Positive Technology Journal

Potential for new technologies in clinical practice.

Curr Opin Neurol. 2010 Oct 18;

Authors: Burridge JH, Hughes AM

PURPOSE OF REVIEW: Cost-effective neurorehabilitation is essential owing to financial constraints on healthcare resources. Technologies have the potential to contribute but without strong clinical evidence are unlikely to be widely reimbursed. This review presents evidence of new technologies since 2008 and identifies barriers to translation of technologies into clinical practice. RECENT FINDINGS: Technology has not been shown to be superior to intensively matched existing therapies. Research has been undertaken into the development and preliminary clinical testing of novel technologies including robotics, electrical stimulation, constraint-induced movement therapy, assistive orthoses, noninvasive brain stimulation, virtual reality and gaming devices. Translation of the research into clinical practice has been impeded by a lack of robust evidence of clinical effectiveness and usability. Underlying mechanisms associated with recovery are beginning to be explored, which may lead to more targeted interventions. Improvements in function have been demonstrated beyond the normal recovery period, but few trials demonstrate lasting effects. SUMMARY: Technologies, alone or combined, may offer a cost-effective way to deliver intensive neurorehabilitation therapy in clinical and community environments, and have the potential to empower patients to take more responsibility for their rehabilitation and continue with long-term exercise.

The new issue of Cybertherapy and Rehabilitation magazine (3/2) is now online and available for full-text download. Topics covered by this issue include brain-computer interface, cognitive enhancement and trainers and the use of massive multiplayer online games in rehabilitation and therapy.

A randomized, controlled trial of immersive virtual reality analgesia, during physical therapy for pediatric burns.

Burns. 2010 Aug 6;

Authors: Schmitt YS, Hoffman HG, Blough DK, Patterson DR, Jensen MP, Soltani M, Carrougher GJ, Nakamura D, Sharar SR

This randomized, controlled, within-subjects (crossover design) study examined the effects of immersive virtual reality as an adjunctive analgesic technique for hospitalized pediatric burn inpatients undergoing painful physical therapy. Fifty-four subjects (6-19 years old) performed range-of-motion exercises under a therapist's direction for 1-5 days. During each session, subjects spent equivalent time in both the virtual reality and the control conditions (treatment order randomized and counterbalanced). Graphic rating scale scores assessing the sensory, affective, and cognitive components of pain were obtained for each treatment condition. Secondary outcomes assessed subjects' perception of the virtual reality experience and maximum range-of-motion. Results showed that on study day one, subjects reported significant decreases (27-44%) in pain ratings during virtual reality. They also reported improved affect ("fun") during virtual reality. The analgesia and affect improvements were maintained with repeated virtual reality use over multiple therapy sessions. Maximum range-of-motion was not different between treatment conditions, but was significantly greater after the second treatment condition (regardless of treatment order). These results suggest that immersive virtual reality is an effective nonpharmacologic, adjunctive pain reduction technique in the pediatric burn population undergoing painful rehabilitation therapy. The magnitude of the analgesic effect is clinically meaningful and is maintained with repeated use.

Therapists' Perception of Benefits and Costs of Using Virtual Reality Treatments.

Cyberpsychol Behav Soc Netw. 2010 Jun 14;

Authors: Segal R, Bhatia M, Drapeau M

Abstract Research indicates that virtual reality is effective in the treatment of many psychological difficulties and is being used more frequently. However, little is known about therapists' perception of the benefits and costs related to the use of virtual therapy in treatment delivery. In the present study, 271 therapists completed an online questionnaire that assessed their perceptions about the potential benefits and costs of using virtual reality in psychotherapy. Results indicated that therapists perceived the potential benefits as outweighing the potential costs. Therapists' self-reported knowledge of virtual reality, theoretical orientation, and interest in using virtual reality were found to be associated with perceptual measures. These findings contribute to the current knowledge of the perception of virtual reality amongst psychotherapists.

An Adaptive Display for the Treatment of Diverse Trauma PTSD Victims.

Cyberpsychol Behav. 2009 Dec 20;

Authors: Botella C, García-Palacios A, Guillen V, Baños RM, Quero S, Alcaniz M

Abstract Posttraumatic stress disorder (PTSD) can develop after exposure to a terrifying event. People who suffer from PTSD experience hyperarousal and avoidance, and they reexperience symptoms that provoke distress and impairment in significant life areas. Cognitive behavior programs, including exposure therapy, are currently the treatment of choice for PTSD. Although these programs are effective, there is room for improvement; utilization of exposure therapy by clinicians is low, and attrition rates are high. Application of new technologies, especially virtual reality (VR), could help to overcome these issues. Several VR programs that address PTSD already exist. This study presents preliminary data on the efficacy of a VR adaptive display called EMMA's World, as applied in the treatment of diverse trauma PTSD victims. This VR program is unique; its flexibility allows it to be used to treat patients who suffer from PTSD due to different kinds of traumatic events. Results support the utility of EMMA's World in the treatment of PTSD.

Virtual reality for obsessive-compulsive disorder: past and the future.

Psychiatry Investig. 2009 Sep;6(3):115-21

Authors: Kim K, Kim CH, Kim SY, Roh D, Kim SI

The use of computers, especially for virtual reality (VR), to understand, assess, and treat various mental health problems has been developed for the last decade, including application for phobia, post-traumatic stress disorder, attention deficits, and schizophrenia. However, the number of VR tools addressing obsessive-compulsive disorder (OCD) is still lacking due to the heterogeneous symptoms of OCD and poor understanding of the relationship between VR and OCD. This article reviews the empirical literatures for VR tools in the future, which involve applications for both clinical work and experimental research in this area, including examining symptoms using VR according to OCD patients' individual symptoms, extending OCD research in the VR setting to also study behavioral and physiological correlations of the symptoms, and expanding the use of VR for OCD to cognitive-behavioral intervention.

Increased personal space of patients with schizophrenia in a virtual social environment.

Psychiatry Res. 2009 Sep 15;

Authors: Park SH, Ku J, Kim JJ, Jang HJ, Kim SY, Kim SH, Kim CH, Lee H, Kim IY, Kim SI

Virtual reality may be a good alternative method for measuring personal space and overcoming some limitations in previous studies on the social aspects of schizophrenia. Using this technology, we aimed to investigate the characteristics of personal space in patients with schizophrenia and evaluate the relationship between their social behaviors and schizophrenic symptoms. The distance from a virtual person and the angle of head orientation while talking to a virtual person in a virtual environment were measured in 30 patients with schizophrenia and 30 normal controls. It was found that patients with schizophrenia had longer distances and larger angles than did normal controls. The severity of the negative syndrome had significant inverse correlations with the distance from the angry and neutral virtual persons and with the angle of head orientation toward the happy and angry virtual persons, suggesting that negative symptoms may have a close relationship with personal space, including distancing and eye gaze. The larger personal space of patients may reflect their discomfort in close situations or cognitive deficits. Showing these profiles to patients could help them realize the amount of personal space they need.

Scientists from the Universities of York and Warwick have developed the first Virtual Reality system that allows users to see, hear, smell taste and even touch. The prototype will be presented at Pioneers 09', an EPSRC showcase event to be held at London's Olympia Conference Centre on March 4

If the prototype can really do what it promises, it can have widespread applications in education, business, medical visualization and cybertherapy.

Virtual reality in acquired brain injury upper limb rehabilitation: evidence-based evaluation of clinical research.

Brain Inj. 2009 Mar;23(3):179-91

Authors: Mumford N, Wilson PH

PRIMARY OBJECTIVE: Acquired brain injury (ABI) is associated with significant cognitive, behavioural, psychological and physical impairment. Hence, it has been important to leverage assessment approaches in rehabilitation by using current and emerging technologies, including virtual reality (VR). A number of VR rehabilitation programmes have been designed in recent years, mainly to improve upper limb function. However, before this technology gains widespread use, evaluation of the scientific evidence supporting VR-assisted rehabilitation is needed. The present review aimed to assess the rationale, design and methodology of research investigating the clinical impact of VR on ABI upper-limb rehabilitation. RESEARCH DESIGN: A total of 22 studies were surveyed using a Cochrane-style review. RESEARCH METHODS: Studies were classified on a number of key criteria: theoretical bases and aims, sample populations and recruitment procedures, characteristics of the VR systems, evaluation design including control procedures and statistical analysis of results. Studies were rated using the Downs and Black (DB) scale. RESULTS: The review demonstrated that few studies used a conventional randomized controlled study design. Moderate support was shown for both teacher-animation and game-like systems. CONCLUSION: While VR-assisted rehabilitation shows early promise, clinicians are advised to be cautious about adopting these technologies before adequate data is available.

The new open-access journal "Annual Review of Cybertherapy and Telemedicine" is online.

ARCTT is a peer-reviewed journal covering a wide variety of topics of interest to the mental health, neuroscience, and rehabilitation communities.

The mission of ARCTT is to provide systematic, periodic examinations of scholarly advances in the field of CyberTherapy and Telemedicine through novel experimental clinical studies or critical authoritative reviews. It is directed to healthcare providers and researchers who are interested in the applications of advanced media for improving the delivery and efficacy of mental healthcare and rehabilitative services.

Assessing craving in young adult smokers using virtual reality.

Am J Addict. 2008 Sep-Oct;17(5):436-40

Authors: Traylor AC, Bordnick PS, Carter BL

Cigarette smokers, when confronted with cues associated with smoking, evidence strong reactions, including increased craving. These reactions have not been extensively studied in young adult smokers, a group that research suggests may respond differently than adults or adolescent smokers. We used virtual reality, which presents a complex array of smoking cues that may be particularly salient to young adult smokers, and measured self-report of craving. Young adult smokers responded strongly to these cues and, unlike adults, did not return to a baseline of craving following cue exposure, suggesting young adult smokers differ from other smokers in terms of cue responses.

Virtual Rehabilitation in an Activity Centre for Community-Dwelling Persons with Stroke. The Possibilities of 3-Dimensional Computer Games.

Cerebrovasc Dis. 2008 Jul 31;26(3):289-296

Authors: Broeren J, Claesson L, Goude D, Rydmark M, Sunnerhagen KS

Background: The main purpose of this study was to place a virtual reality (VR) system, designed to assess and to promote motor performance in the affected upper extremity in subjects after stroke, in a nonhospital environment. We also wanted to investigate if playing computer games resulted in improved motor function in persons with prior stroke. Methods: The intervention involved 11 patients after stroke who received extra rehabilitation by training on a computer 3 times a week during a 4-week period. The control group involved 11 patients after stroke who continued their previous rehabilitation (no extra computer training) during this period. The mean age of all was 68 years (range = 47-85) and the average time after stroke 66 months (range = 15-140). The VR training consisted of challenging games, which provided a range of difficulty levels that allow practice to be fun and motivating. An additional group of 11 right-handed aged matched individuals without history of neurological or psychiatric illnesses served as reference subjects. Results: All the participants reported that they were novel computer game players. After an initial introduction they learned to use the VR system quickly. The treatment group demonstrated improvements in motor outcome for the trained upper extremity, but this was not detected in real-life activities. Conclusions: The results of this research suggest the usefulness of computer games in training motor performance. VR can be used beneficially not only by younger participants but also by older persons to enhance their motor performance after stroke.

Virtual reality exposure therapy for active duty soldiers.

J Clin Psychol. 2008 Jul 8;

Authors: Reger GM, Gahm GA

Virtual reality and persecutory delusions: Safety and feasibility.

Schizophr Res. 2008 Jun 20;

Authors: Fornells-Ambrojo M, Barker C, Swapp D, Slater M, Antley A, Freeman D

OBJECTIVE: Virtual reality (VR) has begun to be used to research the key psychotic symptom of paranoia. The initial studies have been with non-clinical individuals and individuals at high risk of psychosis. The next step is to develop the technology for the understanding and treatment of clinical delusions. Therefore the present study investigated the acceptability and safety of using VR with individuals with current persecutory delusions. Further, it set out to determine whether patients feel immersed in a VR social environment and, consequently, experience paranoid thoughts. METHOD: Twenty individuals with persecutory delusions and twenty non-clinical individuals spent 4 min in a VR underground train containing neutral characters. Levels of simulator sickness, distress, sense of presence, and persecutory ideation about the computer characters were measured. A one-week follow-up was conducted to check longer-term side effects. RESULTS: The VR experience did not raise levels of anxiety or symptoms of simulator sickness. No side effects were reported at the follow-up. There was a considerable degree of presence in the VR scenario for all participants. A high proportion of the persecutory delusions group (65%) had persecutory thinking about the computer characters, although this rate was not significantly higher than the non-clinical group. CONCLUSIONS: The study indicates that brief experiences in VR are safe and acceptable to people with psychosis. Further, patients with paranoia can feel engaged in VR scenes and experience persecutory thoughts. Exposure to social situations using VR has the potential to be incorporated into cognitive behavioural interventions for paranoia.

When spiders appear suddenly: Spider-phobic patients are distracted by task-irrelevant spiders.

Behav Res Ther. 2007 Nov 17;

Authors: Gerdes AB, Alpers GW, Pauli P

Fear is thought to facilitate the detection of threatening stimuli. Few studies have examined the effects of task-irrelevant phobic cues in search tasks that do not involve semantic categorization. In a combined reaction time and eye-tracking experiment we investigated whether peripheral visual cues capture initial attention and distract from the execution of goal-directed eye movements. Twenty-one spider-phobic patients and 21 control participants were instructed to search for a color singleton while ignoring task-irrelevant abrupt-onset distractors which contained either a small picture of a spider (phobic), a flower (non-phobic, but similar to spiders in shape), a mushroom (non-phobic, and not similar to spiders in shape), or no picture. As expected, patients' reaction times were longer on trials with spider distractors. However, eye movements revealed that this was not due to attentional capture by spider distractors; patients more often fixated on all distractors with pictures, but their reaction times were delayed by longer fixation durations on spider distractors. These data do not support automatic capture of attention by phobic cues but suggest that phobic patients fail to disengage attention from spiders.

Robot-based hand motor therapy after stroke.

Brain. 2007 Dec 20;

Authors: Takahashi CD, Der-Yeghiaian L, Le V, Motiwala RR, Cramer SC

Robots can improve motor status after stroke with certain advantages, but there has been less emphasis to date on robotic developments for the hand. The goal of this study was to determine whether a hand-wrist robot would improve motor function, and to evaluate the specificity of therapy effects on brain reorganization. Subjects with chronic stroke producing moderate right arm/hand weakness received 3 weeks therapy that emphasized intense active movement repetition as well as attention, speed, force, precision and timing, and included virtual reality games. Subjects initiated hand movements. If necessary, the robot completed movements, a feature available at all visits for seven of the subjects and at the latter half of visits for six of the subjects. Significant behavioural gains were found at end of treatment, for example, in Action Research Arm Test (34 +/- 20 to 38 +/- 19, P< 0.0005) and arm motor Fugl-Meyer score (45 +/- 10 to 52 +/- 10, P < 0.0001). Results suggest greater gains for subjects receiving robotic assistance in all sessions as compared to those receiving robotic assistance in half of sessions. The grasp task practiced during robotic therapy, when performed during functional MRI, showed increased sensorimotor cortex activation across the period of therapy, while a non-practiced task, supination/pronation, did not. A robot-based therapy showed improvements in hand motor function after chronic stroke. Reorganization of motor maps during the current therapy was task-specific, a finding useful when considering generalization of rehabilitation therapy.

Feasibility of Using the Sony PlayStation 2 Gaming Platform for an Individual Poststroke: A Case Report.

J Neurol Phys Ther. 2007 Dec;31(4):180-9

Authors: Flynn S, Palma P, Bender A

RATIONALE:: Many Americans live with physical functional limitations stemming from stroke. These functional limitations can be reduced by task-specific training that is repetitive, motivating, and augmented with feedback. Virtual reality (VR) is reported to offer an engaging environment that is repetitive, safe, motivating, and gives task-specific feedback. The purpose of this case report was to explore the use of a low-cost VR device [Sony PlayStation 2 (PS2) EyeToy] for an individual in the chronic phase of stroke recovery. CASE:: An individual two years poststroke with residual sensorimotor deficits completed 20 one-hour sessions using the PS2 EyeToy. The game's task requirements included target-based motion, dynamic balance, and motor planning. The feasibility of using the gaming platform was explored and a broad selection of outcomes was used to assess change in performance. OUTCOMES:: Device use was feasible. Clinically relevant improvements were found on the Dynamic Gait Index and trends toward improvement on the Fugl-Meyer Assesment, Berg Balance Scale, UE Functional Index, Motor Activity Log, and Beck Depression Inventory. CONCLUSION:: A low-cost VR system was easily used in the home. In the future it may be used to improve sensory/motor recovery following stroke as an adjunct to standard care physical therapy.

Via Medgadget

Dutch company relaxView B.V. is marketing a heads up display that purports to be effective at distracting the patient during dentistry intervention.

Press release: Newest Video Eyewear Helps Dental Patient to Relax

The analgesic effects of opioids and immersive virtual reality distraction: evidence from subjective and functional brain imaging assessments.

Anesth Analg. 2007 Dec;105(6):1776-83, table of contents

Authors: Hoffman HG, Richards TL, Van Oostrom T, Coda BA, Jensen MP, Blough DK, Sharar SR

BACKGROUND: Immersive virtual reality (VR) is a novel form of distraction analgesia, yet its effects on pain-related brain activity when used adjunctively with opioid analgesics are unknown. We used subjective pain ratings and functional magnetic resonance imaging to measure pain and pain-related brain activity in subjects receiving opioid and/or VR distraction. METHODS: Healthy subjects (n = 9) received thermal pain stimulation and were exposed to four intervention conditions in a within-subjects design: (a) control (no analgesia), (b) opioid administration [hydromorphone (4 ng/mL target plasma level)], (c) immersive VR distraction, and (d) combined opioid + VR. Outcomes included subjective pain reports (0-10 labeled graphic rating scales) and blood oxygen level-dependent assessments of brain activity in five specific, pain-related regions of interest. RESULTS: Opioid alone significantly reduced subjective pain unpleasantness ratings (P < 0.05) and significantly reduced pain-related brain activity in the insula (P < 0.05) and thalamus (P < 0.05). VR alone significantly reduced both worst pain (P < 0.01) and pain unpleasantness (P < 0.01) and significantly reduced pain-related brain activity in the insula (P < 0.05), thalamus (P < 0.05), and SS2 (P < 0.05). Combined opioid + VR reduced pain reports more effectively than did opioid alone on all subjective pain measures (P < 0.01). Patterns of pain-related blood oxygen level-dependent activity were consistent with subjective analgesic reports. CONCLUSIONS: These subjective pain reports and objective functional magnetic resonance imaging results demonstrate converging evidence for the analgesic efficacy of opioid administration alone and VR distraction alone. Furthermore, patterns of pain-related brain activity support the significant subjective analgesic effects of VR distraction when used as an adjunct to opioid analgesia. These results provide preliminary data to support the clinical use of multimodal (e.g., combined pharmacologic and nonpharmacologic) analgesic techniques.

Motor learning and the use of videotape feedback after stroke.

Top Stroke Rehabil. 2007 Sep-Oct;14(5):28-36

Authors: Gilmore PE, Spaulding SJ

BACKGROUND: Efforts have been made to apply motor learning theories to the rehabilitation of individuals following stroke. Motor learning poststroke has not been well investigated in the literature. This research attempted to fill the gap regarding motor learning applied to practice. PURPOSE: This two-group research study attempted to determine the effectiveness of an experimental therapy combining videotape feedback with occupational therapy compared to only occupational therapy in learning the motor skill of donning socks and shoes after stroke. METHOD: Ten participants were randomly assigned to one of the two groups and all participants were videotaped during pretest and up to 10 treatment sessions aimed at donning socks and shoes. Only one group viewed their videotape replay. The acquisition of donning socks and shoes was measured using the socks and shoes subtests of the Klein-Bell Activities of Daily Living Scale and their scores on the Canadian Occupational Performance Measure. RESULTS: There was no significant difference between the two groups and both groups improved. However, the group that received videotape feedback thought they performed better and were more satisfied with their ability to don shoes, lending support for the use of videotape feedback poststroke to improve satisfaction with performance.