Virtual reality training is a relatively new rehabilitation method used for patients with Parkinson’s Disease (PD). It involves using a gaming system such as the Wii fit board or other virtual reality systems in order to put the patients in different scenarios so that their balance, gait, and obstacle training can improve. Many studies have been conducted, supporting the findings that the use of a virtual reality system can improve the symptoms of patients with PD. Virtual reality training can improve the motor function and sensory organization in PD patients if used in a physical therapy treatment protocol. There are little to no legal concerns when using a VR system as long as the patient is aware of the possible side effects. Based on the research, VR training should be implemented into a PD physical therapy treatment protocol in order to increase the gait, balance, and obstacle negotiation of the patient.
Keywords: parkinson’s disease rehab, virtual reality rehab, virtual reality motor training
The Use of Virtual Reality in Parkinson’s Disease Rehabilitation
Parkinson’s Disease (PD) is the second most common degenerative neurological disorder
that affects nearly one million Americans (Marras et al., 2018). Several types of treatment plans are recommended for people suffering from PD including medication and physical therapy. According to the Parkinson’s Disease Foundation (2019), Parkinson’s Disease affects the motor function of people, making it difficult for them to walk, balance, and step over obstacles. A large part of physical therapy for PD patients is to improve their gait and balance. Improvement of gait and balance decreases the patients’ fall risk when they are walking or standing. Physical therapists work with PD patients to improve their gait, balance, and strength by using a variety of exercises.
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Today, the traditional treatment protocol is strengthening exercises combined with treadmill training (TT). The typical PD treatment protocol only focuses on flat gait training with no obstacles, which is not always the type of surface a patient may be walking on. However, physical therapists are constantly trying to find better exercises and treatment practices to better serve their patients with Parkinson’s Disease. A new treatment protocol that some physical therapists have been using with their PD patients is virtual reality (VR) training. VR training allows the patient to practice their gait, balance, and obstacle negotiation while improving their sensory organization (Liao, Yang, Cheng, Wu, Fuh, & Wang, 2015). The use of the VR-based gaming system allows the physical therapist to put the patient into different scenarios including a variety of surfaces and obstacles depending on the severity of their symptoms. Even though this type of treatment is relatively new, data has shown that VR training can improve gait function, dynamic balance, and obstacle negotiation in patients with Parkinson’s Disease. The goal of this paper is to determine if the use of virtual reality (VR) gait training treatment can improve dynamic balance, gait, and obstacle negotiation in patients with Parkinson’s Disease more effectively compared to face-to-face balance and gait training.
The use of virtual reality in PD rehabilitation is relatively new; however, there have been many studies regarding how VR training can improve the dynamic balance, gait, and obstacle negotiation in PD patients. The studies that have been conducted used patients with varying levels of Hoehn and Yahr staging scales and varying severity of symptoms. Most of the studies used the traditional protocol of treadmill training (TT) as the control group and the virtual reality training as the experimental group. Researchers looked at how virtual reality training can improve gait by first having the patients walk normally to get a baseline result and then walk with the VR system. The results show that following virtual reality (VR) training, patients with Parkinson’s Disease experienced a sustained improvement in their walking abilities (Badarny, Aharon-Peretz, Susel, Habib, & Baram, 2014). If a PD patient can improve their walking abilities, this increases their activity level which is an important aspect in PD rehabilitation.
Likewise, similar research focused on looking at how the virtual reality gaming system can improve gait and balance in patients with Parkinson’s disease (Esculier, Vaudrin, Beriault, Gagnon, & Tremblay, 2012; Gonçalves, Leite, Orsini, & Pereira, 2014). These studies provide evidence that by implementing the VR gaming system into a PD patients’ physical therapy rehabilitation protocol it can improve their gait, balance, and quality of life. By using the activities (games) on the Wii Fit, physical therapists can put their PD patients in a variety of settings in order to improve their motor function. Researchers also looked at how using different activities on the Wii Fit effected their PD patients’ gait. By using multiple activities in the VR programs, patients showed improvements in sensorimotor performance in gait, with an increase in stride length and gait speed, and a reduction in motor impairment (Gonçalves, Leite, Orsini, & Pereira, 2014; Pompeu et al., 2014). Stride length and gait speed are important factors when considering gait ability; if a patient has a longer stride length, it allows him to walk further in a shorter amount of time with an increase in stability. Along with improving motor function in PD patients, some studies suggest that VR training can also improve non-motor function and quality of life. According to Herz, Mehta, Sethi, Jackson, Hall, and Morgan (2013), Wii therapy provides short-term motor, non-motor, and quality of life benefits in PD patients. The Parkinson’s Disease Questionnaire (PDQ-39) evaluates the quality of life of PD patients and is used in many studies. Improving quality of life is another main goal of a physical therapist working with a PD patient that needs to be addressed during their therapy sessions.
Freezing of gait (FOG) is a main symptom of gait in patients who have Parkinson’s Disease. This is a major concern for physical therapists because it can allow the patient to increase their fall risk as well as decrease the accuracy of their gait. Along with their increased fall risk, their quality of life could be decreased because they do not want to walk in public fearing they will be judged. Researchers have found that following the virtual reality intervention, dual-task cognitive and motor parameters (stepping time and rhythmicity) significantly improved and the number of FOG episodes decreased (Killane et al., 2015). By reducing the amount of FOG episodes, a patient has, he/she will be able to stay more active which has been shown to improve symptoms. Along with decreasing the amount of FOG episodes a patient has, his/her balance would improve as well, decreasing his/her fall risk.
Another main concern for physical therapists is the balance of their PD patients. Researchers found that the use of the Wii Fit balance board improved balance, postural sway, and the ability of modify gait to different demands (Mhatre et al., 2013; Yen et al., 2011). Yen et al. (2011) specifically looked at the sensory organization test (SOT) which provides information on the three main sensory systems that are involved in balance and stability. The research found that patients that are engaging in VR training improve their SOT scores, leading to an increase in balance and stability when they are walking or standing. Along with gait, balance is an important aspect that PD patients should improve on. As research shows, implementation of a VR system can improve both balance and gait in patients with Parkinson’s Disease.
Most of the studies that looked at VR training did not look at the differences between VR training and TT. However, Mirelman et al., (2010) concluded that by combining TT and VR training, gait speed significantly improved during usual walking, during dual task, and while negotiating over ground obstacles. These findings are significant because the treatment protocol for PD patients could shift by adding VR training to TT since it has been shown to increase gait, balance, and obstacle negotiation. Balance and stability scores of the VR group were greater than that of the conventional balance training group. Patients that are engaging in VR training improve their balance and gait, leading to an increase in stability when they are walking or standing compared to the use of the conventional balance training protocol. Implementation of the VR gait and balance training into the rehabilitation plan of a PD patient allows the patient to work on and improve these facets more effectively compared to the traditional balance and gait protocol.
Positive and Negative Effect of Virtual Reality Training
Virtual reality training in Parkinson’s Disease patients has the potential to improve their dynamic balance, gait, and obstacle negotiation. If PD patients have improved balance, gait, and obstacle negotiation they will be able to be more active throughout the day which has been shown to decrease the severity of their symptoms. Along with improving the level of physical activity, if a PD patient has improved balance and gait the chance of them having a fall is decreased. Studies suggest that VR training programs can improve balance, gait, and obstacle negotiation in PD patients effectively. Another positive effect of VR training is that a physical therapist can put his/her patients in a variety of environments and difficulties to improve their motor function. A physical therapist cannot do this with the traditional treadmill training. Also, VR training can be engaging and even fun for the patient which can also stimulate their brain function and help improve motor function. This type of treatment is relatively inexpensive and can be purchased at any store that sells video games. Since a Wii Fit or similar gaming system is so available it would be easy for physical therapists or rehabilitation facilities to purchase in order to improve PD treatment plans. The Wii Fit board or a similar gaming system can also give the physical therapist real-time feedback as to how the patient is progressing through each game or how they have progressed or regressed from week to week. VR training has been shown to be safe for both the patient and the physical therapist, with little to no adverse side effects on patients. Even though VR training has many positive effects, it also has some negative effects.
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Some negative effects of VR training are that there could be some side effects including nausea, motion sickness, dizziness, and eye soreness. Another possible negative effect of VR training is that if the rehabilitation facility only has one VR game, that means that only one patient could be on it at a time and the other patient would have to wait or they would be involved in traditional treadmill training or balance exercises. As with any type of therapy, a patient might not like one of the games that they have to play, and that could cause some irritation on the part of the patient. This may lead the patient to not come back to therapy because they do not enjoy using the virtual reality system. Since PD affects mostly older adults, they might not be comfortable using this VR system and would rather use the traditional treadmill and balance exercises. Even with all of these negatives, using a VR system has many positive effects that outweigh the negative ones. If a patient is not comfortable using the new system, the physical therapist could slowly integrate it into their treatment plan. The VR system can be individualized to the specific patients’ needs and can be changed during a therapy session depending on how they are progressing.
Recommendations for Practice Guidelines
Based on the evidence collected, it is recommended that physical therapists start implementing virtual reality systems into their treatment plans for patients with Parkinson’s Disease. This treatment option has been shown to improve patient gait, balance, and obstacle negotiation in PD patients. By improving those facets in patients, it will allow the patient to be more active in their everyday life, reduce the risk of falling, and increase the overall quality of life. Since the VR system can be tailored to specific patient needs it can provide a more effective treatment plan for PD patients. When combined with traditional treadmill training, it can improve these factors which has been shown to directly affect the patients’ quality of life. Virtual reality training can work on a patients’ balance, obstacle negotiation, and gait through the use of one or several games. This increases the efficiency of the therapy session, whereas before with traditional treadmill training a patient could only work on their gait and balance.
It is important for a physical therapist to still include balance exercises, traditional treadmill training along with VR training. VR training is a fun way for the patient to be engaged in their therapy by being in different environments and varying levels of difficulty. VR training adds another level of therapy that a traditional treadmill and balance exercises cannot give a patient. During a VR training session, a physical therapist can put the patient on different terrains in order to train them how to walk in real life since not every surface a person walks on is flat. Some of the researchers even concluded that the use of VR training has improved a patients’ quality of life, which is very important especially when they are dealing with this disease. By improving a patients’ gait, balance, and obstacle negotiation, a patient can start to become more independent. Being more independent is what all physical therapists want for their patients, especially ones with PD. Integrating VR training into a PD patients physical therapy session, can improve both motor and non-motor function in a patient which is the overall goal of a physical therapist. Since VR training is relatively inexpensive and has been shown to improve those facets of a patients’ life, it is recommended that VR training be implemented into therapy protocols for patients with PD.
Legal and/or Ethical Concerns
There are not many ethical or legal concerns when considering the implementation of a virtual reality training program in Parkinson’s Disease patient rehabilitation. The only legal concern that a physical therapist would have to think about is providing the patient with proper paperwork explaining what the virtual reality system is and how it will be used. In this paperwork, it should also state the possible side effects of the VR system such as dizziness, nausea, and eye soreness. The patient would have to be informed about the VR system enough so that they would be able to make an informative decision if they would like to use it during their therapy session. As long as the patient gives consent to use the virtual reality system, there are no other legal or ethical concerns of using the VR system. With this in mind, the use of a virtual reality system is a safe and feasible way for patients with Parkinson’s Disease to improve their gait, balance, and obstacle negotiation during their physical therapy sessions.
Suggestions for Future Research
Presently, there are a variety of research studies that are investigating the effects of the use of a virtual reality system on the gait, balance, and obstacle negotiation of patients with Parkinson’s Disease. However, with all of the research studies the researchers noted one major limitation of their study. The use of a small sample size was a concern for all of the researchers and how it could apply to the rest of the PD population. Even though many individuals are suffering from Parkinson’s Disease, it is difficult to find these participants and involve them in a research study using the VR system. Even with this limitation, the results are still valid; however, future research needs to be done with a larger sample size in order to determine if the effects of the VR system can be applied to all individuals with PD. Future research should also be done in larger time amounts. Most of the current studies were in the time frame of three to six months. It would be suggested that future research looks at a longer time period such as eight to twelve months to examine if the results are similar. If the results were similar, then the use of a VR system could be used in therapy sessions, as well as in the homes of PD patients in order to keep improving their symptoms.
Another suggestion for future research is using PD patients with varying severity of symptoms. Most of the current studies that has been done looked at patients with low to moderate symptoms. Even though the research has been positive for those patients, the VR system might not have the same results with patients of higher ratings. If future research were to look at all patients of severity, then the results would be able to be generalizable to all types of patients. Using a control group in future studies could also improve the validity of the results. If studies looked at patients who did not have any type of gait or balance training and compared them to patients who were involved in VR system training, that would only enhance the legitimacy of the results. Researchers could also look at a control group that had no gait or balance training, a group who had traditional treadmill training (TT) combined with VR training, and a group that only had TT. This research would allow physical therapists to create a more effective treatment plan for their PD patients. If those results concluded that a treatment plan using both TT and VR significantly improved balance, gait, and obstacle negotiation compared to the other groups, then a patient could experience a more effective treatment plan for their PD that included TT and VR training. Furthermore, future research should always be conducted in order to keep giving PD patients the best possible treatment. It is important for physical therapists to keep updating themselves on current PD treatment research so that they are able to continue to improve their patients’ symptoms and the overall quality of life.
Overall, the use of a virtual reality system can improve a number of symptoms a patient with Parkinson’s Disease may be experiencing. VR systems allow a physical therapist to create an individualized experience for each patient while working on multiple facets of their gait, balance, and obstacle negotiation. Moreover, VR systems have shown to increase gait stride length, balance, and obstacle negotiation better than the traditional face-to-face treadmill and balance exercises. Along with increasing the motor function of PD patients, VR training has shown to improve the quality of life and independence in those individuals. If a PD patient has more independence, they will be able to continue to stay active throughout their life without fear of falling every time they try to get up and walk around. If a PD patient is able to improve his/her gait, balance, and obstacle negotiation their risk of falling decreases, especially as they continue to improve those factors. Since the VR system is relatively inexpensive and can be purchased almost anywhere, it is a feasible way for physical therapists to implement this into their PD patient’s treatment plan. If a patient continues to improve, there is a possibility that they could have a VR system in their home so that they can continue to work on their balance, gait, and obstacle negotiation anytime they want and not just during their therapy sessions. Upon future research, the use of a VR system could be applied to the physical therapy treatment plan since it has been shown to increase those factors more effectively compared to face-to-face treadmill and balance training. Since there are little to no legal concerns involved in using the VR system it would be very realistic for a physical therapist to implement this type of training into a treatment plan. As long as a patient gives consent to using this system after knowing and understanding all about this system there are no other legal or ethical concerns that the physical therapist has to think about. Based on the research done on this type of treatment, VR training should be implemented in the therapy plan for patients suffering from Parkinson’s Disease since it has been shown to be more effective compared to the traditional face-to-face training protocol.
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