Showing papers by "Albert Rizzo published in 2009"

Virtual reality in paediatric rehabilitation: A review

Abstract: Objective: To provide a narrative review of studies regarding the outcomes of Virtual Reality (VR)-based treatment and rehabilitation programmes within the paediatric population. Methods: Studies related to the use of VR across a number of paediatric areas (e.g. cerebral palsy, autism, foetal alcohol syndrome and attention deficits) were identified and summarized. Results: Outcomes from the studies reviewed provide preliminary support for the use of VR. Conclusion: VR may be an effective treatment method for specific disorders, although the generalizability of this literature is hindered by several methodological limitations, such as small samples and the absence of appropriate control participants.

Initial usability assessment of off-the-shelf video game consoles for clinical game-based motor rehabilitation

Abstract: Aims/background: Off-the-shelf games for consoles such as the Nintendo Wii, Nintendo WiiFit and Sony PlayStation 2 EyeToy have been developed and tested for the purpose of entertainment. Many clinics are adopting the use of these off-the-shelf devices for exercise, social interaction and rehabilitation because they are affordable, accessible and can be used within the clinic and home. Our group carried out initial usability evaluations for these off-the-shelf games and a prototype game (using an off-the-shelf device) specifically developed for people with disabilities. Methods: A series of studies have been undertaken through formative and summative evaluation and focus group research with a sample of people recovering from spinal cord injury, traumatic brain injury and stroke. Findings from two studies are presented. Following a demonstration and trial of the devices, observational and questionnaire data were collected to determine participants' perception of each system's usability, appeal and ...

Distractibility in Attention/Deficit/ Hyperactivity Disorder (ADHD): the virtual reality classroom.

Abstract: Nineteen boys aged 8 to 14 with a diagnosis of ADHD and 16 age-matched controls were compared in a virtual reality (VR) classroom version of a continuous performance task (CPT), with a second standard CPT presentation using the same projection display dome system. The Virtual Classroom included simulated "real-world" auditory and visual distracters. Parent ratings of attention, hyperactivity, internalizing problems, and adaptive skills on the Behavior Assessment System for Children (BASC) Monitor for ADHD confirmed that the ADHD children had more problems in these areas than controls. The difference between the ADHD group (who performed worse) and the control group approached significance (p = .05; adjusted p = .02) in the Virtual Classroom presentation, and the classification rate of the Virtual Classroom was better than when the standard CPT was used (87.5% versus 68.8%). Children with ADHD were more affected by distractions in the VR classroom than those without ADHD. Results are discussed in relation to distractibility in ADHD.

Virtual reality exposure therapy for combat-related PTSD.

Abstract: War is one of the most challenging environments that a human can experience. The cognitive, emotional, and physical demands of a combat environment place enormous stress on even the best-prepared military personnel. The OEF-OIF (Operation Enduring Freedom-Operation Iraqi Freedom) combat theatre, with its ubiquitous battlefronts, ambiguous enemy identification, and repeated extended deployments, was anticipated to produce significant numbers of military personnel with post-traumatic stress disorder (PTSD) and other mental disorders. Recent studies are now confirming this expectation. Among the many approaches that have been used to treat PTSD, exposure therapy appears to have the best-documented therapeutic efficacy. Such treatment typically involves the graded and repeated imaginal reliving of the traumatic event within the therapeutic setting and is believed to provide a low-threat context in which the patient can begin to therapeutically process trauma-relevant emotions as well as decondition the learning cycle of the disorder via a habituation/extinction process. While the efficacy of imaginal exposure has been established in multiple studies with diverse trauma populations, many patients are unwilling or unable to effectively visualize the traumatic event. To address this problem, researchers have recently turned to the use of virtual reality (VR) to deliver exposure therapy by immersing patients in simulations of trauma-relevant environments that allow for precise control of stimulus conditions. This chapter presents an overview of PTSD exposure therapy, a description of VR, and the rationale for how this technology has been applied as a tool to deliver exposure therapy along with a brief review of current research. We then provide a description of the current Virtual Iraq exposure therapy system and treatment protocol and present initial results from an open clinical trial with active duty military personnel and a brief case study. The chapter concludes with a summary of future directions in which VR technology can be further applied to more comprehensively address a range of PTSD-relevant issues.

The Utility of a Continuous Performance Test Embedded in Virtual Reality in Measuring ADHD-Related Deficits:

Abstract: :Objective:Continuous performance tasks (CPT) are popular in the diagnostic process of Attention Deficit/Hyperactivity Disorder (ADHD), providing an objective measure of attention for a disorder with otherwise subjective criteria. Aims of the study were to: (1) compare the performance of chi

Experimental Evidence for Suspense as Determinant of Video Game Enjoyment

Abstract: Based on theoretical assumptions from film psychology and their application to video games, the hypothesis is tested that suspense is a major factor in video game enjoyment. A first-person...

Game-based telerehabilitation.

Abstract: This article summarizes the recent accomplishments and current challenges facing game-based virtual reality (VR) telerehabilitation. Specifically this article addresses accomplishments relative to realistic practice scenarios, part to whole practice, objective measurement of performance and progress, motivation, low cost, interaction devices and game design. Furthermore, a description of the current challenges facing game based telerehabilitation including the packaging, internet capabilities and access, data management, technical support, privacy protection, seizures, distance trials, scientific scrutiny and support from insurance companies.

VR PTSD exposure therapy results with active duty OIF/OEF combatants.

Abstract: Post Traumatic Stress Disorder (PTSD) is reported to be caused by traumatic events that are outside the range of usual human experience including military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Reports indicate that at least 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality exposure therapy has been previously used for PTSD with reports of positive outcomes. This paper will present a brief description of the USC/ICT Virtual Iraq/Afghanistan PTSD therapy application and present clinical outcome data from active duty patients treated at the Naval Medical Center-San Diego (NMCSD) as of October 2009. Initial outcomes from the first twenty patients to complete treatment indicate that 16 no longer meet diagnostic criteria for PTSD at post treatment. Research and clinical tests using the Virtual Iraq/Afghanistan software are also currently underway at Weill Cornell Medical College, Emory University, Fort Lewis and WRAMC along with 20 other test sites.

Soldier evaluation of the virtual reality Iraq.

Abstract: The treatment of posttraumatic stress disorder (PTSD) is challenging, and the value of realistic virtual reality (VR) scenarios has been implied in order to activate the traumatic memory in exposure therapy. Furthermore, evocation of the memory by VR is assumed to be more acceptable to the patient for this treatment approach. A VR Iraq experience was developed for a convoy event and urban event. Ninety-three soldiers returning in the last year who screened negative for PTSD evaluated the material of the two scenarios and rated them adequate to excellent by over 80%. Clinical trials are to follow.

Development and Clinical Results from the Virtual Iraq Exposure Therapy Application for PTSD

Abstract: Post Traumatic Stress Disorder (PTSD) is reported to be caused by exposure to an extreme traumatic stressor involving direct personal experience of (or witnessing/learning about) an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Such incidents would be distressing to almost anyone, and are usually experienced with intense fear, horror, and helplessness. Initial data suggests that at least 1 out of 5 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality (VR) delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. The current paper will present the rationale and description of a VR PTSD therapy application (Virtual Iraq/Afghanistan) and present initial findings from a number of early studies of its use with active duty service members. Virtual Iraq/Afghanistan consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern VR contexts for exposure therapy, including a city and desert road convoy environment. User-centered design feedback needed to iteratively evolve the system was gathered from returning Iraq War veterans in the USA and from a system deployed in Iraq and tested by an Army Combat Stress Control Team. Results from an open clinical trial using Virtual Iraq with 20 treatment completers indicated that 16 no longer met PTSD diagnostic criteria at post-treatment, with only one not maintaining treatment gains at 3 month follow-up.

Human Computer Interaction in Virtual Standardized Patient Systems

Abstract: Interactive computer generated characters can be applied to the medical field as virtual patients for clinical training. The user interface for the virtual characters takes on the same appearance and behavior as a human. To assess if these virtual patients can be used to train skills such as interviewing and diagnosis they need to respond as a patient would. The primary goal of this study was to investigate if clinicians could elicit proper responses from questions relevant for an interview from a virtual patient. A secondary goal was to evaluate psychological variables such as openness and immersion on the question/response composites and the believability of the character as a patient.

Neurocognitive Workload Assessment Using the Virtual Reality Cognitive Performance Assessment Test

Abstract: The traditional approach to assessing neurocognitive performance makes use of paper and pencil neuropsychological assessments. This received approach has been criticized as limited in the area of ecological validity. While virtual reality environments provide increased ecological validity, they are often done without taking seriously the demands of rigorous research design and control for potentially confounding variables. The newly developed Virtual Reality Cognitive Performance Assessment Test (VRCPAT) focuses upon enhanced ecological validity using virtual environment scenarios to assess neurocognitive processing. After an assessment for potential confounds (i.e. appropriate level of immersion and performance on neuropsychological measures), the VRCPAT battery's Attention Module (i.e. Humvee scenario) was administered to a sample of healthy adults. Findings suggest that increase in stimulus complexity and stimulus intensity can manipulate attention performance within the Attention Module.

Neurocognitive and psychophysiological analysis of human performance within virtual reality environments.

Abstract: Monitoring the neurocognitive and psychophysiological activity of persons operating within a complex environment poses exacting measurement challenges. Three experiments are reported in this paper. In these experiments we made use of VRCPAT to assess persons' neurocognitive and psychophysiological responses to high-fidelity, immersive virtual environments. The first experiment provided continued support for the validity of the VRCPAT as a measure of learning and memory through the use of an increased sample size. In the second experiment we aimed at assessing whether an increase in stimulus complexity would result in a significant decrease in performance on attentional tasks. We also wanted to see whether an increase in stimulus intensity would result in a significant decrease in performance on attentional tasks. The third experiment looked at participants' psychophysiological responses in both low and high immersion virtual environments.

Virtual reality in rehabilitation of attention deficit / hyperactivity disorder The instrument construction principles

Abstract: Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric childhood disorders. Good clinical practices are therefore needed regarding both assessment and therapy. In which assessment is concerned, valid instruments are available, one of the last developments in the field being the virtual reality guided assessment (VirtualClassroom). Regarding intervention, the multimodal, cognitive behavioral therapy (CBT) oriented approach is the most frequently employed. However, this approach has some limitations, one of them concerning ecological validity. Our VR-based intervention addresses this issue, by providing a high ecological validity therapeutic tool. We do not propose a new therapeutic paradigm. We instead move the intervention from the clinician's office into the virtual classroom, where we still use cognitive restructuring and the behavioral techniques of the classic intervention. This paper highlights the implementation of the psychotherapeutic principles involved in ADHD therapy in the VR environment. The different features of this instrument are designed to address specific cognitive-behavioral modifications involved in the therapeutic process.

Assessment of Psychophysiological Differences of West Point Cadets and Civilian Controls Immersed within a Virtual Environment

Abstract: An important question for ecologically valid virtual environments is whether cohort characteristics affect immersion. If a method for assessing a certain neurocognitive capacity (e.g. attentional processing) is adapted to a cohort other than the one that was used for the initial normative distribution, data obtained in the new cohort may not be reflective of the neurocognitive capacity in question. We assessed the psychophysiological impact of different levels of immersion upon persons from two cohorts: 1) civilian university students; and 2) West Point Cadets. Cadets were found to have diminished startle eyeblink amplitude compared with civilians, which may reflect that cadets experienced less negative affect during the scenario in general. Further, heart rate data revealed that Cadets had significantly lower heart rates than Civilians in the "low" but not "high" immersion condition. This suggests that "low" immersion conditions may not have the ecological validity necessary to evoke consistent affect across cohorts.

A Virtual Human Agent for Assessing Bias in Novice Therapists

Abstract: Monitoring the psychological and physiological activity of persons interacting with virtual humans poses exacting measurement challenges. Three experiments are reported in this paper. In these experiments we made use of Virtual Human Agent technology to assess persons' psychological and physiological responses to Virtual Standardized Patients. The first experiment provided support for the usability of the Virtual Standardized Patients through the use of a virtual character emulating an adolescent male with conduct disorder. In the second experiment we further developed the technology and aimed at assessing whether novice mental health clinicians could conduct an interview with a virtual character that emulates an adolescent female who has recently been physically traumatized. The third experiment looked at the usability of Virtual Standardized Patients for eliciting psychophysiological responses following exposure to virtual humans representing different ethnicities.

A Virtual Iraq System for the Treatment of Combat-Related Posttraumatic Stress Disorder

Abstract: Posttraumatic Stress Disorder (PTSD) is reported to be caused by traumatic events that are outside the range of usual human experience including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggests that at least 1 out of 5 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality (VR) delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. The current paper is a follow-up to a paper presented at IEEE VR2006 and will present the rationale and description of a VR PTSD therapy application (Virtual Iraq) and present the findings from its use with active duty service members since the VR2006 presentation. Virtual Iraq consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern VR contexts for exposure therapy, including a city and desert road convoy environment. User-centered design feedback needed to iteratively evolve the system was gathered from returning Iraq War veterans in the USA and from a system deployed in Iraq and tested by an Army Combat Stress Control Team. Results from an open clinical trial using Virtual Iraq at the Naval Medical Center-San Diego with 20 treatment completers indicate that 16 no longer met PTSD diagnostic criteria at post-treatment, with only one not maintaining treatment gains at 3 month follow-up.

Breath: A game to motivate the compliance of postoperative breathing exercises

Abstract: The use of breathing exercises post surgery can reduce pulmonary complications. Incentive spirometry is a widely used device that provides visual feedback for patients during breathing exercises. This paper describes the initial development of an interaction device, game design and initial playtesting and usability of a game to motivate patients to perform post operative breathing exercises.

Virtual Reality in the Rehabilitation of Attention Deficit / Hyperactivity Disorder. Instrument Construction Principles

Abstract: Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric childhood disorders. Good clinical practices are therefore needed regarding both assessment and therapy. In which assessment is concerned, valid instruments are available, one of the last developments in the field being the virtual reality guided assessment (VirtualClassroom). Regarding intervention, the multimodal, cognitive behavioral therapy (CBT) oriented approach is the most frequently employed. However, this approach has some limitations, one of them concerning ecological validity. Our VR-based intervention addresses this issue, by providing a high ecological validity therapeutic tool. We do not propose a new therapeutic paradigm. We instead move the intervention from the clinician's office into the virtual classroom, where we still use cognitive restructuring and the behavioral techniques of the classic intervention. This paper highlights the implementation of the psychotherapeutic principles of ADHD therapy in the VR environment. The different features of this instrument are designed to address specific cognitive-behavioral modifications involved in the therapeutic process. Keywords: VR, ADHD, CBT, psychotherapy Virtual reality (VR) is being increasingly used in a number of psychotherapy and rehabilitation contexts (Glanz, Rizzo, & Graap, 2003). An important feature of VR is its capacity to deliver environments that allow precise control of complex, immersive, and dynamic three-dimensional stimulus presentations, where sophisticated interaction, behavioral tracking and performance recording is possible (Rizzo, 2006). These environments can be used for assessment, training or treatment purposes, and can address situations that are not easily deliverable or controllable in the "real-world", leading to enhanced ecological validity. Treatment in ADHD Attention-deficit/hyperactivity disorder (ADHD) is among the most prevalent psychiatric childhood disorders, affecting 8% to 10% of children (Baren, 2002) and persisting into adolescence in approximately 80% of cases (Baren, 1998; Schubiner, Robin, & Neustern, 1996). However, ADHD is largely considered a childhood disorder, so most patients are diagnosed during childhood. The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition) definition of ADHD requires symptoms to be present before the age of 7 years (DSM-IV-TR, 2000). Accurate ADHD diagnosis in this age group is particularly important because of the impact of untreated ADHD on adolescents, their immediate family, and society as a whole. If the condition remains untreated, the adolescent is likely to underachieve in school, leading to poor employment prospects (Baren, 2002). Relationships with family, peers, teachers, and employers are likely to be fraught with difficulties, further impacting on educational and employment prospects and leading to poor social relationships (Baren, 2002). Adolescents with ADHD are more likely to become involved in risk-taking behaviors such as reckless driving, risky sexual activities, substance abuse, and criminality (Barkley, Fischer, Edelbrock, & Smallish, 1990) which may negatively affect their life into adulthood. Clinical research and consensus guidelines on the treatment of ADHD over the past few years have increasingly clarified the most effective treatment approaches. A recent review of evidence based psychosocial treatments for children and adolescents with ADHD indicates that there is adequate evidence for behavioral parent training and behavioral school interventions that has resulted in such treatments being classified as empirically validated interventions (Chronis, Jones, & Raggi, 2006). Both behavioral parent training and classroom behavior management involve teaching parents and teachers to use behavior modification strategies based on social learning principles, such as praise, positive attention and rewards to increase positive behavior, and ignoring, timeout and non - physical disciplining strategies to decrease unwanted behavior. …

Evaluation of Novice and Expert Interpersonal Interaction Skills with a Virtual Patient

Abstract: Interactive Virtual Standardized Patients (VP) can provide meaningful training for clinicians. These VP's portray interactive embodied conversational characters with realistic representations of a mental or physical problem to be diagnosed or discussed. This research is a continuation of evaluating of our VP "Justina" [2] which suffers from Posttraumatic Stress Disorder (PTSD) from a sexual attack and presents the results of comparing novices, test subjects without medical training, and experts interacting with `Justina' to find out if they could elicit the proper responses to make a diagnosis and to investigate the topics and questions the novices asked for coverage of the categories and criteria of PTSD as defined in the DSM-IV [1]. It is assumed that novices will perform better than experts, however the main investigation is to gather empirical data and understand why this is true and how this can be used to improve the system. There have not been, to the authors' knowledge, any studies in evaluating experts and non-experts with virtual human characters in the psychological domain.

Optimizing Clinical Training for the Treatment of PTSD Using Virtual Patients.

Abstract: Adequate treatment of PTSD is a growing concern for the military. However, there is a shortage of qualified personnel available to apply this treatment. Virtual patient systems offer a novel technology to enhance the training needs of such health providers. This pilot project builds on previous work done with virtual patients and describes a novel scenario wherein a virtual patient is immersed within an exposure therapy simulation while a clinician interacts and guides the virtual patient through the recovery process using exposure therapy for PTSD. While this work is ongoing, preliminary results will be presented.

A Comparative Analysis between Experts and Novices Interacting with a Virtual Patient with PTSD.

Abstract: Virtual patients will provide a means to train the next generation of clinical residents. Interacting and engaging with virtual characters portraying standardized patients can have meaningful outcomes. As a cumulative set of data analysis, we investigate the comparison of how well novices, subjects without any clinical interviewing background, with experts, clinicians, or resident student clinicians with interviewing skills to assess if they could elicit the proper information from verbal interactions with a virtual character.

Considerations for Designing Response Quantification Procedures in Non-traditional Psychophysiological Applications

Abstract: Psychophysiological assessment in the context of virtual environments is a promising means for benchmarking the efficacy and ecological validity of virtual reality scenarios. When applied to human-computer interaction, psychophysiological and affective computing approaches may increase facility for development of the next generation of human-computer systems. Such systems have the potential to use psychophysiological signals for user-feedback and adaptive responding. As the composition of investigating teams becomes diverse in keeping with interdisciplinary trends, there is a need to review de-facto standards of psychophysiological response quantification and arrive at consensus protocols adequately addressing the concerns of basic researchers and application developers. The current paper offers a demonstration of the ways in which such consensus scoring protocols may be derived. Electromyographic eye-blink scoring from an immersion investigation is used as an illustrative case study.

Application Development and Clinical Results from a Virtual Iraq System for the Treatment of Iraq War PTSD

Abstract: Post Traumatic Stress Disorder (PTSD) is reported to be caused by traumatic events that are outside the range of usual human experience including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggests that at least 1 out of 5 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality (VR) delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. The current paper is a follow-up to a paper presented at IEEE VR2006 and will present the rationale and description of a VR PTSD therapy application (Virtual Iraq) and present the findings from its use with active duty service members since the VR2006 presentation. Virtual Iraq consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern VR contexts for exposure therapy, including a city and desert road convoy environment. User-centered design feedback needed to iteratively evolve the system was gathered from returning Iraq War veterans in the USA and from a system deployed in Iraq and tested by an Army Combat Stress Control Team. Results from an open clinical trial using Virtual Iraq at the Naval Medical CenterSan Diego with 20 treatment completers indicate that 16 no longer met PTSD diagnostic criteria at post-treatment, with only one not maintaining treatment gains at 3 month follow-up.

Computer-based visuospatial and wayfindng assessment for mild dementia of the Alzheimer's type: Preliminary results of healthy control group

Abstract: Background: Word finding difficulty, assessed by naming tests, has been considered as a symptom for diagnosis of MCI, but the integrity and functioning of semantic, lexical and phonological processes involved in that difficulty is a controversial issue. Our aim is to contribute to that controversy investigating tip-of-the-tongue events (TOTs) in MCI subjects. Methods: 28 multi-domain MCI subjects and 50 normal elderly (NE) subjects participated in an experimental task of naming from 50 famous persons pictures (familiarity controlled) included into a paradigm for facilitating TOTs for proper names. Results: The number of TOTs was significantly greater and the number of correct names was significantly lower in MCI group than in the NE group after controlling age and level of education as covariables. No differences on production of errors and semantic paraphasias were fund. Conclusions: Our findings suggest that lexical access difficulty in MCI may be produced, according to the transmission deficit hypothesis, by a transmission deficit from the semantic representations to the phonological representations, and that this deficit is stronger in MCI than in normal aging.

An overview of a USC Rehabilitation Engineering Research Center: The use of virtual reality for a range of motor impairments

Abstract: This paper describes the use of Virtual Reality in four projects within a Rehabilitation Engineering Research Center at the University of Southern California. The Research Center aims to develop and assess a range of technologies for people aging with and into a disability. One of the deliverables of this Center will be the development of a Virtual Rehabilitation Toolkit, a series of Virtual Reality video based games for use with a range of impairments for a variety of disabilities including spinal cord injury, traumatic brain injury, stroke, Parkinson's disease, and cerebral palsy.

Human Computer Interaction in Virtual Standardized Patient Systems

Abstract: Interactive computer generated characters can be applied to the medical field as virtual patients for clinical training. The user interface for the virtual characters takes on the same appearance and behavior as a human. To assess if these virtual patients can be used to train skills such as interviewing and diagnosis they need to respond as a patient would. The primary goal of this study was to investigate if clinicians could elicit proper responses from questions relevant for an interview from a virtual patient. A secondary goal was to evaluate psychological variables such as openness and immersion on the question/response composites and the believability of the character as a patient.