Each year, emergency departments treat approximately 2.5 million traumatic brain injuries (TBIs) (Langlois, Rutland-Brown, & Thomas, 2006; Marin, Weaver, Yealy, & Mannix, 2014). TBI can affect a wide range of brain systems, resulting in sensorimotor deficits (e.g., coordination, visual perception), cognitive deficits (e.g., memory, attention), emotional dysregulation (e.g., irritability, depression), and somatic symptoms (e.g., headache, fatigue) (Ponsford et al., 2014). These TBI-related impairments can have significant life consequences. Studies conducted across a wide range of neurological and psychiatric conditions show that neuropsychological abilities are strongly associated with functional skills and employment outcomes (Andelic, Stevens, Sigurdardottir, Arango-Lasprilla, & Roe, 2012; Dawson, Schwartz, Winocur, & Stuss, 2007; Drake, Gray, Yoder, Pramuka, & Llewellyn, 2000; Kalechstein, Newton, & van Gorp, 2003; Leahy & Lam, 1998; Wehman, Targett, West, & Kregel, 2005). For example, challenges in attention and concentration could result in distractibility and errors in work settings, and deficits in executive functions could lead to poor organization and problems with setting and achieving occupational goals. As many as 3.2–5.3 million people in the US are living with TBI-related disability (Selassie et al., 2008).
Rehabilitation has been shown to improve outcomes for those experiencing chronic effects of TBI (Cicerone, 2002; Cicerone et al., 2011; Cooper et al., 2017; Kennedy et al., 2008; Rohling, Faust, Beverly, & Demakis, 2009). Previously-validated rehabilitation approaches for TBI include both ‘cognitive’ and ‘functional’ approaches. ‘Cognitive’ methods of rehabilitation are focused on improving performance on individual cognitive tasks, with the hope that these gains will generalize to functional activities (Cicerone, 2002; Giles, 2010). Restorative cognitive training approaches have been shown to improve cognitive functioning across multiple conditions such as schizophrenia, traumatic brain injury, and normal aging (Ball, Edwards, & Ross, 2007; Fisher, Holland, Merzenich, & Vinogradov, 2009; Lebowitz, Dams-O’Connor, & Cantor, 2012; Lovell & Solomon, 2011; Smith et al., 2009). Some of the most promising results to date have been demonstrated for training of attention and working memory, which have been shown to correspond to changes in functional brain activity (Kim et al., 2009). Evidence suggests that the format of therapist-guided rehabilitation is able to harness some of the well-established benefits of the therapeutic relationship, and may be preferable to computer-guided training (Cooper et al., 2017). While there is some evidence indicating that benefits of cognitive remediation extend to untrained tasks, a number of studies have shown that improvements in performance on individual cognitive tasks tend to generalize very weakly, if at all, to other cognitive tasks and functional abilities (Devos et al., 2009; Owen et al., 2010). This weak transfer of training might be attributable to low levels of correspondence between the cognitive and sensorimotor demands of rehabilitation tasks and those encountered during challenging real-world situations.
In contrast to methods of rehabilitation that rely upon generalization of cognitive benefits to functional outcomes, ‘functional’ methods of rehabilitation focus on improving performance on real-life activities through direct practice of those activities (Fadyl & McPherson, 2009; Giles, 2010; Vanderploeg et al., 2008). This approach requires effective targeting of specific functional tasks that are relevant to each patient and may be limited by the physical environments available within the treatment setting (e.g., a simulated home environment used to practice activities of daily living). However, the basic functional tasks that are often emphasized in functional rehabilitation (e.g., self-care, food preparation) may not be sufficiently challenging to address more subtle or ‘higher order’ cognitive and functional deficits that many mild to moderate TBI patients experience in the long-term phase of recovery (Giles, 2010).
Virtual reality (VR) technology may provide an effective means to integrate cognitive and functional approaches to TBI rehabilitation (Imhoff, Lavallière, Teasdale, & Fait, 2016; Lew, Rosen, Thomander, & Poole, 2009). The guiding concept for VR rehabilitation is to provide an immersive, engaging, and realistic environment in which to practice cognitive, sensorimotor, and functional skills. VR scenarios can simulate a wide range of real or imagined tasks and environments. While VR may not be necessary for tasks that are easily recreated in existing therapy environments, it is particularly well-suited for tasks that are challenging or dangerous to recreate within real-world treatment environments, such as driving an automobile (Imhoff et al., 2016; Lew et al., 2009).
Driving is one of the most universal, cognitively challenging, and potentially-dangerous activities of everyday life. Safe driving requires continuous synchronization of processes like reaction time, visuo-spatial skills, attention, executive function, and planning (Lundqvist, 2001; Lundqvist & Rönnberg, 2001; Spiers & Maguire, 2007). Whereas it would be obviously unsafe to place an impaired patient into many real-world driving situations, VR allows for safe assessment and rehabilitation of driving-relevant skills at the true limits of the individual’s current capabilities. Individuals with TBI are at elevated risk for motor vehicle accidents and other driving difficulties (Bivona et al., 2012; Bottari, Lamothe, Gosselin, Gélinas, & Ptito, 2012; Classen et al., 2011; Cyr et al., 2009; Formisano et al., 2005; Lundqvist & Rönnberg, 2001). Many individuals with severe TBI never return to driving (Novack, Alderson, Bush, Meythaler, & Canupp, 2000; Ponsford et al., 2014), and an estimated 63% of those with severe TBI who do return to driving are involved in motor vehicle accidents (Bivona et al., 2012). Available evidence suggests that deficits in attention and visual search may underlie these driving impairments. While most of this research has been conducted with moderate-to-severe TBI populations, these issues are not exclusive to severe forms of TBI. Individuals recovering from mild TBI have also been found to exhibit slower detection of driving hazards in simulated driving experiments (Preece, Horswill, & Geffen, 2010, 2011) and to be at increased risk for real-world motor vehicle accidents (Schneider & Gouvier, 2005).
Previous results suggest that VR driving rehabilitation can be effective for improving driving skills among those with moderate-to-severe TBI (Cox et al., 2010). However, these findings have not been replicated or validated for those with symptomatic mild TBI. Additionally, little is known about the effectiveness of VR rehabilitation programs for TBI-related cognitive deficits (Imhoff et al., 2016). In response to these clinical and research gaps, we developed an intervention known as Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE), which was designed to improve cognitive performance and overall driving safety by providing integrated training in these skills. In contrast to intervention approaches that are geared toward more severely impaired individuals, NeuroDRIVE was designed for use with a wide range of TBI patients (i.e., mild, moderate, or severe TBI) who are seeking treatment in these areas and have the capability to engage in the driving process. This pilot clinical trial examined feasibility and preliminary efficacy of NeuroDRIVE for improving VR driving performance, cognitive performance, and symptom outcomes among those with chronic TBI. Given the focus of the intervention, effects on attention and working memory were of particular interest. Additionally, we have provided the NeuroDRIVE treatment manual as a supplementary document to facilitate continued development of VR rehabilitation for those with TBI.