Games For Health 2006: Addressing PTSD, Psychotherapy & Stroke Rehabilitation with Games & Game Technologies- Rusel DeMaria Introduction As part of the Games For Health day held at the University of Southern California on May 9th, USC's Dr. Albert “Skip” Rizzo presented an interesting study on psychotherapy and stroke rehabilitation using video games and related technologies, such as virtual reality (VR). Dr. Rizzo began his talk by presenting the three therapeutic areas he is working in, and the three main strategies he is using, which he abbreviates as Expose, Distract and Motivate. To develop the therapeutic VR systems he talked about, Dr. Rizzo worked with a host of other collaborators from different departments at USC, including Computer Science, Electrical Engineering, School of Fine Arts, School of Cinema/TV, Neuroscience, Annenberg School of Communication and Journalism, Department of Biokinesiology and Physical Therapy, Department of Occupational Sciences, USC Keck School of Medicine, Department of Psychology, School of Gerontology & Neurology, Department of Cell and Neurobiology and also the Children's Hospital of Los Angeles. In addition to the USC departments, Dr. Rizzo mentioned nearly a dozen clinical partners at universities and hospitals around the U.S., as well as at the University of Haifa. The 'Expose' Strategy For PTSD For PTSD (Post Traumatic Stress Disorder), the first type of therapy discussed, Dr. Rizzo dealt with the strategy referred to as “Expose”. In order to create simulations for treating soldiers suffering from PTSD, including soldiers currently serving in Iraq, Dr. Rizzo worked closely with Jarrell Pair of the Institute for Creative Studies at USC. Quoting from the New England Journal of Medicine, Time Magazine and other sources, Dr. Rizzo established that symptoms of PTSD are increasing with soldiers involved in the war in Iraq, compared, for instance, with soldiers who fought in Afghanistan. The definition of PTSD (from Dr. Rizzo's Power Point slide) was as follows: “ Post Traumatic Stress Disorder (DSM-4) is caused by traumatic events that are outside the range of usual human experiences such as military combat, violent personal assault, being kidnapped or taken hostage, terrorist attack, torture, incarceration as a prisoner of war, natural or man-made disasters, automobile accidents, or being diagnosed with a life-threatening illness. The disorder also appears to be more severe and longer lasting when the event is caused by human means and design (bombings, shootings, combat, etc.).” Dr. Rizzo described some of the symptoms of PTSD, such as flashbacks, reoccurring nightmares, avoidance, emotional numbing, hyper arousal, drug abuse and relationship problems. These are just some of the symptoms, however, which can extend into many areas of a person's life. He said that over time, some people adapt or habituate to the effects of their experiences, and can return to baseline levels. However, people with PTSD may begin to suffer symptoms after 30 days and, though some symptoms appear to lessen at first, the effects tend to flatten out without getting any better over time. The therapeutic approach Dr. Rizzo's project is taking uses gradual exposure to trauma in a manageable way, which eventually leads to habituation and extinction of the syndrome. Normally, about 75% of soldiers will begin to display PTSD symptoms within about six months. With traditional therapy, this is reduced to about 67%. But with exposure therapy, this can be reduced to only 27%. “We normally rely on a patient's imagination – what is called ‘imaginal therapy', but we know we can provide the exposure to them through game environments,” said Rizzo. Problems with imaginal therapy include patients being unwilling or unable to visualize effectively or avoidance of the reminders of the trauma. When a patient can't emotionally engage through imagination, it is unlikely that imaginal therapy will be effective. Tools For Gradually Exposing Sufferers To Trauma? Dr. Rizzo then mentioned several virtual tools, such as Virtual Vietnam from Emory University, as well as several others including a World Trade Center simulation from Cornell. Showing images from the Virtual Vietnam simulation, which depicts realistic scenes typical of that conflict, Dr. Rizzo cited a 1998 study that found, even 20 years after the events, that symptoms of sufferers of PTSD were reduced by 34 percent, while patients engaged in self-assessment though their symptoms saw reductions of 45 percent. Dr. Rizzo skipped over the World Trade Center simulation, saying we didn't need to see that again, but he did show a video clip of a virtual terrorist bus bombing from a collaboration between the University of Haifa and the University of Washington, demonstrating how the severity and realism of the simulation could be adjusted for therapeutic purposes. Other examples shown during the presentation of VR employed in treating PTSD included Motor Vehicle Accidents, a simulation from the University of Buffalo and Virtual Angola, which was created in Portugal. Dr. Rizzo then returned to his project at USC, Virtual Iraq, which is based on the popular commercial Xbox game, Full Spectrum Warrior, using assets from the game on top of others that have been added. This of course saved both time and money, as Dr. Rizzo and his team worked with the Office of Naval Research (ONR) as well as ICT, Virtually Better, Inc. and the Virtual Reality Medical Center (VRMC).
Making Virtual Iraq Although they began with Full Spectrum Warrior, they wanted to create high levels of stress in patients (the Expose part of the plan), so they modified content to accomplish these goals and recreate stressful situations similar to those the patients may have encountered on the battlefield and in war zones. As a therapeutic tool, aside from its game-related elements, the project needed full immersion, which they accomplished by employing VR headsets. They also needed a variety of situations, which the team provided by creating a library of trigger simulations in multiple scenarios. And they needed some way to control the intensity and content from outside the game environment, which was provided by creating what they called a “Wizard of Oz” clinician's interface, which according to the project's website “enables the clinician to control the virtual environment in real time to modulate the patient's anxiety level as is required for therapeutic gain”. Finally, they needed to develop a way to record physiological data into the clinician interface. The simulation included city streets, desert highways, city scenes, small rural villages, building interiors, convoys, checkpoints, and a desert base. It also included controllable time of day, situations in which the patient is alone or when they are in groups, driving a Humvee in various views, or from a helicopter interior. The simulations went beyond the normal Xbox experience, providing 3D sound, vibration and even scents (such as gunpowder, cordite, body odor, garbage, burning rubber, diesel fuel and Iraqi spices) to further simulate the reality. They even had a night vision infrared mode. Dr. Rizzo stressed that their goal was not to eliminate therapists, and that the clinician has full control over what goes on in the world. Using the clinician's interface, they can add levels of detail slowly, observing physiological data as the stimuli are added. Identifying Traumatic Situations As part of the development of the clinician's interface, they also identified a long list of possible situations that could cause trauma, including being attacked or ambushed, being responsible for the death of an enemy (combatant or non-combatant), seeing dead bodies or human remains, handling dead bodies, seeing dead or seriously injured Americans, etc. Each of the identified scenarios could be recreated in appropriate levels of detail. Given that a high percentage of sufferers of PTSD never seek treatment, part of Dr. Rizzo's theory is that patients who grew up in the digital age may be receptive to this approach, thereby eliminating some barriers that may be seen to exist in people approaching and receiving therapy. Another part of the strategy is to “re-conceptualize” therapy, calling it “VR Post-Combat Reintegration Training,” which sounds better than therapy. The necessary equipment, Rizzo added, does not have to be supremely expensive. For instance, he mentioned an $899 VR headset from eMagine, Inc. and other reasonably priced components. With Version 1.4 complete, they have begun clinical trials in a number of places, and have even taken the system to Iraq, where soldiers have confirmed that they “got it right.” As to why they are working on this, it's a matter of ethics and also may lead to stress inoculation to prevent such symptoms in the future. Moreover, it's about healthcare costs. Dr. Rizzo asserted that if they could “fix” 20 people, it would more than pay for itself in healthcare savings.
The 'Distract' PTSD Method? Dr. Rizzo then moved on to the “Distract” model, called “VR Games Pain Distraction Project”, which is used in pain mitigation.. He talked about how VR games can distract children during painful medical procedures, such as burns and wound care. There was a dramatic change in pain levels when they were distracted by VR play versus when they were not. He also mentioned some experimental work being done with thermal stimulus of the feet. The theory of these distraction methods, he said, has to do with the brain's limited capacity of attention. If you distribute the attention elsewhere, it can distract the patient from the pain associated with a procedure. Of course, there are other methods of distraction – even simply blocking the patient's ability to see the procedure – occlusion. Another game-related therapy approach used Nintendo games, but without VR immersion. Comparative results in a limited trial showed a significant advantage for VR game technology. However, the engagement of the VR interactive experience proved far more effective according to children going through procedures as well as the children's parents. Getting very technical, Dr. Rizzo stated that pain related brain activity is reduced during VR experiences primarily due to reduced activation in the primary and secondary Somatosensory cortex, anterior cingulate, thalamus and insula. In more layman's terms, he compared attention and pain with the following points:
Using the Unreal engine, they simulated four worlds – a water world, a snow world, a gorilla world and one called “Bush Soul”, which has nothing to do with George Bush. In practice, the patient would wear the head-mounted display and enter into one of the interactive worlds. Afterwards, they would fill out a simple graphical measure of the pain they experienced (see figure), as well as the subjective impressions of parents observing their children. Comparisons in the tests were made between four approaches: VR, flat screen interactive, cartoons, and standard care. Results showed that the VR approach was significantly more effective at distracting patients from pain. In other tests, they are creating new games for VR, working with Fifth Dimension Technologies. For children 4-6 years old, they have Jelly Men, an immersive playground, and for older kids there is Street Luge, which sets you in a modified third person perspective, flying down a road on a luge. Mentioning that in the year 2000 the U.S. Congress passed a law declaring the “Decade of Pain Control Research” to begin in 2001, Dr. Rizzo then moved on to the next item in his therapeutic triumvirate. Therapeutic Motivation Through Gaming The Interdisciplinary Study of Neuroplasticity and Stroke Rehabilitation is another polydisciplinary project that is working to help stroke victims recover their abilities. Although it is based at USC, some participants from the University of Texas, Austin, are also involved. Dr. Rizzo began this part of his talk with a couple of relevant quotes, one more easily grasped than the other:
He then preceded to get very technical for a bit, talking about Merzenich's Model on drivers for neuroplasticity states that attention drives the cholinergic system, novelty drives the noradrenergic/serotonergic systems and reward drives the dopaminergic system. And attention, novelty and reward, he contends, are all elements of well-designed games! In traditional therapy, Dr. Rizzo stated, therapists work with “shoulder flexion and abduction, pincer grasp, forearm supination and pronation and other movement foci.” Normal therapy involves pretty boring physical activities, which patients can quickly lose interest in. But with new technologies, such as Vivid's Irex system (which seems to be a more expensive version of the PlayStation 2's EyeToy), patents can be engaged in therapeutic exercises that appear to be anything from being a soccer goalie to skydiving, snowboarding swimming with sharks and playing a virtual drum set. The Irex system offers direct feedback to patients, showing the time elapsed, total attempts and successful attempts. And, in fact, Irex costs $15,000 while EyeToy is around $150, and Dr. Rizzo contended that similar results could be obtained working with EyeToy and appropriate software and sensors. Other studies help patients regain flexibility and motor control in their feet by playing a virtual foot in an interactive environment that engages their imaginations. Dr. Rizzo then showed some of his team's research using full VR environments. A variety of simple games created to exercise specific areas and accomplish the tasks traditionally used in stroke recovery therapy helped patients go through their rehabilitation while remaining engaged and motivated. In many cases, even after the patient had already accomplished the session goals, they still wanted to play on, and in cases where patients had considerable difficulties, instead of quitting in frustration, they seemed to be motivated to succeed despite the challenges they faced. Dr. Rizzo concluded this section by mentioning that many novel interfaces can be used in therapeutic situations, naming the Dance Dance Revolution pads, the apparently defunct PS2 Action Stick peripheral, and new training equipment options from Cybex Trazer, Inc. But there was more. The last item Dr. Rizzo mentioned was a fourth aspect of his philosophy – Expose, Distract, Motivate… and Measure. Quickly going through some slides that showed classroom and workplace simulations as well as a wheelchair interface that could measure collisions with objects, a driving scenario designed to retrain driving skills following spinal chord injuries, a “simon-says” application for therapy, and several others that went by in a blur (as he was running out of time), he concluded his talk by stating that the field of “VRPsych” technology was also a psychologists dream, and if the world of psychology doesn't jump on it, they're missing the boat.
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