A systematic review on the use of virtual reality in post-stroke patients: exploring when modalities make the difference in executive and motor recovery

Davide Cardile¹Chiara Arena^1*Francesco Corallo¹Giulia Maria Giuffrida²Andreina Giustiniani¹Maria Grazia Maggio¹Carmela Rifici¹Angelo Quartarone^1,3Francesco Tomaiuolo²Rocco Salvatore Calabrò¹

• ¹Bonino Pulejo Neurology Center (IRCCS), Messina, Italy
• ²Universita degli Studi di Messina Dipartimento di Medicina Clinica e Sperimentale, Messina, Italy
• ³Universita degli Studi di Messina Dipartimento di Scienze biomediche odontoiatriche e delle immagini morfologiche e funzionali, Messina, Italy

Background: Virtual Reality (VR) has emerged as a promising tool in post-stroke neurorehabilitation, offering immersive and interactive environments capable of enhancing motor and executive function recovery through mechanisms of neuroplasticity. While various VR modalities— immersive (I), semi-immersive (SI), non-immersive (NI), and mixed (MXD)—have been employed, their relative effectiveness remains unclear. Objective: This systematic review aimed to evaluate the efficacy of different VR modalities in improving motor and/or executive functions in post-stroke patients, and to explore how stroke phase and the type of VR system used influence treatment outcomes.how factors such as stroke phase and VR typology influence treatment outcomes. Methods: A comprehensive literature search was conducted across PubMed, Embase, Scopus, and the Cochrane Library, resulting in 46 eligible peer-reviewed studies published between 2014 and 2024. These studies included randomized controlled trials, quasi-experimental designs, and observational studies, with an average sample size of approximately 35 participants. Inclusion criteria focused on studies utilizing VR as a therapeutic modality for motor and/or executive function recovery in post-stroke populations. Results: Forty-six studies met the inclusion criteria. VR interventions overall yielded positive motor outcomes in 76.3% of cases, with SI-VR achieving the highest proportion of significant improvements (88.24%), followed by NI-VR (66.67%) and I-VR (50%). Only 13% of studies assessed executive functions, Executive functions were less frequently assessed (13% of studies), but SI and I-VR modalities showed more consistent benefits compared to NI-VR. No statistically significant associations were found between VR typology or stroke phase (chronic vs. subacute) and motor outcome efficacy. Conclusions: VR is an effective and versatile adjunct to conventional stroke rehabilitation, with SI-VR showing the most consistent motor benefits and immersive systems offering additional cognitive engagement. The lack of significant differences by stroke phase suggests that VR can be applied across recovery stages. Future research should address the underrepresentation of executive function outcomes and directly compare modalities in well-powered trials.