Virtual Reality Dual Task Training in SCI: Effects on Cognition and Cortical Activation

A portable functional near-infrared spectroscopy (fNIRS) system (Brite MKIII, Artinis, The Netherlands) will be used to monitor hemodynamic changes during patients' cognitive tasks. Optode placement will be based on previous studies and Brodmann areas. Data will be simultaneously collected and analyzed using OxySoft software. The device includes ten emitters and eight detectors arranged in a 2 × 12 channel layout, covering cortical regions related to upper extremity representation. Channels will be symmetrically distributed across hemispheres. The emitter-detector distance will be set at 30 mm, and light wavelengths of 763 nm and 842 nm will be used. HbO₂ concentrations in regions of interest (PFC, SFC, SMA, and PMC) will be measured. ΔHbO₂, ΔHbR, and ΔHbT values will be recorded per channel as time-series data in units of μmol/L.

The scale consists of five sections: motor function (upper and lower extremities), sensory function, balance, joint range of motion, and joint pain; however, the motor function assessment is the most commonly used section. It includes 33 items, each scored on a three-point ordinal scale based on the participant's ability to perform the task. For the upper extremity motor function, a participant can achieve a maximum score of 66. Higher scores indicate better motor function.

MoCA consists of nine subtests. It assesses multiple cognitive domains, including executive functions (e.g., trail making), visuospatial abilities (clock drawing task and three-dimensional cube copying), attention, concentration, working memory, language (e.g., a three-item naming task with low-familiarity animals), short-term memory, and orientation to time and place. These correspond to the following MoCA subtests: trail making, visuoconstructional skills, naming, attention, sentence repetition, verbal fluency, abstraction, delayed recall, and orientation. A score of 21 or higher on the scale is considered normal.

The test is conducted with the individual seated in a standard wheelchair with footrests. The measuring rod is mounted on the wall at the level of the acromion process of the shoulder. To measure reach, the ulnar styloid process is used as the anatomical landmark. The participant is asked to flexion their shoulder to 90 degrees for the first reading, then to reach as far as possible without any support for the second reading, and finally to return to the starting position. The difference between the two readings is recorded. Each participant is given three trials, and the average is calculated.

Standard grip strength is measured using the Jamar hand dynamometer (Pro Med Products, Atlanta, GA) in the standardized test position recommended by the American Society of Hand Therapists, with the patient seated, the arm positioned at the side of the body, and the elbow flexed at 90 degrees. Participants are instructed to squeeze the dynamometer with maximum effort and then fully relax. This procedure is repeated three times for both the right and left hands, and the average values are calculated in kilograms.

The Canadian Occupational Performance Measure (COPM) is a semi-structured, client-centered scale designed to detect changes over time in self-reported occupational performance. It consists of five steps and three scoring phases: (1) The individual identifies occupations in the areas of self-care, productivity, and leisure, rating their importance on a scale from 1 (not important at all) to 10 (extremely important). (2) Using these ratings, the individual selects the five most important occupations. (3) The individual then rates their performance and satisfaction with performance in these selected occupations on a scale from 1 to 10. Two distinct dimensions-Performance and Satisfaction-are evaluated. Each dimension is scored from 1 to 10, with a maximum score of 10 for each. Higher scores indicate better performance and greater satisfaction.

The level of patient satisfaction with the treatment they receive is a critical variable for their adherence to treatment and the continuity of their well-being. The scale developed to measure this can yield scores ranging from 0 to 28. Higher scores indicate a greater level of dissatisfaction.