THE JOURNAL OF VISUALIZATION AND COMPUTER ANIMATION
J. Visual. Comput. Animat. 2003; 14: 261–268 (DOI: 10.1002/vis.323)
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Adapting an immersive virtual reality
system for rehabilitation
By Rachel Kizony, Noomi Katzand Patrice L. (Tamar) Weiss*
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The purpose of this paper is to present an overview of the adaptations that have been done to
VividGroup’s Gesture Xtreme projected VR scenarios in order to facilitate their use in
neurological rehabilitation. First, the scenarios and the adaptation (control of the type,
speed, location and direction of all stimuli) are briefly described. The advantages and
limitations of the adapted VR system as a rehabilitation tool are presented. Next, initial
results and two examples of case studies, one a patient following stroke and one who
requires balance training as a result of complete spinal cord injury, are used to illustrate
applications of this VR system to rehabilitation. Copyright # 2003 John Wiley & Sons, Ltd.
Received: 1 October 2002; Revised 1 March 2003
KEY WORDS: virtual reality; neurological rehabilitation; presence; immersion
Introduction
Injury to or disease of the central or peripheral nervous
system typically results in a decreased ability to perform
activities of daily living due to the resulting cognitive
and motor deficits. An essential part of the rehabilitation
process is remediation of these deficits in order to
improve the functional ability of the patient, and to
enable him or her to achieve greater independence.
This is achieved by using tasks of increasing difficulty
while the therapist physically or verbally guides the
patient’s movements or actions. One of the major chal-
lenges facing therapists in neurological rehabilitation is
identifying intervention tools that are effective, motivat-
ing and enable transfer of the skills and abilities
achieved during rehabilitation to function in the ‘real’
world.
In recent years, virtual reality (VR) technologies have
begun to be used as an assessment and intervention tool
in rehabilitation.1–4 Virtual environments provide pa-
tients with safe access to interactive, true-to-life situa-
tions that would otherwise be inaccessible to them due
to motor, cognitive and psychological limitations.3 The
ability to change the virtual environment relatively
easily, to grade task difficulty and to adapt it according
*Correspondence to: Patrice L. (Tamar) Weiss, Department of
Occupational Therapy, University of Haifa, Mount Carmel,
Haifa 31905, Israel. E-mail: tamar@research.haifa.ac.il
Contract/grant sponsors: Fondation Ida et Avrohom Baruch;
Israeli Ministry of Health.
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Copyright # 2003 John Wiley & Sons, Ltd.
to the patient’s capabilities are important advantages of
VR, since these features are essential to cognitive and
motor remediation.4 In addition, patients such as those
who have used a virtual environment in Rose et al.’s3
study reported the experience to be very enjoyable; it
appears that participating in such activities can increase
motivation for treatment.5
Rizzo et al.4 and Schultheis and Rizzo6 have suggested
several additional advantages for using VR in cognitive
rehabilitation including control and consistency in the
delivery of stimulation, immediate feedback through
different senses, ability to intervene during practice in
order to provide further instruction or guidance, oppor-
tunity for self-training and learning in a safe environ-
ment, documentation of the patient’s performance and
the ability to create customized training environments at
low cost.
Initial research suggests the usefulness of VR in
rehabilitation. Christiansen et al.1 found a virtual
kitchen to be efficient in assessing the ability of patients
with traumatic brain injury to perform such an activity
on the basis of task performance in the correct sequence.
Rose et al.3 showed that memory training in virtual
rooms improved performance on a recognition test of
the spatial arrangement of the rooms in a group of
patients with vascular brain injury. Grealy et al.’s2 find-
ings suggest that training in a virtual environment
improved cognitive function in brain-injured patients.
Wilson et al.7 found that children with physical disabil-
ities were able to transfer spatial information from
virtual to real environments, and Lahav and Mioduser8
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have shown that opportunities to explore a virtual room
enhance the ability of adults who are blind to navigate
within a similar real environment. In addition, Wilson
et al.9, in their review of the literature regarding VR in
rehabilitation, indicated that children and students with
learning disabilities were able to transfer abilities that
were taught in the virtual environment to the real world.
The purpose of this paper is to describe the use of a
projected, video-based VR system for use in neurologi-
cal rehabilitation. Our objective is to present work
carried out in our laboratory over the past 2 years that
has resulted in the adaptation of several of the Vivid-
Group’s Gesture Xtreme projected VR scenarios for use
in rehabilitation of people with neurological deficits.
The paper will present initial results of our currently
ongoing research programme in which the system is
being used in a clinical study with patients following
stroke and people with complete or incomplete spinal
cord injuries. These results were first reported at the
Fourth International Conference on Disability, Virtual
Reality and Associated Technologies10 and at the
First International Workshop on Virtual Reality
Rehabilitation.11
VividGroup’s Gesture Xtreme
VR System
We have adapted VividGroup’s Gesture Xtreme VR sys-
tem, which has potentially important applications for
the rehabilitation of children and adults with physical
and/or cognitive impairment (www.vividgroup.com).
When using the Gesture Xtreme VR system, users stand
or sit in a demarcated area viewing a large video screen
that displays one of a series of simulated functional
tasks, such as catching virtual balls or skiing down a
Figure 1. VividGroup’s Gesture Xtreme VR system.
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Copyright # 2003 John Wiley & Sons, Ltd.
mountain (Figure 1). Users see themselves on the screen,
in the virtual environment, and their movements enti-
rely direct the progression of the task. The result is a
complete engagement of the user in the simulated task.
A video camera converts the video signal of the user’s
movements wherein the participant’s image is pro-
cessed on the same plane as screen animation, text,
graphics and sound, which react accordingly depending
on his or her movement. This process is referred to as
‘video gesture’, i.e. the initiation of changes in a virtual
reality environment through video contact. The partici-
pant’s live, on-screen video image responds at exactly
the same time to movements, lending an intensified
degree of realism to the VR experience. This system pro-
vides both visual and auditory feedback, with the visual
cues being most predominant. The Gesture Xtreme VR
system was originally developed as an entertainment
system, designed to demonstrate VR in science mu-
seums and popular expositions. It is only via adapta-
tions complying with principles based on rehabilitation
intervention principles that permit its use as an effective
rehabilitation intervention tool. Applications based on
projection of the user’s image onto computer-generated
graphics originated with Myron Krueger’s12 Videoplace
scenarios. More recently, commercial products such
as RealityFusion (http://www.usbman.com/Reviews/
gamecam_reality fusion.htm) have also employed a
similar approach.
Gesture XtremeVR Applications
and Adaptations
The Gesture Xtreme VR system contains a number of
virtual environments. In our studies we are initially
using four of these environments, three of which we
have adapted as an intervention tool.
Birds and Balls
Users see themselves standing in a pastoral setting
(Figure 2). Balls of different colours emerge from differ-
ent locations and fly towards the user. Touching these
balls with any part of the body causes them to turn into
doves (if the touch is ‘gentle’) or to burst (if the touch is
‘abrupt’). Our adaptations include the ability to control
the direction in which they appear on the screen from
one or more of four quadrants, singly or in combination
(i.e. from a single quadrant or from two quadrants
representing the right or left or top or bottom halves
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Figure 2. Individual with a spinal cord injury using the
Birds & Balls environment.
of the screen). The colour of the balls may be selected
and stimuli of different shapes (e.g. a star) may be
added as distracters. In addition, a new mode was
programmed wherein the level of the task difficulty
may be increased in accordance with the user’s perfor-
mance and the therapeutic goals. Thus the level of
difficulty will increase automatically and successively
in preset increments when the patient’s performance
reaches a predetermined level.
Soccer
Users see themselves as the goalkeeper in a soccer game
(Figure 3). Soccer balls are shot at the goalie from
different locations, and the task is to hit them with
different parts of the body in order to prevent them
from entering the goal area. Successfully repelled balls
Figure 3. Individual with a stroke using the Soccer environ-
ment.
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Copyright # 2003 John Wiley & Sons, Ltd.
remain white while the ones that enter the goal crease
change colour from white to orange. Our adaptations for
grading the level of difficulty include changing the
number of balls that appear simultaneously as well as
their direction and speed. Here too a level mode has
been programmed to enable automatic progression un-
der preset conditions.
Snowboard
Users see a back view of themselves mounted on a
snowboard. As he or she skis downhill, rocks, trees
and other obstacles need to be avoided by leaning
from side to side or moving the whole body. We
adapted the level of difficulty of this environment by
changing the speed of skiing.
For the above three environments a database that
records the participant’s performance was also pro-
grammed.
Sharkbait
Users see themselves immersed within an ocean sur-
rounded by fish, eels and sharks. The objective is to
swim within the environment and catch floating stars
while avoiding the electric eels and sharks.
Suitability of Gesture Xtreme
VR for Rehabilitation
To date, this system has been used to provide occupa-
tional therapy intervention with adult neurological pa-
tients,10,11,13,14 graded physiotherapy exercises15 and
for recreational activities for children with cerebral
palsy.16–18 A commercial product, IREX (www.irexonli-
ne.com), is also now available, which offers exercise-
oriented adaptations that are suitable for use in rehabi-
litation settings. The Gesture Xtreme system appears to
have some advantages and some limitations for applica-
tion to rehabilitation.
Advantages
The Gesture Xtreme system appears to be suited to the
rehabilitation of individuals with motor and cognitive
deficits for two main reasons. First, the user does not
have to use a head-mounted display (HMD) or other
special apparatus in order to feel immersed within the
virtual environment. This both reduces the likelihood of
developing side effects and eliminates a source of
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encumbrance that would likely hinder the motor re-
sponse of patients with neurological deficits. Although
the newer HMDs and stereoscopic glasses are consider-
ably less cumbersome than previous models, little in-
formation is available regarding their use by individuals
with cognitive deficits and brain injury.
Second, the users view themselves actively participat-
ing within the environment rather than being repre-
sented by an avatar. The use of the user’s own image as
an avatar has been suggested to add to the realism of the
environment and to the sense of presence.19 It may
be that the sense of realism will be greater when the
image is a real-time representation of the user, as in the
case with the Gesture Xtreme system.
The third feature relates to how the user controls
movement within the virtual environments; rather
than relying on a pointing device or tracker, navigation
within the Gesture Xtreme environments is accom-
plished in a completely natural and intuitive manner.
Not only is the control of movement more natural, it also
involves the use of as many body parts as are deemed to
be suitable to the therapeutic goals. For example, the
user may respond to the projected balls via a specific
body part (e.g. the head or hand) when it is appropriate
to have the intervention directed in a more precise
manner, or via any part of the body when intervention
is more global. Indeed, it is possible to train different
motor abilities such as the range of motion of different
limbs and whole-body balance training.
Fourth, the system enables great flexibility in the way it
can be interfaced with patients and adapted to suit
specific therapeutic goals. The patient can, in accordance
with his or her abilities and type of injury, sit or stand
while performing within the virtual environments.
Equally important, the therapist can intervene during
the session in order to enhance motor or cognitive learn-
ing and achieve improvement of the patient’s abilities.
Finally, the existing scenarios provide opportunities
to facilitate a patient’s residual cognitive, motor and
sensory abilities in functionally meaningful contexts.
Since the ultimate goal of rehabilitation is to maximize
a patient’s independence in activities related to daily
performance skills, functional relevance and integra-
tion of performance components are of paramount
importance.20
The Contribution of the Adaptations to
theVR System as a RehabilitationTool
The ability to grade the tasks in terms of speed and
number of stimuli in the various virtual environments is
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Copyright # 2003 John Wiley & Sons, Ltd.
a key treatment principle in rehabilitation since clinicians
are obliged to suit the task and exercises to the patients’
abilities. Thus the level mode was added to the Birds and
Balls and to the Soccer scenarios, thereby enabling pa-
tients to receive feedback and improve their abilities as an
immediate and direct consequence of their performance.
Control over stimulus point of onset and direction via
the ability to discharge the balls from preset quadrants
is extremely useful for cognitive rehabilitation in gen-
eral, and for the remediation of attention deficits in
particular. Attention deficits are common after brain
damage21 and have severe functional consequences
since the attainment of a sufficient level of attention is
a necessary prerequisite for learning, an essential part of
the recovery of function process following brain da-
mage.22 One of the manifestations of attention deficits is
unilateral spatial neglect (USN), which is characterized
by a reduced ability to respond to stimuli presented to
the contralesional space.23 Training USN by visual
search tasks has been useful and there is some evidence
of transfer to functional tasks.22 Thus the ability to train
patients to search different parts of the screen appears to
be useful for the treatment of attention deficits. This
adaptation may also help during rehabilitation of motor
deficits. This is important, for example, following stroke
since one side of the body is more affected than the other
and one of the primary goals of treatment is to train the
affected side. The ability to change stimulus colour and
to add other objects with different shapes is also im-
portant for the training of attention deficits, especially
selective attention and the ability to shift between dif-
ferent tasks. Training specific attention components has
been shown to be useful in rehabilitation.22
Limitations
The Gesture Xtreme system does have several limita-
tions that should be taken into account when consider-
ing the use of this system in rehabilitation. The use of a
single camera means that the environments and move-
ment within them essentially take place within a single
plane. The existing virtual environments are typically
performed within the coronal plane, although it is
possible to position a patient during some of the scenar-
ios such that he or she may perform in the sagittal plane.
Nevertheless, movement is always two-dimensional.
This is in contrast to HMD-based VR systems in which
the user operates within a fully three-dimensional
world. A second limitation of the Gesture Xtreme sys-
tem is that the feedback provided is visual and auditory
with no additional sensory information such as haptics.
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Although the haptic sense is not yet widely used in
rehabilitation there is considerable evidence24 that it can
be an effective addition towards the accomplishment of
certain treatment objectives (e.g. increasing joint range
of motion and force).
Gesture XtremeVR and the
Sense of Presence
We first designed and carried out a pilot study in order
to characterize the VR system and, specifically, in order
to examine and describe the sense of presence it creates
in comparison with a non-immersive VR system, a
desktop street-crossing VR scenario.25 We found no
significant differences in the scores of the presence
questionnaire26 when the combined results for all four
Gesture Xtreme scenarios were compared to the street-
crossing scenario, although there appeared to be a trend
in favour of the Gesture Xtreme system.27 When analys-
ing the results of a short presence questionnaire com-
posed for the purpose of the study, which was filled by
the participants after they experienced each scenario, we
found differences in their responses to individual Ges-
ture Xtreme environments and the street-crossing en-
vironment. The soccer scenario created the highest level
of presence followed by snowboarding, street crossing,
birds and balls and, finally, sharkbait, which created the
lowest sense of presence. These findings suggest that the
virtual scenarios which are more functionally relevant
and more similar to realistic, true-to-life activities such
as soccer or street crossing create higher levels of pre-
sence regardless of the type of the virtual reality system.
Thus it seems that the type of virtual scenario or
environment and the extent to which it is perceived as
being functional and realistic plays an important role in
creating a sense of presence. Based on these results we
decided to carry out our initial intervention studies with
the soccer, snowboarding, and birds and balls environ-
ments and not to adapt or use the sharkbait application.
Initial Clinical Results
Usability studies with patients with stroke and with
spinal cord injury are currently in progress. Our
purpose at this stage is to examine the patients’ re-
sponses to a one-time VR experience. To date, we have
tested two individuals with stroke and 10 who have a
paraplegic spinal cord injury. None of the participants
reported feeling side effects. The participants with
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Copyright # 2003 John Wiley & Sons, Ltd.
stroke (two men, aged 72 and 68 years) were able to
use the system at different levels of task difficulty and
they described the experience as enjoyable and worth-
while. Their responses to a short presence questionnaire
that included six questions related to presence based on
Witmer and Singer’s26 presence questionnaire, on a
scale of 1–5, indicated that they felt a marked sense of
presence during their VR experiences; both gave high
scores, ranging between 4 and 5 for all three scenarios
(birds and balls, soccer, and snowboard).
The participants with spinal cord injury (seven men
and three women, mean age ¼ 27.8 years, SD ¼ 9.7) had
sustained incomplete (one) or complete (nine) low-level
spinal cord injuries. Their responses to the presence
questionnaire were similar to the subjects with stroke,
showing a mean (SD) for birds and balls equal to 4.2
(0.51), soccer equal to 3.9 (0.56) and snowboard equal to
4.2 (0.68). Analysis of their performance showed that
they made considerably more effort with respect to
balance training and postural adjustment than during
conventional therapy.
Case Examples
The following two typical case studies illustrate the
usability of the Gesture Xtreme system for people fol-
lowing spinal cord injury and stroke. ‘M’, aged 22 years,
sustained a complete, paraplegic spinal cord injury at
the level of D9 2 months prior to VR therapy. ‘M’ is
shown in Figure 2 while participating in the birds and
balls environment. He requires the use of a wheelchair
for all activities involving mobility. One of the primary
rehabilitation goals was to improve his sitting balance in
order to enable him to perform functional activities such
as reaching out for a book placed on a shelf. While
interacting within the three Gesture Xtreme scenarios he
had to maintain his sitting balance while using his
upper extremities or trunk. Analysis of the videotaped
records of his performance revealed that initially he
used only one hand at a time while interacting (i.e.
touching or repelling the balls); the other hand was
kept on the wheelchair arm rest or on his lap in order
to maintain balance. However, as the session continued,
‘M’ began to use both hands during the VR tasks,
relying only on his weak trunk muscles to maintain
balance. His ability to do so was striking since at his
level of spinal cord injury the contribution of abdominal
muscles, normally essential for maintaining trunk bal-
ance, was moderate. It would appear that the level mode
motivated him to reach the highest level possible and
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added a sense of competition to the experience. His
performance results showed a high rate of success, 75%
in soccer, 81% in birds and balls and 100% in snow-
board. In addition, while analysing the videos it was
evident how enjoyable the experience was to him and he
said that he wanted to repeat the experience. Finally, his
responses to the presence questionnaire of each scenario
showed a high level of presence (ranging between 3.8
and 4.5 out of 5 for the different scenarios), especially in
soccer, which attained a presence score of 4.5.
‘K’ is a 72-year-old man who had a right hemisphere
stroke 6 months prior to his experience in the virtual
environments. ‘K’ is shown in Figure 3 while participat-
ing in the soccer environment. At the time of this
experience he was ambulating with a cane owing to
poor control of his foot and poor standing balance. He
had functional movement in his upper extremity and he
suffered from a mild attention deficit. In addition, ‘K’
needed some help in dressing of the lower extremity
only (his score of the motor part of the Functional
Independent Measure (FIM)28 was 78/91). Analysis of
the videotaped record of his performance during VR
showed that at the beginning of the session he per-
formed while sitting; movement was restricted almost
entirely to his upper extremities although he did trans-
fer weight from side to side in order to maintain his
sitting balance. Since the balls came from all directions
he had to pay attention to the entire visual space. After 3
minutes he asked to get up and to continue the session
while standing. Since his standing balance was poor, a
therapist stood behind him to provide supervision in
order to ensure his safety. The rate of success showed a
difference between his performance within the various
scenarios; he achieved 100% accuracy with the snow-
board, 85% accuracy with birds and balls and only 38%
with soccer. ‘K’ enjoyed the experience very much and
indicated that it was a good way to enhance his motor
abilities after the stroke. He stated that ‘this is the real
thing’. His responses to the presence questionnaire
showed high levels of presence (ranging from 4 to 5),
especially in the snowboard, which attained the max-
imal presence score of 5. ‘K’ wanted to combine the VR
experience with his ongoing outpatient rehabilitation
and had come to our lab several more times.
Conclusions
These examples demonstrate the usability of the Gesture
Xtreme VR system with different clinical populations as
well as different age groups. We have seen that the
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Copyright # 2003 John Wiley & Sons, Ltd.
participants were able to interact within the various
virtual environments and achieve different levels of
performance without feeling side effects. Furthermore,
they enjoyed the activities, acknowledged their rele-
vance to their rehabilitation process and stated that
they wanted to repeat the experience if possible. A
number of clinical intervention studies with these and
other populations (e.g. patients following orthopaedic
injuries) are currently in progress. During the planning
of the VR system adaptations we consulted with experts
in rehabilitation, including occupational and physical
therapists and physicians, in order to ensure their
relevance to therapy and to formulate clinically mean-
ingful assessment and treatment protocols. Our future
plans include the testing of other clinical populations
such as patients with multiple sclerosis and traumatic
brain injury, as well as the development of scenarios of
functional environments such as a shopping centre.
ACKNOWLEDGEMENTS
Financial support from Fondation Ida et Avrohom Baruch and
the Israeli Ministry of Health is gratefully acknowledged.
Programming of specific adaptations has been carried out by
Meir Shahar and Yuval Naveh and Liat Raz has helped with the
data collection and analysis.
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R. KIZONY, N. KATZ AND P. L. (TAMAR) WEISS
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Authors’ biographies:

Rachel Kizony is a doctoral candidate at the Hebrew Patrice L. (Tamar) Weiss is an Associate Professor of
University in Jerusalem, Israel. She received a BOT occupational therapy at the University of Haifa’s
degree from the Tel Aviv University in 1992 and a Faculty of Social Welfare and Health Studies. She re-
MSc degree in medical sciences from the Hebrew Uni- ceived a BSc in occupational therapy from the Univer-
versity in 1999. She also works as an occupational sity of Western Ontario in 1977, an MSc in 1979 in
therapist at the Chaim Sheba Medical Center located kinesiology from Waterloo University and a PhD in
at Tel Hashomer, Israel. Her interests include applica- 1985 in biomedical engineering and physiology from
tions of virtual reality to rehabilitation, cognitive reha- McGill University. She is currently Head of Laboratory
bilitation and physical and geriatric interventions. for Innovations in Rehabilitation Technology at the
University of Haifa. Her research interests include vir-
tual reality, assistive technology, online learning, ergo-
nomics and biomechanics.

Noomi Katz is a Professor of occupational therapy at

the Hebrew University’s Faculty of Medicine. She re-
ceived a diploma in occupatonal therapy in 1963 from
Hadassah-Hebrew University, and an MA in 1979 in
occupational therapy and a PhD in 1981 in Health
Profession Education, both from the University of
Southern California Los Angeles. She is currently
Head of the Graduate Program at the School of Occupa-
tional Therapy at the Hebrew University. Her research
interests include cognitive rehabilitation, stroke impact,
unilateral spatial neglect, unawareness, cognition and
occupation, and neuronal brain recovery.

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Copyright # 2003 John Wiley & Sons, Ltd. 268 J. Visual. Comput. Animat. 2003; 14: 261–268