Reimagining rehabilitation in Christianson syndrome: can virtual reality bridge the gap?

To the Editor,

Christianson syndrome (CS) is a rare autosomal recessive X-linked disorder with a mutation in the SLC9A6 gene, exhibited mainly in males with females as carriers. It is represented by intellectual disability, developmental delay, and regression. The clinical presentation of CS comprises autism or Angelman syndrome characteristics, microcephaly, sensory deficits, craniofacial dysmorphism, ataxia, absent verbal communication, seizures (epilepsy), low weight, height, and oculomotor palsy with reduced life span. The treatment plan for CS does not depend solely on medications, but effective rehabilitation training is a more significant symptomatic and supportive approach^[1].

Virtual Reality (VR) therapy is one of the emerging and optimistic treatment approaches for neurological disorders such as Parkinson’s disease, various postural control disorders, and mobility disorders. It provides high-intensity, repetitive visual, auditory, motor, and somatosensory stimuli to interact with cognitive, motor, and sensory functions, offering individuals’ feedback to sense their own body position and movement directions. This is based on visual tracking and an interactive environment reproducing the surrounding reality to coordinate their body position^[2,3]. Incorporation of sensory feedback, such as spatial audio and haptic feedback, enhances the feeling of an actual real surrounding in the virtual reality, further supporting rehabilitation^[3].

Globally, 2.5 million individuals have been reported to suffer from multiple sclerosis (MS). A 40-participant trial showed significant improvement of neurological functions for 19 individuals in the VR group compared to the non-VR group^[3]. The symptoms of MS often coincide with CS, highlighting the advancement of VR therapy. A study revealed that a patient 2 years poststroke exhibited improved sensorimotor functions using a PS2 EyeToy, a low-cost VR device. This demonstrates that low-cost VR devices can provide convenient home-based rehabilitation^[4]. Since sensorimotor dysfunction is seen in CS, applying VR technology should improve the sensory deficits. A 12-week VR program improved proprioception while maintaining balance in patients with Parkinson’s disease^[2]. Additionally, a cohort study of 16 healthy older adults showed that prompt gamma sensory stimulation via VR technology affects various sensory modalities^[5].

Despite all these advancements, the validity of VR programs is yet to be explored because of the highly expensive technologies that require great expertise to employ them. It is not fully confirmed if the virtual world experiences actually transfer to an individual’s daily habits and life. The social and societal acceptance of the VR devices’ usage is also crucial to create a safe environment for pupils to rehabilitate. Another challenge revolves around the heterogeneous nature of neurological disorders, which makes it difficult to perform homogeneous trials on patients, even if a much smaller group is considered. It may be addressed by the personalized phenotypic interventional approach that again requires a highly skilled healthcare team to give an individual treatment plan^[6].

As the burden of neurological diseases is increasing worldwide, it is necessary to address the rising sensorimotor disability by incorporating advanced rehabilitation. VR Therapy is changing the future of disability because of its real-life-based virtual reality, where patient engagement is optimal. So, for this purpose, research-based trials should be prioritized in order to learn VR therapy effectiveness, cost cost-effective programs with a skilled workforce must be started^[2,6]. The need for interdisciplinary approaches between artificial intelligence and medicine would help healthcare providers better understand the application of these fields^[6]. This highlights the need for integrated schemes and strategies between policymakers and healthcare professionals for further interventional investigations.

The focus of the current research on CS has mostly been on its genetic basis and its symptomatic treatment through traditional rehabilitation^[1]. However, similar neurological conditions highlighting the potential of using technological innovations in these aspects have also been pointed out by recent studies^[2,3]. Sensory-motor integration and quality of life, in general, could be improved via such technologies. One can make a connection between the CS symptoms, notably ataxia, loss of sensation, and behavioral regression, and the positive effects of VR on patients with similar problems in MS^[3], Parkinson’s disease^[2], or even Post-stroke^[4] rehabilitation, thus shedding light on the ways of overcoming the insufficient support therapies for rare X-linked disorders. To move forward in this direction, it is essential to conduct large-scale randomized controlled trials assessing the effectiveness of VR in CS patients, create affordable VR programs that can be used at home with little training, and establish collaborations among neuroscientists, technologists, and policymakers to make individual VR treatment a part of the clinical guidelines^[6]. This will not only improve the quality of life of such patients but also lead to a breakthrough in the field of rehabilitation.

In conclusion, VR-based therapy represents an emerging and potentially transformative modality in the management and rehabilitation of neurological disorders. Future efforts should focus on the establishment of standardized clinical protocols, the conduct of large-scale randomized controlled trials, and the integration of VR interventions into evidence-based clinical practice. These strategies are essential to validate efficacy, ensure safety, and optimize patient-centered outcomes, ultimately contributing to improved quality of life among neurological patient populations.

This letter to the editor adheres to the Transparency in the Reporting of Artificial Intelligence in Research (TITAN) guideline^[7].

Ethical approval

Not applicable – this article does not involve original research on human or animal subjects.

Consent

Not applicable – no patient identifiable data are included.

Sources of funding

The authors received no financial support for the research, authorship, or publication of this article.

Author contributions

T.I.: conceptualized the letter, performed the primary literature review, and drafted the initial manuscript. S.u.A.: contributed to background research, synthesis of evidence related to virtual reality-based rehabilitation, and critical revision of the manuscript for intellectual content. S.M.H.: assisted in refining the clinical context of Christianson syndrome, supported literature appraisal, and contributed to manuscript editing. M.T.: contributed to drafting and revising the manuscript, with emphasis on neurological rehabilitation frameworks and translational relevance. R.K.M.: supervised the overall development of the manuscript, provided senior intellectual input, performed final critical revisions, ensured compliance with journal and ethical standards, and serves as the corresponding author and guarantor, taking full responsibility for the integrity and accuracy of the work. All authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship, have reviewed and approved the final version of the manuscript, and agree to be accountable for all aspects of the work.

Conflicts of interest disclosure

The authors declared no potential conflicts of interest with respect to the research, authorship, or publication of this article.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Raghbendra Kumar Mahato.

Peer and provenance statement

Not commissioned, externally peer reviewed.

Data availability statement

Not applicable.

Acknowledgements

Not applicable.