Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea.
1Department of Rehabilitation Medicine, Jeju National University College of Medicine, Jeju 690-767, Korea.
2Department of Rehabilitation Medicine, Philip Hospital, Seoul 138-170, Korea.
Corresponding author: Min Ho Chun. Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap-2 dong, Songpa-gu, Seoul 138-736, Korea. Tel: +82-2-3010-3800, Fax: +82-2-3010-6964, mhchun@amc.seoul.kr
• Received: September 29, 2010 • Accepted: February 5, 2011
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
To investigate the effect of virtual reality on the recovery of cognitive impairment in stroke patients.
Method
Twenty-eight patients (11 males and 17 females, mean age 64.2) with cognitive impairment following stroke were recruited for this study. All patients were randomly assigned to one of two groups, the virtual reality (VR) group (n=15) or the control group (n=13). The VR group received both virtual reality training and computer-based cognitive rehabilitation, whereas the control group received only computer-based cognitive rehabilitation. To measure, activity of daily living cognitive and motor functions, the following assessment tools were used: computerized neuropsychological test and the Tower of London (TOL) test for cognitive function assessment, Korean-Modified Barthel index (K-MBI) for functional status evaluation, and the motricity index (MI) for motor function assessment. All recruited patients underwent these evaluations before rehabilitation and four weeks after rehabilitation.
Results
The VR group showed significant improvement in the K-MMSE, visual and auditory continuous performance tests (CPT), forward digit span test (DST), forward and backward visual span tests (VST), visual and verbal learning tests, TOL, K-MBI, and MI scores, while the control group showed significant improvement in the K-MMSE, forward DST, visual and verbal learning tests, trail-making test-type A, TOL, K-MBI, and MI scores after rehabilitation. The changes in the visual CPT and backward VST in the VR group after rehabilitation were significantly higher than those in the control group.
Conclusion
Our findings suggest that virtual reality training combined with computer-based cognitive rehabilitation may be of additional benefit for treating cognitive impairment in stroke patients.
Cognitive impairment after stroke is an important factor affecting independent function and activity participation of patients, and dementia syndrome has been known to occur in approximately 8 to 26% of stroke patients within 12 months of the onset of stroke.1,2 In cases of severe cognitive impairment, it decreases morale and motivation to participate in an intensive rehabilitation program during the acute phase. It may also affect the ability to acquire motor skills, thus becoming the main cause of poor prognosis for rehabilitation. In addition, it may affect only one area of cognitive function, but in most cases, it is accompanied by impairment of the overall area of attention, concentration, memory, spatial processing skills, language, problem-solving skills, and planning skills. Therefore, accurate assessment of cognitive function and prompt initiation of treatment in the early stage is needed for successful rehabilitation.3-5
In the meantime, variable cognitive rehabilitation programs using computer technology have been developed for cognitive rehabilitation, and several studies on brain-injured patients have reported that computer-assisted cognitive therapy can be effective in treating cognitive disorders of various areas including memory, attention, spatial perception.6-9 Compared with conventional therapy, computer-assisted cognitive rehabilitation programs have the advantage in that patients can repeat themselves to learn, provide immediate feedback on the performance of patients, and adjust the difficulty level by selecting the appropriate program level for patients.
More recently, studies in the area of cognitive function using three-dimensional virtual reality (VR) programs have been actively conducted.10-13 Virtual reality has the advantage of being able to implement the specific cir cum stance or situation just like a real three-dimensional environment under a virtual environment using a computer and it can be performed regardless of physical disability using the unconstrained interface and minimizing the difference between laboratory environment and real life by interaction with the virtual environment. In particular, recently published studies have reported diagnosis of ambulatory navigational skill delay or reduced ability to perform activities of daily living through the virtual environment or improvement in memory or problem-solving skills through the virtual reality treatment for patients with dementia for whom cognitive decline was observed,14,15 patients with Parkinson's disease16 or elderly persons with mild cognitive impairment.17,18 However, whereas studies of cognitive function using virtual reality for stroke patients are mostly to assess unilateral neglect or overall cognitive impairment using the virtual reality program,19-22 there are relatively few studies to prove the effectiveness of virtual reality treatments for cognitive impairment.23 In particular, there is little research on the influence on cognitive function when computer-assisted cognitive rehabilitation and virtual reality training are performed at the same time, by comparison with when only computer-assisted cognitive rehabilitation is performed.
The aim of our study was to evaluate the influence on the recovery of cognitive function when the computer-assisted cognitive rehabilitation and the virtual reality training are performed together for acute stroke patients with cognitive impairment.
MATERIALS AND METHODS
Study subjects
Among patients diagnosed with stroke for the first time by magnetic resonance imaging and computerized tomography from July 1, 2009 to June 30, 2010, we recruited 28 patients who were stabilized neurologically and surgically after undergoing acute phase treatment at the Department of Neurology or Neurosurgery in our hospital and transferred to the Department of Rehabilitation Medicine for comprehensive rehabilitation treatment. All patients had cognitive impairment with a K-MMSE (Korean version of the Mini-Mental Status Examination) score range from 10 to 24. We excluded patients with a K-MMSE score of less than 10, patients presenting with severe cognitive impairment or aphasia and not being able to understand instructions, patients with poor sitting balance such that they could not sit on a chair with back and armrests, patients with limited range of motion of the neck due to orthopedic problems, and patients with loss of visual acuity such that they could not perceive content on a computer screen. Through random sampling, target patients were classified into two groups. One group was the VR group, which consisted of 15 patients who underwent virtual reality training and computer-assisted cognitive rehabilitation, and the other group was the control group, which consisted of 13 patients who underwent computer-assisted cognitive rehabilitation only. The average ages of the VR and control groups were 66.5 and 62.0 years old, respectively. The average stroke durations from stroke onset to the time of initial evaluation were 18.2 and 24.0 days, respectively. No statistically significant difference was observed in age, sex, duration from stroke onset to the time of initial evaluation, lesion location, number of patients with unilateral neglect, and K-MMSE score before treatment of the VR and control groups (Table 1).
Research methods
The VR group underwent both virtual reality training and computer-assisted cognitive rehabilitation together. Virtual reality training underwent a total of 30 minutes, 3 times a week, and computer-assisted cognitive rehabilitation underwent a total of 30 minutes, 2 times a week for a total of 5 times a week and 4 weeks. The control group underwent computer-assisted cognitive rehabilitation for a total of 30 minutes, 5 times a week, for a total of 4 weeks. All patients were treated with physical therapy and occupational therapy of the same intensity and time duration.
Virtual reality training was performed by one occupational therapist and IREX system® (Vivid group, Toronto, Canada) was used for the virtual reality system. Virtual reality environment consisted of television monitor, video camera, data gloves, and virtual objects (Fig. 1). A video camera recognized the movement or location of a patient and placed them in a virtual reality space, and data gloves recognized the motion of patients responding to virtual reality. We selected 5 out of a total of 20 virtual reality programs for our study. Four different programs were used for one time of virtual reality training, and the programs were correctly set up depending on the patient's condition. Each program was performed in 6 minutes, taking the 2-minute break between programs. Patients were mainly asked to move the affected upper extremity, but were allowed to use the unaffected upper extremity if their motor power was poor grade not being able to lift in themselves against gravity, and sometimes we allowed them to use both upper extremities depending on the program. In addition, since not all patients could be trained while standing, training was performed in the sitting position in a wheelchair. For patients who could not follow the instructions well, it was performed with verbal cues given by the therapist. The first program was called "Bird and Balls", in which balls appeared from various directions on the screen and the patient burst the balls with his/her hands to change them into birds. The second program was called "Coconuts", in which coconut fruits fell down from the top of the screen and the patient put them into a basket by moving his/her arms to the left or right. The third program was called "Conveyor", in which conveyor belts appeared on the left and right sides of the screen and the patient held the box coming from the conveyor belt in one side and moved it to the conveyor belt on the opposite side. The fourth program was called "Juggler", in which one or more balls came up on the screen at the same time, and the patient continued to hit the balls and move them upward to avoid dropping the balls on the ground. The fifth program was called "Soccer", in which a soccer ball came up on the screen and the patient stopped the ball from going in the goal with his/her hands by playing the role of a goalkeeper (Fig. 2). In all programs, the level of difficulty could be controlled by adjusting the velocity, quantity, distance and angle of the object provided by virtual reality depending on the patient's condition. After the end of each program, the screen displayed the score achieved by the patient to make it possible to obtain feedback. In addition, a variety of background music associated with the game was provided in each program.
Computer-assisted cognitive rehabilitation used Com Cog® (Maxmedica Inc., Seoul, Korea), which was composed of programs designed to promote attention and memory for patients with cognitive impairment. Attention program was divided into three types of courses, which included the beginner course, intermediate course and advanced course. Based on the complete learning method, the training level could be determined according to the difficulty of the task, and the program details consisted of basic visual perception training, auditory perception training, attention training, attention discrimination training, continuous attention training, attention integration training, and emotion training. Memory programs consisted of three kinds of training courses (beginner, intermediate and advanced) by combining verbal/non-verbal tasks and sequential/non-sequential tasks. It could be classified according to the level of difficulty in the same way as the attention program and the program details consisted of simple recognition memory training, simple spatial memory training, sequential recall memory training, sequential verbal recall memory training, associated recall memory training, verbal categorization memory training, and integrated memory training.
Evaluation methods
To evaluate cognitive function for all patients before treatment, we performed computerized neuropsychological test (CNT, MaxMedica)24 and Tower of London test (TOL).25
We performed CNT including visual & auditory continuous performance tests (CPT) to evaluate continuous concentration on visual and auditory stimulations, and word-color test to evaluate the selective attention, and we evaluated forward & backward digit span tests (DST) and verbal learning test for verbal memory evaluation tests. For the verbal learning test, after letting the patients hear 15 target words through the speaker, we scored the number of words they first recalled, the number of words they recalled after repeating the same target words five times, the number of words they recalled after 20 minutes, and the number of words they found after presenting on the screen a list of 30 words containing the previous 15 words. For the spatial memory test, forward and backward visual span tests (VST) and visual learning tests were performed. For the visual learning test, after presenting 15 different figures sequentially, and then showing 30 figures including 15 figures that were not presented and 15 figures that were previously presented, we scored the number of presented figures they first found, the number of figures they found after showing the same figures five times, the number of figures they found after 20 minutes, and the number of figures they found after showing all 30 figures on the screen. For the visual motor coordination test (Trail making test-type A), we evaluated the time taken to drawing lines connecting 25 small circles on the screen, containing numbers 1 to 25 in each small circle.
For Tower of London (TOL) test to assess executive functioning, 5 balls of different colors were put into each bar among a total of 3 bars and after the occupational therapist showed the final goal position of 5 balls evenly put into 3 bars, we measured the time taken to make the final goal position by moving the balls as little as possible.
We evaluated activities of daily living function using Korean-Modified Barthel Index (K-MBI), and also evaluated motor function using the Motricity Index (MI) for the assessment of upper and lower muscle strength of the affected side after stroke. After 4 weeks of rehabilitation treatment, we re-evaluated the above clinical examination items.
Statistical analysis
SPSS 14.0 was used for statistical analysis. We analyzed the changes of the described test items including the evaluation of cognitive function before and after treatment within VR and control groups using Wilcoxon signed rank test, and we compared the difference of above test items including the evaluation of cognitive function before and after treatment between the VR and control groups using Mann-Whitney test. For statistical significance, we used 95% confidence interval, p<0.05.
RESULTS
In the comparison of evaluation items including cognitive function, ability to perform activities of daily living and motor function between the two groups that were tested before treatment, no significant differences between the two groups were observed in all the test items, except for the K-MBI scores (50.1±20.3 vs 30.2±21.6, p=0.03), which were significantly higher in the VR group than in the control group.
In the comparison of changes of cognitive function, ability to perform activities of daily living and motor function before and after treatment within the VR and control groups, among the K-MMSE, CNT items, visual and auditory CPTs, forward DST, forward and backward VSTs, and verbal and visual learning tests, TOL test, K-MBI, and MI scores showed statistically significant improvement in the VR group after treatment when compared with before treatment. In the control group, among the K-MMSE, CNT items, forward DST, visual and verbal learning tests, trail making test-type A, TOL test, K-MBI, and MI scores showed statistically significant improvement after treatment (Table 2).
When comparing the differences of cognitive function, ability to perform activities of daily living and motor function before and after treatment between the VR and control groups, among the CNT items, visual CPT and backward VST showed significant improvement compared to the control group (Table 3).
DISCUSSION
In our study, we found that visual attention and short-term visuospatial memory showed significant improvement in the VR group compared to the control group for acute stroke patients with cognitive impairment. Ben-Yishay et al.26 reported that intact attention is required to use higher cognitive functions effectively and when the ability to pay attention and concentrate on the information given outside is impaired, memory, problem solving, and production of appropriate actions could be difficult. In other words, they suggested that the loss of attention due to brain injury could interfere with the recovery of other cognitive functions such as memory, executive function, and planning ability. This implies that the cognitive treatment for training and improvement of attention should be based and preceded in order to improve overall cognitive function for brain-injured patients with cognitive impairment. In this sense, it is very meaningful that the results of this study showed the improvement of visual attention and short-term visuospatial memory after treatment with the virtual reality program.
Considering the reasons why visual attention and short-term visuospatial memory significantly improved after virtual reality training: First, virtual reality program was conducted in the forms of the game that could induce motivation and interest of the patients, leading to the improvement of procedural memory and the reactivation of brain neurotransmitters. Therefore, it was likely to improve visual attention and short-term visuospatial memory finally. Rose et al.23 reported that among patients with vascular brain injury, the patient group that showed interests in virtual reality environment and actively participated in the program, presented significantly improved spatial awareness test scores, compared to the patient group who watched the program passively. Rose et al.23 explained that since there were many cases in which procedural memory was preserved even if there was brain injury, procedural memory would have been helpful to improve visuospatial memory during the active participation and devotion in virtual reality program. In addition, Kim et al.27 reported that if the patients were motivated by experiencing a diverse and stimulating environment through the virtual reality program, it would be able to result in the improvement of attention and memory by the reactivation of brain neurotransmitter capability such as cholinergic and dopaminergic systems when combined with cognitive treatment. Second, the screen backgrounds for the virtual reality used in our study were a natural environment such as mountains and fields, skiing resorts, soccer grounds suitable for each program, and by placing the patients in the stimulus-rich virtual backgrounds for visuospatial perception, their visuospatial perception abilities were likely to be improved. Several studies28,29 demonstrated that visuospatial learning ability improved significantly when treated with stimulus training of visuospatial perception through the virtual reality program in the form of game for patients with physical disability, compared with the patients not treated with virtual reality program. Third, it might be able to improve the patient's level of alertness and visual attention during the treatment by providing continuous visual stimulus through the dynamic screen along with various auditory stimulus such as background music offered in the virtual reality program. In fact, we found that visual attention as well as auditory attention showed significant improvement within the VR group before and after treatment. Kim et al.27 reported the results of attention and memory performance improvement after performing virtual reality program of cognitive function for the elderly. The previous study proposed an explainable mechanism that strong virtual reality stimulus (visual and auditory) and immersiveness enough to induce the user active cognitive activities have been involved in improvement of cognitive function.
In addition, our study showed significant improvement in verbal and visual learning tests reflecting relatively long-term memory as well as short-term memory and attention before and after treatment in the VR group. Patients in the VR group performed simple and repetitive motions primarily using shoulder flexion and abduction through the virtual reality program, and repetitive physical movements in such virtual reality was likely to improve cognitive function by increasing the activation of the brain responsible for cognitive functions. Fordyce and Farrar30 reported that continued treadmill exercise of rats brought improvements in visuospatial memory. Grealy et al.31 observed in their study that when various visual stimulus were given to patients with traumatic brain injury by experiencing bicycle riding by themselves in virtual reality, they showed significant improvement in digit symbol tests as well as visual and verbal learning tests. Grealy et al.31 suggested that an interactive exercise could be associated with improvement of functions in the hippocampal region and a relatively simple physical exercise could result in the improvement of learning ability by reducing the overload of attention through virtual reality. However, because the control group showed significant improvement in one item of visual learning test and verbal learning test, it may be difficult to conclude simply that it was therapeutic effects of virtual reality. In addition, a TOL test to assess planning ability showed significant improvement in both groups before and after treatment, and there are limitations to conclude that it was the effect of virtual reality only. In order to prove its effectiveness, it is considered necessary to compare the group treated only with virtual reality training and the group treated only with computer-assisted cognitive rehabilitation.
In our study, we did not observe significant improvement of ability to perform activities of daily living in patients treated with virtual reality, compared to other patients. We considered that repetitive movements of the shoulder are required in the virtual reality programs, but making fine motor movements of hand such as catching and moving things are usually required in the activities of daily living. Therefore, it may cause limitations that lead to functional improvement. In addition, the improvement in activities of daily living may not appear significant because there are many cases which need other cognitive functions such as planning ability, problem solving ability and working memory in everyday life.
Limitations of our study included not observing significant differences in the number of patients showing unilateral neglect between both groups before treatment. Nonetheless, we have not determined whether the improvement of visual attention and short-term visuospatial memory correlated with the improvement of unilateral neglect because we did not investigate whether the unilateral neglect improved after treatment. Of course, several studies22,32,33 reported the improvement of unilateral neglect through virtual reality training, but the virtual reality programs used in those studies reproduced the situations representing unilateral neglect by letting patients cross the virtual street or to respond to objects that appear in the direction of occurring unilateral neglect by using only the upper extremity. Thus, those programs are different from the contents of virtual reality program that is conducted in the form of game as shown in our study. Therefore, further research is needed to investigate the improvement of unilateral neglect by using the virtual reality programs used in our study. Second, as mentioned earlier, we failed to clarify the effectiveness of virtual reality treatment for long-term visual and verbal memory since the comparison with the group underwent virtual reality treatment only was not performed. However, because computer-assisted cognitive rehabilitation has been used widely for cognitive treatment of stroke patients with cognitive impairment, we could not perform only virtual reality treatment for these patients. Finally, we could not conduct a comparative study on the effectiveness of virtual reality treatment depending on lesion location of cerebral hemisphere, cerebral cortical or subcortical areas due to the small number of patients.
CONCLUSION
In our study, we found that stroke patients with cognitive impairment showed significant improvement of visual attention and short-term visuospatial memory when treated with computer-assisted cognitive rehabilitation and virtual reality training together, compared to the cases when treated with computer-assisted cognitive rehabilitation only. Thus, in clinical practice, the additional effect is expected for the improvement of cognitive function when treated with virtual reality therapy together with computer-assisted cognitive rehabilitation therapy for cognitive rehabilitation of stroke patients with cognitive impairment. In the future, further efforts will be needed to develop virtual reality programs and demonstrate their effectiveness for improvement in various cognitive areas including verbal memory, problem-solving ability, and planning ability as well as attention and short-term visuospatial memory.
REFERENCES
1. Leys D, Henon H, Pasquier F. White matter changes and poststroke dementia. Dement Geriatr Cogn Disord 1998;9(Suppl 1):25-29.
2. Pohjasvaara T, Erkinjuntti T, Vataja R, Kaste M. Dementia three months after stroke. Baseline frequency and effect of different definitions of dementia in the Helsinki Stroke Aging Memory Study (SAM) cohort. Stroke 1997;28:785-792.
5. Diamond PT, Felsenthal G, Maccinocchi SN, Butler DH, Lally-Cassady D. Effect of cognitive impairment on rehabilitation outcome. Am J Phys Med Rehabil 1996;75:40-43.
6. Glisky EL, Schacter DL, Tulving E. Learning and retention of compter-related vocabulary in memory-impaired patients: method of vanishing cues. J Clin Exp Neuropsychol 1986;8:292-312.
7. Chen SH, Thomas JD, Glueckauf RL, Bracy OL. The effectiveness of computer-assisted cognitive rehabilitation for persons with traumatic brain injury. Brain injury 1997;11:197-209.
8. Niemann H, Ruff RM, Base CA. Computer-assisted attention retraining in head-injured individuals: a controlled efficacy study of an outpatient program. J Consult Clin Psychol 1990;58:811-817.
9. Kim YH, Ko MH, Seo JH, Park SH, Kim KS, Jang EH, Park SW, Park JH, Cho YJ. Effect of computer-assisted cognitive rehabilitation program for attention training in brain injury. J Korean Acad Rehabil Med 2003;27:830-839.
10. Parsons TD, Rizzo AA. Initial validation of a virtual environment for assessment of memory functioning: virtual reality cognitive performance assessment test. Cyberpsychol Behav 2008;11:17-25.
11. Parsons TD, Rizzo AA. Neurpsychological assessment using the virtual reality cognitive performance assessment test. Proceedings of the 7th ICDVRAT with Art-Abilitation 2008;2008 Aug 31-Sep 2; Maia, Portugal. UK, University of Reading.
12. Parsons TD, Larson P, Kratz K, Thiebaux M, Bluestein B, Buckwalter JG, Rizzo AA. Sex differences in mental rotation and spatial rotation in a virtual environment. Neuropsychologia 2004;42:555-562.
13. Matheis RJ, Schultheis MT, Tiersky LA, Deluca J, Millis SR, Rizzo A. Is learning and memory different in a virtual environment? Clin Neuropsychol 2007;21:146-161.
14. Hofmann M, Rosler A, Schwarz W, Muller-Spahn F, Krauchi K, Hock C, Seifritz E. Interactive computer-training as a therapeutic tool in Alzheimer's disease. Compr Psychiatry 2003;44:213-219.
16. Davidsdottir S, Wagenaar R, Young D, Cronin-Golomb A. Impact of optic flow perception and egocentric coordinates on veering in Parkinson's disease. Brain 2008;131:2882-2893.
17. Werner P, Rabinowitz S, Klinger E, Korczyn AD, Josman N. Use of the virtual action planning super market for the diagnosis of mild cognitive impairment: a preliminary study. Dement Geriatr Cogn Disord 2009;27:301-309.
19. Kim DY, Joo SY, Park CI, Park TH, Par KD, Jung KJ, Lee JH. Assessment of post-stroke cognitive dysfunction using 3-dimensional virtual reality program. J Korean Acad Rehabil Med 2009;33:12-20.
20. Kim DY, Lee JH, Park CI, Kim YW, Chang WH, Kim IY, Kim SI, Chon JS, Chang HJ. Assessment of post-stroke unilateral neglect using 3-dimensional virtual reality program. J Korean Acad Rehabil Med 2005;29:1-8.
21. Kang YJ, Ku JG, Han KW, Kim SI, Yu TW, Lee JH, Park CI. Development and clinical trial of virtual reality-based cognitive assessment in people with stroke: preliminary study. Cyberpsychol Behav 2008;11:329-339.
22. Kim JH, Kim KG, Kim DY, Chang WH, Park CI, Ohn SH, Han KW, Ku JH, Nam SW, Kim IY, et al. Virtual environment training system for rehabilitation of stroke patients with unilateral neglect: crossing the virtual street. Cyberpsychol Behav 2007;10:7-15.
23. Rose FD, Brooks BM, Attree EA, Parslow DM, Leadbetter AG, McNaill JE, Jayawardena S, Greenwood R, Potter J. A preliminary investigation into the use of virtual environments in memory retraining after vascular brain injury: indications for future strategy? Disabil Rehabil 1999;21:548-554.
24. Kim YH, Shin SH, Park SH, Ko MH. Cognitive assessment for patient with brain injury by computerized neuropsychological test. J Korean Acad Rehabil Med 2001;25:209-216.
25. Phillips LH, Wynn V, Gilhooly KJ, Della Sala S, Logie RH. The role of memory in the tower of London task. Memory 1999;7:209-231.
26. Ben-Yishay Y, Piasetsky EB, Rattock J. In: Meier MJ, Benton AL, Diller L, A systematic method for ameliorating disorders in basic attention. editors. Neuropsychological rehabilitation. 1987.1st ed. New York: Churchill Livingstone; p. 165-181.
27. Kim MY, Lee KS, Choi JS, Kim HB, Park CI. Effectiveness of cognitive training based on virtual reality for the elderly. J Korean Acad Rehabil Med 2005;29:424-433.
28. Wilson PN, Foreman N, Tlauka M. Transfer of spatial information from a virtual to a real environment in physically disabled children. Disabil Rehabil 1996;18:633-637.
29. Stanton D, Foreman N, Wilson P, Duffy H, Parnell R. Use of virtual environments to acquire spatial under standing of real-world multi-level environments. Proceedings of the 4th International Conference on Disability, Virtual Reality and associated Technologies 2002;2002 Sep 18-20; Veszprem, Hungary. UK, University of Reading.
30. Fordyce DE, Farrar RP. Enhancement of spatial learning in F344 rats by physical activity and related learning-associated alterations in hippocampal and cortical cholinergic functioning. Behav Brain Res 1991;46:123-133.
31. Grealy MA, Johnson DA, Rushton SK. Improving cognitive function after brain injury: the use of exercise and virtual reality. Arch Phys Med Rehabil 1999;80:661-667.
33. Glover S, Castiello U. Recovering space in unilateral neglect: a neurological dissociation revealed by virtual reality. J Cogn Neurosci 2006;18:833-843.
Virtual reality experimental set up of IREX System® (Vivid group, Toronto, Canada).
Fig. 2
Five virtual reality programs of IREX system® (Vivid group, Toronto, Canada) (A) Bird and balls (B) Coconutz (C) Conveyor (D) Juggler (E) Soccer.
Table 1
Demographic Characteristics of the Subjects
VR: Virtual reality, K-MMSE: Korean version of the Minimental
status examination
Table 2
The Changes of Cognitive Activity of Daily Living and Motor Functions before and after Rehabilitation within Each Group
K-MMSE: Korean version of the Mini-mental status examination, VCPT: Visual continuous performance test, ACPT : Auditory continuous performance test, WCW: Word of color word in word-color test, CCW: Color of color word in word-color test, FDST: Forward digit span test, BDST: Backward digit span test, FVST: Forward visual span test, BVST: Backward visual span test, ViLT: Visual learning test, VeLT: Verbal learning test, TMT-A: Trail making test-type A, TOL: Tower of London test, K-MBI: Korean-Modified Barthel index, MI: Motricity index
*p<0.05, †p<0.01
Table 3
The Comparison of Differences in Cognitive Activity of Daily Living and Motor Functions after Rehabilitation between Two Groups
K-MMSE: Korean version of the Mini-mental status examination, VCPT: Visual continuous performance test, ACPT: Auditory continuous performance test, WCW: Word of color word in word-color test, CCW: Color of color word in word-color test, FDST: Forward digit span test, BDST: Backward digit span test, FVST: Forward visual span test, BVST: Backward visual span test, ViLT: Visual learning test, VeLT: Verbal learning test, TMT-A: Trail making test-type A, TOL: Tower of London test, K-MBI: Korean-Modified Barthel index, MI: Motricity index
*p<0.05, †p<0.01
Figure & Data
References
Citations
Citations to this article as recorded by
Rehabilitation interventions for cognitive deficits in stroke survivors: A systematic review of randomized controlled trials Anas R. Alashram, Giuseppe Annino, Elvira Padua Applied Neuropsychology: Adult.2025; 32(1): 262. CrossRef
VR Cognitive-based Intervention for Enhancing Cognitive Functions and Well-being in Older Adults with Mild Cognitive Impairment: Behavioral and EEG Evidence Pattrawadee Makmee, Peera Wongupparaj Psychosocial Intervention.2025; 34(1): 37. CrossRef
Virtual Reality Interventions for Older Adults With Mild Cognitive Impairment: Systematic Review and Meta-Analysis of Randomized Controlled Trials Qin Yang, Liuxin Zhang, Fangyuan Chang, Hongyi Yang, Bin Chen, Zhao Liu Journal of Medical Internet Research.2025; 27: e59195. CrossRef
Effect of Customized Rehabilitation Training Programs with Cognitive-Motor Sequential Dual-task using Virtual Reality on Cognitive and Physical Function in Disabled Persons with Chronic Stroke Hyeyun Kang, Bo-Ra Kang, Seong Hun Park, Young-Hyeon Bae The Journal of Korean Academy of Physical Therapy Science.2025; 32(1): 42. CrossRef
Predicting and Explaining Cognitive Load, Attention, and Working Memory in Virtual Multitasking Jyotirmay Nag Setu, Joshua M Le, Ripan Kumar Kundu, Barry Giesbrecht, Tobias Höllerer, Khaza Anuarul Hoque, Kevin Desai, John Quarles IEEE Transactions on Visualization and Computer Graphics.2025; 31(5): 3014. CrossRef
Digital Interventions for Cognitive Dysfunction in Patients With Stroke: Systematic Review and Meta-Analysis Chen Wang, Min Liu Journal of Medical Internet Research.2025; 27: e73687. CrossRef
Efficacy of different digital interventions in patients with mild cognitive impairment or dementia: A systematic review and network meta-analysis Xin Lin, Guangyi Xu, Mengjiao Zhao, Yunxia Jiang International Journal of Nursing Studies.2025; 169: 105129. CrossRef
Virtual reality for stroke rehabilitation Kate E Laver, Belinda Lange, Stacey George, Judith E Deutsch, Gustavo Saposnik, Madison Chapman, Maria Crotty Cochrane Database of Systematic Reviews.2025;[Epub] CrossRef
Subjective Performance Expectations From and Demographic and Categorical Differences in the Acceptance of Virtual Reality or AI Technologies in Rehabilitation Programs: Cross-Sectional Questionnaire Survey With Rehabilitation Patients Guido Waldmann, Dominik Raab Journal of Participatory Medicine.2025; 17: e69350. CrossRef
Effects of telemedicine interventions on cognitive function in post-stroke cognitive impairment: A systematic review and meta-analysis Qiqing Zhong, Yifan Wu, Shengze Zhi, Shuyan Fang, Mengyuan Li, Jiaxin Li, Huizhen Zhang, Jianing Lang, Rui Wang, Jiao Sun Journal of Telemedicine and Telecare.2025;[Epub] CrossRef
Nonimmersive Virtual Reality-Based Exercises Improve Muscle Excitability and Balance in Patients with Knee Osteoarthritis: A Sham-Controlled Study Mehmet Sönmez, Şebnem Avcı, Fatma Şimşek, Fatih Baygutalp Games for Health Journal.2025; 14(6): 493. CrossRef
Effects of dual-task training on walking and balance in stroke patients: A systematic review and network meta-analysis Yuxin Zhao, Chuanle Guo, Deqi Zhang, Xiaohui Wei, Xiaoyu Jiang, Hongyan Bi Clinical Rehabilitation.2025;[Epub] CrossRef
Could Immersive Virtual Reality Facilitate the Recovery of Survivors of Critical Illness? A Systematic Review Irini Patsaki, Dimitra Tzoumi, Marios Kalyviotis, Akylina Despoti, Eleftherios Karatzanos, Serafim Nanas, Eleni Magira Healthcare.2025; 13(22): 2942. CrossRef
Effectiveness of VR-based cognitive training and games on cognitive rehabilitation in patients with MCI: a systematic review and meta-analysis Peiming Yuan, Jiaxi Chen, Dianhui Peng, Qian Yang, Bin Liu, Chunxia Lu Frontiers in Neurology.2025;[Epub] CrossRef
Efficacy of the cognifit app in improving cognitive function and balance in post-stroke patient S. Santhana Lakshmi, S. Mythili, Prathap Suganthirababu, Dhanusia Suresh Acta Balneologica.2025; : 397. CrossRef
Effects of Short-Term Exposure to Interactive vs. Non-Interactive Virtual Nature on Cognitive Performance and Mental Health in College Students Francisco de Asís Martínez Manchón, Ana Šimunić International Journal of Human–Computer Interaction.2024; 40(18): 5443. CrossRef
Teaching cardiopulmonary resuscitation using virtual reality: A randomized study P.M. Alcázar Artero, R. Greif, J.J. Cerón Madrigal, D. Escribano, M.T. Pérez Rubio, M.E. Alcázar Artero, P. López Guardiola, M. Mendoza López, R. Melendreras Ruiz, M. Pardo Ríos Australasian Emergency Care.2024; 27(1): 57. CrossRef
Effects of virtual reality‐based cognitive interventions on cognitive function and activity of daily living among stroke patients: Systematic review and meta‐analysis Lin Rose Sin Yi, Su Jing Jing, Abu‐Odah Hammoda, Bayuo Jonathan, Batalik Ladislav, Qin Jing Journal of Clinical Nursing.2024; 33(3): 1169. CrossRef
Efficacy of virtual reality-based training programs and games on the improvement of cognitive disorders in patients: a systematic review and meta-analysis Khadijeh Moulaei, Hamid Sharifi, Kambiz Bahaadinbeigy, Fatemeh Dinari BMC Psychiatry.2024;[Epub] CrossRef
Effectiveness of reinforced feedback in virtual environment for upper limb rehabilitation in acute stroke Hemayuthika Loganathan, Rajeswari Muthusamy, Sivakumar Ramachandran Fizjoterapia Polska.2024; 24(1): 146. CrossRef
Transcranial Direct Current Stimulation to Ameliorate Post-Stroke Cognitive Impairment Kelly L. Sloane, Roy H. Hamilton Brain Sciences.2024; 14(6): 614. CrossRef
A Comprehensive Review of Virtual Reality Technology for Cognitive Rehabilitation in Patients with Neurological Conditions Wei Quan, Shikai Liu, Meng Cao, Jiale Zhao Applied Sciences.2024; 14(14): 6285. CrossRef
The influence of eight cognitive training regimes upon cognitive screening tool performance in post-stroke survivors: a network meta-analysis Liqin Zhou, Xiaofeng Huang, Jieyu Wang, Fengming Wang, Jihong Liu, Nanhai Liu Frontiers in Aging Neuroscience.2024;[Epub] CrossRef
Efficacy of adaptive cognitive training through desktop virtual reality and paper-and-pencil in the treatment of mental and behavioral disorders Joana Câmara, Rute Ferreira, Liliana Teixeira, Joana Nóbrega, Carina Romeira, Sergi Bermúdez i Badia, Ana Lúcia Faria Virtual Reality.2023; 27(1): 291. CrossRef
Virtual reality in post-stroke neurorehabilitation – a systematic review and meta-analysis Azka Khan, Anna Podlasek, Fahad Somaa Topics in Stroke Rehabilitation.2023; 30(1): 53. CrossRef
The effect of virtual reality on executive function in older adults with mild cognitive impairment: a systematic review and meta-analysis Dan Yu, Xun Li, Frank Ho-yin Lai Aging & Mental Health.2023; 27(4): 663. CrossRef
Effects of virtual reality in the early-stage stroke rehabilitation: A systematic review and meta-analysis of randomized controlled trials Jie Hao, Zixuan Yao, Kimberly Harp, Dr. Yeongjin Gwon, Zhen Chen, Ka-Chun Siu Physiotherapy Theory and Practice.2023; 39(12): 2569. CrossRef
Effectiveness of Active Exergames for Improving Cognitive Function in Patients with Neurological Disabilities: A Systematic Review and Meta-Analysis Kunbin Li, Yan Wang, Zhiyuan Wu, Xianli Yao, Yindi Fan Games for Health Journal.2023; 12(3): 198. CrossRef
Digital healthcare for dementia and cognitive impairment: A scoping review Minsung Sohn, JungYeon Yang, Junyoung Sohn, Jun-Hyup Lee International Journal of Nursing Studies.2023; 140: 104413. CrossRef
The effect of Computer Assisted Rehabilitation Environment (CAREN) in cognitive impairment and coping strategies in Parkinson's disease: a preliminary study Caterina Formica, Lilla Bonanno, Desiree Latella, Maria Cristina Ferrera, Giuseppa Maresca, Anna Lisa Logiudice, Chiara Sorbera, Amelia Brigandì, Giuseppe Di Lorenzo, Silvia Marino Scientific Reports.2023;[Epub] CrossRef
Efficiency of virtual reality for cardiopulmonary resuscitation training of adult laypersons: A systematic review Petronila Mireia Alcázar Artero, Manuel Pardo Rios, Robert Greif, Ana Belén Ocampo Cervantes, Gabriel Gijón-Nogueron, Roberto Barcala-Furelos, Silvia Aranda-García, Laura Ramos Petersen Medicine.2023; 102(4): e32736. CrossRef
Verification of the effect on short-term memory in VR space by audio-visual stimulation Woong Choi Journal of Digital Contents Society.2023; 24(2): 229. CrossRef
Head-mounted display virtual reality cognitive training in neurorehabilitation: Randomized controlled pilot study (Preprint) Julian Specht, Barbara Stegmann, Hanna Gross, Karsten Krakow JMIR Serious Games.2023;[Epub] CrossRef
The effectiveness of virtual reality games in improving cognition, mobility, and emotion in elderly post-stroke patients: a systematic review and meta-analysis Chenli Lin, Yuanyuan Ren, Aming Lu Neurosurgical Review.2023;[Epub] CrossRef
Cognitive and Motor Therapy After Stroke Is Not Superior to Motor and Cognitive Therapy Alone to Improve Cognitive and Motor Outcomes: New Insights From a Meta-analysis Elissa Embrechts, Thomas B. McGuckian, Jeffrey M. Rogers, Chris H. Dijkerman, Bert Steenbergen, Peter H. Wilson, Tanja C.W. Nijboer Archives of Physical Medicine and Rehabilitation.2023; 104(10): 1720. CrossRef
Memory rehabilitation during the COVID-19 pandemic José Luis Varela-Aldás, Jorge Buele, Doris Pérez, Guillermo Palacios-Navarro BMC Medical Informatics and Decision Making.2023;[Epub] CrossRef
Effects of Virtual Reality Physical and Cognitive Training Intervention On Cognitive Abilities of Elders with Mild Cognitive Impairment Eleni Baldimtsi, Christos Mouzakidis, Eleni Maria Karathanasi, Eleni Verykouki, Mary Hassandra, Evangelos Galanis, Antonis Hatzigeorgiadis, Marios Goudas, Paul Zikas, Giannis Evangelou, George Papagiannakis, George Bellis, Christos Kokkotis, Themistoklis Journal of Alzheimer's Disease Reports.2023; 7(1): 1475. CrossRef
Effectiveness of Virtual Reality in Reducing Kinesiophobia. A Systematic Review Daniel Mădălin Coja, Laurențiu Gabriel Talaghir, Luminița Georgescu, Corneliu Mircea Codreanu Balneo and PRM Research Journal.2023; 14(Vol.14, no): 629. CrossRef
Examining the effect of virtual reality therapy on cognition post-stroke: a systematic review and meta-analysis Elise Wiley, Shereen Khattab, Ada Tang Disability and Rehabilitation: Assistive Technology.2022; 17(1): 50. CrossRef
Integration of Virtual Reality into Transcranial Magnetic Stimulation Improves Cognitive Function in Patients with Parkinson’s Disease with Cognitive Impairment: A Proof-of-Concept Study Tsai-Chin Cheng, Shih-Fong Huang, Shang-Yu Wu, Fu-Gong Lin, Wang-Sheng Lin, Po-Yi Tsai Journal of Parkinson’s Disease.2022; 12(2): 723. CrossRef
Young and old users prefer immersive virtual reality over a social robot for short-term cognitive training Orit Cohavi, Shelly Levy-Tzedek International Journal of Human-Computer Studies.2022; 161: 102775. CrossRef
Meta-analysis of Virtual Reality Based on Delaying Mild Cognitive Impairment Guanqun Chao, Liying Chen Journal of Nervous & Mental Disease.2022; 210(3): 194. CrossRef
Immersive Virtual Reality for the Cognitive Rehabilitation of Stroke Survivors Kausik Chatterjee, Alastair Buchanan, Katy Cottrell, Sara Hughes, Thomas W. Day, Nigel W. John IEEE Transactions on Neural Systems and Rehabilitation Engineering.2022; 30: 719. CrossRef
Occupational therapy for cognitive impairment in stroke patients Elizabeth Gibson, Chia-Lin Koh, Sally Eames, Sally Bennett, Anna Mae Scott, Tammy C Hoffmann Cochrane Database of Systematic Reviews.2022;[Epub] CrossRef
Impact of age, VR, immersion, and spatial resolution on classifier performance for a MI-based BCI D.A. Blanco-Mora, A. Aldridge, C. Jorge, A. Vourvopoulos, P. Figueiredo, S. Bermúdez I Badia Brain-Computer Interfaces.2022; 9(3): 169. CrossRef
The Impact of VR-CALM Intervention Based on VR on Psychological Distress and Symptom Management in Breast Cancer Survivors Xiuqing Zhang, Senbang Yao, Menglian Wang, Xiangxiang Yin, Ziran Bi, Yanyan Jing, Huaidong Cheng, Yingming Sun Journal of Oncology.2022; 2022: 1. CrossRef
Memory rehabilitation: restorative, specific knowledge acquisition, compensatory, and holistic approaches Yashoda Gopi, Edward Wilding, Christopher R. Madan Cognitive Processing.2022; 23(4): 537. CrossRef
Rehabilitation efficacy comparison of virtual reality technology and computer-assisted cognitive rehabilitation in patients with post-stroke cognitive impairment: A network meta-analysis Zihao Xiao, Zhenni Wang, Ge Song, Ying Zhong, Weiming Zhang Journal of Clinical Neuroscience.2022; 103: 85. CrossRef
Efficacy of Multisensory Technology in Post-Stroke Cognitive Rehabilitation: A Systematic Review Alessandra Parisi, Francesca Bellinzona, Daniele Di Lernia, Claudia Repetto, Stefano De Gaspari, Giulia Brizzi, Giuseppe Riva, Cosimo Tuena Journal of Clinical Medicine.2022; 11(21): 6324. CrossRef
Application of Immersive Virtual-Reality-Based Puzzle Games in Elderly Patients with Post-Stroke Cognitive Impairment: A Pilot Study Zhilan Liu, Zhijie He, Jing Yuan, Hua Lin, Conghui Fu, Yan Zhang, Nian Wang, Guo Li, Jing Bu, Mei Chen, Jie Jia Brain Sciences.2022; 13(1): 79. CrossRef
Psychological Effects of Green Experiences in a Virtual Environment: A Systematic Review Mijin Lee, Eunsoo Kim, Jiwon Choe, Seonhye Choi, Siyeon Ha, Geonwoo Kim Forests.2022; 13(10): 1625. CrossRef
Effectiveness of Nintendo Wii and Physical Therapy in Functionality, Balance, and Daily Activities in Chronic Stroke Patients Elena Marques-Sule, Anna Arnal-Gómez, Gloria Buitrago-Jiménez, Luis Suso-Martí, Ferran Cuenca-Martínez, Gemma Victoria Espí-López Journal of the American Medical Directors Association.2021; 22(5): 1073. CrossRef
What is the future for immersive virtual reality in memory rehabilitation? A systematic review Adéla Plechatá, Tereza Nekovářová, Iveta Fajnerová NeuroRehabilitation.2021; 48(4): 389. CrossRef
Effects of a cognitive rehabilitation programme on cognitive function, self‐management and quality of life in patients with chronic obstructive pulmonary disease Myoung Ok Park, Hyun Soo Oh, Wha Sook Seo International Journal of Nursing Practice.2021;[Epub] CrossRef
Test-retest reliability and practice effects of the virtual environment grocery store (VEGS) Daniel S. Weitzner, Matthew Calamia, Thomas D. Parsons Journal of Clinical and Experimental Neuropsychology.2021; 43(6): 547. CrossRef
Experiences of Stroke Survivors and Clinicians With a Fully Immersive Virtual Reality Treadmill Exergame for Stroke Rehabilitation: A Qualitative Pilot Study Merete Endresen Moan, Elise Klæbo Vonstad, Xiaomeng Su, Beatrix Vereijken, Marit Solbjør, Nina Skjæret-Maroni Frontiers in Aging Neuroscience.2021;[Epub] CrossRef
An Immersive and Interactive Platform for Cognitive Assessment and Rehabilitation (bWell): Design and Iterative Development Process Vincent Gagnon Shaigetz, Catherine Proulx, Anne Cabral, Nusrat Choudhury, Mark Hewko, Elicia Kohlenberg, Melanie Segado, Michael S D Smith, Patricia Debergue JMIR Rehabilitation and Assistive Technologies.2021; 8(4): e26629. CrossRef
Impact of Virtual Reality-Based Therapies on Cognition and Mental Health of Stroke Patients: Systematic Review and Meta-analysis Qi Zhang, Yu Fu, Yanhui Lu, Yating Zhang, Qifang Huang, Yajie Yang, Ke Zhang, Mingzi Li Journal of Medical Internet Research.2021; 23(11): e31007. CrossRef
Effects of Virtual Reality-Based Intervention on Cognition, Motor Function, Mood, and Activities of Daily Living in Patients With Chronic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Yong Gao, Lu Ma, Changsheng Lin, Shizhe Zhu, Lingling Yao, Hong Fan, Jianqiu Gong, Xiaobo Yan, Tong Wang Frontiers in Aging Neuroscience.2021;[Epub] CrossRef
The differentiated effect of the task complexity on retention and transfer of stroke survivors Gisele Carla dos Santos Palma, Umberto Cesar Corrêa, Camila Torriani-Pasin Human Movement Science.2020; 69: 102545. CrossRef
Effectiveness of Early Rehabilitation Combined With Virtual Reality Training on Muscle Strength, Mood State, and Functional Status in Patients With Acute Stroke: A Randomized Controlled Trial Ruei‐Ching Lin, Shang‐Lin Chiang, Margaret McLean Heitkemper, Shu‐Min Weng, Chi‐Feng Lin, Fu‐Chi Yang, Chia‐Huei Lin Worldviews on Evidence-Based Nursing.2020; 17(2): 158. CrossRef
Neurotechnologies as tools for cognitive rehabilitation in stroke patients Laurijn R. Draaisma, Maximilian J. Wessel, Friedhelm C. Hummel Expert Review of Neurotherapeutics.2020; 20(12): 1249. CrossRef
Noninvasive Brain Stimulation & Space Exploration: Opportunities and Challenges S. Romanella, G. Sprugnoli, G. Ruffini, K. Seyedmadani, S. Rossi, E. Santarnecchi Neuroscience & Biobehavioral Reviews.2020;[Epub] CrossRef
Virtual Reality-Based Cognitive–Motor Rehabilitation in Older Adults with Mild Cognitive Impairment: A Randomized Controlled Study on Motivation and Cognitive Function Ji-Su Park, Young-Jin Jung, Gihyoun Lee Healthcare.2020; 8(3): 335. CrossRef
Effectiveness of a Serious Game for Cognitive Training in Chronic Stroke Survivors with Mild-to-Moderate Cognitive Impairment: A Pilot Randomized Controlled Trial Hee-Tae Jung, Jean-Francois Daneault, Tenzin Nanglo, Hyunsuk Lee, Byeongil Kim, Yangsoo Kim, Sunghoon Ivan Lee Applied Sciences.2020; 10(19): 6703. CrossRef
Competition Enhances the Effectiveness and Motivation of Attention Rehabilitation After Stroke. A Randomized Controlled Trial María Dolores Navarro, Roberto Llorens, Adrián Borrego, Mariano Alcañiz, Enrique Noé, Joan Ferri Frontiers in Human Neuroscience.2020;[Epub] CrossRef
Rehabilitation Games in Real-World Clinical Settings Hee-Tae Jung, Taiwoo Park, Narges MAhyar, Sungji Park, Taekyeong Ryu, Yangsoo Kim, Sunghoon Ivan Lee ACM Transactions on Computer-Human Interaction.2020; 27(6): 1. CrossRef
The effect of virtual reality based cognitive-motor training on psychophysiological parameters and balance function in the elderl N A. Suponeva, Anastasia E. Khizhnikova, M. A Piradov Physical and rehabilitation medicine, medical rehabilitation.2020; : 392. CrossRef
Rehabilitation of elderly patients at risk of falling: the value of psychophysiological parameters and cognitive-motor training using virtual reality
Anton S. Klochkov, Anastasia E. Khizhnikova, Anna A. Fuks, Artem M. Kotov-Smolenskiy, Natalia A. Suponeva, Mikhail A. Piradov Annals of Clinical and Experimental Neurology.2020;[Epub] CrossRef
The Growing Use of Virtual Reality in Cognitive Rehabilitation: Fact, Fake or Vision? A Scoping Review Maria Grazia Maggio, Giuseppa Maresca, Rosaria De Luca, Maria Chiara Stagnitti, Bruno Porcari, Maria Cristina Ferrera, Franco Galletti, Carmela Casella, Alfredo Manuli, Rocco Salvatore Calabrò Journal of the National Medical Association.2019; 111(4): 457. CrossRef
Acceptance of immersive head-mounted virtual reality in older adults Hanne Huygelier, Brenda Schraepen, Raymond van Ee, Vero Vanden Abeele, Céline R. Gillebert Scientific Reports.2019;[Epub] CrossRef
Evidence-Based Cognitive Rehabilitation: Systematic Review of the Literature From 2009 Through 2014 Keith D. Cicerone, Yelena Goldin, Keith Ganci, Amy Rosenbaum, Jennifer V. Wethe, Donna M. Langenbahn, James F. Malec, Thomas F. Bergquist, Kristine Kingsley, Drew Nagele, Lance Trexler, Michael Fraas, Yelena Bogdanova, J. Preston Harley Archives of Physical Medicine and Rehabilitation.2019; 100(8): 1515. CrossRef
Elements virtual rehabilitation improves motor, cognitive, and functional outcomes in adult stroke: evidence from a randomized controlled pilot study Jeffrey M. Rogers, Jonathan Duckworth, Sandy Middleton, Bert Steenbergen, Peter H. Wilson Journal of NeuroEngineering and Rehabilitation.2019;[Epub] CrossRef
Rehabilitation Technology: Assistance from Hospital to Home Ester Martinez-Martin, Miguel Cazorla Computational Intelligence and Neuroscience.2019; 2019: 1. CrossRef
Cognitive-motor exergaming for reducing fall risk in people with chronic stroke: A randomized controlled trial Lakshmi Kannan, Jinal Vora, Tanvi Bhatt, Susan L. Hughes NeuroRehabilitation.2019; 44(4): 493. CrossRef
Change of cognitive functions after stroke with rehabilitation systems Daiva Baltaduonienė, Raimondas Kubilius, Kristina Berškienė, Linas Vitkus, Daiva Petruševičienė Translational Neuroscience.2019; 10(1): 118. CrossRef
Meta-Analysis of the Efficacy of Virtual Reality–Based Interventions in Cancer-Related Symptom Management Yingchun Zeng, Jun-E Zhang, Andy S. K. Cheng, Huaidong Cheng, Jeffrey Scott Wefel Integrative Cancer Therapies.2019;[Epub] CrossRef
A systematic review of the use of virtual reality and its effects on cognition in individuals with neurocognitive disorders Alexander Moreno, Kylie Janine Wall, Karthick Thangavelu, Lucas Craven, Emma Ward, Nadeeka N. Dissanayaka Alzheimer's & Dementia: Translational Research & Clinical Interventions.2019; 5(1): 834. CrossRef
What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes Anna Aminov, Jeffrey M. Rogers, Sandy Middleton, Karen Caeyenberghs, Peter H. Wilson Journal of NeuroEngineering and Rehabilitation.2018;[Epub] CrossRef
Novel Virtual Reality Application in Field of Neurorehabilitation Jeonghun Ku, Youn Joo Kang Brain & Neurorehabilitation.2018;[Epub] CrossRef
Effects of virtual reality-based training with BTs-Nirvana on functional recovery in stroke patients: preliminary considerations Rosaria De Luca, Margherita Russo, Antonino Naro, Provvidenza Tomasello, Simona Leonardi, Floriana Santamaria, Latella Desireè, Alessia Bramanti, Giuseppe Silvestri, Placido Bramanti, Rocco Salvatore Calabrò International Journal of Neuroscience.2018; 128(9): 791. CrossRef
Cognitive rehabilitation after severe acquired brain injury: current evidence and future directions Rosaria De Luca, Rocco Salvatore Calabrò, Placido Bramanti Neuropsychological Rehabilitation.2018; 28(6): 879. CrossRef
Aerobic Stimulus Induced by Virtual Reality Games in Stroke Survivors Julio Cesar Silva de Sousa, Camila Torriani-Pasin, Amanda Barboza Tosi, Rafael Yokoyama Fecchio, Luiz Augusto Riani Costa, Cláudia Lúcia de Moraes Forjaz Archives of Physical Medicine and Rehabilitation.2018; 99(5): 927. CrossRef
Combined Cognitive-Motor Rehabilitation in Virtual Reality Improves Motor Outcomes in Chronic Stroke – A Pilot Study Ana L. Faria, Mónica S. Cameirão, Joana F. Couras, Joana R. O. Aguiar, Gabriel M. Costa, Sergi Bermúdez i Badia Frontiers in Psychology.2018;[Epub] CrossRef
General and Domain-Specific Effectiveness of Cognitive Remediation after Stroke: Systematic Literature Review and Meta-Analysis Jeffrey M. Rogers, Rachael Foord, Renerus J. Stolwyk, Dana Wong, Peter H. Wilson Neuropsychology Review.2018; 28(3): 285. CrossRef
Clinical instructors’ perceptions of virtual reality in health professionals’ cardiopulmonary resuscitation education Marie Ann Mae En Wong, Shien Chue, Michelle Jong, Ho Wye Kei Benny, Nabil Zary SAGE Open Medicine.2018;[Epub] CrossRef
What About the Role of Virtual Reality in Parkinson Disease’s Cognitive Rehabilitation? Preliminary Findings From a Randomized Clinical Trial Maria Grazia Maggio, Maria Cristina De Cola, Desirèe Latella, Giuseppa Maresca, Chiara Finocchiaro, Gianluca La Rosa, Vincenzo Cimino, Chiara Sorbera, Placido Bramanti, Rosaria De Luca, Rocco Salvatore Calabrò Journal of Geriatric Psychiatry and Neurology.2018; 31(6): 312. CrossRef
Effects of virtual reality and motor imagery techniques using Fugl Meyer Assessment scale in post-stroke patients Suélen Santos Alves, Gabriela Nagai Ocamoto, Patrícia Silva de Camargo, Adriana Teresa Silva Santos, Andreia Maria Silva Vilela Terra International Journal of Therapy and Rehabilitation.2018; 25(11): 587. CrossRef
Influence of Nintendo Wii Fit Balance Game on Visual Perception, Postural Balance, and Walking in Stroke Survivors: A Pilot Randomized Clinical Trial Donmo Choi, Wonjae Choi, Seungwon Lee Games for Health Journal.2018; 7(6): 377. CrossRef
Effects of a Cognitive Training Program on Cognitive Function and Activities of Daily Living in Patients with Acute Ischemic Stroke Eun Young Oh, Mi Sook Jung Journal of Korean Academy of Nursing.2017; 47(1): 1. CrossRef
Application of virtual environments in a multi-disciplinary day neurorehabilitation program to improve executive functioning using the Stroop task Marie N. Dahdah, Monica Bennett, Purvi Prajapati, Thomas D. Parsons, Erin Sullivan, Simon Driver NeuroRehabilitation.2017; 41(4): 721. CrossRef
Cognitive training on stroke patients via virtual reality-based serious games Pedro Gamito, Jorge Oliveira, Carla Coelho, Diogo Morais, Paulo Lopes, José Pacheco, Rodrigo Brito, Fabio Soares, Nuno Santos, Ana Filipa Barata Disability and Rehabilitation.2017; 39(4): 385. CrossRef
Review of Virtual Reality Treatment in Psychiatry: Evidence Versus Current Diffusion and Use Matthew C. Mishkind, Aaron M. Norr, Andrea C. Katz, Greg M. Reger Current Psychiatry Reports.2017;[Epub] CrossRef
Effects of virtual reality for stroke individuals based on the International Classification of Functioning and Health: a systematic review Gisele Carla dos Santos Palma, Tatiana Beline Freitas, Giordano Márcio Gatinho Bonuzzi, Marcos Antonio Arlindo Soares, Paulo Henrique Wong Leite, Natália Araújo Mazzini, Murilo Ruas Groschitz Almeida, José Eduardo Pompeu, Camila Torriani-Pasin Topics in Stroke Rehabilitation.2017; 24(4): 269. CrossRef
Exergames Encouraging Exploration of Hemineglected Space in Stroke Patients With Visuospatial Neglect: A Feasibility Study Bernadette C Tobler-Ammann, Elif Surer, Eling D de Bruin, Marco Rabuffetti, N Alberto Borghese, Renato Mainetti, Michele Pirovano, Lia Wittwer, Ruud H Knols JMIR Serious Games.2017; 5(3): e17. CrossRef
Virtual reality for stroke rehabilitation Kate E Laver, Belinda Lange, Stacey George, Judith E Deutsch, Gustavo Saposnik, Maria Crotty Cochrane Database of Systematic Reviews.2017;[Epub] CrossRef
Does a Combination of Virtual Reality, Neuromodulation and Neuroimaging Provide a Comprehensive Platform for Neurorehabilitation? – A Narrative Review of the Literature Wei-Peng Teo, Makii Muthalib, Sami Yamin, Ashlee M. Hendy, Kelly Bramstedt, Eleftheria Kotsopoulos, Stephane Perrey, Hasan Ayaz Frontiers in Human Neuroscience.2016;[Epub] CrossRef
Efeitos da intervenção com game na atenção e na independência funcional em idosos após acidente vascular encefálico Magliani Reis Fiorin Martel, Eliane Lucia Colussi, Ana Carolina Bertoletti De Marchi Fisioterapia e Pesquisa.2016; 23(1): 52. CrossRef
Benefits of virtual reality based cognitive rehabilitation through simulated activities of daily living: a randomized controlled trial with stroke patients Ana Lúcia Faria, Andreia Andrade, Luísa Soares, Sergi Bermúdez i Badia Journal of NeuroEngineering and Rehabilitation.2016;[Epub] CrossRef
Computerized Cognitive Rehabilitation of Attention and Executive Function in Acquired Brain Injury: A Systematic Review Yelena Bogdanova, Megan K. Yee, Vivian T. Ho, Keith D. Cicerone Journal of Head Trauma Rehabilitation.2016; 31(6): 419. CrossRef
Guidelines for Adult Stroke Rehabilitation and Recovery Carolee J. Winstein, Joel Stein, Ross Arena, Barbara Bates, Leora R. Cherney, Steven C. Cramer, Frank Deruyter, Janice J. Eng, Beth Fisher, Richard L. Harvey, Catherine E. Lang, Marilyn MacKay-Lyons, Kenneth J. Ottenbacher, Sue Pugh, Mathew J. Reeves, Lor Stroke.2016;[Epub] CrossRef
Effect of Virtual Reality–Based Rehabilitation on Upper-Extremity Function in Patients with Brain Tumor Jisun Yoon, Min Ho Chun, Sook Joung Lee, Bo Ryun Kim American Journal of Physical Medicine & Rehabilitation.2015; 94(6): 449. CrossRef
Virtual reality for stroke rehabilitation Kate E Laver, Stacey George, Susie Thomas, Judith E Deutsch, Maria Crotty Cochrane Database of Systematic Reviews.2015;[Epub] CrossRef
Effects of a virtual reality-based exercise program on functional recovery in stroke patients: part 1 Kyoung-Hee Lee Journal of Physical Therapy Science.2015; 27(6): 1637. CrossRef
Virtual reality for cognitive rehabilitation after brain injury: a systematic review HyeonHui Shin, KyeongMi Kim Journal of Physical Therapy Science.2015; 27(9): 2999. CrossRef
A Cognitive-Balance Control Training Paradigm Using Wii Fit to Reduce Fall Risk in Chronic Stroke Survivors Savitha Subramaniam, Christina Wan-Ying Hui-Chan, Tanvi Bhatt Journal of Neurologic Physical Therapy.2014; 38(4): 216. CrossRef
Effect of Virtual Reality on Cognitive Dysfunction in Patients With Brain Tumor Seoyon Yang, Min Ho Chun, Yu Ri Son Annals of Rehabilitation Medicine.2014; 38(6): 726. CrossRef
Effectiveness of Commercial Gaming-Based Virtual Reality Movement Therapy on Functional Recovery of Upper Extremity in Subacute Stroke Patients Jun Hwan Choi, Eun Young Han, Bo Ryun Kim, Sun Mi Kim, Sang Hee Im, So Young Lee, Chul Woong Hyun Annals of Rehabilitation Medicine.2014; 38(4): 485. CrossRef
A virtual rehabilitation program after amputation: a phenomenological exploration Marloes Moraal, Jenny Slatman, Toine Pieters, Agali Mert, Guy Widdershoven Disability and Rehabilitation: Assistive Technology.2013; 8(6): 511. CrossRef
Effect of Virtual Reality on Cognition in Stroke Patients
Fig. 1 Virtual reality experimental set up of IREX System® (Vivid group, Toronto, Canada).
Fig. 2 Five virtual reality programs of IREX system® (Vivid group, Toronto, Canada) (A) Bird and balls (B) Coconutz (C) Conveyor (D) Juggler (E) Soccer.
Fig. 1
Fig. 2
Effect of Virtual Reality on Cognition in Stroke Patients
Demographic Characteristics of the Subjects
VR: Virtual reality, K-MMSE: Korean version of the Minimental
status examination
The Changes of Cognitive Activity of Daily Living and Motor Functions before and after Rehabilitation within Each Group
K-MMSE: Korean version of the Mini-mental status examination, VCPT: Visual continuous performance test, ACPT : Auditory continuous performance test, WCW: Word of color word in word-color test, CCW: Color of color word in word-color test, FDST: Forward digit span test, BDST: Backward digit span test, FVST: Forward visual span test, BVST: Backward visual span test, ViLT: Visual learning test, VeLT: Verbal learning test, TMT-A: Trail making test-type A, TOL: Tower of London test, K-MBI: Korean-Modified Barthel index, MI: Motricity index
*p<0.05, †p<0.01
The Comparison of Differences in Cognitive Activity of Daily Living and Motor Functions after Rehabilitation between Two Groups
K-MMSE: Korean version of the Mini-mental status examination, VCPT: Visual continuous performance test, ACPT: Auditory continuous performance test, WCW: Word of color word in word-color test, CCW: Color of color word in word-color test, FDST: Forward digit span test, BDST: Backward digit span test, FVST: Forward visual span test, BVST: Backward visual span test, ViLT: Visual learning test, VeLT: Verbal learning test, TMT-A: Trail making test-type A, TOL: Tower of London test, K-MBI: Korean-Modified Barthel index, MI: Motricity index
*p<0.05, †p<0.01
Table 1 Demographic Characteristics of the Subjects
VR: Virtual reality, K-MMSE: Korean version of the Minimental
status examination
Table 2 The Changes of Cognitive Activity of Daily Living and Motor Functions before and after Rehabilitation within Each Group
K-MMSE: Korean version of the Mini-mental status examination, VCPT: Visual continuous performance test, ACPT : Auditory continuous performance test, WCW: Word of color word in word-color test, CCW: Color of color word in word-color test, FDST: Forward digit span test, BDST: Backward digit span test, FVST: Forward visual span test, BVST: Backward visual span test, ViLT: Visual learning test, VeLT: Verbal learning test, TMT-A: Trail making test-type A, TOL: Tower of London test, K-MBI: Korean-Modified Barthel index, MI: Motricity index
*p<0.05, †p<0.01
Table 3 The Comparison of Differences in Cognitive Activity of Daily Living and Motor Functions after Rehabilitation between Two Groups
K-MMSE: Korean version of the Mini-mental status examination, VCPT: Visual continuous performance test, ACPT: Auditory continuous performance test, WCW: Word of color word in word-color test, CCW: Color of color word in word-color test, FDST: Forward digit span test, BDST: Backward digit span test, FVST: Forward visual span test, BVST: Backward visual span test, ViLT: Visual learning test, VeLT: Verbal learning test, TMT-A: Trail making test-type A, TOL: Tower of London test, K-MBI: Korean-Modified Barthel index, MI: Motricity index
