Balance and gait impairments are associated with reduced mobility, independence, and quality of life and an increased risk for falls in people with multiple sclerosis (MS).¹ Inpatient and outpatient rehabilitation programs have been found to improve these and other outcomes in this population. However, some patients may be unable to access such programs for various reasons and others may not be motivated to engage in conventional training, underscoring the need for alternate training modalities.

Emerging research shows promise with the use of virtual reality (VR) for motor and cognitive rehabilitation in MS. “Studies suggest that VR can produce benefits in balance, gait, and mobility in persons with MS, and might also have some cognitive benefits — most studies have shown it to be better than no intervention, but not necessarily superior to conventional gait training or physical therapy,” said Barbara S Giesser, MD, professor of neurology at the University of California, Los Angeles, clinical director of the MS program there, and fellow of the American Academy of Neurology. In addition, VR “has been shown to enhance conventional locomotor training, with a combination of VR and locomotor training conferring better results than locomotor training alone,” she told Neurology Advisor.

VR training may use video game consoles or interactive “exergaming” systems such as the Xbox 360^® Kinect. A range of software programs and approaches may be used and interventions may be home based or delivered on-site at treatment centers. “From a motor learning approach, virtual reality offers the possibility of high-intensity, task-oriented, multisensorial feedback training,” according to researchers who published a systematic review and meta-analysis in 2018 in Clinical Rehabilitation.¹

The authors examined randomized controlled trials and quasirandomized clinical trials published through February 2018 that focused on VR-based interventions for balance and gait training in MS.¹ Based on pooled data from 9 randomized controlled trials and 2 clinical trials representing a total of 466 people with MS (65.8% female), the results showed no significant overall effect for VR balance training compared with conventional training (standard mean difference  = −0.04; 95% CI, −0.70 to 0.62; P =.90), although this approach was more effective for postural control than no intervention (standard mean difference  = −0.64; 95% CI, −1.05 to −0.24; P =.002). Results were inconclusive regarding the effects of VR-based training on gait control.

Most studies included in the analysis involved patient-tailored interventions supervised by a physiotherapist. Two additional interventions were home based and another intervention was delivered remotely (telerehabilitation). There was substantial heterogeneity across studies, with a range of systems, training modalities, and number and length of sessions used. 

Another systematic review published in 2016 examined 10 studies on VR for MS and reported improvements in arm movement and control, balance, and walking.² Another small study investigated the effects of VR training using functional electrical stimulation combined with passive robotic support (18 one-hour sessions for 10 weeks) to improve upper limb function in 5 individuals with MS.³ The researchers observed significant improvements in reaching accuracy both with and without functional electrical stimulation, as well as reduced impairment in the proximal arm, and the intervention was well tolerated with no reported increase in muscle fatigue. 

In a randomized controlled trial published in 2015 (n=30), significant improvement in scores on the timed up and go test, fall risk index, and overall stability index were noted in patients who participated in 24 VR training sessions using the Biodex Balance System SD compared with the control group.⁴

A 2013 study investigated the use of a VR-based telerehabilitation program as an alternative when conventional physical therapy was unavailable.⁵ Over the 10-week treatment period, the control group (n=25) received 40-minute physiotherapy sessions twice weekly, and the intervention group received 20-minute monitored VR sessions by means of videoconference 4 times weekly using the Xbox 360^® Kinect system. Compared with the control treatment, the intervention was found to “optimize the sensory information processing and integration systems necessary to maintain…balance and postural control,” the authors wrote.

Earlier research supported the use of cues “superimposed on the real world in a closed-loop fashion” through a visual-feedback VR system to improve gait control in MS.⁶ In patients with a baseline walking speed below the median, the average short-term residual therapeutic improvement in walking speed was 24.49%, whereas an increase of 9.09% was observed in patients with a baseline walking speed above the median. Similar improvements were noted in stride length.

In addition to favorable effects on measurable outcomes, there are numerous other benefits of VR-based rehabilitation. “One of the main advantages of VR is that it can be delivered at home or other nonclinic setting via computer, and thus may be a very appropriate modality for patients who cannot access a physical therapist or trainer in person,” said Dr Giesser. “Also, a patient may be more motivated to use VR (ie, play a game) than participate in conventional therapy or exercise.”

Future studies on VR training for MS should include large randomized controlled trials using clear protocols and comparable between-group tasks. “Virtual reality use and research are still in early stages. We need data to tell us which protocols are most effective, and which types of VR training are most beneficial for specific impairments,” Dr Giesser stated. “We also need information on when VR is most effectively added to conventional rehabilitation modalities.”

References

1. Casuso-Holgado MJ, Martín-Valero R, Carazo AF, Medrano-Sánchez EM, Cortés-Vega MD, Montero-Bancalero FJ. Effectiveness of virtual reality training for balance and gait rehabilitation in people with multiple sclerosis: a systematic review and meta-analysis.Clin Rehabil. 2018;32(9):1220-1234.
   

2. Massetti T, Trevizan IL, Arab C, Favero FM, Ribeiro-Papa DC, de Mello Monteiro CB. Virtual reality in multiple sclerosis – A systematic review.Mult Scler Relat Disord. 2016;8:107-112.
   

3. Sampson P, Freeman  C, Coote S, et al. Using functional electrical stimulation mediated by iterative learning control and robotics to improve arm movement for people with multiple sclerosis. IEEE Trans Neural Syst Rehabil Eng. 2016;24(2):235-248.
   

4. Eftekharsadat B, Babaei-Ghazani A, Mohammadzadeh M, Talebi M, Eslamian F, Azari E. Effect of virtual reality-based balance training in multiple sclerosis.Neurol Res. 2015;37(6):539-544.
   

5. Gutiérrez RO, Galán Del Rio F, Cano de la Cuerda R, Alguacil Diego IM, González RA, Page JCM. A telerehabilitation program by virtual reality-video games improves balance and postural control in multiple sclerosis patients. NeuroRehabilitation. 2013;33(4):545-554.
   

6. Baram Y, Miller A. Virtual reality cues for improvement of gait in patients with multiple sclerosis. Neurology. 2006;66(2):178-181.