Virtual Reality Enhances Gait in Cerebral Palsy: A Training Dose-Response Meta-Analysis

Will it do the same for stroke? Ask your doctor when such research will start up.  No response, then call the stroke hospital president and ask when incompetent doctors are fired. I take no prisoners. 

Virtual Reality Enhances Gait in Cerebral Palsy: A Training Dose-Response Meta-Analysis

Shashank Ghai^1* and Ishan Ghai²

• ¹Institute for Sports Science, Leibniz University Hannover, Hannover, Germany
• ²Rsgbiogen, New Delhi, India

Virtual-reality-based training can influence gait recovery in children with cerebral palsy. A consensus concerning its influence on spatiotemporal gait parameters and effective training dosage is still warranted. This study analyzes the influence of virtual-reality training (relevant training dosage) on gait recovery in children with cerebral palsy. A search was performed by two reviewers according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on nine databases: PEDro, EBSCO, PubMed, Cochrane, Web of Science, EMBASE, ICI, Scopus, and PROQUEST. Of 989 records, 16 studies involving a total of 274 children with cerebral palsy met our inclusion criteria. Eighty-eight percent of the studies reported significant enhancements in gait performance after training with virtual reality. Meta-analyses revealed positive effects of virtual-reality training on gait velocity (Hedge's g = 0.68), stride length (0.30), cadence (0.66), and gross motor function measure (0.44). Subgroup analysis reported a training duration of 20–30 min per session, ≤4 times per week across ≥8 weeks to allow maximum enhancements in gait velocity. This study provides preliminary evidence for the beneficial influence of virtual-reality training in gait rehabilitation for children with cerebral palsy.

Introduction

Gait dysfunctions are prominent in children with cerebral palsy (1, 2). Reduction in gait velocity, cadence and stride length are common spatiotemporal gait characteristics exhibited by children with cerebral palsy (2). Recent experimental and review studies have reported the beneficial influence of virtual-reality training strategies to considerably influence gait performance in children with cerebral palsy (3, 4). According to Aminov et al. (5), virtual reality is a superior rehabilitative approach when compared with conventional therapeutic approaches. The authors suggest that this strategy can allow a patient to (re)learn motor skills while interacting with real-life scenarios in an ecological yet patient-centric manner (6).

The application of this intervention is dynamic as it allows real-time “multisensory” feedback of executed movement to both the performer and the medical practitioner. This further can simultaneously facilitate the motor planning and perception of the performer and allow the medical practitioner to monitor and control the complexity of the virtual-reality task/environment according to each performer's capability (7). Several underlying mechanisms through which virtual-reality training can facilitate motor rehabilitation have been reported. For instance, amplification of sensorimotor representation by augmented sensory feedback (8–12), enhancement of error feedback (13), reduction of cognitive load (14–17), reduction of musculoskeletal coactivation (18), increased arousal (19), and motivation (20) are few of the reasons by which virtual-reality training might enhance gait recovery (3, 4, 21). Moreover, neuroimaging studies have reported that training with virtual reality can facilitate recovery by instigating cortical reorganization (22) and neural plasticity (23, 24), thus suggesting a strong potential for virtual-reality-based training for recovering gait in children with cerebral palsy.

Recent systematic reviews have reported the beneficial effects of virtual-reality-based training on gait performance in children with cerebral palsy (3, 4). However, to the best of our knowledge, only one study has elucidated the influence of virtual-reality training on gait performance in children with cerebral palsy statistically, i.e., a meta-analysis (3). Chen et al. (3) performed a meta-analysis on eight studies and reported a positive effect size of 0.75 (0.34–1.16) on the ambulation function after training with virtual reality. Although the findings of this study are in line with previous reviews, there were certain limitations. Firstly, the authors did not explore the cause of heterogeneity observed in the analysis, i.e., I² = 59%. Secondly, the authors did not describe the specific variables evaluated in the ambulation function, i.e., no information was provided as to what these enhancements were applicable on, for instance, gait velocity, stride length, etc. Thirdly, the authors included some studies in the analysis that, on re-evaluation, were found to not have evaluated any gait parameter at all.

In the present systematic review and meta-analysis, our aim is to develop a state of evidence defining the influence of virtual-reality training on spatiotemporal gait parameters in children with cerebral palsy. Moreover, the importance of determining training dosages in neurological rehabilitation has been emphasized in several studies (25–31). Therefore, as a secondary objective, this present review also aims to elucidate effective training dosages for virtual-reality-based gait training that could be incorporated by medical practitioners during gait rehabilitation for children with cerebral palsy.

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