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Effectiveness of Virtual Reality- and Gaming-Based Interventions for Upper Extremity Rehabilitation Poststroke: A Meta-analysis

Published:December 07, 2019DOI:https://doi.org/10.1016/j.apmr.2019.10.195

      Abstract

      Objective

      To investigate the efficacy of virtual reality (VR)- and gaming-based interventions for improving upper extremity function poststroke, and to examine demographic and treatment-related factors that may moderate treatment response.

      Data Sources

      A comprehensive search was conducted within the PubMed, CINAHL/EBSCO, SCOPUS, Ovid MEDLINE, and EMBASE databases for articles published between 2005 and 2019.

      Study Selection

      Articles investigating gaming and VR methods of treatment for upper extremity weakness were collected with the following study inclusion criteria: (1) participants aged 18 years or older with upper extremity deficits; (2) randomized controlled trials or prospective study design; (3) Downs-Black rating score of ≥18; and (4) outcome measure was the Wolf Motor Functioning Test, the Fugl-Meyer, or the Action Research Arm Test.

      Data Extraction

      Thirty-eight articles met inclusion criteria. The primary outcome was proportional improvement on the Wolf Motor Functioning Test, Fugl-Meyer, or Action Research Arm Test. The following individual or treatment factors were extracted: VR or gaming dose, total treatment dose, chronicity (> or <6mo), severity of motor impairment, and presence of a gaming component.

      Data Analysis

      Random effects meta-analysis models were utilized to quantify (1) the proportional recovery that occurs after VR or gaming; (2) the comparative treatment effect of VR or gaming vs conventional physiotherapy; and (3) whether the benefit of virtual reality differed based on participant characteristics or elements of the treatment.

      Results

      On average, VR or gaming interventions produced an improvement of 28.5% of the maximal possible improvement. Dose and severity of motor impairment did not significantly influence rehabilitation outcomes. Treatment gains were significantly larger overall (10.8%) when the computerized training involved a gaming component vs just visual feedback. VR or gaming interventions showed a significant treatment advantage (10.4%) over active control treatments.

      Conclusions

      Overall, VR- or gaming-based upper extremity rehabilitation poststroke appears to be more effective than conventional methods. Further in-depth study of variables affecting improvement, such as individual motor presentation, treatment dose, and the relationship between them, are needed.

      Keywords

      List of abbreviations:

      VR (virtual reality)
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      References

        • World Health Organization
        Global status report on noncommunicable diseases.
        WHO Press, Geneva, Switzerland2014
        • Feigin V.L.
        • Forouzanfar M.H.
        • Krishnamurthi R.
        • et al.
        Global and regional burden of stroke during 1990–2010: findings from the global burden of disease study 2010.
        Lancet. 2014; 383: 245-255
        • Roger V.L.
        • Go A.S.
        • Lloyd-Jones D.M.
        • et al.
        Heart disease and stroke statistics—2011 update: a report from the American Heart Association.
        Circulation. 2011; 123: e18-e209
        • Patel M.D.
        • Tilling K.
        • Lawrence E.
        • Rudd A.G.
        • Wolfe C.D.
        • McKevitt C.
        Relationships between long-term stroke disability, handicap and health-related quality of life.
        Age Ageing. 2006; 35: 273-279
        • Mercier C.
        • Bourbonnais D.
        Relative shoulder flexor and handgrip strength is related to upper limb function after stroke.
        Clin Rehabil. 2004; 18: 215-221
        • Hocine N.
        • Gouaïch A.
        • Cerri S.A.
        • Mottet D.
        • Froger J.
        • Laffont I.
        Adaptation in serious games for upper-limb rehabilitation: an approach to improve training outcomes.
        User Model User-Adap. 2015; 25: 65-98
        • Douiri A.
        • Rudd A.G.
        • Wolfe C.D.
        Prevalence of poststroke cognitive impairment: south London stroke register 1995–2010.
        Stroke. 2013; 44: 138-145
        • Kalaria R.N.
        • Akinyemi R.
        • Ihara M.
        Stroke injury, cognitive impairment and vascular dementia.
        Biochim Biophys Acta. 2016; 1862: 915-925
        • Shah S.
        • Vanclay F.
        • Cooper B.
        improving the sensitivity of the Barthel Index for stroke rehabilitation.
        J Clin Epidemiol. 1989; 42: 703-709
        • Jack D.
        • Boian R.
        • Merians A.S.
        • et al.
        Virtual reality-enhanced stroke rehabilitation.
        IEEE Trans Neural Syst Rehabil Eng. 2001; 9: 308-318
        • Visser M.M.
        • Heijenbrok-Kal M.H.
        • van't Spijker A.
        • Oostra K.M.
        • Busschbach J.J.
        • Ribbers G.M.
        Coping, problem solving, depression, and health-related quality of life in patients receiving outpatient stroke rehabilitation.
        Arch Phys Med Rehabil. 2015; 96: 1492-1498
        • Laver K.E.
        • Lange B.
        • George S.
        • Deutsch J.E.
        • Saposnik G.
        • Crotty M.
        Virtual reality for stroke rehabilitation.
        Cochrane Database Syst Rev. 2017; 11: CD008349
        • Weiss P.L.
        • Naveh Y.
        • Katz N.
        Design and testing of a virtual environment to train stroke patients with unilateral spatial neglect to cross a street safely.
        Occup Ther Int. 2003; 10: 39-55
        • Harvie D.S.
        • Smith R.T.
        • Hunter E.V.
        • Davis M.G.
        • Sterling M.
        • Moseley G.L.
        Using visuo-kinetic virtual reality to induce illusory spinal movement: the MoOVi Illusion.
        PeerJ. 2017; 5e3023
        • Weber L.M.
        • Nilsen D.M.
        • Gillen G.
        • Yoon J.
        • Stein J.
        Immersive virtual reality mirror therapy for upper limb recovery after stroke: a pilot study.
        Am J Phys Med Rehabil. 2019; 98: 783-788
        • Rossini P.M.
        • Rossi S.
        • Tecchio F.
        • Pasqualetti P.
        • Finazzi-Agrò A.
        • Sabato A.
        Focal brain stimulation in healthy humans: motor maps changes following partial hand sensory deprivation.
        Neurosci Lett. 1996; 214: 191-195
        • Carteron A.
        • McPartlan K.
        • Gioeli C.
        • et al.
        Temporary nerve block at selected digits revealed hand motor deficits in grasping tasks.
        Front Hum Neurosci. 2016; 10: 596
        • Conforto A.B.
        • Kaelin-Lang A.
        • Cohen L.G.
        Increase in hand muscle strength of stroke patients after somatosensory stimulation.
        Ann Neurol. 2002; 51: 122-125
        • Timmermans A.A.
        • Spooren A.I.
        • Kingma H.
        • Seelen H.A.
        Influence of task-oriented training content on skilled arm-hand performance in stroke: a systematic review.
        Neurorehabil Neural Repair. 2010; 24: 858-870
        • Krakauer J.W.
        Motor learning: its relevance to stroke recovery and neurorehabilitation.
        Curr Opin Neurol. 2006; 19: 84-90
        • Hart T.
        • Whyte J.
        • Dijkers M.
        • et al.
        Manual of rehabilitation treatment specification.
        (Available at:)
        • Everhart J.S.
        • Cole D.
        • Sojka J.H.
        • et al.
        Treatment options for patellar tendinopathy: a systematic review.
        Arthroscopy. 2017; 33: 861-872
        • Wolf S.L.
        • Catlin P.A.
        • Ellis M.
        • Archer A.L.
        • Morgan B.
        • Piacentino A.
        Assessing wolf motor function test as outcome measure for research in patients after stroke.
        Stroke. 2001; 32: 1635-1639
        • Fugl-Meyer A.R.
        • Jaasko L.
        • Leyman I.
        • Olsson S.
        • Steglind S.
        The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance.
        Scand J Rehabil Med. 1975; 7: 13-31
        • Yozbatiran N.
        • Der-Yeghiaian L.
        • Cramer S.C.
        A standardized approach to performing the action research arm test.
        Neurorehabil Neural Repair. 2008; 22: 78-90
        • Hatano S.
        Experience from a multicentre stroke register: a preliminary report.
        Bull World Health Organ. 1976; 54: 541-553
        • Downs S.H.
        • Black N.
        The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions.
        J Epidemiol Community Health. 1998; 52: 377-384
        • Adie K.
        • Schofield C.
        • Berrow M.
        • et al.
        Does the use of Nintendo Wii SportsTM improve arm function? Trial of WiiTM in stroke: a randomized controlled trial and economics analysis.
        Clin Rehabil. 2017; 31: 173-185
        • Ballester B.R.
        • Maier M.
        • San Segundo Mozo R.M.
        • Castañeda V.
        • Duff A.
        • Verschure M.J.
        • F P.
        Counteracting learned non-use in chronic stroke patients with reinforcement-induced movement therapy.
        J Neuroeng Rehabil. 2016; 13: 74
        • Boone A.E.
        • Wolf T.J.
        • Engsberg J.R.
        Combining virtual reality motor rehabilitation with cognitive strategy use in chronic stroke.
        Am J Occup Ther. 2019; 73 (7304345020p1-9)
        • Borstad A.L.
        • Crawfis R.
        • Phillips K.
        • et al.
        In-home delivery of constraint-induced movement therapy via virtual reality gaming.
        J Patient Cent Res Rev. 2018; 5: 6
        • Brunner I.
        • Skouen J.S.
        • Hofstad H.
        • et al.
        Virtual reality training for upper extremity in subacute stroke (VIRTUES): study protocol for a randomized controlled multicenter trial.
        BMC Neurol. 2014; 14: 186
        • da Silva Cameirão M.
        • Bermudez i Badia S.
        • Duarte E.
        • Verschure P.F.
        Virtual reality based rehabilitation speeds up functional recovery of the upper extremities after stroke: a randomized controlled pilot study in the acute phase of stroke using the rehabilitation gaming system.
        Restor Neurol Neurosci. 2011; 29: 287-298
        • Chen M.
        • Huang L.
        • Lee C.
        • et al.
        A controlled pilot trial of two commercial video games for rehabilitation of arm function after stroke.
        Clin Rehabil. 2015; 29: 674-682
        • Choi Y.
        • Ku J.
        • Lim H.
        • Kim Y.H.
        • Paik N.
        Mobile game-based virtual reality rehabilitation program for upper limb dysfunction after ischemic stroke.
        Restor Neurol Neurosci. 2016; 34: 455-463
        • Colomer C.
        • Llorens R.
        • Noé E.
        • Alcañiz M.
        Effect of a mixed reality-based intervention on arm, hand, and finger function on chronic stroke.
        J Neuroeng Rehabil. 2016; 13: 45
        • Combs S.A.
        • Finley M.A.
        • Henss M.
        • Himmler S.
        • Lapota K.
        • Stillwell D.
        Effects of a repetitive gaming intervention on upper extremity impairments and function in persons with chronic stroke: a preliminary study.
        Disabil Rehabil. 2012; 34: 1291-1298
        • Connelly L.
        • Jia Y.
        • Toro M.L.
        • Stoykov M.E.
        • Kenyon R.V.
        • Kamper D.G.
        A pneumatic glove and immersive virtual reality environment for hand rehabilitative training after stroke.
        IEEE Trans Neural Syst Rehabil Eng. 2010; 18: 551-559
        • Crosbie J.H.
        • Lennon S.
        • McGoldrick M.C.
        • McNeill M.
        • McDonough S.M.
        Virtual reality in the rehabilitation of the arm after hemiplegic stroke: a randomized controlled pilot study.
        Clin Rehabil. 2012; 26: 798-806
        • Givon N.
        • Zeilig G.
        • Weingarden H.
        • Rand D.
        Video-games used in a group setting is feasible and effective to improve indicators of physical activity in individuals with chronic stroke: a randomized controlled trial.
        Clin Rehabil. 2016; 30: 383-392
        • Jang S.H.
        • You S.H.
        • Hallett M.
        • et al.
        Cortical reorganization and associated functional motor recovery after virtual reality in patients with chronic stroke: an experimenter-blind preliminary study.
        Arch Phys Med Rehabil. 2005; 86: 2218-2223
        • Jo K.
        • Jaeho Y.
        • Jinhwa J.
        • Jung J.
        Effects of virtual reality-based rehabilitation on upper extremity function and visual perception in stroke patients: a randomized control trial.
        J Phys Ther Sci. 2012; 24: 1205-1208
        • dos Santos Junior V.A.
        • Santos M.D.
        • Ribeiro N.M.
        • Maldonado I.L.
        Combining proprioceptive neuromuscular facilitation and virtual reality for improving sensorimotor function in stroke survivors: a randomized clinical trial.
        J Cent Nerv Syst Dis. 2011; 11 (1179573519863826)
        • Kiper P.
        • Piron L.
        • Turolla A.
        • Stożek J.
        • Tonin P.
        The effectiveness of reinforced feedback in virtual environment in the first 12 months after stroke.
        Neurol Neurochir Pol. 2011; 45: 436-444
        • Kiper P.
        • Agostini M.
        • Luque-Moreno C.
        • Tonin P.
        • Turolla A.
        Reinforced feedback in virtual environment for rehabilitation of upper extremity dysfunction after stroke: preliminary data from a randomized controlled trial.
        BioMed Res Int. 2014; (2014)
        • Kiper P.
        • Szczudlik A.
        • Agostini M.
        • et al.
        Virtual reality for upper limb rehabilitation in subacute and chronic stroke: a randomized controlled trial.
        Arch Phys Med Rehabil. 2018; 99: 83-842
        • Kong K.
        • Loh Y.
        • Thia E.
        • et al.
        Efficacy of a virtual reality commercial gaming device in upper limb recovery after stroke: a randomized, controlled study.
        Top Stroke Rehabil. 2016; 23: 333-340
        • Kwon J.
        • Park M.
        • Yoon I.
        • Park S.
        Effects of virtual reality on upper extremity function and activities of daily living performance in acute stroke: a double-blind randomized clinical trial.
        NeuroRehabilitation. 2012; 31: 379-385
        • Lee D.
        • Lee M.
        • Lee K.
        • Song C.
        Asymmetric training using virtual reality reflection equipment and the enhancement of upper limb function in stroke patients: a randomized controlled trial.
        Journal of stroke and cerebrovascular diseases. 2014; 23: 1319-1326
        • Levin M.
        • Snir O.
        • Lieberman D.
        • Weingarten H.
        • Weiss P.
        Virtual reality versus conventional treatment of reaching ability in chronic stroke: clinical feasibility study.
        Neurol Ther. 2012; 1: 1-15
        • Oh Y.B.
        • Kim G.W.
        • Han K.S.
        • et al.
        Efficacy of virtual reality combined with real instrument training for patients with stroke: a randomized controlled trial.
        Arch Phys Med Rehabil. 2019; 100: 1400-1408
        • Park J.
        • Park J.
        The effects of game-based virtual reality movement therapy plus mental practice on upper extremity function in chronic stroke patients with hemiparesis: a randomized controlled trial.
        J Phys Ther Sci. 2016; 28: 811-815
        • Piron L.
        • Turolla A.
        • Agostini M.
        • et al.
        Exercises for paretic upper limb after stroke: a combined virtual-reality and telemedicine approach.
        J Rehabil Med. 2009; 41: 1016-1102
        • Piron L.
        • Turolla A.
        • Agostini M.
        • et al.
        Motor learning principles for rehabilitation: a pilot randomized controlled study in poststroke patients.
        Neurorehabil Neural Repair. 2010; 24: 501-508
        • Rand D.
        • Weingarden H.
        • Weiss R.
        • et al.
        Self-training to improve UE function at the chronic stage post-stroke: a pilot randomized controlled trial.
        Disabil Rehabil. 2017; 39: 1541-1548
        • Reinthal A.
        • Szirony K.
        • Clark C.
        • Swiers J.
        • Kellicker M.
        • Linder S.
        ENGAGE: Guided activity-based gaming in neurorehabilitation after stroke: a pilot study.
        Stroke Res Treat. 2012; 2012: 784232
        • Saposnik G.
        • Cohen L.G.
        • Mamdani M.
        • et al.
        Efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST): a randomised, multicentre, single-blind, controlled trial.
        Lancet Neurol. 2016; 15: 1019-1027
        • Shin J.
        • Ryu H.
        • Jang S.H.
        A task-specific interactive game-based virtual reality rehabilitation system for patients with stroke: a usability test and two clinical experiments.
        J Neuroeng Rehab. 2014; 11: 32
        • Shiri S.
        • Feintuch U.
        • Lorber-Haddad A.
        • et al.
        A novel virtual reality system integrating online self-face viewing and mirror visual feedback for stroke rehabilitation: rationale and feasibility.
        Top Stroke Rehabil. 2012; 19: 277-286
        • Sin H.
        • Lee G.
        Additional virtual reality training using xbox kinect in stroke survivors with hemiplegia.
        Am J Phys Med Rehabil. 2013; 92: 871-880
        • Thielbar K.O.
        • Lord T.J.
        • Fischer H.C.
        • et al.
        Training finger individuation with a mechatronic-virtual reality system leads to improved fine motor control post-stroke.
        J Neuroeng Rehabil. 2014; 11: 171
        • Tsoupikova D.
        • Stoykov N.S.
        • Corrigan M.
        • et al.
        Virtual immersion for post-stroke hand rehabilitation therapy.
        Ann Biomed Eng. 2015; 43: 467-477
        • Turolla A.
        • Dam M.
        • Ventura L.
        • et al.
        Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial.
        J Neuroeng Rehabil. 2013; 10: 1-9
        • Wang Z.
        • Wang P.
        • Xing L.
        • Mei L.
        • Zhao J.
        • Zhang T.
        Leap motion-based virtual reality training for improving motor functional recovery of upper limbs and neural reorganization in subacute stroke patients.
        Neural Regen Res. 2017; 12: 1823
        • Gladstone D.J.
        • Danells C.J.
        • Black S.E.
        The fugl-meyer assessment of motor recovery after stroke: a critical review of its measurement properties.
        Neurorehabil Neural Repair. 2002; 16: 232-240
        • George S.H.
        • Rafiei M.H.
        • Borstad A.
        • Adeli H.
        • Gauthier L.V.
        Gross motor ability predicts response to upper extremity rehabilitation in chronic stroke.
        Behav Brain Res. 2017; 333: 314-322
        • Karin E.
        • Dear B.F.
        • Heller G.Z.
        • Gandy M.
        • Titov N.
        Measurement of symptom change following web-based psychotherapy: statistical characteristics and analytical methods for measuring and interpreting change.
        JMIR Ment Health. 2018; 5e10200
        • Prabhakaran S.
        • Zarahn E.
        • Riley C.
        • et al.
        Inter-individual variability in the capacity for motor recovery after ischemic stroke.
        Neurorehabil Neural Repair. 2008; 22: 64-71
        • Winters C.
        • van Wegen E.E.
        • Daffertshofer A.
        • Kwakkel G.
        Generalizability of the proportional recovery model for the upper extremity after an ischemic stroke.
        Neurorehabil Neural Repair. 2015; 29: 614-622
        • Byblow W.D.
        • Stinear C.M.
        • Barber P.A.
        • Petoe M.A.
        • Ackerley S.J.
        Proportional recovery after stroke depends on corticomotor integrity.
        Ann Neurol. 2015; 78: 848-859
        • DerSimonian R.
        • Laird N.
        Meta-analysis in clinical trials.
        Control Clin Trials. 1986; 7: 177-188
        • Winstein C.J.
        • Rose D.K.
        • Tan S.M.
        • Lewthwaite R.
        • Chui H.C.
        • Azen S.P.
        A randomized controlled comparison of upper-extremity rehabilitation strategies in acute stroke: a pilot study of immediate and long-term outcomes.
        Arch Phys Med Rehabil. 2004; 85 (620-8)
        • Wu X.
        • Guarino P.
        • Lo A.C.
        • Peduzzi P.
        • Wininger M.
        Long-term effectiveness of intensive therapy in chronic stroke.
        Neurorehabil Neural Repair. 2016; 30: 583-590
        • Nakayama H.
        • Jørgensen H.S.
        • Raaschou H.O.
        • Olsen T.S.
        Recovery of upper extremity function in stroke patients: the Copenhagen Stroke Study.
        Arch Phys Med Rehabil. 1994; 75: 394-398
        • Dobkin B.H.
        Strategies for stroke rehabilitation.
        Lancet Neurol. 2004; 3: 528-536
        • Kreisel S.H.
        • Hennerici M.G.
        • Bäzner H.
        Pathophysiology of stroke rehabilitation: the natural course of clinical recovery, use-dependent plasticity and rehabilitative outcome.
        Cerebrovasc Dis. 2007; 23: 243-255
        • Van der Lee J.H.
        • Wagenaar R.C.
        • Lankhorst G.J.
        • Vogelaar T.W.
        • Devillé W.L.
        • Bouter L.M.
        Forced use of the upper extremity in chronic stroke patients: results from a single-blind randomized clinical trial.
        Stroke. 1999; 30: 2369-2375
        • Cauraugh J.H.
        • Summers J.J.
        Neural plasticity and bilateral movements: a rehabilitation approach for chronic stroke.
        Prog Neurobiol. 2005; 75: 309-320
        • Lohse K.
        • Shirzad N.
        • Verster A.
        • Hodges N.
        • Van der Loos
        • Machiel H.F.
        Video games and rehabilitation: using design principles to enhance engagement in physical therapy.
        J Neurol Phys Ther. 2013; 37: 166-175
        • Lohse K.R.
        • Hilderman C.G.
        • Cheung K.L.
        • Tatla S.
        • Van der Loos
        • Machiel H.F.
        Virtual reality therapy for adults post-stroke: a systematic review and meta-analysis exploring virtual environments and commercial games in therapy.
        PloS One. 2014; 9e93318
        • Hsieh Y.
        • Wu C.
        • Lin K.
        • Yao G.
        • Wu K.
        • Chang Y.
        Dose–response relationship of robot-assisted stroke motor rehabilitation: the impact of initial motor status.
        Stroke. 2012; 43: 2729-2734
        • Lang C.E.
        • Strube M.J.
        • Bland M.D.
        • et al.
        Dose response of task-specific upper limb training in people at least 6 months poststroke: a phase II, single-blind, randomized, controlled trial.
        Ann Neurol. 2016; 80: 342-354
        • Cirstea C.M.
        • Ptito A.
        • Levin M.F.
        Feedback and cognition in arm motor skill reacquisition after stroke.
        Stroke. 2006; 37: 1237-1242
        • Ertelt D.
        • Small S.
        • Solodkin A.
        • et al.
        Action observation has a positive impact on rehabilitation of motor deficits after stroke.
        Neuroimage. 2007; 36: T164-T173
        • Franceschini M.
        • Ceravolo M.G.
        • Agosti M.
        • et al.
        Clinical relevance of action observation in upper-limb stroke rehabilitation: a possible role in recovery of functional dexterity. A randomized clinical trial.
        Neurorehabil Neural Repair. 2012; 26: 456-462
        • Michielsen M.E.
        • Selles R.W.
        • van der Geest
        • Jos N.
        • et al.
        Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial.
        Neurorehabil Neural Repair. 2011; 25: 223-233
        • Kwakkel G.
        • Veerbeek J.M.
        • van Wegen E.E.
        • Wolf S.L.
        Constraint-induced movement therapy after stroke.
        Lancet Neurol. 2015; 14: 224-234
        • Waddell K.J.
        • Strube M.J.
        • Bailey R.R.
        • et al.
        Does task-specific training improve upper limb performance in daily life poststroke?.
        Neurorehabil Neural Repair. 2017; 31: 290-300
        • Galvin R.
        • Murphy B.
        • Cusack T.
        • Stokes E.
        The impact of increased duration of exercise therapy on functional recovery following stroke—what is the evidence?.
        Top Stroke Rehabil. 2008; 15: 365-377
        • Kwakkel G.
        • Wagenaar R.C.
        • Twisk J.W.
        • Lankhorst G.J.
        • Koetsier J.C.
        Intensity of leg and arm training after primary middle-cerebral-artery stroke: a randomised trial.
        Lancet. 1999; 354: 191-196
        • Yang Z.
        • Rafiei M.H.
        • Hall A.
        • et al.
        A novel methodology for extracting and evaluating therapeutic movements in game-based motion capture rehabilitation systems.
        J Med Syst. 2018; 42: 1-14
        • Lang C.E.
        • Lohse K.R.
        • Birkenmeier R.L.
        Dose and timing in neurorehabilitation: prescribing motor therapy after stroke.
        Curr Opin Neurol. 2015; 28: 549-555
        • Gauthier L.V.
        • Kane C.
        • Borstad A.
        • et al.
        Video game rehabilitation for outpatient stroke (VIGoROUS): protocol for a multi-center comparative effectiveness trial of in-home gamified constraint-induced movement therapy for rehabilitation of chronic upper extremity hemiparesis.
        BMC Neurol. 2017; 17: 109