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Josman 2004 Epub Download

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The user's image is thereby embedded within a simulated environment such that it is possible to interact with animated graphics in a completely natural manner. Although this technology first became available more than 25 years ago, it is only within the past five years that it has been applied in rehabilitation. The objective of this article is to describe the way this technology works, to review its assets relative to other VR platforms, and to provide an overview of some of the major studies that have evaluated the use of video capture technologies for rehabilitation. Introduction Two major goals of rehabilitation are the enhancement of functional ability and the realization of greater participation in community life. These goals are achieved by intensive intervention aimed at improving sensory, motor, cognitive and higher level-cognitive functions on the one hand, and practice in everyday activities and occupations to increase participation on the other hand [ 1 , 2 ]. The client's cognitive and motor abilities are assessed throughout the intervention period so that therapy may be continually adjusted to the client's needs.

Isolation of Antifolate-sensitive Mutants of M. Wild-type M. Five wells at different positions of well plates inoculated with wild-type M. Colonies that grew on NE-kanamycin plates but failed to grow on plates supplemented with antifolates were subjected to two rounds of additional replication to confirm drug susceptibility patterns.

Minimum inhibitory concentrations MICs of selected mutants to antifolates were determined by serial dilution assays see below. Mapping of transposon insertion sites in the mutants by using an arbitrary PCR method was carried out as described previously 16 , PCR products were gel-purified and directly electroporated to E.

Homologous recombination was verified by PCR using primers annealing to chromosomal regions outside the homologous sequences YgfA1. NE and YgfA2.

Clement Ho

BH; supplemental Table S2. The entire open reading frame of M. Similarly, the bp downstream region was amplified using primers fuel-Del3 and fuel-Del4.

Xb and p2. BH supplemental Table S2. For expressing M. Transformants were selected for resistance to kanamycin plus hygromycin.

Site-directed Mutagenesis of H. NE and mthfs2. To stabilize the overproduced enzyme, 0. The protein concentration in the total cell lysate was determined by the Bradford method Bio-Rad.

Unbroken cells and cell debris were removed by centrifugation at 12, rpm in an SS rotor Sorvall for 15 min to yield soluble fraction. The soluble fraction was further diluted with buffer A 50 mm sodium phosphate, mm NaCl, and 10 mm imidazole and loaded to a cobalt metal affinity spin column Pierce pre-equilibrated with the same buffer.

The column was washed three times with 2 column volumes of buffer A followed by elution by 3 volumes of the same buffer A supplemented with a higher concentration of imidazole mm.

Fractions containing purified protein were pooled, 0. Chemical Complementation Cultures of M. Paper discs embedded with 0. A successful complementation was regarded as the disappearance of the inhibition zones. Extraction and Determination of Cellular Levels of Folate Derivatives Sample preparation was handled under subdued light to minimize folate degradation.

Aliquots of identical cultures were also harvested for determination of total protein and wet weight. Unbroken cells and debris were removed by centrifugation and filtered through 0.

Viewing medium affects arm motor performance in 3D virtual environments

Conditions for HPLC and mass spectrometric analyses using a Q-trap mass spectrometer Applied Biosystems, Foster City, CA , preparation of calibrators, and data analyses were carried out as before 24 , The assay mixture contained, in 1 ml, 50 mm MES buffer pH 6.

Reactions were conducted in quartz cuvettes of 0. The absorbance was recorded using an Evolution spectrophotometer Thermo Scientific equipped with VisionLife software. Protein concentrations were determined by the Bradford method. Furthermore, the ASD group showed less congruent emotions in response to the emotion displayed by the avatar Parsons et al. Compared to healthy controls, the ASD patients showed less of a tendency to avoid a couple standing at an otherwise empty bar when ordering drinks.

Other studies in this field are directed at gaining insight in the pathophysiology of ASD by studying neural mechanisms of deviant non-verbal behavior Four research groups investigated the neural mechanisms in response to avatar gaze direction or duration in ASD subjects 37 — They consistently found deviations in the networks involved in the theory of mind ToM and gaze perception in ASD subjects compared to healthy controls.

Von Dem Hagen et al. They found several deviations, which included an increased activation of the right temporoparietal junction and the dorsal area of the medial prefrontal cortex during processing in ASD subjects, speculating subjects with ASD address different cognitive strategies to access their own emotional state in response to emotions displayed by others Forensic Psychiatry Only one study evaluated the use of VR in the assessment of forensic patients.

The research group of Renaud et al. They found a more pronounced erectile response in child molesters in reaction to the child avatars, as opposed to healthy controls who showed this response to the adult avatars. Also, a more focused gaze toward the sexual relevant areas in all avatars was found in the child molester group, possibly referring to their sexual preoccupation Craving is an important diagnostic criterion of substance use disorders and is defined as an intense preoccupation or urge to use the desired substance Most of the studies using VR to assess craving in alcohol-, cannabis-, and hard drug dependence focused on a comparison between neutral and substance cue-related VR environments in patients with a substance use disorder and did not include a healthy control group.

Virtual reality was used to create realistic scenes including substance-related cues, avatars, and even the smell of beer or cannabis. The studies generally showed a higher level of subjective craving in VR environments containing substance-related cues compared to neutral VR environments 44 — Only in the study of Saladin et al.

Finally, in a study by Lee et al. They tested a VR environment with alcohol-related cues and an environment with avatars exerting social pressure. Their results showed that both patients and healthy controls experienced an increase in subjective craving in response to virtual social pressure in the absence of alcohol related cues.

However, only the alcohol-dependent patients experienced an increase in craving in response to the VR environment with alcohol-related cues, as opposed to the healthy controls. Eating Disorders We found three studies using VR in the assessment of eating disorders, additionally, a review article was identified The studies focused on body image and body dissatisfaction, but also on anxiety and physical reactions in response to virtual food or dining scenarios.

Gorini et al. In eating disorder patients, anxiety, heart rate, and skin conductance in response to virtual food were significantly higher compared to healthy controls. Patients showed more body distortion and dissatisfaction in all virtual scenarios and a significantly higher level of anxiety and depression compared to healthy controls, especially in the scenarios with high calorie food.

The same research group examined food craving in response to virtual food in patients with bulimia and binge eating disorder compared to healthy controls. They found a higher level of subjective food craving, determined by a visual analog scale VAS , in the patient group in response to the virtual food compared to healthy controls.

They suggest this could underlie the binges and higher BMI in patients with bulimia and binge eating disorder Mood and Anxiety Disorders We found just a solitary study on the use of VR in the assessment of mood disorders; Gould et al. In anxiety disorders, six studies were identified. We found four studies on self-reported and physiological anxiety responses to a virtual tunnel in patients with tunnel phobia 56 , to virtual combat scenes in veterans with PTSD 57 , in a virtual bus trip in patients with panic disorder 58 , and in response to a virtual audience in social anxiety In the tunnel phobic patients group, self-reported anxiety was measured by means of the subjective unit of discomfort scale SUDS Both the self-reported anxiety and heart rate increased with the transition of an open to a tunnel VR-environment.

The skin conductance level was higher compared to healthy controls in all environments The veterans with PTSD showed a slower decrease in skin conductance amplitude compared to healthy controls in the course of five virtual combat scenes, possibly indicating slower habituation. No correlations between the physiological measures and the self-reported anxiety and PTSD-related questionnaires were determined During a virtual bus trip, patients with panic disorder had higher scores on self-reported anxiety SUDS , panic attack symptoms diagnostic symptom questionnaire 61 , and physiological anxiety measures compared to healthy controls Cornwell and colleagues investigated patients with social anxiety in a virtual public speech setting by means of startle reactivity as a physiological anxiety measure in addition to self-reported levels of distress on a VAS.

They found significantly higher self-reported anxiety and startle reactivity in response to focused attention of the audience In all these studies, the physiological anxiety measures are heterogeneous but generally in line with the self-reported anxiety measures.

Finally, the research group of Kim et al.

Publications Authored by Clement Ho | PubFacts

They found a higher level of provoked anxiety VAS before and after checking a situation in OCD patients compared to healthy controls, and a larger decrease in anxiety after checking. They also found OCD patients showed a higher checking frequency, spent more time on checking, a longer trajectory in the environment, and more gazing time during checking behavior.

Discussion The primary purpose of this review was to investigate whether VR environments used in the assessment of psychiatric disorders were able to show a relevant difference in outcome measures between patients with a psychiatric disorder and healthy controls. Generally, the virtual environments were able to show significant differences in outcome measures between patients and healthy controls.

This highlights the great potential of VR in a psychiatric assessment.

Video capture virtual reality as a flexible and effective rehabilitation tool

Only in two studies on emotion recognition in autism and paranoia in psychosis 10 , 32 , no significant differences were found between patients and healthy controls, probably due to small sample sizes or clinical groups with relatively mild symptoms. The results on the use of VR in the assessment of psychotic disorders show virtual environments are capable of provoking paranoid ideations and assess deficits in social behavior and cognitive disabilities in patients.

This shows great potential for the assessment of a population that might be more at ease with a computerized assessment than a face-to-face assessment with a clinician. From the studies on VR in ADHD and autism, it is clear that the inclusion of parameters such as hyperactivity measured by tracking devices and neural mechanisms measured by fMRI is of value.

If a virtual environment is able to activate both subjective symptoms and the neural and physiological substrate associated with a disorder, this can contribute to a more comprehensive and objective assessment of this disorder.

For children with ADHD and autism, the implementation of VR to assess symptoms would provide a more realistic and immersive experience than current laboratory settings, possibly contributing to increased motivation and participation.

In forensic psychiatry, VR provides the opportunity to expose offenders with a psychiatric disorder to potential risky situations in order to evaluate their symptoms, without posing an actual threat to the environment Therefore, although research in this area is scarce, forensic psychiatry has great potential for VR assessment.

In substance use disorders pertaining the misuse of alcohol- and cannabis, VR seems to be an adequate technique to provoke craving.

The addition of olfactory stimuli complements the experience in VR. However, studies on other substances including hard drugs are necessary before definite conclusions can be drawn.

In eating disorders, VR has the potential to assess both key symptoms like a deviant body image and additional symptoms like anxiety. In these studies, only virtual food or dining scenarios were used to provoke symptoms. It would be interesting to explore more possibilities, for example, by assessing body image in relation to avatars with various body shapes. The use of VR in anxiety disorders is promising since physiological mechanisms of the anxiety response are largely known. This enables the inclusion of physiological measures such as heart rate, respiration rate, and skin conductance in response to a virtual environment, thus contributing to an objective assessment of anxiety Efforts are made to create VR environments to assess multiple symptoms of a disorder; the study of Rizzo evaluated the most comprehensive VR environment, evaluating both cognitive functions like attention and distractibility and physical activity, which are core symptoms of ADHD 28 — However, in most of the reviewed studies, VR was used to assess only one symptom of the specific disorder.

Interestingly, this could be in line with the introduction of dimensional criteria to the categorical diagnostic classification in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders In this edition, apart from marking a symptom as present, dimensions are included to determine symptom severity.

It would be worthwhile to investigate if VR can be used to measure the severity of specific symptoms transdiagnostically. More research on the correlation between traditional symptom severity measures and VR environments in patients in different diagnostic categories would be necessary to explore this potential.

The second purpose was to determine correlations between VR outcome measures and traditional diagnostic measures in patients with psychiatric disorders. Not all studies included a correlation measurement.

In 14 studies, significant correlations were found between VR outcome measures and traditional measures.

The authors usually expressed a preference for VR because contrary to retrospective traditional measures, in VR, real-time assessments of behavior, affect, and social interaction are possible in response to realistic environments resembling daily activities However, VR outcome measures were often determined using symptom scoring through both state and trait questionnaires after immersion in the VR environment. State questionnaires are designed to measure temporarily induced symptoms whereas trait questionnaires are designed to measure an enduring disposition State questionnaires, like the State Social Paranoia Scale, therefore, seem more suited for this purpose.

It could be argued that short state questionnaires obtained during instead of after the VR experience are more objective, though this might disturb the immersion in the virtual environment. The objectivity of a VR measurement can be further improved when other measures are added, such as physical activity, eye tracking, distance tracking, physiological measures, and neural activation.

These measures can often be obtained without distracting the participants so the immersion in the VR environment is not disturbed. The addition of these measures contributes to a more objective assessment of the psychiatric disorder. Since this literature review concerns a novel technique, which has only recently been investigated in the psychiatric diagnostic process, sample sizes of the included studies are generally small. Furthermore, only publications in the English language have been included in this review.

Due to the great variety in investigated virtual environments and outcome measures, merging the results was not possible. More studies with larger sample sizes and more uniformity in outcome measures are necessary to enable a more systematic review including a meta-analysis.

Not all studies reported results on correlations between the VR-measures and traditional measures of the aspect of the disorder, presumably because of small sample sizes or absence of comparable assessment methods. This impairs a conclusion on construct validity.


In conclusion, VR shows potential to be implemented in the diagnostic process. The advantages are numerous and include the use of an immersive, modern technique instead of a standard laboratory setting that could motivate participating patients.

Most of the studies investigated made use of computer-animated VR environments with divergent levels of realism.

New VR techniques such as video VR or augmented reality are developing at great speed and will drastically improve the resemblance to real-life situations. This will enlarge the efficacy of virtual environments in assessing psychiatric disorders.

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