Proprioception: New approach to support with Virtual Reality

Virtual Reality (VR) is attracting growing interest in Rehabilitation (there are 2,408 publications containing “virtual reality rehabilitation” on Pubmed, with 16 times more articles published in 2019 compared to 2005).

In particular, it makes it possible to evaluate and rehabilitate the balance of patients consulting daily in practices and rehabilitation centers, for various conditions: · Sport (ACL, sprains, post-injury muscle recovery, injury prevention) · Rheumatology/orthopedics (prosthetics , fractures, etc.) · Geriatrics (fall prevention, maintaining autonomy) · Neurology (Parkinson's, MS, post-stroke, etc.) · Vestibular disorders

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VR allows precise work on proprioception

Indeed, the immersion provided is such that the source of destabilization can be caused by a moving virtual environment controlled by the therapist.

The patient thus triggers permanent rebalancing reactions. It is possible to have patients work at the global or analytical level along one axis, for example: the patient works the medio-lateral stabilizers of the knee in a forward lunge with lateral visual destabilization. In progress, VR can be associated with foams (Airex type) or a dynamic platform. The work can be done seated (trunk balance), bipodal, forward lunge, unipodal, etc.

It is also possible to induce reflex movements of the center of gravity in an analytical and controlled manner, such as for example: anteriorizing a patient in gravity posterior. Associated with force platforms, this movement of body weight can also be voluntary, with VR producing immersive 3D feedback that is motivating and allows the patient to know precisely whether they are achieving the objective.

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What is actually happening?

Several systems intervene to govern balance: Somesthesia (proprioception, plantar information, etc.), Vision and Vestibular.

The brain processes this various information with prioritization based on experience, pathologies, etc. However, many of us develop visual dependence over the years, or following trauma, such that the proprioceptive system can lose of its effectiveness.

[1]The Sensory Organization Test (SOT) can be used to isolate and quantify each of these systems and thus compare the results against the norm by age group. Where it was still complex and expensive to set up, this test is now quick and accessible. In less than 5 minutes, it allows you to direct the rest of the rehabilitation according to the deficits highlighted.

This assessment is still referred to as an analysis of the balancing strategy in France and internationally. [2][3][4][5].As vision can be used as a source of instability in VR, the brain will have no choice but to rebalance its systems by prioritizing other information. You can therefore target the work of my proprioception much more effectively. [6][7][8]Various exercises and assessments are possible, allowing the results to be assessed in terms of the balancing strategy.

The gain in performance and rehabilitation time will therefore be easy to objectify. Virtual Reality therefore opens up today considerable new perspectives in terms of assessments and possible treatments in the care of patients suffering from pathologies or disorders affecting their proprioception and becomes a complementary therapeutic tool for any Physiotherapist.

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Bibliography : 

_{[1] Médecine du sport : Pour le Praticien Chapitre 7 :Equilibration, proprioception et sport, Pr Ph. Perrin Elsevier Masson 2020.Richard Amoretti, Xavier Bigard, Hugues Monod, Daniel Rivière, PierreRochcongar, Jacques Rodineau
[2] Comparison of Elderly Nonfallers and Fallers onPerformance Measures of Functional Reach, Sensory Organization, and Limits ofStability, Harvey W. Wallmann, The Journals of Gerontology: Series A, Volume56, Issue 9, 1 September 2001, Pages M580–M583,https://doi.org/10.1093/gerona/56.9.M580
[3] Test-retest reliability of the sensory organization testin noninstitutionalized older adults MS ,PTCheryl D.Ford-SmithaPhD, RNJeanF.WymanbPhDR.K.ElswickJr.cMS, RNTheresaFernandezbPhD, PTRoberta A.NewtondArchives of Physical Medicine and Rehabilitation Volume 76, Issue 1, January1995, Pages 77-81, https://doi.org/10.1016/S0003-9993(95)80047-6
[4] Relationship of Sensory Organization to Balance Functionin Patients with Hemiplegia, Richard P Di Fabio, Mary Beth Badke, PhysicalTherapy, Volume 70, Issue 9, 1 September 1990, Pages 542–548,https://doi.org/10.1093/ptj/70.9.542
[5] Reliability and Validity of the Computerized DynamicPosturography Sensory Organization Test in People with Multiple Scleros,Jeffrey R. Hebert, PT, PhD  and Mark M. Manago, PT, DPT, Int J MS Care.2017 May-Jun; 19(3): 151–157, doi: 10.7224/1537-2073.2016-027
[6] Proprioception rehabilitation training system for strokepatients using virtual reality technology. Kim SI, Song IH, Cho S, Kim IY, KuJ, Kang YJ, Jang DP. Annu Int Conf IEEE Eng Med Biol Soc. 2013. doi:10.1109/EMBC.2013.6610577
[7] Development of virtual reality proprioceptiverehabilitation system for stroke patients, Cho S, Ku J, Cho YK, Kim IY, KangYJ, Jang DP, Kim SI. Comput Methods Programs Biomed. 2014;113(1):258-65. doi:10.1016/j.cmpb.2013.09.006
[8] The use of virtual reality for balance among individualswith chronic stroke: a systematic review and meta-analysis Iruthayarajah J,McIntyre A, Cotoi A, Macaluso S, Teasell R.. Top Stroke Rehabil. 2017Jan;24(1):68-79. doi: 10.1080/10749357.2016.1192361}