Virtual reality in the rehabilitation of people with intellectual disabilities: review.

Virtual reality (VR) possesses many qualities that give it rehabilitative potential for people with intellectual disabilities, both as an intervention and an assessment. It can provide a safe setting in which to practice skills that might carry too many risks in the real world. Unlike human tutors, computers are infinitely patient and consistent. Virtual worlds can be manipulated in ways the real world cannot be and can convey concepts without the use of language or other symbol systems. Published applications for this client group have all been as rehabilitative interventions. These are described in three groups: promoting skills for independent living, enhancing cognitive performance, and improving social skills. Five groups of studies are reviewed that utilize virtual technology to promote skills for independent living: grocery shopping, preparing food, orientation, road safety, and manufacturing skills. Fears that skills or habits learnt in a virtual setting would not transfer to the real world setting have not been supported by the available evidence, apart from those studies with people with autistic spectrum disorders. Future directions are in the development of more applications for independent living skills, exploring interventions for promoting motor and cognitive skills, and the developments of ecologically valid forms of assessment.     

Virtual reality as a representative training environment for football referees

Visual experience plays an important role in facilitating referee decision-making. Video training can be used to train these perceptual-cognitive skills in discrete scenarios, for instance in foul situations in football, but is less suitable in other instances such as when seeking to make decisions in open-play scenarios due to a lack of representativeness. Recent technological advances enable the use of virtual reality (VR) to replicate game situations in a controlled and realistic manner. It is however not yet known how representative behaviour in VR would be of behaviour on-field in the natural environment. The aim of the study was therefore to examine the degree to which visual behaviour of football referees in virtual reality would reflect behaviour found when adjudicating matches on-field. Sub-elite football referees completed decision-making tasks in three experimental conditions: on-field (in a real match), in virtual reality and when observing video footage. Across the three environments we compared decision-making performance, visual behaviour (including search rate, fixation duration, and head movements) and the user experience of the referees. Results revealed that behaviour in the VR environment was indistinguishable from that on-field. In contrast, visual-motor behaviour when observing video footage was markedly different to that found on-field (and in VR). The results show that visual-motor behaviour in VR is representative of that found on-field and therefore suggests that VR offers promise as a representative training environment for sports officials to improve on-field performance in the natural environment.     

Effects of an external focus of attention and target occlusion on performance in virtual reality

The use of virtual reality as a training mechanism continues to gain popularity as equipment becomes more readily available. It is important to not only understand the relationship between virtual reality training and motor learning, but to understand the extent to which practice manipulations enhance performance in virtual reality. One common practice manipulation is adopting an external focus of attention, which has been shown to facilitate motor learning in a variety tasks. The purposes of the present study were to investigate the effectiveness of an external focus of attention and the effects of target occlusion times in virtual reality. Fifty-six participants performed a single-leg long jump during baseline, training, and retention and were randomly assigned to either an external or control group. During baseline and retention, all participants performed the task in both a virtual reality (VR) and real world (RW) environments. Training was all done in VR where participants were provided an external focus cue or no cue. Results revealed that individuals jumped significantly further in RW than VR in both baseline and retention (p < .001). During training, the external group jumped significantly further than control (p < .05). These results suggest that the adoption of an external focus improves performance during training. However, we did not see a benefit of an external focus in retention. These findings should be taken into consideration when using virtual reality as a training tool when performance must be transferred to a real world environment.     

Gymnastic skills on a balance beam with simulated height

Virtual reality (VR) is a valuable tool for simulating dangerous situations and training under these conditions with a reduced possibility of injury. This could be beneficial within different sports scenarios. In gymnastics, the height of the balance beam can be dangerous and frightening, especially for beginners. Here, a simulated height can reduce the participant's risk of injury and facilitate entry to balance beam gymnastics. However, the investigation of sports performance in a virtual environment is rare. Therefore, the current study aims to compare beginners' performance in balance beam tasks between the real world (RW) and VR. 34 sports students executed gymnastic balancing forward, backward and the extension of one leg to the front, the side and the back on a regular balance beam in the RW and on a balance beam with simulated height in VR (using a head-mounted display). We analyzed beginners' performance in both conditions (RW and VR) regarding different criteria for each balance beam task. Statistical analyses show significant differences in performance with better results in RW (p < .05). Especially the body tension and the upper body posture were superior in RW. One explanation can be the more difficult regulation of the balance in VR. For the tasks where the motion took part in a fixed position on the beam, the further performance aspects were similar for RW and VR. When the participants moved along the beam, further performance aspects, like the leg extension, were better in RW. In total, the participants executed the VR balance beam tasks with decreased danger of injury due to the simulated height of the balance beam, but their performance was slightly limited. We conclude that for the first contact with the height of a balance beam, VR is a suitable tool to reduce the danger of injury occurring from falling off the beam and facilitate entry to balance beam gymnastics.     

Using presence to improve a virtual training environment.

In the rail industry, drivers must be trained to operate complex heavy machinery while responding appropriately to rapidly unfolding events in environments that are expensive and often dangerous to replicate in the real world. Virtual training environments (VTEs) can deliver stress exposure training to improve the decision-making skills of train drivers. Higher levels of recallable knowledge in the real world have been linked directly to the degree to which trainees have been engrossed in their VTE, an experience often measured through the concept of "presence." This paper reports on the use of presence to guide improvements to a VTE developed to deliver driver training in degraded track conditions. Two surveys were used to collect data on train drivers' introspective feedback on the level of presence created by the virtual rail environment and the simulator's effectiveness in generating immersion across a range of presence causal factors. Results indicate that using presence to investigate VTEs has practical significance. Outcomes provide direct information on where future improvements and modifications to the VTE can be made.     

The Effect of Interactivity on Learning Physical Actions in Virtual Reality

Virtual reality (VR) offers new possibilities for learning, specifically for training individuals to perform physical movements such as physical therapy and exercise. The current article examines two aspects of VR that uniquely contribute to media interactivity: the ability to capture and review physical behavior and the ability to see one's avatar rendered in real time from third person points of view. In two studies, we utilized a state-of-the-art, image-based tele-immersive system, capable of tracking and rendering many degrees of freedom of human motion in real time. In Experiment 1, participants learned better in VR than in a video learning condition according to self-report measures, and the cause of the advantage was seeing one's avatar stereoscopically in the third person. In Experiment 2, we added a virtual mirror in the learning environment to further leverage the ability to see oneself from novel angles in real time. Participants learned better in VR than in video according to objective performance measures. Implications for learning via interactive digital media are discussed.     

Virtual environments for motor rehabilitation: review.

In this paper, the current "state of the art" for virtual reality (VR) applications in the field of motor rehabilitation is reviewed. The paper begins with a brief overview of available equipment options. Next, a discussion of the scientific rationale for use of VR in motor rehabilitation is provided. Finally, the major portion of the paper describes the various VR systems that have been developed for use with patients, and the results of clinical studies reported to date in the literature. Areas covered include stroke rehabilitation (upper and lower extremity training, spatial and perceptual-motor training), acquired brain injury, Parkinson's disease, orthopedic rehabilitation, balance training, wheelchair mobility and functional activities of daily living training, and the newly developing field of telerehabilitation. Four major findings emerge from these studies: (1) people with disabilities appear capable of motor learning within virtual environments; (2) movements learned by people with disabilities in VR transfer to real world equivalent motor tasks in most cases, and in some cases even generalize to other untrained tasks; (3) in the few studies (n = 5) that have compared motor learning in real versus virtual environments, some advantage for VR training has been found in all cases; and (4) no occurrences of cybersickness in impaired populations have been reported to date in experiments where VR has been used to train motor abilities.     

Virtual action planning in Parkinson's disease: a control study.

Cognitive planning deficits affect patients with Parkinson's disease (PD) and traditional psychometric tests meet difficulties to evaluate their impact on daily life activities. Virtual reality (VR) may provide a new means of assessment. The objective of this study was firstly to develop a virtual environment (VE) useful to explore planning and secondly to examine the effectiveness of using VR in the assessment of cognitive planning for patients with PD. A virtual supermarket (VS) was designed in which participants carried out a task close to daily activities: a test of shopping list. There were two preliminary sessions to familiarize the participants with the software and the supermarket's layout. Then, during the assessment session, participants completed the task, without any time limitation. Global intellectual efficiency was assessed in order to exclude patients with dementia. Data related to the performance in the VS were recorded. Five patients with PD and five age-matched healthy volunteers, meeting inclusion criteria, constituted our convenience sample. The patients did not perform as well as the control group. In particular, the session's duration and the distance covered were longer. The patients' path is specific with numerous stops, turning around, and hesitancies. Finally, their motivation for further training sessions is aroused. The results underline the potential of using VR in the assessment of cognitive planning in PD. A larger analysis is currently being carried out to confirm and to explore all the outcome measures.     

Introducing a new age-and-cognition-sensitive measurement for assessing spatial orientation using a landmark-less virtual reality navigational task

Age-related impairments during spatial navigation have been widely reported in egocentric and allocentric paradigms. However, the effect of age on more specific navigational components such as the ability to drive or update directional information has not received enough attention. In this study we investigated the effect of age on spatial updating of a visual target after a series of whole–body rotations and transitions using a novel landmark-less virtual reality (VR) environment. Moreover, a significant number of previous studies focused on measures susceptible to a general decline in motor skills such as the spent time navigating, the distance traversed. The current paper proposes a new compound spatial measure to assess navigational performance, examines its reliability and compares its power with those of the measures of duration and traversed distance in predicting participants' age and cognitive groups assessed by Montreal Cognitive Assessment (MoCA) scores. Using data from 319 adults (20–83 years), our results confirm the reliability, the age sensitivity, and the cognitive validity of the designed spatial measure as well as its superiority to the measures of duration and traversed distance in predicting age and MoCA score. In addition, the results show the significant effect of age cognitive status on spatial updating.     

VR-based conversation training program for patients with schizophrenia: a preliminary clinical trial.

Schizophrenia is a devastating mental illness and is characterized by hallucinations and delusions as well as social skills deficits. Generally, social skills training designed to help patients develop social skills includes role-playing, but this form of training has typical shortcomings, which are largely due to a trainer's difficulties to project emotion. Virtual reality (VR)-based techniques have the potential to solve these difficulties, because they provide a computer-generated but realistic three-dimensional world and humanlike avatars that can provide emotional stimuli. In this paper, we report on a method of implementing virtual environments (VEs) in order to train people with schizophrenia to develop conversational skills in specific situations, which could overcome the shortcomings of or complement conventional role-playing techniques. The paper reports the efficacy of the proposed approach in a preliminary clinical trial with 10 patients with schizophrenia.     

Using a virtual reality cricket simulator to explore the effects of pressure,competition anxiety on batting performance in cricket

Virtual reality (VR) has created opportunities to innovatively re-imagine the way we examine the relations between pressure, competition anxiety and performance. This study aimed to determine the efficacy of VR as a means of measuring the effects of competition anxiety when pressure manipulations are applied while participants bat in a cricket batting VR simulator. The twenty-eight male participants who took part in two experiments were divided into a high (14, mean age: 22.94, SD: 5.4) and a low skill group (14; mean age: 23.55, SD: 9.9). The aim of the first experiment was to validate the VR simulator as a tool that could capture differences in batting performance between a high and low skilled group. The results showed that high skill participants not only scored significantly higher run rates than low skill participants, but they outperformed the low skill group in all performance measures including higher incidences of correct foot placements that reflect better anticipatory responses. Having established the VR batting simulator as being a reliable tool for capturing batting dynamics, experiment 2 aimed to explore the effects of a pressure manipulation on competition anxiety and batting performance. All measures of competition anxiety were significantly greater for both groups in the high-pressure condition compared to the two low-pressure conditions (p < 0.001). The magnitude of this effect was greater in the low skill group for cognitive (0.59) and somatic (0.794) anxiety. Despite anxiety levels significantly increasing in the high-pressure condition, no significant negative changes to batting performance were found for either group, with both groups actually demonstrating performance improvements. Overall, the findings show how a cricket batting virtual reality simulator can be used as a tool to measure the effects of pressure on competition anxiety and batting performance in tasks involving dynamic skill execution.     

The effect of a virtual reality environment on gaze behaviour and motor skill learning

ObjectiveVirtual reality (VR) systems hold significant potential for training skilled behaviours and are currently receiving intense interest in the sporting domain. They offer both practical and pedagogical benefits, but there are concerns about the effect that perceptual deficiencies in VR systems (e.g. reduced haptic information, and stereoscopic display distortions) may have on learning and performance. ‘Specificity of learning’ theories suggest that VR could be ineffective (or even detrimental) if important differences (e.g. perceptual deficiencies) exist between practice and real task performance conditions. Nevertheless, ‘structural learning’ theories suggest VR could be a useful training tool, despite these deficiencies, because a trainee can still learn the underlying structure of the behaviour. We explored these theoretical predictions using golf putting as an exemplar skill.MethodIn Experiment 1 we used a repeated measures design to assess putting accuracy (radial error) and quiet eye duration of expert golfers (n = 18) on real putts before and after 40 VR ‘warm up’ putts. In Experiment 2, novice golfers (n = 40) were assigned to either VR or real-world putting training. Putting accuracy and quiet eye durations were then assessed on a real-world retention test.ResultsBoth visual guidance (quiet eye) and putting accuracy were disrupted temporarily when moving from VR to real putting (Experiment 1). However, real-world and VR practice produced comparable improvements in putting accuracy in novice golfers (Experiment 2).ConclusionOverall, the results suggest that: (i) underlying skill structures can be learned in VR and transferred to the real-world; (ii) perceptual deficiencies will place limits on the use of VR. These findings demonstrate the challenges and opportunities for VR as a training tool, and emphasise the need to empirically test the costs and benefits of specific systems before deploying VR training.     

Neurofeedback training with virtual reality for inattention and impulsiveness.

In this research, the effectiveness of neurofeedback, along with virtual reality (VR), in reducing the level of inattention and impulsiveness was investigated. Twenty-eight male participants, aged 14-18, with social problems, took part in this study. They were separated into three groups: a control group, a VR group, and a non-VR group. The VR and non-VR groups underwent eight sessions of neurofeedback training over 2 weeks, while the control group just waited during the same period. The VR group used a head-mounted display (HMD) and a head tracker, which let them look around the virtual world. Conversely, the non-VR group used only a computer monitor with a fixed viewpoint. All participants performed a continuous performance task (CPT) before and after the complete training session. The results showed that both the VR and non-VR groups achieved better scores in the CPT after the training session, while the control group showed no significant difference. Compared with the other groups, the VR group presented a tendency to get better results, suggesting that immersive VR is applicable to neurofeedback for the rehabilitation of inattention and impulsiveness.     

Characteristics of social perception assessed in schizophrenia using virtual reality.

Impairment in social skills is one of the few criteria that all individuals diagnosed with schizophrenia must meet. Successful social skills require the coordination of many abilities, including social perception, which involves the decoding and interpretation of social cues from others. In this study, we examined the potential for virtual reality (VR) in social skill training. We attempted to determine if VR can be used to measure social skills and social perception, and to determine which VR parameters are related to schizophrenic symptoms. Some of these results have clear clinical relevance, while other observations need further study. The VR system appears to be useful in assessing the social perception of schizophrenics and normal people, and could be more widely used in the future for social training and in the assessment of social problem-solving abilities, assertiveness skills, and general social skills.     

The Assessment of Spatial Orientation Using Virtual Reality Techniques

Visual-spatial ability has been identified as one of the primary factors of intelligence. Numerous tests, including paper-and-pencil tasks and laboratory experiments, have attempted to provide an accurate measure of this ability. However, the majority of these tests serve only as surrogate measures of visual-spatial ability and may not provide a precise prediction of the individuals' performance in a real environment. We propose a new approach for evaluating spatial ability. In this article, we introduce the use of virtual reality (VR) or virtual environments (VEs) as a new method to measure human spatial orientation. We then discuss the advantages of using VR or VE over traditional measures. We also comment on their limitations and their future direction.     

Virtual reality promotes greater improvements than video-stimulation screen on perceptual-cognitive skills in young soccer athletes

BackgroundThe literature has shown the positive effect of virtual reality (VR) in percepto-cognitive skills. However, the literature lacks findings about at what extent VR would be better than video.PurposeThis study aimed to analyze the chronic effect of VR and video-stimulation screen training on passing decision-making, visual search behavior, and inhibitory control performance in young soccer athletes.MethodA total of 26 young soccer players underwent an 8-week training protocol after being randomly assigned to the VR (n = 13) or video-screen (VID, n = 13) group. Passing decision-making, visual search behavior, and inhibitory control performance were measured before and after both interventions.ResultsA group x time interaction was found for decision-making performance (p < 0.01) and visual search behavior (p < 0.01). Both groups improved both decision-making performance (p < 0.01) and visual search behavior (p < 0.01); however, greater improvements were verified in VR (p < 0.01). Both VR and VID improved inhibitory control (p < 0.01), but no group interaction effect was observed (p > 0.05).ConclusionOur results suggest that VR leads to greater improvements in decision-making and visual search behavior in young soccer athletes than VID.     

Overground gait training using virtual reality aimed at gait symmetry

This study investigated if training in a virtual reality (VR) environment that provides visual and audio biofeedback on foot placement can induce changes to spatial and temporal parameters of gait during overground walking. Eighteen healthy young adults walked for 23 min back and forth on an instrumented walkway in three different conditions: (i) real environment (RE), (ii) virtual environment (VE) with no biofeedback, and (iii) VE with biofeedback. Visual and audio biofeedback while stepping on virtual footprint targets appearing along a straight path encouraged participants to walk with an asymmetrical step length (SL). A repeated-measures, one-way ANOVA, followed by a pairwise comparison post-hoc analysis with Bonferroni's correction, was performed to compare the step length difference (SLD), stance phase percentage difference (SPPD), and double-support percentage difference (DSPD) between early and late phases of all walking conditions. The results demonstrate the efficacy of the VE biofeedback system for training asymmetrical gait patterns. Participants temporarily adapted an asymmetrical gait pattern immediately post-training in the VE. Induced asymmetries persisted significantly while later walking in the RE. Asymmetry was significant in the spatial parameters of gait (SLD) but not in the temporal parameters (SPPD and DSPD). This paper demonstrates a method to induce unilateral changes in spatial parameters of gait using a novel VR tool. This study provides a proof-of-concept validation that VR biofeedback training can be conducted directly overground and could potentially provide a new method for treatment of hemiplegic gait or asymmetrical walking.     

Virtual environment training system for rehabilitation of stroke patients with unilateral neglect: crossing the virtual street.

In this paper, we propose a system for training of stroke patients with unilateral neglect by using technology of virtual reality (VR). The proposed system is designed to compensate for unilateral neglect. This system contains the calibration of unilateral neglect and the training of this disease. The calibration procedure is implemented by aligning the virtual object at a subjective middle line. The training procedure is implemented by completing the missions that are used to keep the virtual avatar safe during crossing the street in a virtual environment. The results of this study show that the proposed system is effective to train unilateral neglect. The left to right ratio scores extracted from this system gradually decrease as the sessions of training are repeated. To validate the VR system parameters, the parameters are analyzed by correlation with those of traditional unilateral neglect assessment methods (such as the line bisection test and the cancellation test).     

Frequency of stuttering during challenging and supportive virtual reality job interviews

This paper seeks to demonstrate the possibility of manipulating the frequency of stuttering using virtual reality environments (VREs). If stuttering manifests itself in VREs similarly to the way it manifests itself in real world interactions, then VREs can provide a controlled, safe, and confidential method for treatment practice and generalization. Though many researchers and clinicians recognize the need for generalization activities in the treatment of stuttering, achieving generalization in a clinical setting poses challenges to client confidentiality, safety, and the efficient use of a professionals’ time. Virtual reality (VR) technology may allow professionals the opportunity to enhance and assess treatment generalization while protecting the safety and confidentiality of their clients. In this study, we developed a VR job interview environment which allowed experimental control over communication style and gender of interviewers. In this first trial, persons who stutter (PWS) experienced both challenging and supportive VR job interview conditions. The percentage of stuttered syllables was calculated for both interviews for each participant. Self-reported ratings of communication apprehension and confidence were also obtained, and were not significantly correlated with stuttering severity. Results indicated that interviewer communication style affected the amount of stuttering produced by participants, with more stuttering observed during challenging virtual interviews. Additionally, the amount of stuttering observed during the VR job interviews was significantly, positively correlated with the amount of stuttering observed during an interview with the investigator prior to VR exposure. Participants’ subjective reports of the VR experience indicate reactions similar to those they report experiencing in the real world. Possible implications for the use of VR in the assessment and treatment of stuttering are discussed.

Educational objectives: After reading this article, the reader will be able to—(1) list some of the challenges to treatment generalization; (2) describe how virtual reality technology can assist in alleviating some of these challenges; (3) describe how the frequency of stuttering varies across two different virtual environments.     

Multisensory Assessment of Acoustic Comfort Aboard Metros: a Virtual Reality Study

In this study, a multisensory methodology is used to assess acoustic comfort aboard different real‐world metros by means of subjective annoyance and cognitive performance measures. Two experimental conditions were compared: unimodal versus bimodal. Immersive virtual reality was used to simulate journeys aboard metro coaches. Participants performed four tasks (Rey Test, Verbal Fluency, Backward Counting and Auditory Words Discrimination) while listening to metro sounds (unimodal condition) or while listening to metro sounds within a virtual metro coach (bimodal condition). At the end of each journey, participants reported their degree of noise annoyance. The results showed that cognitive performances were worse in the bimodal than in the unimodal condition. Moreover, the bimodal condition affected negatively the capacity to discriminate words and to count backward. However, reported noise annoyance was higher in the unimodal than bimodal condition. The theoretical and practical implications of these findings are discussed. Copyright © 2012 John Wiley & Sons, Ltd.