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• Stimulus response task using virtual reality can improve spatial reactivity. • Background shift emphasizes the intervention effect of neglected space. • The combination of sudden stimulus and background shift is effective for unilateral spatial neglect. • Changes in egocentric center position may not affect reactivity. To investigate the effects of a stimulus response task using virtual reality (VR) for unilateral spatial neglect (USN). Double-blind randomized controlled trial. Acute phase hospital where stroke patients are hospitalized. 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). 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. 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. 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. Our results suggest that the use of stimulus response tasks using VR combined with background shifts may improve left-sided USN. [ABSTRACT FROM AUTHOR]

Il s'agit de réinterroger le concept de clivage au moi proposé par R. Roussillon dans les champs psychopathologiques et psychanalytiques à partir d'une situation clinique d'adolescent hikikomori. Adoptant une approche conceptuelle, notre propos se centre sur une forme particulière du clivage qui, au-delà d'une visée purement déficitaire et défensive, peut également se comprendre comme une première forme d'appropriation de soi. Il s'inscrit alors dans un processus de construction identitaire. À partir d'une analyse qualitative d'entretiens cliniques auprès d'un adolescent, il s'agit de montrer en quoi le dispositif de la rencontre thérapeutique dans un centre de soins, et en appui sur une médiation virtuelle, permet la réappropriation de parts de soi initialement clivées. Également, une exploration conceptuelle du clivage, notamment par la notion de verwerfung ainsi que la lecture d'un clivage profond proposée par S. Ferenczi, permet de mieux comprendre ses manifestations, entre besoin développemental et troubles psychopathologiques. Les enjeux développementaux liés à un clivage au moi chez l'adolescent sont multiples. Parfois proche, voire synonyme de la dissociation péritraumatique , le clivage au moi illustre les défenses du sujet contre un événement inélaborable et l'ampute de tout un pan de sa subjectivité. Il concerne aussi l'expérience du corps pubère et son rejet par l'adolescent, ce que le developmental breakdown a fortement mis en évidence. Enfin, il peut favoriser une forme de repli ou de retrait social tel que l' hikikomori et certainement d'autres destins liés à l'évolution du sujet. Dans tous les cas, cette évolution reste incertaine. Si différentes formes de psychopathologies peuvent se manifester, en revanche, le clivage au moi peut signifier une forme de mise en abîme de soi pour tenter de se réapproprier certains éléments douloureux ou non symbolisés de son histoire. Il existe une forme de clivage qui n'est pas seulement une défense pouvant aboutir dans les situations les plus graves à des vécus de morcellement et de déréalisation. Il peut aussi s'inscrire dans un processus « limite » de construction identitaire, une forme de dissociation momentanée du sujet ou schize permettant un retour des parts de soi dans une boucle rétroactive, informant en quelque sorte l'état actuel du Moi. À l'adolescence, ce processus est particulièrement sollicité de par l'intégration du nouveau corps pubère. Soit le sujet, en fonction de sa maturation psychoaffective, s'auto-informe des processus en cours de son monde interne : sa vie fantasmatique, l'intégration du corps sexué, etc. Soit la réduction du clivage opère par le recours à une fonction réceptive et transformationnelle de l'objet, inscrivant ce processus dans une intersubjectivité « croisée ». Penser le sujet, notamment adolescent, dans des formes de dissociation qui ne sont pas uniquement l'expression d'une vulnérabilité, permet de maintenir un regard clinique qui soutient un potentiel de croissance, une capacité résiliente du Moi. L'attention portée aux différents destins du clivage soutient une approche dynamique du fonctionnement psychique et inscrit le sujet dans un continuum entre normal et pathologique. Le clivage au moi, en tant que processus limite, offre une lecture originale des enjeux sous-jacents à l'expression contemporaine des souffrances narcissiques et identitaires, et dynamise une approche purement nosographique. The aim of this article is to re-examine the concept of ego splitting proposed by R. Roussillon in the psychopathological and psychoanalytical fields, based on a clinical case of a teenage hikikomori. In a conceptual approach, our article addresses a specific form of splitting which, beyond a vision, only focuses on its defensive and deficient aspects, can also be understood as a first form of self-appropriation. It then becomes a part of a process of identity construction. Based on a qualitative analysis of several clinical interviews with an adolescent, this article aims to demonstrate the extent to which the therapeutic encounter setting in a Care Center, with the support of virtual mediation, can allow for the reappropriation of some parts of the self that were initially split off. Additionally, a conceptual exploration of ego splitting, notably through the notion of verwerfung as well as the reading of a profound splitting proposed by S. Ferenczi, allows us to better understand its manifestations, depending on whether it is seen as a developmental need or a psychopathological disorder. The developmental stakes associated with ego splitting in adolescents are multiple. Sometimes very similar to a peritraumatic dissociation , ego splitting illustrates the subject's defenses when faced with an event which the psyche cannot deal with, and thus severs an entire part of his subjectivity. It is also about the experience of the newly pubescent body and the adolescent's rejection of it, which was emphasized in the concept of developmental breakdown. Finally, it can lead to a form of withdrawal or social isolation such as with the hikikomori disorder, and certainly other outcomes depending on the subject's evolution. In all cases, this evolution remains uncertain. If different forms of psychopathology can manifest themselves, ego splitting however can signify a form of self-immersion, in an attempt to reappropriate certain painful or unsymbolized elements from his past history. There is a type of splitting, which is not only a defense that can lead to feelings of fragmentation and derealization in the worst-case scenarios. It can also be inscribed in the borderline process of identity construction, a form of temporary dissociation of the patient, or schize , allowing parts of the self to return in a sort of retroactive loop, as an informer of the current state of the ego. In adolescence, this process is particularly active, due to the integration of the newly pubescent body. Either the subject, depending on his psychoaffective maturation, will enquire about the ongoing processes in progress in his inner world (his phantasmatic life, integration of the sexual body, etc.); or the splitting reduction takes place through a receptive and transformational function of the object, aligning this process with a form of "crossed" intersubjectivity. Thinking about the subject, especially during in his teenage years, as he encounters forms of dissociations which are not only the expression of a vulnerability, allows us to maintain a clinical vision which supports a potential for growth, a resilient capacity of the ego. The way we consider different outcomes of ego splitting in this article supports a dynamic approach of the psychological functioning, which places the subject in a continuum between what is normal and what is pathological. Splitting of the ego, as a borderline process, allows for a different reading of the underlying stakes of the contemporary expression of narcissistic and identity-related suffering. It also gives a dynamic perspective to what is usually a nosographic approach. [ABSTRACT FROM AUTHOR]

In the current time, Virtual Reality (VR) technologies are improving rapidly. Virtual Reality (VR) allows the user to experience immersive environment that they can interact with through the creation of a 3D digital world. Many studies have explored the potential efficacy of using Virtual Reality (VR) as a form of exposure therapy to treat patients with mental health problems. In this paper, we explored the efficacy of using Virtual Reality Exposure Therapy (VRET) with other extra intervention (e.g., medicine, extra hardware, etc.) to treat patients diagnosed with PTSD. The result indicates that some extra intervention does influence the outcome by seeing the difference in CAPS score. The highest CAPS score difference of 17.7 is achieved by 3MDR which combines the use of VRET (Virtual Reality Exposure Therapy), EMDR (Eye Movement Desensitization and Reprocessing) and walking on a treadmill. [ABSTRACT FROM AUTHOR]

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. • Two sessions of virtual reality exposure therapy led to a significant reduction in acrophobic symptoms. • The overall remission rate at follow-up was 79 %. • Intermittent theta burst stimulation over the left dorsolateral prefrontal cortex showed no additional effect. • The expectancy of being in the verum iTBS group was a predictor of short-term treatment response. [ABSTRACT FROM AUTHOR]

Exposure therapy is the recommended treatment for anxiety disorders, but many anxious individuals are unwilling to expose themselves to feared situations. Episodic simulation of future situations contributes to adaptive emotion regulation and motivates behavior. This study investigated whether future-oriented positive mental imagery reduces anticipatory anxiety and distress during exposure, and increases exposure willingness and duration. Forty-three individuals with moderate public speaking anxiety were randomized to a standardized positive mental imagery exercise about future public speaking or no-task. All participants were then asked to present in a virtual reality environment. Anticipatory anxiety reduced in the positive mental imagery group, but not in the control group. Additionally, the positive mental imagery group reported lower distress during exposure than the control group, but groups did not differ in exposure willingness. Due to limited variance, effects on exposure duration could not be tested. Future-oriented positive mental imagery is promising to prepare individuals for exposure to previously avoided situations. [ABSTRACT FROM AUTHOR]

The aim of the study was to assess whether two weeks of therapy (traditional and VR) may improve balance in children and adolescents with neurological problems of different origins and whether the deterioration in gait dynamic balance showed by patient's ground reaction forces (GRF) determinates therapy effectiveness. 29 participants aged 9–17 attended traditional therapy supplemented by tailor-made games. Therapy comprised exercises improving balance, range of motion, posture control, proprioception, muscle strength. Biodex Balance System was used for main assessment before and after therapy in tests: Postural Stability, modified Clinical Test of Sensory Integration and Balance, and Limits of Stability. Participants underwent gait analysis before the therapy to determine GRF. An increased maximal lateral component or decreased maximal anterior component in the push-off phase taking place in both legs were regarded as deterioration. This enabled the division into two groups with and without such a deterioration. Results were compared between the groups before and within groups before and after therapy. The precision of forward-backwards body sway improved most significantly in the group with decreased GRF and reached the level of the second group, who worsened antero-posterior repeatability during stance on an unstable surface with eyes open. Two weeks of combined traditional and VR therapy tailored to patients' functional weakness positively influenced the balance of neurologically impaired children. The group with decreased gait dynamic balance improved the tasks, which were intensively trained in the games. The second group remained more spontaneous in the trained direction. [ABSTRACT FROM AUTHOR]

therapy based on non-immersive virtual reality (VRT) comprises a technique of interaction between the user and the interface system that allows the creation of an environment in which functional and motivational activities can be performed, while training with restricted blood flow (RBF) is an intervention modality that has been used in individuals who do not have good tolerance to high intensities of exercise. Among the various training modalities for the elderly population, both therapies have easy applicability and low financial cost. However, there are no studies on the combination of such interventions in relation to the autonomic outcome in elderly women. To evaluate the behavior of cardiac autonomic modulation after VRT with or without RBF in elderly women. This is a cross-over clinical trial composed of 17 elderly women with a mean age of 66.82±4.11 years who underwent three conditions: VRT-RBF, VRT only and control. The VRT was performed using a Nintendo Wii® videogame with the games Hulla Hoop, Free Run and Free Step with a total duration of 21 minutes approximately. For VRT-RBF, occlusion occurred in the proximal thigh and was set at 40% of the absolute occlusion pressure. The control group received an educational session of the same duration as the other conditions. For all groups, initially at rest (20 minutes), during the conditions, and in the recovery period (60 minutes analyzed every 10 minutes), RR intervals were collected for analysis of linear indices of heart rate variability (HRV) in the time domain (RR interval, SDNN, and rMSSD). Descriptive statistics were used and analysis of variance for repeated measures with two factors and significance level of p<0.05 was used for comparisons. There was no effect between conditions and interaction conditions vs. moments for all analyzed indices (p>0.05). There was an effect of moment for the RR intervals in the VRT-RBF condition in which the values showed a significant reduction from the baseline moment (95%CI 666-765) until 30 minutes [10′ (95%CI 599-725; p<0.05), 20′ (95%CI 618-719; p<0.05) and 30′ (95%CI 637-741; p<0.05)] of the recovery period. VRT with or without RBF did not promote autonomic imbalance in the recovery period. VRT-RBF can be an exercise alternative for the elderly population, due to its low financial cost and easy applicability that can promote the reduction of the deleterious effects of aging and sedentarism, providing an activity through playful games and favoring motivation and adherence in rehabilitation programs. [ABSTRACT FROM AUTHOR]

Highlights • VRET seems to be an effective treatment for dental phobia. • Six months after VRET, 85% of patients had lost their dental phobia diagnosis. • Majority of the patients scheduled dental appointments within 6-months post-VRET. • Advantage of VRET is that it can be carried out by trained auxiliary personnel. Abstract Background Although Virtual Reality Exposure Therapy (VRET) has proven to be effective in the treatment of various subtypes of specific phobia, there is limited evidence of its role in the treatment of dental phobia. Method A single-blind RCT was conducted among 30 randomized patients with dental phobia to either VRET or informational pamphlet (IP) condition. Primary outcome anxiety measures (VAS-A, MDAS and DFS) were evaluated at baseline, pre- and post-intervention, 1-week, 3-months and 6-months follow-up. Secondary outcome measures assessed were pre-post behavioral avoidance, temporal variations of heart rate and VR-experience during and post-VRET, and dental treatment acceptance in both conditions at 6-month follow-up. Results Intention to treat analysis, using a repeated measures MANOVA, revealed a multivariate interaction effect between time and condition (p = 0.015) for all primary outcome measures (all ps < 0.001). Only patients of the VRET condition showed a significant reduction in anxiety scores (mean reduction [s.d.]: VAS-A 44.4 [36.1]; MDAS 7.1 [5.4]; DFS 21.2 [13.1]) whereas the patients in the IP group did not (mean reduction [s.d.]: VAS-A −0.33 [7.7]; MDAS −0.33 [1.3]; DFS −1.9 [3.8]), F (15, 14) = 3.3, p = 0.015. Conclusions VRET was found to be efficacious in the treatment of dental phobia. [ABSTRACT FROM AUTHOR]

Highlights • Virtual reality exposure therapy shows a large effect size compared to control conditions. • Virtual reality exposure therapy did not show significant differences from in vivo exposure therapy. • Effect sizes for disorder types were relatively consistent. Abstract Trials of virtual reality exposure therapy (VRET) for anxiety-related disorders have proliferated in number and diversity since our previous meta-analysis that examined 13 total trials, most of which were for specific phobias (Powers & Emmelkamp, 2008). Since then, new trials have compared VRET to more diverse anxiety and related disorders including social anxiety disorder (SAD), posttraumatic stress disorder (PTSD), and panic disorder (PD) with and without agoraphobia. With the availability of this data, it is imperative to re-examine the efficacy of VRET for anxiety. A literature search for randomized controlled trials of VRET versus control or in vivo exposure yielded 30 studies with 1057 participants. Fourteen studies tested VRET for specific phobias, 8 for SAD or performance anxiety, 5 for PTSD, and 3 for PD. A random effects analysis estimated a large effect size for VRET versus waitlist (g = 0.90) and a medium to large effect size for VRET versus psychological placebo conditions (g = 0.78). A comparison of VRET and in vivo conditions did not show significantly different effect sizes (g = −0.07). These findings were relatively consistent across disorders. A meta-regression analysis revealed that larger sample sizes were associated with lower effect sizes in VRET versus control comparisons (β = −0.007, p < 0.05). These results indicate that VRET is an effective and equal medium for exposure therapy. [ABSTRACT FROM AUTHOR]

Highlights • Posttraumatic and depressive symptoms change reciprocally in virtual reality exposure. • Virtual reality exposure mainly reduces posttraumatic symptoms, which in turn drives subsequent reductions in depressive symptoms. • DCS may augment the strength of the relationship between decreases in posttraumatic symptoms and successive decreases in depressive symptoms during virtual reality exposure. Abstract Two studies suggest that reductions in posttraumatic symptoms (Aderka et al., 2013) and cognitions (Zalta et al., 2014) precede reductions in depressive symptoms during prolonged exposure (PE) therapy for posttraumatic stress disorder (PTSD) in female assault survivors. The present study explored the temporal relationship between posttraumatic and depressive symptoms in a randomized trial of D-Cycloserine (DCS) versus placebo augmented virtual reality exposure (VRE) therapy for chronic World Trade Center-related PTSD following the September 11, 2001 terrorist attacks. Twenty-five male and female participants were randomly assigned to receive either 100 mg DCS (N = 13) or placebo (N = 12) 90 min before 12 weekly VRE sessions. Participants contributed a total of 280 weekly PTSD Checklist (PCL; Weathers et al., 1993) and Beck Depression Inventory-second edition (BDI-II; Beck et al., 1996) symptom scores. Two sets of mediation analyses for longitudinal mixed models assessed the effects of 1) lagged PCL on BDI-II (Model 1), and 2) lagged BDI-II on PCL (Model 2) in the VRE-DCS and VRE-Placebo treatment groups, respectively. Results revealed reciprocal relations between posttraumatic and depressive symptoms during VRE treatment, although reductions in posttraumatic symptoms led to subsequent reductions in depressive symptoms to a greater extent than the converse. These effects were stronger in the DCS-enhanced group. Findings suggest that VRE primarily decreases posttraumatic symptoms, which in turn leads to decreased depressive symptoms, and that DCS may strengthen these effects. [ABSTRACT FROM AUTHOR]

Aim: To identify studies that approach immersive virtual realities and its main effects in the treatment of burn patients in the context of the scientific world of literature.Methods: A systematic review following the steps of Cochrane. The search was conducted in eight databases between May and August 2016.Results: 34 studies were analyzed, including 23 randomized clinical trials. VR was applied using three-dimensional features and video games. The findings demonstrate the association of this technology with increased enjoyment and the reduction of pain, anxiety and stress during dressing changes and also during physical rehabilitation and physiotherapy. Few side effects have been reported.Conclusion: VR is a complementary drug strategy that has proven beneficial results in the treatment of burn patients. [ABSTRACT FROM AUTHOR]

Background Recent research indicates that pharmacological agents may enhance psychotherapeutic outcome. Yet, empirical results have not been conclusive with respect to two pharmacological agents, yohimbine hydrochloride (YOH) and propranolol. YOH is suggested to enhance emotional memory by elevating norepinephrine, whereas the β-adrenergic receptor antagonist propranolol might help better cope with feared situations by reducing accompanying bodily sensations. Methods In this controlled trial, fifty-six participants with specific phobia were randomly assigned to either 1) virtual reality exposure therapy (VRET) plus YOH, 2) VRET plus Propranolol, or 3) VRET plus placebo. Participants in all conditions received three sessions of VRET over a period of two weeks. Results We conducted 2 × 3 repeated measures MANOVA’s. Results showed a significant effect for time, with partial eta squared ranging from ηp2 = 0.647 to ηp2 = 0.692, for specific phobia, yet no significant interaction effects were found. Conclusion No significant differences were found when VRET with YOH or a beta-blocker was compared to VRET with a non-active placebo. Implications for clinical practice and future research are discussed. [ABSTRACT FROM AUTHOR]

Objective To evaluate whether virtual reality games (VRGs) in stroke survivors produce significant and reproducible heart rate and oxygen consumption ( V ˙ o 2 ) responses during their execution, corresponding to an intensity between the anaerobic threshold (AT) and the respiratory compensation point (RCP). Design Single-subject, repeated-measure design. Setting Stroke survivors registered from a rehabilitation program. Participants Chronic hemiparetic stroke survivors (N=12; 10 men; mean age ± SD, 58±12y) rated at 3 or 4 in the Functional Ambulation Categories. Interventions Participants underwent, in a random order, 2 identical sessions of VRGs (console Xbox 360 + Kinect) and 1 control session (38min watching a movie). The VRG sessions were composed of 4 sets of VRGs (3min of tennis, 1min for changing the game, and 4min of boxing) interspaced with 2 minutes of rest. Main Outcome Measures Heart rate and V ˙ o 2 were measured during the experimental sessions and compared with heart rate and V ˙ o 2 obtained at AT and RCP assessed during a maximal cardiopulmonary exercise test. Results Heart rate and V ˙ o 2 during VRGs had good reproducibility (intraclass correlation coefficients, ≥.91 and ≥.85, respectively; coefficients of variation, ≤6.7% and ≤13.7%, respectively). Heart rate during VRGs was similar to AT and significantly lower than RCP ( P ≤.05), while V ˙ o 2 was significantly lower than AT and RCP ( P <.05). Conclusions An acute session of VRGs composed of tennis and boxing games using the console XBox 360 + Kinect promotes reproducible responses of heart rate and V ˙ o 2 that corresponded, respectively, to AT and below AT, characterizing a low-intensity aerobic stimulus. [ABSTRACT FROM AUTHOR]

Objectives To compare the effects of functional training, bicycle exercise, and exergaming on walking capacity of elderly with Parkinson disease (PD). Design A pilot randomized, controlled, single-blinded trial. Setting A state reference health care center for elderly, a public reference outpatient clinic for the elderly. Participants Elderly individuals (≥60 years of age; N=62) with idiopathic PD (stage 2 to 3 of modified Hoehn and Yahr staging scale) according to the London Brain Bank. Intervention The participants were randomly assigned to three groups. Group 1 (G1) participated in functional training (n=22); group 2 (G2) performed bicycle exercise (n=20), and group 3 (G3) trained with Kinect Adventures (Microsoft, Redmond, WA) exergames (n=20). Main Outcome Measures The primary outcome measure was the 6-minute walk test (6MWT); secondary outcome measures were the 10-m walk test (10MWT), sitting-rising test (SRT), body mass index, Parkinson Disease Questionnaire-39, World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), and 15-item Geriatric Depression Scale. Results All groups showed significant improvements in 6MWT (G1 P =.008; G2 P =.001; G3 P =.005), SRT (G1 P <.001; G2 P =.001; G3 P =.003), and WHODAS 2.0 (G1 P =.018; G2 P =.019; G3 P =.041). Only G3 improved gait speed in 10MWT ( P =.11). G1 ( P =.014) and G3 ( P =.004) improved quality of life. No difference was found between groups. Conclusions Eight weeks of exergaming can improve the walking capacity of elderly patients with PD. Exergame training had similar outcomes compared with functional training and bicycle exercise. The three physical exercise modalities presented significant improvements on walking capacity, ability to stand up and sit, and functionality of the participants. [ABSTRACT FROM AUTHOR]

Objective: To evaluate in the follow-up the sensory-motor recovery and quality of life patients 2 months after completion of the Nintendo Wii console intervention and determine whether learning retention was obtained through the technique.Methods: Five hemiplegics patients participated in the study, of whom 3 were male with an average age of 54.8 years (SD = 4.6). Everyone practiced Nintendo Wii therapy for 2 months (50 minutes/day, 2 times/week, during 16 sessions). Each session lasting 60 minutes, under a protocol in which only the games played were changed, plus 10 minutes of stretching. In the first session, tennis and hula hoop games were used; in the second session, football (soccer) and boxing were used. For the evaluation, the Fulg-Meyer and Short Form Health Survey 36 (SF-36) scales were utilized. The patients were immediately evaluated upon the conclusion of the intervention and 2 months after the second evaluation (follow-up).Results: Values for the upper limb motor function sub-items and total score in the Fugl-Meyer scale evaluation and functional capacity in the SF-36 questionnaire were sustained, indicating a possible maintenance of the therapeutic effects.Conclusion: The results suggest that after Nintendo Wii therapy, patients had motor learning retention, achieving a sustained benefit through the technique. [ABSTRACT FROM AUTHOR]

The Virtual Reality technology is nowadays dynamically developed, thanks to appearance of low-cost devices and interest by large companies related to entertainment, communication and visualization. It is especially important in medicine, as it allows a much wider access to tools such as Virtual Reality Exposure Therapy. The paper presents possibilities of using low-cost VR devices in curing phobias by exposure to a stress-generating factor in an immersive virtual environment. Several use scenarios are presented for a simple application aimed at exposing a patient to fear of heights. A test group consisted of healthy individuals. To evaluate level of immersion and fear caused by the application, a heart rate monitor was used, to record heartbeat in real time. [ABSTRACT FROM AUTHOR]

Objective To assess the stability of clinicians' and users' rating of electric-powered wheelchair (EPW) driving while using 4 different human-machine interfaces (HMIs) within the Virtual Reality-based SIMulator-version 2 (VRSIM-2) and in the real world (accounting for a total of 5 unique driving conditions). Design Within-subjects repeated-measures design. Setting Simulation-based assessment in a research laboratory. Participants A convenience sample of EPW athletes (N=21) recruited at the 31st National Veterans Wheelchair Games. Interventions Not applicable. Main Outcome Measures Composite PMRT scores from the Power Mobility Road Test (PMRT); Raw Task Load Index; and the 6 subscale scores from the Task Load Index developed by the National Aeronautics and Space Administration (NASA-TLX). Results There was moderate stability (intraclass correlation coefficient between .50 and .75) in the total composite PMRT scores (P<.001) and the users' self-reported performance scores (P<.001) among the 5 driving conditions. There was a significant difference in the workload among the 5 different driving conditions as reflected by the Raw Task Load Index (P=.009). Subanalyses revealed this difference was due to the difference in the mental demand (P=.007) and frustration (P=.007) subscales. Post hoc analyses revealed that these differences in the NASA-TLX subscale scores were due to the differences between real-world and virtual driving scores, particularly attributable to the conditions (1 and 3) that lacked the rollers as a part of the simulation. Conclusions Further design improvements in the simulator to increase immersion experienced by the EPW user, along with a standardized training program for clinicians to deliver PMRT in VRSIM-2, could improve the stability between the different HMIs and real-world driving. [ABSTRACT FROM AUTHOR]

Objective To assess interrater reliability of the Power Mobility Road Test (PMRT) when administered through the Virtual Reality-based SIMulator-version 2 (VRSIM-2). Design Within-subjects repeated-measures design. Setting Participants interacted with VRSIM-2 through 2 display options (desktop monitor vs immersive virtual reality screens) using 2 control interfaces (roller system vs conventional movement-sensing joystick), providing 4 different driving scenarios (driving conditions 1-4). Participants performed 3 virtual driving sessions for each of the 2 display screens and 1 session through a real-world driving course (driving condition 5). The virtual PMRT was conducted in a simulated indoor office space, and an equivalent course was charted in an open space for the real-world assessment. After every change in driving condition, participants completed a self-reported workload assessment questionnaire, the Task Load Index, developed by the National Aeronautics and Space Administration. Participants A convenience sample of electric-powered wheelchair (EPW) athletes (N=21) recruited at the 31st National Veterans Wheelchair Games. Interventions Not applicable. Main Outcome Measures Total composite PMRT score. Results The PMRT had high interrater reliability (intraclass correlation coefficient [ICC]>.75) between the 2 raters in all 5 driving conditions. Post hoc analyses revealed that the reliability analyses had >80% power to detect high ICCs in driving conditions 1 and 4. Conclusions The PMRT has high interrater reliability in conditions 1 and 4 and could be used to assess EPW driving performance virtually in VRSIM-2. However, further psychometric assessment is necessary to assess the feasibility of administering the PMRT using the different interfaces of VRSIM-2. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness of abdominopelvic training by virtual reality compared to pelvic floor muscle training (PFMT) using a gym ball (a previously tested and efficient protocol) on postmenopausal women's pelvic floor muscle (PFM) strength. Method: A randomized controlled trial was conducted with 60 postmenopausal women, randomly allocated into two groups: Abdominopelvic training by virtual reality - APT_VR (n=30) and PFMT using a gym ball - PFMT_GB (n=30). Both types of training were supervised by the same physical therapist, during 10 sessions each, for 30 minutes. The participants' PFM strength was evaluated by digital palpation and vaginal dynamometry, considering three different parameters: maximum strength, average strength and endurance. An intention-to-treat approach was used to analyze the participants according to original groups. Results: No significant between-group differences were observed in most analyzed parameters. The outcome endurance was higher in the APT_VR group (p=0.003; effect size=0.89; mean difference=1.37; 95% CI=0.46 to 2.28). Conclusion: Both protocols have improved the overall PFM strength, suggesting that both are equally beneficial and can be used in clinical practice. Muscle endurance was higher in patients who trained using virtual reality. [ABSTRACT FROM AUTHOR]

Objective To use Nintendo's Wii Fit balance board to determine the effectiveness of exergaming training in reducing risk and incidence of falls in older adults with a history of falls. Design Randomized controlled trial. Setting Nursing home for older adults. Participants Adults aged 65 years and older (N=60). Interventions Participants who lived in a nursing home had 6 weeks of balance training with either Wii Fit equipment or conventional exercise. Main Outcome Measures Physiological Profile Assessment scores and incidence of falls were observed with subsequent intention-to-treat statistical analyses. Results Physiological Profile Assessment scores and incidence of falls improved significantly in both groups after the intervention (all P <.01), but participants in the Wii Fit training group showed a significantly greater improvement in both outcome measures ( P =.004 and P <.001, respectively). Conclusions In institutionalized older adults with a history of falls, Wii Fit balance training was more effective than conventional balance training in reducing the risk and incidence of falls. [ABSTRACT FROM AUTHOR]

• Exposure therapy in virtual reality enables fine-grained personalisation. • A support system can provide suggestions for patient tailored therapy environments. • The Rescorla Wagner model can predict learning to maximise therapy efficiency. • Adaptation algorithms facilitate tailoring VR exposure therapy to patients' needs. Anxiety disorders are highly prevalent in mental health problems. The lives of people suffering from an anxiety disorder can be severely impaired. Virtual Reality Exposure Therapy (VRET) is an effective treatment, which immerses patients in a controlled Virtual Environment (VE). This creates the opportunity to confront feared stimuli and learn how to deal with them, which may result in the reduction of anxiety. The configuration of these VEs requires extensive effort to maximise the potential of Virtual Reality (VR) and the effectiveness of the therapy. Manual configuration becomes infeasible when the number of possible virtual stimuli combinations is infinite. Due to the growing complexity, acquiring the skills to truly master a VR system is difficult and it increases the threshold for psychotherapists to use such useful systems. We therefore developed a prototype of a supportive algorithm to facilitate the use of VRET in a clinical setting. This automatised system assists psychotherapists to use the wide range of functionalities without burdening them with technical challenges. Thus, psychotherapists can focus their attention on the patient. In this paper both the prototype of the algorithm and a first proof of concept are described. The algorithm suggests environment configurations for VRET, tailored to the individual therapeutic needs of each patient. The system aims to maximise learning during exposure therapy for different combinations of stimuli by using the Rescorla–Wagner model as a predictor for learning. In a first proof of concept, the VE configurations suggested by the algorithm for three anonymised clinical vignettes were compared with prior manual configurations by two psychotherapists. The prototype of the algorithm and a first proof of concept are described. The first proof of concept demonstrated the relevance and potential of the proposed system, as it managed to propose similar configurations for the clinical vignettes compared to those made by therapists. Nonetheless, because of the exploratory nature of the study, no claims can yet be made about its efficacy. With the increasing ubiquity of immersive technologies, this technology for assisted configuration of VEs could make VRET a valuable tool for psychotherapists. [ABSTRACT FROM AUTHOR]

Background: To evaluate the effectiveness of the video game console Nintendo Wii (NW) in motor function, balance, and functional independence in the treatment of poststroke patients and to identify which games are commonly used in therapy. Methods: Randomized controlled trials were researched in MEDLINE, Cochrane Library, PEDro, CAPES Periodic, BIREME, and LILACS databases, covering publications up to March 31, 2014. The assessment of methodological quality was performed using the PEDro Scale as reference. Results: The 5 studies included for analysis showed that NW can provide an improvement of motor function of the individual, but the data are unclear when it comes to the balance and functional independence. Conclusions: It was concluded that there is little evidence to ensure the effectiveness and support the inclusion of the treatment with NW in patients with sequelae caused by a stroke; however, some of the studies analyzed suggest that NW can provide improvement in motor function. [ABSTRACT FROM AUTHOR]

Question: In people after stroke, does virtual reality based rehabilitation (VRBR) improve walking speed, balance and mobility more than the same duration of standard rehabilitation? In people after stroke, does adding extra VRBR to standard rehabilitation improve the effects on gait, balance and mobility? Design: Systematic review with meta-analysis of randomised trials. Participants: Adults with a clinical diagnosis of stroke. Intervention: Eligible trials had to include one these comparisons: VRBR replacing some or all of standard rehabilitation or VRBR used as extra rehabilitation time added to a standard rehabilitation regimen. Outcome measures: Walking speed, balance, mobility and adverse events. Results: In total, 15 trials involving 341 participants were included. When VRBR replaced some or all of the standard rehabilitation, there were statistically significant benefits in walking speed (MD 0.15 m/s, 95% CI 0.10 to 0.19), balance (MD 2.1 points on the Berg Balance Scale, 95% CI 1.8 to 2.5) and mobility (MD 2.3 seconds on the Timed Up and Go test, 95% CI 1.2 to 3.4). When VRBR was added to standard rehabilitation, mobility showed a significant benefit (0.7 seconds on the Timed Up and Go test, 95% CI 0.4 to 1.1), but insufficient evidence was found to comment about walking speed (one trial) and balance (high heterogeneity). Conclusion: Substituting some or all of a standard rehabilitation regimen with VRBR elicits greater benefits in walking speed, balance and mobility in people with stroke. Although the benefits are small, the extra cost of applying virtual reality to standard rehabilitation is also small, especially when spread over many patients in a clinic. Adding extra VRBR time to standard rehabilitation also has some benefits; further research is needed to determine if these benefits are clinically worthwhile. [Corbetta D, Imeri F, Gatti R (2015) Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: a systematic review. Journal of Physiotherapy 61: 117–124] [ABSTRACT FROM AUTHOR]

Abstract: Objective: To investigate the effects of combination cathodal transcranial direct current stimulation (tDCS) and virtual reality (VR) therapy for upper extremity (UE) training in patients with subacute stroke. Design: Pilot randomized controlled trial. Patients were randomly assigned to 1 of 3 groups: group A received cathodal tDCS, group B received VR, and group C received combination therapy (cathodal tDCS was simultaneously applied during VR therapy). Setting: University hospital. Participants: Patients (N=59) with impaired unilateral UE motor function after stroke. Intervention: Fifteen sessions of treatment over a 3-week period. Main Outcome Measures: The Modified Ashworth Scale, manual muscle test (MMT), Manual Function Test (MFT), Fugl-Meyer Scale (FMS), and Box and Block Test were used to assess UE function. To evaluate activities of daily living, the Korean-Modified Barthel Index (K-MBI) was used. All outcomes were measured before and immediately after treatment. Results: After treatment, all groups demonstrated significant improvements in MMT, MFT, FMS, and K-MBI scores. The change in MFT and FMS scores was different between the 3 groups. Post hoc analysis revealed that the improvement of MFT and FMS scores in group C was significantly higher than those of the other 2 groups. Conclusions: In the present pilot study, the combination of brain stimulation using tDCS and peripheral arm training using VR could facilitate a stronger beneficial effect on UE impairment than using each intervention alone. This combination therapy might be a helpful method to enhance recovery of the paretic UE in patients with stroke. [Copyright &y& Elsevier]

• VRBT is a satisfactory therapy, that allows diversification of training. • Possibility of inserting VRBT into a CRP associated with conventional therapy. • Use VRBT in phase 4 of CRP for eligible patients. Virtual reality-based therapy (VRBT) has been recently used in rehabilitation programs, as it can improve patient's adherence to treatment. However, patients' acceptance of VRBT has been scarcely investigated. To qualitatively analyze the perceptions and preferences of patients about the inclusion of VRBT to a conventional cardiovascular rehabilitation program (CRP). Fifteen patients from a randomized clinical trial participated in focus groups for qualitative assessment. Patients demonstrated good acceptance and satisfaction of VRBT. Physical and psychosocial benefits were highlighted, and patients reported the perception of higher exercise intensity in VRBT then when doing conventional training. In addition, the frequency of VRBT (once a week), associated with conventional treatment was reported as satisfactory. Cognitive aspects that influenced participation to the new approach were also raised by study participants. Patients with cardiac conditions demonstrated satisfaction with the inclusion of VRBT in a conventional CRP, demonstrating that VRBT has the potential to be a new approach for this patient population, allowing training diversification. Benefits perceived by patients include physical, mental, and social aspects. NCT04336306 (https://clinicaltrials.gov/ct2/show/NCT04336306) [ABSTRACT FROM AUTHOR]

Abstract: Objective: To assess the effects of an unsupervised virtual reality (VR)-based exercise program on hip muscle strength and balance control in older adults. Design: Controlled cohort repeated-measures experimental design, a pilot study. Setting: University research laboratory. Participants: Ambulatory older adults (N=32) from a local community. Intervention: The VR group (n=18; mean ± SD, 68.28±3.74y; 4 men) completed the VR-based exercise program, whereas the remaining subjects in the control group (n=14; mean ± SD, 66.21±3.87y, 1 man) were asked to continue their daily routine for 8 weeks. Main Outcome Measures: Hip muscle strength was measured using a multimodal dynamometer, and ground reaction force using the backward stepping test and the results of the crossover stepping test were recorded using a force platform. Results: The VR group showed significant improvement in hip muscle strength of the extensors, flexors, adductors, and abductors after 8 weeks (all P≤.001). However, no significant improvement was observed in the control group. The VR group had significantly greater ground reaction force on the backward stepping test (with eyes opened and closed) (all P<.005) and the crossover stepping test (with eyes opened and closed) (all P≤.001) compared with those at baseline. However, no significant improvement was observed in the control group. Conclusions: The VR-based exercise program includes the role of supervisor and feedback, which is important for older adults. Therefore, a VR-based exercise program may be a useful tool to improve decreased physical function in older adults as a home-based exercise. [Copyright &y& Elsevier]

Abstract: Recent reviews point towards that Virtual Reality Exposure Therapy (VRET) can be an effective medium to provide exposure therapy for anxiety disorders. The concept of presence, usually defined as the sense of being inside the virtual environment, has been considered the principal mechanism that leads to the experience of anxiety in clinical virtual environments. The present study sought to examine the relationship between sense of presence and in-session anxiety in a sample of 210 students showing high and low test anxiety when exposed to both clinical and non-stressful virtual environments. This is the largest study conducted to date with the aim of examining the relationship between presence and anxiety in clinical virtual environments, and the first to explore separately the relationship between presence and state-anxiety in phobic and non-phobic participants. The results suggest that presence was not related to anxiety in a non-stressful environment. It was also found that although presence is related to anxiety in both groups of students when exposed to clinical virtual environments, this relationship was clearly stronger for high test anxiety students. This line of research will broaden our understanding of the mechanisms that lead to the efficacy of VRET. [ABSTRACT FROM AUTHOR]

Abstract: Virtual reality exposure therapy (VRET) is an increasingly common treatment for anxiety and specific phobias. Lacking is a quantitative meta-analysis that enhances understanding of the variability and clinical significance of anxiety reduction outcomes after VRET. Searches of electronic databases yielded 52 studies, and of these, 21 studies (300 subjects) met inclusion criteria. Although meta-analysis revealed large declines in anxiety symptoms following VRET, moderator analyses were limited due to inconsistent reporting in the VRET literature. This highlights the need for future research studies that report uniform and detailed information regarding presence, immersion, anxiety and/or phobia duration, and demographics. [Copyright &y& Elsevier]

What are the effects of immersive virtual reality (IVR) training compared to conventional physiotherapy on body balance and risk of falls in older adults with balance disorders? A randomized controlled trial with two intervention arms, concealed allocation, per-protocol analysis, and blinded assessment. Thirty-seven older adults with balance disorders and risk of falling. Participants were randomized into two groups: a control group, which received balance training with conventional physiotherapy using multimodal circuit exercises, and an experimental group, which received balance training using immersive virtual reality. Both groups received 16 individual sessions, twice a week. The primary outcome was functional balance. Secondary outcomes were static balance, gait speed, functional range, dizziness symptoms, and fear of falling. Safety was ensured by assessing any adverse events during the intervention. After 16 sessions, in the intragroup analysis, the functional balance score in the experimental group increased by 3.00 (95% CI 1.42 to 4.57) and in the control group by 3.88 (95% CI 2.16 to 5.59). Both groups improved in assessments of sensory interaction and anterior reach. Only the experimental group presented increased mobility and reduced dizziness. After two months, there was a maintenance of gains in functional balance and a reduction of the gains in functional reach for both groups. In the intergroup comparison, there was no significant difference. Immersive Virtual Reality training proved to be effective for balance-related outcomes, although it was not superior to conventional therapy. RBR-3tk7fw. [ABSTRACT FROM AUTHOR]

Objective To compare the effectiveness of virtual reality–based balance exercises to conventional balance exercises during vestibular rehabilitation in patients with unilateral peripheral vestibular loss (UVL). Design Assessor-blind, randomized controlled trial. Setting Two acute care university teaching hospitals. Participants Patients with UVL (N=71) who had dizziness/vertigo, and gait and balance impairment. Interventions Patients with UVL were randomly assigned to receive 6 weeks of either conventional (n=36) or virtual reality–based (n=35) balance exercises during vestibular rehabilitation. The virtual reality-based group received an off-the-shelf virtual reality gaming system for home exercise, and the conventional group received a foam balance mat. Treatment comprised weekly visits to a physiotherapist and a daily home exercise program. Main Outcome Measures The primary outcome was self-preferred gait speed. Secondary outcomes included other gait parameters and tasks, Sensory Organization Test (SOT), dynamic visual acuity, Hospital Anxiety and Depression Scale, Vestibular Rehabilitation Benefits Questionnaire, and Activities Balance Confidence Questionnaire. The subjective experience of vestibular rehabilitation was measured with a questionnaire. Results Both groups improved, but there were no significant differences in gait speed between the groups postintervention (mean difference, −.03m/s; 95% confidence interval [CI], −.09 to .02m/s). There were also no significant differences between the groups in SOT scores (mean difference, .82%; 95% CI, −5.00% to 6.63%) or on any of the other secondary outcomes ( P >.05). In both groups, adherence to exercise was high (∼77%), but the virtual reality–based group reported significantly more enjoyment ( P =.001), less difficulty with ( P =.009) and less tiredness after ( P =.03) balance exercises. At 6 months, there were no significant between-group differences in physical outcomes. Conclusions Virtual reality–based balance exercises performed during vestibular rehabilitation were not superior to conventional balance exercises during vestibular rehabilitation but may provide a more enjoyable method of retraining balance after unilateral peripheral vestibular loss. [ABSTRACT FROM AUTHOR]