Effects of virtual reality with different modalities on upper limb recovery: a systematic review and network meta-analysis on optimizing stroke rehabilitation

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Effects of virtual reality with different modalities on upper limb recovery: a systematic review and network meta-analysis on optimizing stroke rehabilitation

Jiali Zhang^1†‡Mingxiu Liu^2†Junlin Yue¹Jinmei Yang¹Yan Xiao¹Jie Yang^1*Enli Cai^3*‡

• ¹The Third Affiliated Hospital of Yunnan University of Chinese Medicine, Kunming Municipal Hospital of Traditional Chinese Medicine, Kunming, Yunnan, China
• ²Bishan Hospital of Chongqing Medical University, Chongqing, China
• ³College of Nursing, Yunnan University of Chinese Medicine, Kunming, Yunnan, China

Background: As a major cause of disability worldwide, stroke affects about 80% of survivors with upper limb (UL) motor dysfunction, significantly impairing their quality of life. Virtual reality (VR) has been recognized as an innovative rehabilitation tool; however, the effectiveness of VR systems with different immersion modalities is still uncertain. This systematic review and network meta-analysis (NMA) aims to evaluate the comparative effectiveness of intervention measures, including non-immersive gaming consoles, immersive VR (IVR), non-immersive VR (NIVR), and conventional therapy (CT) on upper limb motor function in stroke rehabilitation.

Materials and methods: A systematic search of PubMed, Embase, Cochrane Library, and Scopus identified randomized controlled trials (RCTs) published up to 12 June 2024. UL motor recovery was assessed using the Fugl-Meyer Upper Extremity (FMUE) scale. The NMA was performed using the Bayesian approach with the BUGSnet package in R software to calculate the relative effectiveness of each intervention.

Results: 34 RCTs involving 1,704 participants were included. Among non-immersive gaming systems, Microsoft Kinect demonstrated the greatest effective in enhancing UL motor function, followed by Nintendo Wii, then NIVR and IVR head-mounted devices. CT showed the least effective. Specifically, Microsoft Kinect significantly improved FMUE scores (mean difference [MD] = 7.27, 95% confidence interval [CI]: 0.59 to 13.77, p < 0.05), followed by Nintendo Wii (MD = 4.53, 95% CI: 0.87 to 8.14, p < 0.05), and NIVR (MD = 3.57, 95% CI: 1.18 to 6.01, p < 0.05). In contrast, IVR head-mounted devices showed no statistically significant differences in outcomes, with MD of 4.16 (95% CI: −0.02 to 8.38).

Conclusion: Non-immersive gaming console of Microsoft Kinect is the most effective intervention for improving UL motor function in stroke survivors. In contrast, IVR head-mounted devices did not offer significant advantages over CT. These findings suggest that non-immersive gaming consoles of Microsoft Kinect could be a more cost-effective and accessible alternative for stroke rehabilitation.

1 Introduction

Stroke represents a leading cause of global disability, impacting nearly 14 million individuals each year (1, 2). Although stroke-related mortality rates exhibit a downward trajectory, the prevalence of stroke survivors with long-term sequelae is increasing. This rise is primarily due to population growth and aging (3). As a result, the prevalence of persistent disabilities among adult populations is growing (4), which is increasing the demand for rehabilitation. Data from the Global Burden of Disease study indicate that over 2.4 billion people worldwide required rehabilitation services in 2019, with a significant proportion being stroke survivors with motor impairments (5). Among the various sequelae, approximately 80% of stroke survivors experience UL motor impairments. These impairments vary and often manifest as reduced hand grip strength, diminished finger dexterity, and limited elbow and shoulder mobility (6). Such deficits severely impact daily functioning, making it difficult for patients to perform tasks such as dressing, eating and maintaining personal hygiene. As a result, stroke survivors often experience a decline in autonomy and quality of life (7). Moreover, these impairments can increase dependence on others and lead to psychological distress and social isolation (8). Rehabilitation of UL motor function in stroke patients requires ongoing, dedicated efforts over an extended period. However, traditional rehabilitation approaches often encounter barriers like resource limitations and insufficient patient engagement (9), which lead to rehabilitation outcomes, emphasizing the need for innovative interventions. VR has emerged as a promising therapeutic modality to address these challenges. By providing a highly realistic three-dimensional environment, VR enables patients to engage in simulated activities. Through the integration of visual, auditory, and tactile elements, VR provides real-time feedback to patients (10, 11). Additionally, VR may also facilitate functional recovery by activating mechanisms of neuroplasticity (12).

In the field of post-stroke UL functional recovery, VR technologies encompass a variety of applications. These primarily include IVR, such as head-mounted devices, NIVR, and non-immersive gaming consoles (e.g., Nintendo Wii and Microsoft Kinect) (13, 14). While IVR provides high immersion levels, which may enhance motor recovery (15, 16), its widespread adoption is limited by challenges such as high costs and patient discomfort (17). NIVR, in contrast, is more accessible but has shown variability in its effectiveness due to differences in technological features and interactivity (18, 19).

Many existing studies focus on individual VR modalities, leaving a gap in direct comparisons of different VR technologies for UL rehabilitation (20, 21). A 2022 NMA (22) suggested the potential benefits of IVR for UL motor recovery. However, it did not incorporate recent advances in VR technologies or newly published RCTs. Moreover, the study did not consider the practical limitations of IVR, which have prompted a growing interest in NIVR systems for scalable stroke rehabilitation. Based on these considerations, we hypothesize that non-immersive gaming consoles, such as Microsoft Kinect, may offer a superior effect due to their accessibility, affordability, and ease of integration into clinical and home-based rehabilitation. Therefore, we will test this through a systematic review and NMA to provide a comprehensive comparison of VR interventions with varying levels of immersion. By doing so, it offers updated evidence to guide clinical decision-making and enhance rehabilitation strategies for stroke survivors.