applying game-based approaches for physical rehabilitation

Review ArticleApplying Game-Based Approaches for Physical Rehabilitation ofPoststroke Patients: A Systematic Review

Soheila Saeedi , Marjan Ghazisaeedi , and Sorayya Rezayi

Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences,Tehran, Iran

Correspondence should be addressed to Sorayya Rezayi; [email protected]

Received 21 March 2021; Revised 15 June 2021; Accepted 31 July 2021; Published 15 September 2021

Academic Editor: Redha Taiar

Copyright © 2021 Soheila Saeedi et al. (is is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Objective. A large number of patients need critical physical rehabilitation after the stroke. (is study aimed to review and reportthe result of published studies, in which newly emerged games were employed for physical rehabilitating in poststrokepatients. Materials and Methods. (is systematic review study was performed based on the PRISMA method. A compre-hensive 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 exclusioncriteria, in which new games have been used for physical rehabilitation. Results. Of the 1326 retrieved studies, 60 of them metour inclusion criteria. Virtual reality-oriented games were the most popular type of physical rehabilitation approach forpoststroke patients. “(e NintendoWii Fit” game was used more than other games.(e reviewed games were mostly operatedto balance training and limb mobilization. Based on the evaluation results of the utilized games, only in three studies, appliedgames were not effective. In other studies, games had effective outcomes for target body members. Conclusions. (e resultsindicate that modern games are efficient in poststroke patients’ physical rehabilitation and can be used alongsideconventional methods.

1. Introduction

Stroke is one of the diseases that can lead to disability andaffect people’s daily activities and lead to reduced perfor-mance [1]. According to the Global Burden of Diseases(GBD 2010), stroke is the second most common cause ofdeath worldwide [2]. In 2010, the number of people with thefirst stroke was 16.9 million, and people who died of strokewas 5.9 million [2]. Disability-adjusted life years (DALYs)lost also was 102 million, and the number of stroke survivorswas 33 million [2]. Ninety percent of stroke survivors have adisability in one of their functions [3]. Most people withpoststroke disability experience changes in emotionalfunction, limbmovement, balance, and muscle strength, andthere is a risk of falling for these patients in performingordinary activities, all of which affect the quality of life ofsurvivors [4]. (e main treatment solution to reduce

functional defects after stroke is rehabilitation [5]. Post-stroke physical rehabilitation in common is a gradualprocess that can take months or even years, and these pa-tients require multiple sessions of treatment.

However, patients may not be able to attend thesetreatment sessions for rehabilitation fully. Several factorsmay lead to limited access to these treatment sessions, in-cluding the following: difficulty accessing a physiotherapistby the patient, high cost of attending the treatment session,patient’s age and disability, the long distance that the patienthas to travel, or poor patient compliance [6]. One of thesolutions that can be offered to overcome these problems isto do rehabilitation activities at home; for rehabilitationexercises to be effective at home, high-intensity methodsfocused on specific repetitions of the practice with thefeedback of performance should be used [7]. Consequently,one of the innovative methods that can obviate the above

HindawiJournal of Healthcare EngineeringVolume 2021, Article ID 9928509, 27 pageshttps://doi.org/10.1155/2021/9928509

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https://doi.org/10.1155/2021/9928509

problems is applying modern games; these games have beenused in various fields, including education, public policy,and healthcare [8]. Furthermore, they can also be utilized asa support tool for rehabilitation activities and provide anenjoyable environment for patients and increase adherenceto treatment sessions [9, 10].

As it turns out, various studies have been performed todetermine the effectiveness of the mentioned games. Asystematic review study by Primack et al. found that gamesimproved 69% of psychological therapy outcomes, 46% ofclinician skills outcomes, 42% of health education outcomes,and 37% of disease self-management outcomes [11]. An-other study examined the games managed for rehabilitationin respiratory conditions and concluded these games wereeffective [12, 13]. (e purpose of this study is reviewing,summarizing, and reporting studies in which modern gameshave been used for physical rehabilitation of poststrokepatients 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 re-

habilitation in stroke survivors?(4) What are the evaluation results of games used in

poststroke patients?

2. Research Methodology

(is systematic review was conducted based on Prefer-red Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) checklist to ensure inclusion of relevantstudies [14].

2.1. Design. In this review, a systematic search of scientificdatabases including ISI Web of Science, PubMed, IEEEXplore Digital Library, and Scopus was performed fromJanuary 1, 2014, to November 9, 2020. (e comprehensivesearch strategy comprised a set of main keywords fromPubMed Mesh terms and Emtree related to “game,” “re-habilitation,” and “poststroke” patients.(e specific detail ofmain applied keywords for each database is presented inTable 1.

2.2. Inclusion and Exclusion Criteria for Study Selection.(e extracted studies were included if they fulfilled thefollowing criteria: (1) original articles and proceedings, (2)the focus of this review was on only physical rehabilitationinnovative game-based solutions for poststroke physicaldisabilities, (3) one of the gamification techniques wasemployed for physical rehabilitation or disability treatment,(4) in this study, the result of using different games andoutcomes of video games or immersive-oriented approacheson physical rehabilitation were reviewed, and (5) studieswere limited to those published in the English language.Besides, the studies were excluded if they met the followingcriteria: (1) the title, abstract, or full text of the article that didnot relate to video games, virtual, or mixed reality-based

games, (2) studies which were review or meta-analysis, bookchapters, letter, reports, and technical reports, (3) articles inwhich the result of applying games was not reportedquantitatively, (4) articles about cognitive rehabilitation, and(4) non-English published ones.

2.3. Literature Refinement. In comprehensive and scientificdatabases searching, 833 studies were retrieved after du-plicate removal. Some inclusion and exclusion criteria wereset for the study selecting phase. In the first phase, twoindependent reviewers (SS and SR) specified the primaryclassification of included studies; then, they synthesizedselected citations’ critical features. MG validated the pri-marily determined classifications. All titles and abstracts ofextracted studies were investigated and screened based onthe research questions and unique aims to select relevantones by two reviewers under MG’s supervision. In the lastphase, citations that met inclusion and exclusion criteriawere selected to enter the full-text review phase. (e full-texts of relevant studies were screened by SS and SR thor-oughly. Key characteristics were entered into a spreadsheetin Excel for each study. Two authors (SR and SS) inde-pendently extracted the study characteristics based on thepredefined classifications. For reaching an agreement, theinformation was examined again by two authors. (e nextreviewer (MG) evaluated and validated all of the obtainedresults. EndNote X9 was used for resource management, andall qualitative analyses were performed in SPSS v20. (emain classifications of screened citations are shown inFigure 1.

3. Results

(e flow of screening articles based on the PRISMA methodis shown in Figure 2. Prior scientific searches assigned 833citations after the duplicate removal phase. Next, 41 studieswere eliminated due to their irrelevancy in the full-textscreening phase. In the last screening step, 60 studies wereincluded based on our main study objectives as eligiblestudies. Based on the predefined classification elements, asummary of the key results is described in Table 2.

3.1. Study Characteristics. (e reviewed studies in this studywere published in 53 journals and 7 international confer-ences. All the names of journals and conferences are listed inTable 3 based on their frequency. As it is clear, the “Archivesof Physical Medicine and Rehabilitation,” “Clinical Reha-bilitation,” “Games for Health Journal: Research, Develop-ment, and Clinical Applications,” and “Journal of Stroke andCerebrovascular Diseases” have the first rank with 5 or 4published studies among journals. (e distribution ofstudies by year and country of publication is presented inTable 4. As it is conducted, the majority of citations werepublished in 2019. Accordingly, in different countries, in-novative physical rehabilitation solutions were employedand Korea with 13 citations had the highest numberof studies.

2 Journal of Healthcare Engineering

3.2.+eDistribution of Literature byMainGamificationTypesand Approaches. Based on analysis, virtual reality-orientedgames and video games are the most popular physical re-habilitation types for poststroke patients. (e distribution ofreviewed literature based on the type of games is shown inFigure 3. Besides, it turns out “Microsoft Xbox 360 Kinect”and “the NintendoWii Fit” approaches have been the widestutilized game-based tools that have been extracted in studies(Figure 4).

(e deployment platform for most of the studies in-cluded in this review (n� 28, 46.66%) was Nintendo andMicrosoft Xbox 360 Kinect.

(ere are many games in the field of rehabilitation thatresearchers and therapists can use for rehabilitating patients.However, in this systematic review, most studies have usedexisting games in rehabilitation and do not develop gamesfor the purpose of research that we can refer to the NintendoWii Fit, Microsoft Xbox 360 Kinect games, Peggle, IREX,and HTC Vive games.

3.3. Distribution of Studies Based on Type of PhysicalRehabilitation. (e critical types of physical rehabilitationtherapies applied for poststroke patients based on differentgames were divided into several main categories. (e mostimportant types of rehabilitation are “Balance training,”“Mobilization of the limbs,” and “Muscular strengthening”(Figure 5).

3.4. Distribution of Studies Based on Type of Studies, SampleSize, and Session Detail. In the investigated studies, threetypes of intervention studies and their effectiveness have beenutilized (Table 5). (e sample size from minimum to maxi-mum number is 5 people in 2 studies and 209 people in onestudy. (e highest frequency for the selected sample size was10 people, which is in 4 studies.(e lowest age of the recruitedsubjects in studies was 24 years on average, and the highestmean of age was 72 years old. In most studies, the number ofmales included in the intervention was higher than females; in4 studies, the exact number of genders was not reported.

MainClassification

PublicationInformation

Gamificationapproach

details

Rehabilitationtype

Target bodymember

study details Assessmentdetails Effectiveness Sample ize Results

Figure 1: (e key classification of relevant studies.

Table 1: Search strategy for each database.

Database Search strategy

PubMed

(“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: 2014–2020

Scopus

TITLE-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 ofScience

TS� (“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

Journal of Healthcare Engineering 3

(e frequency of physical rehabilitation time (by unittime) is shown in Figure 6. In this study, the length of re-habilitation time is converted to hour to compare thetreatment time in different studies. In studies, the minimumduration of treatment to provide rehabilitation is one hour;besides, 10, 9, and 12 hours is the highest frequency oftreatment time in studies, which was intended in a total of 12studies.

3.5. Distribution of Studies Based on Assessment Scores.According to the results of reviewed different studies, nu-merous indicators and tests have been applied to evaluatephysical rehabilitation outcomes in poststroke patients. Inother words, according to the type of rehabilitation treat-ment provided to patients, different indicators and metricshave been calculated to assess the condition of the reha-bilitated organs of the body (before and after the inter-vention). For this reason, we were unable to compare theassessment scores calculated during the intervention.

However, considering how many indicators and metrics ineach study were affected by physical rehabilitation duringthe intervention treatment, we added a brief assessmentfrom the authors’ perspective. At the end of the intervention,if all indicators of functional or physical appraisal of patientsare affected by game-based rehabilitation and a significantdifference is seen, then we have labeled this rehabilitationapproach “Effective.” If only one or two of the severalevaluation metrics are not affected by game-based rehabil-itation, then we label them “Partly effective.” Finally, if thereis no significant difference in all evaluation measures beforeand after the intervention, we label them “No effective.” Inthe following, the distribution of the reviewed studies basedon effectiveness is shown in Figure 7.

4. Discussion

(is survey’s main objective was to review the studies inwhich games were applied for improving the physicalfunctions and rehabilitation of poststroke patients.

Scre

enin

gIn

clud

edEl

igib

ility

Iden

tific

atio

n

Citations after duplicates removal(n = 833)

Full-text articles assessed for eligibility

(n = 101)

Full-text articles excluded with reasons (n = 41)

Articles in which the effectiveness of applying games was not reported quantitatively.

Articles about cognitive rehabilitations were excluded.

Not available full-text papers. Non-English and published ones.

Studies included in full synthesis (n = 60)

Records screened based on abstracts and titles

(n = 833)

Records excluded with reasons (n = 732)

The title, abstract did not relate to video games, virtual or mixed reality-based games

papers which are review or meta-analysis, book chapters, letter, reports and technical reports

Citations identified through databases comprehensive search:PubMed (n = 138), Scopus (n = 640),

Web of Science (n = 375), IEEE Xplore digital library (n = 173)Total retrieved articles: (n = 1326)

Figure 2: (e PRISMA diagram for the records search and study selection.


Tabl

e2:

Maincharacteristicsof

includ

edstud

ies.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

1Laffo

ntI

etal.[15]

2019

Not

mentio

ned

Video

game

Mob

ilizatio

nof

thelim

bsSh

oulder,

arm,and

hand

RCT

51AgeM

�58:

male�

31and

female�

20

45min,5

sessions

ina

weekfor6

weeks

Baselin

eand

postinterventio

nat

theendof

the

program,b

etween

days

45and60

and

follo

w-upat

6mon

ths

Inthesubacute

stroke

stage,adifferenceof

9/10

points

ontheUL-

FMSisconsidered,

andBB

Tminim

ally

detectable

change

isgained

tobe

5.5

blocks/m

in.

Effectiv

e

Postho

canalysis

show

edthatscores

inUL-FM

Sor

BBT

weresig

nificantly

high

erin

theVG

grou

pthan

inthe

CRgrou

p

2Cikajlo

Iet

al.[16]

2020

Nintend

oWii

Fit

Virtual

reality

game

Balance

training

Legs

RCT

20AgeM

�50.3:

male�

15and

female�

2

15min,5

sessions

for1

week

Baselin

eand

postinterventio

n

Sign

ificant

differences

betweenthegrou

pswerefoun

dwith

the

eyes

closed,sharpened

Romberg

test

(p�0.05),and

standing

ontherigh

tleg(p

�0.035).

Effectiv

e

Video

games

enable

independ

ent

balancetraining

isfeasible

with

out

strenu

ous

physiotherapy.

3GlueckAC

andHan

DY[17]

2019

Microsoft

developed

Robo

Raid

Mixed

reality

game

Balance

training

Legs

Before

andafter

trial

14AgeM

�25.21:

male�

11and

female�

3

59.12min,

35.71days

Baselin

eand

postinterventio

n

MRgametraining

provided

significant

reactio

ntim

eim

provem

ents

(p<0.05)and

vestibular

performances

(p<0.05).

Effectiv

e

(er

esultsshow

edvisuom

otor

reactio

ntim

e,and

balancemetrics

weresig

nificantly

improved

follo

wingMR

game

rehabilitation.

4Ayoub

iFet

al.[18]

2020

Nintend

oWii

Fit

Virtual

reality

game

Mob

ilizatio

nof

thelim

bs

Shou

lder,

wrist,h

and,

andfin

ger

Before

andafter

trial

10AgeM

�61.1:

male�

5and

female�

5

30min,1

0sessions,2

days

in5

weeks

Baselin

eand

postinterventio

n

FMAscores

revealed

asig

nificant

improvem

entinthe

motor

functio

n(p

�0.001).B

BTscores

increasedfrom

12pretherapy

to20.6

posttherapy,

andthe

MAL-AOM

scores

increasedfrom

1.09

pretherapy

to1.8

posttherapy.

Effectiv

e

Sign

ificant

improvem

entin

allo

utcome

measureswas

foun

dafterthe

interventio

n.

5de

Gou

vea

JXet

al.

[19]

2015

Nintend

oWii

Fit

Virtual

reality

game

Mob

ilizatio

nof

thelim

bsSh

oulder

and

elbo

wBe

fore

andafter

trial

22AgeM

�66.4:

male�

15and

female�

7

60min,3

sessions

ina

week

Baselin

eand

postinterventio

n

Elbo

wflexion

score

(jointrange

ofmotion)

increasedfrom

127to

134,

andshou

lder

flexion

scoreincreased

from

114to

134.

Effectiv

e

Metrics

show

edthat

therewere

statistically

significant

improvem

ents

for

alltrained

measures.


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

6Cano-

Mañas

MJ

etal.[20].

2020

Microsoft

Xbo

x360

Kinect

Video

game

with

Kinect

Balance

training

Postural

control

Functio

nality

Not

mentio

ned

RCT

48AgeM

�63.13:

male�

23and

female�

25

20min,2

4sessions

in8

weeks.

Baselin

eand

postinterventio

nassessments:8

weeks

afterthe

interventio

n

Sign

ificant

differences

resultedin

the

baropo

dometric

(p<0.01),the

mod

ified

Rank

inscores

(p<0.01),and

thevariable

relatedto

streng

thandthepain/

discom

fort

dimensio

n(p<0.01)of

theEQ

-5D

.

Effectiv

e

(efin

ding

sshow

that

applying

avideogame

approach

combinedwith

conv

entio

nal

therapymay

prod

ucepo

stural

control,

improvem

ents

inbalance,

functio

nality,

and

quality

oflife.

7SimsekTT

andÇekok

[21]

2015

Nintend

oWii

Fit

Virtual

reality

game

Balance

training

Mob

ilizatio

nof

thelim

bs

Shou

ler,wrist,

andelbo

wRC

T42

AgeM

�58.04:

male�

29and

female�

13

45–60min,10

week,

3days/

week.

Baselin

eand

postinterventio

nassessment:after10

weeks,a

fter

interventio

n,and

treatm

ent

satisfactionafter10

sessions

Astatistically

significantdifference

was

foun

dbetween

before

andafter

treatm

entFIM

(fun

ctional

independ

ence

measure)scores

(p<0.05).

Partly

effectiv

e

(eseresults

indicatedthe

Nintend

oWiiFit

training

was

aseffectiv

eon

daily

livingfunctio

nsandqu

ality

oflife

insubacute

stroke

patients.

8Hun

gJW

etal.[22]

2019

Kinect2Scratch

Video

game

with

Kinect

Mob

ilizatio

nof

theup

per

limbs

Shou

lder,

elbo

w,a

ndforearm

RCT

33AgeM

�58.98:

male�

22and

female�

11

30min,2

4sessions

in12

weeks

Baselin

e,po

stinterventio

n,andat

the3-mon

thfollo

w-up.

(etotala

ctivity

scores

ofthetraining

onup

perextrem

itywas

significantly

high

erin

the

Kinect2Scratchgrou

pthan

inthetherapist-

basedtraining

grou

p(p<0.001)

Effectiv

e

(eapplicationof

Kinect2Scratch-

oriented

games

may

indicate

acomplem

entary

strategy

toconv

entio

nal

therapyfor

decreasin

gthe

therapists’

workload.

9AdieK

etal.[23]

2016

Nintend

oWii

Fit

Virtual

reality

game

Mob

ilizatio

nof

thearms

Arm

RCT

209

AgeM

�67.3:

male�

105and

female�

104

45min,4

2sessions

in6

weeks

Baselin

eand

postinterventio

nafter6

weeks

andsix

mon

ths

(erewas

nosig

nificantdifference

intheprim

ary

outcom

eof

affected

arm

functio

nat

sixweeks

follo

w-up

(p�0.12)andno

significantdifference

insecond

ary

outcom

es.

Noeffectiv

e

(eresults

indicatedthat

the

WiiT

Mwas

not

superior

toarm

exercisesin

home-

based

rehabilitationfor

stroke

survivors

with

arm

weakn

ess.


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

10Ahm

adMA

etal.

[24]

2019

Not

mentio

ned

Virtual

reality

game

Mob

ilizatio

nof

theup

per

limbs

Not

mentio

ned

Before

andafter

trial

34AgeM

�63:

male�

31and

female�

5

30min,8

sessions

in8

weeks

Baselin

eand

postinterventio

non

completionof

the8

weeks

(eresults

show

eda

significanttim

e-grou

pinteractioneffectfor

IMI(p

�0.001),

LawtonIA

DL

(p�0.01),andSIS

domainof

commun

ication

(p�0.03).A

significanttim

ewas

foun

din

FMA-U

E(p

�0.001),W

MFT

(p�0.001),and

LawtonIA

DL

(p�0.01).

Effectiv

e

(eintegrationof

VRgames

asan

adjunctto

standard

physiotherapyfor

upperlim

bstroke

rehabilitationwas

considered

tobe

equally

beneficial

comparedto

standard

physiotherapy.

11Cho

iYH

etal.[25]

2016

MoU

-Rehab

Virtual

reality

game

Mob

ilizatio

nof

theup

per

limbs

Shou

lder,

elbo

w,a

ndwrist

RCT

24AgeM

�66.55:

male�

17and

female�

14

30min,1

0sessions

in2

weeks

Baselin

eand

postinterventio

non

endof

treatm

entand

at1mon

th

FMA-U

Ein

experimentala

ndcontrolg

roup

swas

calculated

34/67and

53.75.

Chang

esin

the

B-stagein

expandcon

grou

pswereindicated

3.17–4.24forthearm

and3.08–4.58forthe

hand

.

Effectiv

e

Alarger

improvem

entin

theFM

A-U

E,B-

stage,andMMT

was

foun

dafter

treatm

entw

iththe

MoU

-Rehab

than

with

conv

entio

nal

therapy

12Cho

iHS

etal.[26]

2017

Nintend

oWii

Fit

Virtual

reality

game

Balance

training

Lower

extrem

ity

Not

mentio

ned

RCT

36AgeM

�61.91:

male�

21and

female�

15

30min,1

2sessions

in4

weeks

Baselin

eand

postinterventio

n

Post

hocanalysis

revealed

significant

differences

inAP-axis,

andsw

ayarea;

weigh

tbearing

symmetry

oftheg

ame-

basedCIM

Tgrou

pis

comparedwith

the

othergrou

ps(p<0.05).

Effectiv

e

Gam

e-based

CIM

Twas

more

effectiv

eat

improvingstatic

balancecontrol

(AP-axisandsw

ayarea)and

weigh

tbearing

symmetry

comparedwith

the

othergrou

ps.

13Cho

iHS

etal.[27]

2019

Not

mentio

ned

Virtual

reality

game

Mob

ilizatio

nof

theup

per

limbs

Elbo

ws,

hand

s,wrists,

andfin

ger

RCT

36AgeM

�58.97:

male�

23and

female�

13

30min,1

5sessions

in5

weeks

Baselin

eand

postinterventio

nassessmento

nendof

5weeks

(edifference

betweentheGR

mirrortherapygrou

pversus

the

conv

entio

nalm

irror

therapyandcontrol

grou

pswas

statistically

significant(

p<0.05).

Effectiv

e

Itindicatedthat

GRdevice-based

mirrortherapyis

aninterventio

nthat

improves

upperextrem

ityfunctio

n,neck

discom

fort,a

ndqu

ality

oflife


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

14de

Paula

Oliveira

Tet

al.[28]

2015

Nintend

oWii

Fit

Virtual

reality

game

Balance

training

Not

mentio

ned

RCT

23AgeM

�50.21:

male�

13and

female�

10

30min,1

4sessions

in7

weeks

Baselin

eand

postinterventio

nassessmenton

1-weekATandat

a2-

mon

thFU

(eanalyses

ofthe

FMA-LEscoreat

FUforthecontrola

ndexperimentg

roup

are

21.39–24.58.

(e

analyses

ofthe

BESTestscoreat

FUforthecontrola

ndexperimentg

roup

are

75–83.

Effectiv

e

Balancetraining

performed

invirtualrealityby

usingNWFwas

moreeffi

cientthan

conv

entio

nal

balancetraining

15Givon

Net

al.[29]

2015

Nintend

oWii

Fit

Virtual

reality

game

Balance

training

Mob

ilizatio

nof

theup

per

limbs

Not

mentio

ned

RCT

47AgeM

�56.35:

male�

28and

female�

19

60min,2

sessions

ina

weekfor3

mon

ths

Baselin

eand

postinterventio

n,a

3-mon

thinterventio

nandat

3-mon

thfollo

w-up

Sign

ificant

improvem

ents

were

presentedin

both

grou

psforgaitspeed

(F�3.9,

p�0.02),

grip

streng

thof

the

weaker(F

�6.67,

p�0.002),a

ndstrong

erhand

s(F

�7.5,

p�0.001).

Daily

stepsand

functio

nala

bilityof

theweakerhand

did

notincrease

ineither

grou

p

Partly

effectiv

e

Video

andVR

games

can

prom

otemeasures

ofph

ysicalactiv

ityof

patientswith

chronicstroke.

16Hou

seG

etal.[30]

2016

(e

BrightArm

TM

Virtual

reality

game

Mob

ilizatio

nof

theup

per

limbs

Arm

,hand,

shou

lder,a

ndwrist

Before

andafter

trial

7AgeM

�69.7:

male�

5and

female�

2

45–50min,16

sessions

in8

weeks

Baselin

eand

postinterventio

n,on

each

boosterperiod

,each

consistingof

4sessions

over

2weeks

in8weeks

Rang

eof

motion

improved

for1

8ou

tof

23up

perextrem

itymovem

entvariables

(p�0.01)between

pretou

rnam

enta

ndpo

sttournament

assessments.

Effectiv

e

(eresults

indicate

that

BrightArm

iseffectiv

ein

improvingthe

rang

eof

motionof

theup

per

extrem

ity

17Hsie

hHC

[31]

2018

Not

mentio

ned

Video

game

Walking

Balance

training

Not

mentio

ned

RCT

56AgeM

�58.5:

male�

33and

female�

23

30min,3

.5ho

urs/week,

10weeks

Baselin

eand

postinterventio

n

(ecalculated

metrics

show

edthat

the

patientsin

the

interventio

ngrou

pshow

edsig

nificantly

bette

r10MWT

(p�0.033),the

CoP

APsw

ay(p

�0.01),andthe

sway

area

(p�0.006)

than

inthecontrol

grou

p.

Effectiv

e

(isgame

improves

exercise

complianceand

prom

otes

recovery

ofbalanceand

mob

ility

after

stroke.


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

18Hsie

hHC

[32]

2018

Not

mentio

ned

Video

game

Balance

training

Leg

RCT

54AgeM

�64.07

40min,3

sessions

in1

weekfor12

weeks

Baselin

eand

postinterventio

n

Sign

ificant

changesin

CoP

sway

kinematics

wereob

served

insw

aypath

(p�0.001),sway

area

(,p

�0.002),and

sway

velocity

(p�0.007).B

alanced

testsaretheBB

Stest:

p�0.001andTU

Gtest:p

�0.001),and

therewas

nosig

nificantc

hang

ein

theFA

BStest

Partly

effectiv

e

(isinno

vativ

egamingapproach

with

adaptiv

ePC

games

will

bea

useful

therapyfor

stroke

rehabilitation

19Huang

LLandChen

MH

[33]

2016

Gardening

digitalg

ame

Video

game

with

Kinect

Mob

ilizatio

nof

theup

per

limbs

Not

mentio

ned

Before

andafter

trial

10AgeM

�61.20:

male�

5and

female�

5

24sessions

inthreesessions

perweek

Baselin

eand

postinterventio

n

Fugl–M

eyer

Assessm

entof

motor

functio

n(in

creasesof

9.30);theBo

xand

BlockTestof

manual

dexterity

(increasesof

5.80);high

erfunctio

nal

independ

ence

measure

(increasesof

6.50);andrang

eof

motionmeasurement

oftheup

perextrem

ityproxim

a(in

creasesof

5.56)anddistal

(increasesof

3.83)

Effectiv

e

(egardening

digitalg

ameis

benefit

toim

prove

upperextrem

itymotor

functio

n.

20KhanRU

etal.[34]

2019

Not

mentio

ned

Video

game

Muscular

streng

thening

Fist,w

rist,and

forearm

Before

andafter

trial

5AgeM

�24:

male�

3and

female�

2

Not

mentio

ned

Baselin

eand

postinterventio

n

(escores

of3players

wereim

proved

upto

150,

171,

and172,

respectiv

ely,

for2

players,andthereis

notm

ainly

improvem

ent.

Partly

effectiv

e

(isresultshow

sthat

anattractiv

eenvironm

enta

ndreal-tim

efeedback

mechanism

can

improvethe

rehabilitation

process.

21Afsar

SIet

al.[35]

2018

Microsoft

Xbo

x360

Kinect

Virtual

reality

game

Mob

ilizatio

nof

theup

per

limbs

Shou

lder

and

elbo

wRC

T35

AgeM

�66.43:

male�

20and

female�

15

30min,p

erdayfor4

weeks

Baselin

eand

postinterventio

n

Fortheexperimental

grou

p,thechange

ofBB

T(pre-to-

postdifference)

scores

show

edasig

nificant

improvem

entwhen

comparedto

the

controlg

roup

(p�0.007),b

utthe

change

ofFM

A-U

EandtheFIM

scores

for

theexperimental

grou

pwereno

tsig

nificantly

high

er(p

�0.057,

p�0.677)

Partly

effectiv

e

(eKinect-based

gamesystem

inadditio

nto

conv

entio

nal

therapyhas

supp

lemental

effectiv

enessfor

stroke

patients.


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

22LeeMM

etal.[36]

2016

Canoe

game

Virtual

reality

game

Trun

kpo

stural

stability

Balance

training

Trun

kmuscles

and

leg

RCT

10AgeM

�65.7:

male�

5and

female�

5

30min

aday,

3sessions

aweekfor4

weeks

Baselin

eand

postinterventio

n

Improvem

ents

intrun

kpo

stural

stability,b

alance,and

upperlim

bmotor

functio

nwere

observed

intheEG

andCG,b

utwere

greaterin

theEG

.(e

meanSU

Sscores

intheEG

andTG

were

71±5.2and74.2±4.8,

respectiv

ely.

Effectiv

e

Canoe

game-based

virtualreality

training

isa

beneficial

interventio

nfor

improvingtrun

kpo

stural

stability,

balancetraining

,andup

perlim

bmotor

instroke

patients.

23LeeD

and

BaeY[37]

2019

DBIVG

Video

game

Trun

kpo

stural

stability

Walking

Trun

kandleg

RCT

21AgeM

�55.1:

male�

14and

female�

7

30min,1

2sessions

in4

weeks

Baselin

eand

postinterventio

n

(escores

ofTISssb,

TISd

sb,and

TIScofor

theinterventio

ngrou

pim

proved

upto

5.9,

6.18,and

3.0.(

escore

ofDGIisc

alculatedup

to17.27.

(escores

ofTW

TandTU

GT

decreasedup

to42.27

and39.32.

Effectiv

e

(eanalysis

demon

strated

DBIVG

can

improvetrun

kcontrola

ndgait

ability

inpatients

with

chronic

stroke.

24LeeSH

etal.[38]

2019

HTC

Vive

Virtual

reality

game

Mob

ilizatio

nof

theup

per

limbs

Hand,

shou

lder,

fingers,a

ndwrist

Before

andafter

trial

12AgeM

�40.2:

male�

7and

female�

5

30min,1

0sessions

2-3

times

aweek

Baselin

eand

postinterventio

n

Infiveparticipants,

scores

show

edim

provem

entbo

thin

ARA

TandBB

T.ARA

T(pretraining

22.3

andpo

sttraining

31.1),BB

T(pretraining

11.2

and

posttraining

19.6),and

MBI

(pretraining

90.4

andpo

sttraining

93.0)

Partly

effectiv

e

(isstud

yindicatesafully

immersiv

eVR

rehabilitation

program

canbe

used

forup

per

extrem

ityrehabilitationin

patientswith

chronicstroke

25McN

ulty

PAet

al.

[39]

2015

Nintend

oWii

Fit

Virtual

reality

game

Mob

ilizatio

nof

theup

per

limbs

Shou

lder,

elbo

w,a

ndwrist

RCT

41AgeM

�58:

male�

31and

female�

10

60min,1

0consecutive

weekd

ays

Prebaseline(14days

pretherapy),

baselin

e,po

stinterventio

n,andpo

stinterventio

naftersix

-mon

thfollo

w-up

(eWolfM

otor

Functio

nTest

(WMFT

-tt)im

proved

from

21to

17after

Wii-basedmovem

ent

therapy,

andMotor

Activity

LogQualityof

Movem

entScale

scores

improved

from

67.7to

102.4afterW

ii-basedmovem

ent

therapy.

Effectiv

e

(isresult

indicatedWii-

basedmovem

ent

therapyisan

effectiv

eup

per

limbrehabilitation

poststroke


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

26Nijenh

uis

SMet

al.

[40]

2016

MyoCI

Video

game

Muscular

streng

thening

Arm

and

hand

RCT

19AgeM

�60:

male�

10,and

female�

9

30min,6

sessions

ina

weekforsix

weeks

Prebaseline(one

weekbefore

training

),baselin

e,and1weekafter

training

(postin

terventio

n)andtwomon

ths

aftertheendof

training

follo

w-up

(econtrolg

roup

repo

rted

ahigh

ertraining

duratio

n(189

versus

118minutesper

week).N

odifferences

inclinical

outcom

esover

training

between

grou

pswerefoun

d(p>0.165).

Noeffectiv

e

Anextra

advantageof

this

arm

andhand

training

over

the

conv

entio

nala

rmandhand

exercises

atho

mewas

not

proven.

27Pa

quin

Ket

al.[41]

2015

Nintend

oWii

Fit

Virtual

reality

game

Mob

ilizatio

nof

theup

per

limbs

Hand,

finger,

andwrist

Before

andafter

trial

10AgeM

�72.1:

male�

10

15min,1

6sessions,2

sessions

per

week,

for8

weeks

Baselin

eand

postinterventio

n

Sign

ificant

improvem

ents

were

resultedwith

the

JHFT

,BBT

,and

NHPT

from

pretestin

gto

posttesting

(p�0.03,p

�0.03,

and

p�0.01,

respectiv

ely).A

nincrease

inQOLfrom

pretestin

gto

posttestingis

determ

ined

bytheSIS

(p�0.009).

Effectiv

e

Find

ings

demon

strated

impo

rtant

improvem

ents

occurred

between

pretestin

gand

posttestingon

4metrics.

28da

Fonseca

EPet

al.

[42]

2016

Nintend

oWii

Fit

Virtual

reality

game

Balance

training

Legs,arm

s,trun

k,andhip

RCT

27AgeM

�52.4:

male�

9and

female�

18

45min,2

0sessions

in3

mon

ths

Baselin

eand

postinterventio

n

(enu

mberof

falls

was

statistically

significant(

p�0.049)

only

inthetreatm

ent

grou

p.(

edifferences

ingaitbalancein

the

controlg

roup

(p�0.047)

isresulted.

Partly

effectiv

e

(erehabilitation

ofgaitbalancein

poststroke

peop

leapplying

virtual

reality

hadthe

redu

ctionof

falls.

29Ra

ndD

etal.[43]

2016

Microsoft

Xbo

x360

Kinect

Virtual

reality

game

Balance

training

Mob

ilizatio

nof

theup

per

limbs

Legs,

shou

lder,

elbo

w,a

ndfin

ger

RCT

24AgeM

�62:

male�

15and

female�

9

60min

aday,

6tim

es/w

eek

for5weeks

Baselin

e(anaverage

oftwoassessments)

and

postinterventio

n,andat

the4-week

follo

w-up

ARA

Textrem

ely

improved

by13.9%

and9.6%

follo

wingthe

videogames

and

tradition

alself-

training

programs.

(escores

fortheBo

xandBlockTest

were

20.6

and21.3

forpre

andpo

sttreatm

entin

theexperimental

grou

p.

Effectiv

e

Video

games

orself-training

programscanbe

appliedfor

practicerepetitive

upperextrem

itymovem

ents

with

outthe

supervision

ofa

clinician.


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

30Sh

inJH

etal.[44]

2015

RehabM

aster ™

Virtual

reality

game

Mob

ilizatio

nof

theup

per

limbs

Upp

erlim

bandtrun

kRC

T32

AgeM

�53.95:

male�

24and

female�

8

30min

for5

days

perw

eek

for4weeks

Baselin

eand

postinterventio

n

(escores

ofFM

A-

UE,

physical

functio

ning

were

improved

forpreand

post

treatm

ent

(experim

entalg

roup

)35.5up

to38.5

and15

upto

20.B

othgrou

psexhibitedsig

nificantly

improved

upper

extrem

ityfunctio

n(p

�0.001)

Effectiv

e

Results

indicate

that

game-based

VRrehabilitation

hasspecificeffects

onhealth-related

quality

oflifeand

upperextrem

ityfunctio

n

31Sh

inJH

etal.[45]

2016

(eRA

PAEL

SmartG

love™

Virtual

reality

game

Mob

ilizatio

nof

theup

per

limbs

Forearm,

wrist,fi

nger,

shou

lder,a

ndelbo

w

RCT

46AgeM

�58.5:

male�

36and

female�

10

30min,2

0sessions

for4

weeks

Baselin

eand

postinterventio

nin

themiddleof

the

treatm

ent

immediately

after

theinterventio

nand

1mon

thafterthe

interventio

n

(eim

provem

ents

inthegamegrou

pwere

supp

ortedby

significantFM

-total:

F�6.48,p

�0.006;

FM-prox:

F�5.73,

p�0.007;

FM-dist:

F�4.64,p

�0.024).

(eim

provem

ents

intheJTTtotal

inthe

gamegrou

pwas

supp

ortedby

significantJTTtotal:

F�4.073,

p�0.032)

Effectiv

e

(egamesystem

used

inVR-based

rehabilitation

might

bean

ideal

rehabilitationtool

forthe

distalup

per

extrem

ityin

stroke

survivors.

32StandenPJ

etal.[46]

2016

Nintend

oWii

Fit

Virtual

reality

game

Mob

ilizatio

nof

theup

per

limbs

Arm

,hand,

shou

lder,a

ndfin

ger

RCT

27AgeM

�61:

male�

16and

female�

11

20min,3

times

aday,

for8weeks

Baselin

eand

postinterventio

nfour

weeks

(midpo

int)andeigh

tweeks

(final)

(erewas

asig

nificantly

greater

change

from

baselin

ein

theinterventio

ngrou

pon

midpo

int

wolfM

FTstreng

th(in

terventio

ngrou

p:2.47;con

trol

grou

p:2.19),andtwo

subscalesof

thefin

alMotor

Activity

Logare

improved

(interventio

ngrou

p:12.80;

controlg

roup

:12.53)

Effectiv

e

(ereisagreater

improvem

ent

from

baselin

ein

theinterventio

ngrou

p,so

itis

effectiv

eto

usea

ndhelp

clinicians.

33Ra

ndD

etal.[47]

2015

Microsoft

Xbo

x360

Kinect

Virtual

reality

game

Balance

training

Mob

ilizatio

nof

theup

per

limbs

Not

mentio

ned

RCT

12AgeM

�63:

male�

7and

female�

5

60min,5

times

aweek

for5weeks

Prebaseline,

baselin

e,po

stinterventio

n,and4weeks

afterthe

interventio

n.

(escores

ofARA

Tfortheexperimental

game-basedgrou

pim

proved

from

30up

to40,also

theBo

xand

BlockTest

improved

forthisgrou

pfrom

25up

to30,and

standing

balanceim

proved

too

from

16pto

29.

Effectiv

e

(esevideogames

encouraged

upper

extrem

itymovem

ents

and

have

potentialto

prom

otestanding

balance.


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

34Kottin

kAIR

etal.

[48]

2014

Not

mentio

ned

Virtual

reality

game

Mob

ilizatio

nof

thelim

bsArm

and

hand

RCT

18AgeM

�61.4:

male�

13and

female�

5

30min,3

sessions

ina

weekfor6

weeks

Baselin

eand

postinterventio

n

ARA

andFM

improvem

ents

were

significantw

ithin

both

grou

ps(p≤0.009for

themaineffectfor

session),w

itheffect

sizes

(partia

leta

squared)

of0.47

and

0.53

fortheARA

test

andFM

assessment,

respectiv

ely.

Effectiv

e

(epresentstud

yshow

edthat

both

thearm

andhand

functio

nim

proved

aftertraining

.

35Ra

ndD

etal.[49]

2014

Microsoft

Xbo

x360

Kinect

Video

game

Mob

ilizatio

nof

thelim

bsUpp

erextrem

ityRC

T29

AgeM

�59:

male�

17and

female�

12

60min,2

sessions

per

weekfor3

mon

ths

Postinterventio

ndu

ring

thelast

mon

thof

the

interventio

nand1-2

weeks

follo

wingthe

sessions

Participants

inthe

VGG

performed

amedian(IQR)

of271

(157–490)activ

epu

rposeful

movem

entscompared

to48

(3–123)activ

epu

rposeful

movem

ents

intheTG

(z�.3.0,p

�0.001).

Partly

effectiv

e

Video

games

elicitedmoreUE

purposeful

repetitions

and

high

eracceleratio

nof

movem

ent

comparedwith

tradition

altherapy.

36Jordan

Ket

al.[50]

2014

Not

mentio

ned

Virtual

reality

game

Mob

ilizatio

nof

thelim

bsUpp

erlim

bBe

fore

andafter

trial

12AgeM

�68.6

45min,3

sessions

per

weekfor4–6

weeks

Baselin

e(t1),4

weeks

later(t2),

with

in1weekof

completingthe

interventio

n(t3),

andafin

alassessmentw

asgiven4weeks

later

(t4).

Nochange

inthe

FMA-U

Lscores

betweent1

andt2,

indicatin

gastable

baselin

e;asig

nificant

increase

intheFM

A-

ULscores

betweent2

andt3;a

significant

increase

intheFM

A-

ULscores

betweent2

andt4;and

nochange

intheFM

A-U

Lscores

betweent3

andt4

Effectiv

e

(einterventio

nim

proved

thearm

functio

nin

survivorsof

chronicstroke.

37FanSC

etal.[51]

2014

Nintend

oWii

Fit

Virtual

reality

game

Mob

ilizatio

nof

thelim

bsUpp

erarm

RCT

20AgeM

�64.4:

male�

14and

female�

6

60min,3

sessions

per

weekfor3

weeks

Baselin

eand

postinterventio

n(w

eek0),

immediately

after

treatm

ent(week4)

andfour

weeks

after

treatm

ent(week8).

Dun

n’spairwise

comparisonshow

edthat

TTPcontractions

intheWiigrou

pim

proved

significantly

morethan

that

ofthe

no-treatmentg

roup

(p<0.005).

Effectiv

e

Inthispilotstudy,

OTS

VRgaming

hadim

mediate

effects

onmotor

recovery

and

provided

motivationfor

treatm

ent

compliancein

stroke

patients.


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

38McEwen

Det

al.[52]

2014

IREX

Virtual

reality

game

Mob

ilizatio

nof

thelim

bsBa

lance

training

Lower

extrem

ityRC

T59

AgeM

�64.1:

male�

32and

female�

27

30min,d

aily

sessions

for3

weeks

Before,immediately

after,and1mon

thaftertraining

Moreindividu

alsin

thetreatm

entgrou

pthan

inthecontrol

grou

pshow

edredu

ced

impairmentin

the

lower

extrem

ityas

measuredby

the

Chedo

keMcM

aster

LegDom

ain

(p�0.04)

immediately

after

training

.

Effectiv

e

VRexercise

interventio

nfor

inpatient

stroke

rehabilitation

improved

mob

ility-related

outcom

es.

39Hun

gJW

etal.[53]

2014

Nintend

oWii

Fit

Video

game

Balance

training

Leg

RCT

28AgeM

�54.4:

male�

18and

female�

10

30min,2

sessions

per

weekfor12

weeks

Baselin

e,po

stinterventio

n,andat

3-mon

thfollo

w-up

At3

-mon

thfollo

w-up,

theim

provem

entin

TUG

andFR

testswas

maintained(tim

eeffectinTU

G,

p�0.03,p

artia

ls2

�0.17;F

Rp

�0.01,

andpartials

2�0.22),

buttherewas

anincreasedfear

offalling

inbo

thgrou

ps

Partly

effectiv

e

Exergamingis

enjoyableand

effectiv

efor

patientswith

chronicstroke.

40Norou

zi-

GheidariN

etal.[54]

2019

Jintron

ixsystem

Virtual

reality

game

with

Kinect

Mob

ilizatio

nof

thelim

bsUpp

erextrem

ityRC

T18

AgeM

�49.9:

male�

10and

female�

8

44min,2

-3sessions

per

weekfor4

weeks

Baselin

e,po

stinterventio

n,and4-weekfollo

w-

up

MAL-QOM

andbo

thmob

ility

andph

ysical

domains

oftheSIS

with

meandifference

of1.0%

,5.5%,a

nd6.7%

betweenthe

interventio

nand

controlg

roup

s,respectiv

ely)

atpo

stinterventio

n.

Partly

effectiv

e

Usin

gvirtual

reality

exergaming

techno

logy

may

bebeneficialtoup

per

extrem

ityfunctio

nal

recovery.

41Askın

Aet

al.[55]

2018

KineLabs

Virtual

reality

game

with

Kinect

Mob

ilizatio

nof

thelim

bsUpp

erextrem

ityRC

T38

AgeM

�55.0:

male�

27and

female�

11

60min,5

sessions

per

weekfor4

weeks

Baselin

eand

postinterventio

n

Differencesfrom

baselin

eof

FMA,M

I,andARO

M(except

addu

ctionof

the

shou

lder

and

extensionof

the

elbo

w)weregreaterin

grou

pA

(p<0.05).

Partly

effectiv

e

Kinect-basedVR

training

may

contribu

teto

the

improvem

ento

ftheUEmotor

functio

nand

ARO

Min

chronic

stroke

patients.

42Miranda

CSet

al.

[56]

2019

Nintend

oWii

Fit

Virtual

reality

game

Balance

training

Lower

limbs

RCT

29AgeM

�50.96:

male�

15and

female�

14

3sessions

for

1week.

Session1:

60min;

sessions

2and

3:30

min

Baselin

eand

postinterventio

n,1S

(firstsession),2

S(2

days

afterthe1

session),a

nd3S

(7days

afterthe1

session)

oftraining

.

(eanalyses

show

edon

lyasig

nificanteffect

forthesid

e(A

NOVA:

F�27.80,

p<0.001,

ES�0.99).

Partly

effectiv

e

Peop

leshow

edperformance

improvem

enta

fter

training

with

VR,

butthere

was

notransfer

ofthe

gainsob

tained

toan

untrainedtask

with

similar

balancedemands.


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

43Fernandes

ABet

al.

[57]

2014

“PaddlePa

nic

MiniG

ame”

Virtual

reality

game

with

Kinect

Mob

ilizatio

nof

thelim

bsUpp

erextrem

ityNon

rand

omized

clinical

trials

40AgeM

�50.75:

male�

20and

female�

20

Not

mentio

ned

Baselin

eand

postinterventio

n

Com

paring

the

participants’

performance

byANOVA,there

was

asig

nificantdifference

inthenu

mberof

hits

betweenthepatients

andhealthy

individu

als’grou

ps,

accordingto

thetrials

(p�0.008).

Effectiv

e

Patientswith

righ

tbraininjury

respon

dedbette

rto

thevirtual

reality

game.

44Moron

eG

etal.[58]

2014

Nintend

oWii

Fit

Video

game

Balance

training

Standing

Transferring

Facilitationof

movem

ents

Paretic

side,

upperlim

b,andleg

RCT

50AgeM

�60.16

20min,3

sessions

per

weekfor4

weeks

Baselin

eand

postinterventio

n(third

evaluatio

noccurred

onemon

thaftertheendof

rehabilitation)

Wiifit

training

was

moreeffectiv

ethan

usualb

alance

therapy

inim

provingbalance

(BBS

:53versus

48,

p�0.004)

and

independ

ency

inactiv

ityof

daily

living

(BI:98

versus

93,

p�0.021).

Effectiv

e

Balancetraining

with

gamewas

foun

dto

bemore

effectiv

ethan

conv

entio

nal

therapyalon

ein

improvingbalance

andredu

cing

disabilityin

patientswith

subacute

stroke.

45Noveletto

Fetal.[59]

2020

Mim

Pong

Video

game

Muscular

streng

thening

Lower

limb

Before

andafter

trial

11AgeM

�59.0:

male�

6and

female�

5

12min,2

sessions

per

weekfor10

weeks

Baselin

eand

postinterventio

n(three

alternatedays

attheendof

the

program)

Sign

ificant

effects

izes

(d)werefoun

dfor

QFG

streng

th(d

�0.5;

p�0.021),Q

FGcontrol(d

�1.1;

p<0.001),H

SGstreng

th(d

�1.1;

p�0.001),H

SGcontrol(d

�1.5;

p�0.003),fun

ctional

mob

ility

(d�0.3;

p<0.001),g

aits

peed

(d�0.4;

p�0.007),

andmotor

recovery

(d�1.0;

p<0.001).

Effectiv

e

Results

indicate

that

the

interventio

nof

aSG

with

both

the

prop

erapparatus

andevaluatio

nsystem

may

effectiv

ely

prom

otelower

limbmotor

rehabilitationof

hemipareticstroke

patients.

46Junior

VA

dosSet

al.

[60]

2019

Nintend

oWii

Fit

Virtual

reality

game

Mob

ilizatio

nof

thelim

bsBa

lance

training

Sensory

functio

nim

provem

ent

Upp

erlim

bandlower

limb

RCT

40AgeM

�55.6:

male�

23and

female�

17

50min,2

sessions

per

weekfor2

mon

ths

Baselin

eand

postinterventio

n(secon

dassessment

after2mon

thsof

treatm

ent)

Anim

provem

entin

themeanscores

was

observed

after

treatm

ent

independ

entof

the

allocatio

ngrou

pwith

significantintragroup

changes:14.5,1

0.5,

and10.4forPN

F,VR,

andPN

F/VR,

respectiv

ely.

Partly

effectiv

e

(euseof

aprogram

combining

virtual

rehabilitationand

PNFpresented

results

that

were

comparablewith

thoseob

tained

with

theiso

lated

techniqu

es.


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

47Cho

iDet

al.[61]

2018

Nintend

oWii

Fit

Virtual

reality

game

Balance

training

Walking

Lower

limb

RCT

28AgeM

�50.25:

male�

17and

female�

11

30min,3

sessions

per

weekfor6

weeks

Prebaseline,

baselin

e,and

postinterventio

n(1

weekbefore

and

aftertraining

)

WVRT

grou

pshow

edsig

nificant

improvem

ents

of+3

.00(5.25)

intheB

BSscoreand

−1.92

(6.33)

sintheTU

Gtest,w

ithallresults

being

significantly

bette

rthan

thoseof

theGBT

grou

p(p<0.05).

Effectiv

e

(eWVRT

was

auseful

program

for

improvingvisual

perceptio

nand

posturalbalancein

individu

alswith

chronicstroke.

48Bo

rstadAL

etal.[62]

2018

Recovery

rapids

Virtual

reality

game

with

Kinect

Mob

ilizatio

nof

thelim

bsUpp

erlim

bBe

fore

andafter

trial

16AgeM

�49:

male�

10and

female�

6

3ho

ursper

dayfor10

days

over

2weeks

Baselin

eand

postinterventio

n

(emean,

median,

andinterquartile

rang

eforwith

in-sub

jects

change

ontheWMFT

(rate/60

second

s)and

MAL-QOM

(0–5

scale)

were5.8(3.7),

5.8,

2.7–9.4and0.74

(0.66),0

.46,

0.28–1.11,

respectiv

ely.

Partly

effectiv

e

Favorablechanges

inperformance

speedandqu

ality

ofarm

usewere

foun

din

this

stud

y.

49Noveletto

Fetal.[63]

2018

MyB

alance

Video

game

Balance

training

Not

mentio

ned

Before

andafter

trial

18AgeM

�55.3:

male�

8and

female�

10

12minutes

perdayin

the

first

ten

sessions

and

20minutes

perdayin

the

remaining

sessions;2

sessions

per

weekfor10

weeks

Baselin

eand

postinterventio

n

Evaluatedou

tcom

eswerebette

rforallE

Gparticipants.(

eBB

Stest

show

edabalance

improvem

ento

f12.1±7.8%

with

alargeES

(0.9).(

efunctio

nalm

obility

assessed

bytheTU

Gtest

show

edan

improvem

ento

f15.1±7.4%

,but

ESwas

small(0.4).

Effectiv

e

(eresults

ofthis

stud

ysupp

ortthe

clinical

potential

ofabiom

edicalSG

forbalance

rehabilitationof

hemipareticstroke

patients.

50Carregosa

AA

etal.

[64]

2018

Nintend

oWii

Fit

Virtual

reality

game

Mob

ilizatio

nof

thelim

bsMuscular

streng

thening

Balance

training

Coo

rdination

Upp

erlim

bandlower

limb

Before

andafter

trial

5AgeM

�54.8:

male�

3and

female�

2

50min,2

sessions

per

weekfor2

mon

ths

Baselin

e,po

stinterventio

n,and8weeks

afterthe

treatm

ent

Descriptiv

edata

show

edan

improvem

entof

the

motor

functio

nof

the

upperlim

bitems

(26±19.5)andtotal

score(36.6±20.2)of

thescale.

Effectiv

e

(eresults

suggest

that

patientshad

motor

learning

retention,

achievinga

sustainedbenefit

throughthe

techniqu

e.


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

51Pa

rkJH

andPa

rkJH

[65]

2016

Nintend

oWii

Fit

Virtual

reality

game

Mob

ilizatio

nof

thelim

bsUpp

erextrem

ityRC

T30

Male�

16and

female�

14

30min,5

sessions

per

weekfor4

weeks

Baselin

eand

postinterventio

n(afte

r4weeks)

(ereweresig

nificant

differences

inthe

changesbetweenthe

twogrou

psin

theFM

(p<0.05),BB

T(p<0.05),andMAL-

QOM

(p<0.05).FM

pre:49.3

andFM

post:

54.4

(Fugl–Meyer

Assessm

ent)

Effectiv

e

Gam

e-based

virtualreality

movem

enttherapy

alon

emay

behelpfultoim

prove

functio

nal

recovery

ofthe

upperextrem

ity,

butthe

additio

nof

MPprod

uces

alarger

improvem

ent.

52HocineN

etal.[8]

2015

PRehab

Video

game

Mob

ilizatio

nof

thelim

bsUpp

erlim

bRC

T6

AgeM

�60.66:

male�

4and

female�

2

20min,for

2weeks

(3sessions)

Baselin

eand

postinterventio

n

Itrevealed

asignificant

effecto

fthe

difficulty

strategy

onpatient

performance

(Wilk

s’Lambd

a�0.10;

F�2.38;p<0.02).

Partly

effectiv

e

(eresults

ofthe

experimentshow

that

dynamic

adaptatio

ntechniqu

eincreases

movem

ent

amplitu

dedu

ring

atherapeutic

session.

53Bo

wer

KJ

etal.[66]

2014

Nintend

oWii

Fit

Not

mentio

ned

Balance

training

Mob

ilizatio

nof

thelim

bs

Upp

erlim

bandlower

limb

RCT

30AgeM

�63.6:

male�

17and

female�

13

45min,3

sessions

per

weekover

2–4weeks

Baselin

e,twoweeks,

andfour

weeks

Improvem

ents

were

observed

inthe

majority

ofsecond

ary

outcom

esover

timein

both

grou

ps.(

ebalancegrou

pparticipants

demon

stratedgreater

improvem

ents

inWii

balancebo

ard-derived

measuresw

ithsm

allto

largeeffects

izes

(d�0.30–1.00)

atfour

weeks

(p�0.007

−0.048).

Partly

effectiv

e

Specificactiv

ities

targeted

atbalance

training

are

potentially

effectiv

efor

improving

standing

balance.

54Brow

nEV

Det

al.

[67]

2014

Peggle

Video

game

Balancing

training

Upp

erextrem

ityRC

T9

AgeM

�60:

male�

5and

female�

4

45min,5

sessions

per

weekfor4

weeks

Baselin

eand

postinterventio

nassessments,

approxim

ately4

weeks

apart,before

system

use

Nodifferences

were

foun

dacross

timeon

anyof

theWMFT

subscalesor

the

CAHAI-9WMFT

functio

nala

ctivity

score:A1:1.79±0.71;

A2:1.77±0.68;A

3:1.79±0

.66

Noeffectiv

e

(isstud

yhad

limitedchangesin

kinematic

and

activ

itylevel

outcom

es


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

55Slijp

erA

etal.[68]

2014

Not

mentio

ned

Video

game

Mob

ilizatio

nof

thelim

bsUpp

erextrem

ityBe

fore

andafter

trial

11AgeM

�58:

male�

5and

female�

6

5weeks,

meantim

e:1070

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Baselin

e,du

ring

,po

stinterventio

n,andfollo

w-up1

6–18

weeks

afterthe

treatm

entph

ase

FMA-U

EA-D

(motor

functio

n)show

edsig

nificant

improvem

ents

inthe

upperextrem

ityfunctio

nbetween

baselin

e(A

1)and

posttest

(A2)

(0.005)

aswella

safollo

w-up

(<0.0001).Fu

gl–M

eyer

A-D

:preinterventio

n:44,intervention:

49,

postinterventio

n:51

Effectiv

e

(eresults

indicate

that

compu

tergame-

basedtraining

couldbe

aprom

ising

approach

toim

proveup

per

extrem

ityfunctio

n.

56ChenCC

etal.[69]

2017

Not

mentio

ned

Virtual

reality

game

Muscular

streng

thening

Mob

ilizatio

nof

thelim

bs

Upp

erlim

bBe

fore

andafter

trial

21AgeM

�55.7:

male�

14and

female�

7

60min,3

sessions

per

weekfor8

weeks

Baselin

eand

postinterventio

n

(estatistical

results

confi

rmed

asignificant

effecto

ftreatment.

FMA:b

aseline:

30.35±13.8.A

fter

interventio

n:38.80±14.61

Effectiv

e

Find

ingsuggests

that

VR-based

rehabilitationcan

indu

cesig

nificantly

kinetic

changes

than

facilitate

recovery.

57LeeMM

etal.[70]

2018

Nintend

oWii

Fit

Virtual

reality

game

Balance

training

Mob

ilizatio

nof

thelim

bs

Upp

erextrem

ityRC

T30

AgeM

�61.56:

male�

18and

female�

12

30min,3

sessions

per

week,

for5

weeks

Baselin

eand

postinterventio

non

edayafterthefive-

weekinterventio

nperiod

MFT

was

significantly

improved

inbo

thgrou

pscomparedwith

baselin

evalues

(p<0.05).Pre:

8.93±1.53;p

ost:

11.40±2.47

Effectiv

e

Gam

e-basedVR

Canoe

padd

ling

training

isan

effectiv

erehabilitation

therapythat

enhances

postural

balanceandup

per

extrem

ityfunctio

n.

58Pa

rkDS

etal.[71]

2017

Microsoft

Xbo

x360

Kinect

Virtual

reality

game

with

Kinect

Mob

ilizatio

nof

thelim

bsBa

lance

training

Motor

functio

n

Lower

extrem

ityRC

T20

AgeM

�63.65:

male�

10and

female�

10

30min,d

aily

sessions

fora

6-week

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Baselin

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postinterventio

n

(epre-to-post

differencescores

onBB

S,TU

G,and

10mWTforthe

interventio

ngrou

pweresig

nificantly

moreim

proved

than

thoseforthecontrol

grou

p(p<0.05).

Effectiv

e

Evidence

supp

orts

theuseof

additio

nalV

Rtraining

with

the

Xbo

xKinect

gamingsystem

asan

effectiv

etherapeutic

approach

for

improvingmotor

functio

n.

59Pa

rkJS

etal.[72]

2019

Not

mentio

ned

Video

game

Muscular

streng

thening

Motor

functio

n

Hand

RCT

43AgeM

�59.43:

male�

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30min,5

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per

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n

Afte

rtraining

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th,M

FT,a

ndBB

Twereim

proved

intheexperimental

grou

pcomparedto

the

controlg

roup

(P<0.001,

both).

MFT

:pre:12.91±5.73;

post:16.23±5.95

Effectiv

e

Gam

e-based

exercise

ismore

effectiv

ethan

manualexercise

inim

provingmuscle

streng

th,m

otor

functio

n,and

compliancein

stroke

patients.


Tabl

e2:

Con

tinued.

No.

Autho

rsYe

arNam

eof

gamificatio

napproach

Type

ofgamificatio

napproach

Type

ofrehabilitation

Rehabilitated

target

mem

bers

Stud

ydesig

nSample

size

Sample

description

(sex,age

(year))

Session

details

Assessm

enttim

eAssessm

entscore

Effectiv

eness

Results

60Ahm

adi

HSet

al.

[73]

2019

E-Link

Virtual

reality

game

Mob

ilizatio

nof

thelim

bsUpp

erlim

bNon

rand

omized

clinical

trials

30AgeM

�55.24:

male�

20and

female�

10

40min,3

sessions

per

week,

for4

weeks

Baselin

eand

postinterventio

n

(efin

ding

show

sthe

improvem

ento

fupp

erlim

bmotor

functio

n,tone,a

ndrang

eof

motionin

thisgrou

p.Meandifferences:

FMA

(total

score);

interventio

n:6.53;

control:3.86

Effectiv

e

Com

putergames

canim

proveu

pper

limbmotor

functio

n,muscle

tone,and

the

rang

eof

motionin

stroke

patients.

FMA-U

E,Fu

gl–M

eyer

Assessm

entfor

Upp

erEx

trem

ity;W

MFT

,WolfM

otor

Functio

nTest;IMI,Intrinsic

MotivationInventory;IA

DL,Lawtonof

instrumentalactivities

ofdaily

living;SIS,Stroke

ImpactScale;

B-stage,brainstorm

stage;MMT,

manualm

uscletesting;AP-axis,

anterior-posterior

axis;

CIM

T,constraint-in

ducedmovem

enttherapy;G

R,gesturerecogn

ition

;NWF,Nintend

oWiiFitT

Mgame;FU

,follow-up;

FMA-LE,

Fugl–M

eyer

Assessm

ent;BE

STest,Ba

lanceEv

aluatio

nSystem

sTest;A

T,aftertraining

;10M

WT,

10-m

eter

testof

walking

score;CoP

,centerof

pressure;A

Psw

ay,sway

kinematicsin

theanterior-

posterior;BB

S,theBe

rgBa

lanceScale;FA

BS,F

ullerton

AdvancedBa

lanceScale;TU

G,T

imed

UpandGo;

FM,F

ugl–Meyer;A

RA,A

ctionRe

search

Arm

;UE,

upperextrem

ity;V

GG,video

gamegrou

p;TG

,tradition

algrou

p;IQ

R,interquartile

rang

e;FM

A-U

L,Fu

gl–M

eyer

upperlim

itassessment;OTS

VR,

off-the-shelfvirtualreality;

TTP,

time-to-peak;

VR,

virtualreality;

FR,forwardreach;

MAL-QOM,M

otor

Activity

LogQualityof

Movem

ent;FM

A,F

ugl–Meyer

Assessm

ent;MI,Motricity

Index;ARO

M,activerang

eof

motion;

BI,B

arthelIndex;SG

,serious

games;Q

FG,quadricepsfem

oris;

HSG

,ham

string

s;PN

F,prop

rioceptiv

eneuromuscularfacilitatio

n;WVRT

,WiiFitvirtualreality

training

;GBT

,generalbalancetraining;EG

,experim

entalgroup

;ES,effectsizes;B

BT,B

oxandBlockTest;M

P,mentalpractice;CAHAI-9,

Chedo

keArm

andHandActivity

Inventory-9;

MFT

,manualfun

ctiontest;R

CT,

rand

omized

controlledtrialo

rrand

omized

controltrial.


According to results, emerging games possess the capacityand potential to rehabilitate physical aspects in poststrokepatients; furthermore, these games can help patients im-prove their independence. According to surveys, virtualreality-based approaches and “the Nintendo Wii Fit” gameswere used more than other games. (e most common use ofgames in poststroke survivors’ rehabilitation was related tolimb movement and balance training.

Due to the included studies’ results, different indicatorsand scales have been calculated and statistically analyzed toevaluate and test game-based physical rehabilitation ther-apies for poststroke patients. (ese statistical analysesdemonstrated the positive effect of innovative rehabilitationis provided in the form of games for these patients. Even inmany studies, applied games in different environments

(virtual reality, and video-based games) have led to a greatimprovement in patients’ physical problems such as balancedisorder, upper extremity spasticity, and limbs’ immobilityand muscular weakness [3, 5, 11, 74–77]. Researchers inthese studies have concluded that they can incorporate thesegames into the treatment plan and physiotherapy of post-stroke patients and use them as alternative therapies totraditional methods because, in these experimental studies,significant improvements in all outcome measures werefound after the intervention [76, 78]. However, in infrequentarticles, no significant differences can be observed in allassessment scales (baseline and post-intervention assess-ments in the experimental and control groups) to evaluategame-oriented physiotherapies’ effectiveness. For this rea-son, in these studies, the researcher has concluded that the

Table 3: Distribution of studies based on publication type.

Journal/conference name Conference JournalClinical Rehabilitation 5Journal of Stroke and Cerebrovascular Diseases 4Archives of Physical Medicine and Rehabilitation 4Games for Health Journal: Research, development, and clinical applications 4Disability and Rehabilitation 2Journal of NeuroEngineering and Rehabilitation 2NeuroRehabilitation 2IEEE Transactions on Neural Systems and Rehabilitation Engineering 2International Journal of Environmental Research and Public Health 2Journal of Medical and Biological Engineering 1International Medical Journal of Experimental and Clinical Research 1American Journal of Physical Medicine and Rehabilitation 1Computers in Biology and Medicine 1Journal of Central Nervous System Disease 1BioMed Research International 1Brain Impairment 1European Journal of Physical and Rehabilitation Medicine 1User Modeling and User-Adapted Interaction 1Frontiers in Psychology 1Iranian Rehabilitation Journal 1Journal of Physical (erapy Science 1Journal of Healthcare Engineering 1Annals of Physical and Rehabilitation Medicine 1Journal of Motor Behavior 1American Academy of Physical Medicine and Rehabilitation 1Journal of Patient-Centered Research and Reviews 1Restorative Neurology and Neuroscience 1Stroke 1Medical Science Monitor 1Neurorehabilitation and Neural Repair 1Somatosensory and Motor Research 1(e Journal of Physical (erapy Science 1International Journal of Stroke 1Virtual Reality 1International Journal of Neuroscience 1In Proceedings of the 3rd 2015 Workshop on ICTs for improving Patients Rehabilitation Research Techniques 2Proceedings of the IEEE International Conference on Advanced Materials for Science and Engineering 1In 2019 International Conference on Robotics and Automation in Industry 12019 Fifth International Conference on Advances in Biomedical Engineering (ICABME) 1International Conference on Virtual Rehabilitation 12017 International Conference on Applied System Innovation (ICASI) 1Total 7 53


game chosen to rehabilitate poststroke patients cannot be auseful tool to alternate with the traditional physical reha-bilitation methods, and applying them can destroy the pa-tient’s time and motivation.

(e reason for the ineffectiveness of newly emergedgames for motor rehabilitation of stroke patients can havedifferent reasons as follows: insufficient session times andtraining duration to generate consistent improvements in allpatients, the insufficient number of participants in the ex-perimental studies (randomized trails would require at least

25 participants in each group) [38, 76], the high mean age ofpatients in both intervention and control groups (underlyingdisability of people due to their age), and excessive move-ment limitations of the patients recruited in the study[79, 80].

According to this study’s results, the most popular typeof game for physical rehabilitation of poststroke patients wasvirtual reality games. Virtual reality-based games allowpatients to interact with a virtual environment while per-forming rehabilitation exercises and simulating real

Table 4: Distributions of studies of publication years and country.

Row labelsColumn labels

2013 2014 2015 2016 2017 2018 2019 2020 TotalAustralia 1 1 2Brazil∗ 1 2 1 2 2 1 9Canada 1 1 1 3China 1 1France 1 1 2Iran 1 1Israel 1 2 1 4Italy 1 1 2Lebanon 1 1Malaysia 1 1Netherlands 1 1 2New Zealand 1 1Pakistan 1 1Republic of Korea∗ 1 4 2 2 4 13Spain 1 1Sweden 1 1Taiwan∗ 1 1 1 2 1 6Turkey 1 2 3UK 2 2USA 1 1 1 1 4Grand total 1 10 9 11 3 9 13 4 60∗3 countries with the highest number of study prints.

1

13

5

1535

Not mentionedMixed reality gameVideo game withkinect

Virtual reality gamewith kinectVideo gameVirtual reality game

Figure 3: (e distribution of studies based on gamification types.


1 11 1 11

1 1 1 12

6 1

1 1 1 1 1 1

19

5

3

1 1 1 1 1 1 1 10

5

10

15

20

25

�e N

inte

ndo

Wii

Fit

Not

men

tione

d�

e Xbo

x 36

0°E-

Link

Reha

bMas

terTM

Gar

deni

ng d

igita

l gam

ePR

ehab

HTC

Viv

eD

BIVG

IREX

MyB

alan

ceM

yoCI

Padd

le P

anic

Min

i Gam

eJin

troni

x sy

stem

Pegg

leKi

nect

2Scr

atch

Reco

very

Rap

ids

Kine

Labs

�e B

right

Arm

TM

Mic

roso

� de

velo

ped

Robo

Raid

�e R

APA

EL S

mar

t Glo

veTM

Mim

Pong

Cano

e gam

eM

oU-R

ehab

Virtual reality gameVideo gameVirtual reality game with kinect

Video game with kinectMixed reality gameNot mentioned

Figure 4: (e distribution of studies based on type and name of games.

Mobilization of the limbsLower extremityWalkingMuscular strengthening

Balance trainingTrunk postural stabilityStandingPostural control

Mobilization of the armsSensory function improvementCoordinationMotor function

Mobilization of the limbs,24 Balance training, 23Walking,

4

Muscular strengthening,8

Motorfunction, 5

Trunkpostural

stability, 2Postural

control, 2

Mobilization of...

Sensoryfuncti...

Lowerextre...

Standing, 1

Coordinat...

Figure 5: Physical rehabilitation therapies in reviewed studies.


functions. (ese games increase patients’ motivation toperform rehabilitation exercises and provide a pleasantenvironment for patients, which can lead to more repetitionof rehabilitation exercises in these patients [77]. People getfeedback while playing virtual reality games, and this factorencourages patients with disabilities to attend therapy ses-sions and use their remaining functional capacity to succeedin the game [81].

Results have shown that “the Nintendo Wii Fit” gamesare used more than other games to rehabilitate poststrokepatients. Several factors can lead to the most use of thisgame. Among these factors, we can mention the price ofthese games, which are relatively inexpensive. (ese gamesare 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 thestimulation of people’s interest in continuing to play andcan be useful for improving motor function and balancecontrol [61].

Studies showed that the most common use of games inthe rehabilitation of stroke survivors was related to limbmovement and balance training. In other words, the resultsof studies that were run to examine the effect of games onpeople after a stroke had shown these games were effective inimproving the balance of people and strengthening themuscles of the limbs [85]. In a systematic review conductedby Corbetta, the effectiveness of virtual reality games has

Table 5: Distribution of studies based on the type of study and effectiveness.

Row labels EffectivenessEffective 41Before and after trial 13Nonrandomized clinical trials 2RCT 26

Not effective 3RCT 3

Partly effective 16Before and after trial 3RCT 13

Total 60

0

1

2

3

4

5

6

13.5 1 14 3

17.8

3 18 5.5 20 8.6 21

10.5 25 90

31.5 8.8

34.4

17.

5 351.

25 56 15 26 30 822

.5 613

.3 24 7no

t men

tiend 5 12 4 9 10

Figure 6: (e distribution of studies based on the total time of rehabilitation duration.

41

316

Effective

No effectivePartly effective

Total

Figure 7: (e distribution of the reviewed studies based on effectiveness.


been investigated and concluded that managed games havethe most significant impact on patient mobility [75].According to the results of this survey and other studies thatshow the effect of the game on maintaining balance andmovement, it is recommended to use these games inpoststroke survivors.

(is systematic review had several strengths and limi-tations. One of the strengths was the use of broad keywordsto search in 4 crucial databases. Another strength of thissurvey was the inclusion of studies presented at conferences.(e limitations were the exclusion of articles in non-Englishlanguage and the time limit imposed on searching databases(from 2014 onwards). Another limitation of this review wasthe different scales used to measure people’s performance,and this factor made it difficult to compare the results ofdifferent surveys.

5. Conclusion

Game-based approaches lead to patients being able tosmoothly perform their rehabilitation movement techniqueswithout going to the treatment centers. (ese games canimmerse the person in the environment by providing virtualor augmented reality capabilities and multiplying the ef-fectiveness of the treatment. (erefore, the use of appro-priate technology-based gaming solutions can improvepatients’ treatment and minimize the waste of time and costof providing traditional motor rehabilitation. Consequently,these game-based treatments are considered complementaryto traditional ones and can reduce the workload of therapistsand accelerate the rehabilitation process. Future researchshould focus on how task-specific game-oriented systemscan improve function after stroke, and statistical studies canshow this effect more.

Data Availability

All data generated or analyzed during this study are includedwithin this article.

Conflicts of Interest

(e authors declare that there are no conflicts of interest.

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