1. ELHIT Évelyne Klinger Laval, April 10, 2008
The VAP-S: A Virtual Supermarket for the Assessment of Executive Functioning
Évelyne Klinger
Laval, April 10, 2008

2. ELHIT
The VAP-S: A Virtual Supermarket for the Assessment of Metacognitive Executive Functioning
Klinger E.1, Marié R.M.2, Lebreton S.2,
Weiss P.L.3, Hof, E.3, and Josman N.3
1 ELHIT, P&I Laboratory Arts et Métiers ParisTech Angers-Laval, France
2 University of Caen- Basse Normandie, UPRES-EA 3917, Caen, France
3 Department of Occupational Therapy, Faculty of Social Welfare and Health Sciences,
University of Haifa, Israel

3. Plan Rational The VAP-S project Two clinical applications Conclusion
VRIC’08, April 10, 2008

4. Modification of the frontal areas of the cerebral cortex
ELHIT
Executive Functions
Executive Functions
Higher-order functions that are needed for performing complex, new, or non routine tasks (Godefroy, 2003)
Planning: Ability to organize a behavior in a spatio-temporal context (Lezak, 1990)
Clinical Context of dysexecutive syndrome
Normal and Pathological Ageing
Neurological diseases
Brain damage
Observations
Decreased ability to perform basic and instrumental ADL
Impact on people independence
Necessity of Assessment of Executive Functions
Fonctions exécutives
Ensemble des fonctions nécessaires au contrôle et à la réalisation de tâches complexes, nouvelles ou non automatiques (Godefroy, 2003)
Planification: Capacité à organiser un comportement cognitif dans le temps et dans l’espace (Lezak, 1990)
Contexte clinique du syndrome dysexécutif
Vieillissement Normal et pathologique : En 2000, 1 habitant sur 5 de plus de 65 ans, En 2050, 1 habitant sur 3 de plus de 65 ans
A titre d’exemple 2% des plus de 65 ans sont atteints de la maladie de Parkinson
Maladies neurodégénératives (Parkinson, Alzheimer, démence frontotemporale, …ou encore la sclérose en plaques)
Lésions cérébrales (chaque année, par exemple personnes sont victimes en France d’un AVC)
Constats
Conséquences dans les activités de vie quotidienne
Nécessité d’évaluation
Modification of the frontal areas of the cerebral cortex
VRIC’08, April 10, 2008

5. Traditional Assessment’s Procedures
WCST
Standard neurocognitive tests:
Lack of sensitivity
Far away from everyday life situations (Godefroy et al., 2004)
Ecological neurocognitive tests:
Real time, Real situation (MET)
Limited use for patients without autonomy (Shallice & Burgess, 1991)
Test of scripts :
Plan generation
No action (Abbott et al., 1985)
Interest in functional virtual environments  The VAP-S
VRIC’08, April 10, 2008

6. VAP-S: Virtual Action Planning Supermarket
ELHIT
VAP-S: Virtual Action Planning Supermarket
Designed with two main softwares 3DStudioMax and Virtools
Klinger E., Marié R.M. et al., , GREYC-ENSICAEN, CHU de Caen
VRIC’08, April 10, 2008

7. First Person Perspective
Participant = Subjective camera
Navigation with cursor movement keys or game pad
VRIC’08, April 10, 2008

8. Task of Shopping List Verbal information :
ELHIT
Task of Shopping List
Verbal information :
In the supermarket, you should buy: one baguette; green apples; a 2kg drum of washing powder; one kilo of flour; a t-shirt for child; two  artichokes; and beige socks.
You may pay by clicking on the purse icon that is on the screen. .
List display on the screen
Marié et al., 2003
VRIC’08, April 10, 2008

9. Assessment Session The user The items Selects items by using the mouse
ELHIT
Assessment Session
The user
Selects items by using the mouse
The items
Appear in the cart
Disappear from the icon list
Feedback cues
Record of positions, time and actions
VRIC’08, April 10, 2008

10. Payement
Paying
Reaching the exit
VRIC’08, April 10, 2008

11. Record of Data Record of positions, time, actions
ELHIT
Record of Data
Departure
Cash desks
Record of positions, time, actions
Duration : 4 min, Distance : 124 m, Stops : 9
VRIC’08, April 10, 2008

12. Procedure
The participant is screened with the traditional assessments (inclusion criteria/cognitive evaluation)
The participant sits in front of a PC screen monitor
Two preliminary sessions
First, participant = passive observer (5 minutes)
Second, participant = active attitude (no limit)
Assessment session
No time limit
Execution of the task
Performance review
Therapist with/without participant
VRIC’08, April 10, 2008

13. Plan Rational The VAP-S project Two clinical applications Conclusion
VRIC’08, April 10, 2008

14. Elderly and Parkinson’s Disease
Approximately 2% of the French population beyond the age of sixty-five suffer from Parkinson’s Disease (De Rijk et al., 1997)
Parkinson ’s Disease: 90%: Executive dysfunction (Owen, Doyon 1999)
Objectives of the study (CHU Caen)
To test the feasibility of the VAP-S for elderly people
To investigate the capacity of the VAP-S to discriminate between patients with PD and age-matched control subjects
Traditional psychometric assessment
Global intellectual efficiency : Mattis (Mattis, 1975)
Exploration of executive functions: Wisconsin, Stroop, Brown-Peterson, Verbal fluency
VRIC’08, April 10, 2008

15. Performance comparison
ELHIT
Performance comparison
Control :
Duration : 8 min
Distance : 215 m
Stops :
Klinger et al., 2006
Patient with PD :
Duration : 25 min
Distance : 469 m
Stops :

16. Parkinson’s Conclusion
5 patients with PD (2 F, 3 M) / 5 age-matched healthy controls (4 F, 1 M)
Results show
The feasibility of the VAP-S for use with patients who have PD
The behavioral difference between patients and controls: spatio-temporal organization
The impact of the review of the trajectory
Klinger et al., 2006
VRIC’08, April 10, 2008

17. ELHIT
Stroke patients
Each year in France, approximately people suffer from stroke with disabling consequences (ANAES, 2002)
Among the symptoms
Sensory & cognitive deficits which result in a decreased ability to perform basic and instrumental ADL (Woodson, 1995)
Deficits in Executive Functions (Pohjasvaara et al., 2002)
Objectives of the study (Israel)
To test the feasibility of the VAP-S for post-stroke patients
To examine the relationships between performance within the VAP-S and standard outcome measures of Executive Functions
Traditional psychometric assessment
Mini Mental State Examination, Clock drawing, Star cancellation test
Exploration of executive functions: 6 subtests of the Behavioral Assessment of Dysexecutive Syndrome (BADS) (Wilson et al., 1996)
Scores above 24 in Mini Mental State Examinations.
Intact clock drawing according to Freedman’s scoring method
Absence of unilateral spatial neglect according to the star cancellation test from the behavioral inattention test.
The purpose of the test is to predict problems in everyday activities that are caused from the Dysexecutive syndrome. The assessment consists of 6 subtests & a Questionnaire.
The rule shift card test,
Action program test,
Key search test,
Temporal judgment test,
Zoo map test,
Modified six elements test
We used only the 6 subtests . Scores range between 0 and 4 for each test and between 0 and 24 for a total profile score.
VRIC’08, April 10, 2008

18. Behavioral Assessment of Dysexecutive Syndrome (BADS)
ELHIT
Behavioral Assessment of Dysexecutive Syndrome (BADS)
The assessment consists of 6 subtests and a questionnaire:
The rule shift card test,
Action program test,
Key search test,
Temporal judgment test,
Zoo map test,
Modified six elements test
Wilson et al., 1996
Description:
The term ‘Dysexecutive Syndrome’ (DES) includes disorders of planning, organisation, problem solving and attention. The DES is one of the major areas of cognitive deficit that may impede functional recovery and the ability to respond to rehabilitation programmes.
BADS specifically assesses the skills and demands involved in everyday life. It is sensitive to the capacities affected by frontal lobe damage, emphasising those usually exercised in everyday situations:
Temporal judgement - This test uses four questions to assess subjects’ ability to estimate how long various complete events (such as a dental appointment) last.
Rule shift cards - Tests the ability to change an established pattern of responding, using familiar materials. In part 1 a response pattern is established according to a simple rule. In part 2 the rule is changed and subjects have to adapt their responses, inhibiting their original response set.
Action program - Tests practical problem solving. A cork has to be extracted from a tall tube, a result which can only be achieved by the planned use of various other materials provided.
Key search - A test of strategy formation. In an analogue of a common problem, subjects are required to demonstrate how they would search a field for a set of lost keys and their strategy is scored according to its functionality.
Zoo map - This is a test of planning. It provides information about subjects’ ability to plan a route to visit six of a possible 12 locations in a zoo, firstly in a demanding, open-ended situation where little external structure is provided, and secondly in a situation that involves simply following a concrete, externally imposed strategy.
Modified six elements - This is a test of planning, task scheduling and performance monitoring. It is a simplified version of the original Shallice Burgess (1991) test. Subjects have to schedule their time to work on six tasks over a ten minute period. Dysexecutive Questionnaire
The battery includes a 20-item Dysexecutive Questionnaire (DEX) that samples the range of problems in four broad areas of likely change: emotional or personality changes, motivational changes, behavioural changes and cognitive changes. Validation
Validation studies show that the BADS is sensitive to the everyday problems experienced by patients with brain injury, and a small study was conducted on people with schizophrenia to identify executive deficits in this group.
VRIC’08, April 10, 2008

19. The Hebrew version of the VAP-S
VRIC’08, April 10, 2008

20. Stroke’s Conclusion 26 post-stroke participants (3 F and 23 M)
Large variance of scores within the VAP-S
Significant positive correlations were found between
Mean number of items purchased and key search subtest from the BADS
Number of correct actions and key search subtest from the BADS
Results show
The feasibility of the VAP-S for use with patients who had a stroke
The relationships between performance within the VAP-S and the key search sub tests from the BADS, which requires planning ability
Josman et al., 2006
VRIC’08, April 10, 2008

21. Table of VAP-S results VAP-S variables PD Elderly Controls Stroke
ELHIT
Table of VAP-S results
VAP-S
variables PD
Elderly Controls
Stroke
Number, Gender
N= 5
(2 F, 3 M)
(4 F, 1 M)
N= 26
(3 F, 23 M)
Age
74.0 ± 5.4
66.6 ± 7.7
56.9 ± 8.9
Trajectory (m)
343.1 ± 113.9
224.8 ± 36.4
209.5 ± 84.2
Trajectory
Duration (min)
20.7 ± 8.3
10.5 ± 1.4
11.0 ± 4.4
Number of pauses
56.6 ± 32.9
25.4 ± 3.5
26.0 ± 13.2
Time to Pay (s)
14 ± 12
5 ± 8
3.9 ± 3.9
Correct Actions
11.4 ± 1.3
12.0 ± 0.0
10.7 ± 2.5
Incorrect actions
3.6 ± 3.3
2.0 ± 0.7
3.2 ± 3.6
Si les différences entre les patients MP et les sujets contrôles apparaissent au niveau de la durée et de la longueur de la trajectoire, ainsi qu’au niveau du nombre d’arrêts et des temps de réaction
Les différences entre des des patients après AVC et des sujets normaux, mais âgés, semblent plutôt se situer au niveau de la réalisation de la tâche.
Tous ces résultats sont à examiner avec des échantillons plus grands et des échantillons appariés.
VRIC’08, April 10, 2008

22. The VMall for the treatment of Executive Functions
Based on the video-capture GestureTek VR system
Motor input
Potential for Executive Functions assessment and treatment
But
Relatively expensive VR system that requires
Chroma key backdrop
Good lighting
Enough room
Rand et al., 2005
GestureTek
VRIC’08, April 10, 2008

23. Final Conclusion
Validity of the VAP-S as an assessment tool for executive functions
New studies have been carried out: results will be soon published
Potential of the VAP-S
Investigation of inhibition and sequence
Low cost  attractive and feasible tool for wide implementation
Rehabilitation: first attempts
Further developments
Examination of the VAP-S as a training tool
VRIC’08, April 10, 2008

24. Thanks for your attention
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