Prof. Patrice L. (Tamar) Weiss Laboratory for Innovations in Rehabilitation Technology Department of Occupational Therapy University of Haifa, Israel Virtual Rehabilitation

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.

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 Gait, Endurance Strength, 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……. Static Boring Rote Isolated Effective?

Why do we need VR?... its well-known assets Motivating Ecologically valid Documentation Dynamic 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 controversial Schuemie et al., 2001 Presence and its relationship to the effectiveness of VR-based therapy

Low Tech Virtual Reality Continuum – Desktop Systems High Tech

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 = 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 Participants ParametersResearchControl Demographic parameters Mean age Age range Males1615 Females1216 Mean weight Mean height Mean rest pulse Mean activity pulse Overall N2831 Assistive technology Wheelchair1215 Rolator1314 Crutches22 Walking cane10 Facility Quitmann1312 Kfar Nahman156 Ruhama----6 Bare Dror----9

Pre-Post Intervention Tests GroupNAmbulation style Cooper test (m) Mean ± (SD) Energy Expenditure Index (EEI) Mean Total heart Beat Index (HB/m) Mean PrePostPrePostPrePost Research 28All *** * 16Walking Aid ** Wheelchair ** Control 31All Walking Aid Wheelchair P value < *P value < **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 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.

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 Relative improvement

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 Relative improvement

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 Percent improvement

Social and Clinical Validation

Motion Capture (marker-based) systems with dynamic platforms Motek-CAREN,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) Posen - how the user and others in the VE are represented –1 st Person –3 rd Person –Avatar Fear of Public Speaking, Slater, London How should the patient be represented?

How much should it cost? Versus

School of Occupational Therapy, Hebrew University 2. Chaim Sheba Medical Center 3. Dept. of Occupational Therapy, University of Haifa 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?

School of Occupational Therapy, Hebrew University 2. Chaim Sheba Medical Center 3. Dept. of Occupational Therapy, University of Haifa 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...

School of Occupational Therapy, Hebrew University 2. Chaim Sheba Medical Center 3. Dept. of Occupational Therapy, University of Haifa 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 Institute Fondation Ida et Avrohom Baruch Israeli Ministry of Health Israeli Ministry of Defense Yad Hanadiv-Keren Rothschild Israeli Foundation for Spinal Cord Injured due to Gunshot Israel Science Foundation Keren Shalem Koniver Foundation Rayne Foundation Acknowledgements Laboratory for Innovations in Rehabilitation Technology University of Haifa, Haifa, Israel