Subjective visual vertical assessment with mobile virtual reality system

Leveraging Technology for Vestibular Assessment and Rehabilitation in the Operational Environment: A Scoping Review

INTRODUCTION

The vestibular system, essential for gaze and postural stability, can be damaged by threats on the battlefield. Technology can aid in vestibular assessment and rehabilitation; however, not all devices are conducive to the delivery of healthcare in an austere setting. This scoping review aimed to examine the literature for technologies that can be utilized for vestibular assessment and rehabilitation in operational environments.

MATERIALS AND METHODS

A comprehensive search of PubMed was performed. Articles were included if they related to central or peripheral vestibular disorders, addressed assessment or rehabilitation, leveraged technology, and were written in English. Articles were excluded if they discussed health conditions other than vestibular disorders, focused on devices or techniques not conducive to the operational environment, or were written in a language other than English.

RESULTS

Our search strategy yielded 32 articles: 8 articles met our inclusion and exclusion criteria whereas the other 24 articles were rejected.

DISCUSSION

There is untapped potential for leveraging technology for vestibular assessment and rehabilitation in the operational environment. Few studies were found in the peer-reviewed literature that described the application of technology to improve the identification of central and/or peripheral vestibular system impairments; triage of acutely injured patients; diagnosis; delivery and monitoring of rehabilitation; and determination of readiness for return to duty.

CONCLUSIONS

This scoping review highlighted technology for vestibular assessment and rehabilitation feasible for use in an austere setting. Such technology may be leveraged for prevention; monitoring exposure to mechanisms of injury; vestibular-ocular motor evaluation; assessment, treatment, and monitoring of rehabilitation progress; and return-to-duty determination after vestibular injury.

FUTURE DIRECTIONS

The future of vestibular assessment and rehabilitation may be shaped by austere manufacturing and 3D printing; artificial intelligence; drug delivery in combination with vestibular implantation; organ-on-chip and organoids; cell and gene therapy; and bioprinting.

Vestibular perceptual testing from lab to clinic: a review

Not all dizziness presents as vertigo, suggesting other perceptual symptoms for individuals with vestibular disease. These non-specific perceptual complaints of dizziness have led to a recent resurgence in literature examining vestibular perceptual testing with the aim to enhance clinical diagnostics and therapeutics. Recent evidence supports incorporating rehabilitation methods to retrain vestibular perception. This review describes the current field of vestibular perceptual testing from scientific laboratory techniques that may not be clinic friendly to some low-tech options that may be more clinic friendly. Limitations are highlighted suggesting directions for additional research.

Test-retest of the Subjective Visual Vertical Test performed using a mobile application with the smartphone anchored to a turntable

PURPOSE

The alterations of the Subjective visual vertical test are related to vestibular pathology. Our previously validated method to distinguish between healthy and pathological individuals measures the deviation from the Subjective visual vertical using a mobile application installed on a smartphone fixed to a turntable anchored to the wall. The aim of this study was evaluating the intra-observer reliability of our method in individuals with or without vestibular pathology.

METHODS

Participants were recruited consecutively. In each individual two measurements with an interval of 2 h were made. Both tests were performed by the same examiner. A total of 91 patients were included in this study, of which 25 were healthy and 66 diseased. Intra-observer reliability was evaluated using the intraclass correlation coefficient (ICC). To assess the clinical accuracy of the measurement, we calculated the standard error of the measurement (SEM) and the minimum detectable change (MDC) with a 95% confidence interval.

RESULTS

Intra-observer reliability was excellent with an ICC 0.95 (0.92-0.97) in the whole sample, in healthy patients 0.91 (0.80-0.96) and in pathological patients 0.92 (0.87-0.95). The SEM was calculated to be 0.59 for the whole sample (0.26 in the "healthy" group, and 0.67 in the pathological group). Likewise, the sample's MDC was 1.16, being 0.52 and 1.36 for the healthy and the pathological group, respectively.

CONCLUSIONS

Considering the results, our method presents an excellent intraobserver reliability. Furthermore, changes in deviation greater than 0.52 in healthy individuals and 1.36 in pathological individuals can be considered a real change in deviation.

Subjective visual vertical imprecision during lateral head tilt in patients with chronic dizziness

Most prior studies of the subjective visual vertical (SVV) focus on inaccuracy of subjects' SVV responses with the head in an upright position. Here we investigated SVV imprecision during lateral head tilt in patients with chronic dizziness compared to healthy controls. Forty-five dizzy patients and 45 healthy controls underwent SVV testing wearing virtual reality (VR) goggles, sitting upright (0°) and during head tilt in the roll plane (± 30°). Ten trials were completed in each of three static head positions. The SVV inaccuracy and SVV imprecision were analyzed and compared between groups, along with systematic errors during head tilt, i.e., A-effect and E-effect (E-effect is a typical SVV response during head tilts of ± 30°). The SVV imprecision was found to be affected by head position (upright/right head tilt/left head tilt, p < 0.001) and underlying dizziness (dizzy patients/healthy controls, p = 0.005). The SVV imprecision during left head tilt was greater in dizzy patients compared to healthy controls (p = 0.04). With right head tilt, there was a trend towards greater SVV imprecision in dizzy patients (p = 0.08). Dizzy patients were more likely to have bilateral (6.7%) or unilateral (22.2%) A-effect during lateral head tilt than healthy controls (bilateral (0%) or unilateral (6.7%) A-effect, p < 0.01). Greater SVV imprecision in chronically dizzy patients during head tilts may be attributable to increased noise of vestibular sensory afferents or disturbances of multisensory integration. Our findings suggest that SVV imprecision may be a useful clinical parameter of underlying dizziness measurable with bedside SVV testing in VR.

Efficacy of the subjective visual vertical test performed using a mobile application to detect vestibular pathology

BACKGROUND

The subjective visual vertical (SVV) test is a sensitive test of vestibular dysfunction that allows the evaluation of otolithic organs; however, with the current method, there are technical and logistical limitations that make the application of this test difficult in the conventional clinic.

OBJECTIVE

The objective of this study is to assess the effectiveness of detecting vestibular pathology using the SVV via a new screening method.

METHODS

A consecutive sample of 62 patients with suspected vestibular pathology was included in the study. The patients were clinically diagnosed according to the Barany Society criteria. An exploratory system was designed using a mobile application in Android that detects accelerometer oscillations and involves placing the smartphone on a rotating disk anchored to the wall. All patients underwent a SVV examination using the bucket method and the study test. A cut-off point of the ROC curve was calculated for each test, and its sensitivity, specificity, diagnostic accuracy and probability ratios for detecting vestibular pathology were analysed. The SVV results were compared using the bucket test and the study test.

RESULTS

We observed significant differences in sensitivity between the two tests: 86.95% for the study test versus 67.4% for the bucket test (p <  0.01). In the ROC curve, an area under the curve of 0.90 was observed for the study test, with a cut-off of 2.43 for a sensitivity of 86.95% and a specificity of 93.75%.

CONCLUSIONS

SVV testing using a smartphone placed on a rotating disk anchored to the wall offers greater diagnostic accuracy than SVV using the bucket test. Both methods are inexpensive, harmless and easily accepted by patients.

Multisensory contribution in visuospatial orientation: an interaction between neck and trunk proprioception

A coherent perception of spatial orientation is key in maintaining postural control. To achieve this the brain must access sensory inputs encoding both the body and the head position and integrate them with incoming visual information. Here we isolated the contribution of proprioception to verticality perception and further investigated whether changing the body position without moving the head can modulate visual dependence-the extent to which an individual relies on visual cues for spatial orientation. Spatial orientation was measured in ten healthy individuals [6 female; 25-47 years (SD 7.8 years)] using a virtual reality based subjective visual vertical (SVV) task. Individuals aligned an arrow to their perceived gravitational vertical, initially against a static black background (10 trials), and then in other conditions with clockwise and counterclockwise background rotations (each 10 trials). In all conditions, subjects were seated first in the upright position, then with trunk tilted 20° to the right, followed by 20° to the left while the head was always aligned vertically. The SVV error was modulated by the trunk position, and it was greater when the trunk was tilted to the left compared to right or upright trunk positions (p < 0.001). Likewise, background rotation had an effect on SVV errors as these were greater with counterclockwise visual rotation compared to static background and clockwise roll motion (p < 0.001). Our results show that the interaction between neck and trunk proprioception can modulate how visual inputs affect spatial orientation.

Impaired Subjective Visual Vertical and Increased Visual Dependence in Older Adults With Falls

Aging affects the vestibular system and may disturb the perception of verticality and lead to increased visual dependence (VD). Studies have identified that abnormal upright perception influences the risk of falling. The aim of our study was to evaluate subjective visual vertical (SVV) and VD using a mobile virtual reality-based system for SVV assessment (VIRVEST) in older adults with falls and evaluate its relationship with clinical balance assessment tools, dizziness, mental state, and depression level. This study included 37 adults >65 years who experienced falls and 40 non-faller age-matched controls. Three tests were performed using the VIRVEST system: a static SVV, dynamic SVV with clockwise and counter-clockwise background stimulus motion. VD was calculated as the mean of absolute values of the rod tilt from each trial of dynamic SVV minus the mean static SVV rod tilt. Older adults who experienced falls manifested significantly larger biases in static SVV (p = 0.012), dynamic SVV (p < 0.001), and VD (p = 0.014) than controls. The increase in static SVV (odds ratio = 1.365, p = 0.023), dynamic SVV (odds ratio = 1.623, p < 0.001) and VD (odds ratio = 1.460, p = 0.010) tilt by one degree significantly related to falls risk in the faller group. Fallers who had a high risk of falling according to the Tinetti test exhibited significantly higher tilts of dynamic SVV than those who had a low or medium risk (p = 0.037). In the faller group, the increase of the dynamic SVV tilt by one degree was significantly related to falls risk according to the Tinetti test (odds ratio = 1.356, p = 0.049). SVV errors, particularly with the dynamic SVV test (i.e., greater VD) were associated with an increased risk of falling in the faller group. The VIRVEST system may be applicable in clinical settings for SVV testing and predicting falls in older adults.

Influence of vestibular signals on bodily self-consciousness: Different sensory weighting strategies based on visual dependency

Previous studies showed that the vestibular system is crucial for multisensory integration, however, its contribution to bodily self-consciousness more specifically on full-body illusions is not well understood. Thus, the current study examined the role of visuo-vestibular conflict on a full-body illusion (FBI) experiment that was induced during a supine body position. In a mixed design experiment, 56 participants underwent through a full-body illusion protocol. During the experiment, half of the participants received synchronous visuo-tactile stimulation, and the other half received asynchronous visuo-tactile stimulation, while their physical body was lying in a supine position, but the virtual body was standing. Additionally, the contribution of individual sensory weighting strategies was investigated via the Rod and Frame task (RFT), which was applied both before (pre-FBI standing and pre-FBI supine) and after the full-body illusion (post-FBI supine) protocol. Subjective reports of the participants confirmed previous findings suggesting that there was a significant increase in ownership over a virtual body during synchronous visuo-tactile stimulation. Additionally, further categorization of participants based on their visual dependency (by RFT) showed that those participants who rely more on visual information (visual field dependents) perceived the full-body illusion more strongly than non-visual field dependents during the synchronous visuo-tactile stimulation condition. Further analysis provided not only a quantitative demonstration of full-body illusion but also revealed changes in perceived self-orientation based on their field dependency. Altogether, findings of the current study make further contributions to our understanding of the vestibular system and brought new insight for individual sensory weighting strategies during a full-body illusion.

The role of virtual and augmented reality in orthopedic trauma surgery: From diagnosis to rehabilitation

Virtual and augmented reality have been used to assist and improve human capabilities in many fields. Most recent advances allow the usage of these technologies for personal and professional purposes. In particular, they have been progressively introduced in many medical procedures since the last century. Thanks to immersive training systems and a better comprehension of the ongoing procedure, their main objectives are to increase patient safety and decrease recovery time. The current and future possibilities of virtual and augmented reality in the context of bone fracture reduction are the main focus of this review. This medical procedure requires meticulous planning and a complex intervention in many cases, hence becoming a promising candidate to be benefited from this kind of technology. In this paper, we exhaustively analyze the impact of virtual and augmented reality to bone fracture healing, detailing each task from diagnosis to rehabilitation. Our primary goal is to introduce novel researchers to current trends applied to orthopedic trauma surgery, proposing new lines of research. To that end, we propose and evaluate a set of qualitative metrics to highlight the most promising challenges of virtual and augmented reality technologies in this context.

Text Input in Virtual Reality: A Preliminary Evaluation of the Drum-Like VR Keyboard

The drum-like virtual reality (VR) keyboard is a contemporary, controller-based interface for text input in VR that uses a drum set metaphor. The controllers are used as sticks which, through downward movements, “press” the keys of the virtual keyboard. In this work, a preliminary feasibility study of the drum-like VR keyboard is described, focusing on the text entry rate and accuracy as well as its usability and the user experience it offers. Seventeen participants evaluated the drum-like VR keyboard by having a typing session and completing a usability and a user experience questionnaire. The interface achieved a good usability score, positive experiential feedback around its entertaining and immersive qualities, a satisfying text entry rate (24.61 words-per-minute), as well as moderate-to-high total error rate (7.2%) that can probably be further improved in future studies. The work provides strong indications that the drum-like VR keyboard can be an effective and entertaining way to type in VR.

VR Locomotion in the New Era of Virtual Reality: An Empirical Comparison of Prevalent Techniques

The latest technical and interaction advancements within the virtual reality (VR) field have marked a new era, not only for VR, but also for VR locomotion. In this era, well-established, prevalent VR locomotion techniques are mostly used as points of comparison for benchmarking of new VR locomotion designs. At the same time, there is the need for more exploratory, comparative studies of contemporary VR locomotion techniques, so that their distinguished interaction aspects can be documented and guide the design process of new techniques. This article presents a comparative, empirical evaluation study of contemporary and prevalent VR locomotion techniques, examining the user experience (UX) they offer. First, the prevalent VR locomotion techniques are identified based on literature, i.e., walking-in-place, controller/joystick, and teleportation. Twenty-six adults are enrolled in the study and perform a game-like task using the techniques. The study follows a mixed methods approach, utilising the System Usability Scale survey, the Game Experience Questionnaire, and a semistructured interview to assess user experiences. Results indicate that the walking-in-place technique offers the highest immersion but also presents high levels of psychophysical discomfort. Controller/joystick VR locomotion is perceived as easy-to-use due to the users’ familiarity with controllers, whereas teleportation is considered to be effective due to its fast navigation, although its visual ‘jumps’ do break the users’ sense of immersion. Based on the interviews, the users focused on the following interaction dimensions to describe their VR locomotion experiences: (i) immersion and flow, (ii) ease-of-use and mastering, (iii) competence and sense of effectiveness, and (iv) psychophysical discomfort. The study implications for VR locomotion are discussed, along with the study limitations and the future direction for research.