Received: 19 July 2021 I Revised: 12 October 2021 Accepted: 25 November2021

DOI: 10.1111/jan.15125

REVIEW WILEY

Effects of exergaming on functional outcomes in people with

chronic stroke: A systematic review and meta-analysis

Kendy Gui Fang Chan1 I Ying Jlang1 I Wen Tlng Choo1 I Hadassah Joann Ramachandran1
Yanjuan Lin2 I Wenru Wang1 •

1
Alice L.,., C4!ntr" for Nursing Studies,
Yong Loo Un School of M edicine. National Abstract
University o f Singapore, Singapo<e,
Alms: The aim of this review is to synthesize and evaluate effectiveness of exergaming
Singapore
2
Department of Nursing. Fuji.in Medical
on balance, lower limb functional mobility and functional independence in individuals
University Union Hospital, FuzhoY. China with chronic stroke.

Correspondence Desl1n: The present review is a systematic review and meta-analysis. The review is
Ying Jiang, A lice lee Centre for Nursing written in accordance with the guidelines from the Preferred Reporting Items for
Studies, Yong loo Lin School of M edicine.
National University o f Singapore, level
Systematic Review and Meta-Analysis (PRISMA)
2. Clinical Research Centre, Block MD Data Source: Searches were conducted across seven databases (PubMed, EMBASE,
11, 10 Medical Drive, Singapore 117597,
Sing,1pore. Web of Science, CINAHL, CENTRAL. Scopus and PEDro) and in grey literature from
Email: [email protected] inception until January 2021.
Y11nju.. n Lin, Drparlment ol Nur>ing, Review Methods: Only randomized controlled trials (RCTs) written in English were
Fujlan Medical University Union Hosp ital.
Fuzhou 350001 , China. included. All eligible studies were assessed for risk of bias by two reviewers indepen-
Email: [email protected] dently. Meta-analyses were performed using RevMan 5.4.1 software. Narrative syn-
theses were adopted whenever meta-analysis was inappropriate. The overall quality of
evidence from included studies was assessed using the Grading of Recommendations,
Assessment, Development and Evaluations (GRADE) framework.
Results: 4511 records were retrieved, with 32 RCTs eligible for inclusion and 27 RCTs
Included In meta-analysis. Meta-analyses reported statistically significant small ef·
fect sizes favouring exergaming on balance (pooled standardized mean difference
[SMD) = 0.25, 95% confidence interval [Cl, 0.08-0.41), p = .004), lower limb func-
= 0.29. 95% Cl (0.08-0.50), p = .007) and functional
tional mobility (pooled SMD
independence (pooled SMD = 0.41, 95% Cl (0.09- 0.73], p =.01). Most of the included
studies failed to provide adequate description of the measures taken to prevent bias.
Conclusion: Exergaming has favourable effects on improving balance, lower limb
functional mobility and functional independence among individuals with chronic
stroke, making it a suitable adjunct to conventional physiotherapy.
Impact People with chronic stroke have difficulty achieving the required rehab inten·
sity. Exergaming can help individuals with chronic stroke to undertake further rehabil·
itation exercises at home. It can be a suitable adjunct to conventional physiotherapy.

KEYWORDS
balance, chronic stroke, exergam es. functional independence, stroke rehabilit ation

J Adv Nurs. 2022:78:929-946. wileyonlinelibrary.com/ joumalr1,m C> 2021 John Wiley & Sons ltd 929
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1 INTRODUCTION adherence to t herapy, which is especially relevant for chronic stroke

individuals per sisting with long-term rehabilitation despite pain and
Globally, more than 13.7 million new strokes occur each year. Stroke slow progress (de Vries et al., 2018).
incidence increases with age, with older adults being the most af· For chronic stroke survivors, the most crucial functional outcomes
fected (Lindsay et al., 2019). Despite improvements In acute ischaemic are balance, lower limb functional mobility and functional indepen·
stroke management and recurrent stroke prevention strategies, stroke dence. Balance comprises both the abilities to sustain various positions
remains one of the leading causes of disability worldwide (Gorelick. at rest (static balance) and to neutralize e)(ternal forces acting on the
2019). Stroke survivors experience impairments in multiple domains,. body while in motion (dynamic balance), through muscle coordination
including sensory. motor. cognitive and/or emotional domains. These and sensory integration (<;:elenk et al., 2018). Lower limb functional
impairments are often so disabling that it may take months to years mobility refers to the physiological ability to move independently and
for the individuals to return to normal In various aspects of their lives. safely in a variety of environments to accomplish functional tasks re·
Particularly, motor impairment is the most prevalent, affecting about liant on lower limb strength, muscle tone, coordination and reflexes
80% of the stroke survivors (Arienti et al., 2019). Problems with gait (Bouc;a-Machado et al., 2018). Functional independence is defined as
and balance hinder mobility and restrict Individuals to the spaces in an individual's autonomy in performing AD Ls (Curzel et al., 2013). The
their homes fo:r activities of dally living (ADLs). This leads to barriers three are closely Intertwined since balance is the greatest contributor
to social participation, which is Important to an Individual's perception towards one's gait and Independent performance of ADls (Cordun &
of stroke recovery and the resulting quality of life (Woodman et al.. Marinescu, 2014). Attainment of these physical rehabilitation goals
2014). The impact of stroke also extends beyond the individual: it allows stroke survivors to reclaim their various social roles.
places an additional burden on families who have to take up caregiving Previous systematic reviews have largely explored the effect
roles (Camak, 2015), and post-stroke care Incurs substantial financial of virtual reality (VR) interventions on balance and mobility in all
costs that indirectly affect the society at large (Rajsic et al.. 2019). phases of stroke, but few focused on the chronic stroke population
(lruthayarajah et al., 2017: Lee et al., 2019) and on exergames alone
(Dos Santos et al., 2015; Xavier-Rocha et al., 2020). Findings pertaining
2 BACKGROUND to all phases of stroke may not be generalizable to the chronic stroke
population due to differences in rehabilitation needs (Milovanovic: &
Traditionally, the most intense rehabilitation regimens are prescribed Popovic, 2012). Furthermore, exergames are distinguished from typ·
in the first 3- 6 months after a stroke, the widely accepted 'critical ical VR inter ventions due to its ease of use, cost-effectiveness and
window for recovery' (Ballester et al., 2019). In fact , more than 30%. ease of integrating into home settings (Stanmore et al., 2019).
of stroke survivors are still unable to walk independently 6 months
after their stroke (Arienti et al .. 2019), but functiona l improvements
can continue to be achieved with considerably Intensive rehabilita· 3 THE REVIEW
tion 1 year after the stroke (Ballester et al., 2019). However, due
to resource constraints at rehabilitation facilities, individuals w ith 3.1 Alm
chronic stroke .are mostly prescribed home-based rehabilitation regi·
mens that may be less rigorous and effective in the absence of timely This systematic review aimed to synthesize t he latest available evi·
feedback from their physiotherapists (van der Veen et al., 2019). dence to evaluate the effectiveness of exergaming on balance, lower
Exergames are video games that require players to interact with limb functional mobility and functional independence in individuals
t he game scenario through purposeful body movements. offering fun with chronic stroke.
while stimulating their sensorial, cognitive, psychological and motor
functions (Pacheco et al.. 2020). Similar to the traditional repetitive
task-oriented exercises used to achieve neuroplastic changes that 3.2 Design
t ranslate into functional recovery in brain-injured patients (Kleim1
& Jones, 2008), sufficiently high repetition of goal-oriented move· This systematic review and meta-analysis is written in accord·
ments from considerably intense exergaming may provide similar ance with the guidelines from the Preferred Reporting Items for
benefits. With current technology, exergames can be designed to Systematic Review and M eta-Analysis (PRI SMA) (M oher et al.,
elicit complex and dynamic movements varying in step length, di· 2009). A review protocol was prepared prior to the review but was
rection and speed, as well as avoidance of virtual obstacles- skills not published.
necessary for successful navigation through real -life environments
(Skjaeret et al., 2014). The multisensory exergaming environment
increases accuracy of movements by providing real-time feedback,. 3.3 Ellglblllty criteria
ensuring that individuals reap the full benefit of therapy while avoid·
ing further injury. Moreover, the rewarding experience of game· Randomized cont rolled trials (RCTs) wh ich met the following
play induces high intrinsic motivation and consequently Improves eligibility criteria were included In this review: (1) participants
CHAN ET AL. I 931
- - - - - - - - - - - - - - - - - - - - - - - - - ,- -
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i!:18 years old clinically diagnosed with stroke, and with onset of 3.6 Data extraction
stroke symptoms i!:6 months prior to randomization (population);
(2) exergames aimed at improving balance and/or lower limb mo- The data extraction form was adapted from Cochrane s 'Data col-
bility being a major/ only component of the experimental group lection for Intervention reviews for RCTs only' form (Higgins. 2020).
intervention (intervention); (3) studies that compared exergames and had been piloted In five studies to determine its usability. Data
to conventional forms of stroke rehabilitation (e.g. weight-shift were extracted by the first author and cross-checked by a second
training, treadmill walking), placebo (e.g., upper limb-only rehabili- researcher. Data from multiple publications of the same study were
tation) or no intervention (comparison); (4) studies that assessed at extracted onto a single form. We also contacted study authors to
least one of these outcomes: balance, lower limb functional mobil- obtain missing information necessary for the review.
ity or functional independence.
We excluded studies with non-game (e.g. VR treadmill, robot-
assisted training). dual-task (e.g., cognitive-motor exergaming) and 3.7 Quality appraisal
group-based experimental group interventions.
The methodological quality of the Included studies was assessed
using the Cochrane Risk of Blas assessment tool (Higgins, 2020). Two
3.4 Search methods independent researchers assessed each study and categorized them
as 'low', 'high' or 'unclear risk ' of selection bias, performance bias,
3.4.1 Information sources detection bias, attrition bias and reporting bias. Justifications for the
categorizat ions were documented, usually w ith a direct quote from
Studies were identified through systematic searches in PubMed, the study. Disagreements were resolved through discussion w ith a
EM BASE, Web of Science, CINAHL, CENTRAL, Scopus and PEDro third reviewer.
from inception until January 2021. We also searched the Clinical The overall quality of evidence supporting each outcome was fur-
Trials Registry (www. ClinicalTrials.gov) for relevant unpub- ther assessed using the Grading of Recommendations, Assessment,
lished trials. and sources of grey literature (i.e. ProQuest. Scopus Development and Evaluations (GRADE) framework . The GRADE
and IEEE Xplore) to retrieve studies that were published non- framework takes into considerations of risk of bias, indirectness
commercially or remained unpublished. Hand-searching of ref- of evidence, serious inconsistency, imprecision of effect estimates
erence lists of included articles and relevant systematic reviews and potential publication bias (Guyatt et al., 2011). It assigns a level
were also done. of certainty of evidence to each outcome from 'high' to 'moderate'.
'low' and 'very low' (Guyatt et al., 2011).

3.4.2 Search strategy

3.8 Data analyses and synthesis
Guided by the Peer Review of Electronic Search Strategies (PRESS)
checklist (McGowan et al., 2016), the search strategy for PubMed 3.8.1 Calculation of effect sizes
was constructed using keywords and Index terms by the first author
and reviewed by the second author to ensure a comprehensive yet The Review Manager (RevMan) software was used to perform
concise search. Initial keyword terms included "stroke." "hemiplegia." the data analysis. The inverse-variance method was used to as-
"cerebrovascular accident." "video games," "virtual reality• and •ex- sign weights to studies included for each continuous outcome. We
ergaming." The search strategy was then replicated considering the used the summary statistic standardized mean ditterence (SMD)
index terms, syntax rules, and appropriate RCT filter of each data- as all outcomes involved studies that used ditterent measurement
base (Table S1). scales. The SMD implemented in RevMan is Hedges' s (Higgins,
2020), which adjusts for small sample bias, where 0.2, 0.5 and 0.8
correspond to 'small', 'moderate' and 'large' effects respectively.
3.5 Selection of studies Studies that did not provide sufficient data or provided data In an
inappropriate format for conversion to means and standard de·
After duplicate removal using the EndNote X9.3.3 software, two viations were excluded from the meta-analysis and summarized
independent researchers screened the title and abstract of every narratively. For multiple-armed RCTs with multiple experimental
record retrieved from the search. The full texts of those that met intervention groups and only one comparator intervention group,
or potentially met the eligibility criteria were obtained, and the two we Included each pair-wise compari son separately but divided
researchers read and identified studies for inclusion independently. the number of participants in the comparator intervention group
All disagreements were resolved through discussion, with a third equally among the comparisons (Higgins, 2020). The significance
researcher. level was set at p-value <.05.
~WI LEY_ _,...________________________c _HA_N_ n_ AL

The random-effects model was adopted for meta-analysis as the 0.03%). Taiwan (n = 4, 12.5%}, Pakistan (n = 1, 0.03%), Israel
studies differed considerably in terms of format and type of exer- (n = 1, 0.03%}, India (n = 1, 0 .03%) and Turkey (n = 1, 0.03%).
games. The random-effects model assumes that the true effect size Among the 34 [Publications (32 RCTs) included in thi s review.
varies from study to study, and it does not impose a restriction of a (Miranda et al .. 2015) and (Rand et al .. 2015) were earlier publica·
common effect size among studies (Borenstein et al.. 2010). tlons reporting o n the same RCTs as (Miranda et al., 2019) and
(Rand et al.. 2017), and w ill hencefor th be referred by the lat est
publications. All studies were individualized RCTs, excep t for one
3.8.2 Test of homogeneity and subgroup analyses cluster RCT (Lee & Bae, 2020).

The chi-squa red test and I-squared (/ 2) statistic w ere used to deter·
mine the heterogeneity among the studies. A chi -squared test w ith 4.3 Description of participants
p < .10 indicated statistically significant heteroge neity across trials.
The /2 statistic assessed the extent of heterogeneity, with /2 values The combined sample size w as 900 participants, with individual
between 0% and 40% indicating low heterogeneity, 30% to 60% in· sample sizes varying from 10 to 50 participants (Lee et al., 2017;
dicating moderate heterogeneity, 50%- 90% lndkating substantial You et al.. 2005). The mean age of participants ranged from 40 to
heterogeneity and 75%-100% indicating considerable heterogene· 76.4 years (Lee et al., 2013; Shobhana & Rakholiya, 2020). All partici-
ity (Higgins, 2020). Sensitivity and subgroup analyses were con· pants were at least 6 months post-stroke, with mean months post·
ducted if there was significant heterogeneity across trials (p < .10 stroke ranging from 7.29 to 87.9 months in the exergaming group
and /2 > 40%). (Junior et al., 2019; Lee, 2013), and ranging from 8.29 to 9S.8 months
in the control group (Junior et al .. 2019; Lee, 2013).

3.8.3 Test of publication bias

4.4 Description of the Interventions
Publication bias was assessed through funnel plot and Egger's test
if 10 or more studies were pooled for an outcome (Higgins, 2020). A summary table for characteri stics of exergame interverntions can
be found in Table S2. M ost studies (n = 25; 78.1%) offered commer·
d ally available exergames while six studies (18.8%) offer ed thera·
4 RESULTS peutic exergames designed for rehabilitation. Hung et al.'s (2017)
three -arm RCT offered the commercially available Nintendo W li In
4.1 Studies Identification one arm and the therapeutic Tetrax biofeedback exercise system In
another arm. The duration of exergame interventions ranged from
The systematic search yielded 2883 records. and 1628 additional 1 week (Miranda et al., 2019) to 12 weeks (Henrique et al., 2019;
records w ere sourced from grey literature. After duplicate removal, Hung et al., 2014. 2017; Kim. 2018), w ith each session lasting from
2679 records underwent dual independent screen ing of title and 20 min (Hung et al, 2016) to 60 min (Deutsch et al .. 2017; Fritz
abstract to exclude another 2591 records. The full text of the re· et al., 2013; Rand et al., 2015; Shobhana & Rakholiya, 2020; da Silva
maining 88 records were retrieved and screened independently by Ribeiro et al., 2015; You et al., 2005).
two reviewers against the eligibility criteria. In addition. two articles
were identified by hand-searching the reference lists of included
studies and contacting the author for missing outcome data (Lee 4.5 Description of the comparators
et al., 2013; Rand et al .. 201S). Fifty-six articles were excluded for
various reasons as detailed in Figure 1. Finally, 34 articles consisting Thirty studies (93.8%) were active control trials, of which 17 (53.1%)
of 32 trials were included in th is review. The PRISMA flow diagram had control groups that received a dosage of physical therapy com·
(Figure 1) details the search process. parable to the exergaming group, and 13 (40.6%) had con trol groups
that received les.ser intervention time. Only studies by Fritz et al.
(2013) and You et al. (2005) were passive control trials (6.25%), in
4.2 Description of Included studies which the contro l groups did not receive any Intervent ion.
Choi et al. (2017) had a third intervention arm that offered game-
The summary table for char acteri stics of included studies can based constraint-induced movement therapy, while Junior et al.
be found in Table 1. Majority of the studies w ere two-arm RCT (2019) had a third intervention arm exposed to both Nintendo Wii ex-
designs {n = 29. 90.6%), while only three were three-arm RCTs ergaming and proprioceptive neuromuscular facilitation. As both the
(9.4%). Studies were conducted In Brazil (n = 7, 21.9%). South third intervention arms were mixed interventions that did not fulfil
Korea (n = 14, 43.8%), United States (n = 2, 6 .3%). Egypt (n = 1. the eligibility criteria. t hey were not included in our meta-analyses.
_
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FIGURE 1 PRISMA flow diagram. Additional records Records identified ltvough data.base Adci1ional
PRIS1',,1A, Preferred Reporting Items for identified through: searching records Identified
Systematic Review and Meta-Analysis • Reference lists (n (n =2883) throughi,ey
= 1) PubMed (n:203), Embase (n:395), Web literalunl
• Contacting study of Science (n=374). CINAHL (n=362). (n .. 1628)
author (n = 1) Cochrane (n:685). PEDro (n=37). and
Soopus (n:627)

! 1
Recolds alter duplicates removed
(n = 2679)

I Records~
(n = 2679) f---.
Records excluded
(n = 2591)

Full-text artldes exckJded. with

Full-leX1 ar1lcles assessed for eligibility reasons
(n = 90) (n = 56)
• No full-teX1 (n = 7).
• Abstract only (n • 17):
• Ongowlg trial (n • 1):
• Non-RCT (n • 5):
Sludln lncl11ded In
• Non-English (n • 4);
qualltatlve synthesis
• Includes participants with
(n = 32: 34 ar1icles)
subacute stroke (n • 13):
• Includes participants ol mixed
aellologlea (n = 1 ).
• Only Involves upper
extremities (n • 3):
Sludles inc:11/ded In • lnteM111tlon requires no
quantltallve synthesis physical exer1ion (n • 1):
(meta-analylis) • Non-game inte,-ition (n = 4)
(n • 27: 28 ar1icles)

4.6 Quality of the studies reasons for attrition could have related to treatment or outcome
(n = 3; 9.38%). Finally, 28 studies (87.5%) were rated unclear risk of
The risk of bias summary is presented in Figure 2. Low risk of selec· repor ting bias either because there was no accessible protocol or
tion bias for random sequence generation and for allocation conceal- because pre-specified secondary outcome measures were not re-
ment was observed in 19 (59.4%) and 12 studies (37.5%) respectively. ported. Four studies (12.5%) were rated low risk of reporting bias for
As blinding of participants and study personnel is difficult due to the reporting all outcomes planned for in the registered protocol.
distinctiveness of exergames. only two studies (6.25%) were rated There is an overall low quality of evidence for all outcomes,
low risk of performance bias for c.o nducting a double-blind study downgraded for unclear or high risk of bias. small sample size and/or
design. Twelve studies (37.5%) were rated high risk of performance wide confidence interval. as detailed in Table 2.
bias for not blinding either the study personnel or the par ticipant s.
Only one study (3.13%) was rated high risk of detection bias as the
outcome assessor was aware of the group allocation. Eleven st ud· 4.7 Effectiveness of exergaming on balance
ies (34.4%) were appraised with low risk of attrition bias for either
having no attrition (n = 8; 25%). having conducted intention-to· Twenty-seven studies assessed balance using Berg Balance Scale
treat analysis (n = 1: 3.13%). or having equal attr ition rates across (BBS), Functional Reach Test (FRT). Dynamic Gait Index (DGI),
all groups with reasons unrelated to treatment or outcome (n = 2: modified FRT. Fugl-M eyer Assessment balance subscale. Postural
6.25%). Ten studies (31.3%) were rated high risk of attrition bias ei- Assessment Scale for Stroke and Balance Evaluation Systems Test.
ther due to unequal attrition across groups (n = 7; 2 1.9%) or because The meta-analysis for the over all effect of exergaming on balance
~WILEY- - CHAN ET AL.

TABLE 1 Charac teristics of included studies

Number of A1e of participants Time since stroke (months)

Author, year Study desl1n Country participants Mean (SO) Mean (SO)

Barcala et al., Two -arm RCT Brazil Total: 20 IG: IG:

2013 IG: 10 65.2 (12.5) 12.3 (7.1)
CG: 10 CG: CG:
63.5 (14.5) 15.2 (6.6)
Cho et al., 2012 Two-arm RCT South Korea Total: 24 IG: IG:
IG:12 65.26 (8.3S) 12.S4 (2.58)
CG: 12 CG: CG:
63.13 (6.87) 12.63 (2.54)
Choi et al., 2017 Three-arm RCT South Korea Total: 36 CIMT-gaming group: CIMT-gaming group:
CIMT·gamlng group: 61.25 (5.59) 13.75 (3.86)
12 Gaming group: Gaming group: 13.58 (5.53)
Gaming group: 12 62.58 (5.51) CG:
CG: 12 CG: 14.25 {4.81)
61.92 (6.08)
Choi et al., 2018 Two-arm RCT South Korea Total: 28 IG: 49.50 (23.00)• ~ 12 months after first stroke
IG: 14 CG: 51.00 (13.75)1
CG: 14

da Silva Ribeiro Two -arm RCT Brazil Total: 30 IG: IG:

et al., 2015 IG: 15 53.7 (6.1) 42.1 (26.9)
CG: 15 CG: CG:
52.8 (8.6) 60.4 (44.1)
Deutsch et al.. Two-arm RCT United States Total: 13 IG: ~ 6 months after stroke
2017 IG: 7 53.0(6.00)
CG: 6 CG:
49.0(12.0)
Elhakk et al.. Two -arm RCT Egypt Total: 30 IG: IG:
2018 IG: 15 57.28 (5.31) 10.61 (2.24)
CG: 15 CG: CG:
55.57 (4.21) 9.90(1.28)

Fritz et al., 2013 Two-arm RCT United States Total: 30 IG: IG:
IG: 16 67.6(9.3) 2.5 (2.6)b
CG: 14 CG: CG:
64.5 (10.1) 3.6(3.2)b
Henrique et al .. Two -arm RCT Brazil Total: 31 IG: IG:
2019 IG: 16 76.19 (10.09) 15.63 (6.60)
CG: 15 CG: CG:
76.20 (10.41) 17.07 (10.00)
Hung et al., 2014 Two-arm RCT Taiwan Total: 30 IG: IG:
IG: 15 55.38 (9.95) 21.00 (11 .26)
CG: 15 CG: CG:
53.40 (10.03) 15.93 (8.02)

Hung et al., 2016 Two-arm RCT Taiwan Total: 27 IG: 52.75 (16.20)0 IG: 17.50 (11.26) 1
IG: 14 CG: 55.20(20.20)" CG: 18.60 (22.06)•
CG: 13

Hung et al., 2017 Three-arm RCT Taiwan Total: 43 Wii Fit group: 55.66 Wii Flt group: 23.00 (24.00)"
WII Flt group: 14 (14.22)" Tetrax group: 19.00 (21.00)"
Tetrax group: 15 Tetrax group: 60.90 CG: 25.50 (20.50)•
CG: 14 (7.87)·
CG: 51.75 (17.15)"
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Attrition rate;
Exel'Jame Intervention Control Intervention Outcome measures ITT (Y/N) GS
Nintendo Wii Fit Conventional physical therapy AP. Ml and COP oscillations (EC. EO). 0%;NA y
exergames + Conventional peak plantar pressure (PS. NPS).
physical therapy BBS, TUG, FIM

Nintendo Wii Fit Standard rehabilitation program AP and Ml PSV (EC, EO), BBS, TUG Total: 8.33% y
exergames + Standard IG: 8.33'6
rehabllltatlon program CG: 8.33%;
ITT:N
Nintendo Wii Fit exergames Conventional physical therapy COP-AP and Ml displacement. sway 0%;NA y
(±CIMT) + Conventional mean velocity. sway area. SWB.
physical therapy FRT, modified FRT. TUG

Nintendo Wii Fit General weight-shift BBS. TUG, 10MWT Total: 10.7'6 y
exergames + Conventional training + Conventional physic.al IG: 7.14%
phvsical and occupational and occupational therapy CG:14.3%:
therapy ITT:Y
Nintendo Wii exergames Conventional physiotherapy SF-36, FMA subsca le and total scores 0%;NA y

Nintendo Wii exergames Standard of care DGI, Gait speed, ABC, COPM 23.1%; ITT: N N

Nintendo Wii Fit exergames + Task Task oriented approach training BBS. FRT, FIM. TUG, COP (PS. NPS) 0%;NA N
oriented approach training

Nintendo Wii Sports and Wii Fit, Nil; continued w ith normal activity FMA. BBS, DGI, 6MWT. 3-meter walk Total: 13.3% y
and PlayStation EyeToy Play 2 {self·selected and tas0, SIS, TUG IG: 12.S%
and Kinetic exergames CG: 14.3%: ITT
-N
Motion Rehab AVE 3 0 exergames Conventional physiotherapy BBS 0%;NA y

Nintendo Wii Flt exergames Conventional weight-shift training Stability index and PWB on the PS in Total: 10% y
eight poslllons- HSEO and HSEC IG: 20%
on solid surface, HSEO and HSEC CG: 0'6; ITT: N
on foam surface, EC on solid
surface w ith head turned at 30° to
the right. left. up, and down. TUG,
FRT, FES-1
Tetrax biofeedback Conventional outpatient Knee proprioception, quadriceps Total: 14.8% N
exercise syst em rehabilitation therapy strength, simple reaction t ime. IG: 14.3%
exergames + Conventional postural sway area. SWB, TUG. CG: 15.4%;
outpatient rehabilitation FRT ITT: N
therapy
Nintendo Wii Fit exergames OR Conventional we.i ght-shift training BBS Total: 14.0% y
Tetrax biofeedback exercise WTi Fit group:
system exergames 14.3%
Tetrax group:
13.3'6
CG: 14.3%; ITT: N

(Continues)
~WILEY- - CHAN ET AL.

TABLE 1 (Continued)

Number ot Aae ot 1>11rtlclpants Time since stroke (month s)

Author, year Study deslan Country participants Mean(SD) Mean(SD)

Junior et al.. Three-arm RCT Brazil Total: 48 VR: VR(IG):

2019 VR: 16 55.5 (9.6) 87.9 (64.7)
PNF: 16 PNF: PNF(CG):
PNF/VR: 16 58.2(7.7) 95.8 (99.4)
PNF/VR: 52.7 (13.3) PNF/VR:
46.7 (58.6)
Khan et al., 2018 Two-arm RCT Pakistan Total: 22 Elderly; 2! 10 months post stroke
IG: 11 IG: 52.1
CG: 11 CG: 50.4
Klm,2018 Two -arm RCT South Korea Total: 24 IG: i 6 months post stroke
IG: 12 50.91 (9.57)
CG: 12 CG:
57.23 (14.63)
Kim et al., 2009 Two·armRCT South Korea Total: 24 IG: IG:
IG: 12 52.42 (10.09) 25.91 (9.96)
CG: 12 CG: CG:
51.75 (7.09) 24.25 (8.87)
Kim et al.. 2012 Two·arm RCT South Korea Total: 20 IG: IG:
IG: 10 41.30(6.61) 12.6 (7.12)
CG: 10 CG: CG:
55.00 (13.02) 12.85 (6.06)
l ee & Bae, 2020 Two -arm South Korea Total: 38 IG: IG:
cluster RCT IG: 21 52.9 (10.3) 42.3 (19.9)
CG: 17 CG: CG:
57.3 (7.1) 47.2(23.3)
Lee, 2013 Two·arm RCT South Korea Total: 14 IG: IG:
IC: 7 71.71 (9.14) 7.29 (1.38)
CG:7 CG: CG:
76.43 (5.80) 8.29 (3.40)
Lee et al., 2013 Two •arm RCT South Korea Total: 26 IG: i 6 months post stroke
IG: 13 60.6(8.8)
CG: 13 CG:
63.7 (4.7)
Lee et al., 2015 Two -arm RCT South Korea Total: 24 IG: i 6 months post stroke
IG: 12 45.91 (12.28)
CG: 12 CG:
49.16 (12.85)
Lee etal., 2017 Two-arm RCT Taiwan Total: 50 IG: IG:
IG:26 59.35 (8.95) 839.77 (719.13)'
CG:24 CG: CG:
55.76 (9.59) 653.24 (589.70)'
Miranda et al .. Two -arm RCT Brazil Total: 32 IG: IG:
2019 IG: 17 53.5 (9.7) 45.7 (27.8)
CG: 15 CG: CG:
47.8 (12.0) 54.1 (37.6)
de Paula Ollvelra Two•armRCT Brazil Total: 23 IG: IG:
et al., 2015 IG: 12 47.08 (10.30) 5.83 (5.90)b
CG: 11 CG: CG:
53.63 (12.16) 6.19 (5.41)b
Park et al., 2017 Two-arm RCT South Korea Total: 24 IG: IG:
IG: 12 62.00 (17.14) 10.78 (7.06)
CG: 12 CG: CG:
65.30 (10.51) 14.10 (7.73)
Pedrelra da Two·arm RCT Brazil Total: 30 IG (n • 15): 53.8 (6.3) IG (n• 15):
Fonseca IG: 15 CG (n = 15): 50.9 44.1 (25.0)
et al., 2017 CG: 15 (10.9) CG (n = 15): 64.5 (41.9)
CHANn AL ~ I 0'17
- - - - - - - - - - - - - - - - -~ WILEY_i___:_:_:_

Attrition rate:
Exerpme lnterwntlon Control lnterwntlon OutQ>me meuura ITT (Y/N) GS

Nintendo Wil exergames Proprioceptive Neuromuscular FMA subscale and tot al scores Total: 16.7% V
Facilitation (PNF) VR: 31.3%
PNF:6.25%
PNFNR: 12.5%.;
ITT: N

Non-commercial exergames Low· and moderate-intensity TUG O'-";NA N

exercises prescribed using FITT
principle
Nintendo Wii Conventional rehabilitation 515 0%:NA V
exergames + Conventional
rehabilitation

Interactive Rehabilitation and Conventional physical therapy BBS, 10MWT, Modified MAS, static O'-"; NA N
Exercise System (IREX9) and dynamic mean balance, sway
exergames + Conventional area, MSV, AP and ML angles
physical therapy
Nintendo Wii Sports General exercise + Electrical Postural As.sessment Scale for Stroke, Total: 1S% N
exergames + General stimulation of t ibialis anterior Modified MAS. RM IG:0%
exercise + Electrical stimulation (PS) CG: 30%: ITT: N
of tibialis anterior (PS)

Driving game in a chair without Treadmill walking TIS (subscale and total scores), DGI, Total: 17.2% N
backrest + C-ntional training + Conventional therapy 10MWT, TUG IG: 18.8"
therapy CG: 15.4":
ITT: N
Kinect sports and Kinect adventure Conventional OT FIM 0": NA V
exergames + Conventional OT

BIORescue exergames + General General physical therapy Modified FRT, AP and M L sway speed, Total: 15.4% N
physical therapy velocity moment IG:7.69"
CG: 23.1%;
ITT: N
Nintendo Wii exergames + Gerneral General exercise therapy FRT, COP path length and velocity 0%:NA N
exercise therapy (NBEC. NBEO. WBEC . WBEO)

Kinect Sports, K"inect Adventures, Standard treatment BBS, FRT, TUG-cog. MBI. ABC, SIS Total: 6" y
and Yoor Shape Fitness IG: 0%
exergames + Standard CG: 12.5":
treatment ITT: N
Nintendo Wii Fit exergames Received counselling about the risk AP and ML directional control ot RWS, Total: 9.38% N
of falls and optimal posture in endpoint excursion and maximum IG: 5.88%
different activities excursion of LOS CG: 13.3%:
ITT: N
Nintendo Wu Fit Balance training + Wanning FMA-l.E, BESTest, SSQOL O'-"; NA N
exergames + Warming exen:i.ses
exercises

Kinect Sports Conventional physical t herapy FMA· LE. BBS. TUG. l0MWT Total: 20% N
exergames + Conventional IG: 20%
physical therapy CG: 20%: ITT: N

Nintendo Wii exergames Conventional therapy DGI Total: 10% N

IG: 6.67%
CG: 13.3"; ITT: N
(Continues)
=-i_WI
938 I LEY-!Q\•t ~w::::::::::::1-------------------------_
f _ '.C:'.:H~AN~E~TAL~.
TABLE 1 (Continued)

Number of Age of participants Tlme since stroke (months)

Author, year Study design Country participants Mean (SD) Mean (SD)

Rand et al.. 2016 Two-arm RCT Israel Total: 24 IG: IG:

IG: 13 59.1 (10.5) 19.6 (11.3)
CG: 11 CG: CG:
64.9 (6.9) 13.0(6.0)
Shobhana& Two-armRCT India Total: 30 40- 60 years old >6 months after stroke
Rakholiya, IG: 15
2020 CG: 15
Song & Park. Two -arm RCT South Korea Total: 40 IG: IG:
2015 IG: 20 51.37 (40.6) 14.75 (6.06)
CG: 20 CG: CG:
50.10 (7.83) 14.30 (3.40)
Yatar & Yildiri m, Two-armRCT Turkey Total: 33 IG: IG:
2015 IG: 17 62.80 (10.87) 3.70 (4.42)b
CG: 16 CG: CG:
56.60 (16.42) 4.23 (4.86)b
You et al .. 2005 Two-arm RCT South Korea Total: 10 54.60 (10.88) IG:
IG: 5 18.20 (5.08)
CG: 5 CG:
19.40 (9.55)
Yu & Cho. 2016 Two-armRCT South Korea Total: 22 IG: IG:
IG: 11 64.80 (5.67) 12.40 (2.67)
CG:11 CG: CG:
62.70 (5.10) 12.80 (2.61)

Abbreviations: 10MWT, 10-metre walk test; 6MWT, 6-minute walk test; ABC. Activities-specific Balance Confidence scale; AP, anterior- posterior:
BBS, Berg Balance Scale; BESTest. Balance Evaluation Systems Test: CG, control group; CIMT, constraint-induced movement therapy; COP. centre
of pressure; COPM, Canadian occupational performance measure; DGI, dynamic gait index; EC, eyes closed; EO, eyes opened; FAC. functional
ambulation category; FAI, Frenchay activities index; FES-1, Falls Efficacy Scale-International; FIM, functional independence measure; FMA,
Fugl-Meyer assessment; FMA-LE, Fugl-Meyer Assessment Lower Extremity subscale: FRT, functional reach test; GS. grant support; HS, head
straight: IG. intervention group: ITT. intention-to-treat analysis: LOS. limits of stability: MAS. Motor Assessment Scale: MBI. Modified Barthel Index:
ML, rnediolateral: MSV. maximal sway velocity: NB. narrow base; NPS, non-paretic side; OT. occupational therapy; PNF. proprioceptive neuromuscular
facilitation: PS, paretic side; PSV, postural sway velocity; PWB, percentage weight bearing: RCT, randomized controlled trial; RWS, rhythmic weight
shift: SD. standard deviation: SF-36, 36-ltem Short Form Survey: SIS. Stroke Impact Scale: SSQOL. Stroke-specific quality of life: SWB. symmetric
weight bearing; TIS, Trunk Impairment Scale: TUG, timed up and go test; WB. wide base.
•Reported in median and interquartile range (IQR).
bReported in years.
' Reported in days.

was performed on 23 studies involving 299 participants in the exer- a statistically significant greater improvement in BBS scores in the
gaming arm and 274 participants in the control arm (Figure 3). The exergaming group compared with the control group. Henrique et al.
result of the meta-analysis showed a statistically significant small (2019) demonstrated statistically significant improvements in BBS
effect favouring exergaming (pooled SMD = 0 .25, 95% confidence scores in both arms without significant between-group difference.
interval [Cl. 0 .08 - 0.411. p = .004), without significant heterogeneity da Fonseca et al. (2017) observed statistically significant improve-
between studies (p = .89, / 2 = 0%). ment in DGI scores only in the control group and M iranda et al.
Four studies were excluded from the meta-analysis (Choi et al., (2019) observed that no significant improvement in both arms.
2018; Henrique et al., 2019; Miranda et al., 2019; da Fonseca et al.,
2017). Choi et al. (2018) reported insufficient information for con -
version of medians and interquartile ranges (IQRs), while Miranda 4.8 Effectiveness of exergamlng on lower limb
et al. (2019) reported only force platform measurements that were functional mobility
incompatible w ith other clinical rating scales. Additionally. two stud-
ies reported change from baseline values (Henrique et al., 2019; da Twenty-one studies assessed lower limb functional mobility using
Fonseca et al., 2017) that were unsuitable for pooling with other Timed Up and Go test (TUG). Fugl-Meyer Assessment lower extrem·
post-intervention values when calculating SMD (Higgins. 2020). ity (FMA- LE) subscale, modified Motor Assessment Scale walking
Substantial heterogeneity arose (1 2 = 96%, p < .001) when these item , 6-minute walk test and 10-metre walk test. The meta-analysis
scores were pooled. In these four studies, Choi et al. (2018) found for the overall effect of exergaming on lower limb functional mobility
c
_ H_AN
_n_AL
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ w, LEY-1..!:!

Attrition rate;
Exerpme Intervention Control ln~tion Outcome measures ITT (V/N) GS
Kinect exergames while standing Graded Repetitive Arm FRT Total: 12.5% y
OR EyeToy games while sitting Supplementary Program IG: 15.4%
(GRASP) exercises CG: 9.09%;
ITT: N
Kinect Sports and Kinect Conventional physical therapy BBS, 6MWT. step length, stride 0%:NA N
Adventures exergames length. cadence

Kinect Sports. Kinect Adventure. Ergometer bicycle training PWB (PS). LOS (forward and 0%; NA N
and Kinect Gunstringer backward). TUG, 10MWT
exergames

Nintendo Wii Fit Progressive balance PWB (PS and NPS). BBS, TUG, DGI, Total: 9.09% N
exergames + Neuro- exercises + Neuro- FRT, ABC, FAI IG: 11.8%
developmental training developmental training CG:6. 25%:
ITT: N
IREX VR system exergames Nil FAC, Modified MAS walking item only 0%: NA y

Nintendo Wii Fit exergames Conventional physical therapy BBS, TUG, MBI Total: 9.09% N
+ Conventional physical therapy IG:9.09%
CG:9.09%;
ITT: N

was performed on 16 studies involving 177 participants in the exer- with other post-intervention values (H iggins, 2020). In these five
gaming ann and 178 participants in the control ann (Figure 4). The studies, three studies found that the exergaming group had TUG
results demonstrated a statistically significant small effect favour- scores that improved significantly more than the control group (Choi
ing exergaming (pooled SMD = 0.29, 95% Cl [0.08- 0.50), p = .007), et al., 2018; Park et al., 2017; Song & Park, 2015), while the other
without significant heterogeneity between studies (p = .SO, t2 = 0%). two studies did not find significant between-group difference post-
Five studies were excluded from the meta-analysis (Choi et al., intervention (da Silva Ribeiro et al., 2015; Yatar & Yildirim, 2015).
2018; Park et al., 2017; da Silva Ribeiro et al., 2015; Song & Park,
2015; Yatar & Yildirim, 2015). Choi et al. (2018) reported insuffi-
cient information for conversion of medians and IQ Rs, while da Silva 4.9 Effectiveness of exergaming on functional
Ribeiro et al. (2015) reported FMA-LE motor function and coordina- independence
tion subscale scores separately instead of the FMA-LE total score. In
addition. the studies by Song and Park (2015) and Yatar and Yildirim Eight studies assessed for functional independence using Functional
(2015) found significant between-group differences in baseline TUG Independence Measure, modified Barthel Index and Frenchay
scores. Combining the post-intervention values in the meta-analysis Activities Index (FAI). The meta-analysis for the overall effect of
could lead to misleading conclusions (Trowman et al., 2007), there- exergaming on functional independence was performed on seven
fore, these two studies were ex-eluded. Lastly, Park et al. (2017) re- studies involving 83 participants in the exergaming ann and 75
ported change from baseline values that were unsuitable for pooling participants in the control arm (Figure 5). The result showed a
940 I CHAN El AL.
.:...:.:.._L_WILEY- -- - - - - - - - - - - - - - - - - - - -

j statistically significant small-to-moderate effect favouring exergam·

.0
ing (pooled SMD = 0.41, 95% Cl (0.09-0.73), p = ..01), without signifi-

io ., cant heterogeneity between studies (p = .86, 12 = 0%).

~ The study by Yatar and Yildirim (2015) was excluded from the
I liI
~
meta-analysis because the between-group differences in baseline FAI

i ~
scores were statistically significant and pooling these values could lead
to misleading conclusions (Trowman et al., 2007). The study reported

i I Improvements in FAI scores In both groups but did not find significant
differences between groups (Yatar & Yildlrim, 2015).

:I
0
I
0 4.10 Publlcatlon bias

ff Publication bias was assessed for balance and lower limb functional
Barcala et al. 2013
Cho et al. 2012
•• • • ••
?
?
? ?
?
?
mobility (Figure 6). The results of Egger's test were not statistically
significant (p = .627 and p = .624 respectively).

••• •• ••• •• •••

Choi et al. 2017 ? ?
Chol et al. 2018 ? ?
da Sliva Alberio et al. 2015
5 DISCUSSION
?
Deutsch et al. 2017
Elhakk et al. 2018
? ?

•• • • • ••
? ?
•
?
• • ?
?
This review evaluated the effectiveness of exer,gaming on balance,
lower limb functional mobility and functional Independence in In-
Fritz et al. 2013 ? dividuals with chronic stroke. All 32 RCTs recruited participants In
Henrique et al. 2019
Hung et al. 2014
? ? ? 1

•• • • •• •• • ?
?
the chronic phase of stroke and offered a variety of commercial and
therapeutic exergames that spanned across 1 week to 12 weeks.
Hung et al. 2018 ? ? ? Overall, the meta-analyses demonstrated that exergaming had a

Hung et al. 2017 -tetrax

Hung et al. 2017 -wll
•• •• •• •• ?
?
?
?
positive effect In Improving balance, lower limb functional mobility
and functional independence.

Junior et al. 2019

Khan et al. 2018 ? ?
•• •••
?
? ? ? ?
The significant but small effect of exergaming on improving bal-
ance among Individuals with chronic stroke Is not consistent with

• • •• •• •
previous systematic review on the effect of Nintendo Wil Flt exer·
Kim 2018 ? ? gaming on balance in individuals with chronic stroke (lruthayar ajah
Kim et al. 2009 ? ? ? et al., 2017). While this previous review only Included Nintendo Wii
Kim et al. 2012 ? ? ? ? ? ? Fit exergames, our review included more studies offering varied ex·
Lee & Bae 2020
Lee 2013
?
?
?
?
?
? ?
•• ?
?
?
ergame interventions. Exergaming improves balance through elicit·
Ing whole -body movements and stepping actions that contribute to

Lee et al. 2013

Lee et al. 2015 ?

?
?
• • ••
?
?
?
?
?
forward and sideways leaning and postural control with a changing
base of stability, all of which are components integral to a balance

••• •• •• • •
training programme effective in reduction of falls (Tahmosybayat
Lee et al. 2017 ? ?
et al., 2018).
Miranda et al. 2019 ? ? ? ? On the other hand, the effect size is considerably smaller than
Oliveira et al. 2015 ? ? ? the moderate effect sizes observed in previous reviews about the
Park et al. 2017
Pedrelra et al. 2017
•• •• •• • •
?
? ?
? effectiveness of the VR interventions as an adjunct intervention on
balance (Laver et al., 2017: Mohammadi et al., 2019). Those reviews
Rand et al. 2018

Shobhana & Rakholiya 2020 ?

?
?
• • • • ••
? ? ?
included participants across all stages of stroke. The small effect
size found in this current review could be due to differences in par·
ticipants' characteristics, where the chronicity of stroke may have
Song et al. 2015 ? ? ? ? ? ?
Yater et al. 2015

You et al. 2005

Yu & Cho, 2016

?
?
?
?
?
?
?

?
•
•••
?

?
?
?
?
slowed the improvements in functional outcomes (Milovanovic &
Popovic, 2012).
Our review also found that exergaming has a significant but small
? effect on improving lower limb functional mobility among individu·
als with chronic stroke. This is consistent w ith a previous finding that
FIG U RE 2 Risk of bias summary VR training improves TUG scores in individuals with chronic stroke
 n
I
>
z
~
~

TABLE 2 GRADE summary of findings table

Summary of flndlngs

Exerpmlng compared with comparator for chronic stroke rehabilitation

Patient or population: chronic stroke rehabilitation

Settlna:
Intervention: exerpmln1
Comparison: comparator

Anticipated absolute effects· (9S"CI)

Relatlw No. of
RJskwlth effect (95" participants Cerulnty of the
Outcomes comparator Risk with exeraamlng Cl) (studies) evidence (GRADE) Comments
Balance SMD 0.25 SD higher 573 (23 RCTs) ©EBOO The evidence suggests exergaming results in a slight
(0.08 higher to 0.41 higher) LOW".., increase in balance
Lower limb SMD 0.29 SD higher 355 (16 RCTs) ©EBOO The evidence suggests exergamlng results in a slight
functional (0.08 higher to 0 .5 higher) LOW'.b increase in lower limb functional mobility
mobility
Functional SMD 0.41 SD higher 158(7 RCTs) ©EBOO The evidence suggests exergaming results in a slight
independence (0.09 higher to 0.73 higher) LOW"·b.c increase in functional independence

Note: GRADE Working Group grades of evidence:

High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: We are moderately confident In the effect estimate: The true effect is likely to be close to the estimate of the effect. but there is an opportunity that it is substantially different.
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low certainty: We have very little confidence In the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
Abbreviations: Cl. confidence interval: GRADE, Grading of Recommendations. Assessment. Development and Evaluations; RCT. randomized controlled trial; SMD, standardized mean difference.
•Downgraded for unclear or high risk of bias.
bDowngraded for small sample size.
' Downgraded for wide confidence interval.
0
The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% Cl).

-rnr~
-<
~
~ WILEY- - CHAN ET AL

E.xergaming Control Std. Mean Ollfrence Std. Mean Diffrence

St or s rou Mean SD Total Mean SO Total Wei ht IV Random 95% Cl IV ,Random,95% Cl
Barcala et al. 2013 41.9 6.91 10 42.2 4.8 10 3.6% -0.05 [-0.92. 0.83)
Cho et al. 2012 43.09 4.8 11 43.9 4.06 11 4.0% -0.18 (-1 .01 , 0.66)
Chol et al. 2017 15.27 4.6 12 15.71 7.37 12 4.3% -0.07 (-0.87, 0.73)
da Silva Alberio et al. 2015 12.9 1.8 15 11 .9 1.8 15 5.2% -0.54 [-0.19, 1.27)
da Paula Oliveira et al. 2015 74.33 12.22 12 71 .36 18.65 11 4.1% -0.18 (-0.64, 1.00)
Oeulsch et al. 2017 16.8 3.7 5 16.8 2.5 5 1.8% -0.00 (-1.24, 1.24)
Elhakk et al. 2018 43.33 5.19 15 40 5.93 15 5.2% -0.58 (-0.15, 1.31)
Fritz et al. 2013 48.7 7.7 15 47.7 5,8 13 5.0% -0.14 (-0.60, 0.88)
Hung et al. 2014 25.35 3.92 13 25.37 4.99 15 5.0% -0.00 [-0.75, 0.74)
Hung et al. 2016 30.33 6.3 12 29.17 7.41 11 4.1% -0.16 [-0.66, 0.98)
Hung et al. 2017 - tetrax 46.92 5.n 13 50.42 3.82 6 2.8% -0.63 (-1.63, 0.36)
Hung et al. 2017 -wli 48.83 4.81 12 50.42 3.82 6 2.9% -0.33 (-1 .32, 0.65]
Junior et al. 2019 11.5 2 11 11 .3 1.4 15 4.6% 0.12 (-0.66, 0.89]
Kim et al. 2009 51 .17 4.02 12 48.25 4.22 12 4.1% 0.68 (-0.14, 1.51)
Kim et al. 2012 30.3 3.19 10 28 1.63 7 2.7% 0.82 (-0.20, 1.83)
Lee & Bae 2020 17.27 4.56 8 14.8 5.82 7 2.6% -0.45 (-0.58, 1.48)
Lee et al. 2013 341.1 126.6 12 310.2 126.7 10 3.9% -0.23 [-0.61 . 1.08]
LN et al. 2015 24.75 7.44 12 21 .39 6.31 12 4.2% -0.4 7 [-0.34, 1.28]
Lee et al. 2017 46.19 5.57 26 45.71 6.64 21 8.4% -0.08 [-0.50. 0.65]
Pall! et al. 2017 50 6.27 10 44.7 7.47 10 3.3% -0.74 (-0.18, 1.65]
Rand et al. 2016 21 .93 4.9 13 17.84 9.51 10 3.9% -0.54 (-0.30, 1.39]
Shobhana & Rakhollya 2020 50.13 3.7 15 48.6 3.35 15 5.3% -0.42 (-0.30, 1.15]
Y atar & Ylldirlm 2015 16.86 3.35 15 14.46 3.48 15 5.1% -0.68 (-0.06, 1.42)
Yu& Cho2016 43.7 4.59 10 43.7 4.21 10 3.6% -0.00 (-0.88, 0.88)

Total (95% Cl) 299 274 100.0o/o 0.25 (0.08,0.41) ♦

Hetergenelty: Tau2 = 0.00; Chi2 = 15 .12, di = 23 (P = 0.89); 12 = 0%
-4 -2 0 2 4
Tes1 for overall effect: Z = 2.89 (P = 0.004)
Favours (oontrol] Favours [Ex.ergames]

FIGURE 3 Forest plots of effect of effectiveness o f exergaming on balance

Exergaming Conlrol Sid. Mean Oill19nCe Sid. Mean Oillref1ce

$1Udy Of Subgroup MNn SO TOlal Mean SO Total Weight IV,Random,.9 5% CI IV,Random,95% Ct
Ban:alaelal. 2013 -24 .3 8 .64 10 ·25.2 2.78 10 5.9% 0. 13 1-0,74, 1.01)
Cho el al. 2012 ·20.4 3.19 11 ·19.08 4 .52 11 8.4% -0,321•1 , 17, 0.52)
Cholelal. 2017 · 13.63 3.58 12 · 12.92 3.46 12 7.0'M, -0. 191•1.00, 0.81 1
Dlullcllelal. 2017 102 22.7 5 100.5 10.7 5 2.9% 0.081· 1. 16. 1.32)
a-ketal. 2018 -25.2 4 .8 15 -29.2 6.4 15 8 .2% 0.891-0.06. 1.43)
Fritz et al. 2013 317.7 17&2 15 258. 1 174 13 8.0'M. 0.331-0,42. 1.08)
Hung et al. 2014 ·20J18 7.77 13 -26.61 12.92 15 7.9% 0.51 l-0.24, 1.27]
Hung el al. 2016 ·12.62 6 .73 12 · 19.04 5 .97 11 5.9% 0.9710, 10. 1.114)
Junior el al. 2019 27.2 3.9 11 26.7 3 .6 15 7.4% 0. 131-0.65. 0.91 )
Khan el al. 2018 -21.89 2.89 11 ·22.44 2.77 11 6.4% 0. 191-0,65. 1.02)
Kim el al. 2019 64 22. 66 12 46.75 13.07 12 6.3% 0.90 (0.06. 1.75]
Lee & Bae 2020 .39.32 25.42 8 -36.3 35.33 7 4.4% -0.09 (· 1. 11 . 0.92)
Oliveira 84 al 2015 211.5 4.25 12 22.18 4 .97 11 6.7% -0.14 (-0.96. 0.68)
Shoti1181111&Rakholiya2020 625.33 47.3'4 15 592.67 35.55 15 8 .1% 0.76 (0.01 . 1.50)
You et al. 2006 4 .6 0.24 5 4.4 0.24 5 2.6% 0.75 (-0.56. 2.06)
Yu & Cho. 2018 -20.22 3.3 10 -19.47 4 .58 10 5.8% -0. 18 (•1 .06. 0.70)

.....
Total (95% Cl) 177
ga, ieilsy:• Tau'• 0.00; Chi'• 14.39, di • 15 P • 0 .50 ; 12 • O'%
TNI lot 01191a11 effecl: Z • 2.70 (P • 0 .007)
178 100.0'M. 0.29 (0.08. 0.50)

·2 ·1 0
• 1 2
Favours IConlrolJ Favours (Exe~)

FIGURE 4 Forest plots of effectiveness of exergaming on lower limb functional m obility

Exefoamino Control Std. Mean Oitfe<ence Sid. Mew, Oillenlnce

S1udy Of Subgroup Mean SO TOlal Mean SO Tocat Weight IV, Random, 95% Cl IV. Random. 95% Ct
Ban:ala el at. 2013 6.12 0.68 10 5.72 0.67 10 12.6% 0.57 [-0.33. 1.47]
Deustch 84 al. 2017 6.01 1 .9 5 5 .88 3. 1 5 6 .6% 0.12(-1 . 12. 1.36)
0-8481. 2018 89 2.96 15 86.33 4 .44 15 18.5% 0.69 (-0.05. 1.43)
Kim el al 2012 103.3 4.32 10 101 .28 8.11 7 10.7% 0.31 (~ .66. 1.29)
Lee 2013 71 .42 15 7 61.24 11 .93 7 8 .5% 0.70 (-0.39. 1.79)
Lee et al.2017 88.27 14.63 26 88.9 12.79 21 30.6% 0.10 (-0.48. 0.67] -
Yu & Qlo, 2016 68.5 11 .1174 10 61 .6 9 .68 10 12.4% 0.63 (-0.27, 1.54)

Total (95% Cl) 83 75 100.0% 0.41 (0.09. 0 .73) ~

I lele,ogenel1y: Tau' • 0 .00; Chi' • 2.55, ell • 6 (P • 0 .86); I' • O'% j
·2 ·1 2
TNI lo, overal ellecl: Z • 2.52 (P • 0 .01 I Favours (ConllOIJ Favours [ExergamtngJ

FIGURE 5 Forest plots of effectiveness of exergaming on functional independen ce

CHAN CTAL
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Standardized Mean Difference Standardized Mean Difference

F I G U RE 6 Funnel plots for balance (left) and lower limb functional mobility (risht) outcomes

compared with conventional rehabilitation (lruthayarajah et al., individuals with chronic stroke y ielded statistically significant
2017). Exergaming improves dual-task function, which is commonly small effect s favouring exer gaming. Exergaming is a fun alterna·
impaired in individuals after stroke, by involving cognitive input tive to conventional stroke rehabilitation that is both easy to use
and physical exercise. This in turn helps achieve no rmal gait and and easy to integrate into home settings (Stanmore et al., 2019).
promotes navigation of more complex and realistic environments In the face of resource constraints at rehabilitation facilities and
(Ogawa et al., 2016). declining motivation among chronic stroke survivors, these attrib·
Lastly, the finding of a statistically significant small to moderate utes of exergaming make continuatio n of ther apy more accessible
effect of exergaming on functional independence among individu· and bearable. Therefore, exergaming may be a feasible solution
als with chronic stroke is consistent with the findings of a previous for supporting long·term stroke rehabil itat ion to elicit continued
review on the effectiveness of VR interventions on ADLs (Lee et al.. f unctional improvement beyond the subacute stage. Healthcare
2019). Since balance and mobility are essential for performing nu· professionals can introduce exergaming as an adjunct to conven·
merous ADLs that involve standing and walking, it is not surprising tional physiotherapy as an enjoyable way to Increase t herapy t ime
that the improved balance and lower limb functional mobility gained while overcom ing discouraging recovery plateaus In the chronic
from the exergaming ultimately led to greater functional indepen· phase of stroke.
dence (<;:elenk et al., 2018).
CONFLICT OF INTEREST
The authors declare that they have no competing interest.
5.1 Limitations
PEER REVIEW
This review has some limitations. First, most of the included stud· The peer review history for this article is available at https://publo
ies did not adequately describe the measures taken to prevent bias, ns.com/ publon/ 10.1111/jan.15125.
resulting in a low overall quality of evidence. Second, although a con·
siderable number of studies were included in this review, the small DATA AVAILABILTY STATEMENT
sample sizes of all Included studies raise some concerns that they Authors do not wish to share the data.
were underpow ered and potentially overestimated the significance
of the findings. While these issues were inher ent in the original ORCID
studies, our find ings were nonetheless based on these studies, thus Yins Jians https://orcid.org/ 0000· 0002·1496-0825
affecting the confidence in our findings. Finally, as only articles in Hadassah Joann Ramac.handran . https://orcid.
t he English language were considered for inclusion, this review in· org/ 0000· 0001· 9576·7607
evitably missed out on non-English articles with relevant outcomes. Wenru Wans O https://orcid.org/ 0000· 0002· 0265· 8215
Hence, findings from this review must be interpreted w ith caution,
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