Prof. Patrice L. (Tamar) Weisstamar@research.haifa.ac.il

Laboratory for Innovations in Rehabilitation Technology

Department of Occupational TherapyUniversity of Haifa, Israel

Virtual Rehabilitation

Neurological RehabilitationAssessment and intensive therapy to

enable participation of clients in community life by improving motor,

cognitive, and metacognitive abilities as well as activities of daily living.

Neurological RehabilitationAssessment and intensive therapy to

enable participation of clients in community life by improving motor,

cognitive, and metacognitive abilities as well as activities of daily living.

BalanceGait,

EnduranceStrength,Dexterity

Range of Motion

Major Goals for Motor Rehabilitation

Increase level of interaction

with the physical

environment

Decrease impairments

and maximize return to

community life

Key Principles for Motor Rehabilitation

Rehabilitation following a neurological deficit requires:

• task-specific practice• high intensity, repetitive exercise• demanding, • varied, meaningful & purposeful environmental

contexts • increased patient empowerment

(Carr & Shepherd 1987; Winstein 1991; Dean et al. 2000; Lamontagne & Fung, 2005)

Why do we need VR?

Consider conventional therapy…….

StaticBoring

RoteIsolated

Effective?

Why do we need VR?

. . .its well-known assets

MotivatingEcologically valid

DocumentationDynamic

Effective?

“Virtual presence...is experienced by a person when sensory information generated only by and within a computer compels a feeling of being present in an environment other than the one the person is actually in.”

(Sheridan,1992,pg.6)

Virtual Presence – subjective feeling of being present in a simulated environment

A key concept for VR-based therapy: Presence

• increased motivation

• deeper emotional response

• enhanced performance

A high sense of presence may lead to..…

However, the evidence from the literature is still controversialSchuemie et al., 2001

Presence and its relationship to the effectiveness of VR-based

therapy

Low Tech

Virtual Reality Continuum – Desktop Systems

High Tech

Veridian System

Low Tech

Virtual Reality Continuum – Head Mounted Displays

High Tech

Low Tech

Virtual Reality Continuum – Video/Marker Capture

High Tech

Stroke Sony PlayStation II EyeToy

Using VR Games for Different Clinical Populations:Mental retardation (and Cerebral Palsy)

Improving physical fitness of individuals with intellectual and developmental disability through a Virtual Reality

Intervention Program

Objective: To test the effectiveness of a VR-based exercise program in improving the physical fitness of adults with IDD.

Methods:

• Research group (N=30; age range = 37-60 years, mean age = 52.3 ± 5.8 years; IDD level - moderate)

• Matched control group

• Both groups were divided into two sub-groups; ambulatory and wheelchair users

• 5-6 weeks fitness program, two 30 min sessions per week

• game-like exercises provided by the Sony PlayStation II EyeToy video capture VR system

• Pre- and post-intervention changes in physical fitness were monitored by the Energy Expenditure Index (EEI), the modified 12 min walk\run Cooper test and the Total Heart Bit Index (THBI)

Study ParticipantsParametersResearchControl

Demographic parameters

Mean age52.354Age range37-6034-60Males1615Females1216Mean weight 62.866.5

Mean height1.51.6Mean rest pulse 80.472.9Mean activity pulse 97.194.6

Overall N2831Assistive

technologyWheelchair1215Rolator1314Crutches22Walking cane10

FacilityQuitmann1312Kfar Nahman156Ruhama----6Bare Dror----9

Pre-Post Intervention TestsGroupNAmbulation

styleCooper test (m)

Mean ± (SD)Energy

Expenditure Index (EEI)

Mean

Total heart Beat Index

(HB/m )Mean

PrePostPrePostPrePost

Research28All211.8304.3**

*3.472.7428.315.6*

16Walking Aid

340.1486.7**1.20.878.13.9

12Wheelchair40.761.1**6.55.353.531.3

Control31All175.6183.92.12.315.214.8

15Walking Aid

253.3261.41.92.17.58.8

16Wheelchair87.696.12.52.523.921.5

P value <0.05-0.01*P value <0.01-0.001**P value <0.001***

VividGroup’s GX / IREX VR

Birds and Balls

Virtual Environments

Snowboard

Soccer

Using VR Games for Different Clinical Populations

Stroke

Using VR Scenarios for Different Populations

Sample Therapeutic Objectives Used in the VMall :

• Range of motion• Strength• Endurance• Planning• Memory• Multi-tasking

Sample Therapeutic Strategies Used in the VMall :

• Patient with a stroke initially has a list of products that he needs to buy.

• He navigates using the stronger upper extremity first only in a single aisle.

• The products are then located in multiple aisles and he needs to plan an efficient way to purchase them.

• Next he has to listen to the loudspeaker announcements in order to identify which sale products to buy.

• Number, location and distracters can be increased and then use of only impaired upper extremity can be enforced.

The use of the VMall as an intervention tool with post-stroke patients

Objective: To explore the potential of the VMall, a virtual supermarket running on a video-capture VR system, as an

intervention tool for post-stroke participants. Methods :

• Seven post-stroke participants using an A-B-A design

• 10 60-minute sessions using the VMall and other virtual games

• Intervention focused on improving the motor and functional ability of the upper extremity and executive function deficits while the participant was engaged in a task that was similar to the daily functional task of shopping.

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Relative improvement of the Fugl-Meyer Assessment (to assess motor impairment of the weak upper extremity,

scores range from 0-60 points)

Pure Motor Executive Function All & Motor Participants

Intervention phase follow-up

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PM EFM All

Relative improvement of the Arm Function Questionnaire (14 questions about ADL functions graded on

3-point scale ability of weak upper extremity)

Pure Motor Executive Function All & Motor Participants

Intervention phase follow-up

Rel

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imp

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PM EFM All

Percent improvement of time to perform Wolf Motor Function Test

(17 simple tasks to assess functional ability of weak upper extremity)

Pure Motor Executive Function All & Motor Participants

Intervention phase follow-up

Per

cent

im

prov

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Social and

Clinical Validation

Motion Capture (marker-based) systems with dynamic platforms

Motek-CAREN, Haim Sheba, Israel

VR and Motor Rehabilitation:Open Questions

Link to ST

Realism (vividness)Some aspects of realism appear to

be more important than others– Motion– Gravity– Texture– Shadows– Ambient Sound

How important is realism?

And, to whom is it important

Meaningfulness– Context– Relevance

How important is meaning?

“I like soccer the best since it reminds me of my grandson who plays soccer in a professional youth team”.

Larry Hodges ,Georgia Institute of Technology

CAREN System,MOTEK B.V. Amsterdam

Multimodality Number and quality of feedback channels (visual, auditory, haptic, olfactory, vesitbular)

What about more than just audio-visual feedback?

Encumbrance

Can patients cope with encumbrance?

Encumbrance

Can patients cope with encumbrance?

Representation (Fear of Public Speaking, Les

Posen, Australia)

- how the user and others in the VE are represented– 1st Person– 3rd Person– Avatar

Fear of Public Speaking, Slater, London

How should the patient be represented?

How much should it cost?

Versus

There are still some significant limitations

• Subject numbers in clinical effectiveness studies still small

• Time and effort still needed for system development

• New field - therefore tools and terminology still under development

• Unanswered issues still problematic (e.g., encumbrance, 3D, cost)

Is VR effective for motor rehabilitation?

• reliability and validity of many of the VR tools has been demonstrated on control subjects

• clinical feasibility has been demonstrated (with small numbers of patient subjects)

• outcome measures are evolving well

• major research groups are now conducting clinical trials

VR does appear to have great potential for motor rehabilitation!

The bottom line (to date) is. . .

Clinical effectiveness for many VR based interventions for motor rehabilitation will likely be unequivocally demonstrated within the next 2 years.

Given VR’s “added value” (e.g., motivation, ecological validity, safety, documentation), it doesn’t have to be more effective than conventional rehabilitation in order to be useful!

The bottom line is. . .

Caesarea-Rothschild InstituteFondation Ida et Avrohom Baruch

Israeli Ministry of HealthIsraeli Ministry of Defense

Yad Hanadiv-Keren RothschildIsraeli Foundation for Spinal Cord Injured due to Gunshot

Israel Science FoundationKeren Shalem

Koniver FoundationRayne Foundation

AcknowledgementsLaboratory for Innovations

in Rehabilitation TechnologyUniversity of Haifa, Haifa, Israel