Virtual reality in paediatric rehabilitation: a review

Efficacy of videogames and exergames in pediatric neurorehabilitation: a systematic review

INTRODUCTION

In recent years, the rehabilitation of children with neurological disorders has taken into account the possibility of using videogaming consoles and virtual reality systems to make children's therapy more enjoyable, motivating, participated and effective. This study aims at conducting a systematic review about the use and the efficacy of digital games in pediatric neurorehabilitation.

EVIDENCE ACQUISITION

In accordance with the PRISMA approach, a rather wide-ranging search was conducted on PubMed, Scopus, and Web of Science databases by using different combinations of keywords based on MeSH terms.

EVIDENCE SYNTHESIS

Fifty-five papers have been included into this review, namely, 38 original studies and 17 reviews. The total number of children and adolescents is 573, with 58% of them being affected by cerebral palsy. Despite a wide variability in the adopted protocols, devices, assessment tools, and a more frequent focus on motor aspects than on cognitive ones, the results of the majority of the analyzed studies support the safety (i.e., absence of severe adverse effects) and efficacy of the videogame-based therapy.

CONCLUSIONS

Videogames, when administered by means of commercial consoles or ad-hoc digital systems, seem to be a valid support for physical therapy. Further researchers are needed to deeply investigate the role of this approach in cognitive therapy and cognitive outcomes.

Evaluating the impact of virtual reality game training on upper limb motor performance in children and adolescents with developmental coordination disorder: a scoping review using the ICF framework

OBJECTIVE

This scoping review aims to explore published literature testing Virtual Reality (VR) interventions for improving upper limb motor performance in children and adolescents with Developmental Coordination Disorder (DCD). Our primary focus was on the types of VR systems used and the measurement tools employed within the International Classification of Functioning, Disability and Health Children and Youth Version (ICF-CY) domains in these studies.

METHODS

A comprehensive search of six electronic databases up to 11th January 2024 was conducted using predefined terms. Inclusion and exclusion criteria were applied to determine study eligibility, with two authors independently assessing titles, abstracts, and full-text articles.

RESULTS

Out of 788 potential studies, 14 met the eligibility criteria. Studies predominantly utilized non-immersive VR (nVR) systems, for example, commercial platforms such as Nintendo Wii. Most interventions targeted general motor coordination or balance, with only four studies specifically focusing on upper limb motor performance. The Movement Assessment Battery for Children-2 was the predominant assessment tool. However, the use of game scores and trial durations raised concerns about the accuracy of assessments. The majority of studies reported no significant improvement in upper limb motor performance following VR interventions, though some noted improvements in specific tasks or overall outcomes.

CONCLUSION

The findings suggest that, while nVR interventions are being explored for paediatric motor rehabilitation, their impact on enhancing upper limb motor performance in children with DCD is unclear. The variability in intervention designs, outcome measures, and the predominant focus on general motor skills rather than specific upper limb improvements highlight the need for more targeted research in this area.

IMPACT

This review underscores the importance of developing precise and clinically relevant measurement tools in a broader range of VR technologies to optimize the use of VR in therapy for children with DCD. Future research should aim for more rigorous study designs and emerging immersive technologies to maximize therapeutic benefits.

Non-immersive virtual reality based treatment for children with unilateral cerebral palsy: Preliminary results

PURPOSE

Unilateral cerebral palsy (UCP) represents about 30-40% of overall cerebral palsy diagnoses. Upper limb impairment has a significant negative impact on activities of daily living (ADL), and recent studies have shown that the use of virtual reality (VR) can increase motivation and promote an improvement in ADL. This preliminary study was aimed at exploring the acceptability and usability of a VR rehabilitation treatment, using the VITAMIN Platform, for children with UCP. A secondary goal of the study was to compare the results of usual standardized clinical scales and questionnaires with kinematic results as well as with the quantitative measures acquired by the VITAMIN platform in each exercise of the rehabilitation sessions.

METHODS

Six children with UCP (aged 7-15) were recruited for a preliminary investigation in using a non-immersive VR system. The treatment was composed of 10 weekly sessions of 45 minutes. Each child played five types of exergames, using the impaired upper limb to hit virtual objects projected on a wide screen. Standardized clinical scales, kinematic analysis, and questionnaires were used to extensively assess upper limb function before and at the end of treatment. Five typically-developing children provided a reference for the instrumented kinematic assessment.

RESULTS

At the end of the treatment, Melbourne Assessment 2 (MA2) scores increased for all the participants (mean increase in range of movement (ROM) + 19.1%, accuracy + 4.6%, dexterity + 13.1%, fluency + 10.3%). Shoulder flexion-extension ROM also improved (mean increase + 10.5°), and according to the kinematic analysis, shoulder movements became more similar to reference profiles. These results were confirmed by a general improvement in performing ADL, assessed by the ABILHAND-Kids questionnaire. Finally, a general agreement among the different measures and indexes emerged from the acquired data.

CONCLUSION

The results show that VR treatment with the VITAMIN platform could be engaging and functional for rehabilitation of children with UCP. The good agreement among the qualitative and quantitative measures and indexes confirms the potential of such novel treatment. However, due to the limited sample size and small number of sessions, further and larger investigations are required to evaluate the effectiveness and to generalize the results.

Virtual Reality-Based Intervention to Reduce Preoperative Anxiety in Adults Undergoing Elective Surgery: A Randomized Clinical Trial

IMPORTANCE

Preoperative anxiety is common among adult patients undergoing elective surgery and is associated with negative outcomes. Virtual reality (VR)-based interventions have been considered simpler, safer, and more effective for reducing anxiety in patients undergoing surgery than conventional care.

OBJECTIVE

To examine the effectiveness of a VR-based intervention with preoperative education in reducing preoperative anxiety among adult patients undergoing elective surgery.

DESIGN, SETTING, AND PARTICIPANTS

An assessor-blinded prospective randomized clinical trial was conducted to recruit adult patients aged 18 years or older who were scheduled for their first elective surgery procedure under general anesthesia within the next 2 to 4 weeks at a preanesthesia assessment clinic in Hong Kong from July to December 2022.

INTERVENTIONS

Participants were randomly assigned to either an intervention group (an 8-minute immersive 360° VR video tour in the operating theater via a head-mounted display console) or a control group (standard care).

MAIN OUTCOMES AND MEASURES

The primary outcome of preoperative anxiety was measured using the Amsterdam Preoperative Anxiety and Information Scale (range, 6-30; higher scores indicate greater anxiety), and the secondary outcomes (ie, stress, preparedness, and pain) were assessed by Visual Analog Scale at 3 time points: baseline at beginning of clinical session (T0), at the end of the clinical session immediately after the intervention (T1), and before the surgery (T2). Pain, satisfaction levels, and postoperative length of stay were evaluated after the surgery (T3). Simulation sickness was assessed after the intervention by use of the Simulation Sickness Questionnaire. A generalized estimating equations model was applied to compare changes in outcomes over time.

RESULTS

A total of 74 participants (mean [SD] age, 46.34 [14.52] years; 38 men [51.4%] and 36 women [48.6%]) were recruited and randomized to the control group (37 participants) and intervention group (37 participants). Compared with the control group, the VR-based intervention group showed significantly decreased preoperative anxiety at T1 (β, -5.46; 95% CI, -7.60 to -3.32; P < .001) and T2 (β, -5.57; 95% CI, -7.73 to -3.41; P < .001), lower stress at T1 (β, -10.68; 95% CI, -16.00 to -5.36; P < .001) and T2 (β, -5.16; 95% CI, -9.87 to -0.45; P = .03), and higher preparedness at T1 (β, 6.60; 95% CI, 0.97 to 12.19; P = .02). Satisfaction levels were significantly increased in the intervention group vs the control group (mean [SD] score, 81.35 [9.24] vs 65.28 [8.16]; difference, 16.07; 95% CI, 12.00 to 20.15; P < .001). No significant differences in pain and postoperative length of stay were found.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that a VR-based intervention is a feasible and effective way to reduce preoperative anxiety in adult patients undergoing elective surgery. Given the promising results of this study, further study in the form of large-scale, multicenter, randomized clinical trials with broader implementation is warranted.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR2100051690.

Pediatric powered mobility training: powered wheelchair versus simulator-based practice

METHOD

Participants included 30 children and adolescents (23 males, 13 females) with cerebral palsy and other neuromuscular diseases, aged 6-18. Data were collected and compared at baseline and after 12 weeks of home-based practice via a powered wheelchair or a simulator. Powered mobility ability was determined by the Powered Mobility Program (PMP), the Israel Ministry of Health's Powered Mobility Proficiency Test (PM-PT) and the Assessment of Learning Powered Mobility (ALP).

RESULTS

All participants practiced for the required amount of time and both groups reported a similar user experience. Both groups achieved significant improvement following the practice period as assessed by the PMP and PM-PT assessments, with no significant differences between them. A significant improvement was found in the ALP assessment outcomes for the powered wheelchair group only.

CONCLUSIONS

This is the first study, to our knowledge, that compares two different wheelchair training methods. Simulator-based practice is an effective training option for powered mobility for children with physical disabilities aged 6-18 years old, demonstrating that it is possible to provide driving skill practice opportunities safe, controlled environments.

Effectiveness of virtual reality on activities of daily living in children with cerebral palsy: a systematic review and meta-analysis

Background

No meta-analysis has been conducted on the effect of specific virtual reality (VR) treatment modes on activities of daily living (ADL) in children with cerebral palsy (CP). Therefore, this study aimed to confirm whether VR therapy is effective in improving ADL in children with CP according to subgroups.

Methodology

Literature published in the Cumulated Index to Nursing and Allied Health Literature (CINAHL), Embase, the Physiotherapy Evidence Database (PEDro), and PubMed was reviewed, and Risk of Bias 2.0 (RoB 2) was used to evaluate the quality of the literature. A funnel plot was visually observed to confirm publication bias, supplemented with Egger's regression test. Data analysis was performed using R version 4.2.1. Subgroup analysis was performed according to the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), treatment minutes per week, treatment period, age, and RoB.

Results

Eleven of 2,978 studies were included, and the overall effect size was 0.37 (95% confidence interval = 0.17-0.57). Regarding GMFCS, effect sizes of 0.41 and 0.33 was observed for the low- and high-function groups, respectively. For MACS, 0.27 and 0.43 were observed for the low and high-function groups. Regarding treatment minutes per week, the values were 0.22, 0.44, and 0.27 in the 1-100, 101-200, and 201-300 min groups, respectively. In the classification according to age, 0.29 was observed for school-age children and 0.98 for preschool children. Lastly, in the classification according to the RoB, 0.52, -0.01, and 0.23 indicated studies with low risk, some concern, and high risk, respectively.

Conclusions

The highest effect was observed when VR was applied within 6 weeks of 101-200 per week. Therefore, it is suggested that if the results of this review are applied to children with cerebral palsy in the community, it will be an effective intervention method.

Systematic review registration

PROPEROS (registration number CRD42023409801).

PedBotHome: A Video Game-Based Robotic Ankle Device Created for Home Exercise in Children With Neurological Impairments

PURPOSE

This pilot study assesses the feasibility of using PedBotHome to promote adherence to a home exercise program, the ability of the device to withstand frequent use, and changes in participant ankle mobility.PedBotHome is a robotic ankle device with integrated video game software designed to improve ankle mobility in children with cerebral palsy.

METHODS

Eight participants enrolled in a 28-day trial of PedBotHome. Ankle strength, range of motion, and plantar flexor spasticity were measured pre- and posttrial. Performance was monitored remotely, and game settings were modified weekly by physical therapists.

RESULTS

Four participants met the study goal of 20 days of use. There were statistically significant improvements in ankle strength, spasticity, and range of motion.

CONCLUSIONS

PedBotHome is a feasible device to engage children with static neurological injuries in ankle home exercise. This pilot study expands the paradigm for future innovative home-based robotic rehabilitation.

Medical Interactive Recovery Assistant: a useful clinical tool in paediatric shoulder rehabilitation?

Background/aims

Outpatient physical therapy is the mainstay of treatment in shoulder instability, but lack of motivation and intermittent monitoring of progress is associated with poor compliance. ‘Exergames’ (a combination of videogames and physical exercise) may provide an additional or alternative motivational factor. The aim of this study was to determine the applicability of the Medical Interactive Recovery Assistant Xbox Kinect gaming software in the management of adolescent atraumatic shoulder instability.

Methods

Patients completed six 30-minute sessions playing games using the Medical Interactive Recovery Assistant while participating in a therapy programme. Pain and fatigue questionnaires, functional assessments and a framework analysis of free-text comments were used.

Results

A total of 20 female patients (15 unilateral, five bilateral pathology, mean age 14.1 years) completed the sessions. An average session length was 10.8 mins (range 0–24 mins). After each session using the Medical Interactive Recovery Assistant, 80% were neither in pain, nor overly tired. At 2 weeks, the Stanmore Percentage of Normal Shoulder Assessment scores had improved by a mean 17.9% and 10 (50%) patients showed improvements in Oxford Shoulder Instability Scores. Overall, 15 participants (75%) liked the technology; however six (32%) preferred standard physiotherapy, because of software limitations and lack of personal interaction.

Conclusions

Medical Interactive Recovery Assistant gamification is applicable for this patient cohort and could be integrated into adolescent atraumatic shoulder instability rehabilitation programmes; however, results emphasise the importance of personal contact.

Playing your pain away: designing a virtual reality physical therapy for children with upper limb motor impairment

Children with upper limb motor impairment often undergo repetitive therapeutic physiotherapy sessions to minimize functional disabilities of the affected area. Even though therapeutic processes can improve functional outcomes and minimize persistent disabilities, patients often neglect to participate fully in physical therapies due to the associated procedural pain. Over recent decades, there has been a growing interest in designing non-pharmacological interventions which aim to minimize pain during physical therapies and improve functional outcomes. Via two interrelated studies, we explored the use of virtual reality (VR) as a tool to provide therapeutic physiotherapy for child patients in an out-patient hospital department. We found that VR is an effective solution for children with upper limb motor impairment undergoing painful therapeutic process within a hospital environment. VR can improve functional disabilities, alleviate perceived pain, reduce the perceived difficulty of rehabilitation exercises, increase exercise duration and produce positive emotions towards the therapy. Trial registration number and date of registration Protocol ID NCT03998995. Release Date: June 25, 2019.

Safety and Tolerability of an Innovative Virtual Reality-Based Deep Breathing Exercise in Concussion Rehabilitation: A Pilot Study

To examine the safety and tolerability of a virtual reality-based deep breathing exercise for children and adolescents who are slow to recover from concussion. Methods: Fifteen participants (ages 11 to 22; mean = 16.9 years) were recruited from a specialty concussion clinic within a tertiary care medical center. Participants completed a 5-min paced deep breathing exercise administered via a virtual reality headset. Results: Nearly all participants (93.3%) reported the experience was either positive or extremely positive. No participants reported significant discomfort or discontinued the exercise. Three participants reported a mild increase in headache, dizziness, or nausea. Participants reported significant decreases in stress (r =.57), tension (r =.73), fatigue (r =.73), and confusion (r =.67), with large effect sizes, following the deep breathing exercise. Conclusion: A brief, virtual reality-based deep breathing exercise is worthy of additional study as a rehabilitation component for children and adolescents with prolonged concussion recoveries.

A serious-gamification blueprint towards a normalized attention

Attention is an important commodity in the human skills set. It can be trained to overcome deficits in the short term which might be based on multiple cognitive complications to entail inability to keep focus and mined wondering. On the long term, however, it might be a symptom of chronic diseases that acquire attention to include the spectra of many mental health disorders, e.g., attention deficit hyperactivity disorder (ADHD). This paper, therefore, introduces a generic reference model that guides in the design of proper treatment method for patients in short of attention to engage in a game-based environment in order to enhance the behavior of their current state of attention which may hopefully lead to a better focus. When considering the volatility of traditional cognitive behavioral therapies (CBTs), the model reflects and analyzes evolving serious games design directed for the treatment of ADHD. It serves as an instrument that spawn over a specific treatment design since it introduces essential components that depicts essential units of traditional CBT when they are modularly combined. The components will be introduced and the processes of the reference model will be elaborated as a roadmap for the formation and the operation of augmented reality treatment games.

[Using new media in pediatric psychosomatic medicine]

Neue Medien wie Smartphone-Apps oder virtuelle Realitäten (VR) finden zunehmend Anwendung in der pädiatrischen Psychosomatik. In der Diagnostik liegen die Vorteile in der Erfassung von Daten im Alltag sowie in der realitätsnahen und zugleich standardisierten Erfassung mithilfe der VR. In der Behandlung lassen sich selbstadministrierte und hybride Technologien von computerassistierten und computerspielbasierten Interventionen unterscheiden, die allesamt zunehmend in der pädiatrischen Psychosomatik zum Einsatz kommen, so z. B. bei Schmerzerkrankungen, Enkopresis, chronischen Erkrankungen oder auch begleitenden Depressionen und Ängsten. Durch das Auslösen alltagsnaher Reaktionen bei gleichzeitiger maximaler Kontrolle bieten VR auch in der Forschung große Vorteile. Nichtsdestotrotz sind Kontraindikationen wie Psychosen, Epilepsie und Migräne zu beachten. Eine umfassende Schulung des Fachpersonals ist daher für die Nutzung neuer Medien in der Diagnostik, Behandlung und Forschung essenziell.

Immersive virtual reality in children with upper limb injuries: Findings from a feasibility study

PURPOSE

Children who sustain Upper Limb Injuries (ULIs), including fractures and burns, may undergo intensive rehabilitation. The discomfort of therapy can reduce their compliance, limit their range of motion (ROM) and lead to chronic pain. Virtual Reality (VR) interventions have been found to reduce anticipated and procedural pain.This feasibility study aimed to explore perceptions and impacts of a custom-made, fully immersive Head-Mounted Display VR (HMD-VR) experience within a United Kingdom (UK) National Health Service (NHS) outpatient rehabilitation service for children with ULIs.

METHODS

Ten children aged 9-16 in one UK Children's hospital trialled HMD-VR during one rehabilitation session. They, their parents (n = 10), and hospital physiotherapy staff (n = 2) were interviewed about their perceptions of pain, difficulty, enjoyability, therapeutic impacts, benefits, and limitations. Children rated the sessions on enjoyability, difficulty, and pain compared to usual rehabilitation exercises. Physiotherapists were asked to provide range of motion readings.

RESULTS

Inductive thematic analysis of interview data generated three themes, 'Escape through Engagement'; 'Enhanced Movement'; and 'Adaptability and Practicality'. Children rated the session as more enjoyable, less difficult and painful than their usual rehabilitation exercises. Findings suggested that HMD-VR was an engaging, enjoyable experience that distracted children from the pain and boredom of therapy. Also, it seemed to enhance the movement they achieved. Participants perceived it was useful for rehabilitation and adaptable to individual needs and other patient groups. Suggestions were made to increase adaptability and build in practical safeguards.

CONCLUSION

Findings from this small-scale feasibility study suggested HMD-VR was perceived as usable, acceptable, and effective with potential for further development. Future work could include larger scale trials.

Effects of Virtual Reality-Based Rehabilitation on Upper Extremity Function among Children with Cerebral Palsy

Background: Deterioration in upper extremity function has been a common problem among children with cerebral palsy (CP). The present study evaluated the effects of virtual reality (VR)-based rehabilitation combined with conventional occupational therapy (COT) on upper extremity function and caregiver assistance among children with CP. Methods: Medical records of 17 children with CP who regularly participated in a rehabilitation program at Samsung Changwon Hospital were retrospectively reviewed. Ten children received VR-based rehabilitation, which utilized RAPAEL Smart Kids and video games combined with COT. Seven children received COT alone, which was provided by a trained occupational therapist and focused on their upper extremities. Clinical outcomes were determined using the Quality of Upper Extremity Skills Test (QUEST) and Pediatric Evaluation of Disability Inventory (PEDI), which were administered before and 8 weeks after the first intervention session. Results: The smart glove (SG) group showed significant improvements in all QUEST domains and five PEDI domains (p < 0.05), whereas the COT group showed a significant change only in total QUEST scores. A comparison between both groups revealed that the SG group had significantly greater improvements in five QUEST domains and two PEDI domains (p < 0.05). Conclusions: Our results suggest that VR-based rehabilitation combined with COT may improve the upper extremity functions and decrease caregiver burden among children with CP.

A survey of research trends in assistive technologies using information modelling techniques

BACKGROUND

Despite the rapid proliferation and emphasis on technology, the use of assistive technology among individuals with varying disabilities and age is different. This situation instigates the need for a systematic review to gain a realistic understanding of prominent issues, research trends and assistive technology applications with minimal bias.

OBJECTIVE

Identification of leading researchers and prominent publications in assistive technologies. Subsequently, semantic relation between qualitative and quantitative research literature on assistive technologies was explored to future research directions.

METHODS

A manual search across reputed research databases was done to find out relevant literature from January 2005 to April 2020. In this paper, latent semantic analysis (LSA) was done to develop an information model for achieving defined objectives.

RESULTS

A corpus of 367 research papers published during 2005-2020 was processed using LSA. Term frequency, inverse document frequency of high loading terms provided five major topic solutions. Marcia Scherer, Rory Cooper and Stefano Federici are most noticed authors in assistive technology research. "Smart Assistive Technologies" and "Wearable Technologies for Rehabilitation" came out as contemporary research trends within assistive technologies.

CONCLUSIONS

The manuscript concludes the fact that assistive technologies for rehabilitation are experiencing a transition from standalone mechanical devices towards smart, wearable and connected devices.Implications for RehabilitationCustomized assistive devices could be programmed for multiple uses.User data privacy and internet dependency of smart assistive technologies must be taken care of while designing smart assistive devices for rehabilitation.Fog devices could eliminate the latency issues associated with cloud-based rehabilitation services.

Virtual Reality and Symptoms Management of Anxiety, Depression, Fatigue, and Pain: A Systematic Review

In recent years, virtual reality (VR) has become an interesting alternative to traditional exposure-based therapies for many symptoms. VR involves immersion in a computer-generated virtual environment that minimizes avoidance and facilitates emotional processing. The objective of this systematic review is to evaluate evidence on the intervention effect of VR on anxiety, depression, fatigue, and pain. The research strategy of this systematic review included three electronic databases (MEDLINE/PubMed, Cochrane Library, and ScienceDirect) based on predetermined inclusion and exclusion criteria. Published quantitative studies from 2000 to 2020 were identified, which examined the effect of VR intervention on four different symptoms related to symptoms experienced by cancer patients. Quality assessments, data extractions, and analysis were completed on all included studies. A total of 882 titles and abstracts were screened, and 23 studies were included in the review. The studies were grouped according to the symptoms: anxiety and depression, fatigue, and pain. The review showed that VR intervention is more effective compared with the control (i.e., standard care) for anxiety, depression, fatigue, and pain. VR can reduce effectively these symptoms in different contexts and diseases, including cancer. The evidence suggests that there is value in exploring this intervention as a potential crossover treatment for these symptoms in patients. This study contributes to evidence that distraction is an effective symptom management mechanism. The findings are congruent with the theoretical framework, supporting the premise that VR, as an emotion-focused distraction intervention, decreases the severity of these symptoms.

Virtual reality in psychiatric disorders: A systematic review of reviews

BACKGROUND

Virtual reality (VR) is being used more and more often as a therapeutic tool in psychology or psychiatry. In recent years, VR interventions appear more extensively also in disorders such as depression, anxiety and phobia. However, there has yet to be a comprehensive synthesis and critical review of the literature to identify future directions to advance the field in this area.

OBJECTIVES

To broadly characterize the literature to date on the application of VR in psychiatric disorders by conducting a systematic review of reviews, describe the limitations of existing research, suggest avenues for future research to address gaps in the current literature and provide practical recommendations for incorporating VR into various treatments for psychiatric disorders.

METHODS

PubMed and Web of Science databases were searched for reviews on VR use in psychiatric disorders (e.g. various pain perceptions, post-traumatic stress disorder, phobias, attention deficit hyperactivity disorder, psychosis, depression). The methodological quality of each literature review was assessed using AMSTAR.

RESULTS

The original search identified 848 reviews, of which 70 were included in the systematic review of reviews. Broadly, the literature indicates that various VR interventions could be useful in different psychiatric disorders.

CONCLUSION

This study provides evidence supporting the positive impact of VR therapy in psychiatric disorders. However, the impact is defined differently according to the studied area. Nevertheless, due to the continuous development of VR hardware and software, it is essential to conduct further research in the area of psychiatric disorders, especially as no review has concluded that VR does not work.

Exploring the use of Immersive Virtual Reality to enhance Psychological Well-Being in Pediatric Oncology: A pilot randomized controlled trial

PURPOSE

To investigate whether Immersive Virtual Reality (VR) has a greater positive influence on oncology patients' physical and emotional mood states when compared to an iPad attentional control condition. Our secondary objective was to understand what factors influenced VR effectiveness.

METHOD

Participants were 90 oncology inpatients, aged 7-19 years, and their primary parent caregiver. Using a randomized controlled study design patients were allocated to VR (three content groups) or an iPad control condition. Pre-post-intervention self-report state measures were collected using visual analogue scales and an objective measure of physiological arousal (pulse rate). Post-intervention, patients reported on level of immersion, enjoyment and simulator sickness.

RESULTS

Patients benefited from both Immersive VR and novel iPad intervention with no statistically significant differences found between conditions on child outcomes. However, patients accessing Immersive VR consistently reported greater positive shifts in mood state and reductions in negative symptoms when compared with iPad. No change was observed in physiological arousal levels (pulse rate) in either condition before, during or immediately after intervention. Moderation analysis showed that the degree of child illness (PedsQL), sex, age, and level of immersion were important in influencing the magnitude of differences between the VR and iPad conditions on mood, anxiety and pain.

CONCLUSIONS

These preliminary findings support the use of Immersive VR in clinical oncology settings to improve patient well-being. Further studies examining the application of Immersive VR in supporting children adjusting to hospitalization and cancer treatment are therefore warranted. Factors found to moderate VR effectiveness provide important clinical implications.

Self-Administered Skills-Based Virtual Reality Intervention for Chronic Pain: Randomized Controlled Pilot Study

Background

Patients with chronic pain often have limited access to comprehensive care that includes behavioral pain management strategies. Virtual reality (VR) is an immersive technology and emerging digital behavioral pain therapy with analgesic efficacy for acute pain. We found no scientific literature on skills-based VR behavioral programs for chronic pain populations.

Objective

The primary aim of this study is to evaluate the feasibility of a self-administered VR program that included content and skills informed by evidence-based behavioral treatment for chronic pain. The secondary aim is to determine the preliminary efficacy of the VR program in terms of average pain intensity and pain-related interference with activity, stress, mood, and sleep, and its impact on pain-related cognition and self-efficacy. The tertiary aim was to conduct a randomized controlled trial (RCT) and compare the VR treatment with an audio-only treatment. This comparison isolated the immersive effects of the VR program, thereby informing potential mechanisms of effect.

Methods

We conducted an RCT involving a web-based convenience sample of adults (N=97) aged 18-75 years with self-reported chronic nonmalignant low back pain or fibromyalgia, with an average pain intensity >4 over the past month and chronic pain duration >6 months. Enrolled participants were randomly assigned to 1 of 2 unblinded treatments: (1) VR: a 21-day, skills-based VR program for chronic pain; and (2) audio: an audio-only version of the 21-day VR program. The analytic data set included participants who completed at least 1 of 8 surveys administered during the intervention period: VR (n=39) and audio (n=35).

Results

The VR and audio groups launched a total of 1067 and 1048 sessions, respectively. The majority of VR participants (n=19/25, 76%) reported no nausea or motion sickness. High satisfaction ratings were reported for VR (n=24/29, 83%) and audio (n=26/33, 72%). For VR efficacy, symptom improvement over time was found for each pain variable (all P<.001), with results strengthening after 2 weeks. Importantly, significant time×group effects were found in favor of the VR group for average pain intensity (P=.04), pain-related inference with activity (P=.005), sleep (P<.001), mood (P<.001), and stress (P=.003). For pain catastrophizing and pain self-efficacy, we found a significant declining trend for both treatment groups.

Conclusions

High engagement and satisfaction combined with low levels of adverse effects support the feasibility and acceptability of at-home skills-based VR for chronic pain. A significant reduction in pain outcomes over the course of the 21-day treatment both within the VR group and compared with an audio-only version suggests that VR has the potential to provide enhanced treatment and greater improvement across a range of pain outcomes. These findings provide a foundation for future research on VR behavioral interventions for chronic pain.

Machine Learning and Virtual Reality on Body Movements' Behaviors to Classify Children with Autism Spectrum Disorder

Autism spectrum disorder (ASD) is mostly diagnosed according to behavioral symptoms in sensory, social, and motor domains. Improper motor functioning, during diagnosis, involves the qualitative evaluation of stereotyped and repetitive behaviors, while quantitative methods that classify body movements' frequencies of children with ASD are less addressed. Recent advances in neuroscience, technology, and data analysis techniques are improving the quantitative and ecological validity methods to measure specific functioning in ASD children. On one side, cutting-edge technologies, such as cameras, sensors, and virtual reality can accurately detect and classify behavioral biomarkers, as body movements in real-life simulations. On the other, machine-learning techniques are showing the potential for identifying and classifying patients' subgroups. Starting from these premises, three real-simulated imitation tasks have been implemented in a virtual reality system whose aim is to investigate if machine-learning methods on movement features and frequency could be useful in discriminating ASD children from children with typical neurodevelopment. In this experiment, 24 children with ASD and 25 children with typical neurodevelopment participated in a multimodal virtual reality experience, and changes in their body movements were tracked by a depth sensor camera during the presentation of visual, auditive, and olfactive stimuli. The main results showed that ASD children presented larger body movements than TD children, and that head, trunk, and feet represent the maximum classification with an accuracy of 82.98%. Regarding stimuli, visual condition showed the highest accuracy (89.36%), followed by the visual-auditive stimuli (74.47%), and visual-auditive-olfactory stimuli (70.21%). Finally, the head showed the most consistent performance along with the stimuli, from 80.85% in visual to 89.36% in visual-auditive-olfactory condition. The findings showed the feasibility of applying machine learning and virtual reality to identify body movements' biomarkers that could contribute to improving ASD diagnosis.

The Use of Virtual Reality in Psychiatry: A Review

With the advancement in modern information technology, virtual reality (VR) is being increasingly used for the diagnosis, assessment, and treatment of mental disorders. Recently, a VR-based cognitive behavioral therapy for social phobia has been recognized as a new medical technology in South Korea. This might lead to an increase in the use of VR in the field of psychiatry. The present review provides an overview of the status of VR therapies in various psychiatric conditions such as anxiety disorder, post-traumatic stress disorder, psychosis, addiction, and eating disorder. Besides, it summarizes the role of VR therapy in the management of disorders associated with child and adolescence psychiatry as well as various other clinical applications. Additionally, we discuss the merits and limitations of VR therapy, which might serve as a useful reference for researchers. In the current environment wherein novel medical models consisting of a combination of digital devices and medicine are being developed; understanding new technologies such as VR could open new doors to mental health treatments.

Effect of virtual reality therapy on functional development in children with cerebral palsy: A single-blind, prospective, randomized-controlled study

Objectives

The aim of this study was to investigate the effect of virtual reality (VR) therapy on motor and functional development in children with cerebral palsy (CP).

Patients and methods

In this single-blind, prospective, randomized-controlled study, a total of 41 patients (28 males, 13 females; mean age 8.49 years; range, 5 to 15 years) receiving inpatient treatment for CP were included between April 2009 and September 2009. The patients were randomly divided into two groups as the study group (n=21) and control group (n=20). Neurophysiological and conventional treatment methods, and occupational therapy were applied to all patients. In addition, a total of 12 VR therapy sessions for one hour were administered three days a week for four weeks to the study group. Before and after treatment, the Bimanual Fine Motor Function (BFMF) test was performed to measure hand functioning, Gross Motor Function Classification System (GMFCS) for functional levels, and Functional Mobility Scale (FMS) for mobility.

Results

There was a significant increase in the BFMF, GMFCS, and FMS scores after treatment, compared to baseline values in the study group (p<0.05). There was a statistically significant results in favor of the study group for all parameters after treatment compared to pre-treatment values (p<0.05).

Conclusion

Our study results indicate that VR therapy is a useful treatment method which can be used in rehabilitation of CP with improved motor function. The addition of this method to conventional rehabilitation techniques may have a significant impact on treatment success.

AR-Therapist: Design and Simulation of an AR-Game Environment as a CBT for Patients with ADHD

Attention Deficit Hyperactivity Disorder is one of the most common neurodevelopmental disorders in which patients have difficulties related to inattention, hyperactivity, and impulsivity. Those patients are in need of a psychological therapy use Cognitive Behavioral Therapy (CBT) to enhance the way they think and behave. This type of therapy is mostly common in treating patients with anxiety and depression but also is useful in treating autism, obsessive compulsive disorder and post-traumatic stress disorder. A major limitation of traditional CBT is that therapists may face difficulty in optimizing patients' neuropsychological stimulus following a specified treatment plan. Other limitations include availability, accessibility and level-of-experience of the therapists. Hence, this paper aims to design and simulate a generic cognitive model that can be used as an appropriate alternative treatment to traditional CBT, we term as "AR-Therapist." This model takes advantage of the current developments of augmented reality to engage patients in both real and virtual game-based environments.

The Effects of Virtual Reality on Motor Functions and Daily Life Activities in Unilateral Spastic Cerebral Palsy: A Single-Blind Randomized Controlled Trial

Aim: This study was designed to investigate the effects of virtual reality (VR) through Kinect on both gross and fine motor functions and independence in daily living activities in children with unilateral spastic cerebral palsy (USCP). Materials and Methods: This study was designed as a single-blind, randomized, controlled trial. Sixty children with USCP were randomized and split equally between the VR intervention group (10 females and 20 males with a mean age of 10.5 ± 3.62 years) and the traditional occupational therapy (TOT) intervention group (13 females and 17 males with a mean age of 10.06 ± 3.24 years). Both groups were evaluated in terms of motor functioning via the Bruininks-Oseretsky Test of Motor Proficiency-Short Form (BOTMP-SF) and were assessed in accordance with independence in daily activities via the WeeFunctional Independence Measure (WeeFIM). Interventions were conducted for 8 weeks with the main objective of improving motor functions and independence in daily activities. Results: Total motor functions and total independence in daily lives in both groups improved after 8 weeks of intervention. A comparison between groups revealed significantly greater improvements in both gross and fine motor functions and daily activities in the VR group than in the TOT group (P < 0.001). Conclusion: The Kinect-based VR intervention approach is important to improving motor functions and independence in daily activities of children with USCP.

Moving Beyond Role-Play: Evaluating the Use of Virtual Reality to Teach Emotion Regulation for the Prevention of Adolescent Risk Behavior Within a Randomized Pilot Trial

OBJECTIVE

The purpose of the current pilot study was to evaluate the acceptability and preliminary impact of using immersive virtual reality environments (IVREs) paired with a brief emotion regulation and risk reduction intervention (ER + IVRE) relative to this same intervention content paired with role-plays (ER + RP).

METHODS

Eighty-five adolescents attending middle school (grades 6th-8th; ages 12-15 years) in an urban northeast city were recruited and randomized to ER + IVRE (n = 44) or ER + RP (n = 41) and had complete data. Data examining acceptability, feasibility, sexual knowledge and attitudes, and ER were collected at baseline and 3 months after intervention completion. Analyses of covariance controlling for baseline scores were used to evaluate study outcomes. Within and between intervention effect sizes were calculated with effect sizes ≥.20 considered meaningful.

RESULTS

At the 3-month follow-up assessment, several within intervention condition effect sizes were found to exceed d = 0.20 across the measured sexual attitudes and ER outcomes. Between intervention analyses found that adolescents randomized to ER + IVRE attended more intervention sessions, reported less difficulty accessing ER strategies (d = 0.46), and reported higher emotional self-efficacy (d = 0.20) at the 3-month follow-up relative to adolescents randomized to the ER + RP intervention.

CONCLUSIONS

This study provides preliminary evidence that using virtual reality environments to enhance ER skill building in risk situations was acceptable, feasible to deliver, and positively impacted ER abilities.

User-Centered Virtual Reality for Promoting Relaxation: An Innovative Approach

Virtual reality has been used effectively to promote relaxation and reduce stress. It is possible to find two main approaches to achieve such aims across the literature. The first one is focused on generic environments filled with relaxing "narratives" to induce control over one's own body and physiological response, while the second one engages the user in virtual reality-mediated activities to empower his/her own abilities to regulate emotion. The scope of the present contribution is to extend the discourse on VR use to promote relaxation, by proposing a third approach. This would be based on VR with personalized content, based on user research to identify important life events. As a second step, distinctive features of such events may be rendered with symbols, activities or other virtual environments contents. According to literature, it is possible that such an approach would obtain more sophisticated and long-lasting relaxation in users. The present contribution explores this innovative theoretical proposal and its potential applications within future research and interventions.

Do video game interventions improve motor outcomes in children with developmental coordination disorder? A systematic review using the ICF framework

Background

Children with developmental coordination disorder (DCD) experience a range of difficulties that can potentially limit their academic, social and physical ability. Recent research has developed interventions that aim to improve motor outcomes in a variety of paediatric cohorts using video gaming equipment. Therefore, we aimed to systematically review the literature on virtual reality or video game interventions that aim to improve motor outcomes in children with DCD.

Methods

Seven databases were searched for studies using the following criteria: a) virtual reality or video game based intervention; b) children with DCD; and c) motor outcomes relating to body structure and function, activity or participation. Data were extracted relating to study design, participant characteristics, details of the intervention, outcome measures, results, and feasibility/adherence.

Results

Fifteen articles were included for review, including eight randomised controlled trials. No studies used virtual reality equipment, with all interventions using video games (Nintendo Wii in 12/15 articles). Mixed effects of video game intervention on outcome were found, with conflicting evidence across studies. Studies that reported on feasibility found most children enjoyed and adhered to the video game interventions.

Conclusions

This review found limited evidence for the effectiveness of video game interventions for children with DCD to improve motor outcomes due to limitations in the research including low sample sizes and low to moderate methodological quality. Further research is needed to determine the effect of video game or virtual reality interventions on motor outcomes in children with DCD.

Protocol registration

The protocol for this systematic review can be found on PROSPERO (CRD42017064427).

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1381-7) contains supplementary material, which is available to authorized users.

The State of Virtual and Augmented Reality Therapy for Autism Spectrum Disorder (ASD)

Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental condition affecting a growing number of individuals across the lifespan. It is characterized by observable impairments in social communication, as well as repetitive behaviors and restricted patterns of interests. Early, intensive behavioral interventions improve long-term outcomes in ASD, but are often expensive and hard to administer consistently. This chapter describes a new approach to autism intervention, using highly motivating virtual reality (VR) and augmented reality (AR) technologies that could soon support traditional autism therapies across ages and ability levels. The chapter begins by reviewing the ASD phenotype, followed by a review of the current landscape of research on VR and AR in ASD. A discussion of ASD-specific benefits and risks is followed by a presentation of new, harnessed immersive VR technology from Floreo, Inc. Finally, we propose a series of future research directions.

Clinical Virtual Reality: Emerging Opportunities for Psychiatry

Virtual reality (VR) technology offers new opportunities for the development of innovative clinical research, assessment, and intervention tools. VR-based testing, training, teaching, and treatment approaches that would be difficult, if not impossible, to deliver with traditional methods are now being developed that take advantage of the assets that are available with VR technology. As research evidence continues to indicate clinical efficacy, VR applications are being increasingly regarded as providing innovative options for targeting the cognitive, psychological, motor, and functional impairments that result from various clinical health conditions. VR allows for the precise presentation and control of stimuli in dynamic, multisensory, 3D computer-generated simulations as well as providing advanced methods for capturing and quantifying behavioral responses. These characteristics support the rationale for the use of VR applications in clinical assessment, intervention, and training. This article begins with a brief review of the history of and rationale for the use of VR with clinical populations. It then details one use case for the clinical application of VR-the exposure-therapy treatment of anxiety disorders and posttraumatic stress disorder. Although significant work is cited in other areas of clinical VR (e.g., pain management, cognitive and physical assessment and rehabilitation, eating disorders, social skills, and clinical training), a full overview of such a broad literature is beyond the scope of this article. Thus, the authors have opted to provide more in-depth analysis of one specific clinical area that clearly illustrates how VR has been successfully applied and is supported by an encouraging and evolving scientific literature.

Designing Gesture-Based Applications for Individuals with Developmental Disabilities

Gesture interaction provides a multitude of benefits to individuals with developmental disabilities, from enhancing social, motor and cognitive skills to providing a safe and controlled environment for simulating real-world scenarios. As gesture-based applications gain ground in the special education domain, we study their potential in the Indian context. Together with Tamana, an NGO in New Delhi, we have been conducting a series of exploratory user studies since October 2013. This includes the design and evaluation of three gesture-based applications to impart social and life skills to individuals with developmental disabilities. The Kirana application employs socially appropriate gestures to teach the life skill of buying day-to-day items from a local Indian grocery. Balloons promotes joint attention skills through collaborative interaction. HOPE improves motor coordination and social and cognitive skills, with increasing levels of difficulty. Based on studies with these applications, this article presents guidelines for designing gesture-based applications for individuals with developmental disabilities. The guidelines focus on (a) designing applications that cater to a larger group of individuals to encourage collaboration and inclusion, for instance, providing easy and controllable transitions between different task levels, and balancing interaction and content complexity; (b) addressing the challenges in conducting research in this domain, with respect to ethical and procedural decisions; and (c) designing for technology acceptance within the Indian context, for example, by following a collaborative and stakeholder inclusive approach, and addressing apprehensions towards technology adoption. These guidelines aim to benefit other practitioners working in this domain and especially in the educational technology context of India.

Effectiveness of Virtual Reality in Children With Cerebral Palsy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Researchers recently investigated the effectiveness of virtual reality (VR) in helping children with cerebral palsy (CP) to improve motor function. A systematic review of randomized controlled trials (RCTs) using a meta-analytic method to examine the effectiveness of VR in children with CP was thus needed.

PURPOSE

The purpose of this study was to update the current evidence about VR by systematically examining the research literature.

DATA SOURCES

A systematic literature search of PubMed, CINAHL, Cochrane Central Register of Controlled Trials, ERIC, PsycINFO, and Web of Science up to December 2016 was conducted.

STUDY SELECTION

Studies with an RCT design, children with CP, comparisons of VR with other interventions, and movement-related outcomes were included.

DATA EXTRACTION

A template was created to systematically code the demographic, methodological, and miscellaneous variables of each RCT. The Physiotherapy Evidence Database (PEDro) scale was used to evaluate the study quality. Effect size was computed and combined using meta-analysis software. Moderator analyses were also used to explain the heterogeneity of the effect sizes in all RCTs.

DATA SYNTHESIS

. The literature search yielded 19 RCT studies with fair to good methodological quality. Overall, VR provided a large effect size (d = 0.861) when compared with other interventions. A large effect of VR on arm function (d = 0.835) and postural control (d = 1.003) and a medium effect on ambulation (d = 0.755) were also found. Only the VR type affected the overall VR effect: an engineer-built system was more effective than a commercial system.

LIMITATIONS

The RCTs included in this study were of fair to good quality, had a high level of heterogeneity and small sample sizes, and used various intervention protocols.

CONCLUSIONS

Then compared with other interventions, VR seems to be an effective intervention for improving motor function in children with CP.

Virtual Reality in Pediatric Psychology

Virtual reality (VR) technologies allow for controlled simulations of affectively engaging background narratives. These virtual environments offer promise for enhancing emotionally relevant experiences and social interactions. Within this context, VR can allow instructors, therapists, neuropsychologists, and service providers to offer safe, repeatable, and diversifiable interventions that can benefit assessments and learning in both typically developing children and children with disabilities. Research has also pointed to VR's capacity to reduce children's experience of aversive stimuli and reduce anxiety levels. Although there are a number of purported advantages of VR technologies, challenges have emerged. One challenge for this field of study is the lack of consensus on how to do trials. A related issue is the need for establishing the psychometric properties of VR assessments and interventions. This review investigates the advantages and challenges inherent in the application of VR technologies to pediatric assessments and interventions.

Feasibility of Pediatric Game-Based Neurorehabilitation Using Telehealth Technologies: A Case Report

This case report is the first in a series of reports designed to determine the feasibility of implementing game-based neurorehabilitation using telehealth technologies (GbN+TT) for children with cerebral palsy, evaluate the responsiveness of relevant outcome measures to changes in motor impairment and activity participation after intervention, and identify technological challenges associated with implementation of GbN+TT. The participant completed more than 56 hr of game-based neurorehabilitation over 8 wk using the Timocco platform in his home. The primary measures of motor impairment (Bruininks-Oseretsky Test of Motor Proficiency, Second Edition) and function (Pediatric Motor Activity Log) were both sensitive to change. Results indicate that it is feasible to administer GbN+TT to a child with cerebral palsy and monitor outcomes using standardized assessments.

Wii-based interactive video games as a supplement to conventional therapy for rehabilitation of children with cerebral palsy: A pilot, randomized controlled trial

OBJECTIVE

To assess the effect of interactive video gaming (IVG) with Nintendo Wii (Wii) supplemented to conventional therapy in rehabilitation of children with cerebral palsy (CP).

DESIGN

Randomized, controlled, assessor-blinded study.

PARTICIPANTS

Children with CP; 10 children each in the control and intervention groups.

INTERVENTION

IVG using Wii, given as a supplement to conventional therapy, for 45 min per day, 6 days a week for 3 weeks. The children in the control group received conventional therapy alone.

OUTCOME MEASURES

Posture control and balance, upper limb function, visual-perceptual skills, and functional mobility.

RESULTS

Significant improvement in upper limb functions was seen in the intervention group but not in the control group. Improvements in balance, visual perception, and functional mobility were not significantly different between control and intervention groups.

CONCLUSIONS

Wii-based IVG may be offered as an effective supplement to conventional therapy in the rehabilitation of children with CP.

Preparing youth with cancer for amputation: A systematic review

Children and adolescents who require limb amputation as part of cancer treatment face many physical and emotional challenges. Preparatory interventions may serve to facilitate positive coping and improve long-term adjustment during pediatric cancer treatment, including decreasing anxiety and postoperative distress. This review aimed to examine and identify the type and degree of psychosocial preparation provided to the child with cancer and family prior to amputation. Electronic databases including Embase, PubMed, and PsycINFO were searched for relevant research articles. Five studies were identified that satisfied inclusion criteria and revealed common themes for preparatory interventions, but results were limited by a lack of empirical approaches and revealed little consensus on pre-operative support prior to amputation. These findings demonstrate that there is a lack of studies to date that have adequately addressed psychosocial preparation prior to amputation for pediatric oncology patients. Future research on preparatory interventions is needed using prospective and quantitative research to establish evidence-based recommendations for interventions to support this vulnerable population.

Clinical Virtual Reality tools to advance the prevention, assessment, and treatment of PTSD

Numerous reports indicate that the incidence of posttraumatic stress disorder (PTSD) in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) military personnel has created a significant behavioural healthcare challenge. These findings have served to motivate research on how to better develop and disseminate evidence-based treatments for PTSD. The current article presents the use of Virtual Reality (VR) as a clinical tool to address the assessment, prevention, and treatment of PTSD, based on the VR projects that were evolved at the University of Southern California Institute for Creative Technologies since 2004. A brief discussion of the definition and rationale for the clinical use of VR is followed by a description of a VR application designed for the delivery of prolonged exposure (PE) for treating Service Members (SMs) and Veterans with combat- and sexual assault-related PTSD. The expansion of the virtual treatment simulations of Iraq and Afghanistan for PTSD assessment and prevention is then presented. This is followed by a forward-looking discussion that details early efforts to develop virtual human agent systems that serve the role of virtual patients for training the next generation of clinical providers, as healthcare guides that can be used to support anonymous access to trauma-relevant behavioural healthcare information, and as clinical interviewers capable of automated behaviour analysis of users to infer psychological state. The paper will conclude with a discussion of VR as a tool for breaking down barriers to care in addition to its direct application in assessment and intervention.

Bimodal Virtual Reality Stroop for Assessing Distractor Inhibition in Autism Spectrum Disorders

Executive functioning deficits found in college students with ASD may have debilitating effects on their everyday activities. Although laboratory studies tend to report unimpaired inhibition in autism, studies of resistance to distractor inhibition reveal difficulties. In two studies, we compared a Virtual Classroom task with paper-and-pencil and computerized Stroop modalities in typically developing individuals and individuals with ASD. While significant differences were not observed between ASD and neurotypical groups on the paper-and-pencil and computerized task, individuals with ASD performed significantly worse on the virtual task with distractors. Findings suggest the potential of the Virtual Classroom Bimodal Stroop task to distinguish between prepotent response inhibition (non-distraction condition) and resistance to distractor inhibition (distraction condition) in adults with high functioning autism.

Virtual reality as an ecologically valid tool for assessing multifaceted episodic memory in children and adolescents

The majority of episodic memory (EM) tests are far removed from what we experience in daily life and from the definition of this type of memory. This study examines the developmental trajectory of the main aspects of episodic memory—what, where, and when—and of feature binding in a naturalistic virtual environment. A population of 125 participants aged from 6 to 24 years was asked to navigate, by using a joystick, in a virtual urban environment composed of specific areas, and to memorize as many elements as possible (e.g., scenes, details, spatial and temporal contexts). The ability to recall factual content associated to details or spatiotemporal context increased steadily from the age of 8 to young adulthood. These results indicate main developmental differences in feature binding abilities in naturalistic events which are very sensitive to age in comparison with a standard EM assessment. Virtual reality therefore appears to be an appropriate technique to assess crucial aspects of EM development in children and adolescents and it should provide helpful tools for the detection of subtle memory deficits.

Attentional Demand of a Virtual Reality-Based Reaching Task in Nondisabled Older Adults

Attention during exercise is known to affect performance; however, the attentional demand inherent to virtual reality (VR)-based exercise is not well understood. We used a dual-task paradigm to compare the attentional demands of VR-based and non-VR-based (conventional, real-world) exercise: 22 non-disabled older adults performed a primary reaching task to virtual and real targets in a counterbalanced block order while verbally responding to an unanticipated auditory tone in one third of the trials. The attentional demand of the primary reaching task was inferred from the voice response time (VRT) to the auditory tone. Participants' engagement level and task experience were also obtained using questionnaires. The virtual target condition was more attention demanding (significantly longer VRT) than the real target condition. Secondary analyses revealed a significant interaction between engagement level and target condition on attentional demand. For participants who were highly engaged, attentional demand was high and independent of target condition. However, for those who were less engaged, attentional demand was low and depended on target condition (i.e., virtual > real). These findings add important knowledge to the growing body of research pertaining to the development and application of technology-enhanced exercise for elders and for rehabilitation purposes.

Level of Immersion in Virtual Environments Impacts the Ability to Assess and Teach Social Skills in Autism Spectrum Disorder

Virtual environments (VEs) may be useful for delivering social skills interventions to individuals with autism spectrum disorder (ASD). Immersive VEs provide opportunities for individuals with ASD to learn and practice skills in a controlled replicable setting. However, not all VEs are delivered using the same technology, and the level of immersion differs across settings. We group studies into low-, moderate-, and high-immersion categories by examining five aspects of immersion. In doing so, we draw conclusions regarding the influence of this technical manipulation on the efficacy of VEs as a tool for assessing and teaching social skills. We also highlight ways in which future studies can advance our understanding of how manipulating aspects of immersion may impact intervention success.

Effect of a Home-Based Virtual Reality Intervention for Children with Cerebral Palsy Using Super Pop VR Evaluation Metrics: A Feasibility Study

Objective. The purpose of this pilot study was to determine whether Super Pop VR, a low-cost virtual reality (VR) system, was a feasible system for documenting improvement in children with cerebral palsy (CP) and whether a home-based VR intervention was effective. Methods. Three children with CP participated in this study and received an 8-week VR intervention (30 minutes × 5 sessions/week) using the commercial EyeToy Play VR system. Reaching kinematics measured by Super Pop VR and two fine motor tools (Bruininks-Oseretsky Test of Motor Proficiency second edition, BOT-2, and Pediatric Motor Activity Log, PMAL) were tested before, mid, and after intervention. Results. All children successfully completed the evaluations using the Super Pop VR system at home where 85% of the reaches collected were used to compute reaching kinematics, which is compatible with literature using expensive motion analysis systems. Only the child with hemiplegic CP and more impaired arm function improved the reaching kinematics and functional use of the affected hand after intervention. Conclusion. Super Pop VR proved to be a feasible evaluation tool in children with CP.

"Kinect-ing" with clinicians: a knowledge translation resource to support decision making about video game use in rehabilitation

Microsoft's Kinect for Xbox 360 virtual reality (VR) video games are promising rehabilitation options because they involve motivating, full-body movement practice. However, these games were designed for recreational use, which creates challenges for clinical implementation. Busy clinicians require decision-making support to inform game selection and implementation that address individual therapeutic goals. This article describes the development and preliminary evaluation of a knowledge translation (KT) resource to support clinical decision making about selection and use of Kinect games in physical therapy. The knowledge-to-action framework guided the development of the Kinecting With Clinicians (KWiC) resource. Five physical therapists with VR and video game expertise analyzed the Kinect Adventure games. A consensus-building method was used to arrive at categories to organize clinically relevant attributes guiding game selection and game play. The process and results of an exploratory usability evaluation of the KWiC resource by clinicians through interviews and focus groups at 4 clinical sites is described. Subsequent steps in the evaluation and KT process are proposed, including making the KWiC resource Web-based and evaluating the utility of the online resource in clinical practice.

Game Analysis, Validation, and Potential Application of EyeToy Play and Play 2 to Upper-Extremity Rehabilitation

Objective. To describe and analyze the potential use of games in the commercially available EyeToy Play and EyeToy Play 2 on required/targeted training skills and feedback provided for clinical application. Methods. A summary table including all games was created. Two movement experts naïve to the software validated required/targeted training skills and feedback for 10 randomly selected games. Ten healthy school-aged children played to further validate the required/targeted training skills. Results. All but two (muscular and cardiovascular endurance) had excellent agreement in required/targeted training skills, and there was 100% agreement on feedback. Children's performance in required/targeted training skills (number of unilateral reaches and bilateral reaches, speed, muscular endurance, and cardiovascular endurance) significantly differed between games (P < .05). Conclusion. EyeToy Play games could be used to train children's arm function. However, a careful evaluation of the games is needed since performance might not be consistent between players and therapists' interpretation.