not permitted.

It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
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COCHRANE CORNER

EUR J ­PHYS REHABIL MED 2015;51:497-506

Virtual reality for stroke rehabilitation:

an abridged version of a Cochrane review
K. LAVER 1, S. GEORGE 1, S. THOMAS 2, J. E. DEUTSCH 3, M. CROTTY 1

® A
T C
H DI
Virtual reality and interactive video gaming have 1Department of Rehabilitation, Aged and Extended Care
emerged as new treatment approaches in stroke re- Flinders University, Adelaide, South Australia
2International Centre for Allied Health Evidence (iCAHE)
habilitation settings over the last ten years. The pri-
mary objective of this review was to determine the University of South Australia (City East)

IG E
effectiveness of virtual reality on upper limb function
and activity after stroke. The impact on secondary out-
Adelaide, Australia
3Department of Rehabilitation and Movement Science
R M
Rutgers University, Newark, New Jersey, USA 
comes including gait, cognitive function and activities
of daily living was also assessed.
Randomized and quasi-randomized controlled trials
comparing virtual reality with an alternative interven-
P A

tion or no intervention were eligible to be included more effective than no therapy in improving upper
in the review. The authors searched a number of elec- limber function (SMD 0.44 [95% CI 0.15 to 0.73])
based on nine studies. The use of virtual reality also
O V

tronic databases including: the Cochrane Stroke Group

Trials Register, the Cochrane Central Register of Con- significantly improved activities of daily living func-
trolled Trials, MEDLINE, EMBASE, AMED, CINAHL, tion when compared to more conventional therapy ap-
C ER

PsycINFO, clinical trial registers, reference lists, Dis- proaches (SMD 0.43 [95% CI 0.18 to 0.69]) based on
sertation Abstracts and contacted key researchers in eight studies.
Y

the field. Search results were independently examined While there are a large number of studies assessing
by two review authors to identify studies meeting the the efficacy of virtual reality they tend to be small
inclusion criteria. and many are at risk of bias. While there is evidence
IN

A total of 37 randomized or quasi randomized con-
trolled trials with a total of 1019 participants were
included in the review. Virtual reality was found to be
significantly more effective than conventional therapy
M
to support the use of virtual reality intervention as
part of upper limb training programs, more research
is required to determine whether it is beneficial in
terms of improving lower limb function and gait and

cognitive function.
in improving upper limb function (standardized mean
difference [SMD] 0.28, 95% confidence intervals [CI] Key Words: Rehabilitation – Stroke - Video games - Virtual
0.08 to 0.49) based on 12 studies and significantly reality exposure therapy.

Notes.—This article is based on a Cochrane Review published in

the Cochrane Database of Systematic Reviews (CDSR) 2015, Issue
2, DOI: 10.1002/14651858.CD008349.pub3. (see www.thecochra-
nelibrary.com for information). Cochrane Reviews are regularly S troke is one of the leading causes of death and
disability worldwide.1, 2 A complex combination
or other proprietary information of the Publisher.

updated as new evidence emerges and in response to feedback,

and the CDSR should be consulted for the most recent version of
the review.
Corresponding author: K. Laver, Department of Rehabilitation,
Aged and Extended Care, Flinders University, Sturt Road, Bedford
Park 5042, Adelaide, South Australia. Email: Kate.Laver@sa.gov.au
of sensory, motor, cognitive and visual impairment is
common following stroke and impacts on the stroke
survivor’s ability to perform activities of daily liv-
ing such as self-care tasks and participation in work
and leisure roles.3 Evidence suggests that although
most recovery is thought to be made in the first few

Vol. 51 - No. 4 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 497

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
LAVER VIRTUAL REALITY FOR STROKE REHABILITATION
weeks after stroke, people may make improvements
on functional tasks many months after the onset of
stroke.4
Virtual reality has been defined as “an advanced
form of human-computer interface that allows the
user to ’interact’ with and become ’immersed’ in a
computer-generated environment in a naturalistic
fashion”.5 The use of virtual reality as a rehabilitation
intervention was first discussed in the mid 1990’s.6
A number of different virtual reality programs were
developed and feasibility studies conducted, yet
these programs were predominantly developed and
® A
tested in research settings rather than in clinical set-
tings. The release of more sophisticated interactive
T C
video games (also referred to as Exergames), such
as the Nintendo Wii in 2006 saw the rapid uptake of
commercially available gaming consoles in rehabili-
H DI
tation settings.
Virtual reality intervention is thought to be a use-
ful rehabilitation approach for a number of reasons.
IG E
It enables the clinician to provide patients with a
method of repetitive task specific training which
R M
is supported by research as being an effective ap-
proach in neurological rehabilitation.7 Training is
conducted in an enriched environment; the stimu-
lating environment is thought to be more effective
P A
in training problem solving and performance of
functional tasks.8 Another desirable feature of vir-
O V
tual reality programs is that they may be designed
to attempt to simulate real-world activities (such as
C ER
walking through a park rather than on a treadmill)
which may provide enhanced ecological validity
Y
when compared with more conventional therapy
tasks. In addition, risky activities that are unsafe to
practice in therapy sessions (such as crossing the
IN
street) can be practiced in a safe and regulated en-
vironment.9 Some studies suggest that the programs
may be more interesting and enjoyable than tradi-
M
tional therapy tasks ultimately encouraging the re-
habilitation participant to engage in longer periods
of therapy.10
Our initial review, published in 2011, identified
19 studies and a number of ongoing studies. Since
then, a large number of studies have been published
and an update of our review was warranted. The
or other proprietary information of the Publisher.
primary objective of this review was to determine
the effect of virtual reality intervention in com-
parison with an alternative intervention or no in-
tervention on upper limb function and activity. The
secondary objective was to examine the effect on
498 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE August 2015
outcomes including gait and balance activity, global
motor function, cognitive function, activities of daily
living limitation, participation restriction and qual-
ity of life and neurophysiological changes identified
via imaging and adverse events. In addition, we re-
ported on feasibility by examining patient eligibility
and recruitment data.
Materials and methods
Inclusion/exclusion criteria
We included randomized or quasi randomized tri-
als that compared virtual reality with an alternative
intervention or no intervention. Studies that com-
pared two different types of virtual reality without
an alternative group were not included. Study par-
ticipants had a diagnosis of stroke. We excluded
studies where participants had mixed etiology un-
less individual data was available for the participants
with stroke only.
Interventions that met the following definition
were considered to be virtual reality: “an advanced
form of human-computer interface that allows the
user to ’interact’ with and become ’immersed’ in a
computer-generated environment in a naturalistic
fashion”.11
Outcomes
The primary outcome was upper limb function
and activity. Secondary outcomes were: gait and bal-
ance function and activity, global motor function,
cognitive function, activity limitation, participation
restriction, quality of life and changes detected in
brain imaging. Adverse events and patient eligibility
and recruitment were also reviewed.
Search strategy
The Cochrane Stroke Group Trials Register was
searched by the Managing Editor in November 2013.
We searched the following databases: the Cochrane
Central Register of Controlled Trials, MEDLINE, EM-
BASE, AMED, CINAHL, PsycINFO, PsycBITE, OT-
seeker, COMPENDEX and INSPEC in October 2013.
Our search strategy was developed with the assist-
ance of the Cochrane Stroke Group Trials Search
Co-ordinator.
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
VIRTUAL REALITY FOR STROKE REHABILITATION LAVER
In an attempt to identify further relevant studies
we searched trial registers, scanned the reference
lists of systematic reviews, searched dissertation ab-
stracts, and contacted key researchers in the area.
Full details of the search and search strategy can be
found in the full version of the review.12
Data collection and management
Two review authors (K. Laver and S. Thomas) in-
dependently reviewed titles and abstracts retrieved
from the search in order to determine whether they
® A
met the predefined inclusion criteria. All potentially
relevant studies were obtained in full text and con-
T C
tact was made with study authors to obtain more
information when required. A third review author
( J. E. Deutsch) moderated any disagreements. Stud-
H DI
ies published in languages other than English were
reviewed by someone fluent in the language as ar-
ranged by the Cochrane Stroke Group Trials Search
IG E
Co-ordinator. Two review authors (K. Laver and S.
Thomas or S. George or J. E. Deutsch) independ-
R M
ently extracted data from the studies using a pre-
designed data extraction form. Disagreements were
moderated by a third review author (M. Crotty)
when necessary. Study authors were contacted by
P A
email to gain missing information required for the
review. Methodological quality of studies was as-
O V
sessed independently by the same authors (K. Laver
and S. Thomas or S. George or J. E. Deutsch) using
C ER
The Cochrane Collaboration’s risk of bias tool. Cat-
egories assessed were: sequence generation, alloca-
Y
tion concealment, blinding of outcome assessors, in-
complete outcome data and selective reporting. Risk
of bias was determined to be “low risk”, “high risk”
IN
or “unclear risk”.
GRADE was used to interpret findings and GRA-
DEpro was used to create a “Summary of findings”
M
table.13 The table provides outcome-specific infor-
mation concerning the overall quality of evidence
from studies included in the comparison, the mag-
nitude of effect of the intervention and the sum of
available data on the outcomes considered. The
overall quality of evidence was dependent on study
limitations (risk of bias), indirectness, inconsistency,
or other proprietary information of the Publisher.
imprecision or publication bias.
Outcomes were classified by category (upper limb
function, hand function, lower limb and gait activity,
global motor function, cognitive function, activity
limitation, participation restriction and quality of life,
Vol. 51 - No. 4 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 499
neuroimaging studies). We calculated mean differ-
ences (MD) or standardized mean differences (SMD)
as appropriate.
We contacted authors for missing data or convert-
ed available data where possible (for example, gait
speed reported as meters per minute was converted
to meters per second). We conducted intention-to-
treat analyses to include all randomized participants
where possible. Where drop outs were clearly iden-
tified we used the actual denominator of participants
contributing data.
Results were pooled using a fixed-effect model
with 95% confidence intervals (CI) using RevMan5.0
to present an overall estimate of effect. Results were
pooled where there were acceptable levels of het-
erogeneity. Heterogeneity was assessed by visual in-
spection of the forest plot and examination of the I2
statistic.14 Where heterogeneity prevented pooling,
we provided a narrative summary of results.
Results
A total of 8244 studies were identified from the
search of which 198 were sought in full text. Further
studies were then excluded and reasons for exclu-
sion documented. This resulted in 37 randomized or
quasi randomized controlled studies meeting the eli-
gibility criteria and being included in the review.15-51
Study characteristics
A total of 1019 participants post stroke were in-
cluded in the trials. Details of sample size, gender
balance, participant age, mean time since stroke and
intervention approach are presented in Table I. Par-
ticipants in the studies were relatively young with
studies reporting mean ages of 46 to 75 years. All
included trials took place between 2004 and 2014.
Many studies excluded people with aphasia, apraxia
and cognitive impairment hence, recruitment data
(when reported) revealed that only 26% of patients
screened were able to be recruited to the studies.
The most common intervention approach used
in studies included in the review was upper limb
retraining with 18 studies using this approach. Oth-
er interventions included driving retraining (three
studies), retraining skills in using the public trans-
port system (one study), lower limb, balance and
gait retraining (eight studies), global motor function
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

LAVER VIRTUAL REALITY FOR STROKE REHABILITATION

Table I.—Study participant details.

Sample Gender Age: Mean (SD) Mean time since
Study Virtual reality intervention
size (%male) years stroke
Akinwuntan 15 2005 83 81% I:54 (12) I:53 (6) days Driving simulator in full sized Ford Fiesta car. A variety of 5 km driv-
C:54 (11) C:54 (6) days ing scenarios were used.
Barcala 16 2013 20 45% I:65 (13) I:12 (7) mo Three activities within the Nintendo Wii Fit program.
C:64 (15) C:15 (7) mo
Byl 172013 15 I:65 (5) I:8 (4) moThree armed trial. Use of a robotic orthosis and task-specific games.
C:54 (21) C:10 (5) Two forms of virtual reality intervention were compared: bilateral and
unilateral tasks.
Cho 18 2012 29 62% I:64 (7) I:NR IREX virtual reality system using a video capture system to capture
C:64 (9) C:NR the patient’s whole body movement. Six programs were utilised.
Coupar 19 2012 12 66% I:65 (14) I:8 (1) days Three armed trial comparing high or low intensity virtual reality inter-
C:59 (16) C:8 (3) days vention with a control group. Use of the Armeo Spring arm orthosis

® A
and virtual reality games for arm rehabilitation.
Crosbie 20 2008 18 55% I:56 (15) I:10 (6) mo Program specifically designed for upper limb rehabilitation. Activi-
C:65 (7) C:12 (8) mo ties involved reaching and grasping of virtual objects at a variety of

T C
heights, speeds and with varied number of targets.
Da Silva 21 Cameirao 19 47% I:64 (12) I:12 (5) days Rehabilitation Gaming System (RGS) which utilises data gloves, a vir-
2011 C:59 (11) C:17 (5) days tual environment and upper limb tracking software.

H DI
Housman 22 2009 34 64% I:54 (12) I:85 (96) mo Program specifically designed for upper limb rehabilitation (“Vu
C:56 (13) C:112 (129) mo Therapy”). Activities included grocery shopping, cleaning a stove and
playing basketball.
Jaffe 23 2004 20 60% I:58 (11) I:4 (2) yrs Program specifically designed for mobility retraining. Patients walked

IG E C:63 (8) C:4 (3) yrs on a treadmill and were secured by an overhead harness. The patient
was asked to step over virtual objects while viewing real-time video
images of their feet walking and the virtual objects.
R M
Jang 24 2005 10 60% I:60 (8) I:14 mo IREX virtual reality system using a video capture system to capture
C:54 (12) C:13 mo the patient’s whole body movement. Games included soccer and
moving objects from a conveyor belt and focused on reaching, lifting
and grasping.
P A

Jannink 25 2008 10 I:62 (3) Electric scooter with customised interface.

C:58 (13)
Jung 26 2012 21 62% I:61 (9) I:13 (3) mo Treadmill training while viewing a virtual scene through a head
O V

C:64 (5) C:15 (5) mo mounted device.

Kang 27 2009 16 I:60 (11) I:64 (37) daysProgram specifically designed to retrain visual perceptual function.
C:63 (10) C:58 (30) daysPatients participated in visual spatial and motor tasks using their un-
C ER

affected arm.
Kim 30 2009 24 54% I:52 (10) I:26 (10) mo IREX virtual reality system using a video capture system to capture
Y

C:52 (7) C:24 (9) mo the patient’s whole body movement. Games included stepping up/
down, shark bait (capturing stars while avoiding eels and sharks by
weight shift) and snowboarding.
IN

Kim 28 2011a 28 39% I:67 (11) I:18 (11) days IREX virtual reality system using a video capture system to capture
C:62 (16) C:24 (31) days the patient’s whole body movement.
Kim 31 2011b 24 58% I:62 (10) I:23 (8) days IREX virtual reality system using a video capture system to capture
C:67 (14) C:26 (19) days the patient’s whole body movement.
Kim 29 2012 20 I:13 (7) mo Nintendo Wii Sports (tennis and boxing).
M

C:13 (6) mo
Kiper 32 2011 80 58% I/C:64 (16) I/C:6 (4) mo Reinforced Feedback in Virtual Environment (RFVE). Participants sat
in front of a wall screen grasping a sensorised real object which was
displayed on the screen. Virtual tasks included pouring water from a
glass and using a hammer.
Kwon 332012 26 I:57 (15) I:25 (16) days IREX virtual reality system using a video capture system to capture
C:58 (12) C:24 (21) days the patient’s whole body movement.
Lam 34 2006 58 31% I:71 (16) I:4 (4) yrs Program specifically designed to retrain skills using the Mass Transit
or other proprietary information of the Publisher.

C:73 (10) C:5 (3) yrs Railway system.

Mazer 49 2005 46 I:68 (14) I:1.4 (1) yrs Driving simulator consisting of a car frame with three large screens
C:69 (9) C:1.7 (1) yrs providing a large field of view.
Mirelman 35 2008 18 83% I:62 (10) I:38 (25) mo Rutgers ankle rehabilitation system. Participants executed the exer-
C:61 (8) C:58 (26) mo cises by using foot movements to navigate a plane or a boat through
a virtual environment.

500 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE August 2015

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

VIRTUAL REALITY FOR STROKE REHABILITATION LAVER

I.—Study participant
Table I.—Continues from previous
details. page.
Sample Gender Age: Mean (SD) Mean time since
Study Virtual reality intervention
size (%male) years stroke
Piron 50 2003 38 66% I:62 (9) I:62 (9) yrs Program specifically designed for upper limb rehabilitation. Sensors
C:61 (7) C:61 (7) yrs on the arm and software
created a virtual environment which displayed virtual handling and
target objects, for example an envelope and a mailbox, a hammer and
a nail, a glass and a carafe. Participants could see not only their own
movement but also the correct trajectory that they had to execute,
prerecorded by the therapist.
Piron 36 2009 36 58% I:66 (8) I: 15 (7) mo Program specifically designed for upper limb rehabilitation. The
C:64 (8) C:12 (4) mo telerehabilitation program used 1 computer workstation at the par-
ticipant’s home and 1 at the rehabilitation hospital. Five virtual tasks
comprising simple arm movements were devised for training.

® A
Piron 37 2010 50 58% I:59 (8) I:15 (13) mo Program specifically designed for upper limb rehabilitation. Par-
C:62 (10) C:15 (12) mo ticipants were asked to perform motor tasks with real objects (for
example a glass) which were displayed as tasks within the virtual

T C
environment (for example moving a glass over a table). Participants
were asked to emulate the tasks as per the therapist’s prerecorded
movement.

H DI
Rajaratnam 38 2013 19 37% I:59 (9) I:15 (8) days Intervention using either a Nintendo Wii Fit or Microsoft Kinect.
C:65 (10) C:15 (6) days
Saposnik 39 2010 22 64% I:55 I:27 (16) days Participants used the NintendoWii gaming console playing “Wii
C:67 C:23 (9) days sports’ and ’Cooking Mama”.
Shin 40 2013

Sin 41 2013
16

35 IG E
50%

43%
I:47 (6)
C:52 (12)
I:72 (9)
I:77
C:67
I:7
(29) days
(45) days
(1) mo
Participants used the RehabMaster™ in which they sit in front of a
screen and complete tasks such as “goalkeeper”’ and “bug hunter”.
Xbox Kinect games involving use of the upper limbs.
R M
C:76 (6) C:8 (3) mo
Standen 42 2011 27 59% I:59 (12) I:38 (41) wks Virtual glove which translates the position of the hand into gameplay.
C:63 (15) C:24 (36) wks
Subramanian 43 2013 32 72% I:62 (10) I:4 (2) yrs 3D virtual environment (CAREN) system simulated a supermarket
C:60 (11) C:3 (2) yrs scene. Intervention involved reaching for objects in the virtual en-
P A

vironment.
Sucar 51 2009 22 I:51 I:22 mo Participants used a “Gesture Therapy” program designed by the re-
O V

C:52 C:26 mo searchers. Movements of the participant’s upper limbs are tracked by
a camera and the person interacts with on-screen games including
shopping in the supermarket, making breakfast and painting.
C ER

Yang 45 2008 24 50% I:55 (12) I:6 (4) yrs Treadmill walking as virtual environments were displayed on a screen
C:61 (9) C:6 (10) yrs in front of the person.
Y

Yang 44 2011 14 I:56 (10) I:17 (9) mo Virtual reality treadmill training. Treadmill coordinated with the in-
C:66 (6) C:16 (10) mo teractive scenes.
Yavuzer 46 2008 20 45% I:58 (10) I:3 (3) mo Playstation Eye Toy games involving use of the upper limbs.
C:64 (11) C:5 (1) mo
IN

You 47 2005 10 70% I:55 I:18 mo IREX virtual reality system using a video capture system. Games in-
C:55 C:19 mo cluded stepping up/down, “shark bait”’ and snowboarding.
Zucconi 48 2012 33 39% I:60 I:10 mo¥ Three armed trial. Two groups received virtual reality involving the
C:60 C:9 mo¥ Reinforced Feedback in Virtual Environment (RFVE) intervention.
M

One of the groups received specific feedback (like a virtual teacher)

and the other did not receive the same feedback.
¥Median reported

retraining (seven studies) and visual perceptual re- Virtual reality intervention was most often com-
training (one study). Six of the studies evaluated the pared with the same dose of therapy based on a
or other proprietary information of the Publisher.

effect of commercial gaming consoles; these were
that Playstation Eye Toy, Nintendo Wii and Micro-
soft Kinect. Other virtual reality programs evaluated
that are available for purchase include the Armeo,
CAREN and the GestureTek.
conventional approach. Eleven studies evaluated the
efficacy of virtual reality when used alone or as an
adjunct to usual rehabilitation.
The risk of bias of included studies is reported
in Figure 1. Where detail was lacking in published

Vol. 51 - No. 4 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 501

This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
or other proprietary information of the Publisher.

502
LAVER

M
IN

Figure 1.—The risk of bias of included studies.

C ER
O V
P A
Y
R M
IG E

EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE

H DI
Figure 2.—Comparison between virtual reality and conventional therapy: outcome-upper limb function.
T C
® A

Figure 3.—The effect of virtual reality on upper limb function when it was used alone or as a way of augmenting usual care.

August 2015
VIRTUAL REALITY FOR STROKE REHABILITATION
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
VIRTUAL REALITY FOR STROKE REHABILITATION LAVER
reports we contacted the study author for additional
information or clarification.
Primary outcomes
Twelve studies (with 375 participants) which
compared the same dose of virtual reality with con-
ventional therapy reported outcomes for upper limb
function and activity postintervention. Results were
pooled finding a small significant effect in favor of
virtual reality intervention (SMD 0.29 [95% CI 0.09 to
0.49]) (Figure 2). Two trials reported outcomes for
® A
grip strength. The effect of virtual reality compared
with conventional therapy was not significant (mean
T C
difference [MD] 3.55 [95% CI -0.2 to 7.30]).
Subgroup analyses examined whether results
varied based on the dose of treatment, time since
H DI
onset of stroke, type of system (specialized versus
commercial) and severity of upper limb impairment.
Results of the analyses suggested that greater ben-
IG E
efits were experienced by those who were within
six months of stroke at the time of recruitment and
R M
those with mild to moderate severity of impairment.
Nine studies (with 190 participants) examined the
effect of virtual reality when it was used alone (i.e.
the control group did not receive any therapy) or
P A
as a way of augmenting usual rehabilitation (i.e. to
increase the total dose of therapy). Results showed a
O V
small to moderate significant effect in favor of virtual
reality (SMD 0.44 [95% CI 0.15 to 0.73]) (Figure 3).
C ER
Secondary outcomes
Y
Seven studies reported on outcomes of gait and
balance however, only the results from three of
IN
these studies could be pooled. Pooling revealed no
significant effect on gait speed (MD 0.07 [95% CI
-0.09 to 0.23]).
M
Three studies reported outcomes related to glo-
bal motor function. Two of these studies (with 27
participants) which examined the effect of virtual
reality intervention compared with no intervention
were pooled. Results did not reveal a significant im-
provement in global motor function (SMD 0.14 [95%
CI -0.63 to 0.90]).
or other proprietary information of the Publisher.
Eight studies, comparing virtual reality interven-
tion with conventional therapy, reported outcomes
for activities of daily living function. Virtual reality
intervention was found to be significantly more ef-
fective (SMD 0.43 [95% CI 0.18 to 0.69]). Heteroge-
Vol. 51 - No. 4 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE 503
neity was negligible (I2=2%). The effect of virtual
reality on ADL function when used as a method of
increasing therapy dose was similar (SMD 0.44 [95%
CI 0.11 to 0.76]).
Two studies examined the effect of virtual reality
on the Stroke Impact Scale; neither identified signifi-
cant differences in outcomes between those in the
intervention and control groups.
There were few adverse events reported across
studies and those reported were mild (i.e. dizziness,
headache).
There were insufficient trials to examine effect on
cognitive function.
Discussion
This review included 37 randomized controlled
trials comparing virtual reality with an alternative in-
tervention or no intervention in patients after stroke.
Intervention approaches, outcome measures and
control groups varied limiting the extent to which
we could pool studies and conduct meta-analyses.
We were able to conduct meta-analysis to examine
the effect of virtual reality on upper limb function,
grip strength, gait speed, and activities of daily living
function.
Virtual reality intervention was found to be a
more effective approach than conventional therapy
in retraining upper limb function. However, this
was considered to be low quality evidence when
graded using GRADE methodology due to risk of
bias and inconsistent findings across trials. There
was insufficient evidence to provide information
about the most effective dose of therapy, type of
virtual reality program however results suggested
most benefit for those within six months of stroke
and with mild to moderate severity arm impair-
ment. Our analysis shows that using virtual reality
as a method of increasing therapy dose is an ef-
fective method of improving arm function. There
was insufficient evidence to draw conclusions on
the effectiveness of virtual reality compared with
conventional therapy in improving gait speed. Al-
though the interventions in these studies did not
specifically target activities of daily living function,
there was a significant effect demonstrated when
using a virtual reality approach (GRADE: very low
quality). Few adverse events were reported sug-
gesting that the virtual reality interventions de-
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
LAVER VIRTUAL REALITY FOR STROKE REHABILITATION
scribed in the studies were relatively safe when
administered by health professionals with appro-
priate patients.
Limitations of the review
The use of meta-analysis can be controversial
where there is heterogeneity present between
studies. Although there was clinical heterogeneity
between studies included in the review we were
careful only to pool studies where participants, in-
terventions and outcome measures were compara-
® A
ble. While we were able to include 37 studies in
this review, sample sizes of the included studies
T C
were generally small and few of the studies exam-
ined whether effects were sustained. Some of the
papers reporting on the included studies lacked
H DI
detail therefore we were unable to ascertain the
risk of bias within some studies. In addition, al-
though many authors responded to queries regard-
IG E
ing study details, some did not, therefore, we were
unable to gather all requested information. Despite
R M
our comprehensive search strategy it is possible
that relevant studies were not identified. This may
include studies where there is no abstract pub-
lished in English.
P A
Implications for practice
O V
There is low quality evidence that virtual reality
C ER
is a safe and effective method of improving arm
function and activities of daily living function fol-
Y
lowing stroke. Patients in the acute and subacute
phases with milder severity strokes appear to be
most likely to benefit. However, there is a lack of
IN
information regarding the most effective types of
programs and even whether programs specifically
designed for rehabilitation settings are more effec-
M
tive than commercial gaming consoles. Studies that
compare different forms of virtual reality interven-
tion will provide information regarding the most
important characteristics of the environment and
interaction methods. The lack of adverse events
reported in research studies suggests that interven-
tion is safe although clinicians need to monitor this
or other proprietary information of the Publisher.
closely in busy clinical settings. Studies included in
the review tended to include younger stroke sur-
vivors without significant cognitive impairment or
aphasia therefore the results do not appear to be
applicable to all stroke survivors.
504 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE August 2015
Implications for research
While this review included a further 18 studies,
the findings and conclusions are not vastly differ-
ent from the previous review. The more recent stud-
ies were not necessarily larger or higher in quality.
Adequately powered trials of high quality are still
required to provide more definitive information re-
garding efficacy.
Most of the studies examined motor retraining in-
terventions. In particular upper limb retraining was
the focus of half of the studies included in the re-
view. In contrast, there is less research into activity
retraining tasks (such as driving simulators) despite
promising results from existing studies. More re-
search is required to determine whether the effects
of task practice in the virtual environment translate
to task performance in real world tasks. The use of
independent practice of virtual reality tasks is con-
sistently identified as a possible method of increas-
ing therapy dose. Yet, research to date has assessed
the efficacy when provided with direct 1:1 supervi-
sion. Further studies are needed to determine feasi-
bility and efficacy of virtual reality when used with-
out direct clinician supervision.
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(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other

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Conflicts of interest.—J.E. Deutsch conducts research on virtual
reality for stroke rehabilitation. This research is funded by various
sources and presented at scientific and professional meetings. She
is co-owner of a company that develops virtual reality for rehabili-
tation. Other authors have no conflicts of interest.
Epub ahead of print on July 9, 2015.

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506 EUROPEAN JOURNAL OF PHYSICAL AND REHABILITATION MEDICINE August 2015