Ebook: Virtual Reality in Neuro-Psycho-Physiology

What is Virtual Reality? Virtual reality is a new technology that alters the way individuals interact with computers. In fact, it can be defined as a set of computer technologies which, when combined, provide an interface to a computer-generated world. In particular it provides such a convincing interface that the user believes he is actually in a three dimensional computer-generated world. A virtual environment is a virtual reality application that lets users navigate and interact with a three-dimensional, computer generated (and computer-maintained) environment in real time.

A key feature of a virtual environment is that the user believes that he is actually in this different world. This is accomplished by immersing the person's senses using a head-mounted display or some other immersive display device. A second key feature of Virtual Reality is that if the user moves his head, arms or legs, the shift of visual cues must be those he would expect in a real world. In other words, besides immersion, in a virtual world we have navigation and interaction.

Although virtual reality is mature enough to have different medical applications, the common use of this technology outside the surgical field is actually limited due to different problems:

• Many of the available products seems to be “a solution in search of a problem”. As with early computer graphics products, the entry-level costs are relatively prohibitive. Although some attempts have been made to use PC-based virtual reality systems, the majority of the existing systems use RISC platforms whose cost is beyond the means of a normal Hospital or Department. A complete VR environment, including workstations, goggles, body suits, and software, ranges from $40.000 to $1.000.000;

• The hyperbole and sensational press coverage associated with this technology has led many potential users to overestimate the actual capabilities of existing systems. Almost all of the applications in this sector can be considered “one-off” creations tied to their development hardware and software, which have been adjusted in the field by a process of trial and error. This makes them difficult to use in contexts other than those in which they were developed. Unless their expertise includes knowledge of the human-machine interface requirements for their application, their resulting product will rarely get beyond a “conceptual demo” that lacks practical utility;

• Although it is theoretically possible to use a single virtual reality system for many different applications, none of the existing systems can be easily adapted to different tasks. This means that two different wards/departments within the same organization may find themselves having to use two different VR systems because of the impossibility of adapting one single system to their different needs;

• Fundamental questions remain about how people interact within a virtual environment and how they can best be employed for instruction, training, assessment, rehabilitation and other clinical oriented applications.

To create successful health care applications with today's virtual environments, we must begin by asking: what are they good at? This book offers an answer to its possible readers - physicians, psychologists and health care provider - by presenting an overview of the current research in this field. Infact the book, whose idea comes from the work made within the EC funded Virtual Reality Environments for Psycho-neuro-physiological Assessment and Rehabilitation VREPAR - project, (HC 1053 - http://www.etho.be/ht_projects/vrepar/), is a collection of chapters from researchers who have pioneered the ideas and the technology associated with virtual reality. More in particular, the book discuss the clinical principles, human factors, and technological issues associated with the use of virtual reality for assessment and treatment.

It should be noted that technical characteristics of virtual worlds change very rapidly; but what will not change is the user of a virtual environment. Thus, to ensure that the contents of this book is not quickly updated, all the contributors have made a great effort to identify possible constraints in the use of this technology and to indicate how they can be faced and solved. The key issue was to integrate knowledge of clinical therapy and psychological principles related to human factors into the design of virtual environments.

The book is divided in three main sections comprising 13 chapters overall: virtual reality for health care, virtual reality for psychological assessment and rehabilitation and virtual reality for neuro-physiological assessment and rehabilitation.

The first section of the book contains two chapter written to provide a broad introduction to the use of virtual reality in health care. The two chapters provide basic definition and background material which thus sets the stage for future chapters. Specifically, Chapter 1, written by Moline, surveys the current applications of virtual environments for health care: surgical procedures (remote surgery or telepresence, augmented or enhanced surgery, and planning and simulation of procedures before surgery); medical therapy; preventive medicine and patient education; medical education and training; visualization of massive medical databases; skill enhancement and rehabilitation; and architectural design for healthcare facilities. Chapter 2, by Lewis and Griffin, provides an excellent overview of the human factors involved in the virtual experience. The authors also identified specific factors which are likely to affect the incidence of side-effects during and after exposures, and which need to be understood in order to minimize undesirable consequences.

The second section of the book provides information on the possible application of virtual environments for psychological assessment and rehabilitation. Chapter 3 and 4 offer a broad introduction to the research in this field. In Chapter 3 M. North, S. North, and Coble describe the Virtual Reality Therapy (VRT), a new therapeutic approach that can be used to overcome some of the difficulties inherent in the traditional treatment of phobias. The chapter also describes how to use virtual reality in the treatment of specific phobias: fear of flying, fear of heights, fear of being in certain situations, and fear of public speaking. Chapter 4, written by me, describes the context of current psychological assessment and underlines possible advantages of a VR based assessment tool. The chapter also details the characteristics of BIVRS, Body Image Virtual Reality Scale, an assessment tool designed to assess cognitive and affective components of body image. The remaining four chapters discuss specific applications of virtual reality: for the treatment of Autism (Chapter 5 by Strickland), for the palliative care of cancer (Chapter 6 by Oyama), for the treatment of body image disturbances (Chapter 7 by me and Melis) and to diagnose and treat patients with psychological and psychiatrical difficulties (Chapter 8 by Hirose, Kijima, Shirakawa and Nihei).

The last section of the book contains five chapters that focus on the current applications of virtual environments in neuro-physiological assessment and rehabilitation. Chapter 9 and 10 define the rationale for the possible application of virtual reality in this field. Specifically, Chapter 9, written by Rizzo and Buckwalter, provide an introduction to the basic concepts of neuro-psychological assessment and cognitive rehabilitation, along with rationales for virtual reality's applicability in these complimentary fields. The authors review the relevant literature regarding theoretical and pragmatic issues for these applications and provide references for further reading. In Chapter 10 Rose, Attree and Brooks describe the new opportunities offered by virtual reality to pursue several aspects of the rehabilitation process. The value of the technology of virtual environments in this context is that it allows the clinicians to immerse people with brain damage in relatively realistic interactive environments which, because of their patterns of impairment, would otherwise be unavailable to them. Finally, in the last chapters are presented many different applications of virtual reality: for the treatment of hemiparesis, unilateral neglect and cerebral palsy (Chapter 11 by Wann, Rushton, Smyth and Jones), for the quantitative analysis of neuromotor diseases (Chapter 12 by Rovetta, Lorini and Canina) and for the therapy of multiple sclerosis and spinal cord injury (Chapter 13 by Steffin).

In the end I want to thank and Carlo Galimberti, Enrico Molinari and Eugenia Scabini for supporting me right from the early days and for turning a blind eye when it was needed. My thanks also go to Luca Melis who spent with me much time and effort to tune-up our VR system. Thanks also to Paolo Mardegan and Cristina Selis who helped me during the last year.

My gratitude goes to my bosses and colleagues al Istituto Auxologico Italiano, one of the leading health care center in Italy and the most important European in-patients center for the treatment of eating disorders, for believing in the possibility of the clinical use of virtual reality and for supporting me in this exciting adventure. Finally I want to dedicate this book to the memory of Giuseppe Girotti, a great man and my first mentor.

I hope that the contents of this book will stimulate additional research on cognitive and human factors related to the virtual experience and on how best use virtual environments in psychology and medicine. In particular I hope that the European Community, that strongly supported the VREPAR project, will keep on in helping European research in this demanding field.

Giuseppe Riva

Istituto Auxologico Italiano Applied Technology for Psychology Lab. Verbania, Italy

May 1997

This report surveys the state of the art in applications of virtual environments and related technologies for health care. Applications of these technologies are being developed for health care in the following areas: surgical procedures (remote surgery or telepresence, augmented or enhanced surgery, and planning and simulation of procedures before surgery); medical therapy; preventive medicine and patient education; medical education and training; visualization of massive medical databases; skill enhancement and rehabilitation; and architectural design for health-care facilities. To date, such applications have improved the quality of health care, and in the future they will result in substantial cost savings. Tools that respond to the needs of present virtual environment systems are being refined or developed. However, additional large-scale research is necessary in the following areas: user studies, use of robots for telepresence procedures, enhanced system reality, and improved system functionality.

Virtual reality environments have many potential applications in medicine, including surgical training, tele-operated robotic surgery, assessment and rehabilitation of behavioural and neurological disorders and diagnosis, therapy and rehabilitation of physical disabilities.

Although there is much potential for the use of immersive virtual reality environments in clinical applications, there are problems which could limit their ultimate usability. Some users have experienced side-effects during and after exposure to virtual reality environments. The symptoms include ocular problems, disorientation and balance disturbances, and nausea. Susceptibility to side-effects can be affected by age, ethnicity, experience, gender and physical fitness, as well as the characteristics of the display, the virtual environment and the tasks.

The characteristics of the virtual reality system have also been shown to affect the ability of users to perform tasks in a virtual environment. Many of these effects can be attributed to delays between the sampling of head and limb positions and the presentation of an appropriate image on the display.

The introduction of patients to virtual reality environments, for assessment, therapy or rehabilitation, raises particular safety and ethical issues. Patients exposed to virtual reality environments for assessment and rehabilitation may have disabilities which increase their susceptibility to certain side-effects. Special precautions therefore need to be taken to ensure the safety and effectiveness of such virtual reality applications.

These precautions include minimisation of possible side-effects at the design stage. Factors are identified which are likely to affect the incidence of side-effects during and after exposures, and which need to be understood in order to minimise undesirable consequences. There is also a need for the establishment of protocols for monitoring and controlling exposures of patients to virtual reality environments. Issues are identified which need to be included in such protocols.

Behavioral therapy techniques for treating phobias often includes graded exposure of the patient to anxiety-producing stimuli (Systematic Desensitization). However, in utilizing systematic desensitization, research reviews demonstrate that many patients appear to have difficulty imagining the prescribed anxiety-evoking scene. They also express strong aversion to experiencing real situations.

This chapter describes the Virtual Reality Therapy (VRT), a new therapeutical approach that can be used to overcome some of the difficulties inherent in the traditional treatment of phobias. VRT, like current imaginal and in vivo modalities, can generate stimuli that could be utilized in desensitization therapy. Like systematic desensitization therapy, VRT can provide stimuli for patients who have difficulty in imagining scenes and/or are too phobic to experience real situations. Unlike in vivo systematic desensitization, VRT can be performed within the privacy of a room, thus avoiding public embarrassment and violation of patient confidentiality. VRT can generate stimuli of much greater magnitude than standard in vivo techniques. Since VRT is under patient control, it appears safer than in vivo desensitization and at the same time more realistic than imaginal desensitization. Finally, VRT adds the advantage of greater efficiency and economy in delivering the equivalent of in vivo systematic desensitization within the therapist's office.

The chapter also describes how to use virtual reality in the treatment of specific phobias: fear of flying, fear of heights, fear of being in certain situations (such as a dark barn, an enclosed bridge over a river, and in the presence of an animal [a black cat] in a dark room), and fear of public speaking.

Virtual environments (VEs), offering a new human-computer interaction paradigm, have attracted much attention in clinical psychology, especially in the treatment of phobias. However, a possible new application of VR in psychology is as assessment tool: YEs can be considered as an highly sophisticated form of adaptive testing. This chapter describes the context of current psychological assessment and underlines possible advantages of a VR based assessment tool.

The chapter also details the characteristics of BIVRS, Body Image Virtual Reality Scale, an assessment tool designed to assess cognitive and affective components of body image. It consists of a non-immersive 3D graphical interface through which the patient is able to choose between 9 figures of different size which vary in size from underweight to overweight. The software was developed in two architectures, the first (A) running on a single user desktop computer equipped with a standard virtual reality development software and the second (B) splitted into a server (B1) accessible via Internet and actually running the same virtual ambient as in (A) and a VRML client (B2) so that anyone can access the application.

Autism is a mental disorder which has received attention in several unrelated studies using virtual reality. One of the first attempts was to diagnose children with special needs at Tokyo University using a sandbox playing technique. Although operating the computer controls proved to be too difficult for the individuals with autism in the Tokyo study, research at the University of Nottingham, UK, is successful in using VR as a learning aid for children with a variety of disorders including autism. Both centers used flat screen computer systems with virtual scenes.

Another study which concentrated on using VR as a learning aid with an immersive headset system is described in detail in this chapter. Perhaps because of the seriousness of the disorder and the lack of effective treatments, autism has received more study than attention deficit disorders, although both would appear to benefit from many of the same technology features.

We have been developing a VR system to provide patients with emotional support and to encourage them to assume an active life against cancer, since patients with an active lifestyle survive longer than those with a passive lifestyle. A possible explanation for this latter fact is that psychological stimulation may also activate the endocrine system and the immune system. Both systems may be able to rapidly repair tissue damaged by cancer and change the characteristics of the cancer itself. Although microelectrical analysis and molecular and genetic analyses are rapidly solving the riddles of the relationship between the brain and thought, we think that our VR research for palliative medicine may also play an important role in this area with regard to the development of new tools for treatment and support.

This notion is based on the hypothesis that the brain can reorganize itself to compensate for irrationality or inappropriateness through pharmacological adaptation and/or anatomical regeneration of synapses. Another reason why VR research in palliative medicine is useful is that VR techniques represent not only an enhanced human-machine interface, but also an enhanced human communication technology.

VR technology may also be used to help patients accept their disease. The mental state of a patient in the terminal stage of cancer changes step by step from denial of cancer, hope for a new treatment for cancer, suspicion of medical treatment, uneasiness regarding their future life, irritation, depression, and acceptance or despair. We plan to develop a new type of counseling system in medical cyberspace to provide mental care. It can also be used for group therapy or humor therapy to reduce loneliness. In summary, we conclude that VR technology can be applied to palliative medicine (1) to support communication between the patient and others, (2) to provide psychological support to treat neurosis and help to stabilize the patient's mental state, and (3) to actually treat cancer.

This chapter describes the characteristics and preliminary evaluation of The Virtual Environment for Body Image Modification (VEBIM), a set of tasks aimed at treating body image disturbances and body dissatisfaction associated with eating disorders. Two methods are commonly used to treat body image: (1) a cognitive/behavioural therapy to influence patients' feelings of dissatisfaction; (2) a visual/motorial therapy with the aim of influencing the level of bodily awareness. VEBIM tries to integrate these two therapeutic approaches within an immersive virtual environment. This choice would not only make it possible to intervene simultaneously on all of the forms of bodily representations, but also to use the psycho-physiological effects provoked on the body by the virtual experience for therapeutic purposes. The chapter, together with the description of the VEBIM theoretical approach, it also presents a study on two preliminary samples (71 normal subjects, uncontrolled study, 48 normal subjects, controlled study) to test its efficacy.

The sand play technique has often been used in psychological treatments or in the diagnosis of autism patients. In this paper, the prototype application called “virtual sand box” is developed as a virtual environment to support this technique. Experimental results show the advantages of applying virtual reality technology to clinical medicine; particularly with respect to the diagnosis of people with psychological and psychiatrical difficulties such as autism and neurosis. The actual system has been implemented by using a graphics workstastion, a wide-view filed display, and 3D input devices.

VR offers the potential to develop human testing and training environments that allow for the precise control of complex stimulus presentations in which human cognitive and functional performance can be accurately assessed and rehabilitated. However, basic feasibility issues need to be addressed in order for this technology to be reasonably and efficiently applied to the neuropsychological assessment (NA) and cognitive rehabilitation (CR) of persons with acquired brain injury and neurological disorders. This chapter will provide an introduction to the basic concepts of neuropsychological assessment and cognitive rehabilitation along with rationales for virtual reality's applicability in these complimentary fields. We review the relevant literature regarding theoretical and pragmatic issues for these applications, and provide a description of our ongoing work developing a mental rotation/spatial skills cognitive assessment and training system. References are provided in each section for further reading in each area reviewed.

Brain damage constitutes a major problem for those affected, for their families and friends and for society as a whole. The need for effective rehabilitation strategies is clear. Yet, until the early 1960s, the brain was generally considered to be a somewhat fixed and inflexible organ. In consequence the impairments associated with brain damage were generally regarded as “incurable”. Since that time neuroscientists have had reason to change their views dramatically. However, much remains to be done. Progress depends upon a co-ordinated multidisciplinary approach within which assistive technology will be a key player. Within the area of assistive technology, one of the developments which holds particular promise for the field of neurological rehabilitation is the computer technology underlying virtual environments (commonly known as virtual reality). In this chapter we describe the new opportunities offered by virtual reality to pursue several aspects of the rehabilitation process.

The value of the technology of virtual environments in this context is that it allows us to immerse people with brain damage in relatively realistic interactive environments which, because of their patterns of impairment, would otherwise be unavailable to them.

The incidence of perceptual-motor disorders arising from stroke is steadily increasing in the population of Europe and USA. This chapter sought to define the role that virtual environments may have in designing remedial programmes for rehabilitation following stroke in the areas of attentional retraining and the reacquisition of perceptuo-motor skills. Principles for the structure of guided learning were identified and emphasis placed on the need to identify when and how virtual environments technology can introduce added value to the therapy situation.

This paper deals with the design and the development of an equipment, called DDI, as acronym for Disease Detector, developed for the quantitative analysis of neuromotor diseases. It measures the reaction of a person evaluating in the motion of one finger of the hand the time response, the velocity of phalanxes, the force exerted from the finger against a button. The condition of motion are ballistic motion, controlled motion guided by vision, controlled motion without vision, motion with a virtual reality modelization on the computer screen. The system performs also the requirements for medical applications and with its portability and accordance to European normative for safety and quality, represents a new step towards the possibility of quantitative analysis of the performances of the human hand both of mechanical phenomenon and electromyographic of neuromotor diseases, which provoke a decrease in upper and lower limbs action.

Multiple sclerosis and spinal cord injury patients can benefit by interaction with a haptic-visual system to increase the accuracy of movements in cases of spasticity, cerebellar tremor, and weakness. The device would apply a counterforce to constrain the upper extremity to a force corridor, a region of force/velocity space, designed to increase movement accuracy. Execution of movements with counterforce assistance under certain conditions improves accuracy and should enable patients to develop enhanced strategies for dealing with the movement disorders resulting from their neurologic deficits. Generation of appropriate force feedback requires dynamic adjustment of feedback plant characteristics and integration of visuospatial information in a virtual reality environment. Sensory augmentation, including compensation for visual and proprioceptive loss, can theoretically also be achieved with this approach. The underlying principles in the development of such a system are presented.