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Understanding The Evidence For Therapeutic Extended Reality (XR) Podcast

Understanding The Evidence For Therapeutic Extended Reality (XR) Podcast
Robert Ferguson, MHS, OTR/L, Dennis Cleary, MS, OTD, OTR/L
June 22, 2022

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Editor's note: This text-based course is a transcript of the Understanding The Evidence For Therapeutic Extended Reality (XR) Podcast, presented by Robert Ferguson, MHS, OTR/L, and Dennis Cleary, MS, OTD, OTR/L.

Learning Outcomes

  • After this course, participants will be able to:
    • Examine the research on the therapeutic use of XR in rehabilitation.
    • Analyze XR technologies with evidence-based treatment strategies and techniques to provide an engaging, motivating, task-oriented, and salient experience that provides the requisite use, repetition, and intensity of training for skill acquisition and performance toward therapy goals.
    • Evaluate opportunities to direct future research and practice in OT.

Dennis: Welcome, everyone. My name is Dennis Cleary. I have been a senior researcher, assistant professor, and occupational therapist for 25 years. I currently work at Cincinnati Children's Hospital Medical Center. I'm joined today by Rob Ferguson, an occupational therapist at the University of Michigan and an expert in virtual reality. Today is going to be a continuation of our first discussion that we had about virtual reality. Rob, can you say hello to the good people out there?

Rob: Hello, good people out there. I'm Rob Ferguson. I'm a clinical specialist at the University of Michigan Hospital in Ann Arbor. I run our therapeutic technology program that includes our computer therapy treatment lab, virtual reality program, and maker pod makerspace in inpatient rehab.

Dennis: Could you summarize our earlier conversation about virtual reality's definitions and how you are starting to use it within your practice?

Rob: The biggest problem with virtual reality, both for the technologies and its use, is that the definition is broad and changes over time. The way I want to frame it for our discussion is to stick with virtual reality versus the more general term extended realities. In virtual reality, we're talking about computer-generated environments on a console, PC, television, monitor, phone, or tablet. It could also be an environment on a virtual reality headset or augmented reality glasses. The biggest problem is that all those things are lumped together in virtual reality but are very different.

Augmented reality is a digital overlay onto a real-world view and is not commonly considered a mixed reality. You are overlaying either digital content over a real view or your view over digital content. For example, augmented reality can be a heads-up display on your car dashboard or PokemonGO on your device. These are overlays in two dimensions, and you interact with a simple swipe on the screen. In contrast, Microsoft HoloLens spatially locks the digital information to the environment so you can reach out, grab, and manipulate the pretend computer-generated objects. You can also move to the other side and view both the real and digital worlds.

Fully immersive virtual realities using a head-mounted display is all virtual, and you are "immersed" in them. You have a sense of being there versus being in the real world.

These are the perspectives I want you to consider as we talk about the different kinds of technology, especially when we talk about research and practice, as they are very different in how you go about understanding and using it.

Dennis: Our first conversation was about describing the technology and how you would use it. Could you give us an example of how some of these technologies have been useful for some of your clients meet their goals and be more independent long term?

Rob: In the first podcast, we briefly discussed a non-immersive example using a computer. An immersive example that's easy to picture is a patient with a below-knee amputation. He was having difficulty in physical therapy and occupational therapy with independent standing. He could not do this without external support or holding onto something, and this lack of standing affected transfers and pulling up his pants.

Before his surgery, he was a bow hunter. His goal was to work on balance to free up his extremities so he could do things while standing and be fitted for a prosthesis down the road. We had him stand with his hips against the exercise mat and play an archery game where he was "defending a castle." If you can imagine a bunch of minion sounds, that's the sound that these characters make as they're attacking your castle. You shoot arrows at these characters wearing Viking helmets, which is entertaining.

Dennis: You have a Viking helmet, if I'm not mistaken?

Rob: Yes. I have a Viking helmet, but I am not wearing it now. He loved this game and utilized the same balance strategies for therapy but just in a virtual context. Once he started balancing within this context, he started doing more things that he could not do in a typical treatment session or "real reality." He began pivoting on his one foot, leaned away from the mat table, and started pivoting back and forth and left and right as he was visually chasing these little minions. They were attacking his castle that nobody else could see. He was also making bow and arrow movements. When we sat down and showed him the video of his performance, he said, "But I can't do that." And I replied, "You just did." He said it was the hardest yet most fun thing he'd done in any of his therapy sessions.

Additionally, he was having phantom sensations in his right leg. Using free apps through Steam, an online gaming platform, allowed us to virtually manipulate where the controller was so he could play Fruit Ninja with his left foot and right upper thigh. We could manipulate what he saw so that the sword was where his foot should have been. He said it was weird because he could feel that the rest of his amputated leg was participating, but the pain and hypersensitivity were gone while he played. When I asked him later, he said the reprieve from pain and hypersensitivity lasted for about two hours. Reduction in hypersensitivity wasn't the original intent of the activity as it was more for strengthening, but it was a bonus. After this realization, whenever he had some of those sensations, he asked for just a few minutes in the virtual environment before starting other activities.

Dennis: Those are great examples. As we move forward today, one of the things we're going to start talking about is the research in this area. As you have stated, there is the good, the bad, and the ugly. As with everything, why don't we start with the ugly? As therapists trying to work on our clinical reasoning and making good decisions about the types of interventions we select, what's the current research about virtual reality?

Rob: The research reality is that most decisions people make in the clinic to use virtual reality or not are based on non-immersive technologies. They use the Wii, Connect, or PlayStation Eye 2 and 3.

Dennis: What do you think about the Wii?

Rob: I still use the balance board and have two Wii consoles.

Dennis: How about Wii Bowling? 

Rob: I haven't done Wii Bowling in years. It hurts my shoulder, but some people still enjoy it. As we discussed in the first session, it's not about the game but how you use it and what kind of interventions. We'll talk about that a little bit later.

Dennis: It's not about the game but the player?

Rob: It's about the therapeutic strategies you're using. You're just using the game and the technology as a tool to provide the intervention. There are some gray areas when we talk about some of the evidence about the effectiveness of VR. Let's start with the beginning points. We selected the American Heart Association/Stroke Association Stroke Rehab Guidelines for our stroke rehab program. Those guidelines say that virtual reality is a reasonable intervention for patients with motor and some cognitive and visual impairment. When you look at the research, it's only based on a few articles focused on the Wii, the Connect, and other non-immersive gaming technologies. While they may be effective, they aren't the same as immersive technologies. When you read about virtual reality in the research, everyone thinks about head-mounted displays because the context of that technology is very different.

The lens is very different from what it was ten years ago. So when looking at research recommendations and meta-analyses, they're still referring to some of those technologies as virtual reality. Part of that is because of the technology industries' ambiguity in some technology terms. However, when looking at the research, it's essential to see if the authors have defined virtual reality. If they don't define it, you'll have to try to figure out the kind of virtual reality. Are they talking about Wii Bowling, a balance board, an immersive virtual environment, or the difference between using a HoloLens and manipulating digital information as if it were truly there? Or are they talking about swiping on a screen?

The different kinds of technology affect the way that you motor plan, move, and the cognitive strategies that you use. First and foremost, when you're evaluating the evidence, it is crucial to know precisely what they are using. I approach reading literature as a cynic, and if they aren't defining what virtual reality is and I have to figure it out, then I'm not sure they know what it is. Then I have to figure out if their recommendations are something that I want to use clinically.

The biggest problem is the dichotomy between the research's context and how the treatment is done. In research, you're trying to reduce the confounding variables to demonstrate whether this intervention is effective. You also can't generalize the results beyond the population in the article. We all know rehab clients are not a homogenous group in research and practice. In practice, a therapist trying to apply the evidence has to decide now if the evidence is appropriate for their client. The decision comes down to clinical reasoning. It is imperative to understand how to read the evidence to determine whether to use it or not.

We must account for those variables and the things that affect their treatment. But I think that's also why, Dennis, when they start comparing interventions to each other (comparative research), the one that usually comes out the best is when they do both interventions together as they both have evidence. I don't care if one is 10% more effective than the other. If I know that both interventions are better than one, I will use both. You must look at the evidence with your critical lens and decide whether it is appropriate for your client. This is not always easy, especially when the evidence is confusing, like in virtual reality.

The evidence has been slowly changing in the last year or two. The research has been nice, but most of the evidence is based on research-based games that are not commercially available. They're more conceptual. In the clinic, if we don't have access to that game, we have to look at it conceptually. For example, I know that if I use a bimanual isochromatic training strategy in VR, it works in both a virtual and a real-world context. My treatment approach will be to use the evidence that I know works, and I will use that virtual context as the intervention environment, which is consistent with our practice framework.

Dennis: Would you mind if I quoted my wife again? My wife, Dr. Clare Kilbane, who teaches at the University of Notre Dame, has a textbook soon. She's looking at using technology to differentiate instruction. She talks about how technology can be helpful, but we must consider how we approach it. Is it engaging, is it efficient, and is it effective? I like the bright, shiny piece of foil on the ground, and I aim for it because it's fun, interactive, and bright. We often go for those things that encourage engagement, which is essential, but we also need to use our clinical reasoning to see what will be the most helpful for our patients.

Fortunately, we have an ever-growing knowledge base and now more research scientists within our profession. How do you translate research done in the lab to help your clinical practice?

Rob: I try to read each research article as a conceptual piece versus a specific intervention unless it's something I'm able to get my hands on readily. If there's a commercial product made for rehab that is currently available or if there's research for a particular made-for-therapy virtual reality system, I try it to see if that fits with what I read. Since most of the research is not available in the clinic, I think conceptually. Yoo and colleagues looked at how people without a condition perceived exertion while in VR (Yoo, Heywood, Tang, Kummerfeld, & Kay, 2017). They had participants play some commercially available games and assessed their perception of exertion. They found that when people were in virtual reality, their perception of how hard they were working was less than if it was in the real world, even though their heart rate was high compared to other activities like walking, running, and dancing. And depending on the game that you had them play, their perception was that they weren't working as hard. 

Another study (Chen, Ponto, Tredinnick, & Radwin, 2015) had participants stand against the wall with two dumbbells in their hands and flex their elbows to 90 degrees. The object was to hold this position until the pain became too much or the muscle fatigued, and they lost the position. They then created a virtual version with the same weight and tracked it. They used a headset where they could only see an avatar of an embodiment of themselves, not their real bodies. They could see the avatar doing the same movement. Due to this, they found that the participants tolerated the activity longer and reported lower pain levels. I believe they could hold it for up to a minute and a half longer before muscle fatigue. The only real difference was the environment. Who knows how to explain that? But it is good information to use in your clinical reasoning during therapy. I think about the patient who has a cardiovascular issue versus a patient who does not. I'm going to approach them both very differently. I know that they perceive that they are not working as hard so I can make someone work longer, but if they have a cardiovascular issue, I have to look at it the exact opposite way and monitor the activity more closely. 

Again, I'm thinking conceptually, as the second study used a very small group that did not have specific conditions. It's about looking at the evidence on a conceptual level and thinking about how I will apply this clinically? And it doesn't necessarily mean you follow a protocol. Protocols are research-based. Every patient is different, and they will respond differently to the same protocol in the clinic. You have to look at the key concepts from the study and figure out how to apply the information to your content. As with any other clinic-based evidence, you don't do it if it doesn't work for your patient. If it works for your patient, they find value in it, and it makes a difference for them, then do the activity. How we approach the evidence is one of the reasons why there's such a gap in translating evidence from research to practice. 

Dennis: Got you.

Rob: That's purely an opinion.

Dennis: That's knowledge translation. Dr. Lisa Juckett has a wonderful knowledge translation course on OccupationalTherapy.com if you want to learn more about the topic and how we can shorten that gap of moving research from the lab to the clinical site. Can you expand on that a little more about the ethical dilemmas this may cause? Do you think there is enough evidence to support the use of virtual reality within occupational therapy practice?

Rob: Absolutely. There is a lot of research about VR and how it can improve things like pain, anxiety, strength, endurance, post-traumatic stress disorder, et cetera. What we don't know is how long the effects last. That's why it's essential to think about the population you're working with and understand that perception of exertion can be positive or negative, depending on the patient. We always have to think about that virtual context in relation to the context of the patient's physical attributes and abilities. Many studies on VR are just now coming out with better rigor. They're not strong studies, but they allow you to consider whether you use the technology.

Virtual reality is intended to be a preparatory or adjunctive treatment. Another excellent example is a patient with a lack of perception in their lower extremities. The physical and occupational therapists discussed the difficulties with gait training and self-care skills. They realized they could use Fruit Ninja and Fruit Saber, the foot version of Beat Saber, as preparatory activities. The client commented that when he went to PT, he was more aware of the strategies they were trying to teach him. He said he was also aware of positional movements and what the impact of those strategies was. On days when he wasn't doing the VR beforehand, he worked on ankle stability for lower extremity dressing activities or transfers and gait. We looked at those activities qualitatively and said, "That's valuable." There's no research to say that that was the way to go, but it presents a research question that somebody could evaluate later. The clinical reasoning in the moment makes sense with the qualitative information available. Would the person continue to make improvements like they did? Probably. At the same rate? Probably. However, I don't know for sure. I know that it was a meaningful treatment approach that impacted his abilities. We made the clinical decision to continue doing VR as an additional treatment session during the day but not as a replacement. In summary, VR is not a replacement for your regular intervention but a way to augment it.

Dennis: Got you. I hadn't even thought about VR exertion until you mentioned it. Do you use physiological monitoring like blood pressure, heart rate, and certain things during VR activities?

Rob: We monitor all of those, especially if a client has cardiopulmonary issues. If they have an LVAD, a left ventricular assisted device, we will use a Doppler to monitor their heart rate and pulse because we can't take a traditional pulse. We want to make sure that they're tolerating it appropriately. It becomes more of a precaution. There may be some guidelines from the research as well. The key is to monitor them like you would anything else. In addition to heart rate and pulse, we can look at their blood pressure and skin. You may be doing an activity that's more relaxing than physical, but they may all of a sudden get clammy. You're going to react to that the same way that you would in under any other activity.

Virtual reality is a sensory-based activity that is primarily visual, but there are a lot of virtual realities out there that incorporate digital smells.

Dennis: Could you explain what that is?

Rob: I wish I could.

Dennis: All right.

Rob: I can't. I know it attaches underneath the headset, and you have it programmed.

Dennis: It's like "Smell-O-Vision" from the good old days.

Rob: Exactly. The actual combination of what is released is programmed into the game. You can smell the rain, smoke, et cetera. It can also be directional and have sound, so it's immersive in all the senses. That's why it's so powerful and could sometimes present problems.

Dennis: For those budding therapists out there younger than the age of Smell-O-Vision back in the movie theaters, they would waft aromas into the entire movie theater.

You talk a lot about clinical reasoning and how important that is to your practice. From a clinical reasoning standpoint, how do you assess? Do you have a rubric you use when a new technology comes onto the market to decide whether or not this is something you want to do? I am sure you look at the research and hope somebody sends you a free sample. How do you approach that?

Rob: There's not a rubric. Students expect to go to fieldwork, read an article, and then apply it as if the article is the rubric to follow. Then they're confused as to why the patient isn't responding the same way as the research. Instead, it's a heuristic approach when using clinical reasoning. But, when looking at technology, is there an approach to use? I always look at it from a very basic framework because technology can be complicated enough as it is. I look at the "knobology" of the technology to determine how it works. How do you turn it on, adjust it, and so on with the hardware and software?

Dennis: Was that knabology or knobology?

Rob: Knobology. I can't remember the name of the physical therapist who coined that terminology in a presentation I attended, but it stuck.

Dennis: Is it what different knob you turn on to get it to work?

Rob: Say I'm using E-stim. I know there's a protocol. I turn it on, put in those settings, and let the protocol happen. I'm not interested in the clinical reasoning about it. I know if I set it up, it will work. Knobology is the starting point-- you have to understand how the technology turns on, the features, and how it adjusts to make it a therapeutic intervention. How do you then use those things to grade the activity? How do I combine it with other technologies? Within the software, can I manipulate where the person's body position is? It is all fascinating.

Here is an example. There's a game called Box VR. Say you have somebody who has arthritis, and they can only raise their shoulder to 20 degrees in their right, but they've got full range in their left. In a boxing simulation where they are punching colored objects to the rhythm of the music, there's a setting where you can adjust where the visual representation of that right glove is to make it even with the left boxing glove. They're punching at 20 degrees shoulder flexion, but they're jabbing in the game with full 90-degree shoulder flexion. It's bizarre because it no longer felt like a mismatch after about a minute, even though I knew cognitively that it was. The perception of virtual reality overrides a lot of your cognitive processes. Virtual reality can be a potent tool.

To grade the activity, I can either lower the boxing glove and tell them to keep it higher as they get stronger or tolerate it more. Or, I can bring it down all the way and put them in a mobile arm support to take the weight of the arm so that they can punch in a more natural combination.

It's knowing the features and the options available both from a hardware side and a software side to manipulate to get a desired cognitive or behavioral response based on what I know about the technology in the game. This knowledge comes through your activity analysis. People forget about that because they just want to play the game. If you're just having somebody play a VR game, you are doing more of an accessible exploration, not an intervention. The intervention requires clinical reasoning and adjusting and grading the activity towards the intended goal.

Dennis: Got you. Is it ever ethical to play a game with your patient?

Rob: Absolutely. For instance, Xbox came out with an adaptive controller that has a function called Copilot. Suppose I am playing a virtual driving game, like Forza Horizon, with a client with a C5 or C6 spinal cord injury. In that case, they may be working on being able to do forward reach as well as controlling their shoulder movements for essential self-care. If you give them a joystick that goes through the Xbox adaptive controller, they may be able to push the joystick either forward and back for gas and brake or move left and right to steer, but somebody may have to do the other movement. As a clinician, what is my goal? If I want them to have an isometric contraction and stabilize that forward reach, I might have them do gas and brake, and I'll steer. Or, if I need them to start moving left and right to get some trunk control, I may do the gas and brake. In this way, we're working together on their goal, but we're both playing. It takes communication, which is a great way to increase their skills to communicate with their loved ones about their care. Suppose you have a patient with a spinal cord injury who is on a bowel program. In that case, it's a very uncomfortable conversation until it becomes more natural as part of a daily routine. So, we may start working on communication skills and applying them during a game. They may say, "I want my spouse to control the gas while I steer," or vice versa. It starts this way, but then you teach them to use their communication skills. For example, in a game, the steering person knows they are not in control and may need to say, "I need you to slow down. There's a corner coming up."  About 40 minutes later, they don't even have to communicate; they start knowing what they need to do and start challenging each other and grading the activity. We tell them to use the same strategy for self-care, especially the bladder and bowel programs. We want to teach them to have these uncomfortable conversations after they have been interacting and communicating in a fun activity. It seems to work well with patients. Again, there's no research on it, but it started because a patient gave us positive feedback, "Hey, that allowed us to have an uncomfortable conversation." 

Dennis: Got you. I used a gaming strategy with a younger person with a traumatic brain injury. He had a lot of frustrations, and gaming seemed to help him get out some frustration. In terms of the evidence, is there much literature in AJOT or some of our more prominent occupational therapy journals about VR?

Rob: Many are industry-related as I use more than therapy professional journals for my research. In therapy literature, I see how researchers in the rehab profession are starting to think about using virtual reality and how are they defining and using it? What kind of technology are they using? Is there something new, or is there some different way that I can incorporate these tools as evidence? If it's a VR program, does that program do what it says it will do?

I look at the industry research and psychology journals because I am looking at the basic concepts. A gaming research journal is solely about rehab gaming and using different platforms. Many gaming articles are not in peer-reviewed journals per se but are still reviewed by peers. They are open-source and are geared towards a genre, a treatment context, or a treatment approach. There's a large community doing that. Sometimes I go to that gaming journal to see how people are starting to use the technology or software, whether it's immersive or non-immersive virtual reality. You will miss the bigger picture if you focus too narrowly on one area.

Dennis: I think gamification seems to be a buzzword in education, especially now.

Rob: When I went to school, we had real cadavers. Many places now can't afford cadavers, and you don't have the experience of visualizing the body in a three-dimensional space. However, numerous virtual reality dissection programs give you the same kind of experience much better than a two-dimensional book or video-based cadaver dissections. Virtual reality is going to continue to play a significant role in education in the future.

Dennis: I think some of those 360-degree models on apps are pretty good. I've understood the brain much better than back in my cadaver dissection days because the app will show you, for example, the hippocampus and where it attaches.

Rob: In virtuality, you can go inside the brain to see the relationship of the hippocampus in relation to the skull and then look around at all the surrounding structures. You can do this with many other structures like lungs, heart, elbow, and so on to see some of the relationships at a very different level. This technology helps you understand the systems a lot better. It's exciting.

Dennis: Back to journals, is there much research on virtual reality in occupational therapy journals, or are we still learning?

Rob: Most articles have been on the Wii, Connect, and some adaptive gaming. As a profession, we don't define virtual reality well enough. I also do not think the virtual reality industry defines it well. It's even worse when you're looking at research by physicians and therapists when they define VR for research projects. The ambiguity in the taxonomy makes it very difficult for a clinician to determine what to use from a virtuality perspective.

Dennis: Could you define the word taxonomy for us?

Rob: Think of taxonomy as a classification and labeling system. You're defining what concepts are. For instance, extended reality is an umbrella term for all the different kinds of realities that there could be or may be in the future. Virtual reality is a computer-generated world or environment, but how you interact with that environment depends on your technology. Is it a phone, a tablet, a computer screen, or an immersive headset? Do you have finger tracking, or do you have to use a controller? The taxonomy also tells you the difference between augmented reality, which has that overlaying layer, or mixed reality, like the HoloLens. I would approach the HoloLens differently than Pokemon GO on the phone. For example, I can't manipulate, resize, or see inside/around things when mixed with the real reality unless it's anchored. Some research articles call augmented reality a mixed reality, which doesn't help.

You have to look at how they define the technology, but there's no set taxonomy or even an industry agreement on all those things. You can have five different developers in a room, and they'll all have a different perception of how they view virtual reality, mixed reality, and augmented reality. There's not a consensus as to how things should be defined. Some companies just decide they're going to create their definition.

Dennis: Fortunately, we don't have any of that happening in occupational therapy. Can you talk a little bit about how you incorporate some of these evidence-based treatment strategies into what you're doing daily with some of the patients you see at the University of Michigan?

Rob: Sure. Let's look at left visual neglect. There are specific scanning strategies or models, whether you're using a lighthouse model approach or a cue withdrawal approach. There are many different ways you can mix some of the evidence to get a client to pay attention and scan with the left visual field. From a technology standpoint, I've had patients sit in front of a computer screen and do those scanning strategies to provide a different context than on the table. You can also have separate switches and controls that they have to interact with on the left side. There's no statistic to show it, but I do not think it is different from a tabletop interactive activity. However, we see different results when putting them in a virtual reality context.

Let me give you an example. I used a mountain climbing game called The Climb. We started a client on a course to see if she could use environmental cues to help guide her. Once you get to a specific checkpoint, if you fall, you do not die and automatically go back to that same checkpoint. She loved that. And she laughed and said, "I love that I can climb a mountain and not die when I fall." Once you're at that checkpoint, a chalk arrow points to the left. She was able to turn her head, reach out, and grab for the handhold. She was able to make her way to a 15-foot ledge, but after a couple of reaches would fall off. She would go right back up there and started to immediately look left for the ledge before she even looked for the next handhold. I didn't even have to cue her. She developed scanning strategies in the context of the mountain climbing game.

The other side was the first time we had her try it on a wall with geometric climbing holes. She could recall what she needed to do, which was much more engaging. She spent the next 35 minutes without me giving her any cues to start navigating and climbing this mountain from her wheelchair. We recognized that she did well with visual environmental cues; when you added those to her environment, she was more successful.

Dennis: Can you give us some examples of how would you add those to her environment?

Rob: It is a little harder to do in a hospital setting, but if you were in their home, you could try different environmental cueing strategies. Similar to the context of rock climbing and the chalk arrow, you could label things in the kitchen like the stove. For example, you could have a reminder to place the pot on the right side when using the stove. It is a very experimental thing and depends on the person. I know a therapist that created a visual chart in plastic that could be placed in the hospital shower to provide a visual cue that the soap dish was on the left side. It's a way to help the client internalize some cues instead of relying on another person or a caregiver.

Dennis: You're using your clinical reasoning skills and taking the behavior you've noticed within the virtual reality and then bringing that over to her real life.

Rob: As I said, virtual reality and therapeutic technologies don't teach you how to do the things you need to do. They only help you build your capacity to do those things and reinforce strategies. Putting on a shirt, cooking a meal, or walking across grass must be done in real-time. You can walk on padding or fake turf in a hospital, but it's very different than the real thing. To teach those real-life skills, you must be in those real-life situations. That's why virtual reality is a context and strategy to build capacity.

Dennis: Earlier, you mentioned that there seems to be a role for occupational therapists with technology companies. Can you discuss what some of these opportunities are?

Rob: Sure. She'll probably throw something at me the next time she sees me, but one example is Caitlin Jones, who works for Microsoft. Her father started doing adaptive gaming setups for veterans on the East Coast. He runs a not-for-profit charity called Warfighter Engaged to help get veterans back to gaming or introduce them to gaming as another activity. He builds accessible technologies. One thing he did was modify the Xbox controller. AbleGamers is another charity that was doing the same thing. Microsoft reached out to these entities to find out why they were messing with their equipment. The answer was that the design was not made for all people. Microsoft decided to start consulting with different people to come up with the Xbox adaptive controller. The individuals they consulted included two occupational therapists, Erin Muston-Firsch from Craig Hospital and Erik Johnson out of Texas. Caitlin was an OT student at the time and ended up getting a job with Microsoft. I believe she was the first OT involved, and she can correct me if I'm wrong. She is now the program manager for Xbox Accessibility and is doing some great things. For example, she has created some excellent videos. I recommend looking at these Microsoft videos as she explains some accessibility solutions. Many tech positions are filled by those who used to be OTs or still are OTs who are providing their expertise in a nontraditional way.

Dennis: I think there will continue to be more of those opportunities. I know many of our speech-language pathology friends have gotten very involved in some of the text-to-speech and some cognitive types of technology. I think we've got a lot of opportunities to do some of that work as well. Steve Sailer is another person I believe is with Microsoft, and Steven Spohn is another self-advocate. 

Rob: AbleGamers recently hired an OT to be the director of their community interaction pillar. He is connecting therapists to make gaming more inclusive on a broad scale and getting all of AbleGamer's capacity out there so that people can use some of the inclusive and adaptive gaming tools.

Dennis: I think he's an escaped academic like myself.

Rob: Yes, he is.

Dennis: I suppose many of us are doing some of that work. Previous versions of the practice framework didn't discuss virtual reality or how vital social networks can be for us, especially during COVID. I don't know if you've seen that much or not.

Rob: Before COVID, we started having an inter-hospital adaptive gaming experience between patients with spinal cord injury at Craig Hospital and our patients with spinal cord injury here at Michigan. They had the opportunity to connect and play games with others from different locations. They could make a new friend going through a similar experience and play a video game together. It was a powerful experience. We're hoping to get back to doing that soon. I also know that Craig Hospital has been working with some other locations doing the same thing. I would love to see that become a "rehab arcade" and be a reality beyond the small group.

Dennis: Ohio State has a rehabilitation hospital, Dodd Rehabilitation Hospital, as well. You could see if you can play with them. As a clinician, you have seen virtual reality improve the lives of your patients. Funders, families, physicians, and others might be skeptical. What would you like to see in this space and research?

Rob: Good question. I think there is a need for more affordable made-for-therapy virtual reality solutions. To do that, it would have to be commercialized. If you're going to develop and build something, you should be able to recoup the cost of that and/or make it into a business where you can provide those solutions to people in an affordable way. We must do more research to make those systems and games specific to rehab and how to make them more accessible. At the same time, how do you then have enough autonomy for the clinician to decide what therapeutic interventions to use with virtual reality? So I think there needs to be research into commercial virtual reality gaming, structured therapeutic virtual reality gaming, and made-for-therapy rehab gaming.

I'm not a researcher, but we need to control the variables. My job is to interpret your research and determine how I'm going to use that in the clinic. There need to be some efficacy studies on made-for-therapy solutions and the clinical reasoning process. Just because you have two therapists using VR and clinical reasoning, this doesn't mean they will think the same way. Currently, there's no consistency. That's the downside of using commercial systems and relying on the clinician to make all the choices about how they interact with it because of the different experience levels, perspectives, and perceptions of the technology. And it doesn't necessarily mean it's going to be as successful as there's some inconsistency with clinical results. There's a trade-off between protocols and research versus autonomy and practice. How do we find a way for both of those to exist more happily?

Another concern I have is virtuality with young children in early developmental stages. Does introducing these alternate perceptual experiences alter their ability to interact with the tangible environment? And is it okay to have three or four VR intersessions? For the kids who are using virtual reality more frequently, is that affecting their developmental skills? We also want to look at those with personality disorders or disorders of perception and reality. If you introduce another reality, is that a good or bad thing? I don't know enough about that to say one way or the other, but that's a question. Is either one of these scenarios ethical?

Dennis: It's a huge issue from a clinical reasoning standpoint. Have you run into something like that in your practice?

Rob: It's not something I'm comfortable doing until there's evidence. It took me a little while to consider using VR with patients with traumatic brain injury due to their confusion. I use it on a case-by-case basis because there's just no research in this area. I typically wait until they're more oriented to what's happening and understand that they are using virtual reality. That's a choice that I make. 

Dennis: In terms of the future, what's the next big thing you'd like to see to help your patients?

Rob: That virtual reality was free and accessible for everybody. I don't know how I feel about it yet, but BCIs, brain-computer interfaces, are not where they need to be. Some people are using brain waves to control computers and move in virtual environments. I think there's a potential for that in the future, but I'm afraid to see how that might look. Are we moving more towards cyborgs?

Dennis: Are you pro-cyborg, or are you anti-cyborg?

Rob: If you have a replacement body part, you might already consider yourself a cyborg. Does science fiction lead to science or the other way around? I've seen both. 

Dennis: I'm on board with almost everything you've said, especially the accessibility piece. Access to computers that are powerful enough to be able to manage virtual reality is a huge first step. 

Rob: Some people are doing great work towards accessibility for virtuality.

Dennis: Excellent. Well, Rob Ferguson from the University of Michigan, I want to thank you again for being a guest here on the podcast, and I hope you have a great day.

Rob: You too, Dennis. Thanks.


Please refer to the outline and handout.


Ferguson, R., and Cleary, D. (2022). Understanding the evidence for therapeutic extended reality (XR) podcast. OccupationalTherapy.com, Article 5516. Available at www.occupationaltherapy.com

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robert ferguson

Robert Ferguson, MHS, OTR/L

Rob is the Clinical Specialist in Therapeutic Technology and Neurorehabilitation at the University of Michigan Health. He provides leadership in program design, competency development, and treatment through the Therapeutic Technology Program, which includes the Computer Therapy Treatment Lab, the Therapeutic Virtual Reality Program, and the inpatient rehabilitation MakerPod.

dennis cleary

Dennis Cleary, MS, OTD, OTR/L

Dr. Dennis Cleary has over 25 years of experience as an occupational therapist.  Dennis’ clinical practice has been primarily with children and adults with intellectual disabilities to encourage their full participation in all aspects of life at home, work, and in the community. He has had faculty positions at The Ohio State University and Indiana University. As a researcher, he has been on teams that have received over seven million dollars in grants from state and federal agencies, including a National Institutes of Health multisite trial of the Vocational Fit Assessment, an age-appropriate transition assessment, which he co-created. He has numerous publications and national and international presentations. Dennis is passionate about increasing the role of Occupational Therapy in transition-age service with the goal of improving outcomes and quality of life for all. 


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