Virtual reality and gamified digital rehabilitation provide small, imprecise functional improvements in spinal cord injuryVirtual Reality Shows Small Gains for Spinal Cord Injury

BackgroundVirtual reality (VR) and gamified digital rehabilitation can increase task-specific practice and feedback for individuals with Spinal Cord Injury (SCI); however, their incremental effects on functional recovery remain uncertain.MethodsWe searched PubMed, Web of Science, Embase, and the Cochrane Library from database inception through July 1, 2026, for randomized controlled trials (RCTs) evaluating VR or gamified digital rehabilitation in adults with SCI. Comparator conditions were classified as active rehabilitation, sham or attention control, or minimal/no intervention. The primary outcome was the Spinal Cord Independence Measure (SCIM). Hedges’ g estimates were synthesized using a Bayesian three-level random-effects model that accounted for within-study dependence. We estimated the 95% credible interval (CrI), 95% prediction interval (PI), and posterior probabilities of any benefit (g > 0) and of meeting a distribution-based threshold for clinical importance (g ≥ 0.40). A post hoc sensitivity analysis restricted the SCIM synthesis to trials with active-rehabilitation comparators. Seven secondary outcomes were synthesized separately. Risk of bias and certainty of evidence were assessed using the Cochrane Risk of Bias 2 tool (RoB 2) and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.ResultsThirteen RCTs involving 295 participants were included; comparator conditions were active rehabilitation in ten trials, sham or attention control in two, and no intervention in one. Seven studies contributed 25 eligible SCIM effect estimates. The pooled posterior mean effect favored digital rehabilitation but was small and imprecisely estimated (Hedges’ g = 0.24; 95% CrI, −0.12 to 0.61; 95% PI, −1.17 to 1.58). The posterior probabilities of any benefit and of a clinically important effect were 91.8 and 17.4%, respectively. Restricting the synthesis to the six SCIM studies with active-rehabilitation comparators yielded a similar, imprecise estimate (g = 0.28; 95% CrI, −0.20 to 0.75). Posterior mean effects for all seven secondary outcomes favored digital rehabilitation, although each 95% CrI included the null value. Direct posterior comparisons provided no clear evidence of effect modification by intervention category, injury completeness, or intervention duration. The weekly-dose association was uncertain and did not improve predictive performance. Overall risk of bias was rated as some concerns, and certainty was very low for all outcomes.ConclusionVR and gamified digital rehabilitation may provide small functional benefits relative to the comparator conditions used in the included trials; however, clinically important and reproducible improvements have not been demonstrated. Current evidence is insufficient to prioritize specific technology types, patient subgroups, intervention durations, or weekly training doses.Systematic review registrationCRD420261458807; https://www.crd.york.ac.uk/PROSPERO/view/CRD420261458807