Evidence & Research

This selection of papers was taken principally from the talk of Dr Itai Danovich as presented at Virtual Medicine 2018, and is reproduced with his kind permission. Additional content has been provided by the members of VR Doctors.

GENERAL

Virtual Reality and Medical Inpatients: A systematic Review of Randomized Controlled Trials.
Dascal J, Reid M, IsHak WW, et al. Virtual Reality and Medical Inpatients: A Systematic Review of Randomized, Controlled Trials. Innovations in Clinical Neuroscience. 2017;14(1-2):14-21.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5373791/

“Virtual reality is a promising intervention with several potential applications in the inpatient medical setting. Studies to date demonstrate some efficacy, but there is a need for larger, well-controlled studies to show clinical and cost-effectiveness.”

ACUTE PAIN

BURNS

Virtual Reality in the treatment of burn patients: A systematic review.
Burns. 2018 Jan 29. pii: S0305-4179(17)30602-2. doi: 10.1016/j.burns.2017.11.002.
https://www.ncbi.nlm.nih.gov/pubmed/29395400

“VR is a complementary drug strategy that has proven beneficial results in the treatment of burn patients.”

General Pain Reduction

The effectiveness of virtual reality distraction for pain reduction: a systematic review
Clin Psychol Rev. 2010 Dec;30(8):1011-8. doi: 10.1016/j.cpr.2010.07.001. Epub 2010 Jul 13.
https://doi.org/10.1016/j.cpr.2010.07.001

“Virtual reality technology enables people to become immersed in a computer-simulated, three-dimensional environment. This article provides a comprehensive review of controlled research on the effectiveness of virtual reality (VR) distraction for reducing pain. To be included in the review, studies were required to use a between-subjects or mixed model design in which VR distraction was compared with a control condition or an alternative intervention in relieving pain. An exhaustive search identified 11 studies satisfying these criteria. VR distraction was shown to be effective for reducing experimental pain, as well as the discomfort associated with burn injury care. Studies of needle-related pain provided less consistent findings. Use of more sophisticated virtual reality technology capable of fully immersing the individual in a virtual environment was associated with greater relief. Overall, controlled research suggests that VR distraction may be a useful tool for clinicians who work with a variety of pain problems.”

Psychological Factors

Psychological factors influencing the effectiveness of virtual reality-based analgesia: a systematic review.
Cyberpsychol Behav Soc Netw. 2014 Jun;17(6):335-45. doi: 10.1089/cyber.2014.0054.
https://doi.org/10.1089/cyber.2014.0054

“The experience of pain is affected by remarkable psychological factors. The concept of neuromatrix suggests that pain is an amalgam of affect, cognition, and sensation mediated through diverse brain regions. Moreover, the experience of pain appears to be reduced by environmental stimuli that drive attention away from the noxious events. Accordingly, immersion in a computer-generated, three-dimensional virtual environment has been used as an efficient distraction tool in a number of studies on pain management. However, no systematic approaches have explored the psychological factors that influence the effectiveness of virtual reality (VR) as a distraction technology. This review aims to outline the fundamental psychological factors involved in the use of VR to provide pain management. An analysis of the literature revealed some important elements associated with the patients’ subjective experience. Eleven studies met the inclusion criteria and were included in the review. The results suggest the importance of different psychological factors in the effectiveness of the analgesic distraction. While sense of presence influence the effectiveness of VR as a distraction tool, anxiety as well as positive emotions directly affect the experience of pain. Future challenges for pain management via VR include adopting properly validated measures to assess psychological factors and using different experimental conditions to better understand their complex effects.”

Distraction

The effectiveness of virtual reality distraction for pain reduction: a systematic review
https://doi.org/10.1016/j.cpr.2010.07.001

“Virtual reality technology enables people to become immersed in a computer-simulated, three-dimensional environment. This article provides a comprehensive review of controlled research on the effectiveness of virtual reality (VR) distraction for reducing pain. To be included in the review, studies were required to use a between-subjects or mixed model design in which VR distraction was compared with a control condition or an alternative intervention in relieving pain. An exhaustive search identified 11 studies satisfying these criteria. VR distraction was shown to be effective for reducing experimental pain, as well as the discomfort associated with burn injury care. Studies of needle-related pain provided less consistent findings. Use of more sophisticated virtual reality technology capable of fully immersing the individual in a virtual environment was associated with greater relief. Overall, controlled research suggests that VR distraction may be a useful tool for clinicians who work with a variety of pain problems.”

Psychiatric Conditions

General

Virtual reality in the assessment, understanding, and treatment of mental health disorders.
Freeman, D., Reeve, S., Robinson, A., Ehlers, A., Clark, D., Spanlang, B., & Slater, M. (2017). Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychological Medicine, 47(14), 2393-2400. doi:10.1017/S003329171700040X
https://www.cambridge.org/core/journals/psychological-medicine/article/virtual-reality-in-the-assessment-understanding-and-treatment-of-mental-health-disorders/A786FC699B11F6A4BB02B6F99DC20237

“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.”

Phobias

Recent Progress in Virtual Reality Exposure Therapy for Phobias: A Systematic Review
Curr Psychiatry Rep. 2017 Jul;19(7):42. doi: 10.1007/s11920-017-0788-4.

“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.

Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial
Freeman D, Haselton P, Freeman J, Spanlang B, Kishore S, Albery E, Denne M, Brown P, Slater M, Nickless A.
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30226-8/fulltext

“Psychological therapy delivered automatically by a VR coach can produce large clinical benefits. Evidence-based VR treatments have the potential to greatly increase treatment provision for mental health disorders.”

PTSD

Efficacy of virtual reality exposure therapy in the treatment of PTSD: a systematic review
PLoS One. 2012;7(12):e48469. doi: 10.1371/journal.pone.0048469. Epub 2012 Dec 27.

“The use of Information and Communication Technologies, such as virtual reality, has been employed in the treatment of anxiety disorders with the goal of augmenting exposure treatment, which is already considered to be the first-line treatment for Post-traumatic Stress Disorder (PTSD). To evaluate the efficacy of virtual reality exposure therapy (VRET) in the treatment of PTSD, we performed a systematic review of published articles using the following electronic databases: Web of Science, PubMed, PsycINFO, and PILOTS. Eligibility criteria included the use of patients diagnosed with PTSD according to DSM-IV, the use of cognitive behavioral therapy (CBT) and the use of virtual reality for performing exposure. 10 articles were selected, seven of which showed that VRET produced statistically significant results in comparison to the waiting list. However, no difference was found between VRET and exposure treatment. Of these 10, four were randomized, two were controlled but not randomized and four were non-controlled. The majority of the articles used head-mounted display virtual reality (VR) equipment and VR systems specific for the population that was being treated. Dropout rates do not seem to be lower than in traditional exposure treatment. However, there are a few limitations. Because this is a new field of research, there are few studies in the literature. There is also a need to standardize the number of sessions used. The randomized studies were analyzed to assess the quality of the methodology, and important deficiencies were noted, such as the non-use of intent-to- treat-analysis and the absence of description of possible concomitant treatments and comorbidities. Preliminary data suggest that VRET is as efficacious as traditional exposure treatment and can be especially useful in the treatment of patients who are resistant to traditional exposure.”

Anxiety Disorders

Virtual reality exposure therapy in anxiety disorders: a quantitative meta-analysis
Depress Anxiety. 2012 Feb;29(2):85-93. doi: 10.1002/da.20910. Epub 2011 Nov 7.
“Virtual reality exposure therapy (VRET) is a promising intervention for the treatment of the anxiety disorders. The main objective of this meta-analysis is to compare the efficacy of VRET, used in a behavioral or cognitive-behavioral framework, with that of the classical evidence-based treatments, in anxiety disorders. A comprehensive search of the literature identified 23 studies (n = 608) that were included in the final analysis. The results show that in the case of anxiety disorders, (1) VRET does far better than the waitlist control; (2) the post-treatment results show similar efficacy between the behavioral and the cognitive behavioral interventions incorporating a virtual reality exposure component and the classical evidence-based interventions, with no virtual reality exposure component; (3) VRET has a powerful real-life impact, similar to that of the classical evidence-based treatments; (4) VRET has a good stability of results over time, similar to that of the classical evidence-based treatments; (5) there is a dose-response relationship for VRET; and (6) there is no difference in the dropout rate between the virtual reality exposure and the in vivo exposure. Implications are discussed”
Virtual reality exposure therapy in anxiety disorders: a systematic review of process-and-outcome studies
Depress Anxiety. 2010 Oct;27(10):933-44. doi: 10.1002/da.20734.
“In recent years, virtual reality exposure therapy (VRET) has become an interesting alternative for the treatment of anxiety disorders. Research has focused on the efficacy of VRET in treating anxiety disorders: phobias, panic disorder, and posttraumatic stress disorder. In this systematic review, strict methodological criteria are used to give an overview of the controlled trials regarding the efficacy of VRET in patients with anxiety disorders. Furthermore, research into process variables such as the therapeutic alliance and cognitions and enhancement of therapy effects through cognitive enhancers is discussed. The implications for implementation into clinical practice are considered”

Addiction

Applications of virtual reality in individuals with alcohol misuse: A systematic review
Addict Behav. 2018 Jun;81:1-11. doi: 10.1016/j.addbeh.2018.01.036. Epub 2018 Feb 2.

“The studies that incorporate VR present clear limitations. First, no clinical trials were conducted to explore the efficacy of the VR as a treatment tool; nor were there any studies of the generalization of craving responses in the real world, or of the long-term effects of VR treatment. Despite these limitations, the studies included showed consistent results as regards eliciting and reducing alcoholcraving. We suggest that VR shows promise as a tool for the assessment and treatment of craving among individuals with alcohol misuse. Further studies implementing VR in the field of alcohol consumption are now required”

Eating Disorders

Virtual Reality as a Promising Strategy in the Assessment and Treatment of Bulimia Nervosa and Binge Eating Disorder: A Systematic Review
Behav Sci (Basel). 2017 Jul 9;7(3). pii: E43. doi: 10.3390/bs7030043.
“Several lines of evidence suggest that Virtual Reality (VR) has a potential utility in eating disorders. The objective of this study is to review the literature on the use of VR in bulimia nervosa (BN) and binge eating disorder (BED). Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for reporting systematic reviews, we performed a PubMed, Web of Knowledge and SCOPUS search to identify studies employing VR in the assessment and treatment of BN and BED. The following search terms were used: “virtual reality”, “eating disorders”, “binge eating”, and “bulimia nervosa”. From the 420 articles identified, 19 were selected, nine investigated VR in assessment and 10 were treatment studies (one case-report, two non-controlled and six randomized controlled trials). The studies using VR in BN and BED are at an early stage. However, considering the available evidence, the use of VR in the assessment of those conditions showed some promise in identifying: (1) how those patients experienced their body image; and (2) environments or specific kinds of foods that may trigger binge-purging cycle. Some studies using VR-based environments associated to cognitive behavioral techniques showed their potential utility in improving motivation for change, self-esteem, body image disturbances and in reducing binge eating and purging behavior.”

Treatment Adherence in SPMI

Virtual reality for treatment compliance for people with serious mental illness
Cochrane Database Syst Rev. 2014 Oct 8;(10):CD009928. doi: 10.1002/14651858.CD009928.pub2.

“There is no clear good quality evidence for or against using virtual reality for treatment compliance among people with serious mental illness. If virtual reality is used, the experimental nature of the intervention should be clearly explained. High-quality studies should be undertaken in this area to explore any effects of this novel intervention and variations of approach”

Psychosis

Virtual reality in the assessment and treatment of psychosis: a systematic review of its utility, acceptability and effectiveness
Psychol Med. 2018 Feb;48(3):362-391. doi: 10.1017/S0033291717001945. Epub 2017 Jul 24.

“Over the last two decades, there has been a rapid increase of studies testing the efficacy and acceptability of virtual reality in the assessment and treatment of mental health problems. This systematic review was carried out to investigate the use of virtual reality in the assessment and the treatment of psychosis. Web of Science, PsychInfo, EMBASE, Scopus, ProQuest and PubMed databases were searched, resulting in the identification of 638 articles potentially eligible for inclusion; of these, 50 studies were included in the review. The main fields of research in virtual reality and psychosis are: safety and acceptability of the technology; neurocognitive evaluation; functional capacity and performance evaluation; assessment of paranoid ideation and auditory hallucinations; and interventions. The studies reviewed indicate that virtual reality offers a valuable method of assessing the presence of symptoms in ecologically valid environments, with the potential to facilitate learning new emotional and behavioural responses. Virtual reality is a promising method to be used in the assessment of neurocognitive deficits and the study of relevant clinical symptoms. Furthermore, preliminary findings suggest that it can be applied to the delivery of cognitive rehabilitation, social skills training interventions and virtual reality-assisted therapies for psychosis. The potential benefits for enhancing treatment are highlighted. Recommendations for future research include demonstrating generalisability to real-life settings, examining potential negative effects, larger sample sizes and long-term follow-up studies. The present review has been registered in the PROSPERO register: CDR 4201507776.”

Neurological Disorders

Cerebral Palsy

Effectiveness of Virtual Reality in Children With Cerebral Palsy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Phys Ther. 2018 Jan 1;98(1):63-77. doi: 10.1093/ptj/pzx107.

“When compared with other interventions, VR seems to be an effective intervention for improving motor function in children with CP”

Effectiveness of virtual reality rehabilitation for children and adolescents with cerebral palsy: an updated evidence-based systematic review
Physiotherapy. 2017 Sep;103(3):245-258. doi: 10.1016/j.physio.2016.08.004. Epub 2016 Sep 27.

“This review uncovered additional literature showing moderate evidence that virtual reality rehabilitation is a promising intervention to improve balance and motor skills in children and adolescents with cerebral palsy. The technique is growing, so long-term follow-up and further research are required to determine its exact place in the management of cerebral palsy.

Parkinson’s Disease

[Effectiveness of virtual immersion programmes in patients with Parkinson’s disease. A systematic review]
Rev Neurol. 2018 Feb 1;66(3):69-80

“The treatments with VR cannot be assumed as more effective than conventional physiotherapy through PD subjects in motor and psychosocial variables.”

Multiple Sclerosis

Virtual reality in multiple sclerosis – A systematic review
Mult Scler Relat Disord. 2016 Jul;8:107-12. doi: 10.1016/j.msard.2016.05.014. Epub 2016 May 21.

“VR represents a motivational and effective alternative to traditional motor rehabilitation for MS patients. The results showed that VR programs could be an effective method of patients with MS rehabilitation in multiple cognitive and / or motor deficits. Additional research is needed to support the rehabilitation protocols with VR and increase the effects of treatment.”

Memory Disorders

Computerized and virtual reality cognitive training for individuals at high risk of cognitive decline: systematic review of the literature
Am J Geriatr Psychiatry. 2015 Apr;23(4):335-359. doi: 10.1016/j.jagp.2014.04.009. Epub 2014 May 14.

“The aim of this study was to assess the efficacy of cognitive training, specifically computerized cognitive training (CCT) and virtual reality cognitive training (VRCT), programs for individuals living with mild cognitive impairment (MCI) or dementia and therefore at high risk of cognitive decline. After searching a range of academic databases (CINHAL, PSYCinfo, and Web of Science), the studies evaluated (N = 16) were categorized as CCT (N = 10), VRCT (N = 3), and multimodal interventions (N = 3). Effect sizes were calculated, but a meta-analysis was not possible because of the large variability of study design and outcome measures adopted. The cognitive domains of attention, executive function, and memory (visual and verbal) showed the most consistent improvements. The positive effects on psychological outcomes (N = 6) were significant reductions on depressive symptoms (N = 3) and anxiety (N = 2) and improved perceived use of memory strategy (N = 1). Assessments of activities of daily living demonstrated no significant improvements (N = 8). Follow-up studies (N = 5) demonstrated long-term improvements in cognitive and psychological outcomes (N = 3), and the intervention groups showed a plateau effect of cognitive functioning compared with the cognitive decline experienced by control groups (N = 2). CCT and VRCT were moderately effective in long-term improvement of cognition for those at high risk of cognitive decline. Total intervention time did not mediate efficacy. Future research needs to improve study design by including larger samples, longitudinal designs, and a greater range of outcome measures, including functional and quality of life measures, to assess the wider effect of cognitive training on individuals at high risk of cognitive decline”

Spatial Navigation Disorders

The contribution of virtual reality to the diagnosis of spatial navigation disorders and to the study of the role of navigational aids: A systematic literature review
Ann Phys Rehabil Med. 2017 Jun;60(3):164-176. doi: 10.1016/j.rehab.2015.12.004. Epub 2016 Mar 24.

“Unlike pencil-and-paper tests, virtual reality is useful to assess large-scale navigation strategies in patients with brain injury or schizophrenia, or in the context of ageing and dementia. Better knowledge about both the impact of the different aids and the cognitive processes involved is essential for the use of aids in neurorehabilitation”

Upper Limb Function

Does intervention using virtual reality improve upper limb function in children with neurological impairment: a systematic review of the evidence
Brain Inj. 2011;25(5):435-42. doi: 10.3109/02699052.2011.558047. Epub 2011 Mar 14.

“Current evidence for the use of VR to improve hand and arm skills is at an emerging stage. Small sample sizes and inconsistencies in outcome measurement limit the ability to generalize findings. Further studies are required to investigate the ability to maintain gains made in VR over time and to determine whether gains transfer from the VR to real life tasks and activities”

Post-Stroke Rehabilitation

General Function

VR for stroke rehabilitation.
Laver et al. Cochrane Database Syst Rev. 2017

Effects of VR for stroke based on the Int’l Classification of Functioning and Health: a systematic review.
Palma et al. Top Stroke Rehabil. 2017

Assessment and rehabilitation of neglect using VR: a systematic review.
Pedroli et al. Front Behav Neurosci. 2015

VR in stroke rehabilitation: a meta-analysis and implications for clinicians.
Outcome Research Canada (SORCan) Working Group. Stroke. 2011

Environment & Context

VR therapy for adults post-stroke: a systematic review and meta-analysis exploring virtual environments and commercial games in therapy.
Lohse et al. PLoS One. 2014

Balance

VR for improving balance in patients after stroke: A systematic review and meta-analysis.
Li et al. Clin Rehabil. 2016

The use of VR for balance among individuals with chronic stroke: a systematic review and meta-analysis.
Iruthayarajah et al. Top Stroke Rehabil. 2017

Effect of VR Training on Balance and Gait Ability in Patients With Stroke: Systematic Review and Meta-Analysis.
de Rooij et al. Phys Ther. 2016

Effect of VR on Postural and Balance Control in Patients with Stroke: A Systematic Literature Review.
Chen et al. Biomed Res Int. 2016

Lower Limb Function

Are VR technologies effective in improving lower limb outcomes for patients following stroke – a systematic review with meta-analysis.
Gibbons et al. Top Stroke Rehabil. 2016

A Decade of Progress Using VR for Poststroke Lower Extremity Rehabilitation: Systematic Review of the Intervention Methods.
Luque-Moreno et al. Biomed Res Int. 2015

Cognitive Rehabilitation

VR for cognitive rehabilitation after brain injury: a systematic review.
Shin et al. J Phys Ther Sci. 2015

General Rehabilitation

Balance

The effectiveness of VR interventions in improving balance in adults with impaired balance compared to standard or no treatment: A systematic review.
Booth et al. JBI Libr Syst Rev

Physical Function in Elderly

VR using games for improving physical functioning in older adults: a systematic review.
Molina et al. J Neuroeng Rehabil. 2014

Mobility in Elderly

Do VR games improve mobility skills and balance measurements in community-dwelling older adults? Systematic review and meta-analysis.
Neri et al. Clin Rehabil. 2017

Lower Limb Amputation

A systematic literature review of physiotherapy and rehabilitation approaches to lower-limb amputation.
Ülger et al. Physiother Theory Pract. 2018