Virtual reality games fail to outplay card and ball games in stroke rehabilitation

By Lucy Piper

Researchers have found inexpensive recreational activities such as playing cards or ball games are as effective add-on therapies to conventional stroke rehabilitation as virtual reality interventions.

"[A]lthough we expect that technology might enhance relearning of motor pathways by intensifying neurorehabilitation, simple motor tasks (that could be implemented worldwide) appear at least as safe and efficacious", says the team led by Gustavo Saposnik (St Michael's Hospital, University of Toronto, Ontario, Canada).

Both recreational activities and non-immersive virtual reality improved motor function performance on the Wolf Motor Function Test (WMFT) by about 30% at the end of the 2 weeks of treatment and by 40% at 4 weeks post-treatment, with no difference between the two groups.

The researchers therefore believe that it is the added intensity and specificity of training rather than the method itself that improves early motor recovery of the upper limb.

The study - Efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST) - involved 141 patients aged an average of 62 years who had a first-ever ischaemic stroke in the 3 months before. The patients received 10 hour-long sessions of either non-immersive virtual reality using the Nintendo Wii gaming system or simple recreational activities such as playing cards, ball games, bingo or Jenga in addition to conventional rehabilitation.

After 2 weeks of treatment, the 71 patients receiving the virtual reality intervention and the 70 participating in recreational activities knocked an average 14.0 and 10.9 seconds off the time it took to complete the WMFT, respectively, reflecting a 32.0% and 28.7% improvement.

Multivariable analysis revealed no significant difference between the two groups either at 2 weeks or 4 weeks later.

Three serious events occurred during treatment - post-discharge seizure and an intracerebral haemorrhage in the recreational group and a heart attack in the virtual reality group - but all were deemed to be unrelated to the interventions.

The findings imply that "[a]dditional investments in virtual reality might not need to be made in resource-limited environments", stress the researchers in The Lancet Neurology.

They recommend that people with stroke be made aware of the comparable benefits of the low-cost, task-specific home-based recreational activities they studied, particularly "[c]onsidering that the greatest burden of stroke occurs in low-income and middle-income countries with constrained resources and limited access to technologies and rehabilitation therapists".

In a related Comment, Brian Silver (Rhode Island Hospital, Providence, USA) says that "EVREST is an important study", but he considers whether additional total duration of therapy with any of these interventions could improve outcomes further.

He outlines evidence suggesting "a U-shaped curve with respect to total therapy time and recovery of function", adding that optimum therapy duration may also vary with patient age.

Silver concludes: "As the mountain of evidence grows regarding the types and doses of treatments for rehabilitation after stroke, so too will the percentage of patients with improved outcomes."

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