An exploration of the ecological validity of the Virtual Action Planning-Supermarket (VAP-S) with people with schizophrenia.

People with schizophrenia often have functional limitations that affect their daily activities due to executive function deficits. One way to assess these deficits is through the use of virtual reality programmes that reproduce real-life instrumental activities of daily living (IADLs). One such programme is the Virtual Action Planning-Supermarket (VAP-S). This exploratory study aimed to examine the ecological validity of this programme, specifically, how task performance in both virtual and natural environments compares. Case studies were used and involved five participants with schizophrenia, who were familiar with grocery shopping. They were assessed during both the VAP-S shopping task and a real-life grocery shopping task using an observational assessment tool, the Perceive, Recall, Plan and Perform (PRPP) System of Task Analysis. The results show that when difficulties were present in the virtual task, difficulties were also observed in the real-life task. For some participants, greater difficulties were observed in the virtual task. These difficulties could be explained by the presence of perceptual deficits and problems remembering the required sequenced actions in the virtual task. In conclusion, performance on the VAP-S by these five participants was generally comparable to the performance in a natural environment.

The effect of contextual auditory stimuli on virtual spatial navigation in patients with focal hemispheric lesions.

Topographical disorientation is a frequent deficit among patients suffering from brain injury. Spatial navigation can be explored in this population using virtual reality environments, even in the presence of motor or sensory disorders. Furthermore, the positive or negative impact of specific stimuli can be investigated. We studied how auditory stimuli influence the performance of brain-injured patients in a navigational task, using the Virtual Action Planning-Supermarket (VAP-S) with the addition of contextual ("sonar effect" and "name of product") and non-contextual ("periodic randomised noises") auditory stimuli. The study included 22 patients with a first unilateral hemispheric brain lesion and 17 healthy age-matched control subjects. After a software familiarisation, all subjects were tested without auditory stimuli, with a sonar effect or periodic random sounds in a random order, and with the stimulus "name of product". Contextual auditory stimuli improved patient performance more than control group performance. Contextual stimuli benefited most patients with severe executive dysfunction or with severe unilateral neglect. These results indicate that contextual auditory stimuli are useful in the assessment of navigational abilities in brain-damaged patients and that they should be used in rehabilitation paradigms.

Virtual reality compared with in vivo exposure in the treatment of social anxiety disorder: a three-arm randomised controlled trial.

BackgroundPeople with social anxiety disorder (SAD) fear social interactions and may be reluctant to seek treatments involving exposure to social situations. Social exposure conducted in virtual reality (VR), embedded in individual cognitive-behavioural therapy (CBT), could be an answer.AimsTo show that conducting VR exposure in CBT for SAD is effective and is more practical for therapists than conducting exposure in vivoMethodParticipants were randomly assigned to either VR exposure (n = 17), in vivo exposure (n = 22) or waiting list (n = 20). Participants in the active arms received individual CBT for 14 weekly sessions and outcome was assessed with questionnaires and a behaviour avoidance test. (Trial registration number ISRCTN99747069)ResultsImprovements were found on the primary (Liebowitz Social Anxiety Scale) and all five secondary outcome measures in both CBT groups compared with the waiting list. Conducting exposure in VR was more effective at post-treatment than in vivo on the primary outcome measure and on one secondary measure. Improvements were maintained at the 6-month follow-up. VR was significantly more practical for therapists than in vivo exposure.ConclusionsUsing VR can be advantageous over standard CBT as a potential solution for treatment avoidance and as an efficient, cost-effective and practical medium of exposure.

Using the virtual action planning-supermarket for evaluating executive functions in people with stroke.

BACKGROUND: Our objectives are (1) to establish construct validity by comparing task performance with the Virtual Action Planning-Supermarket (VAP-S) by patients with stroke to healthy matched control subjects, (2) to establish concurrent validity by exploring relationships between VAP-S performance and Executive Functions (EFs) and ecological validity by exploring relationships between VAP-S performance and the Observed Tasks of Daily Living-Revised (OTDL-R), a measure of Instrumental Activities of Daily Living (IADL), and (3) to determine which measures predict IADL performance in patients with stroke. METHODS: The research group included 24 men and women, aged 44-65 years, poststroke and the control group included 24 matched healthy people. The VAP-S and the Behavioral Assessment of the Dysexecutive Syndrome (BADS) were administered to evaluate EF. The stroke patients were tested with the OTDL-R. RESULTS: Significant differences between groups were found for 2 outcome measures of the VAP-S. In the research group, significant (P ≤ .05) moderate correlations were found between the VAP-S number of purchases and the BADS key search subtest (r = .48) and between the VAP-S number of correct actions and both the BADS action program (r = .47) and key search (r = .52) subtests. An exploratory stepwise multiple regression showed that the VAP-S number of correct actions and the profile score of the BADS were able to predict 56.2% of OTDL-R performance for the clients. CONCLUSIONS: The VAP-S showed adequate validity and an ability to predict IADL performance, providing support for its use in cognitive stroke rehabilitation.

A Virtual Reality Platform for Evaluating Deficits in Executive Functions in Deaf and Hard of Hearing Children-Relation to Daily Function and to Quality of Life.

Background: Childhood hearing loss is a common chronic condition that may have a broad impact on children's communication and motor and cognitive development, resulting in functional challenges and decreased quality of life (QoL). Objectives: This pilot study aimed to compare executive functions (EFs) as expressed in daily life and QoL between deaf and hard-of-hearing (D/HH) children and children with typical hearing. Furthermore, we examined the relationship between EFs and QoL in D/HH children. Methods: The participants were 76 children aged 7-11 yr: 38 D/HH and 38 with typical hearing. Parents completed the Behavior Rating Inventory of Executive Function (BRIEF) and Pediatric Quality of Life Inventory (PedsQL), while the child performed a shopping task in the virtual action planning supermarket (VAP-S) to reflect the use of EFs in daily activity. Results: D/HH children showed significantly poorer EFs (as measured by BRIEF and VAP-S) and reduced QoL. Difficulties in EFs were correlated with lower QoL. BRIEF scores were significant predictors of QoL domains. Conclusions: Difficulties in EFs may characterize children with D/HH and reduce their QoL. Therefore, EFs should be screened and treated. VAP-S and BRIEF are feasible tools for evaluating EFs that reflect children's challenges due to EF difficulties in real-life contexts.

Towards a web 2.0 based software for the design and the facilitation of cognitive stimulation workshops.

Cognitive stimulation workshops (CSW) are recommended for elderly people with a decline in cognitive functions, for example, mild cognitive impairment. Information and Communication Technology (ICT) has the potential to enrich and facilitate preparation, facilitation and assessment of CSW interventions. We present the first steps of our co-design approach towards a Web 2.0 based software, called STIMULEE, for the design and the facilitation of CSW. Its achievement will provide novel therapeutic practices to our clinical partners.

Using virtual humans to alleviate social anxiety: preliminary report from a comparative outcome study.

Empirical studies have consistently shown the effectiveness of a multicomponent CBT treatment of social anxiety disorder (SAD). Previous outcome studies on virtual reality and SAD have focused on people suffering from fear of public speaking and not full blown SAD. In this study, 45 adults receiving a DSM-IV-TR diagnostic of social anxiety were randomly assigned to traditional CBT treatment (with in vivo exposure), CBT-VR combined treatment, or a waiting list. Results show significant reduction of anxiety on all questionnaires as well as statistically significant interactions between both treatment groups and the waiting list.

Immersing Patients in a Virtual Reality Environment for Brain Mapping During Awake Surgery: Safety Study.

BACKGROUND: Brain mapping by direct electrical stimulation during awake craniotomy is now a standard procedure that reduces the risk of permanent neurologic deficits. Virtual reality technology immerses the patient in a virtually controlled, interactive world, offering a unique opportunity to develop innovative tasks for perioperative mapping of complex cognitive functions. The objective of this prospective single-center study was to evaluate the tolerance and safety of a virtual reality headset (VRH) and immersive virtual experiences in patients undergoing awake craniotomy and brain mapping by direct electrical stimulation. METHODS: The study included 30 patients with a brain tumor near the language area. Language mapping was performed with a naming task, DO 80, presented on a digital tablet and then in two-dimensional and three-dimensional formats through a VRH. During wound closure, different virtual reality experiences were proposed to the patient, offering different types of virtual motion or interaction with an avatar piloted by a neuropsychologist. RESULTS: Two patients could not use the VRH owing to technical issues. No procedure was aborted, no patient experienced virtual reality sickness and all patients reported they would repeat the procedure. Despite a high rate of intraoperative focal seizures, there was no argument to attribute the seizures to VRH use. CONCLUSIONS: This study shows that it is possible during awake brain surgery to immerse the patient in a virtual environment and to interact with the patient, opening the field of new brain mapping procedures for complex cognitive functions.

Association between prism adaptation and auditory cues on spatial navigation in individuals with unilateral neglect.

BACKGROUND: Unilateral neglect is common among right-hemispheric stroke individuals and also concerns the auditory modality. Prism adaptation can improve auditory extinction during a dichotic listening task, but its effect during an ecological task has not been studied. OBJECTIVE: The main objective was to evaluate whether lateralized cueing before and after prism adaptation improved virtual spatial navigation of stroke individuals with visual and auditory unilateral neglect. Secondary objectives were to assess spatial memory and obtain a better understanding of the mechanism of the cueing treatment by using an eye-tracker. METHODS: We included 22 stroke individuals with left visual and auditory neglect, 14 individuals without neglect, and 12 healthy controls. After a familiarization task, participants underwent 3 evaluation sessions. Participants were first passively shown a path that they had then to actively reproduce by using a joystick. A path with lateralized beeping sounds indicating direction and a path without any sounds were followed in a randomized order. After prism adaptation, the participants followed a third path with lateralized beeping sounds. The time of navigation and number of trajectory mistakes were recorded. After navigation, spatial memory was assessed. Additionally, an eye-tracker was used during the navigation period. RESULTS: The navigational performance of participants with neglect was significantly better with than without auditory cues, especially after prism adaptation. With auditory cues, participants without neglect reached the navigational performance of healthy controls. The spatial memory of individuals with neglect was significantly lower with auditory cues. Eye-tracking analyses showed that participants with neglect made more saccades and looked longer at the right-square angles in the absence of auditory cues. CONCLUSIONS: This study demonstrates the positive effect of auditory cues in virtual spatial navigation of individuals with visual and auditory neglect and the potentiation of the help of cues after prism adaptation.

Use of the virtual action planning supermarket for the diagnosis of mild cognitive impairment: a preliminary study.

BACKGROUND: Although executive functioning (EF) was found to be associated with cognitive deterioration, the majority of the tests for assessing EF lack ecological validity. AIMS: To examine the feasibility and the validity of the virtual action planning supermarket (VAP-S) for the diagnosis of patients with mild cognitive impairment (MCI). METHODS: Thirty MCI patients (mean age = 69.5 years) were compared to 30 healthy elderly persons (mean age = 69.2 years) in their performance of the VAP-S. RESULTS: Significant differences were found between the groups in the majority of the measures of the VAP-S. The combination of the MMSE and the trajectory duration provided the best predictive classification for the groups. CONCLUSION: MCI patients have EF deficits, and the VAP-S is a viable tool to assess EF deficits in patients with MCI and healthy elderly.

Moving beyond single user, local virtual environments for rehabilitation.

The rapid development of Virtual Reality-based technologies over the past decade is both an asset and a challenge for neuro-rehabilitation. The availability of novel technologies that provide interactive, functional simulations with multimodal feedback enable clinicians to achieve traditional therapeutic goals that would be difficult, if not impossible, to attain via conventional therapy. They also lead to the creation of completely new clinical paradigms which would have been hard to achieve in the past. In applications of rehabilitation for both motor and cognitive deficits the main focus of much of the early exploratory research has been to investigate the use of virtual reality as an assessment tool. To date such environments are primarily: (a) single user (i.e., designed for and used by one clinical client at a time) and (b) used locally within a clinical or educational setting. More recently, researchers have begun the development of new and more complex VR-based approaches according to two dimensions: the number of users and the distance between the users. Driven by a push-pull phenomenon, the original approach has now expanded to three additional avenues: multiple users in co-located settings; single users in remote locations; and multiple users in remote locations. After a presentation of examples that illustrate theses various approaches, we will conclude in addressing questions and ethical considerations raised by this evolution in the use of virtual environments in rehabilitation.

Designing an ecological and adaptable virtual task in the context of executive functions.

Brain damage is a major cause of disability that often leads to deficits in Executive Functions (EF) with dramatic consequences on activities of daily living. While rehabilitation approaches of the dysexecutive syndrome are still limited, Virtual Reality (VR) has shown its potential to propose innovative intervention strategies based on ecologically valid functional tasks. The purpose of this paper is to present the design process of the Therapeutic Virtual Kitchen (TVK) in which ecological and adaptable virtual tasks may be configured by the therapists for patients' assessment and rehabilitation. The outcomes of a preliminary test of feasibility among members of our laboratory and Kerpape Rehabilitation Center are reported and discussed.

Influence of non-contextual auditory stimuli on navigation in a virtual reality context involving executive functions among patients after stroke.

BACKGROUND: Topographical disorientation is frequent among patients after a stroke and can be well explored with virtual environments (VEs). VEs also allow for the addition of stimuli. A previous study did not find any effect of non-contextual auditory stimuli on navigational performance in the virtual action planning-supermarket (VAP-S) simulating a medium-sized 3D supermarket. However, the perceptual or cognitive load of the sounds used was not high. OBJECTIVE: We investigated how non-contextual auditory stimuli with high load affect navigational performance in the VAP-S for patients who have had a stroke and any correlation between this performance and dysexecutive disorders. METHODS: Four kinds of stimuli were considered: sounds from living beings, sounds from supermarket objects, beeping sounds and names of other products that were not available in the VAP-S. The condition without auditory stimuli was the control. The Groupe de réflexion pour l'évaluation des fonctions exécutives (GREFEX) battery was used to evaluate executive functions of patients. RESULTS: The study included 40 patients who have had a stroke (n=22 right-hemisphere and n=18 left-hemisphere stroke). Patients' navigational performance was decreased under the 4 conditions with non-contextual auditory stimuli (P<0.05), especially for those with dysexecutive disorders. For the 5 conditions, the lower the performance, the more GREFEX tests were failed. Patients felt significantly disadvantaged by the non-contextual sounds sounds from living beings, sounds from supermarket objects and names of other products as compared with beeping sounds (P<0.01). Patients' verbal recall of the collected objects was significantly lower under the condition with names of other products (P<0.001). Left and right brain-damaged patients did not differ in navigational performance in the VAP-S under the 5 auditory conditions. CONCLUSIONS: These non-contextual auditory stimuli could be used in neurorehabilitation paradigms to train patients with dysexecutive disorders to inhibit disruptive stimuli.

Are visual cues helpful for virtual spatial navigation and spatial memory in patients with mild cognitive impairment or Alzheimer's disease?

OBJECTIVE: To evaluate whether visual cues are helpful for virtual spatial navigation and memory in Alzheimer's disease (AD) and patients with mild cognitive impairment (MCI). METHOD: 20 patients with AD, 18 patients with MCI and 20 age-matched healthy controls (HC) were included. Participants had to actively reproduce a path that included 5 intersections with one landmark at each intersection that they had seen previously during a learning phase. Three cueing conditions for navigation were offered: salient landmarks, directional arrows and a map. A path without additional visual stimuli served as control condition. Navigation time and number of trajectory mistakes were recorded. RESULTS: With the presence of directional arrows, no significant difference was found between groups concerning the number of trajectory mistakes and navigation time. The number of trajectory mistakes did not differ significantly between patients with AD and patients with MCI on the path with arrows, the path with salient landmarks and the path with a map. There were significant correlations between the number of trajectory mistakes under the arrow condition and executive tests, and between the number of trajectory mistakes under the salient landmark condition and memory tests. CONCLUSION: Visual cueing such as directional arrows and salient landmarks appears helpful for spatial navigation and memory tasks in patients with AD and patients with MCI. This study opens new research avenues for neuro-rehabilitation, such as the use of augmented reality in real-life settings to support the navigational capabilities of patients with MCI and patients with AD. (PsycINFO Database Record

Improvement of Navigation and Representation in Virtual Reality after Prism Adaptation in Neglect Patients.

Prism adaptation (PA) is responsible for an expansion of sensori-motor after-effects to cognitive domains for patients with spatial neglect. One important question is whether the cognitive after-effects induced by PA may also concern higher aspects of spatial cognition, such as navigation and topographic memory, which are critical in everyday life. The aim of this study was to assess whether multiple sessions of right PA can affect navigation and topographic memory. Seven right brain-damaged (RBD) patients with chronic neglect were included. We used a virtual supermarket named VAP-S which is an original paradigm, similar to the "shopping list test" during which patients had to purchase items from a list of eight products. Furthermore, in order to assess generalization of PA effects on constructing a spatial map from virtual information, each participant was then asked to draw the map of the virtual supermarket from memory. Regarding navigation performance, significant results were obtained: session duration reduction, fewer numbers of pauses and omissions, more items purchased on the left side and more items purchased over all. A long-lasting effect was noted, up to one month after PA. The representational task performance was also significantly increased for map drawing, with a reduction of the right shift of the symmetry axis of the map, more items drawn on the left side of maps and over all, and more items correctly located on the map. Some of these effects lasted for at least 7 days. These results suggest an expansion of PA benefit to a virtual environment. Crucially, the cognitive benefits induced by PA were noted for complex spatial cognition tasks required in everyday life such as navigation and topographic memory and this improvement was maintained for up to 1 month.

Intraoperative Subcortical Electrical Mapping of the Optic Tract in Awake Surgery Using a Virtual Reality Headset.

BACKGROUND: Brain mapping during awake craniotomy is a well-known technique to preserve neurological functions, especially the language. It is still challenging to map the optic radiations due to the difficulty to test the visual field intraoperatively. To assess the visual field during awake craniotomy, we developed the Functions' Explorer based on a virtual reality headset (FEX-VRH). METHODS: The impaired visual field of 10 patients was tested with automated perimetry (the gold standard examination) and the FEX-VRH. The proof-of-concept test was done during the surgery performed on a patient who was blind in his right eye and presenting with a left parietotemporal glioblastoma. The FEX-VRH was used intraoperatively, simultaneously with direct subcortical electrostimulation, allowing identification and preservation of the optic radiations. RESULTS: The FEX-VRH detected 9 of the 10 visual field defects found by automated perimetry. The patient who underwent an awake craniotomy with intraoperative mapping of the optic tract using the FEX-VRH had no permanent postoperative visual field defect. CONCLUSION: Intraoperative visual field assessment with the FEX-VRH during direct subcortical electrostimulation is a promising approach to mapping the optical radiations and preventing a permanent visual field defect during awake surgery for epilepsy or tumor.

Virtual action planning in Parkinson's disease: a control study.

Cognitive planning deficits affect patients with Parkinson's disease (PD) and traditional psychometric tests meet difficulties to evaluate their impact on daily life activities. Virtual reality (VR) may provide a new means of assessment. The objective of this study was firstly to develop a virtual environment (VE) useful to explore planning and secondly to examine the effectiveness of using VR in the assessment of cognitive planning for patients with PD. A virtual supermarket (VS) was designed in which participants carried out a task close to daily activities: a test of shopping list. There were two preliminary sessions to familiarize the participants with the software and the supermarket's layout. Then, during the assessment session, participants completed the task, without any time limitation. Global intellectual efficiency was assessed in order to exclude patients with dementia. Data related to the performance in the VS were recorded. Five patients with PD and five age-matched healthy volunteers, meeting inclusion criteria, constituted our convenience sample. The patients did not perform as well as the control group. In particular, the session's duration and the distance covered were longer. The patients' path is specific with numerous stops, turning around, and hesitancies. Finally, their motivation for further training sessions is aroused. The results underline the potential of using VR in the assessment of cognitive planning in PD. A larger analysis is currently being carried out to confirm and to explore all the outcome measures.

Barriers to home-based exercise program adherence with chronic low back pain: Patient expectations regarding new technologies.

OBJECTIVE: To assess views of patients with chronic low back pain (cLBP) concerning barriers to home-based exercise program adherence and to record expectations regarding new technologies. DESIGN: Qualitative study based on semi-structured interviews. PARTICIPANTS: A heterogeneous sample of 29 patients who performed a home-based exercise program for cLBP learned during supervised physiotherapy sessions in a tertiary care hospital. INTERVENTIONS: Patients were interviewed at home by the same trained interviewer. Interviews combined a funnel-shaped structure and an itinerary method. RESULTS: Barriers to adherence related to the exercise program (number, effectiveness, complexity and burden of exercises), the healthcare journey (breakdown between supervised sessions and home exercise, lack of follow-up and difficulties in contacting care providers), patient representations (illness and exercise perception, despondency, depression and lack of motivation), and the environment (attitudes of others, difficulties in planning exercise practice). Adherence could be enhanced by increasing the attractiveness of exercise programs, improving patient performance (following a model or providing feedback), and the feeling of being supported by care providers and other patients. Regarding new technologies, relatively younger patients favored visual and dynamic support that provided an enjoyable and challenging environment and feedback on their performance. Relatively older patients favored the possibility of being guided when doing exercises. Whatever the tool proposed, patients expected its use to be learned during a supervised session and performance regularly checked by care providers; they expected adherence to be discussed with care providers. CONCLUSIONS: For patients with cLBP, adherence to home-based exercise programs could be facilitated by increasing the attractiveness of the programs, improving patient performance and favoring a feeling of being supported. New technologies meet these challenges and seem attractive to patients but are not a substitute for the human relationship between patients and care providers.

Virtual reality exposure in the treatment of social phobia.

Social phobia is one of the most frequent psychiatric disorders and is accessible to two forms of scientifically validated treatments: anti-depressant drugs and cognitive-behavioral therapies. Graded exposure to feared social situations (either in vivo or by imagining the situations) is fundamental to obtain an improvement of the anxious symptoms. Virtual reality (VR) may be an alternative to these standard exposure techniques and seems to bring significant advantages by allowing exposures to numerous and varied situations. Moreover studies have shown that human subjects are appropriately sensitive to virtual environments. This chapter reports the definition of a VR-based clinical protocol and a study to treat social phobia using virtual reality techniques. The virtual environments used in the treatment reproduce four situations that social phobics feel the most threatening: performance, intimacy, scrutiny and assertiveness. With the help of the therapist, the patient learns adapted cognitions and behaviors when coping with social situations, with the aim of reducing her or his anxiety in the corresponding real life situations. Some studies have been carried out using virtual reality in the treatment of fear of public speaking, which is only a small part of the symptomatology of most of social phobic patients. The novelty of our work is to address a larger group of situations that the phobic patients experience with high anxiety. In our protocol, the efficacy of the virtual reality treatment is compared to well established and well validated group cognitive-behavioral treatment.

Using virtual reality to evaluate executive functioning among persons with schizophrenia: a validity study.

Persons with Schizophrenia experience difficulties with Executive Functioning (EF) that affect independence and participation in activities. Specifically, EF impacts performance in Instrumental Activities of Daily Living (IADL) that require flexible thinking and accommodation to complex environments. However, less is known how schizophrenia affects EF and individuals' performance in activities. IADL performance can be tested using a virtual reality (VR) environment that simulates real life activities. The purpose of this study was: 1) to examine the feasibility and validity of the Virtual Action Planning-Supermarket (VAP-S) to assess EF in persons with schizophrenia as compared to a standardized EF measure (the Behavioral Assessment of Dysexecutive Syndrome, BADS); 2) to compare performance of persons with schizophrenia and healthy controls in the VAP-S; 3) to assess the ability of the VAP-S to differentiate between different levels of EF within schizophrenia; 4) to explore the relationships between negative and positive symptoms and performance on the tests. Thirty persons with schizophrenia were matched with 30 healthy controls. Significant differences in performance between research and control groups were detected on the VAP-S and BADS, with the research group performing worse. Large variations in number of purchases within the VAP-S by the research group point to level of task completion thus secondary analysis was conducted. There was a significant negative correlation between level of the negative signs and overall performance on the BADS and on most measures of the VAP-S. Results of this study support the use the VAP-S to assess EF among persons with Schizophrenia.