patients with stroke have a number of physical impairments , including movement , cognitive , 
 sensory , language , and visual disorders . among them , movement disorders can limit muscle 
 control and motion functions or mobility , as well as a degrade in balance control abilities . 
 hemiplegia is accompanied by an increase in postural instability , asymmetrical weight 
 bearing , impairment of body weight transfer capabilities , and a decrease in postural 
 stability1 . as a result , many patients 
 with stroke experience problems with daily activities requiring functional movements such as 
 balance , climbing stairs , gait , and walking2 . one study reported that since stroke patients experience hemiplegia , they become isolated 
 in their daily lives from family members and society , and that as well as experiencing a 
 loss of independence , more than 50% of stroke patients had depression3 . that is , many mental problems , such as depression , apathy , 
 and anxiety , are prevalent in stroke patients , and depression not only has an adverse effect 
 on appetite and sleep4 , but it is also a 
 lives negative factor affecting rehabilitation5 . in addition , due to the sense of loss and helplessness in their 
 life , stroke patients have difficulties maintaining interpersonal relationships with 
 others6 . in terms of interventions that help stroke patients with their functional recovery , one of 
 the most widespread methods is training using a motomed , which is done in a limited 
 environment in a hospital . this training is known to bring about effective improvements in 
 physical functions and increases in grip strength and leg muscle strength , leading to 
 improvements in physical activity abilities and balance due to an increase in muscle 
 strength7 . moreover , this training 
 integrates bilateral movements and assisted active training , thereby inducing alternate 
 movements in the paralyzed leg side with the help of the lower extremity on the 
 non - paralyzed side8 ) , which requires coordinated 
 transfer of body weight between the two sides . this results in increase of physical strength 
 in the lower extremity , as well as providing weight - bearing ability through practice of gait 
 skills9 . a great deal of attention has been paid to virtual reality training programs that involve 
 various treatments providing virtual environments and simulating conditions using virtual 
 reality tools . since intervention methods using virtual reality have been demonstrated to be 
 effective in the rehabilitation of stroke patients , whose physical and recreational 
 activities are limited due to their physical disability and who experience problems carrying 
 out activities of daily living in their environment10 , various studies have proposed this type of training . moreover , positive improvements in the upper extremity functions11 , balance12 , 
 gait13 , and daily living movements14 of stroke patients have been reported . virtual reality training programs initially required much equipment ; however , virtual 
 reality home video games using consoles such as the sony playstation 2 or nintendo wii fit 
 have been widely used since the mid-2000s , as these have penetrated our daily lives and can 
 easily be placed in the home . in recent years , training using the xbox kinect has been 
 employed as a virtual reality training program , which is quite different from the virtual 
 reality computer programs that use a joystick or controller . this training involves playing 
 a virtual reality game in which players move their bodies in front of the game screen by and 
 48 of their joint positions and motions are tracked via the kinect sensors15 . an intervention method using a virtual 
 reality game enables immediate feedback about task performance , and visual and audible 
 stimulation kindle interest16 . it also 
 generates motivation to engage in treatment , as participants enjoy themselves while actively 
 carrying out tasks17 . in addition , it can 
 provide stability in activities of daily living that stroke patients are unable to 
 accomplish or are limited in , thereby giving them an opportunity to explore independently 
 and increase their autonomy18 . training programs using virtual reality games can also be effective at alleviating the 
 psychological problems of stroke patients such as depression , helplessness , and difficult 
 interpersonal relationships . most studies of training programs for stoke patients have 
 focused on physical aspects , but few have been conducted with a view to elucidating 
 psychological and social factors related to rehabilitation . therefore , this study aimed to 
 determine the effects of training using virtual reality games on balance and gait ability , 
 as well as the psychological characteristics of stroke patients , such as depression and 
 interpersonal relationships , by comparing them with the effects of ergometer training . the subjects of this study were 40 patients diagnosed with hemiplegia resulting from stroke 
 by a rehabilitation doctor practicing at n hospital located in daegu , south korea . they were 
 randomly and equally assigned to a virtual reality group ( vrg : 10 males , 10 females ) and an 
 ergometer training group ( etg : 12 males , 8 females ) . the mean  standard deviation ( sd ) age , 
 height , and weight of the vrg were 51.3740.6 years , 167.009.53 cm , and 64.1213.12 kg , 
 respectively . the mean  sd age , height , and weight of etg patients 
 were 50.107.83 years , 169.209.21 cm , and 65.2011.26 kg , respectively . the inclusion criteria were as follows : no visual field defect , no abnormality in the 
 vestibular organs , no orthopedic disease , an unrestricted range of motion , ability to 
 understand and perform the exercise as instructed by the researcher , and a score of 24 or 
 higher on the mini - mental state examination this study was approved by the 
 university s institutional review board and all of the subjects understood the purpose of 
 this study and provided their written informed consent prior to their participation in the 
 study , in accordance with the ethical standards of the declaration of helsinki . the vrg patients performed training using the xbox kinect for 30 minutes per session , five 
 times per week , for a total of 8 weeks . in front of the xbox kinect sensor , various games such as kinect sport , kinect sport 
 season 2 , kinect adventure , and kinect gunstringer were provided to kindle the subjects 
 interest and prevent boredom . during the intervention , mostly , sport programs , such as 10-pin bowling , 
 skiing , and golf , and programs such as ground walking , walking over obstacles , and climbing 
 stairs were used for training . the etg patients performed ergometer bicycle training 30 minutes per session , five times 
 per week , for a total of 8 weeks . training was conducted for 30 minutes so as not to exceed 
 40% of subjects heart rate reserve using a motomed viva 2 . the motomed provides detailed 
 biofeedback , software - controlled therapy programs , and motivation and training games . the subjects in the two experimental groups began training after being given the 
 instruction ,  please start .  in the early stage , the researcher provided help to ensure that 
 the subjects maintained proper posture during the training . if a subject exhibited fatigue , 
 abnormalities in breathing , changes in facial complexion , or complained of pain , training 
 was stopped immediately . for the measurement of balance ability , a biofeedback analysis system ( ap1153 biorescue , rm 
 ingnierie , rodez , france ) was used to determine weight bearing on the affected side , 
 anterior range limit of stability ( los ) , and posterior range los in a static standing 
 position . for the measurement of gait ability , we used the timed up and go ( tug ) test and 
 the 10-m walking test . for the asseement of patients psychology , we used the beck depression inventory [ bdi ] and 
 the relationship change scale ( rcs ) . the bdi is a depression assessmemt tool which was 
 developed by beck in 1961 and adapted for use in korea by han et al . this tool consists of 
 21 questions divided into four sections , namely the cognitive , emotive , motivational , and 
 physiological sections . the 
 possible score ranges from a minimum of 0 points to a maximum of 63 points . if an individual 
 scores 09 points , he or she is not depressed ; a score of 1015 points represents light 
 depression ; 1623 points , heavy depression ; and 2463 points , severe depression . the rcs 
 tool consists of 25 questions divided into seven sections , as follows : understanding , 
 openness , sensitivity , intimacy , trust , communication , and satisfaction . after the general characteristics of the subjects were determined , the 
 paired t - test was used to compare the variations in weight bearing on the affected side when 
 standing , the anterior los standing , and the posterior los standing . the significance of 
 differences between the two groups was investigated using the independent t - test . both the vrg and etg subjects exhibited significant improvements in the weight distribution 
 ratio on the paralyzed side , anterior los , posterior los and tug and 10-m walking times 
 after the intervention ( p<0.05 ) . in addition , the improvements comparison of the 
 post - intervention improvements of the two groups revealed that the vrg showed more 
 significant improvements in weight distribution ratio on the paralyzed side , anterior los , 
 posterior los and tug . and 10-m walking times than the etg ( p<0.05 ; table 1table 1.comparison of changes in the balance and gait functions of the training groups 
 ( mean  sd)vrgetgprepostprepostaffected side wb42.86.146.14.3 * 42.14.343.34.9*forward los ( mm)2732.93137.13311.73786.5 * 5670.84291.14322.63565.5*backward los ( mm)2072.72050.41895.92097.5 * 3971.72794.32889.72769.7*tug ( s)21.177.721.97.9 * 16.64.719.57.5 * 10mwt ( s)18.32.221.48.9 * 14.32.119.18.8 * * significant difference from before therapy , p < 0.05 . vrg : virtual reality group , 
 etg : ergometer training group , wb : weight bearing ratio , los : limit of stability , 
 tug : timed up and go test , 10mwt : 10 m walking test ) . vrg : virtual reality group , 
 etg : ergometer training group , wb : weight bearing ratio , los : limit of stability , 
 tug : timed up and go test , 10mwt : 10 m walking test both the vrg and etg patients showed significant improvements in bdi and rcs scores after 
 the intervention ( p<0.05 ) . the comparison of the post - intervention improvements of the 
 two groups revealed that the vrg showed a more significant increase in bdi than the etg 
 ( p<0.05 ; table 2table 2.comparison of the bdi and rcs scores of the two training groups ( mean  
 sd)vrgetgprepostprepostbdi21.23.814.12.4 * 19.63.217.52.7*rcs49.65.955.16.5 * 49.27.554.16.9 * * significant difference from before therapy , p < 0.05 . vrg : virtual reality group , 
 etg : ergometer training group , bdi : beck depression inventory , rcs : relationship 
 change scale ) . vrg : virtual reality group , 
 etg : ergometer training group , bdi : beck depression inventory , rcs : relationship 
 change scale this study compared the effects of two training programs , virtual reality training and 
 ergometer training , on the balance , gait abilities , depression , and interpersonal 
 relationships of stroke patients . to determine balance and gait abilities , the weight 
 distribution ratio on the paralyzed side , anterior los , posterior los , tug , and 10 m walking 
 test were conducted and their results reveal that both the vrg and etg showed significant 
 improvements in balance and gait abilities . in a study by bateni19 , bbs improvements 
 were shown by elderly patients after using the nintendo wii fit . moreover , vernadakis et 
 al.20 conducted virtual reality balance 
 exercise using the xbox kinect for male soccer players in their teens who had experienced 
 injuries . on average , the participants showed improvements in the overall stability index 
 ( osi ) and los . a study by choi21 
 conducted virtual reality training for stroke patients using the nintendo wii fit and 
 reported that execution times of the timed up and go test and 10-m walking test decreased . a 
 study by lee15 also reported that chronic 
 stroke patients exhibited a significant decrease in execution times of the timed up and go 
 test and 10-m walking test after completing a virtual reality exercise program . in the 
 present study , both the vrg and etg showed significant improvements in balance and gait 
 abilities after training . this result was obtained because patients motivation was 
 increased through the virtual reality games , encouraging their active participation and 
 improving their concentration22 . moreover , this enabled the successful performance of repetitive training exercises for the 
 damaged . in addition , errors of movement in the lower extremity regarding task performance 
 were shown through accurate visual and auditory sensory feedback , thereby achieving 
 re - education of movements of the lower extremity23 . this feedback contributed to postural stability improvements , 
 which increased dynamic balance and gait abilities . in the case of ergometer training , 
 alternate movements were induced on the paralyzed side with the assistance of the lower 
 extremity on the non - paralyzed side , and active training could be achieved8 . this resulted in increased muscle strength 
 of the lower extremity on the paralyzed side and the creation of collaborative movements 
 between both lower extremities , leading to improvements in balance and gait abilities . our study results reveal that the vrg patients showed more significant improvements in 
 balance and gait abilities than those in the etg . virtual reality games such as bowling , 
 skiing , and golf involve many movements in which the body weight is supported by the lower 
 extremity while playing the game , and trunk stability was required during movements , as well 
 as accurate control of the movements . therefore , this training improved patients balance 
 abilities significantly , and gait exercises such as ground walking , walking with obstacles , 
 and walking over stairs were carried out repeatedly . visual and auditory feedback was also 
 provided while performing exercises , thereby encouraging correct posture and facilitating 
 greater improvement of gait abilities than was observed in the etg group . this study also used the bdi and rcs to evaluate depression and interpersonal relationship 
 factors . lee et al.24 reported that when 
 virtual reality games were used by elderly persons , their depression decreased . moreover , 
 lim et al.25 also reported that balance 
 training performed by stroke patients significantly their bdi scores decreases . lee and 
 hong26 conducted a game - like group art 
 therapy program for elderly stroke patients and reported improvement in interpersonal 
 relationships in the subjects who carried out the group art therapy . in the present study , both the vrg and etg subjects showed significant improvements in 
 balance and gait abilities after training . in particular , the achieved vrg patients 
 exhibited a more significant improvement in bdi scores than those in the etg . this result 
 was achieved due to the virtual reality training , in which achievement and satisfaction 
 increased because of active performance of exercises which kindled patients interest . in 
 addition , the etg performed bicycle riding , which is a bilateral exercise , and affects bdi 
 scores through achievement of exercise on the paralyzed side . kim and kim27 proposed that physical activities elderly 
 persons can improve not only physical health , but also happiness and quality of life , and 
 this proposal is supported by our results . however , there was no significant difference in 
 the rcs scores of the two groups . the reason for this is the two groups did not perform 
 their exercise with other people , but did so alone using either the virtual reality training 
 program ( xbox ) or ergometer exercise tool . a limitation of this study was that it was difficult to exclude various variables that can 
 affect psychosocial factors such as depression or subjects interpersonal relationships . in 
 future research , it will be necessary to conduct a study with larger numbers of patients , 
 and include various psychosocial factors such as fear of falling and self - esteem . our study results show that training using virtual reality programs or an ergometer is 
 effective at improving balance , gait abilities , depression , and interpersonal relationships 
 of stroke patients . therefore , virtual reality training and ergometer training should be 
 used to improve these characteristics .
[ purpose ] the purpose of the study was to determine the effects of training using virtual 
 reality games on balance and gait ability , as well as the psychological characteristics of 
 stroke patients , such as depression and interpersonal relationships , by comparing them 
 with the effects of ergometer training . 
 [ subjects ] forty stroke patients were randomly 
 divided into a virtual reality group ( vrg , n = 20 ) and an ergometer training group ( etg , n 
 = 20 ) . [ methods ] vrg performed training using the xbox kinect . 
 etg performed training 
 using an ergometer bicycle . 
 both groups received training 30 min per day , five times per 
 week , for eight weeks . 
 [ results ] both the vrg and etg subjects exhibited a significant 
 difference in weight distribution ratio on the paralyzed side and balance ability . both 
 the vrg and etg 
 patients showed significant improvement in psychological measures bdi and 
 rcs , after the intervention , and the vrg sowed a more significant increase in bdi than the 
 etg . 
 [ conclusion ] according to the result of this study , virtual reality training and 
 ergometer training were both effective at improving balance , gait abilities , depression , 
 and interpersonal relationships among stroke patients .