Neurorehabilitation is a fundamental aspect in the treatment approach for multiple sclerosis (MS), in which new technologies have gained popularity, especially the use of virtual reality (VR). The aim of this paper is to analyze an occupational therapy (OT) intervention compared with OT + VR (OT + VR) on the manual dexterity of patients with MS. 26 MS subjects were initially recruited from an MS patient association and randomized into two groups. The OT group received 20 conventional OT sessions distributed in two sessions per week. The OT + VR group received 20 sessions of VR interventions, twice weekly and lasting 30 minutes, consisting of VR games accessed via the online web page
Multiple sclerosis (MS) is a chronic inflammatory demyelinating illness of the central nervous system (CNS) of unknown etiology, currently representing the most common neurological illness causing disability among young adults in Europe and North America [
Different disease courses exist for MS, according to the appearance of symptoms, characterized by relapses or flare-ups, which vary from one episode to the other, according to the affected CNS region. The different types of MS include relapsing-remitting MS, primary progressive MS, secondary-progressive MS, and progressive-recurrent MS [
The treatment of MS commonly features both pharmacological and rehabilitation treatments. Rehabilitation programs can increase the effectiveness of pharmacological treatment by providing symptomatic treatment of MS to improve the quality of life and functional independence of affected individuals. The main therapeutic demands are the alterations of postural control and the performance of activities of daily living (ADLs) [
At times, rehabilitation treatments for patients with MS can be very lengthy and systematic, leading to loss of motivation and compliance. As a result, in recent years, new intervention strategies have been introduced, such as virtual reality (VR), thanks to VR motion capture technology, without requiring a device or controller. These novel approaches enhance patient motivation by enabling the practice of functional tasks in virtual surroundings, providing patient feedback concerning results, all of which is based on the repetition of ADLs. Thus, rehabilitation professionals have expanded the care of patients with MS, by including this technology as a complement to rehabilitation programs, achieving a higher treatment intensity at a sustainable cost [
We conducted a single-blinded randomized controlled trial (RCT). Nonprobabilistic sampling of consecutive cases was used. The sample was divided into a control group (OT) who received conventional OT treatment and an experimental group (OT + VR) who received VR treatment in addition to their conventional treatment sessions. All interventions were performed at the Mostoleña Association of Multiple Sclerosis (AMDEM) in Madrid (Spain).
The study inclusion criteria were as follows: a diagnosis of MS according to the McDonald criteria [
The exclusion criteria were a diagnosis of another neurological illness or musculoskeletal disorder different to MS; the diagnosis of a cardiovascular, respiratory, or metabolic illness or other conditions which may interfere with the study; suffering a flare-up or hospitalization in the last three months prior to commencement of the assessment protocol or during the process of the therapeutic intervention; receiving a cycle of steroids, either intravenously or oral, six months prior to the commencement of the assessment protocol and within the study period of intervention; receiving treatment with botulinum toxin in the six months prior to the beginning of the study; or the presence of visual disorders noncorrected by optical devices.
All participating subjects voluntarily signed an informed consent form. The present study was approved by the Research Ethics Committee of the Rey Juan Carlos University (Ref 26/12).
Twenty-six subjects with relapsing-remitting MS were initially recruited and randomized into two groups by tossing a coin. Thereafter, 10 subjects could not complete the study due to relapses or noncompliance with the treatment program. Finally, the control group (OT) comprised eight participants (
Flowchart diagram.
Conventional OT treatment consisted of 20 sessions during which subjects performed activities for training manipulative and functional dexterity of the upper limb aimed at ADLs. These were distributed in two OT sessions per week, each lasting 30 minutes.
The intervention applied to the experimental group consisted of 20 sessions of conventional OT distributed in two sessions per week, each lasting 30 minutes. Additionally, they received 20 treatment sessions lasting 20 minutes, twice weekly of VR via the online and free website
All OT and OT + VR interventions were performed by two occupational therapists, one for each modality, experts on MS neurorehabilitation. All interventions considered the level of fatigue experimented by each patient based on a progressive increase in treatment times according to the same.
All assessments were performed by physical therapists trained in the use of the measures and blinded to the intervention received by the subjects. The following outcome measures were used in both groups, both at the beginning and at the end of the intervention.
The
The
All the subtests are performed with the nondominant hand first, followed by the dominant hand. The time the subject takes to perform each subtest is recorded.
The
All the data were introduced into the SPSS v.17.0 statistical package. A descriptive analysis of the quantitative variables was performed using measures of central tendency and dispersion measures: mean ± standard deviation (SD) and range. The pre-post comparison of each group and the comparisons between the control and experimental group were performed via the nonparametric Wilcoxon and Mann–Whitney
16 patients (8 males and 8 females) successfully completed the study. The mean age of subjects was 46.44 years (SD 9.09). Concretely, in the control group (4 males and 4 females), the mean age was 46.13 years (SD 9.49), and in the experimental group (4 males and 4 females), it was 46.75 years (SD 9.31). The age range in the OT group was 32–61 years, and in the OT + VR group, it was 33–62 years. For the totality of the sample, the dominant hand was the right in 62.5% of subjects. Regarding change in dominance (patients who had to change their dominance to the other hand due to impairment), in 25%, the dominant hand prior to the appearance of MS was the left, and for 75% of the sample, it was the right.
Participants from both study groups attended 100% of the proposed sessions in both protocols. No adverse effects were registered.
Regarding the pre-post intervention data for the PPT, in the case of the control group (Table
Differences pre-post intervention in Purdue Pegboard Test (PPT) in the control group and experimental group.
PPT | OT | OT + VR |
|
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Pretreatment | Posttreatment |
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Pretreatment | Posttreatment |
|
||
Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | ||||
DH | 6.25 ± 3.65 | 7.50 ± 4.07 | 0.319 | 7.50 ± 4.07 | 7.37 ± 3.37 | 0.792 | 0.832 |
NDH | 5.25 ± 3.57 | 4.00 ± 2.56 | 0.263 | 4.00 ± 2.56 | 4.25 ± 2.25 | 0.48 | 0.707 |
Bilateral | 3.54 ± 2.11 | 3.62 ± 1.99 | 1 | 3.62 ± 1.99 | 3.37 ± 2.06 | 0.577 | 0.665 |
Assemble | 2.57 ± 1.27 | 3.00 ± 1.63 | 0.518 | 3.00 ± 1.63 | 2.50 ± 2.22 | 0.785 | 0.448 |
Total number of pins | 17.61 | 18.12 | 0.898 | 18.12 | 17.49 | 0.602 |
DH: dominant hand; NDH: nondominant hand. Time in seconds.
Differences pre-post intervention in Jebsen-Taylor Hand Function Test (JTT) in the control group and experimental group.
JTT | OT | OT + VR |
|
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---|---|---|---|---|---|---|---|
Pretreatment | Posttreatment |
|
Pretreatment | Posttreatment |
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Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | ||||
Writing NDH |
93.25 ± 73.68 | 62.92 ± 42.92 |
|
62.92 ± 42.92 | 50.68 ± 39.57 | 0.866 | 0.655 |
Page turning NDH (time) | 7.98 ± 3.75 | 6.34 ± 2.30 | 0.889 | 7.80 ± 4.01 | 8.87 ± 3.25 | 0.208 | 0.248 |
Picking up small common objects NDH (time) | 13.22 ± 6.09 | 10.62 ± 4.15 | 0.779 | 16.24 ± 10.08 | 16.73 ± 10.19 | 0.327 | 0.6 |
Simulated feeding NDH (time) | 32.70 ± 32.66 | 17.75 ± 8.50 | 0.779 | 26.79 ± 19.09 | 26.34 ± 19.87 | 0.779 | 0.793 |
Stacking checkers NDH (time) | 10.68 ± 10.88 | 6.76 ± 5.78 | 0.674 | 13.90 ± 17.87 | 22.91 ± 35.00 | 0.208 | 0.294 |
Moving large light objects NDH |
8.15 ± 5.03 | 5.78 ± 2.05 | 0.08 | 6.98 ± 3.38 | 8.89 ± 5.71 |
|
0.345 |
Moving large heavy objects NDH (time) | 6.84 ± 2.67 | 5.39 ± 1.13 | 0.779 | 7.06 ± 2.20 | 7.64 ± 2.32 | 0.327 | 0.4 |
Writing DH (time) | 39.99 ± 21.68 | 38.40 ± 24.66 | 0.674 | 38.40 ± 24.66 | 37.21 ± 23.44 | 0.674 | 0.834 |
Page turning DH (time) | 8.00 ± 2.75 | 6.34 ± 2.30 | 0.093 | 6.34 ± 2.30 | 8.14 ± 3.16 | 0.069 | 0.208 |
Picking up small common objects DH (time) | 12.26 ± 2.14 | 10.62 ± 4.15 | 0.208 | 10.62 ± 4.15 | 13.02 ± 5.25 | 0.263 | 0.529 |
Simulated feeding DH (time) | 16.39 ± 4.84 | 17.75 ± 8.50 | 0.484 | 17.75 ± 8.50 | 19.09 ± 7.33 | 1 | 0.529 |
Stacking checkers DH (time) | 7.84 ± 4.47 | 6.76 ± 5.78 | 0.401 | 6.76 ± 5.78 | 8.15 ± 3.76 | 0.123 | 0.208 |
Moving large light objects DH |
6.12 ± 1.66 | 5.78 ± 2.05 |
|
5.78 ± 2.05 | 6.45 ± 1.87 |
|
0.294 |
Moving large heavy objects DH (time) | 6.11 ± 1.30 | 5.39 ± 1.13 | 0.208 | 5.39 ± 1.13 | 7.01 ± 1.93 | 0.263 | 0.093 |
Differences pre-post intervention in Grooved Pegboard Test (GPT) in the control group and experimental group.
GPT | OT | OT + VR |
|
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---|---|---|---|---|---|---|---|
Pretreatment | Posttreatment |
|
Pretreatment | Posttreatment |
|
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Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | ||||
Time NDH | 339.12 ± 277.94 | 340.25 ± 276.80 | 0.686 | 340.25 ± 276.80 | 336.18 ± 277.73 | 0.715 | 0.955 |
Number of fallen pegs (and collected to replace) NDH | 3.71 ± 2.98 | 4.85 ± 3.62 | 0.245 | 4.85 ± 3.62 | 5.37 ± 4.56 | 0.336 | 0.861 |
Number of correctly placed pegs NDH | 20.14 ± 8.47 | 21.14 ± 4.63 | 0.465 | 15.37 ± 9.67 | 21.14 ± 4.63 | 0.078 | 0.239 |
Time DH | 203.52 ± 83.98 | 185.40 ± 58.03 | 0.499 | 185.40 ± 58.03 | 205.58 ± 74.64 | 0.237 | 0.674 |
Number of fallen pegs (and collected to replace) NDH | 3.37 ± 3.20 | 2.50 ± 1.92 | 0.246 | 2.50 ± 1.92 | 3.25 ± 3.41 | 0.226 | 0.915 |
Number of correctly placed pegs NDH | 23.75 ± 3.53 | 24.00 ± 2.82 | 0.317 | 24.00 ± 2.82 | 22.75 ± 4.30 | 0.18 | 0.538 |
DH: dominant hand; NDH: nondominant hand. Time in seconds.
Table
The intergroup comparisons for the PPT revealed no statistically significant differences (
Our findings reveal that significant differences do not exist in the treatment of manual dexterity in subjects performing the OT + VR intervention when compared to those receiving conventional OT treatment. However, statistically significant differences were found in items such as “Picking up small common objects” using the nondominant hand and the dominant hand, with a tendency towards statistical significance in the case of “Number of correctly placed pegs” in the OT + VR group. Furthermore, several variables related to effectiveness and motor dexterity also showed a tendency towards statistical significance in both groups.
Regarding the conventional OT intervention, statistically significant differences were observed in the JTT test for the following items: “Writing” in the nondominant hand and “Picking up small objects” with the dominant hand. To our knowledge, this study is the first to evaluate manual dexterity in a population of MS, using the JTT. The results obtained may be due to the therapeutic approach of OT in patients with MS, based on the performance of functional activities with the upper limb, as well as training the change in hand dominance to enable a greater participation in ADLs [
Concerning the combined OT + VR interventions, the number of pins inserted between the initial and final assessments was maintained in the PPT test. Gallus et al. [
We found no differences between the application of OT and OT + VR on the manual dexterity of MS patients with a moderate level of impairment in the PPT, JTT, and GPT tests. However, clinical improvements were found after the OT + VR intervention, with improved precision of the upper limb movements, faster performance. and a greater efficiency in the performance of certain functional tasks. Previous qualitative studies [
As previously mentioned, we were unable to find previous scientific studies associating improvements in manipulative dexterity using OT treatment approaches combined with VR in patients with MS. Shin et al. [
This study has several methodological limitations. We used a small sample size, which hampers the detection of statistically significant differences, although these may well exist. Furthermore, a high number of losses occurred due to the fluctuating nature of the illness. Also, the outcome measures used had not been previously employed in the clinical context of MS; therefore, despite their good psychometric properties, this has hampered the discussion of results regarding the manipulative dexterity in patients with MS. Lastly, future studies should consider assessments with midterm follow-up.
Our results show that there are no significant differences regarding manual dexterity when comparing a conventional OT intervention with an OT + VR intervention in patients with MS with a moderate level of severity. However, patients receiving an OT + VR intervention showed clinical improvements in the precision of certain upper limb movements, faster execution times for certain tests, and greater effectiveness during certain functional tasks. Therefore, VR using video capture of upper limb movements could be a complementary intervention to OT in the treatment of manual dexterity in patients with MS.
All data used to support the findings of this study are included within the article.
The authors declare that they have no conflicts of interest.
CNWP, CGC, and LAT performed treatments; MIJT was responsible for the methodology; ABF, RCC, and RMOG were involved in writing and original draft preparation; RCC was involved in writing, editing, and reviewing of the manuscript.
The authors would like to thank the subjects who participated in this study, without whose co-operation it would have been impossible to complete the research.