Abstract
Objective
This systematic review aimed to compare the effects of immersive and non-immersive virtual reality on upper extremity function in stroke survivors by employing a network meta-analysis approach.
Data sources
MEDLINE, Embase, CINAHL Plus, APA PsycINFO, and Scopus were searched. Virtual reality was used for upper extremity rehabilitation; dose-matched conventional rehabilitation was used for comparison. Fugl-Meyer Assessment was used to assess upper extremity function. Searches were limited to English language randomized controlled trials.
Methods
Two independent reviewers conducted study selection, data extraction, and quality assessment. Methodological quality was assessed using the Physiotherapy Evidence Database scale. A random-effects frequentist network meta-analysis was conducted by assuming a common random-effects standard deviation for all comparisons in the network.
Results
Twenty randomized controlled trials with 813 participants were included, with each study evaluated as good quality. Immersive virtual reality systems were most effective at improving upper extremity function, followed by non-immersive virtual reality systems, then non-immersive gaming consoles of Microsoft Kinect and Nintendo Wii. Conventional rehabilitation was least effective. Immersive virtual reality was estimated to induce 1.39 (95% confidence interval (CI): 0.25, 2.53) and 1.38 (95% CI: 0.55, 2.20) standard mean differences of improvements in upper extremity function, compared to Nintendo Wii intervention and conventional rehabilitation, respectively.
Conclusion
This systematic review and network meta-analysis highlights the superior effects of immersive virtual reality to non-immersive virtual reality systems and gaming consoles on upper extremity motor recovery.
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Notes
“Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE: sensitivity-maximizing version (2008 revision); Ovid format” from Lefebvre C, Glanville J, Briscoe S, Featherstone R, Littlewood A, Marshall C, Metzendorf M-I, Noel-Storr A, Paynter R, Rader T, Thomas J, Wieland LS. Technical Supplement to Chapter 4: Searching for and selecting studies. In: Higgins JPT, Thomas J, Chandler J, Cumpston MS, Li T, Page MJ, Welch VA (eds). Cochrane handbook for systematic reviews of interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from: www.training.cochrane.org/handbook.
Cochrane Highly Sensitive Search Strategy for identifying controlled trials in Embase: (2020 revision); Embase.com format from Lefebvre C, Glanville J, Briscoe S, Featherstone R, Littlewood A, Marshall C, Metzendorf M-I, Noel-Storr A, Paynter R, Rader T, Thomas J, Wieland LS. Technical Supplement to Chapter 4: Searching for and selecting studies. In: Higgins JPT, Thomas J, Chandler J, Cumpston MS, Li T, Page MJ, Welch VA (eds). Cochrane handbook for systematic reviews of interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from: www.training.cochrane.org/handbook.
“Cochrane CINAHL-Plus filter” from Lefebvre C, Glanville J, Briscoe S, Featherstone R, Littlewood A, Marshall C, Metzendorf M-I, Noel-Storr A, Paynter R, Rader T, Thomas J, Wieland LS. Technical Supplement to Chapter 4: Searching for and selecting studies. In: Higgins JPT, Thomas J, Chandler J, Cumpston MS, Li T, Page MJ, Welch VA (eds). Cochrane handbook for systematic reviews of interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from: www.training.cochrane.org/handbook.
Watson RJ, Richardson PH. Identifying randomized controlled trials of cognitive therapy for depression: comparing the efficiency of Embase, Medline and PsycINFO bibliographic databases. Br J Med Psychol. 1999 Dec;72 ( Pt 4):535–42.
Searching Scopus for “Randomised control trials,” NUS library, accessed June 6, 2022 https://libguides.nus.edu.sg/c.php?g=145717&p=2470589.
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Appendix 1. Search strategies in each database
Appendix 1. Search strategies in each database
Medline (Ovid) Footnote 1
1 "virtual realit$".ab,ti.
2 "virtual environment$".ab,ti.
3 "augmented realit$".ab,ti.
4 "mixed realit$".ab,ti.
5 "video gam$".ab,ti.
6 exergam$.ab,ti.
7 "serious gam$".ab,ti.
8 Kinect.ab,ti.
9 Wii.ab,ti.
10 (head mounted adj5 devic$).ab,ti.
11 (head mounted adj5 displa$).ab,ti.
12 "smart glass$".ab,ti.
13 smartglass$.ab,ti.
14 arm$.ab,ti.
15 hand$.ab,ti.
16 "upper limb$".ab,ti.
17 "upper extremit$".ab,ti.
18 $stroke.ab,ti.
19 "cerebral vascular acciden$".ab,ti.
20 "cerebral vascular event$".ab,ti.
21 "cerebrovascular acciden$".ab,ti.
22 "cerebrovascular event$".ab,ti.
23 hemiplegi$.ab,ti
24 hemiparesis.ab,ti.
25 randomized controlled trial.pt.
26 controlled clinical trial.pt.
27 randomized.ab.
28 placebo.ab.
29 drug therapy.fs.
30 randomly.ab.
31 trial.ab.
32 groups.ab.
33 exp virtual reality/
34 exp augmented reality/
35 exp Video Games/
36 exp exergaming/
37 exp Smart Glasses/
38 exp Upper Extremity/
39 exp Stroke/
40 exp animals/ not humans.sh.
41 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13
42 14 or 15 or 16 or 17
43 18 or 19 or 20 or 21 or 22 or 23 or 24
44 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32
45 33 or 34 or 35 or 36 or 37
46 41 or 45
47 38 or 42
48 39 or 43
49 44 not 40
50 46 and 47 and 48 and 49
Embase Footnote 2
#1 'virtual realit*':ab,ti
#2 'virtual environment*':ab,ti
#3 'augmented realit*':ab,ti
#4 'mixed realit*':ab,ti
#5 'video gam*':ab,ti
#6 exergam*:ab,ti
#7 'serious gam*':ab,ti
#8 Kinect:ab,ti
#9 wii:ab,ti
#10 ('head mounted' NEAR/5 devic*):ab,ti
#11 ('head mounted' NEAR/5 displa*):ab,ti
#12 'smart glass*':ab,ti
#13 smartglass*:ab,ti
#14 arm*:ab,ti
#15 hand*:ab,ti
#16 'upper limb*':ab,ti
#17 'upper extremit*':ab,ti
#18 stroke:ab,ti
#19 'post-stroke':ab,ti
#20 poststroke:ab,ti
#21 'cerebral vascular acciden*':ab,ti
#22 'cerebral vascular event*':ab,ti
#23 'cerebrovascular acciden*':ab,ti
#24 'cerebrovascular event*':ab,ti
#25 hemiplegi*:ab,ti
#26 hemiparesis:ab,ti
#27 'randomized controlled trial'/de
#28 'controlled clinical trial'/de
#29 random*:ti,ab,tt
#30 'randomization'/de
#31 'intermethod comparison'/de
#32 placebo:ti,ab,tt
#33 compare:ti,tt OR compared:ti,tt OR comparison:ti,tt
#34 (evaluated:ab OR evaluate:ab OR evaluating:ab OR assessed:ab OR assess:ab) AND (compare:ab OR compared:ab OR comparing:ab OR comparison:ab)
#35 (open NEXT/1 label):ti,ab,tt
#36 ((double OR single OR doubly OR singly) NEXT/1 (blind OR blinded OR blindly)):ti,ab,tt.
#37 'double blind procedure'/de
#38 (parallel NEXT/1 group*):ti,ab,tt
#39 crossover:ti,ab,tt OR 'cross over':ti,ab,tt
#40 ((assign* OR match OR matched OR allocation) NEAR/6 (alternate OR group OR groups OR intervention OR interventions OR patient OR patients OR subject OR subjects OR participant OR participants)):ti,ab,tt
#41 assigned:ti,ab,tt OR allocated:ti,ab,tt
#42 (controlled NEAR/8 (study OR design OR trial)):ti,ab,tt
#43 volunteer:ti,ab,tt OR volunteers:ti,ab,tt
#44 'human experiment'/de
#45 trial:ti,tt
#46 ((random* NEXT/1 sampl* NEAR/8 ('cross section*' OR questionnaire* OR survey OR surveys OR database OR databases)):ti,ab,tt) NOT ('comparative study'/de OR 'controlled study'/de OR 'randomised controlled':ti,ab,tt OR 'randomized controlled':ti,ab,tt OR 'randomly assigned':ti,ab,tt)
#47 'cross‐sectional study' NOT ('randomized controlled trial'/de OR 'controlled clinical study'/de OR 'controlled study'/de OR 'randomised controlled':ti,ab,tt OR 'randomized controlled':ti,ab,tt OR 'control group':ti,ab,tt OR 'control groups':ti,ab,tt)
#48 'case control*':ti,ab,tt AND random*:ti,ab,tt NOT ('randomised controlled':ti,ab,tt OR 'randomized controlled':ti,ab,tt)
#49 'systematic review':ti,tt NOT (trial:ti,tt OR study:ti,tt)
#50 nonrandom*:ti,ab,tt NOT random*:ti,ab,tt
#51 'random field*':ti,ab,tt
#52 ('random cluster' NEAR/4 sampl*):ti,ab,tt
#53 review:ab AND review:it NOT trial:ti,tt
#54 'we searched':ab AND (review:ti,tt OR review:it)
#55 'update review':ab
#56 (databases NEAR/5 searched):ab
#57 (rat:ti,tt OR rats:ti,tt OR mouse:ti,tt OR mice:ti,tt OR swine:ti,tt OR porcine:ti,tt OR murine:ti,tt OR sheep:ti,tt OR lambs:ti,tt OR pigs:ti,tt OR piglets:ti,tt OR rabbit:ti,tt OR rabbits:ti,tt OR cat:ti,tt OR cats:ti,tt OR dog:ti,tt OR dogs:ti,tt OR cattle:ti,tt OR bovine:ti,tt OR monkey:ti,tt OR monkeys:ti,tt OR trout:ti,tt OR marmoset*:ti,tt) AND 'animal experiment'/de
#58 'animal experiment'/de NOT ('human experiment'/de OR 'human'/de)
#59 'virtual reality'/exp
#60 'virtual environment'/exp
#61 'augmented reality'/exp
#62 'mixed reality'/exp
#63 'video game'/exp
#64 'serious game'/exp
#65 'head-mounted display'/exp
#66 'hand'/exp
#67 'upper limb'/exp
#68 'cerebrovascular accident'/exp
#69 'cerebrovascular event'/exp
#70 'hemiplegia'/exp
#71 'hemiparesis'/exp
#72 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13
#73 #14 OR #15 OR #16 OR #17
#74 #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26
#75 #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #45
#76 #46 OR #47 OR #48 OR #49 OR #50 OR #51 OR #52 OR #53 OR #54 OR #55 OR #56 OR #57 OR #58
#77 #59 OR #60 OR #61 OR #62 OR #63 OR #64 OR #65
#78 #66 OR #67
#79 #68 OR #69 OR #70 OR #71
#80 #72 OR #77
#81 #73 OR #78
#82 #74 OR #79
#83 #75 NOT #76
#84 #80 AND #81 AND #82 AND #83
CINAHL Plus Footnote 3
S1 TI (virtual realit*) OR AB (virtual realit*)
S2 TI (virtual environment*) OR AB (virtual environment*)
S3 TI (augmented realit*) OR AB (augmented realit*)
S4 TI (mixed realit*) OR AB (mixed realit*)
S5 TI (video gam*) OR AB (video gam*)
S6 TI (exergam*) OR AB (exergam*)
S7 TI (serious gam*) OR AB (serious gam*)
S8 TI Kinect OR AB Kinect
S9 TI Wii OR AB Wii
S10 TI ((head mounted) N5 (devic*)) OR AB ((head mounted) N5 (devic*))
S11 TI ((head mounted) N5 (displa*)) OR AB ((head mounted) N5 (displa*))
S12 TI (smart glass*) OR AB (smart glass*)
S13 TI (smartglass*) OR AB (smartglass*)
S14 TI (arm*) OR AB (arm*)
S15 TI (hand*) OR AB (hand*)
S16 TI (upper limb*) OR AB (upper limb*)
S17 TI (upper extremit*) OR AB (upper extremit*)
S18 TI stroke OR AB stroke
S19 TI post-stroke OR AB post-stroke
S20 TI poststroke OR AB poststroke
S21 TI (cerebral vascular acciden*) OR AB (cerebral vascular acciden*)
S22 TI (cerebral vascular event*) OR AB (cerebral vascular event*)
S23 TI (cerebrovascular acciden*) OR AB (cerebrovascular acciden*)
S24 TI (cerebrovascular event*) OR AB (cerebrovascular event*)
S25 TI (hemiplegi*) OR AB (hemiplegi*)
S26 TI hemiparesis OR AB hemiparesis
S27 MH randomized controlled trials
S28 MH double‐blind studies
S29 MH single‐blind studies
S30 MH random assignment
S31 MH pretest‐posttest design
S32 MH cluster sample
S33 TI (randomised OR randomized)
S34 AB (random*)
S35 TI (trial)
S36 MH (sample size) AND AB ( assigned OR allocated OR control)
S37 MH (placebos)
S38 PT (randomized controlled trial)
S39 AB (control W5 group)
S40 MH (crossover design) OR MH (comparative studies)
S41 AB (cluster W3 RCT)
S42 MH animals +
S43 MH (animal studies)
S44 TI (animal model*)
S45 MH (human)
S46 MH (Virtual Reality +)
S47 MH (Augmented Reality)
S48 MH (Video Games +)
S49 MH (Smart Glasses)
S50 MH (Upper Extremity +)
S51 MH (Stroke +)
S52 MH (Hemiplegia)
S53 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13
S54 S14 OR S15 OR S16 OR S17
S55 S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26
S56 S27 OR S28 OR S29 OR S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38 OR S39 OR S40 OR S41
S57 S42 OR S43 OR S44
S58 S57 NOT S45
S59 S56 NOT S58
S60 S46 OR S47 OR S48 OR S49
S61 S51 OR S52
S62 S53 OR S60
S63 S50 OR S54
S64 S55 OR S61
S65 S59 AND S62 AND S63 AND S64
APA PsycInfo Footnote 4
S1 TI (virtual realit*) OR AB (virtual realit*)
S2 TI (virtual environment*) OR AB (virtual environment*)
S3 TI (augmented realit*) OR AB (augmented realit*)
S4 TI (mixed realit*) OR AB (mixed realit*)
S5 TI (video gam*) OR AB (video gam*)
S6 TI (exergam*) OR AB (exergam*)
S7 TI (serious gam*) OR AB (serious gam*)
S8 TI Kinect OR AB Kinect
S9 TI Wii OR AB Wii
S10 TI ((head mounted) N5 (devic*)) OR AB ((head mounted) N5 (devic*))
S11 TI ((head mounted) N5 (displa*)) OR AB ((head mounted) N5 (displa*))
S12 TI (smart glass*) OR AB (smart glass*)
S13 TI (smartglass*) OR AB (smartglass*)
S14 TI (arm*) OR AB (arm*)
S15 TI (hand*) OR AB (hand*)
S16 TI (upper limb*) OR AB (upper limb*)
S17 TI (upper extremit*) OR AB (upper extremit*)
S18 TI stroke OR AB stroke
S19 TI post-stroke OR AB post-stroke
S20 TI poststroke OR AB poststroke
S21 TI (cerebral vascular acciden*) OR AB (cerebral vascular acciden*)
S22 TI (cerebral vascular event*) OR AB (cerebral vascular event*)
S23 TI (cerebrovascular acciden*) OR AB (cerebrovascular acciden*)
S24 TI (cerebrovascular event*) OR AB (cerebrovascular event*)
S25 TI (hemiplegi*) OR AB (hemiplegi*)
S26 TI hemiparesis OR AB hemiparesis
S27 SU.EXACT(Treatment Effectiveness Evaluation)
S28 SU.EXACT.EXPLODE(Treatment Outcomes)
S29 SU.EXACT(Placebo)
S30 SU.EXACT(Followup Studies)
S31 (placebo*)
S32 (random*)
S33 (comparative stud*)
S34 (clinical N3 trial*)
S35 (research N3 design)
S36 (evaluat* N3 stud*)
S37 (prospectiv* N3 stud*)
S38 (singl* OR doubl* OR trebl* OR tripl*) N3 (blind* OR mask*)
S39 DE (Virtual Reality) OR DE (Augmented Reality)
S40 MM (Computer Games)
S41 MM "Arm (Anatomy)"
S42 DE "Hand (Anatomy)" OR DE "Fingers (Anatomy)" OR DE "Palm (Anatomy)"
S43 MM (Cerebrovascular Accidents)
S44 MM (Hemiparesis) OR MM (Hemiplegia)
S45 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13
S46 S14 OR S15 OR S16 OR S17
S47 S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26
S48 S27 OR S28 OR S29 OR S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38
S49 S39 OR S40
S50 S41 OR S42
S51 S43 OR S44
S52 S45 OR S49
S53 S46 OR S50
S54 S47 OR S51
S55 S48 AND S52 AND S53 AND S54
Scopus Footnote 5
( ( ( TITLE ( "virtual realit*") OR ABS ( "virtual realit*"))) OR ( ( TITLE ( "virtual environment*") OR ABS ( "virtual environment*"))) OR ( ( TITLE ( "augmented realit*") OR ABS ( "augmented realit*"))) OR ( ( TITLE ( "mixed realit*") OR ABS ( "mixed realit*"))) OR ( ( TITLE ( "video gam*") OR ABS ( "video gam*"))) OR ( ( TITLE ( exergam*) OR ABS ( exergam*))) OR ( ( TITLE ( "serious gam*") OR ABS ( "serious gam*"))) OR ( ( TITLE ( kinect) OR ABS ( kinect))) OR ( ( TITLE ( wii) OR ABS ( wii))) OR ( ( TITLE ( "head mounted" W/5 devic*) OR ABS ( "head mounted" W/5 devic*))) OR ( ( TITLE ( "head mounted" W/5 displa*) OR ABS ( "head mounted" W/5 displa*))) OR ( ( TITLE ( "smart glass*") OR ABS ( "smart glass*"))) OR ( ( TITLE ( smartglass*) OR ABS ( smartglass*)))) AND ( ( ( TITLE ( arm*) OR ABS ( arm*))) OR ( ( TITLE ( hand*) OR ABS ( hand*))) OR ( ( TITLE ( "upper limb*") OR ABS ( "upper limb*"))) OR ( ( TITLE ( "upper extremit*") OR ABS ( "upper extremit*")))) AND ( ( ( TITLE ( *stroke) OR ABS ( *stroke))) OR ( ( TITLE ( "cerebral vascular acciden*") OR ABS ( "cerebral vascular acciden*"))) OR ( ( TITLE ( "cerebral vascular event*") OR ABS ( "cerebral vascular event*"))) OR ( ( TITLE ( "cerebrovascular acciden*") OR ABS ( "cerebrovascular acciden*"))) OR ( ( TITLE ( "cerebrovascular event*") OR ABS ( "cerebrovascular event*"))) OR ( ( TITLE ( hemiplegi*) OR ABS ( hemiplegi*))) OR ( ( TITLE ( hemiparesis) OR ABS ( hemiparesis)))) AND ( ( INDEXTERMS ( "clinical trials" OR "clinical trials as a topic" OR "randomized controlled trial" OR "Randomized Controlled Trials as Topic" OR "controlled clinical trial" OR "Controlled Clinical Trials" OR "random allocation" OR "Double-Blind Method" OR "Single-Blind Method" OR "Cross-Over Studies" OR "Placebos" OR "multicenter study" OR "double blind procedure" OR "single blind procedure" OR "crossover procedure" OR "clinical trial" OR "controlled study" OR "randomization" OR "placebo")) OR ( TITLE-ABS-KEY ( ( "clinical trials" OR "clinical trials as a topic" OR "randomized controlled trial" OR "Randomized Controlled Trials as Topic" OR "controlled clinical trial" OR "Controlled Clinical Trials as Topic" OR "random allocation" OR "randomly allocated" OR "allocated randomly" OR "Double-Blind Method" OR "Single-Blind Method" OR "Cross-Over Studies" OR "Placebos" OR "cross-over trial" OR "single blind" OR "double blind" OR "factorial design" OR "factorial trial"))) OR ( TITLE-ABS ( clinical AND trial* OR trial* OR rct* OR random* OR blind*)))
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Hao, J., He, Z., Yu, X. et al. Comparison of immersive and non-immersive virtual reality for upper extremity functional recovery in patients with stroke: a systematic review and network meta-analysis. Neurol Sci 44, 2679–2697 (2023). https://doi.org/10.1007/s10072-023-06742-8
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DOI: https://doi.org/10.1007/s10072-023-06742-8