Presence and rehabilitation: toward second-generation virtual reality applications in neuropsychology

Virtual Reality (VR) offers a blend of attractive attributes for rehabilitation. The most exploited is its ability to create a 3D simulation of reality that can be explored by patients under the supervision of a therapist. In fact, VR can be defined as an advanced communication interface based on interactive 3D visualization, able to collect and integrate different inputs and data sets in a single real-like experience. However, "treatment is not just fixing what is broken; it is nurturing what is best" (Seligman & Csikszentmihalyi). For rehabilitators, this statement supports the growing interest in the influence of positive psychological state on objective health care outcomes. This paper introduces a bio-cultural theory of presence linking the state of optimal experience defined as "flow" to a virtual reality experience. This suggests the possibility of using VR for a new breed of rehabilitative applications focused on a strategy defined as transformation of flow. In this view, VR can be used to trigger a broad empowerment process within the flow experience induced by a high sense of presence. The link between its experiential and simulative capabilities may transform VR into the ultimate rehabilitative device. Nevertheless, further research is required to explore more in depth the link between cognitive processes, motor activities, presence and flow

Future Trends of Virtual, Augmented Reality, and Games for Health

Serious game is now a multi-billion dollar industry and is still growing steadily in many sectors. As a major subset of serious games, designing and developing Virtual Reality (VR), Augmented Reality (AR), and serious games or adopting off-the-shelf games to support medical education, rehabilitation, or promote health has become a promising frontier in the healthcare sector since 2004, because games technology is inexpensive, widely available, fun and entertaining for people of all ages, with various health conditions and different sensory, motor, and cognitive capabilities. In this chapter, we provide the reader an overview of the book with a perspective of future trends of VR, AR simulation and serious games for healthcare

Novel supports to the assessment of cognitive functions through the combined use of technologies and subjective and objective measurements

Tesis por compendio[ES] Las funciones cognitivas incluyen todos los procesos a través de los cuales un individuo percibe, registra, mantiene, manipula, usa y expresa información que está involucrada en cualquier actividad cotidiana. Las principales herramientas estandarizadas se pueden dividir en tres grupos principales: escalas cortas de pruebas de seguimiento cognitivo: cuestionarios, baterías neuropsicológicas generales y pruebas específicas. Estas herramientas están bien validadas y son confiables, pero, en la última década, varias investigaciones han demostrado que algunos pacientes pueden realizar bien estas pruebas neuropsicológicas, incluso cuando tienen dificultades significativas para adaptar sus comportamientos a las actividades de la vida diaria. De acuerdo con esto, más recientemente, un nuevo enfoque ha aumentado sustancialmente, lo que podría proporcionar una mayor validez ecológica en la evaluación de las capacidades cognitivas funcionales que el enfoque estandarizado: el uso de sistemas tecnológicos avanzados para la evaluación neuropsicológica (STAEN). STAEN se refiere a un conjunto de dispositivos y aplicaciones de software tales como pruebas computarizadas, juegos divertidos e interactivos de fantasía (JS) y / o sistemas de realidad virtual simulada (RV) y / o aumentada (RA) que van más allá de las pruebas de evaluación tradicionales y que Brindar la posibilidad de entregar estímulos controlados y dinámicos, en entornos ecológicamente válidos y seguros. Partiendo de estas premisas, el objetivo principal de la tesis era diseñar, desarrollar y validar un SG 2D no inmersivo versus un JS 3D inmersivo y una actividad de la vida diaria en un entorno 3D RV inmersivo versus un RA para la evaluación de funciones cognitivas, comparando la eficacia y efectividad de ellos. El primer estudio 2D incluyó 354 sujetos sanos y se encontraron correlaciones entre el juego y los métodos tradicionales, lo que sugiere que el juego podría ser una herramienta válida para evaluar las funciones cognitivas en adultos. El segundo estudio, comparó la versión 2D versus una versión 3D STAEN, involucró a 94 sujetos sanos y mostró que la versión 3D fue capaz de generar tiempos más bajos y respuestas correctas más altas que la 2D, lo que sugiere evidencia inicial de la eficacia de un sistema más inmersivo en comparación con un sistema no-inmersivo. Aunque este resultado destaca una posible limitación en el uso de diferentes sistemas tecnológicos debido a las diferencias en los dos métodos de interacción (el sistema 2D aplicó el mouse y el teclado; los controladores de dos manos virtuales 3D) y el registro de datos de latencia de hardware y software. Con respecto a la variabilidad individual en edad, género y educación, los hallazgos mostraron consistencia con la literatura de referencia. Específicamente, los más jóvenes mostraron un mayor rendimiento que los mayores; niveles educativos más altos reflejados en una mejor puntuación y sobre género, los resultados mostraron un panorama más compuesto. Además, para mejorar la validez ecológica de la evaluación, el último estudio de esta tesis comparó el rendimiento conductual y las respuestas fisiológicas, durante una tarea de cocina ecológica, entre un sistema virtual y un sistema aumentado en 50 sujetos sanos. La tarea de cocinar consistió en 4 niveles que aumentaron en dificultad. A medida que el nivel aumentó, aparecieron actividades adicionales. Los resultados de comportamiento mostraron que los tiempos son siempre más bajos en realidad virtual que en RA, aumentando constantemente de acuerdo con la dificultad de las tareas. Con respecto a las respuestas fisiológicas, los hallazgos mostraron que la condición RA produjo más excitación y activación individual que la realidad virtual. Para concluir, STAEN está demostrando ser herramientas confiables y efectivas para la evaluación de las funciones cognitivas en adultos, proporcionando más validez ec[CA] Les funcions cognitives inclouen tots els processos a través dels quals un individu percep, registra, manté, manipula, usa i expressa informació que està involucrada en qualsevol activitat quotidiana. Les principals ferramentes estandarditzades es poden dividir en tres grups principals: escales curtes de proves de seguiment cognitiu: qüestionaris, bateries neuropsicológiques generals i proves específiques. Estes ferramentes estan ben validades i són confiables, però, en l'última dècada, diverses investigacions han demostrat que alguns pacients poden realitzar bé estes proves neuropsicológiques, inclús quan tenen dificultats significatives per a adaptar els seus comportaments a les activitats de la vida diària. D'acord amb açò, més recentment, un nou enfocament ha augmentat substancialment, la qual cosa podria proporcionar una major validesa ecològica en l'avaluació de les capacitats cognitives funcionals que l'enfocament estandarditzat: l'ús de sistemes tecnològics avançats per a l'avaluació neuropsicológica (STAEN). STAEN es referix a un conjunt de dispositius i aplicacions de software com ara proves computaritzades, jocs divertits i interactius de fantasia (JS) i / o sistemes de realitat virtual simulada (RV) i / o augmentada (RA) que van més enllà de les proves d'avaluació tradicionals i que brinden la possibilitat de presentar estímuls controlats i dinàmics, en entorns ecològicament vàlids i segurs. Partint d'estes premisses, l'objectiu principal de la tesi era dissenyar, desenrotllar i validar un SG 2D no inmersiu versus un JS 3D inmersiu i una activitat de la vida diària en un entorn 3D RV inmersiu versus un RA per a l'avaluació de funcions cognitives, comparant l'eficàcia i efectivitat d'ells. El primer estudi 2D va incloure 354 subjectes sans i es van trobar correlacions entre el joc i els mètodes tradicionals, la qual cosa suggerix que el joc podria ser una ferramenta vàlida per a avaluar les funcions cognitives en adults. El segon estudi, va comparar la versió 2D versus una versió 3D STAEN, va involucrar a 94 subjectes sans i va mostrar que la versió 3D va ser capaç de generar temps més baixos i respostes correctes més altes que la 2D, la qual cosa suggerix evidència inicial de l'eficàcia d'un sistema més inmersiu en comparació amb un sistema no-inmersiu. Encara que este resultat destaca una possible limitació en l'ús de diferents sistemes tecnològics a causa de les diferències en els dos mètodes d'interacció (el sistema 2D va aplicar el ratolí i el teclat; els controladors de dos mans virtuals 3D) i el registre de dades de latència de hardware i software. Respecte a la variabilitat individual en edat, gènere i educació, les troballes van mostrar consistència amb la literatura de referència. Específicament, els més jóvens van mostrar un major rendiment que els majors; nivells educatius més alts reflectits en una millor puntuació i sobre gènere, els resultats van mostrar un panorama més compost. A més, per a millorar la validesa ecològica de l'avaluació, l'últim estudi d'esta tesi va comparar el rendiment conductual i les respostes fisiològiques, durant una tasca de cuina ecològica, entre un sistema virtual i un sistema augmentat en 50 subjectes sans. La tasca de cuinar va consistir en 4 nivells que van augmentar en dificultat. A mesura que el nivell va augmentar, van aparéixer activitats addicionals. Els resultats de comportament van mostrar que els temps són sempre més baixos en realitat virtual que en RA, augmentant constantment d'acord amb la dificultat de les tasques. Respecte a les respostes fisiològiques, les troballes van mostrar que la condició RA va produir més excitació i activació individual que la realitat virtual. Per a concloure, STAEN està demostrant ser ferramentes confiables i efectives per a l'avaluació de les funcions cognitives en adults, proporcionant més validesa ecològica i objectivitat que els mètodes tradicio[EN] Cognitive functions include all the processes through which an individual perceives, records, maintains, manipulates, uses and expresses information that are involved in any everyday activity. The main standardized tools can be divided in three main groups: short scales of cognitive tracking tests - questionnaires, general neuropsychological batteries, and specific tests. These tools are well-validated and reliable but, in the last decade, several research have shown that some patients can perform these neuropsychological tests well, even when they have significant difficulties in adapting their behaviours to daily life activities. According to this, more recently, a new approach has substantially increased, potentially providing a higher ecological validity in functional cognitive abilities assessment than standardized approach: the use of advanced technological systems for neuropsychological assessment (ATSNA). ATSNA refer to a set of devices and software applications such as computerized tests, fun and interactive fantasy serious games (SG), and/or simulated virtual (VR) and/or augmented (AR) reality systems that go beyond traditional assessment tests and that supply the possibility to deliver controlled and dynamic stimuli, in ecologically valid, and secure environments. Starting from these premises, the main objective of the thesis was to design, develop, and validate a non-immersive 2D SG versus an immersive 3D SG and a daily life activity in an immersive 3D VR environment versus an AR for the assessment of cognitive functions, comparing the efficacy and effectiveness of them. The first 2D study involved 354 healthy subjects and correlations were found between the game and traditional methods, suggesting that the game could be a valid tool for assessing cognitive functions in adults. The second study, compared 2D versus a 3D ATSNA version, it involved 94 healthy subjects and showed that 3D version was able to generate lower times and higher correct answers that the 2D, suggesting initial evidence of efficacy of a more immersive system compared to a non-immersive system. Although this result highlights a potential limitation on using different technological systems due to the differences on the two interaction methods (the 2D system applied mouse and keyboard; the 3D two virtual hands' controllers) and hardware and software latency data recording. Regarding individual variability on age, gender, and education, the findings showed consistency with the reference literature. Specifically, younger showed higher performance that older; higher educational levels reflected on a better score and about gender, results showed a more composite panorama. Furthermore, to enhance the ecological validity of assessment, the last study of this thesis compared the behavioural performance and physiological responses, during an ecological cooking task, between a virtual and an augmented system on 50 healthy subjects. The cooking task consisted of 4 levels that increased in difficulty. As the level increased, additional activities appeared. The behavioural results showed that times are always lower in VR than in AR, increasing constantly in accordance with the difficulty of the tasks. Regarding physiological responses, the findings showed that AR condition produced more individual excitement and activation than VR. To conclude, ATSNA are proving to be reliable and effective tools for the assessment of cognitive functions in adults, providing more ecological validity and objectivity than traditional methods of assessment.Chicchi Giglioli, IAM. (2020). Novel supports to the assessment of cognitive functions through the combined use of technologies and subjective and objective measurements [Tesis doctoral no publicada]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/139075TESISCompendi

The effectiveness of virtual reality interventions for improvement of neurocognitive performance post-traumatic brain injury: a systematic review

Objective: To evaluate current evidence for the effectiveness of virtual reality (VR) interventions in improving neurocognitive performance in individuals who have sustained a traumatic brain injury (TBI). Methods: A systematic literature search across multiple databases (PubMed, EMBASE, Web of Science) for articles of relevance. Studies were evaluated according to study design, patient cohort, VR intervention, neurocognitive parameters assessed, and outcome. VR interventions were evaluated qualitatively with respect to methodology and extent of immersion and quantitatively with respect to intervention duration. Outcomes: Our search yielded 324 articles, of which only 13 studies including 132 patients with TBI met inclusion criteria. A wide range of VR interventions and cognitive outcome measures is reported. Cognitive measures included learning and memory, attention, executive function, community skills, problem solving, route learning, and attitudes about driving. Several studies (n = 10) reported statistically significant improvements in outcome, and 2 studies demonstrated successful translation to real-life performance. Conclusions: VR interventions hold significant potential for improving neurocognitive performance in patients with TBI. While there is some evidence for translation of gains to activities of daily living, further studies are required to confirm the validity of cognitive measures and reliable translation to real-life performance

Validation of a low-cost virtual reality system for training street-crossing. A comparative study in healthy, neglected and non-neglected stroke individuals

Unilateral spatial neglect is a common consequence of stroke that directly affects the performance of activities of daily living. This impairment is traditionally assessed with paper-and-pencil tests that can lack correspondence to real life and are easily compensated. Virtual reality can immerse patients in more ecological scenarios, thus providing therapists with new tools to assess and train the effects of this impairment in simulated real tasks. This paper presents the clinical validation and convergent validity of a low-cost virtual reality system for training street-crossing in stroke patients with and without neglect. The performance of neglect patients was significantly worse than the performance of non-neglect and healthy participants. In addition, several correlations between the scores in the system and in the traditional scales were detected.This study was funded in part by Ministerio de Educacion y Ciencia Spain, Projects Consolider-C (SEJ2006-14301/PSIC), "CIBER of Physiopathology of Obesity and Nutrition, an initiative of ISCIII" and the Excellence Research Program PROMETEO (Generalitat Valenciana. Conselleria de Educacion, 2008-157).Navarro, MD.; Llorens Rodríguez, R.; Noé, E.; Ferri, J.; Alcañiz Raya, ML. (2013). Validation of a low-cost virtual reality system for training street-crossing. A comparative study in healthy, neglected and non-neglected stroke individuals. Neuropsychological Rehabilitation. 23(4):597-618. https://doi.org/10.1080/09602011.2013.806269S597618234Allegri, R. F. (2000). Atención y negligencia: bases neurológicas, evaluación y trastornos. Revista de Neurología, 30(05), 491. doi:10.33588/rn.3005.99645Appelros, P., Karlsson, G. M., Seiger, Åke, & Nydevik, I. (2002). Neglect and Anosognosia After First-Ever Stroke: Incidence and Relationship to Disability. Journal of Rehabilitation Medicine, 34(5), 215-220. doi:10.1080/165019702760279206Baheux, K., Yoshizawa, M., & Yoshida, Y. (2007). Simulating hemispatial neglect with virtual reality. Journal of NeuroEngineering and Rehabilitation, 4(1). doi:10.1186/1743-0003-4-27Boian, R. F., Burdea, G. C., Deutsch, J. E. and Winter, S. H. Street crossing using a virtual environment mobility simulator.Paper presented at 3rd Annual International Workshop on Virtual Reality. Lausanne, Switzerland.Broeren, J., Samuelsson, H., Stibrant-Sunnerhagen, K., Blomstrand, C., & Rydmark, M. (2007). Neglect assessment as an application of virtual reality. Acta Neurologica Scandinavica, 116(3), 157-163. doi:10.1111/j.1600-0404.2007.00821.xBuxbaum, L. J., Ferraro, M. K., Veramonti, T., Farne, A., Whyte, J., Ladavas, E., … Coslett, H. B. (2004). Hemispatial neglect: Subtypes, neuroanatomy, and disability. Neurology, 62(5), 749-756. doi:10.1212/01.wnl.0000113730.73031.f4Buxbaum, L. J., Palermo, M. A., Mastrogiovanni, D., Read, M. S., Rosenberg-Pitonyak, E., Rizzo, A. A., & Coslett, H. B. (2008). Assessment of spatial attention and neglect with a virtual wheelchair navigation task. Journal of Clinical and Experimental Neuropsychology, 30(6), 650-660. doi:10.1080/13803390701625821Castiello, U., Lusher, D., Burton, C., Glover, S., & Disler, P. (2004). Improving left hemispatial neglect using virtual reality. Neurology, 62(11), 1958-1962. doi:10.1212/01.wnl.0000128183.63917.02Conners, C. K., Epstein, J. N., Angold, A., & Klaric, J. (2003). Journal of Abnormal Child Psychology, 31(5), 555-562. doi:10.1023/a:1025457300409Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). «Mini-mental state». Journal of Psychiatric Research, 12(3), 189-198. doi:10.1016/0022-3956(75)90026-6Fordell, H., Bodin, K., Bucht, G., & Malm, J. (2011). A virtual reality test battery for assessment and screening of spatial neglect. Acta Neurologica Scandinavica, 123(3), 167-174. doi:10.1111/j.1600-0404.2010.01390.xGupta, V., Knott, B. A., Kodgi, S., & Lathan, C. E. (2000). Using the «VREye» System for the Assessment of Unilateral Visual Neglect: Two Case Reports. Presence: Teleoperators and Virtual Environments, 9(3), 268-286. doi:10.1162/105474600566790Hartman-Maeir, A., & Katz, N. (1995). Validity of the Behavioral Inattention Test (BIT): Relationships With Functional Tasks. American Journal of Occupational Therapy, 49(6), 507-516. doi:10.5014/ajot.49.6.507Jannink, M. J. A., Aznar, M., de Kort, A. C., van de Vis, W., Veltink, P., & van der Kooij, H. (2009). Assessment of visuospatial neglect in stroke patients using virtual reality: a pilot study. International Journal of Rehabilitation Research, 32(4), 280-286. doi:10.1097/mrr.0b013e3283013b1cJehkonen, M., Laihosalo, M., & Kettunen, J. (2006). Anosognosia after stroke: assessment, occurrence, subtypes and impact on functional outcome reviewed. Acta Neurologica Scandinavica, 114(5), 293-306. doi:10.1111/j.1600-0404.2006.00723.xKatz, N., Ring, H., Naveh, Y., Kizony, R., Feintuch, U., & Weiss, P. L. (2005). Interactive virtual environment training for safe street crossing of right hemisphere stroke patients with Unilateral Spatial Neglect. Disability and Rehabilitation, 27(20), 1235-1244. doi:10.1080/09638280500076079Kim, D. Y., Ku, J., Chang, W. H., Park, T. H., Lim, J. Y., Han, K., … Kim, S. I. (2010). Assessment of post-stroke extrapersonal neglect using a three-dimensional immersive virtual street crossing program. Acta Neurologica Scandinavica, 121(3), 171-177. doi:10.1111/j.1600-0404.2009.01194.xKim, J., Kim, K., Kim, D. Y., Chang, W. H., Park, C.-I., Ohn, S. H., … Kim, S. I. (2007). Virtual Environment Training System for Rehabilitation of Stroke Patients with Unilateral Neglect: Crossing the Virtual Street. CyberPsychology & Behavior, 10(1), 7-15. doi:10.1089/cpb.2006.9998Kim, K., Kim, J., Ku, J., Kim, D. Y., Chang, W. H., Shin, D. I., … Kim, S. I. (2004). A Virtual Reality Assessment and Training System for Unilateral Neglect. CyberPsychology & Behavior, 7(6), 742-749. doi:10.1089/cpb.2004.7.742Kim, Y. M., Chun, M. H., Yun, G. J., Song, Y. J., & Young, H. E. (2011). The Effect of Virtual Reality Training on Unilateral Spatial Neglect in Stroke Patients. Annals of Rehabilitation Medicine, 35(3), 309. doi:10.5535/arm.2011.35.3.309Krakauer, J. W. (2006). Motor learning: its relevance to stroke recovery and neurorehabilitation. Current Opinion in Neurology, 19(1), 84-90. doi:10.1097/01.wco.0000200544.29915.ccMcComas, J., MacKay, M., & Pivik, J. (2002). Effectiveness of Virtual Reality for Teaching Pedestrian Safety. CyberPsychology & Behavior, 5(3), 185-190. doi:10.1089/109493102760147150Myers, R. L., & Bierig, T. A. (2000). Virtual Reality and Left Hemineglect: A Technology for Assessment and Therapy. CyberPsychology & Behavior, 3(3), 465-468. doi:10.1089/10949310050078922Peskine, A., Rosso, C., Box, N., Galland, A., Caron, E., Rautureau, G., … Pradat-Diehl, P. (2010). Virtual reality assessment for visuospatial neglect: importance of a dynamic task. Journal of Neurology, Neurosurgery & Psychiatry, 82(12), 1407-1409. doi:10.1136/jnnp.2010.217513Romero, M., Sánchez, A., Marín, C., Navarro, M. D., Ferri, J., & Noé, E. (2012). Utilidad clínica de la versión en castellano del Mississippi Aphasia Screening Test (MASTsp): validación en pacientes con ictus. Neurología, 27(4), 216-224. doi:10.1016/j.nrl.2011.06.006Rose, F. D., Brooks, B. M., & Rizzo, A. A. (2005). Virtual Reality in Brain Damage Rehabilitation: Review. CyberPsychology & Behavior, 8(3), 241-262. doi:10.1089/cpb.2005.8.241Schwebel, D. C., & McClure, L. A. (2010). Using virtual reality to train children in safe street-crossing skills. Injury Prevention, 16(1), e1-e1. doi:10.1136/ip.2009.025288Simpson, G., Johnston, L., & Richardson, M. (2003). An investigation of road crossing in a virtual environment. Accident Analysis & Prevention, 35(5), 787-796. doi:10.1016/s0001-4575(02)00081-7Smith, J., Hebert, D., & Reid, D. (2007). Exploring the effects of virtual reality on unilateral neglect caused by stroke: Four case studies. Technology and Disability, 19(1), 29-40. doi:10.3233/tad-2007-19104Sugarman, H., Weisel-Eichler, A., Burstin, A. and Brown, R.Use of novel virtual reality system for the assessment and treatment of unilateral spatial neglect: A feasibility study. Paper presented at International Conference on Virtual Rehabilitation. Zürich.Tanaka, T., Sugihara, S., Nara, H., Ino, S., & Ifukube, T. (2005). Journal of NeuroEngineering and Rehabilitation, 2(1), 31. doi:10.1186/1743-0003-2-31Thomson, J. A., Tolmie, A. K., Foot, H. C., Whelan, K. M., Sarvary, P., & Morrison, S. (2005). Influence of Virtual Reality Training on the Roadside Crossing Judgments of Child Pedestrians. Journal of Experimental Psychology: Applied, 11(3), 175-186. doi:10.1037/1076-898x.11.3.175Weiss, P. L. (Tamar), Naveh, Y., & Katz, N. (2003). Design and testing of a virtual environment to train stroke patients with unilateral spatial neglect to cross a street safely. Occupational Therapy International, 10(1), 39-55. doi:10.1002/oti.176Witmer, B. G., & Singer, M. J. (1998). Measuring Presence in Virtual Environments: A Presence Questionnaire. Presence: Teleoperators and Virtual Environments, 7(3), 225-240. doi:10.1162/105474698565686Wu, H., Ashmead, D. H. and Bodenheimer, B.Using immersive virtual reality to evaluate pedestrian street crossing decisions at a roundabout. Paper presented at 6th Symposium on appied perception in Graphics and Visualization. Chania

A virtual reality game for cognitive impairment screening in the elderly: a user perspective

Today, there are 50 million people who have dementia worldwide, that is a new case every3 seconds and more than 152 million cases expected in 2050. Aging-related morbidity is a real social problem making screening a significant challenge. Early diagnosis and management would improve the quality of life offered to the patient and those around him and reduce the economic and social consequences of dementia. The traditional paper-and-pencil approach does not sufficiently reflect the daily reality of the person and what they can accomplish. So, we designed our own VR environment as a candidate solution to the problem

The VESPA Project: Virtual Reality Interventions for Neurocognitive and Developmental Disorders

VESPA is a financed project supported by the Sicilian Regional Research and Development funds, and it is structured by the development, research and validation of Virtual Reality (VR) based application for the diagnosis and treatment of neurocognitive conditions. In particular, this article presents its characteristics, referred to as the first (2013-2015) and second (2021-ongoing) generations of VESPA, with particular reference to literature regarding the VR technology application and development, the VR treatment of neurocognitive conditions and prior versions of this intervention. Through a comprehensive review of the research conducted over the last 5 years, evidence has emerged supporting VESPA’s aim and scopes, highlighting how the application of VR can be considered to add value to typical rehabilitation/therapeutic paths. VESPA project generations are then presented in detail, including specific session/task battery characteristics, 2.5D, 3D and 5D typologies, system usability and architecture and pathological domain-based dynamics and features. The discussion about VESPA will highlight the current advantages along with limitations and future directions