Virtual reality gaming as a neurorehabilitation tool for brain injuries in adults: A systematic review

Social deficits mirror delayed cerebrovascular dysfunction after traumatic brain injury

Traumatic brain injury (TBI) survivors face debilitating long-term psychosocial consequences, including social isolation and depression. TBI modifies neurovascular physiology and behavior but the chronic physiological implications of altered brain perfusion on social interactions are unknown. Adult C57/BL6 male mice received a moderate cortical TBI, and social behaviors were assessed at baseline, 3-, 7-, 14-, 30-, and 60-days post injury (dpi). Magnetic resonance imaging (MRI, 9.4T) using dynamic susceptibility contrast perfusion weighted MRI were acquired. At 60dpi mice underwent histological angioarchitectural mapping. Analysis utilized standardized protocols followed by cross-correlation metrics. Social behavior deficits at 60dpi emerged as reduced interactions with a familiar cage-mate (partner) that mirrored significant reductions in cerebral blood flow (CBF) at 60dpi. CBF perturbations were dynamic temporally and across brain regions including regions known to regulate social behavior such as hippocampus, hypothalamus, and rhinal cortex. Social isolation in TBI-mice emerged with a significant decline in preference to spend time with a cage mate. Cortical vascular density was also reduced corroborating the decline in brain perfusion and social interactions. Thus, the late emergence of social interaction deficits mirrored the reduced vascular density and CBF in regions known to be involved in social behaviors. Vascular morphology and function improved prior to the late decrements in social function and our correlations strongly implicate a linkage between vascular density, cerebral perfusion, and social interactions. Our study provides a clinically relevant timeline of alterations in social deficits alongside functional vascular recovery that can guide future therapeutics.

Applicability of artificial intelligence in neuropsychological rehabilitation of patients with brain injury

Neuropsychological rehabilitation plays a critical role in helping those recovering from brain injuries restore cognitive and functional abilities. Artificial Intelligence, with its potential, may revolutionize this field further; therefore, this article explores applications of AI for neuropsychological rehabilitation of patients suffering brain injuries. This study employs a systematic review methodology to comprehensively review existing literature regarding Artificial Intelligence use in neuropsychological rehabilitation for people with brain injuries. The systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of electronic databases (PubMed, Scopus, PsycINFO, etc.) showed a total of 212 potentially relevant articles. After removing duplicates and screening titles and abstracts, 186 articles were selected for assessment. Following the assessment, 55 articles met the inclusion criteria and were included in this systematic review. A thematic analysis approach is employed to analyze and synthesize the extracted data. Themes, patterns, and trends are identified across the included studies, allowing for a comprehensive understanding of the applicability of AI in neuropsychological rehabilitation for patients with brain injuries. The identified topics were: AI Applications in Diagnostics of Brain Injuries and their Neuropsychological Repercussions; AI in Personalization and Monitoring of Neuropsychological Rehabilitation for traumatic brain injury (TBI); Leveraging AI for Predicting and Optimizing Neuropsychological Rehabilitation Outcomes in TBI Patients. Based on the review, it was concluded that AI has the potential to enhance neuropsychological rehabilitation for patients with brain injuries. By leveraging AI techniques, personalized rehabilitation programs can be developed, treatment outcomes can be predicted, and interventions can be optimized.

Virtual reality-based training may improve visual memory and some aspects of sustained attention among healthy older adults - preliminary results of a randomized controlled study

BACKGROUND/AIMS

Older age and cognitive inactivity have been associated with cognitive impairment, which in turn is linked to economic and societal burdens due to the high costs of care, especially for care homes and informal care. Emerging non-pharmacological interventions using new technologies, such as virtual reality (VR) delivered on a head-mounted display (HMD), might offer an alternative to maintain or improve cognition. The study aimed to evaluate the efficacy and safety of a VR-based Digital Therapeutics application for improving cognitive functions among healthy older adults.

METHODS

Seventy-two healthy seniors (experimental group N = 35, control group N = 37), aged 65-85 years, were recruited by the Medical University of Lodz (Poland). Participants were randomly allocated to the experimental group (a VR-based cognitive training which consists of a warm-up module and three tasks, including one-back and dual-N-back) or to the control group (a regular VR headset app only showing nature videos). The exercises are performed in different 360-degree natural environments while listening to a preferred music genre and delivered on a head-mounted display (HMD). The 12-week intervention of 12 min was delivered at least three times per week (36 sessions). Compliance and performance were followed through a web-based application. Primary outcomes included attention and working memory (CNS-Vital Signs computerized cognitive battery). Secondary outcomes comprised other cognitive domains. Mixed linear models were constructed to elucidate the difference in pre- and post-intervention measures between the experimental and control groups.

RESULTS

The users performed, on average, 39.8 sessions (range 1-100), and 60% performed more than 36 sessions. The experimental group achieved higher scores in the visual memory module (B = 7.767, p = 0.011) and in the one-back continuous performance test (in terms of correct responses: B = 2.057, p = 0.003 and omission errors: B = -1.950, p = 0.007) than the control group in the post-test assessment. The results were independent of participants' sex, age, and years of education. The differences in CNS Vital Signs' global score, working memory, executive function, reaction time, processing speed, simple and complex attention, verbal memory, cognitive flexibility, motor speed, and psychomotor speed were not statistically significant.

CONCLUSIONS

VR-based cognitive training may prove to be a valuable, efficacious, and well-received tool in terms of improving visual memory and some aspect of sustainability of attention among healthy older adults. This is a preliminary analysis based on part of the obtained results to that point. Final conclusions will be drawn after the analysis of the target sample size.

TRIAL REGISTRATION

Clinicaltrials.gov ID NCT05369897.

Impact of Mobile Games-Aided Neurorehabilitation: A Systematic Literature Review

Neurological rehabilitation is a physician-supervised programme for individuals with nervous system diseases, injuries or disorders. Neurological rehabilitation, also known as neurorehabilitation, is part of the rehabilitation process that improves function, reduces severity and enhances a patient's well-being. Because neurological injuries occur in the brain, spine and nerves, affecting multiple body parts including organs, blood vessels, muscles and bones, rehabilitation requires a multidisciplinary approach. This study conducted a systematic literature review (SLR) on the use of mobile game in neurorehabilitation. The steps undertaken in the literature review included the collection, identification, categorisation, summarisation and synthesis of relevant studies in the research domain. A total of 50 related articles were reviewed. The study identified that the effects on cognitive skills, handgrip strength, memory, attention, visuospatial abilities, executive function tasks, motor functionality, and improvements in balance, visual perception, and functional mobility are impacts of the use of mobile games in neurological rehabilitation. Furthermore, several research challenges and recommendations for future research were identified.

Challenges and promises of mixed-reality interventions in acquired brain injury rehabilitation: A scoping review

BACKGROUND

Acquired brain injury (ABI) can lead to significant impairments and difficulties in everyday life, necessitating the need for rehabilitation. Mixed-reality (MR) technologies have revolutionized the delivery of neurorehabilitation therapies. However, inconsistencies in research methodology, diverse study populations and designs, and exaggerated claims in the research, media, and private consumer sectors have impacted the knowledge base of the field, including within the context of ABI rehabilitation.

OBJECTIVE

This scoping review aims to explore MR-systems in ABI rehabilitation, while assessing the evidence base and technology readiness levels of these systems.

METHODS

Seven databases were searched for studies, which were screened and analyzed by two independent raters. The types of MR systems, levels of evidence, and technology readiness levels were extracted and analyzed using descriptive analyses.

RESULTS

Twenty-six studies were included in the review, all of which focused on ABI etiologies stemming from strokes. Across studies, upper-limb motor rehabilitation was the most common rehabilitation target of MR interventions, followed by gait, cognition, and lower-extremity functioning. At present, overall results indicate low evidence for MR-applications in ABI rehabilitation, with a median technology readiness level of 6, corresponding to system prototypes being tested in relevant environments.

CONCLUSION

Although challenges regarding system usability and design were reported, results appear promising with ongoing research. With variability across studies, technologies, and populations, determining the effectiveness of MR interventions in ABI remains a challenge, necessitating the need for ongoing innovation, research, and development of these systems.

Proposal of neural network model for neurocognitive rehabilitation and its comparison with fuzzy expert system model

This article focuses on the development of algorithms for a smart neurorehabilitation system, whose core is made up of artificial neural networks. The authors of the article have proposed a completely unique transfer of ACE-R results to the CHC model. This unique approach allows for the saturation of the CHC model domains according to modified ACE-R factor analysis. The outputs of the proposed algorithm thus enable the automatic creation of a personalized and optimized neurorehabilitation plan for individual patients to train their cognitive functions. A set of tasks in 6 levels of difficulty (level 1 to level 6) was designed for each of the nine CHC model domains. For each patient, the results of the ACE-R screening helped deter-mine the specific CHC domains to be rehabilitated, as well as the initial gaming level for rehabilitation in each domain. The proposed artificial neural network algorithm was adapted to real data from 703 patients. Experimental outputs were compared to the outputs of the initially designed fuzzy expert system, which was trained on the same real data, and all outputs from both systems were statistically evaluated against expert conclusions that were available. It is evident from the conducted experimental study that the smart neurorehabilitation system using artificial neural networks achieved significantly better results than the neurorehabilitation system whose core is a fuzzy expert system. Both algorithms are implemented into a comprehensive neurorehabilitation portal (Eddie), which was supported by a research project from the Technology Agency of the Czech Republic.

Adjunctive virtual reality pain relief after traumatic injury: a proof-of-concept within-person randomized trial

ABSTRACT

In this study, we hypothesized that immersive virtual reality (VR) environments may reduce pain in patients with acute traumatic injuries, including traumatic brain injuries. We performed a randomized within-subject study in patients hospitalized with acute traumatic injuries, including traumatic brain injury with moderate pain (numeric pain score ≥3 of 10). We compared 3 conditions: (1) an immersive VR environment (VR Blu), (2) a content control with the identical environment delivered through nonimmersive tablet computer (Tablet Blu), and (3) a second control composed of donning VR headgear without content to control for placebo effects and sensory deprivation (VR Blank). We enrolled 60 patients, and 48 patients completed all 3 conditions. Objective and subjective data were analyzed using linear mixed-effects models. Controlling for demographics, baseline pain, and injury severity, we found differences by conditions in relieving pain (F 2,75.43 = 3.32, P = 0.042). VR Blu pain reduction was greater than Tablet Blu (-0.92 vs -0.16, P = 0.043), but VR Blu pain reduction was similar to VR Blank (-0.92 vs -1.24, P = 0.241). VR Blu was perceived as most effective by patients for pain reduction (F 2,66.84 = 16.28, P < 0.001), and changes in measures of parasympathetic activity including heart rate variability (F 2,55.511 = 7.87, P < 0.001) and pupillary maximum constriction velocity (F 2,61.41 = 3.50, 1-tailed P = 0.038) echoed these effects. There were no effects on opioid usage. These findings outlined a potential clinical benefit for mollifying pain related to traumatic injuries.

Acceptance and use of virtual reality games: an extension of HMSAM

Virtual reality (VR) is considered as one of the technological megatrends of 2020s, and today, VR systems are used in various settings, digital gaming being among the most popular ones. However, there has been a dearth of understanding regarding the central factors behind VR gaming acceptance and use. The present study therefore aimed to explain the factors that drive the use and acceptance of VR games. We extended the hedonic-motivation system acceptance model with utilitarian and inconvenience factors to capture the pertinent features of VR systems more holistically. We proposed a theoretical model and analyzed it through covariance-based structural equation modeling using an online survey sample of 473 VR gamers. Our findings help explain the role of different antecedents behind VR gaming acceptance and demonstrate that VR gaming is driven more by the hedonic gaming aspects than by the utilitarian health and well-being aspects of VR games, enjoyment being the strongest driver behind VR gaming intention and immersion. Moreover, findings also suggested that use intentions and immersion levels are not significantly diminished by physical discomfort and VR sickness. The findings, which potentially extend to other VR systems as well, also pose important implications for the providers of VR games. As the main contribution, based on our empirical findings, we provide a greater theoretical understanding on VR gaming acceptance and use.

Innovative Technologies in the Neurorehabilitation of Traumatic Brain Injury: A Systematic Review

Motor and cognitive rehabilitation in individuals with traumatic brain injury (TBI) is a growing field of clinical and research interest. In fact, novel rehabilitative approaches allow a very early verticalization and gait training through robotic devices and other innovative tools boosting neuroplasticity, thanks to the high-intensity, repetitive and task-oriented training. In the same way, cognitive rehabilitation is also evolving towards advanced interventions using virtual reality (VR), computer-based approaches, telerehabilitation and neuromodulation devices. This review aimed to systematically investigate the existing evidence concerning the role of innovative technologies in the motor and cognitive neurorehabilitation of TBI patients. We searched and reviewed the studies published in the Cochrane Library, PEDro, PubMed and Scopus between January 2012 and September 2022. After an accurate screening, only 29 papers were included in this review. This systematic review has demonstrated the beneficial role of innovative technologies when applied to cognitive rehabilitation in patients with TBI, while evidence of their effect on motor rehabilitation in this patient population is poor and still controversial.

Virtual Reality and Lower Limb Rehabilitation: Effects on Motor and Cognitive Outcome-A Crossover Pilot Study

The effectiveness of virtual reality (VR) in the motor and cognitive rehabilitation of patients with severe acquired brain injury (sABI) is unclear. This randomized, controlled, crossover, single-blinded, pilot study investigates the cognitive and motor effects of lower limb robotic therapy with and without VR visual feedback in a group of patients with ABI. A total of 23 patients with ABI were randomized into two groups: one group (VR-NVR) underwent a 2-week rehabilitation for the lower limbs training with a robotic device (Omego^®) with VR feedback, followed by 2 weeks without VR; the other group (NVR-VR) performed the protocol in the opposite order. Patients were evaluated at baseline, after two and four weeks of treatment using the Level of Cognitive Functioning scale (LCF), Disability Rating Scale (DRS), and Motricity Index for Lower Limb (MI-LL) in the most affected limb. At the end of the intervention, both groups significantly improved in all the outcomes. A significant difference was found between VR treatment versus non-VR treatment for LCF (p = 0.024) and for DRS (p = 0.043) after the second week, while no significant differences were found in the group NVR-VR at T1. Our study indicates how the combination of robotic treatment with VR is effective in enhancing the recovery of cognitive function in patients with ABI, also improving disability and muscular function. Further, VR seems to enhance the early recovery process of motor and cognitive functions.

Recommendations for the Design and Implementation of Virtual Reality for Acquired Brain Injury Rehabilitation: Systematic Review

BACKGROUND

Virtual reality (VR) is increasingly being used for the assessment and treatment of impairments arising from acquired brain injuries (ABIs) due to perceived benefits over traditional methods. However, no tailored options exist for the design and implementation of VR for ABI rehabilitation and, more specifically, traumatic brain injury (TBI) rehabilitation. In addition, the evidence base lacks systematic reviews of immersive VR use for TBI rehabilitation. Recommendations for this population are important because of the many complex and diverse impairments that individuals can experience.

OBJECTIVE

This study aims to conduct a two-part systematic review to identify and synthesize existing recommendations for designing and implementing therapeutic VR for ABI rehabilitation, including TBI, and to identify current evidence for using immersive VR for TBI assessment and treatment and to map the degree to which this literature includes recommendations for VR design and implementation.

METHODS

This review was guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A comprehensive search of 11 databases and gray literature was conducted in August 2019 and repeated in June 2020. Studies were included if they met relevant search terms, were peer-reviewed, were written in English, and were published between 2009 and 2020. Studies were reviewed to determine the level of evidence and methodological quality. For the first part, qualitative data were synthesized and categorized via meta-synthesis. For the second part, findings were analyzed and synthesized descriptively owing to the heterogeneity of data extracted from the included studies.

RESULTS

In the first part, a total of 14 papers met the inclusion criteria. Recommendations for VR design and implementation were not specific to TBI but rather to stroke or ABI rehabilitation more broadly. The synthesis and analysis of data resulted in three key phases and nine categories of recommendations for designing and implementing VR for ABI rehabilitation. In the second part, 5 studies met the inclusion criteria. A total of 2 studies reported on VR for assessment and three for treatment. Studies were varied in terms of therapeutic targets, VR tasks, and outcome measures. VR was used to assess or treat impairments in cognition, balance, and anxiety, with positive outcomes. However, the levels of evidence, methodological quality, and inclusion of recommendations for VR design and implementation were poor.

CONCLUSIONS

There is limited research on the use of immersive VR for TBI rehabilitation. Few studies have been conducted, and there is limited inclusion of recommendations for therapeutic VR design and implementation. Future research in ABI rehabilitation should consider a stepwise approach to VR development, from early co-design studies with end users to larger controlled trials. A list of recommendations is offered to provide guidance and a more consistent model to advance clinical research in this area.

Virtual Reality for Neurorehabilitation and Cognitive Enhancement

Our access to computer-generated worlds changes the way we feel, how we think, and how we solve problems. In this review, we explore the utility of different types of virtual reality, immersive or non-immersive, for providing controllable, safe environments that enable individual training, neurorehabilitation, or even replacement of lost functions. The neurobiological effects of virtual reality on neuronal plasticity have been shown to result in increased cortical gray matter volumes, higher concentration of electroencephalographic beta-waves, and enhanced cognitive performance. Clinical application of virtual reality is aided by innovative brain–computer interfaces, which allow direct tapping into the electric activity generated by different brain cortical areas for precise voluntary control of connected robotic devices. Virtual reality is also valuable to healthy individuals as a narrative medium for redesigning their individual stories in an integrative process of self-improvement and personal development. Future upgrades of virtual reality-based technologies promise to help humans transcend the limitations of their biological bodies and augment their capacity to mold physical reality to better meet the needs of a globalized world.

Stakeholder Recommendations to Increase the Accessibility of Online Health Information for Adults Experiencing Concussion Symptoms

Background: Concussion is a global public health problem. In Canada, concussion is among the top five reasons for workplace time-loss. Concussion results in physical, cognitive, and/or emotional symptoms that temporarily worsen with physical and mental exertion, such as viewing electronic screens. The Internet is the primary source of consumer health information. Studies on the end-user needs of adults with brain injuries in regards to digital health technologies largely focus on informational content. There is little to no research on the accessibility of screen-based informational websites and smartphone applications among this population.

Objective: The aim of this research was to involve stakeholders in the design of a comprehensive educational resource to guide concussion recognition, recovery, and return-to-work, called the Concussion Awareness Training Tool for Workers and Workplaces (CATT WW). In order to ensure both relevant content and appropriate delivery of the information to the target groups, participants were asked whether adaptations could increase the accessibility of online health information for the general adult population experiencing concussion symptoms.

Methods: Data have been generated through semi-structured in-depth interviews and focus groups with participants from across British Columbia (BC): workers from various industries who were in the concussion recovery process or had returned to work (n = 31); and healthcare or workplace professionals who support concussion diagnosis, recovery, and return-to-work (n = 16). Data were analyzed using NVivo 12. Before commencing data collection, ethical permission was granted by the University of British Columbia Research Ethics Board (H18-00604), and approval was received from WorkSafeBC Research Services.

Results: Participants (n = 47) recommended twenty adaptations or supplements to electronic screen-based digital health technologies.

Conclusion: Given the high prevalence of concussion among the working adult population, the symptom exacerbation commonly caused by prolonged use of electronic screens, and the demand for online educational resources, these findings can guide clinicians, researchers, technology developers, employers, and occupational health and safety committees to further support adults in concussion recovery and return-to-work.