Neurological Rehabilitation

1. Applications of virtual reality to motor and cognitive rehabilitationProf. Tamar WeissDept. of Occupational TherapyUniversity of Haifatamar@research.haifa.ac.ilDept. of Occupational TherapyFaculty of Social

2. Neurological Rehabilitation • Assessment and intensive therapy to enable participation of clients in community life…..

3. Range of Motion Strength, Endurance Neurological Rehabilitation • Assessment 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. Attention, Dexterity Balance

4. Range of Motion Gait, Endurance Strength, Dexterity Neurological Rehabilitation • Assessment 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. Balance

5. Major Goals for Rehabilitation • Increase level of interaction with the environment • Decrease impairments & maximize return to community life

6. Key Principles for Rehabilitation • Rehabilitation following a neurological deficit requires: • task-specific practice • high intensity, repetitive exercise • activities that can be graded to be demanding but feasible • varied, meaningful & purposeful environmental contexts • increased patient empowerment and participation • (Carr & Shepherd 1987; Winstein 1991; Dean et al. 2000; Lamontagne & Fung, 2005)

7. Enter Virtual Reality Applying interactive simulations created with computer hardware and software to present users with opportunities to engage in environments that appear and feel similar to real world objects and events

8. Why do we need VR for rehabilitation? Consider conventional therapy Boring Isolated Static Rote Effective?

9. Why do we need VR for rehabilitation? . . . its well-known assets Motivating Ecologically valid Documentation Dynamic Effective?

10. Why do we need VR for rehabilitation? its well-known assets Motivating Ecologically valid Documentation Dynamic Effective?

11. Key concept for VR-based therapy: Presence “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

12. Presence and its relationship to the effectiveness of VR-based therapy • increased motivation • deeper emotional response • enhanced performance A high sense of presence may lead to ….. However, the evidence from the literature is still controversial Schuemie et al., 2001

13. What Virtual Reality doesn’t have to be

14. What Virtual Reality can be Head

15. But not yet quite ….. https://www.youtube.com/watch?v=6Cf7IL_eZ38

16. Gartner’s Technology Hype Cycle Visibility Getting better and better 3D video capture Functional Virtual Virtual Humans Environments Social Robots Time Expect too Expect too Making more & more much little realistic progress

17. Current Challenges for VR-based rehabilitation What is unique and critical about a given VR technology that benefits the target population? Do we get more with VR technology support than with hands-on interactive modes? If so, why?

18. Is the technology necessary?

19. Does the intended usage match the technology’s affordances?

20. Virtual Reality Continuum Simple Tech Complex Tech HighTech Low Tech

21. Virtual Reality Continuum: Focus Today Simple Tech Complex Tech HighTech Low Tech For clinical intervention: Aiming to achieve high presence at low cost and technical simplicity

22. WCST TraditionalExecutiveFunctionAssessment • Standard neurocognitive tests: • Lack of sensitivity • Far away from everyday life situations (Godefroy et al., 2004) • Ecological neurocognitive tests: • Real time, Real situation (MET) • Limited use for patients without autonomy (Shallice & Burgess, 1991) • Test of scripts : • Plan generation • No action (Abbott et al., 1985)

23. Desktop Example:VAP-S: Virtual Action Planning Supermarket Designed with two main software: 3DStudioMax and Virtools Klinger E., Marié R.M. et al., 2002-2005, GREYC-ENSICAEN, CHU de Caen Josman, Kizony, Klinger et al.

24. Verbal information: In the supermarket, you should buy: one baguette green apples 2 kg bag of detergent one kilo of flour one t-shirt for child two  artichokes beige socks. You may pay by clicking on the purse icon that is on the screen. Shopping Task List display on the screen Marié et al., 2003

25. Assessment Session • The user • Selects items by using the mouse • The items • Appear in the cart • Disappearfrom the iconlist Record of trajectory, time and actions

26. Performance comparison Control : Duration : 8 min Distance : 215 m Stops : 25 Klinger et al., 2006 Patient with PD : Duration : 25 min Distance : 469 m Stops : 67 Used also for other populations including stroke, and MCI

27. Functional VR Scenarios via Video Capture VR

28. Different Types of Video Capture Systems

29. Different Types of Video Capture Systems

30. Sample Therapeutic Objectives Used in the VMall: • Range of motion • Strength • Endurance • Planning • Memory • Multi-tasking

31. 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.

32. 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. Rand, Katz, Weiss

34. Using a Virtual Kitchen Environment (Meal-Maker) to Assess Performance by Children with Cerebral Palsy Kirshner, Weiss, Tirosh

35. Meal-Maker Virtual Environment Success Failure Meal selection screen Meal preparation screen To serve as a platform for evaluating and treating different aspects of functional performance within a familiar context

37. Subjects 16 children with CP and 16 typically developed children matched by age and gender Age range: 6-12 years (mean 8.69, ± 1.70 in study group / ± 1.82 in control group) Functional ability: GMFCS I-IV Stable general medical condition Vision and hearing intact or corrected to normal Cooperative and able to follow multiple steps

38. Results: Subjective Feedback No significant differences were found between groups Both groups rated all 4 VEs as highly enjoying

39. Borg Scale of Perceived Exertion • Typically Developed • MM and VMall significantly easier than games (p< 0.01) • Soccer significantly more difficult than all other VEs (p< 0.01) • Children with CP • VMall significantly more difficult than for typically developed (U=77.00, p< 0.05) • MM significantly easier than games(p< 0.05)

40. Differences in Task Performance Children with CP had significantly poorer success in all 4 VEs (p< 0.01)

41. Differences in Task Performance Time Children with CP performed slower for all meals (U=35.00, p< 0.001)

42. Conclusions Meal-Maker is a user-friendly, highly enjoying VE for children with CP Meal-Maker was sensitive to differences in performance between children with and without CP

43. Head Mounted Display for Attention Deficit Disorders: Virtual ClassroomRizzo, Pollock, Gross, Weiss

44. Head Mounted Display for Attention Deficit Disorders: Virtual ClassroomRizzo, USC

45. TOVA CPT No VR CPT VR CPT

46. Mean Enjoyment

47. Head Mounted Display for Measuring Cervical MovementSarig-Bahat, Weiss, LauferStudy Objectives • Develop a virtual environment (VE) that will provide an objective and reliable tool for the assessment of cervical spine kinematics. • Compare cervical spine kinematics of asymptomatic subjects with those of individuals suffering from mechanical neck disability.

48. Head Mounted Display (HMD) i-glasses HRV Pro, “Virtual Realities” Features ▪Weight - 200 gram ▪Color display ▪800 X 600 pixel resolution ▪Stereo display Head sensor Sternal sensor

49. Application – “Kill the Fly!” • Fly position – • eliciting flexion-extension & right-left rotations • Head movement – curser • Curser on fly – spray killing the fly with a Buzz! • Initial position – 90% of range (Scaling of screen) • Progression in 2 degree increments • Movement direction randomized • Establishment of maximum range – failing to hit fly 3 times

50. Experimental protocol