Going beyond the mainstream video conferencing experience: exploring the accessibility of virtual reality based therapeutic interventions.

Introduction

The global pandemic in 2020 resulted in many businesses having to adapt their practices: Occupational Therapists included.

COVID led to “…a transformation of how activities of all types, including those related to employment, education, leisure, social and even religious activities, were carried out.” [1]  Organisations with limited previous exposure to video conferencing were placed on a steep learning curve.

The majority of current video conferencing platforms were limited to a two dimensional plane (e.g. screen monitor) and any interventions are restricted in their somatosensory presentation.  Remote meeting platforms existed prior to 2020 and could be delivered in a number of ways including standalone clients, conference or event platforms, educational platforms, medical platforms and extended reality (XR) platforms.  The latter is “…an immersive remote meeting platform where immersive XR environments are used as real-time, virtual meeting places.” [2]

This ePoster explores the potential of XR, or virtual reality platforms, in the context of providing therapeutic interventions and the accessibility challenges that need to be considered.

Potential of VR

Virtual reality (VR) is an example of an XR environment.  It is a simulated experience that can be similar to or completely different from the real world. Applications of virtual reality include entertainment (particularly video games), education (such as medical or military training) and business (such as virtual meetings). [3] The method of accessing VR environments is dependent on the software platform used and the hardware it dictates.  This can include smartphones / tablets, laptop / desktop computers and dedicated wearable headsets.

The use of VR in specific treatment modalities such as pain and stress management, exposure therapy is well documented [4][5][6] and these modalities predominantly focus on 1:1 intervention.

Whilst VR platforms share the same positive financial and environmental impact as traditional two dimensional (2D) options (e.g. reduced costs and emissions related to physical travel to a specific place) they potentially offer other benefits:

• Provide more real-time interaction not achievable on 2D platforms.
• Creates a closer resemblance to face-to-face meetings particularly by generating a 3D scene visually and audibly.
• Allows multiple people with a similar purpose to be in the same virtual location regardless of their physical geographical location.
• Gives individuals the ability to express themselves in the avatar of their choice. 

In the same way visuals (e.g. video from a webcam) are presented in a single plane the majority of video conferencing platform lack the ability to provide spatial or binaural sound similar to what we experience in real life. The use of audio is often overlooked and “…it is nearly impossible to recreate real environments into digital formats without satisfying one of the primary senses—the sense of hearing. The sounds we hear are crucial to the multi-sensory environment needed for compelling immersive worlds.” [7]

Being computer generated a VR environment is adaptable and gradable programmatically.  This is particular of note in physical rehabilitation settings – something that it not easily replicated in 2D meeting environments.

Expanding the therapeutic use of this technology depends on the accessibility of the VR platform being considered and the hardware required.

Accessibility

No VR platform or system currently on the market is 100% accessible: this needs to be considered if used as a therapeutic medium. However there have been significant advances in a short space of time. Within the past 2 years we have seen significant advances in what is possible.

Guidelines to create accessible XR content exist (XR Accessibility User Requirements) [8] however unlike the Web Content Accessibility Guidelines (WCAG) are currently not an international standard nor enforceable. So in very general terms the bulk of VR experiences, at least in relation to gaming, are inaccessible.

That said VR platforms exist that address specific access needs.  The following points outline these features available across different platforms such as Mozilla Hubs [9], VR Chat [10], Engage [11] and MeetinVR. [12]

Mobility

There are multiple ways of accessing and interacting in a VR environment.  Fundamentally this comes down to two elements:

1. The platform used e.g. desktop app versus via dedicated VR headset.
2. Controller option used to access the platform e.g. mouse, keyboard, gaming controller or dedicated VR hand controller.  Typical adaptive gaming controllers such as the Xbox Adaptive Controller. [13]

How a user moves around in a VR environment will also depend on their position in the physical environment.  For example on the Meta Quest 3 there are three modes of physical position adjustments that can adapt to the user’s position: standing, sitting and supine. These position adjustments however are not available in every VR experience.

Within a VR environment there are currently two methods of moving: (1) in a traditional, linear manner (e.g. using a controller to move your avatar) and (2) teleporting. Each creates it own accessible challenges from motion sickness from the vestibular conflict of virtually moving but not physically to disorientation from a sudden change of location. Just as in the physical environment how a space is designed can create its own barriers. For example, if teleporting is not a comfortable experience how do you move between spaces where there are physical barriers in the way? Being a virtual environment programmatically this can often be overcome by modifying the environment itself as in the following example from Mozilla Hubs.

Where the use of physical controllers is not possible VR hardware can now support the remapping of buttons (e.g. if the user only has the functional use of one hand), voice commands, gestures or eye gaze to activate on screen interactive elements. [14]

Hearing

The use of binaural sound in VR platforms, or positional sound, provides another significant impact on making such environments immersive in comparison to traditional 2D meeting platforms.

Whilst VR platforms create a simulated environment it is still possible on some platforms to integrate a live, embedded video feed.  This is certainly applicable where client may have a hearing impairment and rely on the ability to access lip reading or a third party Auslan interpreter.

Captioning (closed or open) is available in the majority of VR platforms.  In comparison to 2D meeting platforms captioning is often only available as a paid service or subscription and poses additional challenges in terms of placement in relation to the user.

Vision

Virtual reality environments are a visually rich environment and create substantial barriers for people with vision loss.  Attempting to access such environments, especially with the absence of realistic haptic feedback and echo location, can prove problematic.  Researchers at Cornell University have explored the use of “virtual sighted guides”, potentially driven by AI, as one means of providing more equitable access. [15]

Colour correction is now common across a variety of VR headsets and platforms allowing a user with colour blindness to apply a colour filter specific to their needs. Without such filters some content within a VR environment can become inaccessible in the same way interactive elements on a traditional website, that rely on colour to be detected, can render a website unuseable.

Knowing how to move in a VR environment without vision is challenging especially with the (current) lack of auditory and tactile cues provided by elements in the space. The release of Microsoft Mesh [16] and Microsoft Teams integration addresses many vision related demands directly and increases the accessibility of VR environments.  This new metaphor addresses a significant issue for people with vision impairment: the ability for an individual to orientate themselves through sonar feedback. This technology is still in its infancy but its potential changes the way we consider how to move in a VR environment.

Limitations

Several aspects limit the potential use in therapeutic environments in comparison to traditional video conferencing options. 

Firstly, given the high level of visual complexity VR environments require high end computing hardware and significant higher costs for initial purchase.  The most fully immersive VR experience requires dedicated hardware such as VR headsets and a steep learning curve in how to operate. However, unlike earlier iterations these headsets do not require sophisticated programming or technical knowledge to use.

Secondly is the lack of haptic feedback from any immersive experience. Whilst the use of VR hand controllers provide some haptic feedback this is limited to the skin surface holding the actual controller. What haptic feedback options exist are prohibitively expensive and difficult to source in Australia.

Conclusion

Virtual reality platforms are a potential alternative for the provision of therapeutic interventions in comparison to current video conferencing technologies.  The viability of their use depends multiple factors including an understanding of the limitation of the platform including it’s accessibility.

References

1. Hersh, M, Leporini B and Buzzi, M, “A comparison study of disabled people’s experience with the video conferencing tools Zoom, MS TEams, Google Meet and Skype” A comparative study of disabled people’s experiences with the video conferencing tools Zoom, MS Teams, Google Meet and Skype (tandfonline.com)
2. https://www.w3.org/TR/remote-meetings/#types-of-remote-meeting-platforms
3. https://en.wikipedia.org/wiki/Virtual_reality
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6917646/
5. https://www.tandfonline.com/doi/full/10.1080/03069885.2021.1885008
6. https://positivepsychology.com/virtual-reality-therapy/
7. https://arpost.co/2022/09/09/enhancing-immersive-experiences-spatial-audio/
8. https://www.w3.org/TR/xaur/
9. https://hubs.mozilla.com/
10. https://hello.vrchat.com/
11. https://engagevr.io/
12. https://www.meetinvr.com/
13. https://www.microsoft.com/en-au/d/xbox-adaptive-controller/8nsdbhz1n3d8
14. https://www.researchgate.net/figure/Three-gestures-supported-by-Meta-Quest-2-4-a-point-and-pinch-b-pinch-and-scroll_fig1_372572118
15. https://xraccess.org/sighted-guides-to-enhance-accessibility-for-blind-and-low-vision-people-in-vr/
16. https://www.microsoft.com/en-us/microsoft-teams/microsoft-mesh