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Why VR?

At first glance, Virtual Reality might seem like an odd choice for therapy, but the body of research surrounding its utility is vast.  Here are just a few of VR's capabilities. Click "read more" under each heading to learn more. 

Mental health and Mood improvements

VR has been effectively utilised to treat anxiety, improve mode, lower stress, and assist with the treatment of eating disorders, phobias, PTSD, and even psychosis. The results are often dramatic - one study of patients with parkinsons showed not only improvement in movement, fine motor skills and energy levels, but also a significant reduction in depression scores, with most participants’ scores dropping to zero. VR has been shown to be particularly useful in treating medication-resistant individuals A number of studies have linked stress with cellular ageing and increased risk of heart attack, diabetes, and cancer. Positive emotions, such as those created through gameplay, can create emotional resilience and fend off the effects of stress. One of the strengths of VR is its ability to produce “ecological validity”, which means that experiences that can be therapeutic in “real life” can be replicated in VR, such as swimming with dolphins to reduce stress, making it particularly useful for housebound individuals who cannot have these experiences first hand. Additionally, housebound individuals suffer high rates of social isolation, which can lead to lowered mood and other poor mental health outcomes. Fortunately, VR is an excellent tool for treating social isolation.

Treating social isolation and loneliness

Speaking at a South by Southwest conference, Allison Seuler, vice president of research at Baycrest Health Sciences discussed VR’s utility in battling loneliness and social isolation among care home residents with dementia. “It's not just making people happy and less lonely,” she said, “it's actually helping the brain.” She and her colleagues also noted that VR distinguishes itself from other forms of virtual therapy. Tablets, smartphones and televisions don’t give “full activation of our brains and our emotions”, but that “there’s actually changes in the brain function when you’re in VR, versus listening to someone on the phone or looking at a screen. Additionally, VR can mitigate loneliness by acting as a social tool. Clinicians noted that among those using games as at-home therapy, many independently use the games as a social activity with other members of their households. VR gets people excited; it gives people something to look forward to as well something to chat about that isn’t their diagnosis or symptoms. In one study of care home residents, VR helped residents with dementia open up to the care home staff about their lives, facilitating better social and emotional care. Programmes like VR Chat, Altspace, and Alcove also provide opportunities for direct socialisation, including chat, multiplayer games, and events . Groups of people with chronic conditions, sometimes called “spoonies” have effectively used VR as a social platform to connect with one another. Participation in social VR games has been shown to positively affect well-being. One study during the Covid-19 lockdowns found that VR presence in social spaces was associated with psychological benefits including feelings of relatedness, self-expansion, and enjoyment. Loneliness and social isolation are linked with cognitive decline, but fortunately VR has also been shown to be an effective source of cognitive rehabilitation.

Cognitive rehabilitation

The first computer games created for treating traumatic brain injury (TBI) were developed in the 1980s and have a long record of effective cognitive rehabilitation thanks to the principle of neuroplasticity. By stimulating undamaged sections of the brain, computer training translates into improvements in real-world function. VR builds on that by creating an environment that is “ecologically valid”, which is considered superior for training executive function. Researchers in brain damage rehabilitation expect that VR will become an integral part of cognitive assessment and rehabilitation in the future. VR has been extensively studied with regard to cognitive rehabilitation. It has been shown to improve memory, attention, information processing, and problem solving. It can also help patients interact with the world by improving wayfinding, visual scanning, and spatial orientation. There is even evidence that VR can provide improvements with regard to daily life activities (DLA). One study focused on “bringing the outside in” to a care home for people living with moderate to severe dementia. Patients were able to choose from one of five outdoor environments to explore, allowing them to have an experience that might otherwise be difficult to achieve given their health. Researchers found that this exploration helped them recall lost memories and engage in conversation about them. These recollections not only provided the patient with mental stimulation, but allowed caregivers to learn more about their lives and thereby improve social interactions between patients and staff. Allowing the patients to choose their own experience allowed them a sense of autonomy, which is often lacking in supported care. The patients rated VR positively as a “change of environment” and scored higher on alertness after their experience. One patient recalled his experience a week later during an art session where he was inspired to draw a seaside scene based on his VR experience, which was in his words “brilliant”. The study concluded that the use of VR was cognitively stimulating, sustained attention, promoted wellbeing among the patients, reduced behaviour that challenges, and offered a unique medium for caregivers and patients to build therapeutic rapport. Speaking at a South by Southwest panel on the study, Allison Sekuler, vice president of research at Baycrest Health Sciences said “That sort of reminiscence, it doesn't necessarily reverse dementia, but it can certainly slow the progression. It's not just making people happy and less lonely, it's actually helping the brain.”

Motor Rehabilitation

Virtual reality can be more effective at enhancing motor improvement when compared with conventional treatments, often producing the same results in less time or with less work for the patient. VR has been shown to be effective in improving Posture, Balance, Gait, Grasping and Fine Motor Skills, Flexibility], Energy Levels, Increased Standing and Walking Time, Increasing Bone Density and Reducing Muscle Wastage, and general function. A meta-analysis showed that VR users were 4.9 times more likely to improve their motor strength when compared with a control. As is also the case with cognitive recovery, the effects of VR are lasting; in one study of post-stroke survivors, walking time, speed, balance, confidence, and self-reported walking ability all improved in VR over the control group, and these scores stayed elevated during a post-test a month later. VR may be particularly useful in treating kinesiophobia, a particularly treatment-resistant fear of movement that many chronic pain sufferers experience. This fear develops as a result of their pain and manifests in more restricted movement, which can lead to reinjury, muscle wastage, and poor health. One patient, who developed a fear of falling post-stroke, showed an increase in standing and walking times after her first experience in VR. “I forgot to be scared”, she reported after her first experience, and after a second session she reported feeling more confident and energised. These were not simply self-report data, however - her chart notes reported “improved balance and decreased reliance on assistive devices after VR” and also noted that she moved faster and more confidently with improved balance. Another patient had been struggling with a physio exercise, until her therapist tried a VR game. “By happenstance” the therapist reported, “the game required that exact movement - and [she] was going for it.” Motion games provide not only challenge, motivation and positive feedback, but they also can provide as much exercise as walking, making them excellent fitness tools for sedentary populations. While kinesiophobia is strictly the fear of movement, we can also conceptualise it as a fear of pain. In fact, VR is an excellent controller of pain and pain-related cognition, and that makes it an excellent tool for rehabilitative therapy.

Pain Management

Pain during therapy can reduce therapeutic compliance, slowing or even stopping progress. VR has been effectively shown to reduce pain levels in both experimental and clinical settings. One mechanism by which VR manages pain is through distraction and increased cognitive load. VR has a higher cognitive load than other distractions such as movies ; in one study a respondent rated their pain during VR usage at 1.2 on a 10 point scale, while pain during movie watching was rated the same as no distraction at 7.2. Another study of burn patients found VR caused a 20% reduction in the worst pain, a 26% reduction in unpleasantness, and a 37% reduction in the time spent thinking about the pain. Another study found a 46 point reduction (on a 100 point scale) in time spent thinking about pain . One burn patient who struggled with wound care using opiates experienced a 43 point reduction (on a 100 point scale) in pain when using VR. In one clinical setting VR was so effective at pain reduction that young patients were enthusiastic about getting lumbar punctures with no anaesthetic. In fact, VR is so effective at pain control that several hospitals are using it as a pseudo-anesthetic. Dr. Gareth Morgan of Children’s Hospital in Colorado explains the usage of VR in young patients requiring a cardiac catheter: “We’re moving away from groin access… [using VR] we can go in through the arm and get the same results. After we finish the case they’re awake, [t]hey just change and head out.” Patients treated in this way rate their pain at or below two on a ten point scale, were exposed to less radiation and anaesthetic, and had appointment times of two hours, versus the six hour appointments required without VR. VR’s pain reduction capabilities are not limited to acute issues. Several studies have noted the distraction effects of gaming on physical therapy patients. In one study, patients with fibromyalgia found motion controlled games “a fun way to get distracted from pain symptoms” while doing their physical therapy. One patient with cerebral palsy experienced 41.2% less pain during their post-surgical physiotherapy (PT) when compared with their non-VR PT. VR has the potential to help any population that needs regular physical or occupational therapy. Virtual reality can be a pain control solution for those unable to utilise pharmacological interventions, such as the very young, patients with drug allergies or those with addiction histories. Moreover, the pain reduction qualities of VR do not diminish over time like some medications. VR has been shown to be effective against conditions that are often treatment resistant, such as phantom limb pain and complex regional pain syndrome. Researchers are optimistic about VR’s utility for treating a variety of pain populations.

Why is VR uniquely suited to these challenges?

There are a number of reasons that VR is such an effective and flexible tool. First, let's look at games more generally. Using games as therapy increases compliance because they are inherently fun and motivating. While some therapies’ effectiveness has an upper limit, games can avoid the “ceiling effect” by scaling with the player. Games have the ability to engage players in more than one way, and so can provide both motor and cognitive rehabilitation in the same play sesion. Games can provide competition, which has been shown to act as an extrinsic reward, improving attention and motivation and potentially better therapeutic results. Games make effective distractions from pain and fatigue as they require a high cognitive load and reduce the perceived repetitions featured in traditional therapy. Games make for better at-home results, and even simply gamifying (utilising game elements in a non-game setting) traditional therapy, creates higher patient engagement and better results. Games are excellent at making use of patients’ neuroplasticity, being built on the foundations of repetition, gradually increasing intensity, and focus on tasks. VR goes beyond the general benefits of games, however. Virtual reality creates a sense of presence and ecological validity so strong that it can be seen in fMFI scans. One study found that not only do subjective reports of pain fall during VR use, but also pain-related brain activity. VR activates the regions of the brain that are used to make sense of non-virtual physical environments. It can cause feelings of awe so strong that they cause goosebumps and even produce “Mystical-type experiences” comparable to those produced by high doses of psilocybin and LSD. One study used VR to trick subject’s brains into underestimating the weight of a lifted object, resulting in an additional two minutes of exercise until exhaustion - with an accompanying 5-7bpm drop in heart rate. The researchers reported that VR “[reduces] the intensity of negative perceptions of pain and effort associated with exercise.” Virtual reality is also unique in the way that it can provide augmented feedback (AF). AF serves two main purposes: to reinforce a person’s sense of position and allows their focus to be on the effects of their actions, rather than the actions themselves. Our actions are most efficient when planned according to their effect rather than an internal state, making VR a more effective tool for motor rehabilitation than repetitive PT exercises. This may explain why VR allows the same rehabilitation results with less work for the patient and can help transfer skills to real life more readily when compared to standard therapies . VR also makes an excellent source of home-based therapy, as it can provide real-time data to therapists, is available to the patient 24/7 and can increase motivation and therapeutic compliance when compared with traditional therapies. VR is even effective in chronic situations and its effects can be sustained for as much as five years after training. There has been extensive research into the utility of VR as a therapeutic tool. While most studies are small and therefore difficult to generalise from, there are now so many that the size of the body of evidence itself becomes impressive. While we recognize that the plural of anecdote is not data, we submit that the preceding review supports the use of VR as an effective therapeutic adjunct.

Some other active VR projects from around the world

We would hardly be the first project to bring VR to patients. As may be apparent by the previous sections, a number of hospitals are actively using VR. At Children's Hospital Colorado, VR provides distraction, motor rehabilitation, as well as procedural support including anxiety relief before and pain relief after . VR is used to show children what it will be like in an MRI and help prepare them to stay still and calm during their test. It is even being used as a pseudo-anesthetic, providing such high quality pain relief that doctors can change catheters, stints, and bandages with their patient awake, enabling better diagnostic assessment and shorter procedure times. Mott’s Children's Hospital has also used VR as a way to reduce isolation by taking kids “outside the hospital”, utilising online gaming, and providing something for kids to share with friends, family, and each other. At St Louis Children’s hospital, VR lets kids with limited mobility explore other worlds while at Boston Children’s, kids can learn about their conditions through a VR tour of their bodies, informed by their own medical histories. While these are in children's wards, we need to remember that 65% of all UK residents play video games. Additionally, we know from the research that VR is effective on all ages - one pain study found that while children reported higher levels of feeling “present” in the game, age was not related to the effectiveness of the VR therapy. Moreover, children are not the only group that are being actively served by VR. KindVR is a research company that is currently working on clinical trials using VR with patients with sickle-cell anaemia, cancer, those with pre-op stress, and those undergoing laceration repair. Rendever is a provider working with care homes that uses VR for remicience training for patients with dementia as well as virtual holidays and bucket list moments, shared community through gaming, and exercises to increase movement, cognitive stimulation and intergenerational engagement. NASA is currently using VR to study the impact of extended space flight and exploring the use of VR to alleviate boredom and homesickness among crew members on long flights. The international space station uses VR in its mandated exercise program, where astronauts look forward to sessions more and exercise for longer thanks to virtual bike rides . Software based interventions are proving so successful that four members of the US Congress have put forward a bill to have them covered by Medicare, the nation’s public health system for pensioners.

A full literature review, complete with citations is coming soon - sign up to the mailing list below to be notified when it is posted.

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