SAR-ACT: A Spatial Augmented Reality Approach to Cognitive Therapy

Rui Silva

1,2 a

and Paulo Menezes

1,2 b

Department of Electrical and Computer Engineering, University of Coimbra, Coimbra, Portugal

Institute of Systems and Robotics, University of Coimbra, Coimbra, Portugal

Keywords:

Interactive Environments, Spatial Augmented Reality, Cognitive Therapy, Elderly Care, Serious Games.

Abstract:

It is predicted that longevity will keep increasing in the forthcoming centuries. Thus, the elder demographic

will grow, and the surge of age-related diseases will become more prevalent. These conditions can affect

autonomy and affect the quality of life by reducing cognitive and motor capacities. While medical interven-

tions have been progressing, preventive and restorative therapies remain an essential part of the rehabilitation

process. Consequently, there is a high demand for tools that can help enhance the effectiveness of therapy.

This work proposes a spatial augmented reality framework for creating card-based serious games for cognitive

therapy. The objectives of the project are: to use this technology to facilitate the adaptability and person-

alization of serious games, to create an engaging tool that helps mitigate frustration in therapy, and to help

therapists to keep track of patients’ progress to adapt future sessions. Two serious games were developed to

test the applicability of the framework. An analysis of the work was made by a specialist that concluded it had

accomplished the desired objectives and that it has promising results for future validation in cognitive therapy.

1 INTRODUCTION

Since the middle of the XIX century, longevity around

the world has increased at an exceptional rate, evolv-

ing from the global average of 29 to 73 years old (in

2019) (Max Roser and Ritchie, 2013). According to

United Nations’ predictions, life expectancy is going

to surpass 100 years by 2300 (United Nations Depart-

ment of Economic and Social Affairs of the United

Nations, 2004). This data gives assurance that the

world’s health will continue its ascending trend, but

also warns us that the population will get consider-

ably older. While it is positive news that people will

have longer-lasting lives, it raises a question on how

will the quality of these lives be (Robine et al., 2009).

Age-related health issues will surge with senescence.

These conditions can occur in multiples ways affect-

ing motor and cognitive skills, and if we do not work

on trying to improve our approach to them, whether

being with lifestyle changes, medically, pharmaceu-

tically and therapeutically, then longer lives will not

translate to healthy lives (Jaul and Barron, 2017). The

surge of neurodegenerative Alzheimer’s or Parkin-

son’s disease and traumatic complications such as

strokes cause cognition to decay. They can signiﬁ-

https://orcid.org/0000-0003-4581-7375

https://orcid.org/0000-0002-4903-3554

cantly impair the execution of daily tasks, causing el-

ders to lose autonomy and, consequently, their quality

of life (Mioshi et al., 2007).

Cognitive impairments can manifest themselves in

various areas such as attention, memory, judgment,

decision making, logic and abstract thinking, orien-

tation, and language (Glisky, 2019). When patients

manifest symptoms of cognitive decay, it is crucial

to diagnose their condition and evaluate their cogni-

tive skills early to counteract the potential evolution

of the disease (Albert et al., 2011; Svenningsson et al.,

2012). Usually, specialists in areas such as neuropsy-

chology, map a neuropsychological proﬁle by per-

forming examinations to evaluate the patient’s cog-

nitive skills (Harvey, 2012; Yi and Belkonen, 2011).

Following this assessment, they usually establish an

individualized rehabilitation plan (IRP) for cognitive

therapy (CT). This data can also help doctors identify

the disease and its stage of development, and to pre-

scribe appropriate pharmaceuticals. The IRP should

result in a series of restorative and compensatory ther-

apeutic activities that can help the elder rehabilitate

functions or delay the development of the disease.

It is well established that therapies should start as

early as possible, before the brain loses its plastic-

ity, especially with the progression of neurodegener-

ative diseases (Choi and Twamley, 2013; Clare et al.,

292

Silva, R. and Menezes, P.

SAR-ACT: A Spatial Augmented Reality Approach to Cognitive Therapy.

DOI: 10.5220/0010322802920299

In Proceedings of the 16th International Joint Conference on Computer Vision, Imaging and Computer Graphics Theory and Applications (VISIGRAPP 2021) - Volume 1: GRAPP, pages

292-299

ISBN: 978-989-758-488-6

2019; Niu et al., 2010). IRPs should include tasks

that stimulate the brain in the affected areas and de-

lay cognitive decline. They should propose methods

to cope with areas where faculties are limited, pro-

moting strategies for enduring plausible advances of

the disease, ensuring patient’s autonomy for as long

as possible.

Serious Games (SGs) can play the necessary ther-

apeutic roles by providing stimuli that aim at sus-

taining executive functions, including visual process-

ing, working memory, attention, language, and ver-

bal communication. Board-, card-, and computer-

based activities can be designed purposely to attain

these therapeutic goals while simultaneously trying to

engage the patients through the exploration of game

principles (Kueider et al., 2012; Lamb et al., 2018;

Peretz et al., 2011; Rocha et al., 2015). Recent

works have explored emerging technologies such as

virtual, augmented and mixed reality (VR, AR, MR)

in this area, intending to bring new tools to the path

of CT (Ferreira and Menezes, 2020a; Ferreira and

Menezes, 2020b; Gamberini et al., 2009; Grealy et al.,

1999; Kirner and Kirner, 2011).

While VR and AR offer great possibilities, the use

of head-mounted devices may lead to discomfort and

rejection by some people. More ecologic approaches

may be achieved with the use of Spatial Augmented

Reality (SAR) principles, integrating, in a naturalis-

tic way, computer-generated graphics with the users’

own physical space, by the use of video mapping tech-

niques (Bimber and Raskar, 2005). Using it, existing

objects can be hidden, highlighted, or have their ap-

pearance modiﬁed to fulﬁll the game’s objectives.

This work comes inline with the above and pro-

poses a framework to support the development of

SAR-based Serious Games for cognitive stimulation.

1.1 Paper Structure

The remainder of this paper is organized as follows:

Section 2 presents an overview of the research con-

ducted in more conventional and recent works in the

area of SGs for CT; section 3 describes a summary of

the process for designing an SG for CT, the challenges

and requirements that are taken into account for out-

lining its development, and illustrates the framework

concept, its development and implementation; section

4 demonstrates the SGs built, describes their function-

ing, and their areas of application. Section 5 com-

prises an overview of a specialist that corroborates the

developed works. A conclusion is made for the po-

tential of the concepts presented through an objective

analysis of the framework and respective SGs built,

comparing them with current and emerging tools for

CT in section 6. In this section, it is also made clear

the intention of future work on this platform.

2 SERIOUS GAMES AND

COGNITIVE THERAPIES

Cognitive exercises frequently simulate everyday

challenges by using various and speciﬁc tools (Faria

et al., 2016; Kurz et al., 2009). These tools can pro-

vide stimuli that help patients to relearn the use of

their lost or degrading abilities. As for every learning

process, it requires consistent repetitions with slight

variations of the same activities (Jeffrey A. Kleim and

Jones, 2008). The repetitive nature of the exercises

and the slow recovery often lead to frustration and

tediousness. Therefore, patients can become unmo-

tivated and unwilling to keep up with therapies.

Unsurprisingly, CT’s effectiveness is affected by

the patient’s capacity to endure his assigned exer-

cises (Choi and Twamley, 2013). The main obsta-

cle in developing tools for CT resides in ﬁnding two

balances: keeping an acceptable challenge threshold

that induces evolution in players performance while

not being frustrating enough to demotivate, and using

mechanisms in game design to lessen the impact of

repetition in therapeutic tasks, keeping the player en-

gaged and entertained (Burke et al., 2009). By main-

taining the patient engaged, these tools will help the

therapist become free to focus on other aspects, such

as assessing performance evolution and planning the

subsequent exercises. Through the fulﬁlment of these

objectives, the role of a therapeutic tool is then ac-

complished, and its application will promote the ef-

fectiveness of the IRP.

The design of the SG for CT, for the reasons de-

tailed above, is a crucial stage of development. When

idealising a game, the developer should focus on one

or more of the cognitive deﬁcits it will address. To en-

sure development will result in useful tools, a strategy

may be to base the project on existing certiﬁed tools

for the intended therapeutic purpose. Then, new cre-

ative outlooks can be added through new technologies

while keeping the target at the requirements.

Since the patients’ conditions can be varied, their

IRPs can be considerably different even for the same

diseases. It can be challenging for therapists to ﬁnd

tools that adapt to each speciﬁc patient’s needs. By

taking advantage of modern tools, when designing an

SG, one should concentrate on adaptability, customi-

sation, and personalisation (Burke et al., 2009; Faria

et al., 2018). The bigger the granularity of the change-

able elements of the SG is, the easier it will be to adapt

to different IRPs, and the more will it suit each pa-

SAR-ACT: A Spatial Augmented Reality Approach to Cognitive Therapy

293

Figure 1: Sgs’ iterative cycle.

tient’s performance and evolution (Burke et al., 2009;

Tong et al., 2014). With speciﬁc personalisation of the

game, by including components of the patient’s life,

like personal objects, or recognisable faces or places,

one can assure that the player will gain some level

of ownership over the therapeutic activities and, this

way, achieve higher levels of engagement and moti-

vation (Faria et al., 2018).

The concept of SGs as therapeutic tools also pro-

poses the gamiﬁcation of therapy to achieve better

entertainment, engagement, motivation, and a sense

of progression. The developer should adopt elements

from traditional game principles like score, time, dif-

ﬁculty, and levels. These components can also help

adapt the game to the player and translate their per-

formance while doing therapy. For example, the ther-

apist can specify a game, its difﬁculty level, and other

parameters for a patient to play during a therapy ses-

sion. Afterward, by analysing the attained score and

execution time, it is possible to infer about perfor-

mance and/or recovery. This way, the SG promotes

changeable iterations of therapy sessions that will

consecutively adapt to the patient’s condition.

To keep players captivated while interacting with

the game, the interface may provide visual and au-

dio stimulus, but their inclusion must be carefully

analysed to make sure they enable the intended

goals. Therefore, a cycle of playing, giving feedback,

analysing performance, and adapting the game is crit-

ical to keep in mind the objectives while establishing

the game design, as portrayed in Figure 1. To allow

every type of person to use it, the game should be ﬂex-

ible and customisable as much as possible. To this

end, it is important to avoid complex control schemes

and dynamics that would be hard to tune or adapt by

the therapist or caregiver.

3 PROPOSING A SAR-BASED

FRAMEWORK FOR CT

From the above, and approaching the available tech-

nological solutions for developing tools supporting

cognitive therapies, spatial augmented reality appears

as an interesting candidate. Contrary to other tech-

nologies, in SAR interfaces the user can beneﬁt from

a wide ﬁeld of view, and the interaction with the en-

vironment can be made through the handling of phys-

ical objects. Since elderly citizens are most likely not

used to computer interfaces, SAR can present a valid

alternative by replacing accessories like keyboards,

computer mice, HMDs, smartphones or tablets with

real objects that are more familiar to the user. This

particular factor highlighted a great opportunity: to

upgrade the use of common therapeutic card games

with SAR.

By creating a framework that enables and expe-

dites the creation of projection-based serious games

for cognitive therapy for elders, developers can fo-

cus on creating engaging, customizable, and adaptive

environments to enhance therapy effectiveness. This

idea led to the solution proposed in this document, for

which the next section presents the concept and iden-

tiﬁed requirements.

3.1 Concept and Requirements

By using a contemporary outlook at a familiar task,

patients can become more captivated in therapy. Con-

sidering they are already used to these objects and

their manoeuvrability, their adaptation process to the

game should be more straightforward. Ideally, by pro-

viding stated beneﬁts, both cognitive stimuli and ther-

apy efﬁciency can be improved.

The interaction of the SAR Cards Framework

works in the following way:

1. The user will manipulate cards in the projection

area;

2. Cards’ locations are tracked by the system;

3. Projections are adapted based on cards’ locations

and game rules/objectives;

4. Interface provides visual and sound feedback

based on player performance;

5. When the session ends, the player

score/performance is recorded.

A global overview of the SAR Card framework

functionality can be seen in Figure 2.

Given the overall concept of the framework and the

design considerations stated in the previous sections,

the following requirements were deﬁned for the de-

velopment of the framework:

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294

Figure 2: Framework functional overview.

• User manipulation of the cards should be analo-

gous to traditional card games;

• The framework must provide ways to measure

user performance in several parameters to encour-

age self-improvement and for the therapist to an-

alyze;

• Player interactions with the system are made ex-

clusively with cards;

• Inclusion of functionalities to enhance adaption to

the player’s needs;

• Deliver visual and sound feedback to signal if the

user is doing well;

• The system should be ﬂexible and expansible to

promote the development of several types of SGs.

3.2 Implementation

The basic elements required to build a SAR system

are a camera and a video projector. By inquiring about

the logistical aspects of an installation of this kind, it

was concluded that it is common for therapy centres

and assisted living facilities to already own these de-

vices for other purposes, which facilitates the deploy-

ment of the system at reduced cost.

To create the illusion of virtual images registered to

physical cards, the following run-time steps are re-

quired:

1. Obtain cards’ location in the camera’s frame

(tracking stage);

2. Translate their locations to the projector’s frame;

3. Adapt the corresponding images for skewness

(mapping stage);

4. Generate a frame of adapted images in their loca-

tions;

5. Project over the cards in the area of the game, here

deﬁned as the interaction planar surface (IPS).

Firstly, a calibration step is made to retrieve the

relationship between three planar surfaces: the cam-

era’s frame, the interaction planar surface (IPS) and

the projector’s frame. This calibration process con-

sists in capturing the projection of a chessboard pat-

tern onto the IPS from the camera’s point of view

(POV).

It was chosen to use a chessboard pattern due to its

regular geometry that allows robust and accurate fea-

ture extraction. OpenCV

library was used to extract

the position of the corners in the camera’s and pro-

jector’s frames, and to establish a correspondence be-

tween projector and camera frames. This correspon-

dence is obtained in a compact form as a homogra-

phy matrix. This relationship also encompasses the

relation of both of them with the IPS. A diagram of

the projective transformations is presented in Figure

3. With these relations deﬁned, for every point in

the physical IPS delimited by the projection area, it

is possible to ﬁnd its approximate projection on both

the frames of the projector and camera.

Figure 3: Homographies between planar surfaces.

To track the locations of the cards in the game

environment in a quick and ﬂexible manner, each

of them received ﬁducial markers. For the sake

of simplicity the ﬁducial markers choice fell on

ARUco (Romero-Ramirez et al., 2018) as their sup-

port is readily available. Besides the markers, the

cards have a blank area used for the projection of im-

ages as described hereafter.

The overall process cycle is as follows:

1. Track cards marker corners positions (X

, Y

) in

the camera’s frame;

https://opencv.org/

SAR-ACT: A Spatial Augmented Reality Approach to Cognitive Therapy

295

2. Transform corners positions to the projector’s

frame (X

, Y

) (using the matrix H

c→p

obtained in

the calibration stage);

3. Find the perspective transformation between each

marker’s corners of a ﬂat source image of a card

(in pixels) and the correspondent corners in the

projector’s frame;

4. Warp the image to be projected respecting the

found perspective transformation matrix;

5. Add it to the projector’s frame in its correct posi-

tion.

The result will be an overlay image projected onto

the cards disposed on the IPS. This enables that the

projection be perfectly adapted to any moving card,

even if tilted. The projection of the image on a spe-

ciﬁc card is only stopped if its marker becomes ob-

structed in the camera view. The setup used to imple-

ment the SAR environment can be observed in Fig-

ure 4. Figure 5 shows a diagram of the complete pro-

cessing pipeline.

Figure 4: Setup used to implement SAR SGs.

4 DEVELOPED GAMES

To demonstrate the applicability of the framework,

two SGs were implemented. These games were based

on established therapeutic tools, and several features

were added to cater to patient’s needs, while the per-

formance of the player was tracked through the use of

game metrics such as score, difﬁculty and time. The

games were integrated into a web platform (composed

by a database and a website), to provide therapists

with a straightforward way to check on the perfor-

mance development of each patient’s case and decide

how to adapt the next therapeutic tasks.

4.1 SAR Cards Memory Game

Memory card-based games are frequently used as a

tool for CT (Muragaki et al., 2006). Hence, it was

decided to build an enhanced version using SAR.

The patient starts with all the cards facing down

on a table (IPS) and has to ﬁnd all the matching pairs.

The player ﬂips cards up one at the time trying to ﬁnd

a pair, if it is a wrong pair, the last two cards have to

be ﬂipped down again, if the pair is correct, the cards

remain face-up, and the player can proceed to ﬁnd the

next pair. This process is repeated until all the pairs

are found. The game is adaptable in the following

ways:

• The number of cards is dynamic: the more cards,

the harder is the game;

• The images that appear on cards can be com-

pletely customised: this allows us to build many

types of games. E.g. cards appear with pictures

of places, colours, animals, fruits, vegetables, fa-

miliar faces, emotions, and the patient has to ﬁnd

matching pairs; cards appear with names of fa-

miliars or personal objects, and the players have

to ﬁnd the card with the corresponding image;

• The game also has an option for providing initial

help, where the player sees which images are on

each card before turning them down.

While the player interacts with the game, the in-

terface provides positive and negative feedback in the

form of visuals and sound.

When the game ends (all pairs found), a celebra-

tory screen is shown with the player’s score. The

score embodies the number of cards (more is better)

and time of completion (less is better) used in that

session.

The images, the number of cards and help mode

should be controlled by the therapist. After ﬁnishing

a CT session, the scores, time, and number of tries

are sent to the web platform for posterior analysis. A

demonstration of this SG is showed in Figure 6.

4.2 SAR Cards Pong Game

Pong was one of the ﬁrst video-games created, and,

from an early stage, its application for cognitive reha-

bilitation was studied. This study helped to introduce

the concept of SGs for CT (Lynch, 1982).

The objective of the game is to score goals, throw-

ing the ball through the defence line of the other

player while defending our line by bouncing the ball

back with the paddle. The game starts with the ball in

the middle of the ﬁeld and goes into a random direc-

tion, the ball is reset to this position after a goal. A

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296

Figure 5: SAR Cards Framework pipeline.

Figure 6: SAR Cards Memory Game demonstration.

SAR implementation of the game was developed us-

ing the framework, where the player controls its pad-

dle position by moving the card vertically in the IPS.

The game-play focuses on the attention span, re-

action speed and spatial awareness of its patients as it

forces the patient to watch, react and predict the tra-

jectory of the ball. The game can be played alone or

with another player (being the therapist, caregiver or

family member/friend). Multiplayer mode can be an

incentive to play since it can be engaging for the pa-

tient to be accompanied while doing therapy.

The therapist can set the following adaptation fac-

tors:

• Game mode: solo or multiplayer;

• Velocity: the velocity of the ball;

• Bounce dynamics: simple or complex;

• Duration of the game: points or time required to

win the match.

The game provides distinct visual and sound feed-

back of the bounces in the walls, paddles, when there

is a goal and when a match is won. The score, the au-

thor of the goal and winner of the match, is presented

on the IPS in textual form. At the end of a match, the

scores, duration, and number of paddle hits are sent to

the platform so they can be analyzed. A demonstra-

tion of this SG is showed in Figure 7.

4.3 Patient Performance Interface

The games were integrated into a therapy SG perfor-

mance analysis web platform. This platform allows us

to download the right therapy parameters for the right

patient and upload the results of each session. The

results are presented with graphs comparing sessions

for more accessible analysis (Figure 8).

5 ANALYSIS

The design principles, requirements, framework, and

the SGs for CT developed were reviewed during and

after the development process by a Superior Educa-

tion Technician. The demonstrated results received

positive feedback. The reviewer considered that the

objectives set for this work were accomplished from

the point of view of the therapist. In her opinion, the

SGs created with the framework show promising fea-

tures that can possibly help in the effectiveness of CT.

Thus, there should be made experiments with patients

in a real therapeutic environment to test the effective-

ness of this SGs. By the specialist’s perspective, only

with real patient-therapist experience, we will gather

information to adapt the SGs to elders’ needs.

SAR-ACT: A Spatial Augmented Reality Approach to Cognitive Therapy

297

Figure 7: Pong game demonstration.

(a) (b)

Figure 8: Login authentication of therapist (a), and patient performance data (b). Created in (Omitted, 2019).

6 CONCLUSION AND FUTURE

WORK

In this paper, we took from the traditional games used

to train cognition in CT and added features to enhance

adaptability, personalization, engagement and perfor-

mance tracking. These features were implemented

through the use of SAR. This technology requires

only a video-projector, a camera, and makes use of the

familiar physical space of its user. By only using these

components, we highlight the beneﬁts of this type of

system when comparing it with more expensive or

cumbersome methods like AR or VR. It was devel-

oped a framework that makes use of SAR for creat-

ing SGs to facilitate cognitive stimulus. The target

audience was older adults that suffer from cognitive

impairments. Two SGs with different cognition tar-

gets were built to test the framework application. The

games were analysed by a specialist who gave a posi-

tive feedback and reinforced the idea that these games

need to be tested with patients in a real-world con-

text. This feedback assures us that our work reveals

promising results to create new CT tools. The next

step will be to study its impact on a small group of

patients to conﬁrm if these beneﬁts translate to more

effective therapy. It will also be interesting to study

if non-cognitive-deﬁcient elders can beneﬁt from this

type of tool.

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