Examining the effectiveness of virtual, augmented, and mixed reality (VAMR) therapy for upper limb recovery and activities of daily living in stroke patients: a systematic review and meta-analysis

Quadruple uselessness:

1. No protocols were written on this.

2. Your hospital will never expend the money on virtual reality.

3. Your hospital doesn't even know about this research.

4. Further research suggested, so the research was not planned correctly
   

Examining the effectiveness of virtual, augmented, and mixed reality (VAMR) therapy for upper limb recovery and activities of daily living in stroke patients: a systematic review and meta-analysis

• Sze Chit Leong,
• Yuk Ming Tang,
• Fong Mei Toh &
• Kenneth N. K. Fong 

Journal of NeuroEngineering and Rehabilitation volume 19, Article number: 93 (2022) Cite this article

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Abstract

Introduction

Virtual reality (VR), augmented reality (AR), and mixed reality (MR) are emerging technologies in the field of stroke rehabilitation that have the potential to overcome the limitations of conventional treatment. Enhancing upper limb (UL) function is critical in stroke impairments because the upper limb is involved in the majority of activities of daily living (ADL).

Methods

This study reviewed the use of virtual, augmented and mixed reality (VAMR) methods for improving UL recovery and ADL, and compared the effectiveness of VAMR treatment to conventional rehabilitation therapy. The databases ScienceDirect, PubMed, IEEE Xplore, and Web of Science were examined, and 50 randomized control trials comparing VAMR treatment to standard therapy were determined. The random effect model and fixed effect model are applied based on heterogeneity.

Results

The most often used outcomes of UL recovery and ADL in stroke rehabilitation were the Fugl-Meyer Assessment for Upper Extremities (FMA-UE), followed by the Box and Block Test (BBT), the Wolf Motor Function Test (WMFT), and the Functional Independence Measure (FIM). According to the meta-analysis, VR, AR, and MR all have a significant positive effect on improving FMA-UE for UL impairment (36 studies, MD = 3.91, 95 percent CI = 1.70–6.12, P = 0.0005) and FIM for ADL (10 studies, MD = 4.25, 95 percent CI = 1.47–7.03, P = 0.003), but not on BBT and WMFT for the UL function tests (16 studies, MD = 2.07, 95 percent CI = − 0.58–4.72, P = 0.13),

Conclusions

VAMR therapy was superior to conventional treatment in UL impairment and daily function outcomes, but not UL function measures. Future studies might include further high-quality trials examining the effect of VR, AR, and MR on UL function measures, with an emphasis on subgroup meta-analysis by stroke type and recovery stage.

Background

Stroke is the world’s second greatest cause of death and the third-leading cause of disability in adults, and 80 million people worldwide suffer from the effect of a stroke [1]. Many stroke survivors suffer from a series of neurological sequelae, including physical, cognitive, and communication disorders. After a stroke, upper limb (UL) motor impairments are common, affecting approximately 80% of stroke survivors [2]. Full recovery of the hemiplegic upper limb function is difficult for most stroke survivors/patients, and this severely impairs their activities of daily living (ADL) and social involvement [3]. Enhancing the functional use of the upper limb after a stroke is important [4] because most tasks in everyday life involve the use of the upper limbs.

Despite the fact that conventional rehabilitation treatment has been shown to provide long-term benefits, patients are usually required to participate in very long-term treatments, and the results may vary depending on the experience of the individual therapists [5]. Patients, on the other hand, can lose motivation for treatment adherence since the treatment movements become tiresome and monotonous with time [6]. The emergence of innovative technologies, including virtual reality (VR), augmented reality (AR) and mixed reality (MR), has improved the conventional rehabilitation environment [7]. These new ways of treatment are valuable and provide substantial benefits not only to motivate patients to participate in long-term treatments but also to standardize the quality of treatment for stroke survivors [8, 9].

For VR therapy, a virtual environment resembling a human is constructed utilizing computer technology. Virtual reality is evolving tremendously, providing increasingly realistic virtual settings, which the user simply accepts while employing these therapies to induce recovery [10], while AR enables individuals to interact with virtual models with the use of a smart device such as a smartphone or tablet. The integration of the actual and virtual worlds enabled by augmented reality has the potential to enable humans to uncover abstract theories, phenomena, processes, and behaviors, as well as characteristics that are generally unavailable in a conventional clinical setting [11]. AR has been recognized as an emerging technology that, due to its ability to facilitate intense, repetitive and context-specific rehabilitation, can improve recovery after stroke [12]. For MR therapy, new digital technology in smart healthcare refers to a new type of environmental visualization created by fusing the actual world and the virtual digital world, in which physical entities and digital things can coexist and interact in real-time [13]. The MR system’s interactive media-based feedback provides an engaging medium for intuitively communicating performance and supporting the stroke survivor’s self-assessment [14].

For the early stages of recovery after stroke, virtual reality-based rehabilitation has received attention as a way to fill the gap between the real and ideal world due to its ability to provide high-intensity, repetitive and task-oriented training, as referenced by Kleim et al. [15]. In addition, Cho et al. [16] showed that the developed VR system can improve the motor control of stroke patients after VR proprioception feedback training. Virtual reality-based rehabilitation has shown similar progress to traditional physical therapy and occupational therapy [17]. Furthermore, this technology is an effective, feasible, and safe approach that simplifies rehabilitation compared to conventional rehabilitation, and creates a flexible and user-friendly interactive technique for demonstrating complicated and perplexing concepts [18]. With high-resolution medical consultation procedures and therapies, VR technology in medical applications can also help improve today’s healthcare systems [19]. Furthermore, a VAMR rehabilitation system provides a close collaborative system with high creativity, enhancing motor movements and minimizing the risk of patients feeling that the treatment is becoming tiresome and monotonous with time [20, 21]. The MR system’s evaluation and customizable feedback capabilities also allow clinicians to provide effective personalized training to patients [14].

As such, numerous systematic reviews have been undertaken to investigate the effectiveness of virtual reality on stroke rehabilitation. Wiley et al. [22] reviewed the use of VR technology that focused on the improvement of cognition and function, including global cognition, attention, memory, and language tests, however with a small number of studies covered, the meta-analysis results were highly affected by studies with a large population, causing lower accuracy. Another review conducted by Lee et al. [23], mainly investigated the effects of function in stroke patients. In their study, most of the cases included used game programs in VR intervention groups, which is less diverse. In addition to a review by Chen et al. [24], it analyzed the effects of balance control in stroke. Only nine studies were used, and most of the study groups had a relatively small sample size. Since it lacked external validity, the recorded results may not be relevant to a broader population. Moreno et al. [25] provided another overview of the literature on describing VR technology information for stroke rehabilitation. However, no quantitative analysis of the impacts was conducted, and the instruments and measures employed in the intervention were not been described. Therefore, we review the VAMR training that has effects on the recovery of upper limb function and ADL in order to generalize the findings. Our research is not only focused on the use of general virtual and augmented realities in rehabilitation treatment, but also includes the application of MR in order to investigate the impact of treatments using immersive technologies.

VR therapy is proven to be a worthwhile treatment for stroke patients, and our review aimed to address the following key research questions:

• RQ1: How virtual, augmented and mixed realities are used as interventions to improve hemiparetic UL function and ADL after stroke;

• RQ2: How does the effectiveness of VAMR therapies compare with conventional rehabilitation treatment for UL function after a stroke by meta-analysis.

This review has significant contributions: (1) not only in the review of VR and AR stroke rehabilitation, but also in investigating how MR can be used for rehabilitation; and (2) identification of the stroke outcome measurement scales used for the VAMR interventions. This study investigates VAMR on upper limb stroke rehabilitation, while fewer MR studies have been investigated in previous studies. More MR studies are included in the paper, examining the effects of the use of MR, identifying their significance and limitations, thus enhancing more future ideas for using MR for upper limb stroke rehabilitation. Furthermore, it is important to identify the most commonly used measures having high reliability for VAMR studies, so further research can focus on their advantages and limitations.