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Cognitive training can potentially prevent cognitive decline. However, the results of recent studies using semi-immersive virtual reality (VR)-assisted cognitive training are inconsistent.
We aimed to examine the hypothesis that cognitive training using fully immersive VR, which may facilitate visuospatial processes, could improve visuospatial functioning, comprehensive neuropsychological functioning, psychiatric symptoms, and functional connectivity in the visual brain network in predementia.
Participants over 60 years old with subjective cognitive decline or mild cognitive impairment from a memory clinic were randomly allocated to the VR (n=23) or the control (n=18) group. The VR group participants received multidomain and neuropsychologist-assisted cognitive training in a fully immersive VR environment twice a week for 1 month. The control group participants did not undergo any additional intervention except for their usual therapy such as pharmacotherapy. Participants of both groups were evaluated for cognitive function using face-to-face comprehensive neuropsychological tests, including the Rey-Osterrieth Complex Figure Test (RCFT) copy task; for psychiatric symptoms such as depression, apathy, affect, and quality of life; as well as resting-state functional magnetic resonance imaging (rsfMRI) at baseline and after training. Repeated-measures analysis of variance was used to compare the effect of cognitive training between groups. Seed-to-voxel–based analyses were used to identify the cognitive improvement–related functional connectivity in the visual network of the brain.
After VR cognitive training, significant improvement was found in the total score (F1,39=14.69,
Fully immersive VR cognitive training had positive effects on the visuospatial function, apathy, affect, quality of life, and increased frontal-occipital functional connectivity in older people in a predementia state. Future trials using VR cognitive training with larger sample sizes and more sophisticated designs over a longer duration may reveal greater improvements in cognition, psychiatric symptoms, and brain functional connectivity.
Clinical Research Information Service KCT0005243; https://tinyurl.com/2a4kfasa
Dementia is a major neurodegenerative disorder, affecting approximately 10% of older people [
To date, many researchers have suggested that prevention is crucial, and have identified risk and protective factors associated with dementia, as well as preventive strategies [
Advances in computer sciences and information and communication technology (ICT) have resulted in increased availability and accessibility of computerized cognitive training. Although conclusive results have yet to be found, preliminary studies have reported improvements in trained and nontrained cognition, and enhanced brain activity in related regions after computerized cognitive training in individuals with mild cognitive impairment (MCI) [
Recently, the number of neuroimaging studies attempting to reveal the underlying neural mechanisms associated with cognitive decline has increased [
To test this hypothesis, we performed a preliminary randomized controlled trial to determine the efficacy and mechanisms of VR cognitive training in a predementia state. We aimed to ascertain the effects of VR multidomain cognitive training on visuospatial function, comprehensive neuropsychological function, and psychiatric symptoms in predementia. Moreover, we examined the hypothesis that cognitive improvement could be related to increased functional connectivity in the visual network of the brain.
Participants over 60 years old in a predementia state (ranging from subjective cognitive decline to MCI) were prospectively recruited between May and December 2019 from the memory clinic of Gachon University Gil Medical Center, Republic of Korea. Among 58 individuals who were assessed for eligibility using structured clinical interviews and brain MRI, four participants were excluded due to cerebral infarction on MRI (n=2), severe white matter hyperintensity on MRI (n=1), and history of a recent dental implant surgery (n=1). Nine participants voluntarily withdrew from the study due to an acute medical condition (n=2), hospitalization of a family member (n=1), scheduling conflict (n=1), and unknown personal reasons (n=5). Finally, a total of 45 participants were randomly assigned to either the VR group or the control group.
All participants had subjective cognitive complaints, including memory decline, but did not meet the criteria for diagnosis of a major neurocognitive disorder based on the Diagnostic and Statistical Manual of Mental Disorders (5th edition) [
The exclusion criteria for the participants were as follows: (i) Korean version of Mini-Mental State Examination (MMSE) score <20; (ii) impaired activities of daily living; (iii) comorbidity of severe medical or surgical conditions; (iv) major psychiatric disorders; (v) history of any kind of dementia; (vi) history of neurodegenerative disorders, including Creutzfeldt-Jakob disease, Pick disease, Huntington disease, Parkinson disease, inflammation associated with HIV, and syphilis; (vii) structural abnormalities on MRI such as intracranial hemorrhage, cerebral, cerebellar, or brainstem infarction, hydrocephalus, traumatic brain injury, severe white matter hyperintensity, tumors, multiple sclerosis, or vasculitis; and (viii) inability to use the VR system.
Information on study objectives, group allocation, cognitive intervention, brief study protocol, risks and benefits, and confidentiality was given to all participants before enrollment. All participants provided offline written informed consent, and the Institutional Review Board of Gachon University Gil Medical Center approved this study (GCIRB2018-396).
This was an open-label, randomized controlled trial (KCT0005243) that aimed to investigate the efficacy of a fully immersive VR cognitive training program on visuospatial function in older people with risk for dementia (
The multidomain VR cognitive training program was developed between November 2018 and April 2019 by the authors who are board-certified geriatric neuropsychiatrists and clinical neuropsychologists with expertise. The VR cognitive training program consisted of multiple games involving multidomain cognitive tasks to assess: (i) attention (to find differences), (ii) executive function and memory (to select items needed to perform certain tasks), (iii) working memory and ability to perform mathematical calculations (to prepare an exact amount of money), (iv) visuospatial orientation (to find a path using a memorized map), (v) visuospatial function (to spatially place furniture exactly based on a memorized drawing), (vi) verbal memory (to remember certain words), (vii) visual memory (to remember specific flags and symbols), and (viii) processing speed and working memory (to catch animals in a certain order). All virtual environments were fully immersive 3D settings allowing for feelings of increased presence and visuospatial stimulation; training was accompanied by game elements to increase the interest and motivation of the participants. Representative images of the VR training program are presented in
Each session lasted approximately 20-30 minutes. The VR training took place using a head-mounted Oculus Rift CV1 display, with Oculus Touch controllers held in both of the participant’s hands. Each training session was performed with the participant in a seated position, and the difficulty level increased throughout the study period from easy to difficult (levels 1-4), with two sessions at each difficulty level. All procedures were performed in the memory clinic of Gachon University Gil Medical Center and were guided by a certified clinical neuropsychologist (SL) in addition to automatic verbal and visual messages from the program. There were no revisions, updates, or breaches of the program during the study period. This program was used exclusively in this study and is not available for commercial use.
All participants underwent face-to-face comprehensive neuropsychological tests and evaluations using psychiatric scales, as well as rsfMRI at baseline and after the VR cognitive training period. Baseline evaluations of diagnostic criteria included global and functional scales such as the Korean version of the MMSE, Clinical Dementia Rating (CDR), CDR Sum of Boxes (CDR-SOB), global deterioration scale, and instrumental activities of daily living scales.
The primary outcome was the effect of the VR cognitive training on visuospatial function measured by the Rey-Osterrieth Complex Figure Test (RCFT) copy task, which has been validated in the Korean population [
The secondary outcomes concerned the effect on comprehensive neuropsychological function; psychiatric symptoms such as affect, apathy, quality of life (QoL), and depression; and functional connectivity in the visual network of the brain.
The neuropsychological tests consisted of the MMSE and subtests from the comprehensive neuropsychological test battery [
Noncognitive psychiatric symptoms that typically start to decline in the early dementia stage were also assessed [
The Simulator Sickness Questionnaire (SSQ) was administered after each session to evaluate tolerability of the VR cognitive training program [
A 3-Tesla whole-body Siemens scanner (TrioTim syngo) was used for functional image acquisition with an interleaved T2*-weighted echo-planar imaging gradient echo sequence (repetition time/echo time=2500/25 milliseconds, flip angle=90°, slice thickness=3.5 mm, in-plane resolution=3.5×3.5 mm, matrix size=64×64) with a 12-channel birdcage head coil. For each participant, 160 functional volumes were acquired at the pretraining and posttraining time points. After rsfMRI, an anatomical image was acquired using a high T1-weighted 3D-gradient echo pulse sequence with magnetization-prepared rapid gradient echo (repetition time/echo time/inversion time=1900/3.3/900 milliseconds, flip angle=9°, slice thickness=1.0 mm, in-plane resolution=0.5×0.5 mm, matrix size=416×512). T1-weighted images were acquired only at the pretraining time point.
Preprocessing of the rsfMRI data was performed using Statistical Parametric Mapping software version 12 (Wellcome Trust Centre for Neuroimaging). First, a slice-timing correction was applied and the center of each image was relocated near the anterior commissure. Second, rsfMRI and T1-weighted images were imported into CONN FC toolbox v19c [
All preprocessed rsfMRI images were bandpass-filtered (0.008-0.09 Hz), and physiological and other spurious noise sources in the blood oxygenation level–dependent signal were removed using the anatomical component-based noise correction strategy implemented in CONN [
Sample calculation was based on a recent meta-analysis on the effectiveness of VR for people with MCI or dementia that produced small-to-medium effect sizes using a random-effects model (effect size=0.29) from a total of 11 studies [
Comparisons of demographic and clinical variables between the two groups were performed using independent
For rsfMRI data, Pearson correlation coefficients were converted to normally distributed scores using the Fisher
Of the 45 participants who were randomly allocated to the VR (n=25) or the control (n=20) group, 41 participants completed the study. After allocation, two participants of the VR group dropped out of the study due to dizziness (n=1) and unfamiliarity with the VR machine during the first session (n=1). Two participants of the control group dropped out because of hospitalization due to a traffic accident (n=1) and unknown personal reasons (n=1). Ultimately, 41 participants were included in the analyses. The trial flow chart is presented in
Trial flow chart. VR: virtual reality; MRI: magnetic resonance imaging.
Demographic and clinical characteristics of all study participants.
Characteristic | Total (N=41) | VRa group (n=23) | Control group (n=18) | χ2 or |
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Age (years), mean (SD) | 74.51 (5.81) | 75.48 (4.67) | 73.28 (6.96) | –1.13 | .26 |
Sex (female), n (%) | 29 (70.7) | 17 (73.9) | 12 (66.7) | 0.26 | .61 |
Education (years), mean (SD) | 8.07 (4.39) | 7.70 (4.10) | 8.56 (4.83) | –0.01 | .99 |
MMSEc, mean (SD) | 26.24 (2.85) | 26.22 (2.91) | 26.28 (2.87) | 0.09 | .93 |
CDRd, mean (SD) | 0.41 (0.22) | 0.41 (0.19) | 0.42 (0.26) | –0.02 | .99 |
CDR-SOBe, mean (SD) | 0.92 (1.00) | 0.98 (0.85) | 0.83 (1.19) | –1.24 | .21 |
Global Deterioration Scale, mean (SD) | 2.20 (0.78) | 2.26 (0.75) | 2.11 (0.83) | –0.78 | .44 |
IADLf, mean (SD) | 0.13 (0.24) | 0.14 (0.21) | 0.11 (0.28) | –1.09 | .27 |
aVR: virtual reality.
bMann-Whitney
cMMSE: Mini-Mental State Examination.
dCDR: Clinical Dementia Rating.
eCDR-SOB: CDR-Sum of Boxes.
fIADL: instrumental activities of daily living.
Group comparisons of visuospatial function pre and post virtual reality (VR) cognitive training.
Function score | Pretraining | Posttraining | Within groups |
Between groups interactiona | |||||||||||
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14.69 | .001 | 0.30 | |||||||||
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VR (n=23) | –0.31 (1.09) | 0.22 (0.78) | –3.50 (22) | .002 |
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Control (n=18) | –0.07 (1.14) | –0.47 (1.22) | 2.15 (17) | .046 |
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9.27 | .005 | 0.22 | |||||||||
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VR | 1.99 (0.59) | 2.14 (0.42) | –2.82 (22) | .01 |
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Control | 2.15 (0.54) | 2.07 (0.59) | 1.53 (17) | .14 |
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aRepeated measures analysis of variance after adjusting for age (for basic components only), years of education (for basic components only), sex, Clinical Dementia Rating-Sum of Boxes, depressive symptoms, and pharmacotherapy.
bRCFT: Rey-Osterrieth Complex Figure Test; basic components consist of a large rectangle, diagonal cross, horizontal midline of a large rectangle, and vertical midline of a large rectangle.
cAdjusted for age and years of education.
dRaw scores.
Group comparisons of comprehensive neuropsychological tests pre and post virtual reality (VR) cognitive training.
Testa | Pretraining, mean (SD) | Posttraining, mean (SD) | Within groups |
Between groups interactionb | ||||||||
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0.75 | .39 | 0.02 | ||||||||
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VR (n=23) | 26.22 (2.91) | 25.87 (3.36) | 0.97 (22) | .34 |
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Control (n=18) | 26.28 (2.87) | 26.67 (3.09) | –0.89 (17) | .39 |
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0.00 | .96 | 0.00 | ||||||||
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VR (n=23) | –0.11 (1.21) | –0.24 (0.87) | 0.57 (22) | .57 |
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Control (n=18) | –0.08 (1.08) | 0.15 (1.03) | –1.42 (17) | .18 |
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0.04 | .84 | 0.00 | ||||
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VR (n=23) | –0.09 (0.99) | –0.15 (0.92) | 0.23 (22) | .82 |
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Control (n=18) | –0.23 (1.26) | –0.25 (0.82) | 0.08 (17) | .94 |
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2.32 | .14 | 0.06 | ||||||||
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VR (n=23) | 0.13 (0.58) | 0.12 (0.64) | 0.10 (22) | .93 |
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Control (n=18) | –0.87 (4.19) | –0.38 (3.53) | –1.00 (17) | .33 |
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3.55 | .07 | 0.09 | ||||||||
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VR (n=23) | –0.23 (1.08) | 0.19 (1.02) | –4.08 (22) | <.001 |
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Control (n=18) | –0.15 (1.00) | –0.01 (1.37) | –0.72 (17) | .48 |
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1.83 | .19 | 0.05 | ||||||||
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VR (n=23) | 0.23 (0.10) | 0.67 (1.24) | –3.10 (22) | .005 |
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Control (n=18) | 0.30 (0.83) | 0.52 (0.89) | –2.29 (17) | .04 |
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3.03 | .09 | 0.08 | ||||||||
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VR (n=23) | –0.10 (1.40) | 0.66 (1.37) | –4.59 (22) | <.001 |
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Control (n=18) | 0.12 (0.97) | 0.58 (0.94) | –3.21 (17) | .005 |
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0.37 | .55 | 0.01 | ||||||||
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VR (n=23) | 0.29 (1.39) | 0.48 (1.30) | –0.93 (22) | .36 |
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Control (n=18) | 0.37 (1.01) | 0.29 (1.07) | 0.41 (17) | .69 |
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0.04 | .85 | 0.00 | ||||||||
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VR (n=23) | –0.25 (0.99) | –0.44 (1.17) | 1.01 (22) | .32 |
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Control (n=18) | –0.41 (1.00) | –0.58 (0.88) | 1.09 (17) | .29 |
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3.08 | .09 | 0.08 | ||||||||
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VR (n=23) | –0.35 (0.88) | –0.41 (0.78) | 0.39 (22) | .70 |
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Control (n=18) | –0.09 (0.82) | 0.27 (1.01) | -1.89 (17) | .08 |
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0.05 | .82 | 0.00 | ||||||||
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VR (n=23) | –0.01 (1.12) | 0.32 (1.04) | –1.99 (22) | .06 |
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Control (n=18) | –0.01 (0.85) | 0.16 (1.21) | –0.64 (17) | .53 |
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0.13 | .73 | 0.00 | ||||||||
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VR (n=23) | –1.43 (2.04) | –0.64 (1.74) | –2.30 (22) | .03 |
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Control (n=18) | –0.55 (1.52) | –0.55 (1.62) | 0.01 (17) | .996 |
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aAll data except for MMSE are presented as age and years of education–adjusted
bRepeated-measures analysis of variance after adjusting for age (for MMSE only), years of education (for MMSE only), sex, Clinical Dementia Rating-Sum of Boxes, depressive symptoms, and pharmacotherapy.
cMMSE: Mini-Mental State Examination.
dTMT-B: Trail Making Test.
eK-BNT: Korean version of the Boston Naming Test.
fSVLT: Seoul Verbal Learning Test.
gCOWAT: Controlled Oral Word Association Test.
Group comparisons of psychiatric symptoms pre and post virtual reality (VR) cognitive training.
Group | Pretraining, mean (SD) | Posttraining, mean (SD) | Within groups |
Between groups interactiona | |||||
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0.88 | .36 | 0.03 | ||
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VR (n=23) | 15.00 (6.08) | 13.26 (6.49) | 2.46 (22) | .02 |
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Control (n=18) | 12.17 (6.85) | 11.72 (7.18) | 0.47 (17) | .65 |
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7.02 | .01 | 0.17 | ||
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VR (n=23) | 47.43 (10.20) | 54.35 (9.41) | –3.04 (22) | .006 |
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Control (n=18) | 52.83 (9.38) | 51.22 (8.72) | 0.98 (17) | .34 |
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14.40 | .001 | 0.30 | ||
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VR (n=23) | 17.00 (6.28) | 21.43 (7.27) | –2.71 (22) | .01 |
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Control (n=18) | 21.83 (7.48) | 16.50 (6.51) | 4.63 (17) | <.001 |
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4.23 | .047 | 0.11 | ||
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VR (n=23) | 18.22 (7.09) | 16.30 (6.35) | 0.97 (22) | .34 |
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Control (n=18) | 18.89 (5.31) | 20.44 (8.42) | –1.16 (17) | .26 |
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4.49 | .04 | 0.12 | ||
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VR (n=18) | 31.04 (4.69) | 32.26 (4.96) | –1.23 (22) | .23 |
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Control (n=23) | 34.94 (9.43) | 32.72 (6.54) | 1.21 (17) | .25 |
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aRepeated-measures analysis of variance after adjusting for age, years of education, sex, Clinical Dementia Rating-Sum of Boxes, and pharmacotherapy.
bGDS: Geriatric Depression Scale.
cAES: Apathy Evaluation Scale.
dPANAS-P: Positive and Negative Affect Schedule-positive affect.
ePANAS-N: Positive and Negative Affect Schedule-negative affect.
fQoL-AD: Quality of Life-Alzheimer Disease.
Interest and satisfaction had mean scores of 79.78 (SD 14.18) and 78.04 (SD 12.50) on a Likert scale ranging from 0 to 100, respectively.
Mean (SD) simulator sickness questionnaire scores associated with the virtual reality cognitive training (n=23).
Session | Nausea | Oculomotor | Disorientation | Total score |
1 | 9.95 (14.80) | 14.83 (14.18) | 22.39 (22.89) | 17.24 (17.53) |
2 | 6.22 (10.61) | 11.53 (16.30) | 15.13 (18.25) | 12.20 (15.59) |
3 | 9.13 (12.69) | 11.21 (16.62) | 16.95 (25.51) | 13.66 (18.86) |
4 | 6.64 (9.73) | 9.89 (14.89) | 10.29 (19.78) | 10.24 (14.97) |
5 | 6.64 (10.54) | 7.91 (13.02) | 13.92 (23.37) | 10.24 (14.63) |
6 | 2.45 (7.17) | 9.56 (15.70) | 20.58 (26.83) | 11.22 (16.18) |
7 | 5.39 (6.94) | 9.89 (12.61) | 19.37 (27.12) | 12.20 (14.93) |
8 | 9.97 (11.20) | 14.82 (17.27) | 18.98 (27.35) | 16.32 (19.47) |
We investigated brain functional connectivity in the visual network associated with the improvement in the RCFT copy task. The areas with significantly increased connectivity in the seed-to-voxel visual networks are presented in
Functional visual network connectivity related to improved Rey-Osterrieth Complex Figure Test copy task scores after virtual reality cognitive training.
Seed and connected regions (voxels) | Clusters | |||
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Voxel (2×2×2) | MNIa coordinates (x, y, z)b | FDRc–corrected |
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291 | –06, +40, +42 | .003 | |
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Paracingulate gyrus, Lf | 118 |
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Paracingulate gyrus, R | 68 |
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Frontal pole, L | 41 |
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Superior frontal gyrus, L | 29 |
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Anterior cingulate gyrus | 7 |
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Frontal pole, R | 1 |
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White matter | 27 |
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719 and 401 | +16, +20, +16 and –22, +22, +16 | <.001 and <.001 | |
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Insular cortex, R | 71 |
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Frontal pole, R | 48 |
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Frontal operculum cortex, R | 25 |
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Caudate, R | 24 |
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Caudate, L | 3 |
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Putamen, R | 2 |
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White matter | 546 |
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Insular cortex, L | 2 |
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White matter | 399 |
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Visual lateral, L | N/Ag | N/A | N/A | |
Visual occipital | N/A | N/A | N/A |
aMNI: Montreal Neurological Institute.
bCoordinates indicate the representative coverage region with maximum power among all connected regions.
cFalse-discovery Rate.
dGroup-level analyses between the VR and control groups were performed using a general linear model with Rey-Osterrieth Complex Figure Test copy task improvement as an explanatory variable and the post-pre training
eR: right side.
fL: left side.
gN/A: not applicable.
Seed-to-voxel analyses based on the right lateral region (a) and the medial region (b) of the visual network (blue circles). Increased frontal-occipital functional connectivity related to the Rey-Osterrieth Complex Figure Test copy task improvement after virtual reality cognitive training. False discovery rate–corrected
This study found that 1-month multidomain cognitive training using fully immersive VR was effective in improving visuospatial function and frontal-occipital functional connectivity, as well as apathy, affect, and QoL in older people in a predementia cognitive state.
The first major finding of this study is that VR cognitive training resulted in improvements in the RCFT copy task. Despite the inconsistent results reported in the literature, training-related changes in cognition have been repeatedly found in older people with cognitive disorders [
Another novel finding was the increased functional connectivity observed in the frontal-occipital cortical network after VR cognitive training, which was associated with improved performance in the RCFT copy task, consistent with the associations between cognitive improvements and neuronal plasticity that have been observed previously [
This evident link between visuospatial construction and frontal-occipital functional connectivity might be explained by the acquired cognitive system engagement induced by the RCFT copy task, which requires the participant to copy a complex geometric figure [
The psychiatric benefit of VR cognitive training in individuals in a predementia state should be considered. In this study, participants in the VR group showed improved apathy, affect, and QoL scores after training compared with those in the control group. A recent review reported that computerized cognitive training resulted in long-term improvements in psychological outcome measures [
Simulator sickness reported after every session was minimal in the VR cognitive training group. In this study, the SSQ total score (mean 12.86, SD 11.82) indicated minimal symptoms (score 5-10) according to the suggested categorization established in flight simulators [
Our study had several strengths and limitations. This is one of the largest VR cognitive training studies to use a fully immersive 3D VR program. Compared to 2D or semi-immersive VR programs, our results highlight the positive effects of employing fully immersive 3D VR in cognitive training, as we found neural evidence supporting the improvement in visuospatial function. However, there are several limitations and lessons learned in this study. First, the small sample size and short training period were the main limitations. Although sample sizes in studies investigating the effects of cognitive training are increasing [
We found that fully immersive VR cognitive training improved cognition and psychiatric symptoms in a predementia state. Visuospatial function improved in such individuals relative to controls, and this finding was supported by increased frontal-occipital functional connectivity assessed by rsfMRI. These findings suggest that VR training can enhance visuospatial ability by exposing patients to an enriched virtual environment, leading to improved apathy, affect, and QoL. Our results support the neurotherapeutic use of VR cognitive training as an effective nonpharmacological intervention for those who are at risk for dementia; however, more rigorous trials should be performed to confirm the effects and identify the associated neural mechanisms.
CONSORT-EHEALTH (V 1.6.1) - Submission/Publication Form.
Representative images of the virtual reality training program.
Alzheimer disease
Apathy Evaluation Scale
Clinical Dementia Rating
Clinical Dementia Rating-Sum of Boxes
functional magnetic resonance imaging
Geriatric Depression Scale
information and communication technology
Korean version of the Boston Naming Test
mild cognitive impairment
Mini-Mental State Examination
magnetic resonance imaging
Positive and Negative Affect Schedule
Positive and Negative Affect Schedule-negative
Positive and Negative Affect Schedule-positive
quality of life
Rey-Osterrieth Complex Figure Test
resting-state functional magnetic resonance imaging
Simulator Sickness Questionnaire
Seoul Verbal Learning Test
Trail Making Test
virtual reality
We would like to thank C2MONSTER for help in designing and manufacturing the multidomain VR cognitive training program. This research was funded by the support program for Development of Dementia Care Service using Advanced ICT Technology 2018 funded by Korea Radio Promotion Association (RAPA) and the Ministry of Science and ICT (MSIT), Korea, under the Information Technology Research Center support program (IITP-2021-2017-0-01630) supervised by the Institute for Information & Communications Technology Promotion. The funding sources had no role in the study design; collection, analysis, and interpretation of data; writing of the manuscript; or decision to submit the article for publication.
JK, NK, and SL conceived and designed the study, acquired and analyzed the data, interpreted the study findings, and drafted the manuscript. SW, GP, and JP analyzed the data. BY, JL, JY, and SR designed the study, interpreted the study findings, supervised and directed the conduct of the study, and critically reviewed the manuscript. SC conceived and designed the study, acquired and analyzed the data, interpreted the study findings, supervised and directed the conduct of the study, and critically reviewed the manuscript.
None declared.