File
Oliveira TDP1, Lourenço MA1, Miranda C1, d'Alencar M1, Pimentel Piemonte ME1
1University of Sao Paulo, Physical Therapy, Sao Paulo, Brazil
Background: Virtual Reality (VR) has been appointed as a novel and efficient tool to advance the results of physiotherapeutic treatment to improve balance in people with Stroke. However, a lot of question about the methods for delivery this kind of approach have to be answered for building a strong evidence to support the recommendation for clinical practice. One of these key questions consists of role of physiotherapist (PT)intervention during this kind of training.
Purpose: To compare the effects of three distinct approaches to improve the balance in people with chronic sequel of Stroke (PWS): (1) balance training using VR with PT´s manual intervention, balance training using VR without PT´s manual intervention and usual balance training.
Methods: A randomized controlled trial was conducted including a total of 45 participants, 14 females, mean age of 49,33 years (SD=11,2), mean post-stroke duration 5.2 years (SD=4.5), 18 right paretic side, selected according to adequate inclusion criteria. Participants were randomly allocated into an PT´s manual intervention group (PTMG) that performed the balance training based on games from Nintendo Wii FitTM (NWF) guided by manual stimulus provided by PT, a PT´s no manual intervention group (PTnMG) that performed an identical training with no PT manual intervention and a control group (CG) that performed usual balance training, without VR, guided by a PT. The NWF game has been proposed as a low-cost alternative for VR training that offers good reliability. Training consists of 14 individual intervention sessions (2 per week). Both trainings using VR (PTMG and PTnMG) were similar apart from the offer of PT's manual intervention for PTMG to help the PWS to reach the best performance without using compensatory movements. The primary outcomes were Balance Evaluation Systems Test (BESTest) to assess the balance and Lower Limb subscale of the Fugl-Meyer Assessment (FMA-LE) to assess lower limb motor function. All outcomes were applied at baseline (BT), 1-week (FU7d) and 2-month follow-up (FU60d).
Results: All participants in PTMG and PTnMG were able to improve their games performance. Two 3X3 ANOVA using as factor Group (PTMG; PTnMG and CG) and Evaluations (BTXFU7dXFU60d) as repeated measures were performed for each outcome score. The results showed a significant interaction between the factors for FMA-LE (F(4, 80)=5.7209, p=.00042, ES=.91) and BESTest (F(4, 80)=3.7536, p=.00753, ES= .99). Tukey pos-hoc test (TT) for these measures showed a significant increase in the score for both outcomes that remained at end of the study only for PTnMG. Most important, the TT showed a significative worsening in section I of BESTest (Biomechanical constraints) for PTnMG (p=.007).
Conclusion(s): Although the balance training based on Virtual Reality can improve the balance of PWS, the similar training in which the PWS receive no PT´s manual intervention during the training can worsen the postural alignment due to the increased asymmetric compensatory strategies.
Implications: The proper manual stimulus provided by a PT during the balance training using RV is crucial to guarantee positive results. The use of this kind of approach without PT assistance can worsen some important aspects of postural control in PWS.
Keywords: Virtual Reality, Balance, Postural control
Funding acknowledgements: Fundação Faculdade de Medicina
Associação Brasil Parkinson
Purpose: To compare the effects of three distinct approaches to improve the balance in people with chronic sequel of Stroke (PWS): (1) balance training using VR with PT´s manual intervention, balance training using VR without PT´s manual intervention and usual balance training.
Methods: A randomized controlled trial was conducted including a total of 45 participants, 14 females, mean age of 49,33 years (SD=11,2), mean post-stroke duration 5.2 years (SD=4.5), 18 right paretic side, selected according to adequate inclusion criteria. Participants were randomly allocated into an PT´s manual intervention group (PTMG) that performed the balance training based on games from Nintendo Wii FitTM (NWF) guided by manual stimulus provided by PT, a PT´s no manual intervention group (PTnMG) that performed an identical training with no PT manual intervention and a control group (CG) that performed usual balance training, without VR, guided by a PT. The NWF game has been proposed as a low-cost alternative for VR training that offers good reliability. Training consists of 14 individual intervention sessions (2 per week). Both trainings using VR (PTMG and PTnMG) were similar apart from the offer of PT's manual intervention for PTMG to help the PWS to reach the best performance without using compensatory movements. The primary outcomes were Balance Evaluation Systems Test (BESTest) to assess the balance and Lower Limb subscale of the Fugl-Meyer Assessment (FMA-LE) to assess lower limb motor function. All outcomes were applied at baseline (BT), 1-week (FU7d) and 2-month follow-up (FU60d).
Results: All participants in PTMG and PTnMG were able to improve their games performance. Two 3X3 ANOVA using as factor Group (PTMG; PTnMG and CG) and Evaluations (BTXFU7dXFU60d) as repeated measures were performed for each outcome score. The results showed a significant interaction between the factors for FMA-LE (F(4, 80)=5.7209, p=.00042, ES=.91) and BESTest (F(4, 80)=3.7536, p=.00753, ES= .99). Tukey pos-hoc test (TT) for these measures showed a significant increase in the score for both outcomes that remained at end of the study only for PTnMG. Most important, the TT showed a significative worsening in section I of BESTest (Biomechanical constraints) for PTnMG (p=.007).
Conclusion(s): Although the balance training based on Virtual Reality can improve the balance of PWS, the similar training in which the PWS receive no PT´s manual intervention during the training can worsen the postural alignment due to the increased asymmetric compensatory strategies.
Implications: The proper manual stimulus provided by a PT during the balance training using RV is crucial to guarantee positive results. The use of this kind of approach without PT assistance can worsen some important aspects of postural control in PWS.
Keywords: Virtual Reality, Balance, Postural control
Funding acknowledgements: Fundação Faculdade de Medicina
Associação Brasil Parkinson
Topic: Neurology: stroke; Disability & rehabilitation; Robotics & technology
Ethics approval required: Yes
Institution: Faculty of Medicine of University of São Paulo
Ethics committee: Ethical commitee of FMUSP
Ethics number: 6365
All authors, affiliations and abstracts have been published as submitted.
