3D Virtual Reality Rehabilitation Therapy for Patients with Vertigo Due to Peripheral Vestibular Dysfunction

Abstract

This study aimed to evaluate 3D virtual reality rehabilitation therapy in patients with vertigo due to peripheral vestibular dysfunction. The subjects were 20 patients with peripheral vestibular dysfunction confirmed by Videonystagmography, Divided into 2 groups: Group 1 (study group) underwent vestibular rehabilitation therapy using 3D virtual reality in a customised VR lab with specific headset (Oculus rift and htc vive) with software application, which allows vestibular rehabilitation treatment using high quality immersive virtual reality console in which environment appears real and in 3D. The exercises are designed for gaze stability, increase postural stability, improve vertigo and daily activities, through sensory stimuli and in addition to conventional Cawthorne-Choksey exercises. Group 2 (control group) are treated by conventional Cawthorne-Choksey exercises alone. A VSS-SF (Vertigo Symptom Scale-short form) questionnaire and VAS (Visual Analog Scale) were used to assess the levels of patient satisfaction compared before and after each treatment session in both groups. A significant higher level of subjective satisfaction was observed in patients who underwent 3D virtual reality rehabilitation therapy with conventional therapy (group 1) compared to patients who underwent conventional cawthorne-Choksey exercises alone (group 2). The study gave a substantial subjective satisfaction in patients using 3D virtual reality rehabilitation therapy with conventional therapy (group1) than conventional Cawthorne-Choksey exercises alone (group 2). Future of VR rehabilitation therapy brings a revolutionary novelty in field of rehabilitation therapy were it involves real time stimulation and interaction between sensory, motor and cognitive channels.

Introduction

In this Modern Era, Technology has become the driving force of the world one of such upcoming technologies is Virtual reality which enables a person to dive into a world of imagination. Virtual reality (VR) is a real-time simulated experience and interaction with a virtual world, through various sensory channels, such as vision, hearing, and touch in a simulated environment.

This technology has been increasingly used for both education and entertainment. Virtual revolution in the field of medicine using 3D VR (Virtual Reality) is been used in various aspect such as planning complex operations beforehand, pain management, health education, Medical education, phobia, ADHD, autism spectrum disorders, post traumatic stress disorders.

Thus Virtual reality is becoming a useful adjunct to vestibular rehabilitation, as it may be helpful to generate realistic and interactive visual environments in which the patient is immersed, which may facilitate adaptation and desensitization. Our study is one of the earlier study to brings 3D VR (virtual reality) vestibular rehabilitation in the field of otorhinolaryngology.

In our study we have used a virtual reality based head mounted goggle with unique games, which mimics real life situations. This enables a person to dive into the world of imagination.

This study aims to assess the benefit of VR (virtual reality) based vestibular rehabilitation in patients with unilateral peripheral vestibular dysfunction confirmed by videonystagmography with chronic symptoms secondary to vestibular pathology.

Study Design

Interventional study.

Study Period

May 2021 to November 2021.

Study Population

Patients with unilateral peripheral vestibular dysfunction confirmed by videonystagmography.

Inclusion Criteria

Unilateral peripheral vestibular dysfunction confirmed by videonystagmography.

Exclusion Criteria

Patients whose health condition precluded them taking part in the therapy, the coexistence of neurological diseases.

Methods and Materials

It’s a interventional study undertaken in department of ENT at RMMCH After obtaining clearance from ethical committee and informed consent from the participants. The study commenced with 20 patients diagnosed with peripheral vestibular dysfunction as confirmed by Videonystagmography.

The study group consisted of 10 patients who underwent 3D VR (Virtual reality) rehabilitation therapy along with conventional Cawthrone-Cooksey exercise (Group 1). And the control group consisted of 10 patients who underwent conventional Cawthrone-Cooksey exercise alone (Group 2).

These patients underwent extended 3D VR therapy in a series of 2 session per week for 3 weeks duration with total 6 session. During which set of conventional Cawthrone-Cooksey exercise were performed but enriched using 3D virtual reality in a customised VR lab with specific headset (Oculus rift and htc vive) with software application. We have customised the 3D virtual reality based head mounted goggle with unique visuals which mimics real life situations and immersed the patient into world of imagination such as Optokinetic Nystagmus Bar, bus Simulator, Roller Coaster Games, Elevator Environment, Walking On A Planks, Supermarket Effect in high quality immersive virtual reality console in which environment appears real and in 3D (Fig. 1).

Fig. 1.

A patient undergoing 3D Virtual Reality rehabilitation therapy in virtual reality lab

In control group the patient performed a set of convention Cawthrone-Cooksey exercises in 2 session per week for 3 weeks duration with total 6 session. A VSS-SF (Vertigo Symptom Scale-short form) questionnaire were completed by patient before the study and after the end of 4th week of treatment session. VAS (Visual Analog Scale) to assess the intensity of vertigo were used before and after each treatment session in both groups. A VSS-SF (Vertigo Symptom Scale-short form) questionnaire were completed by patient before the study and after the end of 4th week of treatment session.VAS (Visual Analog Scale) to assess the intensity of vertigo were used before and after each treatment session in both groups.

Statistical Analysis

The data collected was entered in IBM SPSS Statistics 21 package and before analysis A Shapiro-Wilks test was initially performed to confirm that the data were normally distributed.

T test were used to compare basic data between two groups. One way ANOVA repeated test used to compare pretest and post test assessments between control and study group. 2*2 ANOVA repeated measure test was used to compare study and control group for VSS-sf. 2* 7 ANOVA repeated measure to asses VAS score between study and control group.

Result

Among the participants in study group, consisting of 10 patients with mean age group 45.2 (6 male and 4 female, mean age—45.2). Among the participants in control group, consisting of 10 patients with mean age group 46.8 (6 male and 4 female, mean age − 46.8).

All the 20 patients completed full course of therapy. The results were statistically analysed. The result were measured using scales such as VSS-SF, VAS scale and VAS (satisfaction) given in there vernacular language.

Using VSS-SF scale, assessment done in both groups before and after the end of treatment. We observed significant difference of p < 0.001 in study group and p = 0.001 in control group (Fig. 2).

Fig. 2.

Showing statistical analysis of VSS SF scale in both groups

Using VAS (assessment of vertigo intensity) there is significant decrease in vertigo intensity (p = 0.01) during initial visits in extended 3D VR therapy (Fig. 3). Whereas in group 2 there is no significant improvement in symptoms (p = 0.758) during initial visit in group 2 individual (Fig. 4).

Fig. 3.

Showing VAS Vertigo Assessment scale in 3D VR + Conventional therapy during each visit

Fig. 4.

Showing VAS (vertigo assessment) scale in conventional therapy during each visit

There was 90 percent satisfaction observed in Study group Fig. 5.

Fig. 5.

Comparison of VAS (satisfaction) scale between study and control group

By using VAS (satisfaction) scale in 3D VR therapy group patients gave a substantial subjective satisfaction and improvement during early phase of rehabilitation in patients using 3D virtual reality rehabilitation therapy with conventional therapy (study group) than conventional Cawthorne-Choksey exercises alone (control group). There by our study supports the advantage of therapy reinforcement by 3D virtual reality.

Discussion

The present study aims to assess the role of VR in vestibular rehabilitation. Patient’s compensatory mechanisms were found to be enhanced by introducing a sensory conflicts through 3D VR. We demonstrated significantly higher levels of patient satisfaction in those undergoing the extended VR therapy when compared to conventional therapy, thereby highlighting the advantages of therapy rein forced by VR.

Our finding supported the result obtained by Stakiewicz et al. [1] In their study compared the study group as well control group and found that the outcomes were similar in both groups. Those patients who additionally underwent VR therapy reported much higher levels of satisfaction regarding the severity of their vertigo when measured by the VAS scale.

Doriasala et al. [2] in their study observed Group A patients consisting of VRT and Vestibular Rehabilitation had demonstrated better response to therapy than group B patients consisting of Vestibular Rehabilitation alone.

Virtual Reality enables the patient to dive into world of imagination. Virtual realitytechnology enables therapists to provide patients a wide range of specific stimuli in a very safe environment^.

Rosiaka et al. [3] In their study showed reduction in intensity of vertigo by using posturographic parameters in both the group. According to The Cochrane Review, vestibular rehabilitation is a safe and effective management for unilateral peripheral vestibular dysfunction [4].

The VR significance has emphasised by Pavlou et al., [5] in their study demonstrated that patients treated with VR or by conventional therapy improved by 59.2% and 28.8%, respectively, compared to 1.6% of untreated patients thus they concluded VR rehabilitation therapy is useful in patients with unilateral peripheral damage to the vestibular organ.

A systematic view by Bergeron et al. [6] cornered that the use of Virtual reality might limited to motion sickness because of excessive sensory conflict. However in our study none of our patients complained of motion sickness during 3D VR rehabilitation therapy.

Rosiak et al. [7] in their study used a combination of VR, motion sensors, and a posturographic platform in rehabilitation (ie, a hybrid therapy) was found to be effective in reducing the subjectively assessed symptoms in patients with peripheral vestibular dysfunction.

Conclusion

Virtual reality based Vestibular rehabilitation is most welcoming mode of vestibular rehabilitation. Our study is one of the few study to compare virtual reality Vestibular rehabilitation on time tested vertigo till date in field of otorhinolaryngology. The Future of Virtual Reality rehabilitation therapy beholds revolutionary novelty in field of rehabilitation therapy.

Funding

KKM Soft Private Ltd, Chennai.

Declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

Approval was obtained from the ethics committee of our university. The procedures used in this study adhere to the tenets Of the Declaration of Helsinki.

Informed Consent

Informed consent was obtained from all individual participants included in the study.