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Introduction: The first high-quality clinical trial to support ultrahypofractionated whole-breast irradiation (ultra-HF-WBI) for invasive early-stage breast cancer (ESBC) was published in April 2020, coinciding with the beginning of the COVID-19 pandemic. We analyzed adoption of ultra-HF-WBI for ductal carcinoma in situ (DCIS) and ESBC at our institution after primary trial publication. Methods and Materials: We evaluated radiation fractionation prescriptions for all patients with DCIS or ESBC treated with WBI from March 2020 to May 2021 at our main campus and regional campuses. Demographic and clinical characteristics were extracted from the electronic medical record. Treating physician characteristics were collected from licensure data. Hierarchical logistic regression models identified factors correlated with adoption of ultra-HF-WBI (26 Gy in 5 daily factions [UK-FAST-FORWARD] or 28.5 Gy in 5 weekly fractions [UK-FAST]). Results: Of 665 included patients, the median age was 61.5 years, and 478 patients (71.9%) had invasive, hormone-receptor-positive breast cancer. Twenty-one physicians treated the included patients. In total, 249 patients (37.4%) received ultra-HF-WBI, increasing from 4.3% (2 of 46) in March-April 2020 to a high of 45.5% (45 of 99) in July-August 2020 (P < .001). Patient factors associated with increased use of ultra-HF-WBI included older age (≥50 years old), low-grade WBI without inclusion of the low axilla, no radiation boost, and farther travel distance (P < .03). Physician variation accounted for 21.7% of variance in the outcome, with rate of use of ultra-HF-WBI by the treating physicians ranging from 0% to 75.6%. No measured physician characteristics were associated with use of ultra-HF-WBI. Conclusions: Adoption of ultra-HF-WBI at our institution increased substantially after the publication of randomized evidence supporting its use. Ultra-HF-WBI was preferentially used in patients with lower risk disease, suggesting careful selection for this new approach while long-term data are maturing. Substantial physician-level variation may reflect a lack of consensus on the evidentiary standards required to change practice.

Predicting treatment response can inform treatment decisions, expectations, and optimize use of mental health treatment resources. This study examined heart rate (HR), heart rate variability (HRV), and a modified Stroop task (mStroop) to predict post-traumatic stress disorder (PTSD) treatment response. We report on an observational, longitudinal study with 45 U.S. veterans in outpatient PTSD care, who had deployed to Iraq or Afghanistan. HR and HRV were collected before, during, and after virtual reality (VR) combat and civilian scenes. HRV recovery was defined as HRV after a 3-minute VR simulation minus HRV during a VR scene. mStroop threat variables included index scores for combat and general threat. Self-report data were collected at baseline and 6 months later. The outcome variable was the 17-item Clinician Administered PTSD Scale (CAPS). Controlling for baseline CAPS and number of combat experiences, the following baseline HRV recovery variables were significant predictors of 6-month CAPS: standard deviation of normal beat to beat interval (SDNN) after combat scene minus SDNN during combat scene and low-frequency (LF HRV) after civilian scene minus LF during civilian scene. HRV at rest, HR reactivity, HR recovery, and mStroop scores did not predict treatment response. In conclusion, HRV recovery variables in the context of a standardized VR stressor were significant predictors of PTSD treatment response after controlling for baseline CAPS and number of combat experiences. The direction of this relationship indicates that greater baseline HRV recovery predicts lower 6-month PTSD symptom severity. This was an exploratory study in need of replication.

The U.S. Department of Defense (DoD) and the Department of Veterans Affairs (DVA) seek to enhance the efficacy of treatments for warriors with post-traumatic stress disorder (PTSD) secondary to their combat deployments to Iraq and/or Afghanistan. Virtual Reality Graded Exposure Therapy (VR-GET) with arousal control has shown particular promise in reducing the symptom severity of PTSD in combat veterans. In this report, we describe the outcome of VR-GET for the treatment of combat-related PTSD in two combat veterans, neither of whom had received treatment for PTSD in the initial years after their return from combat duty., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Wood et al.)

Rapid rises in autism diagnoses are increasing the demand for effective services and straining service providers. When individuals on the autism spectrum turn 18, they are faced with even greater barriers to services, since many services are delivered in school settings. Thus, there is a need for more accessible tools that teach daily life and communication skills to autistic adolescents and young adults. The current project reports findings from a pilot study using virtual reality (VR) to teach air travel skills to autistic young adults. The authors repurposed a virtual airport environment previously used to treat fear of flying for this study. Seven participants on the autism spectrum viewed a 5-minute virtual airport simulation with an overlaid narrative script using an iPhone X ® and Google Cardboard ® device once per week for 3 weeks. Researchers collected measures of attentiveness, language function, activity comprehension, and clinical observations on how participants interacted with the technology. Analyses revealed improvements in attentiveness, certain language functions such as labeling vocabulary, and activity comprehension in most participants. Clinical observations revealed acceptability of this technology and its capability to serve as an appealing media to deliver interventions. Thus, it is feasible to apply mobile VR trainings with autistic adolescents and young adults. We discuss ways to improve the pedagogical approach of VR-enhanced interventions in light of these findings. In the future, we plan to develop and test more virtual environments that address the needs of young adults on the autism spectrum, such as interview training and independent living skills., Lay Summary: Why was this virtual reality air travel training program developed?: Each year, more and more people travel via airplane. Long lines, unexpected changes and other stressors can make air travel overwhelming and difficult, particularly for autistic people. Our goal was to develop and pilot test a program to help autistic adults learn air travel skills without needing to physically enter an airport. What does the virtual reality air travel training program do?: Our virtual reality air travel training (VR-ATT) program presents a virtual simulation of the steps that travelers go through in an airport. It guides users through entering, checking in, navigating security, waiting at the departure gate, and boarding. VR-ATT also contains a narrative to guide users by highlighting important information such as: "Look, there's the ticket counter. Let's check in with the attendant." This script was based on social stories, which are often used to help individuals on the autism spectrum learn communication and social interaction strategies. Seven autistic adolescents and adults participated in our program. They watched the VR-ATT simulation on an iPhone X ® and Google Cardboard ® two to three times over the course of 3 weeks. Google Cardboard is an inexpensive virtual reality (VR) headset. How did the researchers evaluate the VR-ATT program?: We evaluated the program in three ways. First, we asked each participant to retell the sequence of events of the simulation. In other research studies, participants who retold what they watched showed a greater ability to apply the skill to the real world. Second, we tracked how and what types of language participants used. Third, we measured if participants could independently view the VR-ATT simulation without side effects such as dizziness or cybersickness (common side effects of VR viewing). This helps us understand the feasibility and acceptability of using VR with autistic individuals. What were the early findings?: Early findings suggest that autistic individuals are accepting of the iPhone and Google Cardboard VR viewing method. They also provide preliminary support for the ability of the program to promote improvements in functional language skills such as labeling vocabulary, which helps individuals interact and navigate busy environments, such as an airport. Finally, the findings suggest that participants can accurately retell the sequence of events in the virtual simulation. What were the weaknesses of this project?: One weakness was that researchers could not test how participants transferred the skills they learned in the virtual training to a real-world airport. Another weakness is the small sample of participants. Finally, not every participant completed all three training sessions, making it difficult to draw precise conclusions about the program's acceptability and success. What are the next steps?: Future studies should include a larger number of participants, a real-world test, changes to the virtual simulation to encourage more language use and interaction with virtual characters, and use more accurate measurement materials. How will this work help autistic adults now or in the future?: This air travel program may someday help autistic people learn what to expect and how to communicate in a busy airport setting. This program also highlights that new technology, such as VR, could potentially improve access to services and help more people in need in the future., Competing Interests: No competing financial interests exist., (Copyright 2020, Mary Ann Liebert, Inc., publishers.)

Autism spectrum disorder (ASD) is categorized by deficits in social communication and interaction, alongside repetitive, restrictive behaviors or interests (RRBIs). Previous research supports the efficacy of virtual reality (VR) to train a variety of specific skills (i.e., riding a bus or crossing the street) as well as more complex social skills, such as emotion recognition and functional communication. The present reports the implementation of a VR-based air travel functional communication activity in five children diagnosed with ASD. Using an iPhone X and Google Cardboard device, researchers delivered the VR intervention once per week for 3 weeks to each participant. During these interventions, researchers measured activity completion ability on a 4-point scale. At week 4, all children participated in a real-world air travel rehearsal at the San Diego International Airport. Parents were asked to rate their child's air travel abilities before week 1 and after week 4. All children improved their air travel skills from pre- to postintervention, reflected in both the researchers' and parents' observations. All children navigated the real-world airport under their own power. This preliminary report suggests the efficacy of VR to teach basic air travel skills to young children diagnosed with autism. Clinician observations regarding attention to the VR and strategies for helping participants accept the intervention technique are discussed. Future iterations of this program will require larger sample sizes and more robust clinical measurements-such as communication samples and physiological monitoring.

Though augmented reality (AR) has existed for decades, the technology's full impact is just beginning to become apparent. Since its inception, AR has shown significant promise for use in a wide variety of fields, including education, entertainment, art, and the sciences. This special issue focuses specifically on the impact of this unique technology on healthcare, particularly the areas of clinical training, patient education and treatment, and its use as a robust assessment tool. Now that technology is catching up with imagination, researchers are able to investigate these applications in earnest.

Augmented reality (AR) is a versatile tool that is changing the way we interact with the world. One way is through exergaming, integrating AR, and gaming with traditional exercise programs. This study aimed to test three different AR systems to determine their ability to elicit physiological responses similar to those experienced while exercising or performing rehabilitation exercises. The systems tested included a head-mounted display experience (Teapots), a Sony EyeToy game (Slap Stream), and a prototype of a PC-camera-based system (Drums). Physiological recordings show that Slap Stream and Drums produced significant increases (p < 0.05) in heart rate (HR) and skin conductance, and all three games produced nonsignificant increase in respiratory rate. Of the three games, Slap Stream produced the highest rates of low- (∼28 percent), moderate- (17 percent), and high-intensity (∼22 percent) HRs. This study successfully showed that inexpensive easy-to-use AR systems can effectively contribute to exercise programs. Future game design recommendations, including feedback, mixed reality, and stress tracking, are discussed.

Virtual reality (VR) pain distraction has been applied across medical, surgical, and behavioral healthcare domains, marking a shift in pain attenuation practices. However, there is little research that has been performed to compare the efficacy of traditional head-mounted displays (HMDs) versus portable VR devices. The present study evaluated 44 outpatients in need of lipoma resection. Randomized into two groups-HMD versus mobile phone VR-participants navigated pain distraction virtual environments while undergoing surgery. Vital signs and subjective pain measurements via a visual analog scale were taken before, during, and after the surgery. Results indicate that the HMD group reported greater pain reduction than the Mobile group. Overall, this study points to the efficacy of nonpharmacological pain attenuation practices. Although both systems reduced pain during surgery, the clinically validated VR environments seen in the HMD group were more effective. This study does show that inexpensive solutions can work in surgical settings. Future research should be performed to identify the most effective VR pain distraction systems.

We evaluated the effect of dichoptic visual training based on a unique virtual reality (VR) platform mounted display in patients with intermittent exotropia (IXT). A total of 25 IXT patients (8 men, 17 women) with a mean age of 12.3 years (range, 5-39 year) were recruited. The Hirschberg test, prism and alternate cover testing (with accommodative targets for fixation at 33 cm in all patients), perceptual eye position (PEP), and stereopsis were evaluated after 1, 3, and 6 months of dichoptic visual neuroplasticity training with a computer-controlled perceptual examination evaluation system. Data collected before and after training were evaluated using SPSS software. After 6 months of perceptual training, a new order stereopsis was established, and eye positions were improved in all 25 patients. After training for 1 and 6 months, the horizontal PEP pixels were much lower than those pretraining, respectively (Δ 1-0  = -0.53, p = 0.028; Δ 6-0  = -0.80, p = 0.018). There was no statistically significant difference between pretraining and 3 months after training in horizontal PEP (Δ 3-0  = -0.29, p = 0.370). There was no significant difference between pretraining and post-training in vertical PEP (p > 0.05). There were significant differences between pretraining and post-training in the cornea's optical reflection and prism diopters (p < 0.01). Dichoptic visual neuroplasticity training based on a VR platform is an effective nonsurgical treatment in patients with IXT. With the VR treatment, the degree of strabismus and stereopsis was improved in IXT patients. Perceptual training with VR can remove obstacles in the visual processing channel and repair defects in visual function. The clinical manifestations of improvement were the decrease in the degree of strabismus and the re-establishment of stereopsis.

Introduction: There is a long history of pre-deployment PTSD prevention efforts in the military and effective pre-deployment strategies to prevent post-deployment PTSD are still needed., Materials and Methods: This randomized controlled trial included three arms: heart rate variability biofeedback (HRVB), cognitive bias modification for interpretation (CBM-I), and control. The hypothesis was that pre-deployment resilience training would result in lower post-deployment PTSD symptoms compared with control. Army National Guard soldiers (n = 342) were enrolled in the Warriors Achieving Resilience (WAR) study and analyzed. The outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at pre-deployment, 3- and 12-month post-deployment. Due to the repeated measures for each participant and cluster randomization at the company level, generalized linear mixed models were used for the analysis. This study was approved by the Army Human Research Protection Office, Central Arkansas Veterans Healthcare System Institutional Review Board (IRB), and Southeast Louisiana Veterans Health Care System IRB., Results: Overall, there was no significant intervention effect. However, there were significant intervention effects for subgroups of soldiers. For example, at 3-months post-deployment, the HRVB arm had significantly lower PCL scores than the control arm for soldiers with no previous combat zone exposure who were age 30 and older and for soldiers with previous combat zone exposure who were 45 and older (unadjusted effect size -0.97 and -1.03, respectively). A significant difference between the CBM-I and control arms was found for soldiers without previous combat zone exposure between ages 23 and 42 (unadjusted effect size -0.41). Similarly, at 12-months post-deployment, the HRVB arm had significantly lower PCL scores in older soldiers., Conclusion: Pre-deployment resilience training was acceptable and feasible and resulted in lower post-deployment PTSD symptom scores in subgroups of older soldiers compared with controls. Strengths of the study included cluster randomization at the company level, use of iPod device to deliver the resilience intervention throughout the deployment cycle, and minimal disruption of pre-deployment training by using self-paced resilience training. Weaknesses included self-report app use, study personnel not able to contact soldiers during deployment, and in general a low level of PTSD symptom severity throughout the study. In future studies, it would important for the study team and/or military personnel implementing the resilience training to be in frequent contact with participants to ensure proper use of the resilience training apps.

Heart rate variability is a physiological measure associated with autonomic nervous system activity. This study hypothesized that lower pre-deployment HRV would be associated with higher post-deployment post-traumatic stress disorder (PTSD) symptoms. Three-hundred-forty-three Army National Guard soldiers enrolled in the Warriors Achieving Resilience (WAR) study were analyzed. The primary outcome was PTSD symptom severity using the PTSD Checklist - Military version (PCL) measured at baseline, 3- and 12-month post-deployment. Heart rate variability predictor variables included: high frequency power (HF) and standard deviation of the normal cardiac inter-beat interval (SDNN). Generalized linear mixed models revealed that the pre-deployment PCL*ln(HF) interaction term was significant (p<0.0001). Pre-deployment SDNN was not a significant predictor of post-deployment PCL. Covariates included age, pre-deployment PCL, race/ethnicity, marital status, tobacco use, childhood abuse, pre-deployment traumatic brain injury, and previous combat zone deployment. Pre-deployment heart rate variability predicts post-deployment PTSD symptoms in the context of higher pre-deployment PCL scores., (Published by Elsevier B.V.)

Creating a significant negative impact on both their quality of life and the quality of patient care with an evident economical burden for the healthcare system, there is a growing concern over physician burnout. The range of interventions and treatments that have been used to address this problem, however, appear quite fragmented and lack compelling efficacy. We describe the main factors known to contribute to the development of physician burnout as well as currently available treatments. Studies seem to indicate that both specialisation area as well as personality traits may contribute to the manifestation. The highest risk specialties appear to be critical care physicians, emergency physicians, oncologists and internal medicine physicians, while the highest risk personality attributes are high neuroticism, low agreeableness, introversion, and negative affectivity. In addition, being exceedingly enthusiastic about one's work and having high aspirations at work, with an idealistic approach, also serve as factors which contribute to increased risk of burnout, and in particular for those who are new to the occupation.

Virtual reality (VR) is an emerging tool to help treat posttraumatic stress disorder (PTSD). Previously published studies have shown that VR graded exposure therapy (VR-GET) treatment can result in improvements in PTSD symptoms. Less is known about the impact on depression, general anxiety, and neuropsychological functioning in patients with PTSD. This study examined changes in self-reports of PTSD, depression, and anxiety before and after treatment, and also examined neuropsychological functioning as assessed by a computerized test of simple reaction time, procedural reaction time, and performance on the congruent, incongruent, emotional, and neutral (match the color of the "nonsense word") Stroop tests. Results showed that subjects treated with VR-GET showed significant reductions in PTSD and anxiety severity and significant improvements on the emotional Stroop test. Changes in depression and other measures of neuropsychological function were not significant. Change scores on the emotional Stroop test did not correlate with changes in self-report measures of PTSD. Overall, these findings support the use of VR-GET as a treatment for PTSD but indicate that benefits may be narrowly focused. Additional treatments may be needed after or alongside VR-GET for service members with neuropsychological impairments.

We explored the use of virtual reality distraction techniques for use as adjunctive therapy to treat chronic pain. Virtual environments were specifically created to provide pleasant and engaging experiences where patients navigated on their own through rich and varied simulated worlds. Real-time physiological monitoring was used as a guide to determine the effectiveness and sustainability of this intervention. Human factors studies showed that virtual navigation is a safe and effective method for use with chronic pain patients. Chronic pain patients demonstrated significant relief in subjective ratings of pain that corresponded to objective measurements in peripheral, noninvasive physiological measures.

Approximately 108 million people in North America and Europe suffer from chronic pain. Virtual reality (VR) is a promising method for pain management in a clinical setting due to the distracting properties of an immersive virtual environment. In this study, we demonstrated the potential use of mobile phones as a means of delivering an easily accessible, immersive experience. Thirty-one patients tested VR pain distraction. Objective measurements of heart rate correlated to decreased anxiety, while, subjectively, patients also reported reduced levels of discomfort. The positive results of this study indicate that mobile phones can provide an immersive experience sufficient to deliver pain management distraction. Because mobile devices are widely available, the potential for developing pain management programs that are accessible has become a realistic possibility.

Surgical anxiety creates psychological and physiological stress, causes complications in surgical procedures, and prolongs recovery. Relaxation of patients in postoperative intensive care units can moderate patient vital signs and reduce discomfort. This experiment explores the use of virtual reality (VR) cybertherapy to reduce postoperative distress in patients that have recently undergone cardiac surgery. Sixty-seven patients were monitored at IMSS La Raza National Medical Center within 24 hours of cardiac surgery. Patients navigated through a 30 minute VR simulation designed for pain management. Results were analyzed through comparison of pre- and postoperative vital signs and Likert scale survey data. A connection was found in several physiological factors with subjective responses from the Likert scale survey. Heavy positive correlation existed between breathing rate and Likert ratings, and a moderate correlation was found between mean arterial pressure and Likert ratings and heart rate and Likert ratings, all of which indicated lower pain and stress within patients. Further study of these factors resulted in the categorization of patients based upon their vital signs and subjective response, providing a context for the effectiveness of the therapy to specific groups of patients.

Virtual reality (VR) has been used by clinicians to manage pain in clinical populations. This study examines the use of VR as a form of distraction for dental patients using both subjective and objective measures to determine how a VR system affects patients' reported anxiety level, pain level, and physiological factors. As predicted, results of self-evaluation questionnaires showed that patients experienced less anxiety and pain after undergoing VR treatment. Physiological data reported similar trends in decreased anxiety. Overall, the favorable subjective and objective responses suggest that VR distraction systems can reduce discomfort and pain for patients with mild to moderate fear and anxiety.

Chronic stress in young adults has become a growing problem within recent decades and many are unable to find cost-effective and accessible treatment for psychological stress in their daily lives. We analyze the market of using a mobile application, Positive Technology, as a solution. Eleven participants, aged between 18 and 24, participated in the exercise. Self-reported stress reduction was measured via an online marketing survey, while physiological measurements were monitored via peripheral devices. Secondary goals assessed the app's ease-of-use, accessibility, and cost. Results indicate that participants enjoyed the availability of the mobile solution and found the app to be fun and easy to learn. Stress levels were reduced in 73% of the participants, with higher effects in females and in participants aged 18-24. We conclude that the mobile platform is an effective means of delivering psychological stress reduction, and could provide an accessible, cost-effective solution.

Important challenges confronting DOD/military medical care are that of maintaining or increasing quality of care and increasing the effectiveness of treatments for warriors diagnosed with Posttraumatic Stress Disorder (PTSD) secondary to their combat deployments to Iraq and/or Afghanistan. Virtual Reality Graded Exposure Therapy with Arousal Control (VR-GET) has demonstrated a positive treatment effectiveness resulting in significant reductions of PTSD symptom severity. This positive treatment effectiveness has been maintained for up to 22 weeks after VR-GET therapy was completed. A robust methodology for the assessment of Virtual Reality efficacy suggests that the ideal time for follow-up begins at twelve months. Others have suggested that follow-up should occur between two and four years post treatment. In this report we describe the outcome of VR-GET for the treatment of combat-related PTSD with three warriors between five and seven years following their having completed treatment.

Sensory pathways, consisting of chains of neurons, which spread from the receptor organ to the cerebral cortex, are responsible for the perception of sensations (including pain). In this study, we set out to determine how effective virtual reality (VR) could be in distracting patients from pain experienced through thermoreceptors on the skin. Six healthy subjects were exposed to uncomfortable pain stimuli with and without VR distraction. Subjects reported a drop in pain while in the VR environment, and mean pain rating was significantly lower than the session with no VR distraction. These results indicate that VR distraction can diminish pain experienced by subjects, thus we conclude by eliciting future directions for quantifying effectiveness of VR as a pain management solution.

Smoking has increasingly become a burden on America's health and economic status. The fact that four out of every five adult smokers begins tobacco use before the age of eighteen indicates a need for teenage smoking cessation programs. The Virtual Reality Medical Center created an internet-based program that addresses the issue by utilizing cue exposure therapy in home and school environments to teach teens which cues trigger nicotine cravings and how to combat those cravings. The effectiveness of the program was measured through questionnaires administered before and after its use. Results indicated that the participants were engaged in the virtual environment, and that, in every aspect of the program, at least 8% more participants were knowledgeable about the subject than prior to the use of the program. Success of such a program could reduce teen smoking rates, ultimately leading to reduced smoking mortalities, complications, and costs overall.

Of the available training methods for emergency responders, including other methods based on computer technology, virtual reality video game training with haptics (tactile) features will be shown to provide the most effective transfer of skills to real-world emergency situations, providing a model for the development of new training products for combat medics and civilian first responders. This paper aims to provide a methodological case study of haptics use in medical training programs and highlight achievements in terms of performance. Review of these cases show that the addition of haptics to an existing simulation-based training program increases user performance in terms of completion time, error rates, and learning rate. With this case study, haptics can be further incorporated into training programs designed for military combat medics.

This article discusses the potential of emotionally based strategic communications (EBSCs) as an extension of traditional strategic communications in prevention of societal stress-related disorders. The concept of EBSCs takes into consideration dominant emotional maps of a specific sociocultural environment in which communications take place. EBSCs may have a significant potential to transform mainly negative-dominant emotional maps of targeted social groups into more positive ones, as a precondition of building a more resilient and stress-resistant social environment. A better understanding of dominant emotional maps and their conditioning may facilitate restoration of more positive emotional maps by touching the right emotions of significant parts of the targeted social groups in the right way. Dominant emotional maps of societies afflicted by economic downturns, natural disasters, conflicts etc., are typically characterized by negatively valenced emotions. Persistent negatively valenced group-based dominant emotions may be used as a quantitative statistical measure of potential stress-related disorders and post-traumatic stress disorders among respected group members. The toxic power of extreme negative emotions, attitudes, actions, and behavior might be reduced by EBSCs as a communication method for transforming negative-dominant emotional maps into more positive ones. EBSCs are conceptualized as the positively valenced stimulation of a negatively emotionally affected group by an appropriate communication strategy to minimize dominant-negative emotional maps and behavior of the targeted group.

Abstract Virtual reality (VR)-based therapy has emerged as a potentially useful means to treat post-traumatic stress disorder (PTSD), but randomized studies have been lacking for Service Members from Iraq or Afghanistan. This study documents a small, randomized, controlled trial of VR-graded exposure therapy (VR-GET) versus treatment as usual (TAU) for PTSD in Active Duty military personnel with combat-related PTSD. Success was gauged according to whether treatment resulted in a 30 percent or greater improvement in the PTSD symptom severity as assessed by the Clinician Administered PTSD Scale (CAPS) after 10 weeks of treatment. Seven of 10 participants improved by 30 percent or greater while in VR-GET, whereas only 1 of the 9 returning participants in TAU showed similar improvement. This is a clinically and statistically significant result (χ(2) = 6.74, p < 0.01, relative risk 3.2). Participants in VR-GET improved an average of 35 points on the CAPS, whereas those in TAU averaged a 9-point improvement (p < 0.05). The results are limited by small size, lack of blinding, a single therapist, and comparison to a relatively uncontrolled usual care condition, but did show VR-GET to be a safe and effective treatment for combat-related PTSD.

A high percentage of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat veterans have been diagnosed with Posttraumatic Stress Disorder (PTSD) during and following their respective combat tours. Virtual Reality (VR) treatment has been documented as an exceptional treatment for anxiety disorders and specifically for PTSD. An Office of Naval Research (ONR) funded pilot study, completed by the Virtual Reality Medical Center and Naval Medical Center San Diego (NMCSD), investigated the use of Virtual Reality Graded Exposure Therapy (VR-GET) study with participants who had been diagnosed with PTSD following their combat deployments. A significant reduction in PTSD symptoms severity was noted. Implications for treatment with VR-GET and future research areas of investigation, including the use of VR-GET with smart phones and the internet, are suggested.

Posttraumatic stress disorder (PTSD) is a complex, multifaceted disorder encompassing behavioral, emotional, cognitive, and physiological factors. Although PTSD was only codified in 1980, there has been an increasing interest in this area of research. Unfortunately, relatively little attention has been given to the psychological treatment of motor vehicle accident survivors, which is remarkable because vehicular collisions are deemed the number one cause of PTSD. As the emotional consequences of vehicular collisions prevail, so does the need for more effective treatments. Randomized controlled clinical trials have identified exposure-based therapies as being the most efficacious for extinguishing fears. One type of exposure-based treatment, called virtual reality exposure therapy (VRET), provides a safe, controlled, and effective therapeutic alternative that is not dependent on real-life props, situations, or even a person's imagination capabilities. This modality, while relatively new, has been implemented successfully in the treatment of a variety of anxiety disorders and may offer a particularly beneficial and intermediary step for the treatment of collision-related PTSD. In particular, VRET combined with physiological monitoring and feedback provides a unique opportunity for individuals to objectively recognize both anxiety and relaxation; learn how to manage their anxiety during difficult, albeit simulated, driving conditions; and then transfer these skills onto real-life roadways.

Exposure therapy (ET) has been observed to be an effective modality for the treatment of combat-related posttraumatic stress disorder (PTSD). Recently, efforts have been made to use virtual reality (VR) to enhance outcome with modes of ET. How such therapy applies to service members who are facing the reality of a combat deployment has been unknown. This case series documents the first use of VR-based therapy to the treatment of PTSD in a combat theater. Results of therapy are reported from a mental health clinic in Camp Fallujah, Iraq. Combat PTSD constituted a relatively small percentage of overall mental health patients seen. Those who did present with PTSD were offered VR-based ET or traditional ET. Patients who received either treatment modality showed significant gains, and no service member in treatment had to be medically evacuated because of ongoing PTSD symptoms. This demonstrates that ET, with or without the use of VR, can be an effective means of helping service members with mental health issues while they serve in theater.

Previous research suggests that the effectiveness of virtual reality exposure therapy should increase as the experience becomes more immersive. However, the neural mechanisms underlying the experience of immersion are not yet well understood. To address this question, neural activity during exposure to two virtual worlds was measured by functional magnetic resonance imaging (fMRI). Two levels of immersion were used: unimodal (video only) and multimodal (video plus audio). The results indicated increased activity in both auditory and visual sensory cortices during multimodal presentation. Additionally, multimodal presentation elicited increased activity in the hippocampus, a region well known to be involved in learning and memory. The implications of this finding for exposure therapy are discussed.

There is new research showing that interactive multimodal rehabilitation may enhance cognitive therapy after cerebrovascular accident. A well-designed Mixed Reality system provides a diverse, controllable and versatile therapeutic environment to help promote neural plasticity during recovery. In addition to stroke patients, there are other groups, such as those with traumatic brain injury (TBI) that could benefit from the system. Initial results, both paper-and-pencil measures and physiological measures, in a trial with fourteen participants are discussed.

By integrating medical science with cutting edge simulation and training technologies, realistic prosthetic tissue, wounds, and part task trainers have been developed for the training of trauma care clinicians. The next generation of Stress Inoculation Training (SIT) includes the use of prosthetics developed based on human anatomy and physiology, material science, and nanotechnology. Testing has revealed that these products are highly useful and reliable.

Smokers who are exposed to cues associated with smoking show cardiovascular reactivity and an increase in smoking urges as compared to when they are presented with neutral cues. Cue exposure therapy (CET), which refers to the repeated exposure to drug-related cues in order to extinguish this learned association, has increasingly been proposed as a potential treatment of addictive behaviors, including tobacco smoking. The result of our pilot study suggests that a cue elicited using a virtual environment (VE) is more effective than other cue exposure devices. The VE was composed of craving environments (virtual bar) and objects (an alcoholic drink, a packet of cigarettes, a lighter, an ashtray, a glass of beer, and advertising posters) that are likely to trigger craving, a smoking avatar, and an audio environment that included the noisy sound and music of a restaurant. Sixteen late-adolescent males who smoked at least 10 cigarettes a day were recruited to participate in the VE-CET study. The CET virtual bar program consisted of six sessions, and the participants were exposed repeatedly to each session using different questions and procedures. Although the effects of CET did not yield significant reductions in all of the dependent variables, the craving for cigarettes was gradually decreased during the course of the sessions. This tendency was closely related to the reduction in the smoking count between the morning before the experiment and the start of the experiment. Based on these preliminary results, it appears that VE-CET maybe a useful tool to use in treatment programs to help reduce craving in those who are nicotine dependent.

Cybertherapy is a field that is growing rapidly due to today's technology and information boom. Virtual reality and advanced technologies have been used successfully to in a variety of healthcare issues, including treatment of anxiety disorders and phobias, treatment of eating and body dysmorphic disorders, neuropsychological assessment and rehabilitation and distraction during painful or unpleasant medical procedures. The novel applications of these technologies yield many advantages over traditional treatment modalities, and the disadvantages that accompanied the first trials of virtual reality are quickly being addressed and eliminated. Virtual reality peripherals such as data gloves, physiological monitoring and Internet worlds are swiftly demonstrating their usefulness in cybertherapy applications. Future directions for research include improvements of objective measures of efficacy such as fMRI and physiological monitoring devices, and investigations are being carried out to determine if virtual reality and advanced technologies can be used to treat a broader scope of disorders, including depression, schizophrenia, drug addiction, and autism.

Patients with schizophrenia have thinking disorders such as delusions or hallucinations because they have a deficit in the ability to systematize and integrate information. Therefore, they cannot integrate or systematize visual, auditory, and tactile stimuli. The multimodal integration model of the brain can provide a theoretical background from which one can approach multimodal stimulus integration. In this study, we suggest a virtual reality system for the multi-modal assessment of cognitive ability of schizophrenia patients. The virtual reality system can provide multimodal stimuli, such as visual and auditory stimuli, to the patient and can evaluate the patient's multimodal integration and working memory integration abilities by making the patient interpret and react to multimodal stimuli, which must be remembered for a given period of time. The clinical study showed that the virtual reality program developed is comparable to those of the Wisconsin Card Sorting Test (WCST) and the Standard Progressive Matrices (SPM), and it provides some information related to the schizophrenic patients' behavior in 3D virtual environment.

Successful rehabilitation with respect to the activities of daily living (ADL) requires accurate and effective assessment and training. A number of studies have emphasized the requirement for rehabilitation methods that are both relevant to the patient's real world environment, and that can also be transferred to other daily living tasks. Virtual reality (VR) has many advantages over other ADL rehabilitation techniques, and offers the potential to develop a human performance testing and training environment. Therefore, in this study, the virtual supermarket was developed and the possibility of using a VR system to assess and train cognitive ability in ADL investigated. This study demonstrates that VR technology offers great promise in the field of ADL training.

Thirty participants who had been treated for aviophobia with virtual reality graded exposure therapy with physiological monitoring and visual feedback (VRGETpm), virtual reality graded exposure therapy with physiological monitoring only (VRGETno), or imaginal exposure therapy (visualization) with physiological monitoring only (IET) between January 1998 and January 1999 were contacted in January 2002 for a 3-year posttreatment follow-up assessment. Of the participants in the VRGETpm group who had flown successfully by the end of treatment, all had maintained their ability to fly at follow-up. Of the participants in the VRGETno group who had flown successfully by the end of treatment, two were no longer able to fly. Of the participants in the IET group who had flown successfully, all were still able to fly. It appears that the addition of teaching self-control via visual feedback of physiological signals may serve to maintain treatment gains in long-term follow-up.

Research has shown that many smokers experience an increase in the desire to smoke when exposed to smoking-related cues. Cue exposure treatment (CET) refers to the manualized, repeated exposure to smoking-related cues, aimed at the reducing cue reactivity by extinction. In this study, we constructed a virtual reality system for evoking a desire of nicotine, which was based on the results of a Questionnaire of Nicotine-craving. And we investigated the effectiveness of the virtual reality system as compared to classical device (pictures). As a result, we reached the conclusion that virtual reality elicits more craving symptoms than the classical devices.

The goal of this study was to determine if virtual reality graded exposure therapy (VRGET) was equally efficacious, more efficacious, or less efficacious, than imaginal exposure therapy in the treatment of fear of flying. Thirty participants (Age = 39.8 +/- 9.7) with confirmed DSM-IV diagnosis of specific phobia fear of flying were randomly assigned to one of three groups: VRGET with no physiological feedback (VRGETno), VRGET with physiological feedback (VRGETpm), or systematic desensitization with imaginal exposure therapy (IET). Eight sessions were conducted once a week. During each session, physiology was measured to give an objective measurement of improvement over the course of exposure therapy. In addition, self-report questionnaires, subjective ratings of anxiety (SUDs), and behavioral observations (included here as flying behavior before beginning treatment and at a three-month posttreatment followup) were included. In the analysis of results, the Chi-square test of behavioral observations based on a three-month posttreatment followup revealed a statistically significant difference in flying behavior between the groups [chi(2) (4) = 19.41, p < 0.001]. Only one participant (10%) who received IET, eight of the ten participants (80%) who received VRGETno, and ten out of the ten participants (100%) who received VRGETpm reported an ability to fly without medication or alcohol at three-month followup. Although this study included small sample sizes for the three groups, the results showed VRGET was more effective than IET in the treatment of flying. It also suggests that physiological feedback may add to the efficacy of VR treatment.