Posts Tagged cognitive impairment
[Abstract + References] Effects of immersive and non-immersive virtual reality-based rehabilitation training on cognition, motor function, and daily functioning in patients with mild cognitive impairment or dementia: A systematic review and meta-analysis
Posted by Kostas Pantremenos in REHABILITATION, Virtual reality rehabilitation on November 29, 2023
Abstract
Objective
To examine the effectiveness of virtual reality (VR)-based rehabilitation training in improving cognition, motor function, and daily functioning in patients with mild cognitive impairment and dementia.
Data sources
A systematic review of published literature was conducted using PubMed, Web of Science, Elsevier, Embase, Cochrane, CNKI, Networked Digital Library of Theses and Dissertations.
Methods
The search period was from inception to 7 October 2023. Eligible studies were randomized controlled trials evaluating the efficacy of VR-based rehabilitation training in patients with mild cognitive impairment or dementia versus control subjects. Methodologic quality was assessed with the Cochrane risk of bias tool, and outcomes were calculated as the standard mean difference between participant groups with 95% confidence interval.
Results
A total of 21 randomized controlled trials with 1138 patients were included. The meta-analysis showed that VR-based rehabilitation training had significant effects on Montreal Cognitive Assessment (SMD: 0.50; 95%CI: 0.05 to 0.95; P = 0.030), Trail-making test A (SMD: −0.38; 95%CI: −0.61 to −0.14; P = 0.002), and Berg Balance Scale scores (SMD: 0.79; 95%CI: 0.13 to 1.45; P = 0.020). A subgroup analysis revealed that the type of VR, and duration and frequency of interventions had statistically significant effects on cognition and motor function.
Conclusion
VR-based rehabilitation training is a beneficial nonpharmacologic approach for managing mild cognitive impairment or dementia. Immersive VR-based training had greater effects on cognition and motor function than non-immersive VR-based training, but non-immersive VR-based training was more convenient for patients with limitations imposed by their disease. Also, an intervention lasting 5–8 weeks and for >30 min at a frequency of ≥3 times/week achieved the best results. It indicated that a longer intervention cycle may not achieve the best intervention effect and training duration and schedule should be carefully considered when managing patients.
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[ARTICLE] Virtual reality technology in the rehabilitation of post-stroke cognitive impairment: an opinion article on recent findings – Full Text
Posted by Kostas Pantremenos in Cognitive Rehabilitation, Virtual reality rehabilitation on November 9, 2023
Introduction
Post-stroke cognitive impairment (PSCI) is a group of syndromes in which one or more cognitive dysfunctions, such as memory, executive function, orientation and attention, occur within 6 months after stroke (Lim et al., 2021). The prevalence of PSCI is as high as 64%, and 1/3 of these patients will progress to dementia, seriously affecting their quality of life (Delavaran et al., 2017). Post-stroke limb movement disorders have long received widespread attention and have a well-established clinical rehabilitation system (Nakawah and Lai, 2016). However, PSCI is often neglected.
Currently, oral medications and rehabilitation are the main treatment modalities for PSCI, but the therapeutic effects are not satisfactory. Animal models cannot reproduce several features of the pathogenesis of vascular cognitive impairment, which limits the development of relevant drugs (Kuang et al., 2021). To date, no drug for vascular cognitive impairment has been approved by the Food and Drug Administration (USA) (Gorelick et al., 2011). Vascular dementia and Alzheimer’s disease (AD) overlap in their neuropathological mechanisms (Sun, 2018). Drugs for AD can also improve cognitive function and activities of daily living in patients with PSCI, such as donepezil, galantamine and memantine (Glass et al., 2020; Cichon et al., 2021). However, the side effects and potential harms of long-term drug use need to be considered (Shetty, 2013). Cognitive impairment is mainly assessed with paper and pencil tests (De Roeck et al., 2019). The occupational therapist provides therapeutic or adaptive tasks depending on the patient’s cognitive status (Mijajlović et al., 2017). This type of training is tedious and the results vary widely in clinical practice. However, there is no clear treatment for PSCI (Rost and Brodtmann, 2022).
The effective integration of rehabilitation for cognitive impairment with computer technology has led to new and more interesting treatment modalities, such as virtual reality (VR) (Ge et al., 2018). VR is a new computer-generated technology that is being widely used clinically for the diagnosis, assessment, and treatment of mental disorders (Freeman et al., 2017). VR has two key features: immersion and interaction, providing a three-dimensional environment for the user to interact with the virtual environment through multiple sensory channels, including visual, auditory, and tactile (García-Betances et al., 2015). Previous studies have shown that cognitive training, physical training, and lifestyle can improve cognitive function (Stern, 2012; Huang et al., 2017). Compared to traditional rehabilitation therapies, VR incorporates some game-like elements that increase participants’ motivation, cooperation, and satisfaction. VR can be designed with different scenarios and training to target different cognitive areas, and can be adapted in a timely manner according to patients’ needs and cognitive status. In addition, compared to traditional paper-and-pencil tests, VR-based goal-directed navigation and recognition tasks are performed by immersing patients in a 3D virtual environment (La Corte et al., 2019). VR navigation tasks may involve more complex processes, including representational updating, spatial memory, and adaptation of the self when approaching a distant spatial target (Brument et al., 2021). These skills and manipulations cannot be accounted for in paper-and-pencil tests.
VR technology has been initially demonstrated in the treatment of cognitive disorders, such as memory impairment, attention impairment, executive function, language and numeracy impairment (D’Cunha et al., 2019). Several studies have shown that VR technology improves visuospatial motion perception, delayed memory, orientation and attention better than traditional cognitive rehabilitation (Liao et al., 2020; Torpil et al., 2021). Besides, a study by Liao et al. (2019) found significant improvements in self-care and gait in patients who underwent VR interventions (task-based interventions: simulated grocery store, simulated kitchen, finding a store, etc.). A meta-analysis found that VR was less effective in improving cognitive function in patients with AD than in normal elderly and people with MCI. However, the feasibility of VR technology has been demonstrated in a non-immersive VR intervention for patients with AD (Hofmann et al., 2003; Kim et al., 2019). Notably, the effect of the intervention was correlated with patient cooperation. Impaired memory and executive function are key features of AD. Several studies have used VR tasks to intervene with AD patients for 2–4 months (Serino et al., 2017; Oliveira et al., 2021). The results showed that the VR task was effective in improving patients’ overall cognitive function, memory and executive function, especially spatial navigation and memory.
At present, with the rise of virtual reality technology, VR technology has a good prospect of being applied to PSCI. PSCI seriously threatens patients’ quality of life, and VR technology has a potential role in rehabilitation. VR technology applied to the rehabilitation of PSCI not only allows patients to train in a safe and interesting environment, but also provides timely feedback on the effectiveness of treatment. This paper aims to outline the key role of VR technology in improving cognition in patients with PSCI. Moreover, the authors highlight the limitations and challenges of current research related to VR technologies for improving cognition in stroke patients. […]
[ARTICLE] Virtual Reality in the Rehabilitation of Cognitive Impairment after Stroke – Full Text PDF
Posted by Kostas Pantremenos in Cognitive Rehabilitation, Virtual reality rehabilitation on January 7, 2023
Abstract
Virtual reality (VR) is seen by some as a tool that may greatly improve, or even revolutionize cognitive rehabilitation. VR offers distinct advantages compared to classic rehabilitation using paper-and-pencil or computer-based training, such as immersion, the feeling of presence, embodiment of virtual players, ecological and multisensory stimulation. We here review recent clinical studies examining the effects of VR training in patients with stroke-induced cognitive deficits. Several trials reported evidence that VR training improves general cognition compared to standard cognitive training. However, the evidence remains controversial, as some of these studies had a high risk of bias. Regarding mood, there is some indication that immersive training improves depression scores in stroke patients, but the number of studies examining mood changes is very low. Finally, in the domain of spatial cognition the development of specific intervention techniques such as virtual prism adaptation provide avenues for clinical interventions, though well-controlled clinical trials are lacking. Together, the available evidence suggests that VR has the potential to improve rehabilitation particularly in domains requiring repetitive training in an immersed, ecological setting, or when a mismatch between body frames and the environment is created. Controlled clinical studies are required to examine the specific advantages of VR compared to classic interventions.
[Abstract] The Impact of Cognitive Impairment on Robot-Based Upper-Limb Motor Assessment in Chronic Stroke
Posted by Kostas Pantremenos in Paretic Hand, Rehabilitation robotics on August 30, 2022
Abstract
Background
Chronic upper extremity motor deficits are present in up to 65% of stroke survivors, and cognitive impairment is prevalent in 46-61% of stroke survivors even 10 years after their stroke. Robot-assisted therapy programs tend to focus on motor recovery and do not include stroke patients with cognitive impairment.
Objective
This study aims to investigate performance on the individual cognitive domains evaluated in the MoCA and their relation to upper-limb motor performance on a robotic system.
Methods
Participants were recruited from the stroke population with a wide range of cognitive and motor levels to complete a trajectory tracking task using the Haptic TheraDrive rehabilitation robot system. Motor performance was evaluated against standard clinical cognitive and motor assessments. Our hypothesis is that the cognitive domains involved in the visuomotor tracking task are significant predictors of performance on the robot-based task and that impairment in these domains results in worse motor performance on the task compared to subjects with no cognitive impairment.
Results
Our results support the hypothesis that visuospatial and executive function have a significant impact on motor performance, with differences emerging between different functional groups on the various robot-based metrics. We also show that the kinematic metrics from this task differentiate cognitive-motor functional groups differently.
Conclusion
This study demonstrates that performance on a motor-based robotic assessment task also involves a significant visuospatial and executive function component and highlights the need to account for cognitive impairment in the assessment of motor performance.
[Abstract] Epidemiology of Cognitive impairment after stroke- natural history, risk factors, outcomes, treatments and interaction with depression – Thesis
Posted by Kostas Pantremenos in Cognitive Rehabilitation, Depression on January 5, 2022
Background Recovery from stroke poses physical and psychological challenges with significant consequences, not only on patients, but also on families, informal caregivers and stroke services. Early risk profiling, patient needs identification, and intervention of cognitive disorders could potentially offer increased psychological follow-up and support to those at risk.
Aims This PhD project aims to investigate the long-term natural history of post-stroke cognitive impairment, identify risk factors, treatments, outcomes, and interaction with depression.
Methods Study (i) is a systematic review of systematic reviews (umbrella review) of the risk factors and interventions to prevent cognitive decline in stroke patients. Studies (ii, iii and iv) analyse data from the South London Stroke Register, examining the natural history of post-stroke cognitive impairment, the association of primary and secondary preventive treatments as well as stroke management strategies on the risk of post-stroke cognitive impairment, and long-term outcomes in stroke patients with cognitive impairment, respectively. Study (v) uses stroke and cognition data (STROKOG), to generalise results of the fourth study on data from an international consortium. Study (vi) examine the interactions between post-stroke cognitive impairment and depression using stroke register.
Results: Study (i), an umbrella review, included 22 systematic reviews. The major risk factorts of cognitive impairment included atrial fibrillation, leukoaraiosis, and multiple and recurrent strokes. The main interventions that could improve cognitive function were physical activity or cognitive rehabilitation.
Study (ii) found that the prevalence of cognitive impairment was around one-third and remained stable at this level within 15 years of follow up, with incidence ranging from 6% to 20%; almost two-thirds of the patients with cognitive impairment at stroke onset had recovered within the first year after stroke. Study (iii) found that admission to acute stroke unit and preventive treatment strategies especially with combined treatments of antihypertensive, lipid lowering and anti-thrombotic, were associated with significant risk reduction of cognitive impairment. Study (iv) observed that during the first three-months post-stoke, approximately one-third of these stroke survivors with cognitive impairment either cognitively improved (37%), deteriorated (30%), or remained unchanged (33%). Early presentation of cognitive impairment, and further deterioration in cognitive function within the first three months after stroke were associated significantly with negative health outcomes, including mortality, depression, physical dependency, being institutionalised and further cognitive decline. Study (v) generalise results of the study (iv) on international data from seven different countries. The pooled prevalence across international data was 28% (95% confidence interval=19%-37%). Compared to patients with normal cognitive function measured by MMSE or AMT at three months, there was a 47% increased risk of depression in patients with cognitive impairment (risk ratio (RR)=1.47, 95% CI=0.96-2.24), a 69% increased risk of further cognitive decline (RR=1.69, CI=1.56-1.83), a two-fold increased risk of physical dependence (RR=2.14, CI=1.20-3.81) and a close to three-fold increased risk of mortality (RR=2.71, CI=2.00-3.66) at one year. Study (vi) found that cognitive impairment interacts significantly with depression symptoms where the co-existence of both conditions was associated with a potential increased risk of negative outcomes.
Conclusion: This thesis provides an insight into the burden of post-stroke cognitive impairment, its risk factors, and the current state of evidence around prevention. Cognitive impairment after stroke is common and fluctuating, and is strongly associated with poor outcome, especially if depression symptoms co-exist. There is a need for research into interventions to prevent and early treat cognitive impairment; the research here suggests that good quality acute stroke care and secondary prevention is likely to be important in preserving cognitive status.
[Abstract] Accelerated rTMS and cognitive training in chronic stroke: a safety and feasibility study
Posted by Kostas Pantremenos in Cognitive Rehabilitation, tDCS/rTMS on December 2, 2021
Abstract
Background: Nearly 70% of patients with chronic stroke demonstrate impairment in at least one cognitive domain. Effective cognitive rehabilitation approaches have been established for focal cortical deficits such as neglect and aphasia, but treatments for more prevalent and diffusely represented cognitive impairment remain elusive. Repetitive transcranial magnetic stimulation is a promising intervention for targeting the multiple demand network that undergirds domain general cognitive processing. Furthermore, a delivery schedule readily paired with other rehabilitation interventions could be especially powerful. We examined the safety of accelerated rTMS as well as its feasibility in a delivery schedule interleaved with computerized cognitive training in individuals with chronic stroke and cognitive impairment.
Methods: Fourteen chronic stroke patients with intact left prefrontal cortex who met DSM-5 criteria for mild neurocognitive disorder completed open-label high-dose rTMS (intermittent theta burst) to left dlPFC (600 pulses, eight sessions/day for three days), interleaved every 15 minutes between cognitive training sessions. Participants completed at pre- and post-treatment: 1) neuroradiological lesion characterization and safety assessment with flair, diffusion, susceptibility, angiography, perfusion gradient and volumetric scans, 2) neuropsychological and psychosocial assessment as well as assessment of neglect and aphasia, and 3) ratings of treatment acceptability and credibility.
Results: No study-related adverse events occurred as indexed in neuroradiological, neuropsychological or subjective quantitative or qualitative report of side effects. Accelerated rTMS was rated as acceptable and credible with no more than minor discomfort in line with conventional once daily delivery schedules. Retention was feasible as all participants who began treatment completed.
Conclusions: This is the first comprehensive neuroradiological and neuropsychological examination of the safety of accelerated rTMS in chronic stroke, or any condition. Across objective and subjective indices, up to 24 sessions of accelerated intermittent theta burst rTMS was safe, acceptable, and tolerable, even in a neurologically vulnerable condition such as chronic stroke.
[Abstract] Designing stroke services for the delivery of cognitive rehabilitation: A qualitative study with stroke rehabilitation professionals
Posted by Kostas Pantremenos in Cognitive Rehabilitation, REHABILITATION on October 17, 2021
ABSTRACT
This qualitative study explored the potential to deliver cognitive rehabilitation for post-stroke cognitive impairment (PSCI), with a specific focus on barriers and facilitators to its delivery from the perspective of Irish stroke rehabilitation professionals.
Sixteen semi-structured interviews were completed with healthcare professionals in both hospital and community settings. The sample comprised physiotherapists, occupational therapists, nurses, a stroke physician, a psychologist, a neuropsychologist, a speech and language therapist, a dietician, and a public health nurse.
Interviews were audio-recorded and analysed in NVivo using inductive Thematic Analysis. Barriers and facilitators to the delivery of cognitive rehabilitation were identified and described under four key themes:
(i) Cognitive screening;
(ii) Cognitive rehabilitation: no one size fits all;
(iii) Psychology: the lost dimension of stroke rehabilitation; and
(iv) Joining the dots in the community.
Staffing required to deliver cognitive rehabilitation for PSCI was highlighted as under-resourced in the Republic of Ireland. Inadequate resourcing of neuropsychology and stroke-related psychological services, in particular, has had negative implications for the delivery of cognitive rehabilitation. Stroke-specific cognitive rehabilitation expertise is virtually inaccessible in the community, highlighting an urgent need for investment in specialist rehabilitation teams to deliver cognitive rehabilitation in this setting.
[Abstract] The effects of computer‐assisted cognitive rehabilitation on cognitive impairment after stroke: A systematic review and meta‐analysis
Posted by Kostas Pantremenos in Cognitive Rehabilitation on September 9, 2021
Abstract
Objectives
To determine the effectiveness of computer-assisted cognitive rehabilitation in improving cognitive function in patients with post-stroke cognitive impairment.
Background
In recent years, computer-assisted cognitive rehabilitation has been accepted as a good substitute or supplement for traditional cognitive rehabilitation. Some clinical randomised controlled trials have been carried out, but no relevant systematic evaluations have been performed. Therefore, we conducted a systematic review of studies involving computer-assisted cognitive rehabilitation to provide evidence-based data for its promotion and application.
Methods
Nine databases (Cochrane Library, PubMed, Web of Science, Embase, OVID, Wanfang Data, CNKI, VIP and SinoMed databases) were systematically searched. Randomised controlled trials that assessed computer-assisted cognitive rehabilitation for patients with post-stroke cognitive impairment were included. Two reviewers appraised the risks of bias through the Cochrane Collaboration’s tool and performed the meta-analysis, including the assessment of heterogeneity. We follow the PRISMA 2020 guidelines.
Results
Thirty-two studies comprising 1837 participants were included. Compared with conventional therapy alone, the addition of computer-assisted cognitive rehabilitation significantly improved the global cognition of patients, evaluated using the Montreal cognitive assessment, mini-mental state examination and Loewenstein occupational therapy cognitive assessment (p < .01 for all tests). The therapy also significantly improved activities of daily living, assessed using the Barthel index, modified Barthel index and functional independence measure (p < .05 for all tests).
Conclusion
Computer-assisted cognitive rehabilitation significantly improved the cognitive function and activities of daily living of patients with post-stroke cognitive impairment.
Relevance to clinical practice
Computer-assisted cognitive rehabilitation can be a valuable technique for cognitive rehabilitation after stroke. It is advantageous for improving patient cognition and restoring the overall functional state of patients. Moreover, the research findings can provide suggestions and inspiration for researchers to implement the proposal, which is conducive to the design of more rigorous and high-quality randomised controlled trials.
[Abstract] Effect of RehaCom cognitive rehabilitation software on working memory and processing speed in chronic ischemic stroke patients
Posted by Kostas Pantremenos in Assistive Technology, Cognitive Rehabilitation on May 29, 2021
Abstract
Stroke survivors need assistance to overcome cognitive impairments. Working memory (WM) and processing speed (PS) as two critical cognitive functions are disrupted by stroke. The goal of this study was to investigate the effect of RehaCom rehabilitation software on WM and PS in participants with chronic ischemic stroke with hemiplegia (right/left side). Participants were selected among stroke patients who were referred to our special rehabilitation clinic. Fifty participants were assigned to control (n = 25) and experimental (n = 25) groups. The results of the experimental group were compared with the control group before and after the treatment with RehaCom (ten 45-min sessions across five weeks, two sessions per week). The results showed a significant improvement in WM and PS in the experimental group in comparison with the control group after a 5-week training with RehaCom. In conclusion, our findings indicate that treatment with RehaCom software improves WM and PS in chronic ischemic stroke participants with hemiplegia. The exact mechanism of RehaCom is largely unknown and further studies are needed, but its effects on the function of brain regions involved in modulating cognitive functions such as the prefrontal cortex, cingulate cortex, and parietal cortex may be mechanisms of interest.
TBI Rehabilitation 