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Hi, I'm Todd! Welcome to the Learning Hub

Todd Maddox, PhD

Learning Scientist | Researcher

Hi, I'm Todd Maddox. I've spent over two decades researching and teaching the brain science behind how humans learn. This page is meant to be a resource for you — to expand your knowledge of what's possible with VR, what's working and why, and what we still hope to discover.

Definitions of VR / AR / MR

"Virtual Reality (VR) refers to a intuitive interaction between exploiting human sensory, motor and cognitive affective responses, that are relevant “presence” are often associated with VR, but are prerequisites in the delivery of engaging virtual worlds. a range of devices, from so-called “immersive” scale computer technologies, and from whole traditional gaming controllers to physiological interfaces (such as eye links). Although predominantly associated with 3D computer symbolic, photographic/video and multisensory when judged appropriate to the task being undertaken (touch and force), proprioceptive (body to a suite of technologies that strive to support real interaction between humans and simulated/computer-generated environments loiting human sensory, motor and cognitive capabilities, in addition to human emotion and are relevant to the task being undertaken.

The terms “immersion” or “presence” are often associated with VR, but are future ideal states and prerequisites in the delivery of engaging virtual worlds. Interaction within VR may be achieved using called “immersive” wearable displays to conventional , and from whole-/part-body motion capture or tracking to physiological interfaces (such as eye-tracking and brain Although predominantly associated with 3D computer-generated graphi and multisensory data can be integrated with virtual environments to the task being undertaken. This includes the use of auditory, haptic and force), proprioceptive (body position and movement) and olfactory stimulation.

Augmented Reality (AR)..."

Find the full paper here.

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This paper was written by Professor Bob Stone in July 2019 to provide his definitions of "VR", "AR", and "MR" after 30+ years working with these technologies. Professor Stone directs the University of Birmingham’s Human Interface Technologies Team.

Is Clinical Virtual Reality Ready for Primetime?

Objective: Since the mid-1990s, a significant scientific literature has evolved regarding the outcomes from the use of what we now refer to as clinical virtual reality (VR). This use of VR simulation technology has produced encouraging results when applied to address cognitive, psychological, motor, and functional impairments across a wide range of clinical health conditions. This article addresses the question, "Is clinical VR ready for primetime?"

Conclusions: Although there is still much research needed to advance the science in this area, we strongly believe that clinical VR applications will become indispensable tools in the toolbox of psychological researchers and practitioners and will only grow in relevance and popularity in the future.

Find the full report here.

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Rizzo AS. Keynote Speaker is Clinical Virtual Reality Ready for Primetime? 2018 IEEE Conference on Virtual Reality and 3D User Interfaces (VR). 2018. doi:10.1109/vr.2018.8446505

Virtual Reality Clinical Research: Promises and Challenges

Background: Virtual reality (VR) therapy has been explored as a novel therapeutic approach for numerous health applications, in which three-dimensional virtual environments can be explored in real time. Studies have found positive outcomes for patients using VR for clinical conditions such as anxiety disorders, addictions, phobias, posttraumatic stress disorder, eating disorders, stroke rehabilitation, and for pain management.

Objective: This work aims to highlight key issues in the implementation of clinical research for VR technologies.

Find the full paper here.

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Garrett, Bernie, et al. “Virtual Reality Clinical Research: Promises and Challenges.” JMIR Serious Games, vol. 6, no. 4, 2018, doi:10.2196/10839.

The Past, Present, and Future of Virtual and Augmented Reality Research: A Network and Cluster Analysis of the Literature

Abstract: The recent appearance of low cost virtual reality (VR) technologies – like the Oculus Rift, the HTC Vive and the Sony PlayStation VR – and Mixed Reality Interfaces (MRITF) – like the Hololens – is attracting the attention of users and researchers suggesting it may be the next largest stepping stone in technological innovation. However, the history of VR technology is longer than it may seem: the concept of VR was formulated in the 1960s and the first commercial VR tools appeared in the late 1980s. For this reason, during the last 20 years, 100s of researchers explored the processes, effects, and applications of this technology producing 1000s of scientific papers. What is the outcome of this significant research work? This paper wants to provide an answer to this question by exploring, using advanced scientometric techniques, the existing research corpus in the field.

Find the full report here.

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Inzerillo L. Augmented reality: past, present, future. The Engineering Reality of Virtual Reality 2013. 2013. doi:10.1117/12.2001833

Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an International Working Group: Iterative Study

Background: Therapeutic virtual reality (VR) has emerged as an efficacious treatment modality for a wide range of health conditions. However, despite encouraging outcomes from early stage research, a consensus for the best way to develop and evaluate VR treatments within a scientific framework is needed.

ObjectiveWe aimed to develop a methodological framework with input from an international working group in order to guide the design, implementation, analysis, interpretation, and communication of trials that develop and test VR treatments.

Methods: A group of 21 international experts was recruited based on their contributions to the VR literature. The resulting Virtual Reality Clinical Outcomes Research Experts held iterative meetings to seek consensus on best practices for the development and testing of VR treatments.

Results: The interactions were transcribed, and key themes were identified to develop a scientific framework in order to support best practices in methodology of clinical VR trials. Using the Food and Drug Administration Phase I-III pharmacotherapy model as guidance, a framework emerged to support three phases of VR clinical study designs—VR1, VR2, and VR3. VR1 studies focus on content development by working with patients and providers through the principles of human-centered design. VR2 trials conduct early testing with a focus on feasibility, acceptability, tolerability, and initial clinical efficacy. VR3 trials are randomized, controlled studies that evaluate efficacy against a control condition. Best practice recommendations for each trial were provided.

Find the full paper here.

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Birckhead B, Khalil C, Liu X, Conovitz S, Rizzo A, Danovitch I, Bullock K, Spiegel B "Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an International Working Group: Iterative Study"JMIR Ment Health 2019;6 (1):e11973

Clinical Results Using Virtual Reality

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

Find the full article here.

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Rizzo, Albert, et al. “Clinical Results Using Virtual Reality.” Journal of Technology in Human Services, vol. 37, no. 1, 2019, pp. 51–74., doi:10.1080/15228835.2019.1604292.

Open-Source Physiological Computing Framework using Heart Rate Variability in Mobile Virtual Reality Applications

Abstract:

Electronic and mobile health technologies are posed as a tool that can promote self-care and extend coverage to bridge the gap in accessibility to mental care services between low-and high-income communities. However, the current technology-based mental health interventions use systems that are either cumbersome, expensive or require specialized knowledge to be operated. This paper describes the open-source framework PARE-VR, which provides heart rate variability (HRV) analysis to mobile virtual reality (VR) applications. It further outlines the advantages of the presented architecture as an initial step to provide more scalable mental health therapies in comparison to current technical setups; and as an approach with the capability to merge physiological data and artificial intelligence agents to provide computing systems with user understanding and adaptive functionalities. Furthermore, PARE-VR is evaluated with a feasibility study using a specific relaxation exercise with slow-paced breathing. The aim of the study is to get insights of the system performance, its capability to detect HRV metrics in real-time, as well as to identify changes between normal and slow-paced breathing using the HRV data. Preliminary results of the study, with the participation of eleven volunteers, showed high engagement of users towards the VR activity, and demonstrated technical potentialities of the framework to create physiological computing systems using mobile VR and wearable smartwatches for scalable health interventions. Several insights and recommendations were concluded from the study for enhancing the HRV analysis in real-time and conducting future similar studies.
 

Find the full paper here.

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Quintero, Luis & Papapetrou, Panagiotis & Muñoz, John. (2019). Open-Source Physiological Computing Framework using Heart Rate Variability in Mobile Virtual Reality Applications. 126-1267. 10.1109/AIVR46125.2019.00027.

 

Application of virtual reality technology in clinical medicine

Abstract: The present review discusses the application of virtual reality (VR) technology in clinical medicine, especially in surgical training, pain management and therapeutic treatment of mental illness. We introduce the common types of VR simulators and their operational principles in aforementioned fields. The clinical effects are also discussed. In almost every study that dealt with VR simulators, researchers have arrived at the same conclusion that both doctors and patients could benefit from this novel technology. Moreover, advantages and disadvantages of the utilization of VR technology in each field were discussed, and the future research directions were proposed.

Find the full paper here.

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Li L, Yu F, Shi D, et al. Application of virtual reality technology in clinical medicine. Am J Transl Res. 2017;9(9):3867–3880. Published 2017 Sep 15.

Virtual reality in medicine: a brief overview and future research directions

Virtual reality (VR), also called phantomatics, is an image of artificial reality created entirely in three-dimensional graphics with the use of information technology. VR makes it possible to experience the imaginary world as if it was real, where sensory data are delivered to the brain through a specialized system. The purpose of virtual medicine is to minimize direct contact and impact on human body during treatment. Taking into consideration the increasing accessibility of high quality electronic devices, their immense computing powers, and the continuously developing Internet infrastructure, the advancement in this area is only a matter of time. Therefore, the aim of the study was to identify the applications of VR in medicine, focusing on the areas of psychiatry and rehabilitation and considering guidelines for future research.

Find the full paper here.

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Mazurek J, Kiper P, Cieślik B, et al. Virtual reality in medicine: a brief overview and future research directions. Human Movement. 2019;20(3):16-22. doi:10.5114/hm.2019.83529.

Technological Competence Is a Pre-Condition for Effective Implementation of Virtual Reality Head Mounted Displays in Human Neuroscience: A Technological Review and Meta-Analysis

Immersive virtual reality (VR) emerges as a promising research and clinical tool. However, several studies suggest that VR induced adverse symptoms and effects (VRISE) may undermine the health and safety standards, and the reliability of the scientific results. In the current literature review, the technical reasons for the adverse symptomatology are investigated to provide suggestions and technological knowledge for the implementation of VR head-mounted display (HMD) systems in cognitive neuroscience. The technological systematic literature indicated features pertinent to display, sound, motion tracking, navigation, ergonomic interactions, user experience, and computer hardware that should be considered by the researchers. Subsequently, a meta-analysis of 44 neuroscientific or neuropsychological studies involving VR HMD systems was performed. The meta-analysis of the VR studies demonstrated that new generation HMDs induced significantly less VRISE and marginally fewer dropouts. Importantly, the commercial versions of the new generation HMDs with ergonomic interactions had zero incidents of adverse symptomatology and dropouts. HMDs equivalent to or greater than the commercial versions of contemporary HMDs accompanied with ergonomic interactions are suitable for implementation in cognitive neuroscience. In conclusion, researchers' technological competency, along with meticulous methods and reports pertinent to software, hardware, and VRISE, are paramount to ensure the health and safety standards and the reliability of neuroscientific results

Find the full paper here.

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Kourtesis, Panagiotis, et al. “Technological Competence Is a Pre-Condition for Effective Implementation of Virtual Reality Head Mounted Displays in Human Neuroscience: A Technological Review and Meta-Analysis.” Frontiers in Human Neuroscience, vol. 13, 2019, doi:10.3389/fnhum.2019.00342.

Video Games and Virtual Reality as Persuasive Technologies for Health Care: An Overview

Abstract: Over the last two decades, persuasive technology has gained much of interest and attention. One of the major disciplines of focus for persuasive technology is health care. The vast majority of persuasive technologies for health care are predominantly based on web and mobile platforms. Nevertheless, video games and virtual reality are recognized as effective persuasive platforms, as computer simulation is a platform for enabling users to observe the immediate and long term relationships between cause and effect. As such, the use of these persuasive technologies, can potentially facilitate change in a person’s attitudes or behaviors. This paper considers persuasive technology in the form of video games and virtual reality as a means to change attitudes and/or behaviors in the area of health care. The role of these types of computer simulation, their advantages and challenges, along with the incorporation of persuasive strategies in the design of such interactive simulations are discussed in relation to health care

Find the full paper here.

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Chow, Yang-Wai, et al. “Video Games and Virtual Reality as Persuasive Technologies for Health Care: An Overview.” ResearchGate, 2017, www.researchgate.net/publication/321920611_Video_games_and_virtual_reality_as_persuasive_technologies_for_health_care_An_overview.

Beyond Feeling Sick: The Visual and Cognitive Aftereffects of Virtual Reality

Abstract: Despite continued improvements in virtual reality (VR) technologies, many people still experience adverse symptoms from using head-mounted displays (HMDs). Typically, these symptoms are monitored through self-report measures, such as the Simulator Sickness Questionnaire (SSQ); however, by only using subjective measures many symptoms may be overlooked. In an application-based study, we investigated visual and cognitive aftereffects of using HMDs and their relationship to the reporting of sickness on the SSQ. Visual (accommodation and vergence) and cognitive (reaction time and rapid visual processing) assessments were employed before and after participants engaged in a 30-minute VR table tennis game (VR group, n = 27) or went about their daily activities (control group, n = 28). The data showed changes in accommodation but no concurrent changes in vergence, which likely stems from decoupling accommodation and vergence in VR. Furthermore, larger changes in accommodation were linked to more severe sickness symptoms suggesting that decoupling accommodation and vergence could be more adverse than previously thought. The VR group also had slower decision (cognitive) times, but movement times were unaffected. These findings go beyond the typical self-reporting of sickness in VR studies. Moreover, we demonstrate that even in a high-quality commercial virtual environment, users may experience visual and cognitive aftereffects that may negatively influence their experience with subsequent activities in the real world. Developing an understanding of how VR aftereffects may influence later activities could help to minimise the risk of using HMDs for various applications and may be valuable to obtain a better understanding of user issues and VR safety.

Find the full study here.

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A. Szpak, S. C. Michalski, D. Saredakis, C. S. Chen and T. Loetscher, "Beyond Feeling Sick: The Visual and Cognitive Aftereffects of Virtual Reality," in IEEE Access, vol. 7, pp. 130883-130892, 2019.
doi: 10.1109/ACCESS.2019.2940073

Validation of the Virtual Reality Neuroscience Questionnaire: Maximum Duration of Immersive Virtual Reality Sessions Without the Presence of Pertinent Adverse Symptomatology

Abstract: There are major concerns about the suitability of immersive virtual reality (VR) systems (i.e., head-mounted display; HMD) to be implemented in research and clinical settings, because of the presence of nausea, dizziness, disorientation, fatigue, and instability (i.e., VR induced symptoms and effects; VRISE). Research suggests that the duration of a VR session modulates the presence and intensity of VRISE, but there are no suggestions regarding the appropriate maximum duration of VR sessions. The implementation of high-end VR HMDs in conjunction with ergonomic VR software seems to mitigate the presence of VRISE substantially. However, a brief tool does not currently exist to appraise and report both the quality of software features and VRISE intensity quantitatively. The Virtual Reality Neuroscience Questionnaire (VRNQ) was developed to assess the quality of VR software in terms of user experience, game mechanics, in-game assistance, and VRISE. Forty participants aged between 28 and 43 years were recruited (18 gamers and 22 non-gamers) for the study. They participated in 3 different VR sessions until they felt weary or discomfort and subsequently filled in the VRNQ. Our results demonstrated that VRNQ is a valid tool for assessing VR software as it has good convergent, discriminant, and construct validity. The maximum duration of VR sessions should be between 55 and 70 min when the VR software meets or exceeds the parsimonious cut-offs of the VRNQ and the users are familiarized with the VR system. Also, the gaming experience does not seem to affect how long VR sessions should last. Also, while the quality of VR software substantially modulates the maximum duration of VR sessions, age and education do not. Finally, deeper immersion, better quality of graphics and sound, and more helpful in-game instructions and prompts were found to reduce VRISE intensity. The VRNQ facilitates the brief assessment and reporting of the quality of VR software features and/or the intensity of VRISE, while its minimum and parsimonious cut-offs may appraise the suitability of VR software for implementation in research and clinical settings. The findings of this study contribute to the establishment of rigorous VR methods that are crucial for the viability of immersive VR as a research and clinical tool in cognitive neuroscience and neuropsychology.

Find the full paper here.

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Kourtesis, Panagiotis, et al. “Validation of the Virtual Reality Neuroscience Questionnaire: Maximum Duration of Immersive Virtual Reality Sessions Without the Presence of Pertinent Adverse Symptomatology.” Frontiers in Human Neuroscience, vol. 13, 2019, doi:10.3389/fnhum.2019.00417.

Feasibility of an Immersive Virtual Reality Intervention for Hospitalized Patients: An Observational Cohort Study

Background: Virtual reality (VR) offers immersive, realistic, three-dimensional experiences that “transport” users to novel environments. Because VR is effective for acute pain and anxiety, it may have benefits for hospitalized patients; however, there are few reports using VR in this setting.

Objective: The aim was to evaluate the acceptability and feasibility of VR in a diverse cohort of hospitalized patients.

Methods: We assessed the acceptability and feasibility of VR in a cohort of patients admitted to an inpatient hospitalist service over a 4-month period. We excluded patients with motion sickness, stroke, seizure, dementia, nausea, and in isolation. Eligible patients viewed VR experiences (eg, ocean exploration; Cirque du Soleil; tour of Iceland) with Samsung Gear VR goggles. We then conducted semistructured patient interview and performed statistical testing to compare patients willing versus unwilling to use VR.

 

Find the full study here.

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Mosadeghi, Sasan et al. “Feasibility of an Immersive Virtual Reality Intervention for Hospitalized Patients: An Observational Cohort Study.” JMIR mental healthvol. 3,2 e28. 27 Jun. 2016, doi:10.2196/mental.5801

Neuroscience of Virtual Reality: From Virtual Exposure to Embodied Medicine

Abstract: Is virtual reality (VR) already a reality in behavioral health? To answer this question, a meta-review was conducted to assess the meta-analyses and systematic and narrative reviews published in this field in the last twenty-two months. Twenty-five different articles demonstrated the clinical potential of this technology in both the diagnosis and the treatment of mental health disorders: VR compares favorably to existing treatments in anxiety disorders, eating and weight disorders, and pain management, with long-term effects that generalize to the real world. But why is VR so effective? Here, the following answer is suggested: VR shares with the brain the same basic mechanism: embodied simulations. According to neuroscience, to regulate and control the body in the world effectively, the brain creates an embodied simulation of the body in the world used to represent and predict actions, concepts, and emotions. VR works in a similar way: the VR experience tries to predict the sensory consequences of an individual's movements, providing to him/her the same scene he/she will see in the real world. To achieve this, the VR system, like the brain, maintains a model (simulation) of the body and the space around it. If the presence in the body is the outcome of different embodied simulations, concepts are embodied simulations, and VR is an embodied technology, this suggests a new clinical approach discussed in this article: the possibility of altering the experience of the body and facilitating cognitive modeling/change by designing targeted virtual environments able to simulate both the external and the internal world/body.

Find the full meta-analysis here.

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Riva, Giuseppe, et al. “Neuroscience of Virtual Reality: From Virtual Exposure to Embodied Medicine.” Cyberpsychology, Behavior, and Social Networking, vol. 22, no. 1, 2019, pp. 82–96., doi:10.1089/cyber.2017.29099.gri.

Virtual reality and the role of the prefrontal cortex in adults and children

In this review, the neural underpinnings of the experience of presence are outlined. Firstly, it is shown that presence is associated with activation of a distributed network, which includes the dorsal and ventral visual stream, the parietal cortex, the premotor cortex, mesial temporal areas, the brainstem and the thalamus. Secondly, the dorsolateral prefrontal cortex (DLPFC) is identified as a key node of the network as it modulates the activity of the network and the associated experience of presence. Thirdly, children lack the strong modulatory influence of the DLPFC on the network due to their unmatured frontal cortex. Fourthly, it is shown that presence-related measures are influenced by manipulating the activation in the DLPFC using transcranial direct current stimulation (tDCS) while participants are exposed to the virtual roller coaster ride. Finally, the findings are discussed in the context of current models explaining the experience of presence, the rubber hand illusion, and out-of-body experiences.

Find the full study here.

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Jäncke L. Virtual reality and the role of the prefrontal cortex in adults and children. Frontiers in Neuroscience. 2009;3(1). doi:10.3389/neuro.01.006.2009

Report: Using Extended Reality in Healthcare

The healthcare industry is ripe for embracing immersive learning technologies in training professionals and informing patients.

After a 25-year career as a learning scientist and the last 3 years “immersed” in the private sector, Todd's opinion is that immersive technologies have the potential to improve the quality and quantity of training, to reduce training costs and to enhance patient satisfaction through better care from healthcare professionals and a deeper understanding for patients.

This report was originally published in Tech Trends.

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Maddox T, Bonasio A, Barber T. Report: Using Extended Reality in Healthcare. Tech Trends. https://techtrends.tech/tech-trends/report-using-extended-reality-in-healthcare/. Published September 7, 2018. Accessed April 5, 2019.

The Effects of Immersion and Real-World Distractions on Virtual Social Interactions

Abstract: This study explores the independent and joint effects of immersion and real-world distractions (a ringing cell phone) on cognitive (i.e., recognition and recall), affective valence, and interpersonal outcomes (i.e., interpersonal liking and communication satisfaction) as well as general feelings of presence (social presence and telepresence) during a virtual experience. Participants interacted with a virtual agent in an immersive virtual environment or nonimmersive virtual environment under three different levels of real-world distractions (i.e., no distraction, passively being exposed to the sound of a ringing cell phone, and actively responding to ringing cell phone). Increased immersion had a positive effect on telepresence, but a negative effect on recognition and recall; immersion did not have a significant effect on social presence. Real-world distractions had a negative effect on recognition, recall, and social presence, but did not affect telepresence or affective valence. Participants who were actively distracted performed more poorly on the recall measure and reported lower levels of social presence than their passively distracted counterparts. These findings suggest that (a) increased immersion will not uniformly improve social virtual reality experiences and (b) more research is needed on whether and how real-world events should be integrated into virtual environments.

Find the full report here.

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Oh C, Herrera F, Bailenson J. The Effects of Immersion and Real-World Distractions on Virtual Social Interactions. Cyberpsychology, Behavior, and Social Networking. 2019;22(6):365-372. doi:10.1089/cyber.2018.0404

A Review on Interaction Techniques in Virtual Environments

Abstract: With continuous interest and effort over the past few decades, the field of virtual reality has gone through a rapid development. However, improvements in virtual reality technologies and virtual environment interaction have not been matched by corresponding improvement in our knowledge of how to classify the interaction techniques in an established way. Thus, the goal of this paper is to classify the existing interaction techniques in virtual environments and identify the classification factors. First, we gathered previous studies and reviews related to virtual environment interaction. After a thorough examination of the collected works, we were able to identify a variety of virtual environment interaction techniques and their underlying characteristics. According to the characteristics, the existing virtual environment interaction techniques were classified into two main categories, each with three different subcategories. The categories were characterized to clarify the classification scheme used. Through a systematic review on the virtual environment interaction techniques and their classification methods, this paper would serve as a reference and guidance in understanding the current research trend, and further formulate new research topics related to interaction techniques in virtual environments.

Find the full paper here.

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Jung, Jaemoon, et al. “A Review on Interaction Techniques in Virtual Environments.” Proceedings of the 2014 International Conference on Industrial Engineering and Operations Management , Jan. 2014.

Emerging Roles of Virtual Patients in the Age of AI

Abstract: Today’s web-enabled and virtual approach to medical education is different from the 20th century’s Flexner-dominated approach. Now, lectures get less emphasis and more emphasis is placed on learning via early clinical exposure, standardized patients, and other simulations. This article reviews literature on virtual patients (VPs) and their underlying virtual reality technology, examines VPs’ potential through the example of psychiatric intake teaching, and identifies promises and perils posed by VP use in medical education.

Find the full article here.

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“Emerging Roles of Virtual Patients in the Age of AI.” AMA Journal of Ethics, vol. 21, no. 2, 2019, doi:10.1001/amajethics.2019.153.

Utilization of a Voice-Based Virtual Reality Advanced Cardiac Life Support Team Leader Refresher: Prospective Observational Study

Background: The incidence of cardiac arrests per year in the United States continues to increase, yet in-hospital cardiac arrest survival rates significantly vary between hospitals. Current methods of training are expensive, time consuming, and difficult to scale, which necessitates improvements in advanced cardiac life support (ACLS) training. Virtual reality (VR) has been proposed as an alternative or adjunct to high-fidelity simulation (HFS) in several environments. No evaluations to date have explored the ability of a VR program to examine both technical and behavioral skills and demonstrate a cost comparison.

Objective: This study aimed to explore the utility of a voice-based VR ACLS team leader refresher as compared with HFS.

Methods: This prospective observational study performed at an academic institution consisted of 25 postgraduate year 2 residents. Participants were randomized to HFS or VR training and then crossed groups after a 2-week washout. Participants were graded on technical and nontechnical skills. Participants also completed self-assessments about the modules. Proctors were assessed for fatigue and task saturation, and cost analysis based on local economic data was performed

Find the full paper here.

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Katz, Daniel, et al. “Utilization of a Voice-Based Virtual Reality Advanced Cardiac Life Support Team Leader Refresher: Prospective Observational Study.” Journal of Medical Internet Research, vol. 22, no. 3, 2020, doi:10.2196/17425.

Sound source localization with varying amount of visual information in virtual reality

Abstract: To achieve accurate spatial auditory perception, subjects typically require personal headrelated transfer functions (HRTFs) and the freedom for head movements. Loudspeakerbased virtual sound environments allow for realism without individualized measurements. To study audio-visual perception in realistic environments, the combination of spatially tracked head mounted displays (HMDs), also known as virtual reality glasses, and virtual sound environments may be valuable. However, HMDs were recently shown to affect the subjects’ HRTFs and thus might influence sound localization performance. Furthermore, due to limitations of the reproduction of visual information on the HMD, audio-visual perception might be influenced. Here, a sound localization experiment was conducted both with and without an HMD and with a varying amount of visual information provided to the subjects. Furthermore, interaural time and level difference errors (ITDs and ILDs) as well as spectral perturbations induced by the HMD were analyzed and compared to the perceptual localization data. The results showed a reduction of the localization accuracy when the subjects were wearing an HMD and when they were blindfolded. The HMD-induced error in azimuth localization was found to be larger in the left than in the right hemisphere. When visual information of the limited set of source locations was provided, the localization error induced by the HMD was found to be negligible. Presenting visual information of hand-location and room dimensions showed better sound localization performance compared to the condition with no visual information. The addition of possible source locations further improved the localization accuracy. Also adding pointing feedback in form of a virtual laser pointer improved the accuracy of elevation perception but not of azimuth perception.

Find the full paper here.

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Ahrens, A., Lund, K. D., Marschall, M., & Dau, T. (2019). Sound source localization with varying amount of visual information in virtual reality. PLOS ONE, 14(3), [e0214603]. https://doi.org/10.1371/journal.pone.0214603

A Content-Analysis Approach for Exploring Usability Problems in a Collaborative Virtual Environment

Abstract: As Virtual Reality (VR) products are becoming more widely available in the consumer market, improving the usability of these devices and environments is crucial. In this paper, we are going to introduce a framework for the usability evaluation of collaborative 3D virtual environments based on a large-scale usability study of a mixed modality collaborative VR system. We first review previous literature about important usability issues related to collaborative 3D virtual environments, supplemented with our research in which we conducted 122 interviews after participants solved a collaborative virtual reality task. Then, building on the literature review and our results, we extend previous usability frameworks. We identified twelve different usability problems, and based on the causes of the problems, we grouped them into three main categories: VR environment-, device interaction-, and task-specific problems. The framework can be used to guide the usability evaluation of collaborative VR environments.

Find the full paper here.

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Geszten, Dalma. “A Content-Analysis Approach for Exploring Usability Problems in a Collaborative Virtual Environment .” Acta Polytechnica Hungarica, vol. 15, no. 5, 2018, doi:10.12700/aph.15.5.2018.5.5.

Virtual and Augmented Reality Systems for Renal Interventions: A Systematic Review

Abstract: Purpose: Many virtual and augmented reality systems have been proposed to support renal interventions. This paper reviews such systems employed in the treatment of renal cell carcinoma and renal stones. Methods: A systematic literature search was performed. Inclusion criteria were virtual and augmented reality systems for radical or partial nephrectomy and renal stone treatment, excluding systems solely developed or evaluated for training purposes. Results: In total, 52 research papers were identified and analyzed. Most of the identified literature (87%) deals with systems for renal cell carcinoma treatment. About 44% of the systems have already been employed in clinical practice, but only 20% in studies with ten or more patients. Main challenges remaining for future research include the consideration of organ movement and deformation, human factor issues, and the conduction of large clinical studies. Conclusion: Augmented and virtual reality systems have the potential to improve safety and outcomes of renal interventions. In the last ten years, many technical advances have led to more sophisticated systems, which are already applied in clinical practice. Further research is required to cope with current limitations of virtual and augmented reality assistance in clinical environments.

Find the full paper here.

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F. J. Detmer, J. Hettig, D. Schindele, M. Schostak and C. Hansen, "Virtual and Augmented Reality Systems for Renal Interventions: A Systematic Review," in IEEE Reviews in Biomedical Engineering, vol. 10, pp. 78-94, 2017.
doi: 10.1109/RBME.2017.2749527

Effect of an Augmented Reality Ultrasound Trainer App on the Motor Skills Needed for a Kidney Ultrasound: Prospective Trial

Background: Medical education is evolving from "learning by doing" to simulation-based hands-on tutorials.

Objective: The aim of this prospective 2-armed study was to evaluate a newly developed augmented reality ultrasound app and its effect on educational training and diagnostic accuracy.

Methods: We recruited 66 medical students and, using imaging and measuring a kidney as quality indicators, tested them on the time they needed for these tasks. Both groups used textbooks as preparation; in addition, the study group had access to a virtual ultrasound simulation app for mobile devices.

Find the full paper here.

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Ebner F, De Gregorio A, Schochter F, Bekes I, Janni W, Lato K. Effect of an Augmented Reality Ultrasound Trainer App on the Motor Skills Needed for a Kidney Ultrasound: Prospective Trial. JMIR Serious Games. 2019;7(2):e12713. Published 2019 May 1. doi:10.2196/12713

The Effect of a Virtual Reality Exercise Program on Physical Fitness, Body Composition, and Fatigue in Hemodialysis Patients.

Abstract: [Purpose] The aim of the present study was to investigate the effects of a virtual reality exercise program (VREP) on physical fitness, body composition, and fatigue in hemodialysis (HD) patients with end-stage renal failure. [Subjects and Methods] A nonequivalent control group pretest-posttest design was used. Forty-six HD patients were divided into exercise (n=23) and control groups (n=23); while waiting for their dialyses, the exercise group followed a VREP, and the control group received only their usual care. The VREP was accomplished using Nintendo’s Wii Fit Plus for 40 minutes, 3 times a week for 8 weeks during the period of May 27 to July 19, 2013. Physical fitness (muscle strength, balance, flexibility), body composition (skeletal muscle mass, body fat rate, arm and leg muscle mass), and fatigue were measured at baseline and after the intervention. [Results] After the VREP, physical fitness and body composition significantly increased, and the level of fatigue significantly decreased in the exercise group. [Conclusion] These results suggest that a VREP improves physical fitness, body composition, and fatigue in HD patients. Based on the findings, VREPs should be used as a health promotion programs for HD patients.

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Cho, Hyeyoung, and Kyeong-Yae Sohng. “The Effect of a Virtual Reality Exercise Program on Physical Fitness, Body Composition, and Fatigue in Hemodialysis Patients.” Journal of Physical Therapy Science, vol. 26, no. 10, 2014, pp. 1661–1665., doi:10.1589/jpts.26.1661.

Virtual Reality in Health System: Beyond Entertainment. A Mini-Review on the Efficacy of VR During Cancer Treatment

Abstract: Virtual reality (VR), a computer-generated virtual environment, has been increasingly used in the entertainment world becoming a very new evolving field, but VR technology has also found a variety of applications in the biomedical field. VR can offer to subjects a safe environment within which to carry on different interventions ranging from the rehabilitation of discharged patients directly at home, to the support of hospitalized patients during different procedures and also of oncological inpatient subjects. VR appears as a promising tool for support and monitoring treatments in cancer patients influencing psychological and physiological functions. The aim of this systematic review is to provide an overview of all the studies that used VR intervention on cancer patients and analyze their main findings. Nineteen studies across nearly a thousand articles were identified that explored effects of VR interventions on cancer patients. Although these studies varied greatly in setting and design, this review identified some overarching themes. Results found that VR improved patients' emotional well-being, and diminished cancer-related psychological symptoms. The studies explored various relevant variables including different types of settings (i.e., during chemotherapy, during pain procedures, during hospitalization). Here, we point to the need of a global and multi-disciplinary approach aimed at analyzing the effects of VR taking advantage of the new technology systems like biosensors as well as electroencephalogram monitoring pre, during, and after intervention. Devoting more attention to bio-physiological variables, standardized procedures, extending duration to longitudinal studies and adjusting for motion sickness related to VR treatment need to become standard of this research field.

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Chirico, Andrea, et al. “Virtual Reality in Health System: Beyond Entertainment. A Mini-Review on the Efficacy of VR During Cancer Treatment.” Journal of Cellular Physiology, vol. 231, no. 2, 2015, pp. 275–287., doi:10.1002/jcp.25117.

Combined application of virtual surgery and 3D printing technology in postoperative reconstruction of head and neck cancers

Background: 

The complex anatomy of the head and neck creates a formidable challenge for surgical reconstruction. However, good functional reconstruction plays a vital role in the quality of life of patients undergoing head and neck surgery. Precision medical treatment in the field of head and neck surgery can greatly improve the prognosis of patients with head and neck tumors. In order to achieve better shape and function, a variety of modern techniques have been introduced to improve the restoration and reconstruction of head and neck surgical defects. Digital surgical technology has great potential applications in the clinical treatment of head and neck cancer because of its advantages of personalization and accuracy.

Case presentation: Our department has identified the value of modern digital surgical techniques in the field of head and neck surgery and has explored its utility, including CAD/CAM technology and VR technology. We have achieved good results in the reconstruction of head and neck surgical resection defects.

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Li C, Cai Y, Wang W, et al. Combined application of virtual surgery and 3D printing technology in postoperative reconstruction of head and neck cancers. BMC Surg. 2019;19(1):182. Published 2019 Nov 28. doi:10.1186/s12893-019-0616-3

Innovative Use of Google Cardboard in Clinical Examination of Patients with Vertigo

Background:Vertigo is 1 of the most prominent and frequent neurological symptom. It is estimated that about 30% of all people need medical care once in their life due to this index symptom. The neurological expertise required is usually scarce in underprivileged areas. One has to look for spontaneous nystagmus, and perform Dix–Hallpike maneuver and Head Impulse test specifically to differentiate central from peripheral vertigo. The nystagmus, that is spontaneous, involuntary to-and-fro movement of the eyeball which aids in the diagnosis, can be better elicited by Frenzel glasses, Munich glasses. These devices consist of the combination of magnifying glasses and a lighting system to detect eye movements better than routine examination.

Objective: To test usefulness of modified Google cardboard as Frenzel glasses in poor resource setting.

Study Design: A modified Google cardboard was used in 52 consecutive cases of vertigo and compared with examination with naked eye. The device consists of 2 magnifying lenses, 1 for each eye with power of +24 dioptres.

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Yeolekar AM, Shinde KJ, Qadri H. Innovative Use of Google Cardboard in Clinical Examination of Patients of Vertigo. Clin Med Insights Ear Nose Throat. 2019;12:1179550619882012. Published 2019 Oct 21. doi:10.1177/1179550619882012

Enhanced Depth Navigation Through Augmented Reality Depth Mapping in Patients with Low Vision

Abstract: Patients diagnosed with Retinitis Pigmentosa (RP) show, in the advanced stage of the disease, severely restricted peripheral vision causing poor mobility and decline in quality of life. This vision loss causes difficulty identifying obstacles and their relative distances. Thus, RP patients use mobility aids such as canes to navigate, especially in dark environments. A number of high-tech visual aids using virtual reality (VR) and sensory substitution have been developed to support or supplant traditional visual aids. These have not achieved widespread use because they are difficult to use or block off residual vision. This paper presents a unique depth to high-contrast pseudocolor mapping overlay developed and tested on a Microsoft Hololens 1 as a low vision aid for RP patients. A single-masked and randomized trial of the AR pseudocolor low vision aid to evaluate real world mobility and near obstacle avoidance was conducted consisting of 10 RP subjects. An FDA-validated functional obstacle course and a custom-made grasping setup were used. The use of the AR visual aid reduced collisions by 50% in mobility testing (p = 0.02), and by 70% in grasp testing (p = 0.03). This paper introduces a new technique, the pseudocolor wireframe, and reports the first significant statistics showing improvements for the population of RP patients with mobility and grasp.

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Angelopoulos AN, Ameri H, Mitra D, Humayun M. Enhanced Depth Navigation Through Augmented Reality Depth Mapping in Patients with Low Vision. Sci Rep. 2019;9(1):11230. Published 2019 Aug 2. doi:10.1038/s41598-019-47397-w

Development and Evaluation of a Virtual Research Environment to Improve Quality of Care in Overcrowded Emergency Departments: Observational Study

Background: Despite a wide range of literature on emergency department (ED) overcrowding, scientific knowledge on emergency physicians’ cognitive processes coping with overcrowding is limited.

Objective: This study aimed to develop and evaluate a virtual research environment that will allow us to study the effect of physicians’ strategies and behaviors on quality of care in the context of ED overcrowding.

Methods: A simulation-based observational study was conducted over two stages: the development of a simulation model and its evaluation. A research environment in emergency medicine combining virtual reality and simulated patients was designed and developed. Afterwards, 12 emergency physicians took part in simulation scenarios and had to manage 13 patients during a 2-hour period. The study outcome was the authenticity of the environment through realism, consistency, and mastering. The realism was the resemblance perceived by the participants between virtual and real ED. The consistency of the scenario and the participants’ mastering of the environment was expected for 90% (12/13) of the participants.

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Houze-Cerfon CH, Vaissié C, Gout L, Bastiani B, Charpentier S, Lauque D. Development and Evaluation of a Virtual Research Environment to Improve Quality of Care in Overcrowded Emergency Departments: Observational Study. JMIR Serious Games. 2019;7(3):e13993. Published 2019 Aug 8. doi:10.2196/13993

The Effect of a Virtual-Reality Full-Body Illusion on Body Representation in Obesity

Background. The effective illusory ownership over an artificial body in modulating body representations in healthy and eating disorders population has been repeatedly reported in recent literature. In this study, we extended this research in the field of obesity: specifically, we investigated whether ownership over a virtual body with a skinny abdomen might be successfully experienced by participants affected by obesity. 

Methods. Fifteen participants with obesity and fifteen healthy-weight participants took part at this study in which the VR-Full-Body Illusion was adopted. The strength of illusion was investigated through the traditional Embodiment Questionnaire, while changes in bodily experience were measured through a body size estimation task. 

Results. Participants with obesity as well as healthy-weight participants reported to experience the illusion. About the body size estimation task, both groups reported changes only in the estimation of the abdomen’s circumference after the experimental condition, in absence of any another difference. 

Discussion. Participants with obesity reported to experience the illusion over a skinny avatar, but the modulation of the bodily experience seems controversial. Future lines of research exploiting this technique for modulating body representations in obesity, specifically in terms of potential therapeutic use, were discussed.

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Scarpina, F.; Serino, S.; Keizer, A.; Chirico, A.; Scacchi, M.; Castelnuovo, G.; Mauro, A.; Riva, G. The Effect of a Virtual-Reality Full-Body Illusion on Body Representation in Obesity. J. Clin. Med. 20198, 1330.

 

The Importance of Systematically Reporting and Reflecting on eHealth Development: Participatory Development Process of a Virtual Reality Application for Forensic Mental Health Care

Background: The use of electronic health (eHealth) technologies in practice often is lower than expected, mostly because there is no optimal fit among a technology, the characteristics of prospective users, and their context. To improve this fit, a thorough systematic development process is recommended. However, more knowledge about suitable development methods is necessary to create a tool kit that guides researchers in choosing development methods that are appropriate for their context and users. In addition, there is a need for reflection on the existing frameworks for eHealth development to be able to constantly improve them.

Objective: The two main objectives of this case study were to present and reflect on the (1) methods used in the development process of a virtual reality application for forensic mental health care and (2) development model that was used: the CeHRes Roadmap (the Centre for eHealth Research Roadmap).

Methods: In the development process, multiple methods were used to operationalize the first 2 phases of the CeHRes Roadmap: the contextual inquiry and value specification. To summarize the most relevant information for the goals of this study, the following information was extracted per method: (1) research goal, (2) explanation of the method used, (3) main results, (4) main conclusions, and (5) lessons learned about the method.

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Kip H, Kelders SM, Bouman YHA, van Gemert-Pijnen LJEWC. The Importance of Systematically Reporting and Reflecting on eHealth Development: Participatory Development Process of a Virtual Reality Application for Forensic Mental Health Care. J Med Internet Res. 2019;21(8):e12972. Published 2019 Aug 19. doi:10.2196/12972

The Responses of Medical General Practitioners to Unreasonable Patient Demand for Antibiotics - A Study of Medical Ethics Using Immersive Virtual Reality

Background: Dealing with insistent patient demand for antibiotics is an all too common part of a General Practitioner’s daily routine. This study explores the extent to which portable Immersive Virtual Reality technology can help us gain an accurate understanding of the factors that influence a doctor’s response to the ethical challenge underlying such tenacious requests for antibiotics (given the threat posed by growing anti-bacterial resistance worldwide). It also considers the potential of such technology to train doctors to face such dilemmas.

Experiment: Twelve experienced GPs and nine trainees were confronted with an increasingly angry demand by a woman to prescribe antibiotics to her mother in the face of inconclusive evidence that such antibiotic prescription is necessary. The daughter and mother were virtual characters displayed in immersive virtual reality. The specific purposes of the study were twofold: first, whether experienced GPs would be more resistant to patient demands than the trainees, and second, to investigate whether medical doctors would take the virtual situation seriously.

Results: Eight out of the 9 trainees prescribed the antibiotics, whereas 7 out of the 12 GPs did so. On the basis of a Bayesian analysis, these results yield reasonable statistical evidence in favor of the notion that experienced GPs are more likely to withstand the pressure to prescribe antibiotics than trainee doctors, thus answering our first question positively. As for the second question, a post experience questionnaire assessing the participants’ level of presence (together with participants’ feedback and body language) suggested that overall participants did tend towards the illusion of being in the consultation room depicted in the virtual reality and that the virtual consultation taking place was really happening.

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Pan X, Slater M, Beacco A, Navarro X, Bellido Rivas AI, et al. (2016) The Responses of Medical General Practitioners to Unreasonable Patient Demand for Antibiotics - A Study of Medical Ethics Using Immersive Virtual Reality. PLOS ONE 11(2): e0146837. https://doi.org/10.1371/journal.pone.0146837

Attitudes Toward and Familiarity With Virtual Reality Therapy Among Practicing Cognitive Behavior Therapists: A Cross-Sectional Survey Study in the Era of Consumer VR Platforms

Abstract: Virtual reality exposure therapy (VRET) is an efficacious treatment for fear and anxiety and has the potential to solve both logistic issues for therapists and be used for scalable self-help interventions. However, VRET has yet to see large-scale implementation in clinical settings or as a consumer product, and past research suggests that while therapists may acknowledge the many advantages of VRET, they view the technology as technically inaccessible and expensive. We reasoned that after the 2016 release of several consumer virtual reality (VR) platforms and associated public acquaintance with VR, therapists' concerns about VRET may have evolved. The present study surveyed attitudes toward and familiarity with VR and VRET among practicing cognitive behavior therapists (n = 185) attending a conference. Results showed that therapists had an overall positive attitude toward VRET (pros rated higher than cons) and viewed VR as applicable to conditions other than anxiety. Unlike in earlier research, high financial costs and technical difficulties were no longer top-rated negative aspects. Average negative attitude was a larger negative predictor of self-rated likelihood of future use than positive attitude was a positive predictor and partially mediated the positive association between VRET knowledge and likelihood of future use, suggesting that promotional efforts should focus on addressing concerns. We conclude that therapist's attitudes toward VRET appear to have evolved in recent years, and no longer appear to constitute a major barrier to implementing the next generation of VR technology in regular clinical practice.

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Lindner, Philip, et al. “Attitudes Toward and Familiarity With Virtual Reality Therapy Among Practicing Cognitive Behavior Therapists: A Cross-Sectional Survey Study in the Era of Consumer VR Platforms.” Frontiers in Psychology, vol. 10, 2019, doi:10.3389/fpsyg.2019.00176.

USE: An integrative suite for temporally-precise psychophysical experiments in virtual environments for human, nonhuman, and artificially intelligent agents

Background: There is a growing interest in complex, active, and immersive behavioral neuroscience tasks. However, the development and control of such tasks present unique challenges.

New Method: The Unified Suite for Experiments (USE) is an integrated set of hardware and software tools for the design and control of behavioral neuroscience experiments. The software, developed using the Unity video game engine, supports both active tasks in immersive 3D environments and static 2D tasks used in more traditional visual experiments. The custom USE SyncBox hardware, based around an Arduino Mega2560 board, integrates and synchronizes multiple data streams from different pieces of experimental hardware. The suite addresses three key issues with developing cognitive neuroscience experiments in Unity: tight experimental control, accurate sub-ms timing, and accurate gaze target identification.

Results: USE is a flexible framework to realize experiments, enabling (i) nested control over complex tasks, (ii) flexible use of 3D or 2D scenes and objects, (iii) touchscreen-, button-, joystick- and gaze-based interaction, and (v) complete offline reconstruction of experiments for post-processing and temporal alignment of data streams.

Comparison with Existing Methods: Most existing experiment-creation tools are not designed to support the development of video-game-like tasks. Those that do use older or less popular video game engines as their base, and are not as feature-rich or enable as precise control over timing as USE.

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Watson, Marcus R, et al. “USE: An Integrative Suite for Temporally-Precise Psychophysical Experiments in Virtual Environments for Human, Nonhuman, and Artificially Intelligent Agents.” Journal of Neuroscience Methods, vol. 326, 2019, p. 108374., doi:10.1016/j.jneumeth.2019.108374.

Meta-Analysis of the Efficacy of Virtual Reality–Based Interventions in Cancer-Related Symptom Management

Background. This meta-analysis summarizes the results from recent studies that examined the use of virtual reality (VR)-based interventions on health-related outcomes in patients with cancer, and quantitatively evaluates the efficacy of VR-based interventions. Findings of this meta-analysis can provide direction for future symptom management research. 

Methods. The search terms included a combination of "virtual reality" OR "virtual environment" OR "head-mounted display" with "oncology" OR "cancer." Three databases (Medline, PubMed, and CAJ Full-text Database), one search engine (Google Scholar), and the website of ResearchGate, covering the period from December 2013 to May 15, 2019, and including articles published in both English and Chinese, were searched. Data synthesis used the RevMan 5.3 to generate pooled estimates of effect size. 

Results. A total of 6 empirical studies met the eligibility criteria. VR-based interventions had statistically significant effects on reducing symptoms of anxiety, depression, pain, and cognitive function, whereas statistically significant benefit was observed for fatigue (Z = 2.76, P = .006). 

Conclusion. Most recent studies have primarily examined VR-based interventions for symptom management in the acute stages of cancer care. However, the management of late and long-term side effects is central to cancer survivorship care. There is burgeoning empirical support for further research to evaluate the efficacy of VR-based interventions in cancer rehabilitation.

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Zeng, Yingchun, et al. “Meta-Analysis of the Efficacy of Virtual Reality–Based Interventions in Cancer-Related Symptom Management.” Integrative Cancer Therapies, vol. 18, 2019, p. 153473541987110., doi:10.1177/1534735419871108.

Coronavirus disinfection in histopathology

Abstract: The 2019 Coronavirus epidemic, provisionally called 2019-nCoV, was first identified in Wuhan, China, in persons exposed to a seafood or wet market. There is an international push to contain the virus and prevent its spread. It is feasible that potentially infectious samples may be received in histopathology laboratories for diagnosis. This technical note presents disinfection procedures and histotechnology processes that should alleviate the risk of infection to laboratory staff. Using data obtained from similar coronaviruses, e.g. severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), experts are confident that 70% ethanol and 0.1% sodium hypochlorite should inactivate the virus. Formalin fixation and heating samples to 56oC, as used in routine tissue processing, were found to inactivate several coronaviruses and it is believed that 2019-nCoV would be similarly affected.

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Henwood AF. Coronavirus disinfection in histopathology [published online ahead of print, 2020 Mar 1]. J Histotechnol. 2020;1–3. doi:10.1080/01478885.2020.1734718

Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents

Abstract: Currently, the emergence of a novel human coronavirus, SARS-CoV-2, has become a global health concern causing severe respiratory tract infections in humans. Human-to-human transmissions have been described with incubation times between 2-10 days, facilitating its spread via droplets, contaminated hands or surfaces. We therefore reviewed the literature on all available information about the persistence of human and veterinary coronaviruses on inanimate surfaces as well as inactivation strategies with biocidal agents used for chemical disinfection, e.g. in healthcare facilities. The analysis of 22 studies reveals that human coronaviruses such as Severe Acute Respiratory Syndrome (SARS) coronavirus, Middle East Respiratory Syndrome (MERS) coronavirus or endemic human coronaviruses (HCoV) can persist on inanimate surfaces like metal, glass or plastic for up to 9 days, but can be efficiently inactivated by surface disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite within 1 minute. Other biocidal agents such as 0.05-0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate are less effective. As no specific therapies are available for SARS-CoV-2, early containment and prevention of further spread will be crucial to stop the ongoing outbreak and to control this novel infectious thread.

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Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect. 2020;104(3):246–251. doi:10.1016/j.jhin.2020.01.022

Transmission of SARS and MERS coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination

Abstract: Viruses with pandemic potential including H1N1, H5N1, and H5N7 influenza viruses, and severe acute respiratory syndrome (SARS)/Middle East respiratory syndrome (MERS) coronaviruses (CoV) have emerged in recent years. SARS-CoV, MERS-CoV, and influenza virus can survive on surfaces for extended periods, sometimes up to months. Factors influencing the survival of these viruses on surfaces include: strain variation, titre, surface type, suspending medium, mode of deposition, temperature and relative humidity, and the method used to determine the viability of the virus. Environmental sampling has identified contamination in field-settings with SARS-CoV and influenza virus, although the frequent use of molecular detection methods may not necessarily represent the presence of viable virus. The importance of indirect contact transmission (involving contamination of inanimate surfaces) is uncertain compared with other transmission routes, principally direct contact transmission (independent of surface contamination), droplet, and airborne routes. However, influenza virus and SARS-CoV may be shed into the environment and be transferred from environmental surfaces to hands of patients and healthcare providers. Emerging data suggest that MERS-CoV also shares these properties. Once contaminated from the environment, hands can then initiate self-inoculation of mucous membranes of the nose, eyes or mouth. Mathematical and animal models, and intervention studies suggest that contact transmission is the most important route in some scenarios. Infection prevention and control implications include the need for hand hygiene and personal protective equipment to minimize self-contamination and to protect against inoculation of mucosal surfaces and the respiratory tract, and enhanced surface cleaning and disinfection in healthcare settings.

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Otter JA, Donskey C, Yezli S, Douthwaite S, Goldenberg SD, Weber DJ. Transmission of SARS and MERS coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination. J Hosp Infect. 2016;92(3):235–250. doi:10.1016/j.jhin.2015.08.027

Ultraviolet Germicidal Irradiation of Influenza-Contaminated N95 Filtering Facepiece Respirators

Background: Safe and effective decontamination and reuse of N95 filtering facepiece respirators (FFRs) has the potential to significantly extend FFR holdings, mitigating a potential shortage due to an influenza pandemic or other pandemic events. Ultraviolet germicidal irradiation (UVGI) has been shown to be effective for decontaminating influenza-contaminated FFRs. This study aims to build on past research by evaluating the UVGI decontamination efficiency of influenza-contaminated FFRs in the presence of soiling
agents using an optimized UVGI dose.

Methods: Twelve samples each of 15 N95 FFR models were contaminated with H1N1 influenza (facepiece and strap), then covered with a soiling agent—artificial saliva or artificial skin oil. For each soiling agent, 3 contaminated FFRs were treated with 1 J/cm2 UVGI for approximately 1 minute, whereas 3 other contaminated FFRs remained untreated. All contaminated surfaces were cut out and virus extracted. Viable influenza was quantified using a median tissue culture infectious dose assay.

Results: Significant reductions (≥3 log) in influenza viability for both soiling conditions were observed
on facepieces from 12 of 15 FFR models and straps from 7 of 15 FFR models.

Conclusions: These data suggest that FFR decontamination and reuse using UVGI can be effective. Implementation of a UVGI method will require careful consideration of FFR model, material type, and design.

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Mills, Devin, et al. “Ultraviolet Germicidal Irradiation of Influenza-Contaminated N95 Filtering Facepiece Respirators.” American Journal of Infection Control, vol. 46, no. 7, 2018, doi:10.1016/j.ajic.2018.02.018.

Ultraviolet-C Irradiation for Inactivation of Viruses in Foetal Bovine Serum

Abstract: Foetal Bovine Serum (FBS) and porcine trypsin are one of the essential raw materials used in the manufacturing of cell culture based viral vaccines. Being from animal origin, these raw materials can potentially contaminate the final product by known or unknown adventitious agents. The issue is more serious in case of live attenuated viral vaccines, where there is no inactivation step which can take care of such adventitious agents. It is essential to design production processes which can offer maximum viral clearance potential for animal origin products. Ultraviolet-C irradiation is known to inactivate various adventitious viral agents; however there are limited studies on ultraviolet inactivation of viruses in liquid media. We obtained a recently developed UVivatec ultraviolet-C (UV-C) irradiation based viral clearance system for evaluating its efficacy to inactivate selected model viruses. This system has a unique design with spiral path of liquid allowing maximum exposure to UV-C light of a short wavelength of 254 nm. Five live attenuated vaccine viruses and four other model viruses were spiked in tissue culture media and exposed to UV-C irradiation. The pre and post UV-C irradiation samples were analyzed for virus content to find out the extent of inactivation of various viruses. These experiments showed substantial log reduction for the majority of the viruses with few exceptions based on the characteristics of these viruses. Having known the effect of UV irradiation on protein structure, we also evaluated the post irradiation samples of culture media for growth promoting properties using one of the most fastidious human diploid cells (MRC-5). UV-C exposure did not show any notable impact on the nutritional properties of culture media. The use of an UV-C irradiation based system is considered to be promising approach to mitigate the risk of adventitious agents in cell culture media arising through animal derived products.

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Vaidya, Vivek, et al. “Ultraviolet-C Irradiation for Inactivation of Viruses in Foetal Bovine Serum.” Vaccine, vol. 36, no. 29, 2018, pp. 4215–4221., doi:10.1016/j.vaccine.2018.06.008.

Effect of ultraviolet germicidal irradiation on viral aerosols

Abstract: Ultraviolet (UV) germicidal air disinfection is an engineering method used to control the airborne transmission of pathogenic microorganisms in high-risk settings. Despite the recent emergence of respiratory viral pathogens such as SARS and avian influenza viruses, UV disinfection of pathogenic viral aerosols has not been examined. Hence, we characterized the UV disinfection of viral aerosols using the bacteriophage MS2, adenovirus, and coronavirus. Our objectives were to characterize the effect of nebulization and air sampling on the survival of important viral pathogens, quantitatively characterize and estimate the UV susceptibility of pathogenic viral aerosols, and evaluate the effect of relative humidity (RH) on the susceptibility of viral aerosols, to 254 nm UV-C. The viruses were aerosolized into an experimental chamber using a six-jet Collison nebulizer, exposed to 254 nm UV, and sampled using an AGI-30 liquid impinger. Both the MS2 and adenovirus aerosols were very resistant to UV air disinfection, with a reduction of less than 1 logarithm in viable viral aerosols at a UV dose of 2608 microW s/cm2. The susceptibility of coronavirus aerosols was 7-10 times that of the MS2 and adenovirus aerosols. Unlike bacterial aerosols, there was no significant protective effect of high RH on UV susceptibility of the tested viral aerosols. We confirmed that the UV disinfection rate differs greatly between viral aerosols and viruses suspended in liquid.

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Walker CM, Ko G. Effect of ultraviolet germicidal irradiation on viral aerosols. Environ Sci Technol. 2007;41(15):5460–5465. doi:10.1021/es070056u

Evaluation of Viral Inactivation Efficacy of a Continuous Flow Ultraviolet-C Reactor (UVivatec)

Abstract: Viral safety is an important prerequisite for clinical preparations of all biopharmaceuticals derived from plasma, cell lines, or tissues of human or animal origin. To ensure the safety, implementation of multiple viral clearance (inactivation and/or removal) steps has been highly recommended for manufacturing of biopharmaceuticals. Of the possible viral clearance strategies, Ultraviolet-C (UVC) irradiation has been known as an effective viral inactivating method. However it has been dismissed by biopharmaceutical industry as a result of the potential for protein damage and the difficulty in delivering uniform doses. Recently a continuous flow UVC reactor (UVivatec) was developed to provide highly efficient mixing and maximize virus exposure to the UV light. In order to investigate the effectiveness of UVivatec to inactivate viruses without causing significant protein damage, the feasibility of the UVC irradiation process was studied with a commercial therapeutic protein. Recovery yield in the optimized condition of 3,000 J/m2 irradiation was more than 98%. The efficacy and robustness of the UVC reactor was evaluated with regard to the inactivation of human immunodeficiency virus (HIV), hepatitis A virus (HAV), bovine herpes virus (BHV), bovine viral diarrhea virus (BVDV), porcine parvovirus (PPV), bovine parvovirus (BPV), minute virus of mice (MVM), reovirus type 3 (REO), and bovine parainfluenza virus type 3 (BPIV). Non enveloped viruses (HAV, PPV, BPV, MVM, and REO) were completely inactivated to undetectable levels by 3,000 J/m2 irradiation. Enveloped viruses such as HIV, BVDV, and BPIV were completely inactivated to undetectable levels. However BHV was incompletely inactivated with slight residual infectivity remaining even after 3,000 J/m2 irradiation. The log reduction factors achieved by UVC irradiation were ≥3.89 for HIV, ≥5.27 for HAV, 5.29 for BHV, ≥5.96 for BVDV, ≥4.37 for PPV, ≥3.55 for BPV, ≥3.51 for MVM, ≥4.20 for REO, and ≥4.15 for BPIV. These results indicate that UVC irradiation using UVivatec was very effective and robust in inactivating all the viruses tested. 

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Bae, Jung Eun, et al. “Evaluation of Viral Inactivation Efficacy of a Continuous Flow Ultraviolet-C Reactor (UVivatec).” Korean Journal of Microbiology and Microtechnology, vol. 37, no. 4, 2009, pp. 377–382.

Inactivation of the Coronavirus That Induces Severe Acute Respiratory Syndrome, SARS-CoV

Abstract: Severe acute respiratory syndrome (SARS) is a life-threatening disease caused by a novel coronavirus termed SARS-CoV. Due to the severity of this disease, the World Health Organization (WHO) recommends that manipulation of active viral cultures of SARS-CoV be performed in containment laboratories at biosafety level 3 (BSL3). The virus was inactivated by ultraviolet light (UV) at 254 nm, heat treatment of 65 degrees C or greater, alkaline (pH > 12) or acidic (pH < 3) conditions, formalin and glutaraldehyde treatments. We describe the kinetics of these efficient viral inactivation methods, which will allow research with SARS-CoV containing materials, that are rendered non-infectious, to be conducted at reduced safety levels.

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Darnell, Miriam E.r., et al. “Inactivation of the Coronavirus That Induces Severe Acute Respiratory Syndrome, SARS-CoV.” Journal of Virological Methods, vol. 121, no. 1, 2004, pp. 85–91., doi:10.1016/j.jviromet.2004.06.006.

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

The article presents the use of Virtual Reality (VR) as a clinical tool to address the assessment, prevention, and treatment of PTSD, based on the VR projects that were evolved at the University of Southern California Institute for Creative Technologies since 2004.

You can find the full article here.

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Rizzo A‘S, Shilling R. Clinical Virtual Reality tools to advance the prevention, assessment, and treatment of PTSD. European Journal of Psychotraumatology. 2017;8(sup5):1414560. doi:10.1080/20008198.2017.1414560

Implementations of Virtual Reality for Anxiety-Related Disorders: Systematic Review

Background: Although traditional forms of therapy for anxiety-related disorders (eg, cognitive behavioral therapy, CBT) have been effective, there have been long-standing issues with these therapies that largely center around the costs and risks associated with the components comprising the therapeutic process. To treat certain types of specific phobias, sessions may need to be held in public, therefore risking patient confidentiality and the occurrence of uncontrollable circumstances (eg, weather and bystander behavior) or additional expenses such as travel to reach a destination. To address these issues, past studies have implemented virtual reality (VR) technologies for virtual reality exposure therapy (VRET) to provide an immersive, interactive experience that can be conducted privately and inexpensively. The versatility of VR allows various environments and scenarios to be generated while giving therapists control over variables that would otherwise be impossible in a natural setting. Although the outcomes from these studies have been generally positive despite the limitations of legacy VR systems, it is necessary to review these studies to identify how modern VR systems can and should improve to treat disorders in which anxiety is a key symptom, including specific phobias, posttraumatic stress disorder and acute stress disorder, generalized anxiety disorder, and paranoid ideations.

Find the full study here.

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Oing, Theodore, and Julie Prescott. “Implementations of Virtual Reality for Anxiety-Related Disorders: Systematic Review.” JMIR Serious Games, vol. 6, no. 4, 2018, doi:10.2196/10965.

Design Strategies for Virtual Reality Interventions for Managing Pain and Anxiety in Children and Adolescents: Scoping Review

Background: Virtual reality (VR) technology has been explored in the health sector as a novel tool for supporting treatment side effects, including managing pain and anxiety. VR has recently become more available with the launch of low-cost devices and apps.

Objective: This study aimed to provide an updated review of the research into VR use for pain and anxiety in pediatric patients undergoing medical procedures. Specifically, we wanted to gain an understanding of the techniques and goals used in selecting or designing VR apps in this context.

Methods: We performed a scoping review. To identify relevant studies, we searched three electronic databases. Two authors screened the titles and abstracts for relevance and eligibility criteria.

Results: Overall, 1386 articles published between 2013 and 2018 were identified. In total 18 articles were included in the review, with 7 reporting significant reduction in pediatric pain or anxiety, 3 testing but finding no significant impact of the VR apps employed, and the rest not conducting any test of significance. We identified 9 articles that were based on VR apps specifically designed and tailored for pediatric patients. The findings were analyzed to develop a holistic model and describe the product, experience, and intervention aspects that need to be considered in designing such medical VR apps.

Find the full review here.

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Ahmadpour N, Keep M, Janssen A, Rouf AS, Marthick M Design Strategies for Virtual Reality Interventions for Managing Pain and Anxiety in Children and Adolescents: Scoping Review
JMIR Serious Games 2020;8(1):e14565
URL: https://games.jmir.org/2020/1/e14565
DOI: 10.2196/14565
PMID: 32012042

Using Virtual Reality Exposure Therapy to Enhance Treatment of Anxiety Disorders: Identifying Areas of Clinical Adoption and Potential Obstacles

Abstract: Despite strong evidence of effectiveness, exposure therapy is an underutilized treatment for anxiety disorders at a time when effective treatment for anxiety is greatly needed. The significant worldwide prevalence and negative impact of anxiety are documented and highlight the importance of increasing therapist and patient use of effective treatment. Obstacles to the use of exposure therapy are explored and steps to lessen these obstacles are proposed. In particular, virtual reality (VR) technology is discussed as a way to increase the availability of exposure therapy. Incorporating VR in therapy can increase the ease, acceptability, and effectiveness of treatment for anxiety. VR exposure therapy (VRET) permits individualized, gradual, controlled, immersive exposure that is easy for therapists to implement and often more acceptable to patients than in vivo or imaginal exposure. VR is presented as a scalable tool that can augment access to and effectiveness of exposure therapy thus improving treatment of anxiety disorders. VR also has the potential to help with assessment and with therapist training standardization. The authors advocate for providing continuing education in VRET to practicing clinicians and including training in exposure therapy and VRET in training programs. Ongoing development of VR applications for clinical use is encouraged, especially when developed in collaboration with software developers, clinical users, therapists who are experienced in VRET, and researchers.

Find the full paper here.

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Boeldt D, McMahon E, McFaul M, Greenleaf W. Using Virtual Reality Exposure Therapy to Enhance Treatment of Anxiety Disorders: Identifying Areas of Clinical Adoption and Potential Obstacles. Front Psychiatry. 2019;10:773. Published 2019 Oct 25. doi:10.3389/fpsyt.2019.00773

Perception and Performance on a Virtual Reality Cognitive Stimulation for Use in the Intensive Care Unit: A Non-Randomized Trial in Critically Ill Patients

Background: Newly acquired long-term cognitive impairments are common among survivors of critical illness. They have been linked to the stressful situation that patients experience in the intensive care unit (ICU). In this paper we use virtual reality (VR) technology to comfort critically ill patients and reduce stress during their ICU stay. We investigate the acceptance, comfort, recollection, and visual perception of VR stimulation and how it affects physiological parameters.

Methods: A VR head-mounted display was used to present immersive nature scenes to 33 critically ill cardiac surgery patients [mean age 63 years (range 32–83)]. Data was collected with an eye tracker fitted inside the VR head-mounted display to measure eye movements (250 Hz) and sensors to record physiological parameters (240 Hz). Patients received VR stimulation (for 5 min.) prior to ICU admission, during ICU stay, and 3 months after discharge. Acceptance, recollection and comfort were assessed with validated questionnaires.

Results: The number of gazed meaningful objects per minute was significantly lower during the ICU session compared to pre- and follow-up sessions, whereas mean duration of fixation on meaningful moving objects did not differ between the sessions. While respiratory rate decreased significantly during VR stimulation, heart rate and blood pressure remained constant. Post-ICU rating of VR acceptance during ICU stay was moderate to high and discomfort low. Recollection of VR was high [28/33 patients (84.8%)], while recollection of ICU stay was low [10/33 patients (30.3%)].

Find the full paper here.

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Gerber, Stephan M., et al. “Perception and Performance on a Virtual Reality Cognitive Stimulation for Use in the Intensive Care Unit: A Non-Randomized Trial in Critically Ill Patients.” Frontiers in Medicine, vol. 6, 2019, doi:10.3389/fmed.2019.00287.

Heart Rate Variability Biofeedback Based on Slow-Paced Breathing With Immersive Virtual Reality Nature Scenery

This study investigated the benefits of using a virtual nature environment to administer immersive heart rate variability biofeedback (HRV-BF) based on slow-paced breathing. We compared the virtual reality (VR)-based HRV-BF with a standard implementation in a randomized controlled experiment with 60 healthy employees. After a cognitive stress induction, the participants performed a single-session of HRV-BF before repeating the cognitive stressor task. VR-based versus standard HRV-BF was comparable in terms of biofeedback performance (cardiac coherence and cardiac vagal tone). However, the VR-based implementation buffered perceived stress in the subsequent stressor task, increased relaxation self-efficacy more, reduced mind wandering, helped participants focus on the present moment, and helped preserve attentional resources. Potential long-term effects and generalizability need to be assessed in future research.

Find the full study here.

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Blum, Johannes, et al. “Heart Rate Variability Biofeedback Based on Slow-Paced Breathing With Immersive Virtual Reality Nature Scenery.” Frontiers in Psychology, vol. 10, 2019, doi:10.3389/fpsyg.2019.02172.

Virtual reality exposure before elective day care surgery to reduce anxiety and pain in children: A randomised controlled trial

Background: Pre-operative anxiety in children is very common and is associated with adverse outcomes.

Objective: The aim of this study was to investigate if virtual reality exposure (VRE) as a preparation tool for elective day care surgery in children is associated with lower levels of anxiety, pain and emergence delirium compared with a control group receiving care as usual (CAU).

Design: A randomised controlled single-blind trial.

Setting: A single university children's hospital in the Netherlands from March 2017 to October 2018.

Patients: Two-hundred children, 4 to 12 years old, undergoing elective day care surgery under general anaesthesia.

Intervention: On the day of surgery, children receiving VRE were exposed to a realistic child-friendly immersive virtual version of the operating theatre, so that they could get accustomed to the environment and general anaesthesia procedures.

Find the full study here.

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Eijlers R, Dierckx B, Staals LM, et al. Virtual reality exposure before elective day care surgery to reduce anxiety and pain in children: A randomised controlled trial. Eur J Anaesthesiol. 2019;36(10):728–737. doi:10.1097/EJA.0000000000001059

Editorial: Assessing the Therapeutic Uses and Effectiveness of Virtual Reality, Augmented Reality and Video Games for Emotion Regulation and Stress Management

Background:

Virtual reality (VR), Augmented Reality (AR), and Video games (VGs), because of their reasonable cost and increasing diffusion among the public, are becoming very interesting and promising therapeutic approaches for improving individuals' health and well-being (e.g., Granic et al., 2014Giglioli et al., 2015Riva et al., 2016Hemenover and Bowman, 2018).

However, despite that numerous scientific studies have demonstrated the therapeutic benefits of these technologies for diverse cognitive functions and individual patients (e.g., Parsons et al., 2017Bediou et al., 2018Bouchard and Rizzo, 2019Riva et al., 2019), less attention has been devoted to the therapeutic use of such tools for the assessment and training of emotion regulation and stress management skills.

Therefore, we brought together within this Research Topic contributions from researchers investigating theoretical, empirical, experimental, and case studies of VR, AR, and VGs for emotion regulation and stress management assessment and training. This Editorial will provide an overview of the articles accepted for publication in the Research Topic.

Find the full paper here.

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Pallavicini, Federica, and Stéphane Bouchard. “Editorial: Assessing the Therapeutic Uses and Effectiveness of Virtual Reality, Augmented Reality and Video Games for Emotion Regulation and Stress Management.” Frontiers in Psychology, vol. 10, 2019, doi:10.3389/fpsyg.2019.02763.

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

Objective: A range of recent studies suggest that overall mindset about stress is related to health, performance, and well-being. Therefore, an exploratory study was conducted to examine whether virtual reality (VR) with real-time biofeedback would have potential in training people in an engaging way to develop a new stress-is-enhancing mindset.

Materials and Methods: The specific application to improve people's stress mindset that was used in this study is Stressjam. The application was tested on its attractiveness by 111 healthy participants, specifically on their personal involvement through the Personal Involvement Inventory and its usability through the System Usability Scale. In addition to the healthy participants, a group of 64 patients dealing with stress used Stressjam for at least three sessions. The Stress Mindset Measure was used to assess the stress mindset of both groups, at baseline and after finishing their session(s).

Results: Stressjam appears to be an application that is user friendly with good user involvement. The healthy participants and the patient sample both had a more positive stress mindset after using the application than at baseline, t(111) = 4.38, P < 0.001, and F(1,63) = 66.57, P < 0.001, respectively.

Find the full study here.

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Maarsingh BM, Bos J, Van Tuijn CFJ, Renard SB. Changing Stress Mindset Through Stressjam: A Virtual Reality Game Using Biofeedback. Games Health J. 2019;8(5):326–331. doi:10.1089/g4h.2018.0145

A Free Virtual Reality Experience to Prepare Pediatric Patients for Magnetic Resonance Imaging: Cross-Sectional Questionnaire Study

Background: A magnetic resonance image (MRI) is a diagnostic test that requires patients to lie still for prolonged periods within a claustrophobic and noisy environment. This can be difficult for children to tolerate, and often general anesthetic (GA) is required at considerable cost and detriment to patient safety. Virtual reality (VR) is a newly emerging technology that can be implemented at low cost within a health care setting. It has been shown to reduce fear associated with a number of high-anxiety situations and medical procedures.

Objective: The goal of the research was to develop a VR resource to prepare pediatric patients for MRI, helping to reduce anxieties in children undergoing the procedure.

Find the full study here.

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Ashmore J, Di Pietro J, Williams K, Stokes E, Symons A, Smith M, Clegg L, McGrath C "A Free Virtual Reality Experience to Prepare Pediatric Patients for Magnetic Resonance Imaging: Cross-Sectional Questionnaire Study" JMIR Pediatr Parent 2019;2(1):e11684

Inferiority or Even Superiority of Virtual Reality Exposure Therapy in Phobias?—A Systematic Review and Quantitative Meta-Analysis on Randomized Controlled Trials

Background: Convincing evidence on Virtual Reality (VR) exposure for phobic anxiety disorders has been reported, however, the benchmark and golden standard for phobia treatment is in vivo exposure. For direct treatment comparisons, the control of confounding variables is essential. Therefore, the comparison of VR and in vivo exposure in studies applying an equivalent amount of exposure in both treatments is necessary.

Methods: We conducted a systematic search of reports published until June 2019. Inclusion criteria covered the diagnosis of Specific Phobia, Social Phobia, or Agoraphobia, and a randomized-controlled design with an equivalent amount of exposure in VR and in vivo. We qualitatively reviewed participants' characteristics, materials, and the treatment procedures of all included studies. For quantitative synthesis, we calculated Hedges' g effect sizes for the treatment effects of VR exposure, in vivo exposure, and the comparison of VR to in vivo exposure in all studies and separately for studies on each diagnosis.

Results: Nine studies (n = 371) were included, four on Specific Phobia, three on Social Phobia, and two on Agoraphobia. VR and in vivo exposure both showed large, significant effect sizes. The comparison of VR to in vivo exposure revealed a small, but non-significant effect size favoring in vivo (g = −0.20). Specifically, effect sizes for Specific Phobia (g = −0.15) and Agoraphobia (g = −0.01) were non-significant, only for Social Phobia we found a significant effect size favoring in vivo (g = −0.50). Except for Agoraphobia, effect sizes varied across studies from favoring VR to favoring in vivo exposure.

Find the full study here.

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Wechsler, Theresa F., et al. “Inferiority or Even Superiority of Virtual Reality Exposure Therapy in Phobias?—A Systematic Review and Quantitative Meta-Analysis on Randomized Controlled Trials Specifically Comparing the Efficacy of Virtual Reality Exposure to Gold Standard in Vivo Exposure in Agoraphobia, Specific Phobia, and Social Phobia.” Frontiers in Psychology, vol. 10, 2019, doi:10.3389/fpsyg.2019.01758.

Home to Hospital Live Streaming With Virtual Reality Goggles: A Qualitative Study Exploring the Experiences of Hospitalized Children

Background: Being separated from home and relatives is a major stressor for children and adolescents when hospitalized. Children long for a manner to be distracted, pleasured, and socially connected during hospitalization. Different technological devices have been applied in health care to answer those needs. Both virtual reality (VR) and videoconferencing have proven their value in hospital wards and pediatrics. VisitU combines these 2 technologies innovatively. VisitU is a recently launched VR product enabling users to be virtually at home during hospitalization.

Objective: This study aims to explore the experiences of hospitalized patients with the VR intervention of VisitU in addition to standard care.

Find the full paper here.

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Bakker, Aafke, et al. “Home to Hospital Live Streaming With Virtual Reality Goggles: A Qualitative Study Exploring the Experiences of Hospitalized Children.” JMIR Pediatrics and Parenting, vol. 1, no. 2, 2018, doi:10.2196/pediatrics.9576.

Virtual Reality-Enhanced Extinction of Phobias and Post-Traumatic Stress

Abstract: Virtual reality (VR) refers to an advanced technological communication interface in which the user is actively participating in a computer-generated 3-dimensional virtual world that includes computer sensory input devices used to simulate real-world interactive experiences. VR has been used within psychiatric treatment for anxiety disorders, particularly specific phobias and post-traumatic stress disorder, given several advantages that VR provides for use within treatment for these disorders. Exposure therapy for anxiety disorder is grounded in fear-conditioning models, in which extinction learning involves the process through which conditioned fear responses decrease or are inhibited. The present review will provide an overview of extinction training and anxiety disorder treatment, advantages for using VR within extinction training, a review of the literature regarding the effectiveness of VR within exposure therapy for specific phobias and post-traumatic stress disorder, and limitations and future directions of the extant empirical literature.

Find the full study here.

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Maples-Keller, Jessica L., et al. “Virtual Reality-Enhanced Extinction of Phobias and Post-Traumatic Stress.” Neurotherapeutics, vol. 14, no. 3, 2017, pp. 554–563., doi:10.1007/s13311-017-0534-y.

VR-based cognitive behavioral therapy for patients with generalized social anxiety disorder

Aims: To assess the feasibility and potential effect of virtual reality-based cognitive behavioral therapy (VR-CBT) for patients with severe generalized social anxiety disorder (SAD).

Conclusions: This uncontrolled pilot study demonstrated the feasibility and treatment potential of VR-CBT in a difficult-to-treat group of patients with generalized SAD. Results suggest that VR-CBT may be effective in reducing anxiety as well as depression, and can increase quality of life.

You can find the full pilot study here.

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Geraets CN, Veling W, Witlox M, Staring AB, Matthijssen SJ, Cath D. Virtual reality-based cognitive behavioural therapy for patients with generalized social anxiety disorder: a pilot study. Behavioural and Cognitive Psychotherapy. 2019:1-6. doi:10.1017/s1352465819000225

Recent Progress in Virtual Reality Exposure Therapy for Phobias: A Systematic Review

Abstract: This review is designed to systematically examine the available evidence about virtual reality exposure therapy's (VRET) efficacy for phobias, critically describe some of the most important challenges in the field and discuss possible directions. Evidence reveals that virtual reality (VR) is an effective treatment for phobias and useful for studying specific issues, such as pharmacological compounds and behavioral manipulations, that can enhance treatment outcomes. In addition, some variables, such as sense of presence in virtual environments, have a significant influence on outcomes, but further research is needed to better understand their role in therapeutic outcomes. We conclude that VR is a useful tool to improve exposure therapy and it can be a good option to analyze the processes and mechanisms involved in exposure therapy and the ways this strategy can be enhanced. In the coming years, there will be a significant expansion of VR in routine practice in clinical contexts.

Find the full study here.

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Botella, Cristina, et al. “Recent Progress in Virtual Reality Exposure Therapy for Phobias: A Systematic Review.” Current Psychiatry Reports, vol. 19, no. 7, 2017, doi:10.1007/s11920-017-0788-4.

Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: study protocol for a randomized controlled non-inferiority trial

Background: Traditional one-session exposure therapy (OST) in which a patient is gradually exposed to feared stimuli for up to 3 h in a one-session format has been found effective for the treatment of specific phobias. However, many individuals with specific phobia are reluctant to seek help, and access to care is lacking due to logistic challenges of accessing, collecting, storing, and/or maintaining stimuli. Virtual reality (VR) exposure therapy may improve upon existing techniques by facilitating access, decreasing cost, and increasing acceptability and effectiveness. The aim of this study is to compare traditional OST with in vivo spiders and a human therapist with a newly developed single-session gamified VR exposure therapy application with modern VR hardware, virtual spiders, and a virtual therapist.

Discussion: VR exposure therapy has previously been evaluated as a treatment for specific phobias, but there has been a lack of high-quality randomized controlled trials. A new generation of modern, consumer-ready VR devices is being released that are advancing existing technology and have the potential to improve clinical availability and treatment effectiveness. The VR medium is also particularly suitable for taking advantage of recent phobia treatment research emphasizing engagement and new learning, as opposed to physiological habituation. This study compares a market-ready, gamified VR spider phobia exposure application, delivered using consumer VR hardware, with the current gold standard treatment. Implications are discussed.

Find the full study here.

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Miloff, Alexander, et al. “Single-Session Gamified Virtual Reality Exposure Therapy for Spider Phobia vs. Traditional Exposure Therapy: Study Protocol for a Randomized Controlled Non-Inferiority Trial.” Trials, vol. 17, no. 1, 2016, doi:10.1186/s13063-016-1171-1.

Virtual Reality for Anxiety Reduction Demonstrated by Quantitative EEG: A Pilot Study

Abstract: 

While previous research has established that virtual reality (VR) can be successfully used in the treatment of anxiety disorders, including phobias and PTSD, no research has examined changes in brain patterns associated with the use of VR for generalized anxiety management. In the current study, we compared a brief nature-based mindfulness VR experience to a resting control condition on anxious participants. Self-reported anxiety symptoms and resting-state EEG were recorded across intervals containing quiet rest or the VR intervention. EEG activity was analyzed as a function of global power shifts in Alpha and Beta activity, and with sLORETA current source density estimates of cingulate cortex regions of interest. Results demonstrated that both a quiet rest control condition and the VR meditation significantly reduced subjective reports of anxiety and increased Alpha power. However, the VR intervention uniquely resulted in shifting proportional power from higher Beta frequencies into lower Beta frequencies, and significantly reduced broadband Beta activity in the anterior cingulate cortex. These effects are consistent with a physiological reduction of anxiety. This pilot study provides preliminary evidence supporting the therapeutic potential of VR for anxiety management and stress reduction programs.

Find the full report here.

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Tarrant J, Viczko J, Cope H. Virtual Reality for Anxiety Reduction Demonstrated by Quantitative EEG: A Pilot Study. Frontiers in Psychology. 2018;9. doi:10.3389/fpsyg.2018.01280

Inducing an Anxiety Response Using a Contaminated Virtual Environment: Validation of a Therapeutic Tool for Obsessive–Compulsive Disorder.

Obsessive–compulsive disorder (OCD) is characterized by the presence of unwanted and repetitive thoughts triggering significant anxiety, as well as the presence of ritual behaviors or mental acts carried out in response to obsessions to reduce the associated distress. In the contamination subtype, individuals are scared of germs and bacteria, are excessively concerned with cleaning, fear contamination and the spread of disease, and may have a very strong aversion to bodily secretions. A few studies on virtual reality (VR) have been conducted with people suffering from OCD, but they all focus on the subtype characterized by checking rituals. The goal of this study is to confirm the potential of a “contaminated” virtual environment in inducing anxiety in 12 adults suffering from contamination-subtype OCD compared to 20 adults without OCD (N = 32) using a within–between protocol. Subjective (questionnaire) and objective (heart rate) measurements were compiled.

Participants were immersed in a control virtual environment (empty and clean room) and a “contaminated” virtual environment (filthy public restroom) designed for the treatment of OCD. Immersions were conducted in a 6-wall CAVE-like system. As hypothesized, the results of repeated-measures ANCOVAs revealed the significant impact of immersion in a filthy public restroom for participants suffering from OCD on both measures. Presence was correlated with anxiety in OCD participants and no difference in presence was observed between groups. Unwanted negative side effects induced by immersions in VR were higher in the OCD group. The clinical implications of the results and directions for further studies are discussed.

Find the full report here.

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Laforest M, Bouchard S, Crétu A-M, Mesly O. Inducing an Anxiety Response Using a Contaminated Virtual Environment: Validation of a Therapeutic Tool for Obsessive–Compulsive Disorder. Frontiers in ICT. 2016;3. doi:10.3389/fict.2016.00018

Single-Session Gamified Virtual Reality Exposure Therapy for Spider Phobia vs. Traditional Exposure Therapy: Study Protocol for a Randomized Controlled Non-Inferiority Trial

Background: Traditional one-session exposure therapy (OST) in which a patient is gradually exposed to feared stimuli for up to 3 h in a one-session format has been found effective for the treatment of specific phobias. However, many individuals with specific phobia are reluctant to seek help, and access to care is lacking due to logistic challenges of accessing, collecting, storing, and/or maintaining stimuli. Virtual reality (VR) exposure therapy may improve upon existing techniques by facilitating access, decreasing cost, and increasing acceptability and effectiveness. The aim of this study is to compare traditional OST with in vivo spiders and a human therapist with a newly developed single-session gamified VR exposure therapy application with modern VR hardware, virtual spiders, and a virtual therapist.

Methods/Design: Participants with specific phobia to spiders (N = 100) will be recruited from the general public, screened, and randomized to either VR exposure therapy (n = 50) or traditional OST (n = 50). A behavioral approach test using in vivo spiders will serve as the primary outcome measure. Secondary outcome measures will include spider phobia questionnaires and self-reported anxiety, depression, and quality of life. Outcomes will be assessed using a non-inferiority design at baseline and at 1, 12, and 52 weeks after treatment.

Find the full paper here.

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Miloff, Alexander, et al. “Single-Session Gamified Virtual Reality Exposure Therapy for Spider Phobia vs. Traditional Exposure Therapy: Study Protocol for a Randomized Controlled Non-Inferiority Trial.” Trials, vol. 17, no. 1, 2016, doi:10.1186/s13063-016-1171-1.

Can VR reduce fear of spiders?

Findings: Compared to a control group of standard psychoeducation, VR exposure therapy significantly reduced arachnophobia in a randomized trial.

You can find the full study here.

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Minns S, Levihn-Coon A, Carl E, et al. Immersive 3D exposure-based treatment for spider fear: A randomized controlled trial. Journal of Anxiety Disorders. 2018;58:1-7. doi:10.1016/j.janxdis.2018.05.006

Controlling Social Stress in Virtual Reality Environments

Abstract: Virtual reality exposure therapy has been proposed as a viable alternative in the treatment of anxiety disorders, including social anxiety disorder. Therapists could benefit from extensive control of anxiety eliciting stimuli during virtual exposure. Two stimuli controls are studied in this study: the social dialogue situation, and the dialogue feedback responses (negative or positive) between a human and a virtual character. In the first study, 16 participants were exposed in three virtual reality scenarios: a neutral virtual world, blind date scenario, and job interview scenario. Results showed a significant difference between the three virtual scenarios in the level of self-reported anxiety and heart rate.

In the second study, 24 participants were exposed to a job interview scenario in a virtual environment where the ratio between negative and positive dialogue feedback responses of a virtual character was systematically varied on-the-fly. Results yielded that within a dialogue the more positive dialogue feedback resulted in less self-reported anxiety, lower heart rate, and longer answers, while more negative dialogue feedback of the virtual character resulted in the opposite. The correlations between on the one hand the dialogue stressor ratio and on the other hand the means of SUD score, heart rate and audio length in the eight dialogue conditions showed a strong relationship: r(6) = 0.91, p = 0.002; r(6) = 0.76, p = 0.028 and r(6) = −0.94, p = 0.001 respectively. Furthermore, more anticipatory anxiety reported before exposure was found to coincide with more self-reported anxiety, and shorter answers during the virtual exposure. These results demonstrate that social dialogues in a virtual environment can be effectively manipulated for therapeutic purposes.

Find the full study here.

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Hartanto D, Kampmann IL, Morina N, Emmelkamp PGM, Neerincx MA, Brinkman W-P. Controlling Social Stress in Virtual Reality Environments. PLoS ONE. 2014;9(3). doi:10.1371/journal.pone.0092804

Virtual and Augmented Reality Systems for Renal Interventions: A Systematic Review

Abstract: Purpose: Many virtual and augmented reality systems have been proposed to support renal interventions. This paper reviews such systems employed in the treatment of renal cell carcinoma and renal stones. Methods: A systematic literature search was performed. Inclusion criteria were virtual and augmented reality systems for radical or partial nephrectomy and renal stone treatment, excluding systems solely developed or evaluated for training purposes. Results: In total, 52 research papers were identified and analyzed. Most of the identified literature (87%) deals with systems for renal cell carcinoma treatment. About 44% of the systems have already been employed in clinical practice, but only 20% in studies with ten or more patients. Main challenges remaining for future research include the consideration of organ movement and deformation, human factor issues, and the conduction of large clinical studies. Conclusion: Augmented and virtual reality systems have the potential to improve safety and outcomes of renal interventions. In the last ten years, many technical advances have led to more sophisticated systems, which are already applied in clinical practice. Further research is required to cope with current limitations of virtual and augmented reality assistance in clinical environments.

Find the full paper here.

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F. J. Detmer, J. Hettig, D. Schindele, M. Schostak and C. Hansen, "Virtual and Augmented Reality Systems for Renal Interventions: A Systematic Review," in IEEE Reviews in Biomedical Engineering, vol. 10, pp. 78-94, 2017.
doi: 10.1109/RBME.2017.2749527

Virtual Reality Simulation in Peritoneal Dialysis Training

Background/Aim: Peritonitis rates in peritoneal dialysis (PD) vary considerably not only across countries but also between centers in the same country. Patient education has been shown to significantly reduce infection rates but up till now training lacks standardization with patients being trained using different methods and media (e.g., illustrations, videos). As a result, patients may be insufficiently experienced in performing PD, which might be one of the causes for high peritonitis rates. To address these issues, we developed a PD training program based on virtual reality (VR).

Conclusion: Previous studies on the effectiveness of learning showed that VR training applications are superior to traditional methods, such as text- or video-based training. However, no study has been undertaken in the context of dialysis. We believe that the implementation of VR training programs in clinical practice will be beneficial in improving the patient's proficiency, and thereby the quality and safety of PD.

Find the full report here.

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Zgoura P, Hettich D, Natzel J, Özcan F, Kantzow B. Virtual Reality Simulation in Peritoneal Dialysis Training: The Beginning of a New Era. Blood Purification. 2018;47(1-3):265-269. doi:10.1159/000494595

Virtual Reality Exercise Intradialysis to Improve Physical Function: A Feasibility Randomized Trial

Objective: The main objective of this investigation was to assess feasibility of conducting a future RCT with an intradialysis non-immersive virtual reality exercise intervention. The secondary aim was to explore the impact of either conventional or VR exercise on physical function.

Design: Feasibility randomized trial.

Participants: Eighteen subjects who participated in a 16-week intradialysis combined exercise program.

Intervention: The program lasted four additional weeks of either combined exercise or virtual reality exercise.

Main Outcome Measures: Physical function was measured through several reliable tests (sit-to-stand-to-sit tests 10 and 60, gait speed, one-leg heel-rise tests, and 6-minute walk test) at baseline, after 16 weeks of intradialysis combined exercise and by the end of four additional weeks of exercise. Adherence to the exercise programs was registered.

Results: There was a significant time effect, so that physical function improved in both groups. By the end of the 20 weeks, function improved as measured through the sit-to-stand-to-sit tests 10 and 60, gait speed, one-leg heel-rise left leg, and the 6-minute walk test. Changes that did not occur due to error in the test were seen after 20 weeks were achieved in the sit-to-stand-to-sit test 60, gait speed, one-leg heel-rise test for the left leg, and 6-minute walking test.

Conclusion: Virtual reality was a feasible intervention. Both interventions improved physical function. Adherence was not significantly different between groups.

Find the full study here.

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Segura‐Ortí, Eva, et al. “Virtual Reality Exercise Intradialysis to Improve Physical Function: A Feasibility Randomized Trial.” Scandinavian Journal of Medicine & Science in Sports, vol. 29, no. 1, 2018, pp. 89–94., doi:10.1111/sms.13304.

Comparison of 3-Dimensional and Augmented Reality Kidney Models With Conventional Imaging Data in the Preoperative Assessment of Children With Wilms Tumors

Question: What is the value of 3-dimensional (3-D) visualization methods, augmented reality holograms, and 3-D printing for the preoperative assessment of anatomical structures in children with Wilms tumors?

Findings: In this survey study of 7 pediatric surgeons for which 10 personalized, augmented reality holograms and 3-D prints of children with Wilms tumors were created, there was a significant added value from the 3-D visualization methods compared with conventional imaging for the preoperative assessment.

Meaning: Three-dimensional visualizations may provide added value for the pediatric surgeon in the anatomical assessment of Wilms tumors, may help in future preoperative planning of nephron-sparing surgery, and may be considered an innovative supplementary visualization in clinical care.

Find the full paper here.

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Wellens LM, Meulstee J, van de Ven CP, et al. Comparison of 3-Dimensional and Augmented Reality Kidney Models With Conventional Imaging Data in the Preoperative Assessment of Children With Wilms Tumors. JAMA Netw Open. 2019;2(4):e192633. Published 2019 Apr 5. doi:10.1001/jamanetworkopen.2019.2633

Power Doppler Rendering of Fetal Bilateral Accessory Renal Arteries in Virtual Reality

Background: The renal arteries normally arise from the abdominal aortaproximal to the bifurcation. Known anatomic variations in renal arteries, for example accessory renal arteries, are present in 20 – 30% of the general population and show different places of origin and various courses. Accessoryrenal arteries are embryonic mesonephric arteries that failed to degenerate. Accessory renal arteries may be parallel to the main renal arteries, this being the most common anatomic variation. Other known variations include a divergent, convergent or crossed trajectory of the renal arteries on the same side. We observed, in a fetus at 26 weeks’ gestation, two normal kidneys with bilateral accessory renal arteries.Three-dimensional (3D) power Doppler data sets were obtained using a GE Voluson E8 system (GE Medical Systems, Zipf, Austria). These data sets were analyzed in 4D view and by use of a virtual reality system to render images in the Barco I-space. The BarcoI-space is a CAVE-like virtual reality system, which, by use of the V-scope volume rendering application, creates a hologram from a 3D data set. The hologram, projected onto the walls and floor of a dark room, is analyzed wearing 3D glasses and using a special joystick. By making use of the third dimension, ‘depth perception’, virtual reality-enabled us to visualize the fetal vascular anatomy in more detail. The different kinds of voxels (3D pixels),i.e. power Doppler and gray-scale voxels, can easily be separated, allowing visualization of Doppler images of the fetal vasculature with and without the internal organs.

Find the full paper here.

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Bazelmans, M., et al. “Power Doppler Rendering of Fetal Bilateral Accessory Renal Arteries in Virtual Reality.” Ultrasound in Obstetrics & Gynecology, vol. 44, no. 3, 2014, pp. 375–376., doi:10.1002/uog.13410.

The Effect of a Virtual Reality Exercise Program on Physical Fitness, Body Composition, and Fatigue in Hemodialysis Patients

Abstract: [Purpose] The aim of the present study was to investigate the effects of a virtual reality exercise program (VREP) on physical fitness, body composition, and fatigue in hemodialysis (HD) patients with end-stage renal failure. [Subjects and Methods] A nonequivalent control group pretest-posttest design was used. Forty-six HD patients were divided into exercise (n=23) and control groups (n=23); while waiting for their dialyses, the exercise group followed a VREP, and the control group received only their usual care. The VREP was accomplished using Nintendo’s Wii Fit Plus for 40 minutes, 3 times a week for 8 weeks during the period of May 27 to July 19, 2013. Physical fitness (muscle strength, balance, flexibility), body composition (skeletal muscle mass, body fat rate, arm and leg muscle mass), and fatigue were measured at baseline and after the intervention. [Results] After the VREP, physical fitness and body composition significantly increased, and the level of fatigue significantly decreased in the exercise group. [Conclusion] These results suggest that a VREP improves physical fitness, body composition, and fatigue in HD patients. Based on the findings, VREPs should be used as a health promotion programs for HD patients.

Find the full paper here.

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Cho, Hyeyoung, and Kyeong-Yae Sohng. “The Effect of a Virtual Reality Exercise Program on Physical Fitness, Body Composition, and Fatigue in Hemodialysis Patients.” Journal of Physical Therapy Science, vol. 26, no. 10, 2014, pp. 1661–1665., doi:10.1589/jpts.26.1661.

Using Augmented Reality to Train Kidney Care Professionals
Meet Kelly

For years Kelly was working as a nursing assistant for a home health care provider. She was working towards her RN in hopes of transitioning into a role in the kidney care field. Growing up, two of Kelly’s uncles had been on dialysis, so she had always wanted to help patients like them and others in her community with kidney disease. Before graduation, a few friends from her nursing program — all of whom went on to work with dialysis patients —  had been asking Kelly to make the career transition and join them as a home therapies RN.

So when the opportunity presented itself for the position she had been waiting for, Kelly took it. She enrolled in the company's in-house training program where she spent six months learning to care for and maintain three home dialysis machines for two home therapies. She was surprised to learn that although the machines accomplished similar tasks for patients, the operational differences were far more complex and detailed than she had expected. Even further, she had not expected the training materials to be as difficult to translate into practice, nor did she think patients could have so many questions about their dialysis treatments and considerations. Luckily, throughout the training process and beyond, Kelly was surrounded by a great network of supportive RNs to help her get up to speed and established in the field. 

Continue reading in our blog.

Using Immersive Technologies to Educate Home Dialysis Patients
Meet Samuel 

Two years ago Samuel landed in the hospital unexpectedly after his kidneys failed. It was scary for Samuel and his family. Fortunately, he was in good hands with his care team and nephrologist and soon started dialysis treatments at a treatment facility in a nearby town. Samuel has been on hemodialysis ever since, driving 10 miles to the dialysis clinic three times each week. He spends hours there and feels tied down, with little opportunity to travel or relax at home with family and friends. But time isn't his only obstacle to maintaining some sense of normalcy — he just doesn't feel up to doing anything following his treatments.

Recently, a friend at work told Samuel how home dialysis had been the right decision for his wife, so Samuel wanted to learn more and decided to follow up with his doctor. He talked to his nephrologist who then directed him to a number of websites where he could find documents describing the pros and cons of home dialysis. Samuel struggled to fully comprehend how his day-to-day life would be different on home dialysis, but in the end, he decided that he wanted to give it a go. [For a discussion of the problems associated with medical device decisions based solely on documents follow this link.

Although different dialysis providers offer different training curriculum, Samuel’s dialysis provider offered a 12 week home dialysis training course that promised to train Samuel on the home dialysis machine. The education and training curriculum involved a combination of online learning (at home) for approximately 4 weeks and once a week in-person classroom instruction at the dialysis clinic’s training facility for 8 weeks.

The learning curve was steep...

Continue reading in our blog.

Using Immersive Technology To Train Frontline Kidney Care Staff
Meet Susan. 

By this time last year, Susan had been on the job hunt for a while – looking for an entry level opportunity in the fast-growing healthcare profession – before she finally came across an opening for a home dialysis patient care technician in her area. Fortunately, the position came with several months of paid training, so her lack of experience in the industry would not be an obstacle in getting up to speed in her new role.

Susan landed the job and was soon scheduled to begin training the following month through a combination of online learning (at home) and in-person classroom instruction at the company’s regional training facility.

The learning curve was steep, especially for not having the healthcare experience that a few of her classmates had gained through recent direct care roles. Susan had always been an average performer on tests, and this case was no different. She was able to learn the information contained in the online classes and reading materials, and it served her well in taking the written exams.

Then something unexpected happened.

When Susan showed up to her first week of in-person training, very little seemed familiar. The information she had covered and memorized in the online classes did not translate well to the hands-on practical tasks in front of her. In fact, she was not even sure whether the instructor was covering the same material, let alone which material she ought to be focusing on most.

Continue reading in our blog.

Why VR Provides An Ideal Tool For Kidney Care Education

Kidney disease ranks as the ninth leading cause of death in America. Approximately 20% of dollars in traditional Medicare—$114 billion a year—are spent on Americans with kidney disease. For patients who require dialysis, which typically happens when you have only 10 to 15 percent of your kidney function left, hemodialysis is the most common modality. In fact, approximately 90% of kidney dialysis patients are on hemodialysis in a hospital or dialysis center setting.

There is a second dialysis option available to patients called peritoneal dialysis that is done at home. Peritoneal dialysis is more cost effective than hemodialysis and often provides patients with more flexibility and freedom when compared to the hemodialysis regimen. Despite the cost and quality of life advantages of peritoneal dialysis, only 10% of kidney patients use peritoneal dialysis.

Federal Governments around the world have long been aware of the cost and quality issues associated with providing dialysis treatment options — for most patients in the United States, Medicare pays 80 percent of all dialysis charges. A recently announced mandate aims to improve care quality and reduce costs in part by drastically increasing home dialysis usage. From an education, training and decision-making standpoint the current modality imbalance is problematic. Since patients frequently start in a hospital or in-center setting, they become biased to follow the path of least resistance and remain on the modality and routine where they began. Add to this the fact that all decisions in kidney care are multilateral, involving nephrologists, patients and care providers, and depend greatly on patient motivations. It is for all of these reasons that education is so critical to quality in kidney care.  Patients need high-quality and highly-effective educational experiences in order to make the decision to switch modalities.

By far the most common approach to dialysis education, like in most other domains of care, is to have patients read documents describing the treatment.

Continue reading in our blog.

Effect of an Augmented Reality Ultrasound Trainer App on the Motor Skills Needed for a Kidney Ultrasound: Prospective Trial
Background: Medical education is evolving from "learning by doing" to simulation-based hands-on tutorials.
 
Objective: The aim of this prospective 2-armed study was to evaluate a newly developed augmented reality ultrasound app and its effect on educational training and diagnostic accuracy.

Methods: We recruited 66 medical students and, using imaging and measuring a kidney as quality indicators, tested them on the time they needed for these tasks. Both groups used textbooks as preparation; in addition, the study group had access to a virtual ultrasound simulation app for mobile devices.

Find the full paper here.

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Ebner F, De Gregorio A, Schochter F, Bekes I, Janni W, Lato K. Effect of an Augmented Reality Ultrasound Trainer App on the Motor Skills Needed for a Kidney Ultrasound: Prospective Trial. JMIR Serious Games. 2019;7(2):e12713. Published 2019 May 1. doi:10.2196/12713

Why Shared Experiences Matter in Kidney Care
Meet Aiko

Aiko is a 59-year old mother of three. Aiko was diagnosed with Type 2 diabetes over a decade ago now, but was hospitalized four years ago when her kidneys “crashed”, landing her in the hospital rather unexpectedly. Though she has been on dialysis ever since that first surprise trip to the hospital, recently she was informed that her long wait for a kidney transplant might finally be over. Aiko is excited about the prospect of having a healthy kidney that will free her from the dialysis regiment that has controlled her life for years, but naturally she is anxious and stressed about the upcoming surgery and its implications for returning to normal life.

Like 9 in 10 Americans, Aiko has struggled to understand her medical conditions and treatment...

Continue reading in our blog.

Effect of an Immersive Preoperative VR Experience on Patient Reported Outcomes

Objective: To investigate the effect of exposure to a virtual reality (VR) environment preoperatively on patient-reported outcomes for surgical operations.

Background: There is a scarcity of well-developed quality improvement initiatives targeting patient satisfaction.

Methods: We performed a randomized controlled trial of patients undergoing cranial and spinal operations in a tertiary referral center. Patients underwent a 1:1 randomization to an immersive preoperative VR experience or standard preoperative experience stratified on type of operation. The primary outcome measures were the Evaluation du Vecu de l'Anesthesie Generale (EVAN-G) score and the Amsterdam Preoperative Anxiety and Information (APAIS) score, as markers of the patient's experience during the surgical encounter

Conclusions: In a randomized controlled trial, the research team demonstrated that patients exposed to preoperative VR had increased satisfaction during the surgical encounter. Harnessing the power of this technology, hospitals can create an immersive environment that minimizes stress, and enhances the perioperative experience.

You can find the full report here.

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Bekelis K, Calnan D, Simmons N, Mackenzie TA, Kakoulides G. Effect of an Immersive Preoperative Virtual Reality Experience on Patient Reported Outcomes. Annals of Surgery. 2017;265(6):1068-1073.

Using mobile VR to enhance medical comprehension and satisfaction in patients and their families

 Abstract: Patients are typically debriefed by their healthcare provider after any medical procedure or surgery to discuss their findings and any next steps involving medication or treatment instructions. However, without any medical or scientific background knowledge, it can feel overwhelming and esoteric for a patient to listen to a physician describe a complex operation. Instead, providing patients with engaging visuals and a virtual reality (VR) simulation of their individual clinical findings could lead to more effective transfer of medical knowledge and comprehension of treatment information. A newly developed VR technology is described, called HealthVoyager, which is designed to help facilitate this knowledge transfer between physicians and patients. The platform represents a customizable, VR software system utilizing a smartphone or tablet computer to portray personalized surgical or procedural findings as well as representations of normal anatomy. The use of such technology for eliciting medical understanding and patient satisfaction can have many practical and clinical applications for a variety of disease states and patient populations.

Find the full report here.

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Palanica A, Docktor MJ, Lee A, Fossat Y. Using mobile virtual reality to enhance medical comprehension and satisfaction in patients and their families. Perspectives on Medical Education. 2019. doi:10.1007/s40037-019-0504-7

Using the Virtual Reality World of Second Life to Promote Patient Engagement

Abstract: Patients have typically been passive participants in their own healthcare. However, with a change in philosophy towards outcomes driven care, it has become necessary to make sure that patients mutually set their healthcare goals with their providers Both eHealth and mobile health applications have required patient participation in ways never before valued. The virtual reality world of Second Life offers one eHealth solution that requires computer literate patients to participate via avatars in synchronous healthcare visits and support groups, as well as explore online resources asynchronously. This paper describes the development of a Second Life environment that served as a platform for nurse practitioner driven care supplemented by a patient portal as well as the institutional electronic health record. In addition, the use of Second Life is described as an active exercise to expose students in a Consumer Health course to support groups and resources available to actively engage patients.

Find the full paper here.

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Weiner E, Trangenstein P, McNew R, Gordon J. Using the Virtual Reality World of Second Life to Promote Patient Engagement. Stud Health Technol Inform. 2016;225:198–202.

Brain Science of Satisfaction and Why VR Provides an Ideal Solution

Familiarity and experience can reduce stress, anxiety, and discomfort while enhancing preparedness and satisfaction for patients and their loved ones. 

Virtual reality achieves these goals; the psychological and brain research are clear on that point.

Read the full article here.

This article was originally published by the Association for Talent Development.

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Maddox T, Fitzpatrick T. The Brain Science of Patient Satisfaction and Why VR Provides an Ideal Solution. Main. https://www.td.org/insights/the-brain-science-of-patient-satisfaction-and-why-vr-provides-an-ideal-solution. Published December 19, 2018. Accessed April 5, 2019.

Virtual Reality Simulation in Peritoneal Dialysis Training

Background/Aim: Peritonitis rates in peritoneal dialysis (PD) vary considerably not only across countries but also between centers in the same country. Patient education has been shown to significantly reduce infection rates but up till now training lacks standardization with patients being trained using different methods and media (e.g., illustrations, videos). As a result, patients may be insufficiently experienced in performing PD, which might be one of the causes for high peritonitis rates. To address these issues, we developed a PD training program based on virtual reality (VR).

Conclusion: Previous studies on the effectiveness of learning showed that VR training applications are superior to traditional methods, such as text- or video-based training. However, no study has been undertaken in the context of dialysis. We believe that the implementation of VR training programs in clinical practice will be beneficial in improving the patient's proficiency, and thereby the quality and safety of PD.

Find the full report here.

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Zgoura P, Hettich D, Natzel J, Özcan F, Kantzow B. Virtual Reality Simulation in Peritoneal Dialysis Training: The Beginning of a New Era. Blood Purification. 2018;47(1-3):265-269. doi:10.1159/000494595

The Role of Personalized Virtual Reality in Education for Patients Post Stroke

Background/Aim: Education is essential to promote prevention of recurrent stroke and maximize rehabilitation; however, current techniques are limited and many patients remain dissatisfied. Virtual reality (VR) may provide an alternative way of conveying complex information through a more universal language. To develop and conduct preliminary assessments on the use of a guided and personalized 3D visualization education session via VR, for stroke survivors and primary caregivers.

Conclusions: Preliminary results suggest this approach provides a safe and promising educational tool to promote understanding of individualized stroke experiences.

Find the full report here.

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Thompson-Butel AG, Shiner CT, Mcghee J, et al. The Role of Personalized Virtual Reality in Education for Patients Post Stroke—A Qualitative Case Series. Journal of Stroke and Cerebrovascular Diseases. 2019;28(2):450-457. doi:10.1016/j.jstrokecerebrovasdis.2018.10.018

Educational Virtual Reality Videos in Improving Bowel Preparation Quality and Satisfaction of Outpatients Undergoing Colonoscopy: Protocol of a Randomised Controlled Trial

Introduction: Colonoscopy is the reference method in screening and diagnosis of colorectal neoplasm, but its efficacy is closely related to the quality of bowel preparation. Poor patient compliance is a major risk factor for inadequate bowel preparation likely due to poor patient education. Such an education is usually provided via either oral or written instructions by clinicians. However, multiple education methods, such as smartphone applications, have been proved useful in aiding patients through bowel preparation. Also, it was reported that a large proportion of patients feel anxious before colonoscopy. Virtual reality (VR) is a novel method to educate patients and provides them with an immersive experience. Theoretically, it can make patients better prepared for bowel preparation and colonoscopy. However, no prospective studies have assessed the role of this novel technology in patient education before colonoscopy. We hypothesise that VR videos can improve bowel preparation quality and reduce pre-procedure anxiety.

Methods/Design: The trial is a prospective, randomised, single-blinded, single-centre trial. Outpatients who are scheduled to undergo colonoscopy for screening or diagnostic purposes for the first time will be randomised to receive either the conventional patient education or the conventional methods plus VR videos, and 322 patients will be enrolled from the Peking Union Medical College Hospital. The primary endpoint is the quality of bowel preparation, measured by the Boston bowel preparation score. Secondary endpoints include polyp detection rate, adenoma detection rate, cecal intubation rate, patient compliance to complete bowel cleansing, withdrawal time, pre-procedure anxiety, overall satisfaction and willingness for the next colonoscopy.

Find the full study here.

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Zhao, Yi, et al. “Educational Virtual Reality Videos in Improving Bowel Preparation Quality and Satisfaction of Outpatients Undergoing Colonoscopy: Protocol of a Randomised Controlled Trial.” BMJ Open, vol. 9, no. 8, 2019, doi:10.1136/bmjopen-2019-029483.

Radiation therapy patient education using VERT: combination of technology with human care

Abstract: The Virtual Environment for Radiotherapy Training (VERT) system is a recently available tool for radiation therapy education. The majority of research regarding VERT-based education is focused on students, with a growing area of research being VERT's role in patient education. Because large differences in educational requirements exist between students and patients, focused resources and subsequent evaluations are necessary to provide solid justification for the unique benefits and challenges posed by VERT in a patient education context. This commentary article examines VERT's role in patient education, with a focus on salient visual features, VERT's ability to address some of the spatial challenges associated with RT patient education and how to combine technology with human care.

Find the full report here.

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Jimenez YA, Lewis SJ. Radiation therapy patient education using VERT: combination of technology with human care. Journal of Medical Radiation Sciences. 2018;65(2):158-162. doi:10.1002/jmrs.282

Patient education using VR increases knowledge and positive experience for breast cancer patients undergoing radiation therapy

Purpose: Improved access to technology in the radiation therapy (RT) workforce education has resulted in opportunities for innovative patient education methods. This study investigated the impact of a newly developed education tool using the Virtual Environment for Radiotherapy Training (VERT) system on patients' RT knowledge and anxiety.

Conclusions: This study reports the high value of VERT breast cancer-targeted education programs in improving RT knowledge and perhaps decreasing patient anxiety. Continued efforts are required to improve patients' accessibility to VERT in Australia, and to better understand the effect of VERT's unique educational features on patients' emotional and physical needs throughout their RT.

Find the full report here.

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Jimenez YA, Cumming S, Wang W, Stuart K, Thwaites DI, Lewis SJ. Patient education using virtual reality increases knowledge and positive experience for breast cancer patients undergoing radiation therapy. Supportive Care in Cancer. 2018;26(8):2879-2888. doi:10.1007/s00520-018-4114-4

Clinical Virtual Simulation in Nursing Education: Randomized Controlled Trial

Objective: This study aimed to evaluate the effect of clinical virtual simulation with regard to knowledge retention, clinical reasoning, self-efficacy, and satisfaction with the learning experience among nursing students.

Conclusions: The introduction of clinical virtual simulation in nursing education has the potential to improve knowledge retention and clinical reasoning in an initial stage and over time, and it increases the satisfaction with the learning experience among nursing students.

You can find the full study here.

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Padilha JM, Machado PP, Ribeiro A, Ramos J, Costa P. Clinical Virtual Simulation in Nursing Education: Randomized Controlled Trial (Preprint). 2018. doi:10.2196/preprints.11529

Feasibility of Developing a 360° Video-Based Virtual Reality Simulation of a Stressful Clinical Event

Abstract: Individuals early in their medical career feel unprepared for acute high-stress clinical situations such as managing a deteriorating patient. Simulation-based learning (SBL) is a method used within medical education to prepare for the clinical environment. SBL has been successfully integrated with virtual reality technology, however there is a lack of literature regarding its use for replicating the stress of a clinical environment and using 360° video to improve fidelity. Our non-specialist team aimed to develop and test the acceptability and feasibility of an interactive 360° video-based virtual reality simulation of a high-stress clinical situation. The simulation was developed within the ten weeks allocated to this project, however standardised measures from our sample could not be collected. Important information regarding the development and creation process was obtained and alpha testing of simulations were perceived acceptable and useful, thus, highlighting the merit of further research in this area.

Find the full paper here.

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Mohammed, Shakeel. “Feasibility of Developing a 360° Video-Based Virtual Reality Simulation of a Stressful Clinical Event.” New Zealand Medical Student Journal, 2019, www.nzmsj.com/feasibility-of-developing-a-360deg-video-based-virtual-reality-simulation-of-a-stressful-clinical-event.html.

Augmented Reality and Mixed Reality for Healthcare Education beyond Surgery: an Integrative Review

Objectives: This study aimed to review and synthesize the current research and state of augmented reality (AR), mixed reality (MR) and the applications developed for healthcare education beyond surgery.

Methods: An integrative review was conducted on all relevant material, drawing on different data sources, including the databases of PubMed, PsycINFO, and ERIC from January 2013 till September 2018. Inductive content analysis and qualitative synthesis were performed. Additionally, the quality of the studies was assessed with different structured tools.

Results: Twenty-six studies were included. Studies based on both AR and MR involved established applications in 27% of all cases (n=6), the rest being prototypes. The most frequently studied subjects were related to anatomy and anesthesia (n=13). All studies showed several healthcare educational benefits of AR and MR, significantly outperforming traditional learning approaches in 11 studies examining various outcomes. Studies had a low-to-medium quality overall with a MERSQI mean of 12.26 (SD=2.63), while the single qualitative study had high quality.

Conclusions: This review suggests the progress of learning approaches based on AR and MR for various medical subjects while moving the research base away from feasibility studies on prototypes. Yet, lacking validity of study conclusions, heterogeneity of research designs and widely varied reporting challenges transferability of the findings in the studies included in the review. Future studies should examine suitable research designs and instructional objectives achievable by AR and MR-based applications to strengthen the evidence base, making it relevant for medical educators and institutions to apply the technologies.

Find the full paper here.

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Gerup, Jaris, et al. “Augmented Reality and Mixed Reality for Healthcare Education beyond Surgery: an Integrative Review.” International Journal of Medical Education, vol. 11, 2020, pp. 1–18., doi:10.5116/ijme.5e01.eb1a.

Medical Students’ Experiences and Outcomes Using a Virtual Human Simulation to Improve Communication Skills: Mixed Methods Study

Background: Attending to the wide range of communication behaviors that convey empathy is an important but often underemphasized concept to reduce errors in care, improve patient satisfaction, and improve cancer patient outcomes. A virtual human (VH)–based simulation, MPathic-VR, was developed to train health care providers in empathic communication with patients and in interprofessional settings and evaluated through a randomized controlled trial.

Objective: This mixed methods study aimed to investigate the differential effects of a VH-based simulation developed to train health care providers in empathic patient-provider and interprofessional communication.

Methods: We employed a mixed methods intervention design, involving a comparison of 2 quantitative measures—MPathic-VR–calculated scores and the objective structured clinical exam (OSCE) scores—with qualitative reflections by medical students about their experiences. This paper is a secondary, focused analysis of intervention arm data from the larger trial. Students at 3 medical schools in the United States (n=206) received simulation to improve empathic communication skills. We conducted analysis of variance, thematic text analysis, and merging mixed methods analysis.

Find the full paper here.

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Guetterman TC, Sakakibara R, Baireddy S, Kron FW, Scerbo MW, Cleary JF, Fetters MD Medical Students’ Experiences and Outcomes Using a Virtual Human Simulation to Improve Communication Skills: Mixed Methods Study. J Med Internet Res 2019;21(11):e15459

Digital Education for the Management of Chronic Wounds in Healthcare Professionals

Objective: Our main objective is to assess the effectiveness of digital education as a stand-alone approach or as part of a blended-learning approach in improving pre- and postregistration health care professionals' knowledge, attitudes, practical skills, and behavior in the management of chronic wounds, as well as their satisfaction with the intervention. Secondary objectives are to evaluate patient-related outcomes, cost-effectiveness of the interventions, and any unfavorable or undesirable outcomes that may arise.

Conclusions: This systematic review will provide an in-depth analysis of digital education strategies to train health care providers in the management of chronic wounds. We consider this topic particularly relevant given the current challenges facing health care systems worldwide, including shortages of skilled personnel and a steep increase in the population of older adults as a result of a prolonged life expectancy.

Find the full report here.

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Martinengo L, Yeo NJY, Tang ZQ, Markandran KD, Kyaw BM, Car LT. Digital Education for the Management of Chronic Wounds in Health Care Professionals: Protocol for a Systematic Review by the Digital Health Education Collaboration. JMIR Research Protocols. 2019;8(3). doi:10.2196/12488

Virtual Reality in Spinal Endoscopy: a Paradigm Shift in Education to Support Spine Surgeons

Background: Minimally invasive spine surgery (MISS) and endoscopic spine surgery have continually evolving indications in the cervical, thoracic, and lumbar spine. Endoscopic spine surgery entails treatment of disc disease, stenosis, spondylolisthesis, radiculopathy, and deformity. MISS involves complex motor skills in regions of variable anatomy. Simulator use has been proposed to aid in training and skill retention, preoperative planning, and intraoperative use.

Methods: A systematic review of five databases was performed for publications pertaining to the use of virtual (VR), augmented (AR), and mixed (MR) reality in MISS and spinal endoscopic surgery. Qualitative data analysis was undertaken with focus of study design, quality, and reported outcomes. Study quality was assessed using the Medical Education Research Quality Instrument (MERSQI) score and level of evidence (LoE) by a modified Oxford Centre for Evidence-Based Medicine (OCEBM) level for simulation in medicine.

Results: Thirty-eight studies were retained for data collection. Studies were of intervention-control, clinical application, and pilot or cross-sectional design. Identified articles illustrated use of VR, AR, and MR in all study designs. Procedures included pedicle cannulation and screw insertion, vertebroplasty, kyphoplasty, percutaneous transforaminal endoscopic discectomy (PTED), lumbar puncture and facet injection, transvertebral anterior cervical foraminotomy (TVACF) and posterior cervical laminoforaminotomy. Overall MERSQI score was low-to-medium [M =9.71 (SD =2.60); range, 4.5–13.5], and LoE was predominantly low given the number of purely descriptive articles, or low-quality randomized studies.

Conclusions: The current scope of VR, AR, and MR surgical simulators in MISS and spinal endoscopic surgery was described. Studies demonstrate improvement in technical skill and patient outcomes in short term follow-up. Despite this, overall study quality and levels of evidence remain low. Cohesive study design and reporting with focus on transfer validity in training scenarios, and patient derived outcome measures in clinical studies are required to further advance the field.

Find the full review here.

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Lohre, Ryan, et al. “Virtual Reality in Spinal Endoscopy: a Paradigm Shift in Education to Support Spine Surgeons.” Journal of Spine Surgery, vol. 6, no. S1, 2020, doi:10.21037/jss.2019.11.16.

Feasibility of an augmented reality cardiopulmonary resuscitation training system for health care providers.

Aim of the study:Augmented reality (AR) has the potential to offer a novel approach to CPR training that supplements conventional training methods with gamification and a more interactive learning experience. This is done through computer-generated imagery superimposed on users’ view of the real environment to simulate interactive training scenarios. We sought to test the feasibility of an AR CPR training system (CPReality) for health care providers (HCPs).

Methods: In this feasibility trial, a CPR training manikin was integrated with a commercial AR device (Microsoft HoloLens) to provide participants with real-time audio-visual feedback via a holographic overlay of blood flow to vital organs dependent on CC quality. In this system, higher quality CC visually improved virtual blood circulation. HCPs performed a 2-minute cycle of hands-only CPR using only the AR system, and CC parameters were recorded. Descriptive data on participants’ demographics, CC quality, and satisfaction with the training environment were reported using quantitative and qualitative analysis.

Find the full paper here.

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Balian S, McGovern SK, Abella BS, Blewer AL, Leary M. Feasibility of an augmented reality cardiopulmonary resuscitation training system for health care providers. Heliyon. 2019;5(8):e02205. Published 2019 Aug 2. doi:10.1016/j.heliyon.2019.e02205

Virtual Reality Simulation in Nontechnical Skills Training for Healthcare Professionals: A Systematic Review

Abstract: This systematic review, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, is aimed to review current research in virtual reality (VR) for healthcare training, specifically pertaining to nontechnical skills. PsycInfo and Medline databases were queried for relevant articles published through December 2017. Of the 1377 publications identified, 80 were assessed for eligibility and 26 were finally included in the qualitative synthesis. Overall, the use of virtual training for nontechnical skills is recent in healthcare education and has increased since 2010. Screen-based VR simulators or virtual worlds are the most frequently used systems. The nontechnical skills addressed in VR simulation include mainly teamwork, communication, and situation awareness. Most studies evaluate the usability and acceptability of VR simulation, and few studies have measured the effects of VR simulation on nontechnical skills development.

Find the full review here.

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Bracq, Marie-Stéphanie, et al. “Virtual Reality Simulation in Nontechnical Skills Training for Healthcare Professionals.” Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, vol. 14, no. 3, 2019, pp. 188–194., doi:10.1097/sih.0000000000000347.

Comparison of knowledge and confidence between medical students as leaders and followers in simulated resuscitation

Objectives: To compare both the knowledge and self-reported confidence levels between medical students as the team leaders and followers in shock resuscitation simulation training.

Methods: A cross-sectional study was conducted with all fifth-year medical students participating in a shock resuscitation simulation-based training between May 2017 and March 2018. The simulation class was a 3-hour session that consisted of 4 shock type scenarios as well as a post-training debriefing. Medical students were assigned into groups of 4-5 members, in which they freely selected a leader, and the rest filled the roles of followers. Of 139 medical students, 32 students were leaders. A 10-question pre-test and post-test determined knowledge assessment. At the end of the class, the students completed a 5-point Likert scale confidence level evaluation questionnaire. A t-test was applied to compare knowledge scores and confidence levels between the leaders and followers.

Results: At the end of the class, the knowledge scores between the leaders (M=6.72, SD=1.51) and followers (M=6.93, SD=1.26) were not different (t(137)= -0.81, p=0.42). In addition, the student confidence levels were also similar between the leaders (M=3.63, SD=0.55) and followers (M=3.41, SD=0.64) after training (t(137)=1.70, p=0.09).

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Vattanavanit V, Khwannimit B, Nilmoje T. Comparison of knowledge and confidence between medical students as leaders and followers in simulated resuscitation. Int J Med Educ. 2020;11:19–24. Published 2020 Jan 21. doi:10.5116/ijme.5e01.f00c

A Discussion of the Use of Virtual Reality for Training Healthcare Practitioners to Recognize Child Protection Issues

Background: Virtual reality technology is a rapidly developing tool which has been shown to have exciting prospects in the field of medical education (). In a recent, subsequent study, Pan et al. consider the potential of the same technology in the realm of child protection training and safeguarding issues (). To build upon the Pan et al. () study, a panel discussion was held at The Centre for Behavior Change Annual Conference 2018 to discuss the question “Can a virtual reality communication scenario be used to teach General Practitioners and trainees how to recognize and manage child protection issues?.”

Methodology: The above study comprised an immersive virtual reality consultation, in which the ability of 63 doctors to pick up covert safeguarding cues was tested in the context of a consultation with an adult patient, where the patient's child happened to be present as well. The study and its findings were discussed at the Centre for Behavior Change 4th Annual Conference, and this paper summarizes the opinions of both the panel and the audience.

Viewpoint: Safeguarding is a challenging area of practice where we must listen to the child, and tackle difficult conversations with parents. Within medical training, role play is the gold standard for teaching how to communicate in difficult scenarios. Given the ethical questions surrounding children being asked to role play such abuse, the use of virtual reality characters could have a key role in upgrading current practices in medical education on safeguarding.

Find the full paper here.

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Drewett O, Hann G, Gillies M, et al. A Discussion of the Use of Virtual Reality for Training Healthcare Practitioners to Recognize Child Protection Issues. Front Public Health. 2019;7:255. Published 2019 Sep 13. doi:10.3389/fpubh.2019.00255

Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy

Background: Endoscopy has traditionally been taught with novices practicing on real patients under the supervision of experienced endoscopists. Recently, the growing awareness of the need for patient safety has brought simulation training to the forefront. Simulation training can provide trainees with the chance to practice their skills in a learner-centred, risk-free environment. It is important to ensure that skills gained through simulation positively transfer to the clinical environment. This updated review was performed to evaluate the effectiveness of virtual reality (VR) simulation training in gastrointestinal endoscopy.

Objectives: To determine whether virtual reality simulation training can supplement and/or replace early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy, and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience.

Find the full paper here.

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Walsh, Catharine M, et al. “Virtual Reality Simulation Training for Health Professions Trainees in Gastrointestinal Endoscopy.” Cochrane Database of Systematic Reviews, 2010, doi:10.1002/14651858.cd008237.

Computer-Based Virtual Reality Colonoscopy Simulation Improves Patient-Based Colonoscopy Performance

Background: Colonoscopy simulators that enable one to perform computer-based virtual colonoscopy now exist. However, data regarding the effectiveness of this virtual training are limited.

Objective: To determine whether virtual reality simulator training translates into improved patient-based colonoscopy performance.

Methods: The present study was a prospective controlled trial involving 18 residents between postgraduate years 2 and 4 with no previous colonoscopy experience. These residents were assigned to receive 16 h of virtual reality simulator training or no training. Both groups were evaluated on their first five patient-based colonoscopies. The primary outcome was the number of proctor 'assists' required per colonoscopy. Secondary outcomes included insertion time, depth of insertion, cecal intubation rate, proctor- and nurse-rated competence, and patient-rated pain.

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Mcintosh, Keith S, et al. “Computer-Based Virtual Reality Colonoscopy Simulation Improves Patient-Based Colonoscopy Performance.” Canadian Journal of Gastroenterology and Hepatology, vol. 28, no. 4, 2014, pp. 203–206., doi:10.1155/2014/804367.

Exploratory Application of Augmented Reality/Mixed Reality Devices for Acute Care Procedure Training

Introduction: Augmented reality (AR), mixed reality (MR), and virtual reality devices are enabling technologies that may facilitate effective communication in healthcare between those with information and knowledge (clinician/specialist; expert; educator) and those seeking understanding and insight (patient/family; non-expert; learner). Investigators initiated an exploratory program to enable the study of AR/MR use-cases in acute care clinical and instructional settings.

Methods: Academic clinician educators, computer scientists, and diagnostic imaging specialists conducted a proof-of-concept project to 1) implement a core holoimaging pipeline infrastructure and open-access repository at the study institution, and 2) use novel AR/MR techniques on off-the-shelf devices with holoimages generated by the infrastructure to demonstrate their potential role in the instructive communication of complex medical information.

Results: The study team successfully developed a medical holoimaging infrastructure methodology to identify, retrieve, and manipulate real patients' de-identified computed tomography and magnetic resonance imagesets for rendering, packaging, transfer, and display of modular holoimages onto AR/MR headset devices and connected displays. Holoimages containing key segmentations of cervical and thoracic anatomic structures and pathology were overlaid and registered onto physical task trainers for simulation-based "blind insertion" invasive procedural training. During the session, learners experienced and used task-relevant anatomic holoimages for central venous catheter and tube thoracostomy insertion training with enhanced visual cues and haptic feedback. Direct instructor access into the learner's AR/MR headset view of the task trainer was achieved for visual-axis interactive instructional guidance.

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Kobayashi, Leo, et al. “Exploratory Application of Augmented Reality/Mixed Reality Devices for Acute Care Procedure Training.” Western Journal of Emergency Medicine, 2018, pp. 158–164., doi:10.5811/westjem.2017.10.35026.

Virtual Reality for Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration

Background: Virtual reality (VR) is a technology that allows the user to explore and manipulate computer-generated real or artificial three-dimensional multimedia sensory environments in real time to gain practical knowledge that can be used in clinical practice.

Objective: The aim of this systematic review was to evaluate the effectiveness of VR for educating health professionals and improving their knowledge, cognitive skills, attitudes, and satisfaction.

Methods: We performed a systematic review of the effectiveness of VR in pre- and postregistration health professions education following the gold standard Cochrane methodology. We searched 7 databases from the year 1990 to August 2017. No language restrictions were applied. We included randomized controlled trials and cluster-randomized trials. We independently selected studies, extracted data, and assessed risk of bias, and then, we compared the information in pairs. We contacted authors of the studies for additional information if necessary. All pooled analyses were based on random-effects models. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to rate the quality of the body of evidence.

Find the full study here.

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Kyaw, Bhone Myint, et al. “Virtual Reality for Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration.” Journal of Medical Internet Research, vol. 21, no. 1, 2019, doi:10.2196/12959.

OR fire virtual training simulator: design and face validity

Background: The Virtual Electrosurgical Skill Trainer (VEST) is a tool for training surgeons the safe operation of electrosurgery tools in both open and minimally invasive surgery. This training includes a dedicated team-training module that focuses on operating room (OR) fire prevention and response. The module was developed to allow trainees, practicing surgeons, anesthesiologist and nurses to interact with a virtual OR environment, which includes anesthesia apparatus, electrosurgical equipment, a virtual patient, and a fire extinguisher. Wearing a head mounted display, participants must correctly identify the ‘fire triangle’ elements and then successfully contain an OR fire. Within these virtual reality (VR) scenarios, trainees learn to react appropriately to the simulated emergency. A study targeted at establishing the face validity of the virtual OR fire simulator was undertaken at the 2015 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conference.

Methods: Forty-nine subjects with varying experience participated in this Institutional Review Board approved study. The subjects were asked to complete the OR fire training/prevention sequence in the VEST simulator. Subjects were then asked to answer a subjective preference questionnaire consisting of sixteen questions, focused on the usefulness and fidelity of the simulator.

Find the full study here:

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Dorozhkin D, Olasky J, Jones DB, et al. OR fire virtual training simulator: design and face validity. Surg Endosc. 2017;31(9):3527–3533. doi:10.1007/s00464-016-5379-7

Development of a prototype persuasive virtual reality training to support the prevention of surgical site infections

Background: A surgical site infection (SSI) is a serious nosocomial infection of a surgical wound that occurs within 30 days after surgery [1]. SSIs can cause unnecessary pain, fear and inconvenience for the patient and may lead to longer hospitalization, permanent disability or even death. To prevent SSIs and to maintain a patient’s safety, guidelines are applied before, during and after surgery. These guidelines include hygiene measures (such as hand hygiene, wearing clothes correctly, limiting the number of door openings), antibiotic prophylaxis (administering antibiotics in the right dose at the right time), hair removal, and maintaining the patient’s body temperature during surgery [2]. However, compliance with these guidelines seems to be problematic due to i.e. a lack of awareness about risky situations and difficulties in signaling mistakes within the hierarchical work environment [3]. Virtual reality (VR) as a training approach has the potential to address these determinants due to its focus on both cognitive (situation awareness) and affective components (mindset) [4]. Building upon earlier research [3], this study aimed to translate relevant determinants into an initial VR training prototype to support operating room (OR) staff in preventing SSIs by fostering situation awareness and reducing signaling fatigue.

Find the full paper here.

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Wrede, C., Sieverink, F., Bijker, J. D., & van Gemert-Pijnen, J. E. W. C. (2019). Development of a prototype persuasive virtual reality training to support the prevention of surgical site infections. In E. Kyza , P. Karpinnen, E. Karapanos, K. T. Win , & H. Oinas-Kukkonen (Eds.), Adjunct Proceedings of the 14th International Conference on Persuasive Technology, Limassol, Cyprus (pp. 30-31)

Resident Perspectives on Communication Training That Utilizes Immersive Virtual Reality

Background: Communication skills can be difficult to teach and assess in busy outpatient settings. These skills are important for effective counseling such as in cases of influenza vaccine hesitancy. It is critical to consider novel educational methods to supplement current strategies aimed at teaching relational skills.

Methods: An immersive virtual reality (VR) curriculum on addressing influenza vaccine hesitancy was developed using Kern's six-step approach to curriculum design. The curriculum was meant to teach best-practice communication skills in cases of influenza vaccine hesitancy. Eligible participants included postgraduate level (PL) 2 and PL-3 pediatric residents (n = 24). Immediately following the curriculum, a survey was administered to assess residents' attitudes toward the VR curriculum and perceptions regarding the effectiveness of VR in comparison to other educational modalities. A survey was administered 1 month following the VR curriculum to assess trainee-perceived impact of the curriculum on clinical practice.

Find the full study here.

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Real, Francisj, et al. “Resident Perspectives on Communication Training That Utilizes Immersive Virtual Reality.” Education for Health, vol. 30, no. 3, 2017, p. 228., doi:10.4103/efh.efh_9_17.

Immersive Learning in Nursing Education: Results of a Study

Objective: This study evaluated the effectiveness of an immersive teaching and learning approach for undergraduate nurses. Traditional classroom tutorials were combined with self-directed learning using LabTutorTM, an online learning platform, and clinical nursing simulation using high fidelity manikins. Learning modules were designed to link the student’s knowledge and understanding of biosceince with clinical assessment and nursing management in order to develop clinical decision-making skills. It was anticipated that students’ learning experience would be enhanced by the higher level of realism that is possible using the sophisticated manikins and authentic patient clinical data and case notes provided in LabTutorTM.

Methods: The study took place in a New Zealand School of Nursing in 2014. Qualitative data was gathered using focus groups and an external facilitator. Quantitative data was gathered using an online survey.

Results: Participants were second year undergraduate nursing students (N = 111): 71 (64%) interviewees, and 82 (73%) survey respondents. Qualitative data showed that the immersive learning process was effective. Quantitative data affirmed that immersive learning was liked, confidence improved, students enjoyed the process, and would recommend it to others. Using simulation and patient case studies were preferred teaching strategies. Performing experiments, and using digital LabTutorTM technology challenged many, but skills improved over the year.

Find the full study here.

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Ditzel, Liz Mary, et al. “Immersive Learning in Nursing Education: Results of a Study.” Journal of Nursing Education and Practice, vol. 7, no. 5, 2017, p. 120., doi:10.5430/jnep.v7n5p120.

Virtual Reality for Medical and Nursing Training in Low- and Middle-Income Countries

Background: This paper reviews the potential for the use of new low-cost Virtual Reality (VR) technology for conducting medical simulation training in low- and middle-income countries (LMICs). VR has been used in medical simulation training for many years but has traditionally been very expensive and required large machines that would be difficult to set up and maintain in LMICs. However, new advances in computer technology have enabled a new generation of consumer-focused VR hardware that offers the potential for implementation in LMICs. Our research team based in Oxford and Kenya developed a VR training scenario for the Life-saving Instruction for Emergencies (LIFE) project. We tested LIFE:VR with healthcare workers in Kenya to establish the potential feasibility and acceptability of low-cost VR for medical simulation training. We found that healthcare workers were enthusiastic about the approach but the systems we tested had a number of technical limitations such as requiring powerful laptop computers and the installation of laser tracking base-stations that would limit scale up. However, newly announced hardware from major VR manufacturers appear to address these technical issues and will continue to reduce the costs of devices increasing the potential for wider adoption in LMICs.

Find the full paper here.

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Muinga, N., Paton, C. 2019. Virtual reality for medical and nursing training in low- and middle-income countries. Pathways for Prosperity Commission Background Paper Series; no. 25. Oxford, United Kingdom.

Clinical instructors' perceptions of virtual reality in health professionals' cardiopulmonary resuscitation education

Background: Cardiopulmonary resuscitation (CPR) is lifesaving. Yet, cardiac arrest survival remains low despite CPR intervention. Education has been highlighted as a strategy to overcome this issue. Virtual Reality technology has been gaining momentum in the field of clinical education. Published studies report benefits of virtual reality for CPR education; yet, perceptions of CPR instructors towards virtual reality remain unexplored. CPR instructors are key stakeholders in CPR education and their perceptions are valuable for the design and adoption of virtual reality-enhanced learning. The purpose of this study is therefore to understand the perceptions of CPR instructors towards using virtual reality for health professionals’ CPR education. The aim was addressed via three research questions: (1) What are the perceptions of CPR instructors towards current health professionals’ CPR education? (2) What are the perceptions of CPR instructors towards features of virtual reality ideal for health professionals’ CPR education? (3) What are the perceptions of CPR instructors towards the potential role of virtual reality in health professionals’ CPR education?

Methods: A total of 30 CPR instructors were surveyed on their views towards current health professionals’ CPR education and the use of virtual reality for health professionals’ CPR education, before and after interacting with a CPR virtual reality simulation. Responses were analysed using interpretative thematic analysis.

Results: CPR instructors perceived current health professionals’ CPR education as limited due to unideal test preparation (resources, practice, motivation, and frame of mind) and performance. They perceived fidelity, engagement, resource conservation, and memory enhancement as features of virtual reality ideal for health professionals’ CPR education. Virtual reality was viewed by CPR instructors as having potential as a blended learning tool, targeting both ‘novice’ and ‘experienced’ health professionals.

Find the full study here.

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Wong MAME, Chue S, Jong M, Benny HWK, Zary N. Clinical instructors' perceptions of virtual reality in health professionals' cardiopulmonary resuscitation education. SAGE Open Med. 2018;6:2050312118799602. Published 2018 Sep 17. doi:10.1177/2050312118799602

Using Virtual Reality Simulation Environments to Assess Competence for Emergency Medicine Learners

Abstract: Immersive learning environments that use virtual simulation (VS) technology are increasingly relevant as medical learners train in an environment of restricted clinical training hours and a heightened focus on patient safety. We conducted a consensus process with a breakout group of the 2017 Academic Emergency Medicine Consensus Conference "Catalyzing System Change Through Health Care Simulation: Systems, Competency, and Outcomes." This group examined the current uses of VS in training and assessment, including limitations and challenges in implementing VS into medical education curricula. We discuss the role of virtual environments in formative and summative assessment. Finally, we offer recommended areas of focus for future research examining VS technology for assessment, including high-stakes assessment in medical education. Specifically, we discuss needs for determination of areas of focus for VS training and assessment, development and exploration of virtual platforms, automated feedback within such platforms, and evaluation of effectiveness and validity of VS education.

Find the full study here.

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Mcgrath, Jillian L., et al. “Using Virtual Reality Simulation Environments to Assess Competence for Emergency Medicine Learners.” Academic Emergency Medicine, vol. 25, no. 2, 2017, pp. 186–195., doi:10.1111/acem.13308.

VERT, a Virtual Clinical Environment, Enhances Understanding of Radiation Therapy Planning Concepts

Introduction: The ability to understand treatment plan dosimetry and apply this understanding clinically is fundamental to the role of the radiation therapist. This study evaluates whether or not the Virtual Environment for Radiotherapy Training (VERT) contributes to teaching treatment planning concepts to a cohort of first-year radiation therapy students.

Methods: We directly compared a custom-developed VERT teaching module with a standard teaching module with respect to the understanding of treatment planning concepts using a cross-over design. Students self-reported their understanding of specific concepts before and after delivery of the VERT and standard teaching modules and evaluated aspects of VERT as a learning experience. In addition, teaching staff participated in a semi-structured interview discussing the modules from an educational perspective.

Results: Both the standard teaching module and VERT teaching module enhanced conceptual understanding and level of confidence in the student cohort after both teaching periods. The proportion of students reporting a perceived increase in knowledge/confidence was similar for the VERT teaching module for all but two scenarios. We propose that an integrated approach, providing a strong theoretical conceptual framework, followed by VERT to situate this framework in the (simulated) clinical environment combines the best of both teaching approaches.

Conclusion: This study has established for the first time a clear role for a tailored VERT teaching module in teaching RT planning concepts because of its ability to visualise conceptual information within a simulated clinical environment.

Find the full study here.

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Leong, Aidan, et al. “VERT, a Virtual Clinical Environment, Enhances Understanding of Radiation Therapy Planning Concepts.” Journal of Medical Radiation Sciences, vol. 65, no. 2, 2018, pp. 97–105., doi:10.1002/jmrs.272.

The Implementation of a Haptic Feedback Virtual Reality Simulation Clinic with Dynamic Patient Interaction and Communication for Medical Imaging Students

Introduction: An immersive virtual reality (VR) simulation clinic with dynamic patient interaction and communication was developed to facilitate the training of medical radiation science students. The software "CETSOL VR Clinic" was integrated into the Medical Imaging programme at Monash University in 2016 in order to benchmark student experiences against existing simulation techniques (Shaderware™).

Methods: An iterative approach to development, based on two cycles of user feedback, was used to develop and refine the simulated clinical environment. This environment uses realistic 3D models, embedded clinical scenarios, dynamic communication, 3D hand gesture interaction, gaze and positional stereoscopic tracking and online user capabilities using the Unity™ game and physics engines. Students' perceptions of educational enhancement of their positioning skills following the use of the simulation tools were analysed via a 5-point Likert scale questionnaire.

Results: Student perception scores indicated a significant difference between simulation modalities in favour of the immersive CETSOL VR Clinic, χ2 (4, N = 92) = 9.5, P-value <0.001.

Find the full study here.

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Sapkaroski, Daniel, et al. “The Implementation of a Haptic Feedback Virtual Reality Simulation Clinic with Dynamic Patient Interaction and Communication for Medical Imaging Students.” Journal of Medical Radiation Sciences, vol. 65, no. 3, 2018, pp. 218–225., doi:10.1002/jmrs.288.

Interprofessional Education: Evaluation of a Radiation Therapy and Medical Physics Student Simulation Workshop

Introduction: Interprofessional education (IPE) involves two or more professions engaged in learning with, from and about each other. An initiative was undertaken to explore IPE for radiation therapy (RT) and medical physics (MP) students through a newly developed workshop based around simulated learning. The aims of this study were to explore RT and MP students' perceptions of working as part of a collaborative team and of their own and the other group's professional roles. Student perceptions of the simulation education tool, the virtual environment for radiotherapy training (VERT) system, were also investigated.

Methods: RT and MP students were invited to participate in a 4-hour interprofessional workshop. Pre- and post-workshop surveys were employed to collect demographic data, students' perceptions of interdisciplinary education (interdisciplinary education perception scale (IEPS)) and workshop evaluation (bespoke questionnaire).

Results: Fifteen students attended the workshop (RT, n = 8; MP, n = 7). Thirteen pre- and post-questionnaires were returned (Pre-questionnaire: RT, n = 6, response rate, 75%; MP, n = 7, response rate, 100%; post-questionnaire: RT, n = 7, response rate, 87.5%; MP, n = 6, response rate 85.7%). For both student groups combined, IEPS scores ranged from 64 to 108 and 71 to 108 in the pre- and post-questionnaires, respectively, with insignificant differences in the mean scores post-intervention (Z = -1.305, P = 0.192). Satisfaction with VERT as a simulation tool was high for both student groups.

Find the full paper here.

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Jimenez, Yobelli A., et al. “Interprofessional Education: Evaluation of a Radiation Therapy and Medical Physics Student Simulation Workshop.” Journal of Medical Radiation Sciences, vol. 65, no. 2, 2018, pp. 106–113., doi:10.1002/jmrs.256.

Virtual reality training improves operating room performance: results of a randomized, double-blinded study

Objective: To demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment.

Summary Background Data: The use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study.

Methods: Sixteen surgical residents (PGY 1-4) had baseline psychomotor abilities assessed, then were randomized to either VR training (MIST VR simulator diathermy task) until expert criterion levels established by experienced laparoscopists were achieved (n = 8), or control non-VR-trained (n = 8). All subjects performed laparoscopic cholecystectomy with an attending surgeon blinded to training status. Videotapes of gallbladder dissection were reviewed independently by two investigators blinded to subject identity and training, and scored for eight predefined errors for each procedure minute (interrater reliability of error assessment r > 0.80).

Results: No differences in baseline assessments were found between groups. Gallbladder dissection was 29% faster for VR-trained residents. Non-VR-trained residents were nine times more likely to transiently fail to make progress (P <.007, Mann-Whitney test) and five times more likely to injure the gallbladder or burn nontarget tissue (chi-square = 4.27, P <.04). Mean errors were six times less likely to occur in the VR-trained group (1.19 vs. 7.38 errors per case; P <.008, Mann-Whitney test).

Find the full study here.

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Seymour, Neal E., et al. “Virtual Reality Training Improves Operating Room Performance.” Annals of Surgery, vol. 236, no. 4, 2002, pp. 458–464., doi:10.1097/00000658-200210000-00008.

Virtual Reality Simulation Facilitates Resident Training in Total Hip Arthroplasty: A Randomized Controlled Trial

Background: No study has yet assessed the efficacy of virtual reality (VR) simulation for teaching orthopedic surgery residents. In this blinded, randomized, and controlled trial, we asked if the use of VR simulation improved postgraduate year (PGY)-1 orthopedic residents' performance in cadaver total hip arthroplasty and if the use of VR simulation had a preferentially beneficial effect on specific aspects of surgical skills or knowledge.

Methods: Fourteen PGY-1 orthopedic residents completed a written pretest and a single cadaver total hip arthroplasty (THA) to establish baseline levels of knowledge and surgical ability before 7 were randomized to VR-THA simulation. All participants then completed a second cadaver THA and retook the test to assess for score improvements. The primary outcomes were improvement in test and cadaver THA scores.

Results: There was no significant difference in the improvement in test scores between the VR and control groups (P = .078). In multivariate regression analysis, the VR cohort demonstrated a significant improvement in overall cadaver THA scores (P = .048). The VR cohort demonstrated greater improvement in each specific score category compared with the control group, but this trend was only statistically significant for technical performance (P = .009).

Find the full study here.

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Hooper, Jessica, et al. “Virtual Reality Simulation Facilitates Resident Training in Total Hip Arthroplasty: A Randomized Controlled Trial.” The Journal of Arthroplasty, vol. 34, no. 10, 2019, pp. 2278–2283., doi:10.1016/j.arth.2019.04.002.

The Past, Present, and Future of Virtual Reality in Pharmacy Education

Objective. To characterize how virtual reality (VR) has been and is being used in pharmacy education, and evaluate the projected utility of VR technology in pharmacy education in the future. 

Findings. Virtual reality technology has been used in pharmacy education for many years to provide engaging learning experiences. Although these learning experiences were not available in the three-dimensional digital environments provided by current VR, they demonstrated improvements in learning. Recent technological advancements have substantially increased the potential usefulness of VR for pharmacy education by providing immersive educational activities that mimic real world experiences to reinforce didactic and laboratory concepts. Virtual reality training that uses head-mounted displays is just beginning in pharmacy education, but more educational VR programs are becoming available. Further research will be necessary to fully understand the potential impact of VR on pharmacy education. 

Summary. Virtual reality technology can provide an immersive and interactive learning environment, overcoming many of the early challenges faced by instructors who used virtual activities for pharmacy education. With further technological and software development, VR has the potential to become an integral part of pharmacy education.

Find the full paper here.

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Coyne, L, et al. “The Past, Present, and Future of Virtual Reality in Pharmacy Education.” American Journal of Pharmaceutical Education, Apr. 2019, doi:10.5688/ajpe7456.

Virtual Reality in Pharmacy: Opportunities for Clinical, Research, and Educational Applications

Find the full article here.

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Ventola, C Lee. “Virtual Reality in Pharmacy: Opportunities for Clinical, Research, and Educational Applications.” P&T Community, vol. 44, no. 5, 2019, pp. 267–276.

Virtual reality and the transformation of medical education

Abstract: Medical education is changing. Simulation is increasingly becoming a cornerstone of clinical training and, though effective, is resource intensive. With increasing pressures on budgets and standardisation, virtual reality (VR) is emerging as a new method of delivering simulation. VR offers benefits for learners and educators, delivering cost-effective, repeatable, standardised clinical training on demand. A large body of evidence supports VR simulation in all industries, including healthcare. Though VR is not a panacea, it is a powerful educational tool for defined learning objectives and implementation is growing worldwide. The future of VR lies in its ongoing integration into curricula and with technological developments that allow shared simulated clinical experiences. This will facilitate quality interprofessional education at scale, independent of geography, and transform how we deliver education to the clinicians of the future.

Find the full paper here.

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Pottle J. Virtual reality and the transformation of medical education. Future Healthc J. 2019;6(3):181–185. doi:10.7861/fhj.2019-0036

The Applications of Virtual Reality Technology in Medical Groups Teaching

Introduction: Virtual reality is a new method for training different medical groups. Based on this technology, professionals and students of various medical sciences can determine their level of competence for medical treatment before any performance on the patient. Therefore, the aim of this study was to identify the applications of virtual reality technology for training the medical groups.

Methods: This is a scoping review study conducted in 2016. Articles were retrieved through the search of related keywords in databases such as Pub Med, Scopus, Web of Sciences, Springer, and Google scholar. Then, after applying the entry criteria, 21 papers were selected from a total of 1343. Data extraction was done by a data collection form. The collected data were summarized and reported using content analysis technique according to the study purpose.

Find the full paper here.

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Samadbeik M, Yaaghobi D, Bastani P, Abhari S, Rezaee R, Garavand A. The Applications of Virtual Reality Technology in Medical Groups Teaching. J Adv Med Educ Prof. 2018;6(3):123–129.

Getting VR Right Then and Now … The Indispensable Role of Human Factors and Human Centered Design

Invited Essay

"From that point on, I vowed that we would never undertake another VR (or AR or MxR) project unless we could demand that a proper human-centred design process was put in place from Day One, and that we had the involvement and engagement of key stakeholders and end users throughout the entire project lifecycle. ‘Humans First, Technology Second’ became our ‘battle cry’. Of course, from time to time we would indulge in that ‘fun’ part of research often referred to as developing a ‘technology demonstrator’. Who in the VR community does not? But for mainstream, large-scale projects, a sound HF approach was always mandated. Sometimes, customers would refuse such a ‘luxury’, claiming it would unnecessary time and cost to a project. Often they went away; often the alternative they eventually sponsored failed."― Excerpted from a section of Professor Bob Stone's essay titled "Humans First, Technology Second".

Read the full essay here.

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Stone, R 2016, 'Getting VR Right Then and Now … The Indispensable Role of Human Factors and Human Centred Design' Presence, vol. 25, no. 2, pp. 151-160. https://doi.org/10.1162/PRES_a_00253

The (human) science of medical virtual learning environments

Abstract: The uptake of virtual simulation technologies in both military and civilian surgical contexts has been both slow and patchy. The failure of the virtual reality community in the 1990s and early 2000s to deliver affordable and accessible training systems stems not only from an obsessive quest to develop the ‘ultimate’ in so-called ‘immersive’ hardware solutions, from head-mounted displays to large-scale projection theatres, but also from a comprehensive lack of attention to the needs of the end users. While many still perceive the science of simulation to be defined by technological advances, such as computing power, specialized graphics hardware, advanced interactive controllers, displays and so on, the true science underpinning simulation—the science that helps to guarantee the transfer of skills from the simulated to the real—is that of human factors, a well-established discipline that focuses on the abilities and limitations of the end user when designing interactive systems, as opposed to the more commercially explicit components of technology. Based on three surgical simulation case studies, the importance of a human factors approach to the design of appropriate simulation content and interactive hardware for medical simulation is illustrated. The studies demonstrate that it is unnecessary to pursue real-world fidelity in all instances in order to achieve psychological fidelity—the degree to which the simulated tasks reproduce and foster knowledge, skills and behaviours that can be reliably transferred to real-world training applications.

Find the full report here.

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Stone RJ. The (human) science of medical virtual learning environments. Philosophical Transactions of the Royal Society B: Biological Sciences. 2011;366(1562):276-285. doi:10.1098/rstb.2010.0209

Virtual Reality for Health Professions Education: Systematic Review

Objectives: The aim of this systematic review was to evaluate the effectiveness of VR for educating health professionals and improving their knowledge, cognitive skills, attitudes, and satisfaction.

Conclusions: We found evidence suggesting that VR improves post-intervention knowledge and skills outcomes of health professionals when compared with traditional education or other types of digital education such as online or offline digital education. The findings on other outcomes are limited. Future research should evaluate the effectiveness of immersive and interactive forms of VR and evaluate other outcomes such as attitude, satisfaction, cost-effectiveness, and clinical practice or behavior change.

Find the full report here.

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Dunleavy G, Nikolaou CK, Nifakos S, Atun R, Law GCY, Car LT. Mobile Digital Education for Health Professions: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration. Journal of Medical Internet Research. 2019;21(2). doi:10.2196/12937

Report: Building Healthcare Expertise With Virtual Reality

Q. Can immersive technologies help professionals in the healthcare sector build crucial expertise and save lives?

A. Yes, it certainly can — and it already is!

 

This report was originally published in Tech Trends.

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Maddox T, Bonasio A. Report: Building Healthcare Expertise With VR. Tech Trends. https://techtrends.tech/virtual-reality/report-building-healthcare-expertise-with-vr/. Published January 4, 2019. Accessed April 4, 2019.

How xR Technologies Will Accelerate Healthcare Training

Immersive learning technologies are growing, and one sector embracing them is healthcare training. Immersive learning tools uniquely engage learning systems in the brain that are highly effective for many forms of training, especially training related to healthcare. These technologies have the potential to improve the quality and quantity of training, reduce training costs, and enhance patient satisfaction through better care from healthcare professionals and a deeper understanding for patients.

Read the full article here.

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This article was originally published by the Association for Talent Development.

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Maddox T. How xR Technologies Will Accelerate Healthcare Training. Main. https://www.td.org/insights/how-xr-technologies-will-accelerate-healthcare-training. Published September 19, 2018. Accessed April 5, 2019.

A Discussion of Virtual Reality As a New Tool for Training Healthcare Professionals

Background: Virtual reality technology describes the use of headsets displaying a particular environment to simulate a user’s physical existence in a virtual or imaginary setting. Headsets are sometimes combined with other sensory inputs, such as haptic feedback, smells, and changing temperatures. Avatars (virtual characters with whom the user interacts) can be programmed to express emotions, for example, by blushing or crying. These high-fidelity avatars provide the user a greater sense of reality and facilitate meaningful interaction.

The field of virtual reality first came to light decades ago; however, recent advances in technology have made it the exciting and emerging field it is today. Its applications are vast, ranging from military training to gaming. In medicine, the technology has been trialed for uses such as cognitive rehabilitation post-stroke (), improving reaction times in children with cerebral palsy () and in aiding the diagnosis of psychiatric conditions ().

This paper sets out the viewpoint that virtual reality technology could be a new focus of direction in the development of training tools for medical education. We concentrate on its use in improving the communication skills of clinicians and medical students. 

Find the full report here.

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Fertleman C, Aubugeau-Williams P, Sher C, et al. A Discussion of Virtual Reality As a New Tool for Training Healthcare Professionals. Frontiers in Public Health. 2018;6. doi:10.3389/fpubh.2018.00044

The ENGAGE study: managing depression and obesity in a precision medicine model

Abstract: Precision medicine models for personalizing achieving sustained behavior changeare largely outside of current clinical practice. Yet, changing self-regulatory behaviors is fundamental to the self-management of complex lifestyle-related chronic conditions such as depression and obesity - two top contributors to the global burden of disease and disability. To optimize treatments and address these burdens, behavior change and self-regulation must be better understood in relation to their neurobiological underpinnings. Here, we present the conceptual framework and protocol for a novel study, “Engaging self-regulation targets to understand the mechanisms of behavior change and improve mood and weight outcomes (ENGAGE)”. The ENGAGE study integrates neuroscience with behavioral science to better understand the self-regulation related mechanisms of behavior change for improving mood and weight outcomes among adults with comorbid depression and obesity. We collect assays of three self-regulation targets (emotion, cognition, and self-reflection) in multiple settings: neuroimaging and behavioral lab-based measures, virtual reality, and passive smartphone sampling. By connecting human neuroscience and behavioral science in this manner within the ENGAGE study, we develop a prototype for elucidating the underlying self-regulation mechanisms of behavior change outcomes and their application in optimizing intervention strategies for multiple chronic diseases.

You can access the ENGAGE here.

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Williams LM, Pines A, Goldstein-Piekarski AN, et al. The ENGAGE study: Integrating neuroimaging, virtual reality and smartphone sensing to understand self-regulation for managing depression and obesity in a precision medicine model. Behaviour Research and Therapy. 2018;101:58-70. doi:10.1016/j.brat.2017.09.012

Virtual reality in the assessment, understanding, and treatment of mental health disorders

Abstract: Mental health problems are inseparable from the environment. With virtual reality (VR), computer-generated interactive environments, individuals can repeatedly experience their problematic situations and be taught, via evidence-based psychological treatments, how to overcome difficulties. VR is moving out of specialist laboratories. Our central aim was to describe the potential of VR in mental health, including a consideration of the first 20 years of applications. A systematic review of empirical studies was conducted. In all, 285 studies were identified, with 86 concerning assessment, 45 theory development, and 154 treatment. The main disorders researched were anxiety (n = 192), schizophrenia (n = 44), substance-related disorders (n = 22) and eating disorders (n = 18). There are pioneering early studies, but the methodological quality of studies was generally low. The gaps in meaningful applications to mental health are extensive. The most established finding is that VR exposure-based treatments can reduce anxiety disorders, but there are numerous research and treatment avenues of promise. VR was found to be a much-misused term, often applied to non-interactive and non-immersive technologies. We conclude that VR has the potential to transform the assessment, understanding and treatment of mental health problems. The treatment possibilities will only be realized if - with the user experience at the heart of design - the best immersive VR technology is combined with targeted translational interventions. The capability of VR to simulate reality could greatly increase access to psychological therapies, while treatment outcomes could be enhanced by the technology's ability to create new realities. VR may merit the level of attention given to neuroimaging.

Find the full study here.

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Freeman, D., et al. “Virtual Reality in the Assessment, Understanding, and Treatment of Mental Health Disorders.” Psychological Medicine, vol. 47, no. 14, 2017, pp. 2393–2400., doi:10.1017/s003329171700040x.

From Digital Mental Health Interventions to Digital “Addiction”: Where the Two Fields Converge

Abstract: Scientific literature from the last two decades indicates that, when it comes to mental health, technology is presented either as panacea or anathema. This is partly because researchers, too frequently, have planted themselves either in the field of digital mental health interventions (variably called “telepsychiatry”, “digital therapeutics”, “computerized therapy”, etc.), or in that of the problems arising from technology, with little cross-fertilization between the two. Yet, a closer look at the two fields reveals unifying themes that underpin both the advantages and dangers of technology in mental health. This article discusses five such themes. First, the breakneck pace of technology evolution keeps digital mental health interventions updated and creates more potentially problematic activities, leaving researchers perennially behind, so new technologies become outdated by the time they are studied. Second, the freedom of creating and using technologies in a regulatory vacuum has led to proliferation and choice, but also to a Wild-West online environment. Third, technology is an open window to access information, but also to compromise privacy, with serious implications for online psychology and digital mental health interventions. Fourth, weak bonds characterize online interactions, including those between therapists and patients, contributing to high attrition from digital interventions. Finally, economic analyses of technology-enabled care may show good value for money, but often fail to capture the true costs of technology, a fact that is mirrored in other online activities. The article ends with a call for collaborations between two interrelated fields that have been—till now—mutually insular.

Find the full paper here.

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Aboujaoude, Elias & Gega, Lina. (2020). From Digital Mental Health Interventions to Digital “Addiction”: Where the Two Fields Converge. Frontiers in Psychiatry. 10. 1017. 10.3389/fpsyt.2019.01017.

A Literature Overview of Virtual Reality (VR) in Treatment of Psychiatric Disorders: Recent Advances and Limitations

Abstract: In this paper, we conduct a literature survey on various virtual reality (VR) treatments in psychiatry. We collected 36 studies that used VR to provide clinical trials or therapies for patients with psychiatric disorders. In order to gain a better understanding of the management of pain and stress, we first investigate VR applications for patients to alleviate pain and stress during immersive activities in a virtual environment. VR exposure therapies are particularly effective for anxiety, provoking realistic reactions to feared stimuli. On top of that, exposure therapies with simulated images are beneficial for patients with psychiatric disorders such as phobia and posttraumatic stress disorder (PTSD). Moreover, VR environments have shown the possibility of changing depression, cognition, even social functions. We review empirical evidence from VR-based treatments on psychiatric illnesses such as dementia, mild cognitive impairment (MCI), schizophrenia and autism. Through cognitive training and social skill training, rehabilitation through VR therapies helps patients to improve their quality of life. Recent advances in VR technology also demonstrate potential abilities to address cognitive and functional impairments in dementia. In terms of the different types of VR systems, we discuss the feasibility of the technology within different stages of dementia as well as the methodological limitations. Although there is room for improvement, its widespread adoption in psychiatry is yet to occur due to technical drawbacks such as motion sickness and dry eyes, as well as user issues such as preoccupation and addiction. However, it is worth mentioning that VR systems relatively easily deliver virtual environments with well-controlled sensory stimuli. In the future, VR systems may become an innovative clinical tool for patients with specific psychiatric symptoms.

Find the full review here.

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Park MJ, Kim DJ, Lee U, Na EJ, Jeon HJ. A Literature Overview of Virtual Reality (VR) in Treatment of Psychiatric Disorders: Recent Advances and Limitations. Front Psychiatry. 2019;10:505. Published 2019 Jul 19. doi:10.3389/fpsyt.2019.00505

Can Simulated Nature Support Mental Health? Comparing Short, Single-Doses of 360-Degree Nature Videos in Virtual Reality With the Outdoors

Abstract: Nature exposure in virtual reality (VR) can provide emotional well-being benefits for people who cannot access the outdoors. Little is known about how these simulated experiences compare with real outdoor experiences. We conduct an experiment with healthy undergraduate students that tests the effects of 6 min of outdoor nature exposure with 6 min of exposure to a 360-degree VR nature video, which is recorded at the outdoor nature exposure location. Skin conductivity, restorativeness, and mood before and after exposure are measured. We find that both types of nature exposure increase physiological arousal, benefit positive mood levels, and are restorative compared to an indoor setting without nature; however, for outdoor exposure, positive mood levels increase and for virtual nature, they stay the same. The nature-based experience shows benefits above and beyond the variance explained by participants’ preferences, nature and VR experiences, and demographic characteristics. Settings where people have limited access to nature might consider using VR nature experiences to promote mental health.

Find the full paper here.

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Browning, Matthew H. E. M., et al. “Can Simulated Nature Support Mental Health? Comparing Short, Single-Doses of 360-Degree Nature Videos in Virtual Reality With the Outdoors.” Frontiers in Psychology, vol. 10, 2020, doi:10.3389/fpsyg.2019.02667.

Facilitating Technology-based Mental Health Interventions with Mobile Virtual Reality and Wearable Smartwatches

Background: There is a gap in the accessibility to mental care services between lowincome and high-income countries. World Health Organization has encouraged the use of electronic and mobile health technologies to promote self-care and extend coverage of services. However, the solutions to deliver technology-based mental health therapies use systems that are either expensive, large or require specialized personnel to operate them.

Aim: The thesis aims at validating to what extent is possible to develop an artifact consisting on a physiological computing system for mental health only using mobile virtual reality (VR) and wearable devices.

Methods: The six activities of Design-Science research methodology were used to develop and evaluate the artifact. The construction uses requirements elicited from the analyzes of the available devices and the use-case of slow-pace breathing exercises for relaxation. For the evaluation, 11 volunteers participated in a protocol involving two different parts: normal-paced and slow-paced breathing, PPG signal was captured through smartwatch and processed to analyze HRV in real-time. The artifact was assessed technically by calculating data losses and algorithm performance.

Find the full paper here.

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This is a 2019 Master's Thesis by Luis Quintero of Stockholm University.

Author: Luis Quintero

Main Supervisor: Professor Panagiotis Papapetrou, PhD, Department of Computer and Systems Sciences, Stockholm University

Co-supervisor: Head of Department Uno Fors, PhD, Department of Computer and Systems Sciences, Stockholm University

Examiner: Professor Paul Johannesson, PhD, Department of Computer and Systems Sciences, Stockholm University

Editorial: Assessing the Therapeutic Uses and Effectiveness of Virtual Reality, Augmented Reality and Video Games for Emotion Regulation and Stress Management

Background:

Virtual reality (VR), Augmented Reality (AR), and Video games (VGs), because of their reasonable cost and increasing diffusion among the public, are becoming very interesting and promising therapeutic approaches for improving individuals' health and well-being (e.g., Granic et al., 2014Giglioli et al., 2015Riva et al., 2016Hemenover and Bowman, 2018).

However, despite that numerous scientific studies have demonstrated the therapeutic benefits of these technologies for diverse cognitive functions and individual patients (e.g., Parsons et al., 2017Bediou et al., 2018Bouchard and Rizzo, 2019Riva et al., 2019), less attention has been devoted to the therapeutic use of such tools for the assessment and training of emotion regulation and stress management skills.

Therefore, we brought together within this Research Topic contributions from researchers investigating theoretical, empirical, experimental, and case studies of VR, AR, and VGs for emotion regulation and stress management assessment and training. This Editorial will provide an overview of the articles accepted for publication in the Research Topic.

Find the full paper here.

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Pallavicini, Federica, and Stéphane Bouchard. “Editorial: Assessing the Therapeutic Uses and Effectiveness of Virtual Reality, Augmented Reality and Video Games for Emotion Regulation and Stress Management.” Frontiers in Psychology, vol. 10, 2019, doi:10.3389/fpsyg.2019.02763.

Virtual reality exposure therapy for posttraumatic stress disorder (PTSD): a meta-analysis

Abstract: Contrary to specific phobias, for which Virtual Reality Exposure Therapy (VRET) constitutes an effective treatment, uncertainty still exists regarding the usefulness of VRET for posttraumatic stress disorder (PTSD). Therefore, this meta-analysis investigated the efficacy of VRET for PTSD as compared to waitlist and active comparators. A literature search yielded nine controlled studies encompassing 296 participants (124 VRET, 172 controls). The differences between conditions regarding the primary outcome of PTSD symptom severity and the secondary outcome of depressive and anxiety symptoms post-treatment were calculated using Hedges’ g. Compared to waitlist controls, VRET showed a significantly better outcome for PTSD symptoms (g = 0.62, p = .017) and depressive symptoms (g = 0.50, p = .008). There was no significant difference between VRET and active comparators regarding PTSD symptoms (g = 0.25, p= .356) and depressive symptoms (g = 0.24, p = .340) post-treatment. No significant effects emerged for anxiety symptoms. These findings suggest that VRET may be as effective as active comparators for PTSD patients. However, the results must be interpreted with caution due to the limited number of trials and the substantial number of – predominantly male – military service members studied. Additional controlled trials, considering a wider range of trauma types and balanced gender, are required to strengthen the evidence.

Find the full review here.

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Kothgassner OD, Goreis A, Kafka JX, Van Eickels RL, Plener PL, Felnhofer A. Virtual reality exposure therapy for posttraumatic stress disorder (PTSD): a meta-analysis. Eur J Psychotraumatol. 2019;10(1):1654782. Published 2019 Aug 19. doi:10.1080/20008198.2019.1654782

Virtual Reality for the Treatment of Autism

Abstract: Autism is a mental disorder which has received attention in several unrelated studies using virtual reality. One of the first attempts was to diagnose children with special needs at Tokyo University using a sandbox playing technique. Although operating the computer controls proved to be too difficult for the individuals with autism in the Tokyo study, research at the University of Nottingham, UK, is successful in using VR as a learning aid for children with a variety of disorders including autism. Both centers used flat screen computer systems with virtual scenes. Another study which concentrated on using VR as a learning aid with an immersive headset system is described in detail in this chapter. Perhaps because of the seriousness of the disorder and the lack of effective treatments, autism has received more study than attention deficit disorders, although both would appear to benefit from many of the same technology features.

Find the full paper here.

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Strickland, D. “Virtual Reality for the Treatment of Autism.” IOS Press, vol. 44, 1997, pp. 81–86., doi:10.3233/978-1-60750-888-5-81.

Comprehensive review on virtual reality for the treatment of violence: implications for youth with schizophrenia

Abstract: Youth violence is a complex and multifactorial issue that has severe health and social consequences. While treatment options exist to treat/reduce violence in at-risk populations such as schizophrenia, there remains limitations in the efficacy of current interventions. Virtual reality (VR) appears to be a unique possibility to expose offenders and to train coping skills in virtual situations that are capable of eliciting aggression‐relevant behavior without threatening others. The focus of this paper is to provide a comprehensive review of studies using VR to manage violence across several at-risk populations, with a particular emphasis on youth with schizophrenia. Despite the encouraging success of VR applications for the treatment of different mental health problems, no studies have explored the usability of VR to specifically treat violence in patients with schizophrenia. A limited number of studies have focused on violence risk factors in other mental health problems (i.e., emotion regulation in individual suffering from post-traumatic disorders) that may be targeted in treatments to reduce the risk of violence. The preliminary studies using VR as a therapeutic element have shown reductions in anger, improvements in conflict-resolution skills as well as in empathy levels, and decreases in aggression. Possible applications of these interventions in youth with schizophrenia will be discussed.

Find the full paper here.

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Dellazizzo L, Potvin S, Bahig S, Dumais A. Comprehensive review on virtual reality for the treatment of violence: implications for youth with schizophrenia. NPJ Schizophr. 2019;5(1):11. Published 2019 Jul 23. doi:10.1038/s41537-019-0079-7

Cue-Elicited Anxiety and Alcohol Craving as Indicators of the Validity of ALCO-VR Software: A Virtual Reality Study

Background: This study is part of a larger project aiming to develop a virtual reality (VR) software to be implemented as a clinical tool for patients diagnosed with alcohol use disorder (AUD). The study is based on previous research in which we identified factors that elicit craving for alcohol in a sample of AUD patients, and which led to the development of a virtual reality software to be used in cue exposure treatments of alcohol use disorder (ALCO-VR).

Objective: The main objective of this study was to test the effectiveness of ALCO-VR to elicit cue-induced craving and anxiety responses among social drinkers (SD) and AUD patients. Our secondary objective was to explore which responses (cue-induced craving or anxiety) can best differentiate between AUD patients and the SD group.

Method: Twenty-seven individuals (13 AUD patients and 14 SD) participated in this study after giving written informed consent. Their anxiety and alcohol craving levels were measured by different instruments at different stages of the procedure. The VR equipment consisted of Oculus Rift technology, and the software consisted of the ALCO-VR platform.

Results: Our data indicate that the ALCO-VR software can elicit responses of anxiety and alcohol craving, especially in the group of AUD patients. The cue-induced anxiety response differentiated AUD patients and the SD group better than the cue-induced craving response.

Conclusions: The general interest in applying new technologies to the assessment and treatment of mental health disorders has led to the development of immersive real-life simulations based on the advantages of VR technology. Our study concluded that the ALCO-VR software can elicit anxiety and craving responses and that cue-induced anxiety responses can distinguish between AUD and SD groups better than cue-induced craving. The data on craving and anxiety were assessed consistently by different instruments. In addition, we consider that ALCO-VR is able to ecologically assess cue-induced anxiety and alcohol craving levels during exposure to VR alcohol-related environments.

Find the full study here.

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Ghiţă A, Hernández-Serrano O, Fernández-Ruiz Y, et al. Cue-Elicited Anxiety and Alcohol Craving as Indicators of the Validity of ALCO-VR Software: A Virtual Reality Study. J Clin Med. 2019;8(8):1153. Published 2019 Aug 2. doi:10.3390/jcm8081153

Automated psychological therapy using virtual reality (VR) for patients with persecutory delusions: study protocol for a single-blind parallel-group randomised controlled trial (THRIVE)

Background: Persecutory delusions are a major psychiatric problem and are associated with a wide range of adverse outcomes. Our theoretical model views these delusions as unfounded threat beliefs which persist due to defence behaviours (e.g. avoidance) that prevent disconfirmatory evidence being processed. The treatment implications are that patients need to (1) go into feared situations and (2) not use defence behaviours. This enables relearning of safety and hence paranoia diminution. However, this is very difficult for patients due to their severe anxiety. A solution is to use virtual reality (VR) social situations, which are graded in difficulty and which patients find much easier to enter. We have now automated the provision of cognitive therapy within VR using an avatar coach, so that a therapist is not required and the treatment is scalable. In the THRIVE trial, the automated VR cognitive treatment will be tested against a VR control condition. It will contribute to our wider programme of work developing VR for patients with psychosis.

Methods: Patients with persistent persecutory delusions in the context of non-affective psychosis will be randomised (1:1) to the automated VR cognitive treatment or VR mental relaxation (control condition). Each VR treatment will comprise approximately four sessions of 30 min. Standard care will remain as usual in both groups. Assessments will be carried out at 0, 2, 4 (post treatment), 8, 16, and 24 weeks by a researcher blind to treatment allocation. The primary outcome is degree of conviction in the persecutory delusion (primary endpoint 4 weeks). Effect sizes will be re-established by an interim analysis of 30 patients. If the interim effect size suggests that the treatment is worth pursuing (d > 0.1), then the trial will go on to test 90 patients in total. Secondary outcomes include real world distress, activity levels, suicidal ideation, and quality of life. Mediation will also be tested. All main analyses will follow the intention-to-treat principle. The trial is funded by the Medical Research Council Developmental Pathway Funding Scheme.

Find the full paper here.

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Freeman D, Lister R, Waite F, et al. Automated psychological therapy using virtual reality (VR) for patients with persecutory delusions: study protocol for a single-blind parallel-group randomised controlled trial (THRIVE). Trials. 2019;20(1):87. Published 2019 Jan 29. doi:10.1186/s13063-019-3198-6

Automated virtual reality (VR) cognitive therapy for patients with psychosis: study protocol for a single-blind parallel group randomised controlled trial (gameChange)

Introduction: Many patients with psychosis experience everyday social situations as anxiety-provoking. The fears can arise, for example, from paranoia, hallucinations, social anxiety or negative-self beliefs. The fears lead patients to withdraw from activities, and this isolation leads to a cycle of worsening physical and mental health. Breaking this cycle requires highly active treatment directly in the troubling situations so that patients learn that they can safely and confidently enter them. However patients with psychosis seldom receive such life-changing interventions. To solve this problem we have developed an automated psychological treatment delivered in virtual reality (VR). It allows patients to experience computer simulations of the situations that they find anxiety-provoking. A virtual coach guides patients, using cognitive techniques, in how to overcome their fears. Patients are willing to enter VR simulations of anxiety-provoking situations because they know the simulations are not real, but the learning made transfers to the real world.

Methods and analysis: 432 patients with psychosis and anxious avoidance of social situations will be recruited from National Health Service (NHS) secondary care services. In the gameChange trial, they will be randomised (1:1) to the six-session VR cognitive treatment added to treatment as usual or treatment as usual alone. Assessments will be conducted at 0, 6 (post-treatment) and 26 weeks by a researcher blind to allocation. The primary outcome is avoidance and distress in real-life situations, using a behavioural assessment task, at 6 weeks. The secondary outcomes are psychiatric symptoms, activity levels and quality of life. All main analyses will be intention-to-treat. Moderation and mediation will be tested. An economic evaluation will be conducted.

Find the full study here.

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Freeman D, Yu LM, Kabir T, et al. Automated virtual reality (VR) cognitive therapy for patients with psychosis: study protocol for a single-blind parallel group randomised controlled trial (gameChange). BMJ Open. 2019;9(8):e031606. Published 2019 Aug 27. doi:10.1136/bmjopen-2019-031606

Mental health facility codesign: A new research method for integrating the service user voice in design processes using virtual reality

Background: Within healthcare environments, the emerging field of evidence-based design (EBD) explores the links between wellbeing and good design practice of the built environment.

Aim: By optimising both design processes and design outcomes, knowledge produced within this field seeks to improve staff performance, augment patient healing and enhance service outcomes and experiences.

Methods: In a prior study by the author, a mental health service building design was developed which integrated feedback from mental health service users relative to what aspects of the built environments of their care would enhance their service outcomes and experiences, encourage them to avail themselves of services and/or engage in therapy, and those that would reduce their willingness to avail themselves of services.

Results: The research project protocol detailed here is the final testing stage of this body of work, where service users are invited to evaluate the final building design, experienced through virtual reality. This study addresses a gap in the literature, and aims to advance the field of EBD, and codesign with mental health service users, using virtual reality.

Find the full paper here.

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Liddicoat S. Mental health facility codesign: A new research method for integrating the service user voice in design processes using virtual reality. Gen Psychiatr. 2019;32(3):e100061. Published 2019 Jul 23. doi:10.1136/gpsych-2019-100061

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

Background: eHealth interventions are becoming increasingly used in public health, with virtual reality (VR) being one of the most exciting recent developments. VR consists of a three-dimensional, computer-generated environment viewed through a head-mounted display. This medium has provided new possibilities to adapt problematic behaviors that affect mental health. VR is no longer un-affordable for individuals, and with mobile phone technology being able to track movements and project images through mobile head-mounted devices, VR is now a mobile tool that can be used at work, home, or on the move.

Objective: In line with recent advances in technology, in this review, we aimed to critically assess the current state of research surrounding mental health.

Methods: We compiled a table of 82 studies that made use of head-mounted devices in their interventions.

Results: Our review demonstrated that VR is effective in provoking realistic reactions to feared stimuli, particularly for anxiety; moreover, it proved that the immersive nature of VR is an ideal fit for the management of pain. However, the lack of studies surrounding depression and stress highlight the literature gaps that still exist.

Find the full review here.

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Jerdan SW, Grindle M, van Woerden HC, Kamel Boulos MN. Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research. JMIR Serious Games. 2018;6(3):e14. Published 2018 Jul 6. doi:10.2196/games.9226

The effects of virtual reality on mental wellness: A literature review

Abstract: Virtual Reality (VR) has been gaining popularity as a means to tackle a variety of issues in medicine and beyond, one of which is improving individuals’ mental wellness. The purpose of this review is to examine the body of research specific to the application of VR in improving mental wellness, oftentimes in the context of physical illness or disability. Using keywords “virtual reality”, “mental wellness”, “mental health”, “mood”, “stress”, “distress”, and “quality of life”, a search of the literature was conducted and 22 articles were identified for inclusion in this review. Results suggest that in many cases VR has been effective in improving various attributes of mental wellness in a variety of samples, and that the quality of the VR technology itself may play a role in these results. Overall, more research considering the long-term and large-scale effects of VR, as well as clarifying which technological features of VR are most successful, should be conducted in order to strengthen the applicability of VR for mental wellness in clinical settings, during daily activities, at the workplace and in other stressful situations

Find the full article here.

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Roche, Kayla, et al. “The Effects of Virtual Reality on Mental Wellness: A Literature Review.” Mental Health and Family Medicine, vol. 14, 2019, pp. 811–818.

Identifying the Added Value of Virtual Reality for Treatment in Forensic Mental Health: A Scenario-Based, Qualitative Approach

Background: Although literature and practice underline the potential of virtual reality (VR) for forensic mental healthcare, studies that explore why and in what way VR can be of added value for treatment of forensic psychiatric patients is lacking.

Goals: This study aimed to identify (1) points of improvements in existing forensic mental health treatment of in- and outpatients, (2) possible ways of using VR that can improve current treatment, and (3) positive and negative aspects of the use of VR for the current treatment according to patients and therapists.

Methods: Two scenario-based methods were used. First, semi-structured interviews were conducted with eight therapists and three patients to elicit scenarios from them. Based on these results, six scenarios about possibilities for using VR in treatment were created and presented to 89 therapists and 19 patients in an online questionnaire. The qualitative data from both methods were coded independently by two researchers, using the method of constant comparison.

Find the full paper here.

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Kip H, Kelders SM, Weerink K, et al. Identifying the Added Value of Virtual Reality for Treatment in Forensic Mental Health: A Scenario-Based, Qualitative Approach. Front Psychol. 2019;10:406. Published 2019 Feb 27. doi:10.3389/fpsyg.2019.00406

Improvement of Attention-Deficit/Hyperactivity Disorder Symptoms in School-Aged Children, Adolescents, and Young Adults With Autism via a Digital Smartglasses-Based Socioemotional Coaching Aid: Short-Term, Uncontrolled Pilot Study

Background: People with autism spectrum disorder (ASD) commonly experience symptoms related to attention-deficit/hyperactivity disorder (ADHD), including hyperactivity, inattention, and impulsivity. One-third of ASD cases may be complicated by the presence of ADHD. Individuals with dual diagnoses face greater barriers to accessing treatment for ADHD and respond less positively to primary pharmacologic interventions. Nonpharmacologic technology-aided tools for hyperactivity and inattention in people with ASD are being developed, although research into their efficacy and safety remains limited.

Objective: The objective of this preliminary study was to describe the changes in ADHD-related symptoms in children, adolescents, and young adults with ASD immediately after use of the Empowered Brain system, a behavioral and social communication aid for ASD running on augmented reality smartglasses.

Methods: We recruited 8 children, adolescents, and young adults with ASD (male to female ratio of 7:1, mean age 15 years, range 11.7-20.5 years) through a Web-based research signup form. The baseline score on the hyperactivity subscale of the Aberrant Behavioral Checklist (ABC-H), a measure of hyperactivity, inattention, and impulsivity, determined their classification into a high ADHD-related symptom group (n=4, ABC-H≥13) and a low ADHD-related symptom group (n=4, ABC-H<13). All participants received an intervention with Empowered Brain, where they used smartglasses-based social communication and behavioral modules while interacting with their caregiver. We then calculated caregiver-reported ABC-H scores at 24 and 48 hours after the session.

Find the full study here.

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Vahabzadeh, Arshya, et al. “Improvement of Attention-Deficit/Hyperactivity Disorder Symptoms in School-Aged Children, Adolescents, and Young Adults With Autism via a Digital Smartglasses-Based Socioemotional Coaching Aid: Short-Term, Uncontrolled Pilot Study.” JMIR Mental Health, vol. 5, no. 2, 2018, doi:10.2196/mental.9631.

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

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

Find the full study here.

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Alqithami, Saad, et al. “AR-Therapist: Design and Simulation of an AR-Game Environment as a CBT for Patients with ADHD.” Healthcare, vol. 7, no. 4, 2019, p. 146., doi:10.3390/healthcare7040146.

Simulation and mental health outcomes: a scoping review

Background: A scoping review was conducted in order to map and determine the gaps in literature on the impact of simulation as an educational approach to improve mental health care outcomes. As it became apparent that no literature existed on this topic, the study aimed to examine the educational impact of simulation on mental health education.

Methods: An established five-stage scoping methodology was used: (1) identification of the research question, (2) identification of relevant studies, (3) study selection, (4) charting the data and (5) collation, summarising and reporting of results. CINAHL, ProQuest, PubMed, MEDLINE, EMBASE and PsychINFO databases were searched. These databases were deemed to represent a majority of the literature while accommodating for the particular search strategy used for this review. Websites that provide grey literature were also searched for articles of relevance.

Results: A total of 48 articles were included in this review, with a considerable portion of studies conducted in the USA and UK. Others were conducted in an array of locations including Australia, Canada, Iran and Taiwan. Of the included articles, seven groups of simulation methods (including standardised patients, virtual reality and manikins as patients) were evident, with standardised patients being most prominent.

Find the full article here.

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Williams, B., Reddy, P., Marshall, S. et al. Simulation and mental health outcomes: a scoping review. Adv Simul 2, 2 (2017) doi:10.1186/s41077-016-0035-9

Virtual Reality in Pediatric Psychology

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

Find the full paper here.

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Parsons, Thomas D., et al. “Virtual Reality in Pediatric Psychology.” Pediatrics, vol. 140, no. Supplement 2, 2017, doi:10.1542/peds.2016-1758i.

Application and Effectiveness of Telehealth to Support Severe Mental Illness Management: Systematic Review

Background: People with severe mental illness (SMI) must receive early interventions to prevent mental health deterioration or relapse. Telecommunications and other technologies are increasingly being used to assist in health care delivery using "telehealth," which includes telephones and mobile phones, computers, remote sensors, the internet, and other devices, to provide immediate real-time information to service users to improve the management of chronic health conditions. Some initial findings have suggested that technology could improve the quality of life of people with SMI.

Objective: In this systematic review, we aimed to identify the various uses and efficacy of telehealth technology for SMI.

Methods: We systematically searched electronic databases from inception to March 2016 (MEDLINE, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, Health Technology Assessment, CINAHL Plus, and NHS Economic Evaluations Database) to identify randomized controlled trials evaluating telehealth for adults with SMI published in English. Additional literature was identified through searching reference lists of key articles. The articles meeting the inclusion criteria were systematically reviewed and assessed for quality and risk of bias.

Find the full review here.

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Lawes-Wickwar, Sadie, et al. “Application and Effectiveness of Telehealth to Support Severe Mental Illness Management: Systematic Review.” JMIR Mental Health, vol. 5, no. 4, 2018, doi:10.2196/mental.8816.

Virtual Reality Job Interview Training and 6-Month Employment Outcomes for Individuals with Schizophrenia Seeking Employment

Background: Individuals with schizophrenia have low employment rates and the job interview presents a critical barrier for them to obtain employment. Virtual reality training has demonstrated efficacy at improving interview skills and employment outcomes among multiple clinical populations. However, the effects of this training on individuals with schizophrenia are unknown. This study evaluated the efficacy of virtual reality job interview training (VR-JIT) at improving job interview skills and employment outcomes among individuals with schizophrenia in a small randomized controlled trial (n=21 VR-JIT trainees, n=11 waitlist controls).

Methods: Trainees completed up to 10h of virtual interviews using VR-JIT, while controls received services as usual. Primary outcome measures included two pre-test and two post-test video-recorded role-play interviews scored by blinded raters with expertise in human resources and self-reported interviewing self-confidence. Six-month follow-up data on employment outcomes were collected.

Results: Trainees reported that the intervention was easy-to-use, helpful, and prepared them for future interviews. Trainees demonstrated increased role-play scores between pre-test and post-test while controls did not (p=0.001). After accounting for neurocognition and months since prior employment, trainees had greater odds of receiving a job offer by 6month follow-up compared to controls (OR: 8.73, p=0.04) and more training was associated with fewer weeks until receiving a job offer (r=-0.63, p<0.001).

Find the full study here.

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Smith, Matthew J., et al. “Virtual Reality Job Interview Training and 6-Month Employment Outcomes for Individuals with Schizophrenia Seeking Employment.” Schizophrenia Research, vol. 166, no. 1-3, 2015, pp. 86–91., doi:10.1016/j.schres.2015.05.022.

Trauma and Self-Narrative in Virtual Reality: Toward Recreating a Healthier Mind

This study discusses the concept of virtual selves created in the virtual spaces [e.g. social network services or virtual reality (VR)]. It analyzes the activities in the different virtual spaces and claims that experience gained there can be transferred to real life. In respect to that, the effects of the VR treatment on the self as well as the concept of creating a life story are analyzed as interconnected. The research question which arises from these considerations is how to look at psychological trauma in order to explain the effectiveness of the usage of VR for treatment of traumatic disorders.

The proposal in the study is to see trauma as a shift in the normal storyline of the narrative people create. With this concept in mind, it might be possible to support the claim that reliving traumatic events, regaining control over one’s life narrative, and creating new stories in the VR aids the treatment process in the search for meaning and resolution in life events. Considering the findings of researchers who argue in the field of self-narrative and traumatic treatment, as well as researchers on virtual selves, virtual spaces and VR, this study discusses the virtual as a possible medium to experience narratives and utilize those narratives as better explanatory stories to facilitate the therapeutic process of recovery and self-recreation.

This study supports the idea that VR can be used to visualize patients’ narratives and help them perceive themselves as active authors of their life’s story by retelling traumatic episodes with additional explanation. This experience in the VR is utilized to form healthier narratives and coping techniques for robust therapeutic results that are transferred to real life.

Find the full study here.

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Georgieva I. Trauma and Self-Narrative in Virtual Reality: Toward Recreating a Healthier Mind. Frontiers in ICT. 2017;4. doi:10.3389/fict.2017.00027

A Public Database of Immersive VR Videos with Corresponding Ratings of Arousal, Valence, and Correlations between Head Movements and Self Report Measures

Virtual reality (VR) has been proposed as a methodological tool to study the basic science of psychology and other fields. One key advantage of VR is that sharing of virtual content can lead to more robust replication and representative sampling. A database of standardized content will help fulfill this vision. There are two objectives to this study. First, we seek to establish and allow public access to a database of immersive VR video clips that can act as a potential resource for studies on emotion induction using virtual reality. Second, given the large sample size of participants needed to get reliable valence and arousal ratings for our video, we were able to explore the possible links between the head movements of the observer and the emotions he or she feels while viewing immersive VR. To accomplish our goals, we sourced for and tested 73 immersive VR clips which participants rated on valence and arousal dimensions using self-assessment manikins. We also tracked participants' rotational head movements as they watched the clips, allowing us to correlate head movements and affect. Based on past research, we predicted relationships between the standard deviation of head yaw and valence and arousal ratings. Results showed that the stimuli varied reasonably well along the dimensions of valence and arousal, with a slight underrepresentation of clips that are of negative valence and highly arousing. The standard deviation of yaw positively correlated with valence, while a significant positive relationship was found between head pitch and arousal. The immersive VR clips tested are available online as supplemental material.

You can find the full study here.

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Li BJ, Bailenson JN, Pines A, Greenleaf WJ, Williams LM. A Public Database of Immersive VR Videos with Corresponding Ratings of Arousal, Valence, and Correlations between Head Movements and Self Report Measures. Frontiers in Psychology. 2017;8. doi:10.3389/fpsyg.2017.02116

Building long-term empathy: a large-scale comparison of traditional and virtual reality perspective taking

Abstract: Virtual Reality (VR) has been increasingly referred to as the “ultimate empathy machine” since it allows users to experience any situation from any point of view. However, empirical evidence supporting the claim that VR is a more effective method of eliciting empathy than traditional perspective-taking is limited. Two experiments were conducted in order to compare the short and long-term effects of a traditional perspective-taking task and a VR perspective-taking task (Study 1), and to explore the role of technological immersion when it comes to different types of mediated perspective-taking tasks (Study 2).

You can read the full study here.

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Herrera F, Bailenson J, Weisz E, Ogle E, Zaki J (2018) Building long-term empathy: A largescale comparison of traditional and virtual reality perspective-taking. PLoS ONE 13(10): e0204494. https://doi.org/10.1371/journal.pone.0204494

Interprofessional Empathy and Communication Competency Development in Healthcare Professions’ Curriculum through Immersive Virtual Reality Experiences

Background: Virtual Reality 360 video (VR 360)-based education can immerse healthcare students in clinical and curricular experiential learning.

Purpose: The purpose of this study was to explore Inter Professional (IP) healthcare students’ perceived experience specific to the competency of communication through a virtual reality scenario.

Method: Qualitative focus groups with an exploratory design approach were used to examine the attitudes and lived experiences of 39 students following a VR 360 experience assuming the role of a patient with macular degeneration and high frequency hearing loss.

Discussion: Thematic analysis revealed empathy with subsets of: sentiment, realism and communication. Sentiment was expressed through emotions allowing patient perspective. Realism was expressed as being the patient and feeling presence. Communication was experienced as barriers related to hearing and sight.

Conclusion: Immersive 360degree video as a delivery method for Interprofessional healthcare students studying and practicing communication skills is worthwhile.

Find the full study here.

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Buchman, Sherleena, and Deborah Henderson. “Interprofessional Empathy and Communication Competency Development in Healthcare Professions’ Curriculum through Immersive Virtual Reality Experiences.” Journal of Interprofessional Education & Practice, vol. 15, 2019, pp. 127–130., doi:10.1016/j.xjep.2019.03.010.

Do medical students respond empathetically to a virtual patient?

Background: Significant information exchange occurs between a doctor and patient through nonverbal communication such as gestures, body position, and eye gaze. In addition, empathy is an important trust-building element in a physician: patient relationship. Previous work validates the use of virtual patients (VP) to teach and assess content items related to history-taking and basic communication skills. The purpose of this study was to determine whether more complex communication skills, such as nonverbal behaviors and empathy, were similar when students interacted with a VP or standardized patient (SP).

Methods: Medical students (n = 84) at the University of Florida (UF) and the Medical College of Georgia (MCG) underwent a videotaped interview with either a SP or a highly interactive VP with abdominal pain. In the scenario, a life-sized VP was projected on the wall of an exam room in SP teaching and testing centers at both institutions. VP and SP scripted responses to student questions were identical. To prompt an empathetic response (ie, acknowledging the patients' feelings), during the interview the VP or SP stated "I am scared; can you help me?" Clinicians (n = 4) rated student videotapes with respect to nonverbal communication skills and empathetic behaviors using a Likert-type scale with anchored descriptors.

Find the full study here.

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Deladisma, Adeline M., et al. “Do Medical Students Respond Empathetically to a Virtual Patient?” The American Journal of Surgery, vol. 193, no. 6, 2007, pp. 756–760., doi:10.1016/j.amjsurg.2007.01.021.

Neuroanatomical basis of concern-based altruism in virtual environment

Abstract: Costly altruism entails helping others at a cost to the self and prior work shows that empathic concern (EC) for the well-being of distressed and vulnerable individuals is one of the primary motivators of such behavior. However, extant work has investigated costly altruism with paradigms that did not feature self-relevant and severe costs for the altruist and have solely focused on neurofunctional, and not neuroanatomical, correlates. In the current study, we used a contextually-rich virtual reality environment to study costly altruism and found that individuals who risked their own lives in the virtual world to try to save someone in danger had enlarged right anterior insula and exhibited greater empathic concern than those who did not. These findings add to the growing literature showing the role of caring motivation in promoting altruism and prosociality and its neural correlates in the right anterior insula.

Find the full study here.

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Patil, Indrajeet, et al. “Neuroanatomical Basis of Concern-Based Altruism in Virtual Environment.” Neuropsychologia, vol. 116, 2018, pp. 34–43., doi:10.1016/j.neuropsychologia.2017.02.015.

Enhancing Empathy: a Role for Virtual Reality?

The capacity for empathy is essential to clinical medicine and is of particular importance to the practice of psychiatry. The physician’s experience of empathy in patient care has been described as “a sequence of emotional engagement, compassion, and an urge to help the patient” produced by a “doctor’s awareness of the patient’s concerns” []. Empathic identification with patients’ suffering is the driving force behind the prevention and mitigation of suffering, pain, and distress [], a professional obligation generated by the fundamental professional virtue of compassion.

Strengthening the capacity for empathy is an important goal of medical education, but longitudinal studies suggest that empathy declines during residency and even during medical school []. Fortunately, decreases in medical students’ empathy, while appreciable and statistically significant in a variety of empirical projects, are not thought to be large; effect sizes appear to be small []. For this reason, the threats to empathy may be reversible and, we suggest, a number of steps may be taken (a) to mitigate the factors that are diminishing empathy and (b) to encourage the enhancement of empathy in residency and medical school.

Greater curricular emphasis on empathy should be considered, as well as more attempts at measuring empathy among resident and medical student populations. In order to gain or protect time for teaching empathy, educators must be able to describe precise teaching methods and evidence of positive outcomes. Such efforts are especially important in light of the growing list of topics required in the graduate and undergraduate medical curriculum.

Find the full paper here.

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Louie, Alan K., et al. “Enhancing Empathy: a Role for Virtual Reality?” Academic Psychiatry, vol. 42, no. 6, 2018, pp. 747–752., doi:10.1007/s40596-018-0995-2.

Using Virtual Patients to Teach Empathy: A Randomized Controlled Study to Enhance Medical Students' Empathic Communication

Introduction: Physician empathy is a complex phenomenon known to improve illness outcomes; however, few tools are available for deliberate practice of empathy. We used a virtual patient (VP) to teach empathic communication to first-year medical students. We then evaluated students' verbal empathy in a standardized patient (SP) interaction.

Methods: Seventy medical students, randomly assigned to 3 separate study groups, interacted with (1) a control VP portraying depression, (2) a VP with a backstory simulating patient shadowing, or (3) a VP able to give immediate feedback about empathic communication (empathy-feedback VP). Subsequently, the students interviewed an SP portraying a scenario that included opportunities to express empathy. All SP interviews were recorded and transcribed. The study outcomes were (1) the students' verbal response to the empathic opportunities presented by the SP, as coded by reliable assessors using the Empathic Communication Coding System, and (2) the students' responses as coded by the SPs, using a communication checklist.

Find the full study here.

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Foster, Adriana, et al. “Using Virtual Patients to Teach Empathy.” Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, vol. 11, no. 3, 2016, pp. 181–189., doi:10.1097/sih.0000000000000142.

Empathy toward virtual humans depicting a known or unknown person expressing pain

Abstract: This study is about pain expressed by virtual humans and empathy in users immersed in virtual reality. It focuses on whether people feel more empathy toward the pain of a virtual human when the virtual human is a realistic representation of a known individual, as opposed to an unknown person, and if social presence is related to users' empathy toward a virtual human's pain. The 42 participants were immersed in virtual reality using a large immersive cube with images retro projected on all six faces (CAVE-Like system) where they can interact in real time with virtual characters. The first immersion (baseline/control) was with a virtual animal, followed by immersions involving discussions with a known virtual human (i.e., the avatar of a person they were familiar with) or an unknown virtual human. During the verbal exchanges in virtual reality, the virtual humans expressed acute and very strong pain. The pain reactions were identical in terms of facial expressions, and verbal and nonverbal behaviors. The Conditions by Time interactions in the repeated measures analyses of variance revealed that participants were empathic toward both virtual humans, yet more empathic toward the known virtual human. Multivariate regression analyses revealed that participants' feeling of social presence--impression that the known virtual character is really there, with them--was a significant predictor of empathy.

Find the full study here.

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Bouchard, Stéphane, et al. “Empathy Toward Virtual Humans Depicting a Known or Unknown Person Expressing Pain.” Cyberpsychology, Behavior, and Social Networking, vol. 16, no. 1, 2013, pp. 61–71., doi:10.1089/cyber.2012.1571.

Understanding Empathy Training with Virtual Patients

Abstract: While the use of virtual characters in medical education is becoming more and more commonplace, an understanding of the role they can play in empathetic communication skills training is still lacking. This paper presents a study aimed at building this understanding by determining if students can respond to a virtual patient's statement of concern with an empathetic response. A user study was conducted at the [blinded] College of Medicine in which early stage medical students interacted with virtual patients in one session and real humans trained to portray real patients (i.e., standardized patients) in a separate session about a week apart. During the interactions, the virtual and ‘real' patients presented the students with empathetic opportunities which were later rated by outside observers. The results of pairwise comparisons indicate that empathetic responses made to virtual patients were rated as significantly more empathetic than responses made to standardized patients. Even though virtual patients may be perceived as artificial, the educational benefit of employing them for training medical students' empathetic communications skills is that virtual patients offer a low pressure interaction which allows students to reflect on their responses.

Find the full paper here.

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Kleinsmith, Andrea, et al. “Understanding Empathy Training with Virtual Patients.” Computers in Human Behavior, vol. 52, 2015, pp. 151–158., doi:10.1016/j.chb.2015.05.033.

Using virtual reality in medical education to teach empathy

Objective: The project adopted technology that teaches medical and other health professions students to be empathetic with older adults, through virtual reality (VR) software that allows them to simulate being a patient with age-related diseases, and to familiarize medical students with information resources related to the health of older adults.

Methods: The project uses an application that creates immersive VR experiences for training of the workforce for aging services. Users experience age-related conditions such as macular degeneration and high-frequency hearing loss from the patient's perspective. Librarians and faculty partner to integrate the experience into the curriculum, and students go to the library at their convenience to do the VR assignment.

Find the full study here.

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Dyer, Elizabeth, et al. “Using Virtual Reality in Medical Education to Teach Empathy.” Journal of the Medical Library Association, vol. 106, no. 4, 2018, doi:10.5195/jmla.2018.518.

Combining Virtual Reality and Biofeedback to Foster Empathic Abilities in Humans

Recent technological advances coupled with progress in brain and psychological sciences allow the controlled induction and regulation of human psychophysiological states. These progresses often aim toward the goal of developing human-machine interfaces to improve human factors such as mental health, human relations, well-being, and empathy. In this short article, we present some of such devices with a particular emphasis on technology aiming to foster empathic abilities in humans; that is, our ability to care, understand, and help our fellow human beings. In order to discuss any possible use for such devices in a clinical setting, we start by outlining definitions for the terms used in the article, and present three devices designed with the goal of modulating empathy in humans.

Find the full report here.

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Schoeller F, Bertrand P, Gerry LJ, Jain A, Horowitz AH, Zenasni F. Combining Virtual Reality and Biofeedback to Foster Empathic Abilities in Humans. Frontiers in Psychology. 2019;9. doi:10.3389/fpsyg.2018.02741

VR perspective-taking increases cognitive empathy for specific others

Abstract: Previous research shows that virtual reality perspective-taking experiences (VRPT) can increase prosocial behavior toward others. We extend this research by exploring whether this effect of VRPT is driven by increased empathy and whether the effect extends to ostensibly real-stakes behavioral games. 

You can find the full study here.

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van Loon A, Bailenson J, Zaki J, Bostick J, Willer R (2018) Virtual reality perspective-taking increases cognitive empathy for specific others. PLoS ONE 13(8): e0202442. https://doi.org/ 10.1371/journal.pone.0202442

Learning Empathy Through Virtual Reality: Multiple Strategies for Training Empathy-Related Abilities Using Body Ownership Illusions in Embodied Virtual Reality

Several disciplines have investigated the interconnected empathic abilities behind the proverb “to walk a mile in someone else’s shoes” to determine how the presence, and absence, of empathy-related phenomena affect prosocial behavior and intergroup relations. Empathy enables us to learn from others’ pain and to know when to offer support. Similarly, virtual reality (VR) appears to allow individuals to step into someone else’s shoes, through a perceptual illusion called embodiment, or the body ownership illusion. Considering these perspectives, we propose a theoretical analysis of different mechanisms of empathic practices in order to define a possible framework for the design of empathic training in VR. This is not intended to be an extensive review of all types of practices, but an exploration of empathy and empathy-related phenomena. Empathy-related training practices are analyzed and categorized. We also identify different variables used by pioneer studies in VR to promote empathy-related responses. Finally, we propose strategies for using embodied VR technology to train specific empathy-related abilities.

 

Find the full report here.

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Bertrand P, Guegan J, Robieux L, Mccall CA, Zenasni F. Learning Empathy Through Virtual Reality: Multiple Strategies for Training Empathy-Related Abilities Using Body Ownership Illusions in Embodied Virtual Reality. Frontiers in Robotics and AI. 2018;5. doi:10.3389/frobt.2018.00026

A Cloud-Based Virtual Reality App for a Novel Telemindfulness Service: Rationale, Design and Feasibility Evaluation

Background: Worldwide, there has been a marked increase in stress and anxiety, also among patients with traumatic brain injury (TBI). Access to psychology services is limited, with some estimates suggesting that over 50% of sufferers are not accessing the existing services available to them for reasons such as inconvenience, embarrassment, or stigmatization concerns around mental health. Health service providers have increasingly been turning to drug-free therapies, such as mindfulness programs, as complementary treatments.

Objective: Virtual reality (VR) as a new delivery method for meditation-based stress and anxiety reduction therapy offers configurable environments and privacy protection. Our objective was to design a serious learning-meditation environment and to test the feasibility of the developed telemindfulness approach based on cloud technologies.

Methods: We developed a cloud-based system, which consisted of a Web interface for the mindfulness instructor and remote clients, who had 3D VR headsets. The mindfulness instructor could communicate over the Web interface with the participants using the headset. Additionally, the Web app enabled group sessions in virtual rooms, 360-degree videos, and real interactions or standalone meditation. The mindfulness program was designed as an 8-week Mindfulness-Based Stress Reduction course specifically for the developed virtual environments. The program was tested with four employees and four patients with TBI. The effects were measured with psychometric tests, the Mindful Attention Awareness Scale (MAAS) and the Satisfaction With Life Scale (SWLS). Patients also carried out the Mini-Mental State Examination (MMSE). An additional objective evaluation has also been carried out by tracking head motion. Additionally, the power spectrum analyses of similar tasks between sessions were tested.

Find the full study here.

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Cikajlo, Imre, et al. “A Cloud-Based Virtual Reality App for a Novel Telemindfulness Service: Rationale, Design and Feasibility Evaluation.” JMIR Research Protocols, vol. 6, no. 6, 2017, doi:10.2196/resprot.6849.

Users' Opinion About a Virtual Reality System as an Adjunct to Psychological Treatment for Stress-Related Disorders: A Quantitative and Qualitative Mixed-Methods Study

Abstract: This study aims to explore patients’ and therapists’ attitudes about the psychological treatment they received (patients) or applied (therapists). The treatments were standard CBT protocols for post-traumatic stress disorder (PTSD), complicated grief (CG), or adjustment disorders (ADs), depending on each patient diagnosis. The treatments were delivered following a traditional format or supported by a virtual reality (VR) system “EMMA’s WORLD” designed for the treatment of stress-related disorders. “EMMA’s WORLD” is a VR application in which patients can explore negative experiences using different virtual elements that can be customized to make them more meaningful to the user. The sample was composed of two groups: the “professionals” (N = 10) were all clinical psychologists who applied the same psychological treatment in both the traditional format (“traditional condition”) and using the VR system (“EMMA” condition). The second group consisted of a sample of patients (N = 50) who met the criteria for at least one of three different diagnoses: PTSD (N = 15), CG (N = 15), or AD (N = 20). 25 patients received treatment in the traditional format and 25 supported by the VR system. The patients were asked about their expectations (before treatment) and satisfaction (after treatment) with the treatment they received. All the therapists were asked their opinions about both treatment conditions. A mixed-methods approach using quantitative and qualitative methodologies was used. In both conditions, high scores were observed, and the patient’s opinions were even better when they have already received the treatments. A more pronounced pre-test–post-test change in the EMMA therapy group than in the traditional group was observed. EMMA’s World was well-accepted by both patients and therapists, and it helped to foster motivation in patients, while helping the therapist to apply the treatment. Thus, VR can be useful as an adjunct tool to enhance the treatment.

Find the full study here.

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Guillén V, Baños RM, Botella C. Users' Opinion About a Virtual Reality System as an Adjunct to Psychological Treatment for Stress-Related Disorders: A Quantitative and Qualitative Mixed-Methods Study. Front Psychol. 2018;9:1038. Published 2018 Jun 22. doi:10.3389/fpsyg.2018.01038

Meditation experts try Virtual Reality Mindfulness: A pilot study evaluation of the feasibility and acceptability of Virtual Reality to facilitate mindfulness practice in people attending a Mindfulness conference

Abstract: Regular mindfulness practice benefits people both mentally and physically, but many populations who could benefit do not practice mindfulness. Virtual Reality (VR) is a new technology that helps capture participants’ attention and gives users the illusion of “being there” in the 3D computer generated environment, facilitating sense of presence. By limiting distractions from the real world, increasing sense of presence and giving people an interesting place to go to practice mindfulness, Virtual Reality may facilitate mindfulness practice. Traditional Dialectical Behavioral Therapy (DBT®) mindfulness skills training was specifically designed for clinical treatment of people who have trouble focusing attention, however severe patients often show difficulties or lack of motivation to practice mindfulness during the training. The present pilot study explored whether a sample of mindfulness experts would find useful and recommend a new VR Dialectical Behavioral Therapy (DBT®) mindfulness skills training technique and whether they would show any benefit. Forty four participants attending a mindfulness conference put on an Oculus Rift DK2 Virtual Reality helmet and floated down a calm 3D computer generated virtual river while listening to digitized DBT® mindfulness skills training instructions. On subjective questionnaires completed by the participants before and after the VR DBT® mindfulness skills training session, participants reported increases/improvements in state of mindfulness, and reductions in negative emotional states. After VR, participants reported significantly less sadness, anger, and anxiety, and reported being significantly more relaxed. Participants reported a moderate to strong illusion of going inside the 3D computer generated world (i.e., moderate to high “presence” in VR) and showed high acceptance of VR as a technique to practice mindfulness. These results show encouraging preliminary evidence of the feasibility and acceptability of using VR to practice mindfulness based on clinical expert feedback. VR is a technology with potential to increase computerized dissemination of DBT® skills training modules. Future research is warranted.

Find the full study here.

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Navarro-Haro, María V., et al. “Meditation Experts Try Virtual Reality Mindfulness: A Pilot Study Evaluation of the Feasibility and Acceptability of Virtual Reality to Facilitate Mindfulness Practice in People Attending a Mindfulness Conference.” Plos One, vol. 12, no. 11, 2017, doi:10.1371/journal.pone.0187777.

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

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

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Pizzoli, Silvia Francesca Maria, et al. “User-Centered Virtual Reality for Promoting Relaxation: An Innovative Approach.” Frontiers in Psychology, vol. 10, 2019, doi:10.3389/fpsyg.2019.00479.

Education 4.0 Immersive Learning with Spherical Videos (360°) and Virtual Reality (VR) Experiences

Abstract: 'Education 4.0' is a teaching and learning paradigm that is aligned to the challenges and disruptions of the era of 'Industry 4.0'. Education 4.0 deals with the prevalence of technologies and the problems created by information excess, it also espouses the notion that today's learners need to be trained and not merely taught by rote and memorisation drills. Today is also a period where data and information must be made accessible and open 24/7 so that learners can learn about how to find knowledge rather than to know things from their teacher's textbooks. Education 4.0 acknowledges the precepts that our learners are not alike, they do not follow pre-set paths of growth and development, they acquire and absorb knowledge differently based on their personal focus points, and they would rather know about the skills to get access to knowledge rather than having knowledge spoon-fed to them. To address these challenges and learner differences, Education 4.0 depends on the concept of 'immersive learning'. Immersive learning provides learners with an environment that is highly interactive both at the physical and virtual levels. Hence, immersive learning ‘experiences’ should replicate possible scenarios that learners will face in real life and to teach specific techniques or skills to learners based on their academic syllabus. Another factor that leads to the effectiveness of immersive learning is that realistic and relevant learning settings can have a huge impact on the inner self of a learner, as these grab a learner’s attention and activate her or his learning action better than other teaching methodologies like traditional chalk-and-talk classroom learning, and even modern ones like e-Learning and MOOCs. Whereas the concept of immersive learning does not and might not replace all existing teaching methodologies, it will enrich the learning experiences of our learners and increase the efficiency of their training process. Taking onboard the notion of gamification and putting game-based elements in what we term as virtual reality (VR) learning experiences, we can strongly argue that these experiences are the future of teaching and learning at Malaysian universities. However, there are obstacles to the wider implementation of immersive learning (educational) experiences, for instance, limited time for content development, limited technical knowledge, and particularly limited monetary resources to acquire development software and state-of-the-art hardware for the actual development of immersive contents. Moreover, the definition of what counts as engaging and interactive is constantly shifting, to the point that all learning content developers must be ready to stand at the cutting edge. That being said, the demands to create even more immersive learning experiences continue to grow, not just within the field of education but also in other professional areas and technical disciplines that need sustained exposure together with intensive training. We believe that new learning technologies and educational experiences are not merely fads of the Education 4.0 era but, in reality, they are glimpses of tomorrow’s world, based on the comments shared by end-users (university students) of a learning innovation project that we have been working on called ‘ELSA 360°-Videos’.

Find the full paper here.

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Yusof, Ahmad & Adnan, Airil & Mustafa Kamal, Nurul Nadiah & Mohd Kamal, Muhammad & Ahmad, Muhamad. (2019). Education 4.0 Immersive Learning with Spherical Videos (360°) and Virtual Reality (VR) Experiences.

Comparing Learning in Virtual Reality with Learning on a 2D Screen Using Electrostatics Activities

Abstract: Virtual Reality (VR) has the potential to overcome natural constraints and present things that would not be visible in the physical world. This makes the medium of VR a powerful tool for learning that allows users to become highly immersed in complex topics. In this paper, we compare a VR learning environment with a traditional 2D learning environment. To investigate the differences between VR and 2D learning environments, we designed two activities that help learners gain an intuitive understanding of concepts from electricity and magnetism.We performed an experiment comparing the learning that took place using these two variant. Although our quantitative learning measures did not reveal a significant difference between 2D and VR, VR was perceived by learners to have advantages.We did find significant quantitative differences in learners’ completion times. We share findings, based on the quantitative and qualitative feedback received, about what makes VR environments beneficial for learning about complex spatial topics, and propose corresponding design guidelines.

Find the full paper here.

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Greenwald, Scott, et al. “Comparing Learning in Virtual Reality with Learning on a 2D Screen Using Electrostatics Activities.” Journal of Universal Computer Science, vol. 24, no. 2, doi:10.3217/jucs-024-02-0220.

The Mediating Role of Presence Differs across Types of Spatial Learning in Immersive Technologies

Abstract: The effects of immersive technology on learning have been mixed. It is therefore important to determine the factors that affect when and why immersive technologies are and are not effective. One psychological construct proposed to explain why higher levels of immersive technology may lead to better learning compared to lower immersion is presence, or the subjective feeling of “being there.” Participants completed a spatial task in three levels of immersive technology, reported the amount of presence felt, and completed learning outcome tasks measuring three levels of spatial knowledge: landmark, route, and survey knowledge. The relationships between the level of immersive technology, presence, and spatial learning outcomes were examined. The highest immersion condition led to better performance on landmark, route, survey, and overall spatial knowledge, and also led to higher levels of presence. Higher presence led to better performance on route, survey, and overall spatial knowledge. However, presence only significantly mediated the relationship for survey knowledge, and effects of low vs. medium immersion condition on learning and presence often did not differ, despite the devices having largely different affordances. The relationship between immersion and learning is thus complex, depends on type of learning, and may be mediated by both presence and non-presence effects on cognitive load.

Find the full paper here.

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Parong, Jocelyn, et al. “The Mediating Role of Presence Differs across Types of Spatial Learning in Immersive Technologies.” Computers in Human Behavior, vol. 107, 2020, p. 106290., doi:10.1016/j.chb.2020.106290.

Virtual reality and motivation in the educational context: Bibliometric study of the last twenty years of Scopus

Abstract: Information and communication technologies have undergone great changes in all sectors of today’s society, but especially in the field of education, promoting the development of new methodologies. Among these new teaching methods is Virtual Reality, which in recent years has been of great importance as it has been shown to have a positive influence on the motivation of students and, at the same time, on the improvement of their attention. Hence the interest in carrying out this study, with the aim of analysing the current situation of the existing research in the Scopus database on the use of Virtual Reality in education to improve motivation in teaching-learning processes. The
results reveal that in the last twenty years (1998-2018) the scientific production on the subject in question has grown exponentially, going from 0.27% in 1998 to 14.48% in 2018. We conclude the study by proposing to continue researching on this subject in order to continue verifying to what extent it is possible to improve the quality of education thanks to the use of new methodologies such as Virtual Reality.

Find the full paper here.

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Soto, Natalia Campos, et al. “Virtual reality and motivation in the educational context: Bibliometric study of the last twenty years of Scopus.” Alteridad, vol. 15, no. 1, 2019, pp. 47–60., doi:10.17163/alt.v15n1.2020.04.

Virtual Memory Palaces: Immersion Aids Recall

Abstract: Virtual reality displays, such as head-mounted displays (HMD), aford us a superior spatial awareness by leveraging our vestibular and proprioceptive senses, as compared to traditional desktop displays. Since classical times, people have used memory palaces as a spatial mnemonic to help remember information by organizing it spatially and associating it with salient features in that environment. In this paper, we explore whether using virtual memory palaces in a head-mounted display with head-tracking (HMD condition) would allow a user to better recall information than when using a traditional desktop display with a mouse-based interaction (desktop condition). We found that virtual memory palaces in HMD condition provide a superior memory recall ability compared to the desktop condition. We believe this is a first step in using virtual environments for creating more memorable experiences that enhance productivity through better recall of large amounts of information organized using the idea of virtual memory palaces.

Find the full report here.

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Krokos E, Plaisant C, Varshney A. Correction to: Virtual memory palaces: immersion aids recall. Virtual Reality. 2018;23(1):17-17. doi:10.1007/s10055-018-0360-5

Investigating Learners' Attitudes Toward Virtual Reality Learning Environments in Embryology Education

Abtract: Embryology is taught to undergraduates in a variety of health sciences, largely depending on traditional teaching methods. The human embryo's development is complex and dynamic, and to digest all the related facts, students are always searching for educational tools to enhance their learning experience. Virtual Reality (VR) is a promising technology that aids in the realization of 3 Dimensional (3D) relations of structures by visualization rather than memorization. This paper utilizes a mixed method research consisting of focus group interviews, followed by a questionnaire to evaluate the current teaching methodology, identify shortfalls of traditional learning tools, and determine how VR may enhance the learning process, and the students' acceptance of introduction of this technology into their curriculum. It demonstrates that a VR embryology system would provide a valuable addition to existing educational tools, which is appealing to users, and has the potential to overcome some of the current methods' shortfalls.

Find the full study here.

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Alfalah , Salasabeel F. M., and Jannat F Falah. “ Investigating Learners' Attitudes Toward Virtual Reality Learning Environments in Embryology Education.” Vol. 13, no. 1, 2019, doi:10.5539/mas.v13n1p57.

Innovative Learning Opportunities With Virtual Reality Game Development

Abstract: This article outlines a case study of a team of secondary school students creating a commercially deployed immersive Virtual Reality (VR) game as part of their learning. Given the limited amount of relevant literature on the learning outcomes from students creating and deploying VR games to the commercial marketplace, the study adopted a grounded theory approach to explore the initial ideas, themes and constructs that emerged from a preliminary interview study. From this study, we identified the emergent constructs in their learning process as being authenticity, agency (including processes) and innovation. Although the students developed their technical skills through this activity, most of the ideas that were expressed in the interviews related to the opportunities offered by engaging with innovative technology in an authentic context. Through dealing with stakeholders, gathering and responding to feedback, understanding design requirements and the commercial aspects of VR game development and deployment, the student team created their own powerful learning experience.

Find the full paper here.

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MacCallum, Kathryn; Crow, Tyne; and Parsons, David, "INNOVATIVE LEARNING OPPORTUNITIES WITH VIRTUAL REALITY GAME DEVELOPMENT" (2019). CONF-IRM 2019 Proceedings. 31. 
https://aisel.aisnet.org/confirm2019/31

Immersive VR: A Literature Review and Infographic for Teachers

Introduction: This literature review is written for teachers with the aim of providing a snapshot of the most current research on IVR, children and school education. The methodology for the review can be found as an appendix to this document. In general, this review does not cover the extensive and interesting literature on desktop virtual reality and education or virtual worlds for learning (for a systematic review and a meta-analysis of this literature see Mikropoulos and Natsis, 2011, and Merchant et al., 2014, respectively). The main exception to this is the section on the learning affordances of virtual reality which draws on desktop VR literature. This review is structured according to the following topics: defining IVR; the learning affordances of virtual reality; IVR and school education; and the ethical and safe use of IVR and children.

Find the full review here.

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Southgate, Erica. “Immersive VR: A Literature Review and Infographic for Teachers.” VR School, 17 June 2018, vrschoolresearch.com/2018/06/17/immersive-vr-a-lit-review-and-infographic-for-teachers/.

A Case Study - The Impact of VR on Academic Performance

Objectives: This experiment aims to show the difference between traditional teaching and VR-based teaching in students’ celestial physics learning. 

Results:In Retention Test, the average score of VR group is 90, while that of the traditional teaching group is 68. The gap between the two average scores is 32.4%, higher than that in the Immediate Test 27.4% (# 4.1.1-1), suggesting that knowledge taught in traditional mode is more inclined to be forgotten, while VR-based teaching could help students get a deeper impression and maintain long-term memory because it creates a quasi-real environment, interacts with students and make students more involved in the teaching.

VR-based teaching enjoys tremendously positive reception among students. Students like it very much and students fairly like it account for 100% of all the students. In the experiment, 65% students have heard about VR, 45% students have 15 experienced VR content, most of which is VR games. This is the first time for these students to experience VR in education. The introduction of the latest VR Technology into education is very fascinating to students, who are looking forward to seeing VR-based teaching integrated in their classes.

Find the full report here

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A Case Study - The Impact of VR on Academic Performance. https://cdn.uploadvr.com/wp-content/uploads/2016/11/A-Case-Study-The-Impact-of-VR-on-Academic-Performance_20161125.pdf. Accessed April 4, 2019.

Training Situational Awareness With Virtual Reality

VR provides the ideal training tool for gaining the emotional intelligence and cognitive behavioral understanding needed to develop situational awareness.

Situational awareness involves understanding how information, events and actions around us impact our current situation and how changes might impact the future. While it is important in all settings, it is especially critical in high stakes, rapidly-changing environments such as healthcare, law enforcement, leadership, air traffic control, ship navigation, and nuclear power plant operation (to name but a few) where a bad decision could have serious or dangerous consequences.

This article originally appeared in Tech Trends.

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Maddox T, Atkinson T, Bonasio A. Training Situational Awareness With Virtual Reality. Tech Trends. https://techtrends.tech/uncategorized/training-situational-awareness-with-virtual-reality/. Published July 23, 2018. Accessed April 5, 2019.

AFFECT: Altered-Fidelity Framework for Enhancing Cognition and Training

In this paper, we present a new framework for analyzing and designing virtual reality (VR) techniques. This framework is based on two concepts – system fidelity (i.e., the degree with which real-world experiences are reproduced by a system) and memory (i.e., the formation and activation of perceptual, cognitive, and motor networks of neurons). The premise of the framework is to manipulate an aspect of system fidelity in order to assist a stage of memory. We call it the Altered-Fidelity Framework for Enhancing Cognition and Training (AFFECT). AFFECT provides nine categories of approaches to altering system fidelity to positively affect learning or training. These categories are based on the intersections of three aspects of system fidelity (interaction fidelity, scenario fidelity, and display fidelity) and three stages of memory (encoding, implicit retrieval, and explicit retrieval). In addition to discussing the details of our new framework, we show how AFFECT can be used as a tool for analyzing and categorizing VR techniques designed to facilitate learning or training. We also demonstrate how AFFECT can be used as a design space for creating new VR techniques intended for educational and training systems.

Find the full report here.

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Mcmahan RP, Herrera NS. AFFECT: Altered-Fidelity Framework for Enhancing Cognition and Training. Frontiers in ICT. 2016;3. doi:10.3389/fict.2016.00029

The utility of virtual reality and augmented reality in spine surgery

Abstract: As the number of advances in surgical techniques increases, it becomes increasingly important to assess and research the technology regarding spine surgery techniques in order to increase surgical accuracy, decrease overall length of surgery, and minimize overall radiation exposure. Currently, augmented reality and virtual reality have shown promising results in regard to their applicability beyond their current functions. At present, VR has been generally applied to a teaching and preparatory role, while AR has been utilized in surgical settings. As such, the following review attempts to provide an overview of both virtual reality and augmented reality, followed by a discussion of their current applications and future direction.

Find the full review here.

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Yoo, Joon S., et al. “The Utility of Virtual Reality and Augmented Reality in Spine Surgery.” Annals of Translational Medicine, vol. 7, no. S5, 2019, doi:10.21037/atm.2019.06.38.

Virtual Reality in Spinal Endoscopy: a Paradigm Shift in Education to Support Spine Surgeons

Background: Minimally invasive spine surgery (MISS) and endoscopic spine surgery have continually evolving indications in the cervical, thoracic, and lumbar spine. Endoscopic spine surgery entails treatment of disc disease, stenosis, spondylolisthesis, radiculopathy, and deformity. MISS involves complex motor skills in regions of variable anatomy. Simulator use has been proposed to aid in training and skill retention, preoperative planning, and intraoperative use.

Methods: A systematic review of five databases was performed for publications pertaining to the use of virtual (VR), augmented (AR), and mixed (MR) reality in MISS and spinal endoscopic surgery. Qualitative data analysis was undertaken with focus of study design, quality, and reported outcomes. Study quality was assessed using the Medical Education Research Quality Instrument (MERSQI) score and level of evidence (LoE) by a modified Oxford Centre for Evidence-Based Medicine (OCEBM) level for simulation in medicine.

Results: Thirty-eight studies were retained for data collection. Studies were of intervention-control, clinical application, and pilot or cross-sectional design. Identified articles illustrated use of VR, AR, and MR in all study designs. Procedures included pedicle cannulation and screw insertion, vertebroplasty, kyphoplasty, percutaneous transforaminal endoscopic discectomy (PTED), lumbar puncture and facet injection, transvertebral anterior cervical foraminotomy (TVACF) and posterior cervical laminoforaminotomy. Overall MERSQI score was low-to-medium [M =9.71 (SD =2.60); range, 4.5–13.5], and LoE was predominantly low given the number of purely descriptive articles, or low-quality randomized studies.

Conclusions: The current scope of VR, AR, and MR surgical simulators in MISS and spinal endoscopic surgery was described. Studies demonstrate improvement in technical skill and patient outcomes in short term follow-up. Despite this, overall study quality and levels of evidence remain low. Cohesive study design and reporting with focus on transfer validity in training scenarios, and patient derived outcome measures in clinical studies are required to further advance the field.

Find the full review here.

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Lohre, Ryan, et al. “Virtual Reality in Spinal Endoscopy: a Paradigm Shift in Education to Support Spine Surgeons.” Journal of Spine Surgery, vol. 6, no. S1, 2020, doi:10.21037/jss.2019.11.16.

Advancing Cardiac Surgery Case Planning and Case Review Conferences Using Virtual Reality in Medical Libraries: Evaluation of the Usability of Two Virtual Reality Apps

Background: Care providers and surgeons prepare for cardiac surgery using case conferences to review, discuss, and run through the surgical procedure. Surgeons visualize a patient's anatomy to decide the right surgical approach using magnetic resonance imaging and echocardiograms in a presurgical case planning session. Previous studies have shown that surgical errors can be reduced through the effective use of immersive virtual reality (VR) to visualize patient anatomy. However, inconsistent user interfaces, delegation of view control, and insufficient depth information cause user disorientation and interaction difficulties in using VR apps for case planning.

Objective: The objective of the study was to evaluate and compare the usability of 2 commercially available VR apps-Bosc (Pyrus Medical systems) and Medical Holodeck (Nooon Web & IT GmbH)-using the Vive VR headset (HTC Corporation) to evaluate ease of use, physician attitudes toward VR technology, and viability for presurgical case planning. The role of medical libraries in advancing case planning is also explored.

Methods: After screening a convenience sample of surgeons, fellows, and residents, ethnographic interviews were conducted to understand physician attitudes and experience with VR. Gaps in current case planning methods were also examined. We ran a usability study, employing a concurrent think-aloud protocol. To evaluate user satisfaction, we used the system usability scale (SUS) and the National Aeronautics and Space Administration-Task Load Index (NASA-TLX). A poststudy questionnaire was used to evaluate the VR experience and explore the role of medical libraries in advancing presurgical case planning. Semistructured interview data were analyzed using content analysis with feedback categorization.

Find the full paper here.

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Napa, Sandeep, et al. “Advancing Cardiac Surgery Case Planning and Case Review Conferences Using Virtual Reality in Medical Libraries: Evaluation of the Usability of Two Virtual Reality Apps.” JMIR Human Factors, vol. 6, no. 1, 2019, doi:10.2196/12008.

A feasibility study to determine the benefits of upper extremity virtual rehabilitation therapy for coping with chronic pain post-cancer surgery

Background: Persistent pain in shoulder and arm following post-surgical breast cancer treatment can lead to cognitive and physical deficits. Depression is also common in breast cancer survivors. Virtual reality therapy with integrative cognitive and physical rehabilitation has not been clinically trialed for this population. The novel BrightArm Duo technology improved cognition and upper extremity (UE) function for other diagnoses and has great potential to benefit individuals coping with post-surgical breast cancer pain.

Objectives: The aim of this study was to explore the feasibility of BrightArm Duo therapy for coping with post-surgical chronic pain and associated disability in breast cancer survivors with depression.

Find the full study here.

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House, Gregory et al. “A feasibility study to determine the benefits of upper extremity virtual rehabilitation therapy for coping with chronic pain post-cancer surgery.” British journal of pain vol. 10,4 (2016): 186-197. doi:10.1177/2049463716664370

Augmented Reality Training Platform for Neurosurgical Burr Hole Localization. Journal of Medical Robotics Research

Abstract: Augmented reality (AR) is used in neurosurgery to visualize lesions and plan procedures pre-operatively and intra-operatively, though its use has not been widely adopted in simulation-based neurosurgical training for the same tasks. This work defines metrics to determine performance in drill position and angle identification for neurosurgical training. The metrics were validated intra-operatively and in a simulated training environment, demonstrating that trainees identify drill position and angle faster and more accurately with AR compared with standard techniques. Training using AR and the proposed metrics stands to add value to neurosurgical curricula development.

Find the full paper here.

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Baum, Zachary & Lasso, Andras & Ryan, Sarah & Ungi, Tamas & Rae, Emily & Zevin, Boris & Levy, Ron & Fichtinger, Gabor. (2019). Augmented Reality Training Platform for Neurosurgical Burr Hole Localization. Journal of Medical Robotics Research. 10.1142/S2424905X19420017.

Navigation and visualisation with HoloLens in endovascular aortic repair

Introduction: Endovascular aortic repair (EVAR) is a minimal-invasive technique that prevents life-threatening rupture in patients with aortic pathologies by implantation of an endoluminal stent graft. During the endovascular procedure, device navigation is currently performed by fluoroscopy in combination with digital subtraction angiography. This study presents the current iterative process of biomedical engineering within the disruptive interdisciplinary project Nav EVAR, which includes advanced navigation, image techniques and augmented reality with the aim of reducing side effects (namely radiation exposure and contrast agent administration) and optimising visualisation during EVAR procedures. This article describes the current prototype developed in this project and the experiments conducted to evaluate it.

Find the full paper here.

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García-Vázquez V, von Haxthausen F, Jäckle S, et al. Navigation and visualisation with HoloLens in endovascular aortic repair. Innov Surg Sci. 2018;3(3):167–177. Published 2018 Oct 4. doi:10.1515/iss-2018-2001

HoloLens-Based AR System with a Robust Point Set Registration Algorithm

Abstract: By the standard of today’s image-guided surgery (IGS) technology, in order to check and verify the progress of the surgery, the surgeons still require divert their attention from the patients occasionally to check against the display. In this paper, a mixed-reality system for medical use is proposed that combines an Intel RealSense sensor with Microsoft’s Hololens head-mounted display system, for superimposing medical data onto the physical surface of a patient, so the surgeons do not need to divert their attention from their patients. The main idea of our proposed system is to display the 3D medical images of the patients on the actual patients themselves by placing the medical images and the patients in the same coordinate space. However, the virtual medical data may contain noises and outliers, so the transformation mapping function must be able to handle these problems. The transform function in our system is performed by the use of our proposed Denoised-Resampled-Weighted-and-Perturbed-Iterative Closest Points (DRWP-ICP) algorithm, which performs denoising and removal of outliers before aligning the pre-operative medical image data points to the patient’s physical surface position before displaying the result using the Microsoft HoloLens display system. The experimental results shows that our proposed mixed-reality system using DRWP-ICP is capable of performing accurate and robust mapping despite the presence of noise and outliers.

Find the full paper here.

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Chien JC, Tsai YR, Wu CT, Lee JD. HoloLens-Based AR System with a Robust Point Set Registration Algorithm. Sensors (Basel). 2019;19(16):3555. Published 2019 Aug 15. doi:10.3390/s19163555

Virtual reality as an adjunct to anesthesia in the operating room

Background: Advancements in virtual reality (VR) technology have resulted in its expansion into health care. Preliminary studies have found VR to be effective as an adjunct to anesthesia to reduce pain and anxiety for patients during upper gastrointestinal endoscopies, dental procedures and joint arthroplasties. Current standard care practice for upper extremity surgery includes a combination of regional anesthesia and intraoperative propofol sedation. Commonly, patients receive deep propofol sedation during these cases, leading to potentially avoidable risks of over-sedation, hypotension, upper airway obstruction, and apnea. The objective of this study is to evaluate the effectiveness of VR technology to promote relaxation for patients undergoing upper extremity surgery, thereby reducing intraoperative anesthetic requirements and improving the perioperative patient experience.

Find the full paper here.

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Faruki, A., Nguyen, T., Proeschel, S. et al. Virtual reality as an adjunct to anesthesia in the operating room. Trials 20, 782 (2019). https://doi.org/10.1186/s13063-019-3922-2

The Application of Virtual Reality and Augmented Reality in Oral & Maxillofacial Surgery

Background: Virtual reality is the science of creating a virtual environment for the assessment of various anatomical regions of the body for the diagnosis, planning and surgical training. Augmented reality is the superimposition of a 3D real environment specific to individual patient onto the surgical filed using semi-transparent glasses to augment the virtual scene.. The aim of this study is to provide an over view of the literature on the application of virtual and augmented reality in oral & maxillofacial surgery.

Methods: We reviewed the literature and the existing database using Ovid MEDLINE search, Cochran Library and PubMed. All the studies in the English literature in the last 10 years, from 2009 to 2019 were included.

Results: We identified 101 articles related the broad application of virtual reality in oral & maxillofacial surgery. These included the following: Eight systematic reviews, 4 expert reviews, 9 case reports, 5 retrospective surveys, 2 historical perspectives, 13 manuscripts on virtual education and training, 5 on haptic technology, 4 on augmented reality, 10 on image fusion, 41 articles on the prediction planning for orthognathic surgery and maxillofacial reconstruction. Dental implantology and orthognathic surgery are the most frequent applications of virtual reality and augmented reality. Virtual planning improved the accuracy of inserting dental implants using either a statistic guidance or dynamic navigation. In orthognathic surgery, prediction planning and intraoperative navigation are the main applications of virtual reality. Virtual reality has been utilised to improve the delivery of education and the quality of training in oral & maxillofacial surgery by creating a virtual environment of the surgical procedure. Haptic feedback provided an additional immersive reality to improve manual dexterity and improve clinical training.

Find the full review here.

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Ayoub, Ashraf, and Yeshwanth Pulijala. “The Application of Virtual Reality and Augmented Reality in Oral & Maxillofacial Surgery.” BMC Oral Health, vol. 19, no. 1, 2019, doi:10.1186/s12903-019-0937-8.

Intraoperative Three-dimensional Virtual Reality and Computed Tomographic Guidance in Temporomandibular Joint Arthroplasty of Syndromic Craniofacial Dysostoses

Summary: Bony ankylosis of the temporomandibular joints (TMJ) occurs in up to 28% of patients with syndromic mandibular dysostoses. Release of complete osseous ankylosis is particularly challenging due to the lack of tissue planes separating the mandible from the skull base and the presence of congenital skeletal abnormalities. One recent advance in surgical imaging technology is three-dimensional virtual reality (3D VR), now in common use in neurosurgical resections. In this study, we describe the usage of 3D VR in TMJ arthroplasty and compare 3D VR to traditional computed tomographic (CT) guidance. Pediatric patients with syndromic mandibular micrognathia including Treacher Collins, Nager, and cerebrocostomandibular syndrome were retrospectively evaluated between 2008 and 2016. Patient characteristics, complications, inpatient times, and operative times were recorded. Of the 29 children with syndromic mandibular micrognathia treated between 2008 and 2016, 7 were diagnosed with TMJ ankyloses. Four consecutive pediatric patients (mean 8.7 years) undergoing interpositional TMJ arthroplasty with Matthews device placement were retrospectively evaluated. Two patients underwent traditional CT-guided versus 3D VR-guided temporomandibular joint arthroplasty (TMJA). No statistically significant differences were found among the age, complications, or inpatient hospitalization times. The average operative time in the traditional CT guidance group was 300 minute versus 134 minutes in the 3D VR group. Three-dimensional VR is a useful preoperative planning and intraoperative guidance tool. The major difference between VR and older technologies is the improved imaging in 3 dimensions for guidance, thereby potentially decreasing operative times.

Find the full paper here.

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Bradley D, Willson T, Chang JB, et al. Intraoperative Three-dimensional Virtual Reality and Computed Tomographic Guidance in Temporomandibular Joint Arthroplasty of Syndromic Craniofacial Dysostoses. Plast Reconstr Surg Glob Open. 2019;7(9):e2388. Published 2019 Sep 10. doi:10.1097/GOX.0000000000002388

Haptic feedback improves surgeons' user experience and fracture reduction in facial trauma simulation

Abstract: Computer-assisted surgical (CAS) planning tools are available for craniofacial surgery, but are usually based on computer-aided design (CAD) tools that lack the ability to detect the collision of virtual objects (i.e., fractured bone segments). We developed a CAS system featuring a sense of touch (haptic) that enables surgeons to physically interact with individual, patient-specific anatomy and immerse in a three-dimensional virtual environment. In this study, we evaluated initial user experience with our novel system compared to an existing CAD system. Ten surgery resident trainees received a brief verbal introduction to both the haptic and CAD systems. Users simulated mandibular fracture reduction in three clinical cases within a 15 min time limit for each system and completed a questionnaire to assess their subjective experience. We compared standard landmarks and linear and angular measurements between the simulated results and the actual surgical outcome and found that haptic simulation results were not significantly different from actual postoperative outcomes. In contrast, CAD results significantly differed from both the haptic simulation and actual postoperative results. In addition to enabling a more accurate fracture repair, the haptic system provided a better user experience than the CAD system in terms of intuitiveness and self-reported quality of repair.

Find the full study here.

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Girod, Sabine, et al. “Haptic Feedback Improves Surgeons’ User Experience and Fracture Reduction in Facial Trauma Simulation.” Journal of Rehabilitation Research and Development, vol. 53, no. 5, 2016, pp. 561–570., doi:10.1682/jrrd.2015.03.0043.

A multiparametric magnetic resonance imaging-based virtual reality surgical navigation tool for robotic-assisted radical prostatectomy

Objective: Increased computational power and improved visualization hardware have generated more opportunities for virtual reality (VR) applications in healthcare. In this study, we test the feasibility of a VR-assisted surgical navigation system for robotic-assisted radical prostatectomy.

Materials and methods: The prostate, all magnetic resonance imaging (MRI) visible tumors, and important anatomic structures like the neurovascular bundles, seminal vesicles, bladder, and rectum were contoured on a multiparametric MRI using an in-house segmentation software. Three-dimensional (3-D) VR models were rendered and evaluated in a side room of the operating room. While interacting with the VR platform, a real-time stereo video capture of the in situ prostate was obtained to render a second 3-D model. The MRI-based model was then overlaid on the real-time model by using an automated alignment algorithm.

Results: Ten patients were included in this study. All MRI-based VR models were examined by surgeons immediately prior to surgery and at important steps where visualization of the tumors and their proximity to surrounding anatomic structures were critical. This was mainly during the preparation of the prostatic pedicles, neurovascular plexus, the apex, and bladder neck. All participants found the system useful, especially for tumors with locally aggressive growth patterns. For small and centrally located tumors, the system was not considered beneficial due to lack of integration into the robotic console. A fully integrated system with real-time overlays within the robotic stereo viewer was found to be the ideal scenario.

Find the full paper here.

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Mehralivand S, Kolagunda A, Hammerich K, et al. A multiparametric magnetic resonance imaging-based virtual reality surgical navigation tool for robotic-assisted radical prostatectomy. Turk J Urol. 2019;45(5):357–365. Published 2019 Sep 1. doi:10.5152/tud.2019.19133

Training Together: How Another Human Trainee’s Presence Affects Behavior during Virtual Human-Based Team Training

Despite research showing that team training can lead to strong improvements in team performance, logistical difficulties can prevent team training programs from being adopted on a large scale. A proposed solution to these difficulties is the use of virtual humans to replace missing teammates. Existing research evaluating the use of virtual humans for team training has been conducted in settings involving a single human trainee. However, in the real world, multiple human trainees would most likely train together. In this paper, we explore how the presence of a second human trainee can alter behavior during a medical team training program. Ninety-two nurses and surgical technicians participated in a medical training exercise, where they worked with a virtual surgeon and virtual anesthesiologist to prepare a simulated patient for surgery. The agency of the nurse and the surgical technician were varied between three conditions: human nurses and surgical technicians working together; human nurses working with a virtual surgical technician; and human surgical technicians working with a virtual nurse. Variations in agency did not produce statistically significant differences in the training outcomes, but several notable differences were observed in other aspects of the team’s behavior. Specifically, when working with a virtual nurse, human surgical technicians were more likely to assist with speaking up about patient safety issues that were outside of their normal responsibilities; human trainees spent less time searching for a missing item when working with a virtual partner, likely because the virtual partner was physically unable to move throughout the room and assist with the searching process; and more breaks in presence were observed when two human teammates were present. These results show that some behaviors may be influenced by the presence of multiple human trainees, though these behaviors may not impinge on core training goals. When developing virtual human-based training programs, designers should consider that the presence of other humans may reduce involvement during training moments perceived to be the responsibility of other trainees and also should consider that a virtual teammate’s limitations may cause human teammates to limit their own behaviors in corresponding ways (e.g., searching less).

Find the full report here.

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Robb A, Kleinsmith A, Cordar A, et al. Training Together: How Another Human Trainee’s Presence Affects Behavior during Virtual Human-Based Team Training. Frontiers in ICT. 2016;3. doi:10.3389/fict.2016.00017

VR in Healthcare: Medical Simulation and Experiential Interface

Abstract: Annual Review of CyberTherapy and Telemedicine (ARCTT) ISSN: 1554-8716 is published annually by the Interactive Media Institute (IMI), a 501c3 non-profit organisation, dedicated to the collaboration of interdisciplinary researchers from around the world to create, test and develop clinical tools and protocols for the medical and psychological community. IMI realizes that the mind and body work in concert to affect quality of life in individuals and works to develop technology that can be effectively used to improve the standards and reduce the cost of healthcare delivery worldwide.

You can download the full PDF here.

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Wiederhold, Brenda & Riva, Giuseppe & Wiederhold, Mark. (2015). Annual Review of CyberTherapy and Telemedicine: Virtual Reality in Healthcare: Medical Simulation and Experiential Interface. 

The Importance of Simulation in Nursing Education

Nursing education involves a practice-oriented curriculum in which emphasis is placed on both theoretical knowledge and psychomotor skills. In skill-based education, where learning through practice occupies a central role, it is important to ensure the integration of theoretical knowledge into practice. In this context, simulations represent an innovative teaching method that stimulates a number of senses at the same time among learners. Simulation is a method which can be designed to reflect real-life conditions, and which provides the opportunity to work in contexts that are closer and more representative of real settings. Depending on the clinical situation or scenario; the simulation method will involve a student or a group of students performing a number of patient care activities on a manikin, player or standardized patient. The simulation method allows students to repeatedly practice their clinical skills until they develop a sense of proficiency; to learn at their own pace; and to freely make mistakes. Simulations is an educational process that can replicate clinical practices in a safe environment. Nursing students who take part in education programs involving simulations perform less medical mistakes in clinical settings, and are able to better develop their critical thinking and clinical decision-making skills. For these reasons, we recommend that simulations, which represent an interactive learning method, are rendered more common in institutions providing nursing education.

Find the full paper here.

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Eyikara, Evrim, and Zehra Gocmen Baykara. “The Importance of Simulation in Nursing Education.” World Journal on Educational Technology: Current Issues, vol. 9, no. 1, 2017, p. 02., doi:10.18844/wjet.v9i1.543.

Validation studies of virtual reality simulation performance metrics for mechanical thrombectomy in ischemic stroke

Introduction: Mechanical thrombectomy (MT) has transformed the treatment of ischemic stroke. However, patient access to MT may be limited due to a shortage of doctors specifically trained to perform MT. The studies reported here were done to (1) develop, operationally define, and seek consensus from procedure experts on the metrics which best characterize a reference procedure for the performance of an MT for ischemic stroke and (2) evaluate their construct validity when implemented in a virtual reality (VR) simulation.

Methods: In study 1, the metrics for a reference approach to an MT procedure for ischemic stroke of 10 phases, 46 steps, and 56 errors and critical errors, were presented to an international Delphi panel of 21 consultant level interventional neuroradiologists (INRs). In study 2, the metrics were used to assess 8 expert and 10 novice INRs performing a VR simulated routine MT procedure.

Results: In study 1, the Delphi panel reached consensus on the appropriateness of the procedure metrics for a reference approach to MT in ischemic stroke. Group differences in median scores in study 2 demonstrated that experienced INRs performed the case 19% faster (P=0.029), completed 40% more procedure phases (P=0.009), 20% more steps (P=0.012), and made 42% fewer errors (P=0.016) than the novice group.

Find the full study here.

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Crossley, Robert, et al. “Validation Studies of Virtual Reality Simulation Performance Metrics for Mechanical Thrombectomy in Ischemic Stroke.” Journal of NeuroInterventional Surgery, vol. 11, no. 8, 2019, pp. 775–780., doi:10.1136/neurintsurg-2018-014510.

A preliminary study of a novel emergency department nursing triage simulation for research applications

Background: Studying the effect on functioning of the emergency department of disasters with a potential impact on staff members themselves usually involves table top and simulated patient exercises. Computerized virtual reality simulations have the potential to configure a variety of scenarios to determine likely staff responses and how to address them without intensive utilization of resources. To decide whether such studies are justified, we determined whether a novel computer simulation has the potential to serve as a valid and reliable model of on essential function in a busy ED.

Find the full study here.

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Dubovsky SL, Antonius D, Ellis DG, et al. A preliminary study of a novel emergency department nursing triage simulation for research applications. BMC Res Notes. 2017;10(1):15. Published 2017 Jan 3. doi:10.1186/s13104-016-2337-3

State of Simulation in Healthcare Education: An Initial Survey in Beijing

Background and Objectives: In 2013, medical error was the third leading cause of death in the United States. In China, as in the case with the United States, training and assessment are developing as a strategy to reduce the occurrence of such errors. The objective of this study was to assess the current state of the use of simulation-based training in Beijing and to explore the barriers to further development.

Methods: This study included hospitals in Beijing accredited by the Standardized Residency Training (SRT) program. The questionnaire was designed online and distributed to the SRT management departments by e-mail or instant message.

Results: Thirty hospitals were invited to participate in this survey, and 15 responses were completed and met the inclusion criteria. Task trainers (15/15), full-scale mannequins (14/15), standardized patients (12/15), and virtual reality workstations (11/15) were the most common types of simulation modalities available for use. Among the given specialties for SRT, the availability of simulation courses was 2/2 for pediatric internal medicine, 1/1 for pediatric surgery, 10/11 for surgery, 11/14 for internal medicine, 7/9 for anesthesiology, 6/8 for emergency medicine, and 3/9 for obstetrics/gynecology. Of the 13 institutions with available simulation curricula, 12/13 had simulation focused on proficiency-based skill training, 11/13 had medical knowledge learning, 10/13 had skill competency assessment. The main targeted trainees in these hospitals were residents (or postgraduate residents) and medical students (or interns). The top 2 barriers were the shortage of sustainable financial resources (12/15) and advocacy from their institutional authorities (7/15).

Find the full paper here.

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Zhao Z, Niu P, Ji X, Sweet RM. State of Simulation in Healthcare Education: An Initial Survey in Beijing. JSLS. 2017;21(1):e2016.00090. doi:10.4293/JSLS.2016.00090

A ‘mixed reality’ simulator concept for future Medical Emergency Response Team training

Abstract: The UK Defence Medical Service's Pre-Hospital Emergency Care (PHEC) capability includes rapid-deployment Medical Emergency Response Teams (MERTs) comprising tri-service trauma consultants, paramedics and specialised nurses, all of whom are qualified to administer emergency care under extreme conditions to improve the survival prospects of combat casualties. The pre-deployment training of MERT personnel is designed to foster individual knowledge, skills and abilities in PHEC and in small team performance and cohesion in ‘mission-specific’ contexts. Until now, the provision of airborne pre-deployment MERT training had been dependent on either the availability of an operational aircraft (eg, the CH-47 Chinook helicopter) or access to one of only two ground-based facsimiles of the Chinook's rear cargo/passenger cabin. Although MERT training has high priority, there will always be competition with other military taskings for access to helicopter assets (and for other platforms in other branches of the Armed Forces). This paper describes the development of an inexpensive, reconfigurable and transportable MERT training concept based on ‘mixed reality’ technologies—in effect the ‘blending’ of real-world objects of training relevance with virtual reality reconstructions of operational contexts.

Find the full study here.

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Stone RJ, Guest R, Mahoney P, Lamb D, Gibson C. A ‘mixed reality’ simulator concept for future Medical Emergency Response Team training. Journal of the Royal Army Medical Corps. 2017;163(4):280-287. doi:10.1136/jramc-2016-000726

Human patient simulators and interactive case studies: a comparative analysis of learning outcomes and student perceptions

Abstract: Although human patient simulators provide an innovative teaching method for nursing students, they are quite expensive. To investigate the value of this expenditure, a quantitative, quasi-experimental, two-group pretest and posttest design was used to compare two educational interventions: human patient simulators and interactive case studies. The sample (N = 49) consisted of students from baccalaureate, accelerated baccalaureate, and diploma nursing programs. Custom-designed Health Education Systems, Inc examinations were used to measure knowledge before and after the implementation of the two educational interventions. Students in the human patient simulation group scored significantly higher than did those in the interactive case study group on the post-test Health Education Systems, Inc examination, and no significant difference was found in student scores among the three types of nursing programs that participated in the study. Data obtained from a questionnaire administered to participants indicated that students responded favorably to the use of human patient simulators as a teaching method.

Find the full analysis here.

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Howard, Valerie Michele, et al. “Human Patient Simulators and Interactive Case Studies.” CIN: Computers, Informatics, Nursing, vol. 28, no. 1, 2010, pp. 42–48., doi:10.1097/ncn.0b013e3181c04939.

Economic analysis of implementing virtual reality therapy for pain among hospitalized patients

Abstract: Virtual reality (VR) has emerged as a novel and effective non-pharmacologic therapy for pain, and there is growing interest to use VR in the acute hospital setting. We sought to explore the cost and effectiveness thresholds VR therapy must meet to be cost-saving as an inpatient pain management program. The result is a framework for hospital administrators to evaluate the return on investment of implementing inpatient VR programs of varying effectiveness and cost. Utilizing decision analysis software, we compared adjuvant VR therapy for pain management vs. usual care among hospitalized patients. In the VR strategy, we analyzed potential cost-savings from reductions in opioid utilization and hospital length of stay (LOS), as well as increased reimbursements from higher patient satisfaction as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The average overall hospitalization cost-savings per patient for the VR program vs. usual care was $5.39 (95% confidence interval -$11.00 to $156.17). In a probabilistic sensitivity analysis across 1000 hypothetical hospitals of varying size and staffing, VR remained cost-saving in 89.2% of trials. The VR program was cost-saving so long as it reduced LOS by ≥14.6%; the model was not sensitive to differences in opioid use or HCAHPS. We conclude that inpatient VR therapy may be cost-saving for a hospital system primarily if it reduces LOS. In isolation, cost-savings from reductions in opioid utilization and increased HCAHPS-related reimbursements are not sufficient to overcome the costs of VR.

Find the full study here.

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Delshad, Sean D., et al. “Economic Analysis of Implementing Virtual Reality Therapy for Pain among Hospitalized Patients.” Npj Digital Medicine, vol. 1, no. 1, 2018, doi:10.1038/s41746-018-0026-4.

Virtual Reality as an Analgesic for Acute and Chronic Pain in Adults: a Systematic Review and Meta-Analysis

Background: Previous studies have shown that virtual reality (VR) is effective in reducing acute and chronic pain both in adults and in children. Given the emergence of new VR technology, and the growing body of research surrounding VR and pain management, an updated systematic review is warranted. 

Purpose: The purpose of this systematic review is to compare the effectiveness of VR in reducing acute and chronic pain in adults. 

Data Sources: A search was conducted in three databases (PubMed, CINAHL, Trip) using standardized search terms. 

Study Selection: Twenty experimental and quasi-experimental trials published between January 2007 and December 2018 were included based on prespecified inclusion and exclusion criteria. Pain intensity was the primary outcome. 

Data Extraction: We extracted data and appraised the quality of articles using either the PEDro or Modified Downs and Black risk of bias tools. 

Data Synthesis: The majority of studies supported the use of VR to reduce acute pain both during the procedure and immediately after. Numerous studies found VR reduced chronic pain during VR exposure but there is insufficient evidence to support lasting analgesia. There was considerable variability in patient population, pain condition and dosage of VR exposure. 

Limitations: Due to heterogeneity, we were unable to perform meta-analyses for all study populations and pain conditions. 

Conclusions: VR is an effective treatment for reducing acute pain. There is some research that suggests VR can reduce chronic pain during the intervention; however, more evidence is needed to conclude that VR is effective for lasting reductions in chronic pain.

Find the full review here.

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Mallari, Brian, et al. “Virtual Reality as an Analgesic for Acute and Chronic Pain in Adults: a Systematic Review and Meta-Analysis.” Journal of Pain Research, Volume 12, 2019, pp. 2053–2085., doi:10.2147/jpr.s200498.

Design Strategies for Virtual Reality Interventions for Managing Pain and Anxiety in Children and Adolescents: Scoping Review

Background: Virtual reality (VR) technology has been explored in the health sector as a novel tool for supporting treatment side effects, including managing pain and anxiety. VR has recently become more available with the launch of low-cost devices and apps.

Objective: This study aimed to provide an updated review of the research into VR use for pain and anxiety in pediatric patients undergoing medical procedures. Specifically, we wanted to gain an understanding of the techniques and goals used in selecting or designing VR apps in this context.

Methods: We performed a scoping review. To identify relevant studies, we searched three electronic databases. Two authors screened the titles and abstracts for relevance and eligibility criteria.

Results: Overall, 1386 articles published between 2013 and 2018 were identified. In total 18 articles were included in the review, with 7 reporting significant reduction in pediatric pain or anxiety, 3 testing but finding no significant impact of the VR apps employed, and the rest not conducting any test of significance. We identified 9 articles that were based on VR apps specifically designed and tailored for pediatric patients. The findings were analyzed to develop a holistic model and describe the product, experience, and intervention aspects that need to be considered in designing such medical VR apps.

Find the full review here.

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Ahmadpour N, Keep M, Janssen A, Rouf AS, Marthick M Design Strategies for Virtual Reality Interventions for Managing Pain and Anxiety in Children and Adolescents: Scoping Review
JMIR Serious Games 2020;8(1):e14565
URL: https://games.jmir.org/2020/1/e14565
DOI: 10.2196/14565
PMID: 32012042

Randomized, Crossover Study of Immersive Virtual Reality to Decrease Opioid Use During Painful Wound Care Procedures in Adults

Abstract: The objective of this study was to evaluate the effect of immersive virtual reality (IVR) distraction therapy during painful wound care procedures in adults on the amount of opioid medications required to manage pain. A convenience sample of consenting, adult inpatients requiring recurrent painful wound care procedures was studied. Using a within-subject, randomized controlled trial study design, 2 sequential wound procedures were compared, 1 with IVR distraction therapy and 1 without IVR. Total opioid medications administered before and during the wound procedures were recorded and pain and anxiety were rated before and after the 2 wound procedures. The IVR intervention included the wearing of virtual reality goggles and participation in an immersive, computer generated, interactive, 3-dimensional virtual world program. Data were analyzed with Student's t test and chi-square analysis, with P < 0.05 considered significant. A total of 18 patients were studied, with 12 completing both study wound procedures and 6 completing a single wound procedure. The amount of opioid administered before each of the 2 wound procedures was similar with and without IVR. Total opioid administration during the dressing procedures with IVR was significantly less than when no IVR was used, 17.9 ± 6.0 and 29.2 ± 4.5 mcg/kg fentanyl, respectively (t = -2.7; df = 14; P = 0.02). Two of 15 patients (11%) requested more than 1 opioid rescue dose with IVR and 9 of 15 patients (60%) requested more than 1 rescue dose without IVR. Seventy-five percentage of participants stated that they would want to use IVR with future dressing changes. Pain and anxiety scores were similar for the wound procedures with and without IVR (P > 0.05). IVR significantly reduced the amount of opioid medication administered during painful wound care procedures when IVR was used compared with no IVR. Since pain scores were similar before and after the wound procedures with IVR and without IVR, the 39% reduction in opioid medication during IVR supports its use as a pain distraction therapy during painful procedures.

Find the full study here.

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Mcsherry, Theresa, et al. “Randomized, Crossover Study of Immersive Virtual Reality to Decrease Opioid Use During Painful Wound Care Procedures in Adults.” Journal of Burn Care & Research, 2017, p. 1., doi:10.1097/bcr.0000000000000589.

A Novel Clinician-Orchestrated Virtual Reality Platform for Distraction During Pediatric Intravenous Procedures in Children With Hemophilia: Randomized Controlled Trial.

Background: Needles are frequently required for routine medical procedures. Children with severe hemophilia require intensive intravenous (IV) therapy to treat and prevent life-threatening bleeding and undergo hundreds of IV procedures. Fear of needle-related procedures may lead to avoidance of future health care and poor clinical outcomes. Virtual reality (VR) is a promising distraction technique during procedures, but barriers to commercially available VR platforms for pediatric health care purposes have prevented widespread use.

Objective: We hypothesized that we could create a VR platform that would be used for pediatric hemophilia care, allow clinician orchestration, and be safe and feasible to use for distraction during IV procedures performed as part of complex health care.

Methods: We created a VR platform comprising wireless, adjustable, disposable headsets and a suite of remotely orchestrated VR games. The platform was customized for a pediatric hemophilia population that required hands-free navigation to allow access to a child’s hands or arms for procedures. A hemophilia nurse observing the procedure performed orchestration. The primary endpoint of the trial was safety. Preliminary feasibility and usability of the platform were assessed in a single-center, randomized clinical trial from June to December 2016. Participants were children with hemophilia aged 6-18 years. After obtaining informed consent, 25 patients were enrolled and randomized. Each subject, 1 caregiver, and 1 hemophilia nurse orchestrator assessed the degree of preprocedural nervousness or anxiety with an anchored, combined modified visual analog (VAS)/FACES scale. Each participant then underwent a timed IV procedure with either VR or standard of care (SOC) distraction. Each rater assessed the distraction methods using the VAS/FACES scale at the completion of the IV procedure, with questions targeting usability, engagement, impact on procedural anxiety, impact on procedural pain, and likability of the distraction technique. Participants, caregivers, and nurses also rated how much they would like to use VR for future procedures. To compare the length of procedure time between the groups, Mann-Whitney test was used.

Find the full study here.

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Dunn A, Patterson J, Biega CF, et al. A Novel Clinician-Orchestrated Virtual Reality Platform for Distraction During Pediatric Intravenous Procedures in Children With Hemophilia: Randomized Controlled Trial. JMIR Serious Games. 2019;7(1):e10902. Published 2019 Jan 9. doi:10.2196/10902

Immersive VR as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study

Background/Aim: Using a within-subjects, within-wound care design, this pilot study tested for the first time, whether immersive virtual reality (VR) can serve as an adjunctive non-opioid analgesic for children with large severe burn wounds during burn wound cleaning in the ICU, in a regional burn center in the United States, between 2014–2016.

Methods: Participants included 48 children from 6 years old to 17 years of age with >10% TBSA burn injuries reporting moderate or higher worst pain during no VR on Day 1. Forty-four of the 48 children were from developing Latin American countries. Patients played adjunctive SnowWorld, an interactive 3D snowy canyon in virtual reality during some portions of wound care, vs. No VR during comparable portions of the same wound care session (initial treatment condition randomized). Using Graphic Rating scales, children's worst pain ratings during “No VR” (treatment as usual pain medications) vs. their worst pain during “Yes VR” was measured during at least 1 day of wound care, and was measured for up to 10 study days the patient used VR.

Find the full study here.

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Hoffman HG, Rodriguez RA, Gonzalez M, et al. Immersive Virtual Reality as an Adjunctive Non-opioid Analgesic for Pre-dominantly Latin American Children With Large Severe Burn Wounds During Burn Wound Cleaning in the Intensive Care Unit: A Pilot Study. Front Hum Neurosci. 2019;13:262. Published 2019 Aug 8. doi:10.3389/fnhum.2019.00262

Systematic Review and Meta-analysis of Virtual Reality in Pediatrics: Effects on Pain and Anxiety

Background: Medical procedures often evoke pain and anxiety in pediatric patients. Virtual reality (VR) is a relatively new intervention that can be used to provide distraction during, or to prepare patients for, medical procedures. This meta-analysis is the first to collate evidence on the effectiveness of VR on reducing pain and anxiety in pediatric patients undergoing medical procedures.

Methods: On April 25, 2018, we searched EMBASE, MEDLINE, CENTRAL, PubMed, Web of Science, and PsycINFO with the keywords "VR," "children," and "adolescents." Studies that applied VR in a somatic setting with participants ≤21 years of age were included. VR was defined as a fully immersive 3-dimensional environment displayed in surround stereoscopic vision on a head-mounted display (HMD). We evaluated pain and anxiety outcomes during medical procedures in VR and standard care conditions.

Results: We identified 2889 citations, of which 17 met our inclusion criteria. VR was applied as distraction (n = 16) during venous access, dental, burn, or oncological care or as exposure (n = 1) before elective surgery under general anesthesia. The effect of VR was mostly studied in patients receiving burn care (n = 6). The overall weighted standardized mean difference (SMD) for VR was 1.30 (95% CI, 0.68-1.91) on patient-reported pain (based on 14 studies) and 1.32 (95% CI, 0.21-2.44) on patient-reported anxiety (based on 7 studies). The effect of VR on pediatric pain was also significant when observed by caregivers (SMD = 2.08; 95% CI, 0.55-3.61) or professionals (SMD = 3.02; 95% CI, 0.79-2.25). For anxiety, limited observer data were available.

Find the full study here.

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Eijlers, Robin, et al. “Systematic Review and Meta-Analysis of Virtual Reality in Pediatrics.” Anesthesia & Analgesia, vol. 129, no. 5, 2019, pp. 1344–1353., doi:10.1213/ane.0000000000004165.

Case Report: Pain Neuroscience Education Using Virtual Reality

Abstract: This case study describes the delivery of pain neuroscience education (PNE) in conjunction with breathing and mindfulness strategies using virtual reality (VR) for a patient suffering from chronic neck pain. The patient was an 18-year-old high school girl, following a motor vehicle collision 10 months ago. The patient has previously not responded to massage, exercise and therapeutic modalities (ultrasound and electrical stimulation). Baseline assessment revealed pain ratings of 5/10 for neck pain and 6/10 for upper back pain (Numeric Pain Rating Scale - NPRS); a pain catastrophization score of 31 (Pain Catastrophization Scale - PCS), indicating “high” levels of catastrophising and a neck disability score of 21 (Neck Disability Index - NDI) indicating moderate disability. She underwent three sessions of PNE using VR, in combination with breathing and/or mindfulness. Pre- to post-treatment measurements showed reductions in neck and upper back pain, pain catastrophization, and positive shifts in pressure pain thresholds of the lower back. Overall NDI scores improved 29%. This case study indicates that VR-delivered PNE provides comparable results to what might be expected with therapistdelivered PNE and this combined approach warrants further investigation as a means to make PNE more accessible

Find the full case report here.

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Louw, Adriaan, et al. “CASE REPORT: PAIN NEUROSCIENCE EDUCATION USING VIRTUAL REALITY.” Journal of the Physiotherapy Pain Association, 2019, ingentaconnect.com.

Virtual Reality as a Clinical Tool for Pain Management

Purpose of Review: To evaluate the use of virtual reality (VR) therapies as a clinical tool for the management of acute and chronic pain.

Recent Findings: Recent articles support the hypothesis that VR therapies can effectively distract patients who suffer from chronic pain and from acute pain stimulated in trials. Clinical studies yield promising results in the application of VR therapies to a variety of acute and chronic pain conditions, including fibromyalgia, phantom limb pain, and regional specific pain from past injuries and illnesses. Current management techniques for acute and chronic pain, such as opioids and physical therapy, are often incomplete or ineffective. VR trials demonstrate a potential to redefine the approach to treating acute and chronic pain in the clinical setting. Patient immersion in interactive virtual reality provides distraction from painful stimuli and can decrease an individual's perception of the pain. In this review, we discuss the use of VR to provide patient distraction from acute pain induced from electrical, thermal, and pressure conditions. We also discuss the application of VR technologies to treat various chronic pain conditions in both outpatient and inpatient settings.

Find the full review here.

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Pourmand, Ali, et al. “Virtual Reality as a Clinical Tool for Pain Management.” Current Pain and Headache Reports, vol. 22, no. 8, 2018, doi:10.1007/s11916-018-0708-2.

Immersive Virtual Reality and Virtual Embodiment for Pain Relief

Abstract: A significant body of experimental evidence has demonstrated that it is possible to induce the illusion of ownership of a fake limb or even an entire fake body using multisensory correlations. Recently, immersive virtual reality has allowed users to experience the same sensations of ownership over a virtual body inside an immersive virtual environment, which in turn allows virtual reality users to have the feeling of being “embodied” in a virtual body. Using such virtual embodiment to manipulate body perception is starting to be extensively investigated and may have clinical implications for conditions that involve altered body image such as chronic pain. Here, we review experimental and clinical studies that have explored the manipulation of an embodied virtual body in immersive virtual reality for both experimental and clinical pain relief. We discuss the current state of the art, as well as the challenges faced by, and ideas for, future research. Finally, we explore the potentialities of using an embodied virtual body in immersive virtual reality in the field of neurorehabilitation, specifically in the field of pain.

Find the full study here.

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Matamala-Gomez, Marta, et al. “Immersive Virtual Reality and Virtual Embodiment for Pain Relief.” Frontiers in Human Neuroscience, vol. 13, 2019, doi:10.3389/fnhum.2019.00279.

Future Directions: Advances and Implications of Virtual Environments Designed for Pain Management

Abstract: Pain symptoms have been addressed with a variety of therapeutic measures in the past, but as we look to the future, we begin encountering new options for patient care and individual health and well-being. Recent studies indicate that computer-generated graphic environments--virtual reality (VR)--can offer effective cognitive distractions for individuals suffering from pain arising from a variety of physical and psychological illnesses. Studies also indicate the effectiveness of VR for both chronic and acute pain conditions. Future possibilities for VR to address pain-related concerns include such diverse groups as military personnel, space exploration teams, the general labor force, and our ever increasing elderly population. VR also shows promise to help in such areas as drug abuse, at-home treatments, and athletic injuries.

Find the full study here.

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Wiederhold, Brenda K., et al. “Future Directions: Advances and Implications of Virtual Environments Designed for Pain Management.” Cyberpsychology, Behavior, and Social Networking, vol. 17, no. 6, 2014, pp. 414–422., doi:10.1089/cyber.2014.0197.

The Effect of Interactive Virtual Reality on Pain Perception: a Systematic Review of Clinical Studies

Purpose: The aim of this systematic review was to evaluate the effect of immersive and non-immersive interactive virtual reality on pain perception in patients with a clinical pain condition.

Methods: The following databases were searched from inception: Medline (Ovid), PsychInfo, CINAHL, Cochrane library and Web of Science. Two reviewers screened reports and extracted the data. A third reviewer acted as an arbiter. Studies were eligible if they were randomized controlled trials, quasi-randomized trials, and uncontrolled trials. Crossover and parallel-group designs were included. Risk of bias was assessed for all included studies.

Results: Thirteen clinical studies were included. The majority of studies investigated a sample of participants with chronic pain. Six were controlled trials and seven uncontrolled studies. Findings from controlled research suggest that interactive virtual reality may reduce pain associated with ankylosing spondylitis and post-mastectomy, but results are inconsistent for patients with neck pain. Findings from uncontrolled studies suggest that interactive virtual reality may reduce neuropathic limb pain, and phantom limb pain, but had no effect on nonspecific chronic back pain.

Find the full study here.

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Wittkopf, Priscilla G., et al. “The Effect of Interactive Virtual Reality on Pain Perception: a Systematic Review of Clinical Studies.” Disability and Rehabilitation, 2019, pp. 1–12., doi:10.1080/09638288.2019.1610803.

Virtual Reality Analgesia in Labor: The VRAIL Pilot Study

Findings: Compared to a standard control group, VR reduced sensory pain, affective pain, cognitive pain, and anxiety during childbirth.

You can find the full report here.

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Frey DP, Bauer ME, Bell CL, et al. Virtual Reality Analgesia in Labor. Anesthesia & Analgesia. 2018:1. doi:10.1213/ane.0000000000003649

Virtual Reality as a Distraction Technique for Pain and Anxiety among Patients with Breast Cancer: A Randomized Control Trial

Objective: The goal of this study was to assess the effectiveness of immersive virtual reality (VR) distraction technology in reducing pain and anxiety among female patients with breast cancer.

Method: A randomized control trial design was used with a sample of 80 female patients with breast cancer at a specialized cancer center in Jordan. Participants were randomly assigned into intervention and comparison groups.

Result: The study findings showed that one session of the immersive VR plus morphine made a significant reduction in pain and anxiety self-reported scores, compared with morphine alone, in breast cancer patients.

Significance of results: Immersive VR is an effective distraction intervention for managing pain and anxiety among breast cancer patients. Using immersive VR as an adjuvant intervention is more effective than morphine alone in relieving pain and anxiety; furthermore, VR is a safe intervention more than pharmacological treatment.

Find the full study here.

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Mohammad, Eslam Bani, and Muayyad Ahmad. “Virtual Reality as a Distraction Technique for Pain and Anxiety among Patients with Breast Cancer: A Randomized Control Trial.” Palliative and Supportive Care, vol. 17, no. 1, 2018, pp. 29–34., doi:10.1017/s1478951518000639.

Effects of Immersive Virtual Reality Intervention on Pain and Anxiety among Pediatric Patients Undergoing Venipuncture: a Study Protocol for a Randomized Controlled Trial

Background: Venipuncture is one of the most painful and distressing procedure experienced by pediatric patients. Evidence suggests that distraction combined with age-appropriate procedural information can effectively decrease procedural pain and anxiety in pediatric patients. Immersive virtual reality (IVR) can simultaneously provide complete distraction and procedural information to patients.

Methods: Guided by the gate control theory and Lazarus and Folkman's theory, this study aims to examine the effects of IVR intervention on reducing the pain, anxiety and stress, the duration of venipuncture, and the satisfaction of healthcare providers for the procedure. A randomized controlled trial with repeated assessments will be conducted. A total of 200 pediatric patients aged 4-12 years will be recruited from a regional public hospital and randomly assigned to either the intervention or control group. The study will use two age-appropriate IVR modules that consist of procedural information. The intervention group will receive IVR intervention, whereas the control group will receive standard care only. The cost-effectiveness of IVR intervention will be compared with that of standard care. Outcome evaluation will be conducted at four time points: 10 min before, during, immediately after, and 30 min after the procedure. Intention to treat and generalized estimating equation model will be used to analyze the data.

Find the full study here.

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Wong, Cho Lee, et al. “Effects of Immersive Virtual Reality Intervention on Pain and Anxiety among Pediatric Patients Undergoing Venipuncture: a Study Protocol for a Randomized Controlled Trial.” Trials, vol. 20, no. 1, 2019, doi:10.1186/s13063-019-3443-z.

Virtual reality for management of pain in hospitalized patients: A randomized comparative effectiveness trial

Objectives: Therapeutic virtual reality (VR) has emerged as an effective, drug-free tool for pain management, but there is a lack of randomized, controlled data evaluating its effectiveness in hospitalized patients. We sought to measure the impact of on-demand VR versus "health and wellness" television programming for pain in hospitalized patients.

Methods: We performed a prospective, randomized, comparative effectiveness trial in hospitalized patients with an average pain score of ≥3 out of 10 points. Patients in the experimental group received a library of 21 VR experiences administered using the Samsung Gear Oculus headset; control patients viewed specialized television programming to promote health and wellness. Clinical staff followed usual care; study interventions were not protocolized. The primary outcome was patient-reported pain using a numeric rating scale, as recorded by nursing staff during usual care. Pre- and post-intervention pain scores were compared immediately after initial treatment and after 48- and 72-hours.

Results: There were 120 subjects (61 VR; 59 control). The mean within-subject difference in immediate pre- and post-intervention pain scores was larger in the VR group (-1.72 points; SD 3.56) than in the control group (-0.46 points; SD 3.01); this difference was significant in favor of VR (P < .04). When limited to the subgroup of patients with severe baseline pain (≥7 points), the effect of VR was more pronounced vs. control (-3.04, SD 3.75 vs. -0.93, SD 2.16 points; P = .02). In regression analyses adjusting for pre-intervention pain, time, age, gender, and type of pain, VR yielded a .59 (P = .03) and .56 (P = .04) point incremental reduction in pain versus control during the 48- and 72-hour post-intervention periods, respectively.

Find the full study here.

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Spiegel, Brennan, et al. “Virtual Reality for Management of Pain in Hospitalized Patients: A Randomized Comparative Effectiveness Trial.” Plos One, vol. 14, no. 8, 2019, doi:10.1371/journal.pone.0219115.

Effectiveness of a Virtual Reality Intervention to Minimize Pediatric Stress and Pain Intensity during Venipuncture

Purpose: Virtual reality (VR) technology is an effective tool in treatment of acute pain. Numerous studies show the effectiveness of this method both in a clinical context and in the laboratory. However, research results on the effectiveness of VR in pediatric venipuncture pain is not conclusive-not all studies report the analgesic effect of VR. In addition to testing effectiveness of VR, we also assess the usability of a novel hands-free interface.

Design and Method: Patients of paediatric nephrology clinic (N = 38; mean age 11 years, range 7-17) participated in a posttest only between group quasi-experimental study. Participants in the treatment group received the venipuncture procedure with VR distraction. They were wearing a head-mounted Oculus DK2 HMD, and playing a game designed by the authors of the study. The game was based on Multiple Object Tracking (MOT) task, where players have to remember and simultaneously track several moving targets. MOT has been used in many studies on attention and working memory. Participants rated their pain and stress intensity on visual analogue scales (VAS) on a scale of 0 to 100 and answered a short questionnaire.

Find the full study here.

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Piskorz, Joanna, and Marcin Czub. “Effectiveness of a Virtual Reality Intervention to Minimize Pediatric Stress and Pain Intensity during Venipuncture.” Journal for Specialists in Pediatric Nursing, vol. 23, no. 1, 2017, doi:10.1111/jspn.12201.

Virtual Reality for Spinal Cord Injury-Associated Neuropathic Pain: Systematic Review

Background: Treatment of spinal cord injury (SCI)-associated neuropathic pain is challenging, with limited efficacy and no definitive options, and SCI patients often show resistance to pharmacologic treatment. Virtual reality (VR) therapy is a non-invasive, non-pharmacologic alternative with minimal adverse effects.

Objective: To investigate the effect of VR therapy on SCI-associated neuropathic pain in a systematic review

Find the full study here.

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Chi, B., et al. “Virtual Reality for Spinal Cord Injury-Associated Neuropathic Pain: Systematic Review.” Annals of Physical and Rehabilitation Medicine, vol. 62, no. 1, 2019, pp. 49–57., doi:10.1016/j.rehab.2018.09.006.

Virtual Reality Analgesia During Venipuncture in Pediatric Patients With Onco-Hematological Diseases

Background: Venipuncture is described by children as one of the most painful and frightening medical procedures.

Objective: To evaluate the effectiveness of Virtual Reality (VR) as a distraction technique to help control pain in children and adolescents undergoing venipuncture.

Methods: Using a within-subjects design, fifteen patients (mean age 10.92, SD = 2.64) suffering from oncological or hematological diseases received one venipuncture with “No VR” and one venipuncture with “Yes VR” on two separate days (treatment order randomized). “Time spent thinking about pain”, “Pain Unpleasantness”, “Worst pain” the quality of VR experience, fun during the venipuncture and nausea were measured.

Results: During VR, patients reported significant reductions in “Time spent thinking about pain,” “Pain unpleasantness,” and “Worst pain”. Patients also reported significantly more fun during VR, and reported a “Strong sense of going inside the computer-generated world” during VR. No side effects were reported.

Conclusion: VR can be considered an effective distraction technique for children and adolescents’ pain management during venipuncture. Moreover, VR may elicit positive emotions, more than traditional distraction techniques. This could help patients cope with venipuncture in a non-stressful manner. Additional research and development is needed.

Find the full study here.

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Atzori B, Hoffman HG, Vagnoli L, et al. Virtual Reality Analgesia During Venipuncture in Pediatric Patients With Onco-Hematological Diseases. Frontiers in Psychology. 2018;9. doi:10.3389/fpsyg.2018.02508

Assessing the feasibility of implementing low-cost virtual reality therapy during routine burn care

Abstract: Burn care often involves procedures that result in significant pain experiences for patients which, in turn, can lead to poorer physical and psychological health outcomes. Distraction and virtual reality (VR) are an effective adjunct to pharmacological interventions in reducing pain. Much of the research that has demonstrated efficacy for VR in burn care has involved expensive and extensive technology. Thus, identifying cost-effective, feasible, acceptable, and effective approaches to apply distraction within routine burn care is important. The objective of this mixed-methods study was to evaluate key stakeholder (i.e., patients, providers) perceptions of feasibility, acceptability, and effectiveness for the use of low-cost VR technology during routine burn care with adult patients. Ten adult patients used VR during burn care dressing changes in an outpatient clinic setting, after which they completed a satisfaction survey and individual qualitative interview. Providers also completed a satisfaction/perception survey after each participant's care. Quantitative and qualitative results from both patient and provider perspectives consistently supported the feasibility and utility of applying low-cost VR technology in this outpatient burn clinic setting. Special considerations (e.g., aspects to consider when choosing an apparatus or application) stemming from stakeholder feedback are discussed.

Find the full report here.

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Ford CG, Manegold EM, Randall CL, Aballay AM, Duncan CL. Assessing the feasibility of implementing low-cost virtual reality therapy during routine burn care. Burns. 2018;44(4):886-895. doi:10.1016/j.burns.2017.11.020

Virtual Reality Interventions for Acute and Chronic Pain Management

Abstract: Virtual Reality (VR) is now consumer ready and nearing ubiquity. In terms of clinical applications, several studies suggest that VR can be effective as a complementary adjunct or alternative non-pharmacologic analgesic in a range of pain-inducing procedures and in management of chronic pain. The increasing affordability and quality of portable VR headsets and the ongoing utility of pain therapy signals an exciting future for the use of VR for analgesia. However, further research is needed to establish its long-term benefits if VR is to be adopted into mainstream protocols for analgesia management. This research requires a range of study designs with collection of patient self-report and clinical data together to develop bespoke interventions for different cohorts.

Find the full study here.

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Ahmadpour, Naseem, et al. “Virtual Reality Interventions for Acute and Chronic Pain Management.” The International Journal of Biochemistry & Cell Biology, vol. 114, 2019, p. 105568., doi:10.1016/j.biocel.2019.105568.

Adjunctive VR for procedural pain management of burn patients during dressing change or physical therapy

Abstract: Dressing change and physical therapy are extremely painful procedures for burn patients. Adjunctive virtual reality therapy reportedly reduces pain when added to analgesics, but a summary analysis of the data has yet to be performed. We conducted this systematic review and meta-analysis of randomized controlled trials to verify the pain-reducing efficacy of virtual reality among burn patients undergoing dressing change or physical therapy. We searched MEDLINE (via PubMed), EMBASE (via OVID), and the Cochrane Central Register of Controlled Trials (via OVID) for relevant trials based on predetermined eligibility criteria from database establishment to February 2018. Two reviewers screened citations and extracted data independently. The quality of the included studies was evaluated according to the Cochrane Handbook, whereas statistical heterogeneity was assessed using chi-square tests and I2 statistics. Review Manager 5.3 was used for statistical analysis. Thirteen randomized controlled trials with 362 patients who underwent 627 burn dressing change or physical therapy sessions were included. The additional use of virtual reality significantly reduced pain intensity, time spent thinking about pain, and unpleasantness, and was more fun compared with that of using analgesics alone. Virtual reality is an effective pain reduction measurement added to analgesics for burn patients undergoing dressing change or physical therapy. However, multicenter, parallel group design randomized controlled trials are still required.

Find the full report here.

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Luo H, Cao C, Zhong J, Chen J, Cen Y. Adjunctive virtual reality for procedural pain management of burn patients during dressing change or physical therapy: A systematic review and meta-analysis of randomized controlled trials. Wound Repair and Regeneration. 2018;27(1):90-101. doi:10.1111/wrr.1

Virtual Reality for Management of Pain in Hospitalized Patients

Objective: The objective of the study was to measure the impact of a onetime 3D VR intervention versus a two-dimensional (2D) distraction video for pain in hospitalized patients.

Conclusions: Use of VR in hospitalized patients significantly reduces pain versus a control distraction condition. These results indicate that VR is an effective and safe adjunctive therapy for pain management in the acute inpatient setting; future randomized trials should confirm benefit with different visualizations and exposure periods.

Find the full report here.

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Tashjian VC, Mosadeghi S, Reid MW, Howard A, Lopez M, Spiegel B. Virtual Reality Reduces Abdominal Pain in Hospitalized Patients: Results of a Controlled Trial. Gastroenterology. 2017;152(5). doi:10.1016/s0016-5085(17)30727-8

A Discussion of the Use of Virtual Reality in Dementia

Dementia is a multifaceted disorder that impairs cognitive functions such as memory, language, and executive functions necessary to plan, organize, and prioritize tasks required for goal-directed behaviours. Ninety percent of persons with dementia present with dementia of the Alzheimer’s type, vascular dementia, diffuse Lewy body dementia, or frontotemporal dementia [1]. All of these conditions affect the neurological functioning of the brain with different pathologies resulting in different clinical presentations [1]. In most, if not all cases, individuals with dementia experience difficulties interacting with their physical and social environments. The current chapter supports the use of virtual reality to explore the nature of these interactions.

Find the full text here.

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Garcia, Linda, et al. “A Discussion of the Use of Virtual Reality in Dementia.” Virtual Reality in Psychological, Medical and Pedagogical Applications, 2012, doi:10.5772/46412.

A Review of the Application of Virtual Reality Technology in the Diagnosis and Treatment of Cognitive Impairment

Abstract: At present, with the development of an aging society and an increase in the number of elderly people, in order to ensure the ability and enthusiasm of the elderly to live independently, it is necessary to ensure that they can understand the world in a normal way. More and more elderly people have cognitive impairment, and virtual reality (VR) technology is more effective in cognitive diagnosis and treatment than traditional methods. This review article describes some studies on cognitive diagnosis and training for the elderly, and puts forward some suggestions for current studies, in the hopes that VR technology can be better applied to cognitive diagnosis and training.

Find the full review here.

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Liu, Yao, et al. “A Review of the Application of Virtual Reality Technology in the Diagnosis and Treatment of Cognitive Impairment.” Frontiers in Aging Neuroscience, vol. 11, 2019, doi:10.3389/fnagi.2019.00280.

A Review of the Application of Virtual Reality Technology in the Diagnosis and Treatment of Cognitive Impairment

Abstract: At present, with the development of an aging society and an increase in the number of elderly people, in order to ensure the ability and enthusiasm of the elderly to live independently, it is necessary to ensure that they can understand the world in a normal way. More and more elderly people have cognitive impairment, and virtual reality (VR) technology is more effective in cognitive diagnosis and treatment than traditional methods. This review article describes some studies on cognitive diagnosis and training for the elderly, and puts forward some suggestions for current studies, in the hopes that VR technology can be better applied to cognitive diagnosis and training.

Find the full paper here.

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Liu, Yao, et al. “A Review of the Application of Virtual Reality Technology in the Diagnosis and Treatment of Cognitive Impairment.” Frontiers in Aging Neuroscience, vol. 11, 2019, doi:10.3389/fnagi.2019.00280.

Older Adults With Cognitive and/or Physical Impairments Can Benefit From Immersive Virtual Reality Experiences: A Feasibility Study

Background: Older adults living in long term care, rehabilitation hospitals, and seniors' residences often experience reduced mobility, sometimes resulting in confinement indoors and isolation, which can introduce or aggravate symptoms of depression, anxiety, loneliness, and apathy. As Virtual Reality (VR) technologies become increasingly accessible and affordable, there is a unique opportunity to enable older adults to escape their restricted physical realities and be transported to both stimulating and calming places which may improve their general well-being. To date no robust evaluations of the use of immersive VR therapy [experienced through a head-mounted-display (HMD)] for older adults within these settings have been reported. VR-therapy may prove to be a safe, inexpensive, non-pharmacological means of managing depressive symptoms and providing engagement and enjoyment to this rapidly growing demographic.

Find the full paper here.

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Appel, Lora, et al. “Older Adults With Cognitive and/or Physical Impairments Can Benefit From Immersive Virtual Reality Experiences: A Feasibility Study.” Frontiers in Medicine, vol. 6, 2020, doi:10.3389/fmed.2019.00329.

Neuropsychological Assessment of Older Adults With Virtual Reality: Association of Age, Schooling, and General Cognitive Status

The development of neuropsychological assessment methods using virtual reality (VR) is a valid and promising option for the detection of cognitive impairment in the older people, focusing on activities composed of tasks of multiple demands. This study verified the association of age, schooling, and general cognitive status on the performance of neurologically healthy older adults in ECO-VR, a VR task of multiple demands for neuropsychological assessment. A total of 111 older adults answered a sociodemographic questionnaire, the Mini Mental State Examination, the Vocabulary subtest of the Wechsler Intelligence Scale for Adults (third edition), and the ECO-VR. Correlation analyses, multiple linear regression, and comparisons between groups (effects by age and schooling groups) were used to evaluate the results. The ECO-VR total score was significantly associated with age, years of education, MMSE, and Vocabulary subtest. The linear regression models identified that age was the main predictor for total score and rule breaking of ECO-VR. According to the univariate analysis, it was identified the main effect of age group and schooling group in the total ECO-VR score, but there was no interaction effect. The results are discussed in order to understand the role of sociodemographic characteristics in the performance of older adults in a VR task of multiple demands. It was also verified the possibility use of VR for neuropsychological assessment of older adults.

Find the full study here.

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Oliveira, Camila R., et al. “Neuropsychological Assessment of Older Adults With Virtual Reality: Association of Age, Schooling, and General Cognitive Status.” Frontiers in Psychology, vol. 9, 2018, doi:10.3389/fpsyg.2018.01085.

An Immersive Virtual Reality Platform for Assessing Spatial Navigation Memory in Predementia Screening: Feasibility and Usability Study

Background: Traditional methods for assessing memory are expensive and have high administrative costs. Memory assessment is important for establishing cognitive impairment in cases such as detecting dementia in older adults. Virtual reality (VR) technology can assist in establishing better quality outcome in such crucial screening by supporting the well-being of individuals and offering them an engaging, cognitively challenging task that is not stressful. However, unmet user needs can compromise the validity of the outcome. Therefore, screening technology for older adults must address their specific design and usability requirements.

Objective: This study aimed to design and evaluate the feasibility of an immersive VR platform to assess spatial navigation memory in older adults and establish its compatibility by comparing the outcome to a standard screening platform on a personal computer (PC).

Methods: VR-CogAssess is a platform integrating an Oculus Rift head-mounted display and immersive photorealistic imagery. In a pilot study with healthy older adults (N=42; mean age 73.22 years, SD 9.26), a landmark recall test was conducted, and assessment on the VR-CogAssess was compared against a standard PC (SPC) setup.

Find the full study here.

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Ijaz, Kiran, et al. “An Immersive Virtual Reality Platform for Assessing Spatial Navigation Memory in Predementia Screening: Feasibility and Usability Study.” JMIR Mental Health, vol. 6, no. 9, 2019, doi:10.2196/13887.

The effectiveness of virtual reality for people with mild cognitive impairment or dementia: a meta-analysis

Background: Virtual Reality (VR) is increasingly used in health-related fields and interventions using VR have the potential to be powerful tools in patient management. The aim of this study was to synthesize the effects of VR interventions for people with mild cognitive impairment (MCI) or dementia.

Methods: Electronic databases were searched to identify studies that used an experimental design to investigate VR intervention outcomes for patients with MCI or dementia. Studies were excluded if the intervention did not focus on VR, if relevant quantitative outcomes were not reported, or if the intended study purpose was assessment or diagnosis. Data were extracted and analyzed from studies that met criteria. To synthesize the intervention effect sizes (ES), we used random effects models to accommodate heterogeneity in the main effect and sub-group analyses. To identify the potential reason for heterogeneity and compare ES according to the moderator variables, subgroup analyses were conducted based on study characteristics and intervention outcomes.

Find the full paper here.

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Kim O, Pang Y, Kim JH. The effectiveness of virtual reality for people with mild cognitive impairment or dementia: a meta-analysis. BMC Psychiatry. 2019;19(1):219. Published 2019 Jul 12. doi:10.1186/s12888-019-2180-x

Virtual Reality Using Games for Improving Physical Functioning in Older Adults: a Systematic Review

Abstract: The use of virtual reality through exergames or active video game, i.e. a new form of interactive gaming, as a complementary tool in rehabilitation has been a frequent focus in research and clinical practice in the last few years. However, evidence of their effectiveness is scarce in the older population. This review aim to provide a summary of the effects of exergames in improving physical functioning in older adults. A search for randomized controlled trials was performed in the databases EMBASE, MEDLINE, PsyInfo, Cochrane data base, PEDro and ISI Web of Knowledge. Results from the included studies were analyzed through a critical review and methodological quality by the PEDro scale. Thirteen studies were included in the review. The most common apparatus for exergames intervention was the Nintendo Wii gaming console (8 studies), followed by computers games, Dance video game with pad (two studies each) and only one study with the Balance Rehabilitation Unit. The Timed Up and Go was the most frequently used instrument to assess physical functioning (7 studies). According to the PEDro scale, most of the studies presented methodological problems, with a high proportion of scores below 5 points (8 studies). The exergames protocols and their duration varied widely, and the benefits for physical function in older people remain inconclusive. However, a consensus between studies is the positive motivational aspect that the use of exergames provides. Further studies are needed in order to achieve better methodological quality, external validity and provide stronger scientific evidence.

Find the full study here.

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Molina, Karina, et al. “Virtual Reality Using Games for Improving Physical Functioning in Older Adults: a Systematic Review.” Journal of NeuroEngineering and Rehabilitation, vol. 11, no. 1, 2014, p. 156., doi:10.1186/1743-0003-11-156.

A systematic review of the use of virtual reality and its effects on cognition in individuals with neurocognitive disorders

Introduction: Virtual reality (VR) interventions are increasingly used in individuals with brain injuries. The objective of this study was to determine the effects of VR on overall cognitive functioning in individuals with neurocognitive disorders (NCDs).

Methods: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review of the published literature on immersive and nonimmersive VR technologies targeting cognition in minor and major NCDs was conducted: (PROSPERO registration number: CRD42019121953).

Results: A total of 22 studies were included in the review, for an aggregated sample of 564 individuals with NCDs. Most of the studies were conducted on patients who had stroke (27.3%), followed by mild cognitive impairment (22.7%) and Alzheimer's disease (13.6%). VR interventions used for cognitive rehabilitation suggested to improve cognition (e.g. memory, dual tasking, and visual attention), and secondarily to psychological functioning (e.g. reduction of anxiety, higher levels of well-being, and increased use of coping strategies)

Find the full paper here.

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Moreno A, Wall KJ, Thangavelu K, Craven L, Ward E, Dissanayaka NN. A systematic review of the use of virtual reality and its effects on cognition in individuals with neurocognitive disorders. Alzheimers Dement (N Y). 2019;5:834–850. Published 2019 Nov 22. doi:10.1016/j.trci.2019.09.016

Virtual Reality for Older Users: a Systematic Literature Review

Abstract: The use of technologies by the elderly is still restricted, especially concerning recent technologies. To better understand the older user experience, while using virtual reality technology, we performed a Systematic Literature Review. The databases selected for research were the digital libraries of ACM, IEEE, Science Direct and Google Scholar. During the literature review, we collected information about the characteristics of the participants of the studies selected, the experiences reported about the use of technology, the research method used, the technologies chosen for the tests, the results obtained and future work suggested. The main contributions of this work were to identify the state of art of virtual and augmented reality for older people, the possible applications of these technologies to them, the most used devices and also the considerations reported by previous experiences.

Find the full review here.

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Silva, Rômulo Santos, et al. “Virtual Reality for Older Users: a Systematic Literature Review.” International Journal of Virtual Reality, vol. 19, no. 1, 2019, pp. 11–25., doi:10.20870/ijvr.2019.19.1.2908.

Effectiveness of a VR-Based Tai Chi Exercise on Cognitive and Physical Function in Older Adults with Cognitive Impairment

Findings: Compared to a standard control group, a six-month VR Thai Chi program improved multiple assessments of physical function and cognitive performance.

 

Study link can be found here.

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Hsieh C-C, Lin P-S, Hsu W-C, et al. The Effectiveness of a Virtual Reality-Based Tai Chi Exercise on Cognitive and Physical Function in Older Adults with Cognitive Impairment. Dementia and Geriatric Cognitive Disorders. 2018;46(5-6):358-370.

The feasibility and positive effects of a customized video game rehabilitation program for freezing of gait and falls in Parkinson's disease patients

Background: Freezing of gait and falls represent a major burden in patients with advanced forms of Parkinson's disease (PD). These axial motor signs are not fully alleviated by drug treatment or deep-brain stimulation. Recently, virtual reality has emerged as a rehabilitation option for these patients. In this pilot study, we aim to determine the feasibility and acceptability of rehabilitation with a customized video game to treat gait and balance disorders in PD patients, and assess its effects on these disabling motor signs.

Conclusions: This study suggests that rehabilitation with a customized video game to treat gait and balance disorders is feasible, well accepted, and effective in Parkinson's patients. These data serve as preliminary evidence for further larger and controlled studies to propose this customized video game rehabilitation program at home.

Find the full report here.

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Nuic D, Vinti M, Karachi C, Foulon P, Hamme AV, Welter M-L. The feasibility and positive effects of a customised videogame rehabilitation programme for freezing of gait and falls in Parkinson’s disease patients: a pilot study. Journal of NeuroEngineering and Rehabilitation. 2018;15(1). doi:10.1186/s12984-018-0375-x

The Application Of Virtual Reality In Geriatric Mental Health: The State Of The Evidence

Conclusions: Currently, existing evidence offers clear support for the use of VR as a screening tool for cognitive impairment in older adults, and as a training tool to improve cognitive skills. VR-based tasks demonstrated validity comparable to some traditional paper-based assessments of cognition. Furthermore, there are indications that VR can play a role in delaying the onset of Alzheimer's Disease (AD), mild cognitive impairment (MCI), and other forms of dementia. More work is needed to refine VR screening capabilities for more specific diagnoses, but the potential for innovation in VR environments and tasks makes VR a promising medium to achieve this specificity. 

Find the full report here.

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Mathias L, Rahman A, Skurla M, Vahia I. The Application Of Virtual Reality In Geriatric Mental Health: The State Of The Evidence. The American Journal of Geriatric Psychiatry. 2019;27(3). doi:10.1016/j.jagp.2019.01.085

How Virtual Reality Training Supports Safer Aging

This post is the first installment in a series of blog posts that will cover how virtual reality is being used to change the aging experience for older adults, loved ones and families, and their caregivers in the years ahead.

In fact, virtual reality is already having a tremendous impact on the lives of seniors. This is in large part thanks to outstanding content and applications geared towards combating social isolation by forming connections through travel and therapeutics, for example.

We will continue to focus on the role that training plays in preparing caregivers for what's next. Professional staff and family caregivers alike, the benefits of high-quality training cannot be overstated.

Stay tuned to our blog for more updates as we explore these issues and work towards building a solution to meet the growing demands of our population.

 

 

Using Immersive Technologies with Children and Older Adult Patients

Human development and normal aging have fascinating effects on the prefrontal cortex – the region of the brain associated with working memory and executive attention.

The prefrontal cortex is slow to develop in humans, not reaching full capacity until an individual is in their mid-20s. In addition, prefrontal cortical function declines with normal aging, in many cases starting in middle age. This means that children and older adults are generally going to be less effective learners when content is presented in text or slideshow format, leading to an increase in errors and serious medical consequences in these populations.

This report was originally published in Tech Trends.

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Maddox T, Bonasio A, Barber T. Using Immersive Technologies with Children and Older Adult Patients. Tech Trends. https://techtrends.tech/tech-trends/immersive-technologies-helping-children-and-older-patients/. Published June 17, 2018. Accessed April 5, 2019.

Acceptance of immersive head-mounted virtual reality in older adults

Abstract: Immersive virtual reality has become increasingly popular to improve the assessment and treatment of health problems. This rising popularity is likely to be facilitated by the availability of affordable headsets that deliver high quality immersive experiences. As many health problems are more prevalent in older adults, who are less technology experienced, it is important to know whether they are willing to use immersive virtual reality. In this study, we assessed the initial attitude towards head-mounted immersive virtual reality in 76 older adults who had never used virtual reality before. Furthermore, we assessed changes in attitude as well as self-reported cybersickness after a first exposure to immersive virtual reality relative to exposure to time-lapse videos. Attitudes towards immersive virtual reality changed from neutral to positive after a first exposure to immersive virtual reality, but not after exposure to time-lapse videos. Moreover, self-reported cybersickness was minimal and had no association with exposure to immersive virtual reality. These results imply that the contribution of VR applications to health in older adults will neither be hindered by negative attitudes nor by cybersickness.

Find the full report here.

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Huygelier H, Schraepen B, Ee RV, Abeele VV, Gillebert CR. Acceptance of immersive head-mounted virtual reality in older adults. Scientific Reports. 2019;9(1). doi:10.1038/s41598-019-41200-6

Effectiveness, usability, and cost-benefit of a virtual reality-based telerehabilitation program for balance recovery after stroke: a randomized controlled trial

Objectives: First, to evaluate the clinical effectiveness of a virtual reality (VR)-based telerehabilitation program in the balance recovery of individuals with hemiparesis after stroke in comparison with an in-clinic program; second, to compare the subjective experiences; and third, to contrast the costs of both programs.

Design: Single-blind, randomized, controlled trial.

Setting: Neurorehabilitation unit.

Participants: Chronic outpatients with stroke (N=30) with residual hemiparesis.

Interventions: Twenty 45-minute training sessions with the telerehabilitation system, conducted 3 times a week, in the clinic or in the home.

Main Outcome Measures: First, Berg Balance Scale for balance assessment. The Performance-Oriented Mobility Assessment balance and gait subscales, and the Brunel Balance Assessment were secondary outcome measures. Clinical assessments were conducted at baseline, 8 weeks (posttreatment), and 12 weeks (follow-up). Second, the System Usability Scale and the Intrinsic Motivation Inventory for subjective experiences. Third, cost (in dollars).

Find the full study here.

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Lloréns, Roberto, et al. “Effectiveness, Usability, and Cost-Benefit of a Virtual Reality–Based Telerehabilitation Program for Balance Recovery After Stroke: A Randomized Controlled Trial.” Archives of Physical Medicine and Rehabilitation, vol. 96, no. 3, 2015, doi:10.1016/j.apmr.2014.10.019.

Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review

Abstract: Virtual reality and active video games (VR/AVGs) are promising rehabilitation tools because of their potential to facilitate abundant, motivating, and feedback-rich practice. However, clinical adoption remains low despite a growing evidence base and the recent development of clinically accessible and rehabilitation-specific VR/AVG systems. Given clinicians’ eagerness for resources to support VR/AVG use, a critical need exists for knowledge translation (KT) interventions to facilitate VR/AVG integration into clinical practice. KT interventions have the potential to support adoption by targeting known barriers to, and facilitators of, change. This scoping review of the VR/AVG literature uses the Theoretical Domains Framework (TDF) to (1) structure an overview of known barriers and facilitators to clinical uptake of VR/AVGs for rehabilitation; (2) identify KT strategies to target these factors to facilitate adoption; and (3) report the results of these strategies. Barriers/facilitators and evaluated or proposed KT interventions spanned all but 1 and 2 TDF domains, respectively. Most frequently cited barriers/facilitators were found in the TDF domains of Knowledge, Skills, Beliefs About Capabilities, Beliefs About Consequences, Intentions, Goals, Environmental Context and Resources, and Social Influences. Few studies empirically evaluated KT interventions to support adoption; measured change in VR/AVG use did not accompany improvements in self-reported skills, attitudes, and knowledge. Recommendations to target frequently identified barriers include technology development to meet end-user needs more effectively, competency development for end-users, and facilitated VR/AVG implementation in clinical settings. Subsequent research can address knowledge gaps in both clinical and VR/AVG implementation research, including on KT intervention effectiveness and unexamined TDF domain barriers.

Find the full paper here.

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Glegg SMN, Levac DE. Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review. PM R. 2018;10(11):1237–1251.e1. doi:10.1016/j.pmrj.2018.07.004

Effectiveness of the Virtual Reality on Cognitive Function of Children with Hemiplegic Cerebral Palsy

Abstract: Cerebral palsy is a term covering non-progressive motor and cognitive impairments caused by lesions of the brain. This study aims to evaluate the effectiveness of virtual reality-based rehabilitation program for children with hemiplegic cerebral palsy on cognitive functions. Ninety children (47 boys, 43 girls) with hemiplegic cerebral palsy were randomized to either study (n = 45; 11.18 ± 3.37 years) or control (n = 45; 11.06 ± 3.24 years) groups. The study group received virtual reality intervention in addition to Traditional Occupational Therapy intervention, and the control group received Traditional Occupational Therapy for 20 sessions. Both groups were evaluated by blinded assessors with Dynamic Occupational Therapy Cognitive Assessment for Children to collect information on cognitive functioning. Both groups' cognitive functions were improved after 10 weeks of interventions. The between-group comparison revealed significantly greater improvements in all subtest of cognitive functions in the virtual reality group than in the Traditional Occupational Therapy group (P < 0.001). Our results showed that 10 weeks of virtual reality-based rehabilitation enhanced cognitive functions in children with hemiplegic cerebral palsy. Using virtual reality applications in cognitive rehabilitation was recommended to improve spatial perception, praxis, visuomotor construction and thinking operations in children with cerebral palsy.

Find the full paper here.

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Aran, Orkun Tahir, et al. “Effectiveness of the Virtual Reality on Cognitive Function of Children with Hemiplegic Cerebral Palsy.” International Journal of Rehabilitation Research, 2019, p. 1., doi:10.1097/mrr.0000000000000378.

Neurorehabilitation of Spatial Memory Using Virtual Environments: A Systematic Review

Abstract: In recent years, virtual reality (VR) technologies have become widely used in clinical settings because they offer impressive opportunities for neurorehabilitation of different cognitive deficits. Specifically, virtual environments (VEs) have ideal characteristics for navigational training aimed at rehabilitating spatial memory. A systematic search, following PRISMA guidelines, was carried out to explore the current scenario in neurorehabilitation of spatial memory using virtual reality. The literature on this topic was queried, 5048 papers were screened, and 16 studies were included, covering patients presenting different neuropsychological diseases. Our findings highlight the potential of the navigational task in virtual environments (VEs) for enhancing navigation and orientation abilities in patients with spatial memory disorders. The results are promising and suggest that VR training can facilitate neurorehabilitation, promoting brain plasticity processes. An overview of how VR-based training has been implemented is crucial for using these tools in clinical settings. Hence, in the current manuscript, we have critically debated the structure and the length of training protocols, as well as a different type of exploration through VR devices with different degrees of immersion. Furthermore, we analyzed and highlighted the crucial role played by the selection of the assessment tools.

Find the full study here.

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Montana JI, Tuena C, Serino S, Cipresso P, Riva G. Neurorehabilitation of Spatial Memory Using Virtual Environments: A Systematic Review. J Clin Med. 2019;8(10):1516. Published 2019 Sep 20. doi:10.3390/jcm8101516

Game-Based Virtual Reality Interventions to Improve Upper Limb Motor Function and Quality of Life After Stroke: Systematic Review and Meta-Analysis

Abstract: Stroke is the main cause of disability in adulthood. Recent advances in virtual reality (VR) technologies have led to its increased use in the rehabilitation of stroke patients. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to determine the effectiveness of game-based reality on upper limb (UL) motor function and quality of life after stroke. In March 2018, a search of the following databases was performed: PubMed, PEDro, Web of Science, Scopus, The Cochrane Library, and Medline at EBSCO. The selection criteria were all RCTs published in English or Spanish during the past 10 years. The PEDro scale was used to evaluate the methodological quality of the studies. A total of 20 clinical trials were included in the systemic review, of which 15 contributed information to the meta-analysis. Favorable results were found for VR interventions on UL motor function (Fugl-Meyer Assessment for upper extremity, standardized mean difference [SMD] = 1.53, 95% CI [0.51–2.54]) and quality of life (functional independence measure, SMD = 0.77, 95% CI [0.05–1.49]). The results demonstrate the potential benefits of VR interventions on the recovery of UL motor function and on quality of life after stroke.

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Domínguez-Téllez, Pablo, et al. “Game-Based Virtual Reality Interventions to Improve Upper Limb Motor Function and Quality of Life After Stroke: Systematic Review and Meta-Analysis.” Games for Health Journal, vol. 9, no. 1, 2020, pp. 1–10., doi:10.1089/g4h.2019.0043.

The use of virtual reality in craving assessment and cue-exposure therapy in substance use disorders

Craving is recognized as an important diagnosis criterion for substance use disorders (SUDs) and a predictive factor of relapse. Various methods to study craving exist; however, suppressing craving to successfully promote abstinence remains an unmet clinical need in SUDs. One reason is that social and environmental contexts recalling drug and alcohol consumption in the everyday life of patients suffering from SUDs often initiate craving and provoke relapse. Current behavioral therapies for SUDs use the cue-exposure approach to suppress salience of social and environmental contexts that may induce craving. They facilitate learning and cognitive reinforcement of new behavior and entrain craving suppression in the presence of cues related to drug and alcohol consumption. Unfortunately, craving often overweighs behavioral training especially in real social and environmental contexts with peer pressure encouraging the use of substance, such as parties and bars. In this perspective, virtual reality (VR) is gaining interest in the development of cue-reactivity paradigms and practices new skills in treatment. VR enhances ecological validity of traditional craving-induction measurement. In this review, we discuss results from (1) studies using VR and alternative virtual agents in the induction of craving and (2) studies combining cue-exposure therapy with VR in the promotion of abstinence from drugs and alcohol use. They used virtual environments, displaying alcohol and drugs to SUD patients. Moreover, some environments included avatars. Hence, some studies have focused on the social interactions that are associated with drug-seeking behaviors and peer pressure. Findings indicate that VR can successfully increase craving. Studies combining cue–exposure therapy with virtual environment, however, reported mitigated success so far.

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Hone-Blanchet A, Wensing T, Fecteau S. The Use of Virtual Reality in Craving Assessment and Cue-Exposure Therapy in Substance Use Disorders. Frontiers in Human Neuroscience. 2014;8. doi:10.3389/fnhum.2014.00844

What is the potential of virtual reality for poststroke sensorimotor rehabilitation?

Origin and state-of-the-art: Simulated environments have been developing since they were first introduced by Ivan Sutherland in 1965 [1], but it was not until the middle to late 1990s that virtual reality applications began to emerge as tools for cognitive and motor rehabilitation. Since that time, technological advances have outpaced scientific validation of the approach such that by the time evidence of the effectiveness of a specific technology has accumulated, the technology may already have become obsolete. Nevertheless, both technology and evidence are continuing to advance. Technological advances include higher resolution and less encumbering headmounted displays and motion tracking systems. For example, whereas previous motion tracking was mainly done with wired markers placed on different body segments that confined the user to move within a fixed environment, the accuracy and resolution of markerless, portable systems is advancing. The use of low-cost, higher resolution head-mounted displays is also making visually immersive virtual applications more accessible. However, head-mounted displays still have limitations in their field of view affecting the quality of the viewing environment, which may have implications for the formation of realistic movement patterns. Technological advances also include embedded ambient technologies capable of rendering text, graphics, and sound in relation to user actions and of monitoring real-world activity from a distance so that therapy can be accessible to those unable to travel to a clinic or treatment center. Augmented reality applications are advancing in which a range of elements such as visual graphics and sounds can be superimposed from a computer screen onto a real time environment. One advantage of augmented reality is the provision of the user with haptic feedback about object properties that is not available in virtual environments without the use of end effector accoutrements.

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Mindy F. Levin (2020) What is the potential of virtual reality for poststroke sensorimotor rehabilitation?, Expert Review of Neurotherapeutics, 20:3, 195-197, DOI: 10.1080/14737175.2020.1727741

Improving Cognitive Function after Traumatic Brain Injury: A Clinical Trial on the Potential Use of the Semi-Immersive Virtual Reality.

Abstract: Traumatic brain injury (TBI) is the most common cause of long-term disability and death among young adults, and it represents an enormous socioeconomic and healthcare burden. Our purpose is to evaluate the effects of a virtual reality training with BTs-Nirvana (BTs-N) on the recovery of cognitive functions in TBI subjects, using the interactive semi-immersive program. One hundred patients with TBI were enrolled in this study and randomized into either the Traditional Cognitive Rehabilitation Group (TCRG: n = 50) or the Virtual Reality Training Group (VRTG: n = 50). The VRTG underwent a VRT with BTs-N, whereas the TCRG received a standard cognitive treatment. Each treatment session lasted 60 minutes and was repeated three times a week for 8 weeks. All of the patients were evaluated by a specific psychometric battery before (T0) and immediately (T1) after the end of the training. VRTG and TCRG had a significant improvement in cognitive functioning and in mood, but only VRTG presented with a significant increase in cognitive flexibility and shifting skills and in selective attention. In conclusion, our results suggest that VR may be a useful and effective approach for the rehabilitation of patients with TBI, leading to better cognitive and behavioral outcomes.

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De Luca R, Maggio MG, Maresca G, et al. Improving Cognitive Function after Traumatic Brain Injury: A Clinical Trial on the Potential Use of the Semi-Immersive Virtual Reality. Behav Neurol. 2019;2019:9268179. Published 2019 Jul 30. doi:10.1155/2019/9268179

Advantages of using 3D virtual reality based training in persons with Parkinson's disease: a parallel study

Background: Parkinson’s disease (PD) is a slowly progressive neurodegenerative disease. There are mixed reports on success of physiotherapy in patients with PD. Our objective was to investigate the functional improvements, motivation aspects and clinical effectiveness when using immersive 3D virtual reality versus non-immersive 2D exergaming.

Methods: We designed a randomized parallel study with 97 patients, but only 20 eligible participants were randomized in 2 groups; the one using 3D Oculus Rift CV1 and the other using a laptop. Both groups participated in the 10-session 3 weeks training with a pick and place task in the virtual world requiring precise hand movement to manipulate the virtual cubes. The kinematics of the hand was traced with Leap motion controller, motivation effect was assessed with modified Intrinsic Motivation Inventory and clinical effectiveness was evaluated with Box & Blocks Test (BBT) and shortened Unified Parkinson’s disease rating scale (UPDRS) before and after the training. Mack-Skilling non-parametrical statistical test was used to identify statistically significant differences (p < 0.05) and Cohen’s U3 test to find the effect sizes.

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Cikajlo I, Peterlin Potisk K. Advantages of using 3D virtual reality based training in persons with Parkinson's disease: a parallel study. J Neuroeng Rehabil. 2019;16(1):119. Published 2019 Oct 17. doi:10.1186/s12984-019-0601-1

Bringing the Virtual to Reality- How Virtual Reality Can Enhance People’s Health and Social Lives

Abstract: The application of Virtual Reality (VR) has an increasing capacity to simulate everyday environments. It provides multimodal sensory stimulations that have the ability to influence the human brain to correct neurological and cognitive rehabilitation/behavioral disorders. The purpose of this research is to determine how Virtual Reality (VR) could aid the quest to eliminate or reduce mental disorders/the effects of brain injuries. The outcome suggests that appropriate applications of VR can lead the human brain to improve/reverse neurological activities that lead to mental disorders such as dementia, Alzheimer’s and brain injuries caused by accident or strokes. Cognitive rehabilitation and behavioral therapists would benefit from the application of VR to improve the therapeutic experiences of brain injury or anxiety disorder patients. The coming together of involved parties such as individuals, society, manufacturers of VR technology, neurosurgeons, neurologists and social psychology are paramount to the success of this considered approach to eliminate/reduce various types of mental disorders.

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Fisher, Eddie, et al. “Bringing the Virtual to Reality- How Virtual Reality Can Enhance People’s Health and Social Lives.” Neurology - Research & Surgery, vol. 2, no. 1, 2019.

Home-based virtual reality training after discharge from hospital-based stroke rehabilitation: a parallel randomized feasibility trial

Background: Virtual reality training (VRT) uses computer software to track a user’s movements and allow him or her to interact with a game presented on a television screen. VRT is increasingly being used for the rehabilitation of arm function, balance and walking after stroke. Patients often require ongoing therapy post discharge from inpatient rehabilitation. Outpatient therapy may be limited or inaccessible due to waiting lists, transportation issues, distance etc.; therefore, home-based VRT could provide the required therapy in a more convenient and accessible setting. The objectives of this parallel randomized feasibility trial are to determine (1) the feasibility of using VRT in the home post stroke and (2) the feasibility of a battery of quantitative and qualitative outcome measures of stroke recovery.

Methods: Forty patients who can stand for at least 2 min and are soon to be discharged from inpatient or outpatient rehabilitation post stroke are being recruited in Ottawa, Canada and being randomized to control and experimental groups. Participants in the experimental group use home-based VRT to do rehabilitative exercises for standing balance, stepping, reaching, strengthening and gentle aerobic fitness. Control group participants use an iPad with apps selected to rehabilitate cognition, hand fine motor skills and visual tracking/scanning. Both groups are instructed to perform 30 min of exercise 5 days a week for 6 weeks. VRT intensity and difficulty are monitored and adjusted remotely. Weekly telephone contact is made with all participants. Ability to recruit participants, ability to handle the technology and learn the activities, compliance, safety, enjoyment, perceived efficacy and cost of program delivery will be assessed. A battery of assessments of standing balance, gait and community integration will be assessed for feasibility of completion within this population and potential for improvement following the intervention. Effect sizes will be calculated.

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Sheehy L, Taillon-Hobson A, Sveistrup H, et al. Home-based virtual reality training after discharge from hospital-based stroke rehabilitation: a parallel randomized feasibility trial. Trials. 2019;20(1):333. Published 2019 Jun 7. doi:10.1186/s13063-019-3438-9

Non-Immersive Virtual Reality for Rehabilitation of the Older People: A Systematic Review into Efficacy and Effectivenes

Objective: the objective of this review is to analyze the advances in the field of rehabilitation through virtual reality, while taking into account non-immersive systems, as evidence have them shown to be highly accepted by older people, due to the lowest “cibersikness” symptomatology.

Data sources: a systematic review of the literature was conducted in June 2019. The data were collected from Cochrane, Embase, Scopus, and PubMed databases, analyzing manuscripts and articles of the last 10 years.

Study selection: we only included randomized controlled trials written in English aimed to study the use of the virtual reality in rehabilitation. We selected 10 studies, which were characterized by clinical heterogeneity.

Data extraction: quality evaluation was performed based on the Physioterapy Evidence Database (PEDro) scale, suggested for evidence based review of stroke rehabilitation. Of 10 studies considered, eight were randomized controlled trials and the PEDro score ranged from four to a maximum of nine.

Data synthesis: VR (Virtual Reality) creates artificial environments with the possibility of a patient interaction. This kind of experience leads to the development of cognitive and motor abilities, which usually positively affect the emotional state of the patient, increasing collaboration and compliance. Some recent studies have suggested that rehabilitation treatment interventions might be useful and effective in treating motor and cognitive symptoms in different neurological disorders, including traumatic brain injury, multiple sclerosis, and progressive supranuclear palsy.

Conclusions: as it is shown by the numerous studies in the field, the application of VR has a positive impact on the rehabilitation of the most predominant geriatric syndromes. The level of realism of the virtual stimuli seems to have a crucial role in the training of cognitive abilities. Future research needs to improve study design by including larger samples, longitudinal designs, long term follow-ups, and different outcome measures, including functional and quality of life indexes, to better evaluate the clinical impact of this promising technology in healthy old subjects and in neurological patients

Find the full review here.

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Bevilacqua, R.; Maranesi, E.; Riccardi, G.R.; Di Donna, V.; Pelliccioni, P.; Luzi, R.; Lattanzio, F.; Pelliccioni, G. Non-Immersive Virtual Reality for Rehabilitation of the Older People: A Systematic Review into Efficacy and Effectiveness. J. Clin. Med. 20198, 1882.

Virtual Reality Social Prediction Improvement and Rehabilitation Intensive Training (VR-SPIRIT) for pediatric patients with congenital cerebellar diseases: study protocol of a randomized controlled trial

Background: Patients with cerebellar malformations exhibit not only movement problems, but also important deficits in social cognition. Thus, rehabilitation approaches should not only involve the recovery of motor function but also of higher-order abilities such as processing of social stimuli. In keeping with the general role of the cerebellum in anticipating and predicting events, we used a VR-based rehabilitation system to implement a social cognition intensive training specifically tailored to improve predictive abilities in social scenarios (VR-Spirit).

Methods / Design: The study is an interventional randomised controlled trial that aims to recruit 42 children, adolescents and young adults with congenital cerebellar malformations, randomly allocated to the experimental group or the active control group. The experimental group is administered the VR-Spirit, requiring the participants to compete with different avatars in the reaching of recreational equipment and implicitly prompting them to form expectations about their playing preference. The active control group participates in a VR-training with standard games currently adopted for motor rehabilitation. Both trainings are composed by eight 45-min sessions and are administered in the GRAIL VR laboratory (Motekforce Link, Netherlands), an integrated platform that allows patients to move in natural and attractive VR environments. An evaluation session in VR with the same paradigm used in the VR-Spirit but implemented in a different scenario is administered at the beginning (T0) of the two trainings (T1) and at the end (T2). Moreover, a battery of neurocognitive tests spanning different domains is administered to all participants at T0, T2 and in a follow-up session after 2 months from the end of the two trainings (T3).

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Butti, N., Biffi, E., Genova, C. et al. Virtual Reality Social Prediction Improvement and Rehabilitation Intensive Training (VR-SPIRIT) for paediatric patients with congenital cerebellar diseases: study protocol of a randomised controlled trial. Trials 21, 82 (2020). https://doi.org/10.1186/s13063-019-4001-4

Is virtual reality beneficial for dual-task gait training in patients with Parkinson's disease? A systematic review

Abstract: This systematic review examined the evidence about the effects of virtual reality (VR) on dual-task gait training in Parkinson's disease (PD).

Methods: This study (PROSPERO registration CRD42019114736) aimed to answer the question: “Is VR beneficial for dual-task gait training in patients with PD?” We searched for studies from 2008 to 2018 on Medline/PubMed and Web of Science/Web of knowledge databases. The keywords were Parkinson AND gait training AND virtual reality OR Parkinson AND gait training AND game. A total of 55 articles were retrieved, of which 11 systematic reviews, 11 opinions, letters to the editor, posters or conferences abstracts and 17 studies not evaluating the effects of VR gait training were excluded. Three further studies addressing VR dual-task gait training in PD (found in references of studies selected) were also included. Therefore, 19 studies were included and analysed.

Find the full review here.

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Freitag F, Brucki SMD, Barbosa AF, et al. Is virtual reality beneficial for dual-task gait training in patients with Parkinson's disease? A systematic review. Dement Neuropsychol. 2019;13(3):259–267. doi:10.1590/1980-57642018dn13-030002

Wearable Augmented Reality Application for Shoulder Rehabilitation

Abstract: Augmented reality (AR) technology is gaining popularity and scholarly interest in the rehabilitation sector because of the possibility to generate controlled, user-specific environmental and perceptual stimuli which motivate the patient, while still preserving the possibility to interact with the real environment and other subjects, including the rehabilitation specialist. The paper presents the first wearable AR application for shoulder rehabilitation, based on Microsoft HoloLens, with real-time markerless tracking of the user’s hand. Potentialities and current limits of commercial head-mounted displays (HMDs) are described for the target medical field, and details of the proposed application are reported. A serious game was designed starting from the analysis of a traditional rehabilitation exercise, taking into account HoloLens specifications to maximize user comfort during the AR rehabilitation session. The AR application implemented consistently meets the recommended target frame rate for immersive applications with HoloLens device: 60 fps. Moreover, the ergonomics and the motivational value of the proposed application were positively evaluated by a group of five rehabilitation specialists and 20 healthy subjects. Even if a larger study, including real patients, is necessary for a clinical validation of the proposed application, the results obtained encourage further investigations and the integration of additional technical features for the proposed AR application.

Find the full paper here.

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Condino, S.; Turini, G.; Viglialoro, R.; Gesi, M.; Ferrari, V. Wearable Augmented Reality Application for Shoulder Rehabilitation. Electronics 20198, 1178.

Technology-assisted rehabilitation following total knee or hip replacement for people with osteoarthritis: a systematic review and meta-analysis

Background: To evaluate the effectiveness and safety of technology-assisted rehabilitation following total hip/knee replacement (THR/TKR).

Methods: Six electronic databases were searched without language or time restrictions for relevant studies: MEDLINE, EMBASE, Cochrane Library, CINAHL, SPORTDiscus, Physiotherapy Evidence Database (PEDro); from inception to November 7th, 2018. Two reviewers independently applied inclusion criteria to select eligible randomised controlled trials (RCTs) that investigated the effectiveness of technology-based interventions, compared with usual care or no intervention for people undergoing THR/TKR. Two reviewers independently extracted trial details (e.g. patients’ profile, intervention, outcomes, attrition and adverse events). Study methodological quality was assessed using the PEDro scale. Quality of evidence was critically appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach.

Results: We identified 21 eligible studies assessing telerehabilitation, game- or web-based therapy. There were 17 studies (N = 2188) in post-TKR rehabilitation and 4 studies (N = 783) in post-THR rehabilitation. Compared to usual care, technology-based intervention was more effective in reducing pain (mean difference (MD): − 0.25; 95% confidence interval (CI): − 0.48, − 0.02; moderate evidence) and improving function measured with the timed up-and-go test (MD: -7.03; 95% CI: − 11.18, − 2.88) in people undergoing TKR. No between-group differences were observed in rates of hospital readmissions or treatment-related adverse events (AEs) in those studies.

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Wang X, Hunter DJ, Vesentini G, Pozzobon D, Ferreira ML. Technology-assisted rehabilitation following total knee or hip replacement for people with osteoarthritis: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20(1):506. Published 2019 Nov 3. doi:10.1186/s12891-019-2900-x

Speed-Interactive Pedaling Training Using Smartphone Virtual Reality Application for Stroke Patients: Single-Blinded, Randomized Clinical Trial

Abstract: This study aimed to investigate the effects of speed-interactive pedaling training (SIPT) using a smartphone virtual reality application to improve lower limb motor function, trunk sitting balance, and gait in stroke patients. Forty-two patients who had previously experienced a stroke and could sit independently participated in the study. The subjects were assigned to the SIPT group (n = 21) and the control group (n = 21). The SIPT group had cycle training with SIPT for 40 min a day, five days a week, in a six-week period, in addition to conventional therapy. The control group had cycle training without SIPT and conventional therapy. The Fugl–Meyer Assessment, postural sway, modified functional reach test, trunk impairment scale, and spatiotemporal parameters of gait were used to assess the changes in lower extremity function, the static balance of sitting, the dynamic balance of sitting, and gait ability after the intervention. The Fugl–Meyer Assessment, postural sway, modified functional reach test, trunk impairment scale, and gait ability in the SIPT group were significantly better compared to that of the control group (p < 0.05). Based on this result, we propose that SIPT, which improves function, balance, and gait, could be used as an effective training method to improve patients’ functional activities in the clinical setting. The results of this study suggest that SIPT could be used as an effective training method to restore a patient’s function by improving trunk balance and motor function.

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Lee, K. Speed-Interactive Pedaling Training Using Smartphone Virtual Reality Application for Stroke Patients: Single-Blinded, Randomized Clinical Trial. Brain Sci. 20199, 295.

A Comparative Analysis of 2D and 3D Tasks for Virtual Reality Therapies Based on Robotic-Assisted Neurorehabilitation for Post-Stroke Patients

Abstract: Post-stroke neurorehabilitation based on virtual therapies are performed completing repetitive exercises shown in visual electronic devices, whose content represents imaginary or daily life tasks. Currently, there are two ways of visualization of these task. 3D virtual environments are used to get a three dimensional space that represents the real world with a high level of detail, whose realism is determinated by the resolucion and fidelity of the objects of the task. Furthermore, 2D virtual environments are used to represent the tasks with a low degree of realism using techniques of bidimensional graphics. However, the type of visualization can influence the quality of perception of the task, affecting the patient's sensorimotor performance. The purpose of this paper was to evaluate if there were differences in patterns of kinematic movements when post-stroke patients performed a reach task viewing a virtual therapeutic game with two different type of visualization of virtual environment: 2D and 3D. Nine post-stroke patients have participated in the study receiving a virtual therapy assisted by PUPArm rehabilitation robot. Horizontal movements of the upper limb were performed to complete the aim of the tasks, which consist in reaching peripheral or perspective targets depending on the virtual environment shown. Various parameter types such as the maximum speed, reaction time, path length, or initial movement are analyzed from the data acquired objectively by the robotic device to evaluate the influence of the task visualization. At the end of the study, a usability survey was provided to each patient to analysis his/her satisfaction level. For all patients, the movement trajectories were enhanced when they completed the therapy. This fact suggests that patient's motor recovery was increased. Despite of the similarity in majority of the kinematic parameters, differences in reaction time and path length were higher using the 3D task. Regarding the success rates were very similar. In conclusion, the using of 2D environments in virtual therapy may be a more appropriate and comfortable way to perform tasks for upper limb rehabilitation of post-stroke patients, in terms of accuracy in order to effectuate optimal kinematic trajectories.

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Lledó, Luis D., et al. “A Comparative Analysis of 2D and 3D Tasks for Virtual Reality Therapies Based on Robotic-Assisted Neurorehabilitation for Post-Stroke Patients.” Frontiers in Aging Neuroscience, vol. 8, 2016, doi:10.3389/fnagi.2016.00205.

Virtual reality gait training versus non-virtual reality gait training for improving participation in subacute stroke survivors: study protocol of the ViRTAS randomized controlled trial.

Background:A stroke often results in gait impairments, activity limitations and restricted participation in daily life. Virtual reality (VR) has shown to be beneficial for improving gait ability after stroke. Previous studies regarding VR focused mainly on improvements in functional outcomes. As participation in daily life is an important goal for rehabilitation after stroke, it is of importance to investigate if VR gait training improves participation. The primary aim of this study is to examine the effect of VR gait training on participation in community-living people after stroke.

Methods/Design: The ViRTAS study comprises a single-blinded, randomized controlled trial with two parallel groups. Fifty people between 2 weeks and 6 months after stroke, who experience constraints with walking in daily life, are randomly assigned to the virtual reality gait training (VRT) group or the non-virtual reality gait training (non-VRT) group. Both training interventions consist of 12 30-min sessions in an outpatient rehabilitation clinic during 6 weeks. Assessments are performed at baseline, post intervention and 3 months post intervention. The primary outcome is participation measured with the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P). Secondary outcomes are subjective physical functioning, functional mobility, walking ability, walking activity, fatigue, anxiety and depression, falls efficacy and quality of life.

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de Rooij IJM, van de Port IGL, Visser-Meily JMA, Meijer JG. Virtual reality gait training versus non-virtual reality gait training for improving participation in subacute stroke survivors: study protocol of the ViRTAS randomized controlled trial. Trials. 2019;20(1):89. Published 2019 Jan 29. doi:10.1186/s13063-018-3165-7

Gait Disorders Questionnaire-Promising Tool for Virtual Reality Designing in Patients With Parkinson's Disease

Background: Gait disorders (GD) are frequent and disabling symptoms in patients with Parkinson's disease, mostly because they significantly limit mobility and often lead to fear of falls or actual falls. Nowadays, rehabilitation is considered to be the most effective nonpharmacological approach to reduce risk of falls. Using paradigms in virtual reality (VR) is a promising tool in neurorehabilitation because of the potential improvement in motor learning and improvement in daily functioning by replicating everyday real-life scenarios.

Objective: To identify the most prevalent everyday situations which impair gait in PD that could be simulated in virtual reality (VR) environment.

Methods: A newly developed self-report questionnaire consisting of 15 binary response items (YES/NO) encompassing everyday walking situations was administered to 62 patients diagnosed with idiopathic PD according to MDS Clinical Diagnostic Criteria. We included patients able to walk unassisted for at least 10 min and without significant cognitive impairment. Mokken Scale Analysis was used to evaluate psychometric properties of the scale.

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Kosutzka Z, Kusnirova A, Hajduk M, Straka I, Minar M, Valkovic P. Gait Disorders Questionnaire-Promising Tool for Virtual Reality Designing in Patients With Parkinson's Disease. Front Neurol. 2019;10:1024. Published 2019 Sep 24. doi:10.3389/fneur.2019.01024

Effects of Full Body Exergaming in Virtual Reality on Cardiovascular and Muscular Parameters: Cross-Sectional Experiment

Background: In recent years, many studies have associated sedentary behavior in front of screens with health problems in infants, children, and adolescents. Yet options for exergaming—playing video games that require rigorous physical exercise—seem to fall short of the physical activity levels recommended by the World Health Organization.

Objective: The purpose of this study was to investigate the effect of a fully immersive virtual reality (VR)-based training system on cardiovascular and muscular parameters of young adults.

MethodsA cross-sectional experiment design was used to analyze muscle activity (surface electromyography), heart rate, perceived exertion (RPE), cybersickness symptoms, perceived workload, and physical activity enjoyment (PACES) in 33 participants performing two 5-minute flights on a new training device.

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Feodoroff, Boris, et al. “Effects of Full Body Exergaming in Virtual Reality on Cardiovascular and Muscular Parameters: Cross-Sectional Experiment.” JMIR Serious Games, vol. 7, no. 3, 2019, doi:10.2196/12324.

Virtual Reality Telerehabilitation for Postural Instability in Parkinson's Disease: A Multicenter, Single-Blind, Randomized, Controlled Trial

Introduction: Telerehabilitation enables patients to access remote rehabilitation services for patient-physiotherapist videoconferencing in their own homes. Home-based virtual reality (VR) balance training has been shown to reduce postural instability in patients with Parkinson's disease (PD). The primary aim was to compare improvements in postural stability after remotely supervised in-home VR balance training and in-clinic sensory integration balance training (SIBT).

Methods: In this multicenter study, 76 PD patients (modified Hoehn and Yahr stages 2.5–3) were randomly assigned to receive either in-home VR telerehabilitation (n = 38) or in-clinic SIBT (n = 38) in 21 sessions of 50 minutes each, 3 days/week for 7 consecutive weeks. VR telerehabilitation consisted of graded exergames using the Nintendo Wii Fit system; SIBT included exercises to improve postural stability. Patients were evaluated before treatment, after treatment, and at 1-month follow-up.

Results: Analysis revealed significant between-group differences in improvement on the Berg Balance Scale for the VR telerehabilitation group (p = 0.04) and significant Time × Group interactions in the Dynamic Gait Index (p = 0.04) for the in-clinic group. Both groups showed differences in all outcome measures over time, except for fall frequency. Cost comparison yielded between-group differences in treatment and equipment costs.

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Gandolfi M, Geroin C, Dimitrova E, et al. Virtual Reality Telerehabilitation for Postural Instability in Parkinson's Disease: A Multicenter, Single-Blind, Randomized, Controlled Trial. Biomed Res Int. 2017;2017:7962826. doi:10.1155/2017/7962826

Effect of Specific Over Nonspecific VR-Based Rehabilitation on Poststroke Motor Recovery: A Systematic Meta-analysis

Background. Despite the rise of virtual reality (VR)-based interventions in stroke rehabilitation over the past decade, no consensus has been reached on its efficacy. This ostensibly puzzling outcome might not be that surprising given that VR is intrinsically neutral to its use—that is, an intervention is effective because of its ability to mobilize recovery mechanisms, not its technology. As VR systems specifically built for rehabilitation might capitalize better on the advantages of technology to implement neuroscientifically grounded protocols, they might be more effective than those designed for recreational gaming. 

Objective.We evaluate the efficacy of specific VR (SVR) and nonspecific VR (NSVR) systems for rehabilitating upper-limb function and activity after stroke. 

Methods. We conducted a systematic search for randomized controlled trials with adult stroke patients to analyze the effect of SVR or NSVR systems versus conventional therapy (CT). 

Results. We identified 30 studies including 1473 patients. SVR showed a significant impact on body function (standardized mean difference [SMD] = 0.23; 95% CI = 0.10 to 0.36; P = .0007) versus CT, whereas NSVR did not (SMD = 0.16; 95% CI = −0.14 to 0.47; P = .30). This result was replicated in activity measures. 

Conclusions. Our results suggest that SVR systems are more beneficial than CT for upper-limb recovery, whereas NSVR systems are not. Additionally, we identified 6 principles of neurorehabilitation that are shared across SVR systems and are possibly responsible for their positive effect. These findings may disambiguate the contradictory results found in the current literature.

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Maier M, Rubio Ballester B, Duff A, Duarte Oller E, Verschure PFMJ. Effect of Specific Over Nonspecific VR-Based Rehabilitation on Poststroke Motor Recovery: A Systematic Meta-analysis. Neurorehabil Neural Repair. 2019;33(2):112–129. doi:10.1177/1545968318820169

Effects of Virtual-Reality-Augmented Cardiopulmonary Rehabilitation Programs for Patients with Cardiovascular Diseases: A Systemic Review

Abstract: Because of advancements in computer technology, virtual reality has become a novel approach to enhancing the efficacy of medical therapeutic intervention. Its extensive application has gained popularity and scholarly interest because of its real-time generation of desirable environmental and perceptual stimuli. Cardiopulmonary rehabilitation has been regarded as an integral intervention in patients who survive cardiovascular diseases. However, the adherence to and optimal efficacy of cardiopulmonary rehabilitation are often hindered by negative attitudes of participants because of the tedious nature of endurance training. In this systemic review, we comprehensively retrieved and reviewed studies combining virtual reality and cardiopulmonary rehabilitation; we included a total of six clinical studies from the review for further analysis. We explored the underlying reasons for the lack of evidence in the application of virtual reality to cardiopulmonary rehabilitation. We also delineated the problem of developing virtual reality software that is specifically for use in rehabilitation medicine. We conclude that the complexity and cost inhibit the application of virtual reality in the general population. However, augmented virtual reality seems to be a promising candidate for the next generation of cardiopulmonary rehabilitation treatment with strong compliance

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Penn, I-Wen, et al. “Effects of Virtual-Reality-Augmented Cardiopulmonary Rehabilitation Programs for Patients with Cardiovascular Diseases: A Systemic Review.” Neuropsychiatry, vol. 08, no. 05, 2018, doi:10.4172/neuropsychiatry.1000499.

Virtual rehabilitation of upper extremity function and independence for stroke: a meta-analysis

Abstract: We aimed to conduct a systematic literature review with a meta-analysis to investigate whether virtual reality (VR) approaches have beneficial effects on the upper extremity function and independent activities of stroke survivors. Experimental studies published between 2007 and 2017 were searched from two databases (EBSCOhost and PubMed). This study reviewed abstracts and assessed full articles to obtain evidence on qualitative studies. For the meta-analysis, the studies that estimated the standardized mean between the two groups analyzed the statistical values necessary for calculating the effect size. The present study also evaluated the statistical heterogeneity. In total, 34 studies with 1,604 participants were included, and the number of participants in each study ranged from 10 to 376. Nine studies were assessed to evaluate the quantitative statistical analysis for 698 patients with hemiparetic stroke. The results of the meta-analysis were as follows: The overall effect size was moderate (0.41, P<0.001). The 95% confidence interval ranged from 0.25 to 0.57. However, no significant heterogeneity and publication bias were observed. The results of this study showed that VR approaches are effective in improving upper extremity function and independent activities in stroke survivors.

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Ahn S, Hwang S. Virtual rehabilitation of upper extremity function and independence for stoke: a meta-analysis. J Exerc Rehabil. 2019;15(3):358–369. Published 2019 Jun 30. doi:10.12965/jer.1938174.087

The virtual reality working-memory-training program (VR WORK M): Description of an individualized, integrated program

Abstract: Working memory (WM), which allows us to retain information in memory during a complex task, is a cognitive function that is crucial to daily life. It can be affected by several neurological conditions, such as traumatic brain injury or stroke. Numerous studies suggest that it is possible to resolve WM deficits using targeted rehabilitation programs. Virtual reality (VR) is an innovative technology that has proven to be valuable in the evaluation and rehabilitation of cognitive functions. It potentially optimizes cognitive stimulation in a safe environment and can help improve functional activities of daily living by replicating real-life scenarios. With that in mind, this article introduces the first VR-based WM rehabilitation program. The WM training program (Virtual Reality Working-Memory-Training program, VR-WORK-M) recreates a restaurant environment where participants must complete a WM task consisting in repeating a series of items heard via a headset. The goal is to train WM by simulating a business proposal presentation. The program contains several levels of difficulty resulting from the combination of four complexity factors: (1) the type of business concerned by the proposal (e.g., opening a bakery vs. opening a flower shop); (2) the number of items to repeat (4 vs. 5 vs. 6); (3) the number of subtasks to complete before the WM task (e.g., introducing oneself vs order a drink); and (4) the modality of distractors (e.g., an auditory distractor vs. a visual distractor). VR-WORK-M includes 54 levels of difficulty to be administered in a training program over a period of four weeks, with four or five sessions per week.

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Ansado, J., Brulé, J., Chasen, C., Northoff, G., & Bouchard, S. (2018). The virtual reality working-memory-training program (VR WORK M): Description of an individualized, integrated program. Annual Review of CyberTherapy and Telemedicine2018(16), 101-117.

The Effects of Virtual Reality Training on Function in Chronic Stroke Patients: A Systematic Review and Meta-Analysis

Objective: The aim of this study was to perform a meta-analysis to examine whether virtual reality (VR) training is effective for lower limb function as well as upper limb and overall function in chronic stroke patients.

Methods: Three databases, OVID, PubMed, and EMBASE, were used to collect articles. The search terms used were “cerebrovascular accident (CVA),” “stroke”, and “virtual reality”. Consequently, twenty-one studies were selected in the second screening of meta-analyses. The PEDro scale was used to assess the quality of the selected studies.

Results: The total effect size for VR rehabilitation programs was 0.440. The effect size for upper limb function was 0.431, for lower limb function it was 0.424, and for overall function it was 0.545. The effects of VR programs on specific outcomes were most effective for improving muscle tension, followed by muscle strength, activities of daily living (ADL), joint range of motion, gait, balance, and kinematics.

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Lee HS, Park YJ, Park SW. The Effects of Virtual Reality Training on Function in Chronic Stroke Patients: A Systematic Review and Meta-Analysis. Biomed Res Int. 2019;2019:7595639. Published 2019 Jun 18. doi:10.1155/2019/7595639

Digital Therapeutics: Emerging New Therapy for Neurologic Deficits after Stroke

Abstract: Digital therapeutics is an evidence-based intervention using high-quality software, with the sole purpose of treatment. As many healthcare systems are encountering high demands of quality outcomes, the need for digital therapeutics is gradually increasing in the clinical field. We conducted review of the implications of digital therapeutics in the treatment of neurological deficits for stroke patients. The implications of digital therapeutics have been discussed in four domains: cognition, speech and aphasia, motor, and vision. It was evident that different forms of digital therapeutics such as online platforms, virtual reality trainings, and iPad applications have been investigated in many trials to test its feasibility in clinical use. Although digital therapeutics may deliver high-quality solutions to healthcare services, the medicalization of digital therapeutics is accompanied with many limitations. Clinically validated digital therapeutics should be developed to prove its efficacy in stroke rehabilitation.

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Choi MJ, Kim H, Nah HW, Kang DW. Digital Therapeutics: Emerging New Therapy for Neurologic Deficits after Stroke. J Stroke. 2019;21(3):242–258. doi:10.5853/jos.2019.01963

Comparative Effects of Clinic-and-Virtual Reality-Based McKenzie Therapy in Chronic Non Specific Low-Back Pain

Abstract: Studies on validation of telerehabilitation as an effective platform to help manage as well as reduce burden of care for Low-Back Pain (LBP) are sparse. This study compared the effects of Telerehabilitation-Based McKenzie Therapy (TBMT) and Clinic-Based McKenzie Therapy (CBMT) among patients with LBP. Forty-seven consenting patients with chronic LBP who demonstrated 'directional preference' for McKenzie Extension Protocol (MEP) completed this quasi experimental study. The participants were assigned into either the CBMT or TBMT group using block permuted randomization. Participants in the CBMT and TBMT groups received MEP involving a specific sequence of lumbosacral repeated movements in extension aimed to centralize, decrease, or abolish symptoms, thrice weekly for eight weeks. TBMT is a comparable version of CBMT performed in the home with the assistance of a mobile phone app. Outcomes were assessed at the 4th and 8th weeks of the study in terms of Pain Intensity (PI), Back Extensors Muscles' Endurance (BEME), Activity Limitation (AL), Participation Restriction (PR), and General Health Status (GHS). Data were analyzed using descriptive and inferential statistics. Alpha level was set at p< 0.05. Within-group comparison across baseline, 4th and 8th weeks indicate that both CBMT and TBMT had significant effects on PI (p=0.001), BEME (p=0.001), AL (p=0.001), PR (p=0.001) and GHS (p=0.001) respectively. However, there were no significant differences (p>0.05) in the treatment effects between TBMT and CBMT, except for 'vitality' (p=0.011) scale in the GHS where TBMT led to significantly higher mean score. Mobile-app platform of the McKenzie extension protocol has comparable clinical outcomes with the traditional clinic-based McKenzie Therapy, and thus is an effective supplementary platform for care of patients with low-back pain.

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Mbada, Chidozie E., et al. “Comparative Effects of Clinic-and-Virtual Reality-Based McKenzie Therapy in Chronic Non Specific Low-Back Pain.” Archives of Physical Medicine and Rehabilitation, vol. 99, no. 10, 2018, doi:10.1016/j.apmr.2018.07.295.

Effects of an Immersive Virtual Reality Environment on Muscle Strength, Proprioception, Balance, and Gait of a Middle-Aged Woman Who Had Total Knee Replacement: A Case Report

Background: The purpose of this case study was to apply a training program using virtual reality to a middle-aged woman who had total knee replacement surgery and to investigate its effects on her muscle strength, proprioception, balance, and gait ability.

Case Report: The subject who participated in this study was a 62-year-old woman, who had been diagnosed with moderate osteoarthritis and had a total knee replacement. Post-operative treatment consisted of virtual reality training along with range of motion exercise of the knee joint, light quadriceps isometric exercise, and conventional physical therapy. This also included thermal and electric therapy for pain control conducted on 10 occasions (5 times a week for 2 weeks). Total treatment time, which included 30 min of conventional physical therapy, was 60 min. Measurement of the subject’s lower extremity muscle strength after intervention decreased to 9.43 s, and the error in proprioception decreased to 1.5°. In addition, balance score increased to 56 points, and the time taken to measure gait ability decreased to 9.87 s.

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Hong S, Lee G. Effects of an Immersive Virtual Reality Environment on Muscle Strength, Proprioception, Balance, and Gait of a Middle-Aged Woman Who Had Total Knee Replacement: A Case Report. Am J Case Rep. 2019;20:1636–1642. Published 2019 Nov 7. doi:10.12659/AJCR.918521

Virtual reality applications for chronic conditions management: A review

Background: Virtual Reality (VR) as a computer technology that simulating real environments and situations exploited in numerous healthcare areas such as chronic diseases. The significance of timely treatment and rehabilitation of patients with chronic conditions is high due to the long lasting nature of these conditions. This paper sought to perform a review of published works in the field of VR application in chronic conditions for treatment and rehabilitation purposes.

Methods: We searched the MEDLINE database through PubMed in April 2016 for retrieving published papers from January 2001 to December 2015. From 117 retrieved papers, 52had the inclusion criteria, and their full texts were accessible. Data were extracted from papers based on following items: the name of the first author, year of the study, applied VR methods, type of condition and disease, number of subjects that participated in the study, and finally the status of success and failure of VR application. Data were analyzed using descriptive analysis.

Results: Results of the reviewed investigations have been considered in two main categories including treatment oriented papers (n=38, 73%) while twenty of these papers have been conducted on phobias (53%); also, there are rehabilitation-oriented experiments (n=14, 27%) while thirteen of these papers have been performed on stroke. In 40 papers (77%), the VR technology application reported proper and in 11 papers (21%) the application of VR resulted in relatively proper outcomes and only there is a work (2%) with poor results for VR intervention.

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Hajesmaeel Gohari S, Gozali E, Niakan Kalhori SR. Virtual reality applications for chronic conditions management: A review. Med J Islam Repub Iran. 2019;33:67. Published 2019 Jul 10. doi:10.34171/mjiri.33.67

Effects of virtual reality rehabilitation training on gait and balance in patients with Parkinson's disease: A systematic review

Objective: In recent years, virtual reality (VR) has been tested as a therapeutic tool in neurorehabilitation research. However, the impact effectiveness of VR technology on for Parkinson’s Disease (PD) patients is still remains controversial unclear. In order to provide a more scientific basis for rehabilitation of PD patients’ modality, we conducted a systematic review of VR rehabilitation training for PD patients and focused on the improvement of gait and balance.

Methods: An comprehensive search was conducted using the following databases: PubMed, Web of Science, Cochrane Library, CINHAL, Embase and CNKI (China National Knowledge Infrastructure).Articles published before 30 December 2018 and of a randomized controlled trial design to study the effects of VR for patients with PD were included. The study data were pooled and a meta-analysis was completed. This systematic review was conducted in accordance with the PRISMA guideline statement and was registered in the PROSPERO database (CRD42018110264).

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Lei C, Sunzi K, Dai F, et al. Effects of virtual reality rehabilitation training on gait and balance in patients with Parkinson's disease: A systematic review. PLoS One. 2019;14(11):e0224819. Published 2019 Nov 7. doi:10.1371/journal.pone.0224819

Virtual reality intervention in postoperative rehabilitation after total knee arthroplasty: a prospective and randomized controlled clinical trial

Objective: Our aim was to evaluate clinical benefits of virtual reality (VR) intervention for postoperative rehabilitation in osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA).

Methods: A total of 66 OA patients undergoing unilateral TKA were recruited and randomly assigned to experimental (VR rehabilitation) and control (conventional rehabilitation) groups. Comparison of WOMAC osteoarthritis index, HSS knee score, and VAS scale for pain and knee range of motion (ROM) before and after TKA was performed.

Results: No significant differences were found in preoperative WOMAC index, HSS score, and knee ROM between control and experimental groups (P>0.05). WOMAC indexes were significantly lower and HSS scores were significantly higher in the experimental group than in the control group at 1, 3, and 6 months after TKA, respectively (P<0.05). No significant difference was found in VAS scale for pain at 1 day after TKA, between the two groups (P>0.05). VAS scales were significantly lower in experimental group than the control group at 3, 5, and 7 days after TKA (P<0.05). Knee ROMs were significantly higher in the experimental group than control group at 3, 7, and 14 days after TKA (P<0.05). It took 2.45 ± 0.71 and 13.48 ± 2.48 days for knee ROM to reach 60° and 90° in the experimental group, significantly lower than the 3.09 ± 0.77 and 15.24 ± 2.82 days in the control group (P<0.05).

Conclusion: Clinical application of VR intervention can aid rehabilitation, reduce postoperative pain, and improve functional recovery in OA patients undergoing TKA.

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Jin, Chi et al. “Virtual reality intervention in postoperative rehabilitation after total knee arthroplasty : a prospective and randomized controlled clinical trial.” (2018).

Wearable Sensors Integrated with Virtual Reality: A Self-Guided Healthcare System Measuring Shoulder Joint Mobility for Frozen Shoulder.

Abstract: Frozen shoulder is a common clinical shoulder condition. Measuring the degree of shoulder joint movement is crucial to the rehabilitation process. Such measurements can be used to evaluate the severity of patients' condition, establish rehabilitation goals and appropriate activity difficulty levels, and understand the effects of rehabilitation. Currently, measurements of the shoulder joint movement degree are typically conducted by therapists using a protractor. However, along with the growth of telerehabilitation, measuring the shoulder joint mobility on patients' own at home will be needed. In this study, wireless inertial sensors were combined with the virtual reality interactive technology to provide an innovative shoulder joint mobility self-measurement system that can enable patients to measure their performance of four shoulder joint movements on their own at home. Pilot clinical trials were conducted with 25 patients to confirm the feasibility of the system. In addition, the results of correlation and differential analyses compared with the results of traditional measurement methods exhibited a high correlation, verifying the accuracy of the proposed system. Moreover, according to interviews with patients, they are confident in their ability to measure shoulder joint mobility themselves.

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Cui J, Yeh SC, Lee SH. Wearable Sensors Integrated with Virtual Reality: A Self-Guided Healthcare System Measuring Shoulder Joint Mobility for Frozen Shoulder. J Healthc Eng. 2019;2019:7681237. Published 2019 Apr 10. doi:10.1155/2019/7681237

Effects of Virtual Reality-Based Rehabilitation on Distal Upper Extremity Function and Health-Related Quality of Life: a Single-Blinded, Randomized Controlled Trial

Background: Virtual reality (VR)-based rehabilitation has been reported to have beneficial effects on upper extremity function in stroke survivors; however, there is limited information about its effects on distal upper extremity function and health-related quality of life (HRQoL). The purpose of the present study was to examine the effects of VR-based rehabilitation combined with standard occupational therapy on distal upper extremity function and HRQoL, and compare the findings to those of amount-matched conventional rehabilitation in stroke survivors.

Methods: The present study was a single-blinded, randomized controlled trial. The study included 46 stroke survivors who were randomized to a Smart Glove (SG) group or a conventional intervention (CON) group. In both groups, the interventions were targeted to the distal upper extremity and standard occupational therapy was administered. The primary outcome was the change in the Fugl-Meyer assessment (FM) scores, and the secondary outcomes were the changes in the Jebsen-Taylor hand function test (JTT), Purdue pegboard test, and Stroke Impact Scale (SIS) version 3.0 scores. The outcomes were assessed before the intervention, in the middle of the intervention, immediately after the intervention, and 1 month after the intervention.

Results: The improvements in the FM (FM-total, FM-prox, and FM-dist), JTT (JTT-total and JTT-gross), and SIS (composite and overall SIS, SIS-social participation, and SIS-mobility) scores were significantly greater in the SG group than in the CON group.

Conclusions: VR-based rehabilitation combined with standard occupational therapy might be more effective than amount-matched conventional rehabilitation for improving distal upper extremity function and HRQoL.

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Shin, Joon-Ho, et al. “Effects of Virtual Reality-Based Rehabilitation on Distal Upper Extremity Function and Health-Related Quality of Life: a Single-Blinded, Randomized Controlled Trial.” Journal of NeuroEngineering and Rehabilitation, vol. 13, no. 1, 2016, doi:10.1186/s12984-016-0125-x.

Application and Outcomes of Therapy Combining Transcranial Direct Current Stimulation and Virtual Reality: a Systematic Review

Purpose: To evaluate the methods and major outcomes of transcranial direct current stimulation (tDCS) combined with virtual reality (VR) therapy in randomized controlled trials.

Method: A systematic review was performed following PRISMA guidelines using PubMed, PubMed Central, Web of Science and CAPES periodic databases, with no time restriction. The studies were screened for the following inclusion criteria: human subjects, combination of VR and tDCS methods, and randomized controlled study design. All potentially relevant articles were independently reviewed by two researchers, who reached a consensus on which articles met the inclusion criteria. The PEDro scale was used to evaluate the studies.

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Massetti, Thais, et al. “Application and Outcomes of Therapy Combining Transcranial Direct Current Stimulation and Virtual Reality: a Systematic Review.” Disability and Rehabilitation: Assistive Technology, vol. 12, no. 6, 2016, pp. 551–559., doi:10.1080/17483107.2016.1230152.

Virtual Reality Exercise Intradialysis to Improve Physical Function: A Feasibility Randomized Trial

Objective: The main objective of this investigation was to assess feasibility of conducting a future RCT with an intradialysis non-immersive virtual reality exercise intervention. The secondary aim was to explore the impact of either conventional or VR exercise on physical function.

Design: Feasibility randomized trial.

Participants: Eighteen subjects who participated in a 16-week intradialysis combined exercise program.

Intervention: The program lasted four additional weeks of either combined exercise or virtual reality exercise.

Main Outcome Measures: Physical function was measured through several reliable tests (sit-to-stand-to-sit tests 10 and 60, gait speed, one-leg heel-rise tests, and 6-minute walk test) at baseline, after 16 weeks of intradialysis combined exercise and by the end of four additional weeks of exercise. Adherence to the exercise programs was registered.

Results: There was a significant time effect, so that physical function improved in both groups. By the end of the 20 weeks, function improved as measured through the sit-to-stand-to-sit tests 10 and 60, gait speed, one-leg heel-rise left leg, and the 6-minute walk test. Changes that did not occur due to error in the test were seen after 20 weeks were achieved in the sit-to-stand-to-sit test 60, gait speed, one-leg heel-rise test for the left leg, and 6-minute walking test.

Conclusion: Virtual reality was a feasible intervention. Both interventions improved physical function. Adherence was not significantly different between groups.

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Segura‐Ortí, Eva, et al. “Virtual Reality Exercise Intradialysis to Improve Physical Function: A Feasibility Randomized Trial.” Scandinavian Journal of Medicine & Science in Sports, vol. 29, no. 1, 2018, pp. 89–94., doi:10.1111/sms.13304.

A knowledge translation intervention to enhance clinical application of a virtual reality system in stroke rehabilitation

Background: Despite increasing evidence for the effectiveness of virtual reality (VR)-based therapy in stroke rehabilitation, few knowledge translation (KT) resources exist to support clinical integration. KT interventions addressing known barriers and facilitators to VR use are required. When environmental barriers to VR integration are less amenable to change, KT interventions can target modifiable barriers related to therapist knowledge and skills.

Methods: A multi-faceted KT intervention was designed and implemented to support physical and occupational therapists in two stroke rehabilitation units in acquiring proficiency with use of the Interactive Exercise Rehabilitation System (IREX; GestureTek). The KT intervention consisted of interactive e-learning modules, hands-on workshops and experiential practice. Evaluation included the Assessing Determinants of Prospective Take Up of Virtual Reality (ADOPT-VR) Instrument and self-report confidence ratings of knowledge and skills pre- and post-study. Usability of the IREX was measured with the System Usability Scale (SUS). A focus group gathered therapist experiences. Frequency of IREX use was recorded for 6 months post-study.

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Levac, Danielle, et al. “A Knowledge Translation Intervention to Enhance Clinical Application of a Virtual Reality System in Stroke Rehabilitation.” BMC Health Services Research, vol. 16, no. 1, 2016, doi:10.1186/s12913-016-1807-6.

 

The application of VR technology in rehabilitation

Abstract: Virtual reality (VR) is an emerging technology with a variety of potential benefits for many aspects of rehabilitation assessment, treatment, and research. Through its capacity to allow the creation and control of dynamic 3-dimensional, ecologically valid stimulus environments within which behavioral responding can be recorded and measured, VR offers clinical assessment and rehabilitation options that are not available with traditional methods. Initial applications of VR in other aspects of medicine and psychology have yielded encouraging results, but continued research and understanding of this evolving technology will be crucial for its effective integration into rehabilitation. This article provides a brief introduction to VR technology, examines the specific benefits VR offers consumers and providers of rehabilitation services and discusses potential areas of application and important considerations in applying this technology. Finally, 2 examples of current VR applications are presented

You can find the full study here.

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Schultheis, Maria & Rizzo, Albert. (2001). The application of virtual reality technology in rehabilitation. Rehabilitation Psychology. 46. 296-311. 10.1037/0090-5550.46.3.296. 

Use of client-centered virtual reality in rehabilitation after stroke: a feasibility study

Abstract: Patient-centered virtual reality (VR) programs could assist in the functional recovery of people after a stroke.

Objectives: To analyze the feasibility of a rehabilitation protocol using client-centered VR and to evaluate changes in occupational performance and social participation.

Methods: This was a mixed methods study. Ten subacute and chronic stroke patients participated in the rehabilitation program using games in non-immersive VR for 40 minutes/day, three days/week, for 12 weeks. Sociodemographic information was collected and the outcome variables included were the Canadian Occupational Performance Measure (COPM) and the Participation Scale. A field diary was used to record the frequency of attendance and adherence of participants and an interview was conducted at the end of program.

Results: There were significant and clinically-relevant statistical improvements in the COPM performance score (p < 0.001; CI = 1.29 - 4.858) and in the COPM satisfaction score (p < 0.001; CI = 1.37 - 5.124), with a difference greater than 4.28 points for performance and 4.58 points for satisfaction. The change in the scores for participation was statistically significant (p = 0.046), but there was no clinical improvement (dcohen = -0.596, CI = -1.862 - 0.671). The majority of participants reported more than 75% consecutive attendance of sessions and there was 100% adherence to the program. In the interviews, the participants described their post-stroke difficulties; how the video game motivated their engagement in rehabilitation; and the improvement of occupational performance and social participation after participating in the program.

Conclusions: VR is a viable tool for the rehabilitation of stroke patients with functional gains, mainly regarding occupational performance and performance satisfaction.

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Aramaki, Alberto Luiz, et al. “Use of Client-Centered Virtual Reality in Rehabilitation after Stroke: a Feasibility Study.” Arquivos De Neuro-Psiquiatria, vol. 77, no. 9, 2019, pp. 622–631., doi:10.1590/0004-282x20190103.

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

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

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

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

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Chen, Yuping, et al. “Effectiveness of Virtual Reality in Children With Cerebral Palsy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.” Physical Therapy, vol. 98, no. 1, 2017, pp. 63–77., doi:10.1093/ptj/pzx107.

Experiences of Treadmill Walking with Non-Immersive Virtual Reality after Stroke or Acquired Brain Injury – A Qualitative Study

Objectives: It is well known that physical activity levels for persons after stroke or acquired brain injuries do not reach existing recommendations. Walking training is highly important since the ability to walk is considered to be a meaningful occupation for most people, and is often reduced after a brain injury. This suggests a need to innovate stroke rehabilitation, so that forms of walking training that are user-friendly and enjoyable can be provided.

Method: An interview study was carried out with persons after stroke (n = 8), or acquired brain injury (n = 2) at a rehabilitation unit at Sahlgrenska University Hospital. We used a semi-structured interview guide to investigate experiences and thoughts about walking on a treadmill with non-immersive virtual reality feedback. The contents were analyzed through an inductive approach, using qualitative content analysis.

Results: The virtual reality experience was perceived as enjoyable, exciting, and challenging. Participants stressed that the visual and auditory feedback increased their motivation to walk on a treadmill. However, for some participants, the virtual reality experience was too challenging, and extreme tiredness or fatigue were reported after the walking session.

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Törnbom, Karin, and Anna Danielsson. “Experiences of Treadmill Walking with Non-Immersive Virtual Reality after Stroke or Acquired Brain Injury – A Qualitative Study.” Plos One, vol. 13, no. 12, 2018, doi:10.1371/journal.pone.0209214.

Feasibility of a Walking Virtual Reality System for Rehabilitation: Objective and Subjective Parameters

Background: Even though virtual reality (VR) is increasingly used in rehabilitation, the implementation of walking navigation in VR still poses a technological challenge for current motion tracking systems. Different metaphors simulate locomotion without involving real gait kinematics, which can affect presence, orientation, spatial memory and cognition, and even performance. All these factors can dissuade their use in rehabilitation. We hypothesize that a marker-based head tracking solution would allow walking in VR with high sense of presence and without causing sickness. The objectives of this study were to determine the accuracy, the jitter, and the lag of the tracking system and its elicited sickness and presence in comparison of a CAVE system.

Methods: The accuracy and the jitter around the working area at three different heights and the lag of the head tracking system were analyzed. In addition, 47 healthy subjects completed a search task that involved navigation in the walking VR system and in the CAVE system. Navigation was enabled by natural locomotion in the walking VR system and through a specific device in the CAVE system. An HMD was used as display in the walking VR system. After interacting with each system, subjects rated their sickness in a seven-point scale and their presence in the Slater-Usoh-Steed Questionnaire and a modified version of the Presence Questionnaire.

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Borrego, Adrián, et al. “Feasibility of a Walking Virtual Reality System for Rehabilitation: Objective and Subjective Parameters.” Journal of NeuroEngineering and Rehabilitation, vol. 13, no. 1, 2016, doi:10.1186/s12984-016-0174-1.

Promoting Therapists' Use of Motor Learning Strategies within Virtual Reality-Based Stroke Rehabilitation

Purpose: Therapists use motor learning strategies (MLSs) to structure practice conditions within stroke rehabilitation. Virtual reality (VR)-based rehabilitation is an MLS-oriented stroke intervention, yet little support exists to assist therapists in integrating MLSs with VR system use.

Method: A pre-post design evaluated a knowledge translation (KT) intervention incorporating interactive e-learning and practice, in which 11 therapists learned how to integrate MLSs within VR-based therapy. Self-report and observer-rated outcome measures evaluated therapists' confidence, clinical reasoning and behaviour with respect to MLS use. A focus group captured therapists' perspectives on MLS use during VR-based therapy provision.

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Levac, Danielle E., et al. “Promoting Therapists’ Use of Motor Learning Strategies within Virtual Reality-Based Stroke Rehabilitation.” Plos One, vol. 11, no. 12, 2016, doi:10.1371/journal.pone.0168311.

Virtual Reality for Individuals With Substance Use Disorders

Abstract: Substance use disorders (SUDs) remain difficult to treat, with relapse rates averaging 50% despite available treatment. There is a need for new and novel treatment for treating SUDs. The use of virtual reality (VR) shows promising results as a strategy to help patients with SUDs manage cravings, say no to substance use, reduce stress and anxiety, treat pain, learn life skills, exercise, and use as a substitute for substance use. In VR, patients use a head-mounted device to experience computer-generated 360° simulated environments. Studies have shown that VR activates some of the same areas of the brain that substances activate. The science and technology of VR is evolving, resulting in more affordability, but the price is likely still a barrier for most treatment providers and patients. In addition, applications used to treat SUDs were developed for use in research and are not currently available for public use. More rigorous studies are needed to determine the effectiveness of VR as a treatment for SUDs. [Journal of Psychosocial Nursing and Mental Health Services, 57(6), 15-19.].

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Worley, Julie. “Virtual Reality for Individuals With Substance Use Disorders.” Journal of Psychosocial Nursing and Mental Health Services, vol. 57, no. 6, 2019, pp. 15–19., doi:10.3928/02793695-20190430-01.

 

Virtual Reality for Traumatic Brain Injury

Abstract: In this perspective, we discuss the potential of virtual reality (VR) in the assessment and rehabilitation of traumatic brain injury, a silent epidemic of extremely high burden and no pharmacological therapy available. VR, endorsed by the mobile and gaming industries, is now available in more usable and cheaper tools allowing its therapeutic engagement both at the bedside and during the daily life at chronic stages after injury with terrific potential for a longitudinal disease modifying effect.

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Zanier, Elisa R., et al. “Virtual Reality for Traumatic Brain Injury.” Frontiers in Neurology, vol. 9, 2018, doi:10.3389/fneur.2018.00345.

A Virtual Environment-Based Training System for a Blind Wheelchair User Through Use of Three-Dimensional Audio Supported by Electroencephalography

Abstract: People with disabilities encounter many difficulties, especially when a diagnosis of more than one dysfunction is made, as is the case for visually impaired wheelchair users. In fact, this scenario generates a degree of incapacity in terms of the performance of basic activities on the part of the wheelchair user. The treatment of disabled patients is performed in an individualized manner according to their particular clinical aspects. People with visual and motor disabilities are restricted in independent navigation. In this navigation scenario, there is a requirement for interaction that justifies the use of virtual reality (VR). In addition, locomotion needs to be under natural control to be successfully incorporated. Based on such a condition, electroencephalography (EEG) has shown great advances in the area of health by employing spontaneous brain signals. This research demonstrates, through an experiment, the use of a wheelchair adapted to have the support of VR and EEG for training of locomotion and individualized interaction of wheelchair users with visual impairment. The objective was to provide efficient interactions, thus allowing the social inclusion of patients who are considered otherwise incapacitated. This project was based on the following criteria: natural control, feedback, stimuli, and safety. A multilayer computer rehabilitation system was developed that incorporated natural interaction supported by EEG, which activated the movements in the virtual environment and real wheelchair through adequately performed experiments. This research consisted of elaborating a suitable approach for blind wheelchair user patients. The results demonstrated that the use of VR with EEG signals has the potential for improving the quality of life and independence of blind wheelchair users.

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Souza, Everton Silva De, et al. “A Virtual Environment-Based Training System for a Blind Wheelchair User Through Use of Three-Dimensional Audio Supported by Electroencephalography.” Telemedicine and e-Health, vol. 24, no. 8, 2018, pp. 614–620., doi:10.1089/tmj.2017.0201.

Virtual Restorative Environments: Preliminary Studies in Scene, Sound and Smell

Abstract: Previous restorative environment (RE) research suggests that exposure of individuals to natural settings can reduce stress, improve feelings of well-being, and help individuals to recover from fatigue following intensive mental activities. This paper focuses on possible future opportunities for exploring Virtual Environments (VE) in the pursuit of restorative and rehabilitative therapies. The paper presents early work in developing such a Virtual Restorative Environment (VRE) and includes results from two preliminary studies. The first study compared two VEs (an urban city scene and a rural coastal scene) and showed the effect of ambient sounds on ratings of anxiety and relaxation. The second study explored the opportunity of incorporating odours into a VE using a novel olfactory display system and evaluated methods for measuring their effect on the user. Throughout, the paper discusses human factors and usability issues for VRE technologies and future research opportunities

Find the full paper here.

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Knight JF, Stone RJ, Qian C. Virtual Restorative Environments. International Journal of Gaming and Computer-Mediated Simulations. 2012;4(3):73-91. doi:10.4018/jgcms.2012070106

VR exercise on a home-based phase III cardiac rehabilitation program

 

Purpose: To analyse the effect of a six-month home-based phase III cardiac rehabilitation (CR) specific exercise program, performed in a virtual reality (Kinect) or conventional (booklet) environment, on executive function, quality of life and depression, anxiety and stress of subjects with coronary artery disease.

Conclusions: The virtual reality format had improved selective attention and conflict resolution ability, revealing the potential of CR, specifically with virtual reality exercise, on executive function. Implications for Rehabilitation In cardiac rehabilitation, especially in phase III, it is important to develop and to present alternative strategies, as virtual reality using the Kinect in a home context. Taking into account the relationship between the improvement of the executive function with physical exercise, it is relevant to access the impact of a cardiac rehabilitation program on the executive function. Enhancing the value of the phase III of cardiac rehabilitation.

Find the full report here.

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Vieira Á, Melo C, Machado J, Gabriel J. Virtual reality exercise on a home-based phase III cardiac rehabilitation program, effect on executive function, quality of life and depression, anxiety and stress: a randomized controlled trial. Disability and Rehabilitation: Assistive Technology. 2017;13(2):112-123. doi:10.1080/17483107.2017.1297858

Virtual Natural Environments for Restoration and Rehabilitation in Healthcare

Abstract: For over two decades, research and clinical projects have exploited Virtual Reality technologies in the treatment of numerous human conditions, from desensitisation régimes combating phobias to the use of distraction and exposure therapies for burns victims and those suffering from post-traumatic stress disorders. In contrast to previous “high-tech” interface and combat-oriented approaches to using VR in the psychological rehabilitation process, the present chapter advocates the use of virtual restorative environments (VREs)—the recreation of locations and scenes that, by virtue of their natural beauty and peacefulness, can significantly help to reduce the body’s reactivity to stress and restore cognitive or attentional capacities. The chapter also argues that VREs, suitably enhanced with more interactive and dynamic features, could offer significant benefits to patients in physical rehabilitation programmes. This is especially the case for amputees, for example, who, whilst awaiting the fitting of prosthetic limbs, could undertake competitive and motivational “virtual exercises”, thereby avoiding muscle atrophy and related reductions in residual limb capabilities. The report concludes that the exploitation of simulation technologies in psychological therapies is worthy of continued investigation, especially in the pursuit of enhancing patients’ recovery profiles following surgical procedures, from intensive care to the hospital recovery ward. VREs possess a range of important qualities, not least significant of which is real-time interaction and ease-of-editing, supporting the cost-effective generation of engaging and distributable scenarios that can be tailored relatively easily to meet the needs of individual patients.

Find the full report here.

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Stone R, Small C, Knight J, Qian C, Shingari V. Virtual Natural Environments for Restoration and Rehabilitation in Healthcare. Virtual, Augmented Reality and Serious Games for Healthcare 1 Intelligent Systems Reference Library. 2014:497-521. doi:10.1007/978-3-642-54816-1_24

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Tim Fitzpatrick

Co-founder & CEO

Hi there! Thanks for taking the time to read through our research page. The results you see here are just a fraction of the mounting evidence that supports VR's growing role in healthcare. I'd like to thank all those clinicians and researchers who continue to push the envelope in the name of improving patient care. And I especially want to thank YOU for your support — it's why we're here.

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