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Importance: Venipuncture is one of the most painful and distressing procedures experienced by pediatric patients. Emerging evidence suggests that providing procedural information and distraction using immersive virtual reality (IVR) may reduce pain and anxiety among children undergoing needle-related procedures.

Background: Balance training is considered an important means to decrease fall rates in seniors. Whether virtual reality training (VRT) might serve as an appropriate treatment strategy to improve neuromuscular fall risk parameters in comparison to alternative balance training programs (AT) is as yet unclear.

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Objective: To examine and classify the effects of VRT on fall-risk relevant balance performance and functional mobility compared to AT and an inactive control condition (CON) in healthy seniors.

Data extraction: Eligibility and study quality (PEDro scale) were independently assessed by two researchers. Standardized mean differences (SMDs) served as main outcomes for the comparisons of VRT versus CON and VRT versus AT on balance performance and functional mobility indices. Statistical analyses were conducted using a random effects inverse-variance model.

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Virtual reality (VR)-based rehabilitation has been reported to have beneficial effects on upper extremity function in stroke survivors; however, there is limited information about its effects on distal upper extremity function and health-related quality of life (HRQoL). The purpose of the present study was to examine the effects of VR-based rehabilitation combined with standard occupational therapy on distal upper extremity function and HRQoL, and compare the findings to those of amount-matched conventional rehabilitation in stroke survivors.

VR-based rehabilitation is promising in stroke survivors, and many types of VR-based rehabilitation apparatus from commercial video game equipment to robotics are currently being developed and used. In the area of upper limb rehabilitation, a large number of studies have been performed in stroke survivors, and a recent systematic review concluded that the use of VR-based rehabilitation is superior to amount-matched conventional rehabilitation for improving upper limb function [9]. Nevertheless, most studies on VR-based rehabilitation for the upper extremity reported on the proximal upper extremity, with limited information on the distal upper extremity. Although 2 previous studies showed promising results regarding VR-based rehabilitation for the distal upper extremity, these studies did not include a control group [10, 11]. Randomized control trials have been performed using a VR system with different types of gloves; however, a definite conclusion about the treatment effect could not be obtained owing to the low number of participants [12, 13]. Furthermore, the effects of VR-based rehabilitation on health related quality of life (HRQoL) have not been appropriately assessed, although the QoL of stroke survivors is crucial for comprehensive rehabilitation.

Therefore, the objective of the present study was to examine the effects of VR-based rehabilitation combined with standard occupational therapy (OT) on distal upper extremity function and HRQoL, and compare the findings to those of amount-matched conventional rehabilitation in stroke survivors.

A previous systematic review found that task-specific training enhanced arm function; however, this review failed to show the beneficial effects of the intervention on hand function [24]. Additionally, a recent systematic review failed to show the beneficial effects of VR-based rehabilitation on distal upper extremity function in stroke survivors [9]. However, our study found that the functional improvements of the distal upper extremity were better using VR-based rehabilitation than using conventional rehabilitation, according to the FMA-dist and JTT-total scores. Furthermore, the functional improvements of the distal upper extremity using VR-based rehabilitation were more definite for gross hand function than for fine hand function, as a significant difference was noted in the JTT-gross score but not in the JTT-fine and PPT scores. Therefore, the improvements in distal upper extremity function using VR-based rehabilitation might have resulted from the task-specificity of the SG system, as the intervention mainly consisted of gross movements of the distal upper extremity without fine movements involving individual fingers. The following are the highlights of task-specific training: relevance to the patient and context, randomly ordered practice sequence, repetition, reconstruction of the task, and positive reinforcement [25]. The SG system includes all the abovementioned properties of task-specific training. The games in the SG system require participants to repeat the reconstructed tasks mimicking ADLs, which are relevant to them and the context. Therapists could prepare specific intervention schedules by combining games; thus, a randomly ordered practice sequence could be prepared. In addition, the artificial intelligence of the SG system can adjust the difficulty of tasks according to participant performance; thus, allowing the completion of the task. This provides a feeling of achievement, which is enhanced by audio or visual feedback in the game, leading to positive reinforcement. Therefore, the task-specific training effects might be maximized using the SG system. A recent study showed that the improvement in distal upper limb function was greater using VR-based rehabilitation with an actuated glove than using conventional rehabilitation, according to the JTT scores [13]. In contrast, the SG system used in our study did not include an actuated apparatus; thus, our results represent the task-specific effects of VR-based rehabilitation without the use of additional tools.

We found that VR-based rehabilitation had beneficial effects on both the proximal and distal upper extremity, which were indicated by the FMA-prox and FMA-dist scores, respectively. These results were not expected, as we believed that the VR-based rehabilitation would only influence the distal upper extremity because the SG system focuses on the distal upper extremity. A possible explanation for the results is that the distal part plays a major role in upper extremity function as an end-effector; therefore, the high activity of the distal part during rehabilitation promoted the active use of the affected upper extremity, which was neglected or not used, thus overcoming learned non-use [3]. Training using the SG system allowed the performance improvement to be generalized to untrained tasks. Recent studies have shown that the effects of VR-based rehabilitation for the upper extremity were transferred to distinct tasks in stroke survivors [10, 13]. Moreover, this extension of performance improvement to untrained tasks after task-specific training was not dependent on the similarity between tasks [26]. Krakauer advocated that a rehabilitation technique should allow the extension of performance improvement to untrained tasks [27]. Therefore, we believe that the SG system is an ideal rehabilitation tool.

We noted greater improvements in the composite SIS, overall SIS, and SIS-social participation, and SIS-mobility scores using VR-based rehabilitation than using conventional rehabilitation. These findings are largely consistent with those of previous randomized controlled trials that showed greater improvements in overall SIS scores or some physical domain scores using constraint-induced movement therapy (CIMT) than conventional therapy [28, 29]. However, a previous study on CIMT reported improvements in only SIS-hand function scores [28]. A Cochrane review on VR commented on the low number of studies regarding participation restriction or QoL [9]. Additionally, a recent systematic review suggested the performance of more studies evaluating the effects of upper limb interventions on HRQoL [30]. A recent study, which was not included in these reviews, showed the possible benefits of VR-based rehabilitation on HRQoL by comparing Short-Form Health Survey scores between VR-based rehabilitation and conventional rehabilitation [31]. One item of the Short-Form Health Survey (role limitation due to physical problem) showed greater improvement after VR-based rehabilitation than after conventional rehabilitation. Our study also showed the beneficial effects of VR-based rehabilitation on HRQoL, including more generalized effects on HRQoL, which are represented by improvements in the overall and composite SIS scores in accordance with our functional results.

The present study had several limitations. First, the improvements in the FM scores did not exceed the MCID of 6.6 points [32]. Additionally, the improvements in the JTT and PPT scores did not have established MCID values. Therefore, it is not appropriate to state that the improvements in the SG group were within the minimum values required to consider the intervention clinically important. However, considering the findings of previous studies on VR (FM MCIDs between 3.5 and 4.5) [9, 33], the improvements in the FM scores were good in the SG group. Therefore, the SG system might be a clinically meaningful VR-based rehabilitation tool. Moreover, the improvement in the SIS-ADLs/IADLs score was beyond the MCID of 5.9 in the SG group. Therefore, the SG system can be considered a clinically useful rehabilitation tool. Furthermore, the ceiling effect of the FM score might hamper the observation of a further improvement in the FM score. Second, the FM score was used as the primary outcome and for power calculation; however, the target of the SG system was the distal upper extremity. We used the FM score, as there was no appropriate VR-based rehabilitation study using outcome measures focused on the hand, such as the JTT. In addition, we hoped to investigate the generalized effects of the SG system on the upper extremity by using the FM score. Future studies using outcome measures relevant to the distal upper extremity are needed to examine the efficacy of the present system. Third, the study did not include a group that received training using only the SG system or a group that received only standard OT. We provided 30 min of standard OT in the SG group from an ethical standpoint because there were no clinical data to support the use of the SG system. Thus, it is difficult to state that the good outcomes in the SG group resulted from the use of the SG system. A future study is warranted to compare rehabilitation using the SG system only with conventional rehabilitation. Fourth, follow-up evaluations were not performed with the SIS; thus, the long-term beneficial effects of rehabilitation using the SG system on HRQoL could not be determined. Fifth, we used a new scoring system for the JTT instead of raw time; thus, comparisons with other results or broader interpretation might be limited. Sixth, participants who exhibited hand flaccidity were excluded, as the SG system does not provide assistive force. We are performing another clinical trial with a combination of functional electrical stimulation and the SG system to overcome this limitation. 2351a5e196