Review article

The Effectiveness of Virtual Reality Training for Post-

Stroke Balance: A Literature Review
Rega Sugianto1, Umi Budi Rahayu2*, Rinna Ainul Magfiroh2

Abstract
Background: Virtual reality (VR) training is a technology that allows a user to interact in a
virtual world that appears real to the user. According to some studies, virtual reality improves
the balance of chronic and acute stroke patients. According to other studies, VR training is only
effective in patients with chronic post-stroke after 6 months. The goal of this study was to
determine the efficacy of virtual reality training in post-stroke patients.
Methods: The research implemented Literature Review based on articles published between
2012 and 2022 in an online database. The internet databases PubMed, ScienceDirect, and
PEDro were used to search for articles with the keywords "virtual reality training," "balance,"
and "stroke." The RCT method was used to study stroke patients in both acute and chronic
phases in this review. The study was analyzed using a PICO (population or problem,
intervention, comparison, outcome) study, which was developed as a framework and used
during the article selection process.
Results: The provision of virtual reality training can be a solution for rehabilitation and balance
improvement interventions with various parameters, such as: BBS, 10 m, MMAS, and TUG,
while taking several factors into account, such as virtual reality dosing methods and the
availability of therapeutic tools, particularly in the chronic phase of stroke .
Discussion: Evidence of sufficient to very good quality supports the positive impact of virtual
reality training on static and dynamic balance in stroke patients.
Conclusion: This review provides moderate evidence to support the conception that VR
training is effective for standard rehabilitation programs in improving balance in chronic stroke
patients. In patients with acute stroke, the effect of VR on improving balance is less clear. More
studies are required to figure out the best training intensity and frequency to achieve the desired
results.

Keywords: Virtual Reality Training, Balance, Stroke

Introduction
Stroke is the leading cause of death and
disability on a global scale (1). In 2010, the
global prevalence was estimated to be 33
million. Every year, approximately 795,000
people have a new stroke, and 185,000 people
have recurrent strokes (2). The brain is a
highly adaptable organ. Recent findings have
shown that brain development and nerve cell
changes are not limited to childhood, as
previously thought. Although dead neurons do
not regenerate, the human brain's adaptive
capacity
or certain situations. To put it another way,
parts of the brain appear to be learning new
skills. Brain injuries, such as stroke,result in
neuronal cell damage and death (3). Stroke is
the second leading cause of dementia and
death, and more than 32% of stroke survivors
have cognitive impairment. Stroke is also the
third most common cause of disability or
disability in the last five years, with the
disability rate increasing from 14% to 23%
after stroke (4). The clinical stages of stroke
are classified according to when they occur.

1
1
Physiotherapy Student, Faculty of Health Sciences, Universitas Muhammadiyah Surakarta, Indonesia.
2*
Lecturer, Faculty of Health Sciences, Universitas Muhammadiyah Surakarta, Indonesia
*Corresponding author. Email: ubr155@ums.ac.id
The majority of the changes in the chronic
phase occur between 12 and 24 weeks, which
is the initial chronic phase. The main issues
that
post-stroke patients face in the chronic phase
are impaired balance and posture control,
which leads to increased falls and instability
when walking. Stroke patients typically have
motor control deficits, which contribute to
decreased balance, postural control, mobility,
and propioception (5). Because balance is
influenced by postural control, the ability to
maintain an upright posture is critical for
maintaining balance. After the chronic stage,
the majority of stroke patients regain gait and
balance function (6). Reduced static and
dynamic balance are major risk factors in
post-stroke patients, limiting their ability to
perform daily activities (7). Virtual reality
training can help with postural and balance
issues. VR is a technology that allows users to
interact in a virtual world that appears real to
the user. Unlike traditional interfaces, virtual
reality places the user in a 3D world by
stimulating as many senses as possible,
including sight, hearing, touch, and even the
sense of smell. Face-to-face rehabilitation
training programs necessitate the supervision
of a qualified individual. With the widening
number of elderly people who require health
services, a new method is needed to increase
the elderly's participation and compliance in a
rehabilitation exercise program. A balance
exercise using virtual reality (VR) that can
improve balance and develop fine gross motor
functions and coordination is a new
breakthrough that can be developed (8). VR
immersion can be obtained by combining
three elements: hardware, software, and
sensory organs and nerves. Head-mounted
displays (HMDs) are pieces of hardware that
use visual, auditory, and motion sensor
outputs to enhance the user's sensory
experience in the created virtual environment.
Trackpads, joysticks, treadmills, and clothing-
mounted trackers can provide real-time
sensations (9). Within six months, authors
indicated that virtual reality training is
effective in post-chronic stroke patients. This
is demonstrated by the availability of EEG
and EMG-based VR interventions., p = 0.04),
for the resting state (r = 0.83, p = 0.17), and
for alpha hemispheric asymmetry (r = 0.82, p
= 0.18). This suggests that basic motor
disorders have an effect on a person's ability
to control posture (10). Furthermore, because
of the small sample size and high variability,
the EEG correlation results were insignificant.
In the meantime, EMG activation revealed a
significant difference in signal amplitude 2 (3)
= 2044.43, p 0.001, and resting state
amplitude 2 (3) = 1711.63, p 0.001. These
findings imply that patients with severe motor
impairment benefit the most from EMG
activation. As a result, this EMG-based VR
platform is appropriate for people who have
recurrent strokes (11).
A meta-analysis of randomized controlled
trials provides clinical evidence of the efficacy
of video game-based virtual reality treatment
aimed at improving functional balance in post-
stroke individuals within two weeks. These
interventions had no effect on post-stroke
individuals' mobility or postural balance (12).
Therefore, the goal of this study is to
determine the efficacy of virtual reality
training in post-stroke patients.
Review Methods
Research Design: This type of research is a
literature review, which begins by analizyng
relevant articles in the topic/discussion being
reviewed. Reviewing articles by identifying
and categorizing elements to be reviewed
from several articles that discuss the same
topic.
Identification and Selection of Trials: A
comprehensive search of scientific articles
published between 2012 and 2022 was
conducted. The searchable databases were
PubMed, ScienceDirect, and PEDro. The
retrieved article references were manually
checked for further study as needed. The
terms "virtual reality training," balance," and
"stroke" were used to search the database. The
authors screened titles and abstracts for
relevant studies. The authors then went over
the titles and abstracts to see if the studies met
the inclusion criteria.
2
Inclusion and Exclusion Criteria: The study Participants in the included studies ranged in
that will be included is reviewed first, by age from 52 to 66 years. The median time of
determining the inclusion criteria and intervention ranged between 35 days and 3
exclusion criteria. The following inclusion years after the stroke. Seven trials included
criteria were used: (1) journals are published participants in the chronic post stroke phase,
in English (2) Randomized Controlled Trial and two trials included participants in the
(RCT)’s study that comparing pre and post- acute post stroke phase (13).
intervention (3) adult stroke patients in both
the acute and chronic phases (4) analyze all Interventions: Two research trials with virtual
types of virtual reality training therapy for reality games based on interactive
balance improvement. The study is not used if rehabilitation exercises (IREX). Three trials
there are exclusion criteria such as: (1) type of used virtual reality treadmills, while three
study conference abstract, case report, others used commercial game systems such as
dissertation or article review (2) Stroke Nintendo WiiSport, WiiFit, PC games
sufferers with balance problems. EyeToy: Play 2 and Xbox Kinetic. VR
programs range in length from 20 minutes to
Quality Asessment: The database scale one hour per session (11,14).
(PEDro) was used to evaluate study quality
methods that met the inclusion criteria. The Control group: Five clinical trials used the
PEDro scale is a reliable quality rating scale same treatment dose in both the intervention
with 11 items. The following categories are and control groups. One study included a
used to rate studies from very good to poor : control group that received no intervention.
A score of 9-10 is considered very good, a Three studies combined VR balance training
score of 6-8 is considered good, a score of 4-5 to traditional therapy. Three studies compared
is considered fair,and a score of less than 4 is VR balance training to treadmill balance
considered bad.The author assessed the training that did not include VR (15).
quality of PEDro scale independently.
Data Collection: Data extrected included
age,time since stroke onset, intervention and Outcome measurements
control protocol, frequency and duration of All studies recorded more than one outcome
intervention, outcome measure, primary measure at baseline and after intervention.
outcome, and PEDro score Various outcome measures were used to
measure static balance, dynamic balance, gait
Results balance, gait, and mobility. Seven studies used
Article Search Results: The initial search the Berg Balance Scale (BBS). Six studies
yielded a total of 434 articles from the used the Timed Up and Go (TUG) test. Five
database.After removing the duplicates, 49 studies used strength. platforms such as the
potential articles were identified. There are chedoke-McMaster Stroke Assessment scale,
357 articles that will be filtered based on titles leg domain, and gait temporospatial
and abstrects. After filtering the titles and parameters to evaluate dynamic balance and
abstracts, 28 articles were eliminated, leaving static balance. All studies demonstrated
14 potentially relevant. articles for full-text significant improvements in balance and gait
evaluation. According to the evaluation outcomes. The VR training group showed
results,seven articles did not meet the greater improvement in speed and gait
inclusion criteria. The title and abstracts were parameters when compared to the control
idependently evaluated by the author. Finally, group (16).
seven articles met the inclusion criteria and
were included in this review. Figure 1 depicts Articles included in the review: Following the
a flow chart for the literature search process. screening process, articles are reviewed using
the PICO method as a framework in the
Characristics of Included Trials: All studies review process to determine whether the
included both male and female participants. article is suitable for use as a research basis.
3
The PICO standard has four points, which are
as follows: (population, intervention,
comparison, and outcome). subjects who will
participate in the study; intervention,
specifically the treatment given to patients; In
the article, a comparison or comparison
affects the intervention group. The
achievement or study result in a study related
to the treatment given to research subjects is
referred to as the outcome.

The article's subject population is stroke

patients, and the intervention is some
exercises to improve functional, particularly in
the area of balance, in stroke patients. The
outcome is the result of measuring the
progress of functional improvement or
reduction, particularly patient’s balance.

4
 Identification of studies via databases and registers

Journal Identification and Search Through

Identification
Search Engine

Pubmed (n = 62)
ScienceDirect (n = 168) Duplicate records removed
PEDro (n = 204) (n = 49)
Total : (n = 434)

Journal Excluded Due to Irrelevant

Title
Screening Results after the same journals are deleted (n=357)
(n=378)

Journals Excluded Based on Exclusion

Criteria

Screened journal (n=14 )

(n=378)
Appropriatenes

Testing Journal Eligibility in Full Text

(n=28)

Journals Used in the Study

Results
(n=7)

Figure 1. . Flow Diagram of Study Selection

5
Tabel 1. PICO
AUTHOR STUDY POPULATION INTERVENTION COMPARATION OUTCOMES
(YEAR) DESIGN

Cho et al RCT N=24 Nintedo Wii Fit The independent t-test or chi- Berg Balance Scale (BBS) dan Times Up and
(2012) (Randomized Mean age = 63 dan Occupational Therapy square test is used to compare Go Test (TUG)
Controlled years group characteristics.
Trial) Time since Meanwhile, data from before
stroke> 6 months and after rehabilitation were
analyzed using paired t-tests
and independent t-tests
between groups.
Cho and Lee RCT N=14 VR-based treadmill using Gait and balance parameters Berg Balance Scale (BBS) Timed Up and Go
(2013) (Randomized Mean age = 65 real-world video recording of post-stroke patients were Test (TUG) Gait performance
Controlled years dan non-VR treadmill compared using the Timed
Trial) Time since stroke Up and Go Test in the
> 6 months control group and the Berg
Balance Scale in the
experimental group.
Fritz et al RCT N=30 Nintedo Wii sports , Wii Fit Comparison of the control Berg Balance Scale (BBS) Gait performance 6-
(2013) (Randomized Mean age = 62 dan Ps games Eye Toy : group, which did not receive minute walk test 3-meter walk
Controlled years Play 2 and Kinetic the intervention for 5 weeks,
Trial) Time since and the experimental group,
stroke=3 years which received interventions
such as the Timed Up and Go
Test and 3 meters of walking.
Cho and Lee RCT N=30 VR-based treadmill using Time for dynamic balance Berg Balance Scale (BBS), Timed Up and Go
(2014) (Randomized Mean age = 65 real-world, Occupational and gait of post-stroke Test (TUG), and gait temporospatial parameters
Controlled years therapy , functional patients in TRWVR
Trial) Time since stroke electrical stimulation (treadmill training based real-
> 6 months world video recording)
control and experimental
groups was compared.
McEwen et al RCT N=59 IREX VR games in standing The intervention was Timed Up and Go Test (TUG)
(2014) (Randomized Mean age = 60 dan IREX VR games in compared between groups. Chedoke-Mc Master
Controlled years sitting The control group received a Stroke Assessment scale leg domain
Trial) Time since Chedoke-Mc Master
stroke< 6 months intervention, whereas the
experimental group received
6
 TUG.

Morone et al RCT N=50 Wii Fit dan balance therapy Comparison of the balance Berg Balance Scale (BBS) 10 m walking test
(2014) (Randomized Mean age = 60 therapy control group and the
Controlled years Wii Fit experimental group.
Trial) Time since stroke
< 6 moths

Llorens et al RCT N=20 VR step training Comparison of the control Berg Balance Scale (BBS) Tinetti Performance
(2015) (Randomized Mean age=57 group using traditional Oriented Mobility Assessment BBAC 10 m
Controlled years therapy versus the walking test
Trial) Time since stroke experimental group using
> 6 months virtual-based exercises

7
PICO Results
According to Cho and others, investigated the
effect of virtual reality balance training (VRBT)
with a balance board game system on the
balance of chronic stroke patients. There were
22 patients randomly assigned to the
experimental group (11 stroke patients aged
65.26 years) and the control group (11 stroke
patients aged 63.13 years). The experimental
group underwent standard rehabilitation
exercises (physical and occupational therapy) as
well as VRBT, whereas the control group
received only a standard rehabilitation exercise
program. Balance measurements were taken
using posturography. The Berg Balance Scale
was used to assess balance and mobility in
dynamic balance using static and Timed Up and
Go tests (BBS). After completing the
intervention program for 6 weeks, the group
showed greater improvement in dynamic
balance measurement and evaluation using BBS
and TUG. VRBT was more effective than the
control group. Both groups showed no
improvement on the static balance test using
posturography (3).
According to Cho and Lee, investigated the
effect of virtual reality balance on chronic
stroke patients. Fourteen chronic stroke patients
were randomly assigned to either the
experimental (n = 7) or control (n = 7) groups.
Subjects in both groups underwent standard
rehabilitation programs; additionally, the
experimental group participated in a virtual
walking training program using real-world
video footage for 30 minutes three times a week
for six weeks, and the control group participated
in treadmill gait training for 30 minutes three
times a week for six weeks. Walking balance
was assessed using the Berg Balance Scale
(BBS) and the Timed Up and Go test. An
electric road system is used to measure gait
performance. This study Cho and Lee
demonstrated the beneficial effect of a virtual
walking training program using real-world
video footage on gait performance. These
findings imply that a virtual walking training
program based on real-world video footage may
be a valid
approach to improving gait performance. in
patients suffering from chronic stroke (4).
According to Fritz and others, investigated the
effects of video game-based virtual reality on
chronic stroke patients in a study. Thirty people
with chronic post-stroke hemiparesis (time
since stroke = 3.0 [2.9] years) were randomly
assigned to either the game group or the normal
activity control group. The game system
provides participants with an interactive
interface that displays real-time movements of
themselves or avatars on-screen. For five
weeks, participants played games for 50-60
minutes per day, four days per week. The
intervention consisted of consisted of strictly
standing-up games with no pshyical therapy.
The control group received no special treament
and continued with their normal activities (7).
Both groups were tested before the study, 5
weeks later (post test), and 3 months later. The
Fugl-Meyer Assessment, Berg Balance Scale,
Dynamic Gait Index, Timed Up & Go, 6-minute
walking test, 3 meter walk (handpicked and
fast), and perceived recovery are all outcome
measures. This study (Fritz et al., 2013) found
that a virtual walking training program using
real-world video footage improved gait
performance. These findings suggest that a
virtual walking training program based on real-
world video footage may be a viable approach
to improving gait performance in chronic stroke
patients.
According to Cho and Lee, investigated the
effects of treadmill-based virtual reality. Thirty
chronic stroke patients were randomly assigned
to one of two groups: TRWVR (n = 15) or
control (n = 15). Both groups completed the
standard rehabilitation program; however, the
TRWVR group did TRWVR for 30 minutes per
day, three times per week, for six weeks, while
the control group did treadmill walking training
for 30 minutes per day, three times per week,
8
for six weeks. The Berg Balance Scale (BBS),
Timed Up and Go test (TUG), and postural
sway by force platform system were used to
assess balance ability. A pressure sensitive ramp
was used to assess gait performance. This
study's findings suggest that adding real-world
video footage to treadmill walking improves
dynamic balance and gait in chronic stroke
patients
(21).
According to McEwen, investigated the effects
of virtual reality exercise on chronic stroke
patients. A blinded randomized controlled trial
was conducted on 59 stroke survivors in an
inpatient stroke rehabilitation unit. The
treatment group (n=30) received standard stroke
rehabilitation therapy as well as a balance-
challenging virtual reality exercise program
(e.g., goaltending soccer, snowboarding)
performed while standing. The control group
(n=29) received standard stroke rehabilitation
therapy as well as exposure to identical VR
environments; however, the games did not test
balance (performed in a sitting position). VR
training consists of 10 to 12 daily 30-minute
sessions spread out over a three-week period.
Balance and mobility objective outcome
measures were assessed before, immediately
after, and one month after training. This VR
exercise intervention improves mobility
outcomes in inpatient stroke rehabilitation.
Future research could include nonambulatory
participants as well as strategies for
implementing VR in clinical settings (16).
According to Morone, investigated the effects
of video game-based virtual reality on acute
stroke patients. Patients in the Wii group
completed 12 sessions of 20 minutes each of
balance exercises performed with Wii Fit, three
times a week for four weeks, in addition to
standard physiotherapy. During the
intervention, three games were performed under
the supervision of a physiotherapist to train
balance, coordination, and endurance: hula
hoop, bubble blower, and sky slalom. Patients
in the control group received standard
physiotherapy 20 minutes of balance therapy
three times per week for four weeks. Balance
exercises for the patient's abilities focus on
trunk stabilization, weight transfer to the paresis
of the legs, and exercises with the Freeman
plank for balance and proprioception. The Wii
and control groups received rehabilitative
therapy in addition to standard physiotherapy,
which focused on facilitating movement in
paresis and upper limb exercises as well as
improving balance, standing, and mobility.
The Santa Lucia Foundation's Ethics Committee
approved the protocol, and all participants
provided written informed consent. The primary
outcome measure in this study was balance, as
measured by the Berg Balance Scale, with the
remaining outcomes including an assessment of
walking ability, as measured by a 10 m walking
test at a self-selected pace (10MWT) and
Functional Ambulatory Category (FAC), and
disability, as measured by the Barthel Index
(BI). A physician who was blind to treatment
allocation assessed patients immediately after
randomization, after 4 weeks of intervention,
and after one month of follow-up. The
randomization lists were generated by personal
computers of physicians who were not involved
in the recruitment. Balance exercises using
video game-based therapy, such as Wii Fit,
have been shown to be effective for improving
balance and reducing disability in patients with
subacute stroke in addition to conventional
therapy (17).
According to Llorens, investigated the effects of
virtual reality-based stepping exercise on
chronic stroke patients in a study. The control
group received one hour of traditional therapy
(13).
9
 Study Results

Frequency
Citation year Participants Intervention of stimulation Outcome measurement Main results
BBS,TUG,and postural sway BBS and TUG in
Cho et al., 2012 N = 24 E:Nintendo Wii Fit + PT OT 18 sessions velocity during standing intervention
Mean age = 63 30minutes/day, 3 group were significantly
years C:PT OT days/week higher
time since stroke : > in the intervention group
6 months 6 weeks than
in control group(p< 0,05).
Postural sway velocities
were
not statistically different
between
the two groups (p< 0,05)

.
Cho and Lee, E:VR-based treadmill using real- Greater improvement in
2013 N = 14 world video recording 18 sessions BBS,TUG,and gait performance the BBS,TUG
30 minutes/day , 3 velocity , and cedance in
Mean age : 65 years days/week intervention
group compared to control
time since stroke : > group
6 months C:non-VR treadmill 6 week ( p < 0,05) .

E:Nintedo Wii sports and Wii Fit and No statistifically

Fritz et al., 2013 N = 30 Ps games 20 sessions BBS,FMA,gait performance, significant differences
between or within groups (
Mean age : 62 years Eye Toy: Play 2 and Kinetic 50-60 minutes 6-minute walk test , and 3-meter p > 0,05) .
time since stroke : 3
years C: no intervention 4 days/week walk

5 weeks

10
Cho and Lee, E : VR-based treadmill using real-world Significant improvements
2014 N = 30 video recording + PT,OT,and FES 18 sessions BBS,TUG,postural sway ,and gait were reported
Mean age : 65 in BBS,postural sway during
years 30 minutes/day temporospatial parameters gait,and
time since stroke : gait parameters in both groups
> 6 months C: non-VR treadmill + PT , OT , and FES 3 days/week ( P < 0,05)
Greater improvement were
6 weeks reported in
intervention group compared
to control group
postural sway during static
standing ( P > 0,05)

TUG,TMWT,and Chedoke-
McEwen et al., 10 to 12 McMaster stroke Assessment Both groups had improvement
2014 N=59 E : IREX VR games in standing sessions Scale leg domain. in all outcome
Mean age : 64 measure.Chedoke-McMaster
years C: IREX VR games in sitting 20 minutes/day leg domain score
was significantly higher in
intervention group than
time since stroke : in control group group ( P <
< 6 months 3 weeks 0,05).

Morone et al., BBS,BI,and 10 m walking test test BBS,BI,and 10 m walking test

2014 N= 50 E: Wii Fit + PT 12 sessions recorder at baseline, were significantly
Mean age : 60 20 minutes/day, higher in intervention group
years C:usual balance therapy + PT 3 day/week after intervention than in control
time since stroke : group ( P < 0,05 ) . The
< 6 months 4 weeks and at one-month follow up difference was maintained

11
 Llorens et E: VR step training 20
al.,2015 N=20 with PT sessions BBS,the balance and gait subscales of Both groups have significant improvement
the Tinetti Performance Oriented in BBS and 10 m walking test (P <
Mean age : 57 years C: PT 1 hour/day Mobility 0,01 ).Greater
time since stroke : > 6 5 Assessment,BBAC,and the 10 m improvements were reported in
months days/week walking test intervention
4 weeks group compared to control group.

BBA:Brunel Balance Assessment Category ; BBS : Berg Balance Scale; BI :Barthel Index; BPM:Balance Performance Monitor; C:control group ; COP:center of pressure;
E:experimental group; FAC:Functional Ambulation Categories; FES:functional electrical stimulation; FMA:Fugl- Meyer Assessment; IREX:Interactive Rehabilitation Exercise
Software; MMAS:Modified Motor Assessment Scale; OT:occupational therapy; PT:physical therapy; RCT:randomized controlled trial; TMWT:Two-MinuteWalkTest; TUG:Timed
Up and Go test.

12
13
Discussion
Reduced balance and postural control are major
contributors to functional limitations and
barriers to performing daily activities in stroke
patients (17). The current evidence on balance
and postural control is reviewed in this study.
Evidence of sufficient to very good quality
supports the positive impact of virtual reality
training on static and dynamic balance in stroke
patients. Five of the seven studies included
patients in the chronic phase of a stroke. The
excellent rating on the PEDro scale (18)
provided the strongest evidence that virtual
reality balance is effective for routine
physiotherapy to improve dynamic and static
balance in chronic stroke patients. According to
(19), to improve dynamic balance, effective
evidence suggests increasing traditional
physiotherapist virtual reality or treadmill
exercise programs. However, in the study,
virtual reality training did not appear to have
any benefit in acute phase post stroke patients
(20). They found no statistically significant
difference between groups in terms of balance-
related outcomes. These findings raise questions
about whether virtual reality training would be
an effective method of providing balance
training without the intervention of a therapist.
More research is needed to confirm or disprove
these concerns.
Moderate evidence suggests that successful
virtual reality training has no significant impact
on static balance during standing as measured
by postural sway pressure displacement.
However, the lack of difference does not appear
to be related to or impact dynamic balance or
gait recovery. After VR training, only one study
was of high quality (11,21). Although postural
sway is widely assumed to be the basis of a
feedback system for recalibration of the postural
control system with respect to the center of
gravity, it is debatable whether static balance is
associated with dynamic balance or functional
ability (22). Previous research on weight-
supported treadmill training found that it
improved balance but had no effect on postural
sway while standing (23).
Two moderate-quality studies focused on
restoring balance during the acute and subacute
stages (15). Both studies found that dynamic
balance between groups improved significantly.
However, because the two studies used different
outcome measures to assess balance ability,
strong conclusions about the effectiveness of
VR on restoring balance during the acute and
subacute stages cannot be drawn(15).
conducted a study that included VR training in
both intervention and control groups, with the
same intervention performed in different
positions. As a result, it is difficult to
distinguish between the effects of VR coupling
and balance enhancement. According to another
study (24), his journal was methodologically
biased due to blindness, hidden allocation, and
missing data. The effect of virtual reality on
balance restoration during the early stages of
stroke is unknown.
The included studies all had similar
methodological flaws. None of the included
studies calculated sample sizes for the primary
outcome measure, and the sample size is small.
As a result, the included studies' results may
contain a type one error. Because of the small
sample size and lack of external validity, the
reported findings may not be applicable to the
larger population. The intensity and duration of
intervention varied greatly between studies, and
no justification was provided in any of them.
The number of sessions varies, with lengths
ranging from 20 minutes to an hour. Several
studies included VR training as an adjunct to
routine rehabilitation without increasing the
amount of equivalent input in the recovery
program's optimal "dose" control group. Five
studies were at risk of bias due to therapist or
participant blindness.
All of the studies included use various VR
systems, ranging from sophisticated laboratory-
14
based devices to standard commercial gaming
devices. While they all drop into the "VR"
category, there may be differences between VR
devices, and thus different levels of
effectiveness in balancing abilities. As other
reviews have noted, determining the impact of
each individual system on outcomes is difficult.
Therefore, it is impossible to draw conclusions
about which type of VR system is the most
cost-effective (15).

that can increase the participation and

compliance of the elderly to take part in a
rehabilitation training program. A new
Figure 2 Figure 3
Figure 2 Figure 3 breakthrough that can be developed, namely a
balance exercise using virtual reality (VR) can
improve balance and develop gross fine motor
function and coordination (11). There are
several parameters to measure balance in post-
stroke patients, the following parameters have
validity and reliability values that are classified
Figure 4 Figure 5 as high to very high.

a. Berg Balance Scale (BBS)

BBS has been identified as the most common

balance assessment tool in stroke patients
(Blum and Bitensky, 2008 in Makizako et al.,
2015). Balance assessment was carried out
Figure 6 using the Berg Balance Scale (BBS). The BBS
consists of 14 movement tasks, namely standing
sitting and then standing, standing unaided for 2
Figure 2. VRT with Nintendo Wii Fit (4),
minutes, standing with eyes closed, standing
Figure 3 VRT with Treadmill (Cho and
with feet together, standing and sitting, sitting
Lee,2013), Figure 4 VRT with IREX VR
without support behind him, moving with and
Games in Sitting (5) , Figure 5 VRT with IREX
without assistance, reaching things with his
VR Games in Standing (5) , and Figure 6 VRT
arms. reachable, picks up object from floor,
with Video Based Games (Cho and Lee,2013).
turns to look back, turns 3600 , places 1 foot on
Balance in Post Stroke Patients chair alternately, places 1 foot in front, stands
Postural and balance disorders can be on one leg. Balance assessment takes an
intervened using Virtual reality training. VR is a average of 15 minutes(25).
technology where a user can interact in a virtual
world but looks as real as the person using it. b.Timed Up and Go Test (TUG)
Unlike the use of traditional interfaces, VR no The Timed Up and Go Test (TUGT) is a type of
longer places the user in front of a monitor measurement used to evaluate walking balance
screen, rather in a 3D world by stimulating as related to the risk of falling in patients with a
many senses as possible such as sight, hearing, sensitivity and specificity of 87%. 10MWT is
touch and even the sense of smell. face-to-face an observational clinical measure designed to
rehabilitation training programs require evaluate the walking speed of stroke patients
supervision by a competen person. With the with a significance value of p<0.001 (24).
development of so many elderly people who
need health services, a new method is needed
15
c.Balance with Tinetti's POMA (Performance
Oriented Mobility Assessment)
Tinetti's POMA (Performance Oriented
Mobility Assessment) is a walking balance and
functional examination developed by Mary
Tinnety. This test consists of a balance section
and a gait section that have different criteria and
scoring. Balance training in improving balance
is proven by the examination and evaluation of
Tinetti's POMA (Performance Oriented
Mobility Assessment) (23).
Quality Assessment
The PEDro scale, which contains 11 assessment
items, is used to evaluate the study's quality. If
the item is listed in the article, it is given the
statement "Yes" and is worth 1 point; if it is not
listed, it is given the statement "No" and is
worth 0 points. The first item (eligibility
criteria) was not calculated, so the maximum
total score is 10. The included studies' mean
PEDro score was 6.
All articles assigned participants to groups at
random, reported the same group at baseline
reporting point size estimates of variability,
reported results of statistical comparisons
between groups, and reported patient prognostic
indicators. Four articles reported using hidden
allocation, and six articles reported using a
"intention to treat" analysis. Six articles blinded
raters, but no articles blinded therapists.
16
Table 3. The Physiotherapy Evidence Database scale criteria and trail scores
Cho et Cho and Lee Fritz et Cho and Lee, McEwen Morone Llorens
al.,2012 2013 al.,2013 2014 et al., 2014 et al., 2014 et al., 2015
Random allocation 1 1 1 1 1 1 1
Concealed allocation 0 1 1 1 0 0 1
Baseline comparability 1 1 0 1 1 0 1
Subject blinded 0 0 0 0 1 0 0
Therapist blinded 0 0 0 0 0 0 0
Assessor blinded 0 1 1 1 1 1 1
Data for at least 1 outcome from > 85% 1 0 1 0 0 0 1
of subjects
No missing data or,if missing,intention 1 1 1 1 0 1 1
to treat analysis
Between-group analysis 1 1 1 1 1 1 1
Point estimates and variability 1 1 0 1 1 1 1
Total score(/10) 6 7 6 7 6 5 8

1= yes; 0=no

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Conclusion
Overall, there is some evidence to suggest that
VR training is an effective adjunct to standard
rehabilitation programs for chronic stroke
patients. In patients with acute or subacute
stroke, the effect of VR training on balance
restoration is less clear. More research is
required to determine the best training intensity
and frequency to achieve the desired results.
Clinicians will also benefit from understanding
which training tools may be more beneficial to
patients in each subgroup.
Conflict of interest
The author declared that they have no potential
conflict of interest with respect to the research,
authorship, and/or publication of this article.
Specific recommendations:
1. Establish a home program that contains
virtual reality training that are useful for stroke
balance.
2. Thoroughly test virtual reality training so that
they are valid for use by stroke patients.
3.It is necessary to guide the proper dosage
when performing exercises with virtual reality
traiing with interventions.
4. More research has been carried out on acute
phase stroke patients whether there is
effectiveness when using these virtual reality
training.
Authors’ contribution
All authors contributed with their respective
assignments: U.B.R and R.A.N provided
research ideas, directions and verified any
results, A.A carried out material development.
The final results were discussed jointly by all
authors.
Acknowledgments
All authors express their deepest gratitude for
the guidance and support given by the
Physiotherapy Undergraduate Study Program,
Muhammadiyah University of Surakarta.
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