Chapter 10 Applications of VR Technologies for Childhood Disability Dido Green and Peter Wilson Objective To provide an overview of the evolution of VR technologies across domains of childhood disability that focuses on the evidence base for applications in research, clinical and community settings in order to optimise outcomes for the child and family. 10.1 10.1.1 Introduction Theoretical Models of Rehabilitation: Where Does VR Fit In? The ICF-CY represents a seismic shift away from the notion of disability as a purely medical construct in which the disability or impairment resides entirely with the child. Rather, there has been a move to a more ecological approach which considers the physical and psychological as well as the political and societal experiences of the child who has the “impairment” that then gives rise to disability and potential discrimination. An ecological approach to rehabilitation considers the impact of childhood disability on both the child and their family. Interventions therefore need to address the interaction between factors that lie within the child, the task and/or D. Green (*) Centre for Rehabilitation, Faculty of Health and Life Sciences, Oxford Brookes University, Marston Road Campus, Jack Straw’s Lane, Oxford, OX3 0FL, UK e-mail: dido.green@brookes.ac.uk P. Wilson School of Psychology, Australian Catholic University, 115 Victoria Pde., Melbourne, VIC 3450, Australia e-mail: peterh.wilson@acu.edu.au P.L. (Tamar) Weiss et al. (eds.), Virtual Reality for Physical and Motor Rehabilitation, Virtual Reality Technologies for Health and Clinical Applications, DOI 10.1007/978-1-4939-0968-1_10, © Springer Science+Business Media New York 2014 peterh.wilson@acu.edu.au 203 204 D. Green and P. Wilson the environment in order to maximise participation across contexts. The downside of adopting an ecological approach to intervention is the breadth of areas that may need to be addressed when taking into consideration individual experiences and perspectives. Such a model presents a number of practical and financial barriers in health care delivery. 10.1.2 Child Motor and Cognitive Development: Implications for VR-Based Applications Object knowledge is available to young infants in the form of perceptual primitives, as well as information conveyed by physical interaction with objects in space. Put another way, the rudiments of veridical object concepts are evident in the first 6 months after birth (Johnson, 2005) but more sophisticated object concept knowledge requires volitional interactions. Exploratory actions in both peripersonal and extrapersonal space, particularly those directed at objects, occur readily in infants and promote learning of the systematic co-variation between visual and somatic information (Bremner, Holmes, & Spence, 2008). The plasticity of the neural system enables this active learning by allowing the reinforcement of neural networks that support replication of successful (goal-directed) interactions (Cheung, in press). Ultimately, the child generates a sense of body schema that is attuned to their external world, and that can better anticipate the outcomes of their own actions. The perception of self in relation to the environment develops from active movements in peri-personal space, extending to interactions in extra-personal space, and gradually to actions which may have an impact on imaginary environments or those extended in both time and space. The extension of action planning (anticipatory planning) for potential outcomes of behaviour requires knowledge of alternative or occluded perspectives and is related to the complex interactions underpinning social cognition (Green, 1997). Intriguing is the fact that perception of three dimensional depth cues are not necessary for the perception of occluded objects but rather that this spatial knowledge can arise from motion information (Baillargeon, Spekle, & Wasserman, 1985; Shuwairi, Tran, DeLoache, & Johnson, 2010; Slater, Johnson, & Kellman, 1994). Moreover, projected two-dimensional (2D) images of impossible objects have also been shown to encourage manual exploration, socialisation and vocalisation in infants, reflecting the interrelationship between perceptual and motor mechanisms in development (Shuwairi et al., 2010). Taken together, while infants have a primitive system for spatial (object) perception, they need to interact dynamically with the object in space in order to learn higher-order object concepts and to build knowledge of the dynamics of their own motor system and its potentialities (i.e. the force–time relationships that are needed to impact the physical world and achieve action goals). In short, in order to develop advanced perceptual understanding, the peterh.wilson@acu.edu.au 10 Applications of VR Technologies for Childhood Disability 205 infant needs to interact with objects and interaction of the objects in space in order to understand the dynamics of their own system. The opportunity to present learning environments that provide affordances for interaction can be achieved in both 2D and three-dimensional (3D) projection, provided that the display makes use of kinematic cues. While a 2-D display allows us to derive spatial and perceptual information, manipulation of real objects in 3D space provides a stronger basis for the development of spatial knowledge (Bertenthal, 1996). VR systems that employ tangible interfaces can enhance perceptual experiences for children with disabilities, affording opportunities for manual interactions and exploration they might not otherwise have access to. This can assist children in mapping the relationship between their own actions and object and environment interactions. 10.1.3 Patterns of Neural Development Supporting Goal Directed Actions: Trends in Typical and Atypical Development The recent concept of interactive specialisation suggests that the emergence of a new behaviour is the result of weighted activity from several brain regions whose modular architecture and rate of maturation may vary (Johnson, 2005). Functional circuits within the central nervous system (CNS) are initially ill-defined and may be activated in response to a broad range of stimuli. With the advent of time and experience, these circuits or networks become more specialised. For a given band of stimuli, there develops a shift in activation from diffuse to more focal regions (Durston et al., 2006). The overarching hypothesis is that the functional output of a given cortical region is dependent on the nature of its reciprocal couplings to other regions. As such, new behaviours are seen to emerge as a result of changes to multiple regions rather than particular sites within the CNS. Frontal systems play a particularly important role in the control of goal-directed movement throughout development, enabling more flexible behaviour in the face of changing or more complex environmental constraints (Brocki & Bohlin, 2004). For example, high task complexity and variable constraints during reaching place significant demands on limited capacity working memory systems which are supported by the dorsolateral prefrontal cortex and parietal cortex (Suchy, 2009). Furthermore, differential neural activation of the medial prefrontal cortex versus left premotor cortex has been shown during imitation, depending on knowledge of the intention (or goal) underlying the observed action (Chaminade, Meltzoff, & Decety, 2002). It is a rule of thumb that the amount of top-down (or front to back) control increases substantially over childhood to enable more complex actions (Sommerville, Hare, & Casey, 2011). peterh.wilson@acu.edu.au 206 D. Green and P. Wilson One important implication of these developmental changes is that younger children and those with motor difficulties show limitations in the ability to enlist online control under complex task constraints (i.e. when demand on executive function is high). We see greater reliance on pure feedback systems under these conditions (e.g. Chicoine, Lassonde, & Proteau, 1992; Wilson, Ruddock, SmitsEngelsman, Polatajko, & Blank, 2013). Indeed, given the strong evidence for executive function deficits in Developmental Coordination Disorders (DCD), we may see a double disadvantage in the control of action: poor predictive control coupled with deficits of executive function, resulting in significant delays in skill acquisition and perhaps self-regulation. There is strong evidence of a link between executive control and the development of movement skill, more generally. Levels of inhibitory control, for example, are correlated with movement skill in both younger (Livesey, Keen, Rouse, & White, 2006) and older (Mandich, Buckolz, & Polatajko, 2003; Piek, Dyck, Francis, & Conwell, 2007; Wilmot, Brown, & Wann, 2007) children. 10.1.4 Atypical Development/Neurodevelopmental Disorders In cases of neural damage or problems of functional connectivity, reorganisation of the developing system has been shown to be influenced by activity. Eyre and colleagues (2001) have shown activity dependent withdrawal of ipsilateral corticospinal neural connections during the first 2 years of life which are retained in some children with hemiplegic cerebral palsy with a functional cost (Eyre et al., 2001). Accumulating evidence shows the importance of task specific intense and repetitive training for motor skill acquisition and neural plasticity for improved functional ability (French et al., 2010; Kuhnke et al., 2008; Sutcliffe, Logan, & Fehlings, 2009). However, less evidence is present for the translation of specific gains shown in the clinical setting to longer-term functional benefits. Furthermore, engaging children in such repetitive exercise is challenging and the potential benefits of these therapy programmes can be compromised by frustration and poor compliance (Campbell, 2002; Gilmore, Ziviani, Sakzewski, Shields, & Boyd, 2010). 10.2 Evolution of Technology-Mediated Rehabilitation in Childhood Disability VR technologies offer solutions that can be relatively easily engineered to accommodate to the reduced capabilities of children with varying disabilities. In addition, these may offer ecologically valid interventions, that are also acceptable from a psychosocial perspective, provide motivating and engaging exercise environments that can be scaled to individual needs and encourage repeated practice of functional actions under different task constraints (Bryanton et al., 2006; Snider, Majnemer, & Darsaklis, 2010). peterh.wilson@acu.edu.au 10 Applications of VR Technologies for Childhood Disability 207 Early approaches using VR systems in rehabilitation in childhood disability reported use of video capture technology for children with cerebral palsy (CP) or acquired brain injury (ABI) initially used systems such as the GestureTek Interactive Rehabilitation Exercise virtual reality system (http://www.gesturetekhealth.com/) to target specific areas of motor or cognitive impairment (see Laufer & Weiss, 2011 for review of use of VR systems in both assessment and treatment of children with motor impairments). As there have been only a few randomised controlled trials (RCT) of VR systems which have included children with specific types of CP and as performance profiles differ significantly between groups (and individuals), it is difficult to generalise results; changes in skill and participation have not been demonstrated across settings. While one RCT did not yield significant evidence of a positive treatment effect (n = 31; Reid & Cabell, 2006), a smaller RCT (n = 10, Jannink et al., 2008) using the Eye-Toy system (http://us.playstation.com/ps2/) showed treatment effects only at the body function level without reports of functional activity benefit for children with mixed types of CP. These mixed results are consistent with those summarised in a recent review by Laufer and Weiss (2011) and a study by Jelsma and colleagues (2013). For children with spastic hemiplegic CP, Jelsma et al. (2013) showed benefits from training on the Nintendo Wii Fit (http://wiifit.com/) on clinical measures of balance control; however, these effects did not translate into function. Recommendations for the use of VR for children with CP are thus inconclusive and clinical guidelines emphasise the need for intensive motor based and task specific therapies such as Constraint Induced Movement therapy (Anttila, Autti-Rämö, Suoranta, Mäkelä, & Malmivaara, 2008; NICE guidelines UK, 2012; Sakzewski, Ziviani, & Boyd, 2009). Research using 2D video capture systems (GestureTek IREX) has been undertaken with children with Traumatic Brain Injury (Galvin & Levac, 2011); a glove is used to identify the body part and indirectly embed the “child” into the environment. However, the temporal and sensory experiences are offset by the nature of the interface design such that the sensory feedback is not correlated in a way that reinforces the natural spatiotemporal relationship between modalities, nor reinforces the pragmatics of the task/game at hand (Golomb et al., 2009). By comparison, the use of objects known as tangible-user interfaces (TUIs), which enlist more intuitive forms of workspace interaction and real-time decision making, may provide opportunities to effect higher levels of presence and more natural movement kinematics and have shown stronger treatment effects and greater generalisation, in the main (e.g. Mumford et al., 2010; Subramanian, Massie, Malcolm, & Levin, 2010). Akhutina et al. (2003) successfully recruited an avatar based VE with additional desktop tasks for children with cerebral palsy. However, children with lower levels of cognitive performance did not show benefit from the additional training, indicative of the difficulties of scaling some systems sufficiently at lower levels of ability (Chen et al., 2007). The use of virtual tutors has been exploited within education environments. Of note, is the potential for the use of VR technologies with children with intellectual impairment. Protocols combining a software tutor and human tutor suggest that computer-aided learning may be helpful in assisting people with intellectual peterh.wilson@acu.edu.au 208 D. Green and P. Wilson disabilities in learning that transfers to the real-life situation (Standen, Brown, & Cromby, 2001). However, the variability within and between subjects and wide range of user requirements restrict interpretation. Interesting extensions of VR technologies in paediatric rehabilitation have recently emerged. Bart and colleagues (2008) successfully used VR training to improve confidence in street crossing abilities in children aged 7–12 years and also used the IREX system to distinguish between attentional and behaviour factors of children with and without ABI (Bart, Agam, Weiss, & Kizony, 2011), but less is known about the potential of such systems to improve real “street crossing”. The latter study attempts to address the elements of activity performance and participation in its research design however focusses on the measurement of specific levels of impairment as primary outcomes with as yet, little evidence showing change in specific functions transferring to real-time changes in activity performance or participation. A promising development, extending the role of VR to activity performance is evidenced by Kirshner, Weiss, and Tirosh (2011) in considering a virtual meal preparation environment for children with cerebral palsy. While research has tended to focus on the assessment role of the system, opportunities exist to extend these principles for the training of skills required for successful improvements in skills and participation in an important practical and social activity. Mixed reality environments may offer more opportunities to bridge the virtual to real task divide. Pridmore and colleagues (2007) have focused on developing mixedreality environments to “soften” the real–virtual divide with the aim of improved transfer of rehabilitation activities into everyday life. By placing the markers on objects, the interaction with a virtual world can be bridged by a tangible—or real— interface. The use of TUIs can enable a direct mode of wireless interaction within a visual display unit that has the advantage of overcoming the delay inherent in more “traditional” VR systems. Mixed-reality systems permit real-time tracking of an individual’s movements relative to events presented in a virtual workspace/environment along with more direct feedback of sensory perceptual characteristics of object/action environmental interactions. The Elements system, used in (Mumford & Wilson, 2009), adapted for paediatric use as the Reaction system (Green & Wilson, 2012), shows promise in promoting real-time responses for improved reaching and targeting for adults with acquired brain injury and children with cerebral palsy, respectively. The latter study also showed transfer to improvements in skills affecting performance in daily activities such as ability to open a (real) door. Interaction with multimodal interfaces may support the acquisition of intuitive movements, based on individual and subjective experience (and hence accommodating naturally to constraints of the specific impairments), as well as support the perception–action experiences required for performance of useful actions (Morganti, Goulene, Gaggioli, Stramba-Badiale, & Riva, 2006). Further research is required to see if these early results extend to larger and/or different paediatric populations. Another use of mixed environments has been explored by embedded groups of children (young adults) in real time, within play/games, designed to promote sociocognitive understanding of social engagement to facilitate actual social engagement behaviours in children with Autism (Bauminger-Zviely, Eden, Zancanaro, Weiss, & peterh.wilson@acu.edu.au 10 Applications of VR Technologies for Childhood Disability 209 Gal, 2013; Gal et al., 2009; Kandalaft, Didehbani, Krawczyk, Allen, & Chapman, 2013). This methodology shows potential in harnessing children’s interest in a mutual goal to promote implicit social learning for participation in interactive play activities with further research required to determine whether the impressive gains evidenced transfer beyond the research diads to novel and unexperienced social situations. The use of these technologies by Kandalaft et al. (2013) in young adults with high functioning autism show promise in transfer of skills to real-life social and occupational functioning (Gal, in press). The entertainment field has generated a number of readily available and increasingly more affordable technologies enhancing at one end leisure opportunities for children with disabilities as well as rehabilitation at the impairment level. Figure 9.1 illustrates the areas in which evidence or potential exists for the use of VR technologies across ICF levels. Commercially available gaming consoles using motion sensors such as the Nintendo Wii offer low cost virtual reality therapy options (www. nintendo.co.uk). The motion sensors use differences in the applied forces and movements to change the amount of visual and audio feedback provided. Case-study reports, as well as randomised trials, have suggested the Nintendo Wii Fit to be useful in enhancing motor proficiency in stroke patients (Mouawad, Doust, Max, & McNulty, 2011; Saposnik et al., 2010) and a child with diplegic cerebral palsy (Deutsch, Borbely, Filler et al., 2008) ‘and also 18 children with Developmental Coordination Disorder (Hammond, Jones, Hill, Green, & Male, 2013); however robust empirical data remain limited in childhood disability (Laver, George, Ratcliffe, & Crotty, 2011). Deutsch et al. (2008) demonstrated the effective use of the Wii gaming console, of a minimum of 7 h, in improving postural and functional mobility (distance walked with forearm crutches). The Wii fit programme has recently been used to promote motor and psychosocial skills of children with Developmental Coordination Disorder (DCD) in a programme run during school lunch break (Hammond et al., 2013). This latter study, while measuring the effects on balance and motor coordination, engaged children in a daily activity considered desirable to their non-DCD peers during recess. The use of Sony’s PlayStation2® EyeToy was equally effective as conventional physiotherapy for young children with DCD on balance and functional mobility tasks (Ashkenazi, Orian, Weiss, & Laufer, 2013). The extent to which such systems not only promote specific motor or social skills but act as a mechanism for engagement and enjoyment in meaningful social and leisure activities has yet to be explored. Children without disabilities are reporting an increased amount of time using computers and computer based technologies for both educational as well as leisure tasks (Rideout, Vandewater, & Wartella, 2003; Roberts, Foehr, & Rideout, 2005). Increasing evidence shows many children, with and without disabilities, to be using and engaging with computer and electronic games technologies in both play and educational activities (Green, Meroz, Margalit, & Ratson, 2012; Laufer & Weiss, 2011; Reid, 2002, 2004). While the targeted area of practice effects of research of different VR and mixed reality systems may focus on the impairment level, the outcomes of rehabilitation programmes should be targeted towards developing activity skills for enhanced participation across meaningful areas of performance. peterh.wilson@acu.edu.au 210 D. Green and P. Wilson While research to date has continued to focus on outcomes related to body function levels, the participation in computer/VR games in and of themselves corresponds with participation in activities that are meaningful to children at various levels across educational, leisure and social contexts. Bauminger-Zviely and colleagues (2013) begin to address this question through their studies exploring the use of the Diamond Touch system in developing social cognition for enhanced interactive play. The capacity to adapt and scale access to VR technologies may permit children with motor, social and cognitive deficits to participate in activities not only with matched disability peer groups but also with contemporaries without disabilities. As children with physical disabilities rarely have the opportunity to “compete” in physical activities on an equal playing field with their “non-disabled” peers, VR technologies have the potential to provide competitive/sporting opportunities for these children. Figure 9.1 illustrates the number of areas within the ICFDH-CY framework in which VR technologies have shown promise in promoting function and skills in young people. 10.3 Horses for Courses: Tailored Solutions for Specific Conditions Affecting Movement Rehabilitation systems using new (interactive) technologies can be classified in a number of ways. First, a distinction can be drawn between game-like systems that use the logic of many off-the-shelf technologies, and those systems designed more specifically for learning and rehabilitation (i.e. Virtual tutor/animation and telerehabilitation, respectively). Second, systems can be divided according to the particular behavioural or psychological focus of therapy, e.g. upper- or lower-limb rehabilitation, physical fitness/balance, functional rehabilitation, participation and play, social interaction and self-esteem, and self-empowerment (For review see: Galvin & Levac, 2011). How these distinctions are drawn is often a reflection of the specific neurological condition or disability. 10.3.1 Evidence Across Varieties of Cerebral Palsy Recent evaluations of off-the-shelf systems for children with hemiplegia are encouraging, albeit with small sample sizes. Applications vary across ICF domains targeting specific areas of impairment (upper limb control), activity performance (meal preparation, street crossing, etc.) and participation (notably in leisure activities). Golomb et al. (2010) showed improved manual ability (lifting objects with greater range of motion) in three adolescents with hemiplegic CP (HCP) using a 5DT 5 Ultra Glove and PlayStation3 game console; Chen et al. (2007) showed improved reaching (kinematics) translating to functional performance in three children with HCP using a series of reaching games programmed within the PlayStation2® EyeToy system; peterh.wilson@acu.edu.au 10 Applications of VR Technologies for Childhood Disability 211 and You et al. (2005) used the IREX VR system resulting in improved functional arm movements in a child with HCP with associated enhancement of cortical activation on functional magnetic resonance imaging. Use of these systems with their relatively low cost and fairly intuitive modes of interaction with children with HCP is promising, however it is not possible to separate out the specific benefits of the VR system from the intensity and duration of the protocols implemented in these studies (13–25 h over 36–67 days, 8 h over 4 weeks, 20 h over 4 weeks, respectively). Other intensive therapies such as constraint-induced movement therapy (CIMT) or hand–arm bimanual intensive therapy (HABIT), using protocols varying from 60 to 90 h across 2 weeks to 1 months, show evidence of positive motor skill translating to improved performance in activities of daily living (ADL) (Green et al., 2013). Ready-made, off-the-shelf systems frequently necessitate a prerequisite level of skill and neuromotor integrity to interact effectively with the learning environments (Green & Wilson, 2012). Hence, it is more difficult to vary task constraints below a certain, minimum level to match the developmental and cognitive aspects of children with disabilities. This then restricts application to younger children with movement difficulties whose nervous system may well exhibit greater plasticity and be more responsive to intervention (Eyre, 2007). Recent definitions of CP have highlighted the individualised manner that motor deficits and the frequently accompanying sensory, perceptual, cognitive, psychological and communication deficits interact and contribute to the overall functional impairment and disability (Bax, Tydeman, & Flodmark, 2006; Goble, Hurvitz, & Brown, 2009; Guzzetta, Tinelli, & Cioni, 2008). With a shift in understanding of the importance of collaborative goal setting (Löwing et al., 2009), interventions systems need to provide intuitive interfaces for interaction for many children or young people with motor and intellectual disabilities which also enable identification of the goal of the activity to optimise appropriate responses (Akhutina et al., 2003; Chen et al., 2007; Weiss, Bialik, & Kizony, 2003). Encouraging evidence of the potential of VR systems in rehabilitation of children with CP is provided by Akhutina et al. (2003). There was variation in severity of both motor and cognitive difficulties in their study, suggesting that progress in some aspects of the training was independent of initial severity. In contrast, the results of Jelsma et al. (2013) suggest a potential interaction effect between severity and the extent and nature of the therapeutic response. Consistent with the summary of Laufer and Weiss (2011), greater detail on individual variation and patterns of responses is required in reports of intervention effects, particularly in order to better understand how applications are working and to optimise programmes for individual children. 10.4 Future Directions The capacity of VR technologies to support motor learning through manipulation of feedback is covered in Levac and Sveistrup (in press). Feedback on performance (explicit and implicit) and predictive control play important roles in the course of peterh.wilson@acu.edu.au 212 D. Green and P. Wilson development (Hemayattalab & Rostami, 2009). Integrating technologies which manipulate/augment feedback has been shown to be effective in motor therapy for children with severe motor and cognitive disabilities (Green & Wilson, 2012). Critically, VR-based technologies afford many options for the provision of multisensory AF and avenues for future development in VR-assisted therapy. This form of therapy is an ideal solution for conditions that affect the predictive control of action, including CP and DCD. A recent review of object affordance in therapy suggests that the incorporation of real objects within therapy interventions is more important than either the functionality or number of objects (Hetu & Mercier, 2012). However, definitions of “functionality” vary between studies and the extent to which “conflict/impossibility” may in fact provoke more spontaneous actions has also not been explored within VR environments (Shuwairi et al., 2010). The anticipatory nature of representation, essential for motor planning (Hyde & Wilson, 2011; Liu, Zaine, & Westcott, 2007; Pezzulo, 2008; Steenbergen & Gordon, 2006) may be exploited by VR technologies either in assessment, outcome measurements or in intervention itself. In view of the burgeoning evidence of the relationship of motor imitation and motor planning, an unexplored area for VR technologies could exploit participant generation of images that result in more/less successful outcomes at a motor, social or behavioural level. Contrasting embedded images of self-performing movements versus use of Avatars for replication via imitation or gesture generation may provide important information of the role of imagery in both social and motor development. With advancements in technology, programmes designed which incorporate motor imagery for developing predictive planning may not be too distant. 10.5 Conclusion While little evidence is present for the translation of specific gains shown in the clinical setting to longer-term functional benefits, this may arguably be due to the different context of application across studies in which the variables of the person (motivation and capacity), task and the environment have been shifted in a nonlinear fashion, implicitly altering the nature of the task in both temporal and spatial spheres. Treatment targeting specific modalities such as reaching and grasping and spatial skills should not be considered in isolation from the motivational elements of the end-goal such as playfulness and functional everyday self-care and leisure activities (including ADL). Children need to be engaged in the therapeutic process for therapy to be effective (Löwing et al., 2009), supporting generalisation across specific skills to activity participation. Virtual Reality technologies have the potential to expand the opportunities available for engaging children in therapeutic activities across physical, social and cognitive domains. Indeed, past limitations that restricted access and extension into community and other settings, are being superseded by recent advances in portable, low-costs devices. peterh.wilson@acu.edu.au 10 Applications of VR Technologies for Childhood Disability 213 References Akhutina, T., Foreman, N., Krichevets, A., Matikka, L., Narhi, V., Pylaeva, N., et al. (2003). Improving spatial functioning in children with cerebral palsy using computerized and traditional game tasks. Disability and Rehabilitation, 25, 1361–1371. Anttila, H., Autti-Rämö, I., Suoranta, J., Mäkelä, M., & Malmivaara, A. (2008). 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