Virtual reality-based interventions enhance functional status, balance and muscle strength in patients with ankle instability: a systematic review with meta-analysis of randomized controlled trials.

Introduction: Ankle instability reduces functional status in athletes and overall population after orthopedic ankle injuries. Complementary to physical therapy approaches, virtual reality-based interventions (VRBI) that promote exercises in ludic and gamified environments, are being used in reducing ankle instability during ankle rehabilitation. The aim of this systematic review with meta-analysis was to assess the effectiveness of VRBI in improving ankle function status, postural balance and muscle strength in patients with ankle instability.

Evidence acquisition: A systematic review with meta-analysis, previously registered in PROSPERO (CRD42023460797) was conducted aligned with the PRISMA guidelines. Literature search was performed in PubMed Medline, SCOPUS, WOS, CINAHL and PEDro without year of publication and language restrictions up to November 2024. Randomized controlled trials (RCTs) including patients with ankle instability which assessed the effectiveness of VRBI, compared to others, on ankle function status, postural balance, muscle strength, were included. Methodological quality and risk of bias were assessed using the PEDro Scale. Pooled effect was calculated with the Cohen's standardized mean difference (SMD) and its 95% confidence interval (95% CI) in random-effects models, or mean difference (MD) if studies used the same measure. All methodological phases of this meta-analysis were conducted by peers.

Evidence synthesis: Twelve RCTs, providing data from 555 participants with ankle instability (89% males with a mean age of 21.8±6.2 years), were included. The mean methodological quality of the studies included was moderate (5.8±1.3 in the PEDro scale). Our meta-analysis showed that VRBI is largely effective in increasing ankle function status (SMD=0.86; 95% CI 0.24 to 1.49; P=0.007), static (SMD=1.6; 95% CI 0.74 to 2.4; P<0.001) and dynamic balance (SMD=0.81; 95% CI 0.36 to 1.25; P<0.001), and strength of muscles involved in plantar flexion (MD=5.76; 95% CI 0.22 to 11.3; P=0.042) and eversion movements (MD=1.7; 95% CI 0.5 to 2.9; P=0.005).

Conclusions: VRBI is a safe and effective therapy for improving ankle function status, static and dynamic balance and strength of the muscles involved in plantar flexion eversion movements in patients with ankle instability.