What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes

Anna Aminov, Jeffrey M Rogers, Sandy Middleton, Karen Caeyenberghs, Peter H Wilson, Anna Aminov, Jeffrey M Rogers, Sandy Middleton, Karen Caeyenberghs, Peter H Wilson

Abstract

Background: Virtual-reality based rehabilitation (VR) shows potential as an engaging and effective way to improve upper-limb function and cognitive abilities following a stroke. However, an updated synthesis of the literature is needed to capture growth in recent research and address gaps in our understanding of factors that may optimize training parameters and treatment effects.

Methods: Published randomized controlled trials comparing VR to conventional therapy were retrieved from seven electronic databases. Treatment effects (Hedge's g) were estimated using a random effects model, with motor and functional outcomes between different protocols compared at the Body Structure/Function, Activity, and Participation levels of the International Classification of Functioning.

Results: Thirty-three studies were identified, including 971 participants (492 VR participants). VR produced small to medium overall effects (g = 0.46; 95% CI: 0.33-0.59, p < 0.01), above and beyond conventional therapies. Small to medium effects were observed on Body Structure/Function (g = 0.41; 95% CI: 0.28-0.55; p < 0.01) and Activity outcomes (g = 0.47; 95% CI: 0.34-0.60, p < 0.01), while Participation outcomes failed to reach significance (g = 0.38; 95% CI: -0.29-1.04, p = 0.27). Superior benefits for Body Structure/Function (g = 0.56) and Activity outcomes (g = 0.62) were observed when examining outcomes only from purpose-designed VR systems. Preliminary results (k = 4) suggested small to medium effects for cognitive outcomes (g = 0.41; 95% CI: 0.28-0.55; p < 0.01). Moderator analysis found no advantage for higher doses of VR, massed practice training schedules, or greater time since injury.

Conclusion: VR can effect significant gains on Body Structure/Function and Activity level outcomes, including improvements in cognitive function, for individuals who have sustained a stroke. The evidence supports the use of VR as an adjunct for stroke rehabilitation, with effectiveness evident for a variety of platforms, training parameters, and stages of recovery.

Keywords: Cognition; Meta-analysis; Motor performance; Rehabilitation; Stroke; Virtual reality.

Conflict of interest statement

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors report no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Population, Intervention, Comparison, Outcome (PICO) Question and the main variables included in the systematic literature review and meta-analysis
Fig. 2
Fig. 2
Four-phase Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram, showing the process for identifying and screening of the articles for inclusion and exclusion in the systematic literature review and meta-analysis
Fig. 3
Fig. 3
Forest plot showing the main effect-sizes of Virtual Rehabilitation after stroke on the motor, functional, and cognitive outcomes combined; the three levels of the International Classification of Functioning (Body Function outcomes included Fugl-Meyer Assessment-Upper Extremity and Modified Ashworth Scale; Activity outcomes included Box and Blocks Test; Participation outcomes included Motor Activity Log and Quality of Movement); and cognitive outcomes using the random-effects model. Notes: CG: Computerized Gaming; CI: Confidence Intervals; CT: Conventional Treatment; ICF: International Classifacation of Functioning; VE: Virtual Environment; VR: Virtual Rehabilitation
Fig. 4
Fig. 4
Forest plot showing the main moderator analyses of Virtual Rehabilitation outcomes after stroke using the random-effects model. Note: AR: Additional Rehabilitation; CI: Confidence Intervals; CT: Conventional Treatment; TAU; Treatment As Usual; VR: Virtual Rehabilitation
Fig. 5
Fig. 5
Forest plot showing the main effect-sizes of Virtual Environment therapy after stroke on the three levels of the International Classification of Functioning using the random-effects model. Body Function outcomes included Fugl-Meyer Assessment-Upper Extremity and Modified Ashworth Scale; Activity outcomes included Box and Blocks Test; Participation outcomes included Motor Activity Log and Quality of Movement. Note: CI; Confidence Intervals; CT: Conventional Treatment; ICF: International Classifacation of Functioning; VE: Virtual Environment
Fig. 6
Fig. 6
Forest plot showing the follow-up effects of Virtual Rehabilitation after stroke on the motor, functional, and cognitive outcomes combined using the random-effects model Note: CI; Confidence Intervals; ICF: International Classifacation of Functioning

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Source: PubMed

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