MODULE 3: VIRTUAL REALITY IN STROKE REHABILITATION Session 1: INTRODUCTION TO VIRTUAL REALITY. CLINICAL BASIS&USEFULNESS IN THE REHABILITATION FIELD

Index

1 LEARNING OBJECTIVES .................................................................................................... 3

2 THE SCOPE AND DEFINITIONS OF VIRTUAL REALITY – CONCEPT, HARDWARE, SOFTWARE ....................................................................................................................... 3

2.1 Definition of Virtual Reality .................................................................................. 3

2.2 Components of Virtual Reality ............................................................................. 5

2.3 The scope of functionality of Virtual Reality ........................................................ 9

3 VIRTUAL REALITY AS AT TOOL FOR SUPPORTING REHABILITATION PROCESS OF POST-STROKE PATIENTS .......................................................................................................... 11

3.1 Virtual Reality in motoric and cognitive functionality rehabilitation ................. 11

3.2 Summarising ....................................................................................................... 26

4 KEY IDEAS ....................................................................................................................... 28

BIBLIOGRAPHY ...................................................................................................................... 29

3

1 LEARNING OBJECTIVES

• To provide examples of Virtual Reality tools. • To learn differentiates Virtual Reality Tools in reference to potential scope of

supporting certain impairments of post-stroke patients. • To give evidence of positive feedback of using Virtual Reality tools in stroke

rehabilitation. • To know definition of Virtual Reality • To know software basis for Virtual Reality • To recognize hardware components of Virtual Reality • To know Virtual Reality market products (consoles) of both for entertainment uses

and rehabilitation uses • To know the scope of functionality of Virtual Reality and its potential for stroke

rehabilitation. • To know the neurophysiological foundation of Virtual Reality

2 THE SCOPE AND DEFINITIONS OF VIRTUAL REALITY – CONCEPT, HARDWARE, SOFTWARE

2.1 Definition of Virtual Reality

The history of virtual reality technology dates back to the turn of the 1950s and 1960s. Morton Heilig invented and patented device named Sensorama (Fig.1). It was a simulator for one to four people that provides the illusion of reality using a 3-D motion picture with smell, stereo sound, vibrations of the seat, and wind in the hair to create the illusion (http://www.mortonheilig.com/InventorVR.html).

Fig. 1 First virtual relity machine – Sensorama (screenshot from: https://youtu.be/vSINEBZNCks)

4

However, Jaron Lanier is considered the creator of the term of virtual reality (VR). Lanier and Zimmerman found first company to sell VR googles, gloves and other VR products. (https://en.wikipedia.org/wiki/Jaron_Lanier; https://www.newscientist.com/article/mg21829226-000-virtual-reality-meet-founding-father-jaron-lanier/).

There are many definition of “virtual reality” in the literature. The following are definitions that complement each other and pay attention to the basis aspects of issue.

Virtual Reality is the technology that provides almost real and/or believable experiences in a synthetic or virtual way. To achieve this goal, virtual reality uses the entire spectrum of current multimedia technologies such as image, video, sound and text, as well as newer and upcoming media such as e-touch, e-taste, and e-smell (Furth 2006). Virtual reality is a virtual world which almost describe as the world in the reality. It is composed of an interactive computer simulation which catch the user has current state, the movement, and the action that being sense and give a feedback illustration or information to the user. The sense of being immersed in the virtual world or simulation is called virtual environment (Suyanto et.al 2017). (Fig.2)

Fig. 2 Visualization of “virtual reality” term (https://www.wnycstudios.org/story/virtual-reality-

turning-forest)

VR is a world created using a computer, displayed using three-dimensional, realistic computer graphics, allowing interaction with the objects that are in it. This "artificial world" is designed to reproduce a specific part of the real world as much as possible.

Virtual reality is characterized by six degrees of freedom.

"Reality" is revealed by the fact that the movement takes place in 6 directions, i.e. to forward - back, up - down, left - right as well rotation relative to the three coordinate system axes.

5

2.2 Components of Virtual Reality

Virtual reality can be created in two ways: as a imaging of the real world or as creating from the foundations of artificial reality or fantasy world through computer modeling.

This dependence is shown in the figure 3.

Fig. 3 Creating of Virtual Reality

This approach allows for a wide range of application possibilities of technology through the interest of a wide range of recipients.

The creation of virtual reality and immersion the man in there can't be possible without the use of appropriate hardware and software components.

2.2.1 Hardware basis of Virtual Reality

The goal of virtual reality is to completely immerse the user in artificially created space by some kind of isolation from the place where he is currently located. Integral elements of virtual reality systems are therefore devices related to human senses, such as: image, sound, and interactivity.

The most characteristic and most important sense in the case of virtual reality is vision. Thanks to this, a person moves into a different place than it really is. To achieve this effect, various types of displays are used. The aim of use it is to transfer the user to the selected space.

The most common types of displays are: HMD (Head Mounted Displays), glasses, helmets and googles. On the figure 4 we can see examples of displays available on the market.

Vision (eyesight)

6

Fig. 4 Examples of VR displays (Producers websites: HTC VIVE ®, SAMSUNG HMD ODYSSEY®, OCULUS RIFT®, PlayStation VR®)

HMD are not the only imaging capabilities of the virtual world. All devices designed for displaying the image (e.g. TV set or white screen) can be used for this purpose. However, those devices to the greatest extent transfer human beings to the "other" world are the most desirable.

Apart from the eyesight, another sense that allows the user to immersion into the world created by the computer is hearing. In this case, it is necessary to use equipment to reproduce the desired sounds. Headphones or speakers are used for this. They are an indispensable component of VR technology. At present, in most cases they are integrated with imaging devices. VR helmets or goggles have a built-in sound system (see fig. 4) that simultaneously isolates sounds from the outside and transmits sounds adequate to the simulated environment, while strengthening the sensations.

The main principle of work in virtual space is the interactive interaction of human with virtual forms. Interactivity is understood here as the interaction of user and computer in real time. Two types of interactivity are defined: passive, which provides the possibility of human movement through the virtual space and its perception; an example can be the passage through a computer model of space; and active - the user can move objects located in the virtual space and modify them (change the form of objects, their location, colour and texture)(Asanowicz 2012). In order to ensure the user's ability to influence the virtual environment, appropriate devices are used to allow: moving around in space (motion tracking systems, treadmills, platforms etc.) and controlling virtual objects (controllers, manipulators, capsules, etc.) These devices also give the possibility to strengthen the sense of touch. Figures 5 to 7 show a wide range of diversity in the field of interactive interaction equipment in VR technology. (Websites of VR solution producers and providers)

Sound

Interactivity

7

Fig. 5 Examples of hand controlers (1. Samsung HMD Odyssey controllers, 2. PS VR Aim Controller, 3. Ocululs touch, 4. Thrustmaster T300 RS, 5. Manus VR)

Fig. 6 Examples of VR capsules (1. Car simulator Skyfun, 2. The Ninth Planet. 9D Capsule VR Electric Cinema NINED, 3. 9D VR Capsule NINED)

Fig. 7 Examples of VR platforms (Movie Power, Skyfun, KATVR)

1 2 3

8

There are many pre-set solution of VR equipment available on the IT market. We present few of them to show different possibilities of home using and to facilitate searching for interested persons in this area. Examples of VR technology solutions: Oculus Rift, Sony Project Morpheus, Microsoft HoloLens, Samsung Gear VR, Google Cardboard, Carl Zeiss VR One, HTC Vive, Avegant Glyph, Vuzix IWear 720, Archos VR, Vrizzmo VR. (Websites of VR solution producers and providers)

2.2.2 Software basis of Virtual Reality

The functioning of any computer technology depends on the use of both hardware components, but also the appropriate software. There is a lot of solution to create a virtual world. The software is intended to:

• modeling of geometrical features of a virtual environment (space and items/objects)

• modeling of human body, character • creating a 3d movies • creating sound effects.

Very important thing is to move all modeled things to the real-time engine to turn it into something you can experience in VR. The process of creating VR and the place of software in this process is shown in figure 8.

Fig. 8 The place of software in process of creating VR. On the IT market there are many software tools for the creating VR. Most of these solutions are dedicated for creations of games. These are both open source and commercial tools. The software must meet high requirements to be able to deceive the human mind and senses. Creating a virtual world is connected with the necessity of creating reliable models. Examples of real-time engine are: Unreal Engine, Unity 3D, Cryenginge, eyecad VR. Examples of software to modeling of virtual objects: Cinema 4D Rx (x is number of version), Autodesk Maya, Blender, iClone, Sculptris, 3D Crafter (see fig. 9-11) (Websites of VR solution producers and providers).

9

Fig. 9 3D Models created in Cinema 4D (Maxon)- left and Blender – right.

Fig. 10 3D models made with use of Autodesk Maya software - left and iColne - right

Fig. 11 Virtual models created with use of Sculptris – left and 3D Craft - right

2.3 The scope of functionality of Virtual Reality

Through the years of development of virtual reality technology, it has found its application in many areas of life. The goal of its application is also very diverse. The use of VR technology in terms of industry and goals has been reviewed.

The functional scope includes industries: military, entertainment, archeology, architecture but also medical industry. In every case the application can have different destiny. The scope of functionality can be divided by category shown on figure 12.

The subject of application of VR technology in activities related to educational values in the field of emergency services, police, army or medical staff is discussed in the literature. (Bertram et al. 2015, Farra et al. 2015, Alaker et al. 2016, Wynn et al. 2018)

10

Fig. 12 Sthe scope of funcionality of VR technology In terms of training, topics such as team work, behaviour training in critical conditions (disaster simulation), learning to use specialized equipment, simulation of working conditions or introduction of new techniques and methods of work of specialists (e.g. surgeons - endoscopic treatment) are undertaken. The use of technology has advantages in the form of the possibility of mapping working conditions or non-standard environmental conditions, such as flight simulation, learning to navigate at sea, combat conditions, etc.

The literature describes attempts to use VR technology for therapeutic purposes, e.g. in the treatment of post-traumatic stress disorder (eg soldiers, rape victims, or other traumatic experiences), addiction treatment and phobias. (North 2016; Zinzow et al. 2018, Beidel et al. 2017, Coelho et al. 2009, Sun et al. 2018, Foronda et al. 2016) Examples of contents supporting the treatment processes is shown in figure 13.

Fig. 13 Examples of VR technology application in treatment processes

11

Many applications in the field of widely understood entertainment are known. Computer games are the basic thought that arises in relation to this real world's visualization. As a result, the functionality of the technology has been transferred to cultural or social applications, such as tourism. Visits to virtual spaces were allowed - museums, tourist facilities, hotels, cities, etc. Many such examples can be found on the internet (eg Venice Boat Tour – see fig. 14)

Fig. 14 Example of virtual trip. (https://youtu.be/T_KXSWiPL-4)

From the point of view of this study, a very important example of the use of VR technology is the field of rehabilitation, including people after stroke.

There are papers that point to research undertaken in this topic. Generally, the literature states that actions have been taken in the field of applying the mentioned technology in relation to: rehabilitation of upper limbs, (Gauthier et al. 2018, Afsar et al. 2018) lower limbs, (Trombetta et al. 2017) rehabilitation of neuromotor pathology as well as therapy and analysis of the head movements, shoulders, hips or torso. (Fonseca et al. 2017, Kiper et al. 2018, Laver et al. 2011, Saposnik et al. 2011, Merians et al. 2014, Laver et al. 2011) In addition, the analysis of the industry market indicated specific solutions in this area (www.technomex.pl).

3 VIRTUAL REALITY AS AT TOOL FOR SUPPORTING REHABILITATION PROCESS OF POST-STROKE PATIENTS

3.1 Virtual Reality in motoric and cognitive functionality rehabilitation

Virtual reality is not commonly used in clinical rehabilitation yet, because the new and innovative methods are not available in standard education. The widely accessible knowledge about what is VR technologies and how to use it in stroke rehabilitation gives a great opportunity to support patients rehabilitation with stroke disease.

Stroke disease affects different and important aspect of human activities, functionality, social and daily life. This results from functional impairments that touch people after stroke

12

located in both motor and cognitive functions including deficits in attention and memory (short and long term) (Zinn et al. 2007) as well as concentration, special awareness, perception, praxis and executive functioning (de Luca, Leonardi et al. 2018).

In consequence this even makes post-stroke patients dysfunctional in performing instrumental activities of daily living (IADL) (Conner, Maeir 2011) especially requiring interactions with the environment and basing on manipulation of objects (e.g. shopping or operating telephone) (Josman 2014).

In turn, the prevalence of post-stroke cognitive dysfunction varies from 23% to 55% within 3 months from stroke onset, and declines between 11% and 31% after 1 year (Cumming, Marshall, Lazar 2013). Moreover, cognitive impairment after a stroke is common and leads to post-stroke dementia including vascular dementia, degenerative dementia (VaD), particularly Alzheimer’s disease (AD), or mixed dementia (VaD plus AD) (Leys et al. 2005). Figure 15 presents the cognitive impairment sequences which predispose individuals to the vascular cognitive impairment spectrum which covers cognitive consequence in the cognitive domain, starting from mild cognitive impairment and ending with severe dementia.

Fig. 15 A vascular cognitive impairments spectrum (according to Al-Qazzaz et al. 2014)

Considering all these negative consequences of stroke, dramatically reducing the quality of life for post-stroke patients and their families, it is urgent to offer effective methods and tools for recovering the patients after stroke in order to make them as independent as possible in possible short time. They must be accomplished in a way that preserves dignity and motivates the patient to relearn basic skills that the stroke disease may have impaired like bathing, eating, dressing and walking, shopping, speaking, reading and eventually return to working life.

VR technology creates a new opportunity that meets these needs due to:

• the possibility of both effective rehabilitation under clinical control and self-rehabilitation at home that is safe and efficient,

• easy and intuitive to use, • adaptation to most kind of impairments, • adaptation to individual interests, • quick change of the arrangement and conditions of exercise, • the possibility of achieving milestones, exercises based on competition – prizes, • adjusting the exercises to the temperament and personality of the patient etc.

13

The basic usefulness of VR technology in rehabilitation is the combination of three groups of integrated components:

1. VR software/hardware 2. Exercise devices and platforms 3. Feedback analysis to both patients (biofeedback) and physiotherapists (assessment

tool)

However you can implement VR technologies in different variants of complexity in terms of the range of applications: from the lowest level to the highest level of complexity. You can find the most commonly used variants of VR technologies in stroke patient rehabilitation in the matrix. Table 1. Matrix of the variants of using VR technologies in stroke rehabilitation

VR software/ hardware

Exercise devices and platforms Biofeedback

Rehabilitation assessment tools

implemented

Level 1 x

Level 2 x x

Level 3 x x x x

The basic way of using VR technology for stroke patients is rehabilitation based on games. According to therapy based evidences reported in specialist magazines the most popular VR system in rehabilitation is Kinect – based system that can support stroke patient training on all three complexity levels of using VR technologies. However other VR technology were tested with participation of stroke patients: Nintendo Wii video game console, Tetrax Biofeedback Video Games.

3.1.1 Virtual Reality in motor function rehabilitation

Virtual reality-based rehabilitation programs for motor functions is one of supplemental and alternative therapeutic interventions dedicated stroke survivors (Kim et al. 2016; Turola et al. 2013; Monawad et al. 2001) that would lead to improvement of the physical function and activities daily living ADL in stroke patients. In the Figure 16 there are presented patients after stroke while exercising shoulder flexion pattern (Fig. 16a) in “Training Mode” and shoulder extension pattern (Fig. 16 b) in “Whack-a-mole” game (Kim et al. 2016).

14

Fig. 16. Examples of exercises performed by stroke patients with the use of VR (Kim et al. 2016)

Below you can study three example charts (Table 2, Table 3, Table 4) describing the cases of using these VR systems in rehabilitation.

Table 2. Xbox Kinect games (Park et al. 2017)

Example 1: Xbox Kinect games

Parameter Case description

Level of the VR complexity

2

Patients characteristics

Patients with chronic hemiplegic stroke, n=10

Time characteristic

Duration of one session: 30 minutes, frequency of training: every day, duration of the whole therapy: 6 weeks.

Characteristic of VR system

Camera as a Kinect sensor recognizes the positions and motions of the patients. The console controls the various games. The patients are located 1.5-2m away from the Kinect camera. Before the start of the training session, the assistant adjusts the position of the camera in order to optimize the motion capture.

Additional Harness mounted to the ceiling.

a b

15

equipment

Type of games Commercial Xbox Kinect games: boxing, table tennis, soccer, golf, ski, football.

Type of exercises Active movements of upper extremity, active movements of lower extremity (hip flexion, abduction and external-internal rotation, knee flexion and extension, ankle dorsiflexion and plantarflexion), weight-shifting and weight-bearing training, balance training, trunk rotation.

Results • No participants reported any side effects like nausea, dizziness, headache, or motion sickness while using the VR system.

• Improvements in balance and gait function. • More intense concentration on the task (better motivation).

Table 3. Nintendo Wii video game console (Carregosa et al. 2018)

Example 2 Nintendo Wii video game console

Parameter Case description

Level of the VR complexity

2

Patients characteristics

Patients with hemiplegic stroke, n=5

Time characteristic

Duration of one session: 60 minutes/session, frequency of training: 2 times/week, during 16 sessions every day, duration of the whole therapy: 8 weeks.

Characteristic of VR system

The Nintendo Wii system is a simple and handy virtual mode of therapy that is being used in stroke units and rehabilitation worldwide (Piron et al. 2008). Camera as a Nintendo Wii sensor recognizes the positions and motions of the patients. The console controls the various games.

Additional equipment

n/a

Type of games Commercial Nintendo Wii games: tennis, hula hoop, soccer and boxing.

Type of exercises Active movements of upper extremity, active movements of lower extremity, balance training, coordination training.

Results • Patients had motor learning retention, achieving a sustained benefit through the technique.

16

Table 4. Tetrax biofeedback video game system (Carregosa et al. 2018)

Example 3 Tetrax biofeedback video game system

Parameter Case description

Level of the VR complexity

3

Patients characteristics

Patients with hemiplegic stroke, n=14

Time characteristic

First part: conventional outpatient rehabilitation with duration of one session: 50 minutes of physiotherapy and 50 minutes of occupational therapy per day/ 3 days a week. Second part: Tetrax biofeedback video game sessions with duration of one session 20 minutes/ per day/ 3 days a week. Duration of the whole therapy: 6 weeks

Characteristic of VR system

Tetrax biofeedback video game system (Tetrax Ltd) includes 11 games. It is a center of pressure (COP) – controlled, video game-based exercise system designed for patients requiring rehabilitation. An interface box captures the data from the force plates.

Additional equipment

4 independent force plates under the toes and heels.

Type of games 8 dedicated games based on common balance deficits after a stroke: catch (cathing one ball by moving the other ball), skyball (moving the baseball glove by using right-left movementof the patient’s feet), tag (moving the soccer player by using front-back movement of the patient’s feet), gotcha (moving the bowling pins by using right-left movement of the patient’s feet), speedball (moving the basketball hoop by using front-back movement of the patient’s feet), immobilizer (keeping the top of each columns within the set section), target (moving the red ball by changing pressure of the patient’s feet), freeze (keeping the ball inside circle).

Type of exercises Balance training.

Results • Better adherence, safety and satisfaction of patients. • Significantly better improvement in reaction time, proprioception,

symmetric weight bearing, timed up and go, forward reach.

In the market you can find other VR games with a great potential to support rehabilitation of stroke patients like: PlayStation EyeToy (Yates et al. 2016) or RehabMaster (Shin et al. 2014). (The detailed characteristics of using certain VR solutions in motor function rehabilitation are presented in session 2 and session 3.)

17

3.1.2 Virtual Reality in cognitive function rehabilitation

Virtual Reality is an advanced component of computer-assisted cognitive rehabilitation (CCR). It uses multimedia and informatics recourses (described in the previous section: point 2) to implement cognitive training for:

• Memory, • Attention, • Problem solving, • Job simulation, • Language, • Praxis, • Processing speed, • Auditory learning.

You can find in following section two essential cases describing the ways of improving particular cognitive impairments of stroke patients:

• Memory impairments, • Deficits in Executive Functions (EFs).

MEMORY IMPAIRMENTS

One of the crucial cognitive function that enable people to perform actions in the future is prospective memory that requires coordination of multiple other cognitive abilities: spatial navigation, retrospective memory, attention and executive functioning (Knight, Titov 2009). Simultaneously this function is often severely impaired by stroke patients (Mathias, Mansfield 2005; Brooks et al. 2004).. This function can interfere with independent living and can influence negatively on health and life of stroke patents by e.g. forgetting to take medications, missing doctor’s appointments etc. This also increases the problem of patient's successful community reintegration.

Retrospective memory is remembering what was learnt and experienced previously. Simultaneously it is critical aspect of prospective memory as it is necessary to remember what the task is in order to actually perform the task (Mathias, Mansfield 2005).

In this regard VR technology is suited to prospective memory improvements due to the possibility to reflect complex and dynamic environments that simulate real-life situations and require from stroke patients exercising the coordination of many cognitive abilities.

The base for both prospective and retrospective training with the use of VR technology is integration of VR environment with visual imagery enabling the patient to form visualization of a given word or a pair of words that are lined together.

Please study the example chart (Table 5) and the example of the tasks (Table 6) regarding memory training for stroke patients (Mathias, Mansfield 2005).

18

Table 5. Memory training for stroke patients (Mathias, Mansfield 2005).

Example 4 Memory therapy based on visual imagery & VR

Parameter Case description

Criteria for training

inclusion & exclusion

Inclusion criteria: • Suffering from a stroke at least six months prior the training. • Adequate or corrected hearing and vision. Exclusion criteria: • History of moderate or severe head injury. • Major neurological impairment. • Major medical illness other than having suffered a stroke. • Significant psychiatric illness requiring hospitalization. • Diagnosis of, or special education for, a learning disability. • Major depressive episode in the previous 6 months. • Pre-morbid IQ estimated at <85 using National Adult Reading Test

(NART, www.academia.edu/2515150/National_Adult_Reading_Test_NART_ test_manual_Part_1#).

Patients characteristics

Patients with hemiplegic stroke, n=15 (6 females, 9 males)

Time characteristic

Each participant had 10 sessions: 1st session: test for determining whether the patient met inclusion criteria Two weeks free from training in order to establish a baseline for prospective memory functioning 2-4th session (one-hour-long per week): visual imagery training 5-6th session (one-hour-long per week): visual imagery training with the use of video: 4 different videos presented in a random order. Simultaneously in session 4 and 5, the patient was introduced to the VR environment so that they could became familiar with it and get used to the joystick. 6-9th session: training with the use of VR. 14 problems were presented in the VR environment in the fixed order. The initial VR problem had only three tasks to memorize. The number and complexity of tasks gradually increased, with the last problem having 8 tasks (e.g. Once the cake in the oven is done, take it out and put it on the table). At the end of session 9, the participant’s PM was again assessed, which allowed us to measure the effectiveness of the treatment. 10th session: was held four weeks later, and included a repeated assessment of the patient's prospective memory.

Characteristic of VR system

The training system was developed based on Constraint-Based Modelling (CBM) and Unity game engine (https://unity3d.com/unity)

Results • PM skills of participants have improved significantly after the treatment, as measured by the CAMPROMPT test

• four weeks after the VR practice, the improvement was stable • analyses of the data collected from the visual imagery training, as well as

19

the data from the video and VR practice show that the participants have improved their performance during the study

• the participants found the visual imagery technique easy to use • the majority of the patients reported enjoying the VR environment • some of patients found joystick difficult to use

In order to understand better the idea of training the example of tasks is presented in the Table 6. Table 6. Example of tasks in memory training

Example 5 Memory therapy based on visual imagery & VR - tasks

Stage of training Case description

Visual imaginary training (visual mnemonics training)

The patients were learning how to form mental images in order to remember a list of paired words. Example of pair of words: rabbit, pipe

1. The patients were looking at pictures presenting rabbit and pipe and heard the appropriate text

“Look at the image displayed of a rabbit. Imagine its bristly fur and its long ears wriggling. Really focus on it, like it’s right there in front of you. Now look at the picture of a pipe. Imagine this in your mind. Smoke is coming out of the pipe, giving off a smoky smell. Imagine grasping the pipe, and feeling it. The pipe feels round and smooth in your hands. The more senses you use, the more memorable the image will be.”

20

2. The patients were looking at picture presenting a combination of rabbit and pipe and heard appropriate text

“Now that you have imagined the two images individually, we are going to visually link them together, which will help you to remember them. This technique of visually linking them together will allow you to recall the individual words in the future. So, what I want you to do right now is to imagine the rabbit smoking the pipe, like it is in the third image. Close your eyes and really think about it. The rabbit is puffing away and more and more smoke is coming out. In your mind, imagine the rabbit taking the pipe out and blowing a smoke ring and then putting it back in its mouth. What a silly rabbit! Ok, now open your eyes. Now that you’ve done this, the image of the rabbit smoking the pipe should be firmly in your memory, so that if we gave you the image of a rabbit, you would immediately think of it smoking a pipe, which will lead you to the second word: pipe!”

3. Next, the patients was presented with five pairs at once in order to visualize them and remember but was not guided hot to generate the combined image

21

atients had 5 minutes to memorize the five pairs, then they were presented with the word/image for the first element of each pair and needed to record the second object from each pair.

4. The patients were provided with words and two individual images but the combined image was not provided

5. The patients were provided with words and two individual images but the combined image was not provided.

6. The patients needed to visualize pairs of nouns (such rabbit/pipe).

7. The patients needed to visualize pairs consisting of a noun and an action (e.g. Egg + make an omelet),

8. The patients needed to visualize pair contained a cue and an action corresponding to PM time or event-based tasks (e.g. When you go past the green grocers, go in and buy strawberries).

9. The patients completed four problems. For each problem, they needed to memorize a list of 11 tasks, two of which were time-based tasks (e.g. At 12:36, take your medication), and the rest were event-based tasks (e.g. At Auto Sound and Security, buy a steering wheel lock). The participants had 11 minutes to memorize the tasks, and were instructed to use the visual imagery technique that

22

they were taught. The task list was presented only once, followed immediately by a 25 second distractor task (mental arithmetic) to clear the working memory.

Training in Virtual Reality Environment

The patients were given tasks connected with living at home. For this purpose VR environment, which represents a house with common household objects was provided. Two scenes of the VR environment are presented below.

This VR house is interactive i.e. user can perform actions like at real home such as turn on light, radio, TV, view a clock, cooking etc. To do the action the user should select certain object and then specify the desired action from the menu. The tasks for patients were divided according to the degree of complexity. The tasks with low degree of complexity consist of a cue and a single action, e.g. Turn on the TV at 6pm and listen to the news. The tasks with higher degree of complexity consist of different actions in different times, e.g. When the oven timer beeps, take the roast out of the oven and put it on the dining table. Time-based tasks become active several minutes before the stated

23

time. Event-based cues only begin when the stated event occurs. The scope of cognitive functions trained:

• navigation, • prioritization of tasks, • selection of objects to perform actions on, • remembering/selecting actions to be performed.

General skills of interacting with VR: • selecting objects, • selecting items from the menu or crouching, • manipulating joystick, • navigation on computer interface.

Impaired prospective memory is more likely than any other form of memory impairment to interfere with independent living as sufferers may forget to switch off the stove, to light the gas, or to take medication. A realistic assessment of a patient’s prospective memory ability should therefore be a major focus of any cognitive rehabilitation program (Rose, Brooks, Rizzo 2005). Additionally, the research proved that frontal lobe patients are most impaired at remembering and that VR-based prospective memory task may also be capable of discriminating between the prospective memory abilities of patients suffering from different forms of brain damage (Morris et al. 2002). EXECUTIVE FUNCTIONS DEFICITS

Executive Functions (EFs) are defined as sequencing and organization functions needed to perform complex or nonroutine tasks, including forming, maintaining, and shifting mental set, corresponding to the abilities to (Josman et al. 2014; Suchy 2009):

• reason and generate goals and plans, • maintain focus and motivation to follow through with goals and plans • flexibly alter goals and plans in response to changing contingencies.

According to research provided by (Pohjasvaara et al. 2002) 40% of group of 256 patients who had a stroke 3-4 months before the the study showed deficits in EFs and had more difficulties in performing Basic Activities of Daily Living and Instrumental Activities of Daily Living (IADL). Additionally, people who have deficits in EFs may show increased distractibility and difficulty in learning novel tasks or performing well in real-life situations despite apparently intact basic cognitive abilities or success in traditional neuropsychological assessments (Burges et al. 2006).

Standardized neuropsychological tests have been usually used to assess EFs of post-stroke patients. However, although these tests provide important feedback about EFs impairements, in th same time they have been criticized as lacking ecological validity. More over some patients have been found to perform in the normal range on neuropsychological tests, but demonstrate impaired behavior in everyday life. It is because activities of daily living require several simultaneous tasks are required while typically assessment procedure measures a particular EFs component during isolated tasks(Rose et al. 2005; Chaytor et al. 2006; Odhuba et al. 2005). For this reason VR has the huge potential to simulate real conditions where people live and perform their everyday activities thanks to the possibility of reflecting interactive environments with objects and events that are similar to real world.

24

In the same time this VR environment create objectively measure conditions guaranteeing challenging, safe and ecologically valid environment.

Please study the example chart (Table 7) regarding EFs training for stroke patients (Josman 2014). Particularly the example shows patients’ behaviour while visit a virtual supermarket. Table 7. EFs training for stroke patients (Josman 2014).

Example 6 Executive functions therapy based on VR

Parameter Case description

Criteria for training

inclusion

Inclusion criteria: • Mini-Mental State Examination according to (Folstein et al. 1975), score

greater than 24, • clock drawing test according to (Shulman et al. 1993), score greater than

4 • no unilateral spatial neglect according to the star cancellation test from

the Behavioral Inattention Test according to (Wilson et al. 1987), score greater than 51

• lived in the community.

Patients characteristics

Patients with right hemispheric stroke, n=12 Patients with left hemispheric stroke, n=11 Patients with bilateral stroke, n=1 In total n=24, 22 men, 2 women Mean time since onset of stroke ranged between 3 and 82 months Control group 24 healthy participants (18 men and 6 women)

Time characteristic

Each participant performed a training task within the VAP-S to become familiar with the operation of the virtual environment, including navigation via the keyboard, before performing the VAP-S test task. Testing took place at the participant’s home using the same computer and monitor and lasted for about 1 hour, in 1 or 2 sessions.

Characteristic of VR system

Hardware: 2.4-GHz HP laptop computer, 17-inch LCD monitor. Software: main software tools were 3D Studio Max and 3DVIAVirtools, It was viewable with the dedicated 3DVIA Player. VR supermarket: The Virtual Action Planning-Supermarket (VAP-S) developed in France by Klinger and Marie (Marie et al. 2003; Klinger et al. 2004). VAP-S simulates a fully textured supermarket with multiple aisles displaying food items: drinks, canned food, refrigerated dairy products, meat and fish freezers, fruit and vegetable stalls, a bread and bakery section, cleaning products, clothes, stationery, and flowers. Virtual supermarket includes also 4 cashier check-out counters, a reception point, and a shopping cart. In addition several obstacles, such as boxes of bottles or cartons are available to hinder the progression of the shopper along the aisles as well as static virtual humans populate the supermarket.

Training in Virtual Reality Environment

The VAP-S test task is to purchase 7 items from a clearly marked list of products, to then proceed to the cashier’s desk, and to pay for them.

25

During the training task, the instructions are written on the screen; the target items to purchase and an icon of a purse are displayed on the right side of the screen throughout the training and test tasks.

The overall look of the Virtual supermarket

User’s viewpoint of Virtual supermarket with the list of items to purchase In order to select an item the user should press the left mouse button. If the selected item is from the list it moves to the cart; if not the mistake is recorded. At the cashier, the user places the items on the conveyor belt by pressing the left mouse button with the cursor pointing to the belt. Then the user returns the items placed on the conveyor belt to the cart. By clicking on the purse icon, the user pays and then proceeds to the supermarket exit.

Assessment tests

VAP-S measurement parameters: 1. the total distance in meters traversed by the user (as the virtual

trajectory), 2. the total time needed by the user to complete the task, 3. the number of items purchased, 4. the number of correct actions (the number of items purchased, going

to a checkout counter with an attending cashier, placing the items on the conveyor belt, removing the items from the conveyor belt, and paying and exiting the supermarket),

5. the number of incorrect actions (selecting the wrong item, selecting an item twice, going to a check-out counter without an attending cashier, exiting the supermarket without paying, exiting the super

26

without putting the items on the conveyers belt, exiting the super and living the items on the conveyers belt, staying within the super),

6. the number of pauses, 7. the combined duration of pauses in seconds, 8. the time to pay (i.e., the time between when the cost is displayed on

the screen and when the user clicks on the purse icon). The BADS test (Wilson et al. 1996) – a test for predict problems in everyday activities caused by dysexecutive syndrome. The test consists of 6 subtests covering different aspects of dysexecutive syndrome such as difficulty in planning and abstract thinking. Observed Tasks of Daily Living-Revised (OTDL-R) (Diehl et al. 2005) – a performance-based measure of problem solving in everyday activities. This test is composed by 3 IADL domains: 1. medication use, 2. telephone use, 3. financial management.

Results There were significant differences between stroke patients and healthy controls in 2 VAP-S outcome measures. Stroke patients did not complete the purchasing task, whereas most of the control participants did and the stroke patients made fewer correct actions than the healthy controls. The significant correlations between correct actions on the VAP-S and the BADS action program and key search subtests indicate that this outcome measure, which is a composite score of several measures of the VAP-S test, requires planning, use of strategy, rule compliance, and problem solving. The significant correlations between 2 VAP-S outcomes measures (number of purchases and correct actions) and the OTDL-R total score were indicated. In this study, the OTDL-R, a performance-based assessment of everyday problem solving, was used as a measure of IADL.

3.2 Summarising

The advantage of using VR in cognitive rehabilitation is its potential to simulate many reallife or imaginary situations. Medical or research Institutions that provide rehabilitation and/or do research in this filed proved that the rehabilitation methodology basing on VR serves more ecologically valid and dynamic assessment and training. This results from (Rose, Brooks, Rizzo 2005):

• the possibility to combine a consistency of the environment with the limitless repetitions of the same assessment or training task;

• the flexibility to provide sensory presentations, task complexity, response requirements;

• the possibility of easily modification of nature and pattern of feedback according to patietnt’s impairments;

27

• provision of precise performance measurements and exact replays of task performance.

The examples present the positive results of using video games in rehabilitation. However the greatest benefit of using this unconventional therapy is the motivational force that is extremely important for people needing intensive motor training. Normally, patients tend to get tired and find the trainings monotonous (Trombetta 2017). This often leads to loss of motivation for rehabilitation, whilst the motivation is one of the main factor influencing the plasticity of the Central Nervous System (CNS) (Joo 2010).

Games can replace partially normal life due to the performance of natural movements instead of repeating the same movements. The another positive aspect of using games is the relatively simple customization of training according to the patients’ abilities.

• The features of VR technology that support rehabilitation are listed below: • Thematic video game with game parameters adjusted to individual needs. • Cognitive and motor exercises as a feedback resulting from the game scenario. • Biofeedback (biological feedback) - providing feedback to patient about changes in

their physiological state. Physiological changes in the body are monitored by a suitable device, e.g. a measuring computer system and are announced by both visually or acoustic form.

• Assessment tools – providing feedback to therapist about progress in rehabilitation. Particularly, the visual biofeedback provided during therapy with VR games stimulates proprioceptive information and allows for constant selfcorrection over a series of activities that require balance (Barcala 2011; Barcala 2013).

• More intense concentration on the task, which could increase motor learning and enhance the physical performance of individuals with stroke during activities of daily living.20

In the scheme (Figure 17) you will find the spectrum of supporting activities with the use VR technologies in rehabilitation of stroke patients. These activities are included into three function areas of supporting: cognitive, motor and coordination that is the combination of both cognitive and and motor.

Fig. 17 The areas of supporting functionalities with the use of VR technologies

28

The key role in this approach to rehabilitation is the development of such a tool that will be usefull for both post-stroke patients and their families. However, in order to implement an appropriate and based on customization of rehabilitation process, it is needed to perform the preparatory activities that include at least such stages as:

• Acquisition and organization of extensive and up-to-date knowledge on innovative technologies that can support post-stroke rehabilitation covering particularly the previous experiences, implementations, ranges of uses, and achievements in this area;

• Development of knowledge repositories including scenarios of using innovative technologies according to patient’s individual characteristic;

• Trainings of medical staff who participates in rehabilitation process.

4 KEY IDEAS

• Virtual reality is a technology which have wide range of using scope (from entertainment to medicine)

• Using VR technology enable rehabilitatiors for simple customization of training according to the patients’ abilities

• VR technology not always give better results as traditional trainingb but for sure give better motivation to train by stroke patients what is extremely important for people needing intensive motor and cognitive training

• Patients who have deficits in EFs may show increased distractibility and difficulty in learning novel tasks or performing well in real-life situations despite apparently intact basic cognitive abilities or success in traditional neuropsychological assessments

• Accurate evaluation of cognitive and EFs abilities is critical to develope intervention plans that increase functioning and reduce dependence on social and health services that are both costly and, at times, difficult to access

• VR technologies can be used in both clinical rehabilitation and home rehabilitation • Useful features of available solutions in the field of VR can be directly applied to

stimulate activity and fight dysfunctions resulting from a stroke. • VR hardware and software of VR are easily accessible on the market to a potential

user. Even little advanced VR tools can be used in self-rehabilitation of stroke patients

29

BIBLIOGRAPHY

Afsar Sevgi Ikbali, Mirzayev Ilkin, Yemisci Oya Umit, Sacide Nur Cosar Saracgil; “Virtual Reality in Upper Extremity Rehabilitation of Stroke Patients: A Randomized Controlled Trial”, Journal of Stroke and Cerebrovascular Diseases, Elsevier, September 2018

Alaker Medhat, Wynn Greg R., Arulampalam Tan, “Virtual reality training in laparoscopic surgery: A systematic review & meta-analysis”, International Journal of Surgery, May 2016

Al-Qazzaz NK, Ali SH, Ahmad SA, Islam S, Mohamad K. Cognitive impairment and memory dysfunction after a stroke diagnosis: a post-stroke memory assessment. Neuropsychiatr Dis Treat. 2014 Sep 9(10), pp.1677-1691

Asanowicz A., Systemy rzeczywistości wirtualnej w architekturze, „Architecturae et Artibus” vol. 4, no. 4, 2012

Barcala L, Colella F, Araujo MC, et al. Analise do equilibrio em pacientes hemipareticos apos o treino com o programa Wii Fit. Fisioter Mov, 24, pp. 337-343, 2011

Barcala L, Grecco LA, Colella F, et al. Visual biofeedback balance training using Wii fit after stroke: a randomized controlled trial. J Physther Sci, 25, pp. 1027-1032, 2013

Beidel Deborah C., Frueh B. Christopher, Neer Sandra M., Bowers Clint A., Trachik Benjamin, Uhde Thomas W., Grubaugh Anouk, “Trauma management therapy with virtual-reality augmented exposure therapy for combat-related PTSD: A randomized controlled trial”, Journal of Anxiety Disorders, Elsevier, August 2017

Bertram J, Moskaliuk J, Cress U, “Virtual training: Making reality work?” Computers in Human Behavior, Elsevier, February 2015

Brooks BM, Rose FD, Potter J, Jayawardena S, Morling A. Assessing stroke patients' prospective memory using virtual reality. Brain Injury;18(4), pp. 391-401; 2004

Burgess, P.W.a,bEmail Author, Alderman, N.c, Forbes, C.a,b, Costello, A.e, Coates, L.M.-A.f, Dawson, D.R.d,g, Anderson, N.D.d,h, Gilbert, S.J.a,b, Dumontheil, I.a,b, Channon, S. The case for the development and use of "ecologically valid" measures of executive function in experimental and clinical neuropsychology. Journal of the International Neuropsychological Society, 12(2) 2006, pp.194-209

Carregosa, A.A., Dos Santos, L.R., Masruha, M.R., Da Silveira Coelho, M.L., Machado T.C., Souza D.C.B., Passos G.L.L., Fonesca E.P., da S. Ribeiro N.M., de Souza Melo A.: Virtual Rehabilitation through Nintendo Wii in Poststroke Patients: Follow-Up. Journal of Stroke and Cerebrovascular Diseases, 27(2), pp. 494-498, 2018

Chaytor N, Schmitter-Edgecombe M, Burr R. Improving the ecological validity of executive functioning assessment. Arch Clin Neuropsychol 2006;21, pp.217-227

30

Coelho Carlos M., Waters Allison M., Hine Trevor J., Wallis Guy, “The use of virtual reality in acrophobia research and treatment”, Journal of Anxiety Disorders, Elsevier, June 2009

Conner, L.T., Maeir, A.: Putting executive performance in a theoretical context OTJR Occup Participation Health, 31, pp. 3-7, 2011

Cumming TB, Marshall RS, Lazar RM. Stroke, cognitive deficits, and rehabilitation: still an incomplete picture. Int J Stroke. 2013;8(1), pp. 38–45

De Luca R, Leonardi S, Spadaro L, Russo M, Aragona B,Torrisi M, Maggio MG., Bramanti A, Naro A, De Cola MC, Calabrò RS., Improving Cognitive Function in Patients with Stroke: Can Computerized Training Be the Future? J Stroke Cerebrovasc Dis. 2018 Apr;27(4):1055-1060

Diehl M, Marsiske M, Horgas AL, et al. The Revised Observed Tasks of Daily Living: a performanced-based assessment of everyday problem solving in older adults. J Appl Gerontol 2005;24:211-230.

Farra Sharon L, Miller Elaine T., Hodgson Eric, “Virtual reality disaster training: Translation to practice”, Nurse Education in Practice, Elsevier, January 2015

FolsteinMF, Folstein SE, McHugh PR. ‘‘Mini-mental state’’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-198

Foronda Cynthia L., Shubeck Keith, Swoboda Sandra M., Krysia Warren Hudson, Budhathoki Chakra, Sullivan Nancy, Hu Xiangen, “Impact of Virtual Simulation to Teach Concepts of Disaster Triage”, Clinical Simulation in Nursingce and Technology, Elsevier, April 2016

Furht B. (eds) Virtual Reality, Encyclopedia of Multimedia. Springer, Boston, MA 2006

Gauthier Lynne V., Richter Troy A.,. George Lydia C, Schubauer Kathryn M., “Chapter 33 – Gaming for the Brain: Video Gaming to Rehabilitate the Upper Extremity After Stroke”, Neuromodulation (Second Edition) Comprehensive Textbook of Principles, Technologies, and Therapies, 2018, Pages 465–476, Volume 1

Joo, L.Y., Tjan, S.Y., Donald, X., Ernest, T., Pei, F.C., Christopher, W.K.K., Kong, K.H.: A feasibility study using interactive commercial off-theshelf computer gaming in upper limb rehabilitation in patients after stroke. J. Rehabil. Med., 42, pp. 437-441, 2010

Josman N., Kizony R., Hof E., Goldenberg K., Weiss PL., Klinger E. Using the Virtual Action Planning-Supermarket for Evaluating Executive Functions in People with Stroke. Journal of Stroke and Cerebrovascular Diseases, 23(5), 2014: pp. 879-887

Josman, N., Kizony, R., Hof, E., Goldenberg, K., Weiss, L., . Klinge, E.: Using the Vir-tual Action Planning-Supermarket for Evaluating Executive Functions in People with Stroke. Journal of Stroke and Cerebrovascular Diseases, 23(5), pp. 879-887, 2014

KE Laver, George S, Thomas S, Deutsch JE, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2011;7:CD008349.

Kim J., Lee M., Kim Y., Eun S.-D., Yoon B. Feasibility of an individually tailored virtual reality program for improving upper motor functions and activities of daily living in chronic stroke survivors: A case series. European Journal of Integrative Medicine 8 (2016), pp. 731–737

31

Kiper Pawel, Szczudlik Andrzej, Agostini Michela, Opara Jozef, Nowobilski Roman, Ventura Laura, Tonin Paolo, Turolla Andrea; “Virtual Reality for Upper Limb Rehabilitation in Subacute and Chronic Stroke: A Randomized Controlled Trial”, Archives of Physical Medicine and Rehabilitation, Elsevier, May 2018

Klinger E, Chemin I, Lebreton S, et al. A virtual supermarket to assess cognitive planning. Cyberpsychol Behav 2004;7:292-293

Knight R.G., Titov N.: Use of virtual reality tasks to assess prospective memory: Applicability and evidence. Brain impairment, 10 (01), pp. 3-13, 2009

Leys D, Hénon H, Mackowiak-Cordoliani M-A, Pasquier F. Poststroke dementia. Lancet Neurol. 2005;4(11), pp.752–759

Marie RM, Klinger E, Chemin I, et al. Cognitive planning assessed by virtual reality. Presented at VRIC 2003, Laval Virtual Conference; May 15, 2003; Laval, France

Mathias J.L., Mansfield K.M., Prospective and declarative memory problems following moderate and severe traumatic brain injury, Brain Injury, 19(4), pp. 271-282, 2005

Merians AS, Fluet G, Tunik E, Qiu Q, Saleh S, Adamovich S. Movement rehabilitation in virtual reality from then to now: how are we doing?. Int J Disabil Hum Dev.;13(3):311-317, 2014

Morris, R.G., Kotitsa, M., Bramham, J., Brooks B., Rose FD. Virtual reality investigation of strategy formation, rule breaking and prospective memory in patients with focal prefrontal neurosurgical lesions. In: Sharkey, P., Lányi, C.S., & Standen, P. (eds.), Proceedings of the 4th International Conference on Disability, Virtual Reality & Associated Technologies. Veszprém, Hungary, 2002, pp. 101–108

Mouawad M.R., Doust C.G., Max M.D., McNulty P.A. Wii-based movement therapy to promote improved upper extremity function post-stroke: a pilot study, J. Rehabil. Med. 43 (2011), pp.527–533

North Max M., North Sarah M., “Computer-Assisted and Web-Based Innovations in Psychology, Special Education, and Health. Chapter 6 Virtual Reality Therapy”, Elsevier, 2016

Odhuba RA, van den Broek MD, Johns LC. Ecological validity of measures of executive functioning. Br J Clin Psychol 2005;44, pp.269-278

Park, D.-S., Lee D.-G., Lee, K., Lee, G.CH.: Effects of Virtual Reality Training using Xbox Kinect on Motor Function in Stroke Survivors: A Preliminary Study. Journal of Stroke and Cerebrovascular Diseases, 26(10), pp. 2313-2319, 2017

Pedreira da Fonseca Erika, Ribeiro da Silva Nildo Manoel, Pinto Elen Beatriz; „Therapeutic Effect of Virtual Reality on Post-Stroke Patients: Randomized Clinical Trial”, Journal of Stroke and Cerebrovascular Diseases, Elsevier, January 2017

Piron L, Turolla A, Tonin P, et al. Satisfaction with care in post-stroke patients undergoing a telerehabilitation programme at home. J Telemed Telecare, 14, pp. 257-26, 2008

32

Pohjasvaara T, Leskela M, Vataja R, et al. Post-stroke depression, executive dysfunction and functional outcome. Eur J Neurol 2002;9:269-275

Rizzo, A.A., Buckwalter, J.G., & Van der Zaag, C. (2002). Virtual environment applications for neuropsychological assessment and rehabilitation. In: Stanney, K. (ed.), Handbook of virtual environments. Mahwah, NJ: Earlbaum, pp. 1027–1064

Rizzo, A.A., Buckwalter, J.G., Humphrey, L., et al. (2000). The virtual classroom: a virtual environment for the assessment and rehabilitation of attention deficits. CyberPsychology & Behavior 3: 483– 499. 67

Rose FD, Brooks BM, Rizzo AA. Virtual Reality in Brain Damage Rehabilitation: Review. CYBERPSYCHOLOGY & BEHAVIOR, 8(3), pp. 241-271, 2005

Saposnik G, Levin M. Virtual reality in stroke rehabilitation: a meta-analysis and implications for clinicians. Stroke;42:1380–6., 2011

Shin J-H., Ryu H., Ho Jang S.: A task-specific interactive game-based virtual reality rehabilitation system for patients with stroke: a usability test and two clinical experiments. Journal of NeuroEngineering and Rehabilitation 2014, on 2014, 11:32 http://www.jneuroengrehab.com/content/11/1/32

Shulman K, Gold D, Cohen C, et al. Clock-drawing and dementia in the community: a longitudinal study. Int J Geriatr Psychiatry 1993;8:487-496

Sohlberg, M.M., & Mateer, C.A. (1987). Effectiveness of an attention training program. Journal of Clinical and Experimental Psychology 9:117–130

Suchy Y. Executive functioning: overview, assessment, and research issues for non-neuropsychologists. Annals of Behavioral Medicne 2009;37, pp.106-116

SUN Xue, LIU Hu, WU Guanghui, ZHOU Yaoming, “Training effectiveness evaluation of helicopter emergency relief based on virtual simulation”, Chinese Journal of Aeronautics, Volume 31, Issue 10, Pages 2000-2012, October 2018

Suyanto, E.M., Angkasa, D., Turaga, H., Sutoyo, R. Overcome Acrophobia with the Help of Virtual Reality and Kinect Technology Procedia Computer Science, Volume 116, Issue undefined, 2017

Trombetta Mateus; Bazzanello Henrique Patrícia Paula; Rogofski Brum Manoela; Colussi Eliane Lucia; Bertoletti De Marchi Ana Carolina; Rieder Rafael; “Motion Rehab AVE 3D: A VR-based exergame for post-stroke rehabilitation”, Computer Methods and Programs in Biomedicine, Volume 151, Pages 15-20, November 2017

Trombetta, M., Paula, P., Henrique, B., Rogofski Brum, M., Colussi, E.L., Bertoletti De Marchi, A.C., Rieder, R.,: Motion Rehab AVE 3D: A VR-based exer game for post-stroke rehabilitation. Computer Methods and Programs in Biomedicine, 151, pp. 15-20, 2017

Turolla A., Dam M., Ventura L., Tonin P., Agostini M., Zucconi C., Kiper P., Cagnin A., Piron L. Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial, J. Neuroeng. Rehabil. 10 (2013) pp.85.

33

Wilson BA, Alderman N, Burgess PW, et al. Behavioral assessment of the dysexecutive syndrome manual. London, UK: Thames Valley Test Company, 1996.

Wilson BA, Cockburn J, Halligan PW. Behavioural inattention test manual. Hampshire, London, UK: Thames Valley Test Co, 1987

Wynn Greg, Lykoudis Panagis, Berlingieri Pasquale, “Development and implementation of a virtual reality laparoscopic colorectal training curriculum”, The American Journal of Surgery, September 2018

Yates M., Kelemen A., Sik Lanyi C.: Virtual reality gaming in the rehabilitation of the upper extremities post-stroke, Brain Injury, 30 (7), pp. 855-863, 2016

Zinn, S., Bosworth, H.B., Hoenig, H.M., Swartzwelder, H.S.: Executive function deficits in acute stroke. Arch Phys Med Rehabil., 88, pp. 173-180, 2007

Zinzow Heidi M., Brooks Johnell O., Rosopa Patrick J., Jeffirs Stephanie, Jenkins Casey, Seeanner Julia, McKeeman Alyssa, Hodges Larry F., “Virtual Reality and Cognitive-Behavioral Therapy for Driving Anxiety and Aggression in Veterans: A Pilot Study”, Cognitive and Behavioral Practice, Elsevier, May 2018

Internet sources:

http://www.mortonheilig.com/InventorVR.html).

https://en.wikipedia.org/wiki/Jaron_Lanier;

https://estorm.com.au/news/virtual-reality-changes-medical-education/

https://unimersiv.com/immersive-vr-education-works-with-the-royal-college-of-surgeons-on-a-virtual-reality-medical-training-simulation-33

https://www.newscientist.com/article/mg21829226-000-virtual-reality-meet-founding-father-jaron-lanier/

https://www.wnycstudios.org/story/virtual-reality-turning-forest

https://youtu.be/csD1ue-RuNw

https://youtu.be/T_KXSWiPL-4

https://youtu.be/vSINEBZNCks

https://youtu.be/XNmr16h4IWQ

www. Technomex.pl

Websites of VR solution producers and providers:

3D Crafter: http://amabilis.com

9D VR Capsule: http://www.gznined.com/9d/9d-vr-capsule/2017-nined-innovative-products-9d-virtual.html

34

Archos VR: https://www.archos.com/us/products/objects/cself/avr/index.html

Autodesk Maya: https://www.autodesk.pl/products/maya/overview

Avegant Glyph: https://www.avegant.com/video-headset

Blender: https://www.blender.org

Car simulator Skyfun: http://www.simulatorvirtualreality.com/sale-10900076-coin-slot-project-car-simulator-racing-game-virtual-reality-game-machine.html

Carl Zeiss VR One: https://www.zeiss.com/virtual-reality/home.html

Cinema 4D Rx: https://www.maxon.net/en-us/

Cryenginge: https://www.cryengine.com

eyecad VR: https://eyecadvr.com/pl/

Google Cardboard: https://vr.google.com/cardboard/

HTC VIVE: https://www.vive.com/us/product/vive-virtual-reality-system/

HTC Vive: https://www.vive.com/us/product/vive-virtual-reality-system/

http://katvr.com/product/kat-walk-mini/

http://www.movie-power.com/ProductCenter.aspx

https://www.skyfunvr.com

iClone: https://www.reallusion.com/iclone/

Manus VR: https://manus-vr.com/virtual-reality

Microsoft HoloLens: https://www.microsoft.com/pl-pl/hololens

OCULUS RIFT: https://www.oculus.com/cart/

Oculus Rift: https://www.oculus.com/rift/#oui-csl-rift-games=mages-tale

Oculus touch: https://www.oculus.com/rift/accessories/

PlayStation VR: https://www.playstation.com/pl-pl/explore/playstation-vr/

PS VR Aim Controller: https://www.playstation.com/pl-pl/explore/playstation-vr/

Samsung Gear VR: https://www.samsung.com/pl/wearables/gear-vr-r322/

Samsung HMD Odyssey controllers: https://www.samsung.com/us/support/answer/ANS00078171/

SAMSUNG HMD ODYSSEY: https://www.samsung.com/us/computing/hmd/windows-mixed-reality/xe800zaa-hc1us-xe800zaa-hc1us/

35

Sculptris: http://pixologic.com/sculptris/

Sony Project Morpheus: https://www.playstation.com/pl-pl/explore/playstation-vr/

The Ninth Planet: http://www.gznined.com/9d/9d-vr-capsule/professional-9d-capsule-vr-cinema-electric.html

Thrustmaster T300 RS: http://www.thrustmaster.com/products/t300rs

Unity 3D: https://unity3d.com

Unreal Engine: https://www.unrealengine.com/en-US/what-is-unreal-engine-4

Vrizzmo V: http://www.vrizzmo.com/pl/

Vuzix IWear 720: https://www.vuzix.com/Products/iWear-Video-Headphones

Disclaimer

The information here included is for educational purposes only and is not intended to be a substitute for producer’s documentation, nor professional advice.

36

This project has been funded with support from the European Commission.

This publication reflects the views only of the author, and the Commission cannot be held responsible for any use which

may be made of the information contained therein"

Project Number: 2017-1-PL01-KA202-038370

Project Title: "Development of innovative Training contents based on the applicability of Virtual Reality in the field of Stroke Rehabilitation"

Consortium: