Interface entre as medidas de benefício após a reabilitação vestibular - relato de casos / Interface between measures of benefit after vestibular rehabilitation - case report

RESUMO Esta pesquisa teve como objetivo caracterizar o efeito da reabilitação vestibular (RV) sobre o ganho do reflexo vestíbulo-ocular (RVO), a ocorrência das sacadas compensatórias, bem como sobre o equilíbrio corporal e a qualidade de vida, em três pacientes com hipofunção vestibular periférica. Trata-se de um estudo descritivo. Participaram da pesquisa três pacientes do gênero feminino, duas com 55 anos e uma com 67 anos, com diagnóstico médico de disfunção vestibular periférica. As participantes foram submetidas à anamnese, questionário Dizziness Handicap Inventory (DHI), avaliação clínica do equilíbrio corporal e ao Vídeo Teste do Impulso Cefálico (vHIT), pré e após RV. A RV foi aplicada de forma personalizada, baseada no protocolo de Cawthorne e Cooksey, associada a estímulos de realidade virtual. Após a RV, observou-se a redução da média do escore total do DHI, sugestivo da diminuição na restrição de participação. Na avaliação clínica do equilíbrio obtiveram-se resultados dentro da normalidade para as provas alteradas, pré RV. Quanto ao vHIT, constatou-se aumento do ganho do RVO para os canais semicirculares anteriormente afetados, condizente com padrões de normalidade, e extinção ou diminuição de ocorrência das sacadas compensatórias, nos três casos avaliados. O aumento do ganho do RVO e a extinção ou redução das sacadas compensatórias, após a RV, evidenciam sinais sugestivos de compensação vestibular. Esses resultados mostraram-se compatíveis com o aumento da estabilidade postural e menor restrição da qualidade de vida. Os achados, em conjunto, demonstram o benefício proporcionado pela RV nos três casos avaliados.

ABSTRACT The purpose of this research is to characterize the vestibular rehabilitation (VR), vestibulo-ocular reflex (VOR) gain, the occurrence of compensatory saccades, the static and dynamic balance, and the impact on quality of life in three patients with peripheral vestibular hypofunction. This is a descriptive study, approved by the ethics in research committee, under number 4,462.519. Three female patients participated in the study, two aged 55 and one aged 67, with a medical diagnosis of peripheral vestibular dysfunction. The participants underwent anamnesis, Dizziness Handicap Inventory (DHI) questionnaire, clinical assessment of postural balance and Video Head Impulse Test (vHIT), pre and post VR. The VR was applied in a personalized manner, based on the Cawthorne and Cooksey protocol, associated with virtual reality stimuli. After VR, a reduction in the total score average of DHI was observed, suggesting a decrease in participation restriction. The clinical balance assessment results were within the normal range for the altered tests, pre VR. In the three evaluated cases, vHIT showed increased RVO gain for the previously affected semicircular ducts (SCDs), compatible with normality standards, and reduction or extinction in the occurrence of compensatory saccades. The increase in VOR gain and the reduction or suppression of compensatory saccades after VR are suggestive signs of vestibular compensation. These results were compatible with increased postural stability and less restricted quality of life. These findings demonstrate the benefit provided by VR in the three evaluated cases.

Biomarcadores del trastorno del especto autista basados en bioseñales, realidad virtual e inteligencia artificial / Autism spectrum disorder biomarkers based on biosignals, virtual reality and artificial intelligence

Se ha observado que la estratificación de trastornos del espectro autista (TEA) generada por las escalas actuales no es efectiva para la personalización de tratamientos tempranos. La evaluación clínica de TEA requiere su consideración como un continuo de déficits, y existe la necesidad de identificar parámetros biológicamente significativos (biomarcadores) que tengan el poder de caracterizar automáticamente a cada individuo en diferentes etapas del desarrollo neurológico. El incipiente campo de la psiquiatría computacional (CP) intenta satisfacer las necesidades de diagnóstico de precisión mediante el desarrollo de potentes técnicas computacionales y matemáticas. Una creciente actividad científica propone el uso de medidas implícitas basadas en bioseñales para la clasificación de ASD. Las tecnologías de realidad virtual (VR) han demostrado potencial para las intervenciones de TEA, pero la mayoría de los trabajos han utilizado la realidad virtual para el aprendizaje / objetivo de las intervenciones. Muy pocos estudios han utilizado señales biológicas para el registro y el análisis detallado de las respuestas conductuales que se pueden utilizar para monitorear o producir cambios a lo largo del tiempo. En el presente trabajo se introduce el concepto de biomarcadores conductuales basados en VR o VRBB. Los VRBB van a permitir la clasificación de TEA utilizando un paradigma de psiquiatría computacional basado en procesos cerebrales implícitos medidos a través de señales psicofisiológicas y el comportamiento de sujetos expuestos a complejas réplicas de condiciones sociales utilizando interfaces de realidad virtual.

It has been observed that the stratification of Autism Spectrum Disorders (ASD) generated by the current scales is not effective for the personalization of early treatments. The clinical evaluation of ASD requires its consideration as a continuum of deficits, and there is a need to identify biologically significant parameters (biomarkers) that have the power to automatically characterize each individual at different stages of neurological development. The emerging field of computational psychiatry (CP) attempts to meet the needs of precision diagnosis by developing powerful computational and mathematical techniques. A growing scientific activity proposes the use of implicit measures based on biosignals for the classification of ASD. Virtual reality (VR) technologies have demonstrated potential for ASD interventions, but most of the work has used virtual reality for the learning / objective of interventions. Very few studies have used biological signals for recording and detailed analysis of behavioral responses that can be used to monitor or produce changes over time. In this paper the concept of behavioral biomarkers based on VR or VRBB is introduced. VRBB will allow the classification of ASD using a paradigm of computational psychiatry based on implicit brain processes measured through psychophysiological signals and the behavior of subjects exposed to complex replicas of social conditions using virtual reality interfaces.

Herramientas tecnológicas del diagnóstico y tratamiento del trastorno por déficit de atención e hiperactividad / The technological tools of the diagnosis and treatment of attention deficit disorder and hyperactivity

El trastorno por déficit de atención e hiperactividad (TDAH) es el principal motivo de consulta en la mayoría de las unidades de Neurología Pediátrica en España. Las nuevas tecnologías asocian además beneficios tanto para los pacientes como para los profesionales y el propio sistema sanitario. Se hace imprescindible su implementación racional. La genética, la neuroimagen o la realidad virtual por ejemplo, son claros exponentes de los resultados que se pueden conseguir al optimizar los procesos tradicionales. Las diferentes tecnologías que recogemos en este artículo están completamente operativas y cuentan con miles de pacientes de experiencia. La incorporación de las mismas a la práctica clínica habitual está en nuestras manos.

Attention deficit disorder and hyperactivity (ADHD) is the main reason for consultation in most Pediatric Neurology units in Spain. The new technologies also associate benefits for both patients and professionals and the health system itself, which makes its rational implementation essential. Genetics, neuroimaging or virtual reality, for example, are clear exponents of the results that can be achieved by optimizing traditional processes. The different technologies that we collect in this article are fully operational and have thousands of experience in patients. The incorporation of them to the usual clinical practice is in our hands.

Effect of Leap Motion-based 3D Immersive Virtual Reality Usage on Upper Extremity Function in Ischemic Stroke Patients / Efeito do uso imersivo da realidade virtual 3D baseada em movimento de salto na função de extremidade superior em pacientes com AVC isquêmico

ABSTRACT Immersive virtual reality (VR) is a technology that provides a more realistic environmental design and object tracking than ordinary VR. The aim of this study was to investigate the effectiveness of immersive VR on upper extremity function in patients with ischemic stroke. Sixty-five patients with ischemic stroke were included in this randomized, controlled, double-blind study. Patients were randomly divided into VR (n = 33) and control (n = 32) groups. The VR group received 60 minutes of the upper extremity immersive VR rehabilitation program and the control group received 45 minutes of conventional therapy and 15 minutes of a sham VR program. Rehabilitation consisted of 18 sessions of therapy, three days per week, for six weeks. The outcome measures were the Action Research Arm Test (ARAT), Functional Independence Measure (FIM), Fugl-Meyer Upper Extremity Scale (FMUE) and Performance Assessment of Self-Care Skills (PASS). In both the VR and control groups all parameters except the PASS improved over time. However independent t-test results showed that all of the FMUE, ARAT, FIM and PASS scores were significantly higher in the VR group compared with the control (p < 0.05). The minimal clinically important difference (MCID) scores of the FMUE and ARAT were higher than the cut-off MCID scores described in the literature in the VR group, whereas the FIM scores were below the cut-off MCID scores. All scores in the control group were below the cut-off scores. Immersive VR rehabilitation appeared to be effective in improving upper extremity function and self-care skills, but it did not improve functional independence.

RESUMO A VR imersiva é uma tecnologia que fornece design ambiental e rastreamento de objetos mais realistas do que a VR comum. O objetivo deste estudo foi investigar a eficácia da VR imersiva na função da extremidade superior em pacientes com AVC isquêmico. Sessenta e cinco pacientes com AVC isquêmico foram incluídos neste estudo randomizado, controlado e duplo-cego (clinictrials.gov. ID: NCT03135418). Os pacientes foram divididos aleatoriamente em VR (n = 33) e controle (n = 32). O grupo VR recebeu 60 minutos do programa de reabilitação imersiva da extremidade superior e o grupo controle recebeu 45 minutos de terapia convencional e 15 minutos de um programa falso de VR. A reabilitação consistiu em 18 sessões de terapia, 3 dias por semana, durante 6 semanas. As medidas de resultado foram Teste de braço de pesquisa-ação (ARAT), Medida de independência funcional (FIM), Escala de extremidades superiores de Fugl-Meyer (FMUE) e Avaliação de desempenho de habilidades de autocuidado (PASS). Nos grupos VR e controle, todos os parâmetros, exceto o PASS, melhoraram com o tempo. No entanto, os resultados dos testes t independentes mostraram que todos os escores FMUE, ARAT, FIM e PASS foram significativamente maiores no grupo VR em comparação ao controle (p <0,05). Os escores de FMUE e ARAT de diferença minimamente clinicamente importante (MCID) foram maiores que os pontos de corte de MCID descritos na literatura no grupo VR, enquanto os escores de FIM estiveram abaixo dos pontos de corte de MCID. Todas as pontuações no grupo controle estiveram abaixo das pontuações de corte. A reabilitação imersiva da VR parece ser eficaz para melhorar a função da extremidade superior e as habilidades de autocuidado, mas não melhora a independência funcional.

Use of client-centered virtual reality in rehabilitation after stroke: a feasibility study / Uso da realidade virtual centrada no cliente na reabilitação após acidente vascular encefálico: um estudo de viabilidade

ABSTRACT Patient-centered virtual reality (VR) programs could assist in the functional recovery of people after a stroke. Objectives: To analyze the feasibility of a rehabilitation protocol using client-centered VR and to evaluate changes in occupational performance and social participation. Methods: This was a mixed methods study. Ten subacute and chronic stroke patients participated in the rehabilitation program using games in non-immersive VR for 40 minutes/day, three days/week, for 12 weeks. Sociodemographic information was collected and the outcome variables included were the Canadian Occupational Performance Measure (COPM) and the Participation Scale. A field diary was used to record the frequency of attendance and adherence of participants and an interview was conducted at the end of program. Results: There were significant and clinically-relevant statistical improvements in the COPM performance score (p < 0.001; CI = 1.29 − 4.858) and in the COPM satisfaction score (p < 0.001; CI = 1.37 − 5.124), with a difference greater than 4.28 points for performance and 4.58 points for satisfaction. The change in the scores for participation was statistically significant (p = 0.046), but there was no clinical improvement (dcohen = −0.596, CI = −1.862 − 0.671). The majority of participants reported more than 75% consecutive attendance of sessions and there was 100% adherence to the program. In the interviews, the participants described their post-stroke difficulties; how the video game motivated their engagement in rehabilitation; and the improvement of occupational performance and social participation after participating in the program. Conclusions: VR is a viable tool for the rehabilitation of stroke patients with functional gains, mainly regarding occupational performance and performance satisfaction.

RESUMO Programas de realidade virtual (RV) centrados no paciente poderiam auxiliar na recuperação funcional de pessoas após acidente vascular cerebral (AVC). Objetivos: Analisar a viabilidade de um protocolo de reabilitação usando RV centrada no cliente e avaliar mudanças no desempenho ocupacional e na participação social. Métodos: Dez pacientes com AVC participaram do programa de reabilitação utilizando RV por 40 min/dia, 3 dias/semana, durante 12 semanas. Foram coletadas informações sociodemográficas e as medidas de desfecho incluíram a Medida Canadense de Desempenho Ocupacional (COPM) e a Escala de Participação. Empregou-se um diário para registro da frequência e adesão de cada participante e uma entrevista foi usada para analisar a percepção dos participantes sobre o programa. Resultados: Houve melhora estatisticamente significativa e clinicamente relevante no escore de desempenho da COPM (p < 0,001; IC = 1,219 − 4,858) e no escore de satisfação com o desempenho da COPM (p < 0,001; IC = 1,37 − 5,154); com diferença maior que 4,28 pontos para o desempenho; e 4,58 pontos para a satisfação. A mudança no escore de participação foi estatisticamente significativa (p = 0,046), mas não houve melhora clínica (dcohen = −0,596, IC = −1,862 − 0,671). A maioria dos participantes apresentou mais de 75% de frequência consecutiva e houve 100% de adesão ao programa. Nas entrevistas os participantes relataram as dificuldades pós-AVC; como o video game motivou seu engajamento na reabilitação; e a melhora do desempenho ocupacional e da participação social após participar do programa. Conclusões: Os resultados indicam a viabilidade da RV para reabilitação de pacientes com AVC, com ganhos funcionais, principalmente no desempenho ocupacional e satisfação com o desempenho.

Virtual reality in the rehabilitation of patients with stroke: an integrative review / Realidade virtual na reabilitação de pacientes após acidente vascular cerebral: uma revisão integrativa

ABSTRACT Objective: To describe the intervention protocols to using commercial video games as virtual reality (VR) in rehabilitation of patients with stroke. Methods: Integrative review using the descriptors "rehabilitation", "virtual reality exposure therapy" and "videogames" in the LILACS and PUBMED databases. Articles published from 2011 to 2018 were selected. Results: We found 1,396 articles, 1,383 were excluded and 13 were selected. Most of the articles were randomized clinical trials published in 2014 or later. The sample size varied from 5-47 adults, or adults and elders, with chronic stroke. The Nintendo Wii® was the most used video game system. The intervention happened two or three times a week, each session lasting from 30 to 60 minutes, over 2-12 weeks. Balance, upper limb motor functions, quality of life and daily living activities were the most common evaluated outcomes. The Fugl-Meyer Assessment, Berg Balance Scale, Timed Up and Go test, Barthel Scale and SF-36 were the most common outcome measurement tools. Conclusions: The studies indicated improvement in dynamic balance, upper limb motor function and quality of life after rehabilitation using VR. The VR was more effective than conventional treatments for the outcome of dynamic balance. Two studies did not find any changes in static balance and daily living activities. Physical aspects and quality of life were the outcomes most evaluated by the researchers; as were the population with chronic strokes and protocols of long duration and low intensity. Few studies targeted immediate VR effects, performance in daily living activities and social participation.

RESUMO Objetivo: Descrever os protocolos de intervenção utilizando sistemas de vídeo game comerciais como realidade virtual (RV) na reabilitação de pacientes após AVE. Método: Revisão integrativa usando os descritores "reabilitação", "terapia de exposição a realidade virtual" e "videogames", nas bases de dados LILACS e PUBMED, e artigos publicados entre 2011 e 2018. Resultados: Foram encontrados 1.396, excluídos 1.383 e selecionados 13 artigos. A maioria era ensaio clínico aleatorizado publicados a partir de 2014. O tamanho da amostra variou de 5 a 47 participantes adultos ou adultos e idosos com AVE crônico. O Nintendo Wii® foi o videogame mais empregado. A intervenção constava de duas ou três sessões semanais, com duração de 30 ou 60 minutos por um período de duas a 12 semanas. Equilíbrio, função motora de membro superior, qualidade de vida e atividade de vida diária foram os principais desfechos. Empregou-se principalmente Escala Fugl-Meyer, Escala de Equilíbrio de Berg, teste Timed Up and Go, Índice de Barthel e SF-36 como medidas de desfecho. Conclusões: Os estudos indicaram melhora do equilíbrio dinâmico, função motora de membro superior e qualidade de vida após reabilitação usando RV. A RV se mostrou mais eficaz que tratamentos convencionais para o desfecho equilíbrio dinâmico. Dois estudos não encontraram mudanças no equilíbrio estático e atividade de vida diária. Observou-se maior foco em desfechos relacionados a aspectos físicos e qualidade de vida, em população com AVE crônico e protocolo com maior duração e menor intensidade. Poucos estudos voltados para efeitos imediatos da RV, desempenho em atividades de vida diária e participação social.

Investigation of the effect of the virtual reality application on experimental pain severity in healthy

SUMMARY OBJECTIVE: This study aimed to investigate the effect of virtual reality application on experimental ischemic pain created with a blood pressure instrument in healthy volunteers. METHODS: The research sample consisted of 172 volunteer adult students who conformed to the inclusion criteria. These individuals were assigned into an experimental (n=86) and a control group (n=86) by a simple randomization method. All individuals in the experimental and control groups wereexperimentally subjected to pain for two minutes by applying 260 mmHg of pressure 3-4 cm above the antecubital region of the left arm with an aneroid adult-type blood pressure instrument. During the procedure, the volunteers in the experimental group watched virtual reality images, while those in the control group received no intervention. Immediately after the procedure, the pain levels of the individuals in both groups were assessed with a Visual Analog Scale (VAS). RESULTS: We found that the mean pain score of the individuals in the experimental group was 2.62±1.82, and that of individuals in the control group was 5.75±1.65. Results of the statistical analysis showed a statistically significant difference between the mean pain scores of the individuals in the experimental and control groups (p<0.001). CONCLUSION: This study found that the use of virtual reality was effective in reducing the level of pain in healthy individuals. This method used a smartphone with widespread availability and ease of transportation, which can be used by health professionals as a non-pharmacological method in the management of pain.

RESUMO OBJETIVO: El objetivo de este estudio fue investigar el efecto de la aplicación de realidad virtual en el dolor isquémico experimental creado con un instrumento de presión arterial en voluntarios sanos. MÉTODO: La muestra de investigación consistió en 172 estudiantes adultos voluntarios que cumplieron con los criterios de inclusión. A estos individuos se les asignó mediante un método de aleatorización simple en un grupo experimental (n = 86) y uno de control (n = 86). Todos los individuos en los grupos experimentales y de control fueron sometidos experimentalmente a dolor durante dos minutos aplicando 260 mmHg de presión 3-4 cm por encima de la región antecubital del brazo izquierdo con un instrumento de presión arterial aneroide tipo adulto. Durante el procedimiento, los voluntarios en el grupo experimental observaron imágenes de realidad virtual, mientras que los del grupo de control no recibieron ninguna intervención. Inmediatamente después del procedimiento, los niveles de dolor de los individuos en ambos grupos se evaluaron con una Escala Analógica Visual (EAV). RESULTADOS: Se encontró que el puntaje promedio de dolor de los individuos en el grupo experimental fue 2.62 ± 1.82, y el de los individuos en el grupo control fue de 5.75 ± 1.65. Los resultados del análisis estadístico mostraron una diferencia estadísticamente significativa entre las puntuaciones medias de dolor de los individuos en los grupos experimental y control (p<0,000). CONCLUSÃO: Se encontró en este estudio que el uso de la realidad virtual fue efectivo para reducir el nivel de dolor en individuos sanos. Este método, que se lleva a cabo mediante el uso del teléfono inteligente y que ofrece una amplia disponibilidad y facilidad de transporte, puede ser utilizado por profesionales de la salud como un método no farmacológico en el tratamiento del dolor.

Effects of conventional and virtual reality cardiovascular rehabilitation in body composition and functional capacity of patients with heart diseases: randomized clinical trial / Efeitos da reabilitação cardiovascular convencional e da realidade virtual na composição corporal e na capacidade funcional de pacientes cardiopatas: triagem clínica randomizada

Background: Virtual reality is an alternative therapeutic resource to be inserted into cardiovascular rehabilitation, stimulating the practice of physical activity through man-machine interaction. Objective: To compare the effects of conventional and virtual reality cardiac rehabilitation on body composition and functional capacity in patients with heart disease. Methods: Randomized clinical trial with 27 cardiac patients divided into conventional rehabilitation group (CRG) and virtual reality rehabilitation group (VRG). They underwent a rehabilitation program with 60-minute training sessions twice a week for eight weeks. The VRG training consisted of exercises from the Xbox 360® with Kinect™, using YourShape™ and Dance Central 3™ games. The CRG used conventional treadmills for aerobic exercise and free weights for resistance exercise. Bioimpedance and 6-minute walk test (6MWT) were evaluated at baseline and after training. For main outcome analysis, Student t and Mann Whitney tests were used with a 5% significance level. Results: The VRG showed a significant increase in body fat percentage and fat weight when compared to the CRG, and a smaller amount of total water. There was a significant improvement in functional capacity evidenced by the increase in the distance covered in the 6MWT (54.00 m and 32.25 m in the CRG and VRG, respectively), but the gains did not differ between the groups. Conclusion: The two rehabilitation modalities had no effect on the body composition of the groups. In addition, the improvement in functional capacity was similar in both groups

Effects of virtual reality therapy on upper limb function after stroke and the role of neuroimaging as a predictor of a better response / Efeitos da terapia de realidade virtual na função do membro superior após AVC e o papel da neuroimagem como preditor de melhor resposta

ABSTRACT Background: Virtual reality therapy (VRT) is an interactive intervention that induces neuroplasticity. The aim was to evaluate the effects of VRT associated with conventional rehabilitation for an upper limb after stroke, and the neuroimaging predictors of a better response to VRT. Methods: Patients with stroke were selected, and clinical neurological, upper limb function, and quality of life were evaluated. Statistical analysis was performed using a linear model comparing pre- and post-VRT. Lesions were segmented in the post-stroke computed tomography. A voxel-based lesion-symptom mapping approach was used to investigate the relationship between the lesion and upper limb function. Results: Eighteen patients were studied (55.5 ± 13.9 years of age). Quality of life, functional independence, and dexterity of the upper limb showed improvement after VRT (p < 0.001). Neuroimaging analysis showed negative correlations between the internal capsule lesion and functional recovery. Conclusion: VRT showed benefits for patients with stroke, but when there was an internal capsule lesion, a worse response was observed.

RESUMO Introdução: A realidade virtual (RV) é uma intervenção interativa que induz a neuroplasticidade. O objetivo deste estudo foi avaliar os efeitos da RV associado à reabilitação convencional na função do membro superior após o AVC e as características preditores de neuroimagem de melhor resposta a esta terapia. Métodos: os pacientes com AVC foram selecionados, e as características neurológicas, a função do membro superior e a qualidade de vida foram avaliadas. A análise estatística foi realizada por meio de modelo linear geral comparando resultados pré e pós-intervenção. As lesões foram segmentadas na tomografia computadorizada após o AVC. A abordagem de mapeamento da lesão-sintoma baseada em voxel foi utilizada para avaliar a relação entre a lesão e a função do membro superior. Resultados: Foram estudados 18 pacientes (8 mulheres, 55,5 ± 13,9 anos). A qualidade de vida, independência funcional, características funcionais e destreza do membro superior apresentaram melhora após RV (p < 0,001). A análise de imagem mostrou correlações negativas principalmente entre a cápsula interna e a recuperação funcional do membro superior. Conclusão: A RV mostrou benefícios para pacientes com AVC, mas quando houve lesão da cápsula interna apresentaram pior resposta à terapia.

Realidad virtual y sus aplicaciones en trastornos mentales: una revisión / Virtual reality and its applications in mental disorders: a review

Resumen Las dos últimas décadas han sido testigos de la aparición de la realidad virtual (RV) como una herramienta importante para la investigación, evaluación y tratamiento en los trastornos mentales en la salud mental, creando entornos interactivos generados por computadora, donde los individuos pueden experimentar repetidamente sus situaciones problemáticas y aprender, a través de tratamientos psicológicos basados en la evidencia, cómo superar dificultades. El propósito de este artículo es proporcionar una revisión sistemática actualizada de la literatura sobre la utilización de la RV en los problemas de salud mental. Se realizó una revisión sistemática identificando 245 estudios, de los cuales se utilizaron solo 29 relacionados con modelos de RV, de los cuales 18 correspondían a distintos trastornos (ansiedad, depresión, esquizofrenia, psicosis, trastornos alimenticios, trastorno obsesivo compulsivo) y 11 a estudios empíricos; de su análisis se concluye que la capacidad de la RV para simular la realidad podría aumentar en gran medida el acceso a las terapias en los trastornos mentales mientras que los resultados podrían ser mejorados por la capacidad de la tecnología para crear nuevas realidades.

The last two decades have witnessed the emergence of virtual reality (VR) as an important tool for research, evaluation and treatment in mental disorders in mental health, creating interactive environments generated by computer, where individuals can repeatedly experience their problematic situations and learn, through psychological treatments based on evidence, how to overcome difficulties. The purpose of this article is to provide an updated systematic review of the literature on the use of VR in mental health problems. A systematic review was made identifying 245 studies, of which only 29 were used related to RV models, of which 18 corresponded to different disorders (anxiety, depression, schizophrenia, psychosis, eating disorders, obsessive compulsive disorder) and 11 to empirical studies. From their analysis it is concluded that the ability of the RV to simulate reality could greatly increase access to therapies in mental disorders while the results could be improved by the ability of technology to create new realities.

Virtual reality exposure therapy for fear of driving: analysis of clinical characteristics, physiological response, and sense of presence

Objective: To investigate the reactions of women with driving phobia to a therapeutic program of scheduled virtual reality exposure treatment (VRET) sessions. Methods: The study intervention consisted of a computer game with car-driving scenarios that included several traffic situations. We investigated the participants' sense of presence, subjective distress, and physiological responses during eight virtual-reality exposures. We also evaluated clinical characteristics, driving cognitions, and quality of life in the participants. Results: Thirteen women were selected. Eight were able to complete the protocol. After VRET, there was a decrease in the frequency of distorted thoughts and state anxiety scores, as well as a slight improvement in quality of life. Subjective discomfort scores, heart rate variation, and sense of presence scores confirmed that there was sense of presence in the virtual reality environment. Conclusion: All patients showed some degree of improvement and demonstrated different levels of anxiety in subsequent in vivo driving experiences. Our findings suggest that VRET could be used to facilitate in vivo exposure, because it can induce presence/immersion and reduce anxiety in patients with specific phobia. Furthermore, VRET is not associated with any type of risk.

Working Memory and Executive Functions in Parkinson's disease after intervention with non-immersive virtual reality / Memória Operacional e Funções Executivas na doença de Parkinson: desempenho após intervenção com realidade virtual / Memoria Operativa y Funciones Ejecutivas en la enfermedad de Parkinson: desempeño tras intervención con realidad virtual

To analyze Working Memory (WM) and Executive Function (EF) scores after and before intervention with non-immersive virtual reality in patients with Parkinson's disease (PD). Longitudinal study, with 13 subjects, of both sexes. Fourteen sessions of interventions based on Nintendo games. Cognitive functions were assessed using the Cambridge Cognitive Examination (CAMCOG). Statistical analysis of Wilcoxon was used to compare the performance of WM and EF scores before and after intervention. Results: Improvement in EF and VF scores after intervention was observed with statistically significant differences p= 0.004 and p=0.037, respectively. There were no differences between the interventions for WM scores (p= 0.609). Conclusion: Training with virtual games is suggested as a therapeutic approach that offers cognitive stimulation that improve EF.

Analisar os escores da Memória Operacional (MO) e Funções Executivas (FE), antes e depois da intervenção com realidade virtual, em pacientes com doença de Parkinson (DP). Estudo longitudinal com 13 participantes, de ambos os sexos. Quatorze sessões de intervenção através de jogos do Nintendo. As funções cognitivas foram avaliadas por meio do Cambridge Cognitive Examination (CAMCOG). As análises estatísticas foram realizadas por meio da prova de Wilcoxon, para comparar o desempenho da MO e FE, antes e depois das intervenções. Os resultados mostraram uma melhora nos escores de FE e FV, após a intervenção com diferenças estatisticamente significativas de p= 0,004 e p=0.037, respectivamente. Não foram encontradas diferenças estatisticamente significativas entre os escores de MO (p=0,609). Treinamentos por meio de realidade virtual podem contribuir com uma abordagem terapêutica que ofereça estimulação cognitiva que melhora funções executivas.

Analizar los escores de la Memoria Operativa (MO) y las Funciones Ejecutivas (FE), antes y después de la intervención con realidad virtual, en pacientes con enfermedad de Parkinson (DP). Estudio longitudinal con 13 participantes, de ambos sexos. Catorce sesiones de intervención a través de juegos de Nintendo. Las funciones cognitivas se evaluaron a través del Cambridge Cognitive Examination (CAMCOG). Los análisis estadísticos se realizaron a través de la prueba de Wilcoxon, para comparar el desempeño de la MO y FE, antes y después de las intervenciones. Los resultados mostraron una mejora en los escores de FE y FV, después de la intervención con diferencias estadísticamente significativas de p = 0,004 y p = 0.037, respectivamente. No se encontraron diferencias estadísticamente significativas entre los escores de MO (p = 0,609). Los entrenamientos a través de la realidad virtual pueden contribuir con un enfoque terapéutico que ofrezca estimulación cognitiva que mejora las funciones ejecutivas.

Effect of virtual reality in Parkinson's disease: a prospective observational study / Efeito da realidade virtual na doença de Parkinson: estudo observacional prospectivo

ABSTRACT Objective: To assess the effectiveness of balance exercises by means of virtual reality games in Parkinson's disease. Methods: Sixteen patients were submitted to anamnesis, otorhinolaryngological and vestibular examinations, as well as the Dizziness Handicap Inventory, Berg Balance Scale, SF-36 questionnaire, and the SRT, applied before and after rehabilitation with virtual reality games. Results: Final scoring for the Dizziness Handicap Inventory and Berg Balance Scale was better after rehabilitation. The SRT showed a significant result after rehabilitation. The SF-36 showed a significant change in the functional capacity for the Tightrope Walk and Ski Slalom virtual reality games (p < 0.05), as well as in the mental health aspect of the Ski Slalom game (p < 0.05). The Dizziness Handicap Inventory and Berg Balance Scale showed significant changes in the Ski Slalom game (p < 0.05). There was evidence of clinical improvement in patients in the final assessment after virtual rehabilitation. Conclusion: The Tightrope Walk and Ski Slalom virtual games were shown to be the most effective for this population.

RESUMO Objetivo: Verificar a eficácia dos exercícios de equilíbrio com realidade virtual (RVi) na doença de Parkinson. Métodos: Dezesseis pacientes foram submetidos a uma anamnese, exames otorrinolaringológico e vestibular, ao Dizziness Handicap Inventory (DHI), Escala de Equilíbrio de Berg (EEB), questionário SF-36 e o Teste de Sentar e Levantar (TSL) que foram aplicados antes e após a reabilitação com RVi. Resultados: Os resultados dos escores finais do DHI e EEB foram melhores após a reabilitação. O TSL apresentou resultado significativo após a reabilitação. O SF-36 demonstrou alteração significativa da capacidade funcional para os jogos Tightrope Walk e Ski Slalom (p < 0,05) e da saúde mental para o jogo Ski Slalom (p < 0,05). O DHI e EEB apresentaram alterações significativas no jogo Ski Slalom (p < 0,05). Houve melhora clínica evidente dos pacientes após reabilitação virtual. Conclusão: Os jogos virtuais Tightrope Walk e o Ski Slalom foram os mais eficazes.

Realidade virtual no tratamento da dor em criança queimada: relato de caso / Virtual reality for pain treatment in a burned child: case report / Realidad virtual en el tratamiento del dolor en niño quemado: caso clínico

OBJETIVO: Relatar o uso da realidade virtual e sua relação com a redução da intensidade dolorosa em uma criança queimada, internada em um Centro de Tratamento de Queimaduras (CTQ) pediátrico de referência do Sul do Brasil. RELATO DO CASO: G.H.M., 9 anos de idade, sexo masculino, admitido no Centro de Tratamento de Queimaduras de referência do Sul do Brasil, apresentando queimadura por chama direta em membro inferior direito, há um dia, com 1% da superfície corporal queimada e apresentando queimaduras de espessura parcial superficial. Anteriormente ao começo dos procedimentos de troca de curativo, foi utilizado tratamento farmacológico; durante os procedimentos, empregou-se como tratamento não farmacológico o uso da realidade virtual. A dor foi medida antes, durante e após os cuidados com a ferida, por meio de Escala de Faces e Numérica. No decorrer dos três dias em que foi utilizada a realidade virtual, durante a troca de curativos foi identificada a diminuição das expressões faciais dolorosas e maior colaboração durante o procedimento, além do relato verbal de haver menor tempo pensando na dor. Cabe destacar que no último dia não foi necessária a administração de medicações. CONCLUSÃO: Os métodos não farmacológicos vêm sendo aplicados como complemento ao uso de tratamentos farmacológicos nos cuidados prestados aos pacientes queimados. A realidade virtual apresenta-se como uma alternativa que demonstra resultados promissores, principalmente relacionados à redução da intensidade dolorosa; por isso, apresenta grandes benefícios durante sua utilização.(AU)

OBJECTIVE: To report the use of virtual reality and its relation to the diminishment of pain intensity in a burned child, who is hospitalized at a reference Pediatrics Center for Burnt Treatment (CBT) in the southern Brazil. CASE REPORT: G.H.M., 9 years old, male, hospitalized in the Center for Burnt Treatment in southern Brazil, presenting burns by direct flame in the right leg for one day, 1% body surface burnt, and partial superficial thickness burns. Previously to the beginning of dressing change, pharmacological treatment was used, and during the procedures, the virtual reality was used as non-pharmacological treatment. Pain was measured previously, during and afterwards the wound care through Faces and Numerals Scale. In the three days in which the virtual reality was used during the dressing change, a diminishment of painful facial expressions happened, as well as a better cooperation during the procedures, besides verbal report of less time thinking about the pain. It is important to highlight that, in the last day, medication was not necessary. CONCLUSION: Non-pharmacological methods has been being applied as a complement to the use of pharmacological treatments in the care of burned patients. Virtual reality presents as an alternative, which demonstrates promisor results, mainly the ones concerning reducing pain intensity, which presents huge benefits to its use.(AU)

Relatar el uso de realidad virtual y su relación con la reducción de la intensidad dolorosa en un niño quemado, internado en un Centro de Tratamiento de Quemaduras (CTQ) pediátrico de referencia del sur de Brasil. Relato de Caso: G.H.M., 9 años de edad, sexo masculino, admitido en el Centro de Tratamiento de Quemaduras de referencia del sur de Brasil, presentando quemaduras por fuego directo en miembro inferior derecho, hay un día, con 1% de la superficie corporal quemada y presentando quemaduras de espesura parcial superficial. Previamente al inicio de los procedimientos de troca de curativo, fue utilizado tratamiento farmacológico, y durante los mismos, fue utilizado como tratamiento no-farmacológico la realidad virtual. El dolor fue medida antes, durante y después de los cuidados con la herida por medio de Escala de Faces y Numérica. En el decorrer de los tres días en que fue utilizada la realidad virtual durante la troca de curativos fue identificada diminución de expresiones faciales dolorosas, y una mayor colaboración durante el procedimiento, además del relato verbal de menor tiempo pensando en el dolor. Conclusión: los métodos no-farmacológicos vienen siendo aplicados como complemento al uso de tratamientos farmacológicos en los cuidados prestados a los pacientes quemados. La realidad virtual presentase como una alternativa, que demuestra resultados promisores, principalmente relacionados a la reducción de la intensidad dolorosa, presentando grandes beneficios durante su utilización.(AU)

Tratamiento binocular de la ambliopía basado en la realidad virtual / Binocular treatment of amblyopia based on virtual reality

Aunque los tratamientos predominantes de la ambliopía son monoculares, estos tienen poca aceptación y baja efectividad en el restablecimiento de la combinación binocular. Numerosas evidencias apoyan la idea de que la ambliopía es en esencia un problema binocular y que la supresión juega un papel clave. En esta revisión se exponen dos estrategias para el tratamiento binocular de la ambliopía basado en la realidad virtual; la primera con el objetivo primario de mejorar la agudeza visual y la segunda con el propósito de mejorar las funciones binoculares a través de la reducción de la supresión. Este enfoque binocular expone al paciente a condiciones artificiales de visión con estímulos dicópticos en imágenes relacionadas. Los estudios clínicos realizados, tanto en niños como adultos, reportan mejorías de la agudeza visual y la estereopsia en un tiempo muy inferior al requerido por la oclusión. Los resultados clínicos sugieren que un enfoque binocular que combine ambas estrategias puede utilizarse como complemento de los tratamientos clásicos y como alternativa en adultos y niños con historial de tratamientos fracasados o rechazados(AU)

Although predominant amblyopia treatments are monocular, they have poor compliance and low effectiveness in re-establishing binocular combination. There are many evidences supporting the idea that amblyopia is essentially a binocular problem and its suppression plays a key role. This review showed two binocular treatment strategies of amblyopia based in Virtual Reality. In the first one, the primary goal is to improve visual acuity whereas in the second one the purpose is to improve the binocular functions through reduction of suppression. In this binocular approach, the patient is exposed to artificial vision conditions with dichoptic stimuli in related images. Clinical studies in children and adults have reported improvements of visual acuity and stereopsis in less time than that required by occlusion. Clinical outcomes suggest that a binocular approach with a combination of both strategies can be used as a supplement to classic treatment and as an alternative in adults and children with history of failed or rejected treatments(AU)

The effects of training by virtual reality or gym ball on pelvic floor muscle strength in postmenopausal women: a randomized controlled trial

ABSTRACT Objective To evaluate the effectiveness of abdominopelvic training by virtual reality compared to pelvic floor muscle training (PFMT) using a gym ball (a previously tested and efficient protocol) on postmenopausal women’s pelvic floor muscle (PFM) strength. Method A randomized controlled trial was conducted with 60 postmenopausal women, randomly allocated into two groups: Abdominopelvic training by virtual reality – APT_VR (n=30) and PFMT using a gym ball – PFMT_GB (n=30). Both types of training were supervised by the same physical therapist, during 10 sessions each, for 30 minutes. The participants’ PFM strength was evaluated by digital palpation and vaginal dynamometry, considering three different parameters: maximum strength, average strength and endurance. An intention-to-treat approach was used to analyze the participants according to original groups. Results No significant between-group differences were observed in most analyzed parameters. The outcome endurance was higher in the APT_VR group (p=0.003; effect size=0.89; mean difference=1.37; 95% CI=0.46 to 2.28). Conclusion Both protocols have improved the overall PFM strength, suggesting that both are equally beneficial and can be used in clinical practice. Muscle endurance was higher in patients who trained using virtual reality.

A realidade virtual por meio do tapete de videodança melhora a marcha de pacientes com doença de Parkinson / Virtual reality for video dance pad means better patient running with Parkinson disease

Intervenções com realidade virtual apresentam efeitos positivos em várias habilidades físicas em pacientes com doença de Parkinson (DP). O objetivo foi verificar a efetividade do treinamento de curto prazo baseado em realidade virtual por um tapete de videodança no desempenho da marcha em pacientes com doença de Parkinson. Foram avaliados quatro pacientes pela Escala Hoehn e Yahr, Escala Unificada de Avaliação da Doença de Parkinson (UPDRS), Miniexa-me do Estado Mental, Avaliação Cognitiva Montreal, Escala de Berg e Escala de Atividade de Parkinson. Para avaliar o treinamento, foi realizado o teste de caminhada dos 10 metros antes (A1), após 1 hora de repouso (A2) e após o treino (A3) em seis situações diferentes. Realizou-se intervenção com o tapete de videodança, com uma sessão única de 1 hora. Análise estatística: ANOVA de medidas repetidas, post-hoc de Tukey, para análise das variáveis espaçotemporais da marcha nos três momentos de avaliação e teste de McNemar para investigar diferenças na proporção de acertos nos dois alvos ao longo do trajeto (nível de significância 5%). Resultados evidenciaram redução do tempo para percorrer o trajeto e aumento da cadência na A3 em relação às avaliações iniciais (p < 0,05). Redução do número de erros de colocação do pé no alvo na A3 (p < 0,05). A intervenção foi efetiva principalmente em reduzir o tempo para percorrer o per-curso e corrigir erros de colocação do pé no alvo.

The aim was to verify the effectiveness of short-term training based on virtual reality by video-dance carpetin gait performance in patients with Parkinson's disease (PD). Evaluated four patients with idiopathic PD assessed by Hoehn and Yahr scale, Unified Parkinson's Disease Rating Scale (UPDRS), Mini-Mental Status Examination, Cognitive Assessment Montreal, Berg Scale and Parkinson's Activity Scale. To check the effect of the training, patients held the 10 metres walk test before (A1), after resting one hour (A2) and after training (A3) in six different situations. Held with  the  video-dance mat, with a single session of 1 hour. Statistics analysis: ANOVA for repeated measures and post-hoc Tukey to analyse the spatio-temporal parameters of the gait in three moments of evaluation and for McNemar's test to investigate differences in the proportion of hits in two targets arranged along the path (significance level 5%). Results showed reduction of time to traverse, increase of cadence in A3, regarding to initial assessments (p < 0.05). There has been a reduction in the number of mistakes of placing the foot on target at A3 (p < 0.05). The proposed intervention was effective primarily in reducing the time to traverse the route and correct mistakes of placing the foot on the target.

Virtual reality exposure using three-dimensional images for the treatment of social phobia

Objective: To test a potential treatment for social phobia, which provides exposure to phobia-inducing situations via computer-generated, three-dimensional images, using an open clinical trial design. Methods: Twenty-one patients with a DSM-IV diagnosis of social phobia took part in the trial. Treatment consisted of up to 12 sessions of exposure to relevant images, each session lasting 50 minutes. Results: Improvements in social anxiety were seen in all scales and instruments used, including at follow-up 6 months after the end of treatment. The average number of sessions was seven, as the participants habituated rapidly to the process. Only one participant dropped out. Conclusion: This study provides evidence that exposure to computer-generated three-dimensional images is relatively inexpensive, leads to greater treatment adherence, and can reduce social anxiety. Further studies are needed to corroborate these findings.

Reabilitação vestibular com realidade virtual na doença de Ménière / Vestibular rehabilitation with virtual reality in Ménière's disease

A tecnologia de realidade virtual fornece uma grande variedade de estímulos que geram conflitos sensoriais em diferentes níveis de dificuldades e em ambiente seguro. OBJETIVO: Verificar o efeito de um programa de reabilitação vestibular do equilíbrio corporal com estímulos de realidade virtual em pacientes com doença de Ménière. Forma de estudo: Estudo clínico observacional. MÉTODO: Quarenta e quatro pacientes, com idade entre 18 e 60 anos e doença de Ménière definida, distribuídos em dois grupos - experimental (GE) e controle (GC) - fizeram uso de betaistina e dieta alimentar; o grupo experimental foi submetido adicionalmente a 12 sessões de reabilitação com realidade virtual da BRU TM. Os pacientes responderam ao Dizziness Handicap Inventory (DHI), à escala analógica de tontura e realizaram a posturografia com realidade virtual antes e após a intervenção. RESULTADOS: Após a intervenção, o GE apresentou valores significantemente menores do DHI (p < 0,001) e da escala analógica de tontura (p = 0,012) e valores significantemente maiores da área do limite de estabilidade (p = 0,016), em comparação com o GC. CONCLUSÃO: A reabilitação do equilíbrio corporal com estímulos de realidade virtual é eficaz na melhora da tontura, da qualidade de vida e do limite de estabilidade de pacientes com doença de Ménière.

Virtual reality technology can provide a wide range of sensory stimuli to generate conflicts of varying degrees of complexity in a safe environment. OBJECTIVE: To verify the effect of a virtual realitybased balance rehabilitation program for patients with Menière's disease. METHOD: This observational clinical study included 44 patients aged between 18 and 60 years diagnosed with Menière's disease submitted to a controlled randomized therapeutic intervention. The case and control groups took betahistine and followed a diet. Case group subjects underwent 12 rehabilitation sessions with virtual reality stimuli in a Balance Rehabilitation Unit (BRU TM). Patients were assessed based on DHI scores, the dizziness visual analogue scale, and underwent posturography with virtual reality before and after the intervention. RESULTS: After the intervention, the case group showed significantly lower scores in DHI (p < 0,001) and in the dizziness visual analog scale (p = 0.012), and had significantly greater limit of stability areas (p = 0.016) than controls. CONCLUSION: Virtual reality-based balance rehabilitation effectively improved dizziness, quality of life, and limit of stability of patients with Menière's disease.