Stretch exercise in a dream world

Virtual reality has a future in helping victims of brain damage, Aisling Irwin reports. New to using an electric wheelchair, the patient crashes into walls, furniture, even passing people. Fortunately he damages nothing: he has been learning the technique on a mock wheelchair, set up on a base with sensors. The experience has been simulated in virtual reality, so he can learn to manipulate the vehicle properly before being let loose in the real world.

This use for VR is just at its beginning: there are a few pilot studies around the country. But psychologists are beginning to realise just how useful VR could be as an aid to disabled people, as a way of testing for brain damage, or even as a way of stimulating the brain in the hope of repairing damage as much as is possible.

VR is an immersive computer-generated world that responds to your movements as you walk or joystick through it. It is already the source of a generation of computer games. Excited articles have predicted its potential in conceptual design, internal design of houses, and the training of pilots without expensive flight simulators. Kevin Warwick, professor of cybernetics at the University of Reading, recently took up this theme in the journal Science and Public Affairs.

Psychologists have twigged only recently that the technique could help to combat the effects of brain damage. One person in 400 suffers from traumatic brain injury. More than a third of these injuries are caused by road accidents. The most common age for such injury is between 15 and 24 - and medical science can keep the injured alive for longer. The need to harness technology to help these people is obvious, according to David Rose, professor of psychology at the University of East London.

Paul Sharkey, lecturer in the robotics and VR research groups at Reading University agrees: "There has been a huge amount of interest in disability and technology. There is huge potential".

He first became interested because one of his postgraduate student worked with a disabled group. They held a workshop about 18 months ago to explore how VR might help people with different types of disability.

Now the ideas are flooding in from around the world as he compiles the programme for the first European conference on disability, VR and associated technologies, to be held in Maidenhead in July. What about a virtual headstick - like a joystick but controlled by tiny head movements, for people with motor disabilities? What about three-dimensional sound - a virtual world of sound in which blind people can learn in safety to cross roads and avoid other dangers? What about replacing conventional physio therapy by an enjoyable virtual adventure which, as you participate in it, also rehabilitates the use of your hands and arms?

In Edinburgh, psychologists have been exploring how VR could help stroke sufferers.

An unpleasant consequence of a stroke can be unilateral visual neglect. "The patient fails to recognise that they have one side of their body," says Madelaine Coleman, a psychologist at the university.

The visual data goes in OK but the sufferer does not realise that, for example, there is food lying on the left side of the plate as well as the right.

After a stroke there is a crucial window of about six months, in which the brain reorganises its functions and can even partially regenerate. This is the time when patients need intense attention. At Edinburgh the psychologists are trying to use the three-dimensional movement of VR to reactivate that part of the brain which is neglecting one side of the visual field. Psychologist Simon Rushton has created virtual environments through which the patients can move - for example, by pedalling on a bicycle. The hope is that they can "stimulate some of the areas that they have damaged". A pilot study has encouraged the researchers.

Other research might help babies suffering from brain damage or who are born with or develop another problem so disabling that it prevents them from developing full use of an initially normal brain.

For example, those born with an impediment that prevents them from exploring the space around them as normal children can have problems in later life.Though childhood arthritis does not directly damage the spatial parts of the brain, it can indirectly damage them because the sufferer finds it hard to move around and thereby stimulate them.

Nigel Foreman, lecturer at Leicester University, says that such children develop rather poor cognitive maps of their surroundings. So the question is, how can we help people to move around their environments? Electric wheelchairs are an answer but most children do not get them until they are older. Some people have argued that it is crucial to develop spatial skills very early in life. Like the development of language, if you pass a certain age it becomes too late.

"If you get to the age of 12 with no navigational experience it is going to be very difficult," says Foreman.

With other diseases, such as some types of cerebral palsy, meningitis, or anoxia, the spatial brain structure itself may be damaged. If these children are stimulated, says Foreman, they may find some other way of using the brain to do these tasks. "You might get an improvement," he says.

But there is further to go in exploring the use of VR as a way of preventing primary damage causing side-effect damage. Professor Rose is brimming with ideas. The first stems from observations of rats. If you put a rat into an enriched environment - full of wheels and mazes, for example - its brain gets heavier within a month. The increase is biggest for younger rats but it occurs even in elderly rats.

Transferring the observation to humans, which he admits some would say is speculative, Professor Rose is working on the hypothesis that enriching the environment could help those with brain damage.

The compounding tragedy is that the unstimulated patient's brain atrophies. A sufferer is often in a wheelchair, suffering from fatigue, with little sensory input and with a higher arousal threshold.

Professor Rose says: "Head injury patients suffer from less arousal. They are less interactive than other sorts of patients with similar sorts of motor problems. It is generally agreed that we need to enforce a greater level of interaction than would otherwise exist."

The key word is interaction. "If brain injury causes a decline in action which in turn can have a damaging effect on the brain then it is important to enable them to hold their own while the rehabilitation is taking place."

Yet teams of therapists are expensive, says Professor Rose. And it is not enough to leave such people to stimulate themselves. He is looking for the solution in virtual reality. Inside a headset there is no escape from the virtual world: there is no choice but to interact.

Trials are due to start, subject to ethical committee approval, with colleagues at the Homerton Hospital in London.

"I think it's got a lot of potential," says Rose. Downstairs in the large psychology department, Professor Rose and colleagues have set up a VR laboratory. Instead of a headset they use a screen, which is so large that you feel nearly as immersed as you would with a headset. You can wander through the little screen world - a house with several rooms, each leading onto the next.

Users will complete their "visit" before being asked by the psychologists what they remember about it. The researchers are exploring spatial memory, including the fact that people are more likely to remember the bowl of fruit on the table if they have actually wandered past it rather than seen its picture in a book.

Rose says: "It does give you an idea of what someone's memory would be like in a real world situation". Classic psychometric testing suffers from the fact that it is so artificial - does it really tell the psychologist how the patient's memory is functioning in the real world? "VR is half way between life and the lab."

Foreman agrees that VR could become a very useful tool for diagnosing functional problems: "When you want to answer a question such as can someone drive a car, you can assess it much much better than conventional means, with virtual reality."

He is not so sure about VR diagnosing brain damage. He reckons that brain scans will always be preferable. Wandering around wearing a VR headset can cause problems. Some people suffer from nausea afterwards. The screen version apparently does not cause such problems.

Foreman also fears that some sufferers may prefer to live in the virtual rather than real world. There are other, more mundane problems. Cost: a state-of-the-art headset system is more than Pounds 150,000. A less ambitious system using a screen costs about Pounds 13,500, says Rose. Transferring the technology safely into the marketplace is another hurdle. Rose says psychologists are just at the stage of exploration, of preliminary tests on normal people.

"There are quite a number of departments which have VR facilities that have established their clinical links and done the groundwork."