Virtual reality for stroke rehabilitation

Review question
We wanted to compare the effects of virtual reality versus an alternative treatment or no treatment on recovery after stroke using arm function and other outcomes such as walking speed and independence in managing daily activities after stroke.

Background
Many people after having a stroke have difficulty moving, thinking, and sensing. This often results in problems with everyday activities such as writing, walking, and driving. Virtual reality and interactive video gaming are types of therapy being provided to people after having a stroke. The therapy involves using computer-based programs designed to simulate real life objects and events. Virtual reality and interactive video gaming may have some advantages over traditional therapy approaches as they can give people an opportunity to practise everyday activities that are not or cannot be practised within the hospital environment. Furthermore, there are several features of virtual reality programs that might mean that patients spend more time in therapy: for example, the activity might be more motivating.

Study characteristics
We identified 72 studies involving 2470 people after stroke. A wide range of virtual reality programs were used, with most aimed to improve either arm function or walking ability. The evidence is current to April 2017.

Key results
Twenty-two trials tested whether the use of virtual reality compared with conventional therapy resulted in an improved ability to use one's arm and found that the use of virtual reality did not result in better function (low-quality evidence). When virtual reality was used in addition to usual care or rehabilitation to increase the amount of time the person spent in therapy there were improvements in the functioning of the arm (low-quality evidence). Six trials tested whether the use of virtual reality compared with conventional therapy resulted in improved walking speed. There was no evidence that virtual reality was more effective in this case (low-quality evidence). Ten trials found that there was some evidence that virtual reality resulted in a slightly better ability to manage everyday activities such as showering and dressing (moderate-quality evidence). However, these positive effects were found soon after the end of the treatment and it is not clear whether the effects are long lasting. Results should be interpreted with caution as, while there are a large number of studies, the studies are generally small and not of high quality. A small number of people using virtual reality reported pain, headaches, or dizziness. No serious adverse events were reported.

Quality of the evidence
The quality of the evidence was generally of low or moderate quality. The quality of the evidence for each outcome was limited due to small numbers of study participants, inconsistent results across studies, and poor reporting of study details.

Authors' conclusions: 

We found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function. Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time). There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on gait speed, balance, participation, or quality of life. This review found that time since onset of stroke, severity of impairment, and the type of device (commercial or customised) were not strong influencers of outcome. There was a trend suggesting that higher dose (more than 15 hours of total intervention) was preferable as were customised virtual reality programs; however, these findings were not statistically significant.

Read the full abstract...
Background: 

Virtual reality and interactive video gaming have emerged as recent treatment approaches in stroke rehabilitation with commercial gaming consoles in particular, being rapidly adopted in clinical settings. This is an update of a Cochrane Review published first in 2011 and then again in 2015.

Objectives: 

Primary objective: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity.

Secondary objectives: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on: gait and balance, global motor function, cognitive function, activity limitation, participation restriction, quality of life, and adverse events.

Search strategy: 

We searched the Cochrane Stroke Group Trials Register (April 2017), CENTRAL, MEDLINE, Embase, and seven additional databases. We also searched trials registries and reference lists.

Selection criteria: 

Randomised and quasi-randomised trials of 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") in adults after stroke. The primary outcome of interest was upper limb function and activity. Secondary outcomes included gait and balance and global motor function.

Data collection and analysis: 

Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data, and assessed risk of bias. A third review author moderated disagreements when required. The review authors contacted investigators to obtain missing information.

Main results: 

We included 72 trials that involved 2470 participants. This review includes 35 new studies in addition to the studies included in the previous version of this review. Study sample sizes were generally small and interventions varied in terms of both the goals of treatment and the virtual reality devices used. The risk of bias present in many studies was unclear due to poor reporting. Thus, while there are a large number of randomised controlled trials, the evidence remains mostly low quality when rated using the GRADE system. Control groups usually received no intervention or therapy based on a standard-care approach. Primary outcome: results were not statistically significant for upper limb function (standardised mean difference (SMD) 0.07, 95% confidence intervals (CI) -0.05 to 0.20, 22 studies, 1038 participants, low-quality evidence) when comparing virtual reality to conventional therapy. However, when virtual reality was used in addition to usual care (providing a higher dose of therapy for those in the intervention group) there was a statistically significant difference between groups (SMD 0.49, 0.21 to 0.77, 10 studies, 210 participants, low-quality evidence). Secondary outcomes: when compared to conventional therapy approaches there were no statistically significant effects for gait speed or balance. Results were statistically significant for the activities of daily living (ADL) outcome (SMD 0.25, 95% CI 0.06 to 0.43, 10 studies, 466 participants, moderate-quality evidence); however, we were unable to pool results for cognitive function, participation restriction, or quality of life. Twenty-three studies reported that they monitored for adverse events; across these studies there were few adverse events and those reported were relatively mild.

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