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Lemay M, Levac DE. Toward Physiological Detection of a "Just-Right" Challenge Level for Motor Learning in Immersive Virtual Reality: Protocol for a Cross-Sectional Study. JMIR Res Protoc 2024; 13:e55730. [PMID: 39312763 PMCID: PMC11459106 DOI: 10.2196/55730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 06/19/2024] [Accepted: 07/15/2024] [Indexed: 09/25/2024] Open
Abstract
BACKGROUND Motor learning, a primary goal of pediatric rehabilitation, is facilitated when tasks are presented at a "just-right" challenge level-at the edge of the child's current abilities, yet attainable enough to motivate the child in persistent efforts for success. Immersive virtual reality (VR) may be ideally suited for "just-right" task challenges because it enables precise adjustments of task parameters in motivating environments. Rehabilitation-specific VR tasks often use dynamic difficulty algorithms based on task performance to personalize task difficulty. However, these approaches do not consider relevant cognitive processes that could also impact "just-right" challenges, such as attention and engagement. Objective physiological measurement of these cognitive processes using wearable sensors could support their integration within "just-right" challenge detection and prediction algorithms. As a first step, it is important to explore relationships between objectively and subjectively measured psychophysiological states at progressively challenging task difficulty levels. OBJECTIVE This study aims to (1) evaluate the performance of wearable sensors in a novel movement-based motor learning immersive VR task; (2) evaluate changes in physiological data at 3 task difficulty levels; and (3) explore the relationship between physiological data, task performance, and self-reported cognitive processes at each task difficulty level. METHODS This study uses the within-participant experimental design. Typically developing children and youth aged 8-16 years will be recruited to take part in a single 90-minute data collection session. Physiological sensors include electrodermal activity, heart rate, electroencephalography, and eye-tracking. After collecting physiological data at rest, participants will play a seated unimanual immersive VR task involving bouncing a virtual ball on a virtual racket. They will first play for 3 minutes at a predefined medium level of difficulty to determine their baseline ability level and then at a personalized choice of 3 progressive difficulty levels of 3 minutes each. Following each 3-minute session, participants will complete a short Likert-scale questionnaire evaluating engagement, attention, cognitive workload, physical effort, self-efficacy, and motivation. Data loss and data quality will be calculated for each sensor. Repeated-measures ANOVAs will evaluate changes in physiological response at each difficulty level. Correlation analyses will determine individual relationships between task performance, physiological data, and self-reported data at each difficulty level. RESULTS Research ethics board approval has been obtained, and data collection is underway. Data collection was conducted on December 12, 2023, and April 12, 2024, with a total of 15 typically developing children. Data analysis has been completed, and results are expected to be published in the fall of 2024. CONCLUSIONS Wearable sensors may provide insights into the physiological effects of immersive VR task interaction at progressive difficulty levels in children and youth. Understanding the relationship between physiological and self-reported cognitive processes is a first step in better identifying and predicting "just-right" task challenges during immersive VR motor learning interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/55730.
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Affiliation(s)
- Martin Lemay
- Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine, Montréal, QC, Canada
- Department of Physical Activity Sciences, Faculty of Sciences, Université du Québec à Montréal, Montréal, QC, Canada
| | - Danielle E Levac
- School of Rehabilitation, Faculty of Medicine, University of Montreal, Montréal, QC, Canada
- Centre de Recherche du Centre Hospitalier Universitaire Sainte-Justine, Montréal, QC, Canada
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2
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Fontenot J, Hebert M, Lin HC, Kulshreshth AK. Examining the Perceptions Among Undergraduate Nursing Students Using Virtual Reality in a Community Course: A Mixed-Methods Explanatory Study. J Community Health Nurs 2024; 41:145-155. [PMID: 37966021 DOI: 10.1080/07370016.2023.2280617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
PURPOSE This study investigated undergraduate nursing students' perceptions of integrating virtual reality (VR) technology into a community nursing course, specifically home and environmental patient safety assessments. DESIGN This study used a mixed-methods approach with an explanatory design. METHODS Participants were recruited from a community health course. The students engaged in a VR simulation involving home visits using the vizHome platform. Quantitative and qualitative data were gathered using the Technology Acceptance Model (TAM) and the System Usability Scale (SUS). Semi-structured interviews were conducted. Quantitative data were collected through Qualtrics and secure Zoom connections for the interviews. The data were analyzed with SPSS and MAXQDA. FINDINGS The results indicated that participants perceived VR as valuable and easy to use for learning home assessment skills. The System Usability Scale (SUS) score revealed room for improvement. Technical limitations were identified as challenges that must be addressed to enhance the user experience. CONCLUSION Participants acknowledged VR's potential to supplement traditional learning methods, providing safe and realistic exposure to diverse home environments. While VR was seen as beneficial, it was not considered a replacement for actual home visits in community nursing education. CLINICAL EVIDENCE This study provided clinical teaching evidence on the usability and student perceptions of VR in community courses.
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Affiliation(s)
- Justin Fontenot
- LHC Group Myers School of Nursing, University of Louisiana at Lafayette, Lafayette, Louisiana, USA
| | - Michael Hebert
- LHC Group Myers School of Nursing, University of Louisiana at Lafayette, Lafayette, Louisiana, USA
| | - Hung-Chu Lin
- Department of Psychology, University of Louisiana at Lafayette, Lafayette, Louisiana, USA
| | - Arun K Kulshreshth
- School of Computing and Informatics, University of Louisiana at Lafayette, Lafayette, Louisiana, USA
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Bargeri S, Scalea S, Agosta F, Banfi G, Corbetta D, Filippi M, Sarasso E, Turolla A, Castellini G, Gianola S. Effectiveness and safety of virtual reality rehabilitation after stroke: an overview of systematic reviews. EClinicalMedicine 2023; 64:102220. [PMID: 37745019 PMCID: PMC10514431 DOI: 10.1016/j.eclinm.2023.102220] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/22/2023] [Accepted: 09/01/2023] [Indexed: 09/26/2023] Open
Abstract
Background Virtual reality (VR) is an innovative neurorehabilitation modality that has been variously examined in systematic reviews. We assessed VR effectiveness and safety after cerebral stroke. Methods In this overview of systematic reviews, we searched eleven databases (Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, SCOPUS, ISI Web of Science, CINAHL, PsycINFO, Pedro, Otseeker, Healthevidence.org, Epistemonikos) and grey literature from inception to January 17, 2023. Studies eligible for inclusion were systematic reviews published in English that included adult patients with a clinical diagnosis of stroke (acute to chronic phase) undergoing any kind of immersive, semi-immersive or non-immersive VR intervention with or without conventional therapy versus conventional therapy alone. The primary outcome was motor upper limb function and activity. The secondary outcomes were gait and balance, cognitive and mental function, limitation of activities, participation, and adverse events. We calculated the degree of overlap between reviews based on the corrected covered area (CCA). Methodological quality was assessed using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2) and the Certainty of Evidence (CoE) using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Discordances between results were examined using a conceptual framework based on the Jadad algorithm. This overview is registered with PROSPERO, CRD42022329263. Findings Of the 58 reviews included (n = 345 unique primary studies), 42 (72.4%) had conducted meta-analysis. More than half of the reviews (58.6%) were published between 2020 and 2022 and many (77.6%) were judged critically low in quality by AMSTAR 2. Most reported the Fugl Meyer Assessment scale (FMA-UE) to measure upper limb function and activity. For the primary outcome, there was a moderate overlap of primary studies (CCA 9.0%) with discordant findings. Focusing on upper limb function (FMA-UE), VR with or without conventional therapy seems to be more effective than conventional therapy alone, with low to moderate CoE and probable to definite clinical relevance. For secondary outcomes there was uncertainty about the superiority or no difference between groups due to substantial heterogeneity of measurement scales (eg, methodological choices). A few reviews (n = 6) reported the occurrence of mild adverse events. Interpretation Current evidence suggests that multiple meta-analyses agreed on the superiority of VR with or without conventional therapy over conventional therapy on FME-UE for upper limb. Clinicians may consider embedding VR technologies into their practice as appropriate with patient's goals, abilities, and preferences. However, caution is needed given the poor methodological quality of reviews. Funding Italian Ministry of Health.
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Affiliation(s)
- Silvia Bargeri
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | | | - Federica Agosta
- Vita-Salute San Raffaele University, Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe Banfi
- Vita-Salute San Raffaele University, Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Davide Corbetta
- Vita-Salute San Raffaele University, Milan, Italy
- Department of Rehabilitation and Functional Recovery, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Massimo Filippi
- Vita-Salute San Raffaele University, Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Sarasso
- Vita-Salute San Raffaele University, Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health, University of Genoa, Genoa, Italy
| | - Andrea Turolla
- Department of Biomedical and Neuromotor Sciences – DIBINEM, Alma Mater Università di Bologna, Bologna, Italy
- Unit of Occupational Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Greta Castellini
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | - Silvia Gianola
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
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Jicol C, Cheng HY, Petrini K, O’Neill E. A predictive model for understanding the role of emotion for the formation of presence in virtual reality. PLoS One 2023; 18:e0280390. [PMID: 36928040 PMCID: PMC10019638 DOI: 10.1371/journal.pone.0280390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 12/28/2022] [Indexed: 03/18/2023] Open
Abstract
Users' emotions may influence the formation of presence in virtual reality (VR). Users' expectations, state of arousal and personality may also moderate the relationship between emotions and presence. An interoceptive predictive coding model of conscious presence (IPCM) considers presence as a product of the match between predictions of interoceptive emotional states and the actual states evoked by an experience (Seth et al. 2012). The present paper aims to test this model's applicability to VR for both high-arousal and low-arousal emotions. The moderating effect of personality traits on the creation of presence is also investigated. Results show that user expectations about emotional states in VR have an impact on presence, however, expression of this relationship is moderated by the intensity of an emotion, with only high-arousal emotions showing an effect. Additionally, users' personality traits moderated the relationship between emotions and presence. A refined model is proposed that predicts presence in VR by weighting emotions according to their level of arousal and by considering the impact of personality traits.
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McLean E, Cornwell MA, Bender HA, Sacks-Zimmerman A, Mandelbaum S, Koay JM, Raja N, Kohn A, Meli G, Spat-Lemus J. Innovations in Neuropsychology: Future Applications in Neurosurgical Patient Care. World Neurosurg 2023; 170:286-295. [PMID: 36782427 DOI: 10.1016/j.wneu.2022.09.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 02/11/2023]
Abstract
Over the last century, collaboration between clinical neuropsychologists and neurosurgeons has advanced the state of the science in both disciplines. These advances have provided the field of neuropsychology with many opportunities for innovation in the care of patients prior to, during, and following neurosurgical intervention. Beyond giving a general overview of how present-day advances in technology are being applied in the practice of neuropsychology within a neurological surgery department, this article outlines new developments that are currently unfolding. Improvements in remote platform, computer interface, "real-time" analytics, mobile devices, and immersive virtual reality have the capacity to increase the customization, precision, and accessibility of neuropsychological services. In doing so, such innovations have the potential to improve outcomes and ameliorate health care disparities.
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Affiliation(s)
- Erin McLean
- Department of Psychology, Hofstra University, Hempstead, New York, USA; Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Melinda A Cornwell
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - H Allison Bender
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA.
| | | | - Sarah Mandelbaum
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA; Department of Clinical Psychology with Health Emphasis, Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Jun Min Koay
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA; Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida, USA
| | - Noreen Raja
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA; Graduate School of Applied and Professional Psychology, Rutgers University, Piscataway, New Jersey, USA
| | - Aviva Kohn
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA; Department of Clinical Psychology with Health Emphasis, Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York, USA
| | - Gabrielle Meli
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA; Department of Human Ecology, Cornell University, Ithaca, New York, USA
| | - Jessica Spat-Lemus
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
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Huang XT, Wang J, Wang Z, Wang L, Cheng C. Experimental study on the influence of virtual tourism spatial situation on the tourists' temperature comfort in the context of metaverse. Front Psychol 2023; 13:1062876. [PMID: 36687952 PMCID: PMC9846819 DOI: 10.3389/fpsyg.2022.1062876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/30/2022] [Indexed: 01/06/2023] Open
Abstract
The Metaverse is a new application of the internet and social form which integrates a myriad of new technologies. It can not only create a parallel space that is closely connected to the real world while highly independent, but also bring the immersive experience of virtual scenarios without delay. The virtual tourism space situations that integrate realistic visual, audio, and temperature sensations can restore the real tourism environment to the greatest extent, and improve tourists' perception and satisfaction with the experience. The purpose of this experimental lab study is to examine the effects of the virtual tourism audio-visual conditions and environmental temperature on tourists' thermal sensation and temperature comfort. VR equipment and microclimate simulation technology was applied in a 3 × 2 × 2 experimental design (n = 180), simulating the virtual tourism scenarios. Electrocardiogram devices were also employed to assess participants' physiological indicators. Study results suggest that: (1) Virtual tourism spatial situations (environmental temperature and audio-visual conditions) significantly affect participants' thermal sensation and part of the physiological indicators; (2) Virtual tourism spatial situations (environmental temperature and audio-visual conditions) significantly affect participants' temperature comfort; and (3) Physiological responses (indicators) mediate the effect from tourism spatial situations to temperature comfort. The study mainly contributes to the literature about virtual tourism experience and spatial situations under the concept of the Metaverse, as well as provides theoretical and managerial implications for the development of "immersive" virtual tourism scenarios.
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Affiliation(s)
- Xiao-Ting Huang
- Department of Culture and Tourism Management, School of Management, Shandong University, Jinan, Shandong, China
| | - Jiahui Wang
- Isenberg School of Management, University of Massachusetts, Amherst, MA, United States
| | - Zhihui Wang
- Department of Culture and Tourism Management, School of Management, Shandong University, Jinan, Shandong, China
| | - Linqiang Wang
- Department of Culture and Tourism Management, School of Management, Shandong University, Jinan, Shandong, China,*Correspondence: Linqiang Wang, ✉
| | - Chenfei Cheng
- Department of Culture and Tourism Management, School of Management, Shandong University, Jinan, Shandong, China
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Tan J, Kannis-Dymand L, Jones C. Examining the potential of VR program Tilt Brush in reducing anxiety. VIRTUAL REALITY 2022; 27:1-13. [PMID: 36405877 PMCID: PMC9647245 DOI: 10.1007/s10055-022-00711-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 10/09/2022] [Indexed: 06/16/2023]
Abstract
Recent advancement in technology has made virtual reality (VR) more accessible and immersive than ever before, resulting in its increasing utility in various industries. Despite this, VR has remained an underutilised tool within clinical psychology. This study aimed to explore the potential of using VR for therapeutic benefits through examining the level of flow and anxiety-reducing effects of freeform drawing in real life (on paper) versus drawing in VR (using Tilt Brush) via a randomised-controlled trial with 40 participants. State and trait anxiety was measured using the State-Trait Anxiety Inventory, level of flow was measured using the Long Flow State Scale, and level of presence was measured using the iGroup Presence Questionnaire. Overall level of flow was not significantly different between both groups, implying drawing in VR induces as much flow as drawing in real life. Level of flow was positively correlated to level of presence experienced in the VR group (p < .01). Although there was no significant interaction effect, both groups experienced an overall decrease in state anxiety, with the VR group experiencing a significant reduction of state anxiety from pre- to post-test (p < .01).
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Affiliation(s)
- Janice Tan
- School of Health and Behavioural Sciences, University of the Sunshine Coast, Maroochydore, QLD Australia
| | - Lee Kannis-Dymand
- School of Health and Behavioural Sciences, University of the Sunshine Coast, Maroochydore, QLD Australia
| | - Christian Jones
- School of Law and Society, University of the Sunshine Coast, Maroochydore, QLD Australia
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8
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Best P, Meireles M, Schroeder F, Montgomery L, Maddock A, Davidson G, Galway K, Trainor D, Campbell A, Van Daele T. Freely Available Virtual Reality Experiences as Tools to Support Mental Health Therapy: a Systematic Scoping Review and Consensus Based Interdisciplinary Analysis. ACTA ACUST UNITED AC 2021; 7:100-114. [PMID: 34179349 PMCID: PMC8219512 DOI: 10.1007/s41347-021-00214-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 11/29/2022]
Abstract
The primary purpose of this article is to review the potential therapeutic value of freely available VR content as an addition to the practitioners ‘toolkit’. Research has shown that virtual reality (VR) may be useful to extend existing guided imagery-based practices found in traditional mental health therapy. However, the use of VR technology within routine mental health practice remains low, despite recent reductions in equipment costs. A systematic scoping review and interdisciplinary analysis of freely available VR experiences was performed across two popular online databases (SteamVR and Oculus.com). A total of 1785 experiences were retrieved and screened for relevance with 46 meeting the inclusion criteria. VR content was then reviewed for potential therapeutic value by an interdisciplinary panel with experience across a number of therapeutic interventions including cognitive behavioural therapy, Rogerian counselling, mindfulness-based therapies. and family therapy. Eleven (22%) of the 50 freely available VR experiences were reported to have therapeutic potential as tools to support routine mental health therapy. These included support with the following mental health issues—low mood, social anxiety, stress reduction and fear of heights. Guidance of a qualified mental health practitioner was recommended in all cases to maximise the benefit of the VR experiences retrieved. While the quality is variable, freely available VR experiences may contain valuable content that could support mental health therapy. This includes as a homework activity or as an initial setting for case formulation and behavioural experiments.
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Affiliation(s)
- Paul Best
- School of Social Sciences, Education and Social Work, Queen's University, Belfast, Northern Ireland.,The Immersive Technologies and Digital Mental Health Network, Queen's University, Belfast, Northern Ireland
| | - Matilde Meireles
- Sonic Arts Research Centre (SARC), Queen's University, Belfast, Northern Ireland.,The Immersive Technologies and Digital Mental Health Network, Queen's University, Belfast, Northern Ireland
| | - Franziska Schroeder
- Sonic Arts Research Centre (SARC), Queen's University, Belfast, Northern Ireland.,The Immersive Technologies and Digital Mental Health Network, Queen's University, Belfast, Northern Ireland
| | - Lorna Montgomery
- School of Social Sciences, Education and Social Work, Queen's University, Belfast, Northern Ireland.,The Immersive Technologies and Digital Mental Health Network, Queen's University, Belfast, Northern Ireland
| | - Alan Maddock
- School of Social Sciences, Education and Social Work, Queen's University, Belfast, Northern Ireland.,The Immersive Technologies and Digital Mental Health Network, Queen's University, Belfast, Northern Ireland
| | - Gavin Davidson
- School of Social Sciences, Education and Social Work, Queen's University, Belfast, Northern Ireland.,The Immersive Technologies and Digital Mental Health Network, Queen's University, Belfast, Northern Ireland
| | - Karen Galway
- School of Nursing and Midwifery, Queen's University, Belfast, Northern Ireland.,The Immersive Technologies and Digital Mental Health Network, Queen's University, Belfast, Northern Ireland
| | - David Trainor
- Sentireal Ltd, Belfast, Northern Ireland.,The Immersive Technologies and Digital Mental Health Network, Queen's University, Belfast, Northern Ireland
| | - Anne Campbell
- School of Social Sciences, Education and Social Work, Queen's University, Belfast, Northern Ireland.,The Immersive Technologies and Digital Mental Health Network, Queen's University, Belfast, Northern Ireland
| | - Tom Van Daele
- Expertise Unit Psychology, Technology & Society, Thomas More University of Applied Sciences, Antwerp, Belgium.,The Immersive Technologies and Digital Mental Health Network, Queen's University, Belfast, Northern Ireland
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Riva G, Serino S. Virtual Reality in the Assessment, Understanding and Treatment of Mental Health Disorders. J Clin Med 2020; 9:E3434. [PMID: 33114623 PMCID: PMC7693021 DOI: 10.3390/jcm9113434] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 12/21/2022] Open
Abstract
Computer scientists usually describe virtual reality (VR) as a set of fancy hardware and software technologies. However, psychology and neuroscience are starting to consider VR as the most advanced form of human-computer interaction allowing individuals to act, communicate and become present in a computer-generated environment. In this view, the feeling of "being there" experienced during a VR experience can become a powerful tool for personal change: it offers a dynamic and social world where individuals can live and share a specific experience. For this reason, the use of VR in mental health shows promise: different researches support its clinical efficacy for conditions including anxiety disorders, stress-related disorders, obesity and eating disorders, pain management, addiction and schizophrenia. However, more research is needed to transform the promises of VR in a real clinical tool for mental health. This Special Issue aims to present the most recent advances in the mental health applications of VR, as well as their implications for future patient care.
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Affiliation(s)
- Giuseppe Riva
- Humane Technology Lab, Università Cattolica del Sacro Cuore, 20123 Milan, Italy;
- Istituto Auxologico Italiano, IRCCS, U.O. di Neurologia e Neuroriabilitazione, Ospedale S. Giuseppe, 28824 Piancavallo, Italy
| | - Silvia Serino
- Humane Technology Lab, Università Cattolica del Sacro Cuore, 20123 Milan, Italy;
- MySpace Lab, Department of Clinical Neuroscience, University Hospital Lausanne (CHUV), 1011 Lausanne, Switzerland
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Bisso E, Signorelli MS, Milazzo M, Maglia M, Polosa R, Aguglia E, Caponnetto P. Immersive Virtual Reality Applications in Schizophrenia Spectrum Therapy: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E6111. [PMID: 32842579 PMCID: PMC7504018 DOI: 10.3390/ijerph17176111] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 12/16/2022]
Abstract
(1) Background: Virtual Reality (VR) is a fully immersive computer simulated experience consisting of a three-dimensional interactive virtual environment, through a head-mounted display (HMD) and controller. The use of virtual reality has recently been proposed for the treatment of various psychiatric conditions, including the spectrum of schizophrenia. Our review aims to investigate the current available evidence regarding the use of immersive virtual reality in the treatment of psychotic symptoms. (2) Methods: From April 2019 to June 2020, we conducted a systematic review aimed at identifying therapeutic applications in immersive virtual reality for the spectrum of schizophrenia, searching for relevant studies on Web of Science, EMBASE, PsycINFO and CINHAL. (3) Results: We identified a total of 2601 unique records. Of these, 64 full-text articles were assessed for eligibility, and six out of these met the inclusion criteria and were included in the final systematic review. (4) Conclusions: The available data on immersive virtual reality are currently limited due to the few studies carried out on the topic; however, it has demonstrated its effectiveness and versatility in successfully treating various psychotic symptoms including delusions, hallucinations, or cognitive and social skills. Existing literature agrees on safe, tolerable, and long-term persistence of the therapeutic effects obtained by immersive VR. No serious side effects have been reported. In some specific cases, VR therapy was found to be very effective compared to usual treatment, allowing effective drug free interventions, and therefore without side effects for patients, even in those resistant to normal drug therapies.
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Affiliation(s)
- Emanuele Bisso
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University Hospital “Policlinico G.Rodolico - San Marco”, University of Catania, 95123 Catania, Italy;
| | - Maria Salvina Signorelli
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University Hospital “Policlinico G.Rodolico - San Marco”, University of Catania, 95123 Catania, Italy;
| | - Michele Milazzo
- Center for Tobacco Prevention and Treatment, University Hospital “Policlinico G.Rodolico - San Marco”, University of Catania, 95123 Catania, Italy; (M.M.); (M.M.); (R.P.)
| | - Marilena Maglia
- Center for Tobacco Prevention and Treatment, University Hospital “Policlinico G.Rodolico - San Marco”, University of Catania, 95123 Catania, Italy; (M.M.); (M.M.); (R.P.)
- Department of Clinical and Experimental Medicine, Center of Excellence for the acceleration of Harm Reduction (COEHAR), University of Catania, 95123 Catania, Italy
| | - Riccardo Polosa
- Center for Tobacco Prevention and Treatment, University Hospital “Policlinico G.Rodolico - San Marco”, University of Catania, 95123 Catania, Italy; (M.M.); (M.M.); (R.P.)
- Department of Clinical and Experimental Medicine, Center of Excellence for the acceleration of Harm Reduction (COEHAR), University of Catania, 95123 Catania, Italy
| | - Eugenio Aguglia
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University Hospital “Policlinico G.Rodolico - San Marco”, University of Catania, 95123 Catania, Italy;
| | - Pasquale Caponnetto
- Center for Tobacco Prevention and Treatment, University Hospital “Policlinico G.Rodolico - San Marco”, University of Catania, 95123 Catania, Italy; (M.M.); (M.M.); (R.P.)
- Department of Clinical and Experimental Medicine, Center of Excellence for the acceleration of Harm Reduction (COEHAR), University of Catania, 95123 Catania, Italy
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11
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Mann J. The medical avatar and its role in neurorehabilitation and neuroplasticity: A review. NeuroRehabilitation 2020; 46:467-482. [PMID: 32508340 DOI: 10.3233/nre-203063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND One of the most interesting emerging medical devices is the medical avatar - a digital representation of the patient that can be used toward myriad ends, the full potential of which remains to be explored. Medical avatars have been instantiated as telemedical tools used to establish a representation of the patient in tele-space, upon which data about the patient's health can be represented and goals and progress can be visually tracked. Manipulation of the medical avatar has also been explored as a means of increasing motivation and inducing neural plasticity. OBJECTIVE The article reviews the literature on body representation, simulation, and action-observation and explores how these components of neurorehabilitation are engaged by an avatar-based self-representation. METHODS Through a review of the literature on body representation, simulation, and action-observation and a review of how these components of neurorehabilitation can be engaged and manipulated with an avatar, the neuroplastic potential of the medical avatar is explored. Literature on the use of the medical avatar for neurorehabilitation is also reviewed. RESULTS This review demonstrates that the medical avatar has vast potentialities in neurorehabilitation and that further research on its use and effect is needed.
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Affiliation(s)
- Jessie Mann
- Virginia Tech Carilion Fralin Biomedical Research Institute, 2 Riverside Cr., Roanoke, VA 24016, USA. Tel.: + 1-201-423-3434; E-mail:
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Diaz-Orueta U, Blanco-Campal A, Lamar M, Libon DJ, Burke T. Marrying Past and Present Neuropsychology: Is the Future of the Process-Based Approach Technology-Based? Front Psychol 2020; 11:361. [PMID: 32210882 PMCID: PMC7069278 DOI: 10.3389/fpsyg.2020.00361] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 02/17/2020] [Indexed: 01/05/2023] Open
Abstract
A cognitive assessment strategy that is not limited to examining a set of summary test scores may be more helpful for early detection of emergent illness such as Alzheimer's disease (AD) and may permit a better understanding of cognitive functions and dysfunctions in those with AD and other dementia disorders. A revisit of the work already undertaken by Kaplan and colleagues using the Boston Process-Approach provides a solid basis for identifying new opportunities to capture data on neurocognitive processes, test-taking strategies and response styles. Thus, this critical review will combine traditional process-based assessment strategies with support provided or offered by newer technologies that have the potential to add value to data collection and interpretation. There is now considerable interest in neuropsychological test administration using computer/digital technology, both in research and in clinical settings. To add value, any computerized version of an existing cognitive test should respect the administration procedure for which normative data were obtained, should be time-saving in terms of scoring and interpretation, and should, we argue, facilitate gathering information about the processes and strategies followed in test completion. This article will offer an overview of the steps needed when implementing computerization of neuropsychological tests using a Process-Based Approach (PBA) to these technology-based adaptations and will discuss further developments in this area by linking it to future technological developments that may be possible in the area of neuropsychological assessment. Additionally, an overview of neuropsychological tests that may benefit from computerization will be presented, together with suggestions on the specific processes, strategies and features that may be captured with the aid of such computerization. Finally, hypotheses on how virtual reality could be an asset for the future of the PBA to neuropsychological assessment will also be discussed.
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Affiliation(s)
- Unai Diaz-Orueta
- Department of Psychology, Maynooth University, Maynooth, Ireland
| | - Alberto Blanco-Campal
- Department of Psychiatry for the Older Person, Memory Clinic Services, Health Service Executive, Navan and Ardee, Ireland
| | - Melissa Lamar
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL, United States
| | - David J. Libon
- New Jersey Institute for Successful Aging, School of Osteopathic Medicine, Rowan University, Stratford, NJ, United States
| | - Teresa Burke
- School of Psychology, Faculty of Science and Health, Dublin City University, Dublin, Ireland
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Malihi M, Nguyen J, Cardy RE, Eldon S, Petta C, Kushki A. Data-Driven Discovery of Predictors of Virtual Reality Safety and Sense of Presence for Children With Autism Spectrum Disorder: A Pilot Study. Front Psychiatry 2020; 11:669. [PMID: 32903670 PMCID: PMC7438752 DOI: 10.3389/fpsyt.2020.00669] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 06/26/2020] [Indexed: 11/13/2022] Open
Abstract
Virtual reality (VR) offers children with autism spectrum disorder (ASD) an inexpensive and motivating medium to learn and practice skills in a personalized, controlled, and safe setting; however, outcomes of VR interventions can vary widely. In particular, there is a need to understand the predictors of VR experience in children with ASD to inform the design of these interventions. To address this gap, a sample of children with ASD (n=35, mean age: 13.0 ± 2.6 years; 10 female) participated in a pilot study involving an immersive VR experience delivered through a head-mounted display. A data-driven approach was used to discover predictors of VR safety and sense of presence among a range of demographic and phenotypic user characteristics. Our results suggest that IQ may be a key predictor of VR sense of presence and that anxiety may modify the association between IQ and sense of presence. In particular, in low-anxiety participants, IQ was linearly related to experienced spatial presence and engagement, whereas, in high-anxiety participants, this association followed a quadratic form. The results of this pilot study, when replicated in larger samples, will inform the design of future studies on VR interventions for children with ASD.
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Affiliation(s)
- Mahan Malihi
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada.,Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Jenny Nguyen
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada.,Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Robyn E Cardy
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Salina Eldon
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Cathy Petta
- Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
| | - Azadeh Kushki
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada.,Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada
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Pedroli E, Cipresso P, Greci L, Arlati S, Boilini L, Stefanelli L, Rossi M, Goulene K, Sacco M, Stramba-Badiale M, Gaggioli A, Riva G. An Immersive Motor Protocol for Frailty Rehabilitation. Front Neurol 2019; 10:1078. [PMID: 31681149 PMCID: PMC6803811 DOI: 10.3389/fneur.2019.01078] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 09/24/2019] [Indexed: 01/22/2023] Open
Abstract
Frailty is a pre-clinical condition that worsens physical health and quality of life. One of the most frequent symptoms of frailty is an increased risk of falling. In order to reduce this risk, we propose an innovative virtual reality motor rehabilitation program based on an immersive tool. All exercises will take place in the CAVE, a four-screen room with a stationary bike. The protocol will include two types of exercises for the improvement of balance: "Positive Bike" and "Avoid the Rocks." We will choose evaluation scales related to the functional aspects and subjective perception of balance. Our aim is to prove that our innovative motor rehabilitation protocol is as effective as or more effective than classical rehabilitation.
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Affiliation(s)
- Elisa Pedroli
- Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano - Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Pietro Cipresso
- Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano - Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Luca Greci
- Institute of Intelligent Industrial Technologies and Systems for Advanced Manufacturing, National Research Council, Milan, Italy
| | - Sara Arlati
- Institute of Intelligent Industrial Technologies and Systems for Advanced Manufacturing, National Research Council, Milan, Italy
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Lorenzo Boilini
- Department of Geriatrics and Cardiovascular Medicine, Istituto Auxologico Italiano - Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Laura Stefanelli
- Department of Geriatrics and Cardiovascular Medicine, Istituto Auxologico Italiano - Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Monica Rossi
- Department of Geriatrics and Cardiovascular Medicine, Istituto Auxologico Italiano - Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Karine Goulene
- Department of Geriatrics and Cardiovascular Medicine, Istituto Auxologico Italiano - Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Marco Sacco
- Institute of Intelligent Industrial Technologies and Systems for Advanced Manufacturing, National Research Council, Milan, Italy
| | - Marco Stramba-Badiale
- Department of Geriatrics and Cardiovascular Medicine, Istituto Auxologico Italiano - Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Andrea Gaggioli
- Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano - Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Giuseppe Riva
- Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano - Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
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Cano Porras D, Sharon H, Inzelberg R, Ziv-Ner Y, Zeilig G, Plotnik M. Advanced virtual reality-based rehabilitation of balance and gait in clinical practice. Ther Adv Chronic Dis 2019; 10:2040622319868379. [PMID: 31489154 PMCID: PMC6710712 DOI: 10.1177/2040622319868379] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 07/06/2019] [Indexed: 11/16/2022] Open
Abstract
Background Extensive research shows that virtual reality (VR) enhances motor learning and has advantages in balance and gait rehabilitation of neurological patients. There is still uncertainty, however, as for the practicality and efficacy of VR in long-term clinical routine. The objective of this study was to report on 3 years of clinical practice conducting VR-based rehabilitation of balance and gait in a large medical center. Methods This retrospective study systematically analyzed clinical records of patients who received VR-based rehabilitation in a large rehabilitation center during 3 years. We evaluated the effect of VR-based rehabilitation treatments on balance and gait, cognitive dual-task load, patient's balance confidence (ABC-scale) and perception of suitability. Patients were either neurological patients, allocated to five groups: Parkinson's disease (PD), poststroke (PS), multiple sclerosis, traumatic brain injury, and 'other conditions', or non-neurological patients. Results Records of 167 patients were analyzed. The availability of multiple VR systems and environments contributed to highly personalized interventions that tailored specific deficits with therapeutic goals. VR-based rehabilitation significantly improved balance and gait (measured by 10-Meter Walk Test, Timed-Up-and-Go, Berg Balance Scale, and Mini BESTest). Patients with PD and PS decreased dual-task cost while walking. Patients increased balance confidence and deemed VR suitable for rehabilitation. Conclusions Our results suggest that VR-based rehabilitation is practicable and effective in clinical routine. Functional measures of balance and gait show significant improvements following VR-based interventions. Clinical approaches should exploit VR advantages for promoting motor learning and motivation. This study serves to aid transition to long-term clinical implementation of VR.
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Affiliation(s)
- Desiderio Cano Porras
- Center of Advanced Technologies in Rehabilitation, Sheba Medical Center, Ramat Gan, Tel HaShomer, Israel
| | - Hadar Sharon
- Center of Advanced Technologies in Rehabilitation, Sheba Medical Center, Ramat Gan, Tel HaShomer, Israel
| | - Rivka Inzelberg
- Center of Advanced Technologies in Rehabilitation, Sheba Medical Center, Tel HaShomer, Israel
| | - Yitzhak Ziv-Ner
- Department of Orthopedic Rehabilitation, Sheba Medical Center, Tel HaShomer, Israel
| | - Gabriel Zeilig
- Department of Neurological Rehabilitation, Sheba Medical Center, Tel HaShomer, Israel
| | - Meir Plotnik
- Center of Advanced Technologies in Rehabilitation, Sheba Medical Center, Derech Sheba 2, Ramat Gan, Tel HaShomer 52621, Israel
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Abstract
Augmentation reality technology offers virtual information in addition to that of the real environment and thus opens new possibilities in various fields. The medical applications of augmentation reality are generally concentrated on surgery types, including neurosurgery, laparoscopic surgery and plastic surgery. Augmentation reality technology is also widely used in medical education and training. In dentistry, oral and maxillofacial surgery is the primary area of use, where dental implant placement and orthognathic surgery are the most frequent applications. Recent technological advancements are enabling new applications of restorative dentistry, orthodontics and endodontics. This review briefly summarizes the history, definitions, features, and components of augmented reality technology and discusses its applications and future perspectives in dentistry.
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Affiliation(s)
- Ho-Beom Kwon
- Department of Prosthodontics, School of Dentistry, Seoul National University and Dental Research Institute, Seoul, Korea
| | - Young-Seok Park
- Department of Oral Medicine and Oral Diagnosis, School of Dentistry, Seoul National University and Dental Research Institute, Seoul, Korea
| | - Jung-Suk Han
- Department of Prosthodontics, School of Dentistry, Seoul National University and Dental Research Institute, Seoul, Korea
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Pedroli E, Greci L, Colombo D, Serino S, Cipresso P, Arlati S, Mondellini M, Boilini L, Giussani V, Goulene K, Agostoni M, Sacco M, Stramba-Badiale M, Riva G, Gaggioli A. Characteristics, Usability, and Users Experience of a System Combining Cognitive and Physical Therapy in a Virtual Environment: Positive Bike. SENSORS (BASEL, SWITZERLAND) 2018; 18:E2343. [PMID: 30029502 PMCID: PMC6069444 DOI: 10.3390/s18072343] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/16/2018] [Accepted: 07/17/2018] [Indexed: 02/07/2023]
Abstract
We present the architecture and usability evaluation of virtual reality system-"Positive Bike"-designed for improving cognitive and motor conditions in frail elderly patients. The system consists of a cycle-ergometer integrated in an immersive virtual reality system (CAVE) which allows combining motor and cognitive exercises according to a "dual-task" paradigm. We tested the usability and user's experience of the prototype in a pilot evaluation study that involved five elderly patients. The prototype was tested in one-session training to understand the limitations and areas for improvement of our system. The evaluation consisted in (i) usability assessment using the system usability scale; (ii) evaluation of user's engagement using the flow state scale; and (iii) expert evaluation involving interviews with domain experts. Results showed a good usability, both for system usability scale and the semi-structured interview. The level of flow (i.e., enjoyment with the task at hand) measured using the short flow state scale, was also high. Analysis of semi-structured interview carried out with domain experts provided further indications to improve the system. Overall, these findings show that, despite some limitations, the system is usable and provides an enjoyable user's experience.
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Affiliation(s)
- Elisa Pedroli
- Applied Technology for Neuro-Psychology Lab, I.R.C.C.S. Istituto Auxologico Italiano, 20149 Milano, Italy.
| | - Luca Greci
- Industrial Technologies and Automation, Consiglio Nazionale delle Ricerche, 20133 Milano, Italy.
| | - Desirèe Colombo
- Department of Basic Psychology, Clinic and Psychobiology, Universitat Jaume I, Av. Sos Baynat, s/n, 12071 Castellón, Spain.
| | - Silvia Serino
- Applied Technology for Neuro-Psychology Lab, I.R.C.C.S. Istituto Auxologico Italiano, 20149 Milano, Italy.
- Department of Psychology, Università Cattolica del Sacro Cuore, 20123 Milano, Italy.
| | - Pietro Cipresso
- Applied Technology for Neuro-Psychology Lab, I.R.C.C.S. Istituto Auxologico Italiano, 20149 Milano, Italy.
- Department of Psychology, Università Cattolica del Sacro Cuore, 20123 Milano, Italy.
| | - Sara Arlati
- Industrial Technologies and Automation, Consiglio Nazionale delle Ricerche, 20133 Milano, Italy.
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, 20133 Milano, Italy.
| | - Marta Mondellini
- Industrial Technologies and Automation, Consiglio Nazionale delle Ricerche, 20133 Milano, Italy.
| | - Lorenzo Boilini
- Department of Geriatrics and Cardiovascular Medicine, I.R.C.C.S. Istituto Auxologico Italiano, 20149 Milano, Italy.
| | - Valentina Giussani
- Department of Geriatrics and Cardiovascular Medicine, I.R.C.C.S. Istituto Auxologico Italiano, 20149 Milano, Italy.
| | - Karine Goulene
- Department of Geriatrics and Cardiovascular Medicine, I.R.C.C.S. Istituto Auxologico Italiano, 20149 Milano, Italy.
| | - Monica Agostoni
- Nursing Home Monsignor Bicchierai, I.R.C.C.S. Istituto Auxologico Italiano, 20149 Milano, Italy.
| | - Marco Sacco
- Industrial Technologies and Automation, Consiglio Nazionale delle Ricerche, 20133 Milano, Italy.
| | - Marco Stramba-Badiale
- Department of Geriatrics and Cardiovascular Medicine, I.R.C.C.S. Istituto Auxologico Italiano, 20149 Milano, Italy.
| | - Giuseppe Riva
- Applied Technology for Neuro-Psychology Lab, I.R.C.C.S. Istituto Auxologico Italiano, 20149 Milano, Italy.
- Department of Psychology, Università Cattolica del Sacro Cuore, 20123 Milano, Italy.
| | - Andrea Gaggioli
- Applied Technology for Neuro-Psychology Lab, I.R.C.C.S. Istituto Auxologico Italiano, 20149 Milano, Italy.
- Department of Psychology, Università Cattolica del Sacro Cuore, 20123 Milano, Italy.
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Training in a comprehensive everyday-like virtual reality environment compared to computerized cognitive training for patients with depression. COMPUTERS IN HUMAN BEHAVIOR 2018. [DOI: 10.1016/j.chb.2017.10.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Oliveira SMSD, Medeiros CSPD, Pacheco TBF, Bessa NPOS, Silva FGM, Tavares NSA, Rego IAO, Campos TF, Cavalcanti FADC. Electroencephalographic changes using virtual reality program: technical note. Neurol Res 2018; 40:160-165. [DOI: 10.1080/01616412.2017.1420584] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Síria Monyelle Silva de Oliveira
- Laboratory of Virtual Reality and Rehabilitation, Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Candice Simões Pimenta de Medeiros
- Laboratory of Virtual Reality and Rehabilitation, Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Thaiana Barbosa Ferreira Pacheco
- Laboratory of Virtual Reality and Rehabilitation, Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
| | | | - Fernanda Gabrielle Mendonça Silva
- Laboratory of Virtual Reality and Rehabilitation, Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Nathália Stéphany Araújo Tavares
- Laboratory of Virtual Reality and Rehabilitation, Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Isabelle Ananda Oliveira Rego
- Laboratory of Virtual Reality and Rehabilitation, Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Tania Fernandes Campos
- Laboratory of Virtual Reality and Rehabilitation, Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
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Bashiri A, Ghazisaeedi M, Shahmoradi L. The opportunities of virtual reality in the rehabilitation of children with attention deficit hyperactivity disorder: a literature review. KOREAN JOURNAL OF PEDIATRICS 2017; 60:337-343. [PMID: 29234356 PMCID: PMC5725338 DOI: 10.3345/kjp.2017.60.11.337] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/22/2017] [Accepted: 04/11/2017] [Indexed: 11/30/2022]
Abstract
Attention deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in childhood. This disorder, in addition to its main symptoms, creates significant difficulties in education, social performance, and personal relationships. Given the importance of rehabilitation for these patients to combat the above issues, the use of virtual reality (VR) technology is helpful. The aim of this study was to highlight the opportunities for VR in the rehabilitation of children with ADHD. This narrative review was conducted by searching for articles in scientific databases and e-Journals, using keywords including VR, children, and ADHD. Various studies have shown that VR capabilities in the rehabilitation of children with ADHD include providing flexibility in accordance with the patients' requirements; removing distractions and creating an effective and safe environment away from real-life dangers; saving time and money; increasing patients' incentives based on their interests; providing suitable tools to perform different behavioral tests and increase ecological validity; facilitating better understanding of individuals' cognitive deficits and improving them; helping therapists with accurate diagnosis, assessment, and rehabilitation; and improving working memory, executive function, and cognitive processes such as attention in these children. Rehabilitation of children with ADHD is based on behavior and physical patterns and is thus suitable for VR interventions. This technology, by simulating and providing a virtual environment for diagnosis, training, monitoring, assessment and treatment, is effective in providing optimal rehabilitation of children with ADHD.
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Affiliation(s)
- Azadeh Bashiri
- Health Information Management Department, School of Allied-Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Marjan Ghazisaeedi
- Health Information Management Department, School of Allied-Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Shahmoradi
- Health Information Management Department, School of Allied-Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
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Colombo D, Serino S, Tuena C, Pedroli E, Dakanalis A, Cipresso P, Riva G. Egocentric and allocentric spatial reference frames in aging: A systematic review. Neurosci Biobehav Rev 2017; 80:605-621. [DOI: 10.1016/j.neubiorev.2017.07.012] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/29/2017] [Accepted: 07/27/2017] [Indexed: 01/07/2023]
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Rehabilitation Treatment and Progress of Traumatic Brain Injury Dysfunction. Neural Plast 2017; 2017:1582182. [PMID: 28491478 PMCID: PMC5405588 DOI: 10.1155/2017/1582182] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/28/2017] [Accepted: 03/07/2017] [Indexed: 11/17/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of chronic disability. Worldwide, it is the leading cause of disability in the under 40s. Behavioral problems, mood, cognition, particularly memory, attention, and executive function are commonly impaired by TBI. Spending to assist, TBI survivors with disabilities are estimated to be costly per year. Such impaired functional outcomes following TBI can be improved via various rehabilitative approaches. The objective of the present paper is to review the current rehabilitation treatment of traumatic brain injury in adults.
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Riva G, Baños RM, Botella C, Mantovani F, Gaggioli A. Transforming Experience: The Potential of Augmented Reality and Virtual Reality for Enhancing Personal and Clinical Change. Front Psychiatry 2016; 7:164. [PMID: 27746747 PMCID: PMC5043228 DOI: 10.3389/fpsyt.2016.00164] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 09/15/2016] [Indexed: 01/12/2023] Open
Abstract
During life, many personal changes occur. These include changing house, school, work, and even friends and partners. However, the daily experience shows clearly that, in some situations, subjects are unable to change even if they want to. The recent advances in psychology and neuroscience are now providing a better view of personal change, the change affecting our assumptive world: (a) the focus of personal change is reducing the distance between self and reality (conflict); (b) this reduction is achieved through (1) an intense focus on the particular experience creating the conflict or (2) an internal or external reorganization of this experience; (c) personal change requires a progression through a series of different stages that however happen in discontinuous and non-linear ways; and (d) clinical psychology is often used to facilitate personal change when subjects are unable to move forward. Starting from these premises, the aim of this paper is to review the potential of virtuality for enhancing the processes of personal and clinical change. First, the paper focuses on the two leading virtual technologies - augmented reality (AR) and virtual reality (VR) - exploring their current uses in behavioral health and the outcomes of the 28 available systematic reviews and meta-analyses. Then the paper discusses the added value provided by VR and AR in transforming our external experience by focusing on the high level of personal efficacy and self-reflectiveness generated by their sense of presence and emotional engagement. Finally, it outlines the potential future use of virtuality for transforming our inner experience by structuring, altering, and/or replacing our bodily self-consciousness. The final outcome may be a new generation of transformative experiences that provide knowledge that is epistemically inaccessible to the individual until he or she has that experience, while at the same time transforming the individual's worldview.
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Affiliation(s)
- Giuseppe Riva
- Applied Technology for Neuro-Psychology Laboratory, Istituto Auxologico Italiano, Milan, Italy; Centro Studi e Ricerche di Psicologia della Comunicazione, Università Cattolica del Sacro Cuore, Milano, Italy
| | - Rosa M Baños
- Universidad de Valencia, Valencia, Spain; Instituto Salud Carlos III, Ciber Fisiopatología Obesidad y Nutrición (CB06/03), Madrid, Spain; Red de Excelencia PROMOSAM, Mineco, Spain
| | - Cristina Botella
- Instituto Salud Carlos III, Ciber Fisiopatología Obesidad y Nutrición (CB06/03), Madrid, Spain; Red de Excelencia PROMOSAM, Mineco, Spain; Universitat Jaume I, Castelló de la Plana, Spain
| | - Fabrizia Mantovani
- Università degli Studi Milano Bicocca, Dipartimento di Scienze Umane per la Formazione "Riccardo Massa" , Milan , Italy
| | - Andrea Gaggioli
- Applied Technology for Neuro-Psychology Laboratory, Istituto Auxologico Italiano, Milan, Italy; Centro Studi e Ricerche di Psicologia della Comunicazione, Università Cattolica del Sacro Cuore, Milano, Italy
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Pedroli E, Serino S, Cipresso P, Pallavicini F, Riva G. Assessment and rehabilitation of neglect using virtual reality: a systematic review. Front Behav Neurosci 2015; 9:226. [PMID: 26379519 PMCID: PMC4548208 DOI: 10.3389/fnbeh.2015.00226] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/10/2015] [Indexed: 12/13/2022] Open
Abstract
After experiencing a stroke in the right hemisphere, almost 50% of patients showed Unilateral Spatial Neglect (USN). In recent decades, Virtual Reality (VR) has been used as an effective tool both for the assessment and rehabilitation of USN. Indeed, this advanced technology allows post-stroke patients to interact with ecological and engaging environments similar to real ones, but in a safe and controlled way. To provide an overview of the most recent VR applications for the assessment and rehabilitation of USN, a systematic review has been carried out. Since 2010, 13 studies have proposed and tested innovative VR tools for USN. After a wide description of the selected studies, we discuss the main features of these VR tools in order to provide crucial indications for future studies, neurorehabilitation interventions, and clinical practice.
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Affiliation(s)
- Elisa Pedroli
- Applied Technology for Neuro-Psychology Lab, IRCCS Istituto Auxologico Italiano Milan, Italy
| | - Silvia Serino
- Applied Technology for Neuro-Psychology Lab, IRCCS Istituto Auxologico Italiano Milan, Italy
| | - Pietro Cipresso
- Applied Technology for Neuro-Psychology Lab, IRCCS Istituto Auxologico Italiano Milan, Italy
| | - Federica Pallavicini
- Applied Technology for Neuro-Psychology Lab, IRCCS Istituto Auxologico Italiano Milan, Italy
| | - Giuseppe Riva
- Applied Technology for Neuro-Psychology Lab, IRCCS Istituto Auxologico Italiano Milan, Italy ; Department of Psycholgy, Università Cattolica del Sacro Cuore Milan, Italy
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Serino S, Mestre D, Mallet P, Pergandi JM, Cipresso P, Riva G. Do not get lost in translation: The role of egocentric heading in spatial orientation. Neurosci Lett 2015; 602:84-8. [DOI: 10.1016/j.neulet.2015.06.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/04/2015] [Accepted: 06/29/2015] [Indexed: 02/07/2023]
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Serino S, Riva G. How different spatial representations interact in virtual environments: the role of mental frame syncing. Cogn Process 2015; 16:191-201. [DOI: 10.1007/s10339-015-0646-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 01/28/2015] [Indexed: 11/29/2022]
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Parsons TD, Trost Z. Virtual Reality Graded Exposure Therapy as Treatment for Pain-Related Fear and Disability in Chronic Pain. VIRTUAL, AUGMENTED REALITY AND SERIOUS GAMES FOR HEALTHCARE 1 2014. [DOI: 10.1007/978-3-642-54816-1_25] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Grewe P, Kohsik A, Flentge D, Dyck E, Botsch M, Winter Y, Markowitsch HJ, Bien CG, Piefke M. Learning real-life cognitive abilities in a novel 360°-virtual reality supermarket: a neuropsychological study of healthy participants and patients with epilepsy. J Neuroeng Rehabil 2013; 10:42. [PMID: 23618596 PMCID: PMC3637817 DOI: 10.1186/1743-0003-10-42] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 03/25/2013] [Indexed: 11/10/2022] Open
Abstract
Background To increase the ecological validity of neuropsychological instruments the use of virtual reality (VR) applications can be considered as an effective tool in the field of cognitive neurorehabilitation. Despite the growing use of VR programs, only few studies have considered the application of everyday activities like shopping or travelling in VR training devices. Methods We developed a novel 360°- VR supermarket, which is displayed on a circular arrangement of 8 touch-screens – the “OctaVis”. In this setting, healthy human adults had to memorize an auditorily presented shopping list (list A) and subsequently buy all remembered products of this list in the VR supermarket. This procedure was accomplished on three consecutive days. On day four, a new shopping list (list B) was introduced and participants had to memorize and buy only products of this list. On day five, participants had to buy all remembered items of list A again, but without new presentation of list A. Additionally, we obtained measures of participants’ presence, immersion and figural-spatial memory abilities. We also tested a sample of patients with focal epilepsy with an extended version of our shopping task, which consisted of eight days of training. Results We observed a comprehensive and stable effect of learning for the number of correct products, the required time for shopping, and the length of movement trajectories in the VR supermarket in the course of the training program. Task performance was significantly correlated with participants’ figural-spatial memory abilities and subjective level of immersion into the VR. Conclusions Learning effects in our paradigm extend beyond mere verbal learning of the shopping list as the data show evidence for multi-layered learning (at least visual-spatial, strategic, and verbal) on concordant measures. Importantly, learning also correlated with measures of figural-spatial memory and the degree of immersion into the VR. We propose that cognitive training with the VR supermarket program in the OctaVis will be efficient for the assessment and training of real-life cognitive abilities in healthy subjects and patients with epilepsy. It is most likely that our findings will also apply for patients with cognitive disabilities resulting from other neurological and psychiatric syndromes.
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Affiliation(s)
- Philip Grewe
- Physiological Psychology, Bielefeld University, P.O, Box 100131, Bielefeld, D-33501, Germany.
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Reinthal A, Szirony K, Clark C, Swiers J, Kellicker M, Linder S. ENGAGE: Guided Activity-Based Gaming in Neurorehabilitation after Stroke: A Pilot Study. Stroke Res Treat 2012; 2012:784232. [PMID: 22593835 PMCID: PMC3347781 DOI: 10.1155/2012/784232] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 01/12/2012] [Accepted: 02/04/2012] [Indexed: 11/17/2022] Open
Abstract
Introduction. Stroke is a leading cause of disability in healthy adults. The purpose of this pilot study was to assess the feasibility and outcomes of a novel video gaming repetitive practice paradigm, (ENGAGE) enhanced neurorehabilitation: guided activity-based gaming exercise. Methods. Sixteen individuals at least three months after stroke served as participants. All participants received concurrent outpatient therapy or took part in a stroke exercise class and completed at least 500 minutes of gaming. Primary baseline and posttest outcome measures included the Wolf motor function test (WMFT) and the Fugl-Meyer assessment (FMA). ENGAGE uses a game selection algorithm providing focused, graded activity-based repetitive practice that is highly individualized and directed. The Wilcoxon signed ranks test was used to determine statistical significance. Results. There were improvements in the WMFT (P = 0.003) and the FMA (P = 0.002) that exceeded established values of minimal clinically important difference. Conclusions. ENGAGE was feasible and an effective adjunct to concurrent therapy after stroke.
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Affiliation(s)
- Ann Reinthal
- School of Health Sciences, Cleveland State University, 2121 Euclid Avenue, Cleveland, OH 44115, USA
| | - Kathy Szirony
- Rehabilitation and Sports Therapy, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Cindy Clark
- Rehabilitation and Sports Therapy, Lakewood Hospital, 14519 Detroit Road, Lakewood, OH 44107, USA
| | - Jeffrey Swiers
- School of Health Sciences, Cleveland State University, 2121 Euclid Avenue, Cleveland, OH 44115, USA
| | - Michelle Kellicker
- School of Health Sciences, Cleveland State University, 2121 Euclid Avenue, Cleveland, OH 44115, USA
- Rehabilitation and Sports Therapy, Lakewood Hospital, 14519 Detroit Road, Lakewood, OH 44107, USA
| | - Susan Linder
- School of Health Sciences, Cleveland State University, 2121 Euclid Avenue, Cleveland, OH 44115, USA
- Department of Biomedical Engineering, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Park KM, Ku J, Choi SH, Jang HJ, Park JY, Kim SI, Kim JJ. A virtual reality application in role-plays of social skills training for schizophrenia: a randomized, controlled trial. Psychiatry Res 2011; 189:166-72. [PMID: 21529970 DOI: 10.1016/j.psychres.2011.04.003] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2010] [Revised: 01/25/2011] [Accepted: 04/04/2011] [Indexed: 11/17/2022]
Abstract
Although social skills training (SST) is an effective approach for improving social skills for schizophrenia, the motivational deficit attenuates its efficacy. Virtual reality (VR) applications have allowed individuals with mental disabilities to enhance their motivation for rehabilitation. We compared SST using VR role-playing (SST-VR) to SST using traditional role-playing (SST-TR). This randomized, controlled trial included 91 inpatients with schizophrenia who were assigned to either SST-VR (n=46) or SST-TR (n=45). Both groups were administered over 10 semiweekly group sessions. An experienced, blinded rater assessed vocal, nonverbal and conversational skills. We also obtained data on motivation for SST and various social abilities. Throughout the 10 sessions, the SST-VR group (n=33) showed greater interest in SST and generalization of the skills than the SST-TR group (n=31). After SST, the SST-VR group improved more in conversational skills and assertiveness than the SST-TR group, but less in nonverbal skills. The VR application in role-plays of SST for schizophrenia may be particularly beneficial in terms of improving the conversational skills and assertiveness, possibly through its advantages in enhancing motivation for SST and generalization of the skills, and thus it may be a useful supplement to traditional SST.
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Affiliation(s)
- Kyung-Min Park
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea
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Parsons TD, Courtney CG. Neurocognitive and Psychophysiological Interfaces for Adaptive Virtual Environments. ADVANCES IN HEALTHCARE INFORMATION SYSTEMS AND ADMINISTRATION 2011. [DOI: 10.4018/978-1-60960-177-5.ch009] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The use of neuropsychological and psychophysiological measures in studies of patients immersed in high-fidelity virtual environments offers the potential to develop current psychophysiological computing approaches into affective computing scenarios that can be used for assessment, diagnosis and treatment planning. Such scenarios offer the potential for simulated environments to proffer cogent and calculated response approaches to real-time changes in user emotion, neurocognition, and motivation. The value in using virtual environments to produce simulations targeting these areas has been acknowledged by an encouraging body of research. Herein the authors describe (1) literature on virtual environments for neurocognitive and psychophysiological profiles of users’ individual strengths and weaknesses; and (2) real-time adaptation of virtual environments that could be used for virtual reality exposure therapy and cognitive rehabilitation. Specifically, the authors discuss their approach to an adaptive environment that uses the principles of flow, presence, neuropsychology, psychophysiology to develop a novel application for rehabilitative applications.
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Leocani L, Comi E, Annovazzi P, Rovaris M, Rossi P, Cursi M, Comola M, Martinelli V, Comi G. Impaired short-term motor learning in multiple sclerosis: evidence from virtual reality. Neurorehabil Neural Repair 2007; 21:273-8. [PMID: 17351084 DOI: 10.1177/1545968306294913] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Virtual reality (VR) has been proposed as a potentially useful tool for motor assessment and rehabilitation. The objective of this study was to investigate the usefulness of VR in the assessment of short-term motor learning in multiple sclerosis (MS). METHODS Twelve right-handed MS patients and 12 control individuals performed a motor-tracking task with their right upper limb, following the trajectory of an object projected on a screen along with online visual feedback on hand position from a sensor on the index finger. A pretraining test (3 trials), a training phase (12 trials), and a posttraining test (3 trials) were administered. Distances between performed and required trajectory were computed. RESULTS Both groups performed worse in depth planes compared to the frontal (x,z) plane (P < .006). MS patients performed worse than control individuals in the frontal plane at both evaluations (P < .015), whereas they had lower percent posttraining improvement in the depth planes only (P = .03). CONCLUSIONS The authors' VR system detected impaired motor learning in MS patients, especially for task features requiring a complex integration of sensory information (movement in the depth planes). These findings stress the need for careful customization of rehabilitation strategies, which must take into account the patients' motor, sensory, and cognitive limitations.
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Affiliation(s)
- Letizia Leocani
- Department of Neurology, Clinical Neurophysiology and Neurorehabilitation, University Vita-Salute, Scientific Institute Hospital San Raffaele, Milan, Italy.
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