Keywords
Ataxia - quality of life - rehabilitation - neurodegenerative diseases - postural
balance
Introduction
Spinocerebellar ataxias (SCAs) are a heterogeneous group of neurodegenerative diseases,
especially progressive cerebellar ataxia. They present classical symptoms, such as
ataxia, muscle hypotonia, nystagmus, dysarthria, and movement tremor.[1]
[2]
[3]
The risk of falls is high and frequent in people with SCAs. The body balance depends
on the vestibular system integrity: labyrinth, vestibulocochlear nerve, central nervous
system (CNS) nuclei pathways and interrelationships, somatosensory system (sensory
receptors in tendons, muscles, and joints), and vision.[2]
[4]
Dizziness and/or imbalance may impair the individuals' performance of activities in
daily life (ADLs), such as those that demand quick head movements and tasks that demand
trunk and head flexion.[5] The extent to which dizziness impairs individuals' ADLs can be assessed by validated
questionnaires. Currently, there are questionnaires that assess perceptions of dizziness
and body balance to quantify the impacts of such symptoms on the patient's daily life.
Among the existing instruments, the Vestibular Activities of Daily Living Scale (VADL), adapted to the Brazilian population by Aratani et al.,[6] assesses a scale of the patients' self-perception on their performance and independence
to conduct daily activities. Another instrument, the Activities-Specific Balance Confidence Scale (ABC), adapted to the Brazilian population by Marques et al.,[7] verifies by a scale the individuals' self-confidence to conduct ADLs.
The CNS promptly organizes and processes visual, vestibular, and proprioceptive sensory
information in specific areas in the brainstem and cerebellum, which control head,
neck, cervical spine, legs, arms, eyes, and all body muscles. We stress the importance
of the vestibular system in SCAs.[8]
Vestibular rehabilitation (VR) is considered a therapeutic resource due to its proposal
based on the central mechanisms of neuroplasticity.[4]
[9]
[10] The CNS processes that information and generates responses by means of reflexes.
The vestibule-ocular reflex (VOR), allows visual stabilization during the head movements,
and the vestibulospinal reflex (VSR), generates a body compensation movement to keep
head and body stability, thus preventing falls.[4]
Exercises aim to improve the visual-vestibular interaction during head motion and
expand static and dynamic postural stability – because they produce conflicting sensory
information –, enhance the capability to perform daily activities, and provide greater
physical independence to patients.[10]
[11]
Therefore, this study aims to evaluate the benefit of VR with virtual reality through
the application of the VADL and ABC questionnaires in patients with SCA.
Methods
The study fulfilled the Helsinki Declaration for Ethical use of human material. This
study was approved by the Ethics Board (Plataforma Brasil) under no. 832.502/2014,
CAAE 37083714.0.0000.0103. The anonymity of participants was guaranteed, and informed
consent was obtained from all participants.
A descriptive, retrospective cross-sectional study was carried out. Twenty-eight patients
(eight females and 20 males) (three SCA type 2, five SCA type 3, five SCA type 10,
and eight SCA recessive type). Seven patients were under genetic investigation to
diagnose the type of SCA that comprised the undetermined SCA type.
The SCA diagnosis was done by PCR (Polymerase Chain Reaction).[12]
[13] The PCR reaction is because oligonucleotides (primers) hybridize specifically with
a DNA template strand, enabling the production of multiple copies of specific DNA
sequences.[14]
To measure the severity of ataxia, the Scale for the Assessment and Rating of Ataxia
(SARA) proposed by Schmitz - Hübsch et al.,[15] further translated and validated in Brazil by Braga-Neto et al.[16] was used.
Patients' age ranged from 15 to 70 years (mean age 41.6 ± 16.9 years). Disease onset
ranged from two to 40 years (mean of 13.3 ± 12.4 years).
Patients included in the study: those with no middle-ear disorders, absence of assistive
gait devices, and no former rehabilitation therapy. Patients excluded from the study:
those unable to respond and understand simple verbal commands and severe visual impairment
or other abnormalities that hindered the performance of the proposed procedures.
Limitation of the Study
The study began with 35 patients. However, seven patients did not conclude the study
(three died, two missed the therapy sessions, and two did not meet the inclusion criteria).
We point to the difficulty in adhering this population to exercise since it is a highly
impacting disease not only physically, but also psychologically.
Measurements
All patients underwent an otorhinolaryngological exam, anamnesis, and vestibular assessment
with digital vector electronystagmography (VENG) which has its own software VecWin2
(Neurograff Eletromedicina LTDA, São Paulo/SP, Brazil), a rotating chair model COD
14200, rotation 0.01 to 0.5Hz, (Cadeiras Ferrante Ltda, São Paulo, SP, Brazil), a
visual stimulator model EV VEC (Neurograff Eletromedicina LTDA, São Paulo, SP, Brazil),
and an air caloric stimulator model NGR 05 (Neurograff Eletromedicina LTDA, São Paulo,
SP, Brazil). The flow rate used was 5 and 13 L/min. The VADL and ABC questionnaires
were applied before rehabilitation: 1st assessment (T1) was after ten rehabilitation sessions, the 2nd assessment (T2) was at the end of 20 rehabilitation sessions, and the 3rd assessment (T3) aimed to observe prospective changes after intervention.
Vestibular Disorders Activities of Daily Living Scale (VADL)
This questionnaire assesses the dependence and the impacts of body imbalance on the
performance of daily activities. The questionnaire includes 28 ADLs divided into three
subscales: functional (12 activities), ambulation (nine activities), and instrumental
(seven activities). Using a qualitative scale, the patients scored 0 to 10 points
according to their performance and independence in performing each described activity.
The score is calculated by median values: the higher the score, the higher the dependence
and inability of the patient. For “not applicable” (N/A) answers, that is, if the
patient does not perform the activity or does not want to reply, the question is given
a score of zero.
Activities-specific Balance Confidence Scale (ABC)
This questionnaire assesses the level of confidence of the individual in the ability
to maintain balance while performing specific daily activities. The questionnaire
comprises 16 questions on how confident subjects are to conduct a certain activity
(not confident 0%, and completely confident to conduct the activity without losing
balance 100%). Therefore, the higher the percentage, the greater the self-confidence.
Vestibular Rehabilitation with Virtual Reality
This is a therapeutic method used in body balance rehabilitation. A Nintendo® Wii was used: Wii-Remote and Wii Balance Board (Nintendo Co, Ltd., Kyoto, Japan)
were used. This platform measures the applied strength and senses balance changes
by pressure sensors. The sensors are responsible for the interface between the machine
and the player. Initially, the patients got used to the game and were instructed on
the necessary movements to play it.
Four balance games were played (Soccer Heading, Table Tilt, Tightrope, and Ski Slalom).
Strategies aimed at training gaze stability, head movement, static and dynamic balance,
motor coordination, rotation movement of the pelvis, and weight transfer aiming to
verify changes in balance and postural stability. All patients underwent 20 sessions
of VR of 50 minutes each twice a week. Then, they answered the same assessment questionnaires
before and after the end of rehabilitation sessions.
Statistical Analysis
Comparisons between groups and times were made using Friedman's non-parametric test/two-way
analysis of variance by ranks (Friedman's ANOVA). To compare two nominal variables
in VADL and ABC questionnaires, the Wilcoxon signed-rank test was used considering
Bonferroni correction.
Spearman's correlation was used to analyze the correlation between disease time and
the VADL and ABC questionnaires. The correlation strength between these variables
was considered very strong, strong, moderate, low, and irrelevant, when the values
of the correlation coefficient (positive or negative) were between 0.9 - 1, 0.7 -
0.89, 0.5 - 0.69, 0.3 - 0.49, and 0.0–0.29, respectively.[17]
A comparison of results in games and their interaction with group X time was made
by Student paired t-test.
All statistical analyses were conducted using the software SPSS v. 16.0 (IBM SPSS,
Armonk, NY) and Statistical 6.0 with a significance level of 5%.
Result
The most reported otoneurologic complaints in the anamnesis were imbalance (85.7%),
falls (28.5%), dizziness (17.8%), diplopia (10.7%), and tremor (7.1%).
The vestibular exam pointed to disorders in 18 cases (64.4%), with ten cases (35.8%)
of peripheral vestibular disorders and eight cases (28.6%) of central vestibular disorders.
Testing was normal in ten cases (35.6%).
Friedman's ANOVA showed that the comparison group x time of the VADL questionnaire
for the functional (p = 0.236), ambulation (p = 0.936), and instrumental (p = 0.973)
domains had no significant differences between the scores of the three domains (p > 0.05).
Comparison between the total scores of the VADL questionnaire also showed no significant
differences (p = 0.531). The comparison of two nominal variables by the Wilcoxon signed-rank
test did not show statistically significant differences (p > 0.005) ([Table 1]).
Table 1
Comparisons of the results of the VADL and ABC questionnaire according to the evaluation
time (n = 28)
|
Evaluation time: Mediana (IQR)
|
Valor de p*
|
|
1st assessment (F)
|
2st assessment (F)
|
3st assessment (F)
|
T1 x T2
|
T1 x T3
|
T2 x T3
|
|
1.00 (1.00–3.75)
|
1.00 (1.00–2.75)
|
1.00 (1.00–1.00)
|
0.125
|
0.102
|
0.833
|
|
1st assessment (A)
|
2st assessment (A)
|
3st assessment (A)
|
T1 x T2
|
T1 x T3
|
T2 x T3
|
|
3.00 (1.00–7.75)
|
2.00 (1.00–7.75)
|
2.00 (1.00–8.75)
|
0.929
|
1.00
|
0.944
|
|
1st assessment (I)
|
2st assessment (I)
|
3st assessment (I)
|
T1 x T2
|
T1 x T3
|
T2 x T3
|
|
6.00 (1.00–10.00)
|
4.00 (1.00–10.00)
|
1.00 (1.00–10.00)
|
0.823
|
0.516
|
0.778
|
|
1st assessment (T)
|
2st assessment (T)
|
3st assessment (T)
|
T1 x T2
|
T1 x T3
|
T2 x T3
|
|
4.00 (1.00–8.00)
|
1.75 (1.00–8.37)
|
1.00 (1.00–8.37)
|
0.753
|
0.789
|
0.332
|
|
1st assessment (ABC)
|
2st assessment (ABC)
|
3st assessment (ABC)
|
T1 x T2
|
T1 x T3
|
T2 x T3
|
|
43.75 (24.84–79.06)
|
41.88 (15.93–86.56)
|
56.25 (17.96–80.46)
|
0.767
|
0.121
|
0.123
|
A: Ambulation; ABC: Activities-Specific Balance Confidence; F: Functional; I: Instrumental;
IQR: Interquartile range (IQR, 25th to 75th percentile); T: Total; VADL: Vestibular
Disorders Activities of Daily Living Scale.
* Wilcoxon signed-rank test.
Friedman's ANOVA evidenced no significant differences between the scores in the three
assessments (T1, T2, and T3) (p = 0.119) compared to the interaction group x time
in the ABC questionnaire. The comparison of two nominal variables by the Wilcoxon
test also showed no statistical differences between times (p > 0.005) ([Table 1]).
The application of Spearman correlation showed significant results (p < 0.005) between
the VADL and ABC questionnaires in all cases ([Table 2]). As the correlation coefficient was always negative, there was an inverse correlation
between questionnaires, that is, lower scores in the VADL questionnaire correspond
to higher scores in the ABC questionnaire. Correlation strengths ranged from strong
to moderate between the different variables and are available in [Table 2]. Therefore, the best results in the VADL questionnaire correspond to the best results
in the ABC questionnaire. We can also notice that the greatest correlations between
questionnaires occurred in the T3 assessment. Concerning dimensions, the greatest
correlations were for the functional dimension.
Table 2
Correlation between VADL and ABC questionnaires (n = 28)
|
RESULTS
|
_rs
|
p*
|
CS
|
|
VADL functional and ABC 1st assessment (T1)
|
-0.762
|
*0.000
|
Strong
|
|
VADL ambulation and ABC 1st assessment (T1)
|
-0.662
|
*0.000
|
Moderate
|
|
VADL instrumental and ABC 1st assessment(T1)
|
-0.679
|
*0.000
|
Moderate
|
|
VADL general and ABC 1st assessment (T1)
|
-0.733
|
*0.000
|
Strong
|
|
VADL functional and ABC 2st assessment (T2)
|
-0.707
|
*0.000
|
Strong
|
|
VADL ambulation and ABC 2st assessment (T2)
|
-0.715
|
*0.000
|
Strong
|
|
VADL Instrumental and ABC 2st assessment (T2)
|
-0.549
|
*0.002
|
Moderate
|
|
VADL general and ABC 2st assessment (T2)
|
-0.718
|
*0.000
|
Strong
|
|
VADL functional and ABC 3st assessment (T3)
|
-0.758
|
*0.000
|
Strong
|
|
VADL ambulation and ABC 3st assessment (T3)
|
-0.733
|
*0.000
|
Strong
|
|
VADL instrumental and ABC 3st assessment(T3)
|
-0.740
|
*0.000
|
Strong
|
|
VADL general e ABC 3st assessment (T3)
|
-0.778
|
*0.000
|
Strong
|
ABC: Activities-Specific Balance Confidence Scale; CS: Correlation strength; VADL:
Vestibular Disorders Activities of Daily Living Scale.
Significant p values are in bold *_rs test
The application of the Spearman correlation showed no significant correlations between
ages and the VADL and ABC questionnaires, except for the instrumental dimension of
the VADL questionnaire in the T3 assessment (p = 0.015) ([Table 3]). As for disease time, the correlation was significant in all cases. As the coefficient
correlation was always positive for the VADL questionnaire, there was a direct correlation
to disease time, that is, the questionnaire results worsened as the disease time increased.
Regarding the ABC questionnaire, all correlations were negative and there was an inverse
correlation to disease time, that is, the worst questionnaire results in the ABC questionnaire
are associated with a longer disease time. Correlation strengths for each variable
are available in [Table 3].
Table 3
Correlation between age and length of the disease to the VADL and ABC questionnaires
(n = 28)
|
RESULTS
|
AGE
|
LENGTH OF THE DISEASE
|
|
_rs
|
p*
|
CS
|
_rs
|
p*
|
CS
|
|
VADL functional 1st assessment (T1)
|
0.292
|
0.125
|
Irrelevant
|
0.529
|
*0.003
|
Moderate
|
|
VADL functional 2st assessment (T2)
|
0.244
|
0.201
|
Irrelevant
|
0.506
|
*0.006
|
Moderate
|
|
VADL functional 3st assessment (T3)
|
0.247
|
0.205
|
Irrelevant
|
0.400
|
*0.034
|
Low
|
|
VADL ambulation 1st assessment (T1)
|
0.157
|
0.422
|
Irrelevant
|
0.519
|
*0.004
|
Moderate
|
|
VADL ambulation 2st assessment (T2)
|
0.235
|
0.226
|
Irrelevant
|
0.502
|
*0.006
|
Moderate
|
|
VADL ambulation 3st assessment (T3)
|
0.304
|
0.115
|
Low
|
0.582
|
*0.001
|
Moderate
|
|
VADL instrumental 1st assessment (T1)
|
0.323
|
0.093
|
Low
|
0.535
|
*0.003
|
Moderate
|
|
VADL instrumental 2st assessment (T2)
|
0.343
|
0.073
|
Low
|
0.397
|
*0.036
|
Low
|
|
VADL instrumental 3st assessment (T3)
|
0.470
|
*0.011
|
Low
|
0.381
|
*0.045
|
Low
|
|
VADL general 1st assessment (T1)
|
0.255
|
0.189
|
Irrelevant
|
0.509
|
*0.005
|
Moderate
|
|
VADL general 2st assessment (T2)
|
0.259
|
0.182
|
Irrelevant
|
0.486
|
*0.008
|
Low
|
|
VADL general 3st assessment (T3)
|
0.365
|
0.055
|
Low
|
0.523
|
*0.004
|
Moderate
|
|
ABC 1st assessment (T1)
|
-0.218
|
0.263
|
Irrelevant
|
-0.503
|
*0.006
|
Moderate
|
|
ABC 2st assessment (T2)
|
-0.182
|
0.351
|
Irrelevant
|
-0.493
|
*0.007
|
Low
|
|
ABC 3st assessment (T3)
|
-0.222
|
0.254
|
Irrelevant
|
-0.454
|
*0.015
|
Low
|
ABC: Activities-Specific Balance Confidence; CS: Correlation strength; VADL: Vestibular
Disorders Activities of Daily Living Scale.
Significant p values are in bold * _rs test
The comparison of the games played during the VR with virtual reality in T1 and T2
assessments by Student t-test showed significant differences for the games Soccer
Heading (p = 0.006), Tightrope (p≤0.000), and Table Tilt (p = 0.000), except for the
Ski Slalom (p = 0.100) ([Table 4]).
Table 4
Virtual reality game performance (n = 28)
|
Game
|
Number of sessions (Mean ± Standard Deviation)
|
p*
|
|
Soccer Heading
|
1st assessment (T1)
|
10th assessment (T2)
|
20th assessment (T3)
|
T1 x T2
|
T1 x T3
|
|
27.3 ± 21.8
|
48.0 ± 41.6
|
58.7 ± 64.0
|
*0.006
|
*0.015
|
|
Tightrope
|
1st assessment (T1)
|
10th assessment (T2)
|
20th assessment (T3)
|
T1 x T2
|
T1 x T3
|
|
12.5 ± 8.5
|
19.0 ± 12.1
|
24.0 ± 13.3
|
*0.000
|
*0.000
|
|
Table Tilt
|
1st assessment (T1)
|
10th assessment (T2)
|
20th assessment (T3)
|
T1 x T2
|
T1 x T3
|
|
29.3 ± 13,5
|
40.5 ± 18.2
|
54.7 ± 29.6
|
*0.000
|
*0.000
|
|
Ski Slalom
|
1st assessment (T1)
|
10th assessment (T2)
|
20th assessment (T3)
|
T1 x T2
|
T1 x T3
|
|
85.4 ± 18.5
|
76.5 ± 26.6
|
70.0 ± 24.3
|
0.100
|
*0.017
|
Significant p values are in bold *Paired Student's t-test
The comparison between T1 and T3 assessments regarding the games played during the
VR with virtual reality by Student t-test showed significant differences in all applied
games. There was a major improvement in patients during the rehabilitation therapeutics
playing Soccer Heading (p = 0.015), Tightrope (p = 0.000), Table Tilt (p = 0.000),
and Ski Slalom (p = 0.017) ([Table 4]).
Discussion
Multiple otoneurologic symptoms were detected in anamnesis, among them imbalance (85.7%),
falls (28.5%), dizziness (17.8%), diplopia (10.7%), and tremor (7.1%). According to
Teive,[1] the reported symptoms are common manifestations that may occur along the disease
course. In a study conducted with people with Friedreich's ataxia, the most reported
complaints of the anamnesis were uncoordinated movement (66.7%), gait imbalance (56.7%),
and dizziness (50%). The cerebellum and its medial zone, while promoting the contracture
of the limbic axial and proximal muscles, primarily maintain balance and stance.[18]
Regarding the vestibular testing in this study, vestibular dysfunction (VD) occurred
in 64.8% of participants. 35.7% featured peripheral VD and 28.6% featured central
VD. This corroborates the authors' findings (4): 50% of SCA patients were diagnosed with peripheral VD and the other 50% were diagnosed
with central VD. Faryniuk et al.[19] studied 57 patients with SCA types 2, 3, 6, 7, and 10 and evidenced 72% of central
VD, 12.2% of peripheral VD, and 15.8% had normal diagnosis. Nagaoka et al.[20] explained that VD combined with cerebellar atrophy significantly contributes to
gait instability, an early symptom of SCA.
By comparing assessment times (T1, T2 e T3) to the VADL questionnaire domains (functional,
ambulation, and instrumental), there was no significant result ([Table 1]). Nobre et al.[21] applied the VADL questionnaire before and after ten sessions of VR in a patient
with peripheral VD. The questionnaire evidenced that the patient had an initial scoring
of independence in 14 activities; after rehabilitation, her results improved: there
were 24 activities of independence in reassessment, thus showing a significant improvement.
For Cohen,[5] the VADL questionnaire has a major importance since it aims to assess the impacts
of dizziness and imbalance on the performance of ADLs. Although the current study,
did not show a statistical significance, the medians decreased over time.
There was no significant result between the three assessments in the application of
the ABC questionnaire, as well as in the comparison of two nominal variables between
times ([Table 1]). The ABC questionnaire assesses individuals' level of confidence to keep balance
or become unstable while performing ADLs. Araújo[22] conducted a study with 14 subjects suffering from peripheral vestibulopathy and
applied the ABC questionnaire before and after VR. The authors reported a statistical
difference for all questionnaire items. Similar to that observed for the VADL questionnaire,
the median increase over time shows a tendency for improvement after therapy. This
is corroborated by the statistically significant difference observed when the scoring
of the three games was assessed in the three times ([Table 4]).
The correlation between the VADL and ABC questionnaires showed significant results
for all dimensions ([Table 2]). After the VR, patients reported improvements in body balance, which meant greater
security and confidence to perform daily activities.
The correlation between ages and disease time ([Table 3]) enabled us to observe no significant correlations between ages and the VADL and
ABC questionnaires, except for the instrumental dimension of the VADL questionnaire
in the T3 assessment. Regarding disease time, there was a significant result in both
questionnaires, that is, the longer the disease, the worse the result. Teive[1] reported that the longer the disease, the more severe the symptoms since it is a
degenerative disease.
After the 10th virtual reality session in the current study, there was a significant improvement
in the applied games, except for Ski Slalom ([Table 4]). Hsu et al.[23] studied 70 individuals with chronic imbalance caused by Ménière disease undergoing
VR sessions and observed that there was improvement in the scores of extension movements
and movement coordination after the 6th session. Negrini et al.[24] used virtual reality in a study with patients suffering from Parkinson's disease
and observed that ten sessions with Nintendo Wii were enough to produce positive results
in the short-term concerning the patients' balance. The VR aims at the functionality
of vestibular systems by neuroplasticity mechanisms called habituation, substitution,
and adaptation. This corroborates the findings of this study.
The comparison between the games played during the VR with virtual reality (T1-T3)
showed significant differences in all applied games. There was an outstanding improvement
for all patients undergoing rehabilitative therapeutics ([Table 4]). Silva and Iwabe-Marchese[25] used Wii games in the VR of a child with cerebral palsy and, at the end of the research,
it affected the improvement of the child's functionality. Chen et al.[26] reported a significant improvement in static and dynamic balance and in the quality
of life of patients with brain lesions/cerebral vascular accidents by means of rehabilitation
training with virtual reality using a Nintendo Wii®. The authors observed improvements in gaze stability after 12 sessions of exercises,
40 minutes each, for six weeks. According to the authors, the beneficial training
outcomes may last for at least a month after its end.
According to the authors,[26]
[27] the primary functions of the vestibular system are to detect head movements, keep
the image stability projected in the retinal fovea, and keep the postural control
during head movements. The vestibule works by detecting head position and movement,
thus providing proper sensory information to the CNS. Sensory input is primarily sent
to the vestibular nuclei for processing and to the cerebellum for micro-regulation
and body balance coordination. The CNS stabilizes the head and body by means of neural
reflexes from the vestibular system. For the authors,[26]
[27] slow persecutory movements of the eye, the optokinetic function, and cervical-ocular
reflexes may interact with the VOR to reduce the retinal slip.
With the recent technological breakthroughs, new sensory devices have been developed.
Virtual reality therapy provides patients with a controlled environment and helps
them to adapt gradually to inducing situations of dizziness, imbalance, and falls,
which often affect their QOL in a significant way.[26]
We would like to point out that despite failing to show statistical significance in
the comparison between assessment times (T1, T2, and T3) and the applied VADL and
ABC questionnaires, the median between them pointed to a tendency of improvement.
Such an improvement evidenced by the application of questionnaires was not enough
to show the statistical evidence. However, patients reported postural improvement,
corroborated by the statistically significant differences observed when the scores
of the games were assessed in the three assessment times.
Concerning the games applied, the patients evidenced a significant improvement in
all assessment times.
Virtual reality is a novel rehabilitation strategy regarded as an enjoyable alternative
to enhance motor recovery. Virtual reality ranges from non-immersive to fully immersive,
depending on the degree to which the user is isolated from the physical surroundings
when interacting with the virtual environment. The Wii® requires constant changes
in standing posture from individuals, assessing their ability to control environmental
stimulation using bodily changes.
The game stimulates the patient in a spontaneous and natural way to move using different
motor strategies for each requested challenge in the game. Thus, the greater variability
of movements in a therapeutic context and the increased attention and motivational
demands are constant requirements. And that seems to provide a new and promising strategy
for the rehabilitation of those patients.
Currently, it seems coherent to consider VR as a therapeutic supporting resource in
the process of neurologic rehabilitation. The motivational characteristics, motion
repeatability, and the induction of the directed movement to a goal permit the patient
a diversity of situations and stimuli, challenging him continuously to accomplish
the tasks in a therapeutic context, but there are some issues associated with such
an approach that suggest caution in its use or, at the very least, further in-depth
analyses due to the difficulty of equipment standardization.
In the current study, no side effects were observed, such as dizziness, sickness,
or headache due to the use of the Wii® equipment. However, Park and Lee[28] assessed healthy adults and observed adverse effects while using fully immersive
virtual reality with fixed and moving backgrounds. The authors reported that participants'
adverse effects were reduced with fixed backgrounds. The authors[29] assessed elderly subjects suffering from Parkinson's disease, using immersive virtual
reality by means of the “Oculus Rift”, and no changes were verified in the static
and dynamic postural control. No discomfort was reported either.
Conclusion
There is an effective improvement observed in the reduction of fall frequency and
the improvement in balance and gait. These factors provided greater self-confidence
for patients to perform ADLs, positively impacting the QOL. We emphasize the benefit
of VR with virtual reality due to the symptomatology improvement in this type of population.
