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Introduction
Cerebral palsy (CP) is a movement and posture disorder, which is frequently accompanied by sensory, cognitive, communication disorders, epilepsy, behavior problems, and musculoskeletal disorders1, causing limitation in the performance of activities and restrictions in participation2.
The etiology of this disease is attributed to a non-progressive lesion of the developing brain, which can be acquired in the prenatal stage, related to maternal factors, alterations of the placenta, fetal and perinatal stage due to premature birth, and low weight, encephalopathy hypoxic-ischemic, and hypoglycemia. In addition, it can develop postnatally due to head trauma, seizure status, and infections such as meningitis and encephalitis3.
Therefore, it is considered one of the most frequent neurological disorders of motor disability in early childhood4, with a prevalence of approximately 1 in every 500 live newborns. As a result, it is estimated that 17 million people worldwide have CP5.
Regarding the treatment, it is found that it must be directed to each child’s individual needs, and it is understood as interdisciplinary work. The physiotherapist plays a fundamental role, oriented to the rehabilitation and habilitation of motor functions, management of spasticity, recovery gait, postural control, and prevent bone deformities, among others6 that promote participation social inclusion in the child, safely in the environment in which they live.
Furthermore, most boys and girls with CP start rehabilitation processes at an early age because it leads to daily assistance to health entities, which generate in the child a routine context in an exercise environment, functional tasks based on techniques, procedures, and specific intervention methods, which have been used for decades recognized by the World Confederation for Physical Therapy7. However, sometimes, they generate in the child low or no adherence to neurorehabilitation processes.
Besides, it is essential to mention that other external factors do not favor adherence to treatments, such as the high costs that children with neurological disabilities represent for the health system, population aging, and costs of health administration that influence the cost–benefit ratio. All of the above lead to the search for alternatives that complement these processes.
Virtual reality (VR) is a tool that consists of the simulation of a natural environment generated by a computer. With high graphic, acoustic, and tactile content, a three-dimensional interface allows the user to interact in a biological context through a simulated scenario8.
At present, VR is being used in the rehabilitation of people with neurological sequelae based on task-oriented motor learning9.
Authors such as de la Cuerda et al.10 suggest that it is an essential complement in the rehabilitation process because it allows individuals interaction and training in natural three-dimensional environments, allowing them to simulate the daily life is generated through computer software. Among the relevant effects that virtual reality provides are artificial sensory feedback and the activation of mirror neurons. These neurons are activated by imitating tasks and are commonly associated with different interactions, which represent people’s experiences during the training of daily tasks and leisure.
Another neurophysiological effect that is believed to be conducive is the activation of new neural circuits through brain plasticity at an early age, as well as the activation of mirror neurons from imitation learning mechanisms, in primary motor cortical areas, through a memory of the representation of the movement to be performed11. Given the above, regarding the possible contributions of VR in this pathology, the interest arises to identify, through a review of the literature, the effects of VR in the rehabilitation of the gait of children with CP.
Factors related to CP
First of all, from a neurophysiological point of view, immature brain injury affects a group of neurons that control voluntary movement. What results in the lack of inhibitory control that they exert on the lower motor neurons of the spinal cord, and according to the severity and location of the injury in the brain, will become neurological sequelae.
Second, regarding the traditional models for the classification of CP, the following are found, depending on the damage, it can be classified in: A) spastic CP that occurs when the injury affects the cerebral cortex and pyramidal pathway; B) the athetoid CP when the damage is at the level of the nuclei of the base; C) the ataxic CP, a lesion in the cerebellum, and D) the mixed CP, when the condition is combined.
In addition, it can be classified according to the predominant topographic distribution of the affectation, monoplegia, hemiplegia, diplegia, and quadriplegia12.
Besides, according to the Extended and Revised Gross Motor Function Classification (GMFCS-ER), CP is classified according to function in V levels from highest to lowest functionality: level I: walk without restrictions, level II: walk with limitations, level III: walks using a manual walking aid, level IV: limited self-mobility, may use motorized mobility, and level V: carried in a wheelchair13.
Regarding the limitation in the execution of the gait, it is found that it is one of the most significant and complex neurological sequelae within the rehabilitation processes due to the increase in muscle tone that leads to the disorganization of the development of motor engrams and energy expenditure increases with minimal motor activity. On occasions, they establish synergistic patterns, which are characterized by a shortening of the amplitude of the step, a decrease in the range of motion of the hip and knee, an increase in energy expenditure, and a decrease in speed12 that require support with technical aids such as canes, walkers, and crutches, which may occasionally leave sequelae of crouching gait, scissor gait, or step page gait, which limit and restrict the child in the performance and participation of activities of daily living and every day2.
VR in CP
Now let us see how in the review carried out by Alcides et al., in 2012, on virtual environments for physical and cognitive rehabilitation, they show that VR has a favorable development in neuroscience and physical rehabilitation. The positive effects of VR are appreciated, especially in the learning processes through the imitation of movement patterns in people with neurological sequelae14.
Likewise, other authors such as de la Cuerda et al. refer that VR complements the rehabilitation processes of motor and cognitive alterations in patients with disabilities of neurological origin, given that VR allows the training of stretching, manipulation, grip, postural control, balance, and gait of patients15.
These virtual environments have the characteristics of being multimodal and controllable. They are commonly associated with interactive applications, which simulate experiences that allow the subject to entertainment, leisure, and recreation, which can help the diagnosis, study, and treatment of neurological conditions in clinical-medical settings.
Thus, VR has shown improvements in the functionality of the upper limb, range kinematics, quality of movement, active mobility, and fine motor skills. Besides, it has been used as a rehabilitation mechanism in the upper and lower limbs16.
On the other hand, a recent systematic review and meta-analysis of controlled trials conducted by Chen et al. found that, compared to other interventions, VR appears to be an effective intervention to improve motor function in children with CP17.
At present, the VR systems used in the field of neurorehabilitation are classified into three types. First, the immersive ones are linked to a virtual environment given by a computer. The subject interacts through hardware such as gloves, stereoscopic viewing helmets, screens, virtual booths, or caves16.
The second, VR systems used are robot devices, called haptic systems, which provide training of the upper limb virtual environments, and finally, the non-immersive systems, in which interaction is carried out using a keyboard, a controller, devices, or hardware, are anchored with computers such as Wii (Nintendo), PlayStation (Sony), and Xbox (Microsoft).
Effects of VR in gait rehabilitation in children with CP
Arnoni et al.18 applied the intervention in children with CP level I and II according to the GMFCS Motor Functional, with VR through video games with the available X-Box ™ 360° console and the Kinect sensor (Microsoft®), synced to a 32-inch TV. The authors found that the intervention based on VR showed significant improvements in the dimensions of the Gross Motor Function Measure in dimension D: standing (p = 0.021) and dimension E: walking, running, and jumping (p = 0.008), with clinically significant improvements (D = 10.8%; E = 14.0%).
Similarly, Gagliardi et al.19 found that the intervention carried out in immersive virtual environments proved to be effective in the functional and instrumental parameters of gait in 16 children with CP who received treatment during 18 sessions for 4 weeks.
Likewise, Booth et al.20 studied the effects of Avatar-based biofeedback in children with CP capable of walking without an assistive device, finding favorable results, the participants were able to adapt the gait pattern in an immediate response, reaching significant increases in the generation of ankle power at takeoff (37.7%), and clinically meaningful improvements in knee extension (7.4°) and stride length (12.7%).
On the other hand, Ma et al.21 analyzed the gait characteristics in children with spastic CP during an incline walk on a treadmill in a VR environment. The finding in this analysis shows a decrease in walking speed and the length of the walk a reduction in peak hip abduction moment, an increase in dorsiflexion and knee flexion, and an increase in peak hip extension moment. However, they suggest that the speed needs to be controlled.
Finally, Cho et al.22 verified that VR programs in mobile appointments effectively improve the gait pattern, balance, muscle strength, and gross motor function in children with CP (Table 1).
Table 1 Synthesis of articles related to virtual reality used in gait rehabilitation in children with cerebral palsy
| Year | Author | Results | References |
|---|---|---|---|
| 2019 | Ma Y, Liang Y, Kang X, Shao M, Siemelink L, Zhang Y. |
Improvements in walking speed and stride length. | 21 |
| 2019 | Booth AT, Buizer AI, Harlaar J, Steenbrink F, van der Krogt MM. |
Clinically meaningful gait improvements. | 20 |
| 2019 | Arnoni JLB, Pavão SL, dos Santos Silva FP, Rocha NACF. | A promising tool that can improve gross motor function in children with cerebral palsy, according to Gross Motor Function Classification System level I-II (GMFCS I-II). | 18 |
| 2018 | Yuping Chen, HsinChen D Fanchiang, Ayanna Howard. |
Positive results in the postural control and also a medium effect on ambulation. | 17 |
| 2018 | Gagliardi C, Turconi AC, Biffi E, Maghini C, Marelli A, Cesareo A, et al. |
Gait pattern left and right stride length, gait speed, endurance, gross motor skills, and kinematic and kinetic parameters were significantly improved after the intervention. | 19 |
| 2017 | Cano de la Cuerda R, Martínez Piédrola R,
Miangolarra Page JC. |
Virtual Reality (VR). Provides feedback and analysis of results in real-time. | 15 |
| 2014 | Monge Pereira E MR, Alguacil Diego IM, Cano de la Cuerda R, de Mauro A, Miangolarra Page JC, undefined. |
Virtual reality is helpful in rehabilitation in people with neurological sequelae based on task-oriented motor learning. | 9 |
| 2013 | Díez-Alegre MI, Muñoz-Hellín E. | Improvements in upper limb functionality, reach kinematics, quality of movement, active mobility, fine motor skills, as well as in certain basic activities of daily life. | 16 |
| 2012 | de la Cuerda RC, Vázquez SC. | The relevant effects it provides are artificial sensory feedback and mirror neuron activation, Which are activated by imitating tasks and are commonly associated with interactive applications representing experiences in the subject during daily tasks and leisure training. | 10 |
| 2000 | Santelices Malfanti I, Parra Márquez JC,
García Alvarado R. |
Virtual Reality (VR). A tool that consists of the simulation of a natural environment by computer. Three-dimensional interface with graphic, acoustic, and tactile content allows interaction in an actual but simulated context. | 8 |
| 1999 | Lacoboni M, Woods RP, Brass M, Bekkering H, Mazziott JC. |
Neurophysiological effect believed to be conducive to activation of new neuronal circuits through brain plasticity at an early age, as well as the activation of mirror neurons from imitation learning mechanisms, in primary motor cortical areas, through the memory of the representation of the movement to be carried out. | 11 |
Conclusions
There are literature and studies that verify the efficacy of VR in gait rehabilitation in children with spastic CP, which are being applied by physiotherapists, which leads to the design of software that, through reality, facilitates the processes of rehabilitation and greater adherence to treatments.
This research originates from the research project called: Design of a VR software for gait rehabilitation in children with level I CP according to the GMFCS approved in Session 05-2018 of the research committee of the María Cano University Foundation with code assignment: # 013008089-2018-311.
