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Review

A Comprehensive Review of Virtual Reality Technology for Cognitive Rehabilitation in Patients with Neurological Conditions

by
Wei Quan
,
Shikai Liu
*,
Meng Cao
and
Jiale Zhao
School of Statistics and Data Science, Nanjing Audit University, 86 Yushan West Road, Nanjing 211815, China
*
Author to whom correspondence should be addressed.
Appl. Sci. 2024, 14(14), 6285; https://doi.org/10.3390/app14146285
Submission received: 22 May 2024 / Revised: 17 July 2024 / Accepted: 17 July 2024 / Published: 19 July 2024
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Abstract

:
Amidst population aging and lifestyle shifts, the incidence of neurological disorders such as stroke and Alzheimer’s disease is increasing, profoundly affecting patients’ cognitive functions and everyday life. Conventional cognitive rehabilitation approaches often necessitate substantial time and manpower, yet their outcomes remain uncertain. Although computer-assisted cognitive rehabilitation offers convenience, it can be somewhat monotonous in its experience. Virtual reality (VR) technology has introduced a novel pathway for cognitive rehabilitation, enhancing personalization and outcome assessment through tailored immersive environments and real-time data recording. This paper aims to survey the application of VR in cognitive rehabilitation, examining its impact on improving memory, attention, motor function, and social skills. A systematic review methodology was employed, following PRISMA guidelines, to identify and analyze relevant studies from 2010 to 2023. Recognizing that patients with different conditions have varying needs for the immersive and social aspects of VR, we propose the Multi-Dimensional VR Cognitive Rehabilitation Theory Model (MD-VRCRTM). This model categorizes cognitive rehabilitation technologies into six primary types: individual immersive, individual semi-immersive, individual non-immersive, multiplayer immersive, multiplayer semi-immersive, and multiplayer non-immersive rehabilitation systems. This categorization aims to cater to the specific requirements of various patients. For instance, individuals with autism spectrum disorder (ASD) may benefit more from multiplayer VR applications to enhance social skills; those with Parkinson’s disease (PD) might profit from immersive VR to facilitate motor function recovery; stroke and traumatic brain injury (TBI) patients may require highly immersive VR experiences to boost concentration and treatment efficacy; and Alzheimer’s disease (AD) patients may be better suited to non-immersive or semi-immersive VR to minimize cognitive load and receive cognitive stimulation.

1. Introduction

In recent years, with the intensification of population aging and changes in lifestyle, the incidence of neurological disorders such as stroke, Parkinson’s disease (PD), traumatic brain injury (TBI), multiple sclerosis (MS), Alzheimer’s disease (AD), and autism spectrum disorder (ASD) has been gradually increasing [1,2]. These diseases not only impose a significant burden on patients and their families but also have a considerable impact on social and economic development. Cognitive rehabilitation, as an effective therapeutic intervention, has become an indispensable part of the treatment for these conditions. Cognitive rehabilitation (CR) is a therapeutic approach that aims to improve patients’ cognitive functions through training and practice. In the context of neurological disorders, cognitive rehabilitation is designed to help patients enhance their abilities in attention, memory, language, executive functions, spatial skills, cognitive speed, and problem-solving [3].
Cognitive rehabilitation techniques can be divided into two categories [4,5]: traditional cognitive rehabilitation and computer-assisted cognitive rehabilitation [6]. Traditional cognitive rehabilitation includes three main approaches: cognitive training, behavioral therapy, and physical therapy. Cognitive training improves patients’ cognitive functions through tasks and exercises such as memory games and attention training. Behavioral therapy helps patients cope with cognitive disorders by changing their behaviors and thinking patterns, such as establishing regular habits to improve memory and executive functions. Physical therapy promotes brain function rehabilitation through exercise; for example, improving spatial abilities via balance training. Traditional computer-assisted cognitive rehabilitation methods typically use specially designed software programs to train and improve a patient’s cognitive functioning, and these programs can provide individualized training based on patient needs. These methods do not involve virtual reality technology and only use common computer equipment, including keyboards, mice, and screens, which are easy to use and less expensive, but lack immersion, are less interactive, and are more boring. In recent years, with the advancement of computer technology, some new cognitive rehabilitation has utilized virtual reality technology and computer-assisted training [7] to provide a more personalized and colorful rehabilitation environment to promote cognitive improvement.
The development of virtual reality technology originated in the 1960s, yet it has only recently experienced significant growth. This growth is attributed to advancements in computer graphics, sensor technology, and display devices, which have enhanced the realism, immersion, and practicality of VR technology. Currently, VR technology is extensively utilized in gaming, entertainment, education, and healthcare sectors. Virtual reality technology enables the simulation of real-world environments and immerses users through devices such as head-mounted displays. As VR technology evolves, it has found widespread application in cognitive rehabilitation [8]. In cognitive rehabilitation, VR technology is primarily applied in several ways. Cognitive training uses virtual environments to enhance patients’ attention, memory, and problem-solving abilities through various tasks and exercises. Environmental reconstruction recreates daily life scenarios, such as supermarkets, parks, and traffic scenes, to help patients restore their daily living skills. Situational rehabilitation provides controlled and safe environments for patients with specific cognitive disorders, such as acrophobia and social anxiety, to gradually adapt and overcome these situations. Attention training employs visual and auditory stimuli in virtual environments to improve patients’ attention. Virtual travel offers immersive experiences for patients who are immobile or unable to go outside, helping to alleviate depressive symptoms and enhance overall quality of life. Furthermore, research has demonstrated that VR technology can improve cortical function and promote neural regeneration and functional rehabilitation through cognitive and motor training. Hence, VR technology not only presents new opportunities for cognitive rehabilitation but also holds potential as a crucial tool for enhancing patients’ quality of life and rehabilitation outcomes [9,10].
This paper systematically reviews cognitive rehabilitation technologies based on virtual reality and proposes the Multi-Dimensional Virtual Reality Cognitive Rehabilitation Theory Model (MD-VRCRTM). The model categorizes cognitive rehabilitation technologies into six types: individual immersive systems, individual semi-immersive systems, individual non-immersive systems, multiplayer immersive systems, multiplayer semi-immersive systems, and multiplayer non-immersive systems. This classification approach facilitates a better understanding of the strengths and limitations of various technologies in the cognitive rehabilitation process, providing a theoretical basis for selecting appropriate technologies for practical applications. Furthermore, this paper analyzes the current state of VR technology applications in the field of cognitive rehabilitation and discusses their potential for use in the cognitive rehabilitation of patients with neurological disorders. The aim of this paper is to provide a valuable reference for researchers and practitioners involved in cognitive rehabilitation, promoting the application and development of virtual reality technology in the cognitive rehabilitation of patients with neurological disorders. A comprehensive understanding of the characteristics and application effects of various VR technologies can help optimize cognitive rehabilitation programs, enhance rehabilitation outcomes, and improve the quality of life for patients.
The content of this article is divided into three parts: firstly, a systematic search and selection of the relevant literature; secondly, the construction of a theoretical model to guide practice; and finally, an in-depth analysis of the therapeutic effects of different types of virtual reality technologies.

2. Methodology

This review aims to comprehensively analyze the primary application modes of virtual reality technology in cognitive rehabilitation and their efficacy, and to provide references for further advancing the progress of virtual reality technology in the field of cognitive rehabilitation. Figure 1 below summarizes the detailed process of article selection.

2.1. Search Strategy

We conducted an online search of databases such as Google Scholar, Scopus, PubMed, Cochrane library, ScienceDirect, and CNKI. The search combined the following keywords: virtual reality (VR), cognitive rehabilitation (CR), stroke, Parkinson’s disease (PD), traumatic brain injury (TBI), multiple sclerosis (MS), Alzheimer’s disease (AD), and autism spectrum disorder (ASD). The inclusion criteria for screening literature were articles published between 2010 and 2023, the primary subjects of the articles being patients undergoing cognitive rehabilitation using VR technology, and the study types included randomized controlled trials, case reports, etc. We selected papers from 2010 onwards due to significant advancements in virtual reality technology during this period, as well as improved research methods and evaluation tools, ensuring the timeliness, relevance, and comprehensive accuracy of our review. The exclusion criteria included studies with improper research methods and articles with samples that were not representative. This study found that the number of relevant papers published each year from 2010 to 2023 showed a year-on-year increase, with a more significant acceleration in growth after 2016. Figure 2 shows the trend of the number of relevant papers published each year from 2010 to 2023. Our system evaluation process strictly adheres to the PRISMA [11,12] guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) to ensure the transparency and standardization of the evaluation.

2.2. Model Construction

In the review of research on virtual reality (VR) technology for cognitive rehabilitation over the past decade, we have identified immersion and social interaction as two key factors influencing patient recovery outcomes. In terms of social interaction, VR applications for cognitive rehabilitation can be categorized into two broad types based on the number of participants: individual and multiplayer applications. Individual applications primarily serve a single patient [13], allowing them to engage in personalized cognitive training within a virtual environment through VR headsets or handheld devices, receiving immediate feedback, with a focus on providing a tailored rehabilitation experience. Multiplayer applications, on the other hand, involve interactions between patients, therapists, and other assistants. Multiple participants can engage in collaborative or competitive cognitive training within a shared virtual environment [14]. This not only enhances patients’ cognitive abilities and response speed but also strengthens teamwork and social interaction among patients, thereby enhancing the overall effectiveness of cognitive rehabilitation.
Furthermore, according to the level of immersion, VR technology applications can be classified into three types: non-immersive, semi-immersive, and fully immersive. Non-immersive virtual reality cognitive rehabilitation technology is suitable for patients with various cognitive impairments, providing personalized and controlled training environments to help them improve their cognitive functions [15]. For example, it can be used for patients with stroke, brain injury, Alzheimer’s disease, and autism. In non-immersive settings, users are still aware of the real world’s presence, usually interacting with the virtual environment through a computer screen or head-worn display. Semi-immersive virtual reality cognitive rehabilitation technology is appropriate for patients who require both an immersive experience and a connection to the real world [16], such as those with Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, and stroke. In semi-immersive environments, users partially perceive the real world while their senses are mostly engaged with the virtual environment, typically achieved through head-worn displays and surround sound. Fully immersive virtual reality cognitive rehabilitation technology is designed for patients who need deep immersion and full-body engagement [17], such as those with stroke, brain injury, Parkinson’s disease, multiple sclerosis, and autism. In fully immersive settings, users are completely immersed in the virtual environment and are unaware of the real world’s presence, usually experiencing the virtual environment through head-worn displays, panoramic projection, or panoramic display walls.
By comprehensively considering both immersion and social interaction as key influencing factors, we have proposed a comprehensive multidimensional interactive system model (Figure 3)—the Multi-Dimensional VR Cognitive Rehabilitation Theory Model (MD-VRCRTM)—to better guide the practical application of VR technology in cognitive rehabilitation.

3. Practical Applications of VR in CR

As illustrated in Figure 3, the theoretical model shows that there are six common forms of cognitive rehabilitation technology based on VR: individual non-immersive, individual semi-immersive, individual immersive, multiplayer non-immersive, multiplayer semi-immersive, and multiplayer immersive. In the cognitive rehabilitation research related to the six categories of neurological disorders—stroke, Parkinson’s disease (PD), traumatic brain injury (TBI), multiple sclerosis (MS), Alzheimer’s disease (AD), and autism spectrum disorder (ASD)—one or more of these forms are involved.

3.1. Individual Immersive Systems

Individual immersive rehabilitation is a system that uses virtual reality technology to provide a personalized, immersive cognitive rehabilitation training environment for a single patient. Its highly immersive environment can be customized to individual needs, allowing for personalized therapy sessions [18,19,20]. It is useful for focused, intensive cognitive tasks, as well as for simulating real-life environments that are difficult to reproduce. This type of rehabilitation therapy system is more suitable for stroke patients and Parkinson’s disease patients, among others [21].
Bagce et al. (2012) [22] constructed a individual immersive virtual reality system consisting of head-mounted VR equipment and sensor gloves. Through repeated analysis of variance of virtual hand data from eight chronic stroke patients in VR, the authors discovered that visual feedback can be an effective method for selectively modulating M1 activity. VR training stimulated the contralateral brain areas related to hand control, which is beneficial for the recovery of function after stroke.
Following this, San Luis et al. (2016) [23] developed a individual immersive VR application, mobile-based VR. They employed a randomized controlled trial method. The control group received only standard hospital environment therapy: the use of standardized medical tools and toys managed by physical therapists. The experimental group received hospital environment therapy supplemented by virtual reality therapy. Data from the Ber balance scale indicated that the patients in the experimental group had better improvements in their sensory systems. The results suggest that using this system as a supplement to traditional hospital rehabilitation can enhance the duration and quality of patient recovery.
In 2020, in the cognitive rehabilitation treatment of PD patients, Pazzaglia et al. (2020) [24] randomly assigned 51 Parkinson’s patients to a VR rehabilitation program or a traditional rehabilitation program. The VR group utilized motion analysis equipment and NIRVANA (NIRVANA is a markerless system based on optoelectronic infrared devices, allowing patients to engage in complete auditory and visual sensory immersion exercises in a virtual environment). A series of specific interactive tests were conducted on patients in VR rehabilitation scenarios. Statistical analysis revealed that participants in the VR group had better outcomes in various functional areas compared to those who received traditional rehabilitation. Specifically, the VR group showed greater improvements in balance (Balance Berg Scale, BBS), walking (Dynamic Gait Index, DGI), arm function (Disabilities of the Arm, Shoulder and Hand scale, DASH scale), and the psychological aspects of quality of life (Mental Composite Score, MCS) compared to the traditional group.
Lamontagne et al. (2019) [25] developed a prototype of an immersive VR toolkit with six dimensions, providing intensive, task-specific training for complex movement tasks required for walking in a safe and ecological virtual environment for the community. This toolkit combines VR and on-site training practices, enhancing community walking ability after stroke.
These studies indicate that while individual immersive systems have advantages such as high immersion and personalized experience, they also have some limitations. For example, they may lead to a sense of isolation for users, reducing opportunities for social interaction with others. Additionally, the highly immersive environment may also cause some users to experience motion sickness or other discomfort.

3.2. Individual Semi-Immersive Systems

Individual semi-immersive rehabilitation combines the immersion of virtual reality technology with physical interaction in the real world. By utilizing specific hardware devices such as VR helmets, handheld controllers, or motion capture systems, it provides a training environment that lies between complete virtuality and reality. The characteristic of this technology is its ability to simulate real-life activity scenarios while allowing patients to perform various movements and cognitive tasks in a safe environment, thus promoting the remodelling and recovery of neural systems and functions. Additionally, semi-immersive rehabilitation technology can adjust the difficulty and complexity according to the patient’s progress and needs, achieving personalized rehabilitation training. Compared to individual immersive virtual reality rehabilitation therapy systems, individual semi-immersive virtual reality rehabilitation therapy systems provide a balance between immersion and real-world connection, which may cause less disorientation for some patients [26] and is easier for therapists to monitor and assist [27]. It is suitable for cognitive rehabilitation treatment of patients with stroke, Parkinson’s disease, Alzheimer’s disease, and multiple sclerosis, among others.
Kim et al. (2011) [28] conducted a controlled trial in a 2011 paper, with the virtual reality system in the experimental group being a semi-immersive virtual reality system—the IREX system. The experimental environment consisted of a television monitor, camera data gloves, and virtual objects. The system included five programs with different training items, which could evaluate and train patients’ visual, auditory perception, attention, and memory functions. The experiment analyzed the performance of 28 patients with cognitive impairment after stroke in different rehabilitation treatments. The researchers concluded that compared to the control group that only received computer-based treatment, the VR group that received both virtual reality training and computer-based cognitive rehabilitation could achieve greater benefits.
Burdea et al. (2015) [29] designed the BrightBrainer comprehensive cognitive therapy system in 2015, mainly for the cognitive function rehabilitation treatment of Alzheimer’s disease patients. The system consists of a computer, a dual-hand game controller, a remote clinical server, and a custom-designed comprehensive cognitive simulation library. Participants can achieve virtual reality interaction through single-hand or dual-hand operation. BrightBrainer can also customize unique rehabilitation training games according to the patient’s needs and adjust them at any time based on the patient’s rehabilitation status. The system has multi-sensory perception functions and can train participants’ memory and decision-making ability, and improve their depression.
Calabrò et al. (2017) [30] and Kilic et al. (2017) [31] designed a individual semi-immersive rehabilitation treatment system for multiple sclerosis patients in a 2017 paper. Calabrò designed Robot-Assisted Gait Training (RAGT), a walking function rehabilitation system that combines Lokomat with VR, mainly used for postoperative walking function rehabilitation of multiple sclerosis and stroke patients. Lokomat consists of a treadmill and an exoskeleton with two powered orthoses, fixed to the patient’s limbs with cuffs and belts. The hip and knee joints of Lokomat are driven by linear actuators and move the orthoses in the sagittal plane during the gait cycle. The real-time movement of the patient is projected on the screen through the augmented feedback module. Through the analysis of data from a randomized controlled trial involving 40 volunteers, the researchers found that RAGT combined with VR is more effective in treating walking disability in MS patients compared to RAGT without VR.
Kilic et al. (2017) [31] built the Virtual Reality-Based Rehabilitation (VRBR) system using a layered architecture style. It consists of a sensor that translates body movements, a virtual reality headset, a database, and a computer that runs the program as a server. In this system, patients start exercising by launching the interface on the computer and accessing the system with existing user records in the database. Patients can view their past exercise scores and can also start exercising directly from the interface. The system can determine compensatory movements, range of motion, time, and the angle relationship between limbs. With the help of the Kinect sensor, patients’ body movements are directly translated into games [32]. The visual environment of the game is wirelessly transmitted to the VR headset, and the gyroscope data in the headset are also used to create a faster-responsive and immersive experience.
Maggio et al. (2018) [33] evaluated the effect of a semi-immersive virtual reality system on promoting functional recovery in patients with multiple sclerosis using the Bioengineering Technology and Systems (BTS) Nirvana. The system created a virtual sensory room that enhances sensory engagement in rehabilitation by increasing visual and auditory feedback. Patients can experience immersive stimulation in different real-world scenarios through interactive exercises on the screen, which can involve moving in different directions, manipulating different objects, or creating specific object categories through dynamic interaction with the virtual environment. A statistical analysis of laboratory data revealed that VR can enhance the enthusiasm and compliance of patients during the rehabilitation process, enabling them to engage in long-term, high-intensity training. Patients may be motivated by the variety of environments and stimuli, potentially re-activating or enhancing neural functions in the brain, including those associated with the cholinergic and dopaminergic systems [34].
From the studies mentioned above, it is evident that a drawback of individual semi-immersive virtual reality rehabilitation therapy systems is that the reduced immersion may limit the effectiveness of certain cognitive rehabilitation exercises.

3.3. Individual Non-Immersive Systems

Individual non-immersive rehabilitation typically refers to a cognitive rehabilitation training system that utilizes virtual reality technology but does not provide an immersive experience. Instead, it uses other media or tools to provide cognitive rehabilitation training for a single patient. A significant advantage of an individual non-immersive virtual reality rehabilitation therapy system lies in its intuitive user interface and simple setup process [35,36,37], which greatly reduces the risk of user disorientation. Moreover, its ease of use and maintenance makes it an affordable option, thus making it more suitable for large-scale promotion and popularization. This system is primarily applicable to patients with traumatic brain injury, stroke, and Alzheimer’s disease.
González-Ortega et al. (2014) [38] proposed a real-time 3D computer vision-assisted system for monitoring psychomotor exercises in 2014. The system is designed to assess and evaluate body structure dysfunction and left–right confusion. It achieves monitoring through the tracking of human head and hand joints and the detection of facial featuresusing depth information provided by the Kinect device. The system overcomes the limitations of 2D computer vision methods and is robust to significant changes in the working environment and lighting. The Kinect device has been proven to be an affordable off-the-shelf product that is useful for the development of applications in many fields, including rehabilitation, due to its ease of use and good performance. To address the issue of monotony in traditional rehabilitation therapy, Shapi’i et al. (2015) [39] proposed a conceptual framework for designing a game-based cognitive rehabilitation system in 2015 and developed a rehabilitation game system (RGS) for cognitive rehabilitation. Patient assessments can “tailor” training for specific cognitive functions. Therapists create this game-based training based on the patient’s abilities, limitations, and preferences. To investigate the effect of a wearable multi-inertial sensor virtual reality rehabilitation system on improving upper limb function in children with brain injury, Choi et al. (2021) [40] conducted a randomized controlled trial study on 80 patients with brain injury in 2021. The virtual reality rehabilitation system includes games that promote wrist and forearm joint movements using wearable inertial sensors. This is a non-immersive virtual reality system where sensors upload user information to a computer, and the computer screen moves in sync with the user’s active movements. The virtual reality rehabilitation program consists of multiple games and modules, including daily living activities and movement performance promotion. At the beginning of the training, upper limb ability is assessed using virtual reality equipment to determine the initial difficulty level. Then, the difficulty level of the training scenario is adjusted based on each individual’s performance parameters during each training session. During and after the practice, both auditory and visual feedback are provided on the computer screen. The experimental results indicate that the upper limb rehabilitation effect was better in the experimental group using the virtual reality method.
By comparing the three individual modes of rehabilitation systems, it can be observed that the limited immersion of an individual non-immersive virtual reality rehabilitation therapy system may not provide as engaging or effective a cognitive rehabilitation experience as the more immersive types.

3.4. Multiplayer Immersive Systems

Multiplayer immersive rehabilitation is an advanced cognitive rehabilitation training system that creates a fully immersive virtual environment for patients using virtual reality technology. This system supports multiple patients participating simultaneously in collaborative tasks and interactions within a shared virtual space [41], thereby promoting social interaction and cognitive function development. The advantage of the multiplayer immersive virtual reality rehabilitation therapy system is that it not only promotes social interaction in the virtual environment, which is highly beneficial for social cognitive therapy [42], but also allows for group therapy sessions, enhancing patients’ motivation through social support [43]. This system is particularly suitable for the rehabilitation of patients with stroke, autism, and other diseases, providing them with a safe and controlled environment to promote the recovery of cognitive functions and enhance social skills.
Bozgeyikli et al. (2017) [44] developed a multiplayer immersive virtual reality system, VR4VR, in 2017. The system enables autism spectrum disorder (ASD) patients to master vocational skills through practice in an immersive virtual environment. VR4VR is composed of a head-mounted display (HMD), an optical motion tracking system with multiple cameras, touch screen controls, and a remote control panel. The system provides training in six vocational skills, with three skill modules designed to be executed through the HMD and the remaining three through a 180-degree curved screen. Each skill module includes three sub-tasks of increasing difficulty, each with its own three levels. Studies have shown that trained vocational skills have improved for ASD patients, and VR4VR can provide effective vocational training for ASD patients.
Chatterjee et al. (2022) [45] created a novel multiplayer immersive VR system called VIRTUE. The scene construction in VIRTUE is achieved through a combination of the Unity3D game development platform and the Virtual Reality Toolkit (VRTK). VIRTUE uses a modular architecture that is divided across PC and VR headset devices, allowing for the selection of different scenes and their configuration to suit each patient. Through various tasks (e.g., making toast, paying for a meal), VIRTUE trains patients’ cognitive functions such as memory and discrimination, and collects indicators to help clinical doctors assess performance. This flexible personalized medical approach, without any restrictions, also demonstrates that VR is indeed an effective measure for improving the memory and discrimination of stroke survivors. To promote the training of social skills in autistic teenagers and investigate the feasibility of virtual reality as a training environment for adolescents, Gabrielli et al. (2023) [46] developed Zentastic, an immersive multiplayer VR adventure game, in 2023. Zentastic was developed and deployed on Meta Oculus technology in Unity. The game is designed to be played by groups of teenagers under the guidance of a therapist acting as a guide in the virtual environment. Each task in Zentastic is aimed at addressing target behaviors related to social interaction, with increasing complexity. In recent studies, VR can recreate motivating environments through multisensory and interactive stimulation, allowing for interaction with scenes, thereby improving patients’ cognitive abilities. VR can also be used to improve patients’ balance, coordination, and muscle control, or through the simulation of activities in virtual environments, patients can engage in interactive rehabilitation training to improve motor functions.
Multiplayer immersive rehabilitation systems also have some drawbacks: managing multiple users in a fully immersive environment is more complex. There is a risk of users being distracted by others in the virtual space.

3.5. Multiplayer Semi-Immersive Systems

Multiplayer semi-immersive rehabilitation refers to a cognitive rehabilitation training system that utilizes virtual reality technology to provide partial immersion. It allows multiple patients to participate simultaneously but, compared to fully immersive systems, users can still perceive the existence of the real world during use [47]. Multiplayer semi-immersive rehabilitation systems can encourage cooperative and competitive activities, enhancing cognitive rehabilitation, particularly in social interaction and teamwork skills [48]. These systems are primarily applicable to the cognitive rehabilitation treatment of patients with stroke, autism, multiple sclerosis, and brain injury [49].
Through VR technology, cognitive rehabilitation training can be more personalized, practical, and enjoyable. For example, training can simulate daily living environments, practice language communication, improve reaction speed and attention, and enhance motor coordination and balance [50,51]. VR technology can also be combined with biofeedback technology to monitor and provide feedback on patients’ physiological indicators, helping them better grasp the process and effects of rehabilitation training. Furthermore, VR technology can improve patients’ emotional state and enhance their quality of life and self-satisfaction. Patients often experience emotional issues such as anxiety and depression, and VR technology can provide a comprehensive, immersive entertainment experience to help them relax, reduce tension, and alleviate stress and anxiety [52]; at the same time, the training process involves high-difficulty tasks, which can boost patients’ confidence, reshape their self-esteem, and enhance their sense of self-efficacy. Moro et al. (2016) [53] conducted a study on a new semi-immersive visual motor task (VMT) test in the field of upper limb motor function neurorehabilitation. The semi-immersive VR environment was simulated using the LEAP Motion Controller (a high-resolution 3D hand-tracking device that enables realistic human–computer interaction for semi-immersive VR systems) and monitored using functional near-infrared spectroscopy (fNIRS) to record VMT-related prefrontal cortex (PFC) responses. The researchers analyzed the recorded data using statistical methods and found that semi-immersive VMT is effective for neurorehabilitation.
When using multiplayer semi-immersive rehabilitation systems for treatment, there are also some drawbacks. The presence of others may distract or intimidate some users, potentially reducing the effectiveness of the treatment.

3.6. Multiplayer Non-Immersive Systems

Multiplayer non-immersive rehabilitation typically refers to a cognitive rehabilitation training system that utilizes virtual reality technology but does not provide immersion. Instead, it allows multiple patients to participate simultaneously using other media or tools, and users can still perceive the existence of the real world during use. The advantage of this system is that it provides a relatively controlled and moderately immersive environment to support social interaction, which may be more comfortable and less frightening for users, making it ideal for group-based cognitive exercises [54,55]. This system is particularly suitable for the cognitive rehabilitation of patients with autism, Parkinson’s disease, and Alzheimer’s disease. The advantages provided by VR-based systems are multifaceted. They can enhance users’ positive attitudes, be attractive and encouraging, and provide information in real time [56]. However, users need to have basic knowledge of using computers, and there are significant barriers for older adults to using computers or mouse or keyboard devices. Considering these factors, Ee La Guia et al. (2013) [57] developed a cognitive stimulation game system for a multi-device environment (MDE). The system is primarily aimed at Alzheimer’s disease patients, providing cognitive stimulation to help with cognitive rehabilitation. The system consists of two interactive collaborative games: Co-Brain Training Tool (CBT) and AlzGame. The system integrates a tangible interface with NFC technology, mobile devices with NFC readers, and a projector displaying the main game interface. In the CBT collaborative game, multiple users can interact with each other or use the system individually. The system architecture is a co-brain training structure. The client system is a mobile device with an NFC reader that connects to the server via a wireless network and communicates with the NFC reader when the mobile device is placed near the tangible interface. The tags are integrated into each image of the tangible interface, each describing different content. When the NFC reader is close to the selected image, the tag inside is excited by the electromagnetic waves emitted by the NFC reader, and the mobile device executes the corresponding method on the server. AlzGame is a client–server combined system that executes games and stores results in the server. In this way, therapists can continuously understand the progress of the patient’s rehabilitation. Remote rehabilitation balance plans based on VR have been proven to be feasible and effective in various neurological disorders. An innovative fitness training and rehabilitation method is an active electronic game that combines physical movement with gaming skills, which can be independently performed at home with minimal equipment and low cost. For example, the very popular Nintendo Wii Fit and balance board are VR fitness applications that can be used as auxiliary tools for sensory integration balance training (SIBT); SIBT is one of the most effective methods for improving the posture stability of polio patients. Gandolfi et al. (2017) [58] designed a randomized controlled trial to compare improvements in postural stability after PD patients used the Nintendo Wii Fit system (TeleWii) for VR-based home balance training and after SIBT in the clinic. The TeleWii experimental system includes the Nintendo Wii console for motion control input, the Wii Fit game system, and the balance board. Comparing the above studies, it can be found that multiplayer non-immersive rehabilitation systems also have some drawbacks [59]. For example, the benefits of VR in enhancing experiences that are similar to real life are limited, which may affect the effectiveness of applying the learned skills in real-world scenarios.
Table 1 below summarizes the major studies on VR in CR.

4. Discussion

This review analyzes the main applications and effects of VR technology-assisted cognitive rehabilitation in patients with common neurological disorders. VR has been proven to be an effective adjunctive treatment method, aiding in the repair of damaged neural tissue and enhancing cognitive functions such as resolution, orientation, and memory. Neurological disorders are complex conditions, with varying degrees of severity among patients. Consequently, postoperative rehabilitation for these patients is challenging and requires specialized medical and rehabilitation personnel to develop targeted rehabilitation measures. Patient acceptance and compliance are particularly crucial, as conventional cognitive rehabilitation therapy is often lengthy, costly, and boring, leading to low patient acceptance and compliance [10]. In contrast, VR offers good immersion and social interaction, and cognitive rehabilitation therapy combined with VR can avoid the drawbacks of traditional cognitive rehabilitation. Many studies also indicate that VR-based treatment methods are widely welcomed by patients and can produce effective therapeutic effects. VR technology not only brings new hope to patients with cognitive impairments but also greatly reduces the burden on healthcare professionals [52].
By summarizing the therapeutic effects of VR-assisted cognitive rehabilitation technology in the treatment of stroke, Parkinson’s disease (PD), traumatic brain injury (TBI), multiple sclerosis (MS), Alzheimer’s disease (AD), and autism spectrum disorder (ASD), we can observe that different diseases exhibit varying degrees of sensitivity to the dimensions of immersion and social interaction. For instance, for patients who require improvement in social skills and interactive abilities, such as those with ASD, multiplayer applications may be more suitable as they provide opportunities for communication and collaboration with others. Conversely, for patients with movement limitations that prevent them from engaging in full-body activities in the real world, such as PD patients, immersive VR technology can provide a safe environment for them to engage in activities in the virtual world, thereby facilitating the recovery of motor skills. Furthermore, immersion is crucial for enhancing patient engagement and motivation, particularly in the rehabilitation of stroke and TBI patients, where a highly immersive VR experience can help patients focus better on training tasks, thus improving treatment outcomes. For patients with Alzheimer’s disease (AD) whose cognitive functions are gradually deteriorating, non-immersive or semi-immersive VR technologies may be more appropriate, as they have lower cognitive load requirements while still providing beneficial cognitive stimulation.

5. Conclusions

In this paper, the MD-VRCRTM model is innovatively proposed and a new theoretical framework is provided. Through systematic search and analysis, the application effects of virtual reality technology in patients with stroke, Parkinson’s disease, brain trauma, and Alzheimer’s disease were demonstrated, emphasizing the selection of appropriate VR rehabilitation technology according to different patient needs to improve rehabilitation effects.
Virtual reality technology has demonstrated broad application prospects in the field of cognitive rehabilitation and has proven to have significant clinical benefits. However, our research has certain limitations, such as reliance on specific databases and search terms, which may lead to the omission of relevant studies, and our focus on randomized controlled trials and case reports may have overlooked other research formats. Additionally, sample heterogeneity and the use of different VR technology devices may affect the comparability and consistency of the results. Nevertheless, a substantial body of research still indicates that VR technology has an motivational effect in cognitive rehabilitation, but clinical trial data are limited, and sample sizes are insufficient, necessitating more high-quality empirical research to comprehensively evaluate its effectiveness. At the same time, the increased cost associated with the enhancement of VR device clarity and immersion does not necessarily mean that fully immersive devices are always superior to other types. Therefore, when selecting cognitive rehabilitation systems or devices, a comprehensive consideration of patient needs and cost-effectiveness ratios should be taken into account. Future research should be dedicated to optimizing the application of VR technology to enhance its effectiveness and prevalence in the field of cognitive rehabilitation, and to overcoming the limitations of existing studies.

Author Contributions

Conceptualization, W.Q.; Formal analysis, S.L.; Funding acquisition, M.C.; Methodology, S.L. and W.Q.; Software, J.Z.; Supervision, W.Q.; Writing—original draft, S.L. and W.Q.; Writing—review editing, W.Q. and M.C. All authors have read and agreed to the published version of the manuscript.

Funding

This research was supported by the National Natural Science Foundation of China [62006121]; the National Social Science Fund of China [23BFX038]; the Humanities and Social Science Fund of the Ministry of Education of China [23YJA870009]; the Significant Project of Jiangsu College Philosophy and Social Sciences Research [2021SJZDA153]; and the National College Students Innovation and Entrepreneurship Training Program [202311287050Z].

Data Availability Statement

The data underlying this article will be shared on reasonable request to the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest.

References

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Figure 1. Flow diagram of the study screening process.
Figure 1. Flow diagram of the study screening process.
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Figure 2. Trend in the number of relevant papers published per year from 2010 to 2023.
Figure 2. Trend in the number of relevant papers published per year from 2010 to 2023.
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Figure 3. Multi-Dimensional VR Cognitive Rehabilitation Theory Model.
Figure 3. Multi-Dimensional VR Cognitive Rehabilitation Theory Model.
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Table 1. The principal studies of virtual reality in the cognitive rehabilitation of patients with neurological diseases.
Table 1. The principal studies of virtual reality in the cognitive rehabilitation of patients with neurological diseases.
StudyTechnology TypeStudy TypeSample SizePatientsResults
Chatterjee et al., 2022 [45]Multiplayer Immersive SystemDouble-Blind Phase 2b RCT 140StrokeVR 2 can improve memory and resolution in stroke survivors.
Bagce et al., 2012 [22]Individual Immersive SystemRepeated Measures
Design Experiment		8StrokeVR training is beneficial for the recovery of hand
motor function after stroke.
San Luis et al., 2016 [23]Individual Immersive System and Individual Non-immersive SystemRepeated Measures
Design Experiment		8StrokeVR training is beneficial for the recovery of hand
motor function after stroke.
Lamontagne et al., 2019 [25]Individual Immersive SystemPrototype Development and User Feedback Experiment12StrokeA toolkit using virtual reality technology could improve community walking rehabilitation for stroke survivors.
Kim et al., 2011 [28]Individual Semi-immersive SystemRCT18StrokeThe study found that patients with stroke cognitive impairment showed significant improvements in visual attention and short-term visuospatial memory when receiving a combination of computer-assisted and virtual reality therapy, compared with only receiving computer-assisted cognitive rehabilitation therapy.
Burdea et al., 2013 [27]Individual Semi-immersive SystemFeasibility Study10StrokeStudies have shown that using the Razer Hydra gaming interface, patients can play a series of customized games that help improve focus, decision making (executive function), and short- and long-term memory.
Pazzaglia et al., 2020 [24]Individual Immersive System and Individual Non-immersive SystemRCT51PD 3Compared to the traditional group, the VR group showed greater improvements in the psychological aspects of balance, walking, arm function, and quality of life.
Lozano et al., 2013 [57]Individual Immersive System and Individual Non-immersive SystemFeasibility Study10AD 4Compared to the control group, the experimental group had greater improvements in cognitive function in terms of executive
and visuospatial abilities.
Gandolfi et al., 2017 [58]Multiplayer Non-immersive systemMulticenter, Single-Blind RCT76PDVR balance training can reduce postural instability in PD patients.
Thumm et al., 2021 [60]Multiplayer Semi-immersive Immersive SystemFeasibility Study2PDVR tele-rehabilitation therapy can improve patients’ confidence, gait speed, and mobility. Training multiple participants at the same time is feasible, enabling a personalized approach to therapy
while saving the therapist time.
Choi et al., 2021 [40]Individual Non-immersive SystemRCT80TBI 5The VR treatment group showed more significant improvements in upper limb dexterity function, and children with more severe motor impairments showed significant improvements compared to children with less severe motor impairments.
Shapi’i et al., 2015 [39]Individual Non-immersive SystemDesign and Evaluation Experiment10TBI and StrokeThe rehabilitation game system can improve the rehabilitation effect and ability by providing personalized rehabilitation game experience to improve patients’ enthusiasm.
González-Ortega et al., 2014 [38]Individual Non-immersive SystemSystem Development and Evaluation Experiment15TBIThis paper presents a real-time 3D computer vision aid system for psychomotor exercise monitoring, which is intended to help evaluate structural dysfunction and left–right disorder.
Maggio et al., 2023 [3]Individual Non-immersive SystemRCT60MS 6The VR rehabilitation approach not only improved cognitive and emotional outcomes in people with multiple sclerosis, but also improved motor function.
Calabrò et al., 2017 [30]Individual Semi-immersive SystemRCT40MSRAGT(Robot-Assisted Gait Training) + VR can effectively improve walking ability and hip movement ability.
KıLıC et al., 2017 [31]Individual Semi-immersive SystemMulticenter, Single-Blind, RCT60MS and PDVR-based rehabilitation system that provides active education and rehabilitation processes through gamification for people with Parkinson’s and multiple sclerosis.
De La Guia et al., 2013 [57]Multiplayer Non-immersive systemFeasibility Study10ADThe system can enhance mental abilities such as perception, attention, reasoning, abstraction, memory, language, and orientation processes.
Burdea et a., 2017 [29]Individual Semi-immersive SystemIntegrative Therapy and User Feedback Experiment36ADBrightBrainer bimanual cognitive integrated simulation training improved participants’ executive function,
processing speed, and auditory attention.
DE Luca et al., 2021 [14]Individual Semi-immersive SystemClinical Trial100ASD 7VR therapy can improve patients’ cognitive and behavioral problems such as attention, visuospatial cognition, and anxiety.
Bozgeyikli et al., 2017 [44]Multiplayer Immersive SystemRCT18ASDAfter VR4VR system training, the corresponding skills of ASD patients were improved to a certain extent. The VR4VR system can provide effective vocational training for ASD patients.
Wang et al., 2013 [54]Multiplayer Non-immersive systemExperimental Study4ASDAfter VR cognitive rehabilitation, the overall situation processing ability and cognitive flexibility of children with ASD
were significantly improved.
1 RCT: Randomized controlled trial; 2 VR: virtual reality; 3 PD: Parkinson’s disease; 4 AD: Alzheimer’s disease; 5 TBI: traumatic brain injury; 6 MS: multiple sclerosis; 7 ASD: autism spectrum disorder.
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Quan, W.; Liu, S.; Cao, M.; Zhao, J. A Comprehensive Review of Virtual Reality Technology for Cognitive Rehabilitation in Patients with Neurological Conditions. Appl. Sci. 2024, 14, 6285. https://doi.org/10.3390/app14146285

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Quan W, Liu S, Cao M, Zhao J. A Comprehensive Review of Virtual Reality Technology for Cognitive Rehabilitation in Patients with Neurological Conditions. Applied Sciences. 2024; 14(14):6285. https://doi.org/10.3390/app14146285

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Quan, Wei, Shikai Liu, Meng Cao, and Jiale Zhao. 2024. "A Comprehensive Review of Virtual Reality Technology for Cognitive Rehabilitation in Patients with Neurological Conditions" Applied Sciences 14, no. 14: 6285. https://doi.org/10.3390/app14146285

APA Style

Quan, W., Liu, S., Cao, M., & Zhao, J. (2024). A Comprehensive Review of Virtual Reality Technology for Cognitive Rehabilitation in Patients with Neurological Conditions. Applied Sciences, 14(14), 6285. https://doi.org/10.3390/app14146285

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