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Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
Greenleaf vr medicine
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Greenleaf vr medicine

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  • 1. Telemedicine and Virtual Worlds Next-Generation Tools forBehavioral Medicine, Physical Therapy and Disability Solutions Walter Greenleaf, PhD
  • 2. Virtual Environments - Therapeutic HealthcareCurrent technologies and concepts are founded on of more than 25years of research and developmentChanges in cost and access make VE affordableVE’s are currently used for prevention, coaching, training, evaluation,treatment and rehabilitation…. and as a disability solutionOn the horizon: enhanced, ubiquitous, informative and integrated MSR VE and Medicine May 19, 2011 2
  • 3. ! VR Technology Has Evolved the Last 30 Years Current technologiesand protocols have benefited from morethan 30 years of research and development MSR VE and Medicine May 19, 2011 3
  • 4. ! VR Technology Has Evolved First general purpose and commercially available VR SystemsNow, after morethan 27 years of research and development… 1984 MSR VE and Medicine May 19, 2011 4
  • 5. Personal Quest… Now Close to Fulfilled I startedwork in thisarea in 1984 Now, with a confluence of technologyand changes in healthcare VR is transitioningfrom lab to clinic MSR VE and Medicine May 19, 2011 5
  • 6. Surgical Training Surgical Training Preoperative Planning & Image Guided surgery Preoperative Planning & Image Guided Surgery Rapidly becoming the standard for training… …and soon to be part of thestandard of care MSR VE and Medicine May 19, 2011
  • 7. Virtual Reality Technology is Just Now Emerging Virtual Realitytechnologyhas beenover hyped MSR VE and Medicine May 19, 2011 7
  • 8. MUVE Virtual EnvironmentsTechnology have progressed to the point of acceptable VOIP visual realism, believable real-world Graphic physics, and adequateProcessors sensory immersion.BroadbandMovement TrackingAlgorithms The acceptance of for NVB computers andLow Cost technology as part ofComputers the clinical process has also progressed Smart Phones Tablets
  • 9. Our currentunderstanding of the appropriatetechnologies andmore importantly,appropriate use of VR in clinical psychologyMore than than 25 years of clinical research, development, refinement and validation
  • 10. To Change a Behavior Is to Change a NeurosystemIt is necessary to activate the associated brain systemto enable neuro-plasticity Repetition is requiredIt is critical to engage thebrains reward systems andhigher functions MSR VE and Medicine May 19, 2011 10
  • 11. To Change a Behavior Is to Change a NeurosystemIt is critical to engage thebrains reward systemsand higher functions MSR VE and Medicine May 19, 2011 11
  • 12. Virtual environments are used clinically to treat several important behavioral health problems•  Phobia and anxiety disorders•  Post-traumatic stress disorder (PTSD)•  Developmental disabilities•  Conduct disorders•  Drug and alcohol abuse•  Anger management •  Impulsive disorders•  Eating disorders •  Learning disabilities •  Neuro-cognitive disorders MSR VE and Medicine May 19, 2011 12
  • 13. Benefits of VR Assisted Therapy! ProvidersPatients •  Lower cancellation rates •  Higher engagement, leading to faster, more long-lasting results •  Higher retention from session-to- session •  Less stigma and resistance, •  Improved compliance especially with younger •  Support for remote use, larger group •  Faster results sessions •  Improved long-term results •  Ability to document progress and •  Supports remote use analyze outcomes •  Improved clinical outcomes MSR VE and Medicine May 19, 2011 13
  • 14. Virtual environments are used clinically to treat ! several important behavioral health problems!MSR VE and Medicine May 19, 2011 14
  • 15. Virtual Environments in Therapeutic Health CareImmersive Clinical Virtual Environments PTSD, Phobias, and Anxiety DisordersInteractive Social Virtual Environments Addictions, Social Skills, Anger, Impulsive Disorders“Games” - Wellness and Prevention Diet, Exercise, Smoking Cessation, Stress InoculationRehabilitation- Injury Recovery Stroke, TBI, Physical Therapy, Occupational Therapy
  • 16. Immersive VR for PTSD, Phobias, and Anxiety Disorders !Exposure-based treatments can be conducted in the safety and comfort of an office settingEffective tools for treating a variety of clinical problems, in particular anxiety and addictive disordersFully immersive environments, with include the use of a head mounted display, 3D sound, tactile stimulation via shaking platform, and olfactory stimulus are used for PTSD therapy MSR VE and Medicine May 19, 2011 16
  • 17. Surface and Gesture Interfaces! Mark BolasMSR VE and Medicine May 19, 2011 17
  • 18. Virtual Iraq & Virtual Afghanistan! Developed in collaboration with ICTMSR VE and Medicine May 19, 2011 18
  • 19. Immersive Virtual Environments! Treatment  of  Combat-­‐Related  PTSD  MSR VE and Medicine May 19, 2011 19
  • 20. Immersive Virtual Environments! Treatment of Combat-Related PTSDMSR VE and Medicine May 19, 2011 20
  • 21. Research Has Demonstrated!•  VR can be safely used with persons having Anxiety Disorders and PTSD!•  VR Exposure Therapy, NOT “VR Therapy”!•  VR is MORE effective than imaginal exposure!•  VR is AS effective as in-vivo exposure!•  Doesnt have to be an exact replica of reality to have a positive TX effect!•  VR is a TOOL to extend the skills of a well trained clinician! MSR VE and Medicine May 19, 2011
  • 22. Research and Validation!Current technologies and concepts are founded on of more than25 years of research and development Examples •  Fear Of Flying Exposure Therapy •  Treatment Of Combat PTSD •  Meta-analysis Of VR Treatment For Anxiety Disorders •  fMRI - Before Versus After Treatment MSR VE and Medicine May 19, 2011 22
  • 23. Virtual Airplane for Fear of Flying!•  Patient wears Head-mounted •  Simulates Display –  Sitting in plane on runway, –  Position Tracker engine on/off –  Covers Entire Field of View –  Taxi –  Hears only audio from –  Takeoff earphones (including –  Flight in good weather therapist) –  Flight in bad weather•  Sits in Airline Seat –  Landing MSR VE and Medicine May 19, 2011 23
  • 24. Virtual Airplane for Fear of FlyingMSR VE and Medicine May 19, 2011 24
  • 25. Virtual Airplane for Fear of FlyingMSR VE and Medicine May 19, 2011 25
  • 26. Fear of Flying Study: N = 75!140!120!100! 80! Pre! Post! 60! 6 month! 40! 20! 0! VR! SE! WL! MSR VE and Medicine May 19, 2011 26
  • 27. Virtual Iraq Clinical TrialNaval Medical Center San Diego Camp Pendleton Beck Anxiety & PHQ Depression PreTreatment, PostTreatment & 3 Month Follow-upMSR VE and Medicine May 19, 2011 27
  • 28. PTSD Checklist-Military (PCL-M) PreTreatment, PostTreatment & 3 Month Follow-up 16 of 20 No Longer meet DSM criteria for PTSD at Post-TX 57 52 47 Treatment Completers n=20 p < .001 Average # of Sessions < 11PCL-M 42 (n=20) p < .001 37 (n=14) 32 27 Pre-Treatment Post-Treatment 22 1 Week 3 Month 3 Month FU Pre-TX Post TX Post TX 17 PRE TX POST TX
  • 29. Beck Anxiety & PHQ Depression
 PreTreatment, PostTreatment & 3 Month Follow-up19 16 of 20 No Longer meet DSM18 criteria for PTSD at Post-TX1716 Treatment Completers n=2015 p < .003 Average # of Sessions < 111413 (n=20)12 Pre-Treatment11 Post-Treatment p < .001 p < .00210 3 Month FU 9 (n=14) (n=20) 8 p < .004 (n=14) 7 6 Pre 1 Week 3 Month Pre 1 Week -TX Post TX Post TX -TX Post TX 3Month 5 Beck Anxiety PHQ-Depression
  • 30. ANNALS OF THE NEW YORK ACADEMY OF SCIENCES Issue: Psychiatric and Neurologic Aspects of War Improvement in cerebral function with treatment of posttraumatic stress disorderMichael J. Roy, Jennifer Francis, Joshua Friedlander, Lisa Banks-Williams, Raymond G. Lande, Patricia Taylor, James Blair, Jennifer McLellan, Wendy Law, Vanita Tarpley, Ivy Patt, Henry Yu, Alan Mallinger, Joann Difede, Albert Rizzo, and Barbara Rothbaum MSR VE and Medicine May 19, 2011 30
  • 31. fMRI before versus after treatment; 
 activation across areas of interest. !MSR VE and Medicine May 19, 2011 31
  • 32. Amygdala activation with emotional stimuli, 
 pre- and post treatment!MSR VE and Medicine May 19, 2011 32
  • 33. VR Anxiety Disorders Meta-AnalysisJournal of Anxiety Journal of Behavior Therapy and Disorders Exp. Psychiatry MSR VE and Medicine May 19, 2011 33
  • 34. Cognitive Behavioral Therapy!In traditional behavioralhealthcare, patients andtherapists typically meet in a smalloffice, face-to-face, once a weekBehaviors are explored by therecall of past events, discussionof future possibilities, and thepractice of new skills viaimaginary role play The patient is then on their own until the next appointment to continue to think about themes and try new strategies in the real world. MSR VE and Medicine May 19, 2011 34
  • 35. ! Interactive Virtual Environments for Behavioral Health Traditional ApproachThe patient is then on their own until the next appointment. To continue to think about themes and try new strategies in the real world They can not easily practice on their own. For many people, despite years of work… it doesn’t work Why? Two major reasons: To change a brain system, you must activate it To learn a new behavior, you must practice! MSR VE and Medicine May 19, 2011 35
  • 36. Interactive Virtual Environments!Interactive Virtual Environments are flat-screen, multi-user interactive synthetic environments used when group dynamics or interpersonal skills are paramountKey features: Keyboard-free interactions (voice) Natural movement and expressions Playback from any point of view Imbedded assessment tools and auditory / visual cues MSR VE and Medicine May 19, 2011 36
  • 37. ! Interactive Virtual EnvironmentsProvide the Ability to:•  Engage the user cognitively, and thus make participation engaging, as well as increase compliance•  Conduct group sessions•  Monitor progress using a wide array of assessment tools•  Allow clinicians to build rapport with patients in a neutral environment that can de-stigmatize therapy •  Teach interpersonal and cognitive skills •  Desensitize patients to environmental triggers •  Create and support patient social networks •  Practice skills with clinical trainees and provide an immediate opportunity for testing in a simulated social or clinical setting MSR VE and Medicine May 19, 2011 37
  • 38. Community and Family SupportVirtual Reality Environment for Amputee Support Program MSR VE and Medicine May 19, 2011 38
  • 39. When to use role-playIndividual therapyCouples therapyFamily therapyClinical focus –  Drug addiction –  Trauma –  Sexual abuse –  Domestic violence –  Learning disabilities –  And many others MSR VE and Medicine May 19, 2011 39!
  • 40. Role Playing via Avatars•  Engage rapidly•  Talk naturally•  Build rapport•  Active participation•  Supports anonymity•  Leverage mirror neurons•  Engage multiple neurosystems•  Activate reward systems MSR VE and Medicine May 19, 2011
  • 41. Introducing Dr. Ivana SteigmanMSR VE and Medicine May 19, 2011 41
  • 42. Parent Child Role PlayMSR VE and Medicine May 19, 2011 42
  • 43. Social Skills - Movie InviteMSR VE and Medicine May 19, 2011 43
  • 44. AA MeetingMSR VE and Medicine May 19, 2011 44
  • 45. Refusal-Skill TrainingMSR VE and Medicine May 19, 2011 45
  • 46. Telemedicine Model !MSR VE and Medicine May 19, 2011 46
  • 47. Benefits of VR Assisted Therapy !Clinician Practice Owner or Manager •  Improved clinical outcomes •  Increased revenues, lower costs, higher •  Ability to document progress profits •  Competitive advantage on •  Practice volume scalability their main deliverable •  Ability to serve a larger market •  Job satisfaction •  Ability to quantify resultsReferring Physicians State and Local Government Agencies •  Superior clinical outcomes •  Reduced short-term costs •  Improved documentation and •  Reduced long-term costs proof of results •  Reduced derivative costs (crime, cost for incarceration)Patients •  Faster results School Systems •  Improved long-term results •  Reduced costs for special education •  More convenient •  Improved educational results •  Not boring •  Reduced stigma MSR VE and Medicine May 19, 2011 47
  • 48. Distraction from Pain and Relaxation TrainingMSR VE and Medicine May 19, 2011 48
  • 49. Stress InoculationMSR VE and Medicine May 19, 2011 49
  • 50. Presenting a Terminal DiagnosisMSR VE and Medicine May 19, 2011 50
  • 51. Teaching EmpathyMSR VE and Medicine May 19, 2011 51
  • 52. Executive CoachingMSR VE and Medicine May 19, 2011 52
  • 53. Follow-On System– Cognitive Assessment Virtual Reality CognitivePerformance Assessment Test VRCPAT MSR VE and Medicine May 19, 2011
  • 54. Attention Module Currently testing selective, divided and interference attention challenges in Checkpoint context. MSR VE and Medicine May 19, 2011
  • 55. Traditional Therapeutic Environment In the traditional therapy session, thepatient works one on one with atherapist to address shoulder flexionand abduction, pincer grasp, forearmsupination and pronation and othermovement foci. MSR VE and Medicine May 19, 2011
  • 56. Current Rehabilitation Technology !MSR VE and Medicine May 19, 2011
  • 57. Dynamic TeleRehab System! 57MSR VE and Medicine May 19, 2011
  • 58. Physical Medicine - Injury Recovery Stroke, TBI, Physical Therapy, Occupational TherapyMSR VE and Medicine May 19, 2011 58
  • 59. Distributed Rehabilitation! 59MSR VE and Medicine May 19, 2011
  • 60. Wiihabilitation !MSR VE and Medicine May 19, 2011
  • 61. Kinect and Rehabilitation !MSR VE and Medicine May 19, 2011
  • 62. Dynamic TeleRehab System! 62MSR VE and Medicine May 19, 2011
  • 63. Kinect as a Disability Solution!The Kinect provides a unique way forthose with physical disabilities tocontrol a computer. For many, this technology can lower barriers to employment and social interaction. MSR VE and Medicine May 19, 2011
  • 64. What’s next?!Autonomous Avatars for Coaching Real-Time Facial Expressions Photo-Realistic Avatars Cultural Specific, Non-Verbal Interaction
  • 65. Texture Mapping of Faces to Avatars With Speech Synthesis and EmotionsMSR VE and Medicine May 19, 2011 65
  • 66. SimCoach - Autonomous CoachMSR VE and Medicine May 19, 2011 66
  • 67. Bill Ford - Autonomous CoachMSR VE and Medicine May 19, 2011 67
  • 68. Real-time Avatar Interaction Gesture and Facial Expressions Real-Time Facial ExpressionsMSR VE and Medicine May 19, 2011 68
  • 69. Enhanced InteractionHugging MSR VE and Medicine May 19, 2011 69
  • 70. Photo-realistic Avatars, Cultural Specific NVBMSR VE and Medicine May 19, 2011 70
  • 71. Facial Expressions - Mapped to EmotionsMSR VE and Medicine May 19, 2011 71
  • 72. Virtual Environments and Behavioral HealthcareCurrent technologies and concepts are founded on of more than 25years of research, development, and clinical validationChanges in cost and access make VE affordableVE’s are currently used for prevention, coaching, training,evaluation, treatment and rehabilitation, and as a disability solutionOn the horizon: enhanced, ubiquitous, informative and integrated MSR VE and Medicine May 19, 2011
  • 73. ResourcesMSR VE and Medicine May 19, 2011
  • 74. Thank You! Thank YouWalter Greenleaf, PhD Palo Alto, California Walter@greenleafmed.com

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