Background Virtual reality (VR) is an interactive technology that allows customized treatment and may help in delivering effective person-centered rehabilitation. Purpose The purpose of this review was to systematically review and critically appraise the controlled clinical trials that investigated VR effectiveness in orthopedic rehabilitation. Data Sources Pubmed, CINAHL, Embase, PEDro, REHABDATA, and Sage publications were searched up to September 2018. In addition, manual searching and snowballing using Scopus and Web of Science were done. Study Selection Two reviewers screened studies for eligibility first by title and abstract and then full text. Data Extraction Articles were categorized into general or region-specific (upper limbs, lower limbs, and spine) orthopedic disorders. Study quality was assessed using the Evaluation Guidelines for Rating the Quality of an Intervention Study scoring. Meta-analysis quantified VR effectiveness, compared with no treatment, in back pain. Data Synthesis Nineteen studies were included in the quality assessment. The majority of the studies were of moderate quality. Fourteen studies showed that VR did not differ compared with exercises. Compared with the no-treatment control, 5 studies favored VR and 3 other studies showed no differences. For low back pain, the meta-analysis revealed no significant difference between VR and no-treatment control (n = 116; standardized mean difference = −0.21; 95% confidence interval = −0.58 to 0.15). Limitations Limitations included heterogeneity in interventions and the outcome measures of reviewed studies. Only articles in English were included. Conclusion The evidence of VR effectiveness is promising in chronic neck pain and shoulder impingement syndrome. VR and exercises have similar effects in rheumatoid arthritis, knee arthritis, ankle instability, and post-anterior cruciate reconstruction. For fibromyalgia and back pain, as well as after knee arthroplasty, the evidence of VR effectiveness compared with exercise is absent or inconclusive.

Background COVID 19 is the most recent cause of Adult respiratory distress syndrome ARDS. Invasive mechanical ventilation IMV can support gas exchange in patients failing non-invasive ventilation, but its reported outcome is highly variable between countries. We conducted a systematic review and meta-analysis on IMV for COVID-associated ARDS to study its outcome among different countries. Methods CENTRAL, MEDLINE/PubMed, Cochrane Library, and Scopus were systematically searched up to August 8, 2020. Studies reporting five or more patients with end point outcome for severe COVID 19 infection treated with IMV were included. The main outcome assessed was mortality. Baseline, procedural, outcome, and validity data were systematically appraised and pooled with random-effect methods. Subgroup analysis for different countries was performed. Meta-regression for the effect of study timing and patient age and were tested. Publication bias was examined. This trial was registered with PROSPERO under registration number CRD42020190365. Findings Our electronic search retrieved 4770 citations, 103 of which were selected for full-text review. Twenty-one studies with a combined population of 37359 patients with COVID-19 fulfilled the inclusion criteria. From this population, 5800 patients were treated by invasive mechanical ventilation. Out of those, 3301 patients reached an endpoint of ICU discharge or death after invasive mechanical ventilation while the rest were still in the ICU. Mortality from IMV was highly variable among the included studies ranging between 21% and 100%. Random-effect pooled estimates suggested an overall in-hospital mortality risk ratio of 0.70 (95% confidence interval 0.608 to 0.797; I2 = 98%). Subgroup analysis according to country of origin showed homogeneity in the 8 Chinese studies with high pooled mortality risk ratio of 0.97 (I2 = 24%, p = 0.23) (95% CI = 0.94–1.00), similar to Italy with a low pooled mortality risk ratio of 0.26 (95% CI 0.08–0.43) with homogeneity (p = 0.86) while the later larger studies coming from the USA showed pooled estimate mortality risk ratio of 0.60 (95% CI 0.43–0.76) with persistent heterogeneity (I2 = 98%, p<0.001). Meta-regression showed that outcome from IMV improved with time (p<0.001). Age had no statistically significant effect on mortality (p = 0.102). Publication bias was excluded by visualizing the funnel plot of standard error, Egger’s test with p = 0.714 and Begg&Mazumdar test with p = 0.334. Interpretation The study included the largest number of patients with outcome findings of IMV in this current pandemic. Our findings showed that the use of IMV for selected COVID 19 patients with severe ARDS carries a high mortality, but outcome has improved over the last few months and in more recent studies. The results should encourage physicians to use this facility when indicated for severely ill COVID-19 patients.

Purpose of Review Assessment of the musculoskeletal system requires consideration of its integrated function with the nervous system. This may be assisted by using valid and reliable methods that simulate real-life situations. Interactive virtual reality (VR) technology may introduce various auditory and visual inputs that mimic real-life scenarios. However, evidence supporting the quality and strength of evidence regarding the adequacy of its psychometric properties in assessing the musculoskeletal function has not been evaluated yet. Therefore, this study reviewed the validity and reliability of VR games and real-time feedback in assessing the musculoskeletal system. Recent Findings Nine studies were included in quality assessment. Based on outcome measures, studies were categorized into range of motion (ROM), balance, reaction time, and cervical motion velocity and accuracy. The majority of the studies were of moderate quality and provided evidence of VR adequate concurrent and, in some cases, known-groups validity. Also, VR showed high intra-rater reliability for most of the measured outcomes. Summary Based on the included studies, there is a limited promising evidence that interactive VR using games or real-time feedback is highly valid and reliable in assessing ROM in asymptomatic participants and patients with chronic neck pain and radial fracture. For the remaining outcomes, evidence is limited to draw a robust conclusion. Future studies are recommended to test VR psychometric properties in different patients' population using a rigor research methodology.

Clinicians increasingly use smartphone medical applications. There is no evidence to support the validity and reliability of applications used to assess the neuromusculoskeletal system. The aim of this study was to systematically review the quality of studies as well as the validity and reliability of using a smartphone as a clinical assessment tool for the neuromusculoskeletal system. Areas covered: PubMed, CINAHL and Embase were searched. A manual search was also conducted. Additionally, forward snowballing of relevant articles was performed in Scopus and Web of Science. Two reviewers independently selected the articles, extracted the data using a standardized form and assessed the articles quality based on a scoring system Expert commentary: Thirty-four articles were found eligible and were categorized into four groups: Range of Motion (ROM), posture and deformity, tremors and reflexes, and gait and mobility. Only the ROM category supported the validity and reliability of using smartphone applications as assessment tools. Regarding quality assessment scores, the articles in ROM and posture and deformity categories ranged from poor to good quality, whereas those in the tremors and reflexes and gait and mobility categories had poor quality.