Virtual reality interventions for balance prevention and rehabilitation after musculoskeletal lower limb impairments in young up to middle-aged adults: A comprehensive review on used technology, balance outcome measures and observed effects

https://doi.org/10.1016/j.ijmedinf.2019.03.009Get rights and content

Abstract

Background

Balance training is an important aspect in prevention and rehabilitation of musculoskeletal lower limb injuries. Virtual reality (VR) is a promising addition or alternative to traditional training. This review aims to provide a comprehensive overview of VR technology and games employed for balance prevention and rehabilitation, balance outcome measures, and effects for both balance prevention and balance rehabilitation following musculoskeletal lower limb impairments.

Methods

A systematic literature search was conducted in electronic databases to identify all related articles with a longitudinal study design on VR, balance, and prevention or musculoskeletal rehabilitation of the lower limbs in adult subjects between 19 and 65 years.

Results

Eleven articles concerning balance prevention and five articles regarding balance rehabilitation were included. All studies used screen-based VR and off-the-shelf gaming consoles with accompanying games. The Star Excursion Balance Test (SEBT) was the most frequently used outcome measure. Two studies found positive effects of VR balance training in healthy adults, while none reported negative effects. None of the included studies showed a significant difference in balance performance after a VR balance rehabilitation intervention compared to traditional balance training.

Conclusion

Few studies have been published concerning musculoskeletal balance rehabilitation and balance prevention in healthy adult subjects. However, the studies published have shown that VR exercises are equally effective compared to traditional balance training for both domains of application. As there is large variability between studies, recommendations for future research are given to prospectively investigate the use of VR technology for balance training.

Section snippets

Background

One of the most important components of daily life and athletic performance is the ability to maintain balance. Balance is defined as controlling the position of the center of mass relative to the base of support [1] and is typically classified as either static, maintaining position under stable conditions [2], or dynamic, keeping balance during movement and reacting to internal or external perturbations [2]. Maintaining balance in everyday life situations, and during athletic performance, is

Search strategy and selection criteria

To identify suitable literature, a systematic electronic literature search was performed on September 18th, 2017 in the databases PubMed, SCOPUS, Web of Science, and SPORTdiscus (EBSCO). The search consisted of combinations of controlled terminology and free-text terms including adult subjects, “virtual reality”, balance and “balance prevention/ orthopedic rehabilitation of the lower limbs”, adapted to each database. To ensure inclusion of all notions and synonyms in the search string, search

Study selection

Fig. 1 shows the flow chart of study selection throughout the review process. 992 records were identified through systematic electronic database search. 104 duplicates were removed and 859 publications were excluded after screening title and/ or abstract. During full-text assessment, 14 of 29 publications were excluded due to not meeting selection criteria (subject’s characteristics: age (n = 9); subjects with additional diseases or injuries impairing balance (n = 1); no balance outcome

Discussion

This comprehensive review aimed to give a broad overview of used VR technology, outcome measures, and effects of VR interventions for balance prevention in healthy adults, as well as balance rehabilitation in patients following musculoskeletal lower limb impairments. Overall, 16 studies examining young to middle-aged adults were included in final data analysis. Eleven studies investigated the effects of a VR balance intervention on balance performance in healthy subjects, whereas five studies

Conclusion and recommendations for future research

In general, there are only a few studies published concerning musculoskeletal balance rehabilitation specifically [15,16,[45], [46], [47]], and balance prevention in healthy adult subjects generally [2,14,20,[37], [38], [39], [40], [41], [42], [43], [44]].

Due to a heterogeneous state of research, especially with regards to study characteristics, VR game exercise and balance outcome measures, it is difficult to compare and summarize results. Nevertheless, conducted VR balance interventions have

Conflicts of interest

Sarah Vogt, Nina Skjæret Maroni, Dorothee Neuhaus and Jochen Baumeister declare that they have no conflicts of interest relevant to the content of this review.

Author’s contribution

All authors were involved in the conception and design of this work. Sarah Vogt conducted the systematic search strategy, extracted and analyzed the data and wrote the first draft. Nina Skjæret Maroni and Dorothee Neuhaus independently assessed the full-text papers and assisted with compilation of the review. The entire process was supervised by Jochen Baumeister. All authors contributed to the process of writing and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Summary table

What was known before this review?

  • Clinicians and scientists have used different types of VR training for balance prevention and rehabilitation of the lower limbs for several years.

  • VR is described as a promising tool for preventive and rehabilitative exercise associated with a range of advantages traditional training does not offer.

What did this comprehensive

References (62)

  • A.G. Munro et al.

    Between-session reliability of the star excursion balance test

    Phys. Ther. Sport

    (2010)
  • A. Ruhe et al.

    The test-retest reliability of centre of pressure measures in bipedal static task conditions – a systematic review of literature

    Gait Posture

    (2010)
  • A.S. Pollock et al.

    What is balance?

    Clin. Rehabil.

    (2000)
  • J.M. Byrne et al.

    The effect of a three-week Wii Fit™ balance training program on dynamic balance in healthy young adults

    Int. Sports Med. J.

    (2012)
  • P.O. McKeon et al.

    Systematic review of postural control and lateral ankle instability, part i: can deficits be detected with instrumented testing?

    J. Athl. Train.

    (2008)
  • T. Lehmann et al.

    Single-leg assessment of postural stability after anterior cruciate ligament injury: a systematic review and meta-analysis

    Sport. Exerc. Med. Open J.

    (2017)
  • J.A. Gil-Gómez et al.

    Effectiveness of a Wii balance board-based system (eBaViR) for balance rehabilitation: a pilot randomized clinical trial in patients with acquired brain injury

    J. Neuroeng. Rehabil.

    (2011)
  • Boas YAGV

    Overview of virtual reality technology

    Interactive Multimedia Conference

    (2013)
  • E. Van Wyk et al.

    Virtual Reality Training Applications for the Mining Industry. AFRIGRAPH’ 09 - Proceedings of the 6th International Conference on Computer Graphics, Virtual Reality, Visualisation and Interaction in Africa

    (2009)
  • A. Rizzo et al.

    Virtual reality goes to war: a brief review of the future of military behavioral healthcare

    J. Clin. Psychol. Med. Settings

    (2011)
  • N.E. Seymour et al.

    Virtual reality training improves operating room performance: results of a randomized, double-blinded study

    Ann. Surg.

    (2002)
  • L. Annetta et al.

    Bridging Realty to Virtual Reality: investigating gender effect and student engagement on learning through video game play in an elementary school classroom

    J. Sci. Educ.

    (2009)
  • J. Whyte

    Industrial applications of virtual reality in Arichitecture and construction

    J. Inf. Technol. Constr.

    (2003)
  • A. Gokeler et al.

    Immersive virtual reality improves movement patterns in patients after ACL reconstruction: implications for enhanced criteria based return-to-sport rehabilitation

    Knee Surg. Sports Traumatol. Arthrosc.

    (2016)
  • M.S. Ibrahim et al.

    Efficacy of virtual reality-based balance training versus the Biodex balance system training on the body balance of adults

    J. Phys. Ther. Sci.

    (2016)
  • U. Puh et al.

    Effects of Wii balance board exercises on balance after posterior cruciate ligament reconstruction

    Knee Surg. Sports Traumatol. Arthrosc.

    (2014)
  • J. Sims et al.

    Exergaming and static postural control in individuals with a history of lower limb injury

    J. Athl. Train.

    (2013)
  • M. Slater

    Measuring presence: a response to the Witmer and Singer presence questionnaire

    Presence Teleoperators Virtual Environ.

    (1999)
  • J. Feasel et al.

    The integrated virtual environment rehabilitation treadmill system

    IEEE Trans. Neural Syst. Rehabil. Eng.

    (2011)
  • G. Barry et al.

    Exergaming (XBOX Kinect TM) versus traditional gym-based exercise for postural control, flow and technology acceptance in healthy adults: a randomised controlled trial

    BMC Sports Sci. Med. Rehabil.

    (2016)
  • A. Kim et al.

    Walking in fully immersive virtual environments: an evaluation of potential adverse effects in older adults and individuals with Parkinson’s disease

    J. Neuroeng. Rehabil.

    (2017)
  • Cited by (0)

    View full text