Posts Tagged cognitive impairment

[ARTICLE] Effects of Virtual Reality Exercise Program on Balance, Emotion and Quality of Life in Patients with Cognitive Decline



In this study, we investigated the effectiveness of a 12-week virtual reality exercise program using the Nintendo Wii console (Wii) in improving balance, emotion, and quality of life among patients with cognitive decline.


The study included 30 patients with cognitive decline (12 female, 18 male) who were randomly assigned to an experimental (n=15) and control groups (n=15). All subjects performed a traditional cognitive rehabilitation program and the experimental group performed additional three 40-minute virtual reality based video game (Wii) sessions per week for 12 weeks. The berg balance scale (BBS) was used to assess balance abilities. The short form geriatric depression scale-Korean (GDS-K) and the Korean version of quality of life-Alzheimer’s disease (KQOL-AD) scale were both used to assess life quality in patients. Statistical significance was tested within and between groups before and after treatment, using Wilcoxon signed rank and Mann-Whitney u-tests.


After 36 training sessions, there were significant beneficial effects of the virtual reality game exercise on balance (BBS), GDS-K, and KQOL-AD in the experimental group when compared to the control group. No significant difference was observed within the control group.


These findings demonstrate that a virtual reality-training program could improve the outcomes in terms of balance, depression, and quality of life in patients with cognitive decline. Long-term follow-ups and further studies of more efficient virtual reality training programs are needed.


Dementia is a degenerative disease of the nervous system, which is prevalent in the elderly population. It involves deterioration in cognitive function and ability to perform everyday activities. As the early diagnosis and treatment of dementia is delayed, its economic costs and burden on families and society are gradually increasing and becoming a social problem.1 Older people with dementia have an increased risk of falls and lower levels of everyday activities being performed due to cognitive decline and decreased muscle mass. This is a result of reduced physical activity, which further deteriorates their quality of life.2 Therapeutic interventions to improve cognitive function and to increase activities of daily living (ADL) in patients with dementia are divided into pharmacological and non-pharmacological treatments. For pharmacological treatment, acetylcholinesterase inhibitors and N-methyl-D-aspartate receptor antagonists are the most widely used in clinical practice.3 However, because pharmacological treatment alone cannot prevent the progression of cognitive decline and ADL deterioration in patients with dementia, various non-pharmacological treatments including cognitive therapy or physical exercise are used as additional treatments.4
Recent reports have stated that regular exercise was effective in delaying cognitive impairment in people with dementia.5 In a three-year follow-up study of healthy older people, a combination of cognitive activity and physical activity was found to be effective in reducing the risk for mild cognitive impairment.6 However, physical activity was found to be more important than cognitive activity in order to further reduce the risk for cognitive decline.6 When older people with dementia performed regular physical exercise, there was an improvement in the mini-mental state examination (MMSE) score.7 Physical exercise prevented the deterioration of ADL.8 The mechanism of the benefit of physical exercise on patients with dementia is thought to be that it can facilitate neuroplasticity, promote injury recovery mechanisms at a molecular level and facilitate self-healing of the brain through its neuroprotective effect.9
However, unless individuals perform exercise in the long run, such beneficial effects of exercise may wear off, leading to impaired brain function and worsened disease.10 Therefore, patients with dementia should continue exercise under the supervision of professional physical therapists in order to stop the progression of cognitive impairment for a long time. In order to achieve this, it is required to keep patients interested in the exercise therapy allowing them to maintain adherence. However, it is difficult to execute exercise treatment continuously in patients with dementia because of space, time, and cost issues in Korea. Patients get easily bored and tired of passive and simply repetitive forms of exercise treatment. In general, 20-50% of older people who start an exercise program will stop within six months.11 Patients with dementia are expected to be more likely to discontinue exercise program due to lowered levels of patience and self-regulation abilities. Therefore, exercise programs utilizing media, including games, attempt to keep patients interested in exercise programs and to improve therapeutic effects. With recent advances in scientific technologies and computer programs, exercise and rehabilitation interventions using virtual reality are being introduced in the medical field.12 Virtual reality refers to a computer-generated environment that allows users to have experiences similar to those in the real world. It is an interactive simulation characterized by technology that provides reality through various feedbacks.13 While performing predetermined tasks such as playing a game in virtual reality, users manipulate objects as if they were real and can control their movements by giving and receiving various feedbacks via numerous senses such as sight and hearing.14
The virtual reality-enhanced exercise consisting of exercise with computer-simulated environments and interactive videogame features allows patients to enjoy performing tasks, encourages competition, and creates motivation and interest in their treatment.15 Participation in a virtual reality-enhanced exercise was reported to lead to higher exercise frequency and intensity and enhanced health outcomes when compared with traditional exercise.16
However, despite these advantages, conventional virtual reality systems could not be widely available for patients in clinical settings due to several limitations including high costs and a large size.17 Therefore, it is necessary to develop virtual reality exercise programs that are easy to follow in hospitals and at home. As an alternative, the use of computer-based individual training programmes is becoming increasingly popular due to the low cost, independence and ease of use in the home. One such system that is increasing in popularity for use in exercise training is the Nintendo Wii (Wii; Nintendo Inc., Kyoto, Japan) personal game, which became commercially available. Wii is a video gaming console with a simple method, as its virtual reality system is implemented via a television monitor. It combine physical exercise with computer-simulated environments and interactive videogame features. Because the Wii console is inexpensive and small in size, it is easy to install or move it in hospitals or at home. This gaming console is designed to be controlled using a wireless controller, allowing user to interact with his/her own avatar, which is displayed on the screen through a movement sensing system. The controller is provided with an acceleration sensor that responds to acceleration changes recognizing direction and velocity changes.18 Wii-balance board is being used when playing a Wii Fit game. It is a force plate collecting movement information in the center of pressure of the standing user, enabling reflection of movements in a virtual environment on the monitor and thus constantly resending visual feedback to the user. Through this process, the user can adjust his/her postural responses. Studies have shown that the Wii balance board can be helpful in postural control training.19 Because Wii is a typical example of virtual reality applications and is simple, inexpensive, and easily accessible, Wii is expected to create interest among patients encouraging them to put more efforts in exercise via games and thus augmenting effects of the treatment.
Domestic studies on the use of Wii have reported its effects on the upper extremity function, visual perception and sense of balance in chronic stroke patients,20 spinal cord injury patients,21 Parkinson’s disease patients,22 and multiple sclerosis patients.23 However, there have been only a few controlled research studies about the effects of Wii on patients with cognitive decline. The present study aimed to analyze effects of virtual reality exercise program on balance function, emotions, and quality of life (QOL) in patients with cognitive decline.

Continue —> Effects of Virtual Reality Exercise Program on Balance, Emotion and Quality of Life in Patients with Cognitive Decline – ScienceCentral



Figure 1 The level of satisfaction about Wii game for dementia patients (Number=%).

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[ARTICLE] Cognitive impairment and rehabilitation strategies after traumatic brain injury – Full Text


Traumatic brain injury (TBI) is among the significant causes of morbidity and mortality in the present world. Around 1.6 million persons sustain TBI, whereas 200,000 die annually in India, thus highlighting the rising need for appropriate cognitive rehabilitation strategies. This literature review assesses the current knowledge of various cognitive rehabilitation training strategies. The entire spectrum of TBI severity; mild to severe, is associated with cognitive deficits of varying degree. Cognitive insufficiency is more prevalent and longer lasting in TBI persons than in the general population. A multidisciplinary approach with neuropsychiatric evaluation is warranted. Attention process training and tasks for attention deficits, compensatory strategies and errorless learning training for memory deficits, pragmatic language skills and social behavior guidance for cognitive-communication disorder, meta-cognitive strategy, and problem-solving training for executive disorder are the mainstay of therapy for cognitive deficits in persons with TBI. Cognitive impairments following TBI are common and vary widely. Different cognitive rehabilitation techniques and combinations in addition to pharmacotherapy are helpful in addressing various cognitive deficits.

   Introduction Top

Traumatic brain injury (TBI) is a steadily rising public health concern and one of the significant causes of morbidity and mortality in India.[1] Around 10 million people sustain TBI worldwide annually.[2] The recent global status report on road safety by the World Health Organization, 2013 has clearly highlighted the existing and growing enormity of this problem across the world and has emphasized on the outmost need for well-designed and evaluated programs in prevention, management, and rehabilitation. As India continues to progress to greater urbanization with rapid development in terms of motorization, incidence of TBIs will increase significantly. Data from an epidemiological study undertaken in Bengaluru have shown incidence, mortality, and case fatality rates of 150/100,000, 20/100,000 and 10%, respectively.[3] An estimated 2 million people sustain brain injuries with nearly a million requiring rehabilitation services at the national level.[3]

Persons, who survive TBI, end up with chronic disability.[1] It significantly impacts on an individual’s life, in terms of cognitive, behavioral, psychosocial and physical factors, and vocational issues.[4] Among them, cognitive disabilities are often the most disabling and distressing for the affected persons, family members, and the society. Cognitive deficits can significantly impair activities of daily living (ADL), employment, social relationships, recreation, and active participation in the community.

TBI is classified as mild, moderate, and severe depending on the level of consciousness, particularly duration of coma and posttraumatic amnesia (PTA).[4],[5] In moderate to severe TBI, cognition appears to be markedly impaired around 1-month postinjury [6] or shortly after resolution of PTA.[7],[8] Cognitive impairments persisting even after 3 months were found to be associated with higher frequency disability.[9] In moderate to severe TBI, cognitive recovery does not return to baseline even after 2 years of injury. In contrast, the cognitive recovery tends to be rapid in patients with mild TBI, returning almost to “normal baseline functioning” within 3 months.[10],[11]

Literature and studies have reported that effective cognitive rehabilitation interventions initiated post-TBI enhance the recovery process and minimize the functional disability. Hence, it is necessary to have a proper guideline for the cognitive rehabilitation of traumatic brain injured persons with multiple cognitive impairments. This article has been adapted from various literatures and outlines briefly the commonly encountered cognitive deficits following TBI. It also provides a summary of effective rehabilitation strategies for the cognitively impaired persons.

Continue —> Cognitive impairment and rehabilitation strategies after traumatic brain injury Barman A, Chatterjee A, Bhide R – Indian J Psychol Med

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Apathy Secondary to Stroke: A Systematic Review and Meta-Analysis – Full Text HTML


Background: Apathy is a disturbance of motivation, frequent in survivors of stroke. Several studies have evaluated the rate of apathy secondary to stroke and risk factors. Different conclusions and contradictory findings have been published. We aimed to perform a systematic review and meta-analysis of all studies evaluating apathy secondary to stroke to better estimate its rate and risk factors, and explore associations with poorer outcomes.

Methods: We searched PubMed, Cochrane Library, PsychINFO and PsycBITE databases and screened references of included studies and review articles for additional citations. Search results and data extraction was performed independently. We systematically reviewed available publications reporting investigations on ischemic and intracerebral hemorrhagic stroke and apathy. Quality assessment of the studies was performed independently. Subgroup analyses were performed according to stroke phase (acute and post-acute), stroke past history (first-ever and any-stroke) and patient age (younger and older patients). Pooled odds ratios (OR) and standardized mean difference, and 95% confidence intervals (CI), were derived by random-effects meta-analysis. Heterogeneity was assessed with I2 test.

Results: From the initial 1,399 publications, we included 19 studies (2,221 patients). The pooled rate of apathy was 36.3% (95% CI 30.3–42.8; I2 = 46.8), which was similar for acute [39.5% (95% CI 28.9–51.1)] and post-acute phase [34.3% (95% CI 27.8–41.4)], and about three times higher than the rate of depression [12.1% (95% CI 8.2–17.3)]. Apathetic patients were on average 2.74 years older (95% CI 1.25–4.23; I2 = 0%). No gender differences were found. Depression (OR 2.29; 95% CI 1.41–3.72; I2 = 44%) and cognitive impairment (OR 2.90; 95% CI 1.09–7.72; I2 = 14%) were more frequent and severe in apathetic patients. Apathy rate was similar for ischemic and hemorrhagic stroke type and for left- and right-sided hemispheric lesions. Clinical global outcome was similar between apathetic and nonapathetic patients.

Conclusion: Apathy secondary to stroke is a more frequent neuropsychiatric disturbance than depression. Apathetic patients are more frequently and severely depressed and cognitively impaired. A negative impact of apathy secondary to stroke on clinical global outcome cannot be ascribed. Future research should properly address its predictor factors and evaluate the impact of apathy treatment options in stroke patients.

Continue —> Apathy Secondary to Stroke: A Systematic Review and Meta-Analysis – FullText – Cerebrovascular Diseases 2013, Vol. 35, No. 1 – Karger Publishers

Literature search and results (systematic review flow chart).

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[ARTICLE] Rehabilitation for post-stroke cognitive impairment: an overview of recommendations arising from systematic reviews of current evidence


Background: Although cognitive impairments are common following stroke, there is considerable uncertainty about the types of interventions that can reduce activity restrictions and improve quality of life. Indeed, a recent project to identify priorities for research into life after stroke determined that the top priority for patients, carers and health professionals was how to improve cognitive impairments.

Objective: To provide an overview of the evidence for the effectiveness of cognitive rehabilitation for patients with stroke and to determine the main gaps in the current evidence base.

Methods: Evidence was synthesised for the six Cochrane reviews relating to rehabilitation for post-stroke cognitive impairment and any subsequently published randomized controlled trials to February 2012.

Results: Data arising from 44 trials involving over 1500 patients was identified. Though there was support for the effectiveness of cognitive rehabilitation for some cognitive impairments, significant gaps were found in the current evidence base. All of the Cochrane reviews identified major limitations within the evidence they identified.

Conclusions: There is currently insufficient research evidence, or evidence of insufficient quality, to support clear recommendations for clinical practice. Recommendations are made as to the research required to strengthen the evidence base, and so facilitate the delivery of effective interventions to individuals with cognitive impairment after stroke.

via Rehabilitation for post-stroke cognitive impairment: an overview of recommendations arising from systematic reviews of current evidence.

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[THESIS] Bridge/Adapt: A Systematic Cognitive Rehabilitation Curriculum -Full Text PDF


Cognitive impairment, including deficits in memory, attention, visual perception, executive functioning, and self-awareness, is a common consequence of acquired brain injury (ABI). Subsequently, these cognitive impairments result in functional impairments in daily life activities for clients with ABI.

Rehabilitation efforts are categorized under two broad approaches: remediation and adaptation. Computer-assisted cognitive retraining (CACR) is a remediation approach using a computer platform to deliver cognitive exercises. CACR therapy can lead to improvements in memory and attention for adults with chronic ABI. However, memory and attention improvements from CACR may not carry over to functional improvements in occupational performance. Research suggested that therapy using an adaptive approach can yield functional improvements.

The purpose of this project was to design a systematic cognitive retraining curriculum, Bridge/Adapt, to bridge the gap between memory and attention-skill gains from CACR to functional improvements in occupational performance using adaptive strategies. The Bridge/Adapt curriculum incorporates the cognitive orientation of occupational performance (CO-OP) intervention approach, multicontext approach, and goal oriented attentional self-regulation training.

The curriculum includes eight modules that provide grading options so that occupational therapists can choose which difficulty level best suits the client. Clients practice adaptive strategies during simulations of instrumental activities of daily living (IADL), including financial management, appointment scheduling, and grocery shopping, utilizing the three themes in Bridge/Adapt: salience, context, and hierarchy. Clients use salience to choose meaningful goals to work on at home. Context refers to clients working on goals in varying environments. Lastly, clients work on tasks that increase in complexity with the hierarchical theme.

Full Text PDF


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ARTICLE: Effects of Repetitive Transcranial Magnetic Stimulation on Cognitive Impairment in Stroke Patients: A Meta-Analysis – Online First

…Our findings indicate that rTMS may effectively improve cognitive impairment in stroke patients…

via Effects of Repetitive Transcranial Magnetic Stimulation on Cognitive Impairment in Stroke Patients: A Meta-Analysis – Online First – Springer.

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