cyber therapy & rehabilitation magazine (1, 2008)

Issue 1 / 2008

FEATURES:Facing Your Fears: Virtually

p 12

My Heart’s “Neurological Rehabilitation” Concept

p 17

Using Mobile Phones as Behavioral Technologies

p 20

The Emergence of CyberFashion

p 22

COVER STORY:

p 6

PRODUCT COMPARISON:Head-Mounted Displays

p 10

COUNTRY FOCUS:Spain

p 28

Virtual Realityin Healthcare

T h e O f f i c i a l V o i c e o f I A C R

ISSN 2031 - 278

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cover_C&R_spine:Layout 1 12/01/09 14:59

cover_C&R_no_spine:Layout 1 12/01/09 11:35 Page 1

Dear Reader,

Welcome to the inaugural issue of Cyber -Therapy & Rehabilitation Magazine (C&R),the official voice of the International As-sociation of CyberTherapy & Rehabilita-tion (IACR). IACR is an international as-sociation that has been created with thegoal of disseminating knowledge aboutexciting new f indings being made totransform healthcare through the addi-tion of cutting edge technologies.

An exciting body of research regardingthe utilization of advanced technologiesin the areas of training, therapy, educa-tion, prevention, and rehabilitation hasemerged over the past fifteen years, re-vealing developments and discoveriesmade by over 450 clinicians and r e-searchers. Advanced technologies—suchas virtual reality (VR), robotics, non-inva-sive physiological monitoring, e-health,and adaptive displays—are now beingapplied to several areas of healthcare, in-cluding physical and cognitive rehabili-tation, anxiety disorders, eating disordersand obesity, addictions, stress manage-ment, and as a distraction mechanismduring painful or anxiety-provoking med-ical or dental procedures. These tech-nologies are also providing for improvedquality of life for populations such as theelderly and the disabled.

An increasing number of agencies arerecognizing the huge potential of tech-nology to dramatically improve 21st cen-tury healthcare. The European Commis-sion, in its last three frameworks, hasinvested heavily in research support ofe-health and simulation technologies ap-plied to healthcare and e-inclusion. TheEuropean Union, as well as individualgovernments within Europe, has recog-nized the critical role that advanced tech-nologies can play in both prevention and

treatment. As well, in the United States,forward-thinking organizations such asthe National Institute on Drug Abuse(NIDA), National Institutes of Health(NIH), the National Science Foundation(NSF) and the Department of Defense(DoD) continue to support simulationfor training, education, and therapeuticinterventions.

IACR believes there is an urgent need todevelop a set of standar ds and a“roadmap” for future directions. Sincethis is a rapidly growing field with signif-icant implications to change healthcareas we know it, it is critical that there bea unified voice which brings togetherthought leaders and provides a forum tospeak with policymakers, decision mak-ers, and funding agencies to voice ourneeds and help shape research agendas.There is also a critical necessity to providea central repository of information forthose in both the general public as wellas the scientific community who are ea-ger to learn more about how technologycan enhance healthcare.

This publication will serve as a catalystwhereby society may rapidly benefit fromthe remarkable technological revolutionthat is occurring, with the ultimate aimof impr oving the quality of to day’shealthcare, helping to quickly dissemi-nate research results, and ultimately el-evating the level of care available for eachcitizen. Currently a considerable knowl-edge base exists; however, there is no uni-fied plan for the future of best practicesfor adding advanced technologies to ex-isting clinical protocols. IACR aims to bethe organization that brings ideas anddecision makers together.Topics C&R intends to address include:

• Large-scale display technologies includ-ing 3-wall CAVES.

Letter from the PublisherProfessor Dr. Brenda K. Wiederhold

1

C&R Editorial Board

Professor Brenda K. Wiederhold, Ph.D., MBA, BCIAEditor-in-Chief, C&R MagazineBelgium

Professor Rosa M. Baños, Ph.D.University of ValenciaSpain

Professor Cristina Botella, Ph.D.Universitat Jaume ISpain

Professor Stéphane Bouchard, Ph.D. Université du Québec en OutaouaisCanada

Professor Tony Brooks Aalborg UniversityDenmark

Professor Paul M.G. Emmelkamp, Ph.D. University of AmsterdamThe Netherlands

Professor Luciano Gamberini, Ph.D.University of PadovaItaly

Professor Sun I. Kim, Ph.D.Hanyang UniversityKorea

Professor Dragica Kozaric-Kovacic, M.D., Ph.D.University Hospital DubravaCroatia

Professor Paul Pauli, Ph.D.University of WürzburgGermany

Professor Simon Richir, P.h.DArts et Metiers ParisTechFrance

Professor Giuseppe Riva, Ph.D., M.S., M.A.Istituto Auxologico ItalianoItaly

Professor Paul F.M.J. Verschure, Ph.D.Universitat Pompeu FabraSpain

Professor Mark D. Wiederhold, M.D., Ph.D., FACPVirtual Reality Medical CenterUSA

“This publication will serve as a catalyst wherebysociety may rapidly benefit from the remarkabletechnological revolution...”

C&R_approval:Layout 1 9/01/09 15:34 Page 1

• Low-cost videogame-based simulations in-cluding inexpensive handheld devices, port -able consumer products, and other low-costmobile, wireless, and patient-friendly inter-faces.

• Next-generation immersive head-mount-ed displays (HMDs) which might includeretinal displays.

• Low-cost, interactive haptic devices thatcan be used in the home for education,training, and healthcare delivery.

• Easy-to-use software that allows for real-time creation of any environment from dig-ital photographs.

• Object-oriented software for the creationof digital avatars that can rapidly be madeto perform any type of movement, action,or complex series of commands.

Other thought-provoking questions thatC&R hopes to explore are:

• How can simulation tools become bothdoctor and patient-friendly?

• How can virtual environments and inter-net-based therapies be created so that theyautomatically respond and morph basedupon a predetermined set of criteria estab-lished by the therapist?

• What type of interface needs to be creat-ed so that a continuum from the therapist’soffice to the patient’s home and place ofemployment (etc.) exists?

• How can technologies be specifically fo-cused to meet the needs of varied patientpopulations, their families, and caregivers?

In this first issue, we begin our process ofdiscovery by exploring both currently avail-able technologies as well as some of theirpresent applications. We begin with an in-troduction to “VR in healthcare” in our fea-tures section. Since many of today’s appli-cations employ HMDs, you will f indinformation on some of the currently avail-able HMDs in our product comparison chartand surrounding pages. This issue’s coun-try focus is on Spain. Take a moment to readwhat cutting-edge re searchers are doingthroughout the country.

I hope you will enjoy reading our publicationand find it informative and beneficial for you.Always striving to meet the needs of our read-ers, your suggestions and contributions arealways welcome. Please contact me, or DanielStevens, Managing Editor, at [email protected] with your comments, which we be-lieve are vital to our continued growth.

Create your own reality!Brenda Wiederhold

Letter from the Publisher

2

GENERAL INFORMATION

CyberTherapy & Rehabilitation Magazine

ISSN: 2031-278

GTIN-13 (EAN): 9771784993017

CyberTherapy & Rehabilitation Magazine is published quar-

terly by the Virtual Reality Medical Institute, 28/7 Rue de la

Loi, B-1040 Brussels, Belgium in collaboration with EMC Con-

sulting Group. The magazine explores the uses of advanced

technologies for therapy, training, education, prevention,

and rehabilitation. Areas of interest include, but are not lim-

ited to, psychiatry, psychology, physical medicine and reha-

bilitation, neurology, occupational therapy, physical thera-

py, cognitive rehabilitation, neurorehabilitation, oncology,

obesity, eating disorders, and autism, among many others.

PUBLISHING HOUSEVirtual Reality Medical Institute BVBA

in collaboration with EMC Consulting Group BVBA

28/7 Rue de la Loi,

B-1040 Brussels, Belgium

Telephone: +32 2 286 8505

PUBLISHERS

Brenda K. Wiederhold, Ph.D., MBA, BCIA

Christian Marolt

Fax: +32/2/286 8508

E-mail: [email protected]

Website: http://www.vrphobia.eu

ADVERTISING For advertising information, rates, and specifications please

contact Virtual Reality Medical Institute, 28/7 Rue de la Loi,

B-1040 Brussels, Belgium, Telephone: +32 2 286 8505; Fax:

+32/2/286 8508; E-mail: [email protected]

REPRINTSIndividual article reprints are available from corresponding

authors. Please contact the publisher for rates on special or-

ders of 100 or more.

MANUSCRIPTSSubmissions should be addressed to the JCR Managing Edi-

tor, Virtual Reality Medical Institute, 28/7 Rue de la Loi, B-

1040 Brussels, Belgium, Telephone +32 2 286 8505, Fax: +32

285 8508; E-mail: [email protected].

COPYRIGHTCopyright © 2008 by Virtual Reality Medical Institute. All rights

reserved. CyberTherapy & Rehabilitation Magazine is owned

by Virtual Reality Medical Institute BVBA and published by

the Virtual Reality Medical Institute BVBA and EMC Consult-

ing Group BVBA. Printed in Hungary.

With the exception of fair dealing for the purposes of re-

search or private study, or criticism or review, no part of this

publication may be reproduced, stored, or transmitted in

any form or by any means without prior permission in writ-

ing from the copyright holder.

For permission to photocopy an article for internal purpos-

es, please request permission and pay the appropriate fee

by contacting [email protected].

The accuracy of contents in CyberTherapy & Rehabilitation

Magazine are the responsibility of the author(s) and do not

constitute opinions, findings, conclusions, or recommenda-

tions of the Publisher or editorial staff. In addition, the Pub-

lisher is not responsible for the accuracy of claims or infor-

mation presented in advertising portions of this publication.

SUBSCRIBE TO JCR/C&R

Subscriptions begin with the first issue of the current volume. No cancellations

or refunds are available after the volume’s first issue is published. Publisher is

to be notified of cancellations six weeks before end of subscription. Members

of the International Association of CyberTherapy & Rehabilitation (IACR) receive

a 20% discount. To subscribe please visit www.vrphobia.eu and click “Subscribe.”

Individual

Euro 115

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Europe

International

Institution

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1 Year

2 Years


EDITORIALp 1

COVER STORYVirtual Reality in Healthcare: An IntroductionG. Riva

p 6

PRODUCT COMPARISON CHARTHead-Mounted Displays

p 10

FEATURESFacing Your Fears: VirtuallyB. K. Wiederhold

p 12

My Heart’s “Neurological Rehabilitation” Concept: Technologies for Post-Stroke TreatmentT. Giorgino, P. Tormene, G. Maggioni, B.Cattani, C. Pistarini, S.Quaglini

p 17

Opportunities and Challenges in Using Mobile Phones as Behavioral TechnologiesG. Jacucci

p 20

The Emergence of CyberFashionD. Stevens

p 22

C&R IN BRIEFNorth AmericaC. Pockrandt

p 27

COUNTRY FOCUSSpainD. Stevens

p 28

TABLE OF CONTENTS

3

VR in Healthcare

Virtual Reality, a term used for the first timein the 1980s to describe a computer simu-lated environment within and with which anindividual can interact, has been utilized foralmost two decades to aid in therapy and re-habilitation. Amongst the latest develop-ments are networked virtual environmentsand 3-D interfaces to the Internet.

The Emergence of CyberFashion

Medical experts have begun to realize the in-credible opportunity provided by wearabletechnologies, allowing citizens to benefit froma continuum of care. Prevention, assessment,diagnosis, and treatment can all benefit, al-lowing citizens mor e available acc ess tohealthcare.


International Association of CyberTherapy & Rehabilitation (IACR)

Conference Participation Report Fall/Winter 2008

4

PRESENCE 2008: 11th Annual International Workshop on PresencePadova, Italy / October 16-18, 2008

As part of the PRESENCE 2008 conference, Dr. Anna Spagnolliand Dr. Luciano Gamberini of HTLab, University of Padova, Italyand Dr. Brenda K. Wiederhold of IACR co-organized the SecondEuropean Workshop of Cybertherapy, Rehabilitation and E-Men-tal health. ** JCR Editorial Board Member, Dr. Paul Emmelkamp,University of Amersterdam, chaired the symposium and alsogave an address in the opening session. The speak ers represent-ed 6 countries and spoke on a range of topics from virtual real-ity and eating disorders to on-line counseling and the therapeu-tic value of videogames. In addition studies dealing with basicresearch on presence as well as clinical applications were pre-sented during the pre-conference workshop and as part of theregular conference. The International Society for Presence Re-search also held its first general assembly, chaired by PresidentMatthew Lombard.

** Drs. Spagnolli, Gamberini, and Wiederhold are all Founding Members of IACR.

For further information, please visit:http://www.presence2008.org/uploads/file/PRESENCE_2008_Second_CfP.pdf

Presence: Present and Future Markets, The Peach Industry EventTurin, Italy / November 12-13, 2008

The Peach Industry Event “Presence: Present and Future Mar-kets” was focused on assessing future market trends and op-portunities for presence technologies and applications, andaddressed both market actors and the research community.PEACH is an FP6 funded project. During the event, interna-tional experts discus sed present and future markets, offeredexamples of commercial applications as well as research anddevelopment (R&D) out comes. The event covered topics suchas promising applica tion fields, Presence technologies (e.g. vir-tual agents, brain-computer interface, 3D displays etc.) as wellas training and education.

This year’s event was organized in partnership with the VIEWConference - Digital Transformations - an international eventfocusing on Computer Graphics and covering Digital Cinema,Automotive Design, Virtual Reality, 3D Animation & VFX, Ar-chitecture & Design and Games. Exhibits allowed attendees theopportunity to try many of the new technologies for themselves.

For further information, please visit:http:// peach.tel.fer.hr/industry/peach_industry_event_home.html

The World of Health IT’08 Conference & ExhibitionCopenhagen, Denmark / November 4-6, 2008

The World of Health IT Conference & Exhibition 2008 (WoHIT 2008) hasbeen designed for and by the healthcare ICT community in the Euro-pean region including: technology end users, vendors, providers and pol-icy makers. Addressing the perspectives of clinicians, directors and oth-er healthcare professionals, WoHIT offered:

Speakers included Viviane Reding, the European Commission’s commis-sioner for Information Society and Media; Jakob Axel Nielsen, Denmark’sminister for health and prevention; Former Prime Minister of FinlandEsko Aho; and Nicholas Negroponte, Chairman Emeritus of the MIT Me-dia Lab. Dr. Wiederhold, Secretary General of the IACR and Dr. GiuseppeRiva, Founding Board Member, held a symposium on Virtual Reality inTraining, Therapy, & Rehabilitation. In addition, VR equipment was demon-strated for the audience, and also available in the Exhibit Hall.

In addition, the European Commission, HIMSS Europe, the Ministry ofHealth and Consumption of Spain, and the Government of Catalonia an-nounced that the next WoHIT conference and exhibition will be held inconjunction with the European Union’s annual High Level eHealth Min-isterial Conference in Barcelona on March 15-18, 2010.

For further information, please visit: http://www.worldofhealthit.org

ICT 2008- Setting the ICT Research Agenda for the Next DecadeLyon, France / November 25-27, 2008

The European Commission’s ICT event, held in the Centre de Congrèsin Lyon, examined how and where Europe can lead the ICT agenda inthe next ten years. The main themes covered topics such as:

- European Union priorities in ICT research for over ¤2 billion of funding available in 2009-2010;

- The major current technological trends which impact upon strategic research planning

- Public research policies to stimulate research and innovation.

The ICT event also included 180 exhibits showcasing the latest break-throughs of European research projects as well as networking sessions forresearchers and investors to find partners for potential research initiatives.

For further information, please visit:http://ec.europa.eu/information_society/events/ict/2008/index_en.htm

- IHE Interoperability Showcase- Networking sessions- Continuing Medical Education (CME)

- Educational sessions- Vendor exhibitions- Best practice exchange


Since 1986, when the computer scientistand author Jaron Lanier used the termfor the first time, “virtual reality” (VR) hasbeen usually described as a computer sim-ulated envir onment with and withinwhich people can interact.

The basis for the VR idea is that a com-puter can synthesize a three-dimension-

al (3D) graphical environment from nu-merical data. Using visual, aural or hapticdevices, the human operator can experi-ence the environment as if it were a partof the world. This computer generatedworld may be either a model of a real-world object, such as a house; or an ab-stract world that does not exist in a realsense but is understo od by humans,such as a chemical molecule or a repre-sentation of a set of data; or it might bein a completely imaginary science fic-tion world.

Further, because input devices sense theoperator's reactions and motions, the op-erator can modify the synthetic environ-

ment, creating the illusion of interactingwith and thus being immersed within theenvironment. Typically, a VR system iscomposed by:

• the output tools (visual, aural and haptic), that immerse the user in the virtual environment;

• the input tools (trackers, gloves or a mouse) that continually reports theposition and movements of the users;

• the graphic rendering system that generates, at 20-30 frames per second,the virtual environment;

the database construction and virtualobject modeling software for buildingand maintaining detailed and realisticmodels of the virtual world. In particu-lar, the software handles the geometry,texture, intelligent behavior, and physi-cal modeling of hardness, inertia, sur-face plasticity, of any object included inthe virtual world.

6

Virtual Reality in Health Care:An introductionFor many health care professionals, VR is f irst of all a technology. However, the analysis of the dif ferent VR applications clearly shows that the focus on technological devices is not the same in all the ar eas of medicine and it is related to the specific goals of the health care provider.

COVER STORY

By Giuseppe Riva

Figure 1:Typical head-

mounted displayworn by VR user.

T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l


The computer technology that allows the de-velopment of three-dimensional virtual en-vironments consists of both hardware andsoftware (see Table 1 for VR Hardware). Thecomputer hardware used ranges from stan-dard PCs to high-performance workstationswith parallel processors for the rapid compu-tation of world models, and high-speed com-puter networks for transferring informationamong participants in the virtual world. Theimplementation of the virtual world is accom-plished with software for modeling (geomet-ric, physical, and behavioral), navigation, in-teraction, and hypermedia integration.

The most recent development of VR hasbeen in the area of networking and the Inter-net. Networked virtual environments and 3-D interfaces to the Internet are amongst thelatest applications of VR in a growing telecom-munications market (See Table 2 for a 5-yearforecast of VR in health care).

For many health care professionals, VR is firstof all a technology. However, the analysis ofthe different VR applications clearly shows

7Figure 2: Addition of haptic device on VR user’ shand to allow for “touch sensation”

Figure 3 and 4: Examples of VR environnement before and after mapping

A s s o c i a t i o n o f C y b e r T h e r a p y & R e h a b i l i t a t i o n


that the focus on technological devicesis not the same in all the areas of med-icine and it is related to the specific goalsof the health care provider.

For instance, former Defense AdvancedResearch Projects Agency (DARPA) Pro-gram Manager and retired Army ColonelDr. Richard Satava (M.D., FACS), in his re-cent book “Emerging Technologies inSurgery,” describes VR as: “a collectionof technologies that allow people to in-teract efficiently with 3D computerizeddatabases in real time using their natu-ral senses and skills”. This definition lacksany reference to head mounted displaysand instrumented clothing such asgloves or suits. In fact, less than 20% ofVR health care applications in medicine areactually using any immersive equipment.

However, if we shift our attention to be-havioral scienc es and r ehabilitation,where immersive devices are used bymore than 50% of the applications, VR

is described differently. For instance Drs.Brenda and Mark Wiederhold, in theirbook “Virtual Reality Therapy for Anxi-ety Disorders: Advances in Evaluation andTreatment” define VR as “an advancedform of human-computer interface thatallows the user to interact with and be-come immersed in a computer-generat-ed environment in a naturalistic fashion”.

These two definitions underline two dif-ferent focuses of VR in medicine: VR assimulation tool and VR as interaction tool.

For physicians and surgeons, the simula-tion focus of VR prevails over the interac-tion one: the ultimate goal of VR is thepresentation of virtual objects to all of thehuman senses in a way identical to theirnatural counterpart. As noted by Satava,as more and more of the medical tech-nologies become information-based, itwill be possible to represent a patient withhigher fidelity to a point that the imagemay become a surrogate for the patient

– the medical avatar. In this sense, an ef-fective VR system should offer real lifebody parts or avatars that interact withexternal devices such as surgical instru-ments as near as possible to their realmodels. This view also drives the Informa -tion and Communications Technologies(ICT) Work Programme strategic objective“Virtual Physiological Human” (VPH). TheVPH lists as its main target outcome patient-specific computer models for personal-ized and predictive healthcare and toolsfor modeling and simulation of humanphysiology and disease-related processes.

For clinical psychologists and rehabili-tation specialists, the interaction focusof VR prevails over the simulation one:they use VR to provide a new human-computer inter action p aradigm inwhich users are no longer simply exter-nal observers of images on a computerscreen but are active participants with-in a computer-generated three-dimen-sional virtual world. Within the VE the

8

COVER STORY

Figure 6: Example of Character Design s oftware InterfaceFigure 5: Users interacting with large scale VR environment



patient has the possibility of learning to man-age a problematic situation related to his/herdisturbance. The key characteristics of virtu-al environments for these professionals areboth the high level of control of the interac-tion with the tool without the constraintsusual ly found in computer systems, and theenriched experience provided to the patient.

In the following C&R papers we discuss inmore detail these two visions, describing morein detail different areas of health care in whichthe use of VR is actually investigated.

Both areas of VR are equally important, andequally useful, as we move towards the in-tegration of technology into existing clini-cal and teaching paradigms. Technology worksto assist and enhance existing clinical skillsand training tools, not to replace them.

9

*Prices available upon request at off [email protected].

Table 2: Five Year Forecast

- Health Care VR systems for less than 5000 Euros- Clinical/Well Being VR experiences on the web and on high-end cellular phones- Large scale randomized controlled trials- Integration of VR systems with biosensors: the features of the VR world are adapted according

to the biological responses of the patients [ ]

Table 1: VR Hardware

VR WorkstationNvidia Quadro Plex 2000 D2Nvidia Quadro Plex 1000 Model 4Professional graphic cardsQuadro FX 5800 2048 Mbyte PCI ExpressATI FirePro 8700 2048 Mbyte PCI ExpressQuadro FX 4600 768 Mbyte PCI ExpressConsumer graphic cards Nvidia GeForce 8800 Ultra 768 Mbyte PCI ExpressATI Radeon HD 4870 X2 2048 Mbyte PCI Express

VR GlovesCyberTouch with tactile feedback5DT Data Glove 5 Ultra Wireless Pinch GloveP5 Glove

Tracking systemPolhemus FastrakAscension PC Flock of BirdsIntersense Intertrax 2 3D Shutter GlassesStereoEyes WirelessElsa 3D Revelator IRVRex Cordless Head Mounted DisplayPiSight (2400x1720 resolution - 3D display)VR 1280 (1280x1024 resolution – 3D)Visette 45 (1280x1024 resolution – 3D)3-Scope (800x600 resolution – 2D)Z800 eMagin (800x600 resolution – 3D)I Glassess PC/SVGA (800x600 resolution – 3D)Vuzix iWear VR920 (640x480 resolution – 3D)

Giuseppe Riva, Ph.D., M.S., M.A.Istituto Auxologico Italianowww.auxologico.it/[email protected]

Figure 6: Second Life online world



MODEL

i-Theatre XT

i-glasses VIDEO 3D PRO

DV920

VR920

LV920

hi-Res800

hi-ResSVGA+

Dual input version.

Visette45 SXGA

i-visor FX601

i-visor DH4400VP

i-visor FX605

Z800 3D visor

i-Theater

nVisor ST

nVisor SX

piSight

ARvision 3D HMD

3scope HMD

M3

VR1280

Ruggedized i-visor

Cyberface

Cyberface2

Cyberface3

AddVisor 150

5DT HMD 800-26-3D

ProView XL35

ProView XL40 STm

ProView XL50

Sim Eye XL100A

MANUFACTURER

i-O Display Systems

i-O Display Systems

Vuzix

Vuzix

Vuzix

Cybermind NL

Cybermind NL

Cybermind NL

Daeyang

Daeyang

Daeyang

eMagin

Digital Vision

NVIS

NVIS

Sensics

Trivisio

Trivisio

Trivisio

Virtual Research

Virtual Research

Leep VR

Leep VR

Leep VR

SaabTech

Inition

Rockwell Collins

Rockwell Collins

Rockwell Collins

Rockwell Collins

RESOLUTION

320 x 240

800 x 600

640 x 480

640 x 480

640 x 480

800 X 600

800 x 600

1280 x 1024

800 x 600

800 x 600

800 x 600

800 x 600

320 x 240

1280 X 1024

1280 x 1024

2400 x 1720

800 x 600

800 x 600

800 x 600

1280 x 1024

800 x 600

120 x *1

385 x 119

720 x 240

1280 x 1024

800 X 600

1024 x 768

1024 x 768

1024 x 768

1024 x 768

DISPLAY TYPE

LCD

LCD

LCD

LCD

LCD

LCOS

OLED

FLCOS

OLED

LCOS

OLED

OLED

LCD

LCOS

LCOS

MICRO

LCOS

LCOS

LCOS

FLCOS

LCD

LCD

LCD

LCD

FLCOS

LCOS

XGA

AMLCD

XGA

XGA

FIELD OF VIEW

32°

26°

26°

32°

32°

26°

42°

45°

42°

31°

42°

40°

25°

60°

60°

82°-188°

40°

40°

32°

60°

42°

120°

145°

80°

46°

26°

35°

44°

50°

112°

DEVICE WEIGHT

2.1 oz.

< 8 oz.

3.5 oz.

3 oz.

12 oz.

21.2 oz

17.6 oz

24.7 oz.

4.23 oz.

11.3 oz.

4.23 oz.

< 8 oz.

2.1oz.

45.9 oz.

35.3 oz.

< 35.3 oz.

8.1 oz.

4.2 oz.

3.9 oz.

28 oz.

16 oz.

18 oz.

2 oz.

3 oz.

35.3 oz.

21.2 oz.

35.3 oz.

28.2 oz.

35.3 oz.

88.2 oz.

Head-Mounted Displays (HMDs) are crit-ical tools for medical therapies that in-corporate virtual reality as a basis fortreatment. Therapists use HMDs astools to aid in stimulating emotions, re-

actions, and memories that can triggera patient’s anxiety. HMDs can also beapplied for entertainment purposes,while some c ompanies design theirmodels for military purposes only. C&R

has compiled a list of the most com-mon HMD models and their details inorder to compare the quality, affordabil-ity, weight, and other information tobest suit the consumer.

10

Product Comparison Chart:Head-Mounted Displays

PRODUCT COMPARISON


Register by Friday 31 December 2008 and Save a 25% Discount with Promo Code JFF989 !


What if the thought of entering the en-closed space of an elevator terrified youso badly that you decided to climb theseven flights of stairs to your doctor’soffice? Or imagine having to send re-grets to your best friend’s wedding be-cause you could not stand the idea ofmingling at the reception. Though fearand anxiety are a normal part of the hu-man experience, for some these feelingsare so intense that they can severely im-pact everyday life. For these people, thereare various treatments that can offerhope, some with traditions stretching forhundreds of years, and others newly ar-rived, seemingly from the realm of sci-ence fiction.

Anxiety disorders, as a group, are the mostcommon mental illnesses in the world.According to a 2007 study by the AnxietyDisorder Resource Center, anxiety disor-ders affect approximately 1 in 4 peopleworldwide at some point in their lives.The Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition, Text Re-vision (DSM-IV-TR) lists phobias (specific

phobias, social phobia, and agoraphobia),panic disorder, obsessive-compulsive dis-order, posttraumatic stress disorder andgeneralized anxiety disorder under thebroad category heading of Anxiety Disor-ders. This group of disorders does notdistinguish between age, sex, or race, af-flicting those from all walks of life. Notonly adults, but also children and adoles-cents can develop anxiety disorders.

Most people experience feelings of anxi-ety before an important event such as abusiness presentation, big exam, or firstdate. Anxiety disorders, however, are ill-nesses that fill people's lives with over-whelming anxiety and fear that are chron-ic, unremitting, and can grow progressivelyworse. Tormented by obsessive thoughts,flashbacks of traumatic events, panic at-tacks, nightmares, or countless frighten-ing physical symptoms, some people withanxiety disor ders may even b ecomehousebound. Groups around the worldare, however, advancing the treatment ofthese conditions through the use of vir-tual reality (VR) therapy.

VR exposure therapy immerses an indi-vidual in a computer-generated worldwhere various stimuli related to the pho-bia may be "experienced" three-dimen-sionally. The client wears a head-mount-ed display with small TV monitors andstereo earphones to receive both visualand auditory cues. In careful, controlledstages, the client is exposed to experi-ences that elicit higher levels of anxiety.Each stage c an b e repeated until theclient is comfortable with the experienceand satisfied with the response.

Specific Phobias

Phobias are the most common psychi-atric disorder, more common than alco-hol abuse, alcohol dependence, or majordepression. A specific phobia is definedas an intense and persistent fear that isconsidered excessive or unreasonable inresponse to a situation. Specific phobiasinclude fear of flying, spiders, heights,thunderstorms, public speaking, blood,etc. Exposure to the phobic stimulus con-sistently provokes an anxious reaction,

12

FEATURES

Facing Your Fears: VirtuallyWith over 200 recognized anxiety disorders affecting one-fourth of the world’s population, the need for continued improvement of treatment availability is critical. With advanced technologies,psychology has the opportunity to rise to a new level, movingtowards unprecedented heights to offer more affordable, moreavailable healthcare to a larger portion of our society.

By Brenda K. Wiederhold



which may take the form of a situational-ly predisposed panic attack. Adults recog-nize that their fear is excessive and unrea-sonable, but ar e unable to c ontrol it.Children may or may not have any insightinto the fact that their fear is excessive. Inboth adults and children, the feared objector situation is usually avoided or anticipat-ed with dread. The phobia is diagnosedwhen one’s fear, or evasive actions to avoidthe feared situation, interferes with dailyroutine, employment, or social life.

Over 200 phobias have been identified andnamed, falling into five different subtypes:

Animal Type, which generally has a child -hood onset and includes fear of insectsor other animals.Natural Environment Type, which inclu -d es fear of heights, water, and stormsand generally has a childhood onset.Blood-Injection-Injury Type, including fearof invasive medical or dental proceduressuch as receiving an injection, giving bloodor seeing blood or an injury. This phobiasubtype is often characterized by fainting.

Situational Type, which includes fear offlying, bridges, elevators, driving, or en-closed places. The age of onset is eitherduring childhood or in the mid-20s. Thisis the most fr equent subtype seen inadults.Other Type, which includes fear of fallingdown when away from walls, fear of vom-iting or choking, fear of contracting an ill-ness, fear of loud sounds, and fear of cos-tumed characters.

The most common treatment for specificphobias is exposure therapy. This exposurewas typically done either in real-life (in vivo)or imaginally (in vivo) prior to VR. Howev-er, in vivo exposure is not always conven-ient, safe, or cost-effective (e.g. fear of fly-ing, fear of driving), and in vitro is oftendifficult as only 15% of individuals are ableto imagine the f eared situation vividlyenough to evoke the anxiety response nec-essary for successful treatment. That ’swhere virtual reality (VR) steps in. In Virtuoexposure provides all of the stimuli need-ed for successful treatment while at thesame time allowing therapy to take place

in a secure, controlled environment. Stud-ies around the globe have shown that VRfor specific phobias has approximately a92% success rate in just 8-12 one-hour ses-sions. In addition, by adding physiologicalmonitoring and feedback to the VR proto-col, relapse rate and both short and long-term treatment gains may be further im-proved.

Social Phobia

Social phobia, or social anxiety, is a disor-der characterized by excessive self-con-sciousness and overwhelming anxiety ineveryday social situations. People with so-cial phobia have a persistent, intense, andchronic fear of being watched and judgedby others and of being humiliated or em-barrassed by their own actions. Their fearmay be so severe that it interferes withwork, school, and other ordinary activities.While many people with social phobia rec-ognize their fear is excessive or unreason-able, they are unable to overcome it. Theyoften worry for days or weeks in advanceof the dreaded situation.

13


The Client wears a headmounted display with small monitors to receive both visual and auditory cues

VR environment for treating posttraumatic stress disorder

VR environment for treating aviophobia


14

Social phobia may involve only one typeof situation (such as a fear of speaking informal or informal situations, or eatingor drinking in front of others) or, in itsmost severe form, it may be so broad thata person experiences symptoms almostany time they are around other people.Social phobia can be very debilitating andcan even prevent an individual from go-ing to work or school. Many people withthis illness have a hard time making andkeeping friends.

Physical symptoms often accompany theintense anxiety of social phobia and mayinclude symptoms of anxiety such asprofuse sweating, trembling, blushing, dif-ficulty talking and nausea or other stom-ach discomfort. These visible symptomsheighten the fear of disapproval and thesymptoms themselves can become anadditional focus of fear. Fear of symptomscan create a vicious cycle: as people withsocial phobia worry about experiencingthe symptoms, the chances of develop-ing the symptoms increase. Social pho-bia often runs in families and may be ac-companied by co-morbid disorders suchas depression or alcohol dependence.

Research has shown two main forms ofeffective treatment: medication and cog-nitive-behavioral therapy (CBT). A maincomponent of CBT is exposure therapy,which involves helping patients gradual-ly become more comfortable with situa-tions that frighten them. The exposureprocess often involves three stages. Thefirst is introducing the individual to thefeared situation. The second level is to in-crease the risk for disapproval in that sit-uation so the patient builds confidenceand can handle rejection or criticism. Thethird stage involves teaching the patienttechniques to cope with disapproval. Inthis stage, the individual is asked to imag-ine his/her worst fear and is encouragedto develop constructive responses to thisfear and any perceived disapproval.

All three stages of exposure can be ac-complished in vivo, in vitro, or in virtuo(VR). However, using VR provides certain

advantages. First, therapy is carried outin the privacy of the therapist’s office.Second, the therapist can more carefullycontrol the reactions of the people withwhich the patient is interacting. And mostimportantly, treatment can progress at theuser’s own pace. It allows each session tobe customized to the individual receivingtreatment.

Panic Disorder

Panic disorder is characterized by unex-pected and repeated episodes of intensefear (called panic attacks) accompaniedby physical symptoms that may includeshortness of breath, dizziness, chest pain,heart palpitations, or abdominal distress.These sensations often mimic symptomsof a heart attack or other life-threaten-ing medical condition. As a result, the di-agnosis of panic disorder is unfortunate-ly often not given until extensive andcostly medical procedures fail to providean alternate diagnosis or relief.

Many people with panic disorder devel-op intense anxiety between episodes. Itis not unusual for a person with panicdisorder to develop phobias about placesor situations where panic attacks haveoccurred, such as in supermarkets orother everyday situations. As the fre-quency of panic attacks increases, theperson often begins to avoid situationswhere they fear another attack may oc-cur or where help would not be imme-diately available. This avoidance mayeventually develop into agoraphobia,an inability to go beyond known andsafe surroundings because of intensefear and anxiety.

Appropriate treatment by an experiencedprofessional can help reduce or preventpanic attacks in 70% to 90% of peoplewith panic disorder. Treatment for panicdisorder often includes medications andCBT. CBT teaches people how to view pan-ic attacks differently and demonstratesways to reduce anxiety. VR environmentsused to treat panic disorder involve ex-posing patients to feared situations (sim-

ilar to those where they have experiencedpanic attacks) or to reproductions (inte-roceptive exposure) of the physical symp-toms of panic attacks (e.g., shortness ofbreath, vertigo, and tunnel vision). Thesesymptoms can be recreated in virtual en-vironments with sound (pounding heart,fast br eathing) or with visual ef fects(blurred or stretched images). Each ofthese exposures is accompanied by ther-apist-facilitated cognitive restructuringand coping skills.

Most patients show significant progressaf ter approximately ten treatmentsessions. Relapses may occur, but theycan often be effectively treated with“booster sessions” or a short “refresher”course.

Obsessive-Compulsive Disorder

There are two sides to obsessive-compul-sive disorder (OCD): obsessions and com-pulsions. Obsessions are thoughts, andcompulsions are actions. The obsessionsin OCD are repetitive and persistent, in-appropriate and intrusive, and are impos-sible to suppress. These cause the suf-ferer signif icant distress and anxiety .Compulsions are repetitive behaviors ormental acts that the person applies basedon rigid rules that they follow. The goalof these actions is to prevent a dreadedevent or to lessen distress. They are, how-ever, not really connected in a logical wayto these events. Once the person com-pletes a compulsive behavior, a sense ofrelief is felt. It is easy to imagine howthese unwanted thoughts and disruptivebehaviors cause disturbances and impairthe sufferer from living everyday life. Notonly are these rituals time consuming,but it is quite difficult to function social-ly while experiencing them.

OCD is most often treated with a combi-nation of medication and exposure ther-apy with ritual prevention. Some medica-tions have b een f ound to have asignificant effect on symptoms, but re-lapse rates upon medication cessationare extremely high if coping skills are not

FEATURES Facing Your Fears: Virtually


16

also learned prior to discontinuing med-ication. Research has revealed that VR iseffective at inducing the anxiety responsenecessary for effective treatment to takeplace. The benefit of conducting expo-sure therapy with VR is that situationsthat trigger obsessions and compulsionscan be experienced repeatedly, a neces-sary element of overcoming the repeti-tion of OCD. In addition, this treatmentcan take place in the privacy of a thera-pist’s office, ensuring patient confiden-tiality. Though VR exposure therapy forOCD can take longer than for specificphobias, many patients experience somerelief within the first few sessions.

Posttraumatic Stress Disorder

Many have heard the term “shell shock”in the context of soldiers returning fromwar. The condition’s technical name isPosttraumatic Stress Disorder (PTSD).PTSD can affect anyone who has experi-enced a traumatic event such as a motorvehicle accident, an assault, or anythingthat threatens a person’s life or physicalintegrity. Symptoms may range from in-creased anxiety or arousal to dissociationand flashbacks of the event, though thedisorder may manifest differently in eachindividual.

Because PTSD has such varied symptoms,a combination of treatments is often nec-essary. Anxiety-reducing medications, an-tidepressants, support from friends andfamily, and CBT involving exposure canhelp with recovery. A recent Institute ofMedicine study maintains that exposureis an important component to be includ-ed in treatment regimens. One type ofexposure therapy that has often beenused is imaginal exp osure therapy, inwhich patients are asked to repeatedlyimagine and retell their traumatic expe-rience to their therapist. However, becauseone of the hallmarks of PTSD is an avoid-ance of reminders of the trauma, this isoften difficult for some patients. Thosewho are unable to engage with theirmemories do not evoke an anxiety re-sponse during exposure, and these pa-

tients f ail to impr ove. It is gener allythought that this is due to lack of activa-tion of the brain’s fear structure, wherethe trauma memories are stored. Sincethe structure is not activated, it is thoughtthat the information stored is thereforenot available to receiving “disconfirming”information (e.g., “there is no longer dan-ger here”).

Virtual reality (VR) can solve the problemof avoidance and lack of good imageryabilities that plague some patients andprohibits successful alleviation of symp-toms. By providing the patient with stim-uli that engage multiple senses (audio,visual, tactile, and olfactory), the therapistdoes not have to rely on the imaginationand willingness of the patient to createanxiety, but rather can provide stimuli di-rectly to the patient at the touch of a but-ton. In addition, because the virtual en-vironment allows the ther apist andpatient complete control over the paceand duration of treatment sessions, thedanger of overwhelming the patient withanxiety can be avoided, alleviating the pa-tient’s anxiety at beginning treatment. Inaddition, many clinicians combine phys-iological monitoring and feedback withVR exposure. This has the added advan-tage of providing continuous monitoringof the patient’s heart rate, breathing rateand other physiological signals, allowingfor an objective, real-time measurementof the patient’s condition to occur. Thisalso can be used to teach the patient tovisually understand when relaxation hasbeen achieved. With this addition, thetherapy can be further individualized toprogress according to each individual pa-tient’s needs.

VR exposure treatment has been per-formed for survivors of earthquakes, mo-tor vehicle accidents, terror attacks andother various traumatic events. One ofthe most recent developments has beento use this treatment for those returningfrom Iraq and Afghanistan who are diag-nosed with PTSD (www.vrphobia.com).The Virtual Reality Medical Center andInteractive Media Institute, have both re-

ceived funding from various military andgovernment organizations to develop vir-tual reality software and clinical proto-cols, and to provide treatment to bothU.S.-based active duty and veteran pop-ulations as well as NATO coalition troopsand continuing clinical education andtraining to psychologists and psychiatrists.Currently in use at over thirty installa-tions in the U.S., systems are also nowavailable in both Warsaw, Poland and Za-greb, Croatia. Psychologists and psychia-trists trained on the clinical protocols arenow able to provide this innovative treat-ment to patients.

The VR programs recently established inCroatia and Poland will not only help pa-tients, but will allow for the clinical investi-gation of determining the system’s cross-cultural relevance. Some parts of the sys temmay be shown to be transferable across cul-tures whereas other portions may need tobe re-configured to allow for culturaldifferences.

Conclusion

Virtual reality has made a significant im-pact on the way anxiety disorders are ableto be treated. With increasing advance-ments in technology, and with the avail-ability now to port many VR experiencesover the Internet, the potential for im-proved psychological treatment of men-tal disorders is seemingly endless. Withover 200 recognized anxiety disorders af-fecting one-fourth of the world’s popula-tion, the need for continued improve-ment of treatment availability is critical.With advanced technologies, psychologyhas the opportunity to rise to a new lev-el, moving towar ds unpr ecedentedheights to offer more affordable, moreavailable healthcare to a larger portionof our society.

[ ]

FEATURES Facing Your Fears: Virtually

Brenda K. Wiederhold, Ph.D., MBA, BCIAVirtual Reality Medical [email protected]



Recovery from a stroke begins in the acuteunit and it is articulated into a series of in-tensive and extensive rehabilitation proto-cols. Despite the protocols variability, thereis nowadays a common trend, in clinicalmedicine, to shorten hospitalization andfoster homecare. The reason is both to cutcosts and improve quality of life. The aimof My Heart’s Product Concept NR is to sup-port patients in the performance of speechand motor therapy, both when they are stillhospitalized, and after discharge, at home.Patients eligible for the service must be instable clinical condition and show mild mo-tor impairment and/or aphasia with no oth-

er cognitive impairment that could impacton the system's use.

Liability constraints of Italian hospitalsimpose that IT-based rehabilitation doesnot replace conventional therapy. There-fore, at the hospital, exercise performedwith the system is added to the conven-tional one, resulting in a more intensive,hopefully more effective, program. Thiscould lead to an earlier discharge. Afterdischarge, patients could bring the reha-bilitation device to a long stay ward or athome, and continue exercises with thehelp of their caregivers.

In this paper, the service built within Con-cept NR will be described, in terms of itsarchitecture, technology used and first ex-perimental results.

The system architecture

Figure 1 shows a simplified view of the sys-tem technical architecture.

The infrastructure is based on EvoCare, asolution developed by Dr Hein GmbH. Themain components are one server, and anumber of users’ workstations, connectedby a secure network.

17

MyHeart’s Neurological Rehabilitation (NR) Concept is especially devoted to supporting post-stroketreatment. This paper describes how the concept is structured and how technologies are leveraged tosupport both motor rehabilitation and speech/cognitive training. The architecture permits assistedtraining both at the clinic and at home, after discharge from the in-tensive care unit. Both promis-ing results and issues, collected during the first evaluation phase, will be discussed.

My Heart’s “ Neurological Rehabilitation ” Concept:Technologies for Post-Stroke Treatment

FEATURES

Figure 1:Concept NR’s telemedicine platform

Therapy Modules

UI Technologies

Patient Station

Patient Station

Patient Station

Patient Station

Patient’s Homes or HospitalGymnasia Station

VPN Secured NetworkConnection

VPN Secured NetworkConnection

Therapist Station

Remote Administration Site

Touch ScreenSensorized Garment

SpeechTherapy

MotorTherapy

By Toni Giorgino et al.



18Medical personnel use the therapists’ stationsto administer their assigned patients, pre-scribe exercises, and review their performance.

Patients use the patients’ stations which sup-port the rehabilitation exercises. Patients’ iden-tities are recognized via per-sonal “check-incards.” Once inserted, the exercise protocol(prepared by physicians) and messages aredownloaded automatically at the patient’s site.

The server acts as the repository for exerciseprescriptions, results, and messages.

Specific exercises, including speech therapyand motor therapy, are realized by a “plug-in” mechanism. Each plug-in implements allactivities required by the specific type of ex-ercise: it is responsible for providing config-uration screens, supports the execution ofthe actual exercise, provides appropriate feed-back to the patient, and stores the results. Italso supports browsing and summarizationof the results for the therapist to review.

The technology

Speech therapy is based on the EvoLing soft-ware developed by Dr. Hein GmbH. It includes

an extensive set of exercises, each promot-ing one ability: to r ecognize words, pho -nemes, graphemes, and pictures. Semanticand orthographic information is consideredin order to build exercises with an adaptingdegree of difficulty.

Motor therapy is an innovative componentof the system. When sitting at their station,patients wear a special sensorized garment,plugged into a portable electronics box (fig. 2).After a brief calibration phase, the motionrecognition software is started; it providesreal-time feedback on the progress and ac-curacy of exercises by means of clear sym-bols such as c olored b ars and a smi l -ing/frowning face. The movements have tobe repeated until the assigned number ofrepetitions are performed, or a timeout ex-pires. A traffic light icon shows when to starta new repetition (fig. 3, left).

Motion recognition is based on strain sensortechnology, directly printed on garments.Conductive elastomers are polymer-basedmaterials which exhibit electrical conductiv-ity. Sensing stripes are thin and can be print-ed by cheap industrial processes; they do notalter the mechanical properties of the fabric

(Lycra in our case) and they are stable and non-toxic. The same material can be used to re-alize connection wires between sensors andthe readout electronics (fig. 2).

Movement recognition

When signals from body movement are ac-quired, they are processed in order to verifythe correct execution of the rehabilitationexercise. Since there is no direct correspon-dence between the fabric stretch values atvarious points of the garment and biome-chanical parameters or like angles betweenlimb segments, posture classification wastackled via machine-learning based algo-rithms. Therefore, every repetition is classi-fied evaluating the similarity with a known“correct” or reference path. Some referencepaths correspond to well-known, deficit-related exercises, like adduction, abduction,rotation, extension, etc. But other exercises maybe tailored to the specific patients, in partic-ular functional movements like combing, eat-ing, brushing, etc. A short “calibration session”allows the system to learn such move mentsand store the corresponding reference paths.

The machine learning approach to move-

Figure 2:The sensor printing design, the prototype and the finalversion of the garment. No wir e is visible and theportable electronics are hidden in the pocket

FEATURES My Heart’s “ Neurological Rehabilitation ” Concept



19ment recognition is an important researchtopic by itself, because strain sensors are af-fected by various sources of uncertainty,which make the recovery of limb positionsfrom sensor readings less than straightfor-ward. The accuracy of classification is af-fected by the dynamic nature of the task.Smeared sensors produce velocity-depend-ent artifacts; therefore, the recognition ac-curacy is impaired when limbs are moving.In addi-tion, patients wear the garmenteach time in a different way, and also with-in the same session the garment mayslightly move. Also, one is interested in thecloseness of a movement path to a refer-ence, not just to detect a limited set of ba-sic positions.

Results

The NR system is currently undergoing asmall-scale study to assess user satisfactionand gather initial measures and feedback. Itincludes, in its last phase, 10 months of ex-perience in the field, with real healthcareoperators and at least 20 patients exploitingthe different system functionalities. Resultsof the study will deal with the usability ofthe system (user-friendliness, lack of tech-

nical problems, comfort e.g. possible prob-lems with the garment) and the users' sat-isfaction (perceived usefulness from the pa-tients' and therapists’ point of view).

Preliminary qualitative and quantitative re-sults for speech therapy were obtained fromthe first ten patients enrolled. Most of theenrolled patients enjoy using the system, anduse it about three times a day, in addition totheir traditional face-to-face encounter withthe speech therapist.

Motor therapy support, while representing avery promising technology, is a more chal-lenging task. The preliminary laboratory eval-uation with voluntary subjects showed anoverall efficiency on movement recognitionof 91%. However, we can not report at themoment quantitative results on patients, sincethe first months of the evaluation phase havebeen spent in gathering feedback from pa-tients (six subjects) and therapists in order toimprove the system usability. The garmentdesign has been improved adding a zip to fa-cilitate wearing and markers to facilitate wear-ing the garment always in the same way. Alsothe interfaces have been made more andmore simple and immediate, leaving out all

the pictures, icons and words that couldmake the patient confused.

Conclusion

The integrated nature of the NR system isintended to support a multidisciplinary,telemedicine-based approach to rehabilita-tion. The benefits of this (and similar) IT-based aids are supported by current beliefson rehabilitation, e.g. those expressed in theSPREAD guidelines (www.spread.it). First ofall, long term rehabilitation programmes areconsidered b eneficial f or the r ecoveryprocess, but cost is very high. IT technolo-gies are a promising solution for pro-vidinglong-term rehabilitation at lower costs. Atthe same time, early discharge is recom-mended for patients with less severe dis-ability. The system allows for early dischargewhile still being monitored remotely.

Finally, the concept addresses a frequently-reported issue, i.e. lack of quantitative meas-ures on the progress of rehabilitation. Thediffusion of computerized monitored reha-bilitation aids may increase the objectivityof practice and allow for quantitative progressevaluation and therapy comparisons.

Acknowledgments

The authors thank F. Lorussi and D. De Rossi(University of Pisa); R. Mauri (FondazioneMaugeri, Pavia); M. Stefanelli (University ofPavia); D. Tietze and R. Setz (Dr . HeinGmbH) for essential contributions to theproject. The work was partly funded by EUproject “MyHeart” no. IST-2002-507816.

Figure 3:Two patients mak-ing motor rehabil-itation (lef t) andspeech therapy re -habilitation (right)exercise using theN-concept work-stations

[ ]Toni Giorgino, Ph.D.Paolo Tormene, M.S.Silvana Quaglini, Ph.D.

Laboratory for Biomedical

Informatics, Dipartimento di

Informatica e Sistemistica,

Università di Pavia, Italy

Giorgio Maggioni, M.D.Barbara Cattani, M.S.Caterina Pistarini, M.D.IRCCS Fondazione

Salvatore Maugeri, Pavia, Italy

[email protected]



20Behavioral technology should ideally be alwayswith users, should not burden them with addi-tional devices or force them to learn new in-terfaces, and should be flexibly applicable todifferent tasks and activities. In short, the tech-nology should be easy to weave into the fabricof our everyday life. Recent research in Human-Computer Interaction shows that this integra-tion is made easier if the technology supportssituated use, exploiting user actions and theenvironment as a resource rather than requir-ing explicit commands or data entry by users.There is a candidate platform that can accom-modate these requirements, and that is “whatused to be called the mobile phone.”

Mobile phones have evolved to the extent thatmanufacturers do not call them phones any-more. Features include cameras with ever in-creasing resolution for picture and video cap-ture, internet connectivity (based on operatorsnetwork or WLAN), near field communicationas RFID (Radio Frequency Identification), a va-riety of sensors like accelerators, and GPS (Glob-al Positioning System). Through the bluetoothinterface virtually any sensor can be used inapplications and the bluetooth itself can be asensor that is able to scan and sense the pres-ence of other devices. More importantly, themobile phone contains rich and diverse infor-mation about the user and his or her actionsthat can be used by applications: calendar, com-

munication logs, profile of the phone in silent,usage data of the phone or its applications. All these features are even more powerful whenused in concert rather than separately and ini-tial naturalistic studies show that such novelmobile applications can have a great impact onactivities and experiences of users in particularleveraging social interaction. Let’s review someexamples starting with studies of collective sto-ry creation using mobiles, then studies of mo-bile awareness cues and their integration, andfinally sensing and augmented reality and theirpotential for novel applications.

Collective Creation and Sense Making of Mobile Media

With Comeks on the phone, users create com-ic strips by augmenting and annotating theirown mobile pictures with speech bubbles andother comic-related accessories. Messages areput in a sequence creating stories that can besent to friends. In a longitudinal field studymessages featured performative acts wheremembers play-acted together or turned ob-jects into characters. Collage was frequent, re-using, for example, pictures from the mem-bers of the group or other printed material(Salovaara 2007). The study shows how a mo-bile phone that supports producing and send-ing comic strips out of mobile pictures (figure1, left) can impact group communication and

experience by creating novel expression prac-tices in a group of subjects.In a series of studies on spectators at large-scaleevents we have shown how mobile picturescan affect group experience and action. In afirst study by just utilizing simple c ameraphones with just the built in applications, wewitnessed rich forms of multimedia-mediatedexpression such as staging, competition, story-telling, joking, communicating presence, andportraying others. These expressions were al-ways connected to group practices and weremotivated by how they featured in socially en-gaging, processual, and shared nature of expe-riences. The analysis pointed to how mobilemedia was not only important to mediate ordocument experiences but in how it partici-pated in the very construction of experienceby providing opportunities for action.

In a subsequent study, we equipped groups ofspectators with an application that implement-ed mobile media messaging in collective stories(group messaging spaces) that became archivedgroup media albums. We have used the term“collective” to refer to the experiential compo-nent in joint media creation and sense-making.Collective use appears to be rewarding becauseit not only provides new forms of interpersonaland inter-group communication, but also waysto re-enact and re-use group’s conventions andshared memories in novel inspiring ways. In

Using Mobile Phones asBehavioral TechnologiesOpportunities and Challenges

FEATURES

Technology should be easy to weave into the f abric of our everyday life; recent research in Human-Computer Interaction shows that this integration is made easier if the technology supp orts situateduse, exploiting user actions and the environment as a resource- rather than requiring explicit commands or data entry by users.

Giulio Jacucci



these collective albums awareness and socialpresence are actively constructed achievements.Our work points to how users can actively en-gage in constructing the cues by contributingto build up the medium for presence.

Awareness Cues and Their Integration

Another example is how mobile awarenesscues on other’s context impact coordinationand communication. ContextCues augmentsthe contact list of the mobile phone by juxta-posing to each name and number context in-formation on that person. These cues can in-clude: the location, nearby members, timeelapsed since phone used, and other activitycues. Longitudinal intervention studies showedimpact to coordination whereby cues wereused to infer information, align, and optimisemobility and communication. More impor-tantly, cues were used in the pursuit of con-nectedness, companionship, and a sense ofbelonging with peers and significant others.

In further experiments we have also combinedawareness cues and collective media storiesas shown in Figure 2. Our system combineda group media space with event informationand integrated awareness cues throughout. Intwo field trials we found that the system sup-ported what we call active spectatorship facil-itating onsite reporting to offsite members,coordination of group action, keeping up todate with others, spectating remotely, and jok-ing. In these activities, media, awareness cues,and event information were often used in con-cert, albeit assuming differing roles.

Sensing and Augmented RealityAlso sensor information, for example a heartrate sensor, can be used in mobile applicationsas the one in Kurvinen et al. 2007 that was ex-perimented with sharing real-time perform-ance information of football teenage playersto their parents and coaches during trainingand competition. This exemplifies how easyit is to integrate sensorial information even ata physiological level and also how the sensedinformation can be used not just for the indi-vidual user but in a social application.

Technologically there are some solutions onmobile phones that start to be interesting asways to tag the environment like RFID tags, andoptical markers. The mobile phone increa -singly can interface with a variety of sensors.We have developed at our institute a platform

for this called ContextPhone. Also 3D graph-ics are developing quickly, enabling complexvisualization that could be useful in rehabili-tation scenarios.

Recent developments make Augmented Re-ality visualizations possible to be played onmobile phones which means enabling the abil-ity to register 3D virtual objects in a real sceneusing computer vision tracking optical mark-ers (Figure 1, right). This creates engaging andrich mediation to the physical environmentand has been shown to activate users in nav-igating and using space in a different way forexample in educational games in museums.

A Call for Balance and Artful Integration

The mobile phone is therefore a surprisinglypowerful tool compared to desktop applicationsfor its ability to provide continuous and ubiqui-tous use, meaning also interaction with the en-vironment, which can be useful in physically ac-tivating subjects. Mor e imp ortantly, it c anfunction as a powerful tool for expression andsocial interaction, deeply affecting action andexperience in a variety of activities. Our exam-ples show that to make best use of the rich fea-tures provided by mobile phones, an artful in-tegration is required to create applications thatcan truly be woven in users’ everyday practices.

There are several issues and open questionsconnected to the mobile phone as a behav-ioral technology. On a technical level, develop-ing applications for phones is difficult giventhe portability problems, as there are severalprogramming languages and operating sys-tems on phones. Finally, although phonescreens are getting bigger and their inter faceeasier (see iPhone), a phone application canbe perceived to be difficult and complex touse. More importantly, in some of the studiesmentioned before, the use was so intensive, itraised concerns of negative effects in the longerterm. Some users even reported having felt so-cial uneasiness in public spaces when otherpeople noticed them staring so long at theirmobile phone. Therefore as with any technol-ogy, the design should aim for achieving a bal-anced impact.

21

Figure 1. pictures from two different comicstories created by subjects with a mobilephone using Comeks Salovaara (2007).

Figure 2: awareness cues about other members

Figure 3. recent developments allow Augmented Reality visualizations (by Schamlstieg and Wagner 2007)

Giulio Jacucci, Ph.D.Helsinki Institute for Information www.hiit.fi/[email protected][ ]



22

When most think of fashion, we tend tothink of chic models, latest trends, beau-tiful garments, and innovative designs.The clothing industry has generated bil-lions in revenue by creating enticing de-signs for the general population. Fashiondesigners are always searching for the nextfashion trend for innovative products. I wouldlike to declare that I have discovered thatnew trend; that new, exciting, and innova-tive fad that will change the fashion worldforever: the new trend is here, it is “now,”it is….technology.

Recently, technology has begun to emergeonto the fashion scene, creating uniqueadditions incorporated within fashion de-signs. Products such as mobile phonetechnology, kinetic energy, and sunlightreactors have begun to intertwine withwell-known fashion designers, introduc-ing technology to runways worldwide.However, interestingly enough, technolo-gy companies have begun to “dip theirtoes” in the pool of fashion as well. Com-

panies such as Philips, known throughoutthe world for their technologies and elec-tronics, have begun producing technolo-gy that can be fused with textiles to giveyour clothing that “extra something,” thenew wave of the future.

Wearable Technologies

Medical technology has begun to realizethe incredible market for wearable tech-nology. Wearable health companies havesurfaced in North America, Europe, andAsia as innovators to the new “trends” inhealthcare. Intelligent textile companiesuse their textiles for the wearer’s wellbe-ing, using temperature-changing materi-als to change color in reaction to bodyheat, fabrics that have their own coolingsystem in reaction to the wearer’s envi-ronment, and even clothing that has itsown personal heating system.

With materials and technology like these,the future is electrifying. Imagine being

able to control your own body heat at alltimes, never too cold and never too hot.Envision the possibilities if a material candetermine if an infant has a fever or is toocold when it cannot speak to its parents.

Futuristic Fusion

Mobile phones and telehealth have madeheadway in the medical field, bringingwireless communication for better healthand wellbeing to the user. Companieshave even created clothing that actuallyacts as a mobile phone, catching muchmedia attention worldwide. CNN.com hasrecently described this phenomenon, stat-ing, “Futuristic fusion of fashion and tech-nology is b ecoming more common as[clothing] designers are increasingly incor-porating electronics into their garments.”The article featured fashion companiesthat have added creative technology intheir garments. Products featured includeswimwear that changes colors in reactionto sunlight, a dress that measures air qual-

By Daniel Stevens

FEATURES

The Emergenceof CyberFashionThere is no doubt that wearable technology is on the rise. The future cannot be foreseen, but the possibilities are bright; cyberfashion will most undoubtedly change the way we wear our clothes…



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ity, garments that show moving video im-ages and a self-heating vest, among others.CyberFashion has progressed into the en-tertainment industry, with products suchas the “air guitar t-shirt,” a shirt that allowsthe user to play an objectless musical in-strument by Dr. Richard Helmer of theCommonwealth Scientific and IndustrialResearch Organisation (CSIRO), and Cute-Circuit’s “Hug Shirt,” which enables mobilephones to give someone a “virtual hug.”

But why are these companies moving to-wards technology instead of using, shouldwe call them, “unintelligent” textiles? Isthis a passing fad or has this sparked thenew wave of modern clothing? There isno doubt that wearable technology is onthe rise. The future cannot be foreseen,but the possibilities are so bright; this willmost undoubtedly change the way wewear our clothes. Once these products be-come affordable and commercialized, thetrend will take off and continue to pros-per. Even the “simplest” things, the abili-

ty to change the color of a garment at willor trendy mobile phone accessories, aresure to become more than a passing craze.Investigating these new garments is dif-ficult, as most are not currently commer-cializing their pr oducts for the main-stream market. Philips, who has createdthe LumaLive technology, a material thatcan change colors, shapes, and designscontrolled by the user, rents out their tech-nology for shows, but are still in the “cus-tomizing phase,” working to make theirproduct more flexible. Other designerssuch as Hussein Chalayan and Vega Za-ishi Wang use technology to create visualeffects on a runway, but do not necessar-ily infuse the ef fects in the c om mer -cialized version.

Bruce Damer of CyberWearz has createdthe iDoublet, in which he designs cloth-ing that incorporates an Apple iPod di-rectly into the garment. The iDoublet wasdebuted at MacWorld. In addition, Damerhas presented his research at many pres-

tigious conferences and shows includingthe Second Skin Show in San Francisco,the 11th Annual Presence Conference inPadova, and at the Virtual Worlds Sum-mit in London. “I see a merger betweenthe two fields with textiles becoming hightech and manufacturing of garments be-coming driven by CAD/CAM (ComputerAided Design/Manufacturing),” Damerstates, “The apparel business is one of thelast holdouts of old fashioned 18th Cen-tury hand construction.” A pioneer in ear-ly virtual worlds and avatars now turneddesigner, Bruce foresees fashion movingtowards the medic al realm. “Medic alhealth monitoring [and] cyber-garmentswill bring real breakthroughs such as heartmonitoring, galvanic skin response, andcommunication of health status.”

Other pioneering developments in cloth-ing have made headway in this field. TheMamagoose pajamas, created by the Eu-ropean Space Agency, embody built-insensors and electronic monitoring to de-tect Sudden Inf ant Death Syndr ome(SIDS), more commonly called “cot death.”When symptoms or characteristics of SIDSarise, an alarm sounds to prevent death.The World Health Organization (WHO) hasconducted many studies on using wear-able monitoring systems for the preven-tion of the relapse of depression, moni-toring and c orrelating r esponses toantidepressant drugs, detecting drug mis-

Mamagoose technology for SIDS detection. Photos courtesy VERHAERT

Bruce Damer models hisiDoublet designs. Photocourtesy of CyberWearz.www.cyberwearz.com



24

use, and to warn or obtain feedback in or-der to prevent self-injury and suicide. Themost incredible benefit for using intelli-gent textiles is the ability for the user tolive a “normal life,” while wearing a med-ical disorder preventative aid. Such antic-ipatory garments can be worn underneathother clothing which still appear to be “un-intelligent” textiles, giving the user the feel-ing of normalcy. Even “wearable comput-ing,” a wearable computer that monitorsbehavior and health, can appear to be acommon wristwatch.

Downsides

On the other hand, as critics may suggest,there are a few downsides to technologyin clothing:

Practicality. Clothes become dirty andtherefore must be washed. Modern tech-nology must be made waterproof to becompletely integrated into clothing.

Affordability. Incorporating expensive tech-nology into new designs will b e pricey.Most consumers are not willing to partwith hundreds to thousands of dollars foran article of clothing.

Paranoia. For those conspiracy theorists,one could make the argument that incor-porating technology into clothing is onemore way for an individual to be moni-tored, given the possibility that electron-ics capable of tracking devices could be at-tached to the garment. However, mobilephones already have such tracking capa-bilities; a concerned parent would not haveto worry about their child losing a phoneif the monitoring chip was built into thechild’s clothing.

Longevity. Clothing featuring battery-pow-ered electronics must either be chargedor will most likely have a short life span.If such an expensive garment were pur-chased, the consumer would not look tookindly on its inability to last.

Reliability. Micro-technology and electron-

ics have the tendency to break or go “hay-wire.” Mobile phone companies, small elec-tronic producers, and handheld music de-vice companies have support staff, reliablestore outlets for repair, and can easily ex-change the item f or one similar. Withthese added hassles, mainstream clothingcompanies may avoid selling such mate-rials, despite their ability to appeal to theconsumer.

Positive Attributes

Despite the above complications, cyber-fashion has many positive attributes whilethe complications previously mentionedhave the ability to be fixed. Looking atmedical purposes alone, the positives out-weigh the negatives. Many c ompanieshave solved the waterproofing issue; af-fordability will c ome with time, whilelongevity and reliability can be perfectedin the coming future.

CyberFashion for Wellbeing

CyberFashion has initially emerged at tech-nology conventions and conferences. Theupcoming CyberTherapy & CyberPsychol-ogy (CT14) conference will celebrate cyber-fashion this June near Milan, Italy. The an-nual Cyberarium, which provides a forumfor new and emer ging technology, r e-search, and wearable products, will incor-

porate advanced technology with highfashion at the first CyberFashion for Well-being Show.

Fashion students have already begun toconstruct designs focusing on medical well-being for the show. Conference organiz-ers are engaging with fashion designersand wearable companies to participate inthis innovative fashion show. Taking placein Lago Maggiore, Italy, the venue is beau-tifully set on the gorgeous Italian lake, nearMilan, the fashion capital of the world.

New and emerging technologies will inter-twine with the clothing, textile, and fash-ion industry. Women’s apparel seems tobe the “up and coming” sector of fashionto first feature technology. Look for thelatest trends to materialize in accessoriessuch as purses, bags, and shoes beforeevolving to garments. There is no doubtin my mind that cyberfashion will becomethe new craze and even revolutionize theclothing industry. It just goes to show thatwithin the exciting and innovative field oftechnology, there is always something freshand captivating, delighting the user in amultitude of capacities.

Designs made of a jogging suit that lights up from kinetic energy during evening runs for safe-ty and visibility by fashion students at the University College Ghent for the CyberFashion forWellbeing Show. Designs created by 1. Julie Migneau, 2. Lieve Martens, 3. Saskia Dobbelaere,4. Bertien Boon. Jean Luc Dejaeghere is also involved in the design team.

FEATURES The Emergence of CyberFashion

[ ]Daniel Stevens, LL.M.Managing Editor, C&R [email protected]


26

About Cybermind:

Cybermind Interactive Nederland is a young and dynamic company,founded in April 1997, and has grown to become the leading Europeandistributor/manufacturer of Head Mounted Displays (HMDs). UsingHMDs (Goggles, wearable monitors, personal displays) has a lot of ad-vantages and creates an experience that cannot be realized with anyother form of presenting images, data, or other information to the par-ticipant. Cybermind Interactive Nederland is a technology-based com-pany that seeks to excel in producing affordable, high- end, HMDs thatare durable, comfortable, and versatile. These tools are produced forprofessionals, can be customized according to the requirements of theapplication, and enable effective treatments.

The use of HMDs, and understanding their effectiveness, is widely ac-cepted compared to instance monitors, projection surfaces, and Cave-like projection environments. Scientific research over the last few yearsconfirms the usage and the increased effectiveness and efficiency ofprocedures and treatments.

Virtual Reality (VR) and Augmented Reality (AR) technology within Cy-bertherapy in 2008:

The unique design features of HMDs include the following: completeimmersive design, lightweight, comfortable, functional, and flexible(seamless integration of microphones, cameras, sensors etc). The im-mersive design is also highly effective in combination with AR appli-cations. The treatments of various phobias, including the fear of heights,claustrophobia, and the fear of flying, have proven successful. In ad-dition, other medical applications, such as pain relief during treatmentof burn wounds, are done with “traditional” VR equipment as well.

Cybermind has created their own technology and optics in order to of-fer high-end equipment at an affordable price to make VR and AR ac-cessible for a wider audience. Not only can the equipment be used withmany different sources (PC, cameras, DVD players etc.), but the uniquetechnology also supports content with various resolutions and is com-patible with older VGA animations combined with video segments andSXGA animated content. This is all made possible with the HMD Visetteseries.

The Visette 45, a top range model, complemented with Optical See-through, or combined with one of the headsets containing a camera,can open the world of AR to any user. Adding virtual objects (like spi-ders or fire) to real life scenery has great potential. AR can, for a vari-ety of treatments, be more effective than the complete virtual environ-ments that are utilized by VR.

Future expectations:

With the steps taken by Cybermind to create a technol-ogy platform and its optical system, future developmentswill follow at a faster pace. The last three years havebeen focused on the creation of a versatile platform anda transparent optical system. Creating larger Field ofViews will be the most important achievement for thestandard Visette range, but the possibilities for creat-ing mobile set-ups, and lighter and more attractive de-signs etc. are plentiful. The focus on Field of View is im-portant, although, using motion capture (tracking theperson/object within the virtual environment) createsthe experience of 360° Field of View. In certain cases,mainly in the clinical area, having sight in the peripheryof the eyesight is important.

Cybermind will proceed with creating non-invasive de-signs with specifications (Field of View, resolutions com-fort etc.) that create near-life experiences, which willincrease the already impressive effectiveness of HMDs.

Contact:

Cybermind Interactive Nederland"Supporting Tomorrow's Technology Today"

Forum 55 (MECC)6229 GV MAASTRICHTThe NetherlandsTel: +31.(0)43 3618 300Fax: +31.(0)43 3618 394GSM: +31 651409752Website: www.cybermindnl.com - www.hi-res800.com E-mail: [email protected]

Cybermind, creation of tools for Cybertherapy.

Corporate Presentation


Canada

Universities across Canada are currentlyconducting exciting research projects us-ing virtual reality (VR) to assess, under-stand, and treat mental disorders, includ-ing anxiety disorders and eating disorders.These studies have resulted in the pro-duction of effective clinical protocols, en-abling affected individuals within Canadato undergo enhanced treatment meth-ods. The principal investigators of thesevarious projects use a variety of technolo-gies, such as high quality Head-MountedDisplays (HMDs), eye-tracking systems,physiological measures, and precision mo-tion tracking.

The CyberPsychology Lab of the Univer-site du Quebec en Outaouais, headed byStéphane Bouchard, recently unveiled itsaddition of a CAVE system; one of the fewin use in the world. The University’s CAVE,a 6-wall immersive room, is referred to as“Psyche” and devoted to research on VR,presence and mental disorders. Other re-searchers study eye-gaze patterns to assesssexual preferences among pedophiles, usea virtual bicycle to increase obese children’smotivation to exercise, and validate the VRenvironment to test executive functioning.

United States

Across the United States, small companiesand university research labs are incorpo-rating Virtual Reality (VR) and Mixed Real-ity (MR) technology into more traditional

medicine and therapy protocols. The com-bination of VR, MR, and in some cases hap-tics, provides for the assessment and treat-ment of a variety of disorders ranging fromanxiety to traumatic brain injury to paindistraction. Protocols may include physi-ological monitoring and feedback for fur-ther training of patients or participantsand objectification of results. Americanpsychologists have developed successfulprotocols for the treatment of specific pho-bias (flying, driving, public speaking, claus-trophobia, heights, and spiders), panic dis-order, agoraphobia, posttraumatic stressdisorder due to motor vehicle accidents,and social phobia through conducting con-trolled studies with VR-CBT. Telehealth isalso being explored for treatment throughuse of avatars and Internet-based worlds.

In addition to therapy and rehabilitation,the area of stress inoculation training (SIT)for first responders and military person-nel is being augmented by VR simulationsand more realistic wound creation throughscientific advancements. One small com-pany, Virtual Reality Medical Center, head-ed by Dr. Mark Wiederhold, is working withareas as diverse as posttraumatic stressdisorder, chronic and acute pain, cogni-tive and physical rehabilitation, and SIT.The technology is proving to be an impor-tant adjunct to established methods.

Mexico

In Mexico City, five public health hospi-tals have participated in VR research by

using VR to reduce the distress and painassociated with invasive procedures. Ledby f orward-thinking physician Jose L.Mosso-Vázquez, clinicians ar e using aHead Mounted Display (HMD) system inorder to display VR scenarios to their pa-tients during procedures. To date, almost500 patients have participated in the stud-ies, with the conclusions showing that pos-itive results are being received, throughboth reduced patient discomfort and re-duced cost of certain procedures, sincethe need for pain medication and anes-thesia is greatly reduced.

VR has been shown by many groups tosuccessfully reduce pain or discomfort ina variety of less invasive procedures, suchas dentistry, wound care and physical ther-apy. The use of VR during these proce-dures has led to the exploration of thepotential for VR to be used during pro -cedures of higher complexity. This is thefirst study to document the use of VR forcomplex and invasive medical procedures.

In the upcoming issues of C&R Magazine,we will continue to showcase the advancesbeing made in other parts of the world.In the next issue, cybertherapy and ad-vanced technologies in mental health willbe examined in Asian countries.

C&R IN BRIEF

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Across North America…Over the past two decades, researchers have been busy designing, developing, testing, and implementing advanced technologies to successfully help those with disorders, spanning from anxiety to addiction to phantom limb p ain. Scientists throughout the world are realizing the potential for technology to enhance the medical “continuum of care” beginning with prevention, training, and education and continuing through treatment and rehabilitation.In this issue, we highlight some of the advanc es being made in North America.

[ ]Carrin PockrandtStaff Writer, C&R [email protected]


Many Spanish universities and clinics have b egunusing cybertherapy to treat mental disorders, joining aninternational community of researchers and clinicians.Specifically, over the past few years, the connectionsbetween Spain and the rest of the world have improveddramatically.

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AUTHOR:

Daniel Stevens, LL.M.Managing Editor, C&R Magazine

[email protected][ ]C&R in S pain

With the national motto of “PlusUltra,” meaning “Further Beyond,”

it only seems fitting that cyberther-apy found its way into the Mediterranean-based country of Spain. With over 40 millioninhabitants, Spain shares the highest preva-lence for mental disorders in Europe with theUnited Kingdom. Thus, a heightened needfor increasingly effective treatment for men-tal disorders has become evident in the Reinode España. Many laboratories and clinics inSpanish universities have developed virtualreality and advanced technology-based ther-apy treatments in order to better treat theincreasingly large population of individualswho suffer from mental disorders.

History of Mental Health in Spain

The Proclamation of the Health Reform Lawin 1985, which introduced modernity into theSpanish health care system, came with a hu-manitarian concern for large amounts ofprevalent mental disorders in the population,ideally bringing the general care for the men-tally ill to the same level of their industrial-

ized European neighbors. Since then, mentalhealth care has significantly improved, includ-ing the birth of advanced technologies to aidin the treatment of mental disorders.

Many agree that cybertherapy was first for-mally introduced to the world in 1992 at thefirst Medicine Meets Virtual Reality Confer-ence; however, the use of vir tual reality forthe treatment of mental disorders has beendistinct in Spain for just over 10 years. TheSpanish Ministry of Education and Science,the Government of Catalonia, along with oth-er regional and national agencies currentlyfund projects for research teams towards theapplication of new ICTs in clinical psycholo-gy and rehabilitation. Many award-winningprojects and innovative research have risenout of Spanish laboratories and universities,placing Spain in an impressive position inthe world of cybertherapy.

International Collaborations

Many Spanish universities and clinics havebegun using cybertherapy to treat mental

disorders, joining an international commu-nity of researchers and clinicians. Specifical-ly, over the past few years, the connectionsbetween Spain and the rest of the world hasimproved dramatically. Nonetheless, Spainlacks the same budget for research and de-velopment to comparatively remain at thesame level as its surrounding countries. Manyresearchers use international journals to dis-seminate their findings in an effort to glob-alize their studies.

The European Framework Programmes havedecisively contributed to the connection ofthe research groups in Spain with the rest ofEurope. Currently, Spanish teams are partic-ipating in some of the most imp ortant Eu-ropean projects in mental health, allowingSpanish laboratories to connect and collab-orate with other European institutions. Se-lect labs have ongoing collaborations withuniversities and research centers in Italy, theUnited States, the United Kingdom, Germany,The Netherlands, Portugal, Sweden, Ireland,Canada, Mexico, Colombia, Argentina, andSouth Africa, among others. It is not uncom-

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40,5

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79,9

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35

39

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3,2

45.77 - 46%

1.22 - 1.34%

740.455

325.800

592.364

2008

2006

2007

2008

2008

2008

2001

2002

2005

2005

2004

2004

2004

2004

Population (Million)

Percentage of Urban Population

Unemployment Rate

Life Expectancy (years)

Psychiatrists (per 100,000 Inhabitants)

Number of Universities OfferingPsychology Programs

Population Median Age (years)

Population Self-Assessing

Health as GoodSuicide Rate (per 100,000)

Psychiatric Hospital Beds (per 100,000)

Fertility Rate

Extrapolated Prevalence toEating Disorders (total)

Extrapolated Prevalence to Schizophrenia (total)

Extrapolated Prevalence to Anxiety Disorders (total) 29

mon for Spanish clinics and universities tosolicit foreign researchers as well as visit lab-oratories in other countries.

Research Facilities in Spain

The ability to raise funds for research hasgrown dramatically in Spain in recent years.Both the central government and many ofthe regional administrations are now awarethat the investment in research and devel-opment is vital to ensure the welfare of thepopulation. Private companies of a certainsize, as well, are investing in basic and ap-plied research. Spain is in a relatively goodposition in Europe, with the possibility ofFEDER funds, which have been a notable helptowards the development and up date inmany domains, including research. Nation-al agencies normally fund equipment andpersonnel for furthering research. Nonethe-less, constant funds are needed due to thehigh-speed evolution of the cutting edge sys-tems and platforms as well as other essen-tial equipment such as HMDs, projectors,sound systems, informatics, head position

trackers, and eye tracking displays. Universities work hand-in-hand with clini-cians, realizing the support needed for ICTprojects. Cooperation and mutual enrich-ment make Spanish laboratories’ researchimprove and become more enjoyable. Ingeneral there is a very good relationship be-tween the universities and the research labsthat operate within them. Collaboration be-tween well-connected Spanish colleagues hasalso been beneficial for most Spanish uni-versities with projects such as CONSOLIDER,which includes seven participating universi-ties as well as CENIT, which links Spanish uni-versities and enterprises.

EU Funded Projects

EU funded projects and funding is one of thebest ways to obtain adequate resources thatwill enable Spain to reach levels of scientif-ic output of high quality. The possibility ofcollaborating with first line researchers andto participate in the joint effort of develop-ing scientific knowledge is key for Spanishlaboratories. Extending and disseminating

knowledge and research is of the highest pri-ority. However, some groups hesitate to takeadvantage of EU funded projects because ofthe complexity and time needed to set up aconsortium, a proposal, and finally managethe administrative tasks associated with theprojects, preparation of reports, etc.

Research Areas

Many distinguished studies are being ex-plored in Spain, promising future exempli-fied results. Areas of current study include:

• Theoretical and methodological topics including:

> Reality judgment and sense of presence in virtual environments

> Learning in virtual environments and learning transfer

> Design and development of psychological assessment tools based on ICT

> Development of mood induction and mood change experimental procedures

> Experimental procedures for subliminal perception in virtual environments.



• Advances in the utility of technological developments in clinical psychology including:

> Environmental Intelligence> Augmented reality without traces> Autonomous agents> D systems in real time on ICT mobiles> RFID sensors• Psychological disorders and other

psychological problems including:> Development and consolidation of

technological applications for the assessment and treatment of anxiety, eating disorders, child mental disorders, adjustment disorders and grief, and problems related to violence and aggressiveness

• Physical and health problems including:> Development consolidations of techno-

logical applications for the assessment and treatment of pain management

> Palliative treatment for restricted mobility people

> Palliative treatment of cancer> Cognitive rehabilitation in cognitive

disorders• Quality of life and wellbeing in the

elderly enhancing e-inclusion solutions• Advances in psychopathology and

psychological treatment of several mental disorders including:

> Anxiety disorders> Mood disorders> Somatoform disorders> Adjustment disorders> Substance-related disorders> Impulse control disorders• Kansei engineering and product

evaluation• Basic perceptual processes

Spanish Projects in the Spotlight

Some significant projects to come out fromSpain are: “Development and Applicationof Technologically Advanced Methods Ba -sed on Virtual Reality for Attention-Diver-sion, Visualization and Body Image Modi-fication, and Adjunct Analgesic TechniquesAgainst Chronic Pain”, and the EU fundedEMMA Project (Engaging Media for Men-tal Health Applications).

The first project consists of 19 researchers,deriving from the University of Barcelona,the University Jaume I, the Hospital Provin-cial de Castellón, the University of Valencia,the Polytechnical University of Catalonia,and the University Miguel Hernández of Al-icante for a three-year collaboration. Thegathering of these groups to carry out thisproject has given birth to one of the mostefficient teams in the field of virtual realityapplied to health disorders and disease.

The latter of the two projects, EMMA, de-veloped a mood induction procedure thateffectively changes the users’ mood andhas been proven to be useful in basic andclinical research. An adaptive display wasdeveloped during this project for the de-

livery of psychological treatments in com-plex mental disorders. This display hasbeen effective in the treatment of post-traumatic stress disorder, complicated grief,and adjustment disorders.

The Future of ICT Research in Spain

It is agreed that the future is limitless inSpain due to its efficiency and future col-laboration possibilities. Physical and men-tal health, health in the workplace, leisure,and general wellbeing are among severalpossibilities for the future. CyberTherapyin Spain has left its mark on the world andthe world looks back with interest as fu-ture research emerges. With future collab-orations with European and internationalpartners, advances in cybertherapy will con-tinue to flourish in la España soleada.

Sources:

World Health Organization, European Commission, Medical News Today, personal communication with Dr. Cristina Botella and Dr. José Gutiérrez Maldonado

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cyber therapy & rehabilitation magazine (1, 2008)

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