Virtual multiple errands test (VMET): a virtual reality-based tool to detect early executive functions deficit in Parkinson's disease

Predictive validity of the Oxford digital multiple errands test (OxMET) for functional outcomes after stroke

The Oxford Digital Multiple Errands Test (OxMET) is a brief computer-tablet based cognitive screen, intended as an ecologically valid assessment of executive dysfunction. We examined aspects of predictive validity in relation to functional outcomes. Participants (≤ 2 months post-stroke) were recruited from an English-speaking stroke rehabilitation in-patient setting. Participants completed OxMET. The Barthel Index, Therapy Outcome Measure (TOMS), and modified Rankin Scale (mRS) were collected from medical notes. Participants were followed up after 6-months and completed the Nottingham Extended Activities of Daily Living (NEADL) scale. 117 participants were recruited (M = 26.18 days post-stroke (SD = 25.16), mean 74.44yrs (SD  = 12.88), median NIHSS 8.32 (IQR = 5-11)). Sixty-six completed a follow-up (M = 73.94yrs (SD  = 12.68), median NIHSS 8 (IQR = 4-11)). Significant associations were found between TOMS and mRS. At 6-month follow up, we found a moderate predictive relationship between the OxMET accuracy and NEADL (R2 = .29, p < .001), and we did not find this prediction with MoCA taken at 6-months. The subacute OxMET associated with measures of functionality and disability in a rehabilitation context, and in activities of daily living. The OxMET is an assessment of executive function with good predictive validity on clinically relevant functional outcome measures that may be more predictive than other cognitive tests.

Conceptualization of the term "ecological validity" in neuropsychological research on executive function assessment: a systematic review and call to action

OBJECTIVE

"Ecological validity" (EV) is classically defined as test's ability to predict real-world functioning, either alone or together with test's similarity to real-world tasks. In neuropsychological literature on assessment of executive functions (EF), EV is conceptualized inconsistently, leading to misconceptions about the utility of tests. The goal of this systematic review was to examine how EV is conceptualized in studies of EF tests described as ecologically valid.

METHOD

MEDLINE and PsychINFO Databases were searched. PRISMA guidelines were observed. After applying inclusion and exclusion criteria, this search yielded 90 articles. Deductive content analysis was employed to determine how the term EV was used.

RESULTS

About 1/3 of the studies conceptualized EV as the test's ability to predict functional outcomes, 1/3 as both the ability to predict functional outcome and similarity to real-world tasks, and 1/3 were either unclear about the meaning of the term or relied on notions unrelated to classical definitions (e.g., similarity to real-world tasks alone, association with other tests, or the ability to discriminate between populations).

CONCLUSIONS

Conceptualizations of the term EV in literature on EF assessment vary grossly, subsuming the notions of criterion, construct, and face validity, as well as sensitivity/specificity. Such inconsistency makes it difficult to interpret clinical utility of tests that are described as ecologically valid. We call on the field to require that, at minimum, the term EV be clearly defined in all publications, or replaced with more concrete terminology (e.g., criterion validity).

Comparing the Oxford Digital Multiple Errands Test (OxMET) to a real-life version: Convergence, feasibility, and acceptability

We aimed to assess the convergence, feasibility, and acceptability of the Oxford Digital Multiple Errands Test (OxMET) and the in-person Multiple Errands Test-Home version (MET-Home). Participants completed OxMET, MET-Home, Montreal Cognitive Assessment (MoCA), and questionnaires on activities of daily living, depression, technology usage, mobility, and disability. Forty-eight stroke survivors (mean age 69.61, 41.67% female, and average 16.5 months post-stroke) and 50 controls (mean age 71.46, 56.00% female) took part. No performance differences were found for healthy and stroke participants for MET-Home, and only found below p = .05 for OxMET but not below the corrected p = .006. Convergent validity was found between MET-Home and OxMET metrics (most r ≥ .30, p < .006). MET-Home accuracy was related to age (B = -.04, p = .03), sex (B = -.98, p = .03), disability (B = -0.63, p = .04), and MoCA (B = .26, p < .001), whereas OxMET accuracy was predicted by MoCA score (B = .40, p < .001). Feedback indicated that the OxMET was easy and fun and more acceptable than the MET-Home. The MET-Home was more stressful and interesting. The MET tasks demonstrated good convergent validity, with the OxMET digital administration providing a more feasible, inclusive, and acceptable assessment, especially to people with mobility restrictions and more severe stroke.

Immersive Virtual Reality-Based Methods for Assessing Executive Functioning: Systematic Review

BACKGROUND

Neuropsychological assessments traditionally include tests of executive functioning (EF) because of its critical role in daily activities and link to mental disorders. Established traditional EF assessments, although robust, lack ecological validity and are limited to single cognitive processes. These methods, which are suitable for clinical populations, are less informative regarding EF in healthy individuals. With these limitations in mind, immersive virtual reality (VR)-based assessments of EF have garnered interest because of their potential to increase test sensitivity, ecological validity, and neuropsychological assessment accessibility.

OBJECTIVE

This systematic review aims to explore the literature on immersive VR assessments of EF focusing on (1) EF components being assessed, (2) how these assessments are validated, and (3) strategies for monitoring potential adverse (cybersickness) and beneficial (immersion) effects.

METHODS

EBSCOhost, Scopus, and Web of Science were searched in July 2022 using keywords that reflected the main themes of VR, neuropsychological tests, and EF. Articles had to be peer-reviewed manuscripts written in English and published after 2013 that detailed empirical, clinical, or proof-of-concept studies in which a virtual environment using a head-mounted display was used to assess EF in an adult population. A tabular synthesis method was used in which validation details from each study, including comparative assessments and scores, were systematically organized in a table. The results were summed and qualitatively analyzed to provide a comprehensive overview of the findings.

RESULTS

The search retrieved 555 unique articles, of which 19 (3.4%) met the inclusion criteria. The reviewed studies encompassed EF and associated higher-order cognitive functions such as inhibitory control, cognitive flexibility, working memory, planning, and attention. VR assessments commonly underwent validation against gold-standard traditional tasks. However, discrepancies were observed, with some studies lacking reported a priori planned correlations, omitting detailed descriptions of the EF constructs evaluated using the VR paradigms, and frequently reporting incomplete results. Notably, only 4 of the 19 (21%) studies evaluated cybersickness, and 5 of the 19 (26%) studies included user experience assessments.

CONCLUSIONS

Although it acknowledges the potential of VR paradigms for assessing EF, the evidence has limitations. The methodological and psychometric properties of the included studies were inconsistently addressed, raising concerns about their validity and reliability. Infrequent monitoring of adverse effects such as cybersickness and considerable variability in sample sizes may limit interpretation and hinder psychometric evaluation. Several recommendations are proposed to improve the theory and practice of immersive VR assessments of EF. Future studies should explore the integration of biosensors with VR systems and the capabilities of VR in the context of spatial navigation assessments. Despite considerable promise, the systematic and validated implementation of VR assessments is essential for ensuring their practical utility in real-world applications.

Development of a generic version of the multiple errands test for severe acquired brain injuries

BACKGROUND

Impairment of executive functions is a frequent and disabling consequence of brain injury. In 1991, Shallice and Burgess elaborated the Multiple Errand Test (MET) to assess everyday troubles associated with this impairment.

OBJECTIVE

Our first aim was to create a generic version of MET (MET-G) readily adaptable to different settings and for retesting. The second aim was to validate the revised version to detect executive impairment in individuals with severe ABI.

METHODS

An inter-professional team of experts in neurorehabilitation created a revised version of MET. Twenty-one patients with sABI (severe Acquired Brain Injury) and a control group of 20 neurologically healthy subjects, took part in the testing of MET-G.

RESULTS

MET-G clearly distinguished people with sABI from healthy controls based on Total error score, task completion, and rule breaking. The test showed good inter-rater reliability and internal consistency.

CONCLUSIONS

The new, generic version of MET was able to differentiate adults with sABI from controls and proved to be a good tool for evaluating executive functions in these patients in daily-life contexts. Indications on how to adapt the test to different contexts and different scoring modalities are provided.

Psychometric validation for a brand-new tool for the assessment of executive functions using 360° technology

EXecutive-functions Innovative Tool 360° (EXIT 360°) is an original 360° instrument for an ecologically valid and multicomponent evaluation of executive functioning. This work aimed to test the diagnostic efficacy of EXIT 360° in distinguishing executive functioning between healthy controls (HC) and patients with Parkinson's Disease (PwPD), a neurodegenerative disease in which executive dysfunction is the best-defined cognitive impairment in the early stage. 36 PwPD and 44 HC underwent a one-session evaluation that involved (1) neuropsychological evaluation of executive functionality using traditional paper-and-pencil tests, (2) EXIT 360° session and (3) usability assessment. Our findings revealed that PwPD made significantly more errors in completing EXIT 360° and took longer to conclude the test. A significant correlation appeared between neuropsychological tests and EXIT 360° scores, supporting a good convergent validity. Classification analysis indicated the potential of the EXIT 360° for distinguishing between PwPD and HC in terms of executive functioning. Moreover, indices from EXIT 360° showed higher diagnostic accuracy in predicting PD group membership compared to traditional neuropsychological tests. Interestingly, EXIT 360° performance was not affected by technological usability issues. Overall, this study offers evidence that EXIT 360° can be considered an ecological tool highly sensitive to detect subtle executive deficits in PwPD since the initial phases of the disease.

Virtual reality technology in neuropsychological testing: A systematic review

Neuropsychological testing aims to measure individuals' cognitive abilities (e.g. memory, attention), analysing their performance on specific behavioural tasks. Most neuropsychological tests are administered in the so-called 'paper-and-pencil' modality or via computerised protocols. The adequacy of these procedures has been recently questioned, with more specific concerns about their ecological validity, i.e. the relation between test scores observed in the laboratory setting and the actual everyday cognitive functioning. In developing more ecological tasks, researchers started to implement virtual reality (VR) technology as an administration technique focused on exposing individuals to simulated but realistic stimuli and environments, maintaining at the same time a controlled laboratory setting and collecting advanced measures of cognitive functioning. This systematic review aims to present how VR procedures for neuropsychological testing have been implemented in the last years. We initially explain the rationale for supporting VR as an advanced assessment tool, but we also discuss the challenges and risks that can limit the widespread implementation of this technology. Then, we systematised the large body of studies adopting VR for neuropsychological testing, describing the VR tools' distribution amongst different cognitive functions through a PRISMA-guided systematic review. The systematic review highlighted that only very few instruments are ready for clinical use, reporting psychometric proprieties (e.g. validity) and providing normative data. Most of the tools still need to be standardised on large cohorts of participants, having published only limited data on small samples up to now. Finally, we discussed the possible future directions of the VR neuropsychological test development linked to technological advances.

Virtual Reality for Motor and Cognitive Rehabilitation

Virtual Reality (VR) affords clinicians the ability to deliver safe, controlled, task-specific customised interventions that are enjoyable, motivating and engaging. Elements of training in VR comply with principles of learning implicated in new skill acquisition and re-learning skills post-neurological disorders. However, heterogeneity in the description of VR systems and the description and control of 'active' ingredients of interventions (like dosage, type of feedback, task specificity, etc.) have led to inconsistency in the synthesis and interpretation of evidence related to the effectiveness of VR-based interventions, particularly in post-stroke and Parkinson's Disease (PD) rehabilitation. This chapter attempts to describe VR interventions with respect to their compliance with principles of neurorehabilitation, with the goal of optimising interventions for effective training and facilitation of maximum functional recovery. This chapter also advocates using a uniform framework to describe VR systems to promote homogeneity in literature in order to help in the synthesis of evidence. An overview of the evidence revealed that VR systems are effective in mediating deficits in upper extremity, posture and gait function seen in people post-stroke and PD. Generally, interventions were more effective when they were delivered as an adjunct to conventional therapy and were customised for rehabilitation purposes, in addition to complying with principles of learning and neurorehabilitation. Although recent studies imply that their VR intervention is compliant with principles of learning, only a few explicitly describe how these principles are incorporated as 'active ingredients' of the intervention. Finally, VR interventions targeting community ambulation and cognitive rehabilitation are yet limited and therefore warrant attention.

Digital healthcare for dementia and cognitive impairment: A scoping review

BACKGROUND

Cognitive disorders, such as Alzheimer's disease, are a global health problem. Digital healthcare technology is an innovative management tool for delaying the progression of dementia and mild cognitive impairment. Thanks to digital technology, the possibility of safe and effective care for patients at home and in the community is increasing, even in situations that threaten the continuity of care, such as the COVID-19 pandemic. However, it is difficult to select appropriate technology and alternatives due to the lack of comprehensive reviews on the types and characteristics of digital technology for cognitive impairment, including their effects and limitations.

OBJECTIVE

This study aims to identify the types of digital healthcare technology for dementia and mild cognitive impairment and comprehensively examine how its outcome measures were constructed in line with each technology's purpose.

METHODS

According to the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews guidelines, a literature search was conducted in August 2021 using Medline (Ovid), EMBASE, and Cochrane library. The search terms were constructed based on Population-Concept-Context mnemonic: 'dementia', 'cognitive impairment', and 'cognitive decline'; digital healthcare technology, such as big data, artificial intelligence, virtual reality, robots, applications, and so on; and the outcomes of digital technology, such as accuracy of diagnosis and physical, mental, and social health. After grasping overall research trends, the literature was classified and analysed in terms of the type of service users and technology.

RESULTS

In total, 135 articles were selected. Since 2015, an increase in literature has been observed, and various digital healthcare technologies were identified. For people with mild cognitive impairment, technology for predicting and diagnosing the onset of dementia was studied, and for people with dementia, intervention technology to prevent the deterioration of health and induce significant improvement was considered. Regarding caregivers, many studies were conducted on monitoring and daily living assistive technologies that reduce the burden of care. However, problems such as data collection, storage, safety, and the digital divide persisted at different intensities for each technology type.

CONCLUSIONS

This study revealed that appropriate technology options and considerations may differ depending on the characteristics of users. It also emphasises the role of humans in designing and managing technology to apply digital healthcare technology more effectively.

Virtual reality in the diagnostic and therapy for mental disorders: A systematic review

BACKGROUND

Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders.

OBJECTIVE

To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders.

DATA SOURCE

Systematic literature searches via PubMed (last literature update: 9^th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders.

ELIGIBILITY CRITERIA

To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology.

STUDY EVALUATION

For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria.

RESULTS

Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder.

CONCLUSION

While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application.

REVIEW REGISTRATION

PROSPERO register CRD42020188436.

FUNDING

The review was funded by budgets from the University of Bonn. No third party funding was involved.

Quantifying ADHD Symptoms in Open-Ended Everyday Life Contexts With a New Virtual Reality Task

OBJECTIVE

To quantify goal-directed behavior and ADHD symptoms in naturalistic conditions, we developed a virtual reality task, EPELI (Executive Performance in Everyday LIving), and tested its predictive, discriminant and concurrent validity.

METHOD

We collected EPELI data, conventional neuropsychological task data, and parent-ratings of executive problems and symptoms in 38 ADHD children and 38 typically developing controls.

RESULTS

EPELI showed predictive validity as the ADHD group exhibited higher percentage of irrelevant actions reflecting lower attentional-executive efficacy and more controller movements and total game actions, both indicative of hyperactivity-impulsivity. Further, the five combined EPELI measures showed excellent discriminant validity (area under curve 88 %), while the correlations of the EPELI efficacy measure with parent-rated executive problems (r = .57) and ADHD symptoms (r = .55) pointed to its concurrent validity.

CONCLUSION

We provide a proof-of-concept validation for a new virtual reality tool for ecologically valid assessment of ADHD symptoms.

Identifying Appropriate Neuropsychological Tests for Uneducated/Illiterate Older Individuals

OBJECTIVES

We investigated the utility of traditional neuropsychological tests in older uneducated/illiterate individuals without dementia to determine the possibility that they are likely not appropriate for this group.

METHODS

We assessed the neuropsychological performance of 1122 older adults [≥65 years old; mean age: 74.03 (SD = 5.46); mean education: 4.76 (SD = 2.5) years; women: n = 714], in the context of the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD), a population-based study conducted in Greece.

RESULTS

We based our analyses on three groups: high-functioning/cognitively healthy (i.e., without dementia) uneducated/illiterate individuals (n = 80), high-functioning/cognitively healthy educated/literate individuals (n = 932), and low-functioning/cognitively impaired educated/literate individuals (presumably with dementia; n = 110). We used binary regression analyses with Bonferroni correction to investigate whether test performance differentiated uneducated/illiterate from educated/literate individuals. Models were adjusted for age and sex; raw test scores were the predictor variables. The uneducated/illiterate cohort was at a disadvantage relative to the healthy educated/literate group on all variables but verbal memory recognition and consolidation, congruent motor responses, and phonological fluency clustering (p > .002). Moreover, only word list learning immediate and delayed free recall and delayed cued recall differentiated the high-functioning/cognitively healthy uneducated/illiterate from the low-functioning/cognitively impaired educated/literate group, favoring the former (p's < .002).

CONCLUSIONS

Our findings suggest that only particular verbal memory test variables are fair in determining whether older uneducated/illiterate individuals have functional/cognitive impairment suggestive of a neurodegenerative process. On all other neuropsychological variables, this cohort was at a disadvantage. Therefore, we highlight the need for identifying appropriate methods of assessment for older uneducated/illiterate individuals.

Available Virtual Reality-Based Tools for Executive Functions: A Systematic Review

Introduction

Executive dysfunctions constitute a significant public health problem: their high impact on everyday life makes it a priority to identify early strategies for evaluating and rehabilitating these disorders in a real-life context. The ecological limitation of traditional neuropsychological tests and several difficulties in administering tests or training in real-life scenarios have paved the way to use Virtual Reality-based tools to evaluate and rehabilitate Executive Functions (EFs) in real-life.

Objective

This work aims to conduct a systematic review to provide a detailed description of the VR-based tools currently developed for the evaluation and rehabilitation of EFs.

Methods

We systematically searched for original manuscripts regarding VR tools and EFs by looking for titles and abstracts in the PubMed, Scopus, PsycInfo, and Web of Science databases up to November 2021 that contained the following keywords “Virtual Reality” AND “Executive function^*.”

Results and Conclusion

We analyzed 301 articles, of which 100 were included. Our work shows that available VR-based tools appear promising solutions for an ecological assessment and treatment of EFs in healthy subjects and several clinical populations.

Designing Virtual Reality Assisted Psychotherapy for Anxiety in Older Adults Living with Parkinson's Disease: Integrating Literature for Scoping

Objective: This review integrates literature to discuss the potential use of virtual reality (VR) in treatment of anxiety in Parkinson's disease (PD) and inform next steps.Methods: A systematic search was performed to identify studies of VR use in PD, using four databases. Data were reported in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analyzes extension for Scoping Reviews (PRISMA-ScR).Results: Thirty-two studies met the inclusion criteria with four VR studies from the same study group directly assessing the effects of anxiety on motor symptoms in PD. Primary studies implementing a VR protocol in PD identified focus areas of understanding and alleviating freezing of gait (FOG), balance training, and cognitive and motor rehabilitation, and informed design considerations.Conclusion: VR in PD studies suggested established feasibility. With appropriate design considerations, a VR based protocol could improve anxiety outcomes in PD.Clinical implications: VR in PD provides control of a patient's field of view, which can be exploited to induce specific responses, provide visual feedback, analysis of patient actions, and introduce safe challenges in the context of training. VR assisted Cognitive Behavioral Therapy (CBT) tailored to suit subtypes of anxiety disorders in PD have the potential to improve the efficacy and effectiveness of psychotherapy in PD.

A Psychometric Tool for Evaluating Executive Functions in Parkinson's Disease

Recently, there has been an increasing interest in using 360° virtual-reality video for an ecologically valid assessment of executive functioning in the neurologic population. In this framework, we have developed the EXecutive-functions Innovative Tool (EXIT 360°), an original 360°-based instrument for a multicomponent, ecologically valid evaluation of executive functioning in Parkinson’s Disease (PD). This work aimed to test the usability and user experience of EXIT 360° in patients with PD (PwPD). Twenty-seven PwPD and twenty-seven healthy controls underwent an evaluation that involved: (1) usability assessment by the System Usability Scale and (2) evaluation of user experience using the ICT—Sense of Presence and User Experience Questionnaire. Results showed a satisfactory level of usability for patients (mean = 76.94 ± 9.18) and controls (mean = 80 ± 11.22), with good scores for usability and learnability. Regarding user experience, patients provided a positive overall impression of the tool, evaluating it as attractive, enjoyable, activating, and funny. Moreover, EXIT 360° showed good pragmatic (e.g., efficient, fast, clear) and hedonic quality (e.g., exciting, interesting, and creative). Finally, PwPD considered EXIT 360° as an original tool with high ecological validity (mean = 4.29 ± 0.61), spatial presence (mean = 3.11 ± 0.83) and engagement (mean = 3.43 ± 0.54) without relevant adverse effects. Technological expertise had no impact on performance. Overall, EXIT 360° appeared to be a usable, easy-to-learn, engaging, and innovative instrument for PD. Further studies will be conducted to deepen its efficacy in distinguishing between healthy subjects and patients with executive dysfunctions.

A Review of the Potential of Virtual Walking Techniques for Gait Rehabilitation

Virtual reality (VR) technology has emerged as a promising tool for studying and rehabilitating gait disturbances in different cohorts of patients (such as Parkinson's disease, post-stroke, or other neurological disorders) as it allows patients to be engaged in an immersive and artificial environment, which can be designed to address the particular needs of each individual. This review demonstrates the state of the art in applications of virtual walking techniques and related technologies for gait therapy and rehabilitation of people with movement disorders makes recommendations for future research and discusses the use of VR in the clinic. However, the potential for using these techniques in gait rehabilitation is to provide a more personalized approach by simulate the experience of natural walking, while patients with neurological disorders are maintained localized in the real world. The goal of our work is to investigate how the human nervous system controls movement in health and neurodegenerative disease.

EXecutive-Functions Innovative Tool (EXIT 360°): A Usability and User Experience Study of an Original 360°-Based Assessment Instrument

Over the last few decades, several studies have shown the feasibility, acceptability, and efficacy of VR-based instruments in the early evaluation of executive dysfunction (ED) in psychiatric and neurologic conditions. Due to the negative impact of ED in everyday functioning, identifying innovative strategies for evaluating ED allows clinicians to detect executive impairment early and minimize its effects. This work aimed to test the usability and user experience (UX) of EXecutive-functions Innovative Tool 360° (EXIT 360°), a 360°-based tool for assessing ED. Seventy-six healthy subjects underwent an evaluation that involved (1) usability assessment using System Usability Scale and (2) evaluation of UX using the ICT-Sense of Presence and UX Questionnaire. Results showed a satisfactory level of usability (mean = 75.9 ± 12.8), with good scores for usability and learnability. As regards UX, EXIT 360° showed an absence of negative effects (mean = 1.79 ± 0.95) and high scores in ecological validity (mean = 4.32 ± 0.54) and engagement (mean = 3.76 ± 0.56). Moreover, it obtained good scores in efficiency (mean = 1.84 ± 0.84), originality (mean = 2.49 ± 0.71), and attractiveness (mean = 1.93 ± 0.98). Interestingly, demographic characteristics and technological expertise had no impact on the performance (p > 0.05). Overall, EXIT 360° appeared to be a usable, learn-to-use, engaging, and creative tool with irrelevant negative effects. Further studies will be conducted to evaluate these aspects in the clinical population.

The night out task and scoring application: an ill-structured, open-ended clinic-based test representing cognitive capacities used in everyday situations

OBJECTIVE

The night out task (NOT) was developed as a naturalistic, open-ended, multitasking measure that requires individuals to complete eight subtasks comparable to those encountered during real-world functioning (e.g., pack travel bag, prepare tea). We examined psychometric properties and administration feasibility of this direct observation measure within a clinic-like setting using a tablet-based coding application.

METHOD

A sample of 148 community-dwelling older adults (82% cognitively healthy; 18% mild cognitive impairment) and 57 younger adults completed the NOT along with other neurocognitive tests and questionnaires.

RESULTS

Inter-rater reliability across NOT primary (i.e., time, accuracy, efficiency) and process-related (e.g., error-types, self-corrections) variables was mostly excellent. NOT primary measures showed expected patterns of convergent and discriminant validity with measures of cognition, demographics, and well-being. External validity was established by the NOT ability to distinguish between age and diagnostic (cognitively healthy vs. mild cognitive impairment) groups. Demonstrating incremental validity, the NOT primary variables (execution time in particular) were predictive of self-reported functional abilities and completion quality of in-home everyday tasks over and earlier variables such as demographics, cognition, and mobility.

CONCLUSIONS

These findings suggest that the NOT and its app interface, which allows for continuous logging of observations, are a feasible in-clinic measure to assess cognitive capacities important for real-world functioning. With further validation, the NOT may allow for earlier detection of functional difficulties. Understanding errors and strategies used during NOT performance could also have implications for individualized interventions.

A Simple and Effective Way to Study Executive Functions by Using 360° Videos

Executive dysfunctions constitute a significant public health problem due to their high impact on everyday life and personal independence. Therefore, the identification of early strategies to assess and rehabilitate these impairments appears to be a priority. The ecological limitations of traditional neuropsychological tests and the numerous difficulties in administering tests in real-life scenarios have led to the increasing use of virtual reality (VR) and 360° environment-based tools for assessing executive functions (EFs) in real life. This perspective aims at proposing the development and implementation of Executive-functions Innovative Tool 360° (EXIT 360°), an innovative, enjoyable, and ecologically valid tool for a multidimensional and multicomponent evaluation of executive dysfunctions. EXIT 360° allows a complete and integrated executive functioning assessment through an original task for EFs delivered via a mobile-powered VR headset combined with eye tracker (ET) and electroencephalograms (EEG). Our tool is born as a 360°-based instrument, easily accessible and clinically usable, that will radically transform clinicians’ and patient’s assessment experience. In EXIT 360°, patients are engaged in a “game for health,” where they must perform everyday subtasks in 360° daily life environments. In this way, the clinicians can obtain quickly more ecologically valid information about several aspects of EFs (e.g., planning, problem-solving). Moreover, the multimodal approach allows completing the assessment of EFs by integrating verbal responses, reaction times, and physiological data (eye movements and brain activation). Overall, EXIT 360° will allow obtaining simultaneously and in real time more information about executive dysfunction and its impact in real life, allowing clinicians to tailor the rehabilitation to the subject’s needs.

The Virtual Cooking Task: A Preliminary Comparison Between Neuropsychological and Ecological Virtual Reality Tests to Assess Executive Functions Alterations in Patients Affected by Alcohol Use Disorder

Alcohol use disorder (AUD) is a major global problem. Neuropsychological studies have shown that AUD causes deficits in executive functions (EFs), a set of higher order cognitive skills that govern individual behavior in everyday situations. Many standardized neuropsychological tests are used to evaluate EF. These are reliable and valid but have limitations in predicting real-life performance. To address this, we present a preliminary study to test the virtual cooking task (VCT) as an alternative to standardized neuropsychological tests. The VCT includes four subtasks developed to assess attentional, planning, and cognitive shifting abilities; it was tested in an immersive three-dimensional environment. To evaluate the VCT performance and standardized neuropsychological tests, data were gathered from a sample of healthy subjects (control group [CG]; n = 23) and AUD patients (n = 18). The standardized neuropsychological measures used consisted of questionnaires (Attentional Control Scale, Barratt Impulsiveness Scale, and Cognitive Flexibility Scale) and specific tests (Dot-probe task, Go/No-go test, Stroop test, the trail making test, and Tower of London test). The results showed significant higher correlations for AUD patients than for the CG for the VCT, questionnaires, and specific tests, mainly related to planning and cognitive shifting abilities. Furthermore, comparative analyses of the VCT performance showed that the AUD patients made more errors and had higher latency times than the CG. The present study provides initial evidence that a more ecologically valid assessment can be a useful tool to detect cognitive impairments in many neuropsychological and mental disorders, affecting daily activities.

The Smart Aging Platform for Assessing Early Phases of Cognitive Impairment in Patients With Neurodegenerative Diseases

Background: Smart Aging is a serious game (SG) platform that generates a 3D virtual reality environment in which users perform a set of screening tasks designed to allow evaluation of global cognition. Each task replicates activities of daily living performed in a familiar environment. The main goal of the present study was to ascertain whether Smart Aging could differentiate between different types and levels of cognitive impairment in patients with neurodegenerative disease.

Methods: Ninety-one subjects (mean age = 70.29 ± 7.70 years)—healthy older adults (HCs, n = 23), patients with single-domain amnesic mild cognitive impairment (aMCI, n = 23), patients with single-domain executive Parkinson's disease MCI (PD-MCI, n = 20), and patients with mild Alzheimer's disease (mild AD, n = 25)—were enrolled in the study. All participants underwent cognitive evaluations performed using both traditional neuropsychological assessment tools, including the Mini-Mental State Examination (MMSE), Montreal Overall Cognitive Assessment (MoCA), and the Smart Aging platform. We analyzed global scores on Smart Aging indices (i.e., accuracy, time, distance) as well as the Smart Aging total score, looking for differences between the four groups.

Results: The findings revealed significant between-group differences in all the Smart Aging indices: accuracy (p < 0.001), time (p < 0.001), distance (p < 0.001), and total Smart Aging score (p < 0.001). The HCs outperformed the mild AD, aMCI, and PD-MCI patients in terms of accuracy, time, distance, and Smart Aging total score. In addition, the mild AD group was outperformed both by the HCs and by the aMCI and PD-MCI patients on accuracy and distance. No significant differences were found between aMCI and PD-MCI patients. Finally, the Smart Aging scores significantly correlated with the results of the neuropsychological assessments used.

Conclusion: These findings, although preliminary due to the small sample size, suggest the validity of Smart Aging as a screening tool for the detection of cognitive impairment in patients with neurodegenerative diseases.

Virtual Reality (VR) Applications in Cardiology: A Review

Virtual reality (VR) has applications in cardiology to create enhancement, thereby improving the quality of associated planning, treatment and surgery. The need is to study different applications of this technology in the field of cardiology. We have studied research papers on VR and its applications in cardiology through a detailed bibliometric analysis. The study identified five significant steps for proper implementation of this technology in cardiology. Some challenges are to be undertaken by using this technology, and they can provide some benefits; thus, authors contemplate extensive research and development. This study also identifies 10 major VR technology applications in cardiology and provided a brief description. This innovative technology helps a heart surgeon to perform complex heart surgery effectively. Thus, VR applications have the potential for improving decision-making, which helps save human life. VR plays a significant role in the development of a surgical procedure. This technology undertakes 3D heart model information in full colour, which helps to analyze the overall heart vane, blockage and blood flow. With the help of this digital technology, a surgeon can improve the accuracy of heart surgery, and he can simulate the surgery. A surgeon can undertake surgery in a virtual environment on a virtual patient. The unique purpose of this technology is to practice pre-operatively on the specific circumstance. A cardiologist can also check the proper status of inner and outer heart wall layer. Thus, by using this 3D information, the surgeon can now interact with heart data/information without any physical touch. This technology opens a new opportunity to improve the heart surgery and development in cardiovascular treatment to improve patient outcome.

The Oxford digital multiple errands test (OxMET): Validation of a simplified computer tablet based multiple errands test

Impairments in executive functioning are common following Acquired Brain Injury, though there are few screening tools which present a time efficient and ecologically valid approach to assessing the consequences of executive impairments. We present the Oxford Digital Multiple Errands Test (OxMET), a novel and simplified computer-tablet version of a Multiple Errands Test. We recruited 124 neurologically healthy controls and 105 stroke survivors to complete the OxMET task. Normative data and internal consistency were established from the healthy control data. Convergent and divergent validation was assessed in a mixed subset of 158 participants who completed the OxMET and OCS-Plus. Test-retest reliability was examined across a mixed subset of 39 participants. Finally, we investigated the known-group discriminability of the OxMET. The OxMET demonstrated very high internal consistency, and stable group level test-retest performance as well as good convergent and divergent validity. The OxMET demonstrated high sensitivity and good specificity in overall differentiation of stroke survivors from controls. The Oxford Digital Multiple Errands Test is a brief, easy to administer tool, designed to quickly screen for potential consequences of executive impairments in a virtual environment shopping task on a computer tablet. Initial normative data and validation within a chronic stroke cohort is presented.

Cognition, function and awareness of disease impact in early Parkinson's and Huntington's disease

Purpose: Patients with Parkinson's and Huntington's Disease (PD and HD) present impairments in cognitively challenging everyday activities. This study contrasts these two basal ganglia disorders on the ability to perform daily life- like tasks and their level of awareness regarding the disease impact on function.Methods: 19 controls, 10 early-onset PD, 20 early stage PD, and 15 early manifest HD patients were compared in the "EcoKitchen," a virtual reality task with increasing executive load, the "Behavioural Assessment of Dysexecutive Syndrome battery - BADS," and "The Adults and Older Adults Functional Assessment Inventory - IAFAI," a self-report functional questionnaire. The EcoKitchen clinical correlates were investigated.Results: All clinical groups presented slower EcoKitchen performance than controls, however, only HD patients showed decreased accuracy. HD and PD patients exhibited reduced BADS scores compared to the other study participants. Importantly, on the IAFAI, PD patients signalled more physically related incapacities and HD patients indicated more cognitively related incapacities. Accordingly, the EcoKitchen performance was significantly associated with PD motor symptom severity.Conclusions: Our findings suggest differential disease impact on cognition and function across PD and HD patients, with preserved awareness regarding disease- related functional sequelae. These observations have important implications for clinical management, research and rehabilitation.Implications for rehabilitationPatients with early stage Parkinson's and Huntington's disease have diagnosis-specific impairments in the performance of executively demanding everyday activities and, yet, show preserved awareness about the disease impact on their daily life.An active involvement of patients in the rehabilitation process should be encouraged, as their appraisal of the disease effects can help on practical decisions about meaningful targets for intervention, vocational choices, quality-of-life issues and/or specific everyday skills to boost.The EcoKitchen, a non-immersive virtual reality task, can detect and quantify early deficits in everyday-like tasks and is therefore a valuable tool for assessing the effects of rehabilitation strategies on the functional cognition of these patients.Rehabilitation efforts in the mild stages of Parkinson's and Huntington's disease should be aware of greater time needs from the patients in the performance of daily life tasks, target executive skills, and give a more prominent role to patients in symptoms report and management.

The Use of a Virtual Reality Platform for the Assessment of the Memory Decline and the Hippocampal Neural Injury in Subjects with Mild Cognitive Impairment: The Validity of Smart Aging Serious Game (SASG)

Due to the lack of pharmacological treatment for dementia, timely detection of subjects at risk can be of seminal importance for preemptive rehabilitation interventions. The aim of the study was to determine the usability of the smart aging serious game (SASG), a virtual reality platform, in assessing the cognitive profile of an amnestic mild cognitive impairment (aMCI) population, its validity in discriminating aMCI from healthy controls (HC), and in detecting hippocampal degeneration, a biomarker of clinical progression towards dementia. Thirty-six aMCI and 107 HC subjects were recruited and administered the SASG together with a neuropsychological evaluation. All aMCI and 30 HC subjects performed also an MRI for hippocampal volume measurement. Results showed good usability of the SASG despite the low familiarity with technology in both groups. ROC curve analyses showed similar discriminating abilities for SASG and gold standard tests, and a greater discrimination ability compared to non-specific neuropsychological tests. Finally, linear regression analysis revealed that the SASG outperformed the Montreal cognitive assessment test (MoCA) in the ability to detect neuronal degeneration in the hippocampus on the right side. These data show that SASG is an ecological task, that can be considered a digital biomarker providing objective and clinically meaningful data about the cognitive profile of aMCI subjects.

A Systematic Review of Neuropsychological Tests for the Assessment of Dementia in Non-Western, Low-Educated or Illiterate Populations

OBJECTIVE

Neuropsychological tests are important instruments to determine a cognitive profile, giving insight into the etiology of dementia; however, these tests cannot readily be used in culturally diverse, low-educated populations, due to their dependence upon (Western) culture, education, and literacy. In this review we aim to give an overview of studies investigating domain-specific cognitive tests used to assess dementia in non-Western, low-educated populations. The second aim was to examine the quality of these studies and of the adaptations for culturally, linguistically, and educationally diverse populations.

METHOD

A systematic review was performed using six databases, without restrictions on the year or language of publication.

RESULTS

Forty-four studies were included, stemming mainly from Brazil, Hong Kong, Korea, and considering Hispanics/Latinos residing in the USA. Most studies focused on Alzheimer's disease (n = 17) or unspecified dementia (n = 16). Memory (n = 18) was studied most often, using 14 different tests. The traditional Western tests in the domains of attention (n = 8) and construction (n = 15), were unsuitable for low-educated patients. There was little variety in instruments measuring executive functioning (two tests, n = 13), and language (n = 12, of which 10 were naming tests). Many studies did not report a thorough adaptation procedure (n = 39) or blinding procedures (n = 29).

CONCLUSIONS

Various formats of memory tests seem suitable for low-educated, non-Western populations. Promising tasks in other cognitive domains are the Stick Design Test, Five Digit Test, and verbal fluency test. Further research is needed regarding cross-cultural instruments measuring executive functioning and language in low-educated people.

Virtual Reality for the Assessment of Everyday Cognitive Functions in Older Adults: An Evaluation of the Virtual Reality Action Test and Two Interaction Devices in a 91-Year-Old Woman

Performance-based functional tests for the evaluation of daily living activities demonstrate strong psychometric properties and solve many of the limitations associated with self- and informant-report questionnaires. Virtual reality (VR) technology, which has gained interest as an effective medium for administering interventions in the context of healthcare, has the potential to minimize the time-demands associated with the administration and scoring of performance-based assessments. To date, efforts to develop VR systems for assessment of everyday function in older adults generally have relied on non-immersive systems. The aim of the present study was to evaluate the feasibility of an immersive VR environment for the assessment of everyday function in older adults. We present a detailed case report of an elderly woman who performed an everyday activity in an immersive VR context (Virtual Reality Action Test) with two different types of interaction devices (controller vs. sensor). VR performance was compared to performance of the same task with real objects outside of the VR system (Real Action Test). Comparisons were made on several dimensions, including (1) quality of task performance (e.g., order of task steps, errors, use and speed of hand movements); (2) subjective impression (e.g., attitudes), and (3) physiological markers of stress. Subjective impressions of performance with the different controllers also were compared for presence, cybersickness, and usability. Results showed that the participant was capable of using controllers and sensors to manipulate objects in a purposeful and goal-directed manner in the immersive VR paradigm. She performed the everyday task similarly across all conditions. She reported no cybersickness and even indicated that interactions in the VR environment were pleasant and relaxing. Thus, immersive VR is a feasible approach for function assessment even with older adults who might have very limited computer experience, no prior VR exposure, average educational experiences, and mild cognitive difficulties. Because of inherent limitations of single case reports (e.g., unknown generalizability, potential practice effects, etc.), group studies are needed to establish the full psychometric properties of the Virtual Reality Action Test.

The role of virtual reality on outcomes in rehabilitation of Parkinson's disease: meta-analysis and systematic review in 1031 participants

Introduction

Parkinson’s disease (PD) is managed primarily by dopamine agonists and physiotherapy while virtual reality (VR) has emerged recently as a complementary method. The present study reviewed the effectiveness of VR in rehabilitation of patients with PD.

Methods

Literature search up to June 2019 identified ten studies (n = 343 participants) suitable for meta-analysis and 27 studies (n = 688 participants) for systematic review. Standard mean difference (SMD) and 95% confidence intervals (CI) were calculated using a random effects model.

Results

In meta-analysis, compared with active rehabilitation intervention, VR training led to greater improvement of stride length, SMD = 0.70 (95%CI = 0.32–1.08, p = 0.0003), and was as effective for gait speed, balance and co-ordination, cognitive function and mental health, quality of life and activities of daily living. Compared with passive rehabilitation intervention, VR had greater effects on balance: SMD = 1.02 (95%CI = 0.38–1.65, p = 0.002). Results from single randomised controlled trials showed that VR training was better than passive rehabilitation intervention for improving gait speed SMD = 1.43 (95%CI = 0.51–2.34, p = 0.002), stride length SMD = 1.27 (95%CI = 0.38–2.16, p = 0.005) and activities of daily living SMD = 0.96 (95%CI = 0.02–1.89). Systematic review showed that VR training significantly (p < 0.05) improved motor function, balance and co-ordination, cognitive function and mental health, and quality of life and activities of daily living.

Conclusion

VR used in rehabilitation for patients with PD improves a number of outcomes and may be considered for routine use in rehabilitation.

Electronic supplementary material

The online version of this article (10.1007/s10072-019-04144-3) contains supplementary material, which is available to authorized users.

Virtual reality in the diagnostics and therapy of neurological diseases

Introduction: The use of Virtual Reality (VR) in neurology mainly concerns motor solutions. Such an approach is cost-effective and resource-effective. The aim of this work is to review and assess the effectiveness of proposed VR systems in order to diagnose and rehabilitate neurological patients with cognitive disorders.Areas covered: The existing analog neuropsychological tests lack ecological validity. The literature review revealed that VR solutions' biggest advantage is the possibility of assessing patients in everyday situations. Specific tasks (e.g. spatial, verbal, adaptive) could be focused on examining the exact types of memory disabilities in the heterogeneous group of cognitive impairments. There is a visible promise for further development in this area and a good basis for personalized and remote use. While different methodology is set in the analyzed articles the improvement in neurological functions is seen in all of them.Expert opinion: VR is still a relatively new and understudied solution, but there is a visible progress in its research. This trend could lead to more specific and tailored methods for therapy and diagnostics.

Developing and Validating a Big-Store Multiple Errands Test

The Multiple Errands Test (MET) is an ecologically valid assessment that characterizes how executive dysfunction manifests in everyday activities. Due to the naturalistic nature of this assessment, clinicians and researchers have had to develop site-specific versions resulting in numerous published versions and making it difficult to establish standard psychometric properties. The aim of this study was to develop a standardized, community version of the MET designed to be used in large department stores meeting set criteria that would not require site specific modifications. This paper reports on the development, content validity, feasibility, and inter-rater reliability of a Big-Store MET, and the performance of healthy participants on this test. Items were selected to match previously published versions in relation to quantity and complexity. Content validity was established by having experts (n = 4) on the MET review the proposed Big-Store version and evaluate the task consistency with previously published versions. To assess feasibility of administration, and inter-rater reliability, a convenience sample of 14 community dwelling adults, self-reporting as healthy, were assessed by two trained raters. We found the Big-Store MET to be feasible to deliver (completed within 30 min, scores show variability, acceptable to participants in community environment) and inter-rater reliability to be very high (ICCs = 0.92-0.99) with the exception of frequency of strategy use. This study introduces the Big-Store MET to the literature, establishes its preliminary validity and reliability thus laying the foundation for a standardized, community-based version of the MET.

A Virtual Versus an Augmented Reality Cooking Task Based-Tools: A Behavioral and Physiological Study on the Assessment of Executive Functions

Virtual reality (VR) and augmented reality (AR) are two novel graphics immersive techniques (GIT) that, in the last decade, have been attracting the attention of many researchers, especially in psychological research. VR can provide 3D real-life synthetic environments in which controllers allow human interaction. AR overlays synthetic elements to the real world and the human gaze to target allow hand gesture to act with synthetic elements. Both techniques are providing more ecologically environments than traditional methods, and most of the previous researches, on one side, have more focused on the use of VR for treatment and assessment showing positive effectiveness results. On the other, AR has been proving for the treatment of specific disorders but there are no studies that investigated the feasibility and effectiveness of AR in the neuropsychological assessment. Starting from these premises, the present study aimed to compare the performance and sense of presence using both techniques during an ecological task, such as cooking. The study included 50 cognitively healthy subjects. The cooking task consisted of four levels that increased in difficulty. As the level increased, additional activities appeared. The order of presentation of each exposure condition (AR and VR) was counterbalanced for each participant. The VR-cooking task has been performed through "HTC/VIVE" and AR through "Microsoft HoloLens." Furthermore, the study recorded and compared the psychophysiological changes [heart rate and skin conductance response (SCR)] during the cooking task in both conditions. To measure the sense of presence occurring during the two exposure conditions, subjects completed the Slater-Usoh-Steed Questionnaire (SUSQ) and the ITC-Sense of Presence Inventory (ITC-SOPI) immediately after each condition. The behavioral results showed that times are always lower in VR than in AR, increasing constantly in accordance with the difficulty of the tasks. Regarding physiological responses, the findings showed that AR condition produced more individual excitement and activation than VR. Finally, VR was able to produce higher levels of sense of presence than AR condition. The overall results support that VR currently represents the GIT with greater usability and feasibility compared to AR, probably due to the differences in the human-computer interaction between the two techniques.

A Computational Approach for the Assessment of Executive Functions in Patients with Obsessive-Compulsive Disorder

Previous studies on obsessive–compulsive disorder (OCD) showed impairments in executive domains, particularly in cognitive inhibition. In this perspective, the use of virtual reality showed huge potential in the assessment of executive functions; however, unfortunately, to date, no study on the assessment of these patients took advantage of the use of virtual environments. One of the main problems faced within assessment protocols is the use of a limited number of variables and tools when tailoring a personalized program. The main aim of this study was to provide a heuristic decision tree for the future development of tailored assessment protocols. To this purpose, we conducted a study that involved 58 participants (29 OCD patients and 29 controls) to collect both classic neuropsychological data and precise data based on a validated protocol in virtual reality for the assessment of executive functions, namely, the VMET (virtual multiple errands test). In order to provide clear indications for working on executive functions with these patients, we carried out a cross-validation based on three learning algorithms and computationally defined two decision trees. We found that, by using three neuropsychological tests and two VMET scores, it was possible to discriminate OCD patients from controls, opening a novel scenario for future assessment protocols based on virtual reality and computational techniques.

A meta-analytic review of prospection deficits in Parkinson's disease

Parkinson's disease (PD) is one of the most common neurodegenerative disorders, and is associated with prominent motor deficits. However, neurocognitive impairment is also a common clinical feature that can contribute greatly to the overall disease burden. In the current study, a meta-analysis was conducted to gain a clearer understanding of how PD affects one of the most functionally important domains of cognition: prospection. The results indicate that, relative to controls, PD is associated with a large deficit in the capacity to engage in planning (g = -0.81, K = 25) and a moderate-sized deficit in prospective memory (g = -0.57, K = 16). Sub-analyses indicated that these deficits are evident for both time and event-based prospective memory, as well as for prospective memory tasks that have relatively limited ecological validity. Significant impairment was also evident for both medicated and non-medicated PD sub-groups, but for planning, these deficits were substantially greater in the unmedicated sub-group. The theoretical and practical implications of these findings are discussed.

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.

Lesion Studies in Contemporary Neuroscience

Studies of humans with focal brain damage and non-human animals with experimentally induced brain lesions have provided pivotal insights into the neural basis of behavior. As the repertoire of neural manipulation and recording techniques expands, the utility of studying permanent brain lesions bears re-examination. Studies on the effects of permanent lesions provide vital data about brain function that are distinct from those of reversible manipulations. Focusing on work carried out in humans and nonhuman primates, we address the inferential strengths and limitations of lesion studies, recent methodological developments, the integration of this approach with other methods, and the clinical and ecological relevance of this research. We argue that lesion studies are essential to the rigorous assessment of neuroscience theories.

Executive function training in chronic traumatic brain injury patients: study protocol

Background

Some individuals who sustain traumatic brain injuries (TBIs) continue to experience significant cognitive impairments chronically (months to years post injury). Many tests of executive function are insensitive to these executive function impairments, as such impairments may only appear during complex daily life conditions. Daily life often requires us to divide our attention and focus on abstract goals. In the current study, we compare the effects of two 1-month electronic cognitive rehabilitation programs for individuals with chronic TBI. The active program (Expedition: Strategic Advantage) focuses on improving goal-directed executive functions including working memory, planning, long-term memory, and inhibitory control by challenging participants to accomplish life-like cognitive simulations. The challenge level of the simulations increases in accordance with participant achievement. The control intervention (Expedition: Informational Advantage) is identical to the active program; however, the cognitive demand level is capped, preventing participants from advancing beyond a set level. We will evaluate these interventions with a military veteran TBI population.

Methods/design

One hundred individuals will be enrolled in this double-blinded clinical trial (all participants and testers are blinded to condition). Each individual will be randomly assigned to one of two interventions. The primary anticipated outcomes are improvement of daily life cognitive function skills and daily life functions. These are measured by a daily life performance task, which tests cognitive skills, and a survey that evaluates daily life functions. Secondary outcomes are also predicted to include improvements in working memory, attention, planning, and inhibitory control as measured by a neuropsychological test battery. Lastly, neuroimaging measures will be used to evaluate changes in brain networks supporting cognition pre and post intervention.

Discussion

We will test whether electronically delivered cognitive rehabilitation aimed at improving daily life functional skills will provide cognitive and daily life functional improvements for individuals in the chronic phase of TBI recovery (greater than 3 months post injury). We aim to better understand the cognitive processes involved in recovery and the characteristics of individuals most likely to benefit. This study will also address the potential to observe generalizability or to transfer from a software-based cognitive training tool toward daily life improvement.

Trial registration

ClinicalTrials.gov, NCT03704116. Retrospectively registered on 12 Oct 2018.

An ecological measure to screen executive functioning in MS: the Picture Interpretation Test (PIT) 360°

Executive functions are crucial for performance of everyday activities. In Multiple Sclerosis (MS), executive dysfunctions can be apparent from the early onset of the disease. Technology-based time-efficient and resource-saving tools for early evaluation of executive functions using an ecological approach are needed to assess functional performance in real-life. The aim was to compare the efficiency of the Picture Interpretation Test 360° (PIT 360°) with traditional measures on executive dysfunction in Persons with Multiple Sclerosis (PwMS) and Healthy Controls (HC). Participants were 31 patients with Relapsing-Remitting MS (mean age = 44.323 ± 13.149; mean Expanded Disability Status Scale = 2) and 39 HC (mean age = 39.538 ± 15.728). All were tested with standard neuropsychological tests of executive functions, PIT 360°, and measures of user experience. While standard neuropsychological tests failed to differentiate between PwMS and HC group, the PIT 360° was successful in detecting executive dysfunction in PwMS. All participants reported the PIT 360° to be an engaging tool and endorsed positive reactions to their experience. Overall, the PIT 360° is a quick, sensitive, and ecological tool that captures real-world executive dysfunction in PwMS. This engaging measure is sensitive for the detection of executive deficits since the early phases of the disease.

Neuropsychological Assessment of Older Adults With Virtual Reality: Association of Age, Schooling, and General Cognitive Status

The development of neuropsychological assessment methods using virtual reality (VR) is a valid and promising option for the detection of cognitive impairment in the older people, focusing on activities composed of tasks of multiple demands. This study verified the association of age, schooling, and general cognitive status on the performance of neurologically healthy older adults in ECO-VR, a VR task of multiple demands for neuropsychological assessment. A total of 111 older adults answered a sociodemographic questionnaire, the Mini Mental State Examination, the Vocabulary subtest of the Wechsler Intelligence Scale for Adults (third edition), and the ECO-VR. Correlation analyses, multiple linear regression, and comparisons between groups (effects by age and schooling groups) were used to evaluate the results. The ECO-VR total score was significantly associated with age, years of education, MMSE, and Vocabulary subtest. The linear regression models identified that age was the main predictor for total score and rule breaking of ECO-VR. According to the univariate analysis, it was identified the main effect of age group and schooling group in the total ECO-VR score, but there was no interaction effect. The results are discussed in order to understand the role of sociodemographic characteristics in the performance of older adults in a VR task of multiple demands. It was also verified the possibility use of VR for neuropsychological assessment of older adults.

Picture Interpretation Test (PIT) 360°: An Innovative Measure of Executive Functions

The assessment of executive functions poses researchers with several challenges related to both the complexity of the construct of executive functions itself and/or the methodological difficulties related to its evaluation. The main objective of the current study was to evaluate a 360° version of an ecologically valid assessment called the Picture Interpretation Test (PIT). Participants included 19 patients with Parkinson’s disease (PD) and 19 healthy controls. All participants endorsed globally positive experiences of the PIT 360°. Furthermore, findings indicated that patients with PD took longer to correctly interpret the PIT 360° scene and tended to significantly focus on details of the 360° scene instead of the most informative elements. The time needed for a correct interpretation of the presented scene also correlated significantly with performance in conventional paper and pencil tests of executive functions for patients with PD. Classification analysis indicated the potential of the PIT 360° for distinguishing between patients with PD and healthy controls. Overall, these data provide preliminary evidence in support of the PIT 360° for evaluating executive functions.

A Psychometric Tool for a Virtual Reality Rehabilitation Approach for Dyslexia

Dyslexia is a chronic problem that affects the life of subjects and often influences their life choices. The standard rehabilitation methods all use a classic paper and pencil training format but these exercises are boring and demanding for children who may have difficulty in completing the treatments. It is important to develop a new rehabilitation program that would help children in a funny and engaging way. A Wii-based game was developed to demonstrate that a short treatment with an action video game, rather than phonological or orthographic training, may improve the reading abilities in dyslexic children. According to the results, an approach using cues in the context of a virtual environment may represent a promising tool to improve attentional skills. On the other hand, our results do not demonstrate an immediate effect on reading performance, suggesting that a more prolonged protocol may be a future direction.

Trends on the application of serious games to neuropsychological evaluation: A scoping review

BACKGROUND

The dramatic technological advances witnessed in recent years have resulted in a great opportunity for changing the way neuropsychological evaluations may be performed in clinical practice. Particularly, serious games have been posed as the cornerstone of this still incipient paradigm-shift, as they have characteristics that make them especially advantageous in trying to overcome limitations associated with traditional pen-and-paper based neuropsychological tests: they can be easily administered and they can feature complex environments for the evaluation of neuropsychological constructs that are difficult to evaluate through traditional tests. The objective of this study was to conduct a scoping literature review in order to map rapidly the key concepts underpinning this research area during the last 25years on the use of serious games for neuropsychological evaluation.

METHODS

MEDLINE, PsycINFO, Scopus and IEEE Xplore databases were systematically searched. The main eligibility criteria were to select studies published in a peer-reviewed journal; written in English; published in the last 25years; focused on the human population, and classified in the neuropsychological field. Moreover, to avoid risk of bias, studies were selected by consensus of experts, focusing primarily in psychometric properties. Therefore, selected studies were analyzed in accordance with a set of dimensions of analysis commonly used for evaluating neuropsychological tests.

RESULTS

After applying the selected search strategy, 57 studies -including 54 serious games- met our selection criteria. The selected studies deal with visuospatial capabilities, memory, attention, executive functions, and complex neuropsychological constructs such as Mild Cognitive Impairment (MCI). Results show that the implementation of serious games for neuropsychological evaluation is tackled in several different ways in the selected studies, and that studies have so far been mainly exploratory, just aiming at testing the feasibility of the proposed approaches.

DISCUSSION

It may be argued that the limited number of databases used might compromise this study. However, we think that the finally included sample is representative, in spite of how difficult is to achieve an optimum and maximum scope. Indeed, this review identifies other research issues related to the development of serious games beyond their reliability and validity. The main conclusion of this review is that there is a great interest in the research community in the use of serious games for neuropsychological evaluation. This scoping review is pertinent, in accordance with the increasing number of studies published in the last three years, they demonstrate its potential as a serious alternative to classic neuropsychological tests. Nevertheless, more research is needed in order to implement serious games that are reliable, valid, and ready to be used in the everyday clinical practice.

Psychometric assessment and behavioral experiments using a free virtual reality platform and computational science

Background

Virtual Reality has been extensively used in a wide range of psychological experiments. In this study, we aimed to introduce NeuroVirtual 3D, a platform that clinicians could use free of charge.

Implementation

The platform we developed relies on NeuroVR software, but we extended it to apply to experiments. The software is available free of charge to researchers and clinical practitioners who can also use a large number of virtual environments and objects already developed.

Results

The platform has been developed to connect to virtually every device ever produced by the means of Virtual-Reality Peripheral Network (VRPN) protocols; however, a number of these have already been included and tested in the platform. Among the available devices, the Microsoft Kinect low-cost sensor has already been configured for navigation through the virtual environments and to trigger specific action (sounds, videos, images, and the like) when a specific gesture is recognized, e.g., a step forward or an arm up. A task for neglect and a task for spatial abilities assessment were already implemented within the platform. Moreover, NeuroVirtual 3D integrated a TCP-IP-based module (bridge) to collect the data from virtually any existent biosensor (Thought-Technology, Zephyr and StarStim devices have already been included in the platform). It is able to record any psychophysiological signal during any experiment using also the computed indices in real time.

Conclusions

NeuroVirtual 3D is able to record external and internal (e.g., coordinates, keys-press, timestamp) data with a millisecond precision, representing de facto the most advanced technology for experimental psychology using virtual environments available without the needs to program code.