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Review ArticleApplying Game-Based Approaches for Physical Rehabilitation ofPoststroke Patients: A Systematic Review
Soheila Saeedi , Marjan Ghazisaeedi , and Sorayya Rezayi
Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences,Tehran, Iran
Correspondence should be addressed to Sorayya Rezayi; [email protected]
Received 21 March 2021; Revised 15 June 2021; Accepted 31 July 2021; Published 15 September 2021
Academic Editor: Redha Taiar
Copyright © 2021 Soheila Saeedi et al. (is is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.
Objective. A large number of patients need critical physical rehabilitation after the stroke. (is study aimed to review and reportthe result of published studies, in which newly emerged games were employed for physical rehabilitating in poststrokepatients. Materials and Methods. (is systematic review study was performed based on the PRISMA method. A compre-hensive search of PubMed, Scopus, IEEE Xplore Digital Library, and ISI Web of Science was conducted from January 1, 2014,to November 9, 2020, to identify related articles. Studies have been entered in this review based on inclusion and exclusioncriteria, in which new games have been used for physical rehabilitation. Results. Of the 1326 retrieved studies, 60 of them metour inclusion criteria. Virtual reality-oriented games were the most popular type of physical rehabilitation approach forpoststroke patients. “(e NintendoWii Fit” game was used more than other games.(e reviewed games were mostly operatedto balance training and limb mobilization. Based on the evaluation results of the utilized games, only in three studies, appliedgames were not effective. In other studies, games had effective outcomes for target body members. Conclusions. (e resultsindicate that modern games are efficient in poststroke patients’ physical rehabilitation and can be used alongsideconventional methods.
1. Introduction
Stroke is one of the diseases that can lead to disability andaffect people’s daily activities and lead to reduced perfor-mance [1]. According to the Global Burden of Diseases(GBD 2010), stroke is the second most common cause ofdeath worldwide [2]. In 2010, the number of people with thefirst stroke was 16.9 million, and people who died of strokewas 5.9 million [2]. Disability-adjusted life years (DALYs)lost also was 102 million, and the number of stroke survivorswas 33 million [2]. Ninety percent of stroke survivors have adisability in one of their functions [3]. Most people withpoststroke disability experience changes in emotionalfunction, limbmovement, balance, and muscle strength, andthere is a risk of falling for these patients in performingordinary activities, all of which affect the quality of life ofsurvivors [4]. (e main treatment solution to reduce
functional defects after stroke is rehabilitation [5]. Post-stroke physical rehabilitation in common is a gradualprocess that can take months or even years, and these pa-tients require multiple sessions of treatment.
However, patients may not be able to attend thesetreatment sessions for rehabilitation fully. Several factorsmay lead to limited access to these treatment sessions, in-cluding the following: difficulty accessing a physiotherapistby the patient, high cost of attending the treatment session,patient’s age and disability, the long distance that the patienthas to travel, or poor patient compliance [6]. One of thesolutions that can be offered to overcome these problems isto do rehabilitation activities at home; for rehabilitationexercises to be effective at home, high-intensity methodsfocused on specific repetitions of the practice with thefeedback of performance should be used [7]. Consequently,one of the innovative methods that can obviate the above
HindawiJournal of Healthcare EngineeringVolume 2021, Article ID 9928509, 27 pageshttps://doi.org/10.1155/2021/9928509
problems is applying modern games; these games have beenused in various fields, including education, public policy,and healthcare [8]. Furthermore, they can also be utilized asa support tool for rehabilitation activities and provide anenjoyable environment for patients and increase adherenceto treatment sessions [9, 10].
As it turns out, various studies have been performed todetermine the effectiveness of the mentioned games. Asystematic review study by Primack et al. found that gamesimproved 69% of psychological therapy outcomes, 46% ofclinician skills outcomes, 42% of health education outcomes,and 37% of disease self-management outcomes [11]. An-other study examined the games managed for rehabilitationin respiratory conditions and concluded these games wereeffective [12, 13]. (e purpose of this study is reviewing,summarizing, and reporting studies in which modern gameshave been used for physical rehabilitation of poststrokepatients and tries to answer the following questions:
(1) Which type of games is the most used?(2) Which gamification approaches have been used to
improve the performance of poststroke patients?(3) What was the most common type of physical re-
habilitation in stroke survivors?(4) What are the evaluation results of games used in
poststroke patients?
2. Research Methodology
(is systematic review was conducted based on Prefer-red Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) checklist to ensure inclusion of relevantstudies [14].
2.1. Design. In this review, a systematic search of scientificdatabases including ISI Web of Science, PubMed, IEEEXplore Digital Library, and Scopus was performed fromJanuary 1, 2014, to November 9, 2020. (e comprehensivesearch strategy comprised a set of main keywords fromPubMed Mesh terms and Emtree related to “game,” “re-habilitation,” and “poststroke” patients.(e specific detail ofmain applied keywords for each database is presented inTable 1.
2.2. Inclusion and Exclusion Criteria for Study Selection.(e extracted studies were included if they fulfilled thefollowing criteria: (1) original articles and proceedings, (2)the focus of this review was on only physical rehabilitationinnovative game-based solutions for poststroke physicaldisabilities, (3) one of the gamification techniques wasemployed for physical rehabilitation or disability treatment,(4) in this study, the result of using different games andoutcomes of video games or immersive-oriented approacheson physical rehabilitation were reviewed, and (5) studieswere limited to those published in the English language.Besides, the studies were excluded if they met the followingcriteria: (1) the title, abstract, or full text of the article that didnot relate to video games, virtual, or mixed reality-based
games, (2) studies which were review or meta-analysis, bookchapters, letter, reports, and technical reports, (3) articles inwhich the result of applying games was not reportedquantitatively, (4) articles about cognitive rehabilitation, and(4) non-English published ones.
2.3. Literature Refinement. In comprehensive and scientificdatabases searching, 833 studies were retrieved after du-plicate removal. Some inclusion and exclusion criteria wereset for the study selecting phase. In the first phase, twoindependent reviewers (SS and SR) specified the primaryclassification of included studies; then, they synthesizedselected citations’ critical features. MG validated the pri-marily determined classifications. All titles and abstracts ofextracted studies were investigated and screened based onthe research questions and unique aims to select relevantones by two reviewers under MG’s supervision. In the lastphase, citations that met inclusion and exclusion criteriawere selected to enter the full-text review phase. (e full-texts of relevant studies were screened by SS and SR thor-oughly. Key characteristics were entered into a spreadsheetin Excel for each study. Two authors (SR and SS) inde-pendently extracted the study characteristics based on thepredefined classifications. For reaching an agreement, theinformation was examined again by two authors. (e nextreviewer (MG) evaluated and validated all of the obtainedresults. EndNote X9 was used for resource management, andall qualitative analyses were performed in SPSS v20. (emain classifications of screened citations are shown inFigure 1.
3. Results
(e flow of screening articles based on the PRISMA methodis shown in Figure 2. Prior scientific searches assigned 833citations after the duplicate removal phase. Next, 41 studieswere eliminated due to their irrelevancy in the full-textscreening phase. In the last screening step, 60 studies wereincluded based on our main study objectives as eligiblestudies. Based on the predefined classification elements, asummary of the key results is described in Table 2.
3.1. Study Characteristics. (e reviewed studies in this studywere published in 53 journals and 7 international confer-ences. All the names of journals and conferences are listed inTable 3 based on their frequency. As it is clear, the “Archivesof Physical Medicine and Rehabilitation,” “Clinical Reha-bilitation,” “Games for Health Journal: Research, Develop-ment, and Clinical Applications,” and “Journal of Stroke andCerebrovascular Diseases” have the first rank with 5 or 4published studies among journals. (e distribution ofstudies by year and country of publication is presented inTable 4. As it is conducted, the majority of citations werepublished in 2019. Accordingly, in different countries, in-novative physical rehabilitation solutions were employedand Korea with 13 citations had the highest numberof studies.
2 Journal of Healthcare Engineering
3.2.+eDistribution of Literature byMainGamificationTypesand Approaches. Based on analysis, virtual reality-orientedgames and video games are the most popular physical re-habilitation types for poststroke patients. (e distribution ofreviewed literature based on the type of games is shown inFigure 3. Besides, it turns out “Microsoft Xbox 360 Kinect”and “the NintendoWii Fit” approaches have been the widestutilized game-based tools that have been extracted in studies(Figure 4).
(e deployment platform for most of the studies in-cluded in this review (n� 28, 46.66%) was Nintendo andMicrosoft Xbox 360 Kinect.
(ere are many games in the field of rehabilitation thatresearchers and therapists can use for rehabilitating patients.However, in this systematic review, most studies have usedexisting games in rehabilitation and do not develop gamesfor the purpose of research that we can refer to the NintendoWii Fit, Microsoft Xbox 360 Kinect games, Peggle, IREX,and HTC Vive games.
3.3. Distribution of Studies Based on Type of PhysicalRehabilitation. (e critical types of physical rehabilitationtherapies applied for poststroke patients based on differentgames were divided into several main categories. (e mostimportant types of rehabilitation are “Balance training,”“Mobilization of the limbs,” and “Muscular strengthening”(Figure 5).
3.4. Distribution of Studies Based on Type of Studies, SampleSize, and Session Detail. In the investigated studies, threetypes of intervention studies and their effectiveness have beenutilized (Table 5). (e sample size from minimum to maxi-mum number is 5 people in 2 studies and 209 people in onestudy. (e highest frequency for the selected sample size was10 people, which is in 4 studies.(e lowest age of the recruitedsubjects in studies was 24 years on average, and the highestmean of age was 72 years old. In most studies, the number ofmales included in the intervention was higher than females; in4 studies, the exact number of genders was not reported.
MainClassification
PublicationInformation
Gamificationapproach
details
Rehabilitationtype
Target bodymember
study details Assessmentdetails Effectiveness Sample ize Results
Figure 1: (e key classification of relevant studies.
Table 1: Search strategy for each database.
Database Search strategy
PubMed
(“Stroke”[Mesh] OR “cerebrovascular accident” OR “cerebrovascular accidents” OR “CVA” OR “CVAs” OR“cerebrovascular apoplexy” OR “brain vascular accident” OR “brain vascular accidents” OR “cerebrovascular stroke” OR“cerebrovascular strokes” OR “apoplexy” OR “cerebral stroke” OR “cerebral strokes” OR “acute stroke” OR “acute strokes”OR “acute cerebrovascular accident” OR “acute cerebrovascular accidents”) AND (“video games”[Mesh] OR “game” OR“games” OR “gamification” OR “video game” OR “computer games” OR “computer game”) AND (“rehabilitation”[Mesh]
OR “rehabilitation care”) limit to: 2014–2020
Scopus
TITLE-ABS-KEY (( “stroke” OR “cerebrovascular accident” OR “cerebrovascular accidents” OR “CVA” OR “CVAs” OR“cerebrovascular apoplexy” OR “brain vascular accident” OR “brain vascular accidents” OR “cerebrovascular stroke” OR“cerebrovascular strokes” OR “apoplexy” OR “cerebral stroke” OR “cerebral strokes” OR “acute stroke” OR “acute strokes”OR “acute cerebrovascular accident” OR “acute cerebrovascular accidents”) AND (“video games” OR “game” OR “games”
OR “gamification” OR “video game” OR “computer games” OR “computer game”) AND (“rehabilitation” OR“rehabilitation care”)) AND (limit to (pubyear, 2014–2021)) AND (limit to (doctype, “cp”) OR limit to (doctype, “ar”)
AND (limit to (language, “English”))
Web ofScience
TS� (“Stroke” OR “cerebrovascular accident” OR “cerebrovascular accidents” OR “CVA” OR “CVAs” OR“cerebrovascular apoplexy” OR “brain vascular accident” OR “brain vascular accidents” OR “cerebrovascular stroke” OR“cerebrovascular strokes” OR “apoplexy” OR “cerebral stroke” OR “cerebral strokes” OR “acute stroke” OR “acute strokes”OR “acute cerebrovascular accident” OR “acute cerebrovascular accidents”) AND TS� (“video games” OR “game” OR“games” OR “gamification” OR “video game” OR “computer games” OR “computer game”) AND TS� (“rehabilitation”
OR “rehabilitation care”)Refined by: document types: (article OR proceedings paper)
Timespan: 2014–2020. Indexes: SCI-EXPANDED, SSCI, A&HCI, ESCI.
IEEE Library((((((“All metadata” : “stroke”) OR “all metadata” : “cerebrovascular accident”) OR “all metadata” : “cerebral strokes”)AND “all metadata” : “game”) OR “all metadata” : “computer game”) AND “all metadata” : “rehabilitation”). Filters
applied: 2014–2021
Journal of Healthcare Engineering 3
(e frequency of physical rehabilitation time (by unittime) is shown in Figure 6. In this study, the length of re-habilitation time is converted to hour to compare thetreatment time in different studies. In studies, the minimumduration of treatment to provide rehabilitation is one hour;besides, 10, 9, and 12 hours is the highest frequency oftreatment time in studies, which was intended in a total of 12studies.
3.5. Distribution of Studies Based on Assessment Scores.According to the results of reviewed different studies, nu-merous indicators and tests have been applied to evaluatephysical rehabilitation outcomes in poststroke patients. Inother words, according to the type of rehabilitation treat-ment provided to patients, different indicators and metricshave been calculated to assess the condition of the reha-bilitated organs of the body (before and after the inter-vention). For this reason, we were unable to compare theassessment scores calculated during the intervention.
However, considering how many indicators and metrics ineach study were affected by physical rehabilitation duringthe intervention treatment, we added a brief assessmentfrom the authors’ perspective. At the end of the intervention,if all indicators of functional or physical appraisal of patientsare affected by game-based rehabilitation and a significantdifference is seen, then we have labeled this rehabilitationapproach “Effective.” If only one or two of the severalevaluation metrics are not affected by game-based rehabil-itation, then we label them “Partly effective.” Finally, if thereis no significant difference in all evaluation measures beforeand after the intervention, we label them “No effective.” Inthe following, the distribution of the reviewed studies basedon effectiveness is shown in Figure 7.
4. Discussion
(is survey’s main objective was to review the studies inwhich games were applied for improving the physicalfunctions and rehabilitation of poststroke patients.
Scre
enin
gIn
clud
edEl
igib
ility
Iden
tific
atio
n
Citations after duplicates removal(n = 833)
Full-text articles assessed for eligibility
(n = 101)
Full-text articles excluded with reasons (n = 41)
Articles in which the effectiveness of applying games was not reported quantitatively.
Articles about cognitive rehabilitations were excluded.
Not available full-text papers. Non-English and published ones.
Studies included in full synthesis (n = 60)
Records screened based on abstracts and titles
(n = 833)
Records excluded with reasons (n = 732)
The title, abstract did not relate to video games, virtual or mixed reality-based games
papers which are review or meta-analysis, book chapters, letter, reports and technical reports
Citations identified through databases comprehensive search:PubMed (n = 138), Scopus (n = 640),
Web of Science (n = 375), IEEE Xplore digital library (n = 173)Total retrieved articles: (n = 1326)
Figure 2: (e PRISMA diagram for the records search and study selection.
4 Journal of Healthcare Engineering
Tabl
e2:
Maincharacteristicsof
includ
edstud
ies.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
1Laffo
ntI
etal.[15]
2019
Not
mentio
ned
Video
game
Mob
ilizatio
nof
thelim
bsSh
oulder,
arm,and
hand
RCT
51AgeM
�58:
male�
31and
female�
20
45min,5
sessions
ina
weekfor6
weeks
Baselin
eand
postinterventio
nat
theendof
the
program,b
etween
days
45and60
and
follo
w-upat
6mon
ths
Inthesubacute
stroke
stage,adifferenceof
9/10
points
ontheUL-
FMSisconsidered,
andBB
Tminim
ally
detectable
change
isgained
tobe
5.5
blocks/m
in.
Effectiv
e
Postho
canalysis
show
edthatscores
inUL-FM
Sor
BBT
weresig
nificantly
high
erin
theVG
grou
pthan
inthe
CRgrou
p
2Cikajlo
Iet
al.[16]
2020
Nintend
oWii
Fit
Virtual
reality
game
Balance
training
Legs
RCT
20AgeM
�50.3:
male�
15and
female�
2
15min,5
sessions
for1
week
Baselin
eand
postinterventio
n
Sign
ificant
differences
betweenthegrou
pswerefoun
dwith
the
eyes
closed,sharpened
Romberg
test
(p�0.05),and
standing
ontherigh
tleg(p
�0.035).
Effectiv
e
Video
games
enable
independ
ent
balancetraining
isfeasible
with
out
strenu
ous
physiotherapy.
3GlueckAC
andHan
DY[17]
2019
Microsoft
developed
Robo
Raid
Mixed
reality
game
Balance
training
Legs
Before
andafter
trial
14AgeM
�25.21:
male�
11and
female�
3
59.12min,
35.71days
Baselin
eand
postinterventio
n
MRgametraining
provided
significant
reactio
ntim
eim
provem
ents
(p<0.05)and
vestibular
performances
(p<0.05).
Effectiv
e
(er
esultsshow
edvisuom
otor
reactio
ntim
e,and
balancemetrics
weresig
nificantly
improved
follo
wingMR
game
rehabilitation.
4Ayoub
iFet
al.[18]
2020
Nintend
oWii
Fit
Virtual
reality
game
Mob
ilizatio
nof
thelim
bs
Shou
lder,
wrist,h
and,
andfin
ger
Before
andafter
trial
10AgeM
�61.1:
male�
5and
female�
5
30min,1
0sessions,2
days
in5
weeks
Baselin
eand
postinterventio
n
FMAscores
revealed
asig
nificant
improvem
entinthe
motor
functio
n(p
�0.001).B
BTscores
increasedfrom
12pretherapy
to20.6
posttherapy,
andthe
MAL-AOM
scores
increasedfrom
1.09
pretherapy
to1.8
posttherapy.
Effectiv
e
Sign
ificant
improvem
entin
allo
utcome
measureswas
foun
dafterthe
interventio
n.
5de
Gou
vea
JXet
al.
[19]
2015
Nintend
oWii
Fit
Virtual
reality
game
Mob
ilizatio
nof
thelim
bsSh
oulder
and
elbo
wBe
fore
andafter
trial
22AgeM
�66.4:
male�
15and
female�
7
60min,3
sessions
ina
week
Baselin
eand
postinterventio
n
Elbo
wflexion
score
(jointrange
ofmotion)
increasedfrom
127to
134,
andshou
lder
flexion
scoreincreased
from
114to
134.
Effectiv
e
Metrics
show
edthat
therewere
statistically
significant
improvem
ents
for
alltrained
measures.
Journal of Healthcare Engineering 5
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
6Cano-
Mañas
MJ
etal.[20].
2020
Microsoft
Xbo
x360
Kinect
Video
game
with
Kinect
Balance
training
Postural
control
Functio
nality
Not
mentio
ned
RCT
48AgeM
�63.13:
male�
23and
female�
25
20min,2
4sessions
in8
weeks.
Baselin
eand
postinterventio
nassessments:8
weeks
afterthe
interventio
n
Sign
ificant
differences
resultedin
the
baropo
dometric
(p<0.01),the
mod
ified
Rank
inscores
(p<0.01),and
thevariable
relatedto
streng
thandthepain/
discom
fort
dimensio
n(p<0.01)of
theEQ
-5D
.
Effectiv
e
(efin
ding
sshow
that
applying
avideogame
approach
combinedwith
conv
entio
nal
therapymay
prod
ucepo
stural
control,
improvem
ents
inbalance,
functio
nality,
and
quality
oflife.
7SimsekTT
andÇekok
[21]
2015
Nintend
oWii
Fit
Virtual
reality
game
Balance
training
Mob
ilizatio
nof
thelim
bs
Shou
ler,wrist,
andelbo
wRC
T42
AgeM
�58.04:
male�
29and
female�
13
45–60min,10
week,
3days/
week.
Baselin
eand
postinterventio
nassessment:after10
weeks,a
fter
interventio
n,and
treatm
ent
satisfactionafter10
sessions
Astatistically
significantdifference
was
foun
dbetween
before
andafter
treatm
entFIM
(fun
ctional
independ
ence
measure)scores
(p<0.05).
Partly
effectiv
e
(eseresults
indicatedthe
Nintend
oWiiFit
training
was
aseffectiv
eon
daily
livingfunctio
nsandqu
ality
oflife
insubacute
stroke
patients.
8Hun
gJW
etal.[22]
2019
Kinect2Scratch
Video
game
with
Kinect
Mob
ilizatio
nof
theup
per
limbs
Shou
lder,
elbo
w,a
ndforearm
RCT
33AgeM
�58.98:
male�
22and
female�
11
30min,2
4sessions
in12
weeks
Baselin
e,po
stinterventio
n,andat
the3-mon
thfollo
w-up.
(etotala
ctivity
scores
ofthetraining
onup
perextrem
itywas
significantly
high
erin
the
Kinect2Scratchgrou
pthan
inthetherapist-
basedtraining
grou
p(p<0.001)
Effectiv
e
(eapplicationof
Kinect2Scratch-
oriented
games
may
indicate
acomplem
entary
strategy
toconv
entio
nal
therapyfor
decreasin
gthe
therapists’
workload.
9AdieK
etal.[23]
2016
Nintend
oWii
Fit
Virtual
reality
game
Mob
ilizatio
nof
thearms
Arm
RCT
209
AgeM
�67.3:
male�
105and
female�
104
45min,4
2sessions
in6
weeks
Baselin
eand
postinterventio
nafter6
weeks
andsix
mon
ths
(erewas
nosig
nificantdifference
intheprim
ary
outcom
eof
affected
arm
functio
nat
sixweeks
follo
w-up
(p�0.12)andno
significantdifference
insecond
ary
outcom
es.
Noeffectiv
e
(eresults
indicatedthat
the
WiiT
Mwas
not
superior
toarm
exercisesin
home-
based
rehabilitationfor
stroke
survivors
with
arm
weakn
ess.
6 Journal of Healthcare Engineering
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
10Ahm
adMA
etal.
[24]
2019
Not
mentio
ned
Virtual
reality
game
Mob
ilizatio
nof
theup
per
limbs
Not
mentio
ned
Before
andafter
trial
34AgeM
�63:
male�
31and
female�
5
30min,8
sessions
in8
weeks
Baselin
eand
postinterventio
non
completionof
the8
weeks
(eresults
show
eda
significanttim
e-grou
pinteractioneffectfor
IMI(p
�0.001),
LawtonIA
DL
(p�0.01),andSIS
domainof
commun
ication
(p�0.03).A
significanttim
ewas
foun
din
FMA-U
E(p
�0.001),W
MFT
(p�0.001),and
LawtonIA
DL
(p�0.01).
Effectiv
e
(eintegrationof
VRgames
asan
adjunctto
standard
physiotherapyfor
upperlim
bstroke
rehabilitationwas
considered
tobe
equally
beneficial
comparedto
standard
physiotherapy.
11Cho
iYH
etal.[25]
2016
MoU
-Rehab
Virtual
reality
game
Mob
ilizatio
nof
theup
per
limbs
Shou
lder,
elbo
w,a
ndwrist
RCT
24AgeM
�66.55:
male�
17and
female�
14
30min,1
0sessions
in2
weeks
Baselin
eand
postinterventio
non
endof
treatm
entand
at1mon
th
FMA-U
Ein
experimentala
ndcontrolg
roup
swas
calculated
34/67and
53.75.
Chang
esin
the
B-stagein
expandcon
grou
pswereindicated
3.17–4.24forthearm
and3.08–4.58forthe
hand
.
Effectiv
e
Alarger
improvem
entin
theFM
A-U
E,B-
stage,andMMT
was
foun
dafter
treatm
entw
iththe
MoU
-Rehab
than
with
conv
entio
nal
therapy
12Cho
iHS
etal.[26]
2017
Nintend
oWii
Fit
Virtual
reality
game
Balance
training
Lower
extrem
ity
Not
mentio
ned
RCT
36AgeM
�61.91:
male�
21and
female�
15
30min,1
2sessions
in4
weeks
Baselin
eand
postinterventio
n
Post
hocanalysis
revealed
significant
differences
inAP-axis,
andsw
ayarea;
weigh
tbearing
symmetry
oftheg
ame-
basedCIM
Tgrou
pis
comparedwith
the
othergrou
ps(p<0.05).
Effectiv
e
Gam
e-based
CIM
Twas
more
effectiv
eat
improvingstatic
balancecontrol
(AP-axisandsw
ayarea)and
weigh
tbearing
symmetry
comparedwith
the
othergrou
ps.
13Cho
iHS
etal.[27]
2019
Not
mentio
ned
Virtual
reality
game
Mob
ilizatio
nof
theup
per
limbs
Elbo
ws,
hand
s,wrists,
andfin
ger
RCT
36AgeM
�58.97:
male�
23and
female�
13
30min,1
5sessions
in5
weeks
Baselin
eand
postinterventio
nassessmento
nendof
5weeks
(edifference
betweentheGR
mirrortherapygrou
pversus
the
conv
entio
nalm
irror
therapyandcontrol
grou
pswas
statistically
significant(
p<0.05).
Effectiv
e
Itindicatedthat
GRdevice-based
mirrortherapyis
aninterventio
nthat
improves
upperextrem
ityfunctio
n,neck
discom
fort,a
ndqu
ality
oflife
Journal of Healthcare Engineering 7
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
14de
Paula
Oliveira
Tet
al.[28]
2015
Nintend
oWii
Fit
Virtual
reality
game
Balance
training
Not
mentio
ned
RCT
23AgeM
�50.21:
male�
13and
female�
10
30min,1
4sessions
in7
weeks
Baselin
eand
postinterventio
nassessmenton
1-weekATandat
a2-
mon
thFU
(eanalyses
ofthe
FMA-LEscoreat
FUforthecontrola
ndexperimentg
roup
are
21.39–24.58.
(e
analyses
ofthe
BESTestscoreat
FUforthecontrola
ndexperimentg
roup
are
75–83.
Effectiv
e
Balancetraining
performed
invirtualrealityby
usingNWFwas
moreeffi
cientthan
conv
entio
nal
balancetraining
15Givon
Net
al.[29]
2015
Nintend
oWii
Fit
Virtual
reality
game
Balance
training
Mob
ilizatio
nof
theup
per
limbs
Not
mentio
ned
RCT
47AgeM
�56.35:
male�
28and
female�
19
60min,2
sessions
ina
weekfor3
mon
ths
Baselin
eand
postinterventio
n,a
3-mon
thinterventio
nandat
3-mon
thfollo
w-up
Sign
ificant
improvem
ents
were
presentedin
both
grou
psforgaitspeed
(F�3.9,
p�0.02),
grip
streng
thof
the
weaker(F
�6.67,
p�0.002),a
ndstrong
erhand
s(F
�7.5,
p�0.001).
Daily
stepsand
functio
nala
bilityof
theweakerhand
did
notincrease
ineither
grou
p
Partly
effectiv
e
Video
andVR
games
can
prom
otemeasures
ofph
ysicalactiv
ityof
patientswith
chronicstroke.
16Hou
seG
etal.[30]
2016
(e
BrightArm
TM
Virtual
reality
game
Mob
ilizatio
nof
theup
per
limbs
Arm
,hand,
shou
lder,a
ndwrist
Before
andafter
trial
7AgeM
�69.7:
male�
5and
female�
2
45–50min,16
sessions
in8
weeks
Baselin
eand
postinterventio
n,on
each
boosterperiod
,each
consistingof
4sessions
over
2weeks
in8weeks
Rang
eof
motion
improved
for1
8ou
tof
23up
perextrem
itymovem
entvariables
(p�0.01)between
pretou
rnam
enta
ndpo
sttournament
assessments.
Effectiv
e
(eresults
indicate
that
BrightArm
iseffectiv
ein
improvingthe
rang
eof
motionof
theup
per
extrem
ity
17Hsie
hHC
[31]
2018
Not
mentio
ned
Video
game
Walking
Balance
training
Not
mentio
ned
RCT
56AgeM
�58.5:
male�
33and
female�
23
30min,3
.5ho
urs/week,
10weeks
Baselin
eand
postinterventio
n
(ecalculated
metrics
show
edthat
the
patientsin
the
interventio
ngrou
pshow
edsig
nificantly
bette
r10MWT
(p�0.033),the
CoP
APsw
ay(p
�0.01),andthe
sway
area
(p�0.006)
than
inthecontrol
grou
p.
Effectiv
e
(isgame
improves
exercise
complianceand
prom
otes
recovery
ofbalanceand
mob
ility
after
stroke.
8 Journal of Healthcare Engineering
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
18Hsie
hHC
[32]
2018
Not
mentio
ned
Video
game
Balance
training
Leg
RCT
54AgeM
�64.07
40min,3
sessions
in1
weekfor12
weeks
Baselin
eand
postinterventio
n
Sign
ificant
changesin
CoP
sway
kinematics
wereob
served
insw
aypath
(p�0.001),sway
area
(,p
�0.002),and
sway
velocity
(p�0.007).B
alanced
testsaretheBB
Stest:
p�0.001andTU
Gtest:p
�0.001),and
therewas
nosig
nificantc
hang
ein
theFA
BStest
Partly
effectiv
e
(isinno
vativ
egamingapproach
with
adaptiv
ePC
games
will
bea
useful
therapyfor
stroke
rehabilitation
19Huang
LLandChen
MH
[33]
2016
Gardening
digitalg
ame
Video
game
with
Kinect
Mob
ilizatio
nof
theup
per
limbs
Not
mentio
ned
Before
andafter
trial
10AgeM
�61.20:
male�
5and
female�
5
24sessions
inthreesessions
perweek
Baselin
eand
postinterventio
n
Fugl–M
eyer
Assessm
entof
motor
functio
n(in
creasesof
9.30);theBo
xand
BlockTestof
manual
dexterity
(increasesof
5.80);high
erfunctio
nal
independ
ence
measure
(increasesof
6.50);andrang
eof
motionmeasurement
oftheup
perextrem
ityproxim
a(in
creasesof
5.56)anddistal
(increasesof
3.83)
Effectiv
e
(egardening
digitalg
ameis
benefit
toim
prove
upperextrem
itymotor
functio
n.
20KhanRU
etal.[34]
2019
Not
mentio
ned
Video
game
Muscular
streng
thening
Fist,w
rist,and
forearm
Before
andafter
trial
5AgeM
�24:
male�
3and
female�
2
Not
mentio
ned
Baselin
eand
postinterventio
n
(escores
of3players
wereim
proved
upto
150,
171,
and172,
respectiv
ely,
for2
players,andthereis
notm
ainly
improvem
ent.
Partly
effectiv
e
(isresultshow
sthat
anattractiv
eenvironm
enta
ndreal-tim
efeedback
mechanism
can
improvethe
rehabilitation
process.
21Afsar
SIet
al.[35]
2018
Microsoft
Xbo
x360
Kinect
Virtual
reality
game
Mob
ilizatio
nof
theup
per
limbs
Shou
lder
and
elbo
wRC
T35
AgeM
�66.43:
male�
20and
female�
15
30min,p
erdayfor4
weeks
Baselin
eand
postinterventio
n
Fortheexperimental
grou
p,thechange
ofBB
T(pre-to-
postdifference)
scores
show
edasig
nificant
improvem
entwhen
comparedto
the
controlg
roup
(p�0.007),b
utthe
change
ofFM
A-U
EandtheFIM
scores
for
theexperimental
grou
pwereno
tsig
nificantly
high
er(p
�0.057,
p�0.677)
Partly
effectiv
e
(eKinect-based
gamesystem
inadditio
nto
conv
entio
nal
therapyhas
supp
lemental
effectiv
enessfor
stroke
patients.
Journal of Healthcare Engineering 9
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
22LeeMM
etal.[36]
2016
Canoe
game
Virtual
reality
game
Trun
kpo
stural
stability
Balance
training
Trun
kmuscles
and
leg
RCT
10AgeM
�65.7:
male�
5and
female�
5
30min
aday,
3sessions
aweekfor4
weeks
Baselin
eand
postinterventio
n
Improvem
ents
intrun
kpo
stural
stability,b
alance,and
upperlim
bmotor
functio
nwere
observed
intheEG
andCG,b
utwere
greaterin
theEG
.(e
meanSU
Sscores
intheEG
andTG
were
71±5.2and74.2±4.8,
respectiv
ely.
Effectiv
e
Canoe
game-based
virtualreality
training
isa
beneficial
interventio
nfor
improvingtrun
kpo
stural
stability,
balancetraining
,andup
perlim
bmotor
instroke
patients.
23LeeD
and
BaeY[37]
2019
DBIVG
Video
game
Trun
kpo
stural
stability
Walking
Trun
kandleg
RCT
21AgeM
�55.1:
male�
14and
female�
7
30min,1
2sessions
in4
weeks
Baselin
eand
postinterventio
n
(escores
ofTISssb,
TISd
sb,and
TIScofor
theinterventio
ngrou
pim
proved
upto
5.9,
6.18,and
3.0.(
escore
ofDGIisc
alculatedup
to17.27.
(escores
ofTW
TandTU
GT
decreasedup
to42.27
and39.32.
Effectiv
e
(eanalysis
demon
strated
DBIVG
can
improvetrun
kcontrola
ndgait
ability
inpatients
with
chronic
stroke.
24LeeSH
etal.[38]
2019
HTC
Vive
Virtual
reality
game
Mob
ilizatio
nof
theup
per
limbs
Hand,
shou
lder,
fingers,a
ndwrist
Before
andafter
trial
12AgeM
�40.2:
male�
7and
female�
5
30min,1
0sessions
2-3
times
aweek
Baselin
eand
postinterventio
n
Infiveparticipants,
scores
show
edim
provem
entbo
thin
ARA
TandBB
T.ARA
T(pretraining
22.3
andpo
sttraining
31.1),BB
T(pretraining
11.2
and
posttraining
19.6),and
MBI
(pretraining
90.4
andpo
sttraining
93.0)
Partly
effectiv
e
(isstud
yindicatesafully
immersiv
eVR
rehabilitation
program
canbe
used
forup
per
extrem
ityrehabilitationin
patientswith
chronicstroke
25McN
ulty
PAet
al.
[39]
2015
Nintend
oWii
Fit
Virtual
reality
game
Mob
ilizatio
nof
theup
per
limbs
Shou
lder,
elbo
w,a
ndwrist
RCT
41AgeM
�58:
male�
31and
female�
10
60min,1
0consecutive
weekd
ays
Prebaseline(14days
pretherapy),
baselin
e,po
stinterventio
n,andpo
stinterventio
naftersix
-mon
thfollo
w-up
(eWolfM
otor
Functio
nTest
(WMFT
-tt)im
proved
from
21to
17after
Wii-basedmovem
ent
therapy,
andMotor
Activity
LogQualityof
Movem
entScale
scores
improved
from
67.7to
102.4afterW
ii-basedmovem
ent
therapy.
Effectiv
e
(isresult
indicatedWii-
basedmovem
ent
therapyisan
effectiv
eup
per
limbrehabilitation
poststroke
10 Journal of Healthcare Engineering
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
26Nijenh
uis
SMet
al.
[40]
2016
MyoCI
Video
game
Muscular
streng
thening
Arm
and
hand
RCT
19AgeM
�60:
male�
10,and
female�
9
30min,6
sessions
ina
weekforsix
weeks
Prebaseline(one
weekbefore
training
),baselin
e,and1weekafter
training
(postin
terventio
n)andtwomon
ths
aftertheendof
training
follo
w-up
(econtrolg
roup
repo
rted
ahigh
ertraining
duratio
n(189
versus
118minutesper
week).N
odifferences
inclinical
outcom
esover
training
between
grou
pswerefoun
d(p>0.165).
Noeffectiv
e
Anextra
advantageof
this
arm
andhand
training
over
the
conv
entio
nala
rmandhand
exercises
atho
mewas
not
proven.
27Pa
quin
Ket
al.[41]
2015
Nintend
oWii
Fit
Virtual
reality
game
Mob
ilizatio
nof
theup
per
limbs
Hand,
finger,
andwrist
Before
andafter
trial
10AgeM
�72.1:
male�
10
15min,1
6sessions,2
sessions
per
week,
for8
weeks
Baselin
eand
postinterventio
n
Sign
ificant
improvem
ents
were
resultedwith
the
JHFT
,BBT
,and
NHPT
from
pretestin
gto
posttesting
(p�0.03,p
�0.03,
and
p�0.01,
respectiv
ely).A
nincrease
inQOLfrom
pretestin
gto
posttestingis
determ
ined
bytheSIS
(p�0.009).
Effectiv
e
Find
ings
demon
strated
impo
rtant
improvem
ents
occurred
between
pretestin
gand
posttestingon
4metrics.
28da
Fonseca
EPet
al.
[42]
2016
Nintend
oWii
Fit
Virtual
reality
game
Balance
training
Legs,arm
s,trun
k,andhip
RCT
27AgeM
�52.4:
male�
9and
female�
18
45min,2
0sessions
in3
mon
ths
Baselin
eand
postinterventio
n
(enu
mberof
falls
was
statistically
significant(
p�0.049)
only
inthetreatm
ent
grou
p.(
edifferences
ingaitbalancein
the
controlg
roup
(p�0.047)
isresulted.
Partly
effectiv
e
(erehabilitation
ofgaitbalancein
poststroke
peop
leapplying
virtual
reality
hadthe
redu
ctionof
falls.
29Ra
ndD
etal.[43]
2016
Microsoft
Xbo
x360
Kinect
Virtual
reality
game
Balance
training
Mob
ilizatio
nof
theup
per
limbs
Legs,
shou
lder,
elbo
w,a
ndfin
ger
RCT
24AgeM
�62:
male�
15and
female�
9
60min
aday,
6tim
es/w
eek
for5weeks
Baselin
e(anaverage
oftwoassessments)
and
postinterventio
n,andat
the4-week
follo
w-up
ARA
Textrem
ely
improved
by13.9%
and9.6%
follo
wingthe
videogames
and
tradition
alself-
training
programs.
(escores
fortheBo
xandBlockTest
were
20.6
and21.3
forpre
andpo
sttreatm
entin
theexperimental
grou
p.
Effectiv
e
Video
games
orself-training
programscanbe
appliedfor
practicerepetitive
upperextrem
itymovem
ents
with
outthe
supervision
ofa
clinician.
Journal of Healthcare Engineering 11
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
30Sh
inJH
etal.[44]
2015
RehabM
aster ™
Virtual
reality
game
Mob
ilizatio
nof
theup
per
limbs
Upp
erlim
bandtrun
kRC
T32
AgeM
�53.95:
male�
24and
female�
8
30min
for5
days
perw
eek
for4weeks
Baselin
eand
postinterventio
n
(escores
ofFM
A-
UE,
physical
functio
ning
were
improved
forpreand
post
treatm
ent
(experim
entalg
roup
)35.5up
to38.5
and15
upto
20.B
othgrou
psexhibitedsig
nificantly
improved
upper
extrem
ityfunctio
n(p
�0.001)
Effectiv
e
Results
indicate
that
game-based
VRrehabilitation
hasspecificeffects
onhealth-related
quality
oflifeand
upperextrem
ityfunctio
n
31Sh
inJH
etal.[45]
2016
(eRA
PAEL
SmartG
love™
Virtual
reality
game
Mob
ilizatio
nof
theup
per
limbs
Forearm,
wrist,fi
nger,
shou
lder,a
ndelbo
w
RCT
46AgeM
�58.5:
male�
36and
female�
10
30min,2
0sessions
for4
weeks
Baselin
eand
postinterventio
nin
themiddleof
the
treatm
ent
immediately
after
theinterventio
nand
1mon
thafterthe
interventio
n
(eim
provem
ents
inthegamegrou
pwere
supp
ortedby
significantFM
-total:
F�6.48,p
�0.006;
FM-prox:
F�5.73,
p�0.007;
FM-dist:
F�4.64,p
�0.024).
(eim
provem
ents
intheJTTtotal
inthe
gamegrou
pwas
supp
ortedby
significantJTTtotal:
F�4.073,
p�0.032)
Effectiv
e
(egamesystem
used
inVR-based
rehabilitation
might
bean
ideal
rehabilitationtool
forthe
distalup
per
extrem
ityin
stroke
survivors.
32StandenPJ
etal.[46]
2016
Nintend
oWii
Fit
Virtual
reality
game
Mob
ilizatio
nof
theup
per
limbs
Arm
,hand,
shou
lder,a
ndfin
ger
RCT
27AgeM
�61:
male�
16and
female�
11
20min,3
times
aday,
for8weeks
Baselin
eand
postinterventio
nfour
weeks
(midpo
int)andeigh
tweeks
(final)
(erewas
asig
nificantly
greater
change
from
baselin
ein
theinterventio
ngrou
pon
midpo
int
wolfM
FTstreng
th(in
terventio
ngrou
p:2.47;con
trol
grou
p:2.19),andtwo
subscalesof
thefin
alMotor
Activity
Logare
improved
(interventio
ngrou
p:12.80;
controlg
roup
:12.53)
Effectiv
e
(ereisagreater
improvem
ent
from
baselin
ein
theinterventio
ngrou
p,so
itis
effectiv
eto
usea
ndhelp
clinicians.
33Ra
ndD
etal.[47]
2015
Microsoft
Xbo
x360
Kinect
Virtual
reality
game
Balance
training
Mob
ilizatio
nof
theup
per
limbs
Not
mentio
ned
RCT
12AgeM
�63:
male�
7and
female�
5
60min,5
times
aweek
for5weeks
Prebaseline,
baselin
e,po
stinterventio
n,and4weeks
afterthe
interventio
n.
(escores
ofARA
Tfortheexperimental
game-basedgrou
pim
proved
from
30up
to40,also
theBo
xand
BlockTest
improved
forthisgrou
pfrom
25up
to30,and
standing
balanceim
proved
too
from
16pto
29.
Effectiv
e
(esevideogames
encouraged
upper
extrem
itymovem
ents
and
have
potentialto
prom
otestanding
balance.
12 Journal of Healthcare Engineering
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
34Kottin
kAIR
etal.
[48]
2014
Not
mentio
ned
Virtual
reality
game
Mob
ilizatio
nof
thelim
bsArm
and
hand
RCT
18AgeM
�61.4:
male�
13and
female�
5
30min,3
sessions
ina
weekfor6
weeks
Baselin
eand
postinterventio
n
ARA
andFM
improvem
ents
were
significantw
ithin
both
grou
ps(p≤0.009for
themaineffectfor
session),w
itheffect
sizes
(partia
leta
squared)
of0.47
and
0.53
fortheARA
test
andFM
assessment,
respectiv
ely.
Effectiv
e
(epresentstud
yshow
edthat
both
thearm
andhand
functio
nim
proved
aftertraining
.
35Ra
ndD
etal.[49]
2014
Microsoft
Xbo
x360
Kinect
Video
game
Mob
ilizatio
nof
thelim
bsUpp
erextrem
ityRC
T29
AgeM
�59:
male�
17and
female�
12
60min,2
sessions
per
weekfor3
mon
ths
Postinterventio
ndu
ring
thelast
mon
thof
the
interventio
nand1-2
weeks
follo
wingthe
sessions
Participants
inthe
VGG
performed
amedian(IQR)
of271
(157–490)activ
epu
rposeful
movem
entscompared
to48
(3–123)activ
epu
rposeful
movem
ents
intheTG
(z�.3.0,p
�0.001).
Partly
effectiv
e
Video
games
elicitedmoreUE
purposeful
repetitions
and
high
eracceleratio
nof
movem
ent
comparedwith
tradition
altherapy.
36Jordan
Ket
al.[50]
2014
Not
mentio
ned
Virtual
reality
game
Mob
ilizatio
nof
thelim
bsUpp
erlim
bBe
fore
andafter
trial
12AgeM
�68.6
45min,3
sessions
per
weekfor4–6
weeks
Baselin
e(t1),4
weeks
later(t2),
with
in1weekof
completingthe
interventio
n(t3),
andafin
alassessmentw
asgiven4weeks
later
(t4).
Nochange
inthe
FMA-U
Lscores
betweent1
andt2,
indicatin
gastable
baselin
e;asig
nificant
increase
intheFM
A-
ULscores
betweent2
andt3;a
significant
increase
intheFM
A-
ULscores
betweent2
andt4;and
nochange
intheFM
A-U
Lscores
betweent3
andt4
Effectiv
e
(einterventio
nim
proved
thearm
functio
nin
survivorsof
chronicstroke.
37FanSC
etal.[51]
2014
Nintend
oWii
Fit
Virtual
reality
game
Mob
ilizatio
nof
thelim
bsUpp
erarm
RCT
20AgeM
�64.4:
male�
14and
female�
6
60min,3
sessions
per
weekfor3
weeks
Baselin
eand
postinterventio
n(w
eek0),
immediately
after
treatm
ent(week4)
andfour
weeks
after
treatm
ent(week8).
Dun
n’spairwise
comparisonshow
edthat
TTPcontractions
intheWiigrou
pim
proved
significantly
morethan
that
ofthe
no-treatmentg
roup
(p<0.005).
Effectiv
e
Inthispilotstudy,
OTS
VRgaming
hadim
mediate
effects
onmotor
recovery
and
provided
motivationfor
treatm
ent
compliancein
stroke
patients.
Journal of Healthcare Engineering 13
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
38McEwen
Det
al.[52]
2014
IREX
Virtual
reality
game
Mob
ilizatio
nof
thelim
bsBa
lance
training
Lower
extrem
ityRC
T59
AgeM
�64.1:
male�
32and
female�
27
30min,d
aily
sessions
for3
weeks
Before,immediately
after,and1mon
thaftertraining
Moreindividu
alsin
thetreatm
entgrou
pthan
inthecontrol
grou
pshow
edredu
ced
impairmentin
the
lower
extrem
ityas
measuredby
the
Chedo
keMcM
aster
LegDom
ain
(p�0.04)
immediately
after
training
.
Effectiv
e
VRexercise
interventio
nfor
inpatient
stroke
rehabilitation
improved
mob
ility-related
outcom
es.
39Hun
gJW
etal.[53]
2014
Nintend
oWii
Fit
Video
game
Balance
training
Leg
RCT
28AgeM
�54.4:
male�
18and
female�
10
30min,2
sessions
per
weekfor12
weeks
Baselin
e,po
stinterventio
n,andat
3-mon
thfollo
w-up
At3
-mon
thfollo
w-up,
theim
provem
entin
TUG
andFR
testswas
maintained(tim
eeffectinTU
G,
p�0.03,p
artia
ls2
�0.17;F
Rp
�0.01,
andpartials
2�0.22),
buttherewas
anincreasedfear
offalling
inbo
thgrou
ps
Partly
effectiv
e
Exergamingis
enjoyableand
effectiv
efor
patientswith
chronicstroke.
40Norou
zi-
GheidariN
etal.[54]
2019
Jintron
ixsystem
Virtual
reality
game
with
Kinect
Mob
ilizatio
nof
thelim
bsUpp
erextrem
ityRC
T18
AgeM
�49.9:
male�
10and
female�
8
44min,2
-3sessions
per
weekfor4
weeks
Baselin
e,po
stinterventio
n,and4-weekfollo
w-
up
MAL-QOM
andbo
thmob
ility
andph
ysical
domains
oftheSIS
with
meandifference
of1.0%
,5.5%,a
nd6.7%
betweenthe
interventio
nand
controlg
roup
s,respectiv
ely)
atpo
stinterventio
n.
Partly
effectiv
e
Usin
gvirtual
reality
exergaming
techno
logy
may
bebeneficialtoup
per
extrem
ityfunctio
nal
recovery.
41Askın
Aet
al.[55]
2018
KineLabs
Virtual
reality
game
with
Kinect
Mob
ilizatio
nof
thelim
bsUpp
erextrem
ityRC
T38
AgeM
�55.0:
male�
27and
female�
11
60min,5
sessions
per
weekfor4
weeks
Baselin
eand
postinterventio
n
Differencesfrom
baselin
eof
FMA,M
I,andARO
M(except
addu
ctionof
the
shou
lder
and
extensionof
the
elbo
w)weregreaterin
grou
pA
(p<0.05).
Partly
effectiv
e
Kinect-basedVR
training
may
contribu
teto
the
improvem
ento
ftheUEmotor
functio
nand
ARO
Min
chronic
stroke
patients.
42Miranda
CSet
al.
[56]
2019
Nintend
oWii
Fit
Virtual
reality
game
Balance
training
Lower
limbs
RCT
29AgeM
�50.96:
male�
15and
female�
14
3sessions
for
1week.
Session1:
60min;
sessions
2and
3:30
min
Baselin
eand
postinterventio
n,1S
(firstsession),2
S(2
days
afterthe1
session),a
nd3S
(7days
afterthe1
session)
oftraining
.
(eanalyses
show
edon
lyasig
nificanteffect
forthesid
e(A
NOVA:
F�27.80,
p<0.001,
ES�0.99).
Partly
effectiv
e
Peop
leshow
edperformance
improvem
enta
fter
training
with
VR,
butthere
was
notransfer
ofthe
gainsob
tained
toan
untrainedtask
with
similar
balancedemands.
14 Journal of Healthcare Engineering
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
43Fernandes
ABet
al.
[57]
2014
“PaddlePa
nic
MiniG
ame”
Virtual
reality
game
with
Kinect
Mob
ilizatio
nof
thelim
bsUpp
erextrem
ityNon
rand
omized
clinical
trials
40AgeM
�50.75:
male�
20and
female�
20
Not
mentio
ned
Baselin
eand
postinterventio
n
Com
paring
the
participants’
performance
byANOVA,there
was
asig
nificantdifference
inthenu
mberof
hits
betweenthepatients
andhealthy
individu
als’grou
ps,
accordingto
thetrials
(p�0.008).
Effectiv
e
Patientswith
righ
tbraininjury
respon
dedbette
rto
thevirtual
reality
game.
44Moron
eG
etal.[58]
2014
Nintend
oWii
Fit
Video
game
Balance
training
Standing
Transferring
Facilitationof
movem
ents
Paretic
side,
upperlim
b,andleg
RCT
50AgeM
�60.16
20min,3
sessions
per
weekfor4
weeks
Baselin
eand
postinterventio
n(third
evaluatio
noccurred
onemon
thaftertheendof
rehabilitation)
Wiifit
training
was
moreeffectiv
ethan
usualb
alance
therapy
inim
provingbalance
(BBS
:53versus
48,
p�0.004)
and
independ
ency
inactiv
ityof
daily
living
(BI:98
versus
93,
p�0.021).
Effectiv
e
Balancetraining
with
gamewas
foun
dto
bemore
effectiv
ethan
conv
entio
nal
therapyalon
ein
improvingbalance
andredu
cing
disabilityin
patientswith
subacute
stroke.
45Noveletto
Fetal.[59]
2020
Mim
Pong
Video
game
Muscular
streng
thening
Lower
limb
Before
andafter
trial
11AgeM
�59.0:
male�
6and
female�
5
12min,2
sessions
per
weekfor10
weeks
Baselin
eand
postinterventio
n(three
alternatedays
attheendof
the
program)
Sign
ificant
effects
izes
(d)werefoun
dfor
QFG
streng
th(d
�0.5;
p�0.021),Q
FGcontrol(d
�1.1;
p<0.001),H
SGstreng
th(d
�1.1;
p�0.001),H
SGcontrol(d
�1.5;
p�0.003),fun
ctional
mob
ility
(d�0.3;
p<0.001),g
aits
peed
(d�0.4;
p�0.007),
andmotor
recovery
(d�1.0;
p<0.001).
Effectiv
e
Results
indicate
that
the
interventio
nof
aSG
with
both
the
prop
erapparatus
andevaluatio
nsystem
may
effectiv
ely
prom
otelower
limbmotor
rehabilitationof
hemipareticstroke
patients.
46Junior
VA
dosSet
al.
[60]
2019
Nintend
oWii
Fit
Virtual
reality
game
Mob
ilizatio
nof
thelim
bsBa
lance
training
Sensory
functio
nim
provem
ent
Upp
erlim
bandlower
limb
RCT
40AgeM
�55.6:
male�
23and
female�
17
50min,2
sessions
per
weekfor2
mon
ths
Baselin
eand
postinterventio
n(secon
dassessment
after2mon
thsof
treatm
ent)
Anim
provem
entin
themeanscores
was
observed
after
treatm
ent
independ
entof
the
allocatio
ngrou
pwith
significantintragroup
changes:14.5,1
0.5,
and10.4forPN
F,VR,
andPN
F/VR,
respectiv
ely.
Partly
effectiv
e
(euseof
aprogram
combining
virtual
rehabilitationand
PNFpresented
results
that
were
comparablewith
thoseob
tained
with
theiso
lated
techniqu
es.
Journal of Healthcare Engineering 15
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
47Cho
iDet
al.[61]
2018
Nintend
oWii
Fit
Virtual
reality
game
Balance
training
Walking
Lower
limb
RCT
28AgeM
�50.25:
male�
17and
female�
11
30min,3
sessions
per
weekfor6
weeks
Prebaseline,
baselin
e,and
postinterventio
n(1
weekbefore
and
aftertraining
)
WVRT
grou
pshow
edsig
nificant
improvem
ents
of+3
.00(5.25)
intheB
BSscoreand
−1.92
(6.33)
sintheTU
Gtest,w
ithallresults
being
significantly
bette
rthan
thoseof
theGBT
grou
p(p<0.05).
Effectiv
e
(eWVRT
was
auseful
program
for
improvingvisual
perceptio
nand
posturalbalancein
individu
alswith
chronicstroke.
48Bo
rstadAL
etal.[62]
2018
Recovery
rapids
Virtual
reality
game
with
Kinect
Mob
ilizatio
nof
thelim
bsUpp
erlim
bBe
fore
andafter
trial
16AgeM
�49:
male�
10and
female�
6
3ho
ursper
dayfor10
days
over
2weeks
Baselin
eand
postinterventio
n
(emean,
median,
andinterquartile
rang
eforwith
in-sub
jects
change
ontheWMFT
(rate/60
second
s)and
MAL-QOM
(0–5
scale)
were5.8(3.7),
5.8,
2.7–9.4and0.74
(0.66),0
.46,
0.28–1.11,
respectiv
ely.
Partly
effectiv
e
Favorablechanges
inperformance
speedandqu
ality
ofarm
usewere
foun
din
this
stud
y.
49Noveletto
Fetal.[63]
2018
MyB
alance
Video
game
Balance
training
Not
mentio
ned
Before
andafter
trial
18AgeM
�55.3:
male�
8and
female�
10
12minutes
perdayin
the
first
ten
sessions
and
20minutes
perdayin
the
remaining
sessions;2
sessions
per
weekfor10
weeks
Baselin
eand
postinterventio
n
Evaluatedou
tcom
eswerebette
rforallE
Gparticipants.(
eBB
Stest
show
edabalance
improvem
ento
f12.1±7.8%
with
alargeES
(0.9).(
efunctio
nalm
obility
assessed
bytheTU
Gtest
show
edan
improvem
ento
f15.1±7.4%
,but
ESwas
small(0.4).
Effectiv
e
(eresults
ofthis
stud
ysupp
ortthe
clinical
potential
ofabiom
edicalSG
forbalance
rehabilitationof
hemipareticstroke
patients.
50Carregosa
AA
etal.
[64]
2018
Nintend
oWii
Fit
Virtual
reality
game
Mob
ilizatio
nof
thelim
bsMuscular
streng
thening
Balance
training
Coo
rdination
Upp
erlim
bandlower
limb
Before
andafter
trial
5AgeM
�54.8:
male�
3and
female�
2
50min,2
sessions
per
weekfor2
mon
ths
Baselin
e,po
stinterventio
n,and8weeks
afterthe
treatm
ent
Descriptiv
edata
show
edan
improvem
entof
the
motor
functio
nof
the
upperlim
bitems
(26±19.5)andtotal
score(36.6±20.2)of
thescale.
Effectiv
e
(eresults
suggest
that
patientshad
motor
learning
retention,
achievinga
sustainedbenefit
throughthe
techniqu
e.
16 Journal of Healthcare Engineering
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
51Pa
rkJH
andPa
rkJH
[65]
2016
Nintend
oWii
Fit
Virtual
reality
game
Mob
ilizatio
nof
thelim
bsUpp
erextrem
ityRC
T30
Male�
16and
female�
14
30min,5
sessions
per
weekfor4
weeks
Baselin
eand
postinterventio
n(afte
r4weeks)
(ereweresig
nificant
differences
inthe
changesbetweenthe
twogrou
psin
theFM
(p<0.05),BB
T(p<0.05),andMAL-
QOM
(p<0.05).FM
pre:49.3
andFM
post:
54.4
(Fugl–Meyer
Assessm
ent)
Effectiv
e
Gam
e-based
virtualreality
movem
enttherapy
alon
emay
behelpfultoim
prove
functio
nal
recovery
ofthe
upperextrem
ity,
butthe
additio
nof
MPprod
uces
alarger
improvem
ent.
52HocineN
etal.[8]
2015
PRehab
Video
game
Mob
ilizatio
nof
thelim
bsUpp
erlim
bRC
T6
AgeM
�60.66:
male�
4and
female�
2
20min,for
2weeks
(3sessions)
Baselin
eand
postinterventio
n
Itrevealed
asignificant
effecto
fthe
difficulty
strategy
onpatient
performance
(Wilk
s’Lambd
a�0.10;
F�2.38;p<0.02).
Partly
effectiv
e
(eresults
ofthe
experimentshow
that
dynamic
adaptatio
ntechniqu
eincreases
movem
ent
amplitu
dedu
ring
atherapeutic
session.
53Bo
wer
KJ
etal.[66]
2014
Nintend
oWii
Fit
Not
mentio
ned
Balance
training
Mob
ilizatio
nof
thelim
bs
Upp
erlim
bandlower
limb
RCT
30AgeM
�63.6:
male�
17and
female�
13
45min,3
sessions
per
weekover
2–4weeks
Baselin
e,twoweeks,
andfour
weeks
Improvem
ents
were
observed
inthe
majority
ofsecond
ary
outcom
esover
timein
both
grou
ps.(
ebalancegrou
pparticipants
demon
stratedgreater
improvem
ents
inWii
balancebo
ard-derived
measuresw
ithsm
allto
largeeffects
izes
(d�0.30–1.00)
atfour
weeks
(p�0.007
−0.048).
Partly
effectiv
e
Specificactiv
ities
targeted
atbalance
training
are
potentially
effectiv
efor
improving
standing
balance.
54Brow
nEV
Det
al.
[67]
2014
Peggle
Video
game
Balancing
training
Upp
erextrem
ityRC
T9
AgeM
�60:
male�
5and
female�
4
45min,5
sessions
per
weekfor4
weeks
Baselin
eand
postinterventio
nassessments,
approxim
ately4
weeks
apart,before
system
use
Nodifferences
were
foun
dacross
timeon
anyof
theWMFT
subscalesor
the
CAHAI-9WMFT
functio
nala
ctivity
score:A1:1.79±0.71;
A2:1.77±0.68;A
3:1.79±0
.66
Noeffectiv
e
(isstud
yhad
limitedchangesin
kinematic
and
activ
itylevel
outcom
es
Journal of Healthcare Engineering 17
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
55Slijp
erA
etal.[68]
2014
Not
mentio
ned
Video
game
Mob
ilizatio
nof
thelim
bsUpp
erextrem
ityBe
fore
andafter
trial
11AgeM
�58:
male�
5and
female�
6
5weeks,
meantim
e:1070
min
Baselin
e,du
ring
,po
stinterventio
n,andfollo
w-up1
6–18
weeks
afterthe
treatm
entph
ase
FMA-U
EA-D
(motor
functio
n)show
edsig
nificant
improvem
ents
inthe
upperextrem
ityfunctio
nbetween
baselin
e(A
1)and
posttest
(A2)
(0.005)
aswella
safollo
w-up
(<0.0001).Fu
gl–M
eyer
A-D
:preinterventio
n:44,intervention:
49,
postinterventio
n:51
Effectiv
e
(eresults
indicate
that
compu
tergame-
basedtraining
couldbe
aprom
ising
approach
toim
proveup
per
extrem
ityfunctio
n.
56ChenCC
etal.[69]
2017
Not
mentio
ned
Virtual
reality
game
Muscular
streng
thening
Mob
ilizatio
nof
thelim
bs
Upp
erlim
bBe
fore
andafter
trial
21AgeM
�55.7:
male�
14and
female�
7
60min,3
sessions
per
weekfor8
weeks
Baselin
eand
postinterventio
n
(estatistical
results
confi
rmed
asignificant
effecto
ftreatment.
FMA:b
aseline:
30.35±13.8.A
fter
interventio
n:38.80±14.61
Effectiv
e
Find
ingsuggests
that
VR-based
rehabilitationcan
indu
cesig
nificantly
kinetic
changes
than
facilitate
recovery.
57LeeMM
etal.[70]
2018
Nintend
oWii
Fit
Virtual
reality
game
Balance
training
Mob
ilizatio
nof
thelim
bs
Upp
erextrem
ityRC
T30
AgeM
�61.56:
male�
18and
female�
12
30min,3
sessions
per
week,
for5
weeks
Baselin
eand
postinterventio
non
edayafterthefive-
weekinterventio
nperiod
MFT
was
significantly
improved
inbo
thgrou
pscomparedwith
baselin
evalues
(p<0.05).Pre:
8.93±1.53;p
ost:
11.40±2.47
Effectiv
e
Gam
e-basedVR
Canoe
padd
ling
training
isan
effectiv
erehabilitation
therapythat
enhances
postural
balanceandup
per
extrem
ityfunctio
n.
58Pa
rkDS
etal.[71]
2017
Microsoft
Xbo
x360
Kinect
Virtual
reality
game
with
Kinect
Mob
ilizatio
nof
thelim
bsBa
lance
training
Motor
functio
n
Lower
extrem
ityRC
T20
AgeM
�63.65:
male�
10and
female�
10
30min,d
aily
sessions
fora
6-week
period
Baselin
eand
postinterventio
n
(epre-to-post
differencescores
onBB
S,TU
G,and
10mWTforthe
interventio
ngrou
pweresig
nificantly
moreim
proved
than
thoseforthecontrol
grou
p(p<0.05).
Effectiv
e
Evidence
supp
orts
theuseof
additio
nalV
Rtraining
with
the
Xbo
xKinect
gamingsystem
asan
effectiv
etherapeutic
approach
for
improvingmotor
functio
n.
59Pa
rkJS
etal.[72]
2019
Not
mentio
ned
Video
game
Muscular
streng
thening
Motor
functio
n
Hand
RCT
43AgeM
�59.43:
male�
26and
female�
17
30min,5
sessions
per
week,
for6
weeks
Baselin
eand
postinterventio
n
Afte
rtraining
,hand
streng
th,M
FT,a
ndBB
Twereim
proved
intheexperimental
grou
pcomparedto
the
controlg
roup
(P<0.001,
both).
MFT
:pre:12.91±5.73;
post:16.23±5.95
Effectiv
e
Gam
e-based
exercise
ismore
effectiv
ethan
manualexercise
inim
provingmuscle
streng
th,m
otor
functio
n,and
compliancein
stroke
patients.
18 Journal of Healthcare Engineering
Tabl
e2:
Con
tinued.
No.
Autho
rsYe
arNam
eof
gamificatio
napproach
Type
ofgamificatio
napproach
Type
ofrehabilitation
Rehabilitated
target
mem
bers
Stud
ydesig
nSample
size
Sample
description
(sex,age
(year))
Session
details
Assessm
enttim
eAssessm
entscore
Effectiv
eness
Results
60Ahm
adi
HSet
al.
[73]
2019
E-Link
Virtual
reality
game
Mob
ilizatio
nof
thelim
bsUpp
erlim
bNon
rand
omized
clinical
trials
30AgeM
�55.24:
male�
20and
female�
10
40min,3
sessions
per
week,
for4
weeks
Baselin
eand
postinterventio
n
(efin
ding
show
sthe
improvem
ento
fupp
erlim
bmotor
functio
n,tone,a
ndrang
eof
motionin
thisgrou
p.Meandifferences:
FMA
(total
score);
interventio
n:6.53;
control:3.86
Effectiv
e
Com
putergames
canim
proveu
pper
limbmotor
functio
n,muscle
tone,and
the
rang
eof
motionin
stroke
patients.
FMA-U
E,Fu
gl–M
eyer
Assessm
entfor
Upp
erEx
trem
ity;W
MFT
,WolfM
otor
Functio
nTest;IMI,Intrinsic
MotivationInventory;IA
DL,Lawtonof
instrumentalactivities
ofdaily
living;SIS,Stroke
ImpactScale;
B-stage,brainstorm
stage;MMT,
manualm
uscletesting;AP-axis,
anterior-posterior
axis;
CIM
T,constraint-in
ducedmovem
enttherapy;G
R,gesturerecogn
ition
;NWF,Nintend
oWiiFitT
Mgame;FU
,follow-up;
FMA-LE,
Fugl–M
eyer
Assessm
ent;BE
STest,Ba
lanceEv
aluatio
nSystem
sTest;A
T,aftertraining
;10M
WT,
10-m
eter
testof
walking
score;CoP
,centerof
pressure;A
Psw
ay,sway
kinematicsin
theanterior-
posterior;BB
S,theBe
rgBa
lanceScale;FA
BS,F
ullerton
AdvancedBa
lanceScale;TU
G,T
imed
UpandGo;
FM,F
ugl–Meyer;A
RA,A
ctionRe
search
Arm
;UE,
upperextrem
ity;V
GG,video
gamegrou
p;TG
,tradition
algrou
p;IQ
R,interquartile
rang
e;FM
A-U
L,Fu
gl–M
eyer
upperlim
itassessment;OTS
VR,
off-the-shelfvirtualreality;
TTP,
time-to-peak;
VR,
virtualreality;
FR,forwardreach;
MAL-QOM,M
otor
Activity
LogQualityof
Movem
ent;FM
A,F
ugl–Meyer
Assessm
ent;MI,Motricity
Index;ARO
M,activerang
eof
motion;
BI,B
arthelIndex;SG
,serious
games;Q
FG,quadricepsfem
oris;
HSG
,ham
string
s;PN
F,prop
rioceptiv
eneuromuscularfacilitatio
n;WVRT
,WiiFitvirtualreality
training
;GBT
,generalbalancetraining;EG
,experim
entalgroup
;ES,effectsizes;B
BT,B
oxandBlockTest;M
P,mentalpractice;CAHAI-9,
Chedo
keArm
andHandActivity
Inventory-9;
MFT
,manualfun
ctiontest;R
CT,
rand
omized
controlledtrialo
rrand
omized
controltrial.
Journal of Healthcare Engineering 19
According to results, emerging games possess the capacityand potential to rehabilitate physical aspects in poststrokepatients; furthermore, these games can help patients im-prove their independence. According to surveys, virtualreality-based approaches and “the Nintendo Wii Fit” gameswere used more than other games. (e most common use ofgames in poststroke survivors’ rehabilitation was related tolimb movement and balance training.
Due to the included studies’ results, different indicatorsand scales have been calculated and statistically analyzed toevaluate and test game-based physical rehabilitation ther-apies for poststroke patients. (ese statistical analysesdemonstrated the positive effect of innovative rehabilitationis provided in the form of games for these patients. Even inmany studies, applied games in different environments
(virtual reality, and video-based games) have led to a greatimprovement in patients’ physical problems such as balancedisorder, upper extremity spasticity, and limbs’ immobilityand muscular weakness [3, 5, 11, 74–77]. Researchers inthese studies have concluded that they can incorporate thesegames into the treatment plan and physiotherapy of post-stroke patients and use them as alternative therapies totraditional methods because, in these experimental studies,significant improvements in all outcome measures werefound after the intervention [76, 78]. However, in infrequentarticles, no significant differences can be observed in allassessment scales (baseline and post-intervention assess-ments in the experimental and control groups) to evaluategame-oriented physiotherapies’ effectiveness. For this rea-son, in these studies, the researcher has concluded that the
Table 3: Distribution of studies based on publication type.
Journal/conference name Conference JournalClinical Rehabilitation 5Journal of Stroke and Cerebrovascular Diseases 4Archives of Physical Medicine and Rehabilitation 4Games for Health Journal: Research, development, and clinical applications 4Disability and Rehabilitation 2Journal of NeuroEngineering and Rehabilitation 2NeuroRehabilitation 2IEEE Transactions on Neural Systems and Rehabilitation Engineering 2International Journal of Environmental Research and Public Health 2Journal of Medical and Biological Engineering 1International Medical Journal of Experimental and Clinical Research 1American Journal of Physical Medicine and Rehabilitation 1Computers in Biology and Medicine 1Journal of Central Nervous System Disease 1BioMed Research International 1Brain Impairment 1European Journal of Physical and Rehabilitation Medicine 1User Modeling and User-Adapted Interaction 1Frontiers in Psychology 1Iranian Rehabilitation Journal 1Journal of Physical (erapy Science 1Journal of Healthcare Engineering 1Annals of Physical and Rehabilitation Medicine 1Journal of Motor Behavior 1American Academy of Physical Medicine and Rehabilitation 1Journal of Patient-Centered Research and Reviews 1Restorative Neurology and Neuroscience 1Stroke 1Medical Science Monitor 1Neurorehabilitation and Neural Repair 1Somatosensory and Motor Research 1(e Journal of Physical (erapy Science 1International Journal of Stroke 1Virtual Reality 1International Journal of Neuroscience 1In Proceedings of the 3rd 2015 Workshop on ICTs for improving Patients Rehabilitation Research Techniques 2Proceedings of the IEEE International Conference on Advanced Materials for Science and Engineering 1In 2019 International Conference on Robotics and Automation in Industry 12019 Fifth International Conference on Advances in Biomedical Engineering (ICABME) 1International Conference on Virtual Rehabilitation 12017 International Conference on Applied System Innovation (ICASI) 1Total 7 53
20 Journal of Healthcare Engineering
game chosen to rehabilitate poststroke patients cannot be auseful tool to alternate with the traditional physical reha-bilitation methods, and applying them can destroy the pa-tient’s time and motivation.
(e reason for the ineffectiveness of newly emergedgames for motor rehabilitation of stroke patients can havedifferent reasons as follows: insufficient session times andtraining duration to generate consistent improvements in allpatients, the insufficient number of participants in the ex-perimental studies (randomized trails would require at least
25 participants in each group) [38, 76], the high mean age ofpatients in both intervention and control groups (underlyingdisability of people due to their age), and excessive move-ment limitations of the patients recruited in the study[79, 80].
According to this study’s results, the most popular typeof game for physical rehabilitation of poststroke patients wasvirtual reality games. Virtual reality-based games allowpatients to interact with a virtual environment while per-forming rehabilitation exercises and simulating real
Table 4: Distributions of studies of publication years and country.
Row labelsColumn labels
2013 2014 2015 2016 2017 2018 2019 2020 TotalAustralia 1 1 2Brazil∗ 1 2 1 2 2 1 9Canada 1 1 1 3China 1 1France 1 1 2Iran 1 1Israel 1 2 1 4Italy 1 1 2Lebanon 1 1Malaysia 1 1Netherlands 1 1 2New Zealand 1 1Pakistan 1 1Republic of Korea∗ 1 4 2 2 4 13Spain 1 1Sweden 1 1Taiwan∗ 1 1 1 2 1 6Turkey 1 2 3UK 2 2USA 1 1 1 1 4Grand total 1 10 9 11 3 9 13 4 60∗3 countries with the highest number of study prints.
1
13
5
1535
Not mentionedMixed reality gameVideo game withkinect
Virtual reality gamewith kinectVideo gameVirtual reality game
Figure 3: (e distribution of studies based on gamification types.
Journal of Healthcare Engineering 21
1 11 1 11
1 1 1 12
6 1
1 1 1 1 1 1
19
5
3
1 1 1 1 1 1 1 10
5
10
15
20
25
�e N
inte
ndo
Wii
Fit
Not
men
tione
d�
e Xbo
x 36
0°E-
Link
Reha
bMas
terTM
Gar
deni
ng d
igita
l gam
ePR
ehab
HTC
Viv
eD
BIVG
IREX
MyB
alan
ceM
yoCI
Padd
le P
anic
Min
i Gam
eJin
troni
x sy
stem
Pegg
leKi
nect
2Scr
atch
Reco
very
Rap
ids
Kine
Labs
�e B
right
Arm
TM
Mic
roso
� de
velo
ped
Robo
Raid
�e R
APA
EL S
mar
t Glo
veTM
Mim
Pong
Cano
e gam
eM
oU-R
ehab
Virtual reality gameVideo gameVirtual reality game with kinect
Video game with kinectMixed reality gameNot mentioned
Figure 4: (e distribution of studies based on type and name of games.
Mobilization of the limbsLower extremityWalkingMuscular strengthening
Balance trainingTrunk postural stabilityStandingPostural control
Mobilization of the armsSensory function improvementCoordinationMotor function
Mobilization of the limbs,24 Balance training, 23Walking,
4
Muscular strengthening,8
Motorfunction, 5
Trunkpostural
stability, 2Postural
control, 2
Mobilization of...
Sensoryfuncti...
Lowerextre...
Standing, 1
Coordinat...
Figure 5: Physical rehabilitation therapies in reviewed studies.
22 Journal of Healthcare Engineering
functions. (ese games increase patients’ motivation toperform rehabilitation exercises and provide a pleasantenvironment for patients, which can lead to more repetitionof rehabilitation exercises in these patients [77]. People getfeedback while playing virtual reality games, and this factorencourages patients with disabilities to attend therapy ses-sions and use their remaining functional capacity to succeedin the game [81].
Results have shown that “the Nintendo Wii Fit” gamesare used more than other games to rehabilitate poststrokepatients. Several factors can lead to the most use of thisgame. Among these factors, we can mention the price ofthese games, which are relatively inexpensive. (ese gamesare widely available to people, and studies have shown that
providing an attractive environment increases patients’enjoyment and more repetition of rehabilitation exercises[82–84]. Features of the Wii Fit game system lead to thestimulation of people’s interest in continuing to play andcan be useful for improving motor function and balancecontrol [61].
Studies showed that the most common use of games inthe rehabilitation of stroke survivors was related to limbmovement and balance training. In other words, the resultsof studies that were run to examine the effect of games onpeople after a stroke had shown these games were effective inimproving the balance of people and strengthening themuscles of the limbs [85]. In a systematic review conductedby Corbetta, the effectiveness of virtual reality games has
Table 5: Distribution of studies based on the type of study and effectiveness.
Row labels EffectivenessEffective 41Before and after trial 13Nonrandomized clinical trials 2RCT 26
Not effective 3RCT 3
Partly effective 16Before and after trial 3RCT 13
Total 60
0
1
2
3
4
5
6
13.5 1 14 3
17.8
3 18 5.5 20 8.6 21
10.5 25 90
31.5 8.8
34.4
17.
5 351.
25 56 15 26 30 822
.5 613
.3 24 7no
t men
tiend 5 12 4 9 10
Figure 6: (e distribution of studies based on the total time of rehabilitation duration.
41
316
Effective
No effectivePartly effective
Total
Figure 7: (e distribution of the reviewed studies based on effectiveness.
Journal of Healthcare Engineering 23
been investigated and concluded that managed games havethe most significant impact on patient mobility [75].According to the results of this survey and other studies thatshow the effect of the game on maintaining balance andmovement, it is recommended to use these games inpoststroke survivors.
(is systematic review had several strengths and limi-tations. One of the strengths was the use of broad keywordsto search in 4 crucial databases. Another strength of thissurvey was the inclusion of studies presented at conferences.(e limitations were the exclusion of articles in non-Englishlanguage and the time limit imposed on searching databases(from 2014 onwards). Another limitation of this review wasthe different scales used to measure people’s performance,and this factor made it difficult to compare the results ofdifferent surveys.
5. Conclusion
Game-based approaches lead to patients being able tosmoothly perform their rehabilitation movement techniqueswithout going to the treatment centers. (ese games canimmerse the person in the environment by providing virtualor augmented reality capabilities and multiplying the ef-fectiveness of the treatment. (erefore, the use of appro-priate technology-based gaming solutions can improvepatients’ treatment and minimize the waste of time and costof providing traditional motor rehabilitation. Consequently,these game-based treatments are considered complementaryto traditional ones and can reduce the workload of therapistsand accelerate the rehabilitation process. Future researchshould focus on how task-specific game-oriented systemscan improve function after stroke, and statistical studies canshow this effect more.
Data Availability
All data generated or analyzed during this study are includedwithin this article.
Conflicts of Interest
(e authors declare that there are no conflicts of interest.
References
[1] E. Noe-Sebastian, M. Balasch-Bernat, C. Colomer-Font et al.,“Disability after stroke: a longitudinal study in moderate andsevere stroke patients included in a multidisciplinary reha-bilitation program,” Revista de Neurologia, vol. 64, no. 9,pp. 385–392, 2017.
[2] V. L. Feigin, M. H. Forouzanfar, R. Krishnamurthi et al.,“Global and regional burden of stroke during 1990-2010:findings from the global burden of disease study 2010,” +eLancet, vol. 383, no. 9913, pp. 245–255, 2014.
[3] B. B. Gambassi, Efeitos do treinamento resistido dinamicosobre parametros funcionais, autonomicos e de estresse oxi-dativo em sobreviventes ao acidente vascular cerebralisquemico cronico, Universidade Estadual de Campinas,Campinas, Brazil, 2018.
[4] P. Astuti, K. Kusnanto, and F. Dwi Novitasari, “Depressionand functional disability in stroke patients,” Journal of PublicHealth Research, vol. 9, no. 2, p. 1835, 2020.
[5] N. Takeuchi and S. Izumi, “Rehabilitation with poststrokemotor recovery: a review with a focus on neural plasticity,”Stroke Research and Treatment, vol. 2013, Article ID 128641, ,2013.
[6] L. Dodakian, A. L. McKenzie, V Le et al., “A home-basedtelerehabilitation program for patients with stroke,” Neuro-rehabilitation and Neural Repair, vol. 31, no. 10-11,pp. 923–933, 2017.
[7] H. Soufi Ahmadi, A. Hassani Mehraban, M. Amini, andM. Sheikhi, “(e effects of virtual reality on upper limbfunction in chronic stroke patients: a clinical trial,” IranianRehabilitation Journal, vol. 17, no. 1, pp. 81–89, 2019.
[8] N. Hocine, A. Gouaıch, S. A. Cerri, D. Mottet, J. Froger, andI. Laffont, “Adaptation in serious games for upper-limb re-habilitation: an approach to improve training outcomes,”UserModeling and User-Adapted Interaction, vol. 25, no. 1,pp. 65–98, 2015.
[9] H. Leutwyler, E. M. Hubbard, and G. A. Dowling, “Adherenceto a videogame-based physical activity program for olderadults with schizophrenia,” Games for Health Journal, vol. 3,no. 4, pp. 227–233, 2014.
[10] Y.-L. Ng, F. Ma, F. K. Ho, P. Ip, and K.-w. Fu, “Effectiveness ofvirtual and augmented reality-enhanced exercise on physicalactivity, psychological outcomes, and physical performance: asystematic review and meta-analysis of randomized con-trolled trials,” Computers in Human Behavior, vol. 99,pp. 278–291, 2019.
[11] B. A. Primack, M. V. Carroll, M. McNamara et al., “Role ofvideo games in improving health-related outcomes,”American Journal of Preventive Medicine, vol. 42, no. 6,pp. 630–638, 2012.
[12] J. Simmich, A. J. Deacon, and T. G. Russell, “Active videogames for rehabilitation in respiratory conditions: systematicreview and meta-analysis,” JMIR serious games, vol. 7, no. 1,Article ID e10116, 2019.
[13] H. Tariq, “Effect of balance exercises for person with multiplesclerosis using Wiigame: a systematic review of randomizedand non-randomized control trials,” Acta Medical Interna-tional, vol. 3, no. 1, p. 196, 2016.
[14] D. Moher, A. Liberati, J. Tetzlaff, D. G. Altman, and P. Group,“Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement,” PLoSMedicine, vol. 6, no. 7,Article ID e1000097, 2009.
[15] I. Laffont, J. Froger, C. Jourdan et al., “Rehabilitation of theupper arm early after stroke: video games versus conventionalrehabilitation. A randomized controlled trial,” Annals ofPhysical and Rehabilitation Medicine, vol. 63, no. 3,pp. 173–180, 2020.
[16] I. Cikajlo, M. Rudolf, R. Mainetti, and N. A. Borghese, “Multi-exergames to set targets and supplement the intensifiedconventional balance training in patients with stroke: arandomized pilot trial,” Frontiers in Psychology, vol. 11, p. 572,2020.
[17] A. C. Glueck and D. Y. Han, “Improvement potentials inbalance and visuo-motor reaction time after mixed realityaction game play: a pilot study,” Virtual Reality, vol. 24, no. 2,pp. 223–229, 2020.
[18] F. Ayoubi, S. Chamouni, O. Zein, and A. R. Sarraj, “Virtualreality movement therapy for post-stroke upper limb reha-bilitation trial,” in Proceedings of the 2019 Fifth International
24 Journal of Healthcare Engineering
Conference on Advances in Biomedical Engineering(ICABME), pp. 1–3, Piscataway, NJ, USA, October 2019.
[19] J. X. De Gouvea, D. B. Perez, C. S. Miranda,T. De Paula Oliveira, and M. E. Piemonte, “Upper limbtraining using virtual reality in patients with chronic sequelsof stroke,” in Proceedings of the 3rd 2015Workshop on ICTs forImproving Patients Rehabilitation Research Techniques 2015,pp. 85–88, Lisbon, Portugal, October 2015.
[20] M. J. Cano-Mañas, S. Collado-Vazquez, J. RodrıguezHernandez, A. J. Muñoz Villena, and R. Cano-De-La-Cuerda,“Effects of video-game based therapy on balance, posturalcontrol, functionality, and quality of life of patients withsubacute stroke: a randomized controlled trial,” Journal ofHealthcare Engineering, vol. 2020, Article ID 5480315,11 pages, 2020.
[21] T. T. Simsek and K. Çekok, “(e effects of NintendoWii(TM)-based balance and upper extremity training onactivities of daily living and quality of life in patients with sub-acute stroke: a randomized controlled study,” InternationalJournal of Neuroscience, vol. 126, no. 12, pp. 1061–1070, 2016.
[22] J. W. Hung, C. X. Chou, Y. J. Chang et al., “Comparison ofKinect2Scratch game-based training and therapist-basedtraining for the improvement of upper extremity functions ofpatients with chronic stroke: a randomized controlled single-blinded trial,” European Journal of Physical and RehabilitationMedicine, vol. 55, no. 5, pp. 542–550, 2019.
[23] K. Adie, C. Schofield, M. Berrow et al., “Does the use ofNintendo Wii SportsTM improve arm function? Trial ofWiiTM in Stroke: a randomized controlled trial and eco-nomics analysis,” Clinical Rehabilitation, vol. 31, no. 2,pp. 173–185, 2017.
[24] M. A. Ahmad, D. K. A. Singh, N. A. Mohd Nordin, K. HooiNee, and N. Ibrahim, “Virtual reality games as an adjunct inimproving upper limb function and general health amongstroke survivors,” International Journal of EnvironmentalResearch and Public Health, vol. 16, no. 24, 2019.
[25] Y.-H. Choi, J. Ku, H. Lim, Y. H. Kim, and N.-J. Paik, “Mobilegame-based virtual reality rehabilitation program for upperlimb dysfunction after ischemic stroke,” Restorative Neurologyand Neuroscience, vol. 34, no. 3, pp. 455–463, 2016.
[26] H.-S. Choi, W.-S. Shin, D.-H. Bang, and S.-J. Choi, “Effects ofgame-based constraint-induced movement therapy on bal-ance in patients with stroke: a single-blind randomizedcontrolled trial,” American Journal of Physical Medicine &Rehabilitation, vol. 96, no. 3, pp. 184–190, 2017.
[27] H.-S. Choi, W.-S. Shin, and D.-H. Bang, “Mirror therapyusing gesture recognition for upper limb function, neckdiscomfort, and quality of life after chronic stroke: a single-blind randomized controlled trial,” Medical Science Monitor,vol. 25, pp. 3271–3278, 2019.
[28] T. De Paula Oliveira, C. S. Miranda, J. X. M. De Gouvea,D. B. Perez, A. P. Marques, and M. E. P. Piemonte, “Balancetraining in virtual reality in patients with chronic sequels ofstroke: effects on ICF domains, preliminary data,” in Pro-ceedings of the 3rd 2015 Workshop on ICTs for improvingPatients Rehabilitation Research Techniques, pp. 96–99, Lis-bon, Portugal, October 2015.
[29] N. Givon, G. Zeilig, H. Weingarden, and D. Rand, “Video-games used in a group setting is feasible and effective toimprove indicators of physical activity in individuals withchronic stroke: a randomized controlled trial,” Clinical Re-habilitation, vol. 30, no. 4, pp. 383–392, 2016.
[30] G. House, G. Burdea, K. Polistico et al., “A rehabilitation first-tournament between teams of nursing home residents with
chronic stroke,” Games for Health Journal, vol. 5, no. 1,pp. 75–83, 2016.
[31] H.-C. Hsieh, “Training by using an adaptive foot switch andvideo games to improve balance and mobility followingstroke: a randomised controlled trial,” Brain Impairment,vol. 20, no. 1, pp. 16–23, 2019.
[32] H.-C. Hsieh, “Use of a gaming platform for balance trainingafter a stroke: a randomized trial,” Archives of PhysicalMedicine and Rehabilitation, vol. 100, no. 4, pp. 591–597, 2019.
[33] L. L. Huang and M. H. Chen, “(e effectiveness of gardeninggame design for the upper extremity function of stroke pa-tients,” in Proceedings of the 2016 International Conference onAdvanced Materials for Science and Engineering (ICAMSE),Tainan, China, November 2016.
[34] R. U. Khan, M. W. Tahir, and M. I. Tiwana, “Rehabilitationprocess of upper limbs muscles through EMG based videogame,” in Proceedings of the 2019 International Conference onRobotics and Automation in Industry (ICRAI), pp. 1–5, IEEE,Piscataway, NJ, USA, October 2019.
[35] S. Ikbali Afsar, I. Mirzayev, O. Umit Yemisci, and S. N. CosarSaracgil, “Virtual reality in upper extremity rehabilitation ofstroke patients: a randomized controlled trial,” Journal ofStroke and Cerebrovascular Diseases, vol. 27, no. 12,pp. 3473–3478, 2018.
[36] M.-M. Lee, D.-C. Shin, and C.-H. Song, “Canoe game-basedvirtual reality training to improve trunk postural stability,balance, and upper limb motor function in subacute strokepatients: a randomized controlled pilot study,” Journal ofPhysical +erapy Science, vol. 28, no. 7, pp. 2019–2024, 2016.
[37] M. Serper, A. W. Cubell, M. E. Deleener et al., “Telemedicinein liver disease and beyond: can the COVID-19 crisis lead toaction?” Hepatology, vol. 72, no. 2, pp. 723–728, 2020.
[38] S. H. Lee, H. Y. Jung, S. J. Yun, B. M. Oh, and H. G. Seo,“Upper extremity rehabilitation using fully immersive virtualreality games with a head mount display: a feasibility study,”PM&R: +e Journal of Injury, Function, and Rehabilitation,vol. 12, no. 3, pp. 257–262, 2020.
[39] P. A. McNulty, A. G. (ompson-Butel, S. G. Faux et al., “(eefficacy of Wii-based movement therapy for upper limb re-habilitation in the chronic poststroke period: a randomizedcontrolled trial,” International Journal of Stroke, vol. 10, no. 8,pp. 1253–1260, 2015.
[40] S. M. Nijenhuis, G. B. Prange-Lasonder, A. H. Stienen,J. S. Rietman, and J. H. Buurke, “Effects of training with apassive hand orthosis and games at home in chronic stroke: apilot randomised controlled trial,” Clinical Rehabilitation,vol. 31, no. 2, pp. 207–216, 2017.
[41] K. Paquin, S. Ali, K. Carr, J. Crawley, C. McGowan, andS. Horton, “Effectiveness of commercial video gaming on finemotor control in chronic stroke within community-levelrehabilitation,” Disability & Rehabilitation, vol. 37, no. 23,pp. 2184–2191, 2015.
[42] E. Pedreira da Fonseca, N. M. Ribeiro da Silva, and E. B. Pinto,“(erapeutic effect of virtual reality on post-stroke patients:randomized clinical trial,” Journal of Stroke and Cerebro-vascular Diseases, vol. 26, no. 1, pp. 94–100, 2017.
[43] D. Rand, H. Weingarden, R. Weiss et al., “Self-training toimprove UE function at the chronic stage post-stroke: a pilotrandomized controlled trial,” Disability & Rehabilitation,vol. 39, no. 15, pp. 1541–1548, 2017.
[44] J.-H. Shin, S. Bog Park, and S. Ho Jang, “Effects of game-basedvirtual reality on health-related quality of life in chronic strokepatients: a randomized, controlled study,” Computers in Bi-ology and Medicine, vol. 63, pp. 92–98, 2015.
Journal of Healthcare Engineering 25
[45] J. H. Shin, M. Y. Kim, J. Y. Lee et al., “Effects of virtual reality-based rehabilitation on distal upper extremity function andhealth-related quality of life: a single-blinded, randomizedcontrolled trial,” Journal of NeuroEngineering and Rehabili-tation, vol. 13, no. 1, p. 17, 2016.
[46] P. Standen, K. (reapleton, A. Richardson et al., “A low costvirtual reality system for home based rehabilitation of the armfollowing stroke: a randomised controlled feasibility trial,”Clinical Rehabilitation, vol. 31, no. 3, pp. 340–350, 2017.
[47] D. Rand, A. Yacoby, R. Weiss, S. Reif, R. Malka, andH. Weingarden, Home-based Self-Training Using Video-Games: Preliminary Data from a Randomised ControlledTrial2015.
[48] A. I. R. Kottink, G. B. Prange, T. Krabben, J. S. Rietman, andJ. H. Buurke, “Gaming and conventional exercises for im-provement of arm function after stroke: a randomized con-trolled pilot study,” Games for Health Journal, vol. 3, no. 3,pp. 184–191, 2014.
[49] D. Rand, N. Givon, H. Weingarden, A. Nota, and G. Zeilig,“Eliciting upper extremity purposeful movements using videogames: a comparison with traditional therapy for stroke re-habilitation,” Neurorehabilitation and Neural Repair, vol. 28,no. 8, pp. 733–739, 2014.
[50] K. Jordan, M. Sampson, and M. King, “Gravity-supportedexercise with computer gaming improves arm function inchronic stroke,” Archives of Physical Medicine and Rehabili-tation, vol. 95, no. 8, pp. 1484–1489, 2014.
[51] S. C. Fan, F. C. Su, S. S. Chen, W. H. Hou, J. S. Sun, andK. H. Chen, “Improved intrinsic motivation and muscleactivation patterns in reaching task using virtual realitytraining for stroke rehabilitation: a pilot randomized controltrial,” Journal of Medical and Biological Engineering, vol. 34,no. 4, pp. 399–407, 2014.
[52] D. McEwen, A. Taillon-Hobson, M. Bilodeau, H. Sveistrup,and H. Finestone, “Virtual reality exercise improves mobilityafter stroke,” Stroke, vol. 45, no. 6, pp. 1853–1855, 2014.
[53] J.-W. Hung, C.-X. Chou, Y.-W. Hsieh et al., “Randomizedcomparison trial of balance training by using exergaming andconventional weight-shift therapy in patients with chronicstroke,” Archives of Physical Medicine and Rehabilitation,vol. 95, no. 9, pp. 1629–1637, 2014.
[54] N. Norouzi-Gheidari, A. Hernandez, P. S. Archambault,J. Higgins, L. Poissant, and D. Kairy, “Feasibility, safety andefficacy of a virtual reality exergame system to supplementupper extremity rehabilitation post-stroke: a pilot random-ized clinical trial and proof of principle,” International Journalof Environmental Research and Public Health, vol. 17, no. 1,2019.
[55] A. Askın, E. Atar, H. Koçyigit, and A. Tosun, “Effects ofKinect-based virtual reality game training on upper extremitymotor recovery in chronic stroke,” Somatosensory & MotorResearch, vol. 35, no. 1, pp. 25–32, 2018.
[56] C. S. Miranda, T. d. P. Oliveira, J. X. M. Gouvea, D. B. Perez,A. P. Marques, and M. E. P. Piemonte, “Balance training invirtual reality promotes performance improvement but nottransfer to postural control in people with chronic stroke,”Games for Health Journal, vol. 8, no. 4, pp. 294–300, 2019.
[57] A. B. G. S. Fernandes, J. Oliveira dos Passos, D. Paiva de Brito,and T. Fernandes Campos, “Comparison of the immediateeffect of the training with a virtual reality game in strokepatients according side brain injury,” NeuroRehabilitation,vol. 35, no. 1, pp. 39–45, 2014.
[58] G. Morone, M. Tramontano, M. Iosa et al., “(e efficacy ofbalance training with video game-based therapy in subacute
stroke patients: a randomized controlled trial,” BioMed Re-search International, vol. 2014, Article ID 580861, 6 pages,2014.
[59] F. Noveletto, A. V. Soares, F. L. F. Eichinger, S. C. Domenech,M. d. S. Hounsell, and P. B. Filho, “Biomedical serious gamesystem for lower limb motor rehabilitation of hemipareticstroke patients,” IEEE Transactions on Neural Systems andRehabilitation Engineering, vol. 28, no. 6, pp. 1481–1487, 2020.
[60] V. A. dos Santos, M. D. Santos, N. M. D. Ribeiro, andI. L. Maldonado, “Combining proprioceptive neuromuscularfacilitation and virtual reality for improving sensorimotorfunction in stroke survivors: a randomized clinical trial,”Journal of Central Nervous System Disease, vol. 11, 2019.
[61] D. Choi, W. Choi, and S. Lee, “Influence of nintendo wii fitbalance game on visual perception, postural balance, andwalking in stroke survivors: a pilot randomized clinical trial,”Games for Health Journal, vol. 7, no. 6, pp. 377–384, 2018.
[62] A. L. Borstad, R. Crawfis, K. Phillips et al., “In-Home deliveryof constraint-induced movement therapy via virtual realitygaming,” Journal of Patient-Centered Research and Reviews,vol. 5, no. 1, pp. 6–17, 2018.
[63] F. Noveletto, A. V. Soares, B. A. Mello et al., “Biomedicalserious game system for balance rehabilitation of hemipareticstroke patients,” IEEE Transactions on Neural Systems andRehabilitation Engineering, vol. 26, no. 11, pp. 2179–2188,2018.
[64] A. A. Carregosa, L. R. Aguiar dos Santos, M. R. Masruha et al.,“Virtual rehabilitation through nintendo wii in poststrokepatients: follow-up,” Journal of Stroke and CerebrovascularDiseases, vol. 27, no. 2, pp. 494–498, 2018.
[65] J.-H. Park and J.-H. Park, “(e effects of game-based virtualreality movement therapy plus mental practice on upperextremity function in chronic stroke patients with hemi-paresis: a randomized controlled trial,” Journal of Physical+erapy Science, vol. 28, no. 3, pp. 811–815, 2016.
[66] K. J. Bower, R. A. Clark, J. L. McGinley, C. L. Martin, andK. J. Miller, “Clinical feasibility of the Nintendo Wii forbalance training post-stroke: a phase II randomized con-trolled trial in an inpatient setting,” Clinical Rehabilitation,vol. 28, no. 9, pp. 912–923, 2014.
[67] E. V. Donoso Brown, S. W. McCoy, A. S. Fechko, R. Price,T. Gilbertson, and C. T. Moritz, “Preliminary investigation ofan electromyography-controlled video game as a homeprogram for persons in the chronic phase of stroke recovery,”Archives of Physical Medicine and Rehabilitation, vol. 95,no. 8, pp. 1461–1469, 2014.
[68] A. Slijper, K. E. Svensson, P. Backlund, H. Engstrom, andK. S. Sunnerhagen, “Computer game-based upper extremitytraining in the home environment in stroke persons: a singlesubject design,” Journal of NeuroEngineering and Rehabili-tation, vol. 11, p. 35, 2014.
[69] C. Chen, S. Lee,W.Wang, H. Chen, J. Liu, and Y. Huang, “(echanges of improvement-related motor kinetics after virtualreality based rehabilitation,” in Proceedings of the 2017 In-ternational Conference on Applied System Innovation (ICASI),Sapporo, Japan, May 2017.
[70] M. M. Lee, K. J. Lee, and C. H. Song, “Game-based virtualreality canoe paddling training to improve postural balanceand upper extremity function: a preliminary randomizedcontrolled study of 30 patients with subacute stroke,”MedicalScience Monitor, vol. 24, pp. 2590–2598, 2018.
[71] D.-S. Park, D.-G. Lee, K. Lee, and G. Lee, “Effects of virtualreality training using xbox kinect on motor function in stroke
26 Journal of Healthcare Engineering
survivors: a preliminary study,” Journal of Stroke and Cere-brovascular Diseases, vol. 26, no. 10, pp. 2313–2319, 2017.
[72] J.-S. Park, G. Lee, J.-B. Choi, N.-K. Hwang, and Y.-J. Jung,“Game-based hand resistance exercise versus traditionalmanual hand exercises for improving hand strength, motorfunction, and compliance in stroke patients: a multi-centerrandomized controlled study,” NeuroRehabilitation, vol. 45,no. 2, pp. 221–227, 2019.
[73] H. Soufi Ahmadi, A. Hassani Mehraban, M. Amini, andM. Sheikhi, “(e effects of virtual reality on upper limbfunction in chronic stroke patients: a clinical trial,” IranianRehabilitation Journal, vol. 17, no. 1, pp. 81–89, 2019.
[74] M. de Castro-Cros, M. Sebastian-Romagosa, J. Rodrıguez-Serrano, E. Opisso, M. Ochoa, and R. Ortner, “Effects ofgamification in BCI functional rehabilitation,” Frontiers inNeuroscience, vol. 14, 2020.
[75] D. Corbetta, F. Imeri, and R. Gatti, “Rehabilitation that in-corporates virtual reality is more effective than standard re-habilitation for improving walking speed, balance andmobility after stroke: a systematic review,” Journal of Phys-iotherapy, vol. 61, no. 3, pp. 117–124, 2015.
[76] S. M. Nijenhuis, G. B. Prange-Lasonder, A. H. Stienen,J. S. Rietman, and J. H. Buurke, “Effects of training with apassive hand orthosis and games at home in chronic stroke: apilot randomised controlled trial,” Clinical Rehabilitation,vol. 31, no. 2, pp. 207–216, 2017.
[77] L. Sheehy, A. Taillon-Hobson, H. Sveistrup et al., “Does theaddition of virtual reality training to a standard program ofinpatient rehabilitation improve sitting balance ability andfunction after stroke? Protocol for a single-blind randomizedcontrolled trial,” BMC Neurology, vol. 16, no. 1, p. 42, 2016.
[78] L. Tao, C. Yin, X. Zhou, and J. Liu, “Design and imple-mentation of an interactive hand rehabilitation trainingsystem based on LabVIEW,” in Proceedings of the 2020 12thInternational Conference on Intelligent Human-MachineSystems and Cybernetics (IHMSC), Las Vegas, NV, USA,August 2020.
[79] A. S. Ahuja, “Should RCT’s be used as the gold standard forevidence based medicine?” Integrative medicine research,vol. 8, no. 1, pp. 31-32, 2019.
[80] A. Leinonen, M. Koponen, and S. Hartikainen, “Systematicreview: representativeness of participants in RCTs of acetyl-cholinesterase inhibitors,” PLoS One, vol. 10, no. 5, Article IDe0124500, 2015.
[81] J. Dascal, M. Reid, W. W. IsHak et al., “Virtual reality andmedical inpatients: a systematic review of randomized,controlled trials,” Innovations in clinical neuroscience, vol. 14,no. 1-2, pp. 14–21, 2017.
[82] N. B. Herz, S. H. Mehta, K. D. Sethi, P. Jackson, P. Hall, andJ. C. Morgan, “Nintendo Wii rehabilitation (“Wii-hab”)provides benefits in Parkinson’s disease,” Parkinsonism &Related Disorders, vol. 19, no. 11, pp. 1039–1042, 2013.
[83] D. Tarakci, A. R. Ozdincler, E. Tarakci, F. Tutuncuoglu, andM. Ozmen, “Wii-based balance therapy to improve balancefunction of children with cerebral palsy: a pilot study,” Journalof Physical+erapy Science, vol. 25, no. 9, pp. 1123–1127, 2013.
[84] V. P. Nicholson, M. McKean, J. Lowe, C. Fawcett, andB. Burkett, “Six weeks of unsupervised Nintendo Wii Fitgaming is effective at improving balance in independent olderadults,” Journal of Aging and Physical Activity, vol. 23, no. 1,pp. 153–158, 2015.
[85] A. L. Betker, A. Desai, C. Nett, N. Kapadia, and T. Szturm,“Game-based exercises for dynamic short-sitting balancerehabilitation of people with chronic spinal cord and trau-matic brain injuries,” Physical +erapy, vol. 87, no. 10,pp. 1389–1398, 2007.
Journal of Healthcare Engineering 27