• Cerebrovascular Disease
• Systemic Atrophies

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• Cerebrovascular Disease
• Neurology
• Systemic Atrophies

Stroke is a leading cause of adult disability, and around two thirds of stroke survivors continue to experience motor deficits in their arms and hands that are associated with diminished quality of life [Saposnik G et al. Stroke 2011]. The current paradigm in stroke rehabilitation involves repetitive, high-intensity, task-specific stimulation to improve motor recovery [Luft AR, Hanley DF. JAMA 2006; Kalra L, Ratan R. Stroke 2007]. However, only a few of the current techniques have effectively shown a significant improvement in arm function after stroke [Langhorne P et al. Lancet Neurol 2009]. Gustavo Saposnik, MD, MSc, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada, presented the benefits of using virtual reality (VR) gaming technology in stroke rehabilitation and how VR may engage the brain reward system.

Conventional stroke rehabilitation has several limitations [Langhorne P et al. Lancet Neurol 2009]. It is time consuming, and labor and resource intensive. It provides modest effects that are initially underappreciated by stroke survivors, and compliance problems and high dropout rates can limit recovery. In addition, in certain regions the availability and conventional rehabilitation may be costly.

VR allows a user to interact with a multisensory computer-simulated environment and receive instant feedback on performance. Neuroplasticity and the reorganization of cerebral activity are the basis of stroke rehabilitation, and VR has the potential to affect neuroplasticity through repetition, intensity, and task-oriented training [Kalra L, Ratan R. Stroke 2007; Saposnik G et al. Stroke 2011]. The availability of VR video game systems for home use has made this technology less expensive, and more accessible to clinicians and patients.

A meta-analysis of the available data on VR in stroke rehabilitation revealed that 11 of 12 studies showed a significant benefit of VR in stroke rehabilitation [Saposnik G et al. Stroke 2011]. Five small clinical trials showed that patients randomized to VR were nearly 5 times more likely to benefit compared with controls. Among observational studies, there was a 20.1% (95% CI, 11.0 to 33.8) improvement in motor function and a 14.7% (95% CI, 8.7 to 23.6) improvement in motor impairment after several 30- to 60-minute VR sessions in a 4- to 6-week time period (Figure 1).

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Figure 1.

Meta-Analysis of Observational Studies Using Virtual Reality Systems in Upper Limb Stroke Rehabilitation

Adapted from Saposnik et al. Stroke 2011.

Currently, the Efficacy of Virtual Reality Exercises in Stroke Rehabilitation [EVREST; NCT01406912] multicenter trial is evaluating the effectiveness of the Nintendo Wii gaming technology in promoting motor function improvement of the upper extremities in stroke survivors. Initiated in Canada, and funded by Heart and Stroke Foundation of Canada and the Ontario Ministry of Health, EVREST is being expanded to other countries, including Argentina, Brazil, Peru, Thailand, and possibly the United States. This trial is applying the basic concepts in stroke rehabilitation. It may also engage the “mirror neuron” system, which is a set of neurons activated when individuals observe an action performed by someone else, and the “brain reward system” to promote motor recovery.

The brain reward system, which can be activated by a VR game, involves the mesolimbic structures of the brain and is dopamine-mediated. For the brain reward system to be activated, the game has to be emotionally engaging; give credit for everything the patient does; provide rapid, frequent, and clear feedback; and involve an element of uncertainty.

Prof. Saposnik said, “Virtual reality is a novel, affordable, and enjoyable intervention that may help intensify treatment and promote motor recovery after stroke.” He also emphasized that larger randomized studies are needed before changing practice. He noted that “rewarding the brain is a powerful mechanism to embrace rehabilitation after stroke.”

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