Multimodal immersive trail making-virtual reality paradigm to study cognitive-motor interactions

Sounds like a replacement for real world cognitive solving. One of my therapists tried to get me to do some work problems. Not possible since I was on 6 month medical leave and at that time had no remote access. 

Multimodal immersive trail making-virtual reality paradigm to study cognitive-motor interactions

• Meir Plotnik,
• Oran Ben-Gal,
• Glen M. Doniger,
• Amihai Gottlieb,
• Yotam Bahat,
• Maya Cohen,
• Shani Kimel-Naor,
• Gabi Zeilig &
• Michal Schnaider Beeri 

Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 82 (2021) Cite this article

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Abstract

Background

Neuropsychological tests of executive function have limited real-world predictive and functional relevance. An emerging solution for this limitation is to adapt the tests for implementation in virtual reality (VR). We thus developed two VR-based versions of the classic Color-Trails Test (CTT), a well-validated pencil-and-paper executive function test assessing sustained (Trails A) and divided (Trails B) attention—one for a large-scale VR system (DOME-CTT) and the other for a portable head-mount display VR system (HMD-CTT). We then evaluated construct validity, test–retest reliability, and age-related discriminant validity of the VR-based versions and explored effects on motor function.

Methods

Healthy adults (n = 147) in three age groups (young: n = 50; middle-aged: n = 80; older: n = 17) participated. All participants were administered the original CTT, some completing the DOME-CTT (14 young, 29 middle-aged) and the rest completing the HMD-CTT. Primary outcomes were Trails A and B completion times (t_A, t_B). Spatiotemporal characteristics of upper-limb reaching movements during VR test performance were reconstructed from motion capture data. Statistics included correlations and repeated measures analysis of variance.

Results

Construct validity was substantiated by moderate correlations between the’gold standard’ pencil-and-paper CTT and the VR adaptations (DOME-CTT: t_A 0.58, t_B 0.71; HMD-CTT: t_A 0.62, t_B 0.69). VR versions showed relatively high test–retest reliability (intraclass correlation; VR: t_A 0.60–0.75, t_B 0.59–0.89; original: t_A 0.75–0.85, t_B 0.77–0.80) and discriminant validity (area under the curve; VR: t_A 0.70–0.92, t_B 0.71–0.92; original: t_A 0.73–0.95, t_B 0.77–0.95). VR completion times were longer than for the original pencil-and-paper test; completion times were longer with advanced age. Compared with Trails A, Trails B target-to-target VR hand trajectories were characterized by delayed, more erratic acceleration and deceleration, consistent with the greater executive function demands of divided vs. sustained attention; acceleration onset later for older participants.

Conclusions

The present study demonstrates the feasibility and validity of converting a neuropsychological test from two-dimensional pencil-and-paper to three-dimensional VR-based format while preserving core neuropsychological task features. Findings on the spatiotemporal morphology of motor planning/execution during the cognitive tasks may lead to multimodal analysis methods that enrich the ecological validity of VR-based neuropsychological testing, representing a novel paradigm for studying cognitive-motor interactions.

Background

The term “executive functions” is an umbrella term for a wide range of cognitive processes and behavioral competencies necessary for the cognitive control of behavior including problem solving, planning, sequencing, sustained attention, utilization of feedback, and multitasking [1]. Neuropsychological tests of executive functions aim to assess these processes [2]. Accordingly, performance on these tests is assumed indicative of executive functioning in everyday living [3]. One of the limitations of these tests relates to their low ‘ecological validity’, namely the uncertainty about how closely they reflect capacity of executive function in real life [4,5,6]. In this regard, Burgess et al. [7] has claimed that “the majority of neuropsychological assessments currently in use were developed to assess 'cognitive constructs' without regard for their ability to predict 'functional behavior'."

Neuropsychological assessment in virtual reality (VR)

Early discussions of ecological validity in neuropsychology emphasized that the technologies available at that time could not replicate the setting in which the behavior of interest actually occurs [8]. Furthermore, currently, most neuropsychological assessments still use outdated methods (e.g., pencil-and-paper administration; static stimuli) that have yet to be validated with respect to real-world functioning [9].

To overcome this limitation, testing participants in real word situations (e.g., the Multiple Errands Test [MET] [10]) has been considered an ecologically valid and advantageous alternative to traditional tests [11]. However, this approach is logistically challenging, requiring travel to a naturalistic testing site [12].

In an attempt to overcome this logistical hurdle, the Virtual Errands Test (VET) was devised by McGeorge et al. [13] as an adaptation of the MET for VR-based administration. Still, this test, and similar VR variants, are limited in their ability to distinguish between healthy and clinical cohorts (see [11] for a review) and to yield performance on the virtual tasks similar to performance in the real world (e.g., [14, 15]). Further, most VR-based tests like VET involve presenting a simulated VR environment on a standard computer screen (e.g., Elkind et al. [16]), which may lead to a non-immersive experience, thus paradoxically compromising rather than enhancing ecological validity.

Notably, VR-based tests simulating shopping tasks for the assessment of executive function have demonstrated good ecological validity [17, 18]. However, the approach of adapting executive function testing for the VR environment has not been widely accepted in both research and clinical contexts.

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