Two-week virtual reality training for dementia: Single-case feasibility study

INTRODUCTION Dementia is a growing healthcare concern. The 2012 World Health Organization report on dementia estimated a worldwide prevalence of persons with dementia (PWD) at 35.6 million. This number is expected to double by 2030 and more than triple by 2050. Exercise has been shown to be physically and cognitively beneficial for numerous populations, including those with dementia. A recent systematic review on physical activity for PWD reported randomized controlled trials that assessed a wide range of exercise interventions including aerobics, stretching, and strengthening [1]. Selected outcomes of these trials included improved walking speed [2], improved strength and flexibility [3], and improved performance on the Timed "Up and Go" test (TUG) [4]. Virtual reality (VR) training has been shown to be an effective, motivating, and safe training tool when used alone or as an adjunct to conventional rehabilitation. Several studies have found objective improvements in clinical balance and mobility outcome measures in a variety of populations [5-8]. VR study protocols involve the adjustment of VR training parameters in order to meet the changing needs and rehabilitation goals of each individual patient. Task difficulty should reflect the skill level of the performer [9] in order to maximize performance outcome. Therefore, close monitoring of task difficulty while a patient is engaged in a stimulating environment will help ensure an appropriate level of challenge while maintaining engagement, motivation, and enjoyment. VR training is particularly well suited to allow such a versatile and engaging environment [10]. VR technology has been used with PWD for cognitive assessments [11] and cognitive training [12]. Multiple studies found that using virtual environments is feasible with PWD without problems of cybersickness or disorientation (e.g., Flynn et al. [13]). PWD are known to experience balance and mobility issues [14], and since previous studies have reported improvements in balance and mobility in other populations following an intensive VR training program, similar results could be expected in the PWD population. Because PWD can experience difficulty with exercise program adherence [15], the engaging and motivating nature of VR training may help alleviate this problem. The purpose of this study was to provide initial evidence (case study) of the effect of an intensive VR training program on balance and mobility in a veteran with dementia. The study was conducted on an outpatient basis over an 8 wk period. Because it was unknown whether this methodology and protocol would be feasible for an outpatient client with dementia and his caregivers, this case study had two objectives: (1) to explore the feasibility and safety of an intensive, outpatient-based, VR training exercise program for a veteran with dementia and (2) to assess the effects of VR training on balance and mobility in this individual. METHODS Participant Mr. YZ is a 78 yr old, right-handed veteran who met the criteria for vascular dementia. His score on the Montreal Cognitive Assessment [16], a well-accepted screening test of cognition, was 12/30 (less than 26 is abnormal; 12 is extremely low). At the time of the study, Mr. YZ was taking daily doses of acetylsalicylic acid (81 mg) in addition to Aricept via a patch. Bilateral subcortical microvascular disease was noted on brain imaging. Two years prior to his entry into this study, he presented with a right cortical ischemic stroke affecting his right occipital lobe. He had no known stroke risk factors. Physical examination revealed a left visual field deficit. Mr. YZ ambulated independently with occasional handheld guidance for cueing. He intermittently complained of right tibiofemoral joint pain. However, no palpable warmth, erythema, or limited range of motion were noted on assessment. He demonstrated full range of motion and strength within normal limits for his age in both upper limbs. …