Effectiveness of immersive virtual reality

training to improve sitting balance control

among individuals with acute and sub-acute
paraplegia: A randomized clinical trial
JOURNAL NAME:- The Journal of Spinal Cord Medicine
JOURNAL INDEXING:- Emerging Sources Citation Index
(ESCI), Scopus, Clarivate Science Citation Index Expanded
(SCIE), PubMed
IMPACT FACTOR:- 2.0 (2022) 5 year IF
CITE AS:- Goel T, Sharma N, Gehlot A, Srivastav AK.
Effectiveness of immersive virtual reality training to improve
sitting balance control among individuals with acute and sub-acute
paraplegia: A randomized clinical trial. J Spinal Cord Med. 2023
Nov;46(6):964-974. doi: 10.1080/10790268.2021.2012053

Presented By:- Sana Siddique

Department of Physiotherapy, Integral University
PT512, 31 May 2023
INTRODUCTION

 One of the most rudimentary activities for people with

paraplegia includes sitting control which regulates their
level of independence for further activities of daily
living and interaction with the environment.
 Evidence suggests that sitting balance is considerably
decreased among individuals with spinal cord injury.
 Existence of many strategies like Electrical stimulation,
Non-Invasive Spinal Stimulation, Community exercise
Programme, Functional Electrical Stimulation (FES), and
Virtual Reality (VR) demonstrates mobility improvement
along with postural control in previously conducted
researches.
SIGNIFICANCE OF THE STUDY
 A meta-analysis found that VR therapy was superior to
traditional physiotherapy for improving sitting balance
in people with SCI.
 The significance of FES for improving sitting balance
with transcutaneous electrodes in individuals with Stroke
and SCI has been seen in previous literature.
 Previous literature focuses more on standing and gait
balance in people with SCI but there is a dearth of
literature linking sitting balance improvement with VR
application in the acute rehabilitation phase of SCI.
 Thus, there is a need to establish and recognize a
immersive VR rehabilitation protocol to improve postural
stability among individuals with SCI in the acute and
sub-acute stages.
OBJECTIVE

 The aim of this study was to compare the

effectiveness of immersive virtual reality (VR)
training on sitting balance among individuals with
incomplete paraplegia to that of functional electrical
stimulation (FES).
METHODOLOGY
STUDY DESIGN:- Parallel, Single-centered, Participant-
blinded, Randomized clinical trial.
STUDY POPULATION:- Individuals with incomplete
spinal cord injury.
SAMPLE SIZE:- N = 18
 (VR + CPT) n = 9
 (FES + CPT) n = 9
SAMPLE DESIGN:- Simple random sampling.
METHOD OF RANDOMIZATION:- Block method of
randomization.
METHOD OF ALLOCATION CONCEALMENT:
Sequentially numbered, opaque sealed envelopes method
ELIGIBILITY CRITERIA:-

INCLUSION CRITERIA EXCLUSION CRITERIA

Age group between 18 and Having metal implant at
60 years the site of stimulation

ASIA score: B, C & D Visual disorder

Duration of injury < 10 Deformity of the upper

months extremity

Able to sit unassisted for Other neuromuscular

at least 10 seconds disorder or autonomic
dysreflexia
Have a minimum of 90º Uncooperative individuals
active shoulder flexion
INTERVENTION:-

 45-min session of VR or FES + CPT session of 30 min,

×5days/week, × 4 weeks.

 Virtual Reality training:

o Immersive type of VR via headset, Ocular grand virtual
reality spectacles were utilized.
o The participant was in a sitting position, hands on the
knees, wearing a headset with two screens, one in front of
each eye, into which a mobile phone was inserted,
exhibiting him in the virtual worlds.
 Functional Electrical Stimulation:
o Electrodes placement - rectus abdominis and erector spinae
muscles in the thoraco-lumbar area bilaterally on the motor
points
o Patient position: sitting on chair with back unsupported and,
hands crossed and kept on shoulders or while performing
reach outs.
o Three phases : warm-up- 3 Hz, 5 minutes
work phase- 18 HZ, 30 minutes
Recovery phase- 3 Hz, 5 minutes

 Conventional Physical Therapy:

o ROM exercises- both UL & LL×12 reps×2sets
o Mat exercises- rolling, long sitting and kneeling×2reps
with 5 min hold each.
OUTCOME MEASURES:-

 Outcome measures were assessed at baseline, 2nd and 4th

weeks after intervention.

 Modified Functional Reach Test (mFRT): to evaluate

sitting balance.

 Function in Sitting Test (FIST): to evaluate functional

sitting performance measures.

 Spinal Cord Independence Measure III (SCIM III): to

evaluate level of independence.
RESULTS
CONCLUSION

 VR training and FES were both found to be effective

in improving sitting balance in people with paraplegia.
 In this study, VR rehabilitation protocol proved to be
more effective in terms of improving balance and has a
greater effect than FES.
 As a result, it was determined that VR is an effective
intervention that is also safe and feasible for improving
sitting balance in individuals with incomplete SCI.
CRITIQUE
LIMITATIONS:-
 Small of sample size.
 All the participants recruited being in acute and sub-
acute stages might have shown spontaneous recovery as
improvement naturally occurs faster in this stage rather
than due to interventions implemented.
 Therapist and assessor were not blinded.

STRENGTHS:-
 Well designed methodology- randomization of
participants, participants were blinded, allocation was
concealed.
 Use of reliable and valid outcome measures.
Scoring

7/10