Virtual Reality in Stroke Recovery: A meta-review of Systematic Reviews

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Imam, Mohamed Muneer, Salman Al Jerdi, Sumanjit K Gill This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4319427/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Oct, 2024 Read the published version in Bioelectronic Medicine → Version 1 posted 5 You are reading this latest preprint version Abstract Background Virtual Reality (VR) is an emerging technology in post stroke recovery. However, its precise role in stroke rehabilitation is not well defined. The aim of this paper is to conduct an overview of systematic reviews on the role of VR in stroke rehabilitation. Methods A meta-review with results from a search of 7 databases from inception till 5th December 2022 with subsequent quality appraisal was conducted. The primary outcome was to produce a narrative review on the efficacy of VR versus usual or other care in stroke recovery. Data was synthesized in a descriptive fashion and high-quality systematic reviews were emphasized. The AMSTAR-2 tool was used for quality assessment of the included studies. Results Evidence from high-quality systematic reviews suggests that there is benefit from VR in upper limb, lower limb, gait, and balance recovery particularly when additive to conventional therapy. There is also limited evidence to suggest that VR has a positive effect in those with impaired cognition. Conclusion VR is safe and effective as an adjunct to conventional therapy for adults after stroke and should be used routinely for upper and lower limb motor recovery. Further high-quality studies that evaluate its efficacy and explore ways to increase its positive impact in areas such as cognition are required. There is also a scope for the development of stroke-specific virtual environments. (PROSPERO registration # CRD42022372926). Virtual Reality Stroke Recovery Rehabilitation Systematic Reviews Figures Figure 1 Figure 2 Introduction Stroke is the major cause of mortality and disability in the world affecting over 17 million people annually ( 1 – 3 ). While advancements in medical technology and treatments have led to a decrease in stroke mortality and incidence in high-income countries, patients continue to suffer from long-term neurological deficits, including cognitive, behavioral, functional, language, and mobility deficits ( 2 ). Stroke rehabilitation is a complex process which optimizes recovery of injured neural tissue through enhancement of neural repair, maximizing recovery and minimizing functional deficits ( 4 – 6 ). The mainstay of stroke rehabilitation is a combination of physical, occupational, speech and cognitive psychological therapy, requiring multi-disciplinary input ( 7 ). To be effective, stroke rehabilitation should include goal oriented, task- specific training ( 8 ), sufficient duration and intensity of the intervention i.e. high repetitive volume ( 9 ) and utilization of biofeedback ( 10 ). This can be challenging in terms of costs ( 11 ), time constraints ( 12 ) and in keeping the patients engaged and motivated ( 13 ) . Virtual Reality (VR) is theorized to overcome these limitations particularly those of cost and time constraints. Virtual Reality (VR) is defined as “a computer rendered, 3-dimensional, real-time, interactive experience of artificial reality containing items, characters, and events existing only in the memory of a computer”( 14 ). The user is provided with visual feedback either on a head mounted device, a computer monitor or a screen of any type and can interact with the virtual environment through multiple mechanisms. The platform used to interact with VR is termed an environment; and the environment can be immersive, semi-immersive or non-immersive. Immersive environments are where the subject is surrounded by the virtual environment providing a high degree of realism and immersiveness. This can be achieved through the use of head-mounted devices. A semi-immersive environment is one with a moderate level of realism and immersion, falling in between a fully immersive and a non-immersive environment. A non-immersive environment in one where subjects are fully responsive to the real environment and the virtual environment is viewed via the use of high-resolution monitors and computer devices. Key concepts in the use of VR are immersion, imagination, and interaction ( 15 ). Immersion is the extent to which the user perceives that they are in the virtual environment rather than the real world ( 16 ). The rapid increase and development of video game technology has made semi immersive or non-immersive VR cost effective and available for use in clinical practice ( 16 ). These commercial gaming platforms simulate real life situations and require total body movement similar to the real world and encourage high intensity repetitive hand movements such as seen with the Nintendo Wii and PlayStation gaming platforms ( 17 – 19 ). Immersive environments are thought to be superior due to increased levels of user engagement, participation, and enjoyment ( 15 , 27 ). These environments, however, are not in routine use yet due to lack of guidelines for their use in stroke rehabilitation as well as being more expensive and sophisticated to use. Virtual Reality in Stroke Rehabilitation Earlier studies that used functional imaging showed that functional improvement is associated with ipsilesional activation of the sensorimotor cortex post VR training in patients post stroke ( 15 ). This has continued to drive forward and support the use of VR for stroke rehabilitation. The functional recovery of damaged brain tissue is heavily driven by neural plasticity ( 15 ). Neural plasticity is the ability of the central nervous system to adapt and undergo dynamic changes in terms of structural and functional components in response to experiences and feedback received through the different senses ( 15 ). The underlying neural mechanisms of this adaptability and change are dependent on the strength of the synaptic connections and axonal remodeling of the cortical pathways ( 21 ). To effectively target neural plasticity and functional recovery through rehabilitation, the rehabilitation technique needs to involve goal oriented, intensive, repetitive, and task-specific measures that are reiterated by constant visual and sensory feedback to the user from the environment ( 15 ). VR seems to be able to meet these criteria for efficacy based on functional imaging of patients post-stroke ( 15 , 20 ). The mirror neurons are a class of visuomotor neurons involving interconnected brain regions (premotor cortex, inferior parietal lobule, and inferior frontal gyrus) that play a role in processing information related to the execution of movements ( 15 ). Imitation and imagery have been seen to activate some of the regions of this mirror neuron system in the past ( 15 ). Since the VR environment depicts the user as an avatar on a screen, this means that the patients can also see themselves performing the task through the avatar, much like standing in front of the mirror. Therefore, when that same avatar performs a motion, the mirror neurons in the brain can then be activated allowing the user to initiate that specific motion. VR, when originally developed, was thought to have the potential to revolutionize stroke rehabilitation by providing the flexibility of outpatient treatment as well as by increasing patient engagement, satisfaction, and enjoyment. This remains true to this day. Enjoyability ( 22 ) is believed to be one of the main attractive features of VR. This enjoyment may improve motivation to practice and allows for more therapy time ( 23 ). This is further enhanced by the sense of presence (Immersion) ( 24 ), feeling of success or accomplishment ( 25 ), and synchrony ( 26 ) (playing with other participants and/or engaging in competition). Immersion level is a significant factor that can affect a user’s enjoyment, engagement, and response level. Studies have shown that more immersion leads to an increased sense of a user’s presence in the virtual environment, better learning experience and retrieval movement for virtual objects in post-stroke patients ( 15 ). A more immersive, enriched, interactive, multi-component environment with multimodal stimulation can allow the user to do more complicated tasks and has also been shown to significantly affect both patients’ and clinicians’ engagement, participation, and satisfaction ( 27 ). Earlier studies included a smaller number of participants ( 28 , 29 ) and utilized a different set of outcome measures, which made drawing conclusions and systematically reviewing these studies, a difficult task. Nonetheless, these studies have shown promising results. Meta-analyses have suggested some benefit of VR systems in improving motor function after stroke ( 20 , 30 ). A review looking at the effect of specific over non-specific VR-based rehabilitation (NSVR) on post-stroke recovery ( 31 ) concluded that specific VR-based rehabilitation was more beneficial in improving Upper Limb (UL) recovery than Conventional Therapy (CT), however, non-specific VR was not. This study showed immensely promising results along with highlighting certain principles of VR-based rehabilitation that explain why VR is superior to CT for post-stroke patients. However, the conclusions put forward by this study require further investigations since the number of studies included in the NSVR category was relatively small and may have contributed to the low statistical power of the study. Moreover, the reviews involved were heterogenous in terms of the outcomes measured, time after stroke, and dosage or frequency of the intervention. More recently, several systematic reviews and meta-analyses have been published comparing VR to CT assessing the improvement in upper limb (UL) function, lower limb (LL) function, balance, gait, cognition, and aphasia. These studies were heterogeneous to an extent in terms of the type of VR intervention used, the outcomes measured, and the conclusions drawn ( 32 , 33 ). Due to the large amount of preliminary data with inconclusive, yet promising results, it is important to compile the current systematic reviews to gather current evidence in order to pave the way for virtual reality to be more routinely accessible to patients suffering from post-stroke deficits with clear and evidence-based guidelines for its use. Therefore, this overview of systematic reviews aims at studying VR in a larger context, critiquing available systematic reviews and summarizing in a descriptive manner the available evidence to conclude whether VR is superior to the conventional rehabilitation therapy post stroke across different functional domains. It is hoped that our qualitative analysis, if favorable for VR, would pave the way for establishing guidelines for the routine use of VR either in combination with CT or alone in improving recovery post-stroke. Methods This is an overview of systematic reviews (A meta-review of systematic reviews). Review Question What is the effectiveness of VR in comparison to conventional rehabilitation or no care in stroke recovery? Searches Strategy Synonyms of VR and stroke were used and adapted to different databases and searched using Boolean operators (AND/OR). The detailed search syntax is available in Appendix 1. Published manuscripts from inception up to 5th December 2022 were identified by using electronic and manual searches of the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effectiveness, PsycINFO, EMBASE, Physiotherapy Evidence Database (PEDro), Web of Science and Medline in December 2022. Search limits (English, Humans, Systematic Reviews, Meta-analysis) were employed to select articles. Relevant reference lists of identified studies and published reviews were manually checked for additional reviews. The results of the electronic search were examined for duplicate entries using the ‘find duplicates’ facility of reference management software (EndNote X8) and were manually crosschecked. Studies with mixed etiology groups were excluded unless participants’ stroke-specific data was available. Participants/Population This review includes all systematic reviews on studies that have applied VR for rehabilitation of patients after stroke targeting various outcomes including aphasia, motor, neglect, cognition, executive function, and gait recovery. Inclusion criteria : 1) Adults above 18 years of age. 2) Post stroke (ischemic or hemorrhagic, any time). 3) Systematic reviews. 4) Only English text will be included. 5) Peer reviewed and published. 6) Therapy including a form of VR as a key part of the therapy provided. 7) Therapy targeting language function, motor function, cognitive, executive function, or neglect. 8) Report impairment and/or activity and/or participation-oriented outcome measures. Exclusion criteria : 1) Therapy that does not include a form of VR. 2) Therapy that included exogenous stimulation (such as robotic aid or functional electrical stimulation). 3) Subjects who were animals or children. 4) Reviews were excluded if they were not systematic, i.e., did not have a formal method section detailing how selection bias was excluded. 5) Non-English text Intervention This review considered systematic reviews that included studies that applied VR, immersive or non-immersive, for rehabilitation (language, cognition, motor, gait, neglect, and functionality) after stroke on its own or in addition to usual care. Control Usual care, conventional rehabilitation, any other forms of exercise, or no treatment. Primary Outcome Upper limb function, lower limb function, balance, gait, global cognition, language, memory, attention, visuospatial awareness evidenced from the included high-quality studies. Data Extraction The obtained search results were first screened using the title and abstract utilizing the inclusion/exclusion criteria. Full texts were then analyzed for quality and content. Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement framework for reporting of systematic reviews ( 34 ). Two assessors independently reviewed the search process against the inclusion and exclusion criteria, and the risk of bias assessment. Disagreements were discussed until consensus was achieved. Data was then extracted by the two independent authors and summarized as in Table 1 . Quality Assessment of included studies The AMSTAR-2 ( 35 ) (Appendix 2) tool was used for quality assessment of the included studies. AMSTAR 2 contains 16 items, and is used to rate reviews as high, moderate, low, or critically low quality depending on the presence of critical or non-critical weaknesses. Critical weaknesses are defined by Shea et al. 2017 in appendix 2. Review Registration Before the search was initiated, the protocol was drafted and was registered with PROSPERO. The unique registration number is CRD42022372926 Strategy for Data Synthesis A narrative (descriptive) synthesis was conducted utilizing the evidence, results, and conclusions drawn from the high and moderate-quality reviews only. However, wherever applicable, results from low-quality reviews were also analyzed to reinforce or contradict the conclusions drawn from the high and moderate quality reviews and this was specifically mentioned as such in the results section. A quantitative synthesis including a meta-analysis could not be done due to the amount of heterogeneity and diversity present in these reviews in terms of outcome measures. Outcomes were grouped according to how they were presented in the reviews. The major outcomes were grouped as upper limb outcomes, lower limb outcomes, gait and balance outcomes, and cognition outcomes. Additionally, several moderators and factors that could influence these outcomes were also analyzed and these included degree of immersion, virtual reality platform, time since stroke, and dosing of the intervention. Evidence Map A visual map of the evidence from each systematic review or article was created (Fig. 2 ) to visually display the conclusions of each review and included 4 dimensions as per the map created by Miake-Lye et al. ( 93 ). Number of original studies (bubble size): The number of studies included in each review is represented proportionally by the size of the bubble. Outcome measured (bubble color): The outcome of the review (UL rehabilitation, LL rehabilitation, or cognition) will be determined from each bubble’s color. Effect (x-axis): The authors classified each review according to the effects found and conclusions drawn. When the interventional group showed greater benefits than the control group, the intervention was classified as “better”; otherwise, the intervention was classified as “worse.” When there was insufficient evidence or if a specific conclusion could not be drawn, the intervention was classified as “mixed/unclear.” If there were no differences, the intervention was included as “no differences.” Strength of evidence (y-axis): The reviews were sorted into the following 4 categories high strength of evidence, moderate strength of evidence, low strength of evidence, or very low strength of evidence. This grading depended on several factors such as the specific article’s recommendation, their findings, their assessment of the evidence, and effect size. The AMSTAR-2 ratings of the articles did not affect this grading. If each article explicitly provided its level of recommendation, this was represented. If it was not explicitly reported, this was inferred by the authors of this article. Results Description of the included Systematic Reviews A search of various databases, including Medline, PEDro, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, EMBASE, PsycINFO, and Web of Science, yielded a total of 863 references. After eliminating duplicate references and applying inclusion and exclusion criteria at both the title and abstract level and at the full text level, 57 references met the criteria for inclusion. A detailed list of excluded full text articles can be found in Appendix 3. Upon reviewing the reference lists of the included reviews, no additional references were identified. Thus, a total of 57 systematic reviews were included in this study. The selection process adhered to the PRISMA flow diagram ( 34 ), and a summary of this process can be seen in Fig. 1 . Our overview included a total of 57 articles: 15 were systematic reviews and 42 were systematic reviews with meta-analysis. These articles were published between 2007 and 2022. The number of participants per review ranged from 47 to 3,540. The articles included 1,033 randomized controlled trials (RCTs) and 152 non-randomized or observational studies. Most of the recent systematic reviews (2015–2022) reported selectively on RCTs, while earlier reviews also included observational and non-randomized studies. See Table 1 for details. Figure 1 The selection process summarized in the PRISMA diagram Figure 1 to be inserted here This figure has been created by the author and does not require permission to be included in the article. Table 1 Summary and characteristics of the systematic reviews included Author Date of search No of RCTs No of Non-randomized studies Participants Time since stroke Type of VR Control Target impairments Results/ conclusion Crosbie et al., 2007 ( 36 ) Inception/ 1980 to February 2005 3 8 144 6 weeks-6 years VE No therapy or CT Gait balance, cognition UL and LL Overall safe and beneficial, but not a strong recommendation Henderson et al., 2007 ( 37 ) Varies according to database from Jan 1982-Jan 2006 2 4 79 VR participants (no mention of controls) 3 studies acute & 3 chronic VE No therapy or CT UL IVR Vs no therapy is beneficial -no studies IVR VS CT -less strong evidence NIVR Vs no therapy is effective but not Vs CT Saposnik and Levin, 2011 ( 30 ) 1966 to July 2010 5 7 195 3 subacute, 9 chronic 9 VE;3 CG: (4 = IVR 8 = NIVR) Additive to CT or robotic OR Vs CT or no therapy UL 11/12 in favor of VR Smith et al., 2012 ( 38 ) Inception to December 2009 8 0 189 Mostly chronic (up to 66 months) VE (NIRV) Additive to CT or Vs CT or no therapy Majority UL ( 5 ), balance and gait VR improves UL and walking particularly if additive but not balance Cavalcanti Moreira et al., 2013 ( 39 ) 1966 to 2011 4 0 72 Any time after stroke (not specified) VE CT, robotic and no therapy Gait Better gait velocity and distance walked Casserly and Baer, 2014 ( 19 ) 1995 to 2011 2 6 135 Acute, subacute & chronic stroke VE+ GC CT or alternative UL VR had a positive effect on the UL. (Evidence is of low quality) Thomson et al., 2014 ( 18 ) Inception to January 2013 3 16 215 Mostly Chronic GC CT or no therapy UL CG a positive impact on ADL (3/4 + ve, UL (3/9) + ve and movement (6/11) (weak evidence) Imam and Jarus, 2014 ( 40 ) Inception to July 11, 2013 11 0 213 Mostly chronic Stroke VE + GC Additive to CT or compared CT or robotic device or no intervention LL, gait recovery and balance or a mixture 10/11 studies positive Lohse et al., 2014 ( 41 ) Inception to April 4, 2013 26 0 626 0.04–6.01 years (14 chronic) VE + CG ( 4 ) Additive to CT or robotic device or compared CT or no intervention LL motor recovery, UL recovery, gait recovery, balance, cognitive training VR (VE or CG) effective across ICF domains ( BF, ACT & PART) effect size moderate Rodrigues-Baroni et al., 2014 ( 42 ) Inception to July 2013 7 0 154 Chronic stroke VE + CG CT or none Gait recovery VR effective in increasing walking speed Aguiar Dos Santos et al., 2015 ( 43 ) up to March 31, 2014 5 0 91 Mostly more than 6 months CG (NW) Additive to CT Vs CT UL, motor function, balance, and functionality VR Improved motor function but not static balance or functional independence Luque-Moreno et al., 2015 ( 44 ) January 2004 and January 2014 11 0 231 more than 6 months 10: VE 1: CG Additive to CT or robotic device or compared to CT Lower limb motor recovery, gait recovery and balance or a mixture VR (> 10 sessions) improved gait speed, balance and motor function, best when combined with CT Cheok et al., 2015 ( 45 ) Inception to July 2014 6 0 166 4 = and 2 acute or subacute CG: NW only Additive to CT or compared CT Gait recovery, balance and functional independence When additive to CT, NW improves in TUG and not in the other physical measures. Effect size small Corbetta et al., 2015 ( 23 ) Inception to August 2014, 15 0 341 Majority chronic VE + CG Additive to CT or compared CT Walking speed, balance, mobility When replaces part or all of CT VR Improves walking speed, balance, mobility & TUG test. When additive, improved TUG Chen et al., 2016 ( 46 ) January 2006 and December 2015 9 0 265 Mostly chronic (2 subacute) VE + CG Additive to CT or compared CT or no intervention Balance recovery 8/9 significant improvement in static or dynamic balance evidence = moderate de Rooij et al., 2016 ( 47 ) Inception up to December 1, 2015. 21 0 513 12.7 days and 11.6 years VE + CG Additive to CT or compared to CT balance and gait recovery VR superior to CT. When additive to CT more benefit particularly in gait and balance when compared to duration and dose matched CT. Li et al., 2016 ( 48 ) Inception May 2015 16 0 428 4 Acute/Subacute and 12 Chronic VE +CG Additive to CT or compared to CT Balance recovery Improvement in balance and TUG compared with control Gibbons et al., 2016 ( 49 ) Inception to August 2015 22 0 552 Acute–subacute Chronic CE Majority VR vs CT Functional balance, static balance, functional gait/mobility, spatiotemporal gait parameters or motor function Significant improvement in functional balance, gait velocity, and stride length in the VR group as compared to CT for the chronic group. No differences between groups in motor function, gait, and functional mobility dos Santos Palma et al., 2017 ( 50 ) Inception to 16 June 2015 54 0 1811 39 = chronic, 7 = subacute, or 7 = acute stroke,1 both acute and subacute VE + CG CT or no therapy UL and/or LL and/or balance +ve on BF and BS. inconclusive on ACT &PART Iruthayarajah et al., 2017 ( 51 ) 2009 – September 2015 17 0 469 Chronic stroke Nintendo® Wii Fit balance board ( 7 ), VE Majority additive to CT vs CT alone Dynamic and static balance Compared to CT, VR was found to improve static and dynamic balance in chronic stroke patients. Nintendo® Wii Fit balance board may not be effective Aminov et al., 2018 ( 2 ) inception until 28 June 2017 33 0 971 7 = acute-subacute 26 = chronic 19 VE 14 CG Additive to CT or compared with CT-time matched controls (in 21 /33) UL and cognition VR + ve on BF, BS, ACT & cognition (effect size small to medium) but not on PART best results when utilizing purpose-designed VR systems. Conclusion: evidence supports VR use as an adjunct to CT Laver et al., 2017 ( 20 ) Inception to April 2017 72 0 2470 All stages post stroke (majority chronic) VE + CG Additive to CT or compared CT or no intervention UL gait speed, balance, and ADL improvement in ADL compared to same dose CT = but not UL, gait speed or balance When additive (increasing dose of therapy) improvement in UL recovery. Ahn etl., 2019 ( 52 ) January 1, 2007, to August 31 2017 34 0 1507 Acute, subacute, and chronic phases post-stroke 20 VR-based CG, 6 – Wii and Xbox 2 -Robots Other-Nonimmersive VE Additive to CT vs CT alone or intervention alone vs CT alone UL function and independence in ADL VR intervention is more effective than CT in improving UL function and independence in ADL Aramaki., 2019 ( 53 ) 2011 to April 2018 9 4 353 2 Acute, 11 Chronic 8 Nintendo Wii, 3 Xbox 360, 1 combination of both, and the other combination of Xbox 360 and Playstation SeeMee Additive to CT vs CT alone or intervention alone vs CT alone Balance ( 6 ), UL motor function ( 5 ), quality of life ( 4 ) and ADL ( 3 ) VR is more efficient in the dynamic balance outcome (3 studies). Other studies indicate no difference between outcomes. Overall, there are differences in the results and the evidence is not sufficient to support the use of VR over CT Mohammadi et al., 2019 ( 54 ) January 2000 till August 2017 14 0 367 Acute ( 2 ) Subacute ( 1 ) Chronic ( 11 ) VE, Wii Fit Balance board VR in combination with CT vs CT alone (majority) Balance Significant improvement was observed in the experimental group compared to control group with a medium effect size of .64. VR combined with CT is more effective in improving balance than CT alone De Keersmaecker et al., 2019 ( 55 ) Inception until 4th October 2017 for PubMed and and Web of Science and until 11th January 2018 for Cochrane Central Register of Controlled Trials 10 2 219 Chronic (9 studies) Acute (2 studies) Unknown ( 1 ) 2 Fully immersive VE, 1 semi-immersive VE and the rest non-immersive VE VR + Treadmill vs just treadmill (CT) Gait function VR-enhanced gait training is more effective than an identical gait training without VR to improve spatiotemporal gait parameters (i.e. walking speed, cadence, step length, stride length, single limb support period) and functional gait parameters (i.e. Timed Up and Go) in people post-stroke Ghai et al., 2020 ( 56 ) Inception until August 2019 20 12 809 Acute, subacute, and chronic phases post-stroke VE adjunct with treadmill ( 8 ) VR with robot-assisted training ( 6 ) Additive to the CT vs CT alone or VR alone vs CT alone VR + RAGT vs RAGT only ( 3 ) Gait performance Significant enhancements in gait parameters were observed with VR-based interventions compared with conventional therapy Dominguez-Tellez et al., 2020 ( 57 ) 2007 – March 2018 20 0 874 Acute, subacute, and chronic phases post-stroke Immersive and non-immersive VE including CG Additive to the CT vs CT alone or VR alone vs CT alone UL motor function and quality of life VR seems to be effective for the improvement of motor function of UL and quality of life after stroke Karamians et al., 2020 ( 58 ) January 2005 to May 2019 26 12 1198 Acute ( 8 ) Chronic ( 25 ) Mixed ( 3 ) Unknown ( 2 ) VE or VE + gaming VR or Gaming vs CT UL function VR or gaming interventions produced an improvement of 28.5% of the maximal possible improvement. A gaming component resulted in a significantly larger treatment gain than just visual feedback. VR or gaming interventions showed a significant treatment advantage (10.4%) over CT Mekbib et al., 2020 ( 59 ) 2010 to March 2019 27 0 1094 Subacute ( 12 ) Chronic ( 14 ) Unknown ( 1 ) VE and CG Additive to the CT vs CT alone (majority) or VR alone vs CT alone UL function Statistically significant improvement in the recovery of UL function in the VR group as compared to the CT group. Patients in the subacute phase of stroke may benefit from VR therapies more than patients in chronic phases of stroke Pintado-Izquierdo et al., 2020 ( 60 ) from January 2005 to June 2020 0 18 479 Acute/Subacute ( 4 ) Chronic ( 13 ) All phases ( 1 ) CG – SVR, Nintendo Wii, Wii Fit Plus, Wii Balance Board Additive to CT vs CT alone or CG vs CT alone Balance and gait In 10 of 17 studies balance was improved in the interventional group as compared to the CT group. 6 of the 7 studies that studied gait revealed that improvement in gait was greater in the VR group as compared to the experimental group Amirthalingam et al., 2021 ( 61 ) January 2016 to April 30, 2021 13 0 298 Acute, subacute, and chronic phases post-stroke Immersive VE, Nintendo Wii ( 1 ) CT alone, 1 study with additive to CT vs CT alone UL function, cognitive function, gait, and balance VR-based rehabilitation more effective than CT in improving UL function, gait, and postural balance post-stroke Cao et al., 2021 ( 62 ) Inception to September 2020 5 0 47 Chronic VE, semi-immersive VE (EVA park), Gaming system for aphasia, ELT within VE Additive to CT vs CT alone or VE alone vs CT alone Functional communication No significant differences between VR and the control groups Doumas et al., 2021 ( 63 ) Inception till May 5th 2020 42 0 2083 1/3 of studies – Subacute 2/3 of studies – chronic Serious games across different devices (immersive VR, robotic exoskeleton, Microsoft Kinect etc.) Additive to the CT vs CT alone or VR alone vs CT alone UL motor function, activity and participation Rehabilitation through serious games, targeting UL recovery after stroke, leads to better improvements, compared to conventional treatment, in three ICF-WHO components (motor function, activity, and participation) Cortes-Perez et al., 2021 ( 64 ) Inception to January 2021 2 0 91 Unclear Leap Motion Controller based video games LMC + CT VS CT alone ( 1 ) LMC vs CT ( 1 ) UL motor function A higher effect of LMC when combined with CT in improving UL motor function as compared to CT alone Gao et al., 2021 ( 65 ) Inception to May 31, 2021 6 0 209 Chronic stroke Semi- immersive VR (motion tracking, Kinect etc.) VR + CT vs CT alone Global and overall cognition, attention, execution, motor function, mood, and ADL VR-based intervention combined with traditional rehabilitation showed better outcomes for overall cognition, attention/execution, and depressive mood in individuals with chronic stroke. Non-significant effect for global cognition, motor function, and ADL in individuals with chronic stroke Garay-Sachez et al., 2021 ( 66 ) December 2010 to December 2020 10 0 316 Acute and subacute Immersive and non-immersive VR VR alone vs CT alone ( 1 ) VR + CR vs CT alone Dynamic and static balance Static balance: 4 studies showed significant improvement for non-immersive VR over CT and 1 for immersive VR Dynamic balance: 4 studies using non-immersive VR in combination with CT showed significant improvement and 2 studies using immersive VR in combination with CT showed significant improvement Khan et al., 2021 ( 66 ) 2011–2020 18 55 1617 All phases post stroke VE, rehabilitation gaming system, Nintendo Wii VR + CT vs CT alone or VR vs CT or VR vs no therapy Motor, sensory, and cognitive outcomes Improved functional outcomes reported by studies in all 3 outcomes measured, but meta-analysis done revealed no statistically significant difference compared to CT. Palacios-Navarro et al., 2021 ( 68 ) Inception until 31st October 2020 8 0 1472 Chronic phase Fully immersive VE Immersive VE + CT vs CT alone/Non-immersive VE UL motor function, gait, balance UL Function: Significant improvement in the intervention group compared to the control, exhibiting a large effect size (0.79) VR intervention training achieved significantly faster walking speed compared to CT. Overall significant improvements in favor of the immersive VR group Peng et al., 2021 ( 69 ) Inception until October 10, 2020, 17 2 681 Subacute Stroke VE, CG based VR, Additive to CT vs CT or VR/CG vs CT alone Motor function (UL + LL) When compared to CT, VR resulted in mild improvement in motor function (SMD = 0.47; 95% CI = 0.22–0.72; I 2 = 75%; P < 0.001). Upon trim-and-fill adjustment, this finding was deemed insignificant Zhang et al., 2021 ( 70 ) Inception until 31st December 2019 87 0 3540 All phases were included VE Additive to CT vs CT alone or VR vs CT alone UL and LL motor function, balance, gait, cognition, and daily function “VR improves limb function, walking ability, balance, gait velocity, cadence, and daily life activities to a greater extent than CT. However, VR had a similar effect on improvement of cognition as CT therapy” Zhang et al., 2021 ( 71 ) Inception to April 15, 2021 23 0 894 Unspecified Immersive, semi-immersive and non-immersive VE, CG VR alone vs CT alone ( 16 ), VR + CT vs CT ( 5 ), VR + Computer based cognition vs CT ( 2 ) Global cognition and domain-specific cognition (attention, executive function, memory, psychomotor speed, verbal fluency) VR-based therapies are more efficacious in improving executive function, memory, and visuospatial function post stroke than CT. No significant differences were found between the 2 groups in terms of global cognitive function, attention, verbal fluency, depression, and the quality of life Aguilera-Rubio et al., 2022 ( 72 ) 2012 to December,2020 2 4 144 2 studies – Subacute phase of stroke 1 study – Acute phase 1 study – Subacute and acute phase 1 study – chronic 1 study - unspecified Leap Motion Controller Additive to CT or compared CT or no intervention UL Statistically significant improvement in UL functionality (5 studies), grip strength (4 studies), spasticity ( 1 ), dexterity, performance, participation, satisfaction, and usability. Further research needed due to heterogeneity Al-Whaibi et al., 2022 ( 73 ) 1 search from inception to June 25, 2020 Another search done on 1st Feb, 2021 6 0 174 Chronic stroke VE CT alone UL Motor function No statistical difference in UL performance in VR group as compared to the CT group Chan et al., 2022 ( 74 ) Inception until January 2021 32 2 900 Chronic stroke Exergaming, type of VR Additive to CT vs CT alone ( 30 ) No intervention ( 2 ) Balance, LL functional mobility and functional independence Exergaming shows statistically significant improvement in balance, lower limb functional mobility and functional independence among individuals with chronic stroke as compared to CT alone Chen et al., 2022 ( 75 ) Inception to December 31, 2021 42 0 1893 Subacute and Chronic stroke Specialized VE and CG VR alone vs CT alone OR VR alone vs No intervention OR VR + CT vs CT alone UL Motor Rehabilitation Statistically significant improvement in UL motor function, muscle strength, range of motion and independence in day-to-day activities Chen et al., 2022 ( 76 ) Inception until August 31, 2021 21 0 1149 Unclear VE Additive to the CT vs CT alone or VR alone vs CT alone Cognitive function and ADL VR training improved cognitive function and ADL in PSCI compared to CT Fernandez-Vazquez et al., 2022 ( 77 ) Inception to May 2022 7 0 230 Acute phase ( 3 ) Chronic phase ( 4 ) Haptic Glove Systems in Combination with Semi-Immersive VR Additive to the CT vs CT alone or VR alone vs CT alone UL Motor Rehabilitation Combination of rehabilitation haptic gloves, SVR, and CT produces significant improvement in UL functionality as compared to CT alone Hao, J., Buster, T., 2022 ( 79 ) Inception to September 8th, 2022 8 0 190 Chronic VE VR + treadmill training vs treadmill training only Walking speed and endurance, balance function, number of falls Virtual reality augmented treadmill walking training enhances outcomes compared to treadmill-only training in patients with walking and balance impairments Hao et al., 2022 ( 79 ) 2000 to October 17, 2021 17 0 921 Acute stroke VE (Nintendo Wii, Microsoft Kinect) Additive to the CT vs CT alone or VR alone vs CT alone UL function, cognitive function ( 5 ), gait speed, ADL, and balance ability Effects of VR are comparable to conventional rehabilitation, no differences between VR and dose-matched conventional rehabilitation on UL function, ADL outcomes, balance function, and cognition Leong et al., 2022 ( 80 ) Inception to October 15, 2021 50 0 2271 Acute ( 4 ) Subacute ( 9 ) Chronic ( 26 ) Virtual, augmented, and mixed reality (VAMR) Additive to the CT vs CT alone or intervention alone vs CT alone UL function and ADL VAMR therapy was superior to CT in UL impairment and daily function outcomes, but not UL function measures. Patients with chronic stroke significantly improved better than those with subacute after VAMR training Li et al., 2022 ( 81 ) Inception to May 24, 2021 31 0 1299 Acute ( 1 ) Subacute ( 8 ) Chronic ( 21 ) VE, CG VR + CT vs Time-dosed matched CT or VR only vs Time-dosed matched CT only or CG only vs time-dosed matched CT ICF domains: body structure or function, activity, and participation: UL function, VR is more superior to time-dose matched CT in terms of recovery of upper extremity motor function in patients poststroke, especially when VE is used, or VR is combined with CT. VR does not improve patients’ daily activity performance and participation compared with CT Mugisha et al., 2022 ( 82 ) 2015 to May 2020 22 0 1253 Unspecified Immersive and Non-immersive VE using Nintendo Wii, Miscrosoft Kinect etc. Additive to the CT vs CT alone or intervention alone vs CT alone UL activity and function, LL activity and function, balance, activity of daily life, adverse events No statistical difference between VR and CT in improving UL and LL motor function, balance, and ADL. Immersive VE is superior to non-immersive VE in improving the outcomes measured Parisi et al., 2022 ( 33 ) Inception to 17 January 2022 10 0 283 Acute ( 2 ) Subacute ( 4 ) Chronic ( 3 ) VE/VE + Motion tracking Additive to the CT vs CT alone or intervention alone vs CT alone Cognitive rehabilitation VR without motion tracking was more effective than CT Sevcenko & Lindgren, 2022 ( 83 ) Inception to February 29, 2020 10 0 715 Subacute ( 4 ) Chronic ( 4 ) Both of the above ( 2 ) VE Additive to the CT vs CT alone or intervention alone vs CT alone Functional ability (UL, gait, balance) VR training is suggested as an effective intervention to improve the functional ability in stroke especially when combined with CT. Some studies showed significant improvement of VR group in gait, balance, quality of life and fatigue while no effect was seen in the CT group. Wang et al., 2022 ( 84 ) Inception to December 2021 24 0 793 Acute ( 6 ) Subacute ( 5 ) Chronic ( 13 ) Game-based non-immersive VR, CG and Custom games were included Additive to the CT vs CT alone or intervention alone vs CT alone UL rehabilitation, hand dexterity, daily living ability, and cognitive function Game-based VR UL rehabilitation therapy for cerebral apoplexy is more effective than CT in improving patients’ UL function and hand mobility Wiley et al., 2022 ( 32 ) Inception to November 13th 2019 8 0 196 Majority in the chronic phased Immersive, non-immersive and semi-immersive VE Majority combination of VE + CT vs CT alone Cognition, executive function, language, and memory VR therapy was not more effective than control for improving global cognition and attention Table 1 Summary and characteristics of the systematic reviews Author Date of search No of RCTs No of Non-randomized studies Participants Time since stroke Type of VR Control Target impairments Results/ conclusion Crosbie et al., 2007 ( 36 ) Inception/ 1980 to February 2005 3 8 144 6 weeks-6 years VE No therapy or CT Gait balance, cognition UL and LL Overall safe and beneficial, but not a strong recommendation Henderson et al., 2007 ( 37 ) Varies according to database from Jan 1982-Jan 2006 2 4 79 VR participants (no mention of controls) 3 studies acute & 3 chronic VE No therapy or CT UL IVR Vs no therapy is beneficial -no studies IVR VS CT -less strong evidence NIVR Vs no therapy is effective but not Vs CT Saposnik and Levin, 2011 ( 30 ) 1966 to July 2010 5 7 195 3 subacute, 9 chronic 9 VE;3 CG: (4 = IVR 8 = NIVR) Additive to CT or robotic OR Vs CT or no therapy UL 11/12 in favor of VR Smith et al., 2012 ( 38 ) Inception to December 2009 8 0 189 Mostly chronic (up to 66 months) VE (NIRV) Additive to CT or Vs CT or no therapy Majority UL ( 5 ), balance and gait VR improves UL and walking particularly if additive but not balance Cavalcanti Moreira et al., 2013 ( 39 ) 1966 to 2011 4 0 72 Any time after stroke (not specified) VE CT, robotic and no therapy Gait Better gait velocity and distance walked Casserly and Baer, 2014 ( 19 ) 1995 to 2011 2 6 135 Acute, subacute & chronic stroke VE+ GC CT or alternative UL VR had a positive effect on the UL. (Evidence is of low quality) Thomson et al., 2014 ( 18 ) Inception to January 2013 3 16 215 Mostly Chronic GC CT or no therapy UL CG a positive impact on ADL (3/4 + ve, UL (3/9) + ve and movement (6/11) (weak evidence) Imam and Jarus, 2014 ( 40 ) Inception to July 11, 2013 11 0 213 Mostly chronic Stroke VE + GC Additive to CT or compared CT or robotic device or no intervention LL, gait recovery and balance or a mixture 10/11 studies positive Lohse et al., 2014 ( 41 ) Inception to April 4, 2013 26 0 626 0.04–6.01 years (14 chronic) VE + CG ( 4 ) Additive to CT or robotic device or compared CT or no intervention LL motor recovery, UL recovery, gait recovery, balance, cognitive training VR (VE or CG) effective across ICF domains ( BF, ACT & PART) effect size moderate Rodrigues-Baroni et al., 2014 ( 42 ) Inception to July 2013 7 0 154 Chronic stroke VE + CG CT or none Gait recovery VR effective in increasing walking speed Aguiar Dos Santos et al., 2015 ( 43 ) up to March 31, 2014 5 0 91 Mostly more than 6 months CG (NW) Additive to CT Vs CT UL, motor function, balance, and functionality VR Improved motor function but not static balance or functional independence Luque-Moreno et al., 2015 ( 44 ) January 2004 and January 2014 11 0 231 more than 6 months 10: VE 1: CG Additive to CT or robotic device or compared to CT Lower limb motor recovery, gait recovery and balance or a mixture VR (> 10 sessions) improved gait speed, balance and motor function, best when combined with CT Cheok et al., 2015 ( 45 ) Inception to July 2014 6 0 166 4 = and 2 acute or subacute CG: NW only Additive to CT or compared CT Gait recovery, balance and functional independence When additive to CT, NW improves in TUG and not in the other physical measures. Effect size small Corbetta et al., 2015 ( 23 ) Inception to August 2014, 15 0 341 Majority chronic VE + CG Additive to CT or compared CT Walking speed, balance, mobility When replaces part or all of CT VR Improves walking speed, balance, mobility & TUG test. When additive, improved TUG Chen et al., 2016 ( 46 ) January 2006 and December 2015 9 0 265 Mostly chronic (2 subacute) VE + CG Additive to CT or compared CT or no intervention Balance recovery 8/9 significant improvement in static or dynamic balance evidence = moderate de Rooij et al., 2016 ( 47 ) Inception up to December 1, 2015. 21 0 513 12.7 days and 11.6 years VE + CG Additive to CT or compared to CT balance and gait recovery VR superior to CT. When additive to CT more benefit particularly in gait and balance when compared to duration and dose matched CT. Li et al., 2016 ( 48 ) Inception May 2015 16 0 428 4 Acute/Subacute and 12 Chronic VE +CG Additive to CT or compared to CT Balance recovery Improvement in balance and TUG compared with control Gibbons et al., 2016 ( 49 ) Inception to August 2015 22 0 552 Acute–subacute Chronic CE Majority VR vs CT Functional balance, static balance, functional gait/mobility, spatiotemporal gait parameters or motor function Significant improvement in functional balance, gait velocity, and stride length in the VR group as compared to CT for the chronic group. No differences between groups in motor function, gait, and functional mobility dos Santos Palma et al., 2017 ( 50 ) Inception to 16 June 2015 54 0 1811 39 = chronic, 7 = subacute, or 7 = acute stroke,1 both acute and subacute VE + CG CT or no therapy UL and/or LL and/or balance +ve on BF and BS. inconclusive on ACT &PART Iruthayarajah et al., 2017 ( 51 ) 2009 – September 2015 17 0 469 Chronic stroke Nintendo® Wii Fit balance board ( 7 ), VE Majority additive to CT vs CT alone Dynamic and static balance Compared to CT, VR was found to improve static and dynamic balance in chronic stroke patients. Nintendo® Wii Fit balance board may not be effective Aminov et al., 2018 ( 2 ) inception until 28 June 2017 33 0 971 7 = acute-subacute 26 = chronic 19 VE 14 CG Additive to CT or compared with CT-time matched controls (in 21 /33) UL and cognition VR + ve on BF, BS, ACT & cognition (effect size small to medium) but not on PART best results when utilizing purpose-designed VR systems. Conclusion: evidence supports VR use as an adjunct to CT Laver et al., 2017 ( 20 ) Inception to April 2017 72 0 2470 All stages post stroke (majority chronic) VE + CG Additive to CT or compared CT or no intervention UL gait speed, balance, and ADL improvement in ADL compared to same dose CT = but not UL, gait speed or balance When additive (increasing dose of therapy) improvement in UL recovery. Ahn etl., 2019 ( 52 ) January 1, 2007, to August 31 2017 34 0 1507 Acute, subacute, and chronic phases post-stroke 20 VR-based CG, 6 – Wii and Xbox 2 -Robots Other-Nonimmersive VE Additive to CT vs CT alone or intervention alone vs CT alone UL function and independence in ADL VR intervention is more effective than CT in improving UL function and independence in ADL Aramaki., 2019 ( 53 ) 2011 to April 2018 9 4 353 2 Acute, 11 Chronic 8 Nintendo Wii, 3 Xbox 360, 1 combination of both, and the other combination of Xbox 360 and Playstation SeeMee Additive to CT vs CT alone or intervention alone vs CT alone Balance ( 6 ), UL motor function ( 5 ), quality of life ( 4 ) and ADL ( 3 ) VR is more efficient in the dynamic balance outcome (3 studies). Other studies indicate no difference between outcomes. Overall, there are differences in the results and the evidence is not sufficient to support the use of VR over CT Mohammadi et al., 2019 ( 54 ) January 2000 till August 2017 14 0 367 Acute ( 2 ) Subacute ( 1 ) Chronic ( 11 ) VE, Wii Fit Balance board VR in combination with CT vs CT alone (majority) Balance Significant improvement was observed in the experimental group compared to control group with a medium effect size of .64. VR combined with CT is more effective in improving balance than CT alone De Keersmaecker et al., 2019 ( 55 ) Inception until 4th October 2017 for PubMed and and Web of Science and until 11th January 2018 for Cochrane Central Register of Controlled Trials 10 2 219 Chronic (9 studies) Acute (2 studies) Unknown ( 1 ) 2 Fully immersive VE, 1 semi-immersive VE and the rest non-immersive VE VR + Treadmill vs just treadmill (CT) Gait function VR-enhanced gait training is more effective than an identical gait training without VR to improve spatiotemporal gait parameters (i.e. walking speed, cadence, step length, stride length, single limb support period) and functional gait parameters (i.e. Timed Up and Go) in people post-stroke Ghai et al., 2020 ( 56 ) Inception until August 2019 20 12 809 Acute, subacute, and chronic phases post-stroke VE adjunct with treadmill ( 8 ) VR with robot-assisted training ( 6 ) Additive to the CT vs CT alone or VR alone vs CT alone VR + RAGT vs RAGT only ( 3 ) Gait performance Significant enhancements in gait parameters were observed with VR-based interventions compared with conventional therapy Dominguez-Tellez et al., 2020 ( 57 ) 2007 – March 2018 20 0 874 Acute, subacute, and chronic phases post-stroke Immersive and non-immersive VE including CG Additive to the CT vs CT alone or VR alone vs CT alone UL motor function and quality of life VR seems to be effective for the improvement of motor function of UL and quality of life after stroke Karamians et al., 2020 ( 58 ) January 2005 to May 2019 26 12 1198 Acute ( 8 ) Chronic ( 25 ) Mixed ( 3 ) Unknown ( 2 ) VE or VE + gaming VR or Gaming vs CT UL function VR or gaming interventions produced an improvement of 28.5% of the maximal possible improvement. A gaming component resulted in a significantly larger treatment gain than just visual feedback. VR or gaming interventions showed a significant treatment advantage (10.4%) over CT Mekbib et al., 2020 ( 59 ) 2010 to March 2019 27 0 1094 Subacute ( 12 ) Chronic ( 14 ) Unknown ( 1 ) VE and CG Additive to the CT vs CT alone (majority) or VR alone vs CT alone UL function Statistically significant improvement in the recovery of UL function in the VR group as compared to the CT group. Patients in the subacute phase of stroke may benefit from VR therapies more than patients in chronic phases of stroke Pintado-Izquierdo et al., 2020 ( 60 ) from January 2005 to June 2020 0 18 479 Acute/Subacute ( 4 ) Chronic ( 13 ) All phases ( 1 ) CG – SVR, Nintendo Wii, Wii Fit Plus, Wii Balance Board Additive to CT vs CT alone or CG vs CT alone Balance and gait In 10 of 17 studies balance was improved in the interventional group as compared to the CT group. 6 of the 7 studies that studied gait revealed that improvement in gait was greater in the VR group as compared to the experimental group Amirthalingam et al., 2021 ( 61 ) January 2016 to April 30, 2021 13 0 298 Acute, subacute, and chronic phases post-stroke Immersive VE, Nintendo Wii ( 1 ) CT alone, 1 study with additive to CT vs CT alone UL function, cognitive function, gait, and balance VR-based rehabilitation more effective than CT in improving UL function, gait, and postural balance post-stroke Cao et al., 2021 ( 62 ) Inception to September 2020 5 0 47 Chronic VE, semi-immersive VE (EVA park), Gaming system for aphasia, ELT within VE Additive to CT vs CT alone or VE alone vs CT alone Functional communication No significant differences between VR and the control groups Doumas et al., 2021 ( 63 ) Inception till May 5th 2020 42 0 2083 1/3 of studies – Subacute 2/3 of studies – chronic Serious games across different devices (immersive VR, robotic exoskeleton, Microsoft Kinect etc.) Additive to the CT vs CT alone or VR alone vs CT alone UL motor function, activity and participation Rehabilitation through serious games, targeting UL recovery after stroke, leads to better improvements, compared to conventional treatment, in three ICF-WHO components (motor function, activity, and participation) Cortes-Perez et al., 2021 ( 64 ) Inception to January 2021 2 0 91 Unclear Leap Motion Controller based video games LMC + CT VS CT alone ( 1 ) LMC vs CT ( 1 ) UL motor function A higher effect of LMC when combined with CT in improving UL motor function as compared to CT alone Gao et al., 2021 ( 65 ) Inception to May 31, 2021 6 0 209 Chronic stroke Semi- immersive VR (motion tracking, Kinect etc.) VR + CT vs CT alone Global and overall cognition, attention, execution, motor function, mood, and ADL VR-based intervention combined with traditional rehabilitation showed better outcomes for overall cognition, attention/execution, and depressive mood in individuals with chronic stroke. Non-significant effect for global cognition, motor function, and ADL in individuals with chronic stroke Garay-Sachez et al., 2021 ( 66 ) December 2010 to December 2020 10 0 316 Acute and subacute Immersive and non-immersive VR VR alone vs CT alone ( 1 ) VR + CR vs CT alone Dynamic and static balance Static balance: 4 studies showed significant improvement for non-immersive VR over CT and 1 for immersive VR Dynamic balance: 4 studies using non-immersive VR in combination with CT showed significant improvement and 2 studies using immersive VR in combination with CT showed significant improvement Khan et al., 2021 ( 66 ) 2011–2020 18 55 1617 All phases post stroke VE, rehabilitation gaming system, Nintendo Wii VR + CT vs CT alone or VR vs CT or VR vs no therapy Motor, sensory, and cognitive outcomes Improved functional outcomes reported by studies in all 3 outcomes measured, but meta-analysis done revealed no statistically significant difference compared to CT. Palacios-Navarro et al., 2021 ( 68 ) Inception until 31st October 2020 8 0 1472 Chronic phase Fully immersive VE Immersive VE + CT vs CT alone/Non-immersive VE UL motor function, gait, balance UL Function: Significant improvement in the intervention group compared to the control, exhibiting a large effect size (0.79) VR intervention training achieved significantly faster walking speed compared to CT. Overall significant improvements in favor of the immersive VR group Peng et al., 2021 ( 69 ) Inception until October 10, 2020, 17 2 681 Subacute Stroke VE, CG based VR, Additive to CT vs CT or VR/CG vs CT alone Motor function (UL + LL) When compared to CT, VR resulted in mild improvement in motor function (SMD = 0.47; 95% CI = 0.22–0.72; I 2 = 75%; P < 0.001). Upon trim-and-fill adjustment, this finding was deemed insignificant Zhang et al., 2021 ( 70 ) Inception until 31st December 2019 87 0 3540 All phases were included VE Additive to CT vs CT alone or VR vs CT alone UL and LL motor function, balance, gait, cognition, and daily function “VR improves limb function, walking ability, balance, gait velocity, cadence, and daily life activities to a greater extent than CT. However, VR had a similar effect on improvement of cognition as CT therapy” Zhang et al., 2021 ( 71 ) Inception to April 15, 2021 23 0 894 Unspecified Immersive, semi-immersive and non-immersive VE, CG VR alone vs CT alone ( 16 ), VR + CT vs CT ( 5 ), VR + Computer based cognition vs CT ( 2 ) Global cognition and domain-specific cognition (attention, executive function, memory, psychomotor speed, verbal fluency) VR-based therapies are more efficacious in improving executive function, memory, and visuospatial function post stroke than CT. No significant differences were found between the 2 groups in terms of global cognitive function, attention, verbal fluency, depression, and the quality of life Aguilera-Rubio et al., 2022 ( 72 ) 2012 to December,2020 2 4 144 2 studies – Subacute phase of stroke 1 study – Acute phase 1 study – Subacute and acute phase 1 study – chronic 1 study - unspecified Leap Motion Controller Additive to CT or compared CT or no intervention UL Statistically significant improvement in UL functionality (5 studies), grip strength (4 studies), spasticity ( 1 ), dexterity, performance, participation, satisfaction, and usability. Further research needed due to heterogeneity Al-Whaibi et al., 2022 ( 73 ) 1 search from inception to June 25, 2020 Another search done on 1st Feb, 2021 6 0 174 Chronic stroke VE CT alone UL Motor function No statistical difference in UL performance in VR group as compared to the CT group Chan et al., 2022 ( 74 ) Inception until January 2021 32 2 900 Chronic stroke Exergaming, type of VR Additive to CT vs CT alone ( 30 ) No intervention ( 2 ) Balance, LL functional mobility and functional independence Exergaming shows statistically significant improvement in balance, lower limb functional mobility and functional independence among individuals with chronic stroke as compared to CT alone Chen et al., 2022 ( 75 ) Inception to December 31, 2021 42 0 1893 Subacute and Chronic stroke Specialized VE and CG VR alone vs CT alone OR VR alone vs No intervention OR VR + CT vs CT alone UL Motor Rehabilitation Statistically significant improvement in UL motor function, muscle strength, range of motion and independence in day-to-day activities Chen et al., 2022 ( 76 ) Inception until August 31, 2021 21 0 1149 Unclear VE Additive to the CT vs CT alone or VR alone vs CT alone Cognitive function and ADL VR training improved cognitive function and ADL in PSCI compared to CT Fernandez-Vazquez et al., 2022 ( 77 ) Inception to May 2022 7 0 230 Acute phase ( 3 ) Chronic phase ( 4 ) Haptic Glove Systems in Combination with Semi-Immersive VR Additive to the CT vs CT alone or VR alone vs CT alone UL Motor Rehabilitation Combination of rehabilitation haptic gloves, SVR, and CT produces significant improvement in UL functionality as compared to CT alone Hao, J., Buster, T., 2022 ( 79 ) Inception to September 8th, 2022 8 0 190 Chronic VE VR + treadmill training vs treadmill training only Walking speed and endurance, balance function, number of falls Virtual reality augmented treadmill walking training enhances outcomes compared to treadmill-only training in patients with walking and balance impairments Hao et al., 2022 ( 79 ) 2000 to October 17, 2021 17 0 921 Acute stroke VE (Nintendo Wii, Microsoft Kinect) Additive to the CT vs CT alone or VR alone vs CT alone UL function, cognitive function ( 5 ), gait speed, ADL, and balance ability Effects of VR are comparable to conventional rehabilitation, no differences between VR and dose-matched conventional rehabilitation on UL function, ADL outcomes, balance function, and cognition Leong et al., 2022 ( 80 ) Inception to October 15, 2021 50 0 2271 Acute ( 4 ) Subacute ( 9 ) Chronic ( 26 ) Virtual, augmented, and mixed reality (VAMR) Additive to the CT vs CT alone or intervention alone vs CT alone UL function and ADL VAMR therapy was superior to CT in UL impairment and daily function outcomes, but not UL function measures. Patients with chronic stroke significantly improved better than those with subacute after VAMR training Li et al., 2022 ( 81 ) Inception to May 24, 2021 31 0 1299 Acute ( 1 ) Subacute ( 8 ) Chronic ( 21 ) VE, CG VR + CT vs Time-dosed matched CT or VR only vs Time-dosed matched CT only or CG only vs time-dosed matched CT ICF domains: body structure or function, activity, and participation: UL function, VR is more superior to time-dose matched CT in terms of recovery of upper extremity motor function in patients poststroke, especially when VE is used, or VR is combined with CT. VR does not improve patients’ daily activity performance and participation compared with CT Mugisha et al., 2022 ( 82 ) 2015 to May 2020 22 0 1253 Unspecified Immersive and Non-immersive VE using Nintendo Wii, Miscrosoft Kinect etc. Additive to the CT vs CT alone or intervention alone vs CT alone UL activity and function, LL activity and function, balance, activity of daily life, adverse events No statistical difference between VR and CT in improving UL and LL motor function, balance, and ADL. Immersive VE is superior to non-immersive VE in improving the outcomes measured Parisi et al., 2022 ( 33 ) Inception to 17 January 2022 10 0 283 Acute ( 2 ) Subacute ( 4 ) Chronic ( 3 ) VE/VE + Motion tracking Additive to the CT vs CT alone or intervention alone vs CT alone Cognitive rehabilitation VR without motion tracking was more effective than CT Sevcenko & Lindgren, 2022 ( 83 ) Inception to February 29, 2020 10 0 715 Subacute ( 4 ) Chronic ( 4 ) Both of the above ( 2 ) VE Additive to the CT vs CT alone or intervention alone vs CT alone Functional ability (UL, gait, balance) VR training is suggested as an effective intervention to improve the functional ability in stroke especially when combined with CT. Some studies showed significant improvement of VR group in gait, balance, quality of life and fatigue while no effect was seen in the CT group. Wang et al., 2022 ( 84 ) Inception to December 2021 24 0 793 Acute ( 6 ) Subacute ( 5 ) Chronic ( 13 ) Game-based non-immersive VR, CG and Custom games were included Additive to the CT vs CT alone or intervention alone vs CT alone UL rehabilitation, hand dexterity, daily living ability, and cognitive function Game-based VR UL rehabilitation therapy for cerebral apoplexy is more effective than CT in improving patients’ UL function and hand mobility Wiley et al., 2022 ( 32 ) Inception to November 13th 2019 8 0 196 Majority in the chronic phased Immersive, non-immersive and semi-immersive VE Majority combination of VE + CT vs CT alone Cognition, executive function, language, and memory VR therapy was not more effective than control for improving global cognition and attention CG = Commercial Games, CT = Conventional therapy, UL = Upper limb, LL = lower limb, NW = Nintendo Wii, VE = Virtual Environment, VR = Virtual Reality, IVR = Immersive Virtual Reality, NIVR = Non-Immersive Virtual Reality, Acute Stroke 6 months, BF = Body Function, BS = Body Structure, ACT = Activity, PART = Participation, TUG = Timed Up and Go test, ADL = Activity of daily living, ELT = Experimental Linguistic Treatment, SVR = Semi-immersive VR, RAGT = Robot Assisted Gait Training, (n) = n is the number of studies Table 1 . Summary and characteristics of the systematic reviews Table 1 to be inserted here after Fig. 1 Most of the reviews included studies utilizing virtual environments (VE) and commercial gaming (CG) platforms. Only 15 systematic reviews ( 32 – 35 , 55 , 56 , 57 , 69 , 71 , 73 , 74 , 77 , 79 , 81 , 33 , and 84 ) investigated only VE; whereas, only 7 (17, 41, 47, 54, 61, 80, 85,) investigated CGs alone. In 46/57 reviews VR was either added to conventional therapy (CT) and compared to CT alone or was compared to CT alone without the combination and in 11 it was compared to CT alone or no therapy. The reviews reported various measurements outcomes; these include 14 on upper limb recovery (18, 28, 33, 53, 58, 59, 60, 64, 65, 73, 74, 76, 78, 81,), 5 on balance recovery ( 42 , 44 , 54 , 56 , 75 ), 5 on gait recovery ( 35 , 37 , 55 , 57 , 75 ), 7 on lower limb recovery including gait and balance ( 36 , 39 , 61 , 67 , 71 , 75 , 79 ), 3 on cognition alone ( 33 , 34 , 77 ) and the rest reporting on different combinations of the above. Assessment of Methodological Quality of included Systematic Reviews : Table 2 shows the AMSTAR 2 grade (high, moderate, or low) confidence in the result with missing critical domains noted. Appendix 4 shows the individual reviews’ detailed AMSTAR 2 item scoring. Only 13 reviews were noted to be of methodological good quality (moderate to high) according to the AMSTAR 2 tool, these are 38, 41, 47, 2, 51, 62, 63, 64, 66, 71, 75, 77, and 33; 15 were critically low with multiple critical domains missing, and the remaining 28 were of low methodological quality (Table 2 and Appendix 4). Table 2 Quality rating of the systematic reviews using the AMSTAR 2 tool Author AMSTAR 2 rating Critical domain missing Comment Crosbie et al., 2007 ( 36 ) Critically Low 2,7,9,13 Multiple critical domains Henderson et al., 2007 ( 37 ) Low 7 4,2 = Partial yes and one non-critical item Saposnik and Levin, 2011 ( 30 ) Critically Low 7 ,9 3, 4 = partial yes and multiple ( 4 ) non -critical items Smith et al., 2012 ( 38 ) Moderate 7,2 = partial yes and multiple ( 2 ) non -critical items (downgraded to moderate) Cavalcanti Moreira et al., 2013 ( 39 ) Low 7 2,4 = partial yes Casserly and Baer, 2014 ( 19 ) Low 2 = Partial yes and multiple ( 4 ) non -critical items, (downgraded to low) Thomson et al., 2014 ( 18 ) Low 7 2 = Partial yes and multiple ( 3 ) non- critical items Imam and Jarus, 2014 ( 40 ) Low 13 4,2 = Partial yes Lohse et al., 2014 ( 41 ) High one non -critical items (item 16 not mentioned in the published paper, but was retrieved from PROSPERO registration) Rodrigues-Baroni et al., 2014 ( 42 ) Critically Low 7,15 2 = Partial yes and multiple ( 2 ) non- critical items Aguiar Dos Santos et al., 2015 ( 43 ) Critically Low 2,7 4 = Partial yes and multiple ( 3 ) non- critical items Luque-Moreno et al., 2015 ( 44 ) Low 7 2 = Partial yes and multiple ( 4 ) non- critical items, Cheok et al., 2015 ( 45 ) Low 15 2 = Partial yes and multiple ( 2 ) non- critical items Corbetta et al., 2015 ( 23 ) Low 7 2 = partial yes and one non-critical item Chen et al., 2016 ( 46 ) Low 7 4,2 = Partial yes and multiple ( 2 ) non- critical items de Rooij et al., 2016 ( 47 ) Moderate 2 = partial yes and multiple ( 2 ) non -critical items (downgraded to moderate) Li et al., 2016 ( 48 ) Low 15 4 = Partial yes and one non-critical item Gibbons et al., 2016 ( 49 ) Low 2 Multiple ( 6 ) non-critical domains dos Santos Palma et al., 2017 ( 50 ) Low 7 8,4,2 = Partial yes and multiple ( 2 ) non- critical items Iruthayarajah et al., 2017 ( 51 ) Critically Low 2, 13, 15 7, 11, 14 = partial yes and multiple ( 2 ) non-critical domains Aminov et al., 2018 ( 2 ) High 2,7 = partial yes and one non-critical item Laver et al., 2017 ( 20 ) High one non -critical items Ahn etl., 2019 ( 52 ) Low 2 7, 9 = Partial yes and one non-critical item Aramaki., 2019 ( 53 ) Critically Low 2, 9, 13 1, 4, 7 = Partial yes and multiple ( 2 ) non-critical items Mohammadi et al., 2019 ( 54 ) Critically Low 2, 15 4, 7 = Partial yes and multiple ( 2 ) non -critical items De Keersmaecker et al., 2019 ( 55 ) Low 15 5, 12 = Partial yes and ( 2 ) non -critical items Ghai et al., 2020 ( 56 ) Low 2 3, 4, 7 = Partial yes Dominguez-Tellez et al., 2020 ( 57 ) Critically Low 2, 15 3, 4, 7, 12 = Partial yes and multiple ( 3 ) non-critical items Karamians et al., 2020 ( 58 ) Low 15 4, 7 = Partial yes and multiple ( 2 ) non -critical items Mekbib et al., 2020 ( 59 ) Critically Low 2, 15 2, 4, 7, 8 = Partial yes and multiple ( 2 ) non -critical items Pintado-Izquierdo et al., 2020 ( 60 ) Critically Low 2, 15 7 = Partial yes and multiple ( 2 ) non -critical items Amirthalingam et al., 2021 ( 61 ) Low 2 3, 4, 7 = Partial yes and multiple ( 3 ) non -critical items Cao et al., 2021 ( 62 ) Moderate 2, 4, 7, 15 = Partial yes Doumas et al., 2021 ( 63 ) High 3, 7 = Partial yes and ( 1 ) non -critical item Cortes-Perez et al., 2021 ( 64 ) High 3, 7 = Partial yes and ( 1 ) non -critical item Gao et al., 2021 ( 65 ) Critically Low 2, 15 7, 12, 14 = Partial yes and ( 1 ) non-critical items Garay-Sachez et al., 2021 ( 66 ) Moderate 3, 4, 7, 13 = partial yes and multiple ( 2 ) non -critical items (downgraded to moderate) Khan et al., 2021 ( 66 ) Critically Low 2, 15 3 = Partial yes and multiple ( 2 ) non -critical items Palacios-Navarro et al., 2021 ( 68 ) Low 2 7, 13 = Partial yes and multiple ( 2 ) non-critical item Peng et al., 2021 ( 69 ) Low 2 3, 7 = Partial yes and one non-critical item Zhang et al., 2021 ( 70 ) Low 15 3, 4, 7 = Partial yes and one non-critical item Zhang et al., 2021 ( 71 ) High 3, 7 = partial yes and one non-critical item Aguilera-Rubio et al., 2022 ( 72 ) Low 2 4, 7, 14 = Partial yes and one non-critical item Al-Whaibi et al., 2022 ( 73 ) Low 2 One non-critical item Chan et al., 2022 ( 74 ) Low 2 3, 13, 14 = Partial yes and one non-critical item Chen et al., 2022 ( 75 ) High 3 = Partial yes and ( 1 ) non -critical item Chen et al., 2022 ( 76 ) Low 2 4, 7 = Partial yes and one non-critical item Fernandez-Vazquez et al., 2022 ( 77 ) High 3, 4, 13 = partial yes and one non-critical item Hao, J., Buster, T., 2022 ( 79 ) Low 15 3, 4, 12, 13, 14 = partial yes and one non-critical item Hao et al., 2022 ( 79 ) Low 15 3, 4, 13, 14 = Partial yes and one non -critical items Leong et al., 2022 ( 80 ) Critically Low 2, 13 3, 7, 12, 14 = partial yes and one non -critical item Li et al., 2022 ( 81 ) Low 2 3, 7 = Partial yes and one non -critical items Mugisha et al., 2022 ( 82 ) Low 15 3 = Partial yes and one non -critical items Parisi et al., 2022 ( 33 ) High 4, 14 = partial yes and one non-critical item Sevcenko & Lindgren, 2022 ( 83 ) Low 2 3, 5, 6, 7 = Partial yes and one non -critical item Wang et al., 2022 ( 84 ) Critically Low 2, 15 3, 4, 7, 14 = Partial yes and one non- critical item Wiley et al., 2022 ( 32 ) Critically Low 2, 15 3, 14 = Partial yes and one non- critical item Table 2 . Quality rating of the systematic reviews using the AMSTAR 2 tool. Table 2 to be inserted here The most common missing domain relates to questions 2 and 7 (writing and registering a protocol with the relevant search information and providing a list of excluded full text articles respectively) and question 10 (reporting on the sources of funding for the included studies). 16 reviews had a prior registration; 15 with PROSPERO ( 41 , 48 , 55 , 59 , 63 , 64 , 66 , 70 , 71 , 75 , 77 , 78 , 79 , 81 , 33 ) and one with the Cochrane database ( 20 ). The search strategy was judged to be comprehensive in over 60% of the reviews while the rest were partially comprehensive. 50/57 reviews explicitly disclosed conflicts of interest and/or funding sources, none of the reviews explicitly discussed funding of the studies included in their respective reviews (Question 10 on the AMSTAR 2 tool). Extracted Outcome Measures: Outcomes from the high and moderate quality reviews ( 2 , 20 , 38 , 41 , 47 , 62 , 63 , 64 , 66 , 71 , 75 , 77 , 33 ) were extracted and summarized, as the confidence in these reviews’ results was moderate to high. Upper Limb Outcome The major results and conclusions drawn from the high-moderate quality studies have been summarized in Table 1 . Most of these studies used the Fugl Meyer assessment (FMA) to evaluate the effects of VR on UL function. Consensus from the 8 high to moderate quality reviews show that VR enhances UL recovery, particularly if additive to CT allowing more therapy time. The effect size was moderate at best. Laver et al. ( 20 ) have shown an improvement in activities of daily living (ADL) when compared to CT but not UL recovery, whereas other ( 2 ), ( 38 ), ( 41 ), ( 63 ), ( 64 ), have shown improvement of UL structure and function. Doumas et al. ( 63 ) used leap motion controller, a form of semi-immersive VR that consists of a device with sensors designed to detect, recognize, and capture hand gestures and finger positions in addition to generating a virtual image of the UL on a screen indicating the user the next task to be performed. This device was found to be more effective than CT in improving grips strength (low-quality evidence, medium-high effect) and UL-mobility-oriented tasks (large effect, low-quality evidence). The review done by Chen et al. ( 75 ) showed statistically significant improvement in UL motor function, muscle strength, range of motion and independence in day-to-day activities. The UL motor function was measured using the Fugl Meyer assessment (FMA), Manual Muscle Testing (MMT), Motricity Index (MI) and several other scales. Independence in day-to-day activities was measured using scales such as Functional Independence Measure (FIM), and Barthel Index or modified Barthel Index. This review also showed that when VR rehabilitation exercises were combined with CT, this led to improvement in hand dexterity. Fernández-Vázquez et al. ( 77 ) showed the same effect as Chen et al. ( 75 ) when VR was combined with CT. The evidence, however, is conflicting with regards to the use of VR versus CG. Laver et al. ( 20 ) have shown a trend toward rehab-specific VR to be more beneficial and that CG is not superior when compared to CT, whereas Lohse et al. ( 41 ) have shown effectiveness for both VR and CG. Other reviews ( 28 ), ( 17 ) & ( 47 ) agree with Lohse et al. ( 41 ), however these reviews are observed to be of lower methodological quality. Reviews ( 63 , 64 , 75 , and 77 ) looked at UL rehabilitation post stroke and all of them concluded that there was statistically significant improvement in UL motor function with the use of VR either in combination with CT or alone. Fernández-Vázquez ( 77 ) have shown that the combination of haptic gloves, semi-immersive VR, and CT produce significant improvement in UL functionality (measured by the FMA), Jebson-Taylor Hand Function Test (JTT), or the Block and Box test (BBT)) as compared to CT alone. Apart from these high to moderate quality reviews, the low and critically low-quality studies have also showed similar results (Table 1 ). Lower Limb Recovery, Gait and Balance Outcomes: Most systematic reviews have included outcomes related to lower limbs, balance and walking together as they are interlinked. Several scales were used commonly throughout these studies to measure lower limb and balance. For example, for balance and gait, Brunel Balance Assessment (BBA), Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Fugl-Meyer Assessment balance subscale, Postural Assessment Scale for Stroke and Balance Evaluation Systems Test were some of the scales used in these reviews to measure the LL functionality. Two reviews ( 38 , 40 ) demonstrated benefit of VR when added to CT on gait and balance, one ( 41 ) demonstrated benefit across all three outcomes. Other reviews focusing specifically on balance recovery ( 46 , 48 ) have shown improvement in static and dynamic balance or improvement in balance in timed up and go test. A recent review ( 66 ) evaluating the effect of VR on static and dynamic balance showed significant improvement in static balance when non-immersive VR was used in combination with CT, whereas for dynamic balance, 2 of the reviews in the systematic review showed improvement with immersive VR and 4 reviews showed significant improvement with non-immersive VR both in combination with CT. Likewise systematic reviews focused solely on gait recovery have shown VR to improve walking speed ( 42 ) and walking speed and distance walked ( 39 ) but the confidence in results of these reviews remain low due to heterogeneity between studies, lower number of participants involved, and lack of blinding of therapists and participants. Other reviews that were deemed to be of low quality according to the AMSTAR rating also showed statistically significant improvement in balance, lower limb functional mobility, and functional independence in patients with stroke undergoing a combination of VR + CT ( 60 , 74 , 83 ). Other low-quality reviews conflicted with this evidence by concluding that there was no difference between VR and dose-matched conventional rehabilitation in improving balance function ( 78 ) except for the review done by De Keersmaecker et al. ( 55 ) which reported statistically significant results when VR was combined with treadmill training in improving several outcome measures such as walking speed, cadence, step length, stride length as compared to treadmill alone. Cognitive Outcomes 4 high quality ( 2 ), ( 33 ), ( 41 ), and ( 71 ) (reporting on 7 RCTs), 2 low-quality reviews ( 76 , 79 ), and 3 critically low quality reviews ( 37 , 65 , 67 ) included a cognitive component in their VR assessments. The cognitive domains tested were memory, neglect/visual training, and executive function. The high-quality reviews (41 and 2) showed positive effects of VR (used either in combination or without CT) on cognition with a small to medium effect size. The high-quality review done by Parisi et al. ( 33 ) showed that multisensory technology that includes VR both with and without motion tracking but more so the former, is more effective than conventional therapy for cognition especially for specific domains such as attention, visuospatial processing, memory, and global cognition. One low-quality review that specifically looked at the effects of semi-immersive VR on global cognition, attention, execution, as well as motor function concluded that VR-based intervention combined with traditional rehabilitation showed better outcomes for overall cognition, attention/execution, and depressive mood in individuals with chronic stroke ( 65 ). There was one high quality review ( 62 ) that looked at functional communication as the main outcome of VR (immersive and semi-immersive), however, it was concluded that was no significant difference between VR and the control group in the review. There was also considerable heterogeneity in the results of the reviews included. Study ( 67 ) done by Khan et al., looking at motor, sensory, and cognitive outcomes showed improved functional outcome in all 3 outcomes and Zhang et al. ( 70 ) showed a similar effect of VR on cognition compared to CT. A high-quality review by Zhang et al. ( 71 ) assessing global cognition as well as domain-specific outcomes such as attention, executive function, memory, and verbal fluency revealed no significant effect on global cognition with the use of VR but improved effects on executive function, memory, and visuospatial function. Another high-quality review by Wiley et al. ( 32 ) published recently looked at multi-sensory technology and its effects on cognition, language, executive function, and memory post-stroke. The review found that multisensory technologies without motion tracking were more effective than standard therapies in improving the mentioned domains whilst multi-sensory technology with motion tracking was similar to the conventional group 3 weeks after the interventions. Overall, VR had a positive effect on cognition, effect size was noted to be modest, and the studies were noted to be heterogenous. Moderators of Outcome Degree of Immersion Most studies included reviews with varying degrees of immersion (immersive, semi-immersive and non-immersive), however a few reviews reported on the impact of immersion on outcome. Henderson et al. ( 37 ) found immersive virtual reality (IVR) to be beneficial when compared to no therapy, the authors did not find any studies at the time of conduction of the review on IVR versus CT. They also found non-immersive virtual reality (NIVR) to be less effective than IVR versus no therapy, but outcomes failed to reach significance when compared to CT. A high-quality review by Moher et al. ( 34 ) focusing primarily on non-immersive VR (NIVR) found it to be useful as an adjunct to CT but there was little evidence to suggest improvement of outcomes when it was compared to CT alone. Another high-quality review grouped the interventions into 2 groups (immersive and non-immersive VR) and looked at the effects on static and dynamic balance ( 66 ). Four studies using non-immersive VR within this review showed improvements in static balance whilst a single study using immersive VR showed the same. For dynamic balance, there were 4 non-immersive VR and 2 immersive VR studies that showed favorable outcomes. The low number of studies using immersive VR in the field of neurological disorders can be attributed to the scarce usage of immersive VR devices due to their high cost and availability. However, the results do show promising effects comparable to non-immersive VR. A review ( 77 ) looked at the combination of haptic gloves (greater interaction between the user and the object with more feedback) with semi-immersive VR and their effects on UL motor rehabilitation. This review showed that this combination resulted in significant improvement in UL functionality as compared to CT alone. Overall, there is evidence to suggest that immersive VR is as effective as non-immersive or semi-immersive VR in improving functional outcomes post-stroke. The recent pilot review published looking at fully immersive VR and evaluating patient and clinician’s perceptions showed that patients experienced a greater deal of motivation, felt more engaged, and experienced more enjoyment than what would have been possible in CT ( 26 ). Theoretically, this would lead to better outcomes and increased compliance to the rehabilitation. This shows that there is a great deal of potential in implementing fully immersive VR in post-stroke rehabilitation, however, more evidence is needed to clearly study the effects of immersion of improvement in post-stroke deficits. Virtual Reality Platform The 3 reviews investigating CG as a VR platform reported varying degrees of improvement in the activity of daily living (ADL), upper limb outcomes and static balance. However, these reviews have emphasized CG as an adjunct rather than a replacement of CT. Among the high quality reviews, ( 2 ) found rehab- specific VE platforms to be superior to CG, ( 20 ) found a trend favoring VE over CG and that CG were not more beneficial than CT in UL recovery. Lohse et al. ( 41 ) while demonstrating that both VE and CG are beneficial stated that “current CG interventions have been too few and too small to assess potential benefits of CG” Recent studies have used more CG devices and semi-immersive VR such as Nintendo Wii and Xbox Kinect since these are now readily available and at a lower cost. Serious games are also being used in certain studies ( 63 ). A serious game is defined as a game that has education or rehabilitation as its primary goal ( 63 ). These games would use motion capture systems, robotic exoskeletons, or a simple smartphone or tablet computer. It was seen that rehabilitation through serious games led to better improvements in motor function, activity, and participation as compared to CT. According to ( 64 ), leap motion controller video games have also been shown to improve UL function post-stroke especially when combined with CT. A combination of haptic glove systems combined with CG devices and semi-immersive VR also produces statistical improvement in the outcomes measured. Other low-quality studies have also demonstrated possible benefits of including CG and gaming devices in stroke rehabilitation ( 67 , 69 , 74 ). A review by Chan et al. ( 74 ) looked solely at exergaming (video games that require people to interact with the thorough purposeful body movements) at improving functional outcomes in patients with chronic stroke and it was found that exergaming showed statistically significant improvement in balance, lower limb functional mobility, and functional independence ( 74 ). Time since Stroke: The overwhelming majority of participants were in their chronic phase of stroke (> 6 months), however some reviews included patients in the acute (1 month) and subacute (1–3 months) phase post stroke. Aminov et al. ( 2 ) found no significant differences between overall outcome in patients receiving VR therapy at the subacute and the chronic phases of their stroke. Lohse et al. ( 41 ) could not draw conclusions as the trials were small in size with not enough statistical power for regression analysis. Laver et al. ( 20 ) found no statistically significant difference between stroke patients recruited within 6 months after stroke to those recruited after 6 months. Study ( 74 ) by Chan et al. found that patients with subacute stroke found greater improvements in arm and hand motor ability than those with chronic stroke. However, patients with chronic stroke showed greater improvements in quality of life than patients with subacute stroke ( 74 ). Parisi et al. ( 33 ) used multi-sensory technology with and without motion tracking and found that the group with patients in the subacute stroke stage (3–6 months) benefited the most from the intervention. Fernández-Vázquez et al. ( 77 ) concluded that in the very acute (< 1) month stage, the use of haptic gloves and semi-immersive VR was superior to conventional treatment in the UL functionality regardless of whether it was combined with CT or not. However, for the long-term improvement in UL functionality, the significant effects of the haptic gloves and semi-immersive VR were only preserved if they were combined with CT ( 77 ). Hence, there is evidence to suggest rehabilitation is more effective in the subacute and acute stages of stroke than the chronic stage, however, outcomes such as quality of life improve greatly when rehabilitation is done more than 6 months after stroke. Dosing Intervention VR interventions were delivered in variable ways with respect to intensity, frequency, and duration of the intervention. Laver et al. ( 20 ) compared trials applying under 15 hours of intervention with trials applying 15 hours or more of intervention on upper limb function and found no significant difference. Aminov et al. ( 2 ) found no significant difference for different doses, durations, and frequencies of VR intervention. Study ( 75 ) by Chen et al. showed that “receiving > 15 hours of VR intervention (SMD 0.92, 95% CI 0.35–1.49; P = .002) was associated with significant improvements in hand dexterity (BBT) compared with receiving ≤ 15 hours of VR intervention (SMD − 0.10, 95% CI − 0.35 to 0.15; P = .45)” ( 75 ). Also, “receiving VR-supported exercise therapy for > 1 month (SMD 0.97, 95% CI 0.06–1.89; P = .04) was associated with greater improvements in hand dexterity (BBT) than receiving VR-supported exercise therapy for < 1 month” (SMD 0.02, 95% CI − 0.22 to 0.26; P = .84). However, those who received trial lengths of 2 weeks to 1 month (SMD 0.49, 95% CI − 0.11 to 1.10; P = .11) showed greater improvements in quality of life than those for whom trial lengths were > 1 month (SMD − 0.20, 95% CI − 0.46 to 0.06; P = .13)” ( 74 ). Study ( 20 ) by Laver et al. concluded that at least 15 hours of rehabilitation was needed to achieve significant improvements in UL functionality, however in review ( 77 ), there were 2 studies that showed significant improvement in UL functionality with having done less than 15 hours. This was most likely due to the higher intensity of VR applied in these studies (5 sessions per week in consecutive days). Therefore, the differences can be attributed to the duration as well as the intensity of VR rehabilitation. Adverse Effects The reviewed systematic reviews seldom mention adverse events. However, when these were reported, they were found to be infrequent and mild in nature. These include, headache, dizziness, pain and increased tone ( 20 ). Figure 2 to be inserted here after the Results This figure has been created by the author and does not require permission to be included in the article. Discussion This overview of systematic reviews on the effect of VR on stroke recovery aims at synthesizing and summarizing available evidence from multiple systematic reviews. This allows evidence to be consolidated and recommendations to be strengthened and made easily accessible to clinicians. Additionally, in areas of research where evidence is thin or non-existent, this overview has helped uncover these pertinent areas and generate questions for future research to fill gaps in the current body of literature. Virtual Reality is Beneficial and Safe Evidence from multiple high-quality reviews incorporating high-quality RCTs suggests that VR improves upper limb recovery, balance, gait, and cognition post stroke when added to conventional therapy above and beyond conventional therapy alone. The effect is postulated to be by providing further therapy time, however there seems to be an effect even when therapy is time-matched ( 2 , 81 ). Furthermore, it is shown to be safe with rare and mild side effects. Virtual Reality Effect on UL mobility, LL mobility, balance, gait Almost all the high to moderate quality reviews as well as the low-quality reviews concluded that VR rehabilitation produced statistically significant improvement in UL and LL function, more specifically gross motor function. Thus, from this review we have sufficient good quality evidence to support the claim that VR use should be encouraged for patients with post-stroke rehabilitation. The more immersive and enriched the experience of VR is, the higher the intrinsic motivation and the higher the adherence to the therapy leading to better outcomes ( 15 , 27 ). There are several reasons why VR improves UL and LL motor function more than CT. VR provides access to therapeutic exercises in an environment that stimulates real life experiences and interaction which otherwise the patients may not have been able to access ( 75 ). Moreover, VR provides real-time feedback to the user through various senses including sounds and vibration sense. Positive feedback encourages and motivates users to continue and engage in the therapy, something that CT is unable to provide. Thirdly, VR also provides intensive, goal-oriented, and repetitive tasks involved in exercises that promote muscle coordination and neuronal development. Additionally, VR games have built in reward systems for achieving and reaching certain milestones and this further encourages and motivates users to continue the therapy ( 75 ). Virtual Reality Effect on Cognition: The current data from the available reviews supports the use of VR in post stroke cognitive impairments. This is supported by evidence from other neurological disciplines ( 85 ) ( 86 ) demonstrating that VR can be used for cognitive re-training and could be a valid option were CT has shown shortcomings such as anosognosia ( 24 ). However, for more robust evidence there is a need for systematic reviews to specifically tackle cognitive domains affected. Several trials ( 87 , 88 , 89 ) tackling cognition were reviewed by ( 20 ), they were noted to have low to moderate quality and Laver et al. ( 20 ) could not pool their data due to significant heterogeneity. Recently, several systematic reviews have been published incorporating cognition as one of the outcomes of VR rehabilitation. Out of the 4 high-quality reviews, Zhang et al. ( 71 ) concluded that there was no significant improvement in terms of global cognition, however, there was significant improvement seen in executive function, memory, and visuospatial function post stroke. This result is comparable to the other critically low and low-quality reviews (32 and 70) that included cognition as one of the outcomes measured where they also concluded that VR was not superior to CT in improving cognition. One of the reasons for the conflicting results on cognition may be due to the fact that the VR exercises and rehabilitation interventions may not be focused solely on improving cognition, rather they target other outcomes such as UL and LL function whilst looking at cognition as a secondary outcome. It remains unclear whether increasing VR therapy focusing just on cognition would lead to significant improvement. Furthermore, low-quality reviews, ( 61 ), ( 70 ) and ( 80 ) showed no effect of VR on cognitive outcomes as compared to CT. However, only one review, Chen et al. ( 76 ) concluded that VR improved cognitive function more than CT alone. Interestingly, this review looked at studies that included patients only with a definitive diagnosis of post-stroke cognitive impairment. This involved 21 studies with 1149 patients in total, all with a diagnosis of post-stroke cognitive impairment. They found out that VR rehabilitation resulted in an increase in scores in the various mental status exams including Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), Rivermead Behavioral Memory Test Second Edition (RBMT-Ⅱ) and others. Although classified as a low-quality review according to the AMSTAR-2 tool, this review argues strongly in favor of VR improving post stroke cognitive impairment. There are several theories put forward to explain how VR can affect cognition. The cognitive rehabilitation theory explains that after certain intense, repeated sensory stimulation and functional training”, the part of the brain surrounding the damaged tissue can compensate for the functions of the damaged tissue ( 76 ). Moreover, some reviews have shown that VR stimulates improvement in the excitability of the remaining neurons, improves functional reorganization of the damaged brain area, and forms new neural circuits ( 76 ). Other studies have stated that VR rehabilitation “activates brain metabolism, increases cerebral blood flow, and the release of neurotransmitters” ( 71 ), thus leading to improved cognitive function. Nonetheless, more studies looking specifically at this population of patients with post-stroke cognitive impairment are required utilizing high-quality large sample randomized controlled trials along with adequate follow-up for at least 12 months post-stroke in order to generate high quality evidence regarding the role of VR in improving cognition. Influence of Moderators on Outcomes : Time since Stroke Most of the reviews included patient in the chronic stage of stroke (> 6 month) with only a few of the included trials including patients in the acute and subacute phases. Although a high-quality review reporting on high quality evidence ( 2 ) found no statistical difference between VR applied acute/subacute stage of recovery, as both were equally effective, however optimal timing to apply VR remains to be explored further ( 2 ). Previous research has shown that the majority of gains and motor recovery occur within the first 1–3 months post-stroke ( 90 ). So, capitalizing on this “window of opportunity” of peaked neuroplasticity in the initial period after stroke makes sense biologically ( 91 , 92 ). However, there is some evidence that application of VR in the subacute phase (3–6 month) may be more beneficial. Wang et al. ( 92 ) have shown that applying Leap Motion VR which can track the fine movements of both hands and fingers in the subacute phase of stroke is feasible and promising. Parisi et al. ( 33 ) that used multi-sensory technology with and without motion tracking also found that the group with patients in the subacute stroke stage benefited the most from the intervention. Additionally, Chan et al. ( 74 ) found that patients with subacute stroke found greater improvements in arm and hand motor ability after being subjected to VR and exergaming interventions than those with chronic stroke. Patients with chronic stroke showed greater improvements in quality of life after VR rehabilitation and exergaming than patients with subacute stroke ( 74 ). This is most likely because outcomes such as cognition, activities of daily living, and mental health all play a role in the quality of life post stroke and the recovery of cognition is dissimilar to motor recovery as it usually takes longer ( 92 ). To uncover the impact on cognition with an understanding of any nuanced effect it may have on domain specific recovery, longer follow up periods are needed, something that is currently lacking ( 2 ). This needs to be addressed in specifically designed RCT with adequate follow-up periods after intervention. Intensity, Frequency and Dosing of VR Intervention: VR intervention in the trials included in these reviews were conducted with varying doses of intervention (intensity, frequency and duration) ( 2 ). Some trials did not report the dosing of the intervention, and when dosing was provided, true dose- matching between interventional and control arms, was not ensured (e.g., “matching active time in therapy or numbers of repetitions”) ( 2 ). However, there was one review that looked at the effects of VR and time dosed matched CT and it concluded that VR is superior to time-dose matched CT in terms of recovery of upper extremity motor function in patients poststroke, especially when VR is combined with CT ( 81 ). A study showed that receiving > 15 hours of VR intervention was associated with significant improvements in hand dexterity (BBT) compared with receiving ≤ 15 hours of VR intervention ( 75 ). Also, receiving VR-supported exercise therapy for > 1 month was associated with greater improvements in hand dexterity (BBT) than receiving VR-supported exercise therapy for 1 month ( 75 ). Additionally, Laver et al. ( 20 ) concluded that at least 15 hours of rehabilitation was needed to achieve significant improvements in UL functionality, however in the review by Fernández-Vázquez et al. ( 77 ), there were 2 studies that showed significant improvement in UL functionality with having done less than 15 sessions. This was most likely due to the higher intensity of VR applied in these studies (5 sessions per week in consecutive days). Therefore, the dosing intensity and frequency affect the various outcome measures in different ways. A longer duration of intervention may not always be more beneficial than a shorter duration for all the outcomes as seen by review ( 75 ). Future studies with true matching of intensity, frequency and dosing of the VR intervention are needed to help understand the benefits of VR therapy. Stroke- Specific Virtual Environment: While CGs are not typically designed for rehabilitation purposes, yet a lot of therapists tend to use them as they are available and cheap ( 30 ). VR effect was observed to be more robust when utilizing rehab specific VEs, however CG interventions were valuable as an adjunct to CT, but strong recommendation regarding the preferred platform for VR delivery is yet to be made. Building on the results of this review, a genuine need arises for studies on CG and for the development and testing of stroke specific VEs. Furthermore, availability and affordability of VEs is another concern since the CGs such as Nintendo Wii and Xbox Kinect are very widely available and cheap and therefore can be more routinely used in rehabilitation. Exergaming (video games that require people to interact with the thorough purposeful body movements) was found to show statistically significant improvement in balance, lower limb functional mobility, and functional independence ( 74 ). This may also partly be due to the rewarding experience inducing high intrinsic motivation leading to better adherence to the therapy. Limitations Selection bias was unavoidable as this review included only reviews in the English language. The risk of bias cannot be ruled out as there was considerable heterogeneity even between high quality reviews pertaining to different outcomes. Most of the reviews here were of low-quality AMSTAR 2 ratings with only a handful of high-quality reviews driving the results. Furthermore, the reported evidence grading from some of the high-quality reviews was less than excellent. Additionally, a meta-analysis could not be done due to the vast number of studies and the heterogeneity within them, therefore the absence of quantitative analysis is a limitation that could be worked on in future studies. Conclusion Virtual reality is a promising technology that can add to our rehabilitation armamentarium and aid recovery of the post stroke patient. This overview demonstrates that VR is a safe and effective adjunct to conventional therapy for post stroke recovery across different functional domains. It is especially beneficial when used in combination with CT. There is clear evidence supporting the use of VR rehabilitation (including exergaming and CG) in combination with CT or alone for the use of post-stroke UL and LL impairment. There is potential evidence to apply VR for cognition and balance as well, however due to the heterogeneity and conflicting results, more studies are needed to study the effects of VR on these outcomes. For now, there are clinical implications that can be derived from this meta-review and that is to routinely use VR rehabilitation (VE, CG, exergaming) for patients with post-stroke UL and LL impairment. Having said this, the heterogeneity of the studies and discrepancy in some of the outcomes has raised further questions regarding optimal dose, frequency, timing, and choice of VR intervention which should be continued to be studied in prospective well-designed clinical trials. Abbreviations VR Virtual Reality NSVR Non-Specific VR-based Rehabilitation UL Upper Limb CT Conventional Therapy LL Lower Limb PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses RCTs Randomized Controlled Trials VE Virtual Environment CG Commercial Gaming FMA Fugl Meyer Assessment ADL Activities of Daily Living MMT Manual Muscle Testing MI Motricity Index FIM Functional Independence Measure JTT Jebson-Taylor Hand Function Test BBT Block and Box Test BBA Brunel Balance Assessment BBS Berg Balance Scale DGI Dynamic Gait Index NIVR Non-immersive VR SMD Standardized mean difference CI Confidence interval MMSE Mini-Mental State Examination MoCA Montreal Cognitive Assessment LOTCA Loewenstein Occupational Therapy Cognitive Assessment RBMT-II Rivermead Behavioral Memory Test Second Edition Declarations Ethics approval and consent to participate Not applicable since this is a systematic review Consent for publication Not applicable Availability of data and materials All data generated or analyzed during this study are included in this published article [and its supplementary information files] Competing interests The authors declare that they have no competing interests Funding The open access to this review is funded by Qatar National Library at Qatar Foundation. The funder had no role in the study design, data extraction process, data analysis, result interpretation, or manuscript preparation. Author’s contributions A.K. and Y.I were the two independent reviewers that independently conducted the search, extracted the data, interpreted the results, tabulated, and discussed the data. M.M. was the third reviewer that resolved any disagreements during the initial screening and extraction of the data. S.J. and S.G. were involved in the editing and writing of the manuscript. Acknowledgement We would like to acknowledge Qatar National Library for funding open access to the article. References Wang, Haidong, et al. ‘Global, Regional, and National Life Expectancy, All-Cause Mortality, and Cause-Specific Mortality for 249 Causes of Death, 1980–2015: A Systematic Analysis for the Global Burden of Disease Study 2015’. The Lancet, vol. 388, no. 10053, Oct. 2016, pp. 1459–544. DOI.org (Crossref), https://doi.org/10.1016/S0140-6736(16)31012-1. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4319427","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":297566193,"identity":"24d30a71-42ad-485c-a8da-1d1ca1e4cfe4","order_by":0,"name":"Ammar Khan","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0001-6809-8671","institution":"Weill Cornell Medicine - Qatar","correspondingAuthor":true,"prefix":"","firstName":"Ammar","middleName":"","lastName":"Khan","suffix":""},{"id":297566194,"identity":"3fabd6f2-fd7c-4b1b-9ac3-d1c014bd8978","order_by":1,"name":"Yahia Z. Imam","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"prefix":"","firstName":"Yahia","middleName":"Z.","lastName":"Imam","suffix":""},{"id":297566195,"identity":"671081fb-2927-476b-b5e3-ad1a72192312","order_by":2,"name":"Mohamed Muneer","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"","lastName":"Muneer","suffix":""},{"id":297566196,"identity":"ae3379e4-713f-41d8-a83b-ce84463e7a76","order_by":3,"name":"Salman Al Jerdi","email":"","orcid":"","institution":"Weill Cornell Medicine - Qatar","correspondingAuthor":false,"prefix":"","firstName":"Salman","middleName":"Al","lastName":"Jerdi","suffix":""},{"id":297566197,"identity":"885b0ab6-6369-4e86-b9f4-644fdd868cf6","order_by":4,"name":"Sumanjit K Gill","email":"","orcid":"","institution":"UCL: University College London","correspondingAuthor":false,"prefix":"","firstName":"Sumanjit","middleName":"K","lastName":"Gill","suffix":""}],"badges":[],"createdAt":"2024-04-24 16:01:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4319427/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4319427/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s42234-024-00150-9","type":"published","date":"2024-10-05T15:57:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56010551,"identity":"fc8e622b-427b-4c69-9b86-5a26489ba6f4","added_by":"auto","created_at":"2024-05-07 13:55:35","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":391472,"visible":true,"origin":"","legend":"\u003cp\u003eThe selection process summarized in the PRISMA diagram\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4319427/v1/ea3590896f40b19984c74dc9.jpeg"},{"id":56010550,"identity":"d9a4c26a-a566-43dd-9631-386af38e6d56","added_by":"auto","created_at":"2024-05-07 13:55:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":69188,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-4319427/v1/dcfded0ca383cdb8a30c1f6b.png"},{"id":66097688,"identity":"fcb2c549-f4d0-4828-bf8e-723f4ccc212e","added_by":"auto","created_at":"2024-10-07 16:15:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3722270,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4319427/v1/5446ea6b-4716-4548-a202-255ad5e04be2.pdf"},{"id":56010990,"identity":"8651ce2b-ce8b-4a40-bdcc-877e64a090c4","added_by":"auto","created_at":"2024-05-07 14:03:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":276178,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4319427/v1/bc28b059da1cdf9152730b15.docx"},{"id":56010555,"identity":"7880ff49-944a-418c-878a-8e72afde8eb4","added_by":"auto","created_at":"2024-05-07 13:55:36","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":101313,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4319427/v1/ee57d0be6f447364a7c91ca9.docx"},{"id":56010553,"identity":"08903d33-b700-4369-83f3-eadec5878255","added_by":"auto","created_at":"2024-05-07 13:55:35","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":32111,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix3.docx","url":"https://assets-eu.researchsquare.com/files/rs-4319427/v1/b2666bb2cd14f77f855548f1.docx"},{"id":56010554,"identity":"b768d1de-8af7-442c-b4c5-3572f0993c20","added_by":"auto","created_at":"2024-05-07 13:55:35","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":43170,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix4.docx","url":"https://assets-eu.researchsquare.com/files/rs-4319427/v1/eeb62682fcbe80d5d7d4f727.docx"}],"financialInterests":"","formattedTitle":"Virtual Reality in Stroke Recovery: A meta-review of Systematic Reviews","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eStroke is the major cause of mortality and disability in the world affecting over 17\u0026nbsp;million people annually (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). While advancements in medical technology and treatments have led to a decrease in stroke mortality and incidence in high-income countries, patients continue to suffer from long-term neurological deficits, including cognitive, behavioral, functional, language, and mobility deficits (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStroke rehabilitation is a complex process which optimizes recovery of injured neural tissue through enhancement of neural repair, maximizing recovery and minimizing functional deficits (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The mainstay of stroke rehabilitation is a combination of physical, occupational, speech and cognitive psychological therapy, requiring multi-disciplinary input (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). To be effective, stroke rehabilitation should include goal oriented, task- specific training (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), sufficient duration and intensity of the intervention i.e. high repetitive volume (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and utilization of biofeedback (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This can be challenging in terms of costs (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), time constraints (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) and in keeping the patients engaged and motivated (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) .\u003c/p\u003e\u003cp\u003eVirtual Reality (VR) is theorized to overcome these limitations particularly those of cost and time constraints. Virtual Reality (VR) is defined as \u0026ldquo;a computer rendered, 3-dimensional, real-time, interactive experience of artificial reality containing items, characters, and events existing only in the memory of a computer\u0026rdquo;(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe user is provided with visual feedback either on a head mounted device, a computer monitor or a screen of any type and can interact with the virtual environment through multiple mechanisms. The platform used to interact with VR is termed an environment; and the environment can be immersive, semi-immersive or non-immersive. Immersive environments are where the subject is surrounded by the virtual environment providing a high degree of realism and immersiveness. This can be achieved through the use of head-mounted devices. A semi-immersive environment is one with a moderate level of realism and immersion, falling in between a fully immersive and a non-immersive environment. A non-immersive environment in one where subjects are fully responsive to the real environment and the virtual environment is viewed via the use of high-resolution monitors and computer devices.\u003c/p\u003e\u003cp\u003eKey concepts in the use of VR are immersion, imagination, and interaction (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Immersion is the extent to which the user perceives that they are in the virtual environment rather than the real world (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The rapid increase and development of video game technology has made semi immersive or non-immersive VR cost effective and available for use in clinical practice (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These commercial gaming platforms simulate real life situations and require total body movement similar to the real world and encourage high intensity repetitive hand movements such as seen with the Nintendo Wii and PlayStation gaming platforms (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Immersive environments are thought to be superior due to increased levels of user engagement, participation, and enjoyment (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). These environments, however, are not in routine use yet due to lack of guidelines for their use in stroke rehabilitation as well as being more expensive and sophisticated to use.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eVirtual Reality in Stroke Rehabilitation\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEarlier studies that used functional imaging showed that functional improvement is associated with ipsilesional activation of the sensorimotor cortex post VR training in patients post stroke (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This has continued to drive forward and support the use of VR for stroke rehabilitation.\u003c/p\u003e\u003cp\u003eThe functional recovery of damaged brain tissue is heavily driven by neural plasticity (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Neural plasticity is the ability of the central nervous system to adapt and undergo dynamic changes in terms of structural and functional components in response to experiences and feedback received through the different senses (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The underlying neural mechanisms of this adaptability and change are dependent on the strength of the synaptic connections and axonal remodeling of the cortical pathways (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). To effectively target neural plasticity and functional recovery through rehabilitation, the rehabilitation technique needs to involve goal oriented, intensive, repetitive, and task-specific measures that are reiterated by constant visual and sensory feedback to the user from the environment (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). VR seems to be able to meet these criteria for efficacy based on functional imaging of patients post-stroke (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe mirror neurons are a class of visuomotor neurons involving interconnected brain regions (premotor cortex, inferior parietal lobule, and inferior frontal gyrus) that play a role in processing information related to the execution of movements (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Imitation and imagery have been seen to activate some of the regions of this mirror neuron system in the past (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Since the VR environment depicts the user as an avatar on a screen, this means that the patients can also see themselves performing the task through the avatar, much like standing in front of the mirror. Therefore, when that same avatar performs a motion, the mirror neurons in the brain can then be activated allowing the user to initiate that specific motion.\u003c/p\u003e\u003cp\u003eVR, when originally developed, was thought to have the potential to revolutionize stroke rehabilitation by providing the flexibility of outpatient treatment as well as by increasing patient engagement, satisfaction, and enjoyment. This remains true to this day. Enjoyability (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) is believed to be one of the main attractive features of VR. This enjoyment may improve motivation to practice and allows for more therapy time (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This is further enhanced by the sense of presence (Immersion) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), feeling of success or accomplishment (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), and synchrony (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) (playing with other participants and/or engaging in competition). Immersion level is a significant factor that can affect a user\u0026rsquo;s enjoyment, engagement, and response level. Studies have shown that more immersion leads to an increased sense of a user\u0026rsquo;s presence in the virtual environment, better learning experience and retrieval movement for virtual objects in post-stroke patients (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). A more immersive, enriched, interactive, multi-component environment with multimodal stimulation can allow the user to do more complicated tasks and has also been shown to significantly affect both patients\u0026rsquo; and clinicians\u0026rsquo; engagement, participation, and satisfaction (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEarlier studies included a smaller number of participants (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and utilized a different set of outcome measures, which made drawing conclusions and systematically reviewing these studies, a difficult task. Nonetheless, these studies have shown promising results. Meta-analyses have suggested some benefit of VR systems in improving motor function after stroke (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). A review looking at the effect of specific over non-specific VR-based rehabilitation (NSVR) on post-stroke recovery (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) concluded that specific VR-based rehabilitation was more beneficial in improving Upper Limb (UL) recovery than Conventional Therapy (CT), however, non-specific VR was not. This study showed immensely promising results along with highlighting certain principles of VR-based rehabilitation that explain why VR is superior to CT for post-stroke patients. However, the conclusions put forward by this study require further investigations since the number of studies included in the NSVR category was relatively small and may have contributed to the low statistical power of the study. Moreover, the reviews involved were heterogenous in terms of the outcomes measured, time after stroke, and dosage or frequency of the intervention. More recently, several systematic reviews and meta-analyses have been published comparing VR to CT assessing the improvement in upper limb (UL) function, lower limb (LL) function, balance, gait, cognition, and aphasia. These studies were heterogeneous to an extent in terms of the type of VR intervention used, the outcomes measured, and the conclusions drawn (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Due to the large amount of preliminary data with inconclusive, yet promising results, it is important to compile the current systematic reviews to gather current evidence in order to pave the way for virtual reality to be more routinely accessible to patients suffering from post-stroke deficits with clear and evidence-based guidelines for its use.\u003c/p\u003e\u003cp\u003eTherefore, this overview of systematic reviews aims at studying VR in a larger context, critiquing available systematic reviews and summarizing in a descriptive manner the available evidence to conclude whether VR is superior to the conventional rehabilitation therapy post stroke across different functional domains. It is hoped that our qualitative analysis, if favorable for VR, would pave the way for establishing guidelines for the routine use of VR either in combination with CT or alone in improving recovery post-stroke.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e This is an overview of systematic reviews (A meta-review of systematic reviews).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eReview Question\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWhat is the effectiveness of VR in comparison to conventional rehabilitation or no care in stroke recovery?\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSearches Strategy\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSynonyms of VR and stroke were used and adapted to different databases and searched using Boolean operators (AND/OR). The detailed search syntax is available in Appendix 1. Published manuscripts from inception up to 5th December 2022 were identified by using electronic and manual searches of the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effectiveness, PsycINFO, EMBASE, Physiotherapy Evidence Database (PEDro), Web of Science and Medline in December 2022. Search limits (English, Humans, Systematic Reviews, Meta-analysis) were employed to select articles. Relevant reference lists of identified studies and published reviews were manually checked for additional reviews. The results of the electronic search were examined for duplicate entries using the \u0026lsquo;find duplicates\u0026rsquo; facility of reference management software (EndNote X8) and were manually crosschecked.\u003c/p\u003e\u003cp\u003eStudies with mixed etiology groups were excluded unless participants\u0026rsquo; stroke-specific data was available.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003eParticipants/Population\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis review includes all systematic reviews on studies that have applied VR for rehabilitation of patients after stroke targeting various outcomes including aphasia, motor, neglect, cognition, executive function, and gait recovery.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eInclusion criteria\u003c/b\u003e:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e1) Adults above 18 years of age.\u003c/p\u003e\u003cp\u003e2) Post stroke (ischemic or hemorrhagic, any time).\u003c/p\u003e\u003cp\u003e3) Systematic reviews.\u003c/p\u003e\u003cp\u003e4) Only English text will be included.\u003c/p\u003e\u003cp\u003e5) Peer reviewed and published.\u003c/p\u003e\u003cp\u003e6) Therapy including a form of VR as a key part of the therapy provided.\u003c/p\u003e\u003cp\u003e7) Therapy targeting language function, motor function, cognitive, executive function, or neglect.\u003c/p\u003e\u003cp\u003e8) Report impairment and/or activity and/or participation-oriented outcome measures.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eExclusion criteria\u003c/b\u003e:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e1) Therapy that does not include a form of VR.\u003c/p\u003e\u003cp\u003e2) Therapy that included exogenous stimulation (such as robotic aid or functional electrical stimulation).\u003c/p\u003e\u003cp\u003e3) Subjects who were animals or children.\u003c/p\u003e\u003cp\u003e4) Reviews were excluded if they were not systematic, i.e., did not have a formal method section detailing how selection bias was excluded.\u003c/p\u003e\u003cp\u003e5) Non-English text\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis review considered systematic reviews that included studies that applied VR, immersive or non-immersive, for rehabilitation (language, cognition, motor, gait, neglect, and functionality) after stroke on its own or in addition to usual care.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eControl\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eUsual care, conventional rehabilitation, any other forms of exercise, or no treatment.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003ePrimary Outcome\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eUpper limb function, lower limb function, balance, gait, global cognition, language, memory, attention, visuospatial awareness evidenced from the included high-quality studies.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData Extraction\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe obtained search results were first screened using the title and abstract utilizing the inclusion/exclusion criteria. Full texts were then analyzed for quality and content. Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement framework for reporting of systematic reviews (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Two assessors independently reviewed the search process against the inclusion and exclusion criteria, and the risk of bias assessment. Disagreements were discussed until consensus was achieved. Data was then extracted by the two independent authors and summarized as in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eQuality Assessment of included studies\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe AMSTAR-2 (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) (Appendix 2) tool was used for quality assessment of the included studies. AMSTAR 2 contains 16 items, and is used to rate reviews as high, moderate, low, or critically low quality depending on the presence of critical or non-critical weaknesses. Critical weaknesses are defined by Shea et al. 2017 in appendix 2.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eReview Registration\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eBefore the search was initiated, the protocol was drafted and was registered with PROSPERO. The unique registration number is CRD42022372926\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrategy for Data Synthesis\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e A narrative (descriptive) synthesis was conducted utilizing the evidence, results, and conclusions drawn from the high and moderate-quality reviews only. However, wherever applicable, results from low-quality reviews were also analyzed to reinforce or contradict the conclusions drawn from the high and moderate quality reviews and this was specifically mentioned as such in the \u003cspan refid=\"Sec15\" class=\"InternalRef\"\u003eresults\u003c/span\u003e section. A quantitative synthesis including a meta-analysis could not be done due to the amount of heterogeneity and diversity present in these reviews in terms of outcome measures.\u003c/p\u003e\u003cp\u003eOutcomes were grouped according to how they were presented in the reviews. The major outcomes were grouped as upper limb outcomes, lower limb outcomes, gait and balance outcomes, and cognition outcomes. Additionally, several moderators and factors that could influence these outcomes were also analyzed and these included degree of immersion, virtual reality platform, time since stroke, and dosing of the intervention.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEvidence Map\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA visual map of the evidence from each systematic review or article was created (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e) to visually display the conclusions of each review and included 4 dimensions as per the map created by Miake-Lye et al. (\u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNumber of original studies (bubble size): The number of studies included in each review is represented proportionally by the size of the bubble.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOutcome measured (bubble color): The outcome of the review (UL rehabilitation, LL rehabilitation, or cognition) will be determined from each bubble\u0026rsquo;s color.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEffect (x-axis): The authors classified each review according to the effects found and conclusions drawn. When the interventional group showed greater benefits than the control group, the intervention was classified as \u0026ldquo;better\u0026rdquo;; otherwise, the intervention was classified as \u0026ldquo;worse.\u0026rdquo; When there was insufficient evidence or if a specific conclusion could not be drawn, the intervention was classified as \u0026ldquo;mixed/unclear.\u0026rdquo; If there were no differences, the intervention was included as \u0026ldquo;no differences.\u0026rdquo;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStrength of evidence (y-axis): The reviews were sorted into the following 4 categories high strength of evidence, moderate strength of evidence, low strength of evidence, or very low strength of evidence. This grading depended on several factors such as the specific article\u0026rsquo;s recommendation, their findings, their assessment of the evidence, and effect size. The AMSTAR-2 ratings of the articles did not affect this grading. If each article explicitly provided its level of recommendation, this was represented. If it was not explicitly reported, this was inferred by the authors of this article.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eDescription of the included Systematic Reviews\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e A search of various databases, including Medline, PEDro, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, EMBASE, PsycINFO, and Web of Science, yielded a total of 863 references. After eliminating duplicate references and applying inclusion and exclusion criteria at both the title and abstract level and at the full text level, 57 references met the criteria for inclusion. A detailed list of excluded full text articles can be found in Appendix 3. Upon reviewing the reference lists of the included reviews, no additional references were identified. Thus, a total of 57 systematic reviews were included in this study. The selection process adhered to the PRISMA flow diagram (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), and a summary of this process can be seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Our overview included a total of 57 articles: 15 were systematic reviews and 42 were systematic reviews with meta-analysis. These articles were published between 2007 and 2022. The number of participants per review ranged from 47 to 3,540. The articles included 1,033 randomized controlled trials (RCTs) and 152 non-randomized or observational studies. Most of the recent systematic reviews (2015\u0026ndash;2022) reported selectively on RCTs, while earlier reviews also included observational and non-randomized studies. See Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e for details.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e \u003cp\u003eThe selection process summarized in the PRISMA diagram\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e \u003cem\u003eto be inserted here\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eThis figure has been created by the author and does not require permission to be included in the article.\u003c/p\u003e \n\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary and characteristics of the systematic reviews included\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDate of search\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eof\u003c/p\u003e \u003cp\u003eRCTs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo of Non-randomized studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTime since stroke\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eType of\u003c/p\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTarget impairments\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eResults/\u003c/p\u003e \u003cp\u003econclusion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCrosbie et al., 2007\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception/\u003c/p\u003e \u003cp\u003e1980 to February 2005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 weeks-6 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo therapy or CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait balance, cognition\u003c/p\u003e \u003cp\u003eUL and LL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOverall safe and beneficial, but not a strong recommendation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHenderson et al., 2007\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaries according to database from Jan 1982-Jan 2006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79 VR participants (no mention of controls)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 studies acute \u0026amp; 3 chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo therapy or CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIVR Vs no therapy is beneficial\u003c/p\u003e \u003cp\u003e-no studies IVR VS CT\u003c/p\u003e \u003cp\u003e-less strong evidence NIVR Vs no therapy is effective but not Vs CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSaposnik and Levin, 2011\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1966 to July 2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 subacute, 9 chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9 VE;3 CG:\u003c/p\u003e \u003cp\u003e(4\u0026thinsp;=\u0026thinsp;IVR\u003c/p\u003e \u003cp\u003e8\u0026thinsp;=\u0026thinsp;NIVR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or robotic OR Vs CT or no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e11/12 in favor of VR\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSmith et al., 2012\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to December 2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMostly chronic (up to 66 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e(NIRV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or Vs CT or no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMajority UL (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), balance and gait\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR improves UL and walking particularly if additive\u003c/p\u003e \u003cp\u003ebut not balance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCavalcanti Moreira et al., 2013\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1966 to 2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAny time after stroke (not specified)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT, robotic and no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eBetter gait velocity and distance walked\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCasserly and Baer, 2014\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1995 to 2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute, subacute \u0026amp; chronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE+\u003c/p\u003e \u003cp\u003eGC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT or alternative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR had a positive effect on the UL. (Evidence is of low quality)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThomson et al., 2014\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to January 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMostly Chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT or no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCG a positive impact on ADL (3/4\u0026thinsp;+\u0026thinsp;ve, UL (3/9)\u0026thinsp;+\u0026thinsp;ve and movement (6/11) (weak evidence)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImam and Jarus, 2014\u003c/b\u003e (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to July 11, 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMostly chronic Stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eGC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT\u003c/p\u003e \u003cp\u003eor compared CT or robotic device or no intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLL, gait recovery and balance or a mixture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e10/11 studies positive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eLohse et al., 2014\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to April 4, 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.04\u0026ndash;6.01 years\u003c/p\u003e \u003cp\u003e(14 chronic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or robotic device\u003c/p\u003e \u003cp\u003eor compared CT or no intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLL motor recovery, UL recovery, gait recovery, balance, cognitive training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR (VE or CG)\u003c/p\u003e \u003cp\u003eeffective across ICF domains (\u003c/p\u003e \u003cp\u003eBF, ACT \u0026amp; PART) effect size moderate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRodrigues-Baroni et al., 2014\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to July 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT or none\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR effective in increasing walking speed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAguiar Dos Santos et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eup to March 31, 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMostly more than 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCG\u003c/p\u003e \u003cp\u003e(NW)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT\u003c/p\u003e \u003cp\u003eVs CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL, motor function, balance, and functionality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR Improved motor function but not static balance or functional independence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLuque-Moreno et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary 2004 and January 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003emore than 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10: VE\u003c/p\u003e \u003cp\u003e1:\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or robotic device\u003c/p\u003e \u003cp\u003eor compared to CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLower limb motor recovery, gait recovery and balance or a mixture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003cp\u003e(\u0026gt;\u0026thinsp;10 sessions) improved gait speed, balance and motor function,\u003c/p\u003e \u003cp\u003ebest when combined with CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCheok et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to July 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;and\u003c/p\u003e \u003cp\u003e2 acute or subacute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCG:\u003c/p\u003e \u003cp\u003eNW only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait recovery, balance and functional independence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eWhen additive to CT, NW improves in TUG and not in the other physical measures. Effect size small\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCorbetta et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to August 2014,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMajority chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWalking speed, balance, mobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eWhen replaces part or all of CT VR Improves walking speed, balance, mobility \u0026amp; TUG test.\u003c/p\u003e \u003cp\u003eWhen additive, improved TUG\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChen et al., 2016\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary 2006 and December 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMostly chronic (2 subacute)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+ CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared CT or no intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e8/9 significant improvement in static or dynamic balance evidence\u0026thinsp;=\u0026thinsp;moderate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ede Rooij et al., 2016\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception up to December 1, 2015.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e513\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.7 days and 11.6 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+ CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared to CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ebalance and gait recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR superior to CT.\u003c/p\u003e \u003cp\u003eWhen additive to CT more benefit particularly in gait and balance when compared to duration and dose matched CT.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLi et al., 2016\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception May 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e428\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 Acute/Subacute and 12 Chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared to CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImprovement in balance and TUG compared with control\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGibbons et al., 2016\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to\u003c/p\u003e \u003cp\u003eAugust 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e552\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute\u0026ndash;subacute\u003c/p\u003e \u003cp\u003eChronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMajority VR vs CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFunctional balance, static balance, functional gait/mobility, spatiotemporal gait parameters\u003c/p\u003e \u003cp\u003eor motor function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSignificant improvement in functional balance, gait velocity, and stride length in the VR group as compared to CT for the chronic group.\u003c/p\u003e \u003cp\u003eNo differences between groups in motor function, gait, and functional mobility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003edos Santos Palma et al., 2017\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to 16 June 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1811\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39\u0026thinsp;=\u0026thinsp;chronic, 7\u0026thinsp;=\u0026thinsp;subacute, or 7\u0026thinsp;=\u0026thinsp;acute stroke,1 both acute and subacute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT or no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL and/or LL and/or balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e+ve on BF and BS. inconclusive on ACT \u0026amp;PART\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIruthayarajah et al., 2017\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2009 \u0026ndash; September 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNintendo\u0026reg; Wii Fit balance board (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMajority additive to CT vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDynamic and static balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCompared to CT,\u003c/p\u003e \u003cp\u003eVR was found to improve static and dynamic balance in\u003c/p\u003e \u003cp\u003echronic stroke patients. Nintendo\u0026reg; Wii Fit balance board may not be effective\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eAminov et al., 2018\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003einception until 28 June 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e971\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u0026thinsp;=\u0026thinsp;acute-subacute\u003c/p\u003e \u003cp\u003e26\u0026thinsp;=\u0026thinsp;chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19 VE\u003c/p\u003e \u003cp\u003e14 CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared with CT-time matched controls (in 21 /33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL and cognition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;ve on BF, BS, ACT \u0026amp; cognition (effect size small to medium) but not on PART best results when utilizing purpose-designed VR systems.\u003c/p\u003e \u003cp\u003eConclusion: evidence supports VR use as an adjunct to CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eLaver et al., 2017\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to April 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2470\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll stages post stroke (majority chronic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared CT or no intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003cp\u003egait speed, balance,\u003c/p\u003e \u003cp\u003eand ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eimprovement in ADL compared to same dose CT\u0026thinsp;=\u0026thinsp;but not UL, gait speed or balance\u003c/p\u003e \u003cp\u003eWhen additive (increasing dose of therapy) improvement in UL recovery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAhn etl., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary 1, 2007, to August 31 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1507\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute, subacute, and chronic phases post-stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20 VR-based CG, 6 \u0026ndash; Wii and Xbox\u003c/p\u003e \u003cp\u003e2 -Robots\u003c/p\u003e \u003cp\u003eOther-Nonimmersive VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function and independence in ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR intervention is more effective than CT in improving UL function and independence in ADL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAramaki., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2011 to April 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 Acute, 11 Chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8 Nintendo Wii, 3 Xbox 360, 1 combination of both, and the other combination of Xbox 360 and Playstation SeeMee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), UL motor function (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), quality of life (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and ADL (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR is more efficient in the dynamic balance outcome (3 studies). Other studies indicate no difference between outcomes. Overall, there are differences in the results and the evidence is not sufficient to support the use of VR over CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMohammadi et al., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary 2000 till\u003c/p\u003e \u003cp\u003eAugust 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e367\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE, Wii Fit Balance board\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR in combination with CT vs CT alone (majority)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003cp\u003eimprovement was observed in the experimental group compared to control group\u003c/p\u003e \u003cp\u003ewith a medium effect size of .64. VR combined with CT is more effective in improving balance than CT alone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDe Keersmaecker et al., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until 4th October 2017 for PubMed and and Web of Science and until 11th January 2018 for Cochrane Central Register of Controlled Trials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic (9 studies)\u003c/p\u003e \u003cp\u003eAcute (2 studies)\u003c/p\u003e \u003cp\u003eUnknown (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 Fully immersive VE, 1 semi-immersive VE and the rest non-immersive VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;Treadmill vs just treadmill (CT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR-enhanced gait training is more effective than an identical gait training without VR to improve spatiotemporal gait parameters (i.e. walking speed, cadence, step length, stride length, single limb support period) and functional gait parameters (i.e. Timed Up and Go) in people post-stroke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGhai et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until August 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e809\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute, subacute, and chronic phases post-stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE adjunct with treadmill (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eVR with robot-assisted training (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;RAGT vs RAGT only (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003cp\u003eenhancements in gait parameters were observed with VR-based interventions compared with conventional therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDominguez-Tellez et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2007 \u0026ndash; March 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute, subacute, and chronic phases post-stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive and non-immersive VE including CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL motor function and quality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR seems to be effective for the improvement of motor function of UL and quality of life after stroke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKaramians et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary\u003c/p\u003e \u003cp\u003e2005 to May 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eMixed (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eUnknown (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE or VE\u0026thinsp;+\u0026thinsp;gaming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR or Gaming vs CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR or gaming interventions produced an improvement of 28.5% of the maximal possible improvement. A gaming component resulted in a significantly larger treatment gain than just visual feedback. VR or gaming interventions showed a significant treatment\u003c/p\u003e \u003cp\u003eadvantage (10.4%) over CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMekbib et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2010 to March 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eUnknown (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE and CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone (majority) or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStatistically significant improvement in the recovery of UL function in the VR group as compared to the CT group. Patients in the subacute phase of\u003c/p\u003e \u003cp\u003estroke may benefit from VR therapies more than patients in\u003c/p\u003e \u003cp\u003echronic phases of stroke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePintado-Izquierdo et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efrom January 2005 to June 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e479\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute/Subacute (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAll phases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCG \u0026ndash; SVR, Nintendo Wii, Wii Fit Plus, Wii Balance Board\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone or CG vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance and gait\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIn 10 of 17 studies balance was improved in the interventional group as compared to the CT group. 6 of the 7 studies that studied gait revealed that improvement in gait was greater in the VR group as compared to the experimental group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAmirthalingam et al., 2021\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary 2016 to April 30, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute, subacute, and chronic phases post-stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive VE, Nintendo Wii (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT alone, 1 study with additive to CT vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function, cognitive function, gait, and balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR-based rehabilitation more effective than CT in improving UL function, gait, and postural balance post-stroke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eCao et al., 2021\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to September 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE, semi-immersive VE (EVA park), Gaming system for aphasia, ELT within VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone or VE alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFunctional communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo significant differences between VR and the control groups\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eDoumas et al., 2021\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception till May 5th 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2083\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1/3 of studies \u0026ndash; Subacute\u003c/p\u003e \u003cp\u003e2/3 of studies \u0026ndash; chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSerious games across different devices (immersive VR, robotic exoskeleton, Microsoft Kinect etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL motor function, activity and participation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRehabilitation through serious games, targeting UL recovery after stroke, leads to better improvements, compared to conventional treatment, in three ICF-WHO components (motor function, activity, and participation)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eCortes-Perez et al., 2021\u003c/span\u003e (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to January 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLeap Motion Controller based video games\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLMC\u0026thinsp;+\u0026thinsp;CT VS CT alone (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eLMC vs CT (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL motor function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eA higher effect of LMC when combined with CT in improving UL motor function as compared to CT alone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGao et al., 2021\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to May 31, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSemi- immersive VR (motion tracking, Kinect etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;CT vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGlobal and overall cognition, attention, execution, motor function, mood, and ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR-based intervention combined with traditional\u003c/p\u003e \u003cp\u003erehabilitation showed better outcomes for overall cognition, attention/execution, and\u003c/p\u003e \u003cp\u003edepressive mood in individuals with chronic stroke. Non-significant effect for global\u003c/p\u003e \u003cp\u003ecognition, motor function, and ADL in individuals with chronic stroke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eGaray-Sachez et al., 2021\u003c/span\u003e (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDecember 2010 to December 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e316\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute and subacute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive and non-immersive VR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR alone vs CT alone (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;CR vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDynamic and static balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStatic balance: 4 studies showed significant improvement for non-immersive VR over CT and 1 for immersive VR\u003c/p\u003e \u003cp\u003eDynamic balance: 4 studies using non-immersive VR in combination with CT showed significant improvement and 2 studies using immersive VR in combination with CT showed significant improvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKhan et al., 2021\u003c/b\u003e (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2011\u0026ndash;2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1617\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll phases post stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE, rehabilitation gaming system, Nintendo Wii\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;CT vs CT alone or VR vs CT or VR vs no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMotor, sensory, and cognitive outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImproved functional outcomes reported by studies in all 3 outcomes measured, but meta-analysis done revealed no statistically significant difference\u003c/p\u003e \u003cp\u003ecompared to CT.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePalacios-Navarro et al., 2021\u003c/b\u003e (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until 31st October 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1472\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic phase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFully immersive VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eImmersive VE\u0026thinsp;+\u0026thinsp;CT vs CT alone/Non-immersive VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL motor function, gait, balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUL Function: Significant improvement in the intervention group compared to the control, exhibiting a large effect size (0.79) VR intervention training achieved significantly faster walking speed compared to CT. Overall significant improvements in favor of the immersive VR group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeng et al., 2021\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception\u003c/p\u003e \u003cp\u003euntil October 10, 2020,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e681\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSubacute Stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE, CG based VR,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT or VR/CG vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMotor function (UL\u0026thinsp;+\u0026thinsp;LL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eWhen compared to CT, VR resulted in mild improvement in motor function (SMD\u0026thinsp;=\u0026thinsp;0.47;\u003c/p\u003e \u003cp\u003e95% CI\u0026thinsp;=\u0026thinsp;0.22\u0026ndash;0.72; I\u003c/p\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;75%; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Upon trim-and-fill adjustment, this\u003c/p\u003e \u003cp\u003efinding was deemed insignificant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eZhang et al., 2021\u003c/b\u003e (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until 31st December 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll phases were included\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone or VR vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL and LL motor function, balance, gait, cognition, and daily function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026ldquo;VR improves limb function, walking ability, balance, gait velocity, cadence,\u003c/p\u003e \u003cp\u003eand daily life activities to a greater extent than CT. However, VR had a similar effect on improvement of cognition as CT therapy\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eZhang et al., 2021\u003c/span\u003e (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to April 15, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e894\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive, semi-immersive and non-immersive VE, CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR alone vs CT alone (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), VR\u0026thinsp;+\u0026thinsp;CT vs CT (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), VR\u0026thinsp;+\u0026thinsp;Computer based cognition vs CT (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGlobal cognition and\u003c/p\u003e \u003cp\u003edomain-specific cognition (attention, executive function,\u003c/p\u003e \u003cp\u003ememory, psychomotor speed, verbal fluency)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR-based therapies are more efficacious in improving executive function,\u003c/p\u003e \u003cp\u003ememory, and visuospatial function post stroke than CT. No significant differences were found between the 2 groups in terms of global cognitive function, attention, verbal fluency, depression,\u003c/p\u003e \u003cp\u003eand the quality of life\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAguilera-Rubio et al., 2022\u003c/b\u003e (\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2012 to December,2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 studies \u0026ndash; Subacute phase of stroke\u003c/p\u003e \u003cp\u003e1 study \u0026ndash; Acute phase\u003c/p\u003e \u003cp\u003e1 study \u0026ndash; Subacute and acute phase\u003c/p\u003e \u003cp\u003e1 study \u0026ndash; chronic\u003c/p\u003e \u003cp\u003e1 study - unspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLeap Motion Controller\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared CT or no intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStatistically significant improvement in UL functionality (5 studies), grip strength (4 studies), spasticity (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), dexterity, performance, participation, satisfaction, and usability. Further research needed due to heterogeneity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAl-Whaibi et al., 2022\u003c/b\u003e (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 search from inception to June 25, 2020\u003c/p\u003e \u003cp\u003eAnother search done on 1st Feb, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL Motor function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo statistical difference in UL performance in VR group as compared to the CT group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChan et al., 2022\u003c/b\u003e (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until January 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eExergaming, type of VR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eNo intervention (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance, LL\u003c/p\u003e \u003cp\u003efunctional mobility and functional independence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eExergaming shows statistically significant improvement in balance, lower limb\u003c/p\u003e \u003cp\u003efunctional mobility and functional independence among individuals with chronic\u003c/p\u003e \u003cp\u003estroke as compared to CT alone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eChen et al., 2022\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to December 31, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSubacute and Chronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSpecialized VE and CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR alone vs CT alone OR VR alone vs No intervention OR VR\u0026thinsp;+\u0026thinsp;CT vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL Motor Rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStatistically significant improvement in UL motor function, muscle strength, range of motion and independence in day-to-day activities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChen et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until August 31, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCognitive function and ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR training improved cognitive function and ADL in PSCI compared to CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eFernandez-Vazquez et al., 2022\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to May 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute phase (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Chronic phase (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHaptic Glove Systems in Combination with Semi-Immersive VR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL Motor Rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCombination of rehabilitation haptic gloves, SVR, and CT produces significant improvement in UL functionality as compared to CT alone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHao, J., Buster, T., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to September 8th, 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;treadmill training vs treadmill training only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWalking speed and endurance, balance function, number of falls\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVirtual reality augmented treadmill walking training enhances outcomes compared to treadmill-only training in patients with walking and balance impairments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHao et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2000 to October 17, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e921\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE (Nintendo Wii, Microsoft Kinect)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function, cognitive function (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), gait speed, ADL, and balance ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEffects of VR are\u003c/p\u003e \u003cp\u003ecomparable to conventional rehabilitation, no differences\u003c/p\u003e \u003cp\u003ebetween VR and dose-matched conventional rehabilitation on UL function, ADL\u003c/p\u003e \u003cp\u003eoutcomes, balance function, and cognition\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLeong et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to October 15, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVirtual, augmented, and mixed reality (VAMR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function and ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVAMR therapy was superior to CT in UL impairment and daily function outcomes, but not UL function measures. Patients with chronic stroke significantly improved better than those with subacute after VAMR training\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLi et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to\u003c/p\u003e \u003cp\u003eMay 24, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE, CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;CT vs Time-dosed matched CT or VR only vs Time-dosed matched CT only or CG only vs time-dosed matched CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eICF domains: body structure or function, activity, and participation: UL function,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR is more superior to time-dose matched CT in terms of recovery of upper extremity motor function in patients poststroke, especially when VE is used, or VR is combined with CT. VR does not improve patients\u0026rsquo; daily activity performance\u003c/p\u003e \u003cp\u003eand participation compared with CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMugisha et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2015 to May 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive and Non-immersive VE using Nintendo Wii, Miscrosoft Kinect etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL activity and function, LL activity and function, balance, activity of daily life, adverse events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo statistical difference between VR and CT in improving UL and LL motor function, balance, and ADL. Immersive VE is superior to non-immersive VE in improving the outcomes measured\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eParisi et al., 2022\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to 17 January 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE/VE\u0026thinsp;+\u0026thinsp;Motion tracking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCognitive rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR without motion tracking was more effective than CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSevcenko \u0026amp; Lindgren, 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to February 29, 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e715\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBoth of the above (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFunctional ability (UL, gait, balance)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR training is suggested as an effective intervention to improve the functional ability in stroke especially when combined with CT. Some studies showed significant improvement of VR group in gait, balance, quality of life and fatigue while no effect was seen in the CT group.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWang et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to December 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e793\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGame-based non-immersive VR, CG and Custom games were included\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL rehabilitation, hand dexterity,\u003c/p\u003e \u003cp\u003edaily living ability, and cognitive function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGame-based VR UL rehabilitation therapy for cerebral apoplexy is more effective than CT in improving\u003c/p\u003e \u003cp\u003epatients\u0026rsquo; UL function and hand mobility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWiley et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to November 13th 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMajority in the chronic phased\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive, non-immersive and semi-immersive VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMajority combination of VE\u0026thinsp;+\u0026thinsp;CT vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCognition, executive function, language, and memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR therapy was not more effective than control for\u003c/p\u003e \u003cp\u003eimproving global cognition and attention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary and characteristics of the systematic reviews\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDate of search\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eof\u003c/p\u003e \u003cp\u003eRCTs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo of Non-randomized studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTime since stroke\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eType of\u003c/p\u003e \u003cp\u003eVR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTarget impairments\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eResults/\u003c/p\u003e \u003cp\u003econclusion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCrosbie et al., 2007\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception/\u003c/p\u003e \u003cp\u003e1980 to February 2005\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 weeks-6 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo therapy or CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait balance, cognition\u003c/p\u003e \u003cp\u003eUL and LL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOverall safe and beneficial, but not a strong recommendation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHenderson et al., 2007\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVaries according to database from Jan 1982-Jan 2006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79 VR participants (no mention of controls)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 studies acute \u0026amp; 3 chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo therapy or CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIVR Vs no therapy is beneficial\u003c/p\u003e \u003cp\u003e-no studies IVR VS CT\u003c/p\u003e \u003cp\u003e-less strong evidence NIVR Vs no therapy is effective but not Vs CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSaposnik and Levin, 2011\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1966 to July 2010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 subacute, 9 chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9 VE;3 CG:\u003c/p\u003e \u003cp\u003e(4\u0026thinsp;=\u0026thinsp;IVR\u003c/p\u003e \u003cp\u003e8\u0026thinsp;=\u0026thinsp;NIVR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or robotic OR Vs CT or no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e11/12 in favor of VR\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSmith et al., 2012\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to December 2009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMostly chronic (up to 66 months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e(NIRV)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or Vs CT or no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMajority UL (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), balance and gait\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR improves UL and walking particularly if additive\u003c/p\u003e \u003cp\u003ebut not balance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCavalcanti Moreira et al., 2013\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1966 to 2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAny time after stroke (not specified)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT, robotic and no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eBetter gait velocity and distance walked\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCasserly and Baer, 2014\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1995 to 2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute, subacute \u0026amp; chronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE+\u003c/p\u003e \u003cp\u003eGC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT or alternative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR had a positive effect on the UL. (Evidence is of low quality)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThomson et al., 2014\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to January 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMostly Chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT or no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCG a positive impact on ADL (3/4\u0026thinsp;+\u0026thinsp;ve, UL (3/9)\u0026thinsp;+\u0026thinsp;ve and movement (6/11) (weak evidence)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImam and Jarus, 2014\u003c/b\u003e (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to July 11, 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMostly chronic Stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eGC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT\u003c/p\u003e \u003cp\u003eor compared CT or robotic device or no intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLL, gait recovery and balance or a mixture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e10/11 studies positive\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eLohse et al., 2014\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to April 4, 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.04\u0026ndash;6.01 years\u003c/p\u003e \u003cp\u003e(14 chronic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or robotic device\u003c/p\u003e \u003cp\u003eor compared CT or no intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLL motor recovery, UL recovery, gait recovery, balance, cognitive training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR (VE or CG)\u003c/p\u003e \u003cp\u003eeffective across ICF domains (\u003c/p\u003e \u003cp\u003eBF, ACT \u0026amp; PART) effect size moderate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRodrigues-Baroni et al., 2014\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to July 2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT or none\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR effective in increasing walking speed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAguiar Dos Santos et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eup to March 31, 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMostly more than 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCG\u003c/p\u003e \u003cp\u003e(NW)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT\u003c/p\u003e \u003cp\u003eVs CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL, motor function, balance, and functionality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR Improved motor function but not static balance or functional independence\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLuque-Moreno et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary 2004 and January 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003emore than 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10: VE\u003c/p\u003e \u003cp\u003e1:\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or robotic device\u003c/p\u003e \u003cp\u003eor compared to CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLower limb motor recovery, gait recovery and balance or a mixture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR\u003c/p\u003e \u003cp\u003e(\u0026gt;\u0026thinsp;10 sessions) improved gait speed, balance and motor function,\u003c/p\u003e \u003cp\u003ebest when combined with CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCheok et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to July 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e166\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;and\u003c/p\u003e \u003cp\u003e2 acute or subacute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCG:\u003c/p\u003e \u003cp\u003eNW only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait recovery, balance and functional independence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eWhen additive to CT, NW improves in TUG and not in the other physical measures. Effect size small\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCorbetta et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to August 2014,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMajority chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWalking speed, balance, mobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eWhen replaces part or all of CT VR Improves walking speed, balance, mobility \u0026amp; TUG test.\u003c/p\u003e \u003cp\u003eWhen additive, improved TUG\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChen et al., 2016\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary 2006 and December 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMostly chronic (2 subacute)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+ CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared CT or no intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e8/9 significant improvement in static or dynamic balance evidence\u0026thinsp;=\u0026thinsp;moderate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ede Rooij et al., 2016\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception up to December 1, 2015.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e513\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.7 days and 11.6 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+ CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared to CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ebalance and gait recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR superior to CT.\u003c/p\u003e \u003cp\u003eWhen additive to CT more benefit particularly in gait and balance when compared to duration and dose matched CT.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLi et al., 2016\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception May 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e428\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 Acute/Subacute and 12 Chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared to CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance recovery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImprovement in balance and TUG compared with control\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGibbons et al., 2016\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to\u003c/p\u003e \u003cp\u003eAugust 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e552\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute\u0026ndash;subacute\u003c/p\u003e \u003cp\u003eChronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMajority VR vs CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFunctional balance, static balance, functional gait/mobility, spatiotemporal gait parameters\u003c/p\u003e \u003cp\u003eor motor function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSignificant improvement in functional balance, gait velocity, and stride length in the VR group as compared to CT for the chronic group.\u003c/p\u003e \u003cp\u003eNo differences between groups in motor function, gait, and functional mobility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003edos Santos Palma et al., 2017\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to 16 June 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1811\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39\u0026thinsp;=\u0026thinsp;chronic, 7\u0026thinsp;=\u0026thinsp;subacute, or 7\u0026thinsp;=\u0026thinsp;acute stroke,1 both acute and subacute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT or no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL and/or LL and/or balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e+ve on BF and BS. inconclusive on ACT \u0026amp;PART\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIruthayarajah et al., 2017\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2009 \u0026ndash; September 2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNintendo\u0026reg; Wii Fit balance board (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMajority additive to CT vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDynamic and static balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCompared to CT,\u003c/p\u003e \u003cp\u003eVR was found to improve static and dynamic balance in\u003c/p\u003e \u003cp\u003echronic stroke patients. Nintendo\u0026reg; Wii Fit balance board may not be effective\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eAminov et al., 2018\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003einception until 28 June 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e971\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u0026thinsp;=\u0026thinsp;acute-subacute\u003c/p\u003e \u003cp\u003e26\u0026thinsp;=\u0026thinsp;chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19 VE\u003c/p\u003e \u003cp\u003e14 CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared with CT-time matched controls (in 21 /33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL and cognition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;ve on BF, BS, ACT \u0026amp; cognition (effect size small to medium) but not on PART best results when utilizing purpose-designed VR systems.\u003c/p\u003e \u003cp\u003eConclusion: evidence supports VR use as an adjunct to CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eLaver et al., 2017\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to April 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2470\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll stages post stroke (majority chronic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003eCG\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared CT or no intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003cp\u003egait speed, balance,\u003c/p\u003e \u003cp\u003eand ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eimprovement in ADL compared to same dose CT\u0026thinsp;=\u0026thinsp;but not UL, gait speed or balance\u003c/p\u003e \u003cp\u003eWhen additive (increasing dose of therapy) improvement in UL recovery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAhn etl., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary 1, 2007, to August 31 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1507\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute, subacute, and chronic phases post-stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20 VR-based CG, 6 \u0026ndash; Wii and Xbox\u003c/p\u003e \u003cp\u003e2 -Robots\u003c/p\u003e \u003cp\u003eOther-Nonimmersive VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function and independence in ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR intervention is more effective than CT in improving UL function and independence in ADL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAramaki., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2011 to April 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 Acute, 11 Chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8 Nintendo Wii, 3 Xbox 360, 1 combination of both, and the other combination of Xbox 360 and Playstation SeeMee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), UL motor function (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), quality of life (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and ADL (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR is more efficient in the dynamic balance outcome (3 studies). Other studies indicate no difference between outcomes. Overall, there are differences in the results and the evidence is not sufficient to support the use of VR over CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMohammadi et al., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary 2000 till\u003c/p\u003e \u003cp\u003eAugust 2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e367\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE, Wii Fit Balance board\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR in combination with CT vs CT alone (majority)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003cp\u003eimprovement was observed in the experimental group compared to control group\u003c/p\u003e \u003cp\u003ewith a medium effect size of .64. VR combined with CT is more effective in improving balance than CT alone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDe Keersmaecker et al., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until 4th October 2017 for PubMed and and Web of Science and until 11th January 2018 for Cochrane Central Register of Controlled Trials\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic (9 studies)\u003c/p\u003e \u003cp\u003eAcute (2 studies)\u003c/p\u003e \u003cp\u003eUnknown (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 Fully immersive VE, 1 semi-immersive VE and the rest non-immersive VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;Treadmill vs just treadmill (CT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR-enhanced gait training is more effective than an identical gait training without VR to improve spatiotemporal gait parameters (i.e. walking speed, cadence, step length, stride length, single limb support period) and functional gait parameters (i.e. Timed Up and Go) in people post-stroke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGhai et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until August 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e809\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute, subacute, and chronic phases post-stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE adjunct with treadmill (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eVR with robot-assisted training (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;RAGT vs RAGT only (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGait performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSignificant\u003c/p\u003e \u003cp\u003eenhancements in gait parameters were observed with VR-based interventions compared with conventional therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDominguez-Tellez et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2007 \u0026ndash; March 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e874\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute, subacute, and chronic phases post-stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive and non-immersive VE including CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL motor function and quality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR seems to be effective for the improvement of motor function of UL and quality of life after stroke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKaramians et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary\u003c/p\u003e \u003cp\u003e2005 to May 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eMixed (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eUnknown (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE or VE\u0026thinsp;+\u0026thinsp;gaming\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR or Gaming vs CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR or gaming interventions produced an improvement of 28.5% of the maximal possible improvement. A gaming component resulted in a significantly larger treatment gain than just visual feedback. VR or gaming interventions showed a significant treatment\u003c/p\u003e \u003cp\u003eadvantage (10.4%) over CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMekbib et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2010 to March 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eUnknown (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE and CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone (majority) or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStatistically significant improvement in the recovery of UL function in the VR group as compared to the CT group. Patients in the subacute phase of\u003c/p\u003e \u003cp\u003estroke may benefit from VR therapies more than patients in\u003c/p\u003e \u003cp\u003echronic phases of stroke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePintado-Izquierdo et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003efrom January 2005 to June 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e479\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute/Subacute (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAll phases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCG \u0026ndash; SVR, Nintendo Wii, Wii Fit Plus, Wii Balance Board\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone or CG vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance and gait\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIn 10 of 17 studies balance was improved in the interventional group as compared to the CT group. 6 of the 7 studies that studied gait revealed that improvement in gait was greater in the VR group as compared to the experimental group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAmirthalingam et al., 2021\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJanuary 2016 to April 30, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute, subacute, and chronic phases post-stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive VE, Nintendo Wii (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT alone, 1 study with additive to CT vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function, cognitive function, gait, and balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR-based rehabilitation more effective than CT in improving UL function, gait, and postural balance post-stroke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eCao et al., 2021\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to September 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE, semi-immersive VE (EVA park), Gaming system for aphasia, ELT within VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone or VE alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFunctional communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo significant differences between VR and the control groups\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eDoumas et al., 2021\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception till May 5th 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2083\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1/3 of studies \u0026ndash; Subacute\u003c/p\u003e \u003cp\u003e2/3 of studies \u0026ndash; chronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSerious games across different devices (immersive VR, robotic exoskeleton, Microsoft Kinect etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL motor function, activity and participation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eRehabilitation through serious games, targeting UL recovery after stroke, leads to better improvements, compared to conventional treatment, in three ICF-WHO components (motor function, activity, and participation)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eCortes-Perez et al., 2021\u003c/span\u003e (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to January 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLeap Motion Controller based video games\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLMC\u0026thinsp;+\u0026thinsp;CT VS CT alone (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eLMC vs CT (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL motor function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eA higher effect of LMC when combined with CT in improving UL motor function as compared to CT alone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGao et al., 2021\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to May 31, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSemi- immersive VR (motion tracking, Kinect etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;CT vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGlobal and overall cognition, attention, execution, motor function, mood, and ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR-based intervention combined with traditional\u003c/p\u003e \u003cp\u003erehabilitation showed better outcomes for overall cognition, attention/execution, and\u003c/p\u003e \u003cp\u003edepressive mood in individuals with chronic stroke. Non-significant effect for global\u003c/p\u003e \u003cp\u003ecognition, motor function, and ADL in individuals with chronic stroke\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eGaray-Sachez et al., 2021\u003c/span\u003e (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDecember 2010 to December 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e316\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute and subacute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive and non-immersive VR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR alone vs CT alone (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;CR vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eDynamic and static balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStatic balance: 4 studies showed significant improvement for non-immersive VR over CT and 1 for immersive VR\u003c/p\u003e \u003cp\u003eDynamic balance: 4 studies using non-immersive VR in combination with CT showed significant improvement and 2 studies using immersive VR in combination with CT showed significant improvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKhan et al., 2021\u003c/b\u003e (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2011\u0026ndash;2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1617\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll phases post stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE, rehabilitation gaming system, Nintendo Wii\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;CT vs CT alone or VR vs CT or VR vs no therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMotor, sensory, and cognitive outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImproved functional outcomes reported by studies in all 3 outcomes measured, but meta-analysis done revealed no statistically significant difference\u003c/p\u003e \u003cp\u003ecompared to CT.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePalacios-Navarro et al., 2021\u003c/b\u003e (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until 31st October 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1472\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic phase\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFully immersive VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eImmersive VE\u0026thinsp;+\u0026thinsp;CT vs CT alone/Non-immersive VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL motor function, gait, balance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUL Function: Significant improvement in the intervention group compared to the control, exhibiting a large effect size (0.79) VR intervention training achieved significantly faster walking speed compared to CT. Overall significant improvements in favor of the immersive VR group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeng et al., 2021\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception\u003c/p\u003e \u003cp\u003euntil October 10, 2020,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e681\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSubacute Stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE, CG based VR,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT or VR/CG vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMotor function (UL\u0026thinsp;+\u0026thinsp;LL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eWhen compared to CT, VR resulted in mild improvement in motor function (SMD\u0026thinsp;=\u0026thinsp;0.47;\u003c/p\u003e \u003cp\u003e95% CI\u0026thinsp;=\u0026thinsp;0.22\u0026ndash;0.72; I\u003c/p\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;75%; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Upon trim-and-fill adjustment, this\u003c/p\u003e \u003cp\u003efinding was deemed insignificant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eZhang et al., 2021\u003c/b\u003e (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until 31st December 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAll phases were included\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone or VR vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL and LL motor function, balance, gait, cognition, and daily function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026ldquo;VR improves limb function, walking ability, balance, gait velocity, cadence,\u003c/p\u003e \u003cp\u003eand daily life activities to a greater extent than CT. However, VR had a similar effect on improvement of cognition as CT therapy\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eZhang et al., 2021\u003c/span\u003e (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to April 15, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e894\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive, semi-immersive and non-immersive VE, CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR alone vs CT alone (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), VR\u0026thinsp;+\u0026thinsp;CT vs CT (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), VR\u0026thinsp;+\u0026thinsp;Computer based cognition vs CT (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGlobal cognition and\u003c/p\u003e \u003cp\u003edomain-specific cognition (attention, executive function,\u003c/p\u003e \u003cp\u003ememory, psychomotor speed, verbal fluency)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR-based therapies are more efficacious in improving executive function,\u003c/p\u003e \u003cp\u003ememory, and visuospatial function post stroke than CT. No significant differences were found between the 2 groups in terms of global cognitive function, attention, verbal fluency, depression,\u003c/p\u003e \u003cp\u003eand the quality of life\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAguilera-Rubio et al., 2022\u003c/b\u003e (\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2012 to December,2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 studies \u0026ndash; Subacute phase of stroke\u003c/p\u003e \u003cp\u003e1 study \u0026ndash; Acute phase\u003c/p\u003e \u003cp\u003e1 study \u0026ndash; Subacute and acute phase\u003c/p\u003e \u003cp\u003e1 study \u0026ndash; chronic\u003c/p\u003e \u003cp\u003e1 study - unspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLeap Motion Controller\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT or compared CT or no intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStatistically significant improvement in UL functionality (5 studies), grip strength (4 studies), spasticity (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), dexterity, performance, participation, satisfaction, and usability. Further research needed due to heterogeneity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAl-Whaibi et al., 2022\u003c/b\u003e (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 search from inception to June 25, 2020\u003c/p\u003e \u003cp\u003eAnother search done on 1st Feb, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL Motor function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo statistical difference in UL performance in VR group as compared to the CT group\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChan et al., 2022\u003c/b\u003e (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until January 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eExergaming, type of VR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to CT vs CT alone (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eNo intervention (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBalance, LL\u003c/p\u003e \u003cp\u003efunctional mobility and functional independence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eExergaming shows statistically significant improvement in balance, lower limb\u003c/p\u003e \u003cp\u003efunctional mobility and functional independence among individuals with chronic\u003c/p\u003e \u003cp\u003estroke as compared to CT alone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eChen et al., 2022\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to December 31, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSubacute and Chronic stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSpecialized VE and CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR alone vs CT alone OR VR alone vs No intervention OR VR\u0026thinsp;+\u0026thinsp;CT vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL Motor Rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStatistically significant improvement in UL motor function, muscle strength, range of motion and independence in day-to-day activities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChen et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception until August 31, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCognitive function and ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR training improved cognitive function and ADL in PSCI compared to CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eFernandez-Vazquez et al., 2022\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to May 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute phase (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Chronic phase (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHaptic Glove Systems in Combination with Semi-Immersive VR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL Motor Rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCombination of rehabilitation haptic gloves, SVR, and CT produces significant improvement in UL functionality as compared to CT alone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHao, J., Buster, T., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to September 8th, 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eChronic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;treadmill training vs treadmill training only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eWalking speed and endurance, balance function, number of falls\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVirtual reality augmented treadmill walking training enhances outcomes compared to treadmill-only training in patients with walking and balance impairments\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHao et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2000 to October 17, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e921\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute stroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE (Nintendo Wii, Microsoft Kinect)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or VR alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function, cognitive function (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), gait speed, ADL, and balance ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEffects of VR are\u003c/p\u003e \u003cp\u003ecomparable to conventional rehabilitation, no differences\u003c/p\u003e \u003cp\u003ebetween VR and dose-matched conventional rehabilitation on UL function, ADL\u003c/p\u003e \u003cp\u003eoutcomes, balance function, and cognition\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLeong et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to October 15, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVirtual, augmented, and mixed reality (VAMR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL function and ADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVAMR therapy was superior to CT in UL impairment and daily function outcomes, but not UL function measures. Patients with chronic stroke significantly improved better than those with subacute after VAMR training\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLi et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to\u003c/p\u003e \u003cp\u003eMay 24, 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE, CG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVR\u0026thinsp;+\u0026thinsp;CT vs Time-dosed matched CT or VR only vs Time-dosed matched CT only or CG only vs time-dosed matched CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eICF domains: body structure or function, activity, and participation: UL function,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR is more superior to time-dose matched CT in terms of recovery of upper extremity motor function in patients poststroke, especially when VE is used, or VR is combined with CT. VR does not improve patients\u0026rsquo; daily activity performance\u003c/p\u003e \u003cp\u003eand participation compared with CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMugisha et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2015 to May 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive and Non-immersive VE using Nintendo Wii, Miscrosoft Kinect etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL activity and function, LL activity and function, balance, activity of daily life, adverse events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo statistical difference between VR and CT in improving UL and LL motor function, balance, and ADL. Immersive VE is superior to non-immersive VE in improving the outcomes measured\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eParisi et al., 2022\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to 17 January 2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE/VE\u0026thinsp;+\u0026thinsp;Motion tracking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCognitive rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR without motion tracking was more effective than CT\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSevcenko \u0026amp; Lindgren, 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to February 29, 2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e715\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBoth of the above (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFunctional ability (UL, gait, balance)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR training is suggested as an effective intervention to improve the functional ability in stroke especially when combined with CT. Some studies showed significant improvement of VR group in gait, balance, quality of life and fatigue while no effect was seen in the CT group.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWang et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to December 2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e793\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAcute (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eSubacute (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eChronic (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGame-based non-immersive VR, CG and Custom games were included\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAdditive to the CT vs CT alone or intervention alone vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUL rehabilitation, hand dexterity,\u003c/p\u003e \u003cp\u003edaily living ability, and cognitive function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eGame-based VR UL rehabilitation therapy for cerebral apoplexy is more effective than CT in improving\u003c/p\u003e \u003cp\u003epatients\u0026rsquo; UL function and hand mobility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWiley et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInception to November 13th 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMajority in the chronic phased\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImmersive, non-immersive and semi-immersive VE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMajority combination of VE\u0026thinsp;+\u0026thinsp;CT vs CT alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCognition, executive function, language, and memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVR therapy was not more effective than control for\u003c/p\u003e \u003cp\u003eimproving global cognition and attention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eCG\u0026thinsp;=\u0026thinsp;Commercial Games, CT\u0026thinsp;=\u0026thinsp;Conventional therapy, UL\u0026thinsp;=\u0026thinsp;Upper limb, LL\u0026thinsp;=\u0026thinsp;lower limb, NW\u0026thinsp;=\u0026thinsp;Nintendo Wii, VE\u0026thinsp;=\u0026thinsp;Virtual Environment, VR\u0026thinsp;=\u0026thinsp;Virtual Reality, IVR\u0026thinsp;=\u0026thinsp;Immersive Virtual Reality, NIVR\u0026thinsp;=\u0026thinsp;Non-Immersive Virtual Reality, Acute Stroke\u0026thinsp;\u0026lt;\u0026thinsp;1 months, Subacute 1\u0026ndash;6 months, Chronic\u0026thinsp;\u0026gt;\u0026thinsp;6 months, BF\u0026thinsp;=\u0026thinsp;Body Function, BS\u0026thinsp;=\u0026thinsp;Body Structure, ACT\u0026thinsp;=\u0026thinsp;Activity, PART\u0026thinsp;=\u0026thinsp;Participation, TUG\u0026thinsp;=\u0026thinsp;Timed Up and Go test, ADL\u0026thinsp;=\u0026thinsp;Activity of daily living, ELT\u0026thinsp;=\u0026thinsp;Experimental Linguistic Treatment, SVR\u0026thinsp;=\u0026thinsp;Semi-immersive VR, RAGT\u0026thinsp;=\u0026thinsp;Robot Assisted Gait Training, (n)\u0026thinsp;=\u0026thinsp;n is the number of studies\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Summary and characteristics of the systematic reviews\u003c/p\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cem\u003eto be inserted here after\u003c/em\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e\u003cp\u003e Most of the reviews included studies utilizing virtual environments (VE) and commercial gaming (CG) platforms. Only 15 systematic reviews (\u003cspan additionalcitationids=\"CR33 CR34\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, and \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e) investigated only VE; whereas, only 7 (17, 41, 47, 54, 61, 80, 85,) investigated CGs alone.\u003c/p\u003e\u003cp\u003eIn 46/57 reviews VR was either added to conventional therapy (CT) and compared to CT alone or was compared to CT alone without the combination and in 11 it was compared to CT alone or no therapy.\u003c/p\u003e\u003cp\u003eThe reviews reported various measurements outcomes; these include 14 on upper limb recovery (18, 28, 33, 53, 58, 59, 60, 64, 65, 73, 74, 76, 78, 81,), 5 on balance recovery (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e), 5 on gait recovery (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e), 7 on lower limb recovery including gait and balance (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e), 3 on cognition alone (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e) and the rest reporting on different combinations of the above.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eAssessment of Methodological Quality of included Systematic Reviews\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the AMSTAR 2 grade (high, moderate, or low) confidence in the result with missing critical domains noted. Appendix 4 shows the individual reviews\u0026rsquo; detailed AMSTAR 2 item scoring. Only 13 reviews were noted to be of methodological good quality (moderate to high) according to the AMSTAR 2 tool, these are 38, 41, 47, 2, 51, 62, 63, 64, 66, 71, 75, 77, and 33; 15 were critically low with multiple critical domains missing, and the remaining 28 were of low methodological quality (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Appendix 4).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality rating of the systematic reviews using the AMSTAR 2 tool\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAMSTAR 2 rating\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCritical\u003c/p\u003e \u003cp\u003edomain\u003c/p\u003e \u003cp\u003emissing\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eComment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCrosbie et al., 2007\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,7,9,13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultiple critical domains\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHenderson et al., 2007\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,2\u0026thinsp;=\u0026thinsp;Partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSaposnik and Levin, 2011\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 ,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 4\u0026thinsp;=\u0026thinsp;partial yes and multiple (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eSmith et al., 2012\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eModerate\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7,2\u0026thinsp;=\u0026thinsp;partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non -critical items (downgraded to moderate)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCavalcanti Moreira et al., 2013\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,4\u0026thinsp;=\u0026thinsp;partial yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCasserly and Baer, 2014\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) non -critical items, (downgraded to low)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThomson et al., 2014\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) non- critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImam and Jarus, 2014\u003c/b\u003e (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,2\u0026thinsp;=\u0026thinsp;Partial yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eLohse et al., 2014\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHigh\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eone non -critical items (item 16 not mentioned in the published paper, but was retrieved from PROSPERO registration)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRodrigues-Baroni et al., 2014\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7,15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non- critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAguiar Dos Santos et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) non- critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLuque-Moreno et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) non- critical items,\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCheok et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non- critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCorbetta et al., 2015\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChen et al., 2016\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4,2\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non- critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003ede Rooij et al., 2016\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eModerate\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non -critical items (downgraded to moderate)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLi et al., 2016\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u0026thinsp;=\u0026thinsp;Partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGibbons et al., 2016\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultiple (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) non-critical domains\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003edos Santos Palma et al., 2017\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8,4,2\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non- critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIruthayarajah et al., 2017\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2, 13, 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7, 11, 14\u0026thinsp;=\u0026thinsp;partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non-critical domains\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eAminov et al., 2018\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHigh\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2,7\u0026thinsp;=\u0026thinsp;partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eLaver et al., 2017\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHigh\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eone non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAhn etl., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7, 9\u0026thinsp;=\u0026thinsp;Partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAramaki., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2, 9, 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1, 4, 7\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non-critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMohammadi et al., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2, 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4, 7\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDe Keersmaecker et al., 2019\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5, 12\u0026thinsp;=\u0026thinsp;Partial yes and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGhai et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 4, 7\u0026thinsp;=\u0026thinsp;Partial yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDominguez-Tellez et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2, 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 4, 7, 12\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) non-critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKaramians et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4, 7\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMekbib et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2, 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2, 4, 7, 8\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePintado-Izquierdo et al., 2020\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2, 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAmirthalingam et al., 2021\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 4, 7\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eCao et al., 2021\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eModerate\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2, 4, 7, 15\u0026thinsp;=\u0026thinsp;Partial yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eDoumas et al., 2021\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHigh\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 7\u0026thinsp;=\u0026thinsp;Partial yes and (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) non -critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eCortes-Perez et al., 2021\u003c/span\u003e (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHigh\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 7\u0026thinsp;=\u0026thinsp;Partial yes and (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) non -critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGao et al., 2021\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2, 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7, 12, 14\u0026thinsp;=\u0026thinsp;Partial yes and (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) non-critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eGaray-Sachez et al., 2021\u003c/span\u003e (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eModerate\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 4, 7, 13\u0026thinsp;=\u0026thinsp;partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non -critical items (downgraded to moderate)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKhan et al., 2021\u003c/b\u003e (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2, 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePalacios-Navarro et al., 2021\u003c/b\u003e (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7, 13\u0026thinsp;=\u0026thinsp;Partial yes and multiple (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeng et al., 2021\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 7\u0026thinsp;=\u0026thinsp;Partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eZhang et al., 2021\u003c/b\u003e (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 4, 7\u0026thinsp;=\u0026thinsp;Partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eZhang et al., 2021\u003c/span\u003e (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHigh\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 7\u0026thinsp;=\u0026thinsp;partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAguilera-Rubio et al., 2022\u003c/b\u003e (\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4, 7, 14\u0026thinsp;=\u0026thinsp;Partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAl-Whaibi et al., 2022\u003c/b\u003e (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOne non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChan et al., 2022\u003c/b\u003e (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 13, 14\u0026thinsp;=\u0026thinsp;Partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eChen et al., 2022\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHigh\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;Partial yes and (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) non -critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChen et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4, 7\u0026thinsp;=\u0026thinsp;Partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eFernandez-Vazquez et al., 2022\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHigh\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 4, 13\u0026thinsp;=\u0026thinsp;partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHao, J., Buster, T., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 4, 12, 13, 14\u0026thinsp;=\u0026thinsp;partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHao et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 4, 13, 14\u0026thinsp;=\u0026thinsp;Partial yes and one non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLeong et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2, 13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 7, 12, 14\u0026thinsp;=\u0026thinsp;partial yes and one non -critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLi et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 7\u0026thinsp;=\u0026thinsp;Partial yes and one non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMugisha et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026thinsp;=\u0026thinsp;Partial yes and one non -critical items\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eParisi et al., 2022\u003c/span\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eHigh\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4, 14\u0026thinsp;=\u0026thinsp;partial yes and one non-critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSevcenko \u0026amp; Lindgren, 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 5, 6, 7\u0026thinsp;=\u0026thinsp;Partial yes and one non -critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWang et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2, 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 4, 7, 14\u0026thinsp;=\u0026thinsp;Partial yes and one non- critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWiley et al., 2022\u003c/b\u003e\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritically Low\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2, 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3, 14\u0026thinsp;=\u0026thinsp;Partial yes and one non- critical item\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Quality rating of the systematic reviews using the AMSTAR 2 tool.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cem\u003eto be inserted here\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe most common missing domain relates to questions 2 and 7 (writing and registering a protocol with the relevant search information and providing a list of excluded full text articles respectively) and question 10 (reporting on the sources of funding for the included studies). 16 reviews had a prior registration; 15 with PROSPERO (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) and one with the Cochrane database (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The search strategy was judged to be comprehensive in over 60% of the reviews while the rest were partially comprehensive. 50/57 reviews explicitly disclosed conflicts of interest and/or funding sources, none of the reviews explicitly discussed funding of the studies included in their respective reviews (Question 10 on the AMSTAR 2 tool).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eExtracted Outcome Measures:\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOutcomes from the high and moderate quality reviews (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) were extracted and summarized, as the confidence in these reviews\u0026rsquo; results was moderate to high.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eUpper Limb Outcome\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe major results and conclusions drawn from the high-moderate quality studies have been summarized in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Most of these studies used the Fugl Meyer assessment (FMA) to evaluate the effects of VR on UL function. Consensus from the 8 high to moderate quality reviews show that VR enhances UL recovery, particularly if additive to CT allowing more therapy time. The effect size was moderate at best. Laver et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) have shown an improvement in activities of daily living (ADL) when compared to CT but not UL recovery, whereas other (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e), (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e), have shown improvement of UL structure and function. Doumas et al. (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e) used leap motion controller, a form of semi-immersive VR that consists of a device with sensors designed to detect, recognize, and capture hand gestures and finger positions in addition to generating a virtual image of the UL on a screen indicating the user the next task to be performed. This device was found to be more effective than CT in improving grips strength (low-quality evidence, medium-high effect) and UL-mobility-oriented tasks (large effect, low-quality evidence). The review done by Chen et al. (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e) showed statistically significant improvement in UL motor function, muscle strength, range of motion and independence in day-to-day activities. The UL motor function was measured using the Fugl Meyer assessment (FMA), Manual Muscle Testing (MMT), Motricity Index (MI) and several other scales. Independence in day-to-day activities was measured using scales such as Functional Independence Measure (FIM), and Barthel Index or modified Barthel Index. This review also showed that when VR rehabilitation exercises were combined with CT, this led to improvement in hand dexterity. Fern\u0026aacute;ndez-V\u0026aacute;zquez et al. (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e) showed the same effect as Chen et al. (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e) when VR was combined with CT. The evidence, however, is conflicting with regards to the use of VR versus CG. Laver et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) have shown a trend toward rehab-specific VR to be more beneficial and that CG is not superior when compared to CT, whereas Lohse et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) have shown effectiveness for both VR and CG. Other reviews (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) \u0026amp; (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) agree with Lohse et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), however these reviews are observed to be of lower methodological quality.\u003c/p\u003e\u003cp\u003eReviews (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, and \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e) looked at UL rehabilitation post stroke and all of them concluded that there was statistically significant improvement in UL motor function with the use of VR either in combination with CT or alone. Fern\u0026aacute;ndez-V\u0026aacute;zquez (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e) have shown that the combination of haptic gloves, semi-immersive VR, and CT produce significant improvement in UL functionality (measured by the FMA), Jebson-Taylor Hand Function Test (JTT), or the Block and Box test (BBT)) as compared to CT alone.\u003c/p\u003e\u003cp\u003eApart from these high to moderate quality reviews, the low and critically low-quality studies have also showed similar results (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLower Limb Recovery, Gait and Balance Outcomes:\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMost systematic reviews have included outcomes related to lower limbs, balance and walking together as they are interlinked. Several scales were used commonly throughout these studies to measure lower limb and balance. For example, for balance and gait, Brunel Balance Assessment (BBA), Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Fugl-Meyer Assessment balance subscale, Postural Assessment Scale for Stroke and Balance Evaluation Systems Test were some of the scales used in these reviews to measure the LL functionality.\u003c/p\u003e\u003cp\u003eTwo reviews (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) demonstrated benefit of VR when added to CT on gait and balance, one (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) demonstrated benefit across all three outcomes.\u003c/p\u003e\u003cp\u003eOther reviews focusing specifically on balance recovery (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) have shown improvement in static and dynamic balance or improvement in balance in timed up and go test. A recent review (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e) evaluating the effect of VR on static and dynamic balance showed significant improvement in static balance when non-immersive VR was used in combination with CT, whereas for dynamic balance, 2 of the reviews in the systematic review showed improvement with immersive VR and 4 reviews showed significant improvement with non-immersive VR both in combination with CT. Likewise systematic reviews focused solely on gait recovery have shown VR to improve walking speed (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) and walking speed and distance walked (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) but the confidence in results of these reviews remain low due to heterogeneity between studies, lower number of participants involved, and lack of blinding of therapists and participants. Other reviews that were deemed to be of low quality according to the AMSTAR rating also showed statistically significant improvement in balance, lower limb functional mobility, and functional independence in patients with stroke undergoing a combination of VR\u0026thinsp;+\u0026thinsp;CT (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e). Other low-quality reviews conflicted with this evidence by concluding that there was no difference between VR and dose-matched conventional rehabilitation in improving balance function (\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e) except for the review done by De Keersmaecker et al. (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) which reported statistically significant results when VR was combined with treadmill training in improving several outcome measures such as walking speed, cadence, step length, stride length as compared to treadmill alone.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eCognitive Outcomes\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e4 high quality (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), and (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e) (reporting on 7 RCTs), 2 low-quality reviews (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e), and 3 critically low quality reviews (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e) included a cognitive component in their VR assessments. The cognitive domains tested were memory, neglect/visual training, and executive function. The high-quality reviews (41 and 2) showed positive effects of VR (used either in combination or without CT) on cognition with a small to medium effect size. The high-quality review done by Parisi et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) showed that multisensory technology that includes VR both with and without motion tracking but more so the former, is more effective than conventional therapy for cognition especially for specific domains such as attention, visuospatial processing, memory, and global cognition. One low-quality review that specifically looked at the effects of semi-immersive VR on global cognition, attention, execution, as well as motor function concluded that VR-based intervention combined with traditional rehabilitation showed better outcomes for overall cognition, attention/execution, and depressive mood in individuals with chronic stroke (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). There was one high quality review (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e) that looked at functional communication as the main outcome of VR (immersive and semi-immersive), however, it was concluded that was no significant difference between VR and the control group in the review. There was also considerable heterogeneity in the results of the reviews included. Study (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e) done by Khan et al., looking at motor, sensory, and cognitive outcomes showed improved functional outcome in all 3 outcomes and Zhang et al. (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e) showed a similar effect of VR on cognition compared to CT. A high-quality review by Zhang et al. (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e) assessing global cognition as well as domain-specific outcomes such as attention, executive function, memory, and verbal fluency revealed no significant effect on global cognition with the use of VR but improved effects on executive function, memory, and visuospatial function. Another high-quality review by Wiley et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) published recently looked at multi-sensory technology and its effects on cognition, language, executive function, and memory post-stroke. The review found that multisensory technologies without motion tracking were more effective than standard therapies in improving the mentioned domains whilst multi-sensory technology with motion tracking was similar to the conventional group 3 weeks after the interventions.\u003c/p\u003e\u003cp\u003eOverall, VR had a positive effect on cognition, effect size was noted to be modest, and the studies were noted to be heterogenous.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eModerators of Outcome\u003c/h2\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eDegree of Immersion\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMost studies included reviews with varying degrees of immersion (immersive, semi-immersive and non-immersive), however a few reviews reported on the impact of immersion on outcome.\u003c/p\u003e\u003cp\u003eHenderson et al. (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) found immersive virtual reality (IVR) to be beneficial when compared to no therapy, the authors did not find any studies at the time of conduction of the review on IVR versus CT. They also found non-immersive virtual reality (NIVR) to be less effective than IVR versus no therapy, but outcomes failed to reach significance when compared to CT. A high-quality review by Moher et al. (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) focusing primarily on non-immersive VR (NIVR) found it to be useful as an adjunct to CT but there was little evidence to suggest improvement of outcomes when it was compared to CT alone. Another high-quality review grouped the interventions into 2 groups (immersive and non-immersive VR) and looked at the effects on static and dynamic balance (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Four studies using non-immersive VR within this review showed improvements in static balance whilst a single study using immersive VR showed the same. For dynamic balance, there were 4 non-immersive VR and 2 immersive VR studies that showed favorable outcomes. The low number of studies using immersive VR in the field of neurological disorders can be attributed to the scarce usage of immersive VR devices due to their high cost and availability. However, the results do show promising effects comparable to non-immersive VR. A review (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e) looked at the combination of haptic gloves (greater interaction between the user and the object with more feedback) with semi-immersive VR and their effects on UL motor rehabilitation. This review showed that this combination resulted in significant improvement in UL functionality as compared to CT alone.\u003c/p\u003e\u003cp\u003eOverall, there is evidence to suggest that immersive VR is as effective as non-immersive or semi-immersive VR in improving functional outcomes post-stroke. The recent pilot review published looking at fully immersive VR and evaluating patient and clinician\u0026rsquo;s perceptions showed that patients experienced a greater deal of motivation, felt more engaged, and experienced more enjoyment than what would have been possible in CT (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Theoretically, this would lead to better outcomes and increased compliance to the rehabilitation. This shows that there is a great deal of potential in implementing fully immersive VR in post-stroke rehabilitation, however, more evidence is needed to clearly study the effects of immersion of improvement in post-stroke deficits.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eVirtual Reality Platform\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e The 3 reviews investigating CG as a VR platform reported varying degrees of improvement in the activity of daily living (ADL), upper limb outcomes and static balance. However, these reviews have emphasized CG as an adjunct rather than a replacement of CT. Among the high quality reviews, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) found rehab- specific VE platforms to be superior to CG, (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) found a trend favoring VE over CG and that CG were not more beneficial than CT in UL recovery. Lohse et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) while demonstrating that both VE and CG are beneficial stated that \u0026ldquo;current CG interventions have been too few and too small to assess potential benefits of CG\u0026rdquo;\u003c/p\u003e\u003cp\u003eRecent studies have used more CG devices and semi-immersive VR such as Nintendo Wii and Xbox Kinect since these are now readily available and at a lower cost. Serious games are also being used in certain studies (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). A serious game is defined as a game that has education or rehabilitation as its primary goal (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). These games would use motion capture systems, robotic exoskeletons, or a simple smartphone or tablet computer. It was seen that rehabilitation through serious games led to better improvements in motor function, activity, and participation as compared to CT. According to (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e), leap motion controller video games have also been shown to improve UL function post-stroke especially when combined with CT. A combination of haptic glove systems combined with CG devices and semi-immersive VR also produces statistical improvement in the outcomes measured. Other low-quality studies have also demonstrated possible benefits of including CG and gaming devices in stroke rehabilitation (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). A review by Chan et al. (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e) looked solely at exergaming (video games that require people to interact with the thorough purposeful body movements) at improving functional outcomes in patients with chronic stroke and it was found that exergaming showed statistically significant improvement in balance, lower limb functional mobility, and functional independence (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eTime since Stroke:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe overwhelming majority of participants were in their chronic phase of stroke (\u0026gt;\u0026thinsp;6 months), however some reviews included patients in the acute (1 month) and subacute (1\u0026ndash;3 months) phase post stroke. Aminov et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) found no significant differences between overall outcome in patients receiving VR therapy at the subacute and the chronic phases of their stroke. Lohse et al. (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) could not draw conclusions as the trials were small in size with not enough statistical power for regression analysis. Laver et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) found no statistically significant difference between stroke patients recruited within 6 months after stroke to those recruited after 6 months. Study (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e) by Chan et al. found that patients with subacute stroke found greater improvements in arm and hand motor ability than those with chronic stroke. However, patients with chronic stroke showed greater improvements in quality of life than patients with subacute stroke (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). Parisi et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) used multi-sensory technology with and without motion tracking and found that the group with patients in the subacute stroke stage (3\u0026ndash;6 months) benefited the most from the intervention. Fern\u0026aacute;ndez-V\u0026aacute;zquez et al. (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e) concluded that in the very acute (\u0026lt;\u0026thinsp;1) month stage, the use of haptic gloves and semi-immersive VR was superior to conventional treatment in the UL functionality regardless of whether it was combined with CT or not. However, for the long-term improvement in UL functionality, the significant effects of the haptic gloves and semi-immersive VR were only preserved if they were combined with CT (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHence, there is evidence to suggest rehabilitation is more effective in the subacute and acute stages of stroke than the chronic stage, however, outcomes such as quality of life improve greatly when rehabilitation is done more than 6 months after stroke.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eDosing Intervention\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eVR interventions were delivered in variable ways with respect to intensity, frequency, and duration of the intervention. Laver et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) compared trials applying under 15 hours of intervention with trials applying 15 hours or more of intervention on upper limb function and found no significant difference. Aminov et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) found no significant difference for different doses, durations, and frequencies of VR intervention. Study (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e) by Chen et al. showed that \u0026ldquo;receiving\u0026thinsp;\u0026gt;\u0026thinsp;15 hours of VR intervention (SMD 0.92, 95% CI 0.35\u0026ndash;1.49; P\u0026thinsp;=\u0026thinsp;.002) was associated with significant improvements in hand dexterity (BBT) compared with receiving\u0026thinsp;\u0026le;\u0026thinsp;15 hours of VR intervention (SMD \u0026minus;\u0026thinsp;0.10, 95% CI \u0026minus;\u0026thinsp;0.35 to 0.15; P\u0026thinsp;=\u0026thinsp;.45)\u0026rdquo; (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e). Also, \u0026ldquo;receiving VR-supported exercise therapy for \u0026gt;\u0026thinsp;1 month (SMD 0.97, 95% CI 0.06\u0026ndash;1.89; P\u0026thinsp;=\u0026thinsp;.04) was associated with greater improvements in hand dexterity (BBT) than receiving VR-supported exercise therapy for \u0026lt;\u0026thinsp;1 month\u0026rdquo; (SMD 0.02, 95% CI \u0026minus;\u0026thinsp;0.22 to 0.26; P\u0026thinsp;=\u0026thinsp;.84). However, those who received trial lengths of 2 weeks to 1 month (SMD 0.49, 95% CI \u0026minus;\u0026thinsp;0.11 to 1.10; P\u0026thinsp;=\u0026thinsp;.11) showed greater improvements in quality of life than those for whom trial lengths were \u0026gt;\u0026thinsp;1 month (SMD \u0026minus;\u0026thinsp;0.20, 95% CI \u0026minus;\u0026thinsp;0.46 to 0.06; P\u0026thinsp;=\u0026thinsp;.13)\u0026rdquo; (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). Study (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) by Laver et al. concluded that at least 15 hours of rehabilitation was needed to achieve significant improvements in UL functionality, however in review (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e), there were 2 studies that showed significant improvement in UL functionality with having done less than 15 hours. This was most likely due to the higher intensity of VR applied in these studies (5 sessions per week in consecutive days). Therefore, the differences can be attributed to the duration as well as the intensity of VR rehabilitation.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eAdverse Effects\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe reviewed systematic reviews seldom mention adverse events. However, when these were reported, they were found to be infrequent and mild in nature. These include, headache, dizziness, pain and increased tone (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u003cem\u003eto be inserted here after the Results\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThis figure has been created by the author and does not require permission to be included in the article.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis overview of systematic reviews on the effect of VR on stroke recovery aims at synthesizing and summarizing available evidence from multiple systematic reviews. This allows evidence to be consolidated and recommendations to be strengthened and made easily accessible to clinicians. Additionally, in areas of research where evidence is thin or non-existent, this overview has helped uncover these pertinent areas and generate questions for future research to fill gaps in the current body of literature.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eVirtual Reality is Beneficial and Safe\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eEvidence from multiple high-quality reviews incorporating high-quality RCTs suggests that VR improves upper limb recovery, balance, gait, and cognition post stroke when added to conventional therapy above and beyond conventional therapy alone. The effect is postulated to be by providing further therapy time, however there seems to be an effect even when therapy is time-matched (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e). Furthermore, it is shown to be safe with rare and mild side effects.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eVirtual Reality Effect on UL mobility, LL mobility, balance, gait\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e Almost all the high to moderate quality reviews as well as the low-quality reviews concluded that VR rehabilitation produced statistically significant improvement in UL and LL function, more specifically gross motor function. Thus, from this review we have sufficient good quality evidence to support the claim that VR use should be encouraged for patients with post-stroke rehabilitation. The more immersive and enriched the experience of VR is, the higher the intrinsic motivation and the higher the adherence to the therapy leading to better outcomes (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). There are several reasons why VR improves UL and LL motor function more than CT. VR provides access to therapeutic exercises in an environment that stimulates real life experiences and interaction which otherwise the patients may not have been able to access (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e). Moreover, VR provides real-time feedback to the user through various senses including sounds and vibration sense. Positive feedback encourages and motivates users to continue and engage in the therapy, something that CT is unable to provide. Thirdly, VR also provides intensive, goal-oriented, and repetitive tasks involved in exercises that promote muscle coordination and neuronal development. Additionally, VR games have built in reward systems for achieving and reaching certain milestones and this further encourages and motivates users to continue the therapy (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eVirtual Reality Effect on Cognition:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe current data from the available reviews supports the use of VR in post stroke cognitive impairments. This is supported by evidence from other neurological disciplines (\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e) (\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e) demonstrating that VR can be used for cognitive re-training and could be a valid option were CT has shown shortcomings such as anosognosia (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, for more robust evidence there is a need for systematic reviews to specifically tackle cognitive domains affected. Several trials (\u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e, \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e) tackling cognition were reviewed by (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), they were noted to have low to moderate quality and Laver et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) could not pool their data due to significant heterogeneity.\u003c/p\u003e \u003cp\u003eRecently, several systematic reviews have been published incorporating cognition as one of the outcomes of VR rehabilitation. Out of the 4 high-quality reviews, Zhang et al. (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e) concluded that there was no significant improvement in terms of global cognition, however, there was significant improvement seen in executive function, memory, and visuospatial function post stroke. This result is comparable to the other critically low and low-quality reviews (32 and 70) that included cognition as one of the outcomes measured where they also concluded that VR was not superior to CT in improving cognition. One of the reasons for the conflicting results on cognition may be due to the fact that the VR exercises and rehabilitation interventions may not be focused solely on improving cognition, rather they target other outcomes such as UL and LL function whilst looking at cognition as a secondary outcome. It remains unclear whether increasing VR therapy focusing just on cognition would lead to significant improvement.\u003c/p\u003e \u003cp\u003eFurthermore, low-quality reviews, (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e), (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e) and (\u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e) showed no effect of VR on cognitive outcomes as compared to CT. However, only one review, Chen et al. (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e) concluded that VR improved cognitive function more than CT alone. Interestingly, this review looked at studies that included patients only with a definitive diagnosis of post-stroke cognitive impairment. This involved 21 studies with 1149 patients in total, all with a diagnosis of post-stroke cognitive impairment. They found out that VR rehabilitation resulted in an increase in scores in the various mental status exams including Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), Rivermead Behavioral Memory Test Second Edition (RBMT-Ⅱ) and others. Although classified as a low-quality review according to the AMSTAR-2 tool, this review argues strongly in favor of VR improving post stroke cognitive impairment.\u003c/p\u003e \u003cp\u003eThere are several theories put forward to explain how VR can affect cognition. The cognitive rehabilitation theory explains that after certain intense, repeated sensory stimulation and functional training\u0026rdquo;, the part of the brain surrounding the damaged tissue can compensate for the functions of the damaged tissue (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e). Moreover, some reviews have shown that VR stimulates improvement in the excitability of the remaining neurons, improves functional reorganization of the damaged brain area, and forms new neural circuits (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e). Other studies have stated that VR rehabilitation \u0026ldquo;activates brain metabolism, increases cerebral blood flow, and the release of neurotransmitters\u0026rdquo; (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e), thus leading to improved cognitive function.\u003c/p\u003e \u003cp\u003eNonetheless, more studies looking specifically at this population of patients with post-stroke cognitive impairment are required utilizing high-quality large sample randomized controlled trials along with adequate follow-up for at least 12 months post-stroke in order to generate high quality evidence regarding the role of VR in improving cognition.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eInfluence of Moderators on Outcomes\u003c/b\u003e:\u003c/h2\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eTime since Stroke\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eMost of the reviews included patient in the chronic stage of stroke (\u0026gt;\u0026thinsp;6 month) with only a few of the included trials including patients in the acute and subacute phases.\u003c/p\u003e \u003cp\u003eAlthough a high-quality review reporting on high quality evidence (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) found no statistical difference between VR applied acute/subacute stage of recovery, as both were equally effective, however optimal timing to apply VR remains to be explored further (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrevious research has shown that the majority of gains and motor recovery occur within the first 1\u0026ndash;3 months post-stroke (\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e). So, capitalizing on this \u0026ldquo;window of opportunity\u0026rdquo; of peaked neuroplasticity in the initial period after stroke makes sense biologically (\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e, \u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, there is some evidence that application of VR in the subacute phase (3\u0026ndash;6 month) may be more beneficial. Wang et al. (\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e) have shown that applying Leap Motion VR which can track the fine movements of both hands and fingers in the subacute phase of stroke is feasible and promising. Parisi et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) that used multi-sensory technology with and without motion tracking also found that the group with patients in the subacute stroke stage benefited the most from the intervention.\u003c/p\u003e \u003cp\u003eAdditionally, Chan et al. (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e) found that patients with subacute stroke found greater improvements in arm and hand motor ability after being subjected to VR and exergaming interventions than those with chronic stroke. Patients with chronic stroke showed greater improvements in quality of life after VR rehabilitation and exergaming than patients with subacute stroke (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). This is most likely because outcomes such as cognition, activities of daily living, and mental health all play a role in the quality of life post stroke and the recovery of cognition is dissimilar to motor recovery as it usually takes longer (\u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e). To uncover the impact on cognition with an understanding of any nuanced effect it may have on domain specific recovery, longer follow up periods are needed, something that is currently lacking (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). This needs to be addressed in specifically designed RCT with adequate follow-up periods after intervention.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003eIntensity, Frequency and Dosing of VR Intervention:\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eVR intervention in the trials included in these reviews were conducted with varying doses of intervention (intensity, frequency and duration) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Some trials did not report the dosing of the intervention, and when dosing was provided, true dose- matching between interventional and control arms, was not ensured (e.g., \u0026ldquo;matching active time in therapy or numbers of repetitions\u0026rdquo;) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, there was one review that looked at the effects of VR and time dosed matched CT and it concluded that VR is superior to time-dose matched CT in terms of recovery of upper extremity motor function in patients poststroke, especially when VR is combined with CT (\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA study showed that receiving\u0026thinsp;\u0026gt;\u0026thinsp;15 hours of VR intervention was associated with significant improvements in hand dexterity (BBT) compared with receiving\u0026thinsp;\u0026le;\u0026thinsp;15 hours of VR intervention (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e). Also, receiving VR-supported exercise therapy for \u0026gt;\u0026thinsp;1 month was associated with greater improvements in hand dexterity (BBT) than receiving VR-supported exercise therapy for \u0026lt;\u0026thinsp;1 month. However, those who received trial lengths of 2 weeks to 1 month showed greater improvements in quality of life than those for whom trial lengths were \u0026gt;\u0026thinsp;1 month (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e). Additionally, Laver et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) concluded that at least 15 hours of rehabilitation was needed to achieve significant improvements in UL functionality, however in the review by Fern\u0026aacute;ndez-V\u0026aacute;zquez et al. (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e), there were 2 studies that showed significant improvement in UL functionality with having done less than 15 sessions. This was most likely due to the higher intensity of VR applied in these studies (5 sessions per week in consecutive days). Therefore, the dosing intensity and frequency affect the various outcome measures in different ways. A longer duration of intervention may not always be more beneficial than a shorter duration for all the outcomes as seen by review (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFuture studies with true matching of intensity, frequency and dosing of the VR intervention are needed to help understand the benefits of VR therapy.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eStroke- Specific Virtual Environment:\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWhile CGs are not typically designed for rehabilitation purposes, yet a lot of therapists tend to use them as they are available and cheap (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). VR effect was observed to be more robust when utilizing rehab specific VEs, however CG interventions were valuable as an adjunct to CT, but strong recommendation regarding the preferred platform for VR delivery is yet to be made. Building on the results of this review, a genuine need arises for studies on CG and for the development and testing of stroke specific VEs. Furthermore, availability and affordability of VEs is another concern since the CGs such as Nintendo Wii and Xbox Kinect are very widely available and cheap and therefore can be more routinely used in rehabilitation. Exergaming (video games that require people to interact with the thorough purposeful body movements) was found to show statistically significant improvement in balance, lower limb functional mobility, and functional independence (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). This may also partly be due to the rewarding experience inducing high intrinsic motivation leading to better adherence to the therapy.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSelection bias was unavoidable as this review included only reviews in the English language. The risk of bias cannot be ruled out as there was considerable heterogeneity even between high quality reviews pertaining to different outcomes. Most of the reviews here were of low-quality AMSTAR 2 ratings with only a handful of high-quality reviews driving the results. Furthermore, the reported evidence grading from some of the high-quality reviews was less than excellent. Additionally, a meta-analysis could not be done due to the vast number of studies and the heterogeneity within them, therefore the absence of quantitative analysis is a limitation that could be worked on in future studies.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eVirtual reality is a promising technology that can add to our rehabilitation armamentarium and aid recovery of the post stroke patient. This overview demonstrates that VR is a safe and effective adjunct to conventional therapy for post stroke recovery across different functional domains. It is especially beneficial when used in combination with CT. There is clear evidence supporting the use of VR rehabilitation (including exergaming and CG) in combination with CT or alone for the use of post-stroke UL and LL impairment. There is potential evidence to apply VR for cognition and balance as well, however due to the heterogeneity and conflicting results, more studies are needed to study the effects of VR on these outcomes. For now, there are clinical implications that can be derived from this meta-review and that is to routinely use VR rehabilitation (VE, CG, exergaming) for patients with post-stroke UL and LL impairment. Having said this, the heterogeneity of the studies and discrepancy in some of the outcomes has raised further questions regarding optimal dose, frequency, timing, and choice of VR intervention which should be continued to be studied in prospective well-designed clinical trials.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVirtual Reality\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNSVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-Specific VR-based Rehabilitation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUpper Limb\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConventional Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLower Limb\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePRISMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePreferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCTs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomized Controlled Trials\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVirtual Environment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommercial Gaming\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFMA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFugl Meyer Assessment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eADL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eActivities of Daily Living\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMMT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eManual Muscle Testing\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMotricity Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFIM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFunctional Independence Measure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJTT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJebson-Taylor Hand Function Test\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBBT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBlock and Box Test\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBBA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBrunel Balance Assessment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBBS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBerg Balance Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDGI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDynamic Gait Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNIVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-immersive VR\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSMD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandardized mean difference\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMMSE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMini-Mental State Examination\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMoCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMontreal Cognitive Assessment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLOTCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLoewenstein Occupational Therapy Cognitive Assessment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRBMT-II\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRivermead Behavioral Memory Test Second Edition\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable since this is a systematic review\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article [and its supplementary information files]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe open access to this review is funded by Qatar National Library at Qatar Foundation. The funder had no role in the study design, data extraction process, data analysis, result interpretation, or manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.K. and Y.I were the two independent reviewers that independently conducted the search, extracted the data, interpreted the results, tabulated, and discussed the data. M.M. was the third reviewer that resolved any disagreements during the initial screening and extraction of the data. S.J. and S.G. were involved in the editing and writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge Qatar National Library for funding open access to the article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWang, Haidong, et al. \u0026lsquo;Global, Regional, and National Life Expectancy, All-Cause Mortality, and Cause-Specific Mortality for 249 Causes of Death, 1980\u0026ndash;2015: A Systematic Analysis for the Global Burden of Disease Study 2015\u0026rsquo;. The Lancet, vol. 388, no. 10053, Oct. 2016, pp. 1459\u0026ndash;544. DOI.org (Crossref), https://doi.org/10.1016/S0140-6736(16)31012-1.\u003c/li\u003e\n\u003cli\u003eAminov A, Rogers JM, Middleton S, Caeyenberghs K, Wilson PH. What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes. Journal of NeuroEngineering and Rehabilitation. 2018;15 (1) (no pagination)(29).\u003c/li\u003e\n\u003cli\u003eFeigin VL, Norrving B, Mensah GA. Global Burden of Stroke. Circulation Research. 2017;120(3):439-48.\u003c/li\u003e\n\u003cli\u003eHomberg V. Neurorehabilitation approaches to facilitate motor recovery. Handbook of clinical neurology. 2013;110:161-73.\u003c/li\u003e\n\u003cli\u003eMcDowell FH. Neurorehabilitation. Western Journal of Medicine. 1994;161(3):323-7.\u003c/li\u003e\n\u003cli\u003eKrucoff MO, Rahimpour S, Slutzky MW, Edgerton VR, Turner DA. Enhancing Nervous System Recovery through Neurobiologics, Neural Interface Training, and Neurorehabilitation. Frontiers in Neuroscience. 2016;10(584).\u003c/li\u003e\n\u003cli\u003eTeasell R, Meyer MJ, McClure A, Pan C, Murie-Fernandez M, Foley N, et al. Stroke rehabilitation: an international perspective. 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The journal of alternative and complementary medicine. 2019 May 1;25(5):475-502.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bioelectronic-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"beme","sideBox":"Learn more about [Bioelectronic Medicine](https://bioelecmed.biomedcentral.com)","snPcode":"42234","submissionUrl":"https://submission.springernature.com/new-submission/42234/3","title":"Bioelectronic Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Virtual Reality, Stroke Recovery, Rehabilitation, Systematic Reviews","lastPublishedDoi":"10.21203/rs.3.rs-4319427/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4319427/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eVirtual Reality (VR) is an emerging technology in post stroke recovery. However, its precise role in stroke rehabilitation is not well defined. The aim of this paper is to conduct an overview of systematic reviews on the role of VR in stroke rehabilitation.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e A meta-review with results from a search of 7 databases from inception till 5th December 2022 with subsequent quality appraisal was conducted. The primary outcome was to produce a narrative review on the efficacy of VR versus usual or other care in stroke recovery. Data was synthesized in a descriptive fashion and high-quality systematic reviews were emphasized. The AMSTAR-2 tool was used for quality assessment of the included studies.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEvidence from high-quality systematic reviews suggests that there is benefit from VR in upper limb, lower limb, gait, and balance recovery particularly when additive to conventional therapy. There is also limited evidence to suggest that VR has a positive effect in those with impaired cognition.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eVR is safe and effective as an adjunct to conventional therapy for adults after stroke and should be used routinely for upper and lower limb motor recovery. Further high-quality studies that evaluate its efficacy and explore ways to increase its positive impact in areas such as cognition are required. There is also a scope for the development of stroke-specific virtual environments. 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