Virtual Reality and Parkinson's Disease

Top contributors: Guan, Johnny; Khan, Mohammed; Rice, Trevor

Introduction

Virtual reality (VR) technology has become increasingly prevalent in many spheres of technology, including healthcare rehabilitation. There is substantial research examining the effects of VR on Parkinson’s disease (PD).[1] PD is a neurodegenerative disorder that is traditionally managed by a combination of medication and physical therapy treatment.[1] With VR's increasing popularity, VR has the potential enhance treatment outcomes.


Virtual reality for rehabilitation of gait and balance in patients with parkinson’s

With the advent and recent popularity of VR technology, VR has been proposed as a possible rehabilitation tool in conjunction with traditional physiotherapy approaches. A recent review has illustrated that a sense of control, success, and an appropriate level of challenge are key ingredients that explain a patient’s immersion and enjoyment of VR systems.[2] VR systems optimize motor learning in a safe environment, and can help improve activities of daily living by replicating real-life scenarios.[1]

Within VR, augmented feedback about a PD patient’s performance enables repetitive practice of motor tasks, thus stimulating both motor and cognitive processes simultaneously. VR offers patients with neurological deficits, such as PD, an opportunity to develop new motor strategies, or to relearn motor abilities that were lost due to their injury or disease processes.[3][4][5] For example, a PD patient with akinesia will have trouble initiating a step, but will be able to step over an object that appears in their path.[6] Using this concept, VR can overlay objects in a patient’s visual field, encouraging the initiation of a step, improving function in these patients.[6] Additionally, other VR technologies focus on improving more broad symptoms of PD, such as being able to increase stride length and improve balance, in safe, controlled environments. An example of VR used in such a setting can be found here. When compared to traditional physiotherapy, experiments studying the effectiveness of VR in improving gait and balance outcomes, namely the Six-Minute Walk Test and Berg Balance Scale, have demonstrated that VR based training in PD patients leads to moderate improvements in step and stride length.[1]

The Nintendo Wii and Xbox Kinect have been used as VR tools in addressing PD symptoms. The rationale behind using VR systems lies in providing augmented visual and auditory feedback to gradually challenge postural control and balance during a task. This strategy bypasses the deficient motor generation system present in patients with PD, thus improving their motor response.[7] An area where VR training may be especially effective for addressing PD symptoms is fall prevention when there is poor input of visual and somatosensory systems.[8] A possible explanation for this is due to the conditions under which VR training occurs; where the visual and somatosensory systems are being altered and are unreliable, thus forcing the patient to rely on use of their vestibular system for balance.

Scientific rationale and advantages for using virtual reality

1. Enhance motivation/repetition: to learn a motor skill, patients require sufficient motivation to drive their repetitive practice of a skull.[9] VR may be a novel technology to most people, and with the the variations in environment and task possible with simulated virtual environments, patients are less likely to experience boredom. Patients can tolerate the extensive practice period by the variety provided by video games.[9]

2. Provide precise feedback: there is extensive evidence that the proprioceptive and exteroceptive feedback can induce profound cortical and subcortical changes associated with motor performance.[9] With the use of VR, the feedback is augmented through different settings. This can tailor and further enhance the physiological changes in patients with PD.

3. Transferability: one may be concerned that the motor skills learned from VR may not translate to real-world environments. However, there is a fair amount of evidence suggesting that patients have the ability to not only learn motor skills, but also translate them to the real world.[9]

4. Early stage learning: patients with severe PD may have problems learning a new motor skill, especially when it comes to the performance of complex motor skills.[9] With VR, patients can benefit from simplifying the task to its key components. In contrast, in a real world environment, there are many distractions that could occur and may slow down the learning as the patients attempt to distinguish the key aspects of the task.[9]


Limitations of virtual reality for Parkinson's disease

VR technology holds some limitations for patients with PD. These include the possibility of cognitive overload, cyber-sickness, or an inappropriate level and content of exercises for rehabilitation of PD.[10]

Additionally, home-based VR systems used for rehabilitation may be detrimental to performance, as patients may use compensatory movements to increase game performance. Patients may begin to prioritize game scores over their quality of movement, thus reducing training effects. Future home-based VR systems designed for neurological rehabilitation should ensure that compensatory movements cannot be used to improve game performance.[1]

It still remains unclear how VR systems may be adjusted to the specific needs of PD populations. Commercial VR systems for persons with neurological disorders have yet to be developed. Current systems designed for the general healthy population, such as the Xbox Kinect and Nintendo Wii, can hinder the effectiveness of such interventions and the safety for such populations.[1]

However, VR and physiotherapy interventions both have similar overall effects on gait, balance, and quality of life. In a recent 2016 systematic review, it was concluded that there is only low-quality evidence suggesting that VR can serve as a useful alternative to traditional physiotherapy in improving gait and balance in PD patients.[1]


Future research in virtual reality for Parkinson's disease

VR is still a relatively new technology. Few studies have been done, making generalizations to populations outside of the research circumstances difficult. Further research is needed to expand the evidence for the use of VR in PD populations. Future research should aim to examine the effectiveness of VR interventions in different disease stages of PD to determine the usefulness of VR-based interventions in the prevention of physical decline during the early stages of PD, and during the progression of PD in the middle to late stages.[1] Additionally, it should also focus on providing evidence-based recommendations regarding the frequency, duration, and content of VR interventions for PD populations .[1]


References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Dockx K, Bekkers EM, Van den Bergh V, et al. Virtual reality for rehabilitation in Parkinson’s disease. In: Dockx K, editor. Cochrane Database Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2016
  2. Lewis GN, Rosie JA. Virtual reality games for movement rehabilitation in neurological conditions: how do we meet the needs and expectations of the users?. Disabil Rehabil 2012;34(22):1880-6.
  3. Goble DJ, Cone BL, Fling BW. Using the Wii Fit as a tool for balance assessment and neurorehabilitation: the first half decade of "Wii-search". J Neuroeng Rehab2014;11:12.
  4. Mirelman A, Maidan I, Deutsch JE. Virtual reality and motor imagery: promising tools for assessment and therapy in Parkinson's disease. Movement Disorders2013;28(11):1597-1608.
  5. van Diest M, Lamoth CJC, Stegenga J, Verkerke GJ, Postema K. Exergaming for balance training of elderly: state of the art and future developments. J Neuroeng Rehab 2013;10:101.
  6. 6.0 6.1 Reiss T, Weghorst S: Augmented reality in the treatment of Parkinson's Disease. In In Proceedings of Medicine Meets Virtual Reality 95: January 1995; San Diego. 298-302.
  7. A. Mirelman, I. Maidan, and J. E. Deutsch, “Virtual reality and motor imagery: Promising tools for assessment and therapy in Parkinson's disease,” Movement Disorders, vol. 28, no. 11, pp. 1597–1608, 2013.
  8. Yen, C., Lin, K., Hu, M., Wu, R., Lu, T., and Lin, C. Effects of Virtual Reality–Augmented Balance Training on Sensory Organization and Attentional Demand for Postural Control in People With Parkinson Disease: A Randomized Controlled Trial. American Physical Therapy Association. 2011; 91: 862-74
  9. 9.0 9.1 9.2 9.3 9.4 9.5 Holden, M. K. (2005). Virtual Environments for Motor Rehabilitation: Review. Cyberpsychology & Behavior, 8(3), 187-211. doi:10.1089/cpb.2005.8.187
  10. Barry G, Galna B, Rochester L. The role of exergaming in Parkinson's disease rehabilitation: a systematic review of the evidence. J Neuroeng Rehabil 2014 Mar 7;11:33.