Published Ahead of Print on May 2, 2018 as 10.1212/WNL.

0000000000005603
VIEWS & REVIEWS

Advantages of virtual reality in the rehabilitation

of balance and gait
Systematic review
Desiderio Cano Porras, MSc, Petra Siemonsma, PhD, Rivka Inzelberg, MD, Gabriel Zeilig, MD, Correspondence
and Meir Plotnik, PhD Dr. Plotnik

®
meir.plotnik@
Neurology 2018;0:1-9. doi:10.1212/WNL.0000000000005603 sheba.health.gov.il

Abstract
Background
Virtual reality (VR) has emerged as a therapeutic tool facilitating motor learning for balance and
gait rehabilitation. The evidence, however, has not yet resulted in standardized guidelines. The
aim of this study was to systematically review the application of VR-based rehabilitation of
balance and gait in 6 neurologic cohorts, describing methodologic quality, intervention pro-
grams, and reported efficacy.

Methods
This study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
VR-based treatments of Parkinson disease, multiple sclerosis, acute and chronic poststroke,
traumatic brain injury, and cerebral palsy were researched in PubMed and Scopus, including
earliest available records. Therapeutic validity (CONTENT scale) and risk of bias in ran-
domized controlled trials (RCT) (Cochrane Collaboration tool) and non-RCT (Newcastle-
Ottawa scale) were assessed.

Results
Ninety-seven articles were included, 68 published in 2013 or later. VR improved balance and
gait in all cohorts, especially when combined with conventional rehabilitation. Most studies
presented poor methodologic quality, lacked a clear rationale for intervention programs, and
did not utilize motor learning principles meticulously. RCTs with more robust methodologic
designs were widely recommended.

Conclusion
Our results suggest that VR-based rehabilitation is developing rapidly, has the potential to
improve balance and gait in neurologic patients, and brings additional benefits when combined
with conventional rehabilitation. This systematic review provides detailed information for
developing theory-driven protocols that may assist overcoming the observed lack of argued
choices for intervention programs and motor learning implementation and serves as a reference
for the design and planning of personalized VR-based treatments.

Registration
PROSPERO CRD42016042051.

From the Center of Advanced Technologies in Rehabilitation (D.C.P., M.P.) and Department of Neurological Rehabilitation (G.Z.), Sheba Medical Center, Tel Hashomer; Departments
of Neurology and Neurosurgery (R.I.), Physical and Rehabilitation Medicine (G.Z.), and Physiology and Pharmacology (M.P.), Sackler Faculty of Medicine (D.C.P.), and Sagol School of
Neuroscience (R.I., M.P.), Tel Aviv University, Israel; Perception and Action in Complex Environments (D.C.P.), Marie Curie International Training Network, European Union’s Horizons
2020 Research and Innovation Program, Brussels, Belgium; Division of Health Care (P.S.), University of Applied Science, Leiden; THIM International School for Physiotherapy (P.S.),
Nieuwegein; and Predictive Health Technologies (P.S.), Netherlands Organization for Applied Scientific Research, Leiden, the Netherlands.

Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Copyright © 2018 American Academy of Neurology 1

Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
 Glossary
10-MWT = 10 Meter Walk Test; BBS = Berg Balance Scale; CP = cerebral palsy; CR = conventional rehabilitation; GS = gait
speed; MLS = motor learning strategies; MS = multiple sclerosis; NOS = Newcastle-Ottawa Scale; PD = Parkinson disease;
PRISMA = Preferred Reported Items for Systematic Reviews and Meta-Analyses; RCT = randomized controlled trials; TBI =
traumatic brain injury; TUG = Timed Up and Go; VR = virtual reality.
Virtual reality (VR) has emerged as a rehabilitation tech-
nology for patients with neurologic conditions. Like in other
types of rehabilitation, VR-based interventions attempt to
promote neuroplasticity and motor learning.1,2 To structure
interventions promoting motor learning, therapists conduct
clinical practices known as motor learning strategies (MLS)
that take into consideration specific motor learning
principles.3,4 A recent study defined MLS as “observable
therapeutic actions in which therapists consider task and
client-specific factors to select and to apply evidence-based
practice and feedback variables for optimal motor learning.”4
VR has several advantages over conventional rehabilitation
(CR) for implementing MLS, in particular facilitating the
incorporation of motor learning principles such as real-time
multisensory feedback, task variation, objective progression,
and task-oriented repetitive training.5,6 Performing this type
of training in a VR environment can induce the re-
organization of the neural architecture7 and stimulates
the recovery of motor skills after neurologic damage.1,7,8 VR
also facilitates both standardization and personalized
interventions.5
There is growing evidence of the benefits of VR for improving
balance and gait in neurologic patients.9–11 Balance and gait
are significant predictors of functional independence and are
associated with risk of falls,12,13 ambulation, and physical
activity.13,14 Moreover, deficits in balance and gait limit
activities of daily living and quality of life.10 This growing
evidence has not yet resulted in guidelines for VR-based
rehabilitation of balance and gait,15 and a consensus regarding
optimal intervention programs (for example, dosage and
tasks) and actual effects of VR is lacking. This hampers the
development of standardized interventions and the optimal
use of VR in rehabilitation.1,15,16
This study systematically reviews the implementation of VR
in the rehabilitation of balance and gait in patients with
Parkinson disease (PD), multiple sclerosis (MS), acute and
chronic poststroke, traumatic brain injury (TBI), and cerebral
palsy (CP). The objective is to describe the application of VR
and the reported outcomes and effects from individual
publications, with the goal to provide detailed information for
the design and planning of future VR-based interventions
among neurologic patients. We also aim to clarify aspects
related to the emerging use of VR for each medical condition,
in particular regarding (1) efficacy in improving balance and
gait, (2) intervention programs for VR-based rehabilitation,
and (3) therapeutic validity.
2 Neurology | Volume , Number  | Month 0, 2018
Copyright ª 2018 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Methods
This study followed the Preferred Reported Items for Sys-
tematic Reviews and Meta-Analyses (PRISMA),17 and the
protocol registration is in the PROSPERO International
Prospective Register for Systematic Reviews (crd.york.ac.uk/
prospero/; registration CRD42016042051).
Eligibility criteria
A participants, interventions, comparisons, outcomes, and
study design (PICOS) model defined eligibility criteria.17
Participants: Patients with PD, MS, acute or chronic
(>6 months) poststroke, TBI, or CP.
Interventions: Rehabilitation treatments implementing VR
for recovery of balance and gait.
Comparisons: Pretraining and posttraining or between
interventions (e.g., VR vs CR such as physical therapy or
treadmill training).
Outcomes: Measures of balance and gait.
Study design: Any design with measurement pre–post
training.
Search strategy
Searches included the earliest available records on August
2016 in PubMed and Scopus. The search in PubMed included
the builder “all fields” and the query (virtual reality or video
games) and (motor learning or rehabilitation) and (posture
or gait or balance or mobility). We conducted a similar
strategy in Scopus. A manual search identified additional
records.
Study selection
One author (D.C.P.) performed 2-level eligibility assessment
by first checking the title and abstract and then checking the
full text. Two authors (P.S. and M.P.) checked the included
articles. Disagreements were resolved by consulting R.I.
and G.Z.
Data extraction
We collected data on participants (medical condition, sample
size, age, and time of diagnosis), type of intervention (e.g., VR
combined with CR), measures assessing balance and gait,
follow-up assessment (after intervention), and reported out-
comes and effects of VR. In addition, we described the (1)
characteristics of the study (design, country, and setting); (2)
implementation of motor learning principles, i.e., feedback
(intrinsic, from within [sensory], and extrinsic, from outside),
task variation (e.g., weight-shifting, obstacle negotiation),
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treatment intensity (e.g., total time in VR training) (indicating
repetitions), and progression; and (3) VR system (equip-
ment, level of immersion based on previous definition18).
Assessment of methodologic quality
We used the CONTENT scale to assess therapeutic validity.19
The scale includes 9 items accounting for patient eligibility,
competences and settings, rationale, content, and adherence.
Studies scoring under 6 points are considered to have poor
therapeutic quality.19 Assessment of risk of bias relied on the
study design. The Cochrane Collaboration tool20 was used for
randomized controlled trials (RCT) and quasi-RCT and the
Newcastle-Ottawa Scale (NOS) for cohort studies (non-
RCT) and case reports (5 participants or fewer) (ohri.ca/
programs/clinical_epidemiology/oxford.asp). The Cochrane
tool analyzed 7 domains: random sequence generation, allo-
cation concealment, blinding of participants and personal
data, blinding of outcome assessment, incomplete outcome
data, selective reporting, and other bias. The NOS comprised
8 items reporting on selection, comparability, and outcome.
All the studies were assigned 2 scores: 1 for therapeutic
validity (from 0 to 9) and the other for risk of bias (from 0 to 7
points for RCT and from 0 to 8 stars for non-RCT).
Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of study selection
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Synthesis of results and analysis
Studies were classified by design (RCT, cohort studies, and
case reports). Because of the high number of publications
included, tables e-1 and e-2 (links.lww.com/WNL/A497)
report only about RCTs that (1) were labeled as therapeuti-
cally valid, that is, scored ≥6 the CONTENT scale; and (2)
had the lowest risk of bias, that is, the highest fourth quartile
(≥3 points) in the Cochrane Collaboration tool (table e-3).
Primary outcome was efficacy of VR (outcomes and effects of
individual publications on balance and gait).
Results
Study selection
Figure 1 shows the selection process in a PRISMA diagram
resulting in the final inclusion of 97 studies.
Years of publication and study design
More than 70% (68 studies) were published in 2013 or later
(figure 2). Designs were RCT or quasi-RCT (n = 49 [50%]),
cohort studies (n = 34 [35%]), and case reports (n = 14
[15%]) (tables e-1 and e-4, A–F, links.lww.com/WNL/A497).
The search strategy identified 1,333
records. The screening stage removed
32 duplicates, 1,175 studies based on
title and abstract, and assessed the
eligibility of 126 full texts, for a final
inclusion of 97 studies. Studies on
poststroke were divided into 2 main
groups according to chronicity: acute
and chronic (more than 6 months). VR
= virtual reality.
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 Figure 2 Frequency of publications
The number of publications reporting on rehabilitation programs using virtual reality for training in balance and gait has been growing at an exponential rate
for the last few years, with a remarkable focus on poststroke studies.
Sample sizes ranged from an average of 12 patients with CP to
34 with MS.
Methodologic quality
Forty-nine studies (50%) lacked therapeutic validity and most
studies presented high risk of bias (table e-3, links.lww.com/
WNL/A497).
Treatment intensity
Total VR treatment period averaged 583 ± 430 minutes
(figure 3).
Outcomes measuring balance and gait
Most reported balance measures were Berg Balance Scale
(BBS, n = 38) and Timed Up and Go (TUG, n = 34); for
walking, these were gait speed (GS, n = 22), the 10 Meter
Walk Test (10-MWT, n = 19), and the 6 Meter Walk Test
(n = 13) (tables e-1 and e-4, A–F, links.lww.com/WNL/
A497). Twelve studies performed dual-task conditions (e.g.,
motor-cognitive).
Findings and conclusions reported
by publications
Nearly all studies reported benefits of VR training on balance
and gait (tables e-1 and e-4, A–F, links.lww.com/WNL/
A497). This section reports findings postintervention and
during follow-up assessments.
Parkinson disease (n = 18)
All but one study21 found gains in TUG (n = 7) and BBS (n =
9). Eight studies with follow-up assessments suggested that
gains might remain or continue to improve between 2 weeks
and 6 months after intervention. Some concluded that VR is
useful as therapeutic intervention22 and proposed VR as an
alternative to independent exercise.23 Three home-based
interventions24–26 reported positive findings on gait and bal-
ance. Some authors stated that VR training brings benefits
similar to CR.21,25,27–29 A multimodal intervention (motor-
cognitive) combining VR and treadmill training resulted in
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a more effective reduction of risk of fall compared to a tread-
mill-only intervention.30 However, studies recommend
further RCTs with larger samples, e.g., reference 27.
Multiple sclerosis (n = 11)
Several outcome measures improved on BBS (3/5 studies),
TUG (2/4), and the 4-Step Square Test (3/4). Three studies
reported maintained improvements between 1 and 2 months
follow-up. One study,31 however, did not find significant
benefits using VR and another found a decline in physical
activity at week 14.32 Some authors suggested that VR should
complement CR,15,31 while others recommended its use as
an alternative to CR,33 VR being more effective than CR in
improving balance in one study.34
Acute poststroke (n = 11)
Positive changes were found on BBS (in 6 out of 7 studies),
TUG (5/6), and 10-MWT (3/3). Three studies conducted
2–4 week follow-up assessments; one35 reported benefits in
walking ability at 1-month follow-up and 2 did not find
significant gains (or losses). One study36 suggested that
VR-based telerehabilitation provides similar outcomes of bal-
ance and gait compared to CR, while another35 suggested that
incorporating VR into CR may be more effective than CR only.
However, it was also reported37 that the inclusion of VR into
CR does not lead to overall benefits in balance, although VR
may improve balance in patients with normal sensory function.
Chronic poststroke (n = 35)
Over 80% (13/16 studies) evaluating TUG reported gains.
Improvements occurred on BBS (11/14) and GS (9/10).
Follow-up assessments in 10 studies lacked consensus.
Half38–42 of the studies suggested that gains are not main-
tained and 5 maintained or improved gains.43–47 A home-
based telerehabilitation VR training41 improved balance and
gait as in-clinic VR intervention. Likewise, VR training was as
effective as CR.8,39,40 Some studies found that VR might
have an augmented effect, for example, combined with
robotic-supported training,45,46 stepping over obstacles,44 and
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Figure 3 Treatment intensity

These histograms show the virtual reality (VR) rehabilitation strategies adopted in terms of treatment intensity among the included studies. The upper plots
express the time (in minutes) that patients effectively spent in VR intervention. This does not include time spent in other interventions (e.g., conventional
balance therapy or neurodevelopmental treatment). We observed that the majority of studies implemented interventions of 20–40 minutes of VR per session
for 3 sessions per week over 4–6 weeks. The total time of VR training generally lasted between 300 and 600 minutes.

CR.1,40,47 One study reported that further research is needed
to demonstrate the effect of VR on balance and gait.38
Traumatic brain injury (n = 6)
Significant gains occurred in BBS, functional gait assessment,
and VR scores representing weight-shifting. Three studies
performing follow-up assessments suggested that gains may
persist after VR training (2 days–3 months). One study48
reported that VR only was more effective to improve GS and
weight-shifting compared to a combination of VR and vestibular
therapy. Three other studies suggested that VR leads to nearly
equal outcomes of balance and gait compared to CR.49–51
Cerebral palsy (n = 16)
All studies (n = 11) evaluating 10-MWT, pediatric balance
scale, GS, and gross motor function measure, with the ex-
ception of one study,52 reported gains in these measures. Five
studies with follow-up assessments suggested maintained
gains after 1–3 months of VR training (table e-4, A–F, links.
lww.com/WNL/A497). Other authors suggested that VR is
not effective for balance training53 or that VR should be
viewed as an addition to CR.54,55 The need for studies with
larger sample sizes was emphasized.
treatment,56 transcranial direct current stimulation,16 and
robotic training57,58). Other authors reported on the feasi-
bility of VR for rehabilitation59 at home60 and in clinicse1
(links.lww.com/WNL/A498).
Application of VR and of motor learning
principles: Level of immersion, multisensory
feedback, treatment intensity, task variation
and progression
Tables e-2 and e-5, A–F (links.lww.com/WNL/A497), de-
scribe VR application. Most studies utilized semi-immersive
(n = 15 [16%]) or nonimmersive VR (n = 74 [76%]),
mainly low-cost commercial consoles such as Nintendo Wii
(n = 41).
Up to 88% (n = 85) of studies reported intrinsic feedback:
visual (n = 84 studies), auditory (n = 42), somatosensory
(i.e., haptic, tactile, and vibratory; n = 8), and proprioceptive
(n = 6). In addition, 79% (n = 77) reported extrinsic feedback:
knowledge of performance (n = 70) and knowledge of results
(n = 37). However, studies did not assess or discuss the
benefits of feedback.

Some authors suggested additional benefits of VR in combi- Patients performed a variety of task-oriented and repetitive
nation with other therapies (e.g., neurodevelopmental activities (tables e-2 and e-5, A–F, links.lww.com/WNL/A497).

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 Table e-6 identifies the application of treatment progression
and additional measures for VR application (e.g., safety,
adherence, and self-efficacy).
Discussion
This systematic review assessed and compared VR-based
strategies for rehabilitation of balance and gait across dif-
ferent neurologic conditions, while previous reviews focused
on a sole cohort (e.g., poststroke or MS,10,e2 links.lww.com/
WNL/A498). Our results suggest that VR has additional
benefits for rehabilitation of balance and gait, especially
when combined with other interventions such as CR.
However, most studies presented poor methodologic
quality and intervention programs lacked a clear rationale, in
particular regarding treatment intensity, personalized
training, and task variation. Indeed, the worst scores in
therapeutic validity were in items 6 (“Was the intensity of
the therapeutic exercise selected and adjusted on theoreti-
cally driven and/or argued choices?”) and 8 (“Was the
therapeutic exercise personalized and contextualized to the
individual participants?”) (table e-3, links.lww.com/WNL/
A497).
Summary of main findings
For PD (18 studies), most studies comparing VR to CR found
similar improvements in balance and gait.21,25,28,29 This sup-
ports rehabilitation strategies using VR.
For MS (n = 11), we found discrepancies in the outcomes of
balance and gait among studies with different levels of
methodologic quality. Two studies (therapeutically valid, low
risk of bias, and one utilizing immersive VR) suggested that
VR has similar benefits compared to CR15,e3 (links.lww.com/
WNL/A498). On the other hand, 2 studies (not therapeuti-
cally valid, with high risk of bias, and using nonimmersive VR)
suggested that VR is more effective than CR.33,34 Marked
differences in patient heterogeneity and treatment intensity
may explain these discrepancies. The 4 MS studies with
shortest exposure to VR (260–360 minutes) did not present
significant advantage of VR15,31,e3,e4 (tables e-1 and e-4, A–F,
links.lww.com/WNL/A497).
For poststroke (n = 11 acute and n = 35 chronic), VR seemed
to be more effective at improving dynamic balance than static
balance for both chronice5,e6 (links.lww.com/WNL/A498)
and acute poststroke.e7 Studies of acute poststroke suggest
that VR is safe and improves balance and gait even after recent
episodes of stroke.14
For TBI (n = 6), the additional benefits of VR warrant further
investigation. Although balance and gait improved within VR-
only interventionse7,e8 (links.lww.com/WNL/A498), there
was no consensus in effects when VR was compared to other
interventions. Only 1 study found significant benefits of VR
compared to traditional vestibular therapy.48
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CP studies (n = 16) presented poor methodologic quality. For
preintervention/postintervention comparisons, 3 (therapeu-
tically valid) studies found significant improvements in
balance and gait52,59,e9 (links.lww.com/WNL/A498). In
contrast, 3 studies lacking therapeutic validity did not find
significant results to conclude that VR is effective.54,55,e1 This
suggests that for patients with CP, possibly due to their young
age, more rigorous intervention programs are required for
achieving clinical efficacy.
Finally, follow-up assessments suggest that VR contributes to
maintain benefits for weeks or even months after intervention
(the only exception to this consistent trend was in chronic
poststroke). Others support our findings that improvements
remain for 2 months after intervention for PD.9
Interpretation of results
VR implementation is developing rapidly (figure 2). Most
studies in all 6 cohorts showed certain levels of evidence of the
efficacy of VR for improving balance and gait. Levels of ad-
herence, motivation, and enjoyment consistently favored VR
(table e-6, links.lww.com/WNL/A497). Despite the encour-
aging results, we found some weaknesses on the imple-
mentation of VR. One main source of weakness relates to the
fact that most of the studies do not define a priori rationalized
MLS for the interventions. The lack of rational intervention
programs and personalized interventions are a methodologic
problem that hinder therapeutic validity and represent a seri-
ous limitation.
Incorporating MLS into the design and planning of VR
interventions and treatment intensity may overcome these
challenges.3,4 Researchers recognized that VR is notably
useful to incorporate MLS that optimize motor learning for
a successful rehabilitation program.4–6 The use of MLS may
contribute to reaching homogeneity in the description and
quantification of VR interventions in future studies.
We define theory-driven VR-based rehabilitation protocols as
the evidence-based description and quantification of inter-
ventions aiming to promote motor learning using VR tech-
nology. Such protocols will facilitate the exploitation of MLS.
Wuest et al.e10 (links.lww.com/WNL/A498) reported such an
example with a set of VR applications that systematically exploit
“variance practice” and “progression,” alternating training ses-
sions with different tasks. Similar initiatives may address mul-
tisensory feedback, treatment intensity (i.e., repetitions), or task
specificity.
VR to enhance motor learning
VR enhanced motor learning principles (as shown for ex-
ample in CP,11 MS [links.lww.com/WNL/A498],e2 post-
stroke,e11,e12 and PD9,e13).
For treatment intensity, some authors suggest a minimum of
10 sessions for poststroke18 or 14 sessions for PD.9 This
review found that treatment intensity was heterogeneous with
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a minimum of 9 sessions in acute poststroke and of 8 sessions
in PD. Task variations included weight-shifting, obstacle ne-
gotiation, dual tasking, and treadmill training, among others.
Motivation and enjoyment may assist motor learning. One-
third of studies (n = 32, table e-6, links.lww.com/WNL/
A497) evaluated these features. Lack of motivation or en-
joyment may lead to the interruption or cessation of re-
habilitation treatment (i.e., adherence), which in turn can
hamper the potential of the patient to improve balance and
gaite14–e16 (links.lww.com/WNL/A498).
Nearly 60% of studies (table e-6, links.lww.com/WNL/A497)
reported progression adjustments9,e16 (links.lww.com/
WNL/A498) for an efficient control of the level of difficulty
per VR tasks within and across sessions.
Immediate multisensory feedback is important10,e17 (links.
lww.com/WNL/A498). Adding somatosensory and pro-
prioceptive inputs enriches intrinsic feedback (mainly visual-
auditory in VR studies). Moreover, extrinsic feedback
(knowledge of results and knowledge of performance) is
highly relevant in VR interventions because it facilitates an
objective measure of progress and increases motivation (e.g.,
in poststroke10,e11 and PDe13).
Comparison with the literature
Our results are consistent with a meta-analysis in post-
strokee12 (links.lww.com/WNL/A498) and a review in MSe2
supporting the efficacy of VR for balance and gait re-
habilitation. We also observed that combining VR with CR in
poststroke,10,18,e14 CP,11 and PD30 is beneficial. Our findings
on follow-up assessments for acute poststroke corroborate
others,e12 suggesting that patients may improve in balance
and gait 1–6 months after stroke. Nonetheless, interventions
in acute poststroke applied less intense treatments than in
chronic poststroke (figure 3).
Clinical relevance
The results of this systematic review should benefit clinical
practice with protocols or guidelines incorporating both the
provisional evidence and rational treatment choices. A good
start would be illness-related protocols facilitating the design
of patient-tailored VR interventions.
We thus encourage researchers and clinical experts to take
initiatives to develop theory-driven VR-based rehabilitation
protocols (e.g., references e10 and e18) incorporating MLS.4
This systematic review provides ample information for the
realization of such protocols (e.g., motor tasks and VR games
for each cohort).
Clinicians should strike the right balance between too difficult
and too easy tasks, and as such keeping the patient’s moti-
vation high. This delicate balance deserves much attention. It
seems that extrinsic feedback and progression play a critical
role. Objective progression encourages training,58 elicits
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neuroplasticitye19 (links.lww.com/WNL/A498), and partly
explains the benefits of VR on balance and gait in PD21 and
CP.16 Progression might be adjusted according to extrinsic
feedback and motivation. For instance, if the patient is tired or
bored, she or he should be engaged in less difficult tasks.
Alternatively, if the knowledge of results (extrinsic feedback)
reports very high scores, the therapist can consider engaging
the patient to a more demanding task.
This study presents the most frequently reported measures
measuring balance and gait in each cohort, enabling clinicians
to compare their results with previous studies. BBS, TUG, and
GS-related measures were the most commonly reported, and
they matched the results of other systematic reviews9,18,e14,e15
(links.lww.com/WNL/A498).
Safety is a high priority in clinical interventions (58 studies
evaluated safety levels or adverse events) (table e-6, links.lww.
com/WNL/A497), yet the results are controversiale11,e15
(links.lww.com/WNL/A498). We recommend using objec-
tive and subjective measures of safety.9
Finally, we encourage conducting follow-up assessments to
better understand long-term outcomes of VR rehabilitatione16
(links.lww.com/WNL/A498), as VR is an emerging technology.
Implications for future research
Although training in fully immersive VR may present eco-
logical validity and seems to bring additional benefits com-
pared to training in less immersive VR systemse15 (links.lww.
com/WNL/A498), further work needs to establish whether
the outcomes transfer to the real worlde17 and investigate how
the level of immersion may influence balance and gait.
Finally, further research might attempt differentiating clini-
cally oriented VR vs commercial video games. Several authors
insist that video games were originally designed for healthy
people and therefore are unsuitable for the recovery of sen-
sorimotor impairments40,e20 (links.lww.com/WNL/A498)
(for a comparison of clinically oriented VR vs commercial
video games, see reference e12).
Strengths and limitations
This systematic review evaluated 97 studies using VR for
improving balance and gait in 6 neurologic cohorts and de-
tailed the strategies for applying VR. The study was limited to
balance and gait; however, there are tangential domains (e.g.,
cognitive function) not considered in this review. Another
limitation is the inclusion of low-quality studies. Nevertheless,
considering the novelty of VR for neurologic rehabilitation,
this review may contribute to rational treatment choices in
future VR interventions.
Our results suggest that VR has the ability to improve balance
and gait in neurologic patients, and creates additional benefits
when combined with other interventions such as CR. These
additional benefits seem to rely on the capability of VR to
Neurology | Volume , Number  | Month 0, 2018 7
 exploit MLS (i.e., task variation and repetition, multisensory
feedback, and motivation). This systematic review provides
detailed information for VR-based interventions in different
neurologic cohorts and may serve as a reference for the design
and planning of future VR-based rehabilitation programs.
There are 2 clinical implications. First, given the growing
evidence of the advantages of VR and the lack of argued
choices in VR interventions setup, a clinical practice guide for
VR-based rehabilitation is necessary. This guide should focus
on incorporating MLS and VR-related values.4 Second,
interventions should be personalized according to individual
sensorimotor and cognitive impairments and environmental
factors (e.g., social and family support), regardless of the
neurologic condition.
Author contributions
D. Cano Porras: study concept and design, acquisition of data,
analysis and interpretation, critical revision of the manuscript
for important intellectual content. Dr. Siemonsma: study
concept and design, analysis and interpretation, critical re-
vision of the manuscript for important intellectual content.
Prof. Inzelberg: critical revision of the manuscript for im-
portant intellectual content, study supervision. Prof. Zeilig:
critical revision of the manuscript for important intellectual
content, study supervision. Dr. Plotnik: study concept
and design, analysis and interpretation, critical revision of
the manuscript for important intellectual content, study
supervision.
Study funding
This work received support from the Perception and Action in
Complex Environments (PACE) project, which has received
funding from the European Union’s Horizon 2020 Research
and Innovation Program under the Marie Sklodwska-Curie
grant agreement no. 642961.
Disclosure
The authors report no disclosures relevant to the manuscript.
Go to Neurology.org/N for full disclosures.
Received September 7, 2017. Accepted in final form March 12, 2018.
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Neurology | Volume , Number  | Month 0, 2018 9
 Advantages of virtual reality in the rehabilitation of balance and gait: Systematic
review
Desiderio Cano Porras, Petra Siemonsma, Rivka Inzelberg, et al.
Neurology published online May 2, 2018
DOI 10.1212/WNL.0000000000005603

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