Federica Pallavicini

NeuroVR 2--a free virtual reality platform for the assessment and treatment in behavioral health care.

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

Validating the neuro vr-based virtual version of the multiple errands test: Preliminary results

The purpose of this study was to establish ecological validity and initial construct validity of the virtual reality version of the Multiple Errands Test based on NeuroVR software as an assessment tool for executive functions. In particular, the Multiple Errands Test is an assessment of executive functions in daily life which consists of tasks that abide by certain rules and is performed in a shopping mall-like setting where there are items to be bought and information to be obtained. The study population included three groups: post-stroke participants (n = 9), healthy young participants (n = 10), and healthy older participants (n = 10). The general purpose of the study was investigated through the following specific objectives: (1) to examine the relationships between the performance of three groups of participants in the Virtual Multiple Errands Test (VMET) and in the traditional neuropsychological tests employed to assess executive functions; and (2) to compare the performance of post-stroke participants to those of healthy young and older controls in the Virtual Multiple Errands Test and in the traditional neuropsychological tests employed to assess executive functions. Correlations between Virtual Multiple Errands Test variables and some traditional executive functions measures provide preliminary support for the ecological and construct validity of the VMET; further performance obtained at the Virtual Multiple Errands Test provided a distinction between the clinical and healthy population, and between the two age control groups. These results suggest a possible future application of such an ecological approach for cognitive assessment and rehabilitation of stroke patients and elderly population with age-related cognitive decline.

Interreality in Practice: Bridging Virtual and Real Worlds in the treatment of Posttraumatic Stress Disorders

The use of new technologies, particularly virtual reality, is not new in the treatment of posttraumatic stress disorders (PTSD): VR is used to facilitate the activation of the traumatic event during exposure therapy. However, during the therapy, VR is a new and distinct realm, separate from the emotions and behaviors experienced by the patient in the real world: the behavior of the patient in VR has no direct effects on the real-life experience; the emotions and problems experienced by the patient in the real world are not directly addressed in the VR exposure. In this article, we suggest that the use of a new technological paradigm, Interreality, may improve the clinical outcome of PTSD. The main feature of Interreality is a twofold link between the virtual and real worlds: (a) behavior in the physical world influences the experience in the virtual one; (b) behavior in the virtual world influences the experience in the real one. This is achieved through 3D shared virtual worlds; biosensors and activity sensors (from the real to the virtual world); and personal digital assistants and/or mobile phones (from the virtual world to the real one). We describe different technologies that are involved in the Interreality vision and its clinical rationale. To illustrate the concept of Interreality in practice, a clinical scenario is also presented and discussed: Rosa, a 55-year-old nurse, involved in a major car accident.

Virtual reality and mobile phones in the treatment of generalized anxiety disorders: a phase-2 clinical trial

Several studies have demonstrated that exposure therapy—in which the patient is exposed to specific feared situations or objects that trigger anxiety—is an effective way to treat anxiety disorders. However, to overcome a number of limitations inherent in this approach—lack of full control of the situation, costs and time required, etc.—some therapists have started to add virtual reality (VR) to the in vivo exposure-based therapy, providing in-office, controlled exposure therapy. Compared to the in vivo exposure, VR Exposure Therapy (VRET) is completely controlled: the quality, the intensity and the frequency of the exposure are decided by the therapist, and the therapy can be stopped at any time if the patient does not tolerate it. Moreover, the flexibility of a virtual experience allows the patient to experience situations that are often much worse and more exaggerated than those that are likely to be encountered in real life. However, a critical issue underlying the use of VRET in the treatment of anxiety-related disorders is the lack of a virtual reality system in the patient’s real-life context. In this paper, we present a clinical protocol for the treatment of Generalized Anxiety Disorders (GAD) based on the ubiquitous use of a biofeedback-enhanced VR system. The protocol includes the use of a mobile exposure system allowing patients to perform the virtual experience in an outpatient setting. A between-subjects study, involving 25 GAD patients, was carried out to verify the efficacy of the proposed approach. The clinical data in this pilot study seemed to support the efficacy of the ubiquitous approach.

Is virtual reality always an effective stressors for exposure treatments? some insights from a controlled trial

BackgroundSeveral research studies investigating the effectiveness of the different treatments have demonstrated that exposure-based therapies are more suitable and effective than others for the treatment of anxiety disorders. Traditionally, exposure may be achieved in two manners: in vivo, with direct contact to the stimulus, or by imagery, in the person’s imagination. However, despite its effectiveness, both types of exposure present some limitations that supported the use of Virtual Reality (VR). But is VR always an effective stressor? Are the technological breakdowns that may appear during such an experience a possible risk for its effectiveness?MethodsTo answer these questions we compared changes following the exposure to an academic examination, one of the most universal examples of real-life stressors, in a sample of 39 undergraduate students. The same experience was offered using text (TX), audio (AU), video (VD), and VR. However, in the virtual environment we manipulated the experience introducing technological breakdowns. The Post Media Questionnaire (PMQ) and the Slater-Usoh-Steed Presence Questionnaire (SUS) were administered to each participant in order to evaluated self-report measures of anxiety and relaxation and the level of presence experience during media exposure. Electrocardiogram (ECG), Thoracic Respiration Signal (RSP) and Facial corrugator supercilii muscle Electromyography (EMG) were recorded in order to obtain objective measures of subjects’ emotional state.ResultsAnalyses conducted on PMQ showed a significant increase in anxiety scores and a mirror decrease in relax scores after all our emotional procedures, showing that all the condition were effective in inducing a negative emotional response. Psychometric scores and psychophysiological indexes showed that VR was less effective than other procedures in eliciting stress responses. Moreover, we did not observe significative difference in SUS scores: VR induced a sense of presence similar to that experienced during the exposition to other media.ConclusionsTechnological breakdowns significantly reduce the possibility of VR eliciting emotions related to complex real-life stressors. Without a high sense of presence, the significant advantages offered by VR disappear and its emotional induction abilities are even lower than the ones provided by much cheaper media.Trial registrationTrial registration number: NCT01683617

Assessment and rehabilitation of neglect using virtual reality: a systematic review.

After experiencing a stroke in the right hemisphere, almost 50% of patients showed Unilateral Spatial Neglect (USN). In recent decades, Virtual Reality (VR) has been used as an effective tool both for the assessment and rehabilitation of USN. Indeed, this advanced technology allows post-stroke patients to interact with ecological and engaging environments similar to real ones, but in a safe and controlled way. To provide an overview of the most recent VR applications for the assessment and rehabilitation of USN, a systematic review has been carried out. Since 2010, 13 studies have proposed and tested innovative VR tools for USN. After a wide description of the selected studies, we discuss the main features of these VR tools in order to provide crucial indications for future studies, neurorehabilitation interventions, and clinical practice.

Experiential Virtual Scenarios With Real-Time Monitoring (Interreality) for the Management of Psychological Stress: A Block Randomized Controlled Trial

Background The recent convergence between technology and medicine is offering innovative methods and tools for behavioral health care. Among these, an emerging approach is the use of virtual reality (VR) within exposure-based protocols for anxiety disorders, and in particular posttraumatic stress disorder. However, no systematically tested VR protocols are available for the management of psychological stress. Objective Our goal was to evaluate the efficacy of a new technological paradigm, Interreality, for the management and prevention of psychological stress. The main feature of Interreality is a twofold link between the virtual and the real world achieved through experiential virtual scenarios (fully controlled by the therapist, used to learn coping skills and improve self-efficacy) with real-time monitoring and support (identifying critical situations and assessing clinical change) using advanced technologies (virtual worlds, wearable biosensors, and smartphones). Methods The study was designed as a block randomized controlled trial involving 121 participants recruited from two different worker populations—teachers and nurses—that are highly exposed to psychological stress. Participants were a sample of teachers recruited in Milan (Block 1: n=61) and a sample of nurses recruited in Messina, Italy (Block 2: n=60). Participants within each block were randomly assigned to the (1) Experimental Group (EG): n=40; B1=20, B2=20, which received a 5-week treatment based on the Interreality paradigm; (2) Control Group (CG): n=42; B1=22, B2=20, which received a 5-week traditional stress management training based on cognitive behavioral therapy (CBT); and (3) the Wait-List group (WL): n=39, B1=19, B2=20, which was reassessed and compared with the two other groups 5 weeks after the initial evaluation. Results Although both treatments were able to significantly reduce perceived stress better than WL, only EG participants reported a significant reduction (EG=12% vs CG=0.5%) in chronic “trait” anxiety. A similar pattern was found for coping skills: both treatments were able to significantly increase most coping skills, but only EG participants reported a significant increase (EG=14% vs CG=0.3%) in the Emotional Support skill. Conclusions Our findings provide initial evidence that the Interreality protocol yields better outcomes than the traditionally accepted gold standard for psychological stress treatment: CBT. Consequently, these findings constitute a sound foundation and rationale for the importance of continuing future research in technology-enhanced protocols for psychological stress management. Trial Registration ClinicalTrials.gov: NCT01683617; http://clinicaltrials.gov/show/NCT01683617 (Archived by WebCite at http://www.webcitation.org/6QnziHv3h).

Augmented Reality: A Brand New Challenge for the Assessment and Treatment of Psychological Disorders

Augmented Reality is a new technological system that allows introducing virtual contents in the real world in order to run in the same representation and, in real time, enhancing the users sensory perception of reality. From another point of view, Augmented Reality can be defined as a set of techniques and tools that add information to the physical reality. To date, Augmented Reality has been used in many fields, such as medicine, entertainment, maintenance, architecture, education, and cognitive and motor rehabilitation but very few studies and applications of AR exist in clinical psychology. In the treatment of psychological disorders, Augmented Reality has given preliminary evidence to be a useful tool due to its adaptability to the patient needs and therapeutic purposes and interactivity. Another relevant factor is the quality of the users experience in the Augmented Reality system determined from emotional engagement and sense of presence. This experience could increase the AR ecological validity in the treatment of psychological disorders. This paper reviews the recent studies on the use of Augmented Reality in the evaluation and treatment of psychological disorders, focusing on current uses of this technology and on the specific features that delineate Augmented Reality a new technique useful for psychology.

Virtual multiple errands test (VMET): a virtual reality-based tool to detect early executive functions deficit in Parkinson's disease

Introduction: Several recent studies have pointed out that early impairment of executive functions (EFs) in Parkinson’s Disease (PD) may be a crucial marker to detect patients at risk for developing dementia. The main objective of this study was to compare the performances of PD patients with mild cognitive impairment (PD-MCI) with PD patients with normal cognition (PD-NC) and a control group (CG) using a traditional assessment of EFs and the Virtual Multiple Errands Test (VMET), a virtual reality (VR)-based tool. In order to understand which subcomponents of EFs are early impaired, this experimental study aimed to investigate specifically which instrument best discriminates among these three groups. Materials and methods: The study included three groups of 15 individuals each (for a total of 45 participants): 15 PD-NC; 15 PD-MCI, and 15 cognitively healthy individuals (CG). To assess the global neuropsychological functioning and the EFs, several tests (including the Mini Mental State Examination (MMSE), Clock Drawing Test, and Tower of London test) were administered to the participants. The VMET was used for a more ecologically valid neuropsychological evaluation of EFs. Results: Findings revealed significant differences in the VMET scores between the PD-NC patients vs. the controls. In particular, patients made more errors in the tasks of the VMET, and showed a poorer ability to use effective strategies to complete the tasks. This VMET result seems to be more sensitive in the early detection of executive deficits because these two groups did not differ in the traditional assessment of EFs (neuropsychological battery). Conclusion: This study offers initial evidence that a more ecologically valid evaluation of EFs is more likely to lead to detection of subtle executive deficits.

EEG alpha asymmetry in virtual environments for the assessment of stress-related disorders.

In this study we consider neurophysiological aspects for the assessment of stress-related disorders. EEG Alpha Asymmetry could represent an effective method to be used in the virtual environment. Nonetheless, new protocols need to be defined. In this study herein, we present two methods and a case study.