Virtual enriched environments in paediatric neuropsychological rehabilitation following traumatic brain injury: Feasibility, benefits and challenges

Co-design of a therapeutic virtual reality tool to increase awareness and self-management of cognitive fatigue after traumatic brain injury

PURPOSE

The symptom of cognitive fatigue is reported as one of the longest lasting and most debilitating symptoms of traumatic brain injury (TBI). Virtual reality may be one of the most suitable technologies for neurorehabilitation, able to integrate evidence-based neuroscientific principles into motivating rehabilitation simulations. The purpose of this study was to seek perspectives of individuals with lived experience of TBI and experienced rehabilitation clinicians in the co-design of a novel technology-based tool for cognitive fatigue after TBI.

MATERIALS AND METHOD

Co-design focus groups with a sample of clinicians and individuals with lived experience of TBI were used to identify the design parameters. A prototype was developed using inter-disciplinary design iterations. Focus groups were repeated with participants testing the prototype. Qualitative data were analysed using a general inductive approach.

RESULTS

Feasibility of VR in this population was well tolerated. The focus groups guided development of domains including environment, tasks, level progression, outcome measures and considerations about clinical implementation of VR.

CONCLUSIONS

By merging advancements in VR science with a translational approach, a co-designed virtual reality tool to increase awareness and self-management of cognitive fatigue has been developed, suitable for use in persons with TBI.Implications for rehabilitationImmersive virtual reality tools show promise for addressing awareness of cognitive fatigue after traumatic brain injury in rehabilitation settings.Early engagement with consumers is recommended to produce a usable rehabilitation product.

Application and Effect of Virtual Reality Technology in Motor Skill Intervention for Individuals with Developmental Disabilities: A Systematic Review

Children and adolescents with developmental disabilities are often impaired with motor function, and motor skills are related to the performance of daily living activities, and their defects may limit social participation and reduce the quality of life. With the progress of information technology, virtual reality is used as an emerging and alternative intervention method for the intervention of its motor skills. However, the application of this field is still limited in our country, so it is of great significance to systematically analyze the foreign intervention in this field. The research used Web of Science, EBSCO, PubMed, and other databases to search the literature published in the past ten years on the application of virtual reality technology in the motor skill intervention of people with developmental disabilities, and analyzed the demographic characteristics, intervention target behavior, intervention time, intervention effect, and statistical methods. The advantages and disadvantages of research in this field are summarized, and on this basis, the reflection and prospects for follow-up intervention research are put forward.

Efficacy of a Virtual Reality Program in Pediatric Surgery to Reduce Anxiety and Distress Symptoms in the Preoperative Phase: A Prospective Randomized Clinical Trial

Background: Virtual reality (VR) experience is the most adopted form of video-gaming to reduce preoperative anxiety. This prospective randomized clinical trial aimed to examine the feasibility and efficacy of preoperative VR experience in children undergoing elective surgery. Materials and Methods: All patients older than 13 years and scheduled for elective surgery between March and June 2021 were enrolled. Preoperative VR experience consisted in watching a 5-minute video using a head-mounted display. Four parameters were evaluated and compared between the two groups: (1) patient heart rate (HR) before anesthesia; (2) patient evaluation of preoperative anxiety using facial affective scale (FAS); (3) anesthesiologist evaluation of preoperative anxiety using FAS; and (4) subjective stress scoring using a 5-item Likert-type scale. Results: A total of 40 patients (23 boys) with a median age of 14.5 years (range 12-17) participated in the study. The patients were randomized in two groups, each of 20 patients, according to preoperative VR experience: VR group (G1) and control group (G2). No adverse events related to VR occurred. The patient median HR was significantly lower in G1 (72 bpm) than in G2 (101 bpm) (P = .001). The very relaxed/relaxed face selection rate using FAS was significantly higher in G1 than in G2, in both patient and anesthesiologist evaluations (P = .001). Finally, the subjective patient scoring of operating room experience was significantly greater in G1 [4.6 ± 0.4] than in G2 [2.15 ± 1.07] (P = .001). Conclusions: Our preliminary results showed that VR is safe and effective to relieve anxiety and improve relaxation in the preoperative period in pediatric patients undergoing elective surgery. The VR experience resulted in decreased overall anxiety and increased overall positive affect during the preoperative period in VR group compared with the control group. Further studies are needed to investigate this technology in the postoperative phase and on a larger patient cohort.

A survey of research trends in assistive technologies using information modelling techniques

BACKGROUND

Despite the rapid proliferation and emphasis on technology, the use of assistive technology among individuals with varying disabilities and age is different. This situation instigates the need for a systematic review to gain a realistic understanding of prominent issues, research trends and assistive technology applications with minimal bias.

OBJECTIVE

Identification of leading researchers and prominent publications in assistive technologies. Subsequently, semantic relation between qualitative and quantitative research literature on assistive technologies was explored to future research directions.

METHODS

A manual search across reputed research databases was done to find out relevant literature from January 2005 to April 2020. In this paper, latent semantic analysis (LSA) was done to develop an information model for achieving defined objectives.

RESULTS

A corpus of 367 research papers published during 2005-2020 was processed using LSA. Term frequency, inverse document frequency of high loading terms provided five major topic solutions. Marcia Scherer, Rory Cooper and Stefano Federici are most noticed authors in assistive technology research. "Smart Assistive Technologies" and "Wearable Technologies for Rehabilitation" came out as contemporary research trends within assistive technologies.

CONCLUSIONS

The manuscript concludes the fact that assistive technologies for rehabilitation are experiencing a transition from standalone mechanical devices towards smart, wearable and connected devices.Implications for RehabilitationCustomized assistive devices could be programmed for multiple uses.User data privacy and internet dependency of smart assistive technologies must be taken care of while designing smart assistive devices for rehabilitation.Fog devices could eliminate the latency issues associated with cloud-based rehabilitation services.

Virtual Reality for Pediatric Traumatic Brain Injury Rehabilitation: A Systematic Review

Objective. Pediatric traumatic brain injury (TBI) is associated with physical and psychobehavioral impairment in children. Effective rehabilitation programs postinjury are critical for children with TBI. Virtual reality (VR) has been increasingly adopted for brain injury rehabilitation. However, scientific synthesis is lacking in evaluating its effectiveness in pediatric TBI rehabilitation. This article aimed to conduct a systematic review on the effectiveness of VR-based pediatric TBI rehabilitation. Methods. A systematic literature search was conducted in PubMed, PsycInfo, SCOPUS, CENTRAL, BioMed Central, CiNAHL, and Web of Science through November 2015. Personal libraries and relevant references supplemented the search. Two authors independently reviewed the abstracts and/or full text of 5824 articles. Data extraction and qualitative synthesis was conducted along with quantitative assessment of research quality by 2 authors. Results. A positive impact was found for VR-based interventions on children's physical rehabilitation post-TBI. The quality of research evidence was moderate, which largely suffered from small samples, lack of immersive VR experience, and lack of focus on socioemotional outcomes post-TBI. Conclusions. The present review identified positive effects of VR interventions for pediatric TBI rehabilitation especially in physical outcomes. Future research should include larger samples and broader post-TBI outcomes in children using VR-based interventions.

Wii-habilitation as balance therapy for children with acquired brain injury

PURPOSE

To evaluate the effectiveness of the Nintendo Wii compared to traditional balance therapy in improving balance, motivation, and functional ability in children undergoing acute rehabilitation after brain injury.

METHODS

A non-concurrent, randomized multiple baseline single-subject research design was used with three participants. Data were analyzed by visual inspection of trend lines.

RESULTS

Daily Wii balance training was equally motivating to traditional balance therapy for two participants and more motivating for one participant. While improvements in dynamic balance were observed, the results for static balance remain inconclusive. All participants demonstrated improvements in functional ability.

CONCLUSION

Wii balance therapy is a safe, feasible, and motivating intervention for children undergoing acute rehabilitation after an acquired brain injury. Further research to examine the effectiveness of Wii balance therapy in this population is warranted.

Virtual reality as a screening tool for sports concussion in adolescents

PRIMARY OBJECTIVE

There is controversy surrounding the cognitive effects of sports concussion. This study aimed to verify whether the technique of virtual reality could aid in the identification of attention and inhibition deficits in adolescents.

STUDY DESIGN

A prospective design was used to assess 25 sports-concussed and 25 non-sports-concussed adolescents enrolled in a sport and education programme.

METHODS AND PROCEDURES

Participants were evaluated in immersive virtual reality via ClinicaVR: Classroom-CPT and in real life via the traditional VIGIL-CPT.

MAIN OUTCOMES AND RESULTS

The neuropsychological assessment using virtual reality showed greater sensitivity to the subtle effects of sports concussion compared to the traditional test, which showed no difference between groups. The results also demonstrated that the sports concussion group reported more symptoms of cybersickness and more intense cybersickness than the control group.

CONCLUSIONS

Sports concussion was associated with subtle deficits in attention and inhibition. However, further studies are needed to support these results.

Does intervention using virtual reality improve upper limb function in children with neurological impairment: a systematic review of the evidence

BACKGROUND

Virtual reality (VR) is an emerging area of paediatric clinical and research practice, however the majority of research to date has focused on outcomes for adults following stroke. This paper appraises and describes current evidence for use of virtual reality interventions to improve upper limb function of children with neurological impairment.

METHODS

A comprehensive database search was undertaken to explore literature on the use of VR systems for rehabilitation of upper limb skills of children with neurological impairment. Studies investigating the use of robotics or other mechanical devices were excluded. Five studies were found and were critiqued using the Downs and Black scale for measuring study quality.

RESULTS

One randomized control trial and four case studies were found. No study scored over 50% on the Downs and Black scale, indicating methodological limitations that limit generalizability.

CONCLUSIONS

Current evidence for the use of VR to improve hand and arm skills is at an emerging stage. Small sample sizes and inconsistencies in outcome measurement limit the ability to generalize findings. Further studies are required to investigate the ability to maintain gains made in VR over time and to determine whether gains transfer from the VR to real life tasks and activities.

Neurocognitive and Psychophysiological Interfaces for Adaptive Virtual Environments

The use of neuropsychological and psychophysiological measures in studies of patients immersed in high-fidelity virtual environments offers the potential to develop current psychophysiological computing approaches into affective computing scenarios that can be used for assessment, diagnosis and treatment planning. Such scenarios offer the potential for simulated environments to proffer cogent and calculated response approaches to real-time changes in user emotion, neurocognition, and motivation. The value in using virtual environments to produce simulations targeting these areas has been acknowledged by an encouraging body of research. Herein the authors describe (1) literature on virtual environments for neurocognitive and psychophysiological profiles of users’ individual strengths and weaknesses; and (2) real-time adaptation of virtual environments that could be used for virtual reality exposure therapy and cognitive rehabilitation. Specifically, the authors discuss their approach to an adaptive environment that uses the principles of flow, presence, neuropsychology, psychophysiology to develop a novel application for rehabilitative applications.

An intensive virtual reality program improves functional balance and mobility of adolescents with cerebral palsy

PURPOSE

To examine functional balance and mobility in adolescents with cerebral palsy classified at Gross Motor Function Classification System (GMFCS) level I following an intensive short-duration virtual reality (VR) intervention.

METHODS

Single-subject, multiple-baseline design with 4 adolescents. Outcomes included the Community Balance and Mobility Scale (CB&M), the 6-Minute Walk Test (6MWT), the Timed Up and Down Stairs, and the Gross Motor Function Measure Dimension E. Assessments were recorded 3 to 6 times at baseline, 5 times during intervention, and 4 times at follow-up. Daily 90-minute VR intervention was completed for 5 consecutive days. Visual, statistical, and clinical significance analyses were used.

RESULTS

Statistically significant improvements were shown in all adolescents on CB&M and 6MWT. True change was recorded in all for the CB&M and in 3 for the 6MWT.

CONCLUSIONS

Functional balance and mobility in adolescents with cerebral palsy classified at GMFCS level I improve with intense, short duration VR intervention, and changes are maintained at 1-month posttraining.

The effects of early adversity on the adult and developing brain

PURPOSE OF REVIEW

Recent advances in neuroimaging methods have provided new ways of unravelling the complex interplay between genetic and environmental factors that influence functional brain development in the critical first years of life. This has allowed new insights into the effects that early adverse experience can exert on the brain later in life. We review recent progress in the characterization of those effects and underlying mechanisms through which adverse environment influences the neurocognitive development.

RECENT FINDINGS

Socioeconomic background may have a profound effect on structural and functional brain development, especially in the domains of language and prefrontal executive control. These effects are mediated by several factors: diet, quality of parental care, impoverished environment, prenatal exposure to toxic substances and so on. Other circumstances such as perinatal brain injury, early sensory deprivation or limb malformation may result in atypical functional organization of the brain and lasting cognitive impairment of certain functions. Early experience of maltreatment or institutionalized care may alter the development of the social brain, contributing to negative mental health outcomes, which may be partially reversed through early intervention programmes.

SUMMARY

Subsequent models of psychiatric disorder should take into account early risk factors and embrace developmental models at multiple levels of biological organization. There is a continuing need for the study of optimal environmental input during sensitive periods in brain development.

Staging perspectives in neurodevelopmental aspects of neuropsychiatry: agents, phases and ages at expression

Neurodevelopmental risk factors have assumed a critical role in prevailing notions concerning the etiopathogenesis of neuropsychiatric disorders. Staging, diagnostic elements at which phase of disease is determined, provides a means of conceptualizing the degree and extent of factors affecting brain development trajectories, but is concurrently specified through the particular interactions of genes and environment unique to each individual case. For present purposes, staging perspectives in neurodevelopmental aspects of the disease processes are considered from conditions giving rise to neurodevelopmental staging in affective states, adolescence, dopamine disease states, and autism spectrum disorders. Three major aspects influencing the eventual course of individual developmental trajectories appear to possess an essential determinant influence upon outcome: (i) the type of agent that interferes with brain development, whether chemical, immune system activating or absent (anoxia/hypoxia), (ii) the phase of brain development at which the agent exerts disruption, whether prenatal, postnatal, or adolescent, and (iii) the age of expression of structural and functional abnormalities. Clinical staging may be assumed at any or each developmental phase. The present perspective offers both a challenge to bring further order to diagnosis, intervention, and prognosis and a statement regarding the extreme complexities and interwoven intricacies of epigenetic factors, biomarkers, and neurobehavioral entities that aggravate currents notions of the neuropsychiatric disorders.

Clinical management and functional neuromonitoring in traumatic brain injury in children

PURPOSE OF REVIEW

Traumatic brain injury is the main cause of childhood disability and death. In this review, we highlight recent original findings and emerging themes from published literature on children with serious traumatic brain injury.

RECENT FINDINGS

We focus this review on lessons learned from our recent randomized clinical trial of hypothermia therapy in severe traumatic brain injury in children and on bedside neuromonitoring. We propose that integrating the measurement of biomarkers into clinical care as surrogate endpoints and as potential prognostic markers would allow us to evaluate earlier the effect of injury and clinical care in children after traumatic brain injury. Several methods are now more readily available to monitor cerebral physiology in children. These methods include indices evaluating the integrity of cerebral autoregulation, such as the pressure reactivity index derived from values obtained from intracranial pressure measurements, flow velocity measurements from transcranial Doppler ultrasonography or from cerebral oximetry. Other methods allow the evaluation of coma with the nonlinear analysis of electroencephalography or the evaluation of cerebral metabolism and cell death pathways with biomarkers from serum, cerebral spinal fluid, and cerebral microdialysis.

SUMMARY

We suggest expanding clinical functional neuromonitoring to help clinicians understand the burden of exposure to physiological variables and response to therapies during intensive care in order to enhance the management of critically ill children with traumatic brain injury.