Immersive virtual reality health games: a narrative review of game design

Virtual Reality to Reduce Pain, Fatigue, and Emotional Distress in People With Cancer: A Scoping Review

BACKGROUND

Cancer and its treatments cause symptoms such as pain, fatigue, and emotional distress, which affect the quality of life of patients at different stages of cancer. Virtual reality (VR) has emerged as a promising alternative for addressing these symptoms by immersing patients in a virtual environment that isolates them from reality.

OBJECTIVE

To describe the existing evidence on the use of VR to improve pain, fatigue, and emotional distress in people with cancer at different stages of the cancer trajectory.

METHODS

A scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Search was conducted in PubMed and CINAHL until October 2023.

RESULTS

Twenty-three primary studies related to the study topic were identified, and the following information was collected: type of VR (immersive vs nonimmersive) used in oncology services, purpose (distraction, training, or relaxation), devices used (head-mounted display, headset, or virtual controller), and the environment simulated (natural environment, skill games, or educational environment). The effects of VR on pain, fatigue, and emotional distress are described, highlighting its ability to mitigate these symptoms in the short term.

CONCLUSIONS

Virtual reality has been shown to be an effective technique for reducing pain, fatigue, and emotional distress in people with cancer in the short term.

IMPLICATIONS FOR PRACTICE

Nurses can use VR as a complementary tool to promote virtual environments that improve the care for and therefore the quality of life of people with cancer.

Impact of VR-Based Cognitive Training on Working Memory and Inhibitory Control in IDD Young Adults

BACKGROUND

Young people with intellectual developmental disabilities have a persistent delay in the development of executive functions. Virtual reality (VR) is increasingly being used as a cognitive intervention tool, with significant effectiveness demonstrated in different types of populations.

METHODS

This pilot study aims to investigate the impact of a cognitive training program utilizing VR on young adults diagnosed with intellectual developmental disabilities (IDDs). The participants (N = 15) served as their own control group and were assessed three times: weeks 0, 8, and 16, with a rest period (0-8 weeks) and an intervention period (8-16 weeks). The assessments included measures of cognitive function provided by E-Prime® (Version 3).

RESULTS

Overall, an improvement in working memory and inhibitory control was found after the intervention, but not in sustained attention.

CONCLUSIONS

These findings suggest that VR-based cognitive training holds promise as an effective intervention for enhancing cognitive abilities in young adults with intellectual developmental disabilities. This study provides a foundation for future investigations into VR's role in cognitive rehabilitation and its potential to support daily living skills and overall quality of life for individuals with IDDs. Further research is needed to explore the long-term effects and broader applicability of VR interventions.

Nursing students' perceptions of interaction in a multiplayer virtual reality simulation: A qualitative descriptive study

AIM

To describe nursing students' perceptions of interaction in a multiplayer virtual reality (MPVR) simulation.

DESIGN

A qualitative descriptive study.

METHODS

Second-semester nursing students (n = 24) participated in pairs in MPVR simulations and semi-structured interviews. Data were analysed deductively and inductively.

RESULTS

Four types of interaction in a MPVR simulation were identified: interaction between the students, interaction between the student and the virtual environment (VE), interaction between the student and the virtual patient (VP), and interaction between the student and the simulation facilitator. Interaction consisted of verbal and nonverbal interaction, as well as object manipulation and movement in the VE. The reasons for interaction were to coordinate the care, to assess the VP, and to implement VPs' care.

CONCLUSIONS

MPVR simulation offered nursing students an opportunity to practice nurse-to-nurse interaction and interaction related to nurses' collaboration, which are essential skills in nursing practice. Students were also able to interact with the VP, which can promote students' nurse-patient interaction skills. Therefore, MPVR simulations can be utilized as a platform to enhance interaction skills of future healthcare professionals, which could improve patient safety.

PATIENT OR PUBLIC CONTRIBUTION

None.

CFI: a VR motor rehabilitation serious game design framework integrating rehabilitation function and game design principles with an upper limb case

Virtual reality (VR) Rehabilitation holds the potential to address the challenge that patients feel bored and give up long-term rehabilitation training. Despite the introduction of gaming elements by some researchers in rehabilitation training to enhance engagement, there remains a notable lack of in-depth research on VR rehabilitation serious game design methods, particularly the absence of a concrete design framework for VR rehabilitation serious games. Hence, we introduce the Clinical-Function-Interesting (CFI): a VR rehabilitation serious game design framework, harmonizing rehabilitation function and game design theories. The framework initiates with clinic information, defining game functions through the functional decomposition of rehabilitation training. Subsequently, it integrates gaming elements identified through the analysis and comparison of related literature to provide enduring support for long-term training. Furthermore, VR side-effect and enhancement are considered. Building upon this design framework, we have developed an upper limb VR rehabilitation serious game tailored for mild to moderate stroke patients and aligned our framework with another developed VR rehabilitation serious game to validate its practical feasibility. Overall, the proposed design framework offers a systematic VR rehabilitation serious game design methodology for the VR rehabilitation field, assisting developers in more accurately designing VR rehabilitation serious games that are tailored to specific rehabilitation goals.

Technological Features of Immersive Virtual Reality Systems for Upper Limb Stroke Rehabilitation: A Systematic Review

Stroke is the second most common cause of death worldwide, and it greatly impacts the quality of life for survivors by causing impairments in their upper limbs. Due to the difficulties in accessing rehabilitation services, immersive virtual reality (IVR) is an interesting approach to improve the availability of rehabilitation services. This systematic review evaluates the technological characteristics of IVR systems used in the rehabilitation of upper limb stroke patients. Twenty-five publications were included. Various technical aspects such as game engines, programming languages, headsets, platforms, game genres, and technical evaluation were extracted from these papers. Unity 3D and C# are the primary tools for creating IVR apps, while the Oculus Quest (Meta Platforms Technologies, Menlo Park, CA, USA) is the most often used headset. The majority of systems are created specifically for rehabilitation purposes rather than being readily available for purchase (i.e., commercial games). The analysis also highlights key areas for future research, such as game assessment, the combination of hardware and software, and the potential integration incorporation of biofeedback sensors. The study highlights the significance of technological progress in improving the effectiveness and user-friendliness of IVR. It calls for additional research to fully exploit IVR's potential in enhancing stroke rehabilitation results.

Virtual reality as a method of cognitive training of processing speed, working memory, and sustained attention in persons with acquired brain injury: a protocol for a randomized controlled trial

BACKGROUND

Acquired brain injury (ABI) often leads to persisting somatic, cognitive, and social impairments. Cognitive impairments of processing speed, sustained attention, and working memory are frequently reported and may negatively affect activities of daily living and quality of life. Rehabilitation efforts aiming to retrain these cognitive functions have often consisted of computerized training programs. However, few studies have demonstrated effects that transfer beyond the trained tasks. There is a growing optimism regarding the potential usefulness of virtual reality (VR) in cognitive rehabilitation. The research literature is sparse, and existing studies are characterized by considerable methodological weaknesses. There is also a lack of knowledge about the acceptance and tolerability of VR as an intervention method for people with ABI. The present study aims to investigate whether playing a commercially available VR game is effective in training cognitive functions after ABI and to explore if the possible effects transfer into everyday functioning.

METHODS

One hundred participants (18-65 years), with a verified ABI, impairments of processing speed/attention, and/or working memory, and a minimum of 12 months post injury will be recruited. Participants with severe aphasia, apraxia, visual neglect, epilepsy, and severe mental illness will be excluded. Participants will be randomized into two parallel groups: (1) an intervention group playing a commercial VR game taxing processing speed, working memory, and sustained attention; (2) an active control group receiving psychoeducation regarding compensatory strategies, and general cognitive training tasks such as crossword puzzles or sudoku. The intervention period is 5 weeks. The VR group will be asked to train at home for 30 min 5 days per week. Each participant will be assessed at baseline with neuropsychological tests and questionnaires, after the end of the intervention (5 weeks), and 16 weeks after baseline. After the end of the intervention period, focus group interviews will be conducted with 10 of the participants in the intervention group, in order to investigate acceptance and tolerability of VR as a training method.

DISCUSSION

This study will contribute to improve understanding of how VR is tolerated and experienced by the ABI population. If proven effective, the study can contribute to new rehabilitation methods that persons with ABI can utilize in a home setting, after the post-acute rehabilitation has ended.

The Application of Virtual Reality in Shoulder Surgery Rehabilitation

To achieve a positive functional prognosis in orthopedic surgery, particularly in shoulder surgeries, effective rehabilitation is essential. Recently, there has been growing interest in the use of virtual reality (VR) in the field of orthopedics, particularly for preoperative education and training, as well as clinical and home-based rehabilitation. This report describes the process of developing an application utilizing Meta Quest 2 VR technology (Meta, CA, USA) for rehabilitation after shoulder surgery. This application assists patients in performing postoperative exercises at home by wearing VR equipment tailored to their postoperative weeks. The advantages of VR rehabilitation lie in overcoming the limitations of traditional rehabilitation methods and providing patients with a better rehabilitation experience. Moreover, automating the rehabilitation process and reducing patients' visits to clinics can lead to cost savings. This report raises expectations for the potential and scalability of VR utilization, extending beyond orthopedics to other fields. In addition, it anticipates that with better feedback and motivation, the rehabilitation effects for patients can be further enhanced.

Participatory Development of a Virtual Reality Exercise Program for People with Chronic Pain

Background: By describing how a participatory process led to changes in the design of a study of a virtual reality (VR)-guided exercise and mindfulness intervention tailored to people with chronic musculoskeletal pain, this article makes the case for including end user at an early stage when planning research within this field. Methods: A multidisciplinary panel including end-user representatives, researcher, clinicians, and VR developers participated in a 1-day workshop to design a randomized study and a VR-guided intervention. Results: Through the participatory process, changes were made to the original study design with respect to experimental design, duration, content of VR interventions and mode of delivery. Conclusion: This case exemplifies the importance of including end-user participants in the early phases of planning VR interventions for people with chronic pain.

Training using a commercial immersive virtual reality system on hand–eye coordination and reaction time in students: a randomized controlled trial

Abstract

The implementation of VR games opens up a wide range of opportunities for the development of dexterity, speed and precision of movements among various professional groups. The aim of this study was to investigate the effects of a commercial immersive VR music game on hand–eye coordination and reaction time speed in students. This study enrolled 32 individuals, randomly assigned to the experimental or control group. The intervention consisted of a 15-min training session of the immersive music game “Beat Saber”, once a day for 5 consecutive days. The primary outcomes included reaction time measurements: the plate tapping test and the ruler-drop test (Ditrich's test), trial making test (TMT) A and TMT B to assess coordination and visual attention, likewise VR sickness assessment by Virtual Reality Sickness Questionnaire (VRSQ). The secondary outcome included an energy expenditure assessment (SenseWear Armband). The data analysis revealed a statistically significant improvement in hand–eye coordination in the experimental group, with no improvement in the control group. The results were similar in measurements of reaction time. Analysis of the VRSQ questionnaire results showed a statistically significant reduction in oculomotor domain symptoms and total score during successive training days. The immersive VR music game has the potential to improve reaction time and hand–eye coordination in students.

Graphical abstract

Effect of Virtual Game-Based Integrated Clinical Practice Simulation Program on Undergraduate Nursing Students' Attitude Toward Learning

Game-based virtual reality simulation programs can capitalize on the advantages of non-face-to-face education while effectively stimulating the interest of trainees and improving training efficiency. This study aimed to develop a game-based virtual reality simulation program for nervous system assessment and to evaluate the effects of the program on the learning attitudes of nursing students. Using a one-group pretest-posttest design, 41 senior nursing students were enrolled, and their learning attitudes (self-directed learning attitude, academic self-efficacy, flow-learning experience, and learning presence) were evaluated. The effect of the program was statistically significant in self-directed learning attitude ( t = -2.27, P = .027) and learning presence ( t = -3.07, P = .003), but the difference was not statistically significant in academic self-efficacy ( t = -1.97, P = .054) and learning flow ( t = -0.74, P = .459). The virtual gaming simulation program can be used to effectively replace field training in situations wherein field training is limited, such as during the COVID-19 pandemic.

Efficacy of virtual reality-based training programs and games on the improvement of cognitive disorders in patients: a systematic review and meta-analysis

INTRODUCTION

Cognitive impairments present challenges for patients, impacting memory, attention, and problem-solving abilities. Virtual reality (VR) offers innovative ways to enhance cognitive function and well-being. This study explores the effects of VR-based training programs and games on improving cognitive disorders.

METHODS

PubMed, Scopus, and Web of Science were systematically searched until May 20, 2023. Two researchers selected and extracted data based on inclusion and exclusion criteria, resolving disagreements through consultation with two other authors. Inclusion criteria required studies of individuals with any cognitive disorder engaged in at least one VR-based training session, reporting cognitive impairment data via scales like the MMSE. Only English-published RCTs were considered, while exclusion criteria included materials not primarily focused on the intersection of VR and cognitive disorders. The risk of bias in the included studies was assessed using the MMAT tool. Publication bias was assessed using funnel plots and Egger's test. The collected data were utilized to calculate the standardized mean differences (Hedges's g) between the treatment and control groups. The heterogeneity variance was estimated using the Q test and I2 statistic. The analysis was conducted using Stata version 17.0.

RESULTS

Ten studies were included in the analysis out of a total of 3,157 retrieved articles. VR had a statistically significant improvement in cognitive impairments among patients (Hedges's g = 0.42, 95% CI: 0.15, 0.68; p_value = 0.05). games (Hedges's g = 0.61, 95% CI: 0.30, 0.39; p_value = 0.20) had a more significant impact on cognitive impairment improvement compared to cognitive training programs (Hedges's g = 0.29, 95% CI: -0.11, 0.69; p_value = 0.24). The type of VR intervention was a significant moderator of the heterogeneity between studies.

CONCLUSION

VR-based interventions have demonstrated promise in enhancing cognitive function and addressing cognitive impairment, highlighting their potential as valuable tools in improving care for individuals with cognitive disorders. The findings underscore the relevance of incorporating virtual reality into therapeutic approaches for cognitive disorders.

Design of Virtual Reality Exergames for Upper Limb Stroke Rehabilitation Following Iterative Design Methods: Usability Study

BACKGROUND

Since the early 2000s, there has been a growing interest in using exercise video games (exergames) and virtual reality (VR)-based interventions as innovative methods to enhance physical rehabilitation for individuals with multiple disabilities. Over the past decade, researchers and exercise professionals have focused on developing specialized immersive exercise video games for various populations, including those who have experienced a stroke, revealing tangible benefits for upper limb rehabilitation. However, it is necessary to develop highly engaging, personalized games that can facilitate the creation of experiences aligned with the preferences, motivations, and challenges communicated by people who have had an episode of stroke.

OBJECTIVE

This study seeks to explore the customization potential of an exergame for individuals who have undergone a stroke, concurrently evaluating its usability as a technological tool in the realm of physical therapy and rehabilitation.

METHODS

We introduce a playtest methodology to enhance the design of a VR exergame developed using a user-centered approach for upper limb rehabilitation in stroke survivors. Over 4 playtesting sessions, stroke survivors interacted with initial game versions using VR headsets, providing essential feedback for refining game content and mechanics. Additionally, a pilot study involving 10 stroke survivors collected data through VR-related questionnaires to assess game design aspects such as mechanics, assistance, experience, motion sickness, and immersion.

RESULTS

The playtest methodology was beneficial for improving the exergame to align with user needs, consistently incorporating their perspectives and achieving noteworthy results. The pilot study revealed that users had a positive response. In the first scenario, a carpenter presents a game based on the flexion-extension movement of the elbow; the second scenario includes a tejo game (a traditional Colombian throwing game) designed around game mechanics related to the flexion-extension movement of the shoulder; and in the third scenario, a farmer challenges the player to perform a movement combining elbow flexion and extension with internal and external rotation of the shoulder. These findings suggest the potential of the studied exergame as a tool for the upper limb rehabilitation of individuals who have experienced a stroke.

CONCLUSIONS

The inclusion of exergames in rehabilitation for stroke-induced hemiparesis has significantly benefited the recovery process by focusing on essential shoulder and elbow movements. These interactive games play a crucial role in helping users regain mobility and restore practical use of affected limbs. They also serve as valuable data sources for researchers, improving the system's responsiveness. This iterative approach enhances game design and markedly boosts user satisfaction, suggesting exergames have promising potential as adjunctive elements in traditional therapeutic approaches.

Co-design of a therapeutic virtual reality tool to increase awareness and self-management of cognitive fatigue after traumatic brain injury

PURPOSE

The symptom of cognitive fatigue is reported as one of the longest lasting and most debilitating symptoms of traumatic brain injury (TBI). Virtual reality may be one of the most suitable technologies for neurorehabilitation, able to integrate evidence-based neuroscientific principles into motivating rehabilitation simulations. The purpose of this study was to seek perspectives of individuals with lived experience of TBI and experienced rehabilitation clinicians in the co-design of a novel technology-based tool for cognitive fatigue after TBI.

MATERIALS AND METHOD

Co-design focus groups with a sample of clinicians and individuals with lived experience of TBI were used to identify the design parameters. A prototype was developed using inter-disciplinary design iterations. Focus groups were repeated with participants testing the prototype. Qualitative data were analysed using a general inductive approach.

RESULTS

Feasibility of VR in this population was well tolerated. The focus groups guided development of domains including environment, tasks, level progression, outcome measures and considerations about clinical implementation of VR.

CONCLUSIONS

By merging advancements in VR science with a translational approach, a co-designed virtual reality tool to increase awareness and self-management of cognitive fatigue has been developed, suitable for use in persons with TBI.Implications for rehabilitationImmersive virtual reality tools show promise for addressing awareness of cognitive fatigue after traumatic brain injury in rehabilitation settings.Early engagement with consumers is recommended to produce a usable rehabilitation product.

Individualized Virtual Reality for Increasing Self-Compassion: Evaluation Study

BACKGROUND

Depression and anxiety are common and debilitating mental disorders with severe negative repercussions at both individual and societal levels. Although virtual reality (VR) has emerged as a safe and effective tool for the treatment of anxiety disorders, studies of the therapeutic application of VR to treat depression are more limited.

OBJECTIVE

The purpose of this study was to test whether a novel type of individualized VR (iVR) can be used to improve self-compassion and decrease depressive symptoms and to evaluate the usability and acceptability of this approach, as rated by participants. The iVR system was designed and developed based on the feedback obtained from a previous study, with improved appearance and feel of the avatar and enhanced graphical quality.

METHODS

A total of 36 young adult participants were recruited from a university community social media site. Participants were aware that the study was investigating a treatment for depression but were not recruited based on depression diagnosis. Participants were asked to complete 2 iVR sessions, spaced 2 weeks apart. At baseline and upon completion of each iVR session, participants were asked to complete validated measures of self-compassion and depression. Upon completion of both iVR sessions, additional measures were administered to assess participants' perceptions about the perceived usability and system acceptability of the iVR approach.

RESULTS

Self-compassion was assessed at the beginning of session 1 (preintervention baseline) and at the end of session 1 (postintervention assessment). Owing to COVID-19 constraints, 36% (13/36) of the participants were unable to complete the follow-up iVR session. Self-compassion was assessed again for the remaining 64% (23/36) of the participants at the end of session 2 (postintervention assessment). Within-group analyses revealed that self-compassion was significantly increased at the end of both session 1 (P=.01) and session 2 (P=.03) relative to baseline. There was also a nonsignificant trend for depressive symptoms to be low at the end of session 2 relative to baseline. Both quantitative and qualitative participant data supported the iVR approach as being acceptable and usable.

CONCLUSIONS

Although these data must be treated as preliminary owing to the small sample size and potential selection bias, the data provide encouraging initial evidence that iVR might be a useful tool to enhance self-compassion and reduce depressive symptoms, highlighting the need for randomized controlled trials in the future.

Virtual Reality-Based Exercise Therapy for Patients with Chronic Musculoskeletal Pain: A Scoping Review

This scoping review aimed to identify interventions utilizing virtual-reality-based exercise therapy in patients with chronic musculoskeletal pain. Searches were conducted in four databases using descriptors related to virtual reality, exercise, and chronic musculoskeletal pain. Two reviewers screened the titles and abstracts of the studies to assess eligibility, with a third author resolving any discrepancies. Data were extracted and summarized in a narrative format by three independent raters. Clinical trials were evaluated using the PEDro scale to assess the effectiveness of virtual-reality-based exercise therapy in chronic musculoskeletal pain patients. A total of 162 articles were identified from the databases. After applying the inclusion criteria, nine articles were considered suitable for analysis, including six randomized clinical trials. The selected articles were categorized based on study characteristics, virtual-reality-based exercise therapy interventions (including technologies and equipment used), exercise interventions, outcome measures, and effectiveness. The findings indicate that virtual-reality-based exercise therapy shows promising results in reducing pain, improving disability, enhancing range of motion, and increasing treatment satisfaction in patients with chronic musculoskeletal pain. However, it is not possible to conclude that virtual-reality-based exercise therapy is superior to other treatments due to the limited number of available studies, heterogeneity in application protocols, and varying methodological quality. Further research is needed to draw more definitive conclusions.

Intensity of a Physical Exercise Programme Executed through Immersive Virtual Reality

Evidence suggests that moderate to vigorous physical activity (MVPA) is necessary for health benefits. Immersive virtual reality is a technology that uses images, sounds, and tactile sensations from a simulated world to encourage healthy behaviours and physical activity. The aims of this research are (1) to determine the duration and intensity of physical activity performed through immersive virtual reality; (2) to determine differences in physical activity intensity according to gender.

METHODS

A nonprobabilistic convenience sample composed of 39 university students of physical education pedagogy, who performed, through immersive virtual reality, a physical activity programme composed of three levels that progressively increased in complexity. Physical activity intensity was measured using accelerometers.

RESULTS

Of the three levels, the most complex was not the one that produced the most minutes of MVPA. The three levels added up to 08:53 min of MVPA. No significant differences were found when comparing them by sex.

CONCLUSIONS

The results of this study suggest that an exercise programme delivered through immersive virtual reality generates MVPA levels, with no major differences between sexes. Further research is needed to confirm the contribution of immersive virtual reality to physical activity.

Reliability and Validity of the Arabic Version of the Game Experience Questionnaire: Pilot Questionnaire Study

BACKGROUND

Nowadays, digital gaming occupies a central position in the entertainment industry where it has developed into a cherished kind of entertainment in markets all over the world. In addition, it provides other sectors with various social and economic benefits. The Game Experience Questionnaire (GEQ) is a free, quantitative, and comprehensive self-report measure that was developed to assess the player game experience. Despite having been widely used by many research projects in the past, it has not been adapted into Arabic. Furthermore, several components of the scale proved problematic from a psychometric point of view. Therefore, a modified version of the scale is needed to measure the gaming experience of the Arab population.

OBJECTIVE

The aim of this study was to validate and examine the psychometrics of an adapted Arabic version of the GEQ in Tunisia.

METHODS

A total of 771 volunteer participants completed an online survey, which included an Arabic version of the GEQ, gaming data, and a sociodemographic questionnaire. Subjects were randomized in order to complete two phases of the study: exploratory and confirmatory. The exploratory data were acquired from 360 respondents whose mean age was 23.89 (SD 2.29) years. Out of 360 respondents, 111 (30.8%) were female and 249 (69.2%) were male. Confirmatory data were obtained from the remaining 411 subjects whose mean age was 21.94 (SD 1.80) years. Out of 411 subjects, 169 (41.1%) were female and 242 (58.9%) were male.

RESULTS

After the elimination of two items, the exploratory and the confirmatory factor analyses provided an adequate factor structure of the Arabic version of the GEQ. In addition, the internal consistency coefficients suggested the reliability of the instrument. Significant differences were revealed for three subcomponents: flow by age (η²=0.013, P=.002), gender (η²=0.007, P=.02), and game type (η²=0.03, P<.001). For competence (η²=0.01, P=.03) and immersion (η²=0.02, P=.01), significant differences were highlighted by the type of game. The discriminant and convergent validities of the instrument were supported by calculating the average variance extracted (AVE) and comparing the square roots of the AVE values to the correlation coefficients, respectively.

CONCLUSIONS

The Arabic adapted version of the GEQ is valid and reliable and can be administered to measure the game experience in Arab countries.

Adolescents' perceptions and user experiences with a virtual reality-based alcohol prevention tool in Germany: A focus group study

Background

Excessive alcohol consumption is a major public health problem, with substance use early in life contributing to higher levels of use later in life. Virtual reality (VR) is an innovative technology for alcohol prevention among adolescents that could solve the problem of insufficient outreach to the target group of young people. The co-created German Virtual LimitLab simulation is one of the few examples of VR-based alcohol prevention tools and consists of a virtual house party simulation. The aims of Virtual LimitLab are to increase the users' awareness of how social pressure can influence their own decision-making as well as to enable various actions and communication strategies in order to train competencies when dealing with alcohol. The present study thus aims to explore adolescents' content- and technique-specific perceptions of Virtual LimitLab in order to gain insights into user experiences and to test the prototype with the German target group.

Methods

Four semi-structured focus groups with adolescents aged 15-18 years (n = 13) were conducted and analyzed using thematic analyses. A user experience questionnaire (UEQ-S) was applied in order to quantitatively assess adolescents' satisfaction with Virtual LimitLab.

Results

Three main themes were identified (VR experience, content, and technical aspects). Participants positively assessed both the content and the technical aspects of Virtual LimitLab. This trend was also seen by the UEQ-S data, which yielded positive ratings for both pragmatic and hedonic quality. The broad variety of options in the simulation that allow the user to try new behaviors was perceived particularly positively. In general, Virtual LimitLab was regarded as an innovative tool that encourages adolescents to think critically about their personal alcohol consumption. Technical errors in the simulation and users' difficulties in identifying with the simulation were the main points of criticism.

Conclusions

Feedback from adolescent users revealed positive and therefore promising results when using Virtual LimitLab as a gaming alcohol-prevention tool. Some technical aspects still need to be improved in order to further refine the prototype, and suggestions for expanding the content of the application have already been made.

Effectiveness of virtual reality distraction interventions to reduce dental anxiety in paediatric patients: A systematic review and meta-analysis

OBJECTIVES

To analyse the effectiveness of virtual reality (VR) distraction intervention for the management of dental anxiety in paediatric patients.

DATA

Randomised controlled trials (RCTs) of VR distraction interventions for reducing anxiety in paediatric patients, published in English were included.

SOURCES

Seven databases, including PubMed, Web of Science, Scopus, MEDLINE via ProQuest, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials, covering the period between January 2000 and September 2022 were searched.

STUDY SELECTION

A total of 12 RCTs involving 818 participants were included. Quality appraisal was undertaken using the Cochrane risk-of-bias tool for randomised trials by two authors independently. Random-effects model was used to summarise the effects of the interventions and pool data.

CONCLUSIONS

Results showed that VR distraction interventions were effective in reducing the dental anxiety of paediatric patients. In meta-analysis, the VR distraction interventions had a significant effect on reducing paediatric patients' anxiety (SMD = -1.74, 95%CI = -2.46, -1.02, p < 0.001, I² = 95%), pain (SMD = -1.57, 95%CI = -2.22, -0.91, p < 0.001, I² = 91%) and heart rate (MD = -10.54, 95%CI = -20.26, -0.81, p = 0.03, I² = 99%) during dental treatment. However, the evidence of VR in managing dental anxiety would become weak because of the publication bias.

CLINICAL SIGNIFICANCE

VR distraction interventions could be an effective approach to alleviate the dental anxiety of paediatric patients. Additional well-designed and high-quality RCTs with larger sample sizes are needed to determine the optimal way to deliver VR interventions in paediatric dental clinics.

Effects of virtual reality on physical, cognitive, and psychological outcomes in cancer rehabilitation: a systematic review and meta-analysis

PURPOSE

To systematically examine and summarize the current evidence regarding the effects of virtual reality (VR) on physical, cognitive, and psychological outcomes in cancer rehabilitation.

METHODS

Six bioscience and engineering databases were searched. Two independent reviewers screened the titles and abstracts of 2397 records and retrieved 25 full-text articles. Inclusion criteria included patients with a current or previous diagnosis of cancer; VR was used as an intervention for physical, cognitive, or psychological impairments and functional limitations; and clinical trials with at least two arms and with both pre- and post-intervention assessments. Reviewers assessed methodological quality using the Physiotherapy Evidence Database scale.

RESULTS

Seventeen studies including 799 patients with cancer were identified. Within-group pooled analysis indicated that patients demonstrated significant improvement in pain (P < 0.001), fatigue (P < 0.001), anxiety (P < 0.001), upper extremity function (P < 0.001), and quality of life (P = 0.008) after VR intervention. Between-group pooled analysis indicated significant improvements with VR in pain (P = 0.004), anxiety (P < 0.001), and upper extremity function (P < 0.001) compared with the control. Three studies reported the positive effects of VR on cognition.

CONCLUSIONS

VR demonstrates promising effects in physical, cognitive, and psychological aspects of patients with cancer. VR can be incorporated into a comprehensive cancer rehabilitation program to alleviate impairments and functional limitations.

Effects of Low-Immersive vs. High-Immersive Exercise Environment on Postural Stability and Reaction and Motor Time of Healthy Young Adults

(1) Background: Many young adults spend their time playing games and watching television. This type of spending time should be used effectively, so it's worth adding exercise and immersion to them. Bearing in mind that the video games and physical exercise also improve postural stability, motor time (MT) and reaction time (RT), it is worth reaching for new technologies with immersion that are widely available and can be used, for example, as a remote intervention. This study aimed to compare the effects of a low vs. high-immersive exercise environment on postural stability, RT and MT in young adults. (2) Methods: Ninety-three participants were randomly divided into a control group (CG; n = 48) and experimental group (EG; n = 45). The CG exercised according to the Tabata self-made video display on a television set, and the EG exercised according to the Audio Trip exergame. In addition to the postural stability, RT and MT, we monitored the heart rate, breath rate and energy expenditure for safety reasons and to note any differences. (3) Results: Significant differences were observed for both groups in RT (F(2.182) = 3.14, p = 0.046, η² = 0.03) and MT (F(2.182) = 3.07, p = 0.049, η² = 0.03) and in postural stability in eyes closed (EC): F(2.182) = 3.66, p = 0.028, η² = 0.04 and eyes open in one leg (EO-OL): F(2.182) = 5.814, p = 0.04, η² = 0.07. (4) Conclusions: The inclusion of a higher immersion produces greater improvements in RT, MT. Additionally, after a low-immersive exercise environment, participants have higher center of pressure (COP) path length values with EC and EO-OL tests, which testifies to less postural stability. Regarding COP trajectory, a smaller area surface means better performance for high-immersive participants after 30 min of exercise.

Virtual Reality for Shoulder Rehabilitation: Accuracy Evaluation of Oculus Quest 2

Virtual reality (VR) systems are becoming increasingly attractive as joint kinematics monitoring systems during rehabilitation. This study aimed to evaluate the accuracy of the Oculus Quest 2 in measuring translational and rotational displacements. As the Oculus Quest 2 was chosen for future applications in shoulder rehabilitation, the translation range (minimum: ~200 mm, maximum: ~700 mm) corresponded to the forearm length of the 5th percentile female and the upper limb length of the 95th percentile male. The controller was moved on two structures designed to allow different translational displacements and rotations in the range 0-180°, to cover the range of motion of the upper limb. The controller measures were compared with those of a Qualisys optical capture system. The results showed a mean absolute error of 13.52 ± 6.57 mm at a distance of 500 mm from the head-mounted display along the x-direction. The maximum mean absolute error for rotational displacements was found to be 1.11 ± 0.37° for a rotation of 40° around the z-axis. Oculus Quest 2 is a promising VR tool for monitoring shoulder kinematics during rehabilitation. The inside-out movement tracking makes Oculus Quest 2 a viable alternative to traditional motion analysis systems.

Active Virtual Reality for Chronic Primary Pain: Mixed Methods Randomized Pilot Study

Background

The modern management of chronic pain is largely focused on improving functional capacity (often despite ongoing pain) by using graded activation and exposure paradigms. However, many people with chronic pain find functional activation programs aversive, and dropout rates are high. Modern technologies such as virtual reality (VR) could provide a more enjoyable and less threatening way for people with chronic pain to engage in physical activity. Although VR has been successfully used for pain relief in acute and chronic pain settings, as well as to facilitate rehabilitation in conditions such as stroke and cerebral palsy, it is not known whether VR can also be used to improve functional outcomes in people with chronic pain.

Objective

This study aimed to assess the feasibility of conducting an adequately powered randomized controlled trial (RCT) to test the efficacy of VR in a chronic pain treatment center and assess the acceptability of an active VR treatment program for patients in this setting.

Methods

For this mixed methods pilot study, which was designed to test the feasibility and acceptability of the proposed study methods, 29 people seeking treatment for chronic pain were randomized to an active VR intervention or physiotherapy treatment as usual (TAU). The TAU group completed a 6-week waitlist before receiving standard treatment to act as a no-treatment control group. The VR intervention comprised twice-weekly immersive and embodied VR sessions using commercially available gaming software, which was selected to encourage movement. A total of 7 VR participants completed semistructured interviews to assess their perception of the intervention.

Results

Of the 99 patients referred to physiotherapy, 53 (54%) were eligible, 29 (29%) enrolled, and 17 (17%) completed the trial, indicating that running an adequately powered RCT in this setting would not be feasible. Despite this, those in the VR group showed greater improvements in activity levels, pain intensity, and pain interference and reported greater treatment satisfaction and perceived improvement than both the waitlist and TAU groups. Relative effect sizes were larger when VR was compared with the waitlist (range small to very large) and smaller when VR was compared with TAU (range none to medium). The qualitative analysis produced the following three themes: VR is an enjoyable alternative to traditional physiotherapy, VR has functional and psychological benefits despite continued pain, and a well-designed VR setup is important.

Conclusions

The active VR intervention in this study was highly acceptable to participants, produced favorable effects when compared with the waitlist, and showed similar outcomes as those of TAU. These findings suggest that a confirmatory RCT is warranted; however, substantial barriers to recruitment indicate that incentivizing participation and using a different treatment setting or running a multicenter trial are needed.

Virtual Reality-Based Interface for Advanced Assisted Mobile Robot Teleoperation

This work proposes a new interface for the teleoperation of mobile robots based on virtual reality that allows a natural and intuitive interaction and cooperation between the human and the robot, which is useful for many situations, such as inspection tasks, the mapping of complex environments, etc. Contrary to previous works, the proposed interface does not seek the realism of the virtual environment but provides all the minimum necessary elements that allow the user to carry out the teleoperation task in a more natural and intuitive way. The teleoperation is carried out in such a way that the human user and the mobile robot cooperate in a synergistic way to properly accomplish the task: the user guides the robot through the environment in order to benefit from the intelligence and adaptability of the human, whereas the robot is able to automatically avoid collisions with the objects in the environment in order to benefit from its fast response. The latter is carried out using the well-known potential field-based navigation method. The efficacy of the proposed method is demonstrated through experimentation with the Turtlebot3 Burger mobile robot in both simulation and real-world scenarios. In addition, usability and presence questionnaires were also conducted with users of different ages and backgrounds to demonstrate the benefits of the proposed approach. In particular, the results of these questionnaires show that the proposed virtual reality based interface is intuitive, ergonomic and easy to use.

Mobile-Health based physical activities co-production policies towards cardiovascular diseases prevention: findings from a mixed-method systematic review

BACKGROUND

Cardiovascular disease (CVD) is the first cause of death globally, with huge costs worldwide. Most cases of CVD could be prevented by addressing behavioural risk factors. Among these factors, there is physical and amateur sports activity (PASA), which has a linear negative correlation with the risk of CVD. Nevertheless, attempts to encourage PASA, as exercise prescription programmes, achieved little impact at the community-wide level. A new frontier to promote PASA is represented by mobile health tools, such as exergaming, mobile device apps, health wearables, GPS/GIS and virtual reality. Nevertheless, there has not yet been any evident turnabout in patient active involvement towards CVD prevention, and inactivity rates are even increasing. This study aims at framing the state of the art of the literature about the use of m-health in supporting PASA, as a user-centric innovation strategy, to promote co-production health policies aiming at CVD prevention.

METHODS

A mixed-method systematic literature review was conducted in the fields of health and healthcare management to highlight the intersections between PASA promotion and m-health tools in fostering co-produced services focused on CVD prevention. The literature has been extracted by the PRISMA logic application. The resulting sample has been first statistically described by a bibliometric approach and then further investigated with a conceptual analysis of the most relevant contributions, which have been qualitatively analysed.

RESULTS

We identified 2,295 studies, on which we ran the bibliometric analysis. After narrowing the research around the co-production field, we found 10 papers relevant for the concept analysis of contents. The interest about the theme has increased in the last two decades, with a high prevalence of contributions from higher income countries and those with higher CVD incidence. The field of research is highly multi-disciplinary; most of documents belong to the medical field, with only a few interconnections with the technology and health policy spheres. Although the involvement of patients is recognized as fundamental for CVD prevention through PASA, co-design schemes are still lacking at the public management level.

CONCLUSIONS

While the link between the subjects of motor activity, medicine and technology is clear, the involvement of citizens in the service delivery process is still underinvestigated, especially the issue concerning how "value co-creation" could effectively be applied by public agencies. In synthesis, the analysis of the role of co-production as a system coordination method, which is so important in designing and implementing preventive care, is still lacking.

The Symbiosis of Virtual Reality Exposure Therapy and Telemental Health: A Review

Phobias and related anxiety are common and costly mental health disorders. Experts anticipate the prevalence of phobias will increase due to the COVID-19 pandemic. Exposure therapies have been established as effective and reliable treatments for anxiety, including recent innovations in virtual reality-based exposure therapy (VRET). With the recent advent of telemental health (TMH), VRET is poised to become mainstream. The combination of VRET and TMH has the potential to extend provider treatment options and improve patient care experiences. In this narrative review, we describe how recent events have accelerated VRET + TMH, identify barriers to VRET + TMH implementation, and discuss strategies to navigate those barriers.

Group-based telerehabilitation intervention using Wii Fit to improve walking in older adults with lower limb amputation (WiiNWalk): A randomized control trial

OBJECTIVE

Determine efficacy of the novel WiiNWalk intervention on walking-related outcomes in older adults with lower limb amputation.

DESIGN

Multi-site, parallel, evaluator-masked randomized controlled trial.

SETTING

Home-setting in three Canadian cities.

PARTICIPANTS

Community-dwelling lower limb prosthesis users over 50 years of age.

INTERVENTIONS

The WiiNWalk group (n = 38) used modified Wii Fit activities for prosthetic rehabilitation. The attention control group (n = 33) used Big Brain Academy: Wii Degree, comprising of cognitive activities. Both groups completed a 4-week supervised phase with three 1-h sessions/week in groups of three overseen by a clinician via videoconferencing and a 4-week unstructured and unsupervised phase.

MAIN MEASURES

Primary outcome was walking capacity (2 min walk test); secondary outcomes were balance confidence (activities-specific balance confidence scale), dynamic balance (four-step square test), and lower limb functioning (short physical performance battery). Outcomes were compared across time points with repeated measures analysis of covariance, adjusting for baseline and age.

RESULTS

Mean age was 65.0 (8.4) years, with 179.5 (223.5) months post-amputation and 80% transtibial amputation. No group difference in a 2 min walk test with an effect size: 1.53 95% CI [-3.17, 6.23] m. Activities balance confidence was greater in the WiiNWalk group by 5.53 [2.53, 8.52]%. No group difference in the four-step square test -0.16 [-1.25, 0.92] s, nor short physical performance battery 0.48 [-0.65, 1.61]. A post-hoc analysis showed the greatest difference in balance confidence immediately after an unsupervised phase.

CONCLUSIONS

The WiiNWalk intervention improved balance confidence, but not walking-related physical function in older adult lower limb prosthesis users. Future rehabilitation games should be specific to the amputation context.Clinical Trial Registration number, NCT01942798.

Adaptive Admittance Control Scheme with Virtual Reality Interaction for Robot-Assisted Lower Limb Strength Training

Muscle weakness is the primary impairment causing mobility difficulty among stroke survivors. Millions of people are unable to live normally because of mobility difficulty every year. Strength training is an effective method to improve lower extremity ability but is limited by the shortage of medical staff. Thus, this paper proposes a robot-assisted active training (RAAT) by an adaptive admittance control scheme with virtual reality interaction (AACVRI). AACVRI consists of a stiffness variable admittance controller, an adaptive controller, and virtual reality (VR) interactions. In order to provide human-robot reality interactions corresponding to virtual scenes, an admittance control law with variable stiffness term was developed to define the mechanics property of the end effector. The adaptive controller improves tracking performances by compensating interaction forces and dynamics model deviations. A virtual training environment including action following, event feedback, and competition mechanism is utilized for improving boring training experience and engaging users to maintain active state in cycling training. To verify controller performances and the feasibility of RAAT, experiments were conducted with eight subjects. Admittance control provides desired variable interactions along the trajectory. The robot responds to different virtual events by changing admittance parameters according to trigger feedbacks. Adaptive control ensures tracking errors at a low level. Subjects were maintained in active state during this strength training. Their physiological signals significantly increased, and interaction forces were at a high level. RAAT is a feasible approach for lower limb strength training, and users can independently complete high-quality active strength training under RAAT.

Cardiac Rehabilitation Early after Sternotomy Using New Assistive VR-Enhanced Robotic Exoskeleton-Study Protocol for a Randomised Controlled Trial

(1) Background and objective: Cardiac rehabilitation (CR) means delivering health education by structured exercises with the means of risk reduction, in a cost-effective manner. Well-conducted CR improves functional capacity, decreases re-hospitalization, and reduces mortality up to 25%. We bring to attention the protocol of a randomised control trial with the aim of validating the prototype of an assistive upper-body robotic exoskeleton system enhanced with a non-immersive virtual reality exergame (CardioVR-ReTone) in patients who undergone cardiac surgery. (2) Methods: Description of the CardioVR-ReTone system and the technical specification, followed by the group selection, randomization and evaluated variables. (3) Expected results: The primary outcome measurement is the modification of life quality at the end of the CR exercise training program. Secondary outcomes will encompass measurements of sternal stability, muscular activity, cardiac response to exercise, pain level and compliance/adherence to CR. (4) Conclusions: Implementing these novel features of the CardioVR-ReTone system, addressability, and efficacy of CR, so problematic in certain situations and especially in cardiac surgery, will be greatly facilitated, being independent of the skills and availability of the rehabilitation therapist.

Virtual Reality-Based Treatment Approaches in the Field of Substance Use Disorders

Purpose

Substance use disorders (SUD) are burdening chronic conditions characterized by high relapse rates despite severe negative consequences. Substance-related cues that elicit craving by means of automatic physiological and behavioural responses have long been suggested to predict relapse. One major mechanism contributing to relapse behaviour are cue-induced behavioural approach tendencies towards the addictive agent. Recently, there has been an emerging interest in virtual reality (VR)-based approaches to assess and modify craving and its related responses. This review aims at elucidating (1) VR techniques applied in the field of SUD, (2) VR as an induction/assessment tool for biopsychological correlates of craving and (3) VR-based therapeutic approaches.

Findings

There is an emerging number of studies focusing on different substances of abuse incorporating VR in craving induction/assessment as well as therapy. Despite some limitations as missing of randomized controlled clinical trials with large samples and missing data on the long-term effects of VR treatment, the VR approach showed consistent results in eliciting and reducing craving across different substances.

Summary

This review suggests virtual reality as a promising tool for the assessment and treatment of craving among individuals with substance use disorders. Because of its ecological validity, VR unifies the benefits of a laboratory setting with the advantages of a realistic environment. Further studies with large samples and randomized controlled clinical trials using more homogenous VR techniques as well as assessment of objective biophysiological craving markers are required.