# Exercise as it relates to Disease/Virtual reality: rehabilitation for stroke patients

This wiki page created by u3085734 is a fact sheet of the journal article "Effect of a virtual reality exercise program accompanied by cognitive tasks on the balance and gait of stroke patients" by Lee IW et al. (2015).

## Background

Stroke
A stroke is a blockage of blood to the brain. There are several ways in which this can happen, the most common being an ischemic stroke where part of the brain looses blood supply by a blood clot blocking a blood vessel. Stroke is a chronic condition that can severely impact ones daily living by increasing risk of falls, impair movement, sensation, perception, cognition, and/or language.
Virtual Reality
Virtual reality is a combination of hardware and software that allows users to immerse themselves in a world which provides real world like feedback. It has a wide range of applications such as oil and gas industry, manufacturing industry, military and medical care. Although virtual reality programs require a high level of specificity to the individual in order to be effective, they are able to provide visual, auditory, tactile feedback and motivation.
Context
Strokes cost the Australian economy $5 billion in 2012 alone, was the underlying cause of death for 11 220 Austrlaians in 2010 and of the 381 400 Australians who suffered a stroke in 2009, 133 490 had an impairment lasting for longer than 6 months. Modifiable lifestyle factors can influence the risk of stroke, particularly ischemic stroke.

## Where is the research from?

The study was conducted by researchers from the Department of Physical Therapy in Nambu University and the Department of Rehabilitation Science in Daegu University, all in the Republic of Korea.
The authors of the research
Lee IW, Kim YN and Lee DK have been involved in 109, 339 and 987 published studies on PubMed respectively as of 06/09/2016.

## What kind of research was this?

This is a quantitative randomised controlled study that reported no conflict of interest nor did they report where they received funding from.

## What did the research involve?

20 patients were selected, all of which had been diagnosed with stroke 6 months before the study. They were then randomly divided into two groups. the experimental group consisted of 6 males and 4 females, who participated in a virtual reality program while performing cognitive tasks. The virtual reality exercise program used the city walking (left-right weight shift), hot air balloon (up-down weight shift), and bubble (total weight shift) activities available in BioRescue. This was accompanied by addition and subtraction by tens and backward reading of two or three words or numbers for their cognition training. The control group contained 5 males and 5 females, who participated in a proprioceptive neuromuscular facilitation (PNF - see second paragraph under Introduction) exercise program. Both groups performed their activities 45 minutes a day, 3 times a week, for 6 weeks. Balance and gait were measured using the Berg Balance Scale (BBS) and Timed Up and Go Test (TUGT) respectively.
Was the methodology the best approach?
Several large flaws exist within the study. The small sample size of 20 means a large generalisation of stroke patients would occur, although the researchers acknowledge this. Methodology between the groups are vastly different: more groups should have been added to the study, such as a group where only cognitive training is done, another where only the virtual reality program is used. No follow-up occurred in the study, another limitation acknowledged by the researchers, which could provide information on the length of effect of the interventions used.

## What were the basic results?

$_{ComparisonoftheresultsoftheBBSandTUGTbetweentheexperimentalandcontrolgroups}$
| | Group | Pre | Post | D-Value |
| BBS (score) | EG | 37.8±2.2 | 46.2±2.3* | 8.4±2.5# |
| | CG | 38.6±1.3 | 41.5±3.7 | 2.9±4.3 |
| TUGT (sec) | EG | 21.2±2.9 | 13.6±0.9* | −7.6±2.5# |
| | CG | 22.1±2.1 | 18.3±1.4 | −3.8±2.2 |
aMean±SD. *p<0.05 (paired t-test). # p<0.05 (independent t-test). D-value: difference value; EG: experimental group; CG: control group; BBS: Berg Balance Scale; TUGT: Timed Up and Go Test
Those who participated in the virtual reality training program showed greater increase in both the TUGT and BBS when compared to the control group. It is important to note that both groups performed better post intervention, although virtual reality and PNF stretching has been shown to aid with the rehabilitation of stroke patients, while dual tasks (which requires cognition) can impair gait.

## How did the researchers interpret the results?

The researchers interpretation of the results was that their study supported the findings of other literature that a virtual reality program combined with cognitive training had a positive effect on balance and gait of stroke patients.

## What conclusions can we take from this research?

The thing to take away from this study is that more research needs to be done in this area. The results look promising; the experimental group saw greater increases in measured outcomes when compared with the control group, however all of the methods used are current techniques for stroke patients and an overall increase in measured outcomes would not be uncommon. The flaws within the study means that it is not conclusive information, but rather that this is an area where there is a lot of potential for further research.

## Further information/resources

For more general information regarding stroke: https://strokefoundation.com.au/
For support groups within Australia: https://strokefoundation.com.au/About-Stroke/Help-after-stroke/Local-stroke-support-groups-and-choirs
For more information regarding virtual reality: http://www.vrs.org.uk/virtual-reality/what-is-virtual-reality.html
For more information regarding gait, balance and fall prevention: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116773/

## References

* 1 2 3 4 5 6 7 Lee IW, Kim YN, Lee DK. Effect of a virtual reality exercise program accompanied by cognitive tasks on the balance and gait of stroke patients. J Phys Ther Sci. 2015 07 22; 27(7): 2175–2177.
* ↑ Types of stroke — Stroke Foundation - Australia [Internet]. Australia: Stroke Foundation; 2016 [cited 2016 Sep 24]. Available from: https://strokefoundation.com.au/About-Stroke/Types-of-stroke
* ↑ Simpson L, Miller W, Eng J. Effect of Stroke on Fall Rate, Location and Predictors: A Prospective Comparison of Older Adults with and without Stroke. PLOS ONE. 2011 Apr 29 ;6(4):e19431.
* ↑ Burdea GC. Virtual rehabilitation-benefits and challenges. Methods of information in medicine. 2003 Jan 1;42(5):519-23.
* 1 2 3 Grealy MA, Johnson DA, Rushton SK. Improving cognitive function after brain injury: the use of exercise and virtual reality. Archives of physical medicine and rehabilitation. 1999 Jun 30;80(6):661-7.
* ↑ Facts and figures about stroke — Stroke Foundation - Australia [Internet]. Australia: Stroke Foundation; 2016 [cited 2016 Sep 24]. Available from: https://strokefoundation.com.au/About-Stroke/Facts-and-figures-about-stroke
* 1 2 Australian Bureau of Statistics. Profiles of disabilities. Canberra: The Bureau; 2009. Report No: 4429.0
* ↑ Jamrozik K, Broadhurst RJ, Anderson CS, Stewart-Wynne EG. The role of lifestyle factors in the etiology of stroke. A population-based case-control study in Perth, Western Australia. Stroke. 1994 Jan 1;25(1):51-9.
* ↑ Chiuve SE, Rexrode KM, Spiegelman D, Logroscino G, Manson JE, Rimm EB. Primary prevention of stroke by healthy lifestyle. Circulation. 2008 Aug 26;118(9):947-54.
* ↑ Kurth T, Moore SC, Gaziano JM, Kase CS, Stampfer MJ, Berger K, Buring JE. Healthy lifestyle and the risk of stroke in women. Archives of internal medicine. 2006 Jul 10;166(13):1403-9.
* 1 2 Saposnik G, Levin M, Stroke Outcome Research Canada (SORCan) Working Group. Virtual reality in stroke rehabilitation a meta-analysis and implications for clinicians. Stroke. 2011 May 1;42(5):1380-6.
* 1 2 Jack D, Boian R, Merians AS, Tremaine M, Burdea GC, Adamovich SV, Recce M, Poizner H. Virtual reality-enhanced stroke rehabilitation. IEEE transactions on neural systems and rehabilitation engineering. 2001 Sep;9(3):308-18.
* 1 2 Wang RY. Effect of proprioceptive neuromuscular facilitation on the gait of patients with hemiplegia of long and short duration. Physical Therapy. 1994 Dec 1;74(12):1108-15.
* 1 2 Ali MH, Gaikwad S, Mathew JT. A Comparative Study between Hold Relax Technique and Static Stretching to Improve Gait Parameter of Hemiplegic Stroke Patients. International Journal of Neurorehabilitation. 2015 Sep 26;2015.
* ↑ Plummer-D’Amato P, Altmann LJ, Saracino D, Fox E, Behrman AL, Marsiske M. Interactions between cognitive tasks and gait after stroke: a dual task study. Gait & posture. 2008 May 31;27(4):683-8.
* ↑ Hyndman D, Ashburn A, Yardley L, Stack E. Interference between balance, gait and cognitive task performance among people with stroke living in the community. Disability and rehabilitation. 2006 Jan 1;28(13-14):849-56.