Virtual Reality Rehabilitation Effective for Patients With Multiple Sclerosis


A recent systematic review investigated the use of virtual reality as a therapeutic tool compared to conventional interventions, finding its use may improve quality of life, fatigue, and balance.

Cindy Vieira Fagundes, DPT, Physiotherapist, University of Brasília, BrazilCindy Vieira Fagundes, DPT, Physiotherapist, University of Brasília, Brazil

Cindy Vieira Fagundes, DPT

The use of virtual reality (VR) as a therapeutic intervention for patients with multiple sclerosis (MS) was found to be equally as efficient, when compared to conventional intervention or no intervention. Investigators of the recent systematic review concluded that quality of life (QOL), fatigue, and balance showed equal or greater improvement when introducing VR, while functional mobility otherwise showed no significant improvement.

Investigators evaluated a total of 9 randomized control trials (RCTs), including a total of 424 patients with MS. All studies were published between 2012 and 2020, with 5 published between 2019 and 2020. Participants were aged between 23 to 61 years and were most often diagnosed with relapsing-remitting MS, followed by secondary-progressive MS. 

Fatigue was evaluated in 4 studies, with 1 using the fatigue severity scale (FSS) and 3 using the Modified Fatigue Impact Scale (MFIS), and QOL was evaluated using the Multiple Sclerosis International Quality of Life Questionnaire (MusiQoL). When evaluated on the MFIS scale, fatigue showed a significant effect favorable to VR groups, compared to those using traditional exercise (mean difference [MD], –11.25 [95% CI, –18.49 to –4.00]; I2 = 0%; P = .44). A significant favorable effect was also observed for the MusiQol analysis of QOL when comparing VR groups to groups without exercise, (MD, 8.18 [95% CI, 3.35 to 13.01]; I2 = 0%; P = .93).

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Each of the 9 articles evaluated balance, and the most used test was the Berg Balance Scale (BBS), with 5 studies finding the VR group superior in improving balance and 4 studies finding no observed differences. When conducting a meta-analysis of the BBS, investigators found the VR group showed significant favorable effect when compared to traditional exercises (MD, 3.84 [95% CI, 2.54 to 5.14]; I2 = 4%; P = .35), whereas no difference was observed between experimental groups incorporating both VR and exercises and a control group of just traditional exercises (MD, 2.50 [95% CI, –3.81 to 8.81]; I2 = 58%; P = .12). When comparing a VR group to a group with no exercise, the VR group showed greater improvement (MD, 5.07 [95% CI, 3.01-7.13]; I2 = 0%; P = .47). 

Functional mobility was evaluated with the Time Up and Go (TUG) test most frequently, and despite some improvement reported in the intervention group, there was no significant difference observed. A meta-analysis of the TUG test conclused that when VR-associated exercises were compared with traditional exercises, the findings were not significant (MD, 0.94 [95% CI, –1.25 to 3.14]; I2 = 42%; P = .19). Additionally, when VR games were compared to a metagroup without exercises, there was no superiority between groups and no significant effect (MD, 0.19 [95% CI, –0.77 to 1.14]; I2 = 0%; P = .91). Comparatively, for subjects studied using the 12-item MS Walking Scale (MSWS-12), there was no significant effect between VR groups and traditionally treated groups (MD, -1.67 [95% CI, –6.12 to 2.78]; I2 = 0%; P = .69) and there was no significant effect when comparing a VR group to a group without exercise (MD, –1.67 [95% CI, –6.12 to 2.78]; I2 = 0%; P = .69). 

Four studies used games from Nintendo Wii in the intervention group, while the remaining 5 used games from Microsoft Kinect. Comparatively, some control groups had no exercise used, whereas others used conventional exercises. Future research should include larger sample sizes and more robust study protocols, according to the investigators. 

“This review concluded that, in relation to functional mobility, [the association of VR] or not with conventional exercises does not seem to bring additional benefits,” corresponding author, Cindy Vieira Fagundes, DPT, Physiotherapist, University of Brasília, Brazil, et al wrote. “Regarding fatigue, QOL, and balance, VR promotes benefits that can be similar or greater than conventional exercises and nonintervention.”

Nascimento AS, Fagundes CV, Mendes FADS, Leal JC. Effectiveness of virtual reality rehabilitation in persons with multiple sclerosis: A systematic review and meta-analysis of randomized controlled trials. Mult Scler Relat Disord. Published online July 9, 2021. doi:10.1016/j.msard.2021.103128
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