Virtual reality in vestibular assessment and rehabilitation

Previous experiences on vestibular compensation showed that multisensorial stimulations affect postural unbalance recovery. Virtual Environment (VE) exposure seems very useful in vestibular rehabilitation, since the experience gained during VE exposure is transferable to the reai world. The rearrangement of the hierarchy of the postural cues was evaluated in 105 patients affected by visual, labyrinthic and somatosensory pathology in normal conditions and during sensoriai deprivation. They were divided into five groups according to pathology and compared to 50 normal controls. Our data show that VE exposure is a reliable method to identify the deficient subsystem and the level of substitution. Moreover, Virtual Reality (VR) would accelerate the compensation of an acute loss of labyrinthine function, related to adaptive modifications of thevestibulo-ocularandvestibulo-spinal reflexes, overstimulating the residual labyrinthine function. The residual labyrinthine function is poor in chronic bilateral vestibular deficit and VE exposure should provide sensory substitution or sensory motor reorganisation, thereby modulating the external spatial reference and promoting the reorganisation of the multiple sensory input. The potential for VE exposure perspectives seerns very promising when dealing with the vestibular system where there is a continuous rearrangement of different sensorial informations as a result of environmental and age-related changes

Vestibulo-Ocular Reflex Modification after Virtual Environment Exposure

Immersion in an illusory world is possible by means of virtual reality (VR), where environmental perception is modi bff c1c ed by artificial sensorial stimulation. The application of VR for the assessment and rehabilitation of pathologies affecting the vestibular system, in terms of both diagnosis and care, could represent an interesting new line of research. Our perception of reality is in fact based on static and dynamic spatial information perceived by our senses. During head movements in a virtual environment the images on the display and the labyrinthine information relative to the head angular accelerations differ and therefore a visuo-vestibular conflict is present. It is known that mismatches between visual and labyrinthine information may modify the vestibulo-oculomotor reflex (VOR) gain. We studied the post-immersion modifications in 20 healthy subjects (mean age 25 years) exposed to a virtual environment for 20 min by wearing a head-mounted display. VOR gain and phase were measured by means of harmonic sinusoidal stimulation in the dark before, at the end of and 30 min after VR exposure. A VOR gain reduction was observed in all subjects at the end of VR exposure which disappeared after 30 min. Our data show that exposure to a virtual environment can induce a temporary modi bff c1c cation of the VOR gain. This bff c1c nding can be employed to enable an artificial, instrumental modification of the VOR gain and therefore opens up new perspectives in the assessment and rehabilitation of vestibular diseases

Feasibility and safety of an immersive virtual reality-based vestibular rehabilitation programme in people with multiple sclerosis experiencing vestibular impairment: a protocol for a pilot randomised controlled trial

Introduction: Vestibular system damage in patients with multiple sclerosis (MS) may have a central and/or peripheral origin. Subsequent vestibular impairments may contribute to dizziness, balance disorders and fatigue in this population. Vestibular rehabilitation targeting vestibular impairments may improve these symptoms. Furthermore, as a successful tool in neurological rehabilitation, immersive virtual reality (VRi) could also be implemented within a vestibular rehabilitation intervention. Methods and analysis: This protocol describes a parallel-arm, pilot randomised controlled trial, with blinded assessments, in 30 patients with MS with vestibular impairment (Dizziness Handicap Inventory ≥16). The experimental group will receive a VRi vestibular rehabilitation intervention based on the conventional Cawthorne-Cooksey protocol; the control group will perform the conventional protocol. The duration of the intervention in both groups will be 7 weeks (20 sessions, 3 sessions/week). The primary outcomes are the feasibility and safety of the vestibular VRi intervention in patients with MS. Secondary outcome measures are dizziness symptoms, balance performance, fatigue and quality of life. Quantitative assessment will be carried out at baseline (T0), immediately after intervention (T1), and after a follow-up period of 3 and 6 months (T2 and T3). Additionally, in order to further examine the feasibility of the intervention, a qualitative assessment will be performed at T1. Ethics and dissemination: The study was approved by the Andalusian Review Board and Ethics Committee, Virgen Macarena-Virgen del Rocio Hospitals (ID 2148-N-19, 25 March 2020). Informed consent will be collected from participants who wish to participate in the research. The results of this research will be disseminated by publication in peer-reviewed scientific journals

The effect of virtual reality on visual vertigo symptoms in patients with peripheral vestibular dysfunction: a pilot study

Individuals with vestibular dysfunction may experience visual vertigo (VV), in which symptoms are provoked or exacerbated by excessive or disorientating visual stimuli (e.g. supermarkets). VV can significantly improve when customized vestibular rehabilitation exercises are combined with exposure to optokinetic stimuli. Virtual reality (VR), which immerses patients in realistic, visually challenging environments, has also been suggested as an adjunct to VR to improve VV symptoms. This pilot study compared the responses of sixteen patients with unilateral peripheral vestibular disorder randomly allocated to a VR regime incorporating exposure to a static (Group S) or dynamic (Group D) VR environment. Participants practiced vestibular exercises, twice weekly for four weeks, inside a static (Group S) or dynamic (Group D) virtual crowded square environment, presented in an immersive projection theatre (IPT), and received a vestibular exercise program to practice on days not attending clinic. A third Group D1 completed both the static and dynamic VR training. Treatment response was assessed with the Dynamic Gait Index and questionnaires concerning symptom triggers and psychological state. At final assessment, significant betweengroup differences were noted between Groups D (p = 0.001) and D1 (p = 0.03) compared to Group S for VV symptoms with the former two showing a significant 59.2% and 25.8% improvement respectively compared to 1.6% for the latter. Depression scores improved only for Group S (p = 0.01) while a trend towards significance was noted for Group D regarding anxiety scores (p = 0.07). Conclusion: Exposure to dynamic VR environments should be considered as a useful adjunct to vestibular rehabilitation programs for patients with peripheral vestibular disorders and VV symptoms

Trunk motion visual feedback during walking improves dynamic balance in older adults: Assessor blinded randomized controlled trial.

BACKGROUND: Virtual reality and augmented feedback have become more prevalent as training methods to improve balance. Few reports exist on the benefits of providing trunk motion visual feedback (VFB) during treadmill walking, and most of those reports only describe within session changes. RESEARCH QUESTION: To determine whether trunk motion VFB treadmill walking would improve over-ground balance for older adults with self-reported balance problems. METHODS: 40 adults (75.8 years (SD 6.5)) with self-reported balance difficulties or a history of falling were randomized to a control or experimental group. Everyone walked on a treadmill at a comfortable speed 3×/week for 4 weeks in 2 min bouts separated by a seated rest. The control group was instructed to look at a stationary bulls-eye target while the experimental group also saw a moving cursor superimposed on the stationary bulls-eye that represented VFB of their walking trunk motion. The experimental group was instructed to keep the cursor in the center of the bulls-eye. Somatosensory (monofilaments and joint position testing) and vestibular function (canal specific clinical head impulses) was evaluated prior to intervention. Balance and mobility were tested before and after the intervention using Berg Balance Test, BESTest, mini-BESTest, and Six Minute Walk. RESULTS: There were no significant differences between groups before the intervention. The experimental group significantly improved on the BESTest (p = 0.031) and the mini-BEST (p = 0.019). The control group did not improve significantly on any measure. Individuals with more profound sensory impairments had a larger improvement on dynamic balance subtests of the BESTest. SIGNIFICANCE: Older adults with self-reported balance problems improve their dynamic balance after training using trunk motion VFB treadmill walking. Individuals with worse sensory function may benefit more from trunk motion VFB during walking than individuals with intact sensory function

I-BaR: Integrated Balance Rehabilitation Framework

Neurological diseases are observed in approximately one billion people worldwide. A further increase is foreseen at the global level as a result of population growth and aging. Individuals with neurological disorders often experience cognitive, motor, sensory, and lower extremity dysfunctions. Thus, the possibility of falling and balance problems arise due to the postural control deficiencies that occur as a result of the deterioration in the integration of multi-sensory information. We propose a novel rehabilitation framework, Integrated Balance Rehabilitation (I-BaR), to improve the effectiveness of the rehabilitation with objective assessment, individualized therapy, convenience with different disability levels and adoption of an assist-as-needed paradigm and, with an integrated rehabilitation process as a whole, i.e., ankle-foot preparation, balance, and stepping phases, respectively. Integrated Balance Rehabilitation allows patients to improve their balance ability by providing multi-modal feedback: visual via utilization of Virtual Reality; vestibular via anteroposterior and mediolateral perturbations with the robotic platform; proprioceptive via haptic feedback.Comment: 37 pages, 2 figures, journal pape

Effectiveness of conventional versus virtual reality based vestibular rehabilitation in the treatment of dizziness, gait and balance impairment in adults with unilateral peripheral vestibular loss: a randomised controlled trial.

BACKGROUND: Unilateral peripheral vestibular loss results in gait and balance impairment, dizziness and oscillopsia. Vestibular rehabilitation benefits patients but optimal treatment remains unkown. Virtual reality is an emerging tool in rehabilitation and provides opportunities to improve both outcomes and patient satisfaction with treatment. The Nintendo Wii Fit Plus (R) (NWFP) is a low cost virtual reality system that challenges balance and provides visual and auditory feedback. It may augment the motor learning that is required to improve balance and gait, but no trials to date have investigated efficacy. METHODS: In a single (assessor) blind, two centre randomised controlled superiority trial, 80 patients with unilateral peripheral vestibular loss will be randomised to either conventional or virtual reality based (NWFP) vestibular rehabilitation for 6 weeks. The primary outcome measure is gait speed (measured with three dimensional gait analysis). Secondary outcomes include computerised posturography, dynamic visual acuity, and validated questionnaires on dizziness, confidence and anxiety/depression. Outcome will be assessed post treatment (8 weeks) and at 6 months. DISCUSSION: Advances in the gaming industry have allowed mass production of highly sophisticated low cost virtual reality systems that incorporate technology previously not accessible to most therapists and patients. Importantly, they are not confined to rehabilitation departments, can be used at home and provide an accurate record of adherence to exercise. The benefits of providing augmented feedback, increasing intensity of exercise and accurately measuring adherence may improve conventional vestibular rehabilitation but efficacy must first be demonstrated. Trial registration Clinical trials.gov identifier: NCT01442623

Vestibular rehabilitation with virtual reality in Ménière's disease

Virtual reality technology can provide a wide range of sensory stimuli to generate conflicts of varying degrees of complexity in a safe environment. OBJECTIVE: To verify the effect of a virtual realitybased balance rehabilitation program for patients with Menière's disease. METHOD: This observational clinical study included 44 patients aged between 18 and 60 years diagnosed with Menière's disease submitted to a controlled randomized therapeutic intervention. The case and control groups took betahistine and followed a diet. Case group subjects underwent 12 rehabilitation sessions with virtual reality stimuli in a Balance Rehabilitation Unit (BRU TM). Patients were assessed based on DHI scores, the dizziness visual analogue scale, and underwent posturography with virtual reality before and after the intervention. RESULTS: After the intervention, the case group showed significantly lower scores in DHI (p < 0,001) and in the dizziness visual analog scale (p = 0.012), and had significantly greater limit of stability areas (p = 0.016) than controls. CONCLUSION: Virtual reality-based balance rehabilitation effectively improved dizziness, quality of life, and limit of stability of patients with Menière's disease.A tecnologia de realidade virtual fornece uma grande variedade de estímulos que geram conflitos sensoriais em diferentes níveis de dificuldades e em ambiente seguro. OBJETIVO: Verificar o efeito de um programa de reabilitação vestibular do equilíbrio corporal com estímulos de realidade virtual em pacientes com doença de Ménière. Forma de estudo: Estudo clínico observacional. MÉTODO: Quarenta e quatro pacientes, com idade entre 18 e 60 anos e doença de Ménière definida, distribuídos em dois grupos - experimental (GE) e controle (GC) - fizeram uso de betaistina e dieta alimentar; o grupo experimental foi submetido adicionalmente a 12 sessões de reabilitação com realidade virtual da BRU TM. Os pacientes responderam ao Dizziness Handicap Inventory (DHI), à escala analógica de tontura e realizaram a posturografia com realidade virtual antes e após a intervenção. RESULTADOS: Após a intervenção, o GE apresentou valores significantemente menores do DHI (p < 0,001) e da escala analógica de tontura (p = 0,012) e valores significantemente maiores da área do limite de estabilidade (p = 0,016), em comparação com o GC. CONCLUSÃO: A reabilitação do equilíbrio corporal com estímulos de realidade virtual é eficaz na melhora da tontura, da qualidade de vida e do limite de estabilidade de pacientes com doença de Ménière.FMU curso de FonoaudiologiaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Programa de Pós-Graduação em Distúrbios da Comunicação HumanaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Otorrinolaringologia e Cirurgia de Cabeça e PescoçoUNIFESP, EPM, Programa de Pós-Graduação em Distúrbios da Comunicação HumanaUNIFESP, EPM, Depto. de Otorrinolaringologia e Cirurgia de Cabeça e PescoçoSciEL

Effect of Vestibular Adaptation Exercises on Chronic Motion Sensitivity

Dizziness is one of the most common complaints reported to primary care physicians. It is often associated with vestibular dysfunction and typically impacts postural stability. Motion sickness, or motion sensitivity, is stimulated by abnormal spatial orientation and is a common symptom related to dizziness and postural instability. The main cause of the motion sensitivity is aberrant sensory input from the visual, vestibular and somatosensory systems. The aim of this study was to measure the effect of vestibular adaptation exercises on postural stability in young healthy adults with subjective awareness of chronic motion sensitivity. Methods: Fifty healthy male and female participants between 20 to 40 years of age with chronic motion sensitivity were randomly assigned to either an experimental or control group. Postural stability measurements were taken at baseline and after 6 weeks using computerized dynamic posturography with immersion virtual reality. The experimental group performed daily vestibular adaptation exercises for 6 weeks. Results. There was no significant difference between the two groups at baseline in terms of mean age, height, weight, BMI or baseline postural stability scores (p\u3e0.05). Significant differences in mean postural stability scores were observed post intervention in both groups but larger improvements were detected in the experimental group (p=0.002). Conclusions: Minimal dosage of vestibular adaptation exercises improved postural stability in younger adults with chronic motion sensitivity. Additionally, familiarity of the testing environment during post-test measurements may have contributed to improvements in the control group over time; however, changes were greater in the experimental group