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. 2023 Sep 14:64:102220.
doi: 10.1016/j.eclinm.2023.102220. eCollection 2023 Oct.

Effectiveness and safety of virtual reality rehabilitation after stroke: an overview of systematic reviews

Silvia Bargeri  1 , Sabrina Scalea  2 , Federica Agosta  2   3   4 , Giuseppe Banfi  2   5 , Davide Corbetta  2   6   7 , Massimo Filippi  2   3   4   8   9 , Elisabetta Sarasso  2   3   10 , Andrea Turolla  11   12 , Greta Castellini  1 , Silvia Gianola  1
Affiliations

Effectiveness and safety of virtual reality rehabilitation after stroke: an overview of systematic reviews

Silvia Bargeri et al. EClinicalMedicine. .

Abstract

Background: Virtual reality (VR) is an innovative neurorehabilitation modality that has been variously examined in systematic reviews. We assessed VR effectiveness and safety after cerebral stroke.

Methods: In this overview of systematic reviews, we searched eleven databases (Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, SCOPUS, ISI Web of Science, CINAHL, PsycINFO, Pedro, Otseeker, Healthevidence.org, Epistemonikos) and grey literature from inception to January 17, 2023. Studies eligible for inclusion were systematic reviews published in English that included adult patients with a clinical diagnosis of stroke (acute to chronic phase) undergoing any kind of immersive, semi-immersive or non-immersive VR intervention with or without conventional therapy versus conventional therapy alone. The primary outcome was motor upper limb function and activity. The secondary outcomes were gait and balance, cognitive and mental function, limitation of activities, participation, and adverse events. We calculated the degree of overlap between reviews based on the corrected covered area (CCA). Methodological quality was assessed using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2) and the Certainty of Evidence (CoE) using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Discordances between results were examined using a conceptual framework based on the Jadad algorithm. This overview is registered with PROSPERO, CRD42022329263.

Findings: Of the 58 reviews included (n = 345 unique primary studies), 42 (72.4%) had conducted meta-analysis. More than half of the reviews (58.6%) were published between 2020 and 2022 and many (77.6%) were judged critically low in quality by AMSTAR 2. Most reported the Fugl Meyer Assessment scale (FMA-UE) to measure upper limb function and activity. For the primary outcome, there was a moderate overlap of primary studies (CCA 9.0%) with discordant findings. Focusing on upper limb function (FMA-UE), VR with or without conventional therapy seems to be more effective than conventional therapy alone, with low to moderate CoE and probable to definite clinical relevance. For secondary outcomes there was uncertainty about the superiority or no difference between groups due to substantial heterogeneity of measurement scales (eg, methodological choices). A few reviews (n = 6) reported the occurrence of mild adverse events.

Interpretation: Current evidence suggests that multiple meta-analyses agreed on the superiority of VR with or without conventional therapy over conventional therapy on FME-UE for upper limb. Clinicians may consider embedding VR technologies into their practice as appropriate with patient's goals, abilities, and preferences. However, caution is needed given the poor methodological quality of reviews.

Funding: Italian Ministry of Health.

Keywords: Overview; Stroke; Systematic review; Virtual reality.

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Conflict of interest statement

FA received research grant for San Raffaele Hospital from Italian Minister of Health, AriSLA (Fondazione Italiana di Ricerca per la SLA), the European Research Council, Foundation Research on Alzheimer Disease; consulting fees, Payment for meeting and lectures from Biogen Idec, Roche, Zambon and Italfarmaco. DC received research grant for San Raffaele Hospital from Italian Ministry of Health Grant: Ricerca Finalizzata 2018 (GR-2018-12366005) for Virtual Reality in Parkinson disease. MF received research grant for San Raffaele Hospital from Biogen Idec, Merck Serono, Novartis, Roche, Italian Ministry of Health, Fondazione Italiana Sclerosi Multipla, and ARiSLA; consulting fees, Payment for meeting and lectures from Biogen Idec, Merck Serono, Novartis, Roche, Italian Ministry of Health, Fondazione Italiana Sclerosi Multipla, and ARiSLA, Bayer, Biogen, Celgene, Chiesi Italia SpA, Eli Lilly, Genzyme, Janssen, Merck-Serono, Neopharmed Gentili, Novartis, Novo Nordisk, Roche, Sanofi, Sanofi-Genzyme, Takeda, Bristol-Myers Squibb, and TEVA. In addition, Participation on a Data Safety Monitoring Board or Advisory Board from Alexion, Biogen, Bristol-Myers Squibb, Merck, Novartis, Roche, Sanofi, Sanofi-Aventis, Sanofi-Genzyme, Takeda. ES received research grant for San Raffaele Hospital from Italian Ministry of Health Grant: Ricerca Finalizzata 2021 (GR-2021-12374005) for Parkinson disease and Italian Ministry of Health Grant: PNRR 2022 (PNRR-MAD-2022-12376826) for functional motor disorders. DC, AT, GC, and SG report Italian Physiotherapy Association Board membership (unpaid). All other authors declare no competing interests.

Figures

Fig. 1
Fig. 1
PRISMA flowchart.
Fig. 2
Fig. 2
Outcome measurements scale reported by the meta-analyses. Legend: 6MWT: Six walking test; 10MWT: 10 Meters Walk Test; ABC: Activities-specific Balance Confidence Scale; ACPT: Auditory Continuous Performance Test; ARAT: Action Research Arm Test; BBS: Berg Balance Scale; BBT: Box and Block Test; BI: Barthel Index; FIM: Functional Independent Measure; FMA-UE Fugl-Meyer Assessment-Upper Extremity; FRT: Functional Reaching Test; MAL: Motor Activity Log; MBI: Modified Barthel Index; MMSE: Mini-Mental State Examination; MoCA: Montreal Cognitive Assessment; SIS: Stroke Impact Scale; TMT: Trail Making Test; TUG (Timed Up and Go); VCPT: Visual continuous performance test; Wolf Motor Function Test.
Fig. 3
Fig. 3
Overlapping of primary studies included in systematic reviews for upper limb function and activity outcome.
Fig. 4
Fig. 4
Summary of results grouped by outcome measurements for A) Upper limb function and activity, B) Gait, mobility and balance, C) ADL. Node size is proportional to the number of meta-analyses assessing the corresponding outcome Legend: 6MWT: Six walking test; 10MWT: 10 Meters Walk Test; ABC: Activities-specific Balance Confidence Scale; ADL: Activities of Daily Living; ARAT: Action Research Arm Test; BBS: Berg Balance Scale; BBT: Box and Block Test; BI: Barthel Index; FIM: Functional Independent Measure; FMA-UE Fugl-Meyer Assessment-Upper Extremity; FRT: Functional Reaching Test; MAL: Motor Activity Log; TUG (Timed Up and Go); Wolf Motor Function Test (WMFT).
Fig. 5
Fig. 5
Effect size expressed as mean difference of FMA-UE in the systematic reviews with meta-analyses Red dotted lines indicate the threshold for clinical relevance. Legend: FMA-UE Fugl-Meyer Assessment-Upper Extremity.
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