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C ONTENTS

Orly Lahav, Paul M Sharkey and Joav Merrick

Peter H Wilson

virtual environments for people who are blind 21

Orly Lahav

Takehiko Yamaguchi, Paul Richard, Fabienne Veaux, Mickặl Dinomais and Sylvie N’guyen

conducting design sessions with students with

Laura Millen, Sue Cobb, Harshada Patel and Tony Glover

Lena Pareto

Contents

viii

rehabilitation of children with cerebral palsy 85

Mohammad Al-Amri, Daniel Abásolo, Salim Ghoussayni and David Ewins

Julie Gonneaud, Pascale Piolino, Grégory Lecouvey, Sophie Madeleine, Eric Orriols, Philippe Fleury, Francis Eustache and Béatrice Desgranges

Emilie Loup-Escande, Olivier Christmann, Romain Damiano, Franck Hernoux and Simon Richir

Chapter 10 Haptic presentation of 3D objects in virtual reality

Marcin Moranski and Andrzej Materka

Chapter 11 Haptics visualisation of scientific data for visually

Ruth White and William Harwin

Yasmine Boumenir, Abdelmajid Kadri, Nadège Suire, Corinne Mury

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Contents ix

I NTRODUCTION

In: Virtual Reality ISBN: 978-1-63321-729-4 Editors: P M Sharkey and J Merrick © 2014 Nova Science Publishers, Inc

Division of Pediatrics, Hadassah Hebrew University Medical Center,

Mt Scopus Campus, Jerusalem, Israel



Corresponding author: Orly Lahav, PhD, Senior Researcher, School of Education, Tel Aviv

University, POBox 39040, Tel Aviv, Israel E-mail: lahavo@post.tau.ac.il

The use of virtual reality for learning, training, and rehabilitation for people with special needs has been on the rise in recent years Virtual reality allows the user to be trained, to gather information and to perform rehabilitation tasks in the virtual reality space It allows the user to perform independently, safely, and efficiently, in a combined product of sensory, motor, and cognitive skills The design, development, and evaluation of such virtual reality environments is a multidisciplinary work, the integration of medicine, physical therapy, occupational therapy, neuroscience, psychology, education, engineering, computer science, and art

Since 1996 the ICDVART conference has played a central role in gathering researchers from these disciplines who bring together new, advanced and collaborative work In the past few years, the research and development of virtual reality for people with special needs has included a wide range of hitherto single-user technologies to an environment that allow two or more users to train or learn collaboratively

A common theme across all articles in this special issue is the role of virtual reality in the therapy process and the wide cross-disciplines of the researchers The chapters are covering a broad range of topics from virtual reality-augmented therapy in the development of cognitive neuroscience perspective on motor rehabilitation, the potential of virtual environments to improve orientation and mobility skills for people who are blind, virtual reality for people with cerebral palsy, haptic virtual reality technologies for visual impairment and blindness, perception of space and subsequent design changes needed for accessibility, autism spectrum disorder to improving cognitive and intellectual skills via virtual environments in a range of different topics such as mathematical performance or prospective memory

S ECTION ONE :

In: Virtual Reality ISBN: 978-1-63321-729-4 Editors: P M Sharkey and J Merrick © 2014 Nova Science Publishers, Inc

School of Psychology, Australian Catholic University,

Melbourne, Victoria, Australia

Developmental disorders and disabilities affecting movement can have far reaching, longer-term consequences for the child and their family, and present a great challenge for intervention In the case of upper-limb function, in particular, poor compliance and use of repetitive training routines can restrict progress In this chapter we consider how an understanding of the neurocognitive bases of disorders like cerebral palsy and Developmental Coordination Disorder (DCD) can inform the choice

of therapeutic techniques Using a cognitive neuroscience approach, I

explore the hypothesis that motor prediction is a common, underlying

issue in these disorders I then discuss the role that feedback-based and predictive control plays during the course of normal development and

highlight recent applications of augmented feedback (AF) in motor

therapy Critically, VR-based technologies afford many options for the provision of multisensory AF I describe recent examples of this principled approach to treatment, and conclude by suggesting avenues for future development in VR-assisted therapy



Corresponding author: Peter H Wilson, PhD, School of Psychology, Australian Catholic

University, 115 Victoria Pde, Melbourne, Victoria, 3065, Australia E-mail: peterh.wilson

@acu.edu.au

A principled approach to rehabilitation of manual function has been particularly slow to evolve Most interventions for children with neurological disorders require intensive practice (e.g., Constraint Induced Movement Therapy—CIMT) and/or have poor patient compliance (3) By comparison, virtual-reality (VR) based treatments afford new options for engaging children, maintaining their level of motivation, and for providing a set of scalable movement tasks that utilise real-time feedback VR-augmented therapies have been applied successfully in adult movement rehabilitation, however, a systematic approach to rehabilitation in children is yet to evolve (4,5)

In this paper, I present a new model for movement rehabilitation of children with motor disorders including cerebral palsy and developmental coordination disorder (DCD), a form of severe movement clumsiness in

childhood From the perspective of developmental cognitive neuroscience, I

examine our current understanding of the key concepts of predictive control and multimodal integration I will show these concepts to be pivotal in re-conceptualising our approach to motor intervention In doing so, I will

highlight principles underlying the use of multimodal, augmented feedback

(AF) in therapy, and explain how VR-based systems are the ideal vehicle

I present a conceptual model for the use of AF in VR-based therapy A critical task of motor learning and development is the child‘s ability to extract (implicit) knowledge of the dynamics of their own motor system (6, 7) More precisely, the child must learn the systematic relationship between their own

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Developmental cognitive neuroscience perspective … 9

motor output commands and the effects that these commands have on the physical system; this knowledge enables predictive control, an aspect of internal modelling (8) Mature reaching is now thought to be controlled by an integrated system of feedback and feedforward control This system enables the performer to adjust rapidly in real time to changing environmental constraints, like a moving target, with some movement parameters (like trajectory) changing in as little as 70-80 ms The ability to implement such changes is only viable to the extent that the nervous system can predict the

future location of the moving limb using a forward (internal) model (9)

This flexibility is one of the hallmarks of skilled motor behaviour, and develops gradually over childhood (10)

That predictive control develops rapidly over childhood has been shown in

a range of contexts including force adaptation (11), isometric force control (12), anticipatory postural adjustments (13), and rapid online control of reaching in response to visual perturbation (10) Critically, during middle childhood we see a transition in motor control, with greater reliance on visual feedback, accompanied by longer movement times but not enhanced accuracy (14,15) In later childhood we see a more mature integration of feedback and feedforward control, speeding target-directed responses and improving accuracy

One important feature of the mature motor system is the ability to adapt movement seamlessly and efficiently in real time while maintaining speed and accuracy (16) Hyde and Wilson (10), for example, have shown that younger children are slower to adjust their reaching to visual perturbation than older children, suggesting a reduced ability to integrate predictive estimates of limb position with online feedback For static targets, the movement times of older children (8-12 years) were around 550 ms and increased to around 800 on trials when the target jumped at movement onset By comparison, the relative increase for younger children aged 5 to 7 years was significantly greater, from around 640 to 1030 ms Moreover, younger children took longer to correct their movement trajectory on jump trials These online corrections are thought

to involve internal feedback loops which enable the seamless integration of

predictive error signals with ongoing motor commands (17,18) Indeed, there

is strong evidence that visual feedback is used to control reaching throughout the reaching cycle (19,20) rather than simply towards the end of movement – path corrections are evident within 70-100 ms following target jumps, at least

in healthy adults In short, this process of rapid online control develops rapidly over childhood and is quite well developed in older children (21)

DEVELOPMENTAL MOTOR DISORDERS:

THE CASE OF DCD AND CP

In the case of DCD, there is converging data to show that these children have a fundamental deficit of motor prediction, necessitating a reliance on slower, feedback-based control (6) This accounts for the generally more laboured and inefficient movement patterns we see in this group In the case of cerebral palsy (CP), the motor deficits extend to movement initiation as well as prediction (4)

Developmental coordination disorder

Deficits of motor prediction in children with DCD are evident across a range

of tasks, performed under different spatial and temporal constraints These have included sequential eye movements (22), visual tracking (23), coupling

of grip and load force during lifting (24), visually-guided reaching (25), and visual-motor adaptation (26) Of the first listed example, performance on a double-step saccade task (DSST) is particularly instructive Here children were required to make eye movements to two targets presented sequentially, the first target for 140 ms and the second for 100 ms Because the second target is extinguished before initiation of the first eye movement, the performer must use a forward estimate of the end position of the first saccade in order to then generate a motor command that will enable ―capture‖ of the second target (27) Intriguingly, children with DCD are as accurate as typically developing children for the first eye movement, but significantly less so for the second This pattern of performance underlines a basic deficit of prediction in children with DCD which may be attributable to immaturities at the level of parietal cortex and its reciprocal connections with the cerebellum

Cerebral palsy

Children with cerebral palsy (or spastic hemiplegia) show fundamental deficits

in not only the ability to execute movements but also in movement representation and planning (28,29) The planning issues are manifest, among other things, in the ability to imagine how a prospective action will unfold (aka

motor imagery) This facility to anticipate the spatiotemporal unfolding of an

Developmental cognitive neuroscience perspective … 11

action (without execution) has been assessed using mental rotation tasks involving pictorial representations of body parts (like hands or whole-body stimuli) Steenbergen et al (30) tested both left- and right-sided hemiplegic patients and found that while there was no group difference between patients and healthy controls on accuracy or the timing of responses, the hemiplegic patients were generally slower They concluded that the patients were not adopting an egocentric frame when making responses but rather used a more visually-mediated strategy Similar results have been shown for children with

CP (31) Taken together, poor motor imagery in CP seems to reflect a core deficit in the ability to generate (forward) internal models of movement This argument is supported by neuroimaging data showing overlap in the neural networks that support both motor imagery and predictive control (32)

IMPLICATIONS FOR TREATMENT

A critical part of the motor learning process is the use of feedback as a means

of comparing the executed action with the intended outcome of a movement

In typical learning over repeated trials, we see a gradual reduction in the discrepancy between the two In atypical motor development, sheer repetition does not necessarily translate into improved motor skill; this is evident in both severe DCD and CP Moreover, in the case of CP, the mechanisms by which sensory information is processed may be compromised, which further compounds the ability to implement error correction and predictive control Importantly, methods of augmented feedback have been shown to benefit both populations, with multisensory (extrinsic) feedback and techniques that cue attentional focus being shown to exert good treatment effects (33,34)

Augmented feedback

External (or augmented) feedback (AF) involves providing information about the performance of an action, over and above that available to the performer‘s own cognitive and sensory-motor systems In other words, the external information is additional to the naturally-occurring (or intrinsic) sources of

input There are several basic forms of AF: knowledge of results (KR), knowledge of performance (KP), and concurrent AF KR involves the

provision of information about the outcome of a movement (e.g., percentage success after a set of trials), while KP concerns the manner in which the

movement was performed and its form Concurrent AF involves the provision

of real-time feedback, most often in the form of correlated visual, haptic, or auditory input The benefits of various forms of AF (relative to no AF) have been well documented in the mainstream motor learning literature (35,36) For example, AF has been shown to aid the development of coordination on rhythmic tasks, increasing stability This is provided that multisensory information is presented synchronously with the key movement transitions (37), e.g., flexion-extension movements of the fingers, timed to an external auditory, haptic, and/or visual stimulus

The case for AF in the rehabilitation of brain injury has also been made in

a number of authoritative reviews (38,39) However, the quality of evidence has varied quite significantly across studies (34) In van Dijk‘s systematic review, no conclusive evidence was found for the effectiveness of AF on upper-limb function However, frequently omitted from these studies was crucial information about the specific form of feedback used, adequate follow-

up assessments, and very few studies used RCTs A narrative account by van Vliet (39) suggested more positive effects on different aspects of motor function However, similar to van Dijk, there were a number of outstanding issues in the literature, including the relative effect of visual, verbal, video and kinematic feedback, and the types of task scheduling that yield stronger effects

Attentional training

The mainstream literature has provided some interesting insights into the use

of AF and how it best directs the performer‘s attention The work of Wulf and colleagues (40,41) has been most influential in showing the benefits of an external focus of attention during skill acquisition, both in adults and children (41) That is, external cues are provided that encourage the performer to focus

on the effects of their movement (e.g., trajectory), rather than their internal state or somatic sensations Importantly, it does not appear to be the case that performers become excessively reliant on such cuing to the point where performance declines once it is removed (42) Indeed, performance on retention and transfer tasks has been shown to be superior after external focus training than internal focus (41) More fundamental work has also shown that concurrent AF which biases attention to the effect of the movement yields stronger training and retention effects than feedback about movement form (43,44)

Developmental cognitive neuroscience perspective … 13

From a cognitivist perspective, the advantage of taking an external focus

of attention has been explained by increased automaticity in motor control –

aka the constrained action hypothesis (45) Put simply, the external focus

allows the performer to enlist rapid control processes, including the ability to implement online adjustments By comparison, switching attention to internal

states and body position may encourage greater focus on the self and perhaps

self-evaluation, which may interfere with the unconscious flow we associate with skilled performance A more detailed account of underlying control processes has proved elusive from a purely cognitivist perspective

Ideas encapsulated in the ideomotor theory of Prinz and colleagues has

been more influential, drawing on neurocomputational models of action (46,47) This states quite simply that actions are controlled by their intended effects Ultimately, the performer learns to predict action effects in advance, with this predictive model used as a template against which actual feedback is compared As such, the prediction is used to monitor how well an executed action matches its intended trajectory and goal outcome Action is most efficient, therefore, when planned according to intended effects or outcomes, rather than internal states (40) The use of AF that helps direct attention to movement effects is, thus, a more powerful medium for skill development and rehabilitation than other forms of feedback

With respect to motor rehabilitation, there has been relatively little research that has examined the differential effects of adopting an internal or external focus of attention However, there is some suggestion from cognate research that the advantages of external focus also apply to brain damaged patients (39,48) For example, in cases where predictive control has been disrupted (through brain damage or developmental immaturity), provision of concurrent AF has been shown to assist recovery of upper-limb function What

is sobering, then, is that the vast majority of verbal instructions made by movement therapists to patients in clinical settings are related to body movements and sensation, and are likely to induce an internal focus of attention (49)

RECENT EVIDENCE SUPPORTING THE USE OF

Understanding the mechanisms of normal motor development and those disrupted in CP and DCD has important implications for the choice of therapy

AF, presented using various sensory modalities in real time, can greatly leverage the development of skill in these children Virtual-reality based

systems are the perfect vehicle for this treatment, the Elements VR system

being a recent example (50,51) – see figure 1 This system targets upper-limb function using a series of tangible user interfaces (TUIs), camera-based tracking, and interactive tabletop workspace Both goal-directed and exploratory manual tasks are employed using various forms of concurrent AF The goal-directed tasks are cued from within the virtual workspace, with each form of AF used to reinforce one or more of three outcome parameters (speed, accuracy, and efficiency) Wulf and colleagues have also identified how AF can be used to target particular movement parameters in this way (41,44) For exploratory tasks, children can create their own visual and aural compositions

by manipulating the TUI; for example, coloured trails – one form of AF – are composed as objects are moved across the display In general, the AF serves two main purposes: first, it provides children with additional feedback about the outcomes of their actions; this reinforces the child‘s sense of position in space and of the relationship between motor command and the resultant action

We argue that this process helps train predictive (or forward) models for action Second, AF enables the child to focus their attention on the effects of their movement, rather than on the movement itself (44) This has been shown

to be leverage skill development during the early phases of learning and during rehabilitation

Figure 1 Sample display from the Elements system: Goal-directed task including (visual) augmented feedback

Developmental cognitive neuroscience perspective … 15

A number of studies now support the argument that VR-based systems are

an ideal medium through which AF can leverage the development of motor skill in children with movement disorders The Elements system, for example, has recently been evaluated in childhood CP using a multiple case study design (4) Four children with non-progressive hemiplegia participated in 30-min sessions daily for 3-4 weeks During training, each child was instructed to focus on a type of concurrent AF that was appropriate to the performance variable that was targeted For example, if the aim was to improve accuracy, the child was instructed to focus on ―disk AF‖ which consisted of an increase

in the luminance of the target as the TUI approached it Children engaged well with the system, found it intuitive to use, and derived reward from the movement-dependent AF Critically, training saw considerable improvement

in the motor skill of children with quite severe CP This supports earlier work

in adult patients with TBI (51) Methods to test the hypothesis that improved predictive control underlies these changes are under current investigation

A principled approach to VR-augmented rehabilitation is only possible to the extent that we fully understand the neurocognitive underpinnings of childhood disorders like CP and DCD A review of the literature suggests that predictive control is one pivotal component of the motor system that is frequently disrupted in children with these disorders Predictive control is implemented using a distributed system of cortical and sub-cortical structures including the cerebellum, posterior parietal cortex and their reciprocal connections to frontal motor cortices Critical to predictive control is the performer‘s ability to construct (or re-construct) the systematic relationship that exists between motor command signals and their anticipated effects on the physical system Implicit knowledge of this relationship underpins the use of forward internal modelling as means of rapid online control, for example (52) Intriguingly, AF

is one treatment modality that may foster the development of this ability in children with motor problems More specifically, concurrent AF (which also encourages an external focus of attention) has been shown to be particularly effective when implemented using VR-based systems The Elements system, for example, has used a combination of aural and visual AF to leverage the recovery of children with not only CP, but also childhood stroke and other congenital disorders affecting movement (4)

Our use of the term VR-augmented therapy, thus, takes on a dual meaning:

it suggests both the promise of VR in leveraging rehabilitation in children, as well as its possibilities as a medium for providing AF We suggest that multisensory AF is a particularly powerful way of encouraging children to learn (or re-learn) movement skills Part of this learning process involves the gradual re-construction of the child‘s body schema and the ability to anticipate the outcomes of its interactions with a 3D environment Exactly what aspects

of AF (and their combination) yield the strongest training effects is a prime issue for investigation, as is the extent to which functional gains are correlated with the ability to use predictive control Future research in this area will inform not only the clinical application of VR technologies, but also our basic understanding of the motor control and learning system

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[45] Wulf G, McNevin N, Shea CH The automaticity of complex motor skill learning as a function of attentional focus Quart J Exp Psychol A Hum Exp Psychol 2001;54(4):1143-54

[46] Prinz W Perception and Action Planning Eur J Cogn Psychol 1997;9(2):129-54 [47] Hommel B, Müsseler J, Aschersleben G, Prinz W The Theory of Event Coding (TEC): A framework for perception and action planning Behav Brain Sci 2001;24(5):849-78

[48] Piron L, Tombolini P, Turolla A, Zucconi C, Agostini M, Dam M, et al., eds Reinforced feedback in virtual environment facilitates the arm motor recovery in patients after a recent stroke Virtual Rehabil 2007, Venice, Italy

[49] Durham K, Van Vliet PM, Badger F, Sackley C Use of information feedback and attentional focus of feedback in treating the person with a hemiplegic arm Physiother Res Int 2009;14:77-90

[50] Wilson PH, Duckworth J, Mumford N, Eldridge R, Gugliemetti M, Thomas P, et al., eds A virtual tabletop workspace for the assessment of upper limb function in Traumatic Brain Injury (TBI) Virtual Rehabil 2007, Venice, Italy

[51] Mumford N, Wilson PH Upper limb virtual rehabilitation for traumatic brain injury: Initial evaluation of the Elements system Brain Injury 2010;24(5):780-91

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In: Virtual Reality ISBN: 978-1-63321-729-4 Editors: P M Sharkey and J Merrick © 2014 Nova Science Publishers, Inc

Chapter 3

SKILLS THROUGH VIRTUAL ENVIRONMENTS

FOR PEOPLE WHO ARE BLIND

Orly Lahav

School of Education, Tel Aviv University, Tel Aviv, Israel

This chapter describes and examines 21 virtual environments developed specifically to support people who are blind in collecting spatial information before arrival at a new location and to help people who are newly blind practice orientation and mobility skills during rehabilitation The paper highlights weaknesses and strengths of virtual environments that have been developed in the past 15 years as orientation and mobility aids for people who are blind These results have potential to influence future research and development of a new orientation and mobility aid that could enhance navigation abilities

Corresponding author: Orly Lahav, PhD, Senior Researcher, School of Education, Tel Aviv

University, POBox 39040, Tel Aviv, Israel E-mail: lahavo@post.tau.ac.il

of people who are blind in known and unknown spaces (1,2) indicates that support for the acquisition of spatial mapping and orientation skills should be supplied at two main levels: perceptual and conceptual In this paper we use the term O&M to refer to ―the field dealing with systematic techniques by which blind persons orient themselves to their environment and move about independently‖ (3) At the perceptual level, information perceived via other senses should compensate for the deficiency in the visual channel Thus, the haptic, audio, and olfactory channels become powerful suppliers of information about unknown environments At the conceptual level, the focus is

on supporting the development of appropriate strategies for an efficient mapping of the space and the generation of navigation paths According to Jacobson (4), people who are blind tend to explore the indoor environment through a perimeter-recognition strategy, followed by a grid-scanning strategy Over the years, secondary O&M aids have been developed to help people who are blind explore real spaces There are currently more than 146 O&M electronic systems and devices (5) These secondary aids are not a replacement for primary aids such as the long cane and the dog guide We can divide these aids into two groups: (i) preplanning aids which provide the user with information before arrival in an environment, for example verbal description, tactile maps, physical models, digital audio, and tactile screens; and (ii) in-situ aids which provide the user with information about the environment while in the space, for example obstacle detectors, tactile vision substitution systems, embedded sensors in the environment, and Global Positioning Systems (GPS) There are a number of limitations in the use of these preplanning and in-situ aids For example, the limited dimensions of tactile maps and models may result in poor resolution of the provided spatial information, there are difficulties in manufacturing them and acquiring updated spatial information, and they are rarely available Because of these limitations, people who are blind are less likely to use preplanning aids in everyday life The major limitation of the in-situ aids is that the user must gather the spatial information

in the explored space There is also a safety issue, since the in-situ aids are based mostly on auditory feedback, which in the real space can reduce users‘ attention and isolate them from the surrounding space

Using virtual environments (VEs) has the potential to improve the ability

of people with sensorial, physical, mental, and learning disabilities (6,7) Interaction in the VE by special needs populations presents both benefits and limitations The benefits of the VE mainly include the user‘s independent

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Improving orientation and mobility skills … 23

interaction and activity in the VE Users receive immediate feedback suiting their sensory and cognitive abilities The VE allows the user to practice without fear, time limitations, or the need for the participation of a professional In addition, the VE technology allows the professional to manage the amount of information and sensorial stimuli that users receive during their interaction within the VE These unique capabilities of the VE technology system fulfil the need to design a flexible and adaptive learning or rehabilitation program for each client according to his or her special needs and abilities Moreover, the VE technology can assist professionals in gathering information about their clients‘ interactions, which can assist in designing future learning and rehabilitation programs On the other hand, the VE has some limitations The VE is not a replica or replacement for real space interactions and activities Furthermore, most rehabilitation centers and schools cannot afford these expensive technologies Additionally, some systems under development are still too heavy, bulky, or complicated for use outside the laboratory environment

Technologically advanced virtual devices enable individuals who are blind

to learn by using haptic and audio feedback to detect artificial representations

of reality The most recent generations of haptic devices transmit feeling through direct contact with the virtual object (e.g., SensAble Phantom Desktop, Immersion Corp.‘s CyberForce, Novint Falcon, and Nintendo‘s Wii) Stemming from the development of these devices, applications have been researched and developed especially for people who are blind, including identification of texture and shape recognition (8,9), mathematical learning environments (10-13), and acquisition of spatial information

This paper describes and examines VEs that have been developed to enable people who are blind to improve their O&M skills There are mainly two groups of VEs: (i) systems that support the acquisition of a cognitive map (14-28); and (ii) systems that are used as O&M rehabilitation aids (29-34)

OUR STUDY

This study analyzed 21 peer reviewed papers selected based on research topic:

VE for people who are blind, on O&M as subject matter The first group of papers was found by search engines for scientific journals and conferences, other papers were selected through snowball sampling, using the bibliography

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items to find other papers No papers were excluded on the basis of methodological or result quality

To assess the validity of the database, three evaluators (a researcher and two graduate students) analyzed all the papers Each paper was analyzed twice Each of the two graduate student evaluators received 11 papers, randomly selected from our list, to be characterized according to the variables

To maximize the common framework of analysis, the graduate student evaluators and researcher met several times to discuss the variables and experimentally apply them to a number of papers The author and two evaluators coded all 34 questions Inter-judge reliability was 97.4% and therefore regarded as valid

Variables

Our evaluation characterized 34 variables in three main dimensions:

Descriptive information dimension This dimension included basic

information regarding the paper and research, such as year of publication, researcher affiliation, researcher discipline, state, and source of funding)

System dimension This dimension included four categories: (i) System

features included six variables, such as system type (software and hardware), system developments‘ stage (prototype and off-the-shelf product), number of users (single and multiple), location (local and remote), system modality (haptic, audio, multimodal haptic, and audio), and user‘s input and output device (tracking system, joystick, game controller, Phantom, keyboard, head-mounted display, headphones, loudspeakers, etc.) (ii) Haptic feedback included two variables: type of haptic feedback (thermal, vibration, texture, stiffness, dumping, collision, and gravity) and variety of haptic feedback (iii) Audio feedback included two variables: audio system (mono, stereo, and surrounding) and type of audio feedback (oral virtual guide, user footsteps, echo location/obstacle perception, and sound localization) (iv) Interaction type included four variables: user interaction (user device, body movement and user device, and body movement), virtual object type (static, dynamic and static and dynamic), operation of the virtual object (rotation), and allowing scaling (increase or decrease object or area size)

Research dimension This dimension included five categories: (i)

Research type included three variables: clinical research; type of research

Improving orientation and mobility skills … 25

(preliminary and usability), and research goal (acquire cognitive map, O&M rehabilitation trainee) (ii) Participant category included four variables: participants‘ visual ability, number of participants, age, and gender (iii) Target space category included three variables: VE representing real space, space complexity (simple and complex), and space location (indoor, outdoor) (iv) Research task category also included four variables: length of exposure to VE, type of exploration, construction of cognitive map after exploring VE, and orientation tasks in the real space (v) Data collection category included only one variable: whether the developed system included a user log

Collecting data instrument

For the collection of the data we used a protocol research that included all the research categories and variables described above

Procedure

This study included three stages At the first stage the researcher collected the peer review target papers using academic search engines; other papers were selected through snowball sampling In the second stage a protocol research was developed, which included all the research categories and variables During the third stage the researcher and two graduate students analyzed each paper twice according to the research protocol

Descriptive information dimension

The first paper was published in 1997 (21) Most of the researchers were from academic institutions (82%); only 43% of the groups included interdisciplinary researchers, such as technology disciplines (e.g., computer science, engineering, and industrial science), social sciences (e.g., education, psychology, and rehabilitation), and from the health sciences (e.g., medicine, neuro-psychobiology, and physical therapy) Most of the paper authors were from the EU research community (67%) Worldwide, governments are the major funders (62%) with only 10% of funding from private industrial companies

System dimension

Most of the research groups developed software and used off-the-shelf hardware (77%) All VEs were developed through the prototype stage and were targeted to single users in a local mode The most frequent system modality was auditory (53%); 43% of the VEs were multimodal (audio and haptic) Per examination of input and output user devices, users operated one

or more devices, e.g., tracking system (48%), joystick (15%), game controller (15%), Phantom (19%), keyboard (29%), and head-mounted display (15%) Ten VEs integrated haptic feedback and used one or more types of haptic feedback Ninety-five percent of the VEs included audio feedback, 40% integrated a surrounding audio system, 25% used a mono system, and only 15% included a stereo system By type of audio feedback, 85% used sound localization, 40% echolocation and obstacle perception, 20% user footsteps, and 15% oral virtual guide The interaction type analysis shows that most of the virtual components were static (91%); very few VEs allowed the users to manipulate the VE‘s objects or its space

Research dimension

Most papers included clinical research (82%), while 67% had preliminary research and 29% described usability experiments Seventy-two percent of the research included people who were congenitally blind and late blind in their research; however 24% of the research included sighted participants who were asked to use blindfolds during the experiments Less then half of the examined

Improving orientation and mobility skills … 27

papers (43%) included fewer than ten participants in their research seven percent of these research participants were adults The VEs represented real spaces (67%), simple spaces (67%), and indoor areas (82%) Most of the simple spaces were represented in the auditory modality systems, unlike the multimodal VEs, which represented mainly complex spaces The research results confirm the potential and the effectiveness of VEs as O&M aids In all the clinical research, participants were asked to explore the new space by using the VE systems These results show that most of the participants (60%-100%) explored the VE successfully Some of the VE systems used a haptic device, such as a virtual cane (18-20, 24, 29, 34) These research participants reported that the different virtual canes were useful for active exploration and

Sixty-as pSixty-assive guidance On the other hand, some of the participants reported that they disliked being moved passively by the virtual cane (24) Only one system included a fly mode, and its users were able to determine height by the height

of the directional beacons (21) Nevertheless, most of the researchers noted that the avatar speed motion in the VE was necessary to meet the individual needs Furthermore, Seki and Sato (33) found that the difference in stress pulse ratio in the virtual training group improved in terms of walk stress, as it did also in the real space participants group They suggested that the VE was perceived by the user as a safe training environment and thus it could reduce the stress experienced by the novice trainee, as opposed to the stress experienced in training in the real space Furthermore, the results found by Ohuchi et al (23) showed that participants‘ physically turning right or left in a multimodal VE caused disorientation The multimodal systems mostly focused

on acquiring a cognitive map Accurate spatial descriptions of the explored spaces were given after exploring the VE (14 18, 19, 21, 23, 24) The participants were able to simulate the environment size differences successfully (17, 34) Similar results were found among adults and children who were totally blind or had residual vision, but different results were found among children with residual vision and medium cognitive achievement, who were unable to create a spatial cognitive map (25) In the real space, most of the participants (70%-100%) were able to transfer and apply spatial information that was acquired during their VE exploration (14, 19)

In the past 15 years, 21 VEs have been researched and developed for the use of people who are blind Each research group designed and developed a unique

as an O&M aid by research and development groups, users, rehabilitation services, and other public service providers Unfortunately, today, despite the encouraging results, these VEs are not available outside research labs

The research results showed that some of the VEs ask the user to operate several devices at the same time, which can affect the user‘s ability to work independently or affect his or her cognitive load in gathering and analyzing extensive information Future applications will need to maintain a balance between user-friendly systems and audio and haptic representations

Further research is needed to continue the research of Simonnet et al (26),

to examine if and how the VE‘s spatial exploration methods, allocentric or geocentric representations, influence the user‘s spatial model This is a topic that was less commonly examined and which might have an influence on the user‘s ultimate ability and outcome in using a VE Additionally, the research must proceed to examine the real-life scenarios in which this type of O&M aid

is most needed, such as outdoor and complex spaces

In the mean time, handheld device technologies are increasingly being used by people who are blind Until three years ago, users who are blind carried a variety of devices, including cell phone, GPS, note taker, color identifier, drug labels reader, and music or audio book device Today one handheld device offers all of these technologies and more Two years ago, Google announced a new Android application called Intersection Explorer (35), a preplanning application that allows people who are blind to explore the layout of streets on Google Maps by using touch to move along the street and

to receive auditory directions Tactile handheld devices have been developed (36, 37) which allow users who are blind to gather tactile feedback on the backside of the handheld device Encouraged by research results, we suggest integrating an O&M aid application based on multimodal interfaces in a handheld device The handheld device‘s screen will fit the user‘s palm, enabling collection of all the tactile information This unique application will

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