Multimodal immersive trail making-virtual reality paradigm to study cognitive-motor interactions

Abstract

Background Neuropsychological tests of executive function have limited real-world predictive and functional relevance. An emerging solution for this limitation is to adapt the tests for implementation in virtual reality (VR). We thus developed two VR-based versions of the classic Color-Trails Test (CTT), a well-validated pencil-and-paper executive function test assessing sustained (Trails A) and divided (Trails B) attention—one for a large-scale VR system (DOME-CTT) and the other for a portable head-mount display VR system (HMD-CTT). We then evaluated construct validity, test–retest reliability, and age-related discriminant validity of the VR-based versions and explored effects on motor function. Methods Healthy adults (n = 147) in three age groups (young: n = 50; middle-aged: n = 80; older: n = 17) participated. All participants were administered the original CTT, some completing the DOME-CTT (14 young, 29 middle-aged) and the rest completing the HMD-CTT. Primary outcomes were Trails A and B completion times (tA, tB). Spatiotemporal characteristics of upper-limb reaching movements during VR test performance were reconstructed from motion capture data. Statistics included correlations and repeated measures analysis of variance. Results Construct validity was substantiated by moderate correlations between the’gold standard’ pencil-and-paper CTT and the VR adaptations (DOME-CTT: tA 0.58, tB 0.71; HMD-CTT: tA 0.62, tB 0.69). VR versions showed relatively high test–retest reliability (intraclass correlation; VR: tA 0.60–0.75, tB 0.59–0.89; original: tA 0.75–0.85, tB 0.77–0.80) and discriminant validity (area under the curve; VR: tA 0.70–0.92, tB 0.71–0.92; original: tA 0.73–0.95, tB 0.77–0.95). VR completion times were longer than for the original pencil-and-paper test; completion times were longer with advanced age. Compared with Trails A, Trails B target-to-target VR hand trajectories were characterized by delayed, more erratic acceleration and deceleration, consistent with the greater executive function demands of divided vs. sustained attention; acceleration onset later for older participants. Conclusions The present study demonstrates the feasibility and validity of converting a neuropsychological test from two-dimensional pencil-and-paper to three-dimensional VR-based format while preserving core neuropsychological task features. Findings on the spatiotemporal morphology of motor planning/execution during the cognitive tasks may lead to multimodal analysis methods that enrich the ecological validity of VR-based neuropsychological testing, representing a novel paradigm for studying cognitive-motor interactions.

Available Virtual Reality-Based Tools for Executive Functions: A Systematic Review

“…In this framework, the crucial role of these variables clearly appears; future studies will necessarily have to investigate these aspects involving both healthy subjects and several clinical populations. As regards the last critical components, to date, only one work has focused on test-retest reliability (Plotnik et al, 2021 ), showing interesting results. The concept of test-retest reliability assumes a critical role in the clinical setting in which clinicians must longitudinally monitor the patients, for example, during a rehabilitative path.…”

“…Recently Plotnik et al developed other two VR-based versions of the Color-Trails Test (CTT): one for a large-scale VR system (DOMECTT) and one for a portable HDM VR system (HMD-CTT) (Plotnik et al, 2021 ), exploring the effects on motor and cognitive function on 147 healthy adults. Results indicate average correlations among the pencil-and-paper CTT and the VR adaptations of the task.…”

“…Moreover, VR versions demonstrated significantly high test-retest reliability and discriminant validity. In conclusion, the study of Plotnik et al shows the feasibility and validity of converting a neuropsychological test from pencil-and-paper to a three-dimensional VR-based format for studying cognitive-motor interactions enhancing the ecological validity of the neuropsychological assessment (Plotnik et al, 2021 ). Further studies will have to be conducted to evaluate VR-based tools' efficacy in discriminating between healthy and clinical populations.…”

Development and validation of virtual reality-based Rey Auditory Verbal Learning Test

“…Translations and adaptations of traditional neuropsychological tests to virtual reality (VR) technology bear the potential to increase their ecological validity since the technology enables simulating everyday life conditions in a controlled manner ( Parsons et al, 2017 ; Gal et al, 2019 ; Plotnik et al, 2021 ). However, to date, attempts to translate neuropsychological tests to VR are still rare ( Elkind et al, 2001 ; Pollak et al, 2009 ; Armstrong et al, 2013 ; Parsons et al, 2013 ).…”

Investigating Potential Negative Age-bias in a Virtual Reality Cognitive Assessment Tool for General Aviation Pilots

“…Because virtual environments allow for controlled presentations of stimuli and also provide a realistic experience to its users, cognitive assessments using VR technology are likely to give more accurate outputs compared to traditional methods of cognitive assessment (Diemer et al, 2015;Gorini et al, 2011). Virtual reality also allows for the collection of three-dimensional kinematic data which is not available in the traditional neuropsychological tests (Plotnik et al, 2021).…”