Introduction
Review
Search strategy
Database
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Search strategy
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Articles retrieved
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Ovid Medline | Rehabilitation. mp. or Rehabilitation AND Virtual reality.mp. | 485 |
Ovid Medline | Virtual reality.mp. AND Stroke/OR postural balance/OR balance training .mp. OR Hemiplegia | 166 |
Ovid Medline | Stroke.mp. or cerebrovascular accident/AND balance training.mp. or posture/ AND virtual reality.mp. or user-computer interface | 13 |
Ovid Medline | Gait.mp. or Gait/or Gait disorders, Neurologic/Stroke.mp. or “National Institute of Neurological Disorders and Stroke”/or Stroke/User-computer interface/or virtual reality.mp. | 50 |
Pubmed | “Stroke” [Mesh] OR “National Institute of Neurological Disorders and Stroke” [Mesh] AND (“gait”[Mesh] OR “gait disorders, neurologic” [Mesh]) AND (virtual reality) | 133 |
Pubmed | “Rehabilitation [Mesh] OR “rehabilitation” [Subheading] AND (virtual reality) | 565 |
Selection of articles for review
Study designs
Participant characteristics
VR systems
Study
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VR system
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Training protocol
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Deutsch et al. (2004) [45] | Rutgers Ankle – an airplane simulation task required that the subject control the position of the airplane by using his ankle through a series of targets and not contacting them. For experiment 2, haptic effects were introduced to the Stewart platform and a new simulation that required the subjects to navigate a boat was added. | Exp 1 – 4 one hour sessions Exp 2 – one hour, 3 times per week for 4 weeks |
Jaffe et al. (2004) [28] | Subjects walked on a motorized treadmill at self-selected walking speeds and viewed the real time display of their legs via a helmet mounted display wherein stationary images of obstacles were introduced. The subjects were required to step over the obstacle (take sufficiently higher and larger steps) to complete the task. | Control group: stepping over real foam obstacles Experimental group: stepping over virtual obstacles 1 hour sessions, 6 sessions over 2 weeks |
You et al. (2005) [29] | IREX, GestureTek- stepping up and down, Sharkbait and Snowboarding | Control group: no intervention Experimental group: VR games - 60 minutes per day, 5 times per week for 4 weeks |
Betker et al. (2006) [46] | COP-controlled video-game based exercise games – Under Pressure, Memory Match and Tic-Tac-Toe. The system consisted of a pressure mat which mapped the COP movements as the subjects moved. This was synchronized to the game motion software so as to match the COP movements for game play. The users were supposed to move in the AP and the ML direction at different speeds in order to play the games. | Eight 45-min exercise sessions over 3 weeks, 3 sessions in 1st and 2nd week each and 2 in the 3rd week. |
Fung et al. (2006) [10] | VR-based locomotor system with a self-paced treadmill mounted on a 6-degree of freedom of motion platform. Subjects reacted in three VE’s with 3 levels of complexity. Each VE involved walking 39 m within a predetermined time constraint. Progression from one level to the next was permitted only after successful completion of 3 trials within the time constraint, as the level of complexity increased with environmental perturbations and presence of moving obstacles. | Both control and stroke subjects received the same intervention. Training frequency or length of single session not defined. |
Flynn et. al. (2007) [47] | EyeToy Play Station 2 gaming system. Games played required dynamic balance, upper extremity ROM, speed, cognition, reaction time and accuracy. | Playing games on the gaming console in the standing position 20 one hour sessions over 4 ½ weeks. |
Yang et. al. (2008) [30] | Motorized treadmill placed in front of three 239 cm wide screens Task consisted of walking in a community VE resembling community scenarios in Taipei and involved negotiating slopes, avoiding obstacles etc. | Control group: treadmill walking while performing various tasks, Experimental group: walking in the VE 20 min per session, 3 sessions per week for 3 weeks. |
Dunning et. al. (2008) [48] | SEMG coupled VR system that required the subject to contract and relax the agonist and antagonist muscles of the ankle to complete a “paint” game. | One hour session, 3 times per week for 8 weeks – 30 min functional lower extremity strength training and 30 min sEMG VR training. |
Rutgers Ankle Rehabilitation System - 6-degree of freedom Stewart platform force-feedback system that uses ankle movements to navigate through a VE displayed on a desktop computer as in Deutsch et al. (2004) | Experimental group: Ankle exercises in the form of VR games along with the robot. Control group: training only with the robot, same exercises as the experimental group without VR. One hour sessions, 3 times per week for 4 weeks | |
Kim et al. (2009) [32] | IREX VR system - Shark Bait, stepping up/down and snowboard games were used. | Control group – 40 min of conventional physical therapy (CPT) Experimental group - 40 min of CPT + 30 min of VR therapy, 4times/week for 4 weeks |
Walker et al. (2010) [43] | BWSTT + VR system – Body-weight supported treadmill training combined with VR. Subjects walked on a Biodex Gait Trainer 2 treadmill with an overhead Biodex Unweighting system while a virtual street scene was projected on to a 51-inch television monitor connected to a desktop. The scene was synchronized to the subjects’ motion via an inertial orientation tracking device mounted on a cap worn by the subjects. | 2-3 sessions per week for 4-6 weeks for a total of 12 sessions per subject. Each training session lasted for 10 min initially and the duration was increased for the later sessions as tolerated. |
Shin et al. (2010) [39] | Sony Playstation 2 Eyetoy play gaming system. Games such as Goal Attack, Table Tennis, Homerun, Knockout and Bowling were used. All of the games had a component of dynamic balance, speed and reaction time training. | Control group: no intervention. Game exercise group: 60-min sessions, 3 times per week for 6 weeks. |
Yang et al. (2011) [34] | VR Treadmill system consisting of 4 components: 1) a commercial treadmill modified to operate at speeds ranging from 0.1 to 1 mph, 2) a personal desktop computer with a liquid crystal display projector, 3) a VR training program resembling a video-game developed from commercial software (3DWeb, superspace) consisting of scenes that involved walking in a park along a pathway with eight left and right turns respectively, and indoor activities such as turning a light on/off and opening doors, 4) interactive switches located on each side of the treadmill – stepping switches to turn left/right and touch switch for hand motion tasks. | Both groups: treadmill training (duration 20 min), three times per week for 3 weeks + regular therapy sessions. Experimental group: walking on the treadmill in the VE while stepping on the switches to affect turns. Control group: level walking on the treadmill without VR |
Cikaljo et al. (2012) [44] | Balance Trainer (BT; Medica Medizin-technik GmbH) standing frame fixed to the base with passive controllable springs that control the stiffness of the standing frame which can move within two-degrees of freedom (AP, ML and combinations of both). Virtual environment was built in the 3D rendering program and involved moving along a path (through AP and ML movements) towards a goal while avoiding collisions with obstacles in the path. | Experimental group: BT + VR – 20 min per session, 5 times per week for 3 weeks (2 weeks clinic + 1 week telerehabilitation) Control group: BT – 20 min per session, 5 times per week for 4 weeks. |
Cho et al. (2012) [35] | Conventional 42-inch LCD TV connected to a balance board gaming system (Wii Fit Balance Board, Nintendo, Japan). Commercially available games on the Wii such as balance bubble, ski slalom, ski jump, soccer heading, table tiling and penguin slide were used for training. | Both groups: standard rehabilitation program. Experimental group: additional 30-minVR training thrice a week for 6 weeks. |
Integrated Virtual Environment Rehabilitation Treadmill (IVERT) system consisting of an instrumented dual-belt treadmill coupled to an immersive VE. The treadmill utilized a control algorithm to drive the treadmill speed in congruence with the user’s gait speed (estimated from the ground reaction force). VE consisted of a park with rolling hills, trees, rocks and a trail lined with fence posts. The VE was displayed with the help of three short-throw projectors that were mounted in front of a three-panel display placed a distance of 1.2 m from the front and 0.9 m at the sides respectively. The combined image display had a 170° horizontal and 60° vertical field-of-view. Asymmetry in gait was portrayed as a curved path in the VE and users were encouraged to maintain a straight path during trials. | Feasel et al.: One session consisting of 20-40 min of treadmill walking. Lewek et al.: Two post-stroke individuals performed 18 sessions over 6 weeks consisting of 20 min walking with the IVERT system followed by 10-15 min of overground walking. Each session lasted for 60 min (patient 1) or 45 min (patient 2). | |
Jung et al. (2012) [40] | The set-up consisted of a treadmill and an HMD through the virtual scene was displayed. The virtual scene consisted of a park stroll. The HMD displayed a 100-inch screen and had built-in earphones. Further information about the virtual scene and synchronization of the treadmill with the VR was not provided. | Experimental group: Treadmill walking with VR 30 min/day, 5 days/week for 5 weeks. Control group: treadmill walking without VR, following the same schedule as for experimental group. |
Kim et al. (2012) [41] | Nintendo Wii sports software to play games involving tennis and boxing. The Wii games were displayed on a 30-inch TV display placed at 60 cm above the ground atop which was mounted the motion sensor. The motion sensor communicated with a remote that was either held on or strapped to the unaffected hand of the stroke subjects. Both games required varied motion and acceleration patterns to succeed. | Both groups received general exercises (not specified) for 30 min and electrical stimulation to the tibialis anterior muscle on the paretic side for 15 min. The experimental group received additional VR training for 30 min/session, three times a week for 3 weeks. |
Cho et al. (2013) [36] | The set-up utilized a treadmill, a laptop, projector and speakers. The laptop was used to project real-world video recordings (VRRW) on to the projector which consisted of 10-min recordings of a 400 m walk track, a rainy 400 m walking track, a 400 m walking track with obstacles, walk in the community during daytime and nighttime and walking on a trail. Each recording was repeated thrice during the 30 min training period. | Both groups: standard rehabilitation program, 80 min per day, 5 times a week for 6 weeks. Experimental group: VRRW training, 30 min a day, 3 times per week for 6 weeks. Control group: treadmill training without VR for similar duration. |
Fritz et al. (2013) [38] | Nintendo Wii (Wii sports and Wii Fit) as well as Playstation (Eyetoy play and Kinect) gaming systems were used to train the experimental group. The Wii Fit and Kinect were marketed as physical activity whereas Wii sports and Eyetoy were marketed as ‘fun-based’ games. The patients were encouraged to operate both systems on their own. | Control group: no intervention VR group: 50- 1 hour sessions consisting of 25-30 min physical activity and 25-30 min fun-based games. Frequency: 4 days/week for 5 weeks. |
Rajaratnam et al. (2013) [37] | Nintendo Wii-fit and the Kinect gaming system were used to train the experimental group. Games that required subjects to shift weight in standing (Wii Fit and Kinect) and sitting (Kinect only) were used for training. | Control group: 60 minutes of conventional rehabilitation per session for 15 sessions. Experimental group: 40 min of conventional rehabilitation + 20 min of VR training per session for 15 sessions. |
Singh et al., (2013) [42] | Nintendo Wii Fit plus with Balance Board: Balance Bubble game Xbox 360 Kinect: Rally Ball game, individuals who scored a gold medal on this game progressed on to the Reflex Ridge game. | Control group: standard group exercise therapy 2 hour sessions 2 times per week for 6 weeks. Experimental group: 90 minutes of standard group exercise + 30 min of VR balance games, 15 min each on the WiiFit and Xbox Kinect, twice per week for 6 weeks. |
VR-based interventions
Outcome measures
Study
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Design, level of evidence
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Population N, age, duration post-stroke
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Type of stroke
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Outcome measures
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Results
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Deutsch et al. (2004) [45] | Pilot study, V | Chronic stroke Experiment 1 – 69-year old, 10 months post-stroke (n = 1) Experiment 2 – 1-8 years post-stroke (n = 3), age not given | Exp 1- Right middle cerebral artery CVA Exp 2 – not specified | Exp 1) VR-based measures including power, torque, accuracy,strength and range of motion Exp 2) Walking speed; 6-minute walk test (6MWT); Berg Balance score (BBS); foot strength | Exp 1) One grade increase in the strength of ankle evertors. Increased accuracy on the VR simulations (from 58% to 88%). Exp 2 –Increase in strength increase in 2 to 4 muscle groups and increase in walking speed (80 ft/min to 95 ft/min). |
Jaffe et al. (2004) [28] | Randomized controlled trial, II | Chronic stroke (3.8 ± 2.2 years post-stroke), 60.7 ± 2.3 years; virtual object group (n = 10); real object group (n = 10) | Not specified | Percentage improvement on: 1) Balance tests (natural stance, natural stance eyes closed, on toes, tandem stance, tandem stance eyes closed, left leg only, right leg only) 2) Walking tests (walking velocity, cadence and stride length at self-selected and fast walking) 3) Obstacle test 4) 6-minute walk test (6MWT) | 1) Results related to the Balance tests are not reported. 2) Greater percent improvements in walking speed (20.5% vs. 12.2%) and stride length for fast walking with VR 3) Obstacle crossing showed greater percent improvements with virtual obstacle protocol. Greater than 95% retention in all key gait parameters at 2 week follow-up 4) 6MWT: No significant changes post-treatment observed in both groups. |
You et al. (2005) [29] | Experimenter blind randomized study - RCT, II | Chronic stroke (VR group – n = 5, 54.6 ± 3.0 years, 18.2 ± 2.3 months post-stroke control group – n = 5, 54.6 ± 3.4 years, 19.4 ± 4.3 months post-stroke) | Thalamic hemorrhage (n =2) Corona radiata hemorrhage (n =3) Corona radiata infarct (n = 5) | 1) fMRI – Laterality Index (LI) 2) Functional Ambulation Category (FAC) 3) Modified Motor Assessment Scale (MMAS) | 1) Bilateral activity in the sensory-motor cortex as seen before treatment either disappeared or decreased on the ipsilateral side indicating cortical reorganization. 2) All patients in the VR group were able to achieve a change of at least one level on the FAC as opposed to the control group. 3) Significant changes in MMAS. |
Betker et al. (2006) [46] | Single-subject design: case report, V | n = 3, case 1 – 20-year old case 2 – 58-year old post-stroke (onset not provided) case 3- 14-year old | Case 1- cerebellar tumour excision with ataxia Case 2 – cerebrovascular accident infarction Case 3 – closed TBI (case 1 and 3 will not be discussed in the paper) | 1) Tasks that involved maintaining static and dynamic balance 2) CoP excursion and sway path 3) Number of falls | 1) Successful completion of oscillating head rotations, trunk bending and trunk rotation tasks post-exercise as opposed to failure pre-exercise. 2) Variable findings on CoP excursion and CoP sway path with increase in excursion and sway path in some and decrease in other tasks. 3) 5 falls pre-exercise as opposed to 2 falls post-exercise |
Fung et al. (2006) [10] | Feasibility study, V | Sub-acute stroke (n = 2, 49 & 61 years, 2 and 4.5 months post-stroke) Control – healthy elderly (n = 1, 64 years) | Not specified | Ability to complete the locomotor task within the time constraint and without any collisions with the virtual obstacles. | Both subjects as well as the control were able to increase the walking speed to complete level 1 in all VE’s. The subjects were also able to eventually complete level 2 despite a considerable reduction in gait speed while negotiating platform movements. Both subjects did not reach level 3 to avoid obstacles successfully. The precise increase or decrease in gait speed is not specified. |
Flynn et al. (2007) [47] | Case report, V | Chronic stroke (n = 1, 17 months post-stroke, 76-year old) | Cerebro-vascular accident, area not specified | Only those concerned with balance and mobility are listed here: 1) BBS 2) Dynamic Gait Index (DGI) 3) Timed Up-and-Go (TUG) 4) 6MWT 5) Functional Reach test (FRT) | Only those concerned with balance and mobility are listed here: 1) BBS increased from 51/56 pretest to 54/56 post-test 2) DGI – 16 pre-test to 21post-test 3) TUG - 12.73 s pre to 11.68 s post 4) 6MWT–1282 ft pre to 1337 ft post 5) FRT 11.33 in pre to 11.50 in post |
Yang et al. (2008) [30] | RCT, II | Chronic stroke: VR group (n = 11, 55.5 years; 5.9 years post-stroke) Control group (n = 9, 60.9 years, 6.1 years post-stroke) | Not specified | 1) Walking speed 2) Community walking time 3) Activities-specific Balance Confidence scale (ABC) 4) Walking Ability Questionnaire (WAQ) score | 1) Insignificant change in walking speed but a trend towards increase. 2) Significant improvement in community ambulation time (6.14 ± 5.53 s); 3) ABC scores (8.86 ± 10.10points); 4) WAQ scores (3.45 ± 5.11points); All gains retained at 1 month follow-up. |
Dunning et al. (2008) [48] | Case report, V | Sub-acute stroke (n = 1, 51 years; 9 months post-stroke) | Ischaemic infarct in the posterior limb of the left internal capsule | 1) Modified Emory Functional Ambulation Profile (mEFAP) 2) Lower extremity portion of the Fugl-Meyer (FM) scale 3) Gait velocity: self-selected & fast 4) Temporal distance gait parameters 5) Lower extremity joint kinematics and kinetics | 1) mEFAP – 4.4 s (11.2%) decrease post-intervention 2) FM – 5 point (23.8%) increase with largest changes for obstacles (17.2%) and stairs (13.7%) 3) Gait velocity increase post-intervention -Slow – 0.29 m/s (27.7%) fast – 0.26 m/s (16.4%) 4) Temporal distance gait parameters such as step length, cadence, stance and swing times also showed minor improvements post-treatment. 5) Ankle plantarflexor moment during push off increased 29.5% and 13.3% for self-selected and fast walking speeds respectively Greater hip extension at push off, improved knee extension at heel strike and greater ankle plantarflexion at push-off. |
Mirelman et al. (2009; 2010) [31;33] | Randomized controlled trial, II | Chronic stroke Robotic VR group (n = 9; 61.8 years, 37.7 months post-stroke), robotic group (n = 9; 61 years, 58.2 months post-stroke) | Not specified | 1) 6MWT 2) Community-based walking as measured by the PAM (no. of steps/day, average daily distance walked, speed, cadence, walking strides, maximum walking speed, longest consecutive locomotion period in minutes and longest consecutive distance travelled). 3) Self selected walking speed (SSWS) 4) Joint kinetics – ankle moments during stance and pre-swing, knee flexor moment during stance and push-off, hip flexor moment at initial swing, power at the ankle, knee and hip joints 5) Joint kinematics – ROM of the ankle and hip joints during the gait cycle | 1) 6MWT – 21% increase in the Robotic VR group; 0.5% increase in the robotic group 2) Community based ambulation – significant differences seen in distance walked, no. of steps per day, average speed and maximum speed. All changes were retained in the robotic VR group at 3 months follow –up. 3) SSWS –24% increase (from 0.65 to 0.81 m/s) in the VR group vs. 2% (0.67 – 0.68 m/s) in the NVR group. 4) Joint kinetics- Ankle moment (barefoot walking) – VR group (from 0.74 ± 0.24 Nm/kg to 0.90 ± 0.31 Nm/kg, 21%) vs. NVR group (0.68 ± 0.17 Nm/kg to 0.67 ± 0.08 Nm/kg, 1.5%). Ankle power (barefoot walking) – significant increase in the VR group (0.63 ± 0.28 W/kg to 0.91 ± 0.45 W/kg; 44%) as opposed to the NVR group (0.5 ± 0.27 W/kg to 0.52 ± 0.26 W/kg; 4%). Retention at follow-up was seen in the VR group. 5) Kinematics –Barefoot walking Ankle ROM – increase from 29.3 ± 7.4 degrees (19.5%) in the VR group and from 32.6 ± 13.4 to 36.7 ± 3.2 degrees (3.3%) in the NVR. Both changes were reported to be statistically significant. Knee ROM – significantly greater increases (stance-34%, swing – 15.7%) in the VR group as compared to the NVR group (stance – 7.2%, swing – 3.9%). Both ankle and knee ROM gains were preserved at follow-up. Onset of push-off – improved from 55% of gait cycle in both groups to 57.7% of the gait cycle in the VR group only. |
Kim et al. (2009) [32] | RCT, II | Chronic stroke: Experimental group (n = 12; 52.4 years, 25.9 months post-stroke); Control group (n = 12; 52.4 years, 25.9 months post-stroke) | Intra-cranial hemorrhage in the thalamus, putamen, basal ganglia (n = 13) Infarcts in the deep cerebral white matter, basal ganglia, putamen and pons (n = 11) | 1) BBS 2) Modified motor assessment scale 3) 10 m walk test 4) mean CoP sway area; sway path and maximal sway velocity; antero-posterior (AP) and medio-lateral (ML) sway angles 5) Temporal distance gait parameters: cadence, velocity, step time, stance time, swing time, single/double support time, step/stride length. | 1,2,3) Significant improvement in scores 4) reduction in sway area and maximal CoP velocity; AP and ML sway angles increased 5) cadence, step time, step length showed significant increases |
Walker et al. (2010) [43] | Pre-post design, IV | Sub-acute to chronic stroke (3 weeks to 1 year post-stroke) N = 6, 53.4 years (49-74 years) | Ischaemic stroke with left-side hemiparesis | 1) FGA 2) BBS 3) Overground walking speed Also reported pre-post treadmill walking speed, treadmill walking duration and percentage body-weight supported | Significant increases in 1) FGA (30%); 2) BBS (10%); and 3) overground walking speed (38%, change of 0.19 m/s pre-post). Treadmill walking duration – pre -10 min, post- 19.83 min Treadmill walking speed – pre – 1.31mph, post – 1.7 mph Weight support (% Body weight) – pre- 31.67, post – 18.33. |
Shin et al. (2010) [39] | Pre-post, III | Chronic stroke (Control group, n = 16, 60.7 ± 9.2 years, 71.5 ± 33.9 months post-stroke; Game exercise group, n = 16, 60.8 ± 7.5 years, 69.2 ± 36.4 months post-stroke) | Control group – 11 ischemic and 5 hemorrhagic stroke; Game exercise group – 10 ischemic and 6 hemorrhagic stroke | 1) 10 m walk test 2) 6MWT | 1) Significant improvements in gait speed (0.86 ± 0.32 m/s pre-training to 1.10 ± 0.34 m/s post-training) in the game-exercise group as compared to controls. 2) Significant improvements were also seen in distance walked in the 6MWT (225.87 ± 60.16 m pre-training to 268.79 ± 56.42 m post-training) and was significantly larger than that seen in control group. |
Yang et al. (2011) [34] | Randomized controlled trial, II | Chronic stroke (control group, n = 7; 65.7 ± 5.9 years, 16.3 ± 10.4 months post-stroke Experimental group, n = 7, 56.3 ± 10.2, 17.0 ± 8.6 months post-stroke). | Not specified | 1) Standing eyes open -Maximum CoP displacement in the ML (CoPML) & AP (CoPAP) directions, excursion (CoPE), sway area (CoPA), & bilateral limb-loading symmetrical index (SI). 2) Sit to stand (STS): those included above + CoP excursion for the paretic foot (CoPE/P). 3) Walking: Stance time of the paretic limb (ST/P), number of steps of the paretic limb & contact area of the paretic foot. | 1) Standing eyes open: No statistically significant change in any parameters. A tendency towards increase in CoPML, CoPAP, CoPE, SI and CoPA in the experimental group. 2) STS: a significant improvement in SI and CoPE/P in the experimental group. 3) Walking: Significant increase in stance time of the paretic limb in both groups. Significant increase in the contact area of the paretic foot in the experimental group. |
Cikaljo et al. (2012) [44] | Pre-post (follow-up only for the experimental group), IV | Sub-acute stroke (control group: n = 22, age: 61.0 ± 7.4 years) Experimental group: n = 6, 58.5 ± 12.1 years) | Not mentioned | 1) BBS 2) TUG 3) 10 meter walk time 4) Single leg stance on affected (SAE) and unaffected (SAU) side. 5) Additional outcomes for the experimental group: VR performance time and number of collisions. | 1, 2, 3, 4) No statistically significant between group differences on any clinical outcome. Both groups improved over time on the clinical tests. 5) The experimental group showed improved performance and decrease in the number of collisions post- intervention. |
Cho et al. (2012) [35] | RCT, II | Chronic stroke (experimental group: n = 11, age: 65.3 ± 8.4 years, 12.54 ± 2.58 months post-stroke; control group: n =11, age: 63.3 ± 6.9 years, 12.6 ± 2.5 months post-stroke) | Not described | Static balance using postural sway velocity (PSV) in the AP and ML directions with eyes open (EO) and eyes closed (EC) 1) PSV – APEO, 2) PSV – MLEO, 3) PSV – APEC, 4) PSV-MLEC. Dynamic balance 5) BBS score, 6) TUG (s) | Static balance PSV measures (1,2,3 and 4) did not show statistically significant changes pre and post treatment in both experimental and control group. 5) BBS: BBS scores improved in both groups post treatment; greater increase in the experimental (VR) group. 6) TUG: A significant decrease in TUG times in both groups, decrease significantly larger in the experimental VR group. |
Feasibility study; case report, V | Feasel et al. – Hemiparesis due to various reasons (n = 5). Of these 2 were chronic stroke; 32 and 48 months post-stroke respectively. Lewek et al. Chronic stroke (n = 2; 18 and 21 months post-stroke) | Feasel et al. - Not described Lewek et al.- Patient 1 – right internal carotid artery stroke Patient 2 – embolic stroke to the left middle cerebral artery | Feasel et al. 1) Gait velocity 2) Overground gait symmetry before and after training for stance time, single support time and step length at comfortable and fast walking speeds. 3) Patients’ comments about usability (ease of learning, what was easy or hard, what they liked and did not like about the experience) Lewek et al.: 1) Gait speed (comfortable (CGS) and fast walking (FGS)), 2) Step length asymmetry ratio, 3) Stance time asymmetry ratio | Feasel et al. 1) Gait velocity in the first 5 min of treadmill walking was comparable to overground walking 2) No significant difference in gait symmetry between the first and the last minute of walking. The ‘best minute’ of symmetry was significantly more symmetric than the first minute. No significant differences in average gait symmetry before and immediately after training. 3) Participants reported the task to be mentally taxing. However, positive comments about having visual feedback (walking in the VE) and having a visual goal (keeping the walking path straight) were received. Lewek et al.: 1) Patient 1 improved the CGS from 0.49 m/s (using a large-base quad cane) to 0.84 m/s post-training (without using a cane). This improvement was preserved over the follow-up. The FGS also improved from 0.56 m/s pre-training to 0.95 m/s post-training. Similar results were seen with patient 2, CGS improved from 1.02 m/s pre-training to 1.28 m/s post-training (retained on follow-up) while FGS improved from 1.71 to 1.88 m/s (retained on follow-up). 2) Step-length symmetry improved from 1.52 to 1.32 (with cane) and 1.18 (without cane) in patient 1. The positive effects were maintained on follow-up. Patient 2 did not demonstrate step-length asymmetry to begin with. 3) Stance-time asymmetry did not improve in Patient 1, but improved from 1.11 pre-training to 1.04 post-training. These effects were lost to some degree on follow-up. | |
Jung et al. (2012) [40] | Pre-post design, III | Chronic stroke (control group: n = 10, age 63.6 ± 5.1 years, 15.4 ± 4.7 months post-stroke; experimental group: n = 11, age 60.5 ± 8.6 years, 12.6 ± 3.3 months post-stroke | Control group: 5 ischemic, 5 hemorrhagic and 6 right, 4 left paretic stroke; Experimental group: 7 ischemic, 4 hemorrhagic and 5 right, 6 left paretic stroke | 1) TUG (s) 2) ABC (%) | Both groups improved significantly on outcomes 1 and 2 (TUG change: control: -0.8 ± 0.7 s, stroke: -2.7 ± 1.9 s; ABC change: control: 4.3 ± 3.3%; stroke: 9.5 ± 6.0%). Improvements seen in the experimental group were significantly larger than the control group. |
Kim et al. (2012) [41] | Pre-post design, III | Sub-acute to chronic stroke (control: n = 7, age 55.0 ± 13.0 years,12.9 ± 6.1 months post-stroke; experimental: n = 10, age 41.3 ± 6.6 years, 12.6 ± 7.1 months post-stroke | Control group – 3 hemorrhagic, 4 ischemic stroke, Experimental group – 4 hemorrhagic, 6 ischemic stroke | 1) Postural assessment scale for stroke patients (PASS), 2) MMAS, 3) Functional Independence measure (FIM) | 1 & 2) Both groups showed significant improvements on the PASS and MMAS. The experimental group improved significantly more than the control group. 3) No significant differences were found on the FIM scores both within and between groups. |
Cho et al. (2013) [36] | RCT, II | Sub-acute to chronic stroke (control group: n = 7, age 65.1 ± 4.7 yrs; experimental group: n = 7, age 64.6 ± 4.4 yrs) | Control group: 5 ischemic, 2 hemorrhagic; Experimental group: 4 ischemic, 3 hemorrhagic | Walking balance: 1) BBS, 2) TUG (s), Temporal gait parameters: 3) Gait speed (cm/s), 4) Cadence (steps/min), Spatial gait parameters (paretic side): 5) Step length (cm), 6) Stride length (cm), 7) Single limb support (%) | Both groups showed significant improvements on all outcome measure post-test as compared to pre-test (1-7). The change seen post-test was significantly greater in experimental group as compared to the control group in BBS scores, TUG, gait speed and cadence (1-4). |
Fritz et al. (2013) [38] | Randomized matched single blind design, III | Chronic community dwelling stroke (control group: n = 13, age 64.5 ± 10.1 years, 3.6 ± 3.2 years post-stroke; Experimental group: n = 15, age 67.6 ± 9.3 years, 2.5 ± 2.6 yrs post stroke) | Control group: 4 left, 9 right paretic stroke; Experimental group: 9 left, 6 right paretic stroke | 1) FM 2) BBS 3) DGI 4) 6MWT 5) 3 m walk test 6) 3 m walk test – fast 7) Stroke Impact scale 8) TUG | No between or within group difference on any outcome (1-8). The effect sizes for the outcomes in the VR group were larger than those seen in the control group. These changes were preserved at the 3-month follow-up. |
Rajaratnam et al. (2013) [37] | Randomized controlled trial, II | Acute stroke (control group: n = 9, 65.3 ± 9.6 yrs; Experimental group: n = 10, 58.7 ± 8.6 yrs) | Control group: 8 ischemic, 1 hemorrhagic; Experimental group: 8 ischemic, 2 hemorrhagic | 1) FRT 2) TUG 3) BBS 4) COP sway 5) Modified Barthel Index (MBI) | Both the control and experimental group showed significant improvements in the TUG (2) and the MBI (5) post-intervention. There were significant improvements in FRT (1) post-intervention in only the experimental group. |
Singh et al. (2013) [42] | Controlled pre-post design, III | Chronic community-dwelling stroke (Control group: n = 13, age: 67 ± 8.4 yrs; experimental group: n = 15, age: 65.4 ± 9.8 yrs). | Not specified | 1) TUG 2) 30 s sit to stand test (30sSTS) 3) Timed 10 m walk 4) 6MWT 5) Overall balance score (OBS): RMS of the combined AP and ML sway 6) Barthel Index | Both the control and experimental group showed significant gains in TUG (1) and 30s STS (2) tests post-training. However, no difference between control and experimental groups were found post-training on any outcome. |