2-dimensional Versus 3-dimensional Virtual Reality Game Training in BPPV
Condition: Vertigo
MeSH terms: Vertigo; Benign Paroxysmal Positional Vertigo; Dizziness
Study type: Interventional

Summary: 
      Despite successful maneuver applications in the treatment of BPPV, complaints of balance
      problems and dizziness persist. Many studies supports the notion that virtual reality (VR)
      allowing visual-vestibular interaction with a large number of visual stimuli, contribute to
      successful outcomes in BPPV. VR applications using eye tracking algorithms and 'glasses' can
      be effective however. The research to date covers the VR technologies on the treatment of
      BPPV, however, there is no research comparing the effects of 2D and 3D VR gaming technologies
      with a control group. Therefore, this study aims to examine the effects of different virtual
      reality applications and vestibular rehabilitation on gait, reaction time, balance functions,
      activities of daily living, and quality of life in individuals with benign paroxysmal
      positional vertigo (BPPV) having residual dizziness and balance problems.
    

Detailed description: 
      The vestibular, visual, and somatosensory systems are all important in maintaining posture.
      Multiple structures of the central nervous system process and integrate afferents from these
      systems. The vestibular system is crucial for maintaining static and dynamic posture and
      balance. The vestibular system consists of two structures, peripheral and central. The
      peripheral vestibular system is located within the petrous bone and consists of the
      semicircular canals, utricle, and saccule in the inner ear that are sensitive to head
      movements. The semicircular canals consist of three parts: anterior, posterior and lateral
      semicircular canals. The semicircular canals, which are filled with a viscous fluid called
      endolymph, are located at right angles to each other and help to perceive the angular
      movements of the head. It transmits information about the peripheral vestibular system and
      head movements to the central systems via the vestibular nerve. In this way, it provides
      regulation of head, body, extremities and eye movements.

      BPPV (Benign Paroxysmal Positional Vertigo) is a condition that affects the inner ear and is
      caused by semicircular canal dysfunction. Because the otoliths are placed in the semicircular
      canal and can impair their free movement, the anatomical placement of the canals is critical.
      BPPV is one of the most frequent peripheral vestibular illnesses with a prevalence of 20-40%.
      The first pathogenetic element is canalolithiasis, defined as the dissociation of the
      otoconia from the otolytic membrane and its free movement in the endolymph, which is seen in
      80% of the patients. Cupulolithiasis is the occurrence of dizziness (vertigo) and nystagmus
      specific to the affected canal due to calcium carbonate crystals adhering to the canal.
      Because of its anatomical location, posterior semicircular canal BPPV is observed 80-90% of
      the time, lateral semicircular canal BPPV is seen 10-20% of the time, and anterior
      semicircular canal BPPV is less prevalent. BPPV often is treated with particle repositioning
      maneuvers once the involved canal is identified. These maneuvers are supposed to move
      otoconia particles out of the affected canal and back into the vestibule, where they
      dissolve.

      Vestibular rehabilitation is another non-pharmacological intervention for BPPV. Vestibular
      rehabilitation can enhance general balance function, including gait, gaze, and postural
      stability, physical mobility, and function with activities of daily living, by integrating
      proprioceptive, visual, and residual vestibular function. Vestibular rehabilitation utilizes
      central neuroplasticity mechanisms to improve visuo-vestibular interactions and restore
      static and dynamic postural stability in situations where sensory input is conflicting.
      Vestibular rehabilitation includes adaptation, habituation, and substitution exercises. The
      adaptation exercises are based on the vestibular system's ability to change the magnitude of
      the vestibulo-ocular reflex (VOR) in response to a specific stimulus (head movement).
      Habituation exercises, in contrast to adaptation exercises, are based on the notion that
      frequent exposure to provoking stimuli such as head movements will reduce motion-provoked
      symptoms. Substitution exercises combine vision and somatosensory cues with vestibular cues
      to improve gaze and postural stability by enhancing central programming. Maneuvers are shown
      to be more successful than vestibular rehabilitation in the short term, although combining
      the two is useful for long-term functional recovery in BPPV. However, there is insufficient
      evidence to distinguish between different types of vestibular rehabilitation.

      The positive impact of vestibular rehabilitation on balance is based on mechanisms related to
      the central nervous system's neural plasticity, and its goals are to promote visual
      stabilization, improve vestibular-visual interaction during head movements, thereby improving
      the standing and dynamic postural stability in conditions that produce conflicting sensory
      information, and decrease sensitivity to head movements. However, numerous aspects have been
      identified as having a detrimental impact on the outcome of vestibular rehabilitation,
      including poor exercise execution, the necessity for active efforts, and the patients'
      desire. Given the drawbacks associated with the time-consuming, repetitive, monotonous, and
      non-challenging aspects of vestibular rehabilitation, more efficient and cost-effective types
      of treatments were proposed as a potential alternative. Currently, virtual reality (VR)
      applications, can be outfitted with real-time simulations, interactive functions, and game
      features to allow for more motivated vestibular rehabilitation.

      Many studies suggest that engaging virtual reality components can contribute to successful
      outcomes. It is claimed that it allows visual-vestibular interaction with a large number of
      visual stimuli, resulting in an optimal environment for better VR performance. It is
      suggested that this is due to the activation of target-oriented attention and the brain's
      neural network and that VR applications using eye-tracking algorithms and 'glasses' can be
      effective. In most of the studies, 2-dimensional systems (e.g. Nintendo Wii, Play station)
      has been used for the treatment of patients with BPPV. However, due to their proximity to the
      eye, head-mounted displays (3D VR gaming) may offer high-resolution images which make the
      users feel like they are a part of the computer-created environment. 3D technologies have
      been debated about their negative effects such as discomfort, visual fatigue, dizziness,
      headache, disorientation, motion sickness, which are indicative of VIMS (visually induced
      motion sickness). The most accepted explanation for VIMS is the classical conflict theory
      based on the mismatch between the visual, the proprioceptive, and the vestibular stimuli.

      It is known that brief and sudden positional nystagmus associated with a change in head
      position relative to gravity may temporarily impair visual stability. The otolithic signal is
      created in response to the motion, which plays an important role in the perception of
      orientation and the direction of motion. Compensatory eye movement occurs after linear
      acceleration of the head, opposite in direction to the head movement, and is generated to
      stabilize the image of the target in coordination. The impact of dysfunction on the VOR in
      patients with chronic vestibular problems is associated with the inability to have a clear
      image of the target on the retina during head movements, resulting in blurred vision.
      According to these explanations, head movements while playing 3D VR gaming may pose a
      challenge (sensory mismatch) to the central nervous system, which then attempts to resolve
      the challenge. Habituation exercises included in the 3D VR gaming task might be beneficial in
      opposing over-reliance on a sensory modality, desensitizing patients to visual motion and
      visuo-vestibular conflict, and reducing associated symptoms.

      It was proved out that accommodative facility has a tendency to increase after 2D and 3D VR
      gaming, but particular, the increasing tendency is greater after playing 3D VR gaming. It was
      explained that while playing a game, eyes are stimulated with stereoscopic images, and
      brightness change so that pupils remain under persistent stimulation. Therefore, the depth of
      a focus changes reversely and it results in visual training. In comparison to traditional 2D
      VR gaming technology, which does not provide depth to objects, 3D VR gaming technology may
      enable the perception of spatial depth. Additionally, it was proposed that the type of game
      (action vs. non-action) is important in 3D VR gaming. Especially, action game stimulates the
      overall parts of a brain, requiring multi-tasking skills and speed.

      The research to date covers the VR technologies on the treatment of BPPV. However, to our
      knowledge, there is no research comparing the effects of 2D and 3D VR gaming technologies
      with a control group. Therefore, this study aims to examine the effects of different virtual
      reality applications and vestibular rehabilitation on gait, reaction time, balance functions,
      activities of daily living, and quality of life in individuals with benign paroxysmal
      positional vertigo (BPPV) having residual dizziness and balance problems.
    

Intervention name(s): 2-Dimensional Group; 3-Dimensional Group
Intervention type(s): Other; Other
Intervention description(s): In the 2-Dimensional Group, 2D VR gaming training in addition to traditional vestibular rehabilitation will be employed. In this group, the 'Verti-Go' game from the Playstation 4 VR gaming device will be played in 2D for 20-25 minutes, as well as vestibular therapy for 20-25 minutes. A total of 45-50 minutes will be given over the course of 8 weeks, 3 sessions per week. The intensity of treatment will rise with each session, depending on how well the patient cooperates. Evaluation will be done at the beginning and in the 8th week.; In the 3-Dimensional Group, 3D VR gaming training in addition to traditional vestibular rehabilitation will be employed. In this group, the 'Verti-Go' game from the Playstation 4 VR gaming device with 3D glasses will be played for 20-25 minutes, as well as vestibular therapy for 20-25 minutes. A total of 45-50 minutes will be given over the course of 8 weeks, 3 sessions per week. The intensity of treatment will rise with each session, depending on how well the patient cooperates. Evaluation will be done at the beginning and in the 8th week.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Randomized Controlled Study
Masking: Single (Participant)
Primary purpose: Treatment
Keywords: Benign paroxysmal positional vertigo; Dizziness; Virtual Reality; Vestibular Rehabilitation; Balance functions; Gait