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Pimentel Piemotne M.E.1, Lourenço M.1, D'Allencar M.1, Miranda C.1, Oliveira T.1
1University of Sao Paulo, Physical Therapy, Sao Paulo, Brazil
Background: Stroke causes sensory-motor impairment, leading to balance problems, falls, and functional limitations that result in the incapacity to perform different tasks of daily living. The Virtual Reality (VR) has been proposed as a novel therapeutic tool for motor rehabilitation that offers as main advantage the high level of motivation, augmented feedback and motor and cognition challenges. According to current evidences, the training in VR may be efficient to improve balance and gait performance in people with chronic sequels of Stroke (PWS). However, according to our best knowledge, there is no study that had investigated the role of physiotherapist (PT) during this kind of training. It is a fundamental issue to establish the guidelines for the therapeutic use for this kind of intervention in Stroke.
Purpose: To compare the effect of balance training in VR guided by manual and verbal orientation provided by a physiotherapist during the training versus an identical training in absence of PT orientation, on balance, gait and functional performance in PWS.
Methods: A randomized controlled trial was conducted with a total of 24 participants 14 females, mean age of 54,6 years (SD=10,2), mean post-stroke duration 6,7 years (SD=10,2), 18 left paretic side, took part in the study. Patients were randomly allocated into an experimental group (EG) that performed the balance training based on games from Nintendo Wii FitTM (NWF) guided by manual and verbal orientations provided by PT and a control group (CG) that performed an identical training with no PT orientation. 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 were similar apart from the offer of PT orientation for EG to help the PWS to reach the best performance without using compensatory movements. The primary outcomes were Lower Limb subscale of the Fugl-Meyer Assessment (FMA-LE) to assess lower limb motor function; Dynamic Gait Index (DGI) for gait; Balance Evaluation Systems Test (BESTest) for balance, Limits of Stability for paretic side (LOS) and Rhythmic Weight Shift (RWS) to assess balance on force plate. All outcomes were applied at baseline (BT), 1-week (FU7d) and 2-month follow-up (FU60d).
Results: All participants were able to improve their games performance. Five 2X3 ANOVA using as factor Group (EGXCG) and Evaluations (BTXFU7dXFU60d) as repeated measures were performed for each outcome score. The results showed a significant interaction between the factors for FMA-LE, DGI, LOS, RWS and BESTest (p=.01, ES=.88; p=.0004, ES=.98;p=.02,ES=.83;p=.01,ES=.88). Tukey pos-hoc test (TT) for these measures showed a significant increase in the score for EG only, that remained at end of the study
Conclusion(s): The manual and verbal orientations offered during the balance training based on NWF games were fundamental to improve the balance, gait performance and functionality of PWS.
Implications: The therapeutic effects of balance training in VR for PWS depend on the manual and verbal orientations provided by PT in order to inhibit the compensatory strategies which can increase the asymmetry in postural control.
Funding acknowledgements: Faculty of Medicine-University of Sao Paulo
Topic: Neurology: stroke
Ethics approval: All patients signed a term approved by Faculty of Medicine University of São Paulo, number 303.428
All authors, affiliations and abstracts have been published as submitted.
