Benefits of virtual reality based cognitive rehabilitation through simulated activities of daily living: a randomized controlled trial with stroke patients

When will your hospital get this for stroke rehab? I'm guessing never unless YOU call the board of directors and ask why such fucking incompetency is allowed in their hospital. Yes, use the word incompetency!!!
http://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0204-z

• Ana Lúcia Faria†Email authorView ORCID ID profile,
• Andreia Andrade†,
• Luísa Soares and
• Sergi Bermúdez i Badia

†Contributed equally

Journal of NeuroEngineering and Rehabilitation201613:96

DOI: 10.1186/s12984-016-0204-z

©  The Author(s). 2016

Received: 4 November 2015

Accepted: 25 October 2016

Published: 2 November 2016

Abstract

Background

Stroke is one of the most common causes of acquired disability, leaving numerous adults with cognitive and motor impairments, and affecting patients’ capability to live independently. There is substancial evidence on post-stroke cognitive rehabilitation benefits, but its implementation is generally limited by the use of paper-and-pencil methods, insufficient personalization, and suboptimal intensity. Virtual reality tools have shown potential for improving cognitive rehabilitation by supporting carefully personalized, ecologically valid tasks through accessible technologies. Notwithstanding important progress in VR-based cognitive rehabilitation systems, specially with Activities of Daily Living (ADL’s) simulations, there is still a need of more clinical trials for its validation. In this work we present a one-month randomized controlled trial with 18 stroke in and outpatients from two rehabilitation units: 9 performing a VR-based intervention and 9 performing conventional rehabilitation.

Methods

The VR-based intervention involved a virtual simulation of a city – Reh@City - where memory, attention, visuo-spatial abilities and executive functions tasks are integrated in the performance of several daily routines. The intervention had levels of difficulty progression through a method of fading cues. There was a pre and post-intervention assessment in both groups with the Addenbrooke Cognitive Examination (primary outcome) and the Trail Making Test A and B, Picture Arrangement from WAIS III and Stroke Impact Scale 3.0 (secondary outcomes).

Results

A within groups analysis revealed significant improvements in global cognitive functioning, attention, memory, visuo-spatial abilities, executive functions, emotion and overall recovery in the VR group. The control group only improved in self-reported memory and social participation. A between groups analysis, showed significantly greater improvements in global cognitive functioning, attention and executive functions when comparing VR to conventional therapy.

Conclusions

Our results suggest that cognitive rehabilitation through the Reh@City, an ecologically valid VR system for the training of ADL’s, has more impact than conventional methods.

Trial registration

This trial was not registered because it is a small sample study that evaluates the clinical validity of a prototype virtual reality system.

Keywords

Cognitive rehabilitation Virtual reality Ecological validity Stroke

Background

In most countries, stroke is among most common causes of death and one of the main causes of acquired adult disability [1]. Because most patients with stroke survive the initial illness, the greatest impact is usually caused by the long term consequences for patients and their families [2]. It is estimated that 33 to 42 % of stroke survivors require assistance for daily living activities three to six months post stroke, and of these, 36 % continue to be disabled five years later [3, 4]. Although remarkable developments have been made in the medical treatment of stroke, it continues to heavily rely on rehabilitation interventions. In addition to motor disabilities, more than 40 % of stroke survivors are left with cognitive impairment after the event and almost two thirds are affected by mild cognitive impairment, and therefore are at risk of developing dementia [5]. Besides having a direct influence on the quality of life of patients and their caregivers, cognitive impairment after stroke is also associated with higher mortality [6] and greater rates of institutionalization [7]. Cognition is important for overall recovery since its impairment reduces a person’s ability to plan and initiate self-directed activities, to solve problems, to sustain and divide attention, to memorize information and to understand task instructions. It has been shown that recovery of cognitive function of stroke patients in inpatient rehabilitation is directly related to their level of participation in rehabilitation activities [8]. Thus, reducing the impact of post stroke cognitive impairment through appropriate rehabilitation programs is an essential goal.

Current cognitive rehabilitation practice tends to be directed towards isolated cognitive domains including attention (focusing, shifting, dividing or sustaining), executive functions (planning, inhibition, control), visuo-spatial ability (visual search, drawing, construction), memory (recall and recognition of visual and verbal information) and language (expressive and receptive) [9]. Although there is evidence on the efficacy of current methods [10], an important concern is how effectively the improvements of these abilities that are trained separately generalize, leading to sustained improvement in everyday functioning [11, 12]. When we consider the cognitive domains required for activities of daily living (ADL’s) such as a successful meal preparation – the patient must define a menu, identify the needed ingredients, write a shopping list, organize the time for shopping and preparing the meal – we acknowledge that multiple dimensions of cognition are engaged and, thereby, suggesting that need to be rehabilitated as a whole as opposed to independently [13]. Unfortunately, there is insufficient evidence to determine if and how the ecological validity of current cognitive rehabilitation methods impacts recovery [14, 15].

Current cognitive rehabilitation methodologies suffer other limitations besides the generalization of improvements to functional activities, social participation and life satisfaction. For instance, it is known that an intensive and individualized training is preferable [16]. Personalized rehabilitation involves an assessment of each patient’s impairments, a definition of attainable goals for improvement, an intervention to assist in the achievement of goals and, finally, a reassessment to measure improvements [2]. However, in-depth patient assessment is expensive and time consuming, and currently impracticable due to the scarcity of professionals and resources, resulting in a suboptimal intensity, personalization and duration of rehabilitation interventions [17]. Further, although there is growing evidence that patients may achieve improvements on functional tasks even many months after having a stroke [18], most rehabilitation therapies are only guaranteed within three to 6 months post stroke [19]. Additionally, a James Lind Alliance study [20] interviewed 799 chronic stroke patients who reported that cognitive problems had not been addressed appropriately, especially when compared with mobility, confirming that it is essential to find adaptable and accessible tools that can be used frequently and intensively by patients at the clinic or at home after discharge, in order to maximize rehabilitation outcomes. Caregivers and health professionals were also interviewed and indicated that investigating ways to improve cognition after stroke should be a research priority [21].

Virtual Reality (VR) and interactive technologies have emerged as a valuable approach in stroke rehabilitation by providing the opportunity to practice cognitive and motor activities that are not or cannot be usually practiced within the clinical environment, such as training attention abilities in street crossing situations [22], executive functions by visiting a supermarket [23], or performing simulations of real-life scenarios and activities in urban virtual environments [24, 25]. Yet, the advantages of VR to address stroke impairments go beyond ecological validity of training, with a growing body of evidence especially in the motor rehabilitation domain [26]. Virtual environments are designed to be more enjoyable than conventional rehabilitation methods. The introduction of gaming elements and immediate feedback on performance enhance motivation, thereby encouraging higher numbers of repetitions [27]. Additionally, it enables the systematic presentation of stimulus and challenges in a hierarchical fashion, which can be varied from simple to complex upon success [28], making it progressively challenging according to patients abilities. Further, when stroke survivors suffer of hemiparesis in their dominant arm, this interferes with their ability to perform paper-and-pencil tasks, which in turn may impede cognitive training. Thus, another central advantage of VR is the possibility to be integrated with accessible interfaces such as adapted joysticks, natural user interfaces or robotic systems [29].