Effects of virtual reality training in the upper limb motor coordination of individuals post- stroke: a systematic review with meta-analysis

Meireles, Cecília Vieira; Ferreira, Suelen Félix; Avelino, Patrick Roberto; Menezes, Kênia Kiefer Parreiras de

doi:10.1590/1809-2950/19039029012022PT

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ORIGINAL RESEARCH • Fisioter. Pesqui. 29 (1) • Jan-Mar 2022 • https://doi.org/10.1590/1809-2950/19039029012022EN linkcopy

Effects of virtual reality training in the upper limb motor coordination of individuals post- stroke: a systematic review with meta-analysis

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After a stroke, 75% of people are affected in their upper limbs, remaining with sequelae at these limbs. Results from recent clinical trials have been contradictory regarding the effectiveness of Virtual Reality (VR) therapy in rehabilitating upper limb motor coordination in this population. This study aimed to perform a systematic literature review with meta-analysis to investigate the effects of VR training on upper limb motor coordination in patients post-stroke. Searches were performed in the electronic databases PubMed, LILACS, SciELO, PEDro, in addition to manual searches. The whole process was performed by two independent raters. The methodological quality of the studies was assessed by the PEDro scale. In total, we selected 18 studies, out of which only 13 were included in the meta-analysis. In general, VR training was effective in improving upper limb motor coordination (SMD 0.32; 95% CI 0.08-0.56; I²=42%; p<0.01). When subgroup analysis assessed control group type, VR training was superior than no intervention (SMD 0.36; 95% CI: 0.06-0.66; p<0.05). However, when compared to other interventions, we found no significant difference (SMD 0.26; 95% CI: −0.12-0.64; p=0.18). Overall, VR training is effective in improving upper limb motor coordination in post-stroke individuals compared to no intervention. However, it shows no superiority when compared to other types of intervention used in the rehabilitation of upper limb motor coordination in these patients.

Keywords:
Virtual Reality; Motor Skills; Upper Extremity; Stroke; Systematic Review

STUDY	PARTICIPANTS	PROTOCOL	MOTOR COORDINATION TEST	RESULTS
Adie et al. (2016)	235 participants	Experimental group: performed 45 minutes of exercise at home, sitting, with Nintendo Wii Sports™ every day for six weeks.	action research arm test	There was no significant difference between the experimental and control groups. Both groups improved.
	Age: 67.4±13.3
	Experimental group
	(n=117)	Control group: performed 45 minutes of upper limb exercises, sitting, every day for six weeks at home.
	Control group
	(n=118)
	Acute stroke
Afsar et al. (2018)	35 participantes	Experimental group: 30-minute VR training with Microsoft Xbox 360 Kinect five times a week for four weeks + 60-minute conventional therapy five times a week for four weeks.	box and blocks test	There was a significant improvement in the experimental group when compared to the control group.
	Age: 66.4±8.1
	Experimental group
	(n=19)	Control group: 60-minute conventional therapy five times a week for four weeks.
	Control group
	(n=16)
	Subacute stroke
Askin et al. (2018)	40 participants	Experimental group: 20 one-hour VR training sessions with Microsoft Xbox 360 Kinect five times a week for four weeks + 20 physical therapy sessions five days a week for four weeks.	box and blocks test	Both groups improved significantly. There was no between-group analysis.
	Age: 54.9±10.5
	Experimental group
	(n=20)	Control group: 20 conventional therapy sessions, five days a week for four weeks.
	Control group
	(n=20)
	Chronic stroke
Brunner et al. (2017)	120 participantes	Experimental group: 60-minute VR training with Microsoft Xbox 60 Kinect from four to five times a week for four weeks + conventional therapy.	action research arm test and box and blocks test	There was no significant difference between the experimental and control groups. Both groups improved.
	Age: 62
	Experimental group
	(n=62)	Control group: 60-minute standardized exercises with emphasis on task-oriented practice four to five times a week for four weeks + conventional therapy.
	Control group
	(n=58)
	Subacute stroke
Choi et al. (2014)	20 participants	Experimental group: VR training with the Nintendo Wii game for 30 minutes a day five times a week for four weeks.	box and blocks test	Both groups significantly improved. There was no analysis between groups.
	Age: 64.5±10.8
	Experimental group
	(n=10)	Control group: conventional therapy five times a week for 30 minutes for four weeks.
	Control group
	(n=10)
	Subacute stroke
Givon et al. (2015)	47 participants	Experimental group: VR training with Microsoft Xbox Kinect, Sony PlayStation 2 Eye Toy, Sony PlayStation 3 Move, Nintendo Wii Fit, and the SeeMe VR system with two one-hour sessions per week for three months.	action research arm test	There was no significant difference between the experimental and control groups. Both groups improved.
	Age: 59.4±9.3
	Experimental group
	(n=23)	Control group: conventional therapy with two one-hour sessions per week for three months.
	Control group
	(n=24)
	Chronic stroke
Hung et al. (2019)	33 participants	Experimental group: VR training with Kinect 2 Scratch with 30-minute 24 sessions for 12 weeks + 45 minutes of manual function training and daily activities.	wolf motor function test	There was no significant difference between experimental and control groups. Both groups improved.
	Age: 59
	Experimental group
	(n=17)	Control group: 24 30-minute conventional therapy sessions for 12 weeks + 45 minutes of manual function training and daily activities.
	Control group
	(n=16)
	Chronic stroke
In et al. (2012)	19 participants	Experimental group: 30-minute VR training five days a week for four weeks + conventional therapy.	box and blocks test	There was no significant difference between the experimental and control groups. Both groups improved.
	Age: 64±12.2
	Experimental group
	(n=11)	Control group: conventional therapy.
	Control group
	(n=8)
	Chronic stroke
Jo et al. (2012)	29 participants	Experimental group: VR training with the game Interactive Rehabilitation and Exercise System for 60 minutes a day five times a week for four weeks + conventional therapy three times a week for 30 minutes for four weeks.	wolf motor function test	No group improved significantly. There was no analysis between groups.
	Age: 64±7.1
	Experimental group
	(n=15)	Control group: conventional therapy three times a week for 30 minutes for four weeks.
	Control group
	(n=14)
	Chronic stroke
Kong et al. (2016)	105 participants	Experimental group 1: VR training with the Nintendo Wii Sports game™ for 12 60-minute sessions four times a week for three weeks + one hour of conventional therapy daily.	action research arm test	There was no significant differences among experimental and control groups. All groups improved.
	Mean age:
	57.6±11.4
	Experimental group 1	Experimental group 2: 12 60-minute stretching, strengthening, and range of motion exercises; task-specific training; and upper limb skill training sessions four times a week for three weeks + one hour of conventional therapy daily.
	(n=35)
	Experimental group 2
	(n=35)	Control group: one hour of conventional therapy daily.
	Control group
	(n=35)
	Acute stroke
Lee et al. (2013)	24 participants	Experimental group: VR asymmetric training 30 minutes a day, five days a week for four weeks + 30-minute conventional therapy twice a day, five days a week for four weeks.	box and blocks test	There was a significant improvement in the experimental group when compared to control.
	Age: 61.9±10
	Experimental group
	(n=12)	Control group: conventional therapy twice a day, five times a week for 30 minutes for four weeks.
	Control group
	(n=12)
	Chronic stroke
Lee et al. (2016)	18 participants	Experimental group: upper extremity bilateral exercises in a VR environment in 30-minute sessions thrice a week for six weeks.	box and blocks test	There was a significant improvement in the experimental group when compared to control.
	Age: 71.3±7.3
	Experimental group
	(n=10)	Experimental group: upper extremity bilateral exercises in 30-minute sessions thrice a week for six weeks.
	Control group
	(n=8)
	Chronic stroke
McNulty et al. (2015)	41 participants	Experimental group: VR training with Nintendo Wii for 10 consecutive 60-minute sessions.	wolf motor function test	There was no significant difference between the experimental and control groups. Both groups improved.
	Age: 58 ± 15.4
	Experimental group
	(n=21)	Control group: induced containment therapy with containment for 90% of the day and continuous activity training of 15 to 20 minutes.
	Control group
	(n=20)
	Chronic stroke
Saposnik et al. (2016)	141 participants	Experimental group: non-immersive VR training with Nintendo Wii for 10 60-minute sessions.	wolf motor function test	There was no significant difference between the experimental and control groups. Both groups improved.
	Age: 62±12.5
	Experimental group
	(n=71)	Control group: recreational games (card games or bingo, for example) for 10 60-minute sessions for two weeks.
	Control group
	(n=70)
	Acute stroke
Schuster-Amft et al. (2018)	54 participants	Experimental group: 45-minute VR training four days a week for four weeks + conventional therapy.	box and blocks test	There was no significant difference between the experimental and control groups. Both groups improved.
	Age: 61.3±12.3
	Experimental group
	(n=22)	Control group: 45-minute conventional therapy four times a week for four weeks.
	Control group
	(n=32)
	Chronic stroke
Shin et al. (2016)	46 patients	Experimental group: VR training with RAPAEL Smart Glove™, with 20 30-minute sessions for four weeks + conventional therapy for 30 minutes.	Jebsen-Taylor hand function test	There was a significant improvement in the experimental group when compared to control.
	Age: 58.5±11.7
	Experimental group
	(n=24)	Control group: same category of movements without VR, with 20 30-minute sessions for four weeks + conventional therapy for 30 minutes.
	Control group
	(n=22)
	Chronic stroke
Sin & Lee (2013)	40 participants	Experimental group: VR training with Microsoft Xbox Kinect thrice a week for 30 minutes for six weeks + conventional therapy thrice a week for 30 minutes for six weeks.	box and blocks test	There was a significant improvement in the experimental group when compared to control.
	Age: 73.7±7.5
	Experimental group
	(n=20)	Control group: conventional therapy three times a week for 30 minutes for six weeks.
	Control group
	(n=20)
	Chronic stroke
Subramanian et al. (2013)	32 participants	Experimental group: VR training with Computer Assisted Rehabilitation Environment for 45 minutes thrice a week for four weeks.	wolf motor function test	There was a significant improvement in the experimental group when compared to control.
	Age: 61±10.4
	Experimental group
	(n=16)	Control group: same category of movements without VR for 45 minutes thrice a week for four weeks.
	Control group
	(n=16)
	Chronic stroke

Study	Randomization	Blinded participant distribution	Initial similarity between groups	Participant blinding	Therapist blinding	Evaluator blinding	Measures of primary outcome	“Intent to treat”	Intergroup comparison of primary outcome	Accuracy and variability measures for at least one outcome	Total
Adie et al. (2016)	Y	Y	Y	N	N	N	Y	Y	Y	Y	7/10
Afsar et al. (2018)	Y	Y	Y	N	N	Y	N	N	Y	Y	6/10
Askin et al. (2018)	Y	N	Y	N	N	Y	Y	N	Y	Y	6/10
Brunner et al. (2017)	Y	N	Y	N	N	Y	Y	Y	Y	Y	7/10
Choi et al. (2014)	Y	N	Y	N	N	Y	Y	Y	Y	Y	7/10
Givon et al. (2015)	Y	N	Y	N	N	Y	Y	Y	Y	Y	7/10
Hung et al. (2019)	Y	Y	Y	N	N	Y	Y	Y	Y	Y	8/10
In et al. (2012)	Y	N	Y	N	N	N	N	N	Y	Y	4/10
Jo et al. (2012)	Y	N	Y	N	N	N	Y	N	Y	Y	5/10
Kong et al. (2016)	Y	N	Y	N	N	N	Y	N	Y	Y	5/10
Lee et al. (2013)	Y	N	Y	N	N	Y	N	N	Y	Y	5/10
Lee et al. (2016)	Y	N	Y	N	N	Y	Y	N	Y	Y	6/10
McNulty et al. (2015)	Y	Y	Y	N	N	Y	Y	Y	Y	Y	8/10
Saposnik et al. (2016)	Y	N	Y	N	N	Y	Y	Y	Y	Y	7/10
Schuster-Amft et al. (2018)	Y	Y	Y	N	N	Y	Y	Y	Y	Y	8/10
Shin et al. (2016)	Y	Y	Y	N	N	Y	N	Y	Y	Y	7/10
Sin & Lee (2013)	Y	N	Y	N	N	Y	Y	N	Y	Y	6/10
Subramanian et al. (2013)	Y	Y	Y	N	N	Y	Y	N	Y	Y	7/10

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[TFN2] * VR: virtual reality.