Effectiveness of Using Virtual Reality–Supported Exercise Therapy for Upper Extremity Motor Rehabilitation in Patients With Stroke: Systematic Review and Meta-analysis of Randomized Controlled Trials

Liu K., Or C.K., So M., Cheung B., Chan B., Tiwari A., Tan J.

Health information technologies (HITs) are increasingly being used to support the self-management of chronic diseases. However, patients' initial or continued acceptance of such technologies is not always achieved.The aim of this study was to develop a theory-driven HIT acceptance model to examine factors affecting acceptance of HIT (measured by behavioral intention; BI) for disease self-management among patients with chronic diseases, in which we also focused on three additional, previously unexplored factors related to perceived hand function (PHF), perceived visual function (PVF), and perceived space adequacy (PSA) and a longitudinal scrutinization of changes in the effects of these factors on acceptance over time.The theoretical basis of our acceptance model was drawn from the technology acceptance model and the theory of planned behavior. The model was further extended by including patients' PHF, PVF (related to patients with chronic diseases who are mostly elderly), and PSA (related to the patients' home environment). The model was tested in the context of type 2 diabetes and hypertension self-management via a touchscreen tablet-based system over a 24-week period. A questionnaire was administered at four time points (baseline and 8, 16, and 24 weeks after implementation) to collect data from 151 patients with coexisting type 2 diabetes and hypertension. We tested the model at each time point using partial least squares structural equation modeling.Perceived usefulness of the self-management system influenced BI directly at 8 and 24 weeks and indirectly at 8, 16, and 24 weeks. Perceived ease of use indirectly affected BI at 8, 16, and 24 weeks. Attitude directly affected BI at 8, 16, and 24 weeks. Perceived behavioral control directly influenced BI at baseline and 8 and 16 weeks. Subjective norms indirectly influenced BI at 8, 16, and 24 weeks. PHF and PVF indirectly influenced BI over the entire study period. PSA influenced BI directly at 16 weeks and indirectly at 8, 16, and 24 weeks.The effects of the proposed factors in our model on patient-focused HIT acceptance changed over a longer time period, emphasizing the importance of further investigation of the longitudinal mechanisms influencing technology acceptance behavior. It is recommended that healthcare practitioners consider such changes when implementing comparable technologies. Moreover, beyond technology attributes, the characteristics, needs, and limitations of older adults and elderly patient users and their home environments should also be considered in the design and implementation of patient-focused HIT systems for chronic disease self-management at home.

Xie H., Zhang H., Liang H., Fan H., Zhou J., Ambrose Lo W.L., Li L.

Virtual reality (VR) technology is increasingly used in stroke rehabilitation. This study aimed to investigate the effectiveness of using the glasses-free VR training to improve motor function of upper limb in patients with stroke. Twelve patients with stroke were recruited to participate in the intervention of 3 weeks. At the baseline and post intervention, two times of evaluation including Fugl-Meyer upper-extremity scale (FMS-UE), transcranial magnetic stimulation (TMS) measurement and motion evaluation were performed. No significant difference was observed between two groups at baseline evaluation. After the intervention, the FMS-UE scores presented a greater improvement in the VR group compared with the control group. TMS measurement showed that there was significant difference in cortex latency and central motor conduction time between two groups after the intervention, but no significant difference in the amplitude of motor event potential was observed. In addition, there was a significant correlation between game scores and FMS-UE scores. The novel glasses-free VR training was at least as effective as conventional occupational therapy in upper limb motor function, improving nerve conduction time and corticospinal excitability in patient with stroke.

Chen T., Or C.K.

Exercise therapy is a common and effective approach for managing chronic knee pain. However, individuals often receive minimal supervision from physical therapists when exercises are performed at home. In this study, we developed a video-based training system to allow individuals to perform lower limb exercises, based on a machine learning algorithm for pose detection and estimation. The system included three key features: (1) an exercise video demonstration, (2) real-time tracking and feedback of exercise movements, and (3) an overall score of exercise performance. We also pilot tested the system by having participants (n = 8) to use the system to perform lower limb exercises for 3 consecutive days. The results indicated that, compared with the baseline, the perceived usefulness of the system ( t = 3.25, p = 0.01) and perceived lower limb muscle strength ( t = 2.94, p = 0.02) significantly improved after 3 days. These findings provide knowledge about the initial views on this system by the participants. However, further enhancements of the features and full-scale experiments to examine the usability and acceptance of the system and its impact on knee health are needed.

Chen J., Xie Z., Or C.

The study objective was to conduct a systematic review and meta-analysis to assess the effectiveness of immersive virtual reality (VR)-supported interventions for patients with disorders or impairments. Web Science, MEDLINE, CINAHL Plus, and PsycINFO databases were searched from January 1990 to December 2020. We performed random-effects meta-analyses and calculated the standardized mean difference in the health outcomes before and after applying immersive VR-supported interventions. Forty-eight studies representing 52 experiments were meta-analyzed. Six different disorders or impairments were found to be examined in the experiments: anxiety disorders (n=40), psychotic disorders (n=3), poststroke motor impairment (n=3), mild cognitive impairment (MCI) (n=2), amblyopia (n=2), and unilateral vestibular hypofunction (UVH) (n=2). The use of VR interventions resulted in improvement in the following outcomes for the six disorders or impairments: anxiety-related symptoms (e.g., depression, anxiety), psychiatric symptoms, upper extremity function, cognitive function, visual acuity, and confidence in balance during daily activities and vestibulo-ocular reflex. Immersive VR has been mostly studied in individuals with anxiety disorders and can be effective in improving anxiety-related symptoms. Additionally, immersive VR has shown potential in motor rehabilitation after stroke and treating psychotic disorders, MCI, amblyopia, and UVH, and more research is recommended to further validate the current findings.

Park Y., An C., Lim C.

This study investigated the effects of a rehabilitation program using a wearable device on upper limb function, the performance of activities of daily living, and rehabilitation participation in acute phase stroke patients. A total of 44 patients were randomly divided into two groups. The experimental group (n = 22) was requested to wear a glove-type device while they were administered a game-based virtual reality (VR) rehabilitation program of 30 mins per session, 5 sessions per week, for 4 weeks. The program was given in addition to conventional physical therapy. The control group (n = 22) was administered only conventional physical therapy. To examine the intervention effects, the Fugl-Meyer assessment scale, hand strength test, and Jebsen–Taylor hand function tests were performed to examine upper limb function. The Korean version of the modified Barthel Index was used to assess the performance of activities of daily living, and the Pittsburgh rehabilitation participation scale was used to estimate rehabilitation participation. Neither the experimental nor the control group showed significant differences in the pre-intervention homogeneity test, while both groups showed significant improvement in all post-intervention dependent variables. Notably, the experimental group showed a significantly greater improvement in the results of the hand strength test, Jebsen–Taylor hand function test, and Modified Barthel Index. The findings suggest that the rehabilitation program using a wearable device, in addition to conventional physical therapy, is more effective than conventional therapy alone for improving upper limb function, the performance of activities of daily living, and rehabilitation participation in acute phase stroke patients. Our findings suggest that the novel rehabilitation program using a wearable device will serve not only as an effective therapy for enhancing the upper limb function, the performance of activities of daily living, and rehabilitation participation in acute phase stroke patients but also as a highly useful intervention in actual clinical practice alongside conventional physical therapy.

Page M.J., McKenzie J.E., Bossuyt P.M., Boutron I., Hoffmann T.C., Mulrow C.D., Shamseer L., Tetzlaff J.M., Akl E.A., Brennan S.E., Chou R., Glanville J., Grimshaw J.M., Hróbjartsson A., Lalu M.M., et. al.

The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, published in 2009, was designed to help systematic reviewers transparently report why the review was done, what the authors did, and what they found. Over the past decade, advances in systematic review methodology and terminology have necessitated an update to the guideline. The PRISMA 2020 statement replaces the 2009 statement and includes new reporting guidance that reflects advances in methods to identify, select, appraise, and synthesise studies. The structure and presentation of the items have been modified to facilitate implementation. In this article, we present the PRISMA 2020 27-item checklist, an expanded checklist that details reporting recommendations for each item, the PRISMA 2020 abstract checklist, and the revised flow diagrams for original and updated reviews.

Ain Q.U., Khan S., Ilyas S., Yaseen A., Tariq I., Liu T., Wang J.

Background: Xbox Kinect-based virtual reality, being a novel approach, has therapeutic benefits in rehabilitation and its use is encouraged in stroke rehabilitation of upper extremities. Objective: Primary aim of the current study is to investigate the additional effects of Xbox Kinect training in combination with routine physiotherapy exercises based on each component of Fugl-Meyer Assessment Scale for Upper Extremity (FMA-UE). Moreover, effect of upper limb rehabilitation on cognitive functions was also assessed. Methods: This study was a parallel arm randomized control trial. Fifty-six participants were recruited and randomly allocated to either an Xbox Kinect training group (XKGT) or exercise training group (ETG). Measures of concern were recorded using FMA-UE, Box and Block Test (BBT), and Montreal Cognitive Assessment (MOCA). Evaluation was conducted at baseline and after completion of intervention at the sixth week. Results: There were significant differences from pre- to post-intervention scores of FMA-UE and BBT (p < 0.001) in both groups, whereas no difference was observed for MOCA (XKTG p value 0.417, ETG p value 0.113). At six-week follow-up there were significant differences between both groups in FMA-UE total score (p < 0.001), volitional movement within synergies (p < 0.001), wrist (p = 0.021), hand (p = 0.047), grasp (p = 0.006) and coordination/speed (p = 0.004), favoring the Xbox Kinect training group. Conclusion: To conclude, results indicate repetitive use of the hemiparetic upper extremity by Xbox Kinect-based upper limb rehabilitation training in addition to conventional therapy has a promising potential to enhance upper limb motor function for stroke patients.

Chen T., Kalun Or C., Chen J.

Xie Z., Kalun Or C.

Mobile health (mHealth) appears to be a promising assistive tool for the long-term health management of the elderly. However, mHealth adoption rates remain relatively low among the elderly. In this study, we surveyed 108 elderly adults to determine their perceptions of mHealth applications (apps) and conducted a path analysis with the aim of studying the factors that affected the acceptance of mHealth in this population. Notably, the intention to use health apps was positively affected by the perceived usefulness (PU) (β=0.32, p<0.001), perceived ease of use (PEOU) (β=0.24, p=0.003), mHealth literacy (β=0.21, p=0.004), smartphone screen size (β=0.15, p=0.02), and healthcare providers’ influence (β=0.17, p=0.02), but negatively affected by storage consumption (β=-0.18, p=0.03). PU was positively affected by PEOU (β=0.16, p=0.02), favorable features (β=0.40, p<0.001), and quality of information (β=0.26, p=0.003). Based on these findings, we suggest that high-quality information, a user-friendly interface, intriguing features, low storage consumption, a large display screen, and the involvement of healthcare professionals are needed to promote the acceptance of mHealth interventions among the elderly.

Chen J., Xie Z., Kalun Or C.

Chen T., Or C.K., Chen J.

Abstract Objective The study sought to examine the effects of technology-supported exercise programs on the knee pain, physical function, and quality of life of individuals with knee osteoarthritis and/or chronic knee pain by a systematic review and meta-analysis of randomized controlled trials. Materials and Methods We searched MEDLINE, EMBASE, CINAHL Plus, and the Cochrane Library from database inception to August 2020. A meta-analysis and subgroup analyses, stratified by technology type and program feature, were conducted. Results Twelve randomized controlled trials were reviewed, all of which implemented the programs for 4 weeks to 6 months. Telephone, Web, mobile app, computer, and virtual reality were used to deliver the programs. The meta-analysis showed that these programs were associated with significant improvements in knee pain (standardized mean difference [SMD] = −0.29; 95% confidence interval [CI], −0.48 to −0.10; P = .003) and quality of life (SMD = 0.25; 95% CI, 0.04 to 0.46; P = .02) but not with significant improvement in physical function (SMD = 0.22; 95% CI, 0 to 0.43; P = .053). Subgroup analyses showed that some technology types and program features were suggestive of potential benefits. Conclusions Using technology to deliver the exercise programs appears to offer benefits. The technology types and program features that were associated with health values have been identified, based on which suggestions are discussed for the further research and development of such programs.

Kang M., Yun S.J., Lee S.Y., Oh B., Lee H.H., Lee S., Seo H.G.

Background. Although there have been many trials and interventions for reducing upper-extremity impairment in stroke survivors, it remains a challenge. Objective. This study aimed to investigate the effect of smart glove training (SGT) for upper-extremity rehabilitation in patients with subacute stroke. Methods. A prospective, multicenter, randomized, controlled study was conducted in patients with upper-extremity hemiplegia with Brunnstrom stage 2–5 in the subacute phase after stroke. Eligible participants were randomly allocated to the SGT group or the control group. The SGT group underwent 30 min of standard occupational therapy plus 30 min of upper-extremity training with smart glove. The control group underwent standard occupational therapy for 30 min plus upper-extremity self-training (homework tasks at bedside) for 30 min. All participants underwent each intervention 5 days/week for 2 consecutive weeks. They were evaluated before, immediately after, and 4 weeks after the intervention. Results. Twenty-three patients were enrolled. Repeated-measures analysis of covariance after controlling for age and disease duration showed significant time  group interaction effects in the Fugl-Meyer assessment of the upper extremity (FMA-UE), FMA-distal, and FMA-coordination/speed (p = 0.018, p = 0.002, p = 0.006). Repeated-measures analysis of variance showed significant time  group interaction effects in the FMA-UE, FMA-distal, and Box and Block Test (p = 0.034, p = 0.010, p = 0.046). Mann-Whitney U-test showed a statistically higher increase in the FMA-UE and FMA-distal in the SGT group than in the control group (p = 0.023, p = 0.032). Conclusion. Upper-extremity rehabilitation with a smart glove may reduce upper-extremity impairment in patients with subacute stroke.

Wong R.S., Yu E.Y., Wong T.W., Fung C.S., Choi C.S., Or C.K., Liu K.S., Wong C.K., Ip P., Lam C.L.

Parent-child exercises involve children and parents to do workout together and have positive effects on physical and mental health. We developed a mobile app on parent-child exercises called Family Move, which combines coaching videos with game features such as points and level system to enhance the health and wellbeing of both children and parents through parent-child exercises. This pilot pre-post study investigated whether the Family Move app-based intervention had a positive effect on children’s health-related quality of life (HRQOL), psychosocial wellbeing, and physical activity (PA) level. We recruited 67 parent-child pairs. During the 8-week intervention, these pairs were invited to perform parent-child exercises using the Family Move app. Points were automatically added to the user account after viewing a coaching video. In-game ranking was available to enhance user engagement. Parent proxy-report questionnaires on children’s HRQOL, psychosocial wellbeing, and PA were administered at baseline and 1- and 6-month follow-up. Paired samples t-tests were conducted to evaluate post-intervention changes in child outcomes (HRQOL, psychosocial wellbeing, and PA). Multiple linear regressions were used to examine these changes as a function of in-game ranking. 52 (78%) viewed at least one coaching video in the Family Move app. Children’s PA level significantly increased at 1-month (d = 0.32, p = 0.030) and 6-month (d = 0.30, p = 0.042) follow-up, whereas their psychosocial problems declined at 6-month follow-up (d = 0.35, p = 0.005). Higher in-game ranking was significantly associated with fewer psychosocial problems at 1-month follow-up (β = − 0.15, p = 0.030). Our findings suggest that the Family Move app could be a possible intervention to increase children’s PA level and psychosocial wellbeing through parent-child exercise. ClinicalTrials.gov number, NCT03279354 , registered September 11, 2017 (Prospectively registered).

Miclaus R., Roman N., Caloian S., Mitoiu B., Suciu O., Onofrei R.R., Pavel E., Neculau A.

Immersive and non-immersive virtual reality (NIVR) technology can supplement and improve standard physiotherapy and neurorehabilitation in post-stroke patients. We aimed to use MIRA software to investigate the efficiency of specific NIVR therapy as a standalone intervention, versus standardized physiotherapy for upper extremity rehabilitation in patients post-stroke. Fifty-five inpatients were randomized to control groups (applying standard physiotherapy and dexterity exercises) and experimental groups (applying NIVR and dexterity exercises). The two groups were subdivided into subacute (<six months post-stroke) and chronic (>six months to four years post-stroke survival patients). The following standardized tests were applied at baseline and after two weeks post-therapy: Fugl–Meyer Assessment for Upper Extremity (FMUE), the Modified Rankin Scale (MRS), Functional Independence Measure (FIM), Active Range of Motion (AROM), Manual Muscle Testing (MMT), Modified Ashworth Scale (MAS), and Functional Reach Test (FRT). The Kruskal–Wallis test was used to determine if there were significant differences between the groups, followed with pairwise comparisons. The Wilcoxon Signed-Rank test was used to determine the significance of pre to post-therapy changes. The Wilcoxon Signed-Rank test showed significant differences in all four groups regarding MMT, FMUE, and FIM assessments pre- and post-therapy, while for AROM, only experimental groups registered significant differences. Independent Kruskal–Wallis results showed that the subacute experimental group outcomes were statistically significant regarding the assessments, especially in comparison with the control groups. The results suggest that NIVR rehabilitation is efficient to be administered to post-stroke patients, and the study design can be used for a further trial, in the perspective that NIVR therapy can be more efficient than standard physiotherapy within the first six months post-stroke.

Erdogan S.D., Berkan F., Armagan O., Özgen M., Çıracıoglu A.M., Ozen H.

Wei Y., Chen Y., Ma R., Qiu Y., Su W., Zhang L., Gao Q.

Abstract Background Virtual reality (VR) is a rapidly developing technology that has gained significant traction in the treatment and rehabilitation of individuals with stroke. Research on VR-based stroke treatment has garnered increasing attention. Objective The aim of this study is to present a bibliometric analysis of VR for stroke studies to identify the application status, research hotspots, and emerging trends and guide future scientific research. Methods We included studies and reviews on the topic of VR-based stroke treatment and rehabilitation from 1999 to 2023 were retrieved from Web of Science Core Collection database. Citespace 6.3.1 and VOSviewer 1.6.20 software was used for the visual analysis of publications, institutions, authors, journals, citations, and Scimago Graphica software was used for the geographic visualization of published countries or regions. Results Our study analyzed 1171 papers on VR-based stroke rehabilitation published between 1999 and 2023, revealing a gradual increase in annual publications over the past 2 decades, peaking at 154 in 2022. North America and Western Europe were identified as major contributors, with significant input from their institutions, researchers, and publications. The Journal of NeuroEngineering and Rehabilitation emerged as the leading journal in this field, while Calabrò Rocco Salvatore was recognized as the most prolific author, focusing on the neurophysiological impacts of VR on patients with stroke. Keywords with notable citation bursts, such as “environment,” “trial,” “arm,” and “motor learning,” highlighted the core research themes in this domain. Conclusions Our study provides valuable insights into the current research hotspots and emerging trends in VR-based stroke treatment and rehabilitation. Current research primarily focuses on evaluating the effectiveness of VR in improving upper limb function and balance in patients with stroke. Future directions are shifting towards integrating VR with rehabilitation techniques, such as physiotherapy and occupational therapy, while advancements in VR technology continue to garner increasing attention.

Zhang X., Zhang Z., Zhao M., Zhang X., Wang N., Gao H., Lin Y., Zheng Z.

Wang Y., Duan B., Chen X., Song Y., Liu X.

Rapid technological progress is reshaping human existence globally. The metaverse, a 3D digital realm merging virtual reality (VR) with physical space, exemplifies this fusion. Users can replicate and customize real-world elements within this immersive environment. Over the past decade, VR, augmented reality (AR), and mixed reality (MR) have become effective tools for addressing mental health conditions, offering solutions to the shortage of mental health professionals and limited access to care. However, extensive participation in 3D immersive gaming and social media can lead to insecurity, anxiety, depression, and addictive behaviors, particularly among young adults. This engagement may also impair attention spans, exacerbating symptoms in adolescents with attention deficit hyperactivity disorder. This research examines the impact of expanding metaverse applications on mental health, exploring both risks and benefits.

Chen Y., Zhang Y., Long X., Tu H., Chen J.

Background Chronic obstructive pulmonary disease (COPD) is a progressive respiratory condition characterized by persistent airflow obstruction. Pulmonary rehabilitation (PR) is a cornerstone of COPD management but remains underutilized due to barriers such as low motivation and accessibility issues. Virtual reality (VR)–complemented PR offers a novel approach to overcoming these barriers by enhancing patient engagement and rehabilitation outcomes. Objective This review aims to evaluate the effect of VR-complemented PR compared with comparators on lung function, exercise capacity, dyspnea, health status, and oxygenation in patients with COPD. Additionally, the study aimed to identify which comparator type (active exercise vs nonactive exercise control group) and intervention duration would result in the greatest improvements in rehabilitation outcomes. The study also assessed patient-reported experience measures, including acceptability and engagement. Methods A comprehensive search of 11 international and Chinese databases identified randomized controlled trials (RCTs) published up to November 2024. Data were analyzed using RevMan 5.4, with pooled effect sizes reported as mean differences (MDs) and 95% CIs. Results A total of 16 RCTs involving 1052 participants were included. VR-complemented PR significantly improved lung function (forced expiratory volume in 1 second [FEV1] [L], MD 0.25, P<.001; FEV1/forced vital capacity [FVC], MD 6.12, P<.001; FVC, MD 0.28, P<.001) compared with comparators. Exercise capacity, assessed by the 6MWD, significantly improved (MD 23.49, P<.001) compared with comparators; however, it did not reach the minimally clinically important difference of 26 m, indicating limited clinical significance despite statistical significance. VR-complemented PR also significantly reduced dyspnea measured by the modified British Medical Research Council scale (MD –0.28, P<.001), improved health status measured by the COPD Assessment Test (MD –2.95, P<.001), and enhanced oxygenation status measured by SpO2 (MD 1.35, P=.04) compared with comparators. Subgroup analyses revealed that VR-complemented PR had a significantly greater effect on FEV1 (L) (MD 0.32, P=.005) and 6MWD (MD 40.93, P<.001) compared with the nonactive exercise control group. Additionally, VR-complemented PR showed a greater improvement in FEV1/FVC (MD 6.15, P<.001) compared with the active exercise control group. Intervention duration influenced outcomes, with 5-12-week programs showing the greatest improvement in 6MWD (MD 38.96, P<.001). VR-complemented PR was well-accepted, with higher adherence and engagement rates than comparators. Conclusions VR-complemented PR significantly improves lung function, exercise capacity, dyspnea, health status, and oxygenation in patients with COPD compared with comparators, while enhancing adherence and engagement. Subgroup analyses showed greater effects on FEV1 (L) and 6MWD compared with the nonactive exercise control group, and a larger improvement in FEV1/FVC compared with the active exercise control group. Interventions (5-12 weeks) yielded the most significant benefits in exercise capacity. These findings highlight VR as a promising adjunct to traditional PR, with future research focusing on long-term outcomes and standardized protocols.

Altukhaim S., Sakabe N., Nagaratnam K., Mannava N., Kondo T., Hayashi Y.

Nevi G., Gogiali G., Papa A., Dezi L.

Villarroel R., García‐Ramos B.R., González‐Mora J.L., Modroño C.

ABSTRACTBackground and PurposeStroke is a major cause of disability in adults. Motor recovery through conventional therapy (CT) is a fundamental approach but can sometimes face challenges related to motivation. Virtual reality (VR) rehabilitation, specifically non‐immersive VR, is an alternative therapy aimed at improving upper limb motor function and, consequently, functional independence in daily living activities. However, its effectiveness is still being evaluated. Therefore, a meta‐analysis was conducted to evaluate the effectiveness of non‐immersive VR in upper limb motor function, manual dexterity and the improvement of daily living activities in stroke patients.MethodsThe control groups included physical therapy or occupational therapy. We searched IEEE Digital Library, PubMed, SciELO, Scopus, PEDro, Web of Sciences and ScienceDirect until December 2023 and identified randomized controlled trials (RCTs). Quality and risk were assessed using the revised Cochrane Collaboration tool, PEDro scale, OCEBM, and GRADE. Publication bias and sensitivity analyses were also evaluated. The standardized mean difference (SMD) effect size was calculated to assess the effectiveness of VR therapy compared with conventional therapy. Subgroup analyses were subsequently performed to mitigate the observed heterogeneity and provide further clarity to the results.ResultsIn line with previous research, using VR shows improvements in motor function and manual dexterity for stroke patients. Subgroup analyses reveal that the benefits of VR interventions are most pronounced during the acute and subacute recovery stages, particularly in motor function and manual dexterity. Furthermore, combining VR with traditional therapy seems to yield better outcomes in motor function and manual dexterity compared with VR alone. Notably, the type of VR control—whether sensory or manual—or whether the game is commercially available or rehabilitation‐specific, does not seem to influence the outcomes. VR interventions lasting less than 4 weeks are effective in improving both motor function and manual dexterity, whereas interventions of 4 weeks or longer only show significant benefits in motor function.DiscussionThese findings highlight the versatility and potential of VR as a complementary tool in neurorehabilitation.

Wolfram S., Bauer R.

Krasavina D.A., Ivanov D.O., Orlova O.R., Valiev V.K., Iakovleva P.N., Akulov M.A.

A clinical case of consistent use of botulinum toxin type A (BTA) and azoximer bovhialuronidase (BA) in a 69-year-old patient who suffered an ischemic stroke (II) with right-sided hemiparesis is presented. BTA (incobotulotoxin) was injected under ultrasound control (ultrasound) into the muscles of the target pathological patterns at a dose of 500 units. After 3 weeks, under the control of ultrasound navigation, BA was injected into the 2 most fibrotic shoulder muscles at a dose of 3.000 IU (1.500 IU each). The effectiveness of therapy was monitored using a modified Ashworth scale (MAS), goniometry, and electromyography. A decrease in the severity of the leading pattern of spasticity of the muscles of the upper extremity (on the MAS scale) after injection of BTA was found. After consistent application of BA, a distinct change in the structure of muscle tissue and a decrease in tone in spastic muscles were recorded. The results obtained confirm the safety of botulinum therapy and the good tolerability and efficacy of Xeomin in a patient with spasticity with contracture formation after AI. The introduction of ASTHMA after botulinum therapy makes it possible to increase the elasticity of spastic muscles by reducing the severity of fibrous changes and improving motor function.

Li Y., Peng J., Cao J., Ou Y., Wu J., Ma W., Qian F., Li X.

Background Anterior cruciate ligament reconstruction (ACLR) can be fully recovered with effective rehabilitation, which also lowers the risk of developing osteoarthritis in the knee. Virtual reality technology (VRT) has been used for rehabilitation after ACLR. However, it is unclear how VRT compares to traditional therapy in terms of effectiveness. Design A systematic review and a meta-analysis. Objectives We hypothesised that VRT would be a more effective treatment than traditional therapy in post-ACLR rehabilitation. This study aimed to evaluate the effects of VRT on rehabilitation following ACLR, providing insights for its application in clinical settings. Materials and methods A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed using RevMan and Stata software according to PRISMA guidelines. We conducted a systematic search of the PubMed, Web of Science, Embase, The Cochrane Library, EBSCO, CNKI, CBM, VIP, and Wanfang databases for RCTs examining the effects of VRT in patients following ACLR. The literature search was conducted from the inception of the database to March 2024, utilizing keywords such as “anterior cruciate ligament,” “anterior cruciate ligament reconstruction,” “anterior cruciate ligament injury,” and “virtual reality.” The outcome indicators comprised knee function, walking function, gait function, and knee muscle strength. We assessed the quality of RCTs using the Cochrane Risk of Bias tool and the Jadad scale. Results There were a total of 6 RCTs included in this study, involving 387 patients who had undergone ACLR. The experimental group comprised 194 patients, while the control group comprised 193 patients. The findings demonstrated that VRT significantly enhanced knee function, walking ability, gait function, and knee muscle strength post-ACLR. Specifically, it led to improvements in the IKDC score (MD: 4.23; 95% CI 1.76-6.71), FAC score (0.40; 0.32-0.48), Lysholm score (6.36; 3.05-9.67), step length (3.99; 2.72-5.27), step speed (0.13; 0.10-0.16), step frequency (4.85; 0.22-9.47), extensor peak torque (12.03; 3.28-20.78), and flexor peak torque (14.57; 9.52-19.63). Subgroup analysis revealed that fully immersive VR did not significantly improve knee function as compared to non-immersive VR. Conclusion This study is the first to systematically compare VRT with traditional therapy, and we found that VRT is a more effective treatment than traditional therapy in post-ACLR rehabilitation. This provides evidence for integrating VRT into post-ACLR rehabilitation protocols. However, more high-quality studies with large samples are needed to verify the findings. Protocol registration This study has been registered in PROSPERO (No. CRD42024534918).

Xu S., Xu Y., Wen R., Wang J., Qiu Y., Chan C.C.

Background Recovery of upper limb function after stroke secondary to ischemia or hemorrhage is crucial for patients’ independence in daily living and quality of life. Virtual reality (VR) is a promising computer-based technology designed to enhance the effects of rehabilitation; however, the results of VR-based interventions remain equivocal. Objective This study aims to review the plausible factors that may have influenced VR’s therapeutic effects on improving upper limb function in patients with stroke, with the goal of synthesizing an optimal VR intervention protocol. Methods The databases PubMed, EMBASE, Web of Science, and Cochrane Library were queried for English-language papers published from May 2022 onward. Two reviewers independently extracted data from the included papers, and discrepancies in their findings were resolved through consensus during joint meetings. The risk of bias was assessed using the Physiotherapy Evidence Database Scale and the Methodological Index for Non-Randomized Studies. Outcome variables included the Action Research Arm Test, Box-Block Test, Functional Independence Measure, Upper Extremity Fugl-Meyer Assessment, and Wolf Motor Function Test. The plausible factors examined were age, total dosage (hours), trial length (weeks), session duration (hours/session), frequency (sessions/week), and VR content design. The Bonferroni adjustment was applied to P values to prevent data from being incorrectly deemed statistically significant. Results The final sample included 15 articles with a total of 1243 participants (age range 48.6-75.59 years). Participants in the VR therapy (VRT) group (n=455) demonstrated significantly greater improvements in upper limb function and independence in activities of daily living compared with those in the conventional therapy group (n=301). Significant factors contributing to improved outcomes in upper limb function were younger age (mean difference [MD] 5.34, 95% CI 2.18-8.5, P<.001; I2=0%), interventions lasting more than 15 hours (MD 9.67, 95% CI 4.19-15.15, P<.001; I2=0%), trial lengths exceeding 4 weeks (MD 4.02, 95% CI 1.39-6.65, P=.003; I2=15%), and more than 4 sessions per week (MD 3.48, 95% CI 0.87-6.09, P=.009; I2=0%). However, the design of the VR content, including factors such as the number of features (eg, offering exercise and functional tasks; individualized goals; activity quantification; consideration of comorbidities and baseline activity level; addressing patient needs; aligning with patient background such as education level; patient-directed goals and interests; goal setting; progressive difficulty levels; and promoting self-efficacy), did not demonstrate significant effects (MD 3.89, 95% CI –6.40 to 1.09; effect Z=1.36, P=.16). Conclusions Greater VR effects on improving upper limb function in patients with stroke were associated with higher training doses (exceeding 15 hours) delivered over 4-6 weeks, with shorter sessions (approximately 1 hour) scheduled 4 or more times per week. Additionally, younger patients appeared to benefit more from the VR protocol compared with older patients.

Godoy-Cumillaf A., Fuentes-Merino P., Giakoni-Ramírez F., Maldonado-Sandoval M., Bruneau-Chávez J., Merellano-Navarro E.

Background/Objectives: The practice of physical activity contributes to obtaining adequate values of body composition and physical fitness, which is beneficial for people’s health. However, a large part of the adult population does not comply with the recommendations for physical activity, due to factors such as lack of time and nearby sports venues. Immersive virtual reality is a tool that allows individuals to immerse themselves in a simulated world and perceive visual, auditory, and tactile sensations. Its use in physical activity interventions favors exercise in situations that, due to time and space, could be limited in real life. The objective of this case report is to measure the impact on body composition and physical fitness of an exercise program executed through immersive virtual reality. Methods: The design is a case study with a quantitative approach developed through a physical activity intervention with immersive virtual reality in which body composition was evaluated considering fat and muscle components, and physical fitness considering cardiorespiratory fitness, speed-agility, and hand grip strength, through pre- and post-testing. The physical exercise program based on immersive virtual reality lasted 8 weeks. The subject of the study was a 24-year-old man, a second-year student of Pedagogy in Physical Education at a Chilean university, with no previous experience in this virtual tool. Results: The results indicate that for body composition the study subject decreased the fat component and slightly improved the musculature, while for physical fitness cardiorespiratory fitness and speed-agility improved, but manual grip strength decreased. Conclusions: It is concluded that the training developed through immersive virtual reality proves to be a tool that can promote improvements in body composition and physical fitness; it is necessary to carry out more research to validate the potential of this instrument as a means of contributing to the health of the population.

Ase H., Honaga K., Tani M., Takakura T., Wada F., Murakami Y., Isayama R., Tanuma A., Fujiwara T.

Upper extremity rehabilitation in persons with stroke should be dose-dependent and task-oriented. Virtual reality (VR) has the potential to be used safely and effectively in home-based rehabilitation. This study aimed to investigate the effects of home-based virtual reality upper extremity rehabilitation in persons with chronic stroke. This was a single-blind, randomized, controlled trial conducted at two centers. The subjects were 14 outpatients with chronic stroke more than 6 months after the onset of the stroke. The participants were randomly divided into two groups. The intervention group (n = 7) performed a home rehabilitation program for the paretic hand (30 min/day, five days/week) using a VR device (RAPAEL Smart Glove™; NEOFECT Co., Yung-in, Korea) for four weeks. The control group (n = 7) participated in a conventional home rehabilitation program at the same frequency. All participants received outpatient occupational therapy once a week during the study period. The outcome measures included the Fugl-Meyer Assessment of upper extremity motor function (FMA-UE), Motor Activity Log-14 (MAL), Jebsen-Taylor Hand Function Test (JTT), and Box and Block Test (BBT) scores. All 14 participants completed the study. Compared to the control group, the intervention group showed more significant improvements in FMA-UE (p = 0.027), MAL (p = 0.014), JTT (p = 0.002), and BBT (p = 0.014). No adverse events were observed during or after the intervention. Compared to a conventional home program, combining a task-oriented virtual reality home program and outpatient occupational therapy might lead to greater improvements in upper extremity function and the frequency of use of the paretic hand. Trial registration: This study was registered in the University Hospital Medical Information Network (UMIN) Clinical Trial Registry in Japan (Unique Identifier: UMIN000038469) on November 1, 2019; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000043836 .

Eapen B.C., Tran J., Ballard-Hernandez J., Buelt A., Hoppes C.W., Matthews C., Pundik S., Reston J., Tchopev Z., Wayman L.M., Koehn T.