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

1. Virtual Rehabilitation Prof. Patrice L. (Tamar) Weiss tamar@research.haifa.ac.il Laboratory for Innovations in Rehabilitation Technology Department of Occupational Therapy University of Haifa, Israel

2. 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.

3. Range of Motion Gait, Endurance Strength, Dexterity Balance 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.

4. Major Goals for Motor Rehabilitation • Increase level of interaction with the physical environment • Decrease impairments and maximize return to community life

5. 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)

6. Why do we need VR? Consider conventional therapy……. Boring Isolated Static Rote Effective?

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

8. “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

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

10. Virtual Reality Continuum – Desktop Systems Low Tech High Tech

11. Virtual Reality Continuum – Head Mounted Displays Low Tech High Tech

12. Virtual Reality Continuum – Video/Marker Capture Low Tech High Tech

13. Sony PlayStation II EyeToy Stroke

14. 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

15. 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)

18. VividGroup’s GX / IREX VR

19. Virtual Environments Birds and Balls Snowboard Soccer

20. Using VR Games for Different Clinical Populations Stroke

21. Using VR Scenarios for Different Populations

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

23. 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.

24. 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.

26. Relative improvement of the Fugl-Meyer Assessment (to assess motor impairment of the weak upper extremity, scores range from 0-60 points) follow-up Intervention phase Relative improvement Pure Motor Executive Function All & Motor Participants

27. Relative improvement of the Arm Function Questionnaire (14 questions about ADL functions graded on 3-point scale ability of weak upper extremity) follow-up Intervention phase Relative improvement Pure Motor Executive Function All & Motor Participants

28. Percent improvement of time to perform Wolf Motor Function Test (17 simple tasks to assess functional ability of weak upper extremity) follow-up Intervention phase Percent improvement Pure Motor Executive Function All & Motor Participants

29. Social and Clinical Validation

30. Motion Capture (marker-based) systems with dynamic platforms Motek-CAREN, Haim Sheba, Israel

31. VR and Motor Rehabilitation:Open Questions Link to ST

32. How important is realism? And, to whom is it important Realism (vividness) Some aspects of realism appear to be more important than others • Motion • Gravity • Texture • Shadows • Ambient Sound

33. How important is meaning? Meaningfulness • Context • Relevance “I like soccer the best since it reminds me of my grandson who plays soccer in a professional youth team”.

34. What about more than just audio-visual feedback? MultimodalityNumber and quality of feedback channels (visual, auditory, haptic, olfactory, vesitbular) Larry Hodges, Georgia Institute of Technology CAREN System, MOTEK B.V. Amsterdam

35. Can patients cope with encumbrance? Encumbrance

36. Can patients cope with encumbrance? Encumbrance

37. How should the patient be represented? Representation (Fear of Public Speaking, LesPosen, Australia) - how the user and others in the VE are represented • 1st Person • 3rd Person • Avatar Fear of Public Speaking, Slater, London

38. How much should it cost? Versus

39. School of Occupational Therapy, Hebrew University 2. Chaim Sheba Medical Center 3. Dept. of Occupational Therapy, University of Haifa Is VR effective for motor rehabilitation? • 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)

40. School of Occupational Therapy, Hebrew University 2. Chaim Sheba Medical Center 3. Dept. of Occupational Therapy, University of Haifa The bottom line (to date) is . . . VR does appear to have great potential 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

41. School of Occupational Therapy, Hebrew University 2. Chaim Sheba Medical Center 3. Dept. of Occupational Therapy, University of Haifa The bottom line 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!

42. Acknowledgements Laboratory for Innovations in Rehabilitation Technology University of Haifa, Haifa, Israel 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