Review
M. Gumaa, MSc, Department of
Physical Therapy for Musculoskeletal
Disorders and Its Surgery, Cairo
University, Cairo, Egypt.
A. Rehan Youssef, PhD, Department of
Physical Therapy for Musculoskeletal
Disorders and Its Surgery, Cairo
University, 24 Mohammed Korium St,
6th District, Nasr City, Cairo, Egypt.
Address all correspondence to
Dr Rehan Youssef at:
aliaa.rehan@gmail.com.
[Gumaa M, Youssef AR. Is virtual reality
effective in orthopedic rehabilitation?
A systematic review and meta-analysis.
Phys Ther. 2019;99:1304–1325.]
© 2019 American Physical Therapy
Association
Published Ahead of Print:
July 25, 2019
Accepted: March 8, 2019
Submitted: June 6, 2018
Post a comment for this
article at:
https://academic.oup.com/ptj
1304 Physical Therapy Volume 99 Number 10
Is Virtual Reality Effective in
Orthopedic Rehabilitation?
A Systematic Review and
Meta-Analysis
Mohammed Gumaa and Aliaa Rehan Youssef
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Background. Virtual reality (VR) is an interactive technology that allows customized
treatment and may help in delivering effective person-centered rehabilitation.
Purpose. The purpose of this review was to systematically review and critically
appraise the controlled clinical trials that investigated VR effectiveness in orthopedic
rehabilitation.
Data Sources. Pubmed, CINAHL, Embase, PEDro, REHABDATA, and Sage publications
were searched up to September 2018. In addition, manual searching and snowballing using
Scopus and Web of Science were done.
Study Selection. Two reviewers screened studies for eligibility first by title and abstract
and then full text.
Data Extraction. Articles were categorized into general or region-specific (upper
limbs, lower limbs, and spine) orthopedic disorders. Study quality was assessed using
the Evaluation Guidelines for Rating the Quality of an Intervention Study scoring. Meta-
analysis quantified VR effectiveness, compared with no treatment, in back pain.
Data Synthesis. Nineteen studies were included in the quality assessment. The majority
of the studies were of moderate quality. Fourteen studies showed that VR did not differ
compared with exercises. Compared with the no-treatment control, 5 studies favored VR
and 3 other studies showed no differences. For low back pain, the meta-analysis revealed
no significant difference between VR and no-treatment control (n = 116; standardized
mean difference = −0.21; 95% confidence interval = −0.58 to 0.15).
Limitations. Limitations included heterogeneity in interventions and the outcome
measures of reviewed studies. Only articles in English were included.
Conclusion. The evidence of VR effectiveness is promising 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. For
fibromyalgia and back pain, as well as after knee arthroplasty, the evidence of VR
effectiveness compared with exercise is absent or inconclusive.
October 2019

V
irtual reality (VR) technology involves an interactive
computer environment or games that appear and
feel real.1,2 Users are able to interact with a virtual
environment using off-the-shelf3,4 or custom-made
devices.5 Games may provide an avatar, an object to
follow, or virtual floor steps to navigate.6–9 VR can be
nonimmersive, semi-immersive, or immersive, depending
on the number of stimulated physiologic senses, the
extent of interaction with the virtual environment,
synthetic stimuli reliability, and the user’s isolation from
external stimuli (eg, room light).10,11
In physical rehabilitation, VR represents a valid and
reliable assessment tool for joint (ROM), function, and
balance.9,12–14 It may enable personalizing treatment,
motivating individuals, increasing their compliance, and
documenting their progress.15–17 This may reduce the work
burden on clinicians, because it requires minimal
supervision.18 It is also generally commercially available
and can be used for home-based rehabilitation.
The effectiveness of VR in neurorehabilitation has been
studied extensively1,2,19–22 in individuals with cerebral
palsy,1 stroke,21 and parkinsonism.22 Despite VR’s
promising effects, the quality of scientific evidence was
insufficient to support its recommendation for routine use
in clinical practice.1,21,22
In orthopedic rehabilitation, clinical trials have previously
assessed VR effectiveness in individuals with ankle
sprain,23 anterior cruciate ligament (ACL) injury,24 frozen
shoulder,12 chronic low back pain (LBP), and neck
pain.25,26 However, to our knowledge, the strength of
evidence of VR’s effectiveness has never been studied
systematically. Therefore, the aim of the present study was
to systematically review and critically appraise controlled
clinical trials that have investigated VR’s effectiveness in
orthopedic rehabilitation.
Methods
The protocol for this systematic review was registered in
the PROSPERO database (CRD42017072132).
Data Sources and Searches
Six electronic databases were searched (PubMed, CINAHL,
Embase, PEDro, REHABDATA, and Sage Publications)
using the following keywords and Boolean operators:
(virtual OR virtual reality OR virtual environment OR
computer-based OR computer-interface OR cyberspace OR
artificial intelligence OR computer simulat∗ OR simulator
OR Exergam∗ OR active video gam∗ OR interactive
gam∗ OR game OR gaming OR X-box OR Kinect OR
Nintendo OR Wii) AND (orthopedic∗ OR orthopaedic∗ OR
musculoskeletal) AND (physical therapy OR physiotherapy
OR exercise OR therapeutic∗ OR treatment OR
training OR intervention OR rehabilitation) NOT (stroke
OR cerebral palsy OR cancer OR tumor OR carcinoma
October 2019
Virtual Reality in Orthopedic Rehabilitation
OR oncology OR neurologic∗ OR dentistry OR obesity
OR children OR pediatric) (Supplementary File, available
at https://academic.oup.com/ptj). The search was carried
out from database inception until September 6, 2018.
Further, the bibliographic references of included articles
were searched manually for additional relevant studies.
Finally, all eligible studies were entered in Scopus and the
Web of Science to identify all of the articles that had cited
them (snowballing).
Study Selection
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The primary outcome for this review was VR effectiveness,
whether assessed clinically or self-reported, and the
secondary outcome was participant satisfaction,
enjoyment, and/or compliance. Articles were included if
they were controlled clinical trials conducted involving
adult individuals with orthopedic disorders who were
treated with VR as either a standalone or adjunct therapy
for more than 1 treatment session. Eligible studies needed
to assess clinical outcomes such as ROM, pain, strength,
function, balance, and gait. Only articles published in the
English language were included. Articles were excluded if
they involved participants with neurological dysfunction
or cancer, assessed psychosocial outcomes, or used VR as
an assessment tool only. Reviews and conference
proceedings were also excluded.
The eligibility of retrieved articles was judged by 2 inde-
pendent reviewers by title, then by the abstract, and finally
by reading through the whole article. If disagreement
existed, a consensus was reached through discussion.
Data Extraction and Quality Assessment
Studies were divided into general and region-specific
musculoskeletal disorders. A standardized data extraction
form was used to collect the objective, sample size,
rehabilitation duration, intervention and control groups,
outcome variables, and results for each eligible study
(Tab. 1–3).
The methodological quality of all included studies was
assessed using the Evaluation Guidelines for Rating
the Quality of an Intervention Study scoring system.27 This
tool has high interrater reliability.28 It consists of 24 items,
divided into 7 domains, which evaluate research question,
study design, subject selection, intervention(s), outcome
measures, statistical analysis, and conclusion. Each
question is given a score that ranges from 0 points to 2
points,27 with the total quality score classified as high (36–
48 points), moderate (25–35 points), or low (0–24 points).
Both reviewers underwent a pre-study standardized
training session on the use of the quality scoring tool.
Data Synthesis and Analysis
To examine treatment effect, a meta-analysis was
conducted using the Review Manager (RevMan) software
Volume 99 Number 10 Physical Therapy 1305
1306
Table 1.
Characteristics of Included Studies of General and Upper Limb Musculoskeletal Disordersa

Rehabilitation Comparator Study

Condition Study Objective Participants VR Group Outcomes Results
Duration Group Qualityb
General musculoskeletal
FM Collado- Evaluate effects Eighty-three 8-wk program, Custom-made No treatment Patient-reported outcome: Patients who 37 (high)
Mateo of VR female 1 h/session, hardware and software and continued Disease impact (impact of exercised showed
et al.30 exergaming on participants 2 d/wk (VirtualEx-FM) The their normal FM) significant
(2017) disease impact with FM were program consisted of: daily lives Quality of life (EQ-5D-5 L) improvements in:
and quality of divided into 2 Warm-up by imitating 5 domains of
life in women groups: video movements disease impact
with FM exercise Aerobic exercise questionnaire
(n = 42) and following dance steps 4 domains of
no-treatment Postural control and quality of life
control coordination by
(n = 41) reaching for a target
Walk training on a

Physical Therapy Volume 99 Number 10

Virtual Reality in Orthopedic Rehabilitation

virtual floor
Collado- Evaluate effects Eighty-three 8-wk program, Custom-made No treatment Functional mobility (Timed Patients who 36 (high)
Mateo of VR female 1 h/session, hardware and software and continued “Up & Go” Test) exercised showed
et al.7 exergaming on participants 2 d/wk (VirtualEx-FM) their normal Balance (functional reach significant
(2017) mobility, with FM were The program daily lives and sensory integration improvements in:
balance, and divided into 2 consisted of: tests)Fear of falling (VAS) Functional
fear of falling in groups: Warm-up by imitating mobility
women with exercise video movements Balance with eyes
FM (n = 42) and Aerobic exercise closed on
no-treatment following dance steps unstable surface
control Postural control and Functional reach
(n = 41) coordination by balance scores
reaching out for a Fear-of-falling
target Walk training score
on a virtual floor
RA Zernicke Preliminarily Thirty 12 wk, Off-the-shelf Nintendo 10–12 chosen Patient-reported outcome: All measured 27
et al.31 evaluate participants 1 h/session, Wii Fitc games exercises: Physical function (HAQ-DI) variables were not (moderate)
(2016) feasibility and with RA were 3 d/wk 2 exercises chosen Strengthening Disease activity significantly
acceptance of divided into VR Then from the following: Coordination (participant’s global different between
home-based group (n = 15) participants Yoga Joint mobility assessment using VAS) the 2 groups
VR exercises in and crossed over to Strengthening Relaxation Quality of life (SF-36)
participants home-based other Balance Aerobic Strength of neck, shoulder,
with RA (pilot exercise group treatment arm elbow, hip, and knee
study) (n = 15) muscles (handheld
dynamometry) Functional
mobility (6-MWT) Changes
in physical function
(respiratory function test)

(Continued)

October 2019
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 Virtual Reality in Orthopedic Rehabilitation

(version 5.3; Cochrane, London, UK). Only homogeneous

EQ-5D-5 L = 5-level EQ-5D (EuroQol Research Foundation, Rotterdam, the Netherlands); FM = fibromyalgia; HAQ-DI = Health Assessment Questionnaire; 6-MWT = 6-min walk test; RA = rheumatoid
(moderate)
studies were analyzed when the intervention and control
Qualityb
Study
groups were comparable. For continuous outcome
32 variables, mean differences and 95% confidence intervals
(95% CIs) were used for the same outcome measures
across studies. A random-effects model was chosen to

provoked by Neer
participated in VR

improvements in:
Pain at night and
pool treatment effects across these studies. Standardized
Results

Patients who

exergaming

mean differences and 95% CIs were used for studies that
significant

dyskinesia

Assessed using the Evaluation Guidelines for Rating the Quality of an Intervention Study scoring system27 : high quality = 36–48; moderate quality = 25–35; low quality = 0–24.
Scapular
utilized different outcome measures to assess the same
showed

construct. A P value of .05 or less was considered to be

test statistically significant. When data were unavailable,
authors were contacted by email to obtain clarifications.

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Scapular dyskinesis (lateral
during activity, at night,

retraction, and scapular

Neer and Hawkins tests
and when provoked by

scapular slide, scapular

Self-reported pain and

Heterogeneity between studies was assessed using the I2

Shoulder pain at rest,

(assessed using VAS)

Outcomes

disability (Shoulder

test. The degree of heterogeneity was categorized as

Disability Index)
assistance tests)

either low (I2 < 25%), moderate (I2 = 25%–75%), or high

(I2 > 75%).29 A P value of ≤.05 indicated significant
heterogeneity.

Results
Comparator

Home-based

Search Results
Progressive

stretching

stretching
Group

exercises:

Shoulder
mobility

Pectoral
Capsule

The initial search procedure retrieved 8194 articles. After

resistive

muscle

arthritis; SF-36 = Medical Outcomes Study 36-Item Short Form Health Survey; VAS = visual analog scale; VR = virtual reality.

duplicate removal, 6494 articles remained. Following

screening by title and abstract, 48 articles were deemed
eligible. A reading of the full text for each yielded 17
Off-the-shelf Nintendo

VR exercises included:

Home-based resistive

articles for quality assessment. Snowballing retrieved an

Capsular stretching
Bilateral shoulder

additional 469 articles that were reduced to 10 after

VR Group

duplicate removal and screening by title and abstract.

Tennis games
Wii Fit games

Finally, after reading through the full text of these

elevation

exercises
Bowling
Boxing

additional articles, only 2 were found to be eligible from

snowballing. Thus, a total of 19 articles were included in
the quality assessment (Fig. 1). These articles were
Rehabilitation

45 min/session,

categorized into general disorder (n = 3; fibromyalgia

Duration

[n = 2] and rheumatoid arthritis [RA] [n = 1]),

region-specific disorders (upper limbs [n = 1], lower limbs
2 d/wk
6 wk,

[n = 9]: knee [n = 5], and ankle [n = 4]), and spine (n = 6):

neck [n = 2] and back [n = 4]). All analyzed articles are
summarized in Tables 1 to 3.
exercise (n = 15)
Participants

diagnosed with

dyskinesis were
syndrome and

divided into 2
impingement
Thirty people

(n = 15) and
home-based
subacromial

exergaming

General Musculoskeletal Disorders

groups: VR
scapular

Participants. Two studies involved women with

fibromyalgia with a mean age of 52.5 years
(SD = 9.6 years).7,30 One study investigated VR
VR exergaming
effectiveness of

effectiveness in RA on 30 participants with a mean age of

in participants

impingement
exercises and
Objective

home-based

subacromial

52 to 59 years.31
combined

syndrome
Evaluate

with

VR intervention. The VR program focused on postural

Nintendo, Redmond, WA (USA).

control and coordination of upper and lower limbs,

aerobic conditioning, strength, and functional mobility.7,30
Pekyavas
Study

Ergun3
(2017)

Patients with RA were given various VR exercises

and

including yoga, strengthening, balance and aerobic

training.31
Continued

Condition

loskeletal:
Table 1.

Region-

muscu-
specific

upper

Comparator group. For fibromyalgia, control group

limbs

participants received no treatment and were asked to

b
a

continue with their regular daily life.7,30 For RA, the

c

October 2019 Volume 99 Number 10 Physical Therapy 1307

 Table 2.
Characteristics of Included Studies of Lower Limb Musculoskeletal Disordersa

1308
Rehabilitation Comparator Study
Condition Study Objective Participants VR Group Outcomes Results
Duration Group Qualityb
Knee
Lin Compare 89 participants 8 wk, Custom-made CKCE Active knee joint Patients in CPFE and 30
OA et al.5 proprioceptive VR with OA were 40 min/ses- apparatus and including knee position sense CKCE groups showed (moderate)
(2007) exergaming and divided into 3 sion, 3 tailored computer resisted (electrogoniometer) improved knee joint
closed kinetic groups: d/wk game to train knee flexion and Physical function position sense, function,
exercises in Proprioceptive position sense extension (WOMAC) mobility speed, and
participants with exergaming from supine Functional mobility muscle torque
knee OA (CPFE; n = 30) position speed compared with
Exercises (CKCE; Control group Knee flexor and no-treatment control
n = 29) received only extensor muscle group
No-treatment education torque (isokinetic Patients in CPFE and
control (n = 30) regarding dynamometer) CKCE groups were not
knee OA significantly different in
knee joint position
sense, function, and

Physical Therapy Volume 99 Number 10

mobility speed
Virtual Reality in Orthopedic Rehabilitation

Patients in CKCE group

had higher extensor
muscle torque than
those in CPFE group
Kim Examine effects of 30 elderly 8 wk, Horseback-riding Adduction Functional mobility No significant 22 (low)
et al.32 horseback-riding participants 30 min/ses- simulator exercise (straight-leg (10-MWT) differences between the
(2017) simulator and with knee OA sion, 3 (15 min) raise) Knee extensor and 2 groups in all measured
strengthening were divided d/wk Knee-strengthening Standing flexor muscle variables
exercises on gait into 2 groups: exercises (15 min) flexion strength (manual
ability as well as Horseback- Seated muscle testing
muscle strength riding simulator extension device) and
and activation in (n = 15) Front step-ups activation (EMG)
elderly Strengthening Heel raise
participants with exercises
knee OA (n = 15)
Fung Investigate 50 participants Both groups Off-the-shelf Hip, knee, and Knee active ROM No significant 32
TKA et al.8 acceptability of who underwent received 60 Nintendo Wii Fit ankle active Functional mobility differences between the (moderate)
(2012) Wii Fitc use as TKA were min regular games including: exercises (2-MWT) 2 groups in all measured
adjunctive divided into 2 physical Lateral weight Tandem Pain (NPRS) variables
treatment with groups: therapy 2 shifting (ski slalom, walking Lower extremity
physical therapy VR exercises d/wk; in tight-rope walk, Crossover functional scale
in participants (n = 27) addition, penguin slide) stepping Activities-Specific
after TKA Traditional 15 min of VR Multidirectional Walking Balance Confidence
exercises or traditional balance (table tilt, backward Scale
(n = 23) exercises hula hoop, balance Heel walking Length of outpatient
Treatment bubble) Static and Toe walking rehabilitation
continued dynamic postural
until end of control (deep
outpatient breathing, half-moon,
rehabilitation torso twist)

October 2019
(Continued)

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 Table 2.
Continued

October 2019
Rehabilitation Comparator Study
Condition Study Objective Participants VR Group Outcomes Results
Duration Group Qualityb
Jin Evaluate 66 participants Both groups Immersion Auto-passive Physical function VR group showed 28
et al.33 practicality and who underwent received regular custom-made game maximum (WOMAC) significant (moderate)
(2018) benefits of VR TKA were physical therapy; that simulated boat knee flexion Pain (VAS) improvements in all
intervention after divided into 2 in addition: rowing using knee exercise Knee flexion ROM postintervention
TKA groups: VR group received flexion Days needed to assessments, except
VR exercise 30 min/session, 3 achieve 60◦ and 90◦ pain measured on
(n = 33) times/d of knee flexion postoperative day 1
Exercise control Control group Patient-reported
(n = 33) performed 3 sets outcome (Hospital
of passive for Special Surgery
exercise, 30 Knee Score)
repetitions each/d
ACL Baltaci et Compare 30 men who 12 wk, Off-the-shelf Gradual Dynamic balance The 2 groups were 32
recon- al.34 effectiveness of underwent 1 h/session, 3 Nintendo Wii Fit progressive (modified Star not significantly (moderate)
struction (2013) Nintendo Wii Fit unilateral d/wk games including: exercises Excursion Balance different in all
and exercises in arthroscopic Bowling including: Test) measured variables
participants who ACL Skiing Flexion CKCE Coordination,
underwent ACL reconstruction Boxing Prone proprioception, and
reconstruction were divided Football hanging response time
into 2 groups: Balance board Straight-leg (functional squat
VR exercises Each game was raise test)
(n = 15) played for 15 min Isometric Knee flexor and
Traditional quadriceps set extensor muscle
exercises Cycling strength (isokinetic
(n = 15) Balance dynamometer)
Resistive knee
extension and
flexion
Jogging
Ankle: Vernadakis Evaluate 63 male soccer 10 wk, Off-the-shelf Xbox Exercise Single-leg static Balance significantly 32
lateral et al.4 effectiveness of VR athletes were 24 min/session, 2 Kinect progressive VR group: balance (Biodex improved in VR and (moderate)
sprain (2014) Xbox Kinectd divided into 3 d/wk games including: gradual Balance Systemf ) exercise groups
training in young groups: Rally ball progressive Self-reported activity compared with
athletes with VR exercise Reflex ridge balance Enjoyment (modified control group
recurrent ankle (n = 21) River rush training on Physical Activity VR and exercise
sprain Traditional 2000 leaks minitrampo- Enjoyment Scale) groups were not
exercise (n = 21) Each game was line and BOSU Self-reported significantly
No-treatment repeated 2 times for Balance compliance different in balance
control (n = 21) 3 min each Trainere (10-point Likert and compliance
Control scale) VR group showed
group: no significantly more

Volume 99 Number 10 Physical Therapy

intervention enjoyment than
exercise group

(Continued)
Virtual Reality in Orthopedic Rehabilitation

1309
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1310
Table 2.
Continued

Rehabilitation Comparator Study

Condition Study Objective Participants VR Group Outcomes Results
Duration Group Qualityb
Kim and Examine 20 people with 4 wk, Off-the-shelf Off-the-shelf Static and dynamic VR balance 25
Heo23 impact of VR functional ankle 30 min/session, Nintendo Wii Fit Nintendo Wii Fit ankle balance (Biodex exercise group (moderate)
(2015) training on instability were 3 d/wk games: games: Balance System) showed
ankle static and divided into 2 Soccer heading Lunge significantly
dynamic groups: Ski slalom Single-leg better overall
balance VR balance exercise Tight-rope walk extension static balance
(n = 10) Table tilt Sideways leg lift and overall as
VR strengthening Snowboard slalom Single-leg twist well as
exercise (n = 10) Rowing squat anteroposterior
dynamic
balance
Punt Compare 90 participants with VR group: 6 wk, Off-the-shelf Conventional Self-reported physical The 3 groups 37 (high)
et al.35 effectiveness of mild to moderate 30 min/session, Nintendo Wii Fit physical therapy function (Foot and Ankle were not

Physical Therapy Volume 99 Number 10

Virtual Reality in Orthopedic Rehabilitation

(2016) Wii Fit training lateral ankle sprain 2 d/wk games: group: Ability Measure) significantly
to conventional were divided into 3 Conventional Unsupervised VR Progressive joint Pain at rest and during different in all
physical groups: physical therapy training after initial mobilization walking (assessed using measured
therapy in VR exercises group: 6 wk, 9 supervised session Muscle VAS) variables
participants (n = 30) sessions of Exercises included: strengthening Self-reported satisfaction
with ankle Conventional 30 min each Ski slalom Proprioceptive Subjective perception of
sprain physical therapy Penguin slide exercises treatment effectiveness
(n = 30) Table tilt Control group: Time to return to sport
No-treatment Balance bubble no intervention
control (n = 30)
Punt Examine effect 90 participants with VR group: 6 wk, Off-the-shelf Conventional Temporospatial The 3 groups 34
et al.36 of Wii Fit mild to moderate 30-min sessions, Nintendo Wii Fit physical therapy parameters: were not (moderate)
(2017) exercise lateral ankle sprain 2 d/wk games: group: Cadence significantly
training on gait were divided into 3 Conventional Unsupervised VR Progressive joint Step length different in all
in participants groups: physical therapy training after initial mobilization Single-support time measured
with ankle VR exercises group: 6 wk, 9 supervised session Strengthening Symmetry index variables
sprain (n = 30) sessions of Exercises included: Proprioceptive (motion tracking
Conventional 30 min each Ski slalom exercises system)
physical therapy Penguin slide Control group: Ankle kinematics
(n = 30) Table tilt no intervention (motion tracking
No-treatment Balance bubble system)
control (n = 30) Ankle reinjury rate
a
ACL = anterior cruciate ligament; BOSU = both sides used; CKCE = closed kinetic chain exercise; CPFE = computerized proprioception facilitation exercise; EMG = electromyography; 2-MWT = 2-min walk
test; 10-MWT = 10-min walk test; NPRS = numerical pain rating scale; OA = osteoarthritis; ROM = range of motion; TKA = total knee arthroplasty; TP = traditional physical therapy; VAS = visual analog
scale; VR = virtual reality; WOMAC = Western Ontario and McMaster Universities Arthritis Index.
b
Assessed using the Evaluation Guidelines for Rating the Quality of an Intervention Study scoring system27 : high quality = 36–48; moderate quality = 25–35; low quality = 0–24.
c
Nintendo, Redmond, WA (USA).
d
Microsoft, Redmond, WA (USA).
e
BOSU, Ashland, OH (USA).
f
Biodex Medical Systems, Shirley, NY (USA).

October 2019
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 Table 3.
Characteristics of Included Studies of Spine Musculoskeletal Disordersa

Rehabilitation Comparator Study

Condition Study Objective Participants VR Group Outcomes Results

October 2019
Duration Group Qualityb

Chronic Bahat Investigate 32 participants with 5–6 wk of Customized Supervised and Neck pain (VAS) KTVR group 36 (high)
neck pain et al.25 effectiveness of chronic neck pain supervised VR or progressive neck home-based KT participant-reported pain showed
(2015) KT were divided into 2 KT, 30 min, 4–6 KTVR software Active neck and disability (Neck significantly
with/without groups: sessions operated using movements Disability Index) greater
VR in persons KTVR (n = 16) Both groups head-mounted Quick head Cervical flexion, improvements
with chronic KT only (n = 16) received display equipped movement in extension, and rotation in flexion range
neck pain home-based KT with 3D motion between targets range (assessed by VR) and global
for 18 wk, 3 tracking Static head Cervical movement perceived effect
d/wk KTVR group positioning while velocity (assessed by VR) KT group
received moving the body Kinesiophobia (Tampa showed
15–20 min of VR Smooth head Scale) significantly
training and movement Global perceived effect greater
10–15 min of KT following a (Global Perceived Effect improvements
VR training target Scale) in rotation
included: Static balance (assessed range and
ROM module by computerized stable velocity
Velocity module force platform) The 2 groups
Accuracy Functional balance showed no
Head pursuit task (assessed by single-leg significant
module standing and step tests) differences in
Same home-based Static head stability self-reported
KT as that used for (assessed by VR) exercise
comparator group Head movement participation
positioning accuracy
(assessed by VR)
Self-reported patient
satisfaction
Bahat Compare KT Treatment was Each phase Customized Phase 1: Participant-reported pain VR group 36 (high)
et al.6 home-based given in 2 phases: consisted of 4 home-based KT no-treatment and disability (Neck showed
(2018) training using Phase 1: 90 patients wk, 20 min/d, 4 using control group Disability Index) significant
laser pointer with chronic neck times/wk head-mounted received no Cervical flexion, improvements
and that using pain were divided display equipped intervention extension, and rotation in pain, quality
VR in into 3 groups: with 3D motion Phases 1 and 2: range (assessed by VR) of life, and
participants VR training (n = 30) tracking patients who Cervical movement selected velocity
with chronic Laser training VR training received laser velocity (assessed by VR) and accuracy
neck pain (n = 30) included: training were Kinesiophobia (Tampa measures at
No-treatment ROM module requested to aim Scale) both time
control (n = 30) Velocity module at target (poster Global perceived effect points
Phase 2: 92 Accuracy on wall) using (Global Perceived Effect
participants with Head pursuit task laser beam Scale)
chronic neck pain module secured to their Head movement
were divided into 2 head positioning accuracy
groups: (assessed by VR)

Volume 99 Number 10 Physical Therapy

VR training (n = 48) Quality of life (EQ 5D)
Laser training
(n = 44)
Virtual Reality in Orthopedic Rehabilitation

(Continued)

1311
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 Table 3.
Continued

1312
Rehabilitation Comparator Study
Condition Study Objective Participants VR Group Outcomes Results
Duration Group Qualityb

Low back Park Compare 24 participants 8 wk, Off-the-shelf Nintendo Stabilization Pain (VAS) No between-group 22 (low)
pain et effects of with chronic LBP 30 min/session, 3 Wii Fit games including: exercises Isometric back strength comparisons were done
al.39 Nintendo were divided into d/wk Wakeboard included 3 Static balance (1-leg VR and lumbar
(2013) Wii Fitc 3 groups: Frisbee dog sets, each stance) stabilization groups
and VR (n = 8) Jet ski consisting of Quality of life showed significant
lumbar Lumbar Canoe 7 positions (RAND-36 health status reductions in pain
stabiliza- stabilization maintained inventory) Control and lumbar
tion (n = 8) for 15 s stabilization groups
exercises No-exercise Control showed significant
in patients control (n = 8) group: no improvements in
with In addition, all intervention balance
chronic participants VR group showed
work- received hot significant
related packs and improvement in mental
LBP interferential and health domain
ultrasound All 3 groups showed

Physical Therapy Volume 99 Number 10

treatments significant increases in
Virtual Reality in Orthopedic Rehabilitation

back strength and

physical health domain
Kim Determine 30 female 4 wk, 30 min (VR Off-the-shelf Nintendo Trunk Pain (VAS) VR group showed 24 (low)
et effects of participants with group) or 1 h Wii Fit yoga program stabilization Mechanical PPT of significant
al.37 VR-based chronic LBP were (control group), 3 including: exercises: deep tissue (algometry) improvements in pain,
(2014) yoga divided into 2 d/wk Deep breathing Curl-ups Function level PPT, function, and fear
program groups: Different poses Dead bug (Oswestry Disability avoidance
on women VR yoga (n = 15) (half-moon, warrior, Quadruped Index)
who were Exercise control tree, chest to knee, reach Severity of disability
middle- (n = 15) chair, and palm tree) Bridge (Roland-Morris
aged with Side bridge Disability
LBP on knees Questionnaire)
Balancing Fear of back pain
on unstable (Fear-Avoidance Beliefs
surfaces Questionnaire)
Yoo Investigate 47 participants 8 wk, 3 d/wk Horseback-riding No Self-report of pain and Horseback-riding 29
et effective- with chronic LBP Each session was simulation training intervention function (VAS) simulation group (moderate)
al.38 ness of were divided into composed of progressed over 2 Body composition showed significant
(2014) horseback- 2 groups: 20 min of warm-up phases: (bioelectric impedance improvements in:
riding Horseback-riding and cool-down Phase I (week 1): analysis) Muscle and fat mass
simulator simulator (n = 24) Horseback-riding Ordinary walking Trunk flexion/extension Flexor and extensor
in patients No-treatment simulation group Sitting trotting isokinetic torque at muscle torque
with control (n = 23) started with 10 min Phase II (weeks 2–3): 30o /s and 90 o /s Back pain
chronic and progressively Previous exercises plus Selected functions
LBP increased session rising trotting
duration by 10-min Increased riding time
increments weekly Phase III (weeks 4–8):
until reaching Same previous exercises
40 min by week 6 with gradual increases in
riding time and intensity

October 2019
(Continued)

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 Virtual Reality in Orthopedic Rehabilitation

comparator group received strengthening, coordination,

3D = 3-dimensional; EQ 5D = EuroQol Research Foundation, Rotterdam, the Netherlands; KT = kinematic training; KTVR = kinematic training virtual reality; LBP = low back pain; PPT = pain pressure
(moderate)
Qualityb joint mobility, and relaxation exercises.31
Study

30
Outcomes. Compared with the control group, the VR
participants showed significant improvement in quality of
life and Fibromyalgia Impact Questionnaire scores.30 Also,
different in all
The 2 groups
Results

VR participants showed significant greater functional

threshold; RAND-36 = RAND Health care 36-Item Health Survey; ROM = range of motion; TTP% = time to peak velocity (percentage); VAS = visual analog scale; VR = virtual reality.
significantly

measured

mobility, balance, and decreased fear of falling.7 In the

were not

Assessed using the Evaluation Guidelines for Rating the Quality of an Intervention Study scoring system27 : high quality = 36–48; moderate quality = 25–35; low quality = 0–24.
variables

case of RA, there were no significant differences between

the VR and exercises groups with regard to physical
function, disease activity, muscle strength, functional
assessed by motion tracking)

mobility, and quality of life as well as respiratory

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(standardized reaching task

Pain and harm expectancy

function.31
Lumbar flexion range
Outcomes

Region-Specific Musculoskeletal Disorders:

Upper Limb
Participants. For upper limb disorders, a single study
(VAS)

was conducted involving 30 participants with subacromial

impingement syndrome (mean age = 40.6 years;
SD = 11.7 years).3
Comparator

intervention
Group

VR intervention. The VR program simulated shoulder

movements as well as capsular and pectoral muscle
No

stretching exercises. The games included bilateral

shoulder elevation, boxing, bowling, and tennis.3
gradually increased
Game consisted of

consisted of 2 sets
Custom-made VR
dodgeball game

tracking system
VR Group

of 15 launched
lumbar flexion
with reflective
using motion

Comparator group. The control group participants

3 levels that

Each level

completed unsupervised home-based resistive and

markers

range

mobility exercises for the shoulder as well as scapular and

balls

pectoral muscle stretching.3

Rehabilitation

days, average of
15 min/session,

Outcomes. In impingement syndrome, participants who

3 consecutive
Duration

played a VR exergame showed significant improvement in

1 time/d

nocturnal pain and that which was provoked by Neer,

scapular retraction, and scapular assistance tests.3
were divided into
with chronic LBP

Region-Specific Musculoskeletal Disorders:

control (n = 26)
Participants

53 participants

No-treatment

Lower Limbs
VR (n = 27)
2 groups:

Participants. The knee disorders investigated were knee

osteoarthritis (OA; n = 2),5,32 total knee arthroplasty (TKA;
n = 2),8,33 and post-ACL reconstruction (n = 1).34
intervention for
safety of virtual
feasibility and
Objective

patients with

The 2 OA studies included a sample size of 30 and 89

chronic LBP
Investigate

dodgeball

participants with a mean age ranging between 61 and

78 years.5,32 For studies on TKA, 1 study included 50
Nintendo, Redmond, WA (USA).

participants, and the other included 66 participants. The

mean age of participants in these investigations ranged
between 66 and 68 years.8,33 For post-ACL reconstruction,
Thomas
Study

(2016)
et al.26

a single study involving 30 participants with ages ranging

between 28 and 29 years was conducted.31,34
Continued

Condition

For ankle dysfunction, 4 studies were conducted studying

Table 3.

participants with lateral ankle sprain.4,23,35,36 The sample

size ranged between 20 and 90 participants, and the mean
b
a

age ranged between 16 and 35 years.4,23,35,36

c

October 2019 Volume 99 Number 10 Physical Therapy 1313

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October 2019
A flow diagram showing article selection, screening, and exclusion. VR = virtual reality.
Figure 1.
Virtual Reality in Orthopedic Rehabilitation

Physical Therapy Volume 99 Number 10

1314

VR intervention. For knee OA, 1 study used a
custom-made VR system that focused on proprioceptive
training,5 and the other study used a horseback-riding
simulator.32 Following TKA, 1 study included playing
Nintendo Wii Fit (Nintendo, Redmond, WA, USA) games
that focused on lateral weight-shifting, multidirectional
balance, and static and dynamic postural control,8 and the
other study included a custom-made boat-rowing game
designed to exercise knee flexors.33
For participants who underwent ACL reconstruction, VR
rehabilitation using Nintendo Wii Fit targeted balance by
bowling, skiing, boxing, football, and balance board
games.34
For ankle sprain, the VR program used off-the-shelf
Nintendo Wii Fit and Xbox (Microsoft, Redmond, WA,
USA) games that focused on balance such as slalom skiing,
slalom snowboarding, penguin sliding, table-tilt balance
bubble, rally ball, reflex ridge, river rush, 2000 leaks,
soccer heading, and tight-rope walk.4,23,35,36 The program
was either completed via supervised sessions4,23 or
as an unsupervised home-based rehabilitation
initiative.35,36
Comparator group. For knee OA, 1 study employed a
closed kinetic-chain exercise (CKCE) group as well as a
control group that received no treatment,5 and another
study included a comparator group that was given
different lower limb exercises (eg, straight-leg raise,
adduction, standing flexion, seated extension, front
step-ups, and heel raises).32 Following TKA, 1 study gave
the comparator group hip, knee, and ankle active
exercises as well as those involving tandem walking,
crossover stepping, walking backward, heel walking, and
toe walking actions,8 and the other study provided its
comparator group with only auto-passive knee flexion
exercises.33 Separately, in a different study, for ACL
reconstruction, the comparator group received CKCE,
resistive knee movement, cycling, and balance and jogging
exercises.34
For ankle sprains, in 3 studies, the comparator groups
received an exercise therapy program that either focused
only on balance training4 or included ankle joint
mobilization, muscle strengthening, and proprioceptive
exercises.35,36 In addition, a control group that received no
treatment was also included.4,35,36 The fourth study
included a VR strengthening program (containing lunge,
single-leg extension, sideways leg lift, single-leg twist, and
rowing squat exercises) for comparison with the VR
balance training.23
Outcomes. For knee OA, there were no significant
differences in knee position sense or function or walking
speed when VR was compared with CKCE or exercise
therapy.5,32 In contrast, however, the CKCE group showed
significantly improved extensor muscle torque versus the
October 2019
Virtual Reality in Orthopedic Rehabilitation
VR group.5 On the other hand, the VR group, compared
with the control group, showed significant improvements
in all measured variables.5 After TKA, the use of VR
compared with active lower limb exercises and balance
training showed no significant differences in knee range,
pain, balance, function, and length of rehabilitation as
well as self-reported satisfaction.8 Another study showed
contradictory results, with VR being significantly superior
in terms of knee range, pain, and function compared with
auto-passive exercises.33
Following ACL reconstruction, the use of VR did not
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significantly differ from exercise therapy with regard to
balance, coordination, proprioception, and knee muscle
strength.34
For ankle sprain, although VR did not differ from physical
exercises in terms of balance, self-reported physical
function, pain, gait spatiotemporal parameters, and ankle
kinematics, both satisfaction and compliance were
found.4,35,36 This was also true when VR was compared
with the no-treatment control group35,36 ; however,
Vernadakis et al (2014) showed a significant improvement
of balance for the VR group versus the control group.4
Further, this latter study reported that the VR group
participants enjoyed their treatment regimen more. When
VR was used for balance or strength training, participants
who completed the balance training showed significantly
better balance scores.23
Region-Specific Musculoskeletal Disorders: Spine
Participants. Five studies were eligible for inclusion in
this category; 2 studies involved participants with neck
pain6,25 and 4 included participants with LBP.26,37–39 The
studies on neck pain included 32 and 92 participants,
respectively, with ages ranging between 35 and
59 years6,25 ; the studies on LBP included sample sizes
ranging from 24 to 53 participants with mean ages of
between 20 and 44 years.26,37–39
VR intervention. For neck pain, VR kinematic training
(VRKT) was given using ROM, velocity, accuracy, and head
pursuit task modules that were delivered via a
custom-made system.6,25 For LBP, the program included
yoga training, a horseback-riding simulator, dodgeball,
wakeboard, Frisbee dog, jet skiing, and canoeing as
delivered by Nintendo Wii Fit, horseback-riding simulator,
or custom-made VR system.26,37–39
Comparator group. For neck pain, Bahat et al (2015)
compared VRKT and KT alone. A laser pointer was
secured to the participants’ heads to allow for laser beam
projection on a wall poster for feedback. The program
included active and quick head movements, static head
positioning, and moving the head to follow a target.25 This
was the same comparator group in the other study
conducted by Bahat et al (2018).6 In addition, the latter
Volume 99 Number 10 Physical Therapy 1315
Virtual Reality in Orthopedic Rehabilitation
Figure 2.
A forest plot of standardized (Std.) mean difference, with 95% confidence interval (95% CI) for low back pain measured with visual analogue
scale (VAS) between virtual reality (VR) and no-treatment control. IV = inverse variance.
study included a no-treatment control group in the first
phase as well, whereas the second phase included laser
training only as a comparator.6 For LBP, 2 studies provided
trunk stabilization exercises as a comparator to VR37 ,39 with
the inclusion of a no–treatment control group occurring in
1 study.39 In the study of Park et al, participants in the 3
groups received deep heating and interferential as well.39
In the 2 remaining studies, only a no–treatment control
group was included as a comparator.26,38
Outcomes. For individuals with neck pain, 1 study
showed a significant improvement of cervical flexion ROM
and global perceived effect in favor of the VRKT
treatment. However, the KT alone group showed better
results in terms of cervical rotation range and velocity. No
differences in compliance were found between the 2
groups.25 In the other study, for the first phase, the VR
group showed significant improvement versus the
no-treatment control group in terms of movement velocity,
neck disability, and movement accuracy. Notably, however,
the investigators did not compare the VR group with KT
laser training. In the second phase, VR participants
showed significant improvement in terms of movement
velocity, quality of life, pain intensity, and accuracy
compared with KT laser training over the short and
intermediate term.6
For individuals with LBP, 1 study showed a superior effect
of VR versus the use of trunk stabilization exercises in
terms of pain, function, disability, and fear of pain,37
whereas the other study did not perform a comparison
between the 2 treatments.39 Compared with a no-treatment
control group, Yoo et al showed that participants who
received VR showed significantly greater muscle mass,
less fat mass, and flexor and extensor torques,38 and
Thomas et al revealed an increase in lumbar flexion range
and decrease in pain and expected harm.26
A meta-analysis that considered the pooled pain data of 3
studies26,38,39 revealed no significant difference between
the VR and control groups (n = 115; standardized mean
difference = −0.24; 95% CI = −0.61 to 0.12; P = .19), with
no heterogeneity found (I2 = 0%; P = .72)
(Fig. 2).
1316 Physical Therapy Volume 99 Number 10
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Quality Assessment
Twenty-six percent of eligible studies (n = 5) were
high quality,6 ,7 ,25 ,30 ,35 whereas 58% (n = 11) were of a
moderate quality,3–5,8,23,26,31,33,34,36,38 and 16% (n = 3) were
low quality.32 ,37 ,39 The highest quality score was 37/48,30,35
and the lowest score was 22/4832 ,39 (Tab. 4).
Two studies (11%) did not randomize participants to
groups,31 ,32 8 studies (42%) used an appropriate
randomization method,3 ,6–8,25,26,34,35 and 9 studies (47%) did
not provide adequate information on the randomization
method(s) they used.4 ,5 ,23 ,30 ,33 ,36–39 In all studies, the
masking of participants and treatment providers was not
possible due to the apparent differences between
treatment options. In only 8 studies (42%), the outcomes
assessor was masked.5–8,25,30,35,36 One study involved an
independent assessor who was not involved in treatment
delivery yet who was not masked to treatment allocation.4
The remaining studies did not include an independent
assessor.3 ,23 ,26 ,31–34,37–39 Only 7 studies (37%) calculated the
sample size beforehand.3 ,7 ,26 ,30 ,34–36 The dropout was >30%
in 2 studies (11%),6 ,36 whereas the end of treatment
assessment was done for >90% in 13 studies
(68%)3–5,8,23,26,31–34,37–39 and for >70% in 4 studies
(21%).7 ,25 ,30 ,35 The detailed scoring data of the individual
studies included in this research are presented in
Table 4.
Discussion
This review assessed evidence of VR effectiveness in
orthopedic rehabilitation. Nineteen controlled clinical
trials were eligible for quality assessment. Overall, the
evidence showed that VR is better than no treatment in
individuals with fibromyalgia but not significantly more
beneficial than exercises in RA and other regional
dysfunctions. This lack of supporting evidence is similar
to findings in individuals with Parkinson disease and
stroke.21 ,22 Notably, despite the differences in pathogenesis
between orthopedic and neurology, a central neural
mechanism is involved in mechanical pain, so the
effectiveness of VR in both fields could be
related.40–50
October 2019

VR for General Musculoskeletal Disorders
For fibromyalgia, the 2 eligible studies were high quality;
however, both compared VR with a no-treatment control
protocol.7,30 For RA, only 1 pilot study with a small sample
size showed no difference between VR and exercises.31
Thus, further studies comparing VR and exercise therapy
effectiveness in general musculoskeletal pain
rehabilitation are required.
VR for Regional Dysfunction
Upper limbs. A single, moderate-quality study provided
evidence that supports VR effectiveness in shoulder
impingement syndrome over strengthening and stretching
exercises. However, in this study, supervised VR was
compared with an unsupervised home program,3 so VR
effectiveness could be attributed to the conduct rather
than content of the program.
Lower limbs. For knee OA, evidence from 2 studies of
low to moderate quality revealed VR comparability with
physical exercises5,32 and superiority to no-treatment
control.5 More high-quality studies are thus needed to
confirm VR effectiveness in the management of OA of
different severities and in different joints.
After TKA, 2 studies of moderate quality showed
contradictory results.8,33 Therefore, the evidence regarding
VR effectiveness in this population is inconclusive. Jin
et al attributed VR effectiveness to increased participant
motivation. However, participants in the VR group actively
flexed their knees, whereas participants in the control
group performed passive knee flexion.33 Active exercises
are largely expected to have better long-lasting effects. On
the other hand, Fung et al (2012) did not find any distinct
evidence of VR effectiveness, though their study had a low
statistical power, and, hence, a type II error may have
occurred.8
For post-ACL reconstruction, a moderate-quality study
reported no differences between VR and exercise.34
Importantly, though, this was a single study that had a
small sample size and did not report statistical power,
so it is difficult to conclude definitively that a type II
error may have occurred or not. Thus, the current
evidence of VR effectiveness in ACL rehabilitation is
insufficient.
For ankle sprain, the overall evidence showed that VR is
no more beneficial than exercises, although it may
increase individuals’ enjoyment. Three studies of
moderate to high quality showed that VR and exercises
were comparable in all measured variables,4,35,36 except in
the case of enjoyment.4 Compared with no-treatment
control, 1 study showed superior balance was achieved
with VR,4 and 2 studies did not report differences between
VR or exercises and a no-treatment control protocol.35,36
Separately, although Kim and Heo (2015)23 showed
October 2019
Virtual Reality in Orthopedic Rehabilitation
improved balance with VR, in this study, participants in
the 2 groups received VR that targeted balance in 1 group
and strength training in the other. Because balance was
the only outcome assessed in this study, the rationale for
selecting strengthening exercises as a comparator was
not justified.
Spine. Regarding the spine, 2 high-quality studies on the
topic of chronic neck pain provided evidence of improved
cervical flexion range, movement velocity, and accuracy
with VR in comparison with KT and/or no-treatment
control.6,25 However, the outcomes in the 2 studies were
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assessed by the same VR system that was used for
intervention; thus, participants in the VR group may have
performed better on testing due to their familiarity with
the system, potentially skewing the study results.
For LBP, the evidence is inconclusive. Two studies
supported VR effectiveness in back pain.37,38 Kim et al
(2014) reported a significant reduction in pain and
improved function with VR versus trunk stabilization, yet
this study was low quality. Furthermore, treatment content
and duration differed in that the VR group received
30 minutes of yoga, whereas the exercise group received
1 hour of stabilization exercises.37 Yoo et al (2014)
conducted a moderate-quality study that indicated
improved pain and muscle torque was achieved with VR
compared with the no-treatment control participants.38
However, it is expected that treated participants would
respond better, and, hence, no solid conclusion on VR
effectiveness compared with other treatments can be
drawn from this study. On the other hand, Thomas et al
(2016) found that VR was not better than no-treatment
control with regard to pain, function, and lumbar flexion
range.26 Importantly, though, the treatment duration of
only 3 days in this moderate-quality study is too short to
conclude from. Park et al (2013)39 investigated the
effectiveness of VR, trunk stabilization exercises, and
no-treatment control on pain, back strength, and balance.
In addition, participants in the 3 groups received heat
therapy and interferential. In this low-quality study,
participants in all groups showed improved back strength.
The VR and exercise control showed significant pain
reduction. Interestingly, the VR group did not show any
improvement in balance as the 2 other groups did. Still,
these results were based on within-group differences and
no between-group comparisons were done; thus, no
conclusion can be drawn regarding VR effectiveness
compared with the other treatment options
studied.
For meta-analysis, back pain severity measured by a visual
analogue scale was assessed in 3 studies.26,38,39 A
meta-analysis showed no differences between VR and
no-treatment control participants regarding effects on
back pain. This finding confirms the inconclusive
evidence of VR effectiveness in back
dysfunction.
Volume 99 Number 10 Physical Therapy 1317
 Table 4.

1318
Detailed Quality Score for Eligible Studiesa

General Musculoskeletal Disorders Region-Specific Musculoskeletal

Disorders: Upper Limb
Quality Assessment Item Fibromyalgia RA
Collado-Mateo et al.30 Collado-Mateo et al.7 Zernicke et
Pekyavas and Ergun3 (2017)
(2017) (2017) al.31 (2016)
Study question
The background is relevant and the 2 2 2 2
research question rationale is given
Study design
A comparison group is used 2 2 2 2
Participant status is considered at more 2 2 2 2
than 1 time point
Data are collected prospectively 2 2 2 2

Physical Therapy Volume 99 Number 10

Participants are randomized to groups 1 2 0 2
Virtual Reality in Orthopedic Rehabilitation

Participants are masked 1 1 1 1

Treatment providers are masked 1 1 1 1
An independent evaluator administers 2 2 0 0
outcome measures
Participants
Sampling procedures minimize 1 2 1 1
sample/selection bias
Inclusion/exclusion criteria are defined 2 2 2 2
An appropriate enrollment is obtained 1 1 0 1
An appropriate retention/follow-up is 1 1 2 2
obtained
Intervention
The intervention is applied according to 1 1 1 1
established principles
The biases due to the treatment provider 1 1 1 0
are minimized
The intervention is compared with the 1 1 2 2
appropriate comparator
Outcomes
An appropriate primary outcome is defined 2 1 1 1
Appropriate secondary outcomes are defined 1 1 1 1
The follow-up period is appropriate 1 1 1 1

(Continued)

October 2019
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 Table 4.
Continued

General Musculoskeletal Disorders Region-Specific Musculoskeletal

October 2019
Disorders: Upper Limb
Fibromyalgia RA
Quality Assessment Item
Zernicke
Collado-Mateo Collado-Mateo
et al.31 Pekyavas and Ergun3 (2017)
et al.30 (2017) et al.7 (2017)
(2016)
Analysis
An appropriate statistical test(s) is performed to indicate 2 2 1 2
differences related to the intervention
The study has significant power to identify treatment effects 2 1 0 2
The effect size and significance are reported 2 2 1 1
Management of missing data is clear 2 2 1 2
Clinical and practical significance are considered in 2 1 0 0
interpreting results
Recommendations
The conclusion is supported by the study objectives, analysis, 2 2 2 1
and results
Total scoreb 37 36 27 32
Region-Specific Musculoskeletal Disorders: Lower Limb
Knee
ACL Ankle Sprain
OA TKA Recon-
struction
Lin Kim Fung Jin Baltaci Vernadakis Kim and Punt Punt
et al.5 et al.32 et al.8 et al.33 et al.34 et al.4 Heo23 et al.35 et al.36
(2007) (2007) (2012) (2018) (2013) (2014) (2015) (2016) (2017)
Study question
Background is relevant and research question rationale is given 2 1 2 2 1 2 1 2 1
Study design
A comparison group is used 2 2 2 2 2 2 2 2 2
Participant status is considered at more than 1 time point 2 2 2 2 1 2 2 2 2
Data are collected prospectively 2 2 2 2 2 2 2 2 2
Participants are randomized to groups 1 0 2 1 2 1 1 2 1
Participants are masked 1 1 1 1 1 1 1 1 1

Volume 99 Number 10 Physical Therapy

Treatment providers are masked 1 1 1 1 1 1 1 1 1
An independent evaluator administers outcome measures 2 0 2 0 0 1 0 2 2

(Continued)
Virtual Reality in Orthopedic Rehabilitation

1319
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1320
Table 4.
Continued

Region-Specific Musculoskeletal Disorders: Lower Limb

Knee
ACL Ankle Sprain
Quality Assessment Item OA TKA Recon-
struction
Lin Kim Fung Jin Baltaci Vernadakis Kim and Punt Punt
et al.5 et al.32 et al.8 et al.33 et al.34 et al.4 Heo23 et al.35 et al.36
(2007) (2007) (2012) (2018) (2013) (2014) (2015) (2016) (2017)
Participants
Sampling procedures minimize sample/selection bias 1 1 2 1 1 1 2 2 2
Inclusion/exclusion criteria are defined 2 0 2 2 1 2 1 2 2
Appropriate enrollment is obtained 0 0 0 0 2 0 0 2 2

Physical Therapy Volume 99 Number 10

Appropriate retention/follow-up is obtained 2 2 2 2 2 2 2 1 0
Virtual Reality in Orthopedic Rehabilitation

Intervention
Intervention is applied according to established principles 1 1 1 1 1 1 1 1 1
Biases due to treatment provider are minimized 1 1 0 1 1 1 1 1 1
Intervention is compared with appropriate comparator 2 2 2 1 2 2 1 2 2
Outcomes
Appropriate primary outcome is defined 1 0 0 0 1 1 1 2 1
Appropriate secondary outcomes are defined 1 1 0 0 1 2 0 1 1
Follow-up period is appropriate 0 0 2 2 2 0 0 0 2
Analysis
Appropriate statistical test(s) is performed to indicate 1 2 2 1 2 2 2 2 2
differences related to intervention
Study has significant power to identify treatment effects 0 0 0 0 1 0 0 1 1
Effect size and significance are reported 1 1 2 2 1 2 1 1 1
Management of missing data is clear 1 2 2 2 2 2 2 2 2
Clinical and practical significance are considered in 1 0 0 0 0 0 0 1 0
interpreting results
Recommendations
Conclusion is supported by study objectives, analysis, and 2 0 1 2 2 2 1 2 2
results
Final scoreb 30 22 32 28 32 32 25 37 34

(Continued)

October 2019
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 Table 4.
Continued

Spine

October 2019
Quality Assessment Item Neck Pain Low Back Pain
Bahat et al.25 Bahat et al.6 Park et al.39 Kim et al.37 Yoo et al.38 Thomas et al.26
(2015) (2018) (2013) (2014) (2014) (2016)
Study question
Background is relevant and research question rationale is 1 2 1 1 1 1
given
Study design
Comparison group is used 2 2 2 2 2 2
Participant status is considered at more than 1 time point 2 2 2 2 2 2
Data are collected prospectively 2 2 2 2 2 2
Participants are randomized to groups 2 2 1 1 1 2
Participants are masked 1 1 1 1 1 1
Treatment providers are masked 1 1 1 1 1 1
An independent evaluator administers outcome measures 2 2 0 0 0 0
Participants
Sampling procedures minimize sample/selection bias 2 1 1 1 2 1
Inclusion/exclusion criteria are defined 2 2 1 1 2 2
Appropriate enrollment is obtained 0 0 0 0 0 2
An appropriate retention/follow-up is obtained 1 0 2 2 2 2
Intervention
The intervention is applied according to established 1 1 0 1 2 1
principles
The biases due to the treatment provider are minimized 2 1 0 0 1 1
The intervention is compared with the appropriate 1 2 2 1 1 2
comparator
Outcomes
Appropriate primary outcome is defined 2 2 0 0 0 1
Appropriate secondary outcomes are defined 2 2 1 1 1 1
Follow-up period is appropriate 2 2 0 0 0 0
Analysis

Volume 99 Number 10 Physical Therapy

Appropriate statistical test(s) is performed to indicate 2 2 1 2 2 1
differences related to the intervention
Study has significant power to identify treatment effects 0 0 0 0 0 1
Virtual Reality in Orthopedic Rehabilitation

(Continued)

1321
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Virtual Reality in Orthopedic Rehabilitation

Risk of Bias in Reviewed Studies

Thomas et al.26

ACL = anterior cruciate ligament; OA = osteoarthritis; RA = rheumatoid arthritis. Quality scores are as follows: 2 = item criteria fully described; 1 = item criteria partially described; 0 = item not fulfilled.
In the reviewed studies, randomization was either not
performed or lacking details in more than one-half of the

(2016)
reviewed studies.4 ,5 ,23 ,30–33,36–39

30
1
2
0

1
More than one-half of the reviewed studies enrolled a
Low Back Pain

small sample that was not based on prior calculations.

Yoo et al.38

Also, in these studies, no power calculation was

Assessed using the Evaluation Guidelines for Rating the Quality of an Intervention Study scoring system27 : high quality = 36–48; moderate quality = 25–35; low quality = 0–24.
(2014)

29
conducted for nonsignificant results, which is essential to
2
2
0

2
accurately assess a study’s validity.4–6,8,23,25,31–33,37–39

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In all reviewed studies, the masking of participants and
37
Kim et al.

treatment providers was impossible, resulting in a low-risk

(2014)

24 bias. On the other hand, only 8 studies involved masked

2
2
0

outcome assessors,5–8,25,30,35,36 which represents a potential

substantial source of bias.
39
Spine

Park et al.

Overall, the reviewed clinical trials were limited by the

(2013)

22
1
2
0

heterogeneity in VR and physical therapist interventions

as well as outcome measures. Thus, comparing different
studies and conducting a meta-analysis was not possible,
except for LBP.
6
Bahat et al.
(2018)

36
2
2
2

Only 3 studies described in detail the VR treatment given,

Neck Pain

yet they did not support their choice of the program

by relevant references.4 ,25 ,26 This is expected, because
VR is still a newly emerging rehabilitation technology in
25
Bahat et al.

orthopedic physical therapy and relevant studies remain

(2015)

scarce. Twelve studies used off-the-shelf console games,

36
2
0
2

with the majority (n = 9) using the Nintendo Wii Fit

system.3 ,4 ,8 ,23 ,31 ,32 ,34–39 Researchers instructed control group
participants to refrain from using them, yet because these
commercial console systems and games are potentially
easily accessible to participants in the control group,51 it
remains a possibility that some individuals in the control
Clinical and practical significance are considered in interpreting results

Conclusion is supported by the study objectives, analysis, and results

group may have used them.35 ,36 The use of customized

games or newly released games may overcome this
problem.
Quality Assessment Item

Only 1 study provided clinicians with standardized

training on VR application to minimize treatment
provision bias.25 On the other hand, 4 studies differed in
the conduct of VR rehabilitation with regard to the timing
Effect size and significance are reported

and mode of delivery. For example, Pekyavas and Ergun

Management of missing data is clear

(2017) compared the use of a supervised VR program with

a home-based program and, importantly, the latter could
have deprived the participants from receiving a therapist’s
instantaneous feedback.3 Also, Park et al allowed
participants to choose their desired VR game, so in this
case, the rehabilitation contents varied among
Recommendations

participants. In addition, all participants were given deep

heat and interferential therapy, which could have
b
Continued

Total score

alleviated pain and improved outcomes independently of

Table 4.

VR use.39 Moreover, Fung et al (2012)8 provided

participants with unstandardized physical therapy
b
a

sessions besides the assigned group treatment, which may

1322 Physical Therapy Volume 99 Number 10 October 2019


have influenced individual participants’ responses and led
to greater variation among them. Also, Kim et al (2014)37
varied the session durations between the VR (30 minutes)
and the exercise (1 hour) groups; in this case, the VR
group improved more noticeably, with the shorter
treatment duration potentially reducing exercise-induced
fatigue. In the remaining studies, no clear precautions
were taken to minimize treatment provision bias, yet no
inherent opportunities were evident.
In this review, 3 studies reported participants’ compliance
with the assigned treatments.4,6,25 Bahat et al (2018) was
the only research group to show a higher rate of
participant compliance with VR.6 However, treatment was
provided as an unsupervised home-based program, and
compliance was computed automatically via a computer
software versus manually using an exercise diary in the
control group. Regarding participant satisfaction, 3 studies
reported no differences between VR and exercises.8,25,35
Future studies are recommended to investigate
compliance and enjoyment. In this review, only 4 studies
discussed home-based VR treatment,6,31,35,36 despite the
advantages of commercially available VR systems for
home-based rehabilitation.52
To our knowledge, this is the first study to systematically
review and assess the quality of controlled clinical trials
investigating VR effectiveness in orthopedic rehabilitation.
It is important to note that a few limitations exist: first,
only articles in the English language were included.
Further, studies that assessed psychosocial outcomes were
excluded. The scale of quality assessment used, despite
being valid and reliable, also did not consider a few risks
of bias such as allocation and reporting bias. Finally, all
investigated orthopedic disorders had only a few numbers
of eligible studies, which limits this study’s ability to reach
and present a solid conclusion.
In conclusion, existing evidence of VR effectiveness in
individuals with chronic neck pain and shoulder
impingement syndrome is promising. Furthermore, VR is
comparable with other exercises and can be used as an
alternative option in the rehabilitation of RA, OA, and
post-ACL reconstruction as well as for ankle instability. For
fibromyalgia, TKA, and back dysfunction, the evidence of
VR effectiveness compared with more traditional exercise
is absent or inconclusive. Future clinical studies of a
higher quality are necessary to reach more solid
conclusions.
Author Contributions
Concept/idea/research design: M. Gumaa, A. Rehan Youssef
Writing: M. Gumaa, A. Rehan Youssef
Data collection: M. Gumaa, A. Rehan Youssef
Data analysis: M. Gumaa, A. Rehan Youssef
Project management: M. Gumaa, A. Rehan Youssef
October 2019
Virtual Reality in Orthopedic Rehabilitation
Funding
There are no funders to report.
Systematic Review Registration
The protocol for this study has been registered at PROSPERO
(CRD42017072132).
Disclosures
The authors completed the ICJME Form for Disclosure of Potential
Conflicts of Interest and reported no conflicts of interest.
Downloaded from https://academic.oup.com/ptj/article/99/10/1304/5537309 by guest on 19 August 2020
DOI: 10.1093/ptj/pzz093
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