Virtual reality therapy for adults post-stroke: a systematic review and meta-analysis exploring virtual environments and commercial games in therapy

Abstract

Background: The objective of this analysis was to systematically review the evidence for virtual reality (VR) therapy in an adult post-stroke population in both custom built virtual environments (VE) and commercially available gaming systems (CG).

Methods: MEDLINE, CINAHL, EMBASE, ERIC, PSYCInfo, DARE, PEDro, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were systematically searched from the earliest available date until April 4, 2013. Controlled trials that compared VR to conventional therapy were included. Population criteria included adults (>18) post-stroke, excluding children, cerebral palsy, and other neurological disorders. Included studies were reported in English. Quality of studies was assessed with the Physiotherapy Evidence Database Scale (PEDro).

Results: Twenty-six studies met the inclusion criteria. For body function outcomes, there was a significant benefit of VR therapy compared to conventional therapy controls, G = 0.48, 95% CI = [0.27, 0.70], and no significant difference between VE and CG interventions (P = 0.38). For activity outcomes, there was a significant benefit of VR therapy, G = 0.58, 95% CI = [0.32, 0.85], and no significant difference between VE and CG interventions (P = 0.66). For participation outcomes, the overall effect size was G = 0.56, 95% CI = [0.02, 1.10]. All participation outcomes came from VE studies.

Discussion: VR rehabilitation moderately improves outcomes compared to conventional therapy in adults post-stroke. Current CG interventions have been too few and too small to assess potential benefits of CG. Future research in this area should aim to clearly define conventional therapy, report on participation measures, consider motivational components of therapy, and investigate commercially available systems in larger RCTs.

Trial registration: Prospero CRD42013004338.

Figure 1. Screening of articles.

Four-phase PRISMA flow-diagram for study collection , showing the number of studies identified, screened, eligible, and included in the review and analysis.

Figure 2. Body function outcomes in VE studies.

The funnel plot (top) for body function outcomes showing effect-sizes (G) as a function of precision (standard error) in each virtual environment study. The forest plot (bottom) showing the effect-sizes and 95% confidence intervals for each study and the summary effect-size from the random-effects model. Positive values show a difference in favour of VE therapy. Negative values show a difference in favour of CT. Abbreviations: VE, virtual environments; RE, random effects.

Figure 3. Body function outcomes in CG studies.

The funnel plot (top) for body function outcomes showing effect-sizes (G) as a function of precision (standard error) in each commercial gaming study. The forest plot (bottom) showing the effect-sizes and 95% confidence intervals for each study and the summary effect-size from the random-effects model. Positive values show a difference in favour of CG therapy. Negative values show a difference in favour of CT. Abbreviations: CG, commercial gaming; RE, random effects.

Figure 4. Activity outcomes in VE studies.

The funnel plot (top) for activity outcomes showing effect-sizes (G) as a function of precision (standard error) in each virtual environment study. The forest plot (bottom) shows the effect-sizes and 95% confidence intervals for each study and the summary effect-size from the random-effects model. Positive values show a difference in favour of VE therapy. Negative values show a difference in favour of CT. Abbreviations: RE, random effects.

Figure 5. Activity outcomes in CG studies.

The funnel plot (top) for activity outcomes showing effect-sizes (G) as a function of precision (standard error) in each commercial gaming study. The forest plot (bottom) shows the effect-sizes and 95% confidence intervals for each study and the summary effect-size from the random-effects model. Positive values show a difference in favour of CG therapy. Negative values show a difference in favour of CT. Abbreviations: CG, commercial gaming; RE, random effects.

Figure 6. Participation outcomes in VE studies.

The funnel plot (top) for participation outcomes showing effect-sizes (G) as a function of precision (standard error) in each study. The forest plot (bottom) shows the effect-sizes and 95% confidence intervals for each study and the summary effect-size from the random-effects model. Positive values show a difference in favour of VE therapy. Negative values show a difference in favour of CT. Abbreviations: VE, virtual environments; RE, random effects.