Key messages
- Virtual reality might improve balance and postural control, upper limb function, and participation and quality of life, but the overall quality of the evidence is limited.
- Since these results are based on few studies of lower quality, they should be interpreted with caution.
What is multiple sclerosis?
Multiple sclerosis is the most common neurological disease in young adults. People with multiple sclerosis can have a variety of symptoms, such as fatigue, and sensory, cognitive and sexual dysfunction, but also muscle weakness and co-ordination problems.
How can virtual reality help people with multiple sclerosis?
Virtual reality has been proposed as a new rehabilitation tool and is increasingly being used for the rehabilitation of neurological patients. Virtual reality interventions use computer programs that allow users to navigate in and interact with a virtual environment. The use of virtual reality in rehabilitation offers several advantages, such as providing fully controllable, personalised environments and situations that are too dangerous, expensive or impossible in real life. Moreover, the level of difficulty and intensity can be adapted to the skills of the patient, and virtual reality has the potential to increase patients’ motivation by creating more exciting training environments and providing feedback.
What did we want to find out?
The purpose of this review was to assess the effectiveness of virtual reality interventions for the rehabilitation of people with multiple sclerosis. We wanted to find out whether training with virtual reality resulted in more improvement of lower limb function and gait, balance and postural control, upper limb function, cognition, fatigue, global motor function, activity limitations, participation and quality of life, and the occurrence of adverse (harmful or unwanted) events. We compared virtual reality training to 1) no intervention and 2) conventional therapy or an alternative therapy.
What did we do?
We identified 33 studies with a total of 1294 people with multiple sclerosis, who on average (based on 22 studies) had a significant disability but were able to walk without an aid for 500 metres. A lot of different virtual reality devices and programs were used. Almost 91% (30) of the included studies used non-immersive virtual reality systems (e.g. TV screens), two studies used semi-immersive virtual reality devices (e.g. big screens) and one study used a full-immersive head-mounted display. Most virtual reality interventions aimed to improve balance and gait function.
What did we find?
Ten studies assessed whether virtual reality can be used to improve gait and balance function and found that the use of virtual reality may not result in better function for most outcome measures when compared to no intervention (we are very uncertain about these results). When compared to conventional therapy, the gains in terms of lower limb and gait function were probably not greater for the virtual reality interventions. However, virtual reality is probably superior in improving balance and postural control compared to conventional therapy. Two trials tested whether virtual reality would lead to more improvements in upper limb function compared to no intervention, and found that this may be the case. Virtual reality may be more effective in improving upper limb function than conventional therapy. Studies that assessed participation and quality of life may indicate positive effects in favour of virtual reality, both when compared to no intervention and conventional therapy (we are very uncertain about these results). We were unable to assess the effect of virtual reality interventions on global motor function and adverse events.
What are the limitations of the evidence?
Overall, we have moderate to low or very low confidence in evidence. This was mainly due to the small numbers of participants in the included studies and the poor quality of the studies. Moreover, due to the nature of the included studies, the evidence is mainly limited to people with a relatively low degree of physical disability and virtual reality technology that has a limited degree of immersion. Furthermore, the methods used in the studies varied; for example, regarding the types of outcomes measured and the design of the interventions.
How up-to-date is this evidence?
The evidence is current to August 2022.
We found evidence that the use of virtual reality may be more effective than no intervention in improving upper limb function and participation and quality of life. Training with virtual reality may be superior to conventional therapy for improving balance and postural control, and participation and quality of life. For the other outcomes, there was no clear difference between virtual reality and conventional therapy. There was insufficient evidence to reach conclusions about the effect of virtual reality on global motor function, activity limitations and adverse events. Additional high-quality, large-scale studies are needed to expand and confirm these findings.
Multiple sclerosis (MS) is the most common neurological disease in young adults. Virtual reality (VR) offers a promising rehabilitation tool by providing controllable, personalised environments for safe, adaptable and engaging training. Virtual reality can be tailored to patients' motor and cognitive skills, enhancing motivation through exciting scenarios and feedback.
Primary objective
To assess the effects of virtual reality interventions compared with an alternative or no intervention on lower limb and gait function, and balance and postural control in people with MS.
Secondary objective
To assess the effects of virtual reality interventions compared with an alternative or no intervention on upper limb function, cognitive function, fatigue, global motor function, activity limitation, participation restriction and quality of life, and adverse events in people with MS.
We identified relevant articles through electronic searches of CENTRAL, MEDLINE, Embase, PEDro, CINAHL and Scopus. We also searched trials registries (ClinicalTrials.gov and the WHO ICTRP search portal) and checked reference lists. We carried out all searches up until August 2022.
We included only (quasi-)randomised controlled trials (RCTs) that assessed virtual reality interventions, defined as "an artificial, computer-generated simulation or creation of a real-life environment or situation allowing the user to navigate through and interact with", in people with MS. The primary outcomes were lower limb and gait function, and balance and postural control. Secondary outcome measures were upper limb function, cognitive function, fatigue, global motor function, activity limitation, participation and quality of life, and adverse events. Eligible participants were people with MS who were 18 years or older.
Two review authors independently screened the studies based on pre-specified criteria, extracted study data and assessed the risk of bias of the included studies. We used the risk of bias 2 tool (RoB 2). A third review author was consulted to resolve conflicts.
We included 33 RCTs with 1294 people with MS. The sample sizes of the included studies were relatively small and there was considerable heterogeneity between studies regarding the virtual reality devices and the outcome measures used. The control group either received no intervention, conventional therapy or an alternative intervention (an intervention that does not fit the description of conventional therapy for the rehabilitation of people with MS). We most frequently judged the risk of bias as 'some concerns' across domains, leading to an overall high risk of bias in the majority of included studies for all outcome measures.
Primary outcomes
When compared with no intervention, virtual reality interventions may result in no difference in lower limb and gait function (Timed Up and Go, mean difference (MD) -0.43 sec, 95% confidence interval (CI) -0.85 to 0.00; 6 studies, 264 participants; low-certainty evidence) or balance and postural control (Berg Balance Scale, MD 0.29 points, 95% CI -0.1 to 0.68; 4 studies, 137 participants; very low-certainty evidence).
When virtual reality interventions are compared to conventional therapy, results for lower limb and gait function probably do not differ between interventions (Timed Up and Go, MD -0.2 sec, -1.65 to 1.25; 4 studies, 107 participants; moderate-certainty evidence). However, virtual reality interventions probably improve balance and postural control (Berg Balance Scale, MD 2.39 points, 95% CI 1.22 to 3.57; 7 studies, 201 participants; moderate-certainty evidence), almost reaching the clinically important difference (3 points).
Secondary outcomes
Compared to no intervention, the use of virtual reality may also improve upper limb function (9-Hole Peg Test, MD -4.19 sec, 95% CI -5.86 to -2.52; 2 studies, 84 participants; low-certainty evidence), almost reaching the clinically important difference (4.38 points) and participation and quality of life, but the evidence is very uncertain (MS International QoL, MD 9.24 points, 95% CI 5.76 to 12.73; 2 studies, 82 participants; very low-certainty evidence).
Compared to conventional therapy, virtual reality interventions may improve participation and quality of life (Falls Efficacy Scale-1, MD -3.07 points, 95% CI -5.99 to -0.15; 3 studies, 101 participants; low-certainty evidence), but not upper limb function (9-Hole Peg Test, MD 0.10 sec, 95% CI -1.70 to 1.89; 3 studies, 93 participants; low-certainty evidence). For other key secondary outcome measures, i.e. global motor function and adverse events, there were no data available as these were not measured in the studies.