Changing Stress Mindset Through Stressjam: A Virtual Reality Game Using Biofeedback

Effect of virtual reality-based biofeedback for depressive and anxiety symptoms: Randomized controlled study

BACKGROUND

The use of virtual reality (VR)-based biofeedback (BF), a relatively new intervention, is a non-pharmacological treatment of depressive and anxiety symptoms. However, studies on VR-based BF are lacking and inconclusive.

METHODS

A total of 131 adults were recruited from the community. Participants who scored ≥10 on the Patient Health Questionnaire-9 (PHQ-9) or ≥9 on the Panic Disorder Severity Scale (PDSS) were included in the group with depressive or anxiety symptoms (DAS group), and others as the healthy control group (HC group). Participants from the DAS group were randomly assigned to VR-based or conventional BF intervention. All individuals visited at three times (weeks 0, 2, and 4), and completed the Montgomery-Asberg Depression Rating Scale (MADRS), the State-Trait Anxiety Inventory (STAI), and a visual analog scale (VAS) before and after the intervention, and PHQ-9 at the beginning and final visit.

RESULTS

The analysis included a total of 118 participants (DAS/VR: 40, DAS/BF: 38, HC/VR: 40). There was no significant difference in demographic variables among the three groups. After the intervention, the DAS/VR group exhibited significant decreases in MADRS (70.0 %), PHQ-9 (64.1 %), STAI (29.5 %), and VAS (61.7 %) scores compared to the baseline (p <0.001). There were no significant differences between the effects of VR-based BF and conventional BF with a therapist. The HC group also showed significant decreases in the measures of depression and anxiety after receiving VR-based BF.

CONCLUSION

VR-based BF was effective in reducing depressive and anxiety symptoms, even for subthreshold depression and anxiety symptoms in the HC group.

Virtual reality and immersive technologies to promote workplace wellbeing: a systematic review

BACKGROUND

Work-related stress negatively impacts employee wellbeing. Stress-management interventions that reduce workplace stress can be challenging. Immersive technologies, such as virtual reality (VR), may provide an alternative.

AIMS

This systematic review aimed to evaluate feasibility, acceptability, and effectiveness of immersive technologies to promote workplace wellbeing (PROSPERO 268460).

METHODS

Databases MEDLINE, Web of Science, PsycINFO and Embase were searched until 22nd July 2021. Studies were included if they tested a workforce or were designed for a workplace. Effective Public Health Practice Project quality assessment tool (EPHPP) was used for quality ratings.

RESULTS

There were 17 studies (N = 1270), published 2011-2021. Over half were conducted in Europe. Eight studies were controlled trials. Most studies involved brief, single sessions of immersive VR and provided evidence of feasibility, acceptability, and effectiveness when measuring wellbeing-related variables such as stress, relaxation, and restoration. VR environments included relaxation tasks such as meditation or breathing exercises, and nature-based stimuli, such as forests, beaches, and water. Studies tested office workers, healthcare professionals, social workers, teachers, and military personnel. EPHPP ratings were "strong" (N = 1), "moderate" (N = 13), and "weak" (N = 3).

CONCLUSIONS

VR relaxation appears helpful for workplaces. However, limited longer-term data, controlled trials, and naturalistic studies mean conclusions must be drawn cautiously.

Paediatric pain management: from regional to virtual

PURPOSE OF REVIEW

Due to increased interest in opioid-sparing multimodal analgesic strategies both inside and outside of the operating room, anaesthesiologists have started to look towards regional anaesthesia as well as nonpharmacological pain-reducing techniques. The purpose of this article is to discuss current trends and recent developments in regional anaesthesia and virtual reality for paediatric pain management.

RECENT FINDINGS

The development of novel fascial plane blocks has expanded regional options for anaesthesiologists, especially when neuraxial anaesthesia is not a viable or straightforward option. Other regional techniques, such as spinal anaesthesia and continuous epidural analgesia for infants and neonates, are becoming more popular, as more paediatric anaesthesiologists become familiar with these techniques. Virtual reality for paediatric pain management is a relatively new area of study that has shown promise, but more research needs to be done before widespread adoption of this practice becomes a reality. Various preexisting pain-reducing strategies such as distraction and biofeedback are being integrated with virtual reality to help optimize its effect on pain and anxiety for paediatric patients.

SUMMARY

Regional anaesthesia and virtual reality are valuable tools that serve to alleviate pain in paediatric patients. Advances are being made within both fields in various healthcare settings for different types of pain. Over the next few years, they will likely both play an increasing role in paediatric pain management.

Virtual reality relaxation for people with mental health conditions: a systematic review

PURPOSE

Vulnerability to stress is linked to poor mental health. Stress management interventions for people with mental health conditions are numerous but they are difficult to implement and have limited effectiveness in this population. Virtual reality (VR) relaxation is an innovative intervention that aims to reduce stress. This review aimed to synthesize evidence of VR relaxation for people with mental health conditions (PROSPERO 269405).

METHODS

Embase, Medline, PsycInfo, and Web of Science were searched until 17th September 2021. The review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The Effective Public Health Practice Project (EPHPP) tool assessed methodological quality of studies.

RESULTS

Searching identified 4550 studies. Eighteen studies (N = 848) were included in the review. Studies were published between 2008 and 2021. Eleven were conducted in Europe. Thirteen studies were controlled trials. Participants were mostly working-age adult outpatients experiencing anxiety or stress-related conditions. Other conditions included eating disorders, depression, bipolar disorder, and psychosis. Five studies tested inpatients. All studies used a range of nature-based virtual environments, such as forests, islands, mountains, lakes, waterfalls, and most commonly, beaches to promote relaxation. Studies provided evidence of the feasibility, acceptability, and short-term effectiveness of VR relaxation to increase relaxation and reduce stress. EPHPP ratings were 'strong' (N = 11), 'moderate' (N = 4), and 'weak' (N = 3).

CONCLUSIONS

VR relaxation has potential as a low-intensity intervention to promote relaxation and reduce stress for adults with mental health conditions, especially anxiety and stress-related problems. Further research is warranted on this promising intervention.

The Effects of Stress Mindset, Manipulated Through Serious Game Intervention, on Performance and Situation Awareness of Elite Female Football Players in the Context of a Match: An Experimental Study

Background: Performance levels in football are ever more important and no longer are just physical, technical, and tactical skills, the ones that make an athlete stand out. Cognitive variables, such as stress-coping, become more important and seem to be explaining differences in performance, for example, through reaching an optimal level of arousal. In addition, it is suggested that stress-coping skills also affect situation awareness (SA), important for decision-making in the complex and dynamic situations in football. Objective: This study was conducted to examine how stress-coping skills, such as stress mindset, affect performance and SA in the context of a football match. Methods: Twenty elite female football players participated in the study. The final sample size consisted of 15 players for the Stress Mindset Measure (SMM) analysis and 8 players for the multilevel model analyses. Two types of intervention were used to manipulate stress mindset and control over heart rate variability (HRV); a serious game called "Stressjam," and a reflection tool called "Brainjam." Questionnaires for stress mindset and SA and video analysis for performance were used. A total of three matches were assessed. Results: The "Stressjam" intervention resulted in significant differences in stress mindset throughout the intervention [F(1,5) = 7.357, P = 0.008]. Subsequently, multilevel analysis showed a positive, strong, and significant correlation between stress mindset, manipulated through "Stressjam" and SA [r(14) = 0.69, P = 0.014]. A correlation of practical interest, given the confidence intervals, was found between stress mindset, manipulated through "Stressjam," and performance. Conclusion: Cognitive variables, such as stress-coping, correlate significantly with SA in football. A correlation of practical interest was found between stress-coping and performance. Further research is needed to study the relationship between stress-coping and performance in football.

Enriched environments enhance the development of explicit memory in an incidental learning task

Learning, rendered in an implicit (unconscious) or explicit (conscious) way, is a crucial part of our daily life. Different factors, like attention or motivation, influence the transformation from implicit to explicit memory. Via virtual reality a lively and engaging surrounding can be created, whereby motivational processes are assumed to be a vital part of the transition from implicit to explicit memory. In the present study, we tested the impact of an enriched virtual reality compared to two conventional, non-enriched 2D-computer-screen based tasks on implicit to explicit memory transformation, using an audio-visual sequential association task. We hypothesized, that the immersive nature of the VR surrounding enhances the transfer from implicit to explicit memory. Notably, the overall amount of learned sequence pairs were not significantly different between experimental groups, but the degree of awareness was affected by the different settings. However, we observed an increased level of explicitly remembered pairs within the VR group compared to two screen-based groups. This finding clearly demonstrates that a near-natural experimental setting affects the transformation process from implicit to explicit memory.

Exploring the Effect of a Nature-based Virtual Reality Environment on Stress in Adolescents

Adolescent mental health is a growing public health issue, with 30% of teens reporting increased stress and 20% of adolescents suffering from depression. Given the scarcity and lack of scalability of mental health services available, the use of self-administered, evidence-based technologies to support adolescent mental health is both timely and imperative. We conducted a mixed-methods pilot study with 31 adolescents ages 14-19 (m = 17.97) to explore the self-administration of a nature-based virtual reality tool. Participant use of the VR environment ranged from 1 to 10 sessions (m = 6.6) at home over a 2-week period while reporting their daily stress and mood levels. All participants completed all of the study protocols, indicating our protocol was feasible and the VR environment engaging. Post-study interviews indicated that most participants found the VR tool to be relaxing and helpful with stress. The themes of Calm Down, Relaxation, and Escape emerged to articulate the participants' experiences using the VR environment. Additionally, participants provided rich data regarding their preferences and activity in the VR environment as well as its effect on their emotional states. Although the sample size was insufficient to determine the impact on depression, we found a significant reduction in momentary stress as a result of using the VR tool. These preliminary data inform our own virtual reality environment design, but also provide evidence of the potential for self-administered virtual reality as a promising tool to support adolescent mental health.

Efficacy of Using Retro Games in Multimodal Biofeedback System for Mental Relaxation

Video games are used to increase the engagement of biofeedback systems. For cost-effectiveness, the original Nintendo Entertainment System (NES) games can be used. Therefore, a multimodal biofeedback system was developed to leverage the NES games for biofeedback. This study aims to test the efficacy of the developed system, the motivation of participants, and the usability of the system. A within-group design study was conducted with 16 participants followed through four interventions: deep breathing, stress-test, non-biofeedback game (control), and biofeedback game (experiment), where their HRV was recorded. Participants showed significantly different HRV during interventions (F(1.60, 23.93) = 11.94, p &lt; 0.001) and reported higher HRV when using biofeedback game than the non-biofeedback game (t(15) = 9.14, p &lt; 0.0001). The motivation was reported to be the same with biofeedback and non-biofeedback version of the game and the overall system was reported as usable. The results of this study support the efficacy of using original NES games in biofeedback for mental relaxation.

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.

Commercial Off-The-Shelf Video Games for Reducing Stress and Anxiety: Systematic Review

BACKGROUND

Using commercial off-the-shelf video games rather than custom-made computer games could have several advantages for reducing stress and anxiety, including their low cost, advanced graphics, and the possibility to reach millions of individuals worldwide. However, it is important to emphasize that not all commercial video games are equal, and their effects strongly depend on specific characteristics of the games.

OBJECTIVE

The aim of this systematic review was to describe the literature on the use of commercial off-the-shelf video games for diminishing stress and anxiety, examining the research outcomes along with critical variables related to computer game characteristics (ie, genre, platform, time of play).

METHODS

A systematic search of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. The search databases were PsycINFO, Web of Science, Medline, IEEExplore, and the Cochrane Library. The search string was: [("video game*") OR ("computer game*")] AND [("stress") OR ("anxiety") OR ("relaxation")] AND [("study") OR ("trial") OR ("training")].

RESULTS

A total of 28 studies met the inclusion criteria for the publication period 2006-2021. The findings demonstrate the benefit of commercial off-the-shelf video games for reducing stress in children, adults, and older adults. The majority of the retrieved studies recruited young adults, and fewer studies have involved children, middle-aged adults, and older adults. In addition to exergames and casual video games, other genres of commercial off-the-shelf games helped to reduce stress and anxiety.

CONCLUSIONS

Efficacy in reducing stress and anxiety has been demonstrated not only for exergames and casual video games but also for other genres such as action games, action-adventure games, and augmented reality games. Various gaming platforms, including consoles, PCs, smartphones, mobile consoles, and virtual reality systems, have been used with positive results. Finally, even single and short sessions of play had benefits in reducing stress and anxiety.

TRIAL REGISTRATION

International Platform of Registered Systematic Review and Meta-analysis Protocols INPLASY202130081; https://inplasy.com/?s=INPLASY202130081.

The Use of Virtual Therapy in Cardiac Rehabilitation of Female Patients with Heart Disease

Background and Objectives: Cardiovascular disease (CVD) has become increasingly prevalent in women, and it is also in this group that the risk of developing depression is the highest. The most commonly applied therapeutic intervention in cardiac rehabilitation is Schultz’s autogenic training, which has proven to be of little efficacy in reducing depression and anxiety disorders. At the same time, a growing number of scientific reports have been looking at the use of virtual reality (VR) to treat mental health problems. This study aimed at assessing the efficacy of virtual therapy in reducing levels of depression, anxiety, and stress in female CVD patients. Materials and Methods: The study included 43 women who were randomly divided into two groups: experimental group (N = 17), where eight-week cardiac rehabilitation was enhanced with VR-based therapeutic sessions, and control group (N = 26), where the VR therapy was replaced with Schultz’s autogenic training. Mental state parameters were measured using the Perception of Stress Questionnaire and Hospital Anxiety and Depression Scale (HADS). Results: In the experimental group, the sole parameter which failed to improve was HADS-Anxiety, which remained at the baseline level. In the control group, there was a deterioration in nearly all tested parameters except for HADS-Depression. Statistically significant differences in the efficacy of rehabilitation were recorded in relation to the level of stress in the sub-scales: emotional tension (p = 0.005), external stress (p = 0.012), intrapsychic stress (p = 0.023) and the generalized stress scale (p = 0.004). Conclusions: VR therapy is an efficient and interesting complement to cardiac rehabilitation, with proven efficacy in reducing stress levels.

Development of a modular stress management platform (Performance Edge VR) and a pilot efficacy trial of a bio-feedback enhanced training module for controlled breathing

This paper describes the conceptual design of a virtual reality-based stress management training tool and evaluation of the initial prototype in a pilot efficacy study. Performance Edge virtual-reality (VR) was co-developed with the Australian Defence Force (ADF) to address the need for practical stress management training for ADF personnel. The VR application is biofeedback-enabled and contains key stress management techniques derived from acceptance and commitment and cognitive behavioural therapy in a modular framework. End-user-provided feedback on usability, design, and user experience was positive, and particularly complimentary of the respiratory biofeedback functionality. Training of controlled breathing delivered across 3 sessions increased participants' self-reported use of breath control in everyday life and progressively improved controlled breathing skills (objectively assessed as a reduction in breathing rate and variability). Thus the data show that a biofeedback-enabled controlled breathing protocol delivered through Performance Edge VR can produce both behaviour change and objective improvement in breathing metrics. These results confirm the validity of Performance Edge VR platform, and its Controlled Breathing module, as a novel approach to tailoring VR-based applications to train stress management skills in a workplace setting.

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.