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      Home-Based Virtual Reality-Augmented Training Improves Lower Limb Muscle Strength, Balance, and Functional Mobility following Chronic Incomplete Spinal Cord Injury.

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          Abstract

          Key factors positively influencing rehabilitation and functional recovery after spinal cord injury (SCI) include training variety, intensive movement repetition, and motivating training tasks. Systems supporting these aspects may provide profound gains in rehabilitation, independent of the subject's treatment location. In the present study, we test the hypotheses that virtual reality (VR)-augmented training at home (i.e., unsupervised) is feasible with subjects with an incomplete SCI (iSCI) and that it improves motor functions such as lower limb muscle strength, balance, and functional mobility. In the study, 12 chronic iSCI subjects used a home-based, mobile version of a lower limb VR training system. The system included motivating training scenarios and combined action observation and execution. Virtual representations of the legs and feet were controlled via movement sensors. The subjects performed home-based training over 4 weeks, with 16-20 sessions of 30-45 min each. The outcome measures assessed were the Lower Extremity Motor Score (LEMS), Berg Balance Scale (BBS), Timed Up and Go (TUG), Spinal Cord Independence Measure mobility, Walking Index for Spinal Cord Injury II, and 10 m and 6 min walking tests. Two pre-treatment assessment time points were chosen for outcome stability: 4 weeks before treatment and immediately before treatment. At post-assessment (i.e., immediately after treatment), high motivation and positive changes were reported by the subjects (adapted Patients' Global Impression of Change). Significant improvements were shown in lower limb muscle strength (LEMS, P = 0.008), balance (BBS, P = 0.008), and functional mobility (TUG, P = 0.007). At follow-up assessment (i.e., 2-3 months after treatment), functional mobility (TUG) remained significantly improved (P = 0.005) in contrast to the other outcome measures. In summary, unsupervised exercises at home with the VR training system led to beneficial functional training effects in subjects with chronic iSCI, suggesting that it may be useful as a neurorehabilitation tool.

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          Most cited references39

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          The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke.

          The objective of this study was to assess the reliability of the Balance Scale. Subjects were chosen from a larger group of 113 elderly residents and 70 stroke patients participating in a psychometric study. Elderly residents were examined at baseline, and at 3, 6 and 9 months, and the stroke patients were evaluated at 2, 4, 6 and 12 weeks post onset. The Cronbach's alphas at each evaluation were greater than 0.83 and 0.97 for the elderly residents and stroke patients respectively, showing strong internal consistency. To assess inter-rater reliability, therapists treating 35 stroke patients were asked to administer the Balance Scale within 24 hours of the independent evaluator. Similarly, caregivers at the Residence were asked to test the elderly residents within one week of the independent evaluator. To assess intra-rater reliability, 18 residents and 6 stroke patients were assessed one week apart by the same rater. The agreement between raters was excellent (ICC = 0.98) as was the consistency within the same rater at two points in time (ICC = 0.97). The results support the use of the Balance Scale in these groups.
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            Virtual environments for motor rehabilitation: review.

            In this paper, the current "state of the art" for virtual reality (VR) applications in the field of motor rehabilitation is reviewed. The paper begins with a brief overview of available equipment options. Next, a discussion of the scientific rationale for use of VR in motor rehabilitation is provided. Finally, the major portion of the paper describes the various VR systems that have been developed for use with patients, and the results of clinical studies reported to date in the literature. Areas covered include stroke rehabilitation (upper and lower extremity training, spatial and perceptual-motor training), acquired brain injury, Parkinson's disease, orthopedic rehabilitation, balance training, wheelchair mobility and functional activities of daily living training, and the newly developing field of telerehabilitation. Four major findings emerge from these studies: (1) people with disabilities appear capable of motor learning within virtual environments; (2) movements learned by people with disabilities in VR transfer to real world equivalent motor tasks in most cases, and in some cases even generalize to other untrained tasks; (3) in the few studies (n = 5) that have compared motor learning in real versus virtual environments, some advantage for VR training has been found in all cases; and (4) no occurrences of cybersickness in impaired populations have been reported to date in experiments where VR has been used to train motor abilities.
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              Dynamic properties of human brain structure: learning-related changes in cortical areas and associated fiber connections.

              Recent findings in neuroscience suggest that adult brain structure changes in response to environmental alterations and skill learning. Whereas much is known about structural changes after intensive practice for several months, little is known about the effects of single practice sessions on macroscopic brain structure and about progressive (dynamic) morphological alterations relative to improved task proficiency during learning for several weeks. Using T1-weighted and diffusion tensor imaging in humans, we demonstrate significant gray matter volume increases in frontal and parietal brain areas following only two sessions of practice in a complex whole-body balancing task. Gray matter volume increase in the prefrontal cortex correlated positively with subject's performance improvements during a 6 week learning period. Furthermore, we found that microstructural changes of fractional anisotropy in corresponding white matter regions followed the same temporal dynamic in relation to task performance. The results make clear how marginal alterations in our ever changing environment affect adult brain structure and elucidate the interrelated reorganization in cortical areas and associated fiber connections in correlation with improvements in task performance.
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                Author and article information

                Journal
                Front Neurol
                Frontiers in neurology
                Frontiers Media SA
                1664-2295
                1664-2295
                2017
                : 8
                Affiliations
                [1 ] Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Landquart, Manno, Switzerland.
                [2 ] THIM University of Applied Sciences, Landquart, Switzerland.
                [3 ] Institute of Human Movement Science and Sport, ETH Zurich, Zurich, Switzerland.
                [4 ] Institute of Neurology, University College London, London, United Kingdom.
                [5 ] Spinal Cord Injury Center, University Hospital Balgrist, Zurich, Switzerland.
                [6 ] Institute of Neuroinformatics, University of Zurich and ETH Zurich, Zurich, Switzerland.
                Article
                10.3389/fneur.2017.00635
                5712347
                29234302
                1da1138e-bd08-41b7-b6f7-89dc3a70edac
                History

                lower extremity,motor function,neurological rehabilitation,spinal cord injuries,virtual reality therapy

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