Using Multitouch Collaboration Technology to Enhance Social Interaction of Children with High-Functioning Autism.

AIMS: Children with high-functioning Autism Spectrum Disorder (HFASD) have major difficulties in social communication skills, which may impact their performance and participation in everyday life. The goal of this study was to examine whether the StoryTable, an intervention paradigm based on a collaborative narrative, multitouch tabletop interface, enhanced social interaction for children with HFASD, and to determine whether the acquired abilities were transferred to behaviors during other tasks. METHODS: Fourteen boys with HFASD, aged 7-12 years, participated in a 3-week, 11-session intervention. Social interactions during two nonintervention tasks were videotaped at three points in time, one prior to the intervention (pre), a second immediately following the intervention (post) and a third three weeks after the intervention (follow-up). The video-recorded files were coded using the Friendship Observation Scale to ascertain the frequencies of positive and negative social interactions and collaborative play. Differences in these behaviors were tested for significance using nonparametric statistical tests. RESULTS: There were significantly higher rates of positive social interactions and collaborative play, and lower rates of negative social interactions following the intervention suggesting generalization of the social skills learned during the intervention. Improvement was maintained when tested three weeks later. CONCLUSION: These findings provide support for the use of collaborative technology-based interventions within educational settings to enhance social interaction of children with HFASD.

Use of Gamification for Adult Physical Rehabilitation in Occupational Therapy; A Novel Concept?

AIM: This commentary discusses the concept of 'gamification' as referred to implicitly or explicitly in the occupational therapy literature. Although occasionally noted to be a new frontier for occupational therapy, our analysis suggests that game mechanics and gamification elements are, in fact, a 'road long traveled' by occupational therapists and that gamification evokes the core aims and vision of occupational therapy. Gamification has been implicitly incorporated into the occupational therapy literature for years, and its benefit of enhancing therapeutic outcomes is evident in many instances. We contend that a more explicit use of the term gamification within the occupational therapy literature will lead to a framework in which both practitioners and researchers can structure and evaluate therapeutic outcomes.

Reliability and validity of pediatric powered mobility outcome measures.

PURPOSE: To determine the intra-rater and inter-rater reliability of the Powered Mobility Program (PMP) and the Israel Ministry of Health Powered Mobility Proficiency Test (PM-PT); to test inter-rater reliability of the Assessment of Learning Powered Mobility (ALP) tool; to determine the convergent validity of these measures for children with physical disabilities. MATERIALS AND METHODS: Participants included 30 children (mean 10 years, 6 months [SD 3 years, 7 months]; range: 6-18 years) with cerebral palsy and other neuromuscular disorders. Participants were non-proficient powered wheelchair drivers. Two blinded raters assessed the driving ability by viewing videos of the participants twice as they drove a pre-designed route at ALYN Hospital, Israel. They were assessed via the PMP, ALP and PM-PT outcome measures. Intra-class correlation coefficients (ICC2,1) were used to test intra-rater and inter-rater reliability and Spearman correlation coefficients were used to assess convergent validity. RESULTS: The PMP intra-rater reliability revealed ICCs2,1 of coefficients were 0.97/0.98 for both raters. For the PM-PT the ICC2,1 was 0.89/0.96 for both raters. The PMP inter-rater reliability ICC2,1 was 0.94/0.87 for the two tests, for the PM-PT the ICC2,1 was 0.91/0.87 for the two tests and for the ALP the ICC2,1 was 0.83. The convergent validity between the PMP and the PM-PT was rs=0.96, between the PMP and ALP was rs=0.89 and between the PM-PT and ALP was rs=0.87. CONCLUSIONS: The PMP and PM-PT intra and interrater reliability were good to excellent, the ALP inter-rater reliability was good and the convergent validity between all three measures was good to excellent.Implications for rehabilitationThere is evidence of validity and reliability for three tests of powered wheelchair proficiency (PMP, PM-PT and ALP).Children using powered mobility, aged 6-18 years, now have outcome measures with empirical evidence that was previously lacking.When time for assessment is limited, the shorter PM-PT can be used instead of the more comprehensive PMP.

Validation of the Virtual MET as an assessment tool for executive functions.

The purpose of this study was to establish ecological validity and initial construct validity of a Virtual Multiple Errands Test (VMET) as an assessment tool for executive functions. It was implemented within the Virtual Mall (VMall), a novel functional video-capture virtual shopping environment. The main objectives were (1) to examine the relationships between the performance of three groups of participants in the Multiple Errands Test (MET) carried out in a real shopping mall and their performance in the VMET, (2) to assess the relationships between the MET and VMET of the post-stroke participant's level of executive functioning and independence in instrumental activities of daily living, and (3) to compare the performance of post-stroke participants to those of healthy young and older controls in both the MET and VMET. The study population included three groups; post-stroke participants (n = 9), healthy young participants (n = 20), and healthy older participants (n = 20). The VMET was able to differentiate between two age groups of healthy participants and between healthy and post-stroke participants thus demonstrating that it is sensitive to brain injury and ageing and supports construct validity between known groups. In addition, significant correlations were found between the MET and the VMET for both the post-stroke participants and older healthy participants. This provides initial support for the ecological validity of the VMET as an assessment tool of executive functions. However, further psychometric data on temporal stability are needed, namely test-retest reliability and responsiveness, before it is ready for clinical application. Further research using the VMET as an assessment tool within the VMall with larger groups and in additional populations is also recommended.

Training multitasking in a virtual supermarket: a novel intervention after stroke.

OBJECTIVE: To explore the potential of the VMall, a virtual supermarket running on a video-capture virtual reality system, as an intervention tool for people who have multitasking deficits after stroke. METHOD: Poststroke, 4 participants received ten 60-min sessions over 3 weeks using the VMall. The intervention focused on improving multitasking while the participant was engaged in a virtual shopping task. Instruments included the Multiple Errands Test-Hospital Version (MET-HV) in a real mall and in the VMall. RESULTS: Participants achieved improvements ranging from 20.5% to 51.2% for most of the MET-HV measures performed in a real shopping mall and in the VMall. CONCLUSIONS: The data support the VMall's potential as a motivating and effective intervention tool for the rehabilitation of people poststroke who have multitasking deficits during the performance of daily tasks. However, because the sample was small, additional intervention studies with the VMall should be conducted.

Moving beyond single user, local virtual environments for rehabilitation.

The rapid development of Virtual Reality-based technologies over the past decade is both an asset and a challenge for neuro-rehabilitation. The availability of novel technologies that provide interactive, functional simulations with multimodal feedback enable clinicians to achieve traditional therapeutic goals that would be difficult, if not impossible, to attain via conventional therapy. They also lead to the creation of completely new clinical paradigms which would have been hard to achieve in the past. In applications of rehabilitation for both motor and cognitive deficits the main focus of much of the early exploratory research has been to investigate the use of virtual reality as an assessment tool. To date such environments are primarily: (a) single user (i.e., designed for and used by one clinical client at a time) and (b) used locally within a clinical or educational setting. More recently, researchers have begun the development of new and more complex VR-based approaches according to two dimensions: the number of users and the distance between the users. Driven by a push-pull phenomenon, the original approach has now expanded to three additional avenues: multiple users in co-located settings; single users in remote locations; and multiple users in remote locations. After a presentation of examples that illustrate theses various approaches, we will conclude in addressing questions and ethical considerations raised by this evolution in the use of virtual environments in rehabilitation.

A NeuroVR based tool for cognitive assessment and rehabilitation of post-stroke patients: two case studies.

Neuropsychological disorders are common in stroke patients, ranging from an isolated impairment to impairment in multiple cognitive functions. The cognitive domains affected are in particular executive functions. These comprise planning, organising, conducting, assessing and controlling actions. Dual task abilities, that is the ability to perform successive or simultaneous tasks, are not easy to be evaluated and recovered by traditional paper and pencil methods, due to their ecological and contextual nature. NeuroVR 1.5 is a cost-free virtual reality platform based on open-source software, allowing professionals to easily modify a virtual world, to best suit the needs of the clinical setting.The present study was designed to develop and test a NeuroVR based tool for the rehabilitation of shifting of attention and action planning functions using tasks reminiscent of daily life tasks. We present the virtual environment and the cognitive procedure we developed, discussing two stroke patients case studies, which underwent an integrated neuropsychological and VR assessment.

Virtual reality as a leisure activity for young adults with physical and intellectual disabilities.

Participation in leisure activities is a fundamental human right and an important factor of quality of life. Adults with intellectual disabilities (ID) and physical disabilities often experience limited opportunities to participate in leisure activities, virtual reality (VR) technologies may serve to broaden their repertoire of accessible leisure activities. Although the use of VR in rehabilitation has grown over the past decade, few applications have been reported for people with ID. Thirty-three men and women with moderate ID and severe cerebral palsy participated in the study. Each participant in the experimental group (n=17) took part in VR activity two to three times weekly for 12 weeks. Virtual games were provided via GestureTek's Gesture Xtreme video capture VR system. The VR-based activities were perceived by the participants to be enjoyable and successful. Moreover, participants demonstrated clear preferences, initiation and learning. They performed consistently and maintained a high level of interest throughout the intervention period. VR appears to provide varied and motivating opportunities for leisure activities among young adults with intellectual and physical disabilities. Its ease of use and adaptability make it a feasible option for this population.

E-mentoring for youth with special needs: preliminary results.

Recently, a growing number of electronic mentoring (e-mentoring) Web sites have become available that provide vocational and career support. To date, few researchers have addressed the phenomenon of e-mentoring from a socioemotional perspective for populations with special needs. This paper presents a pilot study designed to test and evaluate an e-mentoring intervention program based on mutual self-disclosure and friendship for youth with special needs. Using qualitative methods, the study characterized the e-mentoring process and its contributions to this population. Results provided support for the socioemotional potential of computer-mediated communication for youth with special needs, although some barriers were found. Practical implications for implementing feasible e-mentoring programs for youth with special needs are discussed.

TIES that BIND: an introduction to domain mapping as a visualization tool for virtual rehabilitation.

The application of virtual reality (VR) to rehabilitation is a young, interdisciplinary field where clinical implementation very rapidly follows scientific discovery and technological advancement. Implementation is often so rapid that demonstration of intervention efficacy by investigators, and establishment of research and development priorities by funding bodies tend to be more reactive than proactive. An examination of the dynamic unfolding of the history of our young discipline may help us recognize the facilitators of current practice and identify the barriers that limit greater progress. This paper presents a first step towards the examination of the past and future growth of VR-based rehabilitation by presenting the use of concept maps to explore the publication history of application of VR to rehabilitation.

Reaching within video-capture virtual reality: using virtual reality as a motor control paradigm.

We have developed a virtual reality (VR) system that integrates a three-dimensional tracking device with a video-capture VR platform to record upper limb movements. The influence of target velocity on planning and execution of reaching movements was studied in five healthy subjects. Our initial results suggest that a target's velocity is considered when planning an interceptive action and that a hand reaching toward a moving virtual target is controlled in a similar way to how it is in the real visual environment.

BusWorld: designing a virtual environment for post-traumatic stress disorder in Israel: a protocol.

A number of carefully controlled studies have documented the effectiveness of traditional imaginal exposure for the treatment of post-traumatic stress disorder (PTSD). Virtual reality (VR) exposure therapy is based on a similar logic but rather than self-generating imagery, patients wear a VR helmet and go into a three-dimensional (3-D) computer generated virtual world to help them gain access to their memory of the traumatic event. Recent preliminary research has shown that some patients who fail to respond to traditional therapy benefit from virtual reality exposure therapy, presumably because VR helps the patient become emotionally engaged while recollecting/recounting/re-interpreting/emotionally processing what happened during the traumatic event. The present paper presents a brief overview of a new VR World we developed to provide virtual reality therapy for terrorist bus bombing victims in Israel, and a brief description of our research protocol and measures (for details, see www.vrpain.com).

Integrating haptic-tactile feedback into a video-capture-based virtual environment for rehabilitation.

Video-capture virtual reality (VR) systems are gaining popularity as intervention tools. To date, these platforms offer visual and audio feedback but do not provide haptic feedback. We contend that adding haptic feedback may enhance the quality of intervention for various theoretical and empirical reasons. This study aims to integrate haptic-tactile feedback into a video capture system (GX VR), which is currently applied for rehabilitation. The proposed multi-modal system can deliver audio-visual as well as vibrotactile feedback. The latter is provided via small vibratory discs attached to the patient's limbs. This paper describes the system, the guidelines of its design, and the ongoing usability study.

Usability of clinical decision support system as a facilitator for learning the assistive technology adaptation process.

The aim of this study was to evaluate the usability of Ontology Supported Computerized Assistive Technology Recommender (OSCAR), a Clinical Decision Support System (CDSS) for the assistive technology adaptation process, its impact on learning the matching process, and to determine the relationship between its usability and learnability. Two groups of expert and novice clinicians (total, n = 26) took part in this study. Each group filled out system usability scale (SUS) to evaluate OSCAR's usability. The novice group completed a learning questionnaire to assess OSCAR's effect on their ability to learn the matching process. Both groups rated OSCAR's usability as "very good", (M [SUS] = 80.7, SD = 11.6, median = 83.7) by the novices, and (M [SUS] = 81.2, SD = 6.8, median = 81.2) by the experts. The Mann-Whitney results indicated that no significant differences were found between the expert and novice groups in terms of OSCAR's usability. A significant positive correlation existed between the usability of OSCAR and the ability to learn the adaptation process (rs = 0.46, p = 0.04). Usability is an important factor in the acceptance of a system. The successful application of user-centered design principles during the development of OSCAR may serve as a case study that models the significant elements to be considered, theoretically and practically in developing other systems. Implications for Rehabilitation Creating a CDSS with a focus on its usability is an important factor for its acceptance by its users. Successful usability outcomes can impact the learning process of the subject matter in general, and the AT prescription process in particular. The successful application of User-Centered Design principles during the development of OSCAR may serve as a case study that models the significant elements to be considered, theoretically and practically. The study emphasizes the importance of close collaboration between the developers and the end users.

Building an effective ontology for assistive technology.

The aim of this paper was to develop and validate an ontology for one class of assistive technology (AT), namely physically controllable pointing devices, using the Delphi method. Six occupational therapists with AT expertise identified important items and categories to the pointing device prescription through a three-round, structured process consisting of responses to a series of questionnaires. The intraclass correlation coefficient (ICC) was used to assess the interrater reliability of items included in categories related to the pointing devices and to the user profile. During the first round, the ICC ranged from 0.19 to 0.97; this improved to ICCs ranging from 0.72 to 1.0 during the second round. A full consensus was reached by the experts during the final round which included 218 items, divided into five categories, for the pointing device list, and 168 items, divided into six categories, for the user profile list. This ontology is expected to help achieve a more systematic regulation of the AT field, leading to greater standardization and increased knowledge sharing.

Balance maintenance as an acquired motor skill: Delayed gains and robust retention after a single session of training in a virtual environment.

Does the learning of a balance and stability skill exhibit time-course phases and transfer limitations characteristic of the acquisition and consolidation of voluntary movement sequences? Here we followed the performance of young adults trained in maintaining balance while standing on a moving platform synchronized with a virtual reality road travel scene. The training protocol included eight 3 min long iterations of the road scene. Center of Pressure (CoP) displacements were analyzed for each task iteration within the training session, as well as during tests at 24h, 4 weeks and 12 weeks post-training to test for consolidation phase ("offline") gains and assess retention. In addition, CoP displacements in reaction to external perturbations were assessed before and after the training session and in the 3 subsequent post-training assessments (stability tests). There were significant reductions in CoP displacements as experience accumulated within session, with performance stabilizing by the end of the session. However, CoP displacements were further reduced at 24h post-training (delayed "offline" gains) and these gains were robustly retained. There was no transfer of the practice-related gains to performance in the stability tests. The time-course of learning the balance maintenance task, as well as the limitation on generalizing the gains to untrained conditions, are in line with the results of studies of manual movement skill learning. The current results support the conjecture that a similar repertoire of basic neuronal mechanisms of plasticity may underlay skill (procedural, "how to" knowledge) acquisition and skill memory consolidation in voluntary and balance maintenance tasks.

Virtual reality provides leisure time opportunities for young adults with physical and intellectual disabilities.

Due to limitations in their physical abilities, adults with cerebral palsy (CP) have relatively few opportunities to engage in independent leisure activities. This pervasive lack of opportunity often leads to the development of dependent behavioral patterns and learned helplessness. The objective of this pilot study was to explore ways in which virtual reality can provide positive and enjoyable leisure experiences during physical interactions with different game-like virtual environments and potentially lead to increased self-esteem and a sense of self-empowerment. The study sample consisted of five young male adults with CP and severe intellectual disabilities who are non-speaking and who use wheelchairs for mobility. Each participant experienced three game-like virtual scenarios via VividGroup's Gesture Xtreme video capture virtual reality (VR) system. The participant's video captured image was processed on the same plane as screen graphical animations that react in real time in response to his movements. Outcome measures included the participants' responses to a five-item presence questionnaire, a 6-item task specific questionnaire and observation of their videotaped performance while participating in the virtual games. Participants' responses to the questionnaire showed a high level of presence in all three scenarios. These participants demonstrated an exceptional degree of enthusiasm during each VR experience; some reacted to the various stimuli via appropriate and goal-oriented responses, in other cases the response was more arbitrary. Documentation of behaviors during and following the VR experiences may provide insight into the important role that VR may play in nurturing their self-esteem and sense of empowerment.

Design and testing of a virtual environment to train stroke patients with unilateral spatial neglect to cross a street safely.

Virtual reality (VR) entails the use of advanced technologies, including computers and various multimedia peripherals, to produce a simulated (that is, virtual) environment that users perceive as comparable to real world objects and events. In recent years, virtual reality technologies have begun to be used as an assessment and treatment tool in occupational therapy, in part because of the ability to create environments that provide patients with opportunities to engage in meaningful, purposeful tasks that are related to real-life interests and activities. The objective of this study was to determine the suitability and feasibility of using a PC-based, non-immersive, VR system (that is, a system in which the user has a reduced sense of actual presence in and control over the simulated environment) for training individuals with unilateral spatial neglect to cross streets in a safe and vigilant manner. A virtual environment, consisting of a typical city street, was programmed using Superscape's 3D-Webmaster, a 3D web-authoring tool. Twelve subjects, aged 55 to 75 years, participated in the initial feasibility study and, to date, a further eight subjects have participated in the intervention study. Six of the initial subjects and all eight of the intervention subjects had sustained a right hemispheric stroke at least 6 weeks prior to the study. The remaining subjects were healthy age-matched adults who were independently mobile and had no difficulty in crossing streets. The results show that this virtual environment was suitable in both its cognitive and motor demands for the targeted population and indicate that the virtual reality training is likely to prove beneficial to people who have difficulty with crossing streets. The generalizability of these results, and recommendations regarding the use of virtual reality as an occupational therapy intervention, must be substantiated by further studies using a range of VR platforms with people with different cognitive and motor disabilities.

Mouse manipulation through single-switch scanning.

Given the current extensive reliance on the graphical user interface, independent access to computer software requires that users be able to manipulate a pointing device of some type (e.g., mouse, trackball) or be able to emulate a mouse by some other means (e.g., scanning). The purpose of the present study was to identify one or more optimal single-switch scanning mouse emulation strategies. Four alternative scanning strategies (continuous Cartesian, discrete Cartesian, rotational, and hybrid quadrant/continuous Cartesian) were selected for testing based on current market availability as well as on theoretical considerations of their potential speed and accuracy. Each strategy was evaluated using a repeated measures study design by means of a test program that permitted mouse emulation via any one of four scanning strategies in a motivating environment; response speed and accuracy could be automatically recorded and considered in view of the motor, cognitive, and perceptual demands of each scanning strategy. Ten individuals whose disabilities required them to operate a computer via single-switch scanning participated in the study. Results indicated that Cartesian scanning was the preferred and most effective scanning strategy. There were no significant differences between results from the Continuous Cartesian and Discrete Cartesian scanning strategies. Rotational scanning was quite slow with respect to the other strategies, although it was equally accurate. Hybrid Quadrant scanning improved access time but at the cost of fewer correct selections. These results demonstrated the importance of testing and comparing alternate single-switch scanning strategies.

An online learning course in Ergonomics.

For the past two years, the Department of Occupational Therapy at the University of Haifa has offered an online course to third year occupational therapists on the topic of Ergonomics for Health Care Professionals. The development and implementation of this course was funded by the Israeli Ministry of Education. Unique teaching materials, developed and uploaded to the University's server via "High Learn", included interactive and self-directed documents containing graphics, animations, and video clips. Extensive use was made of the discussion forum and survey tools, and students submitted all assignments online. For the final topic, an expert in ergonomics from Boston University delivered a lecture via two-way videoconferencing. The course site included comprehensive library listings in which all bibliographic materials were made available online. Students accessed course materials at the University in a computer classroom and at home via modem. In an accompanying research study, the frequency of student usage of the various online tools was tracked and extensive data were collected via questionnaires documenting students' demographic background, preferred learning style, prior usage of technology, satisfaction with the course and academic achievement. This paper focuses on the results of the research study that examined how the students responded to and coped with teaching material presented and accessed in this format.