VR Cognitive Rehabiliation for Pediatric TBI

Study Overview
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Brief Summary
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Childhood traumatic brain injury (TBI) poses significant impairment in children's executive functions (EFs) for moderate to severe injuries, yet interventions specifically designed for children's EF rehabilitation post-TBI and rigorous clinical trials to establish the efficacy of such interventions remain unavailable. In this study, the investigators will conduct a randomized clinical trial to evaluate the efficacy of a novel virtual reality (VR)-based training program for EF rehabilitation for childhood TBI.

Detailed Description
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Traumatic brain injury (TBI) is a leading cause of acquired disability in U.S. children, with an estimated 700,000 cases every year, presenting in 75% of children with trauma and accounting for 70% of deaths from childhood trauma. Childhood TBIs often result in significant impairment in cognitive functions,1 particularly in core executive functions (EFs) due to the vulnerability of the frontal lobes, especially after a moderate to severe TBI. Core EF is composed of three skills: inhibitory control, working memory, and cognitive flexibility. These skills are associated with impaired EF behaviors, increased attention problems, and lower health-related quality-of-life (HRQOL). However, evidence-based EF rehabilitation programs are lacking. Although a combination of diverse cognitive interventions may improve children's EF, limited affordability, accessibility, adherence, and generalizability hamper clinically adapting and implementing such interventions in the rehabilitation setting. Virtual reality (VR) offers an exciting alternative strategy for EF rehabilitation of childhood TBI due to its flexibility, accessibility, and immersive experiences in three dimensions. These properties may increase adherence to training and foster an enhanced transfer of learned EF skills to untrained tasks in everyday life. Thus far, rigor-ous randomized clinical trials (RCTs) have not been conducted to establish the efficacy of VR-based EF reha-bilitation for childhood TBI. The overall goal of the project is to assess the efficacy of a novel VR-based interactive cognitive training (VICT) program for EF rehabilitation in children with TBI with the following aims: Aim 1. Examine VICT's efficacy in improving core and daily EF skills among children with TBI. Hypothesis 1.1: Children in the intervention group will show enhanced improvement over controls in trained VR-based EF tasks and untrained NIH Toolbox tasks from baseline to post-intervention and follow-up visits; Hypothesis 1.2: The intervention group will show better reported daily EF than controls at the follow-up visit; Hypothesis 1.3: Children in the intervention group will show faster improvement than controls in daily-reported EF skills between post-intervention and follow-up visits. Aim 2. Examine VICT's efficacy in reducing attentional problems among children with TBI. Hypothesis 2.1: Children in the intervention group will show a greater reduction in attentional problems as measured by testing on the Conners Continuous Performance Test 3rd Edition™ (Conners CPT 3TM) from baseline to the post-intervention and follow-up visits than controls; Hypothesis 2.2: Children in the intervention group will show fewer everyday attentional problems on the Be-havior Assessment System for Children 3rd Ed (BASC-3) self- and parent-ratings of attention at the follow-up visit than controls; Hypothesis 2.3: The direct effect of the VICT program in reducing attention problems will be mediated by children's EF behaviors as measured by the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2) at the follow-up visit. Aim 3. Examine VICT's efficacy in improving HRQOL among children with TBI. Hypothesis 3.1: The intervention group will show higher levels of reported HRQOL than controls at follow-up; Hypothesis 3.2: The direct effect of the VICT program on HRQOL at follow-up will be mediated by children's EF skills and ratings of EF behaviors and attention at the post-intervention and follow-up visits.

Official Title
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Virtual Reality-based Rehabilitation for Pediatric TBI (R00 Phase)

Conditions
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TBI (Traumatic Brain Injury)

Intervention / Treatment
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* Behavioral: Virtual Reality-based Interactive Cognitive Training Program
* Behavioral: Placebo Virtual Reality Game


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: diagnosed with TBI within the past 12 months and under 18 years at the time of injury; fluent in English; and 3) Score <28 on the Agitated Behavior Scale (if available). Exclusion Criteria: comorbidities or premorbid disorders that prevent proper administration of VR and study measures, restriction from using electronic devices, post-injury seizure activity.

Ages Eligible for Study
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Maximum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Virtual Reality games for training executive functions<br>Virtual Reality games for training three core executive functions | Behavioral: Virtual Reality-based Interactive Cognitive Training Program<br>* Three virtual reality-based games designed to train inhibitory control, working memory, and cognitive flexibility among children with TBI<br>|
| Placebo Comparator: Control VR Game on Playground<br>A relaxing virtual reality game for control group to play in VR playground without training their executive functions | Behavioral: Placebo Virtual Reality Game<br>* A virtual playground for control group to interact without training executive functions<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in Performance-based EF in VR | VR-based EF Assessment Task | Baseline (at recruitment/before intervention), Post-Intervention (after completion of intervention, up to 2 weeks), Follow-Up (up to 6 months after completion of intervention) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in Performance-based EF on Standard Lab Task | NIH Toolbox Cognition Battery | Baseline (at recruitment/before intervention), Post-Intervention (after completion of intervention, up to 2 weeks), Follow-Up (up to 6 months after completion of intervention) | 
| Report-based EF skills | Behavior Rating Inventory of Executive Function 2; T scores are used (M = 50, SD = 10, no lower/upper limit), T scores from 60 to 64 are considered mildly elevated, and T scores from 65 to 69 are considered potentially clinically elevated. T scores at or above 70 are considered clinically elevated | Follow-Up (up to 6 months after completion of intervention) | 
| Daily EF skills | Brief Daily Survey on self-reported EF skills using ecological momentary assessment | 30 days between post-intervention assessment and follow-up assessment | 
| Health-related quality of life | 23-item PedsQL Generic Core Scales (0-100 after transformation, higher scores indicate better quality of life) | Follow-Up (up to 6 months after completion of intervention) |