Ebook: Annual Review of Cybertherapy and Telemedicine 2010

According to the recent “Telemedicine Market Shares, Strategies, and Forecasts, Worldwide, 2010 to 2016” report, presented on March 25th, 2010 by Aarkstore Enterprise Worldwide, telemedicine markets at $7 billion in 2009 are expected to reach $24 billion by 2016. Total healthcare spending worldwide will reach $8.4 trillion. In this context Cybertherapy-the provision of healthcare services using advanced technologies-has the promise of delivering care more adequately to rich and poor people.

As U.S. President Barack Obama underlined in his speech to the American Medical Association, “We are spending over $2 trillion a year on healthcare-almost 50 percent more per person than the next most costly nation. And yet, as I think many of you are aware, for all of this spending, more of our citizens are uninsured, the quality of our care is often lower, and we aren't any healthier. In fact, citizens in some countries that spend substantially less than we do are actually living longer than people in other countries.”

What Obama's statement didn't address is that some portions of the population are healthier. To say that not everyone is treated is not the same as saying that the system does not treat many people very well. Cybertherapy is poised to increase the quality of healthcare delivery and spread its superior healthcare delivery system to a greater portion of the population.

Healthcare delivery systems are moving towards a quantum shift in care delivery. Technology provides new ways to sense and monitor heart disease, inflammation, infection, cancer, diabetic condition, and chronic condition status using technology. This represents a quantum shift in care diagnosis. The old methodologies of patients' verbal descriptions and in-person visual inspections are becoming less important. Monitoring technologies and blood work are being used in combination with imaging and telemetrics to provide a real time, continuous evaluation of patients' conditions.

Moreover, cybertherapy supplements information available from a physical examination by making healthcare delivery more readily available. Cybertherapy is able to supplement traditional care. Cybertherapy is extending monitoring capabilities through the concept of “Interreality” which creates a bridge between the physical and virtual worlds. Using Interreality, cybertherapy is bridging virtual experiences with real experiences using advanced technologies (virtual worlds, advanced sensors and PDA/mobile phones). Therefore, the ability to visualize patient conditions through monitors, sensors, imaging, and biometrics and by adapting their experience through the use of these capabilities changes everything.

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 the U.S., 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 has been recognized that integrating these new types of services into existing healthcare systems is a challenging task. The aim of this volume is to support and encourage all interested countries in this endeavor by identifying and helping to address the main barriers hindering the wider use of cybertherapy and by providing evidence to build trust and acceptance of these practices.

Because of the complexity of this goal, we have put a great deal of effort into the definition of the structure of the volume 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: These chapters summarize and evaluate emerging cybertherapy topics, including technology-enhanced rehabilitation, Interreality, and Intersubjectivity.

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

3. Original Research: These chapters research studies addressing new cybertherapy methods or approaches;

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

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 available, as well as a fair understanding of the context of interaction in which they are operated.

In conclusion, this volume underlines how cybertherapy has made initial progress in treating a variety of disorders. However, 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 need to address potential side effects, and the implementation of more controlled studies to evaluate the strength of cybertherapy in comparison to traditional therapies.

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,

Sun I. Kim

Technology has helped improve rehabilitation programs by providing patients with engaging alternatives to otherwise monotonous and repetitive exercises. In recent years, therapists have looked towards multi-touch technologies to further enhance patient rehabilitation programs. So far, the focus has mainly been on single-user interaction, largely ignoring many of the benefits patients receive from socially interacting with therapists, caregivers and their peers. To make use of these valuable interactions, we have developed a suite of multi-touch activities for motor and cognitive rehabilitation. These applications can easily be adjusted to meet the needs of individual patients and enable therapists to quantitatively measure patient behavior and performance. We also reflect on design-related discussions we had with practicing occupational therapists and provide a set of design considerations to guide future rehabilitation activities.

A change of perspective in online interaction research, shifts attention from technologies to what people actually do online. It's time to study how subjects interact with others and how they ‘take possession’ of virtual environments on a perceptive, emotional and relational plan. This paper illustrates: a) how actors ‘construct’ themselves as subjects facing others during online interactions; b) the relationships actors establish with virtual environments and how actors transform ‘simple’ cyberspaces in cyberplaces; c) how actors – on the basis of a) and b) – ‘bridge the gap’ between them and their interlocutors using communication as a tool to give form to intersubjectivity, intended as an effective relational structure. A research program built around these three issues – both on the theoretical and empirical plan – should become the core of Social Psychology of Cyberplaces as this paper will demonstrate.

A significant proportion of severe psychological problems in recent large-scale peacekeeping operations underscores the importance of effective methods for strengthening the stress resilience. Virtual reality (VR) adaptive stimulation, based on the estimation of the participant's emotional state from physiological signals, may enhance the mental readiness training (MRT). Understanding neurobiological mechanisms by which the MRT based on VR adaptive stimulation can affect the resilience to stress is important for practical application in the stress resilience management. After the delivery of a traumatic audio-visual stimulus in the VR, the cascade of events occurs in the brain, which evokes various physiological manifestations. In addition to the “limbic” emotional and visceral brain circuitry, other large-scale sensory, cognitive, and memory brain networks participate with less known impact in this physiological response. The MRT based on VR adaptive stimulation may strengthen the stress resilience through targeted brain-body interactions. Integrated interdisciplinary efforts, which would integrate the brain imaging and the proposed approach, may contribute to clarifying the neurobiological foundation of the resilience to stress.

The term “psychological stress” describes a situation in which a subject perceives that environmental demands tax or exceed his or her adaptive capacity. According to the Cochrane Database of Systematic Reviews, the best validated approach covering both stress management and stress treatment is the Cognitive Behavioral (CBT) approach. We aim to design, develop and test an advanced ICT based solution for the assessment and treatment of psychological stress that is able to improve the actual CBT approach. To reach this goal we will use the “interreality” paradigm integrating assessment and treatment within a hybrid environment, that creates a bridge between the physical and virtual worlds. Our claim is that bridging virtual experiences (fully controlled by the therapist, used to learn coping skills and emotional regulation) with real experiences (allowing both the identification of any critical stressors and the assessment of what has been learned) using advanced technologies (virtual worlds, advanced sensors and PDA/mobile phones) is the best way to address the above limitations. To illustrate the proposed concept, a clinical scenario is also presented and discussed: Paola, a 45 years old nurse, with a mother affected by progressive senile dementia.

In recent years, videogames have demonstrated their positive effects in the psychological treatments and cognitive training of the old population. In this paper we present a pilot study in which a group of elderly people in an old people's home was requested to play a set of cognitive tasks administered through a popular videogames console, the Nintendo Wii^®. The results obtained by comparing the Wii^® cognitive games with traditional paper and pencil tests are described and discussed to orient further improvements.

In this experimental study, we present the results of user motor responses with and without the use of Tracking Feedback to complete correct movements in Virtual Rehabilitation Therapy. To carry out this study, we used a VRT system for standing balance rehabilitation. We applied it under two different conditions to twenty patients (with and without tracking feedback). We then analyzed their motor responses. By means of this analysis, we have confirmed the importance of Tracking Feedback in the achievement of rehabilitation goals. We also tested the possibility of eliminating the tracking components from the system to lower cost to make the integration of Virtual Rehabilitation systems available to more patients. Our results indicate that is currently not feasible.

Generalized anxiety disorder (GAD) is a common anxiety disorder characterized by 6 months of “excessive anxiety and worry” about a variety of events and situations. Anxiety and worry are often accompanied by additional symptoms like restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension and disturbed sleep. GAD is usually treated with medications and/or psychotherapy. In particular, the two most promising treatments seem to be cognitive therapy and applied relaxation. In this study we integrated these approaches through the use of a biofeedback enhanced virtual reality (VR) system used both for relaxation and controlled exposure. Moreover, this experience is strengthened by the use of a mobile phone that allows patients to perform the virtual experience even in an outpatient setting. This paper describe the results of a controlled trial (NCT00602212) involving 20 GAD patients randomly assigned to the following groups: (1) the VR and Mobile group (VRMB) including biofeedback; (2) the VR and Mobile group (VRM) without biofeedback; (3) the waiting list (WL) group. The clinical data underlined that (a) VR can be used also in the treatment of GAD; (b) in a VR treatment, patients take advantage of a mobile device that delivers in an outpatient setting guided experiences, similar to the one experienced in VR.

Previous research suggests that negative mood increases body image disturbances. The aim of this study was to examine whether the mood produced by virtual reality exposure had any influence on such disturbances. As expected, dysphoric mood increased body image disturbances in patients with eating disorders.

Self-monitoring techniques, such as the use of dietary registers, are considered to be central to cognitive-behavioral treatment of Eating Disorders (ED). This information allows the clinician to identify the triggers of the behaviors associated to ED as purges and/or binges, and the associated thoughts and emotions, helping to carry out a more accurate assessment. Traditionally these registers are made with paper and pencil mode, where the patient has to register every eating and the emotions/thoughts associated; but this system has some problems, as low portability, low adherence or methodological difficulties. The use of PDA for self-registers can help to solve these problems. The aim of this study is to study the levels of acceptability and satisfaction with PDAs self-register system specifically designed for assessment and treatment of ED. Samples of 30 subjects diagnosed with ED are receiving a PDA with software specifically designed for recording type and amount of food, emotions before and after eating and other behaviors. The participants are completing self-register daily during a week, and afterwards answer an acceptance and satisfaction questionnaire. This work is in progress at the moment. It is expected that the PDA system will show high levels of acceptance and satisfaction.

Background: Epidemiological studies indicated that compulsive ordering and arranging, and a preoccupation with symmetry are common presentations of obsessive-compulsive disorder (OCD). Objective: The goal of the current study was to develop and obtain preliminary psychometric data for the objective and quantitative measurement of symmetry and arrangement symptoms in OCD. Method: Twenty-eight normal volunteers were administered computer based assessment tasks with 4 different conditions with or without target and distraction. Primary dependent variables included several indices of time and click of arranging behaviors. Construct validity for the task was examined by comparing the novel behavioral measures with standardized measures such as Symmetry, Ordering and Arranging Questionnaire (SOAQ), Obsessive Compulsive Inventory-Revised (OCI-R), Beck depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Quality of life scale (QOL). Result: We found significant positive correlation between behavioral parameters and standardized scales for OCD (total time and SOAQ: r²=0.623, P<0.001; total number of clicks and ‘ordering’ subscore of OCI-R: r²=0.541, P<0.01). There was no significant correlation between behavioral parameters and other scales measuring constructs less relevant to ordering and arranging. A main effect of target only was observed on behavioral parameters. Conclusion: This study therefore provides preliminary data to support the use of this task as a novel behavioral measure of compulsive symptoms related with symmetry, ordering and arranging.

Empirical studies have consistently shown the effectiveness of a multicomponent CBT treatment of social anxiety disorder (SAD). Previous outcome studies on virtual reality and SAD have focused on people suffering from fear of public speaking and not full blown SAD. In this study, 45 adults receiving a DSM-IV-TR diagnostic of social anxiety were randomly assigned to traditional CBT treatment (with in vivo exposure), CBT-VR combined treatment, or a waiting list. Results show significant reduction of anxiety on all questionnaires as well as statistically significant interactions between both treatment groups and the waiting list.

eBaViR is a virtual rehabilitation system, which has been developed for balance rehabilitation for patients suffering from acquired brain injury. It is a game-based system that uses a low-cost interface, the Nintendo Wii Balance Board. The games have been specifically designed with the help of experts in the rehabilitation of balance disorders and can be adapted to patients according to their needs. We present an experimental study that has been carried out using the system. The aim of the study is to determine whether this setup could be applied as a Virtual Rehabilitation System for balance rehabilitation in Acquired Brain Injury. We randomly divided patients into two groups: a trial group and a control group. The trial group used eBaViR system during the rehabilitation sessions, and the control group followed traditional rehabilitation sessions. We obtained encouraging results.

The article presents the results of post-stroke rehabilitation of patients with brain dysfunctions causing cognitive impairments such as problems with concentrating, reasoning, logical thinking, and memory. Some of those patients suffered from various forms of aphasia as well. The holistic rehabilitation of the stroke patients was aided by specially designed computer systems offering an array of varied multimedia tasks. The research results presented below confirm the usability of the suggested method.

Exposure to phobic stimuli in subjects with specific phobia typically results in increased anxiety, ranging from mild to severe, followed by gradual habituation. The Internet is a candidate medium for the delivery of phobic stimuli to phobic subjects, such as pictures, video clips or computer animations. Delivery of such images in home settings warrants careful attention to the range and time course of anxiety responses elicited, and to tailoring of progression through hierarchies of images. The agency of the user is paramount, they need to have the final say at all stages of exposure as to whether to proceed or not. We have incorporated solutions to these requirements in the design of an internet-based exposure program (FEARDROP). This employs a database repository of pictures and videos of phobic stimuli. Images are called up by the user engaging a tracking circle with their mouse and following it around the screen. The image fades out if the circle is not followed, a form of ‘dead man's brake’. Anxiety responses are measured at intervals on a visual analogue scale and graphed for the user. Initial results show substantial habituation to spider pictures within minutes, with a controlled comparison to video images in progress.

The efficacy of cognitive-behavioral therapy for panic disorder and agoraphobia (PDA) has been widely demonstrated. The exposure technique is the main component of these programs; interoceptive exposure also plays an important role. The virtual reality (VR) program for treating PDA developed by Botella's group can simulate physical sensations in a controlled manner while the user is immersed in the VR environments in the consultation room. These include audible effects, such as rapid heartbeat and panting, as well as visual effects, such as blurry vision, double vision and tunnel vision. This work examines the efficacy of the interoceptive exposure (IE) component in two treatment conditions: 1) VR Interoceptive Exposure Simultaneous Condition (VRIE-sim; N=14), and 2) Interoceptive Exposure Traditional Condition (IET; N=15). Results obtained showed that both treatment conditions significantly reduced the main clinical variables at post-treatment; these results were maintained or even improved at three month follow-up. Simultaneous VR interoceptive and VR external stimuli exposure is a new and effective way to apply PDA treatment.

Poorly managed anger responses can be detrimental to one's physical and psychosocial well-being. Cognitive behavior therapies (CBT) have been found to be effective in treating anger disorders. A key component of CBT treatment is exposure to the anger arousing stimuli. Virtual reality (VR) environments can elicit potent reactions and may facilitate the treatment of anger. An anger VR environment with six video vignettes was developed by this study to examine the anger arousal potential of VR. Outcome measures included assessment of emotional reactivity, state anger, and presence. The results showed that significant anger arousal occurred during exposure to the VR environment, and arousal was greater when viewed in an immersive HMD than a non-immersive flat screen. In addition, presence was found to moderate the effects of VR. Low presence resulted in low reactivity regardless of the display modality.

Simulated immersive environments displayed on large screens are a valuable therapeutic asset in the treatment of a range of psychological disorders. Permanent environments are expensive to build and maintain, require specialized clinician training and technical support and often have limited accessibility for clients. Ideally, virtual reality exposure therapy (VRET) could be accessible to the broader community if we could use inexpensive hardware with specifically designed software. This study tested whether watching a handheld non-immersive media device causes nausea and other cybersickness responses. Using a repeated measure design we found that nausea, general discomfort, eyestrain, blurred vision and an increase in salivation significantly increased in response to handheld non-immersive media device exposure.

In Parkinson's disease executive functions are altered. We used a Virtual Reality version of the Multiple Errand Test in order to evaluate decision-making ability in 12 patients and 14 controls. Patients with Parkinson's disease, even if not-demented, showed strategies full of errors, suggesting that impulse control disorder, very frequent in course of disease, could precede cognitive dysfunctions.

We explored the impact of an interactive VR environment on pain cognitions (in vivo catastrophizing and pain self-efficacy) and pain-related measures: pain threshold, pain tolerance, Pain Sensitivity Range (PSR), pain intensity and time estimation in a sample of healthy students. Sense of presence is essential to conduct a psychological treatment; if patients are not able to involve themselves in a virtual world they cannot experience relevant emotions, and the desired processes that are necessary for most psychological treatments will not occur. However, some authors argue that presence must be distinguished from the degree of engagement, involvement in the portrayed environment. The results obtained in our study are consistent with this view, since the Involvement scale of the IPQ did not correlate with any of the measures related with the treatment's efficacy.

Transcranial Doppler is a tool to measure blood flow velocity (BFV) in the main arteries of the brain that has been used in previous studies to analyze brain activity during virtual reality (VR) experiences. Increments in BFV were found during the exposure to virtual environments in comparison with baseline periods. However, due to the complexity of VR experiences, there are several factors that can be having an influence in these variations, so it is necessary to separately analyze those different aspects. In this work, we summarize our results related to visual perception. A method based on spectral analysis was used to analyze the magnitude and temporal evolution of the maximum BFV signal. Results showed that, in the presence of visual stimuli, BFV quickly rises to a maximum that is achieved after a few seconds. The contribution of the visual stimuli factor to the observed BFV variations during a VR experience can be estimated from the results of the developed work.

The present paper is aimed at analyzing the process of building and programming robots as a metacognitive tool. Quantitative data and qualitative observations from a research performed in a sample of children attending an Italian primary school are described in this work. Results showed that robotics activities may be intended as a new metacognitive environment that allows children to monitor themselves and control their learning actions in an autonomous and self-centered way.