Posts Tagged VR

[BOOK Chapter] Assessment and Rehabilitation Using Virtual Reality after Stroke: A Literature Review – Abstract + References

Abstract

This chapter presents the studies that have used virtual reality as an assessment or rehabilitation tool of cognitive functions following a stroke. To be part of this review, publications must have made a collection of data from individuals who have suffered a stroke and must have been published between 1980 and 2017. A total of 50 publications were selected out of a possible 143 that were identified in the following databases: Academic Search Complete, CINAHL, MEDLINE, PsychINFO, Psychological and Behavioural Sciences Collection. Overall, we find that most of the studies that have used virtual reality with stroke patients focused on attention, spatial neglect, and executive functions/multitasking. Some studies have focused on route representation, episodic memory, and prospective memory. Virtual reality has been used for training of cognitive functions with stroke patients, but also for their assessment. Overall, the studies support the value and relevance of virtual reality as an assessment and rehabilitation tool with people who have suffered a stroke. Virtual reality seems indeed an interesting way to better describe the functioning of the person in everyday life. Virtual reality also sometimes seems to be more sensitive than traditional approaches for detecting deficits in stroke people. However, it is important to pursue work in this emergent field in clinical neuropsychology.

References

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[ARTICLE] Locomotor skill acquisition in virtual reality shows sustained transfer to the real world – Full Text

Abstract

Background

Virtual reality (VR) is a potentially promising tool for enhancing real-world locomotion in individuals with mobility impairment through its ability to provide personalized performance feedback and simulate real-world challenges. However, it is unknown whether novel locomotor skills learned in VR show sustained transfer to the real world. Here, as an initial step towards developing a VR-based clinical intervention, we study how young adults learn and transfer a treadmill-based virtual obstacle negotiation skill to the real world.

Methods

On Day 1, participants crossed virtual obstacles while walking on a treadmill, with the instruction to minimize foot clearance during obstacle crossing. Gradual changes in performance during training were fit via non-linear mixed effect models. Immediate transfer was measured by foot clearance during physical obstacle crossing while walking over-ground. Retention of the obstacle negotiation skill in VR and retention of over-ground transfer were assessed after 24 h.

Results

On Day 1, participants systematically reduced foot clearance throughout practice by an average of 5 cm (SD 4 cm) and transferred 3 cm (SD 1 cm) of this reduction to over-ground walking. The acquired reduction in foot clearance was also retained after 24 h in VR and over-ground. There was only a small, but significant 0.8 cm increase in foot clearance in VR and no significant increase in clearance over-ground on Day 2. Moreover, individual differences in final performance at the end of practice on Day 1 predicted retention both in VR and in the real environment.

Conclusions

Overall, our results support the use of VR for locomotor training as skills learned in a virtual environment readily transfer to real-world locomotion. Future work is needed to determine if VR-based locomotor training leads to sustained transfer in clinical populations with mobility impairments, such as individuals with Parkinson’s disease and stroke survivors.

Background

In recent years, virtual reality (VR) has been increasingly used to provide engaging, interactive, and task-specific locomotor training [1,2,3,4,5,6,7,8]. These studies have simulated walking in different environments such as parks or streets [34], walking on a slope [3], or walking while avoiding obstacles [3,4,57]. VR-based locomotor training frequently includes obstacle negotiation because it is an essential locomotor skill in the community [457] and tripping over obstacles is a common cause of falls in many patient populations [9]. The clinical application of VR-based training interventions is predicated on the idea that practice in VR will lead to lasting changes in trained skills and that these changes will influence real-world behavior. Therefore, understanding how locomotor skills acquired in VR are retained and how these skills generalize to the real world is critical for determining the long-term utility of VR for locomotor rehabilitation.

The presence of lasting changes in a motor skill as a result of practice is a hallmark of motor learning and this retention process has been examined across a wide variety of real and virtual learning contexts. Retention of motor skills has been examined in response to VR training, particularly in fields such as flight and medical procedural training. For example, complex surgical and medical skills are performed faster and more accurately during a retention session following a single day of VR-based training [10,11,12,13]. Retention of locomotor skills is often explored in studies that analyze how people adapt to external perturbations such as a split-belt treadmill which has separate belts for the right and left legs [14,15,16], elastic force fields [17], robotic exoskeletons [18], or added loads [19]. For instance, studies of split-belt treadmill adaptation have revealed that the increases in step length asymmetry observed during initial exposure to the belts moving at different speeds significantly decreased with subsequent exposures to the device [14,15,16]. A recent study by Krishnan and colleagues also investigated locomotor skill learning during a tracking task in which participants were instructed to match a pre-defined target of hip and knee trajectories as accurately as possible during the swing phase of the gait [20]. They found that the reduction in tracking error achieved through practice is retained the following day. Although motor skill learning in VR and locomotor learning have been examined in isolation, it remains to be seen how locomotor skills are acquired and retained following training in a virtual environment.

Skill transfer, which is defined as “the gain or loss in the capability for performance in one task as a result of practice or experience on some other task” [21], is another key feature of motor learning. Skill transfer is particularly critical when skill acquisition occurs in a context that differs from the environment in which the skill is to be expressed. One way in which skill transfer has been evaluated during motor learning is by measuring how the adaptation of reaching in a robot-generated force field generalizes to unconstrained reaching. This work has shown that adaptation to reaching in a curl-field leads to increased curvature during reaching in free space [2223]. Moreover, studies of treadmill-based locomotor skill learning often evaluate transfer of learned skills from treadmill walking to over-ground. For example, during split-belt treadmill adaptation, the learned changes in interlimb symmetry partially transfer to over-ground walking [24]. Further, VR-based training of obstacle negotiation on a treadmill led to increased walking speeds in the lab [57] and community [4]. However, the evaluation of transfer in these VR-based training studies was based on outcome measures such as walking speed that did not reflect the objective of the training task, which was the control of foot clearance obstacle negotiation. Therefore, it remains to be seen if the elements of skill from VR-training transfer to over-ground walking.

Underlying individual differences in learning can influence motor skill retention and transfer to new environments. For example, a recent study demonstrated that healthy older adults and people post-stroke who acquire a motor sequence skill at a faster rate also show greater retention of that skill [25]. Similarly, the rate of skill acquisition for a reaching task during early training predicts faster trial completion time at 1-month follow-up [26]. Lastly, the magnitude of improvements in reaching speed during skill acquisition predicts long-term changes in reaching speed in healthy individuals [27]. Studies of individual differences in transfer have most often sought to understand how the practice of a skill with one limb influences performance of the same skill with the untrained limb. For example, interlimb transfer of motor skills acquired through visuomotor adaptation varies with handedness [28] and individual differences in baseline movement variability [29]. However, far less work has sought to understand how individual differences in skill acquisition affect the transfer of learned skills to new environments. Overall, the influence of individual differences in skill acquisition on locomotor skill retention and sustained transfer has yet to be determined.

Here, we determined how individual differences in locomotor skill learning during virtual reality treadmill-based training influence retention and transfer of learned skills to over-ground walking in the real world. We used a VR-based version of a previously established precision obstacle negotiation task [3031] and asked 1) whether healthy young adults could learn to minimize clearance during virtual obstacle negotiation, 2) if the learned skill transferred to over-ground walking, 3) if the learned skill was retained in both VR and the real world after 24 h, and 4) if individual differences in the amount or rate of skill acquisition could predict retention and transfer. We hypothesized that 1) participants would reduce foot clearance in VR during practice on Day 1 and that 2) the reduced foot clearance in VR would transfer to over-ground obstacle negotiation. We also hypothesized that 3) the reduction in foot clearance in VR and over-ground would be retained in each environment after a 24-h retention period. Lastly, given that the rate and magnitude of the performance improvement during skill acquisition have been established as predictors of skill retention in previous studies, we also hypothesized that 4) these measures would predict retention of the learned skill in VR and over-ground. Given the growing use of VR for motor skill learning, our results may provide a unique opportunity to understand the factors that influence how training in VR might lead to long-term improvements in skilled locomotion. […]

 

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[WEB SITE] Virtual Reality is Finding a Home in Physical Therapy

Credit to: Neuro Rehab VR

Virtual reality has plenty of applications for fitness — you’re here, so you already know that. However, it is increasingly becoming a tool for rehabilitation, as well. Neuro Rehab VR aims to make physical therapy more enjoyable, and it promises to help patients more than traditional physical therapy.

Making physical therapy fun

With only about one-third of patients fully adhering to their rehabilitation plans, Neuro Rehab VR’s goal was to create a platform that was more engaging without making things more cumbersome. During the early days of the Oculus Rift, with its many sensors, that was not possible.

This was made possible with the Oculus Quest, which eliminated the need for extra equipment or wires. Neuro Rehab VR provides several different exercise applications that run patients through less-abstract goals, such as going grocery shopping. The applications are available for the entire body, and also include sports and combat.

In addition to being more interesting, VR physical therapy can have more effective results. Because of  the brain’s neuroplasticity, Neuro Rehab VR says playing games can establish better connections in the brain as you work toward concrete goals. This can, in turn, lead to more complete recovery. Neuro Rehab VR is partnered with Fort Worth’s Neurological Recovery Center. It has dealt with patients of spinal injuries, brain injuries, strokes, and multiple sclerosis. The team decided to expand and make its systems available elsewhere after seeing its success.

Neuro Rehab VR believes its systems can work not only in hospitals, but also for in-home recovery. The low cost of the Quest itself makes it affordable for rental or purchase by the patient. Therapists can see every movement patients make to determine if they are doing exercises correctly. Once the patient is feeling better, they’ll still have a device capable of helping them stay fit from within their home.

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[WEB SITE] Top 10 Virtual Reality Applications In Today’s World

The premise of virtual reality has always been exciting. Slip-on a pair of goggles or a headset, and you’re on your way to another world. Unlike at the cinema or in front of your TV screen, you’re free to interact with your surroundings and wander wherever you please.

VR exploded into public consciousness around the same time as the personal computer in the late ‘80s and early ‘90s. Back in those days, however, the difference between the real world and the pixel-heavy digital landscapes of the time was too great for everyone but for the most hardcore fans. As a result, VR was more or less put on the backburner for a couple of decades.

However, the birth of the Oculus Rift in 2012 and its subsequent purchase by Facebook in 2014 led to a renewal of interest in virtual reality applications. It also served as an uptick in virtual reality recruitment as companies cottoned on to the medium’s vast potential.

How Does Virtual Reality Work?

So, how does virtual reality work? Nowadays, virtual reality is implemented using computer technology via tools such as headsets, goggles, treadmills, and handsets. These tools stimulate our senses to create an illusion of reality. This is far more complicated than it seems: human physiology is calibrated to provide a finely synchronized experience, and if anything is ‘odd’, our bodies will usually let us know via unpleasant sensations such as nausea or motion sickness. A successful virtual reality experience involves careful synchronicity of software, hardware, and of our senses. The most memorable virtual reality uses are those that enable us to interact naturally with our surroundings with no latency or glitches that could create a feeling of artificiality.

This leads us to ask ourselves, “Why do we go to all that trouble to create these highly technical worlds that just aim to imitate reality?” The truth is, virtual reality applications are numerous and beneficial across many fields.

How Does Virtual Reality Work?
Photo by Sales on New Gen Apps

 

Ten Most Exciting Applications Of Virtual Reality

1.  Entertainment

Entertainment is an obvious application of virtual reality. Who wouldn’t want to slip on a headset and escape into another world?

The first thing that comes to mind is gaming. It is a historical virtual reality application that is still very much among the main VR uses today. Other entertainment forms are however hot on its heels. While 3D cinema has been around for quite a while now, the rise of VR headsets is providing users with immersive cinema experiences without them even having to leave the house. Apps such as Oculus Cinema enable viewers to watch movies on their very own virtual screen. At the same time, developers are working on software that will enable sports fans to cheer on their favorite teams from the comfort of their couches. An example is LiveLike VR’s virtual stadium.

Using virtual reality, music lovers can attend concerts and festivals taking place on the other side of the world. Moreover, those who have been bitten by the travel bug can wander sunny beaches without leaving their front yard. What’s not to love?

Virtual Reality In Entertainment
Photo by Liza Brown on Filmora

2.  Training

It is essential for military personnel to gain first-hand experience of the terrain of their deployment. Likewise, when you get on a commercial flight, you assume your pilot has mastered the aircraft and can respond appropriately in any kind of emergency. But have you ever wondered how rookie soldiers and pilots get in their training hours without putting themselves in danger?

Some activities are just too dangerous, impractical, or expensive for beginners to be able to practice them from the get-go. This is where VR comes in. Virtual reality education companies offer software aimed at training new personnel. The US military uses virtual reality simulators to train soldiers before deployment. These VR simulators enable them to practice working together in the kind of environments they will come up against. Likewise, flight simulators are used to train new pilots or refresh their knowledge before they can get before the controls of a real-life plane.

Virtual Reality In Training
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 3. Healthcare

With elevated costs, a tendency towards personnel shortages, and people’s lives at stake, the healthcare industry is generally quick to adopt exciting new tech that can boost efficiency and improve performance. Virtual reality is no exception.

Medical institutions can use VR to make diagnoses and define treatments. Some VR simulators are now able to use images from MRIs or CAT scans to create 3D models of a patient’s anatomy. The training applications of virtual reality enable trainee doctors to practice surgery with no risk to patients. Moreover, they can help more experienced ones to determine the safest way to operate.

There are other interesting virtual reality applications in the healthcare industry beyond surgery and diagnoses. For rehabilitation of stroke and brain injury victims, healthcare industries use VR. It provides virtual exercises to help patients gain independence in everyday activities, aided by real-time feedback.

Virtual Reality In Healthcare
Photo by Reenita Das on Forbes

 

4. The Arts

Fans of the performing arts will probably find the idea of a screen between the artist and audience a strange one. However, there are many exciting virtual reality applications when it comes to theatre, opera, dance, circus, and other performing art forms that are characterized by their fleetingness. That is, you have to be there on the night, or else, it’s gone forever. VR enables you to watch a live performance at any time you please. You can even be in the best seat in your house. Why not even from the middle of the stage if you’re feeling adventurous?

There are many other virtual reality applications when it comes to the arts. Directors can create a stage set before they build it. Applications such as Tvori enable you to create 3D animations that you can walk around. The possibilities are endless!

Virtual Reality In The Arts
Photo by Mark Foster on Unilad

 

5. Meditation

According to the World Health Organization, stress is the health epidemic of the 21st century. Furthermore, many seem to think that tech is part of the problem. But what if it was also part of the solution? Apps along the lines of Calm and Headspace already enable you to take a break wherever you happen to be. Moreover, VR is promising to add an extra dimension to your meditation experience.

One of the hardest things about meditation for people who are just starting their meditation journey is learning to just “let go”. Virtual reality meditation apps make that all easier by allowing you to slip on your headset and instantly slip into another world.

Virtual Reality in Meditation
Photo by Michael Gollust on Health

 

6. Mental Health

Virtual reality applications help you relax and let go. Likewise, its applications include therapeutic tools for people who have been through traumatizing experiences or suffer from debilitating stress, PTSD, or phobias.

Virtual reality can provide a safe virtual environment. This enables patients to come into contact with the source of their phobias or fears without endangering themselves. Moreover, interesting advances have already made notably in the field of treatment for war veterans suffering from PTSD.

Benefits Of Using Virtual Reality For Mental Health
Photo by Abbie Arce on LabRoots

 

7. Marketing

AI-powered data analysis is enabling digital marketers to tailor experiences to fit individual tastes like never before. At the same time, consumers are constantly bombarded with advertising. It means that banner blindness is becoming a real problem – and that’s before we even mention adblockers.

VR is a gamechanger for marketers. It enables them to provide exciting, immersive experiences with high entertainment value. In the UK, the cheese manufacturer, Boursin, recently offered a delightful virtual reality exhibit. Users were taken on a journey through a fridge filled with tasty treats, complete with wind simulators for an even more immersive experience.

8. Shopping

Imagine that you’re wandering through a fashionable SoHo boutique looking to pick out a new accessory, and at the same time on your couch several hundred miles away in your pajamas.

Online retailers are now part and parcel of our day-to-day life and are looking to get a make-over. Thanks to the power of VR. The VR start-up Trillenium creates virtual stores for online retailers and has already partnered with the likes of ASOS, one of Europe’s biggest online retailers. Instead of clicking their way through online catalogs, shoppers can go on a virtual tour of a store for a real-time shopping experience. They can even share it with their friends.

9. Journalism

Another exciting virtual reality application is on journalism and online media. VR is enabling media outlets to create immersive storytelling experiences that give the viewer the impression of truly being part of the action. Major players such as the Washington Post and the New York Times are now entering the VR field by offering 360° reports and documentaries. The New York Times made a big splash in 2014 by sending Google Cardboard headsets to its subscribers for them to use with their smartphones.

 10. Architecture

Another exciting application of virtual reality is in architecture. This is for being able to offer their clients virtual walkthroughs, a great way for firms to showcase their projects compared to more traditional 3D projection. It is by giving clients a true sense of space and design.

The potential uses of virtual reality are widespread and diverse, spanning everything from entertainment to healthcare and from journalism to digital marketing. With technology becoming cheaper and more widely available, we can expect to see many more exciting virtual reality applications in the years to come. Stay tuned!

 

via Top 10 Virtual Reality Applications In Today’s World | Robots.net

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[WEB SITE] Virtual Reality + Psychiatry: VR Storytelling Could Transform Mental Health

Virtual Psychiatry

By Jeffrey Rindskopf  August 21, 2019

In the early ‘90s, psychologist Albert “Skip” Rizzo was trying to rehabilitate cognitive function in brain injury patients with workbooks and pen-and-paper exercises – tools one might expect more from a special education class than a psychiatric treatment center. Then one patient, a frontal lobe-impaired 22-year-old, came in with a Game Boy, playing “Tetris.”

“This is a guy I couldn’t motivate for more than five minutes to stay focused, but there he was lasered in on this Game Boy,” Rizzo recalls. “That was the first lightbulb that we could start using digital technology to motivate and engage people.”

He became one of many medical professionals at the time to recognize the early potential of virtual reality (VR) to help diagnose and treat a wide range of mental health issues. In 1995, Rizzo accepted a research director position at USC’s Institute for Creative Technologies to launch a new kind of cognitive rehab, supplementing the old analog and talk therapy tools with VR simulations.

“Now the technology has caught up with the vision,” he says.

So, what is the vision? Given that most health concerns are inseparable from one’s environment, Rizzo calls VR “the ultimate Skinner box,” meaning it can create safe yet emotionally evocative experiences to serve virtually any assessment or treatment approach imaginable. These therapeutic programs could be uniquely reliable for evaluating patients in the subjective world of mental health, wherein up to 85 percent of conditions can go undetected, according to the World Health Organization.

VR could bridge this gap in awareness and improve diagnoses by letting providers monitor patients’ physiological reactions to virtual scenarios, resulting in better treatment outcomes down the line. At Exeter University, a “mirror game” requiring subjects to duplicate the movements and expressions of a virtual avatar aided early detection of schizophrenia. In a similar vein, University of Oxford researchers are developing a VR-based test that gauges subjects’ reactions to neutral social situations for instances of paranoid thinking. Another study from Cambridge University diagnosed early Alzheimer’s-related spatial impairments more accurately than the current gold standard method, just by having participants don an HTC Vive and retrace their steps along an unmarked L-shaped path.

Another area where VR offers proven advantages is “extinction learning,” a method for overcoming fear and emotional trauma by gradually desensitizing one to the source of their anxiety. Though patients know these experiences aren’t real, that doesn’t change the preconscious response and fear activation of their limbic systems, manifesting in increased heart rate and production of the stress hormone cortisol. Our emotional command centers naturally suspend disbelief even when our logical minds know better, putting VR on par with real-life exposure therapy in clinical effectiveness, but with none of the travel costs or physical danger.

While early programs were calibrated to extinguish common phobias like fear of heights (balancing on a plank between skyscrapers), flying (sitting on the runway in a commercial aircraft) and spiders (progressing through increasingly realistic arachnid encounters), advancements in tech have allowed researchers to tailor more complex experiences, like crowded streets to stimulate social anxiety or traumatic memories for PTSD.

Starting in 2003, Rizzo modified a VR shooter game into an exposure tool called “BRAVEMIND” for veterans to reprocess their traumatic experiences, whether relating to IED blasts or sexual assault, with a therapist virtually recreating the memory as described.

“Most treatments out there for PTSD don’t have a lot of empirical evidence,” explains Rizzo. “The ones that do so far are ones that help a person focus on addressing the trauma, not avoiding it.”

The same principle seems to apply for another trial use of VR to treat schizophrenia. Traditionally, therapists advise patients to ignore auditory hallucinations, but a University of Montreal research team instead helped them create and interact with virtual avatars for the voices in their heads. While four of 19 subjects quit after the first session, the remaining 15 rated each interaction less frightening than the last, and their hallucination-related distress dropped an average of 5 points on a scale of 20 by the study’s end.

More recently, Rizzo and others have taken VR a step further, exploring something increasingly unheard of in American healthcare – prevention.

“BRAVEMIND” was retooled into the award-winning training simulation “STRIVE,” or Stress Resilience In Virtual Environments, preparing military members for the trials and traumas of combat before they’re deployed. Standing atop a vibrating platform in an immersive headset, recruits experience 15-minutes episodes at the midpoint of which an “emotionally challenging” event occurs based on real combat situations, such as the death of a civilian child or beating of a woman for infidelity. The scenario pauses, and a virtual “mentor” pulls players aside to help them process the event and teach physiological coping strategies, like deep breathing with a pair of onscreen lungs.

“We’re trying to engage people in stuff they normally get by way of death by PowerPoint,” says Rizzo. “We know experiential learning with a story sticks in the brain way more than somebody telling you in a lecture.”

Other psychological applications where VR has shown promise include weakening cravings that drive addiction and relapse, reducing body size overestimation in anorexia patients, imparting job interview skills to the autistic or formerly incarcerated, distracting from acutely discomforting procedures like chemotherapy and teaching mindfulness in ways that can engage and offer relief for even chronic pain sufferers. Some VR treatments are already rolling out to clinicians’ offices and consumers – “BRAVEMIND” and “STRIVE” are being donated by the charity SoldierStrong to VA offices across America, while the company Limbix offers $200 monthly subscriptions for a headset with their range of medical-grade VR apps.

Yet this ability to literally shape and heal human minds has mainly been overshadowed by commercial excitement for VR video games, not that Rizzo minds. Gaming industry investment has driven the technology to new heights in sensory immersion and new lows in cost – from $15k for a full setup in the ‘90s to $200 for a standalone headset today – giving it a clinical edge over pricier techniques like neuroimaging.

Now, however, Rizzo considers the incubation period for VR over and stresses the need to distinguish between entertainment versus health-related applications, lest business motives get in the way of credible science and set back public acceptance of the technology. There are many ethical considerations still to be sorted out as well, like ensuring providers have adequate training on the tech as well as patients’ needs and establishing safeguards for self-administered VR treatments.

“We’re not building games here,” Rizzo emphasizes, “we’re building experiences.”

But at the same time, that gaming element may be the key to VR’s revolutionary potential for healthcare. Effective treatment means nothing if people don’t use it, and the allure of VR, demonstrated time and time again in preliminary studies, could actually drive engagement and education in mental health as a whole. Just as the introduction of flight training simulators in the ‘30s led to a precipitous drop in aircraft accidents, this could be another immersive practice tool to minimize real-world distress, but with a universal scope and appeal well beyond that of any Game Boy.

via Virtual Reality + Psychiatry: VR Storytelling Could Transform Mental Health

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[WEB SITE] SeeingVR: A Set of Tools to Make Virtual Reality More Accessible to People with Low Vision – Microsoft Research

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Current virtual reality applications do not support people who have low vision, i.e., vision loss that falls short of complete blindness but is not correctable by glasses. We present SeeingVR, a set of 14 tools that enhance a VR application for people with low vision by providing visual and audio augmentations. A user can select, adjust, and combine different tools based on their preferences. Nine of our tools modify an existing VR application post hoc via a plugin without developer effort. The rest require simple inputs from developers using a Unity toolkit we created that allows integrating all 14 of our low vision support tools during development. Our evaluation with 11 participants
with low vision showed that SeeingVR enabled users to better enjoy VR and complete tasks more quickly and accurately. Developers also found our Unity toolkit easy and convenient to use.

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SeeingVR Toolkit

May 24, 2019

Current virtual reality applications do not support people who have low vision, i.e., vision loss that falls short of complete blindness but is not correctable by glasses. We present SeeingVR, a set of 14 tools that enhance a VR application for people with low vision by providing visual and audio augmentations.

 

SeeingVR: A Set of Tools to Make Virtual Reality More Accessible to People with Low Vision

Video figure accompanying a CHI 2019 paper on the same topic. The research paper will be available in January 2019.

 

via SeeingVR: A Set of Tools to Make Virtual Reality More Accessible to People with Low Vision – Microsoft Research

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[ARTICLE] Efficacy and Brain Imaging Correlates of an Immersive Motor Imagery BCI-Driven VR System for Upper Limb Motor Rehabilitation: A Clinical Case Report – Full Text

To maximize brain plasticity after stroke, a plethora of rehabilitation strategies have been explored. These include the use of intensive motor training, motor-imagery (MI), and action-observation (AO). Growing evidence of the positive impact of virtual reality (VR) techniques on recovery following stroke has been shown. However, most VR tools are designed to exploit active movement, and hence patients with low level of motor control cannot fully benefit from them. Consequently, the idea of directly training the central nervous system has been promoted by utilizing MI with electroencephalography (EEG)-based brain-computer interfaces (BCIs). To date, detailed information on which VR strategies lead to successful functional recovery is still largely missing and very little is known on how to optimally integrate EEG-based BCIs and VR paradigms for stroke rehabilitation. The purpose of this study was to examine the efficacy of an EEG-based BCI-VR system using a MI paradigm for post-stroke upper limb rehabilitation on functional assessments, and related changes in MI ability and brain imaging. To achieve this, a 60 years old male chronic stroke patient was recruited. The patient underwent a 3-week intervention in a clinical environment, resulting in 10 BCI-VR training sessions. The patient was assessed before and after intervention, as well as on a one-month follow-up, in terms of clinical scales and brain imaging using functional MRI (fMRI). Consistent with prior research, we found important improvements in upper extremity scores (Fugl-Meyer) and identified increases in brain activation measured by fMRI that suggest neuroplastic changes in brain motor networks. This study expands on the current body of evidence, as more data are needed on the effect of this type of interventions not only on functional improvement but also on the effect of the intervention on plasticity through brain imaging.

Introduction

Worldwide, stroke is a leading cause of adult long-term disability (Mozaffarian et al., 2015). From those who survive, an increased number is suffering with severe cognitive and motor impairments, resulting in loss of independence in their daily life such as self-care tasks and participation in social activities (Miller et al., 2010). Rehabilitation following stroke is a multidisciplinary approach to disability which focuses on recovery of independence. There is increasing evidence that chronic stoke patients maintain brain plasticity, meaning that there is still potential for additional recovery (Page et al., 2004). Traditional motor rehabilitation is applied through physical therapy and/or occupational therapy. Current approaches of motor rehabilitation include functional training, strengthening exercises, and range of movement exercises. In addition, techniques based on postural control, stages of motor learning, and movement patterns have been proposed such as in the Bobath concept and Bunnstrom approach (amongst others) (Bobath, 1990). After patients complete subacute rehabilitation programs, many still show significant upper limb motor impairment. This has important functional implications that ultimately reduce their quality of life. Therefore, alternative methods to maximize brain plasticity after stroke need to be developed.

So far, there is growing evidence that action observation (AO) (Celnik et al., 2008) and motor imagery (MI) improve motor function (Mizuguchi and Kanosue, 2017) but techniques based on this paradigm are not widespread in clinical settings. As motor recovery is a learning process, the potential of MI as a training paradigm relies on the availability of an efficient feedback system. To date, a number of studies have demonstrated the positive impact of virtual-reality (VR) based on neuroscientific grounds on recovery, with proven effectiveness in the stroke population (Bermúdez i Badia et al., 2016). However, patients with no active movement cannot benefit from current VR tools due to low range of motion, pain, fatigue, etc. (Trompetto et al., 2014). Consequently, the idea of directly training the central nervous system was promoted by establishing an alternative pathway between the user’s brain and a computer system.

This is possible by using electroencephalography (EEG)-based Brain-Computer Interfaces (BCIs), since they can provide an alternative non-muscular channel for communication and control to the external world (Wolpaw et al., 2002), while they could also provide a cost-effective solution for training (Vourvopoulos and Bermúdez, 2016b). In rehabilitation, BCIs could offer a unique tool for rehabilitation since they can stimulate neural networks through the activation of mirror neurons (Rizzolatti and Craighero, 2004) by means of action-observation (Kim et al., 2016), motor-intent and motor-imagery (Neuper et al., 2009), that could potentially lead to post-stroke motor recovery. Thus, BCIs could provide a backdoor to the activation of motor neural circuits that are not stimulated through traditional rehabilitation techniques.

In EEG-based BCI systems for motor rehabilitation, Alpha (8–12 Hz) and Beta (12–30 Hz) EEG rhythms are utilized since they are related to motor planning and execution (McFarland et al., 2000). During a motor attempt or motor imagery, the temporal pattern of the Alpha rhythms desynchronizes. This rhythm is also named Rolandic Mu-rhythm or the sensorimotor rhythm (SMR) because of its localization over the sensorimotor cortices. Mu-rhythms are considered indirect indications of functioning of the mirror neuron system and general sensorimotor activity (Kropotov, 2016). These are often detected together with Beta rhythm changes in the form of an event-related desynchronization (ERD) when a motor action is executed (Pfurtscheller and Lopes da Silva, 1999). These EEG patterns are primarily detected during task-based EEG (e.g., when the participant is actively moving or imagining movement) and they are of high importance in MI-BCIs for motor rehabilitation.

A meta-analysis of nine studies (combined N = 235, sample size variation 14 to 47) evaluated the clinical effectiveness of BCI-based rehabilitation of patients with post-stroke hemiparesis/hemiplegia and concluded that BCI technology could be effective compared to conventional treatment (Cervera et al., 2018). This included ischemic and hemorrhagic stroke in both subacute and chronic stages of stoke, between 2 to 8 weeks. Moreover, there is evidence that BCI-based rehabilitation promotes long-lasting improvements in motor function of chronic stroke patients with severe paresis (Ramos-Murguialday et al., 2019), while overall BCI’s are starting to prove their efficacy as rehabilitative technologies in patients with severe motor impairments (Chaudhary et al., 2016).

The feedback modalities used for BCI motor rehabilitation include: non-embodied simple two-dimensional tariffs on a screen (Prasad et al., 2010Mihara et al., 2013), embodied avatar representation of the patient on a screen or with augmented reality (Holper et al., 2010Pichiorri et al., 2015), neuromuscular electrical stimulation (NMES) (Kim et al., 2016Biasiucci et al., 2018). and robotic exoskeletal orthotic movement facilitation (Ramos-Murguialday et al., 2013Várkuti et al., 2013Ang et al., 2015). In addition, it has been shown that multimodal feedback lead to a significantly better performance in motor-imagery (Sollfrank et al., 2016) but also multimodal feedback combined with motor-priming, (Vourvopoulos and Bermúdez, 2016a). However, there is no evidence which modalities are more efficient in stroke rehabilitation are.

Taking into account all previous findings in the effects of multimodal feedback in MI training, the purpose of this case study is to examine the effect of the MI paradigm as a treatment for post-stroke upper limb motor dysfunction using the NeuRow BCI-VR system. This is achieved through the acquisition of clinical scales, dynamics of EEG during the BCI treatment, and brain activation as measured by functional MRI (fMRI). NeuRow is an immersive VR environment for MI-BCI training that uses an embodied avatar representation of the patient arms and haptic feedback. The combination of MI-BCIs with VR can reinforce activation of motor brain areas, by promoting the illusion of physical movement and the sense of embodiment in VR (Slater, 2017), and hence further engaging specific neural networks and mobilizing the desired neuroplastic changes. Virtual representation of body parts paves the way to include action observation during treatment. Moreover, haptic feedback is added since a combination of feedback modalities could prove to be more effective in terms of motor-learning (Sigrist et al., 2013). Therefore, the target of this system is to be used by patients with low or no levels of motor control. With this integrated BCI-VR approach, severe cases of stroke survivors may be admitted to a VR rehabilitation program, complementing traditional treatment.

Methodology

Patient Profile

In this pilot study we recruited a 60 years old male patient with left hemiparesis following cerebral infarct in the right temporoparietal region 10 months before. The participant had corrected vision through eyewear, he had 4 years of schooling and his experience with computers was reported as low. Moreover, the patient was on a low dose of diazepam (5 mg at night to help sleep), dual antiplatelet therapy, anti-hypertensive drug and metformin. Hemiparesis was associated with reduced dexterity and fine motor function; however, sensitivity was not affected. Other sequelae of the stroke included hemiparetic gait and dysarthria. Moreover, a mild cognitive impairment was identified which did not interfere with his ability to perform the BCI-VR training. The patient had no other relevant comorbidities. Finally, the patient was undergoing physiotherapy and occupational therapy at the time of recruitment and had been treated with botulinum toxin infiltration 2 months before due to focal spasticity of the biceps brachii.

Intervention Protocol

The patient underwent a 3-weeks intervention with NeuRow, resulting in 10 BCI sessions of a 15 min of exposure in VR training per session. Clinical scales, motor imagery capability assessment, and functional -together with structural- MRI data had been gathered in three time-periods: (1) before (serving as baseline), (2) shortly after the intervention and (3) one-month after the intervention (to assess the presence of long-term changes). Finally, electroencephalographic (EEG) data had been gathered during all sessions, resulting in more than 20 datasets of brain electrical activity.

The experimental protocol was designed in collaboration with the local healthcare system of Madeira, Portugal (SESARAM) and approved by the scientific and ethic committees of the Central Hospital of Funchal. Finally, written informed consent was obtained from the participant upon recruitment for participating to the study but also for the publication of the case report in accordance with the 1964 Declaration of Helsinki.

Assessment Tools

A set of clinical scales were acquired including the following:

1. Montreal Cognitive Assessment (MoCA). MoCA is a cognitive screening tool, with a score range between 0 and 30 (a score greater than 26 is considered to be normal) validated also for the Portuguese population, (Nasreddine et al., 2005).

2. Modified Ashworth scale (MAS). MAS is a 6-point rating scale for measuring spasticity. The score range is 0, 1, 1+, 2, 3, and 4 (Ansari et al., 2008).

3. Fugl-Meyer Assessment (FMA). FMA is a stroke specific scale that assesses motor function, sensation, balance, joint range of motion and joint pain. The motor domain for the upper limb has a maximum score of 66 (Fugl-Meyer et al., 1975).

4. Stroke Impact Scale (SIS). SIS is a subjective scale of the perceived stroke impact and recovery as reported by the patient, validated for the Portuguese population. The score of each domain of the questionnaire ranges from 0 to 100 (Duncan et al., 1999).

5. Vividness of Movement Imagery Questionnaire (VMIQ2). VMIQ2 is an instrument that assess the capability of the participant to perform imagined movements from external perspective (EVI), internal perspective imagined movements (IVI) and finally, kinesthetic imagery (KI) (Roberts et al., 2008).

NeuRow BCI-VR System

EEG Acquisition

For EEG data acquisition, the Enobio 8 (Neuroelectrics, Barcelona, Spain) system was used. Enobio is a wearable wireless EEG sensor with 8 EEG channels for the recording and visualization of 24-bit EEG data at 500 Hz and a triaxial accelerometer. The spatial distribution of the electrodes followed the 10–20 system configuration (Klem et al., 1999) with the following electrodes over the somatosensory and motor areas: Frontal-Central (FC5, FC6), Central (C1, C2, C3, C4), and Central-Parietal (CP5, CP6) (Figure 1A). The EEG system was connected via Bluetooth to a dedicated desktop computer, responsible for the EEG signal processing and classification, streaming the data via UDP through the Reh@Panel (RehabNet Control Panel) for controlling the virtual environment. The Reh@Panel is a free tool that acts as a middleware between multiple interfaces and virtual environments (Vourvopoulos et al., 2013).

FIGURE 1

Figure 1. Experimental setup, including: (A) the wireless EEG system; (B) the Oculus HMD, together with headphones reproducing the ambient sound from the virtual environment; (C) the vibrotactile modules supported by a custom-made table-tray, similar to the wheelchair trays used for support; (D) the visual feedback with NeuRow game. A written informed consent was obtained for the publication of this image.

[…]

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[NEWS] New Gaming Platform Aims to Use Virtual Rehab to Help Stroke Survivors

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VirtualRehab

Researchers at UK-based University of East Anglia (UEA), in collaboration with Evolv Rehabilitation Technologies, have created a new virtual reality (VR) gaming platform designed to help improve the lives of stroke patients suffering from complex neurological syndromes caused by their stroke.

The new technology, which has been funded by the National Institute for Health Research (NIHR), was recently unveiled at RehabWeek in Toronto.

Around 30% to 50% of stroke survivors experience Œhemispatial neglect, which leaves people unaware of things located on one side of their body and greatly reduces their ability to live independently.

“A stroke can damage the brain, so that it no longer receives information about the space around one side of the world,” lead researcher Dr Stephanie Rossit, from UEA’s school of Psychology, explains in a media release from UEA.

“If this happens, people may not be aware of anything on one side, usually the same side they also lost their movement. This is called hemispatial neglect.

“These people tend to have very poor recovery and are left with long-term disability. Patients with this condition tell us that it is terrifying. They bump into things, they’re scared to use a wheelchair, so it really is very severe and life-changing.”

Current rehabilitation treatments involve different types of visual and physical coordination tasks (visuomotor) and cognitive exercises, ­ many of which are Œpaper and pen-based.

The new non-immersive VR technology being showcased updates these paper and pen tasks for the digital age – using videogame technology instead, per the release.

“We know that adherence is key to recovery – so we wanted to create something that makes it fun to stick to a rehabilitation task,” Roissit adds.

In one such game, the patient sees a random series of apples, some complete and some with a piece bitten off. The apples vibrate and move to provide greater stimulation to the patient.

“The aim for the patient is to choose the maximum number of complete apples that they see in the quickest time possible,” states David Fried, CEO of Evolv.

“A person with visual neglect would quite often only see a small number of correct targets to the right-hand side of the screen. Therapists can control the complexity of the game by increasing or reducing the number of apples on screen.”

As well as aiding diagnosis, the new game aims to improve rehabilitation by including elements such as scoring and rewards to engage the patient and improve adherence to their treatment.

Fried said: “Traditional rehabilitation treatment is quite monotonous and boring, so this gamification aspect is really important to help people stick with their treatment,” Fried adds.

“Our goal is to use technology to make rehabilitation fun and engaging, and we have applied this to our Spatial Neglect therapy solution. The great thing about it is that it can be used not only in clinics but also in patients’ homes, thereby giving them access to personalized rehabilitation without leaving their living room.”

The team has previously worked with stroke survivors, carers, and clinicians to assess the feasibility, usability, and acceptability of new gaming technology, per the release.

Dr Rossit said: ³This technology has the potential to improve both independence and quality of life of stroke survivors,” Rossit shares.

“This innovative therapy could also improve long-term care after stroke by providing a low-cost, enjoyable therapy that can be self-administered anywhere and anytime, without the need for a therapist to be present on every occasion.”

[Source: University of East Anglia]

 

via New Gaming Platform Aims to Use Virtual Rehab to Help Stroke Survivors – Rehab Managment

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[Abstract] Upper Extremity Rehabilitation Using Fully Immersive Virtual Reality Games with a Head Mount Display: A Feasibility Study

Abstract

Background

Rehabilitation therapy using virtual reality (VR) system for stroke patients has gained attention. However, only few studies have investigated fully immersive VR using a head‐mount display (HMD) for upper extremity rehabilitation in stroke patients.

Objective

To investigate the feasibility, preliminary efficacy, and usability of a fully immersive VR rehabilitation program using a commercially available HMD for upper‐limb rehabilitation in stroke patients.

Design

A feasibility study

Setting

Two rehabilitation centers

Participants

Twelve stroke patients with upper extremity weakness

Interventions

Five upper extremity rehabilitation tasks were implemented in a virtual environment, and the participants wore an HMD (HTC Vive) and trained with appropriate tasks. Participants received a total of 10 sessions two to three times a week, consisting of 30 minutes per session.

Main Outcome Measures

Both patients’ participation and adverse effects of VR training and were monitored. Primary efficacy was assessed using functional outcomes (action arm reach test, box and block test, and modified Barthel index), before and after the intervention. Usability was assessed using a self‐reported questionnaire.

Results

Three patients discontinued VR training, and nine patients completed the entire training sessions and there were no adverse effects due to motion sickness. The patients who received all sessions showed significant functional improvement in all outcome measures after training (P < .05 for all measures). The overall satisfaction was 6.3 ± 0.8 on a 7‐point Likert scale in all participants.

Conclusions

A fully immersive VR rehabilitation program using an HMD for rehabilitation of the upper extremities following stroke is feasible and, in this small study, no serious adverse effects were identified.

 

via Upper Extremity Rehabilitation Using Fully Immersive Virtual Reality Games with a Head Mount Display: A Feasibility Study – Lee – – PM&amp;R – Wiley Online Library

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[ARTICLE] Tracking the evolution of virtual reality applications to rehabilitation as a field of study – Full Text

Abstract

Background

Application of virtual reality (VR) to rehabilitation is relatively recent with clinical implementation very rapidly following technological advancement and scientific discovery. Implementation is often so rapid that demonstrating intervention efficacy and establishing research priorities is more reactive than proactive. This study used analytical tools from information science to examine whether application of VR to rehabilitation has evolved as a distinct field of research or is primarily a methodology in core disciplines such as biomedical engineering, medicine and psychology.

Methods

The analysis was performed in three-stages: 1) a bibliographic search in the ISI Web of Science database created an initial corpus of publications, 2) the corpus was refined through topic modeling, and 3) themes dominating the corpus from the refined search results were identified by topic modeling and network analytics. This was applied separately to each of three time periods: 1996 to 2005 (418 publications), 2006 to 2014 (1454 publications), and 2015 to mid-2018 (1269 publications).

Results

Publication rates have continuously increased across time periods with principal topics shifting from an emphasis on computer science and psychology to rehabilitation and public health. No terminology specific to the field of VR-based rehabilitation emerged; rather a range of central concepts including “virtual reality”, “virtual gaming”, “virtual environments”, “simulated environments” continue to be used. Communities engaged in research or clinical application of VR form assemblages distinguished by a focus on physical or psychological rehabilitation; these appear to be weakly linked through tele-rehabilitation.

Conclusions

Varying terms exemplify the main corpus of VR-based rehabilitation and terms are not consistent across the many scientific domains. Numerous distinguishable areas of research and clinical foci (e.g., Tele-rehabilitation, Gait & Balance, Cognitive Rehabilitation, Gaming) define the agenda. We conclude that VR-based rehabilitation consists of a network of scientific communities with a shared interest in the methodology rather than a directed and focused research field. An interlinked team approach is important to maintain scientific rigor and technological validity within this diverse group. Future studies should examine how these interdisciplinary communities individually define themselves with the goals of gathering knowledge and working collectively toward disseminating information essential to associated research communities.

Background

Virtual Reality (VR) in general, and the application of VR to rehabilitation in particular, is a relatively young, interdisciplinary field where clinical implementation very rapidly follows scientific discovery and technological advancement. Indeed, implementation is often so rapid that demonstration of intervention efficacy by investigators, and establishment of research and development priorities by funding bodies, tends to be more reactive than proactive.

Rapid growth in the number and type of applications of VR to rehabilitation has occurred over the past 15 years, suggesting that the research in this area may be demonstrative of a new scientific field. Reviews of the research in this area (see e.g., Rizzo and Kim [], Sveistrup [], and Levin et al. []), however, focus principally on applications of VR technology to specific disability or impairment. If VR-based rehabilitation is chiefly one more tool in the field of rehabilitation science, then cross-disciplinary communication could consist primarily of reporting methodological approaches. If, however, VR-based rehabilitation has emerged as a distinctive scientific domain, then it becomes the responsibility of the scientists and clinicians engaged in this work to disseminate both research insights and future directions across engaged disciplines. Our aim in the current study is to use tools of analysis from the domain of information science to examine whether application of VR to rehabilitation has evolved as a distinct field of research or is primarily a methodology in core disciplines such as biomedical engineering, medicine and psychology.

We initiated our search in 1996 because only one moderately relevant review article alluding to virtual reality being applied to medicine was found prior to that time []. Thus Period 1 (1996–2005) is defined as the period in which key technological developments emerged that influenced the use of VR technology for rehabilitation (Fig. 1). The most characteristic features of the early technologies in Period 1 were their large size, high cost and limited accuracy. These systems led to several pioneering motor rehabilitation applications [] whose clinical relevance was still uncertain since their high cost, technical complexity, and encumbrance severely limited access to both hardware or software []. Although there was limited recognition of its growing clinical potential, no significant grassroots perception of the need for VR-based interventions took hold during this period.

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