Virtual reality intervention for improving cognitive function in post-stroke patient: A systematic review and meta-analysis

Abstract

Background

Stroke is one of the leading causes of disability worldwide. In the next few decades, post-stroke disability is expected to increase by up to 35% due to the current increase in cerebrovascular risk factors. Disabilities caused by stroke can include cognitive and motor impairment. The current research on post-stroke rehabilitation mostly focuses on the motor disability aspect. Recently, the International Stroke Recovery and Rehabilitation Alliance 2018 stated that post-stroke cognitive impairment (PSCI) is one of the research priorities. Following recent technological developments, virtual reality (VR)-based therapy is now emerging. This technology is attractive because it can simulate various activities in a safe environment. However, research on VR for post-stroke patients still does not have specific guidelines that must be followed, so the types of interventions carried out through VR still vary. Therefore, this study aims to assess how the benefits of using VR in improving cognitive function in post-stroke patients and what VR interventions show the greatest benefits.

Method

This research is a systematic review and meta-analysis conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines. The data used for this study were obtained from PubMed, Scopus, and Science Direct databases. The search conducted in this systematic review was done without any year restriction. The studies included were randomized controlled trials (RCTs) and pilot RCTs.

Results

This systematic review included eight studies involving 313 participants in total. All studies were used for the meta-analysis, with five, four, and six studies used in the rote memory function, executive function, and general cognitive analyses, respectively. Assessment using the trail making test (TMT) on the TMT-A test related to rote memory function (MD = -26.43, 95% CI -43.18 – -9.68, P = 0.002) and TMT-B test related to executive function (MD = -59.23, 95% CI -103.21 – -15.25, P = 0.008) showed significantly better results with shorter processing time in the VR group. In contrast, in the general cognitive assessment using the Montreal cognitive assessment (MoCA), although it showed better results in the VR group (MD = 1.45, 95% CI -0.20 – 3.09, P = 0.08), the results were not significant. The meta-analysis showed homogeneous result in rote memory (I² = 6%) and executive function (I² = 0%) analyses. For general cognitive analysis the result was heterogeneous (I² = 86%).

Conclusion

Interventions using VR have shown promising results in improving rote memory and executive function, especially when VR intervention is combined with a motorized assistive devices. This combination therapy not only trains cognitive skills, but also trains the patient's motor skills simultaneously. For general cognitive interventions, adaptive VR with task generators that represent daily activities showed the best results, but studies using this technology only focused on cognitive interventions. A new trial that uses the combination of these two technologies would be interesting to investigate further, especially considering that the existing trials still use small populations.