Focus Theme – Original Articles 127

A Novel Virtual Motor Rehabili-

tation System for Guillain-Barré
Syndrome

REHAB
Two Single Case Studies
S. Albiol-Pérez1,2,3; M. Forcano-García4; M. T. Muñoz-Tomás4; P. Manzano-Fernández4;
S. Solsona-Hernández4; M. A. Mashat5; J. A. Gil-Gómez6
1Dpto. de Informática e Ingeniería de Sistemas, Universidad de Zaragoza, Teruel, Spain;
2Prometeo, Departamento de Eléctrica y Electrónica, Universidad de las Fuerzas Armadas ESPE, Sangolquí, Ecuador;
3Prometeo Project Researcher (SENESCYT), Ecuador;

4Hospital S. José, Teruel, Spain;

5Medical Education Department, Faculty of Medicine King Abdulaziz University (KAU), Jeddah, Saudi Arabia;

6Instituto Universitario de Automática e Informática Industrial, Universitat Politècnica de València, Valencia, Spain

Keywords Rehabilitation in three periods of time (base- 1. Introduction

Guillain-Barré, postural control, balance dis-
orders, virtual motor rehabilitation, virtual
reality, balance rehabilitation
Summary
Introduction: This article is part of the
Focus Theme of Methods of Information in
Medicine on “New Methodologies for Pa-
tients Rehabilitation”.
Objectives: For Guillain-Barré patients,
motor rehabilitation programs are helpful at
the onset to prevent the complications of
paralysis and in cases of persistent motor
impairment. Traditional motor rehabilitation
programs may be tedious and monotonous,
resulting in low adherence to the treatments.
A Virtual Motor Rehabilitation system has
been tested in Guillain-Barré patients to in-
crease patient adherence and to improve
clinical results.
Methods: Two people with Guillain-Barré
performed 20 rehabilitation sessions. We
tested a novel system based on Motor Virtual
Correspondence to:
Sergio Albiol-Pérez
Dpto. de Informática e Ingeniería de Sistemas
Universidad de Zaragoza
Ciudad Escolar s/n
44003, Teruel
Spain
E-mail: salbiol@unizar.es
line evaluation, final evaluation, and follow-
up. In the training program, the participants
carried out a specific treatment using the
Active Balance Rehabilitation system (ABAR).
The system is composed of customizable vir-
tual games to perform static and dynamic
balance rehabilitation.
Results: Significant improvements in clinical
results were obtained by both participants,
with significant results in the static balance
clinical test of the Anterior Reach test in the
standing position and unipedal stance time.
Other significant results were found in dy-
namic balance clinical tests in the Berg Bal-
ance Scale test and the 30-second Sit-to-
Stand test. With regard to acceptance of the
system, both patients enjoyed the experi-
ence, and both patients thought that this sys-
tem was helpful for their rehabilitation.
Conclusions: The results show that Virtual
Motor Rehabilitation for Guillain-Barré pa-
tients provides clinical improvements in an
entertaining way.
Methods Inf Med 2015; 54: 127–134
http://dx.doi.org/10.3414/ME14-02-0002
received: January 14, 2014
accepted: November 2, 2014
epub ahead of print: January 22, 2015
Guillain-Barré syndrome (GBS) is an in-
flammatory demyelinating polyradiculo-
neuropathy. In this, syndrome the etiology
is not established, but there is progressive
symmetrical weakness, mild sensory motor
disorders and areflexia [1]. Worldwide
incidence rates for GBS vary from 1.1 to 1.8
per 100,000 adults per year, with rates of
0.6 per 100,000 children per year [2], and
an increase of 20% in age-specific inci-
dence rate GBS for each ten-year incre-
ment in age [3]. The cardinal clinical fea-
tures of GBS consist of sensory motor dis-
turbances, relatively progressive limb
weakness [4], and areflexia [5]. Due to
these disturbances, GBS patients suffer
muscle weakness in: 1) lower limbs; 2)
trunk; 3) upper extremities; 4) bilateral fa-
cial palsy [6]; bulbar muscles [7]; cranial
nerve disorders [8]; and respiratory dis-
orders.
About 30% of GBS patients have severe
weaknesses, producing disorders in respi-
ratory muscles and requiring mechanical
ventilation [9]. Approximately 20% of GBS
patients have dysautonomia [10], such as
labile hypertension, orthostatic hypoten-
sion, and sinustachycardia. In an initial
phase (in the first hours), GBS patients
show a progression in muscle weakness,
with loss of feeling in the toes or fingertips.
In the first two-three weeks, half of the
GBS patients manifest symmetric limb
weakness and bilateral weakness of facial
muscles. The muscle weakness is reached

© Schattauer 2015 Methods Inf Med 2/2015

Downloaded from www.methods-online.com on 2017-04-04 | IP: 112.215.154.155

For personal or educational use only. No other uses without permission. All rights reserved.
128 S. Albiol-Pérez et al.: A Novel Virtual Motor Rehabilitation System for Guillain-Barré Syndrome
in the fourth week in 90% of GBS patients,
with this weakness decreasing beyond this
period of time [11, 12]. Different clinical
studies have classified GBS patients into
the following pathological categories: acute
inflammatory demyelinating polyradiculo-
REHAB
neuropathy (AIDP) [13], Miller Fisher syn-
drome (MFS) [14, 15], and axonal forms
such as acute motor axonal neuropathy
(AMAN) [16], and acute motor sensory
axonal neuropathy (AMSAN) [17]. AIDP
incidence is common in developed coun-
tries (North America, Europe [18], and
Australia). AMAN incidence is frequent in
Japan, China, and South America [19],
while AMSAN is more common in South
Asia [20] and Northern India [21].
AIDP is characterized by different
symptoms such as the presence of muscle
weakness, paralysis, and decreased tendon
reflexes. AMAN is a motor disorder that
produces an acute symmetrical paralysis,
with brisk reflexes in the acute phase [22],
increasing the protein levels in cerebrospi-
nal fluid (CSF). AMSAN is a motor and
sensory nerve disorder that is related to
this polyneuropathy, with distal sensory
weakness, arreflexia, and respiratory insuf-
ficiency [23]. MFS has specific clinical
characteristics such as ataxia of a cerebellar
type, external ophthalmoplegia, and de-
creased/absent deep tendon reflexes [24].
As a result of an unpredictable progres-
sion of the disease, a careful clinical presenta-
tion is mandatory in hospital admissions. To
obtain a correct diagnosis of GBS, clinical
specialists have to evaluate if the CFS analysis
indicates high protein levels, and if so, they
must carry out neurophysiological studies.
Disorders associated with muscle weak-
ness symptoms in GBS are postural control,
gait, balance, and also high rates of fatigue
[25]. Due to balance disorders, the risk of
falls increases, and, therefore, the thera-
peutic process in GBS is focused on bal-
ance rehabilitation. The rehabilitation pro-
cess is composed of a customizable pro-
gram, with therapeutic exercises including:
1) isometrics (with mechanical or manual
resistances) and muscle setting; 2) isotonic
exercises, performing muscle contractions
based on low resistances; 3) and progres-
sive activities related to resistances [26].
Physical rehabilitation should include
specific mobility treatment that covers pos-
Methods Inf Med 2/2015
Downloaded from www.methods-online.com on 2017-04-04 | IP: 112.215.154.155
For personal or educational use only. No other uses without permission. All rights reserved.
tural control, partial body weight, use of
ankle foot orthotics (AFO) in gait treat-
ments, and muscle strengthening [27].
After the acute phase, patients with similar
symptoms of Guillain-Barré (Acquired
Brain Injury, Parkinson’s disease, Multiple
Sclerosis disease), the rehabilitation pro-
cess is focused on a specific treatment to
recover motor and sensory disorder and to
improve the muscle tone and proprio-
ceptive sense. This process is composed of
clinical specialists [28] (therapists, nurses,
neurologists, rehabilitation physicians, etc.)
and a technological system that is focused
on a specific treatment.
On the other hand, Khan et al. [29] pub-
lished a novel systematic review with a
summary of different rehabilitation tech-
niques in adults with GBS. The review
found a large number of articles indicating
that it is possible to obtain a reduction in
the impairment of GBS patients. To do this,
a multidisciplinary team is necessary
(nurses, occupational therapists, social
workers, and also physical therapists) to-
gether with occupational, social, psychol-
ogy, or speech sessions. However, there are
few studies focused on treatments to in-
crease balance, postural control, or gait dis-
orders in GBS patients.
Garssen et al. [30] tested the efficacy of a
12-week bicycle training program (and a
follow-up period) in 16 Guillain-Barré pa-
tients with severe fatigue and in four pa-
tients with polyneuropathy. The results
showed improvements in physical fitness
and muscle strength and a 20% reduction
in the fatigue score (p = 0.001).
Mhandi et al. [31] studied six patients
with GBS with an adapted treatment in ac-
cordance with their pathology. They ob-
served improvements in muscle strength
and functional motor independence in the
first 6 months and also at 18 months.
Gait disorders in Guillain-Barré patients
are key points in restoring balance, to-
gether with exercises related to activities of
daily living (ADL).
Traditional rehabilitation techniques are
tedious, monotonous, and boring, with low
adherence to the treatment. New technol-
ogies using Virtual Motor Rehabilitation
(VMR) are used to improve balance and
postural control [32, 33]. Low-cost devices
provide a tool where patients interact by
simulating traditional methods and obtain-
ing significant results [34–36].
NintendoÒWii Balance Board (WBB) is
an interesting device for obtaining balance
and postural control improvements in
VMR [37]. In the last few years, novel soft-
ware tools that are specifically designed for
patients with balance and postural control
disorders have been tested for different pa-
thologies [38–40]. The use of technology
based on VMR in Guillain-Barré patients is
a novel option to improve balance and pos-
tural control disorders.
2. Objectives
Although there are studies that have vali-
dated the effectiveness of traditional re-
habilitation in patients with GBS [29–31,
41], no study to date has tested balance dis-
orders aimed at improving the patient’s
motor recovery using VMR. Therefore, in
this paper, a novel and customizable tool is
presented and tested in two patients with
GBS. The Active Balance Rehabilitation
system (ABAR) [40] was designed for pa-
tients with balance and gait disorders.
3. Methods
3.1 Active Balance Rehabilitation
(ABAR)
The ABAR system is characterized by the
use of different Virtual Environments (VE)
that focus on weight transferences and
specific movements in the rehabilitation
process. The goal of the ABAR system is to
obtain improvements in pathologies that
have balance and postural control disorders.
The most important and representative
characteristics of the ABAR system are that
it is: 1) a flexible system for the recovery of
postural control and for reducing fractures
and the risk of falls; 2) a suitable system
that improves the patient’s motivation and
treatment adherence; 3) a reinforcement
system that allows the results obtained in
each session to be monitored and the ap-
propriate action taken; 4) a robust system
that is able to make a good recovery in pa-
rameters such as balance, postural control,
muscle tone, and stability in the standing/
sitting position in Guillain-Barré patients;
© Schattauer 2015
 S. Albiol-Pérez et al.: A Novel Virtual Motor Rehabilitation System for Guillain-Barré Syndrome 129

5) a portable system that can be used at
home to reinforce the acute and sub-acute
stages; 6) a customizable system that offers
multiples levels of difficulty that are based
on the patients’ progression.
The ABAR system has two levels of dif-
tation, the system offers two movements in
the standing position: to step on the WBB
and the sitting-standing movement. The
characteristics of the ABAR system are
shown in ▶ Table 1.
The ABAR system is composed of low-
weight of 75.5 kg, a calf circumference of
35 cm, a personal history of bronchiectasis
due to a pertussis childhood disease, and a
nasal polypectomy (twice) in the year 2007.
In June 2012, he suddenly presented dif-
ferent symptoms: 1) diplopia; 2) instability;

ficulty (low and medium) with six games.
The lowest level has two virtual environ-
ments (VE) for sitting training. At this
level, the participants can perform medio-
lateral and antero-posterior weight trans-
ferences in the sitting position. ABAR pro-
vides different parameters to customize the
level of difficulty: the number of virtual
sessions, the rest period between virtual
sessions, the session time, the target speed,
and the target display time.
The medium level has four VE for
standing training. These are classified by
the type of balance rehabilitation: static
balance rehabilitation and dynamic bal-
ance rehabilitation. In static balance re-
habilitation, Guillain-Barré patients can
train medio-lateral and antero-posterior
weight transferences in the standing or tan-
dem position. In dynamic balance rehabili-
cost hardware devices: a large 47´´ TV, a
standard PC, a WBB, and a bluetooth
dongle for the communication between
our system and the WBB.
3.2 Case Presentation
In this study, two GBS patients performed
gait and balance by means of traditional
and virtual motor rehabilitation. We used a
low-cost force platform (the NintendoÒ Wii
Balance Board) and our specific Virtual
Environment tool (ABAR).
3.2.1 Case One
A 54-year-old patient with GBS was ad-
mitted to our hospital. His medical history
was the following: 5 feet and 74 inches in
height, with a body-mass index of 24.65, a
REHAB
3) weakness in the upper extremities;
4) symmetrical hypoesthesia in the lower
and upper limbs, hypoesthesia in the eye,
and a feeling of tightness in his throat;
5) binocular ophthalmoplegia in every eye
position; 6) bilateral palpebral ptosis at rest-
time; 7) mandibular nerve paresthesia;
8) tetraparesis around 2+/5 in lower limbs;
9) severe bilateral dysmetria (more severe on
the left side of his body); 10) severe impair-
ment with arthrokinetic sensibility; 11) ab-
sence of postural control in the sitting posi-
tion; 12) absence of tendon reflexes in the
lower and upper limbs; 13) dysphagia to
drink fluids; 14) sweating and difficulty to
start urination. He did not have dysarthria.
3.2.1.1 Admission
Upon hospital admission, the GBS patient
experienced acute respiratory failure,

Table 1 Weight-transferences/movements in the ABAR system. This table shows the different weight-transferences and movements in the intervention
period.

Sitting Position
Weight-transferences/movements
The patient performs weight transferences
in the medio-lateral or antero-posterior
direction in the sitting position.
Visual Aspect Weight-transferences/movements Visual Aspect
The patient performs medio-lateral weight
transferences in the sitting position.

Standing Position
Weight-transferences/movements Visual Aspect Weight-transferences/movements Visual Aspect
The patient moves his feet from left to right The patient moves in the standing or
by shifting his weight in the standing posi- sitting position.
tion.

The patient moves his feet in the tandem The patient makes a step with his right or
position by shifting his weight from foot to left foot onto the WBB in the standing
foot, forwards and backwards. position.

© Schattauer 2015 Methods Inf Med 2/2015

Downloaded from www.methods-online.com on 2017-04-04 | IP: 112.215.154.155

For personal or educational use only. No other uses without permission. All rights reserved.
130 S. Albiol-Pérez et al.: A Novel Virtual Motor Rehabilitation System for Guillain-Barré Syndrome
requiring mechanical ventilation in the In-
tensive Care Unit (ICU). Afterwards, Nu-
clear Magnetic Resonance (NMR) showed
occupancy of maxillary sinuses, right front,
right ethmoid cells, gadolinium-enhanced,
and diffusion restriction on the right side.
REHAB
These results suggested an inflammatory
process. At the same time, a neurophysi-
ological study was performed, indicating
asymmetric bilateral disease in upper and
lower limb nerves, with a greater illness in
sensory nerves, which is compatible with
multiple axonal neuropathies. Based on
these conditions, together with the pres-
ence of ophthalmoplegia, ataxia, arreflexia,
and a gradually favorable evolution, the pa-
tient was diagnosed as having Miller-Fisher
syndrome.
3.2.1.2 Intervention
In the acute phase in the hospital, a corti-
coid and an immunoglobulin therapy were
performed. After the first month of the re-
habilitation process, we saw improvements
in palpebral ptosis. The GBS patient started
eye vertical movements, with improve-
ments in the sitting position and decreased
dysmetria, obtaining improvements in
fine-hand movement, but needing visual
control.
In a second phase of the rehabilitation
process, physiotherapy techniques were
performed progressively; namely, active-
passive movements with coordination ex-
ercises, proprioception, transferences and
gait retraining, Frenkel and Kabat tech-
niques, stationary bicycle, massage therapy,
and activities of daily living (ADL).
Two months after intervention, the GBS
patient showed improvements in the stand-
ing position with assistance, keeping distal
and proximal tetraparesia. Four months
later, the GBS patient could walk using a
walker, with personal assistance. Finally,
five months after hospital admission, the
clinical specialist suggested completing
traditional motor rehabilitation (TMR)
with VMR using the ABAR system.
3.2.2 Case Two
A 33-year-old patient with GBS was ad-
mitted to our hospital. His medical history
was the following: 5 feet and 54 inches in
height, with a body-mass index of 32.91, a
Methods Inf Med 2/2015
Downloaded from www.methods-online.com on 2017-04-04 | IP: 112.215.154.155
For personal or educational use only. No other uses without permission. All rights reserved.
Table 2 Characteristics of the participants. This
table shows the global information of the two
Guillain-Barré patients: age, time since injury,
weight, and height.
Issue Patient Patient
one two
Gender Male Male
Age (years) 54 33
Time since injury (months) 5 4
Weight 75.5 94
Height 5.74 5.54
weight of 94 kg, a calf circumference of
42 cm, a personal history of fracture of the
middle-third right clavicle that required
surgery due to a motorcycle accident
(seven years before).
3.2.2.1 Admission
The patient experienced gait disorders for
four days, with repeated falls and head-
aches, and was attended to in hospital
emergency. He had paresthesia and hypo-
esthesia in lower extremities until the in-
guinal region as well as a decrease in sensi-
tivity in the hands, the lower face, peribuc-
cal area, and cheeks. There was no disturb-
ance in the level of awareness nor were
there sphincter disorders. Neurological
examination showed asymmetric tetra-
paresis, proximal 4/5 in lower limbs, and
distal 4/5 in upper extremities, without os-
teomuscular reflex in lower limbs, and loss
of sensitivity in hands, feet, and jaw. After
the first week of admission, the GBS pa-
tient got worse, with a 3/5 of proximal and
distal tetraparesia, and asymmetric facial
paresis on the left side. The patient was
mobility-impaired, with severe mono-
podal-balance disturbances. The informa-
tion on electronystagmography (ENG) and
the cytology in CSF confirmed the Guil-
lain-Barré diagnosis with disease/pain of
the cranial nerves.
3.2.2.2 Intervention
In the first phase, the rehabilitation process
consisted of a treatment with i.v. immu-
noglobulins, and the patient showed im-
provement at the end of the first month.
The process was based on techniques such
as: muscle tone and strength, coordination,
balance, walking, articular balance, ADL,
global and analytic muscle enhancement of
the hands, superficial and deep sensitive
stimulation in hands/feet, oral praxis, and
phonatory.
In a second phase, the participant was
able to ambulate with the manual contact
of a clinical specialist, with gait instability,
and remaining paresthesia and hypo-
esthesia (both superficial and deep) on the
left side on the face. However, there was a
loss of tendon reflexes with a strong as-
thenia and a global muscle balance of 4/5.
Finally, four months after his initial presen-
tation, the GBS patient started a specific
treatment based on gait, postural control
and ambulation using the ABAR system
tool and the WBB [40]. The characteristics
of the two Guillain-Barré patients are
shown in ▶ Table 2.
3.3 Training Program
The present study was carried out in the
San José metropolitan hospital. The Guil-
lain-Barré patients performed a total of
20 rehabilitation sessions, distributed in
three sessions per week. The rehabilitation
sessions were composed of 30 minutes for
traditional rehabilitation, and afterwards,
30 minutes for VMR using the ABAR sys-
tem. The traditional therapy and VMR
using our system were composed of static
and dynamic balance rehabilitation. In
static balance rehabilitation, the GBS pa-
tients performed medio-lateral and antero-
posterior weight transferences. In dynamic
balance rehabilitation, the GBS patients
performed left-monopodal and right-
monopodal stance, and sit-to-stand move-
ments. During the sessions, the partici-
pants were told to take rest periods of five
minutes between virtual games. ▶ Figure 1
shows a Guillain-Barré patient playing with
the ABAR system. The study was approved
by the Research Ethics Committee of the
Clínica de Aragón (CEICA), Zaragoza,
Spain, following the ethical standards of
the Declaration of Helsinki (DoH).
Both participants were given the same
static and dynamic clinical tests at three
points in time (baseline evaluation-T0,
final evaluation-T1, and follow-up evalu-
ation-T2). The clinical tests were related to
cognitive and functional impairment, static
balance, and dynamic balance.
© Schattauer 2015
 S. Albiol-Pérez et al.: A Novel Virtual Motor Rehabilitation System for Guillain-Barré Syndrome
The motor impairment clinical tests
were measured at baseline evaluation: 1) an
adapted and tested version of the Mini-
Mental state examination (MEC-Lobo)
[42], with a score of > 24 for both patients;
2) the Barthel index [43], with a score of
≥ 60 for both patients; 3) Lawton’s Phila-
delphia Geriatric Center Morale Scale
(PGCMS) [44], (subject one = 10, subject
two = 3); 4) Charlson comobidity index
(CCI) [45].
The static balance clinical tests were:
1) Unipedal stance time (UST) [46]; 2) the
Anterior Reach Test (ART) [47]. The dy-
namic balance clinical tests were: 1) the
Berg Balance Scale Test (BBS) [48]; 2) the
Time “Up and Go” Test (TUG) [49]; 3) the
Timed 10-Meter Walking Test (10 MT)
[52]; 4) the Tinneti Test (TT) [53]; and
5) the 30-second Sit-to-Stand Test (30SST)
[54]. At the end of the first training session,
the patients were requested to fill out the
Suitability Evaluation Questionnaire (SEQ)
[55] in order to measure the usability of the
ABAR system.
Berg Balance Berg Scale. The BBS
measures static/dynamic balance and fall
risk using a 14-item objective measure,
with a five-point attitude Likert scale, rang-
ing from 0 to 4, and a maximum score of
56 points. In general, patients that have
scores lower than 41 have disorders such as
balance and postural control (0–20 have a
high probability of falls; 21– 40 have a
moderate probability of falls; 41–56 have a
low probability of falls).
Time “up and go” test. The TUG
measures the total time in seconds that a
patient needs to stand up from a chair,
walk straight 3 meters, turn around, return
to the chair, and sit down. In this test,
scores greater than or equal to 20 seconds
suggest that patients have problems with
maintaining their balance, asymmetrical
gait speed, and a high probability of falls
[49] (< 20 seconds indicates good mobility;
20–29 indicates normal mobility; > 29 in-
dicates high rates of falls).
Timed 10-Meter Walking test. The
10 MT measures the time in seconds that
a patient needs to walk straight for 10
meters. In this test, if patients have scores
greater than 13 seconds, it suggests that
they have limited walking ability with a
high probability of falls (scores between 10
© Schattauer 2015
Downloaded from www.methods-online.com on 2017-04-04 | IP: 112.215.154.155
For personal or educational use only. No other uses without permission. All rights reserved.
Figure 1 Patient performing weight transferences using the ABAR system
and 12.5 seconds require using to use walk-
ing aids; scores lower than 7 indicate pa-
tients have normal walking ability).
Tinetti test. The TT measures gait and
balance abilities to perform specific tasks; it
is composed of a balance section and a gait
section. In this test, scores lower than 24
indicate that patients have a risk of falls
(scores lower than 19 have a high probabil-
ity of falls; 19–24 have a moderate prob-
ability of falls; > 24 have a low probability
of falls).
30-second Sit-to-Stand test. The 30SST
counts the number of times that a patient
performs the movement sitting-standing-
sitting without use his/her arms in 30 sec-
onds. Outcomes for this test depend on the
gender and the age of the subjects [50].
Normal scores for men ranged from 14–19
sit-to-stand cycles (60–64 years old) to
7–12 sit-to-stand cycles (90–94 years old).
Normal scores for women ranged from
12–17 sit-to-stand cycles (60–64 years old)
to 4–11 sit-to-stand cycles (90–94 years
old).
Unipedal stance time. The UST
measures the time in seconds that a patient
stands up on one foot. Outcomes of the
UST test in healthy subjects depend on age
[51]. Normal scores with eyes opened
ranged from 30 seconds (20–29 years old)
to 14.2 seconds (70 –79 years old).
131
REHAB
Anterior reach test. The ART measures
the furthest distance that a patient can
reach with arms outstretched without mov-
ing his feet. Scores for this test between 0
and 12 cm suggest a significant risk of falls
(scores lower than 12 cm have a high prob-
ability of falls; 13–25 have a moderate
probability of falls; > 25 have a low prob-
ability of falls).
Suitability Evaluation Questionnaire.
The SEQ [55] is composed of 14 questions
where the first 13 questions are answered
by using a five-point Likert attitude scale
(from 1 – Not at all to 5 – Very much) and
the last question is an open response (Yes
or No response). The SEQ tests the suit-
ability of VMR systems on a scale ranging
from 13 (poor suitability) to 65 (excellent
suitability), using questions based on the
enjoyment of using the system (Q1), dis-
comfort (Q9), helpfulness in VMR (Q11),
or the difficulty of performing the task
(Q12). Questions Q1, Q11, and Q12 (en-
joyment, helpfulness, and difficulty) have
been highlighted by clinical specialists as
being particularly important for the moti-
vation of the patient. For this reason, we
also wanted to highlight these particular
items.
After the intervention evaluation, we
measured other parameters such as falls,
dizziness, and altered reality. We also
measured other parameters such as the
Methods Inf Med 2/2015
132 S. Albiol-Pérez et al.: A Novel Virtual Motor Rehabilitation System for Guillain-Barré Syndrome

following: body-mass index, number of
drugs, calf diameter, visual/hearing impair-
ment, education, occupation, rural/urban
area, the evolution time of the illness, tech-
nical assistance in sessions (walking frame,
parallel bars, English stick, chair), and hit
REHAB
need the aid of therapist. He could go up
and go down stairs and walk on the slope,
with improvements in muscle tone in the
left ankle. However, he still had hypesthesia
in fingers, soles, and the back of the feet.
The results obtained for the clinical test
sults for subject two were 27 (T0), 28 (T1),
and 30 (T2).
30-second Sit-to-Stand test. For subject
one, the results were 6 (T0), 8 (T1), and 10
(T2). The results for subject two were 7
(T0), 10 (T1), and 11 (T2).

rates in each session. for dynamic balance were the following: The results obtained for the clinical test
Berg Balance Berg Scale. The results for static balance were the following:
obtained for subject one were 41 (T0), 49 Unipedal stance time. The results for
4. Results (T1), and 53 (T2). The results obtained for subject one were 0.2 s (T0), 3 s (T1), and
subject two were 53 (T0), 56 (T1), and 56 3.5 s (T2). The results for subject two were
The results obtained in both of the Guil- (T2). 11.02 s (T0), 12.14 s (T1), and 15.37 s (T2),
lain-Barré patients after the intervention Time “up and go” test. The results of respectively.
showed improvements in different clinical this test for subject one were 19 s (T0), 15 s Anterior reach test. The results for sub-
tests. After the rehabilitation process, sub- (T1), and 13 s (T2), whereas the results for ject one were 18.6 cm (T0), 21 cm (T1),
ject one was able to walk independently subject two were 10 s (T0), 10 s (T1), and and 21.6 cm (T2). The results for subject
under the supervision of the therapist. He 10 s (T2). two were 14.66 cm (T0), 15.33 cm (T1),
could go up and go down stairs as well as Timed 10-Meter Walking test. For sub- and 23.33 cm (T2), respectively.
walk on the slope, with improvements in ject one, the results were 23.5 (T0), 17.5 s An overview of the clinical results is
muscle mass and joint range in both (T1), and 14.5 s (T2). In contrast, the re- shown in ▶ Table 3.
shoulders. Nevertheless, there were motor sults for subject two were 9.2 s (T0), 8.82 s Suitability Evaluation Questionnaire.
coordination disorders in the upper limbs. (T1), and 9.04 s (T2). The SEQ score for patient one was 49 (nor-
After the intervention, subject two Tinetti test. For subject one, the results malized score: 0.69) and for patient two
achieved independent walking and did not were 23 (T0), 26 (T1), and 26 (T2). The re- was 56 (normalized score: 0.83). With re-
gard to the specific items of the SEQ test,
the results for both participants were: The
Table 3 results for both participants were: enjoy-
Baseline Final Follow-up
evaluation evaluation evaluation
Clinical test scores: ment-Q1 (both patients = 4), helpful-
baseline (T0), final ness-Q11 (patient one = 5, patient two = 4),
BBS (score) (T1), follow-up (T2) and difficulty of the task-Q12 (both pa-
Subject 1 41 49 53 tients = 2).
Subject 2 53 56 56
TUG (seconds)
Subject 1 19 15 13 5. Discussion
Subject 2 10 10 10 In this study, we have tested and analyzed a
10 MT (seconds) new system that is focused on the rehabili-
Subject 1 23.5 17.5 14.5 tation of Guillain-Barré patients. After an
intensive training program using the
Subject 2 9.2 8.82 9.04
ABAR system, we found improvements in
Tinetti (score) both patients. In general, our results show
Subject 1 23 26 26 less improvement for the dynamic clinical
Subject 2 27 28 30 balance test than for the static clinical bal-
ance test.
30SST (repetitions)
The results for the dynamic clinical tests
Subject 1 6 8 10 are explained below:
Subject 2 7 10 11 The BBS scale showed clear improve-
UST (seconds) ment over time for both subjects.
Our results confirm that, after the de-
Subject 1 0.2 3 3.5
velopment of a specific treatment using
Subject 2 11.02 12.14 15.37 VMR, the recovery of balance control is a
ART (centimeters) reality.
Subject 1 18.6 21 21.6 The TUG test showed improvement in
subject one for the three time periods (T0,
Subject 2 14.66 15.33 23.33
T1, and T2); however, for subject two, the

Methods Inf Med 2/2015 © Schattauer 2015

Downloaded from www.methods-online.com on 2017-04-04 | IP: 112.215.154.155

For personal or educational use only. No other uses without permission. All rights reserved.
 S. Albiol-Pérez et al.: A Novel Virtual Motor Rehabilitation System for Guillain-Barré Syndrome
results for the three periods showed no
change. We think that this is due to the fact
that this test mainly evaluates mobility, and
the ABAR system is more focused on static
clinical balance training.
In the 10 MT test, subject one showed a
clear improvement over time, but subject
two had no significant improvement in the
follow-up period. We consider that this is
due to the fact that our system does not
specifically train gait disorders.
The Tinetti test showed significant im-
provement over time for both subjects for
the intervention period (T0-T1); however,
subject one no longer improved in the fol-
low-up period. We think that this is due to
the rating scale of this test; the Tinetti test
evaluates balance and gait disorders, and
our system specifically trains movements
related to balance and postural control.
In the 30SST test, both subjects in-
creased their recovery in all periods. This
may be due to the potential of recovery in
early stages from injury in relation to this
specific movement, and also because the
ABAR system has a specific game for train-
ing the sit-to-stand movement.
The static clinical balance tests showed
significant improvements, due to the fact
that the ABAR system trains tasks that are
close to these tests. The results for the static
clinical tests are explained below:
In the UST test, both subjects improved
their recovery in all periods. We believe
that this improvement is due to specific
games of the ABAR system, where the pa-
tient performs weight transferences in the
standing position.
In the ART test, both subjects obtained
on appreciable improvement of approxi-
mately 3 cm for subject one and 8 cm for
subject two. The reason for this is related to
a specific game of the ABAR system, where
the patient shifts his weight from foot to
foot, forwards and backwards.
We consider that it would be advisable
to use a long-term training program based
on VMR systems such as ABAR to improve
recovery in Guillain-Barré patients. Mhan-
dy et al. [31] suggested a long-term re-
habilitation treatment to improve recovery.
In the SEQ test, both subjects felt well
during each session, indicating good re-
sults in important points related to VMR
such as enjoyment, helpfulness, difficulty,
© Schattauer 2015
Downloaded from www.methods-online.com on 2017-04-04 | IP: 112.215.154.155
For personal or educational use only. No other uses without permission. All rights reserved.
and eye discomfort during the rest period.
We consider that this is due to the fact that
the ABAR system is designed specifically
for retraining in the VMR process and the
clarity of our questionnaire is specifically
designed to test the usability in patients
with motor disorders.
6. Conclusions
The goal of the present study was to test
balance and postural control disorders in
Guillain-Barré patients using the ABAR
system. The use of VMR in patients with
GBS is a novel contribution in traditional
rehabilitation. The clinical and usability re-
sults demonstrate the suitability of this sys-
tem for these patients. One of the main
drawbacks of this study is the reduced
sample, but the good results obtained en-
courage us to carry out a new study with a
larger sample to reinforce our conclusions.
The virtual games of the ABAR system
are designed to obtain improvements in
static/dynamic rehabilitation. However,
clinical specialists argue that it would be
interesting to develop new modules to
complete the dynamic rehabilitation pro-
cess. For this purpose, we are developing
new functionalities to cover this aspect,
and we plan to integrate the new modules
in a future study with more patients.
Acknowledgments
The authors would like to thank all of the
clinical specialists and patients of San José
Hospital for participating in the present
study. We specially thank Carmen Aula-
Valero for her time in the training pro-
gram, and José-Antonio Lozano-Quilis and
Hermenegildo Gil-Gómez for their sugges-
tions in the design of the ABAR system.
This contribution was partially funded by
the Fundación Antonio Gargallo (“Ayudas
financiadas por la Obra Social de Ibercaja
de proyectos de investigación 2013”,
proyecto 2013/B001).
Author contributions
S. Albiol-Pérez, J. A. Gil-Gómez, and M.
Forcano-García contributed to the design
of the ABAR system, the analysis of the re-
133
sults, and the draft of the paper. M. T.
Muñoz-Tomás, P. Manzano-Hernández,
and S. Solsona-Hernández contributed to
the rehabilitation process and the clinical
tests. Mohamed A. Mashat partially funded
this contribution.
REHAB
References
1. Asbury AK, Cornblath DR. Assessment of current
diagnostic criteria for Guillain-Barré syndrome.
Ann Neurol 1990; 27 Suppl: S21–24.
2. McGrogan A, Madle GC, Seaman HE, de Vries CS.
The epidemiology of Guillain-Barré syndrome
worldwide. A systematic literature review. Neuro-
epidemiology 2009; 32 (2): 150 –163.
3. Sejvar JJ, Baughman AL, Wise M, Morgan OW.
Population incidence of Guillain-Barré syndrome:
a systematic review and meta-analysis. Neuroepi-
demiology 2011; 36 (2): 123 –133.
4. Briscoe DM, McMenamin JB, O’Donohoe NV.
Prognosis in Guillain-Barré syndrome. Arch Dis
Child 1987; 62 (7): 733 –735.
5. Burns TM. Guillain-Barré syndrome. Semin Neu-
rol 2008; 28 (2): 152 –167.
6. Verma R, Chaudhari TS, Giri P. Unilateral facial
palsy in Guillain-Barre syndrome (GBS): a rare
occurrence. BMJ Case Rep; 2012.
7. Misra I, Temesgen FD, Soleiman N, Kalyanam J,
Kurukumbi M. Myasthenia gravis presenting like
Guillain-Barré syndrome. Case Rep Neurol 2012;
4 (3): 137–143.
8. Takazawa T, Ikeda K, Murata K, Kawase Y, Hira-
yama T, Ohtsu M, et al. Sudden deafness and facial
diplegia in Guillain-Barré Syndrome: radiological
depiction of facial and acoustic nerve lesions.
Intern Med 2012; 51 (17): 2433.
9. Orlikowski D, Sharshar T, Porcher R, Annane D,
Raphael JC, Clair B. Prognosis and risk factors of
early onset pneumonia in ventilated patients with
Guillain-Barré syndrome. Intensive Care Med
2006; 32 (12): 1962 –1969.
10. Pfeiffer G: Dysautonomia in Guillain-Barré syn-
drome. Nervenarzt 1999; 70 (2): 136 –148.
11. Dimachkie MM, Barohn RJ. Guillain-Barré syn-
drome and variants. Neurol Clin 2013; 31 (2):
491– 510.
12. Ropper AH. The Guillain-Barré syndrome. N Engl
J Med 1992; 326 (17): 1130 –1136. Review.
13. Oh SJ, Kurokawa K, de Almeida DF, Ryan HF Jr,
Claussen GC. Subacute inflammatory demyelinat-
ing polyneuropathy. Neurology 2003; 61 (11):
1507–1512.
14. Drenthen J, Maathuis EM, Visser GH, van Doorn
PA, Blok JH, Jacobs BC. Limb motor nerve dys-
function in Miller Fisher syndrome. J Peripher
Nerv Syst 2013; 18 (1): 25 –29.
15. Fujii D, Manabe Y, Takahasi Y, Narai H, Omori N,
Kusunoki S, et al. A case of Fisher-Bickerstaff syn-
drome overlapped by Guillain-Barré syndrome.
Case Rep Neurol 2012; 4 (3): 212 –215.
16. Chen AC, Chen CM, Chang HR, Yeo KJ, Tsao SM,
Hsiao PC, et al. Complicated acute motor axonal
neuropathy with delayed acute respiratory distress
syndrome and rapidly progressive glomerulo-
Methods Inf Med 2/2015
134 S. Albiol-Pérez et al.: A Novel Virtual Motor Rehabilitation System for Guillain-Barré Syndrome
nephritis: a case report. Acta Neurol Taiwan 2013;
22 (1): 26 –31.
17. Cheng J, Kahn DE, Wang MY. The acute motor-
sensory axonal neuropathy variant of Guillain-
Barré syndrome after thoracic spine surgery. J
Neurosurg Spine 2011; 15 (6): 605 – 609.
18. Sejvar JJ, Baughman AL, Wise M, Morgan OW.
Population incidence of Guillain-Barré syndrome:
REHAB
a systematic review and meta-analysis. Neuroepi-
demiology 2011; 36 (2): 123 –133.
19. Kuwabara S, Yuki N. Axonal Guillain-Barré syn-
drome: concepts and controversies. Lancet Neurol
2013; 12 (12): 1180 –1188.
20. Islam Z, Jacobs BC, van Belkum A, Mohammad
QD, Islam MB, Herbrink P et al. Axonal variant of
Guillain-Barre syndrome associated with Campy-
lobacter infection in Bangladesh. Neurology 2010;
74 (7): 581– 587.
21. Sankhyan N, Sharma S, Konanki R, Gulati S.
Childhood Guillain-Barré syndrome subtypes in
northern India. J Clin Neurosci 2013.
22. Kuwabara S, Ogawara K, Koga M, Mori M, Hattori
T, Yuki N. Hyperreflexia in Guillain-Barré syn-
drome: relation with acute motor axonal neu-
ropathy and anti-GM1 antibody. J Neurol Neuro-
surg Psychiatry 1999; 67 (2): 180 –184.
23. Rostásy KM, Huppke P, Beckers B, Brockmann K,
Degenhardt V, Wesche B, et al. Acute motor and
sensory axonal neuropathy (AMSAN) in a
15-year-old boy presenting with severe pain and
distal muscle weakness. Neuropediatrics 2005; 36
(4): 260 –264.
24. Odaka M, Yuki N, Hirata K. Anti-GQ1b IgG
antibody syndrome: clinical and immunological
range. J Neurol Neurosurg Psychiatry 2001; 70 (1):
50 –55.
25. Drenthen J, Jacobs BC, Maathuis EM, van Doorn
PA, Visser GH, Blok JH. Residual fatigue in Guil-
lain-Barre syndrome is related to axonal loss.
Neurology 2013.
26. Hughes RA, Wijdicks EF, Benson E, Cornblath
DR, Hahn AF, Meythaler JM, et al. Multidiscipli-
nary Consensus Group. Supportive care for pa-
tients with Guillain-Barré syndrome. Arch Neurol
2005; 62 (8): 1194 –1198.
27. Orsini M, de Freitas MRG, Presto B, Mello MP,
Reis CHM, Silveira V, et al. Guideline for Neuro-
muscular Rehabilitation in Guillain-Barré Syn-
drome: What can we do? Rev Neurocienc 2010; 18
(4): 572–580.
28. Khan F, Ng L, Amatya B, Brand C, Turner-Stokes
L. Multidisciplinary care for Guillain-Barré syn-
drome. Cochrane Database Syst Rev 2010; (10).
29. Khan F, Amatya B. Rehabilitation interventions in
patients with acute demyelinating inflammatory
polyneuropathy: a systematic review. Eur J Phys
Rehabil Med 2012; 48 (3): 507– 522.
Methods Inf Med 2/2015
Downloaded from www.methods-online.com on 2017-04-04 | IP: 112.215.154.155
For personal or educational use only. No other uses without permission. All rights reserved.
30. Garssen MP, Bussmann JB, Schmitz PI, Zand-
bergen A, Welter TG, Merkies IS, et al. Physical
training and fatigue, fitness, and quality of life in
Guillain-Barré syndrome and CIDP. Neurology
2004; 63 (12): 2393 –2395.
31. El Mhandi L, Calmels P, Camdessanché JP,
Gautheron V, Féasson L. Muscle strength recovery
in treated Guillain-Barré syndrome: a prospective
study for the first 18 months after onset. Am J Phys
Med Rehabil 2007; 86 (9): 716 –724.
32. Lange B, Koenig S, Chang CY, McConnell E, Suma
E, Bolas M, et al. Designing Informed Game-Based
Rehabilitation Tasks Leveraging Advances in Vir-
tual Reality. Disability and Rehabilitation 2012; 34:
1863–1870.
33. Forcano García M, Albiol-Pérez S, Aula-Valero
MC, Gil-Gómez JA, Solsona Hernández S, Man-
zano-Hernández P. Balance virtual rehabilitation
in the elderly: The use of the “ABAR” system.
European Geriatric Medicine 2013; 4: S109.
34. Koch S, Marschollek M, Wolf KH, Plischke M,
Haux R. On health-enabling and ambient-assistive
technologies. What has been achieved and where
do we have to go? Methods Inf Med 2009; 48 (1):
29 –37.
35. Gietzelt M, von Bargen T, Kohlmann M, Mar-
schollek M, Schwartze J, Song B, Wagner M, Wolf
KH, Haux R. Home-centered health-enabling
technologies and regional health information sys-
tems. An integration approach based on inter-
national standards. Methods Inf Med 2014; 53 (3):
160 –166.
36. Simonov M, Delconte G. Humanoid Assessing Re-
habilitative Exercises. Methods Inf Med 2014; 53
(5).
37. Holmes JD, Jenkins ME, Johnson AM, Hunt MA ,
Clark RA. Validity of the Nintendo Wii(R) balance
board for the assessment of standing balance in
Parkinson’s disease. Clin Rehabil 2012.
38. Gil-Gómez JA, Lloréns R, Alcañiz M, Colomer C.
Effectiveness of a Wii balance board-based system
(eBaViR) for balance rehabilitation: a pilot ran-
domized clinical trial in patients with acquired
brain injury. J Neuroeng Rehabil 2011; 23.
39. Albiol-Perez S, Gil-Gomez JA, Llorens R, Alcaniz
M, Colomer-Font C. The role of Virtual Motor Re-
habilitation. A quantitative analysis between Acute
and Chronic Patients with acquired brain injury.
IEEE Journal of Biomedical and Health In-
formatics 2013; 99.
40. Albiol-Perez S, Gil-Gomez JA, Forcano-García M,
Muñoz-Tomas MT, Manzano-Hernandez P, Sol-
sona-Hernandez S. Development of a novel ther-
apy in virtual motor rehabilitation after severe
Guillain-Barré symptomatology. Pervasive Com-
puting Technologies for Healthcare (Pervasive-
Health) 2013; 370, 373.
41. Tuckey J, Greenwood R. Rehabilitation after severe
Guillain-Barré syndrome: the use of partial body
weight support. Physiother Res Int 2004; 9 (2):
96 –103.
42. Folstein MF, Folstein SE, McHugh PR. “Mini-men-
tal state”. A practical method for grading the cog-
nitive state of patients for the clinician. J Psychiatr
Res 1975; 12 (3): 189 –198.
43. Collin C, Wade DT, Davies S, Horne V. The Bar-
thel ADL Index: a reliability study. Int Disabil Stud
1988; 10 (2): 61– 63.
44. Lawton MP. The Philadelphia Geriatric Center
Morale Scale: a revision. J Gerontol 1975; 30 (1):
85–89.
45. Charlson ME, Pompei P, Ales KL, MacKenzie CR.
A new method of classifying prognostic comorbid-
ity in longitudinal studies: development and vali-
dation. J Chronic Dis 1987; 40 (5): 373 –383.
46. Austin GP, Tiberio D, Garrett GE. Effect of fre-
quency on human unipedal hopping. Percept Mot
Skills 2002; 95 (3 Pt 1): 733 –740.
47. Duncan PW, Weiner DK, Chandler J, Studenski S.
Functional reach: a new clinical measure of bal-
ance. J Gerontol 1990; 45 (6): M192–197.
48. Berg KO, Wood-Dauphinee SL, Williams JI, Maki
B. Measuring balance in the elderly: validation of
an instrument. Can J Public Health 1992; 83
(Suppl 2): S7–11.
49. Podsiadlo D, Richardson S. The timed “Up & Go”:
a test of basic functional mobility for frail elderly
persons. J Am Geriatr Soc 1991; 39 (2): 142 –148.
50. Jones CJ, Rikli RE. Measuring functional fitness of
older adults. International Journal of Active Aging
2002; 1: 25 –30.
51. Bohannon R, Larkin P, Cook A, Singer J. Decrease
in timed balance test scores with aging. Physical
Therapy 1984; 64: 1067–1070.
52. Richards CL, Malouin F, Dumas F, Tardif D. Gait
velocity as an outcome measure of locomotor re-
covery after stroke. In: Craik RL, Oatis CA (eds).
Gait Analysis. Theory and Application. St Louis,
MO: Mosby 1995. pp 355–364.
53. Tinetti ME, Williams TF, Mayewski R. Fall risk
index for elderly patients based on number of
chronic disabilities. Am J Med 1986; 80 (3):
429–434.
54. Verschuren O, Ketelaar M, Takken T, Van Brussel
M, Helders PJ, Gorter JW. Reliability of hand-held
dynamometry and functional strength tests for the
lower extremity in children with Cerebral Palsy.
Disabil Rehabil 2008; 30 (18): 1358 –1366.
55. Muñoz Tomás MT, Gil-Gómez JA, Gil-Gómez H,
Lozano-Quillis JA, Albiol-Pérez S, Forcano-García
M. Suitability of virtual rehabilitation for the
elderly: A study of a virtual rehabilitation system
using the SEQ. European Geriatric Medicine 2013;
4 (1): S109.
© Schattauer 2015