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An Overview of Virtual Reality in Rehabilitation

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Title: An Overview of Virtual Reality in Rehabilitation


1
An Overview of Virtual Reality in Rehabilitation
  • David L. Jaffe, MS
  • VA Palo Alto Health Care System
  • Rehabilitation RD Center

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Topics
  • Definition of terms
  • VR Uses
  • VR Benefits
  • VR Hardware and Software
  • VR Applications in Rehabilitation
  • Specific VR Rehabilitation Projects
  • Stepping-over Responses
  • Driving Simulator

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Definition of VR
  • Virtual Reality is a technology that permits
    users to interact with elements outside the
    immediate physical world
  • Usually computer-based
  • Using one or more of the 5 senses
  • Interaction can occur at a distance
  • Elements can include objects, virtual people, and
    other VR users

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Different types of interactions
  • Virtual reality interaction with mostly virtual
    elements
  • Augmented reality interaction with mostly
    physical elements
  • Simulation interaction with processes that are
    well-defined or modeled in reality
  • Visualization interaction with elements normally
    hidden from view
  • Game interaction is for entertainment purposes

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VR elements
  • Physical people and objects
  • Virtual people and objects
  • Other VR users
  • A combination of above

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VR applications
  • Entertainment and games
  • Exploration of alternate environments
  • Training or practice on equipment
  • Control of devices at a distance
  • Investigation of design alternatives
  • Visualization of micro to macroscopic elements
    (2D and 3D)

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VR benefits - 1
  • Protects users from real physical risks and
    dangers by creating a safe environment for
    training
  • Produces scenarios that are difficult or
    impossible to create in reality
  • Monitors users responses and measure
    improvements in performance

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VR benefits - 2
  • Develops graded scenarios to challenge user
  • Provides real-time sensory feedback
  • Controls at a distance
  • Provides a different sensory perspective
  • Provides a different temporal perspective
  • Occupies users attention
  • Distracts users from pain

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VR technology
  • Displays
  • Head mounted displays
  • Force feedback devices
  • Haptic (tactile or vibro-tactile) devices
  • Actuators
  • Trackers
  • Camera systems

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Head mounted display
The Virtual Research V8 HMD has active matrix
LCDs with 640 by 480 pixel resolution and
headphones.
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Position tracking
  • The 3D-BIRD delivers smooth tracking of
    orientation angles without range limitation or
    line-of-sight restrictions.
  • 160 measurements per second
  • Provides orientation tracking for real-time
    viewing of 3D graphical images and scenes
  • Suited for head-tracking applications in which
    one needs to look around virtual environments and
    simulated worlds.

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Camera tracking
  • Non-contact, accurate motion measurement

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Microvision Nomad
The Microvision Nomad superimposes the equivalent
of a 17 display in the users field of view.
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Mobile VR
Wearable PCs can make the VR experience portable.
Wireless technology can also be employed to
connect users to the Internet.
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CAVE display
  • A multi-person virtual visual environment
  • 3 meter cube
  • Projections on 3 walls and floor
  • Users heads and hands are tracked
  • No force or tactile feedback
  • Can walk around in the virtual space
  • Not quite a Star Trek Holo-suite

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CAVE display
The CAVE has been made relatively small by using
mirrors to deflect the images from the video
projectors to the back-projection screens.
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Immersadesk
The ImmersaDesk is a drafting-table format
virtual prototyping device. Using stereo glasses
and sonic head and hand tracking, this
projection-based system offers a semi-immersive
intreaction. The ImmersaDesk features a 2 by 2.5
meter rear-projected screen at a 45-degree angle.
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P5 controller glove
  • The glove beams finger and hand movements to a
    base station
  • Used for computer gaming
  • Essential Reality - 129

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CyberGrasp by Immersion
  • Force feedback exoskeleton system for fingers and
    hand
  • Grasp computer-generated or tele-manipulated
    objects

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Software
  • Gesture Extreme Software by VividGroup - creates
    dynamic computer applications that allow computer
    users to step inside the screen and have their
    live video image replace the mouse as the
    controlling interface for the computers operation.

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VR in rehabilitation
  • Stake-holders
  • Researchers
  • Practitioners
  • Policy makers and advocates
  • Persons living with a disability

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Why should rehabilitation researchers be
interested in VR?
  • VR technology can provide a means for individuals
    with disability to perceive and interact with
    objects in a non-physical world.
  • Current applications include movement training,
    exploration of accessible environments,
    manipulation of virtual workplaces, assessment
    of mobility and cognitive functions, practice in
    operating a virtual wheelchair or mobile robot,
    treatment of phobias, and behavior modification.

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Why should rehabilitation practitioners be
interested in VR?
  • VR can provide a safe and consistent means of
    assessing and improving a wide variety of
    functional and cognitive abilities. These systems
    can be tailored to an individual's changing
    needs, preferences, and abilities. The degree of
    difficulty of a particular task can be programmed
    by a clinician and the user's performance can be
    measured and recorded. VR applications using a
    head-mounted display can provide an immersive
    visual environment that focuses the user's
    attention on the programmed task and can offer a
    unique viewing perspective.

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Why should rehabilitation policy makers and
advocates be interested in Virtual Reality?
  • VR applications may be able to improve functional
    outcomes in a cost-effective fashion. VR systems
    can be physically compact, taking up minimal
    space in a clinic and can be used with a minimum
    complement of personnel. The instrumentation can
    allow direct data streaming into a patient chart
    and provide objective evidence of effectiveness.

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Why should persons living with a disability be
interested in Virtual Reality?
  • Physical interactions with environments that are
    partially or wholly computer-generated allow a
    person to focus on a particular aspect of
    functional recovery without exposure to
    potentially dangerous situations.
  • For example, practicing stepping over virtual
    obstacles during harnessed treadmill walking is
    safer than stepping over blocks in the clinic
    while aided by a therapist. As proficiency,
    coordination, and strength improve, the more
    complex realities of real-world situations can be
    attempted with increased confidence.

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VR applications in rehabilitation
  • Sensory impairments
  • Physical impairments
  • Cognitive and behavioral impairments
  • Orthopedic and mobility impairments

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Parkinsons and AkinesisTom Reiss and Suzanne
Weghorst
  • Enables initiation of locomotion without visual
    targets through augmented reality
  • Static and moving images provide visual flow
    stimulus
  • http//www.hitl.washington.edu/research/parkinsons
    /

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Exposure Therapy for Spider PhobiaHunter
Hoffman, University of Washington
http//www.hitl.washington.edu/research/exposure/
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Integrated Wearable Orientation and Wayfinding
System for People with Vision LossDavid A. Ross,
Altanta VA Rehab RD Center
  • The wearable system being developed acts as an
    agent to integrate information from five existing
    location technologies into a seamless
    presentation of orientation and way-finding
    information for the blind traveler. The five
    technologies employed include GPS,
    Dead-Reckoning, Talking Signs, Talking Lights,
    and Relume Pedestrian Signals.

http//www.varrd.emory.edu/personnel/ross.htm
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Retractable Cane for the Visually
ImpairedVincent K. Ramsey, Altanta VA Rehab RD
Center
  • This project focuses on the development and
    testing of a retractable long cane that
    accurately simulates the experience of
    encountering a drop-off without exposing a
    visually impaired individual to the risk of
    falling. This device would permit these
    individuals to learn to appropriately respond to
    the kinesthetic feedback produced from a drop-off
    encounter in a safe environment. Three prototype
    canes are now being field tested with a
    videography motion system that analyzes subjects'
    gait parameters and reaction times.

http//www.varrd.emory.edu/personnel/ramsey.htm
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VR Driving SimulatorMaria T. Schultheis, Kessler
Medical Research
  • This project employs a driving simulator to
    evaluate driving capacity following a stroke or
    traumatic brain injury.

http//www.kmrrec.org/KM/bios/mschultheis.php3
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Real-Time 3D Virtual Training in SCI
RehabilitationTom MacLaughlin, Motion Reality,
Inc.
  • The system consists of a state-of-the-art
    real-time 3D Full Body Tracking, Dynamics
    Analysis and Computer Graphics Animation of
    spinal cord injury patient body motion and
    performance data. It provides a unique virtual
    reality/visual biofeedback capability for SCI
    clinical rehabilitation.
  • Additional novel capabilities include the ability
    to immerse the subject inside the body of a
    virtual "model' performer so the subject can
    "feel" what to do in a target task. Real-time EMG
    is converted to changing colors of graphical body
    muscles to provide visual feedback on
    instantaneous levels of muscle activation.
  • http//www.motionrealityinc.com/

Real-time 'step-in transfer skill learning
process
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Tele-Rehabilitation Functional
RehabilitationJared Baer, 5DT Inc.
  • This project involves the design, development,
    and application of a tele-rehabilitation
    application focusing on hand injuries. The system
    can also be used for the tele-rehabilitation of
    other disabilities.
  • http//www.5dt.com/index.html

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Exposure Therapy for Vietnam Veterans with
Posttraumatic Stress Disorder (PTSD)Ken Graap,
Virtually Better, Inc.
  • Two virtual Vietnam environments have been
    constructed to allow exposure based treatment of
    combat related PTSD in an open clinical trial
    with Vietnam Veterans who served in combat.
    Results suggested that many participants
    benefited from this treatment.
  • http//www.virtuallybetter.com/

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Face Attention in Preschoolers with AutismCheryl
Trepagnier, The Catholic University of America
  • Accumulating evidence suggests that failure to
    attend to and process face-borne information
    plays a major contributing role in the autistic
    syndrome. In this environment their gaze is
    monitored using eye tracking, and reward
    attention to people with enjoyable visual and
    auditory displays and rides in the 'pod' in which
    the training is delivered. The goal of the
    training is to provide the child with lots of
    experiences of positive consequences of looking
    at others, and to produce generalization of this
    behavior to peers.
  • http//www.atnrc.org/rd/rd_vrapp/prag/pragmatics.
    html

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Making Exercise FunRory A. Cooper, University of
Pittsburgh
  • Virtual reality provides a safe and effective
    means of developing and testing new interface and
    mobility technology for electric powered
    wheelchairs. In a virtual environment data can be
    gathered to tune devices to match the needs of
    individuals, and the virtual environment can
    serve as a training tool. By capturing the
    immersion offered by virtual gaming environments,
    the project has worked to make exercise and
    manual wheelchair mobility skills training more
    enticing and effective.

36
http//www.herlpitt.org/personnel-main.htmExecuti
ve Staff
37
VR Applications for Patients with Neurologic and
Orthopedic DeficitsLynda S. Savard, Sister Kenny
Rehabilitation Institute
  • Using the IREX VR non-immersive interactive
    technology, clinicians from multiple
    rehabilitation disciplines can present
    challenging and engaging therapeutic activities
    and exercises to patients with neurologic and/or
    orthopedic deficits.
  • mailtolsavard_at_allina.com

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Robotic Neurorehabilitation using Augmented
Reality DisplaysJames Patton, The Rehabilitation
Institute of Chicago
  • The PARIS augmented reality system allows the
    subject to view their own arm while receiving
    enhanced feedback of movement errors, forces, or
    visual distortions that can trick the nervous
    system into recovering faster.

http//www.smpp.northwestern.edu/robotLab/
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Cognitive Virtual Environments in Assessment and
RetrainingMark Dubin, University of Colorado
  • The CoVE project uses a recently opened Immersive
    Virtual Environment at the University of
    Colorado's Visualization Center to develop
    procedures for testing and retraining individuals
    with cognitive disabilities. Work in progress
    consists of the development of a visual, 3D test
    for early stage Alzheimer Disease. A conceptual
    plan and prototype for retraining of attentional
    mechanisms after brain injury is being addressed
    in this project.
  • http//spot.colorado.edu/dubin/

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VR Pain Distraction System
  • Distract the attention of patients who undergo
    painful procedures, useful when anesthesia is not
    an option.
  • User wears a HMD and plays a distraction game
    with a game pad or joystick.
  • HMD isolates user from the sight of the
    procedure.
  • The multi-level games provides a challenging and
    rich visual and auditory experience.

http//www.5dt.com/products/pvrpds.html
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Virtual interactive environments
  • Exposure therapy for phobias spiders, heights,
    fear of flying, fear of driving, fear of
    darkness, fear of small spaces
  • Behavior modification systems for eating
    disorders and teaching proper social behaviors

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VA RRD Projects
  • Using Augmented Reality to Improve Gait of Stroke
    Survivors
  • Driving Simulator to Assess and Improve
    Performance of Individuals after a Brain Injury

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Using Augmented Reality to Improve Gait of Stroke
Survivors
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Stroke
  • A stroke occurs when a rupture or blood clot
    reduces blood flow to an area of the brain,
    killing brain cells and disrupting the abilities
    or functions they control.
  • Many survivors experience weakness and poor
    coordination, which impairs their ability to walk
    and use their hands.

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Strokes impact on walking
  • Shortened stride length
  • Decreased walking speed
  • Balance problems
  • Increased risk of falling
  • Difficulty bending joints
  • Lower walking confidence
  • Diminished ability to climb stairs
  • Lower walking endurance
  • Difficulty stepping over obstacles

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Project hypothesis
Training people with stroke to step over objects
will improve their walking
  • Stride length
  • Walking speed
  • Balance
  • Ability to step over obstacles
  • Walking endurance
  • Confidence
  • Fear of falling
  • Quality of life

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AR training system
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Computer setup
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Camera
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Footswitches
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Vibro-tactile transducer
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Interface box
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Head-mounted display
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All wired up
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Step over
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Toe collision
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Heel collision
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VR training video 1/5
4 by 6 obstacles and stills
This video shows the view through the
head-mounted display. The video pauses to show
the different range of motion of each knee.
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VR training video 2/5
This video shows the assistance provided by the
therapist.
Manual assistance
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VR training video 3/5
The subject steps over 4 by 12 inch virtual
obstacles.
4 by 12 obstacles
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VR training video 4/5
The final VR training session for this subject
shows the best performance.
4 by 14 obstacles
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VR training video 5/5
The subject steps over the 4 by 4 inch virtual
obstacle. The stripe on the pants provide knee
flex information.
4 by 4 obstacle with striped pants
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Subject population
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Outcome summary
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Results
  • Statistically significant improvements with both
    training groups
  • Small differences between groups, but the AR
    group showed slightly better trends
  • All participants expressed positive experiences

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Conclusion
  • This training intervention
  • provides a safe environment for practicing new
    movement strategies
  • provides multiple immediate feedback channels
  • visual, auditory, tactile
  • involves a trained professional (PT)

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Future work
  • New populations
  • Stroke
  • Parkinsons Disease
  • Traumatic Brain Injury
  • Incomplete Spinal Cord Injury
  • New methodology
  • 4 weeks training
  • Addition outcome measures
  • New equipment and upgraded software

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Methodology for Using a Simulator to Assess and
Improve the Driving of Individuals after Brain
Injury
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Background - 1
  • Driving requires a complex set of skills and
    abilities
  • mobility, vision, visual-motor coordination, and
    multiple levels of cognitive function
  • A stroke, TBI, or SCI may result in diminished
    driving ability.
  • After an acute injury, the DMV may suspend
    drivers license upon notification from a
    physician.

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Background - 2
  • The ability to drive is an essential component of
    independent living and increases ones quality of
    life.
  • Disabled veterans and active duty personnel,
    including those undergoing rehabilitation, are
    entitled by Public Law 93-538 to have the
    opportunity to pursue a return to driving.
  • The PMR Service within the VA is responsible for
    providing driving evaluations and training to
    patients with TBI, stroke, SCI, and other
    disabling conditions.

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Driving tests after a CNS injury
  • Tests of vision, reaction time, range of motion,
    strength
  • On-road driving assessment
  • Up to 10 hours of in-car training
  • Prescription of adapted driving equipment

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Considerations
  • Patients may not have driven since accident
  • Accident may have reduced driving skill
  • Patients may be unaware of diminished skill
  • Patients may be stressed, anxious, fearful
  • Patients may lose control of car

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Problems to be addressed
  • In-car assessment and training activities create
    potentially hazardous situations for individuals
    with impaired cognitive function and diminished
    driving skills, their instructor, other cars, and
    pedestrians. Many close calls have been reported.
  • In-car assessments are essentially subjective and
    lack a standardized scoring system.
  • It is difficult to provide a graded driving
    training experience, repetitively practice a
    specific driving task, or test a patients
    ability to respond correctly to an emergency
    situation.

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Ideal solution
  • Means of assessing driving performance without a
    car
  • Method should correlate with existing assessments

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Project goal
  • The long-term goal of this research effort is to
    investigate the effectiveness of a high-quality
    interactive driving simulator to safely evaluate
    and improve the driving ability of individuals
    following brain injury.
  • Returning these individuals to driving satisfies
    the rehabilitation goals of community re-entry,
    improves their independence, and enhances their
    quality of life.

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What is a driving simulator?
  • A computer-based system that reproduces driving
    conditions and elicits driving responses in a
    clinical setting
  • Interactive drivers actions influence display

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Specific project goals
  • Screen for unsafe drivers before an in-car
    assessment is performed
  • Improve patients' awareness of their ability to
    drive safely
  • Reduce time required for assessments and training
  • Provide more effective training
  • Train better drivers
  • Improve patients' cognition, perception, and
    motor responses

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Deficits addressed
  • Cognition
  • Left-right orientation
  • Attention
  • Distraction
  • Visual motor tracking
  • Perceptual motor tracking
  • Spatial judgment depth perception
  • Multiple tasks
  • Divided attention
  • Visual perception
  • Judgment
  • Motor responses

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Photograph of simulator
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DriveSafety Model 550C 3-Channel Simulator with
Saturn cab.
82
Primary benefits of using a driving simulator
  • Safety the patient is not exposed to real
    traffic hazards
  • Reproducibility identical customized road
    courses can be presented to measure improvements
    in proficiency after training
  • Graded challenge training difficulty can be
    increased as patients driving performance
    improves
  • Versatility various road and weather conditions
    can be simulated, including emergency situations

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Benefits of using a simulator - 1
  • Increased safety for patients, pedestrians, and
    the driving evaluator cant run over
    pedestrians, hit other cars, or damage property
  • Ability to reduce fear, anxiety, anger, and
    frustration of veterans with brain injury who
    want to return to driving less stressful for
    those who havent driven since their accident
  • Ability to individually tailor training by
    targeting specific driving performance
    deficiencies

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Benefits of using a simulator - 2
  • Ability to safely and repetitively practice
    specific driving problems at the subject's own
    pace
  • Ability to objectively and consistently measure
    driving performance and track improvements
    including identifying learning plateaus
  • Ability to alter the difficulty of road courses
    to enhance the training experience and challenge
    subjects

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Benefits of using a simulator - 3
  • Ability to avoid inclement weather conditions
    through indoor operation
  • Ability to present unique driving situations such
    as a child running into the street
  • Ability to modify driving parameters such as
    steering effort to accommodate varying abilities

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Benefits of using a simulator - 4
  • New technology provides a high degree of realism
  • Potential time and money savings over the on-road
    assessment
  • Can be fitted with adaptive driving equipment to
    accommodate patients with physical limitations

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Research study
  • The efficacy of using a computer-based driving
    simulator to provide objective data on driving
    ability and driving-related cognitive function
    will be investigated.
  • The study will
  • compare in-car and simulator driving evaluations
  • compare the effectiveness of in-car and simulator
    training to improve driving performance
  • follow-up subjects driving in the community to
    establish correlations with evaluations and
    training

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Methodology
  • Administer questionnaires, neuropsychological
    tests
  • Perform simulator and in-car driving evaluations
  • Train BI subjects based on their in-car
    evaluation
  • Passed
  • Failed, judged trainable
  • Failed, judged not trainable
  • Randomize simulator and in-car training
    intervention
  • Perform post-training simulator and in-car
    evaluations
  • Re-administer tests and questionnaire
  • Analyze differences between in-car and simulator
    assessments and training
  • Monitor driving after 6 months (family member or
    friend)

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Evaluation courses
  • Instruction / Practice course
  • Hospital grounds
  • Residential
  • Commercial
  • Freeway
  • Hills and mountains

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Training courses
  • Several driving challenges presented in the
    context of a road course
  • Driving challenges can be graded from simple to
    difficult
  • The simulator can measure driving performance and
    alter difficulty dynamically

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Course design Step 1
  • Videotape and provide descriptive narration for
    the current on-road evaluation courses
  • The driving instructor was accompanied on the
    five on-road courses used to evaluate drivers.
    The courses were videotaped through the
    windshield. As he drove, the instructor described
    the driving challenges as they presented
    themselves and related the level of driving
    performance he expected from a proficient driver.
    He annunciated the verbal commands he gives the
    subjects as well as the mistakes poor drivers
    make.
  • Verbal notes of the road elements were made
    driveways, trees, buildings, schools, and
    pedestrians. The comments included specific
    driving situations such as people crossing in the
    middle of the street, joggers on the side of the
    road, and other unusual occurrences.

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Photograph from video
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Course design Step 2
  • View the videotape and compose a log of the
    course elements and driving challenges, and
    evaluation items to be measured.
  • The evaluation course videotape is reviewed and a
    chronological diary of the course elements are
    created. They consist of the general road
    conditions, the scenery, and the driving
    challenges experienced during the course. The
    driving challenges are organized into a list of
    specific observational evaluation items. Options
    for increasing the driving challenge are also
    noted. An example is
  • 12. pull into and back out of a diagonal parking
    space
  • 2 lane roadway in a parking lot
  • narrowness of the parking space
    increases difficulty
  • steering wheel control
  • gas/ brake coordination
  • use of turn signal

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Course design Step 3
  • Add / delete specific driving challenges to the
    individual course.
  • Additional driving challenges are added to the
    course list. They include items not easily
    reproduced on the road, such as interaction with
    emergency vehicles and unexpected situations such
    as a child running into the street. Other
    challenges present in the original video may be
    deleted if they have been presented previously.
    Other items can modified to increase their
    difficulty.

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Course design Step 4
  • Draw a roadway course on paper that somewhat
    conforms to the on-road evaluation courses.
  • The purpose of this task is to create a basic
    course layout that can be easily modified before
    it is constructed within the simulators
    authoring environment. The map would include
    roadway types, intersections, and turns.

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Paper course template
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Course design Step 5
  • Create the basic roadway on simulator using
    appropriate roadway tiles
  • The paper map is used as a template to create the
    course on the simulator. Road elements are
    selected and dragged/dropped onto the simulated
    world. Roadway and intersections types are
    designated and connected end-to-end.

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Overhead view of an intersection
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Course design Step 6
  • Add scenery items to the basic roadway
  • Additional buildings, driveways, signs, parked
    cars, pedestrians, and other static items are
    added to the basic roadway to create the proper
    environment for the driving challenges. Items are
    selected, positioned, and dropped into the
    roadway. Orientation and precision placement are
    specified.

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Car pulling out into road
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Perspective view of intersection
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Close-up of House Party
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Perspective view of course
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Close-up of objects
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Course design Step 7
  • Animate vehicles, pedestrians, to create specific
    driving challenges
  • Specific programming is required to specify time
    and location triggers that initiate movement of
    other vehicles and pedestrians and specify the
    path they will follow and the speed at which they
    will move. Sounds files can be added for
    increased realism or presented as instructions.

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Car pulling out of driveway
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Course design Step 8
  • Create programming that will measure performance
    during the driving challenges
  • Additional programming is created to monitor
    specific driving performances. This includes
    minimum/maximum speeds, vehicle following
    distance, quality of turns, lane position,
    stopping distance, brake or accelerator reaction
    time, and judgment during merging, right turn on
    red, etc. This information is written to a file
    during the simulator run and collected for
    subsequent analysis.

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Programming process
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Data collection
  • Speed
  • Acceleration
  • Lane position
  • Steering, throttle, and brake inputs
  • Collisions
  • Failure to stop
  • Speed limit violations
  • Divided attention response time
  • Following speed and distance
  • Reaction time
  • Other, programmable

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Future studies
  • Practice use of hand-control and adaptive driving
    aids
  • Evaluate performance of older drivers

Funding for this project has been provided by VA
Merit Review - B3288R.
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Questions
  • In the Stepping-over VR Project, why was a side
    view of the subject used?
  • What is cybersickness? What causes it? How can
    it be minimized?
  • In the driving simulator project, did anyone
    experience cybersickness?
  • What populations of VR users are more susceptible
    to cybersickness?

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Thanks to
  • VA investigators
  • VR investigators outside VA

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Contact information
  • David L. Jaffe, MS
  • jaffe_at_roses.stanford.edu
  • http//guide.stanford.edu

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