Objective: To investigate the feasibility and effectiveness of virtual reality training for improving balance and/or gait during inpatient rehabilitation of patients within 12 weeks after stroke.
Methods: Sixteen patients within 12 weeks after stroke and dependent gait as categorised with a Functional Ambulation Category score of 2 or 3 were included in this longitudinal pilot study. Participants received eight 30-min sessions of virtual reality training during four weeks as part of the regular inpatient rehabilitation program. Feasibility was assessed using compliance with the training, adverse events, experiences of the participants and the physiotherapists; and effectiveness with the Berg Balance Scale, centre of pressure velocity, Functional Ambulation Category and 10-meter walking test.
Results: Participants positively evaluated the intervention and enjoyed the training sessions. Also, physiotherapists observed the training as feasible and beneficial for improving balance or gait. Compliance with the training was 88% and no serious adverse events occurred. The Berg Balance Scale, anterior-posterior centre of pressure velocity, Functional Ambulation Category and 10-meter walking test showed significant improvement after four weeks of training (p<0.05).
Conclusion: This study demonstrates that virtual reality training in patients early after stroke is feasible and may be effective in improving balance and/or gait ability.
Balance and gait recovery are considered as key aspects in stroke rehabilitation [1–3]. To date, physiotherapy and occupational therapy focus on high intensity, repetitive and task-specific practice, which are important principles of motor learning, to elicit improvements in the early rehabilitation phase [1,4,5]. In addition to high intensity, repetitive and task-specific training, variability in practice is important for motor learning. Also, cognitive involvement, functional relevance and the presence of feedback enhance learning . In current physiotherapy or occupational therapy it is difficult to meet all of these above-mentioned training characteristics as therapy may be tedious and resource-intensive [6–9]. In addition, the frequency and intensity of current therapies have been indicated as insufficient to achieve maximum recovery in the early phase of rehabilitation [8,10]. There is need for engaging, motivating and varied therapy that achieves maximal recovery .
In recent years, virtual reality (VR) is introduced in the field of balance and gait rehabilitation after stroke . Since VR training is characterised by individualised, high intensity training in a variety of virtual environments with a high amount of real-time feedback [13–15] it might be valuable in stroke rehabilitation. This is confirmed by recent studies [12,15–18]. However, almost all studies on the effect of VR on balance and/or gait ability were conducted in the chronic phase after brain injury [9,12,16,17,19–23]. Because of the potential relevant characteristics of VR for motor learning and neuroplasticity , VR may be of even more added value during the earlier rehabilitation phase. Three studies [24–26] that investigated the effect of VR in this time period after stroke indicated a positive effect of commercially available VR systems (Nintendo Wii Fit or IREX) on balance and/or gait recovery. However, the results of these studies cannot be generalised to the whole population of patients with stroke because included participants had a relatively high functional level regarding balance and gait at the start of the VR intervention. A lack of studies including patients with lower functional status after stroke might be caused by the idea that the feasibility of using advanced VR technology may be restricted because of visual, cognitive and/or endurance impairments. These impairments are more often present in the more impaired patients early after stroke [27–29]. Because of the expected promising effects of VR training for the recovery of balance and gait in patients with low functional level early after stroke, it is important to investigate the feasibility of this innovative form of training and to determine whether the above-mentioned impairments interfere with the use of VR training early after stroke.
Therefore, the aim of the present study was to investigate the feasibility and effectiveness of VR training for improving balance and/or gait during the inpatient rehabilitation of patients with stroke. The specific research questions were:
• What is the feasibility, from the perspective of patients and physiotherapists, of VR training aimed to improve balance and gait ability?
• What is the effectiveness of VR training, embedded within an inpatient rehabilitation program, on balance and gait ability in people with impaired balance and dependent gait within 12 weeks after stroke?
This longitudinal pilot study involved two assessments, one before and one after a four-week VR training intervention, performed within the inpatient rehabilitation program of patients with stroke at (Revant Rehabilitation Centres, Breda, the Netherlands).
Patients with stroke who were following an inpatient rehabilitation program with a treatment goal to improve balance and/or gait. They received balance and/or gait training with VR as part of their regular rehabilitation program. Besides the VR training, the regular rehabilitation program could include therapy given by a physiotherapist, occupational therapist, speech therapist, psychomotor therapist, psychologist and social worker, depending on the goals of the patient with stroke. Inclusion criteria consisted of hemiplegia resulting from a stroke, a time since stroke of less than 12 weeks, a Berg Balance Scale (BBS) score of at least 20, i.e. the minimum level of balance deemed safe for balance interventions , and a Functional Ambulation Category (FAC) score of 2 or 3 out of 5 . Exclusion criteria were patients with stroke with terminal diseases, lower-limb impairments not related to stroke, severe cognitive impairments, severe types of expressive or receptive aphasia, visual impairments, age over 80 years and experiencing epileptic seizures. All participants provided written consent to use data obtained during the rehabilitation program for research, and anonymity was assured. The study procedures follow the principles of the Declaration of Helsinki.
VR training intervention
The intervention consisted of balance and gait training using the recently developed treadmill based Gait Real-time Analysis Interactive Lab (GRAIL, Motekforce Link, Amsterdam, The Netherlands). The GRAIL comprises a dual-belt treadmill with force platform, a motion-capture system (Vicon, Oxford, UK) and speed-matched virtual environments projected on a 180° semi-cylindrical screen (Figure 1) .
Continue —> Feasibility and Effectiveness of Virtual Reality Training on Balance and Gait Recovery Early after Stroke: A Pilot Study | Open Access Journals