Summary: According to a new study, combining virtual reality with treadmill training could help prevent dangerous falls associated with Parkinson’s disease.
Intervention can be used in gyms, rehabilitation centers and nursing homes, Tel Aviv University researchers say.
A combination of virtual reality and treadmill training may prove effective in preventing dangerous falls associated with aging, Parkinson’s disease, mild cognitive impairment or dementia, according to a new Tel Aviv University-Tel Aviv Sourasky Medical Center (TASMC) study published in The Lancet.
According to the study’s lead authors, Prof. Jeff Hausdorff and Dr. Anat Mirelman, both of TAU’s Sackler School of Medicine and TASMC’s Center for the Study of Movement, Cognition and Mobility, the intervention combines the physical and cognitive aspects of walking, and could be implemented in gyms, rehabilitation centers and nursing homes to improve walking skills and prevent the falls of older adults and those with movement disorders like Parkinson’s disease.
“Falls often start a vicious cycle with many negative health consequences,” said Dr. Mirelman. “The ability of older people to negotiate obstacles can be impaired because of age-related decline in cognitive abilities like motor planning, divided attention, executive control and judgement. But current interventions typically focus almost exclusively on improving muscle strength, balance and gait.
“Our approach helps improve both physical mobility and cognitive aspects that are important for safe walking,” Dr. Mirelman continued. “We found that virtual reality plus treadmill training helped to reduce fall frequency and fall risk for at least six months after training — significantly more than treadmill training alone. This suggests that our use of virtual reality successfully targeted the cognitive aspects of safe ambulation to reduce the risk of falls.”
Adding virtual reality to the therapeutic recipe
The TAU-TASMC team, in collaboration with partners across Europe, collected data from 282 participants at five clinical sites in Belgium, Israel, Italy, the Netherlands and the UK between 2013 and 2015. The participants, all aged 60-90, were able to walk at least five minutes unassisted, were on stable medications and, critically, had reported at least two falls in the six months prior to the start of the study. Nearly half of all participants (130) had Parkinson’s disease, and some (43) had mild cognitive impairment.
Participants were assigned to treadmill training with virtual reality (146) or treadmill training alone (136). The virtual reality component consisted of a camera that captured the movement of participants’ feet and projected it onto a screen in front of the treadmill, so that participants could “see” their feet walking on the screen in real time.
The game-like simulation was designed to reduce the risk of falls in older adults by including real life challenges such as avoiding and stepping over obstacles like puddles or hurdles, and navigating pathways. It also provided motivation to the participants, giving them feedback on their performance and scores on the game.
Greater satisfaction, more effective therapy
While the incident rate of falls was similar in the two groups prior to the intervention, six months after training the rate of falls among those who trained with VR dropped by almost 50%. In contrast, there was no significant reduction in the fall rates among subjects who did not train with the VR.
“Interestingly, when we asked people if they enjoyed the treatment program, participants in the virtual reality group reported higher scores on user satisfaction questionnaires and a greater desire to continue to exercise with the ‘game,'” said Prof. Hausdorff. “This suggests that the virtual reality not only led to fewer falls, it was also more likely to be used in the long-term. Exercise needs to be fun and effective if it is going to be used continually.
“The biggest improvement was seen in participants with Parkinson’s disease,” Prof. Hausdorff continued. “It was very exciting to see such improvement in the presence of a neurodegenerative disease. Still, we need to conduct further research to verify the results and better understand why the fall rates were so responsive in the people with Parkinson’s disease.”
“Treadmills are widely available, and the additional cost of treadmill training plus virtual reality is only about $4,500. The low cost could permit this approach to be widely used in various settings,” said Dr. Mirelman. “Future studies need to examine whether treadmill training plus virtual reality could be used as part of a prevention package to treat fall risk before falls become common and before injuries occur.”
Funding: The research was funded by the European Commission.
Source: George Hunka – AFTAU
Image Source: NeuroscienceNews.com image is credited to AFTAU.
Original Research: Abstract for “Addition of a non-immersive virtual reality component to treadmill training to reduce fall risk in older adults (V-TIME): a randomised controlled trial” by Dr Anat Mirelman, PhD , Prof Lynn Rochester, PhD, Inbal Maidan, PhD, Silvia Del Din, PhD, Lisa Alcock, PhD, Freek Nieuwhof, MS, Prof Marcel Olde Rikkert, MD, Prof Bastiaan R Bloem, MD, Elisa Pelosin, PhD, Laura Avanzino, MD, Prof Giovanni Abbruzzese, MD, Kim Dockx, MS, Esther Bekkers, MS, Prof Nir Giladi, MD, Prof Alice Nieuwboer, PhD, Prof Jeffrey M Hausdorff, PhD in The Lancet. Published online August 11 2016 doi:10.1016/S0140-6736(16)31325-3
Addition of a non-immersive virtual reality component to treadmill training to reduce fall risk in older adults (V-TIME): a randomised controlled trial
Age-associated motor and cognitive deficits increase the risk of falls, a major cause of morbidity and mortality. Because of the significant ramifications of falls, many interventions have been proposed, but few have aimed to prevent falls via an integrated approach targeting both motor and cognitive function. We aimed to test the hypothesis that an intervention combining treadmill training with non-immersive virtual reality (VR) to target both cognitive aspects of safe ambulation and mobility would lead to fewer falls than would treadmill training alone.
We carried out this randomised controlled trial at five clinical centres across five countries (Belgium, Israel, Italy, the Netherlands, and the UK). Adults aged 60–90 years with a high risk of falls based on a history of two or more falls in the 6 months before the study and with varied motor and cognitive deficits were randomly assigned by use of computer-based allocation to receive 6 weeks of either treadmill training plus VR or treadmill training alone. Randomisation was stratified by subgroups of patients (those with a history of idiopathic falls, those with mild cognitive impairment, and those with Parkinson’s disease) and sex, with stratification per clinical site. Group allocation was done by a third party not involved in onsite study procedures. Both groups aimed to train three times per week for 6 weeks, with each session lasting about 45 min and structured training progression individualised to the participant’s level of performance. The VR system consisted of a motion-capture camera and a computer-generated simulation projected on to a large screen, which was specifically designed to reduce fall risk in older adults by including real-life challenges such as obstacles, multiple pathways, and distracters that required continual adjustment of steps. The primary outcome was the incident rate of falls during the 6 months after the end of training, which was assessed in a modified intention-to-treat population. Safety was assessed in all patients who were assigned a treatment. This study is registered with ClinicalTrials.gov, NCT01732653.
Between Jan 6, 2013, and April 3, 2015, 302 adults were randomly assigned to either the treadmill training plus VR group (n=154) or treadmill training alone group (n=148). Data from 282 (93%) participants were included in the prespecified, modified intention-to-treat analysis. Before training, the incident rate of falls was similar in both groups (10·7 [SD 35·6] falls per 6 months for treadmill training alone vs 11·9 [39·5] falls per 6 months for treadmill training plus VR). In the 6 months after training, the incident rate was significantly lower in the treadmill training plus VR group than it had been before training (6·00 [95% CI 4·36–8·25] falls per 6 months; p<0·0001 vs before training), whereas the incident rate did not decrease significantly in the treadmill training alone group (8·27 [5·55–12·31] falls per 6 months; p=0·49). 6 months after the end of training, the incident rate of falls was also significantly lower in the treadmill training plus VR group than in the treadmill training group (incident rate ratio 0·58, 95% CI 0·36–0·96; p=0·033). No serious training-related adverse events occurred.Interpretation
In a diverse group of older adults at high risk for falls, treadmill training plus VR led to reduced fall rates compared with treadmill training alone.
“Addition of a non-immersive virtual reality component to treadmill training to reduce fall risk in older adults (V-TIME): a randomised controlled trial” by Dr Anat Mirelman, PhD , Prof Lynn Rochester, PhD, Inbal Maidan, PhD, Silvia Del Din, PhD, Lisa Alcock, PhD, Freek Nieuwhof, MS, Prof Marcel Olde Rikkert, MD, Prof Bastiaan R Bloem, MD, Elisa Pelosin, PhD, Laura Avanzino, MD, Prof Giovanni Abbruzzese, MD, Kim Dockx, MS, Esther Bekkers, MS, Prof Nir Giladi, MD, Prof Alice Nieuwboer, PhD, Prof Jeffrey M Hausdorff, PhD in The Lancet. Published online August 11 2016 doi:10.1016/S0140-6736(16)31325-3