Ebook: Annual Review of Cybertherapy and Telemedicine 2009

Cybertherapy – the provision of healthcare services using advanced technologies – can help improve the lives of many of us, both patients and health professionals, while tackling the challenges to healthcare systems.

Despite the potential of cybertherapy, its benefits and the technical maturity of the applications, the use of cybertherapy services is still limited, and the market remains highly fragmented. Although many countries – including USA, Europe, Korea and Japan – have expressed their commitment to wider deployment of cybertherapy, most cybertherapy initiatives are no more than one-off, small-scale projects that are not integrated into healthcare systems.

It is recognised that integrating these new types of services in healthcare systems is a challenging task. The aim of this book is to support and encourage all the interested countries in this endeavour, by identifying and helping to address the main barriers hindering the wider use of cybertherapy and by providing evidence to build trust and acceptance.

Healthcare systems focus on meeting the needs of patients. Achieving cybertherapy's potential, therefore, depends on patients being convinced of its ability to satisfy their healthcare needs. Acceptance by patients depends crucially on acceptance by the health professionals treating them, given the high degree of trust the former place in the latter.

An important factor for ensuring the confidence and acceptance of health professionals is enhanced dissemination of the evidence base regarding the effectiveness of cybertherapy services, their safety features and user-friendliness.

For the complexity of this goal, we have put a great deal of effort in the definition of the structure of the book and in the sequence of the contributions, so that those in search of a specific reading path will be rewarded. To this end we have divided the different chapters in four main Sections:

1. Critical Reviews: They summarize and evaluate emerging cybertherapy topics, including Interreality, CyberAddiction and Telemedicine;

2. Evaluation Studies: They are generally undertaken to solve some specific practical problems and yield decisions about the value of cybertherapy interventions;

3. Original Research: They presents research studies addressing new cybertherapy methods or approaches;

4. Clinical Observations: They include case studies or research protocols with a long-term potential.

Each chapter begins with a brief abstract, helping the readers in identifying the relationships among its sections.

For both health professionals and patients, the selected contents will play an important role in ensuring that the necessary skills and familiarity with the tools are present, as well as a fair understanding of the context of interaction in which they are operated.

Although some cybertherapy services have existed for a long time and most of the ICT has been in place for a while, the chapters underline different areas where technical and social and ethical issues need to be addressed.

Broadband access and the ability of providers to enable full connectivity is a prerequisite for the deployment of many cybertherapy and telemedicine applications.

Interoperability and standardisation are crucial to allow widespread use of the technologies, to enable them to benefit from the single market and to contribute to its completion. Use of existing standards and adoption of new standards and standardised approaches to achieve interoperability should be supported by standards development organisations, with the active participation of industry.

Trust and confidence in new and innovative technologies and ICT-based services within the health sector need to be built through rigorous testing, agreed standards and a widely accepted certification process. Unfortunately, this is a difficult process that requires time and money. In particular, as underlined by the fourth Section of the book, there are many good ideas and protocols that still need further tuning and research. Promising research areas consist of treatment of addictions, depression, attention deficit disorder, stress management, and social skills training.

In conclusion, this book underlines how cybertherapy has made initial progress in treating a variety of mental health disorders, but there is more work to be done in a number of areas including the development of easy to use and more affordable hardware and software, the development of objective measurement tools, the issue of side effects for some patients, and more controlled studies to evaluate the strength of cybertherapy in comparison to traditional therapies.

Wider dissemination of the technology will encourage the industry to develop tools in response to user needs. Web-based resources for cybertherapy practitioners are currently available and are in continuous development. Input on such topics as clinical protocols, equipment updates and purchases, ethical issues, and the newest research findings will be soon easily accessed using the Internet.

We are also grateful to Alessandra Gorini, Daniel Stevens, Federica Pallavicini and Tatiana Hulko for their work in collecting and coordinating chapters for this volume.

We sincerely hope that you will find this year's volume to be a fascinating and intellectually stimulating read. We continue to believe that together we can change the face of healthcare.

Brenda K. Wiederhold

Giuseppe Riva

“Interreality” is a personalized immersive e-therapy whose main novelty is a hybrid, closed-loop empowering experience bridging physical and virtual worlds. The main feature of interreality is a twofold link between the virtual and the real world: (a) behavior in the physical world influences the experience in the virtual one; (b) behavior in the virtual world influences the experience in the real one. This is achieved through: (1) 3D Shared Virtual Worlds: role-playing experiences in which one or more users interact with one another within a 3D world; (2) Bio and Activity Sensors (From the Real to the Virtual World): They are used to track the emotional/health/activity status of the user and to influence his/her experience in the virtual world (aspect, activity and access); (3) Mobile Internet Appliances (From the Virtual to the Real One): In interreality, the social and individual user activity in the virtual world has a direct link with the users' life through a mobile phone/digital assistant. The different technologies that are involved in the interreality vision and its clinical rationale are addressed and discussed.

Our work is aimed at exploring the recent literature data on web sites, forums, and blogs, which promote eating disorders as normal life styles and their implication in the changes of the psychopatology of such disorders. We also want to understand whether new technologies have an impact in the course of the disorders or, on the other hand, whether they can also represent an instrument for searching help or information about them. The search strategy included a search of PsycINFO, Medline, and Ovid databases to identify research reports about pro-ana sites and their implication on the course of anorexia using the following key words: pro-ana, thinspiration, anorexia-web, online help eating disorders, anorexia nation.

The aim of this work is to propose Intersubjectivity as a key concept in a social interpretation of online dynamics while studying CyberPsychology and its applications. Dialogue is the inner soul of the Self, considered as “a dynamic multiplicity of voiced positions.” The link between the Self and the Others must be considered too. Through dialogue, interlocutors negotiate both ideas and their self-images. Starting from ‘single’ intentions (a representation of what each participant wants to present outside), interactions support a co-construction of shared and linked images of interlocutors, called Subjectivities. These two or more Subjectivities are the basis of the Intersubjective dimension of an interaction.

In the last few years the use of medical and biomedical ontologies has increased considerably. It is very common to find applications and semantic webs using this kind of ontologies and a large number of papers have been written explaining why ontologies are useful in these fields. In this paper the use of ontologies for psychology and its benefits is discussed and a first ontology for obesity treatment is presented.

We give an overview of the Second Life (SL) virtual world, explaining what objects can be manipulated to implement user-defined scenari in SL, and give an example of a work-in-progress scenario of exposure therapy for anxiety disorders, coupled with automatic processing of bio-sensed emotional signals. Both e-Health and emotion recognition researchers can benefit from such experiments.

We explore how avatars can be used as social orthotics defined as therapeutic computer-based social companions aimed at promoting healthy behaviors. We review some of the health interventions deployed in helping at-risk populations along with some of the unique advantages that computer-based interventions can add to face-to-face interventions. We posit that artificial intelligence has rendered possible the creation of culturally appropriate dialog-agents for interventions and we identify specific features for social avatars that are important – if not necessary – when applied to the domain of social orthotic systems for health promotion.

The authors, after a initial description of the “Internet phenomenon” and more specifically concerning the psychological and psychopathological risks related to its use, propose a series of unpublished papers on this theme, developed during the last year.

In recent decades, the rapid development of innovative Internet-based communication technologies created a new field of academic study among scholars. Particularly, the attention of researchers is focusing on new ways to form relationship-thought social web. Social Network sites constitute a new form of web communities, where people meet and share interests and activities. Due to exponential growth of these sites, an increasing number of scholars are beginning to study the emergent phenomena in order to identify any psychopathological risk related to use of social web, such as addiction. This article examines the recent literature about this issue.

Autism spectrum disorders (ASD) are a group of developmental neuropsychiatric disorders, comprised of three diagnostic entities – autistic disorder (AD), Asperger's disorder (AS), and Pervasive Developmental Disorder Not Otherwise Specified (including atypical autism) (PDD-NOS). A number of intervention techniques are currently used to reduce some of the associated challenges, with techniques ranging from behavioral therapy to dietary interventions and traditional counseling. This positional paper proposes the use of video games which leverage affective computing technologies as intervention in autism spectrum disorders in the context of the use of traditional play therapy with adolescents, who may feel uncomfortable engaging in traditional play with toys they may be too old for. It aims to explore the potential for greater ‘social physics’ made possible by affective computing technologies. This involves computationally ‘recognizing’ emotions in a user, often through the use of multimodal affective sensors, including facial expressions, postural shifts, and physiological signals such as heart rate, skin conductivity, and EEG signals. However, it is suggested that this should be augmented by researching the effect of social game design mechanisms on social-emotional development, particularly for those who experience difficulty with social interaction.

The objective of this systematic review was to determine the level of scientific evidence for the effectiveness of VR for pain management in adults with pain. A comprehensive systematic search involving major health care databases was undertaken to identify randomized clinical trials (RCTs) and descriptive studies. Twenty-seven studies were identified that fulfilled the inclusion criteria. There was strong (Level 1a) evidence of a greater benefit from immersive VR and limited evidence (Level 2a) for the effectiveness of non-immersive VR in reducing acute pain. Moreover, there is limited evidence (Level 2a) of effectiveness of immersive VR compared to no VR for reducing chronic pain. There is currently no published study that has explored the effectiveness of non-immersive VR for chronic pain (level 5). It is concluded that VR can be recommended as a standard or adjunct clinical intervention for pain management at least in the management of acute pain.

Recently, several robotic solutions for the elderly have been proposed. However, to date, the diffusion of these devices has been limited: available robots are too cumbersome, awkward, and expensive to become widely adopted. Another key issue which reduces the appeal of assistive robots is the lack of socio-emotional interaction: affective interchanges represent key requirements to create sustainable relationships between elderly and robots. In this paper, we propose a new approach to enhance the acceptability of robotic systems, based on the introduction of affective dimensions in human-robot interaction. This strategy is aimed at designing a new generation of relational and cognitive robots fusing information from embodied unobtrusive sensory interfaces. The final objective is to develop embodied interfaces, which are able to learn and adapt their affective responses to the user's behavior. User and robot will engage in natural interactions, involving verbal and non-verbal communication, improving empathic exchange of moods and feelings. Relevant independent living and quality of life related issues will be addressed: on-going monitoring of health parameters, assistance in everyday's activities, social support and cognitive/physical exercises. We expect that the proposed strategy will enhance the user's acceptance and adoption of the assistive robotic system.

Significant proportion of psychological problems related to combat stress in recent large peacekeeping operations underscores importance of effective methods for strengthening the stress resistance of military personnel. Adaptive control of virtual reality (VR) stimulation, based on estimation of the subject's emotional state from physiological signals, may enhance existing stress inoculation training (SIT). Physiology-driven adaptive VR stimulation can tailor the progress of stressful stimuli delivery to the physiological characteristics of each individual, which is indicated for improvement in stress resistance. Therefore, following an overview of SIT and its applications in the military setting, generic concept of physiology-driven adaptive VR stimulation is presented in the paper. Toward the end of the paper, closed-loop adaptive control strategy applicable to SIT is outlined.

At CT 2007, we presented NeuroVR (http://www.neurovr.org), a free virtual reality platform based on open-source software. The software allows non-expert users to adapt the content of 14 pre-designed virtual environments to the specific needs of the clinical or experimental setting. Following the feedbacks of the 700 users who downloaded the first version, we developed a new version – NeuroVR 1.5 – that improves the possibility for the therapist to enhance the patient's feeling of familiarity and intimacy with the virtual scene, by using external sounds, photos or videos. The key characteristics that make NeuroVR suitable for most clinical applications are the high level of control of the interaction with the tool, and the enriched experience provided to the patient. Actually, NeuroVR is used in the assessment and treatment of Obesity, Alcohol Abuse, Anxiety Disorders, Generalized Anxiety Disorders, and Cognitive Rehabilitation.

Recent work in psychology has leveraged the power of Virtual Reality (VR) to study the deterioration of navigation abilities in the elderly. Much of this research has focused on determining the behavioral measurements and paradigms appropriate for such diagnoses. We present a system, the Spatial Navigation Paradigm (SNaP) framework, which can be used to implement a battery of spatial navigation paradigms. This framework integrates a popular VR environment development platform with an extensible representation medium to allow for the precise control of paradigms, the switching between input and output devices, and the recording of accurate behavioral measurements. A preliminary study of the framework indicates that novice and expert VR users are able to quickly and easily specify and deploy experiments and that expert VR users can easily modify and extend existing paradigm implementations.

This paper presents the development of an Immersive Virtual Technology (IVT) system serving a community of practice consisting of psychotherapists who use virtual environments for therapy and treatment of anxiety disorders. The psychosocial theoretical background includes the ethnomethodological approach, Situated Action Theory and the Intersubjectivity of the Utterance model. The dialogical importance promoted at each level of the analysis phases becomes the key to a deeper and more fluid understanding of the assumptions and meaning that guide the actions of and interactions between therapists and patients. The entire system design process is inspired by a dialogical perspective, which aims to effectively and non-rigidly integrate the design stages, analysis in context of use, ergonomic evaluation, creation of the virtual reality (VR) system, and final work on the clinical protocol in use.

In a few years the Internet has become one of the most relevant means of socialization and entertainment for Italian adolescents. Studies have established a correlation between poor interpersonal relationship, poor cognitive coping strategies and Problematic Internet Use. The aim of the research was to study the characteristics and correlates of Problematic Internet Use in an Italian sample of adolescents. 98 Italian adolescents aged 14-19 were administered checklists assessing Problematic Internet Use, quality of interpersonal relationships, and cognitive-driven coping strategies. Of the participants, 36.7% are characterized by Problematic Internet Use. This subsample showed poorer interpersonal relationships and cognitive coping strategies compared to the non-problematic subsample. Overall quality of interpersonal relationships and cognitive coping strategies were found to be predictors of the level of Internet Problematic Use.

The aim of this study was to investigate the effects on gait induced by a completely immersive Virtual Reality (VR) with and without perturbation. Ten healthy subjects were analyzed during over-ground walking in different conditions: standard gait, VR gait and perturbed VR gait. Results showed that subjects immersed in the virtual environment walked slowly, with decreased cadence (-13%) and stride length (-28%) as well as increased base of support in terms of step width (+20%). The perturbation of the VR caused an interesting effect: many computed parameters, still away from the standard gait condition, improved if compared to the unperturbed VR condition. In conclusion, walking in VR leads to gait instability, which is less pronounced in presence of perturbation, probably due to the reweight of sensory inputs. This study could represent the first step for the application of the proposed VR environment to pathological subjects.

The interactivity and attractiveness of video games are increasingly deployed for educational and training purposes in what are called “serious games.” This paper describes Happy Farm, a serious game targeting young people and aimed at increasing their awareness of the risks connected to the consumption of psychoactive substances. The development of the game is driven by the premise that credibility and usability are pre-conditions for persuasion. The achievement of these qualities is pursued in the design and is generally testified by the results of the users' evaluation. Suggestions for the improvement of the game are also outlined.

Millions of Americans in all age groups are affected by deafness and impaired hearing. They communicate with others using the American Sign Language (ASL). Teaching is tutorial (person-to-person) or with limited video content. We believe that high resolution 3D models and their animations can be used to effectively teach the ASL, with the following advantages over the traditional teaching approach: a) signing can be played at varying speeds and as many times as necessary, b) being 3-D constructs, models can be viewed from diverse angles, c) signing can be applied to different characters (male, female, child, elderly, etc.), d) special editing like close-ups, picture-in-picture, and phantom movements, can make learning easier, and e) clothing, surrounding environment and lighting conditions can be varied to present the student to less than ideal situations.

This research introduces a new addictive behavior in cyberspace, which is called Internet Reply Addiction. This phenomenon was found and empirically investigated in Korea where addictive behavior on Internet reply is common. This research suggests that the cause of this kind of addiction can be inferred from the Confucian cultural tradition that oppresses free expressions of individuals in real life settings.

Blended Reality Space is our term for an interactive mixed-reality environment where the physical and the virtual are intimately combined in the service of interaction goals and communication environments aimed at health support and rehabilitation. The present study examines the effect on rated presence and self-presence of three key factors in the way blended realities may be implemented for these purposes. Our findings emphasize the importance of tangibility for presence, but suggest that presence and self-presence are unrelated phenomena. These findings will be incorporated into design principles for our planned work to develop free movement-based interactions for motor rehabilitation as well as blended-reality spaces for collaboration between hospitals, care organizations, and the home.

People with autism spectrum disorder (ASD) find it difficult to recognize and respond to emotions conveyed by the face. Most existing methodologies to teach people with ASD to recognize expressions use still images, and do not take into account that facial expressions have movement. We propose a new approach that uses state of the art technology to solve the problem and to improve interactivity. It is based on an avatar-user interaction model with real time response, which builds upon the patient-therapist relationship: it is designed to be used by the therapist and the patient. The core technology behind it is based on a technique we have developed for real time facial synthesis of 3D characters.