|
 
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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 8
| Issue : 1 | Page : 5 |
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Cognitive rehabilitation via head-mounted virtual reality technology in patients with Alzheimer's disease: A systematic review
Yanfeng Zhao, Junxiao Yu, Jiamin Liu, Zhen Chen, Wentao Xiang, Songsheng Zhu, Yunzhi Qian, Rongkun Wang, Jinyang Mao, Zhaodan Feng, Bin Liu, Jianqing Li
Department of Biomedical Engineering, Nanjing Medical University, Nanjing, Jiangsu, China
| Date of Submission | 20-Oct-2021 |
| Date of Decision | 27-Nov-2021 |
| Date of Acceptance | 14-Dec-2021 |
| Date of Web Publication | 24-Mar-2022 |
Correspondence Address:
Bin Liu
Department of Biomedical Engineering, Nanjing Medical University, Longmiandadao 101, Nanjing, Jiangsu
China
Jianqing Li
Department of Biomedical Engineering, Nanjing Medical University, Longmiandadao 101, Nanjing, Jiangsu
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/digm.digm_42_21
Recent clinical research emphasizes utilizing virtual reality (VR) technology in cognitive impairment rehabilitation. The high immersion and polymorphism make a practical option in cases where the current head-mounted devices (HMD). VR has been used in Alzheimer's disease (AD) patients. The function of HMD is better than traditional therapies in clinical diagnosis; however, its application in treatment for AD patients remains unclear. The Web of Science databases were searched from January 2016 to August 2021. In addition, research or review articles were filtered according to the preferred reporting items for systematic reviews and meta-analyses guidelines. We bring into a total of 11 studies published in recent 5 years which show high degree of clinical feasibility. One study showed combined cognitive-behavioral therapy and VR in designing a reminiscence therapy for dementia patients; five other studies were focused on spatial navigation and posture positioning for AD patients and one of them showed effective clinical feasibility; other two studies were aimed at helping AD patients who lacked of attention and failed to propose unique advantage due to the samples data were not large enough for clinical validation. Last three studies were using a comprehensive task model in overall cognitive level and obtain considerable training in specific AD patients. HMD VR has become a reliable tool for cognitive rehabilitation in AD patients' prophylactic treatment: Patients with AD in nursing homes and families showed greater interest in VR-based attention and spatial way finding tasks, and their performance was better for a period of time after the end of the task. Combining the VR tasks with clinical cognitive theory and traditional task models will exert more benefits. More clinical case will further determine the potential of VR in AD patients to develop a practical new path for cognitive rehabilitation in the near future.
Keywords: Alzheimer's disease, Attention, Cognitive rehabilitation, Space navigation, Virtual reality technology
How to cite this article:
Zhao Y, Yu J, Liu J, Chen Z, Xiang W, Zhu S, Qian Y, Wang R, Mao J, Feng Z, Liu B, Li J. Cognitive rehabilitation via head-mounted virtual reality technology in patients with Alzheimer's disease: A systematic review. Digit Med 2022;8:5 |
How to cite this URL:
Zhao Y, Yu J, Liu J, Chen Z, Xiang W, Zhu S, Qian Y, Wang R, Mao J, Feng Z, Liu B, Li J. Cognitive rehabilitation via head-mounted virtual reality technology in patients with Alzheimer's disease: A systematic review. Digit Med [serial online] 2022 [cited 2023 Mar 29];8:5. Available from: http://www.digitmedicine.com/text.asp?2022/8/1/5/340805 |
| Introduction | |  |
In this review, we had systematically summarized the application and potential of virtual reality (VR) technology as a nondrug treatment to improve the cognitive function of Alzheimer's disease (AD) patients in cognitive therapy. In modern society, where the aging population is becoming more and more universal, the way to seek early cognitive intervention for the elderly to prevent the deterioration of AD has become an urgent tool in need. At the same time, AD population also needs to restore their cognition level to meet social needs and increase social well-being.[1] As a computer-derived product, VR plays an active role in alleviating the suffering of patients with chronic diseases,[2] controlling stress,[3] relieving autism, depression,[4] and treating stroke.[5] At present, many related VR applications have appeared which had an impact on more cognitive impairment patients.[6] As to the AD treatment, VR has been proven to be able to identify the early signs of AD more accurately than clinical diagnostic standards by testing spatial navigation capabilities.[7] It is also used to assist in memory loss, by helping patients to awaken deep memory and meet the hard-to-reach needs and improve mood in the real world. However, it is not clear whether VR technology would improve the cognitive level of AD patients[8] and what advantages it has compared to traditional rehabilitation methods.[9]
VR was proposed in the early 1960s as a computer simulation system.[10] It refers to the use of computer systems and sensor technology to generate a three-dimensional environment and create a new state of human-computer interaction. All the user's testimonials (visual, auditory, tactile, etc.,) bring a more realistic and immersive experience.[11] The most important interactive capabilities of VR rely on the development on stereoscopic display and sensor technology, with the further deep research on mechanics and tactile sensing devices, the existing technology will meet user's various interactive needs. Moreover, the tracking accuracy and tracking range of the device are continuously enhanced in the update interaction makes VR used in medical tests.[12] This article covers VR-based cognitive therapy based on head-mounted devices (HMD), which are the latest products of VR technology and are also the most concentrated in the medical field.[13]
HMDs are different from early VR glasses and provide fully immersive VR experience. Headsets, especially all-in-one devices, provide immersion and interactivity in the helmet. Deep cameras track the head with structural barrier completely isolate the external visual and auditory input, and helmet screen provides visual field, image, and audio information.[14] Continuous innovation and breakthroughs on hardware bring enhancements to the field of view and image refresh rate, which helps users integrate environmental information in VR. When combined with sensing devices, it offers natural vestibular experience information that reduces physical discomfort for participants.[15] When participating in the VR experience, patients feel more intuitive than using the computer system.[16] The price is affordable for normal families due to the optimization of their technical parameters. Therefore HMDs have an increasing affinity for families, nursing homes, and individuals.[17]
VR simulated environments provide AD participants with a safe way to achieve higher attractive interaction as well as the possibility to perform exercises adapted to the characteristics and needs of individual participants. Another key reason for using VR for training is that it offers the data collection in the form of biomedical signals from patients, which could be analyzed to study and explore the potential benefits of VR tasks.[18] In addition, the use of VR involves sensory stimulation, emotional touching which could improve the training efficiency and effectiveness.[19] Dang et al.[20] found that engaging in immersive VR could increase participants' sense of presence during the experience and enhance their confidence in recovery. A growing number of studies had demonstrated the irreplaceable benefits of VR technology in AD rehabilitation, despite the fact that this proposition needs to be validated by more clinical trials.[21]
Cognitive training based on VR serious games has been proven to be significant in mild cognitive impairment (MCI) and AD patients[22] and makes a stimulating effect on the treatment process.[23] There has been preliminary evidence to indicate that VR serious games improve cognitions in AD patients such as attention, memory,[24],[25],[26] and visuospatial ability.[27] Some researchers had designed VR memory stimulation training based on auditory stimulation and music therapy.[28] A randomized controlled trial conducted on healthy elderly participants showed that compared with participants who received classical music therapy intervention, with the participants who received VR intervention had significant improvements in memory tests and mood improvement.
Extensive studies and reviews on the treatment, early intervention, and evaluation of computerized cognitive impairment have been discussed for decades,[29] while the specific application of HMDs in the AD treatment is still defective.[30] After the onset of AD not only will cognitive functions such as memory and judgment decline but also other complications, such as mood disorders, self-doubt, anxiety, and other psychological disorders,[31] and whether the application of HMD technology makes it better that AD patients have higher quality of life because of cognition enhancement needs to be studied in depth.[32] Previous research had produced positive results and stimulated discussions on the improvement of cognitive function and cognitive-behavioral therapy (CBT) in AD cognitive function (immersive VR, immersive virtual reality (IVR)) technology,[16] but the research in this article focused on three key questions to explore and expand the situation of these indicators in HMDs. First, we would focus on cognitive training that concentrated on AD rather than general cognitive impairment. Second, we would also work hard to find research dedicated to cognitive behavioral therapy and using VR to improve patients' wrong thoughts and behaviors. Finally, all research and application of VR technology should be accurately head-mounted type instead of other technical means.
| Methods | | |
Article review
Web of science databases were used to search the literature and design a systematic literature review. Before reading the research literature, we first investigated the existing review literature in the research direction, and finally determined the focus of this article.
Search strategies
The search time was scheduled from 2016 to August 31, 2021. Keywords were determined according to the characteristics of the disease and the tools used. The search tags were optimized to find medical synonyms. At the same time, it focused on contrast with AD rehabilitation in Felix Clay's VR system review which committed to IVR. There were three search keyword strategies: (“VR” or “VR” or “virtual reality cognitive treatment”), (“cognitive treatment” or “cognitive rehabilitation”) and “AD”; apart from that, “reminiscence therapy” was also combined as a representative method of computerized CBT.
Eligibility criteria
Articles published on the database are all within the search range, and the journal type and language are unlimited. The article screening process is shown in [Figure 1], we initially collected 52 academic papers with titles that met the keyword search criteria and after screening by year (January 2016–August 2021), we excluded 22 articles not published in the past 6 years as well as 19 articles through full-text search which did not focused on AD and HMD VR, or the content of the article has been questioned. In the end, 11 eligible articles were included in the study. | Figure 1: Screening Diagram of this article's exclusion process for studies that did not meet the inclusion requirements.
Click here to view |
Inclusion
Participants
Admitted patients/elderly in nursing home/elderly at home suffering from AD. At the same time, this article did not include a study group consisting entirely of patients with MCI since its cognitive function behaves much better generally. Therefore, there must be at least a certain number of AD patients in the study.
Intervention methods
HMDs and three-dimensional (3D) applications, such as HTC VIVE series and Facebook oculus series. The fully immersive VR system had been reviewed and summarized, and the early VR glasses no longer met the technical requirements during the search period (2016–2021).
Result
All research programs, data collection and statistical methods were based on keywords; there was no requirement for the number of people covered by the results.
Exclusion
Participants
Only participants in MCI or other dementia diseases: Vascular dementia and MCI.
Intervention methods
Research that did not apply to VR equipment or used a fully immersive VR system. In addition, private nonpublic VR research for personal use was also excluded because it might point to a certain tendency.
Result
Projects without HMDs.
Data extraction
Used clay-based systematic review data tables. We extracted the data of their research based on the author's article, including: Research author, research purpose, participants (including entry criteria), specific content of the training system, result output method, and comparison results of the components of the experiment.
| Results | | |
The research content of the 11 papers is shown in [Table 1], which detailed the research objectives, participants and grouping, task objectives, training outcomes and comparison between groups. At the same time, we conducted risk assessments on several studies that might have a risk of bias in [Table 2] to ensure rigorous results.
Memory therapy task
Development of a Reminiscence Therapy System for the Elderly Using the Integration of VR and Augmented Reality.
This research was aimed to verify the feasibility when using nostalgic elements as memory triggers in the application of reminiscence therapy in VR. Researchers recruited volunteers from the community and participated in the construction of virtual scenarios. Using the 3D model based on local ancient buildings in Taiwan as the virtual environment, they designed a series of interactive nostalgic elements: videos, images, music and stories. It aimed to arouse the long-term memory of the elderly with sundry cognitive impairment, encouraged them to resonate with the VR situation, and mitigated the depression and incorrect cognitive behaviour caused by cognitive impairment such as memory deficits. No clinical trials and patients were included in this study, there was no scoring information and statistical tests for user experience, and the researchers were too subjective to assess their project as an alternative to traditional reminiscence therapy. High risk of bias in test design was found for test missing. This system had no clinical studies and no continuous trials scheduled, its clinical therapeutic significance remained unclear.[38]
Spatial navigation capability treatment mission
Compensatory Postural Adjustments in an Oculus VR Environment and the Risk of Falling in AD.
Researchers designed unpredictable visual displacement behaviours in VR to observe how AD patients mobilized different cognitive functions during they were stimulated to inspire self-compensatory posture adjustment (CPA). Participants were asked to stand at a flight of stairs, and were guided by VR environment which produced a virtual illusion that they were about to fall by triggering dramatic changes in spatial position or inductive actions of virtual avatars. Then researchers observed the reaction time and CPA acceleration frequency after the visual disturbance occurred between two groups. Twenty-one AD patients were included in the experimental group and 19 healthy people in the control group. After the task, patients who fell and did not fall in the experimental group were divided into two groups again, and the data were processed separately. The results showed that AD patients (both those who fell and those who did not fall) had longer reaction delay time when facing the spatial change at the risk of falling down. At the same time, the data collected by sensor showed that their body movement frequency band was at a higher level than that of normal people in control group. The result showed that in VR tasks based on the sensory conflict paradigm AD patients have inherently lower postural stability than subjects in control group due to the decline in visual cognitive function and some negative moods appeared to be anxiety and fear. Tasks were triggered randomly by the researchers manually, which avoided task adaptation caused by repetitive activities and improved task validity. All subjects received five sets of trials with each of them lasted 30 seconds, and the tasks were completed within half a day. Subjects were in a safe room where the effects of time and space factors could be ignored. This system was more suitable for qualitative assessment of AD patients for the number and quality of tasks were not sufficient to support it as a training program.[35]
Eye tracking analysis of visual cues during way finding in early Stage AD.
This study explored the positive effects of extensive VR spatial active pathfinding tasks on elderly people with AD, and their differences on attention to visual cues with ordinary people. Totally 7 AD patients formed the experimental group and 8 normal people in the control group. They were recruited from communities and clinics, wore VR devices with eye tracking function, and asked in the virtual space to find the way to specific destination. Significant/nonsignificant clues were set up as landmarks and the former were based on previous research on the way finding of the elderly to indicate the correct route for participants in previous studies. The researcher analyzed the differences in the percentage and length of gaze time between two groups on the clues. Statistical analysis was finished by using Statistical Analysis System (SAS). In the results they found that AD patients had significantly less observations on significant cues than ordinary people and took long time to stare at nonsignificant cues blankly. AD group were hard to pay attention to the correct information visually, which might reflect the deterioration of their pathfinding function caused by memory deterioration that made them forget which cues had been exposed to be helpful for finding correct path. Therefore, it was proposed that long-term enhancement methods to prompt patients with useful cues were needed for cognitive training and VR was an appropriate training tool. Early in the trial, two groups of male and female were randomized and averaged to ensure that the gender factors reached the minimum level. This study did not further explore the improvement of training methods. The author's other two articles on pathfinding tasks were aimed at exploring the improvement of pathfinding and the task design were sub-projects based on this study. Bias might appear in mission design. Subjects were tested twice a day and the trial lasted 5 days. The trial was completed in a community of older adults which was familiar to the subjects, and no mention was made of the impact of trial length and the real-world setting on the subjects. The study population consisted of homebound AD patients recruited in the community along with normal individuals, and the success of this VR system in community trials demonstrated its potential for cognitive treatment/assessment in basic community hospitals and nursing rooms. Another similar article[41] overlapped with this study and were not be analyzed separately.[37]
Neurocognitive treatment for a patient with AD using a VR navigational environment.
This research applied the VR pathfinding task Virtual Reality Navigation (VRN) and used a wheelchair to capture the user's spatial movement as a transfer tool in the virtual world to enhance the intuitive sense of body movement. The study used the oculus rift DK2 VR display device and included a 74-year-old male AD patient to invest in a 7 week pathfinding exercise in the VRN building. Destination was made continuously harder by changing the floor and location during pathfinding process. The evaluation was divided into four parts: The number of pathfinding errors, successful navigation, score of Montreal cognitive assessment scale, and real-world driving navigation capabilities. Results showed that the pathfinding error rate of patient per unit time decreased steadily, and finally reached the ceiling effect, his ability to reach the highest floor coordinate improved, the scale score did not change significantly, but real driving error decreased. The study showed that persistent pathfinding tasks in a specific area significantly improved the spatial navigation capabilities of AD patients. However, whether this improvement could be transferred to the real world needs to be tested by longitudinal study. The trial lasted 7 weeks with a controlled training duration of 45 min per week, and patient performed the training activities in a special wheelchair customized for him to interact with the VRN. A blank control group was not possible because the sample size was only one. There was no mention of patient discomfort due to the wheelchair or the environment in the study, while there was insufficient evidence for the clinical usability of the system: a small sample size would have resulted in unconvincing statistical test results and the lack of a control group might have had an impact on the training effect since the cognitive spatial pathfinding ability of patients at the onset of AD over a 7 week period might decline in the absence of the intervention continuously, and the extent of the decline remained unknown.[38]
Treatment tasks such as attention and execution
A feasibility study with image-based rendered VR in patients with MCI and dementia.
The study transferred the attention trainiHng paradigm based on paper and pen to HMDs. AD and MCI patients were required to find characters with specified characteristics in 3D video to verify the feasibility of VR cognitive training based on image rendering. The study included 29 AD patients and 28 MCI patients from related research units, and Statistical Product and Service Solutions software ( SPSS, Chicago, USA) was used for data statistics and analysis. Compared with the results of paper tasks, patients took more interest in VR tasks to help compliance with the implementation of long-term training programs. There was no significant difference in attention improvement between two methods, while MCI patients generally behaved better than AD patients. The inclusion and grouping were adopted the principle of average randomization, while gender factor was not included in the grouping principle which might be a certain risk of bias. The trial was conducted only once, primarily to examine the positive effects of the application of the VR system on mood changes in subjects at the Institute while performing the attention task. Therefore, this system might not be directly qualified for use in the training of patients with AD and MCI; investigators should continue to design clinical trials based on the modules already completed.[33]
The potential of VR-based training to enhance the functional autonomy of AD patients in cooking activities.
Déborah aimed to help an AD patient restore her cooking abilities. Based on VR's error-free learning and disappearing prompts, a series of game tasks were designed for her recovery. The patient was provided with ingredients and raw materials in VR to cook various foods and drinks according to the prompts. Since the tasks were customized (patient was good at cooking before suffering from AD), the prompts were only used for help after long stagnation. After VR training, this patient's functional autonomy in cooking activities improved enough to cook for herself, which indicated that VR customized tasks had great potential for recovery of specific cognitive impairment activities, especially if it was inconvenient to repeat the exercise in real life. Bias existed obviously for only one case. Patients completed the four tasks in 16 days and performed at home. In the article, authors illustrated that time and environmental factors did not negatively affect training, but the accuracy of the statistical tests remained questionable, sample size was too small for the findings to indicate the clinical feasibility of this system.[39]
Comprehensive treatment tasks
A pilot study and brief overview of rehabilitation via virtual environment in patients suffering from dementia.
The researcher proposed a construction and preliminary research about the virtual rehabilitation environment in the cognitive neuro-rehabilitation field: A series of VR games designed, included supermarket shopping, breakfast preparation, room cleaning, involved training on working memory, attention, problem solving, execution, and cognitive behavior correction. The study included 10 patients with vascular dementia, AD and so on. After the 7 week training period, the total cognitive variable scores increased relatively. Bias was believed small. Patients completed 10 h of rehabilitation intervention over 7 weeks and the trial did not set a control group and was conducted in a computer room. The effect of the control group absence could not be excluded, but the results of the trial were very satisfactory and the number of subjects met the post-pretest predictions, which were able to indicate the clinical feasibility of the system.[34]
VR-based cognitive stimulation on people with mild to moderate dementia due to AD: A pilot randomized controlled trial.
This study designed instrumental activity of daily living (IADL) into VR and intervened the cognitive impairment caused by AD, with total 9 different life tasks and 12 different levels of difficulty. Seventeen patients were evenly randomly assigned to the VR/traditional paper scale group with a 7 week IADL game training. The results showed that the overall cognitive outcome of the VR group was significantly improved. However, the difference between groups was not significant. Small bias with more credible results. The trial lasted a total of 2 months, with 2 training sessions per week. The investigators used the content of the IADL scale as a training task. Therefore, the study was initially conducted for clinical rehabilitation training. The control group was set up in a reasonable manner and the subjects were subjected to strict environmental controls.[40]
VR–based cognitive-motor training for middle-aged adults at high AD risk: A randomized controlled trial.
In 125 adults with a family history of AD, an intensive VR cognitive training test combining realistic cognitive tasks and walking on a treadmill at the same time was used to prevent the onset of disease. 125 people were divided into 4 groups (VR training with treadmills for mobile, VR training, treadmill exercise training, and no training), VR training tasks were developed to reproduce daily life behaviours conveniently. After training, a return visit was made to the subjects to observe their living conditions. The training results proved that VR tasks were well accepted by patients and provided evidence that such training results could be well transferred to real life. However, compared with normal cognitive exercises, the introduction of treadmill tasks failed to prove that greater benefits in daily living were realized after combining treadmill with VR. Enrolment was strictly screened and randomized, consequently as low risk of bias. The training lasted for 12 weeks, twice a week, for 45 min each time. Participants were recruited in the community and designed with a strict conditioned control group and a blank control group. The results showed that the system could already be used for training patients with clinical cognitive impairment, but the 45 min training time and the physical demands of the treadmill task might deteriorate the task experience of AD patients.[42]
| Discussion | | |
Our review study demonstrated that there are rich opportunities available to investigator by HMD VR targeted training, including promotion to general cognitive ability, growth in ecological effectiveness combining with CBT as well as task engagement enhancement. This view was organized as followed: HMD spatial navigation recovery task is feasible for AD participants which constructs simulation scenarios and requires participants to use various cues (luminous objects, obstacles, and small maps) to find the correct path to destination; VR-based attention and executive tasks are usually arranged together, participants are arranged to perform specific activities with regularly repetition or adaptive changes in difficulty (character identification and practice cooking skills). Besides, interference items with the same structure but different elements are usually set up and participants are required to remain goal-oriented until the task is completed.
Some comprehensive projects had proposed a hybrid model such as reproducing daily life activities in virtual scenes in the form of tasks and transforming IADL's assessment content into training missions (shopping, financial management, outings, medication, etc.). That was easy for researchers to make accurate clinical assessments of participants as well. Positive effects had been showed in previous studies within a month after training, while no effects were mentioned after a longer period of time in the future, possibly lack of follow-up.
Reminiscence therapy derived from CBT uses long-term memory stimulation. VR memory trigger interaction with nostalgia elements makes participants realize their past lives, in order to correct a negative emotion with negligent behaviours caused by false chaotic memories. Such virtual situational interaction shows the potential to alleviate the decline in participants' memory function and adjust emotions.
Strengths
This review was the first to systematically generalize the new development of VR HMDs in AD cognitive rehabilitation. According to analysis, we found VR shows obvious advantages in improving patient participation and training immersion compared with traditional pen-and-paper training. Moreover, the results showed that comprehensive cognitive training significantly improves the short-term memory of participating patients who related to a large number of task exercises for 2 weeks to 6 month.[43] Spatial route navigation in the virtual scene should be developed as a toolkit for distinguishing between AD participants and healthy controls even though it also improves quality of daily living.[44] We also brought in studies that collected the eye tracking data during the task and found that AD patients' gaze time on clues were behaved apparently less than ordinary people in the pathfinding process,[45] which were expected to propose a new ideas for the clinical diagnosis of early AD and provide training ideas to compensate for decreased concentration. Our review clarified that collaborative treadmills usage in VR cognitive rehabilitation tasks can make progress in patients' daily living cognitive function and gait stability in parallel;[46] Comprehensive VR polymorphic cognitive training tasks are worthy of in-depth clinical promoting which get the best training effect appraisal in all task modes.[47]
Limitations
In this retrospective research we found that, compared with VR conditions, traditional drawing-paper-pen training showed a higher target recognition rate in the image attention task, and we did not delve into whether AD patients were more suitable for staged training mode which might be more suitable for the latter.[48] The results of navigation training were controversial. Some studies believed that VR technology needed to be used as a good ecological tool to assess early AD symptoms,[49] but whether the improvements in navigation are clinically significant or only are regarded as an evaluation parameter, which we hope to summarize more clinical reports below this article. In addition, we found no evidence that the pathfinding and navigation exercises completed in HMDs could be transferred to real life, which is why the visual space obstacles and psychological stress faced by patients in different environments will be different in majority research. Trial lacking group randomization might lead to a greater risk of bias in the statistical results, not all studies we included avoid this risk.
Focus for future research
The cognitive tasks focused on VR should be closer to the realistic tasks that puzzle AD patients.[50] The research on cognitive navigation dysfunction has raised some urgent questions: Is HMD technology fit for navigation or wayfinding? Pathfinding efficiency and eye movement features extraction provide useful evidence for early AD diagnosis,[51] while the violent spatial position changes possibly cause physical discomfort,[52] the design of clinical trials requires extreme caution considering healthy condition among elderly patients. The researchers did not mention the negative effects of training caused by motion sickness and other discomforts which exceed the tolerable threshold of the participants, the type of training could bring about adverse consequences and thereby lose the positive significance.[53] Therefore, attention should be paid to how to reduce the harmful conditions caused by VR to users when formulating mission plans. Is the existing research well integrated with clinical testing, or only based on individual cases or early MCI patients who have been screened to be at risk of AD? By linking more VR task research with clinical cohorts, it will help to verify whether these new training methods bring better results than conventional treatment or computer cognitive behavior therapy. Therefore, future research should focus more on those with symptoms that have already appeared.
Higher numbers of clinical cases are needed to provide enough samples to provide more sufficient samples and more convincing data for statistical testing. Abstract reasoning tasks have been shown to improve the overall cognitive level of the elderly with cognitive impairment,[54] therefore, we have reason to believe that the reasoning tasks included in the comprehensive treatment task will have a good effect on improving the cognitive level. It is worthy of in-depth studying to add training tools such as treadmills, basic robots, and motion capture devices during recovering from cognitive impairment owing to the hard fact that AD patients are often accompanied by a decline in physical performance. Reminiscence therapy combined with virtual scene has been initially proved to be feasible in volunteer subjects. Based on the inspiration of this new application method, researchers may also try to integrate familiar people and places into the virtual world to reduce cognitively stressed and shared memories by simple human-computer interaction to enhance their emotional experience and reduce psychological symptoms caused by dementia behaviors in which the tasks are customized for specific patients.[55] These studies have shown that participants receive both physical and psychological 11 benefits. Future research should quantify the improvement in the AD cognitive ability with this new rehabilitation training tool and determine whether it should be used as an excellent substitute for clinical training in the future in depth.
Acknowledgment
This article was funded by the following projects:
- National Key Research and Development Program of China (2017YFB1303200)
- Leading-edge Technology and Basic Research Program of Jiangsu (BK20192004D)
- Jiangsu Graduate Scientific Research Innovation Program (KYCX20_1391)
- National Natural Science Foundation of China-Youth Science Foundation Project (NSFC62001240)
- Jiangsu College Students' innovation and entrepreneurship training program (202110312013Z)
- We are grateful to authors for their contributions in collecting data and literature reading, as well as Professor Jianqing Li and Professor Bin Liu for their fully support.
Financial support and sponsorship
This document is the results of the research project funded by the National Key Research and Development Program of China (2017YFB1303200), Leading-edge Technology and Basic Research Program of Jiangsu (BK20192004D), Jiangsu Graduate Scientific Research Innovation Program (KYCX20_1391), National Natural Science Foundation of China-Youth Science Foundation Project (NSFC62001240) and Jiangsu College Students' innovation and entrepreneurship training program (202110312013Z).
Conflicts of interest
Jianqing Li is an Honorary Editor-in-Chief of the journal. The article was subject to the journal's standard procedures, with peer review handled independently of this editor and his research groups.
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[Figure 1]
[Table 1], [Table 2]
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