Interactive Video Gaming Improves Functional Balance in Poststroke Individuals: Meta-Analysis of Randomized Controlled Trials

Abstract

The main objective of this study was to evaluate the effects of interactive video games on functional balance and mobility in poststroke individuals. The Health Science databases accessed included Medline via PubMed, LILACS, SciELO, and PEDro. The inclusion criteria were as follows: clinical studies evaluating the use of interactive video games as a treatment to improve functional balance and mobility in individuals poststroke and studies published in the Brazilian Portuguese, English, or Spanish language between 2005 and April 2016. PEDro Scale was used to analyze the methodological quality of the studies. The Berg Balance Scale and Timed Up and Go Test (TUGT) data were evaluated using a meta-analysis, the publication bias was assessed by funnel plots, and the heterogeneity of the studies by I ² statistic. Eleven studies were included in the final analysis. Functional balance improved in individuals treated using interactive video games (mean difference = 2.24, 95% confidence interval [0.45, 4.04], p = .01), but no improvement was observed in mobility as measured by TUGT. The studies presented low heterogeneity (24%). The mean score on the PEDro Scale was 6.2 ± 1.9. Interactive video games were effective in improving functional balance but did not influence the mobility of individuals poststroke.

Keywords

stroke virtual reality postural control balance physical therapy rehabilitation

World Health Organization defines stroke as a rapidly developing syndrome caused by vascular involvement of encephalic arteries, of ischemic or hemorrhagic origin, that may lead to focal disturbance of encephalic function (WHO, 2006). In the United States, about 795,000 people are diagnosed with stroke annually, with 1 in 20 deaths being from stroke resulting in 130,000 deaths per year (Centers for Disease Control and Prevention [CDC], 2017; Mozaffarian et al., 2015).

Stroke can be detrimental to speech as well as sensorimotor and cognitive functions. Among the sensorimotor alterations, impairment of functional balance and mobility (Da, Física, Pacientes, & Acidente, 2013; Mc, Kelly, Godwin, Enderby, & Campbell, 2016; Morelato, Pinto, Regina, & Oliveira, 2015) are the most limiting to the activities of daily living (Soares, Santos, Costa, & Melo, 2015; Veerbeek et al., 2014; Webster & Celik, 2014). Several studies have analyzed the effects of different interventions such as functional electrical stimulation, robotic therapy, and virtual reality (Veerbeek et al., 2014) on improving the functional balance and mobility of individuals poststroke.

Improved functional balance and mobility in individuals with stroke have been associated with reduced risk of mortality (Callaly et al., 2015). After stroke, individuals who experienced at least one fall or presented functional dependence had a higher risk of death within 2 years compared to functionally independent individuals or those with mild/moderate disability (OR = 6.5, p = .001; Callaly et al., 2015).

Virtual reality is defined as the projection of a scenario with which individuals can interact through their sensory channels and body movements (da Silva Ribeiro et al., 2015). Accordingly, interactive video games can be considered a form of virtual reality. Several studies have shown the potential of this new intervention for rehabilitation of individuals poststroke (Laver, George, Thomas, Deutsch, & Crotty, 2015; Li, Han, Sheng, & Ma, 2015; Lloréns, Gil-Gómez, Alcañiz, Colomer, & Noé, 2015).

Among the interactive commercial video game consoles, Nintendo Wii and Xbox with Kinect sensors have been used for the rehabilitation of individuals with neurological impairment. The Nintendo Wii system detects movement using accelerometers, infrared signals, or a platform with pressure sensors. The Xbox with Kinect sensors detects movements through a camera that captures infrared signals from anatomical landmarks, creates an avatar, and projects the reproduced movements of the player on the game screen. This enables interaction without the need of a game controller (Soares et al., 2015; Webster & Celik, 2014).

Systematic reviews have verified the positive effects of virtual reality in poststroke individuals on upper limb function (Laver et al., 2015); gait (Li et al., 2015; Rooij, van de Port, & Meijer, 2016); perception of the affected side of the body; and cognition such as attention, planning, and executive functions (Pompeu et al., 2014). However, the results of these systematic reviews are controversial, given the heterogeneity of the virtual reality systems and study populations between the studies. Therefore, it is important to specifically evaluate the effects of interactive video games, with and without conventional physical therapy, on functional balance and mobility rehabilitation in individuals poststroke.

Hypotheses regarding the effects of interactive games state that the constant self-correction during a series of motor tasks is beneficial to the effected individuals in promoting neuroplasticity as motor planning and motor control abilities are continuously stimulated through visual biofeedback. Studies have demonstrated that mirror neurons activity is modulated to imitate the neural activation pattern of an observed motor task. This improves movement performance and, consequently, the functional balance and mobility of the patient (Brunner, Skouen, Ersland, & Grüner, 2014; Wang et al., 2015). Hence, the objective of this study was to evaluate the effects of interactive video games on functional balance and mobility in individuals poststroke.

Method

This review was registered on the PROSPERO site (http://www.crd.york.ac.uk/prospero/): CRD42015024685. The present study followed the methodological recommendations proposed by Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) (Padula et al., 2012).

Eligibility Criteria

Studies with the following characteristics were included in this systematic review: randomized clinical trials involving individuals poststroke, analyzed the effects of interactive video games, such as Nintendo Wii and Xbox with Kinect sensors, on functional balance and mobility outcomes, and published between 2005 and April 2016 in Brazilian Portuguese, English, or Spanish.

Search Strategies

The search strategy termed “PICO” was used where “P” represents patient, “I” intervention, “C” comparison, and “O” outcome. The search strategy utilized Descriptors in Health Sciences and Medical Subject Headings, which were combined with the Boolean operators (AND, OR). The terms used were “Stroke,” “Virtual Reality Exposure Therapy,” “Video Games,” “Feedback Sensory,” “Postural Balance,” “Postural Equilibrium,” “Virtual Reality,” and “Visual Biofeedback.” These terms were used in the following combinations: “Stroke” AND (“Virtual Reality Exposure Therapy” OR “Video Games” OR “Feedback Sensory” OR “Virtual Reality” OR “Visual Biofeedback”) AND “Postural Balance” as well as “Stroke” AND “Video Games” AND “Postural Equilibrium.” The search strategy was applied in the following databases: PubMed, Latin-American and Caribbean Literature in Health Sciences, Scientific Electronic Library On-line, and Physiotherapy Evidence Database.

Selection of Studies and Extraction of Data

The selection and methodological evaluation of the articles were carried out by two independent reviewers (K.T.K. and V.F.), and a third reviewer (M.C.A.) was consulted in case of a disagreement regarding a study’s eligibility. Initially, the titles and abstracts were screened to identify studies that analyzed the effects of interactive video games (e.g., Nintendo Wii and Xbox with Kinect sensors) on functional balance (evaluated by the Berg Balance Scale [BBS]) and mobility (evaluated by the Timed Up and Go Test [TUGT]) in individuals poststroke. Articles with a study population other than individuals poststroke (e.g., elderly or those with Parkinson’s disease) were excluded by screening the titles and abstracts. Subsequently, full-text articles of eligible studies were accessed to establish whether they meet all the inclusion criteria. To ensure that all potentially eligible scientific articles in the literature were considered, a manual search was performed in the bibliographic references of the selected studies.

Description of Methodological Quality

The included randomized clinical trials were evaluated methodologically using the PEDro Scale (Shiwa, Costa, Moser, Aguiar, & Oliveira, 2011), which consists of 11 items, all based on the Delphi list, except for Criteria 8 and 10. The evaluation criteria of the methodological quality were as follows: (1) specification of the origin of the subjects and requirements for the study, (2) random allocation of subjects to groups, (3) person who determined eligibility of subjects was unaware of their group allocation, (4) study groups presented similar prognoses at the beginning of the study, (5) the study subjects participated “blindly,” (6) therapists administered the study “blindly,” (7) the evaluators measured the key results “blindly,” (8) key results were attributed to 85% of the subjects distributed in the groups, (9) all subjects included in the results received the treatment or control condition according to the group, if not, the data were analyzed for intention to treat, (10) the results of the statistical comparisons were described by the key result, and (11) measures of precision and variability in the key result were presented (Shiwa et al., 2011).

The PEDro Scale uses a procedure that evaluates an article according to its score on the 11 criteria. The article is allocated 1 point for each of the 11 criteria met and 0 points for each criterion not met. Thereafter, the score is summed with the maximum score being 10 as criterion number 1 is not included in the final score. Evaluated articles with a total score close to the maximum (10) are considered to have high methodological quality, while articles with a total score close to the minimum (0) are considered to have low quality.

The PEDro Scale was chosen to assess clinical trials because it is appropriate for assessing methodological quality of studies with an intervention in addition to being quick and easy with high reliability (de Morton, 2009; Shiwa et al., 2011).

Statistical Analysis

Functional balance was evaluated using the BBS and mobility using TUGT. The mean differences and 95% confidence intervals (CIs) were calculated by the inverse variance method (Dersimonian & Laird, 1986; Follmann, Elliott, Suh, & Cutler, 1992). The BBS has predictive validity and the ability to detect changes after interventions in individuals with stroke; a score from 0 to 19 on this scale indicates a high risk of falls, 19 to 24 a moderate risk of falls, and 24 to 28 a low risk of falls (Chou et al., 2006; Juneja, Czyrny, & Linn, 1998; Mao, Hsueh, & Tang, 2002). According to Gervasoni, Jonsdottir, Montesano, and Cattaneo (2017), the minimal clinically important difference for change on the of BBS is three points for patients with multiple sclerosis.

It has been documented that individuals with poor TUGT performance and longer duration since the onset of injury demonstrate particularly high fall rates (Pinto et al., 2014). In the TUGT, individuals with an accomplishment time of less than 10 s have a low risk of falls, 20–29 s an average risk of falls, and more than 30 s a high risk of falls (Barry et al., 2014; Bischoff et al., 2003).

The random effects model was utilized for analyses and to obtain summary effect measures (Kelley & Kelley, 2012). The heterogeneity between the studies was determined through T ² and I ² statistics, accompanied by visual inspection of the forest plot (Follmann et al., 1992). The publication bias was evaluated through analysis of the funnel plots. To adjust for possible publication bias, the trim and fill method was used. Analyses were performed using the R statistical software, Version 3.3.1. The α level was set at .05 for statistical significance.

Results

The search strategy yielded 118 studies and another 2 were found by manually searching the bibliographic references. Afterward, one study was excluded due to duplication and 119 articles remained. Of these, 25 articles were selected after screening the titles and abstracts and their full-text articles were read. Subsequently, 14 of the 25 studies were excluded for the following reasons: did not present a control group, did not use the Nintendo Wii or Xbox with Kinect sensors interactive game types, did not analyze the improvement in functional balance and mobility, or associated the use of interactive video games with interventions rather than conventional physiotherapy. Thus, 11 studies met the inclusion criteria and were included in this systematic review (Barcala, Grecco, Colella, Lucareli, & Oliveira, 2013; Bower, Clark, McGinley, Martin, & Miller, 2014; Cho & Lee, 2013; Cho, Lee, & Song, 2012; Fritz, Peters, Merlo, & Donley, 2013; Hung et al., 2014; Kim, Park, & Lee, 2015; Lloréns et al., 2015; McEwen, Taillon-Hobson, Bilodeau, Sveistrup, & Finestone, 2014; Morone et al., 2014; Rajaratnam et al., 2013). The complete flowchart of the studies’ selection for the meta-analysis is shown in Figure 1.

Figure 1.

Flowchart of the selection of included studies.

The characteristics of the 11 selected studies are displayed in Table 1, outlining the names of the authors, number of participants per study, classification of injury time, outcome analyzed, type of intervention performed both in the study group and in the control group, duration of treatment, and the results.

Table 1.

Description of the Studies Included in the Systematic Review.

Author (Year)	Casuistic	Outcome Analyzed	Study Group	Control Group	Results
Cho et al. (2012)	22 adults, with chronic stroke, divided into two groups	Berg Balance Scale Timed Up and Go Test Force platform	VRBT for 30 min a day, 3 times a week for 6 weeks, and conventional physiotherapy for 60 min a day, 5 times a week for 6 weeks	Conventional physical therapy for 60 min a day, 5 times a week for 6 weeks	There was significant improvement in the BBS and TUGT
Cho and Lee (2013)	14 adults with chronic stroke, divided into two groups	Berg Balance Scale Timed Up and Go Test	Real-world video group: 30 min a day, 3 times a week for 6 weeks	Walking training for 30 min per day, 3 times a week, for 6 weeks	There was significant improvement in the BBS and TUGT
Fritz, Peters, Merlo, and Donley (2013)	28 adults with chronic stroke, divided into two groups	Berg Balance Scale Timed Up and Go Test 6-min walk test 3-meter walk	Intervention group carried out strictly game playing (Wii, Kinect, and PS2) in the standing position. The sessions were 50–60 min a day, 4 days a week, for 5 weeks	No intervention	There was no significant improvement
Morone et al. (2014)	50 adults, with subacute stroke, divided into two groups	Berg Balance Scale 10-meter walk test Function ambulation category	Wii group performed 12 sessions of 20 min each of balance training, performed with a Wii Fit, 3 times a week for 4 weeks, in addition to conventional physiotherapy	Conventional physiotherapy, 20 min of balance training, 3 times a week for 4 weeks	There was significant improvement in the BBS and FAC
Hung et al. (2014)	30 adults with chronic stroke, divided into two groups	Time Up and Go Test 10-meter walk test Falls Efficacy Scale International fear of falling assessment	Balance training performed with the Wii, twice a week for 12 weeks, 30 min of Fit, in addition to conventional physiotherapy	Conventional physiotherapy, 30 min of balance training twice a week for 12 weeks	The results show differences between the groups favoring the SG in postural balance, mainly in the head positions in the straight line with the eyes open on a foam surface (p < .02), eyes closed, standing on a solid surface, and head turned 30° to the left (p = .04), and with the eyes closed, standing on a solid surface with the head up (p = .03). In the TUGT, the two groups obtained a reduction in time, but the SG demonstrated greater improvement (p = .03)
McEwen, Taillon-Hobson, Bilodeau, Sveistrup, and Finestone (2014)	59 adults with subacute stroke, divided into two groups	Timed Up and Go Test 2-min walk test	Balance-challenging virtual reality exercise program performed standing 10 to 12 sessions of 20 minutes	Conventional physiotherapy 3 times a week for 20 m, and exposure to identical virtual reality environments, but whose games did not challenge balance	There was significant improvement in the TUGT and 2-min walk test
Bower, Clark, McGinley, Martin, and Miller (2014)	28 adults with subacute stroke, divided into two groups	Berg Balance Scale Dynamic walking index 6-min walk test 3-meter walk test Timed Up and Go Test	Balance group which used “Wii Fit Plus” (n = 17 initial, n = 14 in the 2-week segment and n = 11 in the 4-week segment) performed standing. The sessions were 45 min, 3 times a week for 2–4 weeks. Conventional physiotherapy and OT	Upper limb group which used “Wii Sports Resort” (n = 13 initial and in the 2-week segment, and n = 10 in the 4-week segment) performed seated. The sessions were 45 min, 3 times a week for 2–4 weeks. Conventional physiotherapy and OT	The intervention time with the Wii in the Balance group was better than for the Upper limbs group after 2 weeks (p < .03), but not after 4 weeks (p < 0.64)
Lloréns, Gil-Gómez, Alcañiz, Colomer and Noé (2015)	20 adults with chronic stroke, divided into two groups	Berg Balance Scale Tinetti Scale 10-meter walk test	Five sessions per week with a total of 20 one-hr sessions, being 30 min with intervention based on virtual reality and 30 min of conventional physiotherapy	Underwent conventional physiotherapy, 5 times a week for a total of 20 one-hr sessions	There was a significant improvement in the BBS (p = .047) and 10-min walk test (p = .048)
Rajaratnam et al. (2013)	19 adults with acute stroke, divided into two groups	Berg Balance Scale Functional Reach Test Pressure center Timed Up and Go Test	40 min of conventional physiotherapy and 20 min of balance training, using Kinect or Wii Fit, for 15 sessions	Conventional physical therapy for 60 min for 15 sessions	There was significant improvement in the TUGT and Functional Reach Test
Barcala, Grecco, Colella, Lucareli, and Oliveira (2013)	20 adults with chronic stroke, divided into two groups	Berg Balance Scale Timed Up and Go Test	30 min of conventional physiotherapy and 30 min of balance training using Wii Balance Board, 2 days a week for 5 weeks	60 min of conventional physiotherapy including balance training, 2 days a week, for 5 weeks	There was no significant improvement
Kim, Park, and Lee (2015)	20 adults with chronic stroke, divided into two groups	Force platform Gait step lengths and speed	Conventional therapy 60 min a day, 5 days a week for 4 weeks, in addition, there was exposure to the virtual reality scene using Wii Balance Board	Conventional physical therapy, including muscle strengthening, balance training, and outdoor walking training, 30 min per day, 3 days a week, for 4 weeks	Significant improvement in the indicators of the Balance Board

Note. VRBT = virtual reality balance training; SG = study group; CG = control group; TMWT = two-minute walk test; TUGT = Timed Up and Go Test; IMI = Intrinsic Motivation Inventory; FAC = function ambulation category; BBS = Berg Balance Scale; OT = occupational therapy; T0 = initiation of treatment; T1 = end of treatment; s = seconds.

The mean score of the methodological quality of the studies evaluated using the PEDro Scale was 6.2 ± 1.9, with only one study achieving a score of 3, two studies scoring 4, one study scoring 5, three studies scoring 7, and four studies scoring 8 (Table 2).

Table 2.

Description of the Methodological Quality of the Studies According to the PEDro Scale.

Criteria Studies	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)	(11)	Total Score
Cho et al. (2012)	Y	Y	N	Y	N	N	N	Y	N	Y	Y	5/10
Cho and Lee (2013)	Y	Y	Y	Y	N	N	Y	Y	N	Y	Y	7/10
Fritz, Peters, Merlo, and Donley (2013)	Y	Y	Y	Y	N	N	Y	Y	Y	Y	Y	8/10
Morone et al. (2014)	Y	Y	Y	Y	N	N	Y	Y	N	Y	Y	7/10
Hung et al. (2014)	Y	Y	Y	Y	N	N	Y	Y	Y	Y	Y	8/10
McEwen, Taillon-Hobson, Bilodeau, Sveistrup, and Finestone (2014)	Y	N	N	Y	N	N	N	N	N	Y	Y	3/10
Bower, Clark, McGinley, Martin, and Miller (2014)	Y	Y	Y	Y	Y	N	Y	Y	N	Y	Y	8/10
Lloréns, Gil-Gómez, Alcañiz, Colomer and Noé (2015)	Y	Y	Y	Y	N	N	Y	Y	Y	Y	Y	8/10
Kim, Park, and Lee (2015)	N	Y	N	Y	N	N	N	N	N	Y	Y	4/10
Rajaratnam et al. (2013)	Y	Y	N	N	N	N	Y	N	Y	Y	N	4/10
Barcala, Grecco, Colella, Lucareli, and Oliveira (2013)	Y	Y	Y	Y	N	N	Y	Y	N	Y	Y	7/10

Note. The PEDro Scale classifies the study according to its score, being that, (Y) yes = 1 point and (N) no = 0 points, where the criterion of number (1) is not considered in the total score.

Meta-Analysis of the Effects of Interactive Video Games on the Functional Balance of Individuals Poststroke

The summary effect from the meta-analysis (Figure 2) indicated a mean difference of 2.24 (95% CI [0.45, 4.04], p = .01) demonstrating that the treatment with interactive video games improved functional balance of individuals with stroke compared to the control treatment. The heterogeneity (I ²) of 24% is considered low. Two studies showed a significant improvement in functional balance (3.33%) in the treatment groups with interactive video games compared to their respective controls (Figure 2). Additionally, the funnel plot did not suggest evidence of publication bias (Figure 3A).

Figure 2.

Forest graph of the rehabilitation effects of using interactive video games over the BERG Balance Scale. The effects to the right of the vertical line of the figure indicate favorable results for functional balance and mobility.

Figure 3.

Funnel graph of publication bias. (A) Studies using interactive video games over the Berg Balance Scale. (B) Studies using interactive video games over the Timed Up and Go Test. Dark gray “.1 > p > .05”; gray “.05 > p > .1”; Light gray “<.01.”

Meta-Analysis of the Effects of Interactive Video Games on the Mobility of Individuals Poststroke

The summary effect from the meta-analysis (Figure 4) indicated a mean difference of 0.51 (95% CI [−2.66, 1.64], p = .74) demonstrating the absence of a significant rehabilitation effect of interactive video games on the mobility of individuals poststroke. The I ² statistic (0%) indicated no heterogeneity. The funnel plot suggested publication bias; however, the trim and fill method adjusted for publication bias (Figure 3B).

Figure 4.

Forest graph of the rehabilitation effects of using interactive video games over the Timed Up and Go Test in individuals with stroke.

Discussion

This systematic review with meta-analysis provided clinical evidence that treatment with interactive video games may be effective in improving functional balance of individuals poststroke. Clinically, the results indicated that interventions with interactive video games are more beneficial compared to the presence or absence of any other type of intervention. Improved functional balance is especially beneficial for individuals with stroke since they have impaired functional balance and a significant risk of falls (Subramaniam & Bhatt, 2015).

In addition, the I ² statistic (24%) indicated that the studies are similar in methodological terms, making it possible to combine the data in the meta-analysis. These data attest to the similarity between the studies included in this systematic review, guaranteeing the absence of clinical and statistical heterogeneity and thus supporting the clinical evidence that interventions with interactive video games are beneficial for individuals poststroke to improve functional balance.

The lack of blinding of therapists or poststroke individuals in all but one study (Bower et al., 2014), may have introduced bias in the results of the meta-analysis. However, it is worth mentioning that the blinding of participants and therapists is often impractical in interventions that involve rehabilitation using interactive video games. Moreover, Fritz, Peters, Merlo, and Donley (2013) had no intervention in control groups which may also introduce possible bias and compromise the effect analysis of the interactive video games. On the other hand, despite the presence of some methodological limitations, the mean PEDro score was 6.2, which represents high methodological quality (Canadian Partnership for Stroke Recovery, n.d.—PEDRo score) of the studies included in the meta-analysis.

In regard to the populations of the 11 studies included in the analyses, seven articles studied individuals with chronic stroke with 6 months to at least 1 year of injury (Barcala et al., 2013; Cho & Lee, 2013; Cho et al., 2012; Fritz et al., 2013; Hung et al., 2014; Kim et al., 2015; Lloréns et al., 2015), three studied subacute stroke with 1 to 2 months of injury (Bower et al., 2014; McEwen et al., 2014; Morone et al., 2014), and one study included individuals with acute stroke with less than 16 days of injury (Rajaratnam et al., 2013). The differences in the poststroke periods appeared not to have influenced the potential recovery, since low heterogeneity was observed among the studies.

Conventional physical therapy treatment for patients poststroke may include different strategies and techniques for improving motor control, such as physical exercise and functional electric stimulation (Dobkin, 2004; Veerbeek et al., 2014). However, as an alternative to conventional therapy, the interactive video games presented promising results when comparing pre and posttreatment; moreover, some studies presented superior results for the treatment group compared to the control group treated with conventional therapy (Hung et al., 2014; Kim et al., 2015; Lloréns et al., 2015). These results may encourage clinicians to think about potentially incorporating commercial video gaming in rehabilitation programs, especially to increase motivation and adherence rate to conventional physical therapy treatments.

The present systematic review has several strengths: (1) a clearly defined objective, (2) a comprehensive and systematic study search, with explicit and reproducible eligibility criteria without language restrictions, and (3) selection of included studies by two independent authors. On the other hand, the low number of studies included in this review may limit the findings. An attempt to access additional data for inclusion in the meta-analysis was made by contacting the authors of another study (Morone et al., 2014), but no response was received.

This meta-analysis of randomized controlled trials provided clinical evidence on the efficacy of treatment with interactive video games aimed at improving functional balance in poststroke individuals when compared to other or absence of interventions but did not influence the mobility of individuals poststroke. Thus, clinical studies with high methodological quality are still necessary to establish whether interactive video games result in mobility improvement of individuals poststroke. Interactive video games represent a viable option for therapy to improve patient care, adopt available technology in rehabilitation therapy, and customize treatment of patients with neurological disorders using functional and dynamic exercises (Cho & Lee, 2013).

Footnotes

Authors’ Note

Vilma Ferreira and Karina Tamy Kasawara developed the research question and the study design. Two independent researchers, Vilma Ferreira and Karina Tamy Kasawara, performed the search strategy into scientific databases, whereas Mariana Cunha Artilheiro was consulted in cases of disagreements regarding inclusion of studies in this systematic review. Nelson Carvas performed all the statistical analysis. José Eduardo Pompeu substantially contributed to data interpretation and manuscript preparation. Vilma Ferreira and Karina Tamy Kasawara, Mariana Cunha Artilheiro and Nelson Carvas wrote the first draft of the manuscript. Syed Ahmed Hassan reviewed, edited, proofread, and provided feedback on the manuscript. All authors approved the last version of the manuscript before submission.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Systematic review registration number: PROSPERO CRD42015024685.

ORCID iD

Karina Tamy Kasawara

References

Barcala

Grecco

L. A. C.

Colella

Lucareli

P. R. G.

Oliveira

C. S

. (2013). Visual biofeedback balance training using wii fit after stroke: A randomized controlled trial. Journal of Physiology Therapy Science, 25, 1027–1032.

Barry

Galvin

Keogh

Horgan

Fahey

Tinetti

… Kivela

(2014). Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: A systematic review and meta-analysis. BMC Geriatrics, 14, 14. doi:10.1186/1471-2318-14-14

Bischoff

H. A.

Stähelin

H. B.

Monsch

A. U.

Iversen

M. D.

Weyh

von Dechend

… Theiler

(2003). Identifying a cut-off point for normal mobility: A comparison of the timed “up and go” test in community-dwelling and institutionalised elderly women. Age and Ageing, 32, 315–320. doi:10.1093/ageing/32.3.315

Bower

K. J.

Clark

R. A.

McGinley

J. L.

Martin

C. L.

Miller

K. J.

(2014). Clinical feasibility of the Nintendo Wii^TM for balance training post-stroke: A phase II randomized controlled trial in an inpatient setting. Clinical Rehabilitation, 28, 912–923. doi:10.1177/0269215514527597

Brunner

I. C.

Skouen

J. S.

Ersland

Grüner

(2014). Plasticity and response to action observation: A longitudinal FMRI study of potential mirror neurons in patients with subacute stroke. Neurorehabilitation and Neural Repair, 28, 874–884. doi:10.1177/1545968314527350

Callaly

E. L.

Ni Chroinin

Hannon

Sheehan

Marnane

Merwick

… Kyne

(2015). Falls and fractures 2 years after acute stroke: The North Dublin Population Stroke Study. Age and Ageing, 44, 882–886. doi:10.1093/ageing/afv093

Canadian Partnership for Stroke Recovery. (n.d.). PEDro score—Stroke engine. Retrieved January 14, 2018, from https://www.strokengine.ca/glossary/pedro-score/

Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention. (2017). Stroke Facts. Retrieved from: https://www.cdc.gov/stroke/facts.htm.

Cho

K. H.

Lee

W. H.

(2013). Virtual walking training program using a real-world video recording for patients with chronic stroke. American Journal of Physical Medicine & Rehabilitation, 92, 371–384. doi:10.1097/PHM.0b013e31828cd5d3

10.

Cho

K. H.

Lee

K. J.

Song

C. H.

(2012). Virtual-reality balance training with a video-game system improves dynamic balance in chronic stroke patients. The Tohoku Journal of Experimental Medicine, 228, 69–74. doi:10.1620/tjem.228.69

11.

Chou

C.-Y.

Chien

C.-W.

Hsueh

I.-P.

Sheu

C.-F.

Wang

C.-H.

Hsieh

C.-L.

(2006). Research report developing a short form of the berg. Physical Therapy, 86, 195–204.

12.

Física

Pacientes

E. M.

Acidente

A. O.

(2013). Limitação da mobilidade física em pacientes após o acidente vascular encefálico no domilílio: Proposta de um conceito [Physical mobility of stroke patients in the home: a proposed concept]. Revrene, 14, 920–928.

13.

da Silva Ribeiro

N. M.

Ferraz

D. D.

Pedreira

É.

Pinheiro

Í.

da Silva Pinto

A. C.

Neto

M. G.

… Masruha

M. R.

(2015). Virtual rehabilitation via Nintendo Wii® and conventional physical therapy effectively treat post-stroke hemiparetic patients. Topics in Stroke Rehabilitation, 22, 299–305. doi:10.1179/1074935714Z.0000000017

14.

de Morton

N. A.

(2009). The PEDro scale is a valid measure of the methodological quality of clinical trials: A demographic study. The Australian Journal of Physiotherapy, 55, 129–133. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19463084

15.

de Rooij

I. J. M.

van de Port

I. G. L.

Meijer

J-W. G.

(2017). Feasibility and effectiveness of virtual reality training on balance and gait recovery early after stroke: a pilot study. Int J Phys Med Rehabil, 5, 418. doi:10.4172/2329-9096.1000418

16.

Dersimonian

Laird

(1986). Meta-analysis in clinical trials. Contemporary Clinical Trials, 7, 177–188.

17.

Dobkin

B. H.

(2004). Strategies for stroke rehabilitation. The Lancet. Neurology, 3, 528–536. doi:10.1016/S1474-4422(04)00851-8

18.

Follmann

Elliott

Suh

Cutler

(1992). Variance imputation for overviews clinical trials with continuous response. Journal of Clinical Epidemiology, 45, 769–773.

19.

Fritz

S. L.

Peters

D. M.

Merlo

A. M.

Donley

(2013). Active video-gaming effects on balance and mobility in individuals with chronic stroke: A randomized controlled trial. Topics in Stroke Rehabilitation, 20, 218–225. doi:10.1310/tsr2003-218

20.

Gervasoni

Jonsdottir

Montesano

Cattaneo

(2017). Minimal clinically important difference of berg balance scale in people with multiple sclerosis. Archives of Physical Medicine and Rehabilitation, 98, 337–340. doi:10.1016/j.apmr.2016.09.128

21.

Hung

J.-W.

Chou

C.-X.

Hsieh

Y.-W.

W.-C.

M.-Y.

Chen

P.-C.

… Ding

S.-E.

(2014). A randomized comparison trial of balance training by using exergaming and conventional weight-shifting therapy in patients with chronic stroke. Archives of Physical Medicine and Rehabilitation, 95, 1629–1637. doi:10.1016/j.apmr.2014.04.029

22.

Juneja

Czyrny

Linn

(1998). Admission balance and outcomes of patients admitted for acute inpatient rehabilitation. Physical Medicine and Rehabilitation, 77, 388–393.

23.

Kelley

G. A.

Kelley

K. S.

(2012). Statiatical models for meta-analysis: A brief turorial. World Journal of Methodology, 2, 27–32. doi:10.5662/wjm.v2.i4.27

24.

Kim

Park

Lee

B.-H.

(2015). Effects of community-based virtual reality treadmill training on balance ability in patients with chronic stroke. Journal of Physical Therapy Science, 27, 655–658. doi:10.1589/jpts.27.655

25.

Laver

K. E.

George

Thomas

Deutsch

J. E.

Crotty

(2015). Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews (Online), 9, 1–107. doi:10.1002/14651858.CD008349.pub3

26.

Han

Sheng

S.-J.

(2015). Virtual reality for improving balance in patients after stroke: A systematic review meta-analysis. Clinical Rehabilitation, 30, 432–440. doi:10.1177/0269215515593611

27.

Lloréns

Gil-Gómez

J.-A.

Alcañiz

Colomer

Noé

(2015). Improvement in balance using a virtual reality-based stepping exercise: A randomized controlled trial involving individuals with chronic stroke. Clinical Rehabilitation, 29, 261–268. doi:10.1177/0269215514543333

28.

Mao

Hsueh

Tang

(2002). Analysis and comparison of the psychometric properties of three balance measures for stroke patients. Stroke, 33, 1022–1027.

29.

Kelly

Godwin

Enderby

Campbell

(2016). Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews (Online). doi:10.1002/14651858.CD000425.pub3

30.

McEwen

Taillon-Hobson

Bilodeau

Sveistrup

Finestone

(2014). Virtual reality exercise improves mobility after stroke: An inpatient randomized controlled trial. Stroke, 45, 1853–1855. doi:10.1161/STROKEAHA.114.005362

31.

Morelato

R. L.

Pinto

H. P.

Regina

de Oliveira

(2015). Disability after stroke: A systematic review. Fisioterapia Em Movimento, 28, 407–418.

32.

Morone

Tramontano

Iosa

Shofany

Iemma

Musicco

… Caltagirone

(2014). The efficacy of balance training with video game-based therapy in subacute stroke patients: A randomized controlled trial. BioMed Research International, 1–6. doi:10.1155/2014/580861

33.

Mozaffarian

Benjamin

E. J.

A. S.

Arnett

D. K.

Blaha

M. J.

Cushman

… Yeh

R. W.

(2015). AHA statistical update heart disease and stroke statistics—2015 update a report from the american heart association. Circulation, 131, e29–e332. doi:10.1161/CIR.0000000000000152

34.

Padula

R. S.

Pires

R. S.

Alouche

S. R.

Chiavegato

L. D.

Lopes

A. D.

Costa

L. O. P.

(2012). Analysis of reporting of systematic reviews in physical therapy published in Portuguese. Brazilian Journal of Physical Therapy, 16, 381–388.

35.

Pinto

E. B.

Nascimento

Marinho

Oliveira

Monteiro

Castro

… Oliveira-Filho

(2014). Risk factors associated with falls in adult patients after stroke living in the community: Baseline data from a stroke cohort in Brazil. Topics in Stroke Rehabilitation, 21, 220–227. doi:10.1310/tsr2103-220

36.

Pompeu

J. E.

Alonso

T. H.

Masson

I. B.

Maria

Pompeu

A. A.

Torriani-pasin

(2014). Os efeitos da realidade virtual na reabilitação do acidente vascular encefálico: Uma revisão sistemática [The effects of virtual reality on stroke rehabilitation: A systematic review]. Motricidade, 10, 111–122. doi:10.6063/motricidade.10(4).3341

37.

Rajaratnam

B. S.

KaiEn

J. G.

JiaLin

K. L.

SweeSin

FenRu

S. S.

Enting

… SiaoTing

S. T.

(2013). Does the inclusion of virtual reality games within conventional rehabilitation enhance balance retraining after a recent episode of stroke? Rehabilitation Research and Practice, 2013, 649561.

38.

Shiwa

S. R.

Costa

L. O. P.

de Moser

A. D. L.

de Aguiar

I. C.

de Oliveira

L. V. F.

(2011). PEDro: A base de dados de evidências em fisioterapia. Fisioterapia Em Movimento (Impresso), 24, 523–533. doi:10.1590/S0103-51502011000300017

39.

Soares

Santos

Costa

Melo

(2015). Wii rehabilitation and neurological physiotherapy: A systematic review. Revista Neurociências, 23, 81–88. doi:10.4181/RNC.2015.23.01.982.8p

40.

Subramaniam

Bhatt

(2015). Does a virtual reality-based dance training paradigm increase balance control in chronic stroke survivors? A preliminary study. International Journal of Neurorehabilitation, 2. doi:10.4172/2376-0281.1000185

41.

Veerbeek

J. M.

van Wegen

van Peppen

van der Wees

P. J.

Hendriks

Rietberg

Kwakkel

(2014). What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PLoS One, 9. doi:10.1371/journal.pone.0087987

42.

Wang

Zhang

Chen

… Shan

. (2015). Mirror neuron therapy for hemispatial neglect patients. Scientific Reports, 5, 8664. doi:10.1038/srep08664

43.

Webster

Celik

(2014). Systematic review of Kinect applications in elderly care and stroke rehabilitation. Journal of Neuroengineering and Rehabilitation, 11, 108.

44.

World Health Organization. (2006). The WHO STEPwise approach to stroke surveillance. WHO STEPS Stroke Manual. Retrieved January 14, 2018 from: http://www.who.int/ncds/surveillance/steps/Manual.pdf