Type of Article:  Meta-Analysis

Volume 10; Issue 3 (June 2022)

Page No.: 4225-4242

DOI: https://dx.doi.org/10.16965/ijpr.2022.121

Rehabilitation Interventions Using Immersive Virtual Reality for People With Parkinson’s Disease: A Systematic Review and Meta-Analysis

Patrice Piette *, Bastien Fraudet, Constant Vinatier,  Emilie Leblong, Philippe Galien.

Pole St Helier, rehabilitation centre, clinical research department, 35 000 Rennes Britanny France.

Corresponding Author:  Patrice Piette, Centre de rééducation Pôle St Helier, rue St Helier, 35000 Rennes, Britanny, France. Mobile.  [33] 0681264490. E-Mail: patrice.piette@pole-sthelier.com


Background: Research into motor rehabilitation using Immersive Virtual Reality [Immersive Virtual Reality] for people with Parkinson’s Disease s rapidly growing in popularity. The aims of this review were to investigate the effect of VR interventions on lower limb and upper limb function in people with Parkinson’s disease and determine whether the type of virtual reality intervention used influences intervention effect.

Method: Seven databases [PubMed, EMBASE, Scopus, CINAHL, SPORTDiscus, TRIP database, google scholar] were searched using keywords relating to Parkinson’s disease, immersive virtual reality and lower limb.

Results: Sixteen articles were included: two randomised controlled trials and fourteen quasi-experimental designs. Augmented reality or immersive virtual reality technologies were used in interventions. Three studies looked at the upper limb, and thirteen the lower limb. For the upper limb, the box and block test was used in two studies but only one produced relevant data for meta-analysis. For the lower limb, six studies had relevant data [gait analysis] for meta-analysis: Using Augmented Reality, cadence, standardised mean difference = -0.08, 95% CI [‐0.54 to 0.28], I2 = 52%; Length standardised mean difference= -0.00, 95% CI [‐0.21 to 0.20], I2= 0%; Speed standardised mean difference= -0.08, 95% CI [‐0.32 to 0.16], I2= 0%. Using Immersive Virtual Reality, cadence standardised mean difference = -0.16, 95% CI [ ‐1.89 to 2.21], I2 = 71%; Length standardised mean difference= -0.28, 95% CI [‐1.73 to 1.13], I2=44%; Speed standardised mean difference= -0.06, 95% CI [‐1.44 to 1.34], I2=71%.

Conclusion: There is therefore no clear evidence that either Immersive Virtual Reality or Augmented Reality is effective in improving motor function in the lower limb or upper limb. There is no clear consensus on which virtual reality-based approach out of Augmented Reality or Immersive Virtual Reality is the most effective. Moreover, risk of bias is high as many of the studies used non-randomised methods.

Keywords: Parkinson’s disease, Rehabilitation, Virtual reality, Augmented reality, gait.


[1]. Pringsheim T, Jette N, Frolkis A, Steeves TDL. The prevalence of Parkinson’s disease: A systematic review and meta-analysis. Mov Disord. 2014;29[13]:1583–90.
[2]. Berg D, Postuma RB, Bloem B, Chan P, Dubois B, Gasser T, et al. Time to Redefine PD? Introductory Statement of the MDS Task Force on the Definition of Parkinson’s Disease. Mov Disord. 2014 Apr;29[4]:454–62.
[3]. Canning CG, Paul SS, Nieuwboer A. Prevention of falls in Parkinson’s disease: a review of fall risk factors and the role of physical interventions. Neurodegener Dis Manag. 2014;4[3]:203–21.
[4]. van der Marck MA, Munneke M, Mulleners W, Hoogerwaard EM, Borm GF, Overeem S, et al. Integrated multidisciplinary care in Parkinson’s disease: a non-randomised, controlled trial [IMPACT]. Lancet Neurol. 2013 Oct;12[10]:947–56.
[5]. Fox SH, Katzenschlager R, Lim SY, Barton B, de Bie RMA, Seppi K, et al. International Parkinson and movement disorder society evidence-based medicine review: Update on treatments for the motor symptoms of Parkinson’s disease. Mov Disord Off J Mov Disord Soc. 2018;33[8]:1248–66.
[6]. Tomlinson CL, Patel S, Meek C, Herd CP, Clarke CE, Stowe R, et al. Physiotherapy versus placebo or no intervention in Parkinson’s disease. Cochrane Database Syst Rev. 2013 Sep 10;[9]:CD002817.
[7]. van Nimwegen M, Speelman AD, Hofman-van Rossum EJM, Overeem S, Deeg DJH, Borm GF, et al. Physical inactivity in Parkinson’s disease. J Neurol. 2011 Dec;258[12]:2214–21.
[8]. Sutherland J, Belec J, Sheikh A, Chepelev L, Althobaity W, Chow BJW, et al. Applying Modern Virtual and Augmented Reality Technologies to Medical Images and Models. J Digit Imaging. 2019 Feb;32[1]:38–53.
[9]. Bohil CJ, Alicea B, Biocca FA. Virtual reality in neuroscience research and therapy. Nat Rev Neurosci. 2011 03;12[12]:752–62.
[10]. Juras G, Brachman A, Michalska J, Kamieniarz A, Pawłowski M, Hadamus A, et al. Standards of Virtual Reality Application in Balance Training Programs in Clinical Practice: A Systematic Review. Games Health J. 2019 Apr;8[2]:101–11.
[11]. Kardong-Edgren S [Suzie], Farra SL, Alinier G, Young HM. A Call to Unify Definitions of Virtual Reality. Clin Simul Nurs. 2019 Jun 1;31:28–34.
[12]. Rousseaux F, Bicego A, Ledoux D, Massion P, Nyssen AS, Faymonville ME, et al. Hypnosis Associated with 3D Immersive Virtual Reality Technology in the Management of Pain: A Review of the Literature. J Pain Res. 2020 May 21;13:1129–38.
[13]. Lauwens Y, Rafaatpoor F, Corbeel K, Broekmans S, Toelen J, Allegaert K. Immersive Virtual Reality as Analgesia during Dressing Changes of Hospitalized Children and Adolescents with Burns: A Systematic Review with Meta-Analysis. Child Basel Switz. 2020 Oct 22;7[11]:E194.
[14]. Matamala-Gomez M, Donegan T, Bottiroli S, Sandrini G, Sanchez-Vives MV, Tassorelli C. Immersive Virtual Reality and Virtual Embodiment for Pain Relief. Front Hum Neurosci. 2019 Aug 21;13:279.
[15]. Berryman DR. Augmented reality: a review. Med Ref Serv Q. 2012;31[2]:212–8.
[16]. Negrillo-Cárdenas J, Jiménez-Pérez JR, Feito FR. The role of virtual and augmented reality in orthopedic trauma surgery: From diagnosis to rehabilitation. Comput Methods Programs Biomed. 2020 Jul 1;191:105407.
[17]. Hayes MT. Parkinson’s Disease and Parkinsonism. Am J Med. 2019;132[7]:802–7.
[18]. Vojciechowski A, Zotz T, Loureiro AP, Israel V. The International Classification of Functioning, Disability and Health as Applied to Parkinson’s Disease: A Literature Review. Adv Park Dis. 2016 Apr 1;5:29–40.
[19]. Parkinson Evidence Database to Guide Effectiveness [Internet]. [cited 2022 Jan 17]. Available from: https://www.neuropt.org/practice-resources/neurology-section-outcome-measures-recommendations/parkinson-disease
[20]. Yorke AM, Trojanowski S, Fritz NE, Ludwa A, Schroeder M. Standardizing Outcome Assessment in Parkinson Disease: A Knowledge Translation Project. J Neurol Phys Ther JNPT. 2021 Jan;45[1]:21–7.
[21]. Lee M, Youm C, Noh B, Park H, Cheon SM. Gait Characteristics under Imposed Challenge Speed Conditions in Patients with Parkinson’s Disease During Overground Walking. Sensors. 2020 Apr 10;20[7]:E2132.
[22]. Ambrus M, Sanchez JA, Sanchez Miguel JA, Del-Olmo F. Test-retest reliability of stride length-cadence gait relationship in Parkinson’s disease. Gait Posture. 2019 Jun;71:177–80.
[23]. Welzel J, Wendtland D, Warmerdam E, Romijnders R, Elshehabi M, Geritz J, et al. Step Length Is a Promising Progression Marker in Parkinson’s Disease. Sensors. 2021 Mar 25;21[7]:2292.
[24]. Nieuwboer A, Rochester L, Herman T, Vandenberghe W, Emil GE, Thomaes T, et al. Reliability of the new freezing of gait questionnaire: agreement between patients with Parkinson’s disease and their carers. Gait Posture. 2009 Nov;30[4]:459–63.
[25]. Opara J, Małecki A, Małecka E, Socha T. Motor assessment in Parkinson`s disease. Ann Agric Environ Med. 2017 Sep 21;24[3]:411–5.
[26]. Mathiowetz V, Volland G, Kashman N, Weber K. Adult norms for the Box and Block Test of manual dexterity. Am J Occup Ther Off Publ Am Occup Ther Assoc. 1985 Jun;39[6]:386–91.
[27]. Skorvanek M, Martinez‐Martin P, Kovacs N, Rodriguez‐Violante M, Corvol J, Taba P, et al. Differences in MDS‐UPDRS Scores Based on Hoehn and Yahr Stage and Disease Duration. Mov Disord Clin Pract. 2017 Mar 11;4[4]:536–44.
[28]. Armijo-Olivo S, da Costa BR, Cummings GG, Ha C, Fuentes J, Saltaji H, et al. PEDro or Cochrane to Assess the Quality of Clinical Trials? A Meta-Epidemiological Study. PLoS ONE [Internet]. 2015 Jul 10 [cited 2020 Nov 4];10[7]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4498768/
[29]. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019 Aug 28;l4898.
[30]. Worrall J. Why There’s No Cause to Randomize. Br J Philos Sci. 2007 Sep 1;58[3]:451–88.
[31]. Colliver JA, Kucera K, Verhulst SJ. Meta-analysis of quasi-experimental research: are systematic narrative reviews indicated? Med Educ. 2008;42[9]:858–65.
[32]. Portney LG, Watkins MP. Foundations of Clinical Research Applications to Practice. F.A. Davis Company; 2015.
[33]. Calabrò RS, Naro A, Cimino V, Buda A, Paladina G, Di Lorenzo G, et al. Improving motor performance in Parkinson’s disease: a preliminary study on the promising use of the computer assisted virtual reality environment [CAREN]. Neurol Sci. 2020 Apr;41[4]:933–41.
[34]. Cikajlo I, Peterlin Potisk K. Advantages of using 3D virtual reality based training in persons with Parkinson’s disease: a parallel study. J NeuroEngineering Rehabil. 2019 Dec;16[1]:119.
[35]. Badarny S, Aharon-Peretz J, Susel Z, Habib G, Baram Y. Virtual Reality Feedback Cues for Improvement of Gait in Patients with Parkinson’s Disease. Tremor Hyperkinetic Mov. 2014 Apr 1;4[0]:225.
[36]. Espay AJ, Baram Y, Dwivedi AK, Shukla R, Gartner M, Gaines L, et al. At-home training with closed-loop augmented-reality cueing device for improving gait in patients with Parkinson disease. J Rehabil Res Dev. 2010;47[6]:573.
[37]. Gómez-Jordana LI, Stafford J, Peper C [Lieke] E, Craig CM. Virtual Footprints Can Improve Walking Performance in People With Parkinson’s Disease. Front Neurol. 2018 Aug 17;9:681.
[38]. Griffin HJ, Greenlaw R, Limousin P, Bhatia K, Quinn NP, Jahanshahi M. The effect of real and virtual visual cues on walking in Parkinson’s disease. J Neurol. 2011 Jun;258[6]:991–1000.
[39]. Janeh O, Fründt O, Schönwald B, Gulberti A, Buhmann C, Gerloff C, et al. Gait Training in Virtual Reality: Short-Term Effects of Different Virtual Manipulation Techniques in Parkinson’s Disease. Cells. 2019 May 6;8[5]:419.
[40]. Janssen S, Bolte B, Nonnekes J, Bittner M, Bloem BR, Heida T, et al. Usability of Three-dimensional Augmented Visual Cues Delivered by Smart Glasses on [Freezing of] Gait in Parkinson’s Disease. Front Neurol. 2017 Jun 13;8:279.
[41]. Janssen S, de Ruyter van Steveninck J, Salim HS, Cockx HM, Bloem BR, Heida T, et al. The Effects of Augmented Reality Visual Cues on Turning in Place in Parkinson’s Disease Patients With Freezing of Gait. Front Neurol. 2020 Mar 24;11:185.
[42]. Kim A, Darakjian N, Finley JM. Walking in fully immersive virtual environments: an evaluation of potential adverse effects in older adults and individuals with Parkinson’s disease. J NeuroEngineering Rehabil. 2017 Dec;14[1]:1–12.
[43]. Lheureux A, Lebleu J, Frisque C, Sion C, Stoquart G, Warlop T, et al. Immersive Virtual Reality to Restore Natural Long-Range Autocorrelations in Parkinson’s Disease Patients’ Gait During Treadmill Walking. Front Physiol. 2020 Sep 23;11:572063.
[44]. Messier J, Adamovich S, Jack D, Hening W, Sage J, Poizner H. Visuomotor learning in immersive 3D virtual reality in Parkinson’s disease and in aging. Exp Brain Res. 2007 May;179[3]:457–74.
[45]. Penko AL, Streicher MC, Koop MM, Dey T, Rosenfeldt AB, Bazyk AS, et al. Dual-task Interference Disrupts Parkinson’s Gait Across Multiple Cognitive Domains. Neuroscience. 2018 May 21;379:375–82.
[46]. Robles-García V, Corral-Bergantiños Y, Espinosa N, García-Sancho C, Sanmartín G, Flores J, et al. Effects of movement imitation training in Parkinson’s disease: A virtual reality pilot study. Parkinsonism Relat Disord. 2016 May;26:17–23.
[47]. Sánchez-Herrera-Baeza P, Cano-de-la-Cuerda R, Oña-Simbaña ED, Palacios-Ceña D, Pérez-Corrales J, Cuenca-Zaldivar JN, et al. The Impact of a Novel Immersive Virtual Reality Technology Associated with Serious Games in Parkinson’s Disease Patients on Upper Limb Rehabilitation: A Mixed Methods Intervention Study. Sensors. 2020 Apr 11;20[8]:2168.
[48]. Tunur T, DeBlois A, Yates-Horton E, Rickford K, Columna LA. Augmented reality-based dance intervention for individuals with Parkinson’s disease: A pilot study. Disabil Health J. 2020 Apr;13[2]:100848.
[49]. Mirelman A, Maidan I, Herman T, Deutsch JE, Giladi N, Hausdorff JM. Virtual reality for gait training: can it induce motor learning to enhance complex walking and reduce fall risk in patients with Parkinson’s disease? J Gerontol A Biol Sci Med Sci. 2011 Feb;66[2]:234–40.
[50]. Park HS, Yoon JW, Kim J, Iseki K, Hallett M. Development of a VR-based treadmill control interface for gait assessment of patients with Parkinson’s disease. IEEE Int Conf Rehabil Robot Proc. 2011;2011:5975463.
[51]. Gallagher R, Damodaran H, Werner WG, Powell W, Deutsch JE. Auditory and visual cueing modulate cycling speed of older adults and persons with Parkinson’s disease in a Virtual Cycling [V-Cycle] system. J Neuroengineering Rehabil. 2016 Aug 19;13[1]:77.
[52]. Ma HI, Hwang WJ, Fang JJ, Kuo JK, Wang CY, Leong IF, et al. Effects of virtual reality training on functional reaching movements in people with Parkinson’s disease: a randomized controlled pilot trial. Clin Rehabil. 2011 Oct;25[10]:892–902.
[53]. de Melo GEL, Kleiner AFR, Lopes JBP, Dumont AJL, Lazzari RD, Galli M, et al. Effect of virtual reality training on walking distance and physical fitness in individuals with Parkinson’s disease. NeuroRehabilitation. 2018;42[4]:473–80.
[54]. Dockx K, Bekkers EM, Van den Bergh V, Ginis P, Rochester L, Hausdorff JM, et al. Virtual reality for rehabilitation in Parkinson’s disease. Cochrane Database Syst Rev. 2016 21;12:CD010760.
[55]. Santos P, Scaldaferri G, Santos L, Ribeiro N, Neto M, Melo A. Effects of the Nintendo Wii training on balance rehabilitation and quality of life of patients with Parkinson’s disease: A systematic review and meta-analysis. NeuroRehabilitation. 2019;44[4]:569–77.
[56]. Chau B, Humbert S, Shou A. Systemic Literature Review of the Use of Virtual Reality for Rehabilitation in Parkinson Disease. Fed Pract Health Care Prof VA DoD PHS. 2021 Apr;38[Suppl 1]:S20–7.
[57]. Tarsy D. Neuroleptic-induced extrapyramidal reactions: classification, description, and diagnosis. Clin Neuropharmacol. 1983;6 Suppl 1:S9-26.
[58]. Tonini M, Cipollina L, Poluzzi E, Crema F, Corazza GR, De Ponti F. Clinical implications of enteric and central D2 receptor blockade by antidopaminergic gastrointestinal prokinetics. Aliment Pharmacol Ther. 2004;19[4]:379–90.
[59]. Dickson DW, Ahmed Z, Algom AA, Tsuboi Y, Josephs KA. Neuropathology of variants of progressive supranuclear palsy. Curr Opin Neurol. 2010 Aug;23[4]:394–400.
[60]. Perju-Dumbrava LD, Kovacs GG, Pirker S, Jellinger K, Hoffmann M, Asenbaum S, et al. Dopamine transporter imaging in autopsy-confirmed Parkinson’s disease and multiple system atrophy. Mov Disord. 2012;27[1]:65–71.
[61]. Fanciulli A, Wenning GK. Multiple-system atrophy. N Engl J Med. 2015 Jan 15;372[3]:249–63.
[62]. Litvan I, Grimes DA, Lang AE. Phenotypes and prognosis: clinicopathologic studies of corticobasal degeneration. Adv Neurol. 2000;82:183–96.
[63]. Armstrong RA. Visual Dysfunction in Parkinson’s Disease. Int Rev Neurobiol. 2017;134:921–46.
[64]. Archibald NK, Clarke MP, Mosimann UP, Burn DJ. The retina in Parkinson’s disease. Brain J Neurol. 2009 May;132[Pt 5]:1128–45.
[65]. Yu JG, Feng YF, Xiang Y, Huang JH, Savini G, Parisi V, et al. Retinal nerve fiber layer thickness changes in Parkinson disease: a meta-analysis. PloS One. 2014;9[1]:e85718.
[66]. Garcia-Martin E, Larrosa JM, Polo V, Satue M, Marques ML, Alarcia R, et al. Distribution of retinal layer atrophy in patients with Parkinson disease and association with disease severity and duration. Am J Ophthalmol. 2014 Feb;157[2]:470-478.e2.
[67]. Berliner JM, Kluger BM, Corcos DM, Pelak VS, Gisbert R, McRae C, et al. Patient perceptions of visual, vestibular, and oculomotor deficits in people with Parkinson’s disease. Physiother Theory Pract. 2020 Jun;36[6]:701–8.
[68]. Srivastava A, Sharma R, Sood SK, Shukla G, Goyal V, Behari M. Saccadic eye movements in Parkinson’s disease. Indian J Ophthalmol. 2014 May;62[5]:538–44.
[69]. Diederich NJ, Raman R, Leurgans S, Goetz CG. Progressive worsening of spatial and chromatic processing deficits in Parkinson disease. Arch Neurol. 2002 Aug;59[8]:1249–52.
[70]. Lin TP, Rigby H, Adler JS, Hentz JG, Balcer LJ, Galetta SL, et al. Abnormal visual contrast acuity in Parkinson’s disease. J Park Dis. 2015;5[1]:125–30.
[71]. Woo BH. Analysis of Stability on Single-leg Standing by Wearing a Head Mounted Display. Korean J Sport Biomech. 2017;27[2]:149–55.
[72]. Horiuchi K, Ishihara M, Imanaka K. The essential role of optical flow in the peripheral visual field for stable quiet standing: Evidence from the use of a head-mounted display. PLOS ONE. 2017 Oct 9;12[10]:e0184552.
[73]. O’Connell C, Mahboobin A, Drexler S, Redfern MS, Perera S, Nau AC, et al. Effects of acute peripheral/central visual field loss on standing balance. Exp Brain Res. 2017 Nov;235[11]:3261–70.
[74]. Mohler BJ, Creem-Regehr SH, Thompson WB, Bülthoff HH. The Effect of Viewing a Self-Avatar on Distance Judgments in an HMD-Based Virtual Environment. Presence Teleoperators Virtual Environ. 2010 Jun 1;19[3]:230–42.
[75]. Ambrus M, Sanchez JA, Fernandez-del-Olmo M. Walking on a treadmill improves the stride length-cadence relationship in individuals with Parkinson’s disease. Gait Posture. 2019 Feb 1;68:136–40.
[76]. Shulman LM, Katzel LI, Ivey FM, Sorkin JD, Favors K, Anderson KE, et al. Randomized Clinical Trial of 3 Types of Physical Exercise for Patients With Parkinson Disease. JAMA Neurol. 2013 Feb 1;70[2]:183–90.
[77]. Bello O, Marquez G, Fernandez-Del-Olmo M. Effect of Treadmill Walking on Leg Muscle Activation in Parkinson’s Disease. Rejuvenation Res. 2019 Feb 1;22[1]:71–8.

Cite this article: Patrice Piette, Bastien Fraudet, Constant Vinatier, Emilie Leblong, Philippe Galien.  Rehabilitation Interventions Using Immersive Virtual Reality for People With Parkinson’s Disease: A Systematic Review and Meta-Analysis. Int J Physiother Res 2022;10(3):4225-4242. DOI: 10.16965/ijpr.2022.121