2ViTA-B Cognitive: A Virtual Assistant for Cognitive Rehabilitation
Nicoletta Balletti
1
, Antonella Cascitelli
2
, Patrizia Gabrieli
2
, Aldo Lazich
1
,
Gianluca Maria Marcilli
3
, Marco Notarantonio
1
, Rocco Oliveto
4,5
and Daniela Scognamiglio
2
1
Defense Veteran Center, Ministry of Defense, Rome, Italy
2
Atlantica Digital Spa, Rome, Italy
3
National Armaments Directorate (NAVARM), Ministry of Defense, Rome, Italy
4
University of Molise, Pesche (IS), Italy
5
Datasound srl, Spin-off of the University of Molise, Pesche (IS), Italy
Keywords: Cognitive Rehabilitation, Medical Support, Home Rehabilitation, Virtual Reality, Meta Quest 2, EEG.
Abstract: We present 2ViTA-B Cognitive, an advanced virtual assistant designed to effectively address emotional
functioning disorders and enhance emotional well-being. The system is carefully crafted to engage with users
and positively influence their emotions, supporting cognitive rehabilitation in both real and virtual
environments. A controlled experiment has been conducted to evaluate the benefits of the proposed system.
The results provide valuable insights into the potential benefits of immersive virtual reality interventions for
improving emotional well-being and cognitive functions. These findings suggest promising avenues for
advancements in therapeutic practices within this field.
1 INTRODUCTION
Affectivity, covering emotions, mood, attitudes, and
interpersonal relations, significantly influences
behavior, well-being, and cognition (Sander &
Scherer, 2014). Affective cognition specifically
pertains to cognitive functions responsible for
processing stimuli with emotional significance
(Roiser & Sahakian, 2013). In scientific research,
there is an increasing research interest in treating
emotional disorders to improve affective functions
and reduce symptoms, focusing on the impact of
stimuli on emotions and mood.
These stimuli can be administered through both
analog and digital means, and more recently, virtual
reality (VR) presentations have gained attention
(Tageldeen et al., 2017), (Vargas-Orjuela et al.,
2017), (Wiederhold et al., 2017). Numerous studies
and research initiatives have explored how virtual
reality and related technologies can enhance mental
well-being (Gaggioli et al., 2014; Oing & Prescott,
2018; Pallavicini et al., 2016). These efforts often
align with the principles of positive psychology, a
specialized field of clinical psychology focused on
mental well-being and human happiness (Huppert &
So, 2013). Also, VR is able to improve mood,
reducing conditions such as fear, stress, depression,
and anxiety (Pizzoli et al., 2019) (Malloy & Milling,
2010) (Garrett et al., 2017) (Wiederhold et al., 2014)
(Liu et al., 2015) (Felnhofer et al., 2019) and induce
positive emotions (Baños et al., 2014; Felnhofer et al.,
2015; Herrero et al., 2014). Furthermore, VR has
been applied to the treatment of anxiety disorders,
including phobias, generalized anxiety, social
anxiety, post-traumatic stress disorder, and
obsessive-compulsive disorder (Gerardi et al., 2008;
Oing & Prescott, 2018; Pallavicini et al., 2009; Rizzo
et al., 2010; Takac et al., 2019).
The unique ability of VR to modulate emotions
stems from its highly immersive 360° artificial
environment, offering greater engagement and
emotional impact than other methods (Browning et
al., 2020). However, the use of VR is not without its
drawbacks, as it can lead to side effects such as
nausea, dizziness, and discomfort, which may impact
the quality of the VR experience, depending on
individuals’ sensitivity.
In line with this research direction, we introduce
2ViTA-B Cognitive, a new software/hardware
system, designed for psychological and emotional
Balletti, N., Cascitelli, A., Gabrieli, P., Lazich, A., Marcilli, G., Notarantonio, M., Oliveto, R. and Scognamiglio, D.
2ViTA-B Cognitive: A Virtual Assistant for Cognitive Rehabilitation.
DOI: 10.5220/0012396900003657
Paper published under CC license (CC BY-NC-ND 4.0)
In Proceedings of the 17th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2024) - Volume 2, pages 545-553
ISBN: 978-989-758-688-0; ISSN: 2184-4305
Proceedings Copyright © 2024 by SCITEPRESS – Science and Technology Publications, Lda.
545

engagement, using innovative stimuli to influence
emotions. With 2ViTA-B Cognitive therapists can
customize stimuli sequences, including images,
sounds, and videos, in either standard mode or VR for
cognitive rehabilitation. The results of a controlled
experimented, conducted with 16 participants,
revealed the effectiveness of 2ViTA-B Cognitive, and
in particular the effectiveness of VR, in enhancing
emotional well-being and cognitive functions.
2 RELATED WORKS
Studies have shown that emotions triggered by
images correlate with physical and physiological
parameters, such as facial expressions (Ekman,
1993), heart rate, and body temperature (Davidson et
al., 2009). The valence and activation of images can
be measured by methods such as facial
electromyography, electrocardiogram and skin
conductance (M. M. Bradley et al., 2001) (Lang et al.,
1993). Several scientifically validated sets of images
are available to evoke emotions (Lang et al., 1997)
(Marchewka et al., 2014).
However, static images tend to have less
emotional impact than dynamic stimuli like video or
music (Westermann et al., 1996). For this reason,
numerous studies have delved into the impact of
music and other sounds, including speech, noises, and
sound environments, on the human brain and
psychology, particularly in relation to emotions and
mood (Rauscher, 1994), (Wang & Cheong, 2006).
These acoustic stimuli can induce changes in skin
conductance and heart rate as a physiological
response (Dillman Carpentier & Potter, 2007),
(Khalfa et al., 2002), (Riganello et al., 2010).
While there are few validated sound collections in
the literature, some studies creating specific sounds
or extracting internet-based sounds validated for user
preferences (Greer et al., 2019; Koelsch et al., 2019).
Two libraries, validated using physiological
measures, are commonly used (Koelstra et al., 2011)
(Grewe et al., 2011).
Videos – known to evoke stronger emotions than
images or sounds due to their multimodal, dynamic,
and immersive nature – are effective in inducing
emotional states (Gross & Levenson, 1995; Tempesta
et al., 2017). Video stimuli composed of film
fragments are often used, but sometimes amateur
online videos are also utilized (Samson et al., 2016),
(Knautz & Stock, 2011). Video stimulus libraries
include various movie categories to evoke a wide
range of emotions, from simple ones like anger and
disgust to complex ones like joy and amusement
(Schaefer et al., 2010).
In Ulrich et al. (1991) the authors have opted to
use natural environments as stimuli in virtual reality.
This choice is rooted in the Stress Reduction Theory,
which posits that exposure to natural settings can
activate the parasympathetic system, leading to
reduced feelings of fear, anger, and stress.
3 2ViTA-B COGNITIVE SYSTEM
2ViTA-B Cognitive is a comprehensive hardware and
software system aimed at enhancing mental well-
being and reducing stress. It uses multimedia
sequences in standard and VR modes to evoke
specific emotions and offers daily cognitive training
activities. The system reads physiological data from
wearables, applying AI for therapist decision support
and includes gamification for user engagement. It has
three user roles: administrators manage content,
specialists handle rehabilitation plans, and patients
participate in training.
Patients are enrolled into the system by the
Administrator. During the enrolment phase, patients
must complete an anamnesis questionnaire, which
therapists use to gather information on the subject’s
current and past health status.
Multimedia elements are added to the system
libraries by Administrators, and they are used by
psychologists to create multisensory stimulus
sequences for individuals. These multimedia
elements include images, sounds, videos, and
immersive VR scenes. Patients can also upload
multimedia elements from their personal library to the
system, but these can only be used within sequences
after therapist validation.
When creating a sequence, as shown in Figure 1,
psychologists are aided by the 2ViTA-B virtual
assistant, which suggests additional elements
matching the chosen ones in terms of valence and
arousal. However, the psychologist has the final word
Figure 1: Definition of a sequence for an administration.
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in accepting or rejecting these system-suggested
elements.
A typical administration of the 2ViTA-B
Cognitive system comprises three essential steps:
1. The preliminary screening questionnaire:
Perceived Stress Scale (PSS-10).
2. Three self-assessment questionnaires: Positive
And Negative Affect Scale (PANAS), Self-
Assessment Manikins (SAM), and Global
Vigor-Affect Scale (GVAS).
3. A sequence of media items created by the
psychologist.
The PSS-10 assesses an individual’s perceived
stress (Cohen et al., 1983), while the PANAS
questionnaire defines the subject’s affective state
(Watson et al., 1988). The SAM self-assessment scale
measures emotional reactions to stimuli (M. M.
Bradley & Lang, 1994).
Multimedia sequences can be divided into two
groups: standard and virtual reality. The standard
sequence consists of positively valenced images,
sounds, and videos from validated sources. In the
current implementation of the system there is a library
composed of thirty-two images from the International
Affective Picture System (IAPS) catalogue (Lang et
al., 1997), twenty sounds from the International
Affective Digital Sounds (IADS) (M. Bradley &
Lang, 1999), and five videos validated by (Maffei &
Angrilli, 2019). The multimedia sequence consisted
of a random presentation of thirty-two images, twenty
sounds, and two videos, all of which had a valence
rating greater than 6.5. The display of images and
sounds each lasted six seconds, while the videos had
a duration of approximately two minutes. A two-
second black screen interval separated each stimulus.
The total duration of the entire sequence was
approximately twelve minutes.
Alternatively, the administration can be
performed by using virtual reality. In this case, a VR
visor is required. The current implementation of the
2ViTA-B Cognitive is based on the Oculus Quest 2.
The virtual sequence offers two immersive reality
scenes – one featuring a natural landscape (see Figure
2) and the other taking the viewer into a spacecraft in
space (see Figure 3). The choice of these settings is
not random: several studies have demonstrated a
positive effect of natural environments on affectivity
(Browning et al., 2020), (Ulrich et al., 1991), (Huang
et al., 2020).
In the first virtual scene, which we will hereafter
refer to as the “static scene,” our focus was on
achieving realism, with a dedicated effort to optimize
the scene’s quality and performance. In contrast, the
second scene, which we will also term as the
“dynamic scene,” offers patients the ability to
navigate within the spacecraft, interact with specific
objects, and embark on a virtual space exploration
journey.
Figure 2: The first virtual scene: static scene.
Figure 3: The second virtual scene: dynamic scene.
The system alerts therapists when a new session
starts, offering the option to monitor patient progress
in real-time or later. This includes a dashboard
showing patient’s profile, medical history, responses,
vital parameters, and multimedia sequences (see
Figure 4 and Figure 5).
Figure 4: Patient’s profile visualization during the
execution of administration.
Post-session, therapists can give numerical
evaluations and feedback for each session. They can
assess a patient’s progress by comparing multiple
sessions, assisted by an AI algorithm showing score
trends. Additionally, the system provides optional
2ViTA-B Cognitive: A Virtual Assistant for Cognitive Rehabilitation
547

blockchain verification to ensure data integrity. On
the other hand, after a session patients can access their
administration history, including the date, time, and
therapist evaluations, and track progress through an
avatar-based path in their profile.
Figure 5: Patient’s vital parameters monitoring during an
administration.
4 EMPIRICAL STUDY
The experiment we conducted was designed to
evaluate the impact of hematogenic stimulation on
cognitive attention functions. This section presents
the experiment design and the outcomes, which serve
to validate the 2ViTA-B Cognitive system, and
particularly the effectiveness of using virtual reality
during an administration.
4.1 Study Definition and Context
The objective of this study was to analyze the use of
virtual reality in the context of cognitive
rehabilitation activities and evaluate its potential
impact on the emotional well-being and affectivity of
the assisted users. To assess the advantages of
employing virtual reality, a controlled experiment
was conducted.
In the context of the experiment, participants
interacted with two versions of the virtual assistant.
In the first version of 2ViTA-B Cognitive participants
engaged in cognitive rehabilitation sessions using
multimedia content. This version was designed to
modulate the subjects’ affect, with a particular focus
on reducing negative affect levels (Burattini et al.,
2021). The second is the VR version. In which
participants were involved in virtual reality sessions
aimed at modulating affectivity and enhancing
cognitive functions.
The experiment involved 16 healthy participants
(13 males and 3 females) aged between 22 and 63,
recruited with the assistance of the Italian Ministry of
Defense using convenience sampling.
The participants were divided into two groups and
instructed to complete two separate rehabilitation
sessions using 2ViTA-B Cognitive once and
2ViTA-B Cognitive VR the other time. As said
before, the Oculus Meta Quest 2 headset is used to
experience immersive sessions. Also, independently
by the version of the 2ViTA-B Cognitive system, the
participants wore the Muse S (Gen 2) EEG band to
assess their brain activity (i.e., selective attention).
4.2 Experimental Design
As previously mentioned, the controlled experiment
is designed to ascertain whether the incorporation of
virtual reality into cognitive rehabilitation activities
yields enhancements in participants’ affectivity and
cognitive functions. Additionally, we are keen on
pinpointing methodologies for gauging the positive
impact of this technology on therapeutic approaches
and the well-being of users.
As a result, we formulate the following two null
hypotheses:
o H
01
: The use of 2ViTA-B Cognitive VR does
not result in enhancements in self-
assessment affectiveness.
o H
02
: The use of 2ViTA-B Cognitive VR does
not lead to improvements in participants’
attention.
Thus, this study is guided by the following
research questions:
o RQ
1
: Does the use of 2ViTA-B Cognitive VR
improve self-assessment affectiveness?
o RQ
2
: Does the use of 2ViTA-B Cognitive VR
improve participants’ attention?
To answer these questions, we defined and
controlled several independent variables and defined
and observed several dependent variables. The
independent variables we defined and controlled are
described below. Treatment variable identifies the
type of treatment utilized. It distinguishes between
the conventional version of our 2ViTA-B Cognitive
software (referred to as “Standard”), which allows
users to access multimedia content through a standard
web browser, and the new 2ViTA-B Cognitive VR
(referred to as “VR”) version, offering immersive
experiences through virtual reality. Administration
represents the two administrations selected, denoted
with “S1” and “S2”.
Instead, the dependent variables we defined and
observed are outlined hereafter. Attention is defined
as the cognitive process of selecting specific
environmental stimuli from many available options at
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a given time while disregarding others. We assessed
this cognitive function using the cognitive Stroop test
(Stroop, 1935) and by examining
electroencephalography (EEG) biosignals recorded
during the administration sessions. Self-assessment
affectiveness pertains to the outcomes derived from
self-assessment questionnaires employed to evaluate
the affectivity of the participating subjects.
Specifically, our goal was to gauge the impact of
stimulation on affectivity by administering
questionnaires before and after the presentation of
multimedia sequences or immersive experiences.
This allowed us to calculate the difference in
responses and ascertain the extent to which the
stimulus influenced the emotions of participants.
Given these defined variables, the experiment’s
design is detailed in Table 1.
Table 1: Experiment design.
Group A Group B
S1 VR Standard
S2 Standard VR
In this trial, the combinations explored involved
Group A, who initiated with a VR session followed
by a Standard administration, while Group B
followed the reverse order. A substantial temporal
gap (i.e., one/two days) was introduced between the
two administrations to mitigate potential overlapping
effects of the sessions.
This strategic design facilitated the examination
of distinctions between Standard and VR
administrations, considering diverse ordering
scenarios within the two groups. By systematically
analyzing these combinations, our aim was to detect
the effect of VR without any bias caused by the order
of the administrations.
4.3 Preparation
Individuals of both genders were approached through
direct acquaintances and personal connections of the
researchers involved. Those who expressed a
voluntary interest in participating in the trial without
any form of compensation were requested to
complete a medical history questionnaire and the
PSS-10 stress assessment.
All participants confirmed that they had no
existing medical conditions, no history of
psychological disorders, were not taking any
medications, did not engage in excessive alcohol
consumption, and did not use recreational drugs.
Prior to the commencement of the study, all
participants provided their informed consent. The
experimentation received approval from the Ethical
Committees of the “Celio” Military Policlinic.
The experimentation was conducted in the
laboratories of the “Veterans Defence Centre” in
Rome, Italy. Before the start of the experimentation,
volunteers were briefed on the administration
process, how to utilize the devices (included the VR
headset), and the underlying rationale behind the
Stroop test.
4.4 Experiment Material and
Execution
As previously mentioned, participants were engaged
in two experimental sessions: one involving a
cognitive administration in the standard version and
the other in virtual reality. Efforts were made to
evenly distribute the participants into the two
experimental groups, A and B (see Table 1).
The experimental protocol employed in the study
encompassed three successive phases. These phases
are described below. (i) PRE: participants donned the
vital parameter monitoring devices, GSR, and fitness
tracker. They subsequently completed the PANAS,
GVAS, and SAM questionnaires. Following this,
they wore the EEG device and underwent a brief
calibration of the instrument. To verify correct
positioning, the device prompted participants to relax
for 30 seconds and then concentrate for an additional
30 seconds. Upon completing the calibration, the
cognitive Stroop test was administered, which could
be conducted in real or virtual reality depending on
the treatment. (ii) STIM: in this phase participants
viewed the sequence of multimedia elements or
immersive reality scenes, depending – once again –
by the treatment. (iii) POST: this phase mirrored the
PRE phase, with the same steps performed in the
same order, i.e., participants filled out the PANAS,
GVAS, and SAM questionnaires once more and
repeated the Stroop test. In the case of virtual
administration, participants were required to briefly
remove the headset before completing the three
questionnaires and then put it back on to perform the
Stroop test before concluding the administration.
After the execution of the experimentation, we
gathered the results from the self-assessment
questionnaires, which were used to assess affectivity
(PANAS), as well as the data from the Stroop test for
the evaluation of selective attention. Specifically, for
the Stroop test, we calculate a score by assigning 1
point for each correct answer, -1 point for each
incorrect answer, and 0 points for unanswered
questions.
2ViTA-B Cognitive: A Virtual Assistant for Cognitive Rehabilitation
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Additionally, bio-signal parameters recorded by
the EEG wearable device were collected.
Specifically, we collected data on Beta waves, which
tend to increase during periods of high mental
activity, like reading and conversation. These waves
are associated with attention, complex problem-
solving, and various cognitive processes, typically
falling within the range of 0.1 to 30 Hz. To facilitate
result comparisons, we utilized the Beta score
provided by the mind band vendor. This score is a
normalized value that falls within the range of 0 to 1.
After collecting the data, we performed
descriptive statistical analysis and examined
statistical differences using a one-tailed Wilcoxon
signed-rank test. We set a significance level of 5%
(p-value = 0.05) to determine whether to reject our
null hypotheses.
4.5 Experiment Results
In the following we present the results obtained with
the aim of addressing our research questions and
testing our null hypotheses.
RQ
1
: Does the use of 2Vita-B Cognitive VR
improve self-assessment affectiveness? Table 2
presents the descriptive statistics of the scores
computed from the PANAS questionnaires in both the
treatment (VR or Standard). The scores represent the
difference between the POST and PRE executions for
administrations S1 and S2. The table also reports the
difference of the scores achieved in the two treatments.
Table 2: Descriptive statistics of PANAS questionnaire. A
high score suggests a positive emotional state, while a low
score suggests a less positive or more neutral emotional
state.
Treatment
Difference
VR - Standard
VR Standard
Mean 39.37 -12.50 51.88
Median 35.00 -10.00 40.00
Std.dev. 57.90 56.74 73.50
Based on the results of the self-assessment
affectiveness questionnaire, it is evident that
immersive virtual reality experiences outperformed
the standard administration in significantly enhancing
subjects’ perceived affectivity. Specifically, the mean
score achieved with the VR treatment is 39.37, while
with the standard treatment, the score is notably
lower, at -12.50. It is noteworthy that one subject
reported the lowest score of -50 among all
participants in the VR treatment group. This decrease
in score can be attributed to her experience of nausea
during the VR administration.
The difference between the two treatments is not
only substantial but also statistically significant.
When analyzing the one-tailed Wilcoxon signed-rank
test, we obtain a p-value of 0.006 (with z at -2.54 and
W at 12). Therefore, we can confidently reject the null
hypothesis H
01
and conclude that the use of 2ViTA-B
Cognitive VR results in a substantial improvement
in self-assessment affectiveness.
RQ
2
: Does the use of 2Vita-B Cognitive VR
improve participants’ attention? Table 3 provides
descriptive statistics for the Stroop test scores,
including data for both treatment groups and the
difference between the two treatments.
Table 3: Descriptive statistics of the Stroop test score
differences, calculated as the difference between the Stroop
test scores before and after the administrations.
Treatment Difference
VR - Standard
VR Standard
Mean 2.86 0.50 2.38
Median 2.00 0.50 1.00
Std.dev. 3.56 2.45 4.32
Once more, we have observed a greater number
of correct responses during the VR administrations,
signifying a significant increase in the number of
participating subjects experiencing benefits from the
immersive experience-based therapy. Such a
difference is evident but non statistically significant.
When analyzing the one-tailed Wilcoxon signed-rank
test, we obtain a p-value of 0.05 (with z at -1.61 and
W at 22.5). Therefore, we cannot reject also the null
hypothesis H
02
and we cannot conclude that the use
of 2ViTA-B Cognitive VR improves participants’
attention measured through the Stroop test.
Similar considerations apply to the EEG analysis.
Therefore, based on the results achieved we cannot
reject the null hypothesis H02 also considering the
EEG Beta score. Thus, we cannot conclude that the
use of 2ViTA-B Cognitive VR improves participants’
attention measured through EEG beta score.
Table 4 reveals that VR does not contribute to
enhancing participants’ attention. In fact, after the VR
administration, subjects’ attention slightly decreases,
while with the standard treatment, the difference
between the beta scores before and after
administration is close to zero. When analyzing the
one-tailed Wilcoxon signed-rank test, we obtain a p-
value of 0.12 (with z at - 1.18 and W at 24). This result
suggests that while VR is effective in eliciting
positive emotions, it might also impose a higher
cognitive workload, thereby potentially negatively
affecting attention.
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Table 4: Descriptive statistics of EEG Beta score
differences, calculated as the difference between the beta
scores before and after the administrations.
Treatment
Difference
VR - Standard
VR Standard
Mean -0.11 0.02 -0.13
Median -0.40 0.01 -0.06
Std.dev. 0.27 0.23 0.45
Therefore, based on the results achieved we
cannot reject the null hypothesis H
02
also considering
the EEG Beta score. Thus, we cannot conclude that
the use of 2ViTA-B Cognitive VR improves
participants’ attention measured through EEG beta
score.
4.6 Threats to Validity
The primary threat to the validity of the study arises
from the representativeness of the participants. The
sample size of 16 participants may not be sufficient
to ensure the robustness of the results. While this is a
common challenge in human experiments, recruiting
individuals who are willing to participate without any
form of compensation was particularly challenging,
especially considering each participant underwent a
double experimental session.
Additionally, the gender distribution among
participants is notably skewed towards males.
Research has shown that emotional responses can
vary based on gender, potentially influencing the data
collected and subsequent results.
Finally, it is crucial to note that the system is still
in its early testing stages and has not yet received
medical device certification. As a result, our
experimentation was limited to enrolling only healthy
individuals.
5 CONCLUSION
We introduced 2ViTA-B Cognitive, a virtual assistant
aimed at positively influencing human emotions. A
controlled experiment with sixteen participants
evaluated its effectiveness in cognitive rehabilitation
using VR. The results showed a positive effect on
affectivity but less efficiency in enhancing attention.
These findings suggest avenues for improving
2ViTA-B, including replicating the experiment and
integrating EEG data with biofeedback techniques in
VR environments to enhance participant awareness of
their cognitive state.
ACKNOWLEDGEMENT
The 2ViTA-B project was developed as part of the
National Plan of Military Research (PNRM), with
funding being provided by the Ministry of Defence.
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