## 3 Results and Questions Analysis
### Strategic Question: Are We Doing the Right Things?  
It has been mentioned that strokes are an important public health issue and can cause severe brain damage and neurological consequences [9]. For instance, motor system deficits occur in more than 55% of individuals who suffer them, decreasing quality of life [10] and impacting daily living activities [11]. Moreover, cognitive deficits affect general functioning, including alterations in memory, attention, and cognitive functioning, among others [9]. On the other hand, evidence of the positive effect of virtual rehabilitation in different fields were found [12], even in the case of early detection of neurological diseases [13]. Evidence of the benefits of exergaming and multisensory stimulation (stimulating at least two of the visual, auditory, and somatosensory systems at the same time) shows promising results for rehabilitation after a stroke [14].  
Figure 1: Review process diagram.  
By looking at data from the last 8 years (2015-2022), we can affirm that, although many initiatives on virtual rehabilitation have been provided (a search for \"virtual rehabilitation stroke\" on Google Scholar between 2015 and 2022 returns 34,300 results), an increase of 32% of DALYs was observed from 1990 to 2019 according to the GBD 2019 Stroke Collaborators [15]. There is evidence of the benefits of these virtual reality rehabilitation solutions \"as an adjunct for stroke rehabilitation with evident effectiveness for a variety of platforms, training parameters, and stages of recovery\" [16], and we found other papers where the results were positive even when the game motivation rewards were moderate [17]. Nevertheless, in low and middle income countries, it could be a low-cost way to deliver this kind of rehabilitation at home [3].  
In 2001, [PERSON] and [PERSON] [18] defined the advantages that virtual reality could have in rehabilitation (more realistic environments, stimulus control, and response measurement; provide hazardous situations in a safe environment; personalized training environments; consistency in training and assessment; and an increase in user motivation that should provide more adherence), and they defined potential areas of application: cognitive ability assessment, rehabilitation training, social retraining, education about managing the disease for patients and their families or caregivers.  
Improvements in different aspects like balance, gait, etc. were determined in other studies such as [PERSON] et al. [19], although we see later in this paper that evidence is not always enough.  
The work enumerated a list of cost-benefit questions about the appropriateness of the VR approach as well as the transferability of the training to the real world and usability for patients and clinical users, plus ethics.  
Motivation and participation are also key, according to [PERSON] et al. [20], who reviewed studies published between 2010 and 2017 about the use of virtual reality on stroke patients.  
All previously cited sources confirm that strokes are clearly an important health problem that healthcare systems should deal with and that the use of virtual reality environments for rehabilitation have a positive impact on patients, reducing costs and improving accessibility to the health system without introducing relevant risks to the patients. [21]. Nevertheless, more evidence is needed, so we should evaluate the use of virtual reality environments strategically, since, at the end of the day, everything indicates that these systems can make healthcare systems more sustainable while maintaining quality.