Aphasia is a highly disabling acquired language disorder generally caused by a left-lateralized brain damage. Even if traditional therapies have been shown to induce an adequate clinical improvement, a large percentage of patients are left with some degree of language impairments. Therefore, new approaches to common speech therapies are urgently needed in order to maximize the recovery from aphasia. The recent application of virtual reality (VR) to aphasia rehabilitation has already evidenced its usefulness in promoting a more pragmatically oriented treatment than conventional therapies (CT). In the present study, thirty-six chronic persons with aphasia (PWA) were randomly assigned to two groups. The VR group underwent conversational therapy during VR everyday life setting observation, while the control group was trained in a conventional setting without VR support. All patients were extensively tested through a neuropsychological battery which included not only measures for language skills and communication efficacy but also self-esteem and quality of life questionnairies. All patients were trained through a conversational approach by a speech therapist twice a week for six months (total 48 sessions). After the treatment, no significant differences among groups were found in the different measures. However, the amount of improvement in the different areas was distributed over far more cognitive and psychological aspects in the VR group than in the control group. Indeed, the within-group comparisons showed a significant enhancement in different language tasks (i.e., oral comprehension, repetition, and written language) only in the VR group. Significant gains, after the treatment, were also found, in the VR group, in different psychological dimensions (i.e., self-esteem and emotional and mood state). Given the importance of these aspects for aphasia recovery, we believe that our results add to previous evidence which points to the ecological validity and feasibility of VR treatment for language recovery and psychosocial well-being.
Aphasia is one of the most socially disabling consequences post stroke [
In these last years, scientific advancements in language conceptualization and the progress of new technologies have made new tools available for professional therapists and educators. Digital technologies offer exciting opportunities to PWAs who live with long-term communication deficits (see for review [
Among the applied technologies, an area that particularly merits exploration is virtual reality (VR). Development of VR applications for rehabilitation of aphasia is still in its early stages ([
Performance was measured by averaging the sentence level word accuracy of participants’ production of ten sentences (ten words in length) during each assessment session. Accuracy of words were rated using a previously validated six-point scale, and the overall session score expressed on a scale from 0 to 100%. Training resulted in significant gains in script acquisition with maintenance of skills at three and six weeks posttreatment. Differences between cuing conditions were not significant. Three weeks of computer-based script training resulted in increased accuracy and rate of script production. The mean baseline performance was 50.0 (26.4)% for accuracy and 23.7 (20.6) for rate (words per minute, WPM). At the end of training, it had improved to 77.8 (19.6)% and 60.3 (30.5) WPM for accuracy and rate, respectively. Moreover, although there was a slight drop in performance noted at both three weeks and six weeks posttreatment, the decreases were small. At three weeks posttreatment, the mean scores for accuracy were 72.2 (22.4) and the mean scores for rate were 55.2 (34.0). By six weeks posttreatment, these scores had declined slightly to 68.6 (24.7) for accuracy and 51.4 (35.8) for rate [
The Web Oral Reading for Language in Aphasia (ORLA, Rehabilitation Institute of Chicago) [
Sentactics (Sentactics Corporation, Concord, CA, USA) is a linguistic treatment which aims at improving sentence production and comprehension deficits through a virtual clinician. Patients are trained repeating and reading sentences and describing pictures presented on the screen. Thompson et al. [
More recently, a multiuser virtual world called EVA Park was designed for PWA. The authors wanted to investigate whether virtual environments would enable people with moderate aphasia to practice speech successfully with one or more conversational partners [
Kurland et al. [
Marshall et al. [
Within a case series (
Very recently, Palmer et al. [
Maresca et al. [
In summary, although in the field of aphasia rehabilitation, technical devices have begun to be employed, to date, digital versions of traditional language therapy exercises have been mostly used [
Here, we report a video-based conversational training approach which makes use of semi-immersive VR environments to investigate their therapeutic benefits in enhancing language skills, communication efficacy, and psychosocial aspects (i.e., the self-esteem level; the patient’s emotional, health, and humoral states) in a group of eighteen nonfluent chronic PWA. The efficacy of the VR approach was compared to the results of a matched control group of eighteen PWA who underwent the same conversational training without VR support.
The study addressed the following research questions (RQs):
In line with previous literature [
All patients were recruited from the neurological departments of different hospitals in Turin. Seventy-six have completed their speech therapy cycle and contacted the Experimental Laboratory of Aphasia of the Fondazione Carlo Molo Onlus in Turin in order to participate as volunteers in the research. A preliminary neuropsychological assessment was handled by an independent neuropsychologist who was blinded to the research. The inclusion criteria were fluent users of Italian, premorbidly right handed, a diagnosis of aphasia due to a single left hemisphere stroke occurring more than six months prior to the study; absence of cognitive impairment; ability to follow instructions; no hemispatial neglect; no articulatory disorder; no uncorrected visual impairment (self-report); and no hearing loss (screened via pure tone audiometry). Since our treatment was based on a conversational therapy approach aimed at enhancing verbal communication, we selected only nonfluent patients. Patients were not enrolled if they had a premorbid speech and language disorder caused by a neurological deficit other than stroke. Twenty patients were excluded because they did not meet the criteria. Fifteen people gave up for logistic reasons. Five had another stroke during the enrollment period. The thirty-six patients selected were randomly assigned to two different conditions by a researcher not involved in the research, using the Research Randomizer (
Table
Demographic and clinical data of the thirty-six participants.
Participants | Age | Sex | Educational level | Time post onset | Etiology |
---|---|---|---|---|---|
S1 | 71 | M | 18 | 30 | Frontotemporal hemorrhage |
S2 | 50 | F | 8 | 28 | Frontoparietal ischemia |
S3 | 72 | M | 8 | 30 | Frontotemporal ischemia |
S4 | 68 | M | 13 | 40 | Frontotemporal ischemia |
S5 | 69 | F | 8 | 41 | Frontal ischemia |
S6 | 49 | F | 18 | 48 | Temporoparietal hemorrhage |
S7 | 53 | M | 13 | 36 | Frontotemporal ischemia |
S8 | 53 | M | 13 | 34 | Frontoparietal ischemia |
S9 | 71 | M | 13 | 54 | Temporal ischemia |
S10 | 32 | M | 15 | 40 | Basal ganglia hemorrhage |
S11 | 37 | M | 11 | 35 | Temporoparietal hemorrhage |
S12 | 51 | M | 13 | 30 | Frontotemporal ischemia |
S13 | 61 | M | 8 | 24 | Temporoparietal ischemia |
S14 | 48 | M | 8 | 24 | Frontal hemorrhage |
S15 | 72 | F | 5 | 30 | Temporooccipital hemorrhage |
S16 | 48 | M | 8 | 40 | Frontal hemorrhage |
S17 | 75 | M | 13 | 60 | Temporoparietal ischemia |
S18 | 70 | M | 8 | 30 | Frontoparietal ischemia |
S19 | 60 | M | 18 | 40 | Frontotemporoparietal ischemia |
S20 | 69 | M | 13 | 36 | Frontotemporal ischemia |
S21 | 56 | F | 13 | 35 | Frontotemporal ischemia |
S22 | 60 | F | 8 | 28 | Temporal ischemia |
S23 | 61 | F | 13 | 40 | Frontotemporal ischemia |
S24 | 53 | M | 13 | 42 | Frontotemporal ischemia |
S25 | 47 | F | 18 | 50 | Frontotemporal ischemia |
S26 | 61 | M | 13 | 54 | Frontotemporal ischemia |
S27 | 63 | F | 8 | 52 | Frontotemporal hemorrhage |
S28 | 70 | F | 8 | 60 | Frontotemporal ischemia |
S29 | 61 | M | 13 | 70 | Frontotemporal ischemia |
S30 | 38 | M | 13 | 54 | Temporooccipital ischemia |
S31 | 69 | M | 8 | 60 | Frontotemporal ischemia |
S32 | 70 | M | 8 | 58 | Temporoparietal hemorrhage |
S33 | 63 | M | 8 | 56 | Frontotemporal ischemia |
S34 | 60 | M | 9 | 52 | Frontal ischemia |
S35 | 77 | F | 13 | 50 | Temporoparietal ischemia |
S36 | 63 | F | 7 | 48 | Temporoparietal ischemia |
The data analysed in the current study conformed with the Helsinki Declaration. Our named Institutional Review Board (Ethical Committee, University of Turin) specifically approved this study (protocol 100960) with the understanding and written consent of each subject.
The semi-immersive VR scenarios were projected through a screen (50 inches). They were created with a NeuroVR 2.0 open source software (
Virtual scenarios.
Station |
Hotel |
Restaurant |
Supermarket |
Amusement park |
Cinema |
Travel |
The interaction among patients was mediated by a speech therapist who operated in the VR scenario through the use of a personal computer. As the patient selects a virtual scenario (e.g., supermarket), the therapist presses the keyboard allowing the patient to explore it. Thus, the Neuro VR does not provide for the patient to explore the virtual environments without the help of the therapist. Within each scenario, different choices can be made by the patient (i.e., in the “Travel” scenario, patients could decide which sport to play (tennis or golf)). As the patient communicates to the therapist his/her choice, the therapist moves the mouse by clicking on the option chosen by the patient, thus opening a new screen in which the selected chooses appears. For example, if the patient chooses a tennis court, he/she can move the tennis ball by naming the objects placed on the side of the ball. Then, if the objects are correctly named, the therapist throws the ball to the other side. The response shift will thus be transferred to the patient who is playing together at that time and who, in turn, must name the objects placed on the other side of the field. Each virtual scenario includes the same number of cognitive exercises which train the different functions and the exercises vary in number and difficulty on the basis of the itinerary chosen. Thus, the apparatus automatically selects the exercises to be performed as the patient gets through the virtual environment and makes his/her choice (i.e., if the patient is at the greengrocer, he may be asked to indicate a fruit among semantic or phonological distractors or to perform a category fluency task).
For example, in the Supermarket scenario (see Figure
ScenePlayer NeuroVR: “Supermarket”.
The 36 participants were randomly assigned through a computer software program to one of two training: (1) conversational training combined with VR (
A range of outcome measures was used to evaluate the effects of the two treatments (VR vs. CT). Language, communication skills, and psychosocial aspects were tested before and after the training via standardized test batteries. The primary outcome language measure was the Aachen Aphasia Test (A.A.T.) [
Secondary outcome measures included the Conversation Analysis Profile for People with Aphasia test (C.A.P.P.A. test, [
The six-month training consisted of two-hour therapy sessions twice a week for twenty-four weeks (
The procedure and the training were the same as the one for the experimental group but without the VR scenarios. A total of six months of training and two-hour therapy sessions twice a week (
All statistical analyses were conducted with IBM SPSS Statistics 22 software. For the outcome measures, two ANOVA analyses were planned. The first was a mixed ANOVA with the within variable of time (two levels: pre vs. posttreatment), and the between variable of group (two levels: VR group vs. control group). This directly compared the results of the two groups at two time points (pre vs. posttreatment) on each test. The second analysis was a within-group ANOVA, with the within-variable TIME (two levels: pre vs. posttreatment) comparing, within each group separately, the mean scores at two time points on each test. If the ANOVA showed significant effects, respective post hoc Bonferroni tests were conducted. In order to investigate baseline differences between the two groups, one-way ANOVA comparisons for age, educational level, time post stroke, and screening measures were also applied. Since within each group, subjects were treated in groups of three, we had six comparisons, thus, the significance level was set at
One-way ANOVA comparisons for age, educational level, time post stroke, and screening measures found significant baseline differences between the groups only with respect to time post stroke (
The mixed ANOVA revealed the main effect of time: token test (
No effect of GROUP and no interaction time
So, participants improved between pre- and posttreatment on this measure, but both groups improved equally.
In the VR group, the within-group ANOVA showed a significant effect of time in repetition (
Normalized scores in the different subtests of the Aachen Aphasia Test (AAT) for the VR group. Legend: Pre-Treat: pretreatment; Post-Treat: posttreatment; TT: token test, REPET: repetition; WL = written Language; NAM: naming; Compr: comprehension; OR Compr: oral comprehension; W Compr: written comprehension; PT: normalized scores; Within-group ANOVA:
Summary of the results obtained in the different subtests of the AAT test in the two groups.
Tests | VR group | Partial | Control group | Partial |
---|---|---|---|---|
AAT—token test | 0.018 | 0.385 | 0.094 | 0.216 |
AAT—repetition | 0.002 | 0.559 | 0.004 | 0.505 |
AAT—written language | 0.002 | 0.552 | 0.045 | 0.296 |
AAT—naming | 0.016 | 0.393 | 0.065 | 0.256 |
AAT—comprehension | 0.027 | 0.347 | 0.019 | 0.382 |
AAT—oral comprehension | 0.008 | 0.462 | 0.428 | 0.053 |
AAT—written comprehension | 0.699 | 0.013 | 0.102 | 0.208 |
Sig. within-group ANOVA:
In the control group, the within-group ANOVA showed a significant effect of time only in repetition (
Normalized scores in the different subtests of the Aachen Aphasia Test (AAT) for the control group. Legend: Pre-Treat: pretreatment; Post-Treat: posttreatment; TT: token test, REPET: repetition; WL = written language; NAM: naming; Compr: comprehension; OR Compr: oral comprehension; W Compr: written comprehension; PT: normalized scores; within-group ANOVA:
The mixed ANOVA revealed the main effect of time from the patient’s perspective: language ability for frequency (
No effect of group and no interaction
So participants improved between pre- and posttreatment on this measure from the patient’s perspective, but both groups improved equally.
In the VR group, the within-group ANOVA showed a significant effect of time: language ability (
Mean percentage of scores in the different subtests of the C.A.P.P.A. test, for frequency and severity, in the VR Group from the patient‘s perspective. Legend: Pre-Treat: pretreatment. Post-Treat: posttreatment; LA: language ability; SC: ability to self-correct; TT: turn taking; TM: topic management; within-group ANOVA:
Summary of the results obtained in the different subtests of the C.A.P.P.A. test, for frequency and severity, in the VR and control groups from the patient’s perspective.
VR group | Partial | Control group | Partial | |
---|---|---|---|---|
Frequency | ||||
(i) Language ability | 0.001 | 0.625 | 0.032 | 0.328 |
(ii) Self-correction | 0.234 | 0.116 | 0.229 | 0.118 |
(iii) Turn taking | 0.003 | 0.527 | 0.102 | 0.207 |
(iv) Topic management | 0.278 | 0.097 | 0.001 | 0.685 |
Severity | ||||
(i) Language ability | 0.001 | 0.669 | 0.021 | 0.372 |
(ii) Self-correction | 0.092 | 0.218 | 0.021 | 0.370 |
(iii) Turn taking | 0.001 | 0.810 | 0.050 | 0.284 |
(iv) Topic management | 0.046 | 0.291 | 0.034 | 0.322 |
Sig. within-group ANOVA:
In the control group, the within-group ANOVA revealed a significant effect of time only in the frequency of the topic management subtest (
Mean percentage of scores in the different subtests of the C.A.P.P.A. test, for frequency and severity, in the control group from the patient’s perspective. Legend: Pre-Treat: pretreatment; Post-Treat: posttreatment; LA: language ability; SC: ability to self-correct; TT: turn taking; TM: topic management; within-group ANOVA:
The mixed ANOVA revealed the main effect of time from the caregiver’s perspective: language ability, frequency (
No effect of group and no interaction
So participants improved between pre- and posttreatment on this measure from the caregiver’s perspective, but both groups improved equally.
In the VR group, the within-group ANOVA showed a significant effect of time: language ability (
Mean percentage of scores in the different subtests of the C.A.P.P.A. test, for frequency and severity, in the VR group from the caregiver’s perspective. Legend: Pre-Treat: pretreatment; Post-Treat: posttreatment; LA: language ability; SC: ability to self-correct; TT: turn taking; TM: topic management; within-group ANOVA:
Summary of the results obtained in the different subtests of the C.A.P.P.A. test, for frequency and severity, in the VR group and in the control group from the caregiver’s perspective.
VR group | Partial | Control group | Partial | |
---|---|---|---|---|
Frequency | ||||
(i) Language ability | 0.001 | 0.740 | 0.011 | 0.432 |
(ii) Self-correction | 0.001 | 0.634 | 0.001 | 0.606 |
(iii) Turn taking | 0.001 | 0.662 | 0.085 | 0.227 |
(iv) Topic management | 0.015 | 0.431 | 0.881 | 0.002 |
Severity | ||||
(i) Language ability | 0.001 | 0.677 | 0.001 | 0.614 |
(ii) Self-correction | 0.003 | 0.578 | 0.020 | 0.373 |
(iii) Turn taking | 0.011 | 0.456 | 0.189 | 0.139 |
(iv) Topic management | 0.062 | 0.281 | 0.230 | 0.118 |
Sig. within-group ANOVA:
In the control group, the within-group ANOVA showed a significant effect of time in language ability for severity (
Mean percentage of scores in the different subtests of the C.A.P.P.A. test, for frequency and severity, in the control group from the caregiver‘s perspective. Legend: Pre-Treat: pretreatment; Post-Treat: posttreatment; LA: language ability; SC: ability to self-correct; TT: turn taking; TM: topic management; within-group ANOVA:
The mixed ANOVA revealed the main effect of time (
So participants improved between pre- and posttreatment on this measure, but both groups improved equally.
Only in the virtual group, the within-group comparison showed a significant effect of time (
The mixed ANOVA revealed the main effect of time: WHO physical area (
No effect of group and no interaction
So participants improved between pre- and posttreatment on the different scales of the WHOQoL questionnaire, but both groups improved equally.
In the VR group, the within-group ANOVA revealed a significant effect of time in different areas: WHO physical area (
Mean percentage of scores in the different subtests of the WHOQoL questionnaire (Word Health Organization Quality of Life—WHOQOL group, 1998) for the VR group. Legend: Pre-Treat: pretreatment; Post-Treat: posttreatment; PHY: physical; SOC: social; PSYCH: psychological; ENVIR: environmental; within-group ANOVA:
Summary of the results obtained in the VASES and WHOQoL test for the VR group and the control group.
VR group | Partial | Without VR group | Partial | |
---|---|---|---|---|
VASES | 0.004 | 0.512 | 0.136 | 0.175 |
WHO physical | 0.002 | 0.556 | 0.629 | 0.228 |
WHO social | 0.097 | 0.212 | 0.003 | 0.525 |
WHO psychological | 0.001 | 0.608 | 0.737 | 0.010 |
WHO environmental | 0.001 | 0.720 | 0.114 | 0.194 |
Sig. within-group ANOVA
In the control group, the within-group ANOVA revealed a significant effect of time only in the social area (
Mean percentage of scores in the different subtests of the WHOQoL questionnaire (Word Health Organization Quality of Life–WHOQOL group, 1998) for the control group. Legend: Pre-Treat: pretreatment; Post-Treat: posttreatment; PHY: physical; SOC: social; PSYCH: psychological; ENVIR: environmental; within-group ANOVA:
The present study investigated the usefulness of semi-immersive virtual environments combined with a conversational therapy approach for enhancing language recovery in a sample of post stroke chronic PWA. It employed a randomized controlled design which compared the results of eighteen PWA who received an intensive VR intervention combined with conversational therapy with the performance of eighteen matched controls who underwent the same conversational therapy but without VR. A broad range of outcome measures examined the impact of the two treatments (VR vs. without VR) not only on language-specific tasks (AAT test) but also on the patients’ communication abilities (C.A.P.P.A. test) and on different psychosocial aspects measured through the VASES and WHOQoL. The study showed that substantial improvement can be achieved in the different domains for both groups. Indeed, after the treatment, no significant differences in the different measures were present between the two groups. Thus, these results replicate other findings indicating that even in chronic aphasia, language improvements can be achieved through intensive therapy [
The impact of VR for language recovery is in line with recent proposals from the embodied theory which considers language as represented in a multimodal dimension in which word semantics are also made of sensorimotor properties [
Overall, the results of this six-month study have revealed that language rehabilitation through an ecologically valid VR system can have a large impact in cognitive and psychological functioning. Thus, our results contribute with new evidence and provide further understanding on the use of VR in the rehabilitation of cognitive deficits. Despite the positive impact, some limitations of our study must be considered when interpreting the results. Concerning the sample, it can be observed that eighteen participants are still a small sample, though it is larger than previous studies. Moreover, the time post stroke comparison revealed that, although all patients were in the chronic phase (>36 months), the VR group was less chronic than the control group. Thus, there is still a need of further research considering other clinical populations, larger sample sizes, and more comparative studies. However, given the importance of a positive psychological state in PWA for motivating their participation in the therapy sessions, we believe that the use of VR, in the near future, should be pursued.
Data will be available upon request.
The authors declare that there is no conflict of interests regarding the publication of this paper.