired brain injury – Full Text
Individuals with acquired brain injuries (ABI) are in need of neurorehabilitation and neurorepair. Virtual anatomical interactivity (VAI) presents a digital game-like format in which ABI survivors with upper limb paresis use an unaffected limb to control a standard input device and a commonplace computer mouse to control virtual limb movements and tasks in a virtual world.
In a prospective cohort study, 35 ambulatory survivors of ABI (25/71% stroke, 10/29% traumatic brain injury) were enrolled. The subjects were divided into three groups: group A received VAI therapy only, group B received VAI and physical/occupational therapy (P/OT), and group C received P/OT only. Motor skills were evaluated by muscle strength (hand key pinch strength, grasp, and three-jaw chuck pinch) and active range of motion (AROM) of the shoulder, elbow, and wrist. Changes were analyzed by ANOVA, ANCOVA, and one-tailed Pearson correlation analysis. MRI data was acquired for group A, and volumetric changes in grey matter were analyzed using voxel-based morphometry (VBM) and correlated with quantified motor skills.
AROM of the shoulder, elbow, and wrist improved in all three groups. VBM revealed grey matter increases in five brain areas: the tail of the hippocampus, the left caudate, the rostral cingulate zone, the depth of the central sulcus, and the visual cortex. A positive correlation between the grey matter volumes in three cortical regions (motor and premotor and supplementary motor areas) and motor test results (power and AROM) was detected.
Our findings suggest that the VAI rehabilitation program significantly improved motor function and skills in the affected upper extremities of subjects with acquired brain injuries. Significant increases in grey matter volume in the motor and premotor regions of affected hemisphere and correlations of motor skills and volume in nonaffected brain regions were present, suggesting marked changes in structural brain plasticity.
Neurological disorders, including acquired brain injuries (ABIs) are important causes of disability and death worldwide [1, 2]. Although age-standardized mortality rates for ischemic and hemorrhagic strokes have decreased in the past two decades, the absolute number of stroke survivors is increasing, with most of the burden in low- and middle-income countries . Another major issue is that trends toward increasing stroke incidence at younger ages has been observed . Moreover, this type of ABI is the leading cause of long-term disability in the United States, with an estimated incidence of 795,000 strokes yearly .
In more than 80% of stroke survivors, impairments are seen in at least one of the upper limbs. Six months after a stroke, 38% of patients recover some dexterity in the paretic arm, though only 12% recover substantial function even in spite of having received physical/occupational therapy (P/OT) . Only a few survivors are able to regain some useful function of the upper limb. Failing to achieve useful function has highly negative impacts on the performance of daily living activities [6, 7]. Regaining control and improving upper limb motor function after ABIs are therefore crucial goals of motor system rehabilitation. In left-sided limb impairment, neglect syndrome can contribute to a worsened clinical state, making the alleviation of symptoms even more difficult to achieve. Mirror therapy has been reported as a promising approach to improve neglect symptoms [8, 9].
MRI has been used to track changes in brain connectivity related to rehabilitation , and several studies of healthy individuals playing off-the-shelf video games have demonstrated changes in the human brain resulting from interactions in a virtual world (VW) [11, 12]. Furthermore, playing video games results in brain changes associated with regaining improved, purposeful physical movements [13, 14]. The socio-cultural relevance of virtual reality (VR) and VW applications lies, more generally, in the fact that these technologies offer interactive environments to users. These interactive environments are actually present in the users’ experiences while less so in the world they share as biological creatures . The way in which we engage with VWs allows for rehabilitation exercises and activities that feel similar to their actual physical world counterparts . In the past two decades, researchers have demonstrated the potential for the interactive experiences of VWs to provide engaging, motivating, less physically demanding, and effective environments for ABI rehabilitation [9, 16,17,18].
One of the suitable rehabilitation methods seems to be exercises and tasks in VW called virtual anatomical interactivity (VAI) . This method provides sensory stimulation / afferent feedback and allows the independent control of an anatomically realistic virtual upper extremity capable of simulating human movements with a true range of motion. ABI survivors are able to relearn purposeful physical movements and regain movement in their disabled upper extremities . Contrary to conventional therapy, which exercises impaired upper limbs to improve limb movement, the general VAI hypothesis is that brain exercises alone (or combined with traditional therapy) may positively influence neuroplastic functions. In the VW, subjects can move their virtual impaired limbs using their healthy hands, meaning simulated physical movements are survivor-authored. Virtual visuomotor feedback may help regain functional connectivity between the brain and the impaired limb, therefore also regaining voluntary control of the limb.
The aim of the study was to test if the shoulder, elbow, and wrist movement; hand pinch strength; and grip strength of the paretic side improved through the use of VAI exclusively or combined with P/OT for upper extremities and how these approaches improved functional outcomes measured by the Action Reach Arm Test . The relationship between changes in abilities to control upper extremities and volumetric changes in cortex grey matter measured by VBM and using MRI was also explored.[…]
[Abstract] The predictors of proxy- and self-reported quality of life among individuals with acquired brain injury
Acquired brain injury (ABI) diminishes quality of life (QoL) of affected individuals and their families. Fortunately, new multidimensional instruments such as the calidad de vida en daño cerebral (CAVIDACE) scale are available. However, differences in self- and proxy-reported QoL remain unclear. Therefore, this study examined these differences and identified predictors of QoL among individuals with ABI.
Materials and methods
This cross-sectional study comprised 393 adults with ABI (men: 60%; M age = 54.65, SD = 14.51). Self-, family-, and professional-reported QoL were assessed using the CAVIDACE scale. Other personal and social variables were assessed as predictors of QoL.
Professionals had the lowest QoL scores (M = 1.88, SD = 0.45), followed by family members (M = 2.02, SD = 0.44) and individuals with ABI (M = 2.10, SD = 0.43). Significant differences were found for almost all QoL domains, finding the highest correlations between family and professional proxy measures (r = 0.63). Hierarchical regression analysis revealed that sociodemographic, clinical, rehabilitation, personal, and social variables were significant predictors of QoL.
It is necessary to use both self- and proxy-report measures of QoL. Additionally, the identification of the variables that impact QoL permits us to modify the interventions that are offered to these individuals accordingly.
- Implications for rehabilitation
- Acquired brain injury (ABI) causes significant levels of disability and affects several domains of functioning, which in turn can adversely affect quality of life (QoL).
- QoL is a multidimensional construct that is affected by numerous factors: sociodemographic, clinical, personal, social, etc; and also, with aspects related to the rehabilitation they receive after ABI.
- Rehabilitation programs should address the different domains of functioning that have been affected by ABI.
- Based on research findings about the QoL’s predictors, modifications could be made in the rehabilitation process; paying special attention to the depressive- and anosognosia process, as well as the importance of promoting social support, community integration, and resilience.
Ekso Bionics Holdings Inc announces it has received 501(k) clearance from the U.S. Food and Drug Administration (FDA) to market its EksoNR robotic exoskeleton for use with patients with acquired brain injury (ABI).
EksoNR is reportedly the first exoskeleton device to receive FDA clearance for rehabilitation use with ABI. It was previously cleared by the FDA for stroke and spinal cord injury rehabilitation in 2016.
Ekso Bionics Unveils the EksoNR Neurorehabilitation Device
Post Acute Medical Expands Exoskeleton Rehab with New EksoNR Devices
EksoGT Users Have Walked Around the World Twice, Company Estimates
ABI is comprised of both traumatic (TBI) and non-traumatic (n-TBI) brain injury causes. TBI includes severe head injuries and concussions, while n-TBI includes a broader subset of conditions, such as stroke, aneurysms, brain tumors, anoxia, degenerative and metabolic conditions, infections, and surgical injuries, among others, according to a media release from Ekso Biokics.
“With the expanded indications to include the broad category of acquired brain injuries, the EksoNR has the potential to mobilize significantly more patients and improve patient recovery. Based on their experience with EksoNR, customers at leading rehabilitation centers have acknowledged the benefits our technology can offer during recovery from brain injuries. We are excited to see the device used more widely in neurorehabilitation.”
— Jack Peurach, CEO and president of Ekso Bionics
[Source(s): Ekso Bionics, Globe Newswire]
[ARTICLE] Visual processing speed in hemianopia patients secondary to acquired brain injury: a new assessment methodology – Full Text
There is a clinical need to identify diagnostic parameters that objectively quantify and monitor the effective visual ability of patients with homonymous visual field defects (HVFDs). Visual processing speed (VPS) is an objective measure of visual ability. It is the reaction time (RT) needed to correctly search and/or reach for a visual stimulus. VPS depends on six main brain processing systems: auditory-cognitive, attentional, working memory, visuocognitive, visuomotor, and executive. We designed a new assessment methodology capable of activating these six systems and measuring RTs to determine the VPS of patients with HVFDs.
New software was designed for assessing subject visual stimulus search and reach times (S-RT and R-RT respectively), measured in seconds. Thirty-two different everyday visual stimuli were divided in four complexity groups that were presented along 8 radial visual field positions at three different eccentricities (10o, 20o, and 30o). Thus, for each HVFD and control subject, 96 S- and R-RT measures related to VPS were registered. Three additional variables were measured to gather objective data on the validity of the test: eye-hand coordination mistakes (ehcM), eye-hand coordination accuracy (ehcA), and degrees of head movement (dHM, measured by a head-tracker system). HVFD patients and healthy controls (30 each) matched by age and gender were included. Each subject was assessed in a single visit. VPS measurements for HFVD patients and control subjects were compared for the complete test, for each stimulus complexity group, and for each eccentricity.
VPS was significantly slower (p < 0.0001) in the HVFD group for the complete test, each stimulus complexity group, and each eccentricity. For the complete test, the VPS of the HVFD patients was 73.0% slower than controls. They also had 335.6% more ehcMs, 41.3% worse ehcA, and 189.0% more dHMs than the controls.
Measurement of VPS by this new assessment methodology could be an effective tool for objectively quantifying the visual ability of HVFD patients. Future research should evaluate the effectiveness of this novel method for measuring the impact that any specific neurovisual rehabilitation program has for these patients.
Vision is the dominant sensory function in humans because visual search and reach tasks are crucial to efficient performance of the main activities of daily life [1, 2]. The term visual processing speed (VPS), an important variable of visual sensory function, is the amount of time needed to make a correct interaction with a visual stimulus [3, 4]. The term correct interaction is the effective realization of a complete executive action of visual search and reach , e.g., visualizing a glass of water placed on a table and then grasping it by precise eye-hand coordination (EHC). Accordingly, the VPS variable defines the global reaction time (RT) that is composed of two additive RT sub-variables: search reaction time (S-RT) and reach reaction time (R-RT) [6,7,8]. Furthermore, VPS is mainly interdependent on intrinsic visual cognitive processing mechanisms, the complexity of the determined stimulus to be recognized (defined principally in terms of size, contrast, semantic content, and number of traces or interior angles [9, 10]), the number of distractor stimuli surrounding it, and the distance from the point of fixation to the particular stimulus that the person is tasked to identify (eccentricity) [4, 11,12,13]. Thus, VPS is a quantifiable parameter that objectively reflects a subject’s global visual ability.
Recent findings in the field of visual psychophysics show that having adequate VPS is necessary and dependent upon the proper functioning of six main brain-processing systems: auditory-cognitive, attentional, working-memory, visuocognitive, visuomotor, and executive [14,15,16,17,18]. Consequently, an acquired brain injury (ABI) that affects any of these cerebral processing systems could decrease the VPS.
ABI is one of the most important and disabling public health problems of our era due to the high incidence and prevalence . Following an ABI, between 30 and 85% of patients will experience some type of visual dysfunction [20, 21], especially homonymous visual field defects (HVFDs) secondary to lesions involving the visual afferent pathways posterior to the chiasm . Eye tracking technology has shown that HVFDs prevent patients from having the appropriate control of their oculomotor systems [23,24,25,26]. This is especially apparent in the saccadic system, because it is interdependent with the covert attention mechanisms associated with peripheral vision [27, 28]. Thus, patients with HVFDs tend to perform search tasks using unconscious compensatory head movements [25, 29, 30] and employ longer total search times, more frequent fixations, and shorter saccades than normal controls [23, 31,32,33,34,35,36,37]. Therefore, these patients experience a significant reduction in their quality of life and functional independence. They complain that the time they have to invest in carrying out their daily activities is much greater than before suffering from HVFDs [33, 38,39,40]. In this regard, in recent years the scientific community has joined efforts to develop increasingly effective neurovisual rehabilitation training programs (NVRTPs) for these patients . Different forms of NVRTPs have been developed, including compensatory NVRTP (C-NVRTP), restitution NVRTP (R-NVRTP), and substitution NVRTP (S-NVRTP) [41,42,43,44].[…]
[Abstract + References] Do powered over-ground lower limb robotic exoskeletons affect outcomes in the rehabilitation of people with acquired brain injury?
Purpose: To assess the effects of lower limb robotic exoskeletons on outcomes in the rehabilitation of people with acquired brain injury.
Materials and methods: A systematic review of seven electronic databases was conducted. The primary outcome of interest was neuromuscular function. Secondary outcomes included quality of life, mood, acceptability and safety. Studies were assessed for methodological quality and recommendations were made using the GRADE system.
Results: Of 2469 identified studies, 13 (n = 322) were included in the review. Five contained data suitable for meta-analysis. When the data were pooled, there were no differences between exoskeleton and control for 6-Minute Walk Test, Timed Up and Go or 10-Meter Walk Test. Berg Balance Scale outcomes were significantly better in controls (MD = 2.74, CI = 1.12–4.36, p = 0.0009). There were no severe adverse events but drop-outs were 11.5% (n = 37). No studies reported the effect of robotic therapy on quality of life or mood. Methodological quality was on average fair (15.6/27 on Downs and Black Scale).
Conclusions: Only small numbers of people with acquired brain injury had data suitable for analysis. The available data suggests no more benefit for gait or balance with robotic therapy than conventional therapy. However, some important outcomes have not been studied and further well-conducted research is needed to determine whether such devices offer benefit over conventional therapy, in particular subgroups of those with acquired brain injury.
- Implications for Rehabilitation
- There is adequate evidence to recommend that powered over-ground lower limb robotic exoskeletons should not be used clinically in those with ABI, and that use should be restricted to research.
- Further research (controlled trials) with dependent ambulators is recommended.
- Research of other outcomes such as acceptability, spasticity, sitting posture, cardiorespiratory and psychological function, should be considered.
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[I/Ep] Strategies to Cope With Behavior Changes After Acquired Brain Injury – Archives of Physical Medicine and Rehabilitation
Behavior changes are common after acquired brain injury (ABI) because the brain processes information differently after the injury. About 62% of people with ABI experience behavior changes.1 For some people with ABI, the changes in behavior have a major effect on their daily lives, while for others they may be relatively small. These changes can make daily tasks and social interactions difficult. People with ABI may be more sensitive to stress and fatigue, which can make the behaviors described in this article worse.
[Abstract] A systematic review of personal smart technologies used to improve outcomes in adults with acquired brain injuries
This review aimed to determine the effectiveness of personal smart technologies on outcomes in adults with acquired brain injury.
A systematic literature search was conducted on 30 May 2019. Twelve electronic databases, grey literature databases, PROSPERO, reference list and author citations were searched.
Randomised controlled trials were included if personal smart technology was used to improve independence, goal attainment/function, fatigue or quality of life in adults with acquired brain injury. Data were extracted using a bespoke form and the TIDieR checklist. Studies were graded using the PEDro scale to assess quality of reporting. Meta-analysis was conducted across four studies.
Six studies met the inclusion criteria, generating a total of 244 participants. All studies were of high quality (PEDro ⩾ 6). Interventions included personal digital assistant, smartphone app, mobile phone messaging, Neuropage and an iPad. Reporting of intervention tailoring for individual needs was inconsistent. All studies measured goal attainment/function but none measured independence or fatigue. One study (n = 42) reported a significant increase in memory-specific goal attainment (p = 0.0001) and retrospective memory function (p = 0.042) in favour of the intervention. Another study (n = 8) reported a significant increase in social participation in favour of the intervention (p = 0.01). However, our meta-analyses found no significant effect of personal smart technology on goal attainment, cognitive or psychological function.
[ARTICLE] Experiences of treadmill walking with non-immersive virtual reality after stroke or acquired brain injury : A qualitative study – Full Text
It is well known that physical activity levels for persons after stroke or acquired brain injuries do not reach existing recommendations. Walking training is highly important since the ability to walk is considered to be a meaningful occupation for most people, and is often reduced after a brain injury. This suggests a need to innovate stroke rehabilitation, so that forms of walking training that are user-friendly and enjoyable can be provided.
An interview study was carried out with persons after stroke (n = 8), or acquired brain injury (n = 2) at a rehabilitation unit at Sahlgrenska University Hospital. We used a semi-structured interview guide to investigate experiences and thoughts about walking on a treadmill with non-immersive virtual reality feedback. The contents were analyzed through an inductive approach, using qualitative content analysis.
The virtual reality experience was perceived as enjoyable, exciting, and challenging. Participants stressed that the visual and auditory feedback increased their motivation to walk on a treadmill. However, for some participants, the virtual reality experience was too challenging, and extreme tiredness or fatigue were reported after the walking session.
Participants’ thoughts and experiences indicated that the Virtual Reality walking system could serve as a complement to more traditional forms of walking training. Early after a brain injury, virtual reality could be a way to train the ability to handle individually adapted multisensory input while walking. Obvious benefits were that participants perceived it as engaging and exciting.
In general, physical activity levels in rehabilitation units are low  and do not reach the recommendations for persons with stroke or acquired brain injury (ABI) . There are also indications that the intensity of physiotherapy sessions after stroke is mostly at low levels . Several barriers may contribute to inactivity, such as neurological deficits, cognitive impairment, environmental factors, and lack of motivation [4, 5].
A dose-response effect on exercise outcome after stroke has been shown, and training should be highly repetitive and task oriented . Walking training is important and considered to be a meaningful occupation for most people. To increase walking exercise intensity, treadmill walking has been proposed as a means of task-oriented training that gives the opportunity for many repetitions, and has shown to promote a more normal walking pattern . Walking on a moving surface like a treadmill is more demanding than walking on the ground in terms of sensory processing, postural control and movement coordination. From a motivational perspective, treadmill walking may be perceived as boring the long run.
Training of goal-specific activities with a high number of repetitions may be offered using virtual reality (VR) applications, which have been introduced in neurological rehabilitation [8, 9]. Training using VR has also been suggested to enhance neuroplasticity after stroke  by means of offering multisensory stimulation at a high intensity. VR comprises computer-based real-time simulation of an environment with user interaction  visually displayed on a screen or through head-mounted devices. Differences in technology and visual presentations in 2D or 3D enable varying types of feedback, levels of immersion and sense of presence in the virtual environment [9, 11]. VR feedback can be mediated through vision, hearing, touch, movement, or smell. The technique provides performance feedback–both directly experienced and objectively quantified, and may thereby increase exercise motivation, and improve motor performance [12–14].
Following stroke, VR training has been mostly described for the upper limb but also for the lower limb; balance and walking as well as for perceptual/cognitive skills . VR has shown a potential for positive effects on walking and balance abilities, although the number of studies are low and the evidence for its superiority to other methods is low [8, 15, 16].
Although few adverse events from VR training have been described, some participants have reported headache or dizziness  and knowledge is lacking regarding how persons affected by brain injuries perceive the exposure of multisensory input, during a complex activity such as treadmill walking with VR. The potential effects on motivation and participant experience of VR are scarcely investigated  and mostly focused on upper limb activities and games . Based on this, we wanted to investigate patients’ overall experiences of a VR concept in walking training.
The aim of the present study was to explore the experiences of VR in addition to walking on a treadmill in persons with stroke or acquired brain injuries. Participants’ overall experiences and suggestions for development of the exercise method were areas of interest.[…]