Volume 10, Issue 4 - Special issue on Disability, virtual reality and assistive technologies Editors: Jaime Sánchez, Sue Cobb, Paul Sharkey and Joav Merrick

No abstract available

Over the last 15 years, a virtual revolution has taken place in the use of Virtual Reality simulation technology for clinical purposes. Shifts in the social and scientific landscape have now set the stage for the next major movement in Clinical Virtual Reality with the “birth” of intelligent virtual humans. Seminal research and development has appeared in the creation of highly interactive, artificially intelligent and natural language capable virtual human agents that can engage real human users in a credible fashion. No longer at the level of a prop to add context or minimal faux interaction in a virtual world, virtual humans can be designed to perceive and act in a 3D virtual world, engage in spoken dialogs with real users and can be capable of exhibiting human-like emotional reactions. This paper will present an overview of the SimCoach project that aims to develop virtual human support agents to serve as online guides for promoting access to psychological healthcare information and for assisting military personnel and family members in breaking down barriers to initiating care. The SimCoach experience is being designed to attract and engage military Service Members, Veterans and their significant others who might not otherwise seek help with a live healthcare provider. It is expected that this experience will motivate users to take the first step – to empower themselves to seek advice and information regarding their healthcare and general personal welfare and encourage them to take the next step towards seeking other, more formal resources if needed.

Despite much research effort addressing the development of environments for virtual rehabilitation processes, few of them consider a modeling step before the system implementation. Our previous experience in developing virtual environments for stimulating cognitive functions stresses the necessity of adopting some software engineering practices. System modeling opens new possibilities to extend or integrate the system with other applications. The objective of this paper is to introduce some technical aspects related to modeling and implementing a multi-agent game for training memory and attention. We explore the integration of multi-agent model methodologies and present initial results of an experiment made with two specific languages for building three-dimensional virtual environments.

The COSPATIAL (Communication and social participation: collaborative technologies for interaction and learning) pro-ject explores how we can develop effective and useful educational technologies in the form of shared active surfaces (SAS) and collaborative virtual environments (CVEs) to support the enhancement of social skills for children with autism spectrum conditions (ASC). The UK design team comprises of technology developers, design engineers, educational psychologists as well as teachers from both mainstream and autism specialist schools. A user centred design approach is being used to make decisions and review prototype development using CVE technology. The involvement of teachers throughout the entire process is crucial, but in order to understand the primary user further and design optimally it is also desirable to directly involve the end users in the design process. This paper describes the participatory design approach for elicitation of user requirements and CVE design that is being used with typically developing children and how these methods have been adapted to facilitate involvement of children with ASC.

Little research has been carried out on specialized wearable input interfaced designs to assist memory impaired senior citizens. This paper proposes and implements PiTaSu (Picture based Tapping on wall Surfaces) to realize a direct input interface system to offer visual feedback and tactile feedback. PiTaSu is based on a pictorial based Augmentative and Alternative Communication (AAC) system. PiTaSu consists of a body-worn or shoulder-attached mobile projector, a camera and an accelerometer wrist band. The projector shows information that will help assist the memory impaired senior citizen in their daily task. The camera and the accelerometer detect a tapping position and tapping trigger. Experimental results have demonstrated that a senior citizen can use PiTaSu without learning special skills, and the projection based user interface has potential. Therefore, PiTaSu can assist memory-impaired senior citizens as a daily task reminder.

Posttraumatic stress disorder (PTSD) is reported to be caused by exposure to traumatic events including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggest that at least 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual reality (VR) delivered exposure therapy for PTSD has been used with reports of positive outcomes. The aim of the current paper, is to present the rationale and brief description of a Virtual Iraq/Afghanistan PTSD VR therapy application and present initial findings from its use with PTSD patients. Thus far, Virtual Iraq/Afghanistan consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern VR contexts for exposure therapy, including a city and desert road convoy environment. User-centered design feedback, needed to iteratively evolve the system, was gathered from returning Iraq War veterans in the USA and from a system deployed in Iraq and tested by an Army Combat Stress Control Team. Results from an open clinical trial at San Diego Naval Medical Center of the first 20 treatment completers indicate that 16 no longer met PTSD screening criteria at post-treatment, with only one not maintaining treatment gains at 3 month follow-up.

This study aims at assessing an online portal where patients with traumatic brain injury (TBI) can carry on memory and attention exercises outside clinic premises. The training took place in a virtual reality (VR) setup where one TBI patient had to complete a set of 10 online VR sessions. The neuropsychological evaluation was carried out with the PASAT (Paced Auditory Serial Addition Task) at pre-, during and post-treatment assessments. The results showed an increase in working memory and attention levels from the first to the final assessment, which can suggest that VR applications may promote the autonomy and increase in overall quality of life of these patients. The average time for task conclusion was 5 min.

Gait training is an essential part of the rehabilitation process for those with lower extremity (LE) amputations. For service members at Walter Reed Army Medical Center, the Computer Assisted Rehabilitation Environment (CAREN) allows virtual reality to be incorporated into gait training as an adjunct to conventional therapies. This retrospective case series examines the self-selected velocities achieved in two different virtual environments (VE) by 11 service members with LE amputations. These VEs allowed participants to progress from level walking to more challenging terrain. Over periods of four to eight weeks, all participants were found to increase their self-selected velocities; progression appears to be individual. The preliminary results obtained indicate that further investigation is warranted.

The objective of telerehabilitation is a continuation of the rehabilitation process in the subjects’ home whilst allowing the therapists and physicians the possibility to follow the progress remotely. In this article a pilot project with virtual reality based tasks for dynamic standing, frame supported, balance training is presented. Six stroke subjects participated in the preliminary study. The subjects performed the therapy five times a week, each time for up to 20 min, over a period of 3 weeks. The results were evaluated by objective game parameters as track time, number of collisions and clinical instruments Berg Balance Scale, Timed Up & Go and a 10 m walk test. The outcomes demonstrated a significant improvement of all parameters. However, the follow-up after 2 weeks demonstrated that functional improvement could be possible on a longer term if the subjects continue with targeted tasks for an extended period of time. Additionally, the balance training could be continued at the subject’s home instead of the hospital, which would decrease the number of outpatient visits and reduce related costs.

This study presents an application of biofeedback in balance training, in particular an audio-visual balance biofeedback system for dynamic balance. Motivated by the need to provide portable, cost-effective and accessible training devices, the system implements an accelerometer to quantify the balance board movements during a balancing task and use them to provide a real-time, synchronous audio-visual biofeedback. The visual feedback displays the offset and the overall performance of the balance board. The audio feedback is based on sound localization cues that indicate direction of the balance board movements using stereo sound. Initial results indicate significant improvements in postural stability when audio-visual biofeedback is provided. The study found significant improvements in maintenance and recovery of dynamic balance manifested through decreased variability of balance board dynamics in all directions as well as in lateral and front-to-back directions during balancing tasks when audio-visual biofeedback was used. Future applications will consider embeding the audio-video biofeedback modalities into rehabiliation game training.

For navigation ability, a transfer of knowledge from virtual training environments to real-world scenarios has been shown in several studies in the past. The purpose of this investigation is to demonstrate the equivalence of a series of navigation tasks in complex real-world and virtual buildings. Instead of testing knowledge transfer in very simple environments, identical tasks were performed in either version of a complex building. In this investigation, 29 participants were shown twelve landmarks, followed by a battery of tasks which were carried out in the real building by half of the participants, whereas the other half performed identical tasks in a virtual model of the same environment. No significant differences or effects were found, but due to the multifaceted nature of the gathered data and large variability within groups, overlap of both groups’ distributions was minimal. To discover the underlying factors of this variability, further research is needed.

More than one-third of people over the age of 65 years experience falls each year, and those who fall once are two to three times more likely to fall again. A fall can significantly limit a person’s ability to remain self-sufficient. Fall injuries are responsible for significant disability, reduced physical function, and loss of independence. However, falls are not an inevitable result of aging. Systematic reviews of fall intervention studies have established that prevention programs can reduce falls. Physical activities, including strengthening exercises, Tai Chi, dancing and walking have been demonstrated to improve balance and decrease risk of falls in older adults. Modified dance-based exercises that include step-based movements have been demonstrated to improve endurance and balance in older adults. Dance video games, using a dance mat with areas that the player must step on in time with cues on the screen, have been demonstrated to improve activity and mood and reduce weight in children and youth. However, these dance games often include fast paced music, frequent jumping and an overload of visual information, movement and colors on the screen. This paper outlines the development of a prototype rhythm game that leverages the benefits of step-based exercise and dance video games to improve balance and reduce falls in older adults.

Stroke survivors with continuing impairment in their upper limb find it difficult to access the early intensive, task specific practice that research has shown is necessary for motor recovery. A systematic review of studies that investigate the effects of robot-assisted therapy on motor and functional recovery in patients with stroke, found significant improvement in upper limb motor function, but the systems reviewed are expensive, require technical support, and are hospital or laboratory based. This paper describes the development of a low cost home based system together with a suite of games which would allow patients to practice the movements required for activities of daily living at the frequency required. The ongoing feasibility study is described.

This paper describes a convenient, home-based telerehabilitation system designed to improve upper limb and hand function in adults with cerebral palsy. The training program incorporates a variety of computer-guided sensorimotor activities, such as unilateral and bilateral reaching, reaching and grasping, object manipulation, and tactile discrimination tasks. Quantitative measures of performance are uploaded to the laboratory after each training session for further analysis. Webcam monitoring of performance occurs periodically throughout the training period. Twelve adults with cerebral palsy completed a 45 min/day, 5 days/week training program over 8 weeks. Temporal measures of performance indicated significant improvement in reaching and hand manipulation ability as well as improved tactile discrimination. Preliminary analysis of the time course of change revealed variable patterns within and across participants. The capacity to measure change throughout a training program provides an opportunity to investigate how learning occurs over time in chronic disability. Compliance was excellent, with subjective reports indicating improvement in activities of daily living. Future development includes a fully automated system with stand alone modules, which allow for customization of training protocols depending upon specific needs of the user.

Older people increasingly want to remain living independently in their own homes. The aim of the ENABLE project is to develop a wearable device that can be used to support older people in their daily lives and which can monitor their health status, detect potential problems, provide activity reminders and offer communication and alarm services. In order to determine the specifications and functionality required for the development of the device, user surveys and focus groups were undertaken, use case analysis and scenario modeling carried out. The project has resulted in the development of a wrist-worn device and mobile phone combination that can support and assist older and vulnerable wearers with a range of activities and services both inside their home and as they move around their local environment. The device is currently undergoing pilot trials in five European countries. The aim of this paper is to describe the ENABLE device, its features and services, and the infrastructure within which it operates.

This paper describes preliminary results of a project aimed at adapting workplaces for workers with motion disability through computer simulation and virtual reality techniques. For this task, a computer generated human model with a visualization of maximal arm reach and preferred working space was developed. Custom-made software was used to create a virtual working space, to adjust the human model’s measurements and constraints to reflect a disabled person, and to analyze necessary modifications. An immersive virtual reality environment was used to assess a modified workplace and to add further modifications.

We present a novel way of interacting with an immersive virtual environment which involves inexpensive motion-capture using the Wii Remote ® . A software framework is also presented to visualize and share this information across two remote CAVE TM -like environments. The resulting application can be used to assist rehabilitation by sending motion information across remote sites. The application’s software and hardware components are scalable enough to be used on a desktop computer when home-based rehabilitation is preferred.

People with visual disabilities have serious difficulties when mobilizing through the city on the public transportation system. We introduce AudioTransantiago, a handheld application that allows users to plan trips and provide contextual information during the journey through the use of synthesized voices. The usability and cognitive evaluation of AudioTransantiago was performed using a prototype evaluation in order to identify and solve usability issues, ending up with an intuitive and simple interface. Finally, a cognitive impact evaluation administered during bus trips taken with the assistance of AudioTransantiago demonstrated that the software provides more autonomy and effectiveness for users’ trips, improving their orientation and mobility.

This study explores the feasibility of a novel telehealth system for stroke rehabilitation in a rural area in Sweden. It addresses two major problems of home-based rehabilitation: training motivation and frequent meetings. Three stroke subjects were equipped with 3D computer games workbenches, and were instructed to play with the hemiplegic upper extremity. On-line coaching meetings were performed using bi­directional audiovisual communication. The intervention led to clinical changes for all subjects. On-line coaching is promising, but not yet as effective as desired. However, a distance based approach using 3D games for upper extremity rehabilitation after stroke is feasible.

Exposure to criminal violence is associated with mental health problems, such as depression, substance use and abuse. However, one of the most important psychological problems linked with victims of violence is post-traumatic stress disorder (PSTD). In Mexico, according to the ENSI-5 in 2009, 11% of the population over 18 years of age experienced a crime. One in four of those who were victims of violence develop PSTD symptoms. Due to this socially relevant problem and based on the efficacy of previous virtual reality (VR) clinical applications for combat-related PSTD, our group developed four VR scenarios to treat victims of criminal violence. Data obtained from a case study of a person who experienced assault with violence showed significant changes through reduced levels of anxiety and PTSD symptoms, illustrating the effectiveness of such treatment.