Virtual reality in healthcare - part 1
Our AI has generated this annotated bibliography from recent randomized controlled trials on the use of VR/AR in healthcare
A study on the effects of virtual reality (VR) on neck pain in patients with non-specific chronic neck pain (NS-CNP).
Between 50% and 85% of the general population experience neck pain at some point in their lives. Every person who experiences neck pain is likely to experience it again 1–5 years later. David Tejera and colleagues (2020) reported in ‘Effects of Virtual Reality versus Exercise on Pain, Functional, Somatosensory and Psychosocial Outcomes in Patients with Non-specific Chronic Neck Pain’ that VR was not superior to exercise in improving pain intensity, CPM, ROM, neck disability, pain catastrophizing, fear-avoidance beliefs, PPT or anxiety. Tejera and colleagues found that Kinesiophobia was the only variable to have significantly improved compared to the exercise group, especially at 3 months follow-up. The post hoc analysis revealed significant within-group differences in all groups between baseline and 3 months follow-up- measures.
44 individuals with NS-CNP were involved in the study. Some of the researchers’ conclusions appear to substantiate prior research in this area: “Recent reviews have concluded that more research is needed regarding VR as a treatment of musculoskeletal disorders. The present study matches the protocol of the reviewed articles where the treatment was delivered during four weeks of chronic pain,” Tejera claimed. However, “There was no placebo group, so we could not compare the non-specific effects of this therapy. Motion sickness produced by virtual reality headsets was not taken into account and measuring it could influence its effects on the subjects of study,” note the researchers. The team suggest that the mechanisms of VR and its applicability will be better understood in order to obtain more benefits for patients. It could present collateral benefits such as enhancing their adherence to treatment and autonomy to practice at home.
Using the Leap Motion Controller (LMC) to play serious games to improve grip muscle strength and dexterity in patients with multiple sclerosis has shown significant improvements.
A group at the Department of Physical Therapy led by Alicia Cuesta-Gómez (2020) reported in ‘Effects of virtual reality associated with serious games for upper limbrehabilitation in patients with multiple sclerosis’ that multiple sclerosis (MS) is a chronic inflammatory demyelinating illness of the central nervous system of unknown etiology. This is the first RCT to evaluate grip muscle strength, coordination, speed of movements, fine and gross dexterity, fatigue, and quality of life after using serious games designed for neurological diseases with the LMC system. Results suggest that at least 12 sessions with a virtual environment combined with conventional rehabilitation are necessary to achieve dexterity improvements in MS patients.
3 physical therapists were involved in the study of 30 patients. Their results seem to consolidate prior research in this topic: “These findings seemed to be more outstanding on the more affected side. Our results are in line with other studies that have employed LMC in neurological diseases,” Cuesta-Gómez said. The authors acknowledge that “The results cannot be generalized for all patients with MS, so it is necessary to interpret these findings with caution. The sampling methods could have resulted in selection bias as patients were recruited from different MS associations.” The researchers contend that future studies are necessary to corroborate the findings.
A virtual reality (VR) training program for patients with ischemic heart disease showed improvements in ergometry, metabolic equivalents (METS), resistance to fatigue and health-related quality of life.
In ‘Effects of Virtual Reality on Cardiac Rehabilitation Programs for Ischemic Heart Disease’, Sara García-Bravo et al. (2020) noted that this is the first randomized clinical trial conducted on the use of virtual reality and video games in ischemic heart disease, phase II, in a hospital setting. A VR and video game program produced improvements in ergometry, metabolic equivalents estimation, resistance to fatigue, quality of life and depression. There were no statistically significant differences in relation to the conventional intervention, so these could become alternatives to regular programs. Low-cost VR protocol could be an alternative to the fixed equipment of a CR unit, considering it is a safe intervention.
There were 26 participants included in the study. However, “The results cannot be extrapolated to all CVDs, high-risk patients, or all phases of CR. Older population should be included in future studies because age could influence motivation and compliance results. Non-specific CR software was used, despite monitoring of the training heart rate,” observe the investigators. They argue that future studies taking into account the results should explore a comparison between VR isolated and conventional treatment in patients with ischemic heart disease in phase II.
Preoperative dental anxiety can be reduced by applying virtual reality (VRR) in the waiting room.
S. Lahti et al. (2020) described virtual reality relaxation to decrease dental anxiety. Dental anxiety is common and causes symptomatic use of oral health services. Findings of this study indicate that it is a feasible and effective procedure to help patients with dental anxiety in normal public dental care settings. The aim was to study if a short-term virtual reality intervention reduced preoperative dental anxiety. The VRR group received a 1- to 3.5-min 360° immersion video of a peaceful virtual landscape with audio features and sound supporting the experience. Of the powered sample of 280 participants, 255 consented and had complete data.
The study involved 13 students. Discussing potential improvements, “There are limitations to the study population. Recruiting took place in a setting with on average 200 patient visits per day,” they acknowledge. They argue that this might partly explain the lack of statistical significance of VRR among men. Results referring to the effect of gender should be interpreted with caution.
A group of first-year medical students were asked to perform a CT scan on a donated cadaver and then use 3D tools to create a 3D hologram.
In augmented reality (AR), a computer-generated 3D world is seamlessly merged with the physical world. A research team led by Joanna Weeks at the Department of Radiology (2020) studied harnessing augmented reality and CT to teach first-year medical students head and neck anatomy. Between-group analysis indicated that posttest performance was significantly better in the augmented reality group. This study demonstrates significantly superior performance on National Board of Medical Examiners-style anatomy questions in students who use 3D augmented reality.
30 first-year medical students were randomly assigned into two groups to review head and neck anatomy in a teaching session that incorporated CT. The authors’ results appear to support previous work in this field: “In written feedback, the AR group provided lengthier and more varied responses. These findings add to results from similar studies which have shown increased benefit from the use of holograms or stereoscopic viewers when compared to 2D screens,” Weeks claimed. The investigators observe that “Because the pretest and posttest were separated by the short period of time that it took to complete the educational session, the demonstrated gain reflected short-term recall rather than long-term knowledge acquisition. Larger and multi-institutional trials would improve the representativeness of the sample.” The group contend that as the same five questions were used, a practice effect may account for a portion of the score improvement, it would be expected to affect all groups at the same level. This study was limited by resident and student time constraints. Larger and multi-institutional trials would improve the representativeness of the sample.
A pilot study in Argentina has shown that a self-administered treatment of virtual reality combined with mindfulness can increase adherence and effectiveness of digital interventions for tobacco cessation.
Emilio Goldenhersch et al. (2020) conducted a clinical trial where treatment was remotely self-administered through the use of a mobile application with follow-up assessments at days 1 and 90 post-treatment. They hypothesized that their novel intervention approach would increase both adherence and abstinence rates among participating smokers compared to a treatment as usual control group. At post-intervention, the treatment group reported 23% abstinence on that day compared to 5% of the control group.
120 participants were involved in the study. Some of their conclusions may substantiate prior work in this area: “Another singlearm trial based on acceptance and commitment therapy had abstinence rates of 33% at 7 days and 28% at 30 days. These rates are similar to the 23% and 33% observed in our study,” Goldenhersch posited. The investigators note that “Only between 3% and 5% of smokers remain abstinent within the first year of quitting. Follow-up assessment time-point were not identical across intervention and control groups. Future studies should administer the entire program remotely.” They suggest that the current study is the first to combine virtual realityexposure therapy and mindfulness-based relapse prevention for smoking cessation. Future studies should further explore mechanisms of action of this novel intervention approach.
A study has shown that patients with generalized anxiety disorder (GAD) are more likely to experience stress-relief after cycling in a virtual environment containing natural images.
In ‘Psychological and Physiological Responses in Patients with Generalized Anxiety Disorder’, Tsai-Chiao Wang et al. (2020) noted that generalized anxiety disorder is one of the most common mental disorders. It is characterized by persistent, invasive, excessive problems that make daily life difficult. Patients with GAD have pre-existing anxiety, nervous reactions or worry about many events or activities. The purpose of this study was to explore the different effects of virtual reality exercises via an indoor Cave VE system. In the current study, the virtual nature group obtained more benefits in terms of reduced stress than the virtual abstract painting group when cycling in the virtual reality system. The present findings suggest that exercising in a virtual natural virtual environment is a feasible way to help solve clinical psychological and psychological problems.
The research involved 84 participants. Some of the findings seem to support previous studies in this field: “The more people can reduce stress or restore their spirit during an activity, the more satisfied they will be with the activity. Compared to the abstract painting images, the natural landscape generated by the wraparound VE allows individuals to be more satisfied with the cycling experience,” Wang suggested. Discussing possible improvements, “Acute exercise could only temporarily increase the levels of psychophysiological effects in healthy individuals and patients with chronic disease, but long-term psychological and physiological benefits depend on regular exercise. More research is needed in the future to explore the role of virtual environments in promoting exercise,” they admit. The researchers propose that acute exercise could only temporarily increase the levels of psychophysiological effects in healthy individuals and patients with chronic disease. But long-term psychological and physiological benefits depend on regular exercise. The psychological responses to an acute bout of exercise might be moderated by age.
Breathing exercises with biofeedback can help improve breath awareness and promote slow diaphragmatic breathing.
In ‘Development and Pilot Test of a Virtual Reality Respiratory Biofeedback Approach’, Johannes Blum et al. (2020) reported that in the fast-paced society, stress-related symptoms and disorders are prevalent. A calm and relaxed mind facilitates a clear and conscious focus on the breath. The respiratory biofeedback algorithm makes use of the positionally tracked hand controllers that are part of modern VR systems to capture and feedback the respiration-induced abdominal movement. This study piloted a novel approach to VR-based respiratory treatments using biofeedback. The results from the controlled laboratory study show a satisfactory user experience, a heightened breath awareness and an increased respiratory sinus arrhythmia.
72 healthy undergraduate participants were included in the research. The authors acknowledge that “This initial evidence is based on a randomized and controlled laboratory study with multiple psychophysiological data sources. Future research might investigate the present VR biofeedback procedure in the context of participants with complaints to explore a potential clinical use for this technique.” They contend that future studies need to investigate the broader applicability alongside the real world and long-term usage.
A study on the impact of virtual reality (VR) on ultrasonography training.
Kai-Chun Hu et al. (2020) studied impact of virtual realityanatomy training on ultrasound competency development. Participants in the intervention group had significantly higher scores in ultrasonography task performance tests than the control group. Findings are in line with the hypothesis that VR anatomy training provides learners with a better theoretical understanding of regional anatomy and promotes the development of psychomotor skills. The researchers designed a Virtual Reality-enhanced ultrasonography training program. Hu and colleagues used a plane transection tool to interact with a three-dimensional VR model of the human body. This facilitated the 3D conceptualization of the spatial relationship of anatomical structures. The intervention group performed significantly better in the six out of ten ultrasound tasks.
The study involved 101 students. The researchers admit that “VR-enhanced anatomical training could be of significant benefit in ultrasonography training by promoting a better understanding of the spatial relationships of anatomical structures. The impact of VR anatomy training on the ability to identify pathological findings has not yet been determined.” The authors contend that these changes were not consistent within the entire population of the VR intervention group. Results may be influenced by the general psychomotor ability of individual participants. Another aspect not contemplated in this study was the confidence level of participants to correctly identify target anatomical structures.
A study on the effects of virtual reality (VR) training on occupational performance and self-efficacy in patients with stroke.
Virtual reality (VR) has been broadly applied in post-stroke rehabilitation. Studies on occupational performance and self-efficacy as primary outcomes of stroke rehabilitation using VR are lacking. More randomized controlled trials are needed. A team led by Yi Long at the Yi Long Xiangya Hospital Central South University (2020) reported on effects of virtual reality training on occupational performance and self-efficacy of patients with stroke. They found that virtual reality could be integrated into conventional rehabilitation programs to enhance self-efficacy of patients after stroke. VR training could improve the ADL of patients with stroke, the evidence on improved quality of life and participation restriction is limited.
168 participants were involved in the research. Aspects of the researchers’ conclusions may corroborate earlier work in this topic: “The most important activity in the area of productivity was working, followed by housework. For leisure, the demands appeared to be of diversity and be related to patients’ interests,” Long said. However, “Sample size was small in this study. Intervention protocol was designed completely, it did not exactly match the daily activities. The evaluation was performed by the same research therapist who had no clinical relationship with the participant,” acknowledge the investigators. The researchers advocate that this study did not have any follow-up assessments to track continuous effects. All these limitations need to be reconsidered in future studies.
The aim of this study is to compare the effects of virtual reality training on bone morphogenetic proteins and inflammatory biomarkers in post-traumatic osteoarthritis (PTOA).
In ‘Comparative effects of virtual reality training and sensory motor training on bone morphogenic proteins and inflammatory biomarkers in post-traumatic osteoarthritis’, Gopal Nambi and colleagues (2020) compared the effects of virtual reality training (VRT) and sensory-motor training (SMT) in post-traumatic osteoarthritis (PTOA) after the anterior cruciate ligament injury. The study showed clinical improvement in pain intensity and functional disability in the VRT group than the other two groups. Adding VRT exercises in regular rehabilitation programs shows positive changes in inflammatory biomarkers and mild or zero effect on bone morphogenic proteins. Among eighty-six participants referred from local hospitals, 60 were eligible to participate in the study. Reports suggest that the primary variables such as pain and functional disability improved positively in the VRT group.
Their results appear to reinforce what was previously known about this topic: “Our study reports significant improvement in inflammatory biomarkers after VR training. The reports show a decrease in CRP, TNF-α, IL-6 and increase in IL-2 and IL-4 values after this training,” Nambi suggested. Discussing possible improvements, “This study did not include female participants; hence the reports of this study cannot be generalized to the overall population. The association between the clinical findings, bone morphogenic proteins, and inflammatory biomarkers in PTOA after different training protocols has not been analyzed,” they note. Nambi and colleagues recommend that virtual reality training is considered as the latest exercise training technology in the field of sports rehabilitation. Future studies can be done to investigate the other effects of virtual reality training on different injuries in different games.
Tejera, D., Beltran-Alacreu, H., Cano-de-la-Cuerda, R., Leon Hernández, J. V., Martín-Pintado-Zugasti, A., Calvo-Lobo, C., … Fernández-Carnero, J. (2020). Effects of Virtual Reality versus Exercise on Pain, Functional, Somatosensory and Psychosocial Outcomes in Patients with Non-specific Chronic Neck Pain: A Randomized Clinical Trial. International Journal of Environmental Research and Public Health, 17(16), 5950. doi:10.3390/ijerph17165950 [Link]
Cuesta-Gómez, A., Sánchez-Herrera-Baeza, P., Oña-Simbaña, E. D., Martínez-Medina, A., Ortiz-Comino, C., Balaguer-Bernaldo-de-Quirós, C., … Cano-de-la-Cuerda, R. (2020). Effects of virtual reality associated with serious games for upper limb rehabilitation in patients with multiple sclerosis: randomized controlled trial. Journal of NeuroEngineering and Rehabilitation, 17(1). doi:10.1186/s12984-020-00718-x [Link]
García-Bravo, S., Cano-de-la-Cuerda, R., Domínguez-Paniagua, J., Campuzano-Ruiz, R., Barreñada-Copete, E., López-Navas, M. J., … Cuesta-Gómez, A. (2020). Effects of Virtual Reality on Cardiac Rehabilitation Programs for Ischemic Heart Disease: A Randomized Pilot Clinical Trial. International Journal of Environmental Research and Public Health, 17(22), 8472. doi:10.3390/ijerph17228472 [Link]
Lahti, S., Suominen, A., Freeman, R., Lähteenoja, T., & Humphris, G. (2020). Virtual Reality Relaxation to Decrease Dental Anxiety: Immediate Effect Randomized Clinical Trial. JDR Clinical & Translational Research, 5(4), 312–318. doi:10.1177/2380084420901679 [Link]
Weeks, J. K., Pakpoor, J., Park, B. J., Robinson, N. J., Rubinstein, N. A., Prouty, S. M., & Nachiappan, A. C. (2021). Harnessing Augmented Reality and CT to Teach First-Year Medical Students Head and Neck Anatomy. Academic Radiology, 28(6), 871–876. doi:10.1016/j.acra.2020.07.008 [Link]
Goldenhersch, E., Thrul, J., Ungaretti, J., Rosencovich, N., Waitman, C., & Ceberio, M. R. (2020). Virtual Reality Smartphone-Based Intervention for Smoking Cessation: Pilot Randomized Controlled Trial on Initial Clinical Efficacy and Adherence. Journal of Medical Internet Research, 22(7), e17571. doi:10.2196/17571 [Link]
Wang, T.-C., Sit, C. H.-P., Tang, T.-W., & Tsai, C.-L. (2020). Psychological and Physiological Responses in Patients with Generalized Anxiety Disorder: The Use of Acute Exercise and Virtual Reality Environment. International Journal of Environmental Research and Public Health, 17(13), 4855. doi:10.3390/ijerph17134855 [Link]
Blum, J., Rockstroh, C., & Göritz, A. S. (2020). Development and Pilot Test of a Virtual Reality Respiratory Biofeedback Approach. Applied Psychophysiology and Biofeedback, 45(3), 153–163. doi:10.1007/s10484-020-09468-x [Link]
Hu, K.-C., Salcedo, D., Kang, Y.-N., Lin, C.-W., Hsu, C.-W., Cheng, C.-Y., … Huang, W.-C. (2020). Impact of virtual reality anatomy training on ultrasound competency development: A randomized controlled trial. PLOS ONE, 15(11), e0242731. doi:10.1371/journal.pone.0242731 [Link]
Long, Y., Ouyang, R., & Zhang, J. (2020). Effects of virtual reality training on occupational performance and self-efficacy of patients with stroke: a randomized controlled trial. Journal of NeuroEngineering and Rehabilitation, 17(1). doi:10.1186/s12984-020-00783-2 [Link]
Nambi, G., Abdelbasset, W. K., Elsayed, S. H., Khalil, M. A., Alrawaili, S. M., & Alsubaie, S. F. (2020). Comparative effects of virtual reality training and sensory motor training on bone morphogenic proteins and inflammatory biomarkers in post-traumatic osteoarthritis. Scientific Reports, 10(1). doi:10.1038/s41598-020-72587-2 [Link]