I can't quite see how survivors can afford this.
The efficacy of virtual reality for upper limb rehabilitation in stroke patients: a systematic review and meta-analysis
BMC Medical Informatics and Decision Making volume 24, Article number: 135 (2024)
Abstract
Background
Stroke frequently gives rise to incapacitating motor impairments in the upper limb. Virtual reality (VR) rehabilitation has exhibited potential for augmenting upper extremity recovery; nonetheless, the optimal techniques for such interventions remain a topic of uncertainty. The present systematic review and meta-analysis were undertaken to comprehensively compare VR-based rehabilitation with conventional occupational therapy across a spectrum of immersion levels and outcome domains.
Methods
A systematic search was conducted in PubMed, IEEE, Scopus, Web of Science, and PsycNET databases to identify randomized controlled trials about upper limb rehabilitation in stroke patients utilizing VR interventions. The search encompassed studies published in the English language up to March 2023. The identified studies were stratified into different categories based on the degree of immersion employed: non-immersive, semi-immersive, and fully-immersive settings. Subsequent meta-analyses were executed to assess the impact of VR interventions on various outcome measures.
Results
Of the 11,834 studies screened, 55 studies with 2142 patients met the predefined inclusion criteria. VR conferred benefits over conventional therapy for upper limb motor function, functional independence, Quality of life, Spasticity, and dexterity. Fully immersive VR showed the greatest gains in gross motor function, while non-immersive approaches enhanced fine dexterity. Interventions exceeding six weeks elicited superior results, and initiating VR within six months post-stroke optimized outcomes.
Conclusions
This systematic review and meta-analysis demonstrates that adjunctive VR-based rehabilitation enhances upper limb motor recovery across multiple functional domains compared to conventional occupational therapy alone after stroke. Optimal paradigms likely integrate VR’s immersive capacity with conventional techniques.
Trial registration
This systematic review and meta-analysis retrospectively registered in the OSF registry under the identifier [https://doi.org/10.17605/OSF.IO/YK2RJ].
Introduction
Stroke remains a major global health concern as the second leading cause of mortality and disability worldwide [1]. In 2019, stroke accounted for approximately 11% of all deaths and was the second leading cause of combined death and disability [2]. The risk of stroke rises markedly with age, with 67% of strokes occurring in individuals over 70 years old [3]. Men have a higher incidence compared to women across most age groups [4]. Stroke frequently engenders serious long-term impairment, including hemiplegia, aphasia, vision deficits, and cognitive dysfunction [5]. In particular, upper limb motor dysfunction represents one of the most common and debilitating consequences of stroke, affecting around 80% of survivors [6]. Upper limb motor dysfunction, manifesting as impaired arm and hand function, frequently disrupts the performance of activities of daily living, occupational tasks, and overall quality of life for stroke survivors. Only 5–20% of patients fully recover upper limb function, with nearly half developing chronic spasticity [7]. Effective rehabilitation is therefore paramount for optimizing the recovery of upper limb motor control and performance of functional tasks [8].
Rehabilitation plays a pivotal role in harnessing neuroplasticity and facilitating cortical reorganization, which are essential mechanisms aiding patients in regaining lost skills and fostering the development of compensatory techniques [9]. The significance of early intervention in the rehabilitation process has consistently demonstrated a strong correlation with improved functional outcomes in stroke patients [8]. Within the realm of upper limb rehabilitation, multiple facets warrant meticulous assessment to tailor therapeutic strategies effectively. Several assessment tools have been devised to evaluate distinct dimensions of upper limb recovery. These encompass assessments of motor function, exemplified by the Fugl-Meyer assessment scale (FMA), the Action Research Arm Test (ARAT), and the Wolf Motor Function Test (WMFT). Furthermore, evaluations of independence are essential, with assessments like the Barthel Index (BI) and the Functional Independence Measure serving as valuable instruments. The Box and Block Test (BBT) is a valuable metric for dexterity. Spasticity, a common post-stroke concern, can be assessed using the Modified Ashworth Scale (MAS). Finally, to comprehensively gauge the overall impact of a stroke, the Stroke Impact Scale (SIS) provides a holistic perspective. Incorporating these diverse assessment tools into the rehabilitation process empowers healthcare professionals to tailor interventions precisely, optimizing the recovery trajectory and enhancing the quality of life for stroke survivors.
Upper limb rehabilitation encompasses diverse approaches tailored to patients’ needs after stroke and injury [10]. Physical and occupational therapies provide structured exercises to restore motor skills, range of motion, and activities of daily living [8]. Constraint-induced movement therapy promotes neuroplasticity by restraining the unaffected limb to force the use of the affected limb [11]. Technology-assisted interventions have gained prominence, including virtual reality (VR) with immersive simulated environments for engaging therapy activities, interactive video games that increase motivation, telerehabilitation allowing remote participation for improved access, and robotic devices offering customizable assistance for progressive exercise [6, 12].
VR involves interactive simulation using computer hardware and software to generate immersive 3D environments for rehabilitation activities [12]. VR systems are categorized into three levels of immersion including fully immersive (completely blocking real-world perception), non-immersive (allowing concurrent real and virtual environments), and semi-immersive (using screens or headsets for partial immersion) [12, 13]. Potential advantages of VR for rehabilitation include enhanced user engagement, increased repetitions, and promoted independence [6]; however, challenges remain regarding requisite technology skills, costs, and cyber-sickness [5, 14]. The extant corpus of scholarly research offers preliminary indications regarding the potential efficacy of VR interventions in augmenting upper limb functionality and real-world task performance among individuals afflicted with stroke [15]. Nevertheless, a compelling imperative exists for more exhaustive investigations in this domain. These investigations ought to encompass a diverse array of VR systems and a multitude of upper limb outcome assessment instruments, each designed to discern distinct facets of the post-stroke recovery process.
Despite numerous systematic reviews examining the efficacy of VR systems for upper limb rehabilitation post-stroke [16], salient gaps in the literature remain unaddressed. First, there is a scarcity of meta-analytic studies directly comparing the efficacy of various VR paradigms utilizing different levels of immersion with conventional therapies in improving motor deficits across the entire upper limb post-stroke [17,18,19,20,21,22,23,24,25,26,27,28,29,30]. This obscures conclusions regarding the comparative efficacy of varied levels of VR immersion. Second, extant research has predominantly focused on upper limb activity outcomes, with limited emphasis on VR’s potential to improve performance in all functional autonomy in real-world settings [28]. This restricts the understanding of VR’s broader rehabilitative utility. Finally, a comprehensive appraisal of methodological rigor and risk of bias is lacking in the burgeoning corpus of literature evaluating VR in post-stroke upper limb rehabilitation. While VR shows promise in post-stroke rehabilitation, the rapid pace of technological advances demands rigorous assessment of new VR methods to determine optimal protocols for upper limb recovery. Previous studies have relied heavily on older VR systems and techniques, which may not harness the full potential of modern advancements in the field. The current systematic review and meta-analysis aim to address these limitations by synthesizing studies contrasting different VR systems categorized by immersion level against conventional interventions across various upper limb functional domains. By delineating the effectiveness of diverse VR paradigms compared to traditional approaches across the spectrum of upper limb disability post-stroke, this review seeks to elucidate the optimal utilization of VR to maximize upper extremity recoveries for stroke survivors. The findings shall inform the development of targeted rehabilitation protocols harnessing VR technologies for ameliorating upper limb impairments after stroke.
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