Walking in relation to participation after stroke; is virtual reality training of added value?

A stroke can lead to severe physical and cognitive impairments. As a result of these impairments, many people experience problems with walking after a stroke, such as when walking on irregular terrain or walking in a busy shopping area. Because of these problems with walking people are restricted in their social functioning, also referred to as participation. They can experience difficulties with work, hobby’s, household tasks, and doing the groceries, for example. The thesis of Ilona de Rooij gives insight in the problems that people experience with walking after a stroke and how these problems relate to restrictions in participation. More insight in the problems that people experience with walking and participation, and the association between both, can help to further direct the content of gait rehabilitation. In addition, this thesis investigated the feasibility and effect of virtual reality (VR) training to improve walking ability and participation of people after stroke. VR offers new training opportunities to improve walking ability. High-end VR systems, such as the GRAIL (Gait Real-time Analysis Interactive Lab), create a challenging but safe training environment in which real-life situations can be simulated. The research shows that people who have the physical capacity to walk independently can still have considerable difficulty with walking and participation. People experience multiple barriers to walking and gait-related activities, in both movement-related functions, cognitive functions, personal factors, and environmental factors. Various aspects of walking ability are important for walking in daily life, including the ability to adjust walking to environmental demands. This adjustment of walking is extra difficult for people after stroke. The studies in this thesis show that VR gait training is safe and feasible. The experiences of people after stroke with the VR training were very positive. VR training can contribute to improvements in walking and participation after stroke. The VR gait training was, despite positive results, not significantly better than a gait training without VR for improving walking ability and participation. This suggests that both VR gait training and non-VR gait training can be applied in stroke rehabilitation. VR training seems a valuable addition to the existing training interventions, as high-end VR systems can provide opportunities to train advanced aspects of walking ability in a challenging but safe environment. Using reflective markers that are placed on the body, people can interact with the virtual environment and receive real-time feedback. People can also be challenged to perform dual tasks and to respond to unexpected perturbations. VR gait training may, therefore, be incorporated in the range of interventions for stroke rehabilitation. VR training can then be carefully considered depending on the therapeutic goals and the characteristics of the patient