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[ARTICLE] Efficacy of Virtual Reality Combined With Real Instrument Training for Patients With Stroke: A Randomized Controlled Trial – Full Text
To investigate the efficacy of real instrument training in virtual reality (VR) environment for improving upper-extremity and cognitive function after stroke.
Single-blind, randomized trial.
Enrolled subjects (N=31) were first-episode stroke, assessed for a period of 6 months after stroke onset; age between 20 and 85 years; patients with unilateral paralysis and a Fugl-Meyer assessment upper-extremity scale score >18.
Both groups were trained 30 minutes per day, 3 days a week, for 6 weeks, with the experimental group performing the VR combined real instrument training and the control group performing conventional occupational therapy.
Main Outcome Measures
Manual Muscle Test, modified Ashworth scale, Fugl-Meyer upper motor scale, hand grip, Box and Block, 9-Hole Peg Test (9-HPT), Korean Mini-Mental State Examination, and Korean-Montreal Cognitive Assessment.
The experimental group showed greater therapeutic effects in a time-dependent manner than the control group, especially on the motor power of wrist extension, spasticity of elbow flexion and wrist extension, and Box and Block Tests. Patients in the experimental group, but not the control group, also showed significant improvements on the lateral, palmar, and tip pinch power, Box and Block, and 9-HPTs from before to immediately after training. Significantly greater improvements in the tip pinch power immediately after training and spasticity of elbow flexion 4 weeks after training completion were noted in the experimental group.
VR combined real instrument training was effective at promoting recovery of patients’ upper-extremity and cognitive function, and thus may be an innovative translational neurorehabilitation strategy after stroke.
Stroke is currently the leading cause of disability and death worldwide, and stroke survivors often experience chronic functional impairment and cognition deficits, which are associated with a reduced quality of life including difficulties in social and personal relationships.1, 2 It is well known that patients with stroke have a limited use of their upper extremities owing to motor dysfunction, and such patients experience sensory-motor deficits that affect their ability to perform daily activities. Stroke increases the risk of dementia 4 to 12 times,3 and up to 69% of subjects have a poststroke cognitive impairment.4 Consequently, the aims of the current rehabilitation strategies for these patients are to improve functional ability and cognitive impairments through optimal and comprehensive rehabilitation processes.
Previous studies have reported that a considerable amount of practice using real instruments is required to stimulate functional improvement and neuroplastic changes.5, 6 Conventional occupational therapies promote the recovery of upper-extremity dysfunction by utilizing task-oriented repetition training with real instruments.7, 8 Conventional therapy using real instruments is essential for poststroke rehabilitation, but environmental, individual, and financial limitations are associated with it.9, 10
Over the past 2 decades, the advancement of computer technology has resulted in the development of interventions that involve virtual reality (VR) devices, which are defined as computer hardware and software systems that generate simulations of imagined environments via visual, auditory, and tactile feedback.11 VR environments may be perceptual, such as creating situations with multiple sensory feedback regarding the patients’ kinematic movements, which are passive or active assisted in a virtual environment, and providing high-intensity repetitive multisensory interaction and goal-oriented tasks.12 Repetition and intensity are key factors for promoting neural plasticity in patients with brain damage.13 Additionally, studies have reported that VR training promotes motor recovery and cognition by inducing experience-dependent neural plasticity through repetitive tasks of varying time, high intensity, and complexity levels.14 Various studies have revealed that adaptive neuroplasticity, defined as the reorganization of movement representation in the motor cortex, premotor cortex, supplementary motor area, and somatosensory cortex due to synaptic efficacy and remodeling of the dendritic spines, can be induced by conducting repetitive goal-oriented tasks in VR-based interventions after stroke.15, 16, 17
Recently, various reports have highlighted the potential utility of VR-based rehabilitation strategies for improving upper-limb motor weakness,18, 19 cognitive dysfunction, and balance in patients poststroke.20, 21, 22 Furthermore, research has shown that compared to conventional therapy, VR training can improve the quality of neurologic rehabilitation and enhance productivity.23 Even more, it has more beneficial effects in poststroke rehabilitation, such as an increased motivation and engagement,24 cost, and usability.25, 26, 27 In addition, VR training is able to facilitate an increased therapy time without necessarily having to rely on a therapist.28 For these reasons, the number of complex and realistic VR-based interventions is increasing in neurorehabilitation programs in order to enhance the variability and adaptability of the intervention, as well as patients’ motivation, after stroke. However, comparing the effects of VR training with conventional therapy is still unclear. According to previous mentions, the combination of VR and real instruments is expected to have a synergy effect rather than a conventional occupational therapy in patients with stroke, and we investigated to see the clinical effect by using actual devices combined with a VR system to perform numerous tasks related to real daily activities.
In the present study, we developed a novel rehabilitation training that combined the benefits of real instrument training and VR-based intervention. The aim of this study was to investigate whether the VR combined with real instrument training would be an efficient translational intervention for improving the functional abilities of the upper-extremity and cognitive function in patients with stroke.