Background

Stroke is the second most common cause of death in the world, causing around 6.7 million deaths each year WHO (2014).As stated by Kwakkel et al.,(2003) upper limb impairment affects up to 80% of stroke survivors, with 30-40% of these regaining some function in the sub-acute phase (first six months) post stroke onset.

Virtual reality therapy has the potential to achieve this above mentioned statement Because it combines motor relearning and neuroplasticity principles, by providing visual, tactile and proprioception stimuli coupled with functional tasks training (Levin Pt et al., 2015).

Objectives:

• To evaluate the efficacy of low-cost VR in upper limb stroke rehabilitation on outcomes of treatment.
• To evaluate the feasibility of low-cost VR in upper limb stroke rehabilitation.

Methods: A systematic review using a narrative approach was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.The following databases were searched, CINAHL, Sport Discuss, Pubmed USA, PEDRO, Scopus, MEDLINE, and PsycINFO.Studies published from 1990 up to 29^th September 2018 were searched using relevant keywords and various combinations.

Results: Four randomized controlled studies, with an overall moderate to high methodological quality, satisfied the eligibility criteria and were included in this review.

Givon et al.,( 2016) reported on upper limb impairment such as grip strength of the weaker hand, the Mean (SD) pre-intervention was 12.1 (11.7) and post-intervention was 13.7 (11.7) Mean (SD) in the VR intervention. Compared to the control group which Mean (SD) pre-intervention was 9.6 (9.6) to post-intervention 11.9 (11.0) Mean (SD).  McNulty et al.,(2015) reported on upper limb impairment such as Modified ashworth scale there was improvement at the wrist P=0.046 at both VR intervention and control group which also Improved at the wrist P=0.046 .However no improvement between group was observed.

Adie et al.,(2017) reported on Action Research Arm Test the Mean (SD) pre-intervention was 47.6 (14.2) and Mean (SD) 49.5 (13.8) post-intervention in the VR intervention compared to the control group, which Mean (SD) pre-intervention was 49.0 (13.6) to post-intervention 49.3 (14.2) Mean (SD),No difference between group  P=0.12. McNulty et al.,(2015) reported on Wolf Motor FunctionTest timed task(seconds) in the  VR intervention Mean (SD) was 2·1 (1·5–2·7) pre-intervention to  1·7 (1·1–2·3) P < 0·001 post-intervention,  compared to the control  group the  Mean (SD) was 2·6 (1·9–3·2) pre-intervention to  - 2·3 (1·7–3·0) P < 0·001 post-intervention. Lastly Sin and Lee, (2013) used Fugl–Meyer Assessment (score) in the VR intervention Mean (SD) pre-intervention was  Mean 26.06 (15.81) to 47.72 (15.34) P < 0·001 post-intervention   compared to the control  group  Mean (SD) pre-intervention was  32.29 (20.43) to 34.59 (20.72) P < 0·001 post-intervention with significant difference between groups P=0.041.

Conclusion: There is a moderate evidence to suggest that low-cost virtual reality is feasible and has the ability to improve upper limb impairment and function among sub-acute and chronic stroke patients.Therefore it is recommended to be used as an adjunct to conventional therapy.

Keywords: Virtual reality, upper limb, stroke, and rehabilitation