Virtual reality eye movement training for neglect rehabilitation

Background: Smooth pursuit training (SPT) is recognized as an effective intervention for spatial neglect by guiding patients' attention toward the contralesional hemifield through repetitive tracking of moving visual stimuli. However, traditional SPT approaches lack standardized, real-time feedback on gaze and head position and patient motivation, limiting therapists' ability to monitor attention and patients' engagement effectively. Combining immersive virtual reality (VR) with eye tracking may overcome these limitations by providing immediate automated feedback, enhancing therapeutic outcomes and being associated with increased awareness of deficits. Methods: We developed and evaluated an immersive Virtual Reality Eye Movement Training (VR-EMT) paradigm integrating eye tracking and real-time automated feedback on gaze and head orientation. Twelve chronic post-stroke patients with left-sided neglect completed 10 VR-EMT sessions (each lasting 18 min). We assessed performance in a spatially lateralized object transport task, head rotation behavior, gaze distribution, usability, and patient preferences in comparison to traditional SPT. Results: VR-EMT was independently executable and highly accepted by patients. Real-time feedback improved patients' head orientation awareness and adjustments. Task accuracy decreased with increasing task difficulty, indicating effective demand modulation. A persistent ipsilesional gaze bias was found during breaks. Patients preferred VR-EMT over traditional SPT due to enhanced feedback, motivation, and challenge. Cybersickness was minimal and did not impair performance. Conclusions: This feasibility study demonstrated that VR-EMT integrating eye tracking and immediate feedback is technically feasible, clinically applicable, well-accepted, and subjectively preferred over traditional methods in chronic post-stroke neglect patients. Eye tracking functioned reliably, even as the sole interaction modality. Real-time feedback facilitated rapid behavioral adjustments, highlighting the potential for individualized interventions and remote application. Future studies should evaluate clinical efficacy and the benefits of eye-tracking-based attentional assessment.