Upper limb virtual reality (v no intervention) on upper limb function in people with tetraplegia | SCI Physiotherapy Clinical Practice Guidelines

	Upper limb virtual reality (v no intervention) on upper limb function in people with tetraplegia
P	People with tetraplegia	Evidence recommendation No evidence recommendation Reason: No recommendation due to insufficient or inconclusive evidence.		Weak opinion statement FOR Upper limb virtual reality training may be provided to improve UL function in people with tetraplegia.
I	Upper limb virtual reality training may be provided to improve UL function in people with tetraplegia.
C	No intervention	Consensus-based opinion statement Weak for (100%)
O	Upper limb function	Consensus-based opinion statement Weak for (100%)
	SUMMARY	3 RCTs (see references)		Standardised mean difference (95% CI) 0.7 (-1.6 to 0.2) Favours no intervention
	GRADE Very low certainty ⨁◯◯◯	Risk of bias Very serious	Inconsistency Serious	Imprecision Very serious	Indirectness No serious	Publication bias Serious

UPPER LIMB VIRTUAL REALITY TRAINING ON UPPER LIMB FUNCTION: GRADE Evidence to Decision
PROBLEM	No	Probably no	Probably yes	Yes		Don't know
DESIRABLE EFFECTS	Trivial	Small	Moderate	Large		Don't know
UNDESIRABLE EFFECTS	Large	Moderate	Small	Trivial		Don't know
CERTAINTY OF EVIDENCE	Very low	Low	Moderate	High		No included studies
HOW MUCH PEOPLE VALUE THE MAIN OUTCOME	Important uncertainty or variability	Possibly important uncertainty or variability	Probably no important uncertainty or variability	No important uncertainty or variability
BALANCE OF EFFECTS	Favours the Control	Probably favours the Control	Does not favour either the intervention (I) or the comparison (C)	Probably favours the I	Favours the I	Don't know
RESOURCES REQUIRED	Large costs	Moderate costs	Negligible costs and savings	Moderate savings	Large savings	Don't know
CERTAINTY OF EVIDENCE OF REQUIRED RESOURCES	Very low	Low	Moderate	High		No included studies
COST EFFECTIVENESS	Favours the comparison	Probably favours the comparison	Does not favour either the intervention or the comparison	Probably favours the intervention	Favours the intervention	No included studies
EQUITY	Reduced	Probably reduced	Probably no impact	Probably increased	Increased	Don't know
ACCEPTABILITY	No	Probably no	Probably yes	Yes		Don't know
FEASIBILITY	No	Probably no	Probably yes	Yes		Don't know

UPPER LIMB VIRTUAL REALITY TRAINING ON UPPER LIMB FUNCTION: Randomised Controlled Trial Details
STUDY	COMPARISON	DOSAGE/DETAILS	PARTICIPANTS	N (Rx/C)	OUTCOME	ROB 2 PEDRo
DIMBWADYO-TERRER 2016	Virtual reality UL training (plus usual care) V Usual care	15 sessions with Toyra(®) virtual reality system for 5 30 minutes per day, 3 days/week for 5 weeks	Complete tetraplegia	15/16	SCIM (self-care sub-score)	Some Concerns of Risk Bias PEDro = 6/10
LIM 2020	Virtual reality (plus usual care) V Usual care	30 minutes of VR training and 30 minutes of conventional therapy per day, 4 x per week for 4 weeks	C4-C6 tetraplegia	10/10	SCIM	High Risk of Bias PEDro = 5/10
PRASAD 2018	Virtual reality UL training (plus usual care) V Usual care	3 x per week for 4 weeks	tetraplegia	11/9	Box and block test	High Risk of Bias PEDro = 6/10

The Australian and NZ SCI Physiotherapy guideline committee recommends upper limb virtual reality training to improve UL function in people with tetraplegia.

This is a consensus-based opinion statement supported by the opinions of the experts even though there is one randomised controlled trial related to this topic. However, the result of this randomised controlled trial is inconclusive preventing an evidence recommendation. The guideline states:

Upper limb virtual reality training may be provided to improve UL function in people with tetraplegia.

This statement was formed by considering the opinions of the experts alongside other factors. The other factors that were considered were benefits and harms, values and preferences, resource use, equity, accessibility, and feasibility. The results of one randomised controlled trial was also taken into consideration. This is a consensus-based opinion statement. Consensus-based opinion statements are less robust than evidence-based recommendations. They can be strong or weak.

This is a strong consensus-based opinion statement which means that the guideline panel is confident they can probably recommend upper limb virtual reality training to improve UL function in people with tetraplegia based on opinion.

To learn more about the research related to this intervention go to the research summary.

Dimbwadyo-Terrer I, Gil-Agudo A, Segura-Fragoso A, et al. Effectiveness of the virtual reality system toyra on upper limb function in people with tetraplegia: a pilot randomized clinical trial. BioMed Research International 2016; BioMed Research International 2016; 6397828.
Lim DY, Hwang DM, Cho KH, et al. A Fully Immersive Virtual Reality Method for Upper Limb Rehabilitation in Spinal Cord Injury. Annals of rehabilitation medicine 2020. DOI: https://dx.doi.org/10.5535/arm.19181
Prasad S, Aikat R, Labani S, Khanna N. Efficacy of Virtual Reality in Upper Limb Rehabilitation in Patients with Spinal Cord Injury: A Pilot Randomized Controlled Trial. Asian spine journal 2018; 12: 927-934.