Identifying spatial neglect - an updated systematic review of the psychometric properties of assessment tools in adults post-stroke.

Spatial neglect commonly occurs after a stroke, resulting in diverse impacts depending on the type and severity. There are almost 300 tools for assessing neglect, yet there is a lack of knowledge on the psychometric properties of these tools. The objective of this systematic review, registered on Prospero (CRD42021271779), was to determine the quality of the evidence for assessing spatial neglect, categorized by neglect subtype. The following databases were searched on 3rd May 2022 from database inception: Ovid Emcare, Embase, Ovid MEDLINE, APA PsycINFO, Web of Science (SCI-EXPANDED; SSCI; A&HCI; ESCI) and Scopus. All primary peer-reviewed studies (>5 participants) of adults post stroke, reporting any psychometric property of 33 commonly used neglect assessment tools were included. The COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) risk of bias tool was used to assess the methodological quality of the studies and summarize the psychometric properties of each tool. 164 articles were included, with a total of 12,463 people with stroke. The general quality of the evidence was poor and no one tool had high-quality evidence of both validity and reliability. Eleven tools show some promise as they meet the minimum criteria for good measurement properties for both validity and reliability.

Improving real-world skills in people with intellectual disabilities: an immersive virtual reality intervention.

Virtual reality (VR) is a promising tool for training life skills in people with intellectual disabilities. However, there is a lack of evidence surrounding the implementation, suitability, and effectiveness of VR training in this population. The present study investigated the effectiveness of VR training for people with intellectual disabilities by assessing (1) their ability to complete basic tasks in VR, (2) real-world transfer and skill generalisation, and (3) the individual characteristics of participants able to benefit from VR training. Thirty-two participants with an intellectual disability of varying severity completed a waste management training intervention in VR that involved sorting 18 items into three bins. Real-world performance was measured at pre-test, post-test, and delayed time points. The number of VR training sessions varied as training ceased when participants met the learning target (≈ 90% correct). A survival analysis assessed training success probability as a function of the number of training sessions with participants split by their level of adaptive functioning (as measured on the Adaptive Behaviour Assessment System Third Edition). The learning target was met by 19 participants (59.4%) within ten sessions (Mdn = 8.5, IQR 4-10). Real-world performance significantly improved from pre- to post-test and pre- to delayed test. There was no significant difference from post- to delayed test. Further, there was a significant positive relationship between adaptive functioning and change in the real-world assessment from the pre-test to the post- and delayed tests. VR facilitated the learning of most participants, which led to demonstrations of real-world transfer and skill generalisation. The present study identified a relationship between adaptive functioning and success in VR training. The survival curve may assist in planning future studies and training programs.

The Effect of Reminiscence Therapy Using Virtual Reality on Apathy in Residential Aged Care: Multisite Nonrandomized Controlled Trial.

BACKGROUND: Apathy is a frequent and underrecognized neurological disorder symptom. Reduced goal-directed behavior caused by apathy is associated with poor outcomes for older adults in residential aged care. Recommended nonpharmacological treatments include person-centered therapy using information and communication technology. Virtual reality (VR) in the form of head-mounted displays (HMDs) is a fully immersive technology that provides access to a wide range of freely available content. The use of VR as a therapy tool has demonstrated promise in the treatment of posttraumatic stress disorder and anxiety. In addition, VR has been used to improve conditions including depression, anxiety, cognitive function, and balance in older adults with memory deficits, Alzheimer disease, and Parkinson disease. Research using VR for the symptoms of apathy in older adults living in residential aged care facilities is limited. OBJECTIVE: This study aims to examine whether using HMDs as a tool for reminiscence therapy improves the symptoms of apathy compared with using a laptop computer and physical items with older adults living in residential aged care. METHODS: In this multisite trial, 43 participants were allocated to one of three groups: reminiscence therapy intervention using VR in the form of HMDs, reminiscence therapy using a laptop computer supplemented by physical items if required (active control), and a usual care (passive control) group. The primary outcome was apathy, and the secondary outcomes included cognition and depression. The side effects of using HMDs were also measured in the VR group. RESULTS: Mixed model analyses revealed no significant group interaction over time in outcomes between the VR and laptop groups (estimate=-2.24, SE 1.89; t40=-1.18; P=.24). Pooled apathy scores in the two intervention groups compared with the passive control group also revealed no significant group interaction over time (estimate=-0.26, SE 1.66; t40=-0.16; P=.88). There were no significant secondary outcomes. Most participants in the VR group stated that they would prefer to watch content in VR than on a flat screen (Χ22=11.2; P=.004), side effects from HMD use were negligible to minimal according to the Simulator Sickness Questionnaire cutoff scores. CONCLUSIONS: Although there were no significant results in outcome measures, this study found that participants engaged in the research and enjoyed the process of reminiscing using both forms of technology. It was found that VR can be implemented in an aged care setting with correct protocols in place. Providing residents in aged care with a choice of technology may assist in increasing participation in activities. We cannot dismiss the importance of immediate effects while the therapy was in progress, and this is an avenue for future research. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619001510134; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378564. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-DOI: 10.1136/bmjopen-2020-046030.

Rest Intervals during Virtual Reality Gaming Augments Standing Postural Sway Disturbance.

Immersive virtual reality (VR) can cause acute sickness, visual disturbance, and balance impairment. Some manufacturers recommend intermittent breaks to overcome these issues; however, limited evidence examining whether this is beneficial exists. The aim of this study was to examine whether taking breaks during VR gaming reduced its effect on postural sway during standing balance assessments. Twenty-five people participated in this crossover design study, performing 50 min of VR gaming either continuously or with intermittent 10 min exposure/rest intervals. Standing eyes open, two-legged balance assessments were performed immediately pre-, immediately post- and 40 min post-exposure. The primary outcome measure was total path length; secondary measures included independent axis path velocity, amplitude, standard deviation, discrete and continuous wavelet transform-derived variables, and detrended fluctuation analysis. Total path length was significantly (p < 0.05) reduced immediately post-VR gaming exposure in the intermittent rest break group both in comparison to within-condition baseline values and between-condition timepoint results. Conversely, it remained consistent across timepoints in the continuous exposure group. These changes consisted of a more clustered movement speed pattern about a lower central frequency, evidenced by signal frequency content. These findings indicate that caution is required before recommending rest breaks during VR exposure until we know more about how balance and falls risk are affected.

Exergaming With Beat Saber: An Investigation of Virtual Reality Aftereffects.

BACKGROUND: Virtual reality (VR) exergaming has the potential to target sedentary behavior. Immersive environments can distract users from the physical exertion of exercise and can motivate them to continue exergaming. Despite the recent surge in VR popularity, numerous users still experience VR sickness from using head-mounted displays (HMDs). Apart from the commonly assessed self-reported symptoms, depth perception and cognition may also be affected. Considering the potential benefits of VR exergaming, it is crucial to identify the adverse effects limiting its potential and continued uptake. OBJECTIVE: This study aims to investigate the consequences of playing one of the most popular VR exergames for 10 and 50 min on aspects of vision, cognition, and self-reported VR sickness. METHODS: A total of 36 participants played an exergame, called Beat Saber, using an HMD. A repeated measures within-subject design was conducted to assess changes in vision, cognition, and well-being after short (10 min) and long (50 min) durations of VR exposure. We measured accommodation, convergence, decision speed, movement speed, and self-reported sickness at 3 test periods-before VR, immediately after VR, and 40 min after VR (late). RESULTS: Beat Saber was well tolerated, as there were no dropouts due to sickness. For most participants, any immediate aftereffects were short-lived and returned to baseline levels after 40 min of exiting VR. For both short and long exposures, there were changes in accommodation (F1,35=8.424; P=.006) and convergence (F1,35=7.826; P=.008); however, in the late test period, participants returned to baseline levels. Measures on cognition revealed no concern. The total simulator sickness questionnaire (SSQ) scores increased immediately after VR (F1,35=26.515; P<.001) and were significantly higher for long compared with short exposures (t35=2.807; P=.03), but there were no differences in exposure duration in the late test period, with scores returning to baseline levels. Although at a group level, participants' sickness levels returned to baseline 40 min after VR exposure, approximately 14% of the participants still reported high levels of sickness in the late test period after playing 50 min of Beat Saber. We also showed that the participants who experienced a high level of sickness after a short exposure were almost certain to experience a high level of symptoms after a longer exposure. CONCLUSIONS: Irrespective of the duration of exposure, this study found no strong evidence for adverse symptoms 40 min after exiting VR; however, some individuals still reported high levels of VR sickness at this stage. We recommend that users commit to a waiting period after exiting VR to ensure that any aftereffects have deteriorated. Exergames in HMDs have the potential to encourage people to exercise but are understudied, and the aftereffects of exergaming need to be closely monitored to ensure that VR exergames can reach their full potential.

Using Virtual Reality to Improve Apathy in Residential Aged Care: Mixed Methods Study.

BACKGROUND: Apathy is a common symptom in neurological disorders, including dementia, and is associated with a faster rate of cognitive decline, reduced quality of life, and high caregiver burden. There is a lack of effective pharmacological treatments for apathy, and nonpharmacological interventions are a preferred first-line approach to treatment. Virtual reality (VR) using head-mounted displays (HMDs) is being successfully used in exposure- and distraction-based therapies; however, there is limited research on using HMDs for symptoms of neurological disorders. OBJECTIVE: This feasibility study aimed to assess whether VR using HMDs could be used to deliver tailored reminiscence therapy and examine the willingness to participate, response rates to measures, time taken to create tailored content, and technical problems. In addition, this study aimed to explore the immediate effects between verbal fluency and apathy after exposure to VR. METHODS: A mixed methods study was conducted in a sample of older adults residing in aged care, and 17 participants were recruited. Apathy was measured using the Apathy Evaluation Scale (AES), and verbal fluency was used as a proxy measure of improvements in apathy and debriefing interviews to assess feedback from participants. Side effects that can occur from using HMDs were also measured. RESULTS: We recruited participants from a high socioeconomic status setting with a high education level, and the participation rate was 85% (17/20); most responses to measures were positive. Access to a wide range of freely available content and the absence of technical difficulties made the delivery of a VR reminiscence intervention highly feasible. Participants had improved semantic scores (t14=-3.27; P=.006) but not phonemic fluency scores (t14=0.55; P=.59) immediately after the intervention. Those with higher levels of apathy demonstrated the greatest cognitive improvements after a VR reminiscence experience, which was indicated by a strong positive relationship between the AES and semantic verbal fluency change scores postminus pre-VR (r=0.719; 95% CI 0.327 to 0.900; P=.003). All participants enjoyed the experience despite 35% (6/17) of participants experiencing temporary side effects. CONCLUSIONS: This study provides initial evidence that it is feasible to use VR with HMDs for therapy to treat symptoms of apathy in older adults in residential aged care. However, there is a need to closely monitor the side effects of HMD use in older adults. Further research is needed using an active control group to compare the use of VR with traditional forms of reminiscence therapy.

The effects of risk magnitude training on mapping risks on space.

Risk perception has recently been shown to reveal a mental spatial representation, with people responding faster to low-risk items on the left side, and high-risk items on the right side. Subjective risk perception has a stronger spatial representation than objective risk perception; however, both reveal small effect sizes. With risk magnitude being a new domain within spatial mapping literature, we sought to explore its nuances. Following discussion surrounding the relationship between spatial mapping and level of expertise, this study investigated the effect of training an objective risk magnitude sequence on mental spatial representations. Participants (n = 34) used their left and right hands to indicate whether eight risk stimuli were lower or higher risk than a referent activity, both before and after training. Training involved repetitively learning the objectively correct order of the same eight risk stimuli for approximately 15 min. Pre-training results demonstrated the expected spatial representations. Contrary to our predictions, the spatial representation did not get stronger post-training, but instead disappeared. Previous research has demonstrated a loss of spatial-numerical mappings with increased task load. An increase in post-training reaction times could reflect an increase in task load due to a lack of adequate knowledge of risk stimulus order; thus revealing no mental spatial representation. However, failure to find training effects highlights the flexibility of weaker spatial representations, and supports research demonstrating spatial representation flexibility.

Judging risk magnitude: walking to the left and base jumping to the right.

When thinking about quantifiable domains such as numbers, pitch, and size, they are implicitly mapped on to representational space with small/low/less and large/high/more of the respective domain represented on the left and right sides of representational space, respectively. Recent research has also demonstrated that more abstract domains (colours, language, political party names) are also mapped in the same way. This study investigated a new abstract domain, risk, to examine if this same pattern of effects is apparent (left = low risk/right = high risk) to get a better understanding of how risk magnitudes are processed. Experiment 1 (n = 26) presented objective, statistically calculated risk stimuli (micromorts) to participants, who indicated if the stimuli had lower or higher risks than a referent, with their left and right hands. Experiment 2 (n = 25) utilised the same task, but the risk stimuli were generated by the participants themselves. Both experiments found the expected association of risk with space-indicated by faster left-hand responses to low-risk stimuli and faster right-hand responses to high-risk stimuli. Risks appear to fit onto a standard left-right spatial association; however, the effect sizes for all analyses were small. The results of this study are not only in line with the idea of a generalised magnitude processing system, but might also inform best practices in effective communications of risks.

Cognitive rehabilitation for attention deficits following stroke.

BACKGROUND: Many survivors of stroke report attentional impairments, such as diminished concentration and distractibility. However, the effectiveness of cognitive rehabilitation for improving these impairments is uncertain.This is an update of the Cochrane Review first published in 2000 and previously updated in 2013. OBJECTIVES: To determine whether people receiving cognitive rehabilitation for attention problems 1. show better outcomes in their attentional functions than those given no treatment or treatment as usual, and 2. have a better functional recovery, in terms of independence in activities of daily living, mood, and quality of life, than those given no treatment or treatment as usual. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PsycBITE, REHABDATA and ongoing trials registers up to February 2019. We screened reference lists and tracked citations using Scopus. SELECTION CRITERIA: We included controlled clinical trials (CCTs) and randomised controlled trials (RCTs) of cognitive rehabilitation for impairments of attention for people with stroke. We did not consider listening to music, meditation, yoga, or mindfulness to be a form of cognitive rehabilitation. We only considered trials that selected people with demonstrable or self-reported attentional deficits. The primary outcomes were measures of global attentional functions, and secondary outcomes were measures of attentional domains (i.e. alertness, selective attention, sustained attention, divided attention), functional abilities, mood, and quality of life. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, extracted data, and assessed the risk of bias. We used the GRADE approach to assess the certainty of evidence for each outcome. MAIN RESULTS: We included no new trials in this update. The results are unchanged from the previous review and are based on the data of six RCTs with 223 participants. All six RCTs compared cognitive rehabilitation with a usual care control. Meta-analyses demonstrated no convincing effect of cognitive rehabilitation on subjective measures of attention either immediately after treatment (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) -0.03 to 1.08; P = 0.06; 2 studies, 53 participants; very low-quality evidence) or at follow-up (SMD 0.16, 95% CI -0.23 to 0.56; P = 0.41; 2 studies, 99 participants; very low-quality evidence). People receiving cognitive rehabilitation (when compared with control) showed that measures of divided attention recorded immediately after treatment may improve (SMD 0.67, 95% CI 0.35 to 0.98; P < 0.0001; 4 studies, 165 participants; low-quality evidence), but it is uncertain that these effects persisted (SMD 0.36, 95% CI -0.04 to 0.76; P = 0.08; 2 studies, 99 participants; very low-quality evidence). There was no evidence for immediate or persistent effects of cognitive rehabilitation on alertness, selective attention, and sustained attention. There was no convincing evidence for immediate or long-term effects of cognitive rehabilitation for attentional problems on functional abilities, mood, and quality of life after stroke. AUTHORS' CONCLUSIONS: The effectiveness of cognitive rehabilitation for attention deficits following stroke remains unconfirmed. The results suggest there may be an immediate effect after treatment on attentional abilities, but future studies need to assess what helps this effect persist and generalise to attentional skills in daily life. Trials also need to have higher methodological quality and better reporting.

Mapping of non-numerical domains on space: a systematic review and meta-analysis.

The spatial numerical association of response code (SNARC) effect is characterized by low numbers mapped to the left side of space and high numbers mapped to the right side of space. In addition to numbers, SNARC-like effects have been found in non-numerical magnitude domains such as time, size, letters, luminance, and more, whereby the smaller/earlier and larger/later magnitudes are typically mapped to the left and right of space, respectively. The purpose of this systematic and meta-analytic review was to identify and summarise all empirical papers that have investigated horizontal (left-right) SNARC-like mappings using non-numerical stimuli. A systematic search was conducted using EMBASE, Medline, and PsycINFO, where 2216 publications were identified, with 57 papers meeting the inclusion criteria (representing 112 experiments). Ninety-five of these experiments were included in a meta-analysis, resulting in an overall effect size of d = .488 for a SNARC-like effect. Additional analyses revealed a significant effect size advantage for explicit instruction tasks compared with implicit instructions, yet yielded no difference for the role of expertise on SNARC-like effects. There was clear evidence for a publication bias in the field, but the impact of this bias is likely to be modest, and it is unlikely that the SNARC-like effect is a pure artefact of this bias. The similarities in the response properties for the spatial mappings of numerical and non-numerical domains support the concept of a general higher order magnitude system. Yet, further research will need to be conducted to identify all the factors modulating the strength of the spatial associations.

Reading on the right when there's nothing left? Probabilistic tractography reveals hemispheric asymmetry in pure alexia.

We present a patient with reading inexpertise and right hemianopia following left posterior cerebral artery (PCA) stroke. We examine the extent of disruption to reading performance and the extent of white matter tract damage relative to a patient with more limited PCA infarction and isolated right hemianopia. We show white matter disconnection of the temporal occipital fusiform cortex in our pure alexia patient. Connectivity-based laterality indices revealed right hemisphere laterality in the alexia patient; this was not associated with improved reading function. We speculate that the degree of premorbid laterality may be a critical factor affecting the extent of reading dysfunction in alexia.

Cognitive Outcomes of Cardiovascular Surgical Procedures in the Old: An Important but Neglected Area.

Older individuals can now undergo invasive cardiovascular procedures without serious concern about mortality, and the numbers and proportions of the over 65s and 85s doing so in Australia has been increasing over the last 20 years. There is overwhelming evidence linking cardiovascular conditions to late-life (65 years and over) cognitive impairment and dementia including Alzheimer's Disease, primarily due to impaired cerebrovascularisation and cascading neuropathological processes. Somewhat paradoxically, these cardiovascular interventions, carried out with the primary aim of revascularisation, are not usually associated with short- or long-term improvements in cognitive function in older adults. We discuss factors associated with cognitive outcomes post-cardiovascular surgeries in patients over 65 years of age. There are many opportunities for future research: we know almost nothing about cognitive outcomes following invasive cardiac procedures in the oldest old (85 years and over) nor how to predict the cognitive/delirium outcome using pre-surgical data, and lastly, intervention opportunities exist both pre and postoperatively that have not been tested. As our population ages with increased cardiovascular burden and rates of cardiovascular interventions and surgeries, it is critical that we understand the cognitive consequences of these procedures, who is at greatest risk, and ways to optimise cognition.

A study on the natural history of scanning behaviour in patients with visual field defects after stroke.

BACKGROUND: A visual field defect (VFD) is a common consequence of stroke with a detrimental effect upon the survivors' functional ability and quality of life. The identification of effective treatments for VFD is a key priority relating to life post-stroke. Understanding the natural evolution of scanning compensation over time may have important ramifications for the development of efficacious therapies. The study aims to unravel the natural history of visual scanning behaviour in patients with VFD. The assessment of scanning patterns in the acute to chronic stages of stroke will reveal who does and does not learn to compensate for vision loss. METHODS/DESIGN: Eye-tracking glasses are used to delineate eye movements in a cohort of 100 stroke patients immediately after stroke, and additionally at 6 and 12 months post-stroke. The longitudinal study will assess eye movements in static (sitting) and dynamic (walking) conditions. The primary outcome constitutes the change of lateral eye movements from the acute to chronic stages of stroke. Secondary outcomes include changes of lateral eye movements over time as a function of subgroup characteristics, such as side of VFD, stroke location, stroke severity and cognitive functioning. DISCUSSION: The longitudinal comparison of patients who do and do not learn compensatory scanning techniques may reveal important prognostic markers of natural recovery. Importantly, it may also help to determine the most effective treatment window for visual rehabilitation.

Visual asymmetries for relative depth judgments in a three-dimensional space.

Our ability to process information about an object's location in depth varies along the horizontal and vertical axes. These variations reflect functional specialisation of the cerebral hemispheres as well as the ventral/dorsal visual streams for processing stimuli located in near and far space. Prior research has demonstrated visual field superiorities for processing near space in the lower and right hemispaces and for far space in the upper and left hemispaces. No research, however, has directly tested whether the functional specialisation of the visual fields actually makes objects look closer when presented in the lower or right visual fields. To measure biases in the perception of depth, we employed anaglyph stimuli where participants made closer/further judgments about the relative location of two spheres in a three-dimensional virtual space. We observed clear processing differences in this task where participants perceived the right and lower spheres to be closer and the left and upper spheres to be further away. Furthermore, no relationship between the horizontal and vertical dimensions was observed suggesting separate cognitive/neural mechanisms. Not only does this methodology clearly demonstrate differences in perceived depth across the visual field, it also opens up many possibilities for studying functional asymmetries in three-dimensional space.

Asymmetries in attention as revealed by fixations and saccades.

Neurologically normal individuals devote more attention to the left side; an asymmetry known as pseudoneglect, which reflects right hemisphere involvement in visuospatial attention. The role of eye movements in attentional asymmetries has received little consideration, particularly in terms of the greyscales task. Stimulus length, elevation, and presentation duration were manipulated, while monitoring eye movements during the greyscales task. Region of interest analyses compared time spent examining each quadrant of the stimulus. Further, saccades were examined in conjunction with fixations to gain an understanding of overall eye movement patterns. Scatterplots combining x-and y-coordinates illustrate mean eye position. Results demonstrated a comparison strategy was used, where the dark portions of each rectangle were fixated. Mean eye position was within the lower left quadrant. The left visual field was inspected most for the baseline condition. Interestingly, the lower visual field was examined most when duration, length, or elevation was manipulated. Eye movement patterns provide a possible explanation for why correlations are y not observed between visuospatial tasks. Different strategies, based on specific-task demands, are likely to be used, which in turn, engage separate aspects of visuospatial attention.

Close to me: the effect of asymmetrical environments on spatial attention.

Attention can be captured by distractors and can affect performance. To examine whether asymmetrical distractors, such as a wall, affect spatial attention, Experiment 1 required participants (n = 20) to determine the relative length of pre-bisected lines when a temporary barrier was placed close to the left or right sides of the display. Post-hoc tests showed that attention was drawn towards left, but not right, walls. Experiment 2 (n = 18) sought to increase this effect using a solid brick wall rather than a temporary barrier. Instead of strengthening the result, no effect of barrier was observed. A non-effect was also observed in Experiment 3 (n = 18) when participants moved a cursor to the line's middle. Finally, Experiment 4 (n = 26) showed that asymmetrical barriers had no effect on visual search. While the data showed some evidence that attention is distracted by walls placed to the left, this effect is weak and task-specific. PRACTITIONER SUMMARY: The ability to monitor critical information on displays can be affected by asymmetrical distractors. In many workplaces, a display may be placed alongside a wall. This study explored whether a wall placed to the left/right affects spatial attention. A weak, task-specific, attraction effect was observed for walls on the left.

Personalised virtual reality in palliative care: clinically meaningful symptom improvement for some.

OBJECTIVES: This study examined the effects of virtual reality (VR) among palliative care patients at an acute ward. Objectives included evaluating VR therapy benefits across three sessions, assessing its differential impact on emotional versus physical symptoms and determining the proportion of patients experiencing clinically meaningful improvements after each session. METHODS: A mixed-methods design was employed. Sixteen palliative inpatients completed three personalised 20 min VR sessions. Symptom burden was assessed using the Edmonton Symptom Assessment Scale-Revised and quality of life with the Functional Assessment of Chronic Illness Therapy (FACIT-Pal-14). Standardised criteria assessed clinically meaningful changes. Quantitative data were analysed using linear mixed models. RESULTS: Quality of life improved significantly pre-VR to post-VR with a large effect size (Cohen's d: 0.98). Total symptom burden decreased after 20 min VR sessions (Cohen's d: 0.75), with similar effect sizes for emotional (Cohen's d: 0.67) and physical symptoms (Cohen's d: 0.63). Over 50% of patients experienced clinically meaningful improvements per session, though substantial individual variability occurred. CONCLUSIONS: This study reveals the nuanced efficacy of personalised VR therapy in palliative care, with over half of the patients experiencing meaningful benefits in emotional and physical symptoms. The marked variability in responses underscores the need for realistic expectations when implementing VR therapy.

Cognitive rehabilitation for attention deficits following stroke.

BACKGROUND: Many survivors of stroke complain about attentional impairments, such as diminished concentration and mental slowness. However, the effectiveness of cognitive rehabilitation for improving these impairments is uncertain. OBJECTIVES: To determine whether (1) people receiving attentional treatment show better outcomes in their attentional functions than those given no treatment or treatment as usual, and (2) people receiving attentional treatment techniques have a better functional recovery, in terms of independence in activities of daily living, mood and quality of life, than those given no treatment or treatment as usual. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (October 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library October 2012), MEDLINE (1948 to October 2012), EMBASE (1947 to October 2012), CINAHL (1981 to October 2012), PsycINFO (1806 to October 2012), PsycBITE and REHABDATA (searched October 2012) and ongoing trials registers. We screened reference lists and tracked citations using Scopus. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of cognitive rehabilitation for impairments of attention for people with stroke. The primary outcome was measures of global attentional functions, and secondary outcomes were measures of attention domains, functional abilities, mood and quality of life. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, extracted data and assessed trial quality. MAIN RESULTS: We included six RCTs with 223 participants. All six RCTs compared cognitive rehabilitation with a usual care control. Meta-analyses demonstrated no statistically significant effect of cognitive rehabilitation for persisting effects on global measures of attention (two studies, 99 participants; standardised mean difference (SMD) 0.16, 95% confidence interval (CI) -0.23 to 0.56; P value = 0.41), standardised attention assessments (two studies, 99 participants; P value ≥ 0.08) or functional outcomes (two studies, 99 participants; P value ≥ 0.15). In contrast, a statistically significant effect was found in favour of cognitive rehabilitation when compared with control for immediate effects on measures of divided attention (four studies, 165 participants; SMD 0.67, 95% CI 0.35 to 0.98; P value < 0.0001) but no significant effects on global attention (two studies, 53 participants; P value = 0.06), other attentional domains (six studies, 223 participants; P value ≥ 0.16) or functional outcomes (three studies, 109 participants; P value ≥ 0.21).Thus there was limited evidence that cognitive rehabilitation may improve some aspects of attention in the short term, but there was insufficient evidence to support or refute the persisting effects of cognitive rehabilitation on attention, or on functional outcomes in either the short or long term. AUTHORS' CONCLUSIONS: The effectiveness of cognitive rehabilitation remains unconfirmed. The results suggest there may be a short-term effect on attentional abilities, but future studies need to assess the persisting effects and measure attentional skills in daily life. Trials also need to have higher methodological quality and better reporting.

Low vision devices for age-related macular degeneration: a systematic review.

PURPOSE: Age-related macular degeneration (AMD) is a degenerative condition impacting central vision. Evaluating the effectiveness of low vision devices provides empirical evidence on how devices can rehabilitate and overcome deficits caused by AMD. This evidence could help to facilitate discussion on necessary future improvements to vision enhancement technology. METHODS: A systematic review of the literature was conducted on low vision device use in AMD populations. Relevant peer-reviewed research articles from six databases were screened. RESULTS: The findings of thirty-five studies revealed a significant positive impact of low vision devices leading to improvements in visual acuity, reading performance, facial recognition, and more. While the studies were found to have moderate risks of bias, a GRADE assessment of the evidence suggested the certainty of the evidence was low-moderate. DISCUSSION: Simple hand-held low vision devices (e.g., magnifiers) appear to currently have greater preferential support than newer visual enhancement technology (e.g., head mounted devices). Financial, comfort or usability reasons may influence preferences more than performance-based findings. However, there is a lack of studies examining newer technologies in AMD populations, which future research should address. Moreover, given the presence of bias across the studies and limited controlled experiments, confidence in the results may be low. CONCLUSIONS: Most studies indicated that low vision devices have positive impacts on reading and visual performance. But, even though they are reported to be a valuable asset to AMD populations, more rigorous research is required to draw conclusive evidence. IMPLICATIONS FOR REHABILITATIONLow vision devices can improve patient outcomes (e.g., vision, reading ability) for age-related macular degeneration populations.A multidisciplinary combination of low vision devices and rehabilitative services (i.e., eccentric viewing training, counselling, education) may enhance quality of life.