⬍LEAP⬎
LINKING EVIDENCE AND PRACTICE
Virtual Reality for Stroke Rehabilitation
Tiê P. Yamato, José E. Pompeu, Sandra M.A.A. Pompeu, Leanne Hassett
<LEAP> highlights the findings and
application of Cochrane reviews
and other evidence pertinent to the
practice of physical therapy. The
Cochrane Library is a respected
source of reliable evidence related to
health care. Cochrane systematic
reviews explore the evidence for and
against the effectiveness and appro-
priateness of interventions—medica-
tions, surgery, education, nutrition,
exercises—and the evidence for and
against the use of diagnostic tests for
specific conditions. Cochrane reviews
are designed to facilitate the deci-
sions of clinicians, patients, and oth-
ers in health care by providing a care-
ful review and interpretation of
research studies published in the sci-
entific literature.1 Each article in this
PTJ series will summarize a Cochrane
review or other scientific evidence
resource on a single topic and will
present clinical scenarios based on
real patients to illustrate how the
results of the review can be used to
directly inform clinical decisions. This
article focuses on the effectiveness of
virtual reality for stroke rehabilita-
tion. Can virtual reality systems be
incorporated as part of or instead of
usual rehabilitation programs for a
person after stroke?
Find the <LEAP> case archive at
http://ptjournal.apta.org/
collection/leap-linking-evidence-
and-practice.
1508 f Physical Therapy Volume 96
Stroke is the second leading cause of
death around the world and one of the
main causes of years living with disability
in adults.2,3 A stroke is caused by a dis-
ruption of the blood supply to the brain
because an artery to the brain is either
blocked (ischaemic stroke) or bursts
(hemorrhagic stroke), causing damage to
the brain tissue.4 After a stroke, physical
impairments such as weakness and loss
of coordination are common.5,6 These
impairments cause limitations in mobil-
ity and upper limb activities, restricting
the person with stroke from returning to
his or her everyday activities.7,8
Several treatment options are available
for patients after stroke, with varied evi-
dence to support them.9,10 Repetitive
task-specific training is commonly pre-
scribed in stroke rehabilitation10 and has
been shown to be effective for improv-
ing walking and upper limb function,
especially when higher doses are
used.10,12 However, providing a high
dose of therapy in rehabilitation is chal-
lenging due to a number of factors,
including limitations in staffing and
reducing hospital length of stay. Thus,
alternative and innovative strategies for
delivering a high dose of training are
needed.
Virtual reality is an emerging treatment
option, which may have the capacity to
provide a high dose of repetitive task-
specific training.13 Virtual reality has
been defined as the “use of interactive
simulations created with computer hard-
ware and software to present users with
opportunities to engage in environments
that appear and feel similar to real-world
objects and events.”14 In addition to pro-
viding a high dose of therapy, virtual real-
ity interventions also appear to be well
suited for stroke rehabilitation, as they
provide concurrent feedback, can be tai-
lored to match the person’s ability,15 and
can engage and motivate the person with
stroke to achieve his or her therapy
goals.13 Laver et al16 recently performed
a Cochrane systematic review on virtual
reality for stroke rehabilitation with the
primary objective of determining the
Number 10
effects of virtual reality on upper limb
function and activity compared with an
alternative intervention or no interven-
tion. The review also evaluated the
effects of virtual reality on a number of
other outcomes, including gait and bal-
ance activity, motor and cognitive func-
tion, activity limitation, and participation
restriction. This review included ran-
domized controlled trials and quasi-
randomized controlled trials and partici-
pants 18 years or older with the
diagnosis of stroke of any type, severity,
or time poststroke. The electronic
searches were conducted up to Novem-
ber 2013.
Take-Home Message
The Table summarizes the results of the
systematic review.16 In this review, 37
randomized controlled trials were
included, with a total of 1,019 partici-
pants with stroke. The study sample sizes
varied from 10 to 83 participants, with
59% of the studies having fewer than 25
participants. The risk of bias was unclear
for most of the studies due to poor
reporting and lack of information. Based
on the Grading of Recommendations
Assessment, Development and Evalua-
tion (GRADE) approach, the quality of
evidence was considered “low” (further
research is very likely to have an impor-
tant impact on our confidence in the
estimate of effect) or “very low” (very
little confidence in the effect estimate)
for all comparisons included.17 The stud-
ies included both male and female par-
ticipants with mean ages of 46 to 75
years, any type of stroke and at any time
poststroke, and all levels of severity. For
studies that evaluated upper limb func-
tion, participants with a range of severi-
ties (including severe impairment) were
included, and for studies that evaluated
walking, participants were independent
walkers.
The review included any form of low-
immersive or immersive virtual reality
intervention. The term “immersion”
refers to the degree to which the user
senses that he or she is in the virtual
environment rather than the real
October 2016

Table.
Results of the Cochrane Reviewa
Characteristics of the included
trials
Details of the intervention and
outcomes
Results
Primary outcomes: Virtual reality
compared with conventional
therapy (the same dose of
intervention)
Primary outcomes: Virtual reality
compared with no intervention
or virtual reality provided as an
adjunct to conventional therapy
compared with conventional
therapy alone (a greater dose of
intervention)
Secondary outcomes: Virtual
reality compared with
conventional therapy
world.14 The included studies used com-
mercially available low-immersive recre-
ational gaming systems (eg, Nintendo
Wii, Foxconn, Taipei, Taiwan), commer-
cially available rehabilitation systems (eg,
October 2016
<LEAP> Case #28 Virtual Reality for Stroke Rehabilitation
37 RCTs included (29 in the meta-analysis), providing data from 1,019 participants
Male or female participants with stroke who were 18 years of age or older were included.
Five studies recruited participants within 3 mo of stroke, 1 study recruited participants
within 6 mo, 2 studies recruited participants within 12 mo, and 17 studies recruited
participants with more than 6 mo. The remaining studies did not report time since
stroke.
Virtual reality:
- Compared with the same amount of an alternative intervention, usually conventional
therapy (17 studies)
- Virtual reality provided as an adjunct to conventional therapy compared with
conventional therapy alone or no intervention (12 studies)
The primary outcomes were upper limb function and activity, incorporating arm and
hand function and activity.
The secondary outcomes were walking and balance activity, global motor function,
cognitive function, activity limitation, participation restriction and quality of life, voxels or
regions of interest identified via imaging, and adverse events.
For studies investigating upper limb function, there was a range of severities of arm and
hand function, and for studies investigating walkers, participants were independent
walkers.
The review included any form of immersive or nonimmersive virtual reality: 6 studies used
commercially available recreational gaming systems (eg Nintendo Wii), 9 studies used
commercially available rehabilitation systems (eg, GestureTek IREX), and 22 studies used
customized virtual reality systems.
The interventions were delivered predominantly in inpatient or outpatient settings (35
studies [95%]) and in the home setting in 2 studies.
The total dose of intervention ranged from ⬍5 hours to ⬎21 hours.
There was low-quality evidence that virtual reality was better than conventional therapy
for upper limb function and activity, with a small effect size (SMD⫽0.29;
95% CI⫽0.09, 0.49), based on 12 studies (397 participants).
There was no significant difference of the effect of virtual reality versus conventional
therapy on hand function (grip strength [in kilograms]) (MD⫽3.55;
95% CI⫽–0.20, 7.30), based on 2 trials (44 participants).
Virtual reality as an adjunct to conventional therapy was better than no intervention for
upper limb function, with small-to-medium effect sizes (SMD⫽0.44; 95% CI⫽0.15, 0.73),
based on 9 studies (190 participants).
There was no significant difference of the effect of virtual reality as an adjunct to
conventional therapy versus no intervention on hand function (coordination)
(SMD⫽0.25; 95% CI⫽–0.27, 0.77), based on 3 trials (60 participants).
There was very low-quality evidence that there was no significant difference between
virtual reality and conventional therapy for walking speed (m/s) (MD⫽0.07; 95% CI⫽
–0.09, 0.23), based on 3 studies (58 participants).
There was very low-quality evidence that virtual reality was better than conventional
therapy for activities of daily living, with a medium effect size (SMD⫽0.43; 95%
CI⫽0.18, 0.69), based on 8 studies (253 participants).
Minor adverse effects for the intervention (transient dizziness, headache, and pain) were
reported by 2 studies for a small number of participants.
The other secondary outcomes were not included in the meta-analysis, but no evidence
of effect was reported.
(Continued)
GestureTek IREX, Silicon Valley, Califor- participant’s own home in 2 studies. The
nia), and customized immersive virtual total dose of therapy ranged from less
reality systems. The interventions were than 5 hours to more than 21 hours. Most
delivered in outpatient or inpatient set- studies compared virtual reality with the
tings in the majority of studies and in the same amount of an alternative interven-
Volume 96 Number 10 Physical Therapy f 1509
<LEAP> Case #28 Virtual Reality for Stroke Rehabilitation

Table.
Continued

Secondary outcomes: Virtual
reality compared with no
intervention or virtual reality
provided as an adjunct to
conventional therapy compared
with conventional therapy alone
Virtual reality as an adjunct to conventional therapy was significantly better than
conventional therapy alone for activities of daily living (SMD⫽0.44; 95% CI⫽0.11, 0.76),
based on 8 studies (153 participants).
There was very low-quality evidence that there was no significant difference between
virtual reality in addition to conventional therapy compared with no intervention for
global motor function (SMD⫽0.14; 95% CI⫽–0.63, 0.90), based on 2 studies (27
participants).

Conclusion Virtual reality improved upper limb function and activity, activities of daily living, and
walking speed compared with conventional therapy. However, most comparisons were
based on small sample sizes and very low- to low-quality evidence, which limits the
applicability of the evidence.
a
RCT⫽randomized controlled trial, SMD⫽standardized mean difference, MD⫽mean difference, CI⫽confidence interval.

tion, usually conventional therapy.
Twelve studies investigated virtual
reality as an adjunct to conventional
therapy (the control group received con-
ventional therapy) or compared virtual
reality with no intervention.
The primary outcomes were upper limb
function and activity, incorporating arm
and hand function and activity. Second-
ary outcomes were walking and balance
activity, global motor function, cognitive
function, activity limitation, participa-
tion restriction and quality of life, brain
imaging, and adverse events.
For the primary outcomes, there is low-
quality evidence that virtual reality is bet-
ter than the same amount of conven-
tional therapy for upper limb function
and activity, with a small effect size (stan-
dardized mean difference [SMD]⫽0.29;
95% confidence interval [CI]⫽0.09, 0.49;
which means an improvement of about
4.96 points out of 66; 95% CI⫽1.54,
8.38), based on 12 studies (397 partici-
pants). Subgroup analysis revealed a
greater significant benefit for trials
recruiting participants within 6 months
of their stroke (SMD⫽0.78; 95%
CI⫽0.28, 1.29) compared with more
than 6 months after stroke (SMD⫽0.21;
95% CI⫽0.04, 0.46; ␹2⫽3.90, df⫽1,
P⫽.05). Nine trials (190 participants)
either investigated virtual reality as an
adjunct to conventional therapy or com-
pared virtual reality with no intervention
for upper limb function, and there was a
significant effect in favor of the addition
of virtual reality to conventional therapy
(SMD⫽0.44; 95% CI⫽0.15, 0.73; which
means an improvement of about 7.52
points out of 66; 95% CI⫽2.57, 12.48).
Furthermore, 2 trials (44 participants)
evaluated the effect of virtual reality ver-
sus conventional therapy on hand func-
tion (grip strength), and 3 trials (60 par-
ticipants) either investigated virtual
reality as an adjunct to conventional ther-
apy or compared virtual reality with no
intervention on hand function (coordina-
tion), but for both comparisons, there
was no significant difference in grip
strength (in kilograms) between the
groups (mean difference [MD]⫽3.55;
95% CI⫽⫺0.20, 7.30; and SMD⫽0.25;
95% CI⫽⫺0.27, 0.77, respectively).
For the secondary outcomes, there is
very low-quality evidence that there is no
significant difference between virtual
reality and conventional therapy for
walking speed (m/s), based on 3 studies
(MD⫽0.07; 95% CI⫽⫺0.09, 0.23;
n⫽58). Two studies evaluated the effects
of virtual reality versus conventional
therapy for global motor function, and
there was no significant difference, with
very low-quality evidence (not included
in the meta-analysis). Two studies also
compared virtual reality as an adjunct to
conventional therapy versus conven-
tional therapy alone for global motor
function and did not find significant dif-
ferences (SMD⫽0.14; 95% CI⫽⫺0.63,
0.90; n⫽27). There is very low-quality
evidence that virtual reality was better
than the same amount of conventional
therapy for activities of daily living, with
a medium effect size, based on 8 studies
(SMD⫽0.43; 95% CI⫽0.18, 0.69;
n⫽253). Similarly, low-quality evidence
also showed that virtual reality provided
in addition to conventional therapy was
significantly better than conventional
therapy alone for activities of daily living,
with a medium effect size, based on 8
studies (SMD⫽0.44; 95% CI⫽0.11, 0.76;
n⫽153). Twelve studies evaluated
adverse events, with 2 participants
reporting transient dizziness and head-
aches in the virtual reality group in one
study and 2 participants in the virtual
reality group and 3 participants in the
control group reporting pain caused by
the intervention in another study. The
other secondary outcomes were not
included in the meta-analysis, and no evi-
dence of effect was reported.
Case #28: Applying
Evidence to a Patient
With Stroke
Can virtual reality help this
patient?
Mr Silva is a 72-year-old man who had a
stroke due to a middle cerebral artery
territory infarct. Prior to his stroke, he
was retired, lived independently with his
wife in the community, and walked
unaided. He was admitted to an inpatient
stroke rehabilitation unit 2 weeks after
his stroke, and at that time he scored
25/30 on the Mini-Mental State Examina-
tion,18 indicating normal cognitive
function.
On physical examination, Mr Silva had
right-sided weakness. To measure his
upper limb function, his physical thera-
pist used the Fugl-Meyer Scale19 and the
Box and Block Test.20 On the Fugl-Meyer
Scale (upper limb section), he scored
41/66 points, indicating moderate motor
impairment.17 On the Box and Block
Test, he moved 23 blocks in 60 seconds,
indicating moderate limitation in hand
function.21–24 The normative value (aver-

1510 f Physical Therapy Volume 96 Number 10 October 2016


age performance) on the Box and Block
Test for a man aged 72 years using his
right hand is 68 blocks (SD⫽8).25
On assessment of his walking at this
time, Mr Silva was able to walk short
distances indoors with standby supervi-
sion of one person and was unable to
walk outdoors. To measure his mobility,
his physical therapist conducted the
Short Physical Performance Battery,26 on
which he scored 2/12. For the balance
subscale, he scored 0/4. He was able to
stand in side-by-side stance unassisted,
but only for 8 seconds; thus, semi-
tandem and tandem stance were not
attempted. For the walking subscale, he
scored 1/4 and was able to walk 4 m in
21 seconds (0.19 m/s). For the sit-to-
stand subscale, he scored 1/4 and was
able to stand up without using his hands
5 times in 17.5 seconds.
How did the results of the
Cochrane review apply to
Mr Silva?
During the initial rehabilitation assess-
ment, Mr Silva expressed motivation for
additional exercise and an interest in
technology. The physical therapist,
therefore, considered whether Mr Silva
would benefit from the addition of vir-
tual reality as an adjunct to usual therapy
to improve his upper limb function and
mobility. She, therefore, posed the clini-
cal question: In a 72-year-old man who is
2 weeks poststroke, will virtual reality
(in addition to conventional therapy)
improve upper limb function and mobil-
ity? Thus, the review by Laver et al16 was
identified and provided useful informa-
tion for this patient.
The review16 included studies with both
male and female participants with a
range of upper limb severities (for stud-
ies evaluating the upper limb) and inde-
pendent walkers (for studies evaluating
mobility), with study mean ages of 46 to
75 years. The majority of studies
recruited participants who were more
than 6 months poststroke; however,
some studies recruited participants ear-
lier poststroke, and subgroup analysis
showed greater benefit in upper limb
function for studies recruiting partici-
pants within 6 months of stroke com-
pared with more than 6 months. Mr Silva
October 2016
<LEAP> Case #28 Virtual Reality for Stroke Rehabilitation
was a 72-year-old man 2 weeks after
stroke with moderate upper limb limita-
tions who could walk indoors with
supervision, which is similar to the pop-
ulation included in the review.
The virtual reality intervention in the
review16 was composed of different gam-
ing systems (eg, Nintendo Wii, Ges-
tureTek IREX), of which included studies
focused on different training aspects of
rehabilitation (eg, reaching and manipu-
lation, standing and walking). The phys-
ical therapist working with Mr Silva
opted to use the Nintendo Wii gaming
console (Nintendo Wii Seventh genera-
tion, RVL-001, Foxconn), as this device
was easy to access, there were suitable
games to target upper limb and hand
function and overall mobility, and the
Cochrane review showed no significant
difference between commercially avail-
able systems and more expensive
custom-made systems. The intervention
was applied in a private room of the
hospital, without any distractions. As
most studies included in the review16
provided between 11 and 20 hours of
therapy (range⫽⬎5 hours to ⬎21
hours), the physical therapist decided to
deliver a program of 1 hour of supervised
virtual reality sessions, 5 times per week
for 3 weeks (15 hours total). The games
selected were from the Wii Sports, Wii
Fit, and Cooking Mama software. Games
were selected to address activity limita-
tions (eg, Penguin slide game from Wii
Fit to improve loading the right leg for
standing and walking) and were modi-
fied where necessary to better tailor the
game to suit Mr Silva’s current abilities
(eg, Tightrope game from Wii Fit
changed to a step-touch exercise to a
block). The therapist used about 4 to 6
different games per session, with Mr
Silva playing each game between 3 to 6
times depending on the length and diffi-
culty of the game. Before commencing
the training, the physical therapist intro-
duced Mr Silva to the virtual reality sys-
tem and instructed him on how to move
his body to control the movements of the
avatar within the games. The physical
therapist also assisted Mr Silva in holding
the controls (Wiimote and Nunchuk) and
directed the correct movements of his
arm and hand when necessary.
Volume 96
The virtual reality therapy was accompa-
nied with 1 to 2 hours of conventional
physical therapy (usual care) 5 times per
week (prior to the virtual reality ses-
sions) and with other rehabilitation pro-
vided by the multidisciplinary team. Con-
ventional physical therapy included
exercises to address physical impair-
ments (eg, strength training to address
weakness) and task-specific practice to
address activity limitations, delivered in a
combination of one-on-one, semisuper-
vised and group therapy sessions.
A number of different outcome measures
were reported in the Cochrane review,
most likely due to the diverse interven-
tions addressing different activity limita-
tions (eg, hand function versus walking).
For our case study (Mr Silva), the aim of
therapy was to improve upper limb func-
tion and mobility. We, therefore, chose
the same (Fugl-Meyer Scale and Box and
Block Test) or similar (Short Physical Per-
formance Battery) outcome measures as
reported in the review.16
How well do the outcomes
of the treatment provided to
the patient match those
suggested in the review?
After the 3-week program of virtual real-
ity and conventional therapy, Mr Silva
completed 14 sessions (93%), missing 1
session due to feeling too fatigued, and
showed excellent adherence to the inter-
vention. He showed improvement in
upper limb function, with his Fugl-Meyer
Upper Extremity Scale score increasing
from 41 to 46 points. This improvement
aligns with the Cochrane review,16 and
the increase was greater than the 4-point
change considered to reflect a clinically
important difference for individuals with
stroke.27 Mr Silva also demonstrated
improvement in hand function, with his
posttraining Box and Block Test score
increasing from 23 to 26 blocks. This
improvement is in accordance with the
Cochrane review,16 but it is lower than
the 5.5-point change considered to
reflect a clinically important difference
for individuals with stroke.23
Mr Silva also improved his mobility after
the 3-week training, as demonstrated by
his Short Physical Performance Battery
score increasing from 2 to 8 points. For
Number 10 Physical Therapy f 1511
<LEAP> Case #28 Virtual Reality for Stroke Rehabilitation
the balance subscale scale, he scored
4/4, as he was now able to stand with his
feet side-by-side, semitandem, and tan-
dem stance for 10 seconds each. For the
walking subscale, he still scored 1/4 but
was now able to walk 4 m in 11 seconds
(0.36 m/s). For the sit-to-stand subscale,
he scored 3/4 and was able to stand up
without using his hands 5 times in 11.3
seconds. The minimal detectable change
on the Short Physical Performance Bat-
tery is 2.9 points for elderly people,28
although it is not clear whether it is the
same for patients with stroke. This
mobility improvement exceeded the sys-
tematic review findings, which did not
show a difference between groups. This
discrepancy may be explained by the
very low quality of evidence for this com-
parison, which represents uncertainty
about the effect estimate and a lack of
studies investigating the effects on walk-
ing of virtual reality early after stroke.
Can you apply the results of the
review to your own patient?
The systematic review results applied
well to Mr Silva, who exhibited limita-
tions in reaching and manipulating,
standing, and walking. The studies
included in the Cochrane review by
Laver et al16 included relatively young
people after stroke and often excluded
people with cognitive impairment, apha-
sia, apraxia, and visual impairments;
thus, the results may not generalize to
this subset of people after stroke.
The studies included in the review
focused on different training aspects of
rehabilitation, including upper limb,
activity, lower limb, and balance and
walking; global motor function; and
visual perceptual retraining. The stron-
gest evidence was in improving upper
limb function, particularly in people
within 6 months of stroke. The evidence,
however, is only of low quality due to
small sample sizes and unclear bias
within the study designs, which means
that further research is very likely to
change the effect estimates and that we
lack confidence in the effect estimate.
For other aspects of rehabilitation (eg,
walking, mobility), the evidence from
the review was less clear, with very
little confidence in the effect estimates
provided by the very low-quality evi-
1512 f Physical Therapy Volume 96 Number 10
dence. However, a more recent system-
atic review,29 which incorporated 6
new studies30 –35 published after the
Cochrane review search, was conducted
and reported improvements in walking
speed, balance, and mobility when vir-
tual reality was compared with standard
rehabilitation. The evidence, however,
was less clear when virtual reality was
used as an adjunct to standard
rehabilitation.
The virtual reality systems used in the
studies included in the review ranged
from inexpensive commercially available
recreational gaming systems to more
expensive, commercially available reha-
bilitation systems to expensive custom-
ized virtual reality systems that are not
readily available. Subgroup analysis in
the review did not show any differences
in upper limb function when comparing
different types of virtual reality systems.
These analyses, however, were limited
by the number of studies using the dif-
ferent systems, suggesting that further
research is warranted to understand key
features important in virtual reality sys-
tems. As such, as we demonstrated in our
case study that due to the limited quality
of evidence available, the use of commer-
cially available recreational gaming sys-
tems appears to be reasonable at this
time as an affordable way to provide vir-
tual reality as part of rehabilitation.
What can be advised based on
the results of this systematic
review?
The Cochrane systematic review16
showed low- to very low-quality evi-
dence that virtual reality can be benefical
for people after stroke with activity lim-
itations in reaching and manipulation;
the benefits on standing and walking are
less clear. In addition, minimal adverse
events were reported and considered
minor (eg, transient dizziness). The reha-
bilitation program proposed in this case
study consisted of virtual reality used in
addition to usual care. Mr Silva improved
his upper limb function, walking, and
balance, which may or may not have
been due to the addition of virtual reality
to his usual care and taking into account
the natural recovery after stroke. It is
possible that people after stroke, like Mr
Silva, can benefit from virtual reality as
an adjunct to usual care.
Further research is needed, as virtual
reality is still a new addition to physical
therapy treatment options and the low
and very low quality of the evidence
means there is still uncertainty in the
benefits. Trials including cost-effec-
tiveness analysis and studies evaluating
the acceptibility and feasibility of virtual
reality are needed to guide the imple-
mentation of these systems into clinical
practice. The current evidence does not
support clinical services investing and
utilizing expensive virtual reality systems
or replacing current evidence-based
rehabilitation interventions. However, it
would appear reasonable and safe to
incorporate accessible virtual reality sys-
tems as part of the rehabilitation pro-
gram for a person after stroke, taking
into account the person’s preferences
for this type of intervention.
T.P. Yamato, MSc, Musculoskeletal Division,
The George Institute for Global Health, The
University of Sydney, Level 13/321 Kent St,
Sydney, New South Wales 2000, Australia.
Address all correspondence to Ms Yamato at:
tyamato@georgeinstitute.org.au.
J.E. Pompeu, PhD, Physical Therapy, Speech
and Occupational Therapy Department,
School of Medicine, University of São Paulo,
São Paulo, Brazil.
S.M.A.A. Pompeu, MSc, Discipline of Phys-
iotherapy, Paulista University, São Paulo,
Brazil.
L. Hassett, PhD, Musculoskeletal Division,
The George Institute for Global Health, The
University of Sydney, and Discipline of Phys-
iotherapy, Faculty of Health Sciences, The
University of Sydney.
[Yamato TP, Pompeu JE, Pompeu SMAA,
Hassett L. Virtual reality for stroke rehabilita-
tion. Phys Ther. 2016;96:1508 –1513.]
© 2016 American Physical Therapy Association
Published Ahead of Print:
April 14, 2016
Accepted: March 31, 2016
Submitted: September 22, 2015
All authors provided concept/idea/project
design and writing. Dr Hassett provided data
analysis. Dr J. Pompeu provided project
management. Ms Yamato provided consul-
tation (including review of manuscript
before submission).
October 2016

The case study was developed from data
collected as part of an Australian National
Health and Medical Research Council project
grant: APP1063751. Ms Yamato is sup-
ported by CAPES (Coordenação de Aper-
feiçoamento de Pessoal de Nı́vel Superior),
Brazil.
DOI: 10.2522/ptj.20150539
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