JMIR Publications

ABSTRACT

Background:

Upper limb impairment is a common consequence of stroke, affecting independence and quality of life. Virtual reality (VR) interventions, including serious games designed for therapeutic purposes and commercial games developed primarily for entertainment, have been increasingly used for post-stroke upper limb rehabilitation. Evidence comparing the effectiveness of these game types on functional outcomes remains unclear.

Objective:

This systematic review protocol aims to determine whether serious versus commercial VR games differentially impact upper limb function, measured by the Action Research Arm Test (ARAT), in adults post-stroke. Secondary outcomes will include upper limb motor function by the FMA-UE, BBT, MAL, JTHFT and WMFT, functional independence assessed by the FIM and BI, and adherence indicators, including dropout rates and session completion. Secondary objectives include evaluating pooled VR effects versus conventional therapy and exploring potential moderators, such as VR immersion level and stroke chronicity.

Methods:

Parallel randomized controlled trials involving adults (≥18 years) with ischemic or hemorrhagic stroke in acute, subacute, or chronic phases will be included. Interventions using serious or commercial VR games (non-immersive, semi-immersive, or fully immersive) delivered alone or combined with conventional therapy will be considered. Studies using non-gamified VR, digital technologies without VR, or augmented reality not integrated into VR will be excluded. Eligible comparators include conventional physiotherapy, occupational therapy, usual care, educational interventions, or no therapy. This protocol was developed in accordance with the PRISMA-P guidelines. Systematic searches will be conducted in PubMed, Web of Science, Embase, Scopus, Virtual Health Library, Science Direct, PEDro, CENTRAL, ClinicalTrials.gov, ReBEC, WHO ICTRP, and ISRCTN Registry from inception to February 2026. Data extraction will be performed independently by two reviewers, and risk of bias will be assessed using the Cochrane RoB 2.0 tool. Meta-analyses will be conducted when clinical and methodological homogeneity permits. A random-effects model is planned; however, the final choice of model will be based on the level of heterogeneity observed at the time of analysis. Subgroup analyses will explore stroke phase, immersion level, intervention dosage, and concomitant therapy.

Results:

Data collection is planned from inception to February 2026. Study screening and data extraction are ongoing. Results will be synthesized and reported after completion of the review.

Conclusions:

This systematic review will clarify whether different VR game formats produce distinct effects on upper limb rehabilitation after stroke, providing evidence to inform the design and implementation of VR-based neurorehabilitation interventions. Clinical Trial: PROSPERO CRD42024595266; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024595266