- •Virtual reality technology improves cognitive function post-traumatic brain injury.
- •Optimal treatment protocol is; 10–12 sessions, 20–40 min in duration with 2–4 sessions per week.
- •There was weak evidence for positive effect of virtual reality on attention.
Archive for category Cognitive Rehabilitation
Objective: To examine the prevalence of selected medical and psychiatric comorbidities that existed prior to or up to 10 years following traumatic brain injury (TBI) requiring acute rehabilitation.
Design: Retrospective cohort.
Setting: Six TBI Model Systems (TBIMS) centers.
Participants: In total, 404 participants in the TBIMS National Database who experienced TBI 10 years prior.
Interventions: Not applicable.
Main Outcome Measure: Self-reported medical and psychiatric comorbidities and the onset time of each endorsed comorbidity.
Results: At 10 years postinjury, the most common comorbidities developing postinjury, in order, were back pain, depression, hypertension, anxiety, fractures, high blood cholesterol, sleep disorders, panic attacks, osteoarthritis, and diabetes. Comparing those 50 years and older to those younger than 50 years, diabetes (odds ratio [OR] = 3.54; P = .0016), high blood cholesterol (OR = 2.04; P = .0092), osteoarthritis (OR = 2.02; P = .0454), and hypertension (OR = 1.84; P = .0175) were significantly more prevalent in the older cohort while panic attacks (OR = 0.33; P = .0022) were significantly more prevalent in the younger cohort. No significant differences in prevalence rates between the older and younger cohorts were found for back pain, depression, anxiety, fractures, or sleep disorders.
Conclusions: People with moderate-severe TBI experience other medical and mental health comorbidities during the long-term course of recovery and life after injury. The findings can inform further investigation into comorbidities associated with TBI and the role of medical care, surveillance, prevention, lifestyle, and healthy behaviors in potentially modifying their presence and/or prevalence over the life span.
We present ongoing work to develop a virtual reality environment for the cognitive rehabilitation of patients as a part of their recovery from a stroke. A stroke causes damage to the brain and problem solving, memory and task sequencing are commonly affected. The brain can recover to some extent, however, and stroke patients have to relearn to carry out activities of daily learning. We have created an application called VIRTUE to enable such activities to be practiced using immersive virtual reality. Gamification techniques enhance the motivation of patients such as by making the level of difficulty of a task increase over time. The design and implementation of VIRTUE is presented together with the results of a small acceptability study.
Immersive VR environment for the training of safe road crossing decisions.
Relevant Lanes and Traffic Speed have a clear influence on task difficulty.
No clear influence could be found for the Gap Size.
The Number of Vehicles had almost no effect on the perceived task difficulty.
Two neuropsychologists stated that the system is ready for a study on patients.
[Case Report] Improving neuropsychiatric symptoms following stroke using virtual reality – Full Text
Rationale: Post-stroke cognitive impairment occurs frequently in patients with stroke, with a 20% to 80% prevalence. Anxiety is common after stroke, and is associated with a poorer quality of life. The use of standard relaxation techniques in treating anxiety in patients undergoing post-stroke rehabilitation have shown some positive effects, whereas virtual reality seems to have a role in the treatment of anxiety disorders, especially when associated to neurological damage.
Patients concerns: A 50-year-old woman, smokers, affected by hypertension and right ischemic stroke in the chronic phase (i.e., after 12 months by cerebrovascular event), came to our observation for a severe anxiety state and a mild cognitive deficit, mainly involving attention and visuo-executive processes, besides a mild left hemiparesis.
Diagnosis: Anxiety in a patient with ischemic stroke.
Interventions: Standard relaxation techniques alone in a common clinical setting or the same psychological approach in an immersive virtual environment (i.e., Computer Assisted Rehabilitation Environment – CAREN).
Outcomes: The patient’s cognitive and psychological profile, with regard to attention processes, mood, anxiety, and coping strategies, were evaluated before and after the 2 different trainings. A significant improvement in the functional and behavioral outcomes were observed only at the end of the combined approach.
Lessons: The immersive virtual reality environment CAREN might be useful to improve cognitive and psychological status, with regard to anxiety symptoms, in post-stroke individuals.
Stroke is a neurological syndrome caused by a focal disruption in the cerebral blood flow due to occlusion (ischemic stroke) or rupture of a blood vessel (hemorrhagic stroke). Stroke is the leading cause of disability worldwide and the third cause of death in the western countries.Following stroke, especially in right hemisphere lesions, several psychological changes may arise, being depression and anxiety the most common. The right hemisphere plays an important role in verbal communication, as it is mostly responsible for speech prosody and its emotional aspects. Moreover, previous studies indicate that post-stroke anxiety is also common and persistent,[4,5] and this is attributable to a feeling of impotence and uncertainty about the future. Some personality factors, as coping strategies, can contribute to reduce or increase the anxiety’s level. The prevalence of post-stroke cognitive dysfunctions varies from 23% to 55% within three months from the stroke onset, and declines to a percentage between 11% and 31% after 1 year.[6,7] It has been found that after stroke most of the patients may have enduring difficulties in specific cognitive domains, such as attention process and concentration, memory abilities, spatial awareness, perception, praxis and executive functioning.[8,9] Thus, a proper psychometric evaluation should be the mainstay of post-stroke patient’s treatment. Limited evidences showed the relationship between cognition processes, emotions and anxiety. Anxiety disorders frequently coexist with depression, and may be more common in women and younger stroke survivors.
Patients with a ‘probable anxiety disorder’ at 3-months had a poorer quality of life at 1, 3, and 5-years post-stroke after adjusting for age, gender, and stroke severity. Moreover, anxiety symptoms persisted for up to 10 years.
Relaxation techniques can be considered a useful tool, determining a positive emotional and psychological well-being.[12,13] Among the different relaxation techniques, diaphragmatic breathing (DB), progressive muscle relaxation,[12,13] and autogenic relaxing training are characterized by a significant positive association between physical and cognitive dimensions. The use of these techniques in treating anxiety in patients undergoing post-stroke rehabilitation have shown some positive effects.
In the last years, virtual reality (VR) and interactive video gaming are emerging as promising treatment approaches in stroke rehabilitation, both for cognitive rehabilitation and mood/anxiety disorder treatment. VR can provide exposure to nature for those living in isolated confined environments, and it has been demonstrated to reduce stress and improving mood. Virtual Reality Therapy with an Interactive Semi-Immersive Program (i.e., Bts-Nirvana System) can be considered a useful complementary treatment to potentiate functional recovery, with regard to attention, visual-spatial deficits, and motor function in patients affected by stroke. Moreover, relaxation and respiratory techniques in a semi-immersive virtual reality environment, using Bts-Nirvana, may be a promising tool in improving attention process, coping strategies, and anxiety in individuals with neurological disorders, including stroke.
Aim of this case study is to evaluate the effects of a combined rehabilitative approach, using conventional relaxation and respiratory techniques in a virtual immersive rehabilitative environment, that is, Computer Assisted Rehabilitation ENvironment (CAREN), in a patient with chronic stroke.[…]
[Abstract] Cognitive rehabilitation post traumatic brain injury: A systematic review for emerging use of virtual reality technology
Traumatic brain injury (TBI) can causes numerous cognitive impairments usually in the aspects of problem-solving, executive function, memory, and attention. Several studies has suggested that rehabilitation treatment interventions can be effective in treating cognitive symptoms of brain injury. Virtual reality (VR) technology potential as a useful tool for the assessment and rehabilitation of cognitive processes.
The aims of present systematic review are to examine effects of VR training intervention on cognitive function, and to identify effective VR treatment protocol in patients with TBI.
PubMed, Scopus, PEDro, REHABDATA, EMBASE, web of science, and MEDLINE were searched for studies investigated effect of VR on cognitive functions post TBI. The methodological quality were evaluated using PEDro scale. The results of selected studies were summarized.
Nine studies were included in present study. Four were randomized clinical trials, case studies (n = 3), prospective study (n = 1), and pilot study (n = 1). The scores on the PEDro ranged from 0 to 7 with a mean score of 3. The results showed improvement in various cognitive function aspects such as; memory, executive function, and attention in patients with TBI after VR training.
Using different VR tools with following treatment protocol; 10–12 sessions, 20–40 min in duration with 2–4 sessions per week may improves cognitive function in patients with TBI. There was weak evidence for effects of VR training on attention post TBI.
[ARTICLE] Elements virtual rehabilitation improves motor, cognitive, and functional outcomes in adult stroke: evidence from a randomized controlled pilot study – Full Text
Virtual reality technologies show potential as effective rehabilitation tools following neuro-trauma. In particular, the Elements system, involving customized surface computing and tangible interfaces, produces strong treatment effects for upper-limb and cognitive function following traumatic brain injury. The present study evaluated the efficacy of Elements as a virtual rehabilitation approach for stroke survivors.
Twenty-one adults (42–94 years old) with sub-acute stroke were randomized to four weeks of Elements virtual rehabilitation (three weekly 30–40 min sessions) combined with treatment as usual (conventional occupational and physiotherapy) or to treatment as usual alone. Upper-limb skill (Box and Blocks Test), cognition (Montreal Cognitive Assessment and selected CogState subtests), and everyday participation (Neurobehavioral Functioning Inventory) were examined before and after inpatient training, and one-month later.
Effect sizes for the experimental group (d = 1.05–2.51) were larger compared with controls (d = 0.11–0.86), with Elements training showing statistically greater improvements in motor function of the most affected hand (p = 0.008), and general intellectual status and executive function (p ≤ 0.001). Proportional recovery was two- to three-fold greater than control participants, with superior transfer to everyday motor, cognitive, and communication behaviors. All gains were maintained at follow-up.
A course of Elements virtual rehabilitation using goal-directed and exploratory upper-limb movement tasks facilitates both motor and cognitive recovery after stroke. The magnitude of training effects, maintenance of gains at follow-up, and generalization to daily activities provide compelling preliminary evidence of the power of virtual rehabilitation when applied in a targeted and principled manner.
this pilot study was not registered.
Stroke is one of the most common forms of acquired brain injury (ABI), with around 60,000 new and recurrent strokes occurring every year in Australia alone . The clinical outcome of stroke is variable but often includes persistent upper-limb motor deficits, including weakness, discoordination, and reduced speed and mobility , and cognitive impairments in information processing and executive function [3, 4]. Not surprisingly, stroke is a leading cause of disability worldwide, and the burden of stroke across all levels of the International Classification of Functioning (ICF) – body structures/function, activity, and participation – underlines the importance of interventions that can impact multiple domains of functioning [5, 6].
Recovery of functional performance following stroke remains a significant challenge for rehabilitation specialists [7, 8], but may be enhanced by innovation in the use of new technologies like virtual reality [9, 10, 11, 12]. A critical goal is to find compelling ways of engaging individuals in their therapy by creating meaningful, stimulating and intensive forms of training . The term, virtual rehabilitation (VR), is used to describe a form of training wherein patients interact with virtual or augmented environments, presented with the aid of technology [14, 15]. The technologies can be either commercial systems (e.g. Nintendo Wii, Xbox Kinect) or those customised specifically for rehabilitation. VR offers a number of advantages over traditional therapies, including the ability to engage individuals in the simulated practice of functional tasks at higher doses [16, 17], automated assessment of performance over time, flexibility in the scaling of task constraints, and a variety of reward structures to help maintain compliance .
While evaluation research is still in its infancy, recent systematic reviews and meta-analyses show that VR can enhance upper-limb motor outcomes in stroke [10, 11, 19], yielding treatment effects of medium-to-large magnitude [10, 11], and complementing conventional approaches to rehabilitation. VR has been shown to engender high levels of engagement in stroke patients undergoing physical therapy [20, 21] and training of even moderate intensity can afford functional benefits at the activity/skill level [9, 19]. In the specific case of upper-limb VR, however, there is little available evidence that these benefits transfer to participation . Furthermore, most available data is on patients in chronic stages of recovery, with less on acute stroke . Notwithstanding this, use of VR has begun to emerge in clinical practice, recommended in Australian and international stroke guidelines as a viable adjunct in therapy to improve motor and functional outcomes [22, 23, 24].
Until recently, most VR systems have been designed to improve motor functions, with cognitive outcomes often a secondary consideration in evaluation studies [9, 10, 11]. Notwithstanding this, treatments that target both motor and cognitive functions are indicated for stroke, given evidence that cognitive and motor systems overlap at a structural and functional level [25, 26], and work synergistically in a “perception-action cycle”  in stroke patients undergoing rehabilitation . Recent studies provide preliminary evidence of improved attention and memory in stroke patients following motor-oriented VR [29, 30, 31, 32], amounting to a small-to-medium effect on cognition . When designed to address aspects of cognitive control and planning, VR has the potential to enhance dual-task control, resulting in better generalization of trained skills to daily functioning .
While evaluation research is still in its infancy, several recent customized systems (like Elements, the system evaluated here) have been deliberately designed to exploit factors known to enhance training intensity and motor learning. Informed by neuroscience and learning theory [for a recent review see 12], the Elements VR system was designed to enhance neuro-plastic recovery processes via: (1) an enriched therapeutic environment affording a natural form of user interaction via tangible computing and surface displays , which engage both the cognitive attention of participants and their motivation to explore training tasks; (2) concurrent augmented feedback (AF) on performance  offering participants additional information on the outcome of their actions to assist in re-building a sense of body position in space (aka body schema) and ability to predict/plan future actions; and (3) scaling of task challenges to the current level of motor and cognitive function , ensuring dynamic scaffolding of participants’ information processing and response capabilities. The Elements system, described in detail below and in earlier publications [37, 38], consists of a large (42 in.) tabletop surface display, tangible user interfaces, and software for presenting both goal-directed and exploratory virtual environments. Previous evaluations of the system in patients with traumatic brain injury showed improvements in both motor and cognitive performance, with transfer to activities of daily living [37, 39]. However, the impact of Elements in other forms of ABI, such as stroke, has not been evaluated.
The broad aim of current study was to evaluate the efficacy of the Elements VR interactive tabletop system for rehabilitation of motor and cognitive functions in sub-acute stroke, compared with treatment as usual (TAU). We were particularly interested in motor and cognitive outcomes, their relationship, and the transfer and maintenance of treatment effects. Training-related changes at the activity/skill level on standardized measures of motor and cognitive performance were investigated, together with functional changes. By offering an engaging, principled and customized form of interaction, we predicted that the Elements system would effect (i) greater changes on both motor and cognitive outcomes than with TAU alone; (ii) sustained benefits, as assessed over a short follow-up period, and (iii) transfer to everyday functional performance (i.e. participation).[…]
Continue —> Elements virtual rehabilitation improves motor, cognitive, and functional outcomes in adult stroke: evidence from a randomized controlled pilot study | Journal of NeuroEngineering and Rehabilitation | Full Text
Examples of the Elements (a) goal-directed Bases task with visual augmented feedback, and (b) exploratory Squiggles task
Virtual reality to help more military and other public safety workers cope with PTSD is central to the work of a new group launched in Edmonton.
Heroes in Mind, Advocacy & Research Consortium (HiMARC) is made up of those who want “to serve the men and women in uniform who have served us and continue to serve us daily,” Bob Haennel, dean of the University of Alberta’s Faculty of Rehabilitation Medicine, said in a Wednesday news release.
HiMARC’s Motion-Assisted, Multi-Modal Memory Desensitization and Reconsolidation (3MDR) research study — the largest of its kind in Canada with 40 Armed Forces participants — allows PTSD patients to use the Computer-Assisted Rehabilitation Environment (CAREN) system at the Glenrose Rehabilitation Hospital.
“It was incredible. I don’t know how else to describe it. My senses were heightened. I was even sensitive to the clanging sound of the carabiner on my harness,” said Capt. Anna Harpe, a social worker at CFB Edmonton, after experiencing the 3MDR system.
Patients who step into the CAREN unit walk on a treadmill toward a stimulus, sounds and images that may remind them of events that trigger traumatic memories. A therapist is with them through the process, guiding the patient confronting the memories.
While Harpe does not have PTSD, she said testing the 3MDR brought back vivid recollections of a mission in Afghanistan when she was in the infantry.
“I have worked with some clients who have been diagnosed with PTSD, and I have to say, the 3MDR is mind-blowing. My whole body was activated. You just cannot get the same thing through talk therapy in an office,” she said.
Study participants are receiving the therapy once a week for six weeks.
“By walking towards the fear, there is a shift in the brain,” said Suzette Brémault-Phillips, director of HiMARC in the Faculty of Rehabilitation Medicine and co-principal investigator for the study in Canada.
The 3MDR system — developed by Col. Eric Vermetten, head of research at the Military Mental Health unit of the Dutch ministry of defence in the Netherlands — has been effective in the Netherlands where it’s been used to treat the rise in PTSD cases there after its mission to Afghanistan.
Vermetten traveled to Edmonton to train Brémault-Phillips and her team to use the system.
HiMARC’s founding members also include the Royal Canadian Legion Alberta-NWT Command, NAIT, the Department of National Defence, Veteran Affairs Canada and Covenant Health.
“HiMARC is creating hope and I am so grateful for this group. I really believe this is just the beginning,” added Harpe.
[Abstract] The Effect of Noninvasive Brain Stimulation on Poststroke Cognitive Function: A Systematic Review
Introduction. Cognitive impairment after stroke has been associated with lower quality of life and independence in the long run, stressing the need for methods that target impairment for cognitive rehabilitation. The use of noninvasive brain stimulation (NIBS) on recovery of language functions is well documented, yet the effects of NIBS on other cognitive domains remain largely unknown. Therefore, we conducted a systematic review that evaluates the effects of different stimulation techniques on domain-specific (long-term) cognitive recovery after stroke.
Methods. Three databases (PubMed, EMBASE, and PsycINFO) were searched for articles (in English) on the effects of NIBS on cognitive domains, published up to January 2018.
Results. A total of 40 articles were included: randomized controlled trials (n = 21), studies with a crossover design (n = 9), case studies (n = 6), and studies with a mixed design (n = 4). Most studies tested effects on neglect (n = 25). The majority of the studies revealed treatment effects on at least 1 time point poststroke, in at least 1 cognitive domain. Studies varied highly on the factors time poststroke, number of treatment sessions, and stimulation protocols. Outcome measures were generally limited to a few cognitive tests.
Conclusion. Our review suggests that NIBS is able to alleviate neglect after stroke. However, the results are still inconclusive and preliminary for the effect of NIBS on other cognitive domains. A standardized core set of outcome measures of cognition, also at the level of daily life activities and participation, and international agreement on treatment protocols, could lead to better evaluation of the efficacy of NIBS and comparisons between studies.