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Meta-Analysis
. 2015 Feb 12;2015(2):CD008349.
doi: 10.1002/14651858.CD008349.pub3.

Virtual reality for stroke rehabilitation

Kate E Laver  1 , Stacey George, Susie Thomas, Judith E Deutsch, Maria Crotty
Affiliations
Meta-Analysis

Virtual reality for stroke rehabilitation

Kate E Laver et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Virtual reality and interactive video gaming have emerged as recent treatment approaches in stroke rehabilitation. In particular, commercial gaming consoles have been rapidly adopted in clinical settings. This is an update of a Cochrane Review published in 2011.

Primary objective: To determine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity.

Secondary objective: To determine the efficacy of virtual reality compared with an alternative intervention or no intervention on: gait and balance activity, global motor function, cognitive function, activity limitation, participation restriction and quality of life, voxels or regions of interest identified via imaging, and adverse events. Additionally, we aimed to comment on the feasibility of virtual reality for use with stroke patients by reporting on patient eligibility criteria and recruitment.

Search methods: We searched the Cochrane Stroke Group Trials Register (October 2013), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2013, Issue 11), MEDLINE (1950 to November 2013), EMBASE (1980 to November 2013) and seven additional databases. We also searched trials registries and reference lists.

Selection criteria: Randomised and quasi-randomised trials of virtual reality ("an advanced form of human-computer interface that allows the user to 'interact' with and become 'immersed' in a computer-generated environment in a naturalistic fashion") in adults after stroke. The primary outcome of interest was upper limb function and activity. Secondary outcomes included gait and balance function and activity, and global motor function.

Data collection and analysis: Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data and assessed risk of bias. A third review author moderated disagreements when required. The authors contacted investigators to obtain missing information.

Main results: We included 37 trials that involved 1019 participants. Study sample sizes were generally small and interventions varied. The risk of bias present in many studies was unclear due to poor reporting. Thus, while there are a large number of randomised controlled trials, the evidence remains 'low' or 'very low' quality when rated using the GRADE system. Control groups received no intervention or therapy based on a standard care approach. Intervention approaches in the included studies were predominantly designed to improve motor function rather than cognitive function or activity performance. The majority of participants were relatively young and more than one year post stroke.

Primary outcome: results were statistically significant for upper limb function (standardised mean difference (SMD) 0.28, 95% confidence intervals (CI) 0.08 to 0.49 based on 12 studies with 397 participants).

Secondary outcomes: there were no statistically significant effects for grip strength, gait speed or global motor function. Results were statistically significant for the activities of daily living (ADL) outcome (SMD 0.43, 95% CI 0.18 to 0.69 based on eight studies with 253 participants); however, we were unable to pool results for cognitive function, participation restriction, quality of life or imaging studies. There were few adverse events reported across studies and those reported were relatively mild. Studies that reported on eligibility rates showed that only 26% of participants screened were recruited.

Authors' conclusions: We found evidence that the use of virtual reality and interactive video gaming may be beneficial in improving upper limb function and ADL function when used as an adjunct to usual care (to increase overall therapy time) or when compared with the same dose of conventional therapy. There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on grip strength, gait speed or global motor function. It is unclear at present which characteristics of virtual reality are most important and it is unknown whether effects are sustained in the longer term.

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Conflict of interest statement

Kate Laver: none known.

Stacey George: none known.

Susie Thomas: none known.

Judith Deutsch conducts research on virtual reality for stroke rehabilitation. This research is funded by various sources and presented at scientific and professional meetings. She is co‐owner of a company that develops virtual reality for rehabilitation.

Maria Crotty: none known.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
Figure 3
Figure 3
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Analysis 1.1
Analysis 1.1
Comparison 1 Virtual reality versus conventional therapy: effect on upper limb function post‐treatment, Outcome 1 Upper limb function (composite measure).
Analysis 1.2
Analysis 1.2
Comparison 1 Virtual reality versus conventional therapy: effect on upper limb function post‐treatment, Outcome 2 Upper limb function (Fugl Meyer).
Analysis 1.3
Analysis 1.3
Comparison 1 Virtual reality versus conventional therapy: effect on upper limb function post‐treatment, Outcome 3 Hand function (grip strength).
Analysis 2.1
Analysis 2.1
Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 1 Dose of intervention.
Analysis 2.2
Analysis 2.2
Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 2 Time since onset of stroke.
Analysis 2.3
Analysis 2.3
Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 3 Specialised or gaming.
Analysis 2.4
Analysis 2.4
Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 4 Severity of impairment.
Analysis 3.1
Analysis 3.1
Comparison 3 Additional virtual reality intervention: effect on upper limb function post‐treatment, Outcome 1 Upper limb function (composite measure).
Analysis 3.2
Analysis 3.2
Comparison 3 Additional virtual reality intervention: effect on upper limb function post‐treatment, Outcome 2 Hand function (dexterity).
Analysis 4.1
Analysis 4.1
Comparison 4 Additional virtual reality intervention: effect on upper limb function post‐treatment: subgroup analyses, Outcome 1 Dose of intervention.
Analysis 4.2
Analysis 4.2
Comparison 4 Additional virtual reality intervention: effect on upper limb function post‐treatment: subgroup analyses, Outcome 2 Time since onset of stroke.
Analysis 4.3
Analysis 4.3
Comparison 4 Additional virtual reality intervention: effect on upper limb function post‐treatment: subgroup analyses, Outcome 3 Specialised or gaming.
Analysis 5.1
Analysis 5.1
Comparison 5 Virtual reality versus conventional therapy: effect on lower limb activity post‐treatment, Outcome 1 Gait speed.
Analysis 6.1
Analysis 6.1
Comparison 6 Virtual reality versus conventional therapy: effect on lower limb activity post‐treatment: subgroup analyses, Outcome 1 Dose of intervention: effect on gait speed.
Analysis 7.1
Analysis 7.1
Comparison 7 Additional virtual reality intervention: effect on global motor function post‐treatment, Outcome 1 Global motor function.
Analysis 8.1
Analysis 8.1
Comparison 8 Virtual reality versus conventional therapy: effect on secondary outcomes, Outcome 1 ADL outcome.
Analysis 9.1
Analysis 9.1
Comparison 9 Additional virtual reality intervention: effect on secondary outcomes, Outcome 1 ADL outcome.
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Update of

References

References to studies included in this review

    1. Akinwuntan A, Devos H, Verheyden G, Baten G, Kiekens C, Feys H, et al. Retraining moderately impaired stroke survivors in driving‐related visual attention skills. Topics in Stroke Rehabilitation 2010;17(5):328‐36. - PubMed
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    3. Devos H, Akinwuntan AE, Nieuwboer A, Ringoot I, Berghen K, Tant M, et al. Effect of simulator training on fitness to drive after stroke: a 5‐year follow up of a randomised controlled trial. Neurorehabilitation and Neural Repair 2010;24(9):843‐50. - PubMed
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    1. Barcala L, Grecco LAC, Colella F, Lucareli PRG, Salgado ASI, Oliveira CS. Visual biofeedback balance training using Wii Fit after stroke: a randomized controlled trial. Journal of Physical Therapy Science 2013;25(8):1027‐32. - PMC - PubMed
    1. Byl N, Abrams G, Pitsch E, Fedulow I, Kim H, Simkins M, et al. Chronic stroke survivors achieve comparable outcomes following virtual task specific repetitive training guided by a wearable robotic orthosis (UL‐EXO7) and actual task specific repetitive training guided by a physical therapist. Journal of Hand Therapy 2013;26(4):343‐51. - PubMed
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    1. Coupar F. Exploring Upper Limb Interventions After Stroke [PhD thesis]. Glasgow, UK: University of Glasgow, 2012.

References to studies excluded from this review

    1. Broeren J, Claesson L, Goude D, Rydmark M, Sunnerhagen K. Virtual rehabilitation in an activity centre for community‐dwelling persons with stroke. Cerebrovascular Diseases 2008;26:289‐96. - PubMed
    1. Cameirao M, Badia S, Duarte E, Frisoli A, Verschure P. The combined impact of virtual reality neurorehabilitation and its interfaces on upper extremity functional recovery in patients with chronic stroke. Stroke 2012;43(10):2720‐8. - PubMed
    1. Cho KH, Lee WH. Virtual walking training program using a real‐world video recording for patients with chronic stroke. American Journal of Physical Medicine and Rehabilitation 2013;92:371‐84. - PubMed
    1. Chortis A, Standen PJ, Walker M. Virtual reality system for upper extremity rehabilitation of chronic stroke patients living in the community. Proceedings of ICDVRAT. 2008:221‐8.
    1. Cikaljo I, Rudolf M, Goljar N, Burger H, Matjacic Z. Telerehabilitation using virtual reality task can improve balance in patients with stroke. Disability and Rehabilitation 2012;34(1):13‐8. - PubMed

References to ongoing studies

    1. Adie K, Schofield C, Berrow M, Wingham J, Freeman J, Humfreys J. Trial of Wii in STroke ‐ TWIST: does the use of Nintendo Wii Sports improve dominant arm function and is it acceptable to patients after stroke?. Proceedings of the 21st European Stroke Conference. 2012:Abst OAID23.
    1. Deutsch J. Interactive video gaming compared to optimal standard of care to improve balance and mobility. Personal communication2010.
    1. Karatas GK, Karasu AU, Balevi E. Wii‐based balance rehabilitation is effective in stroke: a randomized controlled study. Neurorehabilitation and Neural Repair 2012;26:767.
    1. Lloréns R, Gil‐Gómez J‐A, Alcañiz M, Colomer C, Noé E. Improvement in balance using a virtual reality‐based stepping exercise: a randomized controlled trial involving individuals with chronic stroke. Clinical Rehabilitation 2014 Jul 23 [Epub ahead of print]. [DOI: 10.1177/0269215514543333] - DOI - PubMed
    1. Rand D. Virtual reality intervention for stroke rehabilitation. https://clinicaltrials.gov/ct2/show/NCT01304017 (accessed December 2013). [NCT01304017]

Additional references

    1. Bagce HF, Saleh S, Adamovich SV, Tunik E. Visuomotor gait distortion alters online motor performance and enhances primary motor cortex excitability in patients with stroke. Neuromodulation 2012;15(4):361‐6. - PMC - PubMed
    1. Bohil CJ, Alicea B, Biocca FA. Virtual reality in neuroscience research and therapy. Nature Reviews Neuroscience 2011;12:752‐62. - PubMed
    1. Burridge JJ, Hughes AM. Potential for new technologies in clinical practice. Current Opinion in Neurology 2010;23:671‐7. - PubMed
    1. Crosbie J, Lennon S, Basford J, McDonough S. Virtual reality in stroke rehabilitation: still more virtual than real. Disability and Rehabilitation 2007;29(14):1139‐46. - PubMed
    1. Demain S, Burridge J, Ellis‐Hill C. Assistive technologies after stroke: self management or fending for yourself? A focus group study. BMC Health Services Research 2013;13:334. - PMC - PubMed

References to other published versions of this review

    1. Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews 2010, Issue 2. [DOI: 10.1002/14651858.CD008349] - DOI - PMC - PubMed
    1. Laver KE, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews 2011, Issue 9. [DOI: 10.1002/14651858.CD008349.pub2] - DOI - PubMed