Effectiveness of virtual reality distraction during a painful medical procedure in pediatric oncology patients

The effectiveness of virtual reality (VR) as a behavioral intervention designed to decrease distress during port access procedure was examined in 20 7- to 14-year-old pediatric oncology patients. Children were randomized to either engage in an immersive VR environment during the procedure or to a no VR control condition. Children's distress was assessed through subjective self-ratings and objective physiological and behavioral ratings. Narrative accounts of the experience were used as a measure of how well the child coped with the procedure. VR was effective in reducing children's distress on all measures. Implications of these findings for intervention are discussed.     

Analgesic effects of posthypnotic suggestions and virtual reality distraction on thermal pain

The individual and combined effects of posthypnotic suggestion (PHS) and virtual reality distraction (VRD) on experimentally induced thermal pain were examined using a 2 x 2, between-groups design. After receiving baseline thermal pain, each participant received hypnosis or no hypnosis, followed by VRD or no VRD during another pain stimulus. Consistent with the hypothesis that hypnosis and VRD work via different mechanisms, results show that posthypnotic analgesia was moderated by hypnotizability but VRD analgesia was not. The impact of PHSs for analgesia was specific to high hypnotizables, whereas VRD was effective independent of hypnotizability. Results also show a nonsignificant but predicted pattern for high hypnotizables: Audio hypnosis combined with VRD reduced worst pain 22% more and pain unpleasantness 25% more than did VRD alone. Theoretical and clinical implications are discussed.     

Comparative study of distraction versus topical anesthesia for pediatric pain management during immunizations.

This study compared distraction, an anesthetic (eutectic mixture of local anesthetics [EMLA]), and typical care during pediatric immunizations. Participants were 39 4th graders receiving a 3-injection vaccination series over a 6-month period. Children displayed low distress despite reporting moderate anxiety and pain. Distraction resulted in more nurse coaching and child coping and less child distress than did EMLA or typical care on an observational measure. EMLA did not result in increased child coping or decreased distress. In fact, the nurse coached more, and trends suggested that children coped more with typical care than with EMLA. Whereas participant ratings and heart rate did not differ among conditions, all 3 conditions demonstrated improvements over time with these measures. Satisfaction ratings suggested that children preferred the treatments to typical care, whereas the nurse appreciated aspects of each of the conditions. Finally, distraction was more economical than EMLA.     

The neurobiology of virtual reality pain attenuation.

During the past decade, virtual reality (VR) has gained recognition as a means of attenuating pain during medical procedures. However, while investigators have examined the effects of virtual environments on level of distraction, subjective pain intensity, and brain activity, there have been only a handful of investigations into the neurobiological mechanisms associated with VR's efficacy. In an effort to explain how VR may alter pain perception and produce analgesia, as well as to guide the development of novel and improved VR pain treatments, this review aims to link the wealth of empirical data examining the neurobiology of pain to the growing field of VR. This review is separated into three main sections: (a) a brief overview of the current literature on the use of VR for the treatment of pain; (b) a review of the basic neurobiology of how pain is detected, processed, and controlled by the brain; and (c) an exploration into how current VR pain treatments may impact the pain system to produce analgesia. In addition, the future of VR for pain treatment is discussed, including how current treatments might be improved and novel ways to use VR to treat pain might be developed. Speculation on future VR interventions is based on our current understanding of how the brain processes pain and how VR appears to alter this process and produce analgesia.     

Use of virtual reality distraction to reduce claustrophobia symptoms during a mock magnetic resonance imaging brain scan: a case report.

The present case series with two patients explored whether virtual reality (VR) distraction could reduce claustrophobia symptoms during a mock magnetic resonance imaging (MRI) brain scan. Two patients who met DSM-IV criteria for specific phobia, situational type (i.e., claustrophobia) reported high levels of anxiety during a mock 10-min MRI procedure with no VR, and asked to terminate the scan early. The patients were randomly assigned to receive either VR or music distraction for their second scan attempt. When immersed in an illusory three-dimensional (3D) virtual world named SnowWorld, patient 1 was able to complete a 10-min mock scan with low anxiety and reported an increase in self-efficacy afterwards. Patient 2 received "music only" distraction during her second scan but was still not able to complete a 10-min scan and asked to terminate her second scan early. These results suggest that immersive VR may prove effective at temporarily reducing claustrophobia symptoms during MRI scans and music may prove less effective.     

Reaching within video-capture virtual reality: using virtual reality as a motor control paradigm.

We have developed a virtual reality (VR) system that integrates a three-dimensional tracking device with a video-capture VR platform to record upper limb movements. The influence of target velocity on planning and execution of reaching movements was studied in five healthy subjects. Our initial results suggest that a target's velocity is considered when planning an interceptive action and that a hand reaching toward a moving virtual target is controlled in a similar way to how it is in the real visual environment.     

Neurofeedback training with virtual reality for inattention and impulsiveness.

In this research, the effectiveness of neurofeedback, along with virtual reality (VR), in reducing the level of inattention and impulsiveness was investigated. Twenty-eight male participants, aged 14-18, with social problems, took part in this study. They were separated into three groups: a control group, a VR group, and a non-VR group. The VR and non-VR groups underwent eight sessions of neurofeedback training over 2 weeks, while the control group just waited during the same period. The VR group used a head-mounted display (HMD) and a head tracker, which let them look around the virtual world. Conversely, the non-VR group used only a computer monitor with a fixed viewpoint. All participants performed a continuous performance task (CPT) before and after the complete training session. The results showed that both the VR and non-VR groups achieved better scores in the CPT after the training session, while the control group showed no significant difference. Compared with the other groups, the VR group presented a tendency to get better results, suggesting that immersive VR is applicable to neurofeedback for the rehabilitation of inattention and impulsiveness.     

Frequency of stuttering during challenging and supportive virtual reality job interviews

This paper seeks to demonstrate the possibility of manipulating the frequency of stuttering using virtual reality environments (VREs). If stuttering manifests itself in VREs similarly to the way it manifests itself in real world interactions, then VREs can provide a controlled, safe, and confidential method for treatment practice and generalization. Though many researchers and clinicians recognize the need for generalization activities in the treatment of stuttering, achieving generalization in a clinical setting poses challenges to client confidentiality, safety, and the efficient use of a professionals’ time. Virtual reality (VR) technology may allow professionals the opportunity to enhance and assess treatment generalization while protecting the safety and confidentiality of their clients. In this study, we developed a VR job interview environment which allowed experimental control over communication style and gender of interviewers. In this first trial, persons who stutter (PWS) experienced both challenging and supportive VR job interview conditions. The percentage of stuttered syllables was calculated for both interviews for each participant. Self-reported ratings of communication apprehension and confidence were also obtained, and were not significantly correlated with stuttering severity. Results indicated that interviewer communication style affected the amount of stuttering produced by participants, with more stuttering observed during challenging virtual interviews. Additionally, the amount of stuttering observed during the VR job interviews was significantly, positively correlated with the amount of stuttering observed during an interview with the investigator prior to VR exposure. Participants’ subjective reports of the VR experience indicate reactions similar to those they report experiencing in the real world. Possible implications for the use of VR in the assessment and treatment of stuttering are discussed.

Educational objectives: After reading this article, the reader will be able to—(1) list some of the challenges to treatment generalization; (2) describe how virtual reality technology can assist in alleviating some of these challenges; (3) describe how the frequency of stuttering varies across two different virtual environments.     

A virtual reality assessment and training system for unilateral neglect.

Patients with unilateral neglect have problems reporting, responding, or orienting to novel or meaningful stimuli that is presented to the side opposite to that of a brain lesion. This creates a serous problem in regards to daily living activities. However, the established methods for assessing and training of unilateral neglect patients have several deficits. Recently, virtual reality (VR) technologies have been used as an assessment and treatment tool for rehabilitation. Hence, this study designed a VR system to assess and train unilateral neglect patients. In addition, the suitability and feasibility of our VR system for unilateral neglect patients was verified.     

A virtual reality scenario for all seasons: the virtual classroom

Treatment and rehabilitation of the cognitive, psychological, and motor sequelae of central nervous system dysfunction often relies on assessment instruments to inform diagnosis and to track changes in clinical status. Typically, these assessments employ paper-and-pencil psychometrics, hands-on analog/computer tests, and rating of behavior within the context of real-world functional environments. Virtual reality offers the option to produce and distribute identical "standard" simulation environments in which performance can be measured and rehabilitated. Within such digital scenarios, normative data can be accumulated for performance comparisons needed for assessment/diagnosis and for treatment/rehabilitation purposes. In this manner, reusable archetypic virtual environments constructed for one purpose can also be applied for applications addressing other clinical targets. This article will provide a review of such a retooling approach using a virtual classroom simulation that was originally developed as a controlled stimulus environment in which attention processes could be systematically assessed in children with attention-deficit/hyperactivity disorder. This system is now being applied to other clinical targets including the development of tests that address other cognitive functions, eye movement under distraction conditions, social anxiety disorder, and the creation of an earthquake safety training application for children with developmental and learning disabilities.     

Virtual reality for the psychophysiological assessment of phobic fear: responses during virtual tunnel driving

An overall assessment of phobic fear requires not only a verbal self-report of fear but also an assessment of behavioral and physiological responses. Virtual reality can be used to simulate realistic (phobic) situations and therefore should be useful for inducing emotions in a controlled, standardized way. Verbal and physiological fear reactions were examined in 15 highly tunnel-fearful and 15 matched control participants in 3 virtual driving scenarios: an open environment, a partially open tunnel (gallery), and a closed tunnel. Highly tunnel-fearful participants were characterized by elevated fear responses specifically during tunnel drives as reflected in verbal fear ratings, heart rate reactions, and startle responses. Heart rate and fear ratings differentiated highly tunnel-fearful from control participants with an accuracy of 88% and 93%, respectively. Results indicate that virtual environments are valuable tools for the assessment of fear reactions and should be used in future experimental research.     

Application of virtual reality graphics in assessment of concussion.

Abnormal balance in individuals suffering from traumatic brain injury (TBI) has been documented in numerous recent studies. However, specific mechanisms causing balance deficits have not been systematically examined. This paper demonstrated the destabilizing effect of visual field motion, induced by virtual reality graphics in concussed individuals but not in normal controls. Fifty five student-athletes at risk for concussion participated in this study prior to injury and 10 of these subjects who suffered MTBI were tested again on day 3, day 10, and day 30 after the incident. Postural responses to visual field motion were recorded using a virtual reality (VR) environment in conjunction with balance (AMTI force plate) and motion tracking (Flock of Birds) technologies. Two experimental conditions were introduced where subjects passively viewed VR scenes or actively manipulated the visual field motion. Long-lasting destabilizing effects of visual field motion were revealed, although subjects were asymptomatic when standard balance tests were introduced. The findings demonstrate that advanced VR technology may detect residual symptoms of concussion at least 30 days post-injury.     

Usability of the remote console for virtual reality telerehabilitation: formative evaluation.

The Remote Console (ReCon) is a telerehabilitation application that allows therapists to remotely communicate with patients while monitoring and controlling their virtual rehabilitation exercises. It provides therapists visual feedback of patients' movements, their exercise simulations replicated in real time and with tools to conduct training without a face-to-face session. The Recon underwent a formative evaluation (a type of usability engineering methodology) used to refine its design. Five physical therapists from different practice settings acted as representative users. During the evaluation, these users made errors related to manipulation and finding and understanding controls. Technical issues with the server and audio communication were identified. These findings were used to fine-tune the ReCon system.     

Initial validation of a virtual environment for assessment of memory functioning: virtual reality cognitive performance assessment test.

The current project is an initial attempt at validating the Virtual Reality Cognitive Performance Assessment Test (VRCPAT), a virtual environment-based measure of learning and memory. To examine convergent and discriminant validity, a multitrait-multimethod matrix was used in which we hypothesized that the VRCPAT's total learning and memory scores would correlate with other neuropsychological measures involving learning and memory but not with measures involving potential confounds (i.e., executive functions; attention; processing speed; and verbal fluency). Using a sequential hierarchical strategy, each stage of test development did not proceed until specified criteria were met. The 15-minute VRCPAT battery and a 1.5-hour in-person neuropsychological assessment were conducted with a sample of 30 healthy adults, between the ages of 21 and 36, that included equivalent distributions of men and women from ethnically diverse populations. Results supported both convergent and discriminant validity. That is, findings suggest that the VRCPAT measures a capacity that is (a) consistent with that assessed by traditional paper-and-pencil measures involving learning and memory and (b) inconsistent with that assessed by traditional paper-and-pencil measures assessing neurocognitive domains traditionally assumed to be other than learning and memory. We conclude that the VRCPAT is a valid test that provides a unique opportunity to reliably and efficiently study memory function within an ecologically valid environment.     

A treadmill and motion coupled virtual reality system for gait training post-stroke.

A virtual reality (VR)-based locomotor training system has been developed for gait rehabilitation post-stroke. The system consists of a self-paced treadmill mounted onto a 6-degrees-of-freedom motion platform. Virtual environments (VEs) that are synchronized with the speed of the treadmill and the motions of the platform are rear-projected onto a screen in front of the walking subject. A feasibility study was conducted to test the capability of two stroke patients and one healthy control to be trained with the system. Three VE scenarios (corridor walking, street crossing, and park stroll) were woven into a gait-training program that provided three levels of complexity (walking speed, slopes, collision avoidances), progression criteria (number of successful trials) and knowledge of results. Results show that, with practice, patients can effectively increase their gait speed as demanded by the task and adapt their gait with respect to the change in physical terrain. However, successful completion of tasks requiring adaptation to increasing demands related to speed and physical terrains does not necessarily predict the patient's ability to anticipate and avoid collision with obstacles during walking. This feasibility study demonstrates that persons with stroke are able to adapt to this novel VR system and be immersed in the VEs for gait training.     

Immersiveness and physiological arousal within panoramic video-based virtual reality.

In this paper, we discuss findings from a study that used panoramic video-based virtual environments (PVVEs) to induce self-reported anger. The study assessed "immersiveness" and physiological correlates of anger arousal (i.e., heart rate, blood pressure, galvanic skin response [GSR], respiration, and skin temperature). Results indicate that over time, panoramic video-based virtual scenarios can be, at the very least, physiologically arousing. Further, it can be affirmed from the results that hypnotizability, as defined by the applied measures, interacts with group on physiological arousal measures. Hence, physiological arousal appeared to be moderated by participant hypnotizability and absorption levels.     

Training cognitive skills in virtual reality: measuring performance.

Across a variety of operational environments, virtual reality (VR) is being increasingly used as a means of simulating hazardous work conditions in order to allow trainees to practice advanced cognitive skills such as problem-solving and decision-making. Replicating dangerous conditions particularly involving heavy machinery in the real world can be dangerous and costly. The use of VR is therefore appealing across many industries such as aviation, mining, and rail. However, while the number of training prototypes increase less focus is being given to appropriate evaluation of the training provided via this technology. Increasing skills acquisition and performance does not depend solely on the appropriate design of simulation training. Of equal importance are strong performance measures which can ultimately feedback on the success or otherwise of training and highlight any deficits to guide ongoing improvements. To ensure cognitive skills acquired in a virtual training environment (VTE) are transferable to the real world, training objectives need to be tied directly to realistic scenario events which in turn are directly linked to measures of specific required behaviors.     

Characteristics of social perception assessed in schizophrenia using virtual reality.

Impairment in social skills is one of the few criteria that all individuals diagnosed with schizophrenia must meet. Successful social skills require the coordination of many abilities, including social perception, which involves the decoding and interpretation of social cues from others. In this study, we examined the potential for virtual reality (VR) in social skill training. We attempted to determine if VR can be used to measure social skills and social perception, and to determine which VR parameters are related to schizophrenic symptoms. Some of these results have clear clinical relevance, while other observations need further study. The VR system appears to be useful in assessing the social perception of schizophrenics and normal people, and could be more widely used in the future for social training and in the assessment of social problem-solving abilities, assertiveness skills, and general social skills.     

Impact of tasks and users' characteristics on virtual reality performance.

A better understanding of how users perform virtual reality (VR) tasks may help build better VR interfaces. In this study, we concentrated on the compensatory behavior in VR depending on the tasks and users' characteristics. The tasks characteristics considered were display size (large display vs. desktop monitor) and tasks types (manipulation and travel). The users' characteristics studied were the visual attention abilities and users' satisfaction. Ninety-five subjects participated in the experimentation composed of two parts: the first one consisted in cognitive tests used to evaluate visual attention abilities, and the second one was based on a set of VR tasks. Our result showed that large displays positively affect on performance for some kinds of VR tasks. Moreover, this impact was linked to users' satisfaction and visual attention abilities. Indeed, users with low-level attention abilities and users who preferred the large display took more advantage of large displays. We concluded that large displays can be considered cognitive aids depending on the tasks and users' characteristics.