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Impact of the combination of virtual reality and noninvasive brain stimulation on the upper limb motor function of stroke patients: a systematic review and meta-analysis
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 179 (2024)
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 179 (2024)
Abstract
Background
Stroke frequently results in upper limb motor dysfunction, with traditional therapies often failing to yield sufficient improvements. Emerging technologies such as virtual reality (VR) and noninvasive brain stimulation (NIBS) present promising new rehabilitation possibilities.
Stroke frequently results in upper limb motor dysfunction, with traditional therapies often failing to yield sufficient improvements. Emerging technologies such as virtual reality (VR) and noninvasive brain stimulation (NIBS) present promising new rehabilitation possibilities.
Objectives
This study systematically reviews and meta-analyses the effectiveness of VR and NIBS in improving upper limb motor function in stroke patients.
This study systematically reviews and meta-analyses the effectiveness of VR and NIBS in improving upper limb motor function in stroke patients.
Methods
Registered with PROSPERO (CRD42023494220) and adhering to the PRISMA guidelines, this study conducted a thorough search of databases including PubMed, MEDLINE, PEDro, REHABDATA, EMBASE, Web of Science, Cochrane, CNKI, Wanfang, and VIP from 2000 to December 1, 2023, to identify relevant studies. The inclusion criterion was stroke patients receiving combined VR and NIBS treatment, while exclusion criteria were studies with incomplete articles and data. The risk of bias was assessed using the Cochrane Collaboration tool. Statistical analysis was performed using Stata SE 15.0, employing either a fixed-effects model or a random-effects model based on the level of heterogeneity.
Registered with PROSPERO (CRD42023494220) and adhering to the PRISMA guidelines, this study conducted a thorough search of databases including PubMed, MEDLINE, PEDro, REHABDATA, EMBASE, Web of Science, Cochrane, CNKI, Wanfang, and VIP from 2000 to December 1, 2023, to identify relevant studies. The inclusion criterion was stroke patients receiving combined VR and NIBS treatment, while exclusion criteria were studies with incomplete articles and data. The risk of bias was assessed using the Cochrane Collaboration tool. Statistical analysis was performed using Stata SE 15.0, employing either a fixed-effects model or a random-effects model based on the level of heterogeneity.
Results
A total of 11 studies involving 493 participants were included, showing a significant improvement in Fugl-Meyer Assessment Upper Extremity (FMA-UE) scores in the combined treatment group compared to the control group (SMD = 0.85, 95% CI [0.40, 1.31], p = 0.017). The Modified Ashworth Scale (MAS) scores significantly decreased (SMD = − 0.51, 95% CI [− 0.83, − 0.20], p = 0.032), the Modified Barthel Index (MBI) scores significantly increased (SMD = 0.97, 95% CI [0.76, 1.17], p = 0.004), and the Wolf Motor Function Test (WMFT) scores also significantly increased (SMD = 0.36, 95% CI [0.08, 0.64], p = 0.021). Subgroup analysis indicated that the duration of treatment influenced the outcomes in daily living activities.
A total of 11 studies involving 493 participants were included, showing a significant improvement in Fugl-Meyer Assessment Upper Extremity (FMA-UE) scores in the combined treatment group compared to the control group (SMD = 0.85, 95% CI [0.40, 1.31], p = 0.017). The Modified Ashworth Scale (MAS) scores significantly decreased (SMD = − 0.51, 95% CI [− 0.83, − 0.20], p = 0.032), the Modified Barthel Index (MBI) scores significantly increased (SMD = 0.97, 95% CI [0.76, 1.17], p = 0.004), and the Wolf Motor Function Test (WMFT) scores also significantly increased (SMD = 0.36, 95% CI [0.08, 0.64], p = 0.021). Subgroup analysis indicated that the duration of treatment influenced the outcomes in daily living activities.
Conclusions
The combination of VR and NIBS demonstrates significant improvements in upper limb motor function in stroke patients. The duration of treatment plays a critical role in influencing the outcomes, particularly in activities of daily living. This systematic review has limitations, including language bias, unclear randomization descriptions, potential study omissions, and insufficient follow-up periods. Future studies should focus on exploring long-term effects and optimizing treatment duration to maximize the benefits of combined VR and NIBS therapy.
The combination of VR and NIBS demonstrates significant improvements in upper limb motor function in stroke patients. The duration of treatment plays a critical role in influencing the outcomes, particularly in activities of daily living. This systematic review has limitations, including language bias, unclear randomization descriptions, potential study omissions, and insufficient follow-up periods. Future studies should focus on exploring long-term effects and optimizing treatment duration to maximize the benefits of combined VR and NIBS therapy.
Introduction
Motor dysfunction is a common post-stroke complication with recovery of the affected upper limb typically being more limited than that of the lower limb due to its inherent flexibility [1]. Approximately 50–60% of stroke patients experience residual upper limb impairment after traditional physical therapy, which significantly impacts their daily life [2]. Since hand function is closely related to activities such as using a mobile phone, eating, and writing, its rehabilitation is crucial for overall well-being [3]. The motor relearning program after stroke is affected by various factors, including training intensity, task specificity, motivation, and feedback [4]. However, traditional rehabilitation approaches that focus primarily on repetition and intensity may not optimally restore neural plasticity and address the diverse needs of stroke patients [5].
Emerging technologies have shown promise in overcoming these limitations and enhancing physical function recovery. Among these, noninvasive brain stimulation (NIBS) has proven effective in enhancing neuroplasticity and facilitating stroke recovery [6]. Techniques like transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS) use electrical and magnetic energy to modulate cortical excitability noninvasively, inducing sustained neuroplasticity changes [7]. The application of repetitive transcranial magnetic stimulation (rTMS) triggers neuronal growth in the brain, leading to the initiation of novel action potentials [8]. Studies have demonstrated the benefits of rTMS for upper limb rehabilitation in stroke patients across different stages of recovery [9], while tDCS has been shown to improve upper limb motor function in chronic stroke patients [10].
Similarly, virtual reality (VR) is increasingly effective in motor function recovery and neuroexcitation. VR training robustly engages key brain regions, including the prefrontal lobe and motor networks, driving significant improvements in motor function and spatial awareness [11].VR can be immersive or non-immersive, depending on the user’s isolation from the physical environment during interaction [12]. Recent studies indicate that VR is beneficial for post-stroke rehabilitation, with positive effects comparable to traditional treatments [13, 14]. Karamians et al. highlighted VR-based rehabilitation as potentially more effective than traditional training methods for upper limb recovery in stroke patients [15].
When combined, noninvasive brain stimulation [16] and virtual reality [17] can synergistically provide personalized training programs that encourage upper limb movement post-stroke. This integrated approach offers a more engaging and personalized rehabilitation experience, potentially overcoming the limitations of conventional therapeutic methods. Previous studies have confirmed the effectiveness of combined VR and NIBS therapy for upper limb rehabilitation in stroke patients [18,19,20]. Moreover, a meta-analysis showed that adding tDCS to VR-mediated movement observation and performance tasks enhances movement improvement after stroke [20].
Considering the limitations of previous meta-analysis, which included a limited number of studies and lacked quality assessment, this study aimed to analyze the current scientific evidence on combined VR and NIBS therapy for restoring upper limb motor function post-stroke. By expanding the range of databases and incorporating quality assessments, this research aims to provide a more comprehensive and reliable evaluation of the combined therapy’s efficacy.
Motor dysfunction is a common post-stroke complication with recovery of the affected upper limb typically being more limited than that of the lower limb due to its inherent flexibility [1]. Approximately 50–60% of stroke patients experience residual upper limb impairment after traditional physical therapy, which significantly impacts their daily life [2]. Since hand function is closely related to activities such as using a mobile phone, eating, and writing, its rehabilitation is crucial for overall well-being [3]. The motor relearning program after stroke is affected by various factors, including training intensity, task specificity, motivation, and feedback [4]. However, traditional rehabilitation approaches that focus primarily on repetition and intensity may not optimally restore neural plasticity and address the diverse needs of stroke patients [5].
Emerging technologies have shown promise in overcoming these limitations and enhancing physical function recovery. Among these, noninvasive brain stimulation (NIBS) has proven effective in enhancing neuroplasticity and facilitating stroke recovery [6]. Techniques like transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS) use electrical and magnetic energy to modulate cortical excitability noninvasively, inducing sustained neuroplasticity changes [7]. The application of repetitive transcranial magnetic stimulation (rTMS) triggers neuronal growth in the brain, leading to the initiation of novel action potentials [8]. Studies have demonstrated the benefits of rTMS for upper limb rehabilitation in stroke patients across different stages of recovery [9], while tDCS has been shown to improve upper limb motor function in chronic stroke patients [10].
Similarly, virtual reality (VR) is increasingly effective in motor function recovery and neuroexcitation. VR training robustly engages key brain regions, including the prefrontal lobe and motor networks, driving significant improvements in motor function and spatial awareness [11].VR can be immersive or non-immersive, depending on the user’s isolation from the physical environment during interaction [12]. Recent studies indicate that VR is beneficial for post-stroke rehabilitation, with positive effects comparable to traditional treatments [13, 14]. Karamians et al. highlighted VR-based rehabilitation as potentially more effective than traditional training methods for upper limb recovery in stroke patients [15].
When combined, noninvasive brain stimulation [16] and virtual reality [17] can synergistically provide personalized training programs that encourage upper limb movement post-stroke. This integrated approach offers a more engaging and personalized rehabilitation experience, potentially overcoming the limitations of conventional therapeutic methods. Previous studies have confirmed the effectiveness of combined VR and NIBS therapy for upper limb rehabilitation in stroke patients [18,19,20]. Moreover, a meta-analysis showed that adding tDCS to VR-mediated movement observation and performance tasks enhances movement improvement after stroke [20].
Considering the limitations of previous meta-analysis, which included a limited number of studies and lacked quality assessment, this study aimed to analyze the current scientific evidence on combined VR and NIBS therapy for restoring upper limb motor function post-stroke. By expanding the range of databases and incorporating quality assessments, this research aims to provide a more comprehensive and reliable evaluation of the combined therapy’s efficacy.
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