CLINICAL COMMENTARY

Response to reviewers commentary on ‘Virtual reality in strokerehabilitation: Still more virtual than real’

J. H. CROSBIE1, S. LENNON1, J. R. BASFORD2 & S. M. MCDONOUGH1

1Health and Rehabilitation Sciences Research Institute, Faculty of Life and Health Sciences, University of Ulster,

Newtownabbey, N Ireland, and 2Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN

55902, USA

Accepted August 2006

We read with interest Drs Weiss and Ring’s

commentary on our review, ‘Virtual reality in stroke

rehabilitation: still more virtue than real’ [1]. We

suspect that we share more areas of agreements than

disagreements with the authors, but it would be

valuable to go through their points below.

Weiss and Ring begin by noting that the introduc-

tion of a new technology is often marked by a pattern

in which an early phase of uncritical acceptance is

followed a period of disappointment and rejection

and ultimately progresses to either being discarded

or slowly gaining credibility and utility. While not all

of us were familiar with the development of this

theme by Rizzo and Buckwalter [2,3], we agree with

its existence and believe that history reveals that the

process can be repeated time and time again [4]. We

also concur with the commentator’s opinion that

VR-based rehabilitation may have entered ‘Slope of

Enlightenment’. Whether any of it has reached a

‘Plateau of Productivity’ seems more arguable.

In any event, this brings us to the issue of

whether virtual reality, particularly its application to

stroke rehabilitation, is ready for the rigours of a

systematic review. The commentators aver ‘no’. We

believe differently, but our differences may be more

apparent than real. First of all, the commentators

and we would both accept that the VR stroke

literature is too heterogeneous and small to warrant

a meta-analysis. We did not attempt to do one. We

do, however, believe that a systematic analysis has

its value, as it requires an objective (as possible)

collection of all articles within the prescribed

databases that match the search words used.

Obviously, articles can be missed but the risk seems

smaller than with the more subjective approach of

the ‘classical’ review.

The issue of whether presentations and proceed-

ings papers should be included a systematic review

frequently arises. The benefits of limiting one’s

survey to the peer reviewed literature are that

supposedly only the best and most rigorous papers

are influencing the reviewer’s assessment. As can be

seen from our review, even the peer-reviewed papers

in VR stroke rehabilitation leave something to

desired. It is not clear that the risks and efforts

involved in the assessing of unreviewed work out-

weigh the potential possibility of missing timely and

exciting new research. In any event, one would hope

that the chance of missing important material would

decrease with time as improvements in technology

reduce the delay from submission to publication.

Authors, at times will include a section in a review on

papers that do not meet the review criteria but which

are pertinent to the topic at hand. We chose not to do

this, due to the difficulty of obtaining a representative

sample, but with hindsight this may have been a

beneficial thing to have done. Recent work by Egger

et al. [5] may provide some support for this view in

that these authors explored the impact of wider

versus narrower based literature searches and con-

cluded that searches limited to the English language

literature available in the major bibliographic data-

bases produced findings that differed little from

broader searches. We did note VR rehabilitation’s

Correspondence: S. M. McDonough, Health and Rehabilitation Sciences Research Institute, Faculty of Life and Health Sciences, University of Ulster, Shore

Road, Newtownabbey, Co. Antrim, BT37 0QB, N Ireland. E-mail: s.mcdonough@ulster.ac.uk

Disability and Rehabilitation, July 2007; 29(14): 1151 – 1152

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2007 Informa UK Ltd.

DOI: 10.1080/09638280600965767

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rapid rate of change and alluded to a few websites

and international meetings. The additional detail

provided by the commentators is appreciated.

In conclusion, we believe that our review, which

included rather detailed discussions of the interven-

tions instead of a mere statistical and mathematical

ranking, provided some value for the reader. The

strength of systematic review is that it allows an

objective survey of the literature. A weakness,

particularly at the level of the abstract, is that

findings of unclear quality or statistically significant

cannot be addressed. This, we contend, is the role of

more speculative papers such as editorials, expert

discussions of health care trend, and perhaps in the

discussion and conclusions of the traditional litera-

ture review.

References

1. Crosbie JH, Lennon S, Basford JR, McDonough SM. Virtual

reality in stroke rehabilitation: Still more virtual than real.

Disabil Rehabil.

2. Rizzo AA, Buckwlater JG. Introduction to the theme issue of

virtual environments for clinical neuropsychology. Presence:

Teleoperators and Virtual Environments 2001;10:3 – 5.

3. Rizzo AA. Virtual reality and disability: Emergence and

challenge. Disabil Rehabil 2002;24:567 – 569.

4. Basford JR. A historical perspective of the popular use of

electric and magnetic therapy. Arch Phys Med Rehabil

2001;82:1261 – 1269.

5. Egger M, Juni P, Bartlett C, Holenstein F, Sterne J. How

important are comprehensive literature searches and the

assessment of trial quality in systematic reviews? Empirical

Study. Health Technol Assess 2003;7(3).

1152 J. H. Crosbie et al.

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