Acquired brain injuries as the result of events such as strokes, cranio-cerebral trauma, lack of oxygen or benign brain tumours often severely impair patients in their everyday lives. Paralysis, spasms or an impaired sense of balance are possible results along with disorders affecting speech, behaviour and self-awareness. The wide range of possible consequences poses a big challenge to rehabilitation. Roberto Lloréns Rodríguez (Polytechnic University, Valencia) and Dr Enrique Noé (NISA Hospitals, Valencia) explained various aspects at the 23rd Meeting of the European Neurological Society (ENS) in Barcelona, where 3,000 experts are gathering to discuss current developments in their field: “One difficulty, amongst others, is that patients often lose motivation for the therapy unless they are given a task to be done and constant positive feedback on their efforts.”
A promising new approach to neuro-rehabilitation is the use of video games because they could provide virtual environments designed to maximise the neurorehabilitation strategies and to solve the issue of motivation. Dr Noé elaborated saying: “Therapists can set which sensory feedback is given. They provide the patients with task-based exercises specially tailored to their needs. The environment is playful and varied so fun is definitely allowed.” The therapists remain “important parts of the system”. After determining the patient’s exact needs, they select the exercises that best address those needs or design new exercises. They monitor progress and fine-tune the process so optimum results can be achieved.
Treating balance disorders
Lloréns and Dr Noé examined the possibilities for using virtual reality in motor therapies as well as cognitive and psychosocial therapies for patients with acquired brain injury. In an initial study series, the researchers tested the “Wii Balance Board” from Nintendo for practicing lost motion sequences in the ankle joints and hips. The Spanish researchers demonstrated that it was also suitable for treating balance disorders following brain injuries. An initial randomized controlled trial involving 18 participants each receiving 20 one hour sessions showed that a combination of virtual and conventional training could provide clinical benefits to traditional physical therapy programs. An undergoing follow-up study is showing that the clinical benefits last in time even in absence of the virtual therapy.
The balance step strategy was also tested in yet another test series. This time, the Microsoft system known as “Kinect” was used for joint motion tracking. 20 patients with acquired brain injury were assigned by a random generator either to a group receiving conventional physiotherapy for four weeks or to a second group additionally engaged in the virtual training. In this case, too, detailed measurements showed that a combination of conventional therapy and virtual activities led to faster progress.
There are several possible explanations that support the hypothesis that virtual reality can maximize the motor learning principles. This technology can provide an intensive, repetitive, adapted, task-oriented exercise with constant feedback that supports the integration of sensory stimuli in the movement generation while engaging the patients in the rehabilitative process.
Disorders of self-awareness
In a third test series, Lloréns and Dr Noé evaluated various ways in which virtual games are used to treat disorders of self-awareness, another possible result of a brain injury. These disorders often pose a major hurdle for progress in rehabilitation and for social integration. The researchers used a 42 inch touch screen embedded on a conventional table as user interface. Players competed with each other in giving answers to knowledge questions about body and illness, in responding in reasonable ways to problem scenarios, in proving their ability to perform in role-plays or to comprehend contexts in jokes and idiomatic expressions.
One group of 15 patients with acquired brain injury took part in this trial and played the one-hour game weekly over a period of eight months. After eight months, it turned out that all participants were able to assess their own deficits correctly – four had been unable to do so before. Initially seven patients had had trouble perceiving their own physical impairments whereas afterwards only two did. Similarly, a lack of social skills disappeared in four out of six affected players. The players showed hardly any improvement in their ability to plan realistically. Five out of seven still had this deficit at the end of the trial.
Lloréns said he was convinced that games involving virtual reality will gain a firm place in many areas of rehabilitation in future. “An increasing number of studies show their clinical advantages,” he emphasised. “The systems needed for this therapy are constantly improving technically. Access and their integration in therapy are still hurdles that might be able to be overcome with a further reduction in costs and increased robustness. It would be ideal if research could close the gap in future between performances in these exercises and their transfer to everyday life.”
23rd Meeting of the European Society of Neurology (ENS) 2013.
ENS Abstract P454: Wii balance board custom-made exercises to regain balance after acquired brain injury: clinical evidence;
ENS Abstract P455: Effectiveness of a virtual board game to improve self-awareness in acquired brain injury patients;
ENS Abstract P456: Balance rehabilitation through virtual reality: a randomized controlled trial with acquired brain injury patients
European Neurological Society