A case report on the integration of the Monitored Augmented Rehabilitation System in a multidisciplinary rehabilitation program for a pediatric patient with a ruptured arteriovenous malformation

Abstract

Cerebral arteriovenous malformations (AVMs) are congenital vascular abnormalities that can lead to neurological impairments following rupture. This proof-of-concept case report examines the integration of the Monitored Augmented Rehabilitation System (MARS), an immersive virtual gaming platform, into a multidisciplinary rehabilitation program for a 12-year-old female recovering from a ruptured AVM. MARS was used as an adjunct modality alongside conventional interventions over a 4-week period to target functional outcomes as assessed by the Neurocom Balance Manager^®. Quantitative results demonstrated targeted functional gains: Directional Control during the Limits of Stability test increased from 66% to 73%, toes-up Adaptation Test scores improved from 104.2 to 116.2, and toes-down scores from 115.6 to 119.0. Clinically observed increases in engagement, motivation, and adherence were noted during therapy sessions. This report underscores the feasibility and clinical potential of MARS as a complementary tool for enhancing motor learning and functional outcomes in pediatric neurorehabilitation. Future research should focus on larger sample sizes and extended intervention periods to validate the efficacy of MARS in improving long-term recovery outcomes.

Introduction

Cerebral arteriovenous malformations (AVMs) are rare congenital vascular abnormalities that involve direct connections between cerebral arteries and veins, bypassing the capillary system. Cerebral AVMs have a population prevalence of approximately 0.5% and an even lower prevalence in children.^1,2 They are the leading cause of spontaneous intracranial hemorrhage in pediatric populations, ³ with a 2% to 3% annual hemorrhage rate.^4,5 These lesions often remain undetected until rupture and are associated with high morbidity, including long-term impairments in mobility, speech, cognition, neuropsychological development, and functional ability; notably, up to half of affected children report persistent cognitive difficulties.^6–8

Rehabilitation for pediatric AVMs is a multidisciplinary process that typically includes exercise-based interventions alongside physiotherapy, occupational therapy, speech therapy, neuropsychological support, and other modalities. ⁹ Multisensory rehabilitation (MR) has gained attention as a promising approach, with studies in adult post-stroke populations demonstrating improvements in cognitive engagement and functional performance.^10,11 Although evidence in pediatric or AVM populations is limited, these findings highlight the potential relevance of MR for supporting rehabilitation in complex neurological conditions.

MR integrates stimulation of multiple sensory systems, including visual, vestibular, and somatosensory inputs, to reinforce sensorimotor integration. ¹² Through this multimodal engagement, MR is thought to enhance balance and physical function by driving central nervous system plasticity.^13,14 In addition, the interactive nature of multisensory and gamified rehabilitation may increase patient engagement, which in turn supports greater repetition and practice intensity, both of which are key contributors to motor learning.^15–17

The Monitored Augmented Rehabilitation System (MARS) is a novel treatment modality, combining immersive virtual gaming with rich multisensory feedback (visual, auditory, and proprioceptive/kinesthetic) to enhance engagement and motor learning. Used alongside traditional exercise-based interventions, MARS complements conventional strategies by gamifying rehabilitation, delivering real-time feedback, and promoting neuroplasticity.

This case report describes the integration of MARS into the rehabilitation of a 12-year-old female with neurological deficits following AVM rupture. The objective of this report is to demonstrate the feasibility and clinical utility of incorporating MARS as an adjunct to traditional outpatient rehabilitation. The primary outcomes assessed were motor control, postural stability, and balance performance as measured by the Neurocom Balance Manager System.

Patient characteristics

A 12-year-old female with no history of neurological dysfunction was admitted to the emergency department with seizures, headache, and nausea. Imaging revealed an intracranial hemorrhage and a ruptured right hemisphere AVM requiring decompressive craniectomy with autologous bone banking and external ventricular drain, followed by AVM resection.

Post-rupture, the patient exhibited neurological and motor impairments: abnormal muscle tone, decreased strength, gait deviations, impaired balance and coordination, and limited range of motion. Physical therapy evaluations identified left-sided hemiplegia, ataxia, reduced gait speed, and a dependence on mobility aids such as a wheelchair and walker. Upon visual gait assessment, the left lower extremity exhibited decreased hip flexion, knee flexion, coordination, and step length during the swing phase compared to the right. No formal gait assessment tool was used, and these findings were visually apparent and documented by the treating therapist.

Treatment

After 6 weeks of inpatient rehabilitation, the patient began intensive outpatient physical and occupational therapy, attending 60-min sessions 3 times a week. These therapies targeted motor function and activities of daily living. Psychological support was also provided for associated emotional challenges, and her medication regimen included levetiracetam, oxcarbazepine, baclofen, and ibuprofen. All dosages remained consistent throughout the study.

The individualized intervention aimed to improve strength, balance, coordination, mobility, and gait mechanics while enhancing postural stability, physical endurance, and reducing fall risk. Six months into recovery (inclusive of the initial 6 weeks of inpatient rehabilitation), MARS was introduced for 4 weeks as a complementary modality alongside evidence-based interventions such as robotic gait training and aquatic therapy. MARS was performed for a minimum of 20 min, twice weekly, and served as the primary modality for balance training. The 4-week duration aligned with the clinic’s standard interval between Neurocom assessments. The CARE Checklist was utilized throughout.

Each MARS session consisted of multiple short gameplay bouts, with rest breaks interspersed as needed to reduce fatigue and maintain focus. The two primary games, Meteor Block and Tuber Runner, were played in alternating sequence to target distinct motor domains. Meteor Block involved coordinated lateral reaching to intercept meteor-like targets, while Tube Runner required fast, precise full-body movements to steer a character through a tunnel and collect items. Both games engaged the patient in visual cue–based reaching and weight-shifting tasks designed to promote motor control and balance. Each bout lasted approximately 2 min and was repeated across the session to total 20 min of gameplay.

Therapists progressively increased difficulty based on patient performance by modifying the base of support (e.g., feet together, tandem stance), surface stability (e.g., foam pad, BOSU ball), and stance complexity (e.g., sitting, tall kneeling, and standing variations). To ensure patient safety, the patient wore a gait belt held by the therapist positioned behind her throughout gameplay. No adverse events were observed during the intervention period.

Outcomes

All functional outcomes were assessed using the Neurocom Balance Manager System Version 9.3^® (Natus Medical Incorporated, Middleton, WI) at pre- and post- intervention timepoints separated by 4 weeks. Each assessment session included a single administration of the Limits of Stability (LOS), Adaptation Test (AT), Rhythmic Weight Shifting (RWS) Test, and Weight Bearing Test/Squat (WBS) protocols to evaluate motor control and postural stability during standing tasks.

Mean LOS results were mixed but overall reflected improved postural precision between pre- and post-testing (values represent averages across all eight directional transitions). Reaction Time slightly increased (0.73 s to 0.76 s), suggesting slower initiation, while Movement Velocity decreased (5.4°/s to 3.6°/s), demonstrating more deliberate, controlled movements. Both Endpoint Excursion and Maximum Excursion declined (59%–53% and 84%–82%, respectively), suggesting smaller movement amplitudes within the stability boundaries. Notably, Directional Control improved from 66% to 73%, indicating greater efficiency in path accuracy for targeted movements (Figure 1).

Figure 1.

Limits of Stability (LOS) pre- and post-intervention results. Average Limits of Stability (LOS) outcomes obtained from the NeuroCom Balance Manager System at pre- and post-intervention assessments. Each plot displays the participant’s average maximum voluntary sway and directional control across all eight directional transitions (single trial per time point). Post-intervention results demonstrate greater accuracy and reduced variability, indicating improved postural control and overall stability. See Outcomes section for numerical comparisons.

AT, which assesses balance responses to unexpected platform perturbations, showed measurable improvements. Toes-up sway scores increased from 104.2 to 116.2, and toes-down scores from 115.6 to 119.0, indicating enhanced automatic postural adjustment. Post-test sway profiles showed tighter congruency and reduced variability (Figure 2).

Figure 2.

Rhythmic Weight Shifting (RWS) pre- and post-intervention results. Comparison of pre- and post-intervention outputs from the Rhythmic Weight Shifting (RWS) test performed on the NeuroCom Balance Manager System. The plots illustrate changes in weight-shifting control in the anterior–posterior (front/back) and medial–lateral (left/right) directions. Post-intervention data show improved control in the front/back direction and slightly reduced control laterally, suggesting enhanced stability in the sagittal plane. See Outcomes section for numerical comparisons.

RWS measures dynamic balance and weight transfer ability, and this testing saw mixed results. Improvements were seen for on-axis velocity in forward/backward (F/B) direction, increasing from 3.8°/s to 4.8°/s, while left/right (L/R) velocity remained stable (5.5°/s–5.7°/s). Directional control improved in the F/B direction (61.3%–71.3%) but declined in the L/R direction (73.3%–62.3%).

Finally, the WBS evaluates stability and strength by comparing weight distribution at various squat depths. WBS results showed improved symmetry in shallow squat positions. At 0°, left-sided weight distribution increased from 32% to 44%; at 30°, from 28% to 37%. Deeper angles showed smaller changes, with slight decreases at 60° (−3%) and 90° (−5%).

In addition to these quantitative findings, clinically observed enhancement of patient engagement and motivation during MARS sessions was noted compared to traditional balance and standing tasks. The patient demonstrated verbal excitement, a greater willingness to attempt difficult tasks, and sustained focus, which highlight MARS’s potential to support a more positive and interactive rehabilitation experience, which can be particularly challenging in pediatric settings.^18,19 These insights, however, are based on therapist observation and clinical impressions recorded during sessions and are not formal outcome measures.

As all NeuroCom assessments were conducted as single trials, observed outcome changes should be interpreted within the context of both functional gains and inherent measurement variability, particularly in pediatric testing.

Discussion

This exploratory case report demonstrates the integration of MARS into a multidisciplinary rehabilitation program for a pediatric patient with a ruptured AVM. While Neurocom assessments revealed mixed quantitative outcomes in postural control and balance, observed improvements in specific dynamic balance metrics suggest the introduction of MARS may have played an important role in enhancing functional stability. For example, Directional Control (LOS) improved from 66% to 73%, indicating enhanced balance recovery accuracy. The AT showed improved postural stability under dynamic conditions, with sway control increasing in both toes-up and toes-down conditions. The observed improvements in weight-bearing symmetry during the WBS at 0° and 30° also indicate significant progress, aligning with documented mechanisms for improving gait mechanics. ²⁰

Although Neurocom results demonstrated several positive trends, the mixed findings warrant further interpretation. It is important to acknowledge that the assessments were performed as single trials, which may not fully account for session-to-session or intra-individual variability. While many metrics improved, some changes may reflect natural measurement fluctuation rather than true motor adaptation. For the LOS, the slight increase in reaction time and decrease in movement velocity may reflect more deliberate, controlled postural strategies typical of early motor relearning. ²¹ Similarly, the RWS findings showed improved forward–backward accuracy but reduced left–right directional control. This asymmetry may relate to the nature of MARS programming, which emphasizes task-relevant movements such as stair negotiation and forward walking, thereby strengthening sagittal plane stability more than lateral control. Given the patient’s concurrent improvements in activities of daily living and gains in other dynamic stability metrics, clinicians did not interpret the decreased L/R scores as indicative of increased fall risk. The WBS pattern likewise reflects the focus of the intervention, with improvements being most evident at shallower squat depths, whereas deeper flexion angles (60°–90°) were not a primary target and therefore showed smaller or inconsistent changes.

Enhanced sensory feedback and cognitive engagement may have facilitated motor relearning through improved sensory integration and error-based adaptation. These findings likely contributed to the observed functional improvements and align with findings from previous extended reality (ER) research (including MR, virtual reality (VR), and augmented reality (AR)), which has documented improvements across functional domains such as gait, balance, processing speed, memory, and global cognition.^10,11,22 A 2022 study by Malick et al. ²³ reported positive outcomes using AR-based interventions in the rehabilitation of spastic hemiplegic cerebral palsy in pediatric populations. A systematic review by Chen et al. ²⁴ demonstrated that VR is an effective mode of rehabilitation for improving motor function in children with cerebral palsy, highlighting the efficacy of ER in clinical cases.

Building on this literature, this case suggests that MARS is, at a minimum, a safe adjunct that offers added clinical value within pediatric neurorehabilitation. The feasibility and promise of MARS as a complementary tool for enhancing functional outcomes and psychosocial factors such as engagement, motivation, and satisfaction (based on therapist observations) is noteworthy,^25,26 highlighting its potential as an innovative MR device for improving motor learning and postural stability.

This case report is limited by its single-subject design, the absence of a control group, and the lack of long-term follow-up to assess the durability of effects. Although MARS was the primary tool used to address static and dynamic balance, concurrent therapies may have confounded outcomes, making it difficult to attribute improvements solely to MARS. In addition, the assessment relied solely on NeuroCom metrics, omitting non-instrumented or endurance-based tests that may better reflect functional gains. Patient- or parent-reported outcomes and fatigue measures were not collected, limiting insight into psychosocial and effort-related impacts.

Conclusions

This case study highlights the successful implementation of MARS within a multidisciplinary rehabilitation program for a pediatric patient with AVM rupture. The findings suggest feasibility and provide preliminary indications that MARS may complement existing pediatric neurorehabilitation practices, particularly in supporting patient engagement and adherence, as observed clinically by therapists, although the mixed quantitative outcomes highlight the need for cautious interpretation. Although promising, these findings warrant further study to assess scalability, durability of benefits, and suitability for broader clinical implementation.