Efficacy of Virtual Reality and Exergaming in Improving Balance in Patients With Multiple Sclerosis: A Systematic Review and Meta-Analysis

Abstract

Multiple sclerosis (MS) is one of the most common causes of neurological progressive disease and can lead to loss of mobility, walk impairment, and balance disturbance. Among several rehabilitative approaches proposed, exergaming and virtual reality (VR) have been studied in the recent years. Active video game therapy could reduce the boredom of the rehabilitation process, increasing patient motivation, providing direct feedback, and enabling dual-task training. Aim of this systematic review was to assess the efficacy of exergaming and VR for balance recovery in patients with MS. PubMed, Scopus, and Web of Science were systematically searched from the inception until May 14, 2021 to identify randomized controlled trials (RCTs) presenting: patients with MS as participants, exergaming and VR as intervention, conventional rehabilitation as comparator, and balance assessment [Berg Balance Scale (BBS)] as outcome measure. We also performed a meta-analysis of the mean difference in the BBS via the random-effects method. Out of 93 records, this systematic review included and analyzed 7 RCTs, involving a total of 209 patients affected by MS, of which 97 patients performed exergaming or VR and 112 patients underwent conventional rehabilitation. The meta-analysis reported a significant overall ES of 4.25 (p < 0.0001), showing in the subgroup analysis a non-significant ES of 1.85 (p = 0.39) for the VR and a significant ES of 4.49 (p < 0.0001) for the exergames in terms of the BBS improvement. Taken together, these findings suggested that balance rehabilitation using exergames appears to be more effective than conventional rehabilitation in patients affected by MS.

Virtual reality-based therapy improves balance and reduces fear of falling in patients with multiple sclerosis. a systematic review and meta-analysis of randomized controlled trials

“…The present findings suggest that VRBT: (1) improves functional and dynamic balance; (2) increases confidence of balance and postural control assessed with posturography; (3) reduces fear of falling; (4) but, does not improve gait speed in PwMS. Compared to previous reviews [29][30][31][32][33][34], the current study provides the most comprehensive meta-analysis to date aimed at assessing the effect of VRBT on balance and its different dimensions. It includes the larger number of studies to date (19 RCTs), and the largest sample of participants (858 PwMS), which increases the robustness and generalization of its findings.…”

“…According to the 20 possible scores provided by Kurtzke, JF (1983) [52], we carried out a more simplified and functional reorganization of this scale, identifying the following subgroups: Only minimal disability = EDDS 0.5; minimal disability = EDDS 1-2.5; moderate disability = EDDS 3-3.5; severe disability = EDDS 4-4.5; and disability affects ADL = EDDS 5-5.5). Finally, the third subgroup analysis was performed to estimate the most appropriate dose of VRBT according to: number of sessions of VRBT (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)…”

“…In recent years, several reviews have analyzed the effect of VRBT on balance and/or risk of falls [29][30][31][32][33][34]. However, all of these reviews included a low number of studies, with the meta-analysis of the Casuso-Holgado containing the larger number studies, 11 in total [31].…”

Efficacy of Transcranial Direct Current Stimulation (tDCS) on Balance and Gait in Multiple Sclerosis Patients: A Machine Learning Approach

“…The goal of rehabilitation interventions is to minimize motor impairments while facilitating the activation of neural pathways in order to achieve the long-term recovery of walking [ 20 , 25 ]. While traditional rehabilitation techniques remain the benchmark, new technologies are emerging, allowing improved management of disabling symptoms [ 26 , 27 , 28 , 29 ].…”

Efficacy of interoceptive and embodied rehabilitative training protocol in patients with mild multiple sclerosis: A randomized controlled trial

“…Postural control relies on the integration of inputs from the visual, somatosensory and vestibular systems, which are frequently impaired in patients with MS and an increase in sway area is an indicator of poor walking and balance capabilities in MS. Therefore, it could be hypothesized that the patient's sense of his own body in space, in static and in dynamic conditions, can represent an additional sense for postural control, particularly considering the virtual reality rehabilitation programs ( 45 , 46 ). Posturography is considered the gold standard objective measure of standing postural control in pwMS, even in early-stage disease: sway area, length, oscillation, and trajectories are key parameters and appropriate outcomes capable of indicating disability deterioration in MS. Future studies specifically focusing on postural self-correction mechanisms and postural balance would be desirable.…”