Temporal virtual reality-guided, dual-task, body trunk-balance training in a sitting position improved persistent postural-perceptual dizziness: proof of concept

doi:10.21203/rs.3.rs-801139/v1

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Temporal virtual reality-guided, dual-task, body trunk-balance training in a sitting position improved persistent postural-perceptual dizziness: proof of concept

https://doi.org/10.21203/rs.3.rs-801139/v1

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Background

Persistent postural-perceptual dizziness (PPPD) is a newly defined disorder of functional dizziness. Due to its recent discovery, definitive treatment for PPPD has not been established; therefore, this study aimed to measure the effectiveness of virtual reality (VR)-guided, dual-task, body trunk balance training using the mediVR KAGURA system for the treatment of PPPD.

Methods

Data from patients with PPPD collected from January 1, 2021 to February 28, 2021 were reviewed. Additionally, healthy people were included as controls. VR-guided training was performed using 100 tasks for 10 min. Equilibrium tests were performed at baseline and immediately after VR-guided training to examine the effectiveness of static and dynamic balance ability. Additionally, assessments of clinical questionnaire-based surveys of balance disorders were performed at baseline and 1 week after VR-guided training to examine the effects on the symptoms related to balance disorders. The primary outcome was the usefulness of static and dynamic body balance and NPQ scores.

Results

VR-guided training using mediVR KAGURA improved objective symptoms, including static and dynamic postural stability (relating to somatosensory and visual weighting, respectively) even when the training was conducted once for 10 min. Additionally, VR-guided training improved the Hospital Anxiety and Depression Scale score and the Niigata PPPD Questionnaire score, 1 week after a 10-min training session.

Conclusion

VR-guided training was found to be a viable method in managing the balancing ability, anxiety, and symptoms of patients with PPPD. VR-guided training offers safety and reduction of human resources; however, its clinical efficiency warrants further evaluation in prospective studies.

Trial registration

Institutional Ethics Committee of Kitano Hospital, approval number: 1911003. Registered 18 December 2019, https://kitano.bvits.com/rinri/publish_document.aspx?ID=426

Health Economics & Outcomes Research

Physical Medicine & Rehab

Medical Informatics

Virtual reality

Persistent postural-perceptual dizziness

rehabilitation

Virtual reality (VR) technology has been recently introduced in a variety of clinical settings, including physical, occupational, cognitive, and psychological rehabilitation or training [1, 2]. In particular, the application of VR technology in body balance training of patients with neurological disorders such as stroke has interested physicians and therapists. Additionally, this technology can be applied for rehabilitation post walking disabilities, particularly in older people presenting with disuse syndrome after a lengthy hospitalization. This technology has the potential to overcome the lack of human and economic resources in rehabilitation medicine; however, the clinical efficacy of VR rehabilitation compared with traditional methods remains unclear [1–4]. Few reports regarding VR rehabilitation for a walk or balance training using a Wii Fit (Nintendo, Kyoto, Japan) have been published; however, none have validated improvement in walking or balancing in patients with chronic vestibular disorders [5, 6]. Recently, some researchers reported successfully managed cases of muscle atrophy or cerebellar ataxia resistant to traditional therapeutic management using VR-guided, dual-task, body balancing training (mediVR KAGURA, mediVR, Inc., Toyonaka, Japan, commercially available from February 4, 2019) [7, 8]. The mediVR KAGURA system was developed to help patients regain their walking ability through the improvement of dual-task processing and trunk balancing [7, 8].

Persistent postural-perceptual dizziness (PPPD) is a functional dizziness disorder characterized by persistent chronic vestibular syndrome lasting for > 3 months, typically preceded by acute vestibular disorders [9]. Furthermore, the International Classification of Diseases 11th edition states that it was previously referred to as phobic postural vertigo (PPV) and chronic subjective dizziness (CSD) [10]. PPPD is characterized by core vestibular symptoms, including dizziness, unsteadiness, or non-spinning vertigo, and it is exacerbated during upright posture/walking, active or passive movement, or complex visual stimuli exposure [10]. In particular, the presence of three exacerbating factors is a characteristic of PPPD [10]. An accurate assessment of symptoms, exacerbating factors, and medical history is essential for diagnosing PPPD since no specific laboratory test is available [10]. The disorder is caused by long-term maladaptation to a neuro-otological, medical, or psychological event that triggered vestibular symptoms. Additionally, it is considered within the spectrum of other functional neurological disorders. Furthermore, studies of PPV and CSD suggest long-term benefits of early treatment [11, 12]. An intractable and persistent disease usually implies a higher degree of maladaptation, more severe disability, and more engrained illness beliefs. Despite a standardized method of diagnosing functional dizziness has been formulated, various phenomena, including comorbidities, triggers, and precipitating factors, urged patients to consult. Therefore, an individualized approach should be appropriate for managing functional dizziness. Currently, definitive treatment for PPPD from randomized controlled trials is yet to be approved. Different therapeutic methods have been investigated to manage PPPD, including selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) [9, 13], vestibular rehabilitation [13–15], cognitive-behavioral therapy (CBT) [16–18], and electrical stimulation [19, 20].

Herein, we investigated the effectiveness of VR-guided, dual-task, body trunk balance training for the management of PPPD using the mediVR KAGURA system.

Participants

Patient records obtained from January 1, 2021 to February 28, 2021 were retrospectively reviewed; data were analyzed in March 2021. This study included patients who met the following criteria: (i) between 20–100 years of age; (ii) obtained a score of > 27 on the Niigata PPPD Questionnaire (NPQ) as described in [21] Supplementary Table 1; (iii) visited the hospital more than twice between January 1, 2020 and December 31, 2020. Patients who presented comorbidities that would prevent the completion of the study were excluded; this included individuals with asthma, uncontrolled cardiac, pulmonary, gastrointestinal, renal, hepatic, endocrine, musculoskeletal, or oncological disorders. Clinical diagnosis of vestibular disorders, which preceded PPPD was based on the diagnostic criteria published by the Japan Society for Equilibrium Research [22, 23] and the Barany Society [10].

Healthy people were included as controls. The control group included participants who met the following criteria: healthy people aged between 20 and 100 years. The exclusion criteria were as follows: (i) history of vertigo/dizziness; (ii) presence of comorbidities that would prevent the completion of the study, including asthma, uncontrolled cardiac, pulmonary, gastrointestinal, renal, hepatic, endocrine, musculoskeletal, or oncological disorders.

Study design and outcome measures

The results of the clinical questionnaires regarding balance disorders and equilibrium tests were compared before and after VR training. VR-guided training was performed for 100 tasks for 10 min each. Equilibrium tests were performed at baseline and immediately after the VR-guided training to examine the effects on static and dynamic balancing ability. Additionally, assessments using clinical questionnaires evaluating vestibular disorders were performed at baseline and 1 week after the VR-guided training to examine the effects on the symptoms related to vestibular disorders.

Patients were administered medications indicated for vertigo and dizziness; other medications were not limited. Additionally, all patients were instructed to perform vestibular rehabilitation to acquire vestibular compensation via the vestibulo-ocular reflex three times at home.

The primary outcome was the effect on static and dynamic body balance and NPQ scores for patients with PPPD.

Detailed methods for VR training

In the 3D virtual space, the participants were instructed to catch red or blue falling objects or touch red or blue fixed targets with their right- or left-hand controllers, respectively. The training was performed with the patient in the sitting position to ensure safety; training while standing was prohibited according to the manufacturer’s instructions. The mediVR KAGURA system can provide video game-like training to enhance motivation and ensure adherence. The therapist can help patients undergo training in a dual-task fashion utilizing various levels of physical and cognitive stimulation through seven parameters. These parameters include distance, angle, height, and size of the object; size of the controller; inter-task interval; and falling speed or time limit for each task (Fig. 1a).

Cognitive stimulation was designed to emulate how cognitive and attention functions are processed while walking. For example, a red object should be caught using the right-hand controller, and the blue object should be caught using the left-hand controller. Differentiation of the color of objects emulates the cognitive processing required to differentiate traffic signals. Considering the seven parameters, recognizing a new object in 3D space and a timely reaching response emulates the cognitive processing involved in hazard perception and facilitates hazard avoidance, such as colliding with other people while walking (Fig. 1b).

The VR system places a radar screen at the center of the head-mounted display to indicate the direction of the next task, and the patient needs to refer to this radar screen regularly. Some gaming characteristics have been added to divert attention away from the radar screen to evaluate or train the patient’s attentiveness.

Detailed methods for assessments

Methodological details and criteria regarding the questionnaires and equilibrium tests are described in Supplementary Table 1. The clinical questionnaires administered were the NPQ [21], the Dizziness Handicap Inventory (DHI) [24, 25], Hospital Anxiety and Depression Scale (HADS) [26, 27], orthostatic dysregulation (OD) questionnaires [28, 29], Graybiel’s motion sickness test [30], and the Pittsburgh sleep quality index (PSQI) [31, 32].

Equilibrium tests included stabilometry with or without foam posturography to assess steady-state postural control [33], and the Foulage stepping test was used to assess dynamic postural control. During stabilometry, the patients were instructed to stand on a strain-gauge force platform (GP-5000 stabilometer; Anima, Tokyo, Japan) for 60 s with their eyes open or closed and with or without the foam rubber [34]. Measurements were performed under background noise conditions (approximately 50 dB). The six parameters were measured [34]. Additionally, to assess vestibular weighting, the velocity of the center of pressure (COP) and the envelopment area traced by the movement of the COP were obtained in the eyes closed/foam rubber position (velocity: VCF, area: ACF). The velocity and area of the Romberg’s ratios were obtained (velocity: VRF, area: ARF) to assess visual weighting. The velocity and area of foam ratios (ratio of a measured parameter with or without the foam rubber) were obtained in the eyes closed position (velocity: VFCF, area: AFCF) to assess somatosensory weighting.

For the dynamic equilibrium test, the Foulage test was used [35–37]. It is a quantified stepping test regulated at 120 bpm. The patient is instructed to stand upright with both arms set on the side of the body, and the foot closed with toes continuously touching the plate so that the object can change only according to the height of the heels to rise up alternatively [35, 36, 38]. The parameters of the Foulage test are FT values (area of front-back width of the locus) with open and close and dynamic Romberg’s ratio (FT value closed/open) [35, 36, 38].

Statistical analyses

Power and sample size calculations were conducted before and after data collection using the PS software (Ver. 3.1.6, Vanderbilt University, Nashville, TN) [39]. For group comparisons, we used two-way analysis of variance followed by multiple comparisons, a two-stage linear step-up procedure of Benjamini, Krieger and Yekutieli to avoid an inflated Type I error rate because the data were normally distributed. For non-parametric analysis of non-normally distributed subjective variables, Mann–Whitney U tests were used. For parametric analysis of normally distributed subjective variables, paired t-tests were used to investigate changes in the questionnaire and equilibrium test results before and after training to avoid Type I error. Residual plots were used to confirm the accuracy of the assumptions made for outcomes. Missing values were imputed by the random forest method. Statistical significance was set at P < 0.05. Evaluations were determined as “not applicable” if the calculated sample size after data collection was found to be insufficient for statistical analysis. All statistical analyses were performed with GraphPad Prism version 8.0.0 for Windows, GraphPad Software, San Diego, California USA, www.graphpad.com.

Patients and Subjects

A total of 18 patients were included in this study that received VR-guided training: 12 outpatients with PPPD (3 men, 9 women; central age ± standard deviation (SD): 58.0 ± 17.1 years) and six controls (4 men, 2 women; central age ± SD: 55.0 ± 6.6 years). Detailed information is shown in Table 1.

Table 1

Demographic information of patients
	PPPD patients (n = 12)	Control (n = 6)	p value
Age	58.0 ± 17.1	55.0 ± 6.6	0.25^a
Sex (M:F)	3:9	4:2	0.20^b
Preceded vestibular disease	Meniere’s disease: 11 BPPV: 1	NA	NA
PPPD, persistent postural-perceptual dizziness
a: Unpaired t-test, b: Fisher’s exact test.

Static postural stability was improved by the mediVR KAGURA-guided training in PPPD patient group

To examine the changes in the static postural stability after mediVR KAGURA-guided training in patients with PPPD, the changes in the parameters regarding vestibular weighting (VCF and ACF), visual weighting (VRF and ARF), and somatosensory weighting (VFCF and AFCF) were assessed. There were no significant differences found in all parameters of foam posturography in the control group (Fig. 2a–f, VCF: P = 0.64, ACF: P = 0.51, VRF: P = 0.63, ARF: P = 0.33, VFCF: P = 0.93, AFCF: P = 0.60). The patient group demonstrated a significant decrease in the ACF and increase in the VFCF after the mediVR KAGURA-guided training (Fig. 2g–l, VCF: P = 0.16, ACF: P = 0.04, VRF: P = 0.31, ARF: P = 0.14, VFCF: P = 0.02, AFCF: P = 0.05).

Furthermore, ACF in the patient group at baseline and after the mediVR KAGURA-guided training were significantly higher compared to the control group (Fig. 2n, before; P = 0.03, after; ACF: P = 0.03). However, other parameters were not significantly different between the groups (Fig. 2m, o–r, before, VCF: P = 0.12, VRF: P = 0.84, ARF: P = 0.45, VFCF: P = 0.24, AFCF: P = 0.61; after, VCF: P = 0.06, VRF: P = 0.24, ARF: P = 0.45, VFCF: P = 0.86, AFCF: P = 0.61). Furthermore, the rate of improvement was compared to investigate the effect of the mediVR KAGURA-guided training; however, no significant difference was found between the groups. (Fig. 3a–f, VCF: P = 0.38, ACF: P = 0.45, VRF: P = 0.17, ARF: P = 0.20, VFCF: P = 0.20, AFCF: P = 0.38).

Dynamic postural stability might be partly improved by mediVR KAGURA-guided training in PPPD patient group

To examine the changes of dynamic postural stability after the mediVR KAGURA-guided training in patients with PPPD, the parameter changes of the FT value with open or closed eyes were compared. All parameters of the control group improved significantly (Fig. 4a, b, FT value with open eyes: P = 0.03, FT value with closed eyes: P = 0.03). However, there was no significant difference observed in the patient group (Fig. 4c, d, FT value with open eyes: P = 0.10, FT value with closed eyes: P = 0.25). Additionally, the dynamic Romberg’s rate increased significantly in the patient group after the mediVR KAGURA-guided training compared to that before (Fig. 4f, P = 0.01); however, there were no significant differences found in the control group (Fig. 4e, P = 0.34).

Furthermore, FT values of the patient group at baseline and after the mediVR KAGURA-guided training were significantly higher compared to the control group when the eyes were closed (Fig. 4h, before; P = 0.01, after; P < 0.001); however, there was no significant difference found when the eyes were open (Fig. 4g, before; P = 0.88, after; P = 0.88). Regarding the dynamic Romberg’s rate, it was significantly higher in the patient group after the mediVR KAGURA-guided training compared to the control group (Fig. 4i, P = 0.01); however, there was no difference found before the mediVR KAGURA-guided training (Fig. 4i, P = 0.59).

Subjective symptoms regarding anxiety and PPPD improved after the mediVR KAGURA-guided training in PPPD patient group

The clinical questionnaire surveys related to vestibular disorders were analyzed at baseline and after the mediVR KAGURA-guided training to examine changes in subjective symptoms. In this regard, the control group was not assessed since all parameters were negative. In the patient group, results showed that the HADS, HADS-A, NPQ, and all NPQ subcategories significantly improved after the mediVR KAGURA compared to those at baseline (Fig. 5e, f, h, I, j, k, HADS: P = 0.04, HADS-A: P = 0.01, NPQ: P = 0.005, NPQ upright posture/walking: P = 0.02, NPQ movement: P = 0.005, NPQ visual stimulation: P = 0.002). There were no significant differences in other parameters between baseline and after the mediVR KAGURA-guided training (Fig. 5a, b, c, d, g, l, m, n, DHI: P = 0.08, DHI-P: P = 0.18, DHI-E: P = 0.06, DHI-F: P = 0.16, HADS-D: P = 0.24, OD: P = 0.17, PSQI: P = 0.50, Graybiel’s motion sickness score: P = 0.31).

This study aimed to determine the effectiveness of VR-guided training for the management of PPPD using the mediVR KAGURA system. Patients with PPPD showed improvements in objective symptoms, including static postural stability (both vestibular and somatosensory weighting), immediately after only one 10-min VR-guided training session. Additionally, this training improved anxiety and all the NPQ subcategories of the symptoms of patients with PPPD after 1 week. Consequently, these findings broaden the possibilities of PPPD management.

PPPD is a newly defined diagnostic syndrome that unifies key features of PPV, CSD, and other related disorders [10]. The exact pathophysiology of PPPD remains to be elucidated; however, physiological, structural, and functional neuroimaging studies of patients with PPV, CSD, and PPPD have revealed three mechanisms that can potentially explain the development of PPPD. These mechanisms include stiffening of postural control, a shift in processing spatial orientation information to favor visual over vestibular inputs, and failure of higher cortical mechanisms to modulate the first two processes [9, 40–45]. Psychological and functional comorbidities develop from maladaptive cognitive-behavior responses, which include acrophobia, anxiety or depressive disorders, and functional gait abnormalities. Therefore, management strategies for PPPD include, 1. therapy for comorbidities, including vestibular diseases; 2. reweighting the sensory postural control; and 3. desensitization to increase the tolerance of perceived stimuli. SSRI and SNRI utilize strategies 1 and 2 by regulating serotonin in the central brain system [3, 4]. PPPD rehabilitation strategies rely on the re-adaptation of the vestibular control systems; therefore, vestibular suppressant drugs, including antihistamines and benzodiazepines, should be avoided to prevent delays in rehabilitation [46]. Vestibular rehabilitation is a general term for a range of physical treatments that utilize habituation exercises and relaxation techniques to desensitize a hyperactive vestibular control system present in vestibular and neurological diseases [13–15]. Vestibular rehabilitation utilizes strategies 2 and 3. CBT uses guided self-observation of physical, emotional, and psychosocial levels to abandon maladaptive cognitive-behavioral cycles. Furthermore, desensitizing exercises can be used to increase the tolerance of perceived disequilibrium and reduce automatic high-risk postural strategies [16–18]. Thus, CBT utilizes strategy 3. Additionally, recent studies have provided evidence of the effectiveness of altering brain activity and structure in patients with PPPD using transcranial direct current stimulation to the left dorsolateral prefrontal cortex [19] and non-invasive vagus nerve stimulation [20], which use strategy 2.

The use of conventional approaches in the quantitative performance of postural balance training may be ineffective [4, 7]. VR creates interactive, multimodal sensory stimuli that offer unique advantages over other approaches in neurorehabilitation. VR facilitates an easy, prompt, quantitative, and replicable training method by accurately setting the distance, angle, height, or other parameters in a 3D virtual space [4, 7]. The therapist’s only responsibility is to adjust these parameters by inputting numbers on the operating panel of the computer. Moreover, the unpredictable nature of VR-training tasks may require significantly greater precise postural control of the patients. Consequently, tailor-made, optimized, and unpredictable VR-guided training tasks resulted in greater improvements in postural and trunk balance compared to conventional approaches, even when performed in a sitting position. VR ameliorates cognitive and motor functions in neurorehabilitation [1]. Several benefits have been widely reported in relation to motor function: upper limb and improvement in balance and gait [47], neuromotor monitoring of recovery [48], improvement of strength fitness, skills [49], improvement in the range of movement of the shoulder, and reduction in spasticity [50]. Furthermore, psychological and cognitive benefits were reported when the VR device was adapted to the patient, such as improvement in attention or memory stimulation and decreased depression symptomology in elderly participants. [1, 51] Thus, VR devices can be used as effective tools to motivate patients during rehabilitation sessions [52], to improve spatial orientation and attention in daily life activities [53], and to improve pain relief scores and emotional aspects related to functionality [51]. Additionally, a VR training environment will provide participants with task-specific training, accurate sensory and tactile feedback, and motivation [54]. Thus, mediVR KAGURA dual-task training might provide cognitive and motor function neurorehabilitation.

In our present study, improvements in the NPQ scores and static postural stability regarding vestibular and somatosensory weighting were speculated to be caused by retuning, desensitizing, and reweighting the impaired balance control via amelioration of cognitive and motor function in patients with PPPD. Additionally, anxiety scores also improved due to mediVR KAGURA training. This was accomplished using tailor-made, optimized, and unpredictable VR-guided training tasks and relaxation techniques by therapists (strategies 2 and 3) using the mediVR KAGURA system. Likewise, conventional dual-task training is provided by asking patients to talk with the therapist, count backward from 100 to a specific number, or simultaneously perform tasks, such as playing rock-paper-scissors while walking [46, 55]. During our VR-guided rehabilitation sessions, the patient had to constantly think of the next task, including the timing of the fall of the next object, followed by timed reaching tasks, to emulate the conditions of hazard perception and avoidance. Compared to augmented and mixed reality technologies, VR may be more appropriate in providing patients with uniform and replicable environments for cognitive stimulation or evaluation. Variations in the environmental information and location in augmented or mixed reality technologies present challenges in standardization. These methods may be useful for patients with PPPD who have sensitized and weighted their vestibular control systems since they are unable to imagine the real world and real life.

However, we could not suggest improvements in dynamic postural stability in patients with PPPD using our VR system. Especially, the dynamic Romberg’s rate worsened in the patient group. Romberg’s rate indicates the visual weighting during the balance test. Those were speculated to be caused by sensory over-reweighting on the vestibular, visual, and somatosensory senses, since visual weighting relatively decreased, as the results showed that static postural stability regarding visual weighting (VRF and ARF) did not improve in patients with PPPD. Additionally, dynamic postural stability improved in the control group, which enhanced the significant differences between control and patient groups. However, we suspect that further VR-guided training by the mediVR KAGURA system will improve the dynamic postural stability in patients with PPPD through “adequate” sensory reweighting. Additionally, we should investigate more appropriate conditions of VR training.

It is also important to note how the use of VR applications in the future may benefit from larger pooled automated data and artificial intelligence. For example, if eye trackers become a standard feature of VR in every headset, this could generate data from healthy controls and individuals with disabilities. This may lead to results that can allow equality of performance, where people with disabilities could interact competitively with people with typical development—we advocate that this should be explored in future studies.

This study has several limitations. First, VR-guided training was only performed once and for a relatively short time. Consequently, adjustments to the settings and treatment were not attempted, considering longer interventions are more effective [55]. Furthermore, the advantages and disadvantages of VR-guided rehabilitation remain unclear. A case report stated that VR-guided training increases the enjoyment and effectiveness of rehabilitation [55]. Additionally, comparisons were not made between VR-guided training and other rehabilitation devices or programs. Further research of randomized comparisons between the mediVR KAGURA and other rehabilitation programs is necessary to further validate its effectiveness.

VR-guided, dual-task, body trunk balance training improved the static balance ability, NPQ scores, and HADS-A scores of PPPD patients even if they underwent training only once. Therefore, VR-guided training in the sitting position offers safety and reduction in the need for human resources; however, the clinical efficacy of this training warrants further evaluation using prospective studies.

PPPD: Persistent postural-perceptual dizziness

VR: vertual reality

NPQ: Niigata PPPD Questionnaire

PPV: phobic postural vertigo

CSD: chronic subjective dizziness

SSRI: selective serotonin reuptake inhibitors

SNRI: serotonin-norepinephrine reuptake inhibitors

CBT: cognitive-behavioral therapy

DHI: the Dizziness Handicap Inventory

OD: orthostatic dysregulation

PSQI: Pittsburgh sleep quality index

COP: center of pressure

VCF: The velocity of COP in the eye closed/foam rubber condition

ACF: The envelopment area tracing by the movement of the COP in eyes closed/foam rubber condition

VRF: Romberg’s ratio of velocity with foam rubber

ARF: Romberg’s ratio of area with foam rubber

VFCF: Foam ratio of velocity in eyes closed/foam rubber condition

AFCF: Foam ratio of area in eyes closed/foam rubber condition

FT: Foulage test

SD: standard deviation

The study adhered to the tenets of the Declaration of Helsinki.

Ethics approval and consent to participate

This study was conducted with the approval of the Kitano Hospital Clinical Research Ethics Committee (Approval Number: 1911003). The participants provided written informed consent.

Consent for publication

All participants gave consent for this publication. All participants enrolled in the study provided written informed consent.

Availability of data and materials

All data that support the findings of this study are available from the corresponding author, Toru Miwa, upon reasonable request.

Conflict of interest

Masahiko Hara is a stockholder of mediVR, Inc., a company with unlisted stock and ongoing international Patent Cooperation Treaty applications that holds several patents on VR-guided rehabilitation. However, this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Any other authors have no conflicts of interest to declare.

Funding

This research received no specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions

TY and TM (investigation, project administration, methodology, visualization, writing—original draft, data curation, formal analysis, conceptualization, writing—review & editing, validation). KT, FI, and NU (investigation, project administration and methodology). MH (project administration, methodology, software, conceptualization, resources and validation). TM and SK(supervision, resources, validation). All authors have approved the final version of this manuscript.

Acknowledgements

Speech therapist Shoko Noda helped in performing the experiment. We would like to thank Editage (http://www.editage.com) for editing and reviewing this manuscript for English language.

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Supplementary Table 1. Overview of the assessment tools used in this study and their respective scoring systems

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Temporal virtual reality-guided, dual-task, body trunk-balance training in a sitting position improved persistent postural-perceptual dizziness: proof of concept

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Abstract

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Background

Methods

Participants

Study design and outcome measures

Detailed methods for VR training

Detailed methods for assessments

Results

Patients and Subjects

Static postural stability was improved by the mediVR KAGURA-guided training in PPPD patient group

Dynamic postural stability might be partly improved by mediVR KAGURA-guided training in PPPD patient group

Discussion

Limitation

Conclusion

Abbreviations

Declarations

References

Supplementary Files

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Version 1