## 4 Discussion  
This case report explored the uses of IVR as a strategy for physical-cognitive stimulation in a woman diagnosed with ALS. The main results showed that this proposal is feasible and safe for people with this condition and was able to generate positive results in the parameters of body composition, anxiety/depression, health-related quality of life [26], and in maintaining functional capacity values (ALSFRS-R). ALS is typically characterized by a rapid disease course, progressing from normal functioning to one requiring assistance with \begin{table}
\begin{tabular}{c c c c} \hline \hline
**Variable** & **Pre (T0)** & **Post (T1)** & **\(\Delta\) \%** \\ \hline Body composition & & & \\ Height (cm) & 161.5 & 161.5 & - \\ Body mass (kg) & 71.7 & 69.8 & 2.64 \\ Body mass index (kg/m\({}^{2}\)) & 27.5 & 26.76 & 2.69 \\ Functional capacity & & & \\ ALSFRS-R & 10 & 10 & - \\ Anxiety and depression & & & - \\ HADS–Depression & 9 & 5 & 44.44 \\ HADS–Arxiety & 10 & 8 & 20.00 \\ Health-related quality of life & & & \\ Mobility & 4 & 4 & - \\ Self-care & 4 & 4 & - \\ Usual activities & 4 & 4 & - \\ Pain/discomfort & 3 & 2 & 33.33 \\ Anxiety/depression & 3 & 2 & 33.33 \\ Visual analogue scale & 50 & 65 & 30.00 \\ \hline \hline \end{tabular}
\end{table} 
Table 1: Assessment and differences between pre- and post-intervention in body composition, functional capacity, anxiety and depression and quality of life in a 76-year-old ALS patient. basic functions, then advancing to significant disability, and ultimately leading to death. ALS has a substantial negative impact on patients' quality of life across multiple domains, such as mobility, self-care, emotional functioning, activity impairment, and fatigue. The use of this technology in people with major functional limitations has not prevented the development of the therapy from being safe, without adverse effects linked to virtual exposure (no SSQ symptoms), and with high levels of usability (>80%). These findings are in line with studies that assessed these aspects in people with advanced PD, who, like our participant, also required a wheelchair to get around [27]. On the other hand, other research with IVR in patients with multiple sclerosis has shown that there are no serious adverse effects and that adherence to treatment increases [28; 29]. Our results have demonstrated that the use of multisensory stimulation programs carried out with IVR, despite being tested on a patient with an advanced case of the disease, can contribute to an improvement in health-related quality of life, primarily in the pain/discomfort and anxiety/depression parameters. Similar results were found by authors such as [PERSON] et al. [30] and [PERSON] et al. [31] when implementing physical stimulation programs (exercise-based programs) in this group, although without having used IVR. [PERSON] et al. [32] confirmed that there is involvement of sensory circuits in ALS, so in addition to obvious motor impairment, somatosensory, auditory and visual pathways can cause significant clinical symptoms. Thus, the use of multisensory therapies is essential for improving the functionality and quality of life of ALS patients. Other studies, such as that performed by [PERSON] et al. [9], have highlighted that devices promoting patients' interaction with computer-based tasks can enhance their performance, leading to greater independence and the use of technology in ALS. High-tech devices such as eye tracking communication devices are used to aid communication in the later stages of ALS [33]. In our case, this same technology has also helped to carry out therapy. Initially, as is usual in the handling of these devices, the patient began to use the controls, taking advantage of the movement she had in her distal phalanges. Seeing in the first sessions that, for the correct development of the intervention, it had to have the continuous support of the attending therapist, the program was managed through head and eye movements.