The impact of virtual reality exercise on motor function, balance and gait function, and cognitive function in stroke patients: an umbrella review of systematic reviews and meta-analyses

Abstract

Background Stroke is a leading cause of adult disability, and most survivors experience motor, balance and gait, and cognitive impairment. Virtual reality exercise is an innovative rehabilitation approach, but fragmented evidence limits its clinical application. This umbrella review synthesized meta-analytic evidence to evaluate VR exercise effects on motor, balance/gait, and cognitive function in stroke patients. Methods This PROSPERO-registered review CRD420261341936 followed PRISMA 2020 guidelines. Systematic reviews and meta-analyses of randomized controlled trials evaluating VR exercise in stroke rehabilitation were identified from six electronic databases. Methodological quality was assessed with AMSTAR 2, and evidence certainty classified via metaumbrella GRADE-based criteria, with quantitative evidence re-analyzed using deduplicated primary RCTs. Results Ten meta-analyses with 367 pre-deduplication RCT entries and 14,352 total participants were included. After deduplication and exclusion of trials with unavailable or incomplete numerical data, 138, 81, and 23 unique RCTs contributed to the motor, balance/gait, and cognitive analyses, respectively. VR exercise was associated with statistically significant improvements in several functional outcomes; however, the magnitude and certainty of effects varied across domains. VR was associated with significant improvements in functional ambulation (equivalent standardized mean difference, eSMD = 0.70, 95% CI 0.23–1.17) and upper limb motor function (eSMD = 0.38, 95% CI 0.21–0.55); gait velocity (eSMD = 0.63, 95% CI 0.43–0.82) and Berg Balance Scale scores (eSMD = 0.69, 95% CI 0.45–0.92); and global cognition measured by Montreal Cognitive Assessment (eSMD = 0.48, 95% CI 0.19–0.76). Most outcomes had very low certainty (MoCA: moderate). Heterogeneity varied considerably across outcome measures (I2 ranging from 0% to 93%), and most included systematic reviews were rated as critically low methodological quality. Conclusions VR exercise may be associated with improvements in selected post-stroke motor, balance and gait, and cognitive outcomes. However, statistically significant effects should not be interpreted as clinically meaningful benefits without established MCID thresholds or interpretable benchmarks. Evidence is further limited by substantial heterogeneity, poor review methodology, and generally low certainty. VR may therefore be a potential adjunctive rehabilitation approach, but current evidence does not support replacing conventional rehabilitation or preferential use in specific patient subgroups. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261341936, PROSPERO CRD420261341936.