Leveron&Nexovas
Neurology India
menu-bar5 Open access journal indexed with Index Medicus
  Users online: 12097  
 Home | Login 
About Editorial board Articlesmenu-bullet NSI Publicationsmenu-bullet Search Instructions Online Submission Subscribe Videos Etcetera Contact
  Navigate Here 
 Search
 
  
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (1,577 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

 
  In this Article
 »  Abstract
 » Subjects and Methods
 » Results
 » Discussion
 » Conclusion
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    Viewed250    
    Printed20    
    Emailed0    
    PDF Downloaded8    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents    
ORIGINAL ARTICLE
Year : 2022  |  Volume : 70  |  Issue : 8  |  Page : 245-250

Combined Effect of Virtual Reality Training (VRT) and Conventional Therapy on Sitting Balance in Patients with Spinal Cord Injury (SCI): Randomized Control Trial


1 Department of Neuro Physiotherapy, Sancheti Institute of Orthopedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India
2 Department of Orthopaedics Surgery, Sancheti Institute of Orthopedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India

Date of Submission01-Oct-2019
Date of Decision11-Feb-2020
Date of Acceptance18-Aug-2020
Date of Web Publication11-Nov-2022

Correspondence Address:
Manasa S Nair
Sancheti Institute College of Physiotherapy, 11/12, Thube Park, Shivajinagar, Pune . 411 005, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.360934

Rights and Permissions

 » Abstract 


Background: Post spinal cord injury (SCI), sitting balance is considered a prerequisite for the effective performance of activities of daily living. Virtual Reality Training (VRT) may provide an interactive medium of rehabilitation, preventing a reduction in active participation of the patients while allowing for the training of sitting balance.
Aim: The aim of this study was to evaluate the effect of the addition of VRT to conventional therapy in improving sitting balance in persons with SCI.
Subjects and Methods: This was a single blinded randomized control trial conducted on 21 subjects with SCI (level of injury: D10 or below). They were randomly allocated into two groups; both groups received their routine exercise program. In addition, the intervention group, that is, Group B (n = 11) received 30 min of VRT in the seated position using Xbox-Kinect, while the conventional therapy group, that is, Group A (n = 10) received 30 min of additional conventional therapy to equalize the duration of the intervention (3 days/week, 4 weeks). The modified functional reach test and T-shirt test were measured at the beginning and at the end of 4 weeks.
Results: MFRT changes for forward (Group A: 1.7 ± 1.09 cm; Group B: 4.83 ± 2.95 cm), right lateral (Group A: 2.43 ± 2.81 cm, Group B: 5.08 ± 1.85 cm), left lateral (Group A: 3.05 ± 4.65 cm, Group B: 6.19 ± 1.51 cm) were statistically significant for Group B (P < 0.05). No significant difference was observed between the two groups for T-shirt test (P > 0.05).
Conclusion: VRT can be used as a part of a comprehensive rehabilitation program to improve sitting balance post-SCI.


Keywords: Paraplegia, trunk control, xbox kinect
Key Message: Sitting balance is an important pre.


How to cite this article:
Nair MS, Kulkarni VN, Shyam AK. Combined Effect of Virtual Reality Training (VRT) and Conventional Therapy on Sitting Balance in Patients with Spinal Cord Injury (SCI): Randomized Control Trial. Neurol India 2022;70, Suppl S2:245-50

How to cite this URL:
Nair MS, Kulkarni VN, Shyam AK. Combined Effect of Virtual Reality Training (VRT) and Conventional Therapy on Sitting Balance in Patients with Spinal Cord Injury (SCI): Randomized Control Trial. Neurol India [serial online] 2022 [cited 2022 Dec 3];70, Suppl S2:245-50. Available from: https://www.neurologyindia.com/text.asp?2022/70/8/245/360934




SCI is a condition that leads to high rates of morbidity as well as mortality with a global incidence of SCI ranging from 9.2 to 56.1 per million.[1] In SCI, there is an impairment in the motor and sensory system, as well as in the transmission of impulses across the site of lesion leading to a variety of impairments, including the ability to maintain balance in sitting. Most of the functional activities performed by SCI survivors are carried out in the seated position.[2] Postural stability in sitting depends on the potential to maintain the center of mass within the base of support while making appropriate adjustments to changes in position.[3] Based on the level of injury, the nerve supply to certain muscles may be disrupted leading to difficulty in maintaining balance during dynamic activities in the sitting posture leading to decreased independence in activities of daily living. Hence new patterns of postural control need to develop using non-postural muscles.[4],[23],[24]

Previous studies have shown that adherence to rehabilitation has proven to be challenging in patients with SCI despite improvements in physical, psychological domains and an overall improvement in the quality of life.[5] This may be attributed to its long and exhausting nature as well as individual variability in prognosis. VRT is an emerging field of rehabilitation, which can be used in addition to conventional therapy in patients with SCI and has been hypothesized to provide an interactive environment, which may encourage active exploration, enhance engagement, and may motivate the individual to exercise.[6] Virtual reality systems using motion detection can incite patients to generate repetitive movements which are of high intensity, while providing multimodal feedback.[7],[25],[26],[27]

Previously, studies have been performed which have shown positive results of VRT on stroke patients[7],[8] cerebral palsy[9] and traumatic brain injuries.[10],[28] However, there is a paucity of literature available on its effect on sitting balance in SCI; therefore, this study is aimed at assessing the effect of a combination of VRT and conventional therapy on sitting balance in individuals with SCI.


 » Subjects and Methods Top


This parallel-group single-blinded randomized control trial was conducted in an Outpatient Neurological Department of a tertiary health care setup. The protocol was approved by the Institutional Ethical Committee. All SCI survivors attending the outpatient department were screened. Those who fulfilled the inclusion criteria and provided their written consent to participate were included in the study. Patients who had a neurological level of injury of D10 and below, and were classified as type A or B on the Asia Impairment Scale were included in the study. The other inclusion criteria were the ability to sit unsupported for 30 s and the ability to raise their hands to the head without losing balance, as this is the minimum requirement to participate in VRT.[11] Patients with musculoskeletal deformities, recent fractures of upper limb or lower limb, visual deficits and significant cognitive impairment were excluded from the study. The subjects were then randomly allocated into two groups; those receiving conventional therapy alone (Group A) and those receiving a combination of VRT and conventional therapy (Group B).

Outcome measures

The outcome measures included the Modified Functional Reach Test (MFRT) and the T-shirt test. Both the tests were conducted by a blinded assessor prior to and post the intervention period of four weeks.

Modified Functional Reach Test (MFRT)

The participant was seated on a chair without arm rests, with hips and knees in 90 degrees of flexion, feet supported, and two inch clearance between the popliteal fossa and the seat of the chair. A tape measure was attached at level of the acromion process of subject's shoulder. The shoulder was flexed to 90 degrees, horizontal to the floor and maximum reach distance was measured. The participants were not allowed to use the non-reaching upper extremity for weight-bearing. The maximum reach distance to the right, left, and forward was measured.[12]

T-shirt test

The participant was placed in the long sitting position with one or both hands supporting the body. A t-shirt slightly larger than the participants' size was placed on the knees and time to put on t-shirt was measured after a signal 'start'. Similarly, the time to take off the T-shirt was measured. This test was repeated thrice and the mean total time was calculated.[13],[14]

Intervention

Both the groups (A and B) received their routine therapy on six days of the week for 45 min. The exercise program received by both the groups is mentioned in [Figure 1]a. In addition, Group B was given 30 min of VRT in the seated position using Xbox Kinect [Figure 1b-d] and Group A received 30 min of conventional therapy focused on training sitting balance so as to equalize the duration of intervention received by both the groups. The additional intervention was provided on three days of the week for four weeks.
Figure 1: (a) Routine therapy and intervention received by Group A and Group B. (b) Subject playing Tennis on Xbox-Kinect. (c) Subject playing Skiing on Xbox-Kinect. (d) Subject playing Darts on Xbox-Kinect

Click here to view


Data analysis

The data were analyzed using SPSS statistical software version 16. The distribution of the variables was assessed using the Shapiro–Wilk test. Normal distribution was observed only for the forward reach distance on the MFRT. The matched pair sample t test was used to compare the pre and post differences within the groups and the independent sample t test was used to compare the differences between the two groups for forward reach distance. The Wilcoxon signed rank test was used to compare within-group differences and the Mann–Whitney U test was used to compare between-group differences for right and left reach distances and t-shirt test time as it was not normally distributed. The statistical level of significance was set at α = 0.05.


 » Results Top


Flow of participants

24 subjects were recruited for the study. Outcomes were attained for all variables of all the participants, except for three subjects who discontinued the intervention. The flow of the participants is mentioned below in [Figure 2]. The demographic data of the subjects are available in [Table 1].
Figure 2: Flow of participants in study

Click here to view
Table 1: Demographics and clinical status of participants in the study (n=21)

Click here to view


Results for MFRT

The within-group analysis showed that both the groups showed significant difference post the intervention (P < 0.05) in all the reach distances. On comparison between the two groups, it was seen that Group B showed significant improvement in all the reach distances [Table 2].
Table 2: Mean difference values obtained using T-shirt test between Group A and Group B

Click here to view


Results for T-shirt test:

The within-group analysis showed that both the groups showed significant differences post the intervention (P < 0.05) in the T-shirt test. On comparison of the two groups, it was seen there was no significant difference between the two groups [Table 3].
Table 3: Mean difference values obtained using MFRT between Group A and Group B

Click here to view



 » Discussion Top


Rehabilitation to improve sitting balance in patients of SCI has been proved to be very important as it is closely associated with improvement in functional independence as well as ability to use upper extremity for purposeful activities of daily living.[14],[29],[30]

The results of this study showed that a combination of VRT and conventional therapy showed significant improvement in the MFRT distances in all directions as compared to conventional therapy alone [Table 2]. However, a combination of VRT and conventional therapy proved to be as effective as conventional therapy alone in improving the time taken to perform the T-shirt test, as no significant difference was obtained between the two groups [Table 3].

The improvement in the MFRT in the VRT group may be attributed to the fact that the postures and movements required during the performance of the games replicated the motion that was required to be performed during the MFRT. The game of tennis demanded the person to lean forward during a power shot, shifting the weight in the medial and lateral directions along with trunk rotation, while using the upper extremity to hit the ball with a racket. Skiing required sustained forward flexion of the trunk through the hips to increase the speed with medial lateral weight shifts in accordance with virtual slope which was visible on the screen, while simultaneously performing controlled skiing movements of the upper extremity. The improvement in the forward reach distance could be attributed to the fact that during forward reaching activities patients with SCI relied on non-postural muscles for trunk stability. In a study performed to assess the postural muscle responses during forward reaching in subjects with SCI, the authors suggested that the subjects relied on the latissmus dorsi and ascending fibers of trapezius in a tonic manner, with the pectoralis major working to stabilize the shoulder girdle against the activity of the aforementioned muscles.[3],[32] The forward displacement of the upper extremities was counteracted by extending the head and upper spine, keeping the line of gravity within the base of support.[3],[33] Similarly, the games included in the present study required to maintain sustained of forward flexion of the trunk in a tonic manner, while engaging the upper extremity in purposeful activity, thereby allowing training for the use of these non-postural muscles to maintain trunk stability.

The improvement in the in right and left reach distances could be due to the fact that the subjects included in the study had a neurological level of injury of D10 and below, which allowed preservation of a part of abdominal muscle function, namely the internal and external obliques which are responsible for postural control in the horizontal plane due to their diagonal and transverse orientation along the trunk.[15] The subjects in the VRT group performed repetitive weight shifts in the horizontal plane along with intra-axial trunk rotation. Trunk rotation is a multi-planar movement with coupling between the torque of trunk rotation and lateral flexion. It is brought about by the compound action of the internal and external obliques, latissmuss dorsi and to a lesser extent the illiocostalis lumborum.[16],[31] Repetitive performance of multi-planar movements during VRT allowed strengthening of the above muscles leading to significant improvement in the right and left reach distances.

In contrast to this, the exercises performed in the conventional therapy group consisted of a variety of task-specific exercises; however, they were majorly in a single plane and did not include much multi-planar movements. The activities performed in the conventional group were more dynamic and did not require the subject to maintain sustained holding of the forward flexed, requiring activation of the muscles only in short bursts in a phasic manner.

Maintenance of balance is an integrated action of inputs from the vestibular, auditory, visual and somatosensory system.[17] In SCI, there is impairment in the somatosensory system. The virtual reality system provided multi-modal feedback, which may have compensated for the somatosensory loss to a certain degree, allowing the person to identify incorrect patterns of ongoing postural control and provided an opportunity to correct them which was not possible in the conventional therapy group.[17] These findings were also consistent with previous studies where Nintendo Wii and Nintendo Wii fit was used in addition to conventional physical therapy to improve balance in patients with complete and incomplete spinal cord injury respectively. Both these studies showed significant improvement in reach distances.[11],[18]

Another outcome measure used in the present study was the T-shirt. The test was selected as it has been found to correlate significantly with the ability to maintain static sitting balance.[14] The absence of additional effect of VRT may be because the games included did not further challenge postural stability through vertical displacement of center of mass as is required during upper body dressing and undressing, with the games facilitating weight shifts namely in the frontal and sagittal plane. Furthermore, most of the subjects included in the study had a more chronic duration since injury and had probably learned and practiced the postural adjustments required to perform upper body dressing and undressing. This is in accordance with the results of a study performed to determine the validity and reliability of assessment tools used to measure unsupported sitting in subjects with SCI which stated that performance times of functional tasks improved with chronicity of injury.[13] This was evident in the fact that the subjects in the present study already had a mean value of ≤12 s at the beginning of trial, leaving little room for improvement and thus, this may have masked the treatment effect. In addition, the test was performed in the long sitting position, in which stability is provided by performing a posterior pelvic tilt, with an increase in the intrathoracic and intra-abdominal pressure and the locking effects of the bones and various ligaments allowing them to hang on these structures.[19] Most of the balance in this position can be maintained by passive mechanisms, with less active contribution of the muscular forces and hence, both the interventions were equally sufficient in improving the minimally required muscular contribution in this position.

These findings are in contrast to a previous study where VRT using Nintendo Wii showed a significant difference in the T-shirt test.[11] This may be because the duration of intervention provided in the aforementioned study was for 6 weeks, whereas the present study provided an intervention for 4 weeks. The aforementioned study also did not provide the equal duration of intervention to both the groups, providing an additional 30 min of VRT for 6 weeks to the experimental group, which was not accounted for in the conventional therapy group, leading to greater improvements in the T-shirt test in the VRT group.

VRT has previously been used as an effective tool in improving balance in various other neurological conditions such as stroke[7],[8],[20],[21] Parkinson disease,[22] and cerebral palsy.[6],[9] The results of this study suggest that a combination of VRT and conventional therapy can be used as a part of a comprehensive rehabilitation program for the training of individuals with SCI to improve their balance in sitting.

The few limitations of the study were the limited generalizability of the results as the subjects included in the study were only low paraplegics and they had a more chronic duration of SCI and its effect in more acute settings couldn't be commented upon. Future research may also focus on the development of virtual reality games specific to the level and type of injury, with parameters for appropriate intensity and task selection.


 » Conclusion Top


The addition of VRT to conventional therapy is effective in improving the sitting balance in individuals with SCI by improving their reaching abilities in the forward, right and left direction and can be used as a part of a comprehensive rehabilitation program.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Mathur N, Jain S, Kumar N, Srivastava A, Purohit N, Patni A. Spinal cord injury: Scenario in an Indian state. Spinal Cord 2015;53:349-52.  Back to cited text no. 1
    
2.
Horak FB. Clinical implications of postural control research. In: Proceedings of the APTA Forum 1989 1990 (pp. 105-111). The American Physical Therapy Association.  Back to cited text no. 2
    
3.
Potten YJ, Seelen HA, Drukker J, Reulen JP, Drost MR. Postural muscle responses in the spinal cord injured persons during forward reaching. Ergonomics 1999;42:1200-15.  Back to cited text no. 3
    
4.
Seelen HA, Potten YJ, Huson A, Spaans F, Reulen JP. Impaired balance control in paraplegic subjects. J Electromyogr Kinesiol 1997;7:149-60.  Back to cited text no. 4
    
5.
Ditor DS, Latimer AE, Ginis KM, Arbour KP, McCartney N, Hicks AL. Maintenance of exercise participation in individuals with spinal cord injury: Effects on quality of life, stress and pain. Spinal Cord 2003;41:446-50.  Back to cited text no. 5
    
6.
Sandlund M, Waterworth EL, Hager C. Using motion interactive games to promote physical activity and enhance motor performance in children with cerebral palsy. Dev Neurorehabil 2011;14:15-21.  Back to cited text no. 6
    
7.
Park DS, Lee DG, Lee K, Lee G. Effects of virtual reality training using xbox kinect on motor function in stroke survivors: A preliminary study. J Stroke Cerebrovasc Dis 2017;26:2313-9.  Back to cited text no. 7
    
8.
Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev 2017;11:CD008349.  Back to cited text no. 8
    
9.
Deutsch JE, Borbely M, Filler J, Huhn K, Guarrera-Bowlby P. Use of a low-cost, commercially available gaming console (Wii) for rehabilitation of an adolescent with cerebral palsy. Phys Ther 2008;88:1196-207.  Back to cited text no. 9
    
10.
Betker AL, Desai A, Nett C, Kapadia N, Szturm T. Game-based exercises for dynamic short-sitting balance rehabilitation of people with chronic spinal cord and traumatic brain injuries. Phys Ther 2007;87:1389-98.  Back to cited text no. 10
    
11.
Tak S, Choi W, Lee S. Game-based virtual reality training improves sitting balance after spinal cord injury: A single-blinded, randomized controlled trial. Med Sci Tech 2015;56:53-9.  Back to cited text no. 11
    
12.
Lynch SM, Leahy P, Barker SP. Reliability of measurements obtained with a modified functional reach test in subjects with spinal cord injury. Phys Ther 1998;78:128-33.  Back to cited text no. 12
    
13.
Boswell-Ruys CL, Sturnieks DL, Harvey LA, Sherrington C, Middleton JW, Lord SR. Validity and reliability of assessment tools for measuring unsupported Sitting in people with a spinal cord injury. Arch Phys Med Rehabil 2009;90:1571-7.  Back to cited text no. 13
    
14.
Chen CL, Yeung KT, Bih LI, Wang CH, Chen MI, Chien JC. The relationship between sitting stability and functional performance in patients with paraplegia. Arch Phys Med Rehabil 2003;84:1276-81.  Back to cited text no. 14
    
15.
Masani K, Sin VW, Vette AH, Thrasher TA, Kawashima N, Morris A, et al. Postural reactions of the trunk muscles to multi-directional perturbations in sitting. Clin Biomech (Bristol, Avon) 2009;24:176-82.  Back to cited text no. 15
    
16.
Ng JK, Parnianpour M, Richardson CA, Kippers V. Functional roles of abdominal and back muscles during isometric axial rotation of the trunk. J Orthop Res 2001;19:463-71.  Back to cited text no. 16
    
17.
Adamovich SV, Fluet GG, Tunik E, Merians AS. Sensorimotor training in virtual reality: A review. Neuro Rehabilitation 2009;25:29-44.  Back to cited text no. 17
    
18.
Wall T, Feinn R, Chui K, Cheng MS. The effects of the Nintendo™ Wii Fit on gait, balance, and quality of life in individuals with incomplete spinal cord injury. J Spinal Cord Med 2015;38:777-83.  Back to cited text no. 18
    
19.
Shirado O, Kawase M, Minami A, Strax TE. Quantitative evaluation of long sitting in paraplegic patients with spinal cord injury. Arch Phys Med Rehabil 2004;85:1251-6.  Back to cited text no. 19
    
20.
Sin H, Lee G. Additional virtual reality training using Xbox Kinect in stroke survivors with hemiplegia. Am J Phys Med Rehabil 2013;92:871-80.  Back to cited text no. 20
    
21.
Bao X, Mao Y, Lin Q, Qiu Y, Chen S, Li L, et al. Mechanism of Kinect-based virtual reality training for motor functional recovery of upper limbs after sub-acute stroke. Neural Regen Res 2013;8:2904-13.  Back to cited text no. 21
  [Full text]  
22.
Liao YY, Yang YR, Cheng SJ, Wu YR, Fuh JL, Wang RY. Virtual reality-based training to improve obstacle-crossing performance and dynamic balance in patients with Parkinson's disease. Neurorehabil Neural Repair 2015;29:658-67.  Back to cited text no. 22
    
23.
Tariq MB, Wu OC, Agulnick MA, Kasliwal MK. The 100 Most-Cited Papers in Traumatic Injury of the Spine. Neurol India 2020;68:741-759.  Back to cited text no. 23
[PUBMED]  [Full text]  
24.
S Divyalasya TV, Kumar AK, Sahana Bhat NR, Lakhan R, Agrawal A. Quality of Life after Surviving a Spinal Cord Injury: An Observational Study in South India. Neurol India 2021;69:861-866.  Back to cited text no. 24
    
25.
Martinez-Perez R, Ganau M, Rayo N, Alemany VS, Boese CK, Moscote-Salazar LR. Prognostic Value of Age and Early Magnetic Resonance Imaging in Patients with Cervical Subaxial Spinal Cord Injuries. Neurol India 2020;68:1345-1350.  Back to cited text no. 25
[PUBMED]  [Full text]  
26.
Deogaonkar M. Peripheral Neuromodulation for Chronic Pain. Neurol India 2020;68(Supplement):S224-S230.  Back to cited text no. 26
    
27.
Vajramani GV. High Frequency (HF10) Spinal Cord Stimulation for Chronic Neuropathic Pain. Neurol India 2020;68(Supplement):S337-S339.  Back to cited text no. 27
    
28.
Raut R, Shams S, Rasheed M, Niaz A, Mehdi W, Chaurasia B. Spinal Cord Stimulation in The Treatment of Phantom Limb Pain: A Case Report and Review of Literature. Neurol India 2021;69:157-160.  Back to cited text no. 28
    
29.
Garg M, Kumar A, Singh PK, Mahalangikar R, Satyarthee GD, Agrawal D, et al. Transpedicular Approach for Corpectomy and Circumferential Arthrodesis in Traumatic Lumbar Vertebral Body Burst Fractures: A Retrospective Analysis of Outcome in 35 Patients. Neurol India 2021;69:399-405.  Back to cited text no. 29
[PUBMED]  [Full text]  
30.
Meena R, Doddamani RS, Agrawal D, Chandra PS. Dorsal Root Entry Zone (DREZ) Lesioning for Brachial Neuralgia. Neurol India 2020;68:1012-1015.  Back to cited text no. 30
[PUBMED]  [Full text]  
31.
Chandra PS, Ghonia R, Singh S, Garg K. Anomalous Vertebral Artery During Cranio Vertebral Junction Surgery Using DCER (Distraction, Compression, Extension, and Reduction): Approach. and Its Repair. Neurol India 2021;69:315-317.  Back to cited text no. 31
[PUBMED]  [Full text]  
32.
Choudhary KS, Doddamani RS, Devarajan LJ, Agrawal M, Sawarkar D, Meena RK, Varma S, Kumar A, Singh P, Chandra PS, Kale SS. Feasibility of Double Anterior Odontoid Screw: A CT-Based Morphometric Analysis of the Axis in Adult Indian Population. Neurol India 2020;68:1361-1366.  Back to cited text no. 32
[PUBMED]  [Full text]  
33.
Martinez-Perez R, Joswig H, Rayo N, Moscote-Salazar LR, Gomez PA. Subacute Management of a Dislocated Hangman Fracture, What Happens Afterwards? A Long-Term Follow Up. Neurol India 2020;68:959-960.  Back to cited text no. 33
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Wolters Kluwer - Medknow