Advertisement

Effect of Time-Dose-Matched Virtual Reality Therapy on Upper Limb Dysfunction in Patients Poststroke: A Meta-Analysis of Randomized Controlled Trials

Published:October 04, 2021DOI:https://doi.org/10.1016/j.apmr.2021.09.003

      Abstract

      Objective

      To investigate the efficacy and acceptability of virtual reality (VR) with time-dose-matched conventional therapy (CT) in patients poststroke with upper limb dysfunction.

      Data Sources

      Cochrane, PubMed, Web of Science, Embase, and ProQuest were systematically searched up to May 24, 2021.

      Study Selection

      Randomized controlled trials comparing VR with time-dose-matched CT in patients poststroke with upper limb dysfunction were included.

      Data Extraction

      The extracted data included efficacy (mean change in structure/function, activity, and participation scores), acceptability (dropouts for all reasons), adverse events, and characteristics of the included studies. The Cochrane risk of bias assessment tool was used to assess the risk of bias.

      Data Synthesis

      Thirty-one randomized controlled trails were included. VR was superior to time-dose-matched CT in terms of the World Health Organization's International Classification of Functioning, Disability and Health structure/function, with a standardized mean difference (SMD) of 0.35, but not activity and participation. Subgroup analyses demonstrated that virtual environment was superior to CT in structure/function (SMD=0.38) and activity (SMD=0.27), whereas there were no significant differences between commercial gaming and CT in any World Health Organization International Classification of Functioning, Disability and Health domain. VR mixed with CT was more effective than time-dose-matched CT in structure/function (SMD=0.56), whereas VR only was not significantly different from CT. There were no significant differences in the incidence of adverse events and dropout rates between VR and CT.

      Conclusions

      The results suggest that VR is superior to time-dose-matched CT in terms of recovery of upper extremity motor function, especially when a virtual environment is used or VR is mixed with CT. However, VR (VR only or mixed with CT) does not improve patients’ daily activity performance and participation compared with CT. Overall, VR appears to be safe and acceptable as CT. Large-scale definitive trials are needed to verify or refute these findings.

      Keywords

      List of abbreviations:

      ARAT (Action Research Arm Test), BBT (Box and Block Test), BI (Barthel Index), CG (commercial gaming), CI (confidence interval), CT (conventional therapy), FMU (Upper Extremity Fugl-Meyer), GS (grip strength), JHFT (Jebsen Hand Function Test), ICF (International Classification of Functioning, Disability and Health), MAL-QOM (Motor Activity Log-Quality of Movement), MBI (Modified Barthel Index), MI (Motricity Index), OR (odds ratio), RCT (randomized controlled trial), SIS Strength (Stroke Impact Scale Strength), SMD (standardized mean difference), VE (virtual environment), VR (virtual reality), WMFT (Wolf Motor Function Test)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Roger VL
        • Go AS
        • Lloyd-Jones DM
        • et al.
        Heart disease and stroke statistics–2011 update: a report from the American Heart Association.
        Circulation. 2011; 123: e18-209
        • Nakayama H
        • Jørgensen HS
        • Raaschou HO
        • Olsen TS
        Recovery of upper extremity function in stroke patients: the Copenhagen Stroke Study.
        Arch Phys Med Rehabil. 1994; 75: 394-398
        • Hendricks HT
        • van Limbeek J
        • Geurts AC
        • Zwarts MJ
        Motor recovery after stroke: a systematic review of the literature.
        Arch Phys Med Rehabil. 2002; 83: 1629-1637
        • Johnston SC
        • Mendis S
        • Mathers CD
        Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling.
        Lancet Neurol. 2009; 8: 345-354
        • Buma FE
        • Lindeman E
        • Ramsey NF
        • Kwakkel G
        Functional neuroimaging studies of early upper limb recovery after stroke: a systematic review of the literature.
        Neurorehabil Neural Repair. 2010; 24: 589-608
        • Nichols-Larsen DS
        • Clark P
        • Zeringue A
        • Greenspan A
        • Blanton S
        Factors influencing stroke survivors’ quality of life during subacute recovery.
        Stroke. 2005; 36: 1480-1484
        • French B
        • Thomas LH
        • Leathley MJ
        • et al.
        Repetitive task training for improving functional ability after stroke.
        Stroke. 2009; 40: e98-e99
        • Pollock A
        • Farmer SE
        • Brady MC
        • et al.
        Interventions for improving upper limb function after stroke.
        Cochrane Database Syst Rev. 2014; CD010820
        • Maclean N
        • Pound P
        • Wolfe C
        • Rudd A
        A critical review of the concept of patient motivation in the literature on physical rehabilitation.
        Soc Sci Med. 2000; 50: 495-506
        • Holden MK
        Virtual environments for motor rehabilitation: review.
        Cyberpsychol Behav. 2005; 8 (discussion 212-189): 187-211
        • Henderson A
        • Korner-Bitensky N
        • Levin M
        Virtual reality in stroke rehabilitation: a systematic review of its effectiveness for upper limb motor recovery.
        Top Stroke Rehabil. 2007; 14: 52-61
        • Rand D
        • Givon N
        • Weingarden H
        • Nota A
        • Zeilig G
        Eliciting upper extremity purposeful movements using video games: a comparison with traditional therapy for stroke rehabilitation.
        Neurorehabil Neural Repair. 2014; 28: 733-739
        • Peters DM
        • McPherson AK
        • Fletcher B
        • McClenaghan BA
        • Fritz SL
        Counting repetitions: an observational study of video game play in people with chronic poststroke hemiparesis.
        J Neurol Phys Ther. 2013; 37: 105-111
        • Kim WS
        • Cho S
        • Ku J
        • et al.
        Clinical application of virtual reality for upper limb motor rehabilitation in stroke: review of technologies and clinical evidence.
        J Clin Med. 2020; 9: 3369
        • Miclaus R
        • Roman N
        • Caloian S
        • et al.
        Non-immersive virtual reality for post-stroke upper extremity rehabilitation: a small cohort randomized trial.
        Brain Sci. 2020; 10: 655
        • Levin MF
        • Weiss PL
        • Keshner EA
        Emergence of virtual reality as a tool for upper limb rehabilitation: incorporation of motor control and motor learning principles.
        Phys Ther. 2015; 95: 415-425
        • Maier M
        • Rubio Ballester B
        • Duff A
        • Duarte Oller E
        • Verschure P
        Effect of specific over nonspecific VR-based rehabilitation on poststroke motor recovery: a systematic meta-analysis.
        Neurorehabil Neural Repair. 2019; 33: 112-129
        • Aminov A
        • Rogers JM
        • Middleton S
        • Caeyenberghs K
        • Wilson PH
        What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes.
        J Neuroeng Rehabil. 2018; 15: 29
        • 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
        • 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: 85
        • Kong KH
        • Loh YJ
        • 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
        • Erhardsson M
        • Alt Murphy M
        • Sunnerhagen KS
        Commercial head-mounted display virtual reality for upper extremity rehabilitation in chronic stroke: a single-case design study.
        J Neuroeng Rehabil. 2020; 17: 154
      1. World Health Organization. Classifications: international classification of functioning, disability and health (ICF). Available at: http://www.who.int/classifications/icf/en/. Accessed September 21, 2018.

        • Moher D
        • Liberati A
        • Tetzlaff J
        • Altman DG
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement.
        Open Med. 2009; 3: e123-e130
        • Fugl-Meyer AR
        • Jääskö 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
        • Lin KC
        • Fu T
        • Wu CY
        • Hsieh YW
        • Chen CL
        • Lee PC
        Psychometric comparisons of the Stroke Impact Scale 3.0 and Stroke-Specific Quality of Life Scale.
        Qual Life Res. 2010; 19: 435-443
        • Demeurisse G
        • Demol O
        • Robaye E
        Motor evaluation in vascular hemiplegia.
        Eur Neurol. 1980; 19: 382-389
        • Mathiowetz V
        • Volland G
        • Kashman N
        • Weber K
        Adult norms for the Box and Block Test of manual dexterity.
        Am J Occup Ther. 1985; 39: 386-391
        • Lyle RC
        A performance test for assessment of upper limb function in physical rehabilitation treatment and research.
        Int J Rehabil Res. 1981; 4: 483-492
        • Wolf SL
        • Catlin PA
        • Ellis M
        • Archer AL
        • Morgan B
        • Piacentino A
        Assessing Wolf Motor Function Test as outcome measure for research in patients after stroke.
        Stroke. 2001; 32: 1635-1639
        • Jung HY
        • Park BK
        • Shin HS
        • et al.
        Development of the Korean version of Modified Barthel Index (K-MBI): multi-center study for subjects with stroke.
        Journal of the Korean Academy of Rehabilitation Medicine. 2007; 31: 283-297
        • Jebsen RH
        • Taylor N
        • Trieschmann RB
        • Trotter MJ
        • Howard LA
        An objective and standardized test of hand function.
        Arch Phys Med Rehabil. 1969; 50: 311-319
        • Keith RA
        • Granger CV
        • Hamilton BB
        • Sherwin FS
        The functional independence measure: a new tool for rehabilitation.
        Adv Clin Rehabil. 1987; 1: 6-18
        • da Silva Cameirão M
        • Bermúdez IBS
        • Duarte E
        • Verschure PF
        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
        • Uswatte G
        • Taub E
        • Morris D
        • Vignolo M
        • McCulloch K
        Reliability and validity of the upper-extremity Motor Activity Log-14 for measuring real-world arm use.
        Stroke. 2005; 36: 2493-2496
        • Duncan PW
        Outcome measures in stroke rehabilitation.
        Handb Clin Neurol. 2013; 110: 105-111
        • Wan X
        • Wang W
        • Liu J
        • Tong T
        Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range.
        BMC Med Res Methodol. 2014; 14: 135
        • Cuijpers P
        Meta-analyses in mental health research: a practical guide. Pim Cuijpers Uitgeverij, Amsterdam, The Netherlands2016
        • Ahmad MA
        • Singh DKA
        • Mohd Nordin NA
        • Hooi Nee K
        • Ibrahim N
        Virtual reality games as an adjunct in improving upper limb function and general health among stroke survivors.
        Int J Environ Res Public Health. 2019; 16: 5144
        • Brunner I
        • Skouen JS
        • Hofstad H
        • et al.
        Virtual reality training for upper extremity in subacute stroke (VIRTUES): a multicenter RCT.
        Neurology. 2017; 89: 2413-2421
        • Cho HY
        • Song E
        • Moon JH
        • Hahm SC
        Effects of virtual reality based therapeutic exercise on the upper extremity function and activities of daily living in patients with acute stroke: a pilot randomized controlled trial.
        Medico Legal Update. 2021; 21: 676-682
        • Choi YH
        • Ku J
        • Lim H
        • Kim YH
        • Paik NJ
        Mobile game–based virtual reality rehabilitation program for upper limb dysfunction after ischemic stroke.
        Restor Neurol Neurosci. 2016; 34: 455-463
        • Crosbie JH
        • Lennon S
        • McGoldrick MC
        • McNeill MD
        • McDonough SM
        Virtual reality in the rehabilitation of the arm after hemiplegic stroke: a randomized controlled pilot study.
        Clin Rehabil. 2012; 26: 798-806
        • Friedman N
        • Chan V
        • Reinkensmeyer AN
        • et al.
        Retraining and assessing hand movement after stroke using the MusicGlove: comparison with conventional hand therapy and isometric grip training.
        J Neuroeng Rehabil. 2014; 11: 76
        • Hung JW
        • Chou CX
        • Chang YJ
        • et al.
        Comparison of Kinect2Scratch game-based training and therapist-based training for the improvement of upper extremity functions of patients with chronic stroke: a randomized controlled single-blinded trial.
        Eur J Phys Rehabil Med. 2019; 55: 542-550
        • In TS
        • Jung KS
        • Lee SW
        • Song CH
        Virtual reality reflection therapy improves motor recovery and motor function in the upper extremities of people with chronic stroke.
        J Phys Ther Sci. 2012; 24: 339-343
        • 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; 2014752128
        • 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 (834-42.e834)
        • Kottink AI
        • Prange GB
        • Krabben T
        • Rietman JS
        • Buurke JH
        Gaming and conventional exercises for improvement of arm function after stroke: a randomized controlled pilot study.
        Games Health J. 2014; 3: 184-191
        • Laffont I
        • Froger J
        • Jourdan C
        • et al.
        Rehabilitation of the upper arm early after stroke: Video games versus conventional rehabilitation. A randomized controlled trial.
        Ann Phys Rehabil Med. 2020; 63: 173-180
        • Lee M
        • Son J
        • Kim J
        • Pyun SB
        • Eun SD
        • Yoon BC
        Comparison of individualized virtual reality– and group-based rehabilitation in older adults with chronic stroke in community settings: a pilot randomized controlled trial.
        Eur J Integr Med. 2016; 8: 738-746
        • Levin MF
        • Snir O
        • Liebermann DG
        • Weingarden H
        • Weiss PL
        Virtual reality versus conventional treatment of reaching ability in chronic stroke: clinical feasibility study.
        Neurol Ther. 2012; 1: 3
        • Lin BS
        • Chen JL
        • Hsu HC
        Novel upper-limb rehabilitation system based on attention technology for post-stroke patients: a preliminary study.
        IEEE Access. 2017; 6: 2720-2731
        • Mekbib DB
        • Debeli DK
        • Zhang L
        • et al.
        A novel fully immersive virtual reality environment for upper extremity rehabilitation in patients with stroke.
        Ann N Y Acad Sci. 2021; 1493: 75-89
        • 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
        • Rodríguez-Hernández M
        • Polonio-López B
        • Corregidor-Sánchez AI
        • Martín-Conty JL
        • Mohedano-Moriano A
        • Criado-Álvarez JJ
        Effects of specific virtual reality–based therapy for the rehabilitation of the upper limb motor function post-ictus: randomized controlled trial.
        Brain Sci. 2021; 11: 555
        • Schuster-Amft C
        • Eng K
        • Suica Z
        • et al.
        Effect of a four-week virtual reality–based training versus conventional therapy on upper limb motor function after stroke: a multicenter parallel group randomized trial.
        PLoS One. 2018; 13e0204455
        • Shin JH
        • Bog Park S
        • Ho Jang S
        Effects of game-based virtual reality on health-related quality of life in chronic stroke patients: a randomized, controlled study.
        Comput Biol Med. 2015; 63: 92-98
        • Shin JH
        • Kim MY
        • Lee JY
        • et al.
        Effects of virtual reality–based rehabilitation on distal upper extremity function and health-related quality of life: a single-blinded, randomized controlled trial.
        J Neuroeng Rehabil. 2016; 13: 17
        • Thielbar KO
        • Lord TJ
        • Fischer HC
        • 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
        • Wang ZR
        • Wang P
        • Xing L
        • Mei LP
        • 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: 1823-1831
        • Yin CW
        • Sien NY
        • Ying LA
        • Chung SF
        • Tan May Leng D
        Virtual reality for upper extremity rehabilitation in early stroke: a pilot randomized controlled trial.
        Clin Rehabil. 2014; 28: 1107-1114
        • Zondervan DK
        • Friedman N
        • Chang E
        • et al.
        Home-based hand rehabilitation after chronic stroke: randomized, controlled single-blind trial comparing the MusicGlove with a conventional exercise program.
        J Rehabil Res Dev. 2016; 53: 457-472
        • Zucconi C
        • Valt V
        • Agostini M
        • Turolla A
        • Tonin P
        • Piron L
        Assessment of a virtual teacher feedback for the recovery of the upper limb after stroke.
        It J Physiother. 2011; 1: 101-106
        • Adie K
        • Schofield C
        • Berrow M
        • et al.
        Does the use of Nintendo Wii Sports(TM) improve arm function? Trial of Wii(TM) in Stroke: a randomized controlled trial and economics analysis.
        Clin Rehabil. 2017; 31: 173-185
        • Choi JH
        • Han EY
        • Kim BR
        • et al.
        Effectiveness of commercial gaming–based virtual reality movement therapy on functional recovery of upper extremity in subacute stroke patients.
        Ann Rehabil Med. 2014; 38: 485-493
        • Fan SC
        • Su F
        • Chen SS
        • et al.
        Improved intrinsic motivation and muscle activation patterns in reaching task using virtual reality training for stroke rehabilitation: a pilot randomized control trial.
        J Med Biol Eng. 2014; 34: 399-407
        • 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
        • Bernhardt J
        • Godeckeb E
        • Johnson L
        • Langhorne P
        Early rehabilitation after stroke.
        Curr Opin Neurol. 2016; 30: 1
        • Lee MM
        • Lee KJ
        • Song CH
        Game-based virtual reality canoe paddling training to improve postural balance and upper extremity function: a preliminary randomized controlled study of 30 patients with subacute stroke.
        Med Sci Monit. 2018; 24: 2590-2598
        • Laver KE
        • George S
        • Thomas S
        • Deutsch JE
        • Crotty M
        Virtual reality for stroke rehabilitation.
        Cochrane Database Syst Rev. 2015; CD008349
        • Muratori LM
        • Lamberg EM
        • Quinn L
        • Duff SV
        Applying principles of motor learning and control to upper extremity rehabilitation.
        J Hand Ther. 2013; 26 (quiz 103): 94-102