Musculoskeletal disorders

Study identification

Participants

Intervention and Comparator

Outcomes

Results

Pathology

Authors/

Publication year/Country

Number of participants, age, sex

Type of VR

Intervention in each Group

Intervention duration and Follow-up

Outcomes (including pain measurement)

Main findings

Effect on pain

Side effects

Degenerative

1. Chronic neck pain

Sarig Bahat et al. [36]

Australia, Israel

32

VR group (kinematic training + VR) =16

Control group (Kinematic training)=16

Age (years)

VR group = 40.63 ± 14.18

Control group = 41.13 ± 12.59

Gender: females, males

VR group = 11,6

 Control group = 11,5

Immersive

(head-mounted display)

VR game

Both groups completed four to six training sessions comprising of similar kinematic training (KT) activities. The head pursuit task was conducted with the VR game in the VR group and with a laser pointer and poster in the control (laser) group.

5 weeks

Neck disability index (NDI), cervical range of motion (ROM), head movement velocity and accuracy. Kinematic measures were collected using the VR system that was also used for training, pain intensity (visual analogic scale- VAS), TAMPA scale of kinesiophobia, static and dynamic balance, global perceived effect and participant satisfaction

Significant improvements in NDI, ROM (rotation), velocity, and the step test in both groups postintervention. At 3-month post-intervention, these improvements were mostly sustained; however, there was no control group, which limits the interpretation of this. Between-group analysis showed a few specific differences including global perceived change that was greater in the VR group

At post-intervention only the VR group improved significantly in VAS:

Pre-intervention (Mean ± SD):

35.72 ± 17.7

Post-intervention (Mean ± SD) 22.10 ± 24.1 (P < 0.05)

 Cohen's d : 0.65 2

Three-month post-intervention (Mean ± SD)  6.95 ± 16.5 Cohen's d : 0.65 2

0.51

4 participants experienced motion sickness with the use of

the VR device during assessment.

.

2. Chronic neck pain

Sarig Bahat et al. [37]

Australia, Israel

90

VR training group=30

Laser training group

=30

Control group=30

Age median (Q1, Q3)

VR=48 (38.5, 57.5)

Laser=48 (35.5, 59)

Control=48 (35, 59)

Gender (F, M): VR= 19 (63%); 11 (37%)

Laser= 21 (70%); 9 (30%) Control= 23 (77%); 7 (23%)

Immersive

(head-mounted display)

VR game

A head-laser beam and poster, or VR hardware and

software was provided for home use while control group waited. The laser beam provided visual

feedback relating to head motion, but unlike the VR, laser training

velocity was not controlled.

12 weeks

Neck disability index (NDI), global perceived effect (GPE), and cervical motion velocity (mean and peak). Secondary outcome measures included pain intensity (VAS), health status (EQ5D), kinesiophobia (TSK), range, smoothness, and accuracy of neck motion as measured by the neck VR system

Significant improvements were demonstrated in NDI and velocity with good effect sizes in intervention groups compared to control. Velocity significantly improved at both time points in both groups. NDI, VAS, EQ5D, TSK and accuracy significantly improved at both time points in VR and in laser at 3 months evaluation in all but TSK. GPE scores showed 74-84% of participants perceived improvement and/or were satisfied. Significant advantages to the VR group compared to laser were found in velocity, pain intensity, health status and accuracy at both time points.

Pain intensity (VAS 0–100 mm)

Pre-intervention

VR group=

Mean 47.11 SD 21.1

Laser group= Mean=45.54 SD=22.35

Post-intervention

VR group: Mean= 25.83** SD=21.1

 Laser group: Mean=39.92 SD=22.4

3 months

VR group:

Mean=25.43** SD=23.1

Laser group= Mean=35.26** SD=24.1

Information not available

3. Neck pain

Rezaei et al

[41]

Iran

44

VR group=22

Control group=22

Age between

20 and 55 years.

Mean age in VR group=36.19 (9.80)

Mean age in control group 31.23 (9.49)

Sex (female %)

VR group: 42.90 Control group: 52.4

Non-immersive (Video game)

PC screen

A video game was placed above the laptop computer monitor screen. The head mouse was aimed on reflective marker, which represented head movements to control pointer movement on the laptop computer. The control group received eye-follow, gaze stability, eye-head coordination and position movement sense training.

4 weeks

Visual analogue scale score, neck disability index and Y-balance test

There were significant improvements in all variables in both groups immediately after and 5 weeks after the intervention. Greater improvements were observed in the visual analogue scale and neck disability index scores in VRT group, and the results for all directions in Y-balance test were similar in both groups. No side effects were reported.

VAS:

There were significant main effects for

time (F2,80=167.16, P<0.001) but not group

(F1,40=2.46, P=0.124) and the interaction

between time and group was significant

(F2,80=17.21, P<0.001). After the intervention, VAS score improved by a mean of 36.36 mm in the VRT group and 19.32 mm in the CPT

group. At the 5-week follow-up appointment,

the improvements were 37.54 mm and 18.78 mm, respectively.

There were no reports of discomfort, motion

sickness or pain exacerbation during or

after playing the VR game.

4.  Cervical Spondylosis

Mukherjee et al.

[35]

India

44

VR group= 22

Control group=22

Age 30 and above

Conventional group:

13 female and 9 male. Mean age: 54.81 ± 13 years.

VRT group: 8 female and 14 male. Mean age: 55.81 ± 15 years.

Immersive

(head-mounted display)

VR game

Both groups were given a hot pack before every session for 3 consecutive days.

The conventional group included active cervical exercises and stretching.

VR group required active cervical ROM to play the game.

Pain and ROM were assessed on the

immediate (day 1) and short-term (day 3) basis while kinesiophobia was assessed only on day 3.

Pain (Numeric Pain Rating Scale),

ROM, Tampa Scale of kinesiophobia (TSK)

VRT is more

effective than conventional treatment alone in the reduction

of pain immediately (day 1) and in short term (day 3). VRT

also demonstrated improvements in ranges of bilateral

cervical rotations and lateral flexion on the short-term

basis (day 3) while there was no improvement observed

immediate posttreatment (day 1). Both the treatment methods

were equally effective in reducing kinesiophobia.

Mean and SD Pain level (VAS):

Conventional group:

Pre: 5.72 ± 1.07 Immediate: 3.94 ± 1.67 Short-term: 2.71±1.45 VR group:

Pre: 5.77 ± 5.05 Immediate: 4.65 ± 1.08

Short term: 1.5 ± 0.80

Information not available

5. Chronic neck pain

Sarig Bahat et al.

[79]

Israel

52

VR group=27

Laser group= 25

Age: Mean 48.3; SD  13.5

Sex, female, n (%): Mean 52; SD 65.8

Immersive

(head-mounted display)

VR game

Participants were taught how to train by a qualified physiotherapist during a 20-minute session at baseline. A head-laser beam and poster or a VR system was provided for 4 weeks of home training. Individuals were instructed to train for short sessions up to 5 minutes continuously to avoid side effects.

4 weeks of KT using laser or virtual reality, with baseline, postintervention, and 3-month follow-up measures

Pain intensity (VAS), Neck Disability Index (NDI), Global perceived effect (GPE), Global mean velocity (°/s) of cervical motion (Vmean), Global Peak velocity (°/s) of cervical motion (Vmean), Tampa Scale of Kinesiophobia (TSK), Home exercise (number of exercise sessions performed in the 4 weeks of training), Global accuracy error (°) was measured during the VR accuracy module (difference between the target’s and the player’s position in degrees).

Self-reported response was 71% to 73% and kinematic response was 41% to 46%. Prediction models indicated an immediate increase in self-reported measures in men with NDI  20% slower (65°/s), and less accurate (16° error) cervical motion at baseline. In the longer term, older patients with higher NDI seemed to benefit more. In the second model, no factors significantly predicted improvement in kinematic measures at either time point.

At post intervention

55 (69.6)

reported pain intensity VAS reduced by over 50%,

At 3 months’ follow-up 38 (73.1)

of participants

reported pain intensity reduced by over 50%

Information not available

6. Chronic neck pain

Tejera et al.

[38]

Spain

44

VR group=22

Control group= 22

Age (years)

VR group (mean ± SD):

32.72 ± 11.63

(27.56–37.88)

Control group:26.68 ÷ 9.21

(22.59–30.76) p = 0.063

Male

VR group:

11

(50%)

Control group

10

(45.5%) p = 0.763

Female

VR group:

11

(50%)

Control group

12

(54.5%)

Immersive

(Head-mounted display)

VR game

Two VR mobile applications were installed: in the first one the participants performed only lateral flexion movements and the second includes flexion, extension and rotation movements. The control group performed neck exercises (flexion, extension, rotation and tilt exercises)

4 weeks

Visual Analog Scale (VAS), Conditioned Pain Modulation (CPM), Temporal Summation (TS), active cervical range of movement (CROM), Neck Disability Index (NDI), Pain Catastrophizing Scale, Pain-Related Fear of Movement/(Re)Injury, fear-avoidance beliefs questionnaire (FABQ), pain pressure threshold (PPT), Pain Anxiety Symptoms Scale (PASS-20),

Statistically significant differences were revealed for time factor and group*time interaction for kinesiophobia showing post-hoc differences in favor of the VR group at 3 months. Significant effects were shown for time factor but not for the group*time interaction for pain intensity, rotation range of motion (ROM), Neck Disability Index, pain catastrophizing, fear-avoidance beliefs, left side pressure pain threshold (PPT) and anxiety. Statistically significant differences were not found for time factor and neither in group*time interaction for CPM, TS, right side PPT, flexo-extension and lateral-flexion ROM.

There was a large effect size for the

VR group post-treatment (p=0.01, d=0.1.21), 1 month follow-up (p<0.01, d=1.12) and 3 month follow-up (p<0.01, d=1.44). There was a large e_ect size for control group post-treatment (p<0.01,

d=0.82), 1 month follow-up (p<0.01, d=1.53) and 3 months follow-up (p<0.01, d=1.44)

Information not available

7. Chronic neck pain

Nusser et al.

[39]

Germany

51

control group (CG) =20; sensorimotor group (SMG) =18; virtual reality group (VR) =17.

Age, year, mean (SD)

CG: 49.8 (8.1) SMG:53.1 (5.7) VR: 51.2 (8.8)

Number of women, n (%)

CG: 12 (66)

SMG: 11 (69)

VR: 9 (53)

Immersive

(head-mounted display)

VR game

The CG underwent a “standard rehabilitation programme”; patients also received special lectures about chronic pain. The SMG received the “standard rehabilitation programme” plus a “general sensorimotor training”. In addition to the “standard rehabilitation programme”,

patients in the VRG completed “neck-specific

sensorimotor training”.

3 weeks

Neck pain, headaches, active cervical range of motion, and Neck Disability Index

Compared with the control group, the virtual reality group showed significant advantages in relief of headaches, and active cervical range of motion in flexion and extension. Compared with the sensorimotor group, the virtual reality group showed significant improvements in cervical extension.

Within-group analysis showed a statistically

significant improvement in the VRG across all pain

categories. For the SMG, significant improvements were seen in reducing headaches while at rest. The CG saw significantly reduced neck pain during motion. Between group

analysis showed that the VRG improved significantly

more than the CG in reducing headaches at rest

(VRG vs CG p=0.008) and headaches during motion

(VRG vs CG p=0.023), each with large effect sizes.

Besides the weight of the helmet, which some patients

found unpleasant, no other negative side-effects were

reported regarding the VR device or in general.

8. Chronic neck pain

Cetin et al.

[40]

Turkey

41

VR group=21

Control group= 20

Age (years) Mean ± SD:

VR group: 40.0 ± 11.88

Control group: 41.94 ± 10.76

Gender

 Female

VR group: 12 (70.5); Control group: 11 (64.7) Male

VR group: 5 (29.5); Control group: 6 (35.3)

Immersive

(Head-mounted display)

Practical exercises

The VR group first performed exercises and then VR. The control group performed only exercises.

6 weeks

Pain intensity (visual analogue scale), pain pressure thresholds (PPTs), joint position sense error (JPSE), and muscle performance, Profile Fitness Mapping Questionnaire (ProFitMap-Neck), Hospital Anxiety-Depression Scale (HADS), and quality of life (SF-36).

VR was advantageous in terms of PPTs of the C1/C2 and C5/C6 articular pillar bilaterally and large effect size. VR was more effective in decreasing JPSE and functional limitation. Neither intervention was superior in terms of pain intensity, muscle performance, symptoms

Pain intensity decreased similarly in the two groups. There were no differences in the deltas of VAS between groups

Information not available

9. LBP

Kim et al.

[45]

South Korea

30 middle-aged female patients 

VR group=15

Control group=15

Age

VR group

mean age of 44.33 years

Control group: 50.46 years

Sex: all females

Non-immersive

(Wii Fit games)

In the experimental group, a virtual reality-based yoga program using Wii Fit activities. The CG performed trunk stabilizing exercise during the same time and same frequency.

The virtual reality-based yoga programs were performed in a total of 12 sessions over the course of four weeks, with each session lasting 30 minutes

VAS, algometer, Oswestry low-back pain disability index (ODI), Roland Morris disability questionnaire (RMDQ), and fear avoidance beliefs questionnaire (FBQ) scores

The experimental group showed a significant increase in VAS, algometer, ODI, RMDQ and FBQ scores. The control group showed a significant increase in VAS, algometer, ODI, RMDQ and FBQ scores.

VR group: significant decrease in

VAS (from 7.00 ± 0.89 points to 2.27 ± 1.10 points.

Control

Group: significant decrease in VAS (from 6.95 ± 0.79

points to 4.63 ± 1.91 points),

Information not available

10. LBP

Yoo et al.

[46]

South Korea

47

VR group=24

Control group=23

Age (mean; SD):

Control: 20.70 ± 1.45

VR group: 20.44 ±1.33

Sex: all men

Non-immersive Exergame

Avatar

The VR group performed horse simulator riding. The control group did any exercise.

8 weeks

VAS, body composition, isokinetic torque

Horse simulator exercise significantly reduced pain scores and enhanced torques of trunk. There was no significant increased muscle mass and decreased fat mass in horse simulator riding group.

Back pain

CG

Baseline: 1.50 ± 0.51

8 weeks: 1.00 ± 0.00

HG

Baseline: 4.37 ± 2.13

8 weeks: 2.22 ± 2.15

Night pain

Baseline:

CG 1.10 ± 0.31 HG: 0.90 ± 0.31

Information not available

11. LBP

Monteiro et al.

[47]

Brazil

30

VR group=16

Control group=14

Thirty older women (68 ± 4 years; 68 ± 12 kg; 154 ± 5 cm

Non-immersive

Exergame

Avatar

The control group was submitted to an exercise program with core and strength training. The VR group received the same intervention plus VR training using Nintendo Wii and Wii Balance Board. To minimize bias, control group performed balance tests on Wii Balance Boad weekly.

8 weeks

-Pain scale: NRS

-Physical tests: balance, sitto-stand test

Significative improve- ment of NRS for all groups after the intervention and functional capacity for sit only in VR group. It was not identified significant differences within or between groups for balance

Both groups showed similar perceived pain post-training (1,4 ± 2,9 and 1,7 ± 1,9, respectively). For this comparison ANOVA 2 x 2 showed F=0.08 and P=0.79 for interaction.

Information not available

12. LBP

Chen et al.

[48]

South Korea

19

VR group=10

Control group=9

Age between 19 and 30

Non-immersive (Indoor riding machine

simulating riding a real horse through the visual information

that appeared on the front screen by diving the virtual

environment.)

Each group carried out for 30 minutes exercise three times a week for 4 weeks. Horse riding simulator exercise group carried out 15 minutes horse riding simulator exercise and 15 minutes lumbar strengthening exercise. Lumbar strengthening exercise group carried out 30 minutes lumbar strengthening exercise.

4 weeks

Visual analogue scale (VAS) was measured for evaluation back pain. Korean oswestry disability index (KODI) was measured for dysfunction. Limits of stability (LOS) were measured for dynamic balance.

VR group and Control group showed significant differences after the intervention in VAS, KODI, and LOS. Comparison between the groups revealed no significant difference between the groups in VAS, KODI, and LOS before and after the intervention.

VAS (Mean ± SD):

Exercise 49.10 ± 18.89 22.70 ± 17.25

Control 43.66 ± 8.23 22.55 ± 7.77

Information not available

13. LBP

Yilmaz et al.

[42]

Turkey

44

VR group=22 Control group= 22 subjects

Age, years

Mean (SD)

VR group: 46.3 (3.4)

Control group: 52.8 (11.5)

Gender, n (%)

Male 12 (54.5) 4 (18.2)

Female 10 (45.5) 18 (81.8)

Immersive

(head-mounted display)

Mindfulness-based intervention

In each group, physical therapy was performed using physical agent modalities and therapeutic exercises. The experimental group was asked to passively watch the same virtual walking video clip in a sitting position with video glasses at each therapy session during hotpack application. For the virtual walking task, a video clip was taken by a cameraman who was naturally walking down Ireland forest.

3 weeks intervention

Visual Analog Scale (VAS), TAMPA Kinesiophobia Scale (TKS), Oswestry Disability Index (ODI), Nottingham Health Profile (NHP), Timed-up and go Test (TUG), 6-Minute Walk Test (6MWT), and Single-Leg Balance Test

Participants in the experimental group reported a significant improvement in the TUG score as compared with those in the control group. The effect size of the pre–post comparison in the experimental group was large. With regard to pain intensity, there was a significant interaction effect. The effect size of the pre–post comparison in the experimental was small. There was no significant interaction effect regarding kinesiophobia, disability, quality of life, balance, and 6MWT, respectively

Activity

Pain

(VAS)

Mean (SD)

Pre intervention

VR: 6 (1.06) Control: 5.63 (2.36)

Group difference: 0.514

Post intervention

VR: 2.52 (1.80) Control: 4.90 (3.39)

Group difference: 0.031 (p<0.05)

Information not available

14. LBP

Thomas et al.

[49]

USA

52

VR group=26

Control group=26

Age (mean (SD))

VR group: 23.9 (6.8)

Control group: 26.7 (8.5)

Sex (% female) VR group: 46.2 Control group: 50.0

Non-immersive

3-D shutter glasses which are required to produce the 3-D effect on television screen

Avatar

All participants completed a pregame baseline and a follow-up assessment (4–6 days later) of lumbar spine motion and expectations of pain and harm during standardized reaches to high (easier), middle, and low (hardest to reach) targets. The game environment was a basketball arena in which the participant played dodgeball against 4 virtual opponents.

For 3 consecutive days, participants in the game group played virtual dodgeball between baseline and follow-up.

(Roland-Morris Disability Questionnaire), pain (McGill Pain Questionnaire; MPQ), fear of movement (Tampa Scale of Kinesiophobia), and anxiety (State-Trait Anxiety Inventory)

For the standardized reaching tests, there were no significant effects of group on changes in lumbar spine flexion, expected pain, or expected harm. However, virtual dodgeball was effective at increasing lumbar flexion within and across gameplay sessions. Participants reported strong positive endorsement of the game, no increases in medication use, pain, or disability, and no adverse events.

The 2 Time (session 1, session

5) _ 2 Group (game, control) repeated measures ANOVAs

revealed significant main effects of time for the

Visual Analog Scale, F1,50=24.82, P<0.001, hp

2=0.33,

and Present Pain Intensity scale, F1,50=10.30, P<0.01,

hp2=0.17, and a marginal effect for the overall Pain Rating

Index, F1,50=3.74, P=0.06, hp2=0.07.

No reported

adverse events related to gameplay.

15. LBP

Zavarize et al.

[50]

Brazil

21

VR=10

Control group=11

Average age of the sample: 46.81 years (46.36 for Control Group and 47.30 for VR Group).

Both sexes

Non-immersive

(video games)

Control group participated in a physical therapy program to provide gain and of lumbar flexibility

and VR group participated in the same physical therapy program plus joint sessions with virtual games

1 week

VAS, Mc Gill’s pain questionnaire (MPQ), heart rate monitor

Significative improvement of VAS for all groups after the intervention, being higher in VR group

VAS (Mean, SD)

Control Group:

Pre-test: 7.18, 0.6

Post test: 3.32, 1.63

VR Group:

Pre-test: 6.7, 1.06

Post test: 1.4, 1.17

Information not available

16. LBP

Zadro et al.

[51]

Australia

60

VR group=30

Control group=30

Age (Mean, SD)

VR group:68.8 (5.5) Control Group: 67.8 (6.0)

Sex

Men

VR group: 29 (48.3) Control group: 12 (20)

Women

VR group: 31 (51.7) Control group: 18 (30)

Non-immersive

Exergames

Participants in the video-game exercise group engaged in

an unsupervised home-based exercise program

using a Nintendo Wii U console. In the control group the participants continued their usual activities.

8 weeks

Pain self-efficacy and care-seeking (primary outcomes), and physical activity, pain, function, disability, fear of movement/reinjury, falls efficacy, recruitment and response rates, adherence, experience with the intervention, and adverse events (secondary outcomes).

Adherence to the total recommended exercise time was 70.8%, and no adverse events were reported. Participants completing Wii Fit U exercises had significantly higher pain self efficacy at 6 months, but not immediately postintervention or at 3 months; there were no between-group differences in care-seeking. Compared with the control group, participants completing Wii Fit U exercises demonstrated significantly greater improvements in pain and function at 8 weeks and were more likely to engage in flexibility exercises at 6 months. There were no significant between-group differences for the remaining outcomes.

Wii Fit U exercises demonstrated significantly greater

improvements in pain (β =−1.07, 95% CI =−2.11 to

−0.03, P=0.04)

immediately post-intervention

compared with the control group.

Information not available

17. LBP

Kim et al.

[56]

South Korea

48

VR group=24

Control group=24

Age (Mean (SD))

VR: 26.0 (3.82)

Control: 28.79 (9.05)

Sex:

VR group:

Female (%): 7 (31.8%); Male: 15 (68.2%)

Control:

VR: 15 (57.7%)

Control: 11 (42.3%)

Non-immersive

(VR-based horse-riding simulator

2D screen visual, motion-haptic feedback)

The VR group performed similar patterns of exercise similar to a real horse riding. Control group performed exercises based on the same manual, focused on the exact motion and posture. The repetition of exercises and time required were dependent on the individual participant.

8 weeks of intervention, 6 month follow-up

Pain scale: NRS

Functional disabilities: Oswestry Disability Index (ODI), Roland- Morris Disability Questionnaire (RMD)

Fear-avoidance belief questionnaire (FABQ)

Both groups demonstrated significant differences in ODI and RMD and NRS at 4 weeks, 8 weeks, and at the 6 months follow-up. The VR group was more effective for reducing work related FABQ compared to control group at 6 month follow-up.

No significant differences in the NRS (F=1.696; p=0.211),

In within-group comparisons, both groups presented significant differences in NRS (both VR and Control groups after 4 weeks)

Information not available

18. LBP

Matheve et al.

[52]

Belgium

84

VR group=42

Control group=42

Age (Mean (SD)))

Control: 44.2 (11.9)

VR: 42.1 (11.5)

Sex (n female, %) Control: 27 (64%) VR: 27 (64%)

Non-immersive (Exergames)

Television screen

The VR group played games with pelvic tilts in the sagittal plane. A wireless motion sensor was placed on the sacrum and the sensor-signals were sent to a laptop connected to a TV screen on which the games were displayed. During the control intervention, participants stood in exactly the same spot as those in the VR group, but with the TV screen switched off and performed pelvic tilts in the sagittal plane according to a beep tone.

A single-session intervention

Numeric pain rating scale (NPRS)

Roland Morris disability questionnaire (RMDQ)

Pain Catastrophizing scale (PCS)

Tampa scale for Kinesiophobia (TSK)

VR distraction had a hypoalgesic effect during and immediately after the exercises, and it also reduced the time spent thinking of pain. Preliminary exploratory analyses showed that pain-related fear, pain catastrophizing and baseline pain intensity did not moderate the effects of VR distraction.

Compared to the control group, the VR-group had a

significantly larger reduction in pain intensity during the

exercises (VR group M=1.66, SE=0.25; Control group

M=− 0.55, SE=0.26; Difference= 2.20, SE=0.36, t80.9=6.11, p<0.0001, d=1.29 (95% CI=0.82–1.76)) and after

the exercises (VR group M=0.81, SE=0.25; Control

group M=− 0.50, SE=0.26; Difference= 1.31, SE=0.36,

t80.9=3.64, p<0.003, d=0.85 (95% CI= 0.40–1.29)).

Information not available

19. LBP

Park et al.

[53]

South Korea

80 elderly woman (61–84 years)

VR group=40

Control group=40

Age (y)

Control: 72.05 ± 6.82

VFR: 71.50 ± 6.34

All women

Non-immersive

(VR Horse simulator)

While the VR group participants were exercising on the horse, the control group participants sat on the horse and watched video from the monitor.

12 weeks

Oswestry Disability Index, visual analogue scale, body composition and spinal alignment measured using bioelectrical impedance and raster stereography. The isokinetic moments of trunk extensor and flexor were measured before and after the training period.

The VR group showed a significant decrease in back pain compared to the control group. No differences were shown in terms of muscle mass. There was an increased basal metabolic rate (BMR) in the VR group. Spinal alignment in the VR group significantly improved. The peak torques of the trunk extensor in the VR group were also significantly increased.

VAS (Mean ± SD)

Pre

Control:7.27 ± 1.52

VR: 7.35 ± 1.63

Post

Control: 7.64 ± 1.31

VR: 2.10 ± 2.54

Information not available

20. LBP

Tomruk et al.

[54]

Turkey

42

VR group=21

Control group= 21

Age (year)

VR: 46.00 (40.05–50.50)

Control: 45.00 (44.00–48.00)

Sex not indicated

Non-immersive

Computer-based stability

training (postural stability training, limits of stability training, weight shift training, and maze control training ) was applied to study group by help of computer-based device while in control group the training was applied in the same manner but without computer-based system.

12 weeks

Numeric Pain Scale, Oswestry Disability Index, limits of stability (LoS) and postural stability (PS) tests were used to evaluate postural control

Significant improvements occurred in LoS and PS scores in both groups after interventions. Physical activity scores

for both groups did not significantly change. There was superiority of computer-based stability training over the traditional training in improving LoS.

NRS scores decreased significantly in both groups with 2.0 points

median change (p<0.05).

NRS score

Pre-intervention VR: 7.00 (4.00–9.00)

Control6.00 (3.00–9.00)

Post-intervention Control:

VR: 3.00 (2.00–5.00)

Control: 4.00 (2.00–7.00)

Information not available

21. LBP

Yalfani et al.

[43]

Iran

25 elderly women

VR group=13, control group=12

Age

VR: 68 ±2.94

Control: 67.08 ±2.9

All women

Immersive

(Head-mounted display)

VR game

The VR group involved weekly sessions of exercises that were carried out using the Xbox Kinect headset. The control group carried on the daily live routines, without any special treatments during this period.

8 weeks

Pain intensity, fall risk, and QoL were assessed via the Visual Analog Scale, the Biodex Balance System, and the 36-Item Short Form Health Survey, respectively

pain intensity score of the intervention group significantly decreased after participation in the VRT program. The intervention group also showed reduced fall risk and elevated QoL. 

VAS

VR:

Pre test: 6.73 ± 2.42

Posr test: 2.19 ± 1.49

Control:

Pre-test: 6.79 ± 1.99

Post-test: 7.54 ± 1.9

Information not available

22. LBP

Afzal et al.

[55]

Pakistan

84

VR group= 42

Control group=42

Non-immersive

Practical exercises

Television screen

The mean age in group A was 37.5 ± 12.5 years and

in group B it was 38.2 ± 11.8 years

28 (33%) males and 56 (66.6%)

females.

CG received routine

physical therapy, while VRG received Virtual Reality exercises with routine physical therapy. In the VR group, the patients were subjected to trunk slide flexion, sitting to avoid obstacles, jumping and combined movement of arms, as displayed on the screen.

4 weeks

Visual Analogue Scale and Modified Oswestry Disability Index 

VR group showed significantly better results than group A.

Significant intra-group improvement in terms of pain and disability with VR showing significant more improvement than routine physical therapy.

Pain score at baseline was 6.62 ± 1.04 in group A and

6.50 ± 1.24 in group B which decreased to 3.32 ± 0.81 and

1.00 ± 0.60 respectively after the 12th session (p<0.05).

Information not available

23.LBP

Groenveld et al.

[44]

Netherland

41

VR group=21

Control group=20

Age (y)

VR:

Mean (SD)

51 (2.9)

Range 27-71

Control:

Mean 52 (2.5)

Range: 30-73

Sex

Females

VR: 17 (85)

Control:  16 (80)

Immersive

(Head-mounted display)

Behavioural therapy-based VR games

The VR and the control group were both on the waiting list for a follow-up visit to discuss advanced pain treatment, but the control group received no additional treatment or VR intervention. Vr games included psychological treatment principles based on the biopsychosocial model of pain.

4 weeks

Quality of life (SF-12), visual analogue scale (VAS), analgesics used daily,

Pain Catastrophizing Scale Pain, Oswestry Low Back Pain Disability Index Nottingham Extended Activities of Daily Living questionnaire (NEADL), Positive Health Questionnaire Hospital anxiety and depression scale (HADS)

No significant treatment effect was found for the short form-12 physical score and mental score 4 weeks. VR seemed to positively affect daily “worst pain score” and “least pain score”. Opioid use in the VR group was halved. VR had good treatment adherence and minimal and mild side effects.

A significant main treatment effect of VR was seen on

the daily worst experienced pain score (F (1, 91.425)=33.3,

P<0.001)

Three patients reported mild and

temporary dizziness.

24. Subacromial impingement syndrome and scapular dyskinesis

Pekyavas et al.

[57]

Turkey

30

VR Group=15

Control Group=15

Control group:

mean age: 40.6 ± 11.7 years

 VR Group: mean age: 40.33 ± 13.2 years

Sex not specified

Non-immersive

Exergames

All the subjects were included in a home exercise program. The VR group received supervised virtual reality exergaming program for shoulder movements with Nintendo Wii. This was parallel to the given home exercise program in control group.

6 weeks

Visual Analogue Scale (based on rest, activity and night pain), Neer and Hawkins Tests, Scapular Retraction Test (SRT), Scapular Assistance Test (SAT), Lateral Scapular Slide Test (LSST) and shoulder disability (Shoulder Pain and Disability Index (SPADI)).

 Intensity of pain was significantly decreased in both groups with the treatment. The VR Group had significantly better results for all Neer test, SRT and SAT than the Control Group.

Intensity of pain was significantly decreased in both groups

between time factors (p<0.05).

Information not available

25. Frozen shoulder

Donny Gunawan et al.

[34]

Indonesia

75

(Not specified how many participants in each group)

35-65 years (Age and sex not specified)

Non-immersive

CG received ultrasound diathermy modal therapy on painful shoulder for 10 minutes and shoulder stretching exercise Over Head Pulley (OHP).

VR group received  ultrasound  diathermy  at  shoulder  pain  area  for  10  minutes  and  shoulder stretching exercises using VR games

3 to 9 times a week

Pain and Functional Ability (DASH), shoulder joint motion range (JMR)

Stretching exercises compared with VG group exercises provided the same benefits of stretching with the OHP on improvement.

No significant difference between the VR and the control groups

Information not available

26. Rotator cuff rupture 

Menek et al.

[58]

Turkey

45

CEG=16

CKCEG=16

VGEG=16 

Age (years),

mean (SD)

CEG=52 (6.3)

CKCEG=50 (5.5)

VGEG=47 (7.1) 0.56

Gender, n (%)

Male

CEG=7 (47) CKCEG=8(53) VGEG=6 (40)

Female

CEG=8 (53) CKCEG=7 (47)

VGEG=9 (60) 0.54

Non-immersive

Exergames

Three arms: conventional exercise group (CEG), a structured closed kinetic chain exercise group (CKCEG), and a video-based game exercise group (VGEG).

6 weeks 

Pain severity; pain threshold; disabilities of the arm, shoulder, and hand questionnaire (DASH); rotator cuff quality of life index (RCQOL); range of motion (ROM); and joint position sense and approximation force of all individuals were evaluated pre- and post-treatment.

Statistically significant difference in all values of the pre- and post-treatment of the groups. When the differences between the groups were compared, CKCEG and VGEG values were more significant than CEG in all parameters. Improvements in pain threshold, ROM in shoulder flexion and abduction, DASH score, and all parameters of the RCQOL questionnaire in VGEG were statistically more significant than CKCEG.

CKCEG and VGEG values were more

significant than CEG in all parameters (P<0.017). Improvements in pain threshold,

in VGEG were statistically more

significant than CKCEG (P<0.017).

Information not available

27. Shoulder pain

Rizzato et al.

[59]

Italy

22

VR group=11

Control group=11

Age

Control: 62 ± 10.20

VR: 59.91 ± 10.93

Non-immersive

Exergames

All the subjects were treated manually by the physiotherapist, while for the last 20 min, they performed active exercises to improve shoulder strength and mobility, which had the same goals but differed in the exercising modality that was non-digital for Control group and digital for VR group.

10 consecutive sessions

VAS, shoulder mobility measured with a wireless inertial sensor, maximal iso­metric strength (Fmax) of the injured shoulder, PENN shoulder Score, Physical Activity Enjoy­ment Scale (PACES-short), Self-efficacy questionnaire, Attitudes to train at home questionnaire, Intention to train at home, and System usability scale (SUS).

Significant improvements in pain, strength, and PENN Shoulder Score in both groups. Patients' engagement improved, with significant increments in Self-efficacy and attitude scores in both groups after the rehabilitation. Pearson correlation showed significant correlations of the Δ scores (T₁ - T₀) between PACES and Self-efficacy and between PACES and Intention to train at home only in the VR group. SUS score after the rehabilitation overcame the cut-off value of 68, representative of good usability of a device.

VAS

Control:

Pre: 4.30 ± 2.52

Post: 2.70 ± 2.02

VR:

Pre: 4.04 ± 2.19

Post: 3.17 ± 2.49

(p<0.01)

Information not available

28. Patellofemoral pain

Ebrahimi et al.

[127]

Iran

26 women

VR group=13

Control group=13

Age (years)

VR group: 29.69 ± 5.69 19 40

Control group: 31.76 ± 5.52 25 40

All women

Non-immersive

Avatar

In the VR group the participants could move

their whole body in the space with Kinect, in addition to educations provided to the control group, who

continued their usual and normal lifestyle without any intervention

24 sessions within 8weeks

Balance was evaluated by modified

star excursion balance test (mSEBT) Other measures were pain, QOL, function, and brain activity, which were assessed using VAS, SF-36 questionnaire, Kujala questionnaire and step-down test, and quantitative EEG

Balance score, function, and quality of life improved significantly at post-intervention and 1 month follow-up in the VR group compared with the control group. VRT group showed a significantly decreased pain score. Alpha and theta power activity also increased in the brain of the VR group.

VR group showed a significantly

decreased pain score (P=0.004).

Information not available

29. Knee Osteoarthritis

Özlü et al.

[61]

Turkey

73

VR group=35

Control group= 38

Age (X ± SD) VR: 53.28 ± 10.42

Control: 53.71 ± 9.65

Gender

Female

VR: 17 (48.6) Control: 26 (68.4) 0.069

Male

VR: 18 (51.4) Control: 12 (31.6)

Immersive

(head-mounted display)

VR game

In the experimental group, plus the conservative treatment, a total of 15 sessions of a disease-specific gamification through VR glasses were applied

3 weeks Assessment before treatment, after treatment (3th weeks), and 4 weeks after treatment (7th weeks). 

Pain (visual analogue scale [VAS]), functionality (Lysholm functional knee score [LFKS], 6 minutes walking test [6MWT]), disability (Western Ontario and McMaster Universities Arthritis Index [WOMAC]), and balance (Berg Balance Scale [BBS]) 

VAS and WOMAC scores of the experimental group were lower at the 3rd and 7th weeks than those of the control group. LFKS of the experimental group was higher at the 3rd and 7th weeks than that of the control group. No difference was found between the groups in terms of 6MWTs. BBS score of the experimental group was higher in the 7th week than that of the control group. 

VAS

Week 0:

VR: 5.57 – 0.88

Control: 5.78 – 0.74

≠ between groups:

0.299

Week 3:

VR: 4.11 – 1.34

Control: 5.05 – 1.43

≠ between groups:

0.005

Week 7

VR: 4.05 – 0.72

Control: 5.36 – 0.99 ≠ between groups:

0.000

Side effects such as mild nausea, headache that did

not last long, require additional treatment.

Traumatic injury with conservative treatment

30. Post-traumatic osteoarthritis

Nambi et al.

[62]

Saudi Arabia

60

VRgroup=20

Sensoriomotor training (SMT) group=20, and control groups=20.

Non-immersive

VR games

The participants of both groups underwent 4 weeks of rehabilitation. The VR group received proprioceptive-stabilometric machine with screen. The SMT group received sensorimotor training exercises. The control group received supervised conventional exercise programs for the knee muscles.

4 weeks of intervention. 3 months of follow-up

Clinical (pain intensity and functional disability) and biochemical (bone morphogenic proteins and inflammatory biomarkers) values were measured at baseline, after 4 weeks, 8 weeks and 3 months follow up.

Four weeks following training, the VRT group shows more significant changes in pain intensity and functional disability than SMT and control groups. Bone morphogenic protein (BMP) measures such as BMP 2, 4, 6, and 7 don't show any significant changes between the groups. But at the same time, the VRT group shows positive improvement in inflammatory biomarkers (CRP, TNF-α, IL-2, IL-4, IL-6) analysis than the other two groups.

Pain intensity (VAS)

Base line

VR: 7.2 ± 0.5 SMT: 7.4 ± 0.4 Control: 7.3 ± 0.4

p-value: 0.355

4 weeks

VR: 3.3 ± 0.4 SMT: 5.8 ± 0.5 Control: 6.5 ± 0.5

p-value: 0.001*

8 weeks

VR: 2.5 ± 0.4 SMT: 3.5 ± 0.5 Control: 4.2 ± 0.5

p-value:  0.001*

3 months

VR:  0.5 ± 0.3 SMT: 1.5 ± 0.4 Control: 3.8 ± 0.4

p-value: 0.001*

Information not available

31. Ankle sprains

Punt et al.

[63]

Switzerland

90

VR group=30 Physical therapy (PT)=30 No treatment group (NT)=30

Age (years): VR group: 34.7 ± 10.7

PT group:

34.7 ± 11.3

NT group: 33.5 ± 9.5

Sex:

M/F

1VR group: 9/11

PT group: 20/10

NT group: 12/18

Non-immersive

(Exergames)

The participants in the VR group received a Wii balance board, the Wii Fit™ software, and detailed instructions so as to independently carry out their rehabilitation program at the difficulty level preferred. Patients allocated to conventional physical therapy received

treatment in order to guarantee homogenous

treatment modalities. The control group, did not receive any exercise therapy.

6 weeks

Foot and Ankle Ability Measure, pain during rest and walking, delay before return to sport, patient satisfaction, and effectiveness of the allocated treatment

Six weeks after the baseline measures, foot and ankle ability scores had improved in all groups, and pain had decreased during walking. VR was not more effective than only

physical therapy, or no exercise therapy at all.

VAS during rest

VR group:

Baseline: 1.3 ± 2.2

6 weeks: 0.6 ± 1.8

P value: 0.045

PT group:

Baseline:1.3 ± 2.1*

6 weeks: 0.9 ± 1.7*

P value: 0.163

NT group:

Baseline:1.1 ± 1.4

6 weeks: 0.7 ± 1.2

P value: 0.091

VAS during walking:

VR group:

Baseline: 2.6 ± 2.6

6 weeks: 0.9 ± 1.9

P value<0.001

PT group:

Baseline: 2.6 ± 2.5*

6 weeks: 1.7 ± 2.5*

P value=0.018

NT group:

Baseline: 2.6 ± 2.1

6 weeks: 1.7 ± 2.1

P value=0.005

Information not available

Orthopaedic surgery

32. Distal radius fracture

Naqvi et al.

[60]

India

20

VR group=10

Control group=10

VR group:

20% 18-25 years, 10% 26-35 years, 50% 36-45 years, 20% 56-65 years 80% males;

20% females. Control group:

30% 18-25 years, 10% 26-35 years, 30% 36-45 years,

30% 56-65 years 50% male-female distribution

Immersive

(Head-mounted display)

VR game

VR patients played on Oculus Quest head-mounted display (HMD), while control group patients received a conventional rehabilitation program.

4 weeks

Visual analogue scale (VAS), universal goniometer, Jamar dynamometer, and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire

There were significant improvements in pain, range of motion (ROM), grip strength, and functional independence in both groups. However, improvements in hand function and functional independence were significantly greater in the gamification group than in the conventional physiotherapy rehabilitation group.

The improvement in pain intensity between the groups was

statistically analyzed with an unpaired t-test and found to be statistically insignificant at t0 - baseline (p=0.08) but

significant at t2 (end of the second week) and t4 (end of the treatment) (p<0.001).

Information not available

33. Total Hip Arthroplasty

Fascio et al.

[64]

Italy

43

VR group=21

Control group=22

Age (years) Control group: 60.9 ± 7.52

VR group: 61.5 ± 6.21

Men—n. (%) Control group: 13 (56.5%)

VR group:

12 (57.1%)

Non-immersive

Practical exercises

All participants were invited to perform a daily home exercise program for rehabilitation after THA with different administration methods—an illustrated booklet for the control group and a tablet with wearable sensors for the VR group

2 weeks of intervention. Outcomes were measured before surgery and at the 4th, 7th, and 15th day after surgery.

BARTHEL: Modified Barthel Index; FIM: Functional Independence Measure; HOOS

JR: Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement and the degree of global perceived effect of the rehabilitation program (GPE).

Virtual-reality-based home rehabilitation resulted in similar

improvements in functional outcomes with a better GPE compared to the traditional rehabilitation

program following THA.

No difference was found in the

HOOS JR between VR and control at T0 (p=0.99), T1 (p=0.99), T2 (p=0.95), or T3

(p=0.855).

Information not available

34. Total hip arthroplasty

Zavala et al.

[65]

Chile

73

VR group=36

Control group=37

Age (yr), mean (SD)

VR group:

69.6 (8.8)

Control group: 69.9 (8.8)

Gender, number (%)

VR group:  

18 (50) female

18 (50) male Control group: 20 (54) female

17 (46) male

Non-immersive

Exergames

The control group received 6 weeks of physiotherapy treatment; the VR group received the same treatment plus virtual reality exercises with the Nintendo Wii console.

6 weeks

WOMAC questionnaire, Berg Balance Scale, distance covered with the six-minute walk test, and difference in weight load on the lower extremities.

The VR group

showed statistically significant differences in the function of patients with total hip replacement,

but these differences were not minimally clinically important

The difference between groups for the total WOMAC score was −10.4

points (p=0.00) in favour of the intervention group.

Information not available

35. Total knee arthroplasty (TKA)

Jin et al.

[66]

China

66

VR group=33

Control group=33

Age (years):

VR group: 66.4

± 3.49

Control group:

66.30 ± 4.41

Gender (n/percentage)

VR group:

15/45.45 male

18/54.55 female

Control group:

13/39.39 male

20/60.61

female

Immersive

Practical exercises

All recruited patients exercised by performing foot dorsiflexion and plantar flexion beginning the first day after TKA. Exercises targeting quadriceps muscle strength occurred from the second day after TKA. Passive exercises on knee flexion began after the drainage tube was removed. Exercises were assisted with psychological intervention and pain management education. In VR group the patients were asked to row a boat using knee flexion, beginning the second day after TKA. Patients in the control group were asked to flex their knees passively using their arms until pain tolerance was reached.

Variable depending on the number of Days needed for knee ROM to reach 60° and 90°

Western Ontario and McMaster University osteoarthritis index (WOMAC) measured before TKA and 1, 3, 6 months after TKA;  Hospital for Special Surgery knee score (HSS) measured before TKA and 1, 3, and 6 months after TKA;  Visual analogue scale (VAS) for pain measured at 1, 3, 5, and 7 days after TKA; Range of motion (ROM) measured before TKA and at 3, 7, and 14 days after TKA. Days needed for knee ROM to reach 60° and 90° were also recorded.

No significant differences were found in preoperative WOMAC index, HSS score, and knee ROM between control and experimental groups. WOMAC indexes were significantly lower and HSS scores were significantly higher in the experimental group than in the control group at 1, 3, and 6 months after TKA, respectively. VAS scales were significantly lower in experimental group than the control group at 3, 5, and 7 days after TKA.

No significant difference was observed in VAS scales between the two groups 1 day after TKA (P>0.05). VAS scales were signifi­cantly lower in VR group than control group at 3, 5, and 7 days after TKA (P<0.05).

WOMAC in-dexes were significantly lower in both groups after TKA as rehabilitation continued (P<0.05). Also, WOMAC indexes were significantly lower in the experimental group than the control group at 1, 3, and 6 months after TKA (P<0.05)

Information not available

36. Primary total knee arthroplasty (TKA)

Gianola et al.

[67]

Italy

85

VR group=44 Control group= 41 subjects

Age (years)

VR group: 66.6 ± 8.7

Control group: 70.7 ± 8.5

Gender

Men – no. (%)

VR group: 24 (54.5)

Control group: 13 (31.7)

Non-immersive

Avatar

Screen

Subjects were randomly allocated 3 to 4 days after TKA to one of two rehabilitation groups: experimental (VR rehabilitation) or control (traditional rehabilitation).

Baseline: 3–4 days after TKA; discharge: 10 days after surgery.

VAS, Western Ontario and McMaster Universities osteoarthritis index (WOMAC); health-related quality was measured by EuroQol five-dimensional (EQ-5D) questionnaire; global perceived effect (GPE) score; the functional independent measure (FIM); the frequency of medication assumption; the isometric strength of the quadriceps and hamstring muscles as assessed using a dynamometer, the knee active range of movement (ROM) and the proprioception assessed using the stabilometric platform of the VRRS.

VR-based and traditional rehabilitation shown no statistically significant pain reduction between groups as well as in all other outcomes, whereas a statistically significant improvement was present in the global proprioception, in favor of the VR-based rehabilitation group.

VAS pain score

Before TKA

VR group: 47.65 ± 21.29 ~

Control group: 60.20 ± 21.71

After TKA

VR group: 24.62 ± 16.80 3Control group: 1.23 ± 19.59

Change

VR group: -23.03 (95% CI _30.26 to _15.79) P value 0.26

Control group:

- 28.97 (95% CI _36.82 to _21.12)

WOMAC-total score

Before TKA

VR group: 1519.85 ± 170.39 Control group: 1670.25±199.03

After TKA

VR group: 729.57 ± 175.73 Control group: 904.48 ± 229.14

Change

VR group: -790.28 (95% CI _870.79 to _709.78)

Control group: -765.77 (95% CI _829.66 to _701.87) p value 0.62

Information not available

37. Total Knee Arthroplasty

Prvu et al.

[68]

USA

287

VR group=143

Control group=144

Age

VR group: 65.4 ± 7.7

Control group: 65.1 ± 9.2

Sex

VR group: 59.6% female

Control group: 65.4% female

Non-immersive

Avatar

After discharge, the VR group used a virtual telehealth system that functions with use of 3- dimensional (3D) tracking technology to quantify pose and motion, an avatar (digitally simulated coach) to demonstrate and guide activity, visual and audible instructions and immediate feedback on exercise quality, and a virtual video connection for synchronous telehealth visits with an assigned intervention telehealth physical therapist.

Patients in the conventional group followed their care team’s recommendations for all preoperative and postoperative medical and rehabilitative care.

12 weeks

The primary outcome was total health-care costs for the 12-week post-hospital period. Secondary (noninferiority) outcomes included 6 and 12-week Knee injury and Osteoarthritis Outcome Score (KOOS); 6-week knee extension, knee flexion, and gait speed; and 12-week safety measures (patient-reported falls, pain, and hospital readmissions).

VR patients had fewer rehospitalizations than the usual care group. VR was noninferior to usual physiotherapy in terms of the KOOS at 6 and 12 weeks. VR was also noninferior to usual care at 6 weeks in terms of knee extension, knee flexion, and gait speed and at 12 weeks in terms of pain and hospital readmissions. Falls were reported by 19.4% of VR patients and 14.6% of usual care patients.

Pain (points)

VR group:  3.6 ± 2.0

Control group: 3.2 ± 2.0 p value 0.120

KOOS (points)

VR group: 61.0 ± 11.5 Control group:

61.8 ± 13.5

P value 0.604

Pain

VR group: 66.6 ± 15.6 Control group: 68.7 ± 17.1

P value 0.286

Information not available

38. Total knee arthroplasty (TKA)

Fuchs et al.

[69]

Israel

55

VR group=30

Control group=25

Age (mean (SD))

VR group: 70 (7)

Control group: 70 (7)

Sex (n (%))

VR group:

19 (63.3%) female

11 (36.7%) male

Control group:

13 (52%) female

12 (48%) male

Immersive

(Head mounted display)

Virtual illusion

Both groups were treated with conventional physiotherapy and CPM equipment (Continuous passive motion device), the VR group received additional VR modality. The VR intervention included a movie that was picked by the patient from several options, either a nature film or a music film. The patient watched the VR film during the CPM physiotherapy.

The intervention was performed in day 1 and day 2 post-operatively. Revaluation after 6 months

State-Trait Anxiety Inventory (STAI) questionnaire (used to diagnose anxiety), Visual analog scale (VAS) for pain and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) (knee function score).

Both groups showed a decrease in pain and anxiety following the intervention but there was no difference between the groups. The was no difference in the WOMAC scores in the six-month postoperative examination between groups.

There was no difference in the amount of decreased pain between the study and the control groups (delta VAS Day 1 p-value=0.141; delta VAS Day 2 p-value=0.365).

Information not available

Rheumatological diseases

39. Ankylosing spondylitis

Karahan et al.

[70]

Turkey

57

VR group=28

 Control group=29

Age in years

(mean ± SD)

VR group: 36.1 ± 12.4 Control Group: 36.6 ± 11.3

Sex (m/f) VR group: 24/6 Control group: 23/7

Non-immersive

Exergames

The VR patients engaged in exergaming, and Control patients did not engage in any exercises.

8 weeks

Visual analogue scale (VAS), the Bath Ankylosing Spondylitis Functional Index (BASFI), the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Ankylosing Spondylitis Quality of Life (ASQOL) questionnaire.

In the exergame group, VAS, BASFI, BASDAI and ASQoL scores improved significantly after eight weeks of the program. The intergroup comparison after the eighth week showed significant differences between the two groups in VAS, BASFI, BASDAI and ASQoL, with the VR patients showing considerable improvement). No strain, injury or other musculoskeletal complications were recorded during the exergame workouts.

VAS

VR group:

Baseline: 4.9 ± 2.0

After 8 weeks: 3.6 ± 1.7*a (*p < 0.001 within groups; a p<0.05 between groups.)

P value<0.001

Control group:

Baseline: 5.1 ± 2.2

After 8 weeks: 5.0 ± 2.4

P value=0.241

No strain, injury or other musculoskeletal

complications were recorded during the exergame

workouts.

40. Juvenile Idiopathic Arthritis

Arman et al.

[71]

Turkey

50

VR group=25

Control group=25

Age, yr (Mean)

Control group=13.16 (3.35)

VR group=12.36 (2.98)

Sex (Female/male)Control group=21/4 VR group=21/4

Non-immersive

Exergames

In control group, activities of daily living were practiced using real materials from daily life, and in VR group, activities of daily living were practiced using video-based games

8 weeks

Numeric Rating Scale Muscle strength

Grips strength

Childhood Health Assessment Questionnaire

Canadian Occupational Performance Measure

Duruoz Hand Index

After treatment in both groups, significant changes were found in the Numeric Rating Scale, muscle strength, grips strength, Childhood Health Assessment Questionnaire, Canadian Occupational Performance Measure, and Duruoz Hand Index. VR group was statistically superior to Control group in changes of almost all upper limb muscle strengths, palmar pinch strength, Canadian Occupational Performance Measure satisfaction, and Duruoz Hand Index scores.

CHAQ-Pain (Mean)

Before

Control group: 43.60 (28.52)

VR group=31.00 (28.68)

P=0.12

After

Control goup=9.20 (17.54)

VR group=8.68 (15.60)

P=0.00

Difference between groups (Mean:

Control group=34.40 (24.03)

VR group=22.32 (21.41)

P=0.06

Information not available

Chronic Pain Generalization

41. Fibromyalgia

Collado-Mateo et al.

[72]

Spain

83

 VR group=42

Control group=41

Mean age ± SD:

VR group=52.52 ± 9.73

Control group=52.47 ± 8.75

Sex: all women

Non-immersive

Exergame

The VRG completed an 8-week training program, while the CG continued their normal daily life.

8 weeks

Fibromyalgia Impact Questionnaire (FIQ), EuroQoL-5 Dimensions-5 Levels (EQ-5D-5L)

97.62% of participants in the exercise group completed the 8-week intervention. The exercise group showed a significant improvement in the EQ-5D-5L utility index, and in 3 of 5 dimensions. For the FIQ, significant improvements were observed in the dimensions of pain, stiffness, anxiety, and feel good. The FIQ score was also reduced. The mean between-group improvement was 8.25 (95% confidence interval, 2.85-13.65).

VAS Health score Mean (SD)

VR group:

Before= 50.12 (14.50)

After= 58.41 (17.12)

Control group:

Before= 51.22 (18.86)

After=49.62 (17.20)

Mean difference (95% CI)=

-9.89 (-18.28 to -1.50)

P=0.021

Effect size= 0.064

Information not available

42. Fibromyalgia

Villafaina et al.

[73]

Spain

50

VR group=25

Control group=25

Age

Mean (SD)

VR group= 54.04 (8.45)

Control group= 52.72 (9.98)

Sex: all women

Non-immersive Exergame

VR participants completed 24 weeks of exercise intervention, whereas the control group continued with their usual daily life, including medication for those who were taking.

24 weeks

Euroqol-5 Dimensions-5 Levels (EQ-5D-5L), visual analogue scale (VAS).

89.29% of adherence in VR group. Significant effects on the perceived health status and pain intensity were found. The respond group obtained significant effects of the exergame intervention in EQ-5D-5L, pain VAS, and VAS-EQ, compared with those who did not respond.

VAS

Mean (SD)

VR group

Before:

64.80 (17.83)

After:

60.20 (16.74)

P=0.029 0.095

Control

Before: 59.20 (19.13)

After: 67.20 (17.44)

Information not available

43. Fibromyalgia

Carvalho et al.

[74]

Brazil

35

VR group=16

Control group=19

Age, years

Mean (SD)

Control group=47.70 (15.46)

VR group=55.64 (9.16)>0.05

Sex: all women

Non-immersive

Wii

Exergames

Six subgames of Wii Fit Plus were chosen for the VR group; the exergames group performed the program thrice per week with each session lasting 1 hour. The control group performed the chain muscle stretching technique thrice per week with each session lasting 1 hour.

7 weeks of intervention with three 1-hour sessions weekly and revaluation after the 10th and the 20th sessions.

Fibromyalgia impact questionnaire (FIQ), algometry, step tests, cardiopulmonary parameters, and fatigue in the lower limbs

The exergames group showed significant reduction of their fibromyalgia symptoms, as demonstrated by lower FIQ scores in the key domains on questions regarding missed work, pain, fatigue, problems resting, stiffness, anxiety, and depression. Significant improvements were observed in mean algometric values in the cervical region, the second chondrocostal junction, the lateral epicondyle, left medial knee border, left occipital region, trapezius, supraspinatus, gluteal muscles, and the greater trochanter. Improved cardiovascular adaptation was reflected by decreased systolic blood pressure, reduction in fatigue of the lower limbs assessed by the CR10 Borg scale, and improved exercise capacity assessed by a step test.

Pain, (cm)

Control group

E0=8.40 (1.50)A

E1=7.00 (2.53)A

E2=5.16 (1.96)B

VR group

E0=7.36 (2.36)A

E1=4.45 (1.57)B

E2=4.44 (1.30)B

ANOVA—P

Time-group=0.214

Time=<0.001

Group=0.030

effect size (f2)=0.753

Bonferroni test: WG versus CG and A versus B P < 0.05; effect size (f2).

E0 Baseline

E1: after10 sessions

E2: after 20 sessions.

Information not available

44. Fibromyalgia

Gulsen et al.

[75]

Turkey

20

VR group=10

Control group=10

Age (years)

Control group=38.50 (29.50–50.00)

VR group= 46.50 (36.50–49.50)

Sex: all women

Immersive

(Head-mounted display)

Practical exercises

The control group had combined exercise training consisted of 30 minutes

of aerobic training and 30 minutes of Pilates training and VR group had the same protocol with EG

plus 20 minutes of IVR, twice a week for 8 weeks

8 weeks

Visual analogue scale for pain, Modified Sensory

Organization Test for balance, Tampa Scale of Kinesiophobia for kinesiophobia, Fibromyalgia Impact

Questionnaire for impact of fibromyalgia, Fatigue Severity Scale for fatigue, International Physical Activity

Questionnaire for level of physical activity, six-minute walk test for functional capacity, and Short-Form 36

Health Survey for quality of life were used for evaluation

Pain, balance, kinesiophobia, impact of fibromyalgia,

fatigue, level of physical activity, functional exercise capacity and quality of life scores improved significantly

in both groups. VR group showed significant improvement compared to the EG regarding

pain, kinesiophobia, fatigue, level of physical activity, and mental component of quality of life.

VAS, cm

Control group:

Before=7.40

(5.92–8.35)

After=4.50

(3.47–5.72)

Within group

Comparison^a:

p=0.012*

Between group

comparison the

baseline^b:

p= 0.225

VR group:

Before=8.00

(7.55–8.95)

After=3.95

(3.32–4.5)

Within group

Comparison^a:

P=0.012*

Between group

comparison the

baseline^b:

p=0.225

*p<0.05

aWilcoxon test

bMann-Whitney U test

Information not available

45.Fibromyalgia

Polat et al

[76]

Turkey

42

VR group=21

Control group=21

Age

VR group= 46.00 (40.05-50.50)

Control group=45.00 (44.00-48.00)

Non-immersive

Biodex Balance System (BBS)

Computer-based stability

training was applied to study group by help of computer-based device two times a week for 12 weeks while traditional training was done to

another group.

12 weeks

Pain and disability were assessed by Numeric Pain Scale and Oswestry Disability Index, respectively. Limits of stability (LoS) and

postural stability (PS) tests were used to evaluate postural control by Biodex Balance System and SenseWear Armband was used for physical

activity assessment. All measurements were applied before and after the training.

Significant improvements occurred in LoS and PS scores in both groups after interventions (p<0.05). However, physical activity scores

for both groups did not significantly change (p<0.05). Statistical analyses of between-group mean differences showed that there was superiority

of computer-based stability training over the traditional training in improving LoS (p=0.023).

NRS score

VR group:

Before=7.00 (4.00-9.00)

After=3.00 (2.00 – 5.00)

P=0.021

Control group:

Before=6.00 (3.00-9.00)

After= 4.00 (2.00 – 7.00)

P=0.038

Difference between groups

Before: p=268

After=0.041

*p<0.05

Information not available

Burn

46. Paediatric burn patients

Parry et al.

[83]

USA

17

VR group=9

Control group=8

Age

Mean (SD)

Control group=

12.3 (± 4.4)

VR group=10.6 (± 4.5)

Non-immersive

(Videogames)

The participants performed exercises

using either standard therapy range of movement activities (Control group) or interactive videogame therapy (VR group).

6 months

Planar and functional ROM was

measured using goniometry and motion analysis

Pain, enjoyment, engagement, and perceived

 “fun” that they experienced during the

treatment session using a 0 to 10 rating scale

Patients in

both groups showed significant improvement in shoulder flexion,

shoulder abduction, shoulder external rotation, and elbow flexion ROM from baseline to 6 months as measured with goniometry.

There was no difference in ROM gains between the groups. Control

subjects showed an increase in pain during the intervention, whereas VR subjects did not.

For the rating of

“worst pain” during therapy session, control group subjects

demonstrated a slight increase over time (r=0.18;

P <0.01) but the VR group group did not (r=0.047).

A significant difference was found between these

correlation coefficient (P=0.015). The difference

between correlation coefficients was also significant

for lower pain before stretching (VR group: r=-0.05,

Control group: r=0.176; P=0.02) and after stretching (VR group:

r=-0.133, Control group: r=0.119; P=0.009).

Information not available

47. Adolescent burned

Waked et al.

[80]

Egypt

56

VR group=28

Control group=28

Age (Mean ± SD)

VR group=13.96 ± 2.05 Control group=13.61 ± 1.97

Sex

VR group:

18(64.3%) male; 10(35.7%) female

Control group:

13(46.4%) male;

15(53.6%) female

Immersive

(Head-mounted display)

Visual illusion

VR group received VR during physiotherapy session while control group received

physiotherapy without VR.

2 weeks

Adolescent Paediatric Pain Tool (APPT)

Range of Motion measurement (ROM)

Highly significant and substantial declines in all pain outcomes

(mean total painful areas, pain intensity, sensory, affective, evaluative and temporal dimensions of pain) and improvement in ROM of Hip extension, hip abduction, dorsiflexion and knee extension in

VR group compared to control group.

Marked decrease in mean total number of descriptive words of sensory F (1.79, 48.52)=259.32, p<0.001, affective F (1.37, 75.66)=122.72, p<0.001, evaluative F (2.22, 59.92)=219.51, p<0.001, and temporal dimensions F (2.52, 68.29)=414.88, p<0.001 in VR group with the time from first session to sixth session. For control group, there is decrease mean total number of descriptive words of sensory F (1.29, 35.02)=13.76, p<0.001, affective F (2.91, 78.49)=41.27, p<0.001, evaluative F (3.06, 82.56)=21.15 p<0.001 and temporal dimension F (3.02, 81.63)=42.57, p<0.001 with the time from first session to sixth session. In comparing both groups, there was highly significant difference between both groups. The percentage of decrement in mean total number of descriptive words of sensory, affective, evaluative and temporal dimension were 45.5%, 68.9%, 60.3% and 58.3% respectively for VR group while for control group the percentage of improvement were 10.8% and 19.7%, 12.1% and 17.7% respectively.

Information not available

48. Burned Hands

Joo et al.

[82]

South Korea

57

VR group=28

Control group=29

Age (years)

VR group= 48.07 ± 8.14

Control group= 41.69 ± 14.05

Sex

Male: Female VR group=28:0

Control group=26:3

Non-immersive

(Exoskeleton type glove combined with the VR system)

.

All patients received a four-week intervention. The VR group received 30-min standard therapy and 30-min VR-based

rehabilitation. The Control group received 60-min standard therapy.

An effort was made to match the exercise rehabilitation in both groups and to adapt the level of difficulty to each patient’s performance. The intervention frequency and duration did not differ between the VR and Control groups.

4-week

Hand function was evaluated before intervention and four weeks after intervention using the Jebsen-Taylor hand function test (JTT), Grasp and Pinch Power Test, Purdue Pegboard test (PPT), and Michigan Hand Outcomes

Questionnaire (MHQ).

The JTT scores for picking up small objects and the MHQ scores for hand function, functional ADL, work, pain, aesthetics, and patient satisfaction were significantly higher in

the VR group than in the Control group

Pain (changes of pre-intervention and post-intervention)

VR group=-23.21 ± 24.62 Control group= -13.62 ± 21.25 p=0.12

Information not available

49. Paediatric burns

Ali et al.

[81]

Egypt

22

VR group=11

Control group=11

Age (years)

VR group= 13.82 ± 1.4

Control group=12.55 ± 2.06

Sex (Boys/Girls) VR group=7/4

Control group=6/5

Immersive

(Head mounted display)

Visual illusion

The control group received physical therapy session. The subjects in the VR group were treated by the same exercises program while using VR oculus as a distraction method. Children look into VR oculus which blocks their view of the hospital room. Earphones block sounds and substitute more calming music and sound effects.

Before-after 20 min treatment assessment

VAS before and immediately after the treatment session. Maximum available range of motion of the treated joints was measured before the physical therapy session and immediately after the session, using an electronic digital goniometer

There was a significant decrease in pain intensity and increase of ROM after application of VR in the study group and a significant difference between groups after treatment for pain and ROM.

Pain

VR group:

Before:

7.27 ± 0.9

After: 3.1 ±1.04 p=0.001

Control group:

Before:7.6 ± 1.02 After: 7.72 ± 1.3 p=0.739 

Between groups p<0.001

Information not available

Neurological disorders

50. Phantom pain (PLP)

Rothgangel et al.

[84]

Netherlands

75

Goup A (n=25): mirror therapy (MT) followed by teletreatment using augmented reality MT

Group B (n=26): traditional MT followed by self-delivered MT (group B)

Group C (n=24):  sensorimotor exercises to the intact limb followed by self-delivered exercises.

Age, mean (SD) Group A=59.7 (16.1)

Group B=62.5 (11.4)

Group C= 61.0 (15.2)

Gender, male Group A=80.8 (21)

Group B=56.0 (14)

Gender, male Group A=80.8 (21)

Group B=56.0 (14)

Group C=70.8 (17)

Group c=70.8 (17)

Non-immersive

(Augmented virtual reality using the tablet-integrated camera)

Four weeks of traditional mirror therapy (MT) followed by six weeks of teletreatment using augmented reality MT (group A), four weeks of traditional MT followed by six weeks of self-delivered MT (group B) and four weeks of sensorimotor exercises to the intact limb followed by six weeks of self-delivered exercises (group C). 

Intervention for 6 weeks. Measurements at baseline and follow-up measurements at 4 weeks, 10 weeks and 6 months

Numeric Rating Scale

Neuropathic Pain Symptom Inventory

German version of the Patient-Specific Functional Scale

Pain-related disturbances in sleep and mood were measured using an 11-point NRS.

German version of the 5-dimensional EuroQol questionnaire

Visual Analogue Scale to score overall health

Global Perceived Effect scale

German version of the Pain Self-Efficacy Questionnaire

Effects of MT at four weeks on PLP were not significant. MT significantly reduced the duration

of PLP at six months compared to the teletreatment and control group.

The teletreatment had no additional effects compared to self-delivered MT at

10 weeks and 6 months

The frequency of PLP showed a positive change in all groups, with 22 patients (47%) in the MT group and 6 patients (32%) in the control group reporting improvement.

Two

patients in the MT group showed complete recovery of PLP.

The duration of PLP improved in 17 patients

(35%) in the MT group and in 3 patients (16%) in

the control group. Patients who suffered from constant pain profiting

most.

Information not available

51. Joint pain in stroke* (^* Joint pain in stroke is a musculoskeletal disorder integrated in a neurological condition)

Anwar et al.

[85]

Pakistan

68

VR group=34

Control group=34

Age

VR group=51.56

Control group=51.35

Non-immersive

(Exergames)

The VR group received a 1-hour session of VR training for 3 weekdays over 6 weeks, and the routine physical therapy group received different stretching and strengthening exercises.

6 weeks

Berg Balance Scale for balance and the Fugl-Meyer Assessment (upper extremity) scale for sensorimotor, joint pain, and range assessment. The assessment was done at the start of treatment and after the 6 weeks of intervention

Significant difference between the two groups was found in the Berg Balance Scale score, Fugl-Meyer Assessment for motor function, and Fugl-Meyer Assessment for joint pain and joint range suggesting a clinically meaningful increase in the VR training community relative to the routine physical therapy group.; no significant difference in the Fugl-Meyer Assessment for upper extremity sensation.

Fugl-Meyer Assessment for joint pain

Mean (SD)

VR group:

Before=12.47 (3.79)

After=19.62 (2.86)

Control group:

Before=11.65 (3.16)

After=14.62 (4.00)

P<0.01

Information not available

Cancer

52. Mastectomy with axillary lymph node dissection

Feyzioglu et al.

[86]

Turkey

All participants were women

40

VR group=20

Control group=20

Age (years)

Mean (SD)

VR group=50.84 (8.53)

Control group=51.00 (7.06)

Non immersive

(Exergames)

The Kinect-based rehabilitation group and the standardized physical therapy group received standard physiotherapy.

6 weeks of intervention. Assessment at baseline and after the 6-week treatment.

Pain (visual analogue scale), grip strength (dynamometer), functionality (disabilities of the arm shoulder and hand questionnaire), muscle strength (handheld dynamometer), ROM (digital goniometer), and fear of movement (Tampa kinesiophobia scale (TKS)).

Both groups detected significant changes in pain, ROM, muscle strength, grip strength, functionality, and TKS scores after the treatment. Fear of movement was significantly improved in the VR and the Control group displayed more

improvement in functionality. There were no differences in ROM, muscle strength, grip strength, and pain between the groups after the treatment.

VAS for pain (0–10)

VR group:

Before treatment=6.53 (1.65)

After=1.53 (1.35)

Control group:

Before treatment=6.53 (2.07)

After=2.56 (1.82)

Pre-post treatment

VR group:

 P=0.001**

Control group

P=0.001*** 0.065

**p values obtained from the paired t test for the VR group

***p values obtained from the paired t test for the Control group

# p overall values obtained from the linear model, repetitive measures=0.065

No complications occurred during Xbox Kinect VR training

performed early in the postoperative period after breast

cancer surgery

53. Breast cancer-related lymphedema 

Basha et al.

[87]

Saudi Arabia

60

VR group=30

Control group=30

Age

Mean (SD)

VR group=48.83 ± 7.0

Control group=52.07 ± 7.48

All participants were women

Non immersive

(Exergames)

The Xbox Kinect group received VR Kinect-based games and Control group received resistance training. In addition, both groups received complex decongestive physiotherapy (manual lymphatic drainage, compression bandages, skin care, and exercises).

8 weeks

Excessive limb volume

visual analogue scale (VAS) Disability of the Arm, Shoulder, and Hand (DASH) questionnaire

shoulder range of motion (ROM) shoulder muscles strength, hand grip strength Study Short-Form (SF-36).

Statistically significant differences were recorded in VAS (pain intensity), DASH, shoulder ROM, bodily pain, general health, and vitality in favour of the VR group. However, there were statistically significant differences in shoulder flexion strength, external rotation strength, and abduction strength and handgrip strength in favour of the Control group

Change from baseline to 8 weeks MD (95% CI)

VR group:

VAS pain= 31.0 (28.85, 33.15), p<0.0001

VAS-heaviness=21.67 (19.58, 23.75), p<0.0001

VAS-tightness=15.67 (12.98, 18.35), p<0.0001

Control group:

VAS pain=15.67 (13.52, 17.82), p<0.0001

VAS-heaviness= 19.0 (16.92, 21.08), p<0.0001

VAS-tightness=12.67 (9.98, 15.35), p<0.0001

Information not available

Other

54. Cardiac Rehabilitation

Cacau et al.

[88]

Brazil

60

VR group=30

Control group=30

Age (Mean ± SD)

VR group= 49.2 ± 2.6

Control group= 52 ± 2.4

Sex (male/female)

VR group= 13/17

Control group= 16/14

Non-immersive

(exergames)

Patients allocated in control group performed conventional physical therapy treatment twice a day. The treatment protocol included: breathing exercises, airway clearance techniques, metabolic exercise and motor exercise. Patients allocated in virtual reality group were treated twice a day performing the same techniques than conventional treatment however the motor exercise was performed using virtual reality.

All patients had their functional performance reassessed on the first, third, postoperative day (PO) and at the discharge day

Six-minute walk test (6MWT) and

Nottingham Health Profile (NHP) reassessed on the first, third, postoperative day (PO) and at the discharge day

On the first day after surgery, patients in both groups showed decreased functional performance. However, the VR group showed lower reduction when compared to Control group in first postoperative day, and no sig­nificant difference in performance on discharge day. In evaluating the NHP field, we observed a significant decrease in pain score at third assessment. There were no differences with statistical significance for emotional reactions, physical ability, and social interaction. The length of stay was significantly shorter in patients of VR group, who also had a higher 6MWD.

Post surgical pain in the field of NHP (Nottingham Health Profile):

Lower score (P<0.05) among deltas 1, 2 and 3 as well as the type of treatment, with a significant statistical improvement in the VR group in delta 3 (P<0.05).

Delta 1 (difference of pre-operative score for first postoperative day);

Delta 2 (difference of pre-operative score for third postoperative day) and

Delta 3 (difference of preoperative score for the discharge day).

Data were analysed using two-way ANOVA (Delta 3 *VR x CG, P<0.05)

Information not available

55. Vestibular disorders

Alahmari et al.

[89]

USA

48

VR group=20

Control group=18

Age (Mean±SD)

VR group=53 ± 2

Control group=61 ± 3

Sex (female/male)

VR group=15/5

Control group=16/2

Immersive

(CAVE)

VR game

For the PT intervention, subjects were treated for 6 treatment sessions (one session per week) by a physical therapist. For the VRBT intervention, subjects were treated for 6 treatment sessions (one session per week) using a virtual grocery store displayed in an immersive environment. Both interventions also included prescription of home exercises, consisting of gaze stabilization or static balance sensory integration tasks.

6 weeks of intervention. Subjects were examined one week before, one week after, and six months after the intervention

Activities-specific Balance Confidence scale

Dizziness Handicap Inventory

Situational Characteristics Questionnaire

Dynamic Gait Index

Functional Gait Assessment

Timed Up and Go test

Sensory Organization Test

nausea, headache, dizziness, and visual blurring using a visual analogue scale (VAS)

Simulator Sickness Questionnaire

In both groups, significant improvements were noted on the majority of self-report and performance measures one week after the intervention. Subjects maintained improvements on self-report and performance measures at 6 months follow up. There were not between group differences. Nausea, headache, dizziness and visual blurring increased significantly during the VR sessions, but overall symptoms were reduced at the end of the six-week intervention.

Headache VAS significantly increased during the session but decrease at the end of the six-week intervention

Pre and post VAS headache ratings (mean ± SEM) :

Before VR= 0.5 ± 0.2

After VR= 0.8 ± 0.3

Time p value=0.034

VAS Headache

After session 1=0.4 ± 0.1

After session 2=0.7 ± 0.2

After session 3=0.5 ± 0.2

After session 4=0.4 ± 0.1

After session 5=0.6 ± 0.3

After session 6=0.2 ± 0.1

Session p value=0.34

Nausea, headache, dizziness and visual blurring increased significantly during the VRBT sessions, but overall symptoms were reduced at the end of the six-week intervention.

56. Active aging

Lee et al.

[90]

South Korea

54

VR group=26

Control group=28

Age, mean (SD) (years)

VR group=68.77 (4.62)

Control group=67.71 (4.31)

Non-immersive

(Xbox games + KINECT to capture the movement)

Both groups received a 60-min intervention three times a week for eight weeks. The VR and the non-VR exercise plan were similar.

8 weeks

Short-Form Health Survey (SF-36)

30-Second Chair Stand Test (30SCST)

8-Foot Up-and-Go Test (8FUGT)

2- Minute Step Test (2MST)

VR group showed

greater improvement in mental health and lower body strength, compared to GG.

Within-group analysis for HRQoL revealed that VR group showed an increase in role-physical,

bodily pain, general health, vitality, role-emotional, and

mental health, whereas control group showed an increase in role-physical, general health, and social functioning. Both groups showed an increase in 30SCST, 2MST and

8FUGT.

Bodily pain

VR group:

Baseline= 65.65 (21.38)

Follow-up=76.31 (19.27)*

Change=10.65 (21.28)

Control group:

Baseline=54.36 (24.70)

Follow-up=64.43 (24.77)

Change=10.07 (28.43)

Adjusted between-group

mean difference (95% CI) b=7.71 (_4.00 to 19.42)

p<0.192

Information not available

Pain condition

Study

PEDRo scale

1

Eligibility

2

Randomization

3

Allocation

Concealed

4

Groups

Similar

5

Blinding

Subjects

6

Blinding

Assessors

7

Outcome

Measures

8

Outcome

Measures

9

Intention to treat

10

Statistical comparison

11

Variability measures

Total

IVS

1. Chronic neck pain

Sarig Bahat

et al. 2015 [36]

 Y

Y 

Y 

Y 

N 

N 

Y 

Y 

Y 

Y 

 Y

9

7

2. Chronic neck pain

Sarig Bahat et al. 2018 [37]

 Y

 Y

Y 

Y 

N

N 

NA 

N 

N 

Y 

Y 

6

2

3. Neck pain

Razae et al.

2019 [41]

 Y

 Y

Y 

Y 

N 

N 

Y 

Y 

N 

Y 

Y 

8

4

4. Cervical Spondylosis

Mukherjee et al. 2020 [35]

 Y

 Y

Y 

Y 

N

N 

Y 

Y 

Y 

Y 

Y 

9

5

5. Chronic neck pain

Sarig Bahat

2020 et al. [79]

 Y

 Y

NA 

NA 

 N

 N

NA 

N 

N 

Y 

 Y

4

1

6. Chronic neck pain

Tejera et al.

2020 [38]

 Y

 Y

Y 

Y 

 N

N 

Y 

Y 

 Y

Y 

Y 

9

5

7. Chronic neck pain

Nusser et al.

2021 [39]

 Y

 Y

Y 

Y 

 N

N 

N 

Y 

Y 

Y 

Y 

8

4

8. Chronic neck pain

Cetin et al.

2022 [40]

 Y

 Y

Y 

Y 

 N

N 

N 

Y 

Y 

Y 

Y 

8

4

9. LBP

Kim et al.

2014 [45]

 Y

 Y

NA 

 Y

 N

 NA

 NA

Y 

Y 

Y 

Y 

7

3

10. LBP

Yoo et al.

2014 [46]

 Y

 Y

 NA

Y 

 N

N 

NA 

Y 

 N

Y 

Y 

6

2

11. LBP

Monteiro et al. 2015 [47]

 Y

 Y

Y 

Y 

 N

NA 

Y 

Y 

N 

Y 

Y 

8

4

12. LBP

Chen et al.

2016 [48]

 Y

 Y

 NA

Y 

 N

NA 

NA 

NA 

Y 

Y 

Y 

6

2

13. LBP

Yilmaz et al.

2016 [42]

 Y

 Y

Y 

Y 

 N

N 

Y 

 Y

Y 

Y 

Y 

9

5

14. LBP

Thomas et al.

2016 [49]

Y

Y

Y

Y

N

N

Y

Y

Y

Y

Y

9

5

15. LBP

Zavarize et al.

2016 [50]

 Y

 Y

Y 

Y 

 N

N 

NA 

Y 

Y 

Y 

Y 

8

4

16. LBP

Zadro et al.

2019 [51]

 Y

 Y

Y 

Y 

 N

N 

Y 

Y 

Y 

Y 

Y 

9

5

17. LBP

Kim et al.

2020 [56]

 Y

 Y

Y 

Y 

 N

N 

NA 

N 

Y 

Y 

Y 

7

3

18. LBP

Matheve et al. 2020 [52]

 Y

 Y

 Y

Y 

 N

N 

NA 

Y 

Y 

Y 

Y 

8

4

19. LBP

Park et al.

2020 [53]

 Y

 Y

NA 

Y 

 N

N 

NA 

Y 

Y 

Y 

Y 

7

3

20. LBP

Tomruk et al.

2020 [54]

 Y

 Y

 Y

Y 

 N

 N

 NA

Y 

 Y

Y 

 Y

8

4

21. LBP

Yalfani et al.

2022 [43]

 Y

 Y

Y 

 Y

 N

N 

 NA

 Y

Y 

 Y

Y 

8

4

22. LBP

Afzal et al.

2022 [55]

 Y

 Y

NA 

Y 

 N

N 

Y 

Y 

Y 

Y 

Y 

8

4

23. LBP

Groenveld et al. 2023 [44]

 Y

 Y

Y 

Y 

 N

N 

Y 

Y 

Y 

Y 

Y 

9

5

24. Subacromial impingement syndrome and scapular dyskinesis

Pekyavas et al. 2017 [57]

 Y

 Y

 NA

Y 

 N

 NA

NA 

Y 

Y 

Y 

Y 

7

3

25. Frozen Shoulder

Gunawan et al. 2020 [34]

 Y

Y 

NA 

Y 

 N

N 

NA 

NA 

Y 

Y 

Y 

6

2

26. Rotator cuff rupture

Menek et al. 2021 [58]

 Y

 Y

Y 

Y 

 Y

 N

N 

Y 

Y 

Y 

Y 

9

5

27. Shoulder

Pain

Rizatto et al.

2023 [59]

 Y

 Y

Y 

Y 

Y

Y 

Y 

Y 

Y 

Y 

Y 

11

7

28. Patellofemoral pain

Ebrahimi et al. 2021 [127]

 Y

Y 

Y 

Y 

N 

N 

Y 

Y 

Y 

Y 

Y 

9

5

29. Knee Osteoarthritis

Özlü et al.

2023 [61]

 Y

Y 

Y 

Y 

N 

N 

Y 

Y 

Y 

Y 

Y 

9

5

30. Post-traumatic knee osteoarthritis

Nambi et al.

2020 [62]

 Y

Y 

Y 

Y 

Y

N 

Y 

Y 

Y 

Y 

Y 

10

5

31. Ankle sprain

Punt et al. 2016 [63]

Y 

Y 

Y 

 Y

 N

N 

Y 

N 

Y 

Y 

Y 

8

4

32. Distal radio fracture

Naqui et al.

2022 [60]

Y

 Y

Y 

Y 

N 

N 

NA 

NA 

Y 

Y 

Y 

7

3

33. Total hip arthroplasty

Fascio et al. 2022 [64]

Y 

Y 

Y 

Y 

 N

N 

Y 

Y 

Y 

Y 

Y 

9

5

34. Total hip arthroplasty

Zavala et al.

2022 [65]

 Y

Y 

Y 

Y 

N 

N 

Y 

Y 

Y 

Y 

Y 

9

5

35. Total knee arthroplasty (TKA)

Jin et al. 2018 [66]

 Y

Y 

NA

Y 

N 

N 

NA

 Y

Y 

Y 

Y 

7

3

36. Primary Total knee arthroplasty (TKA)

Gianola et al.

2020 [67]

 Y

Y 

Y 

Y 

N 

N 

Y 

N 

Y 

Y 

Y 

8

4

37. Total knee arthroplasty (TKA)

Prvu Bettger

et al. 2020 [68]

 Y

 Y

NA

Y 

N 

N 

NA

Y 

Y 

Y 

Y 

7

3

38. Total knee arthroplasty (TKA)

Fuchs et al.

2022 [69]

 Y

Y 

NA

Y 

N 

N 

NA

N 

Y 

Y 

 Y

6

2

39. LBP in ankylosing spondilytis

Karahan et al.

2016 [70]

 Y

Y 

NA

Y

 N

 N

 NA

 Y

 Y

 Y

 Y

7

3

40. Juvenile Idiopathic Arthritis

Arman et al.

2019 [71]

 Y

Y 

N 

Y 

N 

N 

Y 

N

Y 

Y 

Y 

7

3

41. Fibromyalgia

Collado-Mateo et al.

2017 [72]

 Y

Y 

Y 

Y 

N 

N 

Y 

Y 

Y 

Y 

Y 

9

5

42. Fibromyalgia

Villafaina et al. 2019 [73]

 Y

Y 

Y 

Y 

N 

N 

Y 

Y 

Y 

Y 

Y 

9

5

43.. Fibromyalgia

Carvalho et al. 2020 [74]

 Y

Y 

Y 

Y 

N 

N 

Y 

N 

Y 

Y 

Y 

8

5

44. Fibromyalgia

Gulsen et al.

2020 [75]

 Y

 Y

Y 

Y 

N 

N 

 Y

N

Y 

Y 

Y 

8

4

45. Fibromyalgia

Polat et al.

2020 [76]

 Y

Y 

Y 

Y 

N 

N 

Y 

Y 

Y 

Y 

Y 

9

5

46. Pediatric burn patients

Parry et al.

2015 [83]

 Y

Y 

Y 

 Y

 N

 N

NA

 Y

 Y

 Y

 Y

8

4

47. Adolescent burned

Waked et al.

2019 [80]

 Y

Y 

Y 

Y 

 N

N 

N 

 Y

 Y

 Y

 Y

8

4

48. Burned Hands

Joo et al.

2020 [82]

 Y

 Y

 Y

 Y

 N

N 

Y 

Y 

Y 

Y 

Y 

9

5

49. Pediatric Burn

Ali et al.

2022 [81]

 Y

Y 

Y 

Y 

 N

 N

 N

 Y

Y 

Y 

Y 

8

4

50. Phantom pain (PLP)

Rothgangel et al. 2018 [84]

 Y

 Y

Y

Y 

 N

 N

 Y

 N

Y 

Y 

Y 

8

4

51. Joint pain in stroke

Anwar et al.

2022 [85]

 Y

Y 

 Y

 Y

 N

 N

 Y

 Y

 Y

 Y

 Y

9

5

52. Mastectomy with axillary lymph node dissection

Feyzioglu et al. 2020 [86]

 Y

 Y

 Y

 Y

 N

 N

 Y

 Y

 Y

 Y

 Y

9

5

53. Breast cancer related lymphedema

Basha et al.

2022 [87]

 Y

Y 

NA

Y 

N 

N 

 NA

 NA

NA 

 Y

Y 

5

1

54. Cardiac rehabilitation

Cacau et al.

2013 [88]

 Y

Y 

Y 

Y 

N 

N 

Y 

N 

Y 

Y 

Y 

8

4

55. Vestibular rehabilitation

Alahmari et al. 2014 [89]

 Y

N 

N 

 Y

 N

 N

 Y

 Y

 Y

 Y

 Y

7

3

56. Active aging

Lee et al.

2015 [90]

 Y

Y 

 Y

Y 

 N

N 

Y 

Y 

Y 

Y 

Y 

9

5

PEDRo classification (Y: Yes; N: No; NA: Information Not Available)