Virtual enriched environments in paediatric neuropsychological rehabilitation following traumatic brain injury: Feasibility, benefits and challenges.

A frequent consequence of traumatic brain injury (TBI) is a significant reduction in patients' cerebral activation/arousal, which clinicians agree is not conducive to optimal rehabilitation outcomes. In the context of paediatric rehabilitation, sustained periods of inactivity are particularly undesirable, as contemporary research has increasingly called into question the Kennard principle that youth inherently promotes greater neural plasticity and functional recovery following TBI. Therefore, the onus to create rehabilitation conditions most conducive to harnessing plasticity falls squarely on the shoulders of clinicians. Having noted the efficacy of environmental enrichment in promoting neural plasticity and positive functional outcomes in the animal literature, some researchers have suggested that the emerging technology of Virtual Reality (VR) could provide the means to increase patients' cerebral activation levels via the use of enriched Virtual Environments (VEs). However, 10 years on, this intuitively appealing concept has received almost no attention from researchers and clinicians alike. This paper overviews recent research on the benefits of enriched environments in the injured brain and identifies the potential and challenges associated with implementing VR-based enrichment in paediatric neuropsychological rehabilitation.

Assessing stroke patients' prospective memory using virtual reality.

There is a dearth of empirical evidence about prospective memory (remembering to perform actions in the future) in stroke patients. A probable reason for this is that it is difficult to perform a realistic and controlled assessment of prospective memory ability in a rehabilitation setting. Virtual reality may provide a solution to this difficulty by allowing prospective memory to be tested in a simulation of a real-life situation whilst retaining a laboratory level of scientific control. This exploratory study assessed the performance of stroke patients and age-matched control participants on event-, time- and activity-based prospective memory retrieval tasks in a personal computer-based virtual environment. Stroke patients were severely impaired at the event- and activity-based tasks compared with age-matched controls, but only marginally impaired at the time-based task. The additional knowledge gained from this form of assessment could direct rehabilitation more effectively towards specific impairments of individual patients.

Age and recovery from brain injury: legal opinions, clinical beliefs and experimental evidence.

Despite considerable scientific evidence to the contrary, many medical practitioners maintain that children recover from brain injury better than adults. This belief, which is commonly referred to as the "Kennard Principle", has important ramifications for personal injury compensation claims in which the amount of financial damages claimed is partly based on medical experts' prognoses for recovery and long-term outcome. The present study investigated whether legal practitioners' beliefs are consistent with those of medical practitioners. Lawyers were asked to estimate their confidence in consultant neurologists' estimates of recovery in four clinically-based but fictitious case studies which differed only in the reported age of the patient. The lawyers showed more confidence in estimates which coincided with the Kennard Principle than those which did not. These results support previous findings in showing widespread belief that "younger is better" in recovery from brain injury. In consequence, it is likely that financial compensation for children with brain injury is currently being underestimated in litigation, thereby prejudicing the long-term outcome of the child.

The use of virtual reality in memory rehabilitation: current findings and future directions.

There is considerable potential for using virtual reality (VR) in memory rehabilitation which is only just beginning to be realized. PC-based virtual environments are probably better suited for this purpose than more immersive virtual environments because they are relatively inexpensive and portable, and less frightening to patients. Those exploratory studies that have so far been performed indicate that VR involvement would be usefully directed towards improving assessments of memory impairments and in memory remediation using reorganization techniques. In memory assessment, the use of VR could provide more comprehensive, ecologically-valid, and controlled evaluations of prospective, incidental, and spatial memory in a rehabilitation setting than is possible using standardized assessment tests. The additional knowledge gained from these assessments could more effectively direct rehabilitation towards specific impairments of individual patients. In memory remediation, VR training has been found to promote procedural learning in people with memory impairments, and this learning has been found to transfer to improved real-world performance. Future research should investigate ways in which the procedural knowledge gained during VR interaction can be adapted to offset the many disabilities which result from different forms of memory impairment.

Support for children following traumatic brain injury: the views of educational psychologists.

PURPOSE: For many years, neuroscientific research appeared to support the view that the young brain was more resilient and better able to withstand damage than the mature brain. More recent neuroscience research has questioned this view. Nevertheless, the view that 'younger is better' continues to be accepted by many medical practitioners. The present study sought to establish whether the training and experience of educational psychologists has made them aware that young children are particularly vulnerable to long-term effects of brain injury. METHOD: Educational psychologists were asked to estimate the need for additional social/family and educational support, and how long such additional support would be needed, in four fictitious but clinically-based case studies which differed only in the reported age of the child/adolescent at the time of the injury. RESULTS: Educational psychologists consistently rated young children with brain injuries as needing more additional social/family support for longer than adolescents. CONCLUSIONS: These results suggest that there is an appreciation of the additional needs of young children who have sustained brain injuries within our educational system.

The role of virtual reality technology in the assessment and training of inexperienced powered wheelchair users.

PURPOSE: The current paper provides quantitative and qualitative data concerning the application of two virtual environments to the assessment and training of inexperienced powered wheelchair users, both in terms of the ability to control the chair accurately without hitting objects in the environment (manoeuvrability) and in terms of being able to find ones way around a complex environment without becoming lost (route-finding). METHOD: Six novice powered wheelchair users participated in the project, completing either the manoeuvrability or route finding components of the study. Performance measures were taken in real life pre and post training and throughout virtual reality sessions. Participants also completed a questionnaire regarding the aesthetics of the virtual environments and aspects of the powered wheelchair simulation. RESULTS: The participants rated the aesthetics of the virtual environments positively and engaged well with the virtual system. However, they found the manoeuvrability tasks considerably more difficult in virtual reality (VR) than in real life. Some difficulties with controlling the simulated wheelchair were apparent. Some improvements on virtual and real life manoeuvrability tasks and route finding were noted following conventional and virtual training. CONCLUSIONS: The study indicated that the two virtual environments represent a potentially useful means of assessing and training novice powered wheelchair users. The virtual environments however must become less challenging if they are to represent a motivating and effective means of improving performance. Further development of the way in which wheelchair movement is controlled and simulated represents a key element in this multi stage project.

An evaluation of the efficacy of training people with learning disabilities in a virtual environment.

PURPOSE: To evaluate the efficacy of using a virtual kitchen for vocational training of people with learning disabilities. METHOD: Twenty four catering students with learning disabilities participated in the study. Half the students were currently being trained in the kitchen on which the virtual kitchen was modelled but the remaining students were unfamiliar with this kitchen. Students were first pre-tested on four food preparation tasks and identification of 12 hazards in their own training kitchens. They were subsequently trained on one food preparation task and three hazards in their own training kitchens, one food preparation task and three hazards in the virtual kitchen, and one food preparation task and three hazards in specially designed workbooks. They were then retested in their own training kitchens on all the food preparation tasks and all the hazards. RESULTS: Virtual training was found to be as beneficial as real training and more beneficial than workbook and no training in the food preparation tasks. However, virtual, real and workbook training were found to be equally beneficial in the hazard identification task. Students who were unfamiliar with the kitchen on which the virtual kitchen was modelled benefited from virtual training to the same extent as students who were familiar with the kitchen. CONCLUSIONS: Vocational students with learning disabilities were able to use the virtual environment and were motivated to learn using this training method. Depending on the task being trained, virtual training had a more beneficial effect on real task performance than workbook training, even when the virtual kitchen was not modelled on the real training kitchen.

An exploratory investigation into the usability and usefulness of training people with learning disabilities in a virtual environment.

PURPOSE: Two studies sought to answer the following questions. Are people with learning disabilities capable of using a virtual environment? Are they motivated to learn using this training method? Do they show any benefit from using a virtual environment? Does any benefit transfer to improved real world performance? METHOD: In the first study, 30 students with learning disabilities were sequentially allocated to an active or a passive experimental group. Active participants explored a virtual bungalow searching for a toy car. Passive participants watched the exploration undertaken by the preceding active participant and searched for the toy car. All participants then performed spatial and object recognition tests of their knowledge of the virtual environment. In the second study, the errors of 45 participants on a real steadiness tester task were noted before they were randomly allocated to three groups-a real training group, a virtual training group and a no training group. After training, the participants performed a second test trial on the real steadiness tester. RESULTS: The students were capable of using a virtual environment and were motivated to use this training method. Active exploration of a virtual environment was found to enhance their memory of the spatial layout of the bungalow but not their memory of the virtual objects. In the second study, virtual training was found to transfer to real task performance. CONCLUSIONS: These two laboratory-based studies provide answers to four important questions concerning virtual training of people with learning disabilities. Hopefully, the findings will encourage this training aid to be used more widely.

Training in virtual environments: transfer to real world tasks and equivalence to real task training.

Virtual environments (VEs) are extensively used in training but there have been few rigorous scientific investigations of whether and how skills learned in a VE are transferred to the real world. This research aimed to measure and evaluate what is transferring from training a simple sensorimotor task in a VE to real world performance. In experiment 1, real world performances after virtual training, real training and no training were compared. Virtual and real training resulted in equivalent levels of post-training performance, both of which significantly exceeded task performance without training. Experiments 2 and 3 investigated whether virtual and real trained real world performances differed in their susceptibility to cognitive and motor interfering tasks (experiment 2) and in terms of spare attentional capacity to respond to stimuli and instructions which were not directly related to the task (experiment 3). The only significant difference found was that real task performance after training in a VE was less affected by concurrently performed interference tasks than was real task performance after training on the real task. This finding is discussed in terms of the cognitive load characteristics of virtual training. Virtual training therefore resulted in equivalent or even better real world performance than real training in this simple sensorimotor task, but this finding may not apply to other training tasks. Future research should be directed towards establishing a comprehensive knowledge of what is being transferred to real world performance in other tasks currently being trained in VEs and investigating the equivalence of virtual and real trained performances in these situations.

A preliminary investigation into the use of virtual environments in memory retraining after vascular brain injury: indications for future strategy?

PURPOSE: In a preliminary investigation of the use of Virtual Environments (VEs) in neurorehabilitation, this study compares the effects of active and passive experience of a VE on two types of memory in vascular brain injury patients and controls. METHOD: Forty-eight patients with vascular brain injury and 48 non-impaired control participants were randomly assigned to active and passive VE conditions. The active participants explored a virtual bungalow seeking a particular object; the passive participants observed, but did not control movement through the VE, also seeking the object. Afterwards, both active and passive participants completed spatial recognition and object recognition tests. RESULTS: Expectedly, the patients were impaired relative to the controls but were able to perform the virtual tasks. Active participation in the VE enhanced memory for its spatial layout in both patients and controls. On object recognition, active and passive patients performed similarly, but passive controls performed better than active controls. CONCLUSIONS: The findings are discussed in relation to their implications for memory rehabilitation strategies.

The specificity of memory enhancement during interaction with a virtual environment.

Two experiments investigated differences between active and passive participation in a computer-generated virtual environment in terms of spatial memory, object memory, and object location memory. It was found that active participants, who controlled their movements in the virtual environment using a joystick, recalled the spatial layout of the virtual environment better than passive participants, who merely watched the active participants' progress. Conversely, there were no significant differences between the active and passive participants' recall or recognition of the virtual objects, nor in their recall of the correct locations of objects in the virtual environment. These findings are discussed in terms of subject-performed task research and the specificity of memory enhancement in virtual environments.

Virtual environments in the diagnosis, prevention, and intervention of age-related diseases: a review of VR scenarios proposed in the EC VETERAN Project.

A group of worldwide virtual reality and health-care researchers have decided to combine their efforts in a multidisciplinary project titled VETERAN-virtual environments in the diagnosis, prevention and intervention of age-related diseases. The main goal of the VETERAN project is the tuning and testing of different virtual environments, designed to address the cognitive/functional impairments that may occur due to the aging process and age-related disorders. In particular the developed modules will address the problems commonly found in the following pathologies that have a strong impact on the elderly health care policy: Alzheimer's disease and other senile dementias; stroke and unilateral spatial neglect; mobility-related accidents within specific environments (e.g., falls, shocks). The project will focus on research into clinical aspects of age-related diseases and disorders of high morbidity and specifically target goals of prevention, treatment, or delay in onset. Another goal of the VETERAN project is to define and develop new protocols and tools to be used for general rehabilitation purposes. These tools will aim to provide systematic restorative training within the context of functionally relevant, ecologically valid simulated environments. This approach is hoped to optimise the degree of transfer of training and/or generalisation of learning to the person's real world environment.

Virtual reality: a new prosthesis for brain injury rehabilitation.

Virtual Reality (VR) technology is a relatively new application to rehabilitation medicine, yet it offers considerable potential to achieve significant successes in assessment, treatment and improved outcome, thereby increasing our knowledge of neuroplasticity. The capabilities of VR are especially evident in neurological rehabilitation, where cognitive and behavioural problems often interact with physical impairments to reduce the overall level of functioning and interaction. The need for effective interventions in neurological rehabilitation demands communication and collaboration between disciplines. This paper presents some of the current areas of the clinical applications of VR, emphasising the link between experimental evidence on recovery after brain damage and the clinical problems encountered in a ward setting.

Social and behavioural effects of traumatic brain injury in children.

Traumatic brain injury (TBI) is the leading cause of death and permanent disability in children and adolescents. Although cognitive and behavioural effects have now been reported for all degrees of TBI severity in children, other aspects of functioning which might be related (such as psychosocial adjustment), have been neglected. In the present study the social and behavioural effects of TBI were assessed by comparing 27 TBI children with 27 controls. TBI children demonstrated significantly lower levels of self-esteem and adaptive behaviour, and higher levels of loneliness, maladaptive behaviour and aggressive/antisocial behaviour. These findings confirm the previously demonstrated detrimental effects of TBI on children's behavioural functioning and offer new evidence for the detrimental effects of TBI on children's social functioning.

Virtual environments in brain damage rehabilitation: a rationale from basic neuroscience.

The potential of virtual environments in assessment and training of cognitive function is a more than adequate reason for their application to neurorehabilitation. However, there is a more fundamental justification, and one which is firmly rooted in the neuroscience literature. Over the last half century there has been a wealth of published evidence that enriching the environments of laboratory rats stimulates neuroplastic change in the cerebral cortex, enhances learning and problem solving in normal rats and reduces cognitive impairment in brain damaged rats. Central to all three effects of enrichment are the increased levels of interaction with the physical environment engendered by enrichment. Placing humans who have damaged brains in virtual environments is one way of enhancing their levels of environmental interaction which, because of cognitive impairments and sensory and motor disabilities, is otherwise difficult to achieve. In this chapter we explore the potential of virtual environments as enriched environments within the rehabilitation regime. The underlying assumption, that interaction with a virtual environment is functionally equivalent to interaction with a real environment, is examined. Three lines of relevant evidence are reviewed, neuroimaging studies and psychophysiological studies of people in virtual environments and studies of transfer of training from virtual to real tasks. An agenda for future research in this are is proposed.

Rehabilitation of the head-injured child: basic research and new technology.

The view that brain damage in children is less impairing than equivalent damage in adults is no longer acceptable. However, it is acknowledged that recovery following brain damage, when it does occur, owes much to the plasticity of the brain and that the young brain displays greater plasticity than the mature brain. To maximize brain damage recovery in children we need to focus both on what is known about brain plasticity and how to influence it. Research on environmental enrichment in rats has told us that enforced interaction with a complex environment can both stimulate anatomical and biochemical plasticity and ameliorate some of the behavioural consequences of brain damage. The view that environmental interaction has rehabilitative value also accords with clinical experience. However, the sensory, motor and cognitive consequences of brain damage often conspire to make environmental interaction difficult. One potential solution lies in using computers to generate virtual environments tailored to the precise sensory and motor capacities of the brain-injured child. In this way children may be enabled to benefit from environmental interaction whatever their level of disability. The use of Virtual Reality (VR) in the context of rehabilitation is discussed and relevant work reviewed.

Virtual environments in neuropsychological assessment and rehabilitation.

Brain damage constitutes a major problem for those affected, for their families and friends and for society as a whole. The need for effective rehabilitation strategies is clear. Yet, until the early 1960s, the brain was generally considered to be a somewhat fixed and inflexible organ. In consequence the impairments associated with brain damage were generally regarded as "incurable". Since that time neuroscientists have had reason to change their views dramatically. However, much remains to be done. Progress depends upon a co-ordinated multidisciplinary approach within which assistive technology will be a key player. Within the area of assistive technology, one of the developments which holds particular promise for the field of neurological rehabilitation is the computer technology underlying virtual environments (commonly known as virtual reality). In this chapter we describe the new opportunities offered by virtual reality to pursue several aspects of the rehabilitation process. The value of the technology of virtual environments in this context is that it allows us to immerse people with brain damage in relatively realistic interactive environments which, because of their patterns of impairment, would otherwise be unavailable to them.

Virtual reality: an assistive technology in neurological rehabilitation.

The need for improved neurological rehabilitation strategies is self-evident. Recent developments in the computer technology of virtual reality hold the promise of exciting progress in this area. In this paper four areas of potential application of virtual reality to neurological rehabilitation are reviewed.

Age and recovery from brain injury: clinical opinions and experimental evidence.

For many years the notion that brain damage causes less impairment in children than in adults (sometimes known as the 'Kennard Principle') has enjoyed widespread support among scientists and clinicians. More recently neuroscientists have questioned the Principle, most now taking an opposing view that damage to the rapidly developing brain can be more harmful than equivalent damage in adulthood. Many clinicians, however, appear reluctant to reject the Kennard Principle. This study investigates the extent to which the Kennard Principle still guides the judgement of different groups of health-care professionals (neurosurgeons, neurologists, neuropsychologists, general practitioners, nurses, physiotherapists, occupational therapists, and speech therapists). Subjects were asked to estimate the extent of recovery in clinically based but fictitious case studies which differed only in the reported age of the patient. The professions differed in their levels of optimism regarding the extent of recovery to be expected, but all predicted better recovery in younger patients (under 10) than in adults with otherwise similar brain injuries. The results are discussed in terms of their implications for the treatment of brain injuries in the young.

Pain and pain tolerance in professional ballet dancers.

Pain experience in sport had been the subject of increasing research in recent years. While sports professionals have generally been found to have higher pain thresholds than control subjects the reasons for this are not entirely clear. The present study seeks to investigate one possible explanatory factor, the importance of the popular image of the physical activity and of the self-image of its participants, by examining pain experience in professional ballet dancers. Like sports professionals, dancers were found to have higher pain and pain tolerance thresholds than age matched controls in the Cold Pressor Test. However, they also reported a more acute experience of the sensory aspects of the pain. Explanations of this apparent paradox are discussed both in terms of the neuroticism scores of the two groups and in terms of the dancers' greater experience of pain and its relationship with physical activity. The results illustrated the importance of using multidimensional measures of pain in this type of investigation.