Application of Immersive Virtual-Reality-Based Puzzle Games in Elderly Patients with Post-Stroke Cognitive Impairment: A Pilot Study

Abstract

Background: The society is aging in China, and the cognitive level of elderly post-stroke patients gradually declines. Face-to-face cognitive functional training is no longer sufficient. Immersive virtual reality (IVR) is a promising rehabilitation training device. In this study, we developed an IVR-based puzzle game to explore its effectiveness, feasibility, and safety in elderly stroke patients with cognitive dysfunction. Methods: A total of 30 patients with mild post-stroke cognitive impairment after stroke were randomly assigned to a control or IVR group. Patients in both groups received routine rehabilitation therapy. Patients in the control group received traditional cognitive training, and those in the IVR group received IVR-based puzzle game therapy. Before and after treatment, Montreal cognitive assessment (MOCA), trail-making test-A (TMT-A), digit symbol substitution test (DSST), digital span test (DST), verbal fluency test (VFT), and modified Barthel index (MBI) were evaluated in both groups. In addition, the IVR group was administered a self-report questionnaire to obtain feedback on user experience. Results: There was no significant difference in the baseline data between the two groups. After six weeks of treatment, the cognitive assessment scores were improved in both groups. Moreover, the IVR group showed more improvements than the control group in the DSST (Z = 2.203, p = 0.028 < 0.05, η2 = 0.16); MOCA (T = 1.186, p = 0.246 > 0.05, d = 0.44), TMT-A (T = 1.791, p = 0.084 > 0.05, d = 0.65), MBI (T = 0.783, p = 0.44 > 0.05, d = 0.28), FDST (Z = 0.78, p = 0.435 > 0.05, η2 = 0.02), BDST (Z = 0.347, p = 0.728 > 0.05, η2 = 0.004), and VFT(Z = 1.087, p = 0.277 > 0.05, η2 = 0.039) did not significantly improve. The significant difference in DSST represents an improvement in executive function and visual–spatial cognitive characteristics. The other assessment scores did not show such features. Therefore, we did not observe significant differences through this measure. According to the results of the self-report questionnaire, most of the patients were satisfied with the equipment stability and training content. Several individuals reported mild adverse reactions. Conclusions: This pilot study suggests that IVR-based puzzle games are a promising approach to improve post-stroke cognitive function, especially executive cognitive function, and visual–spatial attention in older adults.

Effects of virtual reality‐based cognitive interventions on cognitive function and activity of daily living among stroke patients: Systematic review and meta‐analysis

“…Subject recruitment was conducted from hospitals, community centres and outpatient clinics. Thirteen studies (Ballester et al., 2017; Faria et al., 2016, 2018, 2020; Johnson et al., 2020; Kannan et al., 2019; Kim et al., 2020; Lee et al., 2017; Liu et al., 2022; Maier et al., 2020; Manuli et al., 2020; Navarro et al., 2020; Park & Lee, 2019) recruited individuals with chronic stroke (≥6 months), seven studies (Dąbrowská et al., 2023; De Luca et al., 2018; Lee et al., 2020; Oh et al., 2019; Rogers et al., 2019; Shi et al., 2023; Şimşek & Çekok, 2016) focused on subacute stroke (2 weeks to 6 months), four studies (Baltaduonienė et al., 2019; Kim et al., 2011; Lin et al., 2020; Wilson et al., 2021) with acute stroke (within 2 weeks) and one study (Gamito et al., 2017) did not provide information for stroke stage. The included studies recruited participants with varying levels of cognitive function.…”

“…The majority of studies adopted active control, including conventional paper‐and‐pencil cognitive training ( n = 6) (Faria et al., 2016, 2018, 2020; Maier et al., 2020; Manuli et al., 2020; Oh et al., 2019), occupational/physiotherapy motor training ( n = 11) (Ballester et al., 2017; Dąbrowská et al., 2023; De Luca et al., 2018; Kannan et al., 2019; Kim et al., 2020; Lee et al., 2017; Lin et al., 2020; Park & Lee, 2019; Rogers et al., 2019; Şimşek & Çekok, 2016; Wilson et al., 2021); a combination of conventional computerized and pencil‐and‐paper cognitive training ( n = 1) (Baltaduonienė et al., 2019), individual‐format intervention ( n = 1) (Navarro et al., 2020), recreational activities (i.e. playing video games [ n = 1]) (Lee et al., 2020), computer‐assisted cognitive rehabilitation ( n = 3) (Kim et al., 2011; Liu et al., 2022; Shi et al., 2023), except the study of Johnson et al. (2020) adopted treatment as usual care, and Gamito et al.…”

“…The included studies recruited participants with varying levels of cognitive function. Eleven studies recruited participants without dementia, requiring a Mini‐Mental State Assessment (MMSE) score above 19 to 25 (Ballester et al., 2017; Dąbrowská et al., 2023; Kannan et al., 2019; Lee et al., 2019; Navarro et al., 2020; Oh et al., 2019; Park & Yoon, 2015; Shi et al., 2023; Şimşek & Çekok, 2016), and a Montreal Cognitive Assessment score (MoCA) above 24 (Johnson et al., 2020; Liu et al., 2022). Eight studies recruited participants with or without dementia, based on MMSE score ranging from 10 to 16 (Baltaduonienė et al., 2019; De Luca et al., 2018; Faria et al., 2016, 2018; Kim et al., 2011; Maier et al., 2020; Manuli et al., 2020), or a MoCA score above 16 (Lee et al., 2017).…”

“…No. (Johnson et al, 2020;Liu et al, 2022). Eight studies recruited participants with or without dementia, based on MMSE score ranging from 10 to 16 (Baltaduonienė et al, 2019;De Luca et al, 2018;Faria et al, 2016Faria et al, , 2018Kim et al, 2011;Maier et al, 2020;Manuli et al, 2020), or a MoCA score above 16 (Lee et al, 2017).…”

“…(SMD = 0.94; 95% CI [0.17, 1.71], p = .02; I 2 = 85%), individualized design (SMD = 1.72, 95% CI [0.82, 2.62], p < .01; I 2 = 66%) and virtual system custom-made for cognitive improvement (SMD = 0.87, 95% CI [0.17, 1.58], p = .02; I 2 = 83%). For intervention dosage, adopting more than 20 sessions (SMD = 0.95, 95% CI [0.18, 1.71], p = .01; I 2 = 66%), <45 min (SMD = 1.04; 95% CI [0.02, 2.07], p = .05; ducted for three studies;Faria et al (2018) andGamito et al (2017) demonstrated significant effects, yet not forLiu et al (2022).…”