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Background: Motor imagery (MI) is a cognitive process that has been shown to be useful in the rehabilitation process after brain injury. Moreover, functional electrical stimulation (FES) and virtual reality (VR) have also been shown to be effective interventions in many parameters, and there is some evidence of their contribution to the improvement of MI capacity., Objective: This study aimed to compare the improvements in MI parameters, grip strength, and manual dexterity obtained using VR, FES, and selective FES based on multifield electrodes in healthy people., Methods: This clinical randomized controlled trial (RCT)with 4 branches will involve 80 healthy university students, with blinded third-party assessment. Participants will be divided into 4 groups: control (no intervention), selective FES (Fesia Grasp), traditional FES (Globus Elite), and Virtual Rehab Hands (Leap Motion sensor). Each group will receive 5 daily sessions, and assessments will be conducted at baseline, postintervention, and follow-up. The Movement Imagery Questionnaire-Revised (MIQ-RS) and chronometry will be used to assess MI, strength will be measured with a digital dynamometer, and manual dexterity will be evaluated with the Nine Hole Peg Test (NHPT) and the Box and Block Test (BBT). Statistical analyses will include 2-way repeated-measures ANOVA with post hoc Bonferroni correction to compare group differences over time, with nonparametric tests (eg, Kruskal-Wallis) being used if normality or variance assumptions are violated. The study will be organized into 3 phases: preparation, data collection, and analysis. The preparation phase will involve finalizing project protocols and obtaining ethical approvals. The data collection phase will consist of recruiting participants, randomizing them into 4 intervention groups, and conducting baseline assessments, followed by intervention sessions. Finally, the analysis phase will focus on evaluating the data collected from all groups and compiling the results for presentation., Results: The study received approval in July 2023, with recruitment and data collection starting in September 2023. The recruitment phase was expected to conclude by July 2024, and the entire study, including the 2-week follow-up, was set to finish in September 2024. As of July 2024, we had enrolled 100% of the sample (N=80 students). We plan to publish the study findings by the end of 2024., Conclusions: Improvements in MI and upper limb functionality are expected, particularly in the selective FES group. This RCT will identify which intervention is most effective in enhancing these skills, with potential benefits for patients with neurological motor disorders., Trial Registration: ClinicalTrials.gov NCT06109025; https://clinicaltrials.gov/study/NCT06109025., International Registered Report Identifier (irrid): DERR1-10.2196/63329., (©Montserrat Santamaría-Vázquez, J Hilario Ortiz-Huerta, Aitor Martín-Odriozola, Olalla Saiz-Vazquez. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 22.11.2024.)

Background: Virtual reality exposure therapy (VRET) is a promising treatment approach for anxiety disorders. However, while its efficacy has been demonstrated in adults, research on the efficacy of VRET in the treatment of adolescents with anxiety disorders is largely lacking., Objective: A pilot study was carried out to test whether exposure to a virtual reality (VR) school environment elicits state anxiety and autonomic arousal in adolescents with school anxiety (diagnoses covering social anxiety disorder or specific phobia involving school contexts). In addition, we examined whether repeated VR exposure led to a reduction in this fear response, trait school anxiety, and social anxiety symptoms. Moreover, the relationship of presence, the subjective sense of "being there," during VR exposure with anxiety measures and treatment response was examined., Methods: In a pilot study, 10 adolescents with school anxiety (age range 14 to 17 years) participated in five VRET sessions. Self-reported state anxiety, heart rate, and presence during exposure, as well as trait school anxiety and social anxiety before and after treatment, were measured., Results: The VR scenario induced state anxiety and autonomic arousal. After VRET, a significant reduction in state anxiety (η 2 =0.74) and social anxiety symptoms (d=0.82) as well as a trend toward a decrease in trait school anxiety were observed, while autonomic arousal did not change. In addition, presence during VR exposure was associated with state anxiety and treatment response., Conclusions: Our findings indicate the feasibility and potential effectiveness of VRET as a treatment method for symptoms of school and social anxiety in adolescents., (©Gesa Beele, Paula Liesong, Sabine Bojanowski, Kristian Hildebrand, Malte Weingart, Julia Asbrand, Christoph U Correll, Nexhmedin Morina, Peter J Uhlhaas. Originally published in JMIR Mental Health (https://mental.jmir.org), 05.11.2024.)

Anxiety disorders are among the most common mental disorders. Treatment guidelines recommend pharmacotherapy and cognitive behavioral therapy as standard treatment. Although cognitive behavioral therapy is an effective therapeutic approach, not all patients benefit sufficiently from it. In recent years, non-invasive brain stimulation techniques, such as transcranial magnetic stimulation, have been investigated as promising adjuncts in the treatment of affective disorders. The aim of this study is to investigate whether a combination of intermittent theta burst stimulation (iTBS) and virtual reality exposure therapy leads to a significantly greater reduction in acrophobia than virtual reality exposure with sham stimulation. In this randomized double-blind placebo-controlled study, 43 participants with acrophobia received verum or sham iTBS over the left dorsolateral prefrontal cortex prior to two sessions of virtual reality exposure therapy. Stimulation of the left dorsolateral prefrontal cortex with iTBS was motivated by an experimental study showing a positive effect on extinction memory retention. Acrophobic symptoms were assessed using questionnaires and two behavioral approach tasks one week before, after treatment and six months after the second diagnostic session. The results showed that two sessions of virtual reality exposure therapy led to a significant reduction in acrophobic symptoms, with an overall remission rate of 79 %. However, there was no additional effect of iTBS of the left dorsolateral prefrontal cortex on the therapeutic effects. Further research is needed to determine how exactly a combination of transcranial magnetic stimulation and exposure therapy should be designed to enhance efficacy., Competing Interests: Declaration of Competing Interest PP and AM are shareholders in VTplus GmbH, a commercial company specializing in the development research systems for virtual environments. There are no other financial interests that could potentially compete with this agreement., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Multiple sclerosis is a chronic, inflammatory, neurodegenerative autoimmune disease caused by myelin loss in the central nervous system, which leads to motor and non-motor problems. The main objective of this study was to explore whether an immersive virtual reality (IVR) exercise programme would be feasible as a form of physical therapy for people with MS (pwMS). Methods : 18 participants (13 women; 45.06 years) were assigned to an experimental group (EG, n = 8) and a control group (CG, n = 10). The EG took part in a twice-weekly IVR exergame physical therapy programme-ExeRVIEM programme. A randomised, single-blind clinical trial was conducted and was registered in clinicaltrials (NCT05870254). Results : The intervention was feasible and safe. The participants completed the programme with no adverse effects (no symptoms on the Simulator Sickness Questionnaire), high usability (System Usability Scale 90.31%), and outstandingly positive post-game experiences (Game Experience Questionnaire 3.10/4). In addition, the GE significantly improved several of their functional capacities: increased lower limb strength (Five Times Sit-to-Stand Test p = 0.042), improved functional mobility, and reduced fall risk (Timed Up and Go Test-simple p = 0.009; Timed Up and Go Test-cognitive p = 0.003). There were no statistically significant differences between the groups. Conclusions : The findings support that the use of exergames and IVR as physical therapy in pwMS is feasible and safe. Furthermore, there is the suggestion of possible benefits to participants' functional abilities, all of which position IVR as a promising tool for the rehabilitation of this neurodegenerative pathology affecting young adults.

Purpose: Virtual reality-based therapy (VRBT) may be an effective physical therapy complement employed in the rehabilitation of patients with anterior cruciate ligament (ACL) injury. This study aims to assess the effectiveness of VRBT in improving pain, knee function, strength, proprioception, flexion range of motion (ROM), and dynamic balance after ACL injury., Methods: We conducted this systematic review with meta-analysis following PRISMA criteria. Since inception to June 2024, we searched in PubMed Medline, WOS, SCOPUS, CINAHL and PEDro without publication date and language restrictions. Randomised controlled trials (RCTs), comprising only patients with ACL injury, that assess the effectiveness of VRBT compared to classical interventions on the outcomes of interest were included. PEDro scale was employed to analyze the methodological quality of the RCTs included. Cohen's standardised mean difference (SMD) and its 95% confidence interval (95% CI) was used to calculate the pooled effect in meta-analyses., Results: Nine RCTs, providing data from 330 participants (26.96 ± 3.11 years, 85% males) were included. The RCTs included showed good methodological quality (PEDro scale = 6.88 points), being, performance and detection biases, the most common biases reported. Meta-analyses showed that VRBT was more effective than classical interventions in reducing pain (SMD = -1.15; 95% CI -1.85 to -0.45; p = 0.001; I 2  = 0%), and increasing knee function (SMD = 1.71; 95% CI 0.93 to 2.5; p < 0.001; I 2  = 0%), strength (SMD = 0.82; 95% CI 0.4-1.23; p < 0.001; I 2  = 0%) and flexion ROM (SMD = 0.7; 95% CI 0.37-1.01; p < 0.001; I 2  = 0%). Additionally, VRBT improved postero-medial (SMD = 0.46; 95% CI 0.01-0.9; p = 0.045; I 2  = 15.1%) and postero-lateral CoP excursion (SMD = 0.75; 95% CI 0.3-1.21; p = 0.001; I 2  = 0%), being effective in improving dynamic balance., Conclusion: VRBT is an effective physical therapy complement to be included in the ACL's rehabilitation programmes due to reduces pain and increases knee function, strength, ROM and dynamic balance after ACL injury., Level of Evidence: Level II evidence., (© 2024 The Author(s). Knee Surgery, Sports Traumatology, Arthroscopy published by John Wiley & Sons Ltd on behalf of European Society of Sports Traumatology, Knee Surgery and Arthroscopy.)

Background and Objectives: Anxiety related school avoidance can affect up to 5% of a country's students each year. VRET (Virtual Reality Exposure Therapy) is a novel therapy proven to be as effective as conventional approaches for treating many anxiety disorders. The aim of this research is to co-design and evaluate a VRET intervention for students experiencing school related anxiety., Method: Eighteen adolescents participated in design thinking workshops where they developed a script and storyboard for the VRET. Using an iterative approach, a VRET prototype was developed based on this work. Eighteen teenagers were subsequently recruited to engage with the VRET for one session each and provide feedback on their experience via a structured questionnaire (supervised by a study coordinator) particularly focusing on the ability of the VR experience to reduce school related anxiety., Results: Exposure therapy needs to produce an anxiety response to be effective. The VRET was effective in producing an anxiety response in 89% of participants. Results demonstrated that 93% of participants found the simulations immersive, 94% found the scenarios believable, and 83% could relate to 'Dala', the avatar in the videos. 100% of participants believed that VRET would help with school anxiety., Conclusion: This proof-of-concept study demonstrates favourable face validity indicating promise for this mode of intervention for delivering targeted support to anxious students. VRET could be used as a scalable, cost effective early intervention to reduce the severity of anxiety associated with school avoidance.

Multiple sclerosis (MS) is an autoimmune demyelinating disease of the central nervous system with unknown etiology, resulting in various impairments that necessitate continuous rehabilitation to enhance functionality, quality of life, and motor function, including through Virtual Reality (VR) therapy. Comparing tasks in virtual environments and their potential skill transfer to real-world settings could aid in optimizing treatment programs to improve motor performance in individuals with MS. This study aimed to determine whether practicing acquisition and retention phases using two distinct interfaces (concrete-Touch Screen or abstract-Kinect system) affects performance in a subsequent task using a different interface (transfer phase). A randomized clinical trial was conducted with 56 volunteers with MS and 41 controls. Participants engaged in a computer game where they burst as many bubbles as possible within 10 s per attempt. After the acquisition and retention phases, all participants switched interfaces (e.g., those using Kinect switched to Touchscreen and vice versa). Significant performance improvements were observed in both groups during the acquisition phase, which were maintained in the retention phase. Although the abstract interface was more challenging for both groups, only the MS group that practiced with the abstract interface successfully transferred their improvements to the concrete interface. Thus, despite the increased difficulty of the abstract task during practice, it led to better performance transfer when required to complete a subsequent concrete task, suggesting that abstract devices may be beneficial in clinical practice for improving motor function in people with MS.

Purpose: To evaluate the efficacy of an immersive movement visualization intervention in patients with hemophilia and hemophilic knee arthropathy., Materials and Methods: Randomized, single-blind clinical study. Twenty-eight patients with hemophilia were recruited. Patients were randomized to an experimental group (four weeks of immersive movement visualization) and a control group (no intervention). The intensity of pain, pressure pain threshold in the knee, tibialis anterior muscle, lower back level, conditioned pain modulation, range of knee motion, and lower limb functionality were evaluated., Results: There were statistically significant differences in the intergroup effect on knee pain intensity ( F  = 23.71; p  < 0.001) and lower limb functionality ( F  = 7.11; p  = 0.003). 42.86% of the patients in the experimental group exhibited changes greater than the minimum detectable change (MDC) in functionality. 39.29% of the patients subject to the intervention experienced changes greater than the MDC in the knee pressure pain threshold., Conclusions: Immersive motion visualization can improve the intensity of joint pain and functionality in patients with hemophilic knee arthropathy. Functionality, pressure pain threshold, and pain intensity improved in those patients who conducted immersive movement visualization.Implications for rehabilitationImmersive visualization of movement significantly improves intensity of joint pain, functionality, pressure pain threshold, joint health, and conditioned pain modulation in patients with hemophilic knee arthropathy.The fact that it is a therapy without potential aversive stimuli makes it a possible access pathway for patients with high levels of kinesiophobia and/or catastrophism.This low-cost, home-based technology allows its use in patients far from hemophilia reference centers or with difficult access to physiotherapy treatments.The immersive visualization of movement influences the democratization of treatment, in accordance with the WHO's Sustainable Development Goal 3 (health and well-being for all).

Background: high-intensity exercise is a feasible and effective modality in the early stages of Parkinson's disease (PD). However, there are only a few studies that have carried out this type of intervention in customizable immersive virtual reality (IVR) environments. We explore the feasibility and effects of IVR-based high-intensity training through rowing and cycling exercises on the functional capacity, quality of life, and progression of PD., Methods: a total of 12 participants (61.50 ± 10.49 years old; 41.7% female, 58.3% male; stages I-III) were part of the study, which consisted of interventions of rowing and cycling in an IVR commercial exergame (25 min; twice per week for 14 weeks). The main variables measured were functional capacity, handgrip strength, functional mobility (TUG), functional lower-limb strength (FTSST), aerobic capacity (2-min step test), quality of life (PDQ-39), and Parkinson's disease progression (MDS-UPDRS)., Results: the results showed a general improvement in handgrip strength in both hands ( p = 0.008; d = 0.28), FTSST ( p = 0.029; d = 0.96), and TUG times ( p = 0.152; d = 0.22). Aerobic capacity, assessed by a 2-min step test, showed enhanced scores ( p = 0.031; d = 0.78). Related to the PDQ-39, all dimensions of the scale were enhanced, highlighting activities of daily living ( p = 0.047; d = 0.29) and bodily discomfort ( p = 0.041; d = 0.37). Finally, the main symptoms of the disease were reduced, with an improvement in the parameters that show a better incidence of disease progression, such as Part IA and IB ( p = 0.013; d = 0.29 and p = 0.021; d = 0.25, respectively), Part II ( p = 0.021; d = 0.23), Part III ( p = 0.040; d = 0.39), and Part IV ( p = 0.013; d = 0.39)., Conclusions: the therapeutic exercise (rowing and cycling), when carried out at a high intensity and in a personalized IVR scenario, appear to be a feasible and safe modality for patients with stages I-III of PD, improving their functional capacity, quality of life, and disease progression.

Background and Objectives: Virtual reality exposure therapy offers a unique opportunity to treat social anxiety disorder. This meta-analysis aims to evaluate the effectiveness of virtual reality exposure therapy compared to waitlist comparators or other interventions for individuals with social anxiety disorder in alleviating anxiety symptoms., Methods: A three-step comprehensive search for the randomized controlled trials of virtual reality exposure therapy was conducted from inception to 7 December 2023. The overall effect was measured using Hedges' g and determined using t -statistics at a significance level of p  < 0.05. Sensitivity, subgroup, and meta-regression analyses were carried out., Results: A total of 17 randomized control trials were retrieved from nine electronic databases. Virtual reality exposure therapy has greater efficacy than waitlist comparators in reducing anxiety symptoms at post-intervention and follow-up assessment. Virtual reality exposure therapy demonstrates a similar effect to other interventions at post-intervention and follow-up assessment. We observed a greater effect for participants with symptomatic social anxiety when we combined the intervention with cognitive behavioral therapy compared to its counterpart. Meta-regression analyses found no significant covariate., Conclusions: Overall, virtual reality exposure therapy can provide supplementary therapy for improving anxiety symptoms. Additional high-quality and large-scale trials with long-term follow-up are needed.

Objective: To investigate the effects of a stimulus response task using virtual reality (VR) for unilateral spatial neglect (USN)., Design: Double-blind randomized controlled trial., Setting: Acute phase hospital where stroke patients are hospitalized., Participants: The participants were 42 patients (N=42) with right-hemisphere cerebral damage who had been experiencing USN in their daily lives. They were randomly assigned to 3 groups: a stimulus response task with a background shift (SR+BS group), a stimulus response task without a background shift (SR group), and an object gazing task (control group)., Interventions: The stimulus response task was to search for balloons that suddenly appeared on the VR screen. A background shift was added to highlight the search in the neglected space. The control task was to maintain a controlled gaze on a balloon that appeared on the VR screen. The intervention period was 5 days., Main Outcome Measures: The primary outcome was the participants' scores on a stimulus-driven attention test (SAT) using the reaction time. The stimuli of the SAT were divided into 6 blocks of 3 lines on each side (-3 to +3). The secondary outcomes were their scores on the Behavioral Intention Test conventional, Catherine Bergego Scale, and straight ahead pointing tests., Results: In the SAT, there were significant interaction effects of reaction time between time and group factors in left-2, right+2, and right+3. The SR+BS and SR groups showed significant improvements in the reaction time of left-2 and right+3 compared with the control group. Moreover, the SR+BS group showed a significant improvement in the reaction time of left-2, which was the neglected space, compared with the SR group. However, there were no significant interaction effects of Behavioral Intention Test conventional, Catherine Bergego Scale, and straight ahead pointing., Conclusions: Our results suggest that the use of stimulus response tasks using VR combined with background shifts may improve left-sided USN., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Specific phobias impact over 400 million people worldwide. Digitalizing mental health could alleviate the burden. Still, although the corporate-driven Metaverse is expanding rapidly, there needs to be more momentum in harnessing virtual reality exposure therapy uptake. Objective: This study aims to conceptualize, develop, and deploy a free Virtual Reality Exposure Therapy (VRET) application specifically designed for treating acrophobia and claustrophobia. This pilot study, which holds the promise of a future where mental health is more accessible and effective, explores the feasibility of leveraging transdisciplinary collaboration among specialists to create a safe, accessible, and effective VRET solution. Methods: We conducted a Delphi heuristic approach involving bioethicists, neuroscientists, and tech developers. Second, we reviewed the existing psychological theories and therapeutic strategies for addressing phobias in VR. Third, we conceptualized a thematic analysis-derived framework for a safe, adaptive-gamified free exposure to virtual reality acrophobia and claustrophobia (SAFEvR ACT). Finally, we provide an overview of the iterative improvements made during 12 workshops and 76 weekly briefings on developmental implementations. Results: We developed the SAFEvR ACT into a proof-of-concept application freely deployed on the MentalVerse app platform. Our safety-focused approach can benefit from prevalidation perspectives within future randomized control trials. Conclusions: The resulting application derived from the SAFEvR ACT framework represents a blueprint to counter the current lack of iVR mental health uptake by offering a free VRET alternative. Future research should aim towards developing similar free platforms to lessen mental health burdens and gather quantitative data. We conclude with a call to action to researchers to fine-tune our current approach and take a stand for free digital mental health within MentalVeRse.app.

Purpose: To assess the analgesic and anxiolytic effects of virtual reality (VR) augmentation in patients undergoing peripherally inserted central catheter (PICC) placement or fine-needle aspiration thyroid biopsy., Materials and Methods: This is a prospective, single-center randomized controlled trial with 107 patients enrolled. Patients were randomly assigned to receive standard of care (SOC) or SOC+VR during PICC or thyroid biopsy procedures. Pain and anxiety were individually measured using the visual analog scale (VAS) before and after the procedure. Vital signs including heart rate and systolic and diastolic blood pressure were recorded. One-way analysis of variance test and Games-Howell post hoc analysis were used to assess effect size and statistical significance between SOC and SOC+VR measures., Results: The PICC cohort consisted of 59 patients (33 in SOC+VR and 26 in SOC), with a median age of 53.1 years (interquartile range [IQR], 38.3-62.7 years). The thyroid biopsy cohort consisted of 48 patients (26 in SOC+VR and 22 in SOC), with a median age of 60.1 years (IQR, 49.0-67.2 years). One-way analysis of individuals undergoing thyroid biopsies with adjunctive VR revealed an effect size of -1.74 points (SE ± 0.71; P = .018) on VAS pain scale when compared with SOC. Analysis of individuals undergoing PICC placements revealed an effect size of -1.60 points (SE ± 0.81; P = .053) on VAS anxiety when compared with SOC., Conclusions: VR as a nonpharmacologic adjunct reduced some procedure-related pain and anxiety without increasing the procedural duration., (Copyright © 2024 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Social anxiety disorder (SAD) places a profound burden on public health and individual wellbeing. Systemic inflammation may be important to the onset and maintenance of SAD, and anti-inflammatory treatments have shown promise in relieving symptoms of SAD. In the present study, we conducted secondary analyses on data from a randomized clinical trial to determine whether C-reactive protein (CRP) concentrations and social anxiety symptoms decreased over the course of virtual reality exposure therapy, and whether changes in social anxiety symptoms as a function of treatment varied as a function of CRP., Method: Adult participants (N = 78) with a diagnosis of SAD (59 % female) were randomized to receive exposure therapy alone, or exposure therapy supplemented with scopolamine. Social anxiety symptoms, salivary CRP, and subjective units of distress were measured across three exposure therapy sessions, at a post-treatment extinction retest, and at a 1-month follow-up., Results: CRP decreased over the course of treatment, b = -0.03 (SE = 0.01), p =.02 95 %CI [-0.06, -0.004], as did all social anxiety symptom domains and subjective distress. Higher CRP was associated with greater decreases from pre-treatment to 1-month follow-up in fear, b = -0.45 (SE = 0.15), p =.004 95 %CI [-0.74, -0.15], and avoidance, b = -0.62 (SE = 0.19), p =.002 95 %CI [-1.01, -0.23], and in-session subjective distress from pre-treatment to post-treatment, b = -0.42 (SE = 0.21), p =.05 95 %CI [-0.83, -0.001]. However, declines in CRP were not correlated with declines in fear, r = -0.07, p =.61, or avoidance, r = -0.10, p =.49, within-persons., Conclusions: Virtual reality exposure therapy may be associated with an improvement in systemic inflammation in patients with severe SAD. Pre-treatment CRP may also be of value in predicting which patients stand to benefit the most from this treatment., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The presence of mental health conditions is pervasive in patients who experienced acute myocardial infarction (AMI), significantly disrupting their recovery. Providing timely and easily accessible psychological interventions using virtual reality-based cognitive-behavioural therapy (VR-CBT) could potentially improve both acute and long-term symptoms affecting their mental health., Aims: We aim to examine the effectiveness of VR-CBT on anxiety symptoms in patients with AMI who were admitted to the intensive care unit (ICU) during the acute stage of their illness., Methods: In this single-blind randomised clinical trial, participants with anxiety symptoms who were admitted to the ICU due to AMI were continuously recruited from December 2022 to February 2023. Patients who were Han Chinese aged 18-75 years were randomly assigned (1:1) via block randomisation to either the VR-CBT group to receive VR-CBT in addition to standard mental health support, or the control group to receive standard mental health support only. VR-CBT consisted of four modules and was delivered at the bedside over a 1-week period. Assessments were done at baseline, immediately after treatment and at 3-month follow-up. The intention-to-treat analysis began in June 2023. The primary outcome measure was the changes in anxiety symptoms as assessed by the Hamilton Anxiety Rating Scale (HAM-A)., Results: Among 148 randomised participants, 70 were assigned to the VR-CBT group and 78 to the control group. The 1-week VR-CBT intervention plus standard mental health support significantly reduced the anxiety symptoms compared with standard mental health support alone in terms of HAM-A scores at both post intervention (Cohen's d=-1.27 (95% confidence interval (CI): -1.64 to -0.90, p<0.001) and 3-month follow-up (Cohen's d=-0.37 (95% CI: -0.72 to -0.01, p=0.024). Of the 70 participants who received VR-CBT, 62 (88.6%) completed the entire intervention. Cybersickness was the main reported adverse event (n=5)., Conclusions: Our results indicate that VR-CBT can significantly reduce post-AMI anxiety at the acute stage of the illness; the improvement was maintained at the 3-month follow-up., Trial Registration Number: The trial was registered at www.chictr.org.cn with the identifier: ChiCTR2200066435., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In Cardiovascular Rehabilitation (CR), patient adherence to the maintenance phase is a major challenge. Virtual reality-based therapy (VRBT) promotes acute hemodynamic and autonomic repercussions similar to traditional rehabilitation and can increase patient adherence to the program. However, it is unknown whether the combination of VRBT to a traditional CR manages to maintain or even improve clinical and autonomic variables in long term., Objective: To analyze whether VRBT combination in a traditional CR can maintain or improve clinical and autonomic variables in cardiac patients in the maintenance phase of these programs., Methods: Twenty-six volunteers (62.04 ± 12.22 years) were evaluated, who underwent an initial assessment and two other assessments (in the sixth and 12 th week) of the following outcomes: systolic and diastolic blood pressure, respiratory rate, pulse saturation of oxygen, heart rate, perceived exertion, and cardiac autonomic modulation, using linear and non-linear heart rate variability methods., Results: Except for the apparent lack of clinical significance observed in Shannon Entropy, LF (nu), and HF (nu), the combination of VRBT as routine in a traditional program did not cause significant changes in the analyzed variables., Conclusion: combination of VRBT was able to maintain the chronic hemodynamic and autonomic repercussions caused by traditional CR.

Virtual Reality Exposure Therapy is a method of cognitive behavioural therapy that aids in the treatment of anxiety disorders by making therapy practical and cost-efficient. It also allows for the seamless tailoring of the therapy by using objective, continuous feedback. This feedback can be obtained using biosensors to collect physiological information such as heart rate, electrodermal activity and frontal brain activity. As part of developing our objective feedback framework, we developed a Virtual Reality adaptation of the well-established emotional Stroop Colour-Word Task. We used this adaptation to differentiate three distinct levels of anxiety: no anxiety, mild anxiety and severe anxiety. We tested our environment on twenty-nine participants between the ages of eighteen and sixty-five. After analysing and validating this environment, we used it to create a dataset for further machine-learning classification of the assigned anxiety levels. To apply this information in real-time, all of our information was processed within Virtual Reality. Our Convolutional Neural Network was able to differentiate the anxiety levels with a 75% accuracy using leave-one-out cross-validation. This shows that our system can accurately differentiate between different anxiety levels.

In France, virtual reality has been experimented since 2016 to address addictive behaviors. The existing literature insists on the "immersive" dimension of the technology as a significant factor in the efficacy of exposure. An ethnographic approach, however, suggests that the realism criterion should be reassessed. Based on a fieldwork conducted in the addictology department of a French hospital that made use of Virtual reality therapy (VRT), the article shows that it is a form of technical reiteration designed to develop reflexivity about one's actions, provoking the craving so that it can be domesticated. The patient's engagement in "as if" mode is facilitated by the therapist's work in mapping the patient's addictive practices, personalizing the exposure situations, and elaborating the simulation as being part of a practical experiment. While the question of graphic realism does not seem especially problematic, the question of social plausibility can put the simulation operation under strain., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Virtual reality (VR) as a digital technology has developed rapidly, becoming more realistic, portable, sensory and easier to navigate. Although studies have found VR to be effective for many clinical applications, patients and clinicians have described several barriers to the successful implementation of this technology. To remove barriers for implementation of VR in health care, a greater understanding is needed of how VR can integrate into clinical environments, particularly complex settings such as an intensive care unit., Aim: This study aimed to explore the perceived barriers and facilitators for the implementation of VR exposure therapy for intensive care patients and clinical staff., Study Design: A qualitative study using an Interpretative Description approach was undertaken. Semi-structured focus groups were conducted with 13 participants: nine patients and four health care professionals. Focus groups explored barriers and facilitators of using virtual reality (VR) exposure therapy in intensive care. Thematic analysis was employed to produce codes and themes., Results: In total, eight themes describing the perceived barriers and facilitators to implementing VR exposure therapy were identified. Four themes related to the perceived barriers of implementing VR exposure therapy in intensive care were identified: psychological, sensory, environmental and staff competency and confidence. There were a further four themes related to the perceived facilitators to the implementation of VR exposure therapy: staff training, patient capacity, orientation to technology and support during the intervention., Conclusions: This study identified novel barriers and facilitators that could be expected when implementing VR exposure therapy for patients' post-intensive care unit stay. The findings suggest that psychological barriers of fear and apprehension were expected to provoke patient avoidance of exposure therapy. Perceived barriers for staff focused on preparedness to deliver the VR exposure therapy and a lack of technological competence. Both patients and staff stated that a comprehensive induction, orientation and training could facilitate VR exposure therapy, improving engagement., Relevance to Clinical Practice: This study has identified that with appropriate staff training, resources, and integration into current patient care pathways, VR exposure therapy may be a valuable intervention to support patient recovery following critical illness. Prior to undertaking VR exposure therapy, patients often need reassurance that side-effects can be managed, and that they can easily control their virtual exposure experience., (© 2022 The Authors. Nursing in Critical Care published by John Wiley & Sons Ltd on behalf of British Association of Critical Care Nurses.)

Objective: Virtual reality (VR) is a promising non-pharmacologic tool for managing health care anxiety. We assessed the feasibility and acceptability of a pre-operative VR intervention by adult patients and medical staff and measured anxiety in adult patients pre- and post-VR intervention., Study Design: We recruited 30 patients scheduled to undergo oral surgery and 8 medical staff as participants. The patients completed a verbal demographic survey and rated their anxiety before the VR intervention and at 1 minute and 2 minutes post-intervention. We administered the Acceptability of Intervention Measure to the patients to measure their perceptions of the VR intervention and the Feasibility of Intervention Measure to the medical staff to assess their perception of VR implementation. We performed an analysis of variance to compare pre-operative anxiety over time and assess demographic differences., Results: The patients showed high and consistent acceptability of the pre-operative use of VR among patients, but acceptability varied among medical staff. The patients experienced a statistically significant reduction of pre-operative anxiety (P = .003)., Conclusion: A brief VR pre-intervention is highly accepted by and very beneficial for patients undergoing oral surgery, positively affecting anxiety reduction. The perception of VR by health care providers needs to be explored to increase acceptability., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Virtual reality (VR) is increasingly used in psychotherapy, and the speed of development of therapeutic VR tools is continuously increasing., Objective: This narrative review provides an overview of the state of the art regarding VR applications for psychotherapy., Material and Methods: The current state of VR therapy research for anxiety disorders and posttraumatic stress disorder (PTSD) is summarized. The focus lies on VR exposure therapy. Current developments in the field are outlined., Results: For anxiety disorders, especially phobic disorders, there are already positive recommendations in the current German S3 guidelines. For PTSD, the development of VR therapy tools is still in a relatively early stage., Conclusion: The development of mobile cost-effective VR solutions in recent years has enabled entirely new applications for VR. The empirical challenges of these new developments are considerable. Nevertheless, the chances for an improvement of psychotherapeutic routine care are good., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objectives: Exposure therapy is a cornerstone of social anxiety treatment, yet not all patients respond. Symptoms in certain social situations, including intergroup (ie, out-group) contexts, may be particularly resistant to treatment. Exposure therapy outcomes may be improved by stimulating neural areas associated with safety learning, such as the medial prefrontal cortex (mPFC). The mPFC also plays an important role in identifying others as similar to oneself. We hypothesized that targeting the mPFC during exposure therapy would reduce intergroup anxiety and social anxiety., Methods: Participants (N = 31) with the public speaking subtype of social anxiety received active (anodal) or sham transcranial direct current stimulation (tDCS) targeting the mPFC during exposure therapy. Exposure therapy consisted of giving speeches to audiences in virtual reality. To target intergroup anxiety, half of the public speaking exposure trials were conducted with out-group audiences, defined in this study as audiences of a different ethnicity., Results: Contrary to hypotheses, tDCS did not facilitate symptom reduction. Some evidence even suggested that tDCS temporarily increased in-group favoritism, although these effects dissipated at 1-month follow-up. In addition, collapsing across all participants, we found reductions across time for public speaking anxiety and intergroup anxiety., Conclusions: The data provide evidence that standard exposure therapy techniques for social anxiety can be adapted to target intergroup anxiety. Transcranial direct current stimulation targeting the mPFC may boost safety signaling, but only in contexts previously conditioned to signal safety, such as an in-group context., Competing Interests: The authors have no conflicts of interest or financial disclosures to report., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objectives: Virtual reality (VR) interventions are becoming more prevalent in treating fear of flying (FoF). Since multisensory stimulation can enhance the sense of presence in a virtual environment, the present study compared virtual reality exposure with and without vibrotactile cues to determine its contribution to the realism of the virtual experience., Methods: A repeated measures design was used. Thirty-one participants were exposed to two experimental conditions with a minimum of a one-week interval between them: one in which participants were exposed to the virtual environment with vibrotactile cues (smart chair, SC), and another in which participants were exposed to the virtual environment without vibrotactile cues (ordinary chair, OC). The administration order of both conditions was counterbalanced to avoid possible order effects., Results: Participants felt higher levels of sense of presence when using the SC than the OC. However, the addition of vibrotactile stimulation partially influenced experienced anxiety. Some personality traits were also associated with participants' sense of presence and anxiety responses during the exposure., Limitations: The sample size was smaller than required. Moreover, only self-reported measures were used. Finally, a roller coaster instead of an airplane scenario was used for the exposure, which might not have been suitable enough for provoking anxiety in participants with FoF., Conclusions: Vibrotactile cues enhanced the sense of presence. However, the addition of vibrotactile stimulation did not have a consistent effect on anxiety experienced during exposure. Therefore, the benefits of incorporating vibrotactile cues in virtual reality environments for exposure therapy are not clear., Competing Interests: Declaration of competing interest The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Public Speaking Anxiety (PSA) interventions targeting adolescents exist; however, not all gain improvement. This exploratory study investigated whether PSA interventions resulted in a decrease in perfectionism and whether pre-treatment level and changes in perfectionism moderated the effects on PSA and social anxiety. The sample consisted of 100 adolescents from junior high schools randomized to four groups: 1) VR only ( n  = 20), 2) VR + online exposure program ( n  = 20), 3) online psychoeducation and online exposure program ( n  = 40), 4) waitlist and online psychoeducation program ( n  = 20). Self-reported symptoms of PSA, social anxiety, and perfectionism were measured at pre, week 3, post, and 3-months follow-up. Level and change in outcome variables were analyzed using latent growth curve modeling. Results revealed that the interventions did not lead to a reduction in perfectionism. Reduction in perfectionism was associated with a larger reduction in all outcome measures from post to follow-up. No interaction was found between pre-treatment perfectionism and PSA symptoms. High pre-treatment levels of perfectionism were associated with poorer outcomes on social anxiety symptoms from post to follow-up for online exposure groups. The results indicate that one should assess and address high pre-treatment levels of perfectionism during PSA interventions.

Excessive self-criticism is an important transdiagnostic psychological factor. In contrast, self-compassion can contribute to the resilience and recovery of clinical populations, making this an important target for treatment. Virtual Reality (VR) has the potential to improve existing interventions as it allows for personalized roleplays that can be experienced from different perspectives, by using the novel VR technique of perspective change. We investigated the effects of a VR intervention on self-criticism and self-compassion, and the added value of changing perspectives. In total, 68 undergraduate students with high levels of self-criticism were randomized to either the perspective change condition or the control condition. Participants played two roleplays in which they had to react compassionately toward a virtual character that expressed the participants' own self-critical thoughts. In the perspective change condition, after each roleplay perspective change was used to receive one's own compassionate words. Results showed that self-compassion increased and self-criticism decreased significantly in both conditions. No significant differences were found for negative and positive affect. Furthermore, no differences were found between the conditions. Thus, receiving compassionate words through perspective change had no additional effect. Expressing compassion to someone with similar self-criticism showed to be sufficient to reduce self-criticism and increase self-compassion., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Clinical and experimental studies on virtual reality have shown that this easy-to-use and non-invasive method is a safe and effective strategy during normal labor., Aim: This study aims to analyze the effects of virtual reality (VR) interventions on some of the parameters of normal labor., Design: Systematic review and meta-analysis., Method: Higher Education Council National Thesis Center, Scopus, PubMed, Google Scholar, and Science Direct databases were systematically searched for randomized controlled trials that administered VR to the intervention group but not to the control group and were published through January 2022. RevMan software was used to analyze the meta-analysis data. Pain, anxiety, satisfaction, and the duration of the first and second stages of labor were assessed as outcomes of normal labor., Results: Seven randomized controlled trials, with a total of 756 women in total, met the inclusion criteria. Virtual reality interventions significantly reduced pain scores when cervical dilatation was ≤4 cm (MD = -0.43, 95% expansion here (CI [-0.65, -0.21], p < .001) and ≥9 cm (SMD = -1.91, 95% CI [-2.56, -1.26], p < .001). Anxiety scores significantly decreased (SMD = -1.08, 95% CI [-1.75, 0.41], p < .001), and childbirth satisfaction significantly increased (MD = 11.24, 95% CI [2.17, 20.30], p < .001) in the VR intervention groups. Finally, when compared to the control groups, the duration of the first stage of labor (SMD = -0.53, 95% CI [-0.83, -0.22], p < .01) and the second stage of labor (MD = -0.39, 95% CI [-0.76, -0.02], p = .001) were significantly decreased in the VR intervention groups., Conclusions: Virtual reality interventions are effective methods to reduce pain, anxiety, and the duration of the first and second stages of labor and to increase satisfaction with normal labor., Competing Interests: Declaration of Competing Interests The authors declare that they have no competing interests., (Copyright © 2023. Published by Elsevier Inc.)

Background: Stigma toward people with serious mental illnesses (SMI), like schizophrenia, is a serious global public health challenge that limits the quality of life of those affected and poses a major barrier that keeps people from seeking professional help. There is an urgent need for novel, effective, and scalable interventions to decrease stigmatized perceptions of chronic psychotic disorders and to reduce the health burden imposed by them. Method: We conducted a randomized controlled trial to assess the impact of a new immersive virtual reality game ( Inclúyete-VR ) on the level of stigma toward people with SMI, measured by the Attribution questionnaire (AQ-27). Participants in the experimental group were exposed in an immersive way to hallucinations common in schizophrenia, then shown different psychosocial resources available for their recovery and social inclusion; those in the control group used VR software unrelated to mental health. VR sessions were delivered through Oculus headgear and lasted 25 minutes. Results: We randomly assigned 124 university students (55% female) to experimental or control conditions ( n  = 62 each). We used mixed ANOVA to compare outcomes before and after the intervention between the two groups. We found a significant intervention-by-time interaction ( P  < 0.001), with a reduction in the experimental group of overall stigma levels on the AQ-27 scale and its three subscales: dangerousness-fear, avoidance, and lack of solidarity ( P  < 0.001 for all). Conclusions: The Inclúyete-VR software proved effective in the short term in reducing stigma toward people with severe mental illness. The program's longer-term efficacy, scalability, and dissemination remain to be studied. ClinicalTrials.gov Identifier: NCT05393596.

Purpose: Immersive Virtual Reality (VR) systems allow for highly repetitive tasks to be performed within a virtual environment that increases practice in home environments. VR can increase access to rehabilitation by reducing access barriers. However, rehabilitation outcomes between immersive VR systems and conventional physical rehabilitation are not well understood. The purpose of this case study was to assess the use of a custom clinically based VR simulation for testing gross hand dexterity with an individual with chronic stroke., Materials and Methods: The participant performed the box and blocks test (BBT) in an immersive VR environment and a physical environment. Three trials of the BBT were performed with their less-affected and affected hands each in both environments while measuring cortical activity using fNIRS. Rests were given between trials and environment conditions., Results: Our results show that there was no statistical difference in the number of blocks moved between the physical and VR BBT for both the affected and less-affected hands. Furthermore, our results also indicate no statistically significant difference between the physical BBT and VR BBT conditions on contralateral motor cortex activation, suggesting that cortical involvement is comparable between physical and VR conditions., Conclusions: These results suggest that an immersive VR system may be able to elicit functional and motor cortex activations that are comparable to the conventional physical BBT. Importantly, these findings highlights the potential benefits of VR therapy as a remote therapy intervention and/or to increase the effectiveness and practicality of current in-person rehabilitation programs.Implications for rehabilitationThese findings highlight the potential benefits of immersive virtual reality as a remote therapy intervention.Immersive virtual reality use has potential benefits to increase the effectiveness and practicality of current in-person rehabilitation programs.

Background: Hemodialysis patients are prone to anxiety and depression due to physiological changes and psychological tensions that leave irreversible effects on the patients. In this regard, the present study was an attempt to provide a simulated situation by using virtual reality on the anxiety level of dialysis patients before performing surgical procedures., Methods: This non-equivalent groups pre-posttest quasi-experimental study was conducted in 2022 in a hemodialysis ward of Imam Khomeini General Hospital affiliated with Tehran University of Medical Sciences. The study population was patients suffering from kidney failure referred to this hospital. The participants were 30 patients selected from the study population, who were allocated into two groups (15 in each experimental and control group). The control group received routine training in the ward. The experimental group participants watched five educational virtual reality (VR) contents in addition to the routine training. They used head-mounted display VR (VR BOX headset 2.0 virtual reality glasses) to immerse in a virtual environment similar to the real world covering the experience of entering the operating room, during the surgery, and after surgery. The data gathering instrument was a valid and reliable anxiety inventory. The collected data was analyzed at a significance level of 0.05., Results: The study findings indicated that the anxiety scores of the experimental and control groups had no significant difference before intervention. However, after the intervention of virtual reality, the state and trait anxiety of the experimental group participants were significantly lower than the control group (P-value < 0.01)., Conclusion: The application of VR for maintenance hemodialysis patients before invasive surgical procedures decreases patients' anxiety. Considering the devastating and undeniable impacts of anxiety on the lives of patients referring to hemodialysis centers, the application of VR is suggested to decrease their anxiety., (© 2024. The Author(s).)

Objective: To examine the characteristics and the effectiveness of virtual reality systems on upper limb impairments in children and young adults with cerebral palsy., Data Sources: An electronic search was conducted on PubMed, PEDro, Web of Science, Central, and EMBASE., Methods: The protocol of this review was prospectively registered in the PROSPERO database (CRD42022302271). Randomized controlled trials that tested the effects of virtual reality-based interventions on the upper limb of participants with cerebral palsy were included. The methodological quality of the studies was measured by the PEDro scale. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation. The data of the studies were analyzed in meta-analysis and presented in forest plots and narrative synthesis., Results: Twenty-two studies involving 746 participants were included. Ten different virtual reality systems were used in the interventions, of which six were designed specifically for rehabilitation and four commercial video games. We found an effect in favor of virtual reality when it was used in combination with conventional therapy for upper limb activity (SMD = 0.65; 95% CI (0.19 to 1.11)). However, the certainty of the evidence of the comparisons ranged from very low to low., Conclusion: Virtual reality seems to be an effective tool for upper limb activity in children and young adults with cerebral palsy. Nevertheless, future studies should present a better methodological quality, a larger sample size, and well-defined rehabilitation programs to reduce the inconsistency of the evidence in this domain., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study aims to evaluate the extent to which virtual reality (VR) natural and built settings affect emotional states. Web of Science, SCOPUS, and PubMed were searched for relevant articles prior to February 2022. Of 15 articles identified for systematic review, 6 met the inclusion criteria for meta-analysis (studies with only pre- and post-condition measures of the Positive and Negative Affect Schedule (PANAS) were included). Both positive affect ( g  = 0.20, p  = 0.001) and negative affect ( g  = - 0.30, p  = 0.001) change scores for the VR natural environment were statistically significant. On the other hand, change scores for VR built environment were not significant in both positive affect ( g  = - 0.08, p  = 0.355) and negative affect ( g  = - 0.08, p  = 0.058). The findings revealed that, in addition to a VR natural environment, a VR built environment is capable of providing restorative experiences against negative mood in some circumstances.

Purpose: To evaluate the efficacy of an iVR surgical training system for orthognathic surgery training in medical students., Methods: This study comprised 20 fifth year medical students who were randomly assigned to the VR or traditional group for orthognathic surgical education. All participants were initially provided a lecture on orthognathic surgery. The VR group then received 10 educational sessions using the self-developed iVR training system, whereas the traditional group received 10 sessions using technical manuals and annotated operation videos. These sessions were 40-min long in both the groups. Before the evaluation, the traditional group completed one session using the training and assessment modes to become familiar with the iVR training system. The score in the assessment mode, time to complete the procedure, number of instrument selection errors, number of prompts given by the system, number of positional and angular errors, and number of timeouts during each step were recorded to evaluate the learning effect., Results: The VR group achieved higher scores than the traditional group (94.67 vs. 87.65). Compared with the control group, the VR group completed the procedure more quickly, with fewer instrument selection and angular errors. No difference in the number of prompts given by the system was observed between the two groups., Conclusions: The iVR surgical training system showed a better learning effect than the traditional learning method for orthognathic surgery. The iVR surgical training system may have utility as a supplement and potential substitute for the traditional surgical training method., (© 2023 American Dental Education Association.)

Introduction: Virtual reality (VR) and transcutaneous electrical nerve stimulation (TENS) have emerged as effective interventions for pain reduction. However, their standalone applications often yield limited analgesic effects, particularly in certain painful conditions., Aims: Our hypothesis was that the combination of VR with TENS in a synchronous manner could produce the best analgesic effect among the four experimental conditions., Methods: To address this challenge, we proposed a novel pain modulation strategy that synchronously combines VR and TENS, aiming to capitalise on both techniques' complementary pain modulation mechanisms. Thirty-two healthy subjects participated in the study and underwent three types of interventions: VR alone, a combination of VR with conventional TENS, and a combination of VR with synchronous TENS. Additionally, a control condition with no intervention was included. Perceived pain intensity, pain unpleasantness, positive and negative affect scores, and electroencephalographic (EEG) data were collected before and after the interventions. To delve into the potential moderating role of pain intensity on the analgesic efficacy of VR combined with synchronous TENS, we incorporated two distinct levels of painful stimuli: one representing mild to moderate pain (ie, low pain) and the other representing moderate to severe pain (ie, high pain)., Results: Our findings revealed that both combination interventions exhibited superior analgesic effects compared with the VR-alone intervention when exposed to low and high pain stimuli. Notably, the combination of VR with synchronous TENS demonstrated greater analgesic efficacy than the combination of VR with conventional TENS. EEG data further supported these results, indicating that both combination interventions elicited a greater reduction in event-related potential magnitude compared with the VR-alone intervention during exposure to low and high pain stimuli. Moreover, the synchronous combination intervention induced a more significant reduction in N2 amplitude than the VR-alone intervention during exposure to low pain stimuli. No significant differences in EEG response changes were detected between the two combination interventions. Both combination interventions resulted in a greater reduction in negative affect compared with the VR-alone intervention., Conclusions: Altogether, our study highlights the effectiveness of the synchronous combination of VR and TENS in enhancing pain modulation. These findings offer valuable insights for developing innovative pain treatments, emphasising the importance of tailored and multifaceted therapeutic approaches for various painful conditions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Objective: This research aimed to determine the efficacy of VR therapy in mitigating symptoms of depression, anxiety, and stress among older adults following arthroplasty surgery and to comprehend the influence of psychological improvement on changes in functional outcomes., Methods: Utilizing a parallel-group randomized controlled trial design, the study involved 68 osteoarthritis patients who had recently undergone either total hip or knee arthroplasty. Subjects were split into two groups. The experimental group underwent eight VR therapy sessions during their rehabilitation, while the control group was given standard care. Assessments encompassed both psychological and functional outcomes, with tools like the Hospital Anxiety and Depression Scale, Perceived Stress Scale, and the Barthel Index, among others. The experimental group showcased notable enhancements in both psychological and functional areas compared to the control group., Results: A significant ( p value of < 0.001) relationship was found between psychological progress and functional recovery, indicating that psychological factors can serve as predictors for functional outcomes., Conclusions: The findings emphasize the promising role of VR therapy as a beneficial addition to the rehabilitation process for older adults' post-hip and knee arthroplasty. The integration of psychological interventions in standard rehabilitation practices appears valuable, but further studies are needed to ascertain the long-term advantages of such an approach.

Abstract: This review aimed to assess the effectiveness of nonimmersive virtual reality intervention compared with traditional rehabilitation in improving the functions of the upper and lower limbs, balance, and social participation among children with spastic cerebral palsy. We used librarian-designed searches of 10 databases to identify research articles on randomized controlled trials that assessed the effectiveness of nonimmersive virtual reality in intervening spastic cerebral palsy patients up to April 15, 2023. Independent evaluation was conducted by two trained investigators using the evaluation criteria of randomized controlled trial quality indicated in the Cochrane Manual of Assessment "risk-of-bias tool." The Physical Therapy Evidence Database scale was used to evaluate the method and quality of the literature. Twenty-one research articles involving 779 patients with spastic cerebral palsy were included. Significant differences between the nonimmersive virtual reality rehabilitation and traditional rehabilitation groups were observed in all indicators, except for the Jebsen-Taylor Hand Function Test. Nonimmersive virtual reality intervention is effective in improving the function of the lower extremity, balance, and social participation in children with spastic cerebral palsy, but its effect on upper limb function is still controversial., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: & Objectives: Virtual Reality (VR) refers to an artificial, immersive three-dimensional environment with interactive sensory stimuli. VR is typically incorporated into the psychotherapeutic process as a means of providing exposure therapy. The objectives of this scoping review were to synthesize the most up-to-date evidence on the outcomes, acceptability, and side effects of VR interventions for treating anxiety disorders in adults., Methods: This scoping review is grounded in the methodological framework of Arksey and O'Malley (2005). The databases searched were PubMed, EMBASE, Web of Science, PsycINFO, and ProQuest Dissertations and Theses., Results: The search process identified 112 unique citations. 52 (46%) of the eligible articles examined participants with specific phobias, 25 (22%) with PTSD, 21 (19%) with social anxiety disorder, 12 (10%) with panic disorder with or without agoraphobia, and 3 (3%) with generalized anxiety disorder. VR interventions often led to statistically significant and meaningful reductions in symptoms for people with anxiety disorders. Additionally, they were acceptable to clients and associated with minimal side effects for all types of anxiety disorders, except for Combat-Related PTSD in Vietnam veterans., Limitations: Limitations included the fact that the studies in this review were of varying quality, and that articles in languages other than English and French were excluded., Conclusion: VR interventions appeared to be a viable alternative to conventional exposure therapy. Future research should include more male participants and have a stronger emphasis on acceptability and side effects. Increased traction for VR interventions for generalized anxiety disorder and panic disorder is also important., Competing Interests: Declaration of competing interest None of the authors of conflicts of interest to declare., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background and Objectives: Anxiety disorders are the most prevalent mental disorders worldwide. Virtual reality (VR) treatment approaches have increasingly been studied. Before clinical implementation, it is necessary to evaluate the treatment effect of VR applications. The objective is to evaluate the treatment effect of virtual reality applications in the treatment of anxiety disorders compared to conventional therapy., Methods: A systematic literature review with meta-analysis was conducted. Four databases were used to identify randomized controlled trials published between April 2011 and April 2021 which compare VR applications with non-VR interventions or waiting lists. Study characteristics, pre- and post-treatment data were extracted. Hedges g was calculated as effect size. Primary outcome was anxiety symptoms., Results: Data from 17 studies from 827 participants was extracted. The studies examined specific phobia (n = 9), social anxiety disorder (n = 4), agoraphobia (n = 2) and panic disorder (n = 2). 16 out of 17 studies used head-mounted displays as VR application. A non-significant effect size with significant heterogeneity was observed in favor of the use of VR applications in anxiety symptoms (g, 0.33; 95%-CI, -0.20-0.87). Compared to passive control groups, VR applications are associated significant with lower anxiety symptoms (g, 1.29; 95%-CI, 0.68-1.90)., Limitations: The study and patient characteristics varied between the individual studies which is reflected in a high statistical heterogeneity of the effect sizes., Conclusions: The added value of VR applications over waiting-list or psychoeducation only control groups is obvious. VR applications can be used as part of the treatment of anxiety disorders, especially when conventional therapy is unavailable., Competing Interests: Declaration of competing interest All authors declare that they have no conflicts of interest., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: This systematic review explored how virtual reality (VR) has been used to rehabilitate aphasia., Materials and Methods: Empirical studies were included where VR was used to target language, well-being, or quality of life in adults with acquired language impairment. Degenerative communication disabilities were excluded. Seven health databases were searched in October 2021. Risk of Bias was assessed using published checklists and completeness of intervention reporting evaluated. Narrative synthesis described forms of VR, rationales given, outcome measures, communication functions targeted, characteristics of interventions, and outcomes achieved within the framework of impairment, activity, and participation., Results: Fourteen studies, involving 229 participants, met the criteria. The studies employed four forms of VR with various rationales given. Interventions used published and novel protocols. Primary outcomes targeted language impairment (12/14), activity (1/14), and well-being (1/14) and achieved positive outcomes in impairment and activity. All studies were exploratory. Risk of bias was high. Findings are discussed in the context of gains achieved by VR in other health contexts and the multi-user gaming literature., Conclusions: Uses of VR in aphasia rehabilitation described in the literature are limited. Most applications target the remediation of language impairments. Opportunities to address activity, participation, and wider aspects of well-being are rare.IMPLICATIONS FOR REHABILITATIONResearch documenting the use of virtual reality (VR) to rehabilitate aphasia is limited and exploratory, so does not yet offer clear guidance for clinicians.Many of the identified studies have used known published protocols (e.g., naming therapy or scripts therapy) delivered through the novel VR format and focus on language impairment outcomes.VR offers clinicians a unique opportunity to address communication activity and participation through the use of multi-user virtual worlds, but this has only been explored by only two research teams.

Purpose: Neuromotor impairments can affect any part of the body. It leads to many disorders, injuries, or disabilities, conventional rehabilitation is a long, rigorous, and tedious process. There is a need to inculcate new and innovative techniques in rehabilitation processes, to increase individuals' interest and overall performance with such therapies. Virtual Reality is considered a new technology that has the potential to be a useful aid in overcoming therapeutic problems in clinical and home-based environments. However, providing home-based rehabilitation is more practicable, cost-effective, and even safer than in-hospital rehabilitation. In addition, the need for home-based rehabilitation is growing as the number of neuromotor disorders rises and the capacity of acute inpatient rehabilitation decreases. Therefore, the main objective of this study was to assess the efficacy of a home-based Virtual Reality exercise treatment to identify the areas for future rehabilitation research., Materials and Methods: Data Extraction of 24,257 articles from seven databases were identified and the review is narrowed down and only 45 studies were focussed on efficacy assessment of Virtual Reality in the home environment., Results: The significant outcome of the effective home-based therapy system for the exercise improved functional ability, increasing range of motion, and motivation through Virtual reality-based rehabilitation is inferred., Conclusion: Unlike clinical settings, a home-based system provides efficacious therapy with a controlled environment. This survey facilitates bettering methods and devices for neuromotor disorders. It is a good living long-term problem-solving approach and investigates awareness, needs, and a preferred component of home-based rehabilitation services.IMPLICATIONS FOR REHABILITATIONVR-based rehabilitation in the home environment has many physical and mental benefits in persons with neuromotor disorders.The most commonly neuromotor disorders considered in the study were Stroke, Spinal Cord Injury, Parkinson's disease, and Cerebral Palsy.Assistive technologies in home environments can compensate for long-term disorders or be used in rehabilitation as an addition to conventional therapy.The study gives an overview of current interventions and how they can be of benefit for a person suffering from neuromotor disorders in the home environment.

Objective: This study aimed to evaluate the comparative effectiveness and ranking of robot-assisted training, virtual reality, and robot-assisted rehabilitation combined with virtual reality in improving balance, gait, and daily function in patients with stroke., Data Sources: PubMed, EMBASE, the Cochrane Library, Physiotherapy Evidence Database, CINAHL, Web of Science, and ProQuest Dissertations and Theses abstracting and indexing databases were comprehensively searched to include randomized controlled trials published through August 31, 2022., Study Selection: Randomized controlled trials comparing robot-assisted training, virtual reality, robot-assisted rehabilitation combined with virtual reality, and conventional therapy to assess the effects on balance, gait, and daily function of patients with stroke., Data Extraction: The risk of bias was assessed using the Cochrane Risk of Bias tool and the methodological quality of the studies was assessed using the Physiotherapy Evidence Database scale. A network meta-analysis of random effects models was performed for direct and indirect effects. Data were analyzed using Stata SE 17.0 and R 4.2.1., Data Synthesis: A total of 52 randomized controlled trials involving 1,559 participants were included in this study. Based on the ranking probabilities, robot-assisted rehabilitation combined with virtual reality was most effective in improving balance (surface under the cumulative ranking curve [SUCRA]=82.0%; mean difference [MD]=4.10; 95% confidence interval [CI], 0.43 to 7.67). Virtual reality was most effective in improving velocity (SUCRA=97.8%; MD=-0.15; 95% CI, -0.24 to -0.06) and daily function (SUCRA=92.1%; MD=-7.85; 95% CI, -15.18 to -1.07)., Conclusions: Compared to robot-assisted training and conventional therapy, robot-assisted training combined virtual reality was most likely the best intervention for balance, and virtual reality might be the most helpful in improving daily function for patients after stroke. Further studies are needed to clarify the specific efficacy of robot-assisted training combined with virtual reality and virtual reality on gait., (Copyright © 2023. Published by Elsevier Inc.)

Background and Objectives : The consequences of stroke have a significant impact on self-sufficiency and health-related quality of life (HRQoL). Virtual reality (VR)-based rehabilitation has the potential to impact these modalities, but information on timing, volume, and intensity is not yet available. The aim of this randomized controlled trial (1:1) was to evaluate the impact of conventional rehabilitation combined with VR on self-care and domains of HRQoL in patients ≤6 months post-stroke. Materials and Methods : The intervention group completed a total of 270 min of conventional VR + rehabilitation sessions. The control group underwent conventional rehabilitation only. Primary assessments with the WHO disability assessment schedule 2.0 (WHODAS 2) questionnaire were conducted before rehabilitation (T0), after completion of the intervention (T1), and at the 4-week follow-up (T2); secondary outcomes included self-sufficiency and balance assessments. Results : Fifty patients completed the study (mean age 61.2 ± 9.0 years, time since stroke 114.3 ± 39.4 days). There were no statistically significant differences between the groups in WHODAS 2, self-sufficiency, and balance scores ( p > 0.05). Conclusions : In the experimental group, there was a statistically significant difference in WHODAS 2, assessment of self-sufficiency, and balance scores before and after therapy ( p < 0.05). VR appears to be a suitable tool to supplement and modify rehabilitation in patients after stroke.