A Succinct Overview of Virtual Reality Technology Use in Alzheimer’s Disease
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paper_title: Virtual Immersion for Post-Stroke Hand Rehabilitation Therapy

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Stroke is the leading cause of serious, long-term disability in the United States. Impairment of upper extremity function is a common outcome following stroke, often to the detriment of lifestyle and employment opportunities. While the upper extremity is a natural target for therapy, treatment may be hampered by limitations in baseline capability as lack of success may discourage arm and hand use. We developeda virtual reality (VR) system in order to encourage repetitive task practice. This system combined an assistive glove with a novel VR environment. A set of exercises for this system was developed to encourage specific movements. Six stroke survivors with chronic upper extremity hemiparesis volunteered to participate in a pilot study in which they completed 18 one-hour training sessions with the VR system. Performance with the system was recorded across the 18 training sessions. Clinical evaluations of motor control were conducted at three time points: prior to initiation of training, following the end of training, and 1 month later. Subjects displayed significant improvement on performance of the virtual tasks over the course of the training, although for the clinical outcome measures only lateral pinch showed significant improvement. Future expansion to multi-user virtual environments may extend the benefits of this system for stroke survivors with hemiparesis by furthering engagement in the rehabilitation exercises.
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paper_title: Effects of Virtual Reality Simulator Training Method and Observational Learning on Surgical Performance

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Background ::: Virtual reality (VR) simulators and Web-based instructional videos are valuable supplemental training resources in surgical programs, but it is unclear how to optimally integrate them into minimally invasive surgical training.
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paper_title: Nu!RehaVR: virtual reality in neuro tele-rehabilitation of patients with traumatic brain injury and stroke

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The availability of virtual environments on the Web is fostering new applications of virtual reality in several fields, including some therapeutical applications. We present an application of virtual reality applied to the tele-rehabilitation of patients with traumatic brain injury and stroke. Our system, based on X3D and Ajax3D technologies, enhances the possibility of making tele-rehabilitation exercises aimed at the recovery of the neurological disease. The system, called Nu!RehaVR, has been designed to integrate the activity carried out on a tele-rehabilitation system, Nu!Reha (Nu!Reha is a trademark of Pragma Engineering srl. See http://www.nureha.eu) desk, with the activities performed in the virtual worlds, through some rehabilitation exercises in contexts incompatible with the patients’ impairments (not able to move or forced in static positions because of therapies, etc.). The architecture of Nu!RehaVR and the environments associated to two exercises, “Utilising an elevator to reach a given floor” and “Crossing a road using a traffic light”, are illustrated. These exercises can be considered as prototypes of a series of tele-rehabilitation exercises which help to stimulate the patients performing actions in relatively dangerous scenarios. The system is designed to allow the remote monitoring and assessment of the patient’s activities by the medical staff at the hospital using the communication facilities of the tele-rehabilitation system.
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paper_title: Virtual Reality Therapy for Adults Post-Stroke: A Systematic Review and Meta-Analysis Exploring Virtual Environments and Commercial Games in Therapy

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BACKGROUND ::: The objective of this analysis was to systematically review the evidence for virtual reality (VR) therapy in an adult post-stroke population in both custom built virtual environments (VE) and commercially available gaming systems (CG). ::: ::: ::: METHODS ::: MEDLINE, CINAHL, EMBASE, ERIC, PSYCInfo, DARE, PEDro, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were systematically searched from the earliest available date until April 4, 2013. Controlled trials that compared VR to conventional therapy were included. Population criteria included adults (>18) post-stroke, excluding children, cerebral palsy, and other neurological disorders. Included studies were reported in English. Quality of studies was assessed with the Physiotherapy Evidence Database Scale (PEDro). ::: ::: ::: RESULTS ::: Twenty-six studies met the inclusion criteria. For body function outcomes, there was a significant benefit of VR therapy compared to conventional therapy controls, G = 0.48, 95% CI = [0.27, 0.70], and no significant difference between VE and CG interventions (P = 0.38). For activity outcomes, there was a significant benefit of VR therapy, G = 0.58, 95% CI = [0.32, 0.85], and no significant difference between VE and CG interventions (P = 0.66). For participation outcomes, the overall effect size was G = 0.56, 95% CI = [0.02, 1.10]. All participation outcomes came from VE studies. ::: ::: ::: DISCUSSION ::: VR rehabilitation moderately improves outcomes compared to conventional therapy in adults post-stroke. Current CG interventions have been too few and too small to assess potential benefits of CG. Future research in this area should aim to clearly define conventional therapy, report on participation measures, consider motivational components of therapy, and investigate commercially available systems in larger RCTs. ::: ::: ::: TRIAL REGISTRATION ::: Prospero CRD42013004338.
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paper_title: A meta-analysis of the training effectiveness of virtual reality surgical simulators

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The increasing use of virtual reality (VR) simulators in surgical training makes it imperative that definitive studies be performed to assess their training effectiveness. Indeed, in this paper we report the meta-analysis of the efficacy of virtual reality simulators in: 1) the transference of skills from the simulator training environment to the operating room, and 2) their ability to discriminate between the experience levels of their users. The task completion time and the error score were the two study outcomes collated and analyzed in this meta-analysis. Sixteen studies were identified from a computer-based literature search (1996-2004). The meta-analysis of the random effects model (because of the heterogeneity of the data) revealed that training on virtual reality simulators did lessen the time taken to complete a given surgical task as well as clearly differentiate between the experienced and the novice trainees. Meta-analytic studies such as the one reported here would be very helpful in the planning and setting up of surgical training programs and for the establishment of reference `learning curves' for a specific simulator and surgical task. If any such programs already exist, they can then indicate the improvements to be made in the simulator used, such as providing for more variety in their case scenarios based on the state and/or rate of learning of the trainee
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paper_title: Modulation of cortical activity in 2D versus 3D virtual reality environments: An EEG study

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Abstract There is a growing empirical evidence that virtual reality (VR) is valuable for education, training, entertaining and medical rehabilitation due to its capacity to represent real-life events and situations. However, the neural mechanisms underlying behavioral confounds in VR environments are still poorly understood. In two experiments, we examined the effect of fully immersive 3D stereoscopic presentations and less immersive 2D VR environments on brain functions and behavioral outcomes. In Experiment 1 we examined behavioral and neural underpinnings of spatial navigation tasks using electroencephalography (EEG). In Experiment 2, we examined EEG correlates of postural stability and balance. Our major findings showed that fully immersive 3D VR induced a higher subjective sense of presence along with enhanced success rate of spatial navigation compared to 2D. In Experiment 1 power of frontal midline EEG (FM-theta) was significantly higher during the encoding phase of route presentation in the 3D VR. In Experiment 2, the 3D VR resulted in greater postural instability and modulation of EEG patterns as a function of 3D versus 2D environments. The findings support the inference that the fully immersive 3D enriched-environment requires allocation of more brain and sensory resources for cognitive/motor control during both tasks than 2D presentations. This is further evidence that 3D VR tasks using EEG may be a promising approach for performance enhancement and potential applications in clinical/rehabilitation settings.
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paper_title: Egocentric and allocentric memory as assessed by virtual reality in individuals with amnestic mild cognitive impairment

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Abstract Present evidence suggests that medial temporal cortices subserve allocentric representation and memory, whereas egocentric representation and memory also depends on parietal association cortices and the striatum. Virtual reality environments have a major advantage for the assessment of spatial navigation and memory formation, as computer-simulated first-person environments can simulate navigation in a large-scale space. Twenty-nine patients with amnestic MCI (aMCI) were compared with 29 healthy matched controls on two virtual reality tasks affording to learn a virtual park (allocentric memory) and a virtual maze (egocentric memory). Participants further received a neuropsychological investigation and MRI volumetry at the time of the assessment. Results indicate that aMCI patients had significantly reduced size of the hippocampus bilaterally and the right-sided precuneus and inferior parietal cortex. aMCI patients were severely impaired learning the virtual park and the virtual maze. Smaller volumes of the right-sided precuneus were related to worse performance on the virtual maze. Participants with striatal lacunar lesions committed more errors than participants without such lesions on the virtual maze but not on the virtual park. aMCI patients later converting to dementia (n = 15) had significantly smaller hippocampal size when compared with non-converters (n = 14). However, both groups did not differ on virtual reality task performance. Our study clearly demonstrates the feasibility of virtual reality technology to study spatial memory deficits of persons with aMCI. Future studies should try to design spatial virtual reality tasks being specific enough to predict conversion from MCI to dementia and conversion from normal to MCI.
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paper_title: Health and safety implications of virtual reality : A review of empirical evidence

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For the last 10 years a number of papers have been written that discuss human factors issues associated with virtual reality (VR). The nature of these papers has gradually evolved from speculation and anecdotal report to empirical research. Despite developments in VR technology, some participants still experience health and safety problems associated with VR use-termed VR-induced symptoms and effects (VRISE). The key concern from the literature is VR-induced sickness, experienced by a large proportion of VR participants, but for the majority these effects are mild and subside quickly. This paper makes a number of recommendations regarding the future direction of research into health and safety implications of VR, including the need to take into account the way in which VR is being used when conducting empirical research: first, to ensure that studies consider both effects and their consequences; second, to ensure that empirical trials reflect the actual likely context of VR use; third, to consider interactions between effects; and finally, to consider ways in which effects can be managed.
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paper_title: Virtual Reality Rehabilitation from Social Cognitive and Motor Learning Theoretical Perspectives in Stroke Population

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Objectives. To identify the virtual reality (VR) interventions used for the lower extremity rehabilitation in stroke population and to explain their underlying training mechanisms using Social Cognitive (SCT) and Motor Learning (MLT) theoretical frameworks. Methods. Medline, Embase, Cinahl, and Cochrane databases were searched up to July 11, 2013. Randomized controlled trials that included a VR intervention for lower extremity rehabilitation in stroke population were included. The Physiotherapy Evidence Database (PEDro) scale was used to assess the quality of the included studies. The underlying training mechanisms involved in each VR intervention were explained according to the principles of SCT (vicarious learning, performance accomplishment, and verbal persuasion) and MLT (focus of attention, order and predictability of practice, augmented feedback, and feedback fading). Results. Eleven studies were included. PEDro scores varied from 3 to 7/10. All studies but one showed significant improvement in outcomes in favour of the VR group (P < 0.05). Ten VR interventions followed the principle of performance accomplishment. All the eleven VR interventions directed subject's attention externally, whereas nine provided training in an unpredictable and variable fashion. Conclusions. The results of this review suggest that VR applications used for lower extremity rehabilitation in stroke population predominantly mediate learning through providing a task-oriented and graduated learning under a variable and unpredictable practice.
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paper_title: Virtual reality induced symptoms and effects (VRISE) : Comparison of head mounted display (HMD), desktop and projection display systems

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Abstract Virtual reality (VR) systems are used in a variety of applications within industry, education, public and domestic settings. Research assessing reported symptoms and side effects of using VR systems indicates that these factors combine to influence user experiences of virtual reality induced symptoms and effects (VRISE). Three experiments were conducted to assess prevalence and severity of sickness symptoms experienced in each of four VR display conditions; head mounted display (HMD), desktop, projection screen and reality theatre, with controlled examination of two additional aspects of viewing (active vs. passive viewing and light vs. dark conditions). Results indicate 60–70% participants experience an increase in symptoms pre–post exposure for HMD, projection screen and reality theatre viewing and found higher reported symptoms in HMD compared with desktop viewing (nausea symptoms) and in HMD compared with reality theatre viewing (nausea, oculomotor and disorientation symptoms). No effect of lighting condition was found. Higher levels of symptoms were reported in passive viewing compared to active control over movement in the VE. However, the most notable finding was that of high inter- and intra-participant variability. As this supports other findings of individual susceptibility to VRISE, recommendations are offered concerning design and use of VR systems in order to minimise VRISE.
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paper_title: Virtual Reality as Assessment Tool in Psychology

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Virtual environments (VEs), offering a new human-computer interaction paradigm, have attracted much attention in clinical psychology, especially in the treatment of phobias. However, a possible new application of VR in psychology is as assessment tool: VEs can be considered as an highly sophisticated form of adaptive testing. This chapter describes the context of current psychological assessment and underlines possible advantages of a VR based assessment tool. The chapter also details the characteristics of BIVRS, Body Image Virtual Reality Scale, an assessment tool designed to assess cognitive and affective components of body image. It consists of a non-immersive 3D graphical interface through which the patient is able to choose between 9 figures of different size which vary in size from underweight to overweight. The software was developed in two architectures, the first (A) running on a single user desktop computer equipped with a standard virtual reality development software and the second (B) splitted into a server (B1) accessible via Internet and actually running the same virtual ambient as in (A) and a VRML client (B2) so that anyone can access the application.
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paper_title: Mild cognitive impairment and deficits in instrumental activities of daily living: a systematic review

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IntroductionThere is a growing body of evidence that subtle deficits in instrumental activities of daily living (IADL) may be present in mild cognitive impairment (MCI). However, it is not clear if there are IADL domains that are consistently affected across patients with MCI. In this systematic review, therefore, we aimed to summarize research results regarding the performance of MCI patients in specific IADL (sub)domains compared with persons who are cognitively normal and/or patients with dementia.MethodsThe databases PsycINFO, PubMed and Web of Science were searched for relevant literature in December 2013. Publications from 1999 onward were considered for inclusion. Altogether, 497 articles were retrieved. Reference lists of selected articles were searched for potentially relevant articles. After screening the abstracts of these 497 articles, 37 articles were included in this review.ResultsIn 35 studies, IADL deficits (such as problems with medication intake, telephone use, keeping appointments, finding things at home and using everyday technology) were documented in patients with MCI. Financial capacity in patients with MCI was affected in the majority of studies. Effect sizes for group differences between patients with MCI and healthy controls were predominantly moderate to large. Performance-based instruments showed slight advantages (in terms of effect sizes) in detecting group differences in IADL functioning between patients with MCI, patients with Alzheimer’s disease and healthy controls.ConclusionIADL requiring higher neuropsychological functioning seem to be most severely affected in patients with MCI. A reliable identification of such deficits is necessary, as patients with MCI with IADL deficits seem to have a higher risk of converting to dementia than patients with MCI without IADL deficits. The use of assessment tools specifically designed and validated for patients with MCI is therefore strongly recommended. Furthermore, the development of performance-based assessment instruments should be intensified, as they allow a valid and reliable assessment of subtle IADL deficits in MCI, even if a proxy is not available. Another important point to consider when designing new scales is the inclusion of technology-associated IADL. Novel instruments for clinical practice should be time-efficient and easy to administer.
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paper_title: Virtual reality exposure therapy for the treatment of anxiety disorders: An evaluation of research quality

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Abstract Randomized controlled trials (RCTs) support the effectiveness of virtual reality exposure therapy (VRET) for anxiety disorders; however, the overall quality of the VRET RCT literature base has yet to be evaluated. This study reviewed 27 VRET RCTs and the degree of adherence to 8 RCT research design criteria derived from existing standards. Adherence to the study quality criteria was generally low as the articles met an average 2.85 criteria (SD = 1.56). None of the studies met more than six quality criteria. Study quality did not predict effect size; however, a reduction in effect size magnitude was observed for studies with larger sample sizes when comparing VRET to non-active control groups. VRET may be an effective method of treatment but caution should be exercised in interpreting the existing body of literature supporting VRET relative to existing standards of care. The need for well-designed VRET research is discussed.
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paper_title: Virtual reality in mental health : a review of the literature.

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BACKGROUND ::: Several virtual reality (VR) applications for the understanding, assessment and treatment of mental health problems have been developed in the last 10 years. The purpose of this review is to outline the current state of virtual reality research in the treatment of mental health problems. ::: ::: ::: METHODS ::: PubMed and PsycINFO were searched for all articles containing the words "virtual reality". In addition a manual search of the references contained in the papers resulting from this search was conducted and relevant periodicals were searched. Studies reporting the results of treatment utilizing VR in the mental health field and involving at least one patient were identified. ::: ::: ::: RESULTS ::: More than 50 studies using VR were identified, the majority of which were case studies. Seventeen employed a between groups design: 4 involved patients with fear of flying; 3 involved patients with fear of heights; 3 involved patients with social phobia/public speaking anxiety; 2 involved people with spider phobia; 2 involved patients with agoraphobia; 2 involved patients with body image disturbance and 1 involved obese patients. There are both advantages in terms of delivery and disadvantages in terms of side effects to using VR. Although virtual reality based therapy appears to be superior to no treatment the effectiveness of VR therapy over traditional therapeutic approaches is not supported by the research currently available. ::: ::: ::: CONCLUSIONS ::: There is a lack of good quality research on the effectiveness of VR therapy. Before clinicians will be able to make effective use of this emerging technology greater emphasis must be placed on controlled trials with clinically identified populations.
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paper_title: Using Virtual Reality for Cognitive Training of the Elderly

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There is a pressing demand for improving the quality and efficacy of health care and social support services needed by the world’s growing elderly population, especially by those affected by mild cognitive impairment (MCI) and Alzheimer’s disease (AD)-type early-stage dementia. Meeting that demand can significantly benefit from the deployment of innovative, computer-based applications capable of addressing specific needs, particularly in the area of cognitive impairment mitigation and rehabilitation. In that context, we present here our perspective viewpoint on the use of virtual reality (VR) tools for cognitive rehabilitation training, intended to assist medical personnel, health care workers, and other caregivers in improving the quality of daily life activities of people with MCI and AD. We discuss some effective design criteria and developmental strategies and suggest some possibly useful protocols and procedures. The particular innovative supportive advantages offered by the immersive interactive cha...
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paper_title: How do people with persecutory delusions evaluate threat in a controlled social environment? A qualitative study using virtual reality.

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20 participants with persecutory delusions and 20 controls entereda virtual underground train containing neutral characters. Under these circumstances, peoplewith persecutory delusions reported similar levels of paranoia as non-clinical participants.The transcripts of a post-virtual reality interview of the ﬁrst 10 participants in each groupwere analysed.
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paper_title: Virtual reality in neuroscience research and therapy

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The compatibility of virtual reality systems with brain imaging techniques and their use for animal research have aided the widespread adoption of virtual reality environments in both experimental and therapeutic domains. Here the authors review advances in virtual reality technology and its applications.
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paper_title: Virtual Reality in Psychotherapy: Review

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Virtual reality (VR) has recently emerged as a potentially effective way to provide general and specialty health care services, and appears poised to enter mainstream psychotherapy delivery. Because VR could be part of the future of clinical psychology, it is critical to all psychotherapists that it be defined broadly. To ensure appropriate development of VR applications, clinicians must have a clear understanding of the opportunities and challenges it will provide in professional practice. This review outlines the current state of clinical research relevant to the development of virtual environments for use in psychotherapy. In particular, the paper focuses its analysis on both actual applications of VR in clinical psychology and how different clinical perspectives can use this approach to improve the process of therapeutic change.
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paper_title: Perspective taking abilities in amnestic mild cognitive impairment and Alzheimer's disease

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Abstract Perspective taking is the ability to imagine what a scene looks like from a different viewpoint, which has been reported to be impaired in Alzheimer's disease (AD). This study compared overhead and first-person view perspective taking abilities in patients with mild cognitive impairment (MCI) and AD. A newly developed Arena Perspective Taking Task (APTT), using an environment of a circular arena, was used to compare 23 AD patients and 38 amnestic MCI patients with 18 healthy controls. The results were contrasted with a published perspective taking test (Standardized Road-Map Test of Direction Sense, RMTDS). The AD group was impaired in both overhead and first-person view APTT versions, but the impairment in the overhead view version applied specifically to women. Patients with aMCI were impaired in the first-person view but not in the overhead view version. Substantial sexual differences were found in the overhead but not in the first-person view APTT version. The RMTDS resembled both APTT versions: patients with aMCI were impaired in this test and also women in both patient groups were less accurate than men. Using the receiver operating characteristic analysis, the highest predictive power for MCI and AD patients diagnosis versus controls was observed for their success rate in the first-person view version. The results suggest distinction between overhead and first-person view perspective taking in the impairment of aMCI patients and the sex differences. The first-person view perspective taking is a potentially important candidate psychological marker for AD.
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paper_title: Vection and visually induced motion sickness: how are they related?

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The occurrence of visually induced motion sickness has been frequently linked to the sensation of illusory self-motion (so-called vection), however, the precise nature of this relationship is still not fully understood. To date, it is still a matter of debate whether or not vection is a necessary prerequisite for visually induced motion sickness (VIMS). That is, can there be visually induced motion sickness without any sensation of self-motion? In this paper, we will describe the possible nature of this relationship, review the literature that may speak to this relationship (including theoretical accounts of vection and VIMS), and offer suggestions with respect to operationally defining and reporting these phenomena in future.
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paper_title: Virtual Reality and Serious Games in Healthcare

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This chapter discusses the applications and solutions of emerging Virtual Reality (VR) and video games technologies in the healthcare sector, e.g. physical therapy for motor rehabilitation, exposure therapy for psychological phobias, and pain relief. Section 2 reviews state-of-the-art interactive devices used in current VR systems and high-end games such as sensor-based and camera-based tracking devices, data gloves, and haptic force feedback devices. Section 3 investigates recent advances and key concepts in games technology, including dynamic simulation, flow theory, adaptive games, and their possible implementation in serious games for healthcare. Various serious games are described in this section: some were designed and developed for specific healthcare purposes, e.g. BreakAway (2009)’s Free Dive, HopeLab (2006)’s Re-Mission, and Ma et al. (2007)’s VR game series, others were utilising off-the-shelf games such as Nintendo Wii sports for physiotherapy. A couple of experiments of using VR systems and games for stroke rehabilitation are highlighted in section 4 as examples to showcase the benefits and impacts of these technologies to conventional clinic practice. Finally, section 5 points some future directions of applying emerging games technologies in healthcare, such as augmented reality, Wii-mote motion control system, and even full body motion capture and controller free games technology demonstrated recently on E3 2009 which have great potentials to treat motor disorders, combat obesity, and other healthcare applications.
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paper_title: Moving from Virtual Reality Exposure-Based Therapy to Augmented Reality Exposure-Based Therapy: A Review

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This paper reviews the move from virtual reality exposure-based therapy (VRET) to augmented reality exposure-based therapy (ARET). Unlike virtual reality (VR), which entails a complete virtual environment (VE), augmented reality (AR) limits itself to producing certain virtual elements to then merge them into the view of the physical world. Although the general public may only have become aware of AR in the last few years, AR type applications have been around since beginning of the 20th century. Since, then, technological developments have enabled an ever increasing level of seamless integration of virtual and physical elements into one view. Like VR, AR allows the exposure to stimuli which, due to various reasons, may not be suitable for real-life scenarios. As such, AR has proven itself to be a medium through which individuals suffering from specific phobia can be exposed “safely” to the object(s) of their fear, without the costs associated with programming complete virtual environments. Thus, ARET can offer an efficacious alternative to some less advantageous exposure-based therapies. Above and beyond presenting what has been accomplished in ARET, this paper also raises some ARET related issues, and proposes potential avenues to be followed. These include the definition of an AR related term, the type of measures to be used to qualify the user’s experience in an augmented reality environment (ARE), the development of alternative geospatial referencing systems, as well as the potential use of ARET to treat social phobia. Overall, it may be said that the use of ARET, although promising, is still in its infancy but that, given a continued cooperation between clinical and technical teams, ARET has the potential of going well beyond the treatment of small animal phobia.
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paper_title: Controlling Social Stress in Virtual Reality Environments

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Virtual reality exposure therapy has been proposed as a viable alternative in the treatment of anxiety disorders, including social anxiety disorder. Therapists could benefit from extensive control of anxiety eliciting stimuli during virtual exposure. Two stimuli controls are studied in this study: the social dialogue situation, and the dialogue feedback responses (negative or positive) between a human and a virtual character. In the first study, 16 participants were exposed in three virtual reality scenarios: a neutral virtual world, blind date scenario, and job interview scenario. Results showed a significant difference between the three virtual scenarios in the level of self-reported anxiety and heart rate. In the second study, 24 participants were exposed to a job interview scenario in a virtual environment where the ratio between negative and positive dialogue feedback responses of a virtual character was systematically varied on-the-fly. Results yielded that within a dialogue the more positive dialogue feedback resulted in less self-reported anxiety, lower heart rate, and longer answers, while more negative dialogue feedback of the virtual character resulted in the opposite. The correlations between on the one hand the dialogue stressor ratio and on the other hand the means of SUD score, heart rate and audio length in the eight dialogue conditions showed a strong relationship: r(6)?=?0.91, p?=?0.002; r(6)?=?0.76, p?=?0.028 and r(6)?=?-0.94, p?=?0.001 respectively. Furthermore, more anticipatory anxiety reported before exposure was found to coincide with more self-reported anxiety, and shorter answers during the virtual exposure. These results demonstrate that social dialogues in a virtual environment can be effectively manipulated for therapeutic purposes.
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paper_title: How we experience immersive virtual environments: the concept of presence and its measurement *

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This paper reviews the concept of presence in immersive virtual environments, the sense of being there signalled by people acting and responding realistically to virtual situations and events. We argue that presence is a unique phenomenon that must be distinguished from the degree of engagement, involvement in the portrayed environment. We argue that there are three necessary conditions for presence: the (a) consistent low latency sensorimotor loop between sensory data and proprioception; (b) statistical plausibility: images must be statistically plausible in relation to the probability distribution of images over natural scenes. A constraint on this plausibility is the level of immersion; (c) behaviour-response correlations: Presence may be enhanced and maintained over time by appropriate correlations between the state and behaviour of participants and responses within the environment, correlations that show appropriate responses to the activity of the participants. We conclude with a discussion of methods for assessing whether presence occurs, and in particular recommend the approach of comparison with ground truth and give some examples of this.
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paper_title: Sense of Presence and Metacognition Enhancement in Virtual Reality Exposure Therapy in the Treatment of Social Phobias and the Fear of Flying

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The aim of this research effort is to identify feeling-of-presence and metacognitive amplifiers over existing well-established VRET treatment methods. Patient real time projection in virtual environments during stimuli exposure and electroencephalographyi¾?EEG report sharing are among the techniques, which have been used to achieve the desired result. Initialized from theoretical inferences, is moving towards a proof-of-concept prototype, which has been developed as a realization of the proposed method. The evaluation of the prototype made possible with an expert team of 28 therapists testing the fear of public speaking and fear of flying case studies.
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paper_title: A Dual-Modal Virtual Reality Kitchen for (Re)Learning of Everyday Cooking Activities in Alzheimer's Disease

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Everyday action impairment is one of the diagnostic criteria of Alzheimer's disease and is associated with many serious consequences, including loss of functional autonomy and independence. It has been shown that the (re)learning of everyday activities is possible in Alzheimer's disease by using error reduction teaching approaches in naturalistic clinical settings. The purpose of this study is to develop a dual-modal virtual reality platform for training in everyday cooking activities in Alzheimer's disease and to establish its value as a training tool for everyday activities in these patients. Two everyday tasks and two error reduction learning methods were implemented within a virtual kitchen. Two patients with Alzheimer's disease and two healthy elderly controls were tested. All subjects were trained in two learning sessions on two comparable cooking tasks. Within each group (i.e., patients and controls), the order of the training methods was counterbalanced. Repeated measure analysis before and after learning was performed. A questionnaire of presence and a verbal interview were used to obtain information about the subjective responses of the participants to the VR experience. The results in terms of errors, omissions, and perseverations (i.e., repetitive behaviors) indicate that the patients performed worse than the controls before learning, but that they reached a level of performance similar to that of the controls after a short learning session, regardless of the learning method employed. This finding provides preliminary support for the value of the dual-modal virtual reality platform for training in everyday cooking activities in Alzheimer's disease. However, further work is needed before it is ready for clinical application.
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paper_title: Evaluation of a virtual reality‐based memory training programme for Hong Kong Chinese older adults with questionable dementia: a pilot study

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Background ::: ::: Older adults with questionable dementia are at risk of progressing to dementia, and early intervention is considered important. The present study investigated the effectiveness of a virtual reality (VR)-based memory training for older adults with questionable dementia. ::: ::: ::: ::: Methods ::: ::: A pre-test and post-test design was adopted. Twenty and 24 older adults with questionable dementia were randomly assigned to a VR-based and a therapist-led memory training group, respectively. Primary outcome measures included the Multifactorial Memory Questionnaire and Fuld Object Memory Evaluation. ::: ::: ::: ::: Results ::: ::: Both groups demonstrated positive training effects, with the VR group showing greater improvement in objective memory performance and the non-VR group showing better subjective memory subtest results in the Multifactorial Memory Questionnaire. ::: ::: ::: ::: Conclusion ::: ::: The use of VR seems to be acceptable for older adults with questionable dementia. Further study on the effect of educational background and memory training modality (visual, auditory) is warranted. Copyright © 2011 John Wiley & Sons, Ltd.
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paper_title: Virtual reality in mental health : a review of the literature.

paper_content:

BACKGROUND ::: Several virtual reality (VR) applications for the understanding, assessment and treatment of mental health problems have been developed in the last 10 years. The purpose of this review is to outline the current state of virtual reality research in the treatment of mental health problems. ::: ::: ::: METHODS ::: PubMed and PsycINFO were searched for all articles containing the words "virtual reality". In addition a manual search of the references contained in the papers resulting from this search was conducted and relevant periodicals were searched. Studies reporting the results of treatment utilizing VR in the mental health field and involving at least one patient were identified. ::: ::: ::: RESULTS ::: More than 50 studies using VR were identified, the majority of which were case studies. Seventeen employed a between groups design: 4 involved patients with fear of flying; 3 involved patients with fear of heights; 3 involved patients with social phobia/public speaking anxiety; 2 involved people with spider phobia; 2 involved patients with agoraphobia; 2 involved patients with body image disturbance and 1 involved obese patients. There are both advantages in terms of delivery and disadvantages in terms of side effects to using VR. Although virtual reality based therapy appears to be superior to no treatment the effectiveness of VR therapy over traditional therapeutic approaches is not supported by the research currently available. ::: ::: ::: CONCLUSIONS ::: There is a lack of good quality research on the effectiveness of VR therapy. Before clinicians will be able to make effective use of this emerging technology greater emphasis must be placed on controlled trials with clinically identified populations.
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paper_title: Virtual reality and neuropsychology: upgrading the current tools.

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Background: Virtual reality (VR) is an evolving technology that has been applied in various aspects of medicine, including the treatment of phobia disorders, pain distraction interventions, surgical training, and medical education. These applications have served to demonstrate the various assets offered through the use of VR. Objective: To provide a background and rationale for the application of VR to neuropsychological assessment. Methods: A brief introduction to VR technology and a review of current ongoing neuropsychological research that integrates the use of this technology. Conclusions: VR offers numerous assets that may enhance current neuropsychological assessment protocols and address many of the
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paper_title: Non-Pharmacological Intervention for Memory Decline

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Non-pharmacological intervention of memory difficulties in healthy older adults, as well as those with brain damage and neurodegenerative disorders, has gained much attention in recent years. The two main reasons that explain this growing interest in memory rehabilitation are the limited efficacy of current drug therapies and the plasticity of the human central nervous and the discovery that during aging, the connections in the brain are not fixed but retain the capacity to change with learning. Moreover, several studies have reported enhanced cognitive performance in patients with neurological disease, following non-invasive brain stimulation [i.e., repetitive transcranial magnetic stimulation and transcranial direct current stimulation to specific cortical areas]. The present review provides an overview of memory rehabilitation in individuals with mild cognitive impairment and in patients with Alzheimer’s disease with particular regard to cognitive rehabilitation interventions focused on memory and non-invasive brain stimulation. Reviewed data suggest that in patients with memory deficits, memory intervention therapy could lead to performance improvements in memory, nevertheless further studies need to be conducted in order to establish the real value of this approach.
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paper_title: NeuroVR 2--a free virtual reality platform for the assessment and treatment in behavioral health care.

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At MMVR 2007 we presented NeuroVR (http://www.neurovr.org) a free virtual reality platform based on open-source software. The software allows non-expert users to adapt the content of 14 pre-designed virtual environments to the specific needs of the clinical or experimental setting. Following the feedbacks of the 2000 users who downloaded the first versions (1 and 1.5), we developed a new version--NeuroVR 2 (http://www.neurovr2.org)--that improves the possibility for the therapist to enhance the patient's feeling of familiarity and intimacy with the virtual scene, by using external sounds, photos or videos. More, when running a simulation, the system offers a set of standard features that contribute to increase the realism of the simulated scene. These include collision detection to control movements in the environment, realistic walk-style motion, advanced lighting techniques for enhanced image quality, and streaming of video textures using alpha channel for transparency.
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paper_title: VREAD: A Virtual Simulation to Investigate Cognitive Function in the Elderly

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Recent studies have shown that people with mild cognitive impairment (MCI) may convert to Alzheimer's disease (AD) over time although not all MCI cases progress to dementia. The diagnosis of MCI is important to allow prompt treatment and disease management before the neurons degenerate to a stage beyond repair. Hence, the ability to obtain a method of identifying MCI is of great importance. VREAD is a quick, easy and friendly tool that was developed with an aim to investigate cognitive functioning in a group of healthy elderly and those with MCI. It focuses on the task of following a route, since Topographical Disorientation (TD) is common in AD. The results shows that this novel simulation was able to predict with about 90% overall accuracy using weighting function proposed to discriminate between MCI and healthy elderly.
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paper_title: Video game training enhances cognitive control in older adults

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Cognitive control is defined by a set of neural processes that allow us to interact with our complex environment in a goal-directed manner. Humans regularly challenge these control processes when attempting to simultaneously accomplish multiple goals (multitasking), generating interference as the result of fundamental information processing limitations. It is clear that multitasking behaviour has become ubiquitous in today's technologically dense world, and substantial evidence has accrued regarding multitasking difficulties and cognitive control deficits in our ageing population. Here we show that multitasking performance, as assessed with a custom-designed three-dimensional video game (NeuroRacer), exhibits a linear age-related decline from 20 to 79 years of age. By playing an adaptive version of NeuroRacer in multitasking training mode, older adults (60 to 85 years old) reduced multitasking costs compared to both an active control group and a no-contact control group, attaining levels beyond those achieved by untrained 20-year-old participants, with gains persisting for 6 months. Furthermore, age-related deficits in neural signatures of cognitive control, as measured with electroencephalography, were remediated by multitasking training (enhanced midline frontal theta power and frontal-posterior theta coherence). Critically, this training resulted in performance benefits that extended to untrained cognitive control abilities (enhanced sustained attention and working memory), with an increase in midline frontal theta power predicting the training-induced boost in sustained attention and preservation of multitasking improvement 6 months later. These findings highlight the robust plasticity of the prefrontal cognitive control system in the ageing brain, and provide the first evidence, to our knowledge, of how a custom-designed video game can be used to assess cognitive abilities across the lifespan, evaluate underlying neural mechanisms, and serve as a powerful tool for cognitive enhancement.
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paper_title: Detecting Everyday Action Deficits in Alzheimer’s Disease Using a Nonimmersive Virtual Reality Kitchen

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Alzheimer’s disease (AD) causes impairments affecting instrumental activities of daily living (IADL). Transdisciplinary research in neuropsychology and virtual reality has fostered the development of ecologically valid virtual tools for the assessment of IADL, using simulations of real life activities. Few studies have examined the benefits of this approach in AD patients. Our aim was to examine the utility of a non-immersive virtual coffee task (NI-VCT) for assessment of IADL in these patients. We focus on the assessment results obtained from a group of 24 AD patients on a task designed to assess their ability to prepare a virtual cup of coffee, using a virtual coffee machine. We compared performance on the virtual task to an identical daily living task involving the actual preparation of a cup of coffee, as well as to global cognitive, executive, and caregiver-reported IADL functioning. Relative to 32 comparable, healthy elderly (HE) controls, AD patients performed worse than HE controls on all tasks. Correlation analyses revealed that NI-VCT measures were related to all other neuropsychological measures. Moreover, regression analyses demonstrated that performance on the NI-VCT predicted actual task performance and caregiver-reported IADL functioning. Our results provide initial support for the utility of our virtual kitchen for assessment of IADL in AD patients. ( JINS , 2014, 20 , 1–10)
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paper_title: Egocentric and allocentric memory as assessed by virtual reality in individuals with amnestic mild cognitive impairment

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Abstract Present evidence suggests that medial temporal cortices subserve allocentric representation and memory, whereas egocentric representation and memory also depends on parietal association cortices and the striatum. Virtual reality environments have a major advantage for the assessment of spatial navigation and memory formation, as computer-simulated first-person environments can simulate navigation in a large-scale space. Twenty-nine patients with amnestic MCI (aMCI) were compared with 29 healthy matched controls on two virtual reality tasks affording to learn a virtual park (allocentric memory) and a virtual maze (egocentric memory). Participants further received a neuropsychological investigation and MRI volumetry at the time of the assessment. Results indicate that aMCI patients had significantly reduced size of the hippocampus bilaterally and the right-sided precuneus and inferior parietal cortex. aMCI patients were severely impaired learning the virtual park and the virtual maze. Smaller volumes of the right-sided precuneus were related to worse performance on the virtual maze. Participants with striatal lacunar lesions committed more errors than participants without such lesions on the virtual maze but not on the virtual park. aMCI patients later converting to dementia (n = 15) had significantly smaller hippocampal size when compared with non-converters (n = 14). However, both groups did not differ on virtual reality task performance. Our study clearly demonstrates the feasibility of virtual reality technology to study spatial memory deficits of persons with aMCI. Future studies should try to design spatial virtual reality tasks being specific enough to predict conversion from MCI to dementia and conversion from normal to MCI.
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paper_title: Interactive computer-training as a therapeutic tool in Alzheimer’s disease

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Abstract The current study sought to evaluate a novel kind of interactive computer-based cognitive training (ICT) in Alzheimer’s disease (AD). AD patients (N = 9), age- and gender-matched patients with a major depressive episode (N = 9), and healthy control subjects (N = 10) were trained to use an ICT program that relates to activities of daily living (ADL). Digital photographs of a shopping route were implemented in a close-to-reality simulation on a computer touch-screen. The task was to find a predefined shopping route, to buy three items, and to answer correctly 10 multiple-choice questions addressing knowledge related to the virtual tasks. Training performance was rated using the number of mistakes (wrong way), time needed for the tasks, number of correct multiple-choice answers, and of repeat of instruction. Compared to normal controls and depressed patients, AD patients performed significantly worse with regard to all variables. Within a 4-week training period including 12 sessions, however, substantial training gains were observed, including a significant reduction of mistakes. Training effects were sustained until follow-up 3 weeks later. The performance of the depressed patients and the normal controls improved as well, with no difference between the two groups. Self-reported effects revealed that the training was well perceived. Thus, the task performance of AD patients improved substantially and subjects appeared to have liked this approach to ICT. New interactive media, therefore, may yield interesting opportunities for rehabilitation and (psycho)therapeutic interventions.
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paper_title: Mild cognitive impairment and deficits in instrumental activities of daily living: a systematic review

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IntroductionThere is a growing body of evidence that subtle deficits in instrumental activities of daily living (IADL) may be present in mild cognitive impairment (MCI). However, it is not clear if there are IADL domains that are consistently affected across patients with MCI. In this systematic review, therefore, we aimed to summarize research results regarding the performance of MCI patients in specific IADL (sub)domains compared with persons who are cognitively normal and/or patients with dementia.MethodsThe databases PsycINFO, PubMed and Web of Science were searched for relevant literature in December 2013. Publications from 1999 onward were considered for inclusion. Altogether, 497 articles were retrieved. Reference lists of selected articles were searched for potentially relevant articles. After screening the abstracts of these 497 articles, 37 articles were included in this review.ResultsIn 35 studies, IADL deficits (such as problems with medication intake, telephone use, keeping appointments, finding things at home and using everyday technology) were documented in patients with MCI. Financial capacity in patients with MCI was affected in the majority of studies. Effect sizes for group differences between patients with MCI and healthy controls were predominantly moderate to large. Performance-based instruments showed slight advantages (in terms of effect sizes) in detecting group differences in IADL functioning between patients with MCI, patients with Alzheimer’s disease and healthy controls.ConclusionIADL requiring higher neuropsychological functioning seem to be most severely affected in patients with MCI. A reliable identification of such deficits is necessary, as patients with MCI with IADL deficits seem to have a higher risk of converting to dementia than patients with MCI without IADL deficits. The use of assessment tools specifically designed and validated for patients with MCI is therefore strongly recommended. Furthermore, the development of performance-based assessment instruments should be intensified, as they allow a valid and reliable assessment of subtle IADL deficits in MCI, even if a proxy is not available. Another important point to consider when designing new scales is the inclusion of technology-associated IADL. Novel instruments for clinical practice should be time-efficient and easy to administer.
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paper_title: Allothetic orientation and sequential ordering of places is impaired in early stages of Alzheimer's disease: corresponding results in real space tests and computer tests

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Spatial disorientation and learning problems belong to the integral symptoms of Alzheimer's disease (AD). A circular arena for human subjects (2.9 m diameter, 3 m high) was equipped with a computerized tracking system, similar to that used in animals. We studied navigation in 11 subjects diagnosed with early stages of Alzheimer's disease (AD), 27 subjects with subjective problems with memory or concentration, and 10 controls. The task was to locate one or several unmarked goals using the arena geometry, starting position and/or cues on the arena wall. Navigation in a real version and a computer map view version of the tests yielded similar results. The AD group was severely impaired relative to controls in navigation to one hidden goal in eight rotated positions. The impairment was largest when only the cues on the wall could be used for orientation. Also, the AD group recalled worse than controls the order of six sequentially presented locations, though they recalled similarly to controls the positions of the locations. The group with subjective problems was not impaired in any of the tests. Our results document the spatial navigation and non-verbal episodic memory impairment in the AD. Similar results in real and map view computer tests support the use of computer tests in diagnosis of cognitive disturbances.
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paper_title: Age and dementia related differences in spatial navigation within an immersive virtual environment.

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Immersive virtual reality (VR) is an innovative tool that can allow study of human spatial navigation in a realistic but controlled environment. The purpose of this study was to examine age- and Alzheinrer's disease-related differences in route learning and memory using VR. The spatial memory task took place in a VR environment set up on a Computer Workstation. Participants were immersed by putting video unit goggles over their eyes using a Head Mounted. Participants were shown a path within a virtual city, and then had to navigate it as quickly and accurately as possible. They were granted four learning trials on this path. An interference path was then presented before asking participants to re-navigate the first route at short and long delays. Finally, participants were tested for recognition of the city's buildings and objects. Young adults were consistently quicker and more accurate in their path navigation than older participants whilst those patients with Alzheimer's Disease made more mistakes on the recognition task in particular, being more likely to mistakenly affirm having seen an element in the city when it was in fact a foil. Our study would suggest that spatial navigation is susceptible to the effects of aging and Alzheimer's Disease. The potential applications ofVR to the study of spatial navigation is seemingly important in that it may help place the science of neuropsychology on firmer scientific grounds in terms of its validity to real world function and dysfunction.
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paper_title: An innovative virtual reality system for mild cognitive impairment: Diagnosis and evaluation

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In advanced countries throughout the world, the population of Alzheimer's Disease(AD) patients has been gradually increasing with the aging of the society. As a result, it has become an important research topic how to diagnose AD early and give necessary treatment and training to AD patients, especially those with mild cognitive impairment(MCI), whose executive functions such as response inhibition, cognitive flexibility, attention switching and planning may display evident disorder and impairment. Unlike traditional paper tests and subjective assessments by the patient's relatives, this study adopts virtual reality(VR) technology to develop a novel diagnosis & assessment system, which uses head mounted display(HMD), game technology and sensors to generate an interactive and panoramic scenario—a virtual convenience store—for assessment of executive functions and memory. A variety of tasks of multi-layered difficulty-level hierarchy, such as memorizing a shopping list, looking for certain goods, and checking out, has been designed for customized and adaptive assessment, training, and treatment of MD. In the meantime, the study also records test-takers' performance data (including path and central-vision movement) in the process of all tasks for the development of a novel diagnosis & assessment method. Moreover, test-takers' technology acceptance is measured for assessing the elderly's subjective perception of new technology and discussing the topic of human-machine interaction. In the study, tests on 2 healthy adults have been completed, the system's functionality has been preliminarily verified, and test-takers' subjective perception of the system has been investigated.
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paper_title: Effects of Enactment in Episodic Memory: A Pilot Virtual Reality Study with Young and Elderly Adults

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None of the previous studies on aging have tested the influence of action with respect to the degree of interaction with the environment (active or passive navigation) and the source of itinerary choice (self or externally imposed), on episodic memory encoding. The aim of this pilot study was to explore the influence of these factors on feature binding (the association between what, where and when) in episodic memory and on the subjective sense of remembering. Navigation in a virtual city was performed by 64 young and 64 older adults in one of four modes of exploration: (1) passive condition where participants were immersed as passengers of a virtual car (no interaction, no itinerary control), (2) itinerary control (the subject chose the itinerary, but did not drive the car), (3) low or (4) high navigation control (the subject just moved the car on rails or drove the car with a steering wheel and a gas pedal on a fixed itinerary, respectively). The task was to memorize as many events encountered in the virtual environment as possible along with their factual (what), spatial (where), and temporal (when) details, and then to perform immediate and delayed memory tests. An age-related decline was evidenced for immediate and delayed feature binding. Compared to passive and high navigation conditions, and regardless of age groups, feature binding was enhanced by low navigation and itinerary control conditions. The subjective sense of remembering was boosted by the itinerary control in older adults. Memory performance following high navigation was specifically linked to variability in executive functions. The present findings suggest that the decision of the itinerary is beneficial to boost episodic memory in aging, although it does not eliminate age-related deficits. Active navigation can also enhance episodic memory when it is not too demanding for subjects' cognitive resources.
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paper_title: Can a novel computerized cognitive screening test provide additional information for early detection of Alzheimer's disease?

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Abstract Background Virtual reality testing of everyday activities is a novel type of computerized assessment that measures cognitive, executive, and motor performance as a screening tool for early dementia. This study used a virtual reality day-out task (VR-DOT) environment to evaluate its predictive value in patients with mild cognitive impairment (MCI). Methods One hundred thirty-four patients with MCI were selected and compared with 75 healthy control subjects. Participants received an initial assessment that included VR-DOT, a neuropsychological evaluation, magnetic resonance imaging (MRI) scan, and event-related potentials (ERPs). After 12 months, participants were assessed again with MRI, ERP, VR-DOT, and neuropsychological tests. Results At the end of the study, we differentiated two subgroups of patients with MCI according to their clinical evolution from baseline to follow-up: 56 MCI progressors and 78 MCI nonprogressors. VR-DOT performance profiles correlated strongly with existing predictive biomarkers, especially the ERP and MRI biomarkers of cortical thickness. Conclusions Compared with ERP, MRI, or neuropsychological tests alone, the VR-DOT could provide additional predictive information in a low-cost, computerized, and noninvasive way.
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paper_title: How different spatial representations interact in virtual environments: the role of mental frame syncing

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뀀ഀȠ 뀀ഀȠ Silvia SerinoGiuseppe Riva 뀀ഀȠ 뀀ഀȠ 뀀ഀȠ 뀀ഀȠ 뀀ഀȠ 뀀ഀȠ 뀀ഀȠ Abstract This experiment is aimed at understanding how egocentric experiences, allocentric viewpoint-dependent representations, and allocentric viewpoint-independent representations interact when encoding and retrieving a spatial environment. Although several cognitive theories have highlighted the interaction between reference frames, it is less clear about the role of a real-time presentation of allocentric viewpoint-dependent representation on the spatial organization of information. Sixty participants were asked to navigate in two virtual cities to memorize the position of one hidden object. Half of the participants had the possibility to visualize the virtual city with an inter- active aerial view. Then, they were required to find the position of the object in three different experimental con- ditions (''retrieval with an interactive aerial view'' vs. ''retrieval on a map'' vs. ''retrieval without an interactive aerial view''). Results revealed that participants were sig- nificantly more precise in retrieving the position of the object when immersed in an egocentric experience with the interactive aerial view. The retrieval of spatial information is facilitated by the presence of the interactive aerial view of the city, since it provides a real-time allocentric view- point-dependent representation. More participants with high preference for using cardinal points tend to be more accurate when they were asked to retrieve the position of the object on the map. As suggested by the mental frame syncing hypothesis, the presence of an allocentric 뀀ഀȠ 뀀ഀȠ 뀀ഀȠoduction
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paper_title: Spatial navigation impairment is proportional to right hippocampal volume

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Cognitive deficits in older adults attributable to Alzheimer's disease (AD) pathology are featured early on by hippocampal impairment. Among these individuals, deterioration in spatial navigation, manifested by poor hippocampus-dependent allocentric navigation, may occur well before the clinical onset of dementia. Our aim was to determine whether allocentric spatial navigation impairment would be proportional to right hippocampal volume loss irrespective of general brain atrophy. We also contrasted the respective spatial navigation scores of the real-space human Morris water maze with its corresponding 2D computer version. We included 42 cognitively impaired patients with either amnestic mild cognitive impairment (n = 23) or mild and moderate AD (n = 19), and 14 cognitively intact older controls. All participants underwent 1.5T MRI brain scanning with subsequent automatic measurement of the total brain and hippocampal (right and left) volumes. Allocentric spatial navigation was tested in the real-space version of the human Morris water maze and in its corresponding computer version. Participants used two navigational cues to locate an invisible goal independent of the start position. We found that smaller right hippocampal volume was associated with poorer navigation performance in both the real-space (β = −0.62, P 0.59) subjects. The respective real-space and virtual scores strongly correlated with each other. Our findings indicate that the right hippocampus plays a critical role in allocentric navigation, particularly when cognitive impairment is present.
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paper_title: BrightArm™ therapy for patients with advanced dementia: A feasibility study

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Virtual reality use in cognitive rehabilitation of advanced dementia has been sparse. Three residents of a Dementia Ward participated in a feasibility study of the BrightArm™ system. They played custom games targeting several cognitive domains including short-term and working memory. Clinician observation revealed a positive effect on emotive state, with technology well accepted by all participants.
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paper_title: Spatial navigation deficit in amnestic mild cognitive impairment

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Patients with Alzheimer's disease (AD) frequently have difficulties with spatial orientation in their day-to-day life. Although AD is typically preceded by amnestic mild cognitive impairment (MCI), spatial navigation has not yet been studied in MCI. Sixty-five patients were divided into five groups: probable AD (n = 21); MCI, further classified as amnestic MCI single domain (n = 11); amnestic MCI multiple domain (n = 18), or nonamnestic MCI (n = 7), and subjective memory complaints (n = 8). These patients, together with a group of healthy control subjects (n = 26), were tested by using a four-subtests task that required them to locate an invisible goal inside a circular arena. Each subtest began with an overhead view of the arena showed on a computer monitor. This was followed by a real navigation inside of the actual space, an enclosed arena 2.9 m in diameter. Depending on the subtest, the subjects could use the starting position and/or cues on the wall for navigation. The subtests thus were focused on allocentric and egocentric navigation. The AD group and amnestic MCI multiple-domain group were impaired in all subtests. The amnestic MCI single-domain group was impaired significantly in subtests focused on allocentric orientation and at the beginning of the real space egocentric subtest, suggesting impaired memory for allocentric and real space configurations. Our results suggest that spatial navigation impairment occurs early in the development of AD and can be used for monitoring of the disease progression or for evaluation of presymptomiatic AD.
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paper_title: Temporal Order Memory Assessed during Spatiotemporal Navigation As a Behavioral Cognitive Marker for Differential Alzheimer's Disease Diagnosis

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Episodic memory impairment is a hallmark for early diagnosis of Alzheimer9s disease. Most actual tests used to diagnose Alzheimer9s disease do not assess the spatiotemporal properties of episodic memory and lead to false-positive or -negative diagnosis. We used a newly developed, nonverbal navigation test for Human, based on the objective experimental testing of a spatiotemporal experience, to differentially Alzheimer9s disease at the mild stage ( N = 16 patients) from frontotemporal lobar degeneration ( N = 11 patients) and normal aging ( N = 24 subjects). Comparing navigation parameters and standard neuropsychological tests, temporal order memory appeared to have the highest predictive power for mild Alzheimer9s disease diagnosis versus frontotemporal lobar degeneration and normal aging. This test was also nonredundant with classical neuropsychological tests. As a conclusion, our results suggest that temporal order memory tested in a spatial navigation task may provide a selective behavioral marker of Alzheimer9s disease.
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paper_title: Impaired Allocentric Spatial Memory Underlying Topographical Disorientation

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The cognitive processes supporting spatial navigation are considered in the context of a patient (CF) with possible very early Alzheimer's disease who presents with topographical disorientation. Her verbal memory and her recognition memory for unknown buildings, landmarks and outdoor scenes was intact, although she showed an impairment in face processing. By contrast, her navigational ability, quantitatively assessed within a small virtual reality (VR) town, was significantly impaired. Interestingly, she showed a selective impairment in a VR object-location memory test whenever her viewpoint was shifted between presentation and test, but not when tested from the same viewpoint. We suggest that a specific impairment in locating objects relative to the environment rather than relative to the perceived viewpoint (i.e. allocentric rather than egocentric spatial memory) underlies her topographical disorientation. We discuss the likely neural bases of this deficit in the light of related studies in humans and animals, focusing on the hippocampus and related areas. The specificity of our test indicates a new way of assessing topographical disorientation, with possible application to the assessment of progressive dementias such as Alzheimer's disease.
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paper_title: Spatial memory impairments in amnestic mild cognitive impairment in a virtual radial arm maze

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Author contributions ::: ::: Dr Jun-Young Lee conceived the study, acquired, and interpreted the data. Ms Sooyeon Kho and Ms Hye Bin Yoo analyzed the data and edited the article. Ms Soowon Park made major revisions to the Introduction section. Dr Jung-Seok Choi and Jun Soo Kwon acquired the patients and their clinical reports. The corresponding authors Dr Kyung Ryeol Cha and Dr Hee-Yeon Jung designed the research and the experiments. All authors made substantial contributions to conception and design of the paper, acquisition of data, or analysis and interpretation of data, and drafted the article or revised it for critically important content. ::: ::: ::: ::: Disclosure ::: ::: The authors report no conflict of interest in this work. No competing financial interests exist.
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paper_title: Involving Persons with Dementia in the Evaluation of Outdoor Environments

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ABSTRACT Using virtual reality (VR), we examined the barriers to and facilitators of functioning outdoors in persons with dementia (PwD) and investigated the generalizability of findings in VR to the real world. An existing town center was modeled in VR. PwD took part in both real-world and VR walks. Based on the results, the model was redesigned and then tested again. Performance on the walks improved, and potentially beneficial adaptations to outdoor environments were identified, but limitations of VR as a representation of the real world were also identified. We conclude that VR models, together with a rigorous behavioral testing method, can be a useful tool for the evaluation of outdoor environments and for identifying improvements for PwD.
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paper_title: Detecting navigational deficits in cognitive aging and Alzheimer disease using virtual reality

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Background:Older adults get lost, in many cases because of recognized or incipient Alzheimer disease (AD). In either case, getting lost can be a threat to individual and public safety, as well as to personal autonomy and quality of life. Here we compare our previously described real-world navigation test with a virtual reality (VR) version simulating the same navigational environment. Methods:Quantifying real-world navigational performance is difficult and time-consuming. VR testing is a promising alternative, but it has not been compared with closely corresponding real-world testing in aging and AD. We have studied navigation using both real-world and virtual environments in the same subjects: young normal controls (YNCs, n = 35), older normal controls (ONCs, n = 26), patients with mild cognitive impairment (MCI, n = 12), and patients with early AD (EAD, n = 14). Results:We found close correlations between real-world and virtual navigational deficits that increased across groups from YNC to ONC, to MCI, and to EAD. Analyses of subtest performance showed similar profiles of impairment in real-world and virtual testing in all four subject groups. The ONC, MCI, and EAD subjects all showed greatest difficulty in self-orientation and scene localization tests. MCI and EAD patients also showed impaired verbal recall about both test environments. Conclusions:Virtual environment testing provides a valid assessment of navigational skills. Aging and Alzheimer disease (AD) share the same patterns of difficulty in associating visual scenes and locations, which is complicated in AD by the accompanying loss of verbally mediated navigational capacities. We conclude that virtual navigation testing reveals deficits in aging and AD that are associated with potentially grave risks to our patients and the community. GLOSSARYAD = Alzheimer disease; EAD = early Alzheimer disease; MCI = mild cognitive impairment; MMSE = Mini-Mental State Examination; ONC = older normal control; std. wt. = standardized weight; THSD = Tukey honestly significant difference; VR = virtual reality; YNC = young normal control.
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paper_title: Controlling Memory Impairment in Elderly Adults Using Virtual Reality Memory Training: A Randomized Controlled Pilot Study

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Background. Memory decline is a prevalent aspect of aging but may also be the first sign of cognitive pathology. Virtual reality (VR) using immersion and interaction may provide new approaches to the treatment of memory deficits in elderly individuals. Objective. The authors implemented a VR training intervention to try to lessen cognitive decline and improve memory functions. Methods. The authors randomly assigned 36 elderly residents of a rest care facility (median age 80 years) who were impaired on the Verbal Story Recall Test either to the experimental group (EG) or the control group (CG). The EG underwent 6 months of VR memory training (VRMT) that involved auditory stimulation and VR experiences in path finding. The initial training phase lasted 3 months (3 auditory and 3 VR sessions every 2 weeks), and there was a booster training phase during the following 3 months (1 auditory and 1 VR session per week). The CG underwent equivalent face-to-face training sessions using music therapy. Both groups par...
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paper_title: Autobiographical Memory Deficits in Alzheimer's Disease

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Autobiographical memory comprises memories of one's own past that are characterized by a sense of subjective time and autonoetic awareness. Although autobiographical memory deficits are among the major complaints of patients with dementia, they have rarely been systematically assessed in mild cognitive impairment and Alzheimer's disease. We therefore investigated semantic and episodic aspects of autobiographical memory for remote and recent life periods in a sample of 239 nursing home residents (165 in different stages of Alzheimer's disease, 33 with mild cognitive impairment, and 41 cognitively unimpaired) with respect to potential confounders. Episodic autobiographical memories, especially the richness of details, were impaired early in the course of Alzheimer's disease or even in the preclinical phase, while semantic memories were spared until moderate stages, indicating a dissociation between both memory systems. The examination of autobiographic memory loss can facilitate the clinical diagnosis of Alzheimer's disease.
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paper_title: Augmented reality annotations to assist persons with Alzheimers and their caregivers

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Persons with Alzheimer's disease (AD) and their caregivers implement diverse strategies to cope with memory loss. A common strategy involves placing tags on drawers or removing cabinet doors to make their contents visible. This study describes the Ambient aNnotation System (ANS), aimed at assisting people suffering from AD and their caregivers with this task. The system has two main modules: The tagging subsystem allows caregivers to create and manage ambient annotations in order to assist people with memory problems. The second subsystem allows people with AD to use a mobile phone to recognize tags in the environment and to receive relevant information in the form of audio, text, or images. The identification of these tags is performed in real time by uploading images from the mobile phone to a server, which uses the SURF algorithm for object recognition. We describe the design and implementation of the system as well as results of the evaluation of its performance and efficiency. ANS can process query images approximately every 2 s and is able to locate users in their homes with a precision of 0.93. A usability study conducted with six subjects determined that audio notifications are more effective than vibrating notifications to alert the user about tags in the environment.
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paper_title: Is it possible to use highly realistic virtual reality in the elderly? A feasibility study with image-based rendering

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Background: Virtual reality (VR) opens up a vast number of possibilities in many domains of therapy. The primary objective of the present study was to evaluate the acceptability for elderly subjects of a VR experience using the image-based rendering virtual environment (IBVE) approach and secondly to test the hypothesis that visual cues using VR may enhance the generation of autobiographical memories. ::: Methods: Eighteen healthy volunteers (mean age 68.2 years) presenting memory complaints with a Mini-Mental State Examination score higher than 27 and no history of neuropsychiatric disease were included. Participants were asked to perform an autobiographical fluency task in four conditions. The first condition was a baseline grey screen, the second was a photograph of a well-known location in the participant’s home city (FamPhoto), and the last two conditions displayed VR, ie, a familiar image-based virtual environment (FamIBVE) consisting of an image-based representation of a known landmark square in the center of the city of experimentation (Nice) and an unknown image-based virtual environment (UnknoIBVE), which was captured in a public housing neighborhood containing unrecognizable building fronts. After each of the four experimental conditions, participants filled in self-report questionnaires to assess the task acceptability (levels of emotion, motivation, security, fatigue, and familiarity). CyberSickness and Presence questionnaires were also assessed after the two VR conditions. Autobiographical memory was assessed using a verbal fluency task and quality of the recollection was assessed using the “remember/know” procedure. ::: Results: All subjects completed the experiment. Sense of security and fatigue were not significantly different between the conditions with and without VR. The FamPhoto condition yielded a higher emotion score than the other conditions (P,0.05). The CyberSickness questionnaire showed that participants did not experience sickness during the experiment across the VR conditions. VR stimulates autobiographical memory, as demonstrated by the increased total number of responses on the autobiographical fluency task and the increased number of conscious recollections of memories for familiar versus unknown scenes (P,0.01). ::: Conclusion: The study indicates that VR using the FamIBVE system is well tolerated by the elderly. VR can also stimulate recollections of autobiographical memory and convey familiarity of a given scene, which is an essential requirement for use of VR during reminiscence therapy.
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paper_title: A Pilot Evaluation of a Therapeutic Game Applied to Small Animal Phobia Treatment

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This study presents Catch Me game, a therapeutic game for teaching patients how to confront to their feared animals during spider and cockroach phobia treatment, and evaluates whether inclusion of gaming elements into therapeutic protocol does have an added value for the treatment. The Catch Me game was designed in order to help patients learn about their feared animals and to learn how to apply adapted confrontation strategies and techniques with the lowest possible anxiety level. In this study, Catch Me game was evaluated in terms of knowledge acquisition, anxiety level, self-efficacy belief acquisition, and appeal to both participants and therapists. Data collection consisted of quantitative measures on a sample of 14 non-clinical population. The results showed that the game significantly improved knowledge and self-efficacy belief regarding the feared animal, and significantly decreased the anxiety level of participants. Moreover, both participants and the therapists were highly satisfied with the game.
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paper_title: GenVirtual: An Augmented Reality Musical Game for Cognitive and Motor Rehabilitation

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Electronic games have been used to stimulate cognitive functions such as attention, concentration and memory. This paper presents GenVirtual, which is an augmented reality musical game and is proposed to help people with learning disabilities. The intention is to help the patient in the following skills: creativity, attention, memory (storage and retrieval), planning, concentration, ready-response, hearing and visual perception, and motor coordination. The therapist has flexibility to place the musical and visual elements, allowing him to create different scenarios to each patient. GenVirtual uses Augmented Reality technology to allow people with physical disorders to interact with the game. Patients with no fingers can also play this game. GenVirtual was evaluated by a music therapist who considered it as a facilitating and motivating game to the learning process and that it has the potential to improve the life of the people with special needs.
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paper_title: Mixing Realities? An Application of Augmented Reality for the Treatment of Cockroach Phobia

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Augmented reality (AR) refers to the introduction of virtual elements in the real world. That is, the person is seeing an image composed of a visualization of the real world, and a series of virtual elements that, at that same moment, are super-imposed on the real world. The most important aspect of AR is that the virtual elements supply to the person relevant and useful information that is not contained in the real world. AR has notable potential, and has already been used in diverse fields, such as medicine, the army, coaching, engineering, design, and robotics. Until now, AR has never been used in the scope of psychological treatment. Nevertheless, AR presents various advantages. Just like in the classical systems of virtual reality, it is possible to have total control over the virtual elements that are super-imposed on the real world, and how one interacts with those elements. AR could involve additional advantages; on one side it could be less expensive since it also uses the real world (this does not need to be modeled), and it could facilitate the feeling of presence (the sensation of being there), and reality judgment (the fact of judging the experience as real) of the person since the environment he or she is in, and what he or she is seeing is, in fact the "reality." In this paper, we present the data of the first case study in which AR has been used for the treatment of a specific phobia, cockroaches phobia. It addresses a system of AR that permits exposure to virtual cockroaches super-imposed on the real world. In order to carry out the exposure, the guidelines of Ost with respect to "one-session treatment" were followed. The results are promising. The participant demonstrated notable fear and avoidance in the behavioral avoidance test before the treatment, and not only was an important decrease in the scores of fear and avoidance observed after the treatment, but also the participant was capable of approaching, interacting, and killing live cockroaches immediately following the treatment. The results are maintained in a follow-up conducted 1 month after the termination of the treatment.
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paper_title: Augmented reality cube game for cognitive training: an interaction study.

paper_content:

There is the potential that cognitive activity may delay cognitive decline in people with mild cognitive impairment. Games provide both cognitive challenge and motivation for repeated use, a prerequisite for long lasting effect. Recent advances in technology introduce several new interaction methods, potentially leading to more efficient, personalized cognitive gaming experiences. In this paper, we present an Augmented Reality (AR) cognitive training game, utilizing cubes as input tools, and we test the cube interaction with a pilot study. The results of the study revealed the marker occlusion problem, and that novice AR users can adjust to the developed AR environment after a small number of sessions.
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paper_title: Moving from Virtual Reality Exposure-Based Therapy to Augmented Reality Exposure-Based Therapy: A Review

paper_content:

This paper reviews the move from virtual reality exposure-based therapy (VRET) to augmented reality exposure-based therapy (ARET). Unlike virtual reality (VR), which entails a complete virtual environment (VE), augmented reality (AR) limits itself to producing certain virtual elements to then merge them into the view of the physical world. Although the general public may only have become aware of AR in the last few years, AR type applications have been around since beginning of the 20th century. Since, then, technological developments have enabled an ever increasing level of seamless integration of virtual and physical elements into one view. Like VR, AR allows the exposure to stimuli which, due to various reasons, may not be suitable for real-life scenarios. As such, AR has proven itself to be a medium through which individuals suffering from specific phobia can be exposed “safely” to the object(s) of their fear, without the costs associated with programming complete virtual environments. Thus, ARET can offer an efficacious alternative to some less advantageous exposure-based therapies. Above and beyond presenting what has been accomplished in ARET, this paper also raises some ARET related issues, and proposes potential avenues to be followed. These include the definition of an AR related term, the type of measures to be used to qualify the user’s experience in an augmented reality environment (ARE), the development of alternative geospatial referencing systems, as well as the potential use of ARET to treat social phobia. Overall, it may be said that the use of ARET, although promising, is still in its infancy but that, given a continued cooperation between clinical and technical teams, ARET has the potential of going well beyond the treatment of small animal phobia.
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paper_title: ON THE CONVERGENCE OF AFFECTIVE AND PERSUASIVE TECHNOLOGIES IN COMPUTER-MEDIATED HEALTH-CARE SYSTEMS

paper_content:

This paper offers a portrayal of how affective computing and persuasive technologies can converge into an effective tool for interfacing biomedical engineering with behavioral sciences and medicine. We describe the characteristics, features, applications, present state of the art, perspectives, and trends of both streams of research. In particular, these streams are analyzed in light of the potential contribution of their convergence for improving computer-mediated health-care systems, by facilitating the modification of patients' attitudes and behaviors, such as engagement and compliance. We propose a framework for future research in this emerging area, highlighting how key constructs and intervening variables should be considered. Some specific implications and challenges posed by the convergence of these two technologies in health care, such as paradigm change, multimodality, patients' attitude improvement, and cost reduction, are also briefly addressed and discussed.
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paper_title: Using Virtual Reality for Cognitive Training of the Elderly

paper_content:

There is a pressing demand for improving the quality and efficacy of health care and social support services needed by the world’s growing elderly population, especially by those affected by mild cognitive impairment (MCI) and Alzheimer’s disease (AD)-type early-stage dementia. Meeting that demand can significantly benefit from the deployment of innovative, computer-based applications capable of addressing specific needs, particularly in the area of cognitive impairment mitigation and rehabilitation. In that context, we present here our perspective viewpoint on the use of virtual reality (VR) tools for cognitive rehabilitation training, intended to assist medical personnel, health care workers, and other caregivers in improving the quality of daily life activities of people with MCI and AD. We discuss some effective design criteria and developmental strategies and suggest some possibly useful protocols and procedures. The particular innovative supportive advantages offered by the immersive interactive cha...
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paper_title: Remote measurement of cognitive stress via heart rate variability

paper_content:

Remote detection of cognitive load has many powerful applications, such as measuring stress in the workplace. Cognitive tasks have an impact on breathing and heart rate variability (HRV). We show that changes in physiological parameters during cognitive stress can be captured remotely (at a distance of 3m) using a digital camera. A study (n=10) was conducted with participants at rest and under cognitive stress. A novel five band digital camera was used to capture videos of the face of the participant. Significantly higher normalized low frequency HRV components and breathing rates were measured in the stress condition when compared to the rest condition. Heart rates were not significantly different between the two conditions. We built a person-independent classifier to predict cognitive stress based on the remotely detected physiological parameters (heart rate, breathing rate and heart rate variability). The accuracy of the model was 85% (35% greater than chance).
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Title: A Succinct Overview of Virtual Reality Technology Use in Alzheimer’s Disease

Section 1: Introduction
Description 1: Provide an introduction to the topic, detailing the significance of VR technology in the context of Alzheimer’s disease (AD).

Section 2: Current Applications of VR in Psychotherapy
Description 2: Discuss the general application areas of VR in psychotherapy and list examples relevant to Alzheimer’s disease.

Section 3: VR Technologies and Devices
Description 3: Describe the types of VR technologies and devices used, including their levels of immersion and interaction.

Section 4: Importance of Immersion and Presence
Description 4: Explain the role of immersion and presence in VR applications, and how these factors affect the effectiveness of VR-based interventions for AD patients.

Section 5: Health and Safety Considerations
Description 5: Address the health and safety implications of using VR, particularly focusing on issues like cyber-sickness and VR-induced symptoms.

Section 6: Literature Review Methodology
Description 6: Outline the methodology followed for the literature review, including information on literature search, selection criteria, and categorization.

Section 7: Categorization of VR Applications Used in AD
Description 7: Present a detailed classification of VR systems based on their intended purpose, impairment focus, methodology, and type of interaction.

Section 8: Intended Purpose of VR Applications
Description 8: Discuss the primary goals of VR applications in the context of Alzheimer’s disease – assessment, diagnosis, cognitive training, and caregivers’ training.

Section 9: Focal Aspects in VR Research for AD
Description 9: Identify the specific cognitive impairment features considered most relevant for VR diagnostic and training purposes in AD research.

Section 10: Interaction Techniques in VR
Description 10: Describe the different techniques for user interaction in VR systems, including tasks, activities, and games, and their relevance to AD applications.

Section 11: Emerging Augmented Reality Applications
Description 11: Highlight the emerging use of augmented reality (AR) in addition to VR for cognitive training and rehabilitation of AD patients.

Section 12: Conclusion
Description 12: Summarize the key findings of the review, emphasize the need for more immersive and effective VR applications, and suggest future directions for research and development in this field.