Running Head: VR WITH SS

Evaluating the effectiveness of virtual reality on improvement of limb function in stroke survivors
with hemiparesis

Myles Watkins

Jackson Ball

University of Utah

Introduction
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Stroke is among the leading causes of disability in the United States and often results in

upper extremity hemiparesis, a major and chronic impairment (CDC, 2017). Around 80% of

stroke survivors have upper extremity hemiparesis in the stroke aftermath, 30-40% of which

regain some movement (Delden, 2009). This can seriously affect areas of psychosocial

functioning, mental health, employment, and self-care. The cost of stroke in the United States

each year is estimated to be at $34 billion, which includes the cost of healthcare, missed days at

work, and medications (CDC, 2017). Stroke often involves a lifelong recovery, drastically limiting

the amount of movement in the client’s affected side and will disrupt their ability to perform their

activities of daily living (ADL). Stroke survivors who do not recover upper extremity movement

and dexterity within the first two months after stroke have been shown to have worsened

prognoses, making it critical for healthcare providers to utilize effective therapy approaches

(Kwakkel, 2003). Functional recovery of stroke patients depends largely on improved

corticomuscular coherence and the utilization of neural plasticity (Carlowitz-Ghori, 2014).

Occupational therapists play a critical role in therapy for individuals with hemiparesis, often

specializing in upper extremity function and dysfunction. It is paramount that the medical field is

continuously looking to improve interventions and keep clients’ actively engaged in their own

recovery in the most effective and safest way possible. Technology has always played an

intricate role in therapy, and as it evolves, it is crucial that the field is continuously researching

and evolving alongside it.

The current therapeutic trend is based around simple task-oriented interventions that are

repetitive and intense, and virtual reality (VR) can provide more engaging therapy occupations

with quicker and more accurate feedback on progress (Langhorne, 2009). While many

traditional methods of therapy have been developed, patients may encounter boredom during

therapy tasks and have been shown to desire dynamic visuals and real-time performance

feedback (Palazzo, 2016). Many clinics do not have the space or resources to provide engaging
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options to their clients, but the use of VR can supplement or replace traditional interventions

with meaningful, engaging, and wide-ranging simulated occupations within a safe, clinical

environment. Research has shown that this new technology can quickly and safely provide the

client with ADL tasks where they can practice and improve limb function in an environment that

is meaningful to them (Saposnik, 2010).

VR is still a fairly new form of technology, although it is improving at a very rapid pace.

Previous studies have found it to be a safe and effective form of therapy, although more reliable,

larger, and current studies still need to be conducted as the technology evolves.

This systematic review will examine current VR interventions to determine the trends and

effectiveness of VR-based therapy, within the field of occupational therapy, in improving upper

extremity function in stroke survivors.

Methods

Databases accessed include CINAHL, Pubmed, and Google Scholar. Search terms

included stroke, brain attack, hemiparesis, hemiplegia, upper extremity, limb function, virtual

reality, robot-assisted, game, hand function, therapy, occupational therapy, outcomes, chronic,

acute, dexterity, ADLs, activities of daily living, grip strength, and grasp. The date range of

articles was from 2008-2018. Our initial searches brought up over 40,000 results but we then

added initial terms in order to get our results down to around 8,000. We primarily focused on

finding randomized controlled trials, and fortunately there were numerous to choose from.

Selected articles often utilized a randomized-control trial design and provided level 1-5 evidence

as well as a high rating on the PEDRO scale. We ended up choosing nine articles to include

within our paper, six being randomized-controlled trials, two being case controlled trials, and

one being a review. The selected articles specifically examined the use of virtual reality in

improving upper extremity function. Exclusion criteria were articles focusing on the lower

extremities, balance, cognitive function, or having a PEDro scale score lower than a six, which
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would point to issues with internal validity particularly related to blinding, use of statistics, bias,

attrition, and equality of groups.

Results

In et al. (2012) provided virtual reality reflection therapy to stroke survivors in order to

determine motor rehabilitation effects compared to conventional therapy. The groups were

randomly assigned. Treatment was given 30 minutes per day, 5 days a week, for a total of 4

weeks. Participants completed three sets of 10 repetitions during the session with the exercises

aimed at increasing grasping power, motion of the hand, range of motion, velocity, and

dexterity. Progressively harder tasks were given each week, focusing on hand, wrist, and

forearm movement. No significant differences in baseline performance values were seen

between experimental and control groups. The results post-intervention revealed significant

score increases in motor function using the Fugl-Meyer Assessment for both groups from

baseline as well as significant differences between groups, with the experimental group

displaying more significant improvements in function. Manual dexterity testing revealed

significant improvement for the experimental group, but not the control group. The study reveals

the effectiveness of VR reflection therapy over traditional therapy method of mirror therapy. In

addition to increased rehabilitation, VR reflection therapy does not require an asymmetric

posture like mirror therapy, thereby challenging segmental movement of trunk and limbs and

forcing the client to maintain a crooked spine during therapy, neither of which is desired. A

potential weakness of this study is that the participants were at least 6 months post-stroke and

the intervention may be more effective for those in the acute recovery stage from a stroke. In

addition, the length of the intervention was only 4 weeks. A strength is that it utilizes a RCT

design.

Kiper et al. (2014) included 44 stroke patients to study the effect of reinforced feedback

in virtual environment (RFVE) when compared to traditional rehabilitation on improving UE

motor function. The RFVE group intervention used the “Virtual Reality Rehabilitation System”
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which monitored patients with a 3D motion-tracking system and a large display to depict virtual

scenarios. Therapists designed motor sequence tasks which the patient completed by

manipulating real-life objects with their paretic hand and focusing on the virtual scenario. Each

task was tailored to the patient’s skill level. The control group was introduced to exercises

targeting ROM, ADLs, and strength without virtual assistance. Both hemorrhagic and ischemic

stroke survivors were included in the study and stratified within the randomized experimental

and control groups. Motor functioning measures revealed significant improvements in the RFVE

group while the traditional therapy group did not. Patients who sustained a hemorrhagic stroke

displayed significant improvements in kinematic measurements of time and peak, while

ischemic stroke patients improved significantly only in the kinematic measurement of speed.

Intervention programs for both groups lasted 2 hours a day, 5 days a week for 4 weeks. Results

demonstrated that RFVE treatments combined appear to provide better therapeutic efficacy

than traditional approaches alone. RFVE therapy was beneficial for motor and ADL abilities

independent from stroke etiology (i.e. hemorrhagic, ischemic). The mean time since stroke in

the control group was one month shorter than the experimental group, which should be noted as

a potential confound. The number of patients examined in this study (n=44) is a strength and

may provide more valid results by controlling for outliers and inherent variability that can result

from smaller sample sizes.

Kwon et al. (2012) applied VR therapy and conventional therapy to patients in the acute

stage after stroke (within 3 months of stroke) to determine whether patients would benefit from

increased UE function and performance of ADLs. Twenty-six adults total were placed either in

the VR or CT group in a double-blind RCT design. Patients participated 30 minutes per day, 5

days a week for 4 weeks with a VR system, in addition to 70 minutes per day of conventional

intervention for the control group. The VR intervention incorporates a screen, video camera,

cyber gloves, virtual objects and 5 VR games: Bird and Ball, Drum, Coconutz, Soccer, and

Conveyor. Functional motor performance was assessed post-intervention. The VR group

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improved significantly in upper-extremity function, but not in performance of ADLs compared to

the CT group. However, both groups showed significant improvement in UE and ADLs when

compared to baseline. The authors note that VR could be adapted to be more ADL-specific and

perhaps have a greater effect on ADL outcomes. Because the study occurred during the acute

stage of stroke, it is possible that motor recovery, and the likelihood of spontaneous recovery of

the paretic limb would be greater in a later stage post-stroke. The double-blind RCT design

provided level one evidence, which is a strength of the study.

Lee et al. (2014) utilized a RCT design to examine the effectiveness of asymmetric

upper-extremity training in stroke patients compared to a control group participating in

symmetric training. Both programs occurred for 30 minutes a day, 5 days a week, for 4 weeks

and included conventional physical therapy as an additional intervention. Grip strength, ROM,

spasticity, and results of the motor function testing were all assessed at the end of the trial. Both

groups displayed significant improvements in upper extremity function parameters, except in

tests of spasticity. ROM in the wrist was similar in both groups before treatment; however, after

treatment both groups displayed significant improvement in flexion, extension, ulnar- and radial-

deviation. The asymmetric group displayed significant improvements in motor function over the

control group in shoulder, elbow, and forearm movements. This is likely because activation of

ipsilateral corticospinal and corticoreticular tracts is easier in proximal joints. Prior studies had

examined symmetric manual therapies but not the effectiveness of asymmetric therapy, making

the results of this study novel at the time of publication. One potential weakness is that the study

spanned only four weeks and therefore can only be considered valid when looking at short-term

results.

Saposnik et al. (2010) wanted to examine whether using Wii gaming technology would

result in improved motor recovery, their rationale for this study was that evidence suggests that

increasing intensity of therapy improves motor function, and therefore gaming could assist with

this task since the intensity could easily be manipulated within the technology. They wanted to
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specifically see whether intervention time decreased, how safe it was, and determine efficacy.

The intervention consisted of comparing Wii sports/cooking vs. recreational therapy (cards,

bingo, or Jenga). Patients were randomly put into two groups, where they received an intensive

program consisting of eight sessions (Wii or RT) of 60 minutes over a 2-week period. The arm

movements that were replicated on the affected side involved shoulder flexion and extension,

shoulder rotation, elbow extension and flexion, wrist supination and pronation, wrist flexion and

extension, and thumb flexion. The mean total session time was 388 minutes in the RT group

compared with 364 minutes in the Wii group. There were no safety concerns in either group.

Relative to recreation therapy, participants in the Wii group had an improvement of 7 seconds in

the Wolf Motor Function Test. One strength of this study is that they used a consumer-friendly

VR device, while a weakness of the study is that their sample sizes in both groups were very

small.

Turolla et al. (2013) aimed to examine the effectiveness of VR treatment for the

improvement of upper limb motor function and whether it improves the activities of daily living

for stroke survivors. Their rationale came from other evidence demonstrating the efficacy of VR

in stroke rehabilitation, but they wanted to test this in a much larger sample size by using 376

participants. For the intervention, the 376 subjects were selected based upon their motor arm

subscore and that they did not have any severe neuropsychological impairments that could

disrupt the recovery process. These clients were then split into two treatment groups, combined

VR and conventional therapy or just conventional therapy alone. The virtual reality treatment

consisted of demonstrating certain motor tasks while holding a real object and movement was

monitored by a motion-tracking system that was displayed on a screen, the therapist had the

option of adjusting difficulty based on patient’s skill level. The treatment was 2 hours of therapy

a day, five days a week, for 4 weeks. Once the treatment was completed, they used the

Functional Independence Measure and Fugl-Meyer Upper Extremity scales to score the

outcomes. Both of the groups had an significant? improvement on both scales, but the VR
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group’s scores were significantly greater than the group who only received conventional therapy

alone. These results support the idea that VR could be an appropriate treatment method for

those with stroke, and should also be used with conventional therapy. Strengths of this study

are that they used a much larger sample size than other VR studies, and they also promoted the

idea of using both therapy methods together. A weakness of this study is that they were unable

to randomize the clients when putting them into groups, and this results in other factors possibly

having an affect on the results.

Da Silva Cameirao et al. (2011) wanted to examine the possibility of stroke patient

having more freedom managing their rehab through virtual reality. Their rationale for this study

was due to the potential need to examine therapy methods that can be done in the home since

the rate of stroke is so high and may only keep growing. For this intervention, they used a

system called the Rehabilitation Gaming System that intends to decrease the recovery time of

acute stroke patients. The 16 clients were split into two equal groups, using the Rehabilitation

Gaming System in addition to therapy and the other group just had occupational therapy.

Those in the virtual reality group would wear gloves that could track limb movements using

color, and they went through some practice scenarios in order to obtain baseline values and

determine whether adjustments needed to be made or not. The following sessions over the

next 12 weeks involved doing tasks that intended to train speed and range of motion and

involved placing, hitting, and grabbing. The results showed that the virtual reality group

improved faster over time, and additionally, had a greater improvement in paretic arm speed

along with better scores in the Fugl-Meyer assessment and Chedoke Arm and Hand Activity

Inventory. A strength of this study is that they were able to have the treatment span be much

longer than other virtual reality experiments, while a weakness is that their sample size of 8

participants in each group was very small.

Lucia Francesca Lucca (2009) created this mini review in order to analyze the rationale

behind these studies, see how the studies are being done, and what is the potential and
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limitations to VR setups in a rehabilitation setting. Her rationale for this review consisted of the

increased popularity and research in the idea of how VR can help rebuild the motor cortex, help

patients learn by imitation, and easily be adapted to suit the client and their skills and

preferences. For this review, a classification of the current virtual reality setups was created

and then compared with published studies that were available at the time. The criteria for motor

impairment and recovery was also compared, what rehabilitation techniques were used, and the

efficacy of these studies. The findings showed that studies during this time period did support

the use of virtual reality in rehabilitation therapy for the upper limbs after stroke, but there

currently is not enough evidence or studies to prove virtual reality is better than conventional

therapy or should replace conventional therapy. Suggestions for future research suggests

having studies have similar selection procedures for candidates, larger sample sizes, and clear

definitions for severity and recovery in more controlled study designs. One unique strength of

this review is how symptoms such as nausea, dizziness, and stress while using the virtual

reality systems were compared. A weakness of the review is that it didn’t look into too many

published studies and virtual reality setups were not very common or popular during the time the

review came out.

Discussion

Virtual reality therapy has been shown to be beneficial as a therapeutic intervention for

upper extremity hemiparesis across a number of randomized clinical trials, placing it in the

category of class 1, level A evidence. While VR research and application of VR in the clinic is

ongoing, the use of VR programs will be critical to the future evolution of therapeutic practices.

As VR is developed, it has the potential to become a universal component in the rehabilitation of

stroke patients with acute and chronic upper extremity impairment. VR rehabilitation provides an

opportunity for therapists to engage clients in fun and meaningful tasks that automatically adapt

to each client’s skill level and provide a variety of engaging environments adapted to specific to
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therapy-settings, therapeutic tasks, and therapeutic goals. The wide-ranging utility of VR

applications makes this a critical area for further research.

While studies reviewed in this paper found VR to be an effective method in stroke

therapy, many larger studies will need to be conducted before VR will become commonplace in

clinics. It is also important to take into consideration the high costs often associated with newer

technology such as VR. In addition, not all clients are physically and mentally comfortable with

this form of therapy and the unfamiliar technological aspects. Traditional therapies will remain

effective and useful, but the use of VR therapy will undoubtedly pass on a number of additional

benefits to patients. Within the context of occupational therapy, VR has proven to be an

adaptable approach that can provide client-centered and functional care. VR can be applied in a

number of modalities, including, but not limited to: Teaching of compensatory strategies to

chronically paretic individuals, improvement of upper extremity hemiparesis function,

engagement in ADL tasks, virtual reflection therapy, leisure and game-playing, fine motor, and

gross motor tasks.

Stroke, in both acute and chronic conditions, presents a major health issue affecting

families and individuals in the United States. The combination of an aging U.S. population and

rising risk factors for stroke present a clear need for the use of evidence-based practices within

therapy clinics, making VR therapy an exciting and promising development in the field of

rehabilitation.

Reference List

Carlowitz-Ghori, K. V., Bayraktaroglu, Z., Hohlefeld, F., Losch, F., Curio, G., & Nikulin, V.

(2014). Corticomuscular coherence in acute and chronic stroke. Klinische

ssssssNeurophysiologie,45(01). doi:10.1055/s-0034-1371233

Da Silva Cameirao, M., Bermudez i Badia, S., Duarte, E., & F.M.J. Verschure, P. (2011).

Virtual reality based rehabilitation speeds up functional recovery of the upper

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extremities after stroke: A randomized controlled pilot study in the acute phase of

stroke using the Rehabilitation Gaming System. Restorative Neurology and

Neuroscience, 29(5), 287-298. DOI 10.3233/RNN-2011-0599

Delden, A. E., Peper, C. E., Harlaar, J., Daffertshofer, A., Zijp, N. I., Nienhuys, K., . . . Beek, P.

J. (2009). Comparing unilateral and bilateral upper limb training: The ULTRA-stroke

program design. BMC Neurology, 9(1). doi:10.1186/1471-2377-9-57

Francesca Lucca, L. (2009). Virtual reality and motor rehabilitation of the upper limb after

stroke: A generation of progress? Journal of Rehabilitation Medicine, 41, 1003-1006.

In, T. S., Jung, K. S., Lee, S. W., & Song, C. H. (2012). Virtual reality reflection therapy

improves motor recovery and motor function in the upper extremities of people with

chronic stroke.Journal of Physical Therapy Science, 24(4), 339-343.

doi:10.1589/jpts.24.339

Kiper, P., Agostini, M., Luque-Moreno, C., Tonin, P., & Turolla, A. (2014). Reinforced Feedback

in Virtual environment for rehabilitation of upper extremity dysfunction after stroke:

Preliminary data from a randomized controlled trial. BioMed Research

International, 2014, 1-8. doi:10.1155/2014/752128

Kwakkel, G., Kollen, B. J., Grond, J. V., & Prevo, A. J. (2003). Probability of Regaining

Dexterity in the flaccid upper limb: Impact of severity of paresis and time since

onset in acute stroke. Stroke,34(9), 2181-2186.

doi:10.1161/01.str.0000087172.16305.cd

Kwon, J., Park, M., Yoon, I., & Park, S. (2012). Effects of virtual reality on upper extremity

function and activities of daily living performance in acute stroke: A double-blind

randomized clinical trial. Neurorehabilitation, 31(4), 379–385.

http://dx.doi.org/10.3233/NRE-2012-00807

Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet

Neurology. 2009; 8: 741–754

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Lee, D., Lee, M., Lee, K., & Song, C. (2014). Asymmetric training using virtual reality reflection

equipment and the enhancement of upper limb function in stroke patients: A randomized

controlled trial. Journal of Stroke and Cerebrovascular Diseases, 23(6), 1319-1326.

doi:10.1016/j.jstrokecerebrovasdis.2013.11.006

Palazzo, C., Klinger, E., Dorner, V., Kadri, A., Thierry, O., Boumenir, Y., . . . Ville, I.

(2016). Barriers to home-based exercise program adherence with chronic low back

pain: Patient expectations regarding new technologies. Annals of Physical and

Rehabilitation Medicine,59(2), 107-113. doi:10.1016/j.rehab.2016.01.009

Saposnik, G., Teasell, R., Mamdani, M., Hall, J., McIlroy, W., Cheung, D.,.... Bayley, M.

(2010). Effectiveness of virtual reality using Wii gaming technology in stroke

rehabilitation. Stroke, 41(7), 1477-1484.

https://doi.org/10.1161/STROKEAHA.110.584979

Turolla, A., Dam, M., Ventura, L., Tonin, P., Agostini, M., Zucconi, C.,... Piron, L. (2013).

Virtual reality for the rehabilitation of the upper limb motor function after stroke:

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10(85). https://doi.org/10.1186/1743-0003-10-85

https://www.cdc.gov/stroke/facts.htm

See Table 1 for an overview of studies reviewed.

Article Quality of Evidence Findings

Cameirao et al. 2012
Level 2. Pedro Scale: 7
Visual and haptic feedback
provided the most significant
and lasting improvements in
motor function according to
the clinical evaluation. All
groups showed significant
improvements. The
exoskeleton group displayed
the least benefit.
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In et al. (2012) Level 2. Pedro Scale: 7 Both groups increased UE

recovery/function. More
significant increases seen in
experimental group, but VR
reflection therapy was
demonstrated to be more
effective than traditional
mirror therapy, with less
postural side effects and
more natural movement/body
positioning.

Kiper et al. (2014) Level 1. Pedro Scale: 8 Treatment group, using a

virtual reality program,
displayed greater functional
improvements than the
control group which used
traditional methods of
rehabilitation. Hemorrhagic
stroke patients showed
greater improvements overall
but the treatment group
showed motor and ADL
improvements across both
hemorrhagic and ischemic
stroke patients.

Kwon et al. (2012) Level 1. Pedro Scale: 9 VR group: Significant

(p<0.05) improvement on
FMA and MFT.
CT group: Significant
improvement only in FMA,
not MFT.

No significant difference in
improvement between two
groups in UE function and
ADL performance, however,
VR was more effective than
CT by itself.

Lee et al. (2014) Level 1. Pedro Scale: 8 Groups displayed significant

improvements in UE function
parameters, except in tests of
spasticity and the MAS. ROM
in the wrist was similar in
both groups before treatment,
however, after treatment both
groups displayed significant
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improvement in flexion,
extension, ulnar- and radial-
deviation. The asymmetric
group displayed significant
improvements in motor
function over the control
group in shoulder, elbow, and
forearm movements.

Saposnik et al. (2010) Level 1. Pedro Scale: 9 -No safety or fatigue issues
were found in the study.

-Both groups had

comparable positive
outcomes in the Box and
Block Test, although
participants in the VRWII
group had quicker times in
completing tasks when
assessing using the Wolf
Motor Function Test. Once
adjusting for age, severity,
and baseline grip strength,
there was no significant
difference between
recreational therapy and
VRWII.

-VRWII gaming represents

a safe, feasible, and
potentially effective
alternative to facilitate
rehab therapy and promote
motor recovery.

Turolla et al. (2013) Level 2. Pedro Scale: 9 Both treatments significantly

improved Fugl-Meyer upper
extremity and Functional
Independence Measure
scores, but improvement was
significantly greater in those
using VR than those using
conventional therapy alone.

Da Silva Cameirao et al. Level 2. Pedro Scale: 6 RGS group displayed

(2011) significantly improved
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performance in paretic arm

speed and better arm
performance in the other two
assessments used. In
addition the RGS group had
faster improvement time in all
clinical scales used.

Francesca Lucca, L. (2009) Level 5. Pedro Scale: N/A. Studies completed at this
Review. time show support for using
VR in upper-limb therapy
after stroke. Still a very new
area, and currently is hard to
decipher whether VR should
be used in replace of
conventional therapy. Larger
sample sizes need to be used
in studies.