Moving Beyond Single User, Local Virtual Environments for

Rehabilitation

Patrice L. (Tamar) WeissDepartment of Occupational Therapy

Faculty of Social Welfare and Health Sciences University of Haifa, Israel

Evelyne KlingerArts & Métiers Paris Tech Angers

Team Handicaps et Innovations Technologiques P&I Lab, Laval, France

Applications of Virtual Reality

Veridian System

Virtual Reality Assets for Rehabilitation and Special Education

Ecological validity

Grade cognitive & motor demands

Convenient times & locations

Performance can be documented

Easy to test & change

Safe for user

Virtual Reality Continuum for Rehabilitation

Presence Cost Complexity

HighTech

LowTech

Example

VAP-S: Virtual Action Planning Supermarket

to assess and treat executive function

deficits

Traditional Executive Function Assessment

• 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)

WCST

VAP-S: Virtual Action Planning Supermarket

Designed with two main software: 3DStudioMax and Virtools

Klinger E., Marié R.M. et al., 2002-2005, GREYC-ENSICAEN, CHU de Caen

Shopping Task

• Verbal information:– In the supermarket, you

should buy: • one baguette• green apples• 2 kg bag of detergent• one kilo of flour• one t-shirt for child• two  artichokes• beige socks.

– You may pay by clicking on the purse icon that is on the screen.

List display on the screenMarié et al., 2003

• The user– Selects items by

using the mouse

The items

Appear in the cart

Disappear from the icon list Record of trajectory, time and actions

Assessment Session

Performance comparison

Control:

Duration : 8 min

Distance : 215 m

Stops : 25

Patient with PD:

Duration : 25 min

Distance : 469 m

Stops : 67

Klinger et al., 2006

Example

IREX for Physical Fitness of young adults with intellectual

disabilities

Objective

To test the effectiveness of a VR-based exercise program in improving the physical fitness of adults with IDD.

Methods• Research group (N=30)

• mean age = 52.3 ± 5.8 years• IDD level - moderate)

• Matched control group (no VR-based exercise)• Two sub-groups: ambulatory and wheelchair users • Fitness program

• 5-6 weeks • two 30 min sessions per week • game-like exercises provided by the IREX or Sony PlayStation II EyeToy video capture VR system

• Pre & post-intervention changes in physical fitness• Energy Expenditure Index (EEI)• modified 12 min walk\run Cooper test • Total Heart Bit Index (THBI)

Study ParticipantsVariablesResearch

(n=28)Control(n=31)

DemographicsMean age (yr)52.354Age range (yr)37-6034-60Males1615Females1216Mean weight (kg)62.866.5Mean height (m)1.51.6Mean rest pulse (bpm)80.472.9Mean activity pulse 97.194.6

Assistive technology

Wheelchair1215Rolator1314Crutches22Walking cane10

FacilityQuitmann1312Kfar Nahman156Ruhama----6Bare Dror----9

Pre-Post Intervention TestsGroupNAmbulation

styleCooper test (m)

Mean ± (SD)Energy

Expenditure Index (EEI)

Mean

Total heart Beat Index

(HB/m )Mean

PrePostPrePostPrePost

Research28All211.8304.3**

*3.472.7428.315.6*

16Walking Aid

340.1486.7**1.20.878.13.9

12Wheelchair40.761.1**6.55.353.531.3

Control31All175.6183.92.12.315.214.8

15Walking Aid

253.3261.41.92.17.58.8

16Wheelchair87.696.12.52.523.921.5

P value <0.05-0.01*P value <0.01-0.001**P value <0.001***

Link to video clip for slide 15

Tele-rehabilitation

Second Life

StoryTable, NNR-Table

DiamondTouch Interactive Table

• Mitsubishi Electronic Research Lab (MERL)

• Large horizontal interactive surface

• Table-top interaction modality

• Operated through PC using Flash programming

• Images are top projected 18

19

DiamondTouch Interactive Table

Multi User Actions (MUAs): Interaction modality that requires the simultaneous participation of two or more users

Story Table

– Interface to support pairs of children in the activity of collaborative storytelling

– Implements “Enforced Collaboration” paradigm

20

Alternate story backgrounds

Story characters

Voice recording

Lady bugs to hold audio snippets

Story sequence

Story Table: Initial Study

21

OUTCOME MEASURES1. Behavioral Checklist

(based on Bauminger, Aviezer & Rogers, 2004)

• positive social interactions (e.g., look at peer with positive affect)

• negative social interactions (e.g., ignoring action of peer)

• autistic behaviors (e.g. perseveration)

2. Analysis of language usage in the interactions and in the narrations

22

Story Table: Initial Study

MarbleWorks Free structure play construction game

Pre- and Post-tests

Low-Tech ST scenarios with cardboard figures

Story Table: Initial Study

Link to video clip for slide 23

Comparison of Pre and Post outcomes

•increase in key positive social interactions• decrease in negative interactions• increase in narrative and play ability

Story Table: Initial Study

Tele-Rehabilitation

Patient

Home Unit

Central System(phase II)

Central DB

(phase II)

Therapist /

Clinician

Unit

Link to video clip for slide 27b

Link to video clip for slide 27a

Second Life is an Internet-based virtual world launched in 2003 by Linden’s Lab (http://lindenlab.com).

“Residents” inhabit virtual worlds and interact via avatars

Users participate in individual and group activities, and to create and trade items and services using Linden dollars

By the end of March 2008, 13 million registered accounts. About 38,000 residents are logged on to Second Life at any particular moment.

number of medical & health educational projects: Nutrition Game Occupational Therapy at the Virtual Neurological

Education Centre Brigadoon designed for people with Asperger’s

syndrome. Brigadoon - a controlled environment where users are encouraged to feel comfortable and learn socialization skills at their own pace (Lester).

Issues For Future Consideration

User perspective - effectiveness of providing users with first, third or bird's eye perspectives .

In past such decisions based primarily on the technology selected to render VE.

In the future, should be also driven by educational or therapeutic needs of users.

Issues For Future Consideration

User perspective

Role of virtual presence – generally assumed that increasing the level of virtual presence helps to facilitate the achievement of therapeutic goals due to its impact on motivation and performance.

Important to establish the role of virtual presence in multi-user, remote location VEs due to the added difficulty in achieving it in such settings.

Issues For Future Consideration

User perspective

Role of virtual presence

Technology considerations – Access to remote locations, especially in real-time, adds additional cost and technical complexity to the design and implementation of VEs.

Considerations of increased band width and the use of sensors capable of transmitting high fidelity data must be taken into account.

Issues For Future Consideration

User perspective

Role of virtual presence

Technology considerations

Compliance – user’s motivation to be a willing partner in any educational process of great importance. One of VRs major assets has been the use of game-like environments to increase motivation, participation and performance. Will this be lost in remote settings?

Issues For Future Consideration

User perspective

Role of virtual presence

Technology considerations

Compliance

Ethical considerations – Use of VEs in the traditional single user, local setting retained all elements of privacy that were guarded during conventional rehabilitation.

The addition of other users and the transmission of data, images, and communication over the Internet clearly introduce ethical issues not previously considered.

Issues For Future ConsiderationUser perspective

Role of virtual presence

Technology considerations

Compliance

Ethical considerations

Availability of software supporting functional VEs – most functional VEs have been customized by specific research groups, and often unavailable to other educators and clinicians. Recently publicized NeuroVR initiative (www.neurovr.org) provides a cost-free VE editor, which allows non-expert users to easily setup and tune VEs