Parkinson’s disease (PD) is a neurodegenerative disorder that is best managed by a combination of medication and regular physiotherapy. In this context, virtual reality (VR) technology is proposed as a new rehabilitation tool with a possible added value over traditional physiotherapy approaches. It potentially optimises motor learning in a safe environment, and by replicating real-life scenarios could help improve functional activities of daily living.
The objective of this review was to summarise the current best evidence for the effectiveness of VR interventions for the rehabilitation of people with PD in comparison with 1) active interventions, and 2) passive interventions. Our primary goal was to determine the effect of VR training on gait and balance. Secondary goals included examining the effects of VR on global motor function, activities of daily living, quality of life, cognitive function, exercise adherence, and the occurrence of adverse events.
We identified relevant articles through electronic searches of the Cochrane Movement Disorders Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, Embase, CINAHL, the Physiotherapy Evidence Database (PEDro), online trials registers, and by handsearching reference lists. We carried out all searches up until 26 November 2016.
We searched for randomised and quasi-randomised controlled trials of VR exercise interventions in people with PD. We included only trials where motor rehabilitation was the primary goal.
Data collection and analysis
Two review authors independently searched for trials that corresponded to the predefined inclusion criteria. We independently extracted and assessed all data for methodological quality. A third review author was responsible for conflict resolution when required.
We included 8 trials involving 263 people with PD in the review. Risk of bias was unclear or high for all but one of the included studies. Study sample sizes were small, and there was a large amount of heterogeneity between trials with regard to study design and the outcome measures used. As a result, we graded the quality of the evidence as low or very low. Most of the studies intended to improve motor function using commercially available devices, which were compared with physiotherapy. The interventions lasted for between 4 and 12 weeks.
In comparison to physiotherapy, VR may lead to a moderate improvement in step and stride length (standardised mean difference (SMD) 0.69, 95% confidence interval (CI) 0.30 to 1.08; 3 studies; 106 participants; low-quality evidence). VR and physiotherapy interventions may have similar effects on gait (SMD 0.20, 95% CI -0.14 to 0.55; 4 studies; 129 participants; low-quality evidence), balance (SMD 0.34, 95% CI -0.04 to 0.71; 5 studies; 155 participants; low-quality evidence), and quality of life (mean difference 3.73 units, 95% CI -2.16 to 9.61; 4 studies; 106 participants). VR interventions did not lead to any reported adverse events, and exercise adherence did not differ between VR and other intervention arms.
The evidence available comparing VR exercise with a passive control was more limited. The evidence for the main outcomes of interest was of very low quality due to the very small sample sizes of the two studies available for this comparison.
We found low-quality evidence of a positive effect of short-term VR exercise on step and stride length. VR and physiotherapy may have similar effects on gait, balance, and quality of life. The evidence available comparing VR with passive control interventions was more limited. Additional high-quality, large-scale studies are needed to confirm these findings.
Plain language summary
Virtual reality technology as a useful tool for rehabilitation in Parkinson’s disease
The purpose of this review was to determine the effectiveness of virtual reality (VR) exercise interventions for rehabilitation in Parkinson’s disease (PD). We aimed to investigate whether VR exercise resulted in greater improvements compared to 1) active control interventions, and 2) passive control interventions, on gait, balance, global motor function, activities of daily living, quality of life, cognition, exercise adherence, and the occurrence of adverse events.
PD is a neurodegenerative condition that places a high burden on patient quality of life and independence. As part of a multidisciplinary approach to treatment, regular exercise is encouraged and has been shown to relieve both motor and non-motor symptoms.
VR technology, a promising new rehabilitation tool, stimulates movement by means of computer-based games in a VR environment. Both commercial VR systems, such as Nintendo Wii or Xbox Kinect, and customised VR tools specifically designed to address PD symptoms, are frequently used. VR exercise exhibits potential advantages over regular exercise by allowing for individualised skill practice in a motivating and engaging interactive environment.
We conducted the literature search up until 26 November 2016. We identified 8 studies involving a total of 263 participants with PD. All trials aimed to improve either gait or balance function. Most of the studies compared VR with physiotherapy.
VR interventions may lead to greater improvements in step and stride length compared with physiotherapy interventions. We found limited evidence that improvements in gait, balance, and quality of life were similar to those found in active control interventions. No adverse events were reported. Fewer studies compared VR with passive control interventions, and evidence was insufficient to determine how VR compares with no active intervention. At present, only a few studies have been done, making generalisation of the findings difficult. Further study is needed to confirm and expand the evidence base for VR in PD.
Quality of the evidence
In general, the quality of the evidence was low or very low. This was the result of small sample sizes and a large amount of heterogeneity between trials with regard to study design and outcome measures used.