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VR Series #7 Cognitive Brain Training

21 July 2018
Ian Slater discusses the impact of cognitive rehabilitation through a VR system as opposed to conventional methods.

In some respects this is where it all started for me with the Intendu brain training system which I first saw at ACRM's annual conference back in 2016. 

Intendu isn't a VR system but the aims are very much aligned with some of the research and trials which are currently ongoing. 

Having said all that it seems fair to say that the jury is still out as to the effectiveness of VR when it comes to Cognitive Brain Training. With apologies in advance in writing this article I have had to review a number of research papers in an effort to draw things together. 

I think probably the best place to start is a literature review Using Virtual Reality and Videogames for Traumatic Brain Injury Rehabilitation which assessed 18 articles. In before/after comparisons, improvements in balance were seen in four case studies and two small randomized control trials. Having said that, between-group comparisons in the randomized control trials showed no difference between virtual reality and traditional therapy.

Post-training improvements were also seen for upper extremity functions (five small studies) and for various cognitive function measures (four case studies and one pilot randomized control trial). The good news, however, was that the attitude of participants toward virtual reality interventions was more positive than for traditional therapy (three studies).

The evidence that the use of virtual reality in rehabilitation of traumatic brain injury improves motor and cognitive functionality is currently, therefore, limited but work is ongoing and, as with so many of the potential uses of VR tech, it probably only remains only a matter of time...

One study published in 2016 recognised the need for further work and some of the deficiencies in previous studies…

Benefits of virtual reality based cognitive rehabilitation through simulated activities of daily living: a randomized controlled trial with stroke patients

[Faria et al Journal of NeuroEngineering and Rehabilitation 2016 13:96]

Notwithstanding important progress in VR-based cognitive rehabilitation systems, especially with Activities of Daily Living (ADL’s) simulations, there is still a need of more clinical trials for its validation. This study was a one-month randomized controlled trial with only 18 stroke in and outpatients from two rehabilitation units: 9 performing a VR-based intervention and 9 performing conventional rehabilitation.

The VR-based intervention involved a virtual simulation of a city – Reh@City [warning: link opens YouTube video] where memory, attention, visuo-spatial abilities and executive functions tasks are integrated in the performance of several daily routines. The intervention had levels of difficulty progression. There was a pre and post-intervention assessment in both groups with the Addenbrooke Cognitive Examination (primary outcome) and the Trail Making Test A and B, Picture Arrangement from WAIS III and Stroke Impact Scale 3.0 (secondary outcomes).

A within groups analysis revealed significant improvements in global cognitive functioning, attention, memory, visuo-spatial abilities, executive functions, emotion and overall recovery in the VR group.

The control group only improved in self-reported memory and social participation.

A between groups analysis, showed significantly greater improvements in global cognitive functioning, attention and executive functions when comparing VR to conventional therapy.

Virtual environments are designed to be more enjoyable than conventional rehabilitation methods. The introduction of gaming elements and immediate feedback is said to enhance motivation, thereby encouraging higher numbers of repetitions. Additionally, it enables the systematic presentation of challenges which can be varied from simple to complex: making it progressively more challenging according to the patients' abilities.

Reh@City targets several cognitive domains such as memory, attention, executive functions and visuo-spatial abilities. Patients are required to accomplish some common ADL’s in four frequently visited places: a supermarket, a post office, a bank, and a pharmacy.

Whilst believing that their study demonstrated that cognitive rehabilitation through a VR system can have a larger impact than conventional methods the authors recognised that there is still a need for further research considering other clinical populations, larger sample sizes and more comparative studies.

It remains very early days and at this stage one would struggle to suggest that a VR based cognitive rehab programme could replace rehab in the real world but it may, nevertheless, augment it particularly in those scenarios where one typically sees a questionable range of support workers supposedly targeted with getting a claimant out into their environment in order to practice a range of functional skills. Using a tool such as Reh@City could provide a controlled, readily accessible and progressively challenging environment to encourage functional gains with 'real life' work then being layered on top by skilled support workers. Instinctively that feels much better to me than the chance situation of a disinterested support worker taking their client down to the local Lidl (other supermarkets are available).

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Further Reading