Virtual Exercise in Medicine: A Proof of Concept in a Healthy Population

BACKGROUND

Science is beginning to establish the benefits of the use of virtual reality (VR) in health care. This therapeutic approach may be an appropriate complementary treatment for some mental illnesses. It could prevent high levels of morbidity and improve the physical health of patients. For many years, the literature has shown the health benefits of physical exercise. Physical exercise in a VR environment may improve the management of mild to moderate mental health conditions. In this context, we developed a virtual environment combined with an ergocycle (the augmented physical training for isolated and confined environments [APTICE] system).

OBJECTIVE

This study aims to investigate the impact of physical exercise in a VR environment.

METHODS

A total of 14 healthy participants (11 men and 3 women; mean age 43.28, SD 10.60 years) undertook 15 minutes of immersive physical exercise using the system. Measures included mindfulness and immersion disposition, subjective perceptions of sensory information, user experience, and VR experience (ie, psychological state, flow, and presence).

RESULTS

First, the APTICE system appears to be a useful tool because the user experience is positive (subscales in the AttrakDiff questionnaire: pragmatic quality=0.99; hedonic quality-stimulation=1.90; hedonic quality-identification=0.67; attractiveness=1.58). Second, the system can induce a positive psychological state (negative emotion, P=.06) and an experience of flow and presence (P values ranging from <.001 to .04). Third, individual immersive and mindful disposition plays a role in the VR experience (P values ranging from <.02 to .04). Finally, our findings suggest that there is a link between the subjective perception of sensory information and the VR experience (P values ranging from <.02 to .04).

CONCLUSIONS

These results indicate that the device is well accepted with positive psychological and exteroceptive outcomes. Overall, the APTICE system could be a proof of concept to explore the benefits of virtual physical exercise in clinical medicine.

Virtual reality cue exposure therapy for tobacco relapse prevention: a comparative study with standard intervention

BACKGROUND

Successful interventions have been developed for smoking cessation although the success of smoking relapse prevention protocols has been limited. Cognitive behavioural therapy (CBT) in particular has been hampered by a high relapse rate. Because relapse can be due to conditions associated with tobacco consumption (such as drinking in bars with friends), virtual reality cue exposure therapy (VRCE) can be a potential tool to generate 3D interactive environments that simulate risk situations for relapse prevention procedures.

METHODS

To assess the effectiveness of VRCE with CBT, a comparative trial involving 100 smoking abstinent participants was designed with all required virtual environments (VE) created with an inexpensive graphic engine/game level editor.

RESULTS

Outcome measures confirmed the immersive and craving eliciting effect of these VEs. Results demonstrated that more participants in the VRCE group did not experience smoking relapse and that VRCE is at least as efficacious as traditional CBT in terms of craving reduction and decrease in nicotine dependence. Dropout and relapse rate in the VRCE group was noticeably lower than the CBT group. Aside from mood scores, no significant differences were found regarding the other scales.

CONCLUSION

The present clinical trial provides evidence that VRCE was effective in preventing smoking relapse. Improvement in technology and methodology for future research and applications is delineated.

Virtual Reality and Fear of Shark Attack: A Case Study for the Treatment of Squalophobia

Research treatment protocols are rare regarding an unusual anxiety disorder, namely the fear of sharks (squalophobia). As a possible solution, the effectiveness of virtual reality (VR) exposure therapy for this phobia was tested. The advantage of using VR becomes clearer when a real life set up is impractical, such as exposing a phobic patient to a feared large marine organism, the shark. The effects were evaluated in a single case study involving multiple context-graded aquatic virtual environments with a virtual shark and using affordable VR apparatus and software. Assessment was based on self-report questionnaires. Scores the psychometric instruments exhibited a discernable reduction in fear toward sharks. Such gains were maintained at a 12-month follow-up. Presence rates indicated immersion when confronted to a three-dimensional (3D) virtual shark. This initial study revealed the potential of VR for the treatment of marine biota phobia and its potential to recreate diverse situations for exposure therapy.

Involvement of the cerebellum in EMDR efficiency: a metabolic connectivity PET study in PTSD

BACKGROUND

We recently reported an improvement of precuneus PET metabolism after EMDR therapy in military participants suffering from PTSD.

OBJECTIVE

The aim of the present study was to investigate the metabolic changes of precuneus connectivity in these participants after such treatment.

METHOD

Fifteen participants with PTSD performed a brain 18F-FDG-PET sensitized by virtual reality exposure to war scenes, before and after EMDR treatment. Inter-regional correlation analysis was performed to study metabolic changes of precuneus connectivity through SPMT maps at whole-brain level (p < 0.005 for the voxel, p < 0.05 for the cluster).

RESULTS

A decrease of connectivity was observed after EMDR between the precuneus and two significant bilateral clusters of the cerebellum (bilateral Crus I and VI cerebellar lobules, Tmax voxel of 5.8 and 5.3, and cluster size of 343 and 314 voxels, respectively). Moreover, higher cerebellar metabolism before treatment was associated with reduced clinical PTSD scores after EMDR (p = 0.03).

CONCLUSIONS

The posterior cerebellum and its metabolic connectivity with the precuneus are involved in the clinical efficiency of EMDR in PTSD.

Increase of precuneus metabolism correlates with reduction of PTSD symptoms after EMDR therapy in military veterans: an 18F-FDG PET study during virtual reality exposure to war

PURPOSE

The prevalence of posttraumatic stress disorder (PTSD) is higher among veterans, and can lead to disastrous consequences such as suicide. Eye movement desensitization and reprocessing (EMDR) is recommended in first-line psychotherapies for PTSD. Virtual reality exposure (VRE) coupled with 18F-FDG PET imaging can highlight the activated brain regions during stress exposure. The objective of this study is to identify, after EMDR therapy, the regions of brain metabolism that evolve during the stress exposure of a war scene with symptomatic remission in a group of military veterans suffering from PTSD, and to secondarily search for predictive metabolic features.

METHODS

We recruited 15 military veterans suffering from PTSD who performed an ¹⁸F-FDG PET sensitized by the exposure to a virtual war scene, before (T0) and after (T1) EMDR therapy. Statistical parametric mapping was used to compare brain metabolism before and after treatment and to study correlations between metabolism and evolution scores on PTSD clinical scales (PTSD Checklist Scale, PCLS; Clinician-Administered PTSD Scale, CAPS).

RESULTS

The metabolic activity of the precuneus was increased after EMDR therapy (p < 0.005 uncorrected, k > 180) and correlated with clinical improvement with the CAPS scale (r = -0.73 and p < 0.001). Moreover, the precuneus metabolic value before therapy predicted the clinical improvement on the PCLS scale (T1-T0) after EMDR (r = -0.667 and p < 0.006).

CONCLUSION

The clinical improvement in military patients with PTSD after EMDR is related to increased precuneus metabolism upon VR stress exposure.

Brain metabolism and related connectivity in patients with acrophobia treated by virtual reality therapy: an 18F-FDG PET pilot study sensitized by virtual exposure

Background

The aim of this pilot study is to investigate the impact of virtual reality exposure therapy (VRET) on brain metabolism and connectivity.

Eighteen patients with acrophobia were assessed by an ¹⁸F-FDG PET scan sensitized by virtual exposure before treatment, and nine of them were assessed again after eight sessions of VRET. Statistical Parametric Mapping was used to study the correlations between metabolism and pretherapeutic clinical scores and to compare metabolism before and after VRET (p voxel < 0.005, corrected for cluster volume). Metabolic connectivity was evaluated through interregional correlation analysis.

Results

Before therapy, a positive correlation was found between scores on the behavioural avoidance test and left occipital metabolism (BA17-18). After VRET, patients presented increased metabolism in the left frontal superior gyri and the left precentral gyrus, which showed increased metabolic connectivity with bilateral occipital areas (BA17-18-19), concomitant with clinical recovery.

Conclusions

This study highlights the exciting opportunity to use brain PET imaging to investigate metabolism during virtual exposure and reports the involvement of the visual-motor control system in the treatment of acrophobia by VRET.

Virtual reality cue exposure for the relapse prevention of tobacco consumption: a study protocol for a randomized controlled trial

Background

Successful interventions have been developed for smoking cessation, but the success of smoking relapse prevention interventions has been limited. In particular, cognitive behavioural therapy (CBT) has been hampered by a high relapse rate. Because relapses can be due to the presence of conditions associated with tobacco consumption (such as drinking in bars with friends), virtual reality exposure therapy (VRET) can generate synthetic environments that represent risk situations for the patient in the context of relapse prevention. The primary objective of this study is to evaluate the effectiveness of CBT coupled with VRET, in comparison to CBT alone, in the prevention of smoking relapse. The secondary objectives are to assess the impact of CBT coupled with VRET on anxiety, depression, quality of life, self-esteem and addictive comorbidities (such as alcohol, cannabis, and gambling). A third objective examines the feasibility and acceptability of VR use considering elements such as presence, cybersickness and number of patients who complete the VRET program.

Method/design

The present study is a 14-month (2 months of therapy followed by 12 months of follow-up), prospective, comparative, randomized and open clinical trial, involving two parallel groups (CBT coupled with VRET versus CBT alone). The primary outcome is the proportion of individuals with tobacco abstinence at 6 months after the end of the therapy. Abstinence is defined by the total absence of tobacco consumption assessed during a post-test interview and with an apparatus that measures the carbon monoxide levels expired. A total of 60 individuals per group will be included.

Discussion

This study is the first to examine the efficacy of CBT coupled with VRET in the prevention of smoking relapse. Because VRET is simple to use and has a low cost, this interactive therapeutic method might be easily implemented in clinical practice if the study confirms its efficacy.

Trial registration

ClinicalTrials.gov Identifier: NCT02205060 (registered 25 July 2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1224-5) contains supplementary material, which is available to authorized users.

[Virtual reality in the treatment of mental disorders]

Virtual reality is a media allowing users to interact in real time with computerized virtual environments. The application of this immersive technology to cognitive behavioral therapies is increasingly exploited for the treatment of mental disorders. The present study is a review of literature spanning from 1992 to 2012. It depicts the utility of this new tool for assessment and therapy through the various clinical studies carried out on subjects exhibiting diverse mental disorders. Most of the studies conducted on tested subjects attest to the significant efficacy of the Virtual Reality Exposure Therapy (VRET) for the treatment of distinct mental disorders. Comparative studies of VRET with the treatment of reference (the in vivo exposure component of the cognitive behavioral therapy) document an equal efficacy of the two methods and in some cases a superior therapeutic effect in favor of the VRET. Even though clinical experiments set on a larger scale, extended follow-up and studies about factors influencing presence are needed, virtual reality exposure represents an efficacious, confidential, affordable, flexible, interactive therapeutic method which application will progressively widened in the field of mental health.

A controlled study of agoraphobia and the independent effect of virtual reality exposure therapy

OBJECTIVES

Past controlled clinical trials centred on virtual reality exposure therapy (VRET) for agoraphobia mostly used multicomponent therapy with success. However, the present paper aimed to evaluate the independent effect of VRET for agoraphobia.

METHODS

A controlled study involving 18 agoraphobic participants assigned to two groups: VRET only and VRET with cognitive therapy. Nine specific virtual environments were developed using an affordable game level editor.

RESULTS

Questionnaires, behavioural tests and physiological measures indicated a positive effect of VRET. Correlations supported the predictive value of presence towards treatment outcome. The addition of cognitive therapy did not provide significant additional benefit.

CONCLUSIONS

Overall, the isolated effects of VRET did not seem to be significantly less than the effects of VRET combined with cognitive therapy. Future research should explore the use of other components in addition to cognitive therapy and VRET for agoraphobia as well as its possible use in patients' homes.

Isolating the effect of Virtual Reality Based Exposure Therapy for agoraphobia: a comparative trial

The isolated effect of Virtual Reality Based Exposure Therapy (VRBET) for agoraphobia was analyzed through a comparative trial involving the first 10 agoraphobic participants. The participants were randomly assigned to two groups: VREBT only and VREBT combined with cognitive therapy. All the required Virtual Environments (VE) were created with an inexpensive Game Level Editor (GLE). Outcome measures supported the immersive effect of the VEs. Questionnaires, behavioral tests and physiological measures indicated a positive effect of VRBET alone. The addition of cognitive therapy to VREBT did not appear to generate any significant differences. Consequences for future research and practice are discussed.

Virtual reality and claustrophobia: multiple components therapy involving game editor virtual environments exposure

The effectiveness of a multiple components therapy regarding claustrophobia and involving virtual reality (VR) will be demonstrated through a trial which immersed six claustrophobic patients in multiple context-graded enclosed virtual environments (VE) using affordable VR apparatus and software. The results of the questionnaires and behavior tests exhibited a significant reduction in fear towards the enclosed space and quality of life improvement. Such gains were maintained at 6-month follow-up. Presence score indicated the patients felt immersed and present inside the game editor VE.