Key messages
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Virtual reality may be slightly better than alternative therapy approaches in improving the ability to use one's arm. A very small number of people reported unwanted effects including pain, headaches, or feeling faint or dizzy.
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Virtual reality may be better than alternative therapy in terms of slightly improving balance, and probably reduces activity limitation.
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Very few studies included virtual reality applications that were considered immersive (for example, where the virtual environment was viewed through a head-mounted device).
What are the benefits of virtual reality compared with alternative therapy approaches or no therapy after stroke?
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, cognitive function (thinking), independence, and quality of life after stroke.
What is virtual reality, and why might it be used to help stroke recovery?
Many people have difficulty moving, thinking, and sensing after a stroke. This often results in problems with everyday activities such as writing, walking, and driving. Virtual reality is a broad term used to describe the use of computer-based programs designed to mimic real-life objects and events. Virtual reality-based therapy may have some advantages over traditional therapy approaches, as the applications can allow people to practise everyday activities that are not or cannot be practised within the hospital or clinic environment. In addition, there are several features of virtual reality programmes that might get patients to spend more time in therapy, for example the activity might be more motivating.
What did we want to find out?
We wanted to know whether using virtual reality in stroke recovery programmes was more effective than traditional approaches to therapy. We wanted to understand the effects on various outcomes (including movement, cognition, and activity limitation). We were most interested in outcomes related to arm function, as this is the focus of most studies in this area. We also wanted to understand how we can use virtual reality most effectively (in terms of how much therapy to provide and when) and which types of virtual reality programmes might be most beneficial.
What did we do?
We searched for studies that compared virtual reality with either an alternative form of therapy (for example, traditional physical therapy approaches to improving strength and movement) or no therapy. We included studies that recruited adults at all stages of recovery following a stroke.
What did we find?
We identified 190 studies involving 7188 people after stroke. A wide range of virtual reality programmes were used; most aimed to improve either arm function or mobility (walking speed and balance).
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Sixty-seven trials looked at whether the use of virtual reality compared with alternative therapy resulted in improved ability to use one's arm, and found that the use of virtual reality may result in slightly improved function.
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People who use virtual reality (in comparison to alternative therapy approaches) may experience slight benefits in balance and probably experience benefits in activity limitation, but may not experience benefits in walking speed or quality of life.
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The addition of virtual reality to usual care or rehabilitation (resulting in an increased amount of time spent in therapy) probably increases arm functioning.
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Virtual reality may be most beneficial when people spend many hours using the programme.
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A small number of people using virtual reality reported pain, headaches, or feeling faint or dizzy. No serious unwanted effects were reported.
What are the limitations of the evidence?
There is now a large number of studies; however, the studies were generally small and not of high quality. Also, not all the studies provided information about everything we were interested in. As such, we have moderate to very low confidence in the evidence.
How up-to-date is this evidence?
The evidence is current to September 2023.
Read the full abstract
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 assess the effects of virtual reality compared with an alternative intervention or no intervention for upper limb function and activity in people after stroke.
Secondary objectives: to assess the effects of virtual reality compared with an alternative intervention or no intervention on gait and balance, global motor function, cognitive function, activity limitation, participation restriction and quality of life, and adverse events in people after stroke.
Search strategy
We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, and four additional databases. We also searched trials registries up to September 2023.
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.
Authors' conclusions
We found moderate- to low-certainty evidence that the use of virtual reality and interactive video gaming is slightly more beneficial than alternative therapy approaches in improving upper limb function, balance, and activity limitation. Furthermore, greater benefits were seen for upper limb function when virtual reality was used in addition to usual care (to increase overall therapy time). There was mixed evidence on the effects on mobility outcomes including gait speed, and insufficient evidence to reach any conclusions about the effect of virtual reality and interactive video gaming on participation restriction and quality of life.
Funding
This Cochrane review had no dedicated funding.
Registration
Protocol: doi.org/10.1002/14651858.CD008349
Original review (2011): doi.org/10.1002/14651858.CD008349.pub2
Review update (2015): doi.org/10.1002/14651858.CD008349.pub3
Review update (2017): doi.org/10.1002/14651858.CD008349.pub4
