Housman 2009

Methods	RCT
Participants	Recruited from 1 rehabilitation institute in Chicago, USA 34 participants: 17 intervention, 17 control Inclusion criteria: single stroke ≥ 6 months ago, Fugl Meyer UE score 10 to 30 Exclusion criteria: significant pain or instability of the shoulder, current participation in upper limb therapy program, severe cognitive dysfunction, aphasia, neglect, apraxia Mean (SD) age: intervention group 54 (12) years, control group 56 (13) years 64% male Stroke details: 61% ischaemic, 29% right hemiparesis Timing post stroke: intervention group mean (SD) 85 (96) months, control group 112 (129) months
Interventions	Virtual reality intervention: a custom‐designed software package ('Vu Therapy') provided activities including grocery shopping, cleaning a stove and playing basketball. The participant wore an arm orthosis (T‐WREX), which supports the weight of the arm allowing movement in the horizontal and vertical plane. Position sensors at each joint enable interaction with the virtual environment Control intervention: upper extremity exercises including passive and active ranging, stretching, strengthening and using the arm in functional tasks Both groups involved 3 sessions of direct training followed by semi‐autonomous practice in the research clinic Sessions were 60 minutes, approximately 3 times per week for 6 weeks (approximately 24 hours total)
Outcomes	Outcomes recorded at baseline, post‐intervention and at 6 months Upper limb function and activity outcomes: Fugl Meyer UE Scale, Rancho Functional test UE, Reaching ROM (deficit) Hand function and activity: grip strength (dynamometer) Participation restriction and quality of life: Motor Activity Log (amount of use and quality of movement) Adverse events reported
Notes	—
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Participants were randomly assigned using a lottery system in which the supervising therapist (with an independent witness) drew a labelled tile from an opaque container. Randomisation occurred in blocks of 4 to ensure equal numbers in each group
Allocation concealment (selection bias)	High risk	Participants were allocated in strict sequential order of enrolment. However, with small blocks of 4 and the use of tiles it might have been possible to predict allocation in advance in some cases
Blinding of outcome assessment (detection bias) All outcomes	Low risk
Incomplete outcome data (attrition bias) All outcomes	Low risk	Small number of drop outs balanced across groups with similar reasons for drop out
Selective reporting (reporting bias)	Low risk	No other outcomes were collected