Analysis of Assets for Virtual Reality Applications in Neuropsychology Albert A. Rizzo, Maria Schultheis, Kimberly A. Kerns, and Catherine Mateer, Neuropsychological Rehabilitation (page 9 of 18) Page 9 of 18

6. The capacity to pause assessment, treatment and training for discussion and/or integration of other methods.

In the assessment and rehabilitation of complex behavior and/or functional activities, feedback is often an integral component. Similar to the previous asset regarding the availability of a naturalistic performance record, VR allows for a cumulative record to be reviewed at any point in the testing and training sequence. Specifically, immediate external therapist response to client performance is one form of feedback that is commonly seen in the rehabilitation of clinical populations. This may be of particular value for clinical populations who have memory difficulties that require more frequent review and feedback during a training session. While this may be possible through "traditional" approaches (i.e., one can always pause analog NP testing and training), VRs unique assets offer the opportunity to pause or "freeze time" in the middle of a functional "real-world" simulated task. This can result in additive learning benefits, whereby you can "stop and evaluate" not only individual performance, but also by examining what environmental elements may be effecting performance. For example, during activities in a VR kitchen for the completion of a simple task (i.e., making a can of soup), performance may be paused for the correction of errors (missed procedure steps), evaluation of safety elements of the task (where are the sharp objects) or discussion of perceptual difficulties (inappropriate visual scanning).

Thus, the ability to pause performance "mid-digitalstream" may also foster better processing and discussion of decision-making elements of performance. This may be useful for individuals with frontal lobe damage who have compromised executive skills and subsequently may benefit from an on the spot review of their step-by-step decision-making process. In addition, VR may allow for the clinician to monitor performance and provide problem solving guidance to test out potential alternative solutions, that when integrated into the rehabilitation intervention, may help increase client self-awareness of assets and limitations. For some tasks, the opportunity of combining immediate feedback and processing/discussion, obtainable through VR, may offer safety options not possible in the real world. For example, in driver re-training for individuals with cognitive compromise, the ability to pause performance mid-task and provide guidance may support an increased level of "awareness", which may serve to enhance learning and recall. Participants experiencing an "accident" in a driving VE, can be immediately "pulled over" and assisted in identifying errors that lead to the accident. This may result in fostering a heightened client awareness of the rehabilitation experience due to the immediacy and better specificity of performance feedback.

7. The design of safe testing and training environments that minimize the risks due to errors.

As alluded to in the VR Driving example presented above, when developing certain functionally based assessment and rehabilitation approaches, one must consider the possibility of safety risks that may occur during activities designed to test and train abilities in the real world. Driving would probably represent one of the more risk-laden activities that a client with CNS dysfunction would undertake in order to achieve functional independence. However, even simple functional activities can lead to potential injury when working with persons having CNS-based impairments. Such potential risks can be seen in the relatively "safe" environment of a kitchen (i.e. burns, falls, getting cut with a knife) as well as in more naturally dangerous situations such as in street crossing, the operation of mechanical/industrial equipment and driving a motor vehicle. Additionally, the risk for client/therapist injury and subsequent liability concerns, may actually limit the functional targets that are addressed in the rehabilitation process. These "overlooked" targets may actually put the client at risk later on as they make their initial independent efforts in the real world without having such targets addressed thoroughly in rehabilitation.

This is an area where VR provides an obvious asset by creating options for clients to be tested and trained in the safety of a simulated digital environment. The value of this has already been amply demonstrated in the predecessor field of aviation simulator research where actual flying accidents dropped precipitously following the early introduction of even very crude aircraft simulation training (Johnston, 1995). Thus far, this asset has served as a driving force for VR system design and research with clinical and "at-risk" normal populations. Such applications include: street crossing with unimpaired children (McComas, MacKay & Pivak, 2002), populations with learning and developmental disabilities (Strickland, 2001; Brown et al., 1998), and adult traumatic brain injury groups with neglect (Naveh, Katz & Weiss, 2000); kitchen safety (Rose, Brooks & Attree, 2000); escape from a burning house with autistic children (Strickland, 2001); preventing falls with at risk elderly (Jaffe, 1998); use of public transportation (Mowafty et al., 1995) and driving with a range of clinical populations (Liu, Miyazaki & Watson, 1999; Rizzo, Reinach, McGehee & Dawson, 1997; Schultheis et al., 2001). In addition to the goal of promoting safe performance in the real world, some researchers have reported positive results for building a more rational awareness of limitations using a VR approach. For example, Davis & Wachtel, (2000), have reported a number of instances where older adults, post-stroke, had decided not to continue making a return to driving a primary immediate goal after they had spent time in a challenging VR driving system. It is expected that the VR driving literature will grow as more attention is focused on preventing risk in both novice and aged populations.

From Neuropsychological Rehabilitation, 2004. 14(1/2), 207-239. Reprinted with permission from Albert Rizzo. All rights reserved.

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