Respiratory Biofeedback Does Not Facilitate Lowering Arousal in Meditation Through Virtual Reality

Immersive Innovations: Exploring the Diverse Applications of Virtual Reality (VR) in Healthcare

Virtual reality (VR) has experienced a remarkable evolution over recent decades, evolving from its initial applications in specific military domains to becoming a ubiquitous and easily accessible technology. This thorough review delves into the intricate domain of VR within healthcare, seeking to offer a comprehensive understanding of its historical evolution, theoretical foundations, and current adoption status. The examination explores the advantages of VR in enhancing the educational experience for medical students, with a particular focus on skill acquisition and retention. Within this exploration, the review dissects the applications of VR across diverse medical disciplines, highlighting its role in surgical training and anatomy/physiology education. While navigating the expansive landscape of VR, the review addresses challenges related to technology and pedagogy, providing insights into overcoming technical hurdles and seamlessly integrating VR into healthcare practices. Additionally, the review looks ahead to future directions and emerging trends, examining the potential impact of technological advancements and innovative applications in healthcare. This review illuminates the transformative potential of VR as a tool poised to revolutionize healthcare practices.

Virtual Reality Breathing Interventions for Mental Health: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Breathing exercises have been shown to reduce mental health problems among clinical and non-clinical populations. Although virtual reality (VR) breathing interventions are assumed to have potential benefits, it remains unclear whether VR breathing interventions are more effective at improving mental health than non-VR breathing interventions. We conducted a systematic literature search in six electronic databases (Web of Science, PsycINFO, Embase, Cochrane Central Register of Controlled Trials, Scopus, and PubMed) from inception to 30th September, 2022. We included randomized controlled trials in adults evaluating effects of VR compared to non-VR breathing interventions on primary outcomes of mental health (stress, anxiety and mood), and secondary outcomes of physiological stress measures (e.g., heart rate (HR), heart rate variability (HRV)). Within these selected studies, we explored differences in likeability and future use between VR and non-VR breathing interventions. 2.848 records were identified of which 65 full-text articles were assessed. Six RCTs were included, of which five were suitable for meta-analyses. Comparing VR to non-VR breathing interventions, there were no significant differences in overall mental health, stress, anxiety or mood, nor in HR or HRV. There was no evidence that participants liked VR breathing interventions more than non-VR, nor would use them more in the future. These results suggest that there is no evidence that VR breathing interventions are more effective than non-VR in improving mental health outcomes, HR, HRV. Further research is required to determine whether there may be advantages to longer-term VR-implementation and practice, and explore possible mechanisms.

Virtual Reality for Pulmonary Rehabilitation: Comprehensive Review

BACKGROUND

Pulmonary rehabilitation is a vital component of comprehensive care for patients with respiratory conditions, such as lung cancer, chronic obstructive pulmonary disease, and asthma, and those recovering from respiratory diseases like COVID-19. It aims to enhance patients' functional ability and quality of life, and reduce symptoms, such as stress, anxiety, and chronic pain. Virtual reality is a novel technology that offers new opportunities for customized implementation and self-control of pulmonary rehabilitation through patient engagement.

OBJECTIVE

This review focused on all types of virtual reality technologies (nonimmersive, semi-immersive, and fully immersive) that witnessed significant development and were released in the field of pulmonary rehabilitation, including breathing exercises, biofeedback systems, virtual environments for exercise, and educational models.

METHODS

The review screened 7 electronic libraries from 2010 to 2023. The libraries were ACM Digital Library, Google Scholar, IEEE Xplore, MEDLINE, PubMed, Sage, and ScienceDirect. Thematic analysis was used as an additional methodology to classify our findings based on themes. The themes were virtual reality training, interaction, types of virtual environments, effectiveness, feasibility, design strategies, limitations, and future directions.

RESULTS

A total of 2319 articles were identified, and after a detailed screening process, 32 studies were reviewed. Based on the findings of all the studies that were reviewed (29 with a positive label and 3 with a neutral label), virtual reality can be an effective solution for pulmonary rehabilitation in patients with lung cancer, chronic obstructive pulmonary disease, and asthma, and in individuals and children who are dealing with mental health-related disorders, such as anxiety. The outcomes indicated that virtual reality is a reliable and feasible solution for pulmonary rehabilitation. Interventions can provide immersive experiences to patients and offer tailored and engaging rehabilitation that promotes improved functional outcomes of pulmonary rehabilitation, breathing body awareness, and relaxation breathing techniques.

CONCLUSIONS

The identified studies on virtual reality in pulmonary rehabilitation showed that virtual reality holds great promise for improving the outcomes and experiences of patients. The immersive and interactive nature of virtual reality interventions offers a new dimension to traditional rehabilitation approaches, providing personalized exercises and addressing psychological well-being. However, additional research is needed to establish standardized protocols, identify the most effective strategies, and evaluate long-term benefits. As virtual reality technology continues to advance, it has the potential to revolutionize pulmonary rehabilitation and significantly improve the lives of patients with chronic lung diseases.

Dynamics of Physiological, Biochemical and Psychological Markers during Single Session of Virtual Reality-Based Respiratory Biofeedback Relaxation

Psychological stress exposure is associated with long-lasting health effects including memory problems, depression, aches and pains, eating disorders, and alcohol or drug use. Thus, there is a need to develop effective stress management strategies that are easy to learn and practice. Respiratory biofeedback is an evidence-based stress management technique presenting breathing-related information to help subjects learn specific breathing skills for relaxation. It is suggested that the use of biofeedback techniques in conjunction with virtual reality makes biofeedback training an even more effective tool for stress management. The current study aimed to investigate dynamics of distinct stress indicators before, after, as well as during one brief virtual reality-based respiratory biofeedback session. Thirty-nine healthy volunteers participated in the study. Individuals provided their saliva samples and evaluated their mood status, fatigue, and strain level before and after the session. The subjects' heart and respiratory rate, heart rate variability, and galvanic skin response measures were recorded during the session. The results showed that after single 12 min relaxation session, there was a significant decrease in salivary cortisol concentration, heart and respiratory rate, as well as decrease in skin conductance values. Self-reported strain, fatigue level, and mood status also significantly improved. VR-based respiratory-biofeedback-assisted relaxation sessions might serve as an effective stress management strategy, as even single session had positive effects on subjects' autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) axis activity, as well as self-reported fatigue, strain level, and mood status.

Multi-sensory display of self-avatar's physiological state: virtual breathing and heart beating can increase sensation of effort in VR

In this paper we explore the multi-sensory display of self-avatars' physiological state in Virtual Reality (VR), as a means to enhance the connection between the users and their avatar. Our approach consists in designing and combining a coherent set of visual, auditory and haptic cues to represent the avatar's cardiac and respiratory activity. These sensory cues are modulated depending on the avatar's simulated physical exertion. We notably introduce a novel haptic technique to represent respiratory activity using a compression belt simulating abdominal movements that occur during a breathing cycle. A series of experiments was conducted to evaluate the influence of our multi-sensory rendering techniques on various aspects of the VR user experience, including the sense of virtual embodiment and the sensation of effort during a walking simulation. A first study ($\mathrm{N}=30$) that focused on displaying cardiac activity showed that combining sensory modalities significantly enhances the sensation of effort. A second study ($\mathrm{N}=20$) that focused on respiratory activity showed that combining sensory modalities significantly enhances the sensation of effort as well as two sub-components of the sense of embodiment. Interestingly, the user's actual breathing tended to synchronize with the simulated breathing, especially with the multi-sensory and haptic displays. A third study ($\mathrm{N}=18$) that focused on the combination of cardiac and respiratory activity showed that combining both rendering techniques significantly enhances the sensation of effort. Taken together, our results promote the use of our novel breathing display technique and multi-sensory rendering of physiological parameters in VR applications where effort sensations are prominent, such as for rehabilitation, sport training, or exergames.

Respiratory sinus arrhythmia during biofeedback is linked to persistent improvements in attention, short-term memory, and positive self-referential episodic memory

Background

Heart rate variability (HRV) biofeedback, an intervention based on the voluntary self-regulation of autonomic parameters, has been shown to affect prefrontal brain functioning and improve executive functions. The interest in using HRV biofeedback as cognitive training is typically ascribed to parasympathetic activation and optimized physiological functioning deriving from increased cardiac vagal control. However, the persistence of cognitive effects is poorly studied and their association with biofeedback-evoked autonomic changes has not yet been explored. In addition, no study has so far investigated the influence of HRV biofeedback in adults on long-term episodic memory, which is particularly concerned with self-referential encoding processing.

Methods

In the present study, a novel training system was developed integrating HRV and respiratory biofeedback into an immersive virtual reality environment to enhance training efficacy. Twenty-two young healthy adults were subjected to a blinded randomized placebo-controlled experiment, including six self-regulation training sessions, to evaluate the effect of biofeedback on autonomic and cognitive changes. Cardiac vagal control was assessed before, during, and 5 min after each training session. Executive functions, episodic memory, and the self-referential encoding effect were evaluated 1 week before and after the training program using a set of validated tasks.

Results

Linear mixed-effects models showed that HRV biofeedback greatly stimulated respiratory sinus arrhythmia during and after training. Moreover, it improved the attentional capabilities required for the identification and discrimination of stimuli ( η p 2 = 0.17), auditory short-term memory ( η p 2 = 0.23), and self-referential episodic memory recollection of positive stimuli ( η p 2 = 0.23). Episodic memory outcomes indicated that HRV biofeedback reinforced positive self-reference encoding processing. Cognitive changes were strongly dependent on the level of respiratory sinus arrhythmia evoked during self-regulation training.

Conclusion

The present study provides evidence that biofeedback moderates respiration-related cardiac vagal control, which in turn mediates improvements in several cognitive processes crucial for everyday functioning including episodic memory, that are maintained beyond the training period. The results highlight the interest in HRV biofeedback as an innovative research tool and medication-free therapeutic approach to affect autonomic and neurocognitive functioning. Finally, a neurocognitive model of biofeedback-supported autonomic self-regulation as a scaffolding for episodic memory is proposed.

The Advances of Immersive Virtual Reality Interventions for the Enhancement of Stress Management and Relaxation among Healthy Adults: A Systematic Review

The rapid changes in human contacts due to the COVID-19 crisis have not only posed a huge burden on the population’s health but may have also increased the demand for evidence-based psychological programs delivered through digital technology. A systematic review, following the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)” guidelines, was therefore conducted to explore the advances in stress management interventions utilizing VR and suggest up-to-date directions for future practice. The relevant literature was screened and the search resulted in 22,312 records, of which 16 studies were considered for analysis. The Methodological Index for Non-Randomized Studies (MINORS) was also employed to assess the quality of the included studies. The results suggest that VR-based interventions can facilitate positive changes in subjective stress levels and stress-related biomarkers. However, special attention should be paid to the development of rigorous VR protocols that embrace natural elements and concepts deriving from traditional treatment approaches, such as cognitive behavioral therapy techniques. Overall, this review aims to empower future researchers to grasp the opportunity that the COVID-19 pandemic generated and utilize digital technologies for strengthening individuals’ mental health. Future projects need to conduct large-scale VR studies to evaluate their effectiveness compared to other mental health interventions.

Facilitating relaxation and stress reduction in healthy participants through a virtual reality intervention: study protocol for a non-inferiority randomized controlled trial

BACKGROUND

Repeated or chronic stress is considered a major source of disease, in terms of both somatic and mental illnesses. The prevention of stress-related disease by interventions for relaxation has thus increased societal relevance. In this randomized controlled non-inferiority trial, we will compare a newly developed virtual reality (VR) environment for relaxation to an active control group applying a freely chosen relaxation method. To test if our VR environment supports relaxation in a situation of acute stress, a standardized stress induction protocol will precede the relaxation phase.

METHODS

One hundred healthy participants will be recruited from the University of Siegen and randomly assigned to the VR or the active control group that will be free to choose their own relaxation strategy. The multi-sensory VR includes visual, acoustic, and haptic features to induce a strong feeling of presence. The laboratory testing will comprise a baseline measurement, a stress induction, a relaxation intervention, and a recovery measurement. The primary outcomes are self-reported stress and relaxation measured with a visual analog scale (VAS) at pre- and post-baseline, at the start, middle, and end of the stress induction, at pre- and post-relaxation, at pre- and post-recovery, and in the evening of testing. Secondary outcomes are the physiological parameters, namely heart rate and heart rate variability, tonic skin conductance level as well as the number of non-specific skin conductance responses, systolic and diastolic blood pressure and respiratory rate recorded during the four experimental phases as well as state mood, and state rumination assessed at four time points (pre- and post-stress, post-relaxation, and in the evening of testing). Finally, post-event processing will be assessed after relaxation and in the evening of testing. Repeated measures ANOVAs will be performed to test for statistical effects of group, time, and group × time interaction.

DISCUSSION

The newly developed, multi-sensory VR offers an intervention for relaxation without prior training. Its immersive character might increase efficacy compared to other relaxation methods, especially in situations of acute stress. Future directions could be the development of a mobile version of the VR to enhance accessibility for users. To achieve a transfer of training effects to real life, VR components should successively be eliminated until relaxation is practiced without guidance by the VR.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN11162338 . Retrospectively registered on January 22, 2021.

Effects of Virtual Reality-Based Relaxation Techniques on Psychological, Physiological, and Biochemical Stress Indicators

Various relaxation techniques could benefit from merging with virtual reality (VR) technologies, as these technologies are easily applicable, involving, and user-friendly. To date, it is unclear which relaxation technique using biofeedback combined with VR technology is the most effective. The study aimed to compare the effectiveness of brief VR-based biofeedback-assisted relaxation techniques including electroencephalographic biofeedback, mindfulness-based biofeedback, galvanic skin response biofeedback, and respiratory biofeedback. Forty-three healthy volunteers (age 34.7 ± 7.2 years), comprising 28 (65%) women and 15 (35%) men, were enrolled in the study. All the participants were exposed to four distinct relaxation sessions according to a computer-generated random sequence. The efficacy of relaxation methods was evaluated by examining psychological, physiological, and biochemical stress indicators. All VR-based relaxation techniques reduced salivary steroid hormone (i.e., cortisol, cortisone, and total glucocorticoid) levels and increased galvanic skin response values. Similarly, all interventions led to a significantly reduced subjectively perceived psychological strain level. Three out of the four interventions (i.e., electroencephalographic, respiratory, and galvanic skin response-based biofeedback relaxation sessions) resulted in a decreased self-reported fatigue level. We suggest that newly developed VR-based relaxations techniques are potential tools for stress reduction and might be particularly suitable for individuals who are not capable of adhering to a strict and time-consuming stress management intervention schedule.

Virtual Reality Biofeedback in Health: A Scoping Review

Over the past decades, virtual reality (VR) has found its way into biofeedback (BF) therapy programs. Using VR promises to overcome challenges encountered in traditional BF such as low treatment motivation, low attentional focus and the difficulty of transferring learnt abilities to everyday life. Yet, a comprehensive research synthesis is still missing. Hence, this scoping review aims to provide an overview over empirical studies on VR based BF regarding key outcomes, included samples, used soft- and hardware, BF parameters, mode of application and potential limitations. We systematically searched Medline, PsycINFO, Scopus, CINAHL, Google Scholar and Open Grey for empirical research. Eighteen articles met the inclusion criteria. Samples mostly consisted of healthy (44.4%) and/or adult (77.7%) participants. Outcomes were mainly anxiety (44.4%), stress (44.4%) or pain reduction (11.1%), which were reduced by the VR-BF interventions at least as much as by classical BF. Participants in VR-BF interventions showed higher motivation and involvement as well as a better user experience. Heart rate or heart rate variability were the most frequently used BF parameters (50.0%), and most VR-BF interventions (72.2%) employed a natural environment (e.g., island). Currently, there is no clear evidence that VR-BF is more effective than traditional BF. Yet, results indicate that VR-BF may have advantages regarding motivation, user experience, involvement and attentional focus. Further research is needed to assess the specific impact of VR and gamification. Also, testing a broader range of clinical and younger samples would allow more far-reaching conclusions.

Slow Breathing Exercise with Multimodal Virtual Reality: A Feasibility Study

Many studies have shown that slow breathing training is beneficial for human health. However, several factors might discourage beginners from continuing their training. For example, a long training period is generally required for benefit realization, and there is no real-time feedback to trainees to adjust their breathing control strategy. To raise the user’s interest in breathing exercise training, a virtual reality system with multimodal biofeedback is proposed in this work. In our system, a realistic human model of the trainee is provided in virtual reality (VR). At the same time, abdominal movements are sensed, and the breathing rate can be visualized. Being aware of the breathing rate, the trainee can regulate his or her breathing to achieve a slower breathing rate. An additional source of tactile feedback is combined with visual feedback to provide a more immersive experience for the trainees. Finally, the user’s satisfaction with the proposed system is reported through questionnaires. Most of the users find it enjoyable to use such a system for mediation training.

REALIDADE VIRTUAL NA PRÁTICA DE MINDFULNESS EM PSICOTERAPIA: UMA REVISÃO NARRATIVA

A associação entre mindfulness (MF) e Realidade Virtual (RV) é recente. O MF vem sendo utilizado na psicoterapia em razão dos efeitos terapêuticos observados. Entretanto, não são todos os pacientes que conseguem obter o benefício desse recurso, sendo a RV uma via para o trabalho com o MF por facilitar o sentido de presença. Este artigo teve como objetivo realizar uma revisão narrativa da literatura sobre a utilização terapêutica da RV na prática de MF. Foram analisados 23 artigos completos, sendo os principais focos de pesquisa: o aprimoramento dos ecossistemas imersivos e dos recursos terapêuticos no contexto do MF em relação à experiência do usuário; o desenvolvimento de recursos tecnológicos econômicos; material de fácil manuseio para facilitar a experiência do usuário. Concluímos que a RV pode ser facilitadora como ferramenta no tratamento de pacientes cujo perfil se enquadra em terapia mediada por MF, embora sejam necessários estudos controlados que permitam compreender as especificidades da RV e as variáveis com valor terapêutico.

Addressing virtual reality misclassification: A hardware-based qualification matrix for virtual reality technology

Through its unique sensory synchronized design, virtual reality (VR) provides a convincing, user-centred experience of highly controllable scenarios. Importantly, VR is a promising modality for healthcare, where treatment efficacy has been recognized for a range of conditions. It is equally valuable across wider research disciplines. However, there is a lack of suitable criteria and consistent terminology with which to define VR technology. A considerable number of studies have misclassified VR hardware (e.g. defining laptops as VR), hindering validity and research comparisons. This review addresses these limitations and establishes a standardized VR qualification framework. As a result of a comprehensive theoretical and literature review, the hardware-based VR qualification matrix is proposed. The matrix criteria consist of (1) three-dimensional (3D) synchronized sensory stimulation; (2) degrees of freedom tracking; and (3) visual suppression of physical stimuli. To validate the model and quantify the current scale/diversity of VR misclassification, a 2019 sectional review of health-related studies was conducted. Of the 115 studies examined against standardized criteria, 35.7% utilized VR, 31.3% misclassified VR, 18.3% were considered quasi-VR, and 14.8% omitted critical specifications. The proposed model demonstrates good validity and reliability for qualifying and classifying VR. Key Practitioner Messages Virtual reality (VR) therapy has gained rapid empirical support, although many practitioners do not understand the difference between genuine and less-realistic VR variations. That has resulted from an evident lack of suitable criteria to define VR across a range of studies and protocols. Our proposed hardware-based virtual reality qualification matrix addresses issues to do with misclassification, via the introduction of standardised criteria. Applying the matrix to existing literature has revealed that more than 30% of VR studies use hardware that does not fit the high standards of rigour required for immersion in a simulated space. The model is a practical tool researchers and practitioners can use to quality and verify VR standards across research studies.

Creating Ambassadors of Planet Earth: The Overview Effect in K12 Education

The overview effect is the commonly reported experience of astronauts viewing planet Earth from space and the subsequent reflection on and processing of this experience. The overview effect is associated with feelings of awe, self-transcendence, and a change of perspective and identity that manifest themselves in taking steps toward protecting the fragile ecosystem. In the current study, we investigated whether the overview effect can be obtained in school children when simulated using virtual reality (VR) and whether the effect has a positive impact on learning gains. Using questionnaires and attention data in an existing simulation environment used in the school system, we showed that the VR simulation elicits an overview effect experience. Moreover, the experience yields learning gains in the domain of astrophysics. These findings are in line with past evidence regarding the positive impact of awe on learning and can be used to support further investigations of the relation between the overview effect and behavioral changes, specifically for educational purposes.

Development and Pilot Test of a Virtual Reality Respiratory Biofeedback Approach

Breathing exercises with biofeedback have benefits over breathing exercises without biofeedback. However, the traditional measurement of respiratory signals that is required as part of feeding back the breath incurs high cost and effort. We propose a novel virtual reality (VR) based approach to respiratory biofeedback that utilizes the positionally tracked hand controllers integrated into modern VR systems to capture and feedback the respiration-induced abdominal movements. In a randomized controlled laboratory study, we investigated the feasibility and efficacy of the developed biofeedback algorithm. In total, 72 participants performed a short breathing exercise in VR with or without respiratory biofeedback. The feedback integration resulted in a satisfactory user experience, a heightened breath awareness, a greater focus on slow diaphragmatic breathing and an increased respiratory sinus arrhythmia. This evidences that the novel biofeedback approach is low-cost, unobtrusive, usable and effective in increasing breath awareness and promoting slow diaphragmatic breathing in the context of VR-based breathing exercises. Future studies need to investigate the broader applicability and long-term effects.

Non-invasive Neurophysiology in Learning and Training: Mechanisms and a SWOT Analysis

Although many scholars deem non-invasive measures of neurophysiology to have promise in assessing learning, these measures are currently not widely applied, neither in educational settings nor in training. How can non-invasive neurophysiology provide insight into learning and how should research on this topic move forward to ensure valid applications? The current article addresses these questions by discussing the mechanisms underlying neurophysiological changes during learning followed by a SWOT (strengths, weaknesses, opportunities, and threats) analysis of non-invasive neurophysiology in learning and training. This type of analysis can provide a structured examination of factors relevant to the current state and future of a field. The findings of the SWOT analysis indicate that the field of neurophysiology in learning and training is developing rapidly. By leveraging the opportunities of neurophysiology in learning and training (while bearing in mind weaknesses, threats, and strengths) the field can move forward in promising directions. Suggestions for opportunities for future work are provided to ensure valid and effective application of non-invasive neurophysiology in a wide range of learning and training settings.

A Scoping Review Identifying the Need for Quality Research on the Use of Virtual Reality in Workplace Settings for Stress Management

Workplace stress management is a growing problem that can have significant mental health and financial impact for workers and their employers. There is a growing body of evidence supporting the efficacy of Virtual Reality (VR) treatments for stress and anxiety, however no reviews of VR to date have looked specifically into the use of VR for this purpose in the workplace. This scoping review aimed to identify available evidence in this environment (i.e., workplace) and investigate whether using VR might reduce workplace stress levels. The academic databases, CINAHL, Medline, Proquest, PsychINFO, PubMed, Scopus, and Web of Science, were searched using terms focused on VR, stress or relaxation, and workplaces. Results from the articles reviewed demonstrate a wide variety of study designs and techniques, with a general indication that the interventions reduce stress. Commonalities, differences, and levels of workplace focus are examined. Areas for future studies are highlighted, and the importance of the unique contribution VR can make to stress management in the workplace is identified as a gap in the research to be filled.