Journal of Cyber Therapy and Rehabilitation

Publications
Despite medication with opioids and other powerful pharmacologic pain medications, most patients rate their pain during severe burn wound care as severe to excruciating. Excessive pain is a widespread medical problem in a wide range of patient populations. Immersive virtual reality (VR) distraction may help reduce pain associated with medical procedures. Recent research manipulating immersiveness has shown that a high tech VR helmet reduces pain more effectively than a low tech VR helmet. The present study explores the effect of interactivity on the analgesic effectiveness of virtual reality. Using a double blind design, in the present study, twenty-one volunteers were randomly assigned to one of two groups, and received a thermal pain stimulus during either interactive VR, or during non-interactive VR. Subjects in both groups individually glided through the virtual world, but one group could look around and interact with the environment using the trackball, whereas participants in the other group had no trackball. Afterwards, each participant provided subjective 0-10 ratings of cognitive, sensory and affective components of pain, and the amount of fun during the pain stimulus. Compared to the non-interactive VR group, participants in the interactive VR group showed 75% more reduction in pain unpleasantness (p < .005) and 74% more reduction in worst pain (p < .005). Interactivity increased the analgesic effectiveness of immersive virtual reality.
 
This study examined the influence of Virtual Humans' (VH) sex and race on participants' ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommendations for medical help. Seventy-five undergraduates viewed a series of VHs and provided computerized visual analog scale (VAS) ratings for the five domains listed above. Mixed model ANOVA analyses showed that participants of both sexes and races viewed female VHs as experiencing greater pain intensity, greater pain unpleasantness, a greater number of pain-related negative moods, poorer coping skills, and a greater need to seek medical help for their pain. Participants of both races rated Caucasian VHs as experiencing more negative moods and poorer coping skills do deal with their pain. The novel computerized VH technology used herein allowed for the standardization of pain expression across sexes and races of VH stimuli, thus allowing us to remove the influence of biases when creating the study stimuli. This is a notable advantage over other research methodologies in this line of inquiry. Several future research and education applications of this VH technology are discussed.
 
Researchers and clinicians have recently begun using Virtual Reality (VR) to create immersive and interactive cue exposure paradigms. The current study aimed to assess the effectiveness of individual cue exposure therapy (CET), using smoking-related VR cues (smoking-VR) as a smoking cessation treatment compared to a placebo-VR (neutral cue) treatment. The sample consisted of healthy treatment-seeking cigarette smokers, who underwent bi-weekly cognitive behavioral group therapy (CBT) plus either smoking-VR CET or placebo-VR CET (random assignment). Smoking-VR CET participants had a higher quit rate than placebo-VR CET participants (P = 0.015). Smoking-VR CET treated participants also reported smoking significantly fewer cigarettes per day at the end of treatment than placebo-VR CET treated participants (P = 0.034). These data indicate that smoking-related VR CET may prove useful in enhancing the efficacy of CBT treatment for tobacco dependence.
 
The development of practical brain-computer interfaces (BCI) is proceeding rapidly and devices can now often provide control to select targets or to trigger pre-defined motion sequences. To move toward the eventual goals of restoring lost sensorimotor function, information transfer rates will need to increase. Information transfer can be improved at the signal and application end, and we provide several examples where our laboratory has addressed both issues. In particular, we have implemented P300 control of an autonomous humanoid robot and EEG-based motor imagery control of the Google Earth software. An anatomically correct test bed for a human hand model provides another example where applications are specifically designed to maximize the utility of a readily available control signal. In parallel, we seek signals that can provide improved information and fidelity of signal, including signals obtained from direct recording of the human cortical surface. The high-frequency signals seen at this level show promise for practical BCI applications, such as the use of contralateral and ipsilateral movement signals from the motor cortex, and, once identified by invasive means, may actually be detectable in non-invasive EEG recordings. These combined strategies may improve BCI development.
 
This study examines the relationship between physical aggression, thrill seeking, perceived risk, and behavioral intention of playing violent video games. This study collected data from 619 participants using an online survey, and analyzed the data through structural equation modeling. The results of this study suggest that physical aggression, thrill seeking, and perceived risk affect the behavioral intention of playing violent video games. Physical aggression and thrill seeking are positively related with behavioral intention, while perceived risk is negatively related. Results show that males exhibit higher levels of physical aggression and thrill seeking than females, and lower levels of perceived risk than females. Males also prefer to play violent video games more than females.
 
Besides physical injuries, motor vehicle accidents (MVAs) are responsible for serious mental disorders, up to 40% of the victims of MVAs can develop posttraumatic stress disorder (PTSD). A 42-year old patient was exposed to a virtual highway with an increasing anxiety triggering events (traffic intensity; horns; proximity of the surrounding buildings; tunnels; crossovers). The results indicate that the patient had a decrease in PTSD symptoms, namely in the IES (Intrusion and Avoidance dimensions) and in the HADS (Anxiety and Depression dimensions). As far as the psychophysiological activation concerns, the distribution GSR and ECG values during the 12 sessions followed the expected pattern, being reduced during the final session with statistically significant differences between sessions for ECG (F(11) = 2.842; p <.05). However, the most relevant fact is that this decrease led to the patient being able to drive again.
 
The objective of the study was to determine the clinical utility and the convergent validity of a computer desktopbased virtual reality (VR) street crossing task. Twenty patients who had sustained either a right (n = 13) or a left (n = 7) hemispheric brain lesion due to an acquired brain injury participated in this study. All subjects were assessed with a neuropsychological battery including measures of attention (Color Trail-making Test, CPT) and measures of unilateral spatial neglect (Behavioral Inattention Test.) A standard VR street crossing test was performed within a week after completion of a neuropsycological assessment. Variables measured in the VR task included number of times the participant looked to the left, the total time it took to complete the task and the number of accidents. A Feedback Questionnaire was used to obtain information about the subjective responses of the participants to the VR experience. The results were as follows-four patients in the study showed signs of persistent unilateral spatial neglect (USN =BIT cut-off store < 129.) Two of the four patients with USN and only one of the 16 without USN were unable to complete the task due to four or more accidents (Fisher's exact test, p = 0.08.) The number of accidents and the time taken to complete the virtual task were significantly correlated to the BIT score (r = -0.5, p < 0.05) and time to complete the Color Trail Making Test part A and B (r = 0.7 and r = 0.8 respectively, p < 0.01.) The participants' overall feedback on the VR experience was positive. In conclusion, the results achieved by this VR street crossing intervention correlate with those achieved by conventional neuropsychological tests measuring USN and attentional resources. Further studies should address its clinical validity as an effective instrument for training individuals who suffer from USN.
 
The Trier Social Stress Test (TSST; Kirschbaum et al., 1993) is currently the most commonly used psychosocial stressor to generate a response of the axes involved in stress. The TSST has proven effective in the activation of the hypothalamic-pituitary-adrenal axis. In addition, new technologies, such as virtual reality (VR), are being integrated into stress research protocols (Kelly et al., 2007). To determine whether TSST as applied to VR leads to the sympathetic and neuroendocrine activation in a group of healthy individuals. Also, this study aims to connect this response with different psychological variables regarding stress vulnerability, psychopathology, and personality. Twenty-one university students (6 male and 15 female) were exposed to a modified version of the TSST adapted to a virtual environment (VE), in which they have to deliver a speech. Electrodermal activity and salivary cortisol secretion were simultaneously registered at different instances. After the task, sympathetic activation was observed in all participants, as well as increase in the cortisol secretion in 14 of the students. This increase was statistically significant in the moment prior to the speech and the moment after in the responder group. In the same fashion, statistically significant differences were found in the responder group only regarding obsession and compulsion scales and extroversion, which were higher in the responder group. Our findings support the use of the TSST paradigm in VR as an experimental situation appropriate to research designs in laboratory aiming to study the modulation of the axes implied in response to stress.
 
Consort Diagram  
Outcome Variables
Time on each module by group  
Adolescents in primary care with sub-threshold depression (not reaching criteria for disorder) symptoms may be candidates for early intervention to prevent the onset of major depressive disorder. However, we know little about their attitudes toward such interventions or what may predict motivation or adherence for preventive interventions. We also describe preferences for different types of interventions and conduct exploratory analyses to identify predictors of motivation to prevent depression and subsequent adherence to an Internet-based intervention. Adolescents with sub-threshold depressed mood favored novel behavioral treatment approaches, such as Internet-based models for depression prevention. Adolescent beliefs about the intervention and perceived social norms predicted intention to participate in depression prevention. The most important significant predictors of adherence were beliefs about the intervention. Careful attention to the specific beliefs and attitudes of users toward intervention should be incorporated into intervention design as well as evolving public health strategies to prevent depressive disorders.
 
Mean attentiveness score (with error bars) on ZIPERS per condition at baseline, post stress induction, and then post immersion in VR. Here it can be seen (by comparing the first and second bars in each set) that self-reported attentiveness decreased in all three conditions as a result of the stress induction. It can also be seen (by comparing the second and third bars in each set) that attentiveness stopped declining after participants explored the nature environment, but not when they explored either the geometric or urban environments.
With the rapid advancements in technology, researchers are seeking new ways to incorporate modern high-tech solutions such as Virtual Reality (VR) into treatment paradigms for stress. The current experiment explores the beneficial effects of immersing an individual into VR after a stressful encounter. The potential restorative effects of three unique immersive VR environments were examined by inducing stress and negative affect in 69 participants, and then randomly assigning them to freely explore one of three environments (a virtual nature setting, a virtual urban cityscape, or a neutral environment composed of solid geometric shapes) for 10 min. Participants who explored the nature environment were found to have significantly improved affect (as measured by a standardized questionnaire), and significantly lower stress levels (as measured by self-report and skin conductance levels) compared to those who explored the urban and geometric environments. The results suggest that virtual nature has restorative properties similar to real nature, and that simply immersing participants into a virtual nature setting can reduce stress. These results also suggest that the content of the VR experience (i.e., whether it contains nature) is important in promoting restoration, and that in the absence of nature, stress levels remain unchanged.
 
There are a variety of old and recent studies, which indicate that self-report measures of personality appear susceptible to biased responses, especially when administered in competitive environments (e.g., Barrick & Mount, 1996; Ones, Viswesvaran, & Reiss, 1996; Hirsh & Peterson, 2008). According to these studies, respondents can typically selectively enhance their positive traits while downplaying negative ones. Consequently, it can be difficult to achieve an accurate representation of personality when there is motivation for favorable self-presentation. There has been one recent attempt to address the problem of biased responses and the lack of success in detecting and controlling this tendency, by using a new method of comparative scaling techniques, in which each trait domain was scored relative to all the others, rather than being scored separately (Hirsh & Peterson, 2008). Previous research suggests that these relative-scored, or ipsative, survey formats may be less susceptible to distortion than their Likert scored counterparts (Christiansen, Burns, & Montgomery, 2005; Jackson, Wroblewski, & Ashton, 2000). In this paper we introduce a virtual reality strategy for relatively scoring an individual's personality by means of virtual emotional human agents. Over the last five years, the technology for creating virtual humans (VHs) has evolved to the point where they are no longer regarded as simple background characters, but rather can serve a functional interactional role. Our current project involves the construction of a virtual emotional human agent that animates a personality description. The virtual human's personality descriptors used in the current study were taken from the IPIP five factor questionnaires, including the IPIP NEO, BFI, and the Big Five items from the Seven Factor questionnaire. The relative- scored personality strategy used in the project will be comprised of the following three different comparative scaling methods: paired comparisons, forcedchoice, and rank order techniques. Inside the virtual world, the participants will have different methods of interacting with the virtual humans relative to the three different comparative scaling methods used. For example in the first relative-scored method, the participants have to design a "custom" virtual human by choosing the most appropriate self-description from two different trait categories (e.g., "I see myself as someone who is depressed" vs. "'Am full of ideas" contrasts Emotional Stability with Openness, respectively). In the rank order method, participants will be presented with five animated virtual human's personalities (one from each trait domain) and will be asked to rank them with regards to how well they applied to their own personality. The data collected from this virtual world will not only be the participant's "active" interactions with the virtual humans but also "passive" monitoring and recording of behavioral patterns inside the virtual world during the "active" interaction (e.g. "virtual point of gaze", "point of gaze activity" and "reaction times for the virtual human personality selection process"). Because an individual's score on any personality scale is a function of the true score plus measurement error or response bias, the data collected above offer an additional method of detecting such strategic response manipulations. Overall, then, the present paper aims to describe the basic system architecture used for this virtual reality emotional human agents (VREHA) scored measure of the Big Five, which can be constructed as an alternative to questionnaire responding. As a future study we would like to compare our method with some new personality measures with predictive power, such as the "fake proof" Hirsh and Petersen construct. Herein however we proffer a description of our iterative design process and outline our long-term vision.
 
The St Andrew's Sexual Behavior Assessment (SASBA) scale has recently been proposed as providing a valid, reliable means of recording inappropriate sexual behavior (ISB) exhibited by people with acquired or progressive neurological impairment. ISB amongst these populations has not previously been studied in detail, consequently, little is known about its prevalence or characteristics. In this study, SASBA data collected over a three-month period in a neurobehavioral service was examined to begin ascertaining the extent of ISB amongst people with acquired brain injury (ABI.) Overall, 699 incidents were recorded among 91 patients-most were verbal comments of a sexual nature. Comparable measures of aggression made over the same period suggested ISB was relatively infrequent, accounting for seven percent of all events. Aggression was characteristic of most patients, whereas ISB was exhibited by less than half. Two patients accounted for nearly half the SASBA recordings. Data suggested aggression primarily served an escape or avoidance function while ISB was mostly concerned with social distance reduction. Benefits of encouraging services to utilize the SASBA to ascertain prevalence and characteristics of ISB in other ABI contexts and suggestions for future research are discussed.
 
The anonymity of the Internet may provide depression information to Asian Americans who often associate depression with shame and stigma beliefs and avoid treatment. We interviewed 20 Asian Americans regarding reasons for Internet depression information use, non-use, and relevant Web site topics. Thematic analysis was used to analyze the qualitative responses. Reasons for Internet use included difficulty talking face-to-face, confidential, useful information, and convenience. Reasons for non-Internet use included "not a good source" and denial concerning depression. The Internet can allow for depression information tailored to Asian Americans and this study suggests topics of interest to include on such a Web site.
 
(above) GSR/HR Sensore Module:a) the control box; b) the Skin Conductance Response sensors; c) the Blood Volume Pulse sensor.
(above, right) The control unit: a)a personal computer (Asus G2S; Intel® Core™2 Extreme Processor X7800); b)a crosscable; c)a therapist's laptop (EEPC 100H-BK039X); d)A joypad (Xbox Controller); e)a head-mounted display (Vuzix iWear VR920).
(right) The smartphone given to the patients, in which they can experience a Homecare Scenario, achieved by presenting the same virtual environment of the therapist's office training session.
Generalized Anxiety Disorder (GAD) is a psychiatric disease characterized by long-lasting anxiety that is not focused on a specific object or situation. Within the treatment of GAD, physical (relaxation and controlled breathing), behavioral (visualization and controlled exposure) and cognitive control strategies (challenging negative thoughts) represent a key part of the treatment, even if they difficult to learn. To overcome this limitation, the EU-funded INTREPID research project (IST-2002-507464) proposes improvement of exiting treatment for GAD through the use of a biofeedback-enhanced virtual reality (VR) system, used both for relaxation and controlled exposure. Furthermore, 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 approach was tested in a Phase II randomized controlled trial (NCT00602212), including three groups of four patients each, resulting in a total of 12 patients. The first group consisted of the VR and Mobile group (VRMB) including biofeedback, the second of the VR and Mobile group (VRM) without biofeedback, and the third the waiting list (WL) group. This study provides initial evidence for better efficacy of treatment for the VRMB group. Subjects belonging to this group reported a higher decrease in some of the anxiety psychometric questionnaires after the treatment than both VRM and WL groups, even if the VRM group, too, reported some significant improvements at the end of therapy. Moreover, qualitative reports concerning outpatient use of mobile phones suggests that it can solve a classical problem of VR therapies-the impossibility of using a VR system in the real life context of the patient.
 
The aim of this study is to present a pilot evaluation of the E-Junior application. E-Junior is a Serious Virtual World (SVW) for teaching children natural science and ecology. The application was designed according to pedagogical theories and curricular objectives in order to help children learn about the Mediterranean Sea and its ecological issues while playing. A pilot evaluation on a sample of 24 children showed that students thoroughly enjoyed the virtual learning session, were engaged with, and had fun interacting with the system. Moreover, some suggestions for improvement were given by the participants. The results and their implications are discussed.© Virtual Reality Medical Institute.
 
Traditionally, orthopaedic surgery training has primarily taken place in the operating room. Given the growing trend of decreasing resident work hours in North America and globally, due to political mandate, training time in the operating room has generally been decreased. This has led to less operative exposure, teaching, and feedback of orthopaedic surgery residents. We present a 3-D serious game that was designed using an "iterative test-and-design" method, for the purpose of training orthopaedic surgery residents the series of steps comprising the total knee arthroplasty (replacement) procedure, using a problem-based learning approach. Before implementing the serious game into teaching curricula, the first step, and the purpose of the current instigation, was to conduct a usability study to address user perceptions of the game's ease of use, and the potential for learning and engagement. Real-time, 3-D graphical and sound rendering technologies are employed to provide sensory realism consistent with the real world. This will ensure that the knowledge gained within the serious game can be more easily recalled and applied when the trainee is placed in the real world scenario. Usability test results indicate that the serious game is easy to use, intuitive, and stimulating.
 
The research presented here focuses on the ease of use of an instrument's interface for a target pediatric population, where participants were asked to interpret virtual character facial expressions. Fortyone children, both pediatric cancer survivors and healthy recruits, took part in six tasks that had them describe or express their confidence in descriptions of different facial expressions, portrayed either overtly or subtly and dynamically or statically by eight virtual characters. In this test of usability and feasibility, childhood cancer survivors performed comparably to healthy participants, suggesting that this instrument is feasible for use with cancer patients.
 
This paper presents a study aimed at developing a tool for the assessment of executive functions in patients with different etiologies by customizing a virtual reality (VR) version of the Multiple Errands Test (MET) (Shallice & Burgess, 1991; Fortin et al., 2003). The MET is an assessment of executive functions in daily life which consists of tasks that abide by certain rules. It is performed in an actual shopping mall-like setting where there are items to be bought and information to be obtained. The specific goal of this study was to conduct a pilot study using the virtual version of MET (VMET) with both control subjects and patients suffering from Parkinson's disease and from stroke. The task was supported by the employment of an advanced technology able to ensure an ecologically valid context for the patient. Specifically, the MET procedure, previously modified according to the requirements of the NeuroVR software system, was presented via a virtual supermarket. Subjects were requested to select and buy various products presented on shelves with the aid of a joy-pad. The procedures developed and employed during this pilot phase, results obtained for the two clinical samples and the implications for the assessment of executive functions are addressed in this paper.
 
Correlations between psychometric measures and response levels
Lang and colleagues postulated that fear responses must be described on three levels: subjective-cognitive, physiological, and behavioral. However, in-vivo assessments of fear in phobic situations are complex, difficult to control, and frequently associated with methodological problems. The present studies used a virtual reality spider scenario for a behavior avoidance test (VR-BAT). Subjective anxiety, symptoms, heart rate (HR), skin conductance (SCL), and approach behavior were measured in 34 female spider-phobic participants during two VR-BATs and during eight exposure trials in-between. The distance and fear ratings decreased from the first to the second VR-BAT and during the exposure trials. Interestingly, HR and SCL increased during the exposure trials and HR even between the first to the second VR-BAT. Physiological measures, fear ratings and approach were only partially associated, but approach and fear measures correlated with psychometric measures of spider phobia. The virtual reality scenario seems feasible for the behavioral and physiological assessment of fear.
 
Augmented Reality (AR) technology is being applied in an increasingly large range of applications for improved educational efficiency. In this study, a new approach to the implementation of AR in the educational environment was taken by creating a Chemistry Augmented Reality Learning System (CARLS), using the existing teaching curriculum, together with physical activity. This system combined learning with three types of physical activity-aerobic fitness, muscle strength and flexibility fitness. A large sample of students (n=673) from five high schools was divided into four groups. The first three groups used the CARLS learning system while a control group used a keyboard and a mouse to operate the computer. We explored changes in academic achievement, as well as attitudes towards learning about science, resulting from the implementation of CARLS. This study reveals that the students using all three types of physical activity together with CARLS result in significantly higher academic performance compared to the traditional Keyboard-Mouse CAI (KMCAI). The improvement is most evident for the non-memorized knowledge component of science. Moreover, the students in the AR group with muscle strength physical activity had a significantly more positive learning attitude change toward science than those in the KMCAI group. An additional benefit of our approach is that students also obtained better physical fitness while learning.
 
In the application of training for virtual rehabilitation, virtual avatars are used to help subjects performing exercises in a virtual environment. Effectively, the representative characteristics of virtual avatars have a strong impact on subjects when performing their exercises. Therefore, the selection of a suitable avatar is important. Our work aims to analyze the effects of virtual avatar representative characteristics on the performance of a training task done by healthy subjects. The system used consisted of a Cave Automatic Virtual Environment, a motion capture system and an avatar rendering library called Cal3D. The developed system also captures the gesture of subjects, renders it by virtual avatars and supports a simple game of "Ball Reaching." By changing the representative characteristics of virtual avatars, our scenarios enable the experimentation of two approaches. The first analyzes the effects of virtual avatar representative characteristics on the performances of the subject playing the game "Ball Reaching." The second measures the effect of virtual avatar representative characteristics on the performance of the subject replicating a motion which is represented by a virtual avatar. Based on our proposed real-time weighted Longest Common Sub-Sequence algorithm, the effect measured here is the similarity between represented motion of a virtual avatar and motion replicated by the subject. Our experiment shows that, for doing simple tasks, performance deviation of healthy subjects between the different types of representative avatars isn't considerable. However, when the tasks are complicated, types of representative avatars have a strong impact on the performance of tasks performed by healthy subjects.
 
Cognitive-behavioral therapy (CBT) is rationalized to be a highly appropriate treatment modality for problem and addicted users of video games. Drawing on available empirical research in this and allied areas (e.g., problem gambling), this paper presents some preliminary treatment techniques that may be well suited to the known features, correlates, and consequences of video game addiction. These techniques involve monitoring video game use, setting appropriate goals, and overcoming problem cognitions that intensify and maintain video game use. Specialized knowledge of the structural and situational characteristics that develop and maintain problem video game playing is also provided. While problem video game playing appears to resemble pathological gambling in many ways, some distinct phenomenological aspects of video game playing prevent a direct translation of gambling CBT programs to video game players. It is suggested that further research is needed to provide further guidelines and treatment techniques for video game players who suffer problems with their behavior. There is also need for greater funding for more basic and applied research on problem video game players.
 
This paper offers an overview of recent game-based applications for therapy and rehabilitation of elderly people. Information and Communication Technologies represent a viable solution to meet the various physical and psychological needs of a population growing at an incredibly fast rate. In particular, videogames have proven to improve elderly people's cognitive abilities and take care of psychological problems accompanying illnesses and social isolation. We will present several examples of videogames adopted within training programs for elderly people, and tested through scientific procedures. We will include both old-fashioned games and recent ones. Characterized by a higher naturalness in the input system, the latter rely on already established usage practices with non-digital tools (a pen, a bowling ball, etc) that make the interface more accessible. Finally, we will describe a current European project that aligns with these efforts towards natural interfaces and aims at developing a mixed reality game for cognitive training and sociability of elderly users.
 
Pre-study Questionnaire on what is important in life.
Reminiscence activity is commonplace as an activity that is widely recognized as beneficial to people with dementia. It can offer alleviation of the burden of care for those who look after people with this disease. In reminiscence activities, people may use items including photographs representing their lives, in some form. Reminiscence systems are the use of technology to support reminiscence work. This paper describes a study that carried out an evaluation of card-based versus device-based reminiscing using photographic images. The outcome of the study demonstrated no difference between traditional and device-based reminiscing of photographic images, indicating no barriers to the use of systems for reminiscing activities.
 
Heart Rate Variability Changes
Stress related medical disorders such as cardiovascular disease, diabetes and depression are serious medical issues that can cause disability and death. Techniques to prevent their development and exacerbation are needed. Casual video games (CVGs) are fun, easy to play, spontaneous and are tremendously popular. In this randomized controlled study we tested the effects of CVGs on mood and stress by comparing people playing CVGs with control subjects under similar conditions. Electroencephalography (EEG) changes during game play were consistent with increased mood and corroborated findings on psychological reports. Moreover, heart rate variability (HRV) changes were consistent with autonomic nervous system relaxation or decreased physical stress. In some cases CVGs produced different brain wave, heart rate variability and psychological effects. These finding have broad implications which include the potential development of prescriptive interventions using casual video games to prevent and treat stress related medical disorders.
 
In VR-based cognitive rehabilitation, there is a particular interest in the subject's performance in the virtual tasks in which patients are engaged. This performance is a function of many factors, among which includes the characteristics of visual information delivered by the virtual system. This study was designed to examine the impact of the size of the display screen on the performance in a virtual task in the Virtual Action Planning Supermarket (VAP-S) among patients with brain injury and healthy control subjects. We designed two configurations - Config L with a large screen and Config S with a small screen. Results show that participants of both groups made a fewer number of incorrect actions in the virtual task in the large screen condition. We conclude that, in our study, increasing the size of the screen improved subjects' perception of the visual information and consequently, the performance of the task.
 
Since the prevalence of chronic pain among the elderly is high and reduces their quality of life, effective non-pharmacological pain management should be promoted. The purpose of this quasi-experimental pretest and posttest control design was to enhance pain management via an 8-week multisensory stimulation art and craft appreciation program (MSSAC). Residents from two nursing homes were randomized into an experimental group with MSSAC and a control group with regular care but without MSSAC. Relevant data were collected from both groups before and after the MSSAC. The MSSAC consisted of an 8-week program, with one session per week consisting of an art and craft activity and practicing multisensory stimulation therapy. There were 59 and 82 older people in the experimental and control group respectively. No significant differences were found in their demographic characteristics, pain parameters, number of non-pharmacological strategies for pain relief, effectiveness scores on the non-pharmacological therapies, and psychologica l wellbeing at the baseline. Upon completion of the MSSAC, there was a significant decrease in pain scores and in the use of non-drug methods to control pain. Also, a significant improvement was observed in all psychological parameters in the experimental group, but not for the control group. The MSSAC proved to be effective in reducing pain, enhancing psychological wellbeing, and increasing the use of non-pharmacological therapies for the elderly.
 
Predeployment stress inoculation training (PRESIT) is designed to help personnel cope with combatrelated stressors and trauma exposure. PRESIT comprises education on combat and operational stress control, attentional retraining and relaxation training, and practice and assessment via a multimedia stressor environment (MSE). Heart rate variability (HRV) and a reaction time task assessed learned skills and inoculation to MSE arousal. Participants with deployment experience and who were in the experimental group demonstrated improvement, measured as greater relaxation demonstrated during the MSE of a follow-up session relative to that of a baseline session. There was also a training effect for this group, such that those participants who showed greater relaxation from a baseline HRV state during the training (i.e., on relaxation breathing and focusing) showed more improvement between sessions. In contrast, there were no significant predictive variables for the participants in training who had never deployed. Participants with more Posttraumatic Stress Disorder (PTSD) symptoms at baseline showed more capability for improvement, as was true for participants who were more anxious about their next deployment.
 
Dr. Stetz Monitoring a Participant in the Research Laboratory.
Reported PTSD Symptoms prior the First Session. Figure 3. Sensation Seeking Scores for Each Group.
Hostility Scores for Each Group.
Virtual Reality-Stress Inoculation Training (VR-SIT) is a technique designed to mitigate the negative effects of psychological stressors. This study was designed to examine the usefulness of VR-SIT to increase levels of stress in medical military personnel. We examined the psychological stress levels in 63 participants that were either in a group to practice combat medical skills with virtual scenarios only, or practicing relaxation techniques only, both, or neither. We observed higher levels of hostility in the VR group than in the rest. Also, those practicing relaxation techniques while exposed to the VR games showed higher levels of sensation-seeking. Interestingly, further analyses showed higher levels of both anxiety and dysphoria in those previously deployed that participated either in the VR or the relaxation group. Our results suggest that exposure to VR scenarios where to practice medical skills is a promising way to prepare warfighters for combat stress.
 
The VR Mirror
Mental practice consists of rehearsing a movement with the goal of improving performance. Recent clinical studies suggest that mental practice can be an effective way to facilitate motor recovery after stroke. Though healthy subjects can easily learn to visualize a movement mentally, brain-injured individuals may perceive this task as difficult and overwhelming. We report progress of a research project, which has investigated the feasibility of combining music and Virtual Reality (VR) to support stroke patients in performing mental practice. We tested this approach in two chronic stroke individuals. After four weeks of treatment, both patients showed improved motor function and reported reduced feelings of anxiety. The results of this pilot study are encouraging and deserve further research.
 
Online counseling has gained more recognition in many areas of general and specialized health care. The German ab-server was established in 1998 and offers a highly professional anonymous online counseling service for people suffering from, or wanting to learn about, eating disorders (ED). The aim of the following analysis was to represent an actual user characteristic. Methods: 1,055 inquiries sent to online counsellors of the ab-server by individuals affected by ED and their relatives were evaluated. The inquiries were received between December 2007 and December 2008 and all inquiries were analysed both qualitatively and quantitatively. Results: The symptom descriptions given by persons suffering from an ED mostly referred to bulimia nervosa (BN) (44%); inquiries sent in by relatives of affected persons also mostly referred to BN (42%). Conclusions: The easy access to a professional counseling service online has made it accepted by individuals suffering from ED and their relatives.
 
Although virtual reality (VR) is a promising exposure technique for people suffering from an eating disorder, it had not been used with women who show significant but subclinical concerns with their weight and shape. Twenty-seven women took part in three immersions in VR (10 concerned and 17 non-concerned). Measures of anxiety were taken before, during and after the immersions. Weight, shape and food concerns, drive for thinness and body dissatisfactions were measured immediately after the immersions. Compared to the neutral environment, the buffet and pool immersions caused a significantly higher level of anxiety and weight preoccupations among the women who were concerned than among those who weren't. The study conclude VR is effective through the continuum of eating disorders. Not only does it arouse reactions within people suffering from an eating disorder, but also among women concerned by their weight and shape.
 
In this review the authors, after an initial description of the "Internet phenomenon," particularly of the psychological and psychopathological risks related to its use, propose to the reader a series of works on this theme developed during recent years. In this review many interesting aspects are discussed such as the problem of defining the syndrome and the possible diagnostic criteria, the explanatory models proposed by various authors and possible therapy options to treat the syndrome.
 
Motor rehabilitation needs, in most cases, specialists that indicate exercises to do, and, generally, the specialist must follow the patient most of the time. Moreover, there are not objective measures to evaluate in detail the correction of exercises and the exercises patient's evolution. To improve the motor rehabilitation process, we present a new low-cost system that allows in the first stage, the use of last generation tools for the development of customizable standing exercises. This new system is being validated in an important rehabilitation center with very promising results. The first validations that are taking place indicate that it contributes with important improvements, permitting a smallest dependence of the patient in relation to the specialist, providing objective measures of evolution of the patients in the realization of exercises, and increasing the motivation of the patients in the rehabilitation process.
 
The Use of VR in PTSD Treatment.
Over the past decade, virtual reality (VR) has made a significant impact on behavioral healthcare, permeating the field with its multiple effective uses. One arena in which VR shines is in providing training and treatment for those exposed to traumatic or especially stressful events. Though traditional treatment methods for Posttraumatic Stress Disorder (PTSD) include medication, psychotherapy, and exposure therapy, none of these treatments has been sufficient to alleviate symptoms in many of those who suffer from the disorder. However, when imaginal exposure is replaced with VR exposure, many non-responders seem to receive relief. Over 15 studies entailing diverse populations have shown VR exposure therapy to enhance traditional cogni- tive behavioral treatment regimens for PTSD. Most studies reveal a treatment success rate of 66%-90%. Another area in which VR is contributing to success is in prevention or attenuation of stress-related reactions through Stress Inoculation Training (SIT). SIT is a type of training used to prepare individuals for stressful situations (such as combat or medical emergencies), diminishing the potential for a negative psychological reaction like PTSD. In cognitive-behavioral therapy, SIT is accomplished through gradual, controlled, and repeated exposure to a stressor. The goal behind this exposure is to desensitize the person to the stressful situation, avoiding a panic or "fight or flight" response to the real thing. This not only allows the individual to accomplish the tasks at hand in a stressful environment, but also may act to prevent long-term psychological reactions to stress such as PTSD. Though a relatively new area, several researchers have begun to use VR to enhance SIT techniques. The results to date appear to be quite promising.
 
Virtual reality (VR) has been utilized in conjunction with cognitive behavioural therapy (CBT) to decrease symptoms for people with specific phobias or anxiety disorders. Many studies investigating VR have employed complicated head-mounted displays with intricate software. This study investigates the effectiveness of presenting a 3-D video of a virtual audience to participants who experience the fear of public speaking. The VR environment was presented with a cost effective, standard CRT television using polarized shutter glasses. Results indicate that skin conductance and heart rate measures increased, which suggests that the VR 3-D video is effective in eliciting a fear response. Also, a decrease in anxiety and a decrease in negative self beliefs about public speaking ability suggest that VR 3-D video can provide an effective treatment. Future studies may combine this user-friendly technology with a therapeutic element, such as CBT, to treat anxiety disorders successfully and more cost effectively.
 
"Pseudoneglect" is a small leftward bias, similar to hemispatial neglect, in healthy individuals. Optokinetic stimulation (OKS) is an effective technique based on coherently-moving stimuli used to treat neglect patients. However, OKS effects are temporary, and the task is uninteresting. In this study, we developed a virtual OKS (V-OKS) program that easily generalizes treatment effects to daily life, and is also interesting. Our aim was to examine the V-OKS program's effectiveness on pseudoneglect. 31 healthy individuals conducted a line-bisection test and a cancellation test at baseline, and were tested again after receiving six versions of V-OKS differing in speed and orientation. All speeds of rightward V-OKS made corrections of the leftward bias, the slow speed being most effective. Also, participants made initial cancellations from the left after leftward V-OKS in the cancellation test. Results revealed that V-OKS effectively regulates pseudoneglect and has potential to be clinically applicable to neglect patients.
 
Soldiers can use VR both for medical skill and stress inoculation training pre-deployment, and treatment of posttraumatic stress disorder post-deployment, creating a continuum of care for troops exposed to war time situations.
a) the latest FACE prototype; b) a detail of the android
FACE's cognitive architecture
FACE-T set-up diagram
The emerging approach of "embodied cognition" is redefining the nature of cognition: cognition is no longer a set of formal operations on abstract symbols, but rather a situated embodied activity. On one side, the characteristics of our perceptual and motor systems play a foundational role in concept definition and in rational inference. On the other side, practical activity plays a role in giving meaning to the particular experiences of, and the representations generated by, a given individual agent. Within this framework, virtual reality (VR) can be considered an embodied technology with potential that is wider than the simple reproduction of real worlds. By designing meaningful embodied activities, VR may be used to facilitate cognitive modeling and change. This paper will both discuss this claim and present a possible application of this approach: the therapeutic use of VR for the treatment of body image disturbances.
 
Virtual environments (VE) aim to reproduce life-like experiences, but despite indications that the olfactory sense plays a significant role in everyday life, the integration of olfactory stimuli in VEs is rare. The aim of this paper is to review the literature on olfaction and its potential applications in Virtual Reality (VR). Indications supporting the integration of odorants in VR include the privileged connections between the olfactory system and the brain regions involved in the processing of virtual stimuli used in clinical applications, as well as the interaction between odors, the other senses, and various psychological processes. Presently, smells are mostly integrated in VR applications for post-traumatic stress disorder and drug addiction, but further uses of odorants in VEs could include pain distraction, various training scenarios, such as emergency response and relaxation, and investigations of multi-sensory integration.
 
Fear of flying impacts an estimated 10-20% of the U.S. population. Those suffering from this fear either avoid flying or endure flights with intense anxiety and distress, often relying on alcohol or medication to transcend the experience. Virtual Reality Exposure Therapy (VRET) has been used successfully to treat fear of flying for the past fifteen years. Clinical case reports and controlled studies have shown VR to be highly effective in treating this phobia, since patients can actively practice new coping skills while engaging in a controlled exposure experience. The stimulus of the virtual environment has been found to trigger a dissociative state in patients prone to react this way when confronted with an anxietyprovoking situation. A case report examining the impact of dissociation on VRET for fear of flying will be presented. This case will incorporate physiological data as well as patient information obtained through self-report measures, and will be discussed through modern psychoanalytic theory. VR has typically been thought of as a useful adjunct to traditional cognitive behavioral therapies, however, it is also proving beneficial as an additive to psychodynamic therapy. Viewing a patient through the lens of psychodynamic theory can be particularly helpful in understanding the effectiveness of VRET.
 
This article is a review of the literature on efficacy and outcome studies using in virtuo exposure treatments to treat specific phobias. Thirty-nine studies were examined for this review: 56% were case studies or small sample studies, 13% were studies using larger samples, but no control or comparison condition, 13% used a comparison group (waiting list, placebo), 8% used a comparative treatment condition (usually in vivo expo- sure) and 13% used both. The specific phobias that were treated in these studies were acrophobia, aviophobia, claustrophobia, arachnophobia and fear of driving. The majority of these studies demonstrated that in virtuo exposure is effective and constitutes an interesting alternative to in vivo exposure. However, as the area is still taking its first steps, more studies with stronger methodological validity (control and comparative treatment conditions) are needed.
 
The Nintendo® Wii TM is gaining popularity with clinicians to use with their patients to simulate real world games and sports. Patients enjoy the interaction with the game while the therapist's focus is on improving the patient's function. The Wii Fit TM is being promoted to improve balance. The program begins with assessment tools to give the user an idea of how well they are balancing. This study investigated the reliability and concurrent validity of the Nintendo® Wii Fit TM compared to a known standard in measuring balance, the NeuroCom EquiTest®. The results of this study found that the Wii Fit TM is not reliable or valid in balance assessment as compared to the EquiTest®.
 
Self-determination theory states that motivation plays an important role in initiating, developing and maintaining involvement within an activity. The present study applied this theory to video game playing and surveyed 399 video game players, 82 percent of which were male with a mean age of 20.3 years old, on measures of video game playing involvement, motivation to play video games and problem video game play. Participants were obtained from various video game retail outlets, Internet cafes, and LAN gaming businesses. The results showed that extrinsic motivations to play video games, such as tension release, social approval and external regulation by in-game rewards, and amotivation, or playing without a sense of purpose about the activity, were significant predictors of problem video game playing. The results were discussed in terms of their application to identifying and assisting young people with potentially problematic levels of video game playing.
 
Night vision technology is nothing new. In fact, the military rely significantly on this technology during nighttime operations. A surgeon is like a medical soldier in the battlefield. His/her only mission is that of keeping people alive. Due to many technological advances, patients cannot only train on relaxation while visiting their doctors but also get distracted by playing videogames while waiting for them. Furthermore, this virtual reality experience can be enhanced if the patient wears goggles or Head Mounted Displays under dimmed or absence of lights. The purpose of this study was to test if a surgeon could operate when extending into such a dark condition situation, but in the surgical suite. Therefore, a surgeon performed seven open surgeries on rabbits. All surgeries were performed on the thorax and abdomen regions. Specifically, the surgeon was able to perform these surgeries by wearing on his head a micro camera with infrared light and a night vision goggles. The first assistant used this same system while the scrub nurse and the anesthesiologist did not. There were no complications either during or after these procedures. It is possible to make open surgeries wearing a night vision system. Further approaches should be tested with human volunteers.
 
Stress management (SM) is a term widely used with a seemingly obvious meaning but it is not clear how many different forms of SM exist and how efficacious they are according to the target problem. Stress is a multidimensional condition and we believe that it requires a wide-spectrum approach. We consider that a combination of stress management techniques can produce more significant outcomes than did single-strategy programs. For this reason we propose an integration of three approaches to cope with stress and improve emotional management from different points of view: the Emotion Focused Therapy; the Behavioral Therapy, and in particular Relaxation; the Rational Emotive Therapy. In particular, we decided to use two mediated experiences - audio and immersive 3D video - to support the Relaxation phase. The critical role in mediated experiences is played by the sense of presence that allows the experience to evoke the same perceptual reactions and emotions as a real one. To verify the efficacy of the SM protocol we carried out a controlled trial, comparing an experimental Video group, an Audio group (that only listened to the relaxing narrative), and a control group without treatment. Results showed the efficacy of integrating different approaches to cope with stress and suggested the importance of the sense of presence as a mediating variable between the experience and the efficacy of the relaxation process.
 
The technology for supporting user friendly and intelligent interaction becomes very important for technology applied to rehabilitation. In this paper we review state of the art information and communication technologies (ICT) applied to cognitive and motor rehabilitation in order to discuss the advantages of multitouch technologies over other technologies. We describe a multitouch system specifically developed for use in clinical rehabilitation. The ergonomic analysis and user acceptance results are described. A multitouch tabletop display system based on Frustrated Total Internal Reflection (FTIR) has been developed using user centered design principles in order to adapt the technology to patients with acquired TBI. We also described the classification of hand gesture commands for interacting with the system developed using the library Human-Touch. Several software applications have been developed both for usability tests and for cognitive rehabilitation tasks. The different natural man-machine interface technologies are analyzed for their use in neurorrehabilitation and the possibilities of the multi-touch technology are analyzed. The implementation of a prototype specially adapted for its use in neurorrehabilitation is described and the ergonomic analysis and user satisfaction results are described.
 
Schizophrenia is a brain disorder that is characterized by disturbances in general cognition, such as abnormal expressions of emotion and ways of thinking, mental derangement, regression from reality, strange language or behavior, and delusion or illusion. Family-based interventions, cognitive behavioral therapy, symptom- focused interventions, and social skills training are required for schizophrenic patients to return to normal life. Virtual reality is a medium that can present social and emotional situations via effective human-computer interactions that provide more realistic stimuli than the pictures or movies that are used in existing psychiatric therapy. Using conventional cognitive-behavioral therapy, it is difficult to obtain objective measurements. In addition, it is difficult to provide emotional or social situations. Virtual reality techniques can computerize various parameters so that objective measurements are possible; they can also provide emotional or social situations. Recently, virtual reality techniques have been used in the psychiatric field for effective training and objective assessment, such as in cognitive-behavioral therapy, social skills training, and medication training. In this paper, we describe the potential applications of virtual reality for patients with schizophrenia. More interactive and effective applications for patients with schizophrenia will emerge as virtual reality techniques continue to evolve.
 
This study aims to test how the Technology Acceptance Model (TAM; Davis, 1989, 1993; Venkatesh, 2000) applies to the use of virtual reality in clinical settings. The sample is composed of 141 adults interested in using this technology. We adapted the standard items used to test the TAM and added a perceived cost factor as it was expected to play a role on Intention of Use. Structural equation modeling was used and, after remov- ing several parameters, an adequate fit to the data was found. The final model revealed that Intention to Use VR is predicted only by Perceived Usefulness. These results pinpoint what should be better documented in order to foster the dissemination of virtual reality among clinicians.
 
Counselling and psychotherapy have entered the computer age. Psychological advice, help and treatment for those with addictive behaviours are no exception. The paper overviews the main issues in the area and approaches the discussion acknowledging that online therapy has to be incorporated within the overall framework of the need for clinical assistance. The paper also provides brief overviews of what types of online help and therapy are available. This paper makes particular reference to online help for problem gamblers and will overview a recent study that evaluates the effectiveness of an online help and guidance service for problem gamblers.
 
Top-cited authors
Stéphane Bouchard
  • Université du Québec en Outaouais
Carmen Russoniello
  • East Carolina University
Kevin O’Brien
  • East Carolina University
Brenda Kay Wiederhold
  • Virtual Reality Medical Center
Giuseppe Riva
  • Catholic University of the Sacred Heart