Cover Story: Get Real

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November 2004

By C.A. Wolski

Dan White, a graduate student (left), tests the visualization technology with George Fulk, MS.

As the lights dim, the green walls shimmer to life-a countertop, sink, and coffee maker appearing out of thin air. The patient reaches out and picks up the pixelated carafe, opening the tap, filling the container with blue liquid, pouring it into the coffee maker, and spooning in a few scoops of coffee, and, with a flip of a ghostly electronic switch, the sounds of percolating java fill the air. No, this is not a scene out of Star Trek, but an example of the virtual rehabilitation technology in development at Clarkson University's Center for Assistive and Adaptive Technologies for Rehabilitation Engineering.

For the past 2 years, the Potsdam, NY-headquartered center has been developing a virtual landscape that can be used by stroke patients and others on their road to recovery. The multidisciplinary center includes members of the physical therapy, engineering, and computer science faculty.

The Center for Assistive and Adaptive Technologies for Rehabilitation Engineering is funded by a multimillion- dollar grant from the Coulter Foundation, which has a special interest in rehab engineering. The three-dimensional virtual reality system designed using off-the-shelf software was developed to meet the needs of the local community and follows on the coattails of another virtual reality system developed by the center-a virtual wheelchair.

"The impetus for this whole thrust into visualization and the creation of the advanced visualization lab really came out of that Coulter resource," says James J. Carroll, PhD, associate professor at the Wallace H. Coulter School of Engineering. "I think the resource came to us because of Coulter's recognition that Clarkson was already doing these multidisciplinary [projects] to solve some interesting problems [such as the virtual wheelchair]."

Currently, the system is designed to project images on three walls, allowing the patient to be immersed in the virtual world. With the aid of polarized glasses, the patient can experience the scene three-dimensionally. The experience has a game-like feel to it, says Carroll.

However, the tasks, in order to be successful, have to have meaning for the patient, explains George Fulk, MS, instructor in the physical therapy program. "The thing that's nice about the system from the standpoint of working with patients is you can shape that interaction to make it difficult for the patient, but not so difficult they can't succeed," he says. "And subsequently, as they improve, you can make it harder and harder for them to do, but still make it so they can succeed at the task."

The current interaction is in the kitchen, where patients relearn and perfect skills that will allow them to live successfully at home. According to Fulk, the ideal patient for the system is one who has a good level of recovery.

The few patient volunteers that Fulk selected to first use the device were a bit skeptical of trying it. "There were varying reactions at first because they're not quite sure what it is or how it works, but once they use it a few times, most of the patients enjoyed it, they found it challenging," he says. "If they're using it to help improve their balance, they have to think more about how they're maintaining their balance, but at the same time it helps them make that balance automatic because they're interacting and making it a game."

Fulk understands where his patients are coming from. He has used the system himself and admits that navigating in the virtual world is not easy. "It takes a little time getting used to it in terms of how your perception of how you are moving and how you interact while you're in that virtual world," he says. "It's not something that you put on and figure out right away."

With the initial design, therapists will be on hand to help the patient with alleviating any frustrations they may have with the device.

THE VIRTUAL WORLD
Though three-dimensional and interactive, the visual design of the world is stylized to simply represent various common objects-carafes, water, countertops-rather than providing hyperrealistic simulacra of these items. There were technical and psychological considerations for this-Carroll says that a more realistic setting would take longer to render and could be distracting to the patient. And from a rehab point of view, the environment simply does not need to be so realistic. "There has been some research showing that when people are interacting in a virtual environment....it is so detailed they don't really notice," says Fulk. "[We're trying] to balance how realistic that content should be versus what's good enough to be effective."

Even though the system has clear advantages in the rehab process-helping patients develop the ability to perform a multistage task-it is designed to be an adjunct to rehab. "Hopefully, someone will be able to use it in the initial stage of rehabilitation to help promote that recovery. Then, hopefully, people will be able to use it in a less supervised way, maybe through tele-rehabilitation. And it may be something that they can continue in order to get better once their rehab is completed," says Fulk.

In addition to helping the patient relearn skills, the device will also help the physical therapist monitor the success of the rehab process by recording the results of each interaction, according to Carroll. "If you do something within this virtual world, you have the ability to monitor and track very accurately the motion of the individual in the space," he says. "That information, the angles and the kinematic locations of their arms, the speeds of their limbs, can actually be saved on a back-end database, and the therapist can access that data, crunch it, and produce all sorts of reports. So you not only have a qualitative description of the person's increasing performance, but also a quantitative measure.

"That ability to actually measure what's going on in that virtual environment is an important part of what we're doing." The interactions can be individualized to meet the needs of the patient. The success of the project is not just a tribute to the off-the-shelf technology Carroll used, but to the multidisciplinary interaction by the various faculty involved in development.

MULTIDISCIPLINARY APPROACH
The multidisciplinary committee meets once a week to trade ideas and set them to become virtual reality. There is much collaboration among the committee members. "We try to explain what we'd like to get out of the intervention, or what type of information we would like to gather and store, or what we want the actual intervention to be," says Fulk. "So there's always some give-and-take in terms of what can be done and what we would like to be done and how we should go about getting to that place."

While Carroll and his computer colleagues were responsible for the practical design of the simulated environment, real-life data was needed to create a dynamic interaction. "It's a matter of having content and then adding behavior to the content," says Carroll. "This environment allows you to define behaviors in any way that's programmable." On the other side of the interaction, Carroll uses a variety of tracking and measurement devices to monitor the patient's behavior in the environment, including electromagnetic trackers and EMG sensors. Fulk's primary responsibility was to develop credible interventions for the system. Most of these are daily living scenarios. The kitchen in the current coffee-making scenario is part of a larger environment that will be expanded upon.

Once the initial work on the system was finished, technical communications students in the School of Arts and Sciences were given it to use for testing. "They are responsible for assessing the front end, [examining] how usable this interface is for both the patient and the therapist," says Carroll. "Just because you develop some new technology does not necessarily mean it will be adopted in the field. So the idea is to assess how effective this tool is in terms of the usability and the efficiency of the interface."

From there, it moved on to patient testing at Clarkson, and eventually will move to Good Shepherd Hospital, Allentown, Pa, for additional tests.

The beneficiaries of the new technology are not only the patients and therapists, but students at Clarkson.

REAL-LIFE EXPERIENCE
The Department of Engineering offers a concentration in rehab engineering, and work on the virtual reality system is part of the undergraduate student's capstone design project. Both undergraduate and graduate engineering students regularly sit in on design committee meetings.

The Physical Therapy Department has not incorporated the project into its coursework, though Fulk says several students have been helping on a volunteer basis.

The virtual reality rehab system is not just a project for the ivory tower. Carroll has definite plans to take it to a commercial conclusion.

Carroll has worked closely with the vendor of the visualization software to develop the system. "We have some industrial partners, and there is a company that makes [a system] that is more of a two-dimensional interactive simulation environment that allows the individual to interact with some content," he says. "It's currently a green screen technology....It's very interesting technology, but it has some limitations that we felt we could improve upon.

"We're actually working with that company in addition to Good Shepherd Hospital, and it really was out of that sort of partnership that this notion of trying to build an improved interactive environment that would incorporate three-dimensional capability evolved."

Ultimately, both Carroll and Fulk hope that there will be a home version of the technology available to patients. But even though virtual reality holds real promise to improve the lives of stroke patients, it is no substitute for reality, says Fulk. "Nothing is going to take the place of the therapist, because the therapist still has to have the clinical reasoning and skills to know [what interventions to pursue] and how to progress it to help them get the most out of [the therapy]," he says.

Carroll says that the next step is to get enough data to take the system to the National Institutes of Health or another government organization that would be able to provide the resources to test the technology on a larger scale.

C.A. Wolski is associate editor of Rehab Management.

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November 2004