The Use of Virtual Reality Tools for the Assessment of Executive Functions and Unilateral Spatial Neglect

Abstract

Virtual Reality is one of the most promising tools in the development of new methods for neuropsychological assessment and rehabilitation. Neuropsychological assessment is typically carried out by administering paper-and-pencil tests to patients. However, these tests have some limitations, due to the fact that they are not effectively able to evaluate the subject's performance of daily activities. To cope with this void, neuropsychologists base their evaluation on their clinical experience, often successfully. Nevertheless, this is not an evidence-based practice, thus it is not considered optimal from a medical decision-making perspective. More recently, however, the increasing accessibility of advanced technology such as virtual reality has opened new possibilities for neuropsychological assessment and rehabilitation. Starting with this frame, the chapter explores the changes that have occurred over time in the neuropsychological assessment and rehabilitation up to the most recent VR-based tools. In particular, we will present a VR-based PC tool for the assessment of executive functions, and a VR-based mobile tool for the assessment and rehabilitation of unilateral spatial neglect. In accordance with the literature, we show the potential for virtual reality, highlighting the advantages, limitations, and the possible future challenges.

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DOI: 10.4018/978-1-4666-9740-9.ch007
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Virtual Reality is one of the most promising tools in the development of new methods for neuropsychological
assessment and rehabilitation. Neuropsychological assessment is typically carried out by administering
paper-and-pencil tests to patients. However, these tests have some limitations, due to the fact that they
are not effectively able to evaluate the subject’s performance of daily activities. To cope with this void,
neuropsychologists base their evaluation on their clinical experience, often successfully. Nevertheless,
this is not an evidence-based practice, thus it is not considered optimal from a medical decision-making
perspective. More recently, however, the increasing accessibility of advanced technology such as virtual
reality has opened new possibilities for neuropsychological assessment and rehabilitation. Starting with
this frame, the chapter explores the changes that have occurred over time in the neuropsychological
assessment and rehabilitation up to the most recent VR-based tools. In particular, we will present a VR-
based PC tool for the assessment of executive functions, and a VR-based mobile tool for the assessment
and rehabilitation of unilateral spatial neglect. In accordance with the literature, we show the potential
for virtual reality, highlighting the advantages, limitations, and the possible future challenges.
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Elisa Pedroli
Applied Technology for Neuro-Psychology Lab,
IRCCS Istituto Auxologico Italiano, Italy
Silvia Serino
Applied Technology for Neuro-Psychology Lab,
IRCCS Istituto Auxologico Italiano, Italy
Alice Chicchi Giglioli
Applied Technology for Neuro-Psychology Lab,
IRCCS Istituto Auxologico Italiano, Italy
Federica Pallavicini
Applied Technology for Neuro-Psychology Lab,
IRCCS Istituto Auxologico Italiano, Italy
Pietro Cipresso
Applied Technology for Neuro-Psychology Lab,
IRCCS Istituto Auxologico Italiano, Italy
Giuseppe Riva
Applied Technology for Neuro-Psychology Lab,
IRCCS Istituto Auxologico Italiano, Italy &
Catholic University of Milan, Italy

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The aim of neuropsychological assessment has extensively changed over time. Before the neuroimaging,
neuropsychological assessment was conducted for defining which brain area could have been damaged
after cerebral lesions and was an extension of the neurological examination (Benton, 1984). After the
diffusion of the neuroimaging techniques (for example, TAC), it has been possible to better determine
the brain area damaged and the neuropsychological assessment aims to evaluate cognitive functioning
in order to develop a personalized rehabilitation program (Ruff, 2003).
However, the change in the purpose of neuropsychological assessment did not initially lead to a change
in the used tools. Typically, the neuropsychological assessment is carried out through the administration
to patients of paper-and-pencil tests. This approach presented some limitations in the area of ecological
validity, the degree of relevance or similarity of a test or training system with respect to the real world
and in its value for predicting or improving daily functioning (Parsons, 2011; Wilson, 1998)
With the dramatic advances of new technologies, there has been a change in neuropsychological
assessment. More specifically, thanks to computer-based tools it is possible an easy and standardized
administration, an automatic data recording, and a quick correction of test. On one side, the traditional
classical paper-and-pencil tests have been translated into their computer-based version, and, on the other
side, more recently, new tests have been developed using Virtual Reality (VR). Unlike paper-and-pencil
tests computer-based, that do not seek to develop new tests but mimic existing ones, tests that use VR
has allowed the development of new tests able to assess specific cognitive functions in a similar real
environment.
VR is a technology that has the potential to enhance the abilities to assess various cognitive domains to
identify particular deficits and target real-life activities (Bohil, Alicea, & Biocca, 2011; Riva & Gaggioli
2009; Rose, Brooks, & Rizzo, 2005). VR is usually defined as a computer-simulated life composed by 3D
environments, in which user can interact with the environment as if it were the real world (Biocca, 1992).
Indeed, virtual environments can represent many everyday life scenarios in order to reproduce lifelike-
experience, generating a similar real physical presence and recreating similar real sensory experiences.
The sensory experiences, including virtual sight, sound and touch, are generated by the integration of
input devices, such as stereoscopic displays (Head-Mounted displays), specific sound speakers and/or
headphones, and haptic systems (wired gloves).
In neuropsychology, VR offer to patients the possibility to be active participants within realistic vir-
tual environments and not only passive viewers of their assessment and rehabilitation programs (Riva,
Mantovani et al. 2004), and to clinicians to precisely record the individual’s performance in controlled
situations (Brooks & Rose, 2003).
In literature there are many studies that showed that VR is a promising tool for the assessment and
rehabilitation of cognitive functions (Kim, Chun, Yun, Song, & Young, 2011; Jebara, Orriols, Zaoui,
Berthoz, & Piolino 2014; Pedroli, Serino, Cipresso, Pallavicini, & Riva, 2015; Raspelli et al., 2012). You
and colleagues (You et al., 2005) showed, through fMRI, that virtual environments and situations are
able to activate the same brain areas involved in the real experiences. Furthermore, the high ecological
validity of VR allow to user to perceive the virtual environment as real, tending to transfer the expected
capabilities and skills from the virtual world to the real one in a almost automatic way (Brooks & Rose,
2003).
Furthermore, VR offers several features for improving neuropsychological assessment: controlled and
safe settings, multimodal and multiple stimulation, and feedback about answers, (Bohil, Alicea, & Biocca,

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2011; Riva, Mantovani et al. 2004; Schultheis & Rizzo, 2001). VR also allows controlling and manipulating
the tasks (for example it is possible to change the difficulty levels of a task), keeping a high ecological
validity and engaging patients in their assessment and rehabilitation program (Riva & Gaggioli, 2009).
The high level of engagement derives from a process call “transformation of flow”, that is the ability of
a subjects to use an optimal (flow) experience to discover and use psychological resources as sources of
involvement (Csikszentmihalyi & Csikszentmihalyi, 1988; Csikszentmihalyi, 1998; Riva, Castelnuovo,
& Mantovani, 2006). It’s also important understand the limits of the VR systems in the clinical settings.
Firstly, specific VR environments and tasks for neuropsychological assessment and rehabilitation may
require high costs both for the development of hardware and software applications, high professional
skills, and not all the hospitals can invest in targeted technological development. Then, the maintaining
of the equipment and the technical support over time might be expensive. Secondly, the development of
new functional tasks and environments requires a close collaboration between neuropsychologists and
technicians, and this collaboration is not always possible or easy. Thirdly, it is hard to find a setting and
an adequate number of patients for testing clinical VR applications. Finally, in general, technologies don’t
allow applying normative data and don’t provide additional useful information to neuropsychologists
(Parsey & Schmitter-Edgecombe, 2013; Parsons, Courtney, & Dawson, 2013).
Because of these reasons, among clinicians and researchers there is low availability of standardized
protocols that can be shared (Riva, 2009; Tsirlin, Dupierrix, Chokron, Coquillart, & Ohlmann, 2009).
In the literature there are a lot of example of VR applications for the assessment and rehabilitation
of several cognitive domains: memory (Jebara, Orriols, Zaoui, Berthoz, & Piolino, 2014), executive
functions (Climent-Martinez et al., 2014; Parsons, Courtney, & Dawson, 2013), unilateral spatial neglect
(Fasotti & van Kessel 2013, Mainetti, Sedda, Ronchetti, Bottini, & Borghese, 2013; Navarro, Lloréns,
Noé, Ferri, &Alcañiz, 2013), dementia (Allain et al., 2014; Cipresso et al., 2014). Starting from these
premises, this chapter aims to present two VR applications for the neuropsychoogical assessment and
rehabilitation, one for one for executive functions and one for unilateral spatial neglect.
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Executive functions are one of the most investigated neuropsychological domains and their complexity
makes it an excellent candidate for the VR applications.
Executive functions allow us to respond both to environmental and internal requests thanks to the
ability to manage and orienting the needed cognitive resources. Specifically, the term “executive func-
tions” not define only a simple domain but include a large number of cognitive processes and behavioral
capabilities like: problem-solving, planning, sequencing, the ability to sustain attention, resisting to inter-
ference, utilize of feedback, multitasking, cognitive flexibility, etc. (Burgess, Veitch, de Lacy Costello,
& Shallice, 2000; Chan, Shum, Toulopoulou, & Chen, 2008; Grafman & Litvan, 1999).
Several neurological impairments that involve the frontal cortex or some related structure can lead
to impairments of executive functions, and these impairments have been called the “Dysexecutive Syn-
drome” (Bechara, Damasio, Damasio, & Anderson, 1994; Robertson, Manly, Andrade, Baddeley, &
Yiend 1997; Snyder, Miyake, & Hankin, 2015).
The assessment of executive functions has been generally performed for clinical use and clinicians
usually use paper-and pencil tests or laboratory tasks. In the last years, an increasing number of tests
have been developed for the assessment of different kind of patients (Chan, Shum, Toulopoulou, &

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Chen, 2008). For example, the assessment protocol may include a single task for the evaluation of a
single cognitive process, like the Wisconsin Card Sorting Test, that exams the ability to shift cognitive
strategies in response to environmental changes (Anderson, Damasio, Jones, & Tranel, 1991; Caffarra,
Vezzadini, Dieci, Zonato, & Venneri, 2004) or the Tower of London for problem solving abilities (Al-
lamanno, Della Sala, Laiacona, Pasetti, & Spinnler 1987; Shallice, 1982). Among the various specifics
neuropsychological tests on the executive functions, there are also tests batteries, including the entire
executive functioning, as the Frontal Assessment Battery (FAB) (Appollonio et al., 2005; Dubois,
Slachevsky, Litvan, & Pillon, 2000).
Interestingly, many patients with Dysexecutive Syndrome show normal scores on traditional neu-
ropsychological tests and, at the same time, they complain important difficulties in daily life activities
(Shallice & Burgess, 1991). This problem may result from a lack of ecological validity of the tests,
which is a critical issue of the classical assessment of executive functions (Chan, Shum, Toulopoulou,
& Chen, 2008).
The traditional assessment does not capture the complexity of executive functions in a real environ-
ment. An ecological assessment is crucial to evaluate if patients are able to effectively manage and
orienting cognitive resources within the complexity of external world. This kind of assessment may of-
fer a deeper comprehension of the neuropsychological profile of the patient and it may guide the future
personalized rehabilitation.
These considerations should direct the clinician and researchers to develop more ecological tasks
for executive functions assessment. Some tasks have already been developed with these features: the
Behavioral Assessment of the Dysexecutive Syndrome (BADS) (Perfetti et al., 2010; Wilson, Krabben-
dam, & Kalff, 1997) and the Multiple Errands Test (MET) (Alderman, Burgess, Knight, & Henman,
2003; Shallice & Burgess, 1991).
More specifically, BADS (Perfetti et al., 2010; Wilson, Krabbendam, & Kalff, 1997) is a laboratory-
based battery that includes ecological tasks (temporal judgement, rule shift cards, action program, key
search, Zoo map, modified six) and a dysexecutive questionnaire. The questionnaire is formed by 20
questions that investigate several domains like: emotional or personality, motivational, behavioral, and
cognitive changes.
Instead, the MET (Alderman, Burgess, Knight, & Henman, 2003; Shallice & Burgess, 1991) is a
functional test, specifically developed for high functioning patients that take place in a real shopping
mall or in a hospital shop. More specifically, the MET includes two versions: the simple version (Alder-
man, Burgess, Knight, & Henman, 2003) and the hospital one (Knight, Alderman, & Burgess, 2002).
In the simplified version patients have to make three main tasks: buying six items (e.g., small brown
loaf), finding and remember four items of information (e.g., the closing time of the library on Saturday)
and meeting the clinician at a designated point. Also, the patients have to stating the time 20 minutes
after beginning the test. During the test patients have to follow several rules, such as for instance: “Do
not speak to the person observing you unless this is part of the exercise”. This procedure can be defined
as “open” or “ill-structured” because there are many outcomes: patients have several options and these
choices can allow both right and wrong outcomes (Goel, Grafman, Tajik, Gana, & Danto, 1997).
For this reason clinician follows the patients during the task, both to control it and to score errors like
task failure (e.g., forget the closing time of the library) or rule breaking (e.g., shouted question to shop
staff). The MET has good ecological validity (Burgess et al., 2006) and requires the implementation
of several executive functions: actions plan, list the necessary steps, describe and check the goals and
compare the outcome with the desired aim.

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Despite the many virtues, the test also presents limitations: the participants require good motor skill
to go to a real shop, the protocol is time consuming, both for patient and therapist, and all the procedure
could be particularly challenging for a patient with medium or severe cognitive impairment. Moreover,
the real environment (i.e., the supermarket) is not a controlled and safe setting, and it is not possible to
maintain an experimental control over the stimuli presentation. In order to overcome these limitation,
Riva and his team developed and tested a virtual version of the Multiple Errands Test (VMET) using
the software NeuroVR (http://www.neurovr.org).
The VMET consists of a Blender-based application
1
that allows an active exploration of a virtual
supermarket where participants are requested to select several products on shelves.
Moreover, the participant is able to navigate in the supermarket using up-down joypad arrows and to
collect products by pressing a button placed on the right side of the joypad, after having selected them
with the viewfinder. The virtual supermarket contains products grouped into the main grocery categories
(beverages, breakfast foods, garden products, hygiene products, fruits and vegetables, frozen foods, and
animal products) indicate at the top of each section with a signboard (See Figure 1).
The procedure of the task has been adapted by Shallice and Burgess (Alderman, Burgess, Knight,
& Henman, 2003; Shallice & Burgess, 1991). Before the task, patients undergo a training session in
another supermarket in order to understand how joypad works and how to move in the environment.
After the training session the examiner shows the shop where the test takes place and describe all
the sections. Then, the clinician gives a shopping list, a supermarket’s map, some information about the
Figure 1. The Virtual Multiple Errands Test (VMET): a screenshot of the Virtual Supermarket

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supermarket (opening and closing time, products in sales, etc.), a pen, and a wristwatch to the partici-
pants. Moreover, the clinician illustrates the rules and the instructions to ensure they are fully understood.
When he finished the explanation makes starting the stopwatch.
The four main tasks of the test are: find and buy the six items on the list, ask information about one
item to the examiner, write what products you bought after five minutes from start and answer a series
of questions after finishing the task using the given materials.
The rules are as follows:
• You have to execute all the proposed tasks, but you can run them in any order;
• You cannot go in a place unless this is a part of a task;
• You cannot pass through the same passage more than once;
• You cannot buy more than two items per categories (look at the chart);
• Take as few time as possible to complete this exercise however without hurry;
• Do not talk to the researcher unless this is a part of the task;
• Go to your “shopping cart” after 5 minutes from the beginning of the task and make a list of all
the products that you bought.
During the test, the examiner can’t talk with participant, not even to answer to the questions. When
the participant said, “I finished” the clinician stops the time. During the task, the examiner records all
participants’ behaviors in the virtual supermarket. The errors were divided as following, as suggest
Shallice and Burgess (Shallice & Burgess, 1991):
• Task failure, namely a task not completed satisfactorily;
• Inefficiencies and strategies, where a more effective strategy could have been applied to accom-
plish the task;
• Rule Breaks, where a specific rule listed in the instructions has been violated;
• Interpretation failures, where the requirements of a particular task are not misunderstood.
In the following we illustrate the different studies carried out with the VMET with different clini-
cal population in order to investigate the potentiality of this VR-based tools in capturing the executive
functioning.
It is crucial to note that Chan and colleagues (Chan, Shum, Toulopoulou, & Chen, 2008) reminded to
pay attention in using technology in clinical settings because it may be difficult for the elderly patients
who are not familiar with computers. To get on top of this issue, Pedroli and colleagues (Pedroli, Cipresso,
Serino, Riva, & Albani, 2013) analyzed the usability of the VMET in a sample of 21 healthy participants
and 3 Parkinson’s disease (PD) patients. They administered The System Usability Scale (SUS) to assess
the usability. This test is a “quick and easy to use” measure developed by Brooke (Brooke, 1996), who
defined the usability as “the subjective perception of interaction with a system”. Results showed that
healthy participants had perceived a good usability for the VMET. On the other side, for the patients
is crucial an intensive training phase before the test. These encouraging results led us to consider the
VMET as a useful tool to evaluate executive deficits in every sample, even with elderly subjects with
motor impairment.
The reliability of the VMET was evaluated by Cipresso and colleagues (Cipresso, Serino, Pedroli,
Albani, & Riva, 2013) using two different experiment: in the first, 2 independent researchers analyzed

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11 videos in which 11 healthy subjects were tested with VMET; in the second one 7 researchers scored
2 videos of 2 healthy subjects running the VMET. The results of both studies showed that the test have a
good reliability. On the other side, the VMET has been validated by different groups on different clinical
populations that may show signs of a dysexecutive syndrome or some impairment in executive functions.
Respelli and colleagues (Raspelli et al., 2012) carried out the first study on a clinical sample. They
have analyzed three groups (9 post-stroke participants, 10 healthy young participants, and 10 healthy
older participants) in order to demonstrate the ecological validity and initial construct validity of the
VMET. All groups were tested with VMET and a neuropsychological battery that focuses mainly on
executive functions. The results showed a significant correlation between some variables of VMET and
some traditional executive functions neuropsychological tests. Moreover, the performance obtained at
the VMET showed a distinction between clinical and control group and between the two age control
groups. These outcomes offer preliminary evidence of the ecological and construct validity of the VMET.
At the same time, La Paglia and colleagues (La Paglia, La Cascia, Rizzo, Riva, & La Barbera, 2012)
assessed, with VMET, 10 patients suffering from obsessive-compulsive disorder (OCD) and 10 con-
trols. They used the VMET to evaluate the executive functions in daily life and a neuropsychological
battery to test the executive functions in laboratory. The results showed that OCD patients spent more
time than normal subjects to complete the task; it is possible to suppose that this extra time is used to
planning. Furthermore, patients showed more problems in following rules and sustaining attention than
healthy subjects.
In the 2013, Cipresso and colleagues (Cipresso et al., 2013) analyzed a similar sample (OCD patients)
to investigate deficits of volition during the assessment with VMET.
The sample included 30 participants: 15 OCD patients and 15 controls. The subjects were monitored
during task execution and the relative interferences.
OCD patients showed a specifically pattern of deficits, as defined in the following classification:
1. Break in time (i.e.: go to the shopping chart after 5 min);
2. Break in choice (i.e.: buy two products instead of just one);
3. Break in social rules (i.e.: go into a specific place and to ask the examiner what to buy”)
One of the main fields of application for the VMET is the assessing of the executive functions in
Parkinson’s disease (PD).
As we shall see below, the cognitive disorders in this condition may overshadow compared to other
neurological disorders, probably because the motor symptoms are prevalent. It’s important the early
identification of executive deficits in PD because it could facilitate the identification of patients at risk
of dementia. Having an early diagnosis could give the chance to develop early rehabilitation in order
to avoid a quick cognitive decline. Despite the heterogeneity of the cognitive patients’ profile, the core
of the cognitive impairment of PD patients is composed by the executive functions (Ceravolo, Pagni,
Tognoni, & Bonuccelli, 2012; McKinlay, Grace, Dalrymple-Alford, & Roger, 2010). The impairment
in the executive functions in PD patients is a little different to those seen in patients with a frontal lobe
damage because involve a dysfunction of the front striatal neural circuitry (Rogers et al., 1998; Rowe
et al., 2002).
In such context, Albani and colleagues (Albani et al., 2011) investigated the correlation between
decision-making and alteration of sleep structure in 12 PD patients with and 14 controls. These altera-
tions regard early-middle stages of Parkinson’s disease and may lead to daytime drowsiness, loss of at-

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tention and concentration, feeling of tiredness. All patients have undergone polysomnography, complete
neuropsychological assessment and VMET. Five PD patients showed sleep abnormalities and significant
differences in the VMET performance compared to other patients with normal sleep and controls.
Few years later, Cipresso and colleagues (Cipresso et al., 2014) analyzed the performance of three
groups (15 PD patients with mild cognitive impairment, 15 PD patients with normal cognition and 15
healthy subjects) using a complete neuropsychological battery and the VMET. The aim of the study was
to understand which instruments best discriminates between these three groups and investigated which
components of executive functions are the most damaged. Significant differences in the VMET score
were found between PD patients with normal cognition and control patients. Specifically PD patients
made more errors in the VMET tasks, and showed a poorer ability to use effective strategies to complete
the tasks. No difference was found in the classical neuropsychological tests. This is an important results
because show that VMET result seems to be more sensitive in the early detection of executive deficits
in PD patients and offers initial evidence that an ecologically evaluation of executive functions is more
effective than classic paper-and-pencil tests.
In conclusion, the mentioned studies showed that technologies, in particular VMET, seems sensitive
to assess some aspects of executive functions in ecological setting, offering a more accurate evaluation
of the patient’s deficits that are difficult to reveal with traditional tests. Indeed, as previously exposed,
patients with assumed executive deficits might perform as well as control subjects on traditional tests,
but finding difficulties in daily life activities. Therefore, VR seems to allow overcoming these obstacles
by providing tasks in real-life situations, so that it is possible to structure rehabilitative processes better
targeted on the specific needs of each patient.
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A patient who had a stroke can show two types of consequences: motor disability (including the inability
to walk, problems with coordination and balance, hemiparesis or hemiplegia) and cognitive impairments
(including memory, visuo-spatial or executive functions impairments or aphasia) (Hendricks, van Lim-
beek, Geurts, & Zwarts, 2002; Langhorne, Coupar, & Pollock, 2009; Lloyd-Jones et al., 2009, Sundar &
Adwani, 2010). Almost 50% of stroke patients show, as cognitive impairment, Unilateral Spatial Neglect
(USN) (Appelros, Karlsson, Seiger, & Nydevik, 2002; Bowen, McKenna, & Tallis, 1999; Ringman,
Saver, Woolson, Clarke, & Adams, 2004).
USN can be due to damage of the following areas: the parietal, temporal and/or frontal cortex and,
less frequently, subcortical nuclei (Buxbaum et al., 2004). USN, in 90% of cases, occurs after right
hemisphere’s lesions and neglect symptoms occurs mainly in the left personal, peripersonal, and/or
extrapersonal space or imaginative domain (Bisiach, Perani, Vallar, & Berti 1986; Heilman, Watson, &
Valenstein, 1993; Robertson & Halligan, 1999). The USN patients have usually problems to find, pay
attention and oriented to stimuli located in contralesional space, and these problems do not result from
a sensory or motor impairments. (Azouvi et al., 2002; Bisiach, Perani, Vallar, & Berti, 1986; Heilman,
Bowers, Valenstein, & Watson, 1987; Husain, 2008).
Patients with USN may show a large variety of symptoms in everyday life, like forgetting to look left
before crossing the street, eating food only on the right side of the plate or shave only half of the face.

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Also, USN is a poor prognostic sign for both motor and cognitive rehabilitation outcomes (Buxbaum et
al., 2004, Jehkonen, Laihosalo, & Kettunen, 2006; Mutai, Furukawa, Araki, Misawa, & Hanihara, 2012).
In the clinical setting USN is evaluated using paper-and-pencil tests. Among these, the most used are
the cancellation tasks: patients have to detect specific targets mixed with distractor to improve difficulty.
These tests, among others, include cancellation of line (Albert, 1973), circles (Vallar & Perani, 1986),
letters (Diller & Weinberg, 1977) and stars (Wilson, Cockburn, & Halligan, 1987).
Although paper-and-pencil tests are widely used by clinicians, several studies showed some impor-
tant limitations. Rengachary and colleagues (Rengachary, d’Avossa, Sapir, Shulman, & Corbetta, 2009)
underlined that paper-and-pencil tests might be particularly poor in detecting USN symptoms, especially
in the chronic stage. Several researches showed that paper-and-pencil tests lack of ecological validity
(Levick, 2010; Perez-Garcia, Godoy-Garcia, Vera-Guerrero, Laserna-Triguero, & Ouente, 1998). More-
over, other studies reported some inconsistencies between the performance in the paper-and-pencil test
and the problems occurring in the real life (Bonato, 2012; Eslinger, Flaherty-Craig, & Benton, 2004;
Eslinger, Grattan, Damasio, & Damasio, 1992; Riva, 2009; Tsirlin, Dupierrix, Chokron, Coquillart,
& Ohlmann, 2009; Vriezen, Pigott, & Pelletier, 2001). Eventually, these tasks don’t reply problems of
USN patients occurring in real life but, given the complexity of daily life activities, it is extremely hard
to measure them in a useful way (Chevignard, Soo, Catroppa, & Eren, 2012).
Also, one of two major methods of rehabilitation (visual search) involves paper-and-pencil tasks and
meant to improve voluntary exploration of the contralesional space (Paci, Matulli, Baccini, Rinaldi, &
Baldassi 2010; Pierce & Buxbaum, 2002). This kind of training has the same limitation and problem that
we mentioned before about paper-and-pencil assessment. The other method is the stimulations techniques
like prismatic adaptation or caloric, galvanic and optokinetic stimulation and aims to implicitly force
the patients to explore contralesional space (Kerkhoff & Schenk, 2012).
Neither of these two methods is the gold standard of the rehabilitation of USN (Bowen, Lincoln, &
Dewey, 2007; Pierce & Buxbaum, 2002), but the recommendation is to use both methods combined
(Kerkhoff & Schenk, 2012).
Because paper-and-pencil tasks required acting only in the near space using these tools can only
diagnose of peripersonal USN and we can’t say anything about the elaboration of extrapersonal space
(Aravind & Lamontagne, 2014; Deouell, Sacher, & Soroker, 2005; Kim et al., 2010; Robertson & Hal-
ligan, 1999). In the real environment are required dynamic responses to the relevant and dynamic stimuli
that, both in personal and extrapersonal space (Buxbaum et al., 2008; Deouell, Sacher, & Soroker, 2005;
Kim et al., 2010).
Moving stimuli are crucial also for rehabilitation because modulate visual attention in order to capture
and drive the patient’s attention to the left side of space. Several studies showed that moving items in the
left side of space improved the performance in that area (Butter, Kirsch, & Reeves, 1990; Mattingley,
Bradshaw et al. 1994; Tanaka, Ifukube et al., 2010).
One solution for the problems of USN assessment and rehabilitation are the computerized methods
(Bonato, 2012; Bonato & Deouell, 2013; Dalmaijer, Van der Stigchel, Nijboer, Cornelissen, & Husain,
2014; Deouell, Sacher, & Soroker, 2005; Rabuffetti et al., 2012; Vaes et al., 2014). Computerized tests
are able to identify deficits that a static paper-and-pencil test might miss.
In particular, these tests provide a more detailed and precise recording of behavior during the assess-
ment (Deouell, Sacher, & Soroker, 2005; Schendel & Robertson, 2002), for example a computer-based
assessment are able to analyze the speed of processing of contralesional hemispace (Bonato, Priftis,
Marenzi, Umiltà, & Zorzi, 2012; List et al., 2008; Schendel & Robertson, 2002).

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As previously explained, VR is the most promising solutions to improve the quality of neuropsy-
chological practice. This technology can make neuropsychological assessment and rehabilitation more
involving, generalizable and ecological. This is possible because VR-based software is able to measure
behavior in valid, safe and controlled environments objectively and automatically. Also, the dynamic
learning may increase engagement of the patients. (Brooks & Rose, 2003; Kim, Chun, Yun, Song, &
Young, 2011; Kim, Ku et al., 2010; Mesa-Gresa et al., 2011; Riva, 2009; Sugarman, Weisel-Eichler,
Burstin, & Brown, 2011).
Pedroli and colleagues (Pedroli, Serino, Cipresso, Pallavicini, & Riva, 2015) in their review argued
that VR provides an innovative human-computer interface that allows the USN patients to interact with
and become immersed in a virtual environment like the real one. The results obtained are promising and
showed that VR stimulate and increase interest and participation of patients to rehabilitation excercises.
Indeed, VR simulations can be able to support “transformation of flow” (Riva, Castelnuovo, & Man-
tovani, 2006), defined as the ability to identify and use an optimal experience (i.e., flow) to promote
new psychological resources.
Mobile devices, like tablet, could be a solution of part of the problems mentioned before: these tools
support interactive VR environments, are easy to use and cheapest than traditional settings for VR.
Unfortunately, few study investigated the application of this technology for neuropsychological use
(Rabuffetti et al., 2012; Vaes et al., 2014).
In their study Rabuffetti and colleagues (Rabuffetti et al., 2012) analysed the adaptation of a can-
cellation test on a touchscreen interface monitor, similar to a tablet in brain-damaged subjects with
or without USN. The results showed that touchscreen-based assessment had evidenced disorders in
spatial exploration also in patients without clinically diagnosed USN. Even, Vaes and colleagues (Vaes
et al., 2014), developed a tablet version of a neuropsychological battery that included cancellation and
navigation tasks. They compare the performances at the test using 26 variables and found that 21 were
significantly different between the neglect and non-neglect groups.
A further step should be trying to developed tasks that exploit the specific features of tablets, such
as the possibility to play interactive virtual environments and its graphics capabilities.
The new field of “mobile virtual reality” (Pallavicini et al, in press), that is the applications of VR
on mobile devices have great potentiality for neuropsychology but, unfortunately, is not adequately
explored yet.
After this assumption, we developed a new mobile applications, called “Neglect App” (https://itunes.
apple.com/it/app/neglect-app/id788480837?mt=8) designed and developed for tablet (iPad) for assess-
ment and rehabilitation of neglect.
Neglect App can be used with the aid of a stylus for touch screens, on an IPad (Version 2.0 with IOS
7.1). We used a DTU-2231 from Wacom, because of its active area of 47.70 × 26.82 cm (total iPad screen
size of 56.39 × 37.34 cm). The pen is wireless and battery-free (based on electromagnetic resonance).
Neglect App contains a series of task for the assessment and rehabilitation of the neglect that took
place in interactive virtual environments.
Before starting the tasks, patients underwent training in order to better understand how the tablet
works. Their practice to perform basic actions that will be required for the exercises: dragging and click-
ing the objects and moving in the virtual environment. They are also shown which are the buttons that
the patient will have to use to start and finish the exercise.
Every task is briefly explained by a voice the indications can be replayed until the patient is sure to
understand them. In order to start the exercise patient have to touch the “start” button and, when he fin-

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ish, have to push the “stop” button. These buttons also control the recording of the time that the patient
spend to complete the task. The time starts when patient pushes the “start” button and finishes when
patient touches the “stop” button.
In the assessment part, called “TEST”, there are two sections with different kind of tasks: the “Func-
tional” and “Barrage” task.
The “Functional” section includes 5 tasks, the first two exercises (Serve Tea and Card Dealing) recre-
ate, in a virtual environment on the tablet, two test of the ecological battery of Zoccolotti (Zoccolotti &
Judica, 1991; Zoccolotti, Antonucci, & Judica, 1992). All the tests will be described below (See Figure 2).
• Serve Tea: the patient have to use all objects put in the center of the table in order to set the table
for four people and serve the tea for all ones. The software record the number of correct objects
(correct targets) and the number of objects dealt in excess (error) on the left, on the center and on
the right side of the table.
• Card Dealing: the patient have to give three cards for a game to himself/herself and to each one
of the three persons seated and four in the middle of the table. The software record the number of
cards correctly given (correct targets), the number of cards not deal (omissions) and the number of
cards dealt in excess (error) on the left, on the center and on the right side of the table.
• Controlling an Orders List: the patient should make sure that the dishes marked on the list are
present on the shelves in front of him. The software record the number of dishes and items on the
Figure 2. An example of “Functional Test”

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list correctly select (correct targets), the number of dishes and items on the list omitted (omissions)
and the number of dishes incorrectly selected (error) in the right and in the left side of the screen.
• Exploration: The patient must touch and say the name of all the objects in a virtual room. In this
task objects can be either right or left depending on how the subject is moving in the room. The
software record the number of selected objects (correct targets) in the left and in the right side of
the screen and the total number of omitted objects (omissions).
• Apple’s Pursuit: the patient must try to find all the apples that are located within an office. Apples
touched disappear. In this task there is a fixed viewpoint and then objects can be either right or left
depending on how the subject is moving in the room. The software records the number of selected
apples (correct targets) in the left side and on the right side and the total number of omitted apples
(omissions).
The “Barrage” section includes four tests similar to the classic cancellation tests (Albert, 1973; Diller
& Weinberg, 1977; Wilson, 1993) but recreated in a 3D environment (See Figure 3).
• Simple Barrage: patients have to select the hammers placed on a room’s floor. The software
record the number of hammers selected (correct targets) and the number of item non-selected
(omissions) and the number of hammers touched multiple times (perseverations) on the left side
and on the right side of the room.
Figure 3. An example of “Barrage Test”

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• Simple Barrage with Distractors: patients have to select the screwdrivers placed in a room with
other objects (hammers, wrench and others). The software record the number of selected (correct
targets) and omitted (omissions) screwdrivers, the number of the other object selected (error) and
the number of screwdrivers touched multiple times on the left side and on the right side.
• Dynamic Barrage: patients have to select the moving balloons. The software record the number
of balloons selected (correct targets) and the number of item non-selected (omissions) and the
number of balloons touched multiple times (perseverations) on the left side and on the right side
of the sky.
• Dynamic Barrage with Distractors: patients have to select the kites placed in a sky with bal-
loons and paper airplanes. The software record the number of selected (correct targets) and omit-
ted (omissions) kites, the number of the other object selected (error) and the number of kites
touched multiple times on the left side and on the right side.
In the rehabilitation part, there are nine different and customizable tasks. The entire tasks could be
classified like “visual search” rehabilitation (Paci, Matulli, Baccini, Rinaldi, & Baldassi, 2010; Pierce
& Buxbaum, 2002).
• Find Gems: the patient have to touch all yellow gems, while being carried around in a passive
manner inside a mine. The examiner can choose the number of distractors (0,1,2) and the total
time (1,2 or 3 minutes). The software record the number of chosen gems in the right and wrong
way (correct targets ad error), in the left and in the right side of the screen.
• Breaks Spheres: The patient have to touch all the blue spheres that appear in the room alternating
with spheres of other colors. The examiner can choose the number of different distractors (0,1,2)
and the total time (1,2 or 3 minutes). The software record the numbers of chosen spheres in the
right and wrong way (correct targets ad error), in the left and in the right side of the screen (See
Figure 4).
• Copy Simple Figures: The patient has to copy simple drawings. The examiner can choose how
many drawings submitted simultaneously (1,2 or 3). For this task, the software does not provide
any automatic correction.
Figure 4. An example of Rehabilitation Task

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• Copy of Polygons: The patient has to copy some drawings. The examiner can choose how many
drawings submitted simultaneously (1,2 or 3). For this task, the software does not provide any
correction.
• Draw Freely: The patient must draw what the examiner asks. For this task, the software does not
provide any correction.
• Barrage of Flower: The patient must touch all the yellow flowers that are in the scene. The exam-
iner can choose the number of different distractors (0,1,2) and if you bring up a red bar at the right
or left side of the screen. The software record the number of selected (correct targets) and omitted
(omissions) yellow flowers and the number of the other flowers selected (error).
• Barrage of Birds: The patient must touch all the birds rose and that are in the scene. The exam-
iner can choose the number of different distractors (0,1,2) and if you bring up a red bar at the right
or left side of the screen. The software record the number of selected (correct targets) and omitted
(omissions) pink birds and the number of the other birds selected (error).
• Put in Order: The patient must place all the black pieces on white squares of the chessboard. The
examiner can choose if place a red bar at the side of the screen. The software record the number
of selected (correct targets), omitted (omissions) and misplaced (error) pieces.
• Pop-Up: The patient have to touch all the asteroids that appear in space turns to other objects.
The software record the number of correct objects (correct targets), the number of missing objects
(omissions) and the number of wrong objects (error) in the left side and on the right side of space
(See Figure 5).
Figure 5. An example of Rehabilitation Task

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The software recording all data in a database and the file can be exported by transferring files from
iPad to computer.
A preliminary study (Pallavicini et al, in press) compared the administration of the assessment test in
their traditional and Neglect App version. The results showed that the cancellation tests of the Neglect
App were equally effective to traditional paper-and-pencil version of the same tasks in detecting ne-
glect symptoms. Moreover, the Neglect App Card Dealing task was more sensitive in detecting neglect
symptoms than traditional functional task. Eventually, the preliminary results supporting the feasibility
of Neglect App for the screening of USN symptoms.
A further step would be to test the usability of the Neglect App with both patients and clinicians in
order to obtain information that could drive a further development and improvement. Indeed, patient
cannot use the app alone, but the assessment and rehabilitation process have to carry out in relation
between the need’s patient and the competency of the clinician. For this reason, it is important that both
patients and clinicians conducted the usability test.
After that an extensive trial with patients could be useful in order to better understand if the assess-
ment part is able to overcome the problems that we discussed earlier about the test and make and more
accurate diagnosis. A second trial could be activated to analyse the rehabilitation made with neglect app
compared to the most commonly rehabilitation program.
All these steps are necessary in order to prove the validity of the application and allow the use in the
neuropsychological facilities.
&21&/86,21
The aim of the chapter was to describe a new technological approach to clinical practice in neuropsy-
chology using VR. In the first part, the advantages and disadvantages of classical and new methods of
assessment and rehabilitation were analysed. Largely, thanks to VR, the clinicians are now able to observe
the behavior of the patients in a virtual environment similar to the real one, that is, at the same time,
safer and customizable. Moreover, the possibility to manage the variables of an ecological environment
allows a better understanding of the patient deficits and impairments.
We presented two VR-based applications (VMET and Neglect App) as examples of a new approach
to clinical practice in neuropsychology.. We believe that this will provide a first step in the development
of these tools. Many more steps are required to continue the process of validation and to fully establish
the VR-based applications as methods that add to existing assessment and rehabilitation practises for the
assessment and rehabilitation of cognitive dysfunctions. Simulation of real world environments increases
the ecological validity of the assessment task, maintaining control of variables that can affect performance.
VMET and Neglect App are two systems, one for computer and the other for tablet, that use the non-
immersive VR. In this case the sense of presence is reduced towards a better handling and a reduction
in costs of the instrumentation.
In the last years there was a significant increase in the development of the device also for the im-
mersive VR.
On one side, the use of Head Mounted Displays has moved from research to gamers. This change has
led to the development of cheaper visors with high performance, like Oculus or Gear VR. This tool uses
tracking technology and are able to create a 3D stereoscopic view. 3D stereoscopic view” is obtained
by digitally rendering the stereovision for the two eyes of the user. The gyroscopes, accelerometers and

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magnetometers measure the position and/or the orientation of the head of the user for the navigation in the
environment. These attractive features are leading the way to a possible clinical use of these new devices.
On the other side, also the application of Cave Automatic Virtual Environment (CAVE) has moved
from design and fashion to a healthy context. The CAVE is a room where stereoscopic projectors project
on the walls, floors and, ceiling a 3D virtual environment in high-resolution. In the CAVE the head-
trackers and hand-trackers are using to allow natural movements to interact with the virtual environment.
These features make the CAVE a very expensive, which is found only in contexts where it is possible
to combine research and clinical practice (Bouchard et al., 2013; Meyerbröker, Morina, Kerkhof, &
Emmelkamp, 2010).
However, clinicians are still hesitant to adopt new technologies. This may have several explanations.
On the one hand, the hospitals do not allow to invest in this kind of equipment and the single clinician
cannot always afford such tools. On the other hand, specialists believe these devices hard to use and
the software are not always adequate nor their needs or those of patients. For these reasons, it would be
important to involve clinicians in the development of new programs by following the three principles of
the game design theory (meaningful play, sense of presence and flow theory) (Goude, Björk, & Rydmark,
2007; Mainetti, Sedda, Ronchetti, Bottini, & Borghese, 2013; Schell, 2014; Seyama & Nagayama, 2007).
To improve the meaningfulness of the game the tasks should have a distinguishable positive and
negative feedbacks as well as a reasonably lasting effect. Also s a calm scenario and a positive score
to create a positive and motivating setting are important. The sense of present could be improve using
an enriched environment with a realistic objects (both for distractor and stimuli) and using the virtual
image of the patients like a leading actor in the screen (Buxbaum et al., 2004; Kim, Chun, Yun, Song,
& Young, 2011; Mainetti, Sedda et al., 2013).
Also is important that patients don’t use any kind of joystick but have a hands-free tracking system
(Laver, George, Thomas, Deutsch, & Crotty, 2015; Thornton et al., 2005). To encourage a flow experience
the tasks could not be too difficult or too simple because if the user’s skills are matched to the difficulty
of the level the user enters into a state of complete focus and immersion in the game. Because of this
every task has to have a progressive difficulty that increase increases in parallel with the improvement
of the patient (Schell, 2014).
Further efforts will be needed before this technology can become part of clinical practice but the
growing number of jobs going in this direction indicates that we are on the right track.
$&.12:/('*0(17
This study was supported by the Italian funded project “VRehab. Virtual Reality in the Assessment and
TeleRehabilitation of Parkinson’s Disease and Post-Stroke Disabilities”—RF-2009- 1472190.
5()(5(1&(6
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