Date Published: October 24, 2018
Publisher: Public Library of Science
Author(s): Corina Schuster-Amft, Kynan Eng, Zorica Suica, Irene Thaler, Sandra Signer, Isabelle Lehmann, Ludwig Schmid, Michael A. McCaskey, Miura Hawkins, Martin L. Verra, Daniel Kiper, Jacobus P. van Wouwe.
Virtual reality-based training has found increasing use in neurorehabilitation to improve upper limb training and facilitate motor recovery.
The aim of this study was to directly compare virtual reality-based training with conventional therapy.
In a multi-center, parallel-group randomized controlled trial, patients at least 6 months after stroke onset were allocated either to an experimental group (virtual reality-based training) or a control group receiving conventional therapy (16×45 minutes within 4 weeks). The virtual reality-based training system replicated patients´ upper limb movements in real-time to manipulate virtual objects.
54 eligible patients (70 screened) participated (15 females, mean age 61.3 years, range 20–81 years, time since stroke 3.0±SD 3 years). 22 patients were allocated to the experimental group and 32 to the control group (3 drop-outs). Patients in the experimental and control group improved: Box and Block Test mean 21.5±SD 16 baseline to mean 24.1±SD 17 follow-up; Chedoke-McMaster Arm and Hand Activity Inventory mean 66.0±SD 21 baseline to mean 70.2±SD 19 follow-up. An intention-to-treat analysis found no between-group differences.
Patients in the experimental and control group showed similar effects, with most improvements occurring in the first two weeks and persisting until the end of the two-month follow-up period. The study population had moderate to severely impaired motor function at entry (Box and Block Test mean 21.5±SD 16). Patients, who were less impaired (Box and Block Test range 18 to 72) showed higher improvements in favor of the experimental group. This result could suggest that virtual reality-based training might be more applicable for such patients than for more severely impaired patients.
Virtual reality-based rehabilitation systems are gaining popularity because of their ease of use, applicability to wide range of patients, and ability to provide patient-personalized training [1–3]. Additional reported benefits of virtual reality systems for both patients and health providers include increased therapy efficiency and a high level of attention in patients during training .
The study was conducted between December 1, 2012, and February 15, 2016 including the last follow-up assessment. In total, with a recruitment rate of 1.3, 54 patients were included, of whom 22 patients received virtual reality-based training (40.7%) and 32 (59.3%) patients received conventional therapy. All 22 patients (100%) in the virtual reality-based training group and 30 (93.8%) patients in the conventional therapy group completed the training.
The present multicenter parallel group randomized controlled trial aimed to investigate the efficacy of a virtual reality-based training with YouGrabber compared to conventional therapy as stand-alone therapy in patients in the chronic stage after stroke. As hypothesized, both patient groups significantly improved their performance in primary and secondary outcomes but did not show between-group differences after eight or 16 training sessions or after the two-month follow-up. These results are in line with recent publications on VR-based training from Brunner et al. and the systematic review update from Laver et al. [8, 36]. However, three non-significant trends should be further discussed: (1) subjectively perceived improved strength trend in the virtual reality-based training group compared to the CG, (2) the main scoring increase over the first eight compared to the second eight training sessions, and (3) the increased scoring in the BBT of the non-affected upper limb.
In conclusion, with the YouGrabber (now renamed Bi-Manu-Trainer) we used a virtual reality-based training system that was specifically developed for patients with sensorimotor impairments with three different display modes of the hand and arms as a safe training option. Virtual reality-based training and conventional physiotherapy and occupational therapy did not show significant differences when applied as a supervised one-to-one training. Virtual reality-based training and conventional therapy showed differently weighted therapy contents. However, considering the increasing numbers of patients after stroke in the future and the limited personnel and financial resources, a virtual reality-based training could support the rehabilitation process by increasing training time for patients with virtual reality-based group training sessions in inpatient or outpatient settings or at the patients’ home.