The Challenge of Using Virtual Reality in Telerehabilitation

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TELEMEDICINE JOURNAL AND e-HEALTHVolume 10, Number 2, 2004 Mary Ann Liebert, Inc.

The Challenge of Using Virtual Reality

in Telerehabilitation

ALBERT A. RIZZO, Ph.D.,1,2 DOROTHY STRICKLAND, Ph.D.,3

and STPHANE BOUCHARD, Ph.D.4

ABSTRACT

Continuing advances in virtual reality (VR) technology along with concomitant system costreductions have supported the development of more useful and accessible VR systems that

can uniquely target a wide range of physical, psychological, and cognitive rehabilitation con-cerns and research questions. VR offers the potential to deliver systematic human testing,training, and treatment environments that allow for the precise control of complex dynamicthree-dimensional stimulus presentations, within which sophisticated interaction, behavioraltracking, and performance recording is possible. The next step in this evolution will allowfor Internet accessibility to libraries of VR scenarios as a likely form of distribution and use.VR applications that are Internet deliverable could open up new possibilities for home-basedtherapy and rehabilitation. If executed thoughtfully, they could increase client involvement,enhance outcomes and reduce costs. However, before this vision can be achieved, a numberof significant challenges will need to be addressed and solved. This article will first presentthree fictional case vignettes that illustrate the ways that VR telerehabilitation might be im-plemented with varying degrees of success in the future. We then describe a system that iscurrently being used to deliver virtual worlds over the Internet for training safety skills tochildren with learning disabilities. From these illustrative fictional and reality-based appli-cations, we will then briefly discuss the technical, practical, and user-based challenges for im-plementing VR telerehabilitation, along with views regarding the future of this emergingclinical application.

1Integrated Media Systems Center, University of Southern California, Los Angeles, California.2School of Gerontology, University of Southern California, Los Angeles, California.3Virtual Reality Aids, Inc., Raleigh, North Carolina.4Universit du Qubec en Outaouais, Dept. de Psychoducation et de psychologie, Qubec, Canada.

INTRODUCTION TO VIRTUAL REALITYTELEREHABILITATION

VIRTUAL REALITY (VR) has now emerged as apragmatically viable tool in several as-

pects of therapy and rehabilitation.14 Contin-uing advances in VR technology, along withconcomitant system cost reductions, have sup-

ported the development of more useful and ac-cessible VR systems that can uniquely target awide range of physical, psychological, and cog-nitive rehabilitation concerns and researchquestions. VR represents more than a simplelinear extension of existing computer technol-ogy for human use. It offers the potential to de-liver systematic human testing, training, and


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and had a high-speed Internet 2 connection toher home, she would be a good candidate fortheir new VR telerehabilitation system. Afterbecoming familiar with operating the technol-ogy via a detailed orientation meeting at the re-habilitation facility, she was given the latest

high-resolution, wide field-of-view head-mounted display (HMD) and tracking system.These devices simply require her to plug theminto her existing high-end computing appli-ance at home. The cost of this HMD and track-ing system is only $200. After plugging the sys-tem into her home computer, a connection wasautomatically made to the rehabilitation facil-itys main server that downloaded all the pre-scribed software to her system.

The rehabilitation software involved a gam-ing-like application that presented an engaging

three-dimensional panoramic mountain valleybackdrop with many varieties of colorful birds(Jane likes birds!) flying around within theHMD. Her task was to move her arms andhands, which were tracked and represented inthe HMD using low-cost net cam technology,in a manner to catch the birds or to strategi-cally position her hands such that the birdscould land on them. In this way, the scenariocould be used to provide rehabilitation exer-cises to promote upper body strength, range ofmotion, general motor dexterity, and other rel-evant therapeutic variables. She found thegame compelling and fun, and she was ableto perform quite well at the activity. She alsoliked the fact that after each trial she receiveda score that reflected her increasing skill at thegame. Meanwhile, her performance was routedback to the facilitys database server, whichmonitored and recorded her activity and pro-duced data on relevant performance metrics.The system automatically uploaded the data toher therapist in a format that presented an ef-

ficient and intuitive visualization of Janes per-formance. This allowed the therapist to makechanges promptly in the game programbased on Janes increasing skill level. The au-tomated online query and analysis programalso adjusted the difficulty level of the programto promote optimal success while gradually in-creasing the challenges needed to keep thegame interesting.

As Janes movement parameters began to

suggest that she was at a predefined perfor-mance level, the bird-catching task evolved aset of attentional tasks that required her tocatch only specific birds under certain condi-tions. The new task addressed selective and di-vided attention. This level of mental challenge

excited Jane, and, as she saw her scores con-tinue to improve, her motivation also contin-ued to increase. Over time, new games wereuploaded to her computer from the facilityserver, based on her evolving motor and cog-nitive performance. At this point, while she stilloccasionally played the bird game for fun,she became more involved in the new simula-tion games that reminded her of her past em-ployment working with numbers. The VR tele-rehabilitation system consistently evolved thedemands of the tasks based on Janes improv-

ing performance, kept meticulous records ofJanes activity, and produced intuitively un-derstandable graphic representations of this in-formation for her therapist. As well, Janes ther-apist was able to maintain the therapeuticrelationship based on her capacity to monitorJanes performance data efficiently and via pe-riodic phone, Internet teleconference, and face-to-face contact. Janes therapist also joined herwithin the VE via a shared connection that al-lowed them to interact in virtual real time. In6 months, Jane had regained enough of herphysical and cognitive abilities to begin re-turning successfully to her previous employ-ment on a part-time basis. She stated that whileshe knows that her rehabilitation would be along-term, ongoing process, she felt that shehad accomplished a lot and is overjoyed to seeher independence return as she embarks on therest of her life!

The bad

Billy, a 19-year-old high school graduateworking as a security guard, suffered a T3spinal cord injury (SCI) and an open head trau-matic brain injury in a motorcycle accident. Hedid not have health insurance. After 6 monthsof post acute care, he was released from his re-habilitation facility, now using a wheelchair.His residual impairment included loss of mo-tor function from the chest down below his SCIand severe visual neglect in the upper-left vi-

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life or outside interests. However, he was ableto make a living by working out of his homedesigning Web sites. Recently, he had met awoman online who lived in Europe and thiscyberrelationship blossomed to the pointwhere he decided to fly to France to meet his

financ in person.While ordering his ticket online, he realizedthat he hadnt flown since he was a child. Ashe contemplated the long flight, he felt a surgeof anxiety that typically preceded a panic at-tack. When the anxiety subsided, he searchedthe internet for self-help information regardingfear of flying. This search produced severallinks. The pop-up ad that proclaimed CureFear of Flying Using Virtual Reality in YourOwn Home caught his eye! Upon linking tothe site, he saw that for $900 dollars, he would

be sent a set of 3D Glasses and have accessto the fear of flying virtual reality treatment sitefor 1 month. Extra months could be assessed ata rate of $49.95 per month. The site claimed thatmost customers were cured in the firstmonth. John ordered the service and shortly re-ceived a very flimsy low-resolution HMDalong with Web access software. One of the ear-phones broke off as he first put on the HMD,but John assumed that sound was not all thatimportant, and he signed on for his first net-delivered VR flight. The images he saw of theinside of the plane were a little grainy, and thesound in the remaining earphone was not re-alistic. Nonetheless, he started the program. Itproved to be very easy and he was not anxiousat all. At one point, he drifted off to sleep. Heused the treatment three more times and pro-claimed himself cured. He even sent an e-mailtestimonial to the Internet based company.

Two weeks later John went to the airport,checked in for his flight and was one of the firstpassengers to board the plane. As the cabin

started to fill up with passengers, he began tofeel some apprehension. As he heard the exitdoors close and the engines fire up, he beganto perspire heavily. As the plane started to taxifrom the gate, he began to feel uncontrollabletremors in his legs and arms while his heartstarted to race. As the plane went down therunway for take off, the vibrations and rum-bling brought about a flashback to his earth-quake experience. He felt he had to get out of

there, the whole structure was going to collapseon him, and he would be trapped! He boltedfrom his seat and grabbed at the emergency exitdoor in a state of wild-eyed frenzy. Two pas-sengers in the exit row held him down as theplane lifted off. But his actions panicked some

of the other passengers, and there were screamsand crying throughout the plane. It took the pi-lots 30 minutes to return and make an emer-gency landing back at the airport, where para-medics and FAA security officials were waitingfor John at the gate!

VR TELEREHABILITATION IN THEPRESENTANALYSIS OF AN EXISTING

WEB VIRTUAL REALITY PROGRAM

While the three scenarios described aboveare fictional, they illustrate many of the generalissues and challenges that must be addressedbefore implementing any VR telerehabilitativesystem in a clinically effective and ethical man-ner. Lessons learned from integrating virtualenvironments for training over the Internetwere considered. For example, Do2Learn, acompany that provides resources for childrenwith autism, has developed Web-delivered vir-tual worlds to help teach safety skills for youngchildren with learning disorders. Typically,children have difficulty conceptualizing ab-stract ideas regarding dangers without con-crete examples and repeated practice. Virtualworlds provide one of the few safe methods forunderstanding potentially dangerous situa-tions.

Do2Learn has developed several VR com-puter games for a home PC that create a vir-tual space and introduce dangers within thatspace. An animated computer character in thevirtual world demonstrates how to respond

safely to each danger. A child moves throughthe virtual world with the help of the charac-ter, who tracks and responds to the childs mo-tions, either rewarding safe actions or warningof dangers and demonstrating the correct steps.Because the worlds are computer controlled,they can be customized for each child with amenu, and each safety skill is divided intosmaller steps to allow a child to learn at his orher own pace. For example, a child might learn

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how to cross at a crosswalk before learning tocross at a stoplight with a crosswalk, or learnto cross with no cars before learning to watchfor cars when crossing.

Efficacy tests

In a series of different trials with childrenwho had been previously diagnosed with ei-ther Pervasive Developmental Disorder or Fe-tal Alcohol Syndrome, 19 children between theages of 3 and 7 were tested to see if they couldlearn previously unknown recommendedhome fire safety actions from practicing in avirtual world (see Figs. 14). Sixteen of the chil-dren learned to: (1) recognize a fire, (2) take theshortest safe route outside, and (3) wait at apredetermined meeting place until someone

comes to find you. This game plus a street-crossing game are available at http://www.do2learn.org for free play. Current users ofthese VR safety games are from Europe, Northand South America, Asia, Africa, New Zealand,and Australia.

Despite the obvious advantages of combin-ing VR safety practice with Web delivery, themajor technical challenges encountered in thisapplication are as follows:

1. The Web intrastructure was not originallydesigned to handle a high volume of traf-fic. Hence, it is not easy to keep the con-

nections fast and clean, particularly withproblems of mass spam, denial-of-use at-tacks, and viruses. Do2Learn has to mod-ify code continually while monitoring theflow of data on their server.

2. Any Web delivery requires interaction

with a variety of products from other out-side companies. All Web programs mustrun in someone elses browser and oper-ating system on a range of different hard-ware configurations. Often the details ofhow these outside products are imple-mented are hidden, thereby limiting theirinteroperability.

3. The correct programming language forthe VR code is difficult to project in to-days changing market. Java was used forDo2Learn games and was until recently

the accepted Web standard. Microsoft,however, threw that into turmoil by an-nouncing it would not longer supportJava in the future. The virtual machine tosupport Microsoft Java is different and in-compatible in many ways from the origi-nal SUN Java virtual machine. The long-term existence of Java without Microsoftsupport makes programming a VR engineto support any Web-delivered applicationproblematic.

4. Most service providers tend to protecttheir own remote servers through specialfeatures, such as time-out triggers if trans-

VR IN TELEREHABILITATION 189

FIG. 1. Visual floor cues in virtual house.
http://www/http://www/


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fers take too long. This can make gettingvirtual three-dimensional worlds to theuser difficult. While response and trans-fer rate are highly dependent on the partof the world where the users live and howthey are connected to the network, trans-fer time during peak hours for AOL in the

United States can be 2K baud, as opposedto the 56K baud rate most users think theyare getting over their modem. This cankeep some users from being able to accessVR games or require a high-speed con-nection, which can be expensive or un-available.

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FIG. 2. Different fire locations in virtual house.

FIG. 3. Selectable meeting places.


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5. VR programs require a fast three-dimen-

sional graphics platform and often a three-dimensional graphics card. Substantialfunding is required to develop and updatean interoperable platform for a virtualworld. Fortunately, there are presentlyseveral VR platforms being developed bya variety of sources, such as Atmosphereat Adobe and Wild Tangent, which allowlow-cost virtual worlds using sophisti-cated graphics platforms.

6. Headsets were not an option for theDo2Learn virtual world because of high

cost and limited availability. This mightchange in the future.

However, it is important to address these is-sues because of the potential value of this typeof treatment. While creating bottlenecks, themass use of the Web has also created opportu-nities for trying new ideas such as remote VRtreatment programs.

CHALLENGES OF REMOTE VR

TREATMENT PROGRAMS

The traditional problems in implementingtelemedicine/telehealth have been addressedin the literature,6,7 along with other importantissues, such as the lack of physical touch (e.g.,shaking hands or holding the patients armduring an exercise). But many challenges arespecific to VR rehabilitation. Some of thesechallenges are related to the level of techno-

logical sophistication required to produce a

specific application. Others are more practicalin nature and still others involve essentially thepatients themselves.

Technological challenges

Implementing rehabilitation in VR alreadyinvolves important technological advances andresources. Delivering VR over the Internet orwith any other telecommunication system, sig-nificantly adds to the challenge. The neededprogress in this area is mostly in the hands ofcomputer scientists and other developers of VR

systems and environments. Key challenges in-clude:

Developing affordable high-quality hardware.VR requires fast computers, efficient graphiccards, precise tracking systems, high-resolu-tion displays, and highly specialized pe-ripherals. While the first two components areevolving rapidly, the others are lagging be-hind, especially HMDs and haptic feedbackdevices.

Producing robust hardware. Given the signi-ficant cost of VR hardware, lending theequipment to patients for the duration of re-habilitation treatment could become an at-tractive solution rather than asking them tobuy it. However, VR equipment is still rel-atively fragile, and it is likely that few re-searchers and clinicians would allow pa-tients to take these systems into their homes.Perhaps the expanding market of the gam-ing industry would drive future develop-


FIG. 4. Selectable teaching characters.


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ments leading to the availability of low cost,robust hardware.

Reducing side effects due to VR usage. Cyber-sickness and perceptuomotor aftereffects arereported to be potential side effects from theuse of VR, particularly with HMD-delivered

applications. Similar to motion sickness, cy-bersickness (i.e., dizziness, nausea, disorien-tation, etc.) is related to conflicts betweenvarious sensory systems.8,9 While cybersick-ness may never be entirely eliminated forcertain users, it may be substantially reducedas advances occur in the quality of hard-ware.10 Perceptuomotor after effects (i.e.,eye-hand coordination, postural instability,etc.) due to a lag in the sensorimotor sys-tems readaptation to the real world fol-lowing VR use may also be a concern.11 Pa-

tients must be warned of this potentialproblem and of behaviors not recommendedfor a period of time following use of HMDVR (e.g., driving). Perhaps, some type offlatscreen post-VR activity should be man-dated to monitor patients immediately fol-lowing VR use.

Creating new visual displays. It will soon bepossible for people to meet in a shared vir-tual environment and communicate in real-time. This could provide options for sharedvirtual experiences between patients andtherapists. Much like a videoconference sys-tem, each interlocutor would be immersed ina virtual room where they could see and in-teract with representations of each other.However, when wearing an HMD, it be-comes impossible to see the eyes and muchof the face of the interlocutors. The lack ofsuch nonverbal cues could diminish clinicalutility for certain therapeutic targets.

Facilitating installation and operation of user-friendly programs. When telerehabilitation in-

volves using VR at a patients home, the in-stallation and operation of the software mustbe as an efficient, seamless plug-and-playprocess. This involves attention to program-ming needed to eliminate conflicts amongprograms, missing driver files, and cumber-some installing and calibrating proceduresfor using motion trackers. The installationand operation of complex VR software may

be especially challenging for people with sig-nificant physical and mental impairments.

Making the exercises enticing. Patients must bemotivated to perform repetitive tasks, whichare often involved in the use of VR. Hence,gaming features must be incorporated into

rehabilitation and training exercises includ-ing1,12 a variety of VR scenarios to fit vari-ous tastes.

Practical challenges

Clinicians, researchers, health-care providers,and VR developers must also face certain prac-tical challenges, as follows:

Avoiding false claims. Technological advancesshould not be introduced for public use be-

fore people have the skill to use them effec-tively, and not before empirical validationand practice guidelines are established. Of-ten new psychotherapies are widely dissem-inated long before their efficacy is estab-lished. Patients must be informed of theexperimental nature of treatment when in-dicated. Existing guidelines and criteria fordefining a treatment as empirically sup-ported exist and should be consulted beforeclaims are made to this effect.13

Establishing practice guidelines. Before VR tele-rehabilitation becomes common practice,guidelines must be established that specifyhow, where, and for whom this technologyis appropriate, as in the development ofother mental health approaches.14,15 Theunique psychological, cognitive, physical,and functional characteristics that are com-monly seen in different types of clinicalconditions must be considered, along withan informed sensitivity to vulnerabilities ofspecific patients including, apprehensive-

ness to use a HMD, reality testing, capacityto learn to operate in a VE, susceptibility toside effects, and verbal reporting ability.These issues must be addressed for ethicalreasons as well as for treatment efficacy.16

Establishing safety parameters. Rehabilitationexercises conducted at or outside the homewithout direct in-person therapist super-vision may pose certain risks. Under such

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situations, safety parameters and guidelinesshould be established to ensure the safe useof VR telerehabilitation (e.g., use accom-panied by a relative or in a quite nondis-tracting environment). A system for auto-mated monitoring patient performance that

is embedded in the VR software could rec-ognize problematic activity. It could sup-plement therapist observations and serve toinform the patient when a problem occursand when to discontinue using the system(i.e., acute pain, maladaptive tension in aspecific muscle, movement outside therange of advised action, etc.). Ideally, anavatar would appear to inform the patientto stop and perhaps guide the patient in arelaxation exercise.

Professionally based diagnosis and treatment.

Like any other form of treatment, VR telere-habilitation must be used only when basedon an adequate clinical assessment and di-agnosis conducted by a professional. Self-help VR telerehabilitation services could ex-pose patients to significant risks.

Preparing the patient. Although VR may pro-vide treatment that successfully incorporatesgaming features that may be viewed as ex-otic and fun, this may not be the best ap-proach. The therapist must acknowledgewhile VR-based rehabilitation may be moreengaging than traditional methods, the ther-apy is serious and must be practiced in a ra-tional frame of mind.

Offering in-person clinical support. OfferingVR rehabilitation from a distant site ratherthan on site could be motivated by problemsof accessibility (e.g., patients live in an iso-lated rural area) or financial reasons (e.g., itmay be less expensive than keeping themhospitalized for the length of the treatment).In both instances appropriate clinical moni-

toring and periodic in-person support at theremote site would be essential.

User challenges

Significant human factors issues exist forboth VR, and, to a lesser extent, telemedicine.In this regard, patients who use VR telereha-bilitation in the future will face new challenges.

These challenges may be mitigated by clinicalsupport and those who prescribe them. Theseinclude:

Sense of presence. Presence, or the sense of be-ing in the virtual environment rather than in

an artificially created media experience, is akey moderator variable that influences theexperience of and outcome of VR. Presenceenables people immersed in a virtual envi-ronment to experience emotional reactionsand behave as if the environment were real.But not everyone experiences this situationin the same way (c.f., ref. 17). Certain per-sonal factors (i.e., concentration, emotionalstate, etc.) as well as environmental factors(i.e., reducing external distraction) may beunder the control of the patient at home. Pa-

tients who are depressed or poorly moti-vated to participate in treatment may havedifficulty in this area. Early orientation tothese issues and periodic monitoring wouldbe helpful.

Reducing cybersickness. Certain user behav-iors may exacerbate cybersickness duringthe use of VR. These include looking aroundrapidly while using an HMD and prior orconcurrent use of alcohol and medications.Because individual users vary in their expe-rience of such side effects, the therapistshould investigate reports of cybersicknessto determine user susceptibility and providesuggestions to minimize their occurrence.

Signs of addiction. For now, there is no evi-dence of VR being addictive. However, sen-sitivity to highly immersive and enticing ex-periences has been reported in the popularmedia for certain interactive digital gamessuch as Everquest.18 We need to be aware ofsigns of addictions. These include excessiveuse of VR; giving up important social, occu-

pational, or recreational activities to get im-mersed; persistence of unsuccessful efforts tocut down immersions, etc. The line betweenbeing an avid participant in rehabilitationin VR and becoming addicted deservessome attention when the technology to de-liver truly compelling VR scenarios becomesa reality.

Selective use of VR. If VR equipment is lent



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17. Stanney KM, Salvendy G, Deisigner J, DiZio P, EllisS, Ellison E, Fogleman G, Gallimore J, Hettinger L,Kennedy R, Lackner J, Lawson B, Maida J, Mead A,Mon-Williams M, Newman D, Piantanida T, ReevesL, Riedel O, Singer M, Stoffregen T, Wann J, WelchR, Wilson J, Witmer B. Aftereffects and sense of pres-ence in virtual environments: Formulation of a re-

search and development agenda. Report sponsoredby the Life Sciences Division at NASA Headquarters.Int J Hum-Comp Interact 1998;10:135187.

18. Shachtman N. Everquest: The Latest Addiction. WiredNews. At: http://www.wired.com/news/culture/0,1284,20984.00.html. 1999.

Address reprint requests to:Dr. Albert Skip Rizzo

Director, Virtual Environments LaboratoryIntegrated Media Systems Center

and School of GerontologyUniversity of Southern California

3715 McClintock Avenue, MC-0191Los Angeles, CA 90089-0191

E-mail: [email protected]

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The Challenge of Using Virtual Reality in Telerehabilitation

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