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This systematic review (SR) analyzed the effectiveness of interventions using virtual reality (VR) technology as a neurorehabilitation therapy in people with spinal cord injury (SCI). The SR was developed under the guidelines of the PRISMA statement and the recommendations of the Cochrane Collaboration, along with the PEDro and National Institute of Health scales to assess the risk of bias and methodological quality. The Cochrane, IEEE, BVS/LILACS, MEDLINE/PubMed, and Web of Science databases were browsed to identify studies that, between 2010 and 2020, evaluated the efficacy of these therapies. Out of 353 retrieved studies, 11 were finally selected after the application of the defined inclusion and exclusion criteria. These articles presented good methodological quality as they were mostly controlled clinical trials that analyzed mixed therapies with conventional therapies. Interventions based on non-immersive or immersive VR technology that achieved functional motor, balance, and psycho-emotional health improvement with positive effects on motivation, self-confidence, commitment, and active participation were identified in a total sample of 155 SCI patients. It was concluded that such VR technology is an effective tool of neurorehabilitation complementary to conventional therapies, which promotes functional improvement in SCI patients both in the clinic and at home.
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Vol. 42 | No. 2 | MAY - AUGUS T 2021 | pp 90-103
REVIEW ARTICLE
ib
E-LOCATION ID: 1141
dx.doi.org/10.17488/RMIB.42.2.8
Ecacy of Virtual Reality in Neurorehabilitation of Spinal Cord Injury
Patients: A Systematic Review
Ecacia de la Realidad Virtual en la Neurorrehabilitación de Pacientes con Lesión de Médula
Espinal: una Revisión Sistemática
B. A. Orsatti-Sánchez1, O. Diaz-Hernandez2
1Universidad Nacional Autónoma de México, División de Ingeniería Mecánica e Industrial
2Universidad Nacional Autónoma de México, ENES Juriquilla
ABSTRACT
This systematic review (SR) analyzed the eectiveness of interventions using virtual reality (VR) technology as a
neurorehabilitation therapy in people with spinal cord injury (SCI). The SR was developed under the guidelines of
the PRISMA statement and the recommendations of the Cochrane Collaboration, along with the PEDro and National
Institute of Health scales to assess the risk of bias and methodological quality. The Cochrane, IEEE, BVS/LILACS,
MEDLINE/PubMed, and Web of Science databases were browsed to identify studies that, between 2010 and 2020,
evaluated the ecacy of these therapies. Out of 353 retrieved studies, 11 were nally selected after the application
of the dened inclusion and exclusion criteria. These articles presented good methodological quality as they were
mostly controlled clinical trials that analyzed mixed therapies with conventional therapies. Interventions based
on non-immersive or immersive VR technology that achieved functional motor, balance, and psycho-emotional
health improvement with positive eects on motivation, self-condence, commitment, and active participation
were identied in a total sample of 155 SCI patients. It was concluded that such VR technology is an eective tool
of neurorehabilitation complementary to conventional therapies, which promotes functional improvement in SCI
patients both in the clinic and at home.
KEYWORDS: Spinal cord injury; virtual reality; neurorehabilitation; systematic review
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021 91
Corresponding author
TO: Bruno Alejandro Orsatti Sánchez
INSTITUTION: Universidad Nacional Autónoma de
México, División de Ingeniería Mecánica e Industrial
ADDRESS: Circuito Exterior S/N, Col. Ciudad
Universitaria, C. P. 04510, Coyoacán, CDMX, México
E-MAIL: orsattisba@gmail.com
Received:
21 December 2020
Accepted:
25 March 2021
RESUMEN
Esta revisión sistemática (RS) analizó la ecacia de las intervenciones que utilizan la tecnología de realidad virtual
(RV) como terapia de neurorrehabilitación en personas con lesión de médula espinal (LME). La RS fue desarrollada
bajo los lineamientos de la declaración PRISMA y las recomendaciones de la Colaboración Cochrane, junto con las
escalas de PEDro y del National Institute of Health para evaluar el riego de sesgo y la calidad metodológica. Se revi-
saron las bases de Cochrane, IEEE, BVS/LILACS, MEDLINE/PubMed y Web of Science para identicar estudios que,
entre 2010 y 2020, evaluaron la ecacia de dichas terapias. De 353 estudios recuperados, 11 fueron nalmente
seleccionados tras la aplicación de los criterios de inclusión y exclusión denidos. Dichos artículos presentaron una
buena calidad metodológica, al ser mayormente ensayos clínicos controlados que analizaron terapias mixtas con
terapias convencionales. Se identicaron intervenciones basadas en tecnología de RV no inmersiva o inmersiva que
lograron una mejora funcional motora, de equilibrio y de salud psico-emocional con efectos positivos de motiva-
ción, seguridad, compromiso y activa participación en una muestra total de 155 pacientes con LME. Se concluyó
que dicha tecnología de RV es una herramienta ecaz de neurorrehabilitación complementaria a las terapias con-
vencionales, al promover una mejora funcional en pacientes con LME tanto en la clínica como en casa.
PALABRAS CLAVE: Lesión de medula espinal; realidad virtual; rehabilitación neurológica; revisión sistemática
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021
92
INTRODUCTION
Spinal cord injury SCI is related to damage to the
spinal cord resulting from traumatic external force or
non-traumatic disease or degeneration causes. As the
spinal cord SC is the main information conduit con-
necting the brain to the rest of the body, an SCI can
have signiicant physiological consequences below the
level of injury, ranging from no or mild neurological
deicit to a more serious loss of motor, sensory, and
autonomic functions, or even death, mainly depend-
ing on the number of surviving axons 1 2 3.
The World Health Organization highlights that the
incidence of both traumatic and non-traumatic SCI
ranges from 40 to 80 cases per million inhabitants per
year, with 90% of them caused by trauma 1 . Men in
the 20-29 age group and over 70 are at a higher risk of
suffering an SCI, whereas the risk for women appears
between the ages of 15 and 19 and over 60. The male-
to-female ratio is usually 2:1 1.
The increased life expectancy in high-income coun-
tries accounts for a higher SCI prevalence of around
70% for people with quadriplegia and 88% for people
with complete paraplegia as compared to low- and
middle-income countries 1. By 2020, SCI is expected
to be one leading causes of disability globally 4 .
SCI is often associated with various psychological
and social consequences including low rates of school
enrollment, dificulty with schoolwork, work barriers
as reflected in an overall unemployment rate in excess
of 60%, and the fact that 20% to 30% of these patients
show signs of depression 1.
Injuries may be traumatic in the case of fracture, dis-
location, or compression of one or more vertebrae,
mainly as a result of road accidents, falls, or gunshot
wounds. There are also non-traumatic injuries caused
by arthritis, cancer, inflammation, infections, degen-
erative disc disease, or congenital conditions 1 2 3 4.
The degree of paralysis caused by an SCI depends on
the location of the injury, which will determine
whether it is paraplegia or quadriplegia. The latter is
more serious as it causes a partial or total loss of motor
and/or sensory function in all four extremities, trunk,
and pelvic organs when the injury is located in the
C1-C7 segments. In contrast, there is paraplegia when
the injury is located in the T1-S5 segments, causing
functional disorders in the legs, pelvic organs, and
part of the trunk 1 2 3 4 5 6.
The neurological condition of an SCI patient is deter-
mined by the American Spinal Injury Association
ASIA Impairment Scale, which deines 5 levels of
impairment based on the absence or preservation of
motor and sensory function. In a complete injury
grade A, these functions are not present below the
level of injury up to the S4-S5 sacral segments. In con-
trast, when some signals can still be transmitted
below the level of injury, then the injury is incomplete
grades B, C, and D with some preserved motor and/or
sensory function. Grade E describes normal function
of all segments 3 6 7.
Although, so far, the consequences of an SCI are con-
sidered to be irreversible given the SC’s inability to
regenerate, the development of new surgical proce-
dures and the technological advances in the last few
decades have contributed to the design of new rehabil-
itation programs aimed at improving patients’ progno-
sis and quality of life 1 2 8.
Comprehensive, conventional rehabilitation pro-
grams combine physical therapy with occupational
therapy activities. While the former focuses on main-
taining and strengthening muscle function, improv-
ing balance and coordination in both standing and
seating positions, training gait and weight shifting,
and learning adaptation techniques in order to per-
form daily tasks, the latter aims to recover ine motor
skills in order to achieve greater biopsychosocial well-
B. A. Orsatti-Sánchez et al. Efficacy of Vir tual Reality in Neuror ehabilitation of Spinal C ord Injury Patients: A Sys tematic Review 93
being and independence to perform personal care
activities and adapt the impaired abilities to profes-
sional or academic life 1 2 5.
Against this backdrop, the introduction of virtual
reality VR in rehabilitation therapies after SCI seeks
to contribute to motor and cognitive relearning pro-
cesses by arousing patients’ interest in rehabilitation
programs. This is done through a series of game-
based exercises that also instill higher levels of
self-conidence and self-improvement through the
use of new stimuli to enhance the effectiveness of
patients’ physical and cognitive abilities and func-
tions in controlled virtual environments. These game-
based exercises stimulate the patient to perform a
greater number of repetitions and therefore the inten-
sity of the rehabilitation activities increases, which
stimulates neuroplasticity promoting motor relearn-
ing in SCI patients. Some literature highlights the
importance of using VR as a complement to tradi-
tional rehabilitation programs to improve them, since
these usually involve simple and repetitive move-
ments which causes a feeling of boredom, thus reduc-
ing the motivation of SCI patients. Moreover, the cap-
turing patients’ movements enables therapists to
plan, supervise, and adapt exercises in an individual-
ized manner 1  9 10 .
VR or a virtual environment is an IT-based structure
that creates a simulated or artiicial, three-dimensional
3D environment that mimics the real environment
where a person is located. The application of VR devices
depends on the level of technological advancement,
the level of platform complexity, costs, and the ability
to adapt them to different VR environments 9 10.
VR systems fall into three categories according to the
sense of reality of the created virtual environment: 1
in fully-immersive VR, the user wears a headset or
goggles, earphones, and other special peripherals
gloves, haptic hand controllers, etc.; 2 in semi-im-
mersive VR, the user places himself or herself among
four aligned screens on which the virtual environment
is projected and uses peripherals to interact with the
environment with head movements; 3 in non-immer-
sive VR, the user needs a screen monitor, a keyboard,
a mouse, or other peripherals to place himself or her-
self in the VR environment and interact with it 10 .
There is also the so-called “augmented reality,” which
requires the use of a device that enables users to visu-
alize virtual objects overlaid in the real world; this is
often mixed up with semi-immersive VR.
Since VR technology is an innovative tool that has
been applied in the medical ield of rehabilitation and
should be followed up in terms of its most recent
development over the last few years 1, it is important
to compile, synthesize and analyze the evidence
achieved on the advances, effects and level of accep-
tance of VR in the rehabilitation of motor and cogni-
tive functions after SCI.
The objective was to conduct a systematic review SR
with the aim of analyzing the eficacy of VR technol-
ogy in the neurorehabilitation of SCI patients based on
evidence gathered by the studies included in the
review, with an emphasis on: 1 whether VR was inte-
grated into conventional rehabilitation therapies and
the resulting beneits; 2 whether the results of the use
of VR have been compared with those of conventional
rehabilitation therapies; 3 how VR was applied; 4 the
types of SCI analyzed; 5 patients’ acceptability; 6
main limitations observed; and 7 future work.
MATERIALS AND METHODS
Protocol
This SR was conducted following the 27 guidelines
and the flow diagram structure provided by the
PRISMA statement 11 12 13  as well as the recommenda-
tions of the Cochrane Collaboration to perform an
orderly selection of papers according to the proposed
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021
94
protocol 1 4 . All this enhanced the quality and presen-
tation of the analysis and brought transparency to the
paper selection process.
Search strategy
Between 1 May and 19 June 2020, an electronic
search was carried out in the COCHRANE, IEEE, BVS/
LILACS, MEDLINE/PUBMED, and WEB OF SCIENCE
databases in order to ind any papers published in the
January 2010-June 2020 period, when most of the
development and research work around the use of VR
technology applied to motor and cognitive rehabilita-
tion 9 took place. Additionally, the search was per-
formed in English and Spanish, without a geographic
delimitation with the purpose of obtaining a global
overview.
The search terms in Spanish consisted of combina-
tions of keywords found in the Descriptores en
Ciencias de la Salud DeCS thesaurus: lesión de
médula espinal, traumatismo de médula espinal, tet-
raplejia, cuadriplejia, paraplejia, realidad virtual, real-
idad aumentada, terapia de exposición mediante real-
idad virtual, juego de video, rehabilitación, and reha-
bilitación neurológica. The search terms in English
included terms found in the Medical Subject Headings
MeSH thesaurus: spinal cord injury, spinal cord
trauma, tetraplegia, quadriplegia, paraplegia, virtual
reality, augmented reality, virtual reality immersion
therapy, virtual reality exposure therapy, video game,
rehabilitation, and neurorehabilitation. The inal
structure of each database search strategy was
adjusted based on syntax, logical operators, tags, and
relevant qualiiers 15 16 17 18.
Eligibility criteria
The inclusion criteria were deined based on the
PICOS model Participants, Interventions, Compa-
rators, Outcomes, Study Design 13 . The review took
into account both controlled and randomized con-
trolled clinical trials 14 1 9 conducted on human sub-
jects that provided empirical evidence of the eficacy
of neurorehabilitation of motor and cognitive func-
tions through virtual reality therapies VRT applied
as a complement or not to physical, occupational, or
mixed therapies, and that allowed for a comparison of
an intervention group with a control group. Quasi-
experimental before-and-after studies were also
considered. The patient population included both
male and female subjects with SCI in the 18 to 85 age
range, with traumatic and non-traumatic, complete
and incomplete injuries, regardless of their ASIA
grades or time since injury.
The studies were required to contain this informa-
tion: population sample, assisted limbs and SCI char-
acteristics, objectives, and aspects of the rehabilita-
tion intervention; VR technology type, effects, and
application method; duration, frequency, and accept-
ability; assessment of the effect of the intervention
compared to conventional therapies; validation or
development of VR software or devices; and interven-
tion eficacy indicators.
Any systematic reviews, meta-analyses, lectures,
abstracts, or studies that were duplicated or not
designed to assess the clinical eficacy of motor or cog-
nitive rehabilitation on SCI, that did not focus on VR as
a therapeutic intervention, or that used electrical
stimulation that could have inf luenced its own results
of the technology under study were excluded.
Similarly, studies that did not it the deined study
time period and were not written in English or Spanish
were also excluded.
The selection of potentially relevant studies was per-
formed in three stages. The irst stage focused on
eliminating duplicate records; the second stage cen-
tered on exclusion of papers according to their title
and abstract; inally, the third stage consisted of a full-
text analysis. The last two stages were guided by inclu-
sion and exclusion criteria 14 .
B. A. Orsatti-Sánchez et al. Efficacy of Vir tual Reality in Neuror ehabilitation of Spinal C ord Injury Patients: A Sys tematic Review 95
Data extraction
Two electronic worksheets were created in order to
obtain detailed information from the studies selected
in an organized manner. The irst worksheet con-
tained demographic and clinical information about
the patient population: mean age, sex, cause and level
of SCI, ASIA impairment grade, type of injury, time
since injury, sample distribution across study groups,
and their respective dropout rates. The second work-
sheet summarized the characteristics of the selected
studies: authors’ names, country and year of publica-
tion, study design, and characteristics of the VR tech-
nology used, information on interventions, sessions,
outcome measures, and conclusions.
Risk of bias assessment
The internal validity of the controlled clinical trials
was assessed using the PEDro scale criteria 2 0. For
before-and-after studies without a control group, the
National Institute of Health Quality Assessment Tool
was applied 21 .
Taking the registered level of evidence as a reference,
the internal validity was rated as poor, fair, good, or
excellent for scores in the 0-4, 5-6, 7-8, and 9-10
ranges, respectively, for PEDro. Comparatively, for the
before-and-after studies, it was rated as poor, fair, or
good in the 0-4, 5-6, and 7-10 ranges, respectively.
Studies rated as with good methodological quality and
low risk of bias were identiied with a score higher
than the mean of 5, while those with scores lower than
the mean of 5 were rated as with poor methodological
quality and high risk of bias.
RESULTS AND DISCUSSION
Paper search and selection process
A total of 353 papers were found, 218 of which
remained after eliminating duplicates. Of these, only
207 could be downloaded. During the second stage of
the selection process, 179 papers were ruled out based
on their title and abstract, and only 28 moved forward
to the inal stage for full-text analysis, where another
17 were excluded, resulting in 11 papers inally
selected for the SR. Figure 1 depicts the paper selec-
tion process listing the exclusion criteria in each stage
based on the PRISMA statement 12.
FIGU RE 1. PRISMA flow diagram of the paper search
strategy and selection process.
A larger number of papers were found from India and
Spain, each represented 27.27% of the studies selected,
while Italy, South Korea, Switzerland, Taiwan, and
Australia each represented only 9.09% of these. Over
the entire search time period, no papers were found
for the years 2013 and 2019. English was the main lan-
guage used in 90.91% of the studies selected.
Risk of bias assessment of selected papers
The results of the controlled clinical trials 22 23 24 25
26 27 2 8 2 9 3 0 and the before-and-after studies 31 32
are presented in Tables 1 and 2, respectively. According
to the PEDro scale, the score for the risk of bias of the
controlled clinical trials was 7.22±1.30, and in the case
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021
96
TAB LE 1 . Assessment of the risk of bias of controlled clinical trials according to the PEDro scale.
Table 1
STUDY
CRITERION
D’Addio G,
et. al. (2014)
[22]
Dimbwadyo
Terrer I,
et. al. (2016)
[23]
Dimbwadyo
Terrer I,
et. al. (2015)
[24]
Gil Agudo A,
et. al. (2011)
[25]
Khurana M,
et. al. (2017)
[26]
Lakhani A,
et. al. (2020)
[27]
Tak S,
et. al. (2015)
[28]
Prasad S,
et. al. (2018)
[29]
Sengupta M,
et. al. (2019)
[30]
Randomization
"#
"#
"#
"#
"#
"#
"#
"#
Allocation
concealed
"#
"# "# "# "#
Groups were
similar at baseline
"# "# "# "# "# "# "# "# "#
Blinding
of all subjects
"#
"#
Blinding
of all therapists
"#
Blinding
of all assessors
"#
"#
"# "# "#
Key outcomes
in 85% of the
allocated subjects
"# "# "# "# "# "# "# "# "#
Groups received
planned treatment or
“intention to treat”
"# "# "# "# "# "# "# "#
Statistical
comparisons between
groups
"# "# "# "# "# "# "# "# "#
Point and variability
measures of
treatment effects
"# "# "# "# "# "# "# "# "#
Total
6
9
6
6
9
6
8
8
7
Level of evidence
Fair
Excellent
Fair
Fair
Excellent
Fair
Good
Good
Good
Risk of bias
Low
Low
Low
Low
Low
Low
Low
Low
Low
Note. "#: yes; : no.
of the before-and-after studies, the National Institute
of Health score was 7.5±0.7. This indicates that the
selected papers have a low risk of bias and a high
methodological quality associated with the evidence
they provide.
Ethical statement
All studies reported that, before the start of the inter-
vention, patients were asked to sign an informed con-
sent letter after they were informed, in writing and
verbally, of the experimental procedures in the study
protocol. The interventions were authorized by the
ethics committees of the participating hospitals 23  24
25 , universities 2 7 28 , sites 26 27 2930 31 or state
agency 32 , with the exception of one 22, which did not
report anything in this regard. Only 3 studies 23 2 5  32
adapted their protocols to the Helsinki Declaration of
the World Medical Association.
Design of selected studies
Of the 11 selected papers, 9 were controlled clinical
trials 8 randomized 22 23  24 25 26  27 28 29 and 1 non-ran-
domized 30 , and 2 were before-and-after studies 31 32.
Controlled clinical trials were those in which the sub-
jects had been allocated to a control group CG or an
intervention group IG and which conducted a pro-
spective analysis. If such allocation had been made
through randomization, then the trial was considered
a randomized, controlled clinical trial. Additionally,
the design of before-and-after studies included sub-
jects that received the same treatment without a con-
trol group 1 4 .
Out of the 9 controlled clinical trials, 8 worked with
parallel groups, and only 1 27 worked with crossover
groups. Only 5 of the 8 randomized controlled clinical
B. A. Orsatti-Sánchez et al. Efficacy of Vir tual Reality in Neuror ehabilitation of Spinal C ord Injury Patients: A Sys tematic Review 97
TAB LE 2 . Assessment of the risk of bias
of before-and-after studies according
to the National Institute of Health.
Tabla 2
STUDY
CRITERION
Sung W, et. al.
(2012) [31]
Villiger M, et. al.
(2017) [32]
Stated study
question or objective "# "#
Eligibility
criteria (subjects) "# "#
Representative
participants "# "#
Enrollment of all
eligible participants "# NR
Sample size
sufficiently large
Intervention
clearly described
and delivered
"# "#
Clearly define
outcome measures
Blinding
of all assessors NR
More than 20% of
participants followed-
up after baseline.
"# "#
Statistical analysis (p)
"#
Outcome measures
taken multiple times "# "#
Group level
statistical analysis
NA NA
Total
8
Level of evidence
Good
Risk of bias
Low
Note.
"#
: yes; : no; NR: not reported; NA: not applicable.
trials were blinded and reported the randomization
technique used: opaque envelopes containing sequen-
tial numbers 2 3, computer-generated random num-
bers 26 , the “randbetween” function in Excel 27,
Random Allocation 2.0 software 28 , and an unspeci-
ied ixed randomization method 29. In the case of the
non-randomized study 30, patients were assigned to
the IG and CG based on their demographic characteris-
tics, which is not considered an adequate randomiza-
tion method by PEDro 20 and the Cochrane
Collaboration 14 .
As far as blinding is concerned, 4 controlled clinical
trials and 2 before-and-after studies had no blinding 22
24 25 27 31 32. Moreover, of the 5 controlled clinical tri-
als, 2 were single-blinded to the assessors 28  29 , and 3
were double-blinded to both the subjects and the asses-
sors 23 30 or to the therapists and the assessors 2 6 .
It should be noted that only 3 papers 23 29 32 included
a long-term follow-up on the effects of VRT on subjects
over time.
Population characteristics
All papers reported their inclusion and exclusion cri-
teria for subject eligibility, and only 9 23 25 2 6 27 28  29
30 31 32 indicated their recruitment sources.
The total population sample analyzed was made up of
243 patients with SCI, with 4 studies 22 25 26 28 having
a 1:1 distribution between the IG and the CG. Only 2
randomized controlled trials 27 29, 1 controlled clini-
cal trial 3 0, and 1 before-and-after study 32 reported 1
or 4 dropouts in both groups 27 29 or only in the inter-
vention group 30 32, with a total of 15 patient drop-
outs. The mean age of the total population analyzed
was 40.25 years for both groups, with a majority of
men 78.68% in the reported population n=197 in 9
studies see Table 3.
Traumatic injuries were found in 86% of the popula-
tion analyzed n=150 by 8 studies 23 24 25 2 6 2 7 29  31
32 and only 1 study 30 reported both traumatic and
non-traumatic injuries without providing precise data.
As to the level of injury, all studies n=209 but one 22
observed that 50.72% of injuries were located in the
cervical spine, 44.97% at the thoracic level, and 4.31%
in the lumbar spine. Most studies worked with recently
injured patients < 6 months, and 4 other studies 28  29
31 32 worked with patients who had had their injuries
for more than one year.
Most SCI were incomplete 58.37% in the reported
population n=209, and only 1 study 26 did not report
on this. Regarding the level of impairment of all
patients n=167, according to the ASIA scale, most had
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021
98
TAB LE 3 . Demographic characteristics of patients included in the studies.
Table 3
STUDY
SAMPLE/DROPOUT
AGE (YEARS)#
SEX
AUTHORS IG CG IG CG
IG
CG
M
F
M
F
D’Addio G, et. al. [22]
15/0
15/0
43±18.7
Dimbwadyo Terrer I, et. al. [23]
16/0
15/0
34.53±13.71
40.27±13.61
10
6
12
3
Dimbwadyo Terrer I, et. al. [24]
6/0
3/0
54.3±9.86
44.17±22.92
5
1
2
1
Gil Agudo A, et. al. [25]
5/0
5/0
36.20±10.41
49±6.11
1
4
3
2
Khurana M, et. al. [26]
15/0
15/0
29.47±7.48
29.8±7.32
14
1
14
1
Lakhani A, et. al. * [27]
10/4
14/4
56.20±20.74
48±16.21
10
0
6
8
Tak S, et. al. [28]
13/0
13/0
49.54±8.25
43.08±11.23
10
3
10
3
Prasad S, et. al. * [29]
12/1
10/1
23.7±5.2
33.9±7.1
11
1
10
0
Sengupta M, et. al.** [30]
25/4
12/0
28
30.5
17
4
10
2
Sung W, et al.*** [31]
12
NA
28.5
NA
10
2
NA
Villiger M., et. al. */*** [32]
12/1
NA
60±10.2
NA
NA
Note. IG: intervention group; CG: control group; M: male; F: female; : information not provided; NA: not applicable.
*Data before dropout. **Data after dropout. ***No control group. #The values are represented as mean ± standard deviation.
grade A injuries 47.31%, followed by grade B 23.35%,
grade D 15.57%, and grade C 13.77%. Two studies 22
26 reported, with no details, that they had worked
with certain ASIA grades, and one 31 did not address
this issue.
The clinical characteristics of each population group
analyzed are presented in Table 4.
Characteristics of virtual reality
The studies used different types of commercial VR
technologies, including video game consoles, special-
ized VR peripherals and systems designed for rehabil-
itation, as well as devices developed by the research
teams see Table 5.
Only one study used a commercial, fully-immersive
VR system Oculus Go VR headset 27 , while the other
10 studies used non-immersive VR systems 22 23  24 25
26 28 29 30 31 32. Four of them 22 26 28 2 9 were based on
Nintendo and Sony commercial consoles, with their
video games mainly sports and recreational and
compatible peripherals that, in few cases, were
reported to be adapted for use in rehabilitation of cer-
tain impairment grades for instance, only one men-
tioned attaching the Wiimote controller to the hand
with bandages or a glove in cases of weak grip 2 9.
Additionally, Rhetoric system 30 only used Microsoft
Kinect peripheral. Other studies used motion sensing
devices for rehabilitation such as YouKicker with four
wireless accelerometers 32, TOyRA 23 25based on
ive wireless inertial sensors, and CyberGlove 24
with 22 resistive bend sensing technology and vibrot-
actile stimulators. One study developed a driving
simulator 31 using an adapted real car mounted on a
one-axle tiltable platform to virtually control accelera-
tion and braking.
Regarding those studies where their VRT used com-
mercial consoles along with their video games, only
one 26 explicitly mentioned the adaptation of their
virtual environments for rehabilitation purposes with-
out providing further details. On the other hand, those
studies where commercial video games were not used
as virtual environment, two of them were developed
by the research teams 24 32 and only one speciied the
use of Unity 3D 3 2 as graphic engine for its develop-
ment. In the case of the Rhetoric 30 and TOyRA 23 25
systems, their games were designed for neurorehabili-
tation purposes by specialized teams of Rehametrics
B. A. Orsatti-Sánchez et al. Efficacy of Vir tual Reality in Neuror ehabilitation of Spinal C ord Injury Patients: A Sys tematic Review 99
TAB LE 4 . Clinical characteristics of patients included in the studies.
Table 4
STUDY CAUSE OF SCI LEVEL OF SCI ASIA IMPAIRMENT SCALE TYPE OF INJURY
TIME
AFTER
INJURY
(MONTHS)
Δ
AUTHORS
IG
CG
IG
CG
IG
CG
IG
CG
IG CG
T
NT
T
NT
Cx
Tx
L
Cx
Tx
L
A
B
C
D
A
B
C
D
Co
In
Co
In
D’Addio G,
et. al. [22]
0 0 NR 0 0 N R 0 15 0 15
Dimbwadyo
Terrer I,
et. al. [23]
15 1 14 1 16 0 0 15 0 0 11 5 0 0 10 5 0 0 11 5 10 5 4.31
±2.06
5.6
±2.5
Dimbwadyo
Terrer I,
et. al. [24]
4 2 2 1 1 5 0 0 3 0 5 0 0 1 3 0 0 0 5 1 3 0 5.83
±2.99 5±1
Gil Agudo A,
et. al. [25]
4 1 2 3 5 0 0 5 0 0 3 2 0 0 2 3 0 0 3 2 2 3
4.2
±0.98
5.8
±1.17
Khurana M,
et. al. [26]
15 0 15 0 0 15 0 0 15 0 NR 0 0 NR 0 0 NR
3
±0.66
2.67
±0.72
Lakhani A, et.
al.
*
[27]
9 1 8 6 7 2 1 6 3 5 7 1 2 0 3 0 7 4 7 3 3 11
4.5
±2.12
4.2
±2.65
Tak S,
et. al. [28]
4 9 0 5 8 0 10 3 0 0 10 3 0 0 10 3 10 3
21.69
±8.66
22.38
±9.36
Prasad S,
et. al.
*
[29]
12 0 10 0 12 0 0 10 0 0 1 6 2 3 4 3 2 1 1 11 4 6
15.2
±11.2
10.2
±5.7
Sengupta M,
et. al.** [30] NR 7 14 0 4 8 0 6 5 5 5 4 3 3 2 6 15 4 8 < 6
Sung W,
et. al.
***
[31]
11 1 NA 3 7 2 NA
NA 8 4 NA 23.2 NA
Villiger M, et.
al.
*/***
[32]
8 4 NA 6 5 1 NA 0 0 2 10 NA 0 12 NA 96 NA
Note. IG: intervention group; CG: control group; T: traumatic; NT: no traumatic; Cx: cervical; Tx: thoracic; L: lumbar;
Co: complete; In: incomplete; : information not provided; NR: not reported but was mentioned; NA: not applicable.
*Data before dropout. **Data after dropout. ***No control group. ΔThe values are represented as mean ± standard deviation.
and INDRA systems companies, respectively. It should
be noted that the design of the environments for
TOyRA was developed on the basis of therapeutic
guidelines for SCI rehabilitation, while for another
study 32 it was mentioned that the therapists partici-
pated in the design of the clinically virtual exercises.
In addition, the fully-immersive VR system 2 7 relied
mainly on the use of pre-recorded videos from National
Geographic which were not properly virtual environ-
ments and without any possibility of patient interac-
tion. Details on the orientation of the different virtual
environments in rehabilitation of balance control, ADL
autonomy, motor function, psycho-emotional health
and driving skills are included in Table 5.
The VRT was administered using avatars in virtual
environments 2 2 26  2 8 29 , mirroring of movements
made through an avatar 23 25 30, limb control in a
irst-person virtual environment 24 3 2, activities of
daily living ADL in virtual everyday spaces 23 24 25
26 , projection of pre-recorded 360º real-life natural
environments 27 and driving skills training 31. It
should be noted that in the TOyRA system, the avatar
could be personalized based on the patient’s anthro-
pomorphic traits which increases the patient’s sense
of presence in the virtual environment.
Intervention characteristics
All studies 22 23 24 25 26 27 28 29 30 31  32 provided
information on the baseline assessment carried out
prior to the start of VRT. In controlled clinical trials,
the IG was treated with a mixed therapy including VRT
22 23 24 25 26 27 28 29 30 comprising several VR technol-
ogies, along with traditional rehabilitation therapy
TRT 22 or conventional therapy CT 23 24 25 26 28 27
29 30, based on occupational and/or physical therapy
and in certain cases, supported by other treatments
27. Patients assigned to the CG were administered the
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021
100
Table 5
STUDY DESIGN VR INTERVENTIONS
FREQUENCY
DURATION FOLLOW-
UP
OUTCOME
MEASURES MAIN FINDINGS
D’Addio G,
et. al. (2014)
Italy [22]
Randomized
controlled
clinical trial,
nonblinded.
Nintendo Wii Fit +
Balance board + Games
(“Table Tilt”, “Balance
Bubble” and “Deep
Breathing”).
IG(n:15): VRT
(multidirectional balance
and static postural control
training) + TRT.
CG(n:15): TRT (balance
training with
active/passive UL and LL
stretching and exercises to
increase strength and
improve posture).
Total period = 12 weeks.
IG: 3 VRT sessions +
TRT for 60 [min] per
week.
CG: 3 TRT sessions of
60[min] per week.
BBS (Berg Balance Scale),
SCIM (Spinal Cord
Independence Measure),
COP EO and EC
(Posturographic Index:
Center of Pressure) and
Romberg Index.
An improvement in
balance control was
observed in both IG and
CG. However, the
improvement was grater in
the IG, particularly in
balance and self-
confidence to perform
tasks without external
support. The Wii Fit
system was potentially
acceptable as an adjunct to
TRT. Given its low cost
and intuitive use, it could
be used as a rehabilitation
tool at home under
supervision.
Dimbwadyo
Terrer I,
et. al. (2016)
Spain [23]
Pilot
randomized
controlled
clinical trial,
double-
blinded.
TOyRA wireless system
(LCD monitor + inertial
sensors Xsens + Virtual
environment with 3D
interactive objects and
personalized avatar.
IG(n:16): VRT (ADL
training with dominant
UL) + CT.
CG(n:15): CT (OT: ADL
training + PT:
strengthening exercise and
active/passive
mobilizations of UL).
Total period = 5 weeks.
IG: 3 VRT sessions of 30
[min] + 5 CT sessions of
90 [min] per week.
CG: 5 CT sessions of 90
[min] per week.
Follow-up (n=22: 11 per
group): Only CT 3
months after treatment for
both groups.
SCIM III (self-care
subscore), MI (Motricity
Index), BI (Barthel Index),
MB (Muscle Balance),
FIM (Functional
Independence Measure),
QUEST 2.0 (Quebec User
Evaluation of Satisfaction
with Assistive
Technology) and
Satisfaction Survey (Likert
scale).
The effects of an intensive
and repetitive VRT + CT
compared to those of CT
alone produced similar
functional changes in the
IG and CG in UL
performance in patients
with complete tetraplegia.
A high level of patient
satisfaction was observed
as a result of the gaming
aspects. The TOyRA
system as a complement to
CT can be useful to
increase duration of
therapy, as well as
engagement and
motivation during the
rehabilitation process.
There were no reports of
vertigo, motion sickness or
muscle pain.
Dimbwadyo
Terrer I,
et. al. (2015)
Spain [24]
Pilot
randomized
controlled
clinical trial,
nonblinded.
CyberGlove (resistive
bend-sensors and vibro-
tactile feedback) + LCD
Philips monitor
(autostereoscopic 3D) +
First-person virtual
environment with 3D
objects
IG(n:6): VRT (reach and
release movements with
UL in ADL and trunk
balance control) + CT.
CG(n:3): CT (OT: ADL
training and UL Functional
exercises + PT:
assisted/active
mobilizations of UL and
trunk balance exercises).
Total period = 2 weeks.
IG: 2 VRT sessions of 30
[min] + 2 CT sessions of
30 [min] per week.
CG: 2 CT sessions of 30
[min] per week.
MB, BI, SCIM (self-care
subscore), NHPT (Nine
Hole Peg Test) with JHFT
(Jebsen Taylor Hand
Function Test) + two
implemented parameters:
“Repeatability” and
“Normalized Trajectory
Length”.
The results between the
groups were similar,
although the IG improved
in dexterity, coordination
and fine finger movement
during reaching
movements. The results
showed the usefulness of
VRT in ADLs
rehabilitation as a
complement to CT. VRT
(CyberGlove) based on
functional parameters,
such as normalized
trajectory length and
repeatability, adapted the
level of difficulty of the
tasks to patients’
individual abilities.
Prolonged repetitive
movements led to
functional improvement.
There were no reports of
vertigo, motion sickness or
muscle pain.
TAB LE 5 . Characteristics of included studies.
B. A. Orsatti-Sánchez et al. Efficacy of Vir tual Reality in Neuror ehabilitation of Spinal C ord Injury Patients: A Sys tematic Review 101
Gil Agudo A,
et. al. (2011)
Spain [25]
Randomized
controlled
clinical trial,
nonblinded.
TOyRA system.
IG(n:5): VRT (ADL
training with UL) + CT.
CG(n:5): CT (OT: ADL
training + PT: active-
assisted-resistive
mobilizations of UL
joints).
Total period = 5 weeks.
IG: 15 VRT sessions of 30
[min] on alternated days +
7 OT sessions of 30[min]
and 30[min] of PT per
week.
CG: 7 OT sessions of
30[min] and 30[min] of PT
per week.
ROM (Range of Motion),
BI, FIM, SCIM II, NHPT,
JTHFT and MI.
The use of VRT + CT
produced similar results in
both groups with
tetraplegic patients,
although an improvement
in UL function was
observed in the IG vis-à-
vis CT alone, with
improved dexterity, pincer
grasp, and coordination as
well as a slight improved
ROM for shoulder flexion-
extension and forearm
pronation. The TOyRA
system can be used as a
complementary therapeutic
tool with CT.
Khurana M,
et. al. (2017)
India [26]
Randomized
controlled
clinical trial,
double-
blinded.
Sony PlayStation 2 + Eye
Toy + 3 adapted games
(“Birds and balls”,
“Soccer” and
“Snowboard”).
IG(n:15): VRT (sitting
balance in ADL with UL
and trunk) + CT.
CG(n:15): CT (OT:
balance in ADL moving
upper body over/outside
support base + PT:
stretching of LL, mat and
range of motion exercises).
Total period = 4 weeks.
IG: 5 VRT sessions of 25
[min] + 5 PT sessions of
20 [min] per week.
CG: 5 OT sessions of 25
[min] + 5 PT sessions of
20 [min] per week.
mFRT (modified
Functional Reach Test), t-
shirt test and SCIM III
(self-care subscore).
Game-based (PlayStation
2) VRT + CT improved
sitting balance and
functional performance in
patients with low
paraplegia in the IG vis-à-
vis CT alone. Increasing
the level of difficulty of
the activities and making
them more intense
contributed to motor
function recovery by
promoting neuroplasticity.
Patients’ motivation was
not measured, but
participants showed
interest and enthusiasm for
VRT.
Lakhani A,
et. al. (2020)
Australia [27]
Randomized
controlled
clinical trial,
nonblinded.
Oculus Go headset + 9 real
natural landscapes 360 [º]
videos (London's Natural
History Museum and
National Geographic).
IG(n:10): VRT (videos for
psycho-emotional health)
+ CT
CG(n:14): CT (OT + PT
based on each participant’s
goals and level of injury +
psychological leisure
therapy) + VRT.
Total period = 2 weeks.
IG: Week 1: 3 VRT
sessions of 20 [min]. Week
2: 7 OT sessions + 20
[min] of PT.
CG: Same as IG but in
reversed per week.
PHQ-8 (Patient Health
Questionnaire 8) and
Feeling Intensity
Evaluation (adapted
Depression Intensity Scale
Circles).
VRT (real landscape
projection) + CT promoted
inpatients’ short-term
psycho-emotional health as
reflected in high levels of
happiness, relaxation and
feeling good, even when
performed at the hospital.
This had a positive impact
on patients’ engagement
with rehabilitation. VRT
can have a favorable
impact as a complement to
CT. Signs of depression
were observed in the IG
after VRT, possibly given
that they were the first
ones to experience it
during the first week and
not during the second one.
Tak S, et. al.
(2015) South
Korea [28]
Randomized
controlled
clinical trial,
single-blinded.
Nintendo Wii + Wiimote +
Wii Sports and Wii Sports
Resort games with avatar
(tennis, ping pong, box,
golf, bowling, frisbee,
canoeing and swordplay).
IG(n:13): VRT (static and
dynamic sitting balance
training with UL and
trunk) + CT.
CG(n:13): CT (OT: sitting
balance training, transfer
to toilet and positioning +
PT: stretching and
strengthening).
Total period = 6 weeks.
IG: 3 VRT sessions of 30
[min] + 5 CT sessions of
90 [min] per week.
CG: 5 CT sessions of 90
[min] per week.
mFRT, t-shirt test and the
use of a forceplate for
static balance ability,
postural sway distance and
velocity.
Game-based VRT
(Nintendo Wii) + CT
improved static and
dynamic sitting balance for
IG. It helped with raising
the arms out to the sides
and the head, improved
balance in SCI, and had a
positive effect on sitting
postural balance. VRT can
be used as a complement
to CT both in hospital or
home-based programs as it
is an accessible system that
can arouse patients’
motivation and interest.
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021
102
Prasad S,
et. al. (2018)
India [29]
Pilot
randomized
controlled
clinical trial,
single-blinded.
Nintendo Wii + Wiimote +
Wii Sports Resort games
(ping pong, bowling,
cycling and swordplay
speed slice).
IG(n:12): VRT (dominant
hand movements
depending on the game) +
CT.
CG(n:10): CT (OT:
functional tasks for
handling objects + PT:
strength training with
active or active-assisted
movements of the target
UL).
Total period = 4 weeks.
IG: 3 VRT sessions of 30
[min] + 3 CT sessions of
30 [min] per week.
CG: 3 CT sessions of 30
[min] per week. Follow-
up (IG=11, CG=9): 6
weeks after treatment.
Follow-up (IG=11,
CG=9): 6 weeks after
treatment.
CUE (Capabilities of
Upper Extremity
questionnaire), BBT (Box
and Block Test), SCIM-
SR (selft-report),
WHOWOL-BREF (World
Health Organization
Quality of Life-BREF) and
Satisfaction Evaluation
based on VAS (Visual
Analog Scale).
An intensive and repetitive
VRT + CT improved UL
motor function, similar as
did CT alone. However,
the IG had higher scores.
A high level of satisfaction
and adherence to treatment
was reported, along with a
drive for finding new self-
improvement strategies
based on game scoring and
level of difficulty. VRT
(Nintendo Wii) was
considered as an adjunct to
CT that could be used to
develop home-based
therapies and increase
therapy duration. The
improvements achieved
were maintained during
the follow-up period. No
adverse effects were
reported.
Sengupta M,
et. al. (2020)
India [30]
Controlled
clinical trial,
nonrandomized,
double-blinded.
Rhetoric system
(Microsoft Kinect +
Rehametrics’ neurological
rehabilitation games +
monitor).
IG(n:25): VRT (static and
dynamic balance control
training with UL and
trunk, and static gait with
LL) + CT.
CG(n:12): CT (based on
patient needs and goals).
Total period = 3 weeks.
IG: 5 VRT sessions of 30
[min] with 5 [min] of
warm-up per week. CT
time was not reported.
CG: Not reported.
BBS, POMA-B
(Performance-Oriented
Mobility Assessment-
Balance) and FRS
(Functional Reach Score).
The improvements
produced were similar in
both groups, although the
IG achieved a significant
improvement in all
outcome measures. The
completeness of motor
injury did not influence
the effects of intervention
on balance VR training.
VRT is an enjoyable
adjunct to CT that can be
used for rehabilitation of
balance control in SCI
patients. Virtual objectives
promoted full-body reach
movements of the joints
similar to those of ADLs.
Neck and back pain were
reported during the initial
training sessions.
Sung W,
et. al. (2012)
Taiwan [31]
Before-and-
after study,
noncontrolled,
nonrandomized,
nonblinded.
Driving simulator (5
virtual driving routes and a
single-axis tilting
platform) developed by the
authors.
IG(n:12): VRT (recovery
and enhancement of
driving skills with UL and
LL).
Total period = 6 weeks.
IG: 2 VRT sessions of
30[min] or a bit more per
week.
Total driving time,
average speed, center-line
violation, stop-line
violation, collisions, and
steering or breaking
stability
After five VRT sessions,
improvements were
observed in driving skills.
The VR driving simulator
had a positive effect on
SCI driver training
rehabilitation programs as
a result of the challenges
posed by the simulator’s
tilt effect in sitting posture
and balance.
Villiger M,
et. al. (2017)
Switzerland
[32]
Before-and-
after study,
noncontrolled,
nonrandomized,
nonblinded.
YouKicker
(accelerometers) + 5
virtual environments
created with Unity 3D
(“Footbag”, “Hamster
Splash”, “Get to the
Game”, “Star Kick” and
“Planet Drive”) +
computer monitor.
IG(n:12): VRT (balance
training and
sitting/standing LL
mobility with ADL: ankle
dorsal flexion, knee
extension and leg ad-
/abduction).
Total period = 4 weeks.
IG: 16-20 VRT sessions
of 30-45 [min] per week.
(VRT with supervision by
a physical therapist in the
first session).
Follow-up (IG=11):
1-2 months after
treatment.
LEMS (Lower Extremity
Motor Score), BBS, TUG
(Timed Up and Go),
WISCI II (Walking Index
for Spinal Cord Injury),
SCIM III, 10m and 6min
Walking Test, Motivation
Evaluation scored by 11-
point NRS (Numeric
Rating Scale) and the
Patients’ Global
Impression of Change
(PGIC).
Unsupervised home-based
VRT improved muscle
strength, balance and LL
functional mobility
promoted by structural
brain plasticity due to
intensive and repetitive
movements. In addition,
high levels of motivation
were reported for all
participants. It was noted
that having trained with
specific isolated
movements, there was an
overall motor functional
improvement. The system
is a useful tool for
neurorehabilitation follow-
up during or after
supervised therapy in
home-based training
programs reducing cost
and time of transportation.
The presence of a therapist
during VRT may help with
motivation. There were no
reports of pain or
spasticity.
Note. IG: intervention group; CG: control group; VRT: Virtual Reality Therapy; TRT: Traditional Rehabilitation Therapy; OT:
Occupational Therapy; PT: Physiotherapy; CT: Conventional Therapy (OT + PT); n: number of patients; ADL: Activities of Daily
Living; UL: Upper Limb; LL: Lower Limb; EO: Eyes open; EC: Eyes closed; SCI: Spinal Cord Injury.
B. A. Orsatti-Sánchez et al. Efficacy of Vir tual Reality in Neuror ehabilitation of Spinal C ord Injury Patients: A Sys tematic Review 103
same treatment as those in the IG but without the VR
component. The before-and-after study protocols only
had one group of subjects on which they experimented
with VRT independently 31 32.
Most VRT, TRT, or CT activities focused on balance
control 22 24 26 28 30 32, ADL autonomy 23 24 2 5, other
functional limb movements 29 32, psycho-emotional
health 27 , and driving skills 31. Only 2 studies based
their CT on each subject’s goals or needs 27 30.
It should be highlighted that in 5 studies, VRT aimed
at improving upper limb UL function 23 24 25 2 8 29 ;
in 1 study, VRT aimed at improving lower limb LL 32
function, and in 4 studies, VRT aimed at improving
both UL and LL 22 26 30 31 function. Some therapies
also included trunk movements 22 24 26 28 30.
In most cases, VRT was supervised by an occupa-
tional therapist 23 30, a physical therapist 22 28 30 31,
or several therapists 26  32.
The number of VRT sessions varied from 3 to 80, with
a frequency between 2 and 20 times per week over a
total VRT period of 2 to 12 weeks, mostly with 30-min-
ute sessions. Most of the studies were conducted at
specialized centers or hospital departments 23 2 4 25 27
28, or rehabilitation centers 22 26 29 30 31, while only 1
study 32 reported that VRT was administered at the
patient’s home and set up by a therapist.
It should be pointed out that in 7 studies 23 2 4 25 26  29
30 32, the level of dificulty of the virtual games or
activities was adjusted increasing/reducing speed or
number of repetitions, changing object appearance,
and interaction parameters depending on the level of
progress achieved by patients in the various VRT exer-
cises. It is worth noting that one intervention 31 ,
instead of including gradually increasing levels of difi-
culty according to the patient’s progress, created a
more challenging scenario that brought together all the
isolated activities done in previous scenarios. The
details of the interventions analyzed are included in
Table 5.
Outcome measures
The various scales, indices, or instruments used to
evaluate the effects of interventions on UL and LL
motor function, balance, functional independence in
ADL, and pyscho-emotional health associated with
depression are presented in Table 5 according to the
VRT applied in each study and where at least two or
TAB LE 6 . VRT effects achieved based on rehabilitation goal.
Table 6
STUDY BALANCE CONTROL MOTOR FUNCTION
PSYCHOLOGICAL
ASPECTS
MOTIVATION/
SATISFACTION
D’Addio G, et. al. [22]
"#*
Dimbwadyo Terrer I, et. al. [23]
"#
Dimbwadyo Terrer I, et. al. [24]
"#
"#
Gil Agudo A, et. al. [25]
"#*
Khurana M, et. al. [26]
"#*
"#*
Lakhani A, et. al. [27]
"#*
Tak S, et. al. [28]
"#*
Prasad S, et. al. [29]
"#*
"#
Sengupta M, et. al. [30]
"#
*
Sung W, et. al. [31]
"#*
Villiger M, et. al. [32]
"#*
"#*
"#
Note.
"#
: at least one relevant effect; : no relevant effect achieved. *statistically significant (p< 0.05).
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021
104
more combinations were used. Only 3 studies 23 29 32
assessed the level of acceptance and motivation using
patient satisfaction scales after the intervention.
Other studies came up with new outcome measures,
such as the normalized trajectory length to measure
movement trajectory precision improvement, and
repeatability to measure movement precision improve-
ment 2 4. Similarly, kinematic variables 25 or the simu-
lator’s own aspects 3 1 were used to evaluate the
effects of VRT.
Eects of virtual reality therapy
There were 7 controlled clinical trials 23 2 4 25 2 6 27 2 8
30 that did not report signiicant differences between
both intervention groups at baseline, which means
that at the start of the studies, patients were in similar
functional conditions. The effects of VRT are consoli-
dated in Table 6. From then onwards, VRT was under-
stood as being a mixed or as an individual therapy.
Only 9 papers reported a statistically signiicant dif-
ference in VRT p<0.05 in balance control 22 26 28 30
32 , motor function 25 26 29 31 32, and psychological
aspects 27 . Furthermore, 3 studies assessed the effect
size of the interventions, which was found to be
between medium and large, with Cohen’s d values
between 0.41 and 0.84, and an η2 between 0.21 and
0.95 23 26 27. Similarly, the level of satisfaction 23 29
and motivation 32 were assessed, and one study 26
subjectively observed a high level of interest and
enthusiasm in patients during VRT.
Side eects of virtual reality
There were no adverse or side effects reported, such
as motion sickness, vertigo, muscle pain, or spasticity
23 24 29 30 32. Only one study 27 reported signiicant
signs of depression in its IG immediately after VRT.
Another study 29 reported dificulty in holding the
Wii-mote controller due to weak grip in seven patients,
and another one mentioned 30 that during the inter-
vention there were some cases of back pain and ortho-
static hypotension that were controlled and subsided
with medication, allowing the therapy to continue as
they were not deemed serious side effects.
Limitation of the studies
Some of the controlled clinical trials indicated that
their design did not include any type of blinding 2 2 24
25 27 , concealed allocation 22 24 25 30, or even ran-
domization 30. In the before-and-after studies 31 32, it
was clear that there was no blinding as they did not
include a CG in their design, which implied certain
bias in the results.
Regarding subjects and protocols, it was not possible
to generalize results given the limitations observed,
such as small sample size 23 24 25 28 29 30 32, with par-
ticular SCI characteristics 23 26 28 29 32 and very few
variations in demographic data 27, as well as the fact
of having single selection sources 26 .
As far as interventions are concerned, the identiied
limitations included: the short duration of interven-
tion 23 24 2 7 29  3 1; most studies did not follow-up on
the results, except for 3 of them 23 29 32; only 1 study
explicitly recognized having included a small set of
virtual exercises as a limitation 3 0; the weight of any
other health condition that could have influenced the
results was not considered 27; and the diversity of
interventions did not make it possible to set guidelines
on intensity, dosage, and duration of VRT 30 .
As to the limitations derived from the VR technology,
the need to have more sophisticated and modern soft-
ware commercial or especially designed games and
hardware consoles, controllers, headsets, sensors,
graphic cards was identiied for VRT to be more effective
26 30. The Wii Fit system especially stood out, because as
it is a black box system, it was not possible to monitor
several game parameters included in the VRT, thus limit-
ing its contribution to improving balance control 22.
B. A. Orsatti-Sánchez et al. Efficacy of Vir tual Reality in Neuror ehabilitation of Spinal C ord Injury Patients: A Sys tematic Review 105
Three studies pointed out limitations in terms of
interaction with VR devices, which could have affected
the obtained results. Such was the case with the
Nintendo Wii console 28 2 9, where the patient required
some prior training before using it.
Patients with acute SCI could not use it because they
could not maintain balance, hold the controller, or
even generate motion, especially in the case of higher
cervical injuries. The third study identiied predeined
VR scenarios 360º recordings as a limitation since
patients could not interact with them 27 .
Future development
Based on the above-mentioned limitations, the sub-
jects’ proiles, and the intervention protocol, a sugges-
tion was made to use a broader patient sample 23 24  25
26 27 29 30 31 32, with different SCI characteristics
than the ones included in the studies 26 29 31 32,
involving several recruitment sites 30, and including
more VRT sessions 23 2 4 to better identify VRT bene-
its, the system’s critical characteristics, and the vir-
tual exercises that achieved better results 2 4.
The before-and-after studies 31 32 along with one
controlled clinical trial 30 proposed to carry out future
interventions based on a blinded, randomized, con-
trolled clinical trial with long-term follow-up design
30 31 32 to reduce the risk of bias and monitor the
sustainability of the intervention by means of a longi-
tudinal study to validate the level of skill improve-
ment achieved 31.
Regarding types of VR devices, a proposal was made
to conduct studies that combine VRT such as TOyRA
with robotic devices Amadeo for telerehabilitation
based on VR motion capture systems 25 and develop
new VR devices for rehabilitation with a focus on ADL
or relevant exercises/skills designed to simulate more
realistic situations with higher levels of dificulty
according to different SCI levels 31.
For interventions that used mixed VRT 22 24 29 30, a
proposal was raised to conduct new studies to assess
the impact of VRT individually, compare the results of
home-based therapies with those achieved at the
clinic 32, and develop methods to exercise system-
atized balance control with a focus on SCI level and
sitting balance control 28 .
Main ndings, quality of evidence
and potential application
This SR included a total sample of 243 subjects from
the 11 papers analyzed, out of which 155 experi-
mented with VRT 63.78%. There was a similar num-
ber of paraplegic 69 and tetraplegic 67 patients, and
14 patients did not complete the intervention. Patients
treated with VRT mostly had ASIA grade A/B impair-
ment 42.20% and 20.18%, followed by ASIA grades
C/D 16.51% and 21.10%, with an absence of motor
function and little or no sensory perception below the
neurological level of injury, with a major focus on UL.
Three types of studies were taken into consideration:
randomized controlled clinical trials 2 2 23 24  25 2 6 27
28 2 9, one non-randomized controlled clinical trial 30,
and before-and-after studies 31 32. Over half of the
studies 23 26 28 29 30 31 32 had a good or excellent
level of evidence with low risk of bias and achieved
statistically signiicant results 26 28 29 30 31 32 with
regard to VRT.
The controlled clinical trials exhibited an adequate
level of evidence given that they were mostly random-
ized 2 2 23 24 25 2 6 2 7 28  29 , with 6 of them having an
adequate sample size 22 23 26 27 2 8 2 9. Seven 23 24 25
26 27 28 30 did not show any confounding bias upon
observing a similar baseline functional condition
among patients. Regarding blinding, half of them did
not describe any blinding method 22 24 25 27 , while
the remaining half that reported having used a dou-
ble-blind 23 26 or single-blind 2 8 2 9 method reduced
their detection bias upon including blinded assessors.
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021
106
Given their methodological limitations, the before-
and-after studies and the controlled clinical trials had
to be considered with caution as they had a certain
selection bias for not presenting any randomization
method 30 or control groups 31 32, which could have
affected the VRT evidence obtained.
Most trials aimed at a non-immersive use 22 23  24 2 5 26
28 29 30 31 32 of VR, and only 1 was fully-immersive 27 .
All of them showed a statistically signiicant improve-
ment with VRT p<0.05 in balance control 22 26 28 30
32 , motor function 25 26 29 31 32, and psychological
aspects 2 7. The effect size of the interventions 23 2 6 27
was determined to be between medium and large.
Regarding the type of VRT, although in some con-
trolled clinical trials 23 24 25 29 30 no statistically sig-
niicant differences were observed between the VRT +
CT intervention compared to the CT, signiicant
improvements were found in the IG in different func-
tional parameters Table 6. Additionally, in the
remaining 4 trials 22 2 6 27 2 8, statistically signiicant
differences were observed in the IG that were reflected
in a greater improvement compared to the CG. The
sum of both results suggests that VRT can be an
important adjunct/complementary instrument for CT
when considering the beneits derived from the differ-
ent protocols, particularly in terms of balance control,
motor function, and patients’ moods.
Moreover, even though the evidence was method-
ologically limited, it could be added that the before-
and-after studies 31 32 also showed positive effects of
VRT when applied individually to improve LL motor
function and driving skills, which speaks to the conve-
nience of using VRT along with CT.
Furthermore, the indings 23 25 2 9 32 suggest consid-
ering VRT as a complement to CT that can be used at
home and not just in a hospital setting to extend the
time of therapy sessions and to monitor and/or main-
tain the results achieved after rehabilitation. In this
regard, the need for future studies to compare the
effects of VRT in both settings was highlighted.
Comparatively, 4 controlled clinical trials 22 24 29 30
underlined that it was not possible to visualize the
effect of VRT separately, because it was applied
together with CT. Thus, a proposal was made to con-
duct studies with the same methodological quality
focused on interventions centered on VRT alone, with
a broader and more diverse sample of SCI patients.
Ecacy of virtual reality therapy
Most studies showed a good level of evidence for the
use of VR technology applied to the rehabilitation of
SCI patients based on a detailed description of its
application, movements made, and patient interaction
with the virtual environment. There was only one
exception, where information was inferred from the
system used 29 .
Non-immersive VR was the most commonly imple-
mented type of VR based on games with a scoring
system and a set duration, whose level of dificulty
was determined based on the progress recorded 22 2 3
25 26 28 29 30 32.
Other study 3 2 mentioned that the type of VR used
was augmented reality, which would require virtual
objects to be projected onto real world surfaces.
However, when the VR technological description was
analyzed, it was clear that they had used a non-immer-
sive system that displayed the virtual environment
and objects on a screen.
It was interesting to see how fully-immersive VR tech-
nology 27 used to study patients’ moods only focused
on projecting videos of real landscapes without any
means of interaction with the virtual environment,
given the technological capabilities of the device.
Although an improvement was achieved in patients'
B. A. Orsatti-Sánchez et al. Efficacy of Vir tual Reality in Neuror ehabilitation of Spinal C ord Injury Patients: A Sys tematic Review 107
psycho-emotional health, it will be necessary to gather
more evidence on the effects of fully-immersive tech-
nology on VRT, related with physiotherapy and occupa-
tional therapy exercises, to analyze and determine the
impact of this type of VR on the rehabilitation of SCI
patients. Despite the technological differences inherent
to each VR technology, such as the degree of immersiv-
ity and sensorimotor interaction, previous literature
has shown different beneits of the use of the full-im-
mersive VR and some of them points that full-immer-
sive VR outperforms non-immersive 33 34 35.
Although all the interventions applied different
immersive and non-immersive VR, some signiicant
beneits were identiied that can be generalized as fol-
lows: VR stimulated a wide set of functional move-
ments similar to those of the real world; it promoted
independence and self-conidence; it improved psy-
cho- emotional health; it increased patient motivation
and engagement with the rehabilitation process; and it
promoted VRT with no side effects. Such evidence
made it possible to conirm the potential use of VR
technology as an effective tool for rehabilitation of SCI
patients.
The eficacy of VR was conirmed based on a number
of indicators reported by the studies. Firstly, there was
positive feedback visual and auditory about thera-
peutic sessions designed around games that included a
scoring system to help patients come up with new
self-improvement strategies within certain time-
frames and levels of dificulty established by the
devices and/or adjusted by therapists, which made it
possible to follow-up on the progress made.
In this regard, it was observed that the level of difi-
culty in each round prompted patients to make speciic
movements in an intensive and repetitive manner,
which stimulated the subsequent recovery of motor
function as a result of triggering neuroplasticity mostly
in the motor cortex of the brain 23  24 26  28 2 9 32.
Secondly, real-time visual feedback was another indi-
cator of eficacy of VR environments for motor func-
tion recovery 26 28 29; that is, there was visual feed-
back of the patient’s proper movement execution
within the game’s virtual environment with the use of
an avatar through activation of certain areas of the
motor cortex, leading to improved recovery 32. There
was also activation of the mirror neuron system and
motor cortex of the brain by enabling recovery in spa-
tial orientation and balance 30 . Furthermore, visualiz-
ing the patient’s movements in real-time made by the
avatar through mirror vision produced a feeling of
control and realism with a similar positive effect on
motor function 2 3.
Thirdly, given the importance of patients’ motivation
as an indicator of eficacy, it is interesting to see that
this factor was assessed only by 3 studies 23  29 3 2,
with high levels of satisfaction and motivation
achieved during VRT. However, even when such an
evaluation was not considered, another study 26 indi-
cated that patients showed a high level of interest and
enthusiasm towards VRT, and another one 30 observed
that patients were open to develop new self-improve-
ment strategies as a result of their experience with
VRT. In summary, given the limited evidence on the
level of patient acceptance of VRT, it is suggested that
future research should include instruments to evalu-
ate this aspect as well.
The indings from the above-mentioned evaluations
showed that patients’ satisfaction and motivation with
VRT promoted a higher level of commitment, adher-
ence, active engagement, and dedication to the reha-
bilitation process. Personal motivation due to VR was
promoted by feelings of increased curiosity, self-coni-
dence, self-driven exploration, and imagination which
led to a greater enjoyment of the CT in addition to
functional improvements 23 2 9  32. Moreover, social
motivation that led to the development of self-im-
provement and self-esteem were promoted through
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021
108
competition as a result of the social interaction of
patients based on the level of dificulty and scoring of
VR games 23  29.
As it was conirmed in other studies 33 34 36, these
key elements are not induced by CT, which limits their
level of effectiveness by showing low level of atten-
dance and adherence to the training exercises, thus
limiting the level of intensity necessary to achieve
patient recovery.
This increase in motivation may be related to the
influence of the video games used in VRT with a scor-
ing and reward system positive feedback 29 3 4, and
that it decreases the perception of effort 37 , which
boost active patient participation and therefore
increases adherence and commitment to the rehabili-
tation therapy.
In addition, some studies 35 38 have conirmed that
VRT promotes a deep motivation in patients, which
improves their subjective initiative and commitment
to actively complete various rehabilitation exercises,
thus creating a virtuous circle that improves their
func t io n a l recovery.
Some studies included in the SR underlined that the
VRT was the most effective tool for improving neuro-
plasticity and subsequent recovery of motor function
in SCI patients through intense and repetitive task-ori-
ented practice by increasing exercise therapy time
expressed as time dedicated to practice dosage com-
pared to CT 36 38, which may enhance functional
recovery 23 26 29 30 32 34. However, it is important to
point out that other studies report that the evidence of
neuroplasticity as a result of training in VR is currently
modest and more research it is needed 38. Also, it
should be noted that the relation between dosage and
achieving functional recovery is currently an unsolved
issue in rehabilitation studies  30 32 36, where the need
for further evidence is highlighted.
There is some additional evidence resulting from the
authors’ perceptions during the interventions. For
instance, when patients immersed themselves in VRT
game activities, they forgot about certain fears that
could have affected their performance vis-à-vis the
objectives of the CT activities 26 . The projected images
had a positive impact on the patients’ moods and
reduced the perception of pain from the SCI 2 7, which
reafirmed the convenience of using VRT in conjunc-
tion with CT 28 30.
The importance of the familiarization process
between the patient and the VR technology is a key
element to achieve the objectives of the rehabilitation
programs as it allows the patients to be engaged with
the VRT and to perform the training exercises in a
more effective way, thus promoting their active partic-
ipation and motivation. In this regard, some studies
have highlighted 26 28 33 37 the limitations of com-
mercial VR systems to it the needs of SCI patients,
since these are designed to be used by people without
motor or cognitive impairments. Additionally, previ-
ous studies 34 38 39 have conirmed the importance of
patients perceiving a greater immersion in the virtual
environment rather than in the real world, which is
related to the software and hardware characteristics.
Therefore, it is necessary that research teams seek to
adapt existing devices to provide better grip and
manipulation of the peripherals of VR systems 29  3 3,
or still better to design new devices that allow an
improved handling and capture of the movements
made by patients according to their motor and cogni-
tive skills, along with an appropriate calibration
according to their neurological conditions 2 9, which
will increasing their interaction with the virtual envi-
ronment, thus a better immersive experience.
On the other hand, another important element that
allows patient familiarization is the sense of presence,
which is related to the patients' subjective experience
B. A. Orsatti-Sánchez et al. Efficacy of Vir tual Reality in Neuror ehabilitation of Spinal C ord Injury Patients: A Sys tematic Review 109
of feeling inside the virtual environment and is able to
active brain mechanisms underlying sensorimotor
integration as well cerebral networks regulating
focused attention promoting patients to perform reha-
bilitation programs and patients’ movement recovery
34 37. Since this also depends on the characteristics of
the VR system itself 37, it is important that the games
are able to imitate both in execution and visually the
task-oriented activities and the virtual scenario, as
well as to increase the sensory feedback through the
peripherals, which allows a higher level of realism
when interacting with 3D objects in real-time, for
instance the realistic haptic feedback achieved by the
CyberGlove compared to the simple feedback offered
by most commercial consoles 24   33. In addition, as
already pointed out by some studies included in this
review, the patient's embodiment in the virtual avatar,
either in one part irst person or the whole body
third person, has a key role in developing a sense of
presence in the virtual environment, as it allows the
sensation that the actions performed belong to the
patient 3 4. In this sense the non-commercial devices
achieved better results, especially TOyRA system 23 2 5
by achieving an avatar based on the patients’ anthro-
pometric data.
In addition, it would be important to include induc-
tion training programs 30 32 that make it possible to be
familiar with the VR system and interact with greater
conidence within the virtual environment. Therefore,
all the elements that allow familiarization increase the
acceptance of the system by the patient as he/she feels
that real world movements are performed within the
virtual environment, which allows to obtain adequate
functional improvements by providing a better trans-
fer of skills to the real world and open the possibility of
continuing rehabilitation programs at home 23 33.
Fourthly, another eficacy indicator was the ability to
gradually reduce the help required from the therapist
as therapy progressed, leading to more patient inde-
pendence to choose the VRT activities designed in
accordance with the rehabilitation goals 23 2 9.
Nevertheless, some authors reported that VRT had
been more effective with the help of a therapist 32 .
Fifthly, potential home-based rehabilitation and tel-
erehabilitation were other key eficacy indicators of
the use of VR technology based on commercial con-
soles and other devices. Having more intuitive, smaller
sized, home-based systems could possibly increase
the amount of time devoted to rehabilitation following
therapy administered at the hospital or rehabilitation
center. In this context, it should be stressed 23 that
patients stated their interest in using the virtual sys-
tem at home and would suggest its use to other
patients with the aim of potentially creating an online
gaming network to promote more socializing among
patients and to extend therapy time.
Moreover, home-based VR rehabilitation could have a
positive impact on reducing costs, time, effort, and
travel of patients to the clinics, with systems being
adapted to patients’ needs, particularly those with a
high SCI level 29 32. Based on the aforesaid, it would
be necessary to have data capture systems imbedded
in the consoles or in future rehabilitation dedicated
devices that are capable of sending information of the
activities performed at home to the therapist for anal-
ysis 25 32.
It is important to emphasize that some features of the
VR devices posed some potential limitations to the efi-
cacy of VRT, for instance: the virtual environment used
by the TOyRA system did not represent execution of
ADL in a realistic fashion 23 ; the commercial consoles
or peripherals used in the interventions were relatively
obsolete given the ongoing technological advances
seeking to make VR more eficient and easy to use in
rehabilitation; and the consoles or peripherals could
not be easily modiied black box, thus preventing
adaptation to patients’ functional needs 22 26 28 29 30.
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021
110
It should be noted that only one paper reported hav-
ing used a graphic engine Unity 3D 3 2, given its rele-
vance to the creation of virtual environments and the
effect of VR on rehabilitation. Using a graphic engine
implied a signiicant investment in terms of time and
practice in order to create an appealing virtual envi-
ronment where the patient can properly interact.
Therapists collaborated on this design effort 23 2 5 32.
Finally, this SR identiied some evidence of the
impact of VRT in other neurological disorders, which
conirms some of the indings for SCI, since the
impaired motor function is one of its common conse-
quences. For instance, some reviews have been identi-
ied concerning the use of VR technology applied to
Stroke 38 39 40 41, Parkinson’s Disease 35 42 43, Mul-
tiple Sclerosis 37 44 , Cerebral Palsy 45 and Traumatic
Brain Injury 46, which have reported positive effects
of VRT improving balance control 35 4 0 42 43  44 45 46 ,
UL or LL motor function 37 38 39 40 41 45, gait 35 40 42
43 44  46 and cognitive function 3 7 42 4 6. A systematic
review 47 showed positive impacts in the treatment of
phantom limb pain due to a greater immersive experi-
ence based on the use of the mirror therapy which
induces the perception that the amputated limb is
performing the tasks. However, the authors are incon-
clusive regarding the eficacy of VR and Augmented
Reality therapy and continues to need further research
with higher quality evidence.
As is the case of the interventions with SCI patients,
the role of VR as rehabilitation tool in these neurologi-
cal disorders is still under discussion, although some
studies reported positive results when VR was used as
a complementary therapy which improved ADL per-
formance and quality of life. These studies provided
evidence points toward the advantages of increased
motivation, conidence, engagement, and increase the
intensity of movement based in repetitive and task-ori-
ented with multisensory feedback which is needed for
promoting neuroplasticity 35 37 39 40 43 45 46.
These results align with the main indings on the use
of TRV in patients with SCI and for future development
could be important to follow research on how the VR
devices had been designed to these pathologies,
including the greater use of VR full immersive and
multisensory feedback 33.
In this regard, an interesting feature showed in a
study applied to Stroke 40 was the introduction of a
speciic type of rehabilitation visual feedback named
“virtual teacher”, which can be displayed during
every task repetition and that shows the correct exe-
cution movement of the training exercise so that the
patient can imitate it allowing real-time visual com-
parison between a patient’s execution and the virtual
teacher’s execution of a movement. The incorpora-
tion of this characteristic into the VR systems for SCI
could improve the motor performance quality pro-
moting motor adaptation via supervised learning
mechanism.
Limitations and future work
of the systematic review
One of the main limitations was not having a larger
number of papers providing evidence on the use of
augmented reality and fully-immersive VR technology
as a rehabilitation tool.
Patient sample heterogeneity as well as the applica-
tion of different types of VR technology and VRT pro-
tocols made it impossible to generalize the results and
applied therapies, and since this SR was guided by the
Cochrane recommendations 1 4 , it was deemed advis-
able not to do a meta-analysis.
Moreover, no controlled clinical trials were found to
focus on the use of VRT individually in the IG com-
pared only with the CT. This could be based on the
fact that there is not much research on this, and it was
not possible to access a more specialized, fee-based
database.
B. A. Orsatti-Sánchez et al. Efficacy of Vir tual Reality in Neuror ehabilitation of Spinal C ord Injury Patients: A Sys tematic Review 111
The authors of this SR consider it necessary to update
this SR in the future to largely include blinded, ran-
domized, controlled clinical trials with long-term fol-
low-up to reduce the risk of bias and follow-up on the
sustained effects of the intervention.
CONCLUSIONS
Given the evidence obtained from the papers included
in the review, this SR concludes that non-immersive
VR technology is an effective tool for use in neurore-
habilitation as a complement to CT. It has positive
effects by promoting motivation, self-conidence,
commitment, and active engagement of patients, lead-
ing to improvements in motor function, and balance
control, both in a clinical setting and at home, and it
also increases rehabilitation time. No side effects were
observed throughout the interventions.
Positive effects of VRT were identiied when it was
applied alone, although more evidence is needed to
determine its contribution. Furthermore, there were
psycho-emotional beneits reported with a decrease in
depression in SCI patients when fully-immersive VR
was used, although more research is needed to con-
clude its level of eficacy as a complementary tool to CT.
However, the high cost and the complexity of the new
VR technology is a key limitation to extend the use for
rehabilitation which may explain why the therapy
based on video games consoles and non-immersion
VR systems are playing an important role in rehabilita-
tion programs even considering that these devices are
not suitable to the needs of the SCI patients.
This SR suggest further development of VR systems
customized to the motor and cognitive skills of SCI
patients that achieves increased immersion with a
higher level of realism of the rehabilitation activi-
ties, multisensory stimuli, and patient interaction,
while trying to keep low-cost in order to increase
accessibility.
AUTHOR CONTRIBUTIONS
Both authors formulate and designed the systematic
review; collected, selected, and extracted the data;
assessed the risk of bias and methodological quality of
included papers, and summarized the results. B.A.O.S.
drafted the irst version of the manuscript. Both
authors reviewed the manuscript in depth and wrote
the inal version. Both authors analyzed and included
the reviewers suggested comments.
REVISTA MEXICANA DE INGENIERÍA BIOMÉDICA | Vol. 42 | No. 2 | MAY - AUGUST 2 021
112
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... It also concluded that VR technology is an effective tool of neurorehabilitation complementary to conventional therapies and promotes functional improvement in SCI patients in all types of settings. 13 Biofeedback enables motor control during activities and thus mediates usedependent plasticity in trained neuromotor systems. ...
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This is an Open Access journal, and articles are distributed under a Creative Commons license-CC BY-NC 4.0 DEED. This license permits the use, distribution, and reproduction of the work in any medium, provided that proper citation is given to the original work and its source. It allows for attribution, non-commercial use, and the creation of derivative work. Abstract Background: Spinal cord injury is a devastating condition. In recent years, traumatic spinal cord injury has become one of the major disabling conditions in young males. These chronic complications negatively impact patients' functional independence and thus affect the quality of life.
... Ahn showed that VR and computer game-based cognitive therapy for visual-motor integration is an effective training method for children with ID to promote visual perception and motor function (Ahn, 2021). Furthermore, some studies have shown that VR training can improve the balance and muscle strength of older adults and individuals with neurological diseases, such as patients suffering from stroke, Parkinson's disease and cerebral palsy (Cho et al., 2016;Lee et al., 2019;Mak and Wong-Yu, 2019;Orsatti-Sánchez. and Diaz-Hernandez., 2021;Sadeghi et al., 2021). ...
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Purpose: This study aims to assess the effects of 8-week virtual reality (VR) training on balance and lower extremity muscle strength in adolescents with intellectual disability (ID). Methods: Thirty adolescents with intellectual disability were randomly divided into the virtual reality group and control group. The participants in the virtual reality group and the control group received the virtual reality training and the physical education (PE) course, respectively, for 8 weeks. The Berg Balance Scale (BBS), Timed Up and Go (TUG) test and lower extremity muscle strength were measured before and after the training. Results: The between-group results showed that the participants in the virtual reality group increased the muscle strength of hip flexors (p < 0.001), hip extensors (p = 0.002), hip abductors (p < 0.001), knee flexors (p < 0.001), knee extensors (p = 0.002) and ankle plantar flexors (p = 0.042) significantly after training, compared to the control group. However, no significant improvement was found in the berg balance scale and timed up and go scores between the virtual reality group and control group after training (p > 0.05). The within-group results showed that the strength of all the muscle groups significantly increased after training in the virtual reality group (p < 0.05) compared to the baseline. However, no significant difference was found in the muscle strength in the control group before and after training. The within-group berg balance scale and timed up and go scores showed no significant improvements in both groups. Conclusion: Virtual reality training intervention might be effective in improving the lower extremity muscle strength, but no significant improvement was found on balance ability in adolescents with intellectual disability.
... A study conducted in 2021 by Orsatti wanted to demonstrate the effectiveness of virtual reality intervention in the neuronal rehabilitation of patients with spinal cord injuries. This review was conducted over a period of ten years, from 2010-2020, which concluded with the conclusion that virtual reality is an effective therapy, but it is an effective complementary therapy, which tells us that it must come to the aid of conventional physical therapy [64]. Rutkowski also did a systematic review of virtual reality in upper limb, lower limb, gait and balance rehabilitation, but in the end concluded that virtual reality along with virtual games can bring considerable advantage in upper limb rehabilitation, but not for hand and walk. ...
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Objective: To analyse the effect of virtual reality therapy combined with conventional physiotherapy on balance, gait and motor functional disturbances, and to determine whether subacute (< 6 months) or chronic (> 6 months) phases might influence motor recovery. Methods: A total of 59 stroke inpatients (age 60.3±14.8 years; 14.0±25.7 months post-stroke) were stratified into 2 groups: subacute (n = 31) and chronic (n = 28). Clinical scales (Fugl-Meyer lower extremity (FM LE); Functional Independence Measure (FIM); Berg Balance Scale (BBS); Functional Ambulation Category (FAC); modified Ashworth scale (MAS); 10-metre walk test (10MWT); and kinematic parameters during specific motor tasks in sitting and standing position (speed; time; jerk; spatial error; length) were applied before and after treatment. The virtual reality treatment lasted for 15 sessions, 5 days/week, 1 h/day. Results: The subacute group underwent significant change in all variables, except MAS and length. The chronic group underwent significant improvement in clinical scales, except MAS and kinematics. Motor impairment improved in the severe, moderate and mild groups. Neither time since stroke onset nor affected hemisphere differed significantly between groups. Significant correlations were observed only between spatial error, jerk and BBS. Moreover, FM LE, BBS, MAS, and speed showed high correlations (R2> 0.70) with independent variables. Conclusion: Virtual reality therapy combined with conventional physiotherapy can contribute to functional improvement in the subacute and chronic phases after stroke.
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1) Background: Increasing the amount of therapy time has been shown to improve motor function in stroke survivors. However, it is often not possible to increase the amount of therapy time provided in the current one-on-one therapy models. Rehabilitation-based virtual reality exergame systems, such as Jintronix, can be offered to stroke survivors as an adjunct to traditional therapy. The goal of this study was to examine the safety and feasibility of providing additional therapy using an exergame system and assess its preliminary clinical efficacy. (2) Methods: Stroke survivors receiving outpatient rehabilitation services participated in this pilot randomized control trial in which the intervention group received 4 weeks of exergaming sessions in addition to traditional therapy sessions. (3) Results: Nine subjects in the intervention and nine subjects in the control group completed the study. The intervention group had at least two extra sessions per week, with an average duration of 44 min per session and no serious adverse events (falls, dizziness, or pain). The efficacy measures showed statistically meaningful improvements in the activities of daily living measures (i.e., MAL-QOM (motor activity log-quality of movement) and both mobility and physical domains of the SIS (stroke impact scale) with mean difference of 1.0%, 5.5%, and 6.7% between the intervention and control group, respectively) at post-intervention. (4) Conclusion: Using virtual reality exergaming technology as an adjunct to traditional therapy is feasible and safe in post-stroke rehabilitation and may be beneficial to upper extremity functional recovery.
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Introduction Parkinson’s disease (PD) is managed primarily by dopamine agonists and physiotherapy while virtual reality (VR) has emerged recently as a complementary method. The present study reviewed the effectiveness of VR in rehabilitation of patients with PD. Methods Literature search up to June 2019 identified ten studies (n = 343 participants) suitable for meta-analysis and 27 studies (n = 688 participants) for systematic review. Standard mean difference (SMD) and 95% confidence intervals (CI) were calculated using a random effects model. Results In meta-analysis, compared with active rehabilitation intervention, VR training led to greater improvement of stride length, SMD = 0.70 (95%CI = 0.32–1.08, p = 0.0003), and was as effective for gait speed, balance and co-ordination, cognitive function and mental health, quality of life and activities of daily living. Compared with passive rehabilitation intervention, VR had greater effects on balance: SMD = 1.02 (95%CI = 0.38–1.65, p = 0.002). Results from single randomised controlled trials showed that VR training was better than passive rehabilitation intervention for improving gait speed SMD = 1.43 (95%CI = 0.51–2.34, p = 0.002), stride length SMD = 1.27 (95%CI = 0.38–2.16, p = 0.005) and activities of daily living SMD = 0.96 (95%CI = 0.02–1.89). Systematic review showed that VR training significantly (p < 0.05) improved motor function, balance and co-ordination, cognitive function and mental health, and quality of life and activities of daily living. Conclusion VR used in rehabilitation for patients with PD improves a number of outcomes and may be considered for routine use in rehabilitation.
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Objective In recent years, virtual reality (VR) has been tested as a therapeutic tool in neurorehabilitation research. However, the impact effectiveness of VR technology on for Parkinson’s Disease (PD) patients is still remains controversial unclear. In order to provide a more scientific basis for rehabilitation of PD patients’ modality, we conducted a systematic review of VR rehabilitation training for PD patients and focused on the improvement of gait and balance. Methods An comprehensive search was conducted using the following databases: PubMed, Web of Science, Cochrane Library, CINHAL, Embase and CNKI (China National Knowledge Infrastructure).Articles published before 30 December 2018 and of a randomized controlled trial design to study the effects of VR for patients with PD were included. The study data were pooled and a meta-analysis was completed. This systematic review was conducted in accordance with the PRISMA guideline statement and was registered in the PROSPERO database (CRD42018110264). Results A total of sixteen articles involving 555 participants with PD were included in our analysis. VR rehabilitation training performed better than conventional or traditional rehabilitation training in three aspects: step and stride length (SMD = 0.72, 95%CI = 0.40,1.04, Z = 4.38, P<0.01), balance function (SMD = 0.22, 95%CI = 0.01,0.42, Z = 2.09, P = 0.037), and mobility(MD = -1.95, 95%CI = -2.81,-1.08, Z = 4.41, P<0.01). There was no effect on the dynamic gait index (SMD = -0.15, 95%CI = -0.50,0.19, Z = 0.86, P = 0.387), and gait speed (SMD = 0.19, 95%CI = -0.03,0.40, Z = 1.71, P = 0.088).As for the secondary outcomes, compared with the control group, VR rehabilitation training demonstrated more significant effects on the improvement of quality of life (SMD = -0.47, 95%CI = -0.73,-0.22, Z = 3.64, P<0.01), level of confidence (SMD = -0.73, 95%CI = -1.43,-0.03, Z = 2.05, P = 0.040), and neuropsychiatric symptoms (SMD = -0.96, 95%CI = -1.27,-0.65, Z = 6.07, P<0.01), while it may have similar effects on global motor function (SMD = -0.50, 95%CI = -1.48,0.48, Z = 0.99, P = 0.32), activities of daily living (SMD = 0.25, 95%CI = -0.14,0.64, Z = 1.24, P = 0.216), and cognitive function (SMD = 0.21, 95%CI = -0.28,0.69, Z = 0.84, P = 0.399).During the included interventions, four patients developed mild dizziness and one patient developed severe dizziness and vomiting. Conclusions According to the results of this study, we found that VR rehabilitation training can not only achieve the same effect as conventional rehabilitation training. Moreover, it has better performance on gait and balance in patients with PD. Taken together, when the effect of traditional rehabilitation training on gait and balance of PD patients is not good enough, we believe that VR rehabilitation training can at least be used as an alternative therapy. More rigorous design of large-sample, multicenter randomized controlled trials are needed to provide a stronger evidence-based basis for verifying its potential advantages.
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Study design: Prospective comparative pre-post study. Purpose: To evaluate the effects of game-based virtual reality (VR) training program for trunk postural control and balance in patients with spinal cord injury (SCI) and to assess the results according to the motor completeness (severity) of lesions using the American Spinal Injury Association Impairment Scale (AIS). Overview of literature: Training with VR based gaming has a role to play in improving balance in patients with SCI. Methods: Patients with SCI (traumatic and non-traumatic) for <6 months were included in this hospital-based study. Participants were divided into two groups: experimental group (EG) consisting 21 patients, and control group (CG) consisting 12. Both groups underwent the conventional rehabilitation program. An additional training with semi-immersive VR therapy was conducted 5 days a week for 3 weeks in the EG with the focus on balance rehabilitation using the "Rhetoric." The outcome measures were the Berg Balance Scale (BBS), balance section of the Tinetti Performance-Oriented Mobility Assessment (POMA-B), and Functional Reach Score (FRS). Results: Both groups consisted of young participants (mean age, 28 and 30.5 years, respectively) and predominantly men (>80%). One-third of them had tetraplegia and two-third had paraplegia. Between-group analyses showed no statistically significant differences in the main effects between groups (p-value: BBS, 0.396; POMA-B, 0.238; FRS, 0.294), suggesting that the EG group did not show significant improvement in the trunk and posture at the end of training sessions than the CG group. Similarly, no significant difference was observed according to the severity (completeness) of SCI in the between-group analyses using the AIS (A/B vs. C/D). Conclusions: VR is an adjunctive therapy for balance rehabilitation in patients with SCI.
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Background The aim of this study was to investigate the effect of virtual reality (VR) technology on balance and gait in patients with Parkinson’s disease (PD). Material/Methods The study design was a single-blinded, randomized, controlled study. Twenty-eight patients with PD were randomly divided into the experimental group (n=14) and the control group (n=14). The experimental group received VR training, and the control group received conventional physical therapy. Patients performed 45 minutes per session, 5 days a week, for 12 weeks. Individuals were assessed pre- and post-rehabilitation with the Berg Balance Scale (BBS), Timed Up and Go Test (TUGT), Third Part of Unified Parkinson’s Disease Rating Scale (UPDRS3), and Functional Gait Assessment (FGA). Results After treatment, BBS, TUGT, and FGA scores had improved significantly in both groups (P<0.05). However, there was no significant difference in the UPDRS3 between the pre- and post-rehabilitation data of the control group (P>0.05). VR training resulted in significantly better performance compared with the conventional physical therapy group (P<0.05). Conclusions The results of this study indicate that 12 weeks of VR rehabilitation resulted in a greater improvement in the balance and gait of individuals with PD when compared to conventional physical therapy.
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Background Virtual reality (VR) experiences (through games and virtual environments) are increasingly being used in physical, cognitive, and psychological interventions. However, the impact of VR as an approach to rehabilitation is not fully understood, and its advantages over traditional rehabilitation techniques are yet to be established. Method We present a systematic review which was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). During February and March of 2018, we conducted searches on PubMed (Medline), Virtual Health Library Search Portal databases (BVS), Web of Science (WOS), and Embase for all VR-related publications in the past 4 years (2015, 2016, 2017, and 2018). The keywords used in the search were “neurorehabilitation” AND “Virtual Reality” AND “devices.” Results We summarize the literature which highlights that a range of effective VR approaches are available. Studies identified were conducted with poststroke patients, patients with cerebral palsy, spinal cord injuries, and other pathologies. Healthy populations have been used in the development and testing of VR approaches meant to be used in the future by people with neurological disorders. A range of benefits were associated with VR interventions, including improvement in motor functions, greater community participation, and improved psychological and cognitive function. Conclusions The results from this review provide support for the use of VR as part of a neurorehabilitation program in maximizing recovery.
Article
Objectives This study investigated (i) the impact of engaging with 20 minute simulated natural environments delivered via virtual reality (VR) on current mood state, and (ii) the impact of engaging with multiple VR sessions over a period of a week on the depressive symptoms of people with a SCI. Design A randomized controlled trial design was utilised. Setting Spinal Cord Injury Rehabilitation Unit in Australia Participants Participants (n=24) were assigned to a group engaging in VR sessions during week 1 (Group 1, n=10), or week 2 (Group 2, n=14). Interventions The intervention week involved participation in up to three 20-minute VR sessions over three consecutive days. The control condition involved regular rehabilitation practice over a week. Main Outcome Measures The Patient Health Questionnaire-8 (PHQ-8) was completed prior to the first week (T1), after the first week and prior to the second week (T2), and after the second week (T3). Current feeling states- depressed/happy, anxious/relaxed, and not feeling good/feeling good - were rated immediately prior and after each VR session. Results Levels of happiness, relaxation, and feeling good, were significantly higher subsequent to engaging with each VR session. Between-group differences in PHQ-8 scores were significantly greater for participants who experienced the intervention during the first week compared to participants within the control group: intervention participants had significant improvements in psycho-emotional health. Within-group PHQ-8 scores reduced for each group subsequent to experiencing the intervention, however differences were not significant. Conclusions Engaging with simulated natural environments delivered via VR can favourably impact the psycho-emotional health of people with SCI receiving rehabilitation in hospital. Future research including larger samples and investigating the impact over a longer time period is required to confirm the findings presented.
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Multiple sclerosis (MS) is a demyelinating neurodegenerative disease with lesions involving the central nervous system. Clinical symptoms consist of disturbances in motor activity (e.g., weakness, spasticity, and tremor), sensory functioning (e.g., pain), visual functions (e.g., diplopia and optic neuritis), besides different cognitive (attention deficit and executive dysfunction) and behavioral abnormalities. This review aims to evaluate the role of VR tools in cognitive and motor rehabilitation of MS patients. Studies performed between 2010 and 2017 and fulfilling the selected criteria were searched on PubMed, Scopus, Cochrane and Web of Sciences databases, by combining the terms “VR rehabilitation” and “MS”. Our findings showed that, following the use of VR training, MS patients presented a significant improvement in motor (especially gait and balance) and cognitive function (with regard to executive and visual-spatial abilities, attention and memory skills). This review supports the idea that rehabilitation through new VR tools could positively affect MS patients’ outcomes, by boosting motivation and participation with a better response to treatment.