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Technology and Health Care -1 (2015) 1–13 DOI 10.3233/THC-151039 IOS Press
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Assessing unilateral spatial neglect using advanced technologies: The potentiality of mobile virtual reality
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Federica Pallavicinia,∗, Elisa Pedrolia , Silvia Serinoa , Andrea Dell’Isolab , Pietro Cipressoa , Carlo Cisarib and Giuseppe Rivaa,c
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Technology for Neuro-Psychology Laboratory, IRCCS Istituto Auxologico Italiano, Milan,
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Italy b Physical and Rehabilitative Medicine, Department of Health Sciences, Università del Piemonte Orientale “A. Avogadro”, Novara, Italy c Department of Psychology, Catholic University of Milan, Milan, Italy Received 8 July 2015 Accepted 4 August 2015
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Abstract. BACKGROUND: Unilateral Spatial Neglect, or neglect, is a common behavioral syndrome in patients following unilateral brain damage, such as stroke. In recent years, new technologies, such as computer-based tools and virtual reality have been used in order to solve some limitations of the traditional neglect evaluation. Within this perspective, also mobile devices such as tablets seems to be promising tools, being able to support interactive virtual environments and, at the same time, allowing to easily reproduce traditional paper-and-pencil test. OBJECTIVE: In this context, the aim of our study was to investigate the potentiality of a new mobile application (Neglect App) designed and developed for tablet (iPad) for screening neglect symptoms. METHODS: To address this objective, we divided a sample of 16 right-damaged patients according to the presence or absence of neglect and we administered assessment test in their traditional and Neglect App version. RESULTS: Results showed that the cancellation tests developed within Neglect App were equally effective to traditional paperand-pencil tests (Line cancellation test and Star Cancellation test) in detecting neglect symptoms. Secondly, according to our results, the Neglect App Card Dealing task was more sensitive in detecting neglect symptoms than traditional functional task. CONCLUSIONS: Globally, results gives preliminary evidences supporting the feasibility of Neglect App for the screening of USN symptoms.
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Keywords: Neglect, neuropsychological assessment, tablet, virtual reality
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1. Introduction
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Unilateral Spatial Neglect (USN), or neglect, is a common behavioral syndrome in patients following unilateral brain damage, such as stroke. The reported incidence of USN can be identified in approxi-
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∗ Corresponding author: Federica Pallavicini, Applied Technology for Neuro-Psychology Laboratory (IRCCS Istituto Auxologico Italiano), Via Magnasco, 2, 20149 Milano, Italy. E-mail:
[email protected].
0928-7329/15/$35.00 © 2015 – IOS Press and the authors. All rights reserved
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mately 40–50% of the post-stroke patients [1,2]. This disorder is generally characterized by a difficulty or inability to pay attention, to detect, and to orient toward objects located in the hemi-space contralateral to the lesion of one of the cerebral hemispheres, even in the absence of sensory or motor deficit [3,4]. In particular, neglect symptoms are more both common and severe after damages in the right hemisphere, which consequently affect patients’ behaviors in the left part of the space [5,6]. USN is a complex syndrome, difficult to assess and treat, characterized by heterogeneous symptoms [7–9]. Traditionally, USN is evaluated with paper-and-pencil cancellation tests, where patients are asked to detect specific targets displayed in a sheet: distracters may be inserted to increase the difficulty of the task. These test include line [10], circle [11], letter [12], star [13] and symbol cancellation [14], among others. Although USN diagnosis based on traditional pencil-and-paper test is widely used by clinicians, it has been observed by a lot of studies that they are characterized by two main important limitations. First of all, previous research reported that this type of test lack of ecological validity [15,16] and inconsistencies have been reported between neglect patients’ performance in these test and important deficits occurring in their daily life activities [17–20]. As underlined by Tsirlin and colleagues [21], most of these tests don’t capture everyday problems occurring in natural environments of USN patients. However, given the complexity of patients’ daily life activities, it is extremely difficult to observe them, in term of time and resources [22]. Secondly, traditional paper-and-pencil cancellation test capture the spatial navigation deficit insufficiently, or even not at all, even if it seems to be an important characteristic in the domain of the neglect syndrome [23,24]. In the last few decades, one of the major advances in neuropsychology has been represented by the use of new technologies, during both screening and rehabilitation [25–27]. Regarding USN, numerous efforts have been made to develop new tools that will enable a more complete assessment, trying to go beyond the limits of traditional paper-and-pencil test. In particular, there has been a wide interest in transferring paper-and-pencil cancellation tests to computer-based setting, resulting in a more detailed and precise recording of performance during the assessment, as well as an enhanced consistency in testing across setting [28,29]. Studies have been reported that computer-based assessment tool could be potentially more sensitive than paper-and-pencil tests in detecting a slower processing of contralesional hemispace [20,29–34]. In even more recent years, promising new methods using Virtual Reality (VR) technologies have emerged. In the domain of USN assessment, VR is a relatively new tool [35–40]. However, this instrument, has proven effective in the assessment of neuropsychological functioning, in particular for evaluation of executive [41–43], spatial [38,44] and mental imagery processes [45,46]. Preliminary studies have explored the use of VR for the assessment of USN symptoms, proposing both interesting virtual versions of the traditional pencil-and-paper cancellation tests and virtual tasks specific to the investigation of space exploration [21]. Although the dramatic development in the field of computer-based test and VR, there are still some problems related to the use of these technologies, far from the research and clinical settings. First of all, from a technological point of view, both these tools are not so easy to be used, requiring a specific training for the clinician and the patient. Secondly, both computer-based test and VR system are tools developed to be used in the clinic, since they require a specific setting and staff able to use these type of technological devices. Finally, from a clinical perspective, these technologies are not easy to be moved at patients’ home, where an automatic assessment of USN symptoms may be useful to evaluate the severity of symptoms over time, especially when patients are provided with a rehabilitative training. Within this perspective, mobile devices such as tablets are promising tools that already meet the requirements needed to support interactive VR environments and, at the same time, allow to easily reproduce traditional paper-and-pencil cancellation test. However, still very few experimental studies have
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investigated the potential of the tablet in the assessment of USN [47–49]. So far, moreover, there have been few attempts to reproduce traditional paper-and-pencil cancellation tests on the tablet, with the aim to develop tool able to offer detailed visuo-spatial indexes in order to better understand the peculiar features of the syndrome and to develop a more customized rehabilitation [48,49]. No study, however, has tried to build a tool for the assessment of USN exploiting the peculiar characteristics of tablets, such as the possibility to play interactive virtual environments and its graphics capabilities. The growing availability, low-cost and easy-to-use of “mobile virtual reality”, that is the integration of VR environments on mobile devices, represents a meaningful opportunity for neuropsychological assessment, although unfortunately not yet adequately explored. In this context, the aim of our study was to investigate the potentiality of a new mobile application (Neglect App) designed and developed for tablet (iPad) for screening USN symptoms. Accordingly, in this study we investigated whether our newly developed mobile application could screen USN symptoms through comparison to right hemispheric stroke patients with and without neglect.
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2. Materials and methods
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2.1. Participants
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A sample of 25 patients recruited at Ospedale Maggiore di Novara (Italy) were screened for interviews and neuropsychological assessment for admission to the study. Criteria for participation were the following: (1) Right vascular lesion (which was fully evaluated by the clinical staff of the Ospedale Maggiore di Novara); (2) age between 18 and 85 years; (3) no severe cognitive impairment, as assessed with the Mini Mental State Examination (MMSE) [50] (MMSE > 24); (4) no difficulties in language comprehension; (5) no history of psychosis, alcohol or drug dependence, as assessed by a clinical interview; (6) no motor deficit that would prevent the use of the tablet; (7) normal or corrected-to-normal vision. In particular, if patients present possible factors (e.g., hemianopsia), typically following some type of lesions (e.g., occipital cortex), that may prevent the possibility to take part in this study, were excluded. None of the recruited sample presented posterior cerebral artery or lesions in the occipital cortex. On the other hand, of the initial recruited sample, three patients were excluded due to important motor deficits and six for severe cognitive impairment (MMSE < 24). Of the initial recruited sample, three patients were excluded due to important motor deficits and six for severe cognitive impairment (MMSE < 24) [50]. The final experimental sample included 16 participants with right-hemisphere damage caused by a cerebrovascular lesion, without hemianopia. Participants were 12 men (85.2%) and 4 women (14.8%). The mean age was 66.1 ± 11.9, with mean years of education of 8.56 ± 3.5. All participants were right-handed. According to the score obtained at the Line Cancellation Test [10] and the Star Cancellation Test [53], participants were divided into two groups: patients with USN (Neglect Group), and patients without the USN (Non-neglect Group). Specifically, if the patient omitted more than 1 line or 3 stars in the left side and none in the right side of sheet was included in the Neglect Group. If patients omitted lines or stars in both sides of space, the examiner calculated a value (number of item omitted in left side/total items omitted); values equal or greater than 0.75 indicate USN. Eight participants (5 males, 3 females) were assigned to the Neglect Group, and the other 8 participants (7 males, 1 female) were assigned to the Non-neglect Group. Descriptive of the sample are reported in Table 1. Before participating in the study, each participant was given written information about the study and was asked to give written consent to be included. The study received ethical approval from the Ethical Committee of the Istituto Auxologico Italiano.
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F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies Table 1 Demographic and clinical characteristics of the sample ID
Gender
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M M M M M M M M M M F M F M F F
Age (years) 53 56 74 66 68 69 68 65 77 67 74 67 73 59 74 59
Education (years) 8 13 5 13 13 8 8 13 5 8 5 5 13 8 2 7
Lesion site Temporo-frontal Fronto-parieto-temporal Semioval center Parietal Fronto-parieto-temporal Fronto-parieto-temporal Fronto-parieto-temporal Temporo-parietal Frontal Basal ganglia + white matter Frontal-parietal Temporo-parietal Temporo-parietal Frontal-parietal Frontal-parietal Insular Frontal
Onset (months) 23 26 13 18 18 13 57 21 31 5 71 15 4 4 3 3
Neglect No No Yes Yes Yes Yes No No Yes No No No Yes No Yes Yes
Stroke type Aneurysm Ischemic Aneurysm Hemorrhage Ischemic Ischemic Ischemic Hemorrhage Subarachnoid hemorrhage Ischemic Ischemic Ischemic Ischemic Ischemic Ischemic Subarachnoid hemorrhage
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2.2. Instruments
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2.2.1. The neuropsychological evaluation A neuropsychological evaluation was conducted both to ensure that patients met the aforementioned study criteria and to collect data on the patients’ cognitive profiles. In particular, the Mini Mental State Evaluation (MMSE) [50] was used to assess individuals’ general cognitive level.
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2.2.2. Traditional assessment tests The following traditional neuropsychological test were used for screening for neglect symptoms: 1. Traditional paper-and-pencil cancellation tests, which were used both to evaluate neglect symptoms and consequently to divide the sample in two divided into two groups (i.e., patients with USN – Neglect Group. and patients without the USN – Non-neglect Group) and to collect data for the comparisons with their Neglect App version. In particular, we administered the two following paper-and-pencil cancellation tests: a) Line cancellations test [10]: the patient was given a sheet of paper with three rows of six lines on the left and the same on the right, and one row of four lines in the center. Individuals are asked to cross out all the lines on the page (size of 56.39 × 37.34 cm). The number of lines selected and non-selected (omissions) targets on the left side and on the right side were recorded (for a total of 18). b) Star cancellation test within the behavioural inattention test (BIT) [13]: patient was presented with 56 small stars mixed up with many large stars and capital letters (page size of 56.39 × 37.34 cm). Individual was asked to cross out all the small stars after the examiner had demonstrated this, crossing out two centrally positioned small stars. The number of selected and omitted small stars on the left side and on the right side were recorded (for a total of 28 stars). 2. Traditional card dealing task, taken from Semi-structured Scales for the Functional Evaluation of Hemi-inattention [51,52], was used as a functional and ecological evaluation of USN symptoms, in order to collect data for the comparisons with its Neglect App version, During this task the examiners ask the patient to deal three cards for a game to himself/herself and to each one of the
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three individuals seated at the same table (the examiner in the front of, one person at the right side and another one at the left side of the patient) and four in the middle of the table. The number of cards correctly given and the number of cards not deal in the left side and in the right side of the patient were recorded (for a total of 3 cards). 2.2.3. Neglect App assessment tests Neglect App, the iPad application developed and used in this study, contains a series of test for the evaluation of the USN using interactive virtual environments. Specifically, the app includes two different categories of tasks: 1. Neglect App cancellation tests, which are designed to recreate the traditional paper-and-pencil cancellation test, played within the application in a three-dimensional version. The two cancellation tests included in Neglect App have been developed on the basis of the paper-and-pencil cancellation test described in the previous paragraph and in particular: a) Neglect App simple cancellation test, which corresponds to the Line Cancellations Test [10]. Patients have to selected 30 hammers placed in a room (15 on the left and 15, on the right side). The number of hammers selected (correct targets) and the number of item non selected (omissions) on the left side and on the right side was recorded; b) Neglect App cancellation with distractors test built on the basis of the Star Cancellation Test [53]. Patients have to select 12 screwdrivers (6 in the right and 6 in the left) placed in a room with 22 other objects (hammers, wrench and others, 11 on the right and 11 on the left). The number of selected and omitted screwdrivers on the left side and on the right side were recorded (see Fig. 1). 2. Neglect App card dealing task recreates, in a virtual environment on the tablet, the Card Dealing Task [51,52] described in the previous paragraph. As in the traditional version of the test, the patient have to give three cards for a game to himself/herself and to each one of the three individuals seated and four in the middle of the table. The number of cards correctly given and the number of cards not deal in the left side and on the right side of the patient were recorded (for a total of 3 cards). Neglect App test were carried out with the aid of a stylus for touchscreen, on an iPad2 (Model A1397 with IOS ver. 7.1, screen size active area of 47.70 × 26.82 cm. 2.2.4. Neglect App usability assessment The System Usability Scale (SUS) [54] was used to evaluate the Neglect App usability. The scale is composed of 10 statements that are scored on a 5-point scale of strength of agreement. For each item, the score may range from 0 to 4, and then the sum of score have to be multiplied for 2.5. Consequently, final scores for the SUS can range from 0 to 100, where higher scores indicate better usability.
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2.2.5. Technological skills assessment A self-assessment scale was used to evaluate patients’ technological abilities. The two-item questionnaire was created to assess individuals’ perceived technological skills in the use of personal computers and tablet. The individual is asked to rate from 0 to 100 his/her perceived technological skills both in the use of personal computers and tablet, where higher scores indicate better perceived skills.
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2.3. Procedure test
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Participants were included in the study after a preliminary clinical interview and a neuropsychological evaluation using the Mini Mental State Evaluation (MMSE) [50]. According to this preliminary evalu-
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Fig. 1. Traditional cancellation test, line cancellation test [10] and star cancellation test [13], compared with their Neglect App version, respectively Neglect App simple cancellation test and Neglect App with distractors cancellation test. (Colours are visible in the online version of the article; http://dx.doi.org/10. 3233/THC-151039)
Fig. 2. Screenshot of the Neglect App card dealing task. (Colours are visible in the online version of the article; http: //dx.doi.org/10.3233/THC-151039)
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ation and the inclusion/exclusion criteria described above, participants who were suitable for the study attended a single testing session at the Ospedale Maggiore di Novara, lasting about one hour. Upon arrival the procedure was explained to the individuals and informed consent was obtained. Then, individuals were asked to fill out the technological skills assessment questionnaire. Participants were asked randomly to complete traditional and Neglect App test, following an established randomization schema obtained from http://www.randomizer.org/. The order of tests in both conditions of assessment was also randomized for each subject. Before completing Neglect App tasks, each participant had a training period of about ten minutes in an ad hoc virtual environment within the app, in order to become familiar with both the navigation and selection tasks. Moreover, at the end of the Neglect App tests, participants were asked to fill out the SUS.
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3. Results
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Data were entered into Microsoft Excel and analyzed using SPSS for Windows, version 18.0 (Statistical Package for the Social Sciences-SPSS for Windows, Chicago, IL, USA). Since outcomes were not approximately normally distributed, non parametric statistics were used. Specifically, the Mann-Whitney Test was used to compare the two independent groups. In particular the performance of the Neglect and Non-neglect Group in the traditional and Neglect App tests were compared using non parametric analysis, in order to test whether the number of omitted targets in the traditional and Neglect App tasks changed depending on the neglect condition (Neglect vs. Non-neglect Group). An index of omission error score (one for the left side and one for the right side) has been computed [(number of omissions/number of targets) × 100] for each assessment tasks [55]. These scores were compared between the Neglect and Non-neglect Group using the Mann-Whitney Test. Nonparametric test was used also to test difference between groups in Neglect App usability score, assessed through the SUS. The level of significance was set at α = 0.05.
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Table 2 Median values and Mann-Whitney U test results in the sample divided for group (Neglect and Non-Neglect Group) for age, education, duration from onset, MMSE score and perceived skills in the use of PC and tablet Variables Age Education (years) Duration from onset (months) MMSE score Perceived skills in the use of a PC Perceived skills in the use of a tablet
Neglect Group Median 71 70.5 13 26 35 170.5
Non-neglect Group Median 66 80.5 22 260.8 35 20
U
r
p
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−0.475 −0.08 −0.407 −0.183 −0.013 −0.111
0.06 0.743 0.103 0.462 0.957 0.656
Table 3 Median values and Mann-Whitney U test results in the sample divided for Group (Neglect and Non-neglect Group) for traditional paper-and-pencil and Neglect App assessment test mean scores expressed in %) in the left side Variables Line cancellation test Neglect App simple cancellation test Star cancellation test Neglect App cancellation with distractors test Traditional card dealing task Neglect App card dealing task
Neglect Group Median 660.6 930.3 900.7 100 330.3 100
Non-neglect Group Median 0.000 60.66 70.4 0.000 0.000 0.000
U
r
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−0.496 −0.632 −0.795 −0.66 −0.116 −0.622
p 0.047* 0.01** 0.001*** 0.008** 0.755 0.02*
*P < 0.05, **P < 0.01, ***P < 0.001.
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3.1. General characteristics of Neglect and Non-neglect Group procedure test
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Results did not show any significant differences with regard to age, education, duration from onset, MMSE mean scores and perceived technological skills between the Neglect and Non-neglect Group (p > 0.05) (see Table 2).
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3.2. Comparison of Neglect and Non-neglect Group performance in traditional and Neglect App assessment test
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Two individuals were excluded from the Neglect App Card Dealing analyses due to problems in the score recording; hence, the analyses were conducted with 14 participants: 8 Neglect and 6 Non-Neglect. Non-parametric analyses showed a significant difference in the number of omissions in the left side between Neglect and Non-neglect Group in the Line Cancellation Test (U = 15; r = −0.496; p < 0.05), Neglect App Simple Cancellation Test (U = 8.5; p < 0.01; r = −0.632), Star Cancellation Test (U = 2; p < 0.001; r = −0.795;), Neglect App Cancellation with Distractors Test (U = 8; p < 0.01; r = −0.66;), and in the Neglect App Card Dealing Task (U = 12.5; p < 0.05; r = −0.622;). No difference between groups were found in the Traditional Card Dealing Task (U = 21; p > 0.05; r = −0.116) (see Table 3). Results on the number of omissions in the right side did not show any statistically significant difference between Neglect and Non-neglect Groups (p > 0.05) (see Table 4).
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3.3. Neglect App usability
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The mean SUS score of the all sample was high (80.1 ± 16.6), indicating a high usability of the
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Table 4 Median values and Mann-Whitney U test results in the sample divided for group (Neglect and Non-neglect Group) for traditional paper-and-pencil and Neglect App assessment test mean scores (expressed in %) in the right side Variables Line cancellation test Neglect App simple cancellation test Star cancellation test Neglect App cancellation with distractors test Traditional card dealing task Neglect App card dealing task
Neglect Group Median 20.77 30 330.3 25 0.000 0.000
Non-neglect Group Median 0.000 10 50.55 0.000 0.000 0.000
U
r
p
180.5 150.5 210.5 16 20 310.5
−0.43 −0.438 −0.279 −0.465 −0.307 −0.024
0.084 0.079 0.263 0.063 0.248 0.927
Fig. 3. Whitney U test results in the sample divided for group (neglect and Non-neglect) for line cancellation test star cancellation test, Neglect App simple cancellation test, and Neglect App with distractors cancellation test, in the left-space. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/THC-151039)
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Neglect App. Non-parametric analyses did not show significant difference in the SUS total score between Neglect (Median = 78.7) and Non-neglect Group (Median = 86.2) (U = 18.5; p = 0.154; r = −0.356).
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4. Discussion
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This study provides preliminary evidence supporting the feasibility of Neglect App for the screening of USN symptoms. In particular, results showed that the cancellation tests developed within Neglect App were equally effective to the traditional paper-and-pencil tests in the screening of symptoms between patients with and without neglect. Moreover, according to our results, the Neglect App Card Dealing task was more sensitive in detecting neglect symptoms than traditional functional task. Firstly, regarding cancellation tests, results showed that the percentage of omissions in the left side
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Fig. 4. Whitney U test results in the sample divided for group (neglect and Non-neglect) for traditional and Neglect App card dealing task in the left side. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/THC-151039)
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(but not in the right side) was significantly different between Neglect and Non-neglect Group both in the traditional paper-and-pencil test, (i.e., Line Cancellation Test [10] and Star Cancellation Test [13]) than in the Neglect App versions of these tests, respectively Neglect App Simple Cancellation test and Neglect App with Distractors Cancellation test. Similarly to our results, a recent previous study [49] reported differences in cancellation test between patients with and without neglect in a tablet version of these test. Our results, moreover, seems in accordance to what has been observed in a previous study [56] in which patients with neglect showed aberrant search performance in a virtual reality cancellation task. Secondly, regarding the Card Dealing task, results showed significantly differences in the percentage of omissions between Neglect and Non-neglect Group in the Neglect App version of Card Dealing task but not in the traditional one. This result could be explained thorugh different assumptions. Firstly, results obtained may be related to a specific feature of Neglect App. It is argued that there is a dissociation between a spared strategy-driven attention opposed to a loss of stimuli-related attention [57]. Apparently, in real-life, the external cues orient and guide the preserved attentional strategies, while in a virtual environments experienced on a tablet there are only standardized stimuli and this condition may aggravates USN symptoms. Secondly, our results can be interpreted according to the “pre-motor model” that suggests the presence in the brain of multiple and dissociable frames of spatial reference (personal, peri-personal and extra-personal) [58,59]. In particular the difference we observed could be related to the fact that while Neglect App version of Card Dealing task assess hemispatial neglect in the near extra-personal space, the traditional version involved a more extensive extra-personal space. Finally, it’s interesting to note that in our study, participants, even if they were characterized by low knowledge in the use of PCs and tablets and by a high mean age (about 65 years old), reported excellent user-friendliness of Neglect App, as shown by the analyses on the SUS questionnaire. Moreover, we did not observe difference in Neglect App usability between patient with and without USN. This seems important to exclude that, because of USN patients motor limitations, there are difficulties in the use of the app and its ease of learning.
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5. Conclusion
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Even if our results are interesting for their possible applications in the assessment and rehabilitation of the USN, our study have some limitations, which could affect the generalizability of the results, or that may have influenced the findings. The main one is related to the small sample included in the
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study. However, it’s important to acknowledge that patients with right hemisphere damage caused by a cerebrovascular lesion is really difficult to be recruited. For the same reason, a number of studies in this field have often included an even more limited number of subjects (e.g. [4,56,60]. Moreover, differently from the majority of other studies, we did not include a control group of healthy participants, focusing only on a clinical sample, more complex to be found but more informative. The second limit is related to the fact that, the Neglect App version adopted in the study, did not offer visuospatial data (e.g. latency, distance, search speed) about patients’ performance during the different tasks. To record also this type of data, that could be obtained creating an interface between tablet and software for the recording of visual movements (e.g. eye-tracking software), would give an important additional value to the app. Future studies will investigate deeply this aspect. Finally, future studies are needed also to increase the generalizability of the results found regarding Neglect App and the possibility to use tablets and mobile virtual reality to replace existing traditional USN test (e.g. increasing the number of participants of the study, and conducting a follow-up study repeated administration of the test). As regards to the differences between the existing applications on the app store that attempts to replicate the conventional pencil and paper test and Neglect App, the main ones could be summarized as following: – Neglect App is the only one that contains a functional task that replicate on the tablet an ecological activity (dealing cards), thanks to the adoption of interactive virtual environments. This is relevant since, despite the evidence supporting the possible use of virtual reality in neuropsychological evaluation and the increased interest in its use in cognitive training, this technology is still little explored and exploited [61]. – The tests included in Neglect App (including those of barrage) unlike other app such as iNeglect (©Yonsey Severance Hospital), neglectTest (©Why not Zoidberg UG), and Visual Attention Therapy Lite (©Tactus Therapy Solutions Ltd), are not simple reproductions of classical tests (also from the point of view of graphics and interaction). Neglect App tasks, in fact, have been developed specifically to exploit the specific characteristics of the tablet, such as the possibility to play interactive virtual environments and its graphics features. – Neglect App is available in the app store for free, unlike other app such as neglectTest (©Why not Zoidberg UG, 19.99 C) and CABPad (©Cognisoft ApS; 449.99 C). This appears relevant since cost remains an important factor that can limit access to computerized testing and new technologies in general [61]. In the future, it would be interesting to develop tasks that exploit the full potential of tablets and mobile virtual reality, using their features of navigation, realism and interactivity. In particular, if these results will be confirmed by future studies, it would be possible to develop mobile virtual reality scenarios to evaluate patients on important activities of daily living (such as for example, driving and cooking). This could enable neuropsychologists to save time and costs compared to those of tests administered in the real environment. Moreover, it could be interesting to study the possibility offered by mobile virtual reality and tablets in USN rehabilitation programs. Such technologies, in fact, could make patients’ homework and tasks more engaging, and consequently more effective, than traditional ones. Potentially, moreover, data collected about exercises made on tablet (scores at each task, frequency of use, etc.) could be tracked over time and integrated with other patient information, providing important information to the clinician.
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Acknowledgments
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This study was supported by the Italian funded project “VRehab. Virtual Reality in the Assessment
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and TeleRehabilitation of Parkinson’s Disease and Post-Stroke Disabilities” – RF-2009-1472190. The authors are grateful to Fabio Ferrara and Valentina Virginia Zoffoli for their technical support in the development of Neglect App.
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The authors declare that they have no competing interests. References [1]
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