Objective Longitudinal Monitoring of Postural Stability and Gait During Neurorehabilitation: Clinical Application of Instrumented Posturography and Three-Dimensional Motion Analysis

Posturometry: The Tecnobody ProKin stabilometer and posturometer device is currently one of the most effective for objective measurement of static and dynamic balance. The device can be used for both neurological and orthopedic patients. It can effectively measure the trunk control and sense of balance of patients in several ways: on stable or unstable surfaces, and standing on one or two legs. With the help of various programs, the device determines the oscillations of the center of mass (CoP) of the given patient's body, and is able to accurately determine the patient's proprioceptive perception. Furthermore, ProKin can examine the joint movements of the trunk and lower limbs together or even separately. Thanks to these quantified data, we have the opportunity to map the postural instability and balance disorders caused by different patient groups, and thus we will be able to provide a more accurate treatment for our patients. The ProKin device is not only excellent for diagnosis, but also for training, as it contains numerous interactive programs with which we can improve these stability difficulties.

3D motion analysis: With the help of the 3D motion analysis system (Xsens 3D Motion Capture), we can track and record patients' gait patterns in real time. Sensors were used to measure stride length, stride width, and the number of steps taken over a distance of 10 meters.

Exercise program: Each of the selected participants will participate in a training program, which would essentially be a neurorehabilitation training combined with virtual therapy. A session for patients receiving virtual therapy would be structured as follows: 5 minutes of warm-up, 25 minutes of training, 25 minutes of VR, and 5 minutes of cool-down. The main focus of the warm-up is primarily on increasing circulation and introducing them to the workout. While walking or jogging, the patients perform various trunk and limb mobilization and strengthening exercises, first without equipment, and then with equipment (Pilates ball, ball stick, weight ball). The primary focus of the training is primarily on restoring motor functions, which we try to achieve with coordination and balance development exercises, posture correction tasks, and general muscle strengthening. During the exercises, we regularly modify the directions, surfaces, and height levels. These changes can improve both coordination and balance extremely effectively. We also modify the speed of completing the tasks within and between tasks (slow/fast movement execution, length of pause between tasks). The exercises are mostly performed with some kind of device (Dynair cushion, Bosu, Fitball, coordination ladder, barriers, TRX, ball stick, Pilates ball, weight ball). Patients exercise in various body positions, but most exercises are done while walking or standing. One of the most important parts of the training is the development of gait, for which we perform stabilizing exercises and tasks practicing different step patterns with the given modifications and devices. The difficulty of the tasks is adapted to the patient's daily workload and performance capacity each time. The majority of the tasks consist of complex and compound exercises. This neurorehabilitation training significantly improves the adaptability of the nervous system, as the constantly changing sensory stimuli strongly stimulate it, thus developing increasingly better and more precise movements. Another important aspect is the development of cognitive functions in conjunction with movements, since with this level of neuromuscular stimulation (e.g., repetition of complex exercises), these skills can also improve. To implement VR therapy (also known as exergaming), we use Microsoft Xbox 360 and Xbox Kinect devices. These devices are able to sense and record the individual's shape, then place it in a virtual space, and imitate the patient's specific movements. During the therapy, we select three different programs: Kinect Adventure - Reflex Ridge, Kinect Adventure - Space Pop, and Just Dance. The essence of the Reflex Ridge program is that the patient's avatar moves forward on a platform rolling on rails, while constantly having to avoid obstacles from different directions. The system gives more points if the patient manages to avoid as many obstacles as possible without error, and thus the patient's performance can be easily reviewed. The difficulty level can be adjusted according to the frequency of the obstacles appearing. The essence of the Kinect Adventure - Space Pop program is a little more complex, as the patient needs to be able to move better in space. In the game, the participant performs complex spatial coordination tasks by moving their arms up and down and stepping in all directions of the space, trying to collect as many objects as possible, after which they receive points. In this program, reaction time and the ability to quickly change direction will also be the essential task. The third program is Just Dance, where patients have to imitate the movements of the avatars seen on the screen to given music as accurately as possible. The combined use of acoustic and visual stimuli develops motor functions more effectively, so this program proves to be an excellent choice in the rehabilitation of neurological patients. The performance of patients can also be monitored in this program, as after each level the system ranks the precise execution of movements with points, as well as the connection of movements into a continuous one. The cool-down part includes light walking exercises combined with breathing exercises, as well as a stretch designed to relax larger muscle groups.

Data are expressed as mean (±SD). The normal distribution of variables is checked using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Groups are compared at baseline using one-way parametric or Kruskal Wallis analysis of variance. The extent of changes within groups is checked using paired T-test or Wilcoxon test according to the result of the normality test. The results of the groups are interpreted as the difference between the post-intervention and baseline scores. Significant differences between groups are determined using one-way parametric or Kruskal Wallis analysis of variance in the results. Tukey's post hoc test is used to identify values less than p<0.05 between each group. To examine the effect size within groups, Cohen's d is used (very small, 0.01; small, 0.20; medium, 0.50; large, 0.80; very large, 1.20; huge, 2.00) to determine the size of the effects over time. The data are processed using Microsoft Excel and R software.