Retraining and assessing hand movement after stroke using the MusicGlove: comparison with conventional hand therapy and isometric grip training ''Playstation eyetoy games'' improve upper extremity-related motor functioning in subacute stroke: a randomized controlled clinical trial. Effectiveness of a Wii balance board-based system (eBaViR) for balance rehabilitation: a pilot randomized clinical trial in patients with acquired brain injury Driving rehabilitation for military personnel recovering from traumatic brain injury using virtual reality driving simulation: a feasibility study. Virtual Reality–Induced Cortical Reorganization and Associated Locomotor Recovery in Chronic Stroke: An Experimenter-Blind Randomized Study Feedback-Mediated Upper Extremities Exercise: Increasing Patient Motivation in Poststroke Rehabilitation Effects of Training With a Robot-Virtual Reality System Compared With a Robot Alone on the Gait of Individuals After Stroke Does the Inclusion of Virtual Reality Games within Conventional Rehabilitation Enhance Balance Retraining after a Recent Episode of Stroke? The effects of an occupationally embedded exercise on bilaterally assisted supination in persons with hemiplegia. Effects of Training Using Video Games on the Muscle Strength, Muscle Tone, and Activities of Daily Living of Chronic Stroke Patients The Efficacy of Balance Training with Video Game-Based Therapy in Subacute Stroke Patients: A Randomized Controlled Trial Feasibility, Motivation, and Selective Motor Control: Virtual Reality Compared to Conventional Home Exercise in Children with Cerebral Palsy A checklist designed to aid consistency and reproducibility of GRADE assessments: development and pilot validation Analysis of fMRI and finger tracking training in subjects with chronic stroke. Virtual Reality Exercise Improves Mobility After Stroke: An Inpatient Randomized Controlled Trial Balance and stability-focused exercise program improves stability and balance in patients after acute stroke in a resource-poor setting. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Virtual-reality balance training with a video-game system improves dynamic balance in chronic stroke patients. Cortical reorganization and associated functional motor recovery after virtual reality in patients with chronic stroke: an experimenter-blind preliminary study. Effects of virtual reality on upper extremity function and activities of daily living performance in acute stroke: a double-blind randomized clinical trial. Virtual reality in the rehabilitation of the arm after hemiplegic stroke: a randomized controlled pilot study The Effect of Arm Support Combined With Rehabilitation Games on Upper-Extremity Function in Subacute Stroke Virtual reality for upper extremity rehabilitation in early stroke: a pilot randomized controlled trial Additional Virtual Reality Training Using Xbox Kinect in Stroke Survivors with Hemiplegia Randomized comparison trial of balance training by using exergaming and conventional weight-shift therapy in patients with chronic stroke. A study of interventions and related outcomes in a randomized controlled trial of occupational therapy and leisure therapy for community stroke patients Clinical feasibility of the Nintendo Wii™ for balance training post-stroke: a phase II randomized controlled trial in an inpatient setting Active Video-Gaming Effects on Balance and Mobility in Individuals with Chronic Stroke: A Randomized Controlled Trial Use of Virtual Reality to Enhance Balance and Ambulation in Chronic Stroke: A Double-Blind, Randomized Controlled Study A Randomized Controlled Trial of Gravity-Supported, Computer-Enhanced Arm Exercise for Individuals With Severe Hemiparesis Eliciting Upper Extremity Purposeful Movements Using Video Games Virtual reality-based therapy for the treatment of balance deficits in patients receiving inpatient rehabilitation for traumatic brain injury
Background It is thought that therapy should be functional , be highly repetitive , and promote afferent input to best stimulate h and motor recovery after stroke , yet patients struggle to access such therapy . We developed the MusicGlove , an instrumented glove that requires the user to practice gripping-like movements and thumb-finger opposition to play a highly engaging , music-based , video game . The purpose of this study was to 1 ) compare the effect of training with MusicGlove to conventional h and therapy 2 ) determine if MusicGlove training was more effective than a matched form of isometric h and movement training ; and 3 ) determine if MusicGlove game scores predict clinical outcomes . Methods 12 chronic stroke survivors with moderate hemiparesis were r and omly assigned to receive MusicGlove , isometric , and conventional h and therapy in a within-subjects design . Each subject participated in six one-hour treatment sessions three times per week for two weeks , for each training type , for a total of 18 treatment sessions . A blinded rater assessed h and impairment before and after each training type and at one-month follow-up including the Box and Blocks ( B & B ) test as the primary outcome measure . Subjects also completed the Intrinsic Motivation Inventory ( IMI ) . Results Subjects improved h and function related to grasping small objects more after MusicGlove compared to conventional training , as measured by the B & B score ( improvement of 3.21±3.82 vs. -0.29±2.27 blocks ; P=0.010 ) and the 9 Hole Peg test ( improvement of 2.14±2.98 vs. -0.85±1.29 pegs/minute ; P=0.005 ) . There was no significant difference between training types in the broader assessment batteries of h and function . Subjects benefited less from isometric therapy than MusicGlove training , but the difference was not significant ( P>0.09 ) . Subjects sustained improvements in h and function at a one month follow-up , and found the MusicGlove more motivating than the other two therapies , as measured by the IMI . MusicGlove games scores correlated strongly with the B & B score . Conclusions These results support the hypothesis that h and therapy that is engaging , incorporates high numbers of repetitions of gripping and thumb-finger opposition movements , and promotes afferent input is a promising approach to improving an individual ’s ability to manipulate small objects . The MusicGlove provides a simple way to access such therapy AIM To evaluate the effects of ' ' Playstation EyeToy Games ' ' on upper extremity motor recovery and upper extremity-related motor functioning of patients with subacute stroke . METHODS The authors design ed a r and omized , controlled , assessor-blinded , 4-week trial , with follow-up at 3 months . A total of 20 hemiparetic in patients ( mean age 61.1 years ) , all within 12 months post-stroke , received 30 minutes of treatment with ' ' Playstation EyeToy Games ' ' per day , consisting of flexion and extension of the paretic shoulder , elbow and wrist as well as abduction of the paretic shoulder or placebo therapy ( watching the games for the same duration without physical involvement into the games ) in addition to conventional program , 5 days a week , 2 - 5 hours/day for 4 weeks . Brunnstrom 's staging and self-care sub-items of the functional independence measure ( FIM ) were performed at 0 month ( baseline ) , 4 weeks ( post-treatment ) , and 3 months ( follow-up ) after the treatment . RESULTS The mean change score ( 95 % confidence interval ) of the FIM self-care score ( 5.5 [ 2.9 - 8.0 ] vs 1.8 [ 0.1 - 3.7 ] , P=0.018 ) showed significantly more improvement in the EyeToy group compared to the control group . No significant differences were found between the groups for the Brunnstrom stages for h and and upper extremity . CONCLUSION ' ' Playstation EyeToy Games ' ' combined with a conventional stroke rehabilitation program have a potential to enhance upper extremity-related motor functioning in subacute stroke patients Background Acquired brain injury ( ABI ) is the main cause of death and disability among young adults . In most cases , survivors can experience balance instability , result ing in functional impairments that are associated with diminished health-related quality of life . Traditional rehabilitation therapy may be tedious . This can reduce motivation and adherence to the treatment and thus provide a limited benefit to patients with balance disorders . We present eBaViR ( easy Balance Virtual Rehabilitation ) , a system based on the Nintendo ® Wii Balance Board ® ( WBB ) , which has been design ed by clinical therapists to improve st and ing balance in patients with ABI through motivational and adaptative exercises . We hypothesize that eBaViR , is feasible , safe and potentially effective in enhancing st and ing balance . Methods In this contribution , we present a r and omized and controlled single blinded study to assess the influence of a WBB-based virtual rehabilitation system on balance rehabilitation with ABI hemiparetic patients . This study describes the eBaViR system and evaluates its effectiveness considering 20 one-hour-sessions of virtual reality rehabilitation ( n = 9 ) versus st and ard rehabilitation ( n = 8) . Effectiveness was evaluated by means of traditional static and dynamic balance scales . Results The final sample consisted of 11 men and 6 women . Mean ± SD age was 47.3 ± 17.8 and mean ± SD chronicity was 570.9 ± 313.2 days . Patients using eBaViR had a significant improvement in static balance ( p = 0.011 in Berg Balance Scale and p = 0.011 in Anterior Reaches Test ) compared to patients who underwent traditional therapy . Regarding dynamic balance , the results showed significant improvement over time in all these measures , but no significant group effect or group-by-time interaction was detected for any of them , which suggests that both groups improved in the same way . There were no serious adverse events during treatment in either group . Conclusions The results suggest that eBaViR represents a safe and effective alternative to traditional treatment to improve static balance in the ABI population . These results have encouraged us to reinforce the virtual treatment with new exercises , so an evolution of the system is currently being developed OBJECTIVE To investigate the feasibility of virtual reality driving simulation rehabilitation training ( VRDSRT ) with military personnel recovering from traumatic brain injury ( TBI ) . METHODS Eleven men with TBI were r and omly assigned as controls ( n = 5 ) receiving residential rehabilitation only or the VRDSRT group ( n = 6 ) receiving residential rehabilitation and VRDSRT . All subjects underwent pre- and post- assessment s including simulator driving , and completing road rage and risky driving question naires . Between assessment s , VRDSRT subjects received 4 - 6 , 60- to 90-min rehabilitation training sessions involving practicing progressively more complex driving skills ( lane position , speed control , etc . ) through progressively more dem and ing traffic . RESULTS VRDSRT was well received , considered realistic and effective , with no reported simulation sickness . Driving performance improved significantly in the VRDSRT group only ( p < 0.01 ) . They also demonstrated a reduction in road rage ( p = 0.01 ) and risky driving ( p = 0.04 ) at post- assessment . CONCLUSION VRDSRT showed promising results with respect to retraining driving performance and behavior among military personnel recovering from TBI Background and Purpose — Virtual reality ( VR ) is a new promising computer-assisted technology to promote motor recovery in stroke patients .  VR-induced neuroplasticity supporting locomotor recovery is not known . We investigated the effects of VR intervention on cortical reorganization and associated locomotor recovery in stroke patients . Methods — Ten chronic stroke patients were assigned r and omly to either the control group or the  VR  group . VR was design ed to provide interactive real-life practice environments in which practice parameters can be individualized to optimize motor relearning . Laterality index ( LI ) in the regions of interests ( ROIs ) and locomotor recovery were measured before and after VR using functional MRI ( fMRI ) and st and ardized locomotor tests , respectively . The t test and nonparametric test were performed to compare the mean differences at P<0.05 . Results — There was a significant difference in the interval change in the LI score for the primary sensorimotor cortex ( SMC ) between the groups ( P<0.05 ) , indicating that VR practice produced a greater increase in LI for the control group . However , the interval changes in the other ROIs were not significantly different ( P>0.05 ) . Motor function was significantly improved after VR ( P<0.05 ) . Conclusions — Our novel findings suggest that VR could induce cortical reorganization from aberrant ipsilateral to contralateral SMC activation . This enhanced cortical reorganization might play an important role in recovery of locomotor function in patients with chronic stroke . This is the first fMRI study in the literature that provides evidence for neuroplasticity and associated locomotor recovery after VR Purpose . This proof-of-concept study investigated whether feedback-mediated exercise ( FME ) of the affected arm of hemiplegic patients increases patient motivation and promotes greater improvement of motor function , compared to no-feedback exercise ( NFE ) . Method . We developed a feedback-mediated treatment that uses gaming scenarios and allows online and offline monitoring of both temporal and spatial characteristics of planar movements . Twenty poststroke hemiplegic in patients , r and omly assigned to the FME and NFE group , received therapy five days a week for three weeks . The outcome measures were evaluated from the following : ( 1 ) the modified drawing test ( mDT ) , ( 2 ) received therapy time — RTT , and ( 3 ) intrinsic motivation inventory — IMI . Results . The FME group patients showed significantly higher improvement in the speed metric ( P < 0.01 ) , and smoothness metric ( P < 0.01 ) , as well as higher RTT ( P < 0.01 ) . Significantly higher patient motivation is observed in the FME group ( interest/enjoyment subscale ( P < 0.01 ) and perceived competence subscale ( P < 0.01 ) ) . Conclusion . Prolonged endurance in training and greater improvement in certain areas of motor function , as well as very high patient motivation and strong positive impressions about the treatment , suggest the positive effects of feedback-mediated treatment and its high level of acceptance by patients Background and Purpose — Training of the lower extremity ( LE ) using a robot coupled with virtual environments has shown to transfer to improved overground locomotion . The purpose of this study was to determine whether the transfer of training of LE movements to locomotion was greater using a virtual environment coupled with a robot or with the robot alone . Methods — A single , blind , r and omized clinical trial was conducted . Eighteen individuals poststroke participated in a 4-week training protocol . One group trained with the robot virtual reality ( VR ) system and the other group trained with the robot alone . Outcome measures were temporal features of gait measured in a laboratory setting and the community . Results — Greater changes in velocity and distance walked were demonstrated for the group trained with the robotic device coupled with the VR than training with the robot alone . Similarly , significantly greater improvements in the distance walked and number of steps taken in the community were measured for the group that trained with robot coupled with the VR . These differences were maintained at 3 months ’ follow-up . Conclusions — The study is the first to demonstrate that LE training of individuals with chronic hemiparesis using a robotic device coupled with VR improved walking ability in the laboratory and the community better than robot training alone This r and omised controlled and double-blinded pilot study evaluated if interactive virtual reality balance related games integrated within conventional rehabilitation sessions result ed in more superior retraining of dynamic balance compared to CR after stroke . 19 subjects diagnosed with a recent episode of stroke were recruited from a local rehabilitation hospital and r and omly assigned to either a control or an experimental group . Subjects in the control groups underwent 60 minutes of conventional rehabilitation while those in the experimental groups underwent 40 minutes of convention rehabilitation and 20 minutes of self-directed virtual reality balanced rehabilitation .  Functional Reach Test , Timed Up and Go , Modified Barthel Index , Berg Balance Scale , and Centre of Pressure of subjects in both groups were evaluated before and on completion of the rehabilitation sessions . Results indicate that the inclusion of interactive virtual reality balance related games within conventional rehabilitation can lead to improved functional mobility and balance after a recent episode of stroke without increasing treatment time that requires more health professional manpower OBJECTIVES Occupationally embedded exercise is a central idea in the profession of occupational therapy . This experiment compared the effect of an occupationally embedded exercise involving a simple dice game with a rote exercise in persons with stroke with pronator spasticity . Both exercise conditions involved bilaterally assisted supination , consistent with the neurodevelopmental model of practice . METHODS The sample consisted of 14 men and 12 women post-cerebrovascular accident with a mean age of 68.4 years ( SD = 11.2 ) at six clinical sites in California , Texas , and Michigan . Subjects had pronator spasticity , full passive range for supination after a brief warm-up , and no functional supination . After r and om assignment for experimental condition , the subjects engaged in two sets of 10 repetitions of bilaterally assisted supination in either the occupationally embedded condition ( dice game ) or the rote condition ( no game ) . A pen recorder electronically documented degrees of rotation of the h and le that was grasped during the exercise . RESULTS The occupationally embedded exercise result ed in significantly more h and le rotation ( requiring more supination ) than the rote exercise , t ( 24 ) = 2.28 , p ( one tailed ) < .05 . The effect size was large . CONCLUSION This study advances the experimental analysis of therapeutic occupation in the area of occupationally embedded exercise . Clinicians are urged to consider the multidimensional nature of occupationally embedded exercise [ Purpose ] The purpose of this study was to investigate the effects of training using video games played on the Xbox Kinect on the muscle strength , muscle tone , and activities of daily living of post-stroke patients . [ Subjects ] Fourteen stroke patients were recruited . They were r and omly allocated into two groups ; the experimental group ( n=7 ) and the control group ( n=7 ) . [ Methods ] The experimental group performed training using video games played on the Xbox Kinect together with conventional occupational therapy for 6 weeks ( 1 hour/day , 3 days/week ) , and the control group received conventional occupational therapy only for 6 weeks ( 30 min/day , 3 days/week ) . Before and after the intervention , the participants were measured for muscle strength , muscle tone , and performance of activities of daily living . [ Results ] There were significant differences pre- and post-test in muscle strength of the upper extremities , except the wrist , and performance of activities of daily living in the experimental group . There were no significant differences between the two groups at post-test . [ Conclusion ] The training using video games played on the Xbox Kinect had a positive effect on the motor function and performance of activities of daily living . This study showed that training using video games played on the Xbox Kinect may be an effective intervention for the rehabilitation of stroke patients The video game-based therapy emerged as a potential valid tool in improving balance in several neurological conditions with controversial results , whereas little information is available regarding the use of this therapy in subacute stroke patients . The aim of this study was to investigate the efficacy of balance training using video game-based intervention on functional balance and disability in individuals with hemiparesis due to stroke in subacute phase . Fifty adult stroke patients participated to the study : 25 subjects were r and omly assigned to balance training with Wii Fit , and the other 25 subjects were assigned to usual balance therapy . Both groups were also treated with conventional physical therapy ( 40 min 2 times/day ) . The main outcome was functional balance ( Berg Balance Scale-BBS ) , and secondary outcomes were disability ( Barthel Index-BI ) , walking ability ( Functional Ambulation Category ) , and walking speed ( 10-meters walking test ) .  Wii Fit training was more effective than usual balance therapy in improving balance ( BBS : 53 versus 48 , P = 0.004 ) and independency in activity of daily living ( BI : 98 versus 93 , P = 0.021 ) . A balance training performed with a Wii Fit as an add on to the conventional therapy was found to be more effective than conventional therapy alone in improving balance and reducing disability in patients with subacute stroke Children with cerebral palsy ( CP ) have difficulty controlling and coordinating voluntary muscle , which results in poor selective control of muscle activity . Children with spastic CP completed ankle selective motor control exercises using a virtual reality ( VR ) exercise system and conventional ( Conv ) exercises . Ankle movements were recorded with an electrogoniometer .  Children and their parents were asked to comment on their interest in the exercise programs . Greater fun and enjoyment were expressed during the VR exercises .  Children completed more repetitions of the Conv exercises , but the range of motion and hold time in the stretched position were greater during VR exercises . These data suggest that using VR to elicit or guide exercise may improve exercise compliance and enhance exercise effectiveness Background The grading of recommendation , assessment , development and evaluation ( GRADE ) approach is widely implemented in health technology assessment and guideline development organisations throughout the world . GRADE provides a transparent approach to reaching judgements about the quality of evidence on the effects of a health care intervention , but is complex and therefore challenging to apply in a consistent manner . Methods We developed a checklist to guide the research er to extract the data required to make a GRADE assessment . We applied the checklist to 29 meta-analyses of r and omised controlled trials on the effectiveness of health care interventions . Two review ers used the checklist for each paper and used these data to rate the quality of evidence for a particular outcome . Results For most ( 70 % ) checklist items , there was good agreement between review ers . The main problems were for items relating to indirectness where considerable judgement is required . Conclusions There was consistent agreement between review ers on most items in the checklist . The use of this checklist may be an aid to improving the consistency and reproducibility of GRADE assessment s , particularly for inexperienced users or in rapid review s without the re sources to conduct assessment s by two research ers independently H and movement recovery and cortical reorganization were studied in 10 subjects with chronic stroke using  functional MRI ( fMRI ) before and after training with an intensive finger movement tracking programme . Subjects were assigned r and omly to a treatment or control group . The treatment group received 18 - 20 sessions of finger tracking training using target waveforms under variable conditions . The control group crossed over to receive the same treatment after the control period . For comparison with a healthy population , nine well elderly females were also studied ; however , the well elderly controls did not cross over after the control period . The dependent variables consisted of a Box and Block score to measure prehensile ability ( subjects with stroke only ) , a tracking accuracy score and quantification of active cortical areas using fMRI . For the tracking tests , the subjects tracked a sine wave target on a computer screen with extension and flexion movements of the paretic index finger . Functional brain images were collected from the frontal and parietal lobes of the subject with a 4 tesla magnet . Areas of interest included the sensorimotor cortex ( SMC ) , primary motor area ( M1 ) , primary sensory area ( S1 ) , premotor cortex ( PMC ) and supplementary motor area ( SMA ) . Comparison between all subjects with stroke and all well elderly subjects at pre-test was analysed with two- sample t-tests . Change from pre-test to post-test within subjects was analysed with paired t-tests . Statistical significance was set at P < 0.05 . Stroke treatment subjects demonstrated significant improvement in tracking accuracy , whereas stroke control subjects did not until after crossover treatment . At pre-test , the cortical activation in the subjects with stroke was predominantly ipsilateral to the performing h and , whereas in the well elderly subjects it was contralateral . Activation for the stroke treatment group following training switched to contralateral in SMC , M1 , S1 and PMC . The stroke control group 's activation remained ipsilateral after the control period , but switched to contralateral after crossover to receive treatment . All well elderly subjects maintained predominantly contralateral activation throughout . Transfer of skill to functional activity was shown in significantly improved Box and Block scores for the stroke treatment group , with no such improvement in the stroke control group until after crossover . We concluded that individuals with chronic stroke receiving intensive tracking training showed improved tracking accuracy and grasp and release function , and that these improvements were accompanied by brain reorganization Background and Purpose — Exercise using virtual reality ( VR ) has improved balance in adults with traumatic brain injury and community-dwelling older adults . Rigorous r and omized studies regarding its efficacy , safety , and applicability with individuals after stroke are lacking . The purpose of this study was to determine whether an adjunct VR therapy improves balance , mobility , and gait in stroke rehabilitation in patients . Methods — A blinded r and omized controlled trial study ing 59 stroke survivors on an inpatient stroke rehabilitation unit was performed . The treatment group ( n=30 ) received st and ard stroke rehabilitation therapy plus a program of VR exercises that challenged balance ( eg , soccer goal tending , snowboarding ) performed while st and ing . The control group ( n=29 ) received st and ard stroke rehabilitation therapy plus exposure to identical VR environments but whose games did not challenge balance ( performed in sitting ) . VR training consisted of 10 to 12 thirty-minute daily sessions for a 3-week period . Objective outcome measures of balance and mobility were assessed before , immediately after , and 1 month after training . Results — Confidence intervals and effect sizes favored the treatment group on the Timed Up and Go and the Two-Minute Walk Test , with both groups meeting minimal clinical important differences after training . More individuals in the treatment group than in the control group showed reduced impairment in the lower extremity as measured by the Chedoke McMaster Leg domain ( P=0.04 ) immediately after training . Conclusions — This VR exercise intervention for inpatient stroke rehabilitation improved mobility-related outcomes . Future studies could include nonambulatory participants as well as the implementation strategies for the clinical use of VR . Clinical Trial Registration — URL : http://www.ANZCTR.org.au/. Unique identifier : ACTRN12613000710729 OBJECTIVE To compare the effect of a balance and stability-focused outpatient community-based rehabilitation and a regular physiotherapy program on balance , stability , and perceptions of improvement  after acute stroke . DESIGN A r and omized controlled trial in a community-based therapy center . PARTICIPANTS Fifty consecutive patients with a first stroke , who reported to a community-based therapy center over a 7-month period were allocated to the control group ( regular physiotherapy ) or the experimental group ( balance and stability-focused rehabilitation ) . INTERVENTION A program of physiotherapy focused on balance and stability exercises . The control group received the regular physiotherapy program . MAIN OUTCOME MEASUREMENTS The Postural Assessment Scale for Stroke Patients ( PASS ) and the Berg Balance Scale ( BBS ) monitored stability and balance . The normalized data ( PASS and BBS ) were analyzed by using analysis of covariance . Qualitative data were thematically described . RESULTS Internal consistency of baseline PASS and BBS scores was high ( Cronbach α , .964 and .974 , respectively ) . PASS overall pretest scores increased from 21.96 ± 21.41 ( mean ± st and ard deviation ) and 21.52 ± 8.43 to 67.67 ± 28.42 and 80.16 ± 22.60 posttest in the control and experimental groups , respectively . Posttest scores were significantly different ( P = .004 ) . The effect size was medium ( .490 ) . The overall BBS scores showed overall mean ( st and ard deviation ) increases from 44.71 ± 22.24 and 43.43 ± 17.11 pretest to 48.71 ± 23.18 and 59.71 ± 18.20 posttest for the control and experimental groups , respectively . The effect size was considered medium ( .532 ) . CONCLUSION The balance and stability-focused community-based rehabilitation program was more effective in improving stability and balance in patients with stroke compared with the regular physiotherapy program in re source -poor setting OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity Stroke is one of the most serious healthcare problems and a major cause of impairment of cognition and physical functions . Virtual rehabilitation approaches to postural control have been used for enhancing functional recovery that may lead to a decrease in the risk of falling . In the present study , we investigated the effects of virtual reality balance training ( VRBT ) with a balance board game system on balance of chronic stroke patients . Participants were r and omly assigned to 2 groups : VRBT group ( 11 subjects including 3 women , 65.26 years old ) and control group ( 11 subjects including 5 women , 63.13 years old ) . Both groups participated in a st and ard rehabilitation program ( physical and occupational therapy ) for 60 min a day , 5 times a week for 6 weeks . In addition , the VRBT group participated in VRBT for 30 min a day , 3 times a week for 6 weeks . Static balance ( postural sway velocity with eyes open or closed ) was evaluated with the posturography . Dynamic balance was evaluated with the Berg Balance Scale ( BBS ) and Timed Up and Go test ( TUG ) that measures balance and mobility in dynamic balance . There was greater improvement on BBS ( 4.00 vs. 2.81 scores ) and TUG ( -1.33 vs. -0.52 sec ) in the VRBT group compared with the control group ( P < 0.05 ) , but not on static balance in both groups . In conclusion , we demonstrate a significant improvement in dynamic balance in chronic stroke patients with VRBT . VRBT is feasible and suitable for chronic stroke patients with balance deficit in clinical setting OBJECTIVE To investigate the effects of virtual reality ( VR ) on cortical reorganization and motor recovery . DESIGN Nonparametric pre- and posttest design with experimenter blinded . SETTING University medical center . PARTICIPANTS Five patients with hemiparesis ( age , 59.8+/-3.4y ) were recruited . INTERVENTION Five patients received VR for 60 minutes a day , 5 times a week for 4 weeks . VR was design ed to provide a virtual rehabilitation scene where the intensity of practice and sensory feedback could be systematic ally manipulated to provide the most appropriate , individualized motor retraining program . MAIN OUTCOME MEASURES Cortical activation and associated motor recovery were measured before and after VR using functional magnetic resonance imaging and st and ardized motor tests , respectively . Nonparametric tests were used at P less than .05 . RESULTS Prior to VR , the bilateral primary sensorimotor cortices ( SM1s ) , contralesional premotor cortex , and contralesional or ipsilesional supplementary motor area were activated . After VR , the altered activations disappeared and predominantly the ipsilesional SM1 was activated ( P<.05 ) . Motor function was improved ( P<.05 ) . CONCLUSIONS This is a novel demonstration of  VR-induced neuroplastic changes and associated motor recovery in chronic stroke AIM To examine the effects of conventional therapy ( CT ) combined with intensive virtual reality ( VR ) program on upper extremity function and activities of daily living ( ADL ) in individuals in the acute stage of stroke . METHOD Twenty-six individuals were r and omly assigned to the control or experimental group . The control group received CT , while the experimental group received VR training in addition to CT on same day . The Fugl-Meyer Assessment ( FMA ) and the Manual Function Test ( MFT ) were used to measure improvement of functioning in the affected limb and the Korean version of the Modified Barthel Index ( K-MBI ) was conducted to evaluate ADL . RESULT In tests of upper extremity functioning , VR group showed significant improvement on FMA and MFT ( p < 0.05 ) . In the CT group , only FMA score showed significant change ( p < 0.05 ) . ADL performance improved significantly in both groups ( p < 0.05 ) . However , there were no significant differences between the two groups in upper extremity function and ADL performance ( p > 0.05 ) . CONCLUSION This study observed that VR training has the advantage of improving intended arm function during intensive training for individuals in the acute stage of stroke Objective : To assess the feasibility of a trial to investigate the effectiveness of virtual reality-mediated therapy compared to conventional physiotherapy in the motor rehabilitation of the arm following stroke , and to provide data for a power analysis to determine numbers for a future main trial . Design : Pilot r and omized controlled trial . Setting : Clinical research facility . Participants : Eighteen people with a first stroke , 10 males and 8 females , 7 right and 2 left side most affected . Mean time since stroke 10.8 months . Interventions : Participants were r and omized to a virtual reality group or a conventional arm therapy group for nine sessions over three weeks . Main measures : The upper limb Motricity Index and the Action Research Arm Test were completed at baseline , post intervention and six weeks follow-up . Results : Outcome data were obtained from 95 % of participants at the end of treatment and at follow-up : one participant withdrew . Compliance was high ; only two people reported side-effects from virtual reality exposure . Both groups demonstrated small ( 7–8 points on upper limb Motricity Index and 4 points on the Action Research Arm Test ) , but non-significant , changes to their arm impairment and activity levels . Conclusion : A r and omized controlled trial of virtual reality-mediated therapy comparable to conventional therapy would be feasible , with some suggested improvements in recruitment and outcome measures . Seventy-eight participants ( 39 per group ) would be required for a main trial Background . Use of rehabilitation technology , such as (electro)mechanical devices or robotics , could partly relieve the increasing strain on stroke rehabilitation caused by an increasing prevalence of stroke . Arm support ( AS ) training showed improvement of unsupported arm function in chronic stroke . Objective . To examine the effect of weight-supported arm training combined with computerized exercises on arm function and capacity , compared with dose-matched conventional reach training in subacute stroke patients . Methods . In a single-blind , multicenter , r and omized controlled trial , 70 subacute stroke patients received 6 weeks of training with either an AS device combined with computerized exercises or dose-matched conventional training ( CON ) .  Arm function was evaluated pretraining and posttraining by Fugl-Meyer assessment ( FM ) , maximal reach distance , Stroke Upper Limb Capacity Scale ( SULCS ) , and arm pain via Visual Analogue Scale , in addition to perceived motivation by Intrinsic Motivation Inventory posttraining . Results . FM and SULCS scores and reach distance improved significantly within both groups . These improvements and experienced pain did not differ between groups . The AS group reported higher interest/enjoyment during training than the CON group . Conclusions . AS training with computerized exercises is as effective as conventional therapy dedicated to the arm to improve arm function and activity in subacute stroke rehabilitation , when applied at the same dose Objectives : To investigate the effect of virtual reality ( VR ) rehabilitation on upper extremity motor performance of patients with early stroke . Design : Pilot r and omized controlled trial . Setting : Rehabilitation wards . Participants : Twenty three adults with stroke ( mean age ( SD ) = 58.35 ( 13.45 ) years and mean time since stroke ( SD ) = 16.30 ( 7.44 ) days ) . Interventions : Participants were r and omly assigned to VR group ( n=11 ) or control group ( n=12 ) . VR group received nine 30 minutes upper extremity VR therapy in st and ing ( five weekdays in two weeks ) plus conventional therapy , which included physical and occupational therapy . Control group received only conventional therapy , which was comparable to total training time received by VR group ( mean training hours (SD):VR = 17.07 ( 2.86 ) ; control = 15.50 ( 2.79 ) ) . Main outcome measures : The main outcome measure was the Fugl-Meyer Assessment ( FMA ) . Secondary outcomes included Action Research Arm Test , Motor Activity Log and Functional Independence Measure . Results were taken at baseline , post intervention and 1-month post intervention . Participants ’ feedback and adverse effects were recorded . Results : All participants improved in FMA scores ( mean change ( SD ) = 11.65 ( 8.56 ) , P<.001 ) . These effects were sustained at one month after intervention ( mean ( SD ) change from baseline = 18.67 ( 13.26 ) , P<.001 ) . All other outcome measures showed similar patterns . There were no significant differences in improvement between both groups . Majority of the participants found VR training  useful and enjoyable , with no serious adverse effects reported . Conclusion : Although additional VR training was not superior to conventional therapy alone , this study demonstrates the feasibility of VR training in early stroke Objective The aim of this study was to investigate the effects of additional virtual reality training using Xbox Kinect on upper extremity function , including range of motion , motor function , and gross manual dexterity , in stroke survivors with hemiplegia . Design This study is a r and omized controlled trial . Forty participants were r and omly allocated to either the experimental or control groups ; the experimental group ( n = 20 ) underwent virtual reality training using Xbox Kinect and conventional occupational therapy , and the control group ( n = 20 ) underwent conventional occupational therapy alone . The mean time since the onset of stroke was 7.22 mos in the experimental group and 8.47 mos in the control group . At baseline and after 6 wks of intervention , range of motion of the upper extremity was measured , and the Fugl-Meyer Assessment and the Box and Block Test were performed . Results After intervention , significant improvements from baseline values in range of motion of the upper extremity , Fugl-Meyer Assessment scores , and Box and Block Test scores were observed in the experimental and control groups ( P < 0.05 ) . At follow-up , there were significant differences between the two groups in range of motion ( except for the wrist ) , Fugl-Meyer Assessment scores , and Box and Block Test scores ( P < 0.05 ) . Conclusions The hemiplegic stroke survivors who received additional virtual reality training using Xbox Kinect showed significantly improved function of the upper extremity . However , the effects of the virtual reality training using Xbox Kinect may have been a result of the greater total intervention time in the training group compared with the control group . Thus , the potential efficacy of Xbox Kinect in the rehabilitation of post-stroke survivors needs to be investigated in greater depth OBJECTIVE To compare the effects of exergaming with conventional weight-shift training on balance function in patients with chronic stroke . DESIGN Single-blind r and omized controlled trial . SETTING Medical center . PARTICIPANTS Patients ( N=30 ) with chronic stroke and balance deficits . INTERVENTIONS Twelve weeks of Wii Fit training or conventional weight-shift training . MAIN OUTCOME MEASURES Static balance was assessed using posturography . We recorded the stability index and percentage of weight bearing on the affected leg in 8 positions . We also used the timed Up and Go and forward reach tests for dynamic balance evaluation , Falls Efficacy Scale-International for fear of falling assessment , and Physical Activity Enjoyment Scale for estimating the enjoyment of training . RESULTS The exergaming group showed more improvement in stability index than the control group in head straight with eyes open while st and ing on a foam surface , eyes closed while st and ing on a solid surface with head turned 30 ° to the left , and eyes closed while st and ing on a solid surface with head turned up positions ( time-group interaction P=.02 , .04 , and .03 , respectively ) ; however , the effects were not maintained . At 3-month follow-up , the control group showed more improvement in weight-bearing symmetry in the head straight with eyes open while st and ing on a solid surface position than the exergaming group ( time-group interaction P=.03 ) . Both groups showed improvement in the timed Up and Go test , forward reach test , and fear of falling . The improvement in fear of falling was not maintained . The exergaming group enjoyed training more than the control group ( P=.03 ) . CONCLUSIONS Exergaming is enjoyable and effective for patients with chronic stroke Objective : To undertake a detailed analysis of therapy provided in a multicentred r and omized controlled trial of activities of daily living ( ADL ) and leisure ( TOTAL ) , testing the hypothesis that specific interventions given in the trial affected specific aspects of outcome . Subjects : Three hundred and nine stroke patients who had been r and omly allocated to receive either occupational therapy aim ed at ADL activities ( n = 156 ) or leisure ( n = 153 ) . Measures : Number , duration and type of activity undertaken per patient . Barthel Index , Extended Activities of Daily Living Scale ( EADL ) and Nottingham Leisure Question naire ( NLQ ) six months after entry to the study . Method : Activities that had been used in treatment were coded and categorized . Frequently used activities identified . These activities were matched to items from the six-month outcome measures . Patient independence in these outcome items was compared between the leisure and ADL groups . Results : Three hundred and nine therapy record forms were returned . Patients received a median of ten sessions with a median duration of 55 minutes . The ADL group received significantly more , mobility training , transfer training , cleaning , dressing , cooking and bathing training ( chi-squared , p < 0.05 ) . Sport , creative activities , games , hobbies , gardening , entertainment and shopping were used significantly more in the leisure group ( chi-squared , p < 0.05 ) than the ADL group . Fifteen items from the outcome measures were identified as specific to these interventions . There were no statistically significant differences in outcome on these 15 items between the ADL and leisure groups ( chi-squared , p > 0.05 ) . Conclusions : We found no evidence that specific ADL or leisure interventions led to improvements in specific relevant outcomes . We believe that these findings should prompt a review of the relationship between process and outcome of occupational therapy Objective : To investigate the feasibility and potential efficacy of the Nintendo Wii ™ for balance rehabilitation after stroke . Design : Phase II , single-blind , r and omized controlled trial . Setting : Inpatient rehabilitation facility . Subjects : Thirty adults ( mean age 63.6 ( 14.7 ) years ) undergoing inpatient rehabilitation who were less than three months post-stroke and able to st and unsupported . Interventions : Participants were allocated to a Balance Group , using the ‘ Wii Fit Plus ’ in st and ing , or Upper Limb Group , using the ‘ Wii Sports/Sports Resort ’ in sitting . Both groups undertook three 45 minute sessions per week over two to four weeks in addition to st and ard care . Main measures : The primary focus was feasibility , addressed by recruitment , retention , adherence , acceptability and safety . Efficacy was evaluated by balance , mobility and upper limb outcomes . Results : Twenty-one percent of individuals screened were recruited and 86 % ( n = 30 ) of eligible people agreed to participate . Study retention and session adherence was 90 % and > 99 % , respectively , at two weeks ; dropping to 70 % and 87 % at four weeks due to early discharge . All participants reported enjoying the sessions and most felt they were beneficial . No major adverse events occurred . Wii use by the Balance Group was associated with trends for improved balance , with significantly greater improvement in outcomes including the Step Test and Wii Balance Board-derived centre of pressure scores . The Upper Limb Group had larger , non-significant changes in arm function . Conclusions : A Wii-based approach appears feasible and promising for post-stroke balance rehabilitation . A larger r and omized controlled trial is recommended to further investigate efficacy Abstract Background : Treatments that provide feedback , increase practice with multiple repetitions , and motivate patients are essential to rehabilitation post stroke . Objective : To determine whether playing active video games results in improved balance and mobility post stroke . Methods : Thirty participants with chronic ( time since stroke = 3.0 [ 2.9 ] years ) hemiparesis post stroke were r and omly assigned to a gaming group or normal activity control group . Gaming systems provided participants with an interactive interface of real-time movement of either themselves or an avatar on the screen . Participants played games 50–60 minutes/day , 4 days/week , for 5 weeks . The intervention was strictly game-play , in st and ing position , without physical therapy . The control group received no special intervention and continued with normal activity . Both groups were tested prior to , following the 5 weeks ( post test ) , and 3 months following the completion of the study . Outcome measures included the Fugl-Meyer Assessment , Berg Balance Scale , Dynamic Gait Index , Timed Up & Go , 6-minute walk test , 3-meter walk ( self-selected and fast ) , and perception of recovery . Results : No statistically significant differences between or within groups were found through analysis of covariance ( covaried for side of hemiparesis ) at post test or follow-up . Although the within-group effect sizes were primarily indexed as “ small ” ( < .36 ) , the gaming group exhibited higher within-group effect sizes before and after testing than did the control group on all 7 dependent variables analyzed . Conclusions : Even though the only intervention was game-play , there were small positive effects . Therapist assistance in making more optimum movement choices may be needed before significant improvements are seen with commercially available , general purpose games Kim JH , Jang SH , Kim CS , Jung JH , You JH : Use of virtual reality to enhance balance and ambulation in chronic stroke : A double-blind , r and omized controlled study . Objective : To examine an additive effect of virtual reality on balance and gait function in patients with chronic hemiparetic stroke . Design : Twenty-four adults with hemiparetic stroke were r and omly assigned to either an experimental group ( n = 12 ) or a control group . Both groups underwent conventional physical therapy , 40 mins a day , 4 days a week for 4 wks . The experimental group received an additional 30 mins of virtual reality therapy each session . Balance performance was determined by the Balance Performance Monitor and Berg Balance Scale tests . Gait performance was determined by the 10-m walking test and Modified Motor Assessment Scale , and spatiotemporal parameters were obtained using GAITRite . Analysis of variance and correlation statistics were performed at P < 0.05 . Results : In the balance test , the experimental group had improved Berg Balance Scale scores , balance and dynamic balance angles ( ability to control weight shifting ) compared with the controls ( P < 0.05 ) . In the gait performance test , the experimental group showed significant improvements in velocity , Modified Motor Assessment Scale scores , cadence , step time , step length , and stride length ( P < 0.05 ) . Improvement in dynamic balance angles was correlated with velocity and cadence ( P < 0.01 ) . Conclusions : This study demonstrates that virtual reality has an augmented effect on balance and associated locomotor recovery in adults with hemiparetic stroke when added to conventional therapy Background / Objective . The authors previously developed a passive instrumented arm orthosis ( Therapy Wilmington Robotic Exoskeleton [ T-WREX ] ) that enables individuals with hemiparesis to exercise the arm by playing computer games in a gravity-supported environment . The purpose of this study was to compare semiautonomous training with T-WREX and conventional semiautonomous exercises that used a tabletop for gravity support . Methods . Twenty-eight chronic stroke survivors with moderate/severe hemiparesis were r and omly assigned to experimental ( T-WREX ) or control ( tabletop exercise ) treatment . A blinded rater assessed arm movement before and after twenty-four 1-hour treatment sessions and at 6-month follow-up . Subjects also rated subjective treatment preferences after a single-session crossover treatment . Results . All subjects significantly improved ( P ≤ .05 ) upper extremity motor control ( Fugl-Meyer ) , active reaching range of motion ( ROM ) , and self-reported quality and amount of arm use ( Motor Activity Log ) . Improvements were sustained at 6 months . The T-WREX group maintained gains on the Fugl-Meyer significantly better than controls at 6 months ( improvement of 3.6 ± 3.9 vs 1.5 ± 2.7 points , mean ± SD ; P = .04 ) . Subjects also reported a preference for T-WREX training . Conclusion . Gravity-supported arm exercise , using the T-WREX or tabletop support , can improve arm movement ability after chronic severe hemiparesis with brief one-on-one assistance from a therapist ( approximately 4 minutes per session ) . The 3-dimensional weight support , instant visual movement feedback , and simple virtual reality software provided by T-WREX were associated with modest sustained gains at 6-month follow-up when compared with the conventional approach Background . Video games have become popular in stroke rehabilitation ; however , the nature of this intervention is not fully understood . Objectives . To compare the number of ( a ) purpose ful and non purpose ful repetitions of the weaker upper extremity ( UE ) and ( b ) movement accelerations as assessed by accelerometer activity counts of the weaker and stronger UEs of individuals with chronic stroke while playing video games or participating in traditional therapy .  Methods . Twenty-nine individuals ( mean age 59 years , 1 - 7 years poststroke ) took part in a group intervention of  video -games ( n = 15 ) or traditional therapy ( n = 14 ) as part of a r and omized controlled trial . During 1 - 2 sessions , participants were video-taped while wearing wrist accelerometers . Assessors counted the number of repetitions and classified movements as purpose ful or non purpose ful using videotapes . The weaker UE motor impairments were correlated to movement accelerations , to determine if participants were using their potential during the sessions . Results . Participants in the video game group performed a median of 271 purpose ful movements and 37 970 activity counts compared to 48 purpose ful movements and 14 872 activity counts in the traditional group ( z = −3.0 , P = .001 and z = −1.9 , P = .05 , respectively ) . Participants in the traditional group performed a median of 26 non purpose ful ( exercises ) compared with 0 in the video game group ( z = −4.2 , P = .000 ) . Strong significant correlations were found between the motor ability of the weak UE to repetitions of participants in both groups ( r = .86 , P < .01 ) . Participants with higher motor ability performed more repetitions .  Conclusions . Video games elicited more UE purpose ful repetitions and higher acceleration of movement compared with traditional therapy in individuals with chronic stroke Abstract Objective : To evaluate the feasibility and safety of utilizing a commercially available virtual reality gaming system as a treatment intervention for balance training . Design : A r and omized controlled trial in which assessment and analysis were blinded . Setting : An inpatient rehabilitation facility . Intervention : Interventions included balance-based physical therapy using a Nintendo Wii , as monitored by a physical therapist , and receipt of one-on-one balance-based physical therapy using st and ard physical therapy modalities available for use in the therapy gym . Results : Participants in the st and ard physical therapy group were found to have slightly higher enjoyment at mid-intervention , while those receiving the virtual reality-based balance intervention were found to have higher enjoyment at study completion . Both groups demonstrated improved static and dynamic balance over the course of the study , with no significant differences between groups . Correlational analyses suggest a relationship exists between Wii balance board game scores and BBS scores for measures taken beyond the baseline assessment . Conclusions : This study provides a modest level of evidence to support using commercially available VR gaming systems for the treatment of balance deficits in patients with a primary diagnosis of TBI receiving inpatient rehabilitation . Additional research of these types of interventions for the treatment of balance deficits is warranted
Objective : To undertake a systematic review and meta- analysis of the effectiveness of play-based interventions compared to traditional therapy in rehabilitation of adults with adult-acquired brain injury .