Showing papers by "Albert Rizzo published in 2010"

Development of an Interactive Game-Based Rehabilitation Tool for Dynamic Balance Training

Abstract: Conventional physical therapy techniques have been shown to improve balance, mobility, and gait following neurological injury. Treatment involves training patients to transfer weight onto the impaired limb to improve weight shift while standing and walking. Visual biofeedback and force plate systems are often used for treatment of balance and mobility disorders. Researchers have also been exploring the use of video game consoles such as the Nintendo Wii Fit as rehabilitation tools. Case studies have demonstrated that the use of video games may have promise for balance rehabilitation. However, initial usability studies and anecdotal evidence suggest that the current commercial games are not compatible with controlled, specific exercise required to meet therapy goals. Based on focus group data and observations with patients, a game has been developed to specifically target weight shift training using an open source game engine and the Nintendo Wii Fit Balance Board. The prototype underwent initial usability testing with a sample of clinicians and with persons with neurological injury. Overall, feedback was positive, and areas for improvement were identified. This preliminary research provides support for the development of a game that caters specifically to the key requirements of balance rehabilitation.

Development and early evaluation of the Virtual Iraq/Afghanistan exposure therapy system for combat-related PTSD

Abstract: Numerous reports indicate that the growing incidence of posttraumatic stress disorder (PTSD) in returning Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) military personnel is creating a significant health care and economic challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. Virtual reality-delivered exposure therapy for PTSD has been previously used with reports of positive outcomes. The current paper will detail the development and early results from use of the Virtual Iraq/Afghanistan exposure therapy system. The system consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern contexts for exposure therapy, including a city and desert road convoy environment. The process for gathering user-centered design feedback from returning OEF/OIF military personnel and from a system deployed in Iraq (as was needed to iteratively evolve the system) will be discussed, along with a brief summary of results from an open clinical trial using Virtual Iraq with 20 treatment completers, which indicated that 16 no longer met PTSD checklist-military criteria for PTSD after treatment.

Virtual Reality Exposure Therapy for Post-Traumatic Stress Disorder and Other Anxiety Disorders

Abstract: Anxiety disorders, including phobias and post-traumatic stress disorder, are common and disabling disorders that often involve avoidance behavior. Cognitive-behavioral treatments, specifically imaginal and in vivo forms of exposure therapy, have been accepted and successful forms of treatment for these disorders. Virtual reality exposure therapy, an alternative to more traditional exposure-based therapies, involves immersion in a computer-generated virtual environment that minimizes avoidance and facilitates emotional processing. In this article, we review evidence on the application of virtual reality exposure therapy to the treatment of specific phobias and post-traumatic stress disorder and discuss its advantages and cautions.

Virtual reality exposure therapy for combat-related posttraumatic stress disorder.

Abstract: Posttraumatic stress disorder (PTSD) is a chronic, debilitating, psychological condition that occurs in a subset of individuals who experience or witness life-threatening traumatic events. PTSD is highly prevalent in those who served in the military. In this paper, we present the underlying theoretical foundations and existing research on virtual reality exposure therapy, a recently emerging treatment for PTSD. Three virtual reality scenarios used to treat PTSD in active duty military and combat veterans and survivors of terrorism are presented: Virtual Vietnam, Virtual Iraq, and Virtual World Trade Center. Preliminary results of ongoing trials are presented.

Improvement in cerebral function with treatment of posttraumatic stress disorder.

Abstract: Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are signature illnesses of the Iraq and Afghanistan wars, but current diagnostic and therapeutic measures for these conditions are suboptimal. In our study, functional magnetic resonance imaging (fMRI) is used to try to differentiate military service members with: PTSD and mTBI, PTSD alone, mTBI alone, and neither PTSD nor mTBI. Those with PTSD are then randomized to virtual reality exposure therapy or imaginal exposure. fMRI is repeated after treatment and along with the Clinician-Administered PTSD Scale (CAPS) and Clinical Global Impression (CGI) scores to compare with baseline. Twenty subjects have completed baseline fMRI scans, including four controls and one mTBI only; of 15 treated for PTSD, eight completed posttreatment scans. Most subjects have been male (93%) and Caucasian (83%), with a mean age of 34. Significant improvements are evident on fMRI scans, and corroborated by CGI scores, but CAPS scores improvements are modest. In conclusion, CGI scores and fMRI scans indicate significant improvement in PTSD in both treatment arms, though CAPS score improvements are less robust.

Methylphenidate effect in children with ADHD can be measured by an ecologically valid continuous performance test embedded in virtual reality.

Abstract: BACKGROUND: Continuous performance tasks (CPTs) embedded in a virtual reality (VR) classroom environment have been shown to be a sensitive and user-friendly assessment tool to detect cognitive deficits related to attention-deficit/hyperactivity disorder (ADHD). The aim of the current study was to compare the performance of children with ADHD on a VR-CPT while on and off treatment with methylphenidate (MPH) and to compare the VR-CPT to a currently used CPT, Test of Variables of Attention (TOVA). METHODS: Twenty-seven children with ADHD underwent the VR-CPT, the same CPT without VR (no VR-CPT), and the TOVA, 1 hour after the ingestion of either placebo or 0.3 mg/kg MPH, in a double-blind, placebo-controlled, crossover design. Immediately following CPT, subjects described their subjective experiences on the Short Feedback Questionnaire. RESULTS: MPH reduced omission errors to a greater extent on the VR-CPT compared to the no VR-CPT and the TOVA, and decreased other CPT measures on all types of CPT to a similar degree. Children rated the VR-CPT as more enjoyable compared to the other types of CPT. CONCLUSIONS: It is concluded that the VR-CPT is a sensitive and user-friendly assessment tool in measuring the response to MPH in children with ADHD.

User-centered virtual environment design for virtual rehabilitation

Abstract: Background: As physical and cognitive rehabilitation protocols utilizing virtual environments transition from single applications to comprehensive rehabilitation programs there is a need for a new design cycle methodology. Current human-computer interaction designs focus on usability without benchmarking technology within a user-inthe-loop design cycle. The field of virtual rehabilitation is unique in that determining the efficacy of this genre of computer-aided therapies requires prior knowledge of technology issues that may confound patient outcome measures. Benchmarking the technology (e.g., displays or data gloves) using healthy controls may provide a means of characterizing the “normal” performance range of the virtual rehabilitation system. This standard not only allows therapists to select appropriate technology for use with their patient populations, it also allows them to account for technology limitations when assessing treatment efficacy. Methods: An overview of the proposed user-centered design cycle is given. Comparisons of two optical seethrough head-worn displays provide an example of benchmarking techniques. Benchmarks were obtained using a novel vision test capable of measuring a user’s stereoacuity while wearing different types of head-worn displays. Results from healthy participants who performed both virtual and real-world versions of the stereoacuity test are discussed with respect to virtual rehabilitation design. Results: The user-centered design cycle argues for benchmarking to precede virtual environment construction, especially for therapeutic applications. Results from real-world testing illustrate the general limitations in stereoacuity attained when viewing content using a head-worn display. Further, the stereoacuity vision benchmark test highlights differences in user performance when utilizing a similar style of head-worn display. These results support the need for including benchmarks as a means of better understanding user outcomes, especially for patient populations. Conclusions: The stereoacuity testing confirms that without benchmarking in the design cycle poor user performance could be misconstrued as resulting from the participant’s injury state. Thus, a user-centered design cycle that includes benchmarking for the different sensory modalities is recommended for accurate interpretation of the efficacy of the virtual environment based rehabilitation programs.

House calls revisited: leveraging technology to overcome obstacles to veteran psychiatric care and improve treatment outcomes

Abstract: Despite an increasing number of military service members in need of mental health treatment following deployment to Iraq and Afghanistan, numerous psychological and practical barriers limit access to care. Perceived stigma about admitting psychological difficulties as well as frequent long distances to treatment facilities reduce many veterans' willingness and ability to receive care. Telemedicine and virtual human technologies offer a unique potential to expand services to those in greatest need. Telemedicine-based treatment has been used to address multiple psychiatric disorders, including posttraumatic stress disorder, depression, and substance use, as well as to provide suicide risk assessment and intervention. Clinician education and training has also been enhanced and expanded through the use of distance technologies, with trainees practicing clinical skills with virtual patients and supervisors connecting with clinicians via videoconferencing. The use of these innovative and creative vehicles offers a significant and as yet unfulfilled promise to expand delivery of high-quality psychological therapies, regardless of clinician and patient location.

Use of immersive virtual reality for treating anger.

Abstract: Poorly managed anger responses can be detrimental to one's physical and psychosocial well-being. Cognitive behavior therapies (CBT) have been found to be effective in treating anger disorders. A key component of CBT treatment is exposure to the anger arousing stimuli. Virtual reality (VR) environments can elicit potent reactions and may facilitate the treatment of anger. An anger VR environment with six video vignettes was developed by this study to examine the anger arousal potential of VR. Outcome measures included assessment of emotional reactivity, state anger, and presence. The results showed that significant anger arousal occurred during exposure to the VR environment, and arousal was greater when viewed in an immersive HMD than a non-immersive flat screen. In addition, presence was found to moderate the effects of VR. Low presence resulted in low reactivity regardless of the display modality.

Development of an interactive rehabilitation game using the Nintendo WiiFit Balance Board for people with neurological injury

Abstract: Visual biofeedback and force plate systems are often used for treatment of balance and mobility disorders following neurological injury. Conventional Physical Therapy techniques have been shown to improve balance, mobility and gait. The training program encourages patients to transfer weight onto the impaired limb in order to improve weight shift in standing and during gait. Researchers and therapists have been exploring the use of video game consoles such as the Nintendo® WiiFitTM as rehabilitation tools. Initial case studies have demonstrated that the use of video games has some promise for balance rehabilitation. However, initial usability studies and anecdotal evidence has indicated that the commercial games that are currently available are not necessarily suitable for the controlled, specific exercise required for therapy. Based on focus group data and observations with patients, a game has been developed to specifically target weight shift training using an open source game engine and the WiiFit balance board. The prototype underwent initial usability testing with a sample of four Physical Therapists and four patients with neurological injury or disease. Overall, feedback was positive and areas for improvement were identified. This preliminary research provides support for the development of a game that caters specifically to the key requirements of balance rehabilitation.

A New Generation of Intelligent Virtual Patients for Clinical Training

Abstract: Over the last 15 years, a virtual revolution has taken place in the use of Virtual Reality simulation technology for clinical purposes. Recent shifts in the social and scientific landscape have now set the stage for the next major movement in Clinical Virtual Reality with the “birth” of intelligent virtual humans. Seminal research and development has appeared in the creation of highly interactive, artificially intelligent and natural language capable virtual human agents that can engage real human users in a credible fashion. No longer at the level of a prop to add context or minimal faux interaction in a virtual world, virtual human representations can be designed to perceive and act in a 3D virtual world, engage in face-to-face spoken dialogues with real users (and other virtual humans) and in some cases, they are capable of exhibiting human-like emotional reactions. This paper will present a brief rationale and overview of their use in clinical training and then detail our work developing and evaluating artificially intelligent virtual humans for use as virtual standardized patients in clinical training with novice clinicians. We also discuss a new project that uses a virtual human as an online guide for promoting access to psychological healthcare information and for assisting military personnel and family members in breaking down barriers to initiating care. While we believe that the use of virtual humans to serve the role of virtual therapists is still fraught with both technical and ethical concerns, we have had success in the initial creation of virtual humans that can credibly mimic the content and interaction of a patient with a clinical disorder for training purposes. As technical advances continue, this capability is expected to have a significant impact on how clinical training is conducted in psychology and medicine.

A simple camera tracking virtual reality system for evaluation of wrist range of motion

Abstract: Clinicians assess wrist and hand function to identify pathology, monitor effectiveness of treatment, and determine the readiness to return to work and other activities The goniometer, the conventional evaluation tool used to assess range of motion (ROM), is most suited to the measurement of passive and active joint ROM under conditions that entail static, nonfunctional movements Instruments that measure ROM during complex, dynamic tasks may encumber the movement We have adapted a simple optical tracking device that uses a lowcost webcam to track two diodes, referred to as the Virtual Wrist Tracker (VWT), to assess wrist ROM in 30 subjects, aged 18-65 years; fifteen patients had sustained orthopaedic injuries and 15 were control subjects ROM was assessed by a standard goniometer and by the VWT under two conditions: visual auditory feedback and auditory pacing feedback The results of test-retest analysis of control subjects demonstrated good reliability for the VWT during wrist extension and moderate reliability during wrist flexion High, significant correlations were found between the ROM for wrist extension and flexion as measured by a goniometer and via the VWT in the research group and for wrist extension but not for wrist flexion in the control group A repeated measures ANOVA mixed design showed no significant differences in wrist extension ROM or in wrist flexion ROM during the performance of the task with visual and auditory feedback versus a task with auditory pacing, nor was there interaction effects between task type and group during extension and flexion Wrist ROM in either direction increased as the participant progressed from one target rectangle to the next; statistically significant interaction effect was found between ROM in target position and group indicating that the difference between the targets in the control group was significantly different than in the research group Finally, both groups enjoyed performing the VWT tasks but the control subjects felt greater presence, success and control The VWT appears to be a reliable and valid tool for assessing wrist ROM during dynamic activities

Development of an interactive stepping game to reduce falls in the elderly

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

Comparing Virtual Reality Exposure Therapy to Prolonged Exposure in the Treatment of Soldiers with PTSD

Abstract: : Prolonged exposure (PE) is one of the most researched psychotherapies for PTSD. Virtual reality exposure (VRE) has demonstrated growing support as an innovative method for activating the trauma memory during exposure. However, there is limited research on the effectiveness of either treatment with active duty military personnel and there are no head-to-head clinical trials. Soldiers with PTSD from deployments to Iraq or Afghanistan (N = 162) were randomized to 10 sessions of either PE or VRE or were assigned to a minimal attention wait list. All assessments were conducted by a psychologist blind to treatment group. External, independent treatment fidelity reviews were conducted for both treatments. Service members were assessed before randomization, after 5 sessions, at posttreatment, and 3-and 6-months posttreatment. PTSD was assessed with the Clinician Administered PTSD Scale (CAPS). Data were analyzed at the end of the performance period for this study but prior to the end of the period of performance for another grant/recruitment site. Results indicated significant improvement in symptoms for PE and VRE relative to the waitlist control. Contrary to expectations, PE demonstrated greater PTSD symptom reduction relative to VRE, which was statistically significant at the 12-week follow-up assessment. These findings extend previous findings on the efficacy of exposure therapy to an active duty military population and highlight important areas for future research of VRE.

Breath: a game to motivate the compliance of breathing exercises.

Abstract: Vol 21 ❖ No 4 ❖ December 2010 26 using standardized equations from the American College of Sports Medicine. Results: Pearson correlation coefficient values and standard estimates of error were calculated for all sub-maximal oxygen consumption tests in comparison to the 1.5 mile run. Data for runners: Astrand-Rhyming (r = 0.509, SEE = 3.34); Single-Stage Treadmill Walking Test (r = 0.828, SEE = 2.17); Single-Stage Treadmill Jogging Test (r = 0.849, SEE = 2.04). Data for cyclists: Astrand-Rhyming (r = 0.724, SEE = 2.79); Single-Stage Treadmill Walking Test (r = 0.556, SEE = 4.46); Single-Stage Treadmill Jogging Test (r = 0.918, SEE = 2.12). Combined data: Astrand-Rhyming (r = 0.520, SEE = 3.34); Single-Stage Treadmill Walking Test (r = 0.516, SEE = 3.71); Single-Stage Treadmill Jogging Test (r = 0.847, SEE = 2.30). Conclusions: The Single-Stage Sub-maximal Treadmill Jogging Test had a high correlation and small standard estimate of error in both runners and cyclists. When data from runners and cyclists were combined, the treadmill jog test maintained a high correlation value of 84.7%. These data indicate that use of a simple treadmill jog test is a good clinical predictor of maximal oxygen consumption in both runners and cyclists. In contrast, the Astrand-Rhyming Cycle Ergometer test poorly correlated to maximal oxygen consumption values in runners, and only marginally correlated in cyclists. Clinical Relevance: Results from this study may be used as a reference to select appropriate sub-maximal VO2 tests to prescribe cardiovascular intensity levels. Future Studies: Different versions of sub-maximal VO2 testing should be selected for comparison to maximal tests such as the 1.5 mile run. In addition, utilizing a maximal oxygen consumption test based on cycling versus running might yield a higher correlation to the sub-maximal Astrand-Rhyming cycle test, especially in competitive cyclists.