Bodily resonance: Exploring the effects of virtual embodiment on pain modulation and the fostering of empathy toward pain sufferers

Globally, around 20% of people suffer from chronic pain, an illness that cannot be cured and has been linked to numerous physical and mental conditions. According to the BioPsychoSocial model of pain, chronic pain presents patients with biological, psychological, and social challenges and difficulties. Immersive virtual reality (VR) has shown great promise in helping people manage acute and chronic pain, and facilitating empathy of vulnerable populations. Therefore, the first research trajectory of this dissertation targets chronic pain patients’ biological and psychological sufferings to provide VR analgesia, and the second research trajectory targets healthy people to build empathy and reduce patients’ social stigma. Researchers have taken the attention distraction approach to study how acute pain patients can manage their condition in VR, while the virtual embodiment approach has mostly been studied with healthy people exposed to pain stimulus. My first research trajectory aimed to understand how embodied characteristics affect users’ sense of embodiment and pain. Three studies have been carried out with healthy people under heat pain, complex regional pain syndrome patients, and phantom limb pain patients. My findings indicate that for all three studies, when users see a healthy or intact virtual body or body parts, they experience significant reductions in their self-reported pain ratings. Additionally, I found that the appearance of a virtual body has a significant impact on pain, whereas the virtual body’s motions do not. Despite the prevalence of chronic pain, public awareness of it is remarkably low, and pain patients commonly experience social stigma. Thus, having an embodied perspective of chronic pain patients is critical to understand their social stigma. Although there is a growing interest in using embodied VR to foster empathy towards gender or racial bias, few studies have focused on people with chronic pain. My second trajectory explored how researchers can foster empathy towards pain patients in embodied VR. To conclude, this dissertation uncovers the role of VR embodiment and dissects embodied characteristics in pain modulation and empathy generation. Finally, I summarized a novel conceptual design framework for embodied VR applications with design recommendations and future research directions

A Multi-Modal, Modified-Feedback and Self-Paced Brain-Computer Interface (BCI) to Control an Embodied Avatar's Gait

Brain-computer interfaces (BCI) have been used to control the gait of a virtual self-avatar with the aim of being used in gait rehabilitation. A BCI decodes the brain signals representing a desire to do something and transforms them into a control command for controlling external devices. The feelings described by the participants when they control a self-avatar in an immersive virtual environment (VE) demonstrate that humans can be embodied in the surrogate body of an avatar (ownership illusion). It has recently been shown that inducing the ownership illusion and then manipulating the movements of one’s self-avatar can lead to compensatory motor control strategies. In order to maximize this effect, there is a need for a method that measures and monitors embodiment levels of participants immersed in virtual reality (VR) to induce and maintain a strong ownership illusion. This is particularly true given that reaching a high level of both BCI performance and embodiment are inter-connected. To reach one of them, the second must be reached as well. Some limitations of many existing systems hinder their adoption for neurorehabilitation: 1- some use motor imagery (MI) of movements other than gait; 2- most systems allow the user to take single steps or to walk but do not allow both, which prevents users from progressing from steps to gait; 3- most of them function in a single BCI mode (cue-paced or self-paced), which prevents users from progressing from machine-dependent to machine-independent walking. Overcoming the aforementioned limitations can be done by combining different control modes and options in one single system. However, this would have a negative impact on BCI performance, therefore diminishing its usefulness as a potential rehabilitation tool. In this case, there will be a need to enhance BCI performance. For such purpose, many techniques have been used in the literature, such as providing modified feedback (whereby the presented feedback is not consistent with the user’s MI), sequential training (recalibrating the classifier as more data becomes available). This thesis was developed over 3 studies. The objective in study 1 was to investigate the possibility of measuring the level of embodiment of an immersive self-avatar, during the performing, observing and imagining of gait, using electroencephalogram (EEG) techniques, by presenting visual feedback that conflicts with the desired movement of embodied participants. The objective of study 2 was to develop and validate a BCI to control single steps and forward walking of an immersive virtual reality (VR) self-avatar, using mental imagery of these actions, in cue-paced and self-paced modes. Different performance enhancement strategies were implemented to increase BCI performance. The data of these two studies were then used in study 3 to construct a generic classifier that could eliminate offline calibration for future users and shorten training time. Twenty different healthy participants took part in studies 1 and 2. In study 1, participants wore an EEG cap and motion capture markers, with an avatar displayed in a head-mounted display (HMD) from a first-person perspective (1PP). They were cued to either perform, watch or imagine a single step forward or to initiate walking on a treadmill. For some of the trials, the avatar took a step with the contralateral limb or stopped walking before the participant stopped (modified feedback). In study 2, participants completed a 4-day sequential training to control the gait of an avatar in both BCI modes. In cue-paced mode, they were cued to imagine a single step forward, using their right or left foot, or to walk forward. In the self-paced mode, they were instructed to reach a target using the MI of multiple steps (switch control mode) or maintaining the MI of forward walking (continuous control mode). The avatar moved as a response to two calibrated regularized linear discriminant analysis (RLDA) classifiers that used the μ power spectral density (PSD) over the foot area of the motor cortex as features. The classifiers were retrained after every session. During the training, and for some of the trials, positive modified feedback was presented to half of the participants, where the avatar moved correctly regardless of the participant’s real performance. In both studies, the participants’ subjective experience was analyzed using a questionnaire. Results of study 1 show that subjective levels of embodiment correlate strongly with the power differences of the event-related synchronization (ERS) within the μ frequency band, and over the motor and pre-motor cortices between the modified and regular feedback trials. Results of study 2 show that all participants were able to operate the cued-paced BCI and the selfpaced BCI in both modes. For the cue-paced BCI, the average offline performance (classification rate) on day 1 was 67±6.1% and 86±6.1% on day 3, showing that the recalibration of the classifiers enhanced the offline performance of the BCI (p < 0.01). The average online performance was 85.9±8.4% for the modified feedback group (77-97%) versus 75% for the non-modified feedback group. For self-paced BCI, the average performance was 83% at switch control and 92% at continuous control mode, with a maximum of 12 seconds of control. Modified feedback enhanced BCI performances (p =0.001). Finally, results of study 3 show that the constructed generic models performed as well as models obtained from participant-specific offline data. The results show that there it is possible to design a participant-independent zero-training BCI.Les interfaces cerveau-ordinateur (ICO) ont été utilisées pour contrôler la marche d'un égo-avatar virtuel dans le but d'être utilisées dans la réadaptation de la marche. Une ICO décode les signaux du cerveau représentant un désir de faire produire un mouvement et les transforme en une commande de contrôle pour contrôler des appareils externes. Les sentiments décrits par les participants lorsqu'ils contrôlent un égo-avatar dans un environnement virtuel immersif démontrent que les humains peuvent être incarnés dans un corps d'un avatar (illusion de propriété). Il a été récemment démontré que provoquer l’illusion de propriété puis manipuler les mouvements de l’égo-avatar peut conduire à des stratégies de contrôle moteur compensatoire. Afin de maximiser cet effet, il existe un besoin d'une méthode qui mesure et surveille les niveaux d’incarnation des participants immergés dans la réalité virtuelle (RV) pour induire et maintenir une forte illusion de propriété. D'autre part, atteindre un niveau élevé de performances (taux de classification) ICO et d’incarnation est interconnecté. Pour atteindre l'un d'eux, le second doit également être atteint. Certaines limitations de plusieurs de ces systèmes entravent leur adoption pour la neuroréhabilitation: 1- certains utilisent l'imagerie motrice (IM) des mouvements autres que la marche; 2- la plupart des systèmes permettent à l'utilisateur de faire des pas simples ou de marcher mais pas les deux, ce qui ne permet pas à un utilisateur de passer des pas à la marche; 3- la plupart fonctionnent en un seul mode d’ICO, rythmé (cue-paced) ou auto-rythmé (self-paced). Surmonter les limitations susmentionnées peut être fait en combinant différents modes et options de commande dans un seul système. Cependant, cela aurait un impact négatif sur les performances de l’ICO, diminuant ainsi son utilité en tant qu'outil potentiel de réhabilitation. Dans ce cas, il sera nécessaire d'améliorer les performances des ICO. À cette fin, de nombreuses techniques ont été utilisées dans la littérature, telles que la rétroaction modifiée, le recalibrage du classificateur et l'utilisation d'un classificateur générique. Le projet de cette thèse a été réalisé en 3 études, avec objectif d'étudier dans l'étude 1, la possibilité de mesurer le niveau d'incarnation d'un égo-avatar immersif, lors de l'exécution, de l'observation et de l'imagination de la marche, à l'aide des techniques encéphalogramme (EEG), en présentant une rétroaction visuelle qui entre en conflit avec la commande du contrôle moteur des sujets incarnés. L'objectif de l'étude 2 était de développer un BCI pour contrôler les pas et la marche vers l’avant d'un égo-avatar dans la réalité virtuelle immersive, en utilisant l'imagerie motrice de ces actions, dans des modes rythmés et auto-rythmés. Différentes stratégies d'amélioration des performances ont été mises en œuvre pour augmenter la performance (taux de classification) de l’ICO. Les données de ces deux études ont ensuite été utilisées dans l'étude 3 pour construire des classificateurs génériques qui pourraient éliminer la calibration hors ligne pour les futurs utilisateurs et raccourcir le temps de formation. Vingt participants sains différents ont participé aux études 1 et 2. Dans l'étude 1, les participants portaient un casque EEG et des marqueurs de capture de mouvement, avec un avatar affiché dans un casque de RV du point de vue de la première personne (1PP). Ils ont été invités à performer, à regarder ou à imaginer un seul pas en avant ou la marche vers l’avant (pour quelques secondes) sur le tapis roulant. Pour certains essais, l'avatar a fait un pas avec le membre controlatéral ou a arrêté de marcher avant que le participant ne s'arrête (rétroaction modifiée). Dans l'étude 2, les participants ont participé à un entrainement séquentiel de 4 jours pour contrôler la marche d'un avatar dans les deux modes de l’ICO. En mode rythmé, ils ont imaginé un seul pas en avant, en utilisant leur pied droit ou gauche, ou la marche vers l’avant . En mode auto-rythmé, il leur a été demandé d'atteindre une cible en utilisant l'imagerie motrice (IM) de plusieurs pas (mode de contrôle intermittent) ou en maintenir l'IM de marche vers l’avant (mode de contrôle continu). L'avatar s'est déplacé en réponse à deux classificateurs ‘Regularized Linear Discriminant Analysis’ (RLDA) calibrés qui utilisaient comme caractéristiques la densité spectrale de puissance (Power Spectral Density; PSD) des bandes de fréquences µ (8-12 Hz) sur la zone du pied du cortex moteur. Les classificateurs ont été recalibrés après chaque session. Au cours de l’entrainement et pour certains des essais, une rétroaction modifiée positive a été présentée à la moitié des participants, où l'avatar s'est déplacé correctement quelle que soit la performance réelle du participant. Dans les deux études, l'expérience subjective des participants a été analysée à l'aide d'un questionnaire. Les résultats de l'étude 1 montrent que les niveaux subjectifs d’incarnation sont fortement corrélés à la différence de la puissance de la synchronisation liée à l’événement (Event-Related Synchronization; ERS) sur la bande de fréquence μ et sur le cortex moteur et prémoteur entre les essais de rétroaction modifiés et réguliers. L'étude 2 a montré que tous les participants étaient capables d’utiliser le BCI rythmé et auto-rythmé dans les deux modes. Pour le BCI rythmé, la performance hors ligne moyenne au jour 1 était de 67±6,1% et 86±6,1% au jour 3, ce qui montre que le recalibrage des classificateurs a amélioré la performance hors ligne du BCI (p <0,01). La performance en ligne moyenne était de 85,9±8,4% pour le groupe de rétroaction modifié (77-97%) contre 75% pour le groupe de rétroaction non modifié. Pour le BCI auto-rythmé, la performance moyenne était de 83% en commande de commutateur et de 92% en mode de commande continue, avec un maximum de 12 secondes de commande. Les performances de l’ICO ont été améliorées par la rétroaction modifiée (p = 0,001). Enfin, les résultats de l'étude 3 montrent que pour la classification des initialisations des pas et de la marche, il a été possible de construire des modèles génériques à partir de données hors ligne spécifiques aux participants. Les résultats montrent la possibilité de concevoir une ICO ne nécessitant aucun entraînement spécifique au participant

Survey of movement reproduction in immersive virtual rehabilitation.

This is the author accepted manuscript. The final version is available from the Institute of Electrical and Electronics Engineers via the DOI in this record Virtual reality (VR) has emerged as a powerful tool for rehabilitation. Many effective VR applications have been developed to support motor rehabilitation of people affected by motor issues. Movement reproduction, which transfers users' movements from the physical world to the virtual environment, is commonly used in VR rehabilitation applications. Three major components are required for movement reproduction in VR: (1) movement input, (2) movement representation, and (3) movement modulation. Until now, movement reproduction in virtual rehabilitation has not yet been systematically studied. This paper aims to provide a state-of-the-art review on this subject by focusing on existing literature on immersive motor rehabilitation using VR. In this review, we provided in-depth discussions on the rehabilitation goals and outcomes, technology issues behind virtual rehabilitation, and user experience regarding movement reproduction. Similarly, we present good practices and highlight challenges and opportunities that can form constructive suggestions for the design and development of fit-for-purpose VR rehabilitation applications and can help frame future research directions for this emerging area that combines VR and health.Natural Science Foundation of the Jiangsu Higher Education Institutions of China ProgrammeKey Program Special Fund of Xian Jiaotong-Liverpool UniversityResearch Development Fund of Xian Jiaotong-Liverpool Universit

Altered bodily perceptions in chronic neuropathic pain conditions and implications for treatment using immersive virtual reality

Chronic neuropathic pain is highly disabling and difficult to treat and manage. Patients with such conditions often report altered bodily perceptions that are thought to be associated with maladaptive structural and functional alterations in the somatosensory cortex. Manipulating these altered perceptions using body illusions in virtual reality is being investigated and may have positive clinical implications for the treatment of these conditions. Here, we have conducted a narrative review of the evidence for the types of bodily distortions associated with a variety of peripheral and central neuropathic pain conditions. In addition, we summarize the experimental and clinical studies that have explored embodiment and body transformation illusions in immersive virtual reality for neuropathic pain relief, which are thought to target these maladaptive changes, as well as suggesting directions for future research

Electrocortical underpinnings of error monitoring in health and pathology

It becomes clear from the literature described above (Chapter 1), that the error monitoring mechanisms play a fundamental role in signalling the need for cognitive control. Many studies already provided a consistent evidence on the existence of peculiar ways in which the brain signals this need through electrophysiological changes. However, the following set of empirical studies aims to gain further insight into these complex processes by measuring brain activity changes in situations that alter the way one experience errors. The second Chapter (Chapter 2) consists of a brief commentary that was made in response to an article on the brain activity to action errors. In this commentary we propose new possibilities to explore our topic of interest, by taking advantage of EEG and modern virtual reality facilities. The thesis includes three EEG-VR studies: one on the error-mechanism in healthy participants (Chapter 3) and two studies on error monitoring system in pathological populations (Chapter 4, 5), as main parts of the core of the thesis. As a collateral project, in the Appendix, there is an EEG study on action observation in elite players (Chapter 7). In the first study (Chapter 3), we investigated a very simple but fundamental question. As we saw in the introduction, error-related signatures are evoked when an error occurs. But it is not clear how much of this is due to the occurrence of a violation of the intended goal or simply to the observation of a rare – thus less predictable – event. To this aim, we used a paradigm developed in the former years in our laboratory (Pavone et al., 2016; Spinelli et al., 2017), characterized by a setup in immersive Virtual Reality (VR) and simultaneous EEG recording. Building on the previous findings, we designed an EEG-VR study in which we manipulated the probability of observing errors in actions. In another study (Chapter 4) we investigated how erroneous actions are experienced by people with brain damage and diagnosis of Apraxia. Apraxic patients are people with hemispheric lesions and defective awareness on a variety of aspects that cover perceptuo-motor, cognitive or emotional domains. This study was developed after the results obtained by Canzano and colleagues (2014) in a behavioral study in which apraxic patients were asked to imitate the actions executed by the experimenter and judge their correctness; results revealed that bucco-facial apraxic patients manifest a specific deficit in detecting their own gestural errors when they are explicitly asked to judge them. With the present study we wanted to investigate apraxic brain’ response to action errors, while they embody an avatar in first person perspective (EEG-VR setup). The third study (Chapter 5) investigates the integrity of the error-monitoring system in Parkinson’s Disease and the impact of the dopaminergic treatment in the brain response to errors. To this aim we used the proposed VR action-observation paradigm, in which Parkinson patients observed successful and unsuccessful reach-to-grasp actions in first person perspective while EEG activity was recorded; the same patients were tested while being under dopaminergic treatment and during a dopaminergic withdrawal state. In another chapter we provide a critical overview of the findings of this work (General Discussion, Chapter 6). In the last chapter, the Appendix (Chapter 7), there is a collateral project of another research line of the Laboratory, in which I have being involved. In this study we are investigating the cortical underpinning of elite players during observation of goal-directed actions, in their domain of expertise. We recorded the EEG activity of elite wheelchair basketball players while observing free-throws performed by paraplegic athletes. We expected their brain correlates to be different from novice players and to be able to easily discriminate whether a basketball shot would be successful or unsuccessful (project still ongoing)

Balancing Interoception and Exteroception: Vestibular and Spatial Contributions to the Bodily Self

Experiencing the body as a coherent, stable, entity involves the dynamic integration of information from several internal (i.e. interoceptive) and external (i.e. exteroceptive) sensory sources, to produce a feeling that the body is mine (sense of body ownership), that I am in control (sense of agency) and I am aware of its movements (motor awareness). However, the exact contribution of these different sensory sources to self-consciousness, as well as the context in which we experience them, is still a matter of debate. This thesis aimed to investigate the neurocognitive mechanisms of body ownership, agency and motor awareness, including interoceptive (via affective touch), proprioceptive, exteroceptive (visuo-spatial) and vestibular contributions to body representation, in both healthy subjects and brain damaged patients. To examine the role of the vestibular and interoceptive systems in body ownership, a series of studies in healthy subjects was devised, using multisensory illusions (i.e. the rubber hand illusion; RHI), that involve the integration of interoceptive and exteroceptive sensory sources, and using electrical stimulation of the vestibular system (i.e. Galvanic Vestibular Stimulation; GVS). To investigate ownership, agency and motor awareness in neuropsychological patients with disorders of ownership and/or unawareness of motor deficits, behavioural manipulation of body ownership (via a rubber hand) and visual perspective (via a mirror) were tested. Finally, to explore underlying mechanisms of awareness of one’s own performance (i.e. meta-cognition), two studies were carried out in healthy subjects using behavioural manipulations of spatial reference frames (either centred on the subject, i.e. egocentric, or world-centred, i.e. allocentric). The results of these studies indicate that the vestibular system balances vision and proprioception according to contextual relevance: when there is no tactile stimulation, visual cues are stronger than proprioceptive ones (i.e. proprioceptive drifts are greater); when touch is delivered synchronously, this effect is enhanced (even more when touch is affective rather than neutral). However, when touch is only felt but not seen, the vestibular system downregulates vision in favour of proprioception (i.e. proprioceptive drifts are smaller), whilst the opposite happens when touch is only vicariously perceived via vision. Nevertheless, when the rubber hand is positioned in a non-biomechanically possible fashion, there appears to be no difference in proprioceptive drifts in comparison with anatomically plausible positions, suggesting that such rebalancing may be more related to basic multisensory integration processes underlying body representation. In patients with disorders of the self, visual cues seem to dominate over proprioceptive ones, leading to strong feelings of ownership of a rubber hand following mere exposure to it; however, the same is not true for agency, which seems to be more susceptible to changes in the environment (i.e. presence or absence of a visual feedback following attempted movement). Moreover, manipulating visual perspective using a mirror (from 1st to 3rd) seem to lead to a temporary remission of dis-ownership but not motor unawareness, suggesting that awareness may not be influenced by online changes in visual perspectives. Finally, when judging their own performance in a visuo-proprioceptive task from an egocentric rather than an allocentric perspective, healthy subjects appear less objective prospectively rather than during the task (i.e. their belief updating is biased when judging their ability to complete a task egocentrically). In sum, the work described above adds to the evidence that the sense of self derives from a complex integration of several sensory modalities, flexibly adjusting to the environment. Following brain damage, such flexibility may be impaired, even though it can be influenced by spatial perspective. Similarly, the point of reference from which we perceive stimuli affects the way we judge our own perceptual choices. Hence, the way we represent our bodily self is a dynamic process, constantly updated by exteroceptive and interoceptive incoming stimuli, regulated by the vestibular system. These findings could provide new avenues in rehabilitating disorders of the self (such as unawareness and dis-ownership)

Swarm Body: Embodied Swarm Robots

The human brain's plasticity allows for the integration of artificial body parts into the human body. Leveraging this, embodied systems realize intuitive interactions with the environment. We introduce a novel concept: embodied swarm robots. Swarm robots constitute a collective of robots working in harmony to achieve a common objective, in our case, serving as functional body parts. Embodied swarm robots can dynamically alter their shape, density, and the correspondences between body parts and individual robots. We contribute an investigation of the influence on embodiment of swarm robot-specific factors derived from these characteristics, focusing on a hand. Our paper is the first to examine these factors through virtual reality (VR) and real-world robot studies to provide essential design considerations and applications of embodied swarm robots. Through quantitative and qualitative analysis, we identified a system configuration to achieve the embodiment of swarm robots