Virtual Reality Gets Real Results in TBI Rehabilitation

Daniel M. Keller, PhD

October 03, 2013

VIENNA, Austria — Virtual-reality (VR) game–based therapy led by a virtual personal instructor produces real improvements in coordination in patients with traumatic brain injury (TBI) and moderate postural and coordination deficits, a study shows.

Speaking with Medscape Medical News, lead researcher Ksenia Ustinova, PT, PhD, an associate professor of physical therapy in the School of Rehabilitation and Medical Sciences at Central Michigan University in Mount Pleasant, said that VR game–based therapy can be done at home and augments conventional physical therapy. Patient feedback has been positive.

Presenting her study here at the XXI World Congress of Neurology (WCN), Dr. Ustinova noted that the TBI population is one of the largest disability groups, and most patients are young and responsive to treatment. Regardless of the type and location of the injury, multiple postural and coordination mechanisms may be affected.

VR therapy consists of a series of VR exercises and interactive games that address postural and coordination problems. They resemble the content, sequence, timing, and dosage of a regular therapeutic program, she said. The therapy is delivered through a relatively low-cost Microsoft Xbox Kinect system, which has the ability to record a patient's movements at 30 Hz. Patients can use the VR system in the clinic or at home.

Because patients did not initially perceive the game-based approach as "real therapy," the researchers created an onscreen therapist to lead them, named PIA, the Personal Instructional Avatar. Patients did not seem to care that PIA, too, was virtual.

Therapy in 3 Parts

Each 55-minute therapy session consisted of an introduction by PIA, followed by 15 minutes of seated exercises in which the patient performs exercises that PIA demonstrates to improve coordination, sitting balance, and eye-head coordination.

Next is 10 minutes of seated exercises with an object to improve eye-head coordination, gaze fixation, and coordination while manipulating the object. Finally, PIA leads the standing patient for 20 to 25 minutes in tasks designed to improve dynamic and static balance, arm-trunk-leg coordination, precision of arm motion, and stepping ability and agility.

The single-arm, phase 2 clinical efficacy study that Dr. Ustinova presented was conducted in-clinic at 3 sites by supervised PT students. Fifteen patients (9 men) had a mean age of 33 ± 7.2 years and had sustained a TBI an average of 4.2 years earlier. They were assessed by using various measures of balance, gait, ataxia, and functional reach, as well as with the Mini-Mental State Examination. Participants had no severe spasticity or paresis.

The study design involved 2 pretests conducted 2 to 4 weeks apart, 15 VR game–based sessions over 5 to 6 weeks followed by a post-test, and then a retention test 4 weeks later.

Good Results Within 6 Weeks

"[In] 3 out of 4 skills, movements were significant[ly improved], and they all exceeded the minimum detectable changes established for those skills," Dr. Ustinova reported. Patients improved their postural stability, gait, and arm movements at the time of the post-test, and these improvements were maintained completely or to some degree by the time of the retention test. Only ataxia failed to improve.

Table. Efficacy of Virtual Reality Game Therapy on Physical Outcomes in Patients With TBI

Outcome Post-Test Change From Pretest (Points) P Value
Berg Balance Scale 4.4 <.05
Functional Gait Assessment 4.5 <.05
Functional Reach Test 2.7 <.05
Ataxia Scale –2 NS

NS = not statistically significant.

Dr. Ustinova said appropriate patients can use the therapy at home, and she and her coworkers have established minimum criteria for balance, gait, and Mini-Mental State Examination scores useful in patient eligibility for home use. She said the good thing about failure on the test is that it is "virtual failure," and patients can repeat the exercises at will.

Looking ahead, she plans a larger clinical trial to test the comparative effectiveness of the VR-based therapy and to develop the system so that it can be made available on compact disc or by online subscription.

Although the researchers chose to include only younger TBI patients, session chair Rangrar Steen, MD, a retired neurologist and former head of the Department of Neurology at one of the hospitals of the University of Oslo, Norway, commented to Medscape Medical News that he was quite intrigued with the technology at his age and thinks that there is no reason to believe that older patients would not take to it.

He thought the addition of a virtual therapist was a good move. "I like that idea she said about the PIA. There has to be somebody to show and to be in contact with. I think that was a very good idea," he said.

By being able to use the system at home, "resources are not used to the extent that we see now ... You don't have to be in the institution or what costs a lot of money in the western world," he added. "If they can do it themselves, it would be a large step forward."

One limitation of the study is that it was a single-arm design without a control group. Dr. Steen said that fact makes it hard to tell what the natural course of the disease would be without the intervention.

However, the patients had sustained their TBIs an average of about 4 years earlier, so it may be reasonable to assume that they would not improve much over another 6 weeks without the intervention, but that assumption is yet to be tested.

Dr. Ustinova's research was supported by grants from the U.S. Department of Defense, Blue Cross Blue Shield Foundation of Michigan, and The Association of Schools of Allied Health Professions. Neither she nor Dr. Steen has disclosed any any other relevant financial relationships.

XXI World Congress of Neurology (WCN). Free Papers Session 8. Presented September 22, 2013.

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