Now we just need researchers to fill out that objective and quantitative framework with EXACT PROTOCOLS, and we can finally get somewhere. But since nothing will be done, you're screwed and you'll just have to start guessing on what you need to do to recover your lost 5 cognitive years from the stroke, because your doctor knows nothing and will do nothing. Guidelines don't count, they are practically useless.
A comparison of two personalization and adaptive cognitive rehabilitation approaches: a randomized controlled trial with chronic stroke patients
Abstract
Background
Paper-and-pencil tasks are still widely used for cognitive rehabilitation despite the proliferation of new computer-based methods, like VR-based simulations of ADL’s. Studies have established construct validity of VR assessment tools with their paper-and-pencil version by demonstrating significant associations with their traditional construct-driven measures. However, VR rehabilitation intervention tools are mostly developed to include mechanisms such as personalization and adaptation, elements that are disregarded in their paper-and-pencil counterparts, which is a strong limitation of comparison studies. Here we compare the clinical impact of a personalized and adapted paper-and-pencil training and a content equivalent and more ecologically valid VR-based ADL’s simulation.Methods
We have performed a trial with 36 stroke patients comparing Reh@City v2.0 (adaptive cognitive training through everyday tasks VR simulations) with Task Generator (TG: content equivalent and adaptive paper-and-pencil training). The intervention comprised 12 sessions, with a neuropsychological assessment pre, post-intervention and follow-up, having as primary outcomes: general cognitive functioning (assessed by the Montreal Cognitive Assessment - MoCA), attention, memory, executive functions and language specific domains.Results
A within-group analysis revealed that the Reh@City v2.0 improved general cognitive functioning, attention, visuospatial ability and executive functions. These improvements generalized to verbal memory, processing speed and self-perceived cognitive deficits specific assessments. TG only improved in orientation domain on the MoCA, and specific processing speed and verbal memory outcomes. However, at follow-up, processing speed and verbal memory improvements were maintained, and a new one was revealed in language. A between-groups analysis revealed Reh@City v2.0 superiority in general cognitive functioning, visuospatial ability, and executive functions on the MoCA.Conclusions
The Reh@City v2.0 intervention with higher ecological validity revealed higher effectiveness with improvements in different cognitive domains and self-perceived cognitive deficits in everyday life, and the TG intervention retained fewer cognitive gains for longer.Trial registration
The trial is registered at ClinicalTrials.gov, number NCT02857803. Registered 5 August 2016, .Background
Cognitive rehabilitation after stroke
Stroke is a leading cause of long-term acquired disability in adults [1], predisposing patients toward institutionalization and poorer quality of life [2]. Over the coming decades, the incidence of post-stroke disability is expected to increase by 35% due to the rising prevalence of cerebrovascular risk and advances in medicine which are reducing post-stroke mortality rates [3]. Historically, stroke rehabilitation has been focused on motor rehabilitation [4, 5]. However, post-stroke cognitive deficits are pervasive causing disability with major impacts on quality of life and independence on everyday life activities [6, 7]. In the last years, attention to the impact of cognitive deficits has been growing [8] and finding new ways to improve cognition after stroke is considered a priority [9]. Also, more recently, the International Stroke Recovery and Rehabilitation Alliance 2018 working group has identified post-stroke cognitive impairments as a research priority [10].Regardless of the many new developments in cognitive rehabilitation programs and applications, limited data on the effectiveness of cognitive rehabilitation is available because of the heterogeneity of participants, interventions, and outcome measures [11]. Results from recent reviews corroborate that cognitive rehabilitation has a positive impact on post-stroke cognitive outcomes [12, 13], although of small magnitude (Hedges’ g = 0.48) [12]. This result is in line with the quantitative [14] and qualitative [15,16,17] findings of previous reviews that have analyzed the effect of cognitive rehabilitation across multiple cognitive domains.
Is cognitive rehabilitation’s impact small or are we missing better cognitive rehabilitation methodologies?
Paper-and-pencil tasks are still the most widely used methods for cognitive rehabilitation because of their accessibility, ease of use, clinical validity and reduced cost [18]. In the last years, computer-based versions of these traditional tasks are also starting to become clinically accepted [19, 20]. However, there is an absence of specific methodologies that inform health professionals which tasks to apply and under what clinical conditions [21]. Consequently, rehabilitation professionals perform a selection of tasks based on their clinical experience, missing scientific foundations [22]. We have proposed an objective and quantitative framework for the creation of personalized cognitive rehabilitation tasks based on a participatory design strategy with health professionals [23]. In this work, through computational modeling, the authors operationalized 11 paper-and-pencil tasks and developed an Information and Communication Technologies based tool - the Task Generator (TG) - to tailor each of those 11 paper-and-pencil tasks to each patient in the domains of attention, memory, language and executive functions. A clinical evaluation of the TG with twenty stroke patients showed that the TG is able to adapt task parameters and difficulty levels according to patient’s cognitive assessment, and provide a comprehensive cognitive training [24]. However, although it has been shown that rehabilitation strategies based on paper-and-pencil tasks can be personalized and adapted [24, 25], this approach presents a limited transfer to performance in activities of daily living (ADL) [18].Over the last years, rehabilitation methodologies based on virtual reality (VR) have been developed as promising solutions to improve cognitive functions [26, 27]. VR-based tools have shown potential and to be ideal environments to incorporate cognitive tasks within the simulation of ADL’s [28]. A recent trial with a VR-based simulation of everyday life activities (like going to the pharmacy, buying grocery at the supermarket, paying the water bill) suggested that an ecologically valid intervention has more impact than conventional methods (cognitive training using puzzles, calculus, problem resolution and shape sorting) in cognitive rehabilitation of stroke patients [29]. Also, some of these VR-based systems allow the integration of motor training [30] and recent studies have already shown benefits of performing simultaneous motor and cognitive training with stroke patients using VR [31, 32]. Yet, there is still an insufficient number of rigorous trials to clinically validate VR methods [12] and there are difficulties associated with the limited access which results in a low adoption by health professionals who still prefer mostly use paper-and-pencil interventions [33].
In general, existing ecologically-valid VR-based environments are simulations of cities [29, 34,35,36,37,38], kitchens [39,40,41,42,43,44,45], streets [46,47,48,49,50,51], supermarkets [52,53,54,55,56], malls and other shopping scenarios [57,58,59,60,61]. Of these, only rare cases take into account training personalization according to patient cognitive profile and session-to-session adaptation [29, 36, 38, 41]. Additionally, the results of studies comparing VR cognitive interventions with standard occupational therapy or neuropsychology cognitive paper-and-pencil training are fundamentally subjective as control interventions. OT does not consider cognition as the main training focus, and neuropsychology paper-and-pencil training tasks are too similar to the cognitive assessment scales; additionally, both approaches do not incorporate personalization and dynamic adaptation to performance. Hence, even if rehabilitation sessions last the same, these interventions are not equivalent as they are delivered with uncontrolled difficulty levels and cognitive demands. Personalized rehabilitation is defined as involving an assessment of each patient’s impairments and performing a tailored intervention to his cognitive profile in the different domains. Instead, adaptation deals with the dynamic adjustment of the tasks’ cognitive demands according to the patients’ performance along the intervention sessions, therefore avoiding boredom (tasks that are to easy to solve) or frustration (tasks that are too difficult to solve).
Here we try to address some of the existing limitations in the validation of VR-based cognitive rehabilitation tools. In this study we compared two task content equivalent rehabilitation tools developed under the same personalization and adaptation framework [23]: the TG and the Reh@City v2.0. This framework allows us to make sure that both tools deliver the same controlled adaptation and personalization of difficulty levels, and address the same cognitive demands. Hence, this comparison allows identifying the specific impact of increasing ecological validity of training through VR simulations of ADLs over the same training delivered through clinically accepted paper-and-pencil equivalent tasks. These findings will further inform on the specific benefits of ecologically valid environments delivered though VR and encourage the adoption of these technologies by health professionals.
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