Can serious play and clinical cognitive assessment go together? On the feasibility and user-experience of virtual reality simulations in paediatric neurorehabilitation.

PURPOSE: Cognitive impairments frequently occur in children and adolescents with acquired brain injury (ABI), causing significant disabilities in daily life. Current paper-and-pencil neuropsychological tests do not capture the complexity of daily life activities, often failing to objectify subtle cognitive impairments. Virtual Reality (VR) simulations might overcome this discrepancy, as it resembles daily life situations. The aim of this study was to evaluate the feasibility, user-experience and preference of a VR simulation with a non-immersive (computer monitor; CM)) and immersive (head mounted display; HMD)) VR setup. METHODS: Children and adolescents with ABI (n = 15) and typically developing children and adolescents (n = 21) completed a VR-task with a CM and HMD. RESULTS: Both VR setups were feasible for children and adolescents with ABI. User-experience was enhanced with the HMD compared to CM in both groups. Side effects were low and comparable for both groups, and there were no differences between setups (HMD and CM). The majority of the children and adolescents with ABI preferred the HMD. CONCLUSION: VR simulations appear feasible to use in paediatric rehabilitation. The preference for a VR setup should be discussed with the child. Further research is needed to develop more sensitive measures to further explore the potential of VR for cognitive assessment.

Feasibility and user-experience of virtual reality in neuropsychological assessment following stroke.

Virtual Reality (VR) offers the possibility to assess cognitive functioning in a dynamic environment resembling daily life. In this cross-sectional study, we used two user interfaces, namely non-immersive VR by using a computer monitor (CM) and immersive VR by using a head-mounted display (HMD). We investigated (1) potential differences in feasibility, user-experience, and a potential preference for one user interface over another between stroke patients and healthy controls; (2) potential differences in feasibility, user-experience, and preference between patients referred for inpatient rehabilitation care and patients referred for outpatient rehabilitation care; and (3) potential demographic and clinical characteristics that were related to patients' preference for one user interface over another. Stroke patients (n = 88) and healthy controls (n = 66) performed a VR-task with a CM and HMD. Both user interfaces were feasible to use, irrespective of clinical referral (in- or outpatient rehabilitation care). Patients reported an enhanced feeling of engagement, transportation, flow, and presence, but more negative side effects when tested with a HMD, compared to a CM. The majority of stroke patients had no preference for one user interface over the other, yet younger patients tended to prefer a HMD. VR seems highly feasible in stroke patients.

The journey is just as important as the destination-Digital neuropsychological assessment provides performance stability measures in patients with acquired brain injury.

BACKGROUND: Cognitive performances on neuropsychological paper-and-pencil tests are generally evaluated quantitatively by examining a final score (e.g., total duration). Digital tests allow for a quantitative evaluation of "how" a patient attained a final score, which opens the possibility to assess more subtle cognitive impairment even when final scores are evaluated as normal. We assessed performance stability (i.e., the number of fluctuations in test performance) to investigate (1) differences in performance stability between patients with acquired brain injury (ABI) and healthy controls; (2) the added value of performance stability measures in patients with ABI; and (3) the relation between performance stability and cognitive complaints in daily life in patients with ABI. METHODS: We administered three digital neuropsychological tests (Rey Auditory Verbal Learning Test, Trail Making Test, Stroop Colour and Word Test) and the Cognitive Complaints-Participation (CoCo-P) inventory in patients with ABI (n = 161) and healthy controls (n = 91). RESULTS: Patients with ABI fluctuated more in their performance on all tests, when compared to healthy controls. Furthermore, 4-15% of patients who performed inside normal range on the conventional final scores were outside normal range on the performance stability measures. The performance stability measures, nor the conventional final scores, were associated with cognitive complaints in daily life. CONCLUSIONS: Stability in test performance of patients was clearly dissociable from healthy controls, and may assess additional cognitive weaknesses which might not be observed or objectified with paper-and-pencil tests. More research is needed for developing measures better associated with cognitive complaints.

Cognitive complaints in brain tumor patients and their relatives' perspectives.

BACKGROUND: Cognitive deficits have been frequently assessed in brain tumor patients. However, self-reported cognitive complaints have received little attention so far. Cognitive complaints are important as they often interfere with participation in society. In this study, cognitive complaints were systematically assessed in brain tumor patients. As patients' experiences and relatives' estimations may vary, the level of agreement was investigated. METHODS: Brain tumor outpatients (n = 47) and relatives (n = 42) completed the inventory Cognitive Complaints-Participation, assessing cognitive complaints across 10 daily life activities and cognitive domains (total, memory, executive, attention). Cognitive complaints scores were compared between patients with different clinical characteristics (tumor type, number of treatments, the absence/presence of epilepsy). Complaints difference scores in patient-relative pairs were calculated to explore the level of agreement using intraclass correlations (ICC). Furthermore, we explored whether the level of agreement was related to (1) the magnitude of cognitive complaints in patient-relative pairs and (2) patients' cognitive functioning (assessed with the Montreal Cognitive Assessment). RESULTS: Patients and relatives reported most cognitive complaints during work/education (100%) and social contacts (88.1%). Patients with different clinical characteristics reported comparable cognitive complaints scores. Overall, the level of agreement in patient-relative pairs was moderate-good (ICC 0.73-0.86). Although in 24% of the pairs, there was a substantial disagreement. The level of agreement was not related to the magnitude of complaints in patient-relative pairs or patients' cognitive functioning. CONCLUSION: Both the perspectives of brain tumor patients and their relatives' on cognitive complaints are important. Clinicians could encourage communication to reach mutual understanding.

CoCo - participation: The development and clinical use of a novel inventory measuring cognitive complaints in daily life.

Cognitive difficulties can be subtle and only come to light when patients return home from inpatient care and start to participate in society. Subjective cognitive complaints often interfere with participation, hence capturing cognitive complaints systematically is important. We developed a patient- and relative-reported measure to assess cognitive complaints during daily life activities across the memory, attention and executive domain for patients with acquired brain injury (ABI). The inventory Cognitive Complaints - Participation (CoCo-P) was created based on a literature review, consultations with experts, semi-structured interviews with patients, and a quantitative study. The inventory was administered to patients with ABI (n = 46), their relatives (n = 33) and healthy controls (n = 102) to finalize the inventory. We examined the reported complaints per daily life activity and cognitive domain of patients and healthy controls, and we compared the patients' and relatives' reports. The majority of patients (87-96%) experienced cognitive complaints, mostly related to attention, at work/education, during leisure activities, and in contact with family/friends and community. Patients reported more cognitive complaints than relatives. The CoCo-P seems appropriate to capture cognitive complaints in daily life in patients with mild ABI. Additional research is needed in terms of reliability and validity.

Digital neuropsychological assessment: Feasibility and applicability in patients with acquired brain injury.

INTRODUCTION: Digital neuropsychological assessment (d-NPA) has several advantages over paper-and-pencil tests in neuropsychological assessment, such as a more standardized stimulus presentation and response acquisition. We investigated (1) the feasibility and user-experience of a d-NPA in patients with acquired brain injury (ABI) and healthy controls; (2) the applicability of conventional paper-and-pencil norms on digital tests; and (3) whether familiarity with a tablet would affect test performance on a tablet. METHOD: We administered a d-NPA in stroke patients (n = 59), traumatic brain injury patients (n = 61) and healthy controls (n = 159). The neuropsychological tests were presented on a tablet and participants used a pencil stylus to respond. We examined the completion rate to assess the feasibility, and a semi-structured interview was conducted to examine the user-experience. The applicability of conventional norms was examined by the number of healthy controls performing <10th percentile, which was expected to be no more than 10%. The effect of tablet familiarity on test performance was examined with a regression-based model. RESULTS: Overall, 94% of patients completed the d-NPA. The d-NPA was considered pleasant by patients and healthy controls. Conventional norms that exist for paper-and-pencil tests were not applicable on the digital version of the tests, as up to 34% of healthy controls showed an abnormal performance on half of the tests. Tablet familiarity did not affect test performance on a tablet, indicating that participants who were more experienced with working with a tablet did not perform better on digital tests. CONCLUSIONS: The administration of a d-NPA is feasible in patients with ABI. Familiarity with a tablet did not impact test performance, which is particularly important in neuropsychological assessment. Future research should focus on developing norms in order to implement a d-NPA in clinical practice.

Increasing cognitive demand in assessments of visuo-spatial neglect: Testing the concepts of static and dynamic tests.

INTRODUCTION: Numerous tests of visuo-spatial neglect (VSN) have been developed. In this study, we propose a clustering of VSN tests by making a distinction between static tests with low levels of cognitive demand (i.e. tests without movement or time-restrictions, such as paper-and-pencil tests) and dynamic tests with high levels of cognitive demand (i.e. tests incorporating movement and time-restrictions, such as virtual reality tests). The concepts of static and dynamic tests have not been systematically investigated so far. Here, we investigated (1) whether we would find dissociations between patients showing VSN on test within the static cluster but not on tests within the dynamic cluster, and vice versa; (2) whether differences in demographic or clinical characteristics could be identified between these groups of patients; and (3) whether the underlying factor structure would correspond to our proposed distinction between static and dynamic clusters of tests. METHOD: Sixty-one patients with VSN completed three static tests (shape cancellation, line bisection, letter cancellation) and three dynamic tests (Catherine Bergego Scale, Mobility Assessment Course, simulated driving test). RESULTS: Thirteen percent of patients showed VSN on tests within the static cluster, 33% on tests within the dynamic cluster, and 54% on tests within both clusters. Patients with VSN on the dynamic tests (alone or in addition to static tests) had poorer motor function, poorer walking abilities and were more dependent in daily life than patients showing VSN on the static cluster alone. The underlying factor structure corresponded to our proposed conceptual distinction between static and dynamic clusters of tests. CONCLUSIONS: Static and dynamic tests compose different clusters and double dissociations are shown between clusters. Future research involving data-driven approaches might result in a better understanding on how different tests of VSN relate to each other, and, more importantly, a better understanding of VSN and its phenotypes.

Simulated driving: The added value of dynamic testing in the assessment of visuo-spatial neglect after stroke.

BACKGROUND: Visuo-spatial neglect (VSN) is generally assessed with neuropsychological paper-and-pencil tasks, which are often not sensitive enough to detect mild and/or well-compensated VSN. It is of utmost importance to develop dynamic tasks, resembling the dynamics of daily living. OBJECTIVE: A simulated driving task was used to assess (1) differences in performance (i.e., position on the road and magnitude of sway) between patients with left- and right-sided VSN, recovered VSN, without VSN, and healthy participants; (2) the relation between average position and VSN severity; and (3) its diagnostic accuracy in relation to traditional tasks. METHODS: Stroke inpatients were tested with a cancellation task, the Catherine Bergego Scale and the simulated driving task. RESULTS: Patients with left-sided VSN and recovered VSN deviated more regarding position on the road compared to patients without VSN. The deviation was larger in patients with more severe VSN. Regarding diagnostic accuracy, 29% of recovered VSN patients and 6% of patients without VSN did show abnormal performance on the simulated driving task. The sensitivity was 52% for left-sided VSN. Right-sided VSN was not well detected, probably due to the asymmetric layout. CONCLUSIONS: Based on these results, the simulated driving task should not be the only task to assess VSN, especially in its current form. Given the heterogenic nature of VSN, the assessment should always consist of several tasks varying in nature and complexity and include a dynamic task to detect mild and/or recovered VSN. A symmetric design should be used when designing novel tasks to assess right-sided VSN.

A neuropsychological and behavioral study of PLS.

Background: Primary lateral sclerosis (PLS) is a rare motor neuron disease characterized by progressive degeneration of upper motor neurons, resulting in spasticity and disability. There is, however, mounting evidence that the disease is not limited to upper motor neurons alone and that cognitive and behavioral changes within the spectrum of frontotemporal dementia (FTD) are part of the clinical phenotype. Objectives: To provide an in-depth classification of the cognitive and behavioral profiles of PLS by using the golden standard, a full neuropsychological evaluation, as well as a comprehensive behavioral assessment in a cohort of 30 cases. Results: Only 7 out of 30 PLS patients scored within normal range on all of the tests within our battery. The neuropsychological profile of PLS consists of deficits in social cognition (affective theory of mind (ToM) in particular), fluency, executive functions and memory. Using the revised Strong criteria, we could classify 57% of patients within the FTD spectrum (of which 17% had behavioral variant FTD). An additional 20% of patients had deficits which were not characteristic of FTD. Conclusions: This study confirms that PLS is not a restricted phenotype (only affecting upper motor neurons) and that behavioral and cognitive changes are common. Therefore, clinicians treating PLS patients should routinely assess cognition and behavior as part of routine care as cognitive and behavioral changes impact management, decision-making and care-giver burden. This assessment should be sensitive to the neuropsychological profile of PLS (social cognition (affective ToM in particular), fluency, executive functions and memory) and behavioral changes.

Derivation of norms for the Dutch version of the Edinburgh cognitive and behavioral ALS screen.

BACKGROUND: The Edinburgh cognitive and behavioral ALS screen (ECAS) was developed specifically to detect cognitive and behavioral changes in patients with amyotrophic lateral sclerosis (ALS). Differences with regard to normative data of different (language) versions of neuropsychological tests such as the ECAS exist. OBJECTIVE: To derive norms for the Dutch version of the ECAS. METHODS: Normative data were derived from a large sample of 690 control subjects and cognitive profiles were compared between a matched sample of 428 patients with ALS and 428 control subjects. RESULTS: Age, level of education, and sex were significantly associated with performance on the ECAS in the normative sample. ECAS data were not normally distributed and therefore normative data were expressed as percentile ranks. The comparison of ECAS scores between patients and control subjects demonstrated that patients obtained significantly lower scores for language, executive function, verbal fluency, and memory, which is in line with the established cognitive profile of ALS. CONCLUSION: For an accurate interpretation of ECAS results, it is important to derive normative data in large samples with nonparametric methods. The present normative data provide healthcare professionals with an accurate estimate of how common or uncommon patients' ECAS scores are and provide a useful supplement to existing cut-off scores.

Novel insights into the rehabilitation of memory post acquired brain injury: a systematic review.

OBJECTIVE: Acquired Brain Injury (ABI) frequently results in memory impairment causing significant disabilities in daily life and is therefore a critical target for cognitive rehabilitation. Current understanding of brain plasticity has led to novel insights in remediation-oriented approaches for the rehabilitation of memory deficits. We will describe 3 of these approaches that have emerged in the last decade: Virtual Reality (VR) training, Computer-Based Cognitive Retraining (CBCR) and Non-Invasive Brain Stimulation (NBS) and evaluate its effectiveness. METHODS: A systematic literature search was completed in regard to studies evaluating interventions aiming to improve the memory function after ABI. Information concerning study content and reported effectiveness were extracted. Quality of the studies and methods were evaluated. RESULTS: A total of 786 studies were identified, 15 studies met the inclusion criteria. Three of those studies represent the VR technique, 7 studies represent CBCR and 5 studies NBS. All 3 studies found a significant improvement of the memory function after VR-based training, however these studies are considered preliminary. All 7 studies have shown that CBCR can be effective in improving memory function in patients suffering from ABI. Four studies of the 5 did not find significant improvement of the memory function after the use of NBS in ABI patients. CONCLUSION: On the basis of this review, CBCR is considered the most promising novel approach of the last decade because of the positive results in improving memory function post ABI. The number of studies representing VR were limited and the methodological quality low, therefore the results should be considered preliminary. The studies representing NBS did not detect evidence for the use of NBS in improving memory function.