Virtual reality video gaming was helpful and useable as an exercise tool, and demonstrated positive patient satisfaction with no adverse effects among four people with mild to moderate Parkinson’s disease, a case study reported.
While previous studies have found limitations with using video games among “more fragile groups,” such as older patients and those with Parkinson’s, the researchers here said trying them in a “fully immersive environment,” with guidance by a physiotherapist, seemed to make the therapy an enjoyable — and restorative — one for participants.
“It motivates me to do exercise,” one patient reported after the sessions, while another wrote in a follow-up comment: “The best experience I’ve had to date.”
According to the researchers, “counteracting [its] limitations could make virtual reality (VR) a suitable tool for the application of therapeutic and rehabilitation programs, due to its adaptability to the patient, specificity to the pathology and expected high adherence.”
The study, “Can Immersive Virtual Reality Videogames Help Parkinson’s Disease Patients? A Case Study,” was published in the journal Sensors.
Parkinson’s disease is characterized by motor symptoms such as tremors, slow movements, and body instability, as well as non-motor symptoms such as cognitive impairment, fatigue, pain, and sleep problems. For some patients, exercise therapies can improve both motor and non-motor symptoms.
Video games have been used as a Parkinson’s rehabilitation tool and have demonstrated benefits in increasing physical activity levels and improving balance and cognitive functions in older people. However, there are limitations to video games associated with the interface that can make it difficult for Parkinson’s patients with certain motor symptoms, the researchers said.
An alternative approach is virtual reality (VR) gaming, which is more adaptable to patients with different levels of disability and can be fully immersive using head-mounted displays. Still, few studies have investigated VR as a Parkinson’s rehabilitation tool.
Now, researchers at the University of Vigo, in Spain, evaluated VR in four adults with Parkinson’s, whose ages ranged from 53 to 71. All participants had a Hoehn and Yahr stage 2 score, with motor symptoms affecting both sides of the body, problems walking, and poor posture. Of note, the Hoehn and Yahr scale is used to determine disease stage by rating the severity of motor symptoms: stage zero equals no signs of disease, while stage five means the patient is wheelchair-bound or bedridden unless aided.
“The aim of this study was to describe the cases of [Parkinson’s disease] patients who tried video games with a commercial HMD [head-mounted display] in a fully immersive environment and investigate its possible use as a therapeutic exercise tool in this population,” the team wrote, noting that they were examining “safety, usability, personal experiences, user satisfaction and effort post exergame.”
The gaming system consisted of a head-mounted display, two handheld controllers, two external sensors to define the gaming surface, a wireless adapter, and a computer with software. Two interventions were tested on two different days, with each session including a pretraining and training phase. Participants were supervised by a physiotherapist with experience in Parkinson’s.
The pretraining portion used Steam VR Home, which simulated a room with a door that opened to an exterior mountain landscape, with participants moving around the environment, manipulating different objects. In the training session, patients played BOX VR, a gym simulation game, which involved performing different boxing techniques and maneuvering the entire body with coordinated movements.
The second intervention also included pretraining in which participants were located on a seabed and moved around, interacting with virtual objects. The BOX VR game was used again for the training session but was more demanding in required additional movements, such as squats and broad lateral movements to avoid objects — specifically designed for balance training — and upper limb boxing.
All participants completed the first training session without adverse effects or symptoms of cybersickness, as measured by the Simulator Sickness Questionnaire (SSQ). Using the System Usability Scale (SUS) rating, two participants reported usability scores of 75/100, while one ranked it 80/100, and the other 100/100.
A Game Experience Questionnaire (GEQ) collected personal experiences, with positive experiences ranging from 2.5/4 to 4/4 and negative experiences scoring from 0/4 to 0.33/4. None of the participants reported tiredness. Borg’s perceived effort scale showed low difficulty scores, varying from 1/10 to 3/10. Mean heart rates were 94 beats per minute (bpm) for one patient and 100 bpm for the other three.
After the second session, no adverse symptoms were reported, along with high usability SUS scores of 87.5 and above, and positive and negative experiences similar to the first session. In contrast, three of the participants experienced some level of tiredness with this session. The perceived difficulty was higher in the second session, with Borg scores from 5/10 to 8/10. The mean heart rates from each participant were 86, 90, 103, and 122 bpm.
Finally, a satisfaction questionnaire to assess patient-reported strengths and weaknesses showed that all participants had “a very good experience,” with one reporting “it was a too short experience.” All said they would repeat the training sessions, that the training was appropriate for their age, and that they would recommend VR to other people with Parkinson’s.
Comment answers included “It helps you stay in shape and it’s relaxing,” and “It’s doing exercise in a fun and different way.” One participant added in a free comments section: “I am feeling so good.”
“Immersive virtual reality video gaming was feasible in the patients with mild-moderate [Parkinson’s disease] presented, with positive experience opinions, good usability as well as positive patient satisfaction and no adverse effects,” the researchers concluded.
The team noted that available commercial software and virtual reality exergames “can provide enough exertion to be compared to traditional exercise activities such as walking or dancing (highly recommended in [Parkinson’s disease] physiotherapy clinical guidelines).”
Virtual reality video gaming should be examined in larger patient populations, the investigators said.
“Future research could involve clinical trials, with long-term training effects and a larger sample size, encouraging the evaluation of physical, psychological and social variables in the Parkinsonian population, or even their own aspects to this disorder such as improving balance, strength, gait or functional independence,” they wrote.
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