In recent years a growing body of evidence has demonstrated the benefits of virtual reality (VR) rehabilitation for people with neuromuscular diseases. VR allows individuals to navigate through computer-generated environments allowing users to learn new movement techniques for real-world situations worlds such as crowded places where people move around or walk in uneven surfaces. VR allows for activity-based training by providing users with self-targeted and repetitive actions that provide immediate feedback.
The use of VR rehabilitation for people with Multiple Sclerosis (PwMS) is another emerging field. Very few studies have begun to examine its effects on balance and motor control for this population.
What is Virtual Reality?
Virtual Reality (VR) is a computer-generated three-dimensional environment where the person can interact with the environment using other electronic devices. VR technology provides sensory stimulation and feedback that alters brain function and enhances neuroplasticity as as well as motor learning. For this reason research investigating the effects of VR on individuals with Multiple Sclerosis (MS) has increased dramatically over the past decade.
Multiple sclerosis (MS) is a chronic inflammatory demyelination and destruction of nervous tissue due to an autoimmune disease affecting the central nervous system. Damaged neural structures and connections can lead to a number of symptoms such as ;
- Vision & hearing loss
- Impaired sense of coordination and balance
- Impaired motor control
- Cognitive decline
- Sexual dysfunction and bladder and bowel complications
VR interventions can be used in neurorehabilitation for balance gait and motor control training. It has been suggested that the use of VR is most beneficial for PwMS with motor deficits, especially early in disease progression or after diagnosis.  In the study discussed No one specified what type of MS the participants had. Also, no information was found on whether certain types of MS would benefit more from VR training than others. In PwMS, VR has been shown to enhance balance postural control and walking ability.  Although limited research has Studies that have been conducted have shown that VR can help reduce fatigue in the upper body, which is important for PwMS, who may be confined to a wheelchair and rely on their hands and upper body to use a powered wheelchair.  For those with a more advanced MS input interface Now available for wheelchairs, enabling them to participate in VR interventions. 
Goals of physical therapy for people with multiple sclerosis
- Assess function, posture, and movement.
- Maintain usable feature capability strength ROM balance etc.
- Identify and retrain missing components (eg, improve strength balance sensory coordination, etc.).
- Retraining for Activities of Daily Living (ADL) or Functional Activities.
- Suppresses abnormal tones and prevents abnormal movement patterns.
The impact of VR on Multiple Sclerosis
VR technology is integrated with cognitive-behavioral therapy programs, thereby improving an individual’s pain perception and coping strategies. VR-based games can also distract people from painful stimuli .
Studies have shown that rehabilitation using this technology can significantly improve motor control, sensory coordination, balance, and postural control compared with traditional treatment methods . Reasons for this may include;
- Real-time visual and sensory stimulation and feedback.
- Increase exposure to different environments.
- Heightened motivation and engagement.
- Repetitive motions of functional tasks.
Multiple studies support the use of VR systems to improve balance and postural control in PwMS. Training with the RemoviEM system significantly improved scores on the Berg Balance Scale (BBS) and Tinetti scales.  Furthermore, PwMS using the CAREN system showed significant Improvements to functional scope testing. 
Similar results were seen in a single case study of the use of the IREX system in conjunction with other athletic training systems, which resulted in improvements in the BBS and activity-specific balance confidence scales in one PwMS.  However, since this study was conducted on a single patient and the results In combination with other interventions, there was no direct association between positive changes in balance and postural control outcomes with the IREX system.
Finally, use an Xbox 360 console with Microsoft Kinect software and follow a gaming protocol chosen based on post-treatment difficulty and fatigue. Gaming agreement includes three titles Kinect Sports® Joy Ride® and Adventures® Instruct to use different body parts to throw and avoid objects to climb up obstacles and interact with the virtual environment. Significant improvements in the BBS Tinetti Scale Sensory Organization Test and Motor Control Test were shown using the Xbox 360 Kinect program. 
In conclusion, multiple studies have demonstrated the beneficial effects of VR rehabilitation on postural and balance control in PwMS.
Virtual reality allows individuals to practice functional goals and activities in a more realistic setting (such as the grocery store or walking across the street) rather than an “ideal clinical” setting. Set'. VR Boosts Confidence Performance Motivation and Engagement Functional tasks pass;
- Repetition of activities and sub-tasks,
- Increased sensory and visual feedback.
Multiple VR systems have been shown to significantly improve gait training in PwMS. For example, Baram and Miller used a VR headset to simulate a tiled floor and provided patients with visual cues in a closed-loop design during a 10-meter walk trial. They found visual cues Those using VR improved gait speed and step length during the VR-assisted trial and also had residual improvements after 10 minutes without the device. After the study, PwMS reported that their confidence in their walking ability had increased within a week of the course. 
There is limited research on the use of VR systems to reduce the risk of falls in PwMS. However, in one study, the CAREN-VR system was used to display a “road scene” that required the user to maintain balance while walking on a predetermined path.  PwMS is instructed to maintain They maintain their balance while crossing flat, straight and uneven surface areas. Users were asked to intercept 18 moving targets by hand as a secondary task while walking. The results of this study showed a significant improvement in patient performance on the Falls Efficacy Scale (FES-I). 
In addition to the physical aspects, VR can also improve behavioral and cognitive function in MS patients by alleviating symptoms of depression, anxiety, and stress that are common in MS patients .
The different VR systems that have been studied are described below:
Microsoft’s Kinect-Software RemoviEM: A System Using VR and Natural User Interface (NUI) to Aid PwMS in Motor Rehabilitation.  RemoviEM contains three exercise exercises: TouchBall TakeBall and StepBall. TouchBall encourages PwMS to exercise balance and weight Transitions and lateral movements of the torso, the individual has to “touch” different virtual objects that appear.  TakeBall facilitates coordinated and diagonal movements of the upper limbs, where PwMS uses both hands to move a virtual object to a specific destination.  The StepBall features PwMS balance and weight transfer while performing lateral movement in a single-leg pose by stepping over virtual objects that appear to avoid various obstacles. 
Figure 1 Microsoft Kinect software RemoviEM
GestureTek Interactive Rehabilitation and Exercise System (IREX): Standing in front of TV screens and cameras, PwMS will be able to see themselves in a VR environment on the screen. Various scenarios can be used to facilitate balance training, such as formula racing snowboarding Sharkbait and Soccer, focusing on weight transfer from the trunk or lower body.  Studies using the IREX system and PwMS are lacking, but it is currently used successfully in other neurological disorders such as stroke, spinal cord injury and traumatic brain injury injured
Xbox Kinect: The Xbox360® console with Microsoft® Kinect uses sensors to detect a participant’s position and speech. The system uses 3D technology to create avatars of patients, allowing them to participate in different virtual environments.  There are many games Available on Xbox Kinect software such as Kinect Sports® Joy Ride® and Adventures®, each with varying levels of difficulty. 
Fig 2. Xbox Kinect Program
VR headset device: It consists of a head-mounted display connected to a wearable computer, through which the user can see a virtual floor superimposed on the real floor. 
CAREN: An integrated reality system that can create a variety of simulated environments, including 3D visual sound and proprioceptive stimulation. Users stand on a motion platform in front of a large screen, and a virtual scene is projected in front of them. 
Figure 3. CAREN virtual reality program with PWMS motion task 
VR rehabilitation has been shown to have beneficial effects on neuromuscular disorders. While research on its effects on MS is still emerging, the studies discussed suggest that it has the potential to be used as an alternative treatment or in conjunction with traditional physical therapy. These systems are Relevant to physical therapy as it provides therapists with a new approach to treatment that better simulates the real world and better prepares PwMS with the skills needed to deal with real-world situations. The systems described can be used in therapy clinics and some in patients’ Family. Further research is needed to assess the effectiveness of VR in the treatment of PwMS, but studies of its impact so far have shown promising results.
- ↑ Eftekharsadat B, Babaei-Ghazani A, Mohammadzadeh M, Talebi M, Eslamian F, Azari E. Effect of virtual reality-based balance training in multiple sclerosis. Neurological research. 2015 Jun 1;37(6):539-44. doi:10.1179/1743132815Y.0000000013
- ↑ Jump up to:2.0 2.1 2.2 2.3 2.4 2.5 Kalron A, Fonkatz I, Frid L, Baransi H, Achiron A. The effect of balance training on postural control in people with multiple sclerosis using the CAREN virtual reality system: a pilot randomized controlled trial. Journal of neuroengineering and rehabilitation. 2016 Dec;13(1):13. doi:10.1186/s12984-016-0124-y
- ↑ Jump up to:3.0 3.1 3.2 Baram Y, Miller A. Virtual reality cues for improvement of gait in patients with multiple sclerosis. Neurology. 2006 Jan 24;66(2):178-8. doi:10.1212/01.wnl.0000194255.82542.6b
- ↑ Massetti T, Trevizan IL, Arab C, Favero FM, Ribeiro-Papa DC, de Mello Monteiro CB. Virtual reality in multiple sclerosis–a systematic review. Multiple sclerosis and related disorders. 2016 Jul 1;8:107-12.
- ↑ Ghasemi N, Razavi S, Nikzad E. Multiple sclerosis: pathogenesis, symptoms, diagnoses and cell-based therapy. Cell Journal (Yakhteh). 2017 Apr;19(1):1.
- ↑ Jump up to:6.0 6.1 6.2 6.3 6.4 6.5 6.6 Lozano-Quilis JA, Gil-Gómez H, Gil-Gómez JA, Albiol-Pérez S, Palacios-Navarro G, Fardoun HM, Mashat AS. Virtual rehabilitation for multiple sclerosis using a kinect-based system: randomized controlled trial. JMIR serious games. 2014 Jul;2(2). doi:10.2196/games.2933.
- ↑ Jump up to:7.0 7.1 Massetti T, Trevizan IL, Arab C, Favero FM, Ribeiro-Papa DC, de Mello Monteiro CB. Virtual reality in multiple sclerosis–a systematic review. Multiple sclerosis and related disorders. 2016 Jul 1;8:107-12. doi:10.1016/j.msard.2016.05.014.
- ↑ Jump up to:8.0 8.1 Mahajan HP, Spaeth DM, Dicianno BE, Brown K, Cooper RA. Preliminary evaluation of a variable compliance joystick for people with multiple sclerosis. Journal of rehabilitation research and development. 2014 Jul 1;51(6):951.doi:10.1682/JRRD.2013.01.0023.
- ↑ Malloy KM, Milling LS. The effectiveness of virtual reality distraction for pain reduction: a systematic review. Clinical psychology review. 2010 Dec 1;30(8):1011-8.
- ↑ Gutiérrez RO, Galan del Rio F, Cano de la Cuerda R, Alguacil Diego IM, González RA, Page JC. A telerehabilitation program by virtual reality-video games improves balance and postural control in multiple sclerosis patients. NeuroRehabilitation. 2013 Jan 1;33(4):545-54.
- ↑ Calabrò RS, Russo M, Naro A, De Luca R, Leo A, Tomasello P, Molonia F, Dattola V, Bramanti A, Bramanti P. Robotic gait training in multiple sclerosis rehabilitation: Can virtual reality make the difference? Findings from a randomized controlled trial. Journal of the neurological sciences. 2017 Jun 15;377:25-30.
- ↑ Eftekharsadat B, Babaei-Ghazani A, Mohammadzadeh M, Talebi M, Eslamian F, Azari E. Effect of virtual reality-based balance training in multiple sclerosis. Neurological research. 2015 Jun 1;37(6):539-44.
- ↑ Jump up to:13.0 13.1 Fulk GD. Locomotor Training and Virtual Reality‐based Balance Training for an Individual with Multiple Sclerosis: A Case Report. Journal of Neurologic Physical Therapy. 2005 Mar 1;29(1):34-42. doi:10.1097/01.NPT.0000282260.59078.e4.
- ↑ Jump up to:14.0 14.1 14.2 14.3 Gutiérrez RO, Galán del Río F, Cano de la Cuerda R, Diego A, Isabel M, González RA, Page JC. A telerehabilitation program by virtual reality-video games improves balance and postural control in multiple sclerosis patients. NeuroRehabilitation. 2013 Jan 1;33(4):545-54. doi:10.3233/NRE-130995
- ↑ Perez-Marcos D, Solazzi M, Steptoe W, Oyekoya W, Frisoli A, Weyrich T, Steed A, Tecchia F, Slater M, Sanchez-Vives MV. A fully immersive set-up for remote interaction and neurorehabilitation based on virtual body ownership. Frontiers in neurology. 2012 Jul 10;3:110.
- ↑ Maggio MG, Russo M, Cuzzola MF, Destro M, La Rosa G, Molonia F, Bramanti P, Lombardo G, De Luca R, Calabrò RS. Virtual reality in multiple sclerosis rehabilitation: A review on cognitive and motor outcomes. Journal of Clinical Neuroscience. 2019 Jul 1;65:106-11.
- ↑ Thornton M, Marshall S, McComas J, Finestone H, McCormick A, Sveistrup H. Benefits of activity and virtual reality based balance exercise programmes for adults with traumatic brain injury: perceptions of participants and their caregivers. Brain injury. 2005 Jan 1;19(12):989-1000. doi:10.1080/02699050500109944.
- ↑ Kizrony, R. Katz, N. Weingarde, H. Weiss, P.L. (2002). Proceedings from ICDVRAT ‘02. The 4th International Conference Disability, Virtual Reality and Associated Technology. Immersion without encumbrance: Adapting a virtual reality system for the rehabilitation of individuals with stroke and spinal cord injury. University of Reading, UK; ISBN.