Active Video Games Improve Balance Better Than Conventional Rehab in MS

Video games that involve physical exertion was found to be more effective at improving balance in patients with multiple sclerosis (MS) compared with more conventional rehabilitation methods, investigators concluded.

Conducting balance rehabilitation using exergames, which are video games that involve physical exertion, was found to be more effective than conventional rehabilitation in patients with multiple sclerosis (MS), according to a recent review.

The systematic review and meta-analysis, published in Frontiers in Neurology, compiled published literature that evaluated the efficacy of exergames and virtual reality (VR) games compared with conventional balance rehabilitation in regard to improvement of balance in patients with MS, an area of study that has few randomized controlled trials (RCTs).

“Indeed, human balance control is the results of multiple sensory system inputs, integrated into a complex mechanism of constant reweight and adjustments, as visual, vestibular, and proprioception signals are continuously converted to corrective motor actions. Hence, a multisensorial augmented reality might be a particularly effective rehabilitation approach in MS balance impairments,” the investigators wrote.

VR has been integrated in several neurological diseases rehabilitative protocols, including patients with MS, and has yielded promising results. Exergaming is also widely used in several rehabilitative programs and clinical study. Commercially available exergames, including those using a Nintendo Wii or Microsoft Kinect, have been successful at transforming living spaces into training environments for over a decade. Clinical and home trials investigating the effectiveness of these gaming systems or rehabilitation purposes for neurological conditions have been scarce and produced conflicting results.

The investigators searched 3 databases for articles published in the English language and prior to May 14, 2021. For inclusion, the studies had to include experimental and control groups, evaluate the effectiveness of exergames and/or VR compared with conventional rehabilitation, assess the intervention’s impact on balance, and include patients with MS who were over 18 years old.

Of the 93 studies that were identified, 7 RCTs published between 2003 and 2020 were included in the review after exclusion, 5 of which were from Europe and 2 were from the Eastern Mediterranean. In total, 209 patients were analyzed, 97 of whom performed VR or exergames and 112 were in the control groups. The study cohorts ranged in size from 11 to 47 patients, with the mean (SD) age raging from 34.9 (8.9) to 48.3 (10.8) years. Five studies evaluated exergaming and 2 studies evaluated the effectiveness of VR.

Among the studies assessing exergames compared with conventional training, significant improvements were observed in the scores from a balance assessment (Berg Balance Scale; BBS) of the experimental groups compared with the control groups. Additionally, 1 study found that exergaming using an Xbox360 combined with conventional rehabilitation was more effective at improving balance compared with conventional rehabilitation alone.

Balance was also improved in the experimental groups in the studies comparing VR with conventional training. However, some of the studies produced non-statistically significant results. Like the exergames assessments, 1 study found that Microsoft Kinect-based VR gaming combined with conventional rehabilitation was more effective at improving balance compared with conventional rehabilitation alone.

The meta-analysis reported a significant overall effect size of 4.25 and 4.49 (P < .0001 for both) for VR and exergames in regard to BBS improvement, respectively. The subgroup analysis revealed a nonsignificant effect size of 1.85 (P = .39) for VR and a significant effect size of 4.49 (P < .0001) for exergames in terms of BBS improvement.

With respect of potential bias, 6 studies (85.7%) ensured that their randomization was correct, 5 RCTs (71.4%) excluded performance bias, 6 studies provided guarantees on blinding of outcomes assessment, and 6 studies properly assessed attrition bias.

“It should be considered that VR might be home based, with a telerehabilitation approach, which is highly encouraged during [COVID-19] pandemic, due to psychological and hospitalization issues,” the investigators noted.

The small number of RCTs reviewed and the need for stronger analyses on VR were listed as limitations of the review. The investigators recommended that future evidence is warranted to further clarify the role that VR and exergames could have in the rehabilitative approach to neurological disorders.


Calafiore D, Invernizzi M, Ammendolia A, et al. Efficacy of virtual reality and exergaming in improving balance in patients with multiple sclerosis: A systematic review and meta-analysis. Front Neurol. December 10, 2021;12:773459. doi: 10.3389/fneur.2021.773459