Immersion in Virtual Reality and Games for Therapy and Rehabilitation

When the Oculus Rift launched its Kickstarter campaign in 2012, users truly experienced its tagline, “Step into the Game,” as they adjusted the clunky headset over their heads to explore a new, breathtaking environment. Since then, chatter about virtual reality becoming the next frontier of gaming has erupted over gaming forums and news. The possibilities appear to be endless. The technology could be applied to nearly every aspect of daily lives including communication, entertainment, and education. A specific topic of interest was virtual reality gaming’s application in medicine. Immersing its players in simulated environments, virtual reality gaming can be used not only for improving mental and behavioral health, but also for education in these fields of medicine; the therapeutic uses for this technology introduce a new, creative approach to medical treatment.

I. Military Application and PTSD

Bravemind, an interactive virtual-reality based exposure therapy system, is designed to treat post-traumatic stress disorder (PTSD) for returning veterans. Traditional treatment for PTSD relies on the ability of the patient, aided by a therapist, to recall and confront traumatic experiences through verbally retelling the event. This type of treatment, however, can sometimes be ineffective. A number of patients, though willing to undergo treatment, are unable to engage their emotions. Even more worrisome, “uncontrolled cue exposure may lead the person to react with a survival mentality and mode of response that could put them and others at considerable risk” (Rizzo, 2011). Bravemind addresses this challenge by using a game-like environment to place patients in a realistic, yet safe and controlled, environment. Clinicians are able to alter the settings of the environment (e.g. varying weather conditions, number of people in streets, explosions, etc.) and utilize this step-wise fashion to determine the specific source of the patient’s stress responses. They can further analyze responses “via advanced brain imaging and psychophysiological assessment techniques…[for] the prevention, assessment, and treatment of PTSD.”

Research has shown, alarmingly, that only 23 to 40 percent of Iraq and Afghanistan veterans who tested positive for a mental disorder sought mental health care (Rizzo, 2011). The virtual reality therapy, therefore, is a simple yet effective system that could easily be embedded into post-combat reintegration training for veterans. Furthermore, the younger generation of soldiers, having been exposed to digital gaming technology, may be more attracted to this form of therapy (rather than traditional “talk” therapy), and thus be more likely to seek help.

II. Virtual Reality Games and Aging

As the United States population ages, the number of middle-aged and older adults with disabilities will also subsequently increase. Recent evidence has shown that the productivity, social engagement, and new learning offered in games are possible for those aging. Furthermore, research “indicates that functional motor capacity can be improved, maintained, or recovered via consistent participation in motor exercises and rehabilitation regimens” (Lange, 2010). There are several difficulties, however, that prevent the immediate integration of rehabilitating games. First, the technology must be inexpensive in order to be widespread across the aging community. Furthermore, the technology should be introduced well before impairments have occurred to ensure the successful lifespan development of the patients. It has been suggested that when a patient focuses on a game rather than his or her impairment, “exercise becomes more enjoyable, motivating, and is more likely to be maintained over the many trials needed to induce plastic changes in the nervous system” (Lange, 2010).

Virtual reality systems can be used as an immersive and interactive system to create a computer simulated system where the patient can “play” in real time, immediately feeling the effects of their actions. The use of these types of systems can serve to enhance motivate individuals to participate in physical activities. Virtual reality is especially ideal for treating these types of disabilities since it delivers challenges across a range of difficulty levels. In this way, a patient can customize his challenge level to be at an attainable yet effective goal.

III. Rehabilitation for Balance Impairments

As individuals age, the likelihood of deterioration and damage to postural control gradually increases. The ability to “assess the position of the center of gravity relative to the base of support will disrupt balance” (Lange, 2010) thus leading to falls and restrictions to an individual’s regular motor activities. The recent popularity of Nintendo’s WiiFit has shown significant evidence that exercise can be enjoyable when presented in a distracting, entertaining, and motivating context. The system utilizes a fairly low-cost platform in which the player can control the actions of an onscreen avatar by shifting his or her weight on the platform. In-game activities such as floating down a river, defending a soccer goal, hoola-hooping, or achieving a variety of yoga positions have been introduced through this device. The virtual reality system is particularly helpful because the visual feedback allows the patient to identify and maintain his or her balance as precisely as possible to succeed in the game.

Furthermore, physical activities including dancing, tai chi, and strengthening exercises, have also been proven to increase balance and lessen the risk of falls for aging adults. Dance especially has been shown to improve endurance, balance, strength, and coordination in adults. Dancing can be particularly challenging since it requires dancers to change their base of support while moving to music and shifting weight to achieve certain poses or movements. Games such as Move Fitness, Zumba Fitness, and Get Fit with Mel have been introduced in the Playstation Move. Most well known, however, is the Microsoft Kinect, which utilizes controller-free gaming to enable users to interact with the Xbox 360 through gestures and spoken commands. The Kinect allows for full-body 3D motion-capture and facial recognition capabilities. A number of these games, like Dance Central or Your Shape Fitness Evolved, can be used in rehabilitation and training settings. Games for improving balance and fitness are becoming increasingly prominent in the common household. The next step is creating an even greater immersive experience by using virtual reality technology. Imagine entering a boxing arena or participating in a dance battle without the consequences of a bloodied nose or eternal embarrassment. Clearly, the controlled, yet fascinating, virtual environment offered can not only be used for rehabilitation, but also for encouraging others to increase their levels of exercise.

IV. Rehabilitation at Home for Shoulder

In a recent study, 80.2% out of approximately 1.5 million people in the U.S. who use a manual wheelchair reported some kind of difficulty while operating their wheelchair. Many of these difficulties are attributed to shoulder joint pain during manual wheelchair use or transfers. Research has shown that rotator cuff strengthening and shoulder joint stretching exercises were dramatically effective at reducing long-term shoulder pain in individuals operating manual wheelchairs. Because these types of programs require maintaining the subject’s interest in repetitive tasks, however, it is essential to preclude lack of interest or short attention span. To avoid this problem, clinicians developed an exercise that involved an arm ergometer and a computer game that allowed “the user to control game play…as if using a joystick was shown to elicit the same physiologic response and perceived exertion as arm ergometry (Lange, 2010). The game, however, made the exercises more exciting for the patient, thus increasing his or her overall energy expenditure. This system can be improved with the rising interest in virtual reality. It is highly likely that patients will become even more engaged with the boosted interactivity of a virtual reality game.

There can be a number of ways that virtual reality gaming could be used to improve rehabilitation for those suffering form shoulder pain. By constructing a game with an entertaining storyline or pleasing aesthetics, virtual reality has the ability to engage its users in the game, thus significantly improving the condition of the shoulder.

V. Virtual Reality Exposure Therapy

One of virtual reality’s first uses was treating clinical anxiety disorders. Prior to virtual reality, clinicians relied treatments such as cognitive behavioral therapy that depended on their patient’s ability to visualize the experience that caused their anxiety. Virtual reality makes this treatment more effective by introducing a less time-consuming, affordable, and safe methodology.

One virtual reality project, INTREPID, developed an intelligent multi-sensor wearable system to treat situational anxiety and phobias. This technology integrates emotional intelligence, which utilizes a biosensors fusion system that senses primary phobic’s states “and a virtual environment that, based on the machine’s intelligent decisions, will virtually expose patients in situations that help them overcome their phobias” (Wiederhold, 2006). This system can also be used to communicate this information to clinicians, who can use the data to make crucial decisions regarding the patient’s therapy. The INTREPID project provides a platform that can “expand to wider applications and advanced economic opportunity of the technology” (Wiederhold, 2006). Virtual reality gaming can easily be applied to these types of projects and used to improve therapy for phobias and anxiety.

There are some available virtual reality games catered to the treatment of phobias including SpiderWorld. In this immersive virtual world, patients reach out and touch a furry toy spider. Auditory and tactile cues are added to the virtual image to create the illusion that the patient is truly touching the virtual spider.

VI. Virtual Reality as Distraction Therapy

The use of distraction is an important psychological factor since it reduces the patient’s attention to the stimulus. The ideal distractor would require the optimum amount of attention involving several different senses (visual, auditory, and kinesthetic) as well as “active emotional involvement, and participation form the patient to compete with the signals of the harmful stimuli” (Wiederhold, 2006). Virtual reality as a form of distraction therapy is particularly useful because of its flexibility as a tool during treatment. The clinician can increase or decrease the duration of the immersion with ease and the virtual environment also blocks out clinical noise from the patient. Engaging patients in an immersive virtual environment during clinical procedures would be the ideal form of distraction therapy.

SnowWorld, a game developed by the University of Washington HITLab, is a virtual world designed to reduce pain for burn patients. SnowWorld takes the patient through an icy canyon “filled with snowball hurling snowmen, flocks of squawking penguins, wooly mammoths and other surprises” (Patterson). Because being drawn into this world required many different senses, patients showed a dramatic reduction in pain when they were distracted with their primary goal of exploring a virtual world.

VII. Medical Training and Education

Virtual reality is increasingly being integrated in medical training and education due to its affordability and ability to improve testing in examinations that evaluate manual skills. It is a helpful tool that gives students three-dimensional graphics to improve the understanding anatomy for students. The technology is especially useful in teaching procedures “involved in breast and genitalia exams in which it is difficult to find subjects” (Wiederhold, 2006). Virtual reality is especially useful for surgical training, since a visual environment is vital during training to learn basic surgical operations. This allows surgeons to practice a vast number of procedures with no risk to live patients. This will significantly reduce the high cost of training resources as well as improve the education for aspiring medical students. Some virtual reality surgery simulators include NeuroTouch-Endo, which not only offers the surgical training but also labels anatomic labeling of structures as players perform operations on the carotid arteries and optic nerves.

Although virtual reality is usually associated with entertainment, it also has a variety of applications in therapy and rehabilitation, as well as surgical training. All of these applications use the interactive and immersive virtual environments to improve the speed of recovery and conditions of their patients. For instance, Bravemind and virtual reality games treating phobias placed players directly in a psychologically daunting environment. Others use the games as a medium, like those used for balance impairment and joint rehabilitation, or as a distraction during operations to divert the patient’s attention to the pain. As virtual reality continues to develop at astonishing speeds, current approaches to medicine and therapy, too, will undoubtedly experience an evolution.

 

Bibliography:

(APA Format)

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