The purpose of this study is to evaluate the effects of a treatment using virtual reality on the recovery of unilateral spatial neglect. The investigators hypothesize that the experimental group underwent to a protocol of active exercises within the virtual environment will show an improvement in the exploratory functions of the left hemispace, investigated with specific scales and clinical tests.
Cerebral stroke is the second cause of death and the third cause of disability worldwide, and the first cause of disability in the elderly. One of the most commonly encountered neuropsychological disorders following a stroke is the unilateral spatial neglect. The estimated prevalence of unilateral spatial neglect after stroke is 30%, with a difference in prevalence between subjects with right (38%) and left (18%) lesions. unilateral spatial neglect constitutes a limit in the progression of the patient's rehabilitation, slows down functional recovery and increases stress and burden on the caregiver. In recent decades there has therefore been an appeal to the use of new technologies for the treatment of unilateral spatial neglect. Among these, virtual reality allows us to overcome some limitations of traditional interventions (reduced ecological validity) and has the advantage of using an artificial environment in the virtual space which allows the execution of tasks that simulate the activities of common life. Furthermore, virtual reality systems offer the opportunity to recreate safe, ecological and personalized 3D environments in which patients must perform specific and controlled actions to achieve a goal. Numerous studies have investigated the effectiveness of training with virtual reality showing that it can improve spatial attention in subjects with unilateral spatial neglect and promote the integration of this ability into daily life activities. To date, the studies available in the literature show that through virtual reality treatment it is possible to find significant improvements in the deficit of unilateral spatial neglect. Specifically, patients undergoing virtual reality training showed an increase in visual perception of the left hemispace and in head movements on the affected side following virtual reality training compared to controls, maintaining the results at the 3-month follow-up. Although encouraging, the data available to date are the result of clinical studies characterized by high heterogeneity, medium methodological value and small sample size. Further investigations are needed to generalize the results. Within virtual environments, performance is measured objectively and the level of difficulty can be adjusted to gradually increase the complexity of the tasks by reducing the support and feedback provided by the therapist. Furthermore, through the immersive virtual reality it is possible to record all the data regarding the actions carried out by the patient within the virtual scenario and this can be used to create performance indices with which to measure, in a quantitative and objective manner, the progress during the rehabilitation process.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
DOUBLE
Enrollment
40
Patients wear a head-mounted-display and will be immersed in a virtual environment. The stimuli will be provided in the left, center and right visual fields. Eye-tracking biofeedback will be provided about the real-time performance during each exercise.
The patients performed the same protocol of the experimental group, differently to the immersive virtual reality group, from session 2 to session 8 (7 sessions), the stimuli will be provided in the center and right visual fields.
IRCCS Santa Lucia Foundation
Rome, Lazio, Italy
RECRUITINGChanges in the Behavioural Inattention Test
The Behavioural Inattention Test (BIT) allows for the assessment of the presence and extent of unilateral spatial neglect through a series of tests comprising "conventional" subtests (paper and pencil tasks) and "behavioural" subtests that reflect aspects of neglect interference during the performance of daily activities. The results of the BIT provide a detailed overview of the presentation of patients with neglect across a wide range of visuo-spatial tasks. The total score resulting from performance on the conventional subtests is considered pathological if it is below the threshold value of 129 (129/146), with lower scores indicating an increased level of impairment.
Time frame: Baseline, 4 weeks from baseline, 8 weeks from baseline
Changes in the Copying drawings with or without programming elements
The drawing copy test with or without programming elements is used to assess constructive praxis. It comprises three items that the subject must copy freehand or with the assistance of some graphic elements of the model already present on the sheet on which they are copying. The scoring is differentiated: for freehand copying, the range is 0-12, while for copying with programming elements, the range is 0-70. In both cases, lower scores indicate an increased impairment of the function.
Time frame: Baseline, 4 weeks from baseline, 8 weeks from baseline
Changes in the Barrage Test
Albert's Test is employed to detect the presence of unilateral spatial neglect in stroke patients. In this test, patients are required to cross out all the lines arranged in random orientations on a sheet of paper (A3 format). The score is determined by the number of segments correctly crossed out, for both the right (10 stimuli) and left (11 stimuli) sides. A difference of 1 omission between the right and left sides is considered pathological.
Time frame: Baseline, 4 weeks from baseline, 8 weeks from baseline
Changes in the Wundt Justrow area illusion test
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The Wundt-Jastrow Illusion Test is utilized to assess the presence of unilateral spatial neglect. It employs the Wundt-Jastrow illusion: two sectors of a circle, equal in shape and size, are perceived as different if they are juxtaposed in a way that one of them appears longer. This phenomenon is consistent for all normal subjects but may disappear in the case of neglect. The subject is presented with 40 boards (A3 format), each containing two stimuli, varied in dimensions, convexity orientation (upward or downward), and the position (right or left) of the misaligned margins that induce the illusion. A score is obtained for "expected" responses and one for "unexpected" responses, depending on whether the critical part of the stimulus is on the right or left. A difference greater than 2 between the number of unexpected responses on the right and left indicates neglect.
Time frame: Baseline, 4 weeks from baseline, 8 weeks from baseline
Changes in the Kessler Foundation Neglect Assessment Process
The Kessler Foundation Neglect Assessment Process (KF-NAP™) is used to assess symptoms of spatial neglect in activities of daily living and to assist predicting functional outcomes after a brain damage, such as stroke or traumatic brain injury, in the context of comprehensive clinical evaluation. In addition to the clinical purpose, the KF-NAP™ can be used as an outcome measure in research studies. Behaviours observed in the KF-NAP™ are related to spatial locations in the personal space , the peri-personal space , the extra-personal space, and the mental space. Total scores range from 0 - 30 with higher scores indicating increased disability.
Time frame: Baseline, 4 weeks from baseline, 8 weeks from baseline
Changes in the Stroke Specific Quality of Life Scale
The Stroke Specific Quality of Life Scale (SSQoL) is a patient-centered outcome measure intended to provide an assessment of health-related quality of life specific to patients with stroke. Total scores range from 49-245 with higher scores indicate better functioning
Time frame: Baseline, 4 weeks from baseline, 8 weeks from baseline
Changes in the Fugl-Meyer Assessment scale
The Fugl-Meyer Assessment (FMA) is a stroke-specific, performance-based impairment scale. It is designed to assess motor functioning, sensation, balance, joint range of motion and joint pain in patients with post-stroke hemiplegia. Motor score: ranges from 0 (hemiplegia) to 100 points (normal motor performance). Divided into 66 points for upper extremity and 34 points for the lower extremity. Sensation: ranges from 0 to 24 points. Divided into 8 points for light touch and 16 points for position sense. Balance: ranges from 0 to 14 points. Divided into 6 points for sitting and 8 points for standing. Joint range of motion: ranges from 0 to 44 points. Joint pain: ranges from 0 to 44 points. It determine disease severity, describe motor recovery, and to plan and assess treatment. a score range between 96-99 indicates slight motor discoordination; a score between 85 and 95 indicates hemiparesis; and a score ≤ 84 indicates hemiplegia.
Time frame: Baseline, 4 weeks from baseline, 8 weeks from baseline
Changes in reaction time e time of fixation
The fixation time expressed in percentage and reaction time expressed in millisecond will be recorded via eye-tracking.
Time frame: Baseline, 4 weeks from baseline, 8 weeks from baseline