Who can benefit when Virtual Reality is added to Gait Training?
The purpose of gait training is to improve a person’s ability to walk or balance after an injury or illness. It can consist of physical, vestibular, motor, and/or motor-cognitive exercises and is one of the most common physical therapy treatments.
Because walking is so fundamental to physical and mental health, gait training, also known as gait rehabilitation, is performed on a wide range of indications, including post-acute and chronic neurological conditions (stroke, Parkinson’s disease, multiple sclerosis, cerebral palsy, traumatic brain injury, etc.), orthopedic indications (total joint replacement, lower limb fractures, amputation, etc.), after medical treatment (chemotherapy, radiation, etc.), and those older adults identified as a fall risk.
GaitBetter is a new gait rehabilitation technology using semi-immersive virtual reality that introduces clinical benefits that are sometimes absent from existing treatments. These include simultaneous motor-cognitive training to help accelerate outcomes and gamification that drives deeper engagement and higher adherence rates.
In this article, we will examine how the GaitBetter virtual reality motor-cognitive technology improves key parameters that help us walk and move every day with strength and confidence. We will address a number of conditions, backed up by studies and reviews of the GaitBetter system.
What is GaitBetter?
GaitBetter adds semi-immersive virtual reality (VR) to existing treadmills to deliver a personalized motor-cognitive therapy that prevents falls and accelerates more positive outcomes in neuro, ortho, and cardio rehabilitation. With 5 clinical trials completed, 5 more clinical trials in progress, and over peer-reviewed 20 publications to date, there is substantial evidence that Gaitbetter helps improve traditional gait metrics (TUG, 2MWT, etc.), enhance cognitive performance, reduce falls, and increase overall quality of life.
How does GaitBetter work? The trainee walks on the treadmill and sees her two feet in a virtual reality environment projected on a TV screen in front of her. As she walks, she encounters virtual challenges to practice both cognitive and motor skills at the same time. She works on obstacle negotiation and decision making in an environment that is very similar to the real world. And she receives strong and measurable feedback, such as real-time scoring and trends in performance. The gamification is so motivating that patients are typically willing to walk twice as long compared to treadmill training alone.
Gait training for adults at risk of falling
According to the CDC, 36 million falls occur in the USA each year. This is a devastating number and results in falls being the number one cause of injury-related death among those over 65 years of age. A well-known 5-year longitudinal study of older adults showed conclusively that the primary indicator of fall risk is decline in cognitive abilities, specifically executive function (1). When an older adult fears falling while they walk, one potential outcome is their gait speed starts to slow down. This reduction in gait speed is a critical physical performance indicator, because it is a strong predictor of overall health and life expectancy.
Clinical support:
- In a real-world pilot study with the Israel Ministry of Health and delivered with Maccabi Health Services, Israel’s second-largest HMO, the Gaitbetter system was evaluated to reduce falls in older adults. The pilot involved 200 older adults that were identified as a ‘medium-to high-risk’ for falls.
- The results showed very high positive clinical and financial outcomes including a reduction in the number of falls, emergency room visits, and hospitalization days.
- The enormous success has resulted in Gait Better being rolled out to dozens of Maccabi sites throughout the country. The company is now also working with Clalit Health Services, the largest HMO provider in Israel, to offer the GaitBetter system to their 4.7 million patients.
Download the full case study here
Gait training for Parkinson’s Disease patients
There is extensive evidence that use of GaitBetter for gait training of Parkinson’s patients is effective. Over 10 peer-reviewed publications from the last decade support the use of GaitBetter. This includes the very first study on the predecessor of GaitBetter, which was funded by the Michael J. Fox Foundation. The benefit of GaitBetter for Parkinson’s patients derives from the simultaneous motor-cognitive training enabled through the semi-immersive virtual reality environment. This stimulates brain plasticity not seen in motor training alone. The formation of new neural connections makes brains more efficient, allowing them to handle a larger number and more challenging tasks. (2) For a full clinical summary click here.
Clinical support:
- Gait speed increases while walking, performing dual tasks, and negotiating over-ground obstacles.
https://www.gaitbetter.com/gerontology-virtual-reality-for-gait-training-parkinsons-disease/
- GaitBetter reduced the risk of falls by nearly 60% more than treadmill training alone.
Gait training for Multiple Sclerosis patients
Several factors contribute to gait problems associated with multiple sclerosis (MS). Fatigue is a common symptom of MS, which can limit walking endurance. It may also damage nerve pathways, impairing coordination and/or causing weakness, poor balance, numbness, or spasticity (an abnormal increase in muscle tone).
Training on the treadmill is known to benefit MS patients, but the ability to negotiate virtual physical obstacles while on the treadmill results in a greater range of motion and power generated at the hip, resulting in a longer stride and faster gait.
Clinical support:
- GaitBetter training positively affected complex gait conditions in MS and was an effective therapeutic option for MS subjects with impaired gait. The study showed overall improvement in spatial-temporal parameters, better ability to dual-task, improved endurance as well as increased ability to negotiate through obstacles. https://www.gaitbetter.com/multiple-sclerosis-and-related-disorders/
- These findings support the perceived benefits of training programs that incorporate virtual reality to improve gait in people with MS. The participants significantly improved their walking endurance and speed, cadence and stride length, balance, and lower limb joint ranges of motion during single and dual task gait. The experimental group improved significantly more than the control group in hip range of motion and hip-generated power at terminal stance.
Gait training for joint replacement
Total joint replacement is one of the most common medical procedures, with over 1 million hip and total knee replacement procedures performed each year in the United States.
Joint replacement is effective in relieving pain, restoring function, and improving quality of life, but post-acute physical therapy is critical to prevent functional limitations that may occur after surgery. This includes an altered gait pattern that can result in an increased risk of falls. Gait training can help strengthen relevant muscles and the joint’s range of motion. This can help restore normal walking ability (gait) and ensure patients walk without an aide (such as a walker or cane).
Using GaitBetter as a walking rehabilitation tool can have a variety of benefits. It increases the patient’s effective training time by simulating a challenging walk and including obstacles that exist in their daily lives. The semi-immersive VR experience provides a cognitive challenge for the patients, including movement planning, multi-tasking, and decision making. And the visual feedback on foot placement and feet movement through 3D space accelerates improvement in the complex gait cycle.
Clinical support:
Gait training is an important activity after joint replacement and is recommended by the American Association of Hip and Knee Surgeons. More specifically, gait training on a treadmill (treadmill training) is especially known to be beneficial post-operation for total joint replacement (TJR). This includes reducing level of pain, stimulating a larger amplitude in the activation of the affected hip abductor muscle and inducing a larger improvement in gait parameters than conventional physical therapy. Part of the improvement comes from treadmill training offering a task specific repetitive movement, which helps to practice the complex gait cycle. This practicing of the complex gait cycle can be furthered improved by introducing real-time biofeedback.
“Training with GaitBetter is highly suitable for patients after replacing the hip and knee joints. It allows for the start of a functional and challenging walking practice already in the early stages of rehabilitation” said Sagi Gitterman, a certified physiotherapist and medical director at GaitBetter.
Conclusion
Gait training is a common and critical activity. By utilizing this treatment, physical therapists can help their patients recover from injuries, improve their health, and affect their quality of life. But, existing gait training has some frustrating limitations.
Gait training on a treadmill provides a higher intensity experience, through longer walking distances and higher gait speed, but patients find the exercise boring and repetitive (which results in high dropout rates) and a subset will not go on a treadmill at all (too scary). Therapists also realize that simultaneous motor-cognitive challenges are very beneficial to gait training, but there are limited opportunities to introduce real-world cognitive challenges to treadmill training.
Gait training overground is more aligned with real-world experiences and setting up an obstacle course is very effective in getting patients to practice motor planning. But, the process of setting up and breaking down the course takes precious time away from actual therapy time. The intensity of this type of gait training is also limited by the size of room or hallway where the course has been arranged. And it can be difficult to quantify improvement in performance.
Adding a semi-immersive VR element to gait training on a treadmill overcomes these existing limitations and gives physical therapists the ability to provide personalized training while tracking performance improvements. Real-time biofeedback, simultaneous motor-cognitive challenges, and gamification help drive intensity, improvement and adherence for every patient that needs gait training.
To learn more about GaitBetter’s evidence-based motor-cognitive technology, please schedule a demo.
- Mirelman A, Herman T, Brozgol M, Dorfman M, Sprecher E, Schweiger A, Giladi N, Hausdorff JM. Executive function and falls in older adults: new findings from a five-year prospective study link fall risk to cognition. PLoS One. 2012;7(6):e40297. doi: 10.1371/journal.pone.0040297. Epub 2012 Jun 29. PMID: 22768271; PMCID: PMC3386974.
- Maidan I, Nieuwhof F, Bernad-Elazari H, et al. Evidence for Differential Effects of 2 Forms of Exercise on Prefrontal Plasticity During Walking in Parkinson’s Disease. Neurorehabilitation and Neural Repair. 2018;32(3):200-208. doi:10.1177/1545968318763750