Is Virtual Reality Effective in Orthopedic Rehabilitation? A Systematic Review and Meta-Analysis
Gumaa M, Youssef AR. Is Virtual reality Effective in Orthopedic Rehabilitation? A Systematic Review and Meta-Analysis. Physical Therapy. 2019;99(10):1304-1325. doi:10.1093/ptj/pzz093Link to Original Article: https://academic.oup.com/ptj/article/99/10/1304/5537309
Key Points
- Virtual reality (VR) is a promising technology for orthopedic rehabilitation, with potential benefits in chronic neck pain and shoulder impingement syndrome.
- VR and exercises have similar effects in rheumatoid arthritis, knee arthritis, ankle instability, and post-anterior cruciate reconstruction.
- The evidence of VR effectiveness in fibromyalgia, back pain, and after knee arthroplasty is absent or inconclusive.
- The majority of the reviewed studies were of moderate quality, with few high-quality studies available.
- Heterogeneity in interventions and outcome measures of the reviewed studies was a limitation.
- Further high-quality studies are needed to support the use of VR in orthopedic rehabilitation and to clarify its effectiveness compared to traditional exercise.
Introduction
Virtual reality (VR) technology has the potential to enhance orthopedic rehabilitation by providing a realistic and interactive computer environment for patients. VR can be nonimmersive, semi-immersive, or immersive depending on the level of stimulation of the senses and interaction with the virtual environment. In physical rehabilitation, VR has shown promise as an assessment tool for joint range of motion, function, and balance. It can personalize treatment, motivate patients, increase compliance, and document progress, thereby reducing the workload for clinicians. However, the scientific evidence supporting the routine use of VR in orthopedic rehabilitation is currently insufficient. While VR has been extensively studied in neurorehabilitation for conditions such as cerebral palsy, stroke, and parkinsonism, its effectiveness in orthopedic conditions such as ankle sprain, ACL injury, frozen shoulder, chronic low back pain, and neck pain has not been systematically studied. Therefore, this study aims to review and appraise controlled clinical trials on the effectiveness of VR in orthopedic rehabilitation.
Methods
Data Sources and Searches
The researchers conducted a comprehensive search to gather relevant studies for their research. They searched six electronic databases including PubMed, CINAHL, Embase, PEDro, REHABDATA, and Sage Publications. They used specific keywords and Boolean operators to refine their search and ensure they capture relevant studies in their field. The search terms included various phrases related to virtual reality, computer-based interventions, and musculoskeletal conditions. They excluded studies related to specific health conditions such as stroke, cerebral palsy, cancer, neurology, dentistry, obesity, and pediatrics. The search encompassed articles published from the inception of the databases until September 6, 2018. To supplement their search, they manually examined the bibliographic references of included articles and performed a snowballing technique using Scopus and the Web of Science to identify additional articles that cited the eligible studies. This extensive search strategy aimed to gather all available relevant studies in the field of virtual reality and musculoskeletal interventions.
Study Selection
In this study selection section, the researchers outline their criteria for selecting articles to include in their review on the effectiveness of virtual reality (VR) as a therapy for orthopedic disorders. The primary outcome they focused on was VR effectiveness, whether assessed clinically or self-reported. Participant satisfaction, enjoyment, and compliance were considered as secondary outcomes. The inclusion criteria specified that the articles had to be controlled clinical trials conducted with adult individuals with orthopedic disorders who received VR therapy for more than one treatment session. The studies also had to assess clinical outcomes such as range of motion, pain, strength, function, balance, and gait. Only articles published in English were included, while those involving participants with neurological dysfunction or cancer, assessing psychosocial outcomes, or using VR as an assessment tool were excluded. The eligibility of retrieved articles was evaluated by two independent reviewers based on the title, abstract, and full article until a consensus was reached through discussion.
Data Extraction and Quality Assessment
The Data Extraction and Quality Assessment section of the research paper describes the methods used to collect and evaluate the included studies. The studies were categorized into general and region-specific musculoskeletal disorders. A standardized data extraction form was used to gather information on objective, sample size, rehabilitation duration, intervention and control groups, outcome variables, and results for each study. The Evaluation Guidelines for Rating the Quality of an Intervention Study scoring system was used to assess the methodological quality of the studies. This scoring system consists of 24 items divided into 7 domains, which evaluate different aspects of the research, such as research question, study design, subject selection, intervention, outcome measures, statistical analysis, and conclusion. Each question in the scoring system is given a score ranging from 0 to 2 points, with the total quality score classified as high, moderate, or low. Both reviewers received standardized training on the use of the quality scoring tool prior to conducting the assessment.
Data Synthesis and Analysis
In this research paper, a meta-analysis was conducted to examine the treatment effect using the Review Manager software. Only homogeneous studies that had comparable intervention and control groups were analyzed. Mean differences and 95% confidence intervals were used for continuous outcome variables, and a random-effects model was chosen to pool treatment effects across studies. For studies that utilized different outcome measures, standardized mean differences and 95% confidence intervals were used. A significance level of P ≤ 0.05 was considered statistically significant. When data were unavailable, authors were contacted for clarification. Heterogeneity between studies was assessed using the I2 test, and the degree of heterogeneity was categorized as low, moderate, or high based on certain thresholds. A significance level of P ≤ 0.05 indicated significant heterogeneity.
Results
Search Results
In this section of the research paper, the authors describe their search process. Initially, they retrieved 8194 articles, but after removing duplicates, they were left with 6494 articles. These articles were then screened by title and abstract, and 48 were found to be eligible. The full text of these 48 articles was read, resulting in 17 articles that were further assessed for quality. Additionally, snowballing was conducted, resulting in the retrieval of 469 articles. After removing duplicates and screening by title and abstract, only 10 articles remained. The full text of these 10 articles was read, and 2 were found to be eligible. Overall, a total of 19 articles were included in the quality assessment. These articles were categorized into general disorder, with 3 of them focusing on fibromyalgia.
General Musculoskeletal Disorders
This section of the research paper focuses on the effectiveness of virtual reality (VR) interventions for individuals with fibromyalgia, rheumatoid arthritis (RA), and impingement syndrome. Two studies involving women with fibromyalgia and one study with participants with RA were analyzed. The VR program for fibromyalgia aimed to improve postural control, coordination, strength, and mobility. The control group received no treatment, while the VR group showed significant improvements in quality of life, Fibromyalgia Impact Questionnaire scores, functional mobility, balance, and reduced fear of falling. In the case of RA, the VR group did not show significant differences in physical function, disease activity, muscle strength, functional mobility, quality of life, or respiratory function compared to the exercise group. Additionally, for impingement syndrome, participants who played a VR exergame experienced significant improvements in nocturnal pain and pain during specific tests. Overall, VR interventions showed potential benefits for individuals with fibromyalgia and impingement syndrome, but less impact on individuals with RA.
Region-Specific Musculoskeletal Disorders: Lower Limbs
This section of the research paper focuses on region-specific musculoskeletal disorders in the lower limbs. The knee disorders investigated included knee osteoarthritis (OA), total knee arthroplasty (TKA), and post-ACL reconstruction. VR interventions were used in these studies, with one study using a custom-made VR system for proprioceptive training and another using a horseback-riding simulator for knee OA. Following TKA, one study utilized Nintendo Wii Fit games for lateral weight-shifting and balance, while the other used a custom-made boat-rowing game for knee flexor exercise. For participants who underwent ACL reconstruction, VR rehabilitation using Nintendo Wii Fit targeted balance through various games. For ankle dysfunction, VR programs were used with off-the-shelf Nintendo Wii Fit and Xbox games that focused on balance training. The programs were either completed under supervision or as an unsupervised home-based initiative. Comparator groups in these studies received different lower limb exercises or no treatment. The outcomes varied for each condition, with VR interventions showing mixed results compared to other interventions or control groups. However, VR interventions generally showed improvements in measured variables and satisfaction.
Region-Specific Musculoskeletal Disorders: Spine
This section of the research paper focuses on region-specific musculoskeletal disorders related to the spine, specifically neck pain and lower back pain (LBP). The studies included participants with neck pain and LBP, with varying sample sizes and age ranges. The interventions used virtual reality (VR) training, such as VR kinematic training (VRKT) and various VR exercises/games. The comparator groups included KT alone, trunk stabilization exercises, and a no-treatment control group. The outcomes showed varying results. For neck pain, one study found that VRKT improved cervical flexion range of motion (ROM) and global perceived effect, while KT alone showed better results in cervical rotation range and velocity. Another study showed positive results for VR in terms of movement velocity, neck disability, and accuracy compared to a no-treatment control group. For LBP, one study found VR to be superior to trunk stabilization exercises in terms of pain, function, disability, and fear of pain. Another study showed that VR participants had greater muscle mass, less fat mass, and improved flexor and extensor torques compared to a no-treatment control group. A meta-analysis revealed no significant difference in pain between the VR and control groups.
Quality Assessment
The quality assessment of the eligible studies revealed that 26% (n = 5) were of high quality, 58% (n = 11) were of moderate quality, and 16% (n = 3) were considered low quality. The quality scores ranged from 22/48 to 37/48. In terms of randomization, 11% of the studies did not randomize participants, 42% used an appropriate randomization method, and 47% did not provide sufficient information on their randomization methods. Due to differences in treatment options, masking of participants and treatment providers was not possible in all studies, and only 42% of the studies had a masked outcomes assessor. Only 37% of the studies calculated the sample size beforehand. Two studies had a dropout rate of over 30%, while 68% conducted end-of-treatment assessments for over 90% of participants. The detailed scoring data for each study can be found in the provided table.
Discussion
VR for General Musculoskeletal Disorders
This review assessed the effectiveness of virtual reality (VR) in orthopedic rehabilitation. Nineteen controlled clinical trials were evaluated, and the evidence suggested that VR is more effective than no treatment for individuals with fibromyalgia. However, VR did not show significantly greater benefits compared to exercises for individuals with rheumatoid arthritis (RA) and other regional dysfunctions. These findings align with similar results observed in individuals with Parkinson's disease and stroke. Interestingly, despite the different underlying causes of orthopedic and neurological conditions, a central neural mechanism appears to be involved in mechanical pain. This suggests that the effectiveness of VR in both orthopedic and neurological fields could be related.
VR for Regional Dysfunction
This section of the research paper examines the effectiveness of virtual reality (VR) in treating various regional dysfunctions. For shoulder impingement syndrome, one study showed that supervised VR was more effective than unsupervised home exercises. VR was found to be comparable to physical exercises and superior to no-treatment control for knee osteoarthritis (OA). However, the evidence regarding VR effectiveness after total knee arthroplasty (TKA) is inconclusive. VR did not show distinct benefits in ACL rehabilitation and ankle sprain, except for increased enjoyment in the latter. Two high-quality studies in chronic neck pain demonstrated improved outcomes with VR compared to other interventions, but the results may be biased due to familiarity with the VR system. The evidence for VR effectiveness in lower back pain (LBP) is inconclusive, with some studies showing a reduction in pain and improved function, while others found no significant differences compared to control groups. A meta-analysis revealed no significant effects of VR on back pain severity. Overall, the current evidence is insufficient to draw definitive conclusions about the effectiveness of VR in regional dysfunctions.
Risk of Bias in Reviewed Studies
The reviewed studies on the use of virtual reality (VR) in orthopedic rehabilitation demonstrated several limitations and biases. Randomization was either not performed or lacked details in more than half of the studies reviewed. Many studies enrolled small samples without prior calculations, and no power calculation was conducted for nonsignificant results. Participants and treatment providers could not be masked, resulting in a low-risk bias, while only a small number of studies involved masked outcome assessors. Heterogeneity in VR interventions and outcome measures made it difficult to compare studies and conduct a meta-analysis. The description of VR treatments was lacking, and most studies used commercial console games, potentially causing bias. There was variation in the conduct of VR rehabilitation, such as different timing and mode of delivery. Compliance with the assigned treatments varied, and participant satisfaction with VR was comparable to exercises. The review concluded that VR showed promise in chronic neck pain and shoulder impingement syndrome but had inconclusive evidence for other conditions. High-quality clinical studies are needed to reach more solid conclusions.
Opportunities for Future Research
1. Conduct randomized controlled trials to further investigate the effectiveness of virtual reality (VR) in orthopedic rehabilitation for different musculoskeletal disorders, such as fibromyalgia, knee osteoarthritis, and post-ACL reconstruction.
2. Compare the effectiveness of VR with different types of exercises in orthopedic rehabilitation, including strength training, balance training, and proprioceptive exercises.
3. Investigate the long-term effects of VR on outcomes such as pain, function, and quality of life in individuals with orthopedic disorders.
4. Explore the optimal duration and frequency of VR interventions in orthopedic rehabilitation, as well as the potential benefits of home-based VR programs.
5. Assess participant compliance and satisfaction with VR interventions in orthopedic rehabilitation, and identify factors that may influence adherence to VR therapy.
6. Investigate the specific mechanisms and therapeutic components of VR interventions in orthopedic rehabilitation to better understand how VR can enhance outcomes and inform the development of tailored VR programs for different musculoskeletal disorders.
