As persons with disabilities age, progressive declines in health and medical status can challenge the adaptive resources required to maintain functional independence and quality of life. The effects of these challenges can be further compounded by economic factors (e.g., decreased income, increased medical costs, reductions or loss of medical benefits), medication side effects, loss of a spouse or caregiver, and the impact of psychosocial disorders such as depression or alcohol abuse. As well, with the gradual loss of functional independence and increased reliance on others for transportation, access to general medical and rehabilitation care can be jeopardized. The combination of these factors when seen in the context of the average increase in lifespan that is accelerating in industrialized societies has lead to a growing crisis that is truly global in proportion. While research indicates that functional motor capacity can be improved, maintained, or recovered via consistent participation in a motor exercise and rehabilitation regimen independent adherence to such preventative and/or rehabilitative programming outside the clinic setting is notoriously low. This state of affairs has produced a compelling and ethical motivation to address the needs of individuals who are aging with disabilities by promoting home-based access to low-cost, interactive virtual reality (VR) systems designed to engage and motivate aged individuals to participate with “game”-driven physical activities and rehabilitation programming. The creation of such systems could serve to enhance, maintain and rehabilitate the motor processes that underlie the integrated functional behaviors that are needed to maximize independence and quality of life--beyond what exists with currently available, labor intensive, under-utilized, and more costly approaches.

VR simulation technology using specialized interface devices has been applied to improve motor skill rehabilitation of functional deficits including reaching, hand function and walking.  It has been proposed that such VR-based activities could be delivered in the home via a telerehabilitation approach to support patients’ increased access to rehabilitation and preventative exercise programming. Moreover, when such VR training is embedded in an interactive game-based context, the potential exists to enhance the engagement and motivation needed to drive neuroplastic changes that underlie motor process maintenance and improvement. However, home-based VR systems need to be affordable and easy to deploy and maintain, while still providing the interactional fidelity required to produce the meaningful motor activity required to foster rehabilitative aims and promote transfer to real world activities.

We have addressed the challenge for creating low cost home-based VR systems for motor assessment and rehabilitation via three converging directions: 1) We have created our own low cost optical motion tracking/capture system using off the shelf Webcams and infrared cameras. Both of these systems can track 6 degree of freedom (DOF) movement from low cost LED’s and reflective markers attached to the body or to relevant objects (e.g., handheld “jogging” weights, mugs and other “everyday” items). 2) We have created a prototype series of motor testing and training games that have been designed such that a user without any computer programming skills can modify the stimulus delivery parameters for interaction across a variety of useful dimensions and can easily extract performance data following interaction with the system. These games have targeted a variety of relevant motor functions including, balance, range of motion, supination, grasping, etc. We have also constructed a wireless cell phone vibrating system that provides the patient with feedback to signal collisions with game stimuli or other interactional content in an effort to enhance realism via multisensory stimuli. And 3) We have experimented with a variety of game console and interface systems such as the WiiTM and EyeToyTM, and more recently with a promising system called the Novint Falcon. This is an interface system that mimics the functionality of a robotic Phantom device, but for under $200, thereby making it within the cost range needed to meet the low-cost requirement for telerehabilitation. By yoking two of these systems together (using only one computer), we have experimented with developing games that require Bi-manual control and coordination as an interaction format for game development. Finally, the interface for the WiiTM  supports camera-based and inertial tracking that may be “hacked” to deliver compelling and engaging motor rehabilitation challenges with some creative programming. Unlike the Sony PlayStation® 2 EyeToyTM, user groups have now been able to adapt this interaction device for applications on a basic PC. This now opens possibilities to use this mass produced interface system for the creation of VR games for motor training and rehabilitation.

3) The population to be served: Our interdisciplinary technology development team will support NIDRR’s overall purpose to promote community participation of individuals with disabilities by addressing the motor processes underlying functional deficits that contribute to multiple disabling conditions.  The design, development and evaluation issues directly relevant to the health and function needs of persons aging with and into disabilities will be addressed independent of diagnostic group because disability occurs at the interaction of body structure and function with the environmental opportunities and constraints. Core motor processes will be the focus of our VR application and game development, such that a flexible virtual rehabilitation “toolkit” (VRT) will be created that is capable of addressing a diversity of needs across clinical populations, guided by informed scientific and professional judgment. This approach will also support the VR development needs of the Project 1 (Dexterous Manipulation With the Fingertips) Project 1 (Dexterous Manipulation with the Fingertips) and Project 3 ( (Preserving Community Mobility for Wheelchair Users) ) groups in the current RERC proposal. All research in this core will include a battery of user-centered quantitative and qualitative evaluation metrics that cut across the three domains of disablement (body structure, activity and participation). To this end, the four primary objectives of this Project 2 are:

4) The development and evaluation methods:
Aim 1: Develop and apply evidence-based combinations of task-specific practice and virtual reality (VR) technology for clinic-based and home-based functional motor rehabilitation of upper limb, lower limb and balance impairments. Clinic-based and home-based systems will rely on both off-the-shelf interface tools (e.g., Nintendo Wii, Novint Falcon, Sony Eyetoy, etc.) as well as our own low-cost camera-based tracking system along with refinement and expansion of our library of nearly 20 working VR applications developed for stroke rehabilitation under an Interdisciplinary NIH-Roadmap award (and later supported by the Army for TBI). Display technology options will also be evaluated (e.g., standard PC monitors, stereoscopic displays, projection screens, and head mounted displays) A group of participants will evaluate the developed technology using a battery of user-centered quantitative and qualitative evaluation metrics that cut across the three domains of disablement (body structure, activity and participation). The usability of the developed systems will be tested and the systems will be refined accordingly, to prepare them for Aim 2.

Aim 2: Following refinement of the systems, a larger trial will be undertaken with subjects who have functional deficits with upper limb, lower limb and balance activities that compares traditional clinic- and home- based approaches with virtual reality systems. Functional measures, enjoyment and motivational measures and participation measures will be compared between these groups.
Aim 3: Integrate the technology into the ‘Wheeled Mobility’ project by providing a VR system for patients to interact with during rotator cuff muscle strength training in the clinic and as a home- based exercise.
Aim 4: Integrate the technology into the ‘Manual Dexterity’ project by providing virtual game based environments for patients to interact with using the S-D test prototype system as an assessment and training method. The environment will support testing and training of hand function by providing instructions for patients, recording the interaction and providing the measurement in a user-friendly format for therapists.