Virtual Reality and Multiple Sclerosis Experiment

    Multiple Sclerosis (MS) is a progressive disease of the central nervous system. According to the National Multiple Sclerosis Society, it is estimated that MS affects more than 2.3 million people worldwide.1 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 that surrounds and protects the nerve fibers. The immune system also attacks oligodendrocytes, which are the myelin-producing cells, as well as the underlying nerve fibers.

2 The damage that occurs to the nerve cells can slow down or stops nerve transmission, between different parts of the central nervous system and the body. This disruption can cause a magnitude of symptoms that may enter periods of remissions and exacerbations or persist and worsen over time.

The clinical manifestations appear in everyone differently and may present in extreme fatigue, numbness or tingling, vision problems, weakness, and gait problems– loss of balance and poor coordination.3 Since many people suffering from neurological disorders experience poor balance and coordination4, studies have set out to see if the use of virtual reality can help improve function. The used of virtual reality is a beneficial intervention in 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). This randomized controlled trial was a pilot study looking at how the use of virtual reality could improve balance in people with multiple sclerosis. However, previous studies have been conducted on the use of virtual reality and balance. These studies, however, looked at different demographics such as people with Parkinson’s disease or those who suffered from a stroke. This study took place in Isreal at the Sheba Medical Center over a six-week period. The control and experimental groups each had two balance training sessions a week for thirty minutes at a time. This study also implements the use of 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 diagnose 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 in pyramidal functional. The study stated that the exclusions included anyone with major depression, cognitive decline, or orthopedic disorders that can negatively affect balance. Anyone who had received corticosteroid therapy within six months prior or MS clinical relapse. Exclusion also included pregnancy, blurred vision, and cardiovascular disorders. (What they wrote MS clinical relapse or treatment with corticosteroid therapy within 6-months prior to the examination) The study was conducted used blind accessors who were unaware of which groups the participants were in as well as concealed allocation. Allocation in this study was 1:1 ratio (same amount of people in the control as well as the experimental group). Sealed envelopes marked with either a 0 or an X where made in advance. A physical therapist who was not involved in the treatment, study, or assessment did the randomization, one hour prior to the pretest of the participants. However, during this study, there was no blinding of the therapist administering the test as well as no blinding of the subjects. The study initially examined thirty-two participants, during the course of the study two participants withdrew, data was collected and reported on the remaining thirty subjects. Data on each subject was collected twice, pretest and then again at the end of the six-week period.

Throughout the study, the group randomly assigned to the virtual reality therapy had a screen in front of them where the virtual reality environment was projected. The participants would then stand on a platform and the platform would move to reflect the scene and environment, such as a bump, going around a curve, or walking up an incline. The platform would also move along with the participant’s movements. As the participants would progress down the road there were predetermined points a ball would appear, either on their left or right side, and was 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 physical therapists were allowed to increase the difficulty once the challenge was too low. The control group, however, stood on unstable pieces of foam, during static postural control training and more foam was added and a smaller base of support provided once the challenge was too low. During the static postural testing, participants were asked to stand with there eyes open or closed and motionless for one minute. Testing also included weight shifting exercise, 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 on the board in various directions and speeds while the subject tried to keep their balance. The data collected from this randomized controlled trial does show that the use of virtual reality group did have a greater improvement in balance which does coincide with their original hypothesis. However, there are certain limitations regarding this study that need to be addressed. This study does indicate the use of blind allocation but, lacks to inform how the envelopes were randomized, such as how were the envelopes shuffled together. The study also lacks to specify how the physical therapist distributed the envelopes. Another limitation of this study is the lack of information on how the exclusions of major 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 (p6)”. This statement does not explain which group the missing participants were apart of or how many people actually missed training sessions. This means that it is potentially possible for one group to have an additional thirty hours of training hours 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 there is no way to determine if the ball was thrown at the same force each time. The physical therapist would also manually shake the wobble board, which again, leaves room for discrepancy on the force being used.

When comparing this with the virtual reality group who were able to 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 do believe there is room for improvement on how this study was conducted, I would recommend this article. I feel their setup of the virtual reality group was interesting and beneficial in showing the use of external interventions. However, further investigation is needed on the use of virtual reality. When using the PEDro Scale5 in testing the validity of this trial it scored a 7 out of 10. 

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