Abstract
BackgroundPaper-and-pencil tasks are still widely used for cognitive rehabilitation despite the proliferation of new computer-based methods, like VR-based simulations of ADL’s. Studies have established construct validity of VR assessment tools with their paper-and-pencil version by demonstrating significant associations with their traditional construct-driven measures. However, VR rehabilitation intervention tools are mostly developed to include mechanisms such as personalization and adaptation, elements that are disregarded in their paper-and-pencil counterparts, which is a strong limitation of comparison studies. Here we compare the clinical impact of a personalized and adapted paper-and-pencil training and a content equivalent and more ecologically valid VR-based ADL’s simulation.MethodsWe have performed a trial with 36 stroke patients comparing Reh@City v2.0 (adaptive cognitive training through everyday tasks VR simulations) with Task Generator (TG: content equivalent and adaptive paper-and-pencil training). The intervention comprised 12 sessions, with a neuropsychological assessment pre, post-intervention and follow-up, having as primary outcomes: general cognitive functioning (assessed by the Montreal Cognitive Assessment - MoCA), attention, memory, executive functions and language specific domains.ResultsA within-group analysis revealed that the Reh@City v2.0 improved general cognitive functioning, attention, visuospatial ability and executive functions. These improvements generalized to verbal memory, processing speed and self-perceived cognitive deficits specific assessments. TG only improved in orientation domain on the MoCA, and specific processing speed and verbal memory outcomes. However, at follow-up, processing speed and verbal memory improvements were maintained, and a new one was revealed in language. A between-groups analysis revealed Reh@City v2.0 superiority in general cognitive functioning, visuospatial ability, and executive functions on the MoCA.ConclusionsThe Reh@City v2.0 intervention with higher ecological validity revealed higher effectiveness with improvements in different cognitive domains and self-perceived cognitive deficits in everyday life, and the TG intervention retained fewer cognitive gains for longer.Trial registrationThe trial is registered at ClinicalTrials.gov, number NCT02857803. Registered 5 August 2016, .
Highlights
Paper-and-pencil tasks are still widely used for cognitive rehabilitation despite the proliferation of new computer-based methods, like virtual reality (VR)-based simulations of Activities of Daily Living (ADL’s)
The upgrade to Reh@City v2.0 included: an increase of the ecological validity through the improvement in the overall visual realism of the city and existing tasks, and the interaction through the paretic arm using an adapted handle; the implementation of dynamic difficulty adaptation based on the framework we developed for Task Generator (TG) tasks [23]; and the increase of the number of cognitive training tasks and locations (Magazine Kiosk, Home, Park, and Fashion Store) [67]
The Reh@City v2.0 intervention group had a significant impact, and with large effect sizes, in verbal memory, and processing speed, which is superior to what we have found in the Reh@City v1.0 study, where we only had improvements in the executive functioning measure and the control group improved in the reduction of the number of errors in the Trail Making Test (TMT) B, a processing speed and selective and divided attention measure [29]
Summary
Paper-and-pencil tasks are still widely used for cognitive rehabilitation despite the proliferation of new computer-based methods, like VR-based simulations of ADL’s. VR rehabilitation intervention tools are mostly developed to include mechanisms such as personalization and adaptation, elements that are disregarded in their paper-and-pencil counterparts, which is a strong limitation of comparison studies. We compare the clinical impact of a personalized and adapted paper-and-pencil training and a content equivalent and more ecologically valid VR-based ADL’s simulation. Cognitive rehabilitation after stroke Stroke is a leading cause of long-term acquired disability in adults [1], predisposing patients toward institutionalization and poorer quality of life [2]. Post-stroke cognitive deficits are pervasive causing disability with major impacts on quality of life and independence on everyday life activities [6, 7]. More recently, the International Stroke Recovery and Rehabilitation Alliance 2018 working group has identified post-stroke cognitive impairments as a research priority [10]
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