ArticlePDF Available

Abstract and Figures

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 paper-and-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.
Content may be subject to copyright.
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 1
Technology and Health Care -1 (2015) 1–13 1
DOI 10.3233/THC-151039
IOS Press
Assessing unilateral spatial neglect using1
advanced technologies: The potentiality of2
mobile virtual reality3
Federica Pallavicinia,, Elisa Pedrolia, Silvia Serinoa, Andrea Dell’Isolab, Pietro Cipressoa,4
Carlo Cisariband Giuseppe Rivaa,c
aApplied Technology for Neuro-Psychology Laboratory, IRCCS Istituto Auxologico Italiano, Milan,6
bPhysical and Rehabilitative Medicine, Department of Health Sciences, Università del Piemonte8
Orientale “A. Avogadro”, Novara, Italy9
cDepartment of Psychology, Catholic University of Milan, Milan, Italy10
Received 8 July 201511
Accepted 4 August 201512
BACKGROUND: Unilateral Spatial Neglect, or neglect, is a common behavioral syndrome in patients following unilateral14
brain damage, such as stroke. In recent years, new technologies, such as computer-based tools and virtual reality have been15
used in order to solve some limitations of the traditional neglect evaluation. Within this perspective, also mobile devices such16
as tablets seems to be promising tools, being able to support interactive virtual environments and, at the same time, allowing to17
easily reproduce traditional paper-and-pencil test.18
OBJECTIVE: In this context, the aim of our study was to investigate the potentiality of a new mobile application (Neglect19
App) designed and developed for tablet (iPad) for screening neglect symptoms.20
METHODS: To address this objective, we divided a sample of 16 right-damaged patients according to the presence or absence21
of neglect and we administered assessment test in their traditional and Neglect App version.22
RESULTS: Results showed that the cancellation tests developed within Neglect App were equally effective to traditional paper-23
and-pencil tests (Line cancellation test and Star Cancellation test) in detecting neglect symptoms. Secondly, according to our24
results, the Neglect App Card Dealing task was more sensitive in detecting neglect symptoms than traditional functional task.25
CONCLUSIONS: Globally, results gives preliminary evidences supporting the feasibility of Neglect App for the screening of26
USN symptoms.27
Keywords: Neglect, neuropsychological assessment, tablet, virtual reality28
1. Introduction29
Unilateral Spatial Neglect (USN), or neglect, is a common behavioral syndrome in patients following30
unilateral brain damage, such as stroke. The reported incidence of USN can be identified in approxi-31
Corresponding author: Federica Pallavicini, Applied Technology for Neuro-Psychology Laboratory (IRCCS Istituto Auxo-
logico Italiano), Via Magnasco, 2, 20149 Milano, Italy. E-mail:
0928-7329/15/$35.00 © 2015 – IOS Press and the authors. All rights reserved
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 2
2F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies
mately 40–50% of the post-stroke patients [1,2]. This disorder is generally characterized by a difficulty32
or inability to pay attention, to detect, and to orient toward objects located in the hemi-space contralateral33
to the lesion of one of the cerebral hemispheres, even in the absence of sensory or motor deficit [3,4]. In34
particular, neglect symptoms are more both common and severe after damages in the right hemisphere,35
which consequently affect patients’ behaviors in the left part of the space [5,6]. USN is a complex syn-36
drome, difficult to assess and treat, characterized by heterogeneous symptoms [7–9].37
Traditionally, USN is evaluated with paper-and-pencil cancellation tests, where patients are asked to38
detect specific targets displayed in a sheet: distracters may be inserted to increase the difficulty of the39
task. These test include line [10], circle [11], letter [12], star [13] and symbol cancellation [14], among40
Although USN diagnosis based on traditional pencil-and-paper test is widely used by clinicians, it has42
been observed by a lot of studies that they are characterized by two main important limitations. First of43
all, previous research reported that this type of test lack of ecological validity [15,16] and inconsistencies44
have been reported between neglect patients’ performance in these test and important deficits occurring45
in their daily life activities [17–20]. As underlined by Tsirlin and colleagues [21], most of these tests46
don’t capture everyday problems occurring in natural environments of USN patients.47
However,given the complexity of patients’ daily life activities, it is extremely difficult to observe them,48
in term of time and resources [22]. Secondly, traditional paper-and-pencil cancellation test capture the49
spatial navigation deficit insufficiently, or even not at all, even if it seems to be an important characteristic50
in the domain of the neglect syndrome [23,24].51
In the last few decades, one of the major advances in neuropsychology has been represented by the52
use of new technologies, during both screening and rehabilitation [25–27]. Regarding USN, numerous53
efforts have been made to develop new tools that will enable a more complete assessment, trying to54
go beyond the limits of traditional paper-and-pencil test. In particular, there has been a wide interest in55
transferring paper-and-pencil cancellation tests to computer-based setting, resulting in a more detailed56
and precise recording of performance during the assessment, as well as an enhanced consistency in57
testing across setting [28,29]. Studies have been reported that computer-based assessment tool could be58
potentially more sensitive than paper-and-pencil tests in detecting a slower processing of contralesional59
hemispace [20,29–34]. In even more recent years, promising new methods using Virtual Reality (VR)60
technologies have emerged. In the domain of USN assessment, VR is a relatively new tool [35–40].61
However, this instrument, has proven effective in the assessment of neuropsychological functioning, in62
particular for evaluation of executive [41–43], spatial [38,44] and mental imagery processes [45,46].63
Preliminary studies have explored the use of VR for the assessment of USN symptoms, proposing both64
interesting virtual versions of the traditional pencil-and-paper cancellation tests and virtual tasks specific65
to the investigation of space exploration [21].66
Although the dramatic development in the field of computer-based test and VR, there are still some67
problems related to the use of these technologies, far from the research and clinical settings. First of68
all, from a technological point of view, both these tools are not so easy to be used, requiring a specific69
training for the clinician and the patient. Secondly, both computer-based test and VR system are tools70
developed to be used in the clinic, since they require a specific setting and staff able to use these type of71
technological devices. Finally, from a clinical perspective, these technologies are not easy to be moved at72
patients’ home, where an automatic assessment of USN symptoms may be useful to evaluate the severity73
of symptoms over time, especially when patients are provided with a rehabilitative training.74
Within this perspective, mobile devices such as tablets are promising tools that already meet the re-75
quirements needed to support interactive VR environments and, at the same time, allow to easily repro-76
duce traditional paper-and-pencil cancellation test. However, still very few experimental studies have77
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 3
F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies 3
investigated the potential of the tablet in the assessment of USN [47–49]. So far, moreover, there have78
been few attempts to reproduce traditional paper-and-pencil cancellation tests on the tablet, with the79
aim to develop tool able to offer detailed visuo-spatial indexes in order to better understand the peculiar80
features of the syndrome and to develop a more customized rehabilitation [48,49].81
No study, however, has tried to build a tool for the assessment of USN exploiting the peculiar char-82
acteristics of tablets, such as the possibility to play interactive virtual environments and its graphics83
capabilities. The growing availability, low-cost and easy-to-use of “mobile virtual reality”, that is the84
integration of VR environments on mobile devices, represents a meaningful opportunity for neuropsy-85
chological assessment, although unfortunately not yet adequately explored.86
In this context, the aim of our study was to investigate the potentiality of a new mobile application87
(Neglect App) designed and developed for tablet (iPad) for screening USN symptoms. Accordingly, in88
this study we investigatedwhether our newly developed mobile application could screen USN symptoms89
through comparison to right hemispheric stroke patients with and without neglect.90
2. Materials and methods91
2.1. Participants92
A sample of 25 patients recruited at Ospedale Maggiore di Novara (Italy) were screened for interviews93
and neuropsychological assessmentfor admission to the study. Criteria for participation were the follow-94
ing: (1) Right vascular lesion (which was fully evaluated by the clinical staff of the Ospedale Maggiore95
di Novara); (2) age between 18 and 85 years; (3) no severe cognitive impairment, as assessed with the96
Mini Mental State Examination (MMSE) [50] (MMSE >24); (4) no difficulties in language compre-97
hension; (5) no history of psychosis, alcohol or drug dependence, as assessed by a clinical interview;98
(6) no motor deficit that would prevent the use of the tablet; (7) normal or corrected-to-normal vision.99
In particular, if patients present possible factors (e.g., hemianopsia), typically following some type of100
lesions (e.g., occipital cortex), that may prevent the possibility to take part in this study, were excluded.101
None of the recruited sample presented posterior cerebral artery or lesions in the occipital cortex.102
On the other hand, of the initial recruited sample, three patients were excluded due to important mo-103
tor deficits and six for severe cognitive impairment (MMSE <24). Of the initial recruited sample,104
three patients were excluded due to important motor deficits and six for severe cognitive impairment105
(MMSE <24) [50]. The final experimental sample included 16 participants with right-hemisphere dam-106
age caused by a cerebrovascular lesion, without hemianopia. Participants were 12 men (85.2%) and107
4 women (14.8%). The mean age was 66.1 ±11.9, with mean years of education of 8.56 ±3.5. All108
participants were right-handed.109
According to the score obtained at the Line Cancellation Test [10] and the Star Cancellation Test [53],110
participants were divided into two groups: patients with USN (Neglect Group), and patients without the111
USN (Non-neglect Group). Specifically, if the patient omitted more than 1 line or 3 stars in the left side112
and none in the right side of sheet was included in the Neglect Group. If patients omitted lines or stars113
in both sides of space, the examiner calculated a value (number of item omitted in left side/total items114
omitted); values equal or greater than 0.75 indicate USN. Eight participants (5 males, 3 females) were115
assigned to the Neglect Group, and the other 8 participants (7 males, 1 female) were assigned to the116
Non-neglect Group. Descriptive of the sample are reported in Table 1. Before participating in the study,117
each participant was given written information about the study and was asked to give written consent to118
be included. The study received ethical approval from the Ethical Committee of the Istituto Auxologico119
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 4
4F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies
Tab l e 1
Demographic and clinical characteristics of the sample
ID Gender Age Education Lesion site Onset Neglect Stroke type
(years) (years) (months)
1 M 53 8 Temporo-frontal 23 No Aneurysm
2 M 56 13 Fronto-parieto-temporal 26 No Ischemic
3 M 74 5 Semioval center 13 Yes Aneurysm
4 M 66 13 Parietal 18 Yes Hemorrhage
5 M 68 13 Fronto-parieto-temporal 18 Yes Ischemic
6 M 69 8 Fronto-parieto-temporal 13 Yes Ischemic
7 M 68 8 Fronto-parieto-temporal 57 No Ischemic
8 M 65 13 Temporo-parietal 21 No Hemorrhage
9 M 77 5 Frontal 31 Yes Subarachnoid hemorrhage
10 M 67 8 Basal ganglia +white matter 5 No Ischemic
11 F 74 5 Frontal-parietal 71 No Ischemic
12 M 67 5 Temporo-parietal 15 No Ischemic
13 F 73 13 Temporo-parietal 4 Yes Ischemic
14 M 59 8 Frontal-parietal 4 No Ischemic
15 F 74 2 Frontal-parietal Insular 3 Yes Ischemic
16 F 59 7 Frontal 3 Yes Subarachnoid hemorrhage
2.2. Instruments121
2.2.1. The neuropsychological evaluation122
A neuropsychological evaluation was conducted both to ensure that patients met the aforementioned123
study criteria and to collect data on the patients’ cognitive profiles. In particular, the Mini Mental State124
Evaluation (MMSE) [50] was used to assess individuals’ general cognitive level.125
2.2.2. Traditional assessment tests126
The following traditional neuropsychological test were used for screening for neglect symptoms:127
1. Traditional paper-and-pencil cancellation tests, which were used both to evaluate neglect symp-128
toms and consequently to divide the sample in two divided into two groups (i.e., patients with129
USN – Neglect Group. and patients without the USN Non-neglect Group) and to collect data for130
the comparisons with their Neglect App version.131
In particular, we administered the two following paper-and-pencil cancellation tests:132
a) Line cancellations test [10]: the patient was given a sheet of paper with three rows of six lines on133
the left and the same on the right, and one row of four lines in the center. Individuals are asked134
to cross out all the lines on the page (size of 56.39 ×37.34 cm). The number of lines selected135
and non-selected (omissions) targets on the left side and on the right side were recorded (for a136
total of 18).137
b) Star cancellation test within the behavioural inattention test (BIT) [13]: patient was presented138
with 56 small stars mixed up with many large stars and capital letters (page size of 56.39 ×139
37.34 cm). Individual was asked to cross out all the small stars after the examiner had demon-140
strated this, crossing out two centrally positioned small stars. The number of selected and omit-141
ted small stars on the left side and on the right side were recorded (for a total of 28 stars).142
2. Traditional card dealing task, taken from Semi-structured Scales for the Functional Evaluation of143
Hemi-inattention [51,52], was used as a functional and ecological evaluation of USN symptoms,144
in order to collect data for the comparisons with its Neglect App version, During this task the145
examiners ask the patient to deal three cards for a game to himself/herself and to each one of the146
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 5
F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies 5
three individuals seated at the same table (the examiner in the front of, one person at the right side147
and another one at the left side of the patient) and four in the middle of the table. The number of148
cards correctly given and the number of cards not deal in the left side and in the right side of the149
patient were recorded (for a total of 3 cards).150
2.2.3. Neglect App assessment tests151
Neglect App, the iPad application developed and used in this study, contains a series of test for the152
evaluation of the USN using interactive virtual environments. Specifically, the app includes two different153
categories of tasks:154
1. Neglect App cancellation tests, which are designed to recreate the traditional paper-and-pencil155
cancellation test, played within the application in a three-dimensional version. The two cancellation156
tests included in NeglectApp have been developedon the basis of the paper-and-pencil cancellation157
test described in the previous paragraph and in particular:158
a) Neglect App simple cancellation test, which corresponds to the Line Cancellations Test [10].159
Patients have to selected 30 hammers placed in a room (15 on the left and 15, on the right160
side). The number of hammers selected (correct targets) and the number of item non selected161
(omissions) on the left side and on the right side was recorded;162
b) Neglect App cancellation with distractors test built on the basis of the Star Cancellation163
Test [53]. Patients have to select 12 screwdrivers (6 in the right and 6 in the left) placed in164
a room with 22 other objects (hammers, wrench and others, 11 on the right and 11 on the left).165
The number of selected and omitted screwdrivers on the left side and on the right side were166
recorded (see Fig. 1).167
2. NeglectAppcarddealingtaskrecreates, in a virtual environment on the tablet, the Card Dealing168
Task [51,52] described in the previous paragraph. As in the traditional version of the test, the patient169
have to give three cards for a game to himself/herself and to each one of the three individuals seated170
and four in the middle of the table. The number of cards correctly given and the number of cards171
not deal in the left side and on the right side of the patient were recorded (for a total of 3 cards).172
Neglect App test were carried out with the aid of a stylus for touchscreen, on an iPad2 (Model173
A1397 with IOS ver. 7.1, screen size active area of 47.70 ×26.82 cm.174
2.2.4. Neglect App usability assessment175
The System Usability Scale (SUS) [54] was used to evaluate the Neglect App usability. The scale is176
composed of 10 statements that are scored on a 5-point scale of strength of agreement. For each item,177
the score may range from 0 to 4, and then the sum of score have to be multiplied for 2.5. Consequently,178
final scores for the SUS can range from 0 to 100, where higher scores indicate better usability.179
2.2.5. Technological skills assessment180
A self-assessment scale was used to evaluate patients’ technological abilities. The two-item question-181
naire was created to assess individuals’ perceived technological skills in the use of personal computers182
and tablet. The individual is asked to rate from 0 to 100 his/her perceived technological skills both in the183
use of personal computers and tablet, where higher scores indicate better perceived skills.184
2.3. Procedure test185
Participants were included in the study after a preliminary clinical interview and a neuropsychological186
evaluation using the Mini Mental State Evaluation (MMSE) [50]. According to this preliminary evalu-187
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 6
6F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies
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;
Fig. 2. Screenshot of the Neglect App card dealing task.
(Colours are visible in the online version of the article; http:
ation and the inclusion/exclusion criteria described above, participants who were suitable for the study188
attended a single testing session at the Ospedale Maggiore di Novara, lasting about one hour. Upon189
arrival the procedure was explained to the individuals and informed consent was obtained. Then, indi-190
viduals were asked to fill out the technological skills assessment questionnaire. Participants were asked191
randomly to complete traditional and Neglect App test, following an established randomization schema192
obtained from The order of tests in both conditions of assessment was also193
randomized for each subject. Before completing Neglect App tasks, each participant had a training pe-194
riod of about ten minutes in an ad hoc virtual environment within the app, in order to become familiar195
with both the navigation and selection tasks. Moreover, at the end of the Neglect App tests, participants196
were asked to fill out the SUS.197
3. Results198
Data were entered into Microsoft Excel and analyzed using SPSS for Windows, version 18.0 (Statis-199
tical Package for the Social Sciences-SPSS for Windows, Chicago, IL, USA). Since outcomes were not200
approximately normally distributed, non parametric statistics were used. Specifically, the Mann-Whitney201
Test was used to compare the two independent groups. In particular the performance of the Neglect and202
Non-neglect Group in the traditional and Neglect App tests were compared using non parametric anal-203
ysis, in order to test whether the number of omitted targets in the traditional and Neglect App tasks204
changed depending on the neglect condition (Neglect vs. Non-neglect Group).205
An index of omission error score (one for the left side and one for the right side) has been computed206
[(number of omissions/number of targets) ×100] for each assessment tasks [55]. These scores were207
compared between the Neglect and Non-neglect Group using the Mann-Whitney Test. Nonparametric208
test was used also to test difference between groups in Neglect App usability score, assessed through the209
SUS. The level of significance was set at α=0.05.210
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 7
F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies 7
Tab l e 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
Neglect Group Non-neglect Group Ur p
Variables Median Median
Age 71 66 14 0.475 0.06
Education (years) 70.5 80.5 29 0.08 0.743
Duration from onset (months) 13 22 160.5 0.407 0.103
MMSE score 26 260.8 25 0.183 0.462
Perceived skills in the use of a PC 35 35 310.5 0.013 0.957
Perceived skills in the use of a tablet 170.5 20 28 0.111 0.656
Tab l e 3
Median values and Mann-Whitney U test results in the sample divided for Group (Neglect and Non-neglect Group) for tradi-
tional paper-and-pencil and Neglect App assessment test mean scores expressed in %) in the left side
Neglect Group Non-neglect Group Ur p
Variables Median Median
Line cancellation test 660.6 0.000 15 0.496 0.047*
Neglect App simple cancellation test 930.3 60.66 80.5 0.632 0.01**
Star cancellation test 900.7 70.4 2 0.795 0.001***
Neglect App cancellation with distractors test 100 0.000 8 0.66 0.008**
Traditional card dealing task 330.3 0.000 21 0.116 0.755
Neglect App card dealing task 100 0.000 120.5 0.622 0.02*
*P<0.05, **P<0.01, ***P<0.001.
3.1. General characteristics of Neglect and Non-neglect Group procedure test211
Results did not show any significant differences with regard to age, education, duration from onset,212
MMSE mean scores and perceived technological skills between the Neglect and Non-neglect Group213
(p>0.05) (see Table 2).214
3.2. Comparison of Neglect and Non-neglect Group performance in traditional and Neglect App215
assessment test216
Two individuals were excluded from the Neglect App Card Dealing analyses due to problems in the217
score recording; hence, the analyses were conducted with 14 participants: 8 Neglect and 6 Non-Neglect.218
Non-parametric analyses showed a significant difference in the number of omissions in the left side219
between Neglect and Non-neglect Group in the Line Cancellation Test (U=15; r=0.496; p<220
0.05), Neglect App Simple Cancellation Test (U=8.5; p<0.01; r=0.632), Star Cancellation221
Tes t ( U=2; p<0.001; r=0.795;), Neglect App Cancellation with Distractors Test (U=8; p<222
0.01; r=0.66;), and in the Neglect App Card Dealing Task (U=12.5; p<0.05; r=0.622;).223
No difference between groups were found in the Traditional Card Dealing Task (U=21; p>0.05;224
r=0.116) (see Table 3).225
Results on the number of omissions in the right side did not show any statistically significant difference226
between Neglect and Non-neglect Groups (p>0.05) (see Table 4).227
3.3. Neglect App usability228
The mean SUS score of the all sample was high (80.1 ±16.6), indicating a high usability of the229
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 8
8F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies
Tab l e 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
Neglect Group Non-neglect Group Urp
Variables Median Median
Line cancellation test 20.77 0.000 180.5 0.43 0.084
Neglect App simple cancellation test 30 10 150.5 0.438 0.079
Star cancellation test 330.3 50.55 210.5 0.279 0.263
Neglect App cancellation with distractors test 25 0.000 16 0.465 0.063
Traditional card dealing task 0.000 0.000 20 0.307 0.248
Neglect App card dealing task 0.000 0.000 310.5 0.024 0.927
Fig. 3. Whitney U test results in the sample divided for group (neglect and Non-neglect) for line cancellation test star cancel-
lation 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;
Neglect App. Non-parametric analyses did not show significant difference in the SUS total score between230
Neglect (Median =78.7) and Non-neglect Group (Median =86.2) (U=18.5; p=0.154; r=0.356).231
4. Discussion232
This study provides preliminary evidence supporting the feasibility of Neglect App for the screening of233
USN symptoms. In particular, results showed that the cancellation tests developed within Neglect App234
were equally effective to the traditional paper-and-pencil tests in the screening of symptoms between235
patients with and without neglect. Moreover, according to our results, the Neglect App Card Dealing236
task was more sensitive in detecting neglect symptoms than traditional functional task.237
Firstly, regarding cancellation tests, results showed that the percentage of omissions in the left side238
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 9
F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies 9
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;
(but not in the right side) was significantly different between Neglect and Non-neglect Group both in239
the traditional paper-and-pencil test, (i.e., Line Cancellation Test [10] and Star Cancellation Test [13])240
than in the Neglect App versions of these tests, respectively Neglect App Simple Cancellation test and241
Neglect App with Distractors Cancellation test. Similarly to our results, a recent previous study [49]242
reported differences in cancellation test between patients with and without neglect in a tablet version of243
these test. Our results, moreover, seems in accordance to what has been observed in a previous study [56]244
in which patients with neglect showed aberrant search performance in a virtual reality cancellation task.245
Secondly, regarding the Card Dealing task, results showed significantly differences in the percent-246
age of omissions between Neglect and Non-neglect Group in the Neglect App version of Card Dealing247
task but not in the traditional one. This result could be explained thorugh different assumptions. Firstly,248
results obtained may be related to a specific feature of Neglect App. It is argued that there is a disso-249
ciation between a spared strategy-driven attention opposed to a loss of stimuli-related attention [57].250
Apparently, in real-life, the external cues orient and guide the preserved attentional strategies, while in251
a virtual environments experienced on a tablet there are only standardized stimuli and this condition252
may aggravates USN symptoms. Secondly, our results can be interpreted according to the “pre-motor253
model” that suggests the presence in the brain of multiple and dissociable frames of spatial reference254
(personal, peri-personal and extra-personal) [58,59]. In particular the difference we observed could be255
related to the fact that while Neglect App version of Card Dealing task assess hemispatial neglect in the256
near extra-personal space, the traditional version involved a more extensive extra-personal space.257
Finally, it’s interesting to note that in our study, participants, even if they were characterized by low258
knowledge in the use of PCs and tablets and by a high mean age (about 65 years old), reported excellent259
user-friendliness of Neglect App, as shown by the analyses on the SUS questionnaire. Moreover, we260
did not observe difference in Neglect App usability between patient with and without USN. This seems261
important to exclude that, because of USN patients motor limitations, there are difficulties in the use of262
the app and its ease of learning.263
5. Conclusion264
Even if our results are interesting for their possible applications in the assessment and rehabilitation265
of the USN, our study have some limitations, which could affect the generalizability of the results,266
or that may have influenced the findings. The main one is related to the small sample included in the267
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 10
10 F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies
study. However, it’s important to acknowledge that patients with right hemisphere damage caused by a268
cerebrovascular lesion is really difficult to be recruited. For the same reason, a number of studies in this269
field have often included an even more limited number of subjects (e.g. [4,56,60]. Moreover, differently270
from the majority of other studies, we did not include a control group of healthy participants, focusing271
only on a clinical sample, more complex to be found but more informative. The second limit is related to272
the fact that, the Neglect App version adopted in the study, did not offer visuospatial data (e.g. latency,273
distance, search speed) about patients’ performance during the different tasks. To record also this type274
of data, that could be obtained creating an interface between tablet and software for the recording of275
visual movements (e.g. eye-tracking software), would give an important additional value to the app.276
Future studies will investigate deeply this aspect. Finally, future studies are needed also to increase the277
generalizability of the results found regarding Neglect App and the possibility to use tablets and mobile278
virtual reality to replace existing traditional USN test (e.g. increasing the number of participants of the279
study, and conducting a follow-up study repeated administration of the test).280
As regards to the differences between the existing applications on the app store that attempts to repli-281
cate the conventional pencil and paper test and Neglect App, the main ones could be summarized as282
Neglect App is the only one that contains a functional task that replicate on the tablet an ecological284
activity (dealing cards), thanks to the adoption of interactive virtual environments. This is relevant285
since, despite the evidence supporting the possible use of virtual reality in neuropsychological eval-286
uation and the increased interest in its use in cognitive training, this technology is still little explored287
and exploited [61].288
The tests included in Neglect App (including those of barrage) unlike other app such as iNeglect289
(©Yonsey Severance Hospital), neglectTest (©Why not Zoidberg UG), and Visual Attention Ther-290
apy Lite (©Tactus Therapy Solutions Ltd), are not simple reproductions of classical tests (also291
from the point of view of graphics and interaction). Neglect App tasks, in fact, have been devel-292
oped specifically to exploit the specific characteristics of the tablet, such as the possibility to play293
interactive virtual environments and its graphics features.294
Neglect App is available in the app store for free, unlike other app such as neglectTest (©Why not295
Zoidberg UG, 19.99C) and CABPad (©Cognisoft ApS; 449.99 C). This appears relevant since cost296
remains an important factor that can limit access to computerized testing and new technologies in297
general [61].298
In the future, it would be interesting to develop tasks that exploit the full potential of tablets and mobile299
virtual reality, using their features of navigation, realism and interactivity. In particular, if these results300
will be confirmed by future studies, it would be possible to develop mobile virtual reality scenarios to301
evaluate patients on important activities of daily living (such as for example, driving and cooking). This302
could enable neuropsychologists to save time and costs compared to those of tests administered in the303
real environment. Moreover, it could be interesting to study the possibility offered by mobile virtual304
reality and tablets in USN rehabilitation programs. Such technologies, in fact, could make patients’305
homework and tasks more engaging, and consequently more effective, than traditional ones. Potentially,306
moreover, data collected about exercises made on tablet (scores at each task, frequency of use, etc.) could307
be tracked over time and integrated with other patient information, providing important information to308
the clinician.309
This study was supported by the Italian funded project “VRehab. Virtual Reality in the Assessment311
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 11
F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies 11
and TeleRehabilitation of Parkinson’s Disease and Post-Stroke Disabilities” – RF-2009-1472190. The312
authors are grateful to Fabio Ferrara and Valentina Virginia Zoffoli for their technical support in the313
development of Neglect App.314
Conflict of interest315
The authors declare that they have no competing interests.316
[1] Appelros P, Karlsson GM, Seiger A, Nydevik I. Neglect and anosognosia after first-ever stroke: incidence and relation-318
ship to disability. Journal of Rehabilitation Medicine. 2002; 34(5): 215-20.319
[2] Ringman JM, Saver JL, Woolson RF, Clarke WR, Adams HP. Frequency, risk factors, anatomy, and course of unilateral320
neglect in an acute stroke cohort. Neurology. 2004; 63(3): 468-74.321
[3] Heilman KM, Bowers D, Valenstein E, Watson RT. Hemispace and hemispatial neglect. Advances in Psychology. 1987;322
45: 115-50.323
[4] Buxbaum LJ, Ferraro MK, Veramonti T, Farne A, Whyte J, Ladavas E, et al. Hemispatial neglect: subtypes, neu-324
roanatomy, and disability. Neurology. 2004; 62: 749-56.325
[5] Azouvi P, Samuel C, Louis-Dreyfus A, Bernati T, Bartolomeo P, Beis JM, et al. Sensitivity of clinical and behavioural326
tests of spatial neglect after right hemisphere stroke. J ournal of Neurology, Neurosurgery & Psychiatry. 2002; 73: 160-6.327
[6] Bisiach E, Perani D, Vallar G, Berti A. Unilateral neglect: personal and extra-personal. Neuropsychologia. 1986; 24(6):328
[7] Heilman KM, Valenstein E, Watson RT. The what and the how of neglect. In: Halligan PW, Marshall JC, editors. Spatial330
neglect: position papers on theory and practice Hove, UK: Erlbaum; 1994. p. 133-41.331
[8] Robertson IH, Halligan JC. Spatial neglect: A clinical handbook for diagnosis and treatment. Hove, UK: Psychology332
Press; 2000.333
[9] Stone SP, Wilson B, Wroot A, Halligan PW, Lange LS, Marshall JC, et al. The assessment of visuo-spatial neglect after334
acute stroke. Journal of Neurology, Neurosurgery, and Psychiatry. 1991; 54.335
[10] Albert ML. A simple test of visual neglect. Neurology. 1973.336
[11] Vallar G, Perani D. The anatomy of unilateral neglect after right-hemisphere stroke lesions. A clinical/CT-scan correlation337
study in man. Neuropsychologia. 1986; 24(5): 609-22.338
[12] Diller L, Weinberg J. Hemi-inattention in rehabilitation. The evolution of a rational remediation program. In: Weinstein339
EA, Friedland RP-, editors. Hemi-inattention and hemisphere specialization. New York: Raven Press; 1977. p. 62-82.340
[13] Wilson B, Cockburn J, Halligan P. Behavioural inattention test. Titchfield, Hampshire, UK: Thames Valley Test Com-341
pany; 1987.342
[14] Weintraub S, Mesulam MM. Visual hemispatial inattention: stimulus parameters and exploratory strategies. Journal of343
Neurology, Neurosurgery, and Psychiatry. 1988; 51(12): 1481-8.344
[15] Perez-Garcia M, Godoy-Garcia JF, Vera-Guerrero N, Laserna-Triguero JA, Ouente AE. Neuropsychological evaluation345
of everyday memory. Neuropsychology Review. 1998; 8: 203-27.346
[16] Levick WR. Observer rating of memory in children: a review. Brain Impairment. 2010(11): 144-51.347
[17] Eslinger PJ, Grattan LM, Damasio H, Damasio AR. Developmental consequences of childhood frontal lobe damage.348
Archives of Neurology. 1992; 49: 764-9.349
[18] Eslinger PJ, Flaherty-Craig CV, Benton AL. Developmental outcomes after early prefrontal cortex damage. Brain and350
Cognition. 2004; 55: 84-103.351
[19] Vriezen ER, Pigott SD, Pelletier PM. Developmental implications of early frontal-lobe damage: a case study. Brain and352
Cognition. 2001; 47: 222-5.353
[20] Bonato M. Neglect and extinction depend greatly on task demands: a review. Frontiers in Human Neuroscience. 2012;354
6: 195.355
[21] Tsirlin I, Dupierrix E, Chokron S, Coquillart S, Ohlmann T. Uses of virtual reality for diagnosis, rehabilitation and study356
of unilateral spatial neglect: review and analysis. Cyberpsychology & behavior. 2009; 12(2): 175-81.357
[22] Chevignardi MP, Soo C, Galvin J, Catroppa C, Eren S. Ecological assessment of cognitive functions in children with358
acquired brain injury: a systematic review. Brain Injury. 2012; 26(9): 1033-57.359
[23] Guariglia C, Piccardi L. Environmental orientation and navigation in different types of unilateral neglect. Experimental360
Brain Research. 2010; 206: 163-9.361
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 12
12 F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies
[24] Buxbaum LJ, Palermo MA, Mastrogiovanni D, Schmidt Read M, Rosenberg-Pitonyak E, Rizzo AA, et al. Assessment of
spatial attention and neglect with a virtual wheelchair navigation task. Journal of Clinical and Experimental Neuropsy-363
chology. 2006; 30: 650-60.364
[25] Bohil CJ, Alicea B, Biocca FA. Virtual reality in neuroscience research and therapy. Nature Reviews Neuroscience. 2011;365
12(12): 752-62.366
[26] Rose FD, Brooks BM, Rizzo AA. Virtual reality in brain damage rehabilitation: review. CyberPsychology & Behavior.367
2005; 8(3): 241-62.368
[27] Gaggioli A, Riva G. Psychological treatments: smart tools boost mental-health care. Nature. 2014; 512(7512): 28-.369
[28] Deouell LY, Sacher Y, Soroker N. Assessment of spatial attention after brain damage with a dynamic reaction time test.370
Journal of the International Neuropsychological Society. 2005; 11: 697-707.371
[29] Schendel KL, Robertson LC. Using reaction times to assess patients with unilateral neglect and extinction. Journal of372
Clinical and Experimental Neuropsychology. 2002; 24: 942-50.373
[30] List A, Brooks JL, Esterman M, Fle-varis AV, Landau AN, Bowman G, et al. Visual hemispatial neglect, re-assessed.374
Journal of the International Neuropsychological Society. 2008; 14: 243-56.375
[31] Posner MI, Walker JA, Friedrich FJ, Rafal RD. Effects of parietal injury on covert orienting of attention. Journal of376
Neuroscience. 1984; 4: 1863-74.377
[32] Smania N, Martini MC, Gambina G, Tomelleri G, Palamara A, Natale E, et al. The spatial distribution of visual attention378
in hemineglect and extinction patient. Brain. 1998; 121: 1759-70.379
[33] Losier BJW, Klein RM. A review of the evidence for a disengage deficit following parietal lobe damage. Neuroscience380
& Biobehavioral Reviews. 2001; 25: 1-13.381
[34] Marzi CA, Natale E, Anderson B. Mapping spatial attention with reaction time in neglect patients. In: Karnath H-O,382
Milner AD, Vallar G, editors. The Cognitive and Neural Basis of Spatial Neglect. Oxford: University Press; 2002. p.383
[35] Tsirlin I, Dupierrix E, Chokron S, Coquillart S, Ohlmann T. Uses of virtual reality for diagnosis, rehabilitation and study385
of unilateral spatial neglect: review and analysis. Cyberpsychology & Behavior. 2009; 12(2): 2009.386
[36] Kim DY, Ku J, Chang WH, Park TH, Lim JY, Han K, et al. Assessment of post-stroke extrapersonal neglect using a387
three-dimensional immersive virtual street crossing program. Acta Neurologica Scandinavica. 2010; 121(3): 171-7.388
[37] Mesa-Gresa P, Lozano JA, Llórens R, Alcañiz M, Navarro MD, Noé E, editors. Clinical validation of a virtual environ-389
ment test for safe street crossing in the assessment of acquired brain injury patients with and without neglect. 13th IFIP390
TC 13 International Conference on Human-Computer Interaction 2011; Lisbon, Portugal.391
[38] Fordell H, Bodin K, Bucht G, Malm J. A virtual reality test battery for assessment and screening of spatial neglect. Acta392
Neurologica Scandinavica. 2011; 123(3): 167-74.393
[39] Peskine A, Rosso C, Box N, Galland A, Caron E, Rautureau G, et al. Virtual reality assessment for visuospatial neglect:394
importance of a dynamic task. Journal of Neurology, Neurosurgery & Psychiatry. 2011; 11(12): 1407-9.395
[40] Sugarman H, Weisel-Eichler A, Burstin A, Brown R, editors. Use of novel virtual reality system for the assessment and396
treatment of unilateral spatial neglect: a feasibility study. Virtual Rehabilitation (ICVR), 2011 International Conference397
on; 2011: IEEE.398
[41] Cipresso P, Albani G, Serino S, Pedroli E, Pallavicini F, Mauro A, et al. Virtual multiple errands test (VMET): a virtual399
reality-based tool to detect early executive functions deficit in Parkinson’s disease. Frontiers in Behavioral Neuroscience.400
2014; 8: 405.401
[42] Rand D, Rukan SBA, Weiss PL, Katz N. Validation of the virtual MET as an assessment tool for executive functions.402
Neuropsychological Rehabilitation. 2009; 19(4): 583-602.403
[43] Raspelli S, Pallavicini F, Carelli L, Morganti F, Pedroli E, Cipresso P, et al. Validating the neuro vr-based virtual version404
of the multiple errands test: preliminary results. Presence. 2012; 21(1): 31-42.405
[44] Weniger G, Ruhleder M, Lange C, Wolf S, Irle E. Egocentric and allocentric memory as assessed by virtual reality in406
individuals with amnestic mild cognitive impairment. Neuropsychologia. 2011; 49(3): 518-27.407
[45] Cánovas R, León I, Serrano P, Roldán M, Cimadevilla JM. Spatial navigation impairment in patients with refractory408
temporal lobe epilepsy: evidence from a new virtual reality-based task. Epilepsy & Behavior. 2011; 22(2): 364-9.409
[46] Morganti F, Stefanini S, Riva G. From allo-to egocentric spatial ability in early Alzheimer’s disease: a study with virtual410
reality spatial tasks. Cognitive Neuroscience. 2013; 4(3-4): 171-80.411
[47] Rabuffetti M, Ferrarin M, Spadone R, Pellegatta D, Gentileschi V, Vallar G, et al. Touch-screen system for assessing412
visuo-motor exploratory skills in neuropsychological disorders of spatial cognition. Medical and Biological Engineering413
and Computing. 2002; 40(6): 675-86.414
[48] Rabuffetti M, Farina E, Alberoni M, Pellegatta D, Appollonio I, Affanni P, et al. Spatio-temporal features of visual415
exploration in unilaterally brain-damaged subjects with or without neglect: results from a touchscreen test. PLoS One.416
[49] Vaes N, Lafosse C, Nys G, Schevernels H, Dereymaeker L, Oostra K, et al. Capturing peripersonal spatial neglect: an418
electronic method to quantify visuospatial processes. Behavior Research Methods. 2014; 47(1): 27-44.419
Galley Proof 14/08/2015; 8:53 File: THC1039.tex; BOKCTP/xhs p. 13
F. Pallavicini et al. / Assessing unilateral spatial neglect using advanced technologies 13
[50] Folstein MF, Robins LN, Helzer JE. The mini-mental state examination. Archives of General Psychiatry. 1983; 40(7):
[51] Zoccolotti P, Antonucci G, Judica A. Psychometric characteristics of two semi-structured scales for the functional eval-422
uation of hemi-inattention in extrapersonal and personal space. Neuropsychological Rehabilitation. 1992; 2(3): 179-91.423
[52] Zoccolotti P, Judica A. Functional evaluation of hemineglect by means of a semistructured scale: personal extrapersonal424
differentiation. Neuropsychological Rehabilitation. 1991; 1(1): 33-44.425
[53] Wilson BA. Ecological validity of neuropsychological assessment: Do neuropsychological indexes predict performance426
in everyday activities? Applied and Preventive Psychology. 1993; 2(4): 209-15.427
[54] Brooke J. SUS-A quick and dirty usability scale. Usability evaluation in industry. 1996; 189: 194.428
[55] Ronchi R, Posteraro L, Fortis P, Bricolo E, Vallar G. Perseveration in left spatial neglect: drawing and cancellation tasks.429
Cortex. 2009; 45(3): 300-12.430
[56] Broeren J, Samuelsson H, Stibrant-Sunnerhagen K, Blomstrand C, Rydmark M. Neglect assessment as an application of431
virtual reality. Acta Neurologica Scandinavica. 2007; 116(3): 157-63.432
[57] Eskes GA, Butler B. Using limb movements to improve spatial neglect: the role of functional electrical stimulation.433
Restorative Neurology and Neuroscience. 2006; 24: 385-98.434
[58] Reddon JR, Gill DM, Gauk SE, Marez ND. Purdue pegboard: test-retest estimates. Perceptual and Motor Skills. 1988;435
66: 503-6.436
[59] Tanaka T, Ifukube T, Sugihara S, Izumi T. A case study of new assessment and training of unilateral spatial neglect in437
stroke patients: effect of visual image transformation and visual stimulation by using a head mounted display system438
(HMD). Journal of Neuroengineering and Rehabilitation. 2010; 7(20).439
[60] Bartolomeo P, Chokron S. Orienting of attention in left unilateral neglect. Neuroscience & Biobehavioral Reviews. 2002;440
26(2): 217-34.441
[61] Zygouris S, & Tsolaki M. Computerized cognitive testing for older adults a review. American Journal of Alzheimer’s442
Disease and Other Dementias. 2015; 30(1): 13-28.443
... The authors identified 13 studies, that investigated test batteries of CB versions of conventional tasks, including tasks similar to line bisection (Chiba et al., 2010;Jee et al., 2015), cancellation (Rabuffetti et al., 2002(Rabuffetti et al., , 2012, baking tray (Chung et al., 2016) or combinations of different types of tasks (Liang et al., 2007;Ulm et al., 2013;Pallavicini et al., 2015;Vaes et al., 2015;Mizuno et al., 2016;Ten Brink et al., 2016;Quinn et al., 2018;Morando et al., 2019). Our synthesis included 11 studies exploring visual search tasks such as static (Mizuno et al., 2016;Machner et al., 2018;Ten Brink et al., 2020), feature and conjunction (List et al., 2008;Erez et al., 2009), dynamic and dual tasks (Marshall et al., 1997;Deouell et al., 2005;Van Kessel et al., 2013;Andres et al., 2019;Villarreal et al., 2020). ...
... Most cancellation tasks obtained measures including the number of touched (canceled) targets, revisits, intersections, omissions, center of cancellation (CoC) (Rabuffetti et al., 2002(Rabuffetti et al., , 2012Ulm et al., 2013;Pallavicini et al., 2015;Ten Brink et al., 2016). Line bisection tasks usually captured the mean deviation (Chiba et al., 2010;Ulm et al., 2013;Jee et al., 2015). ...
... In the course of this work, we discovered that (L/R) target detection Van Kessel et al., 2013;Pallavicini et al., 2015;Machner et al., 2018;Andres et al., 2019), hit rate (response rate) (Erez et al., 2009;Ten Brink et al., 2020), RT asymmetry scores (Deouell et al., 2005;Rengachary et al., 2009;Van Kessel et al., 2013;Machner et al., 2018) and the number of intersection (disorganized search) (Ten Brink et al., 2016) were all shown to be among the most sensitive measures for spatial bias and visual search deficits detection in patients with brain damage. ...
Full-text available
Background To date, no gold standard exists for the assessment of unilateral spatial neglect (USN), a common post-stroke cognitive impairment, with limited sensitivity provided by currently used clinical assessments. Extensive research has shown that computer-based (CB) assessment can be more sensitive, but these have not been adopted by stroke services yet.Objective We conducted a systematic review providing an overview of existing CB tests for USN to identify knowledge gaps and positive/negative aspects of different methods. This review also investigated the benefits and barriers of introducing CB assessment tasks to clinical settings and explored practical implications for optimizing future designs.MethodologyWe included studies that investigated the efficacy of CB neglect assessment tasks compared to conventional methods in detecting USN for adults with brain damage. Study identification was conducted through electronic database searches (e.g., Scopus), using keywords and standardized terms combinations, without date limitation (last search: 08/06/2022). Literature review and study selection were based on prespecified inclusion criteria. The quality of studies was assessed with the quality assessment of diagnostic accuracy studies tool (Quadas-2). Data synthesis included a narrative synthesis, a table summarizing the evidence, and vote counting analysis based on a direction of effect plot.ResultsA total of 28 studies met the eligibility criteria and were included in the review. According to our results, 13/28 studies explored CB versions of conventional tasks, 11/28 involved visual search tasks, and 5/28 other types of tasks. The vote counting analysis revealed that 17/28 studies found CB tasks had either equal or higher sensitivity than conventional methods and positive correlation with conventional methods (15/28 studies). Finally, 20/28 studies showed CB tasks effectively detected patients with USN within different patient groups and control groups (17/28).Conclusions The findings of this review provide practical implications for the implementation of CB assessment in the future, offering important information to enhance a variety of methodological issues. The study adds to our understanding of using CB tasks for USN assessment, exploring their efficacy and benefits compared to conventional methods, and considers their adoption in clinical environments.
... No adverse reactions, such as headache, fatigue, or boredom, have been reported. Conversely, digital tests have been evaluated as funnier, more precise and safer than the traditional paper-and-pencil ones (see, for instance, Pallavicini et al., 2015;Quinn et al., 2018;Smit et al., 2013;Ulm et al., 2013). ...
... Four studies (50%) reported convergent or discriminant validity. Ecological validity was underreported also in this group: only the article by Pallavicini et al. (2015) provided these measures. Finally, only two out of eight studies mentioned user experience reporting Quinn et al., 2018), showing high ratings of acceptance and usability of the NeglectApp and of the StrokeVision app. ...
Full-text available
Unilateral Spatial Neglect is a disabling neuropsychological deficit. Patients with spatial neglect fail to detect and report events, and to perform actions in the side of space contralateral to a hemispheric cerebral lesion. Neglect is assessed by evaluating the patients’ abilities in daily life activities and by psychometric tests. Computer-based, portable and Virtual Reality technologies may provide more and precise data, and be more sensitive and informative, compared to current paper-and-pencil procedures. Studies since 2010, in which such technologies have been used, are reviewed. Forty-two articles meeting inclusion criteria are categorized according to their technological approaches (computer-, graphics tablet or tablet-, virtual reality-based assessment, and other). The results are promising. However, a definite golden standard, technologically based procedure cannot be still established. Developing technologically based tests is a laborious process, which requires technical and user experience improvements as well as normative data, to increase the evidence of efficacy for clinical evaluation of at least some of the tests considered in this review.
... cancellation tasks). The adaptation used complex 3D stimuli and environments, allowing for a more advanced and complex investigation of neglect-related impairments (Fordell et al., 2011;Knobel et al., 2020;Pallavicini et al., 2015). ...
Neuropsychological testing aims to measure individu-als' cognitive abilities (e.g. memory, attention), analysing their performance on specific behavioural tasks. Most neuropsychological tests are administered in the so-called 'paper-and-pencil' modality or via computerised protocols. The adequacy of these procedures has been recently questioned , with more specific concerns about their ecological validity, i.e. the relation between test scores observed in the laboratory setting and the actual everyday cognitive functioning. In developing more ecological tasks, researchers started to implement virtual reality (VR) technology as an administration technique focused on exposing individuals to simulated but realistic stimuli and environments, maintaining at the same time a controlled laboratory setting and collecting advanced measures of cognitive functioning. This systematic review aims to present how VR procedures for neuropsy-chological testing have been implemented in the last years. We initially explain the rationale for supporting VR as an advanced assessment tool, but we also discuss the challenges and risks that can limit the widespread implementation of this technology. Then, we systematised the large body of studies adopting VR for neuropsychological testing, describing the VR tools' distribution amongst different cognitive functions through a PRISMA-guided systematic review. The systematic review highlighted that only very few instruments are ready for clinical use, reporting psychometric proprieties (e.g. validity) and providing normative data. Most of the tools still need to be standardised on large cohorts of participants, having published only limited data on small samples up to now. Finally, we discussed the possible future directions of the VR neuropsychological test development linked to technological advances. K E Y W O R D S cognitive assessment, neuropsychology, PRISMA, test, virtual reality, VR
... Paper-and-pencil versus computerized USN assessment (courtesy ofPallavicini et al., 2015b) ...
Full-text available
Unilateral spatial neglect (USN) is a frequent repercussion of a cerebrovascular accident, typically a stroke. USN patients fail to orient their attention to the contralesional side to detect auditory, visual, and somatosensory stimuli, as well as to collect and purposely use this information. Traditional methods for USN assessment and rehabilitation include paper-and-pencil procedures, which address cognitive functions as isolated from other aspects of patients’ functioning within a real-life context. This might compromise the ecological validity of these procedures and limit their generalizability; moreover, USN evaluation and treatment currently lacks a gold standard. The field of technology has provided several promising tools that have been integrated within the clinical practice; over the years, a “first wave” has promoted computerized methods, which cannot provide an ecological and realistic environment and tasks. Thus, a “second wave” has fostered the implementation of virtual reality (VR) devices that, with different degrees of immersiveness, induce a sense of presence and allow patients to actively interact within the life-like setting. The present paper provides an updated, comprehensive picture of VR devices in the assessment and rehabilitation of USN, building on the review of Pedroli et al. (2015). The present paper analyzes the methodological and technological aspects of the studies selected, considering the issue of usability and ecological validity of virtual environments and tasks. Despite the technological advancement, the studies in this field lack methodological rigor as well as a proper evaluation of VR usability and should improve the ecological validity of VR-based assessment and rehabilitation of USN.
... In turn, this technology helps to maintain a high experimental control in the evaluation process, providing internal validity and a high degree of control over the variables of content, the delivery and measurement of stimuli, and the measurement and storage of responses in clinical evaluation or rehabilitation settings [35][36][37]. Allain et al. [38] suggest that, due to their peculiarities, VR tests can identify subtle deficits that are often undetected by traditional neuropsychological tests [39] and, therefore, VR allows a more accurate assessment. It is important to emphasize that the technology does not make the test, but merely provides the means for obtaining the above advantages. ...
Full-text available
To characterize the attention deficits in one-hundred-fifteen participants, comprising two types of clinical profiles (affective and anxiety disorder), through a test of continuous VR execution. Method: Three tests (i.e., Nesplora Aquarium, BDI, and STAI) were used to obtain a standardized measure of attention, as well as the existence and severity of depression and anxiety, respectively. Results: Significant differences (CI = 95%) were found between the control group and the group with depression, in variables related to the speed of visual processing (p = 0.008) in the absence of distractors (p = 0.041) and during the first dual execution task (p = 0.011). For scores related to sustained attention, patients with depression and those with anxiety did not differ from controls. Our results suggest attentional deficits in both clinical populations when performing a continuous performance test that involved the participation of the central executive system of working memory.
This article describes how a neuropsychological assessment and rehabilitation are typically carried out using paper-and-pencil tools. However, these protocols cannot effectively evaluate the subject's performance of daily activities. More recently, the increasing accessibility of new and powerful technology has presented new possibilities. Virtual reality is one of the most promising tools with the increasing ecologicity in the neuropsychological field. The availability of new portable instruments has increased the accessibility and usability of this technology. Using this frame, the changes that have occurred over time in the neuropsychological practice up to the most recent VR-based tools have been explored. In particular, the focus will be on executive functions as the most sensitive cognitive domain within the ecological validity of the tools. In accordance with the literature, the authors show the potential for the use of virtual reality in the assessment and rehabilitation of executive functions, highlighting the advantages, limitations, and potential future challenges.
Focusing on healthcare, in the last few decades advanced technologies have become crucial keys in supporting subjective wellbeing. Among them, virtual reality has been proven to be effective for mental health promotion in several research studies. Although the dramatic development in the field of virtual reality system, there are still important problems related to the use of this technology. Within this perspective, the growing availability, low-cost and easy-to-use mobile virtual reality (i.e., the integration of virtual reality system on mobile devices such as smartphone and tablet) represents a meaningful opportunity to support mental health interventions. The chapter will first briefly describe mobile virtual reality. Then, a mobile virtual reality design practice will be presented. Finally, the current application of mobile virtual reality to enhance subjective wellbeing will be discussed with the support of concrete examples and research study analysis.
Full-text available
Introduction Numerous tests of visuo-spatial neglect (VSN) have been developed. In this study, we propose a clustering of VSN tests by making a distinction between static tests with low levels of cognitive demand (i.e. tests without movement or time-restrictions, such as paper-and-pencil tests) and dynamic tests with high levels of cognitive demand (i.e. tests incorporating movement and time-restrictions, such as virtual reality tests). The concepts of static and dynamic tests have not been systematically investigated so far. Here, we investigated (1) whether we would find dissociations between patients showing VSN on test within the static cluster but not on tests within the dynamic cluster, and vice versa; (2) whether differences in demographic or clinical characteristics could be identified between these groups of patients; and (3) whether the underlying factor structure would correspond to our proposed distinction between static and dynamic clusters of tests. Method Sixty-one patients with VSN completed three static tests (shape cancellation, line bisection, letter cancellation) and three dynamic tests (Catherine Bergego Scale, Mobility Assessment Course, simulated driving test). Results Thirteen percent of patients showed VSN on tests within the static cluster, 33% on tests within the dynamic cluster, and 54% on tests within both clusters. Patients with VSN on the dynamic tests (alone or in addition to static tests) had poorer motor function, poorer walking abilities and were more dependent in daily life than patients showing VSN on the static cluster alone. The underlying factor structure corresponded to our proposed conceptual distinction between static and dynamic clusters of tests. Conclusions Static and dynamic tests compose different clusters and double dissociations are shown between clusters. Future research involving data-driven approaches might result in a better understanding on how different tests of VSN relate to each other, and, more importantly, a better understanding of VSN and its phenotypes.
Full-text available
Aging is a condition that may be characterized by a decline in physical, sensory, and mental capacities, while increased morbidity and multimorbidity may be associated with disability. A wide range of clinical conditions (e.g., frailty, mild cognitive impairment, metabolic syndrome) and age-related diseases (e.g., Alzheimer's and Parkinson's disease, cancer, sarcopenia, cardiovascular and respiratory diseases) affect older people. Virtual reality (VR) is a novel and promising tool for assessment and rehabilitation in older people. Usability is a crucial factor that must be considered when designing virtual systems for medicine. We conducted a systematic review with Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines concerning the usability of VR clinical systems in aging and provided suggestions to structure usability piloting. Findings show that different populations of older people have been recruited to mainly assess usability of non-immersive VR, with particular attention paid to motor/physical rehabilitation. Mixed approach (qualitative and quantitative tools together) is the preferred methodology; technology acceptance models are the most applied theoretical frameworks, however senior adapted models are the best within this context. Despite minor interaction issues and bugs, virtual systems are rated as usable and feasible. We encourage usability and user experience pilot studies to ameliorate interaction and improve acceptance and use of VR clinical applications in older people with the aid of suggestions (VR-USOP) provided by our analysis.
Smart technologies present numerous opportunities for enhancing mobile health care. However, some concerns regarding the viability of smart technology applications must be addressed. This study investigated these concerns by reviewing the current practices of smart technology applications to mobile health care. As a result, five factors critical to the applicability of a smart technology to mobile health care are identified, and the fuzzy geometric mean-fuzzy analytic hierarchy process (FGM-FAHP) approach is proposed to assess the relative importance levels of the identified factors. The experimental results showed that the three most critical factors identified include: (a) the relaxation of the related medical laws; (b) unobtrusiveness; and (c) the precise need and situation of a user. Accordingly, approximately 44%, 26%, and 15% of the budget should be allocated to the realization of the three critical factors, respectively. In addition, the challenges involved and opportunities for enhancing the effectiveness of existing applications are discussed.
Full-text available
Introduction: Several recent studies have pointed out that early impairment of executive functions (EFs) in Parkinson’s Disease (PD) may be a crucial marker to detect patients at risk for developing dementia. The main objective of this study was to compare the performances of PD patients with mild cognitive impairment (PD-MCI) with PD patients with normal cognition (PD-NC) and a control group (CG) using a traditional assessment of EFs and the Virtual Multiple Errands Test (VMET), a virtual reality (VR)-based tool. In order to understand which subcomponents of EFs are early impaired, this experimental study aimed to investigate specifically which instrument best discriminates among these three groups. Materials and methods: The study included three groups of 15 individuals each (for a total of 45 participants): 15 PD-NC; 15 PD-MCI, and 15 cognitively healthy individuals (CG). To assess the global neuropsychological functioning and the EFs, several tests (including the Mini Mental State Examination (MMSE), Clock Drawing Test, and Tower of London test) were administered to the participants. The VMET was used for a more ecologically valid neuropsychological evaluation of EFs. Results: Findings revealed significant differences in the VMET scores between the PD-NC patients vs. the controls. In particular, patients made more errors in the tasks of the VMET, and showed a poorer ability to use effective strategies to complete the tasks. This VMET result seems to be more sensitive in the early detection of executive deficits because these two groups did not differ in the traditional assessment of EFs (neuropsychological battery). Conclusion: This study offers initial evidence that a more ecologically valid evaluation of EFs is more likely to lead to detection of subtle executive deficits.
Full-text available
Computerized as well as paper-and-pencil tasks are applied in mapping visuospatial neglect in experimental research and clinical practice. This article presents a new kind of computer-based assessment method, using an electronic pen display and user-friendly software. The approach is tailored to specific spatial processes and highlights the usefulness of a pen display in neglect patients. The advantages of the introduced method are illustrated by a recently designed battery of classic, as well as new, types of tests. The development of the appropriate stimuli and the assorted scoring systems is addressed, as well as the resulting types of task implementation and data generation. The diagnostic value of the different visuospatial neglect tests is demonstrated by comparative analyses between a neglect group and a control group. Among the benefits of the proposed assessment method are (1) the opportunity to perform standardized repeated measurements to quantify recovery, (2) online performance monitoring, (3) flexible employment, (4) the collection of exact data over a short period, and (5) the easy availability of more refined quantitative as well as interesting qualitative information, especially as compared to classic or paper-and-pencil tasks. To indicate that this method also lends itself well to measures for treatment procedures, an illustration is given with respect to specific measurements during prism adaptation. The tasks of the Visuospatial Neglect Test Battery and the prism adaptation measures are illustrated by a case study. The outlined applications are discussed with respect to experimental as well as clinical purposes.
Full-text available
Objective: This article is a review of computerized tests and batteries used in the cognitive assessment of older adults. Method: A literature search on Medline followed by cross-referencing yielded a total of 76 citations. Results: Seventeen test batteries were identified and categorized according to their scope. Computerized adaptive testing (CAT) and the Cambridge Cognitive Examination CAT battery as well as 3 experimental batteries and an experimental test are discussed in separate sections. All batteries exhibit strengths associated with computerized testing such as standardization of administration, accurate measurement of many variables, automated record keeping, and savings of time and costs. Discriminant validity and test-retest reliability were well documented for most batteries while documentation of other psychometric properties varied. Conclusion: The large number of available batteries can be beneficial to the clinician or researcher; however, care should be taken in order to choose the correct battery for each application.
Spatial neglect is a disorder of space-related behaviour. It is characterized by failure to explore the side of space contralateral to a brain lesion, or to react or respond to stimuli or subjects located on this side. Research on spatial neglect and related disorders has developed rapidly in recent years. These advances have been made as a result of neuropsychological studies of patients with brain damage and behavioural studies of animal models, as well as through functional neurophysiological experiments and functional neuroimaging. This book provides an overview of this wide-ranging field, providing a cohesive synthesis of the most recent observations and results. The study of spatial neglect helps us to understand normal mechanisms of directing and maintaining spatial attention and is relevant to the contemporary search for the cerebral correlates of conscious experience, voluntary action and the nature of personal identity itself. The book is divided into seven sections covering the anatomical and neurophysiological bases of the disorder, frameworks of neglect, perceptual and motor factors, the relation to attention, the cognitive processes involved, and strategies for rehabilitation.
Although case study methodology is popular in neuropsychology, there are few reports concerning frontal-lobe damage in children. We have had the opportunity to monitor the development of a child who sustained a penetrating left frontal injury at age 10 years over the 4.5 years postinjury. Her performance has consistently been average to above average on intelligence tests and intact on standardized tests of frontal-lobe function. However, she has required intensive professional support to address profound deficits in regulating behavior in daily activities. Academic skills have progressed only minimally and she has required placement in a program for children with developmental delays. This case illustrates that a frontal-lobe lesion in childhood can have profound impact on the development of adaptive and academic skills over time.
A patient with hemispatial neglect may fail to report, respond, or orient toward novel or meaningful stimuli presented in the hemispace contralateral to a brain lesion. Hemispatial neglect may be induced by a sensory-attentional, motor-intentional, memory, or an exploratory disorder. This chapter defines hemispatial neglect and describes how it may be tested in patients. There is a review of hemispace studies in normal subjects. The pathophysiology of the attentional, intentional memory, and exploratory defects is discussed. Finally, recovery of function and treatments are also discussed.
We have defined neglect as a failure to report, respond, or orient to novel or meaningful stimuli presented on the side opposite a brain lesion that cannot be attributed to either elemental sensory or motor deficits (Heilman, Watson, & Valenstein, 1993). Many subtypes of neglect have been described, distinguished by the distribution of abnormal behaviour (e.g. spatial versus personal neglect) and the means by which the abnormal behaviour is elicited (e.g. inattention versus extinction). Although at one time we thought that the variety of neglect subtypes could be explained by variations in severity and in means of elicitation, we currently believe that neglect is not a unitary disorder. There is increasing evidence that neglect can be subdivided by the presumed underlying mechanisms: inattention (sensory neglect), disorders of action and intention (motor neglect), and representational disorders.
Spatial neglect is a profound clinical problem as well as intriguing scientific problem. In the last ten years, there has been an explosion of interest in this disorder, which as a result is no longer viewed as a single entity, but rather as a number of different disorders. This book is an attempt to bring the reader up to date with the latest advances in understanding neglect, at least insofar as this contributes to better clinical assessment, management and treatment. This is not a book for the specialist researcher in the neuropsychology of neglect and attention. Rather, it is a book aimed at clinicians - student and trained - from all disciplines involved in the assessment, management and treatment of neglect. The book begins with the description of four cases manifesting different types of unilateral neglect. The reader is introduced to different aspects of neglect through these patients. These distinctions include those between personal and extrapersonal neglect, motor versus sensory neglect and many others. The reader is also introduced to other phenomena that are closely related to neglect, including ansognosia and impaired sustained attention. The latest methodes of assessment of neglect are also described, as are methods of treatment, again with reference to the four introductory specimen cases.