Virtual Reality (VR) for Sitting Balance

In recent years, technological advances such as VR have been introduced in the field of SCI rehabilitation and are being used as a therapeutic tool (Abou et al. 2020). VR is a computer-based technology that allows users to interact in a computer-generated environment, allowing the practice of rehabilitation exercises in a safe, standardized, reproducible, and controlled environment (Abou et al. 2020). VR comprises two types of systems according to the immersion level: (i) semi-immersive or non-immersive systems, and (ii) immersive systems (De Miguel-Rubio et al. 2020). Semi-immersive and non-immersive systems use a screen to display the environment with a low level of immersion (e.g., commercial videogame consoles), and immersive systems offer full integration of the user into the virtual environment, and these systems can incorporate other devices (e.g. gloves, exoskeletons, etc.) to provide sensory inputs to the patient (e.g., VR caves, large-screen projections, and head-mounted displays) (De Miguel-Rubio et al. 2020; Henderson et al. 2007). The use of VR therapy can be considered an additional therapeutic tool that helps practitioners provide external feedback to their patients about their performance and increase their motivation in adhering to intensive and repetitive exercise training (Levin et al. 2015); and may be considered in either an acute or chronic phase of SCI treatment (Ionite et al. 2022; Leemhuis et al. 2021).

Biofeedback may be defined as a process that enables an individual to learn how to change physiological activity for the purpose of improving health and performance (Schwartz 2010). Precise instruments measure physiological activity and rapidly and accurately ‘‘feedback’’ information to the user (Schwartz 2010). The presentation of this information—often in conjunction with changes in thinking, emotions, and behavior—supports desired physiological changes (Schwartz 2010), specifically gait movements and balance in this chapter. Biofeedback techniques in publications include those based on electromyography (EMG) recordings of muscle activation or position or force sensors that provide feedback on joint motion or functional attributes such as weight-shifting.

Discussion

A meta-analysis by Abou et al. (2020) included 6 studies, and found that the effects of virtual reality  (VR) therapy with conventional balance rehabilitation were more effective in improving sitting balance compared to conventional sitting balance rehabilitation only. The combination of the two meta-analyses (T-shirt test and mFRT) showed a statistically significant between-group difference (SMD=1.65; 95% CI 1.21-2.09; p<.01) (Abou et al. 2020). Similarly, a recent systematic review and meta-analysis by Wang et al. (2024), included 16 studies, and supports VR therapy to be beneficial for standing balance in patients with SCI. There were significant differences in BBS (MD = 4.22, 95% CI: 1.78 to 6.66, P < .01) and limit of stability (LOS) (SMD = 1.75, 95% CI: 0.99 to 2.52, P < .01) (Wang et al. 2024). However, it is important to note that frontal plane balance improved while sagittal plane balance did not improve significantly, potentially due to the VR exercises given to participants (Wang et al. 2024).

Khurana et al. (2017) is a high-quality RCT which studied the inclusion of VR in a balance training intervention in acute SCI. Khurana et al. (2017) found that participants who received VR training showed improvement in sitting balance (especially on the t-shirt test) and functional independence (self-care components of the SCIM-III) compared to those who received real-world task-specific balance training. Goel et al. (2023) compared the effects of participants either receiving VR training or functional electrical stimulation (FES) on trunk muscles on static and dynamic sitting balance; it was shown that sitting balance improved in both groups; however, the group that performed VR training showed more significant and clinically relevant results than the group receiving FES. In addition, the VR group outperformed the FES training group in terms of functional independence (SCIM-III scores; p=0.001), though neither group reached clinically significant difference scores (Goel et al. 2023).

There were four other RCTs that investigated the inclusion of VR balance training to usual rehabilitation protocols in patients with chronic paraplegia on sitting balance (Lee & Lee 2021; Manzanares et al. 2021; Tak et al. 2015; Nair et al. 2022). In three of the four RCTs (Lee & Lee 2021; Tak et al. 2015; Nair et al. 2022), there are significantly larger improvements in sitting balance in the VR experimental groups.

Two other studies (Manzanares et al. 2021; Sengupta et al. 2020) found no differences between groups who received additional balance training versus those who did not. It is possible that no differences were found because the studies were small and of short duration.

Conclusions

There is level 1 evidence (from 1 RCT: Goel et al. 2023) that a VR training program along with conventional physical therapy provides significant and more clinically relevant improvements in both static and dynamic sitting balance than a training program involving FES for the trunk muscles along with conventional physical therapy in participants with acute (mean time since injury < 8 months) and complete (AIS B, C, or D) SCI.

There is level 1 evidence (from 1 RCT: Khurana et al. 2017) that VR game-based balance training provides higher improvements in sitting balance (mFRT and t-shirt test) and on self-care components of the SCIM-III compared with real-world task-specific balance training in patients with paraplegia and acute SCI.

There is level 2 evidence (from 1 prospective control trial: Sengupta et al. 2020) that VR training added to routine conventional therapy, in comparison with only conventional therapy, does not provide improvements in sitting balance in patients with acute SCI.

There is level 1 and 2 evidence (from 2 RCTs: Tak et al. 2015; Lee & Lee 2021) that adding seated VR training to standard rehabilitation provides significant improvements in static and dynamic sitting balance versus standard rehabilitation alone in patients with chronic SCI.

There is level 1 evidence (from 1 RCT: Nair et al. 2022) that VR training in sitting position, along with routine therapy, provides larger improvements in sitting balance (mFRT) than conventional therapy focused on training sitting balance, along with the same routine therapy for people with chronic SCI.

There is level 2 evidence (from 1 RCT: Manzanares et al. 2021) that VR balance training can provide statistically significant gains in balance (as measured by the mFRT) and in mobility (as measured by SCIM-III).