Realidad virtual para la rehabilitación del accidente cerebrovascular
Appendices
Appendix 1. CENTRAL search strategy
#1. [mh ^"cerebrovascular disorders"] or [mh "basal ganglia cerebrovascular disease"] or [mh "brain ischemia"] or [mh "carotid artery diseases"] or [mh "intracranial arterial diseases"] or [mh “intracranial arteriovenous malformations”] or [mh "intracranial embolism and thrombosis"] or [mh "intracranial hemorrhages"] or [mh ^stroke] or [mh "brain infarction"]
#2. [mh ^"brain injuries"] or [mh ^"brain injury, chronic"]
#3. (stroke or cva or poststroke or "post‐stroke" or cerebrovasc* or cerebral next vasc*):ti,ab
#4.((cerebral* or cerebell* or brain* or vertebrobasilar) near/5 (isch*emi* or infarct* or thrombo* or emboli* or apoplexy*)):ti,ab
#5. ((brain* or cerebral* or subarachnoid) near/5 (haemorrhage* or hemorrhage* or haematoma* or hematoma* or bleed*)):ti,ab
#6. [mh ^hemiplegia] or [mh paresis]
#7. (hemipleg* or hemipar* or paresis or paretic or brain next injur*):ti,ab
#8. [mh ^"gait disorders, neurologic"]
#9. #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8
#10. [mh ^”user‐computer interface”]
#11. [mh ^computers] or [mh microcomputers] or [mh ^”computer systems”] or [mh ^software]
#12. [mh ^”computer simulation”] or [mh ^”computer‐assisted instruction”] or [mh ^”therapy, computer‐assisted”]
#13. [mh ^”computer graphics”] or [mh ^”video games”] or [mh touch [mj]]
#14. (Virtual next reality* or “virtual‐reality” or VR):ti,ab
#15. (virtual near/3 (environment* or object* or world* or treatment* or system* or program* or rehabilitation* or therap* or driving or drive* or car or tunnel or vehicle)):ti,ab
#16. (computer near/3 (simulat* or graphic* or game* or interact*)):ti,ab
#17. (computer next assist* next (therap* or treat*)):ti,ab
#18. (computer next generat* next (environment* or object*)):ti,ab
#19. (video game* or video next gaming or gaming next console* or interactive next game or interactive next gaming or Nintendo next Wii or gaming next program*):ti,ab
#20. (haptics or haptic next device*):ti,ab
#21. (simulat* near/3 (environment* or object* or event* or events or driving or drive* or car or tunnel or vehicle)):ti,ab
#22. (user next computer next interface):ti,ab
#23. #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22
#24. #9 and #23
Appendix 2. MEDLINE search strategy
We used the following search strategy for MEDLINE (Ovid) and adapted it to search the other databases.
1. cerebrovascular disorders/ or exp basal ganglia cerebrovascular disease/ or exp brain ischemia/ or exp carotid artery diseases/ or exp intracranial arterial diseases/ or exp intracranial arteriovenous malformations/ or exp "intracranial embolism and thrombosis"/ or exp intracranial hemorrhages/ or stroke/ or exp brain infarction/
2. brain injuries/ or brain injury, chronic/
3. (stroke$ or cva or poststroke or post‐stroke or cerebrovasc$ or cerebral vascular).tw.
4. ((cerebral or cerebellar or brain$ or vertebrobasilar) adj5 (infarct$ or isch?emi$ or thrombo$ or emboli$ or apoplexy)).tw.
5. ((cerebral or brain or subarachnoid) adj5 (haemorrhage or hemorrhage or haematoma or hematoma or bleed$)).tw.
6. exp hemiplegia/ or exp paresis/
7. (hempar$ or hemipleg$ or paresis or paretic or brain injur$).tw.
8. Gait Disorders, Neurologic/
9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
10. user‐computer interface/
11. computers/ or exp microcomputers/ or computer systems/ or software/
12. computer simulation/ or computer‐assisted instruction/ or therapy, computer‐assisted/
13. computer graphics/ or video games/ or *touch/
14. (virtual reality$ or virtual‐reality$ or VR).tw.
15. (virtual adj3 (environment$ or object$ or world$ or treatment$ or system$ or program$ or rehabilitation$ or therap$ or driving or drive$ or car or tunnel or vehicle)).tw.
16. (computer adj3 (simulat$ or graphic$ or game$ or interact$)).tw.
17. (computer adj1 assist$ adj1 (therap$ or treat$)).tw.
18. (computer adj1 generat$ adj1 (environment$ or object$)).tw.
19. (video game$ or video gaming or gaming console$ or interactive game or interactive gaming or Nintendo Wii or gaming program$).tw.
20. (haptics or haptic device$).tw.
21. (simulat$ adj3 (environment$ or object$ or event$1 or driving or drive$ or car or tunnel or vehicle)).tw.
22. (user adj1 computer adj1 interface).tw.
23. or/10‐22
24. Randomized Controlled Trials as Topic/
25. random allocation/
26. Controlled Clinical Trials as Topic/
27. control groups/
28. clinical trials as topic/
29. double‐blind method/
30. single‐blind method/
31. Placebos/
32. placebo effect/
33. cross‐over studies/
34. Research Design/
35. randomized controlled trial.pt.
36. controlled clinical trial.pt.
37. clinical trial.pt.
38. (random$ or RCT or RCTs).tw.
39. (controlled adj5 (trial$ or stud$)).tw.
40. (clinical$ adj5 trial$).tw.
41. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
42. (quasi‐random$ or quasi random$ or pseudo‐random$ or pseudo random$).tw.
43. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
44. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
45. (cross‐over or cross over or crossover).tw.
46. (placebo$ or sham).tw.
47. trial.ti.
48. (assign$ or allocat$).tw.
49. or/24‐48
50. 9 and 23 and 49
51. limit 50 to ed=20100301‐20170401
Appendix 3. Embase search strategy
1. cerebrovascular disease/ or exp basal ganglion hemorrhage/ or exp brain hematoma/ or exp brain hemorrhage/ or exp brain infarction/ or exp brain ischemia/ or exp carotid artery disease/ or cerebral artery disease/ or exp cerebrovascular accident/ or exp cerebrovascular malformation/ or exp intracranial aneurysm/ or exp occlusive cerebrovascular disease/ or stroke/ or stroke unit/ or stroke patient/
2. brain injury/ or acquired brain injury/
3. (stroke$ or cva or poststroke or post‐stroke or cerebrovasc$ or cerebral vascular).tw.
4. ((cerebral or cerebellar or brain$ or vertebrobasilar) adj5 (infarct$ or isch?emi$ or thrombo$ or emboli$ or apoplexy)).tw.
5. ((cerebral or brain or subarachnoid) adj5 (haemorrhage or hemorrhage or haematoma or hematoma or bleed$)).tw.
6. hemiparesis/ or hemiplegia/ or paresis/
7. (hempar$ or hemipleg$ or paresis or paretic or brain injur$).tw.
8. exp neurologic gait disorder/
9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
10. virtual reality/ or computer interface/ or exp computer/ or computer program/ or computer simulation/ or computer assisted therapy/ or computer graphics/ or *touch/
11. (virtual reality$ or virtual‐reality$ or VR).tw.
12. (virtual adj3 (environment$ or object$ or world$ or treatment$ or system$ or program$ or rehabilitation$ or therap$ or driving or drive$ or car or tunnel or vehicle)).tw.
13. (computer adj3 (simulat$ or graphic$ or game$ or interact$)).tw.
14. (computer adj1 assist$ adj1 (therap$ or treat$)).tw.
15. (computer adj1 generat$ adj1 (environment$ or object$)).tw.
16. (video game$ or video gaming or gaming console$ or interactive game or interactive gaming or Nintendo Wii or gaming program$).tw.
17. (haptics or haptic device$).tw.
18. (simulat$ adj3 (environment$ or object$ or event$1 or driving or drive$ or car or tunnel or vehicle)).tw.
19. (user adj1 computer adj1 interface).tw.
20. or/10‐19
21. Randomized Controlled Trial/
22. Randomization/
23. Controlled Study/
24. control group/
25. clinical trial/
26. Crossover Procedure/
27. Double Blind Procedure/
28. Single Blind Procedure/ or triple blind procedure/
29. placebo/
30. "types of study"/
31. (random$ or RCT or RCTs).tw.
32. (controlled adj5 (trial$ or stud$)).tw.
33. (clinical$ adj5 trial$).tw.
34. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
35. (quasi‐random$ or quasi random$ or pseudo‐random$ or pseudo random$).tw.
36. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
37. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
38. (cross‐over or cross over or crossover).tw.
39. placebo$ or sham).tw.
40. trial.ti.
41. (assign$ or allocat$).tw.
42. or/21‐41
43. 9 and 20 and 42
44. limit 43 to DD=20131026‐20170401
Appendix 4. AMED search strategy
1. cerebrovascular disorders/ or cerebral hemorrhage/ or cerebral infarction/ or cerebral ischemia/ or cerebrovascular accident/ or stroke/ or brain injuries/
2. (stroke$ or cva or poststroke or post‐stroke or cerebrovasc$ or cerebral vascular).tw.
3. ((cerebral or cerebellar or brain$ or vertebrobasilar) adj5 (infarct$ or isch?emi$ or thrombo$ or emboli$ or apoplexy)).tw.
4. ((cerebral or brain or subarachnoid) adj5 (haemorrhage or hemorrhage or haematoma or hematoma or bleed$)).tw.
5. hemiplegia/ or gait disorders/
6. (hempar$ or hemipleg$ or paresis or paretic or brain injur$).tw.
7. 1 or 2 or 3 or 4 or 5 or 6
8. virtual reality/ or computer systems/ or exp computers/ or internet/ or software/ or computer graphics/ or computer assisted instruction/ or computer simulation/ or therapy computer assisted/ or "play and playthings"/
9. (virtual reality$ or virtual‐reality$ or VR).tw.
10. (virtual adj3 (environment$ or object$ or world$ or treatment$ or system$ or program$ or rehabilitation$ or therap$ or driving or drive$ or car or tunnel or vehicle)).tw.
11. (computer adj3 (simulat$ or graphic$ or game$ or interact$)).tw.
12. (computer adj1 assist$ adj1 (therap$ or treat$)).tw.
13. (computer adj1 generat$ adj1 (environment$ or object$)).tw.
14. (video game$ or video gaming or gaming console$ or interactive game or interactive gaming or Nintendo Wii or gaming program$).tw.
15. (haptics or haptic device$).tw.
16. (simulat$ adj3 (environment$ or object$ or event$1 or driving or drive$ or car or tunnel or vehicle)).tw.
17. (user adj1 computer adj1 interface).tw.
18. or/8‐17
19. 7 and 18
20. limit 19 to UP=201310‐201704
Appendix 5. CINAHL search strategy
S55 S54 and EM 201310‐
S54 ‐S34 AND S53
S53 ‐S35 OR S36 OR S37 OR S38 OR S39 OR S40 OR S41 OR S42 OR S43 OR S46 OR S47 OR S50 OR S51 OR S52
S52 ‐TI trial OR ( TI (RCT or RCTs) OR AB (RCT or RCTs) )
S51 ‐TI ( counterbalance* or multiple baseline* or ABAB design ) or AB ( counterbalance* or multiple baseline* or ABAB design )
S50 ‐S48 and S49
S49 ‐TI trial* or AB trial*
S48 ‐TI ( clin* or intervention* or compar* or experiment* or preventive or therapeutic ) or AB ( clin* or intervention* or compar* or experiment* or preventive or therapeutic )
S47 ‐TI ( crossover or cross‐over or placebo* or control* or factorial or sham ) or AB ( crossover or cross‐over or placebo* or control* or factorial or sham )
S46 ‐S44 and S45
S45 ‐TI ( blind* or mask*) or AB ( blind* or mask* )
S44 ‐TI ( singl* or doubl* or tripl* or trebl* ) or AB ( singl* or doubl* or tripl* or trebl* )
S43 ‐TI random* or AB random*
S42 ‐(MH "Community Trials") or (MH "Experimental Studies") or (MH "One‐Shot Case Study") or (MH "Pretest‐Posttest Design+") or (MH "Solomon Four‐Group Design") or (MH "Static Group Comparison") or (MH "Study Design")
S41 ‐(MH "Clinical Research") or (MH "Clinical Nursing Research")
S40 ‐(MH "Placebo Effect") or (MH "Placebos") or (MH "Meta Analysis")
S39 ‐(MH "Factorial Design") or (MH "Quasi‐Experimental Studies") or (MH "Nonrandomized Trials")
S38 ‐(MH "Control (Research)") or (MH "Control Group")
S37 ‐(MH "Crossover Design") or (MH "Clinical Trials+") or (MH "Comparative Studies")
S36 ‐(MH "Random Assignment") or (MH "Random Sample+")
S35 ‐PT randomized controlled trial or clinical trial
S34 ‐S15 AND S33
S33 ‐S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR S30 OR S31 OR S32
S32 ‐TI (user N2 computer N2 interface) or AB (user N2 computer N2 interface)
S31 ‐TI (simulat* N3 (environment* or object* or event or events or driving or drive* or car or tunnel or vehicle)) or AB (simulat* N3 (environment* or object* or event or events or driving or drive* or car or tunnel or vehicle))
S30 ‐TI (haptics or haptic device*) or AB (haptics or haptic device*)
S29 ‐TI (video game* or video gaming or gaming console* or interactive game or interactive gaming or Nintendo Wii or gaming program*) or AB (video game* or video gaming or gaming console* or interactive game or interactive gaming or Nintendo Wii or gaming program*)
S28 ‐TI (computer generat* N3 (environment* or object*)) or AB (computer generat* N3 (environment* or object*))
S27 ‐TI (computer assist* N3 (therap* or treat*)) or AB (computer assist* N3 (therap* or treat*))
S26 ‐TI (computer N3 (simulat* or graphic* or game* or interact*)) or AB (computer N3 (simulat* or graphic* or game* or interact*))
S25 ‐TI (virtual N3 (environment* or object* or world* or treatment* or system* or program* or rehabilitation* or therap* or driving or drive* or car or tunnel or vehicle)) or AB (virtual N3 (environment* or object* or world* or treatment* or system* or program* or rehabilitation* or therap* or driving or drive* or car or tunnel or vehicle))
S24 ‐TI ( virtual reality* or virtual‐reality* or VR ) OR AB ( virtual reality* or virtual‐reality* or VR )
S23 ‐(MM "Touch")
S22 ‐(MH "Video Games")
S21 ‐(MH "Computer Graphics")
S20 ‐(MH "Microcomputers+")
S19 ‐(MH "Computer Systems") OR (MH "User‐Computer Interface+") OR (MH "Software+")
S18 ‐(MH "Computer Assisted Instruction")
S17 ‐(MH "Therapy, Computer Assisted")
S16 ‐(MH "Computer Simulation") OR (MH "Virtual Reality") OR (MH "Computing Methodologies") OR (MH "Computers and Computerization")
S15 ‐S1 OR S2 OR S3 OR S6 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14
S14 ‐TI brain injur* OR AB brain inju*
S13 ‐(MH "Brain Injuries")
S12 ‐(MH "Gait Disorders, Neurologic+")
S11 ‐TI ( hemipleg* or hemipar* or paresis or paretic ) or AB ( hemipleg* or hemipar* or paresis or paretic )
S10 ‐(MH "Hemiplegia")
S9 ‐S7 and S8
S8 ‐TI ( haemorrhage* or hemorrhage* or haematoma* or hematoma* or bleed* ) or AB ( haemorrhage* or hemorrhage* or haematoma* or hematoma* or bleed* )
S7 ‐TI ( brain* or cerebr* or cerebell* or intracerebral or intracranial or subarachnoid ) or AB ( brain* or cerebr* or cerebell* or intracerebral or intracranial or subarachnoid )
S6 ‐S4 and S5
S5 ‐TI ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* or occlus* ) or AB ( ischemi* or ischaemi* or infarct* or thrombo* or emboli* or occlus* )
S4 ‐TI ( brain* or cerebr* or cerebell* or intracran* or intracerebral ) or AB ( brain* or cerebr* or cerebell* or intracran* or intracerebral )
S3 ‐TI ( stroke or poststroke or post‐stroke or cerebrovasc* or brain vasc* or cerebral vasc or cva or apoplex or SAH ) or AB ( stroke or poststroke or post‐stroke or cerebrovasc* or brain vasc* or cerebral vasc or cva or apoplex or SAH )
S2 ‐(MH "Stroke Patients") OR (MH "Stroke Units")
S1 ‐(MH "Cerebrovascular Disorders") OR (MH "Basal Ganglia Cerebrovascular Disease+") OR (MH "Carotid Artery Diseases+") OR (MH "Cerebral Ischemia+") OR (MH "Cerebral Vasospasm") OR (MH "Intracranial Arterial Diseases+") OR (MH "Intracranial Embolism and Thrombosis") OR (MH "Intracranial Hemorrhage+") OR (MH "Stroke") OR (MH "Vertebral Artery Dissections")
Appendix 6. PsycINFO search strategy
1. cerebrovascular disorders/ or cerebral hemorrhage/ or exp cerebral ischemia/ or cerebrovascular accidents/ or subarachnoid hemorrhage/ or brain damage/
2. (stroke$ or cva or poststroke or post‐stroke or cerebrovasc$ or cerebral vascular).tw.
3. ((cerebral or cerebellar or brain$ or vertebrobasilar) adj5 (infarct$ or isch?emi$ or thrombo$ or emboli$ or apoplexy)).tw.
4. ((cerebral or brain or subarachnoid) adj5 (haemorrhage or hemorrhage or haematoma or hematoma or bleed$)).tw.
5. hemiparesis/ or hemiplegia/
6. (hempar$ or hemipleg$ or paresis or paretic or brain injur$).tw.
7. 1 or 2 or 3 or 4 or 5 or 6
8. virtual reality/ or role playing games/ or exp computer assisted instruction/ or computer assisted therapy/ or computer simulation/ or computer games/ or simulation games/ or computers/ or microcomputers/ or internet/ or computer applications/ or computer software/
9. (virtual reality$ or virtual‐reality$ or VR).tw.
10. (virtual adj3 (environment$ or object$ or world$ or treatment$ or system$ or program$ or rehabilitation$ or therap$ or driving or drive$ or car or tunnel or vehicle)).tw.
11. (computer adj3 (simulat$ or graphic$ or game$ or interact$)).tw.
12. (computer adj1 assist$ adj1 (therap$ or treat$)).tw.
13. (computer adj1 generat$ adj1 (environment$ or object$)).tw.
14. (video game$ or video gaming or gaming console$ or interactive game or interactive gaming or Nintendo Wii or gaming program$).tw.
15. (haptics or haptic device$).tw.
16. (simulat$ adj3 (environment$ or object$ or event$1 or driving or drive$ or car or tunnel or vehicle)).tw.
17. (user adj1 computer adj1 interface).tw.
18. or/8‐17
19. 7 and 18
20. limit 19 to yr=2013‐Current
Appendix 7. Cochrane 'Risk of bias' table
The Cochrane tool for assessing risk of bias (Higgins 2011a)
| Domain | Description | Review authors’ judgement |
| Sequence generation | Describe the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups
| Was the allocation sequence adequately generated?
□ Yes □ No □ Unsure
|
| Allocation concealment | Describe the method used to conceal the allocation sequence in sufficient detail to determine whether intervention allocations could have been foreseen in advance of, or during, enrolment
| Was allocation adequately concealed? □ Yes □ No □ Unsure
|
| Blinding of outcome assessors Assessments should be made for each main outcome (or class of outcomes) | Describe all measures used, if any, to blind personnel from knowledge of which intervention a participant received. Provide any information relating to whether the intended blinding was effective
| Was knowledge of the allocated intervention adequately prevented during the study?
Outcome assessors □ Yes □ No □ Unsure
|
| Incomplete outcome data Assessments should be made for each main outcome (or class of outcomes). | Describe the completeness of outcome data for each main outcome, including attrition and exclusions from the analysis. State whether attrition and exclusions were reported, the numbers in each intervention group (compared with total randomised participants), reasons for attrition/exclusions where reported, and any re‐inclusions in analyses performed by the review authors | Were incomplete outcome data adequately addressed? □ Yes □ No □ Unsure |
| Selective outcome reporting | State how the possibility of selective outcome reporting was examined by the review authors, and what was found | Are reports of the study free of suggestion of selective outcome reporting? □ Yes □ No □ Unsure |
Methodological quality summary: review authors' judgements about each methodological quality item for each included study
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies
Comparison 1 Virtual reality versus conventional therapy: effect on upper limb function post intervention, Outcome 1 Upper limb function post intervention (composite measure).
Comparison 1 Virtual reality versus conventional therapy: effect on upper limb function post intervention, Outcome 2 Upper limb function post intervention (Fugl Meyer).
Comparison 1 Virtual reality versus conventional therapy: effect on upper limb function post intervention, Outcome 3 Hand function post intervention (grip strength).
Comparison 1 Virtual reality versus conventional therapy: effect on upper limb function post intervention, Outcome 4 Upper limb function post intervention: amount of use (subjective).
Comparison 1 Virtual reality versus conventional therapy: effect on upper limb function post intervention, Outcome 5 Upper limb function at short term follow‐up (up to 3 months).
Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 1 Dose of intervention.
Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 2 Time since onset of stroke.
Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 3 Specialised or gaming.
Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 4 Severity of impairment.
Comparison 3 Additional virtual reality intervention: effect on upper limb function post intervention, Outcome 1 Upper limb function (composite measure).
Comparison 4 Additional virtual reality intervention: effect on upper limb function post intervention: subgroup analyses, Outcome 1 Dose of intervention.
Comparison 4 Additional virtual reality intervention: effect on upper limb function post intervention: subgroup analyses, Outcome 2 Time since onset of stroke.
Comparison 4 Additional virtual reality intervention: effect on upper limb function post intervention: subgroup analyses, Outcome 3 Specialised or gaming.
Comparison 5 Virtual reality versus conventional therapy: effect on lower limb activity post intervention, Outcome 1 Gait speed.
Comparison 5 Virtual reality versus conventional therapy: effect on lower limb activity post intervention, Outcome 2 Timed Up and Go Test.
Comparison 5 Virtual reality versus conventional therapy: effect on lower limb activity post intervention, Outcome 3 Balance.
Comparison 6 Virtual reality versus conventional therapy: effect on lower limb activity post intervention: subgroup analyses, Outcome 1 Dose of intervention: effect on gait speed.
Comparison 7 Additional virtual reality intervention: effect on lower limb activity post intervention, Outcome 1 Gait speed.
Comparison 7 Additional virtual reality intervention: effect on lower limb activity post intervention, Outcome 2 Functional mobility (Timed Up and Go).
Comparison 7 Additional virtual reality intervention: effect on lower limb activity post intervention, Outcome 3 Balance.
Comparison 8 Additional virtual reality intervention: effect on global motor function post intervention, Outcome 1 Global motor function.
Comparison 9 Virtual reality versus conventional therapy: effect on activity limitation, Outcome 1 ADL outcome.
Comparison 10 Additional virtual reality intervention: effect on activity limitation, Outcome 1 ADL outcome.
| Virtual reality compared to conventional therapy for stroke rehabilitation | ||||||
| Patient or population: people receiving stroke rehabilitation Comparison: conventional therapy | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Virtual reality | |||||
| Upper limb function | Same dose of conventional therapy | The mean upper limb function in the intervention groups was | 1038 | ⊕⊕⊝⊝ | No statistically significant difference between groups | |
| Quality of life | Same dose of conventional therapy | No significant benefit found on total score of the SF‐36 | 300 (3 studies) | ⊕⊕⊝⊝ low1,2,4 | Studies could not be pooled. None of the 3 studies found significant differences between groups in total score. 2 studies reported significant differences in domains of the SF36 | |
| Gait speed | Same dose of conventional therapy | The mean gait speed in the intervention groups was | 139 | ⊕⊕⊝⊝ | No statistically significant difference between groups | |
| ADL outcome | Same dose of conventional therapy | The mean ADL outcome in the intervention groups was | 466 | ⊕⊕⊕⊝ | Small effect in favour of those receiving virtual reality intervention | |
| ADL: activities of daily living; CI: confidence interval | ||||||
| GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect | ||||||
| 1Risk of bias was unclear in a number of studies. | ||||||
| Virtual reality intervention compared with usual care (thus provided as additional therapy) for stroke rehabilitation | ||||||
| Patient or population: people receiving stroke rehabilitation Settings: hospital, clinic or home Intervention: virtual reality provided in addition to usual care Comparison: usual care | ||||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect | No of participants | Quality of the evidence | Comments | |
| Assumed risk | Corresponding risk | |||||
| Control | Virtual reality (provided in addition to usual care) | |||||
| Upper limb function | Usual care | The SMD in the intervention groups was 0.49 standard deviations higher (0.21 to 0.77) | ‐ | 210 (10 studies) | ⊕⊕⊝⊝ | Moderate effect in favour of providing virtual reality intervention in addition to usual care |
| Quality of life ‐ not measured in any of the studies | ‐ | ‐ | ‐ | ‐ | ‐ | Not measured in the studies |
| Gait speed | Usual care | The mean difference in the intervention groups was | ‐ | 57 (3 studies) | ⊕⊕⊝⊝ | No statistically significant difference between groups |
| Global motor function | Usual care | The SMD in the intervention groups was | ‐ | 43 (3 studies) | ⊕⊕⊝⊝ | No statistically significant difference between groups |
| ADL outcome | Usual care | The SMD in the intervention groups was 0.44 standard deviations higher (0.11 to 0.76) | ‐ | 153 (8 studies) | ⊕⊕⊝⊝ | Small to moderate effect in favour of virtual reality intervention |
| *The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). ADL: activities of daily living; CI: confidence interval; MD: mean difference; RR: risk ratio; SMD: standardised mean difference | ||||||
| GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect | ||||||
| 1Risk of bias was unclear in a number of studies. | ||||||
| Author and year | Upper limb function | Hand function | Lower limb activity | Balance and postural control | Global motor function | Cognitive function | Activity limitation | Participation restriction and QOL |
| Action Research Arm Test, Motor Activity Log Arm Function Test | Modified Rankin Scale | Stroke Impact Scale, EQ5D, Canadian Occupational Performance Measure | ||||||
| — | — | — | — | — | Useful Field of View test | On‐road driving test score, decision of fitness to drive | — | |
| — | — | Timed Up and Go | Berg Balance Scale, centre of pressure data, body symmetry data | — | — | Functional Independence Measure | — | |
| 6‐minute walk test, step test | Functional reach | Motor Assessment Scale | Functional Independence Measure (transfers, mobility, stairs) | |||||
| Fugl Meyer UE Scale, Motor Proficiency Speed (abbreviated Wolf Motor Function test + Digital reaction time test) | Motor skill performance (Box and Block and tapper test) | — | — | — | — | Functional Independence (CAFE40) | ||
| Wolf Motor Function Test | — | — | — | — | Motor Free Visual Perception Test | — | — | |
| 10‐m walk test | Berg Balance Scale | Modified Barthel Index | ||||||
| Action Research Arm Test, Upper Limb Motricity Index | — | — | — | — | — | — | — | |
| Fugl Meyer | Dynamic Gait Index | SF36 | ||||||
| Fugl Meyer UE, Chedoke Arm and Hand Inventory | — | — | — | — | — | Barthel Index | — | |
| Jebsen Taylor Hand Function Test | Stroke Impact Scale | |||||||
| Fugl Meyer, Motor Activity Log | ||||||||
| Action Research Arm Test | Grip strength | 10‐m walk test | ||||||
| Berg Balance Scale | Modified Barthel Index | |||||||
| Fugl Meyer UE Scale, Rancho Functional Test, Motor Activity Log (amount of use and quality of movement) | Grip strength (kg) | — | — | — | — | — | ‐ | |
| Timed Up and Go Test | Forward Reach Test | Falls Efficacy Scale International | ||||||
| — | — | 6‐m walk test, Obstacle Test, 6‐minute walk test | Customised balance test designed by the researchers | — | — | — | — | |
| Fugl Meyer UE Scale, Manual Function Test, Motor Activity Log (amount of use and quality of movement) | Box and Block Test | — | — | — | — | — | ||
| — | — | — | — | — | — | — | — | |
| — | — | Timed Up and Go | — | — | — | — | — | |
| — | — | — | — | — | Mini Mental State Examination | Modified Barthel Index | — | |
| — | — | 10‐m walk test, GAIT‐RITE gait analysis system | Berg Balance Scale, balance performance monitor | Modified Motor Assessment Scale | — | — | — | |
| Motricity Index | — | Motricity Index | — | — | Computerised neuropsychological test and Tower of London test | Korean Modified Barthel Index | — | |
| — | — | — | — | — | Measures of spatial neglect (star cancellation, line bisection test, Catherine Bergego Scale) | Korean Modified Barthel Index | — | |
| — | — | — | Postural assessment scale | Modified Motor Assessment Scale | — | Functional Independence Measure | — | |
| Fugl Meyer UE | — | — | — | — | — | Functional Independence Measure | — | |
| Fugl Meyer UE, Wolf Motor Function Test, Motor Activity Log (quality of movement) | ‐ | ‐ | ‐ | ‐ | ‐ | ‐ | Stroke Impact Scale, Goal attainment scale | |
| Timed Up and Go Test | Berg Balance Scale | |||||||
| Fugl Meyer, Action Research Arm Test | Functional Independence Measure | Stroke Impact Scale | ||||||
| Fugl Meyer UE, Manual Function Test | — | — | — | — | — | Korean Modified Barthel Index | — | |
| — | — | — | — | — | — | — | — | |
| Functional Reach Test | ||||||||
| Timed Up and Go Test | Berg Balance Scale | |||||||
| Functional Reach Test | ||||||||
| Fugl Meyer UE Scale, Reach Performance Scale for Stroke, Box and Blocks Test, Wolf Motor Function Test, Motor Activity Log | ||||||||
| Stroke Impact Scale | ||||||||
| Tinetti Performance Oriented Mobility Assessment, 10‐m walk test | Berg Balance Scale, Brunel Balance Assessment | |||||||
| Fugl Meyer UE Scale, Action Research Arm Test | Gait speed | Berg Balance Scale | Functional Independence Measure | |||||
| Fugl Meyer UE Scale | Motor Assessment Scale | |||||||
| Gait analysis (gaitlab assessment) | ||||||||
| Fugl Meyer UE, Wolf Motor Function Test, Box and Block Test, Motor Activity Log | ||||||||
| — | — | — | — | — | — | DriveAble Testing Ltd Driver Evaluation | — | |
| Wolf Motor Function Test timed tasks and strength subtests, Motor Activity Log QOM scale, Fugl Meyer, Box and Block Test | ||||||||
| — | — | Gait speed over 7‐metre walkway, 6‐minute walk test, Patient Activity Monitor | — | — | — | — | — | |
| 10‐m walk test | Berg Balance Scale | Barthel Index | Functional Ambulation Category | |||||
| Static balance ability | ||||||||
| Fugl Meyer UE Scale | — | — | — | — | — | Functional Independence Measure | — | |
| Fugl Meyer UE Scale, Abilhand Scale | — | — | — | — | — | — | ‐ | |
| Fugl Meyer UE Scale | — | — | — | — | — | Functional Independence Measure | — | |
| Fugl Meyer UE, Stroke Upper Limb Capacity Sclae | ||||||||
| — | — | Timed Up and Go | Berg Balance Scale, functional reach, centre of pressure | — | — | — | — | |
| Fugl Meyer UE, Ranchos Functional Test for UE, Motor Activity Log, Box and Blocks Test | Grip strength | |||||||
| Abbreviated Wolf Motor Function Test | Box and Block Test, grip strength (kg) | — | — | — | — | — | Stroke Impact Scale (hand function, composite function, perception of recovery) | |
| Abbreviated Wolf Motor Function Test, Box and Block Test | Grip strength | Functional Independence Measure, Barthel Index, Modified Rankin Scale | Stroke Impact Scale | |||||
| Fugl Meyer UE | — | — | — | — | — | Modified Barthel Index | — | |
| Fugl Meyer UE | SF36 | |||||||
| Fugl Meyer UE, Box and Block Test | — | — | — | — | — | — | ||
| Timed Up and Go Test, 10‐minute walk test | Balance (Biofeedback system) | |||||||
| Wolf Motor Function Test, Motor Activity Log, Nine Hole Peg Test | — | — | — | — | Nottingham Extended Activities of Daily Living Scale | |||
| Fugl Meyer UE, Wolf Motor Function test, Reaching performance scale for stroke, Motor Activity Log | — | — | — | — | — | — | ||
| Fugl Meyer UE Scale, Upper Limb Motricity Index | — | — | — | — | — | — | — | |
| Action Research Arm Test, Jebsen Taylor Hand Function Test, Fugl Meyer UE | Grip strength | |||||||
| Timed walking speed test, Timed Up and Go | Mini Mental State Examination | Functional Ambulation Category | ||||||
| 10‐m walking speed, Fugl Meyer (LE) | Brunel Balance Assessment | |||||||
| — | — | Walking speed, Community Walk Test | — | — | — | — | Walking Ability Questionnaire, Activities Specific Balance Confidence Scale | |
| — | — | Gait analysis data | Balance analysis data | — | — | — | — | |
| Brunnstrom Upper Extremity Stages | Brunnstrom Hand Stages | — | — | — | — | Functional Independence Measure self‐care section | — | |
| Fugl Meyer, Action Research Arm Test, Motor Activity Log | Functional Independence Measure | |||||||
| — | — | Functional ambulation category | — | Modified Motor Assessment Scale | — | — | — | |
| Fugl Meyer UE, Reaching performance scale | — | — | — | — | — | Functional Independence Measure | — | |
| fMRI: functional magnetic resonance imaging | ||||||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Upper limb function post intervention (composite measure) Show forest plot | 22 | 1038 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.07 [‐0.05, 0.20] |
| 2 Upper limb function post intervention (Fugl Meyer) Show forest plot | 16 | 599 | Mean Difference (IV, Fixed, 95% CI) | 2.85 [1.06, 4.65] |
| 3 Hand function post intervention (grip strength) Show forest plot | 6 | 266 | Std. Mean Difference (IV, Fixed, 95% CI) | ‐0.02 [‐0.27, 0.22] |
| 4 Upper limb function post intervention: amount of use (subjective) Show forest plot | 5 | 161 | Std. Mean Difference (IV, Fixed, 95% CI) | ‐0.11 [‐0.42, 0.21] |
| 5 Upper limb function at short term follow‐up (up to 3 months) Show forest plot | 9 | 366 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.11 [‐0.10, 0.32] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Dose of intervention Show forest plot | 22 | 1038 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.07 [‐0.05, 0.20] |
| 1.1 Less than 15 hours of intervention | 9 | 430 | Std. Mean Difference (IV, Fixed, 95% CI) | ‐0.01 [‐0.20, 0.18] |
| 1.2 More than 15 hours of intervention | 13 | 608 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.13 [‐0.03, 0.29] |
| 2 Time since onset of stroke Show forest plot | 20 | 930 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.04 [‐0.09, 0.17] |
| 2.1 Less than 6 months | 7 | 555 | Std. Mean Difference (IV, Fixed, 95% CI) | ‐0.06 [‐0.23, 0.11] |
| 2.2 More than 6 months | 13 | 375 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.19 [‐0.02, 0.39] |
| 3 Specialised or gaming Show forest plot | 22 | 1038 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.07 [‐0.05, 0.20] |
| 3.1 Specialised | 15 | 506 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.17 [‐0.00, 0.35] |
| 3.2 Gaming | 7 | 532 | Std. Mean Difference (IV, Fixed, 95% CI) | ‐0.02 [‐0.20, 0.15] |
| 4 Severity of impairment Show forest plot | 21 | 998 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.07 [‐0.06, 0.19] |
| 4.1 Mild to moderate impairment | 13 | 678 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.10 [‐0.06, 0.25] |
| 4.2 Moderate to severe impairment | 8 | 320 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.01 [‐0.22, 0.23] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Upper limb function (composite measure) Show forest plot | 10 | 210 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.49 [0.21, 0.77] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Dose of intervention Show forest plot | 10 | 210 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.49 [0.21, 0.77] |
| 1.1 Less than 15 hours of intervention | 7 | 153 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.47 [0.14, 0.80] |
| 1.2 More than 15 hours of intervention | 3 | 57 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.54 [0.00, 1.07] |
| 2 Time since onset of stroke Show forest plot | 9 | 181 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.44 [0.14, 0.74] |
| 2.1 Less than 6 months | 5 | 102 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.28 [‐0.12, 0.67] |
| 2.2 More than 6 months | 4 | 79 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.65 [0.19, 1.11] |
| 3 Specialised or gaming Show forest plot | 10 | 210 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.49 [0.21, 0.77] |
| 3.1 Specialised | 7 | 139 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.40 [0.06, 0.75] |
| 3.2 Gaming | 3 | 71 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.67 [0.18, 1.15] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Gait speed Show forest plot | 6 | 139 | Mean Difference (IV, Fixed, 95% CI) | 0.09 [‐0.04, 0.22] |
| 2 Timed Up and Go Test Show forest plot | 3 | 89 | Mean Difference (IV, Fixed, 95% CI) | ‐1.76 [‐4.67, 1.16] |
| 3 Balance Show forest plot | 3 | 72 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.39 [‐0.09, 0.86] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Dose of intervention: effect on gait speed Show forest plot | 6 | 139 | Mean Difference (IV, Fixed, 95% CI) | 0.09 [‐0.04, 0.22] |
| 1.1 Less than 10 hours of intervention | 2 | 40 | Mean Difference (IV, Fixed, 95% CI) | 0.01 [‐0.22, 0.24] |
| 1.2 More than 10 hours of intervention | 4 | 99 | Mean Difference (IV, Fixed, 95% CI) | 0.12 [‐0.03, 0.28] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Gait speed Show forest plot | 3 | 57 | Mean Difference (IV, Fixed, 95% CI) | 0.08 [‐0.05, 0.21] |
| 2 Functional mobility (Timed Up and Go) Show forest plot | 3 | 93 | Mean Difference (IV, Fixed, 95% CI) | ‐4.76 [‐8.91, ‐0.61] |
| 3 Balance Show forest plot | 7 | 173 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.59 [0.28, 0.90] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Global motor function Show forest plot | 3 | 43 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.01 [‐0.60, 0.61] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 ADL outcome Show forest plot | 10 | 466 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.25 [0.06, 0.43] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 ADL outcome Show forest plot | 8 | 153 | Std. Mean Difference (IV, Fixed, 95% CI) | 0.44 [0.11, 0.76] |
