Cognitive Training With Head-Mounted Display Virtual Reality in Neurorehabilitation: Pilot Randomized Controlled Trial
Authors: Specht Julian , Stegmann Barbara , Gross Hanna , Krakow Karsten 
Published: June 2023

Background
Neurological rehabilitation is technologically evolving rapidly, resulting in new treatments for patients. Stroke, one of the most prevalent conditions in neurorehabilitation, has been a particular focus in recent years. However, patients often need help with physical and cognitive constraints, whereby the cognitive domain in neurorehabilitation does not technologically exploit existing potential. Usually, cognitive rehabilitation is performed with pen and paper or on a computer, which leads to limitations in preparation for activities of daily living. Technologies such as virtual reality (VR) can bridge this gap.

Objective
This pilot study investigated the use of immersive VR in cognitive rehabilitation for patients undergoing inpatient neurorehabilitation. The goal was to determine the difference in rehabilitation effectiveness between a VR serious game that combines everyday activities with cognitive paradigms and conventional computerized cognitive training. We hypothesized the superiority of the VR serious game regarding cognitive abilities and patient-reported outcomes as well as transfer to daily life.

Methods
We recruited 42 patients with acute brain affection from a German neurorehabilitation clinic in inpatient care with a Mini Mental Status Test score >20 to participate in this randomized controlled trial. Participants were randomly assigned to 2 groups, with 1 receiving the experimental VR treatment (n=21). VR training consisted of daily life scenarios, for example, in a kitchen, focusing on treating executive functions such as planning and problem-solving. The control group (n=21) received conventional computerized cognitive training. Each participant received a minimum of 18 treatment sessions in their respective group. Patients were tested for cognitive status, subjective health, and quality of life before and after the intervention (Alters-Konzentrations-Test, Wechsler Memory Scale—Revised, Trail Making Test A and B, Tower of London—German version, Short Form 36, European Quality of Life 5 Dimensions visual analog scale, and Fragebogen zur Erfassung der Performance in VR).

Results
Repeated-measures ANOVA revealed several significant main effects in the cognitive tests: Tower of London—German version (P=.046), Trail Making Test A (P=.01), and Wechsler Memory Scale—Revised (P=.006). However, post hoc tests revealed that the VR group showed significant improvement in the planning, executive control, and problem-solving domains (P=.046, Bonferroni P=.02). In contrast, no significant improvement in the control group between t0 and t1 was detected (all P>.05). Furthermore, a nonsignificant trend was observed in visual speed in the VR group (P=.09, Bonferroni P=.02).

Conclusions
The results of this pilot randomized controlled trial showed that immersive VR training in cognitive rehabilitation had greater effectiveness than the standard of care in treating patients experiencing stroke in some cognitive domains . These findings support the further use and study of VR training incorporating activities of daily living in other neurological disorders involving cognitive dysfunction.

Trial Registration
Federal Registry of Clinical Trials of Germany (DRKS) DRKS00023605; https://drks.de/search/de/trial/DRKS00023605