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Background:
Systematic Review

Improving Balance and Functional Status in Spinal Cord Injury Patients: A Systematic Review Comparing Virtual Reality-Based Therapy and Conventional Therapeutic Exercises

by
Esteban Obrero-Gaitán
1,
Luis López-Nájera
1,
Marina Piñar-Lara
1,
María del Rocío Ibancos-Losada
1,
Irene Cortés-Pérez
1,* and
Héctor García-López
2
1
Faculty of Health Sciences, University of Jaén, Campus Las Lagunillas s/n, 23071 Jaén, Spain
2
Faculty of Nursing, Physiotherapy and Medicine, University of Almería, Ctra Sacramento s/n, La Cañada de San Urbano, 04120 Almería, Spain
*
Author to whom correspondence should be addressed.
Electronics 2024, 13(13), 2594; https://doi.org/10.3390/electronics13132594
Submission received: 6 June 2024 / Revised: 26 June 2024 / Accepted: 29 June 2024 / Published: 2 July 2024
(This article belongs to the Section Bioelectronics)
Browse Figure
Versions Notes

Abstract

:
Background: The objective was to evaluate the efficacy of virtual reality-based therapy (VRBT) compared to therapeutic exercise in increasing balance and functional status in patients with acquired spinal cord injury (SCI). Methods: Following PRISMA recommendations, we searched randomized controlled trials that meets the inclusion criteria in PubMed Medline, Scopus, Web of Science and PEDro without language and publication date limitations. Methodological quality and risk of bias were evaluated using the PEDro scale. Results: Six RCTs providing data on 131 patients with SCI were included in this systematic review. Based on the information gathered from the included studies, both therapies can increase balance and functional status between pre- and post-assessment. However, it seems that there is a higher rate of improvement in balance and function in SCI patients in favor of the group that uses VRBT in their treatment (p < 0.05). Conclusions: Although there is evidence in favor of the effectiveness of VRBT in increasing balance and functional status in patients with SCI, this is limited, and further research is necessary. Even so, taking into account the results found, our systematic review suggests that VRBT provides an effective therapeutic use to implement alongside conventional therapies for patients with SCI.

1. Introduction

Acquired spinal cord injury (SCI) is a pathological condition that results from a traumatic or progressive injury to any segmental level of the spinal cord [1]. It is produced by the interruption of the nerve axons at the affected spinal cord level, causing motor and/or sensory alterations that may be total or partial, depending on whether the spinal cord section is complete or incomplete, and entails a reduction in functional capacity below the injured level [2]. SCI can originate from primary injury mechanisms (contusion, laceration, distraction or compression of neural tissue), responsible for more than 90% of cases, and secondary ones (cancer, infections and autoimmune diseases or spinal canal stenosis) [3,4] that limit recovery and contribute to the extension of the injury [2,5]. Each year, between 250,000 and 500,000 new cases of SCI are reported in the United States, which represents a high direct and indirect socio-health cost [6], estimated to be between USD 2 and 4 billion over a patient’s lifetime [2,3,4].
The American Spinal International Association (ASIA) is the reference institution for evaluating these injuries using its internationally typified scale, which allows patients to be classified through a rigorous and standardized motor, sensory and anorectal examination [3,7]. Patients with SCI present a reduction in personal autonomy and quality of life due to motor and sensory dysfunctions [2], gait and balance disorders in standing and sitting [8], sexual [9], intestinal and bladder dysfunctions [10], and sleep disorders, frequently accompanied by respiratory difficulties [11]. Other common symptoms include chronic neuropathic pain, orthostatic hypotension, neurologic bladder and urinary tract infections (one of the most common causes of death for complications in SCI [12,13]), deep vein thrombosis, and skin damage due to pressure ulcers [2,14].
Regardless of the surgical treatment (laminectomy or early surgical decompression) and pharmacological treatment (thyrotropin-releasing hormone, nimodipine or fibroblast growth factor, among others) used, rehabilitative treatment based on physiotherapy and occupational therapy, among others, is essential for the recuperation, adaptation and reintegration of patients to their new situation. Physiotherapeutic treatment is implemented after the patient’s stabilization and is maintained over time, with the aim of mitigating and recovering musculoskeletal and sensory sequelae, as well as improving motor function and neuronal plasticity [15]. Manual therapy, kinesitherapy, muscle-strengthening exercises, postural transfers and orthoses are used [16]. Therapeutic exercise is an active approach that promotes neuronal regeneration after SCI [4,14]. The literature indicates that patients with SCI may obtain cardiopulmonary benefits with upper extremity aerobic exercises and pain reduction with mobilization and strengthening exercises. However, improvements in functional or psychological status or quality of life are not conclusive and depend on several factors of the patient and the treatment received [17,18]. Currently, treatment is aimed at the acute phase and maintenance of the patients’ condition, with limited neuroregenerative tools [4,14]. Therefore, is necessary to develop and to implement innovative strategies and therapies.
Technological advances have allowed the incorporation of new therapeutic devices, such as virtual reality (VR) devices, which complement the physical therapy intervention and can increase treatment adherence (virtual reality-based therapy, VRBT). VR is defined as a controlled and interactive environment generated by multidimensional computer technology, which recreates virtual environment simulating the real world and daily situations [19]. Presence and immersion are the most important characteristics of these devices [20]. VR has three modalities. Non-immersive VR allows the visualization of virtual environments on a standard screen, and patients can interact using joysticks. Semi-immersive VR uses powerful computer systems to increase immersion, and immersive VR allows the visualization of virtual environments in 360 degrees using head-mounted displays [21]. VRBT offers great potential for neurorehabilitation [19], with long-lasting effects that manifest in the real world [22]. VRBT presents numerous advantages, such as the ability to individualize treatment, the use of tasks with progressive difficulty, the ease of changing environments, adaptation to the patient’s abilities and orientation to specific objectives. Additionally, patients show greater enjoyment, enthusiasm and confidence in the treatment [23]. The advantage of VRBT over conventional therapies lies in the wide variety of exercises and tasks it can offer, increasing participation [24], motivation [24,25,26] and attention, which increases the level of adherence to the therapy, which is crucial for the success of the treatment [25].
Previous studies suggest that VRBT improves balance [27,28], functional motor capacity [27,29], neuropathic pain [27,30] and aerobic function [31,32]. Although previous reviews have reported that both therapeutic exercise [33,34,35,36] and VRBT can be effective in the treatment of patients with SCI [37,38,39], no systematic reviews that specifically compare the efficacy of both therapies have been performed. This research may be new because no similar reviews have been published, and it would be very interesting for clinical practice since it will allow us to know if virtual reality is an effective tool to include in neurorehabilitation protocols, maximizing the effect of physical rehabilitation programs. We hypothesize that VRBT may have a greater effect on balance and functional status in these patients. Therefore, the objective of this systematic review is to retrieve and assess all available published studies to evaluate the efficacy of VRBT compared to conventional therapeutic exercises in increasing balance and functional status in patients with SCI. For this, the research question of this systematic review was as follows: Is VRBT more effective than conventional therapeutic exercises on balance and functional status in patients with SCI?

2. Materials and Methods

2.1. Study Protocol and Register

This systematic review was performed following the recommendations of the 2020 version of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [40] and the Cochrane Handbook of Systematic Intervention Reviews [41]. Furthermore, the protocol of this systematic review was registered in the PROSPERO database: CRD42024528617.

2.2. Literature Search

A bibliographic search was performed in the following databases: PubMed Medline, Scopus, Web of Science (WOS) and PEDro (Physiotherapy Evidence Database) since inception up to May 2024. Additionally, the reference sections of the compiled studies and other sources such as proceedings, abstracts or document experts were explored. To identify the search conditions and select the keywords for each condition, the PICOS tool of the Cochrane collaboration was used [42]. In relation to the PICOS system, a search strategy was carried out using MeSH (medical subject headings) terms such as “Spinal cord injuries”, “virtual reality”, “virtual reality exposure therapy”, “exergaming” and “exercise therapy”, along with its entry terms. All this was combined with Boolean operators (AND and OR) and specific functionalities of each database. Filters or restrictions related to language, date of publication or free access to the study were not set. The search was carried out by two authors (E.O.-G. and L.L.-N.), and it was supervised by another author (I.C.-P.). The search strategy designed and used in each database is shown in Table 1.

2.3. Study Selection: Inclusion and Exclusion Criteria

All studies retrieved from the searches in the different databases were revised by title/abstract by two researchers (E.O.-G. and L.L.-N.), and a third researcher (H.G.-L.) supervised it. One study was selected to be included in this systematic review when it met each one of the following inclusion criteria: randomized controlled trials (RCTs) (1) or pilot RCT comprising patients with SCI (2) with one experimental group that received VRBT (3) and a comparison group, which received exercise therapy (4); and that provided qualitative data of the outcome of interest (balance and functional status). The proposed exclusion criteria were the following: (1) studies whose sample was not exclusively made up of patients with SCI; (2) those that did not provide data that can be integrated into the review; and (3) that have questionable ethical characteristics to safeguard the integrity of our review

2.4. Data Extraction

The data collected were obtained based on the overall characteristics of the studies (author, publication date, country, institution and funding and study design), characteristics of the sample (participant data such as total number, age, sex and pathology, as well as the groups and their division), characteristics of the interventions compared in both groups (type of treatment, frequency and duration) and characteristics of the variables (name, measurement employed and qualitative findings post-intervention). In relation to the type of treatment, when reference was made to the VR group, it was clarified which VR modality was used and whether it was used as a sole technique or complementary to therapeutic exercise.

2.5. Variables

Postural balance and functional status were the main variables assessed in this systematic review. Firstly, postural balance represents the human ability to maintain in stable static and dynamic position being necessary vestibular, visual and somatosensory inputs [43]. The human ability to perform basic physical and cognitive abilities includes activities of daily living, locomotion and cognitive functions [44]. Additionally, quality of life also was assessed.

2.6. Methodological Quality Assessment

The methodological quality and risk of bias in the individual studies included were assessed using the PEDro scale [45]. This scale is widely used for this purpose, with the aim of reviewing studies in Physiotherapy [46]. Eleven items comprise this scale, whose purpose is to demonstrate whether clinical trials have sufficient statistical information, internal and external validity. Each item can be marked with a “yes” (if the criterion is met, and one point is added) or a “no” (if the criterion is not met, and zero points are added). The first of them evaluated external validity, and this criterion was not taken into account for the calculation of the score, so we obtained a score between 0 and 10. Depending on the score obtained (points), a RCT could have excellent methodological quality (10-9), good (8-6), moderate (5-4) or poor/low (3 or fewer points) [47].

3. Results

3.1. Study Selection

The initial searches in the databases reported a total of 105 studies (22 from PubMed Medline, 24 from Scopus, 56 from WOS and 3 from PEDro), and 2 others were retrieved from other sources. Thirteen references were excluded for not being relevant. Later, after screening 95 studies by title and abstract, 79 were excluded for not being relevant and 10 studies for not meeting the inclusion criteria (8 were not RCT, 1 did not include the population of interest, and other did not provide outcomes of interest). Finally, six studies were included in the present systematic review [48,49,50,51,52,53]. Figure 1 shows the PRISMA flow diagram of the study selection phase.

3.2. Characteristics of the Studies Included

The six RCTs included in the present systematic review, carried out in in South Korea [48,53], Spain [49,50] and India [51,52], reported data from a total of 131 patients with SCI, with a mean age of 44 ± 9.21 years old (70% men and 30% female). The intervention group that received VRBT comprised 68 participants (mean age of 43 years old), while the control group that carried out therapeutic exercise comprised 63 participants (mean age of 41 years old). Three studies [48,49,53] reported patients with SCI in the chronic phase, and others with a period of time that suggests the possibility of coincidence of acute and chronic phase [50,51,52]. The participants included were diagnosed with complete [51,52], incomplete SCI [48,53] or mix of both [49,50].
In relation to the characteristics of the different interventions proposed for VRBT, the duration varied between 2 and 8 weeks, with a frequency of 2 to 5 days/week, 30 to 45 min per session. Patients in the experimental groups received immersive VRBT [50,53], semi-immersive VRBT [48,49] and non-immersive VRBT [51,52]. On the other hand, for patients in the control groups, a set of therapeutic exercises (functional, strengthening, mobility and balance exercises) guided in the real world were used, with a duration and frequency homologous to that of the intervention group for each study. All studies included provided data from the immediate post-intervention assessment (no follow-up). Finally, regarding the funding received, two articles received financial aid to carry out their study [48,51]. Table 2 details the characteristics of the studies included in the systematic review.

3.3. Methodological Quality and Risk of Bias Assessment

The average methodological quality of the included RCTs, once analyzed using the PEDro scale, was moderate (5.17 ± 1.57). Still, despite having this level of quality, we must be careful with the results derived from this systematic review, since we must consider a possibility of medium risk of bias in the individual studies. Selection (concealed allocation was not met), performance (participants and therapists were not blinded) and detection biases (evaluators not blinded) were present in all studies. The individual score and quality are shown in more detail in Table 3.

3.4. Qualitative Findings

3.4.1. Postural Balance

A total of five studies [48,49,51,52,53] compared the effect of VRBT and therapeutic exercise on postural balance. These five studies provided data from 122 patients with SCI, assessing balance with the following tests: force-sensitive application (FSA), limit of stability (LOS), modified functional reach test (MFRT), chair stand test (CST), and time up and go (TUG) tests.
All studies included in the assessment on balance reported a statistically significant improvement between pre- and post-assessment on balance in VRBT [48,49,51,52,53], while only 3 showed that therapeutic exercise improved balance in the therapeutic exercise group [48,51,53].
When the therapies were compared after the interventions, statistically significant differences favoring VRBT were found in three studies (60% of the included studies) [48,52,53], while two did not reported that VRBT was better than therapeutic exercise in improving balance [49,51]. Through data from these studies, we suggest that VRBT could be an effective therapy in increasing balance in these patients in comparison to therapeutic exercise. It is important to highlight that that non-immersive VR devices were the modality of VRBT that increased balance more significantly in these patients [48,53] (an, lee).
In Table 2, we provide more detail of the qualitative findings of each individual study.

3.4.2. Functional Status

To compare the efficacy of VRBT and therapeutic exercise, only four studies were used [49,50,52,53]. These studies provided data from 90 participants with SCI, assessing the functional status after interventions. Two studies exclusively evaluated general functional capacity [49,52]; one assessed both general functional performance and the functional capacity of the upper limbs [50]; and one specifically analyzed the function of the lower limbs [53]. The measurements tools used by the included studies were as follows: spinal cord independence measure (SCIM), muscular balance (MB), nine-hole peg test (NHPT), Jebsen–Taylor Hand Function Test (JHFT) and 10-meter walk test (10 MWT).
All studies found improvements for functional status in VRBT and control groups, although statistically significant differences between pre- and post-intervention were only found in two studies [50,53].
Additionally, the comparison between therapies showed statistically significant differences favoring VRBT in all studies [49,52,53] (80% of all included in this assessment), except in one study [50], in which they were not significant for any group. Therefore, these results suggest a greater effect of VRBT in improving functional status related to lower limbs, but not for upper limbs, in which both therapies could be equally effective.
More details about qualitative findings in each study can be found in Table 2.

3.4.3. Quality of Life

The quality of life variable was measured in only one study [49], with data from 11 patients, using Spinal Cord Injury Quality-of-Life-23 (SCI QL-23). For this variable, the study included a statistically significant increase in the global quality of life favoring VRBT group. It seems that VRBT could be more effective than therapeutic exercise alone in improving quality of life [49], although this finding showed a very low quality of evidence due to the inclusion of only one study’s data.

4. Discussion

SCI is a pathological condition in which nerve function is altered at the spinal level, generating motor and/or sensory deficits below the injury [54]. Postural and balance alterations are also frequently evident in these patients [55]. Even so, at the spinal level, there is a high level of spontaneous recovery or plasticity after an injury, although by itself, it does not lead to a recovery of substantial functional capacity, which is why additional interventions are required [56,57,58]. Analyzing the effectiveness of therapies that promote neuronal plasticity is essential to guarantee a good level of recovery in these patients. On the one hand, the literature shows that therapeutic exercise is effective in these patients. Vieira Santos et al. reported in a recent meta-analysis that resistance training is effective in the management of patients with SCI, especially on muscle strength [59]. On the other hand, complementary to therapeutic exercise or other physiotherapy approaches, VRBTs have proven to be effective in the management of these patients, since they promote levels of neuroplasticity at the spinal level [60]. Therefore, the objective of this review was to analyze the effectiveness of VRBT, compared to therapeutic exercise, in improving balance and functional status in patients with SCI. After the literature search and applying the inclusion and exclusion criteria, six RCTs were included, providing data from 131 patients with SCI. Importantly, a strength of this review is its pioneering nature, as it is the first review to compare VRBT and therapeutic exercise in patients with SCI. Therefore, the results derived from this analysis, even taking into account the low level of evidence due to the small number of RCTs included, will be relevant for clinical practice, as they will help physiotherapists decide which of the two comparative clinical tools can be more beneficial for these patients.
In this systematic review, three variables were analyzed. First, the general results of the balance [48,49,51,52,53] and functional status [49,50,52,53] evaluation showed a possible greater efficacy favoring VRBT compared to therapeutic exercise, since the majority of the studies included in each variable showed a greater intergroup improvement in favor of the VRBT group. More specifically, in the balance variable, An and Park additionally showed that VRBT reduced the number of falls in patients with incomplete SCI [53]. The positive effects on balance found in the systematic review are in line with previous reviews that showed a significant balance improvement in these patients. These reviews reported that VRBT could be effective in improving standing balance, balance confidence and gait [37], and functional [38] and dynamic balance, reducing the risk of falls [39]. The possible hypotheses that explains that VRBT can induce improvements in balance may be the visual stimuli received that compensates for impaired somatosensory information after SCI [61]. Additionally, another reason is that repeating physical and ludic tasks can increase the strength of lower limbs in paraplegics or incomplete SCI [62].
Regarding the variable of functional status, our findings showed that the inclusion of VRBT in rehabilitation programs may be more effective in increasing functional status than only therapeutic exercise. This finding coincides with previous reviews. De Araújo, AVL et al. showed in her systematic review that VRBT could improve motor function [24]; De Miguel-Rubio et al. reported in a meta-analysis that VRBT was effective in improving functional independence; and in 2022, authors showed in a systematic review that combining VRBT with robotics could improve motor function in patients [63], and it can contribute to improving their physical functional status. The immersive component of VRBT favors the active participation and motivation of these patients, which improves their functional performance, having a greater impact on the function of their lower limbs [49,53].
Finally, a third variable that was analyzed was quality of life, although after analyzing it, we cannot confirm which of the two therapies was more effective, since only one study was included in this analysis [49]. Manzanares et al. was the only one that additionally evaluated quality of life, where significant differences in favor of VRBT were observed in the self-perception of global quality of life [49]. Previous studies have shown that VRBT may be effective in increasing physical and psychological aspects that are related to improvements in quality of life [24].
Regarding plasticity, it is known that cellular and biochemical modifications can be induced in an activity-dependent manner, which offers a great advantage for the development of useful therapies in functional recovery after SCI [64]. Furthermore, neuronal circuits prior to said injury undergo a reorganization after the injury, in which the return to activity strengthens the new synaptic connections, and inactivity leads to neuronal pruning [65]. Repeated physical and dynamic activity provides stimuli to the spinal cord with demonstrated beneficial effects on functional recovery and the ability to induce synaptic plasticity [66,67]. VRBT is a therapeutic approach that can stimulate this neural plasticity thanks to the production of major levels of brain-derived neurotrophic factor, crucial for neural plasticity processes. Early rehabilitation has shown to be very effective in the production of BDNF, with the aim of accelerating brain plasticity in animal models [68]. Furthermore, rehabilitation strategies that combine different therapies at time (drugs and physical therapies) result in more effective recovery than those that use a single treatment [64].
After everything mentioned above and having collected data on the effects of both therapeutic strategies, it seems that, in clinical practice, treatments that include the use of VRBT may be more effective. One advantage of the inclusion of VRBT in rehabilitation programs is that it seems to be a safe therapy. The most adverse events to take into account depend on the modality of VR device employed, immersive VR devices being the most common to produce adverse events, such as motion sickness, temporo-spatial distortion, vertigo, visual disturbances, headaches and falls [69]. Of the studies included in this review, in five of them, adverse events were not studied, and only Dimbwadyo-Terrer assessed if immersive VRBT induced adverse events, such as motion cybersickness or vertigo, without reporting any patients with these symptoms [50]. Additionally, this study showed that all patients were able to tolerate the immersive VR-based exercises successfully. We suggest clinical recommendations. Firstly, to prevent possible adverse events, a detailed analysis of tolerance to different virtual reality devices will be necessary. And, secondly, non-immersive VR devices are the most recommended to perform virtual exercises with a low risk of adverse events in SCI patients. Another advantage of VRBT is the increase in the level of satisfaction and adherence of these patients to the therapy. SCI is a pathology with a tendency to become chronic, and rehabilitation is a long process that requires the cooperation and involvement of patients. To obtain the best improvements with the rehabilitation program, it is necessary to increase the motivation and satisfaction of patients with the treatment, with the aim of increasing adherence. The ludic and gamified interaction with a virtual environment favors active exploration, increasing engagement with the rehabilitation process with greater motivation [52,70], highlighting VRBT as a good therapeutic option to include in rehabilitation programs. Finally, we must also highlight the decrease in the price of VRBT devices so that they can be used by physiotherapists. Although it should be noted that conventional exercise therapy is an element within the reach of any qualified health professional, VRBT is increasingly affordable, which is why we believe in the convenience of investing in it to achieve better results in this type of patient in the long-term.
Although the results presented in this review can be very useful for clinical practice, it is important to point out some limitations that mean that the results should be taken with caution. First, the main limitation is the absence of statistical analysis (quantitative synthesis or meta-analysis) in this review. It is also important to mention the heterogeneity in the evaluation instruments for balance and functional capacity used in each study, which prevents the performance of a meta-analysis. However, here, it is important to mention that all the measurement instruments that were combined in the same analysis had in common the evaluation of the same construct or variable. Secondly, it should be mentioned that the low number of studies included reduces the quality or level of evidence of the results, as well as their generalization. This especially affects the quality of life variable, which was only analyzed in one study. Third, the heterogeneity in VRBT treatment protocols (VR modality used, number of sessions or sessions per week, among others) makes it difficult to establish generalized treatment protocols. Also worth noting as a limitation is the moderate methodological quality and risk of bias of the included studies, where selection bias (due to not concealing allocation) and detection bias (due to not blinding therapists and evaluators) could influence the results of each individual study and therefore affect the combined effect. It is necessary to continue investigating the effect of VRBT as a therapeutic tool for these patients, aiming for a future meta-analysis that can increase the amount of evidence, the precision and the generalizability of the results of this review.

5. Conclusions

This systematic review, which compares the efficacy of VRBT and therapeutic exercise in improving balance and functional status in patients with SCI, suggests that although both therapies can be effective, VRBT can be slightly better for balance and functional status. Additionally, the global quality of life perceived by the patients has been studied in a secondary way, showing a significant improvement with VRBT, although these results were derived from only one study. Therefore, combined therapy with VR could be a useful alternative in the management of these patients and should therefore be considered as such. Although these findings are interesting, it is important to advertise that the low number of studies included reduces the generalization and evidence of these findings. Future research that compares the effectiveness of both therapies, provides a larger sample size per group, and reduces the individual risk of bias in these studies would help establish more robust and generalizable conclusions. Furthermore, new studies will help confirm and increase the level of evidence of the results of this systematic review, which would favor the inclusion of VR devices in conventional rehabilitation programs, tools that have been shown to be safe and increase the motivation, satisfaction and adherence of participants to therapy.

Author Contributions

Conceptualization, E.O.-G., I.C.-P., L.L.-N. and H.G.-L.; methodology, E.O.-G., I.C.-P. and H.G.-L.; validation, E.O.-G., L.L.-N., M.P.-L., M.d.R.I.-L., I.C.-P. and H.G.-L.; formal analysis, E.O.-G. and I.C.-P.; investigation, E.O.-G., L.L.-N., M.P.-L., M.d.R.I.-L., I.C.-P. and H.G.-L.; resources, E.O.-G.; data curation, E.O.-G., L.L.-N., M.P.-L., M.d.R.I.-L., I.C.-P. and H.G.-L.; writing—original draft preparation, E.O.-G., L.L.-N. and I.C.-P.; writing—review and editing, M.P.-L., M.d.R.I.-L. and H.G.-L.; visualization, E.O.-G., L.L.-N., M.P.-L., M.d.R.I.-L., I.C.-P. and H.G.-L.; supervision, E.O.-G. and I.C.-P.; project administration, E.O.-G.; funding acquisition, E.O.-G. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Data Availability Statement

Request to the corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest.

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Electronics 13 02594 g001
Figure 1. PRISMA flow diagram.
Figure 1. PRISMA flow diagram.
Electronics 13 02594 g001
Table 1. Search strategy for each database.
Table 1. Search strategy for each database.
DatabaseSearch Strategy
PubMed Medline(spinal cord injuries[mh] OR spinal cord injur*[tiab]) AND (virtual reality[mh] OR virtual reality[tiab] OR virtual reality exposure therapy[mh] OR virtual reality exposure therapy[tiab] OR non-immersive virtual reality[tiab] OR immersive virtual reality[tiab] OR semi-immersive virtual reality[tiab] OR video games[mh] OR video game*[tiab] OR serious gam*[tiab] OR exergam*[tiab]) AND (exercise therapy[mh] or exercise therapy[tiab])
SCOPUS(TITLE-ABS-KEY ((“spinal cord injuries”)) AND TITLE-ABS-KEY ((“virtual reality” OR “virtual reality exposure therapy” OR “non-immersive virtual reality” OR “immersive virtual reality” OR “semi-immersive virtual reality” OR “video games” OR “serious games” OR “exercises”)) AND TITLE-ABS-KEY ((“exercise therapy”)))
Web of Science(*spinal cord injury*) AND (*virtual reality* OR *virtual reality exposure therapy* OR *non-immersive virtual reality* OR *immersive virtual reality* OR *semi-immersive virtual reality* OR *video games* OR *serious games* OR *exergames*) AND (*exercise therapy*)
PEDro Spinal Cord Injury AND Virtual Reality
Table 2. Characteristics of the studies included in the systematic review.
Table 2. Characteristics of the studies included in the systematic review.
StudyStudy DesignSampleVRBT GroupControl GroupVariablesQualitative Findings
Lee and Lee, 2021 [48] (South Korea)Single-blind RCTTwenty patients (13M:7F)
54.4 ± 8 years old
Thoracic and lumbar SCI (ASIA: C, D)
16.9 months since diagnosis		Ten patients (55.1 years old)
VR balance training for 30 min (five sessions per week for 8 weeks) using Bio Rescue, plus 30 min of occupational therapy exercises		Ten patients (53.7 years old)
Balance therapeutic exercise in sitting position and unstable surfaces (30 min, five sessions per week for 8 weeks)		Sitting balance for left side (FSA)Significant intragroup improvement for VRBT and control groups (p = 0.011). Statistically significant improvements favor VRBT (p = 0.036)
Sitting balance for right side (FSA)Significant intragroup improvement for VRBT (p = 0.037). Statistically significant improvements favor VRBT (p = 0.027)
Dynamic balance (LOS)Significant intragroup improvement for VRBT (p < 0.001) and control (p = 0.001) group. Statistically significant improvements favor VRBT (p = 0.048)
Manzanares et al., 2023 [49] (Spain)Not blind RCTEleven patients (7M:4F)
42.3 ± 13 years old
<T1 SCI (ASIA: A, C, D)
5.2 months since diagnosis		Six patients (42.3 years old)
Semi-immersive VR-based exercises (30–40 min, three times per week for 6 weeks), plus strength and mobility exercise program (five days per week)		Ten patients (42.4 years old)
Strength and mobility therapeutic exercises (five days per week)		Functional status (SCIM)No statistically significant differences in VRBT (p = 0.278) and control group (p = 0.376). No statistically significant differences between groups (p > 0.05)
Balance (MFRT)Statistically significant differences in VRBT (p = 0.011). No statistically significant differences between groups (p > 0.05)
Quality of life (SCI QL-23)No statistically significant differences pre–post in VRBT (p = 0.092) and control group (p = 0.619). No statistically significant differences between groups (p > 0.05)
Dimbwadyo-Terrer et al., 2016 [50] (Spain)Not blind RCTNine patients (7M:2F)
49.2 ± 7.2 years old
Cervical and thoracic SCI (ASIA: A, D)
>12 months		Six patients (54.3 years old)
Immersive VR-based exercises in the upper limb using CyberGlove® (twice per week for 2 weeks), plus conventional rehabilitation		Three patients (44.2 years old)
Balance exercises and mobilizations (twice per week for 2 weeks).		Functional status (SCIM)No statistically significant differences between groups (p = 0.71)
Nair et al., 2022 [51] (India)Double-blind RCTTwenty-one patients (13M:8F)
31.3 ± 7.5 years old
≤T10 SCI (ASIA: A, B)		Eleven patients (32.5 years old)
Non-immersive VR-based balance exercises with Xbox plus Kinect (30 min, three times per week for 4 weeks), plus conventional rehabilitation program		Ten patients (30.1 years old)
Physiotherapy plus balance training exercises (30 min, three times per week for 4 weeks)		Balance (MFRT and t-shirt test)Statistically significant intragroup improvement for VRBT (p < 0.001) and control (p < 0.05) group. No statistically significant differences between groups (p = 0.085)
Khurana et al., 2017 [52] (India)Not blind RCTThirty patients (28M:2F)
29.6 ± 7.3 years old, complete T6-T12 SCI (ASIA: A, B)
>6 months		Fifteen patients (29.5 years old)
Non-immersive VR-based exercises using PlayStation 2 and Eye Toy (45 min, five times per week for 4 weeks), plus conventional balance exercises		Fifteen patients (29.8 years old)
Physiotherapy plus balance exercises (45 min, five times per week for 4 weeks)		Balance (MFRT and t-shirt test)Significant intragroup improvement for VRBT (p = 0.05). Statistically significant differences between groups favor VRBT (p = 0.001)
Functional status (SCIM)Statistically significant differences between groups favor VRBT (p = 0.001)
An and Park, 2022 [53] (South Korea)Single-blind RCTForty patients (23M:17F)
42.6 ± 6.1 years old
C5-C6 SCI (ASIA: C, D)
>12 months		Twenty patients (42.3 years old)
Immersive VR-based lower limb (30 min, three times per week for 4 weeks)		Twenty patients (43 years old)
Lower limb extension exercises (30 min, three times per week for 4 weeks)		Balance (CST and TUG)Significant intragroup improvement for VRBT (p = 0.01) and control (p = 0.02) group. Statistically significant differences between groups favor VRBT group (p = 0.03 and p = 0.04)
Functional status (10 MWT)Significant intragroup improvement for VRBT (p = 0.01) and control (p = 0.02) group. Statistically significant differences between groups favor VRBT group (p = 0.03)
Abbreviations: VRBT, virtual reality-based therapy; RCT, randomized controlled trial; M, male; F, female; ASIA, American Spinal Injury Association; FSA, force-sensitive application; LOS, limit of stability; SCIM, spinal cord independence measure; SCI QL-23, Spinal Cord Injury Quality-of-Life-23; MFRT, modified functional reach test; MB, muscular balance; NHPT, nine-hole peg test; JHFT, Jebsen–Taylor Hand Function Test; CST, chair stand test; TUG, time up and go; 10MWT, 10-meter walk test.
Table 3. PEDro score of the studies included in the systematic review.
Table 3. PEDro score of the studies included in the systematic review.
StudyI1I2I3I4I5I6I7I8I9I10I11Total
Score		Quality
Lee and Lee, 2021 [48]YYNYNNYYYYY7/10Good
Manzanares et al., 2023 [49]YYNYNNNNNYY4/10Moderate
Dimbwadyo-Terrer et al., 2016 [50]YYNNNNNNNYY3/10Low
Nair et al., 2022 [51]YYNYYNYYNYY7/10Good
Khurana et al., 2017 [52]YYNYNNNYYYY6/10Good
An and Park, 2022 [53]YYNYNNNNNYY4/10Low
Abbreviations: 1: eligibility criteria; 2: random allocation; 3: concealed allocation; 4: baseline comparability; 5: blind subjects; 6: blind therapists; 7: blind assessors: 8. adequate follow-up; 9: intention-to-treat analysis; 10: between-group comparisons; 11: point estimates and variability. Note: Eligibility criteria item does not contribute to total score.
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Obrero-Gaitán, E.; López-Nájera, L.; Piñar-Lara, M.; Ibancos-Losada, M.d.R.; Cortés-Pérez, I.; García-López, H. Improving Balance and Functional Status in Spinal Cord Injury Patients: A Systematic Review Comparing Virtual Reality-Based Therapy and Conventional Therapeutic Exercises. Electronics 2024, 13, 2594. https://doi.org/10.3390/electronics13132594

AMA Style

Obrero-Gaitán E, López-Nájera L, Piñar-Lara M, Ibancos-Losada MdR, Cortés-Pérez I, García-López H. Improving Balance and Functional Status in Spinal Cord Injury Patients: A Systematic Review Comparing Virtual Reality-Based Therapy and Conventional Therapeutic Exercises. Electronics. 2024; 13(13):2594. https://doi.org/10.3390/electronics13132594

Chicago/Turabian Style

Obrero-Gaitán, Esteban, Luis López-Nájera, Marina Piñar-Lara, María del Rocío Ibancos-Losada, Irene Cortés-Pérez, and Héctor García-López. 2024. "Improving Balance and Functional Status in Spinal Cord Injury Patients: A Systematic Review Comparing Virtual Reality-Based Therapy and Conventional Therapeutic Exercises" Electronics 13, no. 13: 2594. https://doi.org/10.3390/electronics13132594

APA Style

Obrero-Gaitán, E., López-Nájera, L., Piñar-Lara, M., Ibancos-Losada, M. d. R., Cortés-Pérez, I., & García-López, H. (2024). Improving Balance and Functional Status in Spinal Cord Injury Patients: A Systematic Review Comparing Virtual Reality-Based Therapy and Conventional Therapeutic Exercises. Electronics, 13(13), 2594. https://doi.org/10.3390/electronics13132594

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