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DOI: 10.1016/j.sedeng.2020.01.001
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Available online 2 April 2020
Rehabilitation through virtual reality therapy after a stroke: A literature review
Rehabilitation mediante terapia de realidad virtual tras un accidente cerebrovascular: una revisión bibliográfica
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Marta A. Montalbána, Oscar Arroganteb,
Corresponding author
oarrogan@nebrija.es

Corresponding author.
a Unidad de Reanimación, Hospital Universitario de La Princesa, Madrid, Spain
b Departamento de Enfermería, Fundación San Juan de Dios, Centro Universitario de Ciencias de la Salud “San Rafael”, Universidad Antonio de Nebrija, Madrid, Spain
Received 16 August 2019. Accepted 20 January 2020
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Tables (3)
Table 1. Key words and document terms.
Table 2. Search equations and article selection.
Table 3. Summary of selected articles.
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Abstract
Introduction

Stroke has increased in incidence worldwide. Although its mortality has reduced, it is the disease with the highest percentage of disability. For this reason, it is necessary to find new methods of rehabilitation and recovery from sequalae after a stroke, such as virtual reality (VR) therapy.

Objective

To analyse the effectiveness of VR as a rehabilitation therapy for movement improvement in adults after suffering a stroke.

Method

A literature review was carried out through a systematic search in the PubMed, ScienceDirect and EBSCO databases (Medline Complete, Academic Search Complete, Academic Search Ultimate and E-Journal). A date restriction of the last five years and a language restriction in English and Spanish were applied.

Results

A total of 13 studies met the inclusion/exclusion criteria and the objectives of this review. The selected studies compared conventional therapy (CT) with VR therapy, or CT with the combination of CT+VR, and other studies assessed VR effectiveness in isolation.

Conclusions

VR therapy would be effective for improving movement in post-stroke patients, either in isolation or as a complement to conventional therapy. The type of VR most used for stroke rehabilitation is the semi-immersive of second person that is generally applied six months after suffering a stroke. Unfortunately, it has not yet been possible to determine the efficacy of VR according to the brain region affected.

Keywords:
Movement
Nursing care
Rehabilitation
Stroke
Virtual reality
Resumen
Introducción

El accidente cerebrovascular (ACV) ha aumentado su incidencia en todo el mundo. Aunque su mortalidad se ha reducido, es la enfermedad con mayor porcentaje de discapacidad. Por todo ello, es necesario encontrar nuevos métodos de rehabilitación y recuperación de las secuelas tras un ACV, como la terapia de realidad virtual (RV).

Objetivo

Analizar la eficacia de la RV como terapia de rehabilitación para la mejora del movimiento en adultos tras sufrir un ACV.

Método

Se llevó a cabo una revisión bibliográfica mediante una búsqueda sistemática en las bases de datos PubMed, ScienceDirect y EBSCO (Medline Complete, Academic Search Complete, Academic Search Ultimate y E-Journal). Se aplicó una restricción de fecha de los últimos cinco años y en los idiomas inglés y español.

Resultados

Un total de 13 estudios cumplieron los criterios de inclusión/exclusión y los objetivos de la revisión. Los estudios seleccionados comparaban la terapia convencional (TC) frente a la terapia de RV o la TC frente a la combinación de TC+RV y otros estudios evaluaron la eficacia de la RV aisladamente.

Conclusiones

La terapia basada en RV puede ser eficaz para mejorar el movimiento en pacientes post-ACV, tanto de manera aislada o como complemento de la terapia convencional. El tipo de RV más utilizada en la rehabilitación del ACV es la semi-inmersiva de segunda persona, siendo aplicada generalmente a los seis meses de haber sufrido un ACV. Desafortunadamente, todavía no se ha podido determinar la eficacia de la RV en función de la región cerebral afectada.

Palabras clave:
Accidente cerebrovascular
Cuidados de enfermería
Movimiento
Realidad virtual
Rehabilitación
Full Text
Introduction

Stroke or ictus is an entity which refers to any type of disorder in brain circulation.1 Mortality rates by stroke in Europe have decreased during the last 20 years.2 on a worldwide level, it is the cause of the highest percentage of disability in the adult according the World Health Organisation: every year some 15 million people suffer from a stroke, 5.5 million of whom die and 5 million of whom suffer from some type of permanent disability for daily life activities. This all leads to high financial coasts, both in the health and family areas.3

The aim of all stroke treatment is rehabilitation for improving the quality of life of patients after it. This is a progressive and dynamic process. Within the said treatment, the actions taken by nursing professionals may include: health advice, help and education for the patient, so that their daily life may adapt to the new situation they must now experience.4

One of the new physiotherapy methods for stroke which is currently booming is virtual reality (VR). This therapy provides a virtual environment created using computer technologies to simulate a human. Machine interface, which will lead to interaction with an environment within a simulated reality.5 VR is exponentially advancing, creating virtual environments which are increasingly more similar to reality, and this is readily accepted by the user when using these therapies to induce their recovery.5 In a complementary fashion to the conventional methods, this therapy has been shown to be beneficial for improving the function of upper limbs and activities of everyday life.6

The most common interface used in VR are glasses so that the senses may be concentrated in the desired environment, which visually provides the user with informaotin.5 Other types of interfaces are projection system or flat screens which combined with other VR media, provide tactile, olfactory, auditory and motor information.5,6 For example, with regard to the sense of touch, there are haptic devices which respond with tactile feedback interaction and provide the user with the sensation they are handling the simulated objects.5,6

Therapies base don VR are divided into7:

  • Immersive: the user is integrated into the virtual world, where they interact thanks to the peripheral devices (such as VR glasses, gloves and helmets) and with no real world references.

  • Semi-immersive: the user interacts with the virtual worlds through screens which Project virtual images that surround the m in a closed booth.

  • Semi-immersive in the second person: the user is projected virtually through a screen but without losing contact with reality. These virtual avatars are generated by an image capturing system or a digital image of the body or part of it. The use of complementary devices is advised.

  • Non-immersive: interaction with the virtual world in 3D format through a screen or monitor.

One of the major advantages of this type of therapy is its specific adaptability to the rehabilitation of each patient’s failings resulting from the sequelae of stroke. For example, for the rehabilitation of daily life activities such as recovery of ambulation, opening a door, cutting up food or filling up a glass of water.8,9 Moreover, the robotics, simulators, stimulators, neuroprosthesis or brain-computer interfaces are increasingly more specific for this type of therapy and reduce the health costs of rehabilitation.10 Other advantages of these therapies based on VR are the possibility of functional and sequential repetition, improvement in motor performance in specific areas and also the ease with which the degree of demand and difficulty in the task to be recovered may be varied.11

However, post stroke rehabilitation depends largely on the patient, since sequelae are highly variable in effect and intensity. The recovery of these patients also depends on their capacity, constancy and effort. In this sense, specific VR programmes have recently been developed offering further advantages in the area of rehabilitation. These new VR programmes facilitate early, intensive interventions aimed at specific recovery and also supply specific sensory feedback. Said programmes are obtaining clearly beneficial results within the area of neuro-rehabilitation.12 For example, VR provides enriched environments in which people with apoplexy may resolve problems and develop new skills through a higher number of repetitions in the sessions.6 These programmes also lead to patient safely through the correct handling of dangerous utensils, such as knives or scissors or the simple task of crossing a road without the danger of being run over.6

However, it has been demonstrated in recent years that nurse-patient paring has been a successful part of new social and health services. Here, nursing professionals must accept the challenge of care and its continuity. From the point’s ova view of self-care, patients and their carers may have the support of professional nurses, who would be their trainers and advisers.13 This role may be accepted by these professionals in VR therapies.

To complete this review of the literature the initial phase of research began, where the review question was formulated: is the use of virtual reality effective as a method of rehabilitation in adult patients after suffering from a stroke?

To respond to this question a primary aim was put forward:

  • Analyse the efficacy of the VR as a therapy for rehabilitation to improve movement in adults after a stroke.

Three specific aims were also put forward were to:

  • Assess at what moment VR therapy is most effective for recovery from a stroke.

  • Analyse the efficacy of VR in accordance with the affected part of the brain.

  • Evaluate which VR therapy is the most highly used in rehabilitation after a stroke.

Method

This review of the literature was carried out during the month of June 2019, following a search of the following data bases: PubMed, Ebsco (Medline Complete, Academic Search Complete, Academic Search Ultimate y E-Journal) and ScienceDirect. The key words and document terms are shown in Table 1.

Table 1.

Key words and document terms.

Field  Key word  Free language  DeCS terms  MeSH terms 
P (population)  Stroke  Stroke  Stroke  Stroke 
I (intervention)  Virtual reality  Virtual reality  Virtual reality  Virtual reality 
  Rehabilitation  Rehabilitation  Rehabilitation  Rehabilitation 
C (compare)  Conventional therapy  Conventional therapy  –  – 
O (outcome)  Movement  Movement  Movement  Movement 

On the one hand, the following inclusion criteria were established: adults who had suffered from a stroke, rehabilitation based on the VR, clinical trials and quasi-experimental studies, articles in Spanish or English, studies taken from the complete text and published between June 2014 and June 2019.

On the other hand, exclusion criteria considered were: studies which applied virtual reality to diseases other than stroke and severe sequelae.

After applying the previous limits, the search equation and selected articles are shown in Table 2.

Table 2.

Search equations and article selection.

Database  Search strategy  Limits  Number of localised references  Number of articles with complete text  Number of articles after reading title and abstract  Number of articles after eliminating duplicates  Articles included in the review after critical review 
PubMed  («stroke»[MeSH Terms] OR «stroke»[All Fields]) AND («virtual reality»[MeSH Terms] OR («virtual»[All Fields] AND «reality»[All Fields]) OR «virtual reality»[All Fields]) AND («rehabilitation»[Subheading] OR «rehabilitation»[All Fields] OR «rehabilitation»[MeSH Terms]) AND («movement»[MeSH Terms] OR «movement»[All Fields])  Clinical trial  22  22  13 
    Complete text          Lee et al. 
    2014−2019          Schuster-Amft et al. 
    Humans          Park et al. 
              In et al. 
              Ballester et al. 
              da Silva Ribeiro et al. 
EBSCO -Medline complete  Stroke AND virtual reality AND rehabilitation AND movement  Complete text  27  26  12 
    2014−2019          Wittmann et al. 
    Spanish          Ballester et al. 
    English          Tsoupikova et al. 
    All the adults: 19+ years of age          Braga et al. 
              Thielbar et al. 
Science Direct  Stroke AND virtual reality AND rehabilitation AND movement  Research articles  50  48 
    2014−2019          Hung et al. 
    Open access          Lee et al. 
Results

A total of 13 articles were selected. The main variable taken into account when analysing each article was the improvement of movement of the paretic limb. Table 3 provides a summary of the selected articles ordered chronologically, from most to least recent and in alphabetic order.

Table 3.

Summary of selected articles.

Authors  Year  Design  Country  Sample  Intervention  Outcome 
Schuster-Amft et al.  2018  Multicentre randomised parallel group trial  Switzerland  54  The CG carried out rehabilitation using conventional physiotherapy or occupational therapy. The EG carried out rehabilitation based on VR therapy through YouGrabbe®  Rehabilitation based on VR compared with the conventional one did not show any significant improvements. However, VR therapy may be effective in patients who have no serious motor alterations. 
Lee et al.  2018  Preliminary randomised blind and controlled study  South Korea  30  The CG carried out rehabilitation using conventional physiotherapy and occupational therapy. The EG received rehabilitation in VR through the Nintendo Wii Sports Resort®  Although the EG and CG obtained significant improvements in postural sway and in motor function of upper limbs, the EG was the group with the greatest improvements in both variables. 
Park et al.  2017  Randomised controlled trial.  South Korea  20  The CG received rehabilitation based on conventional therapy. The EG received VR therapy through the Xbox Kinect®  The 2 groups obtained significant improvements after evaluation. The EG improved significantly in postintervention assessments. 
Ballester et al.  2016  Randomised, double-blind longitudinal study  Spain  18  The CG carried out rehabilitation using VR therapy. The EG received rehabilitation based VR therapy with extended sensomotor feedback  The 2 groups showed significant improvements, but only the EG continued with significant improvements in motor function and of the arm after 12 weeks 
Hung et al.  2016  Randomised controlled trial  China  23  The CG received conventional therapy and occupational therapy whilst the EG received rehabilitation though non immersive VR using the Tetrax® biofeedback system  The EG had significant improvement in reaction times and also its satisfaction when carrying out rehabilitation using VR was significantly higher than that of the CG 
In et al.  2016  Randomised controlled trial  South Korea  25  The CG carried out rehabilitation based on conventional therapy and VR placebo programme. The EG carried out rehabilitation based on conventional therapy and VR therapy  The EG obtained significant improvements in postural sway and dynamic balance. The combination of conventional therapy with VR therapy was the most beneficial 
Wittmann et al.  2016  Open clinical trial of a single group  Switzerland  11  Physiotherapy based on a self-directed workout in the how with the ArmeoSenso® system  Viable and safe therapy with a significant improvement in the rehabilitation of the paretic arm 
Ballester et al.  2015  Clinical trial of a single group  Spain  20  Visual and motor amplification aimed at objects to strengthen the use of the paretic limb through VR  The use of the paretic limb was considerably higher at completion of the study 
Da Silva Ribeiro et al.  2015  Randomised blind and controlled clinical trial  Brazil  30  The CG received rehabilitation based on muscle therapies, balance, movement, grip and gait. The EG received a VR therapy through the Nintendo Wii®  The VR therapy with Nintendo Wii® and the conventional physical therapy obtained significant improvements in motor function of the upper hemiparetic limb 
Tsoupikova et al.  2015  Single group intervention study  United states  A BrightArm Duo®, bimanual system of rehabilitation of upper limbs was used to which feedback was incorporated around the semi-immersive VR through PneuGlove®glove  Participants significantly improved motor coordination in the hand, with significant optimisation of hand-arm coordination. There was also a considerable improvement in side pinching resistance 
Braga et al.  2014  Experimental case and control trial  Holland  40  Workout of the upper right and left limb, depending on the group, with the Kinect of Xbox 360® with software Paddle Panic Mini Game® by Kinect Sport®  The patients with hemiparesis on the left side benefitted more greatly from the workout: they were closer to the patterns of healthy individuals 
Lee et al.  2014  Randomised controlled trial  China  22  The CG carried out rehabilitation by conventional therapy The EG carried out conventional therapy plus workout based on VR  The EG had significant improvements in gait, step and stride. 
Thielbar et al.  2014  Randomised controlled trial  United Kingdom  14  A new mechatronic virtual system was used in the G, using a virtual keyboard activated with the incorporation of a PneuGlove®glove. The CG carried out occupation therapy  The EG shows significant improvements in impairment measurements and performance of tasks. The EG also obtained a significant improvement in independent movement of the fingers. 

CG: control group; EG: experimental group; VR: virtual reality.

After this, the selected articles are grouped together, according to the type of intervention made. On the one hand 3 articles were found in which VR was compared to conventional rehabilitation (CT). In all of these it was observed that the 2 therapies were equally effective.14–16 In 2018 Schuster-Amft et al.14 reached this conclusion, with significant improvements regarding movement in the 2 therapies. On the contrary, they obtained insignificant improvements in favour of VR compared with CT. Also, in 2015, Silva Ribeiro et al.15 obtained significant improvements in favour of the 2 therapies in movement, pain and motor function after a stroke and significant improvement in favour of VR compared with CT in the patients’ mental health. Lastly, in 2014 Thielbar et al.16 showed that the 2 therapies were effective for post-stroke rehabilitation, with significant improvements in favour of VR in measurements of impairment, carrying out of tasks and in independent movement of fingers.

However, we found 4 articles where CT was compared with the combination of CT and VR and it was found that the combination of both therapies was more effective than the application of CT alone.17–20 In the study by Lee et al.17 in 2018 considerable improvements were obtained in favour of the combination of therapies in postural balance and motor function of upper limbs in a seated position. Also, in 2017 Park et al.18 obtained significant improvement in balance and ambulation with the combined therapy. Furthermore, in 2014 Lee et al.19 obtained significant improvements in favour of the combination of CT+VR in motor function, gait speed, stride and pace. Lastly, in 2016 Hunt et al.20 concluded that the combination of the therapies was more effective for movement rehabilitation, with significant improvements in reaction times.

We also found 3 articles which examined the efficacy and viability of VR in single groups. In 2016 Wittmann et al.21 carried out a self-directed workout in the home and obtained significant improvements in paretic arm function. In 2015, Ballester et al.22 examined the viability of VR for extension of movement and found that the applied therapy promoted the use of the paretic limb. Lastly, in the same year Tsupikova et al.23 demonstrated significant improvements in hand movement and side pinching resistance.

Lastly, we would underline the selection of the following 3 articles, which obtained particularly relevant results. On the one hand, in 2016 Ballester et al.24 applied therapies based on VR to 2 groups of their study and added increased sensomotor feed-back to one of them. They obtained significant improvements in movement in favour of the amplified VR. Furthermore, during the same year In et al.25 applied CT to 2 groups. In one of them they added VR and in the other a VR placebo. The result was that in the group to which additional VR was applied, significant improvements were obtained in postural sway and in equilibrium. Lastly, in 2014 Braga et al.26 indicated a significant improvement regarding shoulder and elbow movement after VR therapy in patients with an affected right hemisphere of the brain.

Discussion

Of the 13 selected articles, 9 were clinical trials, 3 were single group intervention studies and one was an experimental study of cases and controls. A total of 313 people participated in these studies. All the studies analysed the efficacy of the rehabilitation therapies based on VR for recovery of motor disorders caused by a stroke. According to the staging of levels of evidence of the Centre for Evidence-Based Medicine in Oxford (CEBM), the selected studies had a low (studies of a single group and cases and controls) to moderate (low quality clinical trials) evidence level.

After this review, it was shown that the VR could be useful and effective as a method of rehabilitation, since the majority of selected studies showed significant improvements in the recovery of the movement of the paretic limb. This result is consistent with the latest 2017 Cochrane systematic review.6 Also, the quality of evidence of studies included in this systematic review is low to moderate, similar to our review of the literature.

The results obtained indicate that motor areas where significant improvements have been observed are in the recovery of equilibrium and postural sway, motor function of upper limbs (arms, hands and fingers) and gait, pace and stride. Most of these studies conclude that VR is a therapy which patients assimilate better than conventional therapy, either because it is novel or because of the variety of exercises. This encourages patients to view physiotherapy with greater interest, perceiving it as an appealing challenge. Also, one of the strong points of VR is its capacity for repetition, a must in rehabilitation, since repetition of exercises is key to the rapid recovery of the individual.

It should be noted that the patient’s age is not an obstacle in the use of VR systems, and older people have not shown any difficulty in handling them.

Regarding the CT+VR combination, studies unanimously show this to be beneficial, since therapy with VR improved specific aspects which CT did not embrace. It is also notable that VR relieves the monotony that CT has in some cases.

In contrast we did not find a single article that used a therapy based on VR before 6 months had passed. All VR therapies were applied after complete stabilization of the disorder. It would be of interest to conduct studies which used these therapies from the first month, since small non immersive easy-to-use VR systems exist. These systems could be applied during the initial period of recovery due to their easy use and convenience.

The most commonly used VR therapy in the articles selected for this review was second person semi-immersive. This type of VR directly interacts with the computer, which presents an avatar, either of the limbs or the complete body, reflecting the patient’s movements in real time. These systems are controlled by therapists who adapt them to the patients’ needs. Also, these systems have movement control functions, such as sensomotor feed-back, which facilitates handling and usage, and they are also relatively inexpensive.

Regarding the efficacy of VR depending on the affected region of the brain, the selected articles did not include this within their inclusion or exclusion criteria, nor did they specify whether the lesion corresponded to the right or left side of the body. Only in their study did Braga et al.26 analyse the efficacy of VR in the affected cerebral region. This aspect is highly important, since sequelae and efficacy of rehabilitation depend on these regions, and further studies in this field regarding them are therefore required.

The satisfaction of most of people’s needs change when they have suffered from a stroke and it is therefore of vital importance that nursing professionals are aware of the new therapies based on VR which may be applied for the recovery of health and are able to recommend and advise on their usage. The incorporation of these therapies in clinical practice should therefore be established in close collaboration with the entire multidisciplinary team caring for these patients.

The main methodological limitation of the selected review articles is the small size of the samples used. Also, their design. Their level of evidence was consequently low to moderate.

With regard to proposals for future research studies, there is a need for the design of studies with larger sample sizes in which VR is compared with conventional rehabilitation therapy, in larger methodological regions and with a higher follow-up period. Lastly, the efficacy of the VR therapies should be researched in the patient’s home. Due to its efficacy and low cost, waiting times linked to conventional rehabilitation would be shorted and health system costs lowered, and these resources could cover other needs.

Conclusions

Based on the results obtained in this review of the literature, it may be concluded that:

  • VR may be effective as a method of rehabilitation for improvement of movement in post-stroke patients, either as a single therapy or one combined with CT.

  • VR therapy has mostly been applied after the first 6 months post stroke.

  • The most used of VR therapy is the semi-immersive of second person, because it is easy to use, low in cost and complexity, compared with the immersive.

  • Studies are insufficient to demonstrate the efficacy of the VR therapy in accordance with the brain region affected.

  • The main methodological limitations of the studies conducted up until now are low sample size and not all clinical trials are randomised or have group control.

  • Nursing professions should be aware of the therapies based on VR for rehabilitation of stroke, aimed at recommending them according to patient needs, or collaborating with other professionals who are using them.

Financing

The authors had no source of financing for this study.

Conflict of interests

The authors have no conflict of interests to declare.

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Please cite this article as: Montalbán MA, Arrogante O. Rehabilitation mediante terapia de realidad virtual tras un accidente cerebrovascular: una revisión bibliográfica. Rev Cient Soc Esp Enferm Neurol. 2020. https://doi.org/10.1016/j.sedene.2020.01.002

Copyright © 2020. Sociedad Española de Enfermería Neurológica
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