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Virtual Reality for Enriched Rehabilitation of Stroke Patients with Spatial Neglect: Diagnostics and the Rehabilitation Effect on Spatial Attention and Neuronal Activity
Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience.ORCID iD: 0000-0003-1650-8856
2017 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Virtual reality-förstärkt rehabilitering för strokepatienter med spatialt neglekt : diagnostik och utvärdering av rehabiliteringseffekt på spatial uppmärksamhet och neuronal aktivitet (Swedish)
Abstract [en]

Background: Approximately a third of all stroke patients develop spatial neglect, a debilitating symptom associated with poor outcome. Spatial neglect is clinically defined as a deficit in processing and responding to stimuli presented on the contralesional side of the body, or the space surrounding that side of the body. The heterogenetic, multi-sensory nature of the symptoms renders it difficult to diagnose and treat; therefor effective methods for screening and intervention for neglect are needed. Virtual reality (VR) is a method of brain–computer interaction that involves realtime simulation of an environment, scenario or activity that allows for user interaction and targets multiple senses. We hypothesize that VR can facilitate identification of spatial neglect in stroke patients and that training with this interface will improve patient’s functional outcome, through stimulation to neuronal networks including those controlling attention.

Objective: The objective was to construct and validate a computerized test battery for spatial neglect and to investigate its usability in stroke patients. Also to design and develop a VR rehabilitation method for spatial neglect and to evaluate its effects on spatial attention and on neuronal activity in the brain.

Method: We designed, developed and evaluated a new concept for assessment (VR-DiSTRO®) and training (RehAtt®) of spatial attention, using VR technology. The hardware consisted of a PC, monitor, 3D-glasses and a force feedback device to control the tasks (i.e., a robotic pen). The software enabled targets to be moved, rotated and manipulated in the 3D environment using the robotic pen. RehAtt® made it possible to combine intense visual scanning training, multi-sensory stimulation (i.e., audio, visual, tactile) and sensory-motor activation of the contralesional arm. In a first study on 31 stroke patients we performed a construct validation of VR-DiSTRO® against Rivermead Behavioural Test Battery (BIT) and investigated the usability. In a second study, 15 subjects with chronic spatial neglect (symptoms >6 month) had self-training, 3 x 1 hour for 5 weeks using RehAtt®. Outcome were measured by changes in neglect tests and in Cathrine Bergego Scale (CBS). Training-related changes in neuronal activity of the brain was studied using fMRI during task and in resting state.

Results: VR-DiSTRO® correctly identified all patients with neglect. The sensitivity was 100% and the specificity 82% for VR-DiSTRO® compared to BIT. Usability was high and no side-effects were noted. Using repeated measurement analysis, improvements due to the RehAtt® intervention were found for Baking tray task (p < 0.001), Star cancellation test (p = 0.006) and Extinction test (p = 0.05). Improvements were also seen in the Posner task as fewer missed targets (p = 0.024). Improvement in activities of daily living (CBS) was shown immediately after training (p < 0.01) and patients still reported improvement at 6 months follow-up. Trainingrelated changes in neuronal activity were seen as an increased task-evoked brain activity in prefrontal and temporal cortex, mainly outside the attention network but in related cortical areas. During resting state, changes in network connectivity were seen after intervention with RehAtt® in the Dorsal Attention Network (DAN) and interhemispheric connectivity.

Conclusion: VR-DiSTRO® identified visuospatial neglect in stroke patients quickly and with a high accuracy. RehAtt® training improved in spatial attention in chronic neglect with transfer to functions in daily living. Increased neuronal brain activity was found in and between attention networks and related brain structures. This could represent a compensatory effect in addition to sign of a restorative effect from the RehAtt training. The results obtained in this study are promising, encourage further development of the methods and merit for further studies.

Place, publisher, year, edition, pages
Umeå universitet , 2017. , 77 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1929
Keyword [en]
Stroke, spatial neglect, rehabilitation, virtual reality, enriched environment, fMRI
National Category
Neurology
Identifiers
URN: urn:nbn:se:umu:diva-141920ISBN: 978-91-7601-792-0 (print)OAI: oai:DiVA.org:umu-141920DiVA: diva2:1157294
Public defence
2017-12-08, Sal E04, R1, Norrlands Universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Funder
Västerbotten County CouncilEU, FP7, Seventh Framework Programme
Available from: 2017-11-16 Created: 2017-11-15 Last updated: 2017-11-16Bibliographically approved
List of papers
1. A virtual reality test battery for assessment and screening of spatial neglect
Open this publication in new window or tab >>A virtual reality test battery for assessment and screening of spatial neglect
2011 (English)In: Acta Neurologica Scandinavica, ISSN 0001-6314, E-ISSN 1600-0404, Vol. 123, no 3, 167-174 p.Article in journal (Refereed) Published
Abstract [en]

Background – There is a need for improved screening methods for spatial neglect.

Aim – To construct a VR-test battery and evaluate its accuracy and usability in patients with acute stroke.

Method –  VR-DiSTRO consists of a standard desktop computer, a CRT monitor and eye shutter stereoscopic glasses, a force feedback interface, and software, developed to create an interactive and immersive 3D experience. VR-tests were developed and validated to the conventional Star Cancellation test, Line bisection, Baking Tray Task (BTT), and Visual Extinction test. A construct validation to The Rivermead Behavioral Inattention Test, used as criterion of visuospatial neglect, was made. Usability was assessed according to ISO 9241-11.

Results –  Thirty-one patients with stroke were included, 9/31 patients had neglect. The sensitivity was 100% and the specificity 82% for the VR-DiSTRO to correctly identify neglect. VR-BTT and VR-Extinction had the highest correlation (r2 = 0.64 and 0.78), as well as high sensitivity and specificity. The kappa values describing the agreement between traditional neglect tests and the corresponding virtual reality test were between 0.47–0.85. Usability was assessed by a questionnaire; 77% reported that the VR-DiSTRO was ‘easy’ to use. Eighty-eight percent reported that they felt ‘focused’, ‘pleased’ or ‘alert’. No patient had adverse symptoms. The test session took 15 min.

Conclusions –  The VR-DiSTRO quickly and with a high accuracy identified visuospatial neglect in patients with stroke in this construct validation. The usability among elderly patients with stroke was high. This VR-test battery has the potential to become an important screening instrument for neglect and a valuable adjunct to the neuropsychological assessment.

Place, publisher, year, edition, pages
John Wiley & Sons, 2011
Keyword
perceptual disorder, hemispatial neglect, diagnosis, neuro psychological tests, task performance and analysis, visual perception, user computer interface, stroke complications, assessment
National Category
Neurology Other Medical Sciences not elsewhere specified
Identifiers
urn:nbn:se:umu:diva-51122 (URN)10.1111/j.1600-0404.2010.01390.x (DOI)000286667900003 ()20569225 (PubMedID)
Available from: 2012-01-11 Created: 2012-01-11 Last updated: 2017-11-15Bibliographically approved
2. RehAtt – scanning training for neglect enhanced by multi-sensory stimulation in Virtual Reality
Open this publication in new window or tab >>RehAtt – scanning training for neglect enhanced by multi-sensory stimulation in Virtual Reality
2016 (English)In: Topics in Stroke Rehabilitation, ISSN 1074-9357, E-ISSN 1945-5119, Vol. 23, no 3, 191-199 p.Article in journal (Refereed) Published
Abstract [en]

Background: There is a lack of effective treatment for neglect. We have developed a new training method, RehAtt (TM). The objective of this study was to determine whether RehAtt (TM) improves spatial attention in chronic neglect after stroke. Methods: RehAtt (TM) consists of a computer with monitor, 3D glasses, and a force feedback interface (Robotic pen) giving sensory motor activation to the contra-lesional arm. The software combines visual scanning training with multi-sensory stimulation in 3D virtual reality (VR) game environment. Fifteen stroke patients with chronic neglect (duration > 6 month) had repeated baseline evaluations to confirm stability of symptoms. There were no test-retest effects for any of the tests. Thereafter, all patients trained 15 h in RehAtt (TM) (3 x 1 h for 5 weeks). A neglect test battery and Catherine Bergego Scale, CBS, were used to assess behavioral outcome after intervention. CBS was also used at a 6-month follow-up. Results: Using repeated measurement analysis improvements due to the training were found for Star cancellation test (p = 0.006), Baking tray task (p < 0.001), and Extinction test (p = 0.05). In the Posner task improvements were seen fewer missed targets (p = 0.024). CBS showed improvements in activities of daily life immediately after training (p < 0.01). After 6 months the patients still reported improvement in CBS. Conclusion: RehAtt (TM) is a new concept for rehabilitation of neglect. Training with the VR-method improved spatial attention and showed transfer to improved spatial attention in activities of daily living in chronic neglect. Our results are promising and merit further studies.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2016
Keyword
Spatial neglect, Cognitive rehabilitation, Attention, treatment, virtual reality, stroke
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-121621 (URN)10.1080/10749357.2016.1138670 (DOI)000375149700007 ()27077985 (PubMedID)
Available from: 2016-06-20 Created: 2016-06-03 Last updated: 2017-11-15Bibliographically approved
3. Increase of frontal neuronal activity in chronic neglect after multi-sensory scanning training in virtual
Open this publication in new window or tab >>Increase of frontal neuronal activity in chronic neglect after multi-sensory scanning training in virtual
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-141923 (URN)
Available from: 2017-11-15 Created: 2017-11-15 Last updated: 2017-11-15
4. Rehabilitation of chronic spatial neglect strengthens functional connectivity between nodes of the dorsal attention network
Open this publication in new window or tab >>Rehabilitation of chronic spatial neglect strengthens functional connectivity between nodes of the dorsal attention network
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-141924 (URN)
Available from: 2017-11-15 Created: 2017-11-15 Last updated: 2017-11-15

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