Virtual snowboarding your way to stroke recovery
McEwen D, Taillon-Hobson A, Bilodeau M, Sveistrup H, and Finestone H. Virtual Reality Exercise Improves Mobility After Stroke: An Inpatient Randomized Controlled Trial. Stroke. 2014
Virtual reality (VR) training has many advantages over other technology-based stroke rehabilitation strategies. VR allows tasks that focus on a particular skill without the need for additional sensors or equipment specific to the task. In addition, positive feedback and incremental increases in task difficulty, once provided by the therapist, can be achieved with VR simply by turning the task into a computer game. Despite these many advantages, few have conducted rigorous studies of VR in a rehabilitation setting. In this article, McEwan and colleagues describe one of the first truly randomized-controlled trials of VR training in stroke patients, showing modest improvements in lower extremity function.
59 stroke patients in an inpatient rehabilitation unit were randomized to 10-12 sessions of standard therapy + VR while standing (soccer goaltending and snowboarding tasks) vs. standard therapy + VR while sitting (games did not require weight shifting). The investigators tested lower extremity function before, immediately after, and at one month post-VR training. Subjects in both groups experienced clinically significant improvement post-training. More subjects in the standing VR training group showed improvement on the Chedoke McMaster Leg Domain both immediately after (P = 0.04) and 1 month (P = 0.02) post-training.
The results of this study, while positive, do not support unbridled enthusiasm for VR-training post-stroke. Although statistically significant, the difference between groups on lower extremity testing was unlikely to be clinically meaningful and seemed to disappear 1 month post-training on 2/3 outcome measures. In addition, these results were obtained in a per-protocol instead of an intention-to-treat analysis.
Further studies of VR training for stroke rehabilitation are warranted. In my mind the VR tasks in this study focused on balance while the outcome measures primarily assessed walking ability. While I do not deny that walking ability is more important than balance, perhaps a better match between tasks and outcome measures would improve results in future trials. The authors are to be commended for adding scientific rigor to the study of VR training post-stroke. It remains unclear whether VR training will emerge as an important rehabilitation tool – these results suggest cautious optimism moving forward.