Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research

Application of virtual reality for supportive care in cancer patients: a systematic review

BACKGROUND

In recent years, virtual reality (VR) technology has been widely used to support cancer patients with physical, emotional, and functional needs. This systematic review aimed to investigate the application of VR in the supportive care of cancer patients.

METHOD

This systematic review was conducted in 2024. In this study, various databases including PubMed, Web of Science, Scopus, the Cochrane Library, Ovid, IEEE Xplore, and ProQuest were searched, and quantitative, qualitative, and mixed-method studies which were in English and published up to 20th May 2024 were included. The keywords consisted of "virtual reality," "supportive care," and "cancer". Studies were assessed in terms of quality and risk of bias using standard tools, and results were analyzed and reported narratively.

RESULTS

A total of 33 articles were reviewed. VR interventions, primarily using fully immersive head-mounted displays, were associated with significant reductions in anxiety, pain, and fatigue. VR also improved mood, relaxation, and overall quality of life, and some studies noted enhanced vital signs such as heart rate and blood pressure. This technology could be used along with other medical interventions. Both patients and healthcare providers reported high level of satisfaction with VR, and appreciated its ease of use and therapeutic benefits. However, some technical barriers, like inadequate visual performance and realism, were reported.

CONCLUSION

VR demonstrates substantial potential benefits as a supportive care tool for cancer patients, effectively addressing their psychological, physiological, psychosocial needs. Despite technical challenges, high level of user satisfaction and benefits underscore the need for further research to optimize VR interventions in cancer care.

Experiences and perceptions of palliative care patients receiving virtual reality therapy: a meta-synthesis of qualitative studies

BACKGROUND

The combination of virtual reality (VR) and palliative care potentially represents a new opportunity for palliative care. Many previous studies have evaluated the application of VR therapy to patients with advanced disease receiving palliative care. However, patient-perspective reviews to comprehensively understand the actual experiences and feelings of patients and provide practical guidance for designing future studies are currently lacking. This review of qualitative evidence aimed to explore the experiences and perceptions of patients receiving VR therapy in palliative care.

METHODS

This study was conducted in accordance with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement guidelines. Ten databases, namely, PubMed, Web of Science, EBSCO, OVID MEDLINE, Scopus, John Wiley, ProQuest, CNKI, WANFANG DATA, and SinoMed, were searched, and qualitative and mixed studies from the establishment of each database to June 30, 2023 were included. The Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research was used to assess the quality of the included studies. The data included in the literature were analyzed and integrated by "thematic synthesis" to formalize the identification and development of themes.

RESULTS

The nine selected studies altogether included 156 participants from seven hospice care facilities of different types and two oncology centers. Three key themes were identified: experiences of palliative care patients in VR therapy, the perceived value that palliative care patients gain in VR therapy, and perspectives of palliative care patients toward using VR therapy.

CONCLUSIONS

The patients' feedback covered discomfort caused by VR devices, good sense of experiences, and situations that affected the interactive experience. Some patients were unable to tolerate VR therapy or reported newer forms of discomfort. The findings indicated that VR therapy may be an effective approach to relieve patients' physical and psychological pain and help them gain self-awareness. Moreover, patients showed a preference for personalized VR therapy.

Using Virtual Reality in a Rehabilitation Program for Patients With Breast Cancer: Phenomenological Study

Background

Surgery is an essential treatment for early-stage breast cancer. However, various side effects of breast cancer surgery, such as arm dysfunction and lymphedema, remain causes for concern. Rehabilitation exercises to prevent such side effects should be initiated within 24 hours after surgery. Virtual reality (VR) can assist the process of rehabilitation; however, the feasibility of applying VR for rehabilitation must be explored, in addition to experiences of this application.

Objective

This study explored patients' attitudes toward and experiences of using VR for their rehabilitation to determine the feasibility of such VR use and to identify potential barriers.

Methods

A phenomenological qualitative study was conducted from September to December 2021. A total of 18 patients with breast cancer who had undergone surgical treatment were interviewed using open-ended questions. The Colaizzi 7-step procedure for phenomenological analysis was used for data analysis. To ensure high study reliability, this study followed previously reported quality criteria for trustworthiness.

Results

Three themes were identified: (1) VR was powerful in facilitating rehabilitation, (2) early and repetitive upper limb movements were an advantage of VR rehabilitation, and (3) extensive VR use had challenges to be overcome. Most of the interviewed patients reported positive experiences of using VR for rehabilitation. Specifically, VR helped these patients identify appropriate motion and angle limits while exercising; in other words, knowledge gained through VR can play a key role in the rehabilitation process. In addition, the patients reported that the use of VR provided them company, similar to when a physiotherapist is present. Finally, the gamified nature of the VR system seemed to make VR-based rehabilitation more engaging than traditional rehabilitation, particularly with respect to early rehabilitation; however, the high cost of VR equipment made VR-based rehabilitation difficult to implement at home.

Conclusions

The interviewed patients with breast cancer had positive experiences in using VR for rehabilitation. The high cost of both VR equipment and software development presents a challenge for applying VR-based rehabilitation.

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.

The effect of virtual reality on reducing patients' anxiety and pain during dental implant surgery

BACKGROUND

Dental anxiety and pain pose serious problems for both patients and dentists. One of the most stressful and frightening dental procedures for patients is dental implant surgery; that even hearing its name causes them stress. Virtual reality (VR) distraction is an effective intervention used by healthcare professionals to help patients cope with unpleasant procedures. Our aim is to evaluate the use of high-quality VR and natural environments on dental implant patients to determine the effect on reducing pain and anxiety.

METHODS

Seventy-three patients having two dental implant surgeries participated in a randomized controlled trial. One surgery was with VR, and one was without. Anxiety was measured with the the State-Trait Anxiety Inventory and the Modified Dental Anxiety Scale tests. The pain was measured with the Numerical Rating Scales. Patient satisfaction, surgeon distress, memory vividness, and time perception were evaluated. Physiological data were collected with biofeedback and neurofeedback device.

RESULTS

VR effectively reduced anxiety and pain compared to no VR. Physiological data validated the questionnaire results. Patient satisfaction increased, with 90.4% willing to reuse VR. VR reduced time perception and memory vividness.

CONCLUSION

Psychometric and psychophysiological assessments showed that VR successfully reduced patient pain and anxiety. More dental clinicians should use VR technology to manage patient anxiety and pain.

Preoperative Virtual Reality to Expose Patients With Breast Cancer to the Operating Room Environment: Feasibility and Pilot Case Series Study

BACKGROUND

Clinically elevated preoperative distress and anxiety are common among patients undergoing cancer surgery. Preoperative interventions have been developed to mitigate this distress and anxiety but are inconsistent in efficacy and feasibility for broad implementation.

OBJECTIVE

This preliminary pilot study aims to assess the feasibility and utility of a newly developed virtual reality (VR) intervention to expose patients awaiting breast cancer surgery to the operating room environment and a simulation of anesthetic induction.

METHODS

Patients undergoing breast cancer surgery (N=7) were assigned to the VR intervention or control (treatment as usual) group and completed self-report measures of distress and anxiety before surgery, on the day of surgery, and after surgery (5 and 30 d postoperatively). Those in the intervention group trialed the VR simulation 1 to 2 weeks preoperatively and provided qualitative and quantitative feedback. We assessed the feasibility of recruitment capability and study design and evaluated participants' impressions of the intervention using self-report rating scales and open-ended questions. We also descriptively examined distress and anxiety levels throughout the duration of the study.

RESULTS

Recruitment occurred between December 2021 and December 2022 and progressed slowly (rate: 1 participant/7 wk on average; some hesitancy because of stress and being overwhelmed). All participants who consented to participate completed the entire study. All participants were female and aged 56 (SD 10.56) years on average. In total, 57% (4/7) of the participants were assigned to the intervention group. On average, intervention participants spent 12 minutes engaged in the VR simulation. In general, the intervention was rated favorably (eg, clear information, enjoyable, and attractive presentation; mean% agreement 95.00-96.25, SD 4.79-10.00) and as helpful (mean% agreement 87.50, SD 25.00). Participants described the intervention as realistic (eg, "It was realistic to my past surgical experiences"), impacting their degree of preparedness and expectations for surgery (eg, "The sounds and sights and procedures give you a test run; they prepare you for the actual day"), and having a calming or relaxing effect (eg, "You feel more relaxed for the surgery").

CONCLUSIONS

This preoperative VR intervention demonstrated preliminary feasibility among a sample of patients undergoing breast cancer surgery. Results and participant feedback will inform modifications to the VR intervention and the study design of a large-scale randomized controlled trial to examine the efficacy of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04544618; https://clinicaltrials.gov/study/NCT04544618.

Nature-based mindfulness programs using virtual reality to reduce pediatric perioperative anxiety: a narrative review

Over 75% of pediatric surgery patients experience preoperative anxiety, which can lead to complicated recoveries. Current interventions are less effective for children over 12 years old. New interventions, like mindfulness-based ones (MBIs), are needed to address this issue. MBIs work well for reducing mental health symptoms in youth, but they can be challenging for beginners. Virtual reality (VR) nature settings can help bridge this gap, providing an engaging 3-D practice environment that minimizes distractions and enhances presence. However, no study has investigated the combined effects of mindfulness training in natural VR settings for pediatric surgery patients, creating a significant gap for a novel intervention. This paper aims to fill that gap by presenting a narrative review exploring the potential of a nature-based mindfulness program using VR to reduce pediatric preoperative anxiety. It begins by addressing the risks of anxiety in children undergoing surgery, emphasizing its impact on physical recovery, and supporting the use of VR for anxiety reduction in hospitals. The review then delves into VR's role in nature and mindfulness, discussing theoretical concepts, clinical applications, and effectiveness. It also examines how the combination of mindfulness, nature, and VR can create an effective intervention, supported by relevant literature. Finally, it synthesizes the existing literature's limitations, findings, gaps, and contradictions, concluding with research and clinical implications.

A systematic review on the efficacy of virtual reality and gamification interventions for managing anxiety and depression

This systematic review aims to assess the effectiveness of virtual reality (VR) and gamification interventions in addressing anxiety and depression. The review also seeks to identify gaps in the current VR treatment landscape and provide guidelines for future research and development. A systematic literature search was conducted using Scopus, Web of Science, and PubMed databases, focusing on studies that utilized VR and gamification technology to address anxiety and depression disorders. A total of 2,664 studies were initially identified, 15 of those studies fulfilled the inclusion criteria for this systematic review. The efficacy of VR in addressing anxiety and depression was evident across all included studies. However, the diversity among VR interventions highlights the need for further investigation. It is advised to incorporate more diverse participant samples and larger cohorts and explore a broader spectrum of therapeutic approaches within VR interventions for addressing anxiety and depression to enhance the credibility of future research. Additionally, conducting studies in varying socioeconomic contexts would contribute to a more comprehensive understanding of their real-world applicability.

Adverse Effects of Virtual and Augmented Reality Interventions in Psychiatry: Systematic Review

BACKGROUND

Virtual reality (VR) and augmented reality (AR) are emerging treatment modalities in psychiatry, which are capable of producing clinical outcomes broadly comparable to those achieved with standard psychotherapies.

OBJECTIVE

Because the side effect profile associated with the clinical use of VR and AR remains largely unknown, we systematically reviewed available evidence of their adverse effects.

METHODS

A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework across 3 mental health databases (PubMed, PsycINFO, and Embase) to identify VR and AR interventions targeting mental health diagnoses.

RESULTS

Of 73 studies meeting the inclusion criteria, 7 reported worsening clinical symptoms or an increased fall risk. Another 21 studies reported "no adverse effects" but failed to identify obvious adverse effects, mainly cybersickness, documented in their results. More concerningly, 45 of the 73 studies made no mention of adverse effects whatsoever.

CONCLUSIONS

An appropriate screening tool would help ensure that VR adverse effects are correctly identified and reported.

TFOS Lifestyle: Impact of the digital environment on the ocular surface

Eye strain when performing tasks reliant on a digital environment can cause discomfort, affecting productivity and quality of life. Digital eye strain (the preferred terminology) was defined as "the development or exacerbation of recurrent ocular symptoms and/or signs related specifically to digital device screen viewing". Digital eye strain prevalence of up to 97% has been reported, due to no previously agreed definition/diagnostic criteria and limitations of current questionnaires which fail to differentiate such symptoms from those arising from non-digital tasks. Objective signs such as blink rate or critical flicker frequency changes are not 'diagnostic' of digital eye strain nor validated as sensitive. The mechanisms attributed to ocular surface disease exacerbation are mainly reduced blink rate and completeness, partial/uncorrected refractive error and/or underlying binocular vision anomalies, together with the cognitive demand of the task and differences in position, size, brightness and glare compared to an equivalent non-digital task. In general, interventions are not well established; patients experiencing digital eye strain should be provided with a full refractive correction for the appropriate working distances. Improving blinking, optimizing the work environment and encouraging regular breaks may help. Based on current, best evidence, blue-light blocking interventions do not appear to be an effective management strategy. More and larger clinical trials are needed to assess artificial tear effectiveness for relieving digital eye strain, particularly comparing different constituents; a systematic review within the report identified use of secretagogues and warm compress/humidity goggles/ambient humidifiers as promising strategies, along with nutritional supplementation (such as omega-3 fatty acid supplementation and berry extracts).

Speech-Language Pathologists' Views of Using Virtual Reality for Managing Cognitive-Communication Disorders Following Traumatic Brain Injury

PURPOSE

Using virtual reality (VR) to support rehabilitation is an emerging area of research that may offer people with communication disorders a stable and safe communication environment to practice their communication skills. There are currently no VR applications that have been designed to assess or treat cognitive-communication disorders (CCDs) following traumatic brain injury (TBI). Therefore, this study aimed to explore the views of speech-language pathologists (SLPs) who work with people who have a TBI to generate ideas and considerations for using VR in rehabilitation for CCDs. VR researchers were included to provide expert advice about VR technology.

METHOD

A total of 14 SLPs and three VR specialists participated in an online interview or focus group. Semistructured discussions explored participants' perspectives related to potential ideas for VR use and any perceived barriers and facilitators to VR implementation for managing CCDs following TBI. Data were video- and audio-recorded, transcribed, and analyzed qualitatively using thematic analysis.

RESULTS

Three main themes were generated from thematic analysis: VR is a tool that could enhance clinical practice, the need to consider and navigate potential red flags, and solutions to pave the way forward. Suggestions to overcome perceived barriers to VR use were also provided.

DISCUSSION

Participants expressed interest in using VR for rehabilitation of CCDs following TBI. However, potential barriers and risks to use should be considered prior to implementation. The findings offer guidance to support future research and development of VR in this field.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21669647.

A Systematic Review and Meta-Analysis of the Effectiveness of Virtual Reality-Based Rehabilitation Therapy on Reducing the Degree of Pain Experienced by Individuals with Low Back Pain

BACKGROUND

The concept of virtual reality (VR)-based rehabilitation therapy for treating people with low back pain is of growing research interest. However, the effectiveness of such therapy for pain reduction in clinical settings remains controversial.

METHODS

The present study was conducted according to the reporting guidelines presented in the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. We searched the PubMed, Embase, CENTRAL, and ProQuest databases for both published and unpublished papers. The Cochrane risk of bias tool (version 2) was used to evaluate the quality of the selected studies. GRADEprofiler software (version 3.6.4) was used to evaluate the level of evidence. We analyzed the included research results using RevMan software (version 5.4.1).

RESULTS

We included a total of 11 articles in the systematic review and meta-analysis, with a total of 1761 subjects. Having assessed the quality of these studies, the risk of bias was generally low with high heterogeneity. The results revealed a small to medium effect (standardized mean difference = ±0.37, 95% confidence interval: 0.75 to 0) based on evidence of moderate overall quality.

CONCLUSION

There is evidence that treatment using VR improves patients' pain. The effect size was small to medium, with the studies presenting evidence of moderate overall quality. VR-based treatment can reduce pain; therefore, it may help in rehabilitation therapy.

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 Treatment of Substance Use Disorders: Recent Developments and New Perspectives

Substance-related disorders are complex psychiatric disorders that are characterized by continued consumption in spite of harmful consequences. Addiction affects various brain networks critically involved in learning, reward, and motivation, as well as inhibitory control. Currently applied therapeutic approaches aim at modification of behavior that ultimately leads to decrease of consumption or abstinence in individuals with substance use disorders. However, traditional treatment methods might benefit from recent neurobiological and cognitive neuroscientific research findings. Novel cognitive-behavioral approaches in the treatment of addictive behavior aim at enhancement of strategies to cope with stressful conditions as well as craving-inducing cues and target erroneous learning mechanisms, including cognitive bias modification, reconsolidation-based interventions, mindfulness-based interventions, virtual-reality-based cue exposure therapy as well as pharmacological augmentation strategies. This review discusses therapeutic strategies that target dysregulated neurocognitive processes associated with the development and maintenance of disordered substance use and may hold promise as effective treatments for substance-related disorders.

The Effectiveness of Immersive Virtual Reality (VR) Based Mindfulness Training on Improvement Mental-Health in Adults: A Narrative Systematic Review

OBJECTIVE

In recent years, digital techniques, such as virtual reality (VR) has been employed in tandem with more traditional psychological interventions. The aim of this study is to investigate whether VR-based mindfulness training can improve mental health outcomes, and notably mindfulness levels amongst adults. In addition, this review seeks to summarise the various designed VR scenarios, as well as those elements around VR that may assist people in practising mindfulness and meditation.

METHODS

The search for eligible studies for inclusion was conducted via the following databases: the Applied Social Science Index & Abstract (ASSIA), PsychINFO, Medline, EMBASE, and the Web-of-Science Core Collection. Only experimental studies were eligible for inclusion, and specifically, those that compared the effectiveness of mindfulness training using immersive VR (on the one hand) with a control condition.

RESULTS

This search generated 2523 articles published between 2016 and 2022, and of these, 106 were assessed for eligibility. This review included seven studies, with a collective total of 798 participants. VR-based mindfulness training has been shown to be more effective than conventional mindfulness - it improves levels of mindfulness and meditation experience; but also shown to reduce anxiety, depression, improve sleep quality, emotion regulation, and generate mood improvement. VR-based mindfulness training frequently contains natural 'environmentally relevant' elements, such as forest, grassland, caves, sea, etc. CONCLUSIONS: This review suggests that using VR to assist mindfulness training is an effective and innovative way to improve mental health conditions within the adult population. Further directions and limitations are discussed.

A virtual reality home-based training for the management of stress and anxiety among healthcare workers during the COVID-19 pandemic: study protocol for a randomized controlled trial

Background

Healthcare workers represent one of the most affected categories by the adverse effects of the COVID-19 pandemic on mental health. Excessive stress and anxiety are critical factors that could compromise work performance. Besides, high levels of stress and anxiety may have long-term physical and psychological consequences. Recent studies investigated virtual reality to reduce stress and anxiety among healthcare workers during the COVID-19 pandemic. However, the proposed virtual reality interventions have important limitations related to their location (i.e., research lab and hospitals) and content (i.e., virtual experiences only for relaxation). Within this context, this randomized controlled trial aims to investigate the efficacy and acceptability of a brief home-based virtual reality training for managing stress and anxiety during the COVID-19 crisis in a sample of Italian healthcare workers.

Methods

The study is a randomized controlled trial. It includes two groups of 30 individuals recruited from healthcare workers: (1) the experimental group and (2) the control group. Participants in the experimental group will receive a training consisting of three home sessions performed in a week. In each session, participants will try through an immersive virtual reality standalone system (i.e., Oculus Quest 2) a virtual psychoeducation experience on stress and anxiety (i.e., MIND-VR). Subsequently, they will try the virtual relaxation content (i.e., The Secret Garden). The control group will receive no training and will be reassessed one week and one month after the initial evaluation.

Discussion

If the proposed brief home-based virtual reality training will result helpful and easy to use, it could become an empirically assessed viable option for protecting healthcare workers’ mental health both during the COVID-19 pandemic and once it will be over. Furthermore, the intervention might be easily adapted for other categories of people who need support in managing stress and anxiety.

Trial registration

ClinicalTrials.gov NCT04611399.

Virtual Reality Behavioral Activation for Adults With Major Depressive Disorder: Feasibility Randomized Controlled Trial

BACKGROUND

Major depressive disorder (MDD) is a global crisis with increasing incidence and prevalence. There are many established evidence-based psychotherapies (EBPs) for depression, but numerous barriers still exist; most notably, access and dissemination. Virtual reality (VR) may offer some solutions to existing constraints of EBPs for MDD.

OBJECTIVE

We aimed to examine the feasibility, acceptability, and tolerability of using VR as a method of delivering behavioral activation (BA) for adults diagnosed with MDD during a global pandemic and to explore for signs of clinical efficacy by comparing VR-enhanced BA (VR BA) to a standard BA treatment and a treatment as usual control group for individuals diagnosed with MDD.

METHODS

A feasibility trial using a 3-armed, unblinded, randomized controlled pilot design was conducted. The study took place remotely via Zoom telehealth visits between April 8, 2020, and January 15, 2021. This study used a 3-week, 4-session protocol in which VR BA participants used a VR headset to complete their BA homework. Feasibility was measured using dropout rates, serious adverse events, completion of homework, an adapted telepresence scale, the Simulator Sickness Questionnaire, the Brief Agitation Measure, and an adapted Technology Acceptance Model. Efficacy was assessed using the Patient Health Questionnaire-9.

RESULTS

Of the 35 participants assessed for eligibility, 13 (37%) were randomized into VR BA (n=5, 38%), traditional BA (n=4, 31%), or a treatment as usual control (n=4, 31%). The mean age of the 13 participants (5/13, 38% male; 7/13, 54% female; and 1/13, 8% nonbinary or third gender) was 35.4 (SD 12.3) years. This study demonstrated VR BA feasibility in participants with MDD through documented high levels of acceptability and tolerability while engaging in VR-induced pleasurable activities in conjunction with a brief BA protocol. No adverse events were reported. This study also illustrated that VR BA may have potential clinical utility for treating MDD, as the average VR BA participant's clinical severity decreased by 5.67 points, signifying a clinically meaningful change in severity from a moderate to a mild level of depression as per the Patient Health Questionnaire-9 score.

CONCLUSIONS

The findings of this study demonstrate that VR BA is safe and feasible to explore for the treatment of MDD. This study documented evidence that VR BA may be efficacious and justifies further examination in an adequately powered randomized controlled trial. This pilot study highlights the potential utility that VR technology may offer patients with MDD, especially those who have difficulty accessing real-world pleasant activities. In addition, for those having difficulty accessing care, VR BA could be adapted as a first step to help people improve their mood and increase their motivation while waiting to connect with a health care professional for other EBPs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04268316; https://clinicaltrials.gov/ct2/show/NCT04268316.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/24331.

Effectiveness of Immersive Virtual Reality in Nursing Education: Systematic Review

BACKGROUND

Digital education using immersive virtual reality (VR) technology is available in nursing. Evidence of its effectiveness is essential.

PURPOSE

This review analyzed the effectiveness of and barriers to using immersive VR in nursing education.

METHODS

A structured search was performed in PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, PsycINFO, Web of Science, and ProQuest Nursing & Allied Health Database. The Medical Education Research Study Quality Instrument was used to assess the quality of studies.

RESULTS

The final review was composed of 9 studies of moderate to high quality published between 2018 and 2020. The review indicated that immersive VR increased learning, cognitive, and psychomotor performance. Most participants of the studies preferred using immersive VR in education and with a variety of experiential scenarios. Barriers were associated with technological hardware and software (eg, simulation sickness, lack of visual comfort).

CONCLUSION

The review supports the viability of immersive VR technology in nursing education.

Evaluation Challenges for the Application of Extended Reality Devices in Medicine

Augmented and virtual reality devices are being actively investigated and implemented for a wide range of medical uses. However, significant gaps in the evaluation of these medical devices and applications hinder their regulatory evaluation. Addressing these gaps is critical to demonstrating the devices' safety and effectiveness. We outline the key technical and clinical evaluation challenges discussed during the US Food and Drug Administration's public workshop, "Medical Extended Reality: Toward Best Evaluation Practices for Virtual and Augmented Reality in Medicine" and future directions for evaluation method development. Evaluation challenges were categorized into several key technical and clinical areas. Finally, we highlight current efforts in the standards communities and illustrate connections between the evaluation challenges and the intended uses of the medical extended reality (MXR) devices. Participants concluded that additional research is needed to assess the safety and effectiveness of MXR devices across the use cases.

Virtual Reality als Trainingstool in der Klinischen und Gesundheitspsychologie

Zusammenfassung. Hintergrund: Virtual Reality (VR) wird zunehmend als Hilfsmittel für psychologische Interventionen eingesetzt. Auch für sozial-emotionale Fähigkeiten kann VR realitätsnahe Übungsszenarien kreieren. Fragestellung: Dieses systematische Review gibt einen Überblick über den aktuellen Forschungsstand zu VR-Trainings sozial-emotionaler Fähigkeiten. Methode: Die systematische Literaturrecherche erfolgte in PSYNDEX, PsycINFO, Scopus, PubMed und Web of Science und orientierte sich an den PRISMA-Richtlinien. Eingeschlossen wurden deutsch- und englischsprachige empirische Studien zu VR-basierten Trainings sozial-emotionaler Fähigkeiten für gesunde oder psychisch beeinträchtigte Personen aller Altersstufen. Ergebnisse: Elf Studien wurden eingeschlossen. Die Mehrheit untersuchte klinische Stichproben. Die methodische Qualität wurde bei zehn Studien positiv beurteilt. Schlussfolgerungen: Insgesamt spricht das Review für die Nützlichkeit VR-basierter Trainings sozial-emotionaler Fähigkeiten, aber der aktuelle Forschungsstand erlaubt noch keine eindeutigen Schlussfolgerungen bezüglich ihrer Wirksamkeit.

Demographic Characteristics and Digital Platforms for Physical Activity Among the Chinese Residents During the COVID-19 Pandemic: A Mediating Analysis

Background

Aim

Methods

Results

Conclusion

Detecting Fear of Heights Response to a Virtual Reality Environment Using Functional Near-Infrared Spectroscopy

To enable virtual reality exposure therapy (VRET) that treats anxiety disorders by gradually exposing the patient to fear using virtual reality (VR), it is important to monitor the patient's fear levels during the exposure. Despite the evidence of a fear circuit in the brain as reflected by functional near-infrared spectroscopy (fNIRS), the measurement of fear response in highly immersive VR using fNIRS is limited, especially in combination with a head-mounted display (HMD). In particular, it is unclear to what extent fNIRS can differentiate users with and without anxiety disorders and detect fear response in a highly ecological setting using an HMD. In this study, we investigated fNIRS signals captured from participants with and without a fear of height response. To examine the extent to which fNIRS signals of both groups differ, we conducted an experiment during which participants with moderate fear of heights and participants without it were exposed to VR scenarios involving heights and no heights. The between-group statistical analysis shows that the fNIRS data of the control group and the experimental group are significantly different only in the channel located close to right frontotemporal lobe, where the grand average oxygenated hemoglobin Δ[HbO] contrast signal of the experimental group exceeds that of the control group. The within-group statistical analysis shows significant differences between the grand average Δ[HbO] contrast values during fear responses and those during no-fear responses, where the Δ[HbO] contrast values of the fear responses were significantly higher than those of the no-fear responses in the channels located towards the frontal part of the prefrontal cortex. Also, the channel located close to frontocentral lobe was found to show significant difference for the grand average deoxygenated hemoglobin contrast signals. Support vector machine-based classifier could detect fear responses at an accuracy up to 70% and 74% in subject-dependent and subject-independent classifications, respectively. The results demonstrate that cortical hemodynamic responses of a control group and an experimental group are different to a considerable extent, exhibiting the feasibility and ecological validity of the combination of VR-HMD and fNIRS to elicit and detect fear responses. This research thus paves a way toward the a brain-computer interface to effectively manipulate and control VRET.

A Human-Centric Model for Sustainable Asset Management in Railway: A Case Study

The ongoing digital transformation is changing asset management in the railway industry. Emerging digital technologies and Artificial Intelligence is expected to facilitate decision-making in management, operation, and maintenance of railway by providing an integrated data-driven and model-driven solution. An important aspect when developing decision-support solutions based on AI and digital technology is the users’ experience. User experience design process aims to create relevance, context-awareness, and meaningfulness for the end-user. In railway contexts, it is believed that applying a human-centric design model in the development of AI-based artefacts, will enhance the usability of the solution, which will have a positive impact on the decision-making processes. In this research, the applicability of such advanced technologies i.e., Virtual Reality, Mixed Reality, and AI have been reviewed for the railway asset management. To carry out this research work, literature review has been conducted related to available Virtual Reality/Augmented Reality/Mixed Reality technologies and their applications within railway industry. It has been found that these technologies are available, but not applied in railway asset management. Thus, the aim of this paper is to propose a human-centric design model for the enhancement of railway asset management using Artificial Intelligence, Virtual Reality, and Mixed Reality technologies. The practical implication of the findings from this work will benefit in increased efficiency and effectiveness of the operation and maintenance processes in railway.

A Decade in Review: A Systematic Review of Virtual Reality Interventions for Emotional Disorders

Research is increasingly demonstrating the therapeutic benefits of virtual reality interventions for various mental health conditions, though these rarely translate from research to application in clinical settings. This systematic review aims to examine the efficacy of current virtual reality interventions for emotional disorders, with a focus on clinical and technological features that influence translation of treatments from research to clinical practice. A comprehensive systematic literature search was conducted following PRISMA guidelines, for studies including the application of a virtual reality intervention to a clinical population of adults with an emotional disorder. Thirty-seven eligible studies were identified, appraised, and assessed for bias. Treatment effects were typically large across studies, with virtual reality being considered an efficacious treatment modality for various anxiety disorders and post-traumatic stress disorder. Virtual reality interventions were typically used for delivering exposure in cognitive behavioural therapy approaches. Considerable variability was seen in cost, technological specifications, degree of therapist involvement, delivery format, dosage, duration, and frequency of treatment. Suboptimal methodological rigour was identified in some studies. Remote use of virtual reality was rare, despite increasing options for in home use. Virtual reality interventions have the potential to overcome barriers to care and better meet the needs of consumers. Future research should examine the efficacy of virtual reality for treatment of depressive disorders and obsesive compulsive disorder. Improved methodological reporting and development of transdiagnostic and remotely delivered virtual reality interventions, will likely increase the translation of this treatment modality.

Pure purr virtual reality technology: measuring heart rate variability and anxiety levels in healthy volunteers affected by moderate stress

INTRODUCTION

Traditional approaches to stress management are difficult to learn and to implicate in daily life. Emerging technologies like virtual reality (VR) have become a target of extensive study for recreational and medical purposes. The autonomic nervous system (ANS) plays a crucial role in stress response, post-stress relaxation, and recovery. This study aimed to assess the effect of modified VR intervention on short-term heart rate variability (HRV) and perceived anxiety levels in healthy volunteers affected by moderate stress. The stressors included mental arithmetic tasks.

MATERIAL AND METHODS

The study involved healthy adults, of both sexes, aged 20 to 60 years, without history of cardiovascular diseases, essential abnormalities on ECG, and with normal or moderate level of situational anxiety. The VR gadgets used in the study were commercially available Bobo-VR X1 headsets, one with modification for medical applications (Pure Purr technology) and one with none (sham technology). The investigational (Pure Purr) headset with an audio-visual sequence was modified by adding a binaural effect and was synchronised with the tract of respiratory movements and the frequency of heart rate. To track changes in the ANS, participants underwent both electrocardiography (ECG) and measurement of HRV.

RESULTS

The findings showed a significant increase in parasympathetic activity after 5-minute exposure to the investigational device compared to stress, as shown by high-frequency HRV (499.8 ms² and 340.5 ms², p < 0.001). RMSSD for a modified headset was higher (p = 0.02) compared to a sham headset with no modifications (RMSSD difference of 12.3% (2.6% to 23.1%)). The LF/HF ratio, however, was lower (difference of 14.5% (2.6% to 23.1%), p = 0.04).

CONCLUSIONS

These findings suggest that a medical device with pre-installed Pure Purr software had a significant effect on the recovery of the ANS in healthy volunteers affected by moderate stress.

Virtual Reality Fitness (VRF) for Behavior Management During the COVID-19 Pandemic: A Mediation Analysis Approach

Background

During the COVID-19 pandemic, cellphone health apps and virtual reality fitness for treating neurological disorders such as Parkinson’s were beneficial. Virtual reality has been used to treat PTSD, depression, anxieties, dementia, ADHD, dyslexia, and pain control in various settings. Virtual reality exercise has been studied for its effects on biological, mental, rehabilitation, behavior, and attitude management.

Purpose

This research aimed to find out the role of virtual reality fitness (VRF) for behavior management during the COVID-19 pandemic concerning the demographic characteristics of the study participants and the use of fitness and health apps.

Methods

The population for the current study was Chinese residents across China who were in home isolation during the early pandemic in China. According to the study objective, a convenience sampling method was used to collect the primary data through an online survey. SPSS-25 statistical software was used to analyze the demographic information and clean and prepare the data to test all proposed hypotheses. The proposed research framework was examined using the structural equation modeling (SEM) approach through SmartPLS 3.0 software.

Results

The structural equation model analysis shows that all the proposed hypotheses (H1: β = 0.137, t = 10.454, p = <0.000; H2: β = 0.256, t = 16.824, p = <0.000; H3: β = 0.418, t = 27.827, p = <0.000; H4: β = 0.133, t = 8.913, p = <0.000; H5: β = 0.076, t = 4.717, p = <0.000; H6: β = 0.162, t = 10.532, p = <0.000; H7: β = 0.384, t = 26.645, p = <0.000) are confirmed.

Conclusion

Fitness and health apps with virtual reality fitness play a substantial role in improving the overall quality of life and positively influencing behavior and attitude.

Evaluating the effect of multi-sensory stimulations on simulator sickness and sense of presence during HMD-mediated VR experience

Some lines of evidence have shown that sensory input, especially related to vestibular and somatosensory stimulation, may reduce the symptoms related to simulator sickness and increase the sense of presence in VR. The present study aims at understanding how mechanical vibration and auditory stimulation can be used to improve user experience in the context of VR mediated by head-mounted displays. Four different groups comprising a total of 80 participants were tested under different conditions of sensory input (visual and vibration, visual-auditory, combined visual-auditory and vibratory, and visual only), during a VR roller-coaster experience. No significant differences in simulator sickness were found between the groups exposed to seat vibration and/or audio. However, sense of presence showed to be increased when vibratory stimuli were included. Post-hoc analyses showed that female users but not male ones, experienced an increase of sense of presence when vibratory stimulation was used. Practitioner summary: The study showed that including sound or vibration stimulation during VR experience does not reduce simulator sickness. However, sense of presence is promoted by vibratory stimulation. Post-hoc analyses showed that female users experienced an increase of sense of presence by vibratory stimulation, but not male ones.

A Structured Approach to Test the Signal Quality of Electroencephalography Measurements During Use of Head-Mounted Displays for Virtual Reality Applications

Joint applications of virtual reality (VR) systems and electroencephalography (EEG) offer numerous new possibilities ranging from behavioral science to therapy. VR systems allow for highly controlled experimental environments, while EEG offers a non-invasive window to brain activity with a millisecond-ranged temporal resolution. However, EEG measurements are highly susceptible to electromagnetic (EM) noise and the influence of EM noise of head-mounted-displays (HMDs) on EEG signal quality has not been conclusively investigated. In this paper, we propose a structured approach to test HMDs for EM noise potentially harmful to EEG measures. The approach verifies the impact of HMDs on the frequency- and time-domain of the EEG signal recorded in healthy subjects. The verification task includes a comparison of conditions with and without an HMD during (i) an eyes-open vs. eyes-closed task, and (ii) with respect to the sensory- evoked brain activity. The approach is developed and tested to derive potential effects of two commercial HMDs, the Oculus Rift and the HTC Vive Pro, on the quality of 64-channel EEG measurements. The results show that the HMDs consistently introduce artifacts, especially at the line hum of 50 Hz and the HMD refresh rate of 90 Hz, respectively, and their harmonics. The frequency range that is typically most important in non-invasive EEG research and applications (<50 Hz) however, remained largely unaffected. Hence, our findings demonstrate that high-quality EEG recordings, at least in the frequency range up to 50 Hz, can be obtained with the two tested HMDs. However, the number of commercially available HMDs is constantly rising. We strongly suggest to thoroughly test such devices upfront since each HMD will most likely have its own EM footprint and this article provides a structured approach to implement such tests with arbitrary devices.

Virtual Reality Applications in Medicine During the COVID-19 Pandemic: Systematic Review (Preprint)

Background

Virtual reality can play an important role during the COVID-19 pandemic in the health care sector. This technology has the potential to supplement the traditional in-hospital medical training and treatment, and may increase access to training and therapies in various health care settings.

Objective

This systematic review aimed to describe the literature on health care–targeted virtual reality applications during the COVID-19 crisis.

Methods

We conducted a systematic search of the literature on the PsycINFO, Web of Science, and MEDLINE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The search string was as follows: “[(virtual reality)] AND [(COVID-19) OR (coronavirus) OR (SARS-CoV-2) OR (healthcare)].” Papers published in English after December 2019 in peer-reviewed journals were selected and subjected to the inclusion and exclusion criteria. We used the Mixed Methods Appraisal Tool to assess the quality of studies and the risk of bias.

Results

Thirty-nine studies met the inclusion criteria. Seventeen studies showed the usefulness of virtual reality during the COVID-19 crisis for reducing stress, anxiety, depression, and pain, and promoting physical activity. Twenty-two studies revealed that virtual reality was a helpful learning and training tool during the COVID-19 crisis in several areas, including emergency medicine, nursing, and pediatrics. This technology was also used as an educational tool for increasing public understanding of the COVID-19 pandemic. Different levels of immersion (ie, immersive and desktop virtual reality), types of head-mounted displays (ie, PC-based, mobile, and standalone), and content (ie, 360° videos and photos, virtual environments, virtual reality video games, and embodied virtual agents) have been successfully used. Virtual reality was helpful in both face-to-face and remote trials.

Conclusions

Virtual reality has been applied frequently in medicine during the COVID-19 pandemic, with positive effects for treating several health conditions and for medical education and training. Some barriers need to be overcome for the broader adoption of virtual reality in the health care panorama.

Trial Registration

International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) INPLASY202190108; https://inplasy.com/inplasy-2021-9-0108/

The Use of Virtual Reality for Managing Psychological Distress in Adolescents: Systematic Review

Acute and chronic psychological distress are prevalent during adolescence and can have negative impacts on adolescents in all life domains. The aim of this systematic review was to appraise the use of virtual reality (VR) interventions to manage symptoms of psychological distress symptoms among adolescents. MEDLINE, PubMed, PsycINFO, and Scopus databases were searched up to June 2020. Available citations were de-duplicated and screened by two authors using title and abstract information. A total of 301 articles were retained for full-text evaluation next to eligibility criteria. Empirical studies of all designs and comparator groups were included if these appraised the impact of an immersive VR intervention on any standardized measure indicative of psychological distress in an adolescent sample. Data were extracted into a standardized coding sheet. Results were tabulated and discussed with a narrative synthesis due to the heterogeneity between studies. A total of seven studies met inclusion criteria. There were four randomized controlled trials and three uncontrolled pilot studies on new VR interventions. Distress-related issues included: state-anxiety, venepuncture, risk taking, public speaking anxiety, social anxiety disorder, sexual victimization, and chemotherapy administration. All studies reported significant changes on outcome measures after VR treatment. Six studies reported small-to-large reductions in symptoms. The average attrition rate was 3.6 percent during the active VR treatment phase. Treatment acceptability was high in the studies that assessed user engagement factors. The VR technology can provide a safe, rapidly efficacious, and acceptable treatment modality for managing psychological distress in several key adolescent populations.

Mobile Augmented Reality Serious Game for Improving Old Adults’ Working Memory

As the aging population increases rapidly throughout the world, various approaches and studies are in progress to prevent age-related diseases. Among the diseases related to the elderly, dementia (in which cognitive function declines) is classified as a mental disorder. Since there is currently no therapeutic agent for dementia, early diagnosis and prophylactic approaches may be useful. In this study, a mobile-based augmented reality system for regular cognitive function training is proposed to minimize declines in cognitive function among the elderly. Using the characteristics of markerless augmented reality technology that can support physical activities, the foregoing system was developed in the form of a serious game based on an understanding of physical aging by the main users and inspired by existing psychological cognitive evaluation tools. The augmented reality system proposed in this study aims to induce the active participation of clients with goal setting and motivation using a gamified training system. In addition, it can ultimately be used as a self-assessment tool by recording an individual users’ performance ability. This proposed system must be used after receiving proper guidance from psychologists. The game protocol was designed together with experts in clinical psychology: therapists as well as neuropsychological assessors who were experienced in carrying out cognitive training sessions. The experts said that the system could help improve cognitive functions, such as working memory, attention concentration, and visual perception memory. However, this system has some limitations. This system was verified once with a small number of experts and could not be introduced to an actual elderly group to undergo verification of effectiveness. To compensate, we will conduct experiments to verify the effectiveness in order to avoid placebo effects. The effectiveness of program implementation will be verified by digitizing the correlations between the results of the neuropsychological assessment in the form of paper and pens and the results of signal data.

Recommendations for the Design and Implementation of Virtual Reality for Acquired Brain Injury Rehabilitation: Systematic Review

BACKGROUND

Virtual reality (VR) is increasingly being used for the assessment and treatment of impairments arising from acquired brain injuries (ABIs) due to perceived benefits over traditional methods. However, no tailored options exist for the design and implementation of VR for ABI rehabilitation and, more specifically, traumatic brain injury (TBI) rehabilitation. In addition, the evidence base lacks systematic reviews of immersive VR use for TBI rehabilitation. Recommendations for this population are important because of the many complex and diverse impairments that individuals can experience.

OBJECTIVE

This study aims to conduct a two-part systematic review to identify and synthesize existing recommendations for designing and implementing therapeutic VR for ABI rehabilitation, including TBI, and to identify current evidence for using immersive VR for TBI assessment and treatment and to map the degree to which this literature includes recommendations for VR design and implementation.

METHODS

This review was guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A comprehensive search of 11 databases and gray literature was conducted in August 2019 and repeated in June 2020. Studies were included if they met relevant search terms, were peer-reviewed, were written in English, and were published between 2009 and 2020. Studies were reviewed to determine the level of evidence and methodological quality. For the first part, qualitative data were synthesized and categorized via meta-synthesis. For the second part, findings were analyzed and synthesized descriptively owing to the heterogeneity of data extracted from the included studies.

RESULTS

In the first part, a total of 14 papers met the inclusion criteria. Recommendations for VR design and implementation were not specific to TBI but rather to stroke or ABI rehabilitation more broadly. The synthesis and analysis of data resulted in three key phases and nine categories of recommendations for designing and implementing VR for ABI rehabilitation. In the second part, 5 studies met the inclusion criteria. A total of 2 studies reported on VR for assessment and three for treatment. Studies were varied in terms of therapeutic targets, VR tasks, and outcome measures. VR was used to assess or treat impairments in cognition, balance, and anxiety, with positive outcomes. However, the levels of evidence, methodological quality, and inclusion of recommendations for VR design and implementation were poor.

CONCLUSIONS

There is limited research on the use of immersive VR for TBI rehabilitation. Few studies have been conducted, and there is limited inclusion of recommendations for therapeutic VR design and implementation. Future research in ABI rehabilitation should consider a stepwise approach to VR development, from early co-design studies with end users to larger controlled trials. A list of recommendations is offered to provide guidance and a more consistent model to advance clinical research in this area.

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.

Extended Reality for Enhanced Telehealth During and Beyond COVID-19: Viewpoint

The COVID-19 pandemic caused widespread challenges and revealed vulnerabilities across global health care systems. In response, many health care providers turned to telehealth solutions, which have been widely embraced and are likely to become standard for modern care. Immersive extended reality (XR) technologies have the potential to enhance telehealth with greater acceptability, engagement, and presence. However, numerous technical, logistic, and clinical barriers remain to the incorporation of XR technology into telehealth practice. COVID-19 may accelerate the union of XR and telehealth as researchers explore novel solutions to close social distances. In this viewpoint, we highlight research demonstrations of XR telehealth during the COVID-19 pandemic and discuss future directions to make XR the next evolution of remote health care.

Virtual Reality Exposure Therapy for Fear of Heights: Clinicians' Attitudes Become More Positive After Trying VRET

Background

Virtual reality exposure therapy (VRET) has the potential to solve logistic challenges when treating specific phobias. However, VRET has yet to see a large-scale implementation in clinical settings despite positive findings in treatment trials. This may partly be due to attitudes and lack of experience among clinicians, but also because of expensive and stationary VR solutions.

Objective

This study tested whether modern, wireless, commercially available VR equipment with controller-free hand tracking could induce and reduce discomfort using scenarios designed for fear of heights. Also, the study tested if clinicians’ attitudes toward using VR in therapy changed after trying it themselves.

Method

Attitudes to using VR in therapy and discomfort ratings were assessed for 74 clinicians before and after completing two VR scenarios. In addition, 54 non-clinicians completed the same scenarios. Participants were not diagnosed with acrophobia.

Results

The VR scenarios induced discomfort comparable to participants’ reported fear of heights in real life. Repeated training reduced discomfort. Positive attitudes toward use of VR in therapy was predicted by previous experience with VR, as well as positive attitudes toward novel technology and exposure therapy. Clinicians’ attitudes became more favorable after trying VRET themselves. Clinicians reported a range of possible advantages and disadvantages of using VR in therapy.

Conclusion

VRET for fear of heights was able to induce and reduce discomfort in clinicians and non-clinicians, and clinicians’ attitudes toward using VRET become more positive after trying VRET for themselves. The latest generation of VR solutions has potential to improve clinical availability and treatment options. Future research should explore how VRET can be implemented in clinical settings.

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.

Freely Available Virtual Reality Experiences as Tools to Support Mental Health Therapy: a Systematic Scoping Review and Consensus Based Interdisciplinary Analysis

The primary purpose of this article is to review the potential therapeutic value of freely available VR content as an addition to the practitioners ‘toolkit’. Research has shown that virtual reality (VR) may be useful to extend existing guided imagery-based practices found in traditional mental health therapy. However, the use of VR technology within routine mental health practice remains low, despite recent reductions in equipment costs. A systematic scoping review and interdisciplinary analysis of freely available VR experiences was performed across two popular online databases (SteamVR and Oculus.com). A total of 1785 experiences were retrieved and screened for relevance with 46 meeting the inclusion criteria. VR content was then reviewed for potential therapeutic value by an interdisciplinary panel with experience across a number of therapeutic interventions including cognitive behavioural therapy, Rogerian counselling, mindfulness-based therapies. and family therapy. Eleven (22%) of the 50 freely available VR experiences were reported to have therapeutic potential as tools to support routine mental health therapy. These included support with the following mental health issues—low mood, social anxiety, stress reduction and fear of heights. Guidance of a qualified mental health practitioner was recommended in all cases to maximise the benefit of the VR experiences retrieved. While the quality is variable, freely available VR experiences may contain valuable content that could support mental health therapy. This includes as a homework activity or as an initial setting for case formulation and behavioural experiments.

Using Medical Device Standards for Design and Risk Management of Immersive Virtual Reality for At-Home Therapy and Remote Patient Monitoring

Numerous virtual reality (VR) systems have received regulatory clearance as therapeutic medical devices for in-clinic and at-home use. These systems enable remote patient monitoring of clinician-prescribed rehabilitation exercises, although most of these systems are nonimmersive. With the expanding availability of affordable and easy-to-use head-mounted display (HMD)-based VR, there is growing interest in immersive VR therapies. However, HMD-based VR presents unique risks. Following standards for medical device development, the objective of this paper is to demonstrate a risk management process for a generic immersive VR system for remote patient monitoring of at-home therapy. Regulations, standards, and guidance documents applicable to therapeutic VR design are reviewed to provide necessary background. Generic requirements for an immersive VR system for home use and remote patient monitoring are identified using predicate analysis and specified for both patients and clinicians using user stories. To analyze risk, failure modes and effects analysis, adapted for medical device risk management, is performed on the generic user stories and a set of risk control measures is proposed. Many therapeutic applications of VR would be regulated as a medical device if they were to be commercially marketed. Understanding relevant standards for design and risk management early in the development process can help expedite the availability of innovative VR therapies that are safe and effective.

Translating Virtual Reality Cue Exposure Therapy for Binge Eating into a Real-World Setting: An Uncontrolled Pilot Study

Binge-eating disorder (BED) and bulimia nervosa (BN) have adverse psychological and medical consequences. Innovative interventions, like the integration of virtual reality (VR) with cue-exposure therapy (VR-CET), enhance outcomes for refractory patients compared to cognitive behavior therapy (CBT). Little is known about the feasibility and acceptability of translating VR-CET into real-world settings. To investigate this question, adults previously treated for BED or BN with at least one objective or subjective binge episode/week were recruited from an outpatient university eating disorder clinic to receive up to eight weekly one-hour VR-CET sessions. Eleven of 16 (68.8%) eligible patients were enrolled; nine (82%) completed treatment; and 82% (9/11) provided follow-up data 7.1 (SD = 2.12) months post-treatment. Overall, participant and therapist acceptability of VR-CET was high. Intent-to-treat objective binge episodes (OBEs) decreased significantly from 3.3 to 0.9/week (p < 0.001). Post-treatment OBE 7-day abstinence rate for completers was 56%, with 22% abstinent for 28 days at follow-up. Among participants purging at baseline, episodes decreased from a mean of one to zero/week, with 100% abstinence maintained at follow-up. The adoption of VR-CET into real-world clinic settings appears feasible and acceptable, with a preliminary signal of effectiveness. Findings, including some loss of treatment gains during follow-up may inform future treatment development.

Impact of the recreational use of virtual reality on physical and mental wellbeing during the Covid-19 lockdown

The Covid-19 pandemic has brought about significant changes to most aspects of our lives. As a result of the quarantine enforced by governments and authorities worldwide, people had to suddenly adapt their daily routines, including work, study, diet, leisure and fitness activities to the new circumstances. A growing body of research indicates that the engagement with virtual reality (VR) activities can have a positive impact on users’ mental and physical wellbeing. This study aims to evaluate the impact of VR activities on users under lockdown due to the Covid-19 pandemic. An online survey was carried out to investigate the recreational use of VR during the lockdown period and to gather users’ opinions on its impact on their physical and mental health. Non-parametric tests were used to evaluate the statistical significance of the responses provided by the 646 participants. The results of the survey show that VR use has significantly increased during the lockdown period for most participants, who expressed overwhelmingly positive opinions on the impact of VR activities on their mental and physical wellbeing. Strikingly, self-reported intensity of physical activity was considerably more strenuous in VR users than in console users. Given the current uncertainty as to the duration and course of the pandemic, as well as the possibility of intermittent lockdown in the upcoming years, the outcomes of this study could have a significant impact towards the development and deployment of VR-based strategies aimed at helping the population cope with prolonged social distancing, with particular regards to vulnerable individuals.

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

BACKGROUND

High quality head-mounted display based virtual reality (HMD-VR) has become widely available, spurring greater development of HMD-VR health games. As a behavior change approach, these applications use HMD-VR and game-based formats to support long-term engagement with therapeutic interventions. While the bulk of research to date has primarily focused on the therapeutic efficacy of particular HMD-VR health games, how developers and researchers incorporate best-practices in game design to achieve engaging experiences remains underexplored. This paper presents the findings of a narrative review exploring the trends and future directions of game design for HMD-VR health games.

METHODS

We searched the literature on the intersection between HMD-VR, games, and health in databases including MEDLINE, Embase, CINAHL, PsycINFO, and Compendex. We identified articles describing HMD-VR games designed specifically as health applications from 2015 onwards in English. HMD-VR health games were charted and tabulated according to technology, health context, outcomes, and user engagement in game design.

FINDINGS

We identified 29 HMD-VR health games from 2015 to 2020, with the majority addressing health contexts related to physical exercise, motor rehabilitation, and pain. These games typically involved obstacle-based challenges and extrinsic reward systems to engage clients in interventions related to physical functioning and pain. Less common were games emphasizing narrative experiences and non-physical exercise interventions. However, discourse regarding game design was diverse and often lacked sufficient detail. Game experience was evaluated using primarily ad-hoc questionnaires. User engagement in the development of HMD-VR health games primarily manifested as user studies.

CONCLUSION

HMD-VR health games are promising tools for engaging clients in highly immersive experiences designed to address diverse health contexts. However, more in-depth and structured attention to how HMD-VR health games are designed as game experiences is needed. Future development of HMD-VR health games may also benefit from greater involvement of end-users in participatory approaches.

Administering Virtual Reality Therapy to Manage Behavioral and Psychological Symptoms in Patients With Dementia Admitted to an Acute Care Hospital: Results of a Pilot Study

BACKGROUND

As virtual reality (VR) technologies become increasingly accessible and affordable, clinicians are eager to try VR therapy as a novel means to manage behavioral and psychological symptoms of dementia, which are exacerbated during acute care hospitalization, with the goal of reducing the use of antipsychotics, sedatives, and physical restraints associated with negative adverse effects, increased length of stay, and caregiver burden. To date, no evaluations of immersive VR therapy have been reported for patients with dementia in acute care hospitals.

OBJECTIVE

This study aimed to determine the feasibility (acceptance, comfort, and safety) of using immersive VR therapy for people living with dementia (mild, moderate, and advanced) during acute care hospitalization and explore its potential to manage behavioral and psychological symptoms of dementia.

METHODS

A prospective, longitudinal pilot study was conducted at a community teaching hospital in Toronto. The study was nonrandomized and unblinded. A total of 10 patients aged >65 years (mean 86.5, SD 5.7) diagnosed with dementia participated in one or more research coordinator-facilitated sessions of viewing immersive 360° VR footage of nature scenes displayed on a Samsung Gear VR head-mounted display. This mixed-methods study included review of patient charts, standardized observations during the intervention, and pre- and postintervention semistructured interviews about the VR experience.

RESULTS

All recruited participants (N=10) completed the study. Of the 10 participants, 7 (70%) displayed enjoyment or relaxation during the VR session, which averaged 6 minutes per view, and 1 (10%) experienced dizziness. No interference between the VR equipment and hearing aids or medical devices was reported.

CONCLUSIONS

It is feasible to expose older people with dementia of various degrees admitted to an acute care hospital to immersive VR therapy. VR therapy was found to be acceptable to and comfortable by most participants. This pilot study provides the basis for conducting the first randomized controlled trial to evaluate the impact of VR therapy on managing behavioral and psychological symptoms of dementia in acute care hospitals.

Virtual Reality Exposure Simulation for Student Veteran Social Anxiety and PTSD: A Case Study

Exposure based exercises are a common element of many gold standard treatments for anxiety disorders and post-traumatic stress disorder and virtual reality simulations have been evaluated as a platform for providing clients with opportunities for repeated exposure during treatment. Although research on virtual reality exposure therapy (VRET) indicates effectiveness and high levels of user satisfaction, VRETs require a participant to complete exposure exercises in-offices with specialized equipment. The current exploratory case method study evaluates the experience and outcomes of one student veteran with social anxiety disorder and PTSD completing twelve sessions of VRET exposure using a mobile phone simulation of a virtual grocery store. The participant reported decreases in psychological symptoms, improvements in neurological connectivity, and better sleep quality upon completing the trial. Results suggest that VRET using a mobile application is feasible and warrants further research to evaluate effectiveness more fully. Implications include the use of a mobile based virtual reality simulation for intervening in social anxiety for student veterans.

Mindfulness-based Virtual Reality Intervention in Hemodialysis Patients: A Pilot Study on End-user Perceptions and Safety

Background

Virtual reality (VR) is an evolving technology that is becoming a common treatment for pain management and psychologic phobias. Although nonimmersive devices (e.g., the Nintendo Wii) have been previously tested with patients on hemodialysis, no studies to date have used fully immersive VR as a tool for intervention delivery. This pilot trial tests the initial safety, acceptability, and utility of VR during maintenance hemodialysis treatment sessions-particularly, whether VR triggers motion sickness that mimics or negatively effects treatment-related symptoms (e.g., nausea).

Methods

Patients on hemodialysis (n=20) were enrolled in a phase 1 single-arm proof-of-concept trial. While undergoing hemodialysis, participants were exposed to our new Joviality VR program. This 25-minute program delivers mindfulness training and guided meditation using the Oculus Rift head-mounted display. Participants experienced the program on two separate occasions. Before and immediately after exposure, participants recorded motion-related symptoms and related discomfort on the Simulator Sickness Questionnaire. Utility measures included the end-user's ability to be fully immersed in the virtual space, interact with virtual objects, find hardware user friendly, and easily navigate the Joviality program with the System Usability Scale.

Results

Mean age was 55.3 (±13.1) years; 80% male; 60% Black; and mean dialysis vintage was 3.56 (±3.75) years. At the first session, there were significant decreases in treatment and/or motion-related symptoms after VR exposure (22.6 versus 11.2; P=0.03); scores >20 indicate problematic immersion. Hemodialysis end-users reported high levels of immersion in the VR environment and rated the software easy to operate, with average System Usability Scale scores of 82.8 out of 100.

Conclusions

Patients on hemodialysis routinely suffer from fatigue, nausea, lightheadedness, and headaches that often manifest during their dialysis sessions. Our Joviality VR program decreased symptom severity without adverse effects. VR programs may be a safe platform to improve the experience of patients on dialysis.

Virtual Reality Behavioral Activation as an Intervention for Major Depressive Disorder: Case Report

BACKGROUND

Major depressive disorder (MDD) is a global problem with an increasing incidence and prevalence. There has additionally been an increase in depression due to the COVID-19 pandemic. Behavioral activation is considered an evidence-based treatment for MDD. However, there are many barriers that could hinder one's ability to engage in behavioral activation, with COVID-19 "shelter-in-place" and social distancing orders being current and large impediments. Virtual reality (VR) has been successfully used to help treat a variety of mental health conditions, but it has not yet been used as a method of administering behavioral activation to a clinical population. Using VR to engage in behavioral activation could eliminate barriers that pandemic precautions place and help decrease symptoms of depression that are especially exacerbated in these times.

OBJECTIVE

The following case report examines the feasibility, acceptability, and tolerability of VR behavioral activation for an adult with MDD during a global pandemic. This participant was part of a larger pilot study, and the case serves as a description of the VR intervention.

METHODS

The participant engaged in a weekly 50-minute psychotherapy Zoom session for 4 weeks, in which a modified behavioral activation protocol was administered using a VR headset to simulate activities. Data on mood ratings, homework compliance, and headset use were obtained from the headset. Acceptability, tolerability, and depression symptoms were obtained using self-report rating scales.

RESULTS

The intervention was feasible, acceptable, and tolerable, as reported by this participant. The participant's depressive symptoms decreased by five-points on the Patient Health Questionnaire-9 over a month, with a beginning score of 10 (moderate depression) and a final score of 5 (mild depression).

CONCLUSIONS

The implications of these findings for future research are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04268316; http://clinicaltrials.gov/ct2/show/NCT04268316.

Reliability and Validity of a Virtual Reality-Based System for Evaluating Postural Stability

Postural stability is an important indicator of balance and is commonly evaluated in neurorehabilitation. We proposed a system based on a virtual reality (HTC Vive) system with a tracker at the lumbar area. The position data of the tracker were obtained through detection of the sensors on the tracker by the VR system. The reliability and validity of these sway parameters to measure postural stability were evaluated. Twenty healthy adults had their postural sway measured with this system and a force platform system under four stance conditions, with wide- or narrow-stance and eyes open or closed. The path data from both systems were computed to obtain the following parameters: the mean distance and the mean velocity in the medial-lateral and anterior-posterior directions and the 95% confidence ellipse area. The reliability of the Vive-based sway measures was tested with intraclass correlation coefficients (ICCs). The convergent validity was tested against the center of pressure (COP) parameters from the force platform system. Finally, the discriminative validity was tested for the above four conditions. The results indicated that the Vive-based sway parameters had moderate to high reliability (ICCs: 0.56 ~ 0.90) across four conditions and correlated moderately to very highly with the COP parameters ( r = 0.420  ∼  0.959 ). Bland-Altman plotting showed generally good agreement, with negative offset for the Vive-based sway parameters. The sway parameters obtained by the Vive-based system also discriminated well among the tasks. In conclusion, the results support this system as a simple and easy-to-use tool to evaluate postural stability with acceptable reliability and validity.