Cyberpsychology & Computer Psychology Conference, Bolton, UK (2012) (the hotel room last night...)

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1 Cyberpsychology & Computer Psychology Conference, Bolton, UK (2012) (the hotel room last night...)

PSCHOLOGY & INFORMATION SCIENCE SCIENCE 2 Brian Dixon, Holger Regenbrecht, Elizabeth

2 Therapeutic Reflection: the Augmented Mirror Box project. A novel augmented reflection interface for pain relief and motor rehabilitation PSCHOLOGY & INFORMATION SCIENCE SCIENCE 2 Brian Dixon, Holger Regenbrecht, Elizabeth Franz, Graham McGregor & Simon Hoermann (University of Otago, Dunedin, New Zealand) June 2012 CyComP 2012 B. Dixon

3 Outline Introduction: Pain, movement, mirrors and brains Theory and practice The Mirror box Potential for neuroplastic change Augmented Reflection Technology The Augmented mirror box AMB studies (non clinical and cases) TheraMem game for physical rehabilitation TheraMem studies Future directions

4 Pain, movement, mirrors & brains

6 Background, theory and practice Some amputees experience phantom pain (and other sensations) in the missing limb. Phenomenon of phantom limb movement (Carlen et al., 1978). Franz et al spatial coupling between limbs (Franz, 1997). Franz and Ramachandran (1998) found bimanual coupling still occurs in amputees (ie central, not peripheral or physical process) Development of therapeutic devices to ameliorate unilateral (one sided) sensory and motor impairments.

$, 2008) increase movement affected by wrist fractures (Altschuler & Jeong, 2008); and enhance motor output in unilateral stroke (Gaggioli et al., 2005; Jang et al., 2005; Dohle et al.$

7 Applications: virtual movement (ie by reflection in a mirror) to: reduce pain for amputees (Ramachandran & Rogers-Ramachandran, 1996) relieve chronic pain (Tichelaar, 2007; Rudd et al., 2008) increase movement affected by wrist fractures (Altschuler & Jeong, 2008); and enhance motor output in unilateral stroke (Gaggioli et al., 2005; Jang et al., 2005; Dohle et al., 2008).

8 VR/AR therapy: Illusory ownership of limb Moseley, Olthof, Venema, Don, Wijers, Gallace, & Spence (2008). Psychologically induced cooling of a specific body part caused by the illusory ownership of an artificial counterpart. PNAS September 2, 2008 vol. 105 no

9 Mirror-Box Therapy

10 Mirror Box therapy: Phantom Limb Ramachandran & Hirstein (1998)

11 Mirror Box therapy: CRPS Type 1 (no nerve damage) McCabe, Haigh, Ring, Halligan, Wall, & Blake (2003). A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology 2003;42:97 101

12 Mirror Box therapy: Pain CRPS Type 2 (nerve damage) Selles, Schreuders, & Stam (2008). Mirror therapy in patients with Causalgia (Complex Regional Pain Syndrome Type II) following peripheral nerve injury: two cases. J Rehabil Med 2008; 40:

13 Mirror Box therapy: Stroke rehabilitation Yavuzer, G., Selles, R., Sezer, N., Sütbeyaz, S., Bussmann, JB., Köseoglu, F., Atay, MB., & Stam, HJ. (2008). Mirror therapy for hand rehabilitation poststroke. Arch Phys Med Rehabil Vol 89, March 2008

14 Neuroplasticity: The flexible brain NZ Listener, 4 May 2012

15 Pros and cons of optical mirrors Standard OMB: Is low cost, portable, readily available and has a long history of use BUT limitations include: Rigidity of use, only presents actual reflected images in real time asymmetrical body postures may be counterproductive Limited scope for augmentation in therapy Proliferation of applications (no protocols, poorly researched, claims untested) Few ways of manipulating a physical mirror (predetermined expectations) This resulted in recently developed prototypes of virtual reality mirror approaches, but with still some use of optical mirrors, eg Giraux & Sirigu, 2003; Sveistrup, 2004.

16 Augmented Reflection Technology Augmented Mirror Box

17 Augmented Mirror Box::from optical to electronic Franz, E. & Packman, T. (2004). Fooling the brain into thinking it sees both hands moving enhances bimanual spatial coupling. Exp Brain Res (2004) 157:

18 Augmented Mirror Box::Working Prototype MkII.1.0

19 Augmented Mirror Box: Non clinical studies Various experimental studies have been carried out to explore the AMB Student volunteers N=22 Temperature/sensation/movement Normals (students and staff) N= 30 Perceptions and ownership Subjects perceived reflections as their own hands (directly reflected) Most were unable to discern manipulation of reflected image (eg left reflected as right; images reversed etc)

believe in/accept ownership of mirrored limb but pain levels decreased.

20 Augmented Mirror Box: Pilot case study F1 First case study on CRPS using AMB Mirror effect seemed to work as well as mirror therapy (F1: subjective report) F1 did not believe in/accept ownership of mirrored limb but pain levels decreased. Development issues: the equipment setup was more suitable for hands; display placement warranted more consideration

21 Subject F1: Pain ratings in foot (light blue) and in CRPS area (dark blue) Right pain R stab 1 0 Pretest VR VR in box VR in box VR mirror water cold VR mirror after cooled water warn warm water using socks normal VR mirror with movement imagine move with mirror Time1 Time2 Time3 Time4 Time5 Time6 A3 (Time7) B (Time8) B2 (Time9) B3 (Time10) post trials Time11

22 Subject F1: Pain ratings in foot (blue) and in CRPS area (red) 10 Food Gas Motel Jan Feb Mar Apr May Jun Pretest VR VR in box VR in box VR mirror water cold VR mirror water warn after cooled warm water using socks normal VR mirror with movement imagine move with mirror post trials

23 Augmented Mirror Box: Case studies Examples of range of patient/subjects presenting problems F1: CRPS in foot F2: Right sided hemiplegia since TBI in m.v.a. 3 years ago F3: Pain left shoulder and arm post surgery 1996 M1: left hand injury, affecting driving work (gear changes) M2: 6 yr history of stroke, no pain but debilitating sensations in right arm, hand, fingers; problems manipulating objects and fine motor tasks (eg use of cutlery) M3: 30 yrs old; 10 yr hx of pain and limited movement after injuring right wrist; impedes writing and flexing / rotation are limited and painful We administer a wide range of psychometric instruments relating to pain, movement and wellbeing and conduct detailed assessment interviews with each patient before baseline assessment with the AMB.

24 Augmented Mirror Box::Potential Application Areas Current focus on primary application fields (unilateral impairments) Stroke and brain injury rehabilitation Complex Regional Pain Syndrome Phantom Limb Pain Management Also: AMB technique as a diagnostic tool AMB to help understanding the underlying (perceptual / neuropsychological) processes

25 Augmented Mirror Box::Objectives Providing more therapeutic control in mirror box applications using Augmented Reality technology Possible use of similar technology in different therapy/rehab areas, e.g. preventive (occupational) healthcare Research into the experienced sense of presence / motor control of real and imagined scenes: embodied interaction, affordances, possible actions Provision of a system (mature prototype) actually usable in clinical settings Extension of clinical and experimental work including that by the research partners (eg Liz s mirror box work and embodied interaction research, Brian s and Holger s VR exposure therapy work, Holger s presence research and technical VR/AR work of work ) utilising the features of the AMB. Exploring the possibility of neuroplastic changes combining the AMB and f MRI techniques.

26 Augmented Reflection Technology system

27 Augmented Reflection Technology image manipulation Desired manipulation options: Mirroring: none, left, right, both Size: environment or limb Position: x, y, z Movement: amplitude, pace (also shake/jitter) Timing: slow down, speed up, delayed Appearance: colour, visibility Touch: virtual or tactile (being touched or touch) Temperature (real, perceived) Grasp: virtual or real (being grasped or grasp) Immersion: resolution, fps, latency Foreign limb vs. own limb...

28 Augmented Reflection Technology augmentation menu Colour etc. Mirroring Size and Position 3D models 2D Backgrounds

29 Augmented Reflection Technology screen views Client s View 3D Scene View

30 TheraMem

Recovery After Virtual Reality in Patients With Chronic

31 TheraMem: Background. Motor Rehabilitation with VR/AR Cameirão, Bermúdez i Badia, Oller & Verschure (2008) Jang et al. (2005). Cortical Reorganization and Associated Functional Motor Recovery After Virtual Reality in Patients With Chronic Stroke: An Experimenter Blind Preliminary Study. Arch Phys Med Rehabil Vol 86, November 2005

32 TheraMem System

33 3D Scene Construction memory and movement game 3D Scene View Client s View

34 Fooling the brain amplifying movements Amplfication Factor 2.0 [s new = s ori * (f+1)] 1cm 3cm Camera Video Stream (original movement) User s View (left hand with amplified movement)

35 TheraMem Usability Study (N=45) Utility Evaluations 100 Physiotherapy Students SoP Seminar & Neuro SIG meeting Interviews with experts Clinical Case Studies with 6 patients

36 Where to from here? Clinical Case Studies (ongoing) Further developments Clinical Feasibility Studies RCT Deployment

37 Augmented Mirror: Potential Application Areas Disorders/conditions with paralysis or disturbances of sensation that may be responsive to augmented virtual mirror approaches: Hemiplegia/hemiparesis (full or partial paralysis) due to traumatic brain injury, stroke, TIA s or spinal injury/neoplasm Alternating Hemiplegias Missing or damaged limb/appendage sensory abnormalities (eg Phantom limb pain). Bell's palsy (Facial palsy; Idiopathic peripheral facial palsy). Conditions involving weakness or altered sensory awareness (eg of pain, temperature, pressure etc) affecting a limb or appendages such as Complex regional pain syndrome (CRPS) and Brown Sèquard syndrome.

38 Research principals Brian Dixon Holger Regenbrecht Liz Franz Graham McGregor Special thanks to Simon Hoermann, Leigh Hale, Claudia Ott, Danielle Windfuhr and Alexander Wollert.

39 Contact Brian Dixon Parts of this research have been funded by a University of Otago Research Grant ( R.DL).

40 Links and publications Regenbrecht, H., Hoermann, S., McGregor, G., Dixon, B., Franz, L., Ott, C. Hale, L., Schubert, T., & Hoermann, J. (in press). Visual Manipulations for Motor Rehabilitation. Computers & Graphics, Elsevier Science. Al Issa, H., Regenbrecht, H., & Hale, L. (2012). Augmented reality applications in rehabilitation to improve physical outcomes: a systematic review. Physical Therapy Reviews 17(1), Maney Publishing, Regenbrecht, H., Franz, L., McGregor, G., Dixon, B., & Hoermann, S. (2011). Beyond the looking glass: Fooling the brain with the Augmented Mirror Box. Presence: Teleoperators and virtual environments 20(6), MIT Press, Cambridge/MA, USA, June 2012 CyComP 2012 B. Dixon

41 Links and publications (contd.) Hoermann, S., Hale, L., Winser, S., & Regenbrecht, H. (accepted). Augmented Reflection Technology for Stroke Rehabilitation A clinical feasibility study. Proceedings of the 9th International Conference on Disability, Virtual Reality and Associated Technologies (ICDVRAT 2012), Laval, France, September 10 12, Regenbrecht, H., McGregor, G., Ott, C., Hoermann, S., Schubert, T., Hale, L., Hoermann, J., Dixon, B., & Franz, E. (2011). Out of reach? A novel AR interface approach for motor rehabilitation. Proceedings of The 10th IEEE International Symposium on Mixed and Augmented Reality (ISMAR 2011), Oct , 2011, Basel, Switzerland, SMAR11.pdf

42 Links and publications (contd.) Regenbrecht, H., Franz, E., McGregor, G., Dixon B., & Hoermann, S. (2011). From Mirror Therapy to Augmentation. Technical Report Discussion Paper. Information Science. University of Otago. Dunedin, New Zealand. Regenbrecht, H., Dixon, B., Franz, L. & McGregor, G. (2008). Videomediated reflection technology in rehabilitation and pain management: Some first steps.. Rehabilitation and Disability Colloquium. December , Dunedin, New Zealand. Dixon, B., & Regenbrecht, H. (2008). Virtual Reality Supported Therapy: Technologies and Ethics. New Zealand Bioethics Conference 'Wellbeing and Technology', Dunedin, New Zealand 1 3 February Dixon, B., & Regenbrecht, H. (2005). Cybertherapy at Otago: Virtual Possibilities and Current Realities. Presentation at NZ PsS Conference, University of Otago, September 2005.

45 45 June 2012 CyComP 2012 B. Dixon

46 46 June 2012 CyComP 2012 B. Dixon

47 (Thanks to Chris Slane)

AUGMENTED REFLECTION TECHNOLOGY

AUGMENTED REFLECTION TECHNOLOGY Feasibility Evaluation for Stroke Rehabilitation 1 with Leigh Hale, Stanley J. Winser and Holger T. Regenbrecht Outline Augmented Reflection Technology (ART) TheraMem Rehabilitation