# Applying Game-Based Approaches for Physical Rehabilitation of Poststroke Patients: A Systematic Review

Authors: Soheila Saeedi; Marjan Ghazisaeedi; Sorayya Rezayi
Journal: Journal of Healthcare Engineering
 (2021)

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## Abstract

Objective. A large number of patients need critical physical rehabilitation after the stroke. This study aimed to review and report the result of published studies, in which newly emerged games were employed for physical rehabilitating in poststroke patients. Materials and Methods. This systematic review study was performed based on the PRISMA method. A comprehensive search of PubMed, Scopus, IEEE Xplore Digital Library, and ISI Web of Science was conducted from January 1, 2014, to November 9, 2020, to identify related articles. Studies have been entered in this review based on inclusion and exclusion criteria, in which new games have been used for physical rehabilitation. Results. Of the 1326 retrieved studies, 60 of them met our inclusion criteria. Virtual reality-oriented games were the most popular type of physical rehabilitation approach for poststroke patients. “The Nintendo Wii Fit” game was used more than other games. The reviewed games were mostly operated to balance training and limb mobilization. Based on the evaluation results of the utilized games, only in three studies, applied games were not effective. In other studies, games had effective outcomes for target body members. Conclusions. The results indicate that modern games are efficient in poststroke patients’ physical rehabilitation and can be used alongside conventional methods.


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## Body

## 1. Introduction

Stroke is one of the diseases that can lead to disability and affect people’s daily activities and lead to reduced performance [1]. According to the Global Burden of Diseases (GBD 2010), stroke is the second most common cause of death worldwide [2]. In 2010, the number of people with the first stroke was 16.9 million, and people who died of stroke was 5.9 million [2]. Disability-adjusted life years (DALYs) lost also was 102 million, and the number of stroke survivors was 33 million [2]. Ninety percent of stroke survivors have a disability in one of their functions [3]. Most people with poststroke disability experience changes in emotional function, limb movement, balance, and muscle strength, and there is a risk of falling for these patients in performing ordinary activities, all of which affect the quality of life of survivors [4]. The main treatment solution to reduce functional defects after stroke is rehabilitation [5]. Poststroke physical rehabilitation in common is a gradual process that can take months or even years, and these patients require multiple sessions of treatment.However, patients may not be able to attend these treatment sessions for rehabilitation fully. Several factors may lead to limited access to these treatment sessions, including the following: difficulty accessing a physiotherapist by the patient, high cost of attending the treatment session, patient’s age and disability, the long distance that the patient has to travel, or poor patient compliance [6]. One of the solutions that can be offered to overcome these problems is to do rehabilitation activities at home; for rehabilitation exercises to be effective at home, high-intensity methods focused on specific repetitions of the practice with the feedback of performance should be used [7]. Consequently, one of the innovative methods that can obviate the above problems is applying modern games; these games have been used in various fields, including education, public policy, and healthcare [8]. Furthermore, they can also be utilized as a support tool for rehabilitation activities and provide an enjoyable environment for patients and increase adherence to treatment sessions [9, 10].As it turns out, various studies have been performed to determine the effectiveness of the mentioned games. A systematic review study by Primack et al. found that games improved 69% of psychological therapy outcomes, 46% of clinician skills outcomes, 42% of health education outcomes, and 37% of disease self-management outcomes [11]. Another study examined the games managed for rehabilitation in respiratory conditions and concluded these games were effective [12, 13]. The purpose of this study is reviewing, summarizing, and reporting studies in which modern games have been used for physical rehabilitation of poststroke patients and tries to answer the following questions:(1)
Which type of games is the most used?(2)
Which gamification approaches have been used to improve the performance of poststroke patients?(3)
What was the most common type of physical rehabilitation in stroke survivors?(4)
What are the evaluation results of games used in poststroke patients?


## 2. Research Methodology

This systematic review was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) checklist to ensure inclusion of relevant studies [14].


### 2.1. Design

In this review, a systematic search of scientific databases including ISI Web of Science, PubMed, IEEE Xplore Digital Library, and Scopus was performed from January 1, 2014, to November 9, 2020. The comprehensive search strategy comprised a set of main keywords from PubMed Mesh terms and Emtree related to “game,” “rehabilitation,” and “poststroke” patients. The specific detail of main applied keywords for each database is presented in Table1.Table 1
Search strategy for each database.
DatabaseSearch strategyPubMed(“Stroke”[Mesh] OR “cerebrovascular accident” OR “cerebrovascular accidents” OR “CVA” OR “CVAs” OR “cerebrovascular apoplexy” OR “brain vascular accident” OR “brain vascular accidents” OR “cerebrovascular stroke” OR “cerebrovascular strokes” OR “apoplexy” OR “cerebral stroke” OR “cerebral strokes” OR “acute stroke” OR “acute strokes” OR “acute cerebrovascular accident” OR “acute cerebrovascular accidents”) AND (“video games”[Mesh] OR “game” OR “games” OR “gamification” OR “video game” OR “computer games” OR “computer game”) AND (“rehabilitation”[Mesh] OR “rehabilitation care”) limit to: 2014–2020ScopusTITLE-ABS-KEY (( “stroke” OR “cerebrovascular accident” OR “cerebrovascular accidents” OR “CVA” OR “CVAs” OR “cerebrovascular apoplexy” OR “brain vascular accident” OR “brain vascular accidents” OR “cerebrovascular stroke” OR “cerebrovascular strokes” OR “apoplexy” OR “cerebral stroke” OR “cerebral strokes” OR “acute stroke” OR “acute strokes” OR “acute cerebrovascular accident” OR “acute cerebrovascular accidents”) AND (“video games” OR “game” OR “games” OR “gamification” OR “video game” OR “computer games” OR “computer game”) AND (“rehabilitation” OR “rehabilitation care”)) AND (limit to (pubyear, 2014–2021)) AND (limit to (doctype, “cp”) OR limit to (doctype, “ar”) AND (limit to (language, “English”))Web of ScienceTS = (“Stroke” OR “cerebrovascular accident” OR “cerebrovascular accidents” OR “CVA” OR “CVAs” OR “cerebrovascular apoplexy” OR “brain vascular accident” OR “brain vascular accidents” OR “cerebrovascular stroke” OR “cerebrovascular strokes” OR “apoplexy” OR “cerebral stroke” OR “cerebral strokes” OR “acute stroke” OR “acute strokes” OR “acute cerebrovascular accident” OR “acute cerebrovascular accidents”) AND TS = (“video games” OR “game” OR “games” OR “gamification” OR “video game” OR “computer games” OR “computer game”) AND TS = (“rehabilitation” OR “rehabilitation care”)Refined by: document types: (article OR proceedings paper)Timespan: 2014–2020. Indexes: SCI-EXPANDED, SSCI, A&HCI, ESCI.IEEE Library((((((“All metadata” : “stroke”) OR “all metadata” : “cerebrovascular accident”) OR “all metadata” : “cerebral strokes”) AND “all metadata” : “game”) OR “all metadata” : “computer game”) AND “all metadata” : “rehabilitation”). Filters applied: 2014–2021


### 2.2. Inclusion and Exclusion Criteria for Study Selection

The extracted studies were included if they fulfilled the following criteria: (1) original articles and proceedings, (2) the focus of this review was on only physical rehabilitation innovative game-based solutions for poststroke physical disabilities, (3) one of the gamification techniques was employed for physical rehabilitation or disability treatment, (4) in this study, the result of using different games and outcomes of video games or immersive-oriented approaches on physical rehabilitation were reviewed, and (5) studies were limited to those published in the English language. Besides, the studies were excluded if they met the following criteria: (1) the title, abstract, or full text of the article that did not relate to video games, virtual, or mixed reality-based games, (2) studies which were review or meta-analysis, book chapters, letter, reports, and technical reports, (3) articles in which the result of applying games was not reported quantitatively, (4) articles about cognitive rehabilitation, and (4) non-English published ones.


### 2.3. Literature Refinement

In comprehensive and scientific databases searching, 833 studies were retrieved after duplicate removal. Some inclusion and exclusion criteria were set for the study selecting phase. In the first phase, two independent reviewers (SS and SR) specified the primary classification of included studies; then, they synthesized selected citations’ critical features. MG validated the primarily determined classifications. All titles and abstracts of extracted studies were investigated and screened based on the research questions and unique aims to select relevant ones by two reviewers under MG’s supervision. In the last phase, citations that met inclusion and exclusion criteria were selected to enter the full-text review phase. The full-texts of relevant studies were screened by SS and SR thoroughly. Key characteristics were entered into a spreadsheet in Excel for each study. Two authors (SR and SS) independently extracted the study characteristics based on the predefined classifications. For reaching an agreement, the information was examined again by two authors. The next reviewer (MG) evaluated and validated all of the obtained results. EndNote X9 was used for resource management, and all qualitative analyses were performed in SPSS v20. The main classifications of screened citations are shown in Figure1.Figure 1
The key classification of relevant studies.


## 2.1. Design

In this review, a systematic search of scientific databases including ISI Web of Science, PubMed, IEEE Xplore Digital Library, and Scopus was performed from January 1, 2014, to November 9, 2020. The comprehensive search strategy comprised a set of main keywords from PubMed Mesh terms and Emtree related to “game,” “rehabilitation,” and “poststroke” patients. The specific detail of main applied keywords for each database is presented in Table1.Table 1
Search strategy for each database.
DatabaseSearch strategyPubMed(“Stroke”[Mesh] OR “cerebrovascular accident” OR “cerebrovascular accidents” OR “CVA” OR “CVAs” OR “cerebrovascular apoplexy” OR “brain vascular accident” OR “brain vascular accidents” OR “cerebrovascular stroke” OR “cerebrovascular strokes” OR “apoplexy” OR “cerebral stroke” OR “cerebral strokes” OR “acute stroke” OR “acute strokes” OR “acute cerebrovascular accident” OR “acute cerebrovascular accidents”) AND (“video games”[Mesh] OR “game” OR “games” OR “gamification” OR “video game” OR “computer games” OR “computer game”) AND (“rehabilitation”[Mesh] OR “rehabilitation care”) limit to: 2014–2020ScopusTITLE-ABS-KEY (( “stroke” OR “cerebrovascular accident” OR “cerebrovascular accidents” OR “CVA” OR “CVAs” OR “cerebrovascular apoplexy” OR “brain vascular accident” OR “brain vascular accidents” OR “cerebrovascular stroke” OR “cerebrovascular strokes” OR “apoplexy” OR “cerebral stroke” OR “cerebral strokes” OR “acute stroke” OR “acute strokes” OR “acute cerebrovascular accident” OR “acute cerebrovascular accidents”) AND (“video games” OR “game” OR “games” OR “gamification” OR “video game” OR “computer games” OR “computer game”) AND (“rehabilitation” OR “rehabilitation care”)) AND (limit to (pubyear, 2014–2021)) AND (limit to (doctype, “cp”) OR limit to (doctype, “ar”) AND (limit to (language, “English”))Web of ScienceTS = (“Stroke” OR “cerebrovascular accident” OR “cerebrovascular accidents” OR “CVA” OR “CVAs” OR “cerebrovascular apoplexy” OR “brain vascular accident” OR “brain vascular accidents” OR “cerebrovascular stroke” OR “cerebrovascular strokes” OR “apoplexy” OR “cerebral stroke” OR “cerebral strokes” OR “acute stroke” OR “acute strokes” OR “acute cerebrovascular accident” OR “acute cerebrovascular accidents”) AND TS = (“video games” OR “game” OR “games” OR “gamification” OR “video game” OR “computer games” OR “computer game”) AND TS = (“rehabilitation” OR “rehabilitation care”)Refined by: document types: (article OR proceedings paper)Timespan: 2014–2020. Indexes: SCI-EXPANDED, SSCI, A&HCI, ESCI.IEEE Library((((((“All metadata” : “stroke”) OR “all metadata” : “cerebrovascular accident”) OR “all metadata” : “cerebral strokes”) AND “all metadata” : “game”) OR “all metadata” : “computer game”) AND “all metadata” : “rehabilitation”). Filters applied: 2014–2021


## 2.2. Inclusion and Exclusion Criteria for Study Selection

The extracted studies were included if they fulfilled the following criteria: (1) original articles and proceedings, (2) the focus of this review was on only physical rehabilitation innovative game-based solutions for poststroke physical disabilities, (3) one of the gamification techniques was employed for physical rehabilitation or disability treatment, (4) in this study, the result of using different games and outcomes of video games or immersive-oriented approaches on physical rehabilitation were reviewed, and (5) studies were limited to those published in the English language. Besides, the studies were excluded if they met the following criteria: (1) the title, abstract, or full text of the article that did not relate to video games, virtual, or mixed reality-based games, (2) studies which were review or meta-analysis, book chapters, letter, reports, and technical reports, (3) articles in which the result of applying games was not reported quantitatively, (4) articles about cognitive rehabilitation, and (4) non-English published ones.


## 2.3. Literature Refinement

In comprehensive and scientific databases searching, 833 studies were retrieved after duplicate removal. Some inclusion and exclusion criteria were set for the study selecting phase. In the first phase, two independent reviewers (SS and SR) specified the primary classification of included studies; then, they synthesized selected citations’ critical features. MG validated the primarily determined classifications. All titles and abstracts of extracted studies were investigated and screened based on the research questions and unique aims to select relevant ones by two reviewers under MG’s supervision. In the last phase, citations that met inclusion and exclusion criteria were selected to enter the full-text review phase. The full-texts of relevant studies were screened by SS and SR thoroughly. Key characteristics were entered into a spreadsheet in Excel for each study. Two authors (SR and SS) independently extracted the study characteristics based on the predefined classifications. For reaching an agreement, the information was examined again by two authors. The next reviewer (MG) evaluated and validated all of the obtained results. EndNote X9 was used for resource management, and all qualitative analyses were performed in SPSS v20. The main classifications of screened citations are shown in Figure1.Figure 1
The key classification of relevant studies.


## 3. Results

The flow of screening articles based on the PRISMA method is shown in Figure2. Prior scientific searches assigned 833 citations after the duplicate removal phase. Next, 41 studies were eliminated due to their irrelevancy in the full-text screening phase. In the last screening step, 60 studies were included based on our main study objectives as eligible studies. Based on the predefined classification elements, a summary of the key results is described in Table 2.Figure 2
The PRISMA diagram for the records search and study selection.Table 2
Main characteristics of included studies.
No.AuthorsYearName of gamification approachType of gamification approachType of rehabilitationRehabilitated target membersStudy designSample sizeSample description (sex, age (year))Session detailsAssessment timeAssessment scoreEffectivenessResults1Laffont I et al. [15]2019Not mentionedVideo gameMobilization of the limbsShoulder, arm, and handRCT51AgeM = 58: male = 31 and female = 2045 min, 5 sessions in a week for 6 weeksBaseline and postintervention at the end of the program, between days 45 and 60 and follow-up at 6 monthsIn the subacute stroke stage, a difference of 9/10 points on the UL-FMS is considered, and BBT minimally detectable change is gained to be 5.5 blocks/min.EffectivePost hoc analysis showed that scores in UL-FMS or BBT were significantly higher in the VG group than in the CR group2Cikajlo I et al. [16]2020Nintendo Wii FitVirtual reality gameBalance trainingLegsRCT20AgeM = 50.3: male = 15 and female = 215 min, 5 sessions for 1 weekBaseline and postinterventionSignificant differences between the groups were found with the eyes closed, sharpened Romberg test (p=0.05), and standing on the right leg (p=0.035).EffectiveVideo games enable independent balance training is feasible without strenuous physiotherapy.3Glueck AC and Han DY [17]2019Microsoft developed RoboRaidMixed reality gameBalance trainingLegsBefore and after trial14AgeM = 25.21: male = 11 and female = 359.12 min, 35.71 daysBaseline and postinterventionMR game training provided significant reaction time improvements (p<0.05) and vestibular performances (p<0.05).EffectiveThe results showed visuomotor reaction time, and balance metrics were significantly improved following MR game rehabilitation.4Ayoubi F et al. [18]2020Nintendo Wii FitVirtual reality gameMobilization of the limbsShoulder, wrist, hand, and fingerBefore and after trial10AgeM = 61.1: male = 5 and female = 530 min, 10 sessions, 2 days in 5 weeksBaseline and postinterventionFMA scores revealed a significant improvement in the motor function (p=0.001). BBT scores increased from 12 pretherapy to 20.6 posttherapy, and the MAL-AOM scores increased from 1.09 pretherapy to 1.8 posttherapy.EffectiveSignificant improvement in all outcome measures was found after the intervention.5de Gouvêa JX et al. [19]2015Nintendo Wii FitVirtual reality gameMobilization of the limbsShoulder and elbowBefore and after trial22AgeM = 66.4: male = 15 and female = 760 min, 3 sessions in a weekBaseline and postinterventionElbow flexion score (joint range of motion) increased from 127 to 134, and shoulder flexion score increased from 114 to 134.EffectiveMetrics showed that there were statistically significant improvements for all trained measures.6Cano-Mañas MJ et al. [20].2020Microsoft Xbox 360 KinectVideo game with KinectBalance trainingPostural controlFunctionalityNot mentionedRCT48AgeM = 63.13: male = 23 and female = 2520 min, 24 sessions in 8 weeks.Baseline and postintervention assessments: 8 weeks after the interventionSignificant differences resulted in the baropodometric (p<0.01), the modified Rankin scores (p<0.01), and the variable related to strength and the pain/discomfort dimension (p<0.01) of the EQ-5D.EffectiveThe findings show that applying a video game approach combined with conventional therapy may produce postural control, improvements in balance, functionality, and quality of life.7Şimşek TT and Çekok [21]2015Nintendo Wii FitVirtual reality gameBalance trainingMobilization of the limbsShouler, wrist, and elbowRCT42AgeM = 58.04: male = 29 and female = 1345–60 min, 10 week, 3 days/week.Baseline and postintervention assessment: after 10 weeks, after intervention, and treatment satisfaction after 10 sessionsA statistically significant difference was found between before and after treatment FIM (functional independence measure) scores (p<0.05).Partly effectiveThese results indicated the Nintendo Wii Fit training was as effective on daily living functions and quality of life in subacute stroke patients.8Hung JW et al. [22]2019Kinect2ScratchVideo game with KinectMobilization of the upper limbsShoulder, elbow, and forearmRCT33AgeM = 58.98: male = 22 and female = 1130 min, 24 sessions in 12 weeksBaseline, postintervention, and at the 3-month follow-up.The total activity scores of the training on upper extremity was significantly higher in the Kinect2Scratch group than in the therapist-based training group (p<0.001)EffectiveThe application of Kinect2Scratch-oriented games may indicate a complementary strategy to conventional therapy for decreasing the therapists’ workload.9Adie K et al. [23]2016Nintendo Wii FitVirtual reality gameMobilization of the armsArmRCT209AgeM = 67.3: male = 105 and female = 10445 min, 42 sessions in 6 weeksBaseline and postintervention after 6 weeks and six monthsThere was no significant difference in the primary outcome of affected arm function at six weeks follow-up (p=0.12) and no significant difference in secondary outcomes.No effectiveThe results indicated that the WiiTM was not superior to arm exercises in home-based rehabilitation for stroke survivors with arm weakness.10Ahmad MA et al. [24]2019Not mentionedVirtual reality gameMobilization of the upper limbsNot mentionedBefore and after trial34AgeM = 63: male = 31 and female = 530 min, 8 sessions in 8 weeksBaseline and postintervention on completion of the 8 weeksThe results showed a significant time-group interaction effect for IMI (p=0.001), Lawton IADL (p = 0.01), and SIS domain of communication (p=0.03). A significant time was found in FMA-UE (p=0.001), WMFT (p=0.001), and Lawton IADL (p=0.01).EffectiveThe integration of VR games as an adjunct to standard physiotherapy for upper limb stroke rehabilitation was considered to be equally beneficial compared to standard physiotherapy.11Choi YH et al. [25]2016MoU-RehabVirtual reality gameMobilization of the upper limbsShoulder, elbow, and wristRCT24AgeM = 66.55: male = 17 and female = 1430 min, 10 sessions in 2 weeksBaseline and postintervention on end of treatment and at 1 monthFMA-UE in experimental and control groups was calculated 34/67 and 53.75. Changes in the B-stage in exp and con groups were indicated 3.17–4.24 for the arm and 3.08–4.58 for the hand.EffectiveA larger improvement in the FMA-UE, B-stage, and MMT was found after treatment with the MoU-Rehab than with conventional therapy12Choi HS et al. [26]2017Nintendo Wii FitVirtual reality gameBalance trainingLower extremityNot mentionedRCT36AgeM = 61.91: male = 21 and female = 1530 min, 12 sessions in 4 weeksBaseline and postinterventionPost hoc analysis revealed significant differences in AP-axis, and sway area; weightbearing symmetry of the game-based CIMT group is compared with the other groups (p<0.05).EffectiveGame-based CIMT was more effective at improving static balance control (AP-axis and sway area) and weightbearing symmetry compared with the other groups.13Choi HS et al. [27]2019Not mentionedVirtual reality gameMobilization of the upper limbsElbows, hands, wrists, and fingerRCT36AgeM = 58.97: male = 23 and female = 1330 min, 15 sessions in 5 weeksBaseline and postintervention assessment on end of 5 weeksThe difference between the GR mirror therapy group versus the conventional mirror therapy and control groups was statistically significant (p<0.05).EffectiveIt indicated that GR device-based mirror therapy is an intervention that improves upper extremity function, neck discomfort, and quality of life14de Paula Oliveira T et al. [28]2015Nintendo Wii FitVirtual reality gameBalance trainingNot mentionedRCT23AgeM = 50.21: male = 13 and female = 1030 min, 14 sessions in 7 weeksBaseline and postintervention assessment on 1-week AT and at a 2-month FUThe analyses of the FMA-LE score at FU for the control and experiment group are 21.39–24.58. The analyses of the BESTest score at FU for the control and experiment group are 75–83.EffectiveBalance training performed in virtual reality by using NWF was more efficient than conventional balance training15Givon N et al. [29]2015Nintendo Wii FitVirtual reality gameBalance trainingMobilization of the upper limbsNot mentionedRCT47AgeM = 56.35: male = 28 and female = 1960 min, 2 sessions in a week for 3 monthsBaseline and postintervention, a 3-month intervention and at 3-month follow-upSignificant improvements were presented in both groups for gait speed (F = 3.9, p=0.02), grip strength of the weaker (F = 6.67, p=0.002), and stronger hands (F = 7.5, p=0.001). Daily steps and functional ability of the weaker hand did not increase in either groupPartly effectiveVideo and VR games can promote measures of physical activity of patients with chronic stroke.16House G et al. [30]2016The BrightArmTMVirtual reality gameMobilization of the upper limbsArm, hand, shoulder, and wristBefore and after trial7AgeM = 69.7: male = 5 and female = 245–50 min, 16 sessions in 8 weeksBaseline and postintervention, on each booster period, each consisting of 4 sessions over 2 weeks in 8 weeksRange of motion improved for 18 out of 23 upper extremity movement variables (p=0.01) between pretournament and posttournament assessments.EffectiveThe results indicate that BrightArm is effective in improving the range of motion of the upper extremity17Hsieh HC [31]2018Not mentionedVideo gameWalkingBalance trainingNot mentionedRCT56AgeM = 58.5: male = 33 and female = 2330 min, 3.5 hours/week, 10 weeksBaseline and postinterventionThe calculated metrics showed that the patients in the intervention group showed significantly better 10MWT (p=0.033), the CoPAP sway (p=0.01), and the sway area (p=0.006) than in the control group.EffectiveThis game improves exercise compliance and promotes recovery of balance and mobility after stroke.18Hsieh HC [32]2018Not mentionedVideo gameBalance trainingLegRCT54AgeM = 64.0740 min, 3 sessions in 1 week for 12 weeksBaseline and postinterventionSignificant changes in CoP sway kinematics were observed in sway path (p=0.001), sway area (, p=0.002), and sway velocity (p=0.007). Balanced tests are the BBS test: p=0.001 and TUG test: p=0.001), and there was no significant change in the FABS testPartly effectiveThis innovative gaming approach with adaptive PC games will be a useful therapy for stroke rehabilitation19Huang LL and Chen MH [33]2016Gardening digital gameVideo game with KinectMobilization of the upper limbsNot mentionedBefore and after trial10AgeM = 61.20: male = 5 and female = 524 sessions in three sessions per weekBaseline and postinterventionFugl–Meyer Assessment of motor function (increases of 9.30); the Box and Block Test of manual dexterity (increases of 5.80); higher functional independence measure (increases of 6.50); and range of motion measurement of the upper extremity proxima (increases of 5.56) and distal (increases of 3.83)EffectiveThe gardening digital game is benefit to improve upper extremity motor function.20Khan RU et al. [34]2019Not mentionedVideo gameMuscular strengtheningFist, wrist, and forearmBefore and after trial5AgeM = 24: male = 3 and female = 2Not mentionedBaseline and postinterventionThe scores of 3 players were improved up to 150, 171, and 172, respectively, for 2 players, and there is not mainly improvement.Partly effectiveThis result shows that an attractive environment and real-time feedback mechanism can improve the rehabilitation process.21Afsar SI et al. [35]2018Microsoft Xbox 360 KinectVirtual reality gameMobilization of the upper limbsShoulder and elbowRCT35AgeM = 66.43: male = 20 and female = 1530 min, per day for 4 weeksBaseline and postinterventionFor the experimental group, the change of BBT (pre-to-postdifference) scores showed a significant improvement when compared to the control group (p=0.007), but the change of FMA-UE and the FIM scores for the experimental group were not significantly higher (p=0.057, p=0.677)Partly effectiveThe Kinect-based game system in addition to conventional therapy has supplemental effectiveness for stroke patients.22Lee MM et al. [36]2016Canoe gameVirtual reality gameTrunk postural stabilityBalance trainingTrunk muscles and legRCT10AgeM = 65.7: male = 5 and female = 530 min a day, 3 sessions a week for 4 weeksBaseline and postinterventionImprovements in trunk postural stability, balance, and upper limb motor function were observed in the EG and CG, but were greater in the EG. The mean SUS scores in the EG and TG were 71 ± 5.2 and 74.2 ± 4.8, respectively.EffectiveCanoe game-based virtual reality training is a beneficial intervention for improving trunk postural stability, balance training, and upper limb motor in stroke patients.23Lee D and Bae Y [37]2019DBIVGVideo gameTrunk postural stabilityWalkingTrunk and legRCT21AgeM = 55.1: male = 14 and female = 730 min, 12 sessions in 4 weeksBaseline and postinterventionThe scores of TISssb, TISdsb, and TISco for the intervention group improved up to 5.9, 6.18, and 3.0. The score of DGI is calculated up to 17.27. The scores of TWT and TUGT decreased up to 42.27 and 39.32.EffectiveThe analysis demonstrated DBIVG can improve trunk control and gait ability in patients with chronic stroke.24Lee SH et al. [38]2019HTC ViveVirtual reality gameMobilization of the upper limbsHand, shoulder, fingers, and wristBefore and after trial12AgeM = 40.2: male = 7 and female = 530 min, 10 sessions 2-3 times a weekBaseline and postinterventionIn five participants, scores showed improvement both in ARAT and BBT. ARAT (pretraining 22.3 and posttraining 31.1), BBT (pretraining 11.2 and posttraining 19.6), and MBI (pretraining 90.4 and posttraining 93.0)Partly effectiveThis study indicates a fully immersive VR rehabilitation program can be used for upper extremity rehabilitation in patients with chronic stroke25McNulty PA et al. [39]2015Nintendo Wii FitVirtual reality gameMobilization of the upper limbsShoulder, elbow, and wristRCT41AgeM = 58: male = 31 and female = 1060 min, 10 consecutive weekdaysPrebaseline (14 days pretherapy), baseline, postintervention, and postintervention after six-month follow-upThe Wolf Motor Function Test (WMFT-tt) improved from 21 to 17 after Wii-based movement therapy, and Motor Activity Log Quality of Movement Scale scores improved from 67.7 to 102.4 after Wii-based movement therapy.EffectiveThis result indicated Wii-based movement therapy is an effective upper limb rehabilitation poststroke26Nijenhuis SM et al. [40]2016MyoCIVideo gameMuscular strengtheningArm and handRCT19AgeM = 60: male = 10, and female = 930 min, 6 sessions in a week for six weeksPrebaseline (one week before training), baseline, and 1 week after training (postintervention) and two months after the end of training follow-upThe control group reported a higher training duration (189 versus 118 minutes per week). No differences in clinical outcomes over training between groups were found (p>0.165).No effectiveAn extra advantage of this arm and hand training over the conventional arm and hand exercises at home was not proven.27Paquin K et al. [41]2015Nintendo Wii FitVirtual reality gameMobilization of the upper limbsHand, finger, and wristBefore and after trial10AgeM = 72.1: male = 1015 min, 16 sessions, 2 sessions per week, for 8 weeksBaseline and postinterventionSignificant improvements were resulted with the JHFT, BBT, and NHPT from pretesting to posttesting (p=0.03, p=0.03, and p=0.01, respectively). An increase in QOL from pretesting to posttesting is determined by the SIS (p=0.009).EffectiveFindings demonstrated important improvements occurred between pretesting and posttesting on 4 metrics.28da Fonseca EP et al. [42]2016Nintendo Wii FitVirtual reality gameBalance trainingLegs, arms, trunk, and hipRCT27AgeM = 52.4: male = 9 and female = 1845 min, 20 sessions in 3 monthsBaseline and postinterventionThe number of falls was statistically significant (p=0.049) only in the treatment group. The differences in gait balance in the control group (p=0.047) is resulted.Partly effectiveThe rehabilitation of gait balance in poststroke people applying virtual reality had the reduction of falls.29Rand D et al. [43]2016Microsoft Xbox 360 KinectVirtual reality gameBalance trainingMobilization of the upper limbsLegs, shoulder, elbow, and fingerRCT24AgeM = 62: male = 15 and female = 960 min a day, 6 times/week for 5 weeksBaseline (an average of two assessments) and postintervention, and at the 4-week follow-upARAT extremely improved by 13.9% and 9.6% following the video games and traditional self-training programs. The scores for the Box and Block Test were 20.6 and 21.3 for pre and posttreatment in the experimental group.EffectiveVideo games or self-training programs can be applied for practice repetitive upper extremity movements without the supervision of a clinician.30Shin JH et al. [44]2015RehabMaster™Virtual reality gameMobilization of the upper limbsUpper limb and trunkRCT32AgeM = 53.95: male = 24 and female = 830 min for 5 days per week for 4 weeksBaseline and postinterventionThe scores of FMA-UE, physical functioning were improved for pre and post treatment (experimental group) 35.5 up to 38.5 and 15 up to 20. Both groups exhibited significantly improved upper extremity function (p=0.001)EffectiveResults indicate that game-based VR rehabilitation has specific effects on health-related quality of life and upper extremity function31Shin JH et al. [45]2016The RAPAEL Smart Glove™Virtual reality gameMobilization of the upper limbsForearm, wrist, finger, shoulder, and elbowRCT46AgeM = 58.5: male = 36 and female = 1030 min, 20 sessions for 4 weeksBaseline and postintervention in the middle of the treatment immediately after the intervention and 1 month after the interventionThe improvements in the game group were supported by significant FM-total:F = 6.48, p=0.006; FM-prox: F = 5.73, p=0.007; FM-dist: F = 4.64, p=0.024). The improvements in the JTTtotal in the game group was supported by significant JTTtotal: F = 4.073, p=0.032)EffectiveThe game system used in VR-based rehabilitation might be an ideal rehabilitation tool for the distal upper extremity in stroke survivors.32Standen PJ et al. [46]2016Nintendo Wii FitVirtual reality gameMobilization of the upper limbsArm, hand, shoulder, and fingerRCT27AgeM = 61: male = 16 and female = 1120 min, 3 times a day, for 8 weeksBaseline and postintervention four weeks (midpoint) and eight weeks (final)There was a significantly greater change from baseline in the intervention group on midpoint wolf MFT strength (intervention group: 2.47; control group: 2.19), and two subscales of the final Motor Activity Log are improved (intervention group:12.80; control group: 12.53)EffectiveThere is a greater improvement from baseline in the intervention group, so it is effective to use and help clinicians.33Rand D et al. [47]2015Microsoft Xbox 360 KinectVirtual reality gameBalance trainingMobilization of the upper limbsNot mentionedRCT12AgeM = 63: male = 7 and female = 560 min, 5 times a week for 5 weeksPrebaseline, baseline, postintervention, and 4 weeks after the intervention.The scores of ARAT for the experimental game-based group improved from 30 up to 40, also the Box and Block Test improved for this group from 25 up to 30, and standing balance improved too from 16p to 29.EffectiveThese video games encouraged upper extremity movements and have potential to promote standing balance.34Kottink AIR et al. [48]2014Not mentionedVirtual reality gameMobilization of the limbsArm and handRCT18AgeM = 61.4: male = 13 and female = 530 min, 3 sessions in a week for 6 weeksBaseline and postinterventionARA and FM improvements were significant within both groups (p≤0.009 for the main effect for session), with effect sizes (partial eta squared) of 0.47 and 0.53 for the ARA test and FM assessment, respectively.EffectiveThe present study showed that both the arm and hand function improved after training.35Rand D et al. [49]2014Microsoft Xbox 360 KinectVideo gameMobilization of the limbsUpper extremityRCT29AgeM = 59: male = 17 and female = 1260 min, 2 sessions per week for 3 monthsPostintervention during the last month of the intervention and 1-2 weeks following the sessionsParticipants in the VGG performed a median (IQR) of 271 (157–490) active purposeful movements compared to 48 (3–123) active purposeful movements in the TG (z = .3.0, p=0.001).Partly effectiveVideo games elicited more UE purposeful repetitions and higher acceleration of movement compared with traditional therapy.36Jordan K et al. [50]2014Not mentionedVirtual reality gameMobilization of the limbsUpper limbBefore and after trial12AgeM = 68.645 min, 3 sessions per week for 4–6 weeksBaseline (t1), 4 weeks later (t2), within 1 week of completing the intervention (t3), and a final assessment was given 4 weeks later (t4).No change in the FMA-UL scores between t1 and t2, indicating a stable baseline; a significant increase in the FMA-UL scores between t2 and t3; a significant increase in the FMA-UL scores between t2 and t4; and no change in the FMA-UL scores between t3 and t4EffectiveThe intervention improved the arm function in survivors of chronic stroke.37Fan SC et al. [51]2014Nintendo Wii FitVirtual reality gameMobilization of the limbsUpper armRCT20AgeM = 64.4: male = 14 and female = 660 min, 3 sessions per week for 3 weeksBaseline and postintervention (week 0), immediately after treatment (week 4) and four weeks after treatment (week 8).Dunn’s pairwise comparison showed that TTP contractions in the Wii group improved significantly more than that of the no-treatment group (p<0.005).EffectiveIn this pilot study, OTSVR gaming had immediate effects on motor recovery and provided motivation for treatment compliance in stroke patients.38McEwen D et al. [52]2014IREXVirtual reality gameMobilization of the limbsBalance trainingLower extremityRCT59AgeM = 64.1: male = 32 and female = 2730 min, daily sessions for 3 weeksBefore, immediately after, and 1 month after trainingMore individuals in the treatment group than in the control group showed reduced impairment in the lower extremity as measured by the Chedoke McMaster Leg Domain (p=0.04) immediately after training.EffectiveVR exercise intervention for inpatient stroke rehabilitation improved mobility-related outcomes.39Hung JW et al. [53]2014Nintendo Wii FitVideo gameBalance trainingLegRCT28AgeM = 54.4: male = 18 and female = 1030 min, 2 sessions per week for 12 weeksBaseline, postintervention, and at 3-month follow-upAt 3-month follow-up, the improvement in TUG and FR tests was maintained (time effect in TUG,p=0.03, partial ŋ 2 = 0.17; FR p=0.01, and partial ŋ2 = 0.22), but there was an increased fear of falling in both groupsPartly effectiveExergaming is enjoyable and effective for patients with chronic stroke.40Norouzi-Gheidari N et al. [54]2019Jintronix systemVirtual reality game with KinectMobilization of the limbsUpper extremityRCT18AgeM = 49.9: male = 10 and female = 844 min, 2-3 sessions per week for 4 weeksBaseline, postintervention, and 4-week follow-upMAL-QOM and both mobility and physical domains of the SIS with mean difference of 1.0%, 5.5%, and 6.7% between the intervention and control groups, respectively) at postintervention.Partly effectiveUsing virtual reality exergaming technology may be beneficial to upper extremity functional recovery.41Aşkın A et al. [55]2018KineLabsVirtual reality game with KinectMobilization of the limbsUpper extremityRCT38AgeM = 55.0: male = 27 and female = 1160 min, 5 sessions per week for 4 weeksBaseline and postinterventionDifferences from baseline of FMA, MI, and AROM (except adduction of the shoulder and extension of the elbow) were greater in group A (p<0.05).Partly effectiveKinect-based VR training may contribute to the improvement of the UE motor function and AROM in chronic stroke patients.42Miranda CS et al. [56]2019Nintendo Wii FitVirtual reality gameBalance trainingLower limbsRCT29AgeM = 50.96: male = 15 and female = 143 sessions for 1 week. Session 1: 60 min; sessions 2 and 3: 30 minBaseline and postintervention, 1S (first session), 2S (2 days after the 1 session), and 3S (7 days after the 1 session) of training.The analyses showed only a significant effect for the side (ANOVA :F = 27.80, p<0.001, ES = 0.99).Partly effectivePeople showed performance improvement after training with VR, but there was no transfer of the gains obtained to an untrained task with similar balance demands.43Fernandes AB et al. [57]2014“Paddle Panic Mini Game”Virtual reality game with KinectMobilization of the limbsUpper extremityNonrandomized clinical trials40AgeM = 50.75: male = 20 and female = 20Not mentionedBaseline and postinterventionComparing the participants’ performance by ANOVA, there was a significant difference in the number of hits between the patients and healthy individuals’ groups, according to the trials (p=0.008).EffectivePatients with right brain injury responded better to the virtual reality game.44Morone G et al. [58]2014Nintendo Wii FitVideo gameBalance trainingStandingTransferringFacilitation of movementsParetic side, upper limb, and legRCT50AgeM = 60.1620 min, 3 sessions per week for 4 weeksBaseline and postintervention (third evaluation occurred one month after the end of rehabilitation)Wii fit training was more effective than usual balance therapy in improving balance (BBS: 53 versus 48,p=0.004) and independency in activity of daily living (BI: 98 versus 93, p=0.021).EffectiveBalance training with game was found to be more effective than conventional therapy alone in improving balance and reducing disability in patients with subacute stroke.45Noveletto F et al. [59]2020MimPongVideo gameMuscular strengtheningLower limbBefore and after trial11AgeM = 59.0: male = 6 and female = 512 min, 2 sessions per week for 10 weeksBaseline and postintervention (three alternate days at the end of the program)Significant effect sizes (d) were found for QFG strength (d = 0.5; p=0.021), QFG control (d = 1.1; p<0.001), HSG strength (d = 1.1; p=0.001), HSG control (d = 1.5; p=0.003), functional mobility (d = 0.3; p<0.001), gait speed (d = 0.4; p=0.007), and motor recovery (d = 1.0; p<0.001).EffectiveResults indicate that the intervention of a SG with both the proper apparatus and evaluation system may effectively promote lower limb motor rehabilitation of hemiparetic stroke patients.46Junior VA dos S et al. [60]2019Nintendo Wii FitVirtual reality gameMobilization of the limbsBalance trainingSensory function improvementUpper limb and lower limbRCT40AgeM = 55.6: male = 23 and female = 1750 min, 2 sessions per week for 2 monthsBaseline and postintervention (second assessment after 2 months of treatment)An improvement in the mean scores was observed after treatment independent of the allocation group with significant intragroup changes: 14.5, 10.5, and 10.4 for PNF, VR, and PNF/VR, respectively.Partly effectiveThe use of a program combining virtual rehabilitation and PNF presented results that were comparable with those obtained with the isolated techniques.47Choi D et al. [61]2018Nintendo Wii FitVirtual reality gameBalance trainingWalkingLower limbRCT28AgeM = 50.25: male = 17 and female = 1130 min, 3 sessions per week for 6 weeksPrebaseline, baseline, and postintervention (1 week before and after training)WVRT group showed significant improvements of +3.00 (5.25) in the BBS score and −1.92 (6.33)s in the TUG test, with all results being significantly better than those of the GBT group (p<0.05).EffectiveThe WVRT was a useful program for improving visual perception and postural balance in individuals with chronic stroke.48Borstad AL et al. [62]2018Recovery rapidsVirtual reality game with KinectMobilization of the limbsUpper limbBefore and after trial16AgeM = 49: male = 10 and female = 63 hours per day for 10 days over 2 weeksBaseline and postinterventionThe mean, median, and interquartile range for within-subjects change on the WMFT (rate/60 seconds) and MAL-QOM (0–5 scale) were 5.8 (3.7), 5.8, 2.7–9.4 and 0.74 (0.66), 0.46, 0.28–1.11, respectively.Partly effectiveFavorable changes in performance speed and quality of arm use were found in this study.49Noveletto F et al. [63]2018MyBalanceVideo gameBalance trainingNot mentionedBefore and after trial18AgeM = 55.3: male = 8 and female = 1012 minutes per day in the first ten sessions and 20 minutes per day in the remaining sessions; 2 sessions per week for 10 weeksBaseline and postinterventionEvaluated outcomes were better for all EG participants. The BBS test showed a balance improvement of 12.1 ± 7.8% with a large ES (0.9). The functional mobility assessed by the TUG test showed an improvement of 15.1 ± 7.4%, but ES was small (0.4).EffectiveThe results of this study support the clinical potential of a biomedical SG for balance rehabilitation of hemiparetic stroke patients.50Carregosa AA et al. [64]2018Nintendo Wii FitVirtual reality gameMobilization of the limbsMuscular strengtheningBalance trainingCoordinationUpper limb and lower limbBefore and after trial5AgeM = 54.8: male = 3 and female = 250 min, 2 sessions per week for 2 monthsBaseline, postintervention, and 8 weeks after the treatmentDescriptive data showed an improvement of the motor function of the upper limb items (26 ± 19.5) and total score (36.6 ± 20.2) of the scale.EffectiveThe results suggest that patients had motor learning retention, achieving a sustained benefit through the technique.51Park JH and Park JH [65]2016Nintendo Wii FitVirtual reality gameMobilization of the limbsUpper extremityRCT30Male = 16 and female = 1430 min, 5 sessions per week for 4 weeksBaseline and postintervention (after 4 weeks)There were significant differences in the changes between the two groups in the FM (p<0.05), BBT (p<0.05), and MAL-QOM (p<0.05). FM pre:49.3 and FM post: 54.4 (Fugl–Meyer Assessment)EffectiveGame-based virtual reality movement therapy alone may be helpful to improve functional recovery of the upper extremity, but the addition of MP produces a larger improvement.52Hocine N et al. [8]2015PRehabVideo gameMobilization of the limbsUpper limbRCT6AgeM = 60.66: male = 4 and female = 220 min, for 2 weeks (3 sessions)Baseline and postinterventionIt revealed a significant effect of the difficulty strategy on patient performance (Wilks’ Lambda = 0.10;F = 2.38; p<0.02).Partly effectiveThe results of the experiment show that dynamic adaptation technique increases movement amplitude during a therapeutic session.53Bower KJ et al. [66]2014Nintendo Wii FitNot mentionedBalance trainingMobilization of the limbsUpper limb and lower limbRCT30AgeM = 63.6: male = 17 and female = 1345 min, 3 sessions per week over 2–4 weeksBaseline, two weeks, and four weeksImprovements were observed in the majority of secondary outcomes over time in both groups. The balance group participants demonstrated greater improvements in Wii balance board-derived measures with small to large effect sizes (d = 0.30–1.00) at four weeks (p=0.007−0.048).Partly effectiveSpecific activities targeted at balance training are potentially effective for improving standing balance.54Brown EVD et al. [67]2014PeggleVideo gameBalancing trainingUpper extremityRCT9AgeM = 60: male = 5 and female = 445 min, 5 sessions per week for 4 weeksBaseline and postintervention assessments, approximately 4 weeks apart, before system useNo differences were found across time on any of the WMFT subscales or the CAHAI-9 WMFT functional activity score: A1: 1.79 ± 0.71; A2: 1.77 ± 0.68; A3:1.79 ±0.66No effectiveThis study had limited changes in kinematic and activity level outcomes55Slijper A et al. [68]2014Not mentionedVideo gameMobilization of the limbsUpper extremityBefore and after trial11AgeM = 58: male = 5 and female = 65 weeks, mean time: 1070 minBaseline, during, postintervention, and follow-up16–18 weeks after the treatment phaseFMA-UE A-D (motor function) showed significant improvements in the upper extremity function between baseline (A1) and posttest (A2) (0.005) as well as a follow-up (<0.0001). Fugl–Meyer A-D: preintervention: 44, intervention: 49 , postintervention: 51EffectiveThe results indicate that computer game-based training could be a promising approach to improve upper extremity function.56Chen CC et al. [69]2017Not mentionedVirtual reality gameMuscular strengtheningMobilization of the limbsUpper limbBefore and after trial21AgeM = 55.7: male = 14 and female = 760 min, 3 sessions per week for 8 weeksBaseline and postinterventionThe statistical results confirmed a significant effect of treatment. FMA: baseline: 30.35 ± 13.8. After intervention: 38.80 ± 14.61EffectiveFinding suggests that VR-based rehabilitation can induce significantly kinetic changes than facilitate recovery.57Lee MM et al. [70]2018Nintendo Wii FitVirtual reality gameBalance trainingMobilization of the limbsUpper extremityRCT30AgeM = 61.56: male = 18 and female = 1230 min, 3 sessions per week, for 5 weeksBaseline and postintervention one day after the five-week intervention periodMFT was significantly improved in both groups compared with baseline values (p<0.05). Pre: 8.93 ± 1.53; post: 11.40 ± 2.47EffectiveGame-based VR Canoe paddling training is an effective rehabilitation therapy that enhances postural balance and upper extremity function.58Park DS et al. [71]2017Microsoft Xbox 360 KinectVirtual reality game with KinectMobilization of the limbsBalance trainingMotor functionLower extremityRCT20AgeM = 63.65: male = 10 and female = 1030 min, daily sessions for a 6-week periodBaseline and postinterventionThe pre-to-post difference scores on BBS, TUG, and 10 mWT for the intervention group were significantly more improved than those for the control group (p<0.05).EffectiveEvidence supports the use of additional VR training with the Xbox Kinect gaming system as an effective therapeutic approach for improving motor function.59Park JS et al. [72]2019Not mentionedVideo gameMuscular strengtheningMotor functionHandRCT43AgeM = 59.43: male = 26 and female = 1730 min, 5 sessions per week, for 6 weeksBaseline and postinterventionAfter training, hand strength, MFT, and BBT were improved in the experimental group compared to the control group (P<0.001, both). MFT: pre: 12.91 ± 5.73; post: 16.23 ± 5.95EffectiveGame-based exercise is more effective than manual exercise in improving muscle strength, motor function, and compliance in stroke patients.60Ahmadi HS et al. [73]2019E-LinkVirtual reality gameMobilization of the limbsUpper limbNonrandomized clinical trials30AgeM = 55.24: male = 20 and female = 1040 min, 3 sessions per week, for 4 weeksBaseline and postinterventionThe finding shows the improvement of upper limb motor function, tone, and range of motion in this group. Mean differences: FMA (total score); intervention: 6.53; control: 3.86EffectiveComputer games can improve upper limb motor function, muscle tone, and the range of motion in stroke patients.FMA-UE, Fugl–Meyer Assessment for Upper Extremity; WMFT, Wolf Motor Function Test; IMI, Intrinsic Motivation Inventory; IADL, Lawton of instrumental activities of daily living; SIS, Stroke Impact Scale; B-stage, brainstorm stage; MMT, manual muscle testing; AP-axis, anterior-posterior axis; CIMT, constraint-induced movement therapy; GR, gesture recognition; NWF, Nintendo Wii FitTM game; FU, follow-up; FMA-LE, Fugl–Meyer Assessment; BESTest, Balance Evaluation Systems Test; AT, after training; 10MWT, 10-meter test of walking score; CoP, center of pressure; AP sway, sway kinematics in the anterior-posterior; BBS, the Berg Balance Scale; FABS, Fullerton Advanced Balance Scale; TUG, Timed Up and Go; FM, Fugl–Meyer; ARA, Action Research Arm; UE, upper extremity; VGG, video game group; TG, traditional group; IQR, interquartile range; FMA-UL, Fugl–Meyer upper limit assessment; OTSVR, off-the-shelf virtual reality; TTP, time-to-peak; VR, virtual reality; FR, forward reach; MAL-QOM, Motor Activity Log Quality of Movement; FMA, Fugl–Meyer Assessment; MI, Motricity Index; AROM, active range of motion; BI, Barthel Index; SG, serious games; QFG, quadriceps femoris; HSG, hamstrings; PNF, proprioceptive neuromuscular facilitation; WVRT, Wii Fit virtual reality training; GBT, general balance training; EG, experimental group; ES, effect sizes; BBT, Box and Block Test; MP, mental practice; CAHAI-9, Chedoke Arm and Hand Activity Inventory-9; MFT, manual function test; RCT, randomized controlled trial or randomized control trial.


### 3.1. Study Characteristics

The reviewed studies in this study were published in 53 journals and 7 international conferences. All the names of journals and conferences are listed in Table3 based on their frequency. As it is clear, the “Archives of Physical Medicine and Rehabilitation,” “Clinical Rehabilitation,” “Games for Health Journal: Research, Development, and Clinical Applications,” and “Journal of Stroke and Cerebrovascular Diseases” have the first rank with 5 or 4 published studies among journals. The distribution of studies by year and country of publication is presented in Table 4. As it is conducted, the majority of citations were published in 2019. Accordingly, in different countries, innovative physical rehabilitation solutions were employed and Korea with 13 citations had the highest number of studies.Table 3
Distribution of studies based on publication type.
Journal/conference nameConferenceJournalClinical Rehabilitation5Journal of Stroke and Cerebrovascular Diseases4Archives of Physical Medicine and Rehabilitation4Games for Health Journal: Research, development, and clinical applications4Disability and Rehabilitation2Journal of NeuroEngineering and Rehabilitation2NeuroRehabilitation2IEEE Transactions on Neural Systems and Rehabilitation Engineering2International Journal of Environmental Research and Public Health2Journal of Medical and Biological Engineering1International Medical Journal of Experimental and Clinical Research1American Journal of Physical Medicine and Rehabilitation1Computers in Biology and Medicine1Journal of Central Nervous System Disease1BioMed Research International1Brain Impairment1European Journal of Physical and Rehabilitation Medicine1User Modeling and User-Adapted Interaction1Frontiers in Psychology1Iranian Rehabilitation Journal1Journal of Physical Therapy Science1Journal of Healthcare Engineering1Annals of Physical and Rehabilitation Medicine1Journal of Motor Behavior1American Academy of Physical Medicine and Rehabilitation1Journal of Patient-Centered Research and Reviews1Restorative Neurology and Neuroscience1Stroke1Medical Science Monitor1Neurorehabilitation and Neural Repair1Somatosensory and Motor Research1The Journal of Physical Therapy Science1International Journal of Stroke1Virtual Reality1International Journal of Neuroscience1In Proceedings of the 3rd 2015 Workshop on ICTs for improving Patients Rehabilitation Research Techniques2Proceedings of the IEEE International Conference on Advanced Materials for Science and Engineering1In 2019 International Conference on Robotics and Automation in Industry12019 Fifth International Conference on Advances in Biomedical Engineering (ICABME)1International Conference on Virtual Rehabilitation12017 International Conference on Applied System Innovation (ICASI)1Total753Table 4
Distributions of studies of publication years and country.
Row labelsColumn labels20132014201520162017201820192020TotalAustralia112Brazil∗1212219Canada1113China11France112Iran11Israel1214Italy112Lebanon11Malaysia11Netherlands112New Zealand11Pakistan11Republic of Korea∗1422413Spain11Sweden11Taiwan∗111216Turkey123UK22USA11114Grand total1109113913460∗3 countries with the highest number of study prints.


### 3.2. The Distribution of Literature by Main Gamification Types and Approaches

Based on analysis, virtual reality-oriented games and video games are the most popular physical rehabilitation types for poststroke patients. The distribution of reviewed literature based on the type of games is shown in Figure3. Besides, it turns out “Microsoft Xbox 360 Kinect” and “the Nintendo Wii Fit” approaches have been the widest utilized game-based tools that have been extracted in studies (Figure 4).Figure 3
The distribution of studies based on gamification types.Figure 4
The distribution of studies based on type and name of games.The deployment platform for most of the studies included in this review (n = 28, 46.66%) was Nintendo and Microsoft Xbox 360 Kinect.There are many games in the field of rehabilitation that researchers and therapists can use for rehabilitating patients. However, in this systematic review, most studies have used existing games in rehabilitation and do not develop games for the purpose of research that we can refer to the Nintendo Wii Fit, Microsoft Xbox 360 Kinect games, Peggle, IREX, and HTC Vive games.


### 3.3. Distribution of Studies Based on Type of Physical Rehabilitation

The critical types of physical rehabilitation therapies applied for poststroke patients based on different games were divided into several main categories. The most important types of rehabilitation are “Balance training,” “Mobilization of the limbs,” and “Muscular strengthening” (Figure5).Figure 5
Physical rehabilitation therapies in reviewed studies.


### 3.4. Distribution of Studies Based on Type of Studies, Sample Size, and Session Detail

In the investigated studies, three types of intervention studies and their effectiveness have been utilized (Table5). The sample size from minimum to maximum number is 5 people in 2 studies and 209 people in one study. The highest frequency for the selected sample size was 10 people, which is in 4 studies. The lowest age of the recruited subjects in studies was 24 years on average, and the highest mean of age was 72 years old. In most studies, the number of males included in the intervention was higher than females; in 4 studies, the exact number of genders was not reported.Table 5
Distribution of studies based on the type of study and effectiveness.
Row labelsEffectivenessEffective41Before and after trial13Nonrandomized clinical trials2RCT26Not effective3RCT3Partly effective16Before and after trial3RCT13Total60The frequency of physical rehabilitation time (by unit time) is shown in Figure6. In this study, the length of rehabilitation time is converted to hour to compare the treatment time in different studies. In studies, the minimum duration of treatment to provide rehabilitation is one hour; besides, 10, 9, and 12 hours is the highest frequency of treatment time in studies, which was intended in a total of 12 studies.Figure 6
The distribution of studies based on the total time of rehabilitation duration.


### 3.5. Distribution of Studies Based on Assessment Scores

According to the results of reviewed different studies, numerous indicators and tests have been applied to evaluate physical rehabilitation outcomes in poststroke patients. In other words, according to the type of rehabilitation treatment provided to patients, different indicators and metrics have been calculated to assess the condition of the rehabilitated organs of the body (before and after the intervention). For this reason, we were unable to compare the assessment scores calculated during the intervention. However, considering how many indicators and metrics in each study were affected by physical rehabilitation during the intervention treatment, we added a brief assessment from the authors’ perspective. At the end of the intervention, if all indicators of functional or physical appraisal of patients are affected by game-based rehabilitation and a significant difference is seen, then we have labeled this rehabilitation approach “Effective.” If only one or two of the several evaluation metrics are not affected by game-based rehabilitation, then we label them “Partly effective.” Finally, if there is no significant difference in all evaluation measures before and after the intervention, we label them “No effective.” In the following, the distribution of the reviewed studies based on effectiveness is shown in Figure7.Figure 7
The distribution of the reviewed studies based on effectiveness.


## 3.1. Study Characteristics

The reviewed studies in this study were published in 53 journals and 7 international conferences. All the names of journals and conferences are listed in Table3 based on their frequency. As it is clear, the “Archives of Physical Medicine and Rehabilitation,” “Clinical Rehabilitation,” “Games for Health Journal: Research, Development, and Clinical Applications,” and “Journal of Stroke and Cerebrovascular Diseases” have the first rank with 5 or 4 published studies among journals. The distribution of studies by year and country of publication is presented in Table 4. As it is conducted, the majority of citations were published in 2019. Accordingly, in different countries, innovative physical rehabilitation solutions were employed and Korea with 13 citations had the highest number of studies.Table 3
Distribution of studies based on publication type.
Journal/conference nameConferenceJournalClinical Rehabilitation5Journal of Stroke and Cerebrovascular Diseases4Archives of Physical Medicine and Rehabilitation4Games for Health Journal: Research, development, and clinical applications4Disability and Rehabilitation2Journal of NeuroEngineering and Rehabilitation2NeuroRehabilitation2IEEE Transactions on Neural Systems and Rehabilitation Engineering2International Journal of Environmental Research and Public Health2Journal of Medical and Biological Engineering1International Medical Journal of Experimental and Clinical Research1American Journal of Physical Medicine and Rehabilitation1Computers in Biology and Medicine1Journal of Central Nervous System Disease1BioMed Research International1Brain Impairment1European Journal of Physical and Rehabilitation Medicine1User Modeling and User-Adapted Interaction1Frontiers in Psychology1Iranian Rehabilitation Journal1Journal of Physical Therapy Science1Journal of Healthcare Engineering1Annals of Physical and Rehabilitation Medicine1Journal of Motor Behavior1American Academy of Physical Medicine and Rehabilitation1Journal of Patient-Centered Research and Reviews1Restorative Neurology and Neuroscience1Stroke1Medical Science Monitor1Neurorehabilitation and Neural Repair1Somatosensory and Motor Research1The Journal of Physical Therapy Science1International Journal of Stroke1Virtual Reality1International Journal of Neuroscience1In Proceedings of the 3rd 2015 Workshop on ICTs for improving Patients Rehabilitation Research Techniques2Proceedings of the IEEE International Conference on Advanced Materials for Science and Engineering1In 2019 International Conference on Robotics and Automation in Industry12019 Fifth International Conference on Advances in Biomedical Engineering (ICABME)1International Conference on Virtual Rehabilitation12017 International Conference on Applied System Innovation (ICASI)1Total753Table 4
Distributions of studies of publication years and country.
Row labelsColumn labels20132014201520162017201820192020TotalAustralia112Brazil∗1212219Canada1113China11France112Iran11Israel1214Italy112Lebanon11Malaysia11Netherlands112New Zealand11Pakistan11Republic of Korea∗1422413Spain11Sweden11Taiwan∗111216Turkey123UK22USA11114Grand total1109113913460∗3 countries with the highest number of study prints.


## 3.2. The Distribution of Literature by Main Gamification Types and Approaches

Based on analysis, virtual reality-oriented games and video games are the most popular physical rehabilitation types for poststroke patients. The distribution of reviewed literature based on the type of games is shown in Figure3. Besides, it turns out “Microsoft Xbox 360 Kinect” and “the Nintendo Wii Fit” approaches have been the widest utilized game-based tools that have been extracted in studies (Figure 4).Figure 3
The distribution of studies based on gamification types.Figure 4
The distribution of studies based on type and name of games.The deployment platform for most of the studies included in this review (n = 28, 46.66%) was Nintendo and Microsoft Xbox 360 Kinect.There are many games in the field of rehabilitation that researchers and therapists can use for rehabilitating patients. However, in this systematic review, most studies have used existing games in rehabilitation and do not develop games for the purpose of research that we can refer to the Nintendo Wii Fit, Microsoft Xbox 360 Kinect games, Peggle, IREX, and HTC Vive games.


## 3.3. Distribution of Studies Based on Type of Physical Rehabilitation

The critical types of physical rehabilitation therapies applied for poststroke patients based on different games were divided into several main categories. The most important types of rehabilitation are “Balance training,” “Mobilization of the limbs,” and “Muscular strengthening” (Figure5).Figure 5
Physical rehabilitation therapies in reviewed studies.


## 3.4. Distribution of Studies Based on Type of Studies, Sample Size, and Session Detail

In the investigated studies, three types of intervention studies and their effectiveness have been utilized (Table5). The sample size from minimum to maximum number is 5 people in 2 studies and 209 people in one study. The highest frequency for the selected sample size was 10 people, which is in 4 studies. The lowest age of the recruited subjects in studies was 24 years on average, and the highest mean of age was 72 years old. In most studies, the number of males included in the intervention was higher than females; in 4 studies, the exact number of genders was not reported.Table 5
Distribution of studies based on the type of study and effectiveness.
Row labelsEffectivenessEffective41Before and after trial13Nonrandomized clinical trials2RCT26Not effective3RCT3Partly effective16Before and after trial3RCT13Total60The frequency of physical rehabilitation time (by unit time) is shown in Figure6. In this study, the length of rehabilitation time is converted to hour to compare the treatment time in different studies. In studies, the minimum duration of treatment to provide rehabilitation is one hour; besides, 10, 9, and 12 hours is the highest frequency of treatment time in studies, which was intended in a total of 12 studies.Figure 6
The distribution of studies based on the total time of rehabilitation duration.


## 3.5. Distribution of Studies Based on Assessment Scores

According to the results of reviewed different studies, numerous indicators and tests have been applied to evaluate physical rehabilitation outcomes in poststroke patients. In other words, according to the type of rehabilitation treatment provided to patients, different indicators and metrics have been calculated to assess the condition of the rehabilitated organs of the body (before and after the intervention). For this reason, we were unable to compare the assessment scores calculated during the intervention. However, considering how many indicators and metrics in each study were affected by physical rehabilitation during the intervention treatment, we added a brief assessment from the authors’ perspective. At the end of the intervention, if all indicators of functional or physical appraisal of patients are affected by game-based rehabilitation and a significant difference is seen, then we have labeled this rehabilitation approach “Effective.” If only one or two of the several evaluation metrics are not affected by game-based rehabilitation, then we label them “Partly effective.” Finally, if there is no significant difference in all evaluation measures before and after the intervention, we label them “No effective.” In the following, the distribution of the reviewed studies based on effectiveness is shown in Figure7.Figure 7
The distribution of the reviewed studies based on effectiveness.


## 4. Discussion

This survey’s main objective was to review the studies in which games were applied for improving the physical functions and rehabilitation of poststroke patients. According to results, emerging games possess the capacity and potential to rehabilitate physical aspects in poststroke patients; furthermore, these games can help patients improve their independence. According to surveys, virtual reality-based approaches and “the Nintendo Wii Fit” games were used more than other games. The most common use of games in poststroke survivors’ rehabilitation was related to limb movement and balance training.Due to the included studies’ results, different indicators and scales have been calculated and statistically analyzed to evaluate and test game-based physical rehabilitation therapies for poststroke patients. These statistical analyses demonstrated the positive effect of innovative rehabilitation is provided in the form of games for these patients. Even in many studies, applied games in different environments (virtual reality, and video-based games) have led to a great improvement in patients’ physical problems such as balance disorder, upper extremity spasticity, and limbs’ immobility and muscular weakness [3, 5, 11, 74–77]. Researchers in these studies have concluded that they can incorporate these games into the treatment plan and physiotherapy of poststroke patients and use them as alternative therapies to traditional methods because, in these experimental studies, significant improvements in all outcome measures were found after the intervention [76, 78]. However, in infrequent articles, no significant differences can be observed in all assessment scales (baseline and post-intervention assessments in the experimental and control groups) to evaluate game-oriented physiotherapies’ effectiveness. For this reason, in these studies, the researcher has concluded that the game chosen to rehabilitate poststroke patients cannot be a useful tool to alternate with the traditional physical rehabilitation methods, and applying them can destroy the patient’s time and motivation.The reason for the ineffectiveness of newly emerged games for motor rehabilitation of stroke patients can have different reasons as follows: insufficient session times and training duration to generate consistent improvements in all patients, the insufficient number of participants in the experimental studies (randomized trails would require at least 25 participants in each group) [38, 76], the high mean age of patients in both intervention and control groups (underlying disability of people due to their age), and excessive movement limitations of the patients recruited in the study [79, 80].According to this study’s results, the most popular type of game for physical rehabilitation of poststroke patients was virtual reality games. Virtual reality-based games allow patients to interact with a virtual environment while performing rehabilitation exercises and simulating real functions. These games increase patients’ motivation to perform rehabilitation exercises and provide a pleasant environment for patients, which can lead to more repetition of rehabilitation exercises in these patients [77]. People get feedback while playing virtual reality games, and this factor encourages patients with disabilities to attend therapy sessions and use their remaining functional capacity to succeed in the game [81].Results have shown that “the Nintendo Wii Fit” games are used more than other games to rehabilitate poststroke patients. Several factors can lead to the most use of this game. Among these factors, we can mention the price of these games, which are relatively inexpensive. These games are widely available to people, and studies have shown that providing an attractive environment increases patients’ enjoyment and more repetition of rehabilitation exercises [82–84]. Features of the Wii Fit game system lead to the stimulation of people’s interest in continuing to play and can be useful for improving motor function and balance control [61].Studies showed that the most common use of games in the rehabilitation of stroke survivors was related to limb movement and balance training. In other words, the results of studies that were run to examine the effect of games on people after a stroke had shown these games were effective in improving the balance of people and strengthening the muscles of the limbs [85]. In a systematic review conducted by Corbetta, the effectiveness of virtual reality games has been investigated and concluded that managed games have the most significant impact on patient mobility [75]. According to the results of this survey and other studies that show the effect of the game on maintaining balance and movement, it is recommended to use these games in poststroke survivors.This systematic review had several strengths and limitations. One of the strengths was the use of broad keywords to search in 4 crucial databases. Another strength of this survey was the inclusion of studies presented at conferences. The limitations were the exclusion of articles in non-English language and the time limit imposed on searching databases (from 2014 onwards). Another limitation of this review was the different scales used to measure people’s performance, and this factor made it difficult to compare the results of different surveys.


## 5. Conclusion

Game-based approaches lead to patients being able to smoothly perform their rehabilitation movement techniques without going to the treatment centers. These games can immerse the person in the environment by providing virtual or augmented reality capabilities and multiplying the effectiveness of the treatment. Therefore, the use of appropriate technology-based gaming solutions can improve patients’ treatment and minimize the waste of time and cost of providing traditional motor rehabilitation. Consequently, these game-based treatments are considered complementary to traditional ones and can reduce the workload of therapists and accelerate the rehabilitation process. Future research should focus on how task-specific game-oriented systems can improve function after stroke, and statistical studies can show this effect more.



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*Source: 9928509-2021-09-15.xml*