Virtual Reality-Based Interventions to Improve Balance in Patients with Traumatic Brain Injury: A Scoping Review

 Do we have ANYONE in the stroke medical world that looks at this and says; 'We need to do the same research for stroke survivors, and we'll assign these people to get it done!' That will never occur, there is NO STROKE LEADERSHIP ANYWHERE!

Virtual Reality-Based Interventions to Improve Balance in Patients with Traumatic Brain Injury: A Scoping Review

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Department of Rehabilitation Medicine, Grossman School of Medicine, New York University, New York, NY 10016, USA

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Author to whom correspondence should be addressed.

Brain Sci. 2024, 14(5), 429; https://doi.org/10.3390/brainsci14050429

Submission received: 26 March 2024 / Revised: 16 April 2024 / Accepted: 23 April 2024 / Published: 26 April 2024

(This article belongs to the Special Issue Neuropsychological Evaluation and Rehabilitation of Traumatic Brain Injury)

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Abstract

Introduction: Virtual reality (VR)-based interventions to improve balance and mobility are gaining increasing traction across patient populations. VR-based interventions are believed to be more enjoyable and engaging for patients with traumatic brain injury. This scoping review aims to summarize existing studies from the literature that used VR to improve balance and mobility and determine the gap in VR-based balance literature specific to individuals with traumatic brain injury. Methods: Two authors independently searched the literature using the search terms “Virtual Reality Traumatic Brain Injury Lower Limb”, “Virtual Reality Traumatic Brain Injury Balance”, and “Virtual Reality Traumatic Brain Injury Gait”. Results: A total of seventeen studies, specifically, three randomized controlled trials, one one-arm experimental study, two retrospective studies, two case studies, one feasibility/usability study, one cohort study, and seven diagnostic (validation) studies, met the inclusion criteria for this review. The methodological quality of the studies evaluated using the PEDro scale was fair. Discussion: Future studies should focus on large-scale clinical trials using validated technology to determine its effectiveness and dose–response characteristics. Additionally, standard assessment tools need to be selected and utilized across interventional studies aimed at improving balance and mobility to help compare results between studies.

Keywords:

neurological impairment; balance; falls; virtual reality; brain injury

1. Introduction

Each year in the United States, approximately 1.7 million individuals encounter traumatic brain injuries (TBIs) [1]. The immediate impacts of a traumatic brain injury may include unconsciousness of varying length, depression, confusion, trouble recalling the traumatic event or learning new information, speech issues, and lack of coordination [2]. Some or all of the immediate impacts may be permanent [2]. Depending on intrinsic variables like length of unconsciousness and post-traumatic amnesia, TBI is categorized as mild, moderate, or severe [3]. Most people with mild TBI (70–90% of TBI cases) experience rapid recovery, allowing them to reach their pre-TBI health status [4]. Those who experience a TBI with symptoms surpassing three months are considered to have transitioned from the acute to the chronic phase of TBI [5]. Five years post-injury, 57% of moderate or severe chronic TBI patients are moderately or severely disabled, with about 33% relying on others to complete everyday activities [6].

Furthermore, regardless of the extent of severity, health problems due to TBI can cause long-term physical and neurological impairments, affecting the person’s ability to perform daily activities and return to work [7]. About 30–65% of TBI patients report balance impairments sometime during their recovery [8]. Damage to the integration of sensory, motor, and musculoskeletal systems leads to balance issues [9,10]. Impaired balance leads to a higher risk of falls. Falls are the leading cause of TBI-related hospitalizations. Multiple interventions are being developed and evaluated to help improve balance deficits post-TBI. With technological development, research utilizing novel technology to help improve balance deficits post-TBI has been gaining traction over the past decade.

Traditionally, the standard of care for treating patients with chronic TBI-related balance issues has consisted of various exercises prescribed by a physical therapist, such as firm static standing, foam static standing, and weight-shifting exercises. Physical therapists also use research-based sensory–motor learning concepts available in the clinical setting [11,12]. Physical therapy focusing on sensory stimulation has become a growing trend as rehabilitation techniques modernize [13,14]. In the past decade, the integration of novel Virtual Reality (VR) technology to treat balance issues associated with TBI has grown. VR is a user–computer interface method that incorporates real-time simulation of an environment or activity and permits user input through various sensory channels [15]. Unlike traditional user interfaces, VR allows users to interact with a three-dimensional simulated environment. In VR-integrated rehab, spatial and temporal manipulations are employed to improve sensorimotor training [15]. The physiological activation of brain areas is achieved using VR rehabilitation programs, as it involves motor learning and repeated practice with stimuli from multiple senses (audio, visual, motor, and proprioceptive) [16].

VR-integrated rehab has some benefits over the standard of care. VR rehabilitation allows for precise, objective progress tracking and seems to motivate patients more than traditional rehabilitation practices [17]. Additionally, using VR to treat TBI balance issues allows therapists to control the stimuli and simulate environments tightly without risking patient safety [18]. Finally, VR therapy has also shown greater ecological validity while having the ability to create more affordable environments that can be reused by other therapists [19].

Research involving VR is broadly classified into three main categories—immersive, non-immersive, and semi-immersive VR. The immersive VR creates a 360-degree environment with a headset or goggles that makes the user feel as though they are inside the virtual environment. Second is the non-immersive VR, which displays content on a device such as a television, computer screen, or any other surface and allows the user to see the computer-generated environment on the screen [20]. Semi-immersive VR is a mixture of immersive and non-immersive VR, allowing users to interact with the virtual environment while physically connecting to their surroundings. The advancement in technology and reduction in cost has allowed these VR devices to expand in scope and thus become widespread in research [21]. While extensive research exists on utilizing VR for upper extremity rehabilitation, research implementing VR to help improve gait and balance deficiencies post-TBI is relatively new. Although systematic reviews summarizing VR interventions on traumatic brain injuries exist, most have focused only on upper extremity rehabilitation. Only one study focused on reviewing five randomized controlled trials (RCT) related to lower extremity VR rehabilitation [22]. A full scoping review of the literature to understand the existing role of VR in balance research post-TBI is needed to determine research gaps and future research directions [22]. This review aims to fill the gap in the literature by completing a full scoping review of VR interventions aimed at improving balance and mobility deficits in adults with TBI. This review will summarize existing literature related to lower limb VR rehabilitation. This review is essential as a starting point in guiding clinical practice. This review will highlight existing gaps in the literature and evoke new research ideas.

 

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