22/03/2011

Contents
VR Simulation in the Development of Movement
Centred Therapies for Young People with
Complex Trauma Symptomatology  Overview of Complex Trauma
 Why Use Movement?
- Progress to Date  Objectives of Research
 Study 1 – Play-test Findings
 Study 2 – Custom Games Findings
 Planning Study 3
 Questions
Alan Cummins

Supervisors:

Dr. Mark Linden (School of Nursing and Midwifery)

Dr. Cathy Craig (School of Psychology)

Complex Trauma Movement

 Complex Trauma is defined as  Movement For Treatment of Complex Trauma Symptoms

the experience of chronic adverse traumatic events, whether real or
subjectively felt, and the associated detrimental affects on children’s
psychological and physiological development
 Seven observed domains of impairment in children:
attachment, biology, affect regulation, dissociation,
behavioral control, cognition and self-concept.
(Pelcovitz, van der Kolk et al. 1997)
 Bodily experience as entry to emotion and cognition
 Physical sense of control, Sense of mastery
 Increasing sense of self, Empowerment
 Self-regulation
 Motivation and engagement
 Means to increasing observation, curiosity and mindfulness
 As a grounding process

 Three stage intervention schemes  Emphasis on a complete mind-body approach rather than
 Stabilization
purely using talk-based therapies.
 Processing of traumatic memories
 Reconnection
(Luxenberg, Spinazzola et al. 2001; Herman 1992)

Objectives Rationale Study 1

 Objectives  Benefits of game playing (Prensky 2005)

 Determine the capabilities of current technology in terms of MOCAP  Enjoyment and pleasure, motivation
and movement-based games from user experience and technical  Sense of structure, flow as games are adaptive
capabilities.  Learning as games have outcomes and provide feedback
 Develop a movement-based intervention.  Ego gratification
 Pilot intervention on CT symptomatic and non-CT groups.  Excitement, creativity, emotion

 Measure and analyse levels pre and post intervention:

 Good game design comes out of Designer, Context, Participants, Meaningful
 Balance
play (Preece, Rogers et al. 2007)
 Self-regulation.
 Executive function.  Flow in games (Csikszentmihalyi, 1975, Sweetser & Wyeth, 2005)

 Mastery
 Key to Success of games is at outset they must be well-designed (Goh, 2008)

 Games are effective when designed and used appropriately (Katz & Wertz, 1997)

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Intervention Design – Study 1 Study 1: Play-Test

WiiFit Plus Kung Fu Rhythm: Asks the user to follow along in a kung fu class
 Usability and Design of Movement Games Mov ement: Temporal control match with the class instructions.
Sensor: Uses of a combination of the Wii Balance Board and Wiimote.
 Participants: n =12, adults (mean age 29 (6)) from QUB
 Purpose: Evaluation of technology, baseline WiiFit Plus Perfect 10: Requires the user to complete a level by hitting markers to
add up to a specified score.
 Method: Mov ement: Shifting of weight to move hips in all directions.
 Play-test of Sensor: It makes use of the Wii Balance Board.

 30 mintues
Know Your Shape: Requires the user to follow an instructor doing exercises.
 Playing several levels of each game Mov ement: Jumping and jogging on the spot.
 Semi-structured interview Sensor: Use of a USB camera to present the participant alongside the trainer.
 Thematic analysis and coding
Dance Dance Rev olution: Requires the user to step in time to a music track.
Mov ement: Stepping forward, backward, left and right.
Sensor: It makes use of a dance-pad peripheral.

WiiFit Plus Yoga:Users follow a yoga trainer practicing basic yoga moves.
Mov ement: They require standing with weight balanced.
Sensor: It makes use of the Wii Balance Board.

Study 1: Some Quotes Study 1 – Findings to Guiding Principles

“Am I supposed to be starting
“A good progression of difficulty..  Aspects of Tutorials  Audio feedback
Something that isn’t too daunting to  Clear  Non-patronising, Positive in tone
now?.. Where’s the target
begin with but still challenging”
like?.. Am I supposed to be  Well paced  Sound coincide w ith action
pressing something?” Challenge
 Controllable
 Control mechanisms
Tutorials  Visual feedback  Controller takes out of situation
“..the breathing one I found it confusing remember the  Sim ple  Need to orient player to controller
“showed you how your centre of circle going in and out.. As well as looking at posture  Focused on goals
as well as tracking balance.. Having three things to
balance was shifting and things..  Positive reassurance
Clear.. That was very helpful” do in a task that was completely novel was too  Progress in games
disconcerting”
 Measurement  Meaningful scores
Measurement Visual Display  Balance of com petition
 Functionally accurate
 Indicate w hat is being measured  Learning by scores tied to performance

“With kung fu things there’s the sound in the middle

 Challenge in Games  Aspects of Fun
“..prefer solid board as with hands go together and everything happens and
know where you are, the screen changes and there’s a sound and  Adaptable level of difficulty  Continuous, Challenging, Pacing
more in control” everything jumps and it’s more fun and less  Structured games
 Well paced
repetitive”  Game context as fun, exercise, therapy or
Control  Clear goals
Audio combination

Intervention Design – Study 2 Study 2 – Implementation & Materials

 Usability Movement Games  Custom game software developed using Virtools (3DVIA Inc.)
 Participants: n =13 adults from QUB  Programming of Game logic and presentation graphics
 mean age 20.26 (3.19)  Connection to Nintendo Wii Balance Board
 89 contacted to 18 accepting to 15 starting to 13 fully completing
 Ability to specify direction, speed, size, life-time of bubbles, sharks and
 Purpose: Initial Testing and refinement of intervention
questions.
 Method: Sessions lasting approximately 40 mins
 Ability to draw any type of puzzle for use in balloon pop.
 One PRE testing session
 Including mazes, questions, keys, bonuses and penalties
 Measure
 Executive Function  Portable making use of laptop, Nintendo Wii Balance Board and projector.
 Trail making - A4 touch screen, Wisconsin Card Sort – Pebl Softw are
 Balance (Static, Dynamic and Sw ay using Custom balance measures Dr. Will
Young, Dr. Cathy Craig)
 Five PLAY sessions (Bubble Pop and Balloon Pop)
 One POST testing session
 Measure
 Tests as in PRE session
 VRUSE Usability Questionnaire

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Demonstration of Balance Tests Demonstration of Bubble Pop

Demonstration of Balloon Pop Game Trace Balloon Pop

 During games the following are stored:
• Game score
• Time to Complete
• Centre of Pressure
• Progress

Balloon Pop

Sm art Shrim p

Game Sessions and User Statistics Executive Function - Trail Making

 Number of Participants n =15  General measure of Frontal Lobe Deficits

 Number completed = 13  Measures sequence ability, ability to shift rule set, processing speed via time to
 4 males, 11 females from QUB 1 st Year Psychology complete
 Participants are novice computer game players spending less than 2 hours a w eek playing games
Trail A Trail B
 Mean age = 20.26 (3.19)
 Total Sessions = 74

 Bubble Pop (Bubble Pop, Avoid the Shark, Smart Shrimp)

 Total Combined Play Time = 15 hrs 19mins 34s for a total level attempts = 827
 Play Time Per Session: Max = 15mins 37s, Min = 10min 27s, Avg = 14 mins 18s

 Balloon Pop
 Total Combined Play Time = 16hrs 20 mins 48s for a total level attempts = 1596
 Play Time Per Session (excluding breaks) Max = 17 min 46s, Min = 8 mins 44s, avg = 13 mins 15s
 Average Success Rate Per Play Session = 75 %  Non-parametric Wilcoxon
 Level Obtained : Max = 41, Min = 24, Avg = 35 (4.87)
% Change Trail A % Change Trail B % Change Sig (2-tailed) Sig (2-tailed) Sig (2-trail)
 Levels Attempted Per Session: Max = 39, Min = 12, Avg = 22.5 (5.2) Combined Trail A Trail B Combined Score
-10.51 -17.32 -26.86 0.064 0.009 0.007

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Executive Function - Wisconsin Card Sort Balance Tests

 General Measure of Frontal Lobe Deficits  Sample Participant Trace Pre and Post Game Sessions
 Measures planning, organized searching, shifting cognitive
0.6
sets, directing behaviour toward achieving a goal, and
modulating impulsive responding 0.5

 Measured by matching card to group based on shifting 0.4

rules according to colour, shape and number 0.3

0.2

 Non-parametric Wilcoxon 0.1

0
Measure Component % Change Sig (2-tailed) -0.2 -0.1 0 0.1 0.2
Pre to Post Pre to Post
Number Categories Completed -4.74 0.524 ANTERIOR Static Test – Centre of Pressure Trace
Percentage Total Error 19.58 0.6
0.6
Percentage Correct Trials -1.68 0.6
Number Preservativ e Errors -7.74 0.5 0.5

Number Trials 0.74 0.7 0.4

Failure to Maintain NA 0.023 0.3

Learning to Learn 45.86 0.249 0.2
Conceptual Level Response -16.97 0.101 0.1

0
-0.2 -0.1 0 0.1 0.2

Balance Tests - Static Balance Tests – Dynamic, Sway

 Comparison of Balance (Static) Pre and Post Game Sessions  Comparison of Balance (Dynamic) Pre and Post Game Sessions
 Percentage Change  Non-parametric Wilcoxon
Balance % Change % Change % Change
Component Excursion Area Excursion Lateral Excursion Medial
Balance Pre Avg Score Post Avg Score % Change Score Sig (2-tailed)
Left -9.2 -17.1 0.9 Component
Right -14.7 -17.3 -1.4
Dynamic 21.6 30.6 113.19 0.001
Centre -15.3 -8.7 -22.2
Posterior -0.2 -4.1 -2.3
 Comparison of Balance (Sway) Pre and Post Game Sessions
Anterior -35.2 -18.2 -22.4
 Non-parametric Wilcoxon

 Non-parametric Wilcoxon Balance Fast Pre / Post Sig Slow Pre / Post Sig Med Pre / Post Sig SlowSlo w Pre /
Component (2-tailed) (2-tailed) (2-tailed) Post Sig (2-tailed)
Balance Component Excursion Area Excursion Lateral Excursion Medial
Sway 0.311 0.311 0.6 0.116
Pre Post Sig (2tailed) Pre Post Sig (2tailed) Pre Post Sig (2tailed)
Left 0.016 0.011 0.182 0.087 0.068 0.028 0.178 0.164 0.638

Right 0.018 0.012 0.087 0.098 0.072 0.101 0.189 0.172 0.552
Centre 0.034 0.008 0.050 0.108 0.055 0.272 0.252 0.142 0.041
Posterior 0.1 0.008 0.382 0.059 0.052 0.196 0.164 0.157 0.382
Anterior 0.024 0.009 0.003 0.092 0.064 0.023 0.217 0.145 0.028

Game Play Progress Usability - VRUSE

 Bubble Pop (Average score improvement)
 VRUSE questionnaire with 100 questions
Sm
1400art Shrim p Avoid Shark
200
Category Average Rating Satisfaction %
1200 195 Functionality 60.87
190
1000 185 User Input 59.78
800 180
175 System Display 59.46
600 170
165 User Guidance 54.06
400
160
200 155 Consistency 59.23
150 Flexibility 53.07
0
145
1 2 3 4 5 Simulation Fidelity 60.41
1 2 3 4 5
Error Correction 49.01
 Balloon Pop (Average score improvement
Sense of Immersion 49.07
Overall Usabilit y 63.21
Score
5000 Tim e
1400000
4500
4000
1200000  Participants were also questioned on favourite games and aspects of engagement,
3500 1000000 control, feedback, physical demands
3000 800000
2500 Favourite Game Ranking
2000 600000
Balloon Pop 1
1500 400000
1000
Avoid the Shark 2
200000 Smart Shrimp 3
500
0 0 Bubble Pop 4
1 2 3 4 5 1 2 3 4 5

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Usability – Participant Comments Lessons Learnt

“Did enjoy some of them, but as with

 Balloon Pop
“The balance board was very sensitive to
changes in movement which meant that your games, felt frustrated if I didn't do  Enjoyed and would stay longer to achieve results
balance w as tested very w ell, the screen w ell, which then made me lose
resolution was v ery clear and I could see where concentration.”  Only two drop-outs
my character was in the visual environment very
easily.”
 Design of games
 Pacing of levels and ability to skip sticking points
 Ending a session on a positive note
 Increased breaks to avoid fatigue
 Comparison of scores to self to motivate but need flexibility
“Really good games all round, I
progressed a lot through out  Motivation to achieve bonuses within games, path of least resistance
the sessions.”  Reduction of number of games played
“The strength is that you are interacting with the
game and so it is most enj oyable this way. The
weakness is that it can get tiring after a period of time  Recruitment is difficult! Retaining is tricky!
and it can be frustrating.”  Need to consider some means of incentive
 Experimental Design
 Fine line between repeated improvement and disruption of enjoyment

Intervention Design – Study 3 Discussion Points

 Movement Intervention with Complex Trauma Population  Initial impression of games

 Participants: n = 20, 10 teenagers with CT symptomatology, Southern  Positives and negatives
Health Trust, Belfast Trust compared with 10 non-CT sample.  Aspect of frustration, concentration with clinical population
 Purpose: Pilot movement sessions with clinical pop
 Thoughts on demands of games
 Method: Experimental
 Structuring play in safe manner
 Movement Game Training Sessions
 Capturing the effects
 Record demographic and abuse history
 Currently capturing executive functioning, balance, usability, mastery
 Measure pre and post
 But what recommendations for capturing effect on general behaviour
 Balance
over and above those captured by IASC, TABS
 Executive functioning
 Mastery

Questions

Any questions, comments, feedback welcome.

Email: acummins02@qub.ac.uk