Virtual reality for vestibular rehabilitation

There are big differences between what people call virtual reality (VR) for persons with balance and vestibular disorders.

Use of a head-mounted device, a CAVE (large scene that is not moveable from place to place that surrounds the person and provides peripheral optic flow) and commercially available devices like the Nintendo Wii have all been called VR when used with persons with vestibular disorders.

These devices all have good and bad points, but they have made the literature more difficult to understand because what might work with one system may not work with another.

What we know about VR for persons with balance and vestibular disorders

There are several benefits to VR that cannot be found with standard vestibular rehabilitation techniques.

1. A controlled dose

One the most important factors is that the dose can be controlled. You know exactly how much of a 'dose' the person receives and can monitor how well it was tolerated by asking about the symptoms afterwards. This is not possible with standard treatment techniques.

2. VR can match the scene to the patient's complaints

You can match the virtual scene to what the person is stating is their complaint. For example, if they have difficulty on a train, a train scene could be used to help them to better manage their symptoms while 'experiencing' a train ride with VR.

3. The sense of presence

People in VR environments 'feel' like they are in a real environment, which elicits emotions that are felt in real life situations.

4. VR can change the VOR gain

Various authors have reported that people who experience VR with a head-mounted device had changes in their VOR gain.^{6, 14} Viziano A et al¹⁴ reported that persons with unilateral vestibular disorders one year after VR training plus conventional training had better Dizziness Handicap Inventory (DHI) scores, better walking (dynamic gait index scores), and better reported balance than subjects who received conventional rehabilitation only. Micarelli et al⁶ also reported changes in the DHI^{4, 6} and others have reported changes in the Vertigo Symptom Scale.⁹

5. VR has been shown to be safe in persons with dizziness and balance problems

Persons with vestibular disorders and older adults¹⁰ will have an increase in symptoms during a session of VR but there is no evidence on any long-term adverse consequences of VR training.^6, 15

6. VR can improve balance

Devices like the Wii balance board with the virtual scene, head-mounted devices, rotating discs during standing and VR CAVEs have been shown to improve balance in people with peripheral vestibular disorders.^{1, 2, 5-7, 9, 11} There are also improvements in persons with symptoms of visual discomfort.^{7, 9} There is evidence that VR can also improve balance in people with mild head injury^{3, 8}, in older adults at fall risk¹³ and in persons with Meniere’s disease.²

How does immersive VR benefit the patient?

Peripheral visual feedback may be critical in rehabilitation to recalibrate the sensory processing areas within the brain.¹²

1. There is an ability to change the parameters of the scene

The ability to change the parameters (speed, color, size of the target, central versus peripheral field of view or both) is very important in determining the exercise 'dose' for the patient. Many VR systems allow the operator control over the above parameters. These parameters can be changed instantaneously.

2. Patients become engaged in the scene

Persons feel 'connected' with the scenes plus the software can provide performance feedback. People love to know how they are doing, and VR can provide objective performance data that is easily understood by the patient.

Conclusion

VR is a promising treatment modality for persons with vestibular disorders.

References

1. Alahmari KA, Sparto PJ, Marchetti GF, Redfern MS, Furman JM, Whitney SL. Comparison of virtual reality based therapy with customized vestibular physical therapy for the treatment of vestibular disorders. IEEE Trans Neural Syst Rehabil Eng. 2014;22(2):389-399.

2. Garcia AP, Gananca MM, Cusin FS, Tomaz A, Gananca FF, Caovilla HH. Vestibular rehabilitation with virtual reality in Meniere's disease. Braz J Otorhinolaryngol. 2013;79(3):366‑374.

3. Gottshall KR, Sessoms PH. Improvements in dizziness and imbalance results from using a multi disciplinary and multi sensory approach to Vestibular Physical Therapy - a case study. Front Syst Neurosci. 2015;9:106.

4. Hondebrink MS, Mert A, van der Lint R, de Ru JA, van der Wurff P. Motion-based equilibrium reprocessing therapy a novel treatment method for chronic peripheral vestibulopathies: A pilot study. Medicine (Baltimore). 2017;96(24):e7128.

5. Meldrum D, Herdman S, Vance R, et al. Effectiveness of conventional versus virtual reality-based balance exercises in vestibular rehabilitation for unilateral peripheral vestibular loss: results of a randomized controlled trial. Arch Phys Med Rehabil. 2015;96(7):1319-1328.e1311.

6. Micarelli A, Viziano A, Augimeri I, Micarelli D, Alessandrini M. Three-dimensional head-mounted gaming task procedure maximizes effects of vestibular rehabilitation in unilateral vestibular hypofunction: a randomized controlled pilot trial. Int J Rehabil Res. 2017;40(4):325‑332.

7. Pavlou M, Kanegaonkar RG, Swapp D, Bamiou DE, Slater M, Luxon LM. The effect of virtual reality on visual vertigo symptoms in patients with peripheral vestibular dysfunction: a pilot study. J Vestib Res. 2012;22(5-6):273-281.

8. Rabago CA, Wilken JM. Application of a mild traumatic brain injury rehabilitation program in a virtual realty environment: a case study. J Neurol Phys Ther. 2011;35(4):185-193.

9. Rosiak O, Krajewski K, Woszczak M, Jozefowicz-Korczynska M. Evaluation of the effectiveness of a Virtual Reality-based exercise program for Unilateral Peripheral Vestibular Deficit. J Vestib Res. 2019.

10. Saldana SJ, Marsh AP, Rejeski WJ, et al. Assessing balance through the use of a low-cost head-mounted display in older adults: a pilot study. Clin Interv Aging. 2017;12:1363-1370.

11. Sparrer I, Duong Dinh TA, Ilgner J, Westhofen M. Vestibular rehabilitation using the Nintendo(R) Wii Balance Board -- a user-friendly alternative for central nervous compensation. Acta Otolaryngol. 2013;133(3):239-245.

12. Sparto PJ, Furman JM, Whitney SL, Hodges LF, Redfern MS. Vestibular rehabilitation using a wide field of view virtual environment. Conf Proc IEEE Eng Med Biol Soc. 2004;7:4836-4839.

13. Suarez H, Suarez A, Lavinsky L. Postural adaptation in elderly patients with instability and risk of falling after balance training using a virtual-reality system. Int Tinnitus J. 2006;12(1):41-44.

14. Viziano A, Micarelli A, Augimeri I, Micarelli D, Alessandrini M. Long-term effects of vestibular rehabilitation and head-mounted gaming task procedure in unilateral vestibular hypofunction: a 12-month follow-up of a randomized controlled trial. Clin Rehabil. 2018:269215518788598.

15. Whitney SL, Sparto PJ, Hodges LF, Babu SV, Furman JM, Redfern MS. Responses to a virtual reality grocery store in persons with and without vestibular dysfunction. Cyberpsychol Behav. 2006;9(2):152-156.

About Dr. Susan L. Whitney