Virtual reality, motor imagery techniques useful in PD, study findings

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A recent study found that virtual reality and motor imagery techniques, such as games for the Wii console, may be more helpful for patients with Parkinson’s disease (PD) than physical therapy.

A recent study, published in the Journal of Personalized Medicine, found that patients with Parkinson’s disease (PD) showed significant improvement in mobility and stiffness after using virtual reality (VR) and motor imagery (MI). This improvement was also significantly greater than that of patients with PD who only used traditional physiotherapy (PT) techniques.

The study aimed to measure whether MI and a virtual reality program along with routine PT had an effect on motor components of patients with PD, including bradykinesia, rigidity, tremor at rest, postural instability, posture and gait, compared to routine PT alone. The study took place from 2020 to 2021 at Safi Hospital, Faisalabad, Pakistan.

The study was small with 41 patients between the ages of 50 and 80. Participants had idiopathic PD, with severity ranging from stage I to stage III, and cognition intact. Patients excluded were those with neurological or orthopedic disorders, visual abnormalities, cardiovascular problems, severe dyskinesia or activation and deactivation phases, history of PD surgery, or treatment with PD therapy. virtual game in the last 3 months.

Each patient was assessed at baseline, 6 and 12 weeks, and 1 month after the end of the trial. All participants remained on the same medication throughout the study. They were assigned either to control group A (21 patients), composed only of routine PTs, or to experimental group B (20 patients), composed of IM, VR and routine PTs. Routine PT included warm-up, stretching, strengthening, and relaxation exercises; limb coordination exercises; and core, neck and gait training as well as cycling and walking. Group B received the same PT treatment as well as VR and MI treatment.

Patients had 3 days of their assigned treatment per week. Group A received 40 minutes of routine PT and 20 minutes of walking and cycling. Group B had 40 minutes of routine PT, 10-15 minutes of VR, and 5-10 minutes of IM.

The VR system used was the Wii console, which included the Wii box, Wii controller, and Wii Fit card. Patients were encouraged to play games on the Wii Fit board. The games have been selected by senior physiotherapists to focus on 3 areas: motor functioning, balance and activities of daily living.

Each VR session started with balance games, with at least 1 dynamic balance game and 1 static balance game used for each session; the difficulty has been adjusted to match the patient’s progress. All MI trainings took place in the last 5-10 minutes of each session.

Each routine PT treatment lasted 40 minutes. Patients participated in a series of warm-up activities, before doing stretching exercises for 15 minutes.

The motor function of the PD patient was recorded using the United Parkinson’s Disease Rating Scale (UPDRS) recording stiffness, bradykinesia, tremor and mobility in all patients. The scale consists of 14 items that are each scored from 0 to 4, with a total potential score of 56. Higher scores indicate more disability.

Between the groups, there were no significant differences in age, disease duration, age at onset of PD and age at diagnosis of PD between the 2 groups. The mean (SD) UPDRS score in the experimental group was 32.45 (3.98) and 31.86 (4.62) in the control group.

UPDRS scores identified that the experimental group showed significant improvement in resting tremor, rigidity, posture, postural stability, and body bradykinesia. The experimental group also had significant improvement in gait, rapid alternating movements, and the ability to rise from a chair after 16 weeks from the start of the intervention. No differences in scores for speech, facial expression, action or postural tremor, finger tapping, hand movements or leg agility were observed between the two groups.

The following mean (SD) scores were observed in this study for various characteristics:

  • Resting tremor after 16 weeks: 3.31 (1.21) experimental, 4.86 (1.28) control
  • Stiffness (baseline and 16 weeks): 4.86 (0.710) and 2.27 (1.55) experimental, 4.68 (0.893) and 4.09 (1.68) control
  • Walking (baseline and 16 weeks): 1.86 (0.468) and 1.00 (0.690) experimental, 1.73 (0.456) and 1.45 (0.671) control
  • Comparison of postural stability between experimental and control (baseline and 16 weeks): 1.50 (0.512) and 0.73 (0.631)
  • body bradykinesia after 16 weeks: 0.95 (0.653) experimental, 1.36 (0.727) control

There were some limitations to this study. The study involved a small sample of patients with PD who had mild to moderate symptoms. Due to the exclusion of patients with cognitive impairment, a study that takes a holistic approach covering both motor and cognitive impairment may have superior results. VR and MI have been identified here as being more effective. This study did not answer whether hybrid care is more effective than VR and MI alone.

“Patients receiving VR and MI training in addition to routine PT showed significant improvements in resting tremor, rigidity, gait, posture, body bradykinesia, resulting from chair and rapid alternating movements compared to patients assigned to a control group that received only physical therapy. Additionally, the gains were maintained at follow-up in the experimental group,” the researchers wrote. They concluded that the VR and MI training with routine PT might be the most effective way to treat older patients with mild to moderate PD symptoms.

Reference

Kashif M, Ahmad A, Bandpei MAM, Syed HA, Raza A, Sana V. A randomized controlled trial of motor imagery combined with virtual reality techniques in patients with Parkinson’s disease. J Pers Med. 2022;12(3):450. doi:10.3390/jpm12030450

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