Therapeutic Effect of Virtual Reality on Post-Stroke Patients:

Randomized Clinical Trial

Erika Pedreira da Fonseca, PT, MSc,*,† Nildo Manoel Ribeiro da Silva, PT, PhD,‡
and Elen Beatriz Pinto, PT, PhD†

Objectives: The study aimed to check the therapeutic effect of virtual reality as-
sociated with conventional physiotherapy on gait balance and the occurrence of
falls after a stroke. Methods: This was a randomized, blinded clinical trial con-
ducted with post-stroke patients, randomized into two groups—treatment group
and control group—and subjected to balance assessments by the Dynamic Gait
Index and investigation of falls before and after 20 intervention sessions. Statis-
tically significant difference was considered at P < .05. Results: We selected 30 patients,
but there were three segment losses, resulting in a total of 13 patients in the control
group and 14 in the treatment group. There was an improvement in gait balance
and reduced occurrence of falls in both groups. After intervention, the differ-
ences in gait balance in the control group (P = .047) and the reduction in the occurrence
of falls in the treatment group (P = .049) were significant. However, in inter-
group analysis, there was no difference in the two outcomes. Conclusions: Therapy
with games was a useful tool for gait balance rehabilitation in post-stroke pa-
tients, with repercussions on the reduction of falls. Key Words: Stroke—
balance—virtual reality—rehabilitation.
© 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Introduction is a functional motor skill6 that may be compromised in

the hemiparetic patient, because of visual, vestibular sensory,
Stroke affects millions of people worldwide annually.1,2
somatosensory information, or motor changes.12-14 In some
Despite the decline in mortality of the disease in Brazil,3
cases, strategies to maintain postural control are not ef-
the affected survivors may present with disabilities.4 The
fective enough, leading to falls.15 Various authors have
main consequence of stroke is hemiplegia or hemiparesis,5
reported that after a stroke, 25%-75% of patients have a
which can result in sensory-motor deficit, and conse-
history of falls, and 10% of those who fall suffer severe
quently change in balance, functional limitation, and risk
consequences,15,16 with 73% of these patients requiring hos-
of falls.5-10 Authors report that these falls frequently oc-
pitalization as a result of the fall.17 A tool used for assessment
curred more in a home environment and during gait.11
is the Dynamic Gait Index (DGI), which evaluates gait
Most of these patients recover the ability to walk, but
balance and is a predictor of falls.9
in many cases there is change in postural control.12-14 Balance
Rehabilitation of the body balance of post-stroke pa-
tients is indispensable9,18 to avoid episodes of falls—the
From the *Católica University of Salvador, Salvador, Bahia, Brazil; main complications after a stroke.18 Among the differ-
†Bahia School of Medicine and Public Health, Salvador, Brazil; and
ent approaches for this purpose is virtual reality,19 which
‡Federal University of Bahia, Salvador, Brazil.
Received May 25, 2016; revision received August 15, 2016; accepted
aims to simulate functional activities that are the basis
August 23, 2016. for rehabilitation of neurologic patients.19-23 Several authors
Address correspondence to Erika Pedreira da Fonseca, PT, MSc, have observed improvement of body balance after a stroke
Católica University of Salvador, Pinto de Aguiar av, n. 2589, Pituaçu, in patients who underwent rehabilitation with virtual reality.
41740-090, Salvador, Bahia, Brazil. E-mail: erikapedreira@gmail.com.
These studies showed the feasibility of virtual reality as
1052-3057/$ - see front matter
© 2017 National Stroke Association. Published by Elsevier Inc. All
a therapeutic resource, although the studies were con-
rights reserved. ducted with a small sample.7,8,20,23-27 Virtual reality has been
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.08.035 reported as an adjunctive tool in the rehabilitation of

94 Journal of Stroke and Cerebrovascular Diseases, Vol. 26, No. 1 (January), 2017: pp 94–100
VIRTUAL REALITY ON POST-STROKE PATIENTS
post-stroke patients, as it is capable of generating more
motivation and entertainment.21,23,27
However, balance during gait and the occurrence of
falls have not been evaluated simultaneously in this pop-
ulation. The therapeutic effect of virtual reality on balance
during gait may have an impact on reducing the occur-
rence of falls and their consequences. Thus, the aim of
this study was to investigate the therapeutic effect of virtual
reality associated with conventional physiotherapy on
balance during gait and the occurrence of falls in post-
stroke patients.
Methods
A clinical randomized trial was conducted, including
patients of both sexes, with hemiparesis after a stroke,
in the age group from 18 to 65 years. We excluded pa-
tients whose injury occurred fewer than 6 months
previously, considering the expected time for spontane-
ous recovery; patients with associated disorders such as
epilepsy, and sensory and perceptual deficits such as
hemineglect and Pusher syndrome; patients with
osteodegenerative disorders that would prevent partici-
pation in the games or that could influence the body
balance; and individuals who had cognitive and com-
munication disorders, affecting understanding, that could
compromise performance in the games.
In accordance with the CONSORT requirements, the pa-
tients included were randomized in blocks of ten, per lot
by the RANDOM.ORG program, carried out by a third
person to preserve allocation concealment, into two groups:
treatment group with conventional physiotherapy associ-
ated with virtual rehabilitation with Nintendo Wii (Nintendo
Company, Limited (NCL), Minami-ku-based, Kyoto, Japan)
and control group with conventional physiotherapy.
After selection and randomization, patients were evalu-
ated at baseline, when demographic and clinical data were
collected; the occurrence of falls was investigated in the
3 months prior to evaluation; and the gait balance was
rated using the DGI.9 Patients were followed up through-
out 20 physiotherapy sessions, in twice-weekly visits lasting
an hour each. The exercises were performed under the
direct and personal supervision of a previously trained
physiotherapist. Balance assessments and investigation of
the occurrence of falls were repeated at the end of treat-
ment, which occurred on average 3 months after the
interventions began, by the same examiner, who re-
mained blind to the group to which the patient belonged.
The group that underwent rehabilitation with Nintendo
Wii was treated in a room with an area of 20 m2, equipped
with the aforementioned apparatus and projector. The image
was projected on the wall at a height of 1 m, and 20 pa-
tients had a large environment, free from external noise,
in which to perform the activity. To follow up with virtual
reality, a protocol was conducted, consisting of trunk mo-
bilizations in the lateral, anterior, and posterior directions,
95
and stretching the arms and legs with a duration of 60
seconds, for a total time of 15 minutes, followed by 45
minutes of exercise with Nintendo Wii. The games used
in the first session were tennis, which stimulates the lat-
eralization of movements of the trunk; weight shift between
the heel and forefoot; and hula hoop, working rotational
movements of the trunk, weight transfer between the heel
and forefoot, rotational movements of hip, and balance re-
action time. The games were performed for 12 minutes each,
with a 1-minute interval between the two games. In the
second session, the following were used: soccer, with side-
ways, anterior, and posterior movements of the trunk, head
movements, and balance reactions; and boxing, involving
selective and rotational movements of the trunk and balance
reactions, both with the same performance time.
Conventional therapy consisted of stretching the arm and
leg muscles for a total time of 10 minutes; trunk mobili-
zation activities in the lateral, anterior, and posterior directions
for 10 minutes; active or active assisted movement of the
leg with the use of movements in diagonal for 15 minutes;
balance training in standing position, when weight trans-
fer activities were done, and balance reactions to a stable
and unstable surface for 10 minutes; and free gait train-
ing for 10 minutes, with emphasis on weight transfer phase
balance, average speed, and workout with obstacles.
The present study was approved by the Research Ethics
Committee in Report No. CAAE 19135213.2.0000.0046, and
it was mandatory for patients to sign the Term of Free
and Informed Consent in order to participate in the study,
in accordance with Resolution 196/96. The study was reg-
istered on www.clinicaltrials.gov (NCT02475083).
The database was created in Excel (Microsoft, Redmond,
Washington, EUA) and analyzed in R v.3.1.3 software.
A descriptive analysis was made (absolute frequency or
relative, average, standard deviation, median, and quartiles)
to identify the general and specific characteristics of the
study sample. To check the normality of distribution, the
Shapiro–Wilk test was used; and to check for the signif-
icant differences before and after the intervention, we used
the t test for paired samples or the nonparametric Wilcoxon
test. To test for differences between each group, the St-
udent’s t test or the nonparametric Mann–Whitney test
was used when variables were quantitative, or the chi-
square test when they were qualitative. To identify
correlations among variables of interest, the Spearman
correlation was used. The level of significance estab-
lished for this study was 5%.
According to the study of DGI, validation identified that
the boundary between deficit and normal balance was only
1 point9; thus, it is possible to consider that the score that
defines the achievement of balance during gait is re-
stricted. We chose to expand this difference to see the effects
of the outcome in clinical practice. The sample size cal-
culation was made in order to detect a difference of 5.5
points in the DGI to identify change of balance during gait,
using a standard deviation of 5.1 for the experimental group
96 E. PEDREIRA DA FONSECA ET AL.

Randomized selection of individuals

(N = 30)

Losses
(N = 3)

Individuals who underwent

treatment (N = 27)

Figure 1. Flowchart of study participants, ac-

cording to CONSORT.

Control Group Experimental Group

(N = 13) (N = 14)

After-test After-test
20 sessions (N = 13) (N = 14)

and 4.8 for the control group, and we would have an alpha
error of 5% and a power of 80%.
Results
We selected 30 patients for the study and the flow-
chart of the study participants is presented, in accordance
with the CONSORT requirements (Fig 1). Analysis of the
sociodemographic and clinical characteristics is pre-
sented in Table 1. There was no statistically significant
difference between groups as regards these characteris-
tics, thus confirming homogeneity between them.
Figure 2 demonstrates that there was an increase in
the DGI score in both groups, with initial values of the
DGI for the treatment and control groups at 13.54 (±5.47)
and 16.29 (±5.01), respectively. However, when comparing
the DGI values before and after treatment, statistically
significant difference was observed only in the control
group (P = .047).
In both groups, the number of falls was reduced after
the intervention, but this difference was statistically sig-
nificant (P = .049) only in the treatment group (Table 2).
In the intergroup analysis, there was no significant dif-
ference in balance during gait (P = .462) after rehabilitation
or in reducing the incidence of falls (P = .653). This result
is shown in Table 3.
Table 4 shows that according to the result of total DGI,
the gait balance performance in the two groups was not
significantly correlated with the number of falls re-
corded after the intervention (P = .129 and P = .541,

Table 1. Demographic and clinical characteristics of 30 post-stroke patients

Variable Total (N = 30) Control group (n = 15) Treatment group (n = 15) P value

Age in years (average/SD)* 52.4 ± 8.9 50.9 ± 10.9 53.8 ± 6.3 .375
Female gender, n (%)† 19 (63.3) 66.7 60 .705
Right side of body affected, n (%)† 17 (56.7) 60 53.3 .713
Time from stroke in months (average/SD)* 54.3 ± 35.5 64.5 ± 41.9 44.1 ± 25.0 .117

Abbreviation: SD, standard deviation.

*t Test.
†Chi-square test.
VIRTUAL REALITY ON POST-STROKE PATIENTS 97

Figure 2. Balance gait performance—intergroup.

Note: Paired t test was used.

DGI BEFORE DGI AFTER

Note: Paired T test was used.

respectively). By correlating each DGI domain with the Discussion

number of falls, the authors of this study observed that
The results of this study showed that after a stroke,
for the control group, only the eighth domain—“going
patients undergoing treatment that included virtual reality
up and down the stairs”—showed positive correlation
and patients receiving conventional therapy showed an
(P = .043).
improvement in balance during gait and a reduction in
the occurrence of falls. The differences in gait balance after
intervention in the control group and the reduction in
the occurrence of falls in the treatment group were sig-
Table 2. Occurrence of falls—intergroup nificant. However, the intergroup analysis showed no
difference between the two outcomes.
Before After
Some authors suggest that the rehabilitation of balance
treatment treatment
should involve the task performed, the particularities of
Median/ Median/ the individual, and the environment in which the
Occurrence of falls‡ Quartiles Quartiles P value

Control group (n = 13) 1 (0-2)† 1 (0-1)† .257

Experimental group 0 (0-1)† 0 (0-0)† .049* Table 4. Correlation between the scores of Dynamic Gait
(n = 14) Index (DGI) domains and number of falls

*Significant difference. Control Experimental

†Quartiles 25-75. group group
‡Wilcoxon test.
Number of falls Number of falls

Table 3. Gait balance performance and occurrence of r P value r P value

falls—intergroup
Item 1 DGI .306 .309 .122 .679
Control Treatment Item 2 DGI .262 .338 −.081 .782
group group P value Item 3 DGI .364 .222 −.028 .434
Item 4 DGI .364 .222 −.030 .920
▲DGI* −2.84 (4.63) −1.71 (3.14) .462 Item 5 DGI .328 .274 −.413 .142
▲Number 1 (0-1) 0 (0-0) .653 Item 6 DGI .411 .163 −.302 .295
of falls† Item 7 DGI .048 .887 −.287 .319
Item 8 DGI .567 .043* −.190 .515
Note: ▲DGI represented in average/SD and ▲number of falls rep- DGI total .444 .129 −.179 .541
resented in median/quartiles 25-75.
*Non–paired t test. Spearman nonparametric test.
†Mann–Whitney test. *Significant difference.
98
6
rehabilitation is being carried out. Balance training with
virtual reality provides patients with enriched environ-
ments and the ability to solve motor problems.23 Different
studies corroborate that therapy with virtual reality as-
sociated with conventional therapy can improve the
performance of balance in post-stroke patients.7,8,13,20,22,23
In this study, the improvement in balance during gait in
both groups can be explained by the fact that all pa-
tients performed task-oriented trainings.
Moreover, virtual reality (VR) therapy is capable of mo-
tivating patients to a larger extent and thereby stimulating
new motor and sensory abilities responsible for main-
taining balance.9,24 A clinical trial that evaluated the
motivational aspects found that the group that under-
went treatment with VR was more motivated than the
control group.28 A recent systematic review drew atten-
tion to the need to include the outcome of motivation
after training with VR in the study.29
The VR can be an important tool in sensorimotor train-
ing of individuals after a stroke, as the visual feedback
provided by this training can modulate a neural network
in the motor, premotor, and parietal cortex. This sug-
gests that sensory information can promote cortical
reorganization.30,31 Some authors have indicated that this
visual feedback imposed by VR may generate an imme-
diate self-correction in the patient, thereby facilitating the
activation of neuronal plasticity,32,33 which increases its
clinical applicability.34
Other authors have suggested that a higher number
of repetitions and a longer treatment time facilitate
neuroplasticity,35 and the association of task-oriented train-
ing with a suitable treatment time may influence the
rehabilitation.36,37 The use of VR favors longer sessions
and greater variability of tasks,38 capable of facilitating
this cortical reorganization. The duration of treatment with
VR, presented in a recent review that included different
studies, ranged from 2 to 22 hours,36 similar to the treat-
ment time of 20 hours used in the present study for both
groups.
In post-stroke patients, reduced gait velocity and risk
of falls are known to occur.39 Although there is no evi-
dence that the stimuli generated by the virtual and real
environments have equivalence in neural activation,40 the
scenes of varying capacity and movement trajectories pro-
vided by VR can stimulate gait training.34 This was verified
in studies that observed an increase in gait speed41 and
reduced time of implementing the 10-m walk test42 after
gait training with VR. However, a systematic review con-
sidered that VR was a safe tool for rehabilitation but was
not a substitute for conventional physical therapy.43
There was no difference in improvement of balance
during gait and the occurrence of falls between the groups
in this study. The authors of this study recognize that
the selection of games may have influenced this result.
The two protocols had similar goals: the activities carried
out in the conventional therapy were directed to balance
E. PEDREIRA DA FONSECA ET AL.
training on a static basis, and the balance in gait and the
games used in VR therapy gave priority to balance train-
ing on a static base. This reaffirms the importance of
planning the intervention protocols and pairing goals more
specifically, advocated in a previous clinical trial that also
did not observe significant differences between the groups.7
In disagreement with these findings, the authors ob-
served that the experimental group had boosted control
of balance after the intervention.8 This difference in find-
ings may be due to changes in the approach to balance
outcome. In the present study, we evaluated the balance
during gait by DGI,9 and in different clinical trials the
performance of balance evaluated was not specifically in
walking and different assessment tools were used.7,8,15,17,26,44
Authors who used the DGI to assess the outcome of
balance after intervention with VR in post-stroke pa-
tients corroborated the results of the present study.27,45
Post-stroke patients can evolve with limitations of balance
skills and gait, with consequent increase in the occur-
rences of falls.27,39 In the present study, investigation of
the occurrence of falls after 3 months found a reduction
in this occurrence in both groups, but it was significant
only in the group that underwent therapy with Nintendo
Wii. This investigation period was similar to that used
by other authors.27,39 This finding corroborates those of
a study including patients with different neurologic dis-
orders, which found the reduction in falls was achieved
after training based on VR games.41 Various authors have
reported that training with VR resulted in improved balance
and auto safety balance, reported by post-stroke patients,27,31
which may reflect on performing daily activities.46,47 The
results of a clinical trial showed that treatment with VR
was effective in improving the balance and functional in-
dependence of individuals after a subacute stroke.42
Despite the risk of falls identified in the study popu-
lation, with an average DGI value ≤19, there was no
correlation between the result of the DGI and the number
of falls. Only in the domain—going up and down the
stairs—was DGI correlated with decreases in the control
group. This can be justified by the fact that after a stroke
individuals became more unstable in the medial-lateral
displacement of the center of gravity,45 which may hinder
the task. In contrast, the variation of sensory environ-
ments provided by the training with VR27,46 can improve
patient safety in carrying out activities that require greater
control of postural stability, such as going up and down
the stairs.
The advantage of this study was the fact that it ex-
panded the investigation of the effects of VR games-
based therapy on gait balance rehabilitation and the
occurrence of falls in post-stroke patients. As limitation,
there is the fact that the games are not specifically mar-
keted for the purpose of rehabilitation, which could limit
physiotherapists in adapting them to specific objectives
of the visits. In addition, the small sample size and the
treatment time may have had a negative influence on
VIRTUAL REALITY ON POST-STROKE PATIENTS
obtaining some inferences and could not provide infor-
mation on the severity of stroke in regard to motor
weakness, and involvement of sensory and visual im-
pairment, and their impact upon balance.
Conclusions
The rehabilitation of gait balance in post-stroke pa-
tients using virtual reality had repercussions on the
reduction of falls. Considering the functional and moti-
vational aspects involved in performing the therapy with
games, this was shown to be a useful tool to achieve these
goals. We suggest conducting further clinical trials with
the use of virtual reality games specifically for rehabil-
itation purposes.
Acknowledgments: The authors would like to thank Daniel
Dominguez, Igor Matos, Marília Lira, and Marcelo Masruha
for their help in the acquisition of data.
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