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CLINICAL
REHABILITATION
https://doi.org/10.1177/0269215517694677
Clinical Rehabilitation
2017, Vol. 31(10) 1292 –1304
© The Author(s) 2017
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DOI: 10.1177/0269215517694677
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Do virtual reality games improve
mobility skills and balance
measurements in community-
dwelling older adults? Systematic
review and meta-analysis
Silvia GR Neri1, Jefferson R Cardoso2, Lorena Cruz1,
Ricardo M Lima1, Ricardo J de Oliveira1,
Maura D Iversen3 and Rodrigo L Carregaro4,5
Abstract
Objective: To summarize evidence on the effectiveness of virtual reality games and conventional therapy
or no-intervention for fall prevention in the elderly.
Data sources: An electronic data search (last searched December 2016) was performed on 10 databases
(Web of Science, EMBASE, PUBMED, CINAHL, LILACS, SPORTDiscus, Cochrane Library, Scopus,
SciELO, PEDro) and retained only randomized controlled trials.
Review method: Sample characteristics and intervention parameters were compared, focusing on
clinical homogeneity of demographic characteristics, type/duration of interventions, outcomes (balance,
reaction time, mobility, lower limb strength and fear of falling) and low risk of bias. Based on homogeneity,
a meta-analysis was considered. Two independent reviewers assessed the risk of bias.
Results: A total of 28 studies met the inclusion criteria and were appraised (n: 1121 elderly
participants). We found that virtual reality games presented positive effects on balance and fear
of falling compared with no-intervention. Virtual reality games were also superior to conventional
interventions for balance improvements and fear of falling. The six studies included in the meta-
analysis demonstrated that virtual reality games significantly improved mobility and balance after 3–6
and 8–12 weeks of intervention when compared with no-intervention. The risk of bias revealed that
less than one-third of the studies correctly described the random sequence generation and allocation
concealment procedures.
1 College of Physical Education, Universidade de Brasília,
Brasília, Brazil
2
Laboratory of Biomechanics and Clinical Epidemiology,
Universidade Estadual de Londrina, PR, Brazil
3 Department of Physical Therapy, Movement and
Rehabilitation Sciences, Northeastern University and Brigham
& Women's Hospital, Boston, MA, USA
4 School of Physical Therapy, Universidade de Brasília (UnB),
Brasília, Brazil
694677CRE0010.1177/0269215517694677Clinical RehabilitationNeri et al.
research-article2017
Article
5 Graduate Program in Rehabilitation Sciences, Universidade
de Brasília (UnB), Brasília, Brazil
Corresponding author:
Rodrigo L Carregaro, School of Physical Therapy,
Universidade de Brasília (UnB), Campus UnB Ceilândia,
Centro Metropolitano, Conjunto A, Lote 01, CEP 72220-900,
Brasília.
Email: rodrigocarregaro@unb.br
Neri et al. 1293
Conclusion: Our review suggests positive clinical effects of virtual reality games for balance and mobility
improvements compared with no-treatment and conventional interventions. However, owing to the high
risk of bias and large variability of intervention protocols, the evidence remains inconclusive and further
research is warranted.
Keywords
Accidental falls, video games, physical therapy, prevention, elderly
Received: 28 September 2016; accepted: 28 January 2017
Introduction
Falls in the elderly represent an important public
health problem. Previous studies of elderly aged 65
years and older have demonstrated a fall preva-
lence of up to 30% at least once a year and a preva-
lence of falls in people aged 80 years or over of
more than 50%,1 with most cases being followed
by subsequent falls.2,3 Falling events can cause
minor injuries, but also more severe ones, which
can cause restriction on activities of daily living
and increased costs with hospitalization and reha-
bilitation.4 In addition, falls are the leading cause
of accidental death in people over 65 years old.5
Since the 1980s and 1990s, falls prevention pro-
grams have been a public health focus around the
world. These programs range from multifactorial
interventions involving physicians, pharmacists,
physical therapists, nurses and social workers, to
structured exercise programs composed by warm-
up, balance and gait training.1 There is consistent
and high-quality evidence supporting exercise pro-
grams such as strength and balance training and
endurance exercises.1,6 However, a disadvantage of
these programs is the low adherence.7
Warburton et al.8 demonstrated that the use of
interactive video games presented a significantly
30% more attendance compared with conventional
exercises. Thus, video games could be an effective
intervention for preventing falls,9 as previous
research reported an association between high
adherence and better results on functional out-
comes.10,11 According to Lange et al.,12 motivation
and engagement are vital to long-term functional
improvement. During the gaming experience, play-
ers direct their attention to the experience rather
than the physical impairment, which makes it
enjoyable.12 Consequently, is more likely that sub-
jects will attend an adequate number of interven-
tion sessions, which will be determinant to induce
neural plasticity and motor learning.12 Virtual real-
ity games offer an enriched, motivating and chal-
lenging environment,7,13,14 and other important
features such as training of both cognitive and
motor skills by performing dual tasks.1,14,15
Recent systematic reviews evaluated the effec-
tiveness of virtual reality games on physical func-
tion and restrictions of activity and participation on
aged population.16,17 Molina et al.16 demonstrated
that virtual reality interventions improved the phys-
ical functioning of older adults with history of falls,
attending rehabilitation programs and hospital/falls
clinics settings. Miller et al.17 evaluated the feasibil-
ity of using virtual reality games, exclusively at
home, for enabling physical activity and found that
evidence was still weak to generate recommenda-
tions for clinical practice. There is only one recent
scoping review that discussed the use of virtual
reality games specifically for falls prevention in the
elderly with or without history of falls and balance
impairments.18 However, the review18 has limita-
tions regarding the effectiveness arising from vir-
tual reality games, as it included different study
designs (not only randomized controlled trials) and
did not evaluate the risk of bias. Therefore, consid-
ering the clinical applications of video games and
the health problem imposed by fall events, there is a
need to confirm the effectiveness of this technology
in the context of fall prevention in elderly popula-
tions. Additionally, it is of relevance to discuss the
1294 Clinical Rehabilitation 31(10)
implications of bias on the true effects of rand-
omized controlled trials that adopted virtual reality
games interventions in this context. Hence, this sys-
tematic review aimed to summarize evidence from
randomized controlled trials that examined the
effectiveness of virtual reality games and conven-
tional therapy or no intervention for fall prevention
in the elderly.
Method
The PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta-Analyses) state-
ment was employed to report this study.19 PRISMA
consists of a 27-item checklist and four-phase flow
diagram. This systematic review was registered in
PROSPERO (CRD42015018998).
Studies included in this review followed the rec-
ommendations from the PICO model (Population:
healthy elderly; Intervention: virtual reality games;
Comparator: any conventional therapy or no inter-
vention; Outcomes: variables related to falls and
fall prevention – postural balance, reaction time,
mobility skills, lower limb strength and fear of fall-
ing).20 According to the recommendations pro-
posed by the Cochrane Collaboration Handbook,21
only randomized controlled trials were included in
this review.
Data sources and searches
An electronic search was conducted on the follow-
ing databases, last searched on December 2016:
Web of Science (1945–2016), EMBASE (Excerpta
Medica Database, 1947–2016), PUBMED (US
National Library of Medicine, 1950–2016),
CINAHL (Cumulative Index to Nursing and Allied
Health Literature, 1982–2016), LILACS (Latin
American and Caribbean Health Science, 1982–
2016), SPORTDiscus (1985–2016), Cochrane
Library (1988–2016), Scopus (1996–2016), SciELO
(Scientific Electronic Library Online, 1998–2016)
and PEDro (Physiotherapy Evidence Database).
The search was conducted combining the
Medical Subject Headings listed keywords in the
following search algorithm: (“elderly” OR “older
adults” OR “older people” OR “aged” OR “sen-
ior”) AND (“video games” OR “serious games”
OR “virtual reality” OR “computer games” OR
“exergames”) AND (“accidental falls” OR “falls
prevention”). The search was not restricted to any
specific language. Once studies were identified,
two independent reviewers screened titles and
abstracts for relevance. In cases of disagreement, a
third reviewer was consulted. The same reviewers
analyzed the full text to determine the studies to be
included.
The lead author extracted the descriptive char-
acteristics of the methods, sample, intervention
and outcomes reported in each study. A second
reviewer, independently, checked the extracted
data. Disagreements were resolved through
discussion.
Risk of bias analysis
Two independent reviewers assessed the risk of
bias using the Cochrane Collaboration Handbook.21
When there was a discrepancy in scoring, agree-
ment and consensus was determined by discussion.
Data on (1) random sequence generation, (2) allo-
cation concealment, (3) blinding of outcome
assessment, (4) incomplete outcome data, (5)
intention-to-treat analysis, and (6) follow-up were
used to assess the studies’ bias. Items were classi-
fied as low risk when clearly described and ade-
quate, high risk when not adopted or inadequate,
and unclear when not clearly described or missing
in the text.21 The “incomplete outcome data” was
also classified as high risk if the drop-out rate was
higher than 20%.22,23
During the risk of bias analysis, if the reviewers
had questions or needed clarification on pertinent
information missing from any of the studies, the
corresponding author was contacted by email. If
none of the authors could be contacted or if the
information was no longer available, the specific
item on the risk of bias form was finally marked as
“unclear”. The risk of bias information from the
included studies was presented descriptively, using
tables and figures.
Data analysis and synthesis
Study sample characteristics and intervention
parameters were compared, focusing on clinical
Neri et al. 1295
homogeneity (demographic characteristics, type
and duration of interventions, outcomes and lower
risk of bias). This approach was considered the first
step in the preparation of the meta-analysis.
As all outcome data were considered continu-
ous, the mean difference and standardized mean
difference were used to pool study data. The mean
difference is used when outcome measurements in
all studies are made on the same scale. The stand-
ardized mean difference expresses the size of the
intervention effect in each study relative to the
variability observed; outcome measurements are
made on different scales – with 95% confidence
interval. For all analyses, a fixed-effects model was
used if the results were homogeneous (P > 0.10),
and a random-effects model was used if heteroge-
neity was present (P < 0.10) based on the I2.22 A
sensitivity analysis was conducted, removing each
study, one at a time from the model, to examine the
effect of each study on the overall results. These
analyses were performed using Review Manager
5.3.5 software.
Results
A total of 376 studies were identified through the
database search and four through other sources.
After removing duplicates, 229 records were
screened. Following reading of the titles and
abstracts, 181 studies were excluded, resulting in
48 studies for further appraisal. Finally, 20 records
did not meet the inclusion criteria and were
excluded. Thus, 28 studies were included in this
review and six were considered for meta-analysis
(Figure 1).
Details regarding study characteristics can be
found in Table 1. All 28 studies were randomized
controlled trials aimed at determining the effects of
Figure 1. Flowchart of the study.
1296 Clinical Rehabilitation 31(10)
virtual reality games on fall prevention in the
elderly. A total of 12 studies investigated virtual
reality games vs. no treatment condition24–35 and 16
studies compared the virtual reality games vs. con-
ventional intervention programs.36–51 The majority
of studies were conducted in community-dwelling
and healthy older adults24–37,39–47,49,50 of both
sexes.24–32,37–42,44–46 The total number of subjects
within the studies was 1121 with sample sizes
ranging between eight and 136 individuals.25,33
Treatment duration ranged between two and 20
weeks,30,44 with a frequency of one to five days/
week.25,44 The training session had a duration of
between 15 and 60 minutes,26,29,31,41,42,44 and commer-
cial video game consoles were the most frequently
used for the virtual reality games interven-
tion.24–28,31,32,36,38–44,46–49 The most common outcomes
comprised postural balance24–34,37–39,42–47,49–51 and fear
of falling.28,29,33,35–38,41,42,46,49,51 Notwithstanding,
lower limb strength measurements,26,31,33,34,38,46,49
reaction time,29,31,33,34,43,47 mobility29,43,45 and risk of
falling (measured through variables such as fear of
falling, spatial-temporal gait parameters, reaction
time, cognitive function and functional mobil-
ity)29,33,34,36,40,42,48 were also common outcomes
related to fall prevention (Table 1).
Table 1 (available online) presents the summary
of studies evaluating virtual reality games for fall
prevention in the elderly, using different compari-
sons (i.e. virtual reality games vs. no treatment, and
virtual reality games vs. conventional interventions).
The 12 studies investigating virtual reality games vs.
no treatment demonstrated that the first had positive
effects on postural balance of elderly adults.24–32 The
fear of falling improved in two studies28,35 that
measured this outcome. With respect to the lower
limb strength, the studies by Maillot et al.26,31 and
Gschwind et al.34 showed strength increases attrib-
uted to the virtual reality game intervention.
Reaction time and mobility also improved after the
use of the virtual reality games.29,31 The risk of fall-
ing was not significantly influenced by the virtual
reality games in one study,29 however, improve-
ments were reported by other studies.33,34
The remaining 16 studies investigated virtual
reality games vs. conventional interventions.36–47
In 12 studies that evaluated the postural balance,
five37,45–47,50 demonstrated a superiority of the vir-
tual reality games. This superiority was also
observed in studies that evaluated the fear of fall-
ing,37,38,46 muscle strength of the lower limbs,46
reaction time47 and mobility.43 A positive effect in
favor of the virtual reality games concerning fall
risk was found40 and the retention of virtual reality
games was superior compared with conventional
exercises regarding fear of falling after 12-weeks
follow-up, in one study.49
The risk of bias analysis demonstrated that 46%
of the studies adopted an appropriate random
sequence generation procedure,29,39–42,44–46 and
only 18% had adequately reported the allocation
concealment26,29,42,45 (Figure 2). Regarding the
blinding of outcome assessment, 54% of the stud-
ies adopted blind assessors.25,26,28,29,32,36,37,43,45,46 In
79% of the studies, incomplete outcome data had a
low risk of bias.24–32,36,37,39,43–46 In 18% of the
included studies29,37–39,42 the intention-to-treat anal-
ysis had a high risk of bias. Moreover, only 11%
presented low risk of bias in the follow-up assess-
ment27,28 (Figure 2).
The studies25–29,31 presenting homogeneity
between the intervention protocols and the out-
comes were pooled in a meta-analysis. Figure 3
shows the meta-analysis of virtual reality games vs.
no treatment for the Timed Up and Go Test meas-
urements, summarized by three to six weeks and
eight to 12 weeks of intervention. For this compari-
son, three studies25,27,28 were included, comprising a
total of 36 subjects for the virtual reality games and
34 for the no-treatment group. Findings demon-
strated a significant improvement of the Timed up
and Go Test after 3–6 weeks of virtual reality games
intervention (MD: –1.20; 95% CI: (–1.62, –0.77);
P < 0.01). Similarly, the virtual reality games
resulted in a significant decrease of the Timed Up
and Go Test after 8–12 weeks of intervention com-
pared with no treatment. This comparison was per-
formed based on three studies,26,29,31 totaling 38
subjects for the virtual reality games group and 40
subjects for the no-treatment group (MD: –0.87;
95% CI: (–1.44, –0.29); P < 0.01).
Figure 4 presents the meta-analysis of virtual
reality games vs. no treatment for the Berg Balance
Scale. For this comparison, three studies25,27,28 were
Neri et al. 1297
included, consisting of 23 subjects in the virtual
reality games and 24 in the no treatment group.
Findings demonstrated a significant improvement in
the Berg Balance Scale in favor of the virtual reality
games intervention (MD: 2.99; 95% CI: (1.80, 4.18);
P < 0.001).
Figure 2. Risk of bias analysis of the included studies (n = 28).
Figure 3. Meta-analysis of virtual reality games vs. no treatment for Time Up and Go Test measurement.
CI: confidence intervals; SD: standard deviation.
1298 Clinical Rehabilitation 31(10)
Discussion
Our systematic review synthesized recent infor-
mation regarding the effectiveness of virtual real-
ity games on fall prevention in the elderly. Several
studies investigating virtual reality games vs. no
treatment and conventional exercise interventions
demonstrated that the virtual reality games had
significant and positive effects on balance and
mobility. Moreover, studies showed benefits in
favor of the virtual reality games for fear of fall-
ing, reaction time and muscle strength of the lower
limbs compared with traditional programs, such as
balance and resistance exercises. However, these
comparisons must be cautious considering the
high methodological risk of bias.
According to Levin13 and Kueider et al.,52
interventions composed of virtual reality games
have clinical advantages compared with conven-
tional interventions, as they offer an exciting and
challenging environment. Moreover, the dual
task training provided by both cognitive and
motor skills1,15 and the possibility of a self-paced
individualized experience,52 are major features of
virtual reality games that could explain our
results. Additionally, computer-based interven-
tions can be cost-effective and easily dissemi-
nated, reaching specific and hard to reach
populations.52 Our search strategy identified 376
studies; however, only 28 were included in this
review. In contrast, previous systematic reviews
investigating the effects of physical exercise and
home safety programs traditionally used to pre-
vent falls identified and included a larger number
of randomized controlled trials.6,53 For instance,
Gillespie et al.6 analyzed 159 randomized trials
totaling 79193 elderly individuals living in the
community enrolled in interventions aimed at
reducing the incidence of falls. The most com-
mon interventions employed were exercise as a
single intervention (59 trials) and multifactorial
intervention programs (40 trials). The low num-
ber of studies included in the present review can
be explained by the recent focus on virtual reality
games as an intervention strategy.
The Timed Up and Go Test is commonly used
and recommended in clinical practice guidelines to
assess the risk of falling.54–56 Logistic regression
models were performed in a few prospective stud-
ies57–59 to examine the association between the
Timed Up and Go Test and the probability of future
falls. Findings demonstrated that each second
increase in the Timed Up and Go Test time was
associated with a 2% to 3% higher risk for future
falls.58,59 Kojima et al.,57 however, found a 9%
increase of future falls for each second in the Timed
Up and Go Test. Our findings demonstrated a mean
decrease of 1.20 seconds in the Timed Up and Go
Test after 3–6 weeks and of 0.87 seconds after
8–12 weeks of virtual reality games training vs. a
no-treatment condition, indicating a clinical impact
on the prevention of falling events. These results
are similar to reductions ranging from 2% to 9%
according to previous studies.57–59
Figure 4. Meta-analysis of virtual reality games vs. no treatment for the Berg Balance Scale measurement.
CI: confidence intervals; SD: standard deviation.
Neri et al. 1299
With respect to the Berg Balance Scale, the pre-
dicted probability for falls increases as the scores
decrease in a non-linear relationship.60 Accordingly,
previous studies demonstrated differences between
elderly fallers and non-fallers, with mean differ-
ences of approximately 11 points in the Berg
Balance Scale, in which fallers produced signifi-
cant lower scores.61,62 Our meta-analyses demon-
strated a 3 point mean difference in favor of the
virtual reality games compared with no-treatment.
Also, the mean Berg Balance Scale was approxi-
mately 53 for the virtual reality games groups. A
previous study demonstrated a cut-off value of 46
points on the Berg Balance Scale as the classifica-
tion for those at risk of falling.61 In addition, the
authors61 presented a regression analysis in which
scores of 41 in the Berg Balance Scale presented an
80% risk of falling, and a risk decrease of approxi-
mately 20% for every 2-point increase in the Berg
Balance Scale. Thus, it is possible to assume that
the 3 point mean difference for the virtual reality
games provided a clinical improvement towards
the prevention of falling events. Notwithstanding,
our findings must be interpreted with caution, as
the participants presented a mean Berg Balance
Scale higher than 46 before the virtual reality
games intervention, indicating a better clinical con-
dition. It is also important to consider the minimal
detectable change of the Berg Balance Scale, which
is an estimate of the smallest change that can be
detected, differentiating a true change of a meas-
urement error.63 Donoghue63 reported that the min-
imal detectable change with 95% confidence
interval for elderly subjects with a Berg Balance
Scale score range of 45–56 was 3.3, thus demon-
strating that a 3-point mean difference between vir-
tual reality games and no-treatment may have, in
fact, a limited clinical impact.
Our findings demonstrated that the comparison
between virtual reality games and traditional exer-
cise programs did not present homogeneity regard-
ing the adopted intervention protocols, which made
it difficult to pool the results in the meta-analysis
and limited our clinical conclusions. Nevertheless,
our qualitative analysis showed a superiority of vir-
tual reality games on balance and mobility skills, as
well as muscle strength of the lower limbs, reaction
time and fear of falling compared with traditional
interventions. Regarding mobility and balance, a
previous systematic review64 reported significant
effects of conventional exercises on the Timed Up
and Go Test and Berg Balance Scale measurements
of frail older adults. The authors64 observed a 1.69
mean difference in favor of traditional exercises
for the Berg Balance Scale compared with no
treatment, however, no significant effects were
found for the Timed Up and Go Test. As Chou
et al.64 demonstrated that conventional programs
were not effective compared with no treatment on a
functional outcome such as mobility, we speculate
that virtual reality games interventions may have a
superior effect compared with traditional programs,
on healthy elderly. Even tough, inconclusive evi-
dence arises from our findings regarding the virtual
reality games vs. conventional exercises, and this
issue must be addressed in future high-quality rand-
omized trials.
It is suggested that virtual reality games could
be useful to overcome barriers to participation in
falls prevention programs. Hutton et al.65 examined
the perceptions related to barriers that impeded the
performance of physical activity of older adults at
risk of falling, and found that lack of access to safe
or accessible facilities and the desire to combine
physical activity in a social interactive environ-
ment were the most prevalent. Interventions com-
bining exercises within a safe home environment
and commercially available equipment, such as
video games, could be an effective alternative to
prevent falls, especially when accessibility is the
issue. Therefore, our review suggests that future
studies might consider evaluating the effectiveness
and economic analysis of fall prevention programs
combining virtual reality games and traditional
interventions prescribed at home for healthy older
adults.
Most of the studies included in our review pre-
sented a high risk of bias, which can lead to over-
estimation of the true intervention effect66 and
may distort the outcomes from systematic reviews
and meta-analyses.67 We showed that the majority
of the studies did not report a proper description
of randomization and allocation concealment.
This is a conflicting finding, as the generation of
1300 Clinical Rehabilitation 31(10)
an unpredictable randomized allocation sequence
represents the first crucial element of a rand-
omized controlled trial.68 The purpose of rand-
omization is to eliminate systematic biases that
can influence the allocation of treatment by the
investigator, meaning that subjects should have
the same chance of receiving any intervention.69
Allocation concealment is the second key-element.70
According to Schulz and Grimes,71 inadequate
allocation concealment introduces bias because it
does not “shield” researchers from knowing the
upcoming assignments. Thus, without conceal-
ment, the randomization collapses and readers
cannot rely on the results from a clinical trial.71
For example; findings from previous investiga-
tions67,70,72 have shown that randomized con-
trolled trials that adopted inadequate or unclear
allocation concealment yielded up to 40% larger
estimates of the effect compared with those with
adequate allocation concealment. Moreover, the
worst concealed trials yielded greater heterogene-
ity in results.70
We also found that several studies presented a
high or unclear risk of bias owing to lack of blind-
ing during the outcome assessment. With respect to
incomplete outcome data, approximately 20% of
the studies were classified as high risk. Empirical
evidence has demonstrated exaggerated estimates
of intervention effects in trials with a lack of blind-
ing of outcome assessment73,74 and incomplete out-
come data.75,76 Therefore, effect sizes from trials
that excluded participants in their analysis tend to
be “more effective” compared with trials without
exclusions.75 This fact demonstrates that the inten-
tion-to-treat analysis principle is important in pre-
serving the benefits of randomization and keeping
unbiased estimates when the objective is to deter-
mine treatment effectiveness.77 Controversially,
most of the studies (86%) included in this review
had not performed an intention-to-treat analysis or
did not report a proper description.
Another important criterion is participant fol-
low-up. Our results established that participant
follow-up was the most common element in the
risk of bias, though it is an important feature of
prospective research.66,78 In this review, 89% of the
included studies presented a high risk of bias for
not adopting a follow-up period. This high bias risk
warrants a caution note, as follow-up measure-
ments rely on the prospective nature of randomized
controlled trials and are essential for understanding
subject retention and, consequently, intervention
effectiveness. This concept aligns with data from
Woolard et al.,79 who demonstrated that inadequate
follow-up limited the usefulness of longitudinal
data, compromising both validity and generaliza-
bility. It is worth noting that methodological bias
can lead to potentially erroneous clinical conclu-
sions and serious consequences for patients.
However, part of these inadequate methods could
have been avoided through simple and inexpensive
methodological adjustments during the planning of
the clinical trials.80
As a limitation, the meta-analysis may be
biased by the low methodological quality and high
risk of bias in the majority of the included studies.
A second limitation of our review is the large vari-
ability in intervention length (weeks) and session
duration, which makes it difficult to determine
the ideal dose–response of virtual reality games
interventions. Third, the majority of the included
studies did not control the history of falls, which
limited our analyses regarding the effects of inter-
ventions on older individuals who had or did not
have a history of falls. Thus, we recommend that
future trials should consider its influences on the
effectiveness of virtual reality games. Finally,
even though we have adopted Medical Subject
Headings-listed keywords for the search strategy,
we may have missed important studies consider-
ing that some databases have their own indexing
systems (for example, SCOPUS).
Nevertheless, our review and meta-analysis has
a number of strengths. First, the literature search
was performed according to the PRISMA state-
ment.19 An electronic search was conducted com-
prising the major databases (10), without language
restriction and combining keywords according to
the clinical recommendations from the PICO
model.20 Furthermore, the risk of bias assessment
was based on the Cochrane Collaboration
Handbook,21 which enabled a comprehensive and
detailed analysis of the methodological quality and
the impact of bias on treatment effects.81
Neri et al. 1301
From a practical standpoint, our review sug-
gests positive clinical effects of the virtual reality
games for improving the Timed Up and Go Test
and Berg Balance Scale measurements compared
with no treatment. Also, the virtual reality games
were superior for improving balance and fear of
falling compared with traditional interventions in
an elderly population. However, owing to the high
risk of bias, large variability of intervention proto-
cols and minimal detectable changes, the evidence
remains inconclusive and further research is
needed. It is recommended that further high-qual-
ity randomized controlled trials with virtual reality
games are conducted, with special attention to the
intention-to-treat principle and adoption of follow-
up measurements. This review also warns research-
ers to include clearer information regarding the
random sequence generation and allocation con-
cealment, considering the high rate of unclear risk
of bias related to those topics.
Clinical messages
Virtual games improved the fear of falling,
balance and mobility of elderly subjects,
which could be useful to prevent falls.
The ideal virtual games intervention
length and session duration, for fall pre-
vention, are still undetermined.
Owing to the high risk of bias, evidence
regarding virtual games and fall preven-
tion remains inconclusive.
Contributors
Silvia Neri and Lorena Cruz were responsible for the
design and execution of the review: Electronic data
search, data extraction and synthesis, inclusion and
exclusion criteria, and writing the first draft of the manu-
script. Jefferson R Cardoso contributed on the design of
the review and the meta-analysis; contributed as the first
risk of bias’s reviewer; and revised the final version of
the manuscript. Ricardo Lima, Ricardo Oliveira and
Maura Iversen reviewed and improved the manuscript.
Rodrigo L Carregaro was responsible for the design,
organization and execution of the review; contributed on
the data extraction and synthesis; contributed as the
second risk of bias’s reviewer; contributed in the writing
of the first draft and reviewed the final version.
Conflict of interest
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
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