Using Virtual Reality and Videogames for Traumatic Brain Injury Rehabilitation: A Structured Literature Review

Effect of immersive virtual reality-based training on cognitive, social, and emotional skills in children and adolescents with autism spectrum disorder: A meta-analysis of randomized controlled trials

BACKGROUND

Virtual Reality (VR) based diagnostic and therapeutic interventions have opened up new possibilities for addressing the challenges in identifying and treating individuals with Autism Spectrum Disorders (ASD).

AIM

To conduct a systematic review and meta-analysis of Randomized Controlled Trials to investigate the impact of Immersive VR techniques on the cognitive, social, and emotional skills of under-18 children and adolescents with ASD.

METHODS AND PROCEDURES

Four databases were systematically searched as per "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines and assessed six RCTs for further analysis. The Cochrane Risk of Bias tool was used to assess the methodological quality of the studies.

OUTCOMES

Pooled results favoured VR and reported significant differences between experimental and control groups concerning social skills (SMD:1.43; 95 % CI: 0.01-2.84; P: 0.05), emotional skills (SMD: 2.45; 95 % CI: 0.21-4.18; P: 0.03) and cognitive skills.

CONCLUSION

VR offers an array of benefits that make it a promising tool for children and adolescents with ASD to improve their cognitive, social and emotional skills in a safe and supportive setting. However, accessibility, affordability, customization, and cost are also significant aspects to consider when developing and implementing VR-based interventions for ASD.

Effect of Exergame on Pain, Function, and Quality of Life in Shoulder Impingement Syndrome: A Prospective Randomized Controlled Study

Objective: This study aimed to investigate the effect of a virtual reality (VR)-mediated gamified rehabilitation program added to a home exercise program on pain, functionality, and quality of life in shoulder impingement syndrome. Methods: Forty-eight participants with shoulder impingement syndrome were included in this prospective, randomized, single-blind study between January and July 2022. The participants were randomized into two groups: the VR group (n = 24) and the control group (n = 24). All participants were given a home exercise program for 3 weeks, with five sessions per week. The participants in the VR group received 15 sessions (45 minutes each session) of a gamified shoulder exercise program with an immersive VR headset, while those in the control group received 15 sessions (45 minutes each session) of supervised therapeutic exercises. The participants were evaluated and compared before and after treatment using the 36-item Short Form Survey (SF-36), range-of-motion (ROM) measurements, the Visual Analog Scale (VAS), and the Shoulder Pain and Disability Scale (SPADI). Results: At the baseline assessment, the two groups were homogenous regarding demographic and clinical parameters. The post-treatment shoulder extension and adduction ROM was significantly greater in the VR group and the post-treatment pain subscales for SPADI and SF-36 were significantly lower in the VR group. Conclusion: In individuals with shoulder impingement syndrome, a VR-mediated gamified exercise program added to a home exercise program increased shoulder ROM and reduced pain scores. Further clinical studies are needed to prove the long-term efficacy of the addition of VR-mediated gamified exercises to the treatment of this condition in clinical settings.

Exploring Discussions About Virtual Reality on Twitter to Inform Brain Injury Rehabilitation: Content and Network Analysis

BACKGROUND

Virtual reality (VR) use in brain injury rehabilitation is emerging. Recommendations for VR development in this field encourage end user engagement to determine the benefits and challenges of VR use; however, existing literature on this topic is limited. Data from social networking sites such as Twitter may further inform development and clinical practice related to the use of VR in brain injury rehabilitation.

OBJECTIVE

This study collected and analyzed VR-related tweets to (1) explore the VR tweeting community to determine topics of conversation and network connections, (2) understand user opinions and experiences of VR, and (3) identify tweets related to VR use in health care and brain injury rehabilitation.

METHODS

Publicly available tweets containing the hashtags #virtualreality and #VR were collected up to twice weekly during a 6-week period from July 2020 to August 2020 using NCapture (QSR International). The included tweets were analyzed using mixed methods. All tweets were coded using inductive content analysis. Relevant tweets (ie, coded as "VR in health care" or "talking about VR") were further analyzed using Dann's content coding. The biographies of users who sent relevant tweets were examined descriptively. Tweet data networks were visualized using Gephi computational analysis.

RESULTS

A total of 260,715 tweets were collected, and 70,051 (26.87%) were analyzed following eligibility screening. The sample comprised 33.68% (23,596/70,051) original tweets and 66.32% (46,455/70,051) retweets. Content analysis generated 10 main categories of original tweets related to VR (ie, advertising and promotion, VR content, talking about VR, VR news, general technology, VR industry, VR live streams, VR in health care, VR events, and VR community). Approximately 4.48% (1056/23,596) of original tweets were related to VR use in health care, whereas 0.19% (45/23,596) referred to VR in brain injury rehabilitation. In total, 14.86% (3506/23,596) of original tweets featured commentary on user opinions and experiences of VR applications, equipment, and software. The VR tweeting community comprised a large network of 26,001 unique Twitter users. Users that posted tweets related to "VR in health care" (2124/26,001, 8.17%) did not form an interconnected VR network, whereas many users "talking about VR" (3752/26,001, 14.43%) were connected within a central network.

CONCLUSIONS

This study provides valuable data on community-based experiences and opinions related to VR. Tweets showcased various VR applications, including in health care, and identified important user-based considerations that can be used to inform VR use in brain injury rehabilitation (eg, technical design, accessibility, and VR sickness). Limited discussions and small user networks related to VR in brain injury rehabilitation reflect the paucity of literature on this topic and the potential underuse of this technology. These findings emphasize that further research is required to understand the specific needs and perspectives of people with brain injuries and clinicians regarding VR use in rehabilitation.

Post-stroke functional assessments based on rehabilitation games and their correlation with clinical scales: A scoping review

Considering that stroke is one of the main causes of adult impairment and the growing interest in Virtual Reality (VR) as a potential assessment and treatment tool for the rehabilitation of stroke patients, a scoping review was conducted to check whether user's motion data obtained from VR games and simulations can be clinically valid. This was done by reviewing studies on parameters for assessing the functional skills and rehabilitation progress using data from VR games or simulations. Then, identifying the most widely used and validated parameters for the quantification of motor ability in a virtual environment and suggesting challenges for future research. For the validation of the parameters obtained from the VR software, only the studies that correlated them with traditional physiotherapy scales were considered. In December 2022, a search of the following databases was performed: IEEE Xplore, ACM Digital Library, PubMed and PEDro. The selection criteria were studies published in English during the past 10 years, with upper-limb based interaction and tested on more than one stroke patient. A total of 14 were included in the PRISMA scoping review. Favorable results were found in 12 of the 14 studies, which reported positive or strongly positive correlations with clinical scales, even when diverse variables were used. In-depth research using a larger sample size is needed. The results demonstrate that data collected while playing a virtual serious game has the potential to be clinically valid, after conducting high-quality supportive studies with controlled variables, potentially helping the practice in terms of time and resources.

Virtual Reality Game Selection for Traumatic Brain Injury Rehabilitation: A Therapist's Wish List for Game Developers

This project explored the selection process of commercially available virtual reality (VR) games for traumatic brain injury rehabilitation. Occupational therapy practitioners (OTPs) developed a classification framework that they used to evaluate VR games. The classification framework focused on movements required to effectively play the game, cognitive demand, position for game play, ease in menu navigation, and perceived therapeutic applications. OTPs used the ratings to aid in game selection and identified relevant game examples that allowed customizable settings and basic navigation with a game focus on functional activities. The OTPs and the research team identified the need for further work on accessibility and adaptability of game features (e.g., difficulty and limb usage) allowing for more individualization to optimize outcomes of VR-enhanced rehabilitation. The classification framework was useful in evaluating the potential therapeutic benefit of commercially available VR games. However, trial of the game by clinicians prior to use was still warranted.

Usability of a virtual reality manual wheelchair simulator

PURPOSE

Individuals with impaired mobility often require assistance for getting around. The skilled use of a manual wheelchair (MW) is required in order to gain independence while preventing injuries. Training in a virtual reality (VR) setting allows for safe practice of MW skills in a wide range of environments. We developed a low-cost MW simulator which includes visual and haptic feedback. Our objectives were to assess the usability and fidelity of the VR simulator, by clinicians and expert MW users, and to determine whether the addition of haptic feedback would positively improve the user's experience.

MATERIALS AND METHODS

This mixed method study investigated the sense of presence, overall experience and ease of use of the experience in six MW users, as well as five clinicians (wheeled mobility experts) who practiced in the simulator.

RESULTS

Participants reported a positive perception of usefulness, sense of presence, and immersion during the MiWe simulator experience. The addition of haptic feedback to the simulator significantly enhanced fidelity of the overall experience, compared to the no-feedback condition.

CONCLUSION

Our low-cost simulator was well perceived by clinicians and MW users and was considered as a potentially useful tool to complement MW skill training.IMPLICATIONS FOR REHABILITATIONWe developed a low-cost, virtual reality simulator with visual and haptic feedback, for the practice of manual wheelchair skills.Expert clinicians and wheelchair users reported a positive experience after practicing in the wheelchair simulator, in terms of presence, realism and usability.Participants highlighted the potential usefulness of our low-cost simulator in the training of manual wheelchair skills.

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.

An Overview of the Body Schema and Body Image: Theoretical Models, Methodological Settings and Pitfalls for Rehabilitation of Persons with Neurological Disorders

Given the widespread debate on the definition of the terms "Body Schema" and "Body Image", this article presents a broad overview of the studies that have investigated the nature of these types of body representations, especially focusing on the innovative information about these two representations that could be useful for the rehabilitation of patients with different neurological disorders with motor deficits (especially those affecting the upper limbs). In particular, we analyzed (i) the different definitions and explicative models proposed, (ii) the empirical settings used to test them and (iii) the clinical and rehabilitative implications derived from the application of interventions on specific case reports. The growing number of neurological diseases with motor impairment in the general population has required the development of new rehabilitation techniques and a new phenomenological paradigm placing body schema as fundamental and intrinsic parts for action in space. In this narrative review, the focus was placed on evidence from the application of innovative rehabilitation techniques and case reports involving the upper limbs, as body parts particularly involved in finalistic voluntary actions in everyday life, discussing body representations and their functional role.

Cognitive Training With Head-Mounted Display Virtual Reality in Neurorehabilitation: Pilot Randomized Controlled Trial

BACKGROUND

Neurological rehabilitation is technologically evolving rapidly, resulting in new treatments for patients. Stroke, one of the most prevalent conditions in neurorehabilitation, has been a particular focus in recent years. However, patients often need help with physical and cognitive constraints, whereby the cognitive domain in neurorehabilitation does not technologically exploit existing potential. Usually, cognitive rehabilitation is performed with pen and paper or on a computer, which leads to limitations in preparation for activities of daily living. Technologies such as virtual reality (VR) can bridge this gap.

OBJECTIVE

This pilot study investigated the use of immersive VR in cognitive rehabilitation for patients undergoing inpatient neurorehabilitation. The goal was to determine the difference in rehabilitation effectiveness between a VR serious game that combines everyday activities with cognitive paradigms and conventional computerized cognitive training. We hypothesized the superiority of the VR serious game regarding cognitive abilities and patient-reported outcomes as well as transfer to daily life.

METHODS

We recruited 42 patients with acute brain affection from a German neurorehabilitation clinic in inpatient care with a Mini Mental Status Test score >20 to participate in this randomized controlled trial. Participants were randomly assigned to 2 groups, with 1 receiving the experimental VR treatment (n=21). VR training consisted of daily life scenarios, for example, in a kitchen, focusing on treating executive functions such as planning and problem-solving. The control group (n=21) received conventional computerized cognitive training. Each participant received a minimum of 18 treatment sessions in their respective group. Patients were tested for cognitive status, subjective health, and quality of life before and after the intervention (Alters-Konzentrations-Test, Wechsler Memory Scale-Revised, Trail Making Test A and B, Tower of London-German version, Short Form 36, European Quality of Life 5 Dimensions visual analog scale, and Fragebogen zur Erfassung der Performance in VR).

RESULTS

Repeated-measures ANOVA revealed several significant main effects in the cognitive tests: Tower of London-German version (P=.046), Trail Making Test A (P=.01), and Wechsler Memory Scale-Revised (P=.006). However, post hoc tests revealed that the VR group showed significant improvement in the planning, executive control, and problem-solving domains (P=.046, Bonferroni P=.02). In contrast, no significant improvement in the control group between t₀ and t₁ was detected (all P>.05). Furthermore, a nonsignificant trend was observed in visual speed in the VR group (P=.09, Bonferroni P=.02).

CONCLUSIONS

The results of this pilot randomized controlled trial showed that immersive VR training in cognitive rehabilitation had greater effectiveness than the standard of care in treating patients experiencing stroke in some cognitive domains . These findings support the further use and study of VR training incorporating activities of daily living in other neurological disorders involving cognitive dysfunction.

TRIAL REGISTRATION

Federal Registry of Clinical Trials of Germany (DRKS) DRKS00023605; https://drks.de/search/de/trial/DRKS00023605.

Effectiveness of Digital Health Interventions in Reducing Bullying and Cyberbullying: A Meta-Analysis

Bullying and cyberbullying bring adverse physical and psychological impacts on individuals and an economic burden for society. Scholars have developed anti-bullying intervention programs to combat these problems. This meta-analysis aims to examine and compare the effectiveness of digital health interventions (DHIs) in reducing bullying and cyberbullying. A comprehensive search was conducted using databases (PsycINFO, Social Service Abstracts, Sociological Abstracts, MEDLINE, ERIC, and EMBASE). Quasi-experimental and randomized controlled trials (RCTs) published before 31 January 2021 that reported the effects of DHIs in reducing bullying or cyberbullying were included. The 16 studies included in the synthesis reported overall random effect sizes (Cohen's d) for bullying and cyberbullying reduction were 0.41 and 0.19, respectively. The results provide evidence on the effectiveness of DHIs, comparable to that of face-to-face interventions. The subgroup analysis revealed that the critical components of effective DHIs include training on bystander and bully-victim dual roles, coping skills, and interactive serious games. It highlights the promising effects of digital health approaches in bullying and cyberbullying interventions. Our review identifies avenues for future research on the development of more effective DHIs to reduce bullying and cyberbullying.

Virtual reality-based interventions for the rehabilitation of vestibular and balance impairments post-concussion: a scoping review

BACKGROUND

Concussions and mild traumatic brain injuries are the most common causes of physical and cognitive disability worldwide. Concussion can result in post-injury vestibular and balance impairments that can present up to five years post initial concussion event, ultimately affecting many daily and functional activities. While current clinical treatment aims to reduce symptoms, the developing use of technology in everyday life has seen the emergence of virtual reality. Current literature has failed to identify substantial evidence regarding the use of virtual reality in rehabilitation. The primary aim of this scoping review is to identify, synthesise, and assess the quality of studies reporting on the effectiveness of virtual reality for the rehabilitation of vestibular and balance impairments post-concussion. Additionally, this review aims to summarise the volume of scientific literature and identify the knowledge gaps in current research pertaining to this topic.

METHODS

A scoping review of six databases (PubMed, Embase, CINAHL, ProQuest, SportDiscus, Scopus) and a grey literature (Google Scholar) was conducted using three key concepts (virtual reality, vestibular symptoms, and post-concussion). Data was charted from studies and outcomes were categorised into one of three categories: (1) balance; (2) gait; or (3) functional outcome measures. Critical appraisal of each study was conducted using the Joanna Briggs Institute checklists. A critical appraisal of each outcome measure was also completed utilising a modified GRADE appraisal tool to summarise the quality of evidence. Effectiveness was assessed using calculations of change in performance and change per exposure time.

RESULTS

Three randomised controlled trials, three quasi-experimental studies, three case studies, and one retrospective cohort study were ultimately included, using a thorough eligibility criteria. All studies were inclusive of different virtual reality interventions. The ten studies had a 10-year range and identified 19 different outcome measures.

CONCLUSION

The findings from this review suggests that virtual reality is an effective tool for the rehabilitation of vestibular and balance impairments post-concussion. Current literature shows sufficient but low level of evidence, and more research is necessary to develop a quantitative standard and to better understand appropriate dosage of virtual reality intervention.

Active Virtual Reality for Chronic Primary Pain: Mixed Methods Randomized Pilot Study

Background

The modern management of chronic pain is largely focused on improving functional capacity (often despite ongoing pain) by using graded activation and exposure paradigms. However, many people with chronic pain find functional activation programs aversive, and dropout rates are high. Modern technologies such as virtual reality (VR) could provide a more enjoyable and less threatening way for people with chronic pain to engage in physical activity. Although VR has been successfully used for pain relief in acute and chronic pain settings, as well as to facilitate rehabilitation in conditions such as stroke and cerebral palsy, it is not known whether VR can also be used to improve functional outcomes in people with chronic pain.

Objective

This study aimed to assess the feasibility of conducting an adequately powered randomized controlled trial (RCT) to test the efficacy of VR in a chronic pain treatment center and assess the acceptability of an active VR treatment program for patients in this setting.

Methods

For this mixed methods pilot study, which was designed to test the feasibility and acceptability of the proposed study methods, 29 people seeking treatment for chronic pain were randomized to an active VR intervention or physiotherapy treatment as usual (TAU). The TAU group completed a 6-week waitlist before receiving standard treatment to act as a no-treatment control group. The VR intervention comprised twice-weekly immersive and embodied VR sessions using commercially available gaming software, which was selected to encourage movement. A total of 7 VR participants completed semistructured interviews to assess their perception of the intervention.

Results

Of the 99 patients referred to physiotherapy, 53 (54%) were eligible, 29 (29%) enrolled, and 17 (17%) completed the trial, indicating that running an adequately powered RCT in this setting would not be feasible. Despite this, those in the VR group showed greater improvements in activity levels, pain intensity, and pain interference and reported greater treatment satisfaction and perceived improvement than both the waitlist and TAU groups. Relative effect sizes were larger when VR was compared with the waitlist (range small to very large) and smaller when VR was compared with TAU (range none to medium). The qualitative analysis produced the following three themes: VR is an enjoyable alternative to traditional physiotherapy, VR has functional and psychological benefits despite continued pain, and a well-designed VR setup is important.

Conclusions

The active VR intervention in this study was highly acceptable to participants, produced favorable effects when compared with the waitlist, and showed similar outcomes as those of TAU. These findings suggest that a confirmatory RCT is warranted; however, substantial barriers to recruitment indicate that incentivizing participation and using a different treatment setting or running a multicenter trial are needed.

Gender Influences Virtual Reality-Based Recovery of Cognitive Functions in Patients with Traumatic Brain Injury: A Secondary Analysis of a Randomized Clinical Trial

The rehabilitation of cognitive deficits in individuals with traumatic brain injury is essential for promoting patients’ recovery and autonomy. Virtual reality (VR) training is a powerful tool for reaching this target, although the effectiveness of this intervention could be interfered with by several factors. In this study, we evaluated if demographical and clinical variables could be related to the recovery of cognitive function in TBI patients after a well-validated VR training. One hundred patients with TBI were enrolled in this study and equally randomized into the Traditional Cognitive Rehabilitation Group (TCRG: n = 50) or Virtual Reality Training Group (VRTG: n = 50). The VRTG underwent a VRT with BTs-N, whereas the TCRG received standard cognitive treatment. All the patients were evaluated by a complete neuropsychological battery before (T0) and after the end of the training (T1). We found that the VR-related improvement in mood, as well as cognitive flexibility, and selective attention were influenced by gender. Indeed, females who underwent VR training were those showing better cognitive recovery. This study highlights the importance of evaluating gender effects in planning cognitive rehabilitation programs. The inclusion of different repetitions and modalities of VR training should be considered for TBI male patients.

A Therapeutic Matrix: Virtual Reality as a Clinical Tool for Spinal Cord Injury-Induced Neuropathic Pain

Neuropathic pain (NP) is a chronic, debilitating, and resistant form of pain. The onset rate of NP following spinal cord injuries (SCI) is high and may reduce the quality of life more than the sensorimotor loss itself. The long-term ineffectiveness of current treatments in managing symptoms and counteracting maladaptive plasticity highlights the need to find alternative therapeutic approaches. Virtual reality (VR) is possibly the best way to administer the specific illusory or reality-like experience and promote behavioral responses that may be effective in mitigating the effects of long-established NP. This approach aims to promote a more systematic adoption of VR-related techniques in pain research and management procedures, highlighting the encouraging preliminary results in SCI. We suggest that the multisensory modulation of the sense of agency and ownership by residual body signals may produce positive responses in cases of brain-body disconnection. First, we focus on the transversal role embodiment and how multisensory and environmental or artificial stimuli modulate illusory sensations of bodily presence and ownership. Then, we present a brief overview of the use of VR in healthcare and pain management. Finally, we discus research experiences which used VR in patients with SCI to treating NP, including the most recent combinations of VR with further stimulation techniques.

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.

Cognitive training with fully immersive virtual reality in patients with neurological and psychiatric disorders: A systematic review of randomized controlled trials

Cognitive impairment occurs across several neuropsychiatric diseases and impede everyday functioning and quality of life. Fully immersive Virtual Reality (VR) aid motivation and engagement and therefore has a potential to help overcome the obstacles in the field of cognitive rehabilitation. The aim of this systematic review is to investigate whether VR can be a useful intervention in cognitive rehabilitation transdiagnostically. We identified nine studies with randomized controlled trials following the PRISMA guidelines in databases Pubmed, Embase and PsychInfo. The trials were all evaluated through Cochrane Collaboration's Risk of Bias. The studies were conducted in patients with mild cognitive impairment (k=4), schizophrenia (k=3), ADHD (k=1), or stroke (k=1) and involved 6-12 weeks of training. Overall, results showed improvement in some domains of cognition, primarily executive function and attention. The studies were pilot studies with 6-34 participants per treatment group. Risk of bias was either high (k=3) or moderate (some concerns) (k=6). Key reasons were suboptimal statistical analyses and lack of clarification on randomization and blinding of participants and assessors. In conclusion, this review found promising evidence for VR cognitive rehabilitation for neuropsychiatric illnesses. However, larger and methodologically stronger studies are warranted to establish the full potential of VR.

Adherence to home-based videogame treatment for amblyopia in children and adults

Clinical relevance: Home-based videogame treatments are increasingly popular for amblyopia treatment. However, at-home treatments tend to be done in short sessions and with frequent disruptions, which may reduce the effectiveness of binocular visual stimulation. These treatment adherence patterns need to be accounted for when considering dose-response relationships and treatment effectiveness.Background: Home-based videogame treatments are increasingly being used for various sensory conditions, including amblyopia ('lazy eye'), but treatment adherence continues to limit success. To examine detailed behavioural patterns associated with home-based videogame treatment, we analysed in detail the videogame adherence data from the Binocular tReatment of Amblyopia with VideOgames (BRAVO) clinical trial (ACTRN12613001004752).Methods: Children (7-12 years), teenagers (13-17 years) and adults (≥ 18 years) with unilateral amblyopia were loaned iPod Touch devices with either an active treatment or placebo videogame and instructed to play for a total of 1-2 hours/day for six weeks at home. Objectively-recorded adherence data from device software were used to analyse adherence patterns such as session length, daily distribution of gameplay, use of the pause function, and differences between age groups. Objectively-recorded adherence was also compared to subjectively-reported adherence from paper-based diaries.Results: One hundred and five of the 115 randomised participants completed six weeks of videogame training. Average adherence was 65% (SD 37%) of the minimum hours prescribed. Game training was generally performed in short sessions (mean 21.5, SD 11.2 minutes), mostly in the evening, with frequent pauses (median every 4.1 minutes, IQR 6.1). Children played in significantly shorter sessions and paused more frequently than older age groups (p < 0.0001). Participants tended to over-report adherence in subjective diaries compared to objectively-recorded gameplay time.Conclusion: Adherence to home-based videogame treatment was characterised by short sessions interspersed with frequent pauses, suggesting regular disengagement. This complicates dose-response calculations and may interfere with the effectiveness of treatments like binocular treatments for amblyopia, which require sustained visual stimulation.

Go Virtual to Get Real: Virtual Reality as a Resource for Spinal Cord Treatment

Increasingly, refined virtual reality (VR) techniques allow for the simultaneous and coherent stimulation of multiple sensory and motor domains. In some clinical interventions, such as those related to spinal cord injuries (SCIs), the impact of VR on people's multisensory perception, movements, attitudes, and even modulations of socio-cognitive aspects of their behavior may influence every phase of their rehabilitation treatment, from the acute to chronic stages. This work describes the potential advantages of using first-person-perspective VR to treat SCIs and its implications for manipulating sensory-motor feedback to alter body signals. By situating a patient with SCI in a virtual environment, sensorial perceptions and motor intention can be enriched into a more coherent bodily experience that also promotes processes of neural regeneration and plasticity. In addition to the great potential of research, the most significant areas of interest concern is managing neuropathic pain, motor rehabilitation, and psychological well-being.

What is the future for immersive virtual reality in memory rehabilitation? A systematic review

BACKGROUND

A growing interest in non-pharmacological approaches aimed at cognitive rehabilitation and cognitive enhancement pointed towards the application of new technologies. The complex virtual reality (VR) presented using immersive devices has been considered a promising approach.

OBJECTIVE

The article provides a systematic review of studies aimed at the efficacy of VR-based rehabilitation. First, we shortly summarize literature relevant to the role of immersion in memory assessment and rehabilitation.

METHODS

We searched Web of Science, ScienceDirect, and PubMed with the search terms "memory rehabilitation", "virtual reality", "memory deficit". Only original studies investigating the efficacy of complex three-dimensional VR in rehabilitation and reporting specific memory output measures were included.

RESULTS

We identified 412 citations, of which 21 met our inclusion criteria. We calculated appropriate effect sizes for 10 studies including control groups and providing descriptive data. The effect sizes range from large to small, or no effect of memory rehabilitation was present, depending on the control condition applied. Summarized studies with missing control groups point out to potential positive effects of VR but do not allow any generalization.

CONCLUSIONS

Even though there are some theoretical advantages of immersive VE over non-immersive technology, there is not enough evidence yet to draw any conclusions.

Game-Based Virtual Reality Interventions to Improve Upper Limb Motor Function and Quality of Life After Stroke: Systematic Review and Meta-analysis

Stroke is the main cause of disability in adulthood. Recent advances in virtual reality (VR) technologies have led to its increased use in the rehabilitation of stroke patients. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to determine the effectiveness of game-based reality on upper limb (UL) motor function and quality of life after stroke. In March 2018, a search of the following databases was performed: PubMed, PEDro, Web of Science, Scopus, The Cochrane Library, and Medline at EBSCO. The selection criteria were all RCTs published in English or Spanish during the past 10 years. The PEDro scale was used to evaluate the methodological quality of the studies. A total of 20 clinical trials were included in the systemic review, of which 15 contributed information to the meta-analysis. Favorable results were found for VR interventions on UL motor function (Fugl-Meyer Assessment for upper extremity, standardized mean difference [SMD] = 1.53, 95% CI [0.51-2.54]) and quality of life (functional independence measure, SMD = 0.77, 95% CI [0.05-1.49]). The results demonstrate the potential benefits of VR interventions on the recovery of UL motor function and on quality of life after stroke.

Exploring perspectives from stroke survivors, carers and clinicians on virtual reality as a precursor to using telerehabilitation for spatial neglect post-stroke

Spatial neglect is a common and severe cognitive consequence of stroke, yet there is currently no effective rehabilitation tool. Virtual Reality (VR) telerehabilitation tools have the potential to provide multisensory and enjoyable therapies and remotely monitor adherence without the presence of a therapist at all times. Researchers and industry need to better understand end-user perspectives about these technologies to ensure these are acceptable and, ultimately, optimize adherence and efficacy. This study aims to explore end-user perspectives on the use of self-administered VR for spatial neglect in a university environment to identify barriers and facilitators prior to extending its use remotely as a telerehabilitation tool. We used a mixed-method design including focus groups, self-administered questionnaires and interviews with stroke survivors (N = 7), their carers (N = 3) and stroke clinicians (N = 6). End-user perspectives identified clarity of instructions, equipment (cost, available resources) and for some, level of experience with technology as barriers of use. Perceived facilitators were performance feedback, engagement and enjoyment, and psychological benefits associated with self-administered VR telerehabilitation. Overall, end-users were positive and interested in using VR telerehabilitation for spatial neglect. These perspectives enabled us to produce practical recommendations to inform development, enhance engagement and uptake of VR telerehabilitation and inform future studies.

Motion-Based Technology for People With Dementia Training at Home: Three-Phase Pilot Study Assessing Feasibility and Efficacy

BACKGROUND

Persons with dementia tend to be vulnerable to mobility challenges and hence face a greater risk of fall and subsequent fractures, morbidity, and mortality. Motion-based technologies (MBTs), also called sensor-based technologies or virtual reality, have the potential for assisting physical exercise and training as a part of a disease management and rehabilitation program, but little is known about its' use for people with dementia.

OBJECTIVE

The purpose of this pilot study was to investigate the feasibility and efficacy of MBT physical training at home for people with dementia.

METHODS

A 3-phase pilot study: (1) baseline start-up, (2) 15 weeks of group training at a local care center twice a week, and (3) 12 weeks of group training reduced to once a week, supplemented with individual MBT training twice a week at home. A total of 26 people with dementia from a municipality in Southern Denmark were eligible and agreed to participate in this study. Three withdrew from the study, leaving 23 participants for the final analysis. Feasibility was measured by the percentage of participants who trained with MBT at home, and their completion rate of total scheduled MBT sessions. Efficacy was evaluated by physical function, measured by Sit-to-Stand (STS), Timed-Up-and-Go (TUG), 6-minute Walk Test (6MW), and 10-meter Dual-task Walking Test (10MDW); cognitive function was measured by Mini-Mental State Examination (MMSE) and Neuropsychiatric Inventory-Questionnaire (NPI-Q); and European Quality of Life 5 dimensions questionnaire (EQOL5) was used for measuring quality of life. Descriptive statistics were applied accordingly. Wilcoxon signed-rank and rank-sum tests were applied to explore significant differences within and between the groups.

RESULTS

As much as 12 of 23 participants (52%) used the supplemental MBT training at home. Among them, 6 (50%) completed 75% or more scheduled sessions, 3 completed 25% or less, and 3 completed between 25% and 75% of scheduled sessions. For physical and cognitive function tests, supplementing with MBT training at home showed a tendency of overall stabilization of scores among the group of participants who actively trained with MBT; especially, the 10MDW test even showed a significant improvement from 9.2 to 7.1 seconds (P=.03). We found no positive effect on EQOL5 tests.

CONCLUSIONS

More than half of the study population with dementia used MBT training at home, and among them, half had an overall high adherence to the home training activity. Physical function tended to remain stable or even improved among high-adherence MBT individuals. We conclude that MBT training at home may be feasible for some individuals with dementia. Further research is warranted.

Virtual Reality-Based Executive Function Rehabilitation System for Children With Traumatic Brain Injury: Design and Usability Study

BACKGROUND

Traumatic brain injury (TBI) poses a significant threat to children's health. Cognitive rehabilitation for pediatric TBI has the potential to improve the quality of life following the injury. Virtual reality (VR) can provide enriched cognitive training in a life-like but safe environment. However, existing VR applications for pediatric TBIs have primarily focused on physical rehabilitation.

OBJECTIVE

This study aims to design and develop an integrative hardware and software VR system to provide rehabilitation of executive functions (EF) for children with TBI, particularly in 3 core EF: inhibitory control, working memory, and cognitive flexibility.

METHODS

The VR training system was developed by an interdisciplinary team with expertise in best practices of VR design, developmental psychology, and pediatric TBI rehabilitation. Pilot usability testing of this novel system was conducted among 10 healthy children and 4 children with TBIs.

RESULTS

Our VR-based interactive cognitive training system was developed to provide assistive training on core EF following pediatric TBI. Pilot usability testing showed adequate user satisfaction ratings for both the hardware and software components of the VR system.

CONCLUSIONS

This project designed and tested a novel VR-based system for executive function rehabilitation that is specifically adapted to children following TBI.

Effects of physical therapy interventions on balance ability in people with traumatic brain injury: A systematic review

BACKGROUND

Balance deficits are common impairments in individuals with post-traumatic brain injury (TBI). Balance deficits can restrict the activities of daily living and productive participation in social life. To date, no systematic reviews have examined the impact of physical therapy intervention on balance post-TBI.

OBJECTIVE

To examine the effects of physical therapy interventions on balance impairments in individuals with TBI.

METHODS

We systematically searched in PubMed, EMBASE, Scopus, PEDro, MEDLINE, REHABDATA, and Web of Science for randomized controlled trials (RCTs), clinical control trials, and pilot studies that examined the effects of physical therapy interventions on balance deficits in individuals post-TBI. The methodological quality was estimated using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Eight studies published from 2003 to 2019 were included in this study. A total of 259 TBI participants post-TBI were included in this review, 71 (27.41%) of which were females. The methodological quality of the selected studies ranged from low to high. There were no significant differences between experimental interventions, virtual reality (VR), vestibular rehabilitation therapy (VRT), control group interventions, and other traditional physical therapy interventions.

CONCLUSIONS

The evidence about the effects of the physical therapy interventions in improving the balance ability post-TBI was limited. Further randomized controlled trials are strongly warranted to understand the role of physical therapy in patients with TBI who complain about balance deficits.

Efficacy of Virtual Reality Rehabilitation after Spinal Cord Injury: A Systematic Review

Background

Spinal cord injury (SCI) is often associated with long-term impairments related to functional limitations in the sensorimotor system. The use of virtual reality (VR) technology may lead to increased motivation and engagement, besides allowing a wide range of possible tasks/exercises to be implemented in rehabilitation programs. The present review aims to investigate the possible benefits and efficacy of VR-based rehabilitation in individuals with SCI.

Methods

An electronically systematic search was performed in multiple databases (PubMed, BVS, Web of Science, Cochrane Central, and Scielo) up to May 2019. MESH terms and keywords were combined in a search strategy. Two reviewers independently selected the studies in accordance with eligibility criteria. The PEDro scale was used to score the methodological quality and risk of bias of the selected studies.

Results

Twenty-five studies (including 482 participants, 47.6 ± 9.5 years, 73% male) were selected and discussed. Overall, the studies used VR devices in different rehabilitation protocols to improve motor function, driving skills, balance, aerobic function, and pain level, as well as psychological and motivational aspects. A large amount of heterogeneity was observed as to the study design, VR protocols, and outcome measures used. Only seven studies (28%) had an excellent/good quality of evidence. However, substantial evidence for significant positive effects associated with VR therapy was found in most of the studies (88%), with no adverse events (88%) being reported.

Conclusion

Although the current evidence is limited, the findings suggest that VR-based rehabilitation in subjects with SCI may lead to positive effects on aerobic function, balance, pain level, and motor function recovery besides improving psychological/motivational aspects. Further high-quality studies are needed to provide a guideline to clinical practice and to draw robust conclusions about the potential benefits of VR therapy for SCI patients. Protocol details are registered on PROSPERO (registration number: CRD42016052629).

Assessment of cognitive instrumental activities of daily living: a systematic review

PURPOSE

Cognitive instrumental activities of daily living are particularly related to executive functions, such as scheduling appointments, monthly payments, managing the household economy, shopping or taking the bus. The aim of this systematic review was to determine the available tests for the assessment of executive functions with ecological validity to predict individuals' functioning.

MATERIALS AND METHODS

An electronic search was conducted in MEDLINE, Cochrane Central, PsyCInfo and IEEE Xplore until May 2019, in addition to a manual search. The PRISMA criteria and the Covidence platform were used to select articles and extract data.

RESULTS

After applying the search selection criteria, 76 studies were identified. They referred to 110 tools to assess instrumental activities of daily living. Those that have received most attention are related to menu preparation and shopping. Performance-based measures are the most widely used traditional methods. Most tests were aimed at the adult population with acquired brain damage, cognitive impairment or dementia. There was a predominance of tests based on the Multiple Errands Test paradigm.

CONCLUSIONS

In recent years, it has increased the number of tools that assess the instrumental activities of daily living based on technologies such as personal or environmental sensors and serious games.IMPLICATIONS FOR REHABILITATIONAssessment of Instrumental Activities of Daily Living through performance-based measures is especially useful for the early detection of dysfunctions or preclinical disability.Difficulties in performing instrumental activities of daily living are closely associated with deficits in executive functions and prospective memory.Activities of Daily Living can be understood as multitasks.The use of virtual reality-based tests was shown to be sensitive to the detection of cognitive deficits in Activities of Daily Living.An advantage of using virtual reality in assessments is that it can help to predict the level of personal autonomy in patients who are in an institutional environment and could be a first approximation to the real environment.

Results From a Randomized Controlled Trial to Address Balance Deficits After Traumatic Brain Injury

OBJECTIVE

To evaluate the efficacy of an in-home 12-week physical therapy (PT) intervention that utilized a virtual reality (VR) gaming system to improve balance in individuals with traumatic brain injury (TBI).

SETTING

Home-based exercise program (HEP).

PARTICIPANTS

Individuals (N=63; traditional HEP n=32; VR n=31) at least 1 year post-TBI, ambulating independently within the home, not currently receiving PT services.

MAIN OUTCOME MEASURES

Primary: Community Balance and Mobility Scale (CB&M); Secondary: Balance Evaluation Systems Test (BESTest), Activities-Specific Balance Confidence Scale (ABC), Participation Assessment with Recombined Tools-Objective (PART-O).

RESULTS

No significant between-group differences were observed in the CB&M over the study duration (P=.9983) for individuals who received VR compared to those who received a HEP to address balance deficits after chronic TBI nor in any of the secondary outcomes: BESTest (P=.8822); ABC (P=.4343) and PART-O (P=.8822). However, both groups demonstrated significant improvements in CB&M and BESTest from baseline to 6, 12, and at 12 weeks follow-up (all P's <.001). Regardless of treatment group, 52% of participants met or exceeded the minimal detectable change of 8 points on the CB&M at 24 weeks and 38% met or exceeded the minimal detectable change of 7.81 points on the BESTest.

CONCLUSION

This study did not find that VR training was more beneficial than a traditional HEP for improving balance. However, individuals with chronic TBI in both treatment groups demonstrated improvements in balance in response to these interventions which were completed independently in the home environment.

Improving Cognitive Function after Traumatic Brain Injury: A Clinical Trial on the Potential Use of the Semi-Immersive Virtual Reality

Traumatic brain injury (TBI) is the most common cause of long-term disability and death among young adults, and it represents an enormous socioeconomic and healthcare burden. Our purpose is to evaluate the effects of a virtual reality training with BTs-Nirvana (BTs-N) on the recovery of cognitive functions in TBI subjects, using the interactive semi-immersive program. One hundred patients with TBI were enrolled in this study and randomized into either the Traditional Cognitive Rehabilitation Group (TCRG: n = 50) or the Virtual Reality Training Group (VRTG: n = 50). The VRTG underwent a VRT with BTs-N, whereas the TCRG received a standard cognitive treatment. Each treatment session lasted 60 minutes and was repeated three times a week for 8 weeks. All of the patients were evaluated by a specific psychometric battery before (T0) and immediately (T1) after the end of the training. VRTG and TCRG had a significant improvement in cognitive functioning and in mood, but only VRTG presented with a significant increase in cognitive flexibility and shifting skills and in selective attention. In conclusion, our results suggest that VR may be a useful and effective approach for the rehabilitation of patients with TBI, leading to better cognitive and behavioral outcomes.

A Randomized Feasibility Trial of a Novel, Integrative, and Intensive Virtual Rehabilitation Program for Service Members Post-Acquired Brain Injury

Introduction

Acquired Brain Injury, whether resulting from Traumatic brain injury (TBI) or Cerebral Vascular Accident (CVA), represent major health concerns for the Department of Defense and the nation. TBI has been referred to as the “signature” injury of recent U.S. military conflicts in Iraq and Afghanistan – affecting approximately 380,000 service members from 2000 to 2017; whereas CVA has been estimated to effect 795,000 individuals each year in the United States. TBI and CVA often present with similar motor, cognitive, and emotional deficits; therefore the treatment interventions for both often overlap. The Defense Health Agency and Veterans Health Administration would benefit from enhanced rehabilitation solutions to treat deficits resulting from acquired brain injuries (ABI), including both TBI and CVA. The purpose of this study was to evaluate the feasibility of implementing a novel, integrative, and intensive virtual rehabilitation system for treating symptoms of ABI in an outpatient clinic. The secondary aim was to evaluate the system’s clinical effectiveness.

Materials and Methods

Military healthcare beneficiaries with ABI diagnoses completed a 6-week randomized feasibility study of the BrightBrainer Virtual Rehabilitation (BBVR) system in an outpatient military hospital clinic. Twenty-six candidates were screened, consented and randomized, 21 of whom completed the study. The BBVR system is an experimental adjunct ABI therapy program which utilizes virtual reality and repetitive bilateral upper extremity training. Four self-report questionnaires measured participant and provider acceptance of the system. Seven clinical outcomes included the Fugl-Meyer Assessment of Upper Extremity, Box and Blocks Test, Jebsen-Taylor Hand Function Test, Automated Neuropsychological Assessment Metrics, Neurobehavioral Symptom Inventory, Quick Inventory of Depressive Symptomatology-Self-Report, and Post Traumatic Stress Disorder Checklist- Civilian Version. The statistical analyses used bootstrapping, non-parametric statistics, and multilevel/hierarchical modeling as appropriate. This research was approved by the Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences Institutional Review Boards.

Results

All of the participants and providers reported moderate to high levels of utility, ease of use and satisfaction with the BBVR system (x̄ = 73–86%). Adjunct therapy with the BBVR system trended towards statistical significance for the measure of cognitive function (ANAM [x̄ = −1.07, 95% CI −2.27 to 0.13, p = 0.074]); however, none of the other effects approached significance.

Conclusion

This research provides evidence for the feasibility of implementing the BBVR system into an outpatient military setting for treatment of ABI symptoms. It is believed these data justify conducting a larger, randomized trial of the clinical effectiveness of the BBVR system.

Cognitive rehabilitation post traumatic brain injury: A systematic review for emerging use of virtual reality technology

BACKGROUND

Traumatic brain injury (TBI) can causes numerous cognitive impairments usually in the aspects of problem-solving, executive function, memory, and attention. Several studies has suggested that rehabilitation treatment interventions can be effective in treating cognitive symptoms of brain injury. Virtual reality (VR) technology potential as a useful tool for the assessment and rehabilitation of cognitive processes.

OBJECTIVES

The aims of present systematic review are to examine effects of VR training intervention on cognitive function, and to identify effective VR treatment protocol in patients with TBI.

METHODS

PubMed, Scopus, PEDro, REHABDATA, EMBASE, web of science, and MEDLINE were searched for studies investigated effect of VR on cognitive functions post TBI. The methodological quality were evaluated using PEDro scale. The results of selected studies were summarized.

RESULTS

Nine studies were included in present study. Four were randomized clinical trials, case studies (n = 3), prospective study (n = 1), and pilot study (n = 1). The scores on the PEDro ranged from 0 to 7 with a mean score of 3. The results showed improvement in various cognitive function aspects such as; memory, executive function, and attention in patients with TBI after VR training.

CONCLUSION

Using different VR tools with following treatment protocol; 10-12 sessions, 20-40 min in duration with 2-4 sessions per week may improves cognitive function in patients with TBI. There was weak evidence for effects of VR training on attention post TBI.

Transcranial direct current stimulation for the treatment of motor impairment following traumatic brain injury

After traumatic brain injury (TBI), motor impairment is less common than neurocognitive or behavioral problems. However, about 30% of TBI survivors have reported motor deficits limiting the activities of daily living or participation. After acute primary and secondary injuries, there are subsequent changes including increased GABA-mediated inhibition during the subacute stage and neuroplastic alterations that are adaptive or maladaptive during the chronic stage. Therefore, timely and appropriate neuromodulation by transcranial direct current stimulation (tDCS) may be beneficial to patients with TBI for neuroprotection or restoration of maladaptive changes.Technologically, combination of imaging-based modelling or simultaneous brain signal monitoring with tDCS could result in greater individualized optimal targeting allowing a more favorable neuroplasticity after TBI. Moreover, a combination of task-oriented training using virtual reality with tDCS can be considered as a potent tele-rehabilitation tool in the home setting, increasing the dose of rehabilitation and neuromodulation, resulting in better motor recovery.This review summarizes the pathophysiology and possible neuroplastic changes in TBI, as well as provides the general concepts and current evidence with respect to the applicability of tDCS in motor recovery. Through its endeavors, it aims to provide insights on further successful development and clinical application of tDCS in motor rehabilitation after TBI.

Neurocognitive Assessment in Virtual Reality Through Behavioral Response Analysis

The ability to detect and diagnose neurocognitive disorders at the earliest possible moment is key to a better prognosis for the patient. Two of the earliest indicators of potential neurocognitive problems are motor and visual dysfunction. Motor disorders and problems in visual cognition can be seen in many neurocognitive disorders, resulting in abnormal physical reactions to visual stimuli. Analyzing physical behaviors when presented with such stimuli can provide insights into the visual perception and motor abilities of an individual, yet there is currently no unbiased, objective, general-purpose tool that analyzes attention and motor behavior to assess neurocognitive function. We propose a novel method of neurocognitive function assessment that tests the patient's cognition using virtual reality with eye tracking and motion analysis. By placing the patient in a controlled virtual environment and analyzing their movements, we can evoke certain physical responses from subjects for neurocognitive assessment. We have developed a prototype system that places the subject in a virtual baseball field and captures their full body motion as they try to catch baseballs. This scenario tests the subject's ability to determine the landing time and position of the ball, as well as the test subject's balance, motor skills, attention, and memory. Preliminary tests with 20 healthy normal individuals demonstrate the ability of this tool to assess the test subject's balance, memory, attention, and reaction to visual stimuli. This platform has a twofold contribution: it is used to assess several neurocognitive constructs that affect visual and motor capability neutrally and objectively based on controlled stimuli, and it enables objective comparison between different neurocognitive disorders research in this field.

The effectiveness of non-invasive brain stimulation on arousal and alertness in patients in coma or persistent vegetative state after traumatic brain injury: Protocol of systematic review and network meta-analysis

BACKGROUND

Traumatic brain injury is a leading cause of death and disability worldwide. The survivors usually suffer from disorders of consciousness, especially coma state and persistent vegetative state. For these patients, there is no standard treatment for them, but non-invasive brain stimulations are considered as relatively more acceptable treatments. However, the knowledge regarding the relative effectiveness and the rank of the effectiveness of the non-invasive brain stimulations is limited. Thus, in this study, we aim to conduct a systematic review and network meta-analysis to evaluate the effect of non-invasive train stimulations on arousal and alertness in patients in a coma or persistent vegetative state after traumatic brain injury.

METHODS AND ANALYSIS

A comprehensive search strategy will be performed in the relevant databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Chinese Biomedical Literature Database, China National Knowledge Infrastructure, Wan Fang Data). The random or quasi-random controlled trails focusing on the effectiveness of the non-invasive brain stimulations will be included. The risk of bias for the included studies will be appraised using the Cochrane collaboration tool for assessing risk of bias. The standard pairwise meta-analysis and a Bayesian network meta-analysis will be conducted.

ETHICS AND DISSEMINATION

This research is a systematic review and network meta-analysis. Thus, there is no requirement of ethical approval and patient informed consent.

PROSPERO REGISTRATION NUMBER

CRD42018104945.

Effectiveness of Virtual Reality for Children and Adolescents with Autism Spectrum Disorder: An Evidence-Based Systematic Review

Autism Spectrum Disorder (ASD) is a neurodevelopmental disease that is specially characterized by impairments in social communication and social skills. ASD has a high prevalence in children, affecting 1 in 160 subjects. Virtual reality (VR) has emerged as an effective tool for intervention in the health field. Different recent papers have reviewed the VR-based treatments in ASD, but they have an important limitation because they only use clinical databases and do not include important technical indexes such as the Web of Science index or the Scimago Journal & Country Rank. To our knowledge, this is the first contribution that has carried out an evidence-based systematic review including both clinical and technical databases about the effectiveness of VR-based intervention in ASD. The initial search identified a total of 450 records. After the exclusion of the papers that are not studies, duplicated articles, and the screening of the abstract and full text, 31 articles met the PICO (Population, Intervention, Comparison and Outcomes) criteria and were selected for analysis. The studies examined suggest moderate evidence about the effectiveness of VR-based treatments in ASD. VR can add many advantages to the treatment of ASD symptomatology, but it is necessary to develop consistent validations in future studies to state that VR can effectively complement the traditional treatments.

Using an interactive virtual environment to integrate a digital Action Research Arm Test, motor imagery and action observation to assess and improve upper limb motor function in patients with neuromuscular impairments: a usability and feasibility study protocol

INTRODUCTION

In the recent past, training systems using an interactive virtual environment have been introduced to neurorehabilitation. Such systems can be applied to encourage purposeful limb movements and will increasingly be used at home by the individual patient. Therefore, an integrated valid and reliable assessment tool on the basis of such a system to monitor the recovery process would be an essential asset.

OBJECTIVES

The aim of the study is to evaluate usability, feasibility and validity of the digital version of the Action Research Arm Test using the Bi-Manu-Trainer system as a platform. Additionally, the feasibility and usability of the implementation of action observation and motor imagery tasks into the Bi-Manu-Trainer software will be evaluated.

PATIENTS AND METHODS

This observational study is planned as a single-arm trial for testing the new assessment and the action observation and motor imagery training module. Therefore, 75 patients with Parkinson's disease, multiple sclerosis, stroke, traumatic brain injury or Guillain-Barré syndrome will be included. 30 out of the 75 patients will additionally take part in a 4-week training on the enhanced Bi-Manu-Trainer system. Primary outcomes will be the score on the System Usability Scale and the correlation between the conventional and digital Action Research Arm Test scores. Secondary outcomes will be hand dexterity, upper limb activities of daily living and quality of life.

HYPOTHESIS

We hypothesise that the digital Action Research Arm Test assessment is a valid and essential tool and that it is feasible to incorporate action observation and motor imagery into Bi-Manu-Trainer practice. The results are expected to give recommendations for necessary modifications and might also contribute knowledge concerning the application of action observation and motor imagery tasks using a training system such as the Bi-Manu-Trainer.

TRIAL REGISTRATION NUMBER

NCT03268304; Pre-results.

Virtual Reality for Traumatic Brain Injury

In this perspective, we discuss the potential of virtual reality (VR) in the assessment and rehabilitation of traumatic brain injury, a silent epidemic of extremely high burden and no pharmacological therapy available. VR, endorsed by the mobile and gaming industries, is now available in more usable and cheaper tools allowing its therapeutic engagement both at the bedside and during the daily life at chronic stages after injury with terrific potential for a longitudinal disease modifying effect.

Public Perceptions Regarding Use of Virtual Reality in Health Care: A Social Media Content Analysis Using Facebook

Background

Virtual reality (VR) technology provides an immersive environment that enables users to have modified experiences of reality. VR is increasingly used to manage patients with pain, disability, obesity, neurologic dysfunction, anxiety, and depression. However, public opinion regarding the use of VR in health care has not been explored. Understanding public opinion of VR is critical to ensuring effective implementation of this emerging technology.

Objective

This study aimed to examine public opinion about health care VR using social listening, a method that allows for the exploration of unfiltered views of topics discussed on social media and online forums.

Methods

In March 2016, NBC News produced a video depicting the use of VR for patient care. The video was repackaged by NowThis, a social media news website, and distributed on Facebook by Upworthy, a news aggregator, yielding 4.3 million views and 2401 comments. We used Microsoft Excel Power Query and ATLAS.ti software (version 7.5, Scientific Software Development) to analyze the comments using content analysis and categorized the comments around first-, second-, and third-order concepts. We determined self-identified gender from the user’s Facebook page and performed sentiment analysis of the language to analyze whether the perception of VR differed by gender using a Pearson’s chi-square test.

Results

Out of the 1614 analyzable comments, 1021 (63.26%) were attributed to female Facebook users, 572 (35.44%) to male users, and 21 (1.30%) to users of unknown gender. There were 1197 comments coded as expressing a positive perception about VR (74.16%), 251 coded as expressing a negative perception and/or concern (15.56%), and 560 coded as neutral (34.70%). Informants identified 20 use cases for VR in health care, including the use of VR for pain and stress reduction; bed-bound individuals; women during labor; and patients undergoing chemotherapy, dialysis, radiation, or imaging procedures. Negative comments expressed concerns about radiation, infection risk, motion sickness, and the ubiquity of and overall dependence on technology. There was a statistically significant association between the language valence of the Facebook post and the gender of the Facebook user; men were more likely to post negative perceptions about the use of VR for health care, whereas women were more likely to post positive perceptions (P<.001).

Conclusions

Most informants expressed positive perceptions about the use of VR in a wide range of health care settings. However, many expressed concerns that should be acknowledged and addressed as health care VR continues to evolve. Our results provide guidance in determining where further research on the use of VR in patient care is needed, and offer a formal opportunity for public opinion to shape the VR research agenda.

Tribes and tribulations: interdisciplinary eHealth in providing services for people with a traumatic brain injury (TBI)

Background

eHealth has potential for supporting interdisciplinary care in contemporary traumatic brain injury (TBI) rehabilitation practice, yet little is known about whether this potential is being realised, or what needs to be done to further support its implementation. The purpose of this study was to explore health professionals’ experiences of, and attitudes towards eHealth technologies to support interdisciplinary practice within rehabilitation for people after TBI.

Methods

A qualitative study using narrative analysis was conducted. One individual interview and three focus groups were conducted with health professionals (n = 17) working in TBI rehabilitation in public and private healthcare settings across regional and metropolitan New South Wales, Australia.

Results

Narrative analysis revealed that participants held largely favourable views about eHealth and its potential to support interdisciplinary practice in TBI rehabilitation. However, participants encountered various issues related to (a) the design of, and access to electronic medical records, (b) technology, (c) eHealth implementation, and (d) information and communication technology processes that disconnected them from the work they needed to accomplish. In response, health professionals attempted to make the most of unsatisfactory eHealth systems and processes, but were still mostly unsuccessful in optimising the quality, efficiency, and client-centredness of their work.

Conclusions

Attention to sources of disconnection experienced by health professionals, specifically design of, and access to electronic health records, eHealth resourcing, and policies and procedures related to eHealth and interdisciplinary practice are required if the potential of eHealth for supporting interdisciplinary practice is to be realised.

Technology-assisted rehabilitation interventions following pediatric brain injury

INTRODUCTION

Following traumatic brain injury (TBI), children experience a variety of physical, motor, speech, and cognitive deficits that can have a long-term detrimental impact. The emergence and popularity of new technologies has led to research into the development of various apps, gaming systems, websites, and robotics that might be applied to rehabilitation. The objective of this narrative review was to describe the current literature regarding technologically-assisted interventions for the rehabilitation of motor, neurocognitive, behavioral, and family impairments following pediatric TBI.

EVIDENCE ACQUISITION

We conducted a series of searches for peer-reviewed manuscripts published between 2000 and 2017 that included a technology-assisted component in the domains of motor, language/communication, cognition, behavior, social competence/functioning, family, and academic/school-based functioning.

EVIDENCE SYNTHESIS

Findings suggested several benefits of utilizing technology in TBI rehabilitation including facilitating engagement/adherence, increasing access to therapies, and improving generalizability across settings. There is fairly robust evidence regarding the efficacy of online family problem-solving therapy in improving behavior problems, executive functioning, and family functioning. There was less compelling, but still promising, evidence regarding the efficacy other technology for motor deficits, apps for social skills, and computerized programs for cognitive skills. Overall, many studies were limited in the rigor of their methodology due to small heterogeneous samples and lack of control groups.

CONCLUSIONS

Technology-assisted interventions have the potential to enhance pediatric rehabilitation after TBI. Future research is needed to further support their efficacy with larger controlled trials and to identify characteristics of children who are most likely to benefit.

The effects of video game therapy on balance and attention in chronic ambulatory traumatic brain injury: an exploratory study

Background

Patients with traumatic brain injury often have balance and attentive disorders. Video game therapy (VGT) has been proposed as a new intervention to improve mobility and attention through a reward-learning approach. In this pilot randomized, controlled trial, we tested the effects of VGT, compared with a balance platform therapy (BPT), on balance, mobility and selective attention in chronic traumatic brain injury patients.

Methods

We enrolled chronic traumatic brain injury patients (n = 21) that randomly received VGT or BPT for 3 sessions per week for 6 weeks. The clinical outcome measures included: i) the Community Balance & Mobility Scale (CB&M); ii) the Unified Balance Scale (UBS); iii) the Timed Up and Go test (TUG); iv) static balance and v) selective visual attention evaluation (Go/Nogo task).

Results

Both groups improved in CB&M scores, but only the VGT group increased on the UBS and TUG with a between-group significance (p < 0.05). Selective attention improved significantly in the VGT group (p < 0.01).

Conclusions

Video game therapy is an option for the management of chronic traumatic brain injury patients to ameliorate balance and attention deficits.

Trial registration

NCT01883830, April 5 2013.

The effects of active video games on patients' rehabilitative outcomes: A meta-analysis

A meta-analysis on Active Video Games (AVG) as a rehabilitative tool does not appear to be available. This meta-analytic review synthesizes the effectiveness of AVGs on patients' rehabilitative outcomes. Ninety-eight published studies on AVGs and rehabilitation were obtained in late 2015 with 14 meeting the following inclusion criteria: 1) data-based English articles; 2) randomized-controlled trials investigating AVG's effect on rehabilitative outcome(s); and 3) ≥1 comparison present in each study. Data extraction for comparisons was completed for three age categories: 1) youth/young adults (5-25years-old); 2) middle-aged adults (40-65years-old); and 3) older adults (≥65years-old). Comprehensive Meta-Analysis software calculated effect size (ES; Hedge's g). Comparison group protocols often employed another non-AVG experimental treatment. Control group protocols implemented standard care. AVGs demonstrated a large positive effect on balance control over control among youth/young adults (ES=0.81, p<0.01). Further, AVGs resulted in small positive effects on middle-aged adults' balance control over control (ES=0.143, p=0.48) and comparison (ES=0.14, p=0.53), with similar results in older adults compared to control (ES=0.16, p=0.27). Notably, AVG's effect on balance control versus comparison among older adults was small yet negative (ES=-0.12, p=0.63). AVGs were also used to enhance general physical functioning (GPF) among middle-aged and older adults. Versus control and comparison, AVGs had no effect on middle-aged adults' GPF (ES=-0.054 and -0.046, respectively) or older adults' GPF (ES=0.04 and 0.002, respectively). Finally, AVGs had a moderate effect on older adults' falls efficacy versus control (ES=0.61, p<0.05). Findings favor AVGs for youth/young adult balance control rehabilitation and falls efficacy promotion in older adults.