Virtual reality in paediatric rehabilitation: A review

Objective: To provide a narrative review of studies regarding the outcomes of Virtual Reality (VR)-based treatment and rehabilitation programmes within the paediatric population.

Methods: Studies related to the use of VR across a number of paediatric areas (e.g. cerebral palsy, autism, foetal alcohol syndrome and attention deficits) were identified and summarized.

Results: Outcomes from the studies reviewed provide preliminary support for the use of VR.

Conclusion: VR may be an effective treatment method for specific disorders, although the generalizability of this literature is hindered by several methodological limitations, such as small samples and the absence of appropriate control participants.     

Examining the beneficial effect of neuropsychological assessment on adult patient outcomes: a systematic review

Objective: Neuropsychological assessment (NPA) addresses important aspects of diagnosis, prognosis, treatment, and rehabilitation planning. This review set out to determine the impact of NPA on the adult patient’s outcome, by examining how and whether NPA influences diagnostic decision-making and surgical planning, how NPA can be used to predict patient outcome, and how clients, referrers, and significant others perceive the value of NPA. Method: Eligible studies were selected according to pre-defined selection criteria and accessed via the electronic databases Medline and PsycInfo. Results: Eighty-one studies were included, with 14 examining the influence of NPA on diagnosis, 62 in predicting outcomes, and 5 addressing the perceptions of NPA by users. The evidence was generally supportive of the value of NPA for its ability to increase the accuracy of diagnoses, to assist with decisions regarding surgical planning, to predict patient outcomes, and in its clinical benefit as reported by physicians and patients. Conclusion: The review demonstrated the benefit of NPA in assisting with diagnosis and prognosis, and showed positive findings with regard to consumer perceptions of NPA. The neuropsychological literature would materially benefit from high-quality randomized control trials of NPA to definitively demonstrate the efficacy of this measure in clinical management.     

Validation of computerized episodic memory measures in a diverse clinical sample referred for neuropsychological assessment

Objective: To examine the convergent and discriminant validity of two brief computerized episodic memory measures in a large, diverse clinical sample of adults undergoing neuropsychological assessment. Method: Computerized measures of word and face memory were administered to 233 adults (age 30 and over) who also completed comprehensive neuropsychological testing. Results: Moderate correlations were observed between the computerized memory tests and a wide range of traditional neuropsychological measures of episodic memory (e.g. word-list learning, story recall, face recognition, design recall). Select measures of visuomotor processing speed and language were also related to performance on the computerized tasks. In contrast, the computerized memory tests showed weak correlations with tests in other cognitive domains (i.e. visuospatial skills, attention/working memory, executive function, motor dexterity, academic skills) and self-report screening measures of mood and anxiety. Similar to traditional measures of episodic memory, the computerized memory measures were sensitive to effects of age and gender. Conclusions: Computerized measures of word and face memory showed good convergent and discriminant validity in this diverse clinical sample supporting the construct validity of these measures. This indicates that it may be feasible to measure memory function in clinical settings using brief, well-designed computerized memory measures.     

Neglect assessment as an application of virtual reality

OBJECTIVE: In this study a cancellation task in a virtual environment was applied to describe the pattern of search and the kinematics of hand movements in eight patients with right hemisphere stroke. METHODS: Four of these patients had visual neglect and four had recovered clinically from initial symptoms of neglect. The performance of the patients was compared with that of a control group consisting of eight subjects with no history of neurological deficits. RESULTS: Patients with neglect as well as patients clinically recovered from neglect showed aberrant search performance in the virtual reality (VR) task, such as mixed search pattern, repeated target pressures and deviating hand movements. The results indicate that in patients with a right hemispheric stroke, this VR application can provide an additional tool for assessment that can identify small variations otherwise not detectable with standard paper-and-pencil tests. CONCLUSION: VR technology seems to be well suited for the assessment of visually guided manual exploration in space.     

Naturalistic tasks performed in realistic environments: a review with implications for neuropsychological assessment

Objective: Understanding functional abilities for those with neurologic disorders is a growing area of investigation. In this paper, performance-based naturalistic tasks used to assess cognitive and functional deficits were reviewed to determine current evidence for effectiveness as valid and reliable assessment measures and to make recommendations for future research.Method: Performance-based naturalistic tasks were defined as observable, rule-based, open-ended tasks completed in an environment that either mimics the real world or is the real world. Thirty-eight studies, discussed by the environment in which the task was performed (i.e. vocational, kitchen, hospital/store, and home), were reviewed.Results: Many studies were found to have significant methodological limitations (e.g. low sample size) and few studies evaluated the relationship between performance on the naturalistic task and everyday functioning. The efficacy of using naturalistic tasks to better understand functional status has yet to be clearly demonstrated across neurologic populations. Numerous factors, including ease of use, limited research on how to best utilize these tasks, and cost impact the use of naturalistic tasks. Nonetheless, given the promising theoretical foundation, opportunities are ripe for further development of assessment strategies that use contextually relevant environments and allow for enhanced safety and controllability of tasks, increased face validity, capitalization on automatic processes, and improved ecological validity.Conclusions: Future research is needed to increase the knowledge base regarding the use of naturalistic tasks, especially as they relate to everyday functioning, because of the potential benefits to advance the standard of care for individuals with neurologic conditions.     

Virtual reality in mental health

BACKGROUND: Several virtual reality (VR) applications for the understanding, assessment and treatment of mental health problems have been developed in the last 10 years. The purpose of this review is to outline the current state of virtual reality research in the treatment of mental health problems. METHODS: PubMed and PsycINFO were searched for all articles containing the words "virtual reality". In addition a manual search of the references contained in the papers resulting from this search was conducted and relevant periodicals were searched. Studies reporting the results of treatment utilizing VR in the mental health field and involving at least one patient were identified. RESULTS: More than 50 studies using VR were identified, the majority of which were case studies. Seventeen employed a between groups design: 4 involved patients with fear of flying; 3 involved patients with fear of heights; 3 involved patients with social phobia/public speaking anxiety; 2 involved people with spider phobia; 2 involved patients with agoraphobia; 2 involved patients with body image disturbance and 1 involved obese patients. There are both advantages in terms of delivery and disadvantages in terms of side effects to using VR. Although virtual reality based therapy appears to be superior to no treatment the effectiveness of VR therapy over traditional therapeutic approaches is not supported by the research currently available. CONCLUSIONS: There is a lack of good quality research on the effectiveness of VR therapy. Before clinicians will be able to make effective use of this emerging technology greater emphasis must be placed on controlled trials with clinically identified populations.     

Virtual reality as a therapeutic modality for children with cerebral palsy

Objective: The evidence for using virtual reality (VR) with children with cerebral palsy (CP) was examined.

Methods: A search of 13 electronic databases identified all types of studies examining VR as an intervention for children with CP. The most recent article included was published in October 2008. For each study, the quality of the methods was assessed using the appropriate scale. A total of 19 articles were retrieved. Thirteen studies from 11 articles were included in the final analysis.

Results: Outcomes documented brain reorganization/plasticity, motor capacity, visual-perceptual skills, social participation and personal factors. Two studies were randomized controlled trials. These reported conflicting results regarding motor outcomes. Twelve of the 13 studies presented positive outcomes in at least one domain.

Conclusions: VR has potential benefits for children with CP. However, the current level of evidence is poor and empirical data is lacking. Future methodologically rigorous studies are required.     

Virtual reality exposure therapy in anxiety disorders: a systematic review of process‐and‐outcome studies

In recent years, virtual reality exposure therapy (VRET) has become an interesting alternative for the treatment of anxiety disorders. Research has focused on the efficacy of VRET in treating anxiety disorders: phobias, panic disorder, and posttraumatic stress disorder. In this systematic review, strict methodological criteria are used to give an overview of the controlled trials regarding the efficacy of VRET in patients with anxiety disorders. Furthermore, research into process variables such as the therapeutic alliance and cognitions and enhancement of therapy effects through cognitive enhancers is discussed. The implications for implementation into clinical practice are considered. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Functional cooking skills and neuropsychological functioning in patients with stroke: An ecological validity study

Efforts to relate neuropsychological performance to real-world task functioning have predominantly yielded lackluster results, typically with neuropsychological performance accounting for modest amounts of variance in function. Nonetheless, the ecological validity of neuropsychological measures for predicting functional abilities remains a strong research interest and clinical necessity. This study relates neuropsychological performance to performance on a standardised cooking task (Rabideau Kitchen Evaluation – Revised; RKE-R) in persons with stroke. Results showed that while the composite score of mean neuropsychological performance had the largest association with meal preparation, several neuropsychological measures were significantly related to the RKE-R. Groups of left and right hemisphere stroke patients were not significantly different in terms of RKE-R performance. These results suggest that functional cooking task performance is related to intact cognitive abilities in delayed verbal memory, simple auditory attention, and visuospatial skills, as well as overall cognitive performance. Implications for neuropsychologists are discussed.     

Primary progressive aphasia: a review of neuropsychological tests for the assessment of speech and language disorders

Background: Speech and language impairments are the key clinical feature in several neurodegenerative disorders and primary progressive aphasia (PPA) is the syndrome where they are the prominent features. Their accurate and early identification may increase the diagnosis in the clinical setting. This approach may allow a better discrimination between the different neurodegenerative disorders and the PPA variants, i.e., nonfluent, semantic, logopenic.

Aims: The aim of this work is twofold: (1) to provide an overview of the available neuropsychological tests for the diagnosis of PPA and/or for the differentiation among the PPA variants and (2) to evaluate the methodological quality and the psychometric characteristics of these tests.

Methods & Procedures: This review was conducted following PRISMA guidelines. Search terms were chosen based on the research questions and used in a search in two databases. Then, inclusion criteria were formulated and papers meeting the criteria were reviewed. The methodological quality of the studies was evaluated examining the following items: (1) blindness of personnel, (2) consecutive inclusion of patients, and (3) representativeness of the sample.

Outcomes & Results: A total of 907 papers have been selected from the databases, and 9 of them were included in this review. Among these, three tests aimed to differentiate between PPA variants, two tests were designed for the assessment of language disorders in PPA patients, and four tests were developed to stage the severity of speech/language disorders in PPA patients. All the included studies provided psychometric data about the clinical validity of the tests; however, they present several limitations, both psychometric and methodological.

Conclusion: The number of validation studies is still limited. This brief review reveals the need of linguistically sophisticated tests, characterized by better quality of methods and psychometric characteristics, to be used to systematically evaluate the linguistic abilities of individuals with PPA.     

Virtual reality as a mechanism for exposure therapy

Virtual reality (VR) is as effective in inducing emotional responses as reality and its application is extremely valuable in exposure treatment. In virtual environments, the patients experience similar physiological symptoms and fear as they do in real life situations, thereby facilitating the habituation process. Our goal is to offer an overview of the current panorama of VR and psychotherapy, underlining the (virtual) exposure technique and the studies that focus on panic disorder treatment through the use of VR. The literature was revised through consultation to the ISI and PubMed databases. Virtual exposure treatment offers good results and great patient acceptability. However, despite the importance of this data for the evaluation of treatment efficacy, only a few studies measure physiological responses during exposure. Lack of controlled studies and standardized treatment protocols were observed. Despite the great advance of VR use in psychotherapy, a great deal of its potential is still unknown, therefore requiring the creation of new virtual environments so that controlled studies regarding its clinical application can be conducted. Throughout the process of elaboration and investigation, clinical experiences in virtual environments must be related to real experiences in a flexible context that combines relevant cultural, physical and cognitive aspects.     

Virtual reality exposure in anxiety disorders: Impact on psychophysiological reactivity

Objectives. Anxiety disorders are among the most frequently encountered psychiatric disorders. Recommended treatments include cognitive behavioural therapy (CBT) and/or medication. In recent years, beneficial effects of virtual reality (VR) exposure therapy have been shown, making this technique a promising addition to CBT. However, the ability of VR to mimic threatening stimuli in a way comparable to in vivo cues has been discussed. In particular, it has been questioned whether VR is capable of provoking psychophysiological symptoms of anxiety. Since psychophysiological arousal is considered a prerequisite for effective exposure treatment, this systematic review aims to evaluate the evidence for the potential of VR exposure to evoke and modulate psychophysiological fear reactions. Methods. PubMed and PsycINFO/Academic Search Premier databases were searched. Thirty-eight studies investigating challenge or habituation effects were included. Results. VR exposure does provoke psychophysiological arousal, especially in terms of electrodermal activity. Results on psychophysiological habituation in VR are inconclusive. Study design and methodological rigour vary widely. Conclusions. Despite several limitations, this review provides evidence that VR exposure elicits psychophysiological fear reactions in patients and healthy subjects, rendering VR a promising treatment for anxiety disorders, and a potent research tool for future investigations of psychophysiological processes and their significance during exposure treatment.     

The role of neuropsychological assessment in adults with attention deficit/hyperactivity disorders

Attention-Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity and/or impulsivity. While ADHD was initially recognized as a childhood syndrome, scientific evidence accumulated to indicate that a significant proportion of ADHD children continue to experience symptoms of ADHD in adulthood. Moreover, the question of ADHD diagnosis can arise in adult patients who were not diagnosed in childhood. Currently, the diagnosis of ADHD in adulthood is based on the revised criteria described for children. However, their application for adults may be difficult for many reasons including compensation and comorbid disorders. To date, no clinical, neuropsychological, biological or imaging marker is available for the diagnosis of ADHD. Considering that ADHD is based on a neuropsychological model, in this article we will examine the usefulness of neuropsychological testing in the diagnosis in adults. We will first present diagnostic criteria of ADHD and the limits of their application in adults. We will then detail the neuropsychological data available in adult ADHD and the French and international clinical recommendations for neuropsychological assessment. Finally, we will explore the predictive value of neuropsychological scores in the diagnosis of ADHD and discuss key methodological points and perspectives for clinical research.     

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

A frequent consequence of traumatic brain injury (TBI) is a significant reduction in patients’ cerebral activation/arousal, which clinicians agree is not conducive to optimal rehabilitation outcomes. In the context of paediatric rehabilitation, sustained periods of inactivity are particularly undesirable, as contemporary research has increasingly called into question the Kennard principle that youth inherently promotes greater neural plasticity and functional recovery following TBI. Therefore, the onus to create rehabilitation conditions most conducive to harnessing plasticity falls squarely on the shoulders of clinicians. Having noted the efficacy of environmental enrichment in promoting neural plasticity and positive functional outcomes in the animal literature, some researchers have suggested that the emerging technology of Virtual Reality (VR) could provide the means to increase patients’ cerebral activation levels via the use of enriched Virtual Environments (VEs). However, 10 years on, this intuitively appealing concept has received almost no attention from researchers and clinicians alike. This paper overviews recent research on the benefits of enriched environments in the injured brain and identifies the potential and challenges associated with implementing VR-based enrichment in paediatric neuropsychological rehabilitation.     

The potential of function-led virtual environments for ecologically valid measures of executive function in experimental and clinical neuropsychology

The assessment of executive functions is an integral task of neuropsychological assessment. Traditional measures of executive function are often based on hypothetical constructs that may have little relevance to real-world behaviours. In fact, some traditional tests utilised today were not originally developed for clinical use. Recently, researchers have been arguing for a new generation of “function-led” neuropsychological assessments that are developed from directly observable everyday behaviours. Although virtual environments (VEs) have been presented as potential aides in enhancing ecological validity, many were modelled on construct-driven approaches found in traditional assessments. In the current paper, we review construct-driven and function-led VE-based neuropsychological assessments of executive functions. Overall, function-led VEs best represent the sorts of tasks needed for enhanced ecological validity and prediction of real-world functioning.     

A multidimensional assessment of obese patients with obstructive sleep apnoea syndrome (OSAS): a study of psychological, neuropsychological and clinical relationships in a disabling multifaceted disease

BackgroundRare are the studies that focus on OSAS (obstructive sleep apnoea syndrome) obese patient assessing neuropsychological, psychological and clinical aspects simultaneously.MethodsOne hundred and fifty-seven obese patients with OSAS were psychologically and neuropsychologically assessed by a standardized battery of validated tests in a cross-sectional study.ResultsPatients reported with higher frequency, compared to the normal distribution, the presence of an extrovert personality trait and depressive behaviours: 15.9% of the patients minimized symptoms and denied distress, whereas 28.0% presented psychological disorders. Compared to the normative group, patients’ results were characterized as impaired with a higher percentage in short-term verbal memory (30.6%) and in short-term visual spatial memory (20.5%). Moreover 30.6% of patients were impaired in one cognitive function, 11.5% in two, 8.9% in three, and 8.2% in four or more cognitive functions. No significant relations between psychological–neuropsychological data and clinical variables emerged.ConclusionsThe results of our obese patients with OSAS were significantly different from the normative data as for psychological and neuropsychological variables (extroversion, depression, short-term verbal and visual spatial memory, logical ability). Further studies are needed in order to investigate the eventual dose effect on psychological and neuropsychological variables of OSAS and obesity severity and treatment efficacy.     

Weak impacts of neuropsychological measures on symptoms of attention deficit hyperactivity disorder in university students

ObjectiveAttention deficit hyperactivity disorder (ADHD) is involved in broad neuropsychological domains, including response inhibition, timing, delay aversion, sustained attention, and working memory. This study aimed to examine the relationship between ADHD symptoms and neuropsychological measures in university students.MethodsA total of 167 graduate and undergraduate students participated in the study. Neuropsychological characteristics were comprehensively assessed using stop signal, delay discounting, time discrimination, sensorimotor synchronization, continuous performance, and digit span tasks. ADHD symptoms were assessed using the Japanese version of Conners’ ADHD Rating Scale.ResultsADHD symptoms were significantly correlated with some neuropsychological measures, such as the false alarm rate in the continuous performance task; however, these correlations were not strong. In the multiple regression analyses, models including neuropsychological measures were significantly associated with ADHD symptoms, but the coefficients of determination ranged from 0.06 to 0.08. Thus, most of the variance in ADHD symptoms was not explained by neuropsychological measures.ConclusionThese findings suggest that the impact of each neuropsychological measure on ADHD symptoms was weak in university students, and ADHD symptoms cannot be explained by neuropsychological characteristics, which are currently considered core characteristics of ADHD. In addition, ADHD symptoms assessed by self-rating questionnaire in the non-clinical sample might not reflect the degree of real ADHD severity.     

Virtual reality interface devices in the reorganization of neural networks in the brain of patients with neurological diseases

Two key characteristics of all virtual reality applications are interaction and immersion. Systemic interaction is achieved through a variety of multisensory channels （hearing, sight, touch, and smell）, permitting the user to interact with the virtual world in real time. Immersion is the degree to which a person can feel wrapped in the virtual world through a defined interface. Virtual real- ity interface devices such as the Nintendo~ Wii and its peripheral nunchuks-balance board, head mounted displays and joystick allow interaction and immersion in unreal environments created from computer software. Virtual environments are highly interactive, generating great activation of visual, vestibular and proprioceptive systems during the execution of a video game. In addi- tion, they are entertaining and safe for the user. Recently, incorporating therapeutic purposes in virtual reality interface devices has allowed them to be used for the rehabilitation of neurological patients, e.g., balance training in older adults and dynamic stability in healthy participants. The improvements observed in neurological diseases （chronic stroke and cerebral palsy） have been shown by changes in the reorganization of neural networks in patients＇ brain, along with better hand function and other skills, contributing to their quality of life. The data generated by such studies could substantially contribute to physical rehabilitation strategies.