Video Game Training – Upper Extremity

Evidence Reviewed as of before: 21-10-2017
Author(s): Tatiana Ogourtsova, PhD Cand MSc BSc OT; Cristina Beloborodova, MSc OT; Annabel McDermott OT; Annie Rochette, PhD OT; Adam Kagan BSc; Dr. Nicol Korner-Bitensky PhD OT
Patient/Family Information Table of contents

Introduction

Video game training refers to the use of commercially available video game consoles (e.g. Nintendo WiiTM, Sony PlayStation EyeToy, Microsoft XBox Kinect) for post-stroke rehabilitation.

Video gaming has the potential to be beneficial as it is affordable, designed to be entertaining and fun, can be used at home, individually or in groups (e.g. pairs), and can provide repetitive exercises with increases in level of difficulty. Before recommending the use of video game training as a common clinical technique for upper limb rehabilitation, it is important to understand the current evidence on its effectiveness.

The present module includes studies that examined the use of commercially available video game consoles for upper limb rehabilitation. Studies that did not report on any upper limb related outcomes were excluded. Similarly, studies that were not randomized clinical trials (RCTs) or poorly designed quasi-experimental studies were excluded.

Currently, eleven RCTs and one well designed quasi-experimental study have investigated the effect of upper limb rehabilitation using commercially available video game consoles. Eight RCTs are of high quality and three are of fair quality.

Patient/Family Information

What is video game training?

Video game training refers to the use of commercially available video game consoles (e.g. Nintendo WiiTM, Sony PlayStation EyeToy, Microsoft XBox Kinect) for post-stroke rehabilitation. After a stroke, the patient can use the gaming system in different ways during rehabilitation, to help improve motor function and motor recovery. The video game systems include hand-held devices and/or pressure sensitive footpads that respond to the patients motion in real-time. Games are typically based around sports and exercise (e.g. tennis, golf, bowling, yoga, dancing etc.), although some games involve daily activities such as cooking.

Nintendo Wii.

Nintendo Wii
Photo courtesy of the Wikimedia Commons, a freely licensed media file repository.

Sony Playstation Eyetoy.

Sony Playstation Eyetoy
Photo courtesy of the Wikimedia Commons, a freely licensed media file repository.

Example of a hand held controller.

Hand held controller
Photo courtesy of Wii-based Movement Therapy from the McNulty group at NeuRA, Australia.

Example of a pressure sensitive foot-pad.

Pressure sensitive foot-pad
Photo courtesy of the Wikimedia Commons, a freely licensed media file repository.

Why use video game training after a stroke?

It is common for individuals to experience loss of movement and strength after a stroke. Difficulties with movement and muscle weakness can impact on the patient’s ability to use his/her arm and hand. Video game training can be a fun and motivating way to improve arm and hand strength and motor function. The video games use visual images that respond to movement made by the patient while he/she is playing the game. These visual images provide the patient with immediate feedback about his/her body movements. The patient can then adjust or adapt his/her movements in response to this visual feedback. This visual feedback has been shown to help with motor learning and motor recovery following stroke.

The patient’s rehabilitation team will identify some video game exercises that will help him/her with the difficulties caused by the stroke. The patient can practice these video game exercises in hospital, and can continue to practice at home after he/she has been discharged from hospital.

Does it work for stroke?

Researchers have studied how video game training can help stroke patients:

In individuals with ACUTE stroke (up to 1 month after stroke), 1 fair quality study found that video game training:

  • Was as helpful as another treatment for improving self-care skills (e.g. dressing and bathing), pain, and physical skills of the arms.

In individuals with SUBACUTE stroke (1 month to 6 months after stroke), no studies up to date have investigated the effects of video game training.

In individuals with CHRONIC stroke (more than 6 months after stroke), 3 high quality studies, 1 fair quality study and 1 non-randomized study found that video game training:

  • Was more helpful than the usual treatment alone for improving dexterity, motivation, arms range of motion, arms activity,
  • Was as helpful as other treatments for improving self-care skills (e.g. dressing and bathing), grip strength, quality of life, physical skills of arms and legs, walking activity level and walking speed.

In individuals with stroke (acute, subacute and/or chronic), 5 high quality studies and 1 fair quality study found that video game training:

  • Was more helpful than the usual treatment alone for improving dexterity, motivation, arms range of motion and arms activity.
  • Was as helpful as other treatments for improving self-care skills (e.g. dressing and bathing), dexterity, cognitive function (e.g. memory), grip strength, quality of life, range of motion, spasticity, physical skills and activity of the arms.

Side effects/risks?

No real risks have been reported as long as you remember to pace your activity level. It is important to try each activity for a short time the first time and see how your muscles feel the next day. Pacing yourself and building up your tolerance is important. So take your time, try out activities slowly and then add in new activities once you have an idea of which activities seem to be best for you.

Who provides the treatment?

It is important to speak to an occupational therapist or physical therapist before beginning video game training after a stroke. He or she can help you to decide which video game exercises will be best suited to you, according to your rehabilitation goals and your level of ability. Different video game exercises will help with different rehabilitation goals such as improving coordination, strength, fine motor control, etc. Once you have a good idea which games best suit your needs you can then use the video game training system at home regularly as a form of therapy. Video game training is also a great activity to do with other family members such as your children and grandchildren.

How many treatments?

Information on the amount and intensity of video game training needed is not yet available. High quality studies need to be conducted before advice can be given regarding specific programs and content of treatment sessions. Speak with your occupational therapist or physical therapist, and use your judgment by beginning slowly and building in new activities and longer periods of training over time.

How much does it cost?

The cost of these various video games and the game console are relatively affordable. The average price in 2017 for commercially available gaming systems in Canada is approximately 300$ – 400$. You will also need to buy different programs, which your therapist can help you pick.

Is video game training for me?

There is some evidence that video games training is more effective than regular therapy or no therapy for improving arm and hand function and functional independence after stroke. However, studies have also shown that it is not more effective than other therapies for improving grip strength, quality of life, hand dexterity and motor recovery in some patients.

It is best to talk with your occupational therapist or physical therapist to decide whether video game therapy is suitable for you.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

The present module includes studies that examined the use of commercially available video game consoles for upper limb rehabilitation. Studies that did not report on any upper limb related outcomes were excluded. Similarly, studies that were not randomized clinical trials (RCTs) or poorly designed quasi-experimental studies were excluded.

Currently, eleven RCTs and one well designed quasi-experimental study have investigated the effect of upper limb rehabilitation using commercially available video game consoles. Eight RCTs are of high quality and three are of fair quality.

Results Table

View results table

Outcomes

Acute Phase

Functional independence
Not effective
2A

One fair quality RCT (Kong et al., 2016) investigated the effect of upper extremity video game training on functional independence in patients with acute stroke. This fair quality RCT randomized patients to receive Nintendo WiiTM upper extremity training, time-matched occupational therapy upper extremity training, or no additional upper extremity training; all groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure at post-treatment (3 weeks), and two follow-up time points (1 and 3 months post-treatment). No significant between-group differences were found at any time points.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that upper extremity video game training is not more effective than comparison interventions (time-matched occupational therapy upper extremity training, no additional training) in improving functional independence in patients with acute stroke.

Pain
Not effective
2A

One fair quality RCT (Kong et al., 2016) investigated the effect of upper extremity video game training on upper extremity pain in patients with acute stroke. This fair quality RCT randomized patients to receive Nintendo WiiTM upper extremity training, time-matched occupational therapy upper extremity training, or no additional upper extremity training; all groups received conventional rehabilitation. Upper extremity pain was measured by Visual Analogue Scale at post-treatment (3 weeks) and at two follow-up time points (1 and 3 months post-treatment). No significant between-group differences were found at any time points.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that upper extremity video game training is not more effective than comparison interventions (time-matched occupational therapy upper extremity training, no additional training) for reducing upper extremity pain in patients with acute stroke.

Stroke outcomes
Not effective
2A

One fair quality RCT (Kong et al., 2016) investigated the effect of upper extremity video game training on stroke outcomes in patients with acute stroke. This fair quality RCT randomized patients to receive Nintendo WiiTM upper extremity training, time-matched occupational therapy upper extremity training, or no additional upper extremity training; all groups received conventional rehabilitation. Stroke outcomes were measured by the Stroke Impact Scale – Upper Limb score at post-treatment (3 weeks), and at two follow-up points (1 and 3 months). No significant between-group differences were found at any time points.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that upper extremity video game training is not more effective than comparison interventions (time-matched occupational therapy upper extremity training, no additional training) in improving stroke outcomes in patients with acute stroke.

Upper extremity motor function
Not effective
2A

One fair quality RCT (Kong et al., 2016) investigated the effect of upper extremity video game training on upper extremity motor function in patients with acute stroke. This fair quality RCT randomized patients to receive Nintendo WiiTM upper extremity training, time-matched occupational therapy upper extremity training, or no additional upper extremity training; all groups received conventional rehabilitation. UE motor function was measured by the Fugl-Meyer Assessment – Upper Extremity score and Action Research Arm Test at post-treatment (3 weeks), and at follow-up points (1 and 3 months). No significant between-group differences were found on any of the measures at all time points.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that upper extremity video game training is not more effective than comparison interventions (time-matched occupational therapy upper extremity training, no additional training) in improving upper extremity motor function in patients with acute stroke.

Chronic Phase

Dexterity
Effective
1b

One high quality RCT (Sin & Lee, 2013) and one quasi-experimental design study (Chen et al., 2015) investigated the effect of upper extremity video game training on dexterity in patients with chronic stroke.

The high quality RCT (Sin & Lee, 2013) randomized patients to receive upper extremity training using Microsoft XBox Kinect + conventional occupational therapy or conventional occupational therapy alone. Dexterity was measured by the Box and Block Test at post-treatment (6 weeks). Significant between-group differences were found, favoring video game training + conventional occupational therapy vs. conventional occupational therapy alone.

The quasi-experimental design study (Chen et al., 2015) assigned patients to receive upper extremity training using Nintendo WiiTM gaming system, XaviX® Port or conventional equipment; all groups received conventional rehabilitation. Dexterity was measured by the Box and Block Test at baseline and at post-treatment (8 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity video game training + conventional occupational therapy is more effective than a comparison intervention (conventional occupational therapy alone) in improving dexterity in patients with chronic stroke. However, one quasi-experimental design study found that upper extremity video game training was not more effective than a comparison intervention (upper extremity training using conventional equipment) in improving dexterity in patients with chronic stroke.

Note: In the high quality study the experimental group received greater training time than the control group.

Functional independence
Not effective
2B

One quasi-experimental design study (Chen et al., 2015) investigated the effect of upper extremity video game training on functional independence in patients with chronic stroke. This quasi-experimental design study assigned patients to receive upper extremity training using Nintendo WiiTM gaming system, XaviX® Port or conventional equipment; all groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure at baseline and at post-treatment (8 weeks). No significant between-group differences were found.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that upper extremity video game training is not more effective than a comparison intervention (upper extremity training using conventional equipment) in improving functional independence in patients with chronic stroke.

Grip strength
Not effective
1B

One high quality RCT (Givon et al., 2016) investigated the effect of upper extremity video game training on grip strength in patients with chronic stroke. This high quality RCT randomized patients to receive upper extremity video game training or conventional rehabilitation exercises. Grip strength was measured by the Jamar Dynamometer (affected and non-affected hands) at post-treatment (3 months) and at follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity video game training is not more effective than a comparison intervention (conventional exercises) in improving grip strength in patients with chronic stroke.

Health-related quality of life
Not effective
1B

One high quality RCT (da Silva Ribeiro et al., 2015) investigated the effect of upper extremity video game training on health-related quality of life in patients with chronic stroke. This high quality RCT randomized patients to receive Nintendo WiiTM training or conventional physical therapy. Health-related quality of life was measured by the Shoft-Form-36 (SF-36 – total, physical functioning, physical aspects, pain, general health status, vitality, social aspects, emotional aspects, mental health) at post-treatment (2 months). Significant between-group differences were found on only one component of health-related quality of life (SF-36 – physical functioning), favoring conventional physical therapy vs. Nintendo WiiTM training.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity video game training is not more effective than a comparison intervention (conventional physical therapy) in improving health-related quality of life in patients with chronic stroke. In fact, video game training was found to be less effective than physical therapy in improving one component of health-related quality of life (physical functioning).

Motivation
Effective
2b

One quasi-experimental design study (Chen et al., 2015) investigated the effect of upper extremity video game training on motivation in patients with chronic stroke. This quasi-experimental design study assigned patients to receive upper extremity training using Nintendo WiiTM gaming system, XaviX®Port or conventional equipment; all groups received conventional rehabilitation. Motivation was measured by a motivation and enjoyment interviewer-administered questionnaire at post-treatment (8 weeks). Significant between-group differences were found, favoring both video game systems vs. conventional equipment.

Conclusion: There is limited evidence (Level 2b) from one quasi-experimental design study that upper extremity video game training is more effective than a comparison intervention (upper extremity training using conventional equipment) in improving motivation in patients with chronic stroke.

Motor function
Not effective
1B

One high quality RCT (da Silva Ribeiro et al., 2015) and one quasi-experimental design study (Chen et al., 2015) investigated the effect of upper extremity video game training on motor function in patients with chronic stroke.

The high quality RCT (da Silva Ribeiro et al., 2015) randomized patients to receive Nintendo WiiTMtraining or conventional physical therapy. Motor function was measured by the Fugl-Meyer Assessment (FMA) at post-treatment (2 months). No significant between-group differences were found.

The quasi-experimental design study (Chen et al., 2015) assigned patients to receive upper extremity training using Nintendo WiiTM gaming system, XaviX®Port or conventional equipment; all groups received conventional rehabilitation. Motor function was measured by the FMA (total score) at post-treatment (8 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one quasi-experimental design study that upper extremity video game training is not more effective than comparison interventions (conventional physical therapy, upper extremity training using conventional equipment) in improving motor function in patients with chronic stroke.

Range of motion
Effective
1B

One high quality RCT (Sin & Lee, 2013) and one quasi-experimental design study (Chen et al., 2015) investigated the effect of upper extremity video game training on upper extremity range of motion (ROM) in patients with chronic stroke.

The high quality RCT (Sin & Lee, 2013) randomized patients to receive upper extremity training using Microsoft XBox Kinect + conventional occupational therapy or conventional occupational therapy alone. Upper extremity ROM (shoulder flexion/extension/abduction, elbow flexion, wrist flexion/extension) was measured by goniometer at post-treatment (6 weeks). Significant between-group differences were found (shoulder flexion/extension/abduction, elbow flexion), favoring video game training + conventional occupational therapy vs. conventional occupational therapy alone.

The quasi-experimental designs study (Chen et al., 2015) randomized patients to receive upper extremity training using Nintendo WiiTM gaming system, XaviX®Port or conventional equipment; all groups received conventional rehabilitation. Upper extremity ROM (proximal: shoulder and elbow; distal: forearm and wrist) was measured by goniometer at post-treatment (8 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity video game training + conventional occupational therapy is more effective than a comparison intervention (conventional occupational therapy alone) in improving upper extremity ROM in patients with chronic stroke. However, one quasi-experimental design study found that upper extremity video game training was not more effective than a comparison intervention (upper extremity training using conventional equipment) in improving upper extremity ROM in patients with chronic stroke.

Note: In the high quality study the experimental group received greater training time than the control group.

Upper extremity activity
Effective
2a

One fair quality RCT (Rand et al., 2014) investigated the effect of upper extremity video game training on upper extremity activity in patients with chronic stroke. This fair quality RCT randomized patients to receive upper extremity training using video games (Microsoft XBox Kinect, Sony PlayStation 2 EyeToy, Sony PlayStation 3 MOVE, SeeMe VR system) or conventional rehabilitation. Upper extremity activity was measured at post-treatment (3 months) according to: (i) number of active/passive purposeful/non-purposeful movement repetitions; and (ii) accelerometer activity count (movement acceleration, intensity) of the affected/unaffected upper extremity. Significant between-group differences were found (active purposeful movements, movement acceleration, intensity of the affected extremity), favoring video game training vs. conventional rehabilitation. In contrast, there were significant between-group differences in active/passive non-purposeful movements, favoring conventional rehabilitation vs. video game training.

Conclusion: There is limited evidence (Level 2a) from one fair quality RCT that upper extremity video game training is more effective than a comparison intervention (conventional rehabilitation) in improving some aspects of upper extremity activity (number of active purposeful movements, movement acceleration and intensity) in patients with chronic stroke. However, this fair quality RCT also found that upper extremity video game training was less effective than conventional rehabilitation in improving number of active/passive non-purposeful movements.

Upper extremity motor function
Conflicting
4

Two high quality RCTs (Sin & Lee, 2013; Givon et al., 2016) and one fair quality RCT (Rand et al., 2014) investigated the effect of upper extremity video game training on upper extremity motor function in patients with chronic stroke.

The first high quality RCT (Sin & Lee, 2013) randomized patients to receive upper extremity training using Microsoft XBox Kinect + conventional occupational therapy or conventional occupational therapy alone. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity score (FMA-UE) at post-treatment (6 weeks). Significant between-group differences were found, favoring video game training + conventional occupational therapy vs. conventional occupational therapy alone.

The second high quality RCT (Givon et al., 2016) randomized patients to receive upper extremity video game training or conventional exercises. Upper extremity motor function was measured by the Action Research Arm Test at post-treatment (3 months) and at follow-up (6 months). No significant between-group differences were found at either time point.

The fair quality RCT (Rand et al., 2014) randomized patients to receive upper extremity training using video games (Microsoft XBox Kinect, Sony PlayStation 2 EyeToy, Sony PlayStation 3 MOVE, SeeMe VR system) or conventional rehabilitation. Upper extremity motor function was measured by the FMA-UE at post-treatment (3 months). No significant between-group differences were found.

Conclusion: There is conflicting evidence (Level 4) from two high quality RCTs regarding the effect of upper extremity upper extremity video game training on upper extremity motor function in patients with chronic stroke. One high quality RCT found that upper extremity upper extremity video game training + conventional occupational therapy was more effective than conventional occupational therapy alone, whereas another high quality RCT and a fair quality RCT found that upper extremity video game training was not more effective than conventional exercises or conventional rehabilitation, respectively.

Note: In the high quality RCT that found improvement, the experimental group received greater training time than the control group.

Walking activity level
Not effective
1B

One high quality RCT (Givon et al., 2016) investigated the effect of upper extremity video game training on walking activity level in patients with chronic stroke. This high quality RCT randomized patients to receive upper extremity video game training or conventional exercises. Walking activity level was measured by an Acticial Minimitter Co. hip accelerometer (number of steps walked/day) at post-treatment (3 months) and at follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity upper extremity video game training is not more effective than a comparison intervention (conventional exercises) in improving walking activity level in patients with chronic stroke.

Walking speed
Not effective
1B

One high quality RCT (Givon et al., 2016) investigated the effect of upper extremity video game training on walking speed in patients with chronic stroke. This high quality RCT randomized patients to receive upper extremity video game training or conventional exercises. Walking speed was measured by the 10 Meter Walk Test at post-treatment (3 months) and at follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity video game training is not more effective than a comparison intervention (conventional exercises) in improving walking speed in patients with chronic stroke.

Phase not specific to one period

Cognitive function
Not effective
1B

One high quality RCT (Choi et al., 2014) investigated the effect of upper extremity video game training on cognitive function in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or occupational therapy; both groups received conventional rehabilitation. Cognitive function was measured by the Korean version of the Mini-Mental State Examination and the Visual and Auditory Continuous Performance Tests at post-treatment (4 weeks). No significant between-group differences were found on either measure.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity upper extremity video game training is not more effective than a comparison intervention (upper extremity occupational therapy) in improving cognitive function in patients with stroke.

Dexterity
Not effective
1a

Three high quality RCTs (Choi et al., 2014; McNulty et al., 2015; Saposnik et al., 2016) and one fair quality RCT (Saposnik et al., 2010) investigated the effect of upper extremity video game training on dexterity in patients with stroke.

The first high quality RCT (Choi et al., 2014) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or conventional occupational therapy; both groups received conventional rehabilitation. Dexterity was measured by the Box and Block Test (BBT) at post-treatment (4 weeks). No significant between-group differences were found.

The second high quality RCT (McNulty et al., 2015) randomized patients with subacute/chronic stroke to receive upper extremity training using Nintendo WiiTM or modified constraint induced therapy. Dexterity was measured by the BBT and the Grooved Pegboard test at post-treatment (10 days) and at follow-up (6 months). No significant between-group differences were found on any measure at either time point.

The third high quality RCT (Saposnik et al., 2016) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or recreational therapy; both groups received conventional rehabilitation. Dexterity was measured by the BBT at post-treatment (2 weeks) and at follow-up (4 weeks post-treatment). Significant between-group differences were found only at post-treatment, favoring recreational therapy vs. video game training.

The fair quality RCT (Saposnik et al., 2010) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or recreational therapy; both groups received conventional rehabilitation. Dexterity was measured by the BBT at post-treatment (2 weeks) and at follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs and one fairquality RCT that upper extremity video game training is not more effective than comparison interventions (conventional occupational therapy, modified constraint induced therapy, recreational therapy) in improving dexterity in patients with stroke. In fact, one high quality RCT found that UE training using gaming was LESS effective than recreational therapy.

Functional independence
Not effective
1A

Four high quality RCTs (Yavuzer et al., 2008; Choi et al., 2014; Saposnik et al., 2016; Simsek & Cekok, 2016) investigated the effect of upper extremity video game training on functional independence in patients with stroke.

The first high quality RCT (Yavuzer et al., 2008) randomized patients with subacute/chronic stroke to receive upper extremity training using Playstation EyeToy or sham video game training; both groups received conventional rehabilitation. Functional independence was measured by the Functional Independence Measure (FIM, self-care item) at baseline, post-treatment (4 weeks), and at follow-up (3 months post-treatment). Significant between-group differences in FIM self-care changes scores from baseline to post-treatment and from post-treatment to follow-up were found, favoring video game training vs. sham video game training.

The second high quality RCT (Choi et al., 2014) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or conventional occupational therapy; both groups received conventional rehabilitation. Functional independence was measured by the Korean version of the modified Barthel Index (BI) at post-treatment (4 weeks). No significant between-group differences were found.

The third high quality RCT (Saposnik et al., 2016) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or recreational therapy; both groups received conventional rehabilitation. Functional independence was measure by the FIM, the BI and the modified Rankin Scale at post-treatment (2 weeks) and at follow-up (4 weeks post-treatment). No significant between-group differences were found on any measure at either time point.

The forth high quality RCT (Simsek & Cekok, 2016) randomized patients with acute/subacute stroke to receive balance and upper extremity training using Nintendo WiiTM or Bobath Neurodevelopmental treatment. Functional independence was measured by the FIM at post-treatment (10 weeks). No significant between-group differences were found.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that upper extremity video game training is not more effective than comparison interventions (conventional occupational therapy, recreational therapy, Bobath Neurodevelopmental treatment) in improving functional independence in patients with stroke.

Note: However, one high quality RCT found that upper extremity video game training was more effective than sham video game training.

Grip strength
Not effective
1A

Two high quality RCTs (Choi et al., 2014; Saposnik et al., 2016) and one fair quality RCT (Saposnik et al., 2010) investigated the effect of upper extremity video game training on grip strength in patients with stroke.

The first high quality RTC (Choi et al., 2014) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or conventional occupational therapy; both groups received conventional rehabilitation. Grip strength was measured by a dynamometer at post-treatment (4 weeks). No significant between-group differences were found.

The second high quality RCT (Saposnik et al., 2016) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or recreational therapy; both groups received conventional rehabilitation. Grip strength was measured by a dynamometer at post-treatment (2 weeks) and at follow-up (4 weeks post-treatment). No significant between-group differences were found at either time point.

The fair quality RCT (Saposnik et al., 2010) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or recreational therapy; both groups received conventional rehabilitation. Grip strength was measured by a dynamometer at post-treatment (2 weeks) and follow-up (1 month). No significant between-group differences were found at either time point.

Conclusion: There is strong evidence (Level 1a) from two high quality RCTs and one fairquality RCT that upper extremity upper extremity video game training is not more effective than comparison interventions (conventional occupational therapy, recreational therapy) in improving grip strength in patients with stroke.

Health-related quality of life
Not effective
1B

One high quality RCT (Simsek & Cekok, 2016) investigated the effect of upper extremity video game training on health-related quality of life in patients with stroke. This high quality RCT randomized patients with acute/subacute stroke to receive balance and upper extremity training using Nintendo WiiTM or Bobath Neurodevelopmental treatment. Health-related quality of life was measured by the Nottingham Health Profile at post-treatment (10 weeks). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity video game training is not more effective than a comparison intervention (Bobath neurodevelopmental treatment) in improving health-related quality of life in patients with stroke.

Range of motion
Not effective
1b

One high quality RCT (McNulty et al., 2015) investigated the effect of upper extremity video game training on range of motion (ROM) in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive upper extremity training using Nintendo WiiTM or modified constraint induced therapy. Range of motion at the shoulder (flexion/extension/abduction), elbow (flexion), wrist (flexion/extension) and digits I/II (flexion) was measured by a goniometer at post-treatment (10 days) and at follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity video game training is not more effective than a comparison intervention (modified constraint induced therapy) in improving upper extremity range of motion in patients with stroke.

Self-perceived improvement
Not effective
1B

One high quality RCT (McNulty et al., 2015) investigated the effect of upper extremity video game training on self-perceived improvement in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive upper extremity training using Nintendo WiiTM or modified constraint induced therapy. Self-perceived improvement was measured by a standardized questionnaire at post-treatment (10 days). No significant between-group differences were found.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity video game training is not more effective than a comparison intervention (modified constraint induced therapy) in improving self-perceived improvement in patients with stroke.

Spasticity
Not effective
1B

One high quality RCT (McNulty et al., 2015) investigated the effect of upper extremity video game training on spasticity in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive upper extremity training using Nintendo WiiTM or modified constraint induced therapy. Upper extremity spasticity was measured by the Modified Ashworth Scale at post-treatment (10 days) and at follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity video game training is not more effective than a comparison intervention (modified constraint induced therapy) for reducing upper extremity spasticity in patients with stroke.

Stroke outcomes
Not effective
1B

One high quality RCT (Saposnik et al., 2016) and one fair quality RCT (Saposnik et al., 2010) investigated the effect of upper extremity video game training on stroke outcomes in patients with stroke.

The high quality RCT (Saposnik et al., 2016) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or recreational therapy; both groups received conventional rehabilitation. Stroke outcomes were measured by the Stroke Impact Scale (SIS – hand function, perception of recovery, composite score: strength, hand function, mobility, activities of daily living/instrumental activities of daily living) at post-treatment (2 weeks) and at follow-up (4 weeks post-treatment). No significant between-group differences were found at either time point.

The fair quality RCT (Saposnik et al., 2010) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or recreational therapy; both groups received conventional rehabilitation. Stroke outcomes were measured by the Stroke Impact Scale (hand function, perception of recovery, composite score: strength, hand function, mobility, activities of daily living/instrumental activities of daily living) at post-treatment (2 weeks) and follow-up (1 month post-treatment). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT and one fairquality RCT that upper extremity video game training is not more effective than a comparison intervention (recreational therapy) in improving stroke outcomes in patients with stroke.

Upper extremity motor activity
Not effective
1b

One high quality RCT (McNulty et al., 2015 investigated the effect of upper extremity video game training on upper extremity motor activity in patients with stroke. This high quality RCT randomized patients with subacute/chronic stroke to receive upper extremity training using Nintendo WiiTM or modified constraint induced therapy. Upper extremity motor activity was measured by the Motor Activity Log (Quality of Movement Scale) at post-treatment (10 days) and follow-up (6 months). No significant between-group differences were found at either time point.

Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that upper extremity video game training is not more effective than a comparison intervention (modified constraint induced therapy) in improving upper extremity motor activity in patients with stroke.

Upper extremity motor function
Not effective
1A

Four high quality RCTs (Yavuzer et al., 2008; Choi et al., 2014; McNulty et al., 2015; Saposnik et al., 2016) and one fair quality RCT (Saposnik et al., 2010) investigated the effect of upper extremity video game training on upper extremity motor function in patients with stroke.

The first high quality RCT (Yavuzer et al., 2008) randomized patients with subacute/chronic stroke to receive upper extremity training using Playstation EyeToy or sham video game training; both groups received conventional rehabilitation. Upper extremity motor function was measured by the Brunnstrom Stages (hand, upper extremity) at baseline, post-treatment (4 weeks), and at follow-up (3 months post-treatment). Significant between-group differences in changes scores from baseline to post-treatment were found, favoring video game training vs. sham video game training. These significant differences were not maintained at follow-up.

The second high quality RCT (Choi et al., 2014) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or conventional occupational therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured by the Fugl-Meyer Assessment – Upper Extremity (FMA-UE) and the Manual Function Test at post-treatment (4 weeks). No significant between-group differences were found on either measure.

The third high quality RCT (McNulty et al., 2015) randomized patients with subacute/chronic stroke to receive upper extremity training using Nintendo WiiTM or modified constraint induced therapy. Upper extremity motor function measured by the Wolf-Motor Function Test (WMFT – time, maximal strength, submaximal strength) and (FMA-UE) at post-treatment (10 days) and follow-up (6 months). No significant between-group differences were found on either measure at ether time point.

The forth high quality RCT (Saposnik et al., 2016) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or recreational therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured using an abbreviated version of the WMFT at post-treatment (2 weeks) and at follow-up (4 weeks post-treatment). No significant between-group differences were found at either time point.

The fair quality RCT (Saposnik et al., 2010) randomized patients with acute/subacute stroke to receive upper extremity training using Nintendo WiiTM or recreational therapy; both groups received conventional rehabilitation. Upper extremity motor function was measured using an abbreviated version of the WMFT at post-treatment (2 weeks) and at follow-up (1 month). Significant between-group differences were found at 1-month follow-up only, favoring video game training vs. recreational therapy.

Conclusion: There is strong evidence (Level 1a) from three high quality RCTs that upper extremity video game training is not more effective than comparison interventions (conventional occupational therapy; modified constraint induced therapy, recreational therapy) in improving upper extremity motor function in patients with stroke.

Note: However, one high quality RCT and one fair quality RCT found that video game training was more effective than comparison interventions (sham video game training, recreational therapy).

References

Chen, M. H., Huang, L. L., Lee, C. F., Hsieh, C. L., Lin, Y. C., Liu, H., Chen, M.I. & Lu, W. S. (2015). A controlled pilot trial of two commercial video games for rehabilitation of arm function after stroke. Clinical Rehabilitation, 29(7), 674-682.
http://journals.sagepub.com/doi/abs/10.1177/0269215514554115

Choi, J. H., Han, E. Y., Kim, B. R., Kim, S. M., Im, S. H., Lee, S. Y., & Hyun, C. W. (2014). Effectiveness of commercial gaming-based virtual reality movement therapy on functional recovery of upper extremity in subacute stroke patients. Annals of Rehabilitation Medicine, 38(4), 485-493.
https://synapse.koreamed.org/DOIx.php?id=10.5535/arm.2014.38.4.485

da Silva Ribeiro, N. M., Ferraz, D. D., Pedreira, É., Pinheiro, Í., da Silva Pinto, A. C., Neto, M. G., … & Masruha, M. R. (2015). Virtual rehabilitation via Nintendo Wii® and conventional physical therapy effectively treat post-stroke hemiparetic patients. Topics in Stroke Rehabilitation, 22(4), 299-305.
http://www.tandfonline.com/doi/abs/10.1179/1074935714Z.0000000017

Givon, N., Zeilig, G., Weingarden, H., & Rand, D. (2016). Video-games used in a group setting is feasible and effective to improve indicators of physical activity in individuals with chronic stroke: a randomized controlled trial. Clinical Rehabilitation, 30(4), 383-392.
http://journals.sagepub.com/doi/abs/10.1177/0269215515584382

Kong, K. H., Loh, Y. J., Thia, E., Chai, A., Ng, C. Y., Soh, Y. M., … & Tjan, S. Y. (2016). Efficacy of a Virtual Reality Commercial Gaming Device in Upper Limb Recovery after Stroke: A Randomized, Controlled Study. Topics in Stroke Rehabilitation, 23(5), 333-340.
http://www.tandfonline.com/doi/abs/10.1080/10749357.2016.1139796

McNulty, P. A., Thompson‐Butel, A. G., Faux, S. G., Lin, G., Katrak, P. H., Harris, L. R., & Shiner, C. T. (2015). The efficacy of Wii‐based Movement Therapy for upper limb rehabilitation in the chronic poststroke period: a randomized controlled trial. International Journal of Stroke, 10(8), 1253-1260.
http://onlinelibrary.wiley.com/doi/10.1111/ijs.12594/full

Rand, D., Givon, N., Weingarden, H., Nota, A., & Zeilig, G. (2014). Eliciting Upper Extremity Purposeful Movements Using Video Games a Comparison with Traditional Therapy for Stroke Rehabilitation. Neurorehabilitation and Neural Repair, 28(8), 733-739.
https://www.ncbi.nlm.nih.gov/pubmed/24515927

Saposnik, G., Teasell, R., Mamdani, M., Hall, J., McIlroy, W., Cheung, D., … & Bayley, M. (2010). Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation. Stroke, 41(7), 1477-1484.
http://stroke.ahajournals.org/content/41/7/1477.short

Saposnik, G., Cohen, L. G., Mamdani, M., Pooyania, S., Ploughman, M., Cheung, D., … & Nilanont, Y. (2016). Efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST): a randomised, multicentre, single-blind, controlled trial. The Lancet Neurology, 15(10), 1019-1027.
http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(16)30121-1/abstract

Şimşek, T. T., & Çekok, K. (2016). The effects of Nintendo WiiTM-based balance and upper extremity training on activities of daily living and quality of life in patients with sub-acute stroke: a randomized controlled study. International Journal of Neuroscience, 126(12), 1061-1070.
http://www.tandfonline.com/doi/abs/10.3109/00207454.2015.1115993

Sin, H., & Lee, G. (2013). Additional virtual reality training using Xbox Kinect in stroke survivors with hemiplegia. American Journal of Physical Medicine & Rehabilitation, 92(10), 871-880.
http://journals.lww.com/ajpmr/Abstract/2013/10000/Additional_Virtual_Reality_Training_Using_Xbox.4.aspx

Yavuzer, G., Senel, A., Atay, M. B., & Stam, H. J. (2008). ”Playstation eyetoy games”improve upper extremity-related motor functioning in subacute stroke: a randomized controlled clinical trial. European journal of physical and rehabilitation medicine, 44(3), 237-244.
http://europepmc.org/abstract/med/18469735

Excluded Studies

Combs, S. A., Finley, M. A., Henss, M., Himmler, S., Lapota, K., & Stillwell, D. (2012). Effects of a repetitive gaming intervention on upper extremity impairments and function in persons with chronic stroke: a preliminary study. Disability and Rehabilitation, 34(15), 1291-1298.
Reason for exclusion: Not a RCT, pre-post study design.

Cheok, G., Tan, D., Low, A., & Hewitt, J. (2015). Is Nintendo Wii an effective intervention for individuals with stroke? A systematic review and meta-analysis. Journal of the American Medical Directors Association, 16(11), 923-932.
Reason for exclusion: Review

Dos Santos, L. R. A., Carregosa, A. A., Masruha, M. R., Dos Santos, P. A., Coêlho, M. L. D. S., Ferraz, D. D., & Ribeiro, N. M. D. S. (2015). The use of Nintendo Wii in the rehabilitation of poststroke patients: a systematic review. Journal of Stroke and Cerebrovascular Diseases, 24(10), 2298-2305.
Reason for exclusion: Review

Hung, J. W., Chou, C. X., Hsieh, Y. W., Wu, W. C., Yu, M. Y., Chen, P. C., … & Ding, S. E. (2014). Randomized comparison trial of balance training by using exergaming and conventional weight-shift therapy in patients with chronic stroke. Archives of Physical Medicine and Rehabilitation, 95(9), 1629-1637.
Reason for exclusion: Not specific to upper extremity rehabilitation.

Iosa, M., Morone, G., Fusco, A., Castagnoli, M., Fusco, F. R., Pratesi, L., & Paolucci, S. (2015). Leap motion controlled videogame-based therapy for rehabilitation of elderly patients with subacute stroke: a feasibility pilot study. Topics in Stroke Rehabilitation, 22(4), 306-316.
Reason for exclusion: Not a RCT, pre-post study design.

Morone, G., Tramontano, M., Iosa, M., Shofany, J., Iemma, A., Musicco, M., … & Caltagirone, C. (2014). The efficacy of balance training with video game-based therapy in subacute stroke patients: a randomized controlled trial. BioMed Research International, 2014.
Reason for exclusion: Not specific to upper extremity rehabilitation.

Kottink, A. I., Prange, G. B., Krabben, T., Rietman, J. S., & Buurke, J. H. (2014). Gaming and conventional exercises for improvement of arm function after stroke: A randomized controlled pilot study. GAMES FOR HEALTH: Research, Development, and Clinical Applications, 3(3), 184-191.
Reason for exclusion: Not commercially available console.

Paquin, K., Ali, S., Carr, K., Crawley, J., McGowan, C., & Horton, S. (2015). Effectiveness of commercial video gaming on fine motor control in chronic stroke within community-level rehabilitation. Disability and Rehabilitation, 37(23), 2184-2191.
Reason for exclusion: Not a RCT, pre-post study design.

Park, D. S., Lee, D. G., Lee, K., & Lee, G. (2017). Effects of Virtual Reality Training using Xbox Kinect on Motor Function in Stroke Survivors: A Preliminary Study. Journal of Stroke and Cerebrovascular Diseases.
Reason for exclusion: No outcome measures related to upper limb function.

Rabin, B. A., Burdea, G. C., Roll, D. T., Hundal, J. S., Damiani, F., & Pollack, S. (2012). Integrative rehabilitation of elderly stroke survivors: The design and evaluation of the BrightArm™. Disability and Rehabilitation: Assistive Technology, 7(4), 323-335.
Reason for exclusion: Not a RCT, pre-post study design.

Redzuan, N. S., Engkasan, J. P., Mazlan, M., & Abdullah, S. J. F. (2012). Effectiveness of a video-based therapy program at home after acute stroke: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 93(12), 2177-2183.
Reason for exclusion: Not specific to upper extremity rehabilitation.

Rozental-Iluz, C., Zeilig, G., Weingarden, H., & Rand, D. (2016). Improving executive function deficits by playing interactive video-games: secondary analysis of a randomized controlled trial for individuals with chronic stroke. European journal of physical and rehabilitation medicine, 52(4), 508-515.
Reason for exclusion: No outcome measures related to upper limb function.

Shin, J. H., Park, S. B., & Jang, S. H. (2015). Effects of game-based virtual reality on health-related quality of life in chronic stroke patients: A randomized, controlled study. Computers in Biology and Medicine, 63, 92-98.
Reason for exclusion: Not commercially available technology.

Trinh, T., Scheuer, S. E., Thompson-Butel, A. G., Shiner, C. T., & McNulty, P. A. (2016). Cardiovascular fitness is improved post-stroke with upper-limb Wii-based Movement Therapy but not dose-matched constraint therapy. Topics in Stroke Rehabilitation, 23(3), 208-216.
Reason for exclusion: Not a RCT, quasi-experimental design study with no between-group analysis and report.

Yates, M., Kelemen, A., & Sik Lanyi, C. (2016). Virtual reality gaming in the rehabilitation of the upper extremities post-stroke. Brain Injury, 30(7), 855-863.
Reason for exclusion: Review

Survey