Background
Methods
Search strategy
Eligibility criteria
Participants
Intervention
Outcome measures
Study selection and data extraction
Risk of bias and certainty of evidence evaluation
Data synthesis and analysis
Results
Flow of studies through the review
Characteristics of studies
Study (author, year) | Participants | Stroke characteristics | Outcome measures related to balance and gait | |||||
---|---|---|---|---|---|---|---|---|
Size (n) | Age (years) | Gender (M/F) | Duration (days) | Type (H/I) | Lesion side (L/R) | Lesion location | ||
Correia, 2021 [28] | E: 33 | 73.3 ± 6.5 | 23/10 | 198.0 ± 77.9 | 5/28 | / | / | Number of falls, BBS and TUG |
C: 35 | 73.5 ± 6.2 | 23/12 | 178.0 ± 66.6 | 7/28 | / | / | ||
Dai, 2013 [29] | E: 24 | 57.2 ± 12.2 | 16/8 | 56.9 ± 38.9 | / | / | / | Number of falls and PASS |
C: 24 | 64.5 ± 14.7 | 12/12 | 73.9 ± 37.9 | / | / | / | ||
Elhamrawy, 2021 [31] | E: 16 | 66.5 ± 3.2 | 11/5 | 264.3 ± 46.5 | 4/12 | / | / | Walking speed, walking cadence, SL-AS, SL-US and step width identified by using the Microsoft Kinect V2 |
C: 16 | 68.5 ± 3.8 | 10/6 | 260.1 ± 40.8 | 5/11 | / | / | ||
Guo, 2022 [40] | E: 14 | 61.07 ± 9.09 | 8/6 | 14.2 ± 4.7 | 6/8 | / | / | BBS, TUG, 10MWT (seconds), APDCOP |
C: 14 | 62.64 ± 9.19 | 7/7 | 15.1 ± 4.7 | 5/9 | / | / | ||
Hansson, 2020 [30] | E: 19 | 71.0 ± 11.1 | 8/11 | 255.0 ± 327.0 | / | 11/16 (no paresis: 5) | / | ABC, BBS and FGA |
C: 13 | 69.0 ± 10.4 | 5/8 | / | / | ||||
Huang, 2019 [33] | E: 20 | 54.6 ± 8.4 | 26/14 | / | 16/24 | / | / | FM-B |
C:20 | / | / | / | |||||
Jiang, 2012 [34] | E: 48 | 50.7 ± 9.2 | 59/37 | 82.5 ± 26.1 | / | / | / | FM-B |
C: 48 | / | / | / | |||||
Li, 2022 [35] | E: 42 | 57.92 ± 2.01 | 25/17 | / | 13/29 | 27/15 | / | BBS, gait parameters (SL-AS, ST-AS and SW-AS) assessed by the Gait Watch |
C: 42 | 57.34 ± 2.11 | 24/18 | / | 11/31 | 26/16 | / | ||
Mitsutake, 2017 [32] | E: 14 | 67.6 ± 9.0 | 11/3 | 52.4 ± 26.4 | / | 6/8 | Supratentorial/infratentorial: 10/4 | 10MWT (m/s), TUG and DGI |
C: 14 | 68.1 ± 13.5 | 11/3 | 64.1 ± 37.7 | / | 7/7 | Supratentorial/infratentorial: 10/4 | ||
Wang YM, 2022 [36] | E: 17 | 66.0 ± 5.4 | 15/2 | 76.0 ± 33.9 | 4/13 | 5/12 | / | BBS |
C:17 | 67.8 ± 4.1 | 14/3 | 90.8 ± 37.1 | 2/15 | 8/9 | / | ||
Wang YQ, 2022 [27] | E: 28 | 51.93 ± 8.14 | 14/14 | 34.3 ± 21.5 | 15/13 | 15/13 | / | BBA, ABC |
C: 27 | 50.52 ± 9.90 | 15/12 | 34.4 ± 22.7 | 16/11 | 15/12 | / | ||
Xie, 2017 [37] | E: 40 | 54.2 ± 18.9 | 19/21 | 42.7 ± 12.0 | 22/18 | / | / | BBS |
C: 40 | 60.3 ± 12.9 | 15/25 | 51.1 ± 8.3 | 21/19 | / | / | ||
Yang, 2021 [41] | E: 30 | 60.5 ± 12.8 | 21/9 | 75.9 ± 46.0 | / | 12/18 | / | BBS, FAC, fall risk assessed by Tetrax |
C: 30 | 61.9 ± 13.3 | 18/12 | 80.7 ± 40.6 | / | 10/20 | / | ||
Yao, 2021 [38] | E: 24 | 67.4 ± 5.8 | 16/8 | 20.3 ± 2.6 | / | / | / | BBS, COP movement distance and movement area with EC/EO |
C: 20 | 66.0 ± 5.2 | 13/7 | 19.7 ± 3.1 | / | / | / | ||
Zhao, 2022 [39] | E: 20 | 60.4 ± 12.3 | 15/5 | 118.5 ± 69.0 | 6/14 | 6/14 | Basal ganglia/cerebral hemisphere: 13/7 | BBS, TUG, gait parameters (ST-AS, ST-US, SW-AS, SW-US, ST-ASI, SW-ASI, APCOPV-US, APCOPV-AS, EEA-EO, EEA-EC, PPF-EO and PPF-EC) assessed by the ODONATE gait analysis system |
C: 20 | 54.5 ± 13.9 | 15/5 | 100.5 ± 56.1 | 8/12 | 9/11 | Basal ganglia/cerebral hemisphere: 12/8 |
Study (author, year) | Experiment group | Control group |
---|---|---|
Correia, 2021 [28] | Domiciliary intervention based on oculomotor and GSE, and stroke rehabilitation program. Oculomotor and GSE (1) eyes movement between two stationary targets while keeping the head still, (2) tracking exercises while keeping the head still, (3) VOR 1 and (4) VOR 2. Twice a day for 3 weeks. | Stroke rehabilitation program was provided for 3 weeks, according to the identified problems and was based on the clinical reasoning, supported on the neurophysiology, motor control, biomechanics and motor learning theories. |
Dai, 2013 [29] | Cawthorne–Cooksey exercises and conventional rehabilitation. The Cawthorne–Cooksey exercises involved side-to-side head turns, up-and-down head movements and gaze movements. Approximately 30 min, 5 days a week for 4 weeks. | Conventional rehabilitation involved PT (passive exercises, active exercises, resistive exercises and ambulation training) and OT (endurance exercise, balance training and ADL training). 1 h for PT and 1 h for OT, 5 days a week for 4 weeks. |
Elhamrawy, 2021 [31] | VRT and traditional gait training. VRT included (1) eye movements, (2) head movements, (3) balancing on mat and swivelling eyes, (4) standing on mat, walking on the spot and rotating the head, (5) weight shifting while keeping the sight fixed, (6) standing on foam with eyes closed and head rotation, (7) forward and backward walking with head turning, (8) sitting on a ball with feet on foam, eyes closed and bouncing slightly while turning the head, (9) marching in place. 1–4 weeks: 40 min traditional gait training and 20 min VRT, 4 days a week. 5–8 weeks: traditional gait training, 60 min a day, 4 days a week. | Traditional gait training included strengthening exercises, walking over obstacles, up and down slopes, and 15–20 min of treadmill walking at a speed of 1.2–2.6 km/h. 60 min per day, 4 days a week for 8 weeks. |
Guo, 2022 [40] | Vestibular sensory integration training and UR. Vestibular sensory integration training included exercises in various position with head and eyes movements, progressed by eyes open/closed and firm/foam surfaces. 15 min a day, 5 days a week for 3 weeks. | UR include electrical stimulation, PT, OT, hyperbaric oxygen therapy, transcranial magnetic stimulation and specific balance training. Balance training was applied by using a balance instrument (E-LINK, Beijing, China). 30 min a day, 5 days a week for 3 weeks. |
Hansson, 2020 [30] | VRT and UR. VRT consisted of (1) standing on a padded mat, feet as close to each other as possible, (2) sitting on a Swiss ball, (3) standing on a trampoline, (4) sitting on a chair or on the edge of a bed. All exercises progressed with eye movements, or/(and) with eyes open/closed, or/(and) with head movements. Twice a week for 3 months. | UR comprised of individually adapted exercises, based on the assessment by the PT. Twice a week for 3 months. |
Huang, 2019 [33] | VRT and UR. VRT included head lateral flexion and shift in the coronal plane in sitting and standing. VRT progressed from eyes open/supported to eyes closed/unsupported. 20 min a day, 5 days a week for 4 weeks. | UR based on Bobath and motor learning, included rolling, sitting balance, sit to standing, standing balance training and weight shifting. 50 min a day, 5 days a week for 4 weeks. |
Jiang, 2012 [34] | Swivel chair vestibular rotational training and UR. Once a day for 4 weeks. | UR included bed mobility, sitting and standing balance training, gait training and ADL training. 30–60 min, once a day for 4 weeks. |
Li, 2022 [35] | VRT and UR. VRT included head lateral flexion and shift in the coronal plane in sitting and standing. VRT progressed from eyes open/supported to eyes closed/unsupported. 20 min a day, once a day for 2 months. | UR included bed mobility, sitting and standing balance training, gait training and ADL training. 30 min a day, once a day for 2 months. |
Mitsutake, 2017 [32] | VRT and conventional rehabilitative intervention. VRT consisted of (1) GSE (VOR 1 and VOR 2), and (2) balance exercises: maintain balance while rotating neck and trunk to the right and left, and weight shifting. VRT was progressed from a firm surface to a foam surface, and from eye-open to eye closed conditions. 1–3 weeks: 40 min conventional intervention and 20 min VRT 4–6 weeks: 60 min conventional intervention | Conventional rehabilitative intervention included a range of motion exercise, strengthening exercise, walking indoors and outdoors, and up and down stairs training. 60 min, 7 days a week for 6 weeks. |
Wang YM, 2022 [36] | VRT and UR. VRT included head flexion, extension, lateral flexion, rotation (right and left and clockwise/counterclockwise). 7 day a week for 1 week. | UR included neuromuscular electrical stimulation, balance training, gait training, up and down stairs training, aerobic exercise, and lower limbs strengthening exercise. 90 min a day, once a day for 1 week. |
Wang YQ, 2022 [27] | VRT and UR. VRT included GSE, eye movement and GSE during transfer. 30 min a day, 5 days a week for 4 weeks. | UR involved PT based on neurodevelopmental theory and OT (upper limb and hand training, activity of daily living training). 5 days a week for 4 weeks. |
Xie, 2017 [37] | VRT and UR. VRT consisted of swivel chair rotational training and VOR training. Twice per day, 6 days a week for 4 weeks. | UR included limb exercises and balance training with visual feedback. 6 days a week for 4 weeks. |
Yang, 2021 [41] | Vestibulo-ocular reflex exercises and UR. Vestibulo-ocular reflex exercises in standing consisted of eye movements between two targets while keeping the head still, eye-tracking exercises while keeping the head still, VOR 1 and VOR 2. 10 repetitions for each exercise. 5 days a week for 4 weeks. | UR included a customized UR program and specific balance training. 5 days a week for 4 weeks. Customized UR program was provided according to the identified dysfunction and supported by neuroplasticity theory. Balance training was applied by using a balance instrument (Tetrax, Israel). |
Yao, 2021 [38] | VRT and UR. VRT included GSE and swivel chair rotational training. 50 min a day, 5 days a week for 4 weeks. | UR included limb exercises, balance board training, standing and gait training. 30 min a day, 5 days a week for 4 weeks. |
Zhao, 2022 [39] | GSE and PT. GSE included saccadic, smooth tracking, VOR 1 and VOR 2 exercises. 30 min a day, 5 days a week for 4 weeks. | PT included standing balance training, weight shifting, walking, strengthening exercise and step-up-and-down training. 30 min a day, 5 days a week for 4 weeks. |
Risk of bias
Effect of VRT on improving balance
Outcomes | Effect (95% CI) | No. of participants (studies) | Certainty of the evidence (GRADE) |
---|---|---|---|
Overall effect on balance scales | SMD 0.59 (0.40 to 0.78) | 708 (13 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
BBS | MD 3.08 (1.86 to 4.31) | 470 (9 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
FM-B | MD 2.74 (1.56 to 3.91) | 136 (2 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
ABC | MD 7.42 (0.83 to 14.00) | 86 (2 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
COP movement area with eyes open | MD −0.70 (−2.00 to 0.59) | 84 (2 studies) | ⨁⊝⊝⊝ Lowa,b due to risk of bias, imprecision |
COP movement area with eyes closed | MD −3.53 (−8.93 to 1.88) | 84 (2 studies) | ⨁⊝⊝⊝ Very lowa,b,c due to risk of bias, inconsistency, imprecision |
Number of falls | RR 0.28 (0.05 to 1.73) | 116 (2 studies) | ⨁⨁⊝⊝ Lowb,d due to risk of bias, imprecision |
Patients with various stroke duration | SMD 0.50 (0.27 to 0.74) | 516 (10 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
Within 6 months | SMD 0.56 (0.33 to 0.79) | 484 (9 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
Within 3 months | SMD 0.65 (0.36 to 0.94) | 206 (4 studies) | ⨁⨁⨁⊝ Moderatee due to risk of bias |
Various types of VRT | SMD 0.59 (0.40 to 0.78) | 708 (13 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
GSE or eye-head movements | SMD 0.40 (0.17 to 0.63) | 298 (6 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
Vestibular sensory stimulation conducted by head movements | SMD 0.75 (0.43 to 1.07) | 158 (3 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
GSE combined with swivel chair training | SMD 0.85 (0.48 to 1.22) | 124 (2 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
Various intervention duration of VRT | SMD 0.59 (0.40 to 0.78) | 708 (13 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
Less than 4 weeks | SMD 0.50 (0.15 to 0.85) | 130 (3 studies) | ⨁⨁⨁⊝ Moderated due to risk of bias |
4 weeks | SMD 0.64 (0.40 to 0.89) | 462 (8 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
More than 4 weeks | SMD 0.42 (−0.50 to 1.33) | 116 (2 studies) | Very lowa,b,c due to risk of bias, inconsistency, imprecision |
Effect of VRT on improving gait
Outcomes | Effect (95% CI) | No. of participants (studies) | Certainty of the evidence (GRADE) |
---|---|---|---|
Various intervention duration of VRT on TUG | MD −4.32 (−6.65 to −1.99) | 164 (4 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
Less than 4 weeks | MD −4.71 (−7.16 to −2.26) | 124 (3 studies) | ⨁⨁⨁⊝ Moderatea due to risk of bias |
VRT on TUG in patients with stroke occurred within 6 months | MD −3.92 (−6.83 to −1.00) | 96 (3 studies) | ⨁⨁⨁⊝ Moderateb due to risk of bias |
SL-AS | MD 2.33 (1.19 to 3.47) | 116 (2 studies) | ⨁⨁⨁⊝ Moderatec due to risk of bias |
ST-AS | SMD −0.36 (−0.98 to 0.26) | 124 (2 studies) | ⨁⊝⊝⊝ Very lowd,e,f due to risk of bias, inconsistency, imprecision |
SW-AS | SMD 0.44 (−0.48 to 1.37) | 124 (2 studies) | ⨁⊝⊝⊝ Very lowd,e,f due to risk of bias, inconsistency, imprecision |
10MWT | SMD −0.44 (−1.61 to 0.74) | 56 (2 studies) | ⨁⊝⊝⊝ Very lowb,d,e due to risk of bias, inconsistency, imprecision |