Faye Bronstein PT, DPT, NCS
Overview
Early intensive gait training is an established best practice in patients with chronic stroke and has been shown to have significant benefits in patients with subacute strokes. Best practice guidelines dictate training at a 60-80% heart rate reserve (HRR) for as long as tolerated within a treatment session, which can be challenging in the inpatient rehabilitation setting. Particular challenges include sustaining the target heart rate (HR) for appropriate periods and maximizing the amount of time spent stepping within a treatment session.
The use of virtual reality (VR) training coupled with gait training has shown benefits in gait outcomes, balance outcomes and lower extremity strengthening5. VR training has been used as a tool to distract and engage patients, allowing for better participation and motivation. To date, there are no studies investigating the use of VR coupled gait training as an adjunct to meet the HR and dosage goals recommended for high intensity gait training (HIGT).
This case series will look at patients with subacute stroke in the inpatient rehabilitation setting who are participating in a HIST protocol and the effects of VR coupled gait training in achieving the recommended parameters during gait training.
Subjects:
This case series looks at 3 patients with subacute strokes who were medically cleared to participate in HIGT during their inpatient rehabilitation stay. All patients participated in physical therapy for 60 minute treatment sessions at least 5 days a week. All patients were ambulatory with assist ranging from minimal assist of 1 therapist to moderate assist of 2 therapists. Gait training was prioritized in each treatment session which aligned with both the therapist and patient goals.
Results:
On average, the patients ambulated 3:45 longer when completing treadmill training with VR than without VR.
The patients average heart rate was 7.6 beats per minute faster when using VR during treadmill training. Patient 3 specifically demonstrated the greatest differences, ambulating over 6 minutes more on average per gait trial and ambulating at a significantly higher intensity when using the VR system during treadmill training. Without use of the VR system, this patient may not have achieved the intensity and time of the stepping practice needed for the recommended gait protocol.
All patients tolerated treadmill training, with and without the VR, without adverse events. 2 of the 3 patients reported enjoying gait training more with the VR than without, while one patient reported no preference between VR versus no VR.
Conclusions:
The use of VR appears to be an effective way to increase dosage and achieve target heart rate when working toward goals of HIGT. VR can engage patients, improve buy in and add variability during gait training, which may result in patients working at higher intensities for longer periods of time. The use of VR may be a good adjunct tool if there is difficulty achieving HIGT principles when treadmill training or over ground training alone is not affective.
Limitations to this case series include a small sample size, varying severity of stroke and endurance, and no control group. Further investigation is needed to understand if using VR during gait training sessions is a superior tool than without to achieve HIGT goals.
GaitBetter is the commercial implementation of the V-TIME academic research project that yield many of these papers.