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Multiple Sclerosis (MS) is a progressive central nervous system disease. According to the National Multiple Sclerosis Society, it is estimated that MS affects more than 2.3 million people worldwide. At this time, the direct cause of MS is still unknown. However, the immune system attacks and damages the myelin sheath of nerve fibers, a fatty covering surrounding and protecting the nerve fibers. The immune system also attacks oligodendrocytes, the myelin-producing cells, and the underlying nerve fibers. The damage to the nerve cells can slow down or stop nerve transmission between different parts of the central nervous system and the body. This disruption can cause many symptoms, which may enter periods of remission and exacerbations or persist and worsen over time.
The clinical manifestations appear in everyone differently and may present as extreme fatigue, numbness or tingling, vision problems, weakness, and gait problems — loss of balance and poor coordination. Since many people suffering from neurological disorders experience poor balance and coordination, studies have set out to see if virtual reality can help improve function. The use of virtual reality is a beneficial intervention for improving balance capabilities in people with MS. This article summarizes and reviews “The effect of balance training on postural control in people with multiple sclerosis using the CAREN virtual reality system: a pilot randomized controlled trial,” presented by Kalron, Fonkatz, Frid, et al.
How it works
This randomized controlled trial was a pilot study examining how virtual reality could improve balance in people with multiple sclerosis. However, previous studies have been conducted on virtual reality and proportion. These studies, however, looked at different demographics, such as people with Parkinson’s disease or those who suffered from a stroke. This study occurred in Israel at the Sheba Medical Center over six weeks.
The control and experimental groups each had two weekly balance training sessions for thirty minutes at a time. This study also implements a computer-assisted rehabilitation environment system-CAREN (virtual reality). The eligibility criteria stated participants were between the ages of twenty-five and fifty-five and, according to the revised McDonald criteria (2010), had a diagnosis of definite relapsing-remitting MS. Participants also needed a score ranging from 3.0 to 6.0 on the expanded disability status scale (EDSS) as well as a score of at least three on the pyramidal functional assessment. The study stated that the exclusions included anyone with major depression, cognitive decline, or orthopedic disorders that can negatively affect balance, anyone who received corticosteroid therapy within six months of their MS clinical relapse, exclusion also included pregnancy, blurred vision, and cardiovascular disorders. The study was conducted using blind assessors, unaware of the participants’ groups, and concealed allocation. Allocation in this study was a 1:1 ratio (the same amount of people in the control and the experimental group). Sealed envelopes marked with a 0 or an X were made in advance. A physical therapist who was not involved in the treatment, study, or assessment did the randomization one hour before the participants’ pretest. However, during this study, neither the therapist administering the test nor the subjects were blinded.
The study initially examined thirty-two participants; during the study, two participants withdrew, and data was collected and reported on the remaining thirty subjects. Data on each subject was collected twice: once at the pretest and again at the end of the six weeks. The group randomly assigned to the virtual reality therapy had a screen where the virtual reality environment was projected throughout the study. The participants would then stand on a platform, and the venue would move to reflect the scene and setting, such as going over a bump, going around a curve, or walking up an incline. The platform would also move along with the participants’ movements. As the participants progressed, there were predetermined points at which a ball would appear, either on their left or right side, and be displayed for five seconds.
Throughout the testing period, there were eighteen colored balls to catch. During the test, two sets of instructions were given. “In front of you will appear a road that advances toward you. Your goal is to keep your balance in response to changes in the slope or direction of the road” and “to maintain his balance (as before) but also to try and reach out with his arms to touch the virtual balls.” Both participants and the physical therapist were allowed to increase the difficulty once the challenge was too low. The control group, however, stood on unstable foam pieces during static postural control training. More foam was added, and a smaller support base was provided once the challenge was too low. During the static postural testing, participants were asked to stand with their eyes open or closed and motionless for one minute. Testing also included weight-shifting exercises, where a physical therapist would throw a ball, and the subject would try to catch it. Once the challenge was too low, the ball size, speed, and distance were increased.
The third test was perturbations, where the subject would stand on a wobble board. The physical therapist would then push and pull on the board in various directions and speeds while the issue tried to keep their balance. The data collected from this randomized controlled trial does show that the group using virtual reality did have a more significant improvement in harmony, which does coincide with their original hypothesis. However, certain limitations regarding this study need to be addressed. This study does indicate the use of blind allocation but lacks information on how the envelopes were randomized, such as how they were shuffled together. The study also lacks specifics on how the physical therapist distributed the envelopes.
Another limitation of this study is the lack of information on how the exclusions of significant depression and cognitive decline were measured. They did not provide a scale that was used or what they considered cognitive decline to be. This trial also reported that some of the participants missed training sessions: “All participants participated in at least 10 (out of the planned 12) training sessions (p. 6).” This statement does not explain which group the missing participants belonged to or how many people missed training sessions. This means that it is potentially possible for one group to have an additional thirty hours of training over another group. Another major limitation of this trial was the exercise program in the control group. The physical therapist would throw a ball at the subject to catch it, but there is no way to determine if it was thrown with the same force each time.
The physical therapist would also manually shake the wobble board, leaving room for discrepancies in the force used. When comparing this with the virtual reality group, who could stand on a flat platform and did not have to catch the weight of a ball, they were only required to raise their arms to touch the ball. While I believe there is room for improvement in how this study was conducted, I recommend this article. Their setup of the virtual reality group was exciting and beneficial in showing the use of external interventions. However, further investigation is needed into the use of virtual reality. When using the PEDro Scale 5 to test the validity of this trial, it scored 7 out of 10.
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