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Pre-post effects within groups were investigated using the Wilcoxon matched-pairs signed-rank test, and between-groups differences were explored using the Wilcoxon rank-sum test. We enrolled 21 ambulatory chronic TBI patients 17 males, 4 females with a median age of 36 12 IQR years; one patient dropped out for personal reasons.
The study flow diagram is shown in Fig. No significant effects after training in AP, ML and total path length or sway speed were found. We performed a sample size calculation using the UBS improvements before and after the treatments. We estimated an effect size of 0. This exploratory study is the first to use the Xbox Kinect in chronic ambulatory TBI patients for balance and attention training.
Chronic TBI patients are usually discharged to their homes when they reach a functional plateau; they accordingly do not receive any form of rehabilitation, even if postural instability and mobility deficits are often reported [ 34 ]. However, our results confirmed previous studies [ 21 , 24 , 35 ] that revealed how even in a chronic phase TBI survivors can improve their mobility and dynamic balance with a therapy based on use-dependent neuroplasticity principles [ 36 ].
Our primary findings are that dynamic balance and overall mobility improved after training; moreover, selective attention resulted increased, revealing a significant cognitive engagement during VGT.
We investigated balance using validated clinical tests and posturographic assessments. However, only in VGT group were the gains clinically significant 8 vs 0. This finding is likely due to the fact that VGT trains patients in more challenging and dynamic motor tasks, such as side stepping, reaching high and low, lateral weight shifting and jumping.
We noted differences in mobility between the groups. Similarly, the UBS that explored both static and dynamic balance was significantly improved in the VGT group, with differences between the groups. This new balance outcome measure covers all of the relevant aspects of balance, exhibits good psychometric properties and avoids the well-known ceiling effect characteristic of other balance scales [ 38 ].
The lack of improvement in static balance is consistent with the fact that it is not considered a predictor of mobility in TBI survivors measured as COP displacement in quiet standing [ 40 ]. Furthermore, VGT trains complex movements that require more acceleration, coordination and precision than standing tasks.
Examining other trials that use video games in TBI survivors [ 23 , 24 ], Cutberth et al. In a subacute phase, it is logical that Nintendo Wii Fit—which permits more active guidance by physiotherapists—is more appropriate. In a chronic phase, training with Xbox Kinect can be introduced. Ustinova et al. This result is consistent with previous studies that highlighted how video game feedback is capable of improving visual selective attention in habitual players [ 41 ].
Video games increase information processing procedures to provide either an adequate response for stimulus processing e. Game benefits might reflect shifts in strategy rather than changes in more basic cognitive capacities [ 46 ]. In our study, VGT was associated with a higher perception, higher attentional capture and a higher motor-load than BPT.
In addition, video games had an influence on the reward system. Consequently, the involved reward system represents a key step in learning and cognitive processing [ 47 ].
Increased attention can help motor skill learning and functional recovery in TBI survivors and can partially explain the functional gains obtained by our cohort of patients who received VGT. This exploratory study presents several limitations: our finding cannot be generalized to the entire TBI population. Specifically, Xbox Kinect, like other gaming devices, was developed for a healthy population and is not adjustable for people with cognitive and sensory-motor impairments.
Furthermore, TBI survivors with extended frontal damage may not benefit from a reward-based learning delivered by VR. Additionally, the therapist was not blinded to the treatments received, which may represent a potential source of bias.
We also have to consider that patients with an higher chronicity may have developed more compensatory strategies over time, rendering them less susceptible to modification with the rehabilitative interventions.
Finally, five of the 20 patients were receiving multidisciplinary rehabilitation, even in a chronic phase, and the multiple interventions could mask specific effects of VGT or BPT.
However, we decided to include chronic TBI patients even if they were undergoing rehabilitation given the preliminary nature of this trial and the difficulty of recruiting members of this particular population. In future studies, it will be important to evaluate the effect of video games on other attention components e.
Such an evaluation can help to predict performance after VGT [ 49 ], either in the early or later phases of learning. It would also be helpful to use an adaptive video game characterized by a progressive increase in attentional and executive loads in order to make the intervention more effective, even for the most compromised patients.
Ambulatory chronic TBI patients appeared to benefit from 6 weeks of VGT in terms of dynamic balance, mobility and selective attention. However, these promising results were obtained from a small sample of convenience. Additional studies with more homogeneous and larger samples are required to confirm and better explore the role of video games on motor learning after TBI. SS performed the statistical analysis.
All of the authors read and approved the final manuscript. The study has been approved by the Ferrara University Hospital Ethics Committee, and all subjects signed a consent form prior to participating in any of the procedures. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Sofia Straudi, Email: ti. Giacomo Severini, Email: ei.
Amira Sabbagh Charabati, Email: moc. Claudia Pavarelli, Email: ti. Giulia Gamberini, Email: moc. Anna Scotti, Email: ti. Nino Basaglia, Email: ti. National Center for Biotechnology Information , U. BMC Neurol. Published online May Author information Article notes Copyright and License information Disclaimer. Intervention: Interventions included balance-based physical therapy using a Nintendo Wii, as monitored by a physical therapist, and receipt of one-on-one balance-based physical therapy using standard physical therapy modalities available for use in the therapy gym.
Results: Participants in the standard physical therapy group were found to have slightly higher enjoyment at mid-intervention, while those receiving the virtual reality-based balance intervention were found to have higher enjoyment at study completion. Has PDF. Publication Type. More Filters. BioMed research international.
Cognitive rehabilitation post traumatic brain injury: A systematic review for emerging use of virtual reality technology. Journal of Clinical Neuroscience.
What is the future for immersive virtual reality in memory rehabilitation? A systematic review. Virtual Reality for Psychological and Neurocognitive Interventions. This chapter is a systematic review of the studies that have used virtual reality VR as an assessment or a rehabilitation tool of cognitive functions following traumatic brain injury TBI.
To be … Expand. Journal of medical Internet research.
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