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Standards of Virtual Reality Application in Balance Training Programs in Clinical

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Article · September 2018

DOI: 10.1089/g4h.2018.0034

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 GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications
Volume 8, Number 2, 2019 Review
ª Mary Ann Liebert, Inc.
DOI: 10.1089/g4h.2018.0034

Standards of Virtual Reality Application

in Balance Training Programs in Clinical Practice:
A Systematic Review

Grzegorz Juras, PhD,1 Anna Brachman, MSc, PT,1 Justyna Michalska, MSc, PT,1
Anna Kamieniarz, MSc, PT,1 Michał Pawłowski, MSc,1 Anna Hadamus, PhD, PT,2
Dariusz Białoszewski, PhD, MD,2 Janusz Błaszczyk, PhD,1 and Kajetan J. Słomka, PhD1
Downloaded by 79.191.142.232 from www.liebertpub.com at 10/02/18. For personal use only.

Abstract

Objective: To determine the effect of virtual reality (VR) games on improving balance in different groups of
neurological patients with a particular focus on the study quality and to determine the gold standard in VR
training in these groups.
Materials and Methods: A systematic review of controlled trials published between January 2009 and
December 2017 was conducted. The PubMed, SCOPUS, SPORTDiscus, and Medline databases were searched.
Studies involved patients with stroke or Parkinson’s disease or children with cerebral palsy. The Physiotherapy
Evidence Database (PEDro) scale was used to assess the methodological quality of the included studies.
Results: A total of 20 studies met the inclusion criteria. The PEDro scores ranged from 4 to 8 points. Analysis
of the rehabilitation programs revealed a very large discrepancy in the planned volume of exercises in different
subgroups of patients.
Conclusions: Overall, the comparison of VR interventions between conventional rehabilitation and no inter-
vention exhibited significantly better results. However, these results should be interpreted with great caution due
to the large diversity of the systems, games, and training volume used in the VR therapy. In all included studies,
only several articles included objective methods to assess the effect of VR. In addition, most of the articles
showed a high risk of bias, such as a lack of randomization and blinding or a small sample size. That is why
further well-designed randomized control trials are required to evaluate the influence of VR on balance in
different groups of neurological patients.

Keywords: Virtual reality, Neurological disorders, Rehabilitation, Balance training

Introduction participant’s motivation; however, this issue has not been

well investigated. According to Meyns et al.,7 it appears that

T he field of virtual reality (VR) has an increasing

role in motor rehabilitation, and it is a promising new
tool with a wide range of applications. Butler and Willett1
define VR as a technology that allows the user to interact
directly with a computer-simulated environment. Thus the
use of VR games in rehabilitation is considered to be a pos-
sible strategy to improve motor performance as it uses visual,
sensory, and auditory feedback in virtual environments and
gives an opportunity to increase the duration, intensity, and
number of repetitions needed to induce neuroplasticity.2–6
Some authors3 suggest that it also strongly increases the
motivation seems to increase when a new variety of the ex-
ercises are provided, such as using VR; moreover, most
studies did not quantify the motivation. In neurological dis-
orders, deteriorated balance is one of the major risk factors of
falls,8,9 and it is strongly associated with decreased quality of
life.7,10–12 There is a high need for the development and ap-
plication of effective training methods.4,5,10–12
A conventional therapy also gives positive effects upon
balance, functional stability, and general motor function
in neurology patients.13,14 However exercise effects in-
crease when the VR intervention is added.7,15 Moreover the

1
Department of Human Motor Behavior, The Jerzy Kukuczka Academy of Physical Education in Katowice, Katowice, Poland.
2
Department of Rehabilitation, Division of Physiotherapy of the 2nd Faculty of Medicine, Medical University of Warsaw, Warsaw,
Poland.

1
 2 JURAS ET AL.
exercises in virtual environment are more pleasure for par-
ticipants than non-VR therapy.16 In addition, VR therapy
reduces costs of rehabilitation and enables treatment of lar-
ger number of patients.17
In recent years, the use of VR has been introduced in the
field of neurological rehabilitation, especially in patients
with stroke (S) or Parkinson’s disease (PD) and in children
with cerebral palsy (CP).6,18–20 In this group VR intervention
is most commonly used and has been well described in lit-
erature. Previous systematic reviews have evaluated VR for
balance in patients with stroke.12,21,22 There are also reviews
assessing the general effectiveness of VR-based rehabilita-
tion for PD patients23 and CP patients.24–26 Although the
methods evaluating the efficacy of therapy, equipment, and
the intensity and duration of intervention varied widely
across studies, the authors reported positive effects of VR
intervention.
In accordance with Evidence-Based Medicine policy,
the most valuable and reliable scientific evidence is based
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on an objective assessment conducted with proper sample
size in a well-designed control trial.27 That is why the
objective of this study was to determine the evidence of VR
on improving balance in different groups of neurological
patients (S, PD, CP) and to determine whether a gold
standard in VR training in these groups of patients exists
with a particular focus on the quality of studies, methods of
assessing the effectiveness of the therapy, equipment, and
FIG. 1. Flowchart for the study search and selection.
the intensity and duration of VR intervention described in
the recent publications.
Materials and Methods
Literature search
A literature search was carried out using the Boolean
search strategy in the PubMed, SCOPUS, SPORTDiscus,
and Medline databases from 2009 to 2017. Combinations of
the following key terms were used for each database: ‘‘vir-
tual reality’’ OR ‘‘virtual rehabilitation’’ AND ‘‘stroke (S)’’
OR ‘‘Parkinson disease (PD)’’ OR ‘‘children with cerebral
palsy (CP)’’ AND ‘‘balance training’’ OR ‘‘balance exer-
cise.’’ Filters were applied in each database to restrict sear-
ches to full-text original articles and English language.
Study selection
The studies were chosen under the following inclusion
criteria: (1) the study included one of the three most common
neurological diseases (S, PD, CP), (2) balance tests were
performed before and after the intervention programs, and
(3) the rehabilitation program contained VR environments.
Studies were excluded if (1) the Physiotherapy Evidence
Database (PEDro) scale was lower than four, (2) the balance
training volume was not described, or (3) the trial was based
on a single-case experimental design. The literature review
 VR IN CLINICAL BALANCE TRAINING PROGRAMS
and the quality assessment (PEDro scale) were conducted
independently by four authors (A.K., A.B., J.M., M.P.). In
total, 20 studies met the inclusion criteria for review (see
Fig. 1 flowchart).
Study quality assessment
The methodological quality of each study was tested by
the PEDro Scale. This scale consists of 11-items, which al-
lows to assess the methodological quality and internal va-
lidity of the randomized controlled trials (RCTs).28
Results
Data synthesis
The initial search retrieved a total of 3156 articles from the
databases. After excluding articles based on the title and
removing duplicates, 402 potential articles were selected.
The authors independently evaluated the abstracts. Finally,
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20 articles met all the inclusion criteria and were included in
this review. Figure 1 presents the flowchart for the literature
search process.
Study characteristics
A summary of the included studies is presented in Table 1.
Population. The total pooled sample size of all included
studies was 101 (S), 84 (PD), and 61 (CP) participants. All
studies included male and female subjects. The mean age of
participants and the timing of intervention are shown in
Table 1.
Outcome measure
Equipment. Many VR systems were used in the reha-
bilitation. In general, there were two types of devices,
commercial (available for purchase; e.g., Nintendo or
Xbox) and ‘‘homemade.’’ A feature connecting all the
systems in the reviewed articles is their similar construction.
They consist primarily of control units (computers with
cameras and special devices), elements projecting a VR en-
vironment (color screens and customized glasses), and var-
ious peripheral devices (platforms and movement sensors). A
large diversity of applications was used to stimulate patients
in various ways. On one hand, this diversity can be a great
advantage, but on the other hand, it requires very careful and
objective verification of the diversified VR training out-
comes.
This urgency was confirmed by de Vries et al.29 who no-
ticed that maximal center of mass (COM) displacement and
COM speed in two very similar Ski games changed differ-
ently over game trials; in the Kinski game, they remained
similar or increased over trials, whereas for the Wii Ski
game, they decreased. The specificities of systems used in
the reviewed articles are described in Table 1.
Balance assessment. A total of 18 functional balance
tests were identified. Some of these tests were represented by
single balance measures (e.g., Timed Up and Go [TUG], the
Functional Reach Test, and 10 Steps Climbing Test) or
batteries of balance tests (e.g., Berg Balance Scale [BBS],
Tinetti Test, Unified Parkinson’s Disease Rating Scale
3
[UPDRS], and Bruininks–Oseretsky test of Motor Perfor-
mance 2 [BOT-2]). According to Verbecque et al.,30 these
balance measurement tools assess static body stability, dy-
namic body and transfer stability, or stability during loco-
motion.
In the reviewed articles, the most common clinical tests
evaluating balance were the BBS and the TUG Test. They
were mostly used in the studies regarding patients after a
stroke,17,31–34 as well as those with PD,19,35–37 and in chil-
dren with CP.4 The Functional Reach Test was used to assess
the limits of stability and the fall risk both in patients with
stroke33,38,39 and in children.4
The dynamic balance and gait were assessed by the nu-
merous clinical tests such as 10 Meter Walk Test (10MWT)
in patients with stroke,17,32–34 CP,4,40 and PD37; the Tinetti
Performance Oriented Mobility Assessment in PD37; the
Dynamic Gait Index after stroke31 and in PD36; the Sit-To-
Stand Test in CP4 and PD37; and the Community Balance
and Mobility assessment (CBM) in PD.37 In other studies
regarding children with CP, the 10 Steps Climbing Test,4 2
Minute Walk Test (2MWT),40 and Pediatric Balance
Scale40,41 were also used.
In addition to universal clinical tests used in different
neurological diseases, there were some specific tests con-
ducted to assess the balance and motor disorders in a par-
ticular disease in reviewed articles. To assess the disability in
PD, most authors used the UPDRS.36,42,43 A tool to examine
trunk motor deficit of stroke patients was the Trunk Im-
pairment Scale (TIS).33 There were also some specific tests
for children with CP: the Trunk Control Measurement Scale
(TCMS),7 the BOT-2,44 the Gross Motor Function Classifi-
cation System (GMFCS),40,44 and the Sitting Assessment for
Children with Neuromotor Dysfunction (SACND).45
Unfortunately, biomechanical measures of balance were
rarely used in reviewed articles. The authors evaluated the
body balance with different equipments, such as force plat-
forms (Kistler, Zebris),32,37 Pedoscan,6 Balance Master
System,19,35 and SMART Balance System.42 These plat-
forms and systems are able to register the center of pressure
(COP) in different conditions. The COP is the point location
of the vertical ground reaction force vector. It represents a
weighted average of all the pressures over the surface of the
area in contact with the ground.46 Different tests can be
performed on stable (Kistler, Zebris, Pedoscan, Balance
Master System, and SMART Balance System) and unstable
(Balance Master System and SMART Balance System)
surfaces. On stable platforms, various tests can be done such
as quiet standing,6 OLS,35 and limits of stability19,35; in
addition, on unstable platforms, the sensory organization test
can be performed to evaluate patients’ sensory integration
ability.19,42 The Wii Balance Board39 contains similar
components to a typical force platform; it is capable of ob-
taining data on movements in the COP.47 Pedoscan and
Smart Step6 or the GAITRite mat31 measure gait patterns for
both time (temporal) and space (spatial) parameters.
All abovementioned clinical and biomechanical measures
evaluating balance were typically performed before and after
the VR training.
VR training modality. Analysis of the rehabilitation pro-
grams revealed a large discrepancy in the planned volume of
exercises (Table 1). The number of exercise sessions
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Table 1. Study Characteristics of Included Studies

Participants
Intervention group Control group VR training modality
Influence
Mean Mean Duration Frequency Time of VR
Disease Reference Qty Male Female age Qty Male Female age Equipment Description Applied VR games (min) (n/week) (week) training
Stroke Deutsch 1 1 — 47 1 — 1 34 Wii Fit System consisted of Wii Fit games: balance 60 3 4 +/-
et al.31 software by software and balance (ski jumps, ski slalom,
Nintendo board as peripheral tightrope); strength
device. It uses over (lunges); aerobic
a dozen games with activities (park strolls)
Lee 12 8 4 45.9 12 8 4 49.1 different kinds of Wii Fit exercises: sitting 30 5 8 +
et al.39 movement posture, knee bend
extending other leg,
walking a tightrope,
penguin teeter-totter
seesaw, balance skiing,
rolling marble board,
balance mill
Bang 20 NR NR 62.2 20 NR NR 63.2 Wii Fit exercises: yoga, 40 3 8 +
et al.6 strength, aerobic, and
balancing exercises
Lee 13 8 5 57.3 12 7 5 54.4 Wii System consisted of Wii games: canoeing 30 3 4 +

4
et al.32 technology software and motion game from Sports
by Nintendo controllers as peripheral Resort on Nintendo
devices. It uses over a
dozen games with
different kinds of
movement
Cikajlo 6 NR NR 58.5 20 NR NR 61.0 Balance trainer System allows for Patients moved on the 20 5 3 +/-
et al.17 (Medica execution standing virtual path
Medizin- tasks. It consisted of (transferring their
technik solid steel construction weight from A-P
Gmbh) and wooden table and M-L planes)
mounted for patient
safety at the level of
pelvis and control unit
with color screen.
In et al.32 13 8 5 57.3 12 7 5 54.4 VRRT box VR reflection therapy Patients watch the 30 5 4 +
consisted of software, movements of the
camera, control unit unaffected lower limb
with screen, and displayed on the screen,
wooden box and their task was to
mimic them with the
affected lower limb
(covered by the
wooden box)

(continued)
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Table 1. (Continued)
Participants
Intervention group Control group VR training modality
Influence
Mean Mean Duration Frequency Time of VR
Disease Reference Qty Male Female age Qty Male Female age Equipment Description Applied VR games (min) (n/week) (week) training
Lee 26 16 10 59.3 24 18 3 55.7 Microsoft System consisted of Xbox, Kinect games: darts, golf, 90 2 6 +
et al.15 Kinect for color screen, and bowling, virtual smash,
Xbox Kinect device light race, space pop,
rally ball, table tennis,
river rush
Park 10 5 5 62.0 10 5 5 65.3 Kinect games: boxing, 30 Everyday 6 +
et al.34 table tennis, soccer,
golf, ski, football
Parkinson’s Yen 28 24 4 70.2 14 9 5 71.6 VR balance System included dynamic VR games: bang bang 30 2 6 -(+)
disease et al.42 training balance board and ball, simulated board
system control unit (computer driving
and screen). It uses the
3D VR games from
Virtools 3.5 software
Laio et al.19 12 6 6 67.3 24 11 13 64.8 Wii Fit Software System consisted of Wii Fit games: yoga 35 2 6 +
by Nintendo software and balance exercises, strengthening
board as peripheral exercises; balance:

5
device soccer heading, marble
balance, ski slalom,
balance bubble
Killane 13 NR NR 64.2 7 NR NR 64.0 Maze Game on System consisted of VR game: maze 20 4 2 +
et al.43 Nintendo Nintendo Balance
Balance Board and control unit
board (screen)
Yang 10 9 1 67.5 10 7 3 68.8 VR balance System consisted of VR programs: star 50 2 6 +
et al.36 training control unit (computer excursion, ball maze,
system and screen), balance table tilt, home yoga,
board, and additional cooking, cloth washing,
sponge foam car racing, park
walking, apple catching
Esculier 11 6 5 61.9 9 5 4 63.5 Wii Fit Software System consisted of Wii Fit games: golf, 40 3 6 +
et al.37 by Nintendo software and balance bowling, yoga, hula-
board as peripheral hoop, table tilt, ski
device. It uses over a slalom, balance bubble,
dozen games with ski jump, penguin slide
different kinds of
movement
Shih 10 9 1 67.5 10 7 3 68.8 Microsoft System consisted of Xbox, Kinect games: reaching 50 2 8 +
et al.35 Kinect for color screen, and task 1, reaching task 2,
Xbox Kinect device obstacle avoidance,
marching

(continued)
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Table 1. (Continued)
Participants
Intervention group Control group VR training modality
Influence
Mean Mean Duration Frequency Time of VR
Disease Reference Qty Male Female age Qty Male Female age Equipment Description Applied VR games (min) (n/week) (week) training
Cerebral Sharan 14 NR NR 10.4 15 NR NR 8.9 Wii Fit Software System consisted of Wii Fit games: different — 3 3 +
Palsy et al.41 by Nintendo software and balance sets of games for each
board as peripheral subject
device
Chen 13 9 4 8.7 15 10 5 8.5 Eloton Stationary cycling system VR activities: tackling the 40 3 12 +/-
et al.44 SimCycle consists of cycling ball according to the
Virtual machine, video workout direction it was
Cycling library, and personal virtually served
System computer with software

6
Wade and 6 NR NR NR 7 NR NR NR — Equipment consisted of VR activities: various — — 12 +/-
Porter45 seat ‘‘cushion’’ with games
two platforms and some
air pressure sensors,
control unit, and
personal computer
Cho et al.40 9 NR NR 10.2 9 NR NR 9.4 Wii Fit software System consisted of Wii Fit games: jogging 30 3 8 +/-
Meyns 4 1 3 13.3 7 3 4 10.7 by Nintendo software and balance Wii Fit games: wipe out, 30 3 Discharge -(+)
et al.7 board as peripheral hitting the boxes, air from
device. It uses over a plane hospital
Tarakci 15 10 5 10.5 15 9 6 10.5 dozen games with Wii Fit games: slalom 50 2 12 +
et al.4 different kinds of skiing, walking on rope,
movement tilt table- balance
board, heading

+, significant differences after using the VR therapy; +/-, significant differences after using the VR therapy, in several of measured variables; -(+), not significant differences after using the VR
therapy, but improvement in several of measured variables; NR, nonreported; VR, virtual reality; VRRT, virtual reality reflection therapy.
 VR IN CLINICAL BALANCE TRAINING PROGRAMS
fluctuated between 12 and 40 in stroke, 8 and 18 in PD, and 9
and 36 in CP. The duration of a single session ranged from 20
to 90 minutes in stroke, from 20 to 50 minutes in PD, and
from 30 to 50 minutes in CP.
Intervention
VR in stroke. Many authors claim that applying VR
treatment as additional training to conventional rehabilita-
tion has more positive effects on patients with stroke than
traditional methods of rehabilitation alone in improving their
balance ability.15,32–34 In et al.32 used the virtual reality re-
flection therapy (VRRT) in an intervention group, and a
placebo VRRT program was used in the control group (CG).
They noticed significant improvements not only in balance
and gait abilities but also in the affected lower limb function.
Some authors33,34 noticed better results of clinical tests after
intervention in both the VR treatment group and the CG with
traditional therapy. However, greater improvement was ob-
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served in patients with additional VR rehabilitation. Park
et al.34 noticed improvements in trunk postural stability and
balance. In addition, Lee et al.33 observed better upper limb
motor function. In a study by Lee et al.,15 both groups ex-
hibited significant improvement, but the VR group experi-
enced more pleasure than the CG group during the
intervention. Lee et al.39 compared VR with task-oriented
training. They obtained significantly better results of static
and functional balance in the VR group. The authors sug-
gested that VR-based training might be a more feasible and
suitable therapeutic intervention for postural stability in
stroke patients compared to task-oriented training. Some
interesting results were obtained by Bang et al.6; they com-
pared VR training with treadmill training without any sup-
port of conventional therapy. Both groups exhibited
significantly greater static balance ability after the inter-
vention, but only in the VR group was an improvement in
gait ability observed. Cikajlo et al.17 created an assistive
device, a dynamic standing frame, for safe balance training
in clinical conditions. This special frame allows patients to
exercise both in a VR environment and in a conventional
way. The researchers compared standard clinical therapy
with VR rehabilitation. In both cases, participants exercised
using the dynamic standing frame. Both groups obtained a
similar improvement of balance ability. However, authors
suggested that, when balance training is continued at a pa-
tient’s home instead of in the hospital, it would eventually
decrease the number of outpatient visits, reduce related costs,
and enable treatment for more patients. Interesting results
were also obtained by Deutsch et al.31; they observed that
retention of improvements was greater for the individual who
had received the standard care. Consequently, the authors
claimed that the enthusiasm for new therapies needs to be
tempered with evidence of efficacy with particular attention
to the retention of gains.
VR in PD. In the reviewed articles, the authors used VR
training as a single intervention without traditional balance
exercises in the group of patients with PD.37,43 In these ar-
ticles about the PEDro scale that have fair and good qualities
(Table 2), the authors claimed that the balance and gait VR
training were effective for PD patients. Killane et al.43 ex-
amined PD patients with or without freezing of gait (FOG)
7
before and after training with VR. The authors determined
that there was a significant improvement in single-task
stepping time and rhythmicity, stepping time, and reaction
time in the dual task in the FOG group. Esculier et al.37 re-
vealed that the PD group improved in the static, dynamic,
and functional balance aspects. After the 6-week VR training
program, the PD patients had better results in TUG, Sit-to-
Stand test, single leg stance, 10MWT, Tinetti Test, CBM,
and tests done on a force platform.
Nevertheless, the authors compared the VR balance
training with the conventional balance training.19,35,36,42 The
two studies36,42 that had very good qualities reported an
improvement of balance and motor skills after both VR and
traditional balance training. However, there were no signif-
icant differences between these two applied trainings. In
contrast, in one study,19 researchers indicated that the VR
training had greater improvement in dynamic balance than
conventional exercises. They showed a positive effect on the
obstacle crossing velocity, crossing stride length and results
of clinical tests. Shih et al.35 also reported a significantly
greater improvement in postural stability after VR training
compared with the conventional balance training. There
were significant improvements in the limits of stability test
(LOS test) performance and in the eyes-closed condition of
the OLS test. In addition, both training programs improved
the results of the BBS and TUG tests.
VR in children with CP. Although there is a growing in-
terest in the significance of VR for children with CP, there is
inconclusive evidence for the effectiveness of this type of
training on balance.24,48,49 The results of this review, which
is only based on control trials of at least moderate quality
(Table 2), also exhibit ambiguous findings. Several authors
included VR training in addition to conventional rehabilita-
tion.7,41 Only one study41 revealed that the balance, moti-
vation, and satisfaction of participants were significantly
higher in the study group. However, as the additional time of
VR exercises was not specified and the CG did not receive an
equivalent amount of training, it is hard to make a convincing
conclusion on whether the observed profits were related to
VR intervention or additional training. In another study,7 the
authors reported significant improvement of sitting balance
in both groups and concluded that VR training was not
perceived as more enjoyable by participants. Wade and
Porter,45 in the randomized crossover trial, claimed that
computer games steered by leaning the upper body could
help to improve sitting balance in children with CP. How-
ever, as the intensity, duration, and games used in virtual
training were not specified, it is hard to make any conclusion.
Although some studies of the highest quality prove the utility
of virtual training in children with CP,4,40,44 one study re-
garding home-based virtual cycling training did not prove a
positive influence on balance; a statistically significant im-
provement was seen only in muscle strength.44 Another
study40 that investigated the effects of treadmill training with
VR indicated significantly greater improvements in balance,
gait, and gross motor functions in the experimental group
compared to the CG, but as a sample size calculation was not
performed, it could be considered to be small. Some authors of
a well-designed experiment4 concluded that VR training is
better at improving static balance and the independence level in
daily life activities than neuro-developmental treatment (NDT)
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Table 2. Physiotherapy Evidence Database Scores of The Reviewed Studies

Eligibility Subjects were Statistical Point
criteria randomly Allocation Groups Blinding Blinding Intention- between measures
were allocated was were similar of all of all Blinding Dropout to- treat group and measure
Disease References specified to groups concealed at baseline subjects therapists assessors <15% method comparison variability Score
Stroke Deutsch et al.31 - + - - - - - + + + - 4
Lee et al.39 + + - - - - - + + + + 6
Bang et al.6 + + - + - - - + + + + 7
Lee et al.33 + + + + - - + - - + + 7
Cikajlo et al.17 + - - - - - - + - + + 4
In et al.32 + + - + - - - + + + + 7
Lee et al.15 + + + + - - + + - + + 8
Park et al.34 + + + + - - - - - + + 6

8
Parkinson’s Yen et al.42 + + - - - + + + + + + 8
disease Laio et al. + + + + - - - + - + + 7
(2014)
Killane et al.43 - - - + - - - + + + + 5
Yang et al.36 + + - + - - - + + + + 7
Esculier et al.37 + - - + - - - + + + + 6
Shih et al.35 + + + + - - - + + + + 8
Cerebral Sharan et al.41 + + - - - - - - - + + 4
palsy Chen et al.44 + + - + - - + + + + 7
Wade and + + - - - - - - - + + 4
Porter45
Cho et al.40 + + - + - + + + + + 8
Meyns et al.7 + - - - - - - + + + - 4
Tarakci et al.4 + + - + - - - + + + + 7
‘‘+’’ indicates a ‘‘YES’’ score; ‘‘-’’ indicates a ‘‘NO’’ score.
 VR IN CLINICAL BALANCE TRAINING PROGRAMS
treatment in children with mild CP, despite the fact that the
individual NDT approach was delivered as part of the ther-
apy in each group. Taken together, as most of the studies
included VR in addition to routine rehabilitation7,41 or were
comparing VR to ‘‘no treatment,’’44,45 there was no solid
conclusion to be drawn. Another issue is that all of the
reviewed studies had a risk of bias due to the lack of blinding
to therapists or assessors; only one study included blinded
assessors.40
Quality of assessment
All included studies have a quality score ranging from 4 to
8 points. Of the included studies, six RCTs were graded as
fair. Fourteen RCTs were graded as good. Table 2 illustrates
the PEDro assessment of all included studies.
Discussion
The presented systematic review synthesized recent in-
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formation regarding the effectiveness of VR games on bal-
ance in a group of patients with stroke, PD, or CP. Overall,
the comparison of VR interventions between conventional
rehabilitation or no intervention exhibited that the training in
a virtual environment showed significantly better results.
However, these results should be interpreted with great
caution due to the large diversity of the systems, games, and
training volume used in VR therapy. One of our goals was to
determine if a gold standard existed in this field. Un-
fortunately, our review reveals a large discrepancy between
the frequency and intensity of applied trainings. It is im-
possible to identify a training protocol that is most com-
monly used.
Moreover, in all included studies (especially in children
with CP), the effectiveness or influence of VR training on
balance was evaluated with functional tests, and only several
articles included objective methods. In addition, most of the
articles drawn upon in our review showed a high risk of bias,
such as a lack of randomization, diversified intensity, and
duration of the intervention or a small sample size, which
could lead to an overestimation of the true therapeutic effect.
In addition, very often the additional time of VR exercises
was not specified, and the CG did not receive an equal
amount of training.
Reviewed articles showed that many of the studies did not
report a proper description of randomization and allocation
concealment. The valid randomization allows subjects to
have the same chance to receive any therapeutic interven-
tion.50 Another important element is an allocation conceal-
ment. The results from previous studies51–53 have shown that
randomized controlled trials without adequate allocation
concealment had a 40% larger estimate of the effect com-
pared to those with proper allocation concealment. We also
noticed that a few studies showed an unclear or high risk of
bias due to a lack of blinding during the outcome assessment.
All the included studies revealed some weaknesses of VR
trainings. First, from a practitioner’s point of view, VR ex-
ercises should include regularly updated information about
patients’ performance, as there is much evidence that addi-
tional guidance helps to achieve better movement perfor-
mance.54 In addition, regular feedback would not allow for
strengthening compensation. Another issue is that the testing
procedure of balance should also be covered in the game.
9
Retesting of patients would allow choosing the proper pro-
gression of each exercise. In most reviewed articles, VR
trainings were based on commercially available games and
were not specifically created for very specific groups of pa-
tients and their demands. Moreover, even the same type of
game played on different devices imposes different chal-
lenges in balance training, and the consequences for balance
control of these different types of VR training still remain
unclear.29
Conclusions
To sum up, findings from this review highlight how little is
known about the implementation of the VR in the rehabili-
tation programs. Unfortunately, because of the large diver-
sity of implemented VR trainings in the reviewed studies, a
gold standard for improving balance in patients with stroke
or PD or children with CP cannot be determined. That is why
well-designed randomized control trials with an appropriate
sample size are further required to evaluate the influence of
virtual training on balance in these patients and to investigate
the optimum frequency and intensity of trainings in a VR
environment. It would also be useful for clinicians to rec-
ognize which types of games and which training devices may
be more valuable for patients in each subgroup.
Acknowledgment
The study was supported by the National Center for Research
and Development Grant under the program STRATEGMED
III within the ‘‘VB-Clinic’’ project no. STRATEGMED3/
306011/1/NCBR/2017.
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Kajetan J. Słomka, PhD
Department Human Motor Behavior
The Jerzy Kukuczka Academy of Physical Education in
Katowice
Mikolowska Str. 72A 40-605 Katowice
Poland
E-mail: k.slomka@awf.katowice.pl