Posts Tagged virtual reality
[Abstract] An Automated Game-Based Variable-Stiffness Exoskeleton for Hand Rehabilitation – Full Text PDF
In this paper, we propose and demonstrate the functionality of a novel exoskeleton which provides variable resistance training for human hands. It is intended for people who suffer from diminished hand strength and low dexterity due to non-severe forms of neuropathy or other ailments. A new variable-stiffness mechanism is designed based on the concept of aligning three different sized springs to produce four different levels of stiffness, for variable kinesthetic feedback during an exercise. Moreover, the design incorporates an interactive computer game and a flexible sensor-based glove that motivates the patients to use the exoskeleton. The patients can exercise their hands by playing the game and see their progress recorded from the glove for further motivation. Thus the rehabilitation training will be consistent and the patients will re-learn proper hand function through neuroplasticity. The developed exoskeleton is intrinsically safe when compared with active exoskeleton systems since the applied compliance provides only passive resistance. The design is also comparatively lighter than literature designs and commercial platforms.
[Abstract] An interactive and innovative application for hand rehabilitation through virtual reality
Physiotherapy has been very monotonous for patients and they tend to lose interest and motivation in exercising. Introducing games with short term goals in the field of rehabilitation is the best alternative, to maintain patients’ motivation. Our research focuses on gamification of hand rehabilitation exercises to engage patients’ wholly in rehab and to maintain their compliance to repeated exercising, for a speedy recovery from hand injuries (wrist, elbow and fingers). This is achieved by integrating leap motion sensor with unity game development engine. Exercises (as gestures) are recognised and validated by leap motion sensor. Game application for exercises is developed using unity. Gamification alternative has been implemented by very few in the globe and it has been taken as a challenge in our research. We could successfully design and build an engine which would be interactive and real-time, providing platform for rehabilitation. We have tested the same with patients and received positive feedbacks. We have enabled the user to know the score through GUI.
[ARTICLE] Adaptive conjunctive cognitive training (ACCT) in virtual reality for chronic stroke patients: a randomized controlled pilot trial – Full Text
Current evidence for the effectiveness of post-stroke cognitive rehabilitation is weak, possibly due to two reasons. First, patients typically express cognitive deficits in several domains. Therapies focusing on specific cognitive deficits might not address their interrelated neurological nature. Second, co-occurring psychological problems are often neglected or not diagnosed, although post-stroke depression is common and related to cognitive deficits. This pilot trial aims to test a rehabilitation program in virtual reality that trains various cognitive domains in conjunction, by adapting to the patient’s disability and while investigating the influence of comorbidities.
Thirty community-dwelling stroke patients at the chronic stage and suffering from cognitive impairment performed 30 min of daily training for 6 weeks. The experimental group followed, so called, adaptive conjunctive cognitive training (ACCT) using RGS, whereas the control group solved standard cognitive tasks at home for an equivalent amount of time. A comprehensive test battery covering executive function, spatial awareness, attention, and memory as well as independence, depression, and motor impairment was applied at baseline, at 6 weeks and 18-weeks follow-up.
At baseline, 75% of our sample had an impairment in more than one cognitive domain. The experimental group showed improvements in attention ( (2) = 9.57, p < .01), spatial awareness ( (2) = 11.23, p < .01) and generalized cognitive functioning ( (2) = 15.5, p < .001). No significant change was seen in the executive function and memory domain. For the control group, no significant change over time was found. Further, they worsened in their depression level after treatment (T = 45, r = .72, p < .01) but returned to baseline at follow-up. The experimental group displayed a lower level of depression than the control group after treatment (Ws = 81.5, z = − 2.76, r = − .60, p < .01) and (Ws = 92, z = − 2.03, r = − .44, p < .05).
ACCT positively influences attention and spatial awareness, as well as depressive mood in chronic stroke patients.
The trial was registered prospectively at ClinicalTrials.gov (NCT02816008) on June 21, 2016.
Cognitive impairments are common after stroke, with incident rates up to 78% . Patients with mild cognitive impairment are at risk for developing dementia . Cognitive deficits correlate with poor functional outcomes and increased risk of dependence , have negative effects on the patient’s quality of life , and alter the patient’s ability to socialize . However, the current clinical practice seems to lack methods that specifically address cognitive sequelae. According to a meta-analysis that aimed at proposing recommendations for new clinical standards, currently available treatments that are used as control conditions are conventional therapies like physical therapy or occupational therapy, pseudo treatments like mental or social stimulation without therapeutic intent, as well as psychosocial interventions like psychotherapy or emotional support for individuals or groups . Besides, it has been shown that cognitively impaired patients participate less in rehabilitation activities, which potentially contributes to the poorer functional outcome they display . Finding effective cognitive rehabilitation methods that can be incorporated in clinical practice is therefore crucial. Numerous methods to improve cognitive deficits, for instance, specifically attention , memory , executive function , or spatial abilities , have been proposed. However, the results show mixed efficacies. A meta-analysis on the impact of attentional treatments showed an effect on divided attention in the short-term, but found no evidence for persisting effects on other attentional domains, global attention, or functional outcomes . Similarly, a meta-review that investigated the effect of memory rehabilitation found that training might benefit subjective reports of memory in the short term, but shows no effect in the long term, on objective memory measures, mood, functional abilities or quality of life . Ultimately, a meta-analysis over 6 Cochrane reviews shows insufficient research evidence or evidence of insufficient quality to support any recommendation for cognitive stroke rehabilitation . Besides methodological issues, one limitation of existing methods could be that they focus on one deficit only, ignoring that patients typically express deficits in multiple cognitive domains [1, 2]. A study on a large sample of heterogeneous stroke patients which aimed at linking lesions to cognitive deficits found that a given lesion location leads to cognitive impairments in several domains . This emphasizes that cognitive functions rely on a network of brain regions. A lesion in one of those regions might cause a disturbance to the network, which leads to a multitude of symptoms. This is further supported by studies that revealed that pathological changes in brain structures are related to the occurrence of various cognitive deficits and symptoms for instance, in Alzheimer’s disease  or spatial neglect . Moreover, the presence of multiple cognitive deficits seems to be a marker in patients that are at risk of developing Alzheimer’s disease later in life . To what extent rehabilitation could potentially drive structural or functional changes to alleviate the symptoms of stroke is still under debate [19, 20]. Nevertheless, rehabilitation methods have to aid the patient in obtaining enough functionality to independently perform instrumental activities of daily living, be it through restoration of function or compensation. With this in mind, focusing on training a single cognitive skill might not be efficient because many daily tasks or jobs require several cognitive abilities for their execution . For instance, most patients would like to be mobile and drive a car again after their stroke. Driving requires the individual to use selective attention to deal with the traffic, traffic signs and distractions, to be cognitively flexible to react to changing situations on the road, to visually scan the mirrors at the front, at the side, and in the back, to have a visual field that includes the sidewalks and to perform all of this while steering the car effectively in real-time . Consequently, rehabilitation methods that address one specific cognitive ability only do not address the requirements of performing the activities of daily living and might not stimulate and train the underlying brain processes adequately. If a stroke leads to impairments in various cognitive domains, then these domains should be treated together to benefit a patient’s performance in everyday life.[…]
[Abstract] Artificial intelligence-based interactive virtual reality-assisted gaming system for hand rehabilitation
[Abstract] Effectiveness of home-based virtual reality on vestibular rehabilitation outcomes: a systematic review
Background: A 2015 systematic review evaluated the efficacy of utilizing virtual reality in vestibular rehabilitation programs. However, the biggest limitation with most of the included virtual reality systems was the associated cost of the equipment. In addition, home-based exercises are the preferred method of vestibular rehabilitation treatments.
Objectives: The purpose of this systematic review was to examine the effectiveness of home-based virtual reality systems on vestibular rehabilitation outcomes.
Methods: The following databases were examined: CINAHL Complete, ProQuest Medical Database, and PubMed. The following search terms were utilized: ‘video OR computer’ AND ‘vestibular’ AND ‘home’. The evidence level for all of the included articles was evaluated using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and the methodological rigor for all of the included articles was evaluated using a 10-item tool created by Medlicott and Harris.
Results: Based on the inclusion and exclusion criteria, seven articles were selected for inclusion in this systematic review. This systematic review found that home-based virtual reality interventions were able to effectively achieve the primary objectives of vestibular rehabilitation and that the use of these interventions was equally as effective as the use of a traditional vestibular rehabilitation program. In addition, it may be most beneficial to combine virtual reality with traditional vestibular rehabilitation.
Conclusions: Clinicians should consider using a combination of virtual reality and traditional vestibular rehabilitation when treating individuals who have been diagnosed with a vestibular dysfunction.
XRHealth, formerly known as VRHealth, announces the opening of reportedly the first virtual reality (VR) telehealth clinic. Patients can now obtain virtual reality treatment without leaving their homes.
VR telehealth clinicians providing care are currently certified in Massachusetts, Connecticut, Florida, Michigan, Washington D.C., Delaware, California, New York, and North Carolina and will be expanding their presence in additional states in the coming months. The XRHealth telehealth services are covered by Medicare and most major insurance providers.
XRHealth is designed to use virtual reality to help rehabilitate patients via an immersive and engaging experience in the comfort of their own home. It combines therapeutic software with virtual reality technology solutions to treat a variety of health conditions. VR therapy transports patients to an environment where they can view and experience treatment as a fun activity, increasing patient participation in prescribed therapeutic treatments, according to XRHealth in a media release.
The XRHealth VR telehealth clinicians will provide an initial patient assessment, ship a VR headset to patients who do not currently have access to one, train them on how to use the technology, provide ongoing telehealth care and remote monitoring, using video call and VR technology, and manage the insurance billing for patients. As the patient is using the XRHealth VR technology for therapeutic treatment, the clinical staff can control the unit remotely and see exactly what the patient is viewing and adjust the settings and treatment in real-time, remotely.
After the initial training session, the patient can then use the headset independently while data from the therapy is stored and analyzed in real-time so that clinicians can monitor patient status regularly while in compliance with the HIPAA privacy rules. Once a week, a report will be generated to the payor/provider that referred the patient.
“XRHealth is modernizing and revolutionizing the way healthcare is operating today,” says Eran Orr, CEO of XRHealth, in the release. “We are utilizing the most advanced forms of technology like virtual reality to provide patients with optimal care in the comfort of their own homes while providing top-notch clinicians with ongoing status of their progress. Patients can now ‘go’ to a virtual clinic without the need to leave their homes at all.”
The XRHealth VR telehealth clinics will open on March 1, and patients can join by submitting a request to enroll for the XRHealth services on the company website.
Background: Stroke is the leading cause of disability worldwide, with many stroke survivors having persistent upper limb functional impairment. Aside from therapist-directed rehabilitation, few efficacious recovery tools are available for use by stroke survivors in their own home. Game-based virtual reality systems have already shown promising results in therapist-supervised settings and may be suitable for home-based use.
Objective: We aimed to assess the feasibility of unsupervised home-based use of a virtual reality device for hand rehabilitation in stroke survivors.
Methodology: Twenty subacute/chronic stroke patients with upper extremity impairment were enrolled in this prospective single-arm study. Participants were instructed to use the Neofect Smart Glove 5 days per week for 8 weeks, in single sessions of 50 minutes or two 25-minute sessions daily. We measured (1) compliance to prescribed rehabilitation dose, (2) patient impression of the intervention, and (3) efficacy measures including the upper extremity Fugl-Meyer (UE-FM), the Jebsen-Taylor hand function test (JTHFT) and the Stroke Impact Scale (SIS).
Results: Seven subjects (35%) met target compliance of 40 days use, and 6 subjects (30%) used the device for 20-39 days; there were no age or gender differences in use. Subjective patient experience was favorable, with ninety percent of subjects reporting satisfaction with their overall experience, and 80% reporting perceived improvement in hand function (figure 1). There was a mean improvement of 26.6±48.8 seconds in the JTHFT (p=0.03) and 16.1±15.3 points in the domain of the SIS that assesses hand function (p<0.01). There was a trend towards improvement in the UE-FM (2.2±5.5 points, p=0.10).
Conclusions: A novel virtual reality gaming device is suitable for unsupervised use in stroke patients and may improve hand/arm function in subacute/chronic stroke patients. A large-scale randomized controlled trial is needed to confirm these results.
[Abstract] Virtual reality therapy for upper limb rehabilitation in patients with stroke: a meta-analysis of randomized clinical trials
Background: Stroke is a major cause of life-long disability in adults, associated with poor quality of life. Virtual reality (VR)-based therapy systems are known to be helpful in improving motor functions following stroke, but recent clinical findings have not been included in the previous publications of meta-analysis studies.
Aims: This meta-analysis was based on the available literature to evaluate the therapeutic potential of VR as compared to dose-matched conventional therapies (CT) in patients with stroke.
Methods: We retrieved relevant articles in EMBASE, MEDLINE, PubMed, and Web of Science published between 2010 and February 2019. Peer-reviewed randomized controlled trials that compared VR with CT were included.
Results: A total of 27 studies met the inclusion criteria. The analysis indicated that the VR group showed statistically significant improvement in the recovery of UL function (Fugl-Meyer Upper Extremity [FM-UE]: n = 20 studies, Mean Difference [MD] = 3.84, P = .01), activity (Box and Block Test [BBT]: n = 13, MD = 3.82, P = .04), and participation (Motor Activity Log [MAL]: n = 6, MD = 0.8, P = .0001) versus the control group.
Conclusion: VR appears to be a promising therapeutic technology for UL motor rehabilitation in patients with stroke.
[ARTICLE] Randomized Feasibility Trial of a Novel, Integrative, and Intensive Virtual Rehabilitation Program for Service Members Post-Acquired Brain Injury – Full Text
Acquired Brain Injury, whether resulting from Traumatic brain injury (TBI) or Cerebral Vascular Accident (CVA), represent major health concerns for the Department of Defense and the nation. TBI has been referred to as the “signature” injury of recent U.S. military conflicts in Iraq and Afghanistan – affecting approximately 380,000 service members from 2000 to 2017; whereas CVA has been estimated to effect 795,000 individuals each year in the United States. TBI and CVA often present with similar motor, cognitive, and emotional deficits; therefore the treatment interventions for both often overlap. The Defense Health Agency and Veterans Health Administration would benefit from enhanced rehabilitation solutions to treat deficits resulting from acquired brain injuries (ABI), including both TBI and CVA. The purpose of this study was to evaluate the feasibility of implementing a novel, integrative, and intensive virtual rehabilitation system for treating symptoms of ABI in an outpatient clinic. The secondary aim was to evaluate the system’s clinical effectiveness.
Materials and Methods
Military healthcare beneficiaries with ABI diagnoses completed a 6-week randomized feasibility study of the BrightBrainer Virtual Rehabilitation (BBVR) system in an outpatient military hospital clinic. Twenty-six candidates were screened, consented and randomized, 21 of whom completed the study. The BBVR system is an experimental adjunct ABI therapy program which utilizes virtual reality and repetitive bilateral upper extremity training. Four self-report questionnaires measured participant and provider acceptance of the system. Seven clinical outcomes included the Fugl-Meyer Assessment of Upper Extremity, Box and Blocks Test, Jebsen-Taylor Hand Function Test, Automated Neuropsychological Assessment Metrics, Neurobehavioral Symptom Inventory, Quick Inventory of Depressive Symptomatology-Self-Report, and Post Traumatic Stress Disorder Checklist- Civilian Version. The statistical analyses used bootstrapping, non-parametric statistics, and multilevel/hierarchical modeling as appropriate. This research was approved by the Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences Institutional Review Boards.
All of the participants and providers reported moderate to high levels of utility, ease of use and satisfaction with the BBVR system (x- = 73–86%). Adjunct therapy with the BBVR system trended towards statistical significance for the measure of cognitive function (ANAM [x- = −1.07, 95% CI −2.27 to 0.13, p = 0.074]); however, none of the other effects approached significance.
This research provides evidence for the feasibility of implementing the BBVR system into an outpatient military setting for treatment of ABI symptoms. It is believed these data justify conducting a larger, randomized trial of the clinical effectiveness of the BBVR system.
Frequent use of improvised explosive devices (IEDs) in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) resulted in traumatic brain injury (TBI) being called the signature injury of recent conflicts.1 According to Department of Defense (DoD) reports, 379,519 service members received a TBI diagnosis from 2000 to 2017.2 Traumatic brain injuries are a subtype of acquired brain injury (ABI), which refers to any post-natal brain injury.3 Acquired brain injuries commonly present with symptoms of cognitive and motor impairment, and emotional instability that may persist for years and affect performance of activities of daily living (ADLs).4,5 Though survival rates of mild TBI (mTBI) are high, the resulting diminished quality of life calls for a greater focus on long-term TBI rehabilitative care.6
Another category of ABI, Cerebral Vascular Accident (CVA), often presents with similar impairments, such as diminished memory, upper extremity weakness and spasms, and depression.7–9 Moreover, those who have experienced a TBI are also at higher risk of CVA than those who have not.10,11 The majority of neurological recovery after TBI and CVA typically occurs within the first 6 months of injury, but training factors such as intensity, repetition, duration, patient motivation, and patient engagement may impact long-term treatment effectiveness on individuals in the chronic phase.12–16
Traditional rehabilitation protocols for individual’s post-ABI, such as proprioceptive neuromuscular facilitation (PNF), are widely recognized but underutilized by therapists.17 Additionally, hands-on interventions, while well known, have limited evidence supporting their success with chronic ABI rehabilitation.18 With technological advancements it may be possible to link the traditional therapies with progressive opportunities, while also increasing patient engagement and decreasing provider burden.
One method of post-ABI rehabilitation with growing clinical acceptance is virtual reality (VR). Virtual reality is defined as a synthetic world that responds in real time to changes in user input, creating a constantly-engaging environment in which users participate.19 Virtual rehabilitation utilizes VR in a variety of clinically relevant domains,20 and offers a unique platform for ABI rehabilitation by engaging patients in appropriately challenging tasks.21 It provides the needed intensity of care, can unify treatment in an integrative rehabilitation, and can involve bimanual interactions engaging both hemispheres.22 A review of studies evaluating improvements in cognitive domains (e.g., executive function) indicates that computer-based cognitive rehabilitation programs which are tailored to the participant’s abilities often produce greater results compared to non-personalized cognitive rehabilitation computer programs.23
BrightBrainer Virtual Rehabilitation System
The BrightBrainer Virtual Rehabilitation (BBVR) program is a computer-based VR platform that utilizes real-time bimanual interaction for the purpose of increasing cognitive engagement compared to simple mouse, or single finger touch interaction. Bilateral training has been found to promote improved motor functioning for people who have experienced ABI, above and beyond unilateral training.24,25 This system facilitates split attention training (focusing), task sequencing (alternating actions between arms), hand-eye coordination, and dual tasking through use of simultaneous cognitive and motor challenges. Though the BBVR system was originally developed for geriatric patients with CVA, the use of adaptable games, bimanual tasks, and repetition may make it translatable as a tool for ABI treatment in a military population.26
While literature on VR therapy post-ABI is abundant, many of the systems either focus only on rehabilitation of one aspect of post-ABI deficits,27 or are too physically large to implement in most clinics.28 The BBVR system is unique because it combines cognitive and physical training in a compact, adaptive VR system which can be implemented largely unobtrusively into clinical space. This pilot study implemented the BBVR system within a Military Treatment Facility’s (MTF) outpatient occupational therapy clinic as a 6-week intervention for participants with ABI. The primary aim was to evaluate the feasibility of integrating the BBVR system into the clinic for both 1-on-1 provider-participant interaction and concurrent treatment in which 1 provider oversees 2 participants at a time. The 3 secondary aims were: (1) to evaluate the preliminary clinical effectiveness of the BBVR system in terms of motor function, cognitive performance, and behavioral/emotional symptoms; (2) to evaluate the dose-response effect of the BBVR system; and (3) to evaluate the correlation between participant-level BBVR game performance and longitudinal change in clinical outcomes.
[ARTICLE] A combination of multimodal physical exercises in real and virtual environments for individuals after chronic stroke: study protocol for a randomized controlled trial – Full Text
Multimodal physical exercises already have well-established benefits for the post-stroke population that influence gait functional capacity, balance, gait, cognition, and quality of life. This type of intervention can be performed in both real and virtual environments. Considering the characteristics of both environments, it is questioned to what extent the combination of interventions in real and virtual environments could result in improvement in post-stroke impairments.
We will conduct a randomized clinical trial with three groups: a real multimodal group (RMG), a virtual multimodal group (VMG), and a combined multimodal group (CMG). It was estimated that we will need a sample of 36 participants (12 per group). RMG individuals will only perform multimodal physical exercises in a real environment two times per week for 60 min per session for 15 weeks. VMG individuals will perform exercises of the same duration over the same time frame but only in a virtual environment. CMG individuals will hold a weekly session in a real environment and another weekly session in virtual environment. The primary outcome measure will be health-related quality of life, evaluated using the Stroke Impact Scale; effects on cognition (Montreal Cognitive Assessment), balance (Berg Balance Scale), mobility (Timed Up & Go), self-selected gait speed (10-meter walk test), and gait functional capacity (6-min walk test) will be investigated as secondary outcome measures. Participants will be evaluated before the beginning of the intervention, immediately after the end of the intervention, and at 1-month follow-up without exercise. If the data meet the assumptions of the parametric analysis, the results will be evaluated by analysis of variance (3 × 3) for the group factor, with repeated measures while taking into account the time factor. The post hoc Tukey test will be used to detect differences (α = 0.05).
This study represents the first clinical trial to include three groups considering physical exercise in real and virtual environments, isolated and combined, that counterbalances the intensity and volume of training in all groups. This study also includes a control of progression in all groups along the 15-week intervention. The outcome measures are innovative because, according to International Classification of Functioning, Disability and Health, activity and participation are the targets for effectiveness evaluation.
The diverse impairments observed after a stroke, associated with the reduction of intrinsic motivation and the presence of preexisting or acquired comorbidities, lead to a vicious cycle of decreased activity and increased exercise intolerance. As a consequence, secondary complications, such as reduced cardiorespiratory fitness, muscle atrophy, osteoporosis, and circulation impairment in the lower extremities, may occur and generate greater dependence in the activities of daily living and impact the social interactions of these individuals .
Different modalities of physical exercises already have well-established benefits for individuals after chronic stroke, including repercussions for cardiovascular capacity , muscle strength [3, 4], balance [5, 6], gait [7, 8], and cognition . In order to maximize the effects of the exercises, there is a tendency to investigate the effects of multimodal protocols. According to Saunders et al. , a multimodal protocol refers to interventions based on the combination of physical exercises of different components, such as cardiorespiratory, muscular strength, and flexibility.
Multimodal physical exercises can be performed in both real and virtual reality environments. The interventions performed in real environments are the most commonly used in the clinical context. Characteristics of interventions performed in real environments include a high interactive relationship between the professional and the patient, high ecological validity, the possibility of individual or group applications, not requiring technological resources, and the ability to be applied in the home according to each patient’s needs.
Conversely, virtual reality-based interventions present features such as an environment rich in visual and auditory information with immediate and multisensory feedback , real-time simulation of tasks or environments, three-dimensional interactive and immersive experiences, a computerized interface, active and safe patient participation , and the ability to provide information with an external focus of attention [13, 14]. In a systematic review, Laver et al.  found that the addition of virtual reality to conventional methods resulted in improved upper limb function. However, they also found insufficient evidence regarding the superiority of virtual reality for promoting walking speed and balance. They were unable to pool results related to cognition, improvement of social participation, and health-related quality of life (HRQoL) because few studies included assessments of cognition and HRQoL to achieve meta-analysis requirements for these outcomes . Therefore, these parameters should be investigated in future studies; in addition, the authors also emphasized the need for training lasting longer than 15 h of intervention and that future studies should set the number of participants screened for eligibility criteria.
Considering the characteristics of both environments, it is questioned to what extent the combination of interventions in the real and virtual environments could result in improvement in post-stroke impairments. There are few studies that have sought to find answers to this question. In the Shin et al.  study, the control group performed 1 h of occupational therapy per session, and the experimental group performed 30 min of occupational therapy plus 30 min of virtual reality. The results showed positive effects in both groups, except for the domain related to the limitations due to physical problems measured by the Short Form Health Survey scores, in which experimental group (EG) obtained greater benefits. Rajaratnam et al.  found positive results for balance and mobility measurements for the group that performed 40 min of conventional therapy plus 20 min of self-directed virtual reality balance training per session, compared with the control group, which performed 60 min of conventional therapy.
Saposnik and Levin  claimed there were few publications regarding the combination of multimodal physical exercises in real and virtual environments. Most of the existing studies did not investigate long-term effects, including follow-up, and added intervention time to the experimental groups, which provided them with an advantage in the total intervention time received. In addition, there is an important diversity in the literature regarding the profile characteristics of individuals with stroke, considering acute, subacute, and chronic patients. Thus, the results found in the previous studies [19,20,21,22,23,24] do not allow consistent conclusions to be made about the effects of the combination of multimodal exercises in real and virtual environments in individuals after chronic stroke.
This study seeks to answer whether the combination of multimodal physical exercises in real and virtual environments could bring additional benefits to the quality of life, cognition, gait, and balance of individuals after chronic stroke. We also intend to clarify the effects of interventions with multimodal physical exercises when performed only in a real environment or only in a virtual environment and to investigate whether the possible effects remain after 1 month without participating in physical exercises.
This study aims to investigate the effects of a protocol of multimodal physical exercises in real and virtual environments for individuals who have survived a stroke.[…]
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