Virtual Reality and Noninvasive Brain Stimulation in Stroke: How Effective Is Their Combination for Upper Limb Motor Improvement?—A Meta-Analysis

Background: Efforts to augment post-stroke upper limb (UL) motor improvement include the use of newer interventions such as noninvasive brain stimulation (NIBS) and task practice in virtual reality environments (VEs). Despite increasing interest in using a combination of these 2 interventions, the effectiveness of this combination to enhance UL motor improvement outcomes has not been examined. Objective: To evaluate the effectiveness of a combination of NIBS and task practice in a VE to augment post-stroke UL motor improvement. Methods: We conducted a systematic search of the published literature using standard methodology. The Down and Black checklist and the Physiotherapy Evidence Database Research Organization Scale were used to assess study quality. We compared changes in UL impairment and activity levels between active stimulation and sham or other interventions using standardized mean differences and derived a summary effect size. Results: We retrieved 5 studies that examined the role of a combination of NIBS and task practice in a VE to optimize UL motor improvement. These 5 studies included 3 randomized controlled trials, 1 cross-sectional study, and 1 crossover study. There was level 1a evidence that the combination was beneficial in subacute stroke. There was level 1b evidence that provision of real stimulation was not superior to sham stimulation in chronic stroke. Effect sizes favoring the combination were moderate for improvements in UL impairment and small for activity levels. Conclusions: Preliminary evidence supports the effectiveness of this combination in subacute stroke. Emergent questions need to be addressed to derive maximum benefit of this combination to augment post-stroke UL motor improvement.