Virtual reality in the rehabilitation of patients with stroke: an integrative review

Realidade virtual na reabilitação de pacientes após acidente vascular cerebral: uma revisão integrativa

Alberto Luiz Aramaki Rosana Ferreira Sampaio Ana Caroline Silva Reis Alessandra Cavalcanti Fabiana Caetano Martins Silva e Dutra About the authors

ABSTRACT

Objective:

To describe the intervention protocols to using commercial video games as virtual reality (VR) in rehabilitation of patients with stroke.

Methods:

Integrative review using the descriptors “rehabilitation”, “virtual reality exposure therapy” and “videogames” in the LILACS and PUBMED databases. Articles published from 2011 to 2018 were selected.

Results:

We found 1,396 articles, 1,383 were excluded and 13 were selected. Most of the articles were randomized clinical trials published in 2014 or later. The sample size varied from 5–47 adults, or adults and elders, with chronic stroke. The Nintendo Wii® was the most used video game system. The intervention happened two or three times a week, each session lasting from 30 to 60 minutes, over 2–12 weeks. Balance, upper limb motor functions, quality of life and daily living activities were the most common evaluated outcomes. The Fugl-Meyer Assessment, Berg Balance Scale, Timed Up and Go test, Barthel Scale and SF-36 were the most common outcome measurement tools.

Conclusions:

The studies indicated improvement in dynamic balance, upper limb motor function and quality of life after rehabilitation using VR. The VR was more effective than conventional treatments for the outcome of dynamic balance. Two studies did not find any changes in static balance and daily living activities. Physical aspects and quality of life were the outcomes most evaluated by the researchers; as were the population with chronic strokes and protocols of long duration and low intensity. Few studies targeted immediate VR effects, performance in daily living activities and social participation.

Keywords:
Rehabilitation; virtual reality exposure therapy; video games; stroke

RESUMO

Objetivo:

Descrever os protocolos de intervenção utilizando sistemas de vídeo game comerciais como realidade virtual (RV) na reabilitação de pacientes após AVE.

Método:

Revisão integrativa usando os descritores “reabilitação”, “terapia de exposição a realidade virtual” e “videogames”, nas bases de dados LILACS e PUBMED, e artigos publicados entre 2011 e 2018.

Resultados:

Foram encontrados 1.396, excluídos 1.383 e selecionados 13 artigos. A maioria era ensaio clínico aleatorizado publicados a partir de 2014. O tamanho da amostra variou de 5 a 47 participantes adultos ou adultos e idosos com AVE crônico. O Nintendo Wii® foi o videogame mais empregado. A intervenção constava de duas ou três sessões semanais, com duração de 30 ou 60 minutos por um período de duas a 12 semanas. Equilíbrio, função motora de membro superior, qualidade de vida e atividade de vida diária foram os principais desfechos. Empregou-se principalmente Escala Fugl-Meyer, Escala de Equilíbrio de Berg, teste Timed Up and Go, Índice de Barthel e SF-36 como medidas de desfecho.

Conclusões:

Os estudos indicaram melhora do equilíbrio dinâmico, função motora de membro superior e qualidade de vida após reabilitação usando RV. A RV se mostrou mais eficaz que tratamentos convencionais para o desfecho equilíbrio dinâmico. Dois estudos não encontraram mudanças no equilíbrio estático e atividade de vida diária. Observou-se maior foco em desfechos relacionados a aspectos físicos e qualidade de vida, em população com AVE crônico e protocolo com maior duração e menor intensidade. Poucos estudos voltados para efeitos imediatos da RV, desempenho em atividades de vida diária e participação social.

Palavras-chave:
Reabilitação; terapia de exposição à realidade virtual; jogos de vídeo; acidente vascular cerebral

Rehabilitation of a patient is a process that involves the knowledge of the professional regarding the health condition and the repercussion it has on the life of the individual, as well as a broad scientific knowledge about the functioning of the human body, so that consistent decisions may be made11. Monteiro Junior RS, Carvalho RJ, Silva EB, Bastos FG. Efeito da reabilitação virtual em diferentes tipos de tratamento. Rev Bras Cienc Saúde. 2011;9(29):56-63. https://doi.org/10.13037/rbcs.vol9n29.1331
https://doi.org/10.13037/rbcs.vol9n29.13...
. In this process, assessing the situation, planning and choosing the best available evidences to perform clinical tasks is paramount to systematize decisions and optimize results22. Sampaio RF, Mancini MC, Fonseca ST. Produção científica e atuação profissional: aspectos que limitam essa integração na Fisioterapia e na Terapia Ocupacional. Braz J Phys Ther. 2002;6(3):113-8..

Many rehabilitation techniques described in the literature may help guide the intervention of professionals, such as physical training, kinesitherapy, robotic therapy, hydrotherapy, music therapy, intracortical stimulation and mental health practices, task-oriented training, mirror therapy, among others33. Assis GA, Corrêa AG, Martins MB, Pedrozo WG, Lopes RD. An augmented reality system for upper-limb post-stroke motor rehabilitation: a feasibility study. Disabil Rehabil Assist Technol. 2016 Aug;11(6):521-8. https://doi.org/10.3109/17483107.2014.979330
https://doi.org/10.3109/17483107.2014.97...
66. Vasileva D, Lubenova D, Mihova M, Dimitrova A, Grigorova-Petrova K. Influence of Kinesitherapy on Gait in Patients with Ischemic Stroke in the Chronic Period. Open Access Maced J Med Sci. 2015 Dec;3(4):619-23. https://doi.org/10.3889/oamjms.2015.107
https://doi.org/10.3889/oamjms.2015.107...
. Virtual reality (VR) is a therapeutic approach that has been used in the field of rehabilitation in recent years. In this approach, users interact with virtual objects through the movements of their hands and body, or through tactile interfaces (gloves, joysticks, mouse), performing actions in a simulated environment77. Levin MF, Snir O, Liebermann DG, Weingarden H, Weiss PL. Virtual reality versus conventional treatment of reaching ability in chronic stroke: clinical feasibility study. Neurol Ther. 2012 Aug;1(1):3. https://doi.org/10.1007/s40120-012-0003-9
https://doi.org/10.1007/s40120-012-0003-...
. The invention of low-cost human movement sensors in commercial game systems has made it easier to use video games for rehabilitation88. Kwon JS, Park MJ, Yoon IJ, Park SH. Effects of virtual reality on upper extremity function and activities of daily living performance in acute stroke: a double-blind randomized clinical trial. NeuroRehabilitation. 2012;31(4):379-85. https://doi.org/10.3233/NRE-2012-00807
https://doi.org/10.3233/NRE-2012-00807...
. Examples of these systems include the Kinect for Microsoft's Xbox®, the Nintendo Wii® and the PlayStationMove® by Sony.

The use of VR has increased the potential for motor learning and neuroplasticity during rehabilitation. A study using magnetic resonance imaging found consistent results, showing a reorganization of the sensorimotor cortex99. Schuster-Amft C, Henneke A, Hartog-Keisker B, Holper L, Siekierka E, Chevrier E, et al. Intensive virtual reality-based training for upper limb motor function in chronic stroke: a feasibility study using a single case experimental design and fMRI. Disabil Rehabil Assist Technol. 2015;10(5):385-92. https://doi.org/10.3109/17483107.2014.908963
https://doi.org/10.3109/17483107.2014.90...
. Functional improvements have also been associated with the use of VR by rehabilitation professionals. Allain et al.1010. Allain P, Foloppe DA, Besnard J, Yamaguchi T, Etcharry-Bouyx F, Le Gall D, et al. Detecting everyday action deficits in Alzheimer's disease using a nonimmersive virtual reality kitchen. J Int Neuropsychol Soc. 2014 May;20(5):468-77. https://doi.org/10.1017/S1355617714000344
https://doi.org/10.1017/S135561771400034...
pointed out that performing a task in a virtual kitchen anticipated carrying out the task in real life. The virtual practice of shopping for groceries is associated with an improvement in the performance of actual grocery shopping1111. Kizony R, Mallory K, Sinoff G, Klinger E, Josman N. Using a virtual supermarket as a tool for training executive functions in people with mild cognitive impairment. J Stroke Cerebrovasc Dis. 2012;23(5):10-2., and patients who interact with the virtual world have fewer limitations when performing daily activities1212. da Costa RM, de Carvalho LA. The acceptance of virtual reality devices for cognitive rehabilitation: a report of positive results with schizophrenia. Comput Methods Programs Biomed. 2004 Mar;73(3):173-82. https://doi.org/10.1016/S0169-2607(03)00066-X
https://doi.org/10.1016/S0169-2607(03)00...
.

When VR has been applied in the rehabilitation of patients after strokes, it has mainly been used to help in the functional recovery of upper limbs, cognitive function, posture control and balance1313. Lee KH. Effects of a virtual reality-based exercise program on functional recovery in stroke patients: part 1. J Phys Ther Sci. 2015 Jun;27(6):1637-40. https://doi.org/10.1589/jpts.27.1637
https://doi.org/10.1589/jpts.27.1637...
,1414. Saposnik G, Levin M, Thomas S, Deutsch JE, Crotty M; Outcome Research Canada (SORCan) Working Group. Virtual reality in stroke rehabilitation: a meta-analysis and implications for clinicians. Stroke. 2011 May;42(5):1380-6. https://doi.org/10.1161/STROKEAHA.110.605451
https://doi.org/10.1161/STROKEAHA.110.60...
. Deficiencies in the upper limb after strokes may negatively impact the daily life of patients, by limiting their ability to carry out essential tasks that are necessary for an independent life1515. Basílio ML, de Faria-Fortini I, Polese JC, Scianni AA, Faria CD, Teixeira-Salmela LF. Handgrip strength deficits best explain limitations in performing bimanual activities after stroke. J Phys Ther Sci. 2016 Apr;28(4):1161-5. https://doi.org/10.1589/jpts.28.1161
https://doi.org/10.1589/jpts.28.1161...
. The VR offers a rich environment in which patients may, after a stroke, solve problems and develop new abilities1616. Laver K, George S, Thomas S, Deutsch JE, Crotty M. Cochrane review: virtual reality for stroke rehabilitation. Eur J Phys Rehabil Med. 2012 Sep;48(3):523-30.. Considering the above, this study aimed to review and analyze information from the literature on the main intervention protocols delineated by rehabilitation professionals, using VR in commercial video game systems for the treatment of patients who had suffered strokes, while also identifying the most common outcomes found by these professionals.

METHODS

This was an integrative literature review, consisting of the analysis of relevant research that gave support for decision-making and the improvement of clinical practice, thus offering instruments for evidence-based practices1717. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (Sao Paulo). 2010;8(1):102-6. https://doi.org/10.1590/s1679-45082010rw1134
https://doi.org/10.1590/s1679-45082010rw...
. An integrative review allows one to summarize the existing knowledge regarding a certain theme and identify how the data from previous publications can be used, in addition to pointing out the gaps in the knowledge that need to be researched by other studies1717. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (Sao Paulo). 2010;8(1):102-6. https://doi.org/10.1590/s1679-45082010rw1134
https://doi.org/10.1590/s1679-45082010rw...
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This review was elaborated in the following stages, as suggested by Souza et al.1717. Souza MT, Silva MD, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (Sao Paulo). 2010;8(1):102-6. https://doi.org/10.1590/s1679-45082010rw1134
https://doi.org/10.1590/s1679-45082010rw...
: delimitation of the theme, hypothesis of the integrative review and objectives; determination of inclusion and exclusion criteria (sample selection); establishment of which data banks should be researched; definition of what information was to be extracted from selected articles; result analysis; discussion and presentation of the results; and, finally, the presentation of the review.

The research took place in April 2018, and the criteria for the inclusion of the studies were: articles that used commercial video game system VR in the rehabilitation of patients who had strokes; were published in 2011 or later; and had their entire content made available. There was no restriction regarding language; however, the Portuguese and English languages were chosen as the basis of the theoretical framework of this review. The bibliographical research was conducted in the LILACS and Medline (PubMed) databanks. The following descriptors, available on DeCS (the Health Science Descriptors website), were chosen for the search of the databanks: virtual reality exposure therapy; videogames; rehabilitation.

The research was conducted by two independent researchers, using the same descriptors, filters and databanks. Filters were used to exclude articles that did not have abstracts and those that were themselves literature reviews. After the filters were used, the abstract and content of the articles were carefully analyzed by two independent researchers who excluded studies with the following traits: interventions that were not focused on rehabilitation; development of intervention protocols in computer games; studies whose participants had primary health conditions different from those of stroke patients; studies whose games were classified as Exergames; articles with qualitative methodologies; and studies that used the video game in the residence of the participants and not in a clinical environment, which is known as telerehabilitation.

RESULTS

Characteristics of included studies

The research strategy using the different descriptors and combinations resulted in 1,396 studies on the theme, from which 1,355 were left after duplicates were excluded. From these, 883 were excluded as they did not make their complete content available, 441 were excluded after their title and abstract were read, 10 were removed after the entire text had been analyzed and eight because they had been published in other languages. There were 13 studies left, which were selected. The main reasons for the exclusion of the articles were: research focused on Exergames and telerehabilitation, research that applied VR to patients with conditions other than a stroke, and research that used computer games and not commercial gaming systems. The Figure is a flow chart detailing the selection of the studies.

Figure 1
Flowchart of studies found and selected after the application of inclusion and exclusion criteria.

Information regarding the title, authors, year of publication and periodical where the studies were published are shown in Table 1. Most of the selected articles had been published in 2014 (30.77%) and 38.46% were published in the years 2015, 2016 and 2017. The studies had been published in 11 different scientific journals (periodicals and magazines), from which the Neurorehabilitation and the Journal of Stroke and Cerebrovascular Diseases stood out, with two published articles each, meeting the inclusion criteria of this research.

Table 1
Summary of the selected studies including title, author/year of publication and name of journal.

Table 2 shows the data on the design, sample, video game system and games used in the articles selected for this review.

Table 2
Characterization of the selected articles regarding type of study, age group, sample, video game system and games.

Most of the case studies selected (n = 9) were randomized clinical trials and four of them were quasi-experimental clinical trials. Studies #3 and #6 used a control group, with no participant randomization; studies #9 and #10 had no control group for comparison of the results. No study had gender restrictions regarding the composition of its sample. Most researchers analyzed a sample that included only adults (6) or included adult and elder (5) populations in their samples, and an age group varying from 18 to 85 years of age. Only two studies analyzed a sample comprising elders alone. The number of participants varied from 5-47. As for the time passed since the stroke, 11 studies were conducted with chronic patients, while two included patients who had a stroke less than six months prior.

The most common video game system was the Nintendo Wii® (n = 8), followed by the Xbox 360® (n = 3). Two studies combined different video game systems in their intervention protocols. One study used the Nintendo Wii® and the Xbox 360®, while the other used the Xbox 360® and the Playstation® SeeMe during intervention. The games chosen in the intervention protocol were mainly sports games, most frequently boxing, tennis, football and bowling.

Main outcomes, intervention protocols and results from the virtual reality activities in patients after a stroke

Table 3 is a summary of the main objectives, outcomes and assessment measures, intervention protocols and results described in the articles selected for this review. These studies had varying objectives and presented, especially, (a) objectives regarding the effects of VR on different physical and functional aspects of the patients or (b) compared the efficiency of VR to that of traditional treatments and/or different combined intervention techniques.

Table 3
Characterization of selected articles according to objectives, type of intervention and main results.

Among the analyzed investigations, the main outcomes evaluated were balance (six studies), upper limb motor function (five studies), quality of life (four studies) and daily living activities (DLA) in three studies. Other, less frequent outcomes evaluated included dexterity evaluations, movement amplitude, spasticity, grip force, physical function, falls, walking, acceleration and movement repetition, energy expenditure, postural control and performance in the video game.

Regarding the assessment of the outcomes, there was a great variety of tests and instruments used to evaluate the participants in the studies. The most commonly used were the Fugl-Meyer Assessment (five studies); the Berg Balance Scale and the Timed Up and Go test, both used in four studies; the Barthel Index (three studies); and the SF-36 Questionnaire, the 10-minute Walk Test and the Functional Reach Test, each used in two studies.

Regarding the intervention protocol, two studies evaluated the effects of an intensive single-session training; six and five studies, respectively, applied VR two or three times a week. The length of each session varied from 30 to 120 minutes, lasting from 30 to 60 minutes in most protocols (four studies each). The intervention also lasted from two to 12 weeks, although six was the total duration of the intervention in most studies (four studies), followed by four and eight weeks (two studies each).

Regarding studies that investigated the effects of the VR on different physical and functional aspects of the patients, most indicated the efficiency of VR regarding the outcomes of dynamic balance (five studies), upper limb motor function (four studies) and quality of life (three studies). Improvements in other outcomes such as dexterity, spasticity, grip force, physical function, walking, DLA, repetition and acceleration of movement, energy expenditure, posture control and falls, were each described in only one study.

The results comparing the VR with conventional treatments indicated that VR is more efficient, especially in the dynamic balance outcome (three studies). For most studies, conventional or standard treatments were those that described weekly sessions of physical or occupational therapy, lasting 30 minutes. For the group of patients who were submitted to VR therapy, each of the following outcomes were significant in only one study: quality of life, movement amplitude, upper limb motor function, dexterity, spasticity, DLA, walking, repetition and acceleration of movement and posture control.

Some studies indicated no difference between the benefits of the control group (under conventional treatment) and the intervention group (VR). The outcomes that had the same results comparing the groups were static balance, DLA, walking and dynamic balance, each mentioned in two studies, and quality of life, mentioned in one.

DISCUSSION

Virtual reality is a technique used in multiple areas and comprises various equipment, hardware and software. It has been applied in research, education, evaluation and therapeutic intervention or rehabilitation1818. Dores AR, Barbosa F, Marques A, Carvalho IP, De Sousa L, Castro-Caldas A. [Virtual reality and rehabilitation: why or why not? A systematic literature review]. Acta Med Port. 2012 Nov-Dec;25(6):414-21. Portuguese.. The growing number of publications in recent years, especially since 2014, indicates the interest of researchers and clinicians in VR. This increase may be related to the improvement and popularization of this technology, which has enabled professionals to access digital media, directly influencing the studies that use this technique1919. Caiana TL, Nogueira DL, Lima AC. A realidade virtual e seu uso como recurso terapêutico ocupacional: revisão integrativa. Cad Ter Ocup UFSCar. 2016;24(3):575-89. https://doi.org/10.4322/0104-4931.ctoAR0619
https://doi.org/10.4322/0104-4931.ctoAR0...
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This review sought to analyze intervention protocols used by rehabilitation professionals, who used VR in commercial video game systems. In this context, the studies analyzed were mostly randomized clinical trials, which were created specifically to analyze the effects of a specific intervention2020. Portney LG, Watkins M. Foundations of clinical research: applications to practice. 3rd ed. Upper Saddle River: Prentice Hall; 2009.. Thus, randomized clinical trials were, among primary studies, the most relevant for the objectives of this review.

The predominance of studies, with a sample comprised specifically of adults, is in line with the epidemiological changes in the incidence of stroke in the last decades. Although the occurrence of stroke is associated with aging, data from 119 countries has shown that the number of cases in the age group 20-64 increased from 25% in 1990 to 31% in 20102121. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet. 2014 Jan;383(9913):245-54. https://doi.org/10.1016/S0140-6736(13)61953-4
https://doi.org/10.1016/S0140-6736(13)61...
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Most analyzed studies evaluated the efficiency of VR in patients with chronic strokes, though the rehabilitation techniques commonly used in this population are focused on the first three months, that is, in the acute stage of the disease2222. Miller EL, Murray L, Richards L, Zorowitz RD, Bakas T, Clark P, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010 Oct;41(10):2402-48. https://doi.org/10.1161/STR.0b013e3181e7512b
https://doi.org/10.1161/STR.0b013e3181e7...
,2323. Gamba RT, Cruz DM. Efeitos da terapia por contensão induzida em longo prazo em pacientes pós AVC. Rev Neurocienc. 2011;19(4):735-40.. The results of this review reiterate the recent change in the rehabilitation intervention paradigm, regarding the time required for a possible motor recovery. Recent studies have presented new experiences that have demonstrated functional gains, even after the spontaneous recovery period2424. Belliveau D, Belliveau I, Camire-Raymond A, Kessler D, Egan M. Use of occupational performance coaching for stroke survivors (OPC-Stroke) in late rehabilitation: a descriptive case study. Open J Occup Ther. 2016;4(2):7. https://doi.org/10.15453/2168-6408.1219
https://doi.org/10.15453/2168-6408.1219...
,2525. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 Jun;47(6):e98-169. https://doi.org/10.1161/STR.0000000000000098
https://doi.org/10.1161/STR.000000000000...
.

The results of this review showed that the Nintendo Wii® was the most commonly used video game system in the articles analyzed. The Nintendo Wii® is a low-cost piece of equipment that is easy for the therapist to handle and can be operated independently by the patient2626. Tripette J, Murakami H, Ryan KR, Ohta Y, Miyachi M. The contribution of Nintendo Wii Fit series in the field of health: a systematic review and meta-analysis. PeerJ. 2017 Sep;5:e3600. https://doi.org/10.7717/peerj.3600
https://doi.org/10.7717/peerj.3600...
. Another commercial video game system used in the protocol of the studies was the Xbox 360®, used in the interventions of five studies. It was used in isolation in three of these studies and combined with other systems in the other two. The fact that the Xbox 360® was used less frequently in the intervention protocols may partially be explained by the fact that it has been on the market for less time2727. Mendes FA, Arduini L, Botelho A, Cruz MB, Paz CCS, Pompeu SMAA et al. Pacientes com a Doença de Parkinson são capazes de melhorar seu desempenho em tarefas virtuais do Xbox Kinect®: “uma série de casos. Motricidade. 2015;11(3):68-80. https://doi.org/10.6063/motricidade.3805
https://doi.org/10.6063/motricidade.3805...
. The Xbox 360® was released in 2010, while the Nintendo Wii® has been on the market since 2006. Nonetheless, the Xbox 360® has advantages when compared with the Nintendo Wii®, as it has a more advanced technology, more realistic and less child-targeted characters, in addition to allowing the interaction of the user with the virtual environment without the need of a manual controller2727. Mendes FA, Arduini L, Botelho A, Cruz MB, Paz CCS, Pompeu SMAA et al. Pacientes com a Doença de Parkinson são capazes de melhorar seu desempenho em tarefas virtuais do Xbox Kinect®: “uma série de casos. Motricidade. 2015;11(3):68-80. https://doi.org/10.6063/motricidade.3805
https://doi.org/10.6063/motricidade.3805...
. As a consequence, the Xbox 360® may offer a better game interface with the player and has broader applications in the therapeutic process, for instance, for patients whose manual functions are more compromised, as no object needs to be gripped throughout the game.

Sports games were the most frequently used in the analyzed studies, which may be related to the main outcomes evaluated in the articles. Balance and motor function were the main outcomes evaluated in the studies that were part of this review, followed by quality of life and DLA. The other evaluated variables were related to dexterity, movement amplitude, spasticity, grip force, physical function, walking and falls. These findings indicate that most studies investigated the effects of VR on outcomes related to structural components and body functions, especially regarding the vestibular system and neuromusculoskeletal functions.

According to the World Health Organization (WHO)2828. Organização Mundial de Saúde – OMS. CIF: Classificação internacional de funcionalidade, incapacidade e saúde. São Paulo: Editora da Universidade de São Paulo; 2003., a health condition such as a stroke can impact different areas and health components of the health and life of a person. Body functions are physiological functions of the body systems and structures involving the anatomic parts of organs and limbs2828. Organização Mundial de Saúde – OMS. CIF: Classificação internacional de funcionalidade, incapacidade e saúde. São Paulo: Editora da Universidade de São Paulo; 2003.. These are components of human functionality that may be impacted by a stroke. In this review, few studies analyzed the effect of VR on the components of activity and participation. The WHO2828. Organização Mundial de Saúde – OMS. CIF: Classificação internacional de funcionalidade, incapacidade e saúde. São Paulo: Editora da Universidade de São Paulo; 2003. describes activity as the execution of a task or action by an individual, while participation is this individual's involvement in daily living situations. Considering these concepts, the activity component was investigated in only three studies, and four studies evaluated the quality of life outcome. However, despite the guidelines for adult stroke rehabilitation and recovery2525. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 Jun;47(6):e98-169. https://doi.org/10.1161/STR.0000000000000098
https://doi.org/10.1161/STR.000000000000...
recommending the evaluation of participation through measures of quality of life, the correlation of this information with participation should be done with care. Quality of life relates to how people “feel” about their health conditions or their consequences2828. Organização Mundial de Saúde – OMS. CIF: Classificação internacional de funcionalidade, incapacidade e saúde. São Paulo: Editora da Universidade de São Paulo; 2003.. Therefore, the quality of life is a construct of “subjective wellbeing” and functionality, on one hand but, on the other hand, refers to objective external signs from the individual2828. Organização Mundial de Saúde – OMS. CIF: Classificação internacional de funcionalidade, incapacidade e saúde. São Paulo: Editora da Universidade de São Paulo; 2003.. As guidance for the development of future studies, the WHO suggests the formulation of investigations that establish associations between the functionality components and the concepts of quality of life and subjective wellbeing2828. Organização Mundial de Saúde – OMS. CIF: Classificação internacional de funcionalidade, incapacidade e saúde. São Paulo: Editora da Universidade de São Paulo; 2003..

The Fugl-Meyer Assessment, the Berg Balance Scale and the Timed Up and Go test were the most common tests in the studies, followed by the Barthel Scale, the SF-36, the 10-minute Walk Test and the Functional Reach Test. The Fugl-Meyer Assessment is largely used in literature to evaluate sensorimotor function in hemiplegic patients2929. Alt Murphy M, Resteghini C, Feys P, Lamers I. An overview of systematic reviews on upper extremity outcome measures after stroke. BMC Neurol. 2015 Mar;15(1):29. https://doi.org/10.1186/s12883-015-0292-6
https://doi.org/10.1186/s12883-015-0292-...
,3030. Santisteban L, Térémetz M, Bleton JP, Baron JC, Maier MA, Lindberg PG. Upper limb outcome measures used in stroke rehabilitation studies: a systematic literature review. PLoS One. 2016 May;11(5):e0154792. https://doi.org/10.1371/journal.pone.0154792
https://doi.org/10.1371/journal.pone.015...
, and it shows high confidence levels, both intra- and inter-examiner, allowing its use as a clinical evaluation instrument and as a research instrument in stroke2929. Alt Murphy M, Resteghini C, Feys P, Lamers I. An overview of systematic reviews on upper extremity outcome measures after stroke. BMC Neurol. 2015 Mar;15(1):29. https://doi.org/10.1186/s12883-015-0292-6
https://doi.org/10.1186/s12883-015-0292-...
3131. Maki T, Quagliato EM, Cacho EW, Paz LP, Nascimento NH, Inoue MM, et al. Estudo de confiabilidade da aplicação da escala de Fugl-Meyer no Brasil. Braz J Phys Ther. 2006;10(2):177-83. https://doi.org/10.1590/S1413-35552006000200007
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Balance evaluations were conducted, in most cases, using the Berg Balance Scale and the Timed Up and Go test, followed by the Functional Reach Test. The Berg Balance Scale was shown to have an excellent confidence level when it comes to stroke patients3232. Tyson SF, Connell LA. How to measure balance in clinical practice: a systematic review of the psychometrics and clinical utility of measures of balance activity for neurological conditions. Clin Rehabil. 2009 Sep;23(9):824-40. https://doi.org/10.1177/0269215509335018
https://doi.org/10.1177/0269215509335018...
. The Timed Up and Go and the Functional Reach Tests are simple and objective measures, easy to apply in clinical practice3333. Woellner SS, Araujo AG, Cabral FM, Uessler PN, Soares AV. Testes de equilíbrio em pacientes hemiparéticos por AVC. Neurociencias. 2015;11(1):32-40.. The validity of these tests are good, with excellent intra- and inter-examiner confidence levels when applied to people after a stroke2929. Alt Murphy M, Resteghini C, Feys P, Lamers I. An overview of systematic reviews on upper extremity outcome measures after stroke. BMC Neurol. 2015 Mar;15(1):29. https://doi.org/10.1186/s12883-015-0292-6
https://doi.org/10.1186/s12883-015-0292-...
,3434. Hafsteinsdóttir TB, Rensink M, Schuurmans M. Clinimetric properties of the Timed Up and Go Test for patients with stroke: a systematic review. Top Stroke Rehabil. 2014 May-Jun;21(3):197-210. https://doi.org/10.1310/tsr2103-197
https://doi.org/10.1310/tsr2103-197...
. The evaluation of the outcome “balance” was conducted combining at least two tests: three studies combined the Berg Balance Scale and the Timed Up and Go test, while two combined these two measurements with the Functional Reach Test. Recent studies highlighted that evaluations of static and dynamic balance are very often in agreement, reiterating the need for the use of the two tools simultaneously – especially the Berg Balance Scale and the Timed Up and Go test3333. Woellner SS, Araujo AG, Cabral FM, Uessler PN, Soares AV. Testes de equilíbrio em pacientes hemiparéticos por AVC. Neurociencias. 2015;11(1):32-40.,3535. Correia A, Pimenta C, Alves M, Virella D. Concordância entre instrumentos de avaliação do equilíbrio após acidente vascular cerebral. Saúde Tecnol. 2017;(17):33-8..

The Barthel Index was the most widely-used instrument to evaluate DLA and was identified in the literature as the second most used tool to evaluate the results of clinical trials after stroke. This index has favorable construct validity to measure activity according to the WHO, and its inter- and intra-examiner reliability is considered moderate to high3636. Taylor-Rowan M, Wilson A, Dawson J, Quinn TJ. Functional assessment for acute stroke trials: properties, analysis, and application. Front Neurol. 2018 Mar;9:191. https://doi.org/10.3389/fneur.2018.00191
https://doi.org/10.3389/fneur.2018.00191...
.

Information on quality of life is an important outcome in the evaluation of stroke patients and in the use of different treatments. The SF-36 was used to evaluate quality of life in two studies in this review, while another two used specific instruments for stroke patients. The SF-36 is described in the literature as the most used generic instrument to measure quality of life in the general population3737. de Haan RJ. Measuring quality of life after stroke using the SF-36. Stroke. 2002 May;33(5):1176-7. https://doi.org/10.1161/01.STR.0000015223.98452.97
https://doi.org/10.1161/01.STR.000001522...
, presenting a satisfactory internal consistency, as well as validity and test-retest reliability for the eight sub-assessments for stroke patients3737. de Haan RJ. Measuring quality of life after stroke using the SF-36. Stroke. 2002 May;33(5):1176-7. https://doi.org/10.1161/01.STR.0000015223.98452.97
https://doi.org/10.1161/01.STR.000001522...
,3838. Anderson C, Laubscher S, Burns R. Validation of the Short Form 36 (SF-36) health survey questionnaire among stroke patients. Stroke. 1996 Oct;27(10):1812-6. https://doi.org/10.1161/01.STR.27.10.1812
https://doi.org/10.1161/01.STR.27.10.181...
.

The analysis of the intervention protocols used in the studies included in this review showed great variability regarding the number of sessions, the length of each session and the total length of the treatment. However, the predominance of short-to-moderate length and low-intensity protocols stand out in regards to weekly sessions. Only two studies applied short high-intensity protocols (one session only). The intervention methodology of most studies was applying two sessions a week, lasting from 30 to 60 minutes each, throughout the six weeks.

Recent systematic reviews have also pointed out these differences in the intensity and length of the interventions that evaluated the efficiency of the VR3939. Iruthayarajah J, McIntyre A, Cotoi A, Macaluso S, Teasell R. The use of virtual reality for balance among individuals with chronic stroke: a systematic review and meta-analysis. Top Stroke Rehabil. 2017 Jan;24(1):68-79. https://doi.org/10.1080/10749357.2016.1192361
https://doi.org/10.1080/10749357.2016.11...
,4040. Yates M, Kelemen A, Sik Lanyi C. Virtual reality gaming in the rehabilitation of the upper extremities post-stroke. Brain Inj. 2016;30(7):855-63. https://doi.org/10.3109/02699052.2016.1144146
https://doi.org/10.3109/02699052.2016.11...
. Laver et al.4141. Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2017 Sep;(9):CD008349. https://doi.org/10.1002/14651858.CD008349.pub2.
https://doi.org/10.1002/14651858.CD00834...
suggested that longer interventions (more than 15 hours overall) were the best option, as well as personalized virtual reality interventions; however, their findings were not statistically significant. Considering the diversity of intervention protocols, future studies need to analyze the prognosis of stroke patients who are going through rehabilitations using VR, to define the minimum length the intervention must have for improvements to be detected, and the ideal length of each session, thus making this technique more viable.

This review found important differences in the results, when the main outcomes of each study were compared. Dynamic balance, upper limb motor function, quality of life and DLA improved significantly in different studies. However, other studies did not find any improvement in the outcome of these variables after VR was used. The comparison between the efficiency of VR coupled with conventional treatments also showed an inconsistency between the evidences, as some investigations found that VR brought benefits, while others did not find differences between the results of the different groups. This result instability is also found in the literature. Li et al.4242. Li Z, Han XG, Sheng J, Ma SJ. Virtual reality for improving balance in patients after stroke: a systematic review and meta-analysis. Clin Rehabil. 2016 May;30(5):432-40. https://doi.org/10.1177/0269215515593611
https://doi.org/10.1177/0269215515593611...
, through a meta-analysis, gave support to the use of VR to improve balance after strokes. However, Santos et al.4343. Santos LRA, Carregosa AA, Masruha MR, Santos PA, Coêlho MLS, Ferraz DD, et al. The use of Nintendo Wii in the rehabilitation of poststroke patients: a systematic review. J Stroke Cerebrovasc Dis. 2015 Oct;24(10):2298-305. https://doi.org/10.1016/j.jstrokecerebrovasdis.2015.06.010
https://doi.org/10.1016/j.jstrokecerebro...
suggested that the data was not clear regarding the efficiency of VR to improve balance and functional independence. Lee1313. Lee KH. Effects of a virtual reality-based exercise program on functional recovery in stroke patients: part 1. J Phys Ther Sci. 2015 Jun;27(6):1637-40. https://doi.org/10.1589/jpts.27.1637
https://doi.org/10.1589/jpts.27.1637...
indicated VR as an effective and clinically-applicable therapeutic strategy for the functional recovery of upper limbs in the treatment of stroke patients. On the contrary, Laver et al.4141. Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2017 Sep;(9):CD008349. https://doi.org/10.1002/14651858.CD008349.pub2.
https://doi.org/10.1002/14651858.CD00834...
found that the use of VR and interactive video games were not more beneficial than conventional therapeutic approaches to improve the function of upper limbs, balance or quality of life. These authors point out that VR may be beneficial to improve DLA only when used as an addition to conventional treatments, increasing the overall duration of the therapy4141. Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2017 Sep;(9):CD008349. https://doi.org/10.1002/14651858.CD008349.pub2.
https://doi.org/10.1002/14651858.CD00834...
.

These results show that there are evidences suggesting the efficiency of VR in the rehabilitation of stroke patients, but that these are not sufficient to support, without doubt, their use in these cases. Therefore, the results found in the articles analyzed in this review must be interpreted carefully, especially regarding the differences in the samples, intensity and length of the therapies, which makes the studies more difficult to compare and less viable for generalization.

FINAL CONSIDERATIONS

This review found a large number of studies, published in 2004 or later, that had analyzed the use of VR in stroke patients, and used research designs that were appropriate to investigate evidence of efficiency. Adult chronic patients were the most prevalent in the samples, which varied greatly in size from one study to the other. The Nintendo Wii® and sports games were the video game system and type of game most used during therapies. The main outcomes measured were balance, upper limb motor function, quality of life and DLA. Most protocols had short to moderate durations (six weeks) and low intensity regarding the number of weekly sessions (two sessions). The results varied with respect to the efficiency of VR, considering both the improvement in the outcomes and the comparison with traditional treatments.

This review contributes to a better understanding of VR and the use of this technique in a clinical context by rehabilitation professionals. The characteristics of the intervention protocols described in this study should be incorporated in the elaboration of new research on the prognosis of stroke patients who are using VR in their rehabilitation. It is also recommended that new research focuses on the efficiency of the VR regarding DLA and social participation.

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Publication Dates

  • Publication in this collection
    13 May 2019
  • Date of issue
    Apr 2019

History

  • Received
    15 Sept 2018
  • Reviewed
    09 Nov 2018
  • Accepted
    10 Dec 2018
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