Adaptive Non-Immersive VR Environment for Eliciting Fear of Cockroaches: A Physiology-Driven Approach Combined with 3D-TV Exposure.

Non-immersive VR environments are related to the least interactive application of VR techniques, such that interaction with the VR environment can occur commonly by 3D-TV without full immersion into the environment. This study presents how 3D-TV exposure combined with physiology recording can elicit fear of cockroaches among individuals with different levels of fear. Thirty-six participants, set apart into three fear groups (low vs. moderate vs. high), were exposed to VR environment with cockroaches for 4 minutes while recording and using cardiac activity as input to the VR environment. Results revealed significant effects on self-report measures and heart rate between different fear groups. Moreover, participants with higher levels of fear were more likely to trigger cockroaches into the scenario due to their cardiac acceleration. Overall results suggest that our physiology-driven VR environment is valid for fear elicitation while having potential use in therapeutic domain.

Los entornos de RV no inmersivos se constituyen en la aplicación de menor interactividad en relación con las técnicas de realidad virtual, de modo que la interacción con el entorno de realidad virtual puede ocurrir de forma común en televisores 3D (TV-3D), sin que exista una inmersión total en el entorno. Este estudio presenta cómo la exposición a la TV-3D, combinada con el registro fisiológico, puede inducir temor a las cucarachas en personas con diferentes niveles de miedo. Treinta y seis participantes, divididos en tres grupos según su nivel de miedo a las cucarachas, fueron expuestos a un entorno de realidad virtual con cucarachas, durante 4 minutos, mientras se registraba su actividad cardíaca, que fue usada como entrada para el entorno de realidad virtual. Los resultados revelaron efectos significativos en las medidas tomadas por autorreporte y en la frecuencia cardíaca de diferentes grupos temerosos a las cucarachas. Además, los participantes más temerosos son más propensos a desencadenar la aparición de cucarachas en el entorno de realidad virtual, debido a su aceleración cardíaca. Los resultados generales sugieren que nuestro entorno de RV es válido para inducir miedo a las cucarachas, con un potencial uso en el dominio terapéutico.

Translation, Cultural Adaptation and Validation of the Current Opioid Misuse Measure for European Portuguese.

INTRODUCTION: Current practice guidelines recommend using Current Opioid Misuse Measure to screen aberrant opioid-related behaviors in chronic pain patients. Our aims were to translate, adapt and validate it to be used in Portuguese chronic pain patients. MATERIAL AND METHODS: Translation and cultural adaptation process followed guidelines and a model of principles for good practice. Adult chronic pain patients on opioid therapy, from one major hospital in Portugal, were invited to complete the translated version. Descriptive statistics, Cronbach's alpha, inter-item, item-total and intra-class correlation coefficients and principal components analysis were applied. RESULTS: Translation process was performed as planned and the validation sample was composed by 98 patients (median age = 62.5 years). Regarding internal consistency, a global Cronbach's alpha of 0.778 was obtained and item-total correlations of all items were above 0.20 with four exceptions. An intra-class correlation coefficient of 0.90 was found between test and retest. Regarding validity, all 17 items presented a content validity index above 0.80. Six principal components were extracted and explained 66.3% of the variance. DISCUSSION: The Portuguese version of Current Opioid Misuse Measure was properly translated, adapted and validated; showing good quality in terms of reliability and validity. This is the first instrument to screen aberrant opioid-related behaviors in Portuguese chronic pain patients. Consequently, it will aid and promote the identification of opioid misuse in these patients. CONCLUSION: The implementation of this questionnaire may reduce the incidence and morbimortality of opioid misuse among chronic pain patients and should improve chronic pain treatment in Portugal.

Introdução: Orientações atuais recomendam a utilização da Escala de Uso Indevido de Opióides para rastrear comportamentos aberrantes, relativos ao uso de opióides em dor crónica. Os objetivos foram a sua tradução, adaptação cultural e validação para a população portuguesa com dor crónica. Material e Métodos: O processo de tradução e adaptação cultural seguiu as recomendações. Adultos com dor crónica medicados com opióides, seguidos num hospital português de grande dimensão, foram convidados a completar a versão traduzida. Recurso a estatística descritiva, alfa de Cronbach, correlações inter-item, item-total, intra-classe, e análise de componentes principais. Resultados: A tradução decorreu conforme planeado e a amostra de validação foi de 98 doentes (mediana de idades = 62,5 anos). Relativamente à consistência interna, alfa Cronbach global = 0,778, correlações item-total dos itens > 0,20 (quatro exceções), e coeficiente de correlação intra-classe = 0,90 (entre teste e reteste). Relativamente à validade, os 17 itens apresentaram um índice de validade de conteúdo > 0,80. Extraíram-se seis componentes principais, que explicaram 66,3% da variância. Discussão: A versão portuguesa da Escala de Uso Indevido de Opióides foi adequadamente traduzida, adaptada e validada; demonstrando boa qualidade relativamente à confiabilidade e validade. Este é o primeiro instrumento para rastrear comportamentos aberrantes, relativos ao uso de opióides em portugueses com dor crónica. Consequentemente, ajudará e promoverá a identificação do uso indevido de opióides nestes doentes. Conclusão: A implementação deste questionário poderá reduzir a incidência e morbimortalidade do uso indevido de opióides em doentes com dor crónica, e deverá melhorar o tratamento da dor crónica em Portugal.

Cognitive Stimulation of Elderly Individuals with Instrumental Virtual Reality-Based Activities of Daily Life: Pre-Post Treatment Study.

As the demographic structure in western societies ages, the prevalence and impact of cognitive decline rises. Thus, new solutions to tackle this problem are required. The use of Information and Communication Technologies (ICT)-based cognitive exercises has emerged in the last few decades, though with inconsistent results. Hence, we conducted a pre-post treatment study to further investigate this approach. We designed a set of virtual reality exercises that mimic activities of daily living by which the patient can train different cognitive domains. Twenty-five participants, ages 65-85, underwent 12 training sessions between the pre-treatment and post-treatment assessments. Significant increases were seen between the two assessments for some of the neuropsychological measures: visual memory, attention, and cognitive flexibility. Results also suggest that participants with lower baseline cognitive performance levels improved most after these sessions.

Performance on naturalistic virtual reality tasks depends on global cognitive functioning as assessed via traditional neurocognitive tests.

This investigation sought to understand whether performance in naturalistic virtual reality tasks for cognitive assessment relates to the cognitive domains that are supposed to be measured. The Shoe Closet Test (SCT) was developed based on a simple visual search task involving attention skills, in which participants have to match each pair of shoes with the colors of the compartments in a virtual shoe closet. The interaction within the virtual environment was made using the Microsoft Kinect. The measures consisted of concurrent paper-and-pencil neurocognitive tests for global cognitive functioning, executive functions, attention, psychomotor ability, and the outcomes of the SCT. The results showed that the SCT correlated with global cognitive performance as measured with the Montreal Cognitive Assessment (MoCA). The SCT explained one third of the total variance of this test and revealed good sensitivity and specificity in discriminating scores below one standard deviation in this screening tool. These findings suggest that performance of such functional tasks involves a broad range of cognitive processes that are associated with global cognitive functioning and that may be difficult to isolate through paper-and-pencil neurocognitive tests.

The Art Gallery Test: A Preliminary Comparison between Traditional Neuropsychological and Ecological VR-Based Tests.

Ecological validity should be the cornerstone of any assessment of cognitive functioning. For this purpose, we have developed a preliminary study to test the Art Gallery Test (AGT) as an alternative to traditional neuropsychological testing. The AGT involves three visual search subtests displayed in a virtual reality (VR) art gallery, designed to assess visual attention within an ecologically valid setting. To evaluate the relation between AGT and standard neuropsychological assessment scales, data were collected on a normative sample of healthy adults (n = 30). The measures consisted of concurrent paper-and-pencil neuropsychological measures [Montreal Cognitive Assessment (MoCA), Frontal Assessment Battery (FAB), and Color Trails Test (CTT)] along with the outcomes from the three subtests of the AGT. The results showed significant correlations between the AGT subtests describing different visual search exercises strategies with global and specific cognitive measures. Comparative visual search was associated with attention and cognitive flexibility (CTT); whereas visual searches involving pictograms correlated with global cognitive function (MoCA).

Cognitive Training through mHealth for Individuals with Substance Use Disorder.

BACKGROUND: Heroin addiction has a negative impact on cognitive functions, and even recovering addicts suffer from cognitive impairment. Recent approaches to cognitive intervention have been taking advantage of what new technologies have to offer. OBJECTIVES: We report a study testing the efficacy of a serious games approach using tablets to stimulate and rehabilitate cognitive functions in recovering addicts. METHODS: A small-scale cognitive training program with serious games was run with a sample of 14 male heroin addicts undergoing a rehabilitation program. RESULTS: We found consistent improvements in cognitive functioning between baseline and follow-up assessments for frontal lobe functions, verbal memory and sustained attention, as well as in some aspects of cognitive flexibility, decision-making and in depression levels. More than two thirds of patients in cognitive training had positive outcomes related to indicators of verbal memory cognitive flexibility, which contrasts to patients not in training, in which only one patient improved between baseline and follow-up. CONCLUSIONS: The results are promising but still require randomized control trials to determine the efficiency of this approach to cognitive rehabilitation programs for the cognitive recovery of heroin addicts.

Cognitive training on stroke patients via virtual reality-based serious games.

PURPOSE: Use of virtual reality environments in cognitive rehabilitation offers cost benefits and other advantages. In order to test the effectiveness of a virtual reality application for neuropsychological rehabilitation, a cognitive training program using virtual reality was applied to stroke patients. METHODS: A virtual reality-based serious games application for cognitive training was developed, with attention and memory tasks consisting of daily life activities. Twenty stroke patients were randomly assigned to two conditions: exposure to the intervention, and waiting list control. RESULTS: The results showed significant improvements in attention and memory functions in the intervention group, but not in the controls. CONCLUSIONS: Overall findings provide further support for the use of VR cognitive training applications in neuropsychological rehabilitation. Implications for Rehabilitation Improvements in memory and attention functions following a virtual reality-based serious games intervention. Training of daily-life activities using a virtual reality application. Accessibility to training contents.

Eye Movement Analysis and Cognitive Assessment. The Use of Comparative Visual Search Tasks in a Non-immersive VR Application.

BACKGROUND: An adequate behavioral response depends on attentional and mnesic processes. When these basic cognitive functions are impaired, the use of non-immersive Virtual Reality Applications (VRAs) can be a reliable technique for assessing the level of impairment. However, most non-immersive VRAs use indirect measures to make inferences about visual attention and mnesic processes (e.g., time to task completion, error rate). OBJECTIVES: To examine whether the eye movement analysis through eye tracking (ET) can be a reliable method to probe more effectively where and how attention is deployed and how it is linked with visual working memory during comparative visual search tasks (CVSTs) in non-immersive VRAs. METHODS: The eye movements of 50 healthy participants were continuously recorded while CVSTs, selected from a set of cognitive tasks in the Systemic Lisbon Battery (SLB). Then a VRA designed to assess of cognitive impairments were randomly presented. RESULTS: The total fixation duration, the number of visits in the areas of interest and in the interstimulus space, along with the total execution time was significantly different as a function of the Mini Mental State Examination (MMSE) scores. CONCLUSIONS: The present study demonstrates that CVSTs in SLB, when combined with ET, can be a reliable and unobtrusive method for assessing cognitive abilities in healthy individuals, opening it to potential use in clinical samples.

The Immersive Virtual Reality Experience: A Typology of Users Revealed Through Multiple Correspondence Analysis Combined with Cluster Analysis Technique.

Immersive virtual reality is thought to be advantageous by leading to higher levels of presence. However, and despite users getting actively involved in immersive three-dimensional virtual environments that incorporate sound and motion, there are individual factors, such as age, video game knowledge, and the predisposition to immersion, that may be associated with the quality of virtual reality experience. Moreover, one particular concern for users engaged in immersive virtual reality environments (VREs) is the possibility of side effects, such as cybersickness. The literature suggests that at least 60% of virtual reality users report having felt symptoms of cybersickness, which reduces the quality of the virtual reality experience. The aim of this study was thus to profile the right user to be involved in a VRE through head-mounted display. To examine which user characteristics are associated with the most effective virtual reality experience (lower cybersickness), a multiple correspondence analysis combined with cluster analysis technique was performed. Results revealed three distinct profiles, showing that the PC gamer profile is more associated with higher levels of virtual reality effectiveness, that is, higher predisposition to be immersed and reduced cybersickness symptoms in the VRE than console gamer and nongamer. These findings can be a useful orientation in clinical practice and future research as they help identify which users are more predisposed to benefit from immersive VREs.

Systemic Lisbon Battery: Normative Data for Memory and Attention Assessments.

BACKGROUND: Memory and attention are two cognitive domains pivotal for the performance of instrumental activities of daily living (IADLs). The assessment of these functions is still widely carried out with pencil-and-paper tests, which lack ecological validity. The evaluation of cognitive and memory functions while the patients are performing IADLs should contribute to the ecological validity of the evaluation process. OBJECTIVE: The objective of this study is to establish normative data from virtual reality (VR) IADLs designed to activate memory and attention functions. METHODS: A total of 243 non-clinical participants carried out a paper-and-pencil Mini-Mental State Examination (MMSE) and performed 3 VR activities: art gallery visual matching task, supermarket shopping task, and memory fruit matching game. The data (execution time and errors, and money spent in the case of the supermarket activity) was automatically generated from the app. RESULTS: Outcomes were computed using non-parametric statistics, due to non-normality of distributions. Age, academic qualifications, and computer experience all had significant effects on most measures. Normative values for different levels of these measures were defined. CONCLUSIONS: Age, academic qualifications, and computer experience should be taken into account while using our VR-based platform for cognitive assessment purposes.

Cognitive assessment of stroke patients with mobile apps: a controlled study.

Stroke is a major cause of cognitive impairments. New technologies such as virtual reality and mobile apps have opened up new possibilities of neuropsychological assessment and intervention. This paper reports a controlled study assessing cognitive functioning through a mobile virtual reality application. Fifteen stroke patients recruited from a rehabilitation hospital and 15 healthy control subjects underwent neuropsychological evaluation with traditional paper-and-pencil tests as well as with a pilot version of the Systemic Lisbon Battery (SLB). The criterion validity was the performance of stroke patients vs. healthy controls - which was lower both on the neuropsychological tests and on the SLB for patients. The pattern of correlations between neuropsychological tests and the SLB sub-tests for the respective dimensions showed overall moderate correlations in the predicted directions. We conclude that the SLB applications were able to discriminate the dimensions that they were designed to assess.

Executive functioning in alcoholics following an mHealth cognitive stimulation program: randomized controlled trial.

BACKGROUND: The consequences of alcohol dependence are severe and may range from physical disease to neuropsychological deficits in several cognitive domains. Alcohol abuse has also been related to brain dysfunction specifically in the prefrontal cortex. Conventional neuropsychological interventions (paper-and-pencil cognitive stimulation training) have a positive effect but are time-consuming, costly, and not motivating for patients. OBJECTIVE: Our goal was to test the cognitive effects of a novel approach to neuropsychological intervention, using mobile technology and serious games, on patients with alcohol dependence. METHODS: The trial design consisted of a two-arm study assessing the cognitive outcomes of neuropsychological intervention with mobile serious games (mHealth) versus control (treatment-as-usual with no neuropsychological intervention) in patients undergoing treatment for alcohol dependence syndrome. Sixty-eight patients were recruited from an alcohol-rehab clinic and randomly assigned to the mHealth (n=33) or control condition (n=35). The intervention on the experimental group consisted of a therapist-assisted cognitive stimulation therapy for 4 weeks on a 2-3 days/week basis. RESULTS: Fourteen patients dropped out of the study. The results of the neuropsychological assessments with the remaining 54 patients showed an overall increase (P<.05) of general cognitive abilities, mental flexibility, psychomotor processing speed, and attentional ability in both experimental (n=26) and control groups (n=28). However, there was a more pronounced improvement (P=.01) specifically in frontal lobe functions from baseline (mean 13.89, SE 0.58) to follow-up (mean 15.50, SE 0.46) in the experimental group but not in the control group. CONCLUSIONS: The overall increase in general cognitive function for both experimental and control groups supports the beneficial role of existing alcohol treatment protocols aimed at minimizing withdrawal symptoms, but the differential improvements observed in frontal lobe functioning supports the use of mobile serious games for neuropsychological stimulation to overcome executive dysfunction in patients with alcohol dependence. This trial was negative on two neuropsychological/cognitive tests, and positive on one. TRIAL REGISTRATION: ClinicalTrials.gov NCT01942954; http://www.clinicaltrials.gov/ct2/show/NCT01942954.

Eliciting nicotine craving with virtual smoking cues.

Craving is a strong desire to consume that emerges in every case of substance addiction. Previous studies have shown that eliciting craving with an exposure cues protocol can be a useful option for the treatment of nicotine dependence. Thus, the main goal of this study was to develop a virtual platform in order to induce craving in smokers. Fifty-five undergraduate students were randomly assigned to two different virtual environments: high arousal contextual cues and low arousal contextual cues scenarios (17 smokers with low nicotine dependency were excluded). An eye-tracker system was used to evaluate attention toward these cues. Eye fixation on smoking-related cues differed between smokers and nonsmokers, indicating that smokers focused more often on smoking-related cues than nonsmokers. Self-reports of craving are in agreement with these results and suggest a significant increase in craving after exposure to smoking cues. In sum, these data support the use of virtual environments for eliciting craving.

Assessment of frontal brain functions in alcoholics following a health mobile cognitive stimulation approach.

The consequences of alcohol dependence syndrome are severe, ranging from physical diseases to neuropsychological deficits in several cognitive domains. Alcohol abuse has also been related to brain dysfunction specifically in the prefrontal cortex. We assessed these deficits and the effects of traditional (pen-and-paper) and novel (mobile technology) approaches to cognitive stimulation of alcoholics in a neuropsychological intervention program. Thirty alcoholics in treatment of alcohol dependence syndrome were assessed during four weeks on a three-day/week basis. The results showed an overall increase in frontal lobe function between the first and the final assessment, being more pronounced in alcoholics who were assigned to a treatment group with mobile technologies than to those assigned to a paper-and-pencil treatment and to a control group. These results support the use of ecologically sound and available approaches of neuropsychological stimulation to treat executive dysfunction in patients with alcohol dependence syndrome.

Nicotine craving: ERPs correlates after VR exposure to smoking cues.

Even though it is diminishing in Europe, smoking is still a serious health problem. The craving of Nicotine is one of the hardest behaviours to tackle when a smoking cessation programme is implemented. Following on previous work [1], which aimed at evaluating the possibility of inducing smoking craving in smokers using a VR platform, the present study was devised to assess the role of craving in cognitive processing through event related potentials (ERP). From an initial sample of 89 university students (smokers and non-smokers), which was randomly exposed to VR smoking cues and VR non-smoking cue scenarios, a subsample of 13 smokers and non-smokers was drawn. This subsample (M = 23.08; SD = 4.39), which had previously been immersed in the VR smoking cues environment, was presented to a rapid (1 sec) serial of smoking and neutral images. Data on brain activity was recorded through an EEG during this task to further estimate ERPs. When compared to non-smokers, smokers showed higher frontal activation when watching smoking related images.

Virtual reality exposure on nicotine craving.

Several forms of treatment for nicotine dependence that combine the classical smoking cessation strategies with new Virtual Reality (VR) exposure techniques to smoking-related cues are in development. In this line, the main goal of our study was to develop a virtual platform in order to induce cravings in smokers. Sixty undergraduate students were randomly assigned to two different virtual environments (high-arousal cues and low-arousal cues). Both environments were based on a three-room apartment with commercial music playing and virtual characters interacting in a social event. The assessment was carried out before and after exposure through psychophysiological activation and self-report data for craving and nicotine dependence levels. No statistical differences were observed between smokers and non-smokers in psychophysiological activation. As far as self-report data is concerned, smokers revealed a significant increase in craving after the VR exposure to high arousal environments. Overall results were in line with previous studies suggesting the use of virtual environments as a tool for the existing smoking cessation programs.

Training presence: the importance of virtual reality experience on the "sense of being there".

Nature and origin of presence are still unclear. Although it can be characterized, under a neurophysiological perspective, as a process resulting from a synchrony between cognitive and perceptive systems, the multitude of associated processes reduces the chances of brain mapping presence. In this way, our study was designed in order to understand the possible role of VR experience on presence in a virtual environment. For our study, 16 participants (M=28.39 years; SD=13.44) of both genders without computer experience were selected. The study design consisted of two assessments (initial and final), where the participants were evaluated with BFI, PQ, ITQ, QC, MCSDS-SF, STAI, visual attention and behavioral measures after playing an first person shooter (FPS) game. In order to manipulate the level of VR experience the participants were trained on, a different FPS was used during the 12 weekly sessions of 30 minutes. Results revealed significant differences between the first and final assessment for presence (F(1,15)=11.583; MSE=775.538; p<01) and immersion scores (F(1,15)=6.234; MSE=204.962; p<05), indicating higher levels of presence and immersion in the final assessment. No statistical significant results were obtained for cybersickness or the behavioral measures. In summary, our results showed that training and the subsequent higher computer experience levels can increase immersion and presence.

PTSD elderly war veterans: a clinical controlled pilot study.

Around 25,000 war veterans in Portugal suffer posttraumatic stress disorder (PTSD). This clinically controlled study evaluates virtual reality exposure therapy (VRET) as an alternative procedure to reduce PTSD symptoms. Ten patients were assigned to three groups: VRET, exposure in imagination (EI), and waiting list (WL). The patients were Portuguese veterans from a series of wars fought in former African colonies more than 30 years ago. While the EI group participated in traditional imagination therapy, the VRET group was exposed to a virtual reality (VR) war scenario. Cues such as ambush, mortar blasting, and waiting for rescue were used in the VR. Patients enrolled in the VRET group showed statistical reduction of PTSD-associated disorders like depression and anxiety. Far from being conclusive, this pilot study nonetheless presents some promising data on the use of VRET on old war veteran populations.

Virtual Reality Therapy Controlled Study for War Veterans with PTSD. Preliminary Results.

More than 30 years after signing truces, there are still around 20,000 Portuguese war veterans that fill PTSD (Posttraumatic Stress Disorder) diagnose criteria. Despite many of them attending therapy, the outcome is not cheerful. In this way, a research protocol was devised to investigate the opportunity of adopting virtual reality exposure therapy (VRET) to reduce PTSD symptomathology. This protocol consists on a controlled study (VRET vs. traditional psychotherapy vs. waiting list), where in the VRET condition patients will be graded by being exposed to a virtual reality jungle scenario. The activating episodes, that are comprised of three cues (ambush, mortar blasting and waiting for injured rescue), are repeated 3 times each session. The cues' intensity and frequency increase from session to session. Patients are exposed to the VR world through a HMD (Head Mounted Display). This paper reports on the ongoing research where 4 VRET patients that filled CAPS DSM-IV PTSD criteria were assessed at pretreatment and at the middle of treatment (5th session). Results from IES and SCL-90R dimensions showed no statistical significant differences between assessments, with exception to obsession-compulsion dimension of SCL-90R (F(1;3)=21.235; p<.05), indicating a decrease in obsessive thoughts. However, through descriptive analysis, it was observed a reduction in all IES and SCL-90R dimensions, except for hostility and psychoticism of SCL-90R.