Background
Virtual reality
Systematic reviews comparing VE and CG systems
Cognition and VR
Analysis of individual domains of functioning
Methods
Data sources and search strategy
Inclusion and exclusion criteria
Identification of relevant studies and data extraction
Quality assessment
Quantitative analysis
Moderator Type | Definition |
---|---|
Design factors | |
Intervention Type | Virtual Environment (VE) design or Computerized Gaming (CG) system |
Simulation Type | Intervention targeting hand/finger function or interventions targeting overall upper-limb function |
Study Quality | Moderate Quality (PEDro score ≤ 6) or High Quality (PEDro score > 6) |
Recovery Stage | Sub-Acute (≤3 months post-stroke) or Chronic (> 3 months post-stroke) |
Control Group Type | Passive (treatment as usual) or Active (treatment as usual + additional rehabilitation) comparison control group |
Implementation Parameters | |
Duration | Total number of sessions per intervention (low: < 15 sessions; high: ≥ 15 sessions) |
Frequency | Number of sessions per week (low: ≤ 3 sessions; high: > 3 sessions) |
Dose | Total number of minutes per intervention (low: < 400 min; medium: 400–800 min; high: > 800 min) |
Daily Intensity | Minutes per session (low: ≤ 30 min; high: > 30 min) |
Weekly Intensity | Total minutes of virtual rehabilitation per week (low: ≤ 100 min; high: > 100 min) |
Results
Participant Characteristics | Study Design | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
First Author, Year (Reference) | N (VR/CT) | Mean Age at Intervention | Time Since Stroke (Weeks) | Recovery stage | Stroke Type | Cohort Origin | VR Type | Implementation Parameters | Control Type | Outcomes |
Assis, 2014 | 4/4 | 55.0 | 269.6 | Chronic | NR | Brazil | VE | One hour training once a week, for 4 weeks | Active | Body Function |
Broeren, 2008a | 11/11 | 68.0 | 306.1 | Chronic | Mixed | Sweden | VE | Forty-five minutes training, 3 times a week for 4 weeks | Passive | Activity |
Chen, 2015 Study 1 | 8/8 | 49.2 | 36.3 | Chronic | NR | Taiwan | CG | Thirty minutes training 3 times a week for 8 weeks | Active | Body Function, Activity |
Chen, 2015 Study 2 | 8/8 | 53.3 | 37.8 | Chronic | NR | Taiwan | CG | Thirty minutes training 3 times a week for 8 weeks | Active | Body Function, Activity |
Choi, 2014c | 10/10 | 64.7 | NR | NR | Mixed | Korea | CG | Thirty minutes training, 5 times a week for 4 weeks | Active | Body Function, Activity, Cognitive |
Crosbie, 2012a,c | 9/9 | 60.4 | 46.9 | Chronic | NR | UK | VE | Thirty minutes training, 3 times a week for 3 weeks | Active | Activity |
da Silva Cameirão, 2011a,b | 8/8 | 61.4 | 1.9 | Subacute | Mixed | Spain | VE | Study 1: Twenty minutes training, 3 times a week for 5 weeks.Study 2: Twenty minutes training, 3 times a week for 12 weeks. | Active | Body Function, Activity |
da Silva Ribeiro, 2015 | 15/15 | 53.3 | 222.7 | Chronic | NR | Brazil | CG | One hour training twice a week, for 8 weeks | Active | Body Function, Activity |
Duff, 2010 | 11/10 | 68.5 | 56.3 | Chronic | Mixed | USA | VE | One hour training 3 times a week, for 4 weeks | Active | Body Function, Activity, Participation |
Gamito, 2015 | 10/10 | 55.0 | NR | NR | NR | Portugal | VE | One hour training 3 times a week, for 6 weeks | Passive | Cognitive |
Givon 2015 | 19/18 | 59.4 | 146.0 | Chronic | Mixed | Israel | CG | One hour training 2 times a week, for 12 weeks | Active | Body Function, Activity |
Housman, 2009b | 15/16 | 55.3 | 427.8 | Chronic | Mixed | USA | VE | One hour training 3 times a week, for 8 weeks | Passive | Body Function, Participation |
In, 2012a | 11/8 | 64.0 | 57.9 | Chronic | Mixed | Korea | VE | Thirty minutes training, 5 times a week for 4 weeks | Active | Body Function, Activity |
Kihoon, 2012a | 15/14 | 63.9 | NR | NR | NR | Korea | CG | One hour training 5 times a week, for 4 weeks | Passive | Body Function, Cognitive |
Kim, 2011b | 15/13 | 64.2 | 3.0 | Subacute | Mixed | Korea | CG | Thirty minutes training, 3 times a week for 4 weeks | Passive | Activity, Cognitive |
Kim, 2012a,b | 10/7 | 48.2 | 54.8 | Chronic | Mixed | Korea | CG | Thirty minutes training, 3 times a week for 3 weeks | Passive | Activity |
Kiper, 2011a,b | 40/40 | 64.0 | 25.0 | Chronic | Mixed | Italy | VE | One hour training 5 times a week, for 4 weeks | Active | Body Function, Activity |
Kiper, 2014 | 23/21 | 64.3 | 18.3 | Chronic | Mixed | Italy | VE | One hour training 5 times a week, for 4 weeks | Active | Body Function, Activity |
Kong, 2016 | 31/33 | 57.5 | 1.96 | Subacute | Mixed | Singapore | CG | One hour training 4 times a week, for 3 weeks | Passive | Body Function, Activity |
Kottink, 2014 | 8/10 | 61.4 | 173.1 | Chronic | Mixed | The Netherlands | VE | Thirty minutes training, 3 times a week for 6 weeks | Active | Body Function, Activity |
Kwon, 2012 a,b | 13/13 | 57.5 | 34.9 | Chronic | Mixed | Korea | CG | Thirty minutes training, 5 times a week for 4 weeks | Passive | Body Function, Activity |
Lee, 2013 | 7/7 | 74.1 | 33.8 | Chronic | Mixed | Korea | CG | Thirty minutes training, 3 times a week for 6 weeks | Passive | Body Function, Activity |
Levin, 2012 | 6/6 | 59.0 | 165.3 | Chronic | Mixed | Israel | VE | Forty-five minutes training, 3 times a week for 3 weeks | Active | Body Function, Participation |
Piron, 2009 a,b,c | 18/18 | 65.2 | 57.9 | Chronic | Ischemic, MCA | Italy | VE | One hour training 5 times a week, for 4 weeks | Active | Body Function |
Piron, 2010 a,b,c | 27/23 | 60.5 | 66.2 | Chronic | Ischemic, MCA | Italy | VE | One hour training 5 times a week, for 4 weeks | Active | Body Function, Activity |
Saposnik, 2016 | 59/62 | 62.0 | 3.7 | Subacute | Ischemic | Canada, Argentina, Peru, Thailand | CG | One hour training 5 times a week, for 2 weeks | Passive | Body Function, Activity |
Shin, 2014 | 9/7 | 49.3 | 10.3 | Subacute | NR | Korea | VE | Twenty minutes training, 5 times a week for 2 weeks | Active | Body Function, Activity |
Shin, 2015 c | 16/16 | 54.0 | 26.2 | Chronic | NR | Korea | VE | Thirty minutes training, 5 times a week for 4 weeks | Active | Body Function, Activity |
Sin, 2013b | 18/17 | 73.7 | 34.1 | Chronic | Mixed | Korea | CG | Thirty minutes training, 3 times a week for 6 weeks | Passive | Body Function, Activity |
Standen, 2017 | 9/9 | 61.0 | NR | NR | NR | UK | VE | Twenty minutes training, 3 times a day for 8 weeks | Passive | Body Function, Activity, Participation |
Yavuzer, 2008 a,b,c | 10/10 | 61.1 | 17.2 | Chronic | NR | Turkey | CG | Thirty minutes training, 5 times a week for 4 weeks | Passive | Activity |
Yin, 2014 | 11/10 | 58.4 | 2.3 | Subacute | NR | Singapore | VE | Thirty minutes training, 5 times a week for 2 weeks | Passive | Body Function, Activity, Participation |
Participant characteristics
VR and control interventions
First Author, Year | Virtual Rehabilitation Intervention | Control Group Intervention |
---|---|---|
Assis, 2014 | VE: NeuroR augmented reality system, with virtual shoulder exercises to extend the upper-limb + TAU | TAU: Standard Therapy (NR) Ancillary: Relaxation session instructed by physiotherapist followed by shoulder movement using both unaffected and injured arms assisted by the physiotherapist and also without the physiotherapist assistance. |
Broeren, 2008 | VE: Semi-immersive table-top workbench with haptic device and 3D computer games + TAU | TAU: Usual activities at the centre, which included different social activities, creative crafts and physical activities. Ancillary: NA |
Chen, 2015 | Study 1 – VE: Wii Nintendo games bowling and boxing games + TAUStudy 2 – VE: XaviX games bowling and ladder climbing games + TAU | TAU: At least one hour of physio- and occupational therapy per week. Ancillary: Two traditional devices, the Curamotion exerciser and the climbing board and bar |
Choi, 2014 | CG: Wii Nintendo games: swordplay, table tennis, and canoe + TAU | TAU: Standard Therapy (NR) Ancillary: OT that involved goal-oriented and highly repetitive trainings for that involved composed of stretching and strengthening exercises using full range of motion of the upper extremity, which was a task-oriented therapy for the ADL, fine motor training, and sensory motor recover |
Crosbie, 2012 | VE: 3D environment system, that included a desktop computer, a head-mounted display unit, a motion tracking system and sensors with tasks focused on reaching and grasping. + TAU | TAU: Standard physiotherapy Ancillary: Delivered by a physiotherapist, experienced in stroke rehabilitation, and followed a programme of techniques, which included muscle facilitation, stretching exercises, strengthening activities and the inclusion of the more affected upper limb in functional tasks |
da Silva Cameirão, 2011 | Study 1 - VE: Rehabilitation Gaming System that captures upper limb movements through color detection; two data gloves to capture finger flexure creating a virtual environment where an avatar mimics the movements of the user. Tasks aimed to target speed, range of motion, grasp and release + TAU for 5 weeks. Study 2 - VE: Rehabilitation Gaming System that captures upper limb movements through color detection; two data gloves to capture finger flexure creating a virtual environment where an avatar mimics the movements of the user. Tasks aimed to target speed, range of motion, grasp and release + TAU for 12 weeks. | TAU: Two weekly physiotherapy sessions Ancillary: involved release or non-specific interactive Wii Nintendo games either intense occupational therapy targeting object displacement, grasp and. |
da Silva Ribeiro, 2015 | CG: Wii Nintendo games: tennis, hula-hoop, soccer and boxing. + TAU | TAU: NR Ancillary: Conventional physiotherapy that included 10-mintes of upper and lower limb stretching or muscles and trunk, passive, active-assisted, and active-resisted mobilisation of the trunk (10 min), straightening and balance reactions with rapid shifts (10 min), scapular mobilisation (5 min), active or active-assisted upper-limb diagonal movements (15 min) and grasping activities (10 min) |
Duff, 2010 | VE: Adaptive mixed reality rehabilitation system + TAU | TAU: Standard Therapy (NR) Ancillary: UL therapy: pegboard reaching tasks, bead threading reaching tasks, cone reaching tasks, and ROM and coordination exercises |
Gamito, 2015 | VE: Cognitive stimulation with Serious Games mobile technology, that included several daily live activities e.g. buying items, findings way to the minimarket, finding a virtual character. + TAU | TAU: Standard Therapy (NR) Ancillary: NA |
Givon 2015 | CG: Microsoft Xbox Kinect, Sony PlayStation 2 Eyetoy, Sony PlayStation 3 MOVE, Nintendo Wii Fit and the SeeMe VR systems. + TAU | TAU: Standard Therapy (NR) Ancillary: Participants were then divided into pairs or triads to perform functional activities such as picking up and transferring objects from one side of the room to the other. |
Gyuchang, 2013 | CG: Xbox Kinect + TAU | TAU: Standard occupational therapy Ancillary: NA |
Housman, 2009 | Therapy Wilmington Robotic Exoskeleton (T-WREX) a passive (non-robotic) arm that provides support for the arm against gravity and measures arm movement and traces hand grasp as users interact with computer games | TAU: Standard Therapy (NR) Ancillary: Conventional semiautonomous training |
In, 2012 | VE: Virtual Reality Reflection Therapy program + TAU | TAU: Standard Therapy (NR)Ancillary: The control group received the same treatment as intervention group, but the monitor was off. |
Kihoon, 2012 | CG: Interactive Rehabilitation and Exercise System (IREX) + TAU | TAU: Standard Therapy (NR) Ancillary: NA |
Kim, 2011 | CG: Interactive Rehabilitation and Exercise System (IREX) + TAU | TAU: Computer assisted cognitive rehabilitation Ancillary: NA |
Kim, 2012 | CG: Nintendo Wii Tennis and boxing games | TAU: Previous therapy (not specified), no therapy at the time of intervention Ancillary: NA |
Kiper, 2011 | VE: Reinforced feedback in virtual environment (RFVE) system + TAU | TAU: Standard Therapy (NR) Ancillary: Additional Standard Therapy (tailored to individual needs) |
Kiper, 2014 | VE: Reinforced feedback in virtual environment (RFVE) system + TAU | TAU: Standard Therapy (NR) Ancillary: Additional Standard Therapy (tailored to individual needs) |
Kong, 2016 | CG: Nintendo Wii Tennis, golf, baseball, table tennis, basketball, cycling, sword play, airplane flight control and boxing games (Wii Sports and Wii Sports resort packages) + TAU | TAU: Standard Therapy consisted of physical and occupational therapy one hour a day, Monday to Friday. Ancillary: NA |
Kottink, 2014 | VE: The Furball Hunt table-top rehabilitation game + TAU | Standard therapy tailored to individual needs Ancillary: Exercises required reaching for targets, such as objects positioned on a table top, or using specific, non-(electro) mechanical equipment (bow, pegs in holes, placing disks, etc.) |
Kwon, 2012 | CG: Interactive Rehabilitation and Exercise System (IREX) + TAU | TAU: Standard physical and occupational therapy Ancillary: NA |
Lee, 2013 | CG: Xbox Kinect + TAU | TAU: Standard occupational therapy Ancillary: NA |
Levin, 2012 | VE: Virtual games and a virtual supermarket (e.g., Birds & Balls, Soccer, Volleyball, VMall) + TAU | TAU: NR Ancillary: Occupational therapy, including exercises involving reaching for and holding cones, cups, and other objects in all motion planes with and without external loading |
Piron, 2009 | VE: Therapist telerehabilitation equipment (VRRS.net®), participant can observe his/her movement on the screen (augmented feedback), and observe the correct trajectory pre-recorded in the virtual scene (virtual teacher) + TAU | TAU: NR Ancillary: Conventional physical therapy, with patients performing specific exercises (e.g. touching different targets arranged in a horizontal plane in front of them) with a strategy of progressive complexity. |
Piron, 2010 | VE: Reinforced feedback in a virtual environment (RFVE) system + TAU | TAU: Conventional physical therapy Ancillary: The CT program was based on Bobath principles. The patients performed specific exercises with the upper limb with progressive complexity. First, the patients were asked to control isolated motions without postural control; subsequently, postural control was included; and finally, complex motion with postural control was practiced. |
Saposnik, 2016 | CG: Nintendo Wii, Wii sports and Game Party 3 packages + TAU | TAU: Standard Therapy (NR) Ancillary: Recreational computer-generated activities (passive control) |
Shin, 2014 | VE: The RehabMaster game-based system + TAU | TAU: Standard Therapy (NR) Ancillary: Occupational therapy |
Shin, 2015 | VE: The RehabMaster game-based system + TAU | TAU: Standard Therapy (NR) Ancillary: Occupational therapy |
Sin, 2013 | CG: Xbox Kinect Microsoft + TAU | TAU: Standard Therapy (NR) Ancillary: NA |
Standen, 2017 | VE: Home-based VR system with three games (Spacerace, Spongeball, Balloonpop) | TAU: Previous therapy, no therapy at the time of intervention Ancillary: NA |
Yavuzer, 2008 | CG: Playstation EyeToy games (Kung-foo, goal attack, MrChef, Dig and HomeRun) + TAU | TAU: Physiotherapy, occupational therapy, speech therapy (if needed) Ancillary: “Sham therapy” (not specified, passive control) |
Yin, 2014 | VE: VE of a local supermarket setting + TAU | TAU: Standard Therapy (NR) Ancillary: NA |
Dose and session scheduling
ICF-WHO outcomes
Body Structure and Function | Activity | Participation | Cognitive | |||||||
---|---|---|---|---|---|---|---|---|---|---|
First Author, Year | FMA-UE | MAS | Other outcomes | BBT | ARAT | FIM | BI | Other outcomes | ||
Assis, 2014 | ✓ | |||||||||
Broeren, 2008 | ✓ | |||||||||
Chen, 2015 | ✓ | ✓ | ✓ | |||||||
Choi, 2014 | ✓ | MFT; Grip Strength | ✓ | ✓ | A-CPT Correct Detection, Reaction Time, Commission Error; V-CPT Correct Detection, Reaction Time | |||||
Crosbie, 2012 | ✓ | MI | ||||||||
da Silva Cameirão, 2011 | ✓ | FMA arm; FMA hand/wrist | ✓ | CAHAI; MI | ||||||
da Silva Ribeiro, 2015 | ✓ | FMA Overall, Physical Functioning (overall motor functioning | SF-36 Social Aspects, Vitality | |||||||
Duff, 2010 | ✓ | FMA range of motion, pain, sensation | SIS; WMFT total; WMFT time. | MAL Amount of Use, Quality of Movement | ||||||
Gamito, 2015 | TP; WMS III | |||||||||
Givon 2015 | Grip Strength Weaker Hand; Gait Speed (Motor Overall) | ✓ | ||||||||
Housman, 2009 | ✓ | Grip strength | Racho level (UL); Racho Speed (UL) | MAL Amount of Use, Quality of Movement | ||||||
In, 2012 | ✓ | ✓ | MFT | ✓ | JHFT | |||||
Kihoon, 2012 | WMFT total, hand, arm | MVPT Reaction time in seconds; MVPT score; Visual discrimination; Visual memory; visual closure | ||||||||
Kim, 2011 | ✓ | MI | VCPT; ACPT; WCW; CCW; FDST; BDST; FVST; BVST; ViLT; VeLT; TMT-A; TOL | |||||||
Kim, 2012 | ✓ | PASS Motor overall | ✓ | |||||||
Kiper, 2011 | ✓ | ✓ | ✓ | |||||||
Kiper, 2014 | ✓ | Mean Duration of Movement – time; peak; speed | ✓ | |||||||
Kong, 2016 | ✓ | ✓ | ✓ | |||||||
Kottink, 2014 | ✓ | ✓ | ||||||||
Kwon, 2012 | ✓ | MFT; FMA arm, hand, wrist | ✓ | K-MBI Self Care | ||||||
Lee, 2013 | ✓ | MMT Muscle Strength; | ✓ | |||||||
Levin, 2012 | ✓ | RPSS | ✓ | WMFT | MAL Amount of Use, Quality of Movement | |||||
Piron, 2009 | ✓ | ✓ | ||||||||
Piron, 2010 | ✓ | ✓ | ||||||||
Saposnik, 2016 | ✓ | ✓ | ✓ | WMFT | ||||||
Shin, 2014 | ✓ | ✓ | ||||||||
Shin, 2015 | ✓ | SF-36 Role limitation due to physical problems; SF-36 Vitality | ||||||||
Sin, 2013 | ✓ | ✓ | ||||||||
Standen, 2017 | NHPT | NEADL; WMFT | MAL Amount of Use, Quality of Movement; MAL-activities | |||||||
Yavuzer, 2008 | Brunnstorm stages hand, Upper Extremity; FIM Self Care | |||||||||
Yin, 2014 | ✓ | ✓ | ✓ | MAL Amount of Use, Quality of Movement |
First Author, Year | C1 | C2 | C3 | C4 | C5 | C6 | C7 | C8 | C9 | C10 | C11 | TOTAL |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Assis, 2014 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 6 |
Broeren, 2008 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 5 |
Chen, 2015 | 1 | 0 | 0 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 7 |
Choi, 2014 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 9 |
Crosbie, 2012 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 9 |
da Silva Cameirão, 2011 | 1 | 1 | 0 | 0 | 0 | 0 | 1 | 0 | 0 | 1 | 1 | 5 |
da Silva Ribeiro, 2015 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 8 |
Duff, 2010 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 0 | 0 | 1 | 1 | 6 |
Gamito, 2015 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 6 |
Givon, 2015 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 8 |
Housman, 2009 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 8 |
In, 2012 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 5 |
Kihoon, 2012 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 0 | 1 | 1 | 6 |
Kim, 2011 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 7 |
Kim, 2012 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 5 |
Kiper, 2011 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 7 |
Kiper, 2014 | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 7 |
Kong, 2016 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 9 |
Kottink, 2014 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 7 |
Kwon, 2012 | 1 | 1 | 0 | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 9 |
Lee, 2013 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 6 |
Levin, 2012 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 7 |
Piron, 2009 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 8 |
Piron, 2010 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 8 |
Saposnik, 2016 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 8 |
Shin, 2014 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 7 |
Shin, 2015 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 7 |
Sin, 2013 | 1 | 1 | 0 | 1 | 0 | 0 | 1 | 1 | 0 | 1 | 1 | 7 |
Standen, 2017 | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 1 | 0 | 1 | 1 | 7 |
Yavuzer, 2008 | 1 | 1 | 1 | 1 | 0 | 0 | 1 | 1 | 1 | 1 | 1 | 9 |
Yin 2014 | 1 | 1 | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 6 |