Virtual Reality, Motor Imagery Techniques Helpful in PD, Study Finds

A recent study, published in the Journal of Personalized Medicine, found that patients with Parkinson disease (PD) displayed significant improvement in mobility and rigidity after using virtual reality (VR) and motor imagery (MI). This improvement was also significantly greater than patients with PD who only used traditional physical therapy (PT) techniques.

The study aimed to measure whether MI and a VR program along with routine PT had any effect on the motor components of patients with PD, including bradykinesia, rigidity, resting tremor, postural instability, posture, and gait, when compared with routine PT alone. The study took place from 2020 to 2021 at the Safi Hospital, Faisalabad, Pakistan.

The study was small with 41 patients who ranged from 50 to 80 years old. Participants had idiopathic PD, with severity ranging from stage I to stage III, and intact cognition. Patients excluded were those with neurological or orthopedic conditions, visual abnormalities, cardiovascular problems, severe dyskinesia or on-and-off phases, prior history of PD surgery, or treatment with virtual game therapy in the past 3 months.

Each patient was evaluated at the baseline, at the 6- and 12-week marks, and 1 month after the trial ended. All participants stayed on the same medication throughout the study. They were assigned to either the control Group A (21 patients), which consisted of only routine PT, or experimental Group B (20 patients), which consisted of MI, VR, and routine PT. Routine PT included warm-ups, stretching, strengthening, and relaxation exercises; limb coordination exercises; and core, neck, and gait training as well as cycling and walking. Group B received the same PT treatment as well as VR and MI treatment.

Patients had 3 days of their assigned treatment per week. Group A was given 40 minutes of routine PT and 20 minutes of walking and cycling. Group B had 40 mins of routine PT, 10 to 15 minutes of VR, and 5 to 10 minutes of MI.

The VR system used was the Wii console, which included the Wii box, the Wii controller, and the Wii Fit board. Patients were encouraged to play games on the Wii Fit board. Games were selected by senior physical therapists to focus on 3 domains: motor functioning, balance, and activities of daily living.

Each VR session started with balance games, with at least 1 dynamic balance game and a static balance game used for each session; difficulty was adjusted to match patient progression. All MI training took place in the final 5 to 10 minutes of each session.

Each routine PT treatment lasted 40 minutes. Patients were taken through a series of warm-up activities, before doing stretching exercises for 15 minutes.

Motor function of the patient with PD was recorded using the United Parkinson’s Disease Rating Scale (UPDRS) recording rigidity, bradykinesia, tremor, and mobility in all patients. The scale consists of 14 elements that are each graded from 0 to 4, with a total potential score of 56. Higher scores indicated more disability.

Between the groups, there were no significant differences in age, disease duration, age at onset of PD, and age at diagnosis of PD between the 2 groups. The mean (SD) score of UPDRS in the experimental group was 32.45 (3.98) and was 31.86 (4.62) in the control group.

The UPDRS scores identified that the experimental group had a significant improvement in tremor at rest, rigidity, posture, postural stability, and body bradykinesia. The experimental group also had a significant improvement in gait, rapid alternating movements, and ability to rise from a chair after 16 weeks since the beginning of the intervention. No differences in outcomes for speech, facial expression, action or postural tremor, finger taps, hand movements, or leg agility were observed in either group.

The following results mean (SD) scores were observed in this study for various characteristics:

• Resting tremor after 16 weeks: 3.31 (1.21) experimental, 4.86 (1.28) control
• Rigidity (baseline and 16 weeks): 4.86 (0.710) and 2.27 (1.55) experimental, 4.68 (0.893) and 4.09 (1.68) control
• Gait (baseline and 16 weeks): 1.86 (0.468) and 1.00 (0.690) experimental, 1.73 (0.456) and 1.45 (0.671) control
• Comparison of postural stability between the experimental and control (baseline and 16 weeks): 1.50 (0.512) and 0.73 (0.631)
• body bradykinesia after 16 weeks: 0.95 (0.653) experimental,1.36 (0.727) control

There were some limitations to this study. The study covered a small sample of patients with PD who had mild to moderate symptoms. Due to the exclusion of patients with cognitive impairment, a study that takes a holistic approach that covers both motor and cognitive impairment may have superior findings. VR and MI have been identified here as being more effective. This study did not answer whether hybrid care is more effective than VR and MI alone.

“Patients receiving VR and MI training in addition to routine PT showed significant improvements in resting tremors, rigidity, gait, posture, body bradykinesia, arising from a chair, and rapid alternating movements compared with patients assigned to a control group that received only physical therapy. Furthermore, the gains were sustained at follow-up in the experimental group,” the researchers wrote. They concluded that VR and MI training with routine PT could be the most effective way of treating older patients with mild to moderate PD symptoms.

Reference

Kashif M, Ahmad A, Bandpei MAM, Syed HA, Raza A, Sana V. A randomized controlled trial of motor imagery combined with virtual reality techniques in patients with parkison’s disease. J Pers Med. 2022;12(3):450. doi:10.3390/jpm12030450