The Use of Virtual Reality with

Unilateral Spatial Neglect

Presented By: Angela Hall, MOTSMarch 24, 2012

Objectives Background Information on CVA, Unilateral Spatial

Neglect, and Virtual Reality

Objective of the Systematic Review

Search Strategies

Summary of Study Procedures

Methodology

Results

Implications for OT practice and future research

Background

Cerebrovascular Accident

Hemorrhagic

photo: www.nhlbi.nih.gov

Cerebrovascular Accident

Ischemicphoto: www.nhlbi.nih.gov

CVA Complications Hemiplegia Impaired

Judgment Impaired Spatial

Relations Unilateral Spatial

Neglect Aphasia

Apraxia Impulsivity Impaired Balance &

Coordination Poor Attention Span Weakness

National Stroke Association

Unilateral Spatial Neglect

Weiss, Naveh, & Katz, 2003

USN and Function Impaired ability to perform self-care activities

Poor mobility

Difficulty feeding oneself

Impaired reading comprehension

Impaired safety

Buxbaum et al, 2008; Weiss et al, 2003

Current Assessment Behavioral Inattention Test Line bisection Cancellation Drawing Reading/Writing

Buxbaum et al, 2008; Pierce & Buxbaum, 2002

Current Treatment

Buxbaum et al, 2008; Pierce & Buxbaum, 2002

photos: kesslerfoundation.org, Harding & Riddoch, 2008

Virtual Reality

Weiss et al, 2003

nmr.mgh.harvard.edu

Benefits of VR Experience real-life situations in safe environment

Simple to change environment & grade activity

Provides immediate feedback

Repeated learning trials

Produces computer generated output

May provide information on head and eye movements

Weiss et al, 2003

ObjectiveThe objective of this review is to examine the extent to which the

research literature supports the use of virtual reality as an effective assessment tool and treatment

technique for patients experiencing USN following a CVA

Search Terms stroke

cerebrovascular accident

visual neglect

unilateral spatial neglect

virtual reality

virtual technologies

left visual neglect

unilateral neglect

hemineglect

Summary of Study Procedures

Study Sizes Groups

Eight studies included a patient group with 2-12 participants and a control group with 3-21 participants

Two studies used only one group Four participants

Eight participants

Participants Gender

Four studies included more men One study included more women Three studies included equal amounts of men and

women Two studies did not specify participant gender

Participants Patient Groups

Eight of ten studies included participants ranging in age from 34-77

Eight of ten studies included participants with a right hemispheric lesion

Eight of ten studies required participants to exhibit clinical visual neglect

All ten studies required participants to understand directions and have functional use of at least one limb

Exclusion criteria: Substance abuse and prior history of neurological or visual impairment

Participants Control Groups

Included participants ranging from 34-77 Seven studies used groups of neurologically healthy

individuals One study used patients with right hemispheric

lesions Exclusion criteria: Substance abuse and prior history

of neurological or visual impairment

Interventions & Outcomes

VR as an AssessmentStudy One

The star cancellation portion of the Behavioral Inattention Test (BIT) and baking tray test

Cancellation test in the VR environment Study Two

Completed the line and star cancellation subtests of the BIT

Same tests using two lenses on a head-mounted display Study Three

BIT 3D neglect test consisting of a city environment

Broeren et al., 2007; Tanaka et al., 2005; Jannink et al., 2009;

VR as an Assessment (2)

Study Four Used a “VREye” system to differentiate between eye

tracking patterns of the control and patient groups by asking participants to identify 10 objects and the time on a clock

Study Five Participants navigated wheelchair along a virtual

path with a variety of conditions Moss-Magee Wheelchair Navigation test, several

subtests of the BIT, and the Bell test

Gupta et al., 2000; Buxbaum et al., 2008

VR as an InterventionStudy One

Practiced street crossing in a virtual environment twelve times over a 4-week period. Frequency, order and direction of subjects’ search Number of trials and length of time it took to complete each level Highest level successfully completed at the end of training. Ability to cross a real street safely

Study Two Patients trained on virtual street crossing,

Deviation angle Reaction time Visual and auditory cues required Failure rate of missions.

Weiss et al., 2003; Kim et al., 2007

VR as an Intervention (2)

Study Three Compared group receiving VR street crossing to a group

receiving visual scanning training. Outcome measures: Star cancellation from the BIT,

Mesulam Symbol Cancellation test, ADL checklist, virtual reality street crossing test, and a real street crossing test.

Study Four Participants received six weeks of VR training consisting of

“Birds and Balls” and “Soccer” games. Outcomes measured by comparing pre-post test scores on

the Bell’s test and BIT.

Katz et al, 2005; Smith; 2007; Ansuini et al, 2006)

VR as an Intervention (3)

Study Five Participants reached for real objects located at 1 of

the 3 locations while viewing the real-time virtual representation of their hand.

Outcome results were measured based on the percentages of trials in which the object was successfully detected.

Common Limitations Lack of randomization No blinding of test administrator Short duration of treatment None of the patient groups had more than 12

subjects Only one study had significant number of participants

(n=50; Kim et al., 2007) Unequal groups Failure to mention psychometric properties of

assessments Failure to use all subsections of a test

Results

Assessment Results Study One (Broeren et al., 2007)

Showed that VR testing yielded more sensitive results 6 of 8 patients demonstrated a difference in search patterns Patients had more hand deviation when moving from

targets

Study Two (Tanaka et al., 2005) Significant difference between conventional neglect

assessments and virtual reality assessments on the left side (p<0.05).

Assessment Results (2)

Study Three (Buxbaum et al., 2008) Patients scored below the control group in four conditions. Significant differences within the patient group with

complexity of object array (p<0.01) and side of object presentation (p<0.05)

Study Four (Jannink et al., 2009) Significant differences exist between groups in total time

spent at the test (p=0.049) and mean response time in left field of view (p=0.037).

No significant differences were found at level 3.

Assessment Results (3)

Study Five (Gupta et al., 2000) Control patients were able to identify and count all

objects and view the entire display. Patient with left neglect identified only 3 of 10

objects and reported the wrong time. Patient with right neglect was only able to identify

one of the objects and reported an incorrect time.

Intervention Results Study One (Kim et al, 2007)

Significant differences (p<0.05) found in deviation angle, reaction time, visual cues, auditory cues, and failure rate of mission.

Study Two (Weiss et al, 2003) Patient group took longer to complete street crossing

levels and had more total accidents. Control group had more accidents in level 3, but the

patient group had more accidents in level 5.

Intervention Results (2)

Study Three (Katz et al, 2005) Improvements (p<0.05) for the group receiving VR

training and the group receiving computerized scanning on and ADL checklist.

The VR group made significant improvements in looking left (p<0.05) and number of accidents (p<0.035) in virtual street crossing.

No significant difference in real street crossing

Intervention Results (3)

Study Four (Smith, 2007) Found no significant differences in the scores of these

patients after 6 weeks of intervention. Qualitative remarks suggest that the clients found the

interventions helpful.

Study Five (Ansuini et al., 2006) Patients with a fronto-parietal lesion demonstrated

significant improvements in response to left targets (p<0.01) and on the sensory task (p< 0.01) while patients with a temporo-parietal lesion did not show improvements.

Discussion Virtual reality may be an effective assessment

tool that can provide more information and more sensitive results compared to conventional neglect assessments.

Studies have compromised validity

Results showed differences in search patterns in two studies, but the authors did not address whether this may be due to visual scanning deficits (Broeren et al., 2007; Gupta et al., 2000).

Discussion (2) Many of the studies showed statistical differences

between the patient groups and control groups Expected result because control groups were primarily

composed of healthy individuals.

Two studies presented evidence suggesting that VR may be more sensitive at detecting mild neglect (Broeren et al., 2007; Jannink et al., 2009). Some patients who were considered “clinically recovered” by

conventional assessments demonstrated at least mild neglect on VR assessments especially with complex environments

Discussion (3) In one study, patients improved performance in the

VR environment, but this did not translate to a real-life setting. May indicate that VR training has limited carry over for

functional improvements.

The vast array of VR technology utilized limits generalizability.

Evidence demonstrates the emerging potential for virtual reality in the assessment and treatment of visual neglect following a CVA.

Conclusions

Implications for OT Practice

VR can help patients and families become more aware of the deficits and safety challenges

May help improve space deficits and maximize compensation of the contralateral visual side to help patients maximize performance in ADLs.

Offers OTs the opportunity to provide the patient with real-time performance feedback and detailed recordings of kinematics of the hand allowing for more in-depth tracking of the progress

Implications for OT Practice (2)

Potential to detect and measure USN in sub-acute and chronic stages of stroke recovery.

Help clients become aware of what they are missing in the real-world and develop strategies to compensate for the neglect.

VR test was also sensitive to mild neglect that is often difficult to detect with conventional neglect assessments.

Implications for Future Research

Improved studies using larger sample sizes, different virtual environments, and patients with various motor and cognitive impairments to generalize specific training skills.

Focus on increasing the array of complexity of objects presented to the clients.

Test the effect of dynamic objects versus static objects on subjects’ eye movements and to determine if this technique can be used to train subjects to visualize information on the neglected side.

Questions?

ReferencesAnsuini, C., Pierno, A., Lusher, D., & Castiello, U. (2006). Virtual reality applications for the remapping of space in neglect patients. Restorative Neurology and Neuroscience, 24, 431—441.

Broeren, J. J., Samuelsson, H. H., Stibrant-Sunnerhagen, K. K., Blomstrand, C. C., & Rydmark, M. M. (2007). Neglect assessment as an application of virtual reality. Acta Neurologica Scandinavica, 116(3), 157-163.

Buxbaum, L., Ferraro, M., Veramonti, T., Farne, A., Whyte, J., Ladavas, E., Frassinetti, F., Coslett, H. (2004). Hemispatial neglect: Subtypes, neuroanatomy, and disability. Neurology, 62(5), 749-756.

Buxbaum, L. J., Palermo, M., Mastrogiovanni, D., Read, M., Rosenberg-Pitonyak, E., Rizzo, A. A., & Coslett, H. (2008). Assessment of spatial attention and neglect with a virtual wheelchair navigation task. Journal of Clinical & Experimental Neuropsychology, 30(6), 650-660. Centers for Disease Control and Prevention. (2011). Stroke. Retrieved from http://www.cdc.gov/stroke/

ReferencesGupta, V., Knott, B. A., Kodgi, S., & Lathan, C. E. (2000). Using the "vreye" system for the assessment of unilateral visual neglect: Two case reports. Presence: Teleoperators & Virtual Environments, 9(3), 268-286.

Jannink, M., Aznar, M., de Kort, A., van de Vis, W., Veltink, P., van der Kooij, H. (2009) Assessment of visuospatial neglect in stroke patients using virtual reality: a pilot study. International Journal of Rehabilitation Research, 32(4), 280-286.

Katz, N. N., Ring, H. H., Naveh, Y. Y., Kizony, R. R., Feintuch, U. U., & Weiss, P. L. (2005). Interactive virtual environment training for safe street crossing of right hemisphere stroke patients with unilateral spatial neglect. Disability & Rehabilitation, 27(20), 1235-1244. doi:10.1080/09638280500076079

Kim, J., Kim, K., Kim, D.Y., Chang, W.H., Park, C., Ohn, S.H., Han, K., Ku, J., Nam, S.W., Kim, I.Y., Kim, S.I. (2007). Virtual environment training system for rehabilitation of stroke patients with unilateral neglect: Crossing the virtual street. CyberPsychology & Behavior, 10(1), 7-15. doi:10.1089/cpb.2006.9998

Smith, J., Hervert, D., Reid, D. (2007). Exploring the effects of virtual reality on unilateral neglect caused by a stroke: Four case studies. Technology and Disability 19, 29-40

National Stroke Association. (2011). Stroke survivors: Effects of stroke. Retrieved from http://www.stroke.org/site/PageServer?pagename=EFFECT.

ReferencesPierce, S., & Buxbaum, L. (2002). Treatments of unilateral neglect: A review. Archives of Physical Medicine and Rehabilitation, 83(2), 256-268.

Tanaka, T., Sugihara, S., Nara, N., Ino, S., Ifukube, T. (2005). A preliminary study of clinical assessment of left unilateral spatial neglect using a head mounted display system (hmd) in rehabilitation engineering technology. Journal of NeuroEndgineering and Rehabilitation, 2(1), 31-40.

Taylor, D. (2003) Measuring mild visual neglect: Do complex visual tests activate rightward attentional bias? New Zealand Journal of Physiotherapy, 31(2), 67-72.

Weiss, P. L., Naveh, Y., & Katz, N. (2003). Design and testing of a virtual environment to train stroke patients with unilateral spatial neglect to cross a street safely. Occupational Therapy International, 10(1), 39.