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Table 2 VR systems and training protocols

From: Efficacy of virtual reality-based intervention on balance and mobility disorders post-stroke: a scoping review

Study

VR system

Training protocol

Deutsch et al. (2004) [45]

Rutgers Ankle – an airplane simulation task required that the subject control the position of the airplane by using his ankle through a series of targets and not contacting them. For experiment 2, haptic effects were introduced to the Stewart platform and a new simulation that required the subjects to navigate a boat was added.

Exp 1 – 4 one hour sessions Exp 2 – one hour, 3 times per week for 4 weeks

Jaffe et al. (2004) [28]

Subjects walked on a motorized treadmill at self-selected walking speeds and viewed the real time display of their legs via a helmet mounted display wherein stationary images of obstacles were introduced. The subjects were required to step over the obstacle (take sufficiently higher and larger steps) to complete the task.

Control group: stepping over real foam obstacles Experimental group: stepping over virtual obstacles 1 hour sessions, 6 sessions over 2 weeks

You et al. (2005) [29]

IREX, GestureTek- stepping up and down, Sharkbait and Snowboarding

Control group: no intervention Experimental group: VR games - 60 minutes per day, 5 times per week for 4 weeks

Betker et al. (2006) [46]

COP-controlled video-game based exercise games – Under Pressure, Memory Match and Tic-Tac-Toe. The system consisted of a pressure mat which mapped the COP movements as the subjects moved. This was synchronized to the game motion software so as to match the COP movements for game play. The users were supposed to move in the AP and the ML direction at different speeds in order to play the games.

Eight 45-min exercise sessions over 3 weeks, 3 sessions in 1st and 2nd week each and 2 in the 3rd week.

Fung et al. (2006) [10]

VR-based locomotor system with a self-paced treadmill mounted on a 6-degree of freedom of motion platform. Subjects reacted in three VE’s with 3 levels of complexity. Each VE involved walking 39 m within a predetermined time constraint. Progression from one level to the next was permitted only after successful completion of 3 trials within the time constraint, as the level of complexity increased with environmental perturbations and presence of moving obstacles.

Both control and stroke subjects received the same intervention. Training frequency or length of single session not defined.

Flynn et. al. (2007) [47]

EyeToy Play Station 2 gaming system. Games played required dynamic balance, upper extremity ROM, speed, cognition, reaction time and accuracy.

Playing games on the gaming console in the standing position 20 one hour sessions over 4 ½ weeks.

Yang et. al. (2008) [30]

Motorized treadmill placed in front of three 239 cm wide screens Task consisted of walking in a community VE resembling community scenarios in Taipei and involved negotiating slopes, avoiding obstacles etc.

Control group: treadmill walking while performing various tasks, Experimental group: walking in the VE 20 min per session, 3 sessions per week for 3 weeks.

Dunning et. al. (2008) [48]

SEMG coupled VR system that required the subject to contract and relax the agonist and antagonist muscles of the ankle to complete a “paint” game.

One hour session, 3 times per week for 8 weeks – 30 min functional lower extremity strength training and 30 min sEMG VR training.

Mirelman et al. (2009 [31]; 2010) [33]

Rutgers Ankle Rehabilitation System - 6-degree of freedom Stewart platform force-feedback system that uses ankle movements to navigate through a VE displayed on a desktop computer as in Deutsch et al. (2004)

Experimental group: Ankle exercises in the form of VR games along with the robot. Control group: training only with the robot, same exercises as the experimental group without VR. One hour sessions, 3 times per week for 4 weeks

Kim et al. (2009) [32]

IREX VR system - Shark Bait, stepping up/down and snowboard games were used.

Control group – 40 min of conventional physical therapy (CPT) Experimental group - 40 min of CPT + 30 min of VR therapy, 4times/week for 4 weeks

Walker et al. (2010) [43]

BWSTT + VR system – Body-weight supported treadmill training combined with VR. Subjects walked on a Biodex Gait Trainer 2 treadmill with an overhead Biodex Unweighting system while a virtual street scene was projected on to a 51-inch television monitor connected to a desktop. The scene was synchronized to the subjects’ motion via an inertial orientation tracking device mounted on a cap worn by the subjects.

2-3 sessions per week for 4-6 weeks for a total of 12 sessions per subject. Each training session lasted for 10 min initially and the duration was increased for the later sessions as tolerated.

Shin et al. (2010) [39]

Sony Playstation 2 Eyetoy play gaming system. Games such as Goal Attack, Table Tennis, Homerun, Knockout and Bowling were used. All of the games had a component of dynamic balance, speed and reaction time training.

Control group: no intervention. Game exercise group: 60-min sessions, 3 times per week for 6 weeks.

Yang et al. (2011) [34]

VR Treadmill system consisting of 4 components: 1) a commercial treadmill modified to operate at speeds ranging from 0.1 to 1 mph, 2) a personal desktop computer with a liquid crystal display projector, 3) a VR training program resembling a video-game developed from commercial software (3DWeb, superspace) consisting of scenes that involved walking in a park along a pathway with eight left and right turns respectively, and indoor activities such as turning a light on/off and opening doors, 4) interactive switches located on each side of the treadmill – stepping switches to turn left/right and touch switch for hand motion tasks.

Both groups: treadmill training (duration 20 min), three times per week for 3 weeks + regular therapy sessions. Experimental group: walking on the treadmill in the VE while stepping on the switches to affect turns. Control group: level walking on the treadmill without VR

Cikaljo et al. (2012) [44]

Balance Trainer (BT; Medica Medizin-technik GmbH) standing frame fixed to the base with passive controllable springs that control the stiffness of the standing frame which can move within two-degrees of freedom (AP, ML and combinations of both). Virtual environment was built in the 3D rendering program and involved moving along a path (through AP and ML movements) towards a goal while avoiding collisions with obstacles in the path.

Experimental group: BT + VR – 20 min per session, 5 times per week for 3 weeks (2 weeks clinic + 1 week telerehabilitation) Control group: BT – 20 min per session, 5 times per week for 4 weeks.

Cho et al. (2012) [35]

Conventional 42-inch LCD TV connected to a balance board gaming system (Wii Fit Balance Board, Nintendo, Japan). Commercially available games on the Wii such as balance bubble, ski slalom, ski jump, soccer heading, table tiling and penguin slide were used for training.

Both groups: standard rehabilitation program. Experimental group: additional 30-minVR training thrice a week for 6 weeks.

Feasel et al. (2011) [49] and Lewek et al. (2012) [50]

Integrated Virtual Environment Rehabilitation Treadmill (IVERT) system consisting of an instrumented dual-belt treadmill coupled to an immersive VE. The treadmill utilized a control algorithm to drive the treadmill speed in congruence with the user’s gait speed (estimated from the ground reaction force). VE consisted of a park with rolling hills, trees, rocks and a trail lined with fence posts. The VE was displayed with the help of three short-throw projectors that were mounted in front of a three-panel display placed a distance of 1.2 m from the front and 0.9 m at the sides respectively. The combined image display had a 170° horizontal and 60° vertical field-of-view. Asymmetry in gait was portrayed as a curved path in the VE and users were encouraged to maintain a straight path during trials.

Feasel et al.: One session consisting of 20-40 min of treadmill walking. Lewek et al.: Two post-stroke individuals performed 18 sessions over 6 weeks consisting of 20 min walking with the IVERT system followed by 10-15 min of overground walking. Each session lasted for 60 min (patient 1) or 45 min (patient 2).

Jung et al. (2012) [40]

The set-up consisted of a treadmill and an HMD through the virtual scene was displayed. The virtual scene consisted of a park stroll. The HMD displayed a 100-inch screen and had built-in earphones. Further information about the virtual scene and synchronization of the treadmill with the VR was not provided.

Experimental group: Treadmill walking with VR 30 min/day, 5 days/week for 5 weeks. Control group: treadmill walking without VR, following the same schedule as for experimental group.

Kim et al. (2012) [41]

Nintendo Wii sports software to play games involving tennis and boxing. The Wii games were displayed on a 30-inch TV display placed at 60 cm above the ground atop which was mounted the motion sensor. The motion sensor communicated with a remote that was either held on or strapped to the unaffected hand of the stroke subjects. Both games required varied motion and acceleration patterns to succeed.

Both groups received general exercises (not specified) for 30 min and electrical stimulation to the tibialis anterior muscle on the paretic side for 15 min. The experimental group received additional VR training for 30 min/session, three times a week for 3 weeks.

Cho et al. (2013) [36]

The set-up utilized a treadmill, a laptop, projector and speakers. The laptop was used to project real-world video recordings (VRRW) on to the projector which consisted of 10-min recordings of a 400 m walk track, a rainy 400 m walking track, a 400 m walking track with obstacles, walk in the community during daytime and nighttime and walking on a trail. Each recording was repeated thrice during the 30 min training period.

Both groups: standard rehabilitation program, 80 min per day, 5 times a week for 6 weeks. Experimental group: VRRW training, 30 min a day, 3 times per week for 6 weeks. Control group: treadmill training without VR for similar duration.

Fritz et al. (2013) [38]

Nintendo Wii (Wii sports and Wii Fit) as well as Playstation (Eyetoy play and Kinect) gaming systems were used to train the experimental group. The Wii Fit and Kinect were marketed as physical activity whereas Wii sports and Eyetoy were marketed as ‘fun-based’ games. The patients were encouraged to operate both systems on their own.

Control group: no intervention VR group: 50- 1 hour sessions consisting of 25-30 min physical activity and 25-30 min fun-based games. Frequency: 4 days/week for 5 weeks.

Rajaratnam et al. (2013) [37]

Nintendo Wii-fit and the Kinect gaming system were used to train the experimental group. Games that required subjects to shift weight in standing (Wii Fit and Kinect) and sitting (Kinect only) were used for training.

Control group: 60 minutes of conventional rehabilitation per session for 15 sessions. Experimental group: 40 min of conventional rehabilitation + 20 min of VR training per session for 15 sessions.

Singh et al., (2013) [42]

Nintendo Wii Fit plus with Balance Board: Balance Bubble game Xbox 360 Kinect: Rally Ball game, individuals who scored a gold medal on this game progressed on to the Reflex Ridge game.

Control group: standard group exercise therapy 2 hour sessions 2 times per week for 6 weeks. Experimental group: 90 minutes of standard group exercise + 30 min of VR balance games, 15 min each on the WiiFit and Xbox Kinect, twice per week for 6 weeks.