So the VR patients got extra rehab, thus any conclusions are invalid. The mentors and senior researchers need to be fired for allowing bad research to be done.
Effects of virtual reality training on occupational performance and self-efficacy of patients with stroke: a randomized controlled trial
Journal of NeuroEngineering and Rehabilitation volume 17, Article number: 150 (2020)
Abstract
Background
Virtual reality (VR) has been broadly applied in post-stroke rehabilitation. However, studies on occupational performance and self-efficacy as primary outcomes of stroke rehabilitation using VR are lacking. Thus, this study aims to investigate the effects of VR training on occupational performance and self-efficacy in patients with stroke.
Methods
This was an assessor-blinded, randomized controlled trial. Sixty participants with first-ever stroke (< 1-year onset) underwent rehabilitation in a single acute hospital. Participants were randomly assigned to either the VR group (n = 30) or control group (n = 30). Both groups received dose-matched conventional rehabilitation (i.e., 45 min, five times per week over 3 weeks). The VR group received additional 45-min VR training for five weekdays over 3 weeks. The primary outcome measures were the Canadian Occupational Performance Measure and Stroke Self-Efficacy Questionnaire. Secondary outcome measures included Modified Barthel Index, Fugl-Meyer Assessment-Upper Extremity, and Functional Test for the Hemiplegic Upper Extremity. The assessment was conducted at baseline and after the 3-week intervention.
Results
A total of 52 participants (86.7%) completed the trial. Significant between-group differences in Stroke Self-Efficacy Questionnaire (Median Difference = 8, P = 0.043) and Modified Barthel Index (Median Difference = 10, P = 0.030) were found; however, no significant between-group differences in Canadian Occupational Performance Measure, Fugl-Meyer Assessment-Upper Extremity, and Functional Test for the Hemiplegic Upper Extremity were noted. No serious adverse reactions related to the program were reported.
Conclusions
Additional VR training could help improve the self-efficacy and activities of daily living of patients with stroke; however, it was not superior to conventional training in the improvement of upper limb functions, occupational performance, and satisfaction. Nevertheless, VR could be integrated into conventional rehabilitation programs to enhance self-efficacy of patients after stroke.
Trial registration
This study was successfully registered under the title “Effects of virtual reality training on occupational performance and self-efficacy of patients with stroke” on October 13 2019 and could be located in https://www.chictr.org with the study identifier ChiCTR1900026550.
Background
Stroke is a common neurological disease associated with high morbidity, mortality, and disability rates [1]. The survival rate of this disease has significantly improved in recent years. However, there are still a large number of stroke survivors experiencing severe dysfunctions. For instance, 85% of stroke survivors had upper extremity dysfunction at the initial stage of onset [2], and approximately 30–36% of patients with stroke still had upper extremity dysfunction at 6 months after stroke [3]. Such dysfunctions could greatly affect patients’ quality of life and prognosis after stroke, and improvement in the ability to complete activities of daily living (ADL) is vital for functional recovery.
Apart from sensation, motor function, and ADL, some important domains, including occupational performance and self-efficacy, have to be considered in stroke rehabilitation [4]. Occupational performance is the ability of the patients to handle different activities in the areas of self-maintenance, productivity, and leisure. Patients with good occupational performance could better perceive, desire, recall, plan, and perform roles, routines, and tasks to adapt to the internal or/and external environment [5]. Self-efficacy is defined as a person's ability to perform a task or activity with confidence [6]. Stroke Self-Efficacy Questionnaire (SSEQ) is the most commonly used measure for self-efficacy in patients with stroke. Compared with other self-efficacy scales for a specific dysfunction or tasks, such as the Self-Efficacy for Exercise Scale and the Falls Efficacy Scale, SSEQ covers all functional tasks and self-management items related to holistic self-efficacy for stroke population [7]. Four principles could enhance self-efficacy, which include direct mastery of experience, substitution of experience, verbal persuasion, and understanding of physiological states and signals [8]. A previous study found that self-efficacy is a moderator of occupational performance in stroke self-management programs [9].
Virtual reality (VR) equipment has become a popular and common rehabilitation tool in numerous hospitals [10]. VR is a computer technology that enables interaction between users and the environment and provides high doses of repetitive task training [11, 12]. The training provides an additional option for the participants, which in turn enhances their motivation of getting involved with daily training. Optimal use of VR equipment could save labor costs in acute hospitals. Previous reviews have suggested that VR is a promising, safe, novel, and exciting treatment tool [13,14,15], especially for the improvement of upper limb function, balance function, and gait [16,17,18,19]. However, in recently published reviews, no significant difference in the improvement of upper limb function between VR training and conventional training was found. VR training could improve the ADL of patients with stroke, the evidence on improved quality of life and participation restriction is limited [20,21,22]. Some studies showed that different outcome measures related to the effect of VR training still need to be specified [23,24,25]. The number of published clinical trials that used occupational performance [26, 27] and self-efficacy [22, 28] as primary outcomes in VR training are few.
In clinical practice, VR training may provide guidance and timely feedback to participants via simulated daily life virtual scene and demonstrations [12], which differs from conventional rehabilitation; the ability acquired in VR training may be better generalized to daily activities. Moreover, VR training could provide participants feedback on their body, voice, and vision as well as timely encouragement and support from therapists and family members [29]. Thus, it may be easier for the participants to understand their own performance and improve their sense of achievement [30], which could in turn improve enthusiasm and confidence in daily activities. Such characteristics of VR interventions are related to the four principles that could improve self-efficacy. Hence, our study will further explore the effect of VR training on self-efficacy and occupational performance.
Currently, a few VR-related studies confirmed a positive effect on occupational performance among patients with stroke [27, 31]. A few studies on VR combined with treadmills found significant improvements in falls-related self-efficacy and balance self-efficacy [22, 32, 33]. However, the evidence on the effect of VR on holistic self-efficacy of patients with stroke is lacking. Thus, VR-related studies that focus on the improvement of occupational performance and self-efficacy of patients with stroke are meaningful. Moreover, improvement of upper limb function by VR training also needs to be investigated.
Our study, which was designed as a randomized controlled trial, aimed to investigate the effect of VR on self-efficacy and occupational performance of patients with stroke. We hypothesized that VR plus conventional training were superior to conventional training in the improvement of self-efficacy, occupational performance and ADL. The results of upper limb function were equivalent in both groups.
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