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Proprioception: New approach to management with virtual reality

Virtual Reality (VR) is attracting growing interest in rehabilitation (there are 2408 publications containing "virtual reality rehabilitation" on Pubmed, with 16 times more articles published in 2019 than in 2005). It allows, in particular, to evaluate and rehabilitate the balance of patients consulting daily in rehabilitation practices and centers, for various affections:

  • Sports (ACL, sprains, post-injury muscle recovery, injury prevention)
  • Rheumatology / orthopedics (prostheses, fractures, ...)
  • Geriatrics (fall prevention, maintenance of autonomy)
  • Neurology (Parkinson, MS, post-stroke, ...)
  • Vestibular disorders

VR allows for precise work on proprioception. Indeed, the immersion provided is such that the source of destabilization can be caused by a virtual environment in motion and controlled by the therapist. The patient thus triggers permanent rebalancing reactions. It is possible to make the patients work at the global or analytical level according to an axis, for example: the patient works the medio-lateral stabilizers of the knee in forward lunge with a lateral visual destabilization. In progression, the VR can be associated with foams (Airex type) or with a dynamic platform. The work can be done seated (trunk balance), in bipodal, in forward lunge, unipodal...

It is also possible to induce reflexive shifts of the center of gravity in an analytical and controlled way, as for example: anteriorizing a patient in posterior gravity. Associated with force platforms, this shift of the body weight can also be voluntary, the VR producing an immersive feedback in 3D, motivating and allowing the patient to know precisely if he reaches the objective.

What happens concretely? Several systems intervene to regulate balance: Somesthesia (proprioception, plantar information, etc.), Vision and Vestibular. The brain processes these various information with a prioritization according to the experience, pathologies, etc... However, many of us develop visual dependence over the years, or following a trauma, so that the proprioceptive system can lose its effectiveness. [1]

The Sensory Organisation Test (SOT) can be used to isolate and quantify each of these systems and thus compare the results with the norm for each age group. Where it was once complex and costly to implement, this test is now fast and accessible. In less than 5 minutes, it allows to orientate the continuation of the rehabilitation according to the deficits highlighted. This assessment is still the reference for the analysis of the balancing strategy in France and abroad [2][3][4][5].

Since 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 my proprioception work much more effectively. [6][7][8]

Various exercises and assessments are possible, allowing the results to be assessed in terms of balancing strategy. The gain in performance and in rehabilitation time will therefore be easy to objectify.

Virtual Reality therefore opens up considerable new perspectives in terms of assessment and possible treatments in the management of patients suffering from pathologies or disorders affecting their proprioception and becomes a complementary therapeutic tool for all physiotherapists.

Article written by Loïc Dupuis, Physiotherapist and External Training Consultant.

Bibliography : 

[1] Sports Medicine: For the Practitioner Chapter 7: Balance, Proprioception and Sport, Pr Ph. Perrin Elsevier Masson 2020. Richard Amoretti, Xavier Bigard, Hugues Monod, Daniel Rivière, Pierre Rochcongar, Jacques Rodineau

[2] Comparison of Elderly Nonfallers and Fallers on Performance Measures of Functional Reach, Sensory Organization, and Limits of Stability, Harvey W. Wallmann, The Journals of Gerontology: Series A, Volume 56, 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 test in noninstitutionalized older adults MS ,PTCheryl D.Ford-SmithaPhD, RNJean F.WymanbPhDR.K.ElswickJr.cMS, RNTheresaFernandezbPhD, PTRoberta A.Newtond Archives of Physical Medicine and Rehabilitation Volume 76, Issue 1, January 1995, Pages 77-81, https://doi.org/10.1016/S0003-9993(95)80047-6

[4] Relationship of Sensory Organization to Balance Function in Patients with Hemiplegia, Richard P Di Fabio, Mary Beth Badke, Physical Therapy, 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 Dynamic Posturography Sensory Organization Test in People with Multiple Sclerosis, 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 stroke patients using virtual reality technology. Kim SI, Song IH, Cho S, Kim IY, Ku J, Kang YJ, Jang DP. Annu Int Conf IEEE Eng Med Biol Soc. 2013. doi: 10.1109/EMBC.2013.6610577

[7] Development of virtual reality proprioceptive rehabilitation system for stroke patients, Cho S, Ku J, Cho YK, Kim IY, Kang YJ, 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 individuals with chronic stroke: a systematic review and meta-analysis Iruthayarajah J, McIntyre A, Cotoi A, Macaluso S, Teasell R.. Top Stroke Rehabil. 2017 Jan;24(1):68-79. doi: 10.1080/10749357.2016.1192361

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