Influence of Immersion Level and Game Type on Virtual Reality Interventions for Upper Limb Function After Stroke: Protocol for a Systematic Review and Meta-Analysis.

backgroundUpper limb impairment is a common consequence of stroke, affecting independence and quality of life. Virtual reality (VR) interventions, including serious games designed for therapeutic purposes and commercial games developed primarily for entertainment, have been increasingly used for poststroke upper limb rehabilitation. Evidence comparing the effectiveness of these game types on functional outcomes remains unclear.

objectiveThis systematic review protocol aims to determine whether serious and commercial VR games differentially impact upper limb function, measured by the Action Research Arm Test, in adults after stroke. Secondary outcomes will include upper limb motor function assessed using the Fugl-Meyer Assessment-Upper Extremity, Box and Block Test, Motor Activity Log, Jebsen-Taylor Hand Function Test, and Wolf Motor Function Test; functional independence assessed using the Functional Independence Measure and Barthel index; and adherence indicators, including dropout rates and session completion. Secondary objectives include evaluating pooled VR effects vs conventional therapy (CT) and exploring potential moderators, such as VR immersion level and stroke chronicity.

methodsParallel randomized controlled trials involving adults (aged ≥18 years) with ischemic or hemorrhagic stroke in the acute, subacute, or chronic phases will be included. Interventions using serious or commercial VR games (nonimmersive, semi-immersive, or fully immersive) delivered alone or combined with CT will be considered. Studies using nongamified VR, digital technologies without VR, or augmented reality not integrated into VR will be excluded. Eligible comparators include conventional physiotherapy, occupational therapy, usual care, educational interventions, or no therapy. This protocol was developed in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Protocols) guidelines. Systematic searches will be conducted in the PubMed (MEDLINE), Web of Science, Embase, Scopus, Virtual Health Library, ScienceDirect, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Brazilian Clinical Trials Registry, World Health Organization (WHO) International Clinical Trial Registry Platform, and ISRCTN Registry databases from inception to February 2026. Data extraction will be performed independently by 2 reviewers, and risk of bias will be assessed using the Cochrane risk of bias 2.0 tool. Meta-analyses will be conducted when clinical and methodological homogeneity permits. A random-effects model is planned; however, the final choice of model will be based on the level of heterogeneity observed at the time of analysis. Subgroup analyses will explore stroke phase, immersion level, intervention dosage, and concomitant therapy.

resultsData collection is planned from inception to February 2026. Study screening and data extraction are ongoing, with synthesis and meta-analysis expected by November 2026 and final publication anticipated in winter 2026.

conclusionsThis systematic review will clarify whether different VR game formats produce distinct effects on upper limb rehabilitation after stroke, providing evidence to inform the design and implementation of VR-based neurorehabilitation interventions.

trial registrationPROSPERO CRD42024595266; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024595266. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/95135.