cybertherapy and rehabiliation, issue 2, 2009

FEATURES:Interactive Mind-Driven Rehabilitationp 12

The Decade of the Handheldp 13

VR in Eating Disorders and Obesityp 16

VR Lab Provides Relief forWarriors and Their Familiesp 19

Transcranial Doppler Moni-toring in Presence Researchp 21

COVER STORY:

Training Tool for the Futurep 23

PRODUCT COMPARISON:Handhelds and Mobile Health p 10

COUNTRY FOCUS:South Koreap 28

Launch iRehab ApplicationsPlatformsNew Mobile

ISSN 2031 - 278

1

Letter from the PublisherProfessor Dr. Brenda K. Wiederhold

Dear Reader,

I would first like to welcome all our new read-ers and thank our returning readers ofCyberTherapy and Rehabilitation Magazine(C&R), the official voice of the InternationalAssociation of CyberPsychology, Training andRehabilitation (iACToR). iACToR, formerlyknown as the International Association ofCyberTherapy and Rehabilitation (IACR), isan international association dedicated to thepromotion of virtual reality and advancedtechnologies as an adjunct to more tradition-al forms of healthcare. It also addressesissues concerning technology’s role in alter-ing behavior on both an individual as well asa societal level.

As well as thanking readers for their encour-agement and support, I would like to special-ly thank C&R’s Editorial Board members’unending dedication as well as theManagement Board and Founding Membersof iACToR. With our combined communica-tions platform we have successfully formedaffiliations with several other associations,conferences, publications and institutionalpartners to further strengthen the goals ofthe association and reach out to experts, aca-demic peers, industry leaders and govern-ment officials.

This issue we focus on iRehab, specificallythe way in which new technology is appliedto rehabilitation, both in the mental andphysical healthcare sectors. Everywherearound us, we hear of change in this direc-tion, from phone applications helping usersbecome healthier through tracking food con-sumption to medical centers across thecountry using Twittercast to reach out topatients and students. The Twitter mediumhas become so popular that it recentlyhelped lead to the successful bone marrowtransplant of a five-year-old girl in New YorkCity. As the use of advanced technology inthese fields has become more establishedthroughout the world, we now turn our

attention not only to Europe and the U.S.but look further afield to its implementationin Asia.

Our lead article discusses the surge inmobile platforms and the ways in which theyaffect handhelds and iRehab applications.Next, we take a closer look at mobile healthand handhelds, in particular, in our ProductComparison Chart. The positive effects ofinteractive rehabilitation will be exploredand the reader will be introduced to thenotion of a “handheld generation” and theeffects of technological innovations in thisarea. Following articles discuss the effects ofvirtual reality exposure on patients with eat-ing disorders and returning war fighters suf-fering from stress and pain. A study measur-ing presence in virtual reality environmentsis presented and lastly, an article on surgicalsimulation. I would like to sincerely thankcontributing authors for their time and ener-gy. These articles and studies are helping topave the way for new advancements inhealthcare and C&R is proud to be a part ofthe movement.

Looking to the future, upcoming issues ofC&R will discuss topics such as robotics,brain imaging, cognitive enhancement withtechnology and much more. There is awealth of advanced technology for health-care, and C&R will continue to dedicate itselfto bringing you news of exciting develop-ments in this field.

I hope that new and returning readers alikefind these topics stimulating and use thematerial to foster new relevant ideas. We wel-come readers’ input so please contact me, orthe C&R Managing Editor, Emily Butcher, [email protected], with your commentsand suggestions.

“The field of rehabilitation is rapidly improvingwith the use of virtual reality, handhelds andmobile health services...”

Create your own reality!Brenda Wiederhold

2

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Professor Brenda K. WiederholdPh.D., MBA, BCIAEditor-in-ChiefC&R MagazineBelgium

Professor Rosa M. Baños, Ph.D.University of Valencia Spain

Professor Cristina Botella, Ph.D.Universitat Jaume ISpain

Professor Stéphane Bouchard, Ph.D. Universite du Quebec en Outaouais (UQO)Canada

A.L. BrooksAalborg UniversityDenmark

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Professor Luciano Gamberini, Ph.D.University of PadovaItaly

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

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Professor Paul Pauli, Ph.D.University of WürzburgGermany

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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

C&R Editorial BoardGENERAL INFORMATION

CyberTherapy & Rehabilitation Magazine

ISSN: 2031-278

GTIN-13 (EAN): 9771784993017

CyberTherapy & Rehabilitation Magazine is published quar-

terly by the Virtual Reality Medical Institute (VRMI), 28/7

Rue de la Loi, B-1040 Brussels, Belgium. The magazine ex-

plores the uses of advanced technologies for therapy, train-

ing, education, prevention, and rehabilitation. Areas of

interest include, but are not limited to, psychiatry, psy-

chology, physical medicine and rehabilitation, neurolo-

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disorders, and autism, among many others.

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

mation presented in advertising portions of this publication.

EDITORIALp 1

COVER STORYNew Mobile Platforms Launch iRehab ApplicationsL. Kongp 6

PRODUCT COMPARISON CHARTHandhelds and Mobile Health Servicesp 10

FEATURESInteractive Mind-Driven RehabilitationD. Jianhuap 12

The Decade of the Handheld: Optimizing Outcomes forthe Handheld GenerationL. Jacksonp 13

Virtual Reality in Eating Disorders and ObesityG. Riva, E. Molinarip 16

VR Lab Provides Relief for Warriors and Their FamiliesM. Stetz, R. Ries, R. Folenp 19

Transcranial Doppler Monitoring in Presence ResearchB. Rey, M. Alcañiz, V. Parkhutik, J. Temblp 21

Surgery Simulation: A Training Tool for the FutureS. Jia, Z. Panp 23

COUNTRY FOCUSSouth KoreaE. Butcherp 28

TABLE OF CONTENTS

3

Handheld Devices

The rate with which the healthcare industryis turning to handhelds is growing rapidly.With iPhone applications becoming morewidespread and accessible, healthcare com-panies are turning to these tiny computersand other handheld devices to launch newforms of communication and informationfor both physicians and patients.

Interactive Rehabilitation

The applications of virtual reality in rehabili-tation offer a new and exciting field of re-search. Existing studies have proved promis-ing effects can be achieved by engagingpatients in interactive rehabilitation. The im-mersion and presence felt in virtual environ-ments encourage users to fully participate inthe experience, yielding better results whenapplied to rehabilitation patients.

International Association of CyberPsychology, Training & Rehabilitation (iACToR)

Conference Participation Report Summer/Fall 2009

4

HSI 2009: Conference on Human System InteractionCatania, Italy / May 21-23, 2009

iACToR and JCR Board Members participated in theHSI 2009 Conference on Human System Interaction.Professor Luciano Gamberini chaired the session onTelemedicine and eHealth. In this session, ProfessorsJosé Gutiérrez Maldonado and Mariano Alcañiz alsogave presentations. Professors Andrea Gaggioli andGiuseppe Riva chaired the session on Positive Technol-ogy. Additional speakers included Professors CristinaBotella and Rosa Baños.

Topics discussed during the conference included hu-man machine interaction, enabling technology for re-mote system interaction, human system interactionsin transportation, and control system resilience.

For further information, please visit:http://www3.unict.it/hsi09/

and Treatment ConferenceOrlando, Florida, U.S.A./ May 28-30, 2009

In late May 2009, the MT3 conference assembledprestigious speakers, exhibitors and two workshopsto showcase innovative healthcare technologies,training and treatment. The Medical Technology,Training and Treatment conference brings togetherleading physicians, health care providers, technolo-gists, educators and industry leaders to stimulatediscussion about current and evolving medical dis-coveries, training and education. In 2009, MT3, inpartnership with the University of Central Florida,offered CEUs. In 2010, in partnership with the Amer-ican College of Surgeons, the conference will offerCMEs (in addition to the CEUs offered by UCF). Con-ference attendees will hear discussions about tech-nological advancements; discuss changes in residenttraining requirements; robotic developments; gamesfor health; and procedures to improve patient safe-ty and quality of care. The purpose of the conferenceis to improve 21st century medicine. Plan now to par-ticipate in MT3 2010 May 6-8 in Orlando, Florida.

For further information, please visit:http://www.mt3.bz.

MT3: The Medical Technology, Training

Beyond Brain Machine Interface: Motor, Cognitive, VirtualMinneapolis, Minnesota, U.S.A. / September 2, 2009

The Interactive Media Institute, along with conference chair Dr.Brenda Wiederhold, organized this scientifically rigorous one-daysymposium on Non-Manual Control Devices, which brought to-gether eminent experts working to offer a more efficient and in-tuitive way of achieving system control than manual manipula-tion, and allowed for discourse and product exhibition amongacademics, members of the scientific community, biomedical de-vice engineers, and the clinician user community The scope ofthe conference was general in nature to focus on the interdisci-plinary fields of biomedical engineering and included presenta-tions on imaging, biosignals, biorobotics, bioinstrumentation,neural rehabilitation, bioinformatics, healthcare IT, and medicaldevices.

This symposium also served to advance the Army Research Of-fice’s mission as the premier extramural basic research agencyin the engineering, physical, information, and life sciences. Theone-day workshop was co-located with the September 3-6, 200931st Annual International Conference of the IEEE Engineering inMedicine and Biology Society (EMBS), which attracts 2,000 atten-dees from 50 countries.

For further information, please visit:http://www.interactivemediainstitute.com/

RehabilitationFrom Basics to FutureValencia, Spain / October 15-16, 2009

Seeing the need to strengthen the collaboration between tech-nical and health related disciplines, the International Sympo-sium on Neurorehabilitation: from Basics to Future was heldin Valencia, Spain and was co-chaired by Professor Mariano Al-cañiz. The main purpose of the Symposium was to bring togeth-er engineers, researchers and health care professionals to shareideas and experiences with the aim of creating a "common lan-guage" that will help to increase the efficacy of the neuroreha-bilitation process and to improve the quality of life of patients.

For further information, please visit: http://www.serviciodc.com/

International Symposium on

The 14th Annual CyberTherapy & CyberPsychology Conference(CT14) co-organized by Professor Brenda K. Wiederhold from theInteractive Media Institute and Professor Giuseppe Riva of the Is-tituto Auxologico Italiano, took place in June 2009 in Verbania, apicturesque location on Lago Maggiore, Italy. CT14 was hosted inVilla Caramora, a historical building owned by Istituto AuxologicoItaliano, and attracted researchers from 27 countries around theworld. According to Alessandra Gorini, the Conference Coordina-tor, “it was a great international success that brought together re-searchers, clinicians, policy makers and funding agents to shareand discuss advancements in the growing disciplines of cyberpsy-chology, cybertherapy, training and rehabilitation.”

Under the direction of Professor Stéphane Bouchard, WorkshopChair, CT14 kicked off with pre-conference workshops on Sundaythe 21st of June, which focused on multiple aspects of cyberther-apy from introduction classes to specific uses for virtual reality(VR) and other advanced technologies such as treatment of Post-traumatic Stress Disorder, brain computer interface, presence, cog-nitive and motor rehabilitation and VR for the treatment and pre-vention of anxiety disorders.

The conference officially began on Monday the 22nd of June, withwelcome remarks from the Conference Chairs, Professor BrendaK. Wiederhold and Professor Giuseppe Riva, followed by the fasci-nating keynote lecture entitled “Advances in Technology for Cy-bertherapy” by world-renowned speaker Dr. Richard Satava.

Monday’s program included three plenary sessions and an expertpanel discussion coordinated by Professor James Spira on the fol-lowing topics: advances in telehealth experiences, VR and pain,VR and the brain, and future directions in the technological ad-vances in prevention, assessment, and treatment for military de-ployment mental health.

Tuesday’s events included eight parallel sessions whose topicswere: VR for the treatment of anxiety disorders, cognitive andspatial assessment and rehabilitation, interventions for the treat-ment of addictions, the treatment of posttraumatic stress disor-der, virtual online interactions and the psychology and psy-chopathology of the web. The conference was closed by the generalassembly of the International Association of CyberPsychology,Training, & Rehabilitation (iACToR) coordinated by Secretary Gen-eral Brenda K. Wiederhold and presided over by President Christi-na Botella.

One of the most attractive and innovative events of the confer-ence was the “Cyberarium and Cyberfashion for Well-being” thattook place at lunch time on the 22nd in the main hall of VillaCaramora. As in the previous CyberTherapy conferences, the Cy-berarium represented a high-profile event open to the press, which

showcased the most advanced interactive exhibits and researchand drew a substantial crowd. The “Cyberfashion for Well-being”event included a fashion show of the most innovative wearabletechnologies that are becoming part of the everyday fabric of so-ciety. These wearables are allowing patients access to continuousmonitoring as well as allowing individuals who want to preventdisease to monitor their own health status.

The conference ended with a social dinner on the lake and anawards ceremony honoring those who have excelled in the fieldof cybertherapy.

Three categories of awards were given for outstanding achieve-ments in CyberTherapy:

–The 5th Annual CyberTherapy Excellence in Research Award –The Annual CRC-Clinical Cyberpsychology New Investigator Awardfor a presentation of outstanding research quality–Four student poster awards

The 15th Annual CyberTherapy & CyberPsychology Conferencewill take place in Seoul, Korea on June 13-15, 2010. Professor Bren-da K. Wiederhold and Professor Sun Kim of Hanyang Universitywill serve as Co-Chairs.

For more information on the conference, please visit the Interac-tive Media Institute’s Web site at www.interactivemediainstitute.com..or e-mail the CT15 Conference Coordinator James Cullen at [email protected].

5

June 22-23, 2009Lago Maggiore, Italy 14th Annual CyberTherapy &

CyberPsychology Conference

The main hall of the Villa Caramora (ground floor) and the theposter exibition (first floor).

There is no doubt that the wireless revolu-tion has had a remarkable impact on soci-ety and people worldwide. Inevitably, thistechnological trend has found itself becom-ing an essential progression and is rapidlyspreading through the medical sector. Mo-bile Healthcare, commonly known asmHealth, is a term used to describe health-care services provided by mobile commu-nications and wireless technologies. Exploit-ing technologies such as mobilecomputing, medical sensors, and wirelesscommunications, mHealth provides cost

effective, easily accessible and overall bet-ter solutions for rehabilitation efforts. Byallowing healthcare professionals, hospitals,and patients to interact on a more real-timebasis, mHealth is dramatically changing andimproving healthcare communications inrehabilitation therapy, training, and edu-cation.

Key Drivers

Value Proposition: Conscious of the valueproposition and future of this emergingtechnology, large business corporations arejumping on board with mHealth healthcareservices. High profile companies such as GEand Intel, UnitedHealth Group, Cisco, QUAL-COMM, and many others are investing andlaunching products that help drive the nextwave of wireless and mobile healthcare tech-nology innovations. To provide better com-munication between patients and health-care providers Microsoft’s HealthVault allowspatients to store their healthcare informa-tion in one convenient location, PhilipsHealthcare’s wireless handheld devices of-fer patients in-home medical care servicesand GE’s QuietCare gives seniors a moni-toring system that signals emergency situ-ations to their healthcare providers. Various

efforts are being undertaken to meet thedemand of mHealth and many are joiningtogether in collaboration. For example, theWireless-Life Sciences Alliance is an organ-ization that puts innovators and wirelesshealth companies together with global lead-ers in healthcare and technology to accel-erate business opportunities.

Patients: For many rehabilitation patients,the cost of physically traveling to a hospi-tal for routine check-ups and services is es-calated by their conditions and preventsthem from getting needed treatments.Those with chronic conditions want to haveaccess to quality healthcare services at theconvenience of their own homes. By pro-viding wireless tools for better patient careat home, healthcare professionals will en-hance their management of ill patients withchronic conditions. According to The De-partment of Health and Human Servicesof the United States, 60% of individuals be-low the age of 65 have at least one chron-ic condition. As for the senior populationover 65 years of age, about 77% have twoor more chronic conditions. The amountof resources spent on chronic disease careaccounts for an unnecessarily large propor-tion of healthcare expense in the

6

New Mobile PlatformsLaunch iRehabApplicationsmHealth is a term used to describe healthcare services provided by mobilecommunications and wireless technologies utilizing technologies such asmobile computing, medical sensors and wireless communications. mHealthprovides cost effective, easily accessible and overall better solutions for reha-bilitation efforts.

COVER STORY

By Lingjun Kong

Figure 1: Cell phones have become anintegral tool in mobile health.

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

5

US–about 90% of the gross domestic prod-uct. The growing number of patients andlarge amount of expenses spent towards theirtreatments makes the convenience oftelecommunications vital.

Doctors: Doctors view the wireless capabili-ties of mHealth as a way to improve treat-ment for all patients. mHealth provides physi-cians with upgraded tools to treat patients.With wireless technology at their fingertips,they are better equipped to manage and di-agnose patients to prevent disease. Doctorsfavor these improvements in mHealth thatallow them to provide treatments and serv-ices and efficiently meet overwhelming de-mands from patients.

Innovators: Because the mHealth is a rela-tively new field, it provides many frontiersfor researchers to explore and attracts manyresearchers who want to improve it. To theseinnovators, mobile technology offers chal-lenges for them, pushing them to take theexisting technologies to the mobile level.

Applications

Innovations in wireless and mobile healthcarehave grown surprisingly fast. By allowing real-time interaction between clinicians and pa-tients, mHealth is enabling a shift in health-care communications. Many forms of mobileapplication have existed in the medical sec-tor such as patient scheduled doctor visits,access to copies of patient medical records,remotely monitored patient data and loca-tions of appropriate hospitals based on re-quirements, rating etc. Presently, a wave ofwireless applications is surging including vitalsign monitoring devices that can track weight,blood pressure, heart rate, and pulse oxime-try and home health gateways that help bridgepatients' homes and healthcare providers.From the intricate high-end technologies tothe simple free application on the iPhone,mHealth is spreading to both professional andcasual users. Moreover, mobile devices are ca-pable of playing a key role in remote manage-ment of patients with rehabilitation condi-tions. Patients can collect data from biometric

devices at remote locations and upload andsend the physiological data to their physicianswhere it could be electronically monitored.Physicians can then evaluate the data andtake action when necessary.

iMAT, Mental Armor Training, is a mobile neu-ropsychological training program that servesto enhance soldiers' abilities to form accurateinterpretations of the events they experienceduring deployment and in everyday life. Theapplication permits users to complete a se-ries of exercises designed to improve judg-ment during stressful situations. The programprovides different levels, each asking the userto apply their training to personal experiences.iMAT takes advantage of mobile platformsduring overseas deployment to aid in thestudy of U.S. Army National Guard to deter-mine appropriate physiological and cognitiveinterventions.

CardioNet, a mobile cardiac telemetry tech-nology provides ambulatory, continuous, real-time outpatient management solutions for

7

patients with cardiopathy. It utilizes wire-less medical technology to provide aportable wireless monitoring device to keeptrack of patients’ heartbeats 24 hours a dayfor an extended period of time. CardioNet'sinitial efforts are focused on the diagnosisand monitoring of cardiac arrhythmias orheart rhythm disorders, with a solutionthat markets it as Mobile Cardiac Outpa-tient Telemetry MCOT™. The newer en-hanced version allows physicians to accessmore in-depth data to better diagnose atri-al fibrillation, abnormal beats, and ventric-ular tachycardia (a potentially dangerousfast heartbeat). With the trended heart ratedata provided by MCOT™, physicians areable to make clear and efficient clinical de-cisions to their patients based off this nor-mally unattainable data at the hospital.

The Power of the Cell Phone

The mobile phone has become the mostfavored platform for innovation in the med-ical sector. With 4-billion total mobile sub-scribers, cell phones are not only growingin popularity, but also in computing capa-bilities. New features are added everydaymaking the cell phone a diverse personal-ized miniature computer. The inventionsof medical professionals and researchersare turning the cell phone into a mobilehospital.

Platforms (Devices): From the mature plat-forms such as Symbian, BREW and Win-dows Mobile, to the current dominators ofthe mobile applications such as Androidand iPhone, cell phone platforms have pre-sented a diverse environment available tomedical researchers (see Table 1).

Android: Growing at a rapid pace, Androidis a hot phone platform built on top of theLinux kernel, and has come a long way ina relatively short time. Although at an ear-ly stage of its life, Android will certainly havea dominating presence in the near future.Launched in November 2007, Android,owned by Google, and now under the con-trol of the Open Handset Alliance (OHA),promotes a free open-source operating sys-tem based on Linux for mobile devices. Asthe only full-stack free open source oper-ating system, opening access to all levelsof the operating system, Android offersthird party developers opportunities towrite applications in Java programming byutilizing Android API. Compared to otherplatforms, it not only is able to access themultitude of Google applications, but alsodoes not require re-development for port-ing among different cellular devices. A sig-nificant feature that differentiates Androidfrom the iPhone platform is that Androidofficially supports background processesin third-party applications.

iPhone: With its numerous applications,the iPhone has become a householdname even in the medical world. Current-ly, no other phone can compare to its pow-erful distribution channel and social im-pacts to influence millions of everydayconsumers and clinicians. From casualwidgets, such as a drug interactive check-er, clinical reference tools, medical news,and contact information for physicians,pharmacies and hospitals, to more sophis-ticated services such as a stethoscope, agame to diagnose diseases and an emer-gency radio, patients and doctors are en-joying these interactive tools at their con-venience. The iPhone has not only evolvedinto more than a consumer electronicsdevice due to its attractive interface, ap-plications marketplace, and consumer ap-peal, it has also been heavily integratedinto the medical field via high resolutionmedical images and various software ap-plications.

Challenges

Mobile technology in the healthcare fieldis still in an early stage and requires a se-lection of hardware upgrades, such as ul-tra-low power usage, computation, andcommunication for overall extended bat-tery life. However, the main issues revolvearound security, interoperability, and regu-latory compliance areas.

Security: The privacy of patients’ data be-comes a pressing issue in the developmentof mHealth technology. Since most casu-al services only offer a username-passwordcombination to access sensitive data,many users are cautious about giving awaythe needed information that is requiredof them. The relative ease of leaking per-sonal information, including identificationand medical histories, makes the need ofwell-regulated security policies extremelyimportant as mHealth continues to pro-liferate.

Interoperability: Due to its fast growth andrelatively new technologies, mHealth serv-ices do not boast interoperability, mean-ing services provided by one platform maynot be understood or transferred to serv-ices offered by another. Medical devices arefrequently not configured in the same wayby the device vendors and as they are bythe network infrastructure. Although cel-lular, Blue-Tooth, and Wi-fi standards havebeen well-established, developing tech-nologies are constantly shifting and stan-dards will take time to become concrete.

8

COVER STORY

Table 1: Platforms

Symbian BlackBerry (RIM) iPhone OS Android Windows Mobile BREW

Unique Feature Low-Power, FastResponse Time

Push Email, QWERTY Keyboard

Long Battery Life,Accelerometer

Full Stack FreeOpen Source

EasySynchronization

Disable/Restore

Programminglanguage

C++, Java ME Java Objective C Java C++ C/C++

Multitasking Yes Yes No Yes Yes Yes

Security Symbian SignedCertificate

Triple DES, AESEncryption

Device RemoteWipe

MandatoryAccess Control

(MAC)ActiveSync,

Remote WipeMulti-level

App. Signature

DevelopmentPeriod

Slow Fast Fast Fast Medium Slow

Release Time June 1998 April 1999 March 2008 Oct. 2008 June 2003 Sept. 2001

IntegratedDevelopmentEnvironment

Carbide C++ Blackberry JDE XCode Eclipse Plug-in Visual Studio Visual Studio


Active rehabilitation is a new but widelyrecognized solution for patients with neu-rological disorders. In active rehabilita-tion, patients perform actively in trainingtherapy to ensure the optimal rehabilita-tion outcome. The key of the solution liesin the active initiation and execution of

movements of the limbs by highly inten-sive training in meaningful environmentsin order to achieve optimal recovery.Amongst the various approaches of ac-tive rehabilitation, the idea of “mind-driv-en” rehabilitation is very new. In the“mind-driven” approach, a user controls

an actuatorwith his/herthoughts sothat the patientis trained withtheir own inten-tion mostly fo-cused on thet r a i n i n gprogress, thusgaining a betterrecovery.

To realize“mind-driven”more effective-ly, an interactiveuser interface isessential. Virtu-al Reality (VR) isone of the bestchoices for itsinteractive com-ponents and va-

riety, both in motor function restorationand in space and cognitive ability recov-ery training. First, research indicated thatpatients could modulate operations, suchas moving, grasping and releasing virtualobjects, through visual, auditory, tactileand olfactory feedback in virtual environ-ments. Distinct improvements of handdexterity and movement control abilityare detected after training. The move-ment skills patients picked up in the vir-tual environments will be retained in thereal-life world. Second, a 3D interactiveimmersive environment provided by VRinspires and maintains training motiva-tion. Last but not least, introduction ofVR in rehabilitation helps establish on-line feedback and real-time quantitativeestimation of function restoration.

Currently, Qiushi Academy for AdvancedStudies of Zhejiang University (QAAS,Hangzhou China) is building an interac-tive mind-driven rehabilitation system.In order to achieve the goal of optimal re-habilitation, three components are need-ed to make the “interactive,” “mind-driv-en” system fully functional–userintention decoder, interactive environ-

Interactive Mind-DrivenRehabilitationBy Zheng Xiaoxiang

continued on page 12

Regulatory compliance: To regulate the floodof new medical services in mHealth, the Fed-eral Communications Commission (FCC)and the Food and Drug Administration(FDA) claim jurisdiction over mobile devicesin healthcare. The FCC must approve all up-coming mobile devices before they can bereleased; while the FDA must approve allmedical devices before entering the mar-ket. Other healthcare regulations, such as

HIPPA, also need to be taken into consider-ation during any deployment of mHealthdevices.

Regardless of the challenges facing it, thenumerous opportunities and medical ben-efits that the mobile platforms offer will berefined and will provide many advantageoussolutions to doctors and patients. The newplatforms are significantly shifting and im-

proving the quality, convenience and acces-sibility of healthcare.

9

[ ]Lingjun Kong, M.S.Virtual Reality Medical [email protected]

The combination of virtual realityand Brain-Computer Interface hasdemonstrated a new future for reha-bilitation. With the development ofthese technologies, rehabilitationtraining will be more controllable.

Figure 1: A subject uses a VR system to actively engage in rehabili-tation. The combination of VR and Brain-Computer Interface has demon-strated a new future for rehabilitation.

DEVICE

HouseCallPlus

Epocrates

iMAT-Mental Armor

Training

mCare

CardioMEMS wireless HF

sensor

Caalyx AAL

Cardiomessenger

QuestCare360

Mobile Cardiac Outpa-

tient Telemetry (MCOT)

Skyscape Medical Re-

sources

Health Hero

Quiet Care

VR Pain Management

System

Implanted glucose

monitor

iStethoscope Pro

DESCRIPTION OF PRODUCT

remote patient monitoring system

provides drug information on drug interactions, pill identification,

peer-reviewed disease management content for on-site diagnosis

enhances soldiers' abilities to form accurate interpretations of the

events they experience during deployment and in every day life

mobile application that facilitates two-way communication with doc-

tors and patients-report changes in mood swings/sleeping behaviors

miniature implantable sensors use radiofrequency to transmit patient

data to help manage congestive heart failure

prototype consisting of mobile roaming monitoring system and a care-

taker center; monitors vital signs at all times, alerts to falls

external device resembling cell phone receives data from an implant-

ed device and forwards information to service center

HIPAA-compliant e-prescribing drug applications, users can view med-

ication history, lab results etc. on the go

cardiac monitoring service with beat-to-beat, real time analysis, au-

tomatic arrhythmia detection and wireless ECG transmission, transmits

data directly from patient to physician to constantly monitor the heart

mobile medical information and decision support tools, drug guide,

medical calculator, information on disease symptoms and topics

telehealth platform to support remote health monitoring and man-

agement programs

remote monitor system for seniors, alerting caregivers to changes that

may signal potential health issues or emergency situations such as a

fall or emerging health problem

virtual reality pain distraction system consisting of software products

with novel stimuli that guide patients to reduce pain and anxiety

discreet, long-term implanted monitor with alerts and alarms de-

signed to wirelessly deliver continuous glucose measurements

phone works as stethoscope to gauge heartbeat, help to diagnose

problems and potential abnormalities in heartbeat

MANUFACTURER

St. Jude Medical

iPhone application

iPhone application/Virtual

Reality Medical Center

AllOne

CardioMEMS, Inc.

Caalyx

BIOTRONIK

iPhone application

CardioNet

iPhone application

Bosch

GM

Virtual Reality Medical

Center

MicroCHIPS

iPhone application

With the growing popularity of theiPhone, more and more consumers arebeing exposed to the mobile healthworld. Handhelds and mobile healthservices have the ability to revolution-

ize the way we view and practice health-care. With new products and softwareliterally at their fingertips, patients anddoctors alike can benefit from the waysin which care will become more stream-

lined and efficient. From a simple textmessage reminder for medication to animplanted device delivering pre-meas-ured doses of a drug, the possibilitiesin this field are endless.

10

Product Comparison Chart:Handhelds and Mobile Health Services

PRODUCT COMPARISON

ment and actuator. An interactive envi-ronment is the key to the system in thatit’s the platform where rehabilitationtraining takes place, the user intentiondecoder detects the user’s subjective in-tention and interprets it into control sig-nals and the signals are then fed into theactuator to improve patients perform-ing. QAAS chose to use Brain-ComputerInterface (BCI), VR and functional elec-trical stimulation (FES) as the above-mentioned three components respec-tively.

VR as the interactive environment pro-vides two things–one is a supervisorwhich indicates the training task the userneeds to conduct, the other is the real-time feedback of the current status ofthe body part being trained. The currentmotion is picked up by sensors in theform of a goneometer, accelerometer,data glove or cameras. A VR platformsends online data of movement statusto FES so it can adjust assistant intensi-ty and pattern accordingly. In the mean-time, VR records the user’s performancestatistics during the whole training ses-sion for rehabilitation evaluation. BCI inQAAS’ system is used to detect the user’smovement-related brain signals fromscalp Electroencephalogram (EEG). Con-sidering the fact that patients’ EEG couldbe different from healthy people (espe-cially in the case of stroke-afflicted pa-

tients), the BCI is designed to detect notonly the EEG components related to mo-tion activity, but also the planning oreven mind intention for non-specificmovement. The FES system, the actua-tor, conducts activities initiated by thecommands from BCI and adjusted byfeedbacks from VR.

In training, motion targets appear ran-domly in the VR interface, toward whichpatients are supposed to move the limb.After the BCI detects that intention, itstarts the FES system to assist the limbmovement. The interaction loop be-tween VR and FES would insure an ac-

curate adjustment of this movement andhelp patients reach toward the target.Once the difference between real move-ment and intended task reaches belowa threshold, a round of training is con-sidered to have been accomplished. Thisprocess repeats itself during the wholetraining session.

The ultimate aim of this technology isto enable patients to use their own mindwith the help of actuators via enhancedVR to play games, cook, learn and liveon their own. The combination of VRand BCI has demonstrated a new futurefor rehabilitation. With the developmentof these technologies, rehabilitationtraining will be more controllable. Thefamous movie “Matrix” shows us a dis-tant (but not remote) future of BCI. To-day we can use VR and some actuatorequipments such as FES to realize thewishes of the brain. Patients no longerneed to go to hospital for rehabilitationtraining. Rather they can easily finish allthe work at home with the help of a per-sonal computer. Drawing on the advance-ment of the Internet, people will be ableto build a community of virtual rehabil-itation online, and those who have un-fortunately lost self-care abilities can re-gain them through interactivemind-driven rehabilitation. VR, BCI andother technologies possess infinite pos-sibilities for rehabilitation.

12

[ ]Zheng Xiaoxiang, Ph.D.Zhejiang UniversityP. R. of [email protected]


FEATURES Interactive Mind-Driven Rehabilitation

You see them here. You see them there. Itseems you see them everywhere. Some-times they’re held against the ear, some-times they‘re attached to it. Sometimesthey’re held at arm;s length, which seemsto trigger rapid activity in both thumbsagainst a tiny keyboard. Other times hold-ing them at arm’s length seems to focus theuser’s attention on the tiny little screen theypossess, often evoking emotional reactionsto what is happening on that screen. Somecan take pictures and save them for you.Some can help you find your way aroundtown. Most make noises¬–funny noises,pleasant noises and downright irritating nois-es. These noises often cause others to lookaround with annoyance for the source ofthe noise, making clear by facial expressionalone that the noise is unwelcome andshould be stopped, immediately. Welcometo 2010. Welcome to the decade of the cellphone, text messenger, iPod, blackberry orany one of a number of devices we will col-lectively call in this article the “handheld.”

What do we know about handhelds? Judg-ing from a Google search entering the word“handhelds” on December 20, 2009, we ap-parently know quite a lot–12,800,000 Websites deal in one way or another with hand-helds. A mere 9,500,000 deal with cellphones. On the other hand, if we search psy-chological literature for professional researcharticles such as PsychINFO with the word“handheld,” that number plummets to 14.Change the target word to “cell phones” andwe’re a bit better off. Sixty-one research ar-ticles address cell phone effects. Thus, weare sorely in need of research on the psy-chological effects of using handhelds, whichinclude their social, cognitive, moral and be-havioral effects. Our knowledge of the psy-chological effects on children, the sure-to-be handheld generation, is abysmallylimited.

A brief look at the statistics on handheldsprompts urgent questions about their psy-chological effects. In June 2009, wireless pen-

etration reached 89% of all U.S. households,compared to 34% in June 2000. Accordingto the Wireless Association, a professionalorganization that has tracked wireless activ-ities for the past 25 years, the annualizedtotal wireless revenues in 2009 was $151.2billion compared to $45.3 billion in 2000.Monthly SMS (short message system) activ-ity, commonly known as text messaging, in-creased from 12.2 million in 2000 to 135.2billion in 2009. Corresponding to thischange, the annualized minutes of cellphone use increased from 194.95 billion in2000 to 2.23 trillion in 2009.

The shift to wireless technology is not a U.S.phenomenon. It is a global trend evident inall of the developed world and in much ofthe developing world. More and more appli-cations that once required a clunky comput-er or portable but heavy laptop are migrat-ing to the handheld world. Already thehandheld has encompassed the most pop-ular information technology (IT) applications

13

The Decade of theHandheld:Optimizing Outcomes

for the Handheld

Generation

By Linda A. Jackson & Alex Games

FEATURES

14

FEATURES The Decade of the Handheld

for adults–the Internet and e-mail. Hand-helds began as cell phones, which remainstheir primary use, but text messaging (SMS)is increasing by leaps and bounds, espe-cially among the under-30 crowd. Mostcell phones now also have cameras andmany have a global positioning system(GPS) that is as sophisticated as a stand-alone GPS. And much to the delight of theunder, under-30 crowd, the tweens or teensand young adults, videogames are quick-ly becoming part of the handheld world.For the right price you can indeed havethe world at your fingertips.

The two most studied IT applications ofgreatest interest to children that have mi-grated to the handheld world arevideogames and cell phones, including thetext messaging and picture-taking featuresof cell phones. Interdisciplinary teams ofresearchers have been addressing the ques-tion of what effects, if any, videogame play-ing and cell phone use have on children.Thus far, more progress has been made onvideogame effects than on cell phone ef-fects. Videogame playing in adults has beencausally related to visual-spatial skills andcorrelated with these skills in children. Vi-sual-spatial skills are viewed by many de-velopmental psychologists as the “trainingwheels” for later performance in science,technology, engineering and mathematics,however, stronger evidence exists for a neg-ative relationship between videogame play-ing and psychological outcomes. Childrenwho play videogame more have more ag-gressive cognition, aggressive behavior,poorer academic performance, more neg-ative teacher ratings of classroom behav-ior and greater body weight than a com-parable sample of non-players. To date, nodistinctions have been made in the litera-ture as to whether the mode of videogamedelivery is over the Internet, through a con-sole or by way of a cell phone, although thecommercialization of videogames suggeststhat the console is currently the most pop-ular mode of videogame delivery.

Conspicuously absent in the developmen-tal and IT literature is research on cell

phone correlates and effects on children.As of 2007, the global cell phone marketcontained approximately 1.8 billion sub-scribers. It is forecasted to reach three bil-lion by the end of 2010, at which timenearly half of all human beings on earthwill have and use a cell phone. Althoughvoice calls currently account for about 80%of cell phone revenue, the short messageservice (SMS), or text messaging, is becom-

ing extremely popular, particularly amongthe under-30 crowd. In fact SMS is expect-ed to dominate mobile messaging in bothtraffic volume and revenue by the end ofthis decade. SMS is a favored mode ofcommunication among youth who haveaccess to cell phones

The lack of research on cell phone use ef-fects on children may be partly attributa-ble to its lower adoption by this age groupthan other forms of IT such asvideogames, but the age at which childrenreceive their own cell phones keeps drop-ping and the time to ascertain effects,good or bad, is now. On the positive side,cell phones used as communication de-vices have the potential to increase socialconnectedness and even improve parent-child relationships with the responsibleuse of the cell phone by both. On the neg-ative side, there is the potential for cellphone use to increase social isolation asmore and more time is devoted to textmessaging and less and less time to face-to-face interaction, with family, friends andacquaintances. The effects of videogameavailability on cell phones raises yet an-other set of important research questionsin child development. The benefits andliabilities of the handheld vidoegame may

depend on child characteristics and per-haps even parent characteristics, whichwill need to be clarified in future research.At this time the best that can be said forcell phone use is that it facilitates socialconnections, including connections withparents, which may outweigh any nega-tive effects in face-to-face social commu-nication. Indeed, some research showsthat youth use cell phones primarily toconnect with existing real-world social net-works to strengthen connections amongmembers.

Handhelds are not the way of thefuture–they are here now and here to stayuntil the next wave of technology innova-tions renders functions too slow, too de-manding or simply inadequate. What weneed to do now for children of the hand-held generation is to determine how tomaximize the good and minimize the badpotential effects that come with everytechnology innovation. The ease and en-joyment with which children use hand-held devices begs for research on the de-velopment of games that foster learning,especially learning in science, technolo-gy, engineering and mathematics (STEMareas). A newborn, an infant, a toddler anda preschooler learn by playing. Why shouldit be otherwise in the K-12 child. We andour colleagues, Jing Lee, at Syracuse Uni-versity, and Yong Zhao, also at MichiganUniversity, intend to experiment withlearning STEM areas wrapped in nanotech-nology concepts using handheld devicesprogrammed to resemble computergames. Our hope is that learning will beas natural an outcome of playing as it isin the early years, when we learn an en-tire language, categorization and social-ization, among other complex concepts.We would like to encourage others to joinin the search.

[ ]Linda Jackson, Ph.D.Alex Games, Ph.D.Michigan UniversityU.S.A.

[email protected]

What we need to do now forchildren of the handheldgeneration is to determinehow to maximize the goodand minimize the bad poten-tial effects that come withevery technology innovation.

FEATURES

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Different new technologies have been in-troduced over the last few years that areincreasingly finding application in healthcare delivery for patients with eating dis-orders and obesity. These include self-help(supervised and unsupervised), telemedi-cine, telephone therapy, e-mail, Internet,computer software, CD-ROMs, portablecomputers, and virtual reality techniques.One of the most promising is virtual real-ity (VR), an advanced form of human-com-puter interface that allows the user to in-teract with and become immersed in acomputer-generated environment in a nat-uralistic fashion.

Distorted body image, negative emotionsand lack of faith in the therapy are typicalfeatures of these disturbances and are themost difficult characteristics to change.One innovative approach to their treat-ment is to enhance traditional cognitive-behavioral therapy (CBT) with the use ofvirtual reality.

A first approach is the one offered by theExperiential Cognitive Therapy (ECT). De-veloped by Giuseppe Riva and his group in-side both the IVT2010 Italian Governmentfunded project and the VEPSY Updated Eu-ropean funded project is a relatively short-term, patient oriented approach that focus-es on individual discovery. IET shares with

the Cognitive Behavioral Therapy (CBT) theuse of a combination of cognitive and be-havioral procedures to help the patientidentify and change the maintaining mech-anisms. However it is different for:

Its use of Virtual Reality (VR): 10 VR ses-sions are part of the standard protocol.

Its focus on the negative emotions relat-ed to the body, a major reason patientswant to lose weight.

Its focus on supporting the empower-ment process. VR has the right features tosupport empowerment process, since it isa special, sheltered setting where patientscan start to explore and act without feelingthreatened.

During the VR sessions (see Figure 1) theyuse the “20/20/20 rule.” During the first 20minutes, the therapist focuses on gettinga clear understanding of the patient's cur-rent concerns, level of general functioning,and their experiences related to food andto the body. This part of the session tendsto be characterized by patients doing mostof the talking, although the therapist canguide with questions and reflection to geta sense of the patient's current status. Thesecond 20 minutes is devoted to the VRexperience. During this part of the session

the patient enters the virtual environmentand faces a specific critical situation suchas a kitchen, supermarket, pub, restaurantor gymnasium. Here, the patient is helpedin developing specific strategies for avoid-ing or coping with the negative emotionsinduced by the situation. In the final 20minutes the therapist explores the patient’sunderstanding of what happened in VRand the specific reactions–emotional andbehavioral–to the different situations ex-perienced. If needed, some new strategiesfor coping with the VR situations are pre-sented and discussed. To support the em-powerment process, the therapists followthe Socratic style–they use a series ofquestions related to the contents of thevirtual environment to help clients synthe-size information and reach conclusions ontheir own.

The different virtual scenes are included inan open source virtual environment–Neu-roVR–that can be downloaded for free fromthe NeuroVR Web site: http://www.neurovr.org.Using this software the therapist may alsocustomize each environment by adding sig-nificant cues such as images, objects, andvideo related to the story of the patient.

This approach was validated through dif-ferent case studies and trials. In the firstone, uncontrolled, three groups of patients

16

Virtual Reality in EatingDisorders and Obesity

FEATURES

By Giuseppe Riva & Enrico Molinari


This review describes how virtual exposure was used to improve the negativeemotions related to food and the body in subjects with obesity and eating disor-ders. With the aid of a therapist, they learned how to better deal with the nega-tive emotions and in turn, to develop healthier behaviors.

were used–patients with Binge Eating Dis-orders, patients with Eating Disorders NotOtherwise Specified, and obese patientswith a body mass index higher than 35.All patients participated in five biweeklysessions of the therapy. All the groupsshowed improvements in overall body sat-isfaction, disordered eating, and related so-cial behaviors, although these changes wereless noticeable in the Eating Disorders NotOtherwise Specified group.

More recently, the approach was tested indifferent controlled studies. The first one in-volved twenty women with Binge Eating Dis-orders who were seeking residential treat-ment. The sample was assigned randomlyto ECT or to CBT based nutritional therapy.Both groups were prescribed a 1,200-calo-rie per day diet and minimal physical activ-ity. Analyses revealed that although bothgroups were binge free at one-month follow-up, ECT was significantly better at increas-ing body satisfaction. In addition, ECT par-ticipants were more likely to report increasedself-efficacy and motivation to change.

In a second study, the same randomized ap-proach was used with a sample of 36 womenwith Binge Eating Disorders. The resultsshowed that 77% of the ECT group quitbingeing after six months versus 56% forthe CBT sample and 22% for the nutrition-al group sample. Moreover, the ECT samplereported better scores in most psychomet-ric tests including EDI-2 and body imagescores.

In the final study, ECT was compared withnutritional and cognitive-behavioral treat-ments, using a randomized controlled trial,in a sample of 211 female obese patients.Both ECT and cognitive-behavioral treat-ments produced a better weight loss thanthe nutritional treatment after a six-monthfollow-up. However, ECT was able to signif-icantly improve, over nutritional and cogni-tive-behavioral treatments, both body im-age satisfaction and self-efficacy. This changeproduced a reduction in the number ofavoidance behaviors as well as an improve-ment in adaptive behaviors.

A second approach was investigated bythe Spanish research group led by Cristi-na Botella. Her group compared the ef-fectiveness of VR to traditional CognitiveBehavior Treatment for body image im-provement (based on the protocol devel-oped by Cash) in a controlled study witha clinical population. Specifically, they de-veloped six different virtual environments,including a 3D figure whose body parts(arms, thighs, legs, breasts, stomach, but-tocks, etc.) could be enlarged or dimin-ished (see Figure 2). The proposed ap-proach addressed several of the bodyimage dimensions–the body could beevaluated wholly or in parts, the bodycould be placed in different contexts, forinstance, in the kitchen, before eating, af-ter eating, facing attractive persons, etc.,behavioral tests could be performed inthese contexts, and several discrepancyindices related to weight and figure couldbe combined such as actual weight, sub-jective weight, desired weight, healthy

weight, how the person thinks others seeher/him, etc.

In the published trial eighteen outpatients,who had been diagnosed as suffering fromeating disorders (anorexia nervosa or bu-limia nervosa), were randomly assigned toone of the two treatment conditions–theVR condition (cognitive-behavioral treat-ment plus VR) and the standard body im-age treatment condition (cognitive-behav-ioral treatment plus relaxation). Thirteen ofthe initial 18 participants completed thetreatment. Results showed that followingtreatment, all patients had improved signif-icantly. However, those who had been treat-ed with the VR component showed a sig-nificantly greater improvement in generalpsychopathology, eating disorders psy-chopathology, and specific body image vari-ables. Since then, the group has also devel-oped a VR simulator of food and eatingcurrently under evaluation with patients.A final approach was proposed by the Span-

17Figure 1: A patient undergoes experiential cognitive therapy.

FEATURES

ish research group led by Gutiérrez-Maldon-ado. This group investigated the emotionalpotential of food-related VR experiences witheating disordered subjects. In a first study,thirty female patients with eating disorderswere exposed to six virtual environments–aliving-room (neutral situation), a kitchen withhigh-calorie food, a kitchen with low-caloriefood, a restaurant with high-calorie food, arestaurant with low-calorie food, and a swim-ming-pool. After exposure to each environ-

ment the researchers evaluated the level ofstate anxiety and depression experiencedby the sample. In a recent study, the re-sponse to the same five experimental vir-tual environments plus a neutral room ina group of eighty-five eating disordered sub-jects was compared with a control group ofstudents. Results of several repeatedmeasures analyses demonstrated that pa-tients show higher levels of anxiety and amore depressed mood after exposure to

high-calorie food and after visiting theswimming pool than in the neutral room.In contrast, controls only show higher lev-els of anxiety in the swimming pool.

Overall, these results show that virtual envi-ronments are particularly useful for simulat-ing everyday situations that may provokeemotional reactions such as anxiety and de-pression, in clinical patients. Specifically, thevirtual experiences in which subjects were

18

FEATURES Virtual Reality in Eating Disorders and Obesity

Published studies related to the use of VR in obesity and eating disorders (source Medline, accessed November 17, 2009)

Ferrer-García M, Gutiérrez-Maldonado J, Caqueo-Urízar A, Moreno E., The Validity of Virtual Environments for Eliciting Emotional Responses in Patients With Eating Disorders and in Controls, Behav Modif. 2009 Oct 12. doi:10.1177/0145445509348056

Manzoni GM, Pagnini F, Gorini A, Preziosa A, Castelnuovo G, Molinari E, Riva G., Can relaxation training reduce emotional eating in women with obesity? An exploratory study with 3 months of follow-up, J Am Diet Assoc. 2009 Aug;109(8):1427-32.

Riva G, Manzoni M, Villani D, Gaggioli A, Molinari E., Why you really eat? Virtual reality in the treatment of obese emotional eaters, Stud Health Technol Inform. 2008;132:417-9.

Gutierrez-Maldonado J, Ferrer-Garcia M, Caqueo-Urizar A, Letosa-Porta A., Assessment of emotional reactivity produced by exposure to virtual environments in patients with eating disorders, Cyberpsychol Behav. 2006 Oct;9(5):507-13.

Emmelkamp PM., Technological innovations in clinical assessment and psychotherapy, Psychother Psychosom. 2005;74(6):336-43. Review.

Myers TC, Swan-Kremeier L, Wonderlich S, Lancaster K, Mitchell JE., The use of alternative delivery systems and new technologies in the treatment of patients with eating disorders, Int J Eat Disord. 2004 Sep;36(2):123-43. Review.

Riva G, Bacchetta M, Cesa G, Conti S, Molinari E., Six-month follow-up of in-patient experiential cognitive therapy for binge eating disorders, Cyberpsychol Behav. 2003 Jun;6(3):2

Perpiña C., Botella C., Baños RM., Virtual reality in eating disorders, European Eating Disorders Review 2003;11(3):261-278.

Lozano JA, Alcaniz M, Gil JA, Moserrat C, Juan MC, Grau V, Varvaro H., Virtual food in virtual environments for the treatment of eating disorders, Stud Health Technol Inform.2002;85:268-73.

Riva G, Bacchetta M, Baruffi M, Molinari E., Virtual-reality-based multidimensional therapy for the treatment of body image disturbances in binge eating disorders: a preliminary controlled study, IEEE Trans Inf Technol Biomed. 2002 Sep;6(3):224-34.

Riva G, Bacchetta M, Baruffi M, Molinari E. , Virtual reality-based multidimensional therapy for the treatment of body image disturbances in obesity: a controlled study, Cyberpsychol Behav. 2001 Aug;4(4):511-26

Perpiña C, Botella C, Baños RM, Marco JH, Alcañiz M, Quero S., Body image and virtual reality in eating disorders: Exposure by virtual reality is more effective than the classical body image treatment? CyberPsychology & Behavior 1999;3(2):149-159.

Riva G, Bacchetta M, Baruffi M, Rinaldi S, Molinari E.,Virtual reality based experiential cognitive treatment of anorexia nervosa, J Behav Ther Exp Psychiatry. 1999 Sep;30(3):221-30.

Riva G, Bacchetta M, Baruffi M, Rinaldi S, Molinari E., Experiential cognitive therapy in anorexia nervosa.Eat Weight Disord. 1998 Sep;3(3):141-50

Riva G. , Modifications of body-image induced by virtual reality., Percept Mot Skills. 1998 Feb;86(1):163-70.


FEATURES

19

forced to ingest high-calorie food induced thehighest levels of state anxiety and depression.

In conclusion, the data available on scientif-ic journals (see Table 1) suggest that VR canhelp in addressing two key features of eatingdisorders and obesity not always adequate-ly addressed by existing approaches–bodyexperience disturbances and self-efficacy. VRtechnology offers an innovative approach tothe treatment of body image disturbance, adifficult concept to address in therapy. Pre-viously, cognitive-behavioral and feminist ap-proaches have been the standard interven-

tions, although in our experience, it seemsthat many patients continue to struggle withnegative body image post-treatment.

Second, as emphasized by social cognitivetheory, performance-based methods are themost effective in producing therapeuticchange across behavioral, cognitive, and af-fective modalities. The proposed experien-tial approaches could help patients in dis-covering that difficulties can be defeated,so improving their cognitive and behavioralskills for coping with stressful situations re-lated both to food and to their body.

Finally, the papers published by the Gutiér-rez-Maldonado group suggest that VR maybe useful, too, for simulating everyday situ-ations to assess emotional reactions in clin-ical patients.

[ ]Giuseppe Riva, Ph.D.Enrico Molinari, Ph.D.Istituto Auxlogico ItalianoItaly

[email protected]@auxologico.it

The National Institute of Mental Health re-ports that over five million individuals in theUnited States suffer annually from stress. In2007, the American Psychological Associa-tion conducted a survey study. Specifically,many participants reported experiencingpsychological symptoms related to stress asanger (50 %), nervousness (45 %). low ener-gy (45 %), and wanting to cry (35 %). It is alsoestimated that stress in the form of post-traumatic stress disorder, for example, im-pacts 3-15% of deployed war fighters in-volved in the current conflicts. About oneout of every 10 veterans from Operation IraqiFreedom/ Operation Enduring Freedom(OIF/OEF) might suffer some type of stressdisorder. Coming back from the battle-zonewith a combat-stress diagnosis might facili-tate access-to-care and potential financial

benefits. In fact, astudy on OIF veter-ans suggested thatabout one-third ofthose that received care from 2001 to 2005were diagnosed with general mental healthor psychosocial problems. That said, beingdiagnosed with combat stress problems alsoinvolves a spillover of other problems thatimpact the readjustment to life out of thebattle-zone.

Mental Health help in the Battlezone

The U.S. military is currently a voluntary force.Some individuals join to follow a family tra-dition, to seek an adventure, to show patriot-ism, such as joining after 9/11, and even toavoid jail.

Nevertheless, the U.S. military can be a verystressful organization. It imposes rigid rulesand expectations. The rationale behind thismodus operandi is that, in the moment oftruth, an automatic “right” decision can makethe difference between life or death.

Psychotherapy can have positive outcomes fora war fighter, but also casts a shadow of nega-tive social outcomes. War fighters who experi-ence combat stress symptoms such as hyper-vigilance and nightmares end up without manyoptions. They can live in denial trying to avoidtheir worst memories, or seek help. If a warriorwants help, she or he will likely have to ask su-

VR Lab Provides Relief forWarriors and Their FamiliesTripler Army Medical Center Uses Next Generation Treatments for Stress and Pain

FEATURES

By Melba C. Stetz et al.It is estimated that 3-15% of deployed war fighters

involved in current conflicts are affected by posttra-

matic stress disorder. New studies show promising

signs that virtual reality may be able to help.

pervisors for time to see a doctor, makingpublic their inner feelings of vulnerability.

In the battle-zone, this truth can be evenworse. A war fighter identified as “havingmental problems” will probably have to beremoved from the battle-zone if not treat-ed on site. If treated on site, she or he mightrestricted from carrying a weapon. The in-dividual might be asked to do things differ-ently from peers, such as sleep in a specificarea under supervision, remove the boltfrom the weapon or other actions. In addi-tion to the potential stigma, getting psycho-logical help is a “luxury.” There are notenough mental health providers or vehiclesto take patients back and forth from ses-sions or meetings.

While deployed to OIF, the author, Stetz, sur-veyed deployed warriors to learn that theirpreferred forms of relaxation were listeningto music (65%), watching movies (62%), andplaying computer games (39%). In conso-nance with previous studies, these individ-uals reported preferring to chat with peers,chaplains, and military leaders about per-sonal difficulties rather than go to therapists.

Therapies for the Digital Generation ofWarriors

One of the preferred methods to help warfighters in distress involves cognitive-behav-ioral therapeutic approaches. A prized tech-nique is called “imaginal” exposure. Patientsrepeatedly imagine their worst traumaticevent(s) in therapy to habituate to the men-tal and emotional experience. The pairing ofautonomic arousal with recounting of stress-

ful memories is then followed by relaxation,with the hope that reduction of associatedpsychosocial impairments will be mitigated.Another technique is called “in vivo” expo-sure. In these sessions, individuals are placedin situations that they find stressful, such asfacing a crowded marketplace. Most clini-cians add positive coping strategies in theform of progressive muscular relaxation andcontrolled breathing in these sessions. Thegoal with these approaches is to help theclient to re-engage in their daily living activ-ities. Nevertheless, imaginal exposure can-not be effective if the patient has problemsimagining things. Similarly, while in vivo ex-posure does not depend on imagination, itcan risk further distress when exposing clientsto situations that they want to avoid.

Interestingly, the U.S. Army has recently re-leased a new Field Manual “Training for Full

Spectrum Operations.” This manual explic-itly references technology and gaming as aneeded military tool. Considering the stig-ma that war fighters and shortcomings withcurrent therapeutic approaches, virtual re-ality (VR) seems to be a keystone point be-tween all roads. That is, there is no need todepend directly upon imagination or to riskexposing a patient to a traumatic stressor. Itcan also present immersive environmentsthat can be experienced simultaneously byboth the therapist/researcher and the indi-vidual in need. Furthermore, stimuli can bepresented within a measured and succes-sive manner to suit treatment goals.

Virtual Reality at Tripler Army MedicalCenter

Tripler Army Medical Center’s Departmentof Psychology is considered a "Center of Ex-

20

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 A s s o c i a t i o n

FEATURES Virtual Reality and Stress Disorders in Returning Troops

Figure 1.Mental Health Specialist (SGT Meyers) simultaneously monitor (a) what a partici-

pant sees via an HMD as well as (2) his stress marker's levels.

Figure 2.Research Assistants (Koliani

and McDermott) test one of the VR systems

to be used during a cystoscopy session.

Figure 3.Re-

search Fellow

Ries (author),

and RA Kaloi-

Chen testing

the VR system

and relaxation

script for a

chronic pain

session.

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

Recovery from a stroke begins in the acuteunit and it is articulatedinto a series of intensiveand extensive rehabilita-tion protocols. Despite the

protocols variability, there is nowadays acommon trend, in clinical medicine, toshorten hospitalization and foster home-care. The reason is both to cut costs andimprove quality of life. The aim of MyHeart’s Product Concept NR is to supportpatients in the performance of speech andmotor therapy, both when they are still hos-pitalized, and after discharge, at home. Pa-tients eligible for the service must be in sta-

ble 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 at

home, 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 a

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

Recovery from a stroke begins in the acuteunit and it is articulatedinto a series of intensiveand extensive rehabilita-tion protocols. Despite the

protocols variability, there is nowadays acommon trend, in clinical medicine, toshorten hospitalization and foster home-care. The reason is both to cut costs andimprove quality of life. The aim of MyHeart’s Product Concept NR is to supportpatients in the performance of speech andmotor therapy, both when they are still hos-pitalized, and after discharge, at home. Pa-tients eligible for the service must be in sta-

ble 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 at

home, 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 a

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’s Homes or HospitalGymnasia Station

Touch ScreenSensorized Garment

FEATURES

cellence in Professional Psychology” serv-icing the Pacific Region. It offers psychol-ogy services to help the local communityand offers top-rated training experiencesto develop the new generation of mentalhealth professionals. Considering theabove-mentioned stigma experienced bymany war fighters and their attraction tocomputers and videogames, this depart-ment has launched several VR clinical re-search projects.

Preliminary data from one of these VRstudies (see Figure 1) suggests deeperimmersion when wearing a head mount-ed display (HMD). That is, participantsthat watched videos of angry bosses

yelling at them had higher levels of sub-jective “presence” and emotional reac-tivity than those watching the videos ona flat screen. In another study, anecdot-al data suggests effective pain distrac-tion by VR for the urology patients thatplayed a videogame while wearing aHMD (Figure 2). Similarly, chronic painpatients involved with another study arereporting more distraction/ immersionwhen using HMDs to play a relaxinggame while listening to relaxation scripts(Figure 3).

As evidenced by studies such as these,embracing the values presented by VRmental health technology can unfurl a

wide range of possibilities, offeringbroader access to self-care adjuncts andpsychotherapy tools. New explorationsof applications for VR in mental healthportend fruitful growth in psychology-related fields and new frontiers for indi-viduals’ healing.

In order to study the psychological mech-anisms underlying experiences in virtu-al environments (VE), one of the conceptsthat are analyzed is presence. A common-ly accepted definition of this concept in-dicates that presence is the subjective ex-perience of being in one place, even whenyou are physically located in another.

One of the possible indicators of pres-ence that have been proposed is neuro-logical activity. Brain activity measures

are promising because they potentiallyprovide data that is not influenced by theparticipant’s interpretation. However, theanalysis of these measures can be diffi-cult since very little is known about theneural processes that are involved in thecomplex experience of presence. Thebrain activity measures that have beenproposed for presence research are theelectroencephalogram (EEG) and thefunctional magnetic resonance imaging(fMRI).

An alternative brain activity measurementtechnique has been proposed recently:Transcranial Doppler Monitoring (TCD).

Transcranial Doppler Monitoring

TCD is a technique of diagnosis by ultra-sound. It requires two probes to be placedon the head of the subject using a head-band or a similar object. It allows us to di-rectly register the information of bloodflow velocity from the Middle Cerebral Ar-

21

By Beatriz Rey et al.

Transcranial Doppler Monitoring in Presence ResearchIn this study, presence is measured in patients exposed to virtual envi-ronments using a method implementing non-invase brain monitoring.

[ ]MAJ Melba C. Stetz, Ph.D.Richard I. Ries, MSEdRaymond A. Folen, Ph.D.Department of PyschologyTripler Army Medical CenterU.S.A.

[email protected]

www.tamc.amedd.army.mil/of-

fices/Psychology/research.html

FEATURES

22

tery (MCA), Anterior Cerebral Artery (ACA)and Posterior Cerebral Artery (PCA). Theprobe direction, the reference volumedepth and the flow direction identify eachcerebral artery.

TCD has important advantages when com-pared to other techniques. First of all, ithas a high temporal resolution, which al-lows instantaneous monitoring of cerebralresponses to specific events. Furthermore,it is non-invasive, so it is possible to use itin an ecological way in a great variety ofenvironments. That constitutes its mainadvantage when compared with othertechniques such as fMRI. The main disad-vantage of TCD is itsspatial resolution,which is limited by thesize of the cortical ar-eas supplied by the ar-teries under study.

TCD has been widelyused to monitor cere-bral hemodynamicsduring the perform-ance of cognitive tasksin psychophysiologicalresearch. These studies

have shown that mean BFV obtained fromTCD signals increases when users are do-ing a cognitive activity when compared tobaseline periods.

TCD and Presence

We have used TCD to analyze cognitivestates related with presence during the ex-posure to VE in different immersion andnavigation conditions.In the first study, two different navigationconditions were compared (user-controlledvs. system-controlled navigation). The per-centage variations between baseline andnavigation were positive in all the arteries

under study (MCAs and ACAs). Significantdifferences occurred only in the left arter-ies. The variations in MCA-L could be dueto the motor tasks with the right hand tocontrol the joystick. However, the variationsin ACA-L can only be explained by otherfactors such as differences in the emotion-al state or the level of presence that theuser is experiencing during the VE expo-sure in the different navigation conditions.Presence questionnaires confirmed thatthe level of presence was different betweenexperimental conditions.

The second study compared the same nav-igation conditions but in two different im-

mersion configurations (CAVE-like vs. projection screen). In thiscase, only MCAs were consid-ered. The navigation factor hadsignificant influence in BFV vari-ations in both MCA.

Discussion

The studies that have been de-scribed show that it is possibleto use TCD monitoring duringexposure to VE. TCD is a toolthat can be easily integrated inVR settings to monitor brain ac-tivity during the VR experience,so it is possible to obtain reliableTCD signals during the exposureto VE. On the other hand, theuse of TCD does not interferewith the capability of the sub-jects to focus their attention onthe VE.

Further research may contribute to discernthe role of each variable in the differencesin the blood flow velocity that have beenobserved in these studies.


FEATURES Transcranial Doppler Monitoring

[ ]Beatriz Rey, Ph.D.Mariano Alcañiz, Ph.D.Universidad Politécnica de ValenciaVera Parkhutik, Ph.D.Jose Tembl, Ph.D.Hospital Universitari La FeSpain

[email protected]

Figure 2. The Transcranial Doppler unit used in the experiments

(Doppler-Box Compumedics Germany GmbH) is connected to a

PC in which BFV signal can be visualized.

Figure 1. Screen

capture of the virtual

environment used

in the experiments.

21

FEATURES

The advantages of teaching surgery using virtual reality simulationsprovide motivation to further develop this field. In the following arti-cle, the authors describe methods they have implemented to make

this training tool more realistic andefficient for training surgeons.

23

Surgery simulation simulates sur-gery processes in a computer-gen-erated virtual environment. It is anapplication of virtual reality tech-nologies in the field of medicine.Non-real-time surgery simulationsare usually used for surgery plan-ning while real-time surgery simu-lations are used for surgery train-ing. Compared to conventionalsurgery training methods, such asusing corpses and dummies, real-time surgery simulation is morecost-effective, can be more immer-sive and interactive, can be repeat-ed unlimited times without anyreal harm, and can easily adapt todifferent physiological parametersof different patients. Our researchfocuses on designing and imple-menting mathematical modelsand algorithms for real-time sur-gery simulation, including defor-mation of deformable objects, userinteraction with haptic devices andsimulating surgical operations suchas cutting.

We have developed a surgery sim-ulation software system using C++.The system is composed of sever-

al modules, including user inter-face, a graphics renderer, haptic de-vice manager, collision detection,deformation calculation, cuttingtool, touching and grasping tool.The system is designed to be mul-ti-threaded, and thus can take ad-vantage of multi-CPU or multi-coreCPU. Graphics rendering is imple-mented using OpenGL 2.0 withGLSL shaders and currently PHAN-ToM haptic devices from SensAbleTechnologies are supported usingGHOST SDK. The haptic updateloop is implemented in a separatethread to decouple it from collisiondetection and deformation calcu-lation.

To facilitate algorithm implemen-tation, we designed a sophisticat-ed data structure to store geomet-rical, topological and mechanicalinformation of a target object. Theobject is represented by tetrahe-dral mesh. The mesh is composedof vertices, edges, triangular facesand tetrahedrons. Each elementhas relational information aboutits neighboring elements. For ex-ample, each edge has two point-

Training Tool of the Future

Shiyu Jia & Zhenkuan Pan

Surgery Simulation:

Figure 1. Surgery

simulation on a test

model.

(d) Cutting in progress

(a) Test model

(b) Touching (c) Grasping

(f) Opening cutting wound by grasping

(e) Cutting finished

FEATURES

24

ers pointing to its two vertices and a list ofpointers pointing to tetrahedrons that con-tain this edge. Each tetrahedron also storesmechanical properties such as density,Young’s modulus and Poisson’s ratio.

Detecting collisions between surgical tools andthe target object is the first step of interaction.We use AABB tree for the target object. Sincethe object can deform, the AABB tree needsto be updated in real-time. To reduce compu-tational cost, a top-down updating algorithmis implemented. Each AABB is enlarged by asmall amount so that updating is not neededif all the vertices still lie within its bound. Thetouching and grasping tool is treated as a pointwhile the cutting tool is treated as a line seg-ment. Once collision is detected, the penetra-tion depth is used for calculating interactionforce. This force is applied to the object sur-face for deformation while the opposite forceis sent to the haptic device. For the cuttingtool, the cutting process begins once the in-teraction force exceeds a certain limit, and analternative neighboring search algorithm us-ing spatial coherence is used for collision de-tection instead of AABB tree.

Target objects in surgery simulation are usu-ally human tissues and organs. These objectsdeform considerably under external force, andare thus referred to as “deformable objects.”Simulating deformation of deformable objectsis what differentiates surgery simulation fromother virtual reality applications involving onlyrigid bodies. Deformation calculation usuallyconsumes a large amount of computationaltime, so efficient algorithms and implemen-tations are essential to meet real-time require-ments. We implement two deformation algo-rithms, both based on the Finite ElementMethod. One algorithm pre-computes defor-

mation modes under unit force vectors anduses super-position to calculate displacementsof vertices under external forces. The other al-gorithm is based on a tensor-mass model. Thestiffness matrix is distributed to vertices andedges as tensors while the mass of each tetra-hedron is distributed to its vertices. The algo-rithm dynamically calculates changes of ve-locities and positions of vertices and iscomputationally more intensive, but does notneed pre-computation.

Cutting is one of the most basic operations insurgery. To make cutting realistic, the cuttingwound has to form gradually following the cut-ting tool movement in the target object. Theconsistency of the mesh data structure has tobe maintained during cutting. We implementtwo cutting methods. The first one uses a min-imal element subdivision method to split tetra-hedrons swept by cutting tools into smallertetrahedrons. This method requires classifica-tion of tetrahedron cutting state and can some-times run into invalid states due to irregularmovements of the cutting tool. The secondmethod forgoes cutting state classifications.It is divided into two stages–subdivision andsplitting. In the subdivision stage, tetrahedronsswept by the cutting tool are subdivided toeliminate face and edge intersections. No cut-ting wound is formed in this stage, but aftersubdivision, the cutting path is composed sole-ly of tetrahedron faces. In the splitting stage,these faces on the cutting path are split intotwo to form cutting wound.

Our future research will focus on the follow-ing aspects:

Simulating sewing operation. This involvessimulating interaction between the needle,suture and target objects, as well as deforma-

tion and knot tying of the suture.

Interaction between two deformable ob-jects. Currently we can only simulate interac-tion between one surgical tool and one targetobject. Real surgical operations often involvemultiple tissues and organs. Collision detec-tion and response algorithms for two de-formable objects are more difficult to designthan two rigid bodies since both objects candeform, and deformation affects collision re-sults conversely.

Non-linear deformation. Our current de-formation algorithms use linear-elasticity. Butreal human tissues are highly non-linear andanisotropic. Non-linear finite element theo-ry is much more complex than linear finiteelement. Also super-position principle nolonger applies in non-linear case. Designingefficient non-linear deformation algorithmsis a challenge.

Using GPGPU. GPU has been used in gen-eral-purpose computation for quite some timenow. With the recent driver support from bothNVidia and AMD, using OpenCL to write plat-form-independent programs to directly har-ness the parallel processing power of GPU with-out going through the rendering pipeline finallybecomes a reality. There has been very little re-search on using GPGPU in surgery simulation.We will explore the possibility of using GPGPUto accelerate deformation and collision detec-tion algorithms of deformable objects.

FEATURES Surgery Simulation

[ ]Shiyu Jia, Ph.D.

Zhenkuan Pan, Ph.D.Qingdao UniversityP.R. of China

[email protected]

(a) Liver model (a) Wireframe(b) Opening cutting wound by grasping

Figure 2.Surgery simula-

tion on a liver

model.

23

Mamagoose technology for SIDS detection. Photos courtesy VERHAERT

FEATURES

Coming in February 2010

Special Issue on PTSD

www.liebertpub.com/cpb

26

Cybertherapy – the provision of healthcare services using advanced tech-nologies – can help improve the lives of many of us, both patients andhealth professionals, while tackling the challenges to healthcare systems.

Despite the potential of cybertherapy, its benefits and the technical ma-turity of the applications, the use of cybertherapy services is still limit-ed, and the market remains highly fragmented. Although many coun-tries – including USA, Europe, Korea and Japan – have expressed theircommitment to wider deployment of cybertherapy, most cybertherapyinitiatives are no more than one-off, small-scale projects that are notintegrated into healthcare systems.

It is recognized that integrating these new types of services in health-care systems is a challenging task. The aim of this book is to supportand encourage all the interested countries in this endeavor, by identify-ing and helping to address the main barriers hindering the wider use ofcybertherapy and by providing evidence to build trust and acceptance.

Healthcare systems focus on meeting the needs of patients. Achievingcybertherapy’s potential, therefore, depends on patients being convincedof its ability to satisfy their healthcare needs. Acceptance by patients de-pends crucially on acceptance by the health professionals treating them,given the high degree of trust the former place in the latter. An impor-tant factor for ensuring the confidence and acceptance of health profes-sionals is enhanced dissemination of the evidence base regarding theeffectiveness of cybertherapy services, their safety features and user-friendliness.

Contents:• Critical Reviews: They summarize and evaluate emerging cyberther-apy topics, including Interreality, CyberAddiction and Telemedicine;

• Evaluation Studies: They are generally undertaken to solve some spe-cific practical problems and yield decisions about the value of cyberther-apy interventions;

• Original Research: They presents research studies addressing newcybertherapy methods or approaches;

• Clinical Observations: They include case studies or research protocolswith a long-term potential

Annual Review of Cybertherapy and Telemedicine 2009

Advanced Technologies in the Behavioral, Social and Neurosciences

Visit our Web site for more information or order online at www.iospress.nl or www.booksonline.iospress.nl

New IOS Press Publication!

Volume 144 Studies in HealthTechnology and InformaticsEditors: B.K. Wiederhold and G. RivaJune 2009, 304 pp., hardcoverISBN: 978-1-60750-017-9Price: US $167 / Euro 115 / £104

Mental illness has long been stigmatized among Asiansocieties and South Korea proves to be no exception.Because of this reason, it is extremely difficult to treatdue to denial and the fear that admitting mental ill-ness will bring shame. The hope is that by doing awaywith this stigma, more may seek treatment.

28

AUTHOR:

Emily ButcherManaging Editor, C&R Magazine

[email protected][ ]C&R in South Korea

urrently experts in the mentalhealth area in South Korea are fo-cused on implementing changes

that will result in heightened awarenessand a broader scope of treatment options.Stigmatization of mental illness in Asiansocieties has made treatment difficult, asmany individuals are hesitant to seek treat-ment and instead suffer in silence ratherthan bring shame to themselves and theirfamilies.

The stigma attached to various mental ill-nesses has resulted in a lack of a well-de-veloped concept of mental illness, a com-mon trait to most Asian nations. Thetreatment used in the West, of a recovery-based consumer-driven system, has notbeen implemented in South Korea. With-out a solid understanding of differenttypes of mental disease, the results havebecome apparent in disheartening statis-tics like a high suicide rate.

Troubling suicide rates

In 2008 South Korea had the highest sui-cide rate out of the 30 nations that makeup the Organization for Economic Cooper-ation and Development (OECD). Between1995 and 2005 the suicide rate more thandoubled from 11.8 per 100,000 to 26.1 per100,000. Currently, an average of 38 peo-ple commit suicide each day in South Ko-rea, making it the fourth cause of death inthe country.

One concern is the “glorification” of sui-cide committed by prominent celebritiessuch as popular actress Choi Jin-sil, whokilled herself in 2008. Copycat suicides havebeen recorded throughout the country,such as five reenactments of a protestor,Chun Se, who set himself on fire andplunged 15 feet to his death to symbolical-ly protest the beating deaths of studentdemonstrators. Surveys have shown that

young people in South Korea view suicideas a right.

Everyday stress in a fast-paced society thatpressures young people to become suc-cessful is trying as well. Suicide rates spikearound midterm exams for high schoolstudents–a time in their life that may de-termine whether or not they will get intoa prestigious university. Stress in the work-place, as well as competition among peers,has also been steadily rising, according tostudies, and has resulted in a higher num-ber of workers suffering from depressionand mental illness.

To explain these numbers, the National Sta-tistics Office, for example, blamed the badeconomic climate resulting from the 1997financial crisis. Social dislocations during aperiod of rabid urbanization in the 1980’shave also been given as a cause for increasedincidence of mental illness and in 2005, the

C

> COUNTRY FOCUS


48.8

10.0

3.3%

79.2

5.1

36

35.4

51%

26.0

75.78

1.2

0.1%

0.1%

6.4%

Population (Million)

Urban Population (Million)

Unemployment Rate

Life Expectancy (years)

Psychiatrists (per 100,000 Inhabitants)

Number of Universities OfferingPsychology Programs

Population Median Age (years)

Population Self-Assessing Health as Good

Suicide 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

> COUNTRY FOCUS

Kim believes that the future of ICT willconsist of a more multimodal environ-ment and the use of bidirectional me-dia. He says, “Technology based on abetter understanding of the human psy-che will play a crucial role.” With increas-ing funding and a focus on intercultur-al research and international projects,South Korea is working to change theway that mental healthcare is bothviewed and treated.

A Bright Future

For the first time in 15 years, The An-nual CyberTherapy & CyberPsychologyconference will be held in Asia. The con-ference will be hosted in Seoul on June13-15, 2010. Topics to be discussed in-clude uses of advanced technologies

such as virtual reality simulations,videogames, telehealth, video-confer-encing, the internet, robotics, brain com-puter interfaces, wearable computing,non-invasive physiological monitoringdevices, in diagnosis, assessment, andprevention of mental and physical dis-orders. In addition, interactive media intraining, education, rehabilitation, andtherapeutic interventions will be ex-plored. A second focus will also includehow new technologies are influencingbehavior and society through cyberad-vertising, cyberfashion, and cyberstalk-ing to name a few.

The time has come for change in thetreatment of mental and physical illness-es in South Korea. Along with a presti-gious conference bringing world-

renowned researchers from around theworld, experts within its borders are tak-ing steps to bring attention to topics thathave long been considered taboo. To con-front these problems head on, the firststeps are awareness and acceptance ofmental health disease. By acknowledg-ing these problems and implementingtools to improve treatment, South Koreais well on the way to improving the over-all mental health of its population.

30

> COUNTRY FOCUS

Sources:

Personal communication with Profes-sors Sun Kim and Jang-Han Lee, WorldHealth Organization and countrystud-ies.us.

29

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