Effectiveness of Virtual Game Therapy for Balance and Quality of
Life in Parkinson’s Patients: A Systematic Review and Meta-Analysis
Arohid Allatib
a
, Pio Maulana Ramadhani and Adelaide Alda Syafa
Faculty of Military Medicine, Republic of Indonesia Defense University, IPSC Citeureup Sentul, Bogor Regency, Indonesia
Keywords: Parkinson’s Diseases, Quality of Life, Virtual Game Therapy.
Abstract: Parkinson's disease is a neurological disorder and one of the degenerative diseases and balance dysfunction
and related falls are common symptoms. Many therapies have been found, one of which is virtual game
therapy, but more research is needed to find the effectiveness of virtual game therapy, and the optimal duration
of intervention. This study aims to assess the effects of virtual game therapy on balance ability and quality of
life in parkinson’s patients. This study followed the guidelines provided by PRISMA. Study searches were
conducted through PubMed, Cochrane, and Embase up to October 31st, 2023. We also use Covidence to
screen studies for inclusion and the Cochrane Risk of Bias 2.0 to assess the risk of bias of inclusion studies.
Then, we analyzed the data using Review Manager v5.4. Eighteen randomized studies, yielding 786 patients
are included. Our study showed the virtual game therapy is significantly increase the balance ability for Berg
Balance Scale (BBS) subgroup (Pooled MD = 1.56; 95% CI [0.50,2.62]; P< 0.004; I2 = 34%), and it is
significantly increasing the quality of life for Parkinson’s Disease Questionnaire (PDQ) subgroup (Pooled
MD = -0.85; 95% CI [-1.58, -0.12]; P=0.02; I2 = 39%). Virtual game therapy is highly recommended to give
120 minutes a week for balance outcomes (Pooled MD = 1.94; 95% CI [1.40, 2.49]; P<0.00001; I2 = 0%).
The results indicate significant effects on increasing balance ability and quality of life for people with
Parkinson's diseases. For optimal balance and quality of life outcomes, we recommend giving virtual game
therapy for 120 minutes a week. Future studies need to have more homogenous study designs, high-quality
randomized studies, and larger populations.
1 INTRODUCTION
Parkinson's disease is a disease caused by nerve
disorders, especially in the substantia nigra area in the
brain (Zafar & Yaddanapudi, 2023). Parkinson's
disease is a neuro-degenerative disease with 4 cardinal
signs such as resting tremor, bradykinesia, rigidity,
and postural instability that affect a person's ability to
move, speak, and perform daily activities (DeMaagd
& Philip, 2015). In the United Kingdom (UK) the
incidence of Parkinson's disease per 100.000 person
years at risk was 149 in 2006 and 144 in 2016
(Okunoye et al., 2022). Parkinson's disease gets worse
over time. Symptoms in Parkinson's patients can have
an adverse impact such as often experiencing
imbalances in their motor resulting in a decrease in
quality of life. Parkinson's disease causes high
disability and the need for treatment. Some types of
Parkinson's treatment can cause side effects that
a
http://orcid.org/0009-0005-1064-5798
impact the patient’s Quality of Life, so an alternative
is needed. One solution that is quite potential to
overcome this is virtual game therapy (VGT). VGT
has been a promising alternative for improving the
balance ability and quality of life of Parkinson's
patients. Virtual gaming therapy (VGT) is a form of
therapy that uses virtual gaming technology to help
improve the balance ability and quality of life of
Parkinson's patients. VGT usually engages the patient
in games specifically designed to improve the body's
balance and coordination abilities. Patients can use
motion controllers or motion sensors to interact with
the virtual environment and accomplish specific tasks.
The mechanism of action of VGT is based on the
concept of neuroplasticity, that is, the ability of the
brain to adapt and repair itself (Campo-Prieto et al.,
2021). VGT can help strengthen nerve pathways
involved in balance and coordination of the body,
thereby improving the balance ability of Parkinson's
238
Allatib, A., Ramadhani, P. M. and Syafa, A. A.
Effectiveness of Virtual Game Therapy for Balance and Quality of Life in Parkinson’s Patients: A Systematic Review and Meta-Analysis.
DOI: 10.5220/0013671100003873
Paper published under CC license (CC BY-NC-ND 4.0)
In Proceedings of the 1st International Conference on Medical Science and Health (ICOMESH 2023), pages 238-257
ISBN: 978-989-758-740-5
Proceedings Copyright © 2025 by SCITEPRESS – Science and Technology Publications, Lda.

patients (Wang et al., 2021). In addition, VGT can also
help improve motor function, mental health, and
quality of life for Parkinson's patients.
2 METHODS
2.1 Research Methodology
Conforming to the guidelines established in the
Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) and the Cochrane
Handbook for Systematic Reviews of Interventions,
version 6.3, 2022, we conducted the systematic
review and meta-analysis study.
2.2 Eligibility Criteria: Inclusion and
Exclusion Criteria
Prior to initiating the literature search, specific
criteria for inclusion and exclusion were established
to assess the relevance of the data. The inclusion
criteria encompassed 1) randomized controlled trial
studies, 2) using parkinson’s patient 3) studies which
given virtual game therapy included virtual exercise
therapy as intervention 4) measuring the balance
ability outcomes and/or quality of life outcomes, and
5) adherence to the English language. On the other
hand, exclusion criteria involved 1) using the virtual
game therapy combined with other therapy, 2) using
virtual intervention as consultation not as therapy 3)
the use of incompatible languages, and 4)
unavailability of full-text access. The selection of
titles and abstracts from the included papers was
performed independently by three reviewers (AA,
PMR), with any disagreements resolved through
consultation with another author (AAS). The results
of inclusion and exclusion criteria are shown in
Figure 1.
2.3 Standard of References
We referred to a randomized controlled trial that
demonstrated the impact of virtual game therapy on
the balance ability and quality of life outcomes for
individuals with Parkinson's disease.
2.4 Search Strategy
As illustrated in the first attachment, the literature
search encompassed databases such as PubMed,
Cochrane, and Embase. The searches were executed
between October 30 and October 31, 2023. All terms
adhered to the Medical Subject Headings (MeSH)
browser. Keywords were incorporated into the search
field using Boolean operators, and specific terms
were employed following the guidelines of Boolean
Figure 1: PRISMA flow Diagram
Effectiveness of Virtual Game Therapy for Balance and Quality of Life in Parkinson’s Patients: A Systematic Review and Meta-Analysis
239

operator keywords, for example, (parkinson disease
[MeSH Terms]) AND (game OR games OR virtual)
AND (balance OR Quality of Life).
2.5 Data Extraction and Analysis
Attachment 2 has a summary of the studies that were
part of this review. Author, year, country, sample
size, length of repetition, kind of control, parkinson's
grade, changes in balance score, and changes in
quality of life score were the data taken out of the
chosen studies. RevMen version 5.4 was utilized for
conducting the meta-analysis.
2.6 Risk of Bias in Individual Studies
(Qualitative Synthesis)
We assessed the quality of the chosen randomized
controlled trials using the Risk of Bias Tool for
Randomized Trials version 2 (RoB2). This tool
comprises five domains and 28 signaling questions
pertaining to the randomized process, intervention,
outcome data, and reported results. Three
independent reviewers (AA, PMR, AAS) conducted
the quality assessment, recording results in the
domain file bias (.xlsx). The outcomes were then
summarized and visualized on the ROBVIS website
using a traffic light system. Scores were assigned
based on RoB2 judgment algorithms, including low
risk, some concerns, and high risk. The indication of
study quality is detailed in Table 1.
2.7 Qualitative Data Synthesis
(Meta-Analysis)
Quantitative analysis of the acquired data was
conducted using Review Manager 5.4.1. (The Nordic
Cochrane Center, The Cochrane Collaboration,
Copenhagen). The Mean Difference (MD) and
Standard Deviation (SD) for both the intervention and
control groups were utilized, considering
measurements before and after treatment extracted
Table 1: Randomized Controlled Trial Risk of Bias
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240

from previously conducted studies. The data,
categorized as continuous, underwent statistical
analysis using the inverse variance method.
Additionally, the fixed effect model (FEM) was
employed when the level of heterogeneity (I2) was <
50%, while the random effect model (REM) was
applied when the level of heterogeneity (I2) was ≥
50%. Primary outcomes guiding the statistical
analysis included MD and SD for the change from
baseline using virtual game therapy for Parkinson's
patients, highlighting significant impacts on life
quality and balance ability. The effects were
quantified through standardized mean differences
(SMD), with corresponding 95% confidence intervals
(CI) for both individual studies and the overall
assessment.
3 RESULTS AND DISCUSSION
Gathered from all eligible journals, a total of 786
samples were categorized into an intervention group
comprising 405 patients and a control group
consisting of 381 patients. Among these, five articles
were sourced from Taiwan, while Italy and Brazil
each contributed three articles. Furthermore, two
articles originated from the Netherlands, and one each
from China, Lahore, Belgium, Switzerland, and
Turkey. Detailed information for each included
journal is presented in the extraction table in Table 2.
Table 2: Summary of Data Extraction
N
o
A
utho
r
,
Y
ea
r
T
itle
(
Coun-
t
ry)
Dura-
tion
(repeti-
tion)
Parti-
cipants
number,
n (trial/
control)
Type
of Con-
trol
G
ra
d
e
of
P
arki
n
-son
D
isea
s
es
Changes in balance score Changes in Quality of Life score
Trial Control Tools Trial Control Tools
Pre Post Pre Post Pre Post Pre Post
1
F
eng
e
t al.,
2
019
V
irtual
R
eality
R
ehabilit
a
tion
V
ersus
C
onventi
o
nal
P
hysical
T
herapy
f
or
I
mprovin
g
B
alance
a
nd Gait
i
n
P
arkinso
n
’s
D
isease
P
atients:
A
R
andomi
z
ed
C
ontrolle
d
Trial
(
China)
45 min
(5
days/we
ek for
12
weeks)
28
(14/14)
Conven
tional
physica
l
therapy
2
,5-4 30.6
4±3.
91
36.7
1±4.
60
30.0
7
±
3.87
32.0
0
±
4.82
Berg
Balan-c
e
Scale
(BBS)
N/A N/A N/A N/A N/A
2
P
azza
g
lia et
a
l.,20
2
0
C
ompari
-
son of
v
irtual
r
eality
r
ehabilita
-
tion and
c
onventi
o
-nal
40 min
(3
times/w
eek for
6
weeks)
51
(25/26)
Under
went
conven
tional
rehabili
ta-tion
N
I 45.6
±7.9
49.2
±8.1
47.3
±7.
6
48.1
±7.2
Berg
Balanc
e Scale
(BBS)
37.7
±11.4
43.5
±9.2
41.9
±12.8
39.2
±12.6
Menta
l
compo
-site
score
(SF-
36)
Effectiveness of Virtual Game Therapy for Balance and Quality of Life in Parkinson’s Patients: A Systematic Review and Meta-Analysis
241

r
ehabilita
-
tion in
P
arkinso
n
’s
d
isease:
a
r
andomis
-
ed
c
ontrolle
d
trial
(
Italy)
3
L
iao
e
t al.,
2
015
V
irtual
R
eality-
B
ased
T
raining
t
o
I
mprove
O
bstacle
-
C
rossing
P
erforma
n
ce and
D
ynamic
B
alance
i
n
P
atients
w
ith
P
arkinso
n
's
D
isease
(
Taiwan)
45 min
(2
times/w
eek for
6
weeks)
24
(12/12)
Traditi
onal
exercis
e/Conv
entiona
l
1-3 N/A N/A N/A N/A N/A 78.2
± 23.3
79.0
±
24.3
84.5
±
26.0
68.8
±
20.0
Parkin
son’s
Diseas
e
Questi
onnair
e
(PDQ
39)
3
L
iao
e
t al.,
2
015
V
irtual
R
eality-
B
ased
T
raining
t
o
I
mprove
O
bstacle
-
C
rossing
P
erforma
n
ce and
D
ynamic
B
alance
i
n
P
atients
w
ith
P
arkinso
n
's
D
isease
(
Taiwan)
45 min
(2
times/w
eek for
6
weeks)
24
(12/12)
Traditi
onal
exercis
e/Conv
entiona
l
1-3 N/A N/A N/A N/A N/A 78.2
± 23.3
79.0
±
24.3
84.5
±
26.0
68.8
±
20.0
Parkin
son’s
Diseas
e
Questi
onnair
e
(PDQ
39)
4
K
ashi
f
e
t al.,
2
022
C
ombine
d
efects
o
f virtual
r
eality
t
echniqu
e
s and
m
otor
i
magery
o
n
60 min
(3
days/we
ek for 6
weeks)
44
(22/22)
physica
l
therapy
treatme
nt
3
38.9
5±
3.23
46.5
9±
3.07
40.2
3
±
4.61
43.2
3
±
4.45
Berg
Balanc
e Scale
(BBS)
N/A N/A N/A N/A N/A
ICOMESH 2023 - INTERNATIONAL CONFERENCE ON MEDICAL SCIENCE AND HEALTH
242

b
alance,
m
otor
f
unction
a
nd
a
ctivities
o
f daily
l
iving in
p
atients
w
ith
P
arkinso
n
’s
d
isease:
a
r
andomiz
e
d
c
ontrolle
d
trial
(
Taiwan)
5
P
omp
e
u et
a
l.,
2
012
E
ffect of
N
intendo
W
iiTM-
b
ased
m
otor
a
nd
c
ognitive
t
raining
o
n
a
ctivities
o
f daily
l
iving in
p
atients
w
ith
P
arkinso
n
’s
d
isease:
A
r
andomis
e
d
c
linical
t
rial
(
Brazil)
60 min
(2
times/w
eek for
7
weeks)
32
(16/16)
Balanc
e
exercis
e
therapy
/Conve
ntional
1-2 52.9
±
4.1
54.4
±
2.2
51.9
±
4.6
53.1
±
3.4
Berg
Balanc
e Scale
(BBS)
N/A N/A N/A N/A N/A
6
Y
ang
e
t al.,
2
016
H
ome-
b
ased
v
irtual
r
eality
b
alance
t
raining
a
nd
c
onventi
o
nal
b
alance
t
raining
i
n
P
arkinso
n
’s
d
isease:
A
r
andomiz
e
d
c
ontrolle
d
trial
50 min
(3
times/w
eek for
6
weeks)
23
(11/12)
license
d
physica
l
therapi
st
N
I 46.9
±
6.5
50.3
±
5.4
46.9
±
6.6
51.1
±
5.9
Berg
Balanc
e
Score
(BBS)
29.2
± 16.3
23.8
±
15.5
31.7
± 17.9
26.4
±
19.1
Parkin
son’s
Diseas
e
Questi
onnair
e
(PDQ-
39)
Effectiveness of Virtual Game Therapy for Balance and Quality of Life in Parkinson’s Patients: A Systematic Review and Meta-Analysis
243

(
Taiwan)
7
Q
ayy
u
m
et
a
l.,
2
022
E
ffects
o
f Exe
r
–
G
aming
o
n
B
alance
a
nd Gait
i
n
P
arkinso
n
’s
P
atients
(
Lahore)
50 min
(3
times/w
eek for
8
weeks)
16
(8/8)
Conven
tional
treatme
nt
N
/I 14.6
±
1.06
19.1
2 ±
0.83
14.8
7
±
0.83
16.3
7
±
0.74
Dyna
mic
Gait
Index
(DGI)
N/A N/A N/A N/A N/A
8
Y
uan
e
t al.,
2
020
E
ffects
o
f
i
nteractiv
e
video-
g
ame–
b
ased
e
xercise
o
n
b
alance
i
n older
a
dults
w
ith
m
il
d
-to-
m
oderate
P
arkinso
n
’s
d
isease
(
Taiwan)
30 min
(3
times/w
eek for
6
weeks)
24
(12/12)
no
IVGB
exercis
e
interve
ntion
during
the first
6
weeks
1-3 1.0 ± 3.8* 1.4 ± 6.7* Berg
Balanc
e
Score
(BBS)
6.7 ± 34.7* 7.9 ± 18.1* Gener
al
health
36-
Item
Short-
Form
Health
Surve
y (SF-
36)
9
B
ekke
r
s et
a
l.,
2
020
D
o
P
atients
w
ith
P
arkinso
n
's
D
isease
w
ith
F
reezing
o
f Gait
R
espond
D
ifferen
t
l
y Than
T
hose
W
ithout
t
o
T
readmil
l
T
raining
A
ugmen
t
e
d by
V
irtual
R
eality?
(
Belgium
)
45 min
(3
times/w
eek for
6
weeks)
121
(77/44)
treadmi
ll
trainin
g
2
-3 21.5
0±
5.8
23.5
1±
5.46
21.0
0
±
6.1
22.2
6
±
5.46
Mini
Balanc
e
Evalua
tion
Syste
m Test
(Mini-
BEST)
N/A N/A N/A N/A N/A
ICOMESH 2023 - INTERNATIONAL CONFERENCE ON MEDICAL SCIENCE AND HEALTH
244

10
K
olk
e
t al.,
2
019
E
ffective
n
ess of
h
ome-
b
ased
a
nd
r
emotely
s
upervise
d
aerobic
e
xercise
i
n
P
arkinso
n
’s
d
isease:
a
double-
b
lind,
r
andomis
e
d
c
ontrolle
d
trial
(
Netherla
n
d)
30-45
min (3
times/w
eek for
6
months)
130
(65/65)
stretchi
ng
1-2 24·3
±0·6
24·4
±0·6 24·
2
±0·
6
24·5
±0·6
Mini-
Balanc
e
Evalua
tion
Syste
ms
Test
(Mini-
BEST)
24·9
±2·2
26·0
±2·3
24·0
±2·2
26·3
±2·3
Parkin
son’s
Diseas
e
Questi
onnair
e 39
summ
ary
index
score
11
G
ando
l
fi et
a
l.,
2
017
V
irtual
R
eality
T
elereha
b
ilitation
f
or
P
ostural
I
nstabilit
y
in
P
arkinso
n
’s
D
isease:
A
M
ulticen
t
er,
Single-
B
lind,
R
andomi
z
ed,
C
ontrolle
d
Trial
(
Italy)
50 min
(3
days/we
ek for 7
weeks)
76
(38/38)
in-
clinic
sensory
integrat
ion
b
alance
trainin
g
(SIBT)
2
,5-3 48.6
3±6.
31
52.3
7 ±
3.29
45.6
1
±7.
97
49.8
2
±
5.70
Berg
Balanc
e
Score
(BBS)
30.72
±15.5
4
24.16
±14.7
8
30.53
±16.0
4
24.21
±15.8
5
Parkin
son’s
Diseas
e
Qualit
y of
Life
questi
onnair
e
(PDQ-
8)
12
M
aran
e
si et
a
l.,
2
022
T
he
E
ffect of
N
on-
I
mmersi
v
e
V
irtual
R
eality
E
xerga
m
e
s versus
T
radition
a
l
P
hysioth
e
rapy in
P
arkinso
n
's
D
isease
O
lder
P
atients:
P
relimin
30 min
(2
times/w
eek for
5
weeks)
30
(14/16)
traditio
nal
therapy
/
Conve
ntional
1-3 13.8
±0.5
14.7
±0.4
12.4
±0.
7
13.5
±0.8
POMA
(Perfor
mance
oriente
d
mobilit
y
assess
ment)
Balanc
e
31.6
±0.7
30.1
±0.6
30.3
±0.7
30.3
±0.7
SF-12
Effectiveness of Virtual Game Therapy for Balance and Quality of Life in Parkinson’s Patients: A Systematic Review and Meta-Analysis
245

a
ry
R
esults
f
rom a
R
andomi
z
e
d
-
C
ontrolle
d
Trial
(
Switzerl
a
nd)
13
C
arpi
n
e
lla et
a
l.,
2
016
W
earabl
e
Senso
r
-
B
ased
B
iofeedb
a
ck
T
raining
f
or
B
alance
a
nd Gait
i
n
P
arkinso
n
D
isease:
A
Pilot
R
andomi
z
ed
C
ontrolle
d
Trial
(
Italy)
45 min
(3
times/w
eek for
4
weeks)
37
(17/20)
physiot
herapy
without
feedba
ck
2
-4 46.0
±
9.3
50.0
±
6.2
42.1
±
10.9
43.8
±
10.9
Berg
Balanc
e
Score
(BBS)
46.4
± 22.9
44.6
±
24.7
61.5
± 24.1
59.2
±
23.3
Parkin
son’s
Diseas
e
Questi
onnair
e 39
summ
ary
index
score
14
S
antos
e
t al.,
2
019
E
fficacy
o
f the
N
intendo
W
ii
c
ombina
t
i
on with
C
onventi
o
nal
E
xercise
s
in the
r
ehabilita
t
ion of
i
ndividua
l
s with
P
arkinso
n
's
d
isease:
A
r
andomiz
e
d
c
linical
t
rial
(
Brazil)
50 min
(2
times/w
eek for
8
weeks)
27
(13/14)
Conven
tional
exercis
e
1-3 43.9
±
5.3
49.2
±
4.4
40.5
±
5.6
45.6
±
5.4
Berg
Balanc
e
Score
(BBS)
37.1
(24.5
-
45.3)
[Medi
an
(25-
75
perce
ntile)]
# ~
37.1 ±
15.5
29.7
(22.4
-
35.1)
[Medi
an
(25-
75
perce
ntile)]
# ~
29.7
± 9.4
32.7
(26.7
- 54)
[Medi
an
(25-
75
perce
ntile)]
# ~
32.7 ±
20.1
25.7
(12.6
-
36.2)
[Medi
an
(25-
75
perce
ntile)]
# ~
25.7
±
17.5
Parkin
son’s
Diseas
e
Questi
onnair
e 39
summ
ary
index
score
15
F
erraz
e
t al.,
2
018
T
he
E
ffects
o
f
F
unction
a
l
50 min
(3
times/w
eek for
8
42
(22/20)
functio
nal
trainin
g
2
-3 N/A N/A N/A N/A N/A 44.7
(26.7)
33.9
(25.2)
47.0
(25.1)
41.7
(21.7)
Parkin
son’s
Diseas
e
Questi
ICOMESH 2023 - INTERNATIONAL CONFERENCE ON MEDICAL SCIENCE AND HEALTH
246

T
raining,
B
icycle
E
xercise,
a
nd
E
xerga
m
i
ng on
W
alking
C
apacity
o
f
E
lderly
P
atients
w
ith
P
arkinso
n
D
isease:
A
Pilot
R
andomi
z
ed
C
ontrolle
d
Single-
b
linded
T
rial
(
Brazil)
weeks) onnair
e 39
summ
ary
index
score
16
H
euve
l
et al.
,
2
014
E
ffects
o
f
a
ugmen
t
e
d visual
f
eedback
d
uring
b
alance
t
raining
i
n
P
arkinso
n
's
d
isease:
a
pilot
r
andomiz
e
d
c
linical
t
rial
(
Netherla
n
ds)
60 min
(2
times/w
eek for
5 week)
31
(14/17)
Conven
tional
trainin
g
2
-3 1.00 (-0.25,
2.00)
[center
(dispersion
)]# ~ 1.00
± 0.56
-1.00 (-
2.00 ,
2.00)
[center
(dispersio
n)]# ~ -
1.00 ±
1.00
Berg
Balanc
e
Score
(BBS)
2.50 (-8.75,
10.00)
[center
(dispersion)]#
~ 2.50 ± 4.44
0.00 (-5.00,
2.50) [center
(dispersion)]#
~ 0.00 ±
1.875
Parkin
son’s
Diseas
e
Questi
onnair
e 39
summ
ary
index
score
17
S
hih
e
t al.,
2
016
E
ffects
o
f a
b
alance-
b
ased
e
xergami
n
g
i
nterven
t
i
on using
t
he
K
inect
s
ensor
o
n
p
osture
s
tability
i
n
i
ndividua
50 min
(2
times/w
eek for
8
weeks)
20
(10/10)
Conven
tional
Balanc
e
trainin
g
1-3 50.9
±
5.32
53.2
±
2.86
50.4
±
4.79
53 ±
1.89
Berg
Balanc
e
Score
(BBS)
N/A N/A N/A N/A N/A
Effectiveness of Virtual Game Therapy for Balance and Quality of Life in Parkinson’s Patients: A Systematic Review and Meta-Analysis
247

l
s with
P
arkinso
n
's
d
isease:
a
single-
b
linded
r
andomiz
e
d
c
ontrolle
d
trial
(
Taiwan)
18
G
ulca
n
et
a
l.,
2
022
T
he
e
ffects o
f
a
ugmen
t
e
d and
v
irtual
r
eality
g
ait
t
raining
o
n
b
alance
a
nd gait
i
n
p
atients
w
ith
P
arkinso
n
's
d
isease
(
Türkiye
)
5 min
(3 days
a week
for 6
weeks)
30
(15/15)
Conven
tional
trainin
g
1-2 53.0
(48.
0 -
55.0
)
[me
dian
(IQ
R)]#
~ 53
±
5.20
54.0
(50.
0 -
56.0
)
[Me
dian
(IQ
R)]#
~ 54
±
4.45
50.0
(39.
0 -
54.0
)
[me
dian
(IQ
R)]
# ~
50
±
11.1
2
52.0
(44.
0 -
55.0
)
[me
dian
(IQ
R)]#
~ 52
±
8.16
Berg
Balanc
e
Score
(BBS)
N/A N/A N/A N/A N/A
T
otal 786
(405/38
1)
NI = No Information
N/A = No Administered
* = Changes score
# = Transformation to mean (SD) with normally distributed data
Virtual game therapy, also known as exer-gaming,
refers to the use of virtual reality (VR) and video
game technology as a form of therapy for various
health conditions, including Parkinson's disease. This
type of therapy includes activities such as virtual-
based games, balance-based exergaming, and Wii-
based motor and cognitive training. The importance
of using virtual game therapy for Parkinson's disease
lies in its potential to improve balance, gait, and
activities of daily living for individuals with
Parkinson's disease. Parkinson's patients often
experience impaired balance and a decrease in quality
of life due to the progressive nature of the disease.
Studies have shown that Parkinson's patients who
underwent virtual game therapy exhibited significant
improvements in postural stability, balance, and
activities of daily living. However, to further validate
the effectiveness of virtual game therapy in
improving balance and quality of life for Parkinson's
patients, a meta-analysis is needed to synthesize and
analyze the existing data from multiple studies. This
meta-analysis would provide a comprehensive and
evidence-based understanding of the effectiveness of
virtual reality therapy in enhancing balance and
quality of life for individuals with Parkinson's
disease, thus guiding future treatment approaches and
interventions.
In our review, we divided the meta-analysis into
subgroups to provide more specific results depending
on the type of outcome. Within outcome types, we
had subgroups of balance outcomes and quality of life
outcomes. There were sixteen inclusion journals that
provided results on the use of virtual game therapy on
balance outcomes in patients with Parkinson's disease
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248

(Bekkers et al., 2020; Carpinella et al., 2017; Feng et
al., 2019; Gandolfi et al., 2017; Gulcan et al., 2023;
Heuvel et al., 2014; Kashif et al., 2022; Kolk et al.,
2019; Maranesi et al., 2022; Pazzaglia et al., 2020;
Pompeu et al., 2012; Qayyum et al., 2022; Santos et
al., 2019; Shih et al., 2016; Yang et al., 2016; Yuan et
al., 2020).In the initial subgroup analysis, we
examined the efficacy of virtual game therapy for
balance outcomes in Parkinson's disease. The meta-
analysis revealed significant results for virtual game
therapy (Pooled MD = 0.33; 95% CI [0.01, 0.64]; P <
0.00001; I2 = 74%) (Figure 1). Given the high
heterogeneity, we further divided the balance
outcome subgroup into smaller subdivisions.
Virtual game therapy, a derivative of virtual
reality (VR) designed for Parkinson's patients,
involves interaction with a computer-simulated
environment through gaming. Unlike traditional
virtual reality, VGT immerses patients in a game-like
setting, replicating either a real or imaginary
environment. Developed to enhance the balance
ability and quality of life for Parkinson's patients,
VGT addresses the primary pathophysiology of the
disease—an insufficient level of dopamine in the rain.
While pharmacological dopamine replacement
therapy is effective, it cannot halt the ongoing
functional decline, necessitating additional
approaches such as physical therapy.
VGT engages patients in specially designed
games to improve balance and coordination using
motion controllers or sensors. The underlying
mechanism is rooted in neuroplasticity, the brain's
capacity to adapt and regenerate. By reinforcing
neural pathways related to balance and coordination,
VGT contributes to enhancing the balance ability of
individuals with Parkinson's disease. This integrated
therapy incorporates elements of balance, visual, and
auditory cues within a gaming context. Enriched
virtual environments provide cues that stimulate
active control of the body, ultimately improving
somatosensory, vestibular, and visual systems
(Gandolfi et al., 2017).
In the first subdivision, we looked at the
effectiveness of virtual game therapy for balanced
outcomes based on the type of measuring tools.
Significant meta-analysis results in the intervention
group were obtained from the Berg Balance Scale
(BBS) types (Pooled MD = 1.56; 95% CI [0.50,2.62];
P< 0.004; I
2
= 34%) (Figure 2).
One of the parameters for measuring balance is the
Berg Balance Scale. Berg balance scale was created
by Katherine Berg in 1989 and has been used until
now and proven to have high validity and reliability
to measure balance so that this tool is used to assess
static balance and risk of falling in people with
Parkinson's disease (Miranda-Cantellops & Tiu.,
2023). Berg balance scale consists of 14 tasks which
are divided into 3 domains namely sitting balance,
standing balance, and dynamic balance. It is an
ordinal scale with a score between the range of 0-4.
The score of 0 means the patient cannot perform it,
and the score of 4 is given when the patient is able to
complete the command independently. The
maximum score is 56, obtained when the patient is
able to follow 14 tasks and complete them
independently. The total score range is interpreted
and classified into: 0-20 (unable to stand, in a
wheelchair), 21-30 (can walk with assistance), 41-56
(independent).
Figure 2: Meta-analysis for balance outcomes.
Effectiveness of Virtual Game Therapy for Balance and Quality of Life in Parkinson’s Patients: A Systematic Review and Meta-Analysis
249

Other considerations for using the berg balance
scale as a tool to measure balance in Parkinson's
patients are flexible, which can be used in several
situations such as before undergoing therapy or after
undergoing therapy, cost effectiveness, time saving in
several aspects, namely easy to do in several
locations, only requires simple equipment, and can be
learned with minimal training (Qutubuddin et al.,
2005). Berg balance scale is very important, doctors
or therapists will understand how the patient's balance
ability and whether there is a risk of falling so that this
helps in the treatment and rehabilitation plan for
people with Parkinson's. Berg balance scale is valid
for measuring balance not only as a screening tool but
also as an ongoing assessment for patients undergoing
intervention (Qutubuddin et al., 2005).
In the second segment, we examined the efficacy
of virtual game therapy concerning balance outcomes
based on the duration of treatment within a one-week
timeframe. Significant meta-analysis findings in the
intervention group were observed for a 120-minute
therapy duration per week (Pooled MD = 1.94; 95%
CI [1.40, 2.49]; P < 0.00001; I2 = 0%). Similarly,
significant results were noted in the intervention
group for a treatment duration exceeding 180 minutes
per week (Figure 3).
Balance, a intricate interplay of sensorimotor
control systems, relies on sensory inputs from vision,
touch (proprioception), and the vestibular system
(movement, balance, spatial orientation). These
sensory inputs are intricately connected with motor
output. As highlighted by Pazzaglia et al. (2020), a
study by Pompeu et al. (2012) underscores two
mechanisms contributing to the enhancement of
patient balance: (1) the repetition of movements
leading to automation, freeing up cognitive resources
for other tasks, and (2) the training of simultaneous
tasks, resulting in improved management of cognitive
resources. Therefore, balance exercise therapy likely
brings about improvement through repetitive practice
(Pompeu et al., 2012).
Figure 3: Meta-analysis for balance outcomes based on type of measuring tools
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250

In the second subgroup, we looked at the
effectiveness of virtual game therapy for quality of
life outcomes in Parkinson's diseases. Insignificant
meta-analysis results in a control group (Pooled MD=
0.12; 95% CI [-0.27, 0.51]; P< 0.00001; I
2
= 76%)
(Figure 4). The heterogenity of the data was very
high, so we subdivided into smaller subdivisions.
Parkinson's disease has a progression that varies from
one patient to another. The characteristics of
Parkinson's disease are characterized by the presence
of dominant motor symptoms in the form of
dyskinesia and motor fluctuations related to quality of
life (Oktariza et al., 2019).
Figure 4: Meta-analysis for balance outcomes based on duration of treatment in 1 week
Effectiveness of Virtual Game Therapy for Balance and Quality of Life in Parkinson’s Patients: A Systematic Review and Meta-Analysis
251

Virtual game therapy is formed in an entertaining
mini games or travel scenes for patients to participate
and reward them after completing the tasks in the
game. During the use of VGT, this technique involves
sensory input, brain assessment and information
integration and is effective for neural control. VGT is
designed to resemble a game such as completing a
mission, during the process of completing the task,
the patient can continuously receive feedback, thus
encouraging the adjustment of movement patterns to
form and restore optimal neural networks. Exercise
programs using VGT can involve attractive images as
well as beautiful music and positive feedback, which
is very different from other conventional therapies.
VGT can distract the patient's attention and make the
patient psychologically reduce the fear of performing
the exercise, thereby achieving a recovery effect. This
VGT technology not only provides a training
environment similar to the real world and meaningful
task- or mission-oriented training for motor therapy,
but also measures the patient's functional status
before and after rehabilitation, and can improve the
patient's quality of life, so that the patient's activities
are no longer limited to the house, room, or even just
staying in bed. With virtual game-based therapy that
is carried out regularly and continuously, it will also
gradually improve postural instability, stiffness in
gait, and speech difficulties in people with
Parkinson's disease. There are no significant side
effects in the use of virtual game-based therapy, such
as illness or balance problems due to, while stress
levels decrease and patients' desire to do VGT therapy
at home increases (Bocci et al., 2023).
In the initial section, we examined the efficacy of
virtual game therapy on quality of life outcomes,
utilizing different measurement tools. The
intervention group showed significant meta-analysis
results with the Parkinson's Disease Questionnaire
(PDQ) (Pooled MD = -0.85; 95% CI [-1.58, -0.12];
P=0.02; I2 = 39%) and the 36 short-form health
survey (SF-36) (Pooled MD = –7.94; 95% CI [-14.07,
-1.81]; P=0.01; I2 = 0%). Conversely, the control
group displayed significant results with the 12 short-
form health survey (SF-12) (Pooled MD = 1.50; 95%
CI [1.01, 1.99]; P<0.00001) (figure 5).
Figure 5: Meta-analysis for quality of life outcomes
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252

The PDQ-39, a widely utilized tool for assessing the
quality of life in Parkinson's patients,
comprehensively evaluates various life aspects
impacted by the disease. Covering mobility, daily
activities, emotional well-being, stigma, social
support, cognition, communication, and bodily
discomfort, the 39-item self-administered
questionnaire provides a holistic view of Parkinson's
impact on an individual's life.
Validated and reliable, the PDQ-39 is a crucial
tool for evaluating health-related quality of life in
Parkinson's patients. It quantifies the disease's impact
on daily living, offering valuable insights into the
subjective experience. Widely employed in clinical
trials, research studies, and routine practice, it aids in
assessing intervention effectiveness, tracking disease
progression, and informing treatment decisions (Al-
Khammash et al., 2023).
In the subsequent section, we assessed the impact
of virtual game therapy on quality of life outcomes
concerning the duration of treatment within a one-
week timeframe. Notably, significant meta-analysis
findings in the intervention group emerged from a 90-
minute therapy session per week (Pooled MD = -1.17;
95% CI [-1.94, -0.40]; P=0.003; I2 = 40%) (Figure 6).
The results of this meta-analysis are not clear because
significant results in the intervention group were only
obtained at 90 minutes a week, and for more than that
duration showed insignificant results. This may be
because the more repetitions of the duration of
therapy resulted in more saturation of patients so as
to reduce the quality of life, but it should be noted that
there are no studies that support this hypothesis.
Figure 6. Meta-analysis for quality of life outcomes based on type of measuring tools
Effectiveness of Virtual Game Therapy for Balance and Quality of Life in Parkinson’s Patients: A Systematic Review and Meta-Analysis
253

Figure 7. Meta-analysis for quality of life outcomes based on duration of treatment in 1 week
4 CONCLUSIONS
4.1 Conclusion
The objective of this systematic review and meta-
analysis was to assess the efficacy of virtual game
therapy for individuals with Parkinson's disease. The
examination of randomized controlled trials revealed
substantial enhancements in both balance and quality
of life when compared to control interventions. These
study outcomes add valuable insights to the current
understanding of treatment options for Parkinson's
patients, emphasizing the potential effectiveness of
virtual game therapy as a viable treatment approach.
Other findings found in our study are: 1) virtual game
therapy is the most effective therapy for increasing
the balance ability, 2) virtual game therapy is the most
effective therapy for increasing the quality of life, 3)
virtual game therapy is more effective for increasing
balance ability if the treatment given for 120 minutes
in 1 week, or like 30 minutes (4 times/week) or 60
minutes (2 times/week).
4.2 Suggestion
Future research should focus on comparing different
durations of intervention in virtual game therapy to
prove the results of our meta-analysis. More
randomized controlled trials with low risk of bias is
needed for more good quality of analysis. Future
studies need to examine the effects of virtual game
therapy for Parkinson's patients with more
ICOMESH 2023 - INTERNATIONAL CONFERENCE ON MEDICAL SCIENCE AND HEALTH
254

homogenous study designs, and also a larger
population.
4.3 Strength and Limitation
This is an updated research to discuss virtual game
therapy and its correlation to balance and quality of
life outcomes for Parkinson's patients while previous
studies looked at 2022 and only assessed balance
outcomes. Here we added 4 recent articles that make
this study more updated. We assessed
comprehensively and successfully recommended an
effective time for virtual game therapy
administration. Due to variations in our journal (table
2) such as sample size, duration of treatment, and
scales used, we decided to divide this meta-analysis
into several subgroups and subsections. The
drawback of this study is that the large number of
journals included in the inclusion has some risk of
bias issues in various domains.
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APPENDIX
First Appendix: Study Selection
Keywords:
PubMed
N
o. Search Resul
t
#1 Parkinson disease[MeSH
Terms] filters: Randomized
Controlled Trial, in the last
10
y
ears
1.171
#2 Game OR games OR virtual
filters: Randomized
Controlled Trial, in the last
10
y
ears
3.588
#3 Balance OR quality of Life
filters: Randomized
Controlled Trial, in the last
10
y
ears
31.196
#4 ((parkinson disease[MeSH
Terms] AND ((y_10[Filter])
AND (randomized
controlled trial[Filter])))
AND (game or games or
virtual AND ((y_10[Filter])
AND (randomized
controlled trial[Filter]))))
AND (balance or Quality of
Life AND ((y_10[Filter])
AND (randomized
controlled trial[Filter])))
25
ICOMESH 2023 - INTERNATIONAL CONFERENCE ON MEDICAL SCIENCE AND HEALTH
256

AND ((y_10[Filter]) AND
(randomized controlled
trial[Filter]))
Total : 25
Cochrane
No. Search Result
#1
MeSH descriptor: [Parkinson
Disease] explode all trees
6.251
#2 Game OR games OR virtual 38.826
#3
Balance OR quality of life
OR QOL
199.948
#4
Randomized controlled trial
OR randomised controlled
trial OR randomized clinical
trial OR randomised clinical
trial
1.036.1
78
#5
#1 AND #2 AND #3 AND
#4
73
Total : 73
Embase
(parkinson disease[MeSH Terms] AND (game OR
games OR virtual) AND (balance OR Quality of Life)
Total : 17
Effectiveness of Virtual Game Therapy for Balance and Quality of Life in Parkinson’s Patients: A Systematic Review and Meta-Analysis
257