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User-centered development of a virtual reality cognitive assessment.

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User-centered development of a virtual reality cognitive assessment.

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Proc. 9th Intl Conf. Disability, Virtual Reality & Associated Technologies
Laval, France, 10–12 Sept. 2012
2012 ICDVRAT; ISBN 978-0-7049-1545-9
247
User-centered development of a virtual reality cognitive assessment
S T Koenig1, D Krch2, N Chiaravalloti2, J Lengenfelder2,
O Nikelshpur2, B S Lange1, J DeLuca2, A A Rizzo1
1USC Institute for Creative Technologies, 12015 Waterfront Drive, Playa Vista, CA 90094, USA
2Kessler Foundation Research Center, Neuropsychology and Neuroscience Laboratory, 1199 Pleasant Valley
Way, West Orange, NJ 07052, USA
{skoenig, lange, rizzo}@ict.usc.edu
{dkrch, nchiaravalloti, jlengenfelder, jdeluca, onikelshpur}@kesslerfoundation.org
1http://ict.usc.edu, 2http://kesslerfoundation.org
ABSTRACT
In recent years user-centered design, participatory design and agile development have seen
much popularity in the field of software development. More specifically, applying these
methods to user groups with cognitive and motor disabilities has been the topic of numerous
publications. However, neuropsychological assessment and training require special
consideration to include therapists and brain-injured patients into the development cycle.
Application goals, development tools and communication between all stakeholders are
interdependent and outlined in a framework that promotes elements of agile development. The
framework is introduced by example of a virtual reality cognitive assessment for patients with
traumatic brain injuries. The assessment has seen a total of 20 iterations over the course of nine
months including changes in task content, task difficulty, user interaction and data collection.
The framework and development of the cognitive assessment are discussed.
1. INTRODUCTION
Virtual reality (VR) applications have been successfully applied in a wide range of clinical scenarios
(Koenig, 2012; Riva, 2005; Rizzo et al., 2010; Rose, Brooks, & Rizzo, 2005). Their strengths and capabilities
have been described numerous times (Rizzo & Kim, 2005; Rizzo, Schultheis, Kerns, & Mateer, 2004). One
of the main weaknesses of virtual environments, their immature engineering process (Rizzo & Kim, 2005),
has seen much improvement by two recent advances in software development. Continuous innovations in
computer technologies and the availability of new software development methods have contributed to VR
applications becoming more accessible to researchers and clinicians. Especially the rise of computer games
and game engines has spurred a vast growth of the number of development tools available to researchers
(Siwek, 2007; Trenholme & Smith, 2008). With such tools the rapid development of virtual environments
and clinical tasks can be achieved (Koenig et al. 2011, Koenig, 2012).
Agile software development (Beck et al., 2001; Cohen, Lindvall, & Costa, 2003) and techniques such as
participatory design (Astell et al., 2009; Bruno & Muzzupappa, 2010), co-design (Dewsbury et al., 2006;
Francis, Balbo & Firth, 2009; Freudenthal, Stüdeli, Lamata & Samset, 2010) and user-centered design
(Fidopiastis, Rizzo & Rolland, 2010) have been successfully applied towards the creation of VR and health
care applications.
An agile development method can best be established by continuous communication between software
developers, clinicians and patients. By iteratively adapting the application requirements to user feedback and
needs, the development process remains flexible throughout the application’s lifecycle. Working software
should be put into the hands of users as early as possible during development while minimizing the time
needed to write documentation or make elaborate plans for the software’s future iterations (Beck et al.,
2001).
In line with agile development, a multitude of design methodologies has been published recently that give
the user a central role in the development process. User-centered design places its focus on defining
requirements and building software that is relevant to the users and their problems. For example, Gabbard,
Hix and Swan II (1999) distinguish a behavioral and constructional domain when developing virtual
Proc. 9th Intl Conf. Disability, Virtual Reality & Associated Technologies
Laval, France, 10–12 Sept. 2012
2012 ICDVRAT; ISBN 978-0-7049-1545-9
248
environments. User interaction and the user’s view of the developed system are represented by the behavioral
domain. Due to the immersive and possibly multimodal nature of virtual environments the authors provide
guidelines and protocols for usability testing and heuristic evaluation of virtual environment characteristics.
Most participatory approaches focus on the inclusion and communication with patients and caregivers
throughout the development cycle. For example, Astell and colleagues (2009) describe such method for the
design of computer-based support systems with dementia patients and their caregivers. They depict the
communication process and the special considerations that are required when working with a user population
with cognitive impairments. The authors name their approach user-centered in nature and describe how the
user is actually involved in the design and evaluation process. This is a situation where the distinction
between different methodologies becomes vague and methods and their respective names overlap.
Participatory design and also co-design have often been described as actively involving the user in the
design and development process of a product or system instead of just adapting the outcome to the user’s
needs. This can be achieved by exploring the user’s habits and problems, discovering solutions together and
iteratively prototyping solutions with the user until an appropriate solution to the user’s problems has been
achieved. Spinuzzi (2005) lays out the details of such methodology, its limitations and how it can be
evaluated. A systematic co-design approach for designing technologies for users with autism spectrum
disorder is described by Francis, Balbo and Firth (2009). In a structured evaluation by a panel of seven
autism experts a set of guidelines has been identified that addresses the use of design techniques and co-
design management when working with individuals with autism spectrum disorders.
Fidopiastis (2006) and Fidopiastis, Rizzo and Rolland (2010) describe a user-centered design approach by
benchmarking immersive technologies before using them for cognitive rehabilitation application. This
approach is aiming to increase validity of virtual reality assessments. The authors base their user-centered
practices on the ISO13407 guidelines which have since then be revised by ISO9241-210:2010 “Human-
centered design for interactive systems”. These standards again put heavy emphasize on understanding and
involving the user throughout the iterative development cycle.
All of the described development methods highlight the importance of including the user into the
development process, both at the design and testing stages. Each existing publication focuses on specific
application areas or user group such as patients with dementia (Astell et al., 2009), autism spectrum disorder
(Francis et al., 2009) amputees (Cole, 2006) or cognitive rehabilitation in general (Fidopiastis et al., 2010). It
becomes apparent that each clinical domain poses its own unique challenges for the development process,
especially with regards to the patients’ ability to partake in the design and evaluation process as outlined by
traditional user-centered and participatory design guidelines. Francis and colleagues (2009) particularly
highlight this discrepancy by contrasting symptoms of autism spectrum disorders with the requirements for
contributing to the participatory design process. The authors conclude that the co-design method can be much
more difficult with users with autism spectrum disorders. Though, the selection of appropriate methods and
tools that empower the users during the design process can greatly facilitate the designer – user interaction.
It is the purpose of this paper to outline methods and challenges for user-centered design in the domain of
neuropsychological rehabilitation. The development of VR applications for neuropsychological training and
assessment requires additional design factors to be considered. The overview in the following chapters
provides details of such factors and their influence on development, testing and communication between
involved stakeholders. An example for applying such framework to a VR assessment for patients with
traumatic brain injuries is presented and discussed.
2. METHOD
Virtual reality technology comes with a well-known set of strengths and limitations (Rizzo & Kim, 2005).
Widely available development tools such as game engines and 3D modeling applications lay the foundation
for effective workflows to build interactive virtual environments within days instead of months (Koenig,
2012). However, the availability of such development tools does not automatically provide a standardized
way of creating applications that solve existing clinical problems. As previously outlined, user-centered and
participatory design provides guidelines for user involvement, but the integration of these guidelines into the
actual development process – from project inception to finished product – is left to the developer. This leads
to the question of how design, development workflow and user integration can effectively be combined to
create applications that provide value in the context of cognitive rehabilitation. The following framework
provides an outline of such workflow in the context of a virtual reality cognitive assessment.
An initial exploration of research questions, scientific inquiries, clinical questions or clinical gaps can
motivate the design and development of an application that addresses an identified problem or opportunity. A
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Proc. 9th Intl Conf. Disability, Virtual Reality & Associated Technologies
Laval, France, 10–12 Sept. 2012
2012 ICDVRAT; ISBN 978-0-7049-1545-9
250
demands that are placed on the cognitive system in a real-world work setting. It is predicted that such
ecologically relevant task scenario is more sensitive to cognitive deficits of brain-injured individuals and can
predict cognitive performance in real-world settings accurately.
3.1 Project Members and Communication
The development of the described framework and its extension for Assessim Office was completed by one
virtual reality developer with clinical background. The clinical research team at the NNL consisted of two
research scientists, one postdoctoral fellow, three research assistants and several additional staff members.
Design decisions were discussed between the virtual reality developer, the research scientists and
postdoctoral fellow at the NNL. Direct communication between the developer and the research team
consisted of email conversations and Skype calls during which one research scientist was the point of contact
for the NNL. Brain-injured patients were only involved in user tests once the initial task design and
development were finished. Assessim Office was designed to be a cognitive assessment administered to
brain-injured patients with traumatic brain injury. Hence, the early task design was not driven by patient
input or user feedback, but rather by scientific theories of human cognition. The researchers at NNL acted as
proxies for the patients (Francis et al., 2009) by providing input about the appropriateness of individual
system components. A first prototype of Assessim Office was installed on a desktop PC at NNL during an
early project meeting. Subsequent updates to the application were exchanged through the filesharing platform
Dropbox.
3.2 Prototyping
Initial prototypes of the Assessim Framework and Assessim Office were developed over the course of three
months. The framework was developed with the game engine Unity and contained a simple event system to
trigger object interactions, audio and visual cues. Further, the saving of text files to the local hard drive was
implemented. The office environment for Assessim Office (Figure 2) was created with Google SketchUp as
outlined by Koenig and colleagues (2011). Before the first prototype was installed at NNL, a menu system
and a practice trial similar to the actual assessment session were developed. The total development time for
these prototypes was approximately 100 hours, most of which were spent for modeling the virtual
environment. The office scene was chosen for its functional relevance, work-related context and relevance
for additional projects.
Figure 2. Virtual office environment rendered in the Unity game engine.
Each of the system components consisted of a minimally viable solution which is based on lean methods as
described by Ries (2011). The goal of the initial prototype was to deliver a simple functional virtual
environment to the researchers at NNL. Without any knowledge of how such system can be adapted to the
needs of a clinic, research laboratory and patient population, any implementation of features or task content is
uncertain and can potentially change several times throughout the development process. The first prototype
consisted of mouse and keyboard input, because it was natively supported by the game engine Unity. Output
through a standard 24-inch LCD monitor and plug-and-play stereo desktop speakers was chosen due to
simplicity, availability and the non-spatial nature of the planned cognitive tasks. The virtual office
Proc. 9th Intl Conf. Disability, Virtual Reality & Associated Technologies
Laval, France, 10–12 Sept. 2012
2012 ICDVRAT; ISBN 978-0-7049-1545-9
251
environment and several simple reaction time and decision tasks (i.e. reply to email, respond to ringing
phone, make decision about email offer) were implemented for an unrelated experiment. This
implementation was based on a simple trigger system which enables the developer to attach a C# single script
to any object within the virtual environment in order to make the object interactive (e.g. turn a monitor on
and off). Instructions about tasks or user input were not included, because tasks and input schemes were
expected to change over time. Data collection capability was recognized a fundamental feature needed for
any clinical trial and was supported through saving and loading text files from the PC’s local hard drive. The
exact content and structure of the saved files was still undetermined.
3.3 Iteration
During December 2011 and July 2012 a total of 20 iterations were developed and tested. On average, the
application received an update every 13 days. Average response time between user feedback or design
decisions and their implementation in the next update is estimated to be approximately three days. Average
development time for each update is estimated to be approximately five hours. Estimations are based on time
stamps of file updates and email conversations between developer and point of contact at NNL. However,
time estimations are approximated due to developer commitments in several parallel projects. Initial
iterations were focused on changes to the task content and user instructions.
Starting after the sixth iteration user testing was extended beyond two research scientists at NNL. Each
subsequent update was first screened by the research scientists and later tested with one to two staff
members. Each user was encouraged to provide verbal feedback about all system components. A total of
seven staff members were tested throughout the development process, three of whom were repeatedly
exposed to the application. During these early iterations adjustments to task content, task instructions, audio
feedback and user interaction were made.
The ninth iteration added a divided attention task during which the user has to turn a projector on
whenever it overheats. The locations of the projector and projector remote control require the user to turn
their attention away from their virtual desk on which all other tasks are positioned. This task was also
intended to increase overall difficulty of the virtual assessment in order to avoid ceiling effects. Further, user
interaction with a joystick was added. It was expected that the navigation through the virtual office was made
more intuitive by the use of a joystick. However, early feedback by researchers and several staff members
confirmed that using a computer mouse was more efficient and intuitive for interacting with items within the
virtual environment.
Iterations nine to thirteen were focused on updates to each of the cognitive tasks. Frequency and timings
of phone rings, email responses and decision-making tasks were adjusted to provide an adequate challenge
for healthy users. Task events were timed to overlap so that the user had to make decisions on which task to
prioritize. Most development time was spent on testing the exact timings of the tasks.
During the thirteenth iteration a major change to the cognitive tasks was implemented. During discussions
between developer and researchers it became apparent that the combination of cognitive tasks did provide an
adequate pacing but did not measure the underlying cognitive construct that it was expected to measure (i.e.
executive functions). Too many reaction time tasks that did not require decision-making or inhibition of false
responses were implemented. Within eight hours of development several tasks were removed and a new task
was added to the system. This change was made possible by the flexibility of the development process which
only required the scripting of the new task within the task component of the outlined system (Figure 1).
Answering phone calls was completely removed from the assessment and phone rings were now solely used
as distractions. Printing documents was also removed as a standalone task and integrated into the decision-
making task. The complexity of the rule-based decision making task was increased to balance the overall
difficulty of the assessment. The user now had to evaluate incoming email offers based on several criteria and
accept or decline them. Further, based on a different criterion the user had to print the incoming offer and
place the printed document at a predefined location. The interference of criteria for both tasks was intended
to assess the user’s ability for inhibition of dominant responses. A new virtual character was added to the
scene to plausibly explain the printing of incoming offers.
During the following iterations minor changes to data saving, instructions and difficulty to the newly
implemented task were made. Again, most of the development time was spent on balancing and testing task
difficulty. During iteration 19 and 20 the application was first pilot-tested with brain-injured patients. Also,
iteration 20 addressed feedback of staff members experiencing dizziness during conducted test trials.
Environmental factors and user interaction were discussed with the developer and the rotation speed of the
virtual camera was reduced to prevent sudden viewpoint changes. User feedback suggested that the camera
moved too fast while the user was getting accustomed to the input scheme during practice trials. Instead of
252
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Proc. 9th Intl Conf. Disability, Virtual Reality & Associated Technologies
Laval, France, 10–12 Sept. 2012
2012 ICDVRAT; ISBN 978-0-7049-1545-9
253
An extension of the current system is being developed by replacing the virtual environment with a larger
office building. The building provides a more complex layout in order to assess the user’s navigation ability.
Additionally, a large number of interactive virtual characters are added to simulate a realistic, distractive
work environment for cognitive assessment (Figure 3). Due to the flexible system architecture such extension
only requires a change in art assets and the adaption of the cognitive tasks to the new environment. All other
system components remain identical. Consequently, the described framework allows the developer to deploy
a large number of cognitive assessments, each customized to a specific environment which is relevant to the
assessed patients and users. This approach extends the context-sensitive clinical framework as described by
Koenig (2012).
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... VR has documented evidence in support of its use for discomfort reduction in cancer patients undergoing chemotherapy (Schneider, Kisby, & Flint, 2010), acute pain reduction during wound care and physical therapy with burn patients (Hoffman et al., 2006(Hoffman et al., , 2019, in other painful procedures (Gold, Kim, Kant, Joseph, & Rizzo, 2006;Mosadeghi, Reid, Martinez, Rosen, & Spiegel, 2016), and body image disturbances in patients with eating disorders . Cognitive research using VR has produced promising results when applied to navigation and spatial training in children and adults with motor impairments (John, Pop, Day, Ritsos, & Headleand, 2017), functional skill training and motor rehabilitation in patients with central nervous system dysfunction (e.g., stroke, traumatic brain injury (TBI), spinal cord injury (SCI), cerebral palsy, multiple sclerosis, etc.) (Deutsch & McCoy, 2017;Howard, 2017;Klamroth-Marganska et al., 2014;Koenig, 2012;Koenig et al., 2012;Lange et al., 2012;Merians et al., 2010), and for the assessment and rehabilitation of attention, memory, spatial skills, and other cognitive functions in both clinical and unimpaired populations (Bogdanova, Yee, Ho, & Cicerone, 2016;Matheis et al., 2007;Parsons, Rizzo, Rogers, & York, 2009, 2019Pugnetti et al., 1995;Rizzo, 1994;Rizzo et al., 2006;Valladares-Rodriguez, Perez-Rodriguez, Anido-Rifon, & Fernandez-Iglesias, 2016). ...
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... VR has documented evidence in support of its use for discomfort reduction in cancer patients undergoing chemotherapy (Schneider, Kisby, & Flint, 2010), acute pain reduction during wound care and physical therapy with burn patients (Hoffman et al., 2006(Hoffman et al., , 2019, in other painful procedures (Gold, Kim, Kant, Joseph, & Rizzo, 2006;Mosadeghi, Reid, Martinez, Rosen, & Spiegel, 2016), and body image disturbances in patients with eating disorders (Riva et al., 2019). Cognitive research using VR has produced promising results when applied to navigation and spatial training in children and adults with motor impairments (John, Pop, Day, Ritsos, & Headleand, 2017), functional skill training and motor rehabilitation in patients with central nervous system dysfunction (e.g., stroke, traumatic brain injury (TBI), spinal cord injury (SCI), cerebral palsy, multiple sclerosis, etc.) (Deutsch & McCoy, 2017;Howard, 2017;Klamroth-Marganska et al., 2014;Koenig, 2012;Koenig et al., 2012;Lange et al., 2012;Merians et al., 2010), and for the assessment and rehabilitation of attention, memory, spatial skills, and other cognitive functions in both clinical and unimpaired populations (Bogdanova, Yee, Ho, & Cicerone, 2016;Matheis et al., 2007;Parsons, Rizzo, Rogers, & York, 2009, 2019Pugnetti et al., 1995;Rizzo, 1994;Rizzo et al., 2006;Valladares-Rodriguez, Perez-Rodriguez, Anido-Rifon, & Fernandez-Iglesias, 2016). ...
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Objective: Since the mid-1990s, a significant scientific literature has evolved regarding the outcomes from the use of what we now refer to as Clinical Virtual Reality (VR). This use of VR simulation technology has produced encouraging results when applied to address cognitive, psychological, motor, and functional impairments across a wide range of clinical health conditions. This article addresses the question, " Is Clinical VR Ready for Primetime? " Method: After a brief description of the various forms of VR technology, we discuss the trajectory of Clinical VR over the last 20 years and summarize the basic assets that VR offers for creating clinical applications. The discussion then addresses the question of readiness in terms of the theoretical basis for Clinical VR assets, the research to date, the pragmatic factors regarding availability, usability, and costs of Clinical VR content/systems, and the ethical issues for the safe use of VR with clinical populations. Results: Our review of the theoretical underpinnings and research findings to date leads to the prediction that Clinical VR will have a significant impact on future research and practice. Pragmatic issues that can influence adoption across many areas of psychology also appear favorable, but professional guidelines will be needed to promote its safe and ethical use. Conclusions: While there is still much research needed to advance the science in this area, we strongly believe that Clinical VR applications will become indispensable tools in the toolbox of psychological researchers and practitioners and will only grow in relevance and popularity in the future.
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