Starwalker is a research and clinical virtual reality video games platform project for a population of children with kinesiophobia. Kinesiophobia is defined as "an excessive, irrational and debilitating fear of movement and physical activity resulting from a sense of vulnerability to a painful injury or painful news" (Vlaeyen & Crombez, 2009). This phenomenon is at the heart of the pain chronicisiation process, generates significant anxiety as well as avoidance behaviours that may ultimately be responsible for the persistence of pain problems. For a complete review of kinesiophobia and avoidance behaviors, see (Conradi & Masselin-Dubois, 2019).
Virtual reality is now seen as a promising tool in motor rehabilitation. A meta-analysis even presents virtual rehabilitation therapies as more effective than traditional therapies (Howard, 2017), and its effectiveness in some cases of kinesiophobia has been demonstrated (Chen et al., 2016; Yelvar et al., 2017). In addition, the analgesic effect of virtual reality is also known, notably thanks to Hoffman's pioneering work on patients with severe burns (Hoffman & Patterson, 1996; Hoffman et al., 2000, Shahrbanian et al., 2009; Malloy et al., 2010, Hoffman et al., 2011; Arane et al., 2017). Burn patients with extreme levels of pain were immersed in a virtual world called SnowWorld. They reported reduced levels of pain following particularly painful dressing operations. This pain distraction effect is often attributed to the sense of presence: the feeling that one is, in virtual reality, actually present in the virtual environment rather than the physical one (Heeter, 1991; Sheridan, 1992). The sense of presence is defined in the Traité de la Réalité Virtuelle as the cognitive, motor and perceptual positioning of the subject between the real and the virtual world (Mestre et al., 2006) and is at the heart of virtual reality.
The combination of the advances of virtual reality in rehabilitation and in pain reduction makes virtual reality a particularly interesting tool to accompany and help child patients in their lower limb kinesiophobia. Two other points should be highlighted in the contributions of virtual reality: firstly, it is a strong phenomenological experience which can offer children playful applications that probably provoke greater commitment from their part (Won et al., 2017). Secondly, a concept related to proprioception and the psychology of perception seems particularly relevant in the case of virtual reality kinesiophobia: the "sense of embodiment", the sensation of owning, being and controlling a body (Kilteni et al., 2012). It would indeed be interesting to see if the subjects, visually cut off from their problematic limbs, would increase their capacities and amplitudes of movement via the control of a virtual avatar.
More pragmatically, Starwalker is mini-games platform where participants interact with the virtual environment with their feet using the 3DRudder, althought Starwalker can also be played using a standart hand controller. The player is immersed in virtual reality and must catch or avoid objects, shoot at aliens, play bowling or pool against the computer. The program, developed in C# on Unity by the authors is currently in beta version. This version will be installed for first tests at the Centre d'Evaluation et de Traitement de la Douleur at the Clémenceau Hospital. The equipment (3DRudder, HTC-Vive head mounted display and computer) was financed by a Pièces Jaunes project. This project is under the CC-BY-SA licensing, so feel free to contact me if you want to try the software or take part in the project.
The structures:
The Pain Assessment and Treatment Center (Centre d’Evaluation et de Traitement de la Douleur, CETD), attached to the Specialty Medicine Center, is located on the site of the Clémenceau Hospital (Caen). The center treats outpatients suffering from chronic pain. The CETD also receives inpatients for consultation, advice or assessment in order to give an opinion on treatments and to guide their pain management after discharge.
The Interdisciplinary Center for Virtual Reality (Centre Interdisciplinaire de Réalité Virtuelle, CIREVE) is a technical platform of the University of Caen Normandy created in March 2006 and attached since the 1st January 2012 to the UFR "Humanities and Social Sciences". It is the result of the "virtual reality" activity carried out since 1994 around the work of restitution of ancient Rome ("Plan of Rome" team, now integrated into ERLIS).
Its main missions are :
Pooling of virtual reality equipment (clusters, projectors, screens, interfaces, etc.).
The pooling of skills and the organisation of training courses.
The promotion and support of the use of virtual reality in research in the human and social sciences as well as in the exact and experimental sciences.
Alexandre Rousseau for the very first tests of the game.
Mysticreator on Sketchfab (Cikitta) for the avatar model and animation.
Nicholas Veselov (#NVJOB) on GitHub for the water shaders.
Richard Whitelock for the skyboxes.
SimpleModels for the handtorches.
Adam Bielecki for the Milky Way.
Highground Assets for the Bowling Kegel & Ball.
Tamarin Studios for the Western Pack.
Herminio Nieves for the Wraith Raider Starship.
VGL for the recording of the video teaser.
References:
Arane, K., Behboudi, A., & Goldman, R. D. (2017). La réalité virtuelle pour la prise en charge de la douleur et de l’anxiété chez l’enfant. Canadian Family Physician, 63(12), 935‑937.
Chen, K. B., Sesto, M. E., Ponto, K., Leonard, J., Mason, A., Vanderheiden, G., Williams, J., & Radwin, R. G. (2017). Use of Virtual Reality Feedback for Patients with Chronic Neck Pain and Kinesiophobia. IEEE Transactions on Neural Systems and Rehabilitation Engineering, 25(8), 1240‑1248. https://doi.org/10.1109/TNSRE.2016.2621886
Conradi, S., & Masselin-Dubois, A. (2019). La kinésiophobie et le modèle d’évitement de la peur de la douleur dans l’évaluation psychologique. Douleurs : Évaluation - Diagnostic - Traitement, 20(4), 151‑157. https://doi.org/10.1016/j.douler.2018.12.005
Heeter, C. (1992). Being There : The Subjective Experience of Presence. Presence: Teleoperators and Virtual Environments, 1(2), 262‑271. https://doi.org/10.1162/pres.1992.1.2.262.
Hoffman, H. G., Chambers, G. T., Meyer, W. J., Arceneaux, L. L., Russell, W. J., Seibel, E. J., Richards, T. L., Sharar, S. R., & Patterson, D. R. (2011). Virtual Reality as an Adjunctive Non-pharmacologic Analgesic for Acute Burn Pain During Medical Procedures. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, 41(2), 183‑191. https://doi.org/10.1007/s12160-010-9248-7
Hoffman, H. G., Patterson, D. R., & Carrougher, G. J. (2000). Use of Virtual Reality for Adjunctive Treatment of Adult Burn Pain During Physical Therapy : A Controlled Study. The Clinical Journal of Pain, 16(3), 244–250.
Howard, M. C. (2017). A meta-analysis and systematic literature review of virtual reality rehabilitation programs. Computers in Human Behavior, 70, 317‑327. https://doi.org/10.1016/j.chb.2017.01.013.
Malloy, K. M., & Milling, L. S. (2010). The effectiveness of virtual reality distraction for pain reduction : A systematic review. Clinical Psychology Review, 30(8), 1011‑1018. https://doi.org/10.1016/j.cpr.2010.07.001.
Sheridan, T. B. (1992). Musings on Telepresence and Virtual Presence. Presence: Teleoperators and Virtual Environments, 1(1), 120‑126. https://doi.org/10.1162/pres.1992.1.1.120.
Vlaeyen, J. W. S., & Crombez, G. (2009). La psychologie de la peur et de la douleur. Revue du Rhumatisme, 76(6), 511‑516. https://doi.org/10.1016/j.rhum.2009.03.004.
Wiederhold, B. K., & Riva, G. (2009). Annual Review of Cybertherapy and Telemedicine 2009 : Advanced Technologies in the Behavioral, Social and Neurosciences. IOS Press.
Yilmaz Yelvar, G. D., Çırak, Y., Dalkılınç, M., Parlak Demir, Y., Guner, Z., & Boydak, A. (2017). Is physiotherapy integrated virtual walking effective on pain, function, and kinesiophobia in patients with non-specific low-back pain? Randomised controlled trial. European Spine Journal, 26(2), 538‑545. https://doi.org/10.1007/s00586-016-4892-7
