Engineered Regeneration 3 (2022) 121–130

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Engineered Regeneration
journal homepage: http://www.keaipublishing.com/en/journals/engineered-regeneration/

Virtual reality based multiple life skill training for intellectual disability: A
multicenter randomized controlled trial
James Chung-Wai Cheung a,b,c,1,∗, Ming Ni d,1, Andy Yiu-Chau Tam a, Tim Tin-Chun Chan a,
Alyssa Ka-Yan Cheung a, Ocean Yu-Hong Tsang e, Chi-Bun Yip f, Wing-Kai Lam g,h,
Duo Wai-Chi Wong a,∗
a
Department of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong 999077, China
b
Research Institute for Smart Ageing, The Hong Kong Polytechnic University, Hong Kong 999077, China
c
Jockey Club Smart Ageing Hub, Department of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong 999077, China
d
Department of Orthopaedics, Pudong New Area People’s Hospital Affiliated to Shanghai Jiaotong University, Shanghai 201299, China
e
Social Service Department, Yan Chai Hospital, Hong Kong 999077, China
f
C2 Innovations and Research Limited, Hong Kong 999077, China
g
Department of Kinesiology, Shenyang Sport University, Shenyang 110102, China
h
Sports Information and External Affairs Centre, Hong Kong Sports Institute, Hong Kong 999077, China

a r t i c l e i n f o a b s t r a c t

Keywords: Life skill-based training is essential for intellectual disabled individuals to regain autonomy and social inclusion.
Mental retardation Virtual reality (VR) could deliver a nascent application that is more engaging and secure. The objective of this
Intellectual development study was to evaluate the training effects of the VR-based multiple life skill training program on life skill perfor-
X-reality
mance, self-efficacy, memory, cognitive and behavioral functions via a multicenter randomized controlled trial.
Immersive rehabilitation
A total of 145 intellectual disabled participants were recruited for a randomized controlled trial with three in-
Metaverse
tervention arms: VR (n = 42); traditional (n = 53); and control (n = 50). The life skill tasks for the interventions
included 1) grocery shopping, 2) cooking, and 3) kitchen cleaning. Outcome measures were performance scores
for the three tasks, self-efficacy scale, digit span score, and Frontal Assessment Battery score, graded by blinded
assessors. Before-after effects of each group were evaluated using separated Wilcoxon Signed-rank tests. VR sig-
nificantly improved cooking, cleaning performance, and memory span, while traditional training significantly
improved shopping, cooking, and cleaning tasks. The generalized estimating equation evaluated effects between
groups adjusted for age, gender and intelligence quotient (IQ). VR had significantly larger improvement effects
in cooking and cleaning than the control group and memory span compared to traditional training and controls
groups. IQ appeared to be a significant confounder on the training effect. Future work may consider developing
artificial intelligence to customize programs depending on IQ level.

1. Introduction
Intellectual disability (or mental retardation) is a developmental con-
dition manifesting a reduced level of intellectual functioning and di-
minished ability to adapt to daily life and social environment [1]. The
developmental problem reaches the ceiling at the age of 18, whereby
all cognitive growth has occurred [1]. Nonetheless, an initial diagnosis
marks the onset of the cumulation until the age of 18 and never dis-
appears and is lifelong once diagnosed [2,3]. A meta-analysis in 2011
showed that there was 10.37 mental retarded individuals in every 1000
population and 18.30 in every 1000 children and adolescents [4]. The
prevalence in China varied from 0.75% to 6.68%, whereas that in Hong
Kong ranged from 1.0% to 1.3% [5,6]. The variations in estimation were
due to different instruments, definitions and rewording in mental retar-
dation and bias because of stigmatization [4].
Apart from impairment academically, the deficiencies in adapta-
tive behaviors represent major challenges in rehabilitation for their
adulthood [7]. Adaptative behaviors included communication, self-care,
home-living, social and interpersonal skills, etc. [8]. In fact, their diffi-
culties in planning, anticipating, and shifting information in working

∗
Corresponding author at: James Chung Wai Cheung, GH137, 1/F, GH Wing, Department of Biomedical Engineering, The Hong Kong Polytechnic University, 11
Yuk Choi Rd., Hung Hom, KLN, Hong Kong, China, Duo Wai-Chi Wong, GH140, 1/F, GH Wing, Department of Engineering, The Hong Kong Polytechnic University,
11 Yuk Choi Rd., Hung Hom, KLN, Hong Kong, China.
E-mail addresses: james.chungwai.cheung@polyu.edu.hk (J.C.-W. Cheung), duo.wong@polyu.edu.hk (D.W.-C. Wong).
1
These authors contributed equally to this work.

https://doi.org/10.1016/j.engreg.2022.03.003
Received 3 March 2022; Received in revised form 26 March 2022; Accepted 26 March 2022
Available online 27 March 2022
2666-1381/© 2022 The Authors. Publishing Services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
J.C.-W. Cheung, M. Ni, A.Y.-C. Tam et al. Engineered Regeneration 3 (2022) 121–130

memory hindered their capability to execute functions in their life [9]. sive environment, supported by the constructivism theory in learning
They are reluctant or impossible to sustain an independent living and so- [30,31].
cial inclusion [10]. The unemployment rate for people with intellectual The primary outcome included performance scores of the three life
disability ranged from 32% to 46% [11], while one study reported an skill tasks of the training program, while the secondary outcome in-
unemployment rate of over 70%, which was ten times higher than the cluded the self-efficacy questionnaire, memory span test and the Frontal
non-disabled people [12]. More than third-quarters of them were highly Assessment Battery at (FAB) scale. The hypotheses were that 1) there
dependent on their parents, siblings, older relatives or public social sup- was a significant improvement in the primary and secondary outcomes
port in their daily living [13]. Supporting employment has been one of before and after the VR-based training; 2) the improvement level was
the government missions to rehabilitate the socio-emotional, well-being significantly better than the traditional training and control groups.
and physical health of people with intellectual disabilities [14]. Subav-
erage functioning and competence could diminish their opportunities to
2. Materials and methods
work [15], and mastering life skills for independence is the first step to
build social autonomy for employment [16,17]. Though cognitive and
2.1. Study design
social skills are essential elements, it is pragmatically demanding to de-
velop a life skills training system for mentally retarded individuals to
This study was a multicenter randomized controlled trial with three
regain independence and relieve the social burden.
parallel groups, including the VR training, traditional training, and con-
Society has been exploring efficient and effective training programs
trol (no training) group. The participants were coded and randomly as-
for mentally retarded individuals using computer-aided technology,
signed into groups by simple randomization using computer software
which could enable the integration of multimedia information, such as
that blocked against the six rehabilitation centers, such that each center
text, diagrams, sound, and videos, for inclusion [18]. A few studies re-
shall have approximately equal number of participants in each group.
ported the use of computer-aided technology to facilitate cognitive train-
The code was executed by the center in-charge. There was no alloca-
ing in rehabilitation, which were proven to produce similar or signifi-
tion concealment and blinding on participants and the trainers since
cantly better training effects than traditional rehabilitation paradigms
they were aware of their conditions during the tasks but the outcome
[19,20]. In fact, the emergence of virtual reality (VR) technology has
assessors were blinded to group allocation. The estimated sample size
sprouted up a new leaf on computer-aided rehabilitation. Through a
was 159 at an equal allocation ratio (i.e. n = 53 per group). The sam-
human-computer interface, users can experience “immersion” by the
ple size was estimated using the software G∗ Power [32] by an F-test
simulated visual, auditory, or even haptic feedback. VR enables prac-
model (repeated MANOVA, within-between interaction, three groups x
tical training otherwise difficult to be presented in words and images.
2 measurements) at 5% significance level, 80% statistical power and an
In addition, mentally retarded individuals could be more engaged to
assumed effect size of 0.25.
VR-based training and education to develop their self-confidence since
The subject recruitment was carried out in the six rehabilitation cen-
it is more recreational and poses less risks and avoid fear encountered in
ters for intellectual disability. These subvented centers provided shel-
public [21–23]. Furthermore, caregivers would have less stress on the
tered workshops and residential services. The participants were graded
safety and reactions from the others on the appearance and challenging
to have mild to moderate severity of intellectual disability previously by
behaviors of their caretakers and the scarce resources to accommodate
physicians. Exclusion criteria included severe epilepsy, vestibular disor-
an actual visit [24].
ders, severe mental disorders, such as Schizophrenia and depression.
VR technology has demonstrated improvements in the motor and
Participants were also excluded if they participated in a VR training in
cognitive learning process, as shown by its effect on cortical neuronal
the past year; did not have sufficient cognitive ability to understand
activity in stroke patients [25,26]. It was applied to cognitive, social,
the training; and had physical conditions that made it difficult to carry
or life skills training to support independent living, such as shopping,
out the VR-based on traditional training, such as visual or function im-
cooking, road safety, and vocational training [24]. VR training on shop-
pairment. If the participants experienced headache, abnormal sweating,
ping revealed improved skills and behaviours, including locating items,
nausea, vomiting, and motor incoordination, the experiment would stop
mathematics, and reduced nervous behaviours [27,28]. Besides, Burke
immediately for rest and postpone. If the problem persisted or happened
et al. [29] developed a virtual interactive training agent to improve the
in consecutive sessions, the participants would be brought to medical
job interview skills among intellectual disabled individuals and demon-
attention and quit the study. All subject enrollment was arranged by
strated improved skills in identifying personal strengths and question-
center in-charge assisted by physicians.
answering. A scoping review of 15 articles revealed positive findings
The study was approved by the Social Welfare Department of Hong
for the use of different VR training designs for mental retardation [30].
Kong (SWD/S/109/10/6–5 PH3(796)). Before the start of the study, the
However, the effectiveness of VR-based training has not been clearly
researchers explained the rationale and procedure of the study. They
confirmed because of the weaknesses of study design, such as small sam-
showed the participants and their family members a video clip to better
ple size, non-standardized assessment, without considering impairment
demonstrate the experiment and steps. The participation was entirely
levels, and without the control or randomized control, etc. [30].
voluntary and shall be agreed by both the participants and their family
To this end, The goal of the VR training program was to improve
members/guardians. They would receive an information sheet, and the
the life skill training (shopping, cooking and cleaning) for intellectual
participants accompanied with their family members/guardians signed
disability employing theme-based Human-virtual environment interac-
consent if they agreed to participate. All patient records and assessment
tions. The objective was to transform a traditional life skill training
results were arranged by members of the rehabilitation centers, checked
program into a theme-based virtual reality environment and evaluated
and passed to the research team for analysis to ensure confidentiality.
its treatment effects. Therefore, the VR-based training encompassed the
same context and dose as the traditional training program designed by
occupational therapists. 2.2. System configuration
Shopping, cooking and cleaning skills were chosen since they were
recognized as the common and important training tasks [24]. The shop- During the virtual reality training, the participants would be required
ping task is an outdoor mission to gain independence, self-efficacy, to be disconnected from the external world and fully immersed and in-
and attentiveness to make decisions. Participants would learn to over- teracted with the computer-generated scene. The system consisted of
come fear, irritation and distraction in a constructed world with in- customized software and a virtual reality hardware kit with a headset
creasing complexity and disturbance. Besides, the design of cooking and and handheld controller. As shown in Fig. 1, the hardware system con-
cleaning tasks targeted step-by-step skill acquisition through an immer- sisted of the head-mounted wearable display with a wireless adapter

122
J.C.-W. Cheung, M. Ni, A.Y.-C. Tam et al.
Fig. 1. System configuration and the interactive zone of the virtual reality sys-
tem.
(HTC Vive Pro, HTC Corp., Taipei). The computer was running on Mi-
crosoft Windows 10 with Intel Core i5–8600 K processor (Intel Corp.,
Santa Clara, US) and Nvidia GeForce GTX 1060 GPU (Nvidia Corp.,
Santa Clara, US) display card.
The VR application was developed using the software Unity 3D game
engine version 2019.2 (Unity Technologies, San Francisco, US). It was a
cross-platform game engine designed to support and develop 2D and 3D
video games, simulations for computers, and virtual reality in desktop
and mobile devices. The control functions in the VR environment were
coded by the Unity3D three-dimensional manipulation and simulation
functions using the C# programming language. The model objects for
the VR application were designed and constructed using the software
3D Studio Max version 2017 (Autodesk Inc., San Rafael, US).
The VR application resembled two realistic virtual training themes,
including the supermarket and kitchen (for cooking and cleaning tasks),
as shown in Fig. 2. The users can ambulate and observe the virtual envi-
ronment through the head-mounted wearable display. Users interacted
with the virtual goods and utensils to complete different missions via
the two handheld controllers. The two wireless handheld controllers and
two ’Lighthouse’ base stations were exploited for providing interactive
control with the virtual objects and to establish interactive zone over an
area size of 3 m x 3 m.
2.3. Experimental procedure and training task
The program curriculum and protocol of the multiple life skill train-
ing was designed by a panel of occupational therapists and other profes-
sionals taking existing work [24,30] and center environment into con-
sideration. Thereafter, we developed and transformed the training pro-
tocol (traditional training group) into a VR-based environment. There-
fore, the training content between the traditional training and VR groups
was basically the same except for the model of delivery.
The life skill training in both VR and traditional modes involved
three daily living tasks: 1) grocery shopping, 2) cooking, and 3) kitchen
cleaning. For each daily living task, there were totally ten training ses-
sions with five different levels of difficulty. Each level was be trained
twice tentatively and advanced according to the progress of the partic-
ipants. An overview of the training sessions and difficulty is shown in
Table 1.
Research and rehabilitation center staff were on standby for system
operation, facilitating the participants to use the system, providing assis-
tance whenever encountering difficulties and ensuring the safety of the
subjects to prevent tip-over accidentally as they are totally unaware of
the situation in the real environment. In addition, staff members would
ensure that the participants were physically and mentally fine for the
training sessions.
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Engineered Regeneration 3 (2022) 121–130
2.3.1. Grocery shopping task
For shopping training, the participants were required to complete
the missions in a virtual supermarket for the VR group, while a spe-
cially designed “board game-like” training package were used to simu-
late shopping tasks in the traditional group in the rehabilitation center
for sake of safety (Fig. 2, lower left sub-figure). The participants were
given a shopping list, instructed to pick the required items and placed
into the virtual trolley for the group and the basket for the traditional
group, and checked out at the cashier (the correct amount of payment
was not tested). The first and second training sessions required the par-
ticipants to purchase three items, while the shopping list item increased
by one in every next two sessions. The trainers would also adjust the dif-
ficulty by adding background noise and introducing more other items
on the shelves (particularly alike items) in the supermarket to distract
the participants.
2.3.2. Cooking task
Prior to the training, a video clip was shown to the participants on
the food preparation and cooking procedures. The trainers then assisted
the participant to resemble the food preparation procedure in either the
real (traditional group) or the virtual kitchen (VR group). The difficulty
of cooking tasks advanced from boiling water, cooking an egg, making
a sandwich, sausage omelet and instant noodles. If the participants felt
the task was too difficult, the trainers would demonstrate and iterate the
task in forward and backward orders. The participants were allowed to
implement the cooking task independently if the trainers believed that
he/she was competent and aware of safety.
2.3.3. Kitchen cleaning task
The participants were required to clean up the kitchen after the cook-
ing task during the cleaning session. They were given a towel and a
bucket of water and were instructed to wet and wring out the towel at
the water tap. The trainers would instruct the participant to clean up
the kitchen and remind them the place of dirt. Finally, the participants
cleaned and wrung out the towel and put it back in place. There was no
fixed step for training in this session, but the difficulty was expected to
increase with the more complicated cooking task.
2.4. Outcome measures for assessment
Outcome evaluation was conducted once before and after the train-
ing course within two days by blinded assessors trained to ensure re-
liability. The before and after assessments were conducted in the real
supermarket and kitchen environment.
The assessors rated the primary outcomes (i.e., the performance
scores for life skills) using the performance evaluation sheet detailed
in the Appendix A, which was designed by occupational therapists of
the rehabilitation centers. Accuracy and time were the evaluation met-
rics for shopping skills to address their attentiveness and self-efficacy in
an outdoor environment without cues from trainers. Participants were
given sufficient time and support for their cooking and cleaning tasks.
Therefore, the evaluation aimed at the competency and level of skill
acquisition.
For secondary outcomes, self-efficacy questionnaire for instrumental
activities of daily living (IADL), digit span test (forward and backward),
and Frontal Assessment Battery (FAB) [33] were applied to evaluate
confidence, memory span, and cognitive functions, respectively. The
self-efficacy questionnaire for IADL consisted of 10 questions on how
confident the participant can complete the task with a 3-point scale (0-,
1-, and 2-point), detailed in Appendix B. In the digit span test, partic-
ipants read and memorized a sequence of numbers and were asked to
repeat in order (forward) and reverse order (backward) [34]. There were
14 sets of sequence in the forward and backward orders and the points
were averaged for analysis. The FAB covered six areas in conceptualiza-
tion, mental flexibility, motor programming, sensitivity to interference,
J.C.-W. Cheung, M. Ni, A.Y.-C. Tam et al.
Table 1
Missions of the life skill training tasks. Detailed elements of rubrics are included in Figure A1.
Tentative session / difficulty∗ Grocery Shopping
1st & 2nd session / Difficulty I Purchase 3 items
3rd & 4th session / Difficulty II Purchase 4 items
5th & 6th session / Difficulty III Purchase 5 items
7th & 8th session / Difficulty IV Purchase 6 items
9th & 10th session / Difficulty V Purchase 7 items
∗
There were totally 10 sessions for the course of the training program. The participants will only advance to the next level when he/she can complete
the current difficulty level satisfactorily.
inhibitory control, and environmental autonomy [33]. It was a 4-point
scale (0 to 3 points) constituted to a total of 18 points.
2.5. Data and statistical analysis
Per protocol approach was used. An intention-to-treat approach was
not adopted because all information of the participants must be de-
stroyed immediately if they quitted or dropped, except the reason, fol-
lowing the stringent ethical requirement for intellectual disabled indi-
viduals.
Since the majority of the outcomes could not pass the Shapiro-Wilk
normality test, separated Wilcoxon Signed-rank tests were performed to
test for significant differences before and after the treatment for each
group. The p-values were adjusted by the Benjamini-Hochberg proce-
dure for family-wise error rate in the multiple tests.
Thereafter, a generalized estimating equation (GEE) was used to
compare the effect change between groups on each outcome variable
adjusted for gender, age, and IQ, as shown in Table 4. The approach
accounted for the correlation between repeated measures within a par-
ticipant and was expressed as the effect coefficient (𝛽) and the 95% con-
fidence intervals (95% CIs). Significance level (𝛼) was set at p = 0.05.
The statistical analysis was conducted using the SPSS 21 package (IBM,
New York, NY, United States).
3. Results
3.1. Participant information
After randomization and group allocation, there were 27 drop-offs
in the study. Two drop-off participants reported nausea when using the
VR system and belonged to the VR group. The others (n = 25) discon-
tinued or were discharged from the rehabilitation center service. The
group allocation of the drop-offs was unobtainable to compile with the
ethical requirement. We further recruited 14 participants to the study
and assigned randomly to groups.
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Engineered Regeneration 3 (2022) 121–130
Fig. 2. The real and virtual environment of the gro-
cery shopping, cooking, and cleaning tasks. top: vir-
tual environment; bottom: real environment; left gro-
cery shopping; middle cooking; right: cleaning.
Food Preparation & Cooking Cleaning
Boil water With the same requirement, cleaning
Cook an egg difficulty increased with increasing
Make a sandwich difficulty in cooking task
Make a sausage omelet
Make instant noodles
As shown in Table 2, there were 80 males and 65 females (Total:
145) completed all training and evaluation sessions. There were 42 par-
ticipants assigned to the VR group; 53 assigned to the traditional group;
and 50 assigned to the control group. The participants did not change
their group assignments throughout the experiment. The average age
was 41.4 with a standard deviation of 11.9. The participants had an
average Intelligence Quotient (IQ) of 50.4 (standard deviation: 10.5).
3.2. Pre- and post-training assessment
As shown in Table 3, After the VR intervention, cooking (Z = 3.536,
p = 0.004) and cleaning scores (Z = 3.305, p = 0.007) were significantly
improved. Moreover, the digit span score was significantly increased
from a median of 2.5 to 2.75 (Z = 2.904, p = 0.011) in the VR group. On
the other hand, traditional intervention demonstrated a significant im-
provement in the accuracy of completing the shopping list (Z = 3.282,
p = 0.005), completion time (Z = −2.882, p = 0.010), the cooking
(Z = 3.693, p = 0.01), and cleaning score (Z = 3.02, p = 0.009). There
was no evidence that the control group imposed significant change on
the outcome measures, except shopping completion time (Z = −3.031,
p = 0.01). In addition, there were no significant differences on self-
efficacy score and FAB total score for all groups.
3.3. Training effects between groups
The results of GEE shown in Table 4 demonstrated the difference in
adjusted training effects among groups. There were significant improve-
ments in shopping task accuracy, cooking score, and cleaning score (p
< 0.05) generally for all groups adjusted for other factors. The effect of
the VR training was significantly better than that of the control group
in the cooking score (Wald 𝜒2 = 4.253, p = 0.039). Besides, the effect
of VR training was also significantly better than both the traditional
score (Wald 𝜒2 = 4.235, p = 0.040) and control groups score (Wald
𝜒2 = 4.210, p = 0.040) in memory span (digit span score). There was
J.C.-W. Cheung, M. Ni, A.Y.-C. Tam et al. Engineered Regeneration 3 (2022) 121–130

Table 2
Participants’ information.

Attributes/Group VR Group Traditional Group Control Total p-valuea

N 42 53 50 145
Gender 0.909
Male/Female 22/20 30/23 28/22 80/65
Age 0.335
Mean (SD) 42.3 (12.6) 42.6 (12.7) 37.4 (10.3) 41.4 (11.9)
Range 23 – 72 20 – 72 21 – 63 20 – 72
IQ 0.745
Mean (SD) 51.0 (10.6) 50.4 (10.3) 49.8 (10.7) 50.4 (10.5)
Range 36 – 70 35 – 66 29 – 67 29 – 70
Centerb
a/b/c/d/e/f 17/2/3/3/6/11 17/7/4/4/8/13 17/8/3/3/6/13 51/17/10/10/20/37

VR: Virtual Reality; SD: Standard Deviation; IQ: Intelligence Quotient.

a
Difference between groups were evaluated using the Chi-square test for gender, one-way ANOVA for age, and Kruskal-Wallis test for IQ due to
non-normality.
b
The six rehabilitation centers were labelled a to f.

Table 3
Comparison of outcome measures before and after training.
†
Variable Group Before Training After Training p-value adjusted
p-value
Shopping: Accuracy VR 100 (30) 100 (0) 0.023∗ 0.053
(%) [85.3 (2.0)] [92.5 (18.1)]
Traditional 100 (30) 100 (20) 0.001∗ 0.005∗
[79.2 (33.0)] [89.9 (18.3)]
Control 83.3 (50) 100 (50) 0.300 0.451
[73.3 (35.8)] [77.7 (30.2)]
Shopping: VR 357 (123) 334.5 (152) 0.140 0.266
Completion time Traditional 378 (134) 329 (147) 0.004∗ 0.010∗
(sec) Control 401 (188) 354 (189) 0.002∗ 0.010∗
Cooking score VR 21(4) 23 (3) < 0.001∗ 0.004∗
Traditional 21 (4) 23 (3.5) < 0.001∗ 0.005∗
Control 21 (3) 21 (3.5) 0.261 0.421
Clean score VR 13 (2) 14 (2) 0.001∗ 0.007∗
Traditional 13 (2) 14 (1.5) 0.003∗ 0.009∗
Control 13 (2) 13(2) 0.122 0.256
Self-efficacy score VR 18.5 (5.3) 18.5 (5.0) 0.688 0.723
Traditional 19.0 (3.5) 19 (3.0) 0.487 0.639
Control 18.0 (6.0) 18.0 (8.0) 0.557 0.649
Digit span score VR 2.50 (3.00) 2.75 (2.63) 0.004∗ 0.011∗
Traditional 2.50 (2.50) 3.00 (2.25) 0.221 0.387
Control 2.00 (1.88) 2.00 (2.75) 0.532 0.658
Frontal Assessment VR 9.0 (4.3) 9.0 (5.3) 0.825 0.825
Battery (FAB) Traditional 9.0 (7.0) 9.0 (7.0) 0.596 0.658
Control 9.0 (5.0) 8.5 (6.0) 0.423 0.593

Results of before and after training are presented as median (interquartile range). For shopping accuracy, results of mean (standard deviation) are
supplemented in squared brackets.
∗
Statistically significant difference (p < 0.05) in the Wilcoxon Signed-Rank test.
†
p-value was adjusted using the Benjamini-Hochberg procedure for multiple tests.

no sufficient evidence to show that the effect of VR training was signif-
icantly better in the other outcome variables.
Moreover, we discovered that IQ was a significant confounder in all
the outcome variables. Gender was also significantly associated with the
cooking performance (Wald 𝜒2 = 4.078, p = 0.043) and the FAB total
score (Wald 𝜒2 = 4.088, p = 0.043) in which males appeared to score
higher.
4. Discussion
The impact of coronavirus (COVID-19) pandemic and social dis-
tancing measures posed a significant breakdown in the training oppor-
tunities of intellectually disabled individuals and thus job placement
[35,36]. VR provides an alternative to maintain life skill training for in-
tellectual disabled individuals upon the restriction in real-setting train-
ing and shortage of caregivers. On the other hand, although the use of
VR in the training and promotion of physical exercises has been success-
ful, few reports substantiate its effectiveness on life skills training for
intellectual disabled individuals [30]. The strengths and significance of
this study were to implement a randomized controlled trial with blinded
outcome assessors using multiple assessment tools to examine the effect
of VR based life skill training and took covariates (age and baseline IQ)
into consideration.
Our study found that VR training had a significant before-after im-
provement in food preparation/cooking skill, cleaning skill, and mem-
ory span despite that the effect of VR training was not proven better in
all areas compared to the traditional life-skill training and control (other
routine) training. In fact, Brooks and colleagues [37] designed a virtual
environment to teach food preparation. We both found a significant im-
provement for both real and virtual kitchen training, while the effects
of VR training were significantly better than that of the control group.
Despite no significant difference between real and virtual kitchens, VR
training provided a safe and harmless environment. On the other hand,
we did not find similar studies regarding the training of cleaning skills.
We believed that the improvement could be attributed to a more engag-
ing environment and less distraction during the cleaning process.
Interestingly, memory span was the only aspect that VR produced
significantly greater training effects compared to that of traditional and

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Table 4
A generalized estimating equation model to compare the difference of training effects among VR, traditional, and control groups adjusted for gender, age, IQ and
centers.

Effect (𝛽) 95% CI Wald 𝜒2 p-value

Lower Upper
Shopping Task: Accuracy to follow shopping list (%)
Gender
Male - 0.022 - 0.097 0.054 0.315 0.574
Female Reference
Age - 0.002 - 0.005 0.001 1.124 0.289
IQ 0.011 0.007 0.014 39.828 < 0.001∗
Time (Before/after)
After Training 0.071 0.011 0.132 5.374 0.020∗
Before Training Reference
Center 0.749 0.387
Group 8.007 0.018∗
Control - 0.110 - 0.216 - 0.005 4.215 0.040∗
Traditional - 0.054 - 0.151 0.044 1.160 0.281
VR Reference
Group x Before/after
Control x After - 0.028 −0.123 0.067 0.333 0.564
Traditional x After 0.035 −0.053 0.124 0.618 0.432
VR x After Reference
Shopping Task: Completion time to follow shopping list (second)
Gender
Male 10.087 −18.521 38.696 0.478 0.490
Female Reference
Age 1.161 −0.145 2.467 3.036 0.081
IQ −1.713 −3.035 −0.391 6.454 0.011∗
Time (Before/after)
After Training −32.762 −72.749 7.225 2.579 0.108
Before Training Reference
Center 13.205 < 0.001∗
Group 2.153 0.341
Control 14.155 −29.521 57.830 0.403 0.525
Traditional −10.672 −49.002 27.658 0.298 0.585
VR Reference
Group x Before/After
Control x After −0.758 −49.510 47.994 0.0001 0.976
Traditional x After −5.729 −52.995 41.538 0.056 0.812
VR x After Reference
Cooking Score
Gender
Male 0.847 0.025 1.668 4.078 0.043∗
Female Reference
Age 0.031 - 0.012 0.074 2.030 0.154
IQ 0.045 0.014 0.076 7.958 0.005∗
Time (Before/after)
After Training 1.738 0.908 2.568 16.858 < 0.001∗
Before Training Reference
Center 0.002 0.968
Group 1.609 0.447
Control 0.074 - 1.208 1.356 0.013 0.910
Traditional 0.043 - 1.137 1.224 0.005 0.943
VR Reference
Group x Time
Control x After - 1.318 - 2.328 - 0.308 6.539 0.011∗
Traditional x After - 0.153 - 1.281 0.975 0.071 0.790
VR x After Reference
Cleaning Score
Gender
Male - 0.095 - 0.543 0.353 0.173 0.678
Female Reference
Age 0.009 - 0.013 0.031 0.593 0.441
IQ 0.022 0.001 0.043 4.210 0.040∗
Time (Before/after)
After Training 0.762 0.384 1.140 15.605 < 0.001∗
Before Training Reference
Center 0.487 0.485
Group 4.137 0.126
Control - 0.296 - 0.891 0.300 0.946 0.331
Traditional - 0.074 - 0.595 0.447 0.077 0.781
VR Reference
Group x Time
Control x After - 0.522 - 1.018 - 0.026 4.253 0.039∗
Traditional x After - 0.290 - 0.928 0.348 0.795 0.373
(continued on next page)

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Table 4 (continued)

VR x After Reference
Self-efficacy Score
Gender
Male - 0.128 - 1.282 1.027 0.047 0.828
Female Reference
Age 0.016 - 0.035 0.068 0.388 0.534
IQ 0.082 0.028 0.136 8.898 0.003∗
Time (Before/after)
After Training 0.571 - 0.879 2.022 0.596 0.440
Before Training Reference
Center 0.393 0.531
Group 2.666 0.264
Control - 0.215 - 2.031 1.601 0.054 0.817
Traditional 0.709 - 1.056 2.473 0.620 0.431
VR Reference
Group x Time
Control x After −1.031 - 3.016 0.953 1.037 0.308
Traditional x After −0.628 - 2.658 1.4020 0.368 0.544
VR x After Reference
Digit Span Score
Gender
Male 0.167 - 0.377 0.711 0.362 0.548
Female Reference
Age - 0.002 - 0.026 0.022 0.032 0.858
IQ 0.082 0.057 0.107 40.530 < 0.001∗
Time (Before/after)
After Training 0.631 0.198 1.064 8.163 0.004∗
Before Training Reference
Center 0.415 0.520
Group 4.613 0.100
Control - 0.371 - 1.027 0.268 1.224 0.269
Traditional 0.186 - 0.460 0.832 0.319 0.572
VR Reference
Group x Time
Control x After - 0.531 - 1.037 - 0.025 4.235 0.040∗
Traditional x After - 0.499 - 0.975 - 0.022 4.210 0.040∗
VR x After Reference
Frontal Assessment Battery (FAB) Total Score
Gender
Male 1.132 0.035 2.229 4.088 0.043∗
Female Reference
Age - 0.013 - 0.060 0.033 0.324 0.569
IQ 0.143 0.090 0.196 28.235 < 0.001∗
Time (Before/after)
After Training 0.071 - 0.788 0.930 0.027 0.871
Before Training Reference
Center 0.429 0.512
Group 0.897 0.639
Control - 0.339 - 1.700 1.021 0.239 0.625
Traditional 0.229 - 1.206 1.664 0.098 0.754
VR Reference
Group x Time
Control x After - 0.291 - 1.311 0.728 0.314 0.575
Traditional x After - 0.222 - 1.312 0.867 0.160 0.689
VR x After Reference

IQ: Intelligence Quotient; VR: Virtual Reality.

control groups. A previous study demonstrated that a VR-based driving
simulation could improve memory span and executive functions of in-
dividuals with Autism Spectrum Disorder [38]. A systematic review on
the use of computer-aided rehabilitation also demonstrated an improve-
ment of working memory in both social and behavior domains, despite
the fact that the exact mechanism was not well understood [39].
Our results showed that the VR training improved before-after shop-
ping task accuracy despite marginal significance. It seems that tradi-
tional training produced higher training effects. However, VR and tra-
ditional training did not significantly differ after covariate adjustment.
Standen and Brown [24] pointed out that the virtual supermarket re-
sembled higher complexity that may hinder the learning progress, while
our study also showed longer completion time. Too many details may
require a lot of cognitive power and prevent the learner from extracting
the salient features, and therefore the completion time was not superior.
It remains a challenging task to determine how many details or interfer-
ence shall be built to accommodate the mentally retarded individuals
[40]. Furthermore, it was also surprising that confidence (self-efficacy
score) did not significantly increase despite positive feedback from the
interviews with the participants and caregivers. We believed that this
could be due to the difficulty in understanding the expression of self-
efficacy in the instrument. A review also reported that VR interventions
did not appear to attenuate the emotional functioning or self-esteem of
individuals [30].
Besides, we collected some feedback from the participants and care-
givers informally to have a basic understanding on the engagement and
perception of the virtual rehabilitation. The participants felt happy and
fulfilled with the new and interesting experience in VR training. In tra-
ditional training, they mentioned that they would hesitate or feel em-
barrassed when making repeated mistakes in front of the trainers or the
public area. They felt that the VR system looked real but was safe and
secure. The caregivers were first worried that the participants would

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J.C.-W. Cheung, M. Ni, A.Y.-C. Tam et al.
deny new experiences and challenges on new technology. However, the
participants were motivated and engaged in the new training because of
the fun and learning through entertainment. The caregivers were look-
ing forward to popularizing VR into routine and formal training and
suggested a lighter device with more interactive components. In view
of the safety concern during the training, the system can be further im-
proved by directing a safety region in the rehabilitation center incorpo-
rated with the virtual environment to reduce their chance of knocking
nearby objects or walls during the VR training. When sensors detect the
participants reaching beyond the safety zone, an alarm signal can be
sent to caregivers or the players [41,42].
We did not conduct a comprehensive analysis and justification on
the design of the life skill training curriculum context since this was
not the focus of this study, while our added value of this study consid-
ered the implementation of VR that integrated multiple training tasks
and evaluated multiple constructs in a relative rigorous study design.
There was several behavioral or social cognitive models facilitating the
training designs for different purposes, such as social interaction, inde-
pendent living, road safety, and occupational skills [24,25,30]. While we
endeavored to transform or match the VR-based and traditional training,
there were many uncertainties concerning the matching of the virtual
environment and the physical tasks performed, despite that the same
problem applied to the matching between traditional training and the
actual environment of the outside world. How these protocol and match-
ing were aligned with the specific cognitive stimulation required further
investigations.
There were some limitations in this study. The per protocol analysis
approach could induce attrition bias in this study, while an intention-
to-treat approach shall be conducted to confirm the findings on digit
span score. Secondly, the scales for the evaluation of life skill perfor-
mance and self-efficacy were developed by occupational therapists but
lacked validation. Besides, since intellectual disability is a highly stig-
matizing condition, we faced extremely stringent control in subject re-
cruitment and data collection, particularly on confidentiality. We could
not access some information, such as diagnoses on Down’s syndrome
and Autism Spectrum Disorder, in addition to the detailed information
of the drop-off participants. Therefore, we could not fully comply with
the CONSORT requirement for a randomized controlled trial. Most of the
drop-offs were due to discharge from service. Two cases of dropped out
were associated with nauseating conditions which was a typical motion
sickness caused by VR [43]. We hope to tackle this problem by dividing
training sessions into days or developing a mixed or augmented reality
system. Furthermore, the center clustering effect of the randomized con-
trolled trial was overlooked during the sample size estimation process,
which may underestimate the sample size without adjusting the intra-
class correlation among the centers even with a GEE was implemented to
attend the random effects of clustering. The GEE model showed a signif-
icant association on the rehabilitation centers in the variable shopping
time, adjusted for other variables. However, we could not confirm the
reason for this particular output while we reckoned that the room size
of the centers or the differences in trainers could be plausible reasons.
Furthermore, personality aspects were also not considered in the exper-
iments, such as previous experience in virtual reality, adaptatively to
the immersive environment, ergonomics and interface.
5. Conclusions
We transformed a multiple life skill training into a theme-based VR
wearable technology with human-virtual world interaction. Our per pro-
tocol GEE analysis showed that VR group had a significant higher level
of improvement in memory span compared to traditional and control
groups, adjusted for age, gender and IQ. However, the improvements
in life skill performance were not significantly different from the tradi-
tional group, despite both groups demonstrating significant before-after
improvements. Nonetheless, we received positive feedback from the in-
terviews that participants were interested, engaged, and secure with the
128
Engineered Regeneration 3 (2022) 121–130
VR system. On the other hand, IQ appeared to be a strong confounder
on the training effect.
In our study, we adjusted the difficulty of the training based on the
decision of the trainers. We may need to develop a more systematic ap-
proach to design and customize the program depending on the IQ of
the participants for better training effects. Furthermore, future direc-
tions may also be considered to investigate long-lasting effects [39] and
invite intellectual disabled individuals to design and develop the train-
ing program for better appeal and applicability [30]. Some dedicated
social platforms could also be developed to improve their social skills
and communications [22,24]. We are developing and heading toward a
virtual world (Metaverse) for social inclusion and rehabilitation.
Author contributions
Conceptualization, J.C.-W.C. and D.W.-C.W.; methodology, J.C.-
W.C; software, C.-B.Y.; validation, J.C.-W.C. and W.-K. L.; formal anal-
ysis, M.N. and D.W.-C.W.; investigation, A.Y.-C.T., T.T.-C.C. and A.K.-
Y.C.; resources, O.Y.-H.T. and C.-B.Y.; data curation, A.Y.-C.T., T.T.-C.C.
and A.K.-Y.C.; writing – original draft preparation, J.C.-W.C. and M.N.;
writing – review and editing, D.W.-C.W.; visualization, C.-B.Y.; supervi-
sion, J.C.-W.C.; project administration, O.Y.-H.T. and D.W.-C.W.; fund-
ing acquisition, M.N., O.Y.-H.T. and D.W.-C.W. All authors have read
and agreed to the published version of the manuscript.
Ethical statement
Ethical approval and clinical trial registry were obtained exclusively
by the Social Welfare Department of Hong Kong (SWD/S/109/10/6–5
PH3(796)). The funding body and all participants acknowledged and
agreed the publication of this paper.
Conflicts of Interest
Chi-Bun Yip is an employee of a commercial company that manu-
factures and sells virtual reality and rehabilitation products. He also co-
designed and supplied the wearable virtual reality system used in this
study. The other authors declare no competing interest. The funders had
no role in design of the study, collection, analyses, interpretation and
writing of the manuscript.
Acknowledgement
The authors would like to thank Yan Chai Hospital for coordinat-
ing the research. Special thanks go to staff members, caregivers, and
physicians of the rehabilitation centers as well as participants and their
guardians/family members.
Appendix
Appendix A: Evaluation form for performance evaluation of life skill
training tasks.
Appendix B: Self-efficacy questionnaire on selected IADL tasks
Appendix A. Performance Evaluation Sheet for the Life Training
Tasks
Shopping Tasks
The testing list for shopping included six types of items: one packet of
tissue, a bottle of cooking oil, 8 cans of coke, 4 packs of instant noodle,
one bar of chocolate, a bottle of dishwashing detergent.
Accuracy = (Number of Correct Items – Number of Exceeding Items
– Number of Missing Items) / 6
Accuracy = _____________
Completion Time = ____________
J.C.-W. Cheung, M. Ni, A.Y.-C. Tam et al.
Cooking Task
Instruction: Please cook an egg for me and deliver it on a bowl to me
when done.
TASKS
1 Fill the pot with
sufficient amount of
water
2 Put the pot on the
stove
3 Put the egg in the
pot
4 Cover the pot
5 Turn on the stove
6 Turn off the stove
when the egg is done
7 Pick up the boiled
egg with a spoon
8 Put the boiled egg in
the a bowl
□0: Failure to perform or with dangerous actions
□1: Task completed with assistance
□2: Task completed with hints
□3: Task completed
Cleaning Task
TASKS
1 Take out the towel
2 Wet the towel sufficiently
3 Clean the dirt on the table
4 Clean the towel
5 Place back the towel
□0: Failure to perform or with dangerous actions
□1: Task completed with assistance
□2: Task completed with hints
□3: Task completed
Appendix B. Self-efficacy questionnaire on selected IADL tasks
How confident are you to complete the following tasks?
Grocery Shopping
1. I can find my way from home to the
supermarket
2. I can recognize three items on sale in
the supermarket
3. I can take the exact quantity of items
that I need and will not pick something
that I do not need
4. I can pay and collect changes correctly
Food Preparation and Cooking
5. I can plan a simple meal myself and for
my family
6. I can collect the appropriate amount of
food ingredient
7. I can clean and prepare the food
ingredient (cut into pieces and seasoning)
8. I know how to use kitchen utensils
(knife and stove)
9. I know how to cook (correct method,
not overcook, know the way to season)
Cleaning
10. I can tidy up and clean the kitchen
Engineered Regeneration 3 (2022) 121–130
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