Date Presented 04/04/19
OTs are increasingly using virtual reality to engage adults in physical rehabilitation after stroke. The results of this systematic review can guide clinical practice for OTs to make evidence-informed decisions when using game-based or nongame-based virtual reality for upper-extremity rehabilitation.
Primary Author and Speaker: Namrata Grampurohit
Contributing Authors: Alexa Knoff, Laura Fritsch, Rochelle Mendonca
PURPOSE: To systematically review the evidence for effectiveness of virtual reality (VR) intervention and compare game based versus non-game based interventions on upper extremity (UE) function and pain outcomes for rehabilitation in adults with chronic stroke. Recent studies have reported increased use of virtual reality (Laver et al., 2015) but the effects of the game and non-game types is not known.
DESIGN: A systematic review methodology was implemented in consultation with a systematic review librarian (PROSPERO # CRD42017062240) with descriptive analysis. The inclusion criteria were: original peer-reviewed research studies inclusive of all years, adults, humans, chronic stroke (6 months and over), UE pain and function, game-based and non-game based VR intervention studies. The exclusion criteria were: acute or subacute stroke (less than 6 months), children or animal studies, systematic reviews, meta-analyses, imaging, diagnostic, and observational studies.
METHOD: Two authors independently completed screening, full-text retrieval, and final inclusion. The third and fourth authors were involved for consensus. Rayyan software was used for management of data. Data extracted from full text included author, date, setting, age, time post-stroke, type of stroke, inclusion/exclusion, number per group, participant notes, study design, description of VR intervention, dose of VR session, control group intervention, dose of control, UE function outcome, UE pain outcome, level of evidence and game vs non game based. The studies had to self-identify themselves as using a game with rewards or feedback. Methodological quality for risk of bias was rated using PEDro (Fitzpartrick, 2008) for all studies and CONSORT (Moher et al., 2012) was further applied for randomized controlled trials (RCT). The American Journal of Occupational Therapy guidelines for systematic review were applied to determine the strength of evidence.
RESULTS: A total of 1915 articles were retrieved after removing duplicates and 24 full-text studies were included for final review after applying the selection criteria. The PRISMA guidelines for reporting of systematic review were followed for this study. The final articles included 13 RCTs, five cohort studies, and six single case design studies. There were two good quality studies with both non-game based VR. There were 14 fair quality studies with four non-game based VR. There were seven poor quality studies with two non-game based VR. There was strong evidence of comparative effectiveness (two good quality RCTs, two fair quality studies) of non-game based VR over conventional or alternative therapy for UE function as measured by Fugl Meyer Assessment and Manual Function Test in people with chronic stroke. There was moderate evidence (multiple fair quality studies) of the effectiveness of game based VR alone. There were three studies that measured pain with inconsistent design, measurement, and reporting.
CONCLUSION: We found overall beneficial effects of virtual reality for upper extremity functional rehabilitation in adults with chronic stroke. Non-game based virtual reality applications had stronger evidence for upper extremity functional benefits over conventional or alternative therapy than game based applications. Future studies with a rigorous methodology for comparative effectiveness are needed to inform clinical practice.
IMPACT: This review can inform the design of future research studies. The evidence synthesis presented in this review can also help clinicians translate current evidence into clinical practice when choosing game based versus non-game based virtual reality interventions for adults with stroke.
References
Laver, K.E., George, S., Thomas, S., Deutsch, J.E., Crotty, M. (2015). Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews, 2. DOI: 10.1002/14651858.CD008349.pub3.
Fitzpatrick, R.B. (2008). PEDro: a physiotherapy evidence database. Med Ref Serv Q., 27(2), 189-198.
Moher, D., Hopewell, S., Schulz, K. F., et al. (2012) CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. Int J Surg., 10(1), 28–55
