## 3 Results and Questions Analysis
### Architecture Question: Are We Doing It the Right Way? By looking at initiatives on virtual rehabilitation meta-analysis studies, augmented feedback to patients, provided by exergaming solutions (playing video games intended as a workout that requires rigorous physical exercise), facilitates individualized training and exercising with higher intensity [22]. On the other hand, other studies [23] found that virtual reality provides a more realistic, motivating, and meaningful context to the patient and the immersive experience improves adherence [24]. Looking for scientific evidence, studies like TWIST [25] reached a large sample of 209 patients for 6 weeks using the Nintendo WiiTM, concluding that the console was well accepted but more expensive than arm exercises and the results were not superior [26]. The EVREST study, with 141 patients also using the Nintendo WiiTM, this time for two weeks, also concluded that no differences were found in motor rehabilitation between simple low-cost recreational activities and innovative non-immersive VR technologies [27]. On the other hand, more recent studies carried out by [PERSON] et al. [28] found that results were better for the Nintendo WiiTM intervention group than the control group, particularly for attention and processing speed. The challenge of proving that VR improves rehabilitation outcomes has been constant since the beginning, although it still seems promising. In 2010, the pilot randomized clinical trial carried out by [PERSON] et al. [10] explained that VR therapy combined with conventional therapy showed better outcomes, but that it could introduce a bias as the total time for rehabilitation increased with this combination. This is supported by more recent studies such as [PERSON] et al. [29]. Later, the Cochrane systematic review by [PERSON] et al. [30] showed that sample sizes were generally small, and interventions used different virtual reality devices and treatment goals. In the same Cochrane review, evidence was rated as low quality according to the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation). Despite this, the review found that a combination of virtual reality and conventional therapies presented a statistically significant difference for upper limb function compared to other approaches. What still needs to be determined is whether the reason for these results is a higher dose of therapy or the addition of VR therapy specifically. Even in 2019, the work of [PERSON] et al. [31] highlighted that the majority of the studies were measuring the extent but not the type of motor recovery; and meta-analysis from [PERSON] et al. [11] showed that VR training was effective in improving motor function, but that to obtain the effects the treatment should last 8 weeks or more. On the other hand, according to [PERSON] et al. [32], sometimes using a 3D scenario instead of a standard 2D scenario could make a simple task more complex for patients, particularly for those not skilled in technology. As indicated in [PERSON] et al. [33], the majority of systematic reviews (78%) showed poor methodological quality. Of those identified as virtual reality interventions (10 of 51, 19.6%), 1 was rated as of High quality, 2 as moderate and 7 as low or critically low. Other works such as [PERSON] et al. [34] support the same conclusion, identifying the outcome of combining traditional and virtual rehabilitation on gait and balance, but a major part of the studies analyzed by them showed poor methodologic quality. Another study by [PERSON] et al. in 2018 [35] compared a VR specific system with a non VR specific system and showed similar efficacy in the short term, although total activity counts (a measure provided by accelerometers) was higher in VR users with no statistical significance, so it doesn't support using VR systems in this case. Again, the reduced size of the sample (12 patients using VR vs. 11 patients using non-VR) and the bias introduced by the design should be taken into consideration. The work from [PERSON] et al.