IN THE PAST few years, virtual reality (VR)

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1 Virtual Reality and Neuropsychology: Upgrading the Current Tools Background: Virtual reality (VR) is an evolving technology that has been applied in various aspects of medicine, including the treatment of phobia disorders, pain distraction interventions, surgical training, and medical education. These applications have served to demonstrate the various assets offered through the use of VR. Objective: To provide a background and rationale for the application of VR to neuropsychological assessment. Methods: A brief introduction to VR technology and a review of current ongoing neuropsychological research that integrates the use of this technology. Conclusions: VR offers numerous assets that may enhance current neuropsychological assessment protocols and address many of the limitations faced by our traditional methods. Key words: neuropsychological tests, technology, virtual reality Maria T. Schultheis, PhD Clinical Research Scientist Neuropsychology & Neuroscience Laboratory Kessler Medical Rehabilitation Research & Education Corporation Department of Physical Medicine & Rehabilitation University of Medicine & Dentistry of New Jersey-New Jersey Medical School West Orange, New Jersey Jessica Himelstein, MA Postdoctoral Fellow Department of Physical Medicine & Rehabilitation University of Medicine & Dentistry of New Jersey-New Jersey Medical School West Orange, New Jersey Albert A. Rizzo, PhD Assistant Research Professor Integrated Media Systems Center School of Gerontology University of Southern California Los Angeles IN THE PAST few years, virtual reality (VR) has undergone a transition that has taken it out of the realm of expensive toy and into that of functional technology. Continuing advances in VR technology, along with concomitant system cost reductions, have supported the development of more usable, useful, and accessible VR systems. These systems have the potential to uniquely target a wide range of physical, cognitive, and behavioral human issues and research questions. Neuropsychology is one discipline that may clearly benefit from the application of VR technology. Address correspondence and requests for reprints to Maria T. Schultheis, PhD, Neuropsychology and Neuroscience Laboratory, Kessler Medical Rehabilitation Research & Education Corporation, 1199 Pleasant Valley Way, West Orange, NJ Telephone: (973) ; Fax: (973) mschultheis@kmrrec.org. Supported in part by grant #HD from the National Institute of Child Health and Human Development, grant #H133G from the National Institute on Disability and Rehabilitation Research, and by the Integrated Media Systems Center, a National Science Foundation Engineering Research Center, Cooperative Agreement No. EEC J Head Trauma Rehabil 2002;17(5): c 2002 Lippincott Williams & Wilkins, Inc. 378

2 Virtual Reality and Neuropsychology 379 The application of VR in neuropsychology is so distinctively important because it represents more than a simple linear extension of existing computer technology for human use. VR offers the potential to deliver systematic human testing and training environments that allow for the precise control of complex dynamic three-dimensional (3D) stimulus presentations, where sophisticated behavioral recording is possible. When combining these assets within the context of functionally relevant, ecologically valid virtual environments, a fundamental advancement emerges in how human behavior can be addressed in many scientific disciplines. In the broadest sense neuropsychology can be defined as an applied science that evaluates how specific activities in the brain are expressed in observable behaviors. 1 Effective neuropsychological assessment is often a key component in both the treatment and the scientific analysis of many central nervous system disorders and can serve a number of functions. These include the use of psychometric evaluation tools for diagnostic purposes, the provision of normative data for comparison with impaired cognitive and functional abilities, the specification of cognitive strengths and weaknesses to help inform the design of rehabilitative strategies, and provision of metrics to assess treatment efficacy or plot neurodegenerative decline. Neuropsychological assessment also serves to create data for the scientific understanding of brain functioning through the examination of measurable sequelae that occur after brain damage or dysfunction. To date, most neuropsychological research has focused on increasing our understanding of component cognitive processes, such as attention, executive functions, memory, and language spatial abilities. More recently, understanding the role of cognitive processes during functionally relevant tasks (i.e., instrumental activities of daily living) has evolved as an area of focus within neuropsychological research. VR offers the potential to integrate these two aspects of neuropsychology and provide an innovative approach to understanding brain behavior relationships. In view of the promising benefits that VR can offer neuropsychological assessment, treatment, and research, this article seeks to (1) provide a brief introduction to VR technology and the potential benefits of the application of VR to the field of neuropsychology, (2) provide a brief overview of recent studies that have successfully applied VR to the assessment of component cognitive abilities and functional evaluations, and (3) discuss important considerations in the application of VR. WHAT IS VR TECHNOLOGY? VR can be viewed as an advanced form of human computer interface that allows the user to interact with and become immersed in a computer-generated environment in a naturalistic fashion. 2 By analogy, much like an aircraft simulator serves to test and train piloting ability, computer-generated interactive virtual environments (VEs) can be designed to assess and rehabilitate cognitive and functional abilities by means of exposure to simulated real world and/or analog tasks. Interaction in three dimensions is a key characteristic that distinguishes a VR experience from other technologies. The believability of the virtual experience (or sense of presence ) is fostered by the use of such specialized technology as head-mounted displays (HMDs), tracking systems, earphones, gesture-sensing gloves, and haptic-feedback devices. An HMD is an image display system worn on the head (like a diving mask) that remains optically coupled to the user s eyes as he or she turns and moves. A tracking system senses the position and orientation of the user s head (and HMD) and reports that information to a computer that updates (in real

3 380 JOURNAL OF HEAD TRAUMA REHABILITATION/OCTOBER 2002 Fig 1. Person in a virtual environment wearing an HMD and head tracker. time) the images for display in the HMD. In most cases full-color stereo image pairs are produced, and earphones may deliver relevant 3D sound. The combination of an HMD and tracking system allows the computer to generate images and sounds in any computermodeled (virtual) scene that corresponds to what the user would see and hear from their current position if the scene were real (Figure 1). The user may walk and turn around to survey a virtual landscape or inspect a virtual object by moving toward it and peering around its sides or back. Although HMDs are most commonly associated with VR, other methods incorporating 3D projection walls and rooms (known as CAVES), as well as basic flat-screen computer systems, have been used to create interactive scenarios. Methods for navigation and interaction such as data gloves, joysticks, and some high-end force feedback mechanisms that can provide haptic feedback are also available and can be used to further enhance realism and the suspension of disbelief required to generate the sense of presence within a VR environment. Although VR remains a developing technology, it is not a new addition to the medical field. Various studies have served to document the successful integration of VR to myriad aspects of medicine, including surgical training, 3 education of patients and medical students, 4 and treatment of sensory mobility deficits. 5 Treatment of psychological dysfunction, including anxiety disorders and phobia, has been successfully reported by numerous researchers who have applied the use of VR for treating fear of flying and fear of heights. 6,7 VR has also been applied to the treatment of posttraumatic stress disorder (PTSD), 8 eating disorders, 9 and pain management. 10 Results from these studies have served to underscore some of the specific assets afforded

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