Virtual reality for stroke rehabilitation

Kate E Laver; Belinda Lange; Stacey George; Judith E Deutsch; Gustavo Saposnik; Maria Crotty

doi:10.1002/14651858.CD008349.pub4

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Figure 1

Study flow diagram

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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study

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Figure 3

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies

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Analysis 1.1

Comparison 1 Virtual reality versus conventional therapy: effect on upper limb function post intervention, Outcome 1 Upper limb function post intervention (composite measure).

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Analysis 1.2

Comparison 1 Virtual reality versus conventional therapy: effect on upper limb function post intervention, Outcome 2 Upper limb function post intervention (Fugl Meyer).

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Analysis 1.3

Comparison 1 Virtual reality versus conventional therapy: effect on upper limb function post intervention, Outcome 3 Hand function post intervention (grip strength).

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Analysis 1.4

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).

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Analysis 1.5

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).

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Analysis 2.1

Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 1 Dose of intervention.

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Analysis 2.2

Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 2 Time since onset of stroke.

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Analysis 2.3

Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 3 Specialised or gaming.

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Analysis 2.4

Comparison 2 Virtual reality versus conventional therapy: upper limb function: subgroup analyses, Outcome 4 Severity of impairment.

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Analysis 3.1

Comparison 3 Additional virtual reality intervention: effect on upper limb function post intervention, Outcome 1 Upper limb function (composite measure).

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Analysis 4.1

Comparison 4 Additional virtual reality intervention: effect on upper limb function post intervention: subgroup analyses, Outcome 1 Dose of intervention.

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Analysis 4.2

Comparison 4 Additional virtual reality intervention: effect on upper limb function post intervention: subgroup analyses, Outcome 2 Time since onset of stroke.

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Analysis 4.3

Comparison 4 Additional virtual reality intervention: effect on upper limb function post intervention: subgroup analyses, Outcome 3 Specialised or gaming.

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Analysis 5.1

Comparison 5 Virtual reality versus conventional therapy: effect on lower limb activity post intervention, Outcome 1 Gait speed.

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Analysis 5.2

Comparison 5 Virtual reality versus conventional therapy: effect on lower limb activity post intervention, Outcome 2 Timed Up and Go Test.

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Analysis 5.3

Comparison 5 Virtual reality versus conventional therapy: effect on lower limb activity post intervention, Outcome 3 Balance.

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Analysis 6.1

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.

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Analysis 7.1

Comparison 7 Additional virtual reality intervention: effect on lower limb activity post intervention, Outcome 1 Gait speed.

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Analysis 7.2

Comparison 7 Additional virtual reality intervention: effect on lower limb activity post intervention, Outcome 2 Functional mobility (Timed Up and Go).

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Analysis 7.3

Comparison 7 Additional virtual reality intervention: effect on lower limb activity post intervention, Outcome 3 Balance.

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Analysis 8.1

Comparison 8 Additional virtual reality intervention: effect on global motor function post intervention, Outcome 1 Global motor function.

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Analysis 9.1

Comparison 9 Virtual reality versus conventional therapy: effect on activity limitation, Outcome 1 ADL outcome.

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Analysis 10.1

Comparison 10 Additional virtual reality intervention: effect on activity limitation, Outcome 1 ADL outcome.

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Summary of findings for the main comparison. Virtual reality compared to conventional therapy for stroke rehabilitation

Virtual reality compared to conventional therapy for stroke rehabilitation
Patient or population: people receiving stroke rehabilitation Settings: hospital, clinic or home Intervention: virtual reality Comparison: conventional therapy
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	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 0.07 standard deviations higher (‐0.05 to 0.20 higher)		1038 (22 studies)	⊕⊕⊝⊝ low^1,2,3	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)	⊕⊕⊝⊝ low^1,2,4	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 0.09 metres per second faster (0.04 lower to 0.22 higher)		139 (6 studies)	⊕⊕⊝⊝ low^1,3,4	No statistically significant difference between groups
ADL outcome	Same dose of conventional therapy	The mean ADL outcome in the intervention groups was 0.25 standard deviations higher (0.06 to 0.43 higher)		466 (10 studies)	⊕⊕⊕⊝ moderate¹	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. ²Downgraded by 1 due to inconsistency in findings across studies. ³Surrogate outcome. ⁴Small total population size (< 400).

Summary of findings for the main comparison. Virtual reality compared to conventional therapy for stroke rehabilitation

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Summary of findings 2. Virtual reality plus usual care compared with usual care alone

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 (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	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)	⊕⊕⊝⊝ low^1,3,4	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 0.08 metres per second faster (‐0.05 to 0.21)	‐	57 (3 studies)	⊕⊕⊝⊝ low^1,3,4	No statistically significant difference between groups
Global motor function	Usual care	The SMD in the intervention groups was 0.01 standard deviations higher (‐0.60 to 0.61)	‐	43 (3 studies)	⊕⊕⊝⊝ low^1,3,4	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)	⊕⊕⊝⊝ low^1,3,4	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. ²Downgraded by 1 due to inconsistency in findings across studies. ³Surrogate outcome. ⁴Small total population size (< 400).

Summary of findings 2. Virtual reality plus usual care compared with usual care alone

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Table 1. Outcome measures used from the included trials

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
Adie 2017	Action Research Arm Test, Motor Activity Log Arm Function Test						Modified Rankin Scale	Stroke Impact Scale, EQ5D, Canadian Occupational Performance Measure
Akinwuntan 2005	—	—	—	—	—	Useful Field of View test	On‐road driving test score, decision of fitness to drive	—
Barcala 2013	—	—	Timed Up and Go	Berg Balance Scale, centre of pressure data, body symmetry data	—	—	Functional Independence Measure	—
Bower 2015			6‐minute walk test, step test	Functional reach	Motor Assessment Scale		Functional Independence Measure (transfers, mobility, stairs)
Byl 2013	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)
Cho 2012	Wolf Motor Function Test	—	—	—	—	Motor Free Visual Perception Test	—	—
Chow 2013			10‐m walk test	Berg Balance Scale			Modified Barthel Index
Crosbie 2008	Action Research Arm Test, Upper Limb Motricity Index	—	—	—	—	—	—	—
da Silva Ribeiro 2015	Fugl Meyer			Dynamic Gait Index				SF36
da Silva Cameirao 2011	Fugl Meyer UE, Chedoke Arm and Hand Inventory	—	—	—	—	—	Barthel Index	—
Fan 2014	Jebsen Taylor Hand Function Test							Stroke Impact Scale
Galvao 2015	Fugl Meyer, Motor Activity Log
Givon 2016	Action Research Arm Test	Grip strength	10‐m walk test
Han 2013				Berg Balance Scale			Modified Barthel Index
Housman 2009	Fugl Meyer UE Scale, Rancho Functional Test, Motor Activity Log (amount of use and quality of movement)	Grip strength (kg)	—	—	—	—	—	‐
Hung 2014			Timed Up and Go Test	Forward Reach Test				Falls Efficacy Scale International
Jaffe 2004	—	—	6‐m walk test, Obstacle Test, 6‐minute walk test	Customised balance test designed by the researchers	—	—	—	—
Jang 2005	Fugl Meyer UE Scale, Manual Function Test, Motor Activity Log (amount of use and quality of movement)	Box and Block Test	—	—	—	—	—
Jannink 2008	—	—	—	—	—	—	—	—
Jung 2012	—	—	Timed Up and Go	—	—	—	—	—
Kang 2009	—	—	—	—	—	Mini Mental State Examination	Modified Barthel Index	—
Kim 2009	—	—	10‐m walk test, GAIT‐RITE gait analysis system	Berg Balance Scale, balance performance monitor	Modified Motor Assessment Scale	—	—	—
Kim 2011a	Motricity Index	—	Motricity Index	—	—	Computerised neuropsychological test and Tower of London test	Korean Modified Barthel Index	—
Kim 2011b	—	—	—	—	—	Measures of spatial neglect (star cancellation, line bisection test, Catherine Bergego Scale)	Korean Modified Barthel Index	—
Kim 2012a	—	—	—	Postural assessment scale	Modified Motor Assessment Scale	—	Functional Independence Measure	—
Kiper 2011	Fugl Meyer UE	—	—	—	—	—	Functional Independence Measure	—
Klamroth‐Marganska 2014	Fugl Meyer UE, Wolf Motor Function Test, Motor Activity Log (quality of movement)	‐	‐	‐	‐	‐	‐	Stroke Impact Scale, Goal attainment scale
Ko 2015			Timed Up and Go Test	Berg Balance Scale
Kong 2014	Fugl Meyer, Action Research Arm Test						Functional Independence Measure	Stroke Impact Scale
Kwon 2012	Fugl Meyer UE, Manual Function Test	—	—	—	—	—	Korean Modified Barthel Index	—
Lam 2006	—	—	—	—	—	—	—	—
Lee 2013				Functional Reach Test
Lee 2014a			Timed Up and Go Test	Berg Balance Scale
Lee 2015a				Functional Reach Test
Lee 2015b
Levin 2012	Fugl Meyer UE Scale, Reach Performance Scale for Stroke, Box and Blocks Test, Wolf Motor Function Test, Motor Activity Log
Linder 2015								Stroke Impact Scale
Llorens 2015			Tinetti Performance Oriented Mobility Assessment, 10‐m walk test	Berg Balance Scale, Brunel Balance Assessment
Low 2012	Fugl Meyer UE Scale, Action Research Arm Test		Gait speed	Berg Balance Scale			Functional Independence Measure
Manlapaz 2010	Fugl Meyer UE Scale				Motor Assessment Scale
Mao 2015			Gait analysis (gaitlab assessment)
Matsuo 2013	Fugl Meyer UE, Wolf Motor Function Test, Box and Block Test, Motor Activity Log
Mazer 2005	—	—	—	—	—	—	DriveAble Testing Ltd Driver Evaluation	—
McNulty 2015	Wolf Motor Function Test timed tasks and strength subtests, Motor Activity Log QOM scale, Fugl Meyer, Box and Block Test
Mirelman 2008	—	—	Gait speed over 7‐metre walkway, 6‐minute walk test, Patient Activity Monitor	—	—	—	—	—
Morone 2014			10‐m walk test	Berg Balance Scale			Barthel Index	Functional Ambulation Category
Nara 2015				Static balance ability
Piron 2007	Fugl Meyer UE Scale	—	—	—	—	—	Functional Independence Measure	—
Piron 2009	Fugl Meyer UE Scale, Abilhand Scale	—	—	—	—	—	—	‐
Piron 2010	Fugl Meyer UE Scale	—	—	—	—	—	Functional Independence Measure	—
Prange 2015	Fugl Meyer UE, Stroke Upper Limb Capacity Sclae
Rajaratnam 2013	—	—	Timed Up and Go	Berg Balance Scale, functional reach, centre of pressure	—	—	—	—
Reinkensmeyer 2012	Fugl Meyer UE, Ranchos Functional Test for UE, Motor Activity Log, Box and Blocks Test	Grip strength
Saposnik 2010	Abbreviated Wolf Motor Function Test	Box and Block Test, grip strength (kg)	—	—	—	—	—	Stroke Impact Scale (hand function, composite function, perception of recovery)
Saposnik 2016	Abbreviated Wolf Motor Function Test, Box and Block Test	Grip strength					Functional Independence Measure, Barthel Index, Modified Rankin Scale	Stroke Impact Scale
Shin 2014	Fugl Meyer UE	—	—	—	—	—	Modified Barthel Index	—
Shin 2015	Fugl Meyer UE							SF36
Sin 2013	Fugl Meyer UE, Box and Block Test		—	—	—	—	—	—
Song 2015			Timed Up and Go Test, 10‐minute walk test	Balance (Biofeedback system)
Standen 2011	Wolf Motor Function Test, Motor Activity Log, Nine Hole Peg Test		—	—	—	—	Nottingham Extended Activities of Daily Living Scale
Subramanian 2013	Fugl Meyer UE, Wolf Motor Function test, Reaching performance scale for stroke, Motor Activity Log	—	—	—	—	—	—
Sucar 2009	Fugl Meyer UE Scale, Upper Limb Motricity Index	—	—	—	—	—	—	—
Thielbar 2014	Action Research Arm Test, Jebsen Taylor Hand Function Test, Fugl Meyer UE	Grip strength
Ucar 2014			Timed walking speed test, Timed Up and Go			Mini Mental State Examination		Functional Ambulation Category
Xiang 2014			10‐m walking speed, Fugl Meyer (LE)	Brunel Balance Assessment
Yang 2008	—	—	Walking speed, Community Walk Test	—	—	—	—	Walking Ability Questionnaire, Activities Specific Balance Confidence Scale
Yang 2011	—	—	Gait analysis data	Balance analysis data	—	—	—	—
Yavuzer 2008	Brunnstrom Upper Extremity Stages	Brunnstrom Hand Stages	—	—	—	—	Functional Independence Measure self‐care section	—
Yin 2014	Fugl Meyer, Action Research Arm Test, Motor Activity Log						Functional Independence Measure
You 2005	—	—	Functional ambulation category	—	Modified Motor Assessment Scale	—	—	—
Zucconi 2012	Fugl Meyer UE, Reaching performance scale	—	—	—	—	—	Functional Independence Measure	—
fMRI: functional magnetic resonance imaging QOL: quality of life UE: upper extremity

Table 1. Outcome measures used from the included trials

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Comparison 1. Virtual reality versus conventional therapy: effect on upper limb function post intervention

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]

Comparison 1. Virtual reality versus conventional therapy: effect on upper limb function post intervention

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Comparison 2. Virtual reality versus conventional therapy: upper limb function: subgroup analyses

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]

Comparison 2. Virtual reality versus conventional therapy: upper limb function: subgroup analyses

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Comparison 3. Additional virtual reality intervention: effect on upper limb function post intervention

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]

Comparison 3. Additional virtual reality intervention: effect on upper limb function post intervention

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Comparison 4. Additional virtual reality intervention: effect on upper limb function post intervention: subgroup analyses

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]

Comparison 4. Additional virtual reality intervention: effect on upper limb function post intervention: subgroup analyses

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Comparison 5. Virtual reality versus conventional therapy: effect on lower limb activity post intervention

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]

Comparison 5. Virtual reality versus conventional therapy: effect on lower limb activity post intervention

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Comparison 6. Virtual reality versus conventional therapy: effect on lower limb activity post intervention: subgroup analyses

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]

Comparison 6. Virtual reality versus conventional therapy: effect on lower limb activity post intervention: subgroup analyses

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Comparison 7. Additional virtual reality intervention: effect on lower limb activity post intervention

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]

Comparison 7. Additional virtual reality intervention: effect on lower limb activity post intervention

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Comparison 8. Additional virtual reality intervention: effect on global motor function post intervention

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]

Comparison 8. Additional virtual reality intervention: effect on global motor function post intervention

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Comparison 9. Virtual reality versus conventional therapy: effect on activity limitation

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]

Comparison 9. Virtual reality versus conventional therapy: effect on activity limitation

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Comparison 10. Additional virtual reality intervention: effect on activity limitation

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]

Comparison 10. Additional virtual reality intervention: effect on activity limitation

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