The efficacy of virtual reality interventions compared with conventional physiotherapy in improving the upper limb motor function of children with cerebral palsy: a systematic review of randomised controlled trials

Figures & data

Figure 1. PRISMA flowchart for the selection process.

Process of the systematic literature review and reasons for excluded studies.

Table 1. Characteristics of the included studies.

Author (location)	Diagnosis total number (n female)	Intervention group age (years) (mean ± SD)	Control group age (years) (mean ± SD)	Outcome tools	Results
Acar et al. [30] (Turkey)	Unilateral CP 30 (16)	Nintendo^® Wii plus NDT (45 min a session; 2 days a week for 6 weeks). (9.5 ± 3.1)	NDT only (45 min a session; 2 days a week for 6 weeks). (9.7 ± 2.8)	(a) QUEST, (b) JTHFT, (c) ABILHAND-Kids test, and d) Pediatric Functional Independence Measure (self-care)	Intervention and control groups had the same improvements on the above measures.
Avcil et al. [31] (Turkey)	Unilateral & bilateral CP 30 (13)	VGBT using Nintendo ^® wii and LMC games (1 h per session; 3 days a week for 8 weeks). (10.9 ± 4.1)	NDT-based upper extremity therapy (1 h per session; 3 days a week for 8 weeks). (11.1 ± 3.2)	MMDT, CHAQ, DEI and grip and pinch strengths using a dynamometer.	The effects of both treatment programs on grip strengths and functional ability were similar beneficial.
El-Shamy [32] (Saudi Arabia)	Unilateral CP 30 (10)	Armeo robotic therapy (for upper limb − 45 min a session; 3 days a week for 12 weeks). (6.9 ± 0.8)	Conventional exercises (45 min a session; 3 days a week for 12 weeks). (6.8 ± 0.7)	MAS and QUEST	The study group showed significant improvement in the mean values of all the measured variables, compared to those in the control group (p < 0.05).
El-Shamy & El-Banna [15] (Saudi Arabia)	Unilateral CP 40 (14)	Wii training plus conventional exercises (40 min a session; 3 days a week for 12 weeks). (9.5 ± 1.2)	Conventional exercises (40 min a session; 3 days a week for 12 weeks). (9.8 ± 1.4)	MAS, hand-held dynamometry, and PDMS-2	The intervention group had: a decrease in the spasticity by 0.4 out of 4.0 (95% CI 0.1 to 0.8); power grip strength increased by 1.6 kg (95% CI 0.7–2.5) and pinch grip strength by 1.2 kg (95% CI 0.8–1.6); and Hand function (compared to the control group) increased by 6 out of 52 (95% CI 5–7).
Sajan et al. [33] (India)	Spastic diaplegic/triplegic/quadriplegic CP 20 (9)	Wii games (boxing and tennis) for 45 min a session; 6 days a week for 3 weeks. Conventional exercises (Swiss ball exercises, visual-perceptual skills (e.g., ball throwing catching) and graded mobility training)	Conventional exercises (Swiss ball exercises, visual-perceptual skills (e.g., ball throwing and catching) and graded mobility training). No information regarding the conventional exercises’ frequency and intensity.	Static posturography PBS; Box and Block Test; QUEST and TVPS	Significant improvement in upper limb functions was seen in the intervention group but not in the control group. For the other outcomes, there were no significant differences between the two groups.
Tarakci et al. [34] (Turkey)	Spastic and dyskinetic CP 30 (13)	LMC-based training (1 h a session; three sessions a week for 8 weeks). (10.9 ± 4.1)	Conventional exercises (1 h a session; three sessions a week for 8 weeks). (11.1 ± 3.2)	DHI, JTHFT, 9HPT, CHAQ, and a dynamometer.	After treatment, significant differences were found in CHAQ, DHI, JTHFT, 9HPT, and grip and pinch strength scores in almost all groups.
Zoccolillo et al. [35] (Italy)	Hemiparetic CP 22 (not stated)	VGT (1 h a session; 2 days a week for 8 weeks). (6.8 ± 1.9)	NDT (1 h a session; 2 days a week for 8 weeks). (6.8 ± 1.9)	QUEST and ABILHAND-Kids test	QUEST scores significantly improved in the VGT period (p = 0.003, from 76 ± 21 to 81 ± 20), but not in CT (p = 0.056). Both these improvements, of about 5 QUEST points after VGT and of about 2 Abilhand points achieved the respective minimal clinically important differences.

Abbreviations: CP: cerebral palsy; CT: conventional therapy; CI: confidence interval; SD: standard deviation; VGBT: video game-based therapy; LMC: leap motion controller; NDT: neurodevelopmental therapy; MMDT = Minnesota Manual Dexterity Test; CHAQ: Childhood Health Assessment Questionnaire; DHI: Duruoz Hand Index; 9HPT: nine-hole peg test; BOTMP-SF: Bruininks-Oseretsky Test of Motor Proficiency-Short Form; QUEST: Quality of Upper Extremity Skills Test; JTHFT: Jebsen Taylor Hand Function Test; PDMS-2: Peabody Developmental motor scale-2nd edition; MAS: Modified Ashworth Scale; PBS: The paediatric Berg’s balance scale; TVPS: Test for Visual-Perceptual Skills.

Figure 2. Risk of bias assessment.

Reviewers’ judgment by the Cochrane collaboration’s risk of bias tool about the potential risk of bias within the seven randomised trials against five different appraisal domains.

Figure 3. Albatross plot of QUEST.

The results of four randomised trials on the upper limb function that assessed by the Quality of Upper Extremity Skills Test. Effect contours show an estimate of the effect sizes from the trials and whether there is a positive effect (right direction), a negative effect (left direction), or no effect (in the middle). Each dot inside the plot represents a subtest of the outcome measure.

Figure 4. Albatross plot of Grip strength.

The results of three randomised trials on the grip strength as an outcome measure. Effect contours show an estimate of the effect sizes from the trials and whether there is a positive effect (right direction), a negative effect (left direction), or no effect (in the middle). Each dot inside the plot represents a specific type of grip.

Table 2. Certainty of the evidence (GRADE).

	Certainty assessment						No. of patients		Certainty	Comments
No. of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other consideration	Intervention	Control	Overall score
QUEST (follow-up: mean 12 weeks; assessed with Questionnaire)
4	Randomised trials	Very serious^a	Very serious^b	Not serious^c	Very serious^c,d	None	51	51	⊕⊝⊝⊝ VERY LOW	The evidence is very uncertain about the effect of VR interventions on QUEST outcomes.
Grip strength (assessed with hand-held dynamometry)
3	Randomised trials	Very serious^a	Not serious^b	Not serious^c	Very serious^c,d	None	50	50	⊕⊝⊝⊝ VERY LOW	The evidence is very uncertain about the effect of VR interventions on grip strength outcomes.

Abbreviation: QUEST: quality of upper extremity skills test.

Explanations:

^aJudged “High” using Cochrane Risk of Bias 2.

^bDowngraded two levels. Methodological diversity between populations and interventions. Unable to pool in meta-analysis due to variability in reporting (i.e., some studies reported sub tests and/or total scores). Effect sizes between studies were very diverse.

^c<400 participants in the analysis (Ryan, 2016).

^dImprecise estimate due to large variability in effect sizes between studies.

Table

Section and Topic	Item #	Checklist item	Page where item is reported
TITLE
Title	1	Identify the report as a systematic review.	2
ABSTRACT
Abstract	2	See the PRISMA 2020 for Abstracts checklist.
INTRODUCTION
Rationale	3	Describe the rationale for the review in the context of existing knowledge.	3
Objectives	4	Provide an explicit statement of the objective(s) or question(s) the review addresses.	4
METHODS
Eligibility criteria	5	Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses.	5
Information sources	6	Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted.	4 & 5
Search strategy	7	Present the full search strategies for all databases, registers and websites, including any filters and limits used.	5
Selection process	8	Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.	5 & 6
Data collection process	9	Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.	5 & 6
Data items	10a	List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g., for all measures, time points, analyses), and if not, the methods used to decide which results to collect.	5 & 6
	10 b	List and define all other variables for which data were sought (e.g., participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information.	8
Study risk of bias assessment	11	Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.	6
Effect measures	12	Specify for each outcome the effect measure(s) (e.g., risk ratio, mean difference) used in the synthesis or presentation of results.
Synthesis methods	13a	Describe the processes used to decide which studies were eligible for each synthesis (e.g., tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).	5
	13 b	Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.
	13c	Describe any methods used to tabulate or visually display results of individual studies and syntheses.	7
	13d	Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.	7
	13e	Describe any methods used to explore possible causes of heterogeneity among study results (e.g., subgroup analysis, meta-regression).
	13f	Describe any sensitivity analyses conducted to assess robustness of the synthesized results.
Reporting bias assessment	14	Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).	7
Certainty assessment	15	Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.	7
RESULTS
Study selection	16a	Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.	7 & 8
	16 b	Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.	8
Study characteristics	17	Cite each included study and present its characteristics.	8
Risk of bias in studies	18	Present assessments of risk of bias for each included study.	8
Results of individual studies	19	For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g., confidence/credible interval), ideally using structured tables or plots.	9
Results of syntheses	20a	For each synthesis, briefly summarise the characteristics and risk of bias among contributing studies.	9
	20b	Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g., confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect.	9
	20c	Present results of all investigations of possible causes of heterogeneity among study results.
	20d	Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.
Reporting biases	21	Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.
Certainty of evidence	22	Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.	9
DISCUSSION
Discussion	23a	Provide a general interpretation of the results in the context of other evidence.	9
	23b	Discuss any limitations of the evidence included in the review.	12
	23c	Discuss any limitations of the review processes used.	12
	23d	Discuss implications of the results for practice, policy, and future research.	9,10,11,12
OTHER INFORMATION
Registration and protocol	24a	Provide registration information for the review, including register name and registration number, or state that the review was not registered.	4
	24b	Indicate where the review protocol can be accessed, or state that a protocol was not prepared.	4
	24c	Describe and explain any amendments to information provided at registration or in the protocol.
Support	25	Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review.	13
Competing interests	26	Declare any competing interests of review authors.	13
Availability of data, code  and other materials	27	Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review.

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