%0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e67501 %T Efficacy of Virtual Reality–Based Interventions on Cognitive Function in Patients With Neuropsychiatric Disorders: Systematic Review and Meta-Analysis of Randomized Controlled Trials %A Du,Qiujing %A Wei,Yuhan %A Ma,Yuexuan %A Liu,Changqing %A Du,Shanshan %A Zhang,Qi %A Gong,Xiaotong %A Yang,Jiaju %A Li,Qijie %A Li,Ka %K virtual reality %K neuropsychiatric disorders %K cognitive function %K systematic review %K meta-analysis %K mobile phone %D 2025 %7 8.5.2025 %9 %J JMIR Serious Games %G English %X Background: Virtual reality (VR) technology has emerged as a promising tool for cognitive rehabilitation in patients with neuropsychiatric disorders. These patients often endure significant cognitive impairments, which are associated with decreased quality of life and increased disease burden. Traditional treatments are limited in improving cognitive functions, making VR-based interventions an area of growing interest. Objective: This meta-analysis aims to evaluate the efficacy of VR-based interventions on cognitive function in patients with neuropsychiatric disorders by synthesizing data from randomized controlled trials (RCTs). Methods: Following PRISMA guidelines, we conducted a comprehensive search across PubMed, Web of Science, MEDLINE, EMBASE, and Cochrane Library for RCTs from January 2010 to December 2024. Studies were included if they evaluated the impact of VR-based interventions on cognitive outcomes in patients with neuropsychiatric disorders. Data extraction and risk of bias assessment were performed independently by 2 researchers. Meta-analyses were conducted using random-effects models, and standardized mean differences (SMDs) as effect size. Results: A total of 21 RCTs involving 1051 participants were included. Overall, VR-based interventions significantly improved cognitive functions of patients with neuropsychiatric disorders (SMD 0.67, 95% CI 0.33-1.01, z=3.85; P<.001). Subgroup analyses revealed significant benefits for cognitive rehabilitation training (SMD 0.75, 95% CI 0.33-1.17, z=3.53; P<.001), exergame-based training (SMD 1.09, 95% CI 0.26-1.91, z=2.57; P=.01), and telerehabilitation and social functioning training (SMD 2.21, 95% CI 1.11-3.32, z=3.92; P<.001). Conversely, immersive cognitive training, music attention training, and vocational and problem-solving skills training did not yield significant improvements (z=1.86, P=.06; z=0.35, P=.72; z=0.88, P=.38; respectively). Disease-type subgroup analyses indicated significant improvements in schizophrenia (SMD 0.92, 95% CI 0.22-1.62, z=2.58; P=.01), and mild cognitive impairment (SMD 0.75, 95% CI 0.16-1.35, z=2.47; P=.01), but not in brain injuries, Parkinson disease, or stroke (z=0.34, P=.73; z=1.26, P=.21; z=1.16, P=.24; respectively). Conclusions: This meta-analysis revealed that VR-based interventions can improve cognitive functions among individuals with neuropsychiatric disorders, with notable improvements observed in cognitive rehabilitation training, exergame-based training, and tele-rehabilitation and social functioning training. These results offer valuable evidence supporting the use of VR technology in rehabilitation for neuropsychiatric conditions and inform the optimization of future intervention approaches. Trial Registration: PROSPERO CRD42023445000; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023445000 %R 10.2196/67501 %U https://games.jmir.org/2025/1/e67501 %U https://doi.org/10.2196/67501 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e68515 %T Measuring Stress and Perceptions for a Virtual Reality–Based Pericardiocentesis Procedure Simulation for Medical Training: Usability Study %A Rubio-López,Alberto %A García Carmona,Rodrigo %A Zarandieta Román,Laura %A Rubio Navas,Alejandro %A González-Pinto,Angel %A Cardinal-Fernández,Pablo %K VR %K pericardiocentesis simulation %K usability assessment %K heart rate variability %K physiological stress %K simulator sickness %K System Usability Scale %K Presence Questionnaire %K virtual reality %D 2025 %7 7.5.2025 %9 %J JMIR Serious Games %G English %X Background: Virtual reality (VR) is increasingly used in medical education, providing immersive environments for training in high-risk procedures such as pericardiocentesis. This lifesaving procedure requires technical precision and induces cognitive and physiological stress. Evaluating both usability and stress responses in a VR-based pericardiocentesis simulation is essential. Heart rate variability (HRV) serves as an objective stress marker, while prior VR experience may influence usability and stress perception. Objectives: This study aimed to assess the usability of a VR-based pericardiocentesis simulation, examine the relationship between usability perceptions and physiological stress (HRV), and determine the impact of prior VR experience on usability scores and stress responses. Methods: A total of 119 final-year medical students participated in a VR pericardiocentesis simulation. Usability was evaluated using the System Usability Scale (SUS), the Post-Study System Usability Questionnaire, the Presence Questionnaire, and the Simulator Sickness Questionnaire. Physiological stress was assessed through HRV parameters, including the root-mean-square of successive differences (rMSSDs), percentage of differences greater than 50 ms (PNN50), low-frequency to high-frequency ratio, and nonlinear HRV indices (SD1/SD2 ratio, Poincaré area). Statistical analyses included descriptive statistics, Spearman correlations, and Mann-Whitney U tests to explore relationships between usability, stress, and prior VR experience. Results: The VR simulation received a mean SUS score of 75.00 (SD 6.41; 95% CI 73.42‐76.58), exceeding the general usability threshold of 68 (P=.002). The mean Post-Study System Usability Questionnaire score of 2.92 (SD 1.83; 95% CI 2.55‐3.29) indicated moderate satisfaction, while the mean Presence Questionnaire score of 109.46 (SD 9.12; 95% CI 107.88‐111.04) reflected strong immersion. Simulator sickness symptoms were mild (mean Simulator Sickness Questionnaire score 12.43, SD 15.41; 95% CI 9.28‐15.58), although novice users reported significantly higher nausea levels (P=.02). Physiological stress analysis revealed a mean rMSSD of 281.27 (SD 98.99; 95% CI 259.45‐303.09) ms and PNN50 of 56.85% (SD 19.70%; 95% CI 52.23%‐61.47%), indicating moderate autonomic balance. A significant negative correlation was observed between HRV parameters (rMSSD and PNN50) and simulator sickness (P=.04; Spearman ρ=−0.23), suggesting that higher physiological stress was associated with increased simulator sickness symptoms. Prior VR experience was linked to higher usability scores (SUS +5.2; 95% CI 3.12-7.28; P=.03) and lower simulator sickness symptoms (P=.02) but did not significantly affect HRV markers. Conclusions: VR-based simulations for high-risk medical procedures are effective training tools with high usability (SUS=75) and strong immersion. Simulator sickness correlated with physiological stress, emphasizing the need for design refinements to improve user comfort. Prior VR experience improved usability and reduced simulator sickness but did not significantly impact HRV markers. Future research should refine VR interfaces to balance immersion with minimized cognitive and physical discomfort. %R 10.2196/68515 %U https://games.jmir.org/2025/1/e68515 %U https://doi.org/10.2196/68515 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e69757 %T Enhancing Adherence to Continuous Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea Using Augmented Reality: Protocol for a Randomized Controlled Trial %A Chen,Ming-Che %A Chen,Yen-Chin %A Lin,Cheng-Yu %+ Department of Nursing, College of Medicine, National Sun Yat-sen University, No.70 Lien-hai Road, Kaohsiung City, 804201, Taiwan, 886 7 5252000 ext 7374, yenchin2427@gmail.com %K obstructive sleep apnea %K continuous positive airway pressure %K augmented reality %K adherence %K feasibility %D 2025 %7 6.5.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Continuous positive airway pressure (CPAP) therapy is the gold standard treatment for treating obstructive sleep apnea (OSA). However, patient adherence to CPAP therapy remains a critical challenge, with many individuals finding it difficult to maintain consistent use due to discomfort, lack of understanding, or perceived inconvenience. Augmented reality (AR) offers a novel approach to overcoming these barriers by providing interactive real-time guidance to users, potentially enhancing adherence rates. Objective: This clinical trial aims to examine the feasibility of AR implementation and the effect of AR on improving CPAP adherence in patients with OSA. Methods: A randomized controlled trial with a parallel assignment will be conducted. Participants will be randomly assigned to either an experimental group receiving AR-guided CPAP therapy or a control group receiving standard care. The study will span 6 months, with assessments at baseline (T0), and with follow-ups at 1 month (T1), 3 months (T2), and 6 months (T3) post intervention. The primary outcome measure is CPAP adherence, defined as using the CPAP device for more than 70% of sleep time, with a minimum of 4 hours per night. Secondary outcomes will evaluate the common adverse effects associated with CPAP therapy, device usability, and time required for CPAP machine use education. Results: This study is funded by the Ministry of Science and Technology, Taiwan (August 2023 to July 2026) and was registered in August 2024 (ClinicalTrials.gov NCT06520592). Participant recruitment is scheduled to begin in April 2025, and by September 2025, we expect to have enrolled 40 participants (50% of the target sample of 80). Preliminary analyses of CPAP adherence at 1 month and usability data are currently underway. Final data collection is anticipated to be completed by December 2025, with results expected to be published by Fall 2026. Conclusions: Anticipated findings suggest that AR-guided CPAP therapy may significantly enhance patient adherence by improving mask fitting and providing effective, interactive education. If validated, this innovative approach could pave the way for more personalized technology-driven interventions in OSA management and other chronic conditions requiring long-term therapy adherence. Trial Registration: ClinicalTrials.gov NCT06520592; https://clinicaltrials.gov/study/NCT06520592 International Registered Report Identifier (IRRID): PRR1-10.2196/69757 %M 40327384 %R 10.2196/69757 %U https://www.researchprotocols.org/2025/1/e69757 %U https://doi.org/10.2196/69757 %U http://www.ncbi.nlm.nih.gov/pubmed/40327384 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e66998 %T Acceptability of and Willingness to Use Virtual Reality Exergames for Weight Loss Among Young Adults With Overweight or Obesity in China: Qualitative Study %A Chen,Yanya %A Guan,Bingsheng %A Zhang,Yaqi %A Lee,Suen Chow %A Liu,Jia-yu %A Li,Sicun %A Liu,Ming %A Zhang,Xiaoshen %A Ming,Wai-kit %K acceptability %K virtual reality %K exergames %K overweight %K obesity %D 2025 %7 1.5.2025 %9 %J JMIR Serious Games %G English %X Background: Overweight and obesity seriously affect physical and psychological health worldwide. They are common public health issues in young adults who are considered a “vulnerable group” prone to adopt unhealthy lifestyles that can lead to overweight and obesity. Virtual reality exergames could help increase balance performance among patients with Parkinson disease and improve depression and pain interference among individuals with chronic neck pain. Still, limited research has been conducted on the use of virtual reality exergames among young adults with overweight and obesity, and their willingness and acceptability remain unclear. Objectives: This study aimed to assess the acceptability of and willingness to use virtual reality exergames for weight loss among young adults with overweight or obesity. Methods: This was a qualitative study. Sixteen young adults with overweight or obesity were recruited in Guangzhou, China, and divided into 4 focus groups. They were interviewed between September and October 2023 through semistructured interviews. NVivo (version 14; Lumivero) was used to transcribe, code, and thematically analyze interviews. Results: Four main themes and 8 subthemes emerged from the data. The main themes included perception of previous weight loss measures (regarded exercise and diet as the main measures for weight loss and difficulties in holding on to the weight loss methods), acceptability of virtual reality exergames (increasing opportunities for exercise, a powerful means for propelling doing exercise, positive impact on psychological well-being, and more appealing to office workers than students), willingness to use virtual reality exergames, and concerns (weight loss effect and other concerns). Conclusions: Virtual reality exergames were seen as beneficial for maintaining exercise and promoting psychological well-being among young adults with overweight or obesity, despite concerns about effectiveness, cost, and privacy. Almost all young adults indicated their willingness to try these kinds of games if given the opportunity. These findings suggested that virtual reality exergames could be a promising tool for weight management in this population. %R 10.2196/66998 %U https://games.jmir.org/2025/1/e66998 %U https://doi.org/10.2196/66998 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 12 %N %P e71708 %T Immersive Virtual Reality eHealth Intervention to Reduce Anxiety and Depression in Pregnant Women: Randomized Controlled Trial %A Jimenez-Barragan,Marta %A Del Pino Gutierrez,Amparo %A Sauch Valmaña,Gloria %A Monistrol,Olga %A Monge Marcet,Carme %A Pallarols Badia,Mar %A Garrido,Ignasi %A Carmona Ruiz,Anna %A Porta Roda,Oriol %A Esquinas,Cristina %A Falguera Puig,Gemma %+ Department of Public Health, Mental Health and Maternal and Child Health Nursing, Faculty of Nursing, Universitat de Barcelona, Feixa Llarga s/n 08907 Hospitalet de Llobregat, Barcelona, Spain, Barcelona, 08907, Spain, 34 934024256, marta.jim@gmail.com %K virtual reality %K eHealth %K pregnancy %K mental health %K anxiety %K depression %K randomized controlled trial %K antenatal care %D 2025 %7 30.4.2025 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Mental health during pregnancy is a critical factor influencing maternal and fetal outcomes. Anxiety and depression affect up to 30% of pregnant women, with significant consequences for maternal well-being and child development. Despite this, interventions during pregnancy remain limited, creating a need for innovative, accessible solutions. Objective: This study aimed to evaluate the effectiveness of an immersive virtual reality (IVR) eHealth intervention in reducing anxiety and depression symptoms in women during pregnancy. Methods: A 2-arm, randomized controlled trial was conducted across 5 primary care centers in Catalonia, Spain, between October 2021 and May 2024. The study included pregnant women (N=70) aged ≥18 years with moderate anxiety and depression symptoms (Edinburgh Postnatal Depression Scale [EPDS] scores: 9-12) at 12 to 14 weeks of gestation. They were randomly assigned (1:1) to an IVR intervention or standard care group. The intervention group engaged in daily 14-minute IVR mindfulness and relaxation sessions for 6 weeks. Mental health outcomes were assessed using the EPDS and State-Trait Anxiety Inventory. Results: The intervention group demonstrated significant reductions in EPDS scores, with a mean decrease from 11.32 (SD 0.96) to 7.25 (SD 1.32; P<.001), compared to an increase in the control group from 11.32 (SD 0.94) to 16.23 (SD 1.25; P<.001). Similarly, State-Trait Anxiety Inventory scores improved markedly in the intervention group (mean decrease from 57.94, SD 5.23 to 35.03, SD 6.12; coefficient –30.47, 95% CI −45.23 to −15.72; P<.001), while the control group experienced a nonsignificant increase (from 66.10, SD 5.89 to 72.91, SD 6.34; P=.68). High adherence rates were observed, with 79% (26/33) of participants completing ≥30 sessions. Participant satisfaction was high, with 87% (29/33) reporting being “very satisfied” with the intervention. Conclusions: The IVR eHealth intervention significantly reduced symptoms of anxiety and depression, demonstrating its potential as an accessible and effective tool for mental health support during pregnancy. High adherence and satisfaction levels underscore its feasibility and acceptability. Future research should explore the long-term effects and scalability of IVR interventions in diverse settings. Trial Registration: ClinicalTrials.gov NCT05756205; https://clinicaltrials.gov/study/NCT05756205 International Registered Report Identifier (IRRID): RR2-10.1186/s12912-023-01440-4 %M 40306641 %R 10.2196/71708 %U https://humanfactors.jmir.org/2025/1/e71708 %U https://doi.org/10.2196/71708 %U http://www.ncbi.nlm.nih.gov/pubmed/40306641 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e69428 %T Immersive Virtual Reality and AI (Generative Pretrained Transformer) to Enhance Student Preparedness for Objective Structured Clinical Examinations: Mixed Methods Study %A Esmail,Shaniff %A Concannon,Brendan %+ Department of Occupational Therapy, University of Alberta, 8205 - 114 St 2-64 Corbett Hall, Edmonton, AB, T6G 2G4, Canada, 1 780 492 2499, shaniff.esmail@ualberta.ca %K virtual reality %K head-mounted display %K immersive technology %K artificial intelligence %K generative pretrained transformer %K occupational therapy %K objective structured clinical examination %K simulation %K psychology %K anxiety %D 2025 %7 30.4.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Immersive virtual reality (VR) and artificial intelligence have been used to determine whether a simulated clinical exam setting can reduce anxiety in first-year occupational therapy students preparing for objective structured clinical examinations (OSCEs). Test anxiety is common among postsecondary students, leading to negative outcomes such as increased dropout risk, lower grades, and limited employment opportunities. Students unfamiliar with specific testing environments are particularly prone to anxiety. VR simulations of OSCEs may allow students to become familiar with the exam setting and reduce anxiety. Objective: This study aimed to assess the efficacy of a VR simulation depicting clinical settings to reduce student anxiety about a clinical exam while gathering perspectives on their first-year coursework experiences to better understand their learning environment. Methods: An experimental, nonrandomized controlled trial compared state anxiety, trait test anxiety, and OSCE grades in 2 groups of first-year occupational therapy students analyzed using independent t tests (2-tailed). Group 1 (NoVR) was not exposed to the VR simulation and acted as a control group for group 2 (YesVR), who were exposed to the VR simulation. The VR used artificial intelligence in the form of a generative pretrained transformer to generate responses from virtual patients as students interacted with them in natural language. Self-reported psychometric scales measured anxiety levels 3 days before the OSCE. YesVR students completed perceived preparation surveys at 2 time points—3 weeks and 3 days before the OSCE—analyzed using dependent t tests. Semistructured interviews and focus groups were conducted within 1 week after the OSCE. Student perspectives on their classes and VR experiences were summarized using interpretative thematic analysis. Results: In total, 60 students—32 (53%) in the NoVR group and 28 (47%) in the YesVR group—participated in the study, and the YesVR group showed a significant reduction in state anxiety (t58=3.96; P<.001; Cohen d=1.02). The mean difference was 11.96 units (95% CI 5.92-18.01). Trait test anxiety and OSCE scores remained static between groups. There was an increase in all perceived preparedness variables in the YesVR group. In total, 42% (25/60) of the participants took part in interviews and focus groups, providing major themes regarding factors that affect OSCE performance, including student experience and background, feedback and support, fear of unknown, self-consciousness, and knowledge of the exam environment. Conclusions: Intolerance of uncertainty may lead students to interpret ambiguous exam situations as overly precarious. Findings suggest that VR simulation was associated with reduced state anxiety, although results from this small, nonrandomized sample should be interpreted cautiously. Qualitative data indicated that VR helped students gain familiarity with clinical exam settings, potentially decreasing uncertainty-based anxiety. Future research with larger or randomized samples is needed to confirm these findings and explore advanced VR tools offering feedback to enhance learning. %M 40306631 %R 10.2196/69428 %U https://games.jmir.org/2025/1/e69428 %U https://doi.org/10.2196/69428 %U http://www.ncbi.nlm.nih.gov/pubmed/40306631 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e62649 %T The Influence of Previous Experience on Virtual Reality Adoption in Medical Rehabilitation and Overcoming Knowledge Gaps Among Health Care Professionals: Qualitative Interview Study %A Schreiter,Melina %A Hennrich,Jasmin %A Wolf,Anna Lina %A Eymann,Torsten %+ Branch Business & Information Systems Engineering, Fraunhofer FIT, Wittelsbacherring 10, Bayreuth, 95444, Germany, 49 921 55 7661, melina.schreiter@fit.fraunhofer.de %K virtual reality %K technology adoption %K medical rehabilitation %K qualitative content analysis %K adoption decision process %K health care professionals %K previous experience %D 2025 %7 30.4.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) technologies in health care, particularly in medical rehabilitation, have demonstrated effectiveness by enabling patient remobilization in virtual environments, offering real-time feedback, enhancing physical function and quality of life, and allowing patients to exercise autonomously. Nevertheless, VR technologies are facing slow adoption in routine rehabilitative practice due to health care professionals’ concerns regarding data security, lack of time, or perceived cost. Objective: This study aimed to explore how previous experience with VR technologies influences health care professionals’ decisions to adopt or reject these technologies in medical rehabilitation. Methods: We conducted 23 semistructured interviews with health care professionals from different rehabilitative fields in Germany, whom we grouped into VR-experienced “innovators” and nonexperienced “laggards” according to their level of innovativeness. When analyzing the interviews, we applied qualitative content analysis techniques and derived 56 preliminary categories from the transcripts. Results: We merged the preliminary categories into 26 adoption and rejection factors, which were grouped under the 4 overarching categories of the diffusion of innovation theory by Rogers. In addition to the pure identification of context-specific influencing factors, we were able to identify differences between these factors concerning the two different adopter groups. VR-experienced innovators exhibited key characteristics such as openness to new technologies, solution-oriented thinking, and opinion leadership, whereas nonexperienced laggards focused on barriers and relied on top-down knowledge transfer. Despite these differences, both groups agreed on the factors that promote the adoption of VR technologies. Our results indicate that addressing the unique needs of both groups is crucial for wider VR acceptance in health care. Conclusions: This study demonstrates the importance of distinguishing between VR-experienced and nonexperienced health care professionals, providing actionable insights for developing adopter-specific communication strategies to overcome barriers and foster broader diffusion of VR technologies in the health care sector. %M 40305102 %R 10.2196/62649 %U https://www.jmir.org/2025/1/e62649 %U https://doi.org/10.2196/62649 %U http://www.ncbi.nlm.nih.gov/pubmed/40305102 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e55291 %T Effects of Virtual Reality–Based Interventions on Preoperative Anxiety in Patients Undergoing Elective Surgery With Anesthesia: Systematic Review and Meta-Analysis %A Li,Huiyuan %A Chiu,Pak Lung %A Efendi,Defi %A Huang,Haiying %A Ko,Ka Yan %A Wong,Cho Lee %+ The Nethersole School of Nursing, Faculty of Medicine, Chinese University of Hong Kong, 8/F, Esther Lee Building, Hong Kong, , China (Hong Kong), 86 39438166, jojowong@cuhk.edu.hk %K meta-analysis %K preoperative anxiety %K surgery %K systematic review %K virtual reality %K anesthesia %K exposure approach %D 2025 %7 30.4.2025 %9 Review %J J Med Internet Res %G English %X Background: Preoperative anxiety is a common yet often neglected problem for patients undergoing surgery. Virtual reality (VR)–based intervention is a promising alternative with benefits for managing preoperative anxiety. However, the components of VR-based intervention and its effectiveness on preoperative anxiety in patients undergoing elective surgery with anesthesia remain unclear. Objective: This study aimed to identify the major components (ie, device, medium, format, and duration) of VR-based interventions and summarize evidence regarding their effectiveness in reducing preoperative anxiety in patients undergoing elective surgery with anesthesia. Methods: Allied and Complementary Medicine, Chinese University of Hong Kong Full Text Journals, CINAHL via EBSCOhost, Cochrane Library, Joanna Briggs Institute EBP Database, EMBASE, MEDLINE via OvidSP, PubMed, PsychINFO, Scopus, China Journal Net, and WanFang Data Chinese Dissertations Database were searched from inception to February 2025. Randomized controlled trials (RCTs) of VR-based interventions for patients undergoing elective surgery with anesthesia were included. The Cochrane Collaboration’s tool was used for risk of bias assessment. A random effect model was used for pooling the results. Results: A total of 35 RCTs with 3341 patients (female: n=1474, 44.1%) were included in this review, of which 29 RCTs were included for meta-analysis. Compared with usual care, VR-based interventions showed substantial benefits in decreasing preoperative anxiety in patients undergoing elective surgery (standardized mean difference [SMD] 0.65, 95% CI 0.37-0.92; P<.001). Regarding the subgroup analysis, VR-based intervention showed significant but moderate effects on preoperative anxiety in the pediatric population (SMD 0.77, 95% CI 0.32-1.22; P<.001) compared to the adult population (SMD 0.58, 95% CI 0.23-0.93; P=.001). The distraction approach showed more significant effects (SMD 0.73, 95% CI 0.24-1.21; P=.004) on preoperative anxiety than the exposure approach (SMD 0.61, 95% CI 0.27-0.95; P<.001). Conclusions: Patients undergoing elective surgery with anesthesia may benefit from VR as a novel alternative to reduce preoperative anxiety, especially pediatric patients via the distraction approach. However, more rigorous research is needed to confirm VR’s effectiveness. %M 40305092 %R 10.2196/55291 %U https://www.jmir.org/2025/1/e55291 %U https://doi.org/10.2196/55291 %U http://www.ncbi.nlm.nih.gov/pubmed/40305092 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e65801 %T School-Based Virtual Reality Programming for Obtaining Moderate-Intensity Exercise Among Children With Disabilities: Pre-Post Feasibility Study %A Lai,Byron %A Wright,Ashley %A Hutchinson,Bailey %A Bright,Larsen %A Young,Raven %A Davis,Drew %A Malik,Sultan Ali %A Rimmer,James H %A , %K disability %K adapted physical activity %K leisure-time exercise %K exercise %K telehealth %K tele-exercise %K cerebral palsy %K pediatric rehabilitation %K intellectual disability %K developmental disability %K child %K high school %K exercise %K mobility %K mobility disability %K cardio %K cardiorespiratory %K cardiometabolic %K feasibility %K virtual reality %K controlled trial %K t test %K VR %K exergame %K mixed method %D 2025 %7 25.4.2025 %9 %J JMIR Form Res %G English %X Background: Children have busy daily schedules, making school an ideal setting for promoting health-enhancing exercise behavior. However, children with mobility disabilities have limited exercise options to improve their cardiorespiratory fitness and cardiometabolic health. Objective: This study aims to test the feasibility of implementing a virtual reality (VR) exercise program for children with mobility disabilities in a high school setting. Methods: A pre- to posttrial single-group design with a 6-week exercise intervention was conducted at a high school. The study aimed to enroll up to 12 students with a disability. Participants were given the option of exercising at home or school. The exercise prescription was three 25-minute sessions per week at a moderate intensity, using a head-mounted VR display. School exercise sessions were supervised by research staff. Home exercise sessions were performed autonomously. Several implementation metrics of feasibility were recorded, including exercise attendance, volume, adverse events or problems, and benefits related to health-related fitness (walking endurance and hand-grip strength). The study also included a qualitative evaluation of critical implementation factors and potential benefits for participants that were not included in the study measures. Outcomes were descriptively analyzed, and 2-tailed t tests were used as appropriate. Results: In total, 10 students enrolled in the program and 9 completed the study (mean age 17, SD 0.6 y). In total, 5 (56%) participants exercised at school, and 4 (44%) exercised at home; 1 participant dropped out prior to exercise. The mean attendance for all 9 completers was 61.1% (11/18 sessions). The mean exercise minutes per week was 35.5 (SD 22) minutes. The mean move minutes per session was 17.7 (SD 11) minutes. The mean minutes per session was 18 (SD 1.4) minutes for school exercisers and 17 (SD 18) minutes for home exercisers, indicating variable responses from home exercisers. The mean rating of perceived exertion per exercise session was 4.3 (SD 2), indicating a moderate intensity that ranged from low to hard intensity. No adverse events or problems were identified. No improvements in walking endurance or hand-grip strength were observed. School exercisers achieved a higher attendance rate (83%) than home exercisers (27%; P<.001) and seemingly had a 2-fold increase in the volume of exercise achieved (school: mean 279, SD 55 min; 95% CI 212‐347; home: mean 131, SD 170 min; 95% CI –140 to 401; P=.10). Qualitative themes relating to implementation factors and benefits to participant well-being were identified. Conclusions: This study identified factors to inform an optimal protocol for implementing a high school–based VR exercise program for children with disabilities. Study findings demonstrated that moderate exercise at school is feasible in VR, but simply providing children with VR exergaming technology at home, without coaching, will not successfully engage them in exercise. Trial Registration: ClinicalTrials.gov NCT05935982; https://clinicaltrials.gov/study/NCT05935982 %R 10.2196/65801 %U https://formative.jmir.org/2025/1/e65801 %U https://doi.org/10.2196/65801 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e64576 %T The Efficacy of Virtual Reality on the Rehabilitation of Musculoskeletal Diseases: Umbrella Review %A Tang,Peiyuan %A Cao,Yangbin %A Vithran,Djandan Tadum Arthur Vithran %A Xiao,Wenfeng %A Wen,Ting %A Liu,Shuguang %A Li,Yusheng %+ , Department of Orthopedics, Xiangya Hospital, Central South University, Xiangya Road, Kaifu District, Changsha, 410000, China, 86 13975889696, liyusheng@csu.edu.cn %K virtual reality %K VR %K umbrella review %K musculoskeletal diseases %K orthopedics %K efficacy %D 2025 %7 25.4.2025 %9 Review %J J Med Internet Res %G English %X Background: Musculoskeletal disorders cause pain, disability, and financial burdens, with rising prevalence. Virtual reality (VR) offers immersive, digital rehabilitation potential, improving motor functions and pain management. Objective: To evaluate the impact of VR on the rehabilitation of musculoskeletal disorders and to assess the consistency of evidence provided by existing systematic reviews and meta-analyses, this study focuses on musculoskeletal disorders, which encompass conditions affecting the locomotor system, such as arthritis, joint deformities, and injuries. VR therapy leverages immersive digital environments to enhance rehabilitation through digital exercises and simulations. Methods: The PubMed or MEDLINE, Embase, and Cochrane Library databases were systematically searched for relevant papers published up to April 2024. Literature screening, quality assessment, and data extraction were conducted according to predefined inclusion and exclusion criteria. The methodological quality of the included meta-analyses was evaluated using the Measurement Tool to Assess Systematic Reviews 2. The Grading of Recommendations Assessment, Development, and Evaluation system was used to classify the evidence level for each outcome as high, moderate, low, or very low. Additionally, the evidence was categorized into 5 levels based on classification criteria: I (convincing), II (highly suggestive), III (suggestive), IV (weak), and nonsignificant. Results: This umbrella review synthesized data from 14 meta-analyses published between 2019 and 2024, involving a total of 13,184 patients. In total, 7 meta-analyses received high Measurement Tool to Assess Systematic Reviews 2 ratings, 7 were rated moderate, and the remainder were rated low. VR demonstrated promising results in musculoskeletal rehabilitation, significantly reducing knee pain (mean difference [MD] –1.38, 95% CI –2.32 to –0.44; P=.004; I2=94%) and improving balance. For patients with fibromyalgia syndrome, VR effectively reduced pain (standardized mean difference [SMD] –0.45, 95% CI –0.70 to –0.20; P<.001), fatigue (SMD –0.58, 95% CI –1.01 to –0.14; P=.01), anxiety (SMD –0.50, 95% CI –0.908 to –0.029; P=.04), and depression (SMD –0.62, 95% CI –0.76 to –0.15; P=.003) while also enhancing quality of life. In individuals with back pain, VR alleviated pain-related fears (MD –5.46, 95% CI –9.40 to –1.52; P=.007; I2=90%) and reduced pain intensity (MD –1.43, 95% CI –1.86 to –1.00; P<.001; I2=95%). After arthroplasty, VR improved knee functionality (MD 8.30, 95% CI 6.92-9.67; P<.001; I2=24%) and decreased anxiety (MD –3.95, 95% CI –7.76 to –0.13; P=.04; I2=0%). Conclusions: VR demonstrates significant potential in the rehabilitation of various musculoskeletal conditions. It effectively alleviates pain, enhances psychological well-being, and facilitates the recovery of motor function in patients. Trial Registration: PROSPERO CRD42024538469; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024538469 %M 40279163 %R 10.2196/64576 %U https://www.jmir.org/2025/1/e64576 %U https://doi.org/10.2196/64576 %U http://www.ncbi.nlm.nih.gov/pubmed/40279163 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e66988 %T Advancing Politeness and Assertive Communication Through Tone of Voice in Crisis Team Situations: Pre-Post Acoustic Analysis Study of Team and Strategies to Enhance Performance and Patient Safety (TeamSTEPPS) Virtual Simulation for Interprofessional Education in Health Care Undergraduate Students %A Jitwiriyanont,Sujinat %A Rawan,Rattanasuwan %A Narajeenron,Khuansiri %+ Department of Emergency Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, 1873 MDCU Faculty, Pathumwan, Bangkok, 10330, Thailand, 66 0855054209, khuansiri.n@chula.ac.th %K virtual simulation %K TeamSTEPPS %K acoustic analysis %K prosodic features %K interprofessional education %K politeness, assertive communication, tone of voice, confident, respect %D 2025 %7 21.4.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Effective interprofessional communication, including politeness, respect for coworkers, and self-control, is crucial in emergency care. These values are emphasized by both Thai and US cultures. Notably, nurses place greater significance on respect and self-control than physicians, underscoring the need for physicians to recognize and adopt these attributes, especially in interactions with nursing staff. To develop these competencies, interprofessional education (IPE) programs are essential, with simulation-based IPE, particularly virtual simulations, showing promise in enhancing teamwork and communication. However, research on the tone of voice in emergency communication is limited, especially in Thailand, where standardized IPE curricula are lacking. Objective: This study aimed to assess the effectiveness of Team and Strategies to Enhance Performance and Patient Safety (TeamSTEPPS) virtual simulation IPE, using a 3D computer-based or virtual reality (VR) approach, in enhancing interprofessional communication among health care students, focusing on politeness and assertiveness in the tone of voice. Methods: An experimental design was used with 30 health care students from 5 disciplines, including medical, nursing, medical technology, radiological technology, and pharmacy students. Participants were recorded during pretraining and posttraining TeamSTEPPS sessions. Acoustic analysis focused on 3 cues: duration, intensity, and fundamental frequency (F0). Duration measured the length of utterances, whereas intensity (loudness) and F0 (pitch) were analyzed using parameters, such as maximum, minimum, mean, SD, and range. In total, 5663 utterances were analyzed, providing a dataset for identifying significant shifts in vocal delivery after training. Using the Wilcoxon signed-rank test, these 11 acoustic parameters were extracted and statistically analyzed to compare pre- and posttraining differences. Results: Significant improvements in the tone of voice were observed. Medical and nursing students exhibited changes in pitch (SD and mean of F0; P<.001) and loudness (mean of intensity, P<.001), suggesting more attentive communication. The increased utterance duration in core team members suggests that they engaged in more elaborate information sharing and verification, critical for patient safety. Medical technology and radiological technology students showed reduced pitch (mean of F0; P<.05 in medical technology students and P<.01 in radiological students) and intensity (mean of intensity; P<.01 in medical technology students), reflecting calmer, more controlled communication. Pharmacy students showed minor changes. Conclusions: TeamSTEPPS virtual simulation IPE, using a 3D computer-based or VR approach, effectively enhances interprofessional nonverbal communication by improving key acoustic features related to politeness and assertiveness within the Thai culture context. Medical and nursing students showed the most notable gains, whereas quieter more controlled communication styles emerged among the other groups. The results demonstrate the ways in which vocal modulations can reflect role-specific responsibilities and interpersonal sensitivity in clinical interactions. These findings highlight the significance of tailored virtual simulation IPE programs for improving teamwork and patient outcomes across health care disciplines. %M 40258598 %R 10.2196/66988 %U https://www.jmir.org/2025/1/e66988 %U https://doi.org/10.2196/66988 %U http://www.ncbi.nlm.nih.gov/pubmed/40258598 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e67755 %T Impact of a Virtual Reality Video ("A Walk-Through Dementia") on YouTube Users: Topic Modeling Analysis %A Li,Xiaoli %A Liu,Xiaoyu %A Yin,Cheng %A Collins,Sandra %A Alanazi,Eman %K Alzheimer disease %K Alzheimer disease and related dementias %K ADRD %K dementia %K public awareness %K text mining %K older adult %K health care student %K training %K health care professional %K simulation %K digital world %K virtual environment %K virtual tour %K walk-through dementia %K virtual reality %K VR %K VR video %K VR application %K topic modeling %K YouTube %K Bidirectional Encoder Representations from Transformers %K BERT %K social media comments %K experiential learning tool %D 2025 %7 16.4.2025 %9 %J JMIR Form Res %G English %X Background: Emerging research has highlighted the potential of virtual reality (VR) as a tool for training health care students and professionals in care skills for individuals with Alzheimer disease and related dementias (ADRD). However, there is limited research on the use of VR to engage the general public in raising awareness about ADRD. Objective: This research aimed to examine the impact of the VR video “A Walk-Through Dementia” on YouTube users by analyzing their posts. Methods: We collected 12,754 comments from the VR video series “A Walk-Through Dementia,” which simulates the everyday challenges faced by individuals with ADRD, providing viewers with an immersive experience of the condition. Topic modeling was conducted to gauge viewer opinions and reactions to the videos. A pretrained Bidirectional Encoder Representations from Transformers (BERT) model was used to transform the YouTube comments into high-dimensional vector embeddings, allowing for systematic identification and detailed analysis of the principal topics and their thematic structures within the dataset. Results: We identified the top 300 most frequent words in the dataset and categorized them into nouns, verbs, and adjectives or adverbs using a part-of-speech tagging model, fine-tuned for accurate tagging tasks. The topic modeling process identified eight8 initial topics based on the most frequent words. After manually reviewing the 8 topics and the content of the comments, we synthesized them into 5 themes. The predominant theme, represented in 2917 comments, centered on users’ personal experiences with the impact of ADRD on patients and caregivers. The remaining themes were categorized into 4 main areas: positive reactions to the VR videos, challenges faced by individuals with ADRD, the role of caregivers, and learning from the VR videos. Conclusions: Using topic modeling, this study demonstrated that VR applications serve as engaging and experiential learning tools, offering the public a deeper understanding of life with ADRD. Future research should explore additional VR applications on social media, as they hold the potential to reach wider audiences and effectively disseminate knowledge about ADRD. %R 10.2196/67755 %U https://formative.jmir.org/2025/1/e67755 %U https://doi.org/10.2196/67755 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e65993 %T Research Hotspots and Trends of Virtual Reality Intervention for Stroke: Bibliometric Analysis %A Wei,Yixin %A Chen,Yuan %A Ma,Runting %A Qiu,Yitong %A Su,Wei %A Zhang,Li %A Gao,Qiang %K virtual reality %K stroke %K bibliometric analysis %K hotspots %K research trends %D 2025 %7 16.4.2025 %9 %J JMIR Serious Games %G English %X Background: Virtual reality (VR) is a rapidly developing technology that has gained significant traction in the treatment and rehabilitation of individuals with stroke. Research on VR-based stroke treatment has garnered increasing attention. Objective: The aim of this study is to present a bibliometric analysis of VR for stroke studies to identify the application status, research hotspots, and emerging trends and guide future scientific research. Methods: We included studies and reviews on the topic of VR-based stroke treatment and rehabilitation from 1999 to 2023 were retrieved from Web of Science Core Collection database. Citespace 6.3.1 and VOSviewer 1.6.20 software was used for the visual analysis of publications, institutions, authors, journals, citations, and Scimago Graphica software was used for the geographic visualization of published countries or regions. Results: Our study analyzed 1171 papers on VR-based stroke rehabilitation published between 1999 and 2023, revealing a gradual increase in annual publications over the past 2 decades, peaking at 154 in 2022. North America and Western Europe were identified as major contributors, with significant input from their institutions, researchers, and publications. The Journal of NeuroEngineering and Rehabilitation emerged as the leading journal in this field, while Calabrò Rocco Salvatore was recognized as the most prolific author, focusing on the neurophysiological impacts of VR on patients with stroke. Keywords with notable citation bursts, such as “environment,” “trial,” “arm,” and “motor learning,” highlighted the core research themes in this domain. Conclusions: Our study provides valuable insights into the current research hotspots and emerging trends in VR-based stroke treatment and rehabilitation. Current research primarily focuses on evaluating the effectiveness of VR in improving upper limb function and balance in patients with stroke. Future directions are shifting towards integrating VR with rehabilitation techniques, such as physiotherapy and occupational therapy, while advancements in VR technology continue to garner increasing attention. %R 10.2196/65993 %U https://games.jmir.org/2025/1/e65993 %U https://doi.org/10.2196/65993 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e68132 %T Acceptability, Usability, and Insights Into Cybersickness Levels of a Novel Virtual Reality Environment for the Evaluation of Depressive Symptoms: Exploratory Observational Study %A Sutori,Sara %A Eliasson,Emma Therése %A Mura,Francesca %A Ortiz,Victor %A Catrambonephd,Vincenzo %A Hadlaczky,Gergö %A Todorov,Ivo %A Alfeo,Antonio Luca %A Cardi,Valentina %A Cimino,Mario G C A %A Mioni,Giovanna %A Raya,Mariano Alcañiz %A Valenza,Gaetano %A Carli,Vladimir %A Gentili,Claudio %+ National Centre for Suicide Research and Prevention, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Granits väg 4, Stockholm, 171 65, Sweden, 46 701407295, emma.eliasson@ki.se %K depression %K virtual reality %K assessment %K acceptability %K usability %K cybersickness %D 2025 %7 16.4.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: There is a clear need for enhanced mental health assessment, depressive symptom (DS) evaluation being no exception. A promising approach to this aim is using virtual reality (VR), which entails the potential of adding a wider set of assessment domains with enhanced ecological validity. However, whilst several studies have used VR for both diagnostic and treatment purposes, its acceptance, in particular how exposure to virtual environments affects populations with psychiatric conditions remains unknown. Objective: This study aims to report on the acceptability, usability, and cybersickness levels of a pilot VR environment designed for the purpose of differentiating between individuals with DSs. Methods: The exploratory study, conducted in Italy, included 50 healthy controls and 50 young adults with mild-to-moderate DSs (without the need for a formal diagnosis). The study used an observational design with approximately 30 minutes of VR exposure followed by a self-report questionnaire battery. The battery included a questionnaire based on the Theoretical Framework of Acceptability, the System Usability Scale as well as the Simulator Sickness Questionnaire. Results: Results indicate that the majority found VR acceptable for the purposes of mental health screening and treatment. However, for diagnostics, there was a clear preference for VR to be used by mental health professionals as a supplementary tool, as opposed to a stand-alone solution. In practice, following exposure to the pilot VR environment, generally, good levels of acceptability and usability were reported, but areas in need of improvement were identified (such as self-efficacy). Self-reported cybersickness levels were comparable to literature averages but were considerably higher among those with DSs. Conclusions: These findings raise questions about the potential interplay between underlying somatic symptoms of depression and VR-induced cybersickness and call for more attention from the scientific community both in terms of methodology as well as potential clinical and theoretical implications. Conclusively, user support indicates a potential for VR to aid mental health assessment, but further research is needed to understand how exposure to virtual environments might affect populations with varying severity and other forms of psychiatric symptoms. International Registered Report Identifier (IRRID): RR2-10.1186/ISRCTN16396369 %M 40238239 %R 10.2196/68132 %U https://formative.jmir.org/2025/1/e68132 %U https://doi.org/10.2196/68132 %U http://www.ncbi.nlm.nih.gov/pubmed/40238239 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 12 %N %P e66352 %T Virtual Reality Respiratory Biofeedback in an Outpatient Pediatric Pain Rehabilitation Program: Mixed Methods Pilot Study %A Recker,Kristin %A Silliman,Julia %A Gifford,Karolina %A Patel,Parth %A Santana,Lisgelia %A Hildenbrand,Aimee K %A Palit,Shreela %A Wasserman,Rachel %K chronic pain %K adolescents %K feasibility %K respiratory biofeedback %K virtual reality %K VR %K applied VR respiratory biofeedback %K acceptability %D 2025 %7 14.4.2025 %9 %J JMIR Rehabil Assist Technol %G English %X Background: Chronic pain in adolescents is a significant and growing concern, as it can have negative implications on physical and psychosocial development. Management can be complicated by the increasing risks associated with opioid misuse, highlighting the need for effective nonpharmacological interventions. Biofeedback is an empirically supported behavioral intervention for chronic pain that targets the self-regulation of physiological responses. Virtual reality (VR) is a novel delivery method for biofeedback that could serve as an engaging and effective platform for adolescents. Objective: The goal of this study was to assess the feasibility, acceptability, and preliminary effectiveness of integrating a VR-delivered respiratory biofeedback intervention into an outpatient pediatric pain rehabilitation program (PPRP) for adolescents with chronic pain. Methods: In this pilot study, we recruited 9 participants from those enrolled in the PPRP at Nemours Children’s Hospital. Participants underwent 2 VR respiratory biofeedback sessions per week over a 4-week period using AppliedVR’s “RelieVRx” program. Feasibility was defined as >60% of eligible patients enrolling with at least 80% of VR sessions completed. Acceptability was assessed via validated acceptability questionnaires, with high acceptability defined as an average acceptability rating score >3 on a 5-point Likert scale. Open-ended responses were analyzed via qualitative analysis. Preliminary effectiveness was assessed with questionnaires measuring the quality of life (Pediatric Quality of Life Inventory [PedsQL]) and level of pain interference in daily activities (Functional Disability Inventory) before and after participation in the pain program. Finally, heart rate (HR) and blood pressure (BP) were measured before and after each VR session. Results: Of 14 eligible PPRP patients, 9 (64%) enrolled in the VR respiratory biofeedback study, and 7 (77% of study participants) completed at least 80% of biofeedback sessions. Participants reported high acceptability with average session ratings ranging from 3.89 to 4.16 on post-VR program questionnaires. Of 224 open-ended responses, participants reported changes in stress and somatic symptoms (ie, pain distraction and breathing regulation). There was a statistically significant increase in the average physical functioning score of the PedsQL among participants (P=.01) from pre- to postparticipation in the overall pain program. The cohort’s average emotional functioning score of the PedsQL also increased, though this change was not statistically significant (P=.17). Participants’ Functional Disability Inventory scores significantly decreased from an average of 25.1 to 11 from before to after the pain program (P=.002). There were no significant differences between pre- versus post-BP or HR for any session. However, decreased BP and HR were observed across most sessions. Conclusions: AppliedVR respiratory biofeedback demonstrated initial feasibility, acceptability, and preliminary effectiveness when implemented as part of a PRPP. This study underscores the need for future larger-scale studies analyzing the use of VR biofeedback in adolescent populations with chronic pain. %R 10.2196/66352 %U https://rehab.jmir.org/2025/1/e66352 %U https://doi.org/10.2196/66352 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e67381 %T Impact of Conversational and Animation Features of a Mental Health App Virtual Agent on Depressive Symptoms and User Experience Among College Students: Randomized Controlled Trial %A Six,Stephanie %A Schlesener,Elizabeth %A Hill,Victoria %A Babu,Sabarish V %A Byrne,Kaileigh %K depression %K mental health app %K virtual agents %K cognitive behavioral therapy %K conversational agents %K virtual agent %K animations %K college student %K CBT %K ANOVA %K randomized controlled trial %K depressive symptoms %K mental disorder %K mental illness %K user experience %K mHealth %K digital health %D 2025 %7 11.4.2025 %9 %J JMIR Ment Health %G English %X Background: Numerous mental health apps purport to alleviate depressive symptoms. Strong evidence suggests that brief cognitive behavioral therapy (bCBT)-based mental health apps can decrease depressive symptoms, yet there is limited research elucidating the specific features that may augment its therapeutic benefits. One potential design feature that may influence effectiveness and user experience is the inclusion of virtual agents that can mimic realistic, human face-to-face interactions. Objective: The goal of the current experiment was to determine the effect of conversational and animation features of a virtual agent within a bCBT-based mental health app on depressive symptoms and user experience in college students with and without depressive symptoms. Methods: College students (N=209) completed a 2-week intervention in which they engaged with a bCBT-based mental health app with a customizable therapeutic virtual agent that varied in conversational and animation features. A 2 (time: baseline vs 2-week follow-up) × 2 (conversational vs non-conversational agent) × 2 (animated vs non-animated agent) randomized controlled trial was used to assess mental health symptoms (Patient Health Questionnaire-8, Perceived Stress Scale-10, and Response Rumination Scale questionnaires) and user experience (mHealth App Usability Questionnaire, MAUQ) in college students with and without current depressive symptoms. The mental health app usability and qualitative questions regarding users’ perceptions of their therapeutic virtual agent interactions and customization process were assessed at follow-up. Results: Mixed ANOVA (analysis of variance) results demonstrated a significant decrease in symptoms of depression (P=.002; mean [SD]=5.5 [4.86] at follow-up vs mean [SD]=6.35 [4.71] at baseline), stress (P=.005; mean [SD]=15.91 [7.67] at follow-up vs mean [SD]=17.02 [6.81] at baseline), and rumination (P=.03; mean [SD]=40.42 [12.96] at follow-up vs mean [SD]=41.92 [13.61] at baseline); however, no significant effect of conversation or animation was observed. Findings also indicate a significant increase in user experience in animated conditions. This significant increase in animated conditions is also reflected in the user’s ease of use and satisfaction (F(1, 201)=102.60, P<.001), system information arrangement (F(1, 201)=123.12, P<.001), and usefulness of the application (F(1, 201)=3667.62, P<.001). Conclusions: The current experiment provides support for bCBT-based mental health apps featuring customizable, humanlike therapeutic virtual agents and their ability to significantly reduce negative symptomology over a brief timeframe. The app intervention reduced mental health symptoms, regardless of whether the agent included conversational or animation features, but animation features enhanced the user experience. These effects were observed in both users with and without depressive symptoms. Trial Registration: Open Science Framework B2HX5; https://doi.org/10.17605/OSF.IO/B2HX5 %R 10.2196/67381 %U https://mental.jmir.org/2025/1/e67381 %U https://doi.org/10.2196/67381 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e65770 %T Examining a Telemedicine-Based Virtual Reality Clinic in Treating Adults With Specific Phobia: Protocol for a Feasibility Randomized Controlled Efficacy Trial %A Schuler,Kaitlyn R %A Ong,Triton %A Welch,Brandon M %A Craggs,Jason G %A Bunnell,Brian E %+ Department of Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, 3515 E. Fletcher Ave, Tampa, FL, 33613, United States, 1 (813) 794 8607, bbunnell@usf.edu %K virtual reality %K exposure therapy %K phobias %K telemedicine %K telemental health %K tele-VR %K immersive simulations %D 2025 %7 10.4.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Virtual reality (VR) has strong potential to enhance the effectiveness of telemental health care (TMH) by providing accessible, personalized treatment from home. While there is ample research supporting VR for in-person treatment, there is only preliminary data on the efficacy of telemedicine-based VR. Furthermore, the majority of VR apps used in therapy are not designed for mental health care. VR has the potential to enhance TMH through innovative technology solutions designed specifically for the enhancement of remotely delivered evidence-based practices. This feasibility randomized controlled efficacy trial aims to fill both of these gaps by piloting a novel telemedicine-based VR app (Doxy.me VR) equipped with animal phobia exposure stimuli. Objective: This is a feasibility randomized controlled efficacy trial comparing exposure therapy via a telemedicine-based VR clinic versus standard TMH with adults with an intense fear of dogs, snakes, or spiders. The primary objective is to assess the feasibility of a fully powered trial. The secondary objective is to conduct a preliminary examination of clinical outcomes (eg, specific phobia symptoms). Methods: This single-site trial will enroll a minimum of 30 and a maximum of 60 adults with self-reported fear of dogs, snakes, or spiders. Potential participants will be recruited through clinical trial and research recruitment websites and posting flyers. All self-report assessments and homework will be partially automated using REDCap (Research Electronic Data Capture; Vanderbilt University) forms and surveys, but the baseline assessment of phobia symptoms and exposure intervention will be administered by the study therapist. Results: The feasibility of the proposed trial methodology will be assessed using enrollment, retention, assessment completion, and treatment protocol fidelity benchmarks. Between-group differences in specific phobia, anxiety, and depression symptoms while covarying for pretreatment scores, will be conducted using repeated measures ANOVA along with differences in therapeutic alliance and presence. Data obtained from these analyses will inform power analyses for a fully powered efficacy trial. In total, 54 participants were randomized between October 25, 2023, and July 26, 2024 (Doxy.me VR n=28 and TMH n=26). Data analysis will be completed and submitted by the end of the second quarter of 2025. Conclusions: This feasibility randomized controlled trial comparing Doxy.me VR versus TMH aims to enhance the delivery of evidence-based treatments via telemedicine and reduce barriers to remotely delivered exposure therapy. This feasibility trial will be followed by a fully powered efficacy trial on telemedicine-based VR for animal phobias. Trial Registration: ClinicalTrials.gov NCT06302868; https://clinicaltrials.gov/study/NCT06302868 International Registered Report Identifier (IRRID): DERR1-10.2196/65770 %M 40209221 %R 10.2196/65770 %U https://www.researchprotocols.org/2025/1/e65770 %U https://doi.org/10.2196/65770 %U http://www.ncbi.nlm.nih.gov/pubmed/40209221 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 8 %N %P e63854 %T Extended Reality (XR) in Pediatric Acute and Chronic Pain: Systematic Review and Evidence Gap Map %A Hess,Courtney W %A Rosenbloom,Brittany N %A Mesaroli,Giulia %A Lopez,Cristal %A Ngo,Nhat %A Cohen,Estreya %A Ouellette,Carley %A Gold,Jeffrey I %A Logan,Deirdre %A Simons,Laura E %A Stinson,Jennifer N %+ Department of Anesthesiology, Perioperative, & Pain Medicine, Stanford University School of Medicine, 3145 Porter Drive, Palo Alto, CA, 94304, United States, 1 650 497 6896, cwhess@stanford.edu %K virtual reality %K augmented reality %K extended reality %K acute pain %K chronic pain %K pediatrics %K adolescents %K safety %K feasibility %K effectiveness %K evidence gap map %K child %K children %K VR %K XR %K biobehavioral %K intervention %K systematic review %D 2025 %7 7.4.2025 %9 Review %J JMIR Pediatr Parent %G English %X Background: The use of extended reality (XR), including virtual reality (VR) and augmented reality (AR), for treating pain has accelerated in the last 10 years. XR is an attractive biobehavioral intervention that may support management of pain or pain-related disability. Reviews of the literature pertaining to adults report promising results, particularly for acute procedural pain. Objective: This study aimed to (1) summarize the available evidence with respect to feasibility, safety, and effectiveness (pain intensity) of XR for pediatric acute and chronic pain; (2) summarize assessment tools used to measure study outcomes; and (3) identify gaps in evidence to guide future research efforts. Methods: This study is a systematic review of the literature. Multiple databases (CINAHL, Cochrane Central, Embase, MEDLINE, PsycINFO) were searched from inception until March 2023. Titles, abstracts, and full-text articles were reviewed by 2 team members to determine eligibility. Articles were included if the (1) participants were aged 0 to 18 years; (2) study intervention was VR or AR; (3) study outcomes included safety, feasibility, acceptability, or effectiveness on the outcome of pain; and (4) study design was observational or interventional. Data were collected on bibliographic information; study characteristics; XR characteristics; outcome domains; outcome measures; and study findings pertaining to safety, feasibility, and effectiveness. Results: We included 90 articles in the review. All included studies used VR, and 93% (84/90) studied VR in the context of acute pain. Of the 90 studies, 74 studies were randomized trials, and 15 studies were observational. Safety was assessed in 23 studies of acute pain, with 13 studies reporting no adverse events and 10 studies reporting events of low concern. Feasibility was assessed in 27 studies. Of the 84 studies of acute pain, 62% (52/84) reported a positive effect on pain intensity, 21% (18/84) reported no effect, and 13% (11/84) reported mixed effects. All 6 studies of chronic pain reported a positive effect on pain intensity. An evidence gap map was used to illuminate gaps in specific research areas stratified by subtypes of pain. Risk of bias assessment revealed 67 studies had a moderate risk of bias, 17 studies had a high risk, and 5 studies were deemed to be low risk. Conclusions: The current body of literature around XR for pediatric pain is focused on acute pain with promising results of safety and effectiveness on pain intensity. The literature pertaining to chronic pain lags behind, limiting our ability to draw conclusions. The risk of bias in studies is problematic in this field, with the inherent challenge of blinding participants and researchers to the intervention. Future research should aim to measure effectiveness beyond pain intensity with a consistent approach to measuring key outcome domains and measures. Current efforts are underway to establish expert consensus on best research practices in this field. Trial Registration: Prospero CRD42022307153; https://www.crd.york.ac.uk/PROSPERO/view/CRD42022307153 %M 40194270 %R 10.2196/63854 %U https://pediatrics.jmir.org/2025/1/e63854 %U https://doi.org/10.2196/63854 %U http://www.ncbi.nlm.nih.gov/pubmed/40194270 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e64742 %T Effectiveness of Virtual Reality–Complemented Pulmonary Rehabilitation on Lung Function, Exercise Capacity, Dyspnea, and Health Status in Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis %A Chen,Yuyin %A Zhang,Yuanyuan %A Long,Xiuhong %A Tu,Huiqiong %A Chen,Jibing %+ Department of Nursing, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, No. 10, Huadong Road, Nanning, 530011, China, 86 13788406562, longxh@gxtcmu.edu.cn %K virtual reality %K video games %K exergaming %K pulmonary rehabilitation %K chronic obstructive pulmonary disease %K lung function %K exercise capacity %K dyspnea %K health status %K randomized controlled trial %K systematic review %K meta-analysis %D 2025 %7 7.4.2025 %9 Review %J J Med Internet Res %G English %X Background: Chronic obstructive pulmonary disease (COPD) is a progressive respiratory condition characterized by persistent airflow obstruction. Pulmonary rehabilitation (PR) is a cornerstone of COPD management but remains underutilized due to barriers such as low motivation and accessibility issues. Virtual reality (VR)–complemented PR offers a novel approach to overcoming these barriers by enhancing patient engagement and rehabilitation outcomes. Objective: This review aims to evaluate the effect of VR-complemented PR compared with comparators on lung function, exercise capacity, dyspnea, health status, and oxygenation in patients with COPD. Additionally, the study aimed to identify which comparator type (active exercise vs nonactive exercise control group) and intervention duration would result in the greatest improvements in rehabilitation outcomes. The study also assessed patient-reported experience measures, including acceptability and engagement. Methods: A comprehensive search of 11 international and Chinese databases identified randomized controlled trials (RCTs) published up to November 2024. Data were analyzed using RevMan 5.4, with pooled effect sizes reported as mean differences (MDs) and 95% CIs. Results: A total of 16 RCTs involving 1052 participants were included. VR-complemented PR significantly improved lung function (forced expiratory volume in 1 second [FEV1] [L], MD 0.25, P<.001; FEV1/forced vital capacity [FVC], MD 6.12, P<.001; FVC, MD 0.28, P<.001) compared with comparators. Exercise capacity, assessed by the 6MWD, significantly improved (MD 23.49, P<.001) compared with comparators; however, it did not reach the minimally clinically important difference of 26 m, indicating limited clinical significance despite statistical significance. VR-complemented PR also significantly reduced dyspnea measured by the modified British Medical Research Council scale (MD –0.28, P<.001), improved health status measured by the COPD Assessment Test (MD –2.95, P<.001), and enhanced oxygenation status measured by SpO2 (MD 1.35, P=.04) compared with comparators. Subgroup analyses revealed that VR-complemented PR had a significantly greater effect on FEV1 (L) (MD 0.32, P=.005) and 6MWD (MD 40.93, P<.001) compared with the nonactive exercise control group. Additionally, VR-complemented PR showed a greater improvement in FEV1/FVC (MD 6.15, P<.001) compared with the active exercise control group. Intervention duration influenced outcomes, with 5-12-week programs showing the greatest improvement in 6MWD (MD 38.96, P<.001). VR-complemented PR was well-accepted, with higher adherence and engagement rates than comparators. Conclusions: VR-complemented PR significantly improves lung function, exercise capacity, dyspnea, health status, and oxygenation in patients with COPD compared with comparators, while enhancing adherence and engagement. Subgroup analyses showed greater effects on FEV1 (L) and 6MWD compared with the nonactive exercise control group, and a larger improvement in FEV1/FVC compared with the active exercise control group. Interventions (5-12 weeks) yielded the most significant benefits in exercise capacity. These findings highlight VR as a promising adjunct to traditional PR, with future research focusing on long-term outcomes and standardized protocols. %M 40193185 %R 10.2196/64742 %U https://www.jmir.org/2025/1/e64742 %U https://doi.org/10.2196/64742 %U http://www.ncbi.nlm.nih.gov/pubmed/40193185 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e69003 %T Effect of Home-Based Virtual Reality Training on Upper Extremity Recovery in Patients With Stroke: Systematic Review %A Huang,Jiaqi %A Wei,Yixi %A Zhou,Ping %A He,Xiaokuo %A Li,Hai %A Wei,Xijun %+ Department of Rehabilitation Medicine, Shenzhen Hospital, Southern Medical University, 13 Xinhu Road, Baoan District, Shenzhen, Guangdong, China, Shenzhen, 518101, China, 86 75523360324, weixj2016@smu.edu.cn %K stroke %K upper extremity %K virtual reality %K home-based %K rehabilitation %K upper extremity %K motor control %K recovery %D 2025 %7 4.4.2025 %9 Review %J J Med Internet Res %G English %X Background: Stroke is a leading cause of long-term disability, often resulting in upper extremity dysfunction. Traditional rehabilitation methods often face challenges such as limited patient access to resources and lack of sustained motivation. Home-based virtual reality (VR) training is gaining traction as an innovative, sustainable, and interactive alternative. However, the effect of home-based VR, specifically for upper extremity recovery in patients with stroke, remains insufficiently explored. Objective: This systematic review aims to synthesize existing evidence to evaluate the impact of home-based VR interventions on upper extremity function recovery in patients with stroke. Methods: This systematic review followed the guidelines of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A comprehensive literature search was conducted across PubMed, Web of Science, Scopus, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) Ultimate databases, targeting English-language randomized controlled trials (RCTs) published up to June 30, 2024. Eligible studies involved patients with stroke with upper extremity dysfunction who received home-based VR interventions. Data extraction was performed by 2 independent reviewers, and study quality was assessed using the Physiotherapy Evidence Database scale. Due to heterogeneity in study designs and outcome measures, a narrative synthesis was performed instead of a meta-analysis. Results: A total of 8 RCTs with 392 participants were included. This review shows that home-based VR training positively affects upper extremity function recovery in patients with stroke, especially in motor control improvement. Customized VR systems were more effective than commercial VR systems in patients with moderate to severe disorders. Although studies generally showed positive results, differences in intervention protocols and small sample sizes limited the validity of results. The effect of VR therapy also varied based on the VR system type, intervention intensity, and the functional level of patients. Conclusions: This systematic review shows that home-based VR training has a positive impact on upper extremity rehabilitation for patients with stroke, particularly in those with varying degrees of dysfunction. However, heterogeneity in study design and differences in outcome measures affect the reliability of the current conclusions. Future studies should include larger, standardized RCTs with long-term follow-up to assess their continued effects. Future research should explore how VR technology can be integrated into comprehensive rehabilitation programs, focusing on patient-centered approaches that incorporate sustainable, personalized technology, and support services to optimize recovery outcomes. Trial Registration: PROSPERO CRD42024526650; https://tinyurl.com/5dny5bhp %M 40074365 %R 10.2196/69003 %U https://www.jmir.org/2025/1/e69003 %U https://doi.org/10.2196/69003 %U http://www.ncbi.nlm.nih.gov/pubmed/40074365 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 11 %N %P e64619 %T Extended Reality–Enhanced Mental Health Consultation Training: Quantitative Evaluation Study %A Hiley,Katherine %A Bi-Mohammad,Zanib %A Taylor,Luke %A Burgess-Dawson,Rebecca %A Patterson,Dominic %A Puttick-Whiteman,Devon %A Gay,Christopher %A Hiscoe,Janette %A Munsch,Chris %A Richardson,Sally %A Knowles-Lee,Mark %A Beecham,Celia %A Ralph,Neil %A Chatterjee,Arunangsu %A Mathew,Ryan %A Mushtaq,Faisal %+ School of Psychology, Faculty of Medicine & Health, University of Leeds, Woodhouse, Leeds, LS2 9JT, United Kingdom, 44 07525418924, f.mushtaq@leeds.ac.uk %K mental health %K training %K consultation %K extended reality %K virtual reality %K augmented reality %D 2025 %7 2.4.2025 %9 Original Paper %J JMIR Med Educ %G English %X Background: The use of extended reality (XR) technologies in health care can potentially address some of the significant resource and time constraints related to delivering training for health care professionals. While substantial progress in realizing this potential has been made across several domains, including surgery, anatomy, and rehabilitation, the implementation of XR in mental health training, where nuanced humanistic interactions are central, has lagged. Objective: Given the growing societal and health care service need for trained mental health and care workers, coupled with the heterogeneity of exposure during training and the shortage of placement opportunities, we explored the feasibility and utility of a novel XR tool for mental health consultation training. Specifically, we set out to evaluate a training simulation created through collaboration among software developers, clinicians, and learning technologists, in which users interact with a virtual patient, “Stacey,” through a virtual reality or augmented reality head-mounted display. The tool was designed to provide trainee health care professionals with an immersive experience of a consultation with a patient presenting with perinatal mental health symptoms. Users verbally interacted with the patient, and a human instructor selected responses from a repository of prerecorded voice-acted clips. Methods: In a pilot experiment, we confirmed the face validity and usability of this platform for perinatal and primary care training with subject-matter experts. In our follow-up experiment, we delivered personalized 1-hour training sessions to 123 participants, comprising mental health nursing trainees, general practitioner doctors in training, and students in psychology and medicine. This phase involved a comprehensive evaluation focusing on usability, validity, and both cognitive and affective learning outcomes. Results: We found significant enhancements in learning metrics across all participant groups. Notably, there was a marked increase in understanding (P<.001) and motivation (P<.001), coupled with decreased anxiety related to mental health consultations (P<.001). There were also significant improvements to considerations toward careers in perinatal mental health (P<.001). Conclusions: Our findings show, for the first time, that XR can be used to provide an effective, standardized, and reproducible tool for trainees to develop their mental health consultation skills. We suggest that XR could provide a solution to overcoming the current resource challenges associated with equipping current and future health care professionals, which are likely to be exacerbated by workforce expansion plans. %M 40173446 %R 10.2196/64619 %U https://mededu.jmir.org/2025/1/e64619 %U https://doi.org/10.2196/64619 %U http://www.ncbi.nlm.nih.gov/pubmed/40173446 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e67782 %T AI-Enhanced Virtual Reality Self-Talk for Psychological Counseling: Formative Qualitative Study %A Zisquit,‪Moreah %A Shoa,Alon %A Oliva,Ramon %A Perry,Stav %A Spanlang,Bernhard %A Brunstein Klomek,Anat %A Slater,Mel %A Friedman,Doron %+ Baruch Ivcher School of Psychology, Reichman University, Baruch Ivcher School of Psychology, Ha'universita 8, Herzliya, Israel, 972 523091406, Zisquit.moreah@post.runi.ac.il %K virtual human %K large language model %K virtual reality %K self-talk %K psychotherapy %K artificial intelligence %K AI %D 2025 %7 2.4.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Access to mental health services continues to pose a global challenge, with current services often unable to meet the growing demand. This has sparked interest in conversational artificial intelligence (AI) agents as potential solutions. Despite this, the development of a reliable virtual therapist remains challenging, and the feasibility of AI fulfilling this sensitive role is still uncertain. One promising approach involves using AI agents for psychological self-talk, particularly within virtual reality (VR) environments. Self-talk in VR allows externalizing self-conversation by enabling individuals to embody avatars representing themselves as both patient and counselor, thus enhancing cognitive flexibility and problem-solving abilities. However, participants sometimes experience difficulties progressing in sessions, which is where AI could offer guidance and support. Objective: This formative study aims to assess the challenges and advantages of integrating an AI agent into self-talk in VR for psychological counseling, focusing on user experience and the potential role of AI in supporting self-reflection, problem-solving, and positive behavioral change. Methods: We carried out an iterative design and development of a system and protocol integrating large language models (LLMs) within VR self-talk during the first two and a half years. The design process addressed user interface, speech-to-text functionalities, fine-tuning the LLMs, and prompt engineering. Upon completion of the design process, we conducted a 3-month long exploratory qualitative study in which 11 healthy participants completed a session that included identifying a problem they wanted to address, attempting to address this problem using self-talk in VR, and then continuing self-talk in VR but this time with the assistance of an LLM-based virtual human. The sessions were carried out with a trained clinical psychologist and followed by semistructured interviews. We used applied thematic analysis after the interviews to code and develop key themes for the participants that addressed our research objective. Results: In total, 4 themes were identified regarding the quality of advice, the potential advantages of human-AI collaboration in self-help, the believability of the virtual human, and user preferences for avatars in the scenario. The participants rated their desire to engage in additional such sessions at 8.3 out of 10, and more than half of the respondents indicated that they preferred using VR self-talk with AI rather than without it. On average, the usefulness of the session was rated 6.9 (SD 0.54), and the degree to which it helped solve their problem was rated 6.1 (SD 1.58). Participants specifically noted that human-AI collaboration led to improved outcomes and facilitated more positive thought processes, thereby enhancing self-reflection and problem-solving abilities. Conclusions: This exploratory study suggests that the VR self-talk paradigm can be enhanced by LLM-based agents and presents the ways to achieve this, potential pitfalls, and additional insights. %M 40173447 %R 10.2196/67782 %U https://formative.jmir.org/2025/1/e67782 %U https://doi.org/10.2196/67782 %U http://www.ncbi.nlm.nih.gov/pubmed/40173447 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e68149 %T Medical Device Based on a Virtual Reality–Based Upper Limb Rehabilitation Software: Usability Evaluation Through Cognitive Walkthrough %A Hong,Seojin %A Choi,Hyun %A Kweon,Hyosun %K usability %K cognitive walkthrough %K virtual reality-based upper limb rehabilitation software %K upper limb %K limb rehabilitation %K rehabilitation %K therapist %K virtual reality %K VR %K medical device %K formative evaluation %K quantitative %K qualitative %K occupational therapy %K user safety %K usability testing %K software %K risk factor %D 2025 %7 1.4.2025 %9 %J JMIR Form Res %G English %X Background: The use of virtual reality (VR) technology in rehabilitation therapy has been growing, leading to the development of VR-based upper-limb rehabilitation softwares. To ensure the effective use of such software, usability evaluations are critical to enhance user satisfaction and identify potential usability issues. Objective: This study aims to evaluate the usability of a VR-based upper-limb rehabilitation software from the perspective of occupational therapists. Specifically, the study seeks to identify usability challenges and provide insights to improve user satisfaction. Methods: The VR-based upper-limb rehabilitation software was tailored for therapists to operate while delivering therapy to patients. Usability testing was conducted with occupational therapists from the Korean National Rehabilitation Center using cognitive walkthroughs and surveys. Participants performed tasks that simulated real clinical scenarios, including turning the device on, assisting patients with wearing the device, and shutting it down. Observers recorded user reactions during task performance, and participants completed surveys to assess the ease of use of the user interface. This mixed-methods approach provided qualitative insights into user difficulties and their root causes. Results: Usability evaluations were conducted with 6 participants. Cognitive walkthroughs revealed potential areas for improvement in the software, including (1) enhancements to the graphical user interface for ease of use, (2) refinements in the natural user interface, and (3) better user manuals for clearer product instructions. The ease-of-use score for the user interface averaged 1.58 on a 5-point scale (1=very easy to 5=very difficult). Conclusions: This study provides valuable insights into improving user satisfaction by focusing on the needs of occupational therapists who operate a VR-based rehabilitation software. Future research should explore software refinement and clinical efficacy to maximize the therapeutic potential of such technologies. %R 10.2196/68149 %U https://formative.jmir.org/2025/1/e68149 %U https://doi.org/10.2196/68149 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e66593 %T Physical Activity and Enjoyment in Active Virtual Reality Games in Youth: Comparative Analysis of Gorilla Tag and Beat Saber %A Boots,Brenden %A Berg,Daniel %A Hewitt,Easton %A Naugle,Keith %A Naugle,Kelly %K active gaming %K movement %K Gorilla Tag %K Beat Saber %K virtual reality %K VR %K physical activity %K youth %K early adolescents %K young adults %K gaming %K heart rate %K exergame %K enjoyment %D 2025 %7 1.4.2025 %9 %J JMIR Serious Games %G English %X Background: Virtual reality (VR) active gaming is growing in popularity, but little is known about physical activity during gameplay. Two popular VR games are Gorilla Tag (Another Axiom Inc) and Beat Saber (Beat Games). Little is known about physical activity during these games in youth. Objective: The purpose of this study was to investigate the enjoyment, intensity, and amount of physical activity while playing Gorilla Tag and Beat Saber in early adolescent youth. Methods: Sixteen participants, 13 males and 3 females with an average age of 10.7 (SD 0.34) years, played 2 VR games (Gorilla Tag and Beat Saber) in a single session. Both games followed the same procedure: a maximum of 10-minute familiarization period, 5 minutes of rest, 15 minutes of gameplay, and 10 minutes of rest. Participants wore a heart rate monitor to track heart rate reserve (%HRR) and accelerometers on the wrist and waist to monitor time in sedentary activity, light physical activity, and moderate to vigorous physical activity of the arm and whole body. The Physical Activity Enjoyment Scale–Child Version (PACES) and ratings of perceived exertion (RPE) were completed after each game. Dependent t tests compared measures between games. Results: The results revealed that average and maximum %HRR were significantly higher during Gorilla Tag than during Beat Saber, with heart rate–based physical activity intensity reaching light for Beat Saber and moderate for Gorilla Tag. Arm moderate to vigorous physical activity and whole-body moderate to vigorous physical activity and light physical activity were greater during Gorilla Tag than during Beat Saber. Arm and whole-body sedentary time were significantly lower during Gorilla Tag than during Beat Saber. Gorilla Tag and Beat Saber were rated as highly enjoyable. There were no differences between games for maximum (P=.352) or average (P=.362) RPE. Both games were rated as light intensity for average RPE (Gorilla Tag: mean 4.3, SD 1.9; Beat Saber: mean 4.7, SD 2.3) and moderate intensity for maximum RPE (Gorilla Tag: mean 5.4, SD 1.9; Beat Saber: mean 5.8, SD 2.4). Conclusions: These results suggest that Beat Saber produced light-intensity physical activity and Gorilla Tag produced light- to moderate-intensity physical activity in early adolescent youth, with both games rated as highly enjoyable. %R 10.2196/66593 %U https://games.jmir.org/2025/1/e66593 %U https://doi.org/10.2196/66593 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e63405 %T Integrating Virtual Reality, Neurofeedback, and Cognitive Behavioral Therapy for Auditory Verbal Hallucinations (Hybrid): Protocol of a Pilot, Unblinded, Single-Arm Interventional Study %A Spark,Jessica %A Rowe,Elise %A Alvarez-Jimenez,Mario %A Bell,Imogen %A Byrne,Linda %A Dzafic,Ilvana %A Ellinghaus,Carli %A Lavoie,Suzie %A Lum,Jarrad %A McLean,Brooke %A Thomas,Neil %A Thompson,Andrew %A Wadley,Greg %A Whitford,Thomas %A Wood,Stephen %A Yuen,Hok Pan %A Nelson,Barnaby %+ Orygen, 35 Poplar Rd, Parkville, 3052, Australia, 61 399669100, elise.rowe@unimelb.edu.au %K psychosis %K first episode psychosis %K schizophrenia %K virtual reality %K neurofeedback %K EEG %K auditory verbal hallucinations %K voices %K cognitive behavior therapy %K youth mental health %K pilot study %K paracusias %K paracusis %K treatment %K medication %K psychotic disorder %K efficacy %K neuroscience %K psychology %K hybrid %K adolescent %K Australia %D 2025 %7 1.4.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: Current treatments for schizophrenia and other psychotic disorders have limited efficacy, with high rates of nonresponse to “gold standard” treatments. New approaches are therefore urgently required. Objective: The aims of this pilot study are to investigate the feasibility, acceptability, safety, and usability of Hybrid treatment (primary aim); and to explore Hybrid’s treatment efficacy and engagement of treatment targets (secondary aim). The primary aim will be assessed via face-to-face user experience surveys on a (self-assessed) 5-point Likert scale (and qualitative open-ended questions) examining: (1) acceptability, (2) helpfulness, (3) engagement, and (4) perceived safety. We will also examine consent and completion rates, and the number of sessions attended. Our threshold for moving on to efficacy trials will be at least 70% of our participants to rate 3 and above (which corresponds to agree or strongly agree) that the intervention package was acceptable, feasible, and safe. The secondary aims will be assessed by observing whether individuals achieve self-directed modulation of high-β neurophysiological activity (neural target) and progression upwards through the VR-based exposure hierarchy (psychological target), and by assessing symptom change scores. This study developed a new treatment approach for auditory verbal hallucinations, a major symptom of psychotic disorders, that integrates advances in psychological therapy (cognitive behavioral therapy for psychosis), technology (virtual reality, VR), and neuroscience (electroencephalography-based neurofeedback). Methods: Hybrid takes a “symptom capture” approach using individually tailored VR-based exposure exercises. Participants (N=10) will receive the intervention package weekly over 12 face-to-face sessions. Here, participants will be progressively exposed to symptom triggers and develop methods of downregulating neural activity associated with these symptoms (neurofeedback component) while concurrently receiving clinician-delivered cognitive behavioral therapy for psychosis. Results: As of February 2025, Hybrid has commenced (unblinded) recruitment activities from Orygen clinical services in Northwestern Melbourne, Australia. A total of 75 individuals have been approached and 64 individuals have been prescreened (41 individuals were deemed eligible, 15 individuals were ineligible, and 8 individuals declined or did not respond to contact attempts) and 5 individuals have been included in the study. Of the 5 individuals who have commenced the Hybrid treatment, 4 are actively engaged in the program and 1 individual has withdrawn. We expect recruitment to conclude in July 2025 and for the results to be published in 2026. Conclusions: The Hybrid study is piloting a novel approach that has the potential to address the shortcomings of current treatments for psychotic symptoms. If there is favorable evidence for the acceptability, feasibility, safety and usability of Hybrid, the study team will move on to efficacy trials. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12624000357550; https://tinyurl.com/24ey8hpy International Registered Report Identifier (IRRID): PRR1-10.2196/63405 %M 40168662 %R 10.2196/63405 %U https://www.researchprotocols.org/2025/1/e63405 %U https://doi.org/10.2196/63405 %U http://www.ncbi.nlm.nih.gov/pubmed/40168662 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e63098 %T Cooperative Virtual Reality Gaming for Anxiety and Pain Reduction in Pediatric Patients and Their Caregivers During Painful Medical Procedures: Protocol for a Randomized Controlled Trial %A Liszio,Stefan %A Bäuerlein,Franziska %A Hildebrand,Jens %A van Nahl,Carolin %A Masuch,Maic %A Basu,Oliver %+ , Center for Virtual and Extended Reality in Medicine, University Hospital Essen, Hufelandstraße 55, Essen, 45147, Germany, 49 201723 ext 1907, stefan.liszio@uk-essen.de %K virtual reality %K extended reality %K mixed reality %K serious game %K video game %K pain %K anxiety %K stress %K child %K caregiver %K patient experience %K well-being %K medical procedures %K punctures %K distraction %K intervention %D 2025 %7 31.3.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: The hospital experience is often marked by fear and pain, particularly for children undergoing medical procedures. Sedation is commonly used to alleviate patient anxiety, but it poses additional health risks. Caregivers, usually the parents, also experience emotional distress during the child’s hospital stay, which can further exacerbate the child’s anxiety and pain. While various interventions exist to ease patient distress, few consider the emotional well-being of caregivers. Objective: This study aims to explore the effectiveness of a cooperative virtual reality (VR) game as a novel nonpharmacological solution to reduce anxiety and pain for both pediatric patients and their caregivers during medical procedures. Specifically, we aim to investigate whether the VR game “Sweet Dive VR” (SDVR), designed for children aged between 6 and 12 years to play with 1 caregiver, can alleviate anxiety and pain during different types of needle punctures and Kirschner-wire removal. Methods: A prospective multicenter randomized clinical trial will be conducted. Eligible participants will be identified by scanning the hospital information system, and group allocation will follow stratified randomization. During the medical procedure, patients in the VR condition will play SDVR with a caregiver present, while patients in the control group will listen to a recording of gently crashing waves. Data collection will be carried out through self-reports of patients and caregivers using visual analog scales and questionnaires at 2 measurement time points: before and after the intervention. In addition, observation by the interviewers will occur during the intervention to capture emotional and pain reactions as well as interaction quality between patients and caregivers and smoothness of the procedure flow using a structured observation protocol. The measured variables will encompass patient affect and pain, caregiver affect, player experience, patient experience, and the flow of the procedure. Results: As of November 2024, we enrolled 39 patients and caregivers, 28 of whom completed the study. Data collection is still ongoing. Conclusions: Cooperative VR gaming, as exemplified by SDVR, emerges as a promising intervention to address anxiety and pain in pediatric patients while involving caregivers to support the emotional well-being of both parties. Our approach strives to foster positive shared experiences and to maintain trust between children and caregivers during emotionally challenging medical situations. Trial Registration: German Clinical Trial Register (DRKS) DRKS00033544; https://drks.de/search/en/trial/DRKS00033544 International Registered Report Identifier (IRRID): DERR1-10.2196/63098 %M 40164171 %R 10.2196/63098 %U https://www.researchprotocols.org/2025/1/e63098 %U https://doi.org/10.2196/63098 %U http://www.ncbi.nlm.nih.gov/pubmed/40164171 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 11 %N %P e59083 %T Media-Induced and Psychological Factors That Foster Empathy Through Virtual Reality in Nursing Education: 2×2 Between-Subjects Experimental Study %A Huang,Kuo-Ting %A Ma,Zexin %A Yao,Lan %K nursing education %K narrative transportation %K presence %K virtual reality %K game-based learning %K affective empathy %D 2025 %7 31.3.2025 %9 %J JMIR Med Educ %G English %X Background: Virtual reality (VR) has emerged as a promising tool in medical education, particularly for fostering critical skills such as empathy. However, how VR, combined with perspective-taking, influences affective empathy in nursing education remains underexplored. Objective: This study investigates the influence of VR and perspective-taking on affective empathy in nursing education, focusing on 4 psychological factors: perceived self-location, narrative transportation, emotional engagement, and affective empathy. Methods: A 2×2 between-subjects design was used, involving 69 nursing undergraduates from two Midwest universities. The participants engaged with a narrative-focused video game, That Dragon, Cancer, in either VR or non-VR conditions and from the perspective of either parents or clinicians. Results: VR significantly enhanced perceived self-location (P=.01), while adopting a clinician’s perspective amplified emotional engagement (P=.03). However, VR did not significantly influence narrative transportation (P=.35). An interaction effect was found between the platform and player’s perspective on narrative transportation (P=.04). Several indirect effects of media elements on affective empathy were observed via other psychological factors, though the direct effect of VR on affective empathy was not significant (P=.84). Conclusions: These findings underscore the potential of VR in medical education, suggesting that perspective-taking should be carefully considered when designing immersive learning experiences. The study advocates for broader integration of VR technologies into medical curricula to enhance instruction quality and patient-centered care. %R 10.2196/59083 %U https://mededu.jmir.org/2025/1/e59083 %U https://doi.org/10.2196/59083 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e59514 %T Considering Theory-Based Gamification in the Co-Design and Development of a Virtual Reality Cognitive Remediation Intervention for Depression (bWell-D): Mixed Methods Study %A Hewko,Mark %A Gagnon Shaigetz,Vincent %A Smith,Michael S %A Kohlenberg,Elicia %A Ahmadi,Pooria %A Hernandez Hernandez,Maria Elena %A Proulx,Catherine %A Cabral,Anne %A Segado,Melanie %A Chakrabarty,Trisha %A Choudhury,Nusrat %+ National Research Council, 435 Ellice Avenue, Winnipeg, MB, R3B 1Y6, Canada, 1 204 984 4625, mark.hewko@nrc-cnrc.gc.ca %K virtual reality %K clinical psychology %K cognitive assessment %K neuropsychology %K mental health %K cognitive training %K cognitive remediation %K cognitive rehabilitation %K digital therapeutics %D 2025 %7 31.3.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: In collaboration with clinical domain experts, we developed a prototype of immersive virtual reality (VR) cognitive remediation for major depressive disorder (bWell-D). In the development of a new digital intervention, there is a need to determine the effective components and clinical relevance using systematic methodologies. From an implementation perspective, the effectiveness of digital intervention delivery is challenged by low uptake and high noncompliance rates. Gamification may play a role in addressing this as it can boost adherence. However, careful consideration is required in its application to promote user motivation intrinsically. Objective: We aimed to address these challenges through an iterative process for development that involves co-design for developing content as well as in the application of gamification while also taking into consideration behavior change theories. This effort followed the methodological framework guidelines outlined by an international working group for development of VR therapies. Methods: In previously reported work, we collected qualitative data from patients and care providers to understand end-user perceptions on the use of VR technologies for cognitive remediation, reveal insights on the drivers for behavior change, and obtain suggestions for changes specific to the VR program. In this study, we translated these findings into concrete representative software functionalities or features and evaluated them against behavioral theories to characterize gamification elements in terms of factors that drive behavior change and intrinsic engagement, which is of particular importance in the context of cognitive remediation. The implemented changes were formally evaluated through user trials. Results: The results indicated that feedback from end users centered on using gamification to add artificial challenges, personalization and customization options, and artificial assistance while focusing on capability as the behavior change driver. It was also found that, in terms of promoting intrinsic engagement, the need to meet competence was most frequently raised. In user trials, bWell-D was well tolerated, and preliminary results suggested an increase in user experience ratings with high engagement reported throughout a 4-week training program. Conclusions: In this paper, we present a process for the application of gamification that includes characterizing what was applied in a standardized way and identifying the underlying mechanisms that are targeted. Typical gamification elements such as points and scoring and rewards and prizes target motivation in an extrinsic fashion. In this work, it was found that modifications suggested by end users resulted in the inclusion of gamification elements less commonly observed and that tend to focus more on individual ability. It was found that the incorporation of end-user feedback can lead to the application of gamification in broader ways, with the identification of elements that are potentially better suited for mental health domains. %M 40163852 %R 10.2196/59514 %U https://games.jmir.org/2025/1/e59514 %U https://doi.org/10.2196/59514 %U http://www.ncbi.nlm.nih.gov/pubmed/40163852 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 12 %N %P e64729 %T Home-Based Nonimmersive Virtual Reality Training After Discharge From Inpatient or Outpatient Stroke Rehabilitation: Parallel Feasibility Randomized Controlled Trial %A Sheehy,Lisa %A Taillon-Hobson,Anne %A Sveistrup,Heidi %A Bilodeau,Martin %A Yang,Christine %A Welch,Vivian %A Finestone,Hillel %+ , Bruyère Health Research Institute, 43 Bruyère St, Ottawa, ON, K1N5C8, Canada, 1 613 562 6262 ext 1593, lsheehy@bruyere.org %K virtual reality %K telerehabilitation %K stroke %K home %K exercises %K physical activity %K physiotherapy %K exergames %K rehabilitation intensity %K randomized controlled feasibility trial %K motor %K movement %K patient care %K patient engagement %K health intervention %K stroke rehabilitation %K interactive games %K game therapy %K interactive therapy %K rehabilitation %D 2025 %7 28.3.2025 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Nonimmersive virtual reality training (NIVRT) can be used to continue rehabilitative exercise for stroke recovery at home after discharge from inpatient or outpatient therapy. Objective: The objectives of this randomized controlled feasibility trial were to assess home-based NIVRT as telerehabilitation with patients living with stroke, and its potential to improve standing function and gait. Methods: Patients approaching discharge from inpatient or outpatient stroke rehabilitation were randomly allocated to NIVRT or iPad interventions. NIVRT provided interactive games and exercises designed to improve balance, stepping, and aerobic capacity. iPad apps addressed cognition and fine motor skills. Participants were visited in their homes by a physiotherapist, taught to use the program, and asked to do 30 minutes of exercise 5 days a week for 6 weeks, asynchronously. Feasibility was assessed by measuring recruitment, adherence, ability to set up and learn NIVRT, enjoyment, intent to continue, perception of impact, and safety. Participants completed assessments of standing balance, gait, and general function, before and after the intervention, by a blinded assessor. Results: NIVRT participants (n=11; 10 male participants; mean age 64, SD 12 years) did an average of 26 sessions (total 700 minutes), while iPad participants (n=9; 6 male participants; mean age 61, SD 20 years) did an average of 33 sessions (total 1241 minutes). Space was tight in 5 homes. All but 1 participant learned NIVRT and progressed. Most enjoyed it and felt that it improved their recovery. There were no serious adverse events. Most assessments showed improvement over time for both groups. Conclusions: Home-based NIVRT is safe and feasible to continue rehabilitative exercise after discharge. More research on efficacy and effectiveness in this population is required. Trial Registration: ClinicalTrials.gov NCT03261713; https://clinicaltrials.gov/study/NCT03261713 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-019-3438-9 %M 40153779 %R 10.2196/64729 %U https://rehab.jmir.org/2025/1/e64729 %U https://doi.org/10.2196/64729 %U http://www.ncbi.nlm.nih.gov/pubmed/40153779 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 12 %N %P e68504 %T Effects of a Home-Based Rehabilitation Exercise Program on Cardiorespiratory Performance in Community-Dwelling Adults Who Underwent Heart Surgery: Randomized Controlled Trial %A Sermsinsaithong,Natsinee %A Yuenyongchaiwat,Kornanong %A Thanawattano,Chusak %A Buekban,Chatchai %A Kulchanarat,Chitima %A Buranapuntalug,Sasipa %A Wattanananont,Khanistha %A Satdhabudha,Opas %K virtual reality %K cardiac surgery %K cardiac rehabilitation %K cardiopulmonary %K aerobic exercise %D 2025 %7 28.3.2025 %9 %J JMIR Rehabil Assist Technol %G English %X Background: Patients undergoing heart surgery demonstrate impaired cardiorespiratory performance. Phase II cardiac rehabilitation (CR) in people undergoing open heart surgery (OHS) aims to reduce the adverse physical effects of cardiovascular diseases. Virtual reality (VR) exercise is now used in CR. Objective: This study aimed to explore the effects of VR exercise on functional capacity, pulmonary function, and respiratory muscle strength in patients who underwent OHS and were in phase II CR. Methods: Forty-nine patients who underwent elective OHS and were in phase II CR were randomized into a VR group (N=24) and a control group (N=25). The VR group completed 8 weeks of a home-based VR exercise program, including chest trunk mobilization and aerobic circuit training for 30 minutes, whereas the control group received an exercise brochure and information regarding the benefits of exercise. Intention-to-treat analysis was conducted, and 2-way mixed ANOVA was performed to compare between- and within-group differences in functional capacity and respiratory performance. Results: After completing the 8-week program, the VR group showed significant improvement in functional capacity compared to the control group (66.29, SD 25.84 m; P=.01). Inspiratory muscle strength increased in both the VR and control groups compared to baseline (9.46, SD 2.85 and 9.64, SD 2.78 cm H2O, respectively). In addition, after the 8-week intervention, significant improvements were found in expiratory muscle strength (15.79, SD 4.65 cm H2O) and forced expiratory volume in 1 second as a percentage of predicted values (2.96%, SD 1.52%) in the VR group compared to the baseline session. Conclusions: The home-based VR exercise program significantly improved functional capacity but not respiratory muscle or pulmonary function. Trial Registration: Thai Clinical Trial Registry TCTR20230602001; https://tinyurl.com/3xn44bku %R 10.2196/68504 %U https://rehab.jmir.org/2025/1/e68504 %U https://doi.org/10.2196/68504 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e54312 %T Effectiveness of Augmented Reality in the Teaching of Health University Students: Quasi-Experimental Study %A Martín-Valero,Rocío %A Vega-Morales Sr,Alejandro %A Martín-Vega,Francisco Javier %A Rodriguez-Huguet,Manuel %A Rodríguez-Martínez,Maria Carmen %A Vinolo-Gil,Maria Jesus %K augmented reality %K qualifications %K usability %K university %K teaching %K education %K implementation %K academic performance %K quasi-experimental design %K control group %K applications %K experimental group %D 2025 %7 27.3.2025 %9 %J JMIR Serious Games %G English %X Background: The exponential growth of new technologies has resulted in the need for updating the field of education. From the educational point of view, there are some studies that have promoted the implementation of new technologies. These facts have raised the need to implement augmented reality in the university environment, especially among students of health sciences. The use of augmented reality can mean a new approach to teaching by teachers and better learning by students. Objective: We aimed to analyze the degree of usability of two augmented reality applications and to compare the academic performance between the control group and the experimental group at the Universities of Cádiz and Málaga. The students at the University of Málaga used the Zapworks augmented reality software, while those at the University of Cádiz used the Aumentaty augmented reality software for their respective experimental groups. The secondary objective was to measure the relationships between all the studied variables. Methods: This was a quasi-experimental design with a posttest as the only evaluation measure. We followed the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) statement and the ethical and legal aspects of the Principles of the Declaration of Helsinki. An intervention was carried out using two augmented reality applications on the subject of General Procedures in Physiotherapy II at the Universities of Málaga and Cádiz. Results: A total of 199 participants took part in the study. Demographic variables, ratings, and usability were assessed, followed by statistical analysis, with the results and their interpretation being described in the study. Significant differences (P<.001) were found in the ratings at both the universities. In addition, significant differences (P<.001) were found between the experimental group and the control group. Regarding the degree of usability in the univariate analysis, no significant differences were found (P=.049). A multiple regression analysis of the rating and usability was performed. The rating showed significant differences, with a beta of 1.4 (P<.001), and usability was also significant (P=.03) in favor of the Aumentaty group. Conclusions: Significant differences were observed in those who used augmented reality compared to the control group, with higher values observed in the University of Cádiz. There are no correlations between the variables of usability and qualifications. Trial Registration: ClinicalTrials.gov NCT05798468; https://clinicaltrials.gov/study/NCT05798468 %R 10.2196/54312 %U https://games.jmir.org/2025/1/e54312 %U https://doi.org/10.2196/54312 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e63137 %T Neurobiological Mechanisms of Enhanced Pain-Relieving Transcutaneous Electrical Nerve Stimulation via Visuo-Tactile Stimulation in Immersive Virtual Reality: Randomized Controlled Trial %A Wang,Chenxi %A Gao,Lanqi %A Zhang,Chuan %A Li,Jun %A Liu,Jixin %+ School of Life Science and Technology, Xidian University, 266 Xinglong Section of Xifeng Road, Xi'an, 710126, China, 86 02981891070, liujixin2010@gmail.com %K pain %K pain-relieving %K transcutaneous electrical nerve stimulation %K virtual reality %K electroencephalography %D 2025 %7 19.3.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Enhancing the effectiveness of current pain relief strategies is a persistent clinical challenge. Although transcutaneous electrical nerve stimulation (TENS) is used in various painful conditions, its effectiveness may decline over time, requiring additional pain management strategies. Immersive virtual reality (VR) with personalized visuo-tactile stimulation has demonstrated analgesic properties. Nevertheless, whether visuo-tactile stimulation can enhance the pain-relieving outcomes of TENS and its underlying neurophysiological mechanisms remains largely unknown. Objective: The study aims to investigate whether the integration of visuo-tactile stimulation with TENS can enhance the pain-relieving outcomes of TENS alone, and we also aim to explore the brain mechanisms underlying the analgesic effect of this integrated intervention. Methods: In this study, 75 healthy participants were enrolled and randomly assigned to 1 of 3 groups: congruent TENS-VR (TENS-ConVR) and 2 control groups (incongruent TENS-VR [TENS-InVR] and TENS alone). In the context of TENS-ConVR, we combined TENS and VR by connecting TENS-induced paresthesia with personalized visual bodily feedback. The visual feedback was designed to align with the spatiotemporal patterns of the paresthesia induced by TENS. A pain rating task and a 32-channel electroencephalography were applied. Results: Two-way ANOVAs showed that TENS-ConVR exhibited a statistically greater reduction in pain rating (F1,48=6.84; P=.01) and N2 amplitude (F1,48=5.69; P=.02) to high-intensity pain stimuli before and after stimulation than TENS alone. The reduction of brain activity was stronger in participants who reported stronger pain-relieving outcomes. TENS-ConVR reduced the brain oscillation in the gamma band, whereas this result was not found in TENS alone. Conclusions: This study observed that combining TENS and visual stimulation in a single solution could enhance the pain-relieving effect of TENS, which has the potential to improve the effectiveness of current pain management treatments. Trial Registration: Chinese Clinical Trial Registry ChiCTR2500098834; https://www.chictr.org.cn/showprojEN.html?proj=254171 %M 40106805 %R 10.2196/63137 %U https://www.jmir.org/2025/1/e63137 %U https://doi.org/10.2196/63137 %U http://www.ncbi.nlm.nih.gov/pubmed/40106805 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e62785 %T Current Clinical and Educational Uses of Immersive Reality in Anesthesia: Narrative Review %A Fleet,Andrew %A Kaustov,Lilia %A Belfiore,Elio BR %A Kapralos,Bill %A Matava,Clyde %A Wiegelmann,Julian %A Giacobbe,Peter %A Alam,Fahad %+ Department of Anesthesia, Sunnybrook Health Sciences Centre, Room M3-200, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada, 1 416 480 4864, fahad.alam@sunnybrook.ca %K virtual reality %K augmented reality %K mixed reality %K anesthesia %K immersive reality %K medical education %K artificial intelligence %D 2025 %7 11.3.2025 %9 Review %J J Med Internet Res %G English %X Background: The concept of immersive reality (IR), an umbrella term that encompasses virtual reality, augmented reality, and mixed reality, has been established within the health care realm as a potentially valuable tool with numerous applications in both medical education and patient care. Objective: This review aimed to introduce anesthesiologists to the emerging and rapidly evolving literature on IR, its use in anesthesia education, and its transferability into the clinical context. Methods: A review of the relevant literature was conducted using the PubMed database from inception to July 5, 2023. Additional references were identified from the reference lists of selected papers. Results: A total of 51 papers related to the use of IR in anesthesia medical education (including both technical and nontechnical skills) and 63 papers related to applications in clinical practice (eg, preprocedure planning, patient education, and pain management) were included. We present evidence supporting the use of IR in the training and clinical practice of modern anesthesiologists. Conclusions: IR is useful for a variety of applications in anesthesia medical education and has potential advantages over existing simulation approaches. Similarly, IR has demonstrated potential improvements in patient care across several clinical contexts relevant to practicing anesthesiologists. However, many applications remain in the early stages of development, and robust trials are urgently needed to confirm clinical or educational effectiveness and to assess mechanisms, educational validity, and cost-effectiveness. %M 40068142 %R 10.2196/62785 %U https://www.jmir.org/2025/1/e62785 %U https://doi.org/10.2196/62785 %U http://www.ncbi.nlm.nih.gov/pubmed/40068142 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e67007 %T Comparative Efficacy of Video Games Versus Midazolam in Reducing Perioperative Anxiety in Pediatric Patients: Systematic Review and Meta-Analysis %A Luo,Ziyue %A Deng,Sisi %A Zhou,Ruihao %A Ye,Ling %A Zhu,Tao %A Chen,Guo %K video games %K midazolam %K perioperative period %K anxiety %K meta-analysis %K pediatric patients %D 2025 %7 10.3.2025 %9 %J JMIR Serious Games %G English %X Background: Pediatric patients undergoing surgery frequently experience significant anxiety, which can result in adverse effects such as prolonged sedation and behavioral changes associated with pharmacological interventions such as oral midazolam. Video games offer a nonpharmacological distraction method that shows promise in alleviating procedural anxiety without significant adverse effects. However, the effectiveness of video games compared to midazolam in managing perioperative anxiety remains uncertain. Objective: This study aimed to evaluate the effectiveness of video game interventions in reducing perioperative anxiety in pediatric patients undergoing general anesthesia. Methods: We conducted a comprehensive search across PubMed, Embase, Web of Science, and the Cochrane Library, supplemented by reference screening. Primary outcomes included anxiety levels assessed during parent separation and mask induction procedures, while secondary outcomes encompassed emergence delirium, postoperative behavior, and length of stay in the postanesthesia care unit (PACU). The risk of bias was assessed using the Risk of Bias 2 scale. Data were synthesized descriptively and through meta-analysis, with the certainty of the evidence evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Results: Six randomized controlled trials involving 612 participants were included in the analysis. Children who participated in video game interventions reported significantly lower anxiety levels during parent separation (standardized mean difference, SMD −0.31, 95% CI −0.50 to −0.12; P=.001), with high certainty, and during mask induction (SMD −0.29, 95% CI −0.52 to −0.05; P=.02), with moderate certainty, compared to those receiving oral midazolam. Additionally, significant differences in postoperative behavior changes in children were observed compared to oral midazolam (SMD −0.35, 95% CI −0.62 to −0.09; P=.008). Children in the video game intervention groups also had a shorter length of stay in the PACU (mean difference, MD −19.43 min, 95% CI −31.71 to −7.16; P=.002). However, no significant differences were found in emergence delirium (MD −2.01, 95% CI −4.62 to 0.59; P=.13). Conclusions: Video game interventions were more effective than midazolam in reducing perioperative anxiety among pediatric patients, improving postoperative behavior, and shortening the length of stay in the PACU. However, video games alone did not outperform midazolam in managing emergence delirium. Further high-quality research is needed for more conclusive results. Trial Registration: PROSPERO CRD42023486085; https://tinyurl.com/yc3suavb %R 10.2196/67007 %U https://games.jmir.org/2025/1/e67007 %U https://doi.org/10.2196/67007 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e50326 %T Effects and Acceptability of a 1-Week Home-Based Virtual Reality Training for Supporting the Management of Stress and Anxiety: Randomized Pilot Trial %A Pallavicini,Federica %A Orena,Eleonora %A Arnoldi,Lisa %A Achille,Federica %A Stefanini,Stefano %A Cassa,Maddalena %A Pepe,Alessandro %A Veronese,Guido %A Bernardelli,Luca %A Sforza,Francesca %A Fascendini,Sara %A Defanti,Carlo Alberto %A Gemma,Marco %A Clerici,Massimo %A Riva,Giuseppe %A Mantovani,Fabrizia %+ Department of Human Sciences for Education “Riccardo Massa”, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, 20126, Milan, 20100, Italy, 39 02 64484944, federica.pallavicini@unimib.it %K virtual reality %K relaxation %K anxiety %K depression %K emotions %K health care professionals %K health care workers %K hospital %K randomized clinicial trial %K hospitals %D 2025 %7 6.3.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) is helpful for the management of stress and anxiety. However, current interventions have limitations related to location (ie, therapist’s office or hospitals) and content (ie, virtual experiences only for relaxation). Objective: This randomized pilot trial aims to investigate the efficacy and acceptability of a brief remote VR-based training for supporting stress and anxiety management in a sample of Italian health care workers. Methods: A total of 29 doctors and nurses (n=21; 72% female; mean age 35.6, SD 10.3 years) were recruited and randomized to a VR intervention group or a control group in a passive control condition. Participants assigned to the VR intervention group received remote VR-based training consisting of 3 sessions at home delivered in 1 week using the VR psychoeducational experience “MIND-VR” and the 360° relaxing video “The Secret Garden.” The primary outcome measures were stress, anxiety, depression, and the knowledge of stress and anxiety assessed at baseline and posttreatment. We also evaluated the immediate effect of the remote VR-based training sessions on the perceived state of anxiety and negative and positive emotions. The secondary outcome measure was the usability at home of the VR system and content. Results: The VR intervention significantly reduced stress levels as assessed by the Perceived Stress Scale (6.46, 95% CI 2.77 to 10.5; P=.046) and increased the knowledge of stress and anxiety, as evaluated by the ad hoc questionnaire adopted (–2.09, 95% CI –3.86 to –0.529; P=.046). However, the home-based VR training did not yield similar reductions in stress, anxiety, and depression levels as assessed by the Depression, Anxiety, and Stress Scale-21 items or in trait anxiety as evaluated through the State-Trait Anxiety Inventory Form Y-1. After the home training sessions with VR, there was a significant decrease in anxiety, anger, and sadness and an increase in happiness levels. Analyses of the questionnaires on usability indicated that the health care workers found using the VR system at home easy and without adverse effects related to cybersickness. Of 33 participants, 29 (88%) adhered to the protocol. Conclusions: The results of this randomized pilot study suggest that a week-long home VR intervention, created with content created specifically for this purpose and available free of charge, can help individuals manage stress and anxiety, encouraging further research investigating the potential of remote VR interventions to support mental health. Trial Registration: ClinicalTrials.gov NCT04611399; https://tinyurl.com/scxunprd %M 40053782 %R 10.2196/50326 %U https://games.jmir.org/2025/1/e50326 %U https://doi.org/10.2196/50326 %U http://www.ncbi.nlm.nih.gov/pubmed/40053782 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e65562 %T Effects of a Session of Exergames and Traditional Games on Inhibitory Control in Children With Autism Spectrum Disorder: Randomized Controlled Crossover Trial %A Miranda,Juliana Macedo %A Browne,Rodrigo Alberto Vieira %A da Silva,Weslley Quirino Alves %A Rodrigues dos Santos,João Paulo %A Campbell,Carmen Silvia Grubert %A Ramos,Isabela Almeida %K children %K pediatric %K autism %K ASD, autistic %K behavior %K exergame %K physical education %K exercise %K physical activity %K cognition %K anthropometric %K Flanker test %K inhibitory control %K randomized control trial %K crossover %D 2025 %7 5.3.2025 %9 %J JMIR Serious Games %G English %X Background: Autism spectrum disorder (ASD) is characterized by deficits in executive functions, such as inhibitory control, which affect behavior and social adaptation. Although physical activity–based interventions, such as exergames, have shown potential to improve these functions, their comparative effects with active traditional games remain underexplored, particularly regarding inhibitory control in children with ASD. Objective: We aim to analyze the effects of a session of exergames and active traditional games on inhibitory control in children with ASD. Methods: This randomized controlled crossover trial included 9 male children with ASD (mean age 8.6, SD 1.4 y). Participants completed three 20-minute experimental sessions in random order, with a minimum interval of 48 hours: (1) active traditional games, (2) exergames using Just Dance 2022, and (3) a control session with manual painting activities. Inhibitory control was assessed 5 minutes postsession using a modified flanker task in the E-Prime (version 3.0; Psychological Software Tools Inc) program, recording reaction time (RT) and accuracy in congruent and incongruent phases. Repeated measures ANOVA was used to compare RT and accuracy between experimental and control conditions. Data are presented as means and 95% CIs. Results: There was a statistically significant effect of condition on RT in the incongruent phase (P=.02). RT in the exergame session (849 ms, 95% CI 642 to 1057) was lower compared to the traditional games (938 ms, 95% CI 684 to 1191; P=.02) and control (969 ms, 95% CI 742, 1196 to P=.01) sessions. No significant differences were observed in RT during the congruent phase or in accuracy across either phase. Conclusions: A 20-minute session of exergame improved inhibitory control performance in children with ASD compared to active traditional games and painting activities. Trial Registration: Brazilian Registry of Clinical Trials (ReBEC) RBR-5r9xzbq, Universal Trial Number U1111-1302-3490; https://ensaiosclinicos.gov.br/rg/RBR-5r9xzbq %R 10.2196/65562 %U https://games.jmir.org/2025/1/e65562 %U https://doi.org/10.2196/65562 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e64492 %T An Integrated Platform Combining Immersive Virtual Reality and Physiological Sensors for Systematic and Individualized Assessment of Stress Response (bWell): Design and Implementation Study %A Khundrakpam,Budhachandra %A Segado,Melanie %A Pazdera,Jesse %A Gagnon Shaigetz,Vincent %A Granek,Joshua A %A Choudhury,Nusrat %+ National Research Council Canada, 75 de Mortagne, Boucherville, QC, J4B 6Y4, Canada, 1 450 978 6198, nusrat.choudhury@nrc-cnrc.gc.ca %K virtual reality %K stress %K physiological response %K NASA-Task Load Index %K cognitive demand %K physical demand %K vagal tone %K heart rate variability %D 2025 %7 4.3.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Stress is a pervasive issue in modern society, manifesting in various forms such as emotional, physical, and work-related stress, each with distinct impacts on individuals and society. Traditional stress studies often rely on psychological, performance, or social tests; however, recently, immersive virtual reality (VR), which provides a sense of presence and natural interaction, offers the opportunity to simulate real-world tasks and stressors in controlled environments. Despite its potential, the use of VR to investigate the multifaceted manifestations of stress has not been thoroughly explored. Objective: This study aimed to explore the feasibility of using a VR-based platform, bWell, to elicit multifaceted stress responses and measure the resulting behavioral and physiological changes. Specifically, we aimed to design various VR stress exercises based on neurocardiac models to systematically test cardiac functioning within specific contexts of self-regulation (executive functioning, physical efforts, and emotional regulation). Methods: The development process adhered to guidelines for VR clinical trials and complex health interventions, encompassing 3 phases: preparation, development, and verification. The preparation phase involved a comprehensive literature review to establish links between stress, the heart, and the brain, leading to the formulation of a conceptual model based on the Neurovisceral Integration Model (NVIM) and Vagal Tank Theory (VTT). The development phase involved designing VR exercises targeting specific stressors and integrating physiological sensors such as photoplethysmography (PPG) and electromyography (EMG) to capture heart rate variability (HRV) and facial expressions. The verification phase, conducted with a small number of trials, aimed to design a study and implement a workflow for testing the feasibility, acceptability, and tolerability of the VR exercises. In addition, the potential for capturing physiological measures along with subjective ratings of stress for specific dimensions was assessed. Results: Verification trials demonstrated that the VR exercises were well tolerated, with negligible cybersickness and high user engagement. The different VR exercises successfully elicited the intended stress demands, along with the physiological responses. Conclusions: The study presents a novel VR-based experimental setup that allows a systematic and individualized assessment of stress responses, paving the way for future research to identify features that confer stress resilience and help individuals manage stress effectively. While our conceptual model highlights the role of HRV in providing valuable insights into stress responses, future research will involve multivariate and machine learning analyses to predict individual stress responses based on comprehensive sensor data, including EMG and the VR-based behavioral data, ultimately guiding personalized stress management interventions. %M 40053709 %R 10.2196/64492 %U https://formative.jmir.org/2025/1/e64492 %U https://doi.org/10.2196/64492 %U http://www.ncbi.nlm.nih.gov/pubmed/40053709 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 2 %N %P e58784 %T At-Home Virtual Reality Intervention for Patients With Chronic Musculoskeletal Pain: Single-Case Experimental Design Study %A Slatman,Syl %A Heesink,Lieke %A Achterkamp,Reinoud %A Broeks,José %A Monteiro de Oliveira,Nelson %A ter Riet,Remko %A Stegeman,Marjolein %A Tabak,Monique %K virtual reality %K VR %K chronic musculoskeletal pain %K CMP %K single-case experimental design %K SCED %K user experience %K self-management %K musculoskeletal pain %D 2025 %7 4.3.2025 %9 %J JMIR XR Spatial Comput %G English %X Background: Virtual reality (VR) could possibly alleviate complaints related to chronic musculoskeletal pain (CMP); however, little is known about how it affects pain-related variables on an individual level and how patients experience this intervention. Objective: This study aimed to gain detailed insight into the influence of an at-home VR intervention for pain education and management on pain-related variables, and to explore its feasibility and general experience. Methods: The study applied a single-case experimental design in which an at-home VR intervention was used for 4 weeks by patients with CMP who were on a waiting list for regular pain treatment. Outcome measures included pain-related variables, functioning, and objectively measured outcomes (ie, stress, sleep, and steps). Outcomes were analyzed using data visualization (based on line plots) and statistical methods (ie, Tau-U and reliable change index) on an individual and group level. In addition, a focus group was conducted to assess feasibility and general experience to substantiate findings from the single-case experimental design study. This focus group was analyzed using inductive thematic analysis. Results: A total of 7 participants (female: n=6, 86%) with a median age of 45 (range 31‐61) years participated in this study. A dataset with 42 measurement moments was collected with a median of 280 (range 241‐315) data points per participant. No statistically significant or clinically relevant differences between the intervention and no-intervention phases were found. Results of the visual analysis of the diary data showed that patients responded differently to the intervention. Results of the focus group with 3 participants showed that the VR intervention was perceived as a feasible and valued additional intervention. Conclusions: Although patients expressed a positive perspective on this VR intervention, it did not seem to influence pain-related outcomes. Individual patients responded differently to the intervention, which implies that this intervention might not be suitable for all patients. Future studies should examine which CMP patients VR is effective for and explore its working mechanisms. In addition, future larger trials should be conducted to complement this study’s findings on the effectiveness of this intervention for patients with CMP and whether VR prevents deterioration on the waiting list compared with a control group. %R 10.2196/58784 %U https://xr.jmir.org/2025/1/e58784 %U https://doi.org/10.2196/58784 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 8 %N %P e64004 %T A Self-Adaptive Serious Game to Improve Motor Learning Among Older Adults in Immersive Virtual Reality: Short-Term Longitudinal Pre-Post Study on Retention and Transfer %A Everard,Gauthier %A Declerck,Louise %A Lejeune,Thierry %A Edwards,Martin Gareth %A Bogacki,Justine %A Reiprich,Cléo %A Delvigne,Kelly %A Legrain,Nicolas %A Batcho,Charles Sebiyo %+ School of Rehabilitation Sciences, Faculty of Medicine, Laval University, 2325 Rue de l'Université, Québec, QC, G1V0A6, Canada, 1 4185299141 ext 46914, gauthier.everard@uclouvain.be %K virtual reality %K aged %K learning %K upper extremity %K video games %K kinematics %D 2025 %7 3.3.2025 %9 Original Paper %J JMIR Aging %G English %X Background: Despite their potential, the use of serious games within immersive virtual reality (iVR) for enhancing motor skills in older adults remains relatively unexplored. In this study, we developed a self-adaptive serious game in iVR called REAsmash-iVR. This game involves swiftly locating and striking a digital mole presented with various distractors. Objective: This short-term longitudinal pre-post study aims to evaluate REAsmash-iVR’s efficacy in promoting motor learning in older adults. Specifically, we seek to determine the transfer and retention of motor learning achieved through REAsmash-iVR to other iVR tasks. Methods: A total of 20 older adults participated in the study, engaging with REAsmash-iVR over 7 consecutive days. The evaluation included iVR tests such as KinematicsVR and a VR adaptation of the Box and Block Test (BBT-VR). KinematicsVR tasks included drawing straight lines and circles as fast and as accurately as possible, while BBT-VR required participants to move digital cubes as quickly as possible within 60 seconds. Assessments were conducted before and after the intervention, with a follow-up at 1 week post intervention. The primary outcome focused on evaluating the impact of REAsmash-iVR on speed-accuracy trade-off during KinematicsVR tasks. Secondary outcomes included analyzing movement smoothness, measured by spectral arc length, and BBT-VR scores. Results: Results revealed significant improvements in speed-accuracy trade-off post intervention compared to that before the intervention, with notable retention of skills for straight lines (t19=5.46; P<.001; Cohen d=1.13) and circle drawing (t19=3.84; P=.001; Cohen d=0.787). Likewise, there was a significant enhancement in spectral arc length, particularly for circle drawing (χ²2=11.2; P=.004; ε2=0.23), but not for straight-line drawing (χ²2=2.1; P=.35; ε2=0.003). Additionally, participants demonstrated transfer with significant improvement (q=5.26; P<.001; Cohen r=0.678) and retention (q=6.82; P<.001; Cohen r=0.880) in BBT-VR skills. Conclusions: These findings provide perspectives for the use of iVR to improve motor learning in older adults through delivering self-adaptive serious games targeting motor and cognitive functions. Trial Registration: ClinicalTrials.gov NCT04694833; https://clinicaltrials.gov/study/NCT04694833 %M 40053708 %R 10.2196/64004 %U https://aging.jmir.org/2025/1/e64004 %U https://doi.org/10.2196/64004 %U http://www.ncbi.nlm.nih.gov/pubmed/40053708 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e63312 %T Virtual Patient Simulations Using Social Robotics Combined With Large Language Models for Clinical Reasoning Training in Medical Education: Mixed Methods Study %A Borg,Alexander %A Georg,Carina %A Jobs,Benjamin %A Huss,Viking %A Waldenlind,Kristin %A Ruiz,Mini %A Edelbring,Samuel %A Skantze,Gabriel %A Parodis,Ioannis %+ Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, and Center for Molecular Medicine (CMM), D2:01 Rheumatology Karolinska University Hospital Solna, Stockholm, SE-171 76, Sweden, 46 722321322, ioannis.parodis@ki.se %K virtual patients %K clinical reasoning %K large language models %K social robotics %K medical education %K sustainable learning %K medical students %D 2025 %7 3.3.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual patients (VPs) are computer-based simulations of clinical scenarios used in health professions education to address various learning outcomes, including clinical reasoning (CR). CR is a crucial skill for health care practitioners, and its inadequacy can compromise patient safety. Recent advancements in large language models (LLMs) and social robots have introduced new possibilities for enhancing VP interactivity and realism. However, their application in VP simulations has been limited, and no studies have investigated the effectiveness of combining LLMs with social robots for CR training. Objective: The aim of the study is to explore the potential added value of a social robotic VP platform combined with an LLM compared to a conventional computer-based VP modality for CR training of medical students. Methods: A Swedish explorative proof-of-concept study was conducted between May and July 2023, combining quantitative and qualitative methodology. In total, 15 medical students from Karolinska Institutet and an international exchange program completed a VP case in a social robotic platform and a computer-based semilinear platform. Students’ self-perceived VP experience focusing on CR training was assessed using a previously developed index, and paired 2-tailed t test was used to compare mean scores (scales from 1 to 5) between the platforms. Moreover, in-depth interviews were conducted with 8 medical students. Results: The social robotic platform was perceived as more authentic (mean 4.5, SD 0.7 vs mean 3.9, SD 0.5; odds ratio [OR] 2.9, 95% CI 0.0-1.0; P=.04) and provided a beneficial overall learning effect (mean 4.4, SD 0.6 versus mean 4.1, SD 0.6; OR 3.7, 95% CI 0.1-0.5; P=.01) compared with the computer-based platform. Qualitative analysis revealed 4 themes, wherein students experienced the social robot as superior to the computer-based platform in training CR, communication, and emotional skills. Limitations related to technical and user-related aspects were identified, and suggestions for improvements included enhanced facial expressions and VP cases simulating multiple personalities. Conclusions: A social robotic platform enhanced by an LLM may provide an authentic and engaging learning experience for medical students in the context of VP simulations for training CR. Beyond its limitations, several aspects of potential improvement were identified for the social robotic platform, lending promise for this technology as a means toward the attainment of learning outcomes within medical education curricula. %M 40053778 %R 10.2196/63312 %U https://www.jmir.org/2025/1/e63312 %U https://doi.org/10.2196/63312 %U http://www.ncbi.nlm.nih.gov/pubmed/40053778 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 12 %N %P e63235 %T Speech and Language Therapists’ Perspectives of Virtual Reality as a Clinical Tool for Autism: Cross-Sectional Survey %A Mills,Jodie %A Duffy,Orla %K virtual reality %K VR %K autistic %K ASD %K speech %K language %K autism %K speech and language therapy %K speech-language pathology %K SLT %K immersive %K voice %K vocal %K cross sectional %K surveys %K questionnaires %K experiences %K attitudes %K opinions %K perceptions %K perspectives %K autism spectrum disorder %D 2025 %7 27.2.2025 %9 %J JMIR Rehabil Assist Technol %G English %X Background: Persistent difficulties with social skills form part of the diagnostic criteria for autism and in the past have required speech and language therapy (SLT) management. However, many speech and language therapists are moving toward neuro-affirmative practices, meaning that social skills approaches are now becoming redundant. Research demonstrates that virtual reality (VR) interventions have shown promise in overcoming challenges and promoting skill generalization for autistic children; however, the majority of these focus on social skills interventions. While VR is emerging as an SLT intervention, its application for autism remains unexamined in clinical practice. Objective: This research aimed to examine speech and language therapists’ knowledge and attitudes toward immersive VR as a clinical tool for autistic children and explore the reasons for its limited integration into clinical practice. Methods: A web-based cross-sectional survey was available from April 3, 2023 to June 30, 2023. The survey, consisting of 23 questions, focused on VR knowledge, attitudes, and the support required by speech and language therapists to incorporate VR into clinical practice. Dissemination occurred through the Royal College of Speech and Language Therapists Clinical Excellence Networks to recruit speech therapists specializing in autism. Results: Analysis included a total of 53 responses from the cross-sectional survey. Approximately 92% (n=49) of speech and language therapists were aware of VR but had not used it, and 1.82% (n=1) had used VR with autistic children. Three key themes that emerged were (1) mixed general knowledge of VR, which was poor in relation to applications for autism; (2) positive and negative attitudes toward VR, with uncertainty about autism specific considerations for VR; and (3) barriers to adoption were noted and speech and language therapists required an improved neuro-affirming evidence base, guidelines, and training to adopt VR into clinical practice. Conclusions: While some speech and language therapists perceive VR as a promising intervention tool for autistic children, various barriers must be addressed before its full integration into the clinical toolkit. This study establishes a foundation for future co-design, development, and implementation of VR applications as clinical tools for autistic children. This study is the first to explore clinical implementation factors for the use of VR in SLT field, specifically with autistic children. Poor autism-specific VR knowledge, and mixed attitudes toward VR, highlight that specific barriers must be addressed before the technology can successfully integrate into the SLT clinical toolkit. Speech and language therapists require support from employers, funding, a robust neuro-affirming evidence base, and education and training to adopt VR into practice. Recommendations for a SLT VR education and training program for use with autistic children, are provided. %R 10.2196/63235 %U https://rehab.jmir.org/2025/1/e63235 %U https://doi.org/10.2196/63235 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 2 %N %P e57361 %T A Local Training Program to Increase Awareness of Emerging Extended Reality Technologies Among Health Care Professionals: Development Study %A Galvin,Charlotte %A Watt,Jonathan %A Ghatnekar,Payal %A Peres,Nicholas %A Rees-Lee,Jacqueline %K health care XR %K extended reality in health care %K XR %K virtual reality in health care %K VR %K digital awareness training %K digital deep dive %K digital literacy %K emerging health care technology %K digital future %K extended reality %K virtual reality %D 2025 %7 27.2.2025 %9 %J JMIR XR Spatial Comput %G English %X Background: Demands on health care services can greatly outweigh capacity. Multifactorial causative factors present great challenges, forcing the National Health Service (NHS) to increase efficiency and adaptivity. Concurrently, digital advancements are excelling and long-term plans for NHS sustainability are focusing on the use of technological interventions to benefit patients. As a result, integration of extended reality (XR) technology has become an important focus of health care research. However, models of how the digital literacy of health care workforces can be developed and how frontline staff can be actively involved in the design and development of creative digital interventions are lacking. Such programs are essential to allow the development and upscaling of digital innovation within the NHS for the benefit of the patients. Such a program has been developed in the Digital Futures research lab at Torbay and South Devon NHS Foundation Trust, representing one of the first immersive digital technologies research spaces embedded within the NHS. A “Digital Deep Dive” training program has been developed, allowing local health care workers to recognize the possibilities of digital health care technologies and supporting them in the evolution of ideas for potential bespoke digital solutions appropriate to their own patient groups and care pathways. Objective: This paper aims to explain the development of this unique XR Deep Dive program and present the evaluation that informed future directions for its ongoing development. Methods: The Deep Dive sessions were designed according to relevant pedagogic principles, including experiential, active, and contextual learning theories. Voluntary pilot sessions were held for local clinical teams comprised of junior doctors, consultants, nurses, and allied health professionals. Self-selection sampling was used. Participants completed an anonymous postsession feedback form, which was used to conduct a service evaluation. Data were analyzed using descriptive statistics (quantitative) and thematic analysis (qualitative). Results: In total, 21 completed questionnaires were analyzed. Overall, the sessions were positively received: all participants reported increased awareness of the potential for digital health care innovation postsession and most found it useful and relevant to their clinical careers. Participants valued the sessions being grounded in a context relevant to local practice with opportunities to interact with the technology through the lens of use cases. Conclusions: We have developed a unique training initiative providing contextually relevant XR technology awareness training for health care professionals locally. Despite the growing pace of digital health care innovation, we recognized a knowledge gap in our local workforce regarding the potential of XR technologies within health care. We responded by developing a training program grounded in the concept of digital co-creation—working with staff and service users to develop bespoke solutions integrated within patient pathways. The results from this paper will help to inform future directions for developing digital awareness training in our trust and have implications for wider NHS digital literacy training. %R 10.2196/57361 %U https://xr.jmir.org/2025/1/e57361 %U https://doi.org/10.2196/57361 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e54452 %T Using Virtual Reality to Improve Outcomes Related to Quality of Life Among Older Adults With Serious Illnesses: Systematic Review of Randomized Controlled Trials %A Maheta,Bhagvat %A Kraft,Alexandra %A Interrante,Nickolas %A Fereydooni,Soraya %A Bailenson,Jeremy %A Beams,Brian %A Keny,​​Christina %A Osborne,Thomas %A Giannitrapani,Karleen %A Lorenz,Karl %+ Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Rd, Palo Alto, CA, 94025, United States, 1 (650) 614 9997, kalorenz@stanford.edu %K virtual reality %K serious illness %K pain %K anxiety %K older adults %K patient outcomes %K systematic review %K palliative care %K hospice %D 2025 %7 26.2.2025 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) has promise as an innovative nonpharmacologic treatment for improving a patient’s quality of life. VR can be used as an adjunct or treatment for many acute and chronic conditions, including serious illnesses. Objective: This systematic review aims to assess the current state of the literature of randomized controlled trials that use VR in patients with serious illnesses. Two secondary aims include assessing intervention components associated with improved quality of life and functional outcomes among older adults, as well as evaluating how well the randomized controlled trials adhere to consensus standards for VR research. Methods: We searched PubMed, Embase, and CINAHL for randomized controlled studies published at any time. We screened and accepted studies that reported outcomes related to patients’ quality of life, provided an immersive VR intervention, and included patients with serious illness. We narratively summarized key attributes of publications that shed light on study efficacy, generalizability, replicability, and clinical utility. All studies were assessed for study quality with the Cochrane Risk of Bias tool and for concordance with 8 recent consensus standards for VR research. Results: From the 12,621 articles searched in May 2024, a total of 24 (0.19%) studies met the inclusion criteria, and of these, 88% (21/24) reported an improvement in at least 1 patient quality of life outcome and 67% (16/24) had a high risk of bias. In 7 (n=24, 29%) studies, VR was used to provide distraction therapy to reduce pain. In total, 5 (n=24, 21%) studies included training, supervision, and assistance in VR use, which demonstrated improvements in patient quality of life–related outcomes. Of 24 studies, 9 (38%) included patients with stroke, 9 (38%) included patients with cancer, 4 (17%) included patients with cardiovascular disease, 1 (4%) included patients with chronic obstructive pulmonary disease, and 1 (4%) included patients who reported pain in hospital. In all 9 studies that included patients with stroke, the main purpose of VR was to improve mobility and strength; these studies had higher frequency and longer durations of VR use, ranging from 2 to 9 weeks, as compared to a VR use duration of <2 weeks for studies aiming to reduce pain or anxiety. Regarding consensus standards for VR research, 29% (7/24) of the studies adhered to all 8 criteria, and all studies (24/24, 100%) adhered to ≥5 criteria. Conclusions: Nascent evidence suggests VR’s potential in mitigating pain, anxiety, and depression and improving mobility among persons with serious illnesses. Most studies did not provide detailed information about unassisted or assisted use, suggesting that VR for older adults is currently most appropriate for observed settings with assistance available. Trial Registration: PROSPERO CRD42022346178; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=346178 %M 40009834 %R 10.2196/54452 %U https://www.jmir.org/2025/1/e54452 %U https://doi.org/10.2196/54452 %U http://www.ncbi.nlm.nih.gov/pubmed/40009834 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e67338 %T Reward Feedback Mechanism in Virtual Reality Serious Games in Interventions for Children With Attention Deficits: Pre- and Posttest Experimental Control Group Study %A Fang,Hao %A Fang,Changqing %A Che,Yan %A Peng,Xinyuan %A Zhang,Xiaofan %A Lin,Di %+ , Engineering Research Center for Big Data Application in Private Health Medicine of Fujian Universities, Putian University, No. 1133, Xueyuan Middle Street, Chengxiang District, Putian, 351100, China, 86 15959234669, lindi1015@163.com %K serious games %K virtual reality %K attention deficit %K inhibitory control ability %K reward feedback %D 2025 %7 24.2.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) serious games, due to their high level of freedom and realism, influence the rehabilitation training of inhibitory control abilities in children with attention-deficit/hyperactivity disorder (ADHD). Although reward feedback has a motivating effect on improving inhibitory control, the effectiveness and differences between various forms of rewards lack empirical research. Objective: This study aimed to investigate the effectiveness of different forms of reward feedback on the inhibitory control abilities of children with attention deficits in a VR serious game environment. Methods: This study focuses on children who meet the diagnostic criteria for ADHD tendencies, using a 2 (material rewards: coin reward and token reward) × 2 (psychological rewards: verbal encouragement and badge reward) factorial between-subject design (N=84), with a control group (n=15) for pre- and posttest experiments. The experimental group received VR feedback reinforcement training, while the control group underwent conventional VR training without feedback. The training period lasted 0.5 months, with each intervention session lasting 25 minutes, occurring twice daily with an interval of at least 5 hours for 28 sessions. Before and after training, the Swanson, Nolan, and Pelham, Version IV Scale (SNAP-IV) Scale, stop signal task, inhibition conflict task, and Simon task were administered to assess the hyperactivity index and the 3 components of inhibitory control ability. The pretest included the SNAP-IV Scale and 3 task tests to obtain baseline data; the posttest involved repeating the above tests after completing all training. Data were entered and analyzed using SPSS (IBM) software. Independent sample t tests were performed on the experimental and control groups’ pre- and posttest task results to determine whether significant differences existed between group means. Paired sample t tests were also conducted on the SNAP-IV Scale’s pre- and posttest results to assess the intervention effect’s significance. Results: Reward feedback was more effective than no reward feedback in improving behaviors related to attention deficits in children. Material rewards showed significant effects in the Stop-Signal Task (F1=13.04, P=.001), Inhibition Conflict Task (F1=7.34, P=.008), and SNAP-IV test (F1=69.23, P<.001); mental rewards showed significant effects in the Stop-Signal Task (F1=38.54, P<.001) and SNAP-IV test (F1=70.78, P<.001); the interaction between the 2 showed significant effects in the Stop-Signal Task (F1=4.47, P=.04) and SNAP-IV test (F1=23.85, P<.001). Conclusions: Combining material and psychological rewards within a VR platform can effectively improve attention-deficit behaviors in children with ADHD, enhancing their inhibitory control abilities. Among these, coin rewards are more effective than token rewards, and verbal encouragement outperforms badge rewards. The combined feedback of coin rewards and verbal encouragement yields the most significant improvement in inhibitory control abilities. %M 39993290 %R 10.2196/67338 %U https://games.jmir.org/2025/1/e67338 %U https://doi.org/10.2196/67338 %U http://www.ncbi.nlm.nih.gov/pubmed/39993290 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 12 %N %P e69205 %T Augmented Reality Exergames for Upcoming Cognitive-Motor Rehabilitation: User-Centered Design Approach and User Experience of Healthy Children %A Balloufaud,Maxime %A Boujut,Arnaud %A Marie,Romain %A Guinaldo,Aurélie %A Fourcade,Laurent %A Hamonet-Torny,Julia %A Perrochon,Anaick %+ 3iL Ingénieurs, 43 Rue de Sainte-Anne, Limoges, 87000, France, 33 603300245, boujut@3il.fr %K augmented reality %K exergames %K user experience %K healthy children %K cognitive-motor intervention %D 2025 %7 19.2.2025 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Traditional rehabilitation programs for children with cerebral palsy and acquired brain injuries aim to enhance motor and cognitive abilities through repetitive exercises, which are often perceived as tedious and demotivating. Extended reality technologies, including augmented reality (AR) and virtual reality, offer more engaging methods through exergames. However, to date, no AR exergames simultaneously integrate cognitive and motor aspects within navigational tasks. Developing these exergames necessitates rigorous methodological steps, especially when using emerging technologies such as AR. The MIDE (Multidisciplinary Iterative Design of Exergames) framework advocates a participatory design approach, involving users from the outset, the objective being to optimize the interface and validate game mechanics through user experience (UX) assessment. Some researchers initially test these mechanisms on healthy children before applying them to clinical populations. Objective: This study aims to evaluate the UX of our AR exergames, consisting of two games (AR Corsi and AR Zoo), in typically developing children. Methods: Typically developing children participated in two 1.5-hour sessions. During each session, they played one of two AR games using the Microsoft HoloLens 2 headset: AR Corsi and AR Zoo, both of which are designed to engage executive functions and motor skills through navigational capabilities. UX was assessed after each session using the following measures: System Usability Scale scores for usability, AttrakDiff for attractiveness and game quality, MeCue for emotional experience, and Rating scale of Perceived Exertion for Children for pre- and postsession mental and physical fatigue. Results: A total of 27 participants (mean age 11.9, SD 1.2 years) were included in the study. Mean System Usability Scale scores were 79.9 (SD 11.4) for AR Corsi and 76.3 (SD 12.1) for AR Zoo, indicating good usability. The AttrakDiff questionnaire yielded favorable results, with scores between 1 and 3 for overall attractiveness, pragmatic quality, and stimulation for both AR games. However, the hedonic quality “identity” received neutral scores (mean 0.6, SD 0.5 for AR Corsi and mean 0.7, SD 0.8 for AR Zoo). The MeCue emotions module yielded average scores of 5.2 (SD 0.7) for AR Corsi and 5.3 (SD 0.8) for AR Zoo, significantly exceeding the theoretical mean of 4 (P<.001). We observed a significant effect of physical fatigue (P=.02) and mental fatigue (P=.002) after exposure to both games. A comparative analysis of UX between the two games showed no significant differences. Conclusions: This study demonstrates that our exergame, comprising two AR games, is user-friendly and well-received by typically developing children, eliciting positive emotions and overall appeal. Although some children reported fatigue, favorable UX evaluation confirms the validity of the game’s content and mechanisms, suggesting its suitability for use among children with cerebral palsy and acquired brain injuries. %M 39970421 %R 10.2196/69205 %U https://rehab.jmir.org/2025/1/e69205 %U https://doi.org/10.2196/69205 %U http://www.ncbi.nlm.nih.gov/pubmed/39970421 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e63324 %T Improving Digital Cancer Care for Older Black Adults: Qualitative Study %A Wankah,Paul %A Chandra,Shivani %A Lofters,Aisha %A Mohamednur,Nebila %A Osei,Beverley %A Makuwaza,Tutsirai %A Sayani,Ambreen %+ Faculty of Dental Medicine and Oral Health Sciences, McGill University, 2001 McGill Avenue, Montreal, QC, H3A 1G1, Canada, 1 5143962402, paul.wankahnji@mcgill.ca %K digital care %K cancer care %K older Black adults %K health equity %K social determinants of health %K access to care %K health quality %D 2025 %7 19.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Health systems are rapidly promoting digital cancer care models to improve cancer care of their populations. However, there is growing evidence that digital cancer care can exacerbate inequities in cancer care for communities experiencing social disadvantage, such as Black communities. Despite the increasing recognition that older Black adults face significant challenges in accessing and using health care services due to multiple socioeconomic and systemic factors, there is still limited evidence regarding how older Black adults’ access and use digital cancer care. Objective: This study aims to better understand the digital cancer care experience of older Black adults, their caregivers, and health care providers to identify strategies that can better support patient-centered digital cancer care. Methods: A total of 6 focus group interviews were conducted with older Black adults living with cancer, caregivers, and health care providers (N=55 participants) across 10 Canadian provinces. Focus group interviews were recorded and transcribed. Through a theory-informed thematic analysis approach, experienced qualitative researchers used the Patient Centered Care model and the synergies of oppression conceptual lens to inductively and deductively code interview transcripts in order to develop key themes that captured the digital cancer care experiences of older Black adults. Results: In total, 5 overarching themes describe the experience of older Black adults, caregivers, and health care providers in accessing and using digital cancer care: (1) barriers to access and participation in digital care services, (2) shifting caregivers’ dynamics, (3) autonomy of choice and choosing based on the purpose of care, (4) digital accessibility, and (5) effective digital communication. We identify 8 barriers and 6 facilitators to optimal digital cancer for older Black adults. Barriers include limited digital literacy, linguistic barriers in traditional African or Caribbean languages, and patient concerns of shifting power dynamics when supported by their children for digital cancer care; and facilitators include community-based cancer support groups, caregiver support, and key features of digital technologies. Conclusions: These findings revealed a multifaceted range of barriers and facilitators to digital cancer care for older Black adults. This means that a multipronged approach that simultaneously focuses on addressing barriers and leveraging community strengths can improve access and usage of digital cancer care. A redesign of digital cancer care programs, tailored to the needs of most structurally marginalized groups like older Black adults, can enhance the digital care experience for all population groups. Public policies and organizational practices that address issues like availability of internet in remote areas, resources to support linguistic barriers, or culturally sensitive training are important in responding to the complexity of access to digital l cancer care. These findings have implications for other structurally marginalized and underresourced communities that have suboptimal access and usage of digital care. %M 39970422 %R 10.2196/63324 %U https://www.jmir.org/2025/1/e63324 %U https://doi.org/10.2196/63324 %U http://www.ncbi.nlm.nih.gov/pubmed/39970422 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e66802 %T Virtual Reality Enhanced Exercise Training in Upper Limb Function of Patients With Stroke: Meta-Analytic Study %A Xu,Shiqi %A Xu,Yanwen %A Wen,Ruyi %A Wang,Jun %A Qiu,Yuyu %A Chan,Chetwyn CH %+ Department of Psychology, The Education University of Hong Kong, Lo Ping Road, Tai Po, New Territories, Hong Kong SAR, China, 852 2948 6322, cchchan@eduhk.hk %K virtual reality %K stroke %K upper limb function %K exercise training %K meta-analysis %D 2025 %7 19.2.2025 %9 Review %J J Med Internet Res %G English %X Background: Recovery of upper limb function after stroke secondary to ischemia or hemorrhage is crucial for patients’ independence in daily living and quality of life. Virtual reality (VR) is a promising computer-based technology designed to enhance the effects of rehabilitation; however, the results of VR-based interventions remain equivocal. Objective: This study aims to review the plausible factors that may have influenced VR’s therapeutic effects on improving upper limb function in patients with stroke, with the goal of synthesizing an optimal VR intervention protocol. Methods: The databases PubMed, EMBASE, Web of Science, and Cochrane Library were queried for English-language papers published from May 2022 onward. Two reviewers independently extracted data from the included papers, and discrepancies in their findings were resolved through consensus during joint meetings. The risk of bias was assessed using the Physiotherapy Evidence Database Scale and the Methodological Index for Non-Randomized Studies. Outcome variables included the Action Research Arm Test, Box-Block Test, Functional Independence Measure, Upper Extremity Fugl-Meyer Assessment, and Wolf Motor Function Test. The plausible factors examined were age, total dosage (hours), trial length (weeks), session duration (hours/session), frequency (sessions/week), and VR content design. The Bonferroni adjustment was applied to P values to prevent data from being incorrectly deemed statistically significant. Results: The final sample included 15 articles with a total of 1243 participants (age range 48.6-75.59 years). Participants in the VR therapy (VRT) group (n=455) demonstrated significantly greater improvements in upper limb function and independence in activities of daily living compared with those in the conventional therapy group (n=301). Significant factors contributing to improved outcomes in upper limb function were younger age (mean difference [MD] 5.34, 95% CI 2.18-8.5, P<.001; I2=0%), interventions lasting more than 15 hours (MD 9.67, 95% CI 4.19-15.15, P<.001; I2=0%), trial lengths exceeding 4 weeks (MD 4.02, 95% CI 1.39-6.65, P=.003; I2=15%), and more than 4 sessions per week (MD 3.48, 95% CI 0.87-6.09, P=.009; I2=0%). However, the design of the VR content, including factors such as the number of features (eg, offering exercise and functional tasks; individualized goals; activity quantification; consideration of comorbidities and baseline activity level; addressing patient needs; aligning with patient background such as education level; patient-directed goals and interests; goal setting; progressive difficulty levels; and promoting self-efficacy), did not demonstrate significant effects (MD 3.89, 95% CI –6.40 to 1.09; effect Z=1.36, P=.16). Conclusions: Greater VR effects on improving upper limb function in patients with stroke were associated with higher training doses (exceeding 15 hours) delivered over 4-6 weeks, with shorter sessions (approximately 1 hour) scheduled 4 or more times per week. Additionally, younger patients appeared to benefit more from the VR protocol compared with older patients. %M 39969977 %R 10.2196/66802 %U https://www.jmir.org/2025/1/e66802 %U https://doi.org/10.2196/66802 %U http://www.ncbi.nlm.nih.gov/pubmed/39969977 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e59922 %T Virtual Reality Interventions and Chronic Pain: Scoping Review %A Ding,Michael E %A Traiba,Hajar %A Perez,Hector R %+ Department of Medicine, Division of General Internal Medicine, Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY, United States, 1 7189205756, heperez@montefiore.org %K virtual reality %K chronic pain %K scoping review %K pain management %K efficacy %K anxiety disorders %K mood %K health condition %K health intervention %K adults %K aging %K therapeutic %K descriptive–analytical method %K monitoring %K US %K PRISMA %D 2025 %7 18.2.2025 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) interventions have demonstrated efficacy for more than a decade for mood and anxiety disorders and emerging evidence suggests they can reduce pain symptoms in both acute and chronic pain. More recently, these interventions have abounded within the commercial and academic sectors, immersing participants within a virtual environment to confer health benefits to users. VR immersion can facilitate the delivery of health interventions by isolating participants from distractors and stressors in a therapeutic environment. While recent studies of VR interventions have exploded, they are not uniform in approach or device type, limiting generalizability. Recent scoping reviews on VR and chronic pain have focused on specific diseases or limited inquiries to specific interventions or study types. Objective: We conducted a scoping review to generate new knowledge about the sum total of VR studies on chronic pain with specific emphasis on the methods and results of each study, including (1) the type of interventions, (2) outcomes chosen, (3) samples studied, and (4) data generated. Methods: A scoping review was performed on the literature on VR and chronic pain to describe themes associated with the literature to date and identify important gaps and unanswered questions to guide future research. CINAHL [EBSCO] (Cumulative Index to Nursing and Allied Health Literature) and PubMed were queried for the terms “virtual reality” and “pain,” providing studies of chronic pain adult participants using VR delivered through headset displays. We included English-language manuscripts that had at least one VR intervention arm with adults with chronic pain. For this analysis, we only included VR interventions that were immersive (ie, using headsets). Non–study reports, studies with no specific chronic pain component, those not involving adults, and those using VR as part of a comprehensive rehabilitation program were excluded. A descriptive analytical method was used to extract data, compare studies, and contextualize the presented outcomes. Articles were categorized into several themes including the type of intervention, outcomes chosen, participant characteristics, degree to which immersion was achieved, and adverse effect monitoring and reporting. Results: A total of 36 articles were included in our analysis. We summarize the literature using 5 themes: (1) heterogeneity of chronic pain types, (2) highly variable intervention types, (3) highly variable secondary and exploratory outcomes, (4) immersion was highly variable between studies and not systemically explored in many articles, and (5) side effect monitoring was limited. Conclusions: The literature on VR in chronic pain is highly variable and lacks theoretical rigor. While there is emerging evidence that supports VR use in a wide variety of health conditions including chronic pain, future research should focus on producing theoretically rigorous work that focuses on mechanisms and that systematically assesses side effects to generate robust generalizable knowledge. %M 39965778 %R 10.2196/59922 %U https://www.jmir.org/2025/1/e59922 %U https://doi.org/10.2196/59922 %U http://www.ncbi.nlm.nih.gov/pubmed/39965778 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e68272 %T Enhancing Immersion in Virtual Reality–Based Advanced Life Support Training: Randomized Controlled Trial %A Kitapcioglu,Dilek %A Aksoy,Mehmet Emin %A Ozkan,Arun Ekin %A Usseli,Tuba %A Cabuk Colak,Dilan %A Torun,Tugrul %+ Center of Advanced Simulation and Education, Acibadem Mehmet Ali Aydinlar University, Kayisdagi cad No 32 Atasehir, Istanbul, 34752, Turkey, 90 05052685158, emin.aksoy@acibadem.edu.tr %K artificial intelligence %K voice recognition %K serious gaming %K immersion %K virtual reality %D 2025 %7 14.2.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious game–based training modules are pivotal for simulation-based health care training. With advancements in artificial intelligence (AI) and natural language processing, voice command interfaces offer an intuitive alternative to traditional virtual reality (VR) controllers in VR applications. Objective: This study aims to compare AI-supported voice command interfaces and traditional VR controllers in terms of user performance, exam scores, presence, and confidence in advanced cardiac life support (ACLS) training. Methods: A total of 62 volunteer students from Acibadem Mehmet Ali Aydinlar University Vocational School for Anesthesiology, aged 20-22 years, participated in the study. All the participants completed a pretest consisting of 10 multiple-choice questions about ACLS. Following the pretest, participants were randomly divided into 2 groups: the voice command group (n=31) and the VR controller group (n=31). The voice command group members completed the VR-based ACLS serious game in training mode twice, using an AI-supported voice command as the game interface. The VR controller group members also completed the VR-based ACLS serious game in training mode twice, but they used VR controllers as the game interface. The participants completed a survey to assess their level of presence and confidence during gameplay. Following the survey, participants completed the exam module of the VR-based serious gaming module. At the final stage of the study, participants completed a posttest, which had the same content as the pretest. VR-based exam scores of the voice command and VR controller groups were compared using a 2-tailed, independent-samples t test, and linear regression analysis was conducted to examine the effect of presence and confidence rating. Results: Both groups showed an improvement in performance from pretest to posttest, with no significant difference in the magnitude of improvement between the 2 groups (P=.83). When comparing presence ratings, there was no significant difference between the voice command group (mean 5.18, SD 0.83) and VR controller group (mean 5.42, SD 0.75; P=.25). However, when comparing VR-based exam scores, the VR controller group (mean 80.47, SD 13.12) significantly outperformed the voice command group (mean 66.70, SD 21.65; P=.005), despite both groups having similar time allocations for the exam (voice command group: mean 18.59, SD 5.28 minutes and VR controller group: mean 17.3, SD 4.83 minutes). Confidence levels were similar between the groups (voice command group: mean 3.79, SD 0.77 and VR controller group: mean 3.60, SD 0.72), but the voice command group displayed a significant overconfidence bias (voice command group: mean 0.09, SD 0.24 and VR controller group: mean –0.09, SD 0.18; P=.002). Conclusions: VR-based ACLS training demonstrated effectiveness; however, the use of voice commands did not result in improved performance. Further research should explore ways to optimize AI’s role in education through VR. Trial Registration: ClinicalTrials.gov NCT06458452; https://clinicaltrials.gov/ct2/show/NCT06458452 %M 39951703 %R 10.2196/68272 %U https://games.jmir.org/2025/1/e68272 %U https://doi.org/10.2196/68272 %U http://www.ncbi.nlm.nih.gov/pubmed/39951703 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e62688 %T Exploring Nursing Students’ Experiences of Empathy and User Experiences in an Immersive Virtual Reality Simulation Game: Cross-Sectional Study %A Koivisto,Jaana-Maija %A Kämäräinen,Sanna %A Mattsson,Katri %A Jumisko-Pyykkö,Satu %A Ikonen,Riikka %A Haavisto,Elina %+ Department of Public Health, Faculty of Medicine, University of Helsinki, PO Box 20, Helsinki, 00014, Finland, 358 503207111, jaana-maija.koivisto@helsinki.fi %K education %K nursing %K learning %K empathy %K virtual reality %K simulation %K user experience %K cross sectional %D 2025 %7 13.2.2025 %9 Original Paper %J JMIR Serious Games %G English %X Background: Empathy is associated with better clinical outcomes and patient-care experiences, and it has been demonstrated that training can improve nursing students’ empathy. The use of virtual reality (VR) as an experiential learning strategy may increase the empathetic behavior of caregivers. Although much research exists on the use of VR in education, there is still little research on learning empathy in nursing education through immersive VR games that include a head-mounted display and hand controllers. In addition, it is important to study both learning and user experiences in nursing education that utilizes VR technology. Objective: This study aims to explore nursing students’ experiences of empathy and user experiences in an immersive VR simulation game. Methods: A cross-sectional design was used. A total of 52 graduating nursing students from 3 universities of applied sciences in Finland participated in the study. The immersive VR simulation game employed in the study was played with a head-mounted display and hand controllers. The instruments used were the Basic Empathy Scale in Adults (BES-A) before the VR simulation gaming session and the Comprehensive State Empathy Scale (CSES) and AttrakDiff 2.0 Scale after the session. Results: The students’ overall level of empathy experienced in the immersive VR simulation game was favorable (CSES; mean 2.9, SD 0.57). Participants who had a higher level of empathy (BES-A) before playing the immersive VR simulation game also experienced slightly more feelings of empathy after playing (CSES). However, the association between the measures was not statistically significant (r=0.187, P=.18). The overall empathy (CSES) experienced in the immersive VR simulation game was positively correlated with its subscales. The use of the VR simulation provided a positive user experience in all 4 factors of the AttrakDiff 2.0 Scale. Overall User Experience and Emotion Sharing correlated negatively (r=−0.248, P=.042), as did Attractiveness and Emotion Sharing (r=−0.327, P=.018). Hedonic Quality Stimulation correlated negatively with Cognitive Empathy (r=–0.279, P=.045). Conclusions: The results of this study indicate that the use of an immersive VR simulation game in nursing education as a means of increasing empathy seems promising and justified. The immersive VR simulation game offered positive user experiences, which further supported the idea of implementing it in education. However, more research is needed on what kinds of VR environments are the most effective in promoting empathy among nursing students. Furthermore, when using VR technology in learning, one should consider that the VR setting must not be too technical but rather simple, straightforward, and predictable. %M 39946691 %R 10.2196/62688 %U https://games.jmir.org/2025/1/e62688 %U https://doi.org/10.2196/62688 %U http://www.ncbi.nlm.nih.gov/pubmed/39946691 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e62663 %T Designing a Smartphone-Based Virtual Reality App for Relaxation: Qualitative Crossover Study %A Verstegen,Amandine %A Van Daele,Tom %A Bonroy,Bert %A Debard,Glen %A Sels,Romy %A van Loo,Marlon %A Bernaerts,Sylvie %+ Psychology and technology, Centre of Expertise - Care and Well-being, Thomas More University of Applied Sciences, Molenstraat 8, Antwerp, 2018, Belgium, 32 34324050, sylvie.bernaerts@thomasmore.be %K smartphone-based virtual reality %K virtual reality %K relaxation %K stress %K user experience %K mobile phone %D 2025 %7 13.2.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Accumulating evidence supports the use of virtual reality (VR) in mental health care, with one potential application being its use to assist individuals with relaxation exercises. Despite studies finding support for the potential of VR to effectively aid in relaxation, its implementation remains limited outside of specialized clinics. Known barriers are insufficient knowledge regarding VR operation, lack of availability of VR relaxation apps tailored to local health care systems, and cost concerns. Unfortunately, many VR relaxation apps are designed exclusively for stand-alone headsets, limiting accessibility for a broad audience. Objective: We aimed to design an accessible, smartphone-based VR relaxation app based on user preferences. This paper describes the assessment of 2 stand-alone VR relaxation apps and the resulting smartphone-based VR relaxation app design. Methods: Overall, 30 participants (n=23, 77% women; n=7, 23% men) took part in 2 separate VR sessions, assessing 1 of the 2 VR relaxation apps (Flowborne and Calm Place) in each session. After each session, participants were presented with open-ended questions to assess their experiences via a web-based survey tool. These questions explored positive and negative features, shortcomings, and suggestions for improvements while also allowing space for additional remarks concerning the 2 VR relaxation apps. Three of the authors analyzed the responses using inductive thematic analysis, a process comprising 6 phases. Results: Across both the apps, 5 recurring themes and 13 recurring subthemes were identified in the participants’ answers: audio (music and sounds, guidance), visuals (content, realism, variation and dynamics in the environment), features (language, options, feedback and instructions, duration, exercise), implementation (technical aspects, cybersickness, acceptability and usability), and experience. We analyzed the participants’ findings and conducted a literature review, which served as the basis for developing the app. The resulting app is a Dutch-language, smartphone-based VR relaxation app, with customization options including 3 types of relaxation exercises, 2 guiding voices, and 3 different environments. Efforts have been made to ensure maximum variation and dynamism in the environments. Calming music and nature sounds accompany the exercises. The efficacy and effectiveness of the resulting app design were not assessed. Conclusions: This study provides insights into key features of VR relaxation apps, which were subsequently used for the development of a novel smartphone-based VR relaxation app. Further research concerning the effectiveness of this app, along with a broader evaluation of the efficacy and user feedback for smartphone-based VR relaxation apps, is needed. More generally, there is a clear need for more research on the impact of interactivity, biofeedback, and type of environment in VR relaxation. %M 39946693 %R 10.2196/62663 %U https://formative.jmir.org/2025/1/e62663 %U https://doi.org/10.2196/62663 %U http://www.ncbi.nlm.nih.gov/pubmed/39946693 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 8 %N %P e64633 %T Feasibility of a Cinematic–Virtual Reality Program Educating Health Professional Students About the Complexity of Geriatric Care: Pilot Pre-Post Study %A Beverly,Elizabeth A %A Miller,Samuel %A Love,Matthew %A Love,Carrie %K virtual reality %K VR %K aging %K geriatric syndromes %K diabetes %K elder abuse and neglect %K gerontology %K geriatrics %K older %K elderly %K education %K student %K cinematic %K video %K head mounted %K feasibility %K experience %K attitude %K opinion %K perception %K elder abuse %K chronic conditions %K older adult care %K health intervention %K randomized controlled trial %D 2025 %7 12.2.2025 %9 %J JMIR Aging %G English %X Background: The US population is aging. With this demographic shift, more older adults will be living with chronic conditions and geriatric syndromes. To prepare the next generation of health care professionals for this aging population, we need to provide training that captures the complexity of geriatric care. Objective: This pilot study aimed to assess the feasibility of the cinematic–virtual reality (cine-VR) training in the complexity of geriatric care. We measured changes in attitudes to disability, self-efficacy to identify and manage elder abuse and neglect, and empathy before and after participating in the training program. Methods: We conducted a single-arm, pretest-posttest pilot study to assess the feasibility of a cine-VR training and measure changes in attitudes to disability, self-efficacy to identify and manage elder abuse and neglect, and empathy. Health professional students from a large university in the Midwest were invited to participate in 1 of 4 cine-VR trainings. Participants completed 3 surveys before and after the cine-VR training. We performed paired t tests to examine changes in these constructs before and after the training. Results: A total of 65 health professional students participated in and completed the full cine-VR training for 100% retention. Participants did not report any technological difficulties or adverse effects from wearing the head-mounted displays or viewing the 360-degree video. Out of the 65 participants, 48 completed the pre- and postassessments. We observed an increase in awareness of discrimination towards people with disability (t47=−3.97; P<.001). In addition, we observed significant improvements in self-efficacy to identify and manage elder abuse and neglect (t47=−3.36; P=.002). Finally, we observed an increase in participants’ empathy (t47=−2.33; P=.02). Conclusions: We demonstrated that our cine-VR training program was feasible and acceptable to health professional students at our Midwestern university. Findings suggest that the cine-VR training increased awareness of discrimination towards people with disabilities, improved self-efficacy to identify and manage elder abuse and neglect, and increased empathy. Future research using a randomized controlled trial design with a larger, more diverse sample and a proper control condition is needed to confirm the effectiveness of our cine-VR training. %R 10.2196/64633 %U https://aging.jmir.org/2025/1/e64633 %U https://doi.org/10.2196/64633 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 11 %N %P e64780 %T Virtual Reality Simulation for Undergraduate Nursing Students for Care of Patients With Infectious Diseases: Mixed Methods Study %A Chang,Wen %A Lin,Chun-Chih %A Crilly,Julia %A Lee,Hui-Ling %A Chen,Li-Chin %A Han,Chin-Yen %+ Department of Nursing, Chang Gung University of Science and Technology, 261, Wenhua 1st Road, Guishan Dist., Taoyuan City, 33303, Taiwan, 886 3 2118999 ext 3417, cyhan@mail.cgust.edu.tw %K virtual reality %K infection control %K learning motivation %K learning attitudes %K nursing education %D 2025 %7 11.2.2025 %9 Original Paper %J JMIR Med Educ %G English %X Background: Virtual reality simulation (VRS) teaching offers nursing students a safe, immersive learning environment with immediate feedback, enhancing learning outcomes. Before the COVID-19 pandemic, nursing students had limited training and opportunities to care for patients in isolation units with infectious diseases. However, the pandemic highlighted the ongoing global priority of providing care for patients with infectious diseases. Objective: This study aims to (1) examine the effectiveness of VRS in preparing nursing students to care for patients with infectious diseases by assessing its impact on their theoretical knowledge, learning motivation, and attitudes; and (2) evaluate their experiences with VRS. Methods: This 2-phased mixed methods study recruited third-year undergraduate nursing students enrolled in the Integrated Emergency and Critical Care course at a university in Taiwan. Phase 1 used a quasi-experimental design to address objective 1 by comparing the learning outcomes of students in the VRS teaching program (experimental group) with those in the traditional teaching program (control group). Tools included an infection control written test, the Instructional Materials Motivation Survey, and a learning attitude questionnaire. The experimental group participated in a VRS lesson titled “Caring for a Patient with COVID-19 in the Negative Pressure Unit” as part of the infection control unit. In phase 2, semistructured interviews were conducted to address objective 2, exploring students’ learning experiences. Results: A total of 107 students participated in phase 1, and 18 students participated in phase 2. Both the VRS and control groups showed significant improvements in theoretical knowledge scores (for the VRS group t46=–7.47; P<.001, for the control group t59=–4.04; P<.001). However, compared with the control group, the VRS group achieved significantly higher theoretical knowledge scores (t98.13=2.70; P=.008) and greater learning attention (t105=2.30; P=.02) at T1. Additionally, the VRS group demonstrated a statistically significant higher regression coefficient for learning confidence compared with the control group (β=.29; P=.03). The students’ learning experiences in the VRS group were categorized into 4 themes: Applying Professional Knowledge to Patient Care, Enhancing Infection Control Skills, Demonstrating Patient Care Confidence, and Engaging in Real Clinical Cases. The core theme identified was Strengthening Clinical Patient Care Competencies. Conclusions: The findings suggest that VRS teaching significantly enhanced undergraduate nursing students’ infection control knowledge, learning attention, and confidence. Qualitative insights reinforced the quantitative results, highlighting the holistic benefits of VRS teaching in nursing education, including improved learning outcomes. The positive impact on student motivation and attitudes indicates a potentially transformative approach to nursing education, particularly in the post–COVID-19 era, where digital and remote learning tools play an increasingly vital role. %M 39933166 %R 10.2196/64780 %U https://mededu.jmir.org/2025/1/e64780 %U https://doi.org/10.2196/64780 %U http://www.ncbi.nlm.nih.gov/pubmed/39933166 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e66979 %T Assessing the Impact of a Virtual Reality Cognitive Intervention on Tennis Performance in Junior Tennis Players: Pilot Study %A Anguera,Joaquin A %A Choudhry,Aleem %A Seaman,Michael %A Fedele,Dominick %+ Neuroscape, Department of Neurology and Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, 675 Nelson Rising Lane, San Francisco, CA, 94158, United States, 1 415 702 4322, joaquin.anguera@ucsf.edu %K executive function %K serious games %K cognitive training %K performance enhancement %K athletes %K sport %K pilot study %K VR %K virtual reality %K serious game %K tennis %K adolescents %K teenagers %K youth %K randomized controlled trial %K players %D 2025 %7 7.2.2025 %9 Short Paper %J JMIR Form Res %G English %X Background: There is evidence that cognitive training interventions can positively impact executive functions, and that some studies have demonstrated that athletes typically exhibit greater accuracy and faster response times on select cognitive tasks. While the engagement of executive functions is suggested to be part of high-level sporting activities, it is unclear whether such training approaches could directly benefit athletic performance. Objective: The objective of this study was to evaluate the impact of a combined virtual reality (VR)– and tablet-based cognitive training intervention on adolescent tennis players’ performance. Here, we examined differences in Universal Tennis Rating (UTR) between players who supplemented their regular tennis training with a cognitive training intervention and a group that continued regular tennis training alone. This custom cognitive training program targeted specific cognitive control abilities including attention, working memory, and goal management. Methods: Data were collected from a cohort of tennis players in a randomized controlled trial design led by the dedicated research team. Participants (N=23, age: mean 14.8, SD 2.4 years) from the Czech Lawn Tenis Klub (Prague, Czech Republic) were invited to participate in this study. These individuals were randomized into an intervention + training-as-usual group (n=13) or training-as-usual group (control group; n=10), with the change in UTR score being the primary metric of interest. Results: There was no difference in UTR between the 2 groups at baseline (intervention: mean 8.32, SD 2.7; control: mean 7.60, SD 2.3). Following the treatment period, individuals in the intervention group showed a significant improvement in their UTR (an increase of 0.5; t12=4.88, P<.001) unlike the control group (an increase of 0.02; t9=1.77, P=.12). On comparing the change in UTR (posttraining UTR minus pretraining UTR) attained by each group, we found that the intervention group had a 38% greater improvement in UTR than the control group. An analysis of covariance revealed a significantly greater improvement in UTR for the intervention group than for the control group (F1,20=8.82, P=.008). Conclusions: The present findings suggest that training cognitive abilities through an immersive visual platform may benefit athletic performance, including tennis. Such a result warrants careful consideration, given the known difficulties in evidencing far transfer not only in cognitive studies but also in athletic activities. These preliminary pilot findings suggest that the Mastermind Cognitive Training program may be a viable tool for supplementing athletic training practices, although this result warrants further investigation and replication. However, many questions remain unanswered, and further work is needed to better understand the potential utility and mechanisms underlying potential effects of such a platform. %M 39918854 %R 10.2196/66979 %U https://formative.jmir.org/2025/1/e66979 %U https://doi.org/10.2196/66979 %U http://www.ncbi.nlm.nih.gov/pubmed/39918854 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e57443 %T Comparing In-Person, Standard Telehealth, and Remote Musculoskeletal Examination With a Novel Augmented Reality Exercise Game System: Pilot Cross-Sectional Comparison Study %A Wu,Richard %A Chakka,Keerthana %A Belko,Sara %A Khargonkar,Ninad %A Desai,Kevin %A Prabhakaran,Balakrishnan %A Annaswamy,Thiru %K physical examination %K telemedicine %K tele-health %K virtual care %K virtual health %K telerehabilitation %K augmented reality %K AR %K game %K simulation %K digital world %K virtual environment %K motion %K strength %K force %K musculoskeletal %K remote examination %K exercise %K physical examinations %K telehealth %K cross-sectional %K VIRTEPEX %K patient %K exergame %D 2025 %7 5.2.2025 %9 %J JMIR Serious Games %G English %X Background: Current telemedicine technologies are not fully optimized for conducting physical examinations. The Virtual Remote Tele-Physical Examination (VIRTEPEX) system, a novel proprietary technology platform using a Microsoft Kinect-based augmented reality game system to track motion and estimate force, has the potential to assist with conducting asynchronous, remote musculoskeletal examinations. Objective: This pilot study evaluated the feasibility of the VIRTEPEX system as a supplement to telehealth musculoskeletal strength assessments. Methods: In this cross-sectional pilot study, 12 study participants with upper extremity pain and/or weakness underwent strength evaluations for four upper extremity movements using in-person, telehealth, VIRTEPEX, and composite (telehealth plus VIRTEPEX) assessments. The evaluators were blinded to each other’s assessments. The primary outcome was feasibility, as determined by participant recruitment, study completion, and safety. The secondary outcome was preliminary evaluation of inter-rater agreement between in-person, telehealth, and VIRTEPEX strength assessments, including κ statistics. Results: This pilot study had an 80% recruitment rate, a 100% completion rate, and reported no adverse events. In-person and telehealth evaluations achieved highest overall agreement (85.71%), followed by agreements between in-person and composite (75%), in-person and VIRTEPEX (62.5%), and telehealth and VIRTEPEX (62.5%) evaluations. However, for shoulder flexion, agreement between in-person and VIRTEPEX evaluations (78.57%; κ=0.571, 95% CI 0.183 to 0.960) and in-person and composite evaluations (78.57%; κ=0.571, 95% CI 0.183 to 0.960) was higher than that between in-person and telehealth evaluations (71.43%; κ=0.429, 95% CI −0.025 to 0.882). Conclusions: This study demonstrates the feasibility of asynchronous VIRTEPEX examinations and supports the potential for VIRTEPEX to supplement and add value to standard telehealth platforms. Further studies with an additional development of VIRTEPEX and larger sample sizes for adequate power are warranted. %R 10.2196/57443 %U https://games.jmir.org/2025/1/e57443 %U https://doi.org/10.2196/57443 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 12 %N %P e66158 %T Exploring User Experience and the Therapeutic Relationship of Short-Term Avatar-Based Psychotherapy: Qualitative Pilot Study %A Jang,Byeul %A Yuh,Chisung %A Lee,Hyeri %A Shin,Yu-Bin %A Lee,Heon-Jeong %A Kang,Eun Kyoung %A Heo,Jeongyun %A Cho,Chul-Hyun %K avatar-based psychotherapy %K telehealth %K therapeutic relationship %K user experience %K anonymity %K nonverbal communication %K mental health %K mobile phone %D 2025 %7 5.2.2025 %9 %J JMIR Hum Factors %G English %X Background: The rapid advancement of telehealth has led to the emergence of avatar-based psychotherapy (ABP), which combines the benefits of anonymity with nonverbal communication. With the adoption of remote mental health services, understanding the efficacy and user experience of ABP has become increasingly important. Objective: This study aimed to explore the user experience and therapeutic relationship formation in short-term ABP environments, focusing on psychological effects, user satisfaction, and critical factors for implementation. Methods: This qualitative study involved 18 adult participants (8 women and 10 men). Participants engaged in two short-term ABP sessions (approximately 50 minutes per session) over 2 weeks, using an ABP metaverse system prototype. Semistructured in-depth interviews were conducted with both the participants and therapists before and after the ABP sessions. The interviews were conducted via an online platform, with each interview lasting approximately 30 minutes. The key topics included the sense of intimacy, communication effectiveness of avatar expressions, emotions toward one’s avatar, concentration during sessions, and perceived important aspects of the ABP. Data were analyzed using thematic analysis. Results: The analysis revealed 3 main themes with 8 subthemes: (1) reduction of psychological barriers through avatar use (subthemes: anonymity, ease of access, self-objectification, and potential for self-disclosure); (2) importance of the avatar–self-connection in therapeutic relationship formation (subthemes: avatar self-relevance and avatar–self-connection fostering intimacy and trust); and (3) importance of nonverbal communication (subthemes: significance of nonverbal expressions and formation of empathy and trust through nonverbal expressions). Participants reported enhanced comfort and self-disclosure owing to the anonymity provided by avatars, while emphasizing the importance of avatar customization and the role of nonverbal cues in facilitating communication and building rapport. Conclusions: This pilot study provides valuable insights into the short-term ABP user experience and therapeutic relationship formation. Our findings suggest that ABP has the potential to reduce barriers to therapy through anonymity, ease of access, and potential for self-disclosure, while allowing for meaningful nonverbal communication. The avatar–self-connection emerged as a crucial factor in the effectiveness of ABP, highlighting the importance of avatar customization in enhancing user engagement and therapeutic outcomes. Future research and development in ABP should focus on improving avatar customization options, enhancing the fidelity of nonverbal cues, and investigating the long-term effectiveness of ABP compared with traditional face-to-face therapy. Trial Registration: CRIS KCT0009695; https://tinyurl.com/2a48s7dh %R 10.2196/66158 %U https://humanfactors.jmir.org/2025/1/e66158 %U https://doi.org/10.2196/66158 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e64634 %T Metaverse Clinic for Pregnant Women With Subclinical Hypothyroidism: Prospective Randomized Study %A Zheng,Yuanyuan %A Chen,Yizhen %A Chen,Yan %A Lin,Liang %A Xue,Ting %A Chen,Chuhui %A Wen,Junping %A Lin,Wei %A Chen,Gang %+ Department of Endocrinology, Fuzhou University Affiliated Provincial Hospital, No134 East Road, Fuzhou, 350001, China, 86 059188217521, chengangfj@163.com %K metaverse %K subclinical hypothyroidism %K adverse pregnancy outcomes %K psychological health %K neurobehavioral development %D 2025 %7 5.2.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Health care is experiencing new opportunities in the emerging digital landscape. The metaverse, a shared virtual space, integrates technologies such as augmented reality, virtual reality, blockchain, and artificial intelligence. It allows users to interact with immersive digital worlds, connect with others, and explore unknowns. While the metaverse is gaining traction across various medical disciplines, its application in thyroid diseases remains unexplored. Subclinical hypothyroidism (SCH) is the most common thyroid disorder during pregnancy and is frequently associated with adverse pregnancy outcomes. Objective: This study aims to evaluate the safety and effectiveness of a metaverse platform in managing SCH during pregnancy. Methods: A randomized controlled trial was conducted at Fujian Provincial Hospital, China, from July 2022 to December 2023. A total of 60 pregnant women diagnosed with SCH were randomly assigned into two groups: the standard group (n=30) and the metaverse group (n=30). Both groups received levothyroxine sodium tablets. Additionally, participants in the metaverse group had access to the metaverse virtual medical consultations and metaverse-based medical games. The primary outcomes were adverse maternal and offspring outcomes, and the secondary outcomes included the neurobehavioral development of offspring and maternal psychological assessments. Results: Of the 30 participants in each group, adverse maternal outcomes were observed in 43% (n=13) of the standard group and 37% (n=11) of the metaverse group (P=.60). The incidence of adverse offspring outcomes was 33% (n=10) in the standard group, compared to 7% (n=2) in the metaverse group (P=.01). The Gesell Development Scale did not show significant differences between the two groups. Notably, the metaverse group demonstrated significantly improved scores on the Self-Rating Depression Scale and the Self-Rating Anxiety Scale scores compared to the standard group (P<.001 and P=.001, respectively). Conclusions: The use of metaverse technology significantly reduced the incidence of adverse offspring outcomes and positively impacted maternal mental health. Maternal adverse outcomes and offspring neurobehavioral development were comparable between the two groups. Trial Registration: Chinese Clinical Trial Registry ChiCTR2300076803; https://www.chictr.org.cn/showproj.html?proj=205905 %M 39908543 %R 10.2196/64634 %U https://www.jmir.org/2025/1/e64634 %U https://doi.org/10.2196/64634 %U http://www.ncbi.nlm.nih.gov/pubmed/39908543 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e60845 %T Effectiveness of Virtual Reality Technology Interventions in Improving the Social Skills of Children and Adolescents With Autism: Systematic Review %A Yang,Xipeng %A Wu,Jinlong %A Ma,Yudan %A Yu,Jingxuan %A Cao,Hong %A Zeng,Aihua %A Fu,Rui %A Tang,Yucheng %A Ren,Zhanbing %+ , College of Physical Education, Shenzhen University, No. 3688,Nanhai Avenue Nanshan District, Shenzhen, 518000, China, 86 13318881919, rzb@szu.edu.cn %K VR technology %K autism spectrum disorder %K children %K adolescents %K social skills %K virtual reality %K VR %D 2025 %7 5.2.2025 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) technology has shown significant potential in improving the social skills of children and adolescents with autism spectrum disorder (ASD). Objective: This study aimed to systematically review the evidence supporting the effectiveness of VR technology in improving the social skills of children and adolescents with ASD. Methods: The search for eligible studies encompassed 4 databases: PubMed, Web of Science, IEEE, and Scopus. Two (XY and JW) researchers independently assessed the extracted studies according to predefined criteria for inclusion and exclusion. These researchers also independently extracted information regarding gathered data on the sources, samples, measurement methods, primary results, and data related to the main results of the studies that met the inclusion criteria. The quality of the studies was further evaluated using the Physiotherapy Evidence Database scale. Results: This review analyzed 14 studies on using VR technology interventions to improve social skills in children and adolescents with ASD. Our findings indicate that VR interventions have a positive effect on improving social skills in children and adolescents with ASD. Compared with individuals with low-functioning autism (LFA), those with high-functioning autism (HFA) benefited more from the intervention. The duration and frequency of the intervention may also influence its effectiveness. In addition, immersive VR is more suitable for training complex skills in individuals with HFA. At the same time, nonimmersive VR stands out in terms of lower cost and flexibility, making it more appropriate for basic skill interventions for people with LFA. Finally, while VR technology positively enhances social skills, some studies have reported potential adverse side effects. According to the quality assessment using the Physiotherapy Evidence Database scale, of the 14 studies, 6 (43%) were classified as high quality, 4 (29%) as moderate quality, and 4 (29%) as low quality. Conclusions: This systematic review found that VR technology interventions positively impact social skills in children and adolescents with ASD, with particularly significant effects on the enhancement of complex social skills in individuals with HFA. For children and adolescents with LFA, progress was mainly observed in basic skills. Immersive VR interventions are more suitable for the development of complex skills. At the same time, nonimmersive VR, due to its lower cost and greater flexibility, also holds potential for application in specific contexts. However, the use of VR technology may lead to side effects such as dizziness, eye fatigue, and sensory overload, particularly in immersive settings. These potential issues should be carefully addressed in intervention designs to ensure user comfort and safety. Future research should focus on optimizing individualized interventions and further exploring the long-term effects of VR interventions. Trial Registration: International Platform of Registered Systematic Review and Meta-analysis Protocols INPLASY202420079U1; https://inplasy.com/inplasy-2024-2-0079/ %M 39907288 %R 10.2196/60845 %U https://www.jmir.org/2025/1/e60845 %U https://doi.org/10.2196/60845 %U http://www.ncbi.nlm.nih.gov/pubmed/39907288 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 12 %N %P e60747 %T Exploring the Differentiation of Self-Concepts in the Physical and Virtual Worlds Using Euclidean Distance Analysis and Its Relationship With Digitalization and Mental Health Among Young People: Cross-Sectional Study %A Chan,Kai Tai %A Hui,Christy LM %A Cheung,Charlton %A Suen,Yi Nam %A Wong,Stephanie Ming Yin %A Wong,Corine SM %A Kam,Bosco PH %A Chen,Eric Yu Hai %+ Department of Psychiatry, University of Hong Kong, Rm 222, New Clinical Buildling, Queen Mary Hospital, 102, Pokfulam Road, Hong Kong, China (Hong Kong), 852 22554486, ericchen.hku@gmail.com %K digitalization %K self %K identity %K psychiatric symptomatology %K youth mental health %K Euclidean distance analysis %K self-differentiation %K smartphone addiction %K personal attributes %D 2025 %7 31.1.2025 %9 Original Paper %J JMIR Ment Health %G English %X Background: Increasing observation and evidence suggest that the process of digitalization could have profound impact to the development of human mind and self, with potential mental health consequences. Self-differentiation is important in human identity and self-concept formation, which is believed to be involved in the process of digitalization. Objective: This study aimed to investigate the relationship between digitalization and personal attributes in the actual selves in the physical and virtual worlds. Methods: A community cohort of 397 participants aged 15 to 24 years old was recruited consecutively over about 3 months. Assessment was conducted upon the indicators of digitalization (smartphone use time, leisure online time, and age of first smartphone ownership), smartphone addiction, 14 selected personal attributes in the actual selves in the physical and virtual worlds, psychiatric symptomatology and personality traits. Euclidean distance analysis between the personal attributes in the actual selves in the physical and virtual worlds for the similarities of the 2 selves was performed in the analysis. Results: The current primary findings are the negative correlations between the similarity of the personal attributes in the physical actual self and virtual actual self, and smartphone use time, smartphone addiction as well as anxiety symptomatology respectively (P<.05 to P<.01). Conclusions: The current findings provide empirical evidence for the importance of maintaining a congruent self across the physical and virtual worlds, regulating smartphone use time, preventing smartphone addiction, and safeguarding mental health. %M 39889302 %R 10.2196/60747 %U https://mental.jmir.org/2025/1/e60747 %U https://doi.org/10.2196/60747 %U http://www.ncbi.nlm.nih.gov/pubmed/39889302 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e57297 %T Exploring Virtual Reality and Exercise Simulator Interventions in Patients With Attention Deficit Hyperactivity Disorder: Comprehensive Literature Review %A Sarai,Gurdeep %A Jayaraman,Prem Prakash %A Tirosh,Oren %A Wickramasinghe,Nilmini %+ School of Health Sciences, Swinburne University of Technology, 1 Almeida Cresent, Melbourne, 3141, Australia, 61 411362177, gurdeep.sarai@gmail.com %K exercise-based simulator %K exergame %K virtual reality %K physical activity %K attention-deficit/hyperactivity disorder %D 2025 %7 29.1.2025 %9 Review %J JMIR Serious Games %G English %X Background: This review explores virtual reality (VR) and exercise simulator–based interventions for individuals with attention-deficit/hyperactivity disorder (ADHD). Past research indicates that both VR and simulator-based interventions enhance cognitive functions, such as executive function and memory, though their impacts on attention vary. Objective: This study aimed to contribute to the ongoing scientific discourse on integrating technology-driven interventions into the management and evaluation of ADHD. It specifically seeks to consolidate findings on how VR and exercise simulators may support individuals with ADHD, acknowledging associated challenges and implications inherent in both technological approaches. Methods: This research looks at existing literature to examine the potential efficacy of VR and exercise simulator–based interventions for individuals with ADHD. It evaluates the capacity of these interventions to address specific challenges along with an emphasis on the adjustments for accommodating unique user behaviors. Additionally, it underscores the limited exploration of user perceptions of exercise simulator–based interventions and the undervalued role of motor function in both ADHD assessment and symptom management. Results: The findings of this scoping review reveal that, while these interventions enhance user motivation and enjoyment, certain challenges resist modification through technology. Furthermore, this study explores the intricate complexities involved in customizing these technologies to accommodate the diverse aspects of user behavior and highlights the potential limitations in the use of VR. Conclusions: This scoping review contributes to the ongoing research on enhancing interventions to support individuals with ADHD. It advocates for participant-centric approaches that aim to optimize both cognitive and motor outcomes while prioritizing the enhancement of user experiences. This study emphasizes the need for a comprehensive approach to interventions, recognizing the relationship between cognitive and motor abilities, and calls for improving technological interventions to address the varied needs of individuals with ADHD. %M 39879092 %R 10.2196/57297 %U https://games.jmir.org/2025/1/e57297 %U https://doi.org/10.2196/57297 %U http://www.ncbi.nlm.nih.gov/pubmed/39879092 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 13 %N %P e62914 %T Preclinical Cognitive Markers of Alzheimer Disease and Early Diagnosis Using Virtual Reality and Artificial Intelligence: Literature Review %A Scribano Parada,María de la Paz %A González Palau,Fátima %A Valladares Rodríguez,Sonia %A Rincon,Mariano %A Rico Barroeta,Maria José %A García Rodriguez,Marta %A Bueno Aguado,Yolanda %A Herrero Blanco,Ana %A Díaz-López,Estela %A Bachiller Mayoral,Margarita %A Losada Durán,Raquel %K dementia %K Alzheimer disease %K mild cognitive impairment %K virtual reality %K artificial intelligence %K early detection %K qualitative review %K literature review %K AI %D 2025 %7 28.1.2025 %9 %J JMIR Med Inform %G English %X Background: This review explores the potential of virtual reality (VR) and artificial intelligence (AI) to identify preclinical cognitive markers of Alzheimer disease (AD). By synthesizing recent studies, it aims to advance early diagnostic methods to detect AD before significant symptoms occur. Objective: Research emphasizes the significance of early detection in AD during the preclinical phase, which does not involve cognitive impairment but nevertheless requires reliable biomarkers. Current biomarkers face challenges, prompting the exploration of cognitive behavior indicators beyond episodic memory. Methods: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched Scopus, PubMed, and Google Scholar for studies on neuropsychiatric disorders utilizing conversational data. Results: Following an analysis of 38 selected articles, we highlight verbal episodic memory as a sensitive preclinical AD marker, with supporting evidence from neuroimaging and genetic profiling. Executive functions precede memory decline, while processing speed is a significant correlate. The potential of VR remains underexplored, and AI algorithms offer a multidimensional approach to early neurocognitive disorder diagnosis. Conclusions: Emerging technologies like VR and AI show promise for preclinical diagnostics, but thorough validation and regulation for clinical safety and efficacy are necessary. Continued technological advancements are expected to enhance early detection and management of AD. %R 10.2196/62914 %U https://medinform.jmir.org/2025/1/e62914 %U https://doi.org/10.2196/62914 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e58108 %T Use of Augmented Reality for Training Assistance in Laparoscopic Surgery: Scoping Literature Review %A Celdrán,Francisco Javier %A Jiménez-Ruescas,Javier %A Lobato,Carlos %A Salazar,Lucía %A Sánchez-Margallo,Juan Alberto %A Sánchez-Margallo,Francisco M %A González,Pascual %+ I3A, LoUISE Research Group, University of Castilla-La Mancha, C/ Investigación 2, Albacete, 02071, Spain, 34 666649104, franciscoj.celdran@uclm.es %K laparoscopic surgery %K surgical training %K surgical simulator %K augmented reality–based laparoscopic simulator %K AR-based laparoscopic simulator %K augmented reality %K mobile phone %D 2025 %7 28.1.2025 %9 Review %J J Med Internet Res %G English %X Background: Laparoscopic surgery training is a demanding process requiring technical and nontechnical skills. Surgical training has evolved from traditional approaches to the use of immersive digital technologies such as virtual, augmented, and mixed reality. These technologies are now integral to laparoscopic surgery training. Objective: This scoping literature review aimed to analyze the current augmented reality (AR) solutions used in laparoscopic surgery training. Methods: Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines, we conducted a scoping review using 4 databases: Scopus, IEEE Xplore, PubMed, and ACM. Inclusion and exclusion criteria were applied to select relevant articles. Exclusion criteria were studies not using AR, not focused on laparoscopic surgery, not focused on training, written in a language other than English, or not providing relevant information on the topics studied. After selecting the articles, research questions (RQs) were formulated to guide the review. In total, 2 independent reviewers then extracted relevant data, and a descriptive analysis of the results was conducted. Results: Of 246 initial records, 172 (69.9%) remained after removing duplicates. After applying the exclusion criteria, 76 articles were selected, with 25 (33%) later excluded for not meeting quality standards, leaving 51 (67%) in the final review. Among the devices analyzed (RQ 1), AR video–based devices were the most prevalent (43/51, 84%). The most common information provided by AR devices (RQ 1) focused on task execution and patient-related data, both appearing in 20% (10/51) of studies. Regarding sensorization (RQ 2), most studies (46/51, 90%) incorporated some form of sensorized environment, with computer vision being the most used technology (21/46, 46%) and the trainee the most frequently sensorized element (41/51, 80%). Regarding training setups (RQ 3), 39% (20/51) of the studies used commercial simulators, and 51% (26/51) made use of artificial models. Concerning the evaluation methods (RQ 4), objective evaluation was the most used, featured in 71% (36/51) of the studies. Regarding tasks (RQ 5), 43% (22/51) of studies focused on full surgical procedures, whereas 57% (29/51) focused on simple training tasks, with suturing being the most common among the latter (11/29, 38%). Conclusions: This scoping review highlights the evolving role of AR technologies in laparoscopic surgery training, although the impact of optical see-through devices remains unclear due to their limited use. It underscores the potential of emerging technologies such as haptic feedback, computer vision, and eye tracking to further enhance laparoscopic skill acquisition. While most relevant articles from other databases were included, some studies may have been missed due to the specific databases and search strategies used. Moreover, the need for standardized evaluation metrics is emphasized, paving the way for future research into AR’s full potential in laparoscopic skill acquisition. %M 39874568 %R 10.2196/58108 %U https://www.jmir.org/2025/1/e58108 %U https://doi.org/10.2196/58108 %U http://www.ncbi.nlm.nih.gov/pubmed/39874568 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e63241 %T Mass Casualty Incident Training in Immersive Virtual Reality: Quasi-Experimental Evaluation of Multimethod Performance Indicators %A Baetzner,Anke Sabine %A Hill,Yannick %A Roszipal,Benjamin %A Gerwann,Solène %A Beutel,Matthias %A Birrenbach,Tanja %A Karlseder,Markus %A Mohr,Stefan %A Salg,Gabriel Alexander %A Schrom-Feiertag,Helmut %A Frenkel,Marie Ottilie %A Wrzus,Cornelia %+ Institute of Sports and Sports Sciences, Heidelberg University, Im Neuenheimer Feld 700, Heidelberg, 69120, Germany, 49 6221544339, anke.baetzner@issw.uni-heidelberg.de %K prehospital decision-making %K disaster medicine %K emergency medicine %K mass casualty incident %K medical education %K eye tracking %K emergency simulation %K virtual reality %D 2025 %7 27.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Immersive virtual reality (iVR) has emerged as a training method to prepare medical first responders (MFRs) for mass casualty incidents (MCIs) and disasters in a resource-efficient, flexible, and safe manner. However, systematic evaluations and validations of potential performance indicators for virtual MCI training are still lacking. Objective: This study aimed to investigate whether different performance indicators based on visual attention, triage performance, and information transmission can be effectively extended to MCI training in iVR by testing if they can discriminate between different levels of expertise. Furthermore, the study examined the extent to which such objective indicators correlate with subjective performance assessments. Methods: A total of 76 participants (mean age 25.54, SD 6.01 y; 45/76, 59% male) with different medical expertise (MFRs: paramedics and emergency physicians; non-MFRs: medical students, in-hospital nurses, and other physicians) participated in 5 virtual MCI scenarios of varying complexity in a randomized order. Tasks involved assessing the situation, triaging virtual patients, and transmitting relevant information to a control center. Performance indicators included eye-tracking–based visual attention, triage accuracy, triage speed, information transmission efficiency, and self-assessment of performance. Expertise was determined based on the occupational group (39/76, 51% MFRs vs 37/76, 49% non-MFRs) and a knowledge test with patient vignettes. Results: Triage accuracy (d=0.48), triage speed (d=0.42), and information transmission efficiency (d=1.13) differentiated significantly between MFRs and non-MFRs. In addition, higher triage accuracy was significantly associated with higher triage knowledge test scores (Spearman ρ=0.40). Visual attention was not significantly associated with expertise. Furthermore, subjective performance was not correlated with any other performance indicator. Conclusions: iVR-based MCI scenarios proved to be a valuable tool for assessing the performance of MFRs. The results suggest that iVR could be integrated into current MCI training curricula to provide frequent, objective, and potentially (partly) automated performance assessments in a controlled environment. In particular, performance indicators, such as triage accuracy, triage speed, and information transmission efficiency, capture multiple aspects of performance and are recommended for integration. While the examined visual attention indicators did not function as valid performance indicators in this study, future research could further explore visual attention in MCI training and examine other indicators, such as holistic gaze patterns. Overall, the results underscore the importance of integrating objective indicators to enhance trainers’ feedback and provide trainees with guidance on evaluating and reflecting on their own performance. %M 39869892 %R 10.2196/63241 %U https://www.jmir.org/2025/1/e63241 %U https://doi.org/10.2196/63241 %U http://www.ncbi.nlm.nih.gov/pubmed/39869892 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 14 %N %P e64560 %T At-Home Immersive Virtual Reality Exergames to Reduce Cardiometabolic Risk Among Office Workers: Protocol for a Randomized Controlled Trial %A Zhao,Jing %A Yasunaga,Akitomo %A Kaczynski,Andrew T %A Park,Hyuntae %A Luo,Yufeng %A Li,Jiuling %A Shibata,Ai %A Ishii,Kaori %A Yano,Shohei %A Oka,Koichiro %A Koohsari,Mohammad Javad %+ School of Architecture and Urban Planning, Guangzhou University, 230 Wai Huan Xi Road, Guangzhou Higher Education Mega Center, Guangzhou, 510006, China, 86 13170322723, zhaojing@gzhu.edu.cn %K metabolic syndrome %K noncommunicable diseases %K active video game %K interactive virtual reality environment %K physical activity %K workplace health %K at-home intervention %D 2025 %7 20.1.2025 %9 Protocol %J JMIR Res Protoc %G English %X Background: The worldwide rise in the prevalence of noncommunicable diseases has increased the recognition of the need to identify modifiable risk factors for preventing and managing these diseases. The office worker, as a representative group of physically inactive workers, is exposed to risk factors for metabolic syndrome, which is a primary driver of noncommunicable diseases. The use of virtual reality (VR) exergames may offer a potential solution to the problem of increasing noncommunicable disease prevalence, as it can help individuals increase their physical activity levels while providing a more immersive experience. Objective: This exploratory study aims to examine the interventional efficacy of at-home immersive VR exergames on metabolic syndrome biomarkers among office workers. Additionally, it seeks to investigate the impacts of at-home immersive VR exergames on the active and sedentary behaviors of office workers. Methods: A 3-arm, single-blinded pilot randomized controlled trial will be conducted to examine the therapeutic effects of at-home immersive VR exergames. A total of 120 Chinese office workers, engaging in less than 150 minutes per week of moderate to vigorous intensity physical activity, will be recruited via a convenience sampling method. The participants, who will be tested over a 12-week period, will be randomly assigned to one of three groups: (1) the VR exergame intervention group, (2) the regular physical activity control group, and (3) the nonexercise control group. Throughout the 12-week trial, three categories of variables will be collected across the three groups: clinical risk factors associated with metabolic syndrome, active and sedentary behaviors, and demographics. To analyze variance among the groups, a mixed linear model will be applied to assess the efficacy of each group. Differences in metabolic syndrome clinical risk factors among all groups will be used to evaluate the effects of at-home immersive VR exergames. Changes in active and sedentary behaviors will also be used to determine the impacts of VR exergames on metabolic syndrome. Results: The ethics committee of Guangzhou University, China, approved this study on September 25, 2024. Participant recruitment will begin in early 2025 and continue for approximately 3 months. Data will be analyzed after the 12-week trial is completed, with full results expected to be presented in early 2026. Conclusions: This study explores an emerging topic by applying an at-home immersive VR exergame intervention, potentially contributing to understanding the effects of an exergame program on metabolic syndrome risk among office workers. Trial Registration: ClinicalTrials.gov NCT06556784; https://clinicaltrials.gov/study/NCT06556784 International Registered Report Identifier (IRRID): PRR1-10.2196/64560 %M 39832174 %R 10.2196/64560 %U https://www.researchprotocols.org/2025/1/e64560 %U https://doi.org/10.2196/64560 %U http://www.ncbi.nlm.nih.gov/pubmed/39832174 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 2 %N %P e49923 %T Immersive Virtual Reality for Health Promotion and Primary Prevention in Psychology: Scoping Review %A Bonneterre,Solenne %A Zerhouni,Oulmann %A Boffo,Marilisa %K virtual reality %K health psychology %K prevention psychology %K health promotion %D 2025 %7 20.1.2025 %9 %J JMIR XR Spatial Comput %G English %X Background: Virtual reality (VR) has emerged as a promising tool in health promotion and prevention psychology. Its ability to create immersive, engaging, and standardized environments offers unique opportunities for interventions and assessments. However, the scope of VR applications in this field remains unclear. Objective: This scoping review aims to identify and map the applications of VR in health promotion and prevention psychology, focusing on its uses, outcomes, and challenges. Methods: A systematic search was conducted across 3 electronic databases (PubMed, PsycINFO, and Scopus) for studies published between 2010 and 2024. Eligibility criteria included empirical studies using immersive VR for health promotion and prevention, while studies using nonimmersive VR, lacking health-related applications, or focusing on clinical interventions were excluded. The review followed PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews) guidelines, and 4295 records were initially identified, with 51 studies included after screening. Data were synthesized qualitatively to identify key applications, limitations, and emerging trends. Results: VR was primarily used in three areas: (1) delivering interventions (eg, pilot testing, skills training), (2) exploring fundamental research questions, and (3) assessing outcomes such as behavioral or psychological responses. Although VR demonstrated potential for enhancing user engagement and replicating ecological scenarios, its effectiveness compared to nonimmersive methods varied. Most studies were pilot or feasibility studies with small, nonrepresentative samples, short follow-up periods, and limited methodological standardization. Conclusions: VR offers a versatile and promising tool for health promotion and prevention but its applications are still in the early stages. The evidence is limited by methodological weaknesses and variability in outcomes. Future research should prioritize replication, longitudinal designs, and standardized methodologies to strengthen the evidence base and expand the applicability of VR interventions. %R 10.2196/49923 %U https://xr.jmir.org/2025/1/e49923 %U https://doi.org/10.2196/49923 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e63131 %T Evaluating Whether Nonimmersion Virtual Reality Simulation Training Improves Nursing Competency in Isolation Wards: Randomized Controlled Trial %A Zhang,Dandan %A Fu,MuLi %A Zhang,Jianzhong %A Li,Yuxuan %A Chen,Li %A Chen,Yong-Jun %A Zhong,Zhefeng %A Zhang,Yin-Ping %+ School of Nursing, Xi'an Jiaotong University Health Science Center, No.76, Yanta West Road, Xi'an, 7100061, China, 86 (29) 8265 7015, cathyzh@mail.xjtu.edu.cn %K virtual reality simulation %K isolation ward %K preparedness %K pandemic %K nurse %D 2025 %7 17.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: During infectious disease outbreaks such as the COVID-19 pandemic, nurses are crucial in patient care and public health safety; however, they face challenges such as inadequate training and high stress in isolation wards. Virtual reality (VR) technology offers innovative training solutions to enhance nurses’ clinical skills and preparedness. However, extensive studies on its effectiveness in isolation ward environments are still limited. Objective: This study aims to develop a nonimmersive VR (NIVR) simulation training program for isolation wards and further validate its feasibility and training effectiveness in aiding nurses in adapting to isolation ward settings. Methods: This study was a prospective, parallel, open-label, randomized controlled trial. A total of 90 nurses from 3 hospitals in China were randomly assigned to either the control or intervention group, with 45 (50%) individuals in each group. Both groups received training on isolation ward layout and nursing procedures. The control group underwent a 4-hour conventional training session consisting of 2 hours of face-to-face lectures and 2 hours of ward visits. The intervention group received a 4-hour NIVR simulation training session. Subsequently, both groups completed approximately 4 hours of emergency drills and assessments. Results: After the intervention, there were no significant differences in theoretical test or performance assessment scores between the 2 groups (t88=–0.30, P=.75; Cohen d=–0.06; z score=0.00, P>.99), using a 2-tailed t test. However, the intervention group completed 6 tasks faster than the control group (t88=5.10, P<.001; Cohen d=1.08), with an average reduction of about 3 minutes (control group: mean 43.91, SD 2.99 min; intervention group: mean 40.77, SD 2.85 min). Notably, they completed task 3 (patient reception inward) and task 6 (exiting the isolation area) significantly quicker (t88=3.22, P=.002; Cohen d=0.68; t88=3.03, P=.003; Cohen d=0.64, respectively), with no significant differences for the other tasks. Conclusions: This study highlights the potential of NIVR simulation training for nurses working in isolation wards. Although NIVR simulation training does not significantly surpass traditional methods in imparting theoretical knowledge, it does reduce task completion time for specific activities. Its capacity for safe, repetitive practice and realistic scenario simulation makes NIVR a valuable tool in medical education. Further research and optimization of VR simulation training programs are recommended to enhance nurses’ practical skills and pandemic preparedness. Trial Registration: Chinese Clinical Trial Registry ChiCTR240083155; https://www.chictr.org.cn/hvshowproject.html?id=250356&v=1.0 %M 39819587 %R 10.2196/63131 %U https://www.jmir.org/2025/1/e63131 %U https://doi.org/10.2196/63131 %U http://www.ncbi.nlm.nih.gov/pubmed/39819587 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e59704 %T Bridging Needs and Expectations of Individuals With Physical Disabilities and Community Services Stakeholders for the Cocreation of an Adapted Physical Activity Platform in Virtual Reality: Qualitative Study %A Ramos,Aurélien %A Boisvert,Maxence %A Traverse,Elodie %A Levac,Danielle %A Lemay,Martin %A Demers,Marika %A Bordeleau,Martine %A Ruest,Sarah-Maude %A Périnet-Lacroix,Roxanne %A Best,Krista L %A Robert,Maxime T %K virtual reality %K physical activity %K community organizations %K accessibility %K physical disability %D 2025 %7 17.1.2025 %9 %J JMIR Serious Games %G English %X Background: Physical activity supports the health and well-being of individuals with physical disabilities. Despite the significance of engaging in physical activity, barriers faced by individuals with disabilities, such as limited access to adapted facilities and lack of transportation, can restrict their participation. Community organizations play a role in addressing these challenges, but virtual reality (VR) also offers a way to diversify adapted activities. In some situations, VR can help overcome the resource limitations of organizations by providing accessible, engaging, and highly personalized options for physical activity. Objective: The aim of this study was to explore the needs and expectations of individuals with physical disabilities and their interventionists for the use of a VR physical activity platform in a community organization. Methods: A descriptive qualitative study was conducted using semistructured interviews with individuals with physical disabilities and their interventionists, all associated with a nonprofit organization promoting physical activity among people with disabilities. Data were analyzed using an inductive thematic approach. Results: In total, 15 participants, including 8 people with physical disabilities and 7 interventionists, were interviewed. Through this discussion, we gained insights into the everyday challenges faced by individuals with disabilities and identified priorities for community organizations. Subsequently, we discussed key considerations for using VR, including adapting activities, the possibility of fostering a more positive perception of physical activity, and harnessing the potential of VR to improve access to physical activity. We also discussed the importance of supporting personal goals and creating inclusive experiences while recognizing challenges such as technical difficulties and connectivity issues. Conclusions: By exploring the needs and expectations regarding VR technology from individuals with physical disabilities and their interventionists, this study provided essential insights for integrating immersive and nonimmersive VR into community organizations, informing next steps for the design of adapted physical activities in VR. %R 10.2196/59704 %U https://games.jmir.org/2025/1/e59704 %U https://doi.org/10.2196/59704 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e59195 %T Virtual Reality Interventions for Older Adults With Mild Cognitive Impairment: Systematic Review and Meta-Analysis of Randomized Controlled Trials %A Yang,Qin %A Zhang,Liuxin %A Chang,Fangyuan %A Yang,Hongyi %A Chen,Bin %A Liu,Zhao %+ School of Design, Shanghai Jiao Tong University, 800 Dongchuan Road, Minhang District, Shanghai, 200240, China, 86 18801971294, hotlz@sjtu.edu.cn %K Alzheimer disease %K virtual reality %K VR %K mild cognitive impairment %K meta-analysis %K health care %K cognitive function %K memory %K attention %K executive function %K older adults %D 2025 %7 10.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Alzheimer disease is incurable, but it is possible to intervene and slow down the progression of dementia during periods of mild cognitive impairment (MCI) through virtual reality (VR) technology. Objective: This study aimed to analyze the effects of VR interventions on older adults with MCI. The examined outcomes include cognitive abilities, mood, quality of life, and physical fitness, including general cognitive function, memory performance, attention and information processing speed, executive function, language proficiency, visuospatial abilities, depression, daily mobility of individuals, muscle performance, and gait and balance. Methods: A total of 4 web-based databases (Web of Science, PubMed, Embase, and Ovid) were searched up to December 30, 2023, for randomized controlled trials assessing the self-reported outcomes of VR-based technology on cognition, mood, quality of life, and physical fitness in older adults (aged ≥55 years) with MCI. Two reviewers independently screened the search results and reference lists of the identified papers and related reviews. Data on the intervention components and delivery and behavioral change techniques used were extracted. A meta-analysis, risk-of-bias sensitivity analysis, and subgroup analysis were performed where appropriate to explore potential moderators. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the quality of evidence. Results: This review analyzed 18 studies involving 722 older adults with MCI. VR was delivered through different immersion levels with VR cognitive training, VR physical training, or VR cognitive-motor dual-task training. VR interventions showed significant improvements in memory (standardized mean difference [SMD] 0.2, 95% CI 0.02-0.38), attention and information processing speed (SMD 0.25, 95% CI 0.06-0.45), and executive function (SMD 0.22, 95% CI 0.02-0.42). VR without therapist involvement improved memory as well as attention and information processing speed. VR cognitive training also resulted in significant improvements in attention and information processing speed in older adults with MCI (SMD 0.31, 95% CI 0.05-0.58). In addition, immersive VR had a significant impact on improving attention and information processing speed (SMD 0.25; 95% CI 0.01-0.50) and executive function (SMD 0.25; 95% CI 0.00-0.50). However, the effects of the intervention were very small in terms of general cognitive function, language proficiency, visuospatial abilities, depression, daily living ability, muscle performance, and gait and balance. Quality of evidence varied, with moderate ratings for certain cognitive functions and low ratings for others, based on the GRADE approach. Conclusions: VR interventions can improve memory, attention and information processing speed, and executive function in older adults with MCI. The quality of evidence is moderate to low, and further research is needed to confirm these findings and explore additional health-related outcomes. %M 39793970 %R 10.2196/59195 %U https://www.jmir.org/2025/1/e59195 %U https://doi.org/10.2196/59195 %U http://www.ncbi.nlm.nih.gov/pubmed/39793970 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e55066 %T Comparing Virtual Reality–Based and Traditional Physical Objective Structured Clinical Examination (OSCE) Stations for Clinical Competency Assessments: Randomized Controlled Trial %A Mühling,Tobias %A Schreiner,Verena %A Appel,Marc %A Leutritz,Tobias %A König,Sarah %+ Institute of Medical Teaching and Medical Education Research, University Hospital Würzburg, Joseph-Schneider-Straße 2, Würzburg, 97080, Germany, 49 931 201 70627, muehling_t@ukw.de %K virtual reality %K VR %K objective structured clinical examination %K OSCE %K medical education %K technological proficiency %K assessment %K clinical competence %K item characteristics %K discrimination power %K acceptance %K technical feasibility %K effectiveness %K comparative study %K physical stations %K medical students %K standardized patients %K cost-effectiveness %D 2025 %7 10.1.2025 %9 Original Paper %J J Med Internet Res %G English %X Background: Objective structured clinical examinations (OSCEs) are a widely recognized and accepted method to assess clinical competencies but are often resource-intensive. Objective: This study aimed to evaluate the feasibility and effectiveness of a virtual reality (VR)–based station (VRS) compared with a traditional physical station (PHS) in an already established curricular OSCE. Methods: Fifth-year medical students participated in an OSCE consisting of 10 stations. One of the stations, emergency medicine, was offered in 2 modalities: VRS and PHS. Students were randomly assigned to 1 of the 2 modalities. We used 2 distinct scenarios to prevent content leakage among participants. Student performance and item characteristics were analyzed, comparing the VRS with PHS as well as with 5 other case-based stations. Student perceptions of the VRS were collected through a quantitative and qualitative postexamination online survey, which included a 5-point Likert scale ranging from 1 (minimum) to 5 (maximum), to evaluate the acceptance and usability of the VR system. Organizational and technical feasibility as well as cost-effectiveness were also evaluated. Results: Following randomization and exclusions of invalid data sets, 57 and 66 participants were assessed for the VRS and PHS, respectively. The feasibility evaluation demonstrated smooth implementation of both VR scenarios (septic and anaphylactic shock) with 93% (53/57) of students using the VR technology without issues. The difficulty levels of the VRS scenarios (septic shock: P=.67; anaphylactic shock: P=.58) were comparable to the average difficulty of all stations (P=.68) and fell within the reference range (0.4-0.8). In contrast, VRS demonstrated above-average values for item discrimination (septic shock: r'=0.40; anaphylactic shock: r'=0.33; overall r'=0.30; with values >0.3 considered good) and discrimination index (septic shock: D=0.25; anaphylactic shock: D=0.26; overall D=0.16, with 0.2-0.3 considered mediocre and <0.2 considered poor). Apart from some hesitancy toward its broader application in future practical assessments (mean 3.07, SD 1.37 for VRS vs mean 3.65, SD 1.18 for PHS; P=.03), there were no other differences in perceptions between VRS and PHS. Thematic analysis highlighted the realistic portrayal of medical emergencies and fair assessment conditions provided by the VRS. Regarding cost-effectiveness, initial development of the VRS can be offset by long-term savings in recurring expenses like standardized patients and consumables. Conclusions: Integration of the VRS into the current OSCE framework proved feasible both technically and organizationally, even within the strict constraints of short examination phases and schedules. The VRS was accepted and positively received by students across various levels of technological proficiency, including those with no prior VR experience. Notably, the VRS demonstrated comparable or even superior item characteristics, particularly in terms of discrimination power. Although challenges remain, such as technical reliability and some acceptance concerns, VR remains promising in applications of clinical competence assessment. %M 39793025 %R 10.2196/55066 %U https://www.jmir.org/2025/1/e55066 %U https://doi.org/10.2196/55066 %U http://www.ncbi.nlm.nih.gov/pubmed/39793025 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e58086 %T Extended Reality Interventions for Health and Procedural Anxiety: Panoramic Meta-Analysis Based on Overviews of Reviews %A Arthur,Tom %A Melendez-Torres,GJ %A Harris,David %A Robinson,Sophie %A Wilson,Mark %A Vine,Sam %+ Faculty of Health and Life Sciences, University of Exeter, St. Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom, 44 1392 722892, T.T.Arthur@exeter.ac.uk %K virtual reality %K exposure therapy %K distraction techniques %K patient education %K fear %K phobia %K immersive %K anxiety %K meta-analysis %K extended reality %K intervention %K procedural anxiety %K patient anxiety %K exposure %K distraction %D 2025 %7 8.1.2025 %9 Review %J J Med Internet Res %G English %X Background: Extended reality (XR) technologies are increasingly being used to reduce health and procedural anxieties. The global effectiveness of these interventions is uncertain, and there is a lack of understanding of how patient outcomes might vary between different contexts and modalities. Objective: This research used panoramic meta-analysis to synthesize evidence across the diverse clinical contexts in which XR is used to address common outcomes of health and procedural anxiety. Methods: Review-level evidence was obtained from 4 databases (MEDLINE, Embase, APA PsycINFO, and Epistemonikos) from the beginning of 2013 until May 30, 2023. Reviews that performed meta-analysis of randomized controlled trials relating to patient-directed XR interventions for health and procedural anxiety were included. Studies that analyzed physiological measures, or focused on technologies that did not include meaningful immersive components, were excluded. Furthermore, data were only included from studies that compared intervention outcomes against no-treatment or treatment-as-usual controls. Analyses followed a preregistered, publicly available protocol. Trial effect sizes were extracted from reviews and expressed as standardized mean differences, which were entered into a 3-level generalized linear model. Here, outcomes were estimated for patients (level 1), studies (level 2), and anxiety indications (level 3), while meta-regressions explored possible influences of age, immersion, and different mechanisms of action. Where relevant, the quality of reviews was appraised using the AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews, Revised Instrument) tool. Results: Data from 83 individual trials were extracted from 18 eligible meta-analyses. Most studies involved pediatric patient groups and focused on procedural, as opposed to general, health anxieties (eg, relating to needle insertion, dental operations, and acute surgery contexts). Interventions targeted distraction-, education-, and exposure-based mechanisms, and were provided via a range of immersive and nonimmersive systems. These interventions proved broadly effective in reducing patient anxiety, with models revealing significant but heterogeneous effects for both procedural (d=–0.75, 95% CI –0.95 to –0.54) and general health (d=–0.82, 95% CI –1.20 to –0.45) indications (when compared with nontreatment or usual-care control conditions). For procedural anxieties, effects may be influenced by publication bias and appear more pronounced for children (vs adults) and nonimmersive (vs immersive) technology interventions, but they were not different by indication. Conclusions: Results demonstrate that XR interventions have successfully reduced patient anxiety across diverse clinical contexts. However, significant uncertainty remains about the generalizability of effects within various unexplored indications, and existing evidence is limited in methodological quality. Although current research is broadly positive in this area, it is premature to assert that XR interventions are effective for any given health or procedural anxiety indication. %M 39778203 %R 10.2196/58086 %U https://www.jmir.org/2025/1/e58086 %U https://doi.org/10.2196/58086 %U http://www.ncbi.nlm.nih.gov/pubmed/39778203 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 27 %N %P e58384 %T Effectiveness of Virtual Reality Training in Improving Outcomes for Dialysis Patients: Systematic Review and Meta-Analysis %A Kang,Xin %A Zhang,Yiping %A Sun,Chaonan %A Zhang,Jiaxin %A Che,Zhe %A Zang,Jinhui %A Zhang,Rongzhi %+ Department of Center for Hemodialysis, The Second Hospital of Dalian Medical University, 467, Zhongshan Road, Shahekou District, Liaoning Province, Dalian, 116000, China, 86 17709870601, zhangxinzhi169@163.com %K virtual reality %K VR %K training %K dialysis %K hemodialysis %K peritoneal dialysis %K chronic kidney disease %K rehabilitation %K quality of life %K meta-analysis %D 2025 %7 8.1.2025 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) training uses computer-generated simulations that enable users to engage with immersive virtual environments, simulating real-world activities or therapeutic exercises. This technology is increasingly recognized as a promising intervention to address the physical and psychological challenges faced by dialysis patients, who frequently experience diminished physical function, social isolation, and emotional distress associated with prolonged treatment regimens. Given the increasing prevalence of dialysis patients and the limitations of conventional rehabilitation approaches, VR presents a novel, interactive method that has the potential to enhance patient well-being and improve quality of life. Objective: This meta-analysis aimed to evaluate the effectiveness of VR training interventions for dialysis patients, with a focus on assessing their impact on motor abilities, psychological symptoms (specifically anxiety and depression), social functioning, and self-efficacy. This analysis also explores whether VR can offer comprehensive benefits to support both the physical and mental health of dialysis patients. Methods: The meta-analysis was conducted following Cochrane guidelines. Comprehensive searches were performed across major databases, including China National Knowledge Infrastructure, Wanfang database, China Science and Technology Journal Database, China Biomedical Literature database, Cochrane library, Web of Science, PubMed, and Embase, encompassing all studies up to December 2023. Inclusion criteria targeted studies assessing VR’s impact on motor performance, psychological well-being, social functioning, and self-efficacy in dialysis patients. Two reviewers independently extracted data and assessed methodological quality using Cochrane’s risk of bias criteria, ensuring data synthesis reliability. Results: A total of 12 studies, involving 625 dialysis patients in total, met the inclusion criteria. The meta-analysis demonstrated that VR training led to significant improvements across multiple domains. VR interventions were associated with improved physical capacity, evidenced by higher scores in the 6-minute walk test (standardized mean difference [SD]=29.36, 95% CI 14.32-44.4, P<.001, I2=46%). VR training was associated with significant reductions in depression (SD=–6.30, 95% CI –7.14 to –5.47, P<.001, I2=96%) and anxiety (SD=–8.91, 95% CI –9.69 to –8.14, P<.001, I2=95%). In addition, VR interventions enhanced social functioning (SD=16.20, 95% CI 14.49-17.9, P<.001, I2=72%), and improved self-efficacy (SD=20.47, 95% CI 18.55-22.39, P<.001, I2=99%). However, VR training did not yield significant differences in gait speed, balance, or functional tests (Ten Sit-to-Stand Test, Five Sit-to-Stand Test, Sixty Sit-to-Stand Test, Timed Up and Go Test, and fatigue) compared with control groups. Conclusions: The findings suggest that VR training is a promising intervention for dialysis patients, providing benefits in physical endurance, social engagement, and psychological well-being. Despite these advantages, VR remains underused among peritoneal dialysis patients compared with hemodialysis patients. Further studies with larger sample sizes and more refined experimental designs are recommended to validate these results and support VR as a complementary tool in the holistic care of dialysis patients. %M 39773859 %R 10.2196/58384 %U https://www.jmir.org/2025/1/e58384 %U https://doi.org/10.2196/58384 %U http://www.ncbi.nlm.nih.gov/pubmed/39773859 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e62740 %T Measuring Bound Attention During Complex Liver Surgery Planning: Feasibility Study %A Schneider,Tim %A Cetin,Timur %A Uppenkamp,Stefan %A Weyhe,Dirk %A Muender,Thomas %A Reinschluessel,Anke V %A Salzmann,Daniela %A Uslar,Verena %+ University Hospital for Visceral Surgery, PIUS-Hospital, Department for Human Medicine, Faculty VI, University of Oldenburg, Ammerländer Heerstraße 114-118, Oldenburg, 26129, Germany, 49 4412292922, tim.schneider@uol.de %K workload measurement %K virtual reality %K VR %K augmented reality %K AR %K electroencephalography %K EEG %K event-related potential %K ERP %K auditory evoked potential %K AEP %K oddball experiment %K National Aeronautics and Space Administration Task Load Index %K NASA-TLX %K surgical planning %D 2025 %7 8.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: The integration of advanced technologies such as augmented reality (AR) and virtual reality (VR) into surgical procedures has garnered significant attention. However, the introduction of these innovations requires thorough evaluation in the context of human-machine interaction. Despite their potential benefits, new technologies can complicate surgical tasks and increase the cognitive load on surgeons, potentially offsetting their intended advantages. It is crucial to evaluate these technologies not only for their functional improvements but also for their impact on the surgeon’s workload in clinical settings. A surgical team today must increasingly navigate advanced technologies such as AR and VR, aiming to reduce surgical trauma and enhance patient safety. However, each innovation needs to be evaluated in terms of human-machine interaction. Even if an innovation appears to bring advancements to the field it is applied in, it may complicate the work and increase the surgeon’s workload rather than benefiting the surgeon. Objective: This study aims to establish a method for objectively determining the additional workload generated using AR or VR glasses in a clinical context for the first time. Methods: Electroencephalography (EEG) signals were recorded using a passive auditory oddball paradigm while 9 participants performed surgical planning for liver resection across 3 different conditions: (1) using AR glasses, (2) VR glasses, and (3) the conventional planning software on a computer. Results: The electrophysiological results, that is, the potentials evoked by the auditory stimulus, were compared with the subjectively perceived stress of the participants, as determined by the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) questionnaire. The AR condition had the highest scores for mental demand (median 75, IQR 70-85), effort (median 55, IQR 30-65), and frustration (median 40, IQR 15-75) compared with the VR and PC conditions. The analysis of the EEG revealed a trend toward a lower amplitude of the N1 component as well as for the P3 component at the central electrodes in the AR condition, suggesting a higher workload for participants when using AR glasses. In addition, EEG components in the VR condition did not reveal any noticeable differences compared with the EEG components in the conventional planning condition. For the P1 component, the VR condition elicited significantly earlier latencies at the Fz electrode (mean 75.3 ms, SD 25.8 ms) compared with the PC condition (mean 99.4 ms, SD 28.6 ms). Conclusions: The results suggest a lower stress level when using VR glasses compared with AR glasses, likely due to the 3D visualization of the liver model. Additionally, the alignment between subjectively determined results and objectively determined results confirms the validity of the study design applied in this research. %M 39773449 %R 10.2196/62740 %U https://formative.jmir.org/2025/1/e62740 %U https://doi.org/10.2196/62740 %U http://www.ncbi.nlm.nih.gov/pubmed/39773449 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e63461 %T Virtual Reality High-Intensity Interval Training Exergaming Compared to Traditional High-Intensity Circuit Training Among Medical Students: Pilot Crossover Study %A Merola,Pietro %A Cardoso,Marcos Barros %A Barreto,Gabriel %A Chagas,Matheus Carvalho %A Farias Oliveira Saunders,Luana %A Saunders,Bryan %A Cortozi Berton,Danilo %K virtual reality %K VR %K high-intensity interval training %K exercise motivation %K exergame %K physical activity %K exercise %K heart rate %D 2025 %7 7.1.2025 %9 %J JMIR Serious Games %G English %X Background: This study evaluated the effectiveness of a virtual reality (VR) high-intensity interval training (HIIT) boxing protocol compared to traditional high-intensity circuit training (HICT) in improving exercise motivation, engagement, and physiological responses among 30 healthy medical students. Objective: The purpose was to compare the VR HIIT protocol, which involved using an Oculus Quest 2 for a futuristic exoskeleton game experience, with a traditional 12-exercise HICT. Methods: In total, 30 medical students engaged in both VR HIIT, using an Oculus Quest 2 for a futuristic exoskeleton game experience, and a traditional 12-exercise HICT. Metrics included heart rate (HR) and blood lactate levels before and after exercise alongside ratings of perceived exertion and the Situational Motivation Scale. Results: VR HIIT showed significantly higher mean HR (mean 161, SD 15 vs mean 144, SD 11 bpm; d=1.5; P<.001), peak HR (mean 182, SD 15 vs mean 176, SD 11 bpm; d=0.8; P=.001), and ratings of perceived exertion (mean 16, SD 2 vs mean 15, SD 2; d=0.4; P=.03). Postexercise lactate levels were higher in HICT (mean 8.8, SD 4.5 vs mean 10.6, SD 3.0 mmol/L; d=0.6; P=.006). Intrinsic motivation and other psychological measures showed no significant differences, except for lower fatigue in HICT (d=0.5; P=.02). Conclusions: VR HIIT significantly enhances physiological parameters while maintaining intrinsic motivation, making it a viable alternative to traditional HICT. However, the short-term nature of this study is a limitation, and future research should explore the long-term engagement and therapeutic impacts of VR exercise in diverse and clinical populations. %R 10.2196/63461 %U https://games.jmir.org/2025/1/e63461 %U https://doi.org/10.2196/63461 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 9 %N %P e58650 %T Co-Design of an Escape Room for e-Mental Health Training of Mental Health Care Professionals: Research Through Design Study %A Bierbooms,Joyce J P A %A Sluis-Thiescheffer,Wouter R J W %A Feijt,Milou Anne %A Bongers,Inge M B %+ Tilburg University, PO box 90153, Tilburg, 5000 LE, Netherlands, 31 13 466 31 39, j.j.p.a.bierbooms@tilburguniversity.edu %K serious gaming %K mental health care professionals %K e-mental health %K skill enhancement %K training %D 2025 %7 7.1.2025 %9 Original Paper %J JMIR Form Res %G English %X Background: Many efforts to increase the uptake of e-mental health (eMH) have failed due to a lack of knowledge and skills, particularly among professionals. To train health care professionals in technology, serious gaming concepts such as educational escape rooms are increasingly used, which could also possibly be used in mental health care. However, such serious-game concepts are scarcely available for eMH training for mental health care professionals. Objective: This study aims to co-design an escape room for training mental health care professionals’ eMH skills and test the escape room’s usability by exploring their experiences with this concept as a training method. Methods: This project used a research through design approach with 3 design stages. In the first stage, the purpose, expectations, and storylines for the escape room were formulated in 2 co-design sessions with mental health care professionals, game designers, innovation staff, and researchers. In the second stage, the results were translated into the first escape room, which was tested in 3 sessions, including one web version of the escape room. In the third stage, the escape room was tested with mental health care professionals outside the co-design team. First, 2 test sessions took place, followed by 3 field study sessions. In the field study sessions, a questionnaire was used in combination with focus groups to assess the usability of the escape room for eMH training in practice. Results: An escape room prototype was iteratively developed and tested by the co-design team, which delivered multiple suggestions for adaptations that were assimilated in each next version of the prototype. The field study showed that the escape room creates a positive mindset toward eMH. The suitability of the escape room to explore the possibilities of eMH was rated 4.7 out of 5 by the professionals who participated in the field study. In addition, it was found to be fun and educational at the same time, scoring 4.7 (SD 0.68) on a 5-point scale. Attention should be paid to the game’s complexity, credibility, and flexibility. This is important for the usefulness of the escape room in clinical practice, which was rated an average of 3.8 (SD 0.77) on a 5-point scale. Finally, implementation challenges should be addressed, including organizational policy and stimulation of eMH training. Conclusions: We can conclude that the perceived usability of an escape room for training mental health care professionals in eMH skills is promising. However, it requires additional effort to transfer the learnings into mental health care professionals’ clinical practice. A straightforward implementation plan and testing the effectiveness of an escape room on skill enhancement in mental health care professionals are essential next steps to reach sustainable goals. %M 39773391 %R 10.2196/58650 %U https://formative.jmir.org/2025/1/e58650 %U https://doi.org/10.2196/58650 %U http://www.ncbi.nlm.nih.gov/pubmed/39773391 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 13 %N %P e57030 %T User Experience of a Semi-Immersive Musical Serious Game to Stimulate Cognitive Functions in Hospitalized Older Patients: Questionnaire Study %A Samson,Laurent %A Carcreff,Lena %A Noublanche,Frédéric %A Noublanche,Sophie %A Vermersch-Leiber,Hélène %A Annweiler,Cédric %K virtual reality %K geriatrics %K reminiscence %K episodic memory %K serious game %K neurocognitive disorders %K older adults %K user experience %D 2025 %7 6.1.2025 %9 %J JMIR Serious Games %G English %X Background: Reminiscence therapy through music is a psychosocial intervention with benefits for older patients with neurocognitive disorders. Therapies using virtual or augmented reality are efficient in ecologically assessing, and eventually training, episodic memory in older populations. We designed a semi-immersive musical game called “A Life in Songs,” which invites patients to immerse themselves in a past era through visuals and songs from that time period. The game aspires to become a playful, easy-to-use, and complete tool for the assessment, rehabilitation, and prevention of neurocognitive decline associated with aging. Objective: This study aimed to assess the user experience (UX) associated with the newly designed serious game. Methods: After one or several sessions of the game guided by the therapist, patients of the geriatric wards were asked to answer questions selected from 2 widely known UX scales (AttrakDiff and meCUE [modular evaluation of the components of user experience]) with the therapist’s help. The internal consistency of the UX dimensions was assessed through Cronbach α to verify the validity of the dimensions. The level of engagement of the patient throughout the experimental session was also assessed following an internally developed scale, which included 5 levels (interactive, constructive, active, passive, and disengaged behaviors). UX mean scores were computed and presented graphically. Verbal feedbacks were reported to support the quantitative results. Results: Overall, 60 inpatients with a mean age of 84.2 (SD 5.5) years, the majority of whom were women (41/60, 68%), were included. Their score on the Mini-Mental State Examination (MMSE) ranged between 12 and 29. A majority of patients (27/56, 48%) had no major neurocognitive disorder (MNCD), 22/56 (39%) had mild MNCD, and 7/56 (13%) had moderate MNCD. The results revealed very positive UX with mean values beyond the neutral values for every UX dimension of both scales. The overall mean (SD) judgment was rated 3.92 (SD 0.87) (on a scale of −5 to 5). Internal consistency was acceptable to good for the emotional dimensions of the meCUE. Questionable to unacceptable consistency was found for the other UX dimensions. Participants were mostly active (23/60, 38%) and constructive (21/60, 35%). Conclusions: These findings demonstrated a very good appreciation of the game by geriatric inpatients. Participants’ and health care professionals’ verbal comments strongly aligned with the quantitative results. The poor internal consistency in the UX dimensions reflected the high heterogeneity among the included patients. Further studies are needed to evaluate the potential benefits of clinical factors such as neurocognitive functions, mood, depression, or quality of life. %R 10.2196/57030 %U https://games.jmir.org/2025/1/e57030 %U https://doi.org/10.2196/57030 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e58422 %T Factors That Influence Young Adults’ Preferences for Virtual Reality Exergames in a Weight Control Setting: Qualitative Study %A Chen,Yanya %A Guan,Lina %A Wu,Weixin %A Ye,Liang %A He,Yan %A Zheng,Xiaofen %A Li,Sicun %A Guan,Bingsheng %A Ming,Wai-kit %+ Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, To Yuen Building, 31 To Yuen Street, Hong Kong, China (Hong Kong), 852 56117116, wkming2@cityu.edu.hk %K virtual reality %K games %K weight control %K preferences %K young adults %K qualitative research %D 2024 %7 30.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Obesity could compromise people’s health and elevate the risk of numerous severe chronic conditions and premature mortality. Young adults are at high risk of adopting unhealthy lifestyles related to overweight and obesity, as they are at a phase marked by several significant life milestones that have been linked to weight gain. They gain weight rapidly and excess adiposity mostly accrues, compared with middle-aged and older adults when weight stabilizes or even decreases. Virtual reality exergames have the potential to increase physical activity in people’s daily lives. However, the factors that influence young adults’ preference for using virtual reality exergames for weight control remain unclear. Objective: The objective of this study is to identify, characterize, and explain the factors influencing young adults' preference for weight control using virtual reality exergames. Methods: This qualitative study used semistructured interviews. In total, 4 focus group interviews were conducted with 23 young adults aged between 18 and 25 years. The qualitative data were analyzed using the Colaizzi phenomenological methodology. Results: In total, 3 major factors were found to influence young adults’ preference for virtual reality exergames in weight control settings: individual factors, social or environmental factors, and expectations of virtual reality exergames. Individual factors included experience with previous weight control methods, previous experience with virtual reality, psychological status, attitudes toward personal BMI, preference for exercise type, and acceptance of virtual reality exergames. Social or environmental factors included social definitions of beauty, weather or public health events, and knowledge of virtual reality provided. Expectations of virtual reality exergames included cost of the device, the fun of virtual reality exergames, supervision, modality of virtual reality exergames, feedback after exercise, convenience to use, and weight loss effect. Conclusions: Young adults take various factors into account when deciding whether to use virtual reality exergames for weight control. These factors can inform the development and further refinement of devices, guides, and policies related to virtual reality exergames for controlling weight. %M 39753223 %R 10.2196/58422 %U https://www.jmir.org/2024/1/e58422 %U https://doi.org/10.2196/58422 %U http://www.ncbi.nlm.nih.gov/pubmed/39753223 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e60374 %T Advanced Technology in a Real-World Rehabilitation Setting: Longitudinal Observational Study on Clinician Adoption and Implementation %A Pearce,Louise Michelle Nettleton %A Pryor,Julie %A Redhead,Jason %A Sherrington,Catherine %A Hassett,Leanne %+ Institute for Musculoskeletal Health, Sydney Local Health District, Level 10N, King George V Building, Missenden Road, Camperdown, Sydney, Australia, 61 8627 6447, louise.pearce@sydney.edu.au %K rehabilitation %K technology %K digital health %K virtual reality %K robotics %K exoskeleton device %K implementation science %K physiotherapy %K physical therapy %K occupational therapy %K mobile phone %D 2024 %7 30.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Advanced technologies are becoming increasingly accessible in rehabilitation. Current research suggests technology can increase therapy dosage, provide multisensory feedback, and reduce manual handling for clinicians. While more high-quality evidence regarding the effectiveness of rehabilitation technologies is needed, understanding of how to effectively integrate technology into clinical practice is also limited. Current implementation of rehabilitation technology is inconsistent, with low uptake among clinicians and frequent reports of technology abandonment. An Australian rehabilitation provider opened a new technology therapy center in 2022, offering a unique opportunity to generate practice-based evidence to inform future technology implementation and research. Objective: This study aimed to investigate the implementation and adoption of advanced technology within a real-world rehabilitation setting. Methods: This study was a longitudinal observational study in a rehabilitation organization with inpatient, outpatient, and community settings. Allied health clinicians (n=119) within the organization had access to advanced technologies, with patients receiving neurological, spinal cord injury, brain injury, or general rehabilitation. Interventions included 21 advanced technologies, including robotic, virtual reality (VR), sensor-based, and functional electrical stimulation devices. Clinicians received training for devices in a staged approach by external and internal trainers. Data were collected from patient electronic medical records from July 1, 2022, to June 30, 2023. Outcomes included frequency of advanced technology use, patient demographics (age, gender, and primary health condition), clinician discipline, rehabilitation service (inpatient, outpatient, or community), goals of technology therapy sessions, and therapy dosage achieved (minutes active, number of repetitions, and meters walked). Results: Clinicians used advanced technology 4208 times with 269 patients over 12 months; specifically, physiotherapists (2716/4208, 65%), occupational therapists (1396/4208, 33%), and allied health assistants (96/4208, 2%). The majority of patients had stroke, spinal cord injury, or brain injury diagnoses (188/269, 70%). Devices were typically used to target impairment and activity limitation–related goals. Frequently used devices included gait training body-weight support (VR treadmill and overground), overground robotic exoskeletons, and upper limb robotic VR devices. Outpatient services were the dominant users of advanced technology (3940/4208, 94%). Clinicians most commonly used devices for patients with stroke (1973/4208, 47%) and the greatest variety of devices for patients with stroke and spinal cord injury. The relative use of lower limb robotic devices was greater in inpatient services (91/178, 51%, vs outpatient services, 963/2335, 41%) (χ21=6.6, P=.01) and for patients with spinal cord injury (48/95, 51%, vs all other conditions, between 24%-31%; χ25=16.8, P=.005). Conclusions: The type and amount of advanced technology use differed between patient populations and rehabilitation settings. To support clinician use of advanced technology, devices should match the rehabilitation context. Tailored strategies are important, such as clinician training. Further practice-based research is required to provide guidance on implementation and to establish the effectiveness of advanced technology use. %M 39753210 %R 10.2196/60374 %U https://www.jmir.org/2024/1/e60374 %U https://doi.org/10.2196/60374 %U http://www.ncbi.nlm.nih.gov/pubmed/39753210 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e58734 %T Virtual Reality–Applied Home-Visit Rehabilitation for Patients With Chronic Pain: Protocol for Single-Arm Pre-Post Comparison Study %A Funao,Hiroki %A Momosaki,Ryo %A Tsujikawa,Mayumi %A Kawamoto,Eiji %A Esumi,Ryo %A Shimaoka,Motomu %+ Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, 514-8507, Japan, 81 59 232 1211, h-funao@med.mie-u.ac.jp %K chronic pain %K homebound patient %K home-visit rehabilitation %K virtual reality %K protocol %K feasibility study %K VR %K pain %K recurrent pain %K home visit %K rehabilitation %K home rehabilitation %K in-home %K effective %K screening %K VR intervention %K feasibility %K alleviate pain %D 2024 %7 30.12.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Pain inhibits rehabilitation. In rehabilitation at medical institutions, the usefulness of virtual reality (VR) has been reported in many cases to alleviate pain. In recent years, the demand for home rehabilitation has increased. Unlike in medical situations, the patients targeted for in-home rehabilitation often have chronic pain due to physical and psychosocial factors, and the environment is not specialized for rehabilitation. However, VR might be effective for in-home rehabilitation settings. Objective: This study aims to evaluate the feasibility of applying VR to home-visit rehabilitation for homebound patients with chronic pain. Methods: This study will test the feasibility of VR applied to home-visit rehabilitation for patients with chronic pain. A single-arm pre-post comparison will be conducted to evaluate its feasibility. Screening will be conducted on patients who have given consent to participate in the study, and those who have pain that persists or recurs for more than 3 months and receive home-visit rehabilitation will be enrolled in the study. Baseline measurements will be conducted on study participants before the start of the VR intervention. VR-applied home-visit rehabilitation will be conducted once a week for a total of 10 VR interventions. The primary endpoint is the change in pain from the baseline to the tenth intervention. Pain is a subjective symptom of the study participants and will be subjectively assessed by the Numerical Rating Scale of 11 levels from 0 to 10. Pain as the primary endpoint will be measured at 3-time points per rehabilitation session: before, during, and after the rehabilitation so that changes between time points can be evaluated. Secondary endpoints are heart rate variability, range of motion of the area in the musculoskeletal system where the pain occurs, motivation for rehabilitation, catastrophic thoughts of pain, mood state, quality of life, and interviews. Assessments will be conducted at the baseline, first, fifth, and tenth interventions. After completing the clinical study (10 VR interventions), patients will continue their regular home-visit rehabilitation as usual. Results: Recruitment of participants began on February 22, 2022, and data collection is ongoing as of November 2024. The research results will be published in international peer-reviewed journals and through presentations at national and international conferences. Conclusions: This study will contribute to the development of novel rehabilitation-based solutions for homebound patients who have had difficulty obtaining adequate relief from chronic pain. Future studies will consider conducting randomized controlled trials as clinical trials to validate the efficacy of VR during home-visit rehabilitation for patients with chronic pain. International Registered Report Identifier (IRRID): DERR1-10.2196/58734 %M 39753216 %R 10.2196/58734 %U https://www.researchprotocols.org/2024/1/e58734 %U https://doi.org/10.2196/58734 %U http://www.ncbi.nlm.nih.gov/pubmed/39753216 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e57655 %T Enhancing Mixed Reality Simulation Training Technology With Real-Time Performance Visualization: Mixed Methods Study With Medical First Responders %A Zechner,Olivia %A Schrom-Feiertag,Helmut %A Wespi,Rafael %A Pretolesi,Daniele %A Nguyen,Quynh %A Tscheligi,Manfred %K mixed reality %K immersive technologies %K simulation training %K simulation %K paramedic %K medical first responders %K human performance %K stress %K stress monitoring %K human-centered design %D 2024 %7 24.12.2024 %9 %J JMIR XR Spatial Comput %G English %X Background: Mixed reality (MR) simulation training is emerging in paramedical education as a way to practice responding to stress-intensive scenarios like mass casualty incidents in a safe and controlled environment. Current training platforms, however, lack real-time stress and human performance monitoring tools. Objective: The study aims to enhance MR training for medical first responders through real-time evaluation of performance and stress levels, leveraging biosignal monitoring and advanced analytics to allow instructors to tailor feedback and maintain optimal challenge and safety levels. Methods: The study includes a structured, multiphase approach including initial requirement gathering (structured interviews and cocreation workshops), an online design survey, iterative prototype development, and a field trial (including training observations and interviews). Data were collected from 5 end user consortium members across Europe. Quantitative data from checklists were analyzed using frequencies and percentages to understand feature usage and event occurrences. Qualitative data from semistructured interviews and cocreation workshops were transcribed, coded, and subjected to thematic analysis to identify patterns and insights into the usability and effectiveness of the enhanced features in the MR training. Results: The study identified a number of requirements that medical first responders have for an MR training system, including requirements not included in currently available solutions. A total of 80 performance metrics were initially identified and refined to a set of 54 metrics, which were categorized into key performance indicator groups such as scene safety, triage performance, and communication. Requirements for smart wearables to monitor stress levels are provided and highlight the importance of a user-centered design process to provide users with effective tools that fit their needs. Stress visualization preferences are described in the form of a dashboard as well as in virtual environments surrounding the avatar. Using an iterative design process and user feedback, a training system was developed, integrating real-time performance tracking and stress monitoring. The field trial provided insights into the practical use of these features during a real training exercise, showed interaction preferences between trainer and trainees, and highlighted further improvement opportunities. Conclusions: This research enhances MR training for paramedics by integrating real-time performance metrics and stress indicators based on a human-centered design approach that aligns with end user needs, thereby laying the foundation for developing more effective and immersive training solutions for high-stress professions. %R 10.2196/57655 %U https://xr.jmir.org/2024/1/e57655 %U https://doi.org/10.2196/57655 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e64879 %T Extended Reality Gaming for Exercise and Mindfulness Throughout Pediatric Cancer Rehabilitation: Protocol for a Randomized Controlled Trial %A Lai,Byron %A Chaviano,Kelli %A Richman,Joshua S %A Ahmad,Mahmoud %A Wright,Ashley %A Young,Raven %A Davis,Drew %A Rimmer,James H %A Madan-Swain,Avi %A Chewning,Joseph H %+ Division of Pediatric Rehabilitation Medicine, Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Avenue South 5 Dearth, McWane 5601, Birmingham, AL, 35233, United States, 1 205 638 9790 ext 8, blai@uabmc.edu %K oncology %K rehabilitation %K bone marrow transplant %K virtual reality %K VR %K physical activity %K exercise %K extended reality %K XR %K pediatric cancer %D 2024 %7 23.12.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Pediatric patients with cancer have limited options to self-manage their health while they are undergoing treatments in the hospital and after they are discharged to their homes. Extended reality (ER) using head-mounted displays has emerged as an immersive method of improving pain and mental health and promoting health-enhancing physical activity among a variety of clinical groups, but there is currently no established protocol for improving both physical and mental health in pediatric cancer rehabilitation. Objective: This phase I, pilot, feasibility randomized controlled trial aims to investigate the potential effects of a 14-week ER program on physical activity participation and indicators of health among pediatric patients with cancer who undergo bone marrow transplantation. An ancillary aim is to evaluate the feasibility of the program through participant engagement. Methods: This study includes a 2-arm parallel group design with a 1-group crossover (the control group will start the intervention after a waiting period). Overall, 16 pediatric patients with cancer undergoing rehabilitation (aged ≥8 years) at a children’s hospital will be randomly allocated into one of two groups: (1) an immediate start group that undergoes an ER program in the hospital until discharge and then for 8 weeks at home (total duration of approximately 14 weeks), and (2) a waitlist control group that undergoes usual care in the hospital and for 8 weeks at home, before receiving the 8-week home ER program. The program will include active video gaming with rhythmic music exercises as well as mindfulness-based practices using a high-quality app. Home-based programming will include behavioral coaching calls. Physical activity will be measured daily through step counts using a tri-axial accelerometer. Health outcomes will be measured across time and include global health, measured by the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Global Health Scale Short Form 7+2, and lung function, measured by a forced expiratory volume using a peak flow meter. Feasibility will be evaluated through participant engagement metrics, such as enrollment, dropout, adverse events, and attendance rates. Descriptive statistics will be obtained for all study variables. Outcomes will be modeled using mixed modeling procedures, and changes in means will be estimated with CIs. Results: The study was funded in February 2024. Recruitment procedures started on June 27, 2024. All data are anticipated to be collected by February 2026. Full trial results are anticipated to be analyzed and submitted for publication by March 2026. The study’s anticipated end date is March 31, 2026. Conclusions: This trial tests an accessible remote program for improving both physical and mental health among pediatric patients with cancer. The knowledge obtained from this study will inform the development of a larger trial. Trial Registration: ClinicalTrials.gov NCT06298357; https://clinicaltrials.gov/study/NCT06298357 International Registered Report Identifier (IRRID): DERR1-10.2196/64879 %M 39714090 %R 10.2196/64879 %U https://www.researchprotocols.org/2024/1/e64879 %U https://doi.org/10.2196/64879 %U http://www.ncbi.nlm.nih.gov/pubmed/39714090 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e63760 %T Open-World Games’ Affordance of Cognitive Escapism, Relaxation, and Mental Well-Being Among Postgraduate Students: Mixed Methods Study %A Anto,Ailin %A Basu,Arunima %A Selim,Rania %A Foscht,Thomas %A Eisingerich,Andreas Benedikt %+ Faculty of Medicine, Imperial College London, Exhibition Rd, South Kensington, London, SW7 2AZ, United Kingdom, 44 020 7589 5111, ailin.anto18@imperial.ac.uk %K open-world games %K cognitive escapism %K relaxation %K mental well-being %K students %K video games %K stress %K freedom to explore %D 2024 %7 17.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Open-world games, characterized by their expansive and interactive environments, may offer unique cognitive escapism opportunities, potentially leading to relaxation and enhanced well-being. These games, such as “The Legend of Zelda: Breath of the Wild” and “The Legend of Zelda: Tears of the Kingdom,” allow players to experience a sense of freedom and autonomy, which can reduce stress and improve mental health. While previous research has examined the general impact of video games on mental well-being, specific studies on the effects of open-world games among postgraduate students are limited. Objective: This study aims to investigate the relationships between cognitive escapism provided by open-world games and their effects on relaxation and well-being. The goal was to understand how the immersive nature of these games contributes to stress reduction and overall mental health improvement among postgraduate students. Methods: A mixed methods approach was used, which involved in-depth exploratory qualitative interviews and a survey of 609 players of popular open-world games. Quantitative data were collected using standardized questionnaires to measure open-world games’ affordance of cognitive escapism, relaxation, and well-being. Qualitative data were obtained through 32 in-depth interviews that explored players’ experiences and perceptions of cognitive escapism, relaxation, and mental well-being. Results: Qualitative data (n=32; n=15, 47% female; n=16, 50% male; n=1, 3% preferred not to disclose gender; mean age 23.19, SD 2.19 y) revealed that cognitive escapism through immersive game worlds allowed players to temporarily disconnect from real-world stressors, resulting in enhanced mood and psychological well-being. Players indicated that the nonlinear gameplay and freedom to explore interactive environments provided a sense of relaxation and mental rejuvenation. Quantitative analysis (N=609) showed a substantial mediating role of relaxation in the relationship between cognitive escapism offered by open-world games and well-being. Specifically, cognitive escapism had a significant positive effect on players’ relaxation (β=.15; SE 0.04; P<.001; 95% CI 0.0695-0.2331), which in turn had a significant and positive effect on players’ well-being scores (β=.12; SE 0.04; P=.002; 95% CI 0.0445-0.2032). Conclusions: The study demonstrates that open-world games offer substantial benefits for cognitive escapism, significantly improving relaxation and well-being among postgraduate students. The immersive and autonomous nature of these games is crucial in reducing stress and enhancing mental health. Future research may investigate the long-term effects of regular engagement with open-world games and explore their potential therapeutic applications for managing stress and anxiety. %M 39689301 %R 10.2196/63760 %U https://www.jmir.org/2024/1/e63760 %U https://doi.org/10.2196/63760 %U http://www.ncbi.nlm.nih.gov/pubmed/39689301 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52340 %T Evaluation of a New Mobile Virtual Reality Setup to Alter Pain Perception: Pilot Development and Usability Study in Healthy Participants %A Knobel,Samuel E J %A Oberson,Raphael %A Räber,Jonas %A Schütz,Narayan %A Egloff,Niklaus %A Botros,Angela %A Gerber,Stephan M %A Nef,Tobias %A Heydrich,Lukas %K immersive virtual reality %K embodiment %K pain management %K chronic pain %K full-body illusion %K cardiovisual illusion %K pain %K virtual reality %K pilot study %K development %K mobile virtual reality %K mobile %K virtual environment %K usability %K heart rate %K mobile phone %D 2024 %7 11.12.2024 %9 %J JMIR Serious Games %G English %X Background: Chronic pain presents a significant treatment challenge, often leading to frustration for both patients and therapists due to the limitations of traditional methods. Research has shown that synchronous visuo-tactile stimulation, as used in the rubber hand experiment, can induce a sense of ownership over a fake body part and reduces pain perception when ownership of the fake body part is reported. The effect of the rubber hand experiment can be extended to the full body, for example, during the full-body illusion, using both visuo-tactile and cardiovisual signals. Objective: This study first aimed to evaluate the usability and accuracy of a novel, mobile virtual reality (VR) setup that displays participants’ heartbeats as a flashing silhouette on a virtual avatar, a technique known as the cardiovisual full-body illusion. The second part of the study investigated the effects of synchronous cardiovisual stimulation on pain perception and ownership in 20 healthy participants as compared with asynchronous stimulation (control condition). Methods: The setup comprised a head-mounted display (HMD) and a heart rate measurement device. A smartphone-based HMD (Samsung Galaxy S8+) was selected for its mobility, and heart rates were measured using smartwatches with photoplethysmography (PPG). The accuracy of 2 smartwatch positions was compared with a 5-point electrocardiogram (ECG) standard in terms of their accuracy (number and percent of missed beats). Each participant underwent two 5-minute sessions of synchronous cardiovisual stimulation and two 5-minute sessions of asynchronous cardiovisual stimulation (total of 4 sessions), followed by pain assessments. Usability, symptoms of cybersickness, and ownership of the virtual body were measured using established questionnaires (System Usability Scale, Simulator Sickness Questionnaire, Ownership Questionnaire). Pain perception was assessed using advanced algometric methods (Algopeg and Somedic algometer). Results: Results demonstrated high usability scores (mean 4.42, SD 0.56; out of 5), indicating ease of use and acceptance, with minimal side effects (mean 1.18, SD 0.46; out of a possible 4 points on the Simulator Sickness Questionnaire). The PPG device showed high heart rate measurement precision, which improved with optimized filtering and peak detection algorithms. However, compared with previous work, no significant effects on body ownership and pain perception were observed between the synchronous and asynchronous conditions. These findings are discussed in the context of existing literature on VR interventions for chronic pain. Conclusions: In conclusion, while the new VR setup showed high usability and minimal side effects, it did not significantly affect ownership or pain perception. This highlights the need for further research to refine VR-based interventions for chronic pain management, considering factors like visual realism and perspective. %R 10.2196/52340 %U https://games.jmir.org/2024/1/e52340 %U https://doi.org/10.2196/52340 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e54389 %T Pulmonary and Physical Virtual Reality Exercises for Patients With Blunt Chest Trauma: Randomized Clinical Trial %A Groenveld,Tjitske D %A Smits,Indy GM %A Scholten,Naomi %A de Vries,Marjan %A van Goor,Harry %A Stirler,Vincent MA %+ Department of Surgery, Radboud University Medical Center, Geert Grooteplein 10, Nijmegen, 6525 GA, Netherlands, 31 243667331, tjitske.groenveld@radboudumc.nl %K virtual reality %K pain %K pulmonary %K chest trauma %K blunt thorax trauma %K pain relief %K breathing %K mobilization %K randomized clinical trial %K clinicians %K rehabilitation %K physical activity %K exercise %K interview %D 2024 %7 9.12.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Adequate pain relief, early restoration of breathing, and rapid mobilization pose a clinical challenge in patients with blunt chest trauma. Virtual reality (VR) has the potential to achieve these 3 interrelated treatment objectives with enhanced self-efficacy and autonomy of patients and limited support by clinicians. Objective: This study aimed to assess the effectivity of breathing and physical exercises using VR on the pulmonary recovery of patients with blunt chest trauma at the ward. Methods: A pilot randomized controlled trial was performed. The control group received usual physiotherapy consisting of protocolized breathing exercises (8 times daily for 10 minutes) and physical exercises (2 times daily for 10 minutes). The VR group was instructed to perform these exercises using VR. The primary outcome was vital lung capacity at day 5 or earlier at discharge. Secondary outcomes were patient mobility (time standing, lying, and sitting), clinical outcomes (length of hospital stay, pulmonary complications, transfer to intensive care unit, and readmission within 30 days), pain, activities of daily living, patient-reported outcome measures (satisfaction and quality of recovery). Patient experiences and barriers and facilitators toward implementation were assessed through interviews. Results: The study was prematurely ended due to enrollment failure combined with poor protocol adherence to exercises in both groups. A total of 27 patients were included, of which 19 patients completed 3 or more days. Vital lung capacity at 5 days (or last measurement) was equal between groups with 1830 (SD 591) mL and 1857 (SD 435) mL in the control and VR groups, respectively. No marked differences were observed in secondary outcomes. Patient interviews showed positive attitudes toward the use of VR, describing that visualization of the exercises helped patients to perform the exercises correctly and to continue the exercises for a longer duration. Also, patients experienced the immersiveness of VR as an analgesic. However, patients did not experience added value over usual care and reported that better integration in treatment and the hectic hospital environment could improve the use of the VR exercises. Conclusions: The suitability of patients to use virtual reality therapy (VRx) in a hospital (trauma) ward setting is lower than generally expected. Effective application of VRx requires professional guidance and needs thorough alignment with clinical practice. For future research, we recommend to chart adherence to study protocol before designing a VR clinical trial. Patient-reported experiences need to be prioritized in evaluating VR acceptance, usability, and effectiveness. In line, we recommend performing a systematic analysis (eg, using the technology acceptance model) on the acceptance before pilot or main effectiveness studies. Finally, the eligibility of patients and exclusion of patients due to the inability to use VRx should be routinely reported. Trial Registration: ClinicalTrials.gov NCT05194176; https://tinyurl.com/2bzh4tzx %M 39652866 %R 10.2196/54389 %U https://games.jmir.org/2024/1/e54389 %U https://doi.org/10.2196/54389 %U http://www.ncbi.nlm.nih.gov/pubmed/39652866 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e45640 %T Examining the Use of Virtual Reality to Support Mindfulness Skills Practice in Mood and Anxiety Disorders: Mixed Methods Study %A Blackmore,Rebecca %A Giles,Claudia %A Tremain,Hailey %A Kelly,Ryan %A Foley,Fiona %A Fletcher,Kathryn %A Nedeljkovic,Maja %A Wadley,Greg %A Seabrook,Elizabeth %A Thomas,Neil %+ Centre for Mental Health and Brain Sciences, Swinburne University of Technology, John Street, Hawthorn, VIC, 3122, Australia, 61 392148444, neilthomas@swin.edu.au %K virtual reality %K mindfulness %K mood disorders %K anxiety disorders %K depression %K bipolar disorder %D 2024 %7 6.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) has been proposed as a technology to support mindfulness practice through promoting increased engagement and presence. The proposed benefits of this technology have been largely unexamined with clinical populations. Further research is required to understand its clinical potential and utility in improving and managing mental health symptoms. Objective: This study aims to investigate the proximal impacts of a single, brief, VR-supported mindfulness practice for individuals with a mood or anxiety disorder and to understand user experiences, which may affect the acceptability and efficacy of VR mindfulness for this population. Methods: This mixed methods study recruited 28 participants with a primary diagnosis of major depressive disorder, bipolar disorder, or anxiety disorder. Participants completed a mindfulness practice wearing a VR headset that was presenting an omnidirectional video of a forest scene, which was overlaid with a guided audio voiceover. Before and after the practice, measures were completed assessing state mindfulness (Toronto Mindfulness Scale), affect (Positive and Negative Affect Schedule), and anxiety (State-Trait Anxiety Inventory Y-1; n=27). Semistructured interviews were then held inquiring about the user experience and were analyzed using thematic analysis (n=24). Results: After completing the VR-supported mindfulness practice, both measures of state mindfulness on the Toronto Mindfulness Scale, mean curiosity and decentering, increased significantly (Cohen d=1.3 and 1.51, respectively; P<.001). Negative affect on the Positive and Negative Affect Schedule (Cohen d=0.62; P=.003) and State-Trait Anxiety Inventory Y-1 state anxiety (Cohen d=0.84; P<.001) significantly reduced. There was no significant change in positive affect (Cohen d=0.29; P=.08). Qualitative analysis of interviews identified 14 themes across 5 primary theme categories. The results suggested that being mindful during the use of the app was experienced as relatively effortless because of the visual and immersive elements. It was also experienced as convenient and safe, including when compared with prior traditional experiences of mindfulness. Participants also identified the uses for VR-supported mindfulness in managing emotions and symptoms of mental illness. Conclusions: The results provide preliminary evidence that VR-supported mindfulness can improve emotional states and manage mental health symptoms for those with mood or anxiety disorders. It offers some potential clinical applications for those with mood or anxiety disorders for exploration within future research. %M 39641990 %R 10.2196/45640 %U https://www.jmir.org/2024/1/e45640 %U https://doi.org/10.2196/45640 %U http://www.ncbi.nlm.nih.gov/pubmed/39641990 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e57327 %T Nurses’ Knowledge and Skills After Use of an Augmented Reality App for Advanced Cardiac Life Support Training: Randomized Controlled Trial %A Sun,Wan-Na %A Hsieh,Min-Chai %A Wang,Wei-Fang %+ Department of Nursing, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, Tainan, 704, Taiwan, 886 62353535 ext 4676, 820hosp@gmail.com %K augmented reality %K technology intervention %K randomized controlled trial %K advanced cardiac life support %K nursing education %D 2024 %7 5.12.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Advanced cardiac life support (ACLS) skills are essential for nurses. During the COVID-19 pandemic, augmented reality (AR) technologies were incorporated into medical education to increase learning motivation and accessibility. Objective: This study aims to determine whether AR for educational applications can significantly improve crash cart learning, learning motivation, cognitive load, and system usability. It focused on a subgroup of nurses with less than 2 years of experience. Methods: This randomized controlled trial study was conducted in a medical center in southern Taiwan. An ACLS cart training course was developed using AR technologies in the first stage. Additionally, the efficacy of the developed ACLS training course was evaluated. The AR group used a crash cart learning system developed with AR technology, while the control group received traditional lecture-based instruction. Both groups were evaluated immediately after the course. Performance was assessed through learning outcomes related to overall ACLS and crash cart use. The Instructional Materials Motivation Survey, System Usability Scale, and Cognitive Load Theory Questionnaire were also used to assess secondary outcomes in the AR group. Subgroup analyses were performed for nurses with less than 2 years of experience. Results: All 102 nurses completed the course, with 43 nurses in the AR group and 59 nurses in the control group. The AR group outperformed the control group regarding overall ACLS outcomes and crash cart learning outcomes (P=.002; P=.01). The improvement rate was the largest for new staff regardless of the overall learning effect and the crash cart effect. Subgroup analysis revealed that nurses with less than 2 years of experience in the AR group showed more significant improvements in both overall learning (P<.001) and crash cart outcomes (P<.001) compared to their counterparts in the control group. For nurses with more than 2 years of experience, no significant differences were found between the AR and control groups in posttraining learning outcomes for the crash cart (P=.32). The AR group demonstrated high scores for motivation (Instructional Materials Motivation Survey mean score 141.65, SD 19.25) and system usability (System Usability Scale mean score 90.47, SD 11.91), as well as a low score for cognitive load (Cognitive Load Theory Questionnaire mean score 15.42, SD 5.76). Conclusions: AR-based learning significantly improves ACLS knowledge and skills, especially for nurses with less experience, compared to traditional methods. The high usability and motivational benefits of AR suggest its potential for broader applications in nursing education. Trial Registration: ClinicalTrials.gov NCT06057285; https://clinicaltrials.gov/ct2/show/NCT06057285 %M 39636667 %R 10.2196/57327 %U https://www.jmir.org/2024/1/e57327 %U https://doi.org/10.2196/57327 %U http://www.ncbi.nlm.nih.gov/pubmed/39636667 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e66430 %T Psychedelic Art and Implications for Mental Health: Randomized Pilot Study %A Peng,Mary L %A Monin,Joan %A Ovchinnikova,Polina %A Levi,Amanda %A McCall,Terika %+ Department of Orthopedics and Sports Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, United States, 1 (617) 355 6021, marypeng@hms.harvard.edu %K digital art %K mental health %K psychedelic art %K well-being %K pilot trial %K digital health tool %K art therapy %D 2024 %7 3.12.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Psychedelic art (PA) emerged in the 1960s during the psychedelic era; then characterized by visuals induced by the ingestion of psychedelic drugs, it is now an art form known for its vibrant colors, distorted forms, and intricate patterns. Building upon the existing research on art viewing as an effective means to improving physiological and psychological well-being, viewing PA is postulated to evoke positive emotions and provide a meditative experience, contributing to improved mental well-being. Objective: This study aims to investigate how digitally rendered PA influences viewers’ perceived emotional, mental, and physical states compared to imagery of natural scenery, offering insights into potential applications in mental health care and well-being. Methods: Overall, 102 participants age 18 to 35 years were randomly assigned to either the experimental group viewing 300 seconds of PA imagery (50/102, 49%) or the control group viewing 300 seconds of scenic imagery (52/102, 51%), after which every participant completed a survey that gathered qualitative data on the perceived impact of viewing their given imagery on their physical, mental, and emotional states through open-ended questions. Thematic analysis was conducted to identify the patterns of experiences reported by the participants. Results: Qualitative analysis unveiled a greater intensity and diversity of emotional, mental, and physical impacts induced by PA compared to natural scenery, including the sense of relaxation and peace, anxiety and stress alleviation, joy, thrill and sense of euphoria, sensations of awe and wonder, hypnotizing effect, holistic meditative effect, provocation of creative thoughts, induced hyperawareness of bodily states, and transitions from induced overstimulation or anxious thoughts to feelings of calmness. Conclusions: The preliminary findings of this study suggest that PA is a rich and complex form of visual art that has the potential to facilitate healing and promote well-being and mental health. PA presents promising avenues for integration into mental health care, therapeutic practices, digital health, health care environment, and medical research. %M 39626224 %R 10.2196/66430 %U https://formative.jmir.org/2024/1/e66430 %U https://doi.org/10.2196/66430 %U http://www.ncbi.nlm.nih.gov/pubmed/39626224 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e59136 %T The Effectiveness of Therapeutic Exercise Interventions With Virtual Reality on Balance and Walking Among Persons With Chronic Stroke: Systematic Review, Meta-Analysis, and Meta-Regression of Randomized Controlled Trials %A Krohn,Maria %A Rintala,Aki %A Immonen,Jaakko %A Sjögren,Tuulikki %+ Faculty of Sport and Health Sciences, University of Jyväskylä, PL 35, Keskussairaalantie 4, Jyväskylä, FI-40014, Finland, 358 405493755, maria_krohn@icloud.com %K stroke %K chronic %K virtual reality %K physiotherapy %K therapeutic exercise %K balance %K walking %D 2024 %7 2.12.2024 %9 Review %J J Med Internet Res %G English %X Background: Well-targeted balance, walking, and weight-shift training can improve balance capabilities in the chronic phase of stroke. There is an urgent need for a long-term approach to rehabilitation that extends beyond the acute and subacute phases, supporting participation without increasing the demand for health care staff. Objective: This study aims to evaluate the effectiveness of therapeutic exercise interventions with virtual reality (VR) training on balance and walking at the activity and participation levels in individuals with chronic stroke, compared with control groups receiving no treatment, conventional physical therapy, specific training, similar treatment, or identical treatment without VR. Methods: Studies were searched across 6 databases. The inclusion criteria were as follows: Adults aged 18 years or older with a stroke diagnosis for at least 6 months (population). Therapeutic exercises within a VR environment, using VR glasses or interactive games (intervention). Control groups without the use of VR (including no treatment, conventional physical therapy, specific training, similar treatment without VR, or identical treatment without the additional use of VR; comparison). We evaluated the Berg Balance Scale score, Functional Reach Test performance, Activities-specific Balance Confidence Scale score, Six-minute Walk Test, Two-minute Walk Test, 10-meter Walk Test results, and cadence (outcome measures). We investigated randomized controlled trials (study design). A meta-analysis and a meta-regression analysis were conducted to evaluate whether the content of VR interventions or control groups, as well as the level of VR immersion used, was related to balance or walking outcomes. Results: A total of 43 randomized controlled trials involving 1136 participants were included in this review. The use of VR training in therapeutic exercise interventions had a large effect on balance (standardized mean difference 0.51, 95% CI 0.29-0.72; P<.001) and a moderate effect on walking (standardized mean difference 0.31, 95% CI 0.09-0.53; P=.006) in individuals with chronic stroke, compared with pooled control groups (no treatment, conventional physical therapy, specific training, similar treatment, or identical treatment without the use of VR). According to the meta-regression findings, the content of VR interventions (P=.52), the type of control groups (P=.79), and the level of VR immersion (P=.82) were not significantly related to the pooled balance or walking outcomes. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) was moderate for balance and low for walking. Conclusions: Therapeutic exercise training with VR had a positive, albeit moderate, effect on balance and a low impact on walking at the level of activity (capacity), even in the chronic phase of stroke, without serious side effects. The results are applicable to working-aged stroke rehabilitees who are able to walk without assistance. Further research is needed with defined VR methods and outcomes that assess performance at the level of real-life participation. %M 39621381 %R 10.2196/59136 %U https://www.jmir.org/2024/1/e59136 %U https://doi.org/10.2196/59136 %U http://www.ncbi.nlm.nih.gov/pubmed/39621381 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e60383 %T Virtual Reality in Clinical Teaching and Diagnostics for Liver Surgery: Prospective Cohort Study %A Preibisch,Joshua %A Tabriz,Navid %A Kaluschke,Maximilian %A Weyhe,Dirk %A Uslar,Verena %K VR %K virtual reality %K multiple-choice test %K anatomy %K patient-specific 3D visualization %K MRI-based segmentation %K liver %K cohort study %K visualization %K tool %K medical diagnostic %K questionnaire %K usability %K diagnostics %K surgery %K 3D %K MRI %K magnetic resonance imaging %D 2024 %7 27.11.2024 %9 %J JMIR XR Spatial Comput %G English %X Background: Learning and applying anatomy are essential but are studied and done through 2D tools and imaging techniques. This study aims to verify the usefulness of an additional 3D technique and ensure an improvement in the visualization of anatomical structures and pathological findings. Objective: The study aims to examine the usefulness of virtual reality (VR) technology as an additional tool in medical diagnostics. Groups of students, residents, and specialists in surgery, radiology, and internal medicine evaluated magnetic resonance imaging (MRI) by answering a multiple-choice questionnaire. Subsequently, a virtual 3D display was used for processing. The questionnaire focused on topographical conditions and the transfer of academic knowledge into clinical application. The main objective was to determine anatomical understanding in a comparison between sectional image (2D) presentation and additional VR (3D) presentation, measured through correctly answered questions and processing time. The system usability scale (SUS) was integrated as another criterion for VR usability. Methods: The cross-over study assessed 63 participants regarding their knowledge of liver anatomy and pathologies based on an interindividual comparison. Group formation according to the respective level of medical training was as follows: students (n=35), residents (n=15), and specialists (n=13). Participants answered 25 multiple-choice questions first using sectional imaging (MRI) in a 2D environment (computer screen) and afterward with the respective segmented 3D model visualized in a VR simulation. The main criteria for the analyses were the number of correctly answered questions and processing time. A customized SUS was used to analyze VR usability. Missing data analysis showed that there were no accounted missing data. Results: The rate of correct answers improved significantly with the additional use of VR (F1,59=314.376; P<.001). Using MRI, a significant difference was observed between students and residents (P=.04) and between students and specialists (P<.001). In the VR condition, no significant differences between groups were found. In the MRI condition, significant differences in processing time were observed between students and specialists (P=.02) and between residents and specialists (P=.04). No differences existed between students and residents. With VR, processing time decreased significantly in all groups (F1,59=280.700; P<.001). Significant differences between students and specialists (P=.02) and between students and residents (P=.004) remained. No notable differences between residents and specialists (P=.72) were found. The SUS showed a subjectively simplified answerability of the questions with additional use of VR. The usefulness and benefits for an additional use of VR were stated. Conclusions: The additional use of VR suggests statistically significant improvements across all groups. VR seems to enable students and residents to participate in diagnostics and create treatment plans at an early stage. Transferred to clinical practice, this may lead to improvement in diagnostics and interventions. The lack of randomization and a potential learning effect are the main limitations to be addressed in future studies. Trial Registration: German Register of Clinical Studies DRKS00030024; https://drks.de/search/de/trial/DRKS00030024 %R 10.2196/60383 %U https://xr.jmir.org/2024/1/e60383 %U https://doi.org/10.2196/60383 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e58499 %T Avatar Intervention in Virtual Reality for Cannabis Use Disorder in Individuals With Severe Mental Disorders: Results From a 1-Year, Single-Arm Clinical Trial %A Giguere,Sabrina %A Beaudoin,Mélissa %A Dellazizzo,Laura %A Phraxayavong,Kingsada %A Potvin,Stéphane %A Dumais,Alexandre %K cannabis use disorder %K cannabis use %K virtual reality therapy %K virtual reality %K addiction intervention %K relational therapy %K avatar %K digital mental health %D 2024 %7 27.11.2024 %9 %J JMIR Ment Health %G English %X Background: The dual diagnosis of cannabis use disorder (CUD) and severe mental disorder (SMD) results in clinically complex individuals. Cannabis use is known to have negative consequences on psychiatric symptoms, medication compliance, and disease prognosis. Moreover, the effectiveness of currently available psychotherapeutic treatments is limited in this population. In this context, our research team developed avatar intervention, an approach using virtual reality as a therapeutic tool to treat CUD in individuals with SMD. Objective: This pilot clinical trial aimed to evaluate, until the 1-year follow-up, the efficacy of avatar intervention for CUD among 32 participants with a dual diagnosis of SMD and CUD. Methods: Over the course of the 8 intervention sessions, participants were given the opportunity to enter a dialogue in virtual reality with an avatar representing a person with a significant role in their consumption, who was animated in real time by a therapist. The primary outcomes were the quantity of cannabis consumed and the frequency of use. Secondary outcomes included severity of problematic cannabis use, motivation for change, protective strategies for cannabis use, consequences of cannabis use, psychiatric symptoms, and quality of life. Changes in reported outcomes during the assessment periods before the intervention; postintervention; and 3, 6, and 12 months after the end of the intervention were assessed using a linear mixed-effects model. Results: Significant reductions were observed in the quantity of cannabis consumed, and these were maintained until the 12-month follow-up visit (d=0.804; P<.001; confirmed by urine quantification). Frequency of cannabis use showed a small significant reduction at the 3-month follow-up (d=0.384; P=.03). Moreover, improvements were observed in the severity of CUD, cannabis-related negative consequences, the motivation to change cannabis use, and the strategies used to mitigate harms related to cannabis use. Finally, moderate benefits were observed for quality of life and psychiatric symptoms. Conclusions: Overall, this unique intervention shows promising results that seem to be maintained up to 12 months after the end of the intervention. With the aim of overcoming the methodological limitations of a pilot study, a single-blind randomized controlled trial is currently underway to compare the avatar intervention for CUD with a conventional addiction intervention. Trial Registration: ClinicalTrials.gov NCT05726617; https://clinicaltrials.gov/study/NCT05726617 %R 10.2196/58499 %U https://mental.jmir.org/2024/1/e58499 %U https://doi.org/10.2196/58499 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52294 %T Using Digital Art and Attachment Priming in a Web-Based Serious Game to Reduce Pain and Social Disconnection in Individuals With Chronic Pain and Loneliness: Randomized Controlled Trial %A Peña,Jorge %A Koebner,Ian %A Weisman,William %K pain %K social disconnection %K loneliness %K randomized controlled trial %K art %K museums %K virtual reality %K serious games %K virtual art %K chronic pain and loneliness %K attachment %K priming %K mediation %K intervention %K cyberpsychology %K mental health %D 2024 %7 27.11.2024 %9 %J JMIR Serious Games %G English %X Background: Arts engagement using virtual reality and serious games represent promising nonpharmacological self-management treatment approaches to chronic pain. This study is the first randomized controlled trial to explore the impact of a web-based serious game that simulated a visit to an art museum on pain and social disconnection among individuals living with chronic pain and loneliness. Objective: This study aimed to test the joint and separate effects of exposure to digital art and attachment figure priming on pain and social disconnection among individuals living with chronic pain and loneliness. Methods: This randomized controlled trial used a 2 (digital artwork present and absent) × 2 (secure attachment and avoidant attachment prime) repeated measures factorial web-based experimental design with a hanging control condition. Mediation and moderation analyses examined how feelings about the social world triggered by the artwork and frequency of museum visits impacted the effects of the interventions on pain and social disconnection. Results: The results are based on 308 participants. Mean age of the participants was 42.78 (SD 13.11; range 18-76) years, and 60.2% (n=186) were women. Posttest pain was lower than pretest pain for the artwork present (P=.001) and absent (P=.001) conditions. Similarly, posttest pain was lower than pretest pain for the secure (P=.001) and avoidant (P=.001) attachment priming conditions. Relative to the control group, artwork present (P=.001) and absent (P=.01) conditions had decreased posttest pain. The secure (P=.001) and avoidant (P=.001) attachment priming conditions also had lower posttest pain scores relative to the control group. Moreover, social disconnection decreased from pre- to posttest for both the artwork present (P=.04) and the secure attachment priming (P=.002) conditions. Relative to the control group, posttest social disconnection was lower for the artwork present (P=.02) and secure attachment priming condition (P=.03). The artwork-secure attachment (P=.001) and artwork-avoidant attachment (P=.006) conditions had lower posttest pain scores compared with the control group. Social disconnection decreased from pre- to posttest for the artwork-secure attachment (P=.01) and no artwork-secure attachment (P=.05) conditions. Posttest social disconnection was lower for the artwork-secure attachment condition compared with the control group (P=.04). Positive feelings about the social world triggered by artwork exposure and frequency of museum visits in the last year played a mediating and moderating role in these effects. Positive feelings about the social world were associated with decreased pain (B=−.53) and social disconnection (B=−.25), and these effects operated on individuals exposed to digital artwork at low, medium, and high frequency of physical museum visits. Conclusions: Relative to a control group, visiting a web-based art museum reliably decreased pain and social disconnection among individuals living with chronic pain and loneliness. Engaging with digital artwork that triggers positive feelings about the social world may mitigate the burden of chronic pain. Trial Registration: ClinicalTrials.gov NCT05310747; https://clinicaltrials.gov/study/NCT05310747 %R 10.2196/52294 %U https://games.jmir.org/2024/1/e52294 %U https://doi.org/10.2196/52294 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e63329 %T Improvement of Motor Imagination and Manual Ability Through Virtual Reality and Selective and Nonselective Functional Electrical Stimulation: Protocol for a Randomized Controlled Trial %A Santamaría-Vázquez,Montserrat %A Ortiz-Huerta,J Hilario %A Martín-Odriozola,Aitor %A Saiz-Vazquez,Olalla %+ Health Sciences Department, Universidad de Burgos, Pº Comendadores, s/n (Hospital Militar), Burgos, 09001, Spain, 34 687192739, jhortiz@ubu.es %K electric stimulation therapy %K motor imagery %K virtual reality exposure therapy %K hand strength %K hand injuries %D 2024 %7 22.11.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Motor imagery (MI) is a cognitive process that has been shown to be useful in the rehabilitation process after brain injury. Moreover, functional electrical stimulation (FES) and virtual reality (VR) have also been shown to be effective interventions in many parameters, and there is some evidence of their contribution to the improvement of MI capacity. Objective: This study aimed to compare the improvements in MI parameters, grip strength, and manual dexterity obtained using VR, FES, and selective FES based on multifield electrodes in healthy people. Methods: This clinical randomized controlled trial (RCT)with 4 branches will involve 80 healthy university students, with blinded third-party assessment. Participants will be divided into 4 groups: control (no intervention), selective FES (Fesia Grasp), traditional FES (Globus Elite), and Virtual Rehab Hands (Leap Motion sensor). Each group will receive 5 daily sessions, and assessments will be conducted at baseline, postintervention, and follow-up. The Movement Imagery Questionnaire-Revised (MIQ-RS) and chronometry will be used to assess MI, strength will be measured with a digital dynamometer, and manual dexterity will be evaluated with the Nine Hole Peg Test (NHPT) and the Box and Block Test (BBT). Statistical analyses will include 2-way repeated-measures ANOVA with post hoc Bonferroni correction to compare group differences over time, with nonparametric tests (eg, Kruskal-Wallis) being used if normality or variance assumptions are violated. The study will be organized into 3 phases: preparation, data collection, and analysis. The preparation phase will involve finalizing project protocols and obtaining ethical approvals. The data collection phase will consist of recruiting participants, randomizing them into 4 intervention groups, and conducting baseline assessments, followed by intervention sessions. Finally, the analysis phase will focus on evaluating the data collected from all groups and compiling the results for presentation. Results: The study received approval in July 2023, with recruitment and data collection starting in September 2023. The recruitment phase was expected to conclude by July 2024, and the entire study, including the 2-week follow-up, was set to finish in September 2024. As of July 2024, we had enrolled 100% of the sample (N=80 students). We plan to publish the study findings by the end of 2024. Conclusions: Improvements in MI and upper limb functionality are expected, particularly in the selective FES group. This RCT will identify which intervention is most effective in enhancing these skills, with potential benefits for patients with neurological motor disorders. Trial Registration: ClinicalTrials.gov NCT06109025; https://clinicaltrials.gov/study/NCT06109025 International Registered Report Identifier (IRRID): DERR1-10.2196/63329 %M 39576986 %R 10.2196/63329 %U https://www.researchprotocols.org/2024/1/e63329 %U https://doi.org/10.2196/63329 %U http://www.ncbi.nlm.nih.gov/pubmed/39576986 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e57225 %T Enhancing Executive Function Skills in Children With Attention-Deficit/Hyperactivity Disorder via Immersive Virtual Reality Interventions: Scoping Review %A Konaç,Asli %A Bini,Maristella %A Fusco,Naomi %A Bourdin-Kreitz,Pierre %K immersive virtual reality %K ADHD %K neurofeedback %K executive functions %K systematic review %K adolescent %K attention-deficit/hyperactivity disorder %K behavioral therapy %K digital health tools %K neurodiversity %K virtual reality %K digital mental health %D 2024 %7 22.11.2024 %9 %J JMIR XR Spatial Comput %G English %X Background: This scoping review investigated immersive virtual reality (IVR) interventions for improving executive function skills of children and adolescents with attention-deficit/hyperactivity disorder (ADHD). Objective: This study aimed to identify and closely inspect the characteristics of these interventions and provide a summary of key findings to guide researchers in their future investigations. Methods: A search across Web of Science, Scopus, PubMed, and APA PsycInfo databases was carried out with restrictions of publication date (2000‐2023) and language (English). The inclusion criteria were (1) research articles, excluding protocols, book chapters, reviews, and meta-analyses; (2) usage of IVR, excluding computer-based VR or augmented reality technologies; (3) aim of targeting executive function skills; (4) sample of children and adolescents diagnosed with ADHD (with or without learning disorder comorbidity); and (5) intervention studies (quasi-experimental clinical trials and randomized controlled trials, excluding assessments). Finally, the characteristics of the studies were summarized and inspected. Results: The search yielded 2484 potential records. After a rigorous screening process, 6 articles (5 randomized controlled trials and 1 pilot study) were included. A certain heterogeneity in duration, designs of IVR interventions, and outcome measures were observed. All studies reported overall improvements in the attentional performances of children; however, only a few reported improvements in executive functions. In addition, a tendency toward integration of neurofeedback systems with IVR technologies was observed. Conclusions: Because of the specific objectives and related inclusion and exclusion criteria of this review, only a few interventions could be included and analyzed. Even though there seem to be promising applications of IVR for children and adolescents with ADHD, heterogeneity in intervention characteristics accompanied by observed overall high or serious risk of bias prevented the authors from making generalized conclusions. %R 10.2196/57225 %U https://xr.jmir.org/2024/1/e57225 %U https://doi.org/10.2196/57225 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e56844 %T Virtual Reality Simulation in Undergraduate Health Care Education Programs: Usability Study %A Mørk,Gry %A Bonsaksen,Tore %A Larsen,Ole Sønnik %A Kunnikoff,Hans Martin %A Lie,Silje Stangeland %+ Department of Health, Faculty of Health Sciences, VID Specialized University, Misjonsmarka 12, Stavanger, 4024, Norway, 47 47234324, gry.mork@vid.no %K 360° videos %K health professions education %K virtual reality %K usability study %K undergraduates %K university %K students %K simulation %D 2024 %7 19.11.2024 %9 Original Paper %J JMIR Med Educ %G English %X Background: Virtual reality (VR) is increasingly being used in higher education for clinical skills training and role-playing among health care students. Using 360° videos in VR headsets, followed by peer debrief and group discussions, may strengthen students’ social and emotional learning. Objective: This study aimed to explore student-perceived usability of VR simulation in three health care education programs in Norway. Methods: Students from one university participated in a VR simulation program. Of these, students in social education (n=74), nursing (n=45), and occupational therapy (n=27) completed a questionnaire asking about their perceptions of the usability of the VR simulation and the related learning activities. Differences between groups of students were examined with Pearson chi-square tests and with 1-way ANOVA. Qualitative content analysis was used to analyze data from open-ended questions. Results: The nursing students were most satisfied with the usability of the VR simulation, while the occupational therapy students were least satisfied. The nursing students had more often prior experience from using VR technology (60%), while occupational therapy students less often had prior experience (37%). Nevertheless, high mean scores indicated that the students experienced the VR simulation and the related learning activities as very useful. The results also showed that by using realistic scenarios in VR simulation, health care students can be prepared for complex clinical situations in a safe environment. Also, group debriefing sessions are a vital part of the learning process that enhance active involvement with peers. Conclusions: VR simulation has promise and potential as a pedagogical tool in health care education, especially for training soft skills relevant for clinical practice, such as communication, decision-making, time management, and critical thinking. %M 39560982 %R 10.2196/56844 %U https://mededu.jmir.org/2024/1/e56844 %U https://doi.org/10.2196/56844 %U http://www.ncbi.nlm.nih.gov/pubmed/39560982 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 11 %N %P e55776 %T Navigation Training for Persons With Visual Disability Through Multisensory Assistive Technology: Mixed Methods Experimental Study %A Ricci,Fabiana Sofia %A Liguori,Lorenzo %A Palermo,Eduardo %A Rizzo,John-Ross %A Porfiri,Maurizio %+ Center for Urban Science and Progress, New York University Tandon School of Engineering, Brooklyn, New York, NY, United States, 1 646 997 3681, mporfiri@nyu.edu %K assistive technology %K human-computer interaction %K multisensory feedback %K virtual reality %K visual impairment %K haptic %D 2024 %7 18.11.2024 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Visual disability is a growing problem for many middle-aged and older adults. Conventional mobility aids, such as white canes and guide dogs, have notable limitations that have led to increasing interest in electronic travel aids (ETAs). Despite remarkable progress, current ETAs lack empirical evidence and realistic testing environments and often focus on the substitution or augmentation of a single sense. Objective: This study aims to (1) establish a novel virtual reality (VR) environment to test the efficacy of ETAs in complex urban environments for a simulated visual impairment (VI) and (2) evaluate the impact of haptic and audio feedback, individually and combined, on navigation performance, movement behavior, and perception. Through this study, we aim to address gaps to advance the pragmatic development of assistive technologies (ATs) for persons with VI. Methods: The VR platform was designed to resemble a subway station environment with the most common challenges faced by persons with VI during navigation. This environment was used to test our multisensory, AT-integrated VR platform among 72 healthy participants performing an obstacle avoidance task while experiencing symptoms of VI. Each participant performed the task 4 times: once with haptic feedback, once with audio feedback, once with both feedback types, and once without any feedback. Data analysis encompassed metrics such as completion time, head and body orientation, and trajectory length and smoothness. To evaluate the effectiveness and interaction of the 2 feedback modalities, we conducted a 2-way repeated measures ANOVA on continuous metrics and a Scheirer-Ray-Hare test on discrete ones. We also conducted a descriptive statistical analysis of participants’ answers to a questionnaire, assessing their experience and preference for feedback modalities. Results: Results from our study showed that haptic feedback significantly reduced collisions (P=.05) and the variability of the pitch angle of the head (P=.02). Audio feedback improved trajectory smoothness (P=.006) and mitigated the increase in the trajectory length from haptic feedback alone (P=.04). Participants reported a high level of engagement during the experiment (52/72, 72%) and found it interesting (42/72, 58%). However, when it came to feedback preferences, less than half of the participants (29/72, 40%) favored combined feedback modalities. This indicates that a majority preferred dedicated single modalities over combined ones. Conclusions: AT is crucial for individuals with VI; however, it often lacks user-centered design principles. Research should prioritize consumer-oriented methodologies, testing devices in a staged manner with progression toward more realistic, ecologically valid settings to ensure safety. Our multisensory, AT-integrated VR system takes a holistic approach, offering a first step toward enhancing users’ spatial awareness, promoting safer mobility, and holds potential for applications in medical treatment, training, and rehabilitation. Technological advancements can further refine such devices, significantly improving independence and quality of life for those with VI. %M 39556804 %R 10.2196/55776 %U https://rehab.jmir.org/2024/1/e55776 %U https://doi.org/10.2196/55776 %U http://www.ncbi.nlm.nih.gov/pubmed/39556804 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e64476 %T The Effect of Virtual Laboratories on the Academic Achievement of Undergraduate Chemistry Students: Quasi-Experimental Study %A Bazie,Hiwot %A Lemma,Bekele %A Workneh,Anteneh %A Estifanos,Ashebir %+ Department of Chemistry, College of Natural and Computational Science, Hawassa University, Hawassa University Main Campus, Hawassa, 1530, Ethiopia, 251 918778422, baziebe@gmail.com %K virtual laboratory %K practical chemistry %K student achievement %K undergraduate student %K Dilla University %K simulation %K chemistry education %D 2024 %7 15.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Experimentation is crucial in chemistry education as it links practical experience with theoretical concepts. However, practical chemistry courses typically rely on real laboratory experiments and often face challenges such as limited resources, equipment shortages, and logistical constraints in university settings. To address these challenges, computer-based laboratories have been introduced as a potential solution, offering electronic simulations that replicate real laboratory experiences. Objective: This study examines the effect of virtual laboratories on the academic achievement of undergraduate chemistry students and evaluates their potential as a viable alternative or complement to traditional laboratory-based instruction. Methods: A quasi-experimental design was implemented to examine the cause-and-effect relationship between instructional methods and student outcomes. The study involved 60 fourth-year BSc chemistry students from Dilla University, divided into 3 groups: a real laboratory group (n=20), which performed real laboratory experiments; a virtual group (n=20), which used virtual laboratory simulations; and a lecture group (n=20), which received lecture-based instruction. Quantitative data were collected through tests administered before and after the intervention to assess academic performance. The data analysis used descriptive and inferential statistics, such as means and SDs, 1-way ANOVA, the Tukey honestly significant difference test, and independent-sample t tests (2-tailed), with a P value of .05 set for determining statistical significance. Results: Before the intervention, the results indicated no significant differences in academic achievement among the 3 groups (P=.99). However, after the intervention, notable differences were observed in student performance across the methods. The real laboratory group had the highest mean posttest score (mean 62.6, SD 10.7), followed by the virtual laboratory group (mean 55.5, SD 6.8) and the lecture-only group, which had the lowest mean score (mean 43.7, SD 11.5). ANOVA results confirmed significant differences between the groups (F2,57=18.429; P<.001). The Tukey post hoc test further revealed that the real laboratory group significantly outperformed the lecture-only group (mean difference 18.88; P<.001), while the virtual laboratory group also performed significantly better than the lecture-only group (mean difference 11.7; P=.001). However, no statistically significant difference was found between the real laboratory and virtual laboratory groups (mean difference 7.12; P=.07). In addition, gender did not significantly influence performance in the virtual laboratory group (P=.21), with no substantial difference in posttest scores between male and female students. Conclusions: These findings suggest that computer-based laboratories are a viable and effective alternative when real laboratories are unavailable, enhancing learning outcomes when compared with traditional lecture-based methods. Therefore, universities should consider integrating computer-based laboratories into their practical chemistry curricula to provide students with interactive and engaging learning experiences, especially when physical laboratories are inaccessible. %M 39546770 %R 10.2196/64476 %U https://formative.jmir.org/2024/1/e64476 %U https://doi.org/10.2196/64476 %U http://www.ncbi.nlm.nih.gov/pubmed/39546770 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e58388 %T Comparison of Occupational Performance in Immersive Virtual and Real Environments Among Patients With Stroke: Observational Randomized Crossover Pilot Study %A Wei,Xijun %A Zhou,Ping %A Wei,Yixi %A Wu,Dashuang %A Qin,Ping %A Zhang,Yingying %A Zhu,Jing %A Ren,Zhanbing %A Li,Hai %A Zhang,Yumei %K instrumental activities of daily living %K immersive virtual reality %K occupational performance %K stroke rehabilitation %K occupational therapy %D 2024 %7 15.11.2024 %9 %J JMIR Serious Games %G English %X Background: Conventional rehabilitation approaches involve therapists simulating various occupational tasks in health care settings or recreating real-life situations to assess and train patients in instrumental activities of daily living (IADLs). As an alternative, immersive virtual reality (IVR) has been widely used in stroke rehabilitation for years, but research comparing occupational performance between virtual and real environments is limited. Objective: This study aims to introduce a novel IVR shopping system designed for patients with stroke and to investigate the correlation of occupational performance in virtual and real environments among patients with stroke. Methods: Ten patients with stroke were recruited from the Department of Rehabilitation Medicine, Shenzhen Hospital, Southern Medical University, who met the inclusion and exclusion criteria for this observational, randomized crossover study; the patients were predominantly male (n=7), had experienced ischemic stroke (n=9), were aged 14 to 73 years, and had a time since stroke of 1 to 42 months. All patients attempted shopping tasks in virtual and real environments. The Mini-Mental State Examination (MMSE), Timed Up and Go Test (TUGT), modified Barthel index (MBI), and Lawton index (LI) were used to assess cognition, ambulation, and activities of daily living. Memory capacity and duration in the virtual and real environments were recorded as the primary parameters of occupational performance. The Wilcoxon test and Spearman correlation coefficients were used to analyze the differences and correlations between the 2 environments. Results: The Wilcoxon test showed no significant differences between the virtual and real environments in memory capacity and duration of task completion (P>.99 and P=.99), and memory capacity in both environments correlated with the LI (ρ=0.81; P=.005). Memory duration had a relationship with the TUGT in the virtual environment (ρ=0.68; P=.03) and a borderline negative correlation with MMSE in the real environment (ρ=−0.58; P=.08). Conclusions: Considering the small sample size used in this study and the study’s limitations, despite the significant correlation between shopping performance in IVR and the real world, it is still too early to conclude that IVR is a noninferior approach, but it presents the potential to be an alternative for assessment and training in IADLs when resources are limited. However, further research is needed to investigate the psychometric properties, clinical effects, and impact of virtual training on real-world performance. The implications for practice might include the following: (1) occupational performance in virtual shopping might be the same as real-world shopping, and more virtual IADLs could thus be developed; (2) virtual IADL assessment and training systems could be used in remote locations or locations with limited resources; and (3) more objective parameters of IADLs could be extracted from virtual environments. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000041058; https://www.chictr.org.cn/showprojEN.html?proj=65714 %R 10.2196/58388 %U https://games.jmir.org/2024/1/e58388 %U https://doi.org/10.2196/58388 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e53348 %T The Effects of Virtual Reality–Based Reminiscence Therapies for Older Adults With Cognitive Impairment: Systematic Review %A Mao,Qian %A Zhao,Zhen %A Yu,Lisha %A Zhao,Yang %A Wang,Hailiang %+ School of Design, The Hong Kong Polytechnic University, 11 Yuk Choi Rd, Hung Hom, Hong Kong, 999077, China, 852 27665471, hailiang.wang@polyu.edu.hk %K virtual reality %K reminiscence therapy %K cognitive impairment %K older adults %K mobile phone %D 2024 %7 12.11.2024 %9 Review %J J Med Internet Res %G English %X Background: Reminiscence therapy (RT) is a commonly used nonpharmaceutical treatment for cognitive impairment. Artifacts or conversations are used in RT to recall individuals’ memories and past experiences. Virtual reality (VR) has increasingly been used as an assistive technology during RT. However, the effects of VR-based RT (VR-RT) methods remain unclear, and insights into the related benefits and challenges are urgently needed. Objective: The study aims to systematically review the effects of VR-RTs for older adults with cognitive impairment. Methods: Seven databases (MEDLINE, Academic Search Premier, CINAHL, Web of Science, PubMed, the Cochrane Central Register of Controlled Trials, and ScienceDirect) were searched to identify relevant articles published from inception to August 10, 2023. Peer-reviewed publications that assessed the effect of VR-RTs (ie, using virtual clues to evoke participants’ memories or past experiences) on cognitive-related outcomes were included. Two independent researchers conducted the literature search, review, and data extraction processes. A narrative synthesis approach was used to analyze the extracted data. Results: Of the 537 identified articles, 22 were ultimately included in the data analysis. The results revealed that VR-RTs could maintain cognitive status (4/4, 100%) and reduce anxiety (2/2, 100%) in older adults with cognitive impairment. Nevertheless, one study found a cognitive improvement after VR-RTs, whereas cognitive degradation was observed at a 3- to 6-month follow-up measure. Around 88% (7/8) of the included studies indicated that VR-RTs improved memory; however, the evidence regarding the beneficial effects of VR-RTs was limited in improving quality of life (1/4, 25%) and reducing apathy (0/2, 0%) and depression (1/3, 33%). The results indicated that VR-RTs are safe, engaging, acceptable, and satisfying for older adults with cognitive impairment. In VR scenarios, personalized stimulus materials related to the users’ youth experiences were more effective for treating cognitive impairment than other stimulus materials. Conclusions: The results of this systematic review demonstrate the potential benefits of VR-RT for older adults with cognitive impairment, especially in improving emotion and memory and maintaining cognitive status. VR-RT is also safe and enjoyable for older adults. However, due to the trial heterogeneity of included studies, we can only provide qualitative results instead of performing meta-analysis to quantify the effect size of VR-RTs. Thus, more randomized controlled trials are required to examine the designs and effects of VR-RTs for groups of older adults with specific needs. %M 39531267 %R 10.2196/53348 %U https://www.jmir.org/2024/1/e53348 %U https://doi.org/10.2196/53348 %U http://www.ncbi.nlm.nih.gov/pubmed/39531267 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e13723 %T Developing Game-Based Design for eHealth in Practice: 4-Phase Game Design Process %A de Vette,Frederiek %A Ruiz-Rodriguez,Aurora %A Tabak,Monique %A Oude Nijeweme-d'Hollosy,Wendy %A Hermens,Hermie %A Vollenbroek-Hutten,Miriam %+ Biomechanical Engineering Group, Faculty of Engineering Technology, University of Twente, Drienerlolaan 5, Enschede, 7522 NB, Netherlands, 31 53 489 5798, a.ruizrodriguez@utwente.nl %K game based %K gamification %K game %K eHealth %K telemedicine %K development %K design %K engagement %K game preferences %K older adults %K self-management %K prototyping %K evaluations %K creative %D 2024 %7 8.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Games are increasingly used in eHealth as a strategy for user engagement. There is an enormous diversity of end users and objectives targeted by eHealth. Hence, identifying game content that drives and sustains engagement is challenging. More openness in the game design process and motivational strategies could aid researchers and designers of future game-based apps. Objective: This study aims to provide insights into our approach to develop game-based eHealth in practice with a case study (Personalised ICT Supported Services for Independent Living and Active Ageing [PERSSILAA]). PERSSILAA is a self-management platform that aims to counter frailty by offering training modules to older adults in the domains of healthy nutrition and physical and cognitive training to maintain a healthy lifestyle. We elaborate on the entire game design process and show the motivational strategies applied. Methods: We introduce four game design phases in the process toward game-based eHealth: (1) end-user research, (2) conceptualization, (3) creative design, and (4) refinement (ie, prototyping and evaluations). Results: First, 168 participants participated in end-user research, resulting in an overview of their preferences for game content and a set of game design recommendations. We found that conventional games popular among older adults do not necessarily translate well into engaging concepts for eHealth. Recommendations include focusing game concepts on thinking, problem-solving, variation, discovery, and achievement and using high-quality aesthetics. Second, stakeholder sessions with development partners resulted in strategies for long-term engagement using indicators of user performance on the platform’s training modules. These performance indicators, for example, completed training sessions or exercises, form the basis for game progression. Third, results from prior phases were used in creative design to create the game “Stranded!” The user plays a person who is shipwrecked who must gather parts for a life raft by completing in-game objectives. Finally, iterative prototyping resulted in the final prototype of the game-based app. A total of 35 older adults participated using simulated training modules. End users scored appreciation (74/100), ease of use (73/100), expected effectivity and motivation (62/100), fun and pleasantness of using the app (75/100), and intended future use (66/100), which implies that the app is ready for use by a larger population. Conclusions: The study resulted in a game-based app for which the entire game design process within eHealth was transparently documented and where engagement strategies were based on extensive user research. Our user evaluations indicate that the strategies for long-term engagement led to game content that was perceived as engaging by older adults. As a next step, research is needed on the user experience and actual engagement with the game to support the self-management of older adults, followed by clinical studies on its added value. %M 39514861 %R 10.2196/13723 %U https://formative.jmir.org/2024/1/e13723 %U https://doi.org/10.2196/13723 %U http://www.ncbi.nlm.nih.gov/pubmed/39514861 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e53156 %T Assessing the Feasibility and Acceptability of Virtual Reality for Remote Group-Mediated Physical Activity in Older Adults: Pilot Randomized Controlled Trial %A Kershner,Kyle %A Morton,David %A Robison,Justin %A N'dah,Kindia Williams %A Fanning,Jason %+ Department of Health and Exercise Science, Wake Forest University, 1834 Wake Forest Road, Winston-Salem, NC, 27109, United States, 1 3367585042, fanninjt@wfu.edu %K virtual reality %K physical activity %K videoconference %K social connection %K remote meeting %K gerontology %K physical inactivity %K at-home intervention %K descriptive statistics %K eHealth %K comorbidity %K cybersickness %D 2024 %7 8.11.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Physical inactivity represents a major health concern for older adults. Most social, at-home physical activity (PA) interventions use videoconference, email, or telephone communication for program delivery. However, evidence suggests that these platforms may hinder the social connection experienced by users. Recent advancements in virtual reality (VR) suggest that it may be a rich platform for social, at-home interventions because it offers legitimate options for intervention delivery and PA. Objective: This pilot study aims to determine the feasibility and acceptability of VR compared to videoconference as a medium for remote group-mediated behavioral intervention for older adults. The information generated from this investigation will inform the use of VR as a medium for intervention delivery. Methods: Nine low-active older adults (mean age 66.8, SD 4.8 y) were randomized to a 4-week home-based, group-mediated PA intervention delivered via VR or videoconference. Feasibility (ie, the total number of sessions attended and the number of VR accesses outside of scheduled meetings) and acceptability (ie, the number of participants reporting high levels of nausea, program evaluations using Likert-style prompts with responses ranging from –5=very difficult or disconnected to 5=very easy or connected, and participant feedback on immersion and social connection) are illustrated via descriptive statistics and quotes from open-ended responses. Results: None of the participants experienced severe VR-related sickness before randomization, with a low average sickness rating of 1.6 (SD 1.6) out of 27 points. Attendance rates for group meetings were 98% (59/60) and 96% (46/48) for the VR and videoconference groups, respectively. Outside of scheduled meeting times, participants reported a median of 5.5 (IQR 5.3-5.8, range 0-27) VR accesses throughout the entire intervention. Program evaluations suggested that participants felt personally connected to their peers (VR group: median 3.0, IQR 2.5-3.5; videoconference group: median 3.0, IQR 2.7-3.3), found that goals were easy to accomplish (VR group: median 3.0, IQR 2.8-3.3; videoconference group: median 3.0, IQR 2.6-3.4), and had ease in finding PA options (VR group: median 4.0, IQR 3.5-4.3; videoconference group: median 2.0, IQR 1.6-2.4) and engaging in meaningful dialogue with peers (VR group: median 4.0, IQR 4.0-4.0; videoconference group: median 3.5, IQR 3.3-3.8). Open-ended responses regarding VR use indicated increased immersion experiences and intrinsic motivation for PA. Conclusions: These findings suggest that VR may be a useful medium for social PA programming in older adults, given it was found to be feasible and acceptable in this sample. Importantly, all participants indicated low levels of VR-related sickness before randomization, and both groups demonstrated very high attendance at meetings with their groups and behavioral coaches, which is promising for using VR and videoconference in future interventions. Modifications for future iterations of similar interventions are provided. Further work using larger samples and longer follow-up durations is needed. Trial Registration: ClinicalTrials.gov NCT04756245; https://www.clinicaltrials.gov/study/NCT04756245 %M 39514256 %R 10.2196/53156 %U https://formative.jmir.org/2024/1/e53156 %U https://doi.org/10.2196/53156 %U http://www.ncbi.nlm.nih.gov/pubmed/39514256 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e60441 %T The Journey From Nonimmersive to Immersive Multiuser Applications in Mental Health Care: Systematic Review %A Fajnerova,Iveta %A Hejtmánek,Lukáš %A Sedlák,Michal %A Jablonská,Markéta %A Francová,Anna %A Stopková,Pavla %+ Research Center for Virtual Reality in Mental Health and Neuroscience, National Institute of Mental Health, Topolová 748, Klecany, 250 67, Czech Republic, 420 283 088 478, Iveta.fajnerova@nudz.cz %K digital health %K mental health care %K clinical interventions %K multiuser %K immersive %K virtual reality %K VR %K app %K mental health %K online tools %K synthesis %K mobile phone %K PRISMA %D 2024 %7 7.11.2024 %9 Review %J J Med Internet Res %G English %X Background: Over the past 25 years, the development of multiuser applications has seen considerable advancements and challenges. The technological development in this field has emerged from simple chat rooms through videoconferencing tools to the creation of complex, interactive, and often multisensory virtual worlds. These multiuser technologies have gradually found their way into mental health care, where they are used in both dyadic counseling and group interventions. However, some limitations in hardware capabilities, user experience designs, and scalability may have hindered the effectiveness of these applications. Objective: This systematic review aims at summarizing the progress made and the potential future directions in this field while evaluating various factors and perspectives relevant to remote multiuser interventions. Methods: The systematic review was performed based on a Web of Science and PubMed database search covering articles in English, published from January 1999 to March 2024, related to multiuser mental health interventions. Several inclusion and exclusion criteria were determined before and during the records screening process, which was performed in several steps. Results: We identified 49 records exploring multiuser applications in mental health care, ranging from text-based interventions to interventions set in fully immersive environments. The number of publications exploring this topic has been growing since 2015, with a large increase during the COVID-19 pandemic. Most digital interventions were delivered in the form of videoconferencing, with only a few implementing immersive environments. The studies used professional or peer-supported group interventions or a combination of both approaches. The research studies targeted diverse groups and topics, from nursing mothers to psychiatric disorders or various minority groups. Most group sessions occurred weekly, or in the case of the peer-support groups, often with a flexible schedule. Conclusions: We identified many benefits to multiuser digital interventions for mental health care. These approaches provide distributed, always available, and affordable peer support that can be used to deliver necessary help to people living outside of areas where in-person interventions are easily available. While immersive virtual environments have become a common tool in many areas of psychiatric care, such as exposure therapy, our results suggest that this technology in multiuser settings is still in its early stages. Most identified studies investigated mainstream technologies, such as videoconferencing or text-based support, substituting the immersive experience for convenience and ease of use. While many studies discuss useful features of virtual environments in group interventions, such as anonymity or stronger engagement with the group, we discuss persisting issues with these technologies, which currently prevent their full adoption. %M 39509153 %R 10.2196/60441 %U https://www.jmir.org/2024/1/e60441 %U https://doi.org/10.2196/60441 %U http://www.ncbi.nlm.nih.gov/pubmed/39509153 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e59014 %T Influence of Distraction Factors on Performance in Laparoscopic Surgery in Immersive Virtual Reality: Study Protocol of a Cross-Over Trial in Medical Students and Residents—DisLapVR %A Hanke,Laura %A Schulte,Richard %A Boedecker,Christian %A Huettl,Florentine %A Saalfeld,Patrick %A Chheang,Vuthea %A Wessels,Marlene %A von Castell,Christoph %A Hecht,Heiko %A Hansen,Christian %A Lang,Hauke %A Huber,Tobias %+ Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstr. 1, Mainz, 55131, Germany, 49 06131177291, tobias.huber@unimedizin-mainz.de %K immersive virtual reality %K distractions in surgery %K %K laparoscopy %K medical training %K medical students %K surgical education %K surgical training %K VR %K cognitive load %K multitasking %K stress resilience %D 2024 %7 5.11.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Working in an operating room (OR) is physically and mentally challenging: the operation itself demands the surgeon's full attention, while time and cost efficiency constraints, daily planning, and emergency care interfere with the procedure. Thus, multitasking becomes an integral surgical competence. This study aims to examine the effect of disruptions during surgery in a highly immersive virtual reality (IVR) operation environment combined with a virtual reality (VR) laparoscopy simulator. Objective: This study aims to identify distractions in the OR and their importance in the clinical setting. Methods: An IVR environment was created using a high-resolution, stereoscopic 360° video of the OR. Different distractions were identified, classified as auditory, visual, or audio-visual, and recorded accordingly. The surrounding was combined with a VR laparoscopic simulator. Participants—medical students and surgical residents—received proficiency-based training in basic laparoscopic skills and were blinded to the aim of the experiment. Following a cross-over design, each participant received a unique order of virtual distraction factors while performing tasks on the laparoscopic simulator. During the experiment, subjective passing of time, stress, heart rate, and visually induced motion sickness are recorded. After the experiment, validated questionnaires for usability, immersion, and stress were completed, as well as subjective evaluation of the distractions. The questionnaires used included the system usability scale, Self-Assessment Manikin score, National Aeronautics and Space Administration Task Load Index, and the immersion rating scale as described by Nichols. Performance in the laparoscopic tasks in relation to distractions will be evaluated by the Wilcoxon test and ANOVA for continuous variables. Subgroup analyses in regard to age, gender, and expertise (medical students vs surgical residents) are planned. Results: The described trial started in August 2022 and is ongoing. By July 2024, a total of 30 medical students and 9 surgeons have completed the study. Conclusions: We present a study protocol aiming to identify the impact of different disruptions in OR during laparoscopic training in IVR. Hence, it may lead to an improved awareness of distractions and facilitate accommodations toward an improved work environment. Prior research leads to the hypothesis that the performance of a more experienced surgeon is less impacted by distractions than the performance of inexperienced surgeons and medical students. Furthermore, we investigate which type of distraction has the largest impact on performance. With this knowledge, specific multitasking training can be devised, which may be particularly useful in medical education, for which VR might play a leading role. Additionally, workplace surroundings in the OR can be optimized with this knowledge. Trial Registration: German Registry for Clinical Trials DRKS00030033; https://drks.de/search/en/trial/DRKS00030033 International Registered Report Identifier (IRRID): DERR1-10.2196/59014 %M 39500487 %R 10.2196/59014 %U https://www.researchprotocols.org/2024/1/e59014 %U https://doi.org/10.2196/59014 %U http://www.ncbi.nlm.nih.gov/pubmed/39500487 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e56235 %T Virtual Reality Exposure Therapy for Reducing School Anxiety in Adolescents: Pilot Study %A Beele,Gesa %A Liesong,Paula %A Bojanowski,Sabine %A Hildebrand,Kristian %A Weingart,Malte %A Asbrand,Julia %A Correll,Christoph U %A Morina,Nexhmedin %A Uhlhaas,Peter J %+ Department of Child and Adolescent Psychiatry, Charité-Universitätsmedizin Berlin, Augustenburgerplatz 1, Berlin, 13353, Germany, 49 30450 ext 516193, peter.uhlhaas@charite.de %K virtual reality exposure therapy %K VRET %K school anxiety %K social anxiety %K adolescents %K virtual reality %K VR %K autonomic arousal %K exposure therapy %K posttreatment %K digital health %K simulation %D 2024 %7 5.11.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Virtual reality exposure therapy (VRET) is a promising treatment approach for anxiety disorders. However, while its efficacy has been demonstrated in adults, research on the efficacy of VRET in the treatment of adolescents with anxiety disorders is largely lacking. Objective: A pilot study was carried out to test whether exposure to a virtual reality (VR) school environment elicits state anxiety and autonomic arousal in adolescents with school anxiety (diagnoses covering social anxiety disorder or specific phobia involving school contexts). In addition, we examined whether repeated VR exposure led to a reduction in this fear response, trait school anxiety, and social anxiety symptoms. Moreover, the relationship of presence, the subjective sense of “being there,” during VR exposure with anxiety measures and treatment response was examined. Methods: In a pilot study, 10 adolescents with school anxiety (age range 14 to 17 years) participated in five VRET sessions. Self-reported state anxiety, heart rate, and presence during exposure, as well as trait school anxiety and social anxiety before and after treatment, were measured. Results: The VR scenario induced state anxiety and autonomic arousal. After VRET, a significant reduction in state anxiety (η2=0.74) and social anxiety symptoms (d=0.82) as well as a trend toward a decrease in trait school anxiety were observed, while autonomic arousal did not change. In addition, presence during VR exposure was associated with state anxiety and treatment response. Conclusions: Our findings indicate the feasibility and potential effectiveness of VRET as a treatment method for symptoms of school and social anxiety in adolescents. %M 39499549 %R 10.2196/56235 %U https://mental.jmir.org/2024/1/e56235 %U https://doi.org/10.2196/56235 %U http://www.ncbi.nlm.nih.gov/pubmed/39499549 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e57117 %T Interprofessional Team Training With Virtual Reality: Acceptance, Learning Outcome, and Feasibility Evaluation Study %A Neher,Andrea N %A Wespi,Rafael %A Rapphold,Benjamin D %A Sauter,Thomas C %A Kämmer,Juliane E %A Birrenbach,Tanja %K medical education %K simulation %K virtual reality %K VR %K emergency medicine %K interprofessional team training %K nursing students %K medical students %K evaluation study %K assessment %K effectiveness %K patient care %K simulation-based training %K hemorrhage %K epileptic seizure %K headache %D 2024 %7 4.11.2024 %9 %J JMIR Serious Games %G English %X Background: Effective interprofessional teamwork is vital for ensuring high-quality patient care, especially in emergency medicine. However, interprofessional education often fails to facilitate meaningful interaction among health care disciplines. It is therefore imperative to afford early opportunities for cultivating interprofessional teamwork skills. While in-person simulation-based training has been shown to improve performance, this is resource-intensive, especially if it involves multiple professions. Virtual reality (VR)–based training is an innovative instructional approach that demands fewer resources and offers the flexibility of location-independent learning. Objective: This study aimed to develop and evaluate the acceptance, learning outcome, and feasibility of an interprofessional team (INTEAM) training course that included a VR simulation of a neurological emergency case. Methods: This 1-group study used a pre- and posttest design to evaluate the 2-hour INTEAM training course for nursing and medical students. The course included an e-learning part, VR simulation, and debriefing. The main learning objectives were derived from the entrustable professional activity 6, namely to handle a common problem in emergency medicine (headache due to subarachnoid hemorrhage and epileptic seizure) that requires interprofessional collaboration, including a structured handover. We used validated and self-constructed questionnaires, pre- and posttests, and open questions to assess the acceptance, learning outcome, and feasibility of the course. Results: The data of 42 students (21 nursing and 21 medical students) were analyzed and showed good usability in the System Usability Scale (median 72.5, IQR 65‐80). The perception of usefulness (median 6, IQR 5.8‐6.9) and ease of use (median 5.9, IQR 5.1‐6.3) was good among all students. There was a significant increase in the handover performance from pre- (median 8, IQR 6‐9) to posttraining (median 8, IQR 7‐9; z=−2.01; P=.045; r=0.33) and of the confidence in caring for patients with seizures (median 3, IQR 2‐3 and median 3.5, IQR 3‐4, respectively; z=−3.8; P<.001; r=0.60). In 67% (14/21) of the simulations, technical issues occurred, but all simulations could be carried out completely. Conclusions: The new INTEAM training course was well received by nursing and medical students. The handover skills and confidence in caring for patients with seizures were improved after the course. Despite technical challenges with the VR simulations, none required termination, and this demonstrates that our approach is feasible. These promising results encourage the use of VR simulations for team training in the education of nursing and medical students. %R 10.2196/57117 %U https://games.jmir.org/2024/1/e57117 %U https://doi.org/10.2196/57117 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e64494 %T Using Extended Reality to Enhance Effectiveness and Group Identification in Remote Group Therapy for Anxiety Disorders: A Critical Analysis %A Bouguettaya,Ayoub %A Aboujaoude,Elias %+ Program of Internet, Health, and Society, Biomedical Sciences, Cedars-Sinai Medical Center, 6500 Wilshire Blvd, Los Angeles, CA, 90048, United States, 1 4152443724, elias.aboujaoude@cshs.org %K group therapy %K psychotherapy %K telepsychiatry %K mental health %K extended reality %K augmented reality %K virtual reality therapy %K anxiety %K cognitive behavioral therapy %D 2024 %7 4.11.2024 %9 Viewpoint %J JMIR Form Res %G English %X Group therapy is a scalable and effective treatment for anxiety disorders. However, when performed online, the reduced ability to identify with group members and the reduced interactivity can limit its appeal and effectiveness. Extended reality (XR) technology, including virtual reality and augmented reality, may help address these limitations, thereby enhancing the reach of online group therapy and the benefits that can be drawn from it. To understand how the incorporation of XR technology may improve online group therapy for anxiety disorders, this viewpoint paper examines evidence related to the treatment of anxiety disorders using offline group therapy, online group therapy, and virtual reality, as well as ways to increase social identification and interactivity with the platform, the therapist, and other users. This viewpoint paper suggests ways to integrate these research streams to leverage the strengths of XR platforms and improve group therapeutic offerings. %M 39496150 %R 10.2196/64494 %U https://formative.jmir.org/2024/1/e64494 %U https://doi.org/10.2196/64494 %U http://www.ncbi.nlm.nih.gov/pubmed/39496150 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e58963 %T Empowering Social Growth Through Virtual Reality–Based Intervention for Children With Attention-Deficit/Hyperactivity Disorder: 3-Arm Randomized Controlled Trial %A Wong,Ka Po %A Zhang,Bohan %A Lai,Cynthia Yuen Yi %A Xie,Yao Jie %A Li,Yan %A Li,Chen %A Qin,Jing %+ Department of Applied Social Sciences, The Hong Kong Polytechnic University, Room GH329, 3rd Floor, Block G, 11 Yuk Choi Rd, Hung Hom, Hong Kong, 000000, China (Hong Kong), 852 64860214, portia.wong@polyu.edu.hk %K attention deficit and hyperactivity disorder %K virtual reality %K social skills %K social skills training %K emotional control %K social growth %K digital world %K social learning theory %D 2024 %7 28.10.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) usually begins in childhood and is often accompanied by impairments in social functioning. Virtual reality (VR) has emerged as an adjunctive tool to embed in social skills training to enhance the social skills of children with ADHD, but its effectiveness requires further investigation. Objective: This study aims to enhance the social skills of children with ADHD by examining the feasibility and effectiveness of VR-based training in comparison to traditional social skills training. Methods: A 3-arm randomized controlled trial was conducted with 90 children with ADHD aged 6-12 years. Participants were randomly assigned to 3 weeks of 12-session VR-based social skills training, traditional social skills training, or a waitlist control group of equivalent duration. Outcome measures included assessments by a clinical psychologist who was blinded to group assignments, the Social Skills Improvement System Rating Scale, the Behavior Rating Inventory of Executive Function, and the Simulator Sickness Questionnaire, conducted at baseline and after the intervention. Results: The preliminary results support the feasibility and acceptability of VR training for children with ADHD aged 6-12 years. Analysis showed that the VR and traditional social skills training groups experienced a statistically significant improvement in the clinical psychologist assessment of social skills and parent-rated self-control, initiative, and emotional control after the intervention compared with baseline. The VR group performed significantly better than the traditional social skills group on social skills assessed by clinical psychologists (F2,85=76.77; P<.001) and on parent-rated self-control (F2,85=18.77; P<.001), initiative (F2,85=11.93; P<.001), and emotional control (F2,85=17.27; P<.001). No significant between-group differences were found for parent-rated cooperation and inhibition (all P>.05). Conclusions: The findings provide preliminary evidence supporting the feasibility and superior effectiveness of VR-based social skills training compared to traditional approaches for enhancing social skills and related executive functions in children with ADHD. These results suggest that VR may be a valuable tool to embed within social skills interventions for this population. Further research is warranted to explore the long-term impacts and generalizability of these benefits. Trial Registration: ClinicalTrials.gov NCT05778526; https://clinicaltrials.gov/study/NCT05778526 International Registered Report Identifier (IRRID): RR2-10.2196/48208 %M 39467288 %R 10.2196/58963 %U https://games.jmir.org/2024/1/e58963 %U https://doi.org/10.2196/58963 %U http://www.ncbi.nlm.nih.gov/pubmed/39467288 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e53683 %T Exploring Immersive Multimodal Virtual Reality Training, Affective States, and Ecological Validity in Healthy Firefighters: Quasi-Experimental Study %A Oliveira,Joana %A Aires Dias,Joana %A Correia,Rita %A Pinheiro,Raquel %A Reis,Vítor %A Sousa,Daniela %A Agostinho,Daniel %A Simões,Marco %A Castelo-Branco,Miguel %+ Coimbra Institute for Biomedical Imaging and Translational Research, Institute for Nuclear Sciences Applied to Health, University of Coimbra, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, Coimbra, 3000-548, Portugal, 351 239488514, mcbranco@fmed.uc.pt %K virtual reality %K firefighter %K training %K posttraumatic stress disorder %K PTSD %K emotion %K situational awareness %K engagement %K ecological validity %K multivariate approach %D 2024 %7 24.10.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Firefighters face stressful life-threatening events requiring fast decision-making. To better prepare for those situations, training is paramount, but errors in real-life training can be harmful. Virtual reality (VR) simulations provide the desired realism while enabling practice in a secure and controlled environment. Firefighters’ affective states are also crucial as they are a higher-risk group. Objective: To assess the impact on affective states of 2 simulated immersive experiences in a sample of healthy firefighters (before, during, and after the simulation), we pursued a multivariate approach comprising cognitive performance, situational awareness, depression, anxiety, stress, number of previous adverse events experienced, posttraumatic stress disorder (PTSD) severity, and emotions. The efficacy and ecological validity of an innovative VR haptic system were also tested, exploring its impact on performance. Methods: In collaboration with the Portuguese National Fire Service School, we exposed 22 healthy firefighters to 2 immersive scenarios using the FLAIM Trainer VR system (neutral and arousing scenarios) while recording physiological data in a quasi-experimental study. Baseline cognitive performance, depression, anxiety, stress, number of adverse events, and severity of PTSD symptoms were evaluated. Positive and negative affective states were measured before, between, and after each scenario. Situational awareness, sense of presence, ecological validity, engagement, and negative effects resulting from VR immersion were tested. Results: Baseline positive affect score was high (mean 32.4, SD 7.2) and increased after the VR tasks (partial η2=0.52; Greenhouse-Geisser F1.82,32.78=19.73; P<.001). Contrarily, mean negative affect score remained low (range 11.0-11.9) throughout the study (partial η2=0.02; Greenhouse-Geisser F2.13,38.4=0.39; P=.69). Participants’ feedback on the VR sense of presence was also positive, reporting a high sense of physical space (mean score 3.9, SD 0.8), ecological validity (mean score 3.8, SD 0.6), and engagement (mean score 3.8, SD 0.6). Engagement was related to the number of previously experienced adverse events (r=0.49; P=.02) and positive affect (after the last VR task; r=0.55; P=.02). Conversely, participants reported few negative effects (mean score 1.7, SD 0.6). The negative effects correlated positively with negative affect (after the last VR task; r=0.53; P=.03); and avoidance (r=0.73; P<.001), a PTSD symptom, controlling for relevant baseline variables. Performance related to situational awareness was positive (mean 46.4, SD 34.5), although no relation was found to metacognitively perceived situational awareness (r=–0.12; P=.59). Conclusions: We show that VR is an effective alternative to in-person training as it was considered ecologically valid and engaging while promoting positive emotions, with few negative repercussions. This corroborates the use of VR to test firefighters’ performance and situational awareness. Further research is needed to ascertain that firefighters with PTSD symptomatology are not negatively affected by VR. This study favors the use of VR training and provides new insights on its emotional and cognitive impact on the trainee. %M 39446479 %R 10.2196/53683 %U https://games.jmir.org/2024/1/e53683 %U https://doi.org/10.2196/53683 %U http://www.ncbi.nlm.nih.gov/pubmed/39446479 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e56704 %T Influence of Avatar Identification on the Attraction of Virtual Reality Games: Survey Study %A Li,PengFei %A Qi,Fa %A Ye,Zhihai %+ Art College, Jinan University, No. 601 Huangpu Avenue West, Tianhe District, Guangzhou City, Guangdong Province, Guangzhou, 510632, China, 86 198 3289 9510, tlipengfei@jnu.edu.cn %K avatar identification %K self-differentiation theory %K immersion %K attractiveness %K virtual reality games %D 2024 %7 22.10.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: In gaming, the embodied interaction experience of avatars serves as a key to emotional sublimation in artistic creation. This presents the emotional expression of art in a more vivid form, which is a critical factor in the high attractiveness of virtual reality (VR) games to players. Intertwined with players’ physiological and psychological responses, immersion is an essential element for enhancing gaming attractiveness. Objective: This study aims to explore how to help players establish a sense of identity with their embodied avatars in VR game environments and enhance the attractiveness of games to players through the mediating effect of immersion. Methods: We conducted a structured questionnaire survey refined through repeated validation. A total of 402 VR users were publicly recruited through the internet from March 22, 2024, to April 13, 2024. Statistical analysis was conducted using the SPSS and Amos tools, including correlation analysis, regression analysis, and mediation effect verification. We divided the self-differentiation theory into 4 dimensions to validate their impact on avatar identification. Subsequently, we correlated the effects of avatar identification, game immersion, and game attractiveness and proposed a hypothetical mediating model. Results: Regression analysis of the predictor variables and the dependent variable indicated a significant positive predictive effect (P<.001); the variance inflation factor values for each independent variable were all <5. In the hypothesis testing of the mediating effect, the total mediating effect was significant (P<.001). Regarding the direct impact, both the effect of avatar identification on immersion and the effect of immersion on game attractiveness were significant (P<.001). However, the direct effect of avatar identification on game attractiveness was not significant (P=.28). Regarding the indirect impact, the effect of avatar identification on game attractiveness was significant (P<.001). The results indicate a significant positive correlation between different dimensions of the self-differentiation theory and identification with avatars. Moreover, immersion in the game fully mediated the relationship between identification with avatars and game attractiveness. Conclusions: This study underscores that the embodiment of avatar identification is influenced by dimensions of self-differentiation, and the impact of identification with avatars on game attractiveness is contingent upon full mediation by immersion. These findings deepen our understanding of the role of avatar identification in VR gaming. %M 39437383 %R 10.2196/56704 %U https://formative.jmir.org/2024/1/e56704 %U https://doi.org/10.2196/56704 %U http://www.ncbi.nlm.nih.gov/pubmed/39437383 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e63390 %T Gamification in the Design of Virtual Patients for Swedish Military Medics to Support Trauma Training: Interaction Analysis and Semistructured Interview Study %A Stathakarou,Natalia %A Kononowicz,Andrzej A %A Mattsson,Erik %A Karlgren,Klas %+ Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Tomtebodavägen 18A, Solna, Stockholm, 171 77, Sweden, 46 707799671, natalia.stathakarou@ki.se %K military trauma %K gamification %K game elements %K serious games %K virtual patients %K trauma %K medical training %K medical education %K medical assessment %K emergency care %K first aid %K basic life support %K trauma care %K medics %K military %D 2024 %7 22.10.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: This study explores gamification in the design of virtual patients (VPs) to enhance the training of Swedish military medics in trauma care. The challenges related to prehospital trauma care faced on the battlefield require tailored educational tools that support military medics’ education and training. Objective: The aim of the study is to investigate how to design VPs with game elements for Swedish military medics to support learning in military trauma care. By understanding the reasoning and perceptions of military medics when interacting with VPs, this study aims to provide insights and recommendations for designing VPs with game elements that are specifically tailored to their needs. Methods: The study involved 14 Swedish military medics of the Home Guard–National Security Forces participating in a tactical combat care course. Participants interacted with 3 different VP cases designed to simulate military trauma scenarios. Data were collected through think-aloud sessions and semistructured interviews. The data were analyzed using interaction analysis, structured by the unawareness, problem identification, explanation, and alternative strategies or solutions (uPEA) framework, and reflexive thematic analysis to explore participants’ reasoning processes and perceptions and identify possible game elements to inform the VP design. Results: Mapping the military medics’ reasoning to the uPEA framework revealed that study participants became more creative after making a mistake followed by feedback and after receiving a prompt to make a new decision. The thematic analysis revealed 6 themes: motivation, “keep on trying”; agency in interaction with VPs; realistic tactical experience; confidence, “I know that the knowledge I have works”; social influence on motivation; and personalized learning. Participants suggested that game elements such as scoring; badges; virtual goods; progress bars; performance tables; content unlocking; hints; challenge; control; imposed choice; narrative; avatars; sensation; randomness; difficulty adapting; competition; leaderboards; social pressure; progression; and renovation can promote engagement, motivation, and support confidence in decision-making. Conclusions: Gamification in the design of VPs represents a promising approach to military medical training, offering a platform for medics to practice medical and tactical decision-making in a risk-free environment. The insights gained by the study may encourage designing VPs with game elements, as well as including possibly wrong decisions, their consequences, and relevant feedback, that may support military medics’ reflections and decision-making. %M 39436692 %R 10.2196/63390 %U https://games.jmir.org/2024/1/e63390 %U https://doi.org/10.2196/63390 %U http://www.ncbi.nlm.nih.gov/pubmed/39436692 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e55679 %T Virtual Reality–Based Exposure With 360° Environments for Social Anxiety Disorder: Usability and Feasibility Study %A Ernst,Mathias %A Bouchard,Stéphane %A Andersen,Tonny %A Orskov,Per Trads %A Tarp,Kristine %A Lichtenstein,Mia Beck %+ Department of Psychology, University of Southern Denmark, Campusvej 55, Odense, 5230, Denmark, 45 26218846, mlichtenstein@health.sdu.dk %K anxiety %K exposure therapy %K social anxiety disorder %K virtual reality %K 360° %K mixed methods %K interactive %D 2024 %7 21.10.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Social anxiety disorder (SAD) is a long-term and overwhelming fear of social situations that can affect work, school, and other daily activities. Although cognitive behavioral therapy is effective, few seek treatment, and many who do start often drop out. This may be due to the component of exposure inherent to cognitive behavioral therapy, where the patient confronts feared stimuli outside the therapist’s office, which they otherwise try to avoid. As an alternative, research has explored the effectiveness of virtual reality (VR)–based exposure therapy with promising results. However, few studies have investigated the feasibility of VR tools using mixed methodologies before assessing their efficacy. Objective: This study aims to assess the usability, feasibility, and presence of four 360° virtual environments and whether these were able to evoke anxiety in patients with SAD. Methods: A total of 10 adult participants with SAD and 10 healthy controls were recruited for 1 experimental session (age range 21-32 y; 12/20, 60% male participants). Questionnaire and interview data were collected and analyzed. A mixed methods triangulation design was applied to analyze and compare the data. Results: Participants with SAD experienced increased anxiety when exposed to VR, and environments were considered relevant and useful as an exposure tool. Participants with SAD reported significantly higher average anxiety levels (P=.01) and peak anxiety levels (P=.01) compared with controls during exposure; however, significant differences in anxiety when accounting for baseline anxiety levels were only found in 2 of 4 environments (P=.01, P=.01, P=.07, and P=.06). While presence scores were acceptable in both groups, participants with SAD scored significantly lower than controls. Qualitative analyses highlight this finding within the SAD group, where some participants experienced presence reduction due to being observed while in VR and in situations with reduced interaction in VR. Conclusions: VR exposure with 360° videos seems to be useful as a first step of exposure therapy for patients with SAD. Future exploration in the clinical application of VR-based exposure for SAD, as well as means of increasing presence within the virtual environments, may be useful. %M 39432344 %R 10.2196/55679 %U https://formative.jmir.org/2024/1/e55679 %U https://doi.org/10.2196/55679 %U http://www.ncbi.nlm.nih.gov/pubmed/39432344 %0 Journal Article %@ 2369-2960 %I JMIR Publications %V 10 %N %P e62807 %T Virtual Reality–Based Food and Beverage Marketing: Potential Implications for Young People of Color, Knowledge Gaps, and Future Research Directions %A Cassidy,Omni %A Bragg,Marie %A Elbel,Brian %K virtual reality %K VR %K digital food and beverage marketing %K obesity %K marketing %K food %K consumption %K beverage %K immersive %K market %K consumer %D 2024 %7 17.10.2024 %9 %J JMIR Public Health Surveill %G English %X Exposure to unhealthy food and beverage marketing is a major contributor to excessive weight gain among young people and it may disproportionately affect Black and Latinx communities. Appropriate and comprehensive regulations on food and beverage companies are essential, particularly as companies expand their reach and leverage the latest technologies to create marketing experiences using immersive virtual reality (VR). Although immersive VR technology is in its infancy, the potential effects of immersive VR food and beverage marketing on consumption, coupled with the history of racially targeted marketing by food and beverage corporations toward Black and Latinx communities, and the heightened burden of diet-related illnesses in Black and Latinx communities underscore a critical need to investigate immersive VR marketing targeting young people of color. This viewpoint will provide a brief description of VR food and beverage marketing as the newest food and beverage marketing frontier, highlight key concerns and knowledge gaps, and underscore future directions in research. %R 10.2196/62807 %U https://publichealth.jmir.org/2024/1/e62807 %U https://doi.org/10.2196/62807 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e53825 %T Effects of Virtual Reality Therapy for Patients With Breast Cancer During Chemotherapy: Randomized Controlled Trial %A Li,Mengdan %A Yu,Zhifu %A Li,Hui %A Cao,Li %A Yu,Huihui %A Deng,Ning %A Liu,Yunyong %K virtual reality %K breast neoplasms %K quality of life %K psychological distress %K longitudinal studies %D 2024 %7 17.10.2024 %9 %J JMIR Serious Games %G English %X Background: Patients with breast cancer endure high levels of psychological and physical pain. Virtual reality (VR) may be an acceptable, safe intervention to alleviate the negative emotions and pain of patients with cancer. Objective: We aimed to test the long-term effects of VR on psychological distress and quality of life (QOL) with traditional care in Chinese patients with breast cancer. We also explored the intervention mechanism and the acceptability of VR. Methods: A total of 327 eligible participants were randomly assigned to a VR intervention group or a control group. The Distress Thermometer, QLQ-C30 (Quality of Life Questionnaire version 3.0), and Virtual Reality Symptom Questionnaire were assessed at baseline, postintervention (3 mo), and follow-up (6 mo). Analysis followed the intention-to-treat (ITT) principle. The generalized estimating equations model was used to analyze the longitudinal data, and the PROCESS macro was used to analyze the mediating effect. Results: Compared with the control group, patients with breast cancer in the VR group had lower distress scores (P=.007), and higher health-related QOL scores (physical, role, emotional, cognitive, and social functioning) after 6 months (P<.05). Psychological distress had mediating effects on the longitudinal association between VR and the health-related QOL (indirect effect=4.572‐6.672, all P<.05). Conclusions: VR intervention technology may help reduce distress and improve QOL for patients with breast cancer over time. By incorporating a mediating analysis, we showed that the QOL benefits of VR intervention was manifested through positive effects on psychological distress risk factors. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000035049; https://www.chictr.org.cn/showproj.html?proj=53648 %R 10.2196/53825 %U https://games.jmir.org/2024/1/e53825 %U https://doi.org/10.2196/53825 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e59409 %T Cybersecurity and Privacy Issues in Extended Reality Health Care Applications: Scoping Review %A Lake,Kaitlyn %A Mc Kittrick,Andrea %A Desselle,Mathilde %A Padilha Lanari Bo,Antonio %A Abayasiri,R Achintha M %A Fleming,Jennifer %A Baghaei,Nilufar %A Kim,Dan Dongseong %K cyberattacks %K cyber defence %K cyber security %K extended reality %K health care %K privacy %K risk mitigation %K virtual reality %K cybersecurity %D 2024 %7 17.10.2024 %9 %J JMIR XR Spatial Comput %G English %X Background: Virtual reality (VR) is a type of extended reality (XR) technology that is seeing increasing adoption in health care. There is robust evidence articulating how consumer-grade VR presents significant cybersecurity and privacy risks due to the often ubiquitous and wide range of data collection and user monitoring, as well as the unique user impact of attacks due to the immersive nature of the technology. However, little is known about how these risks translate in the use of VR systems in health care settings. Objective: The objective of this scoping review is to identify potential cybersecurity risks associated with clinical XR systems, with a focus on VR, and potential mitigations for them. Methods: The scoping review followed the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews), and publications were reviewed using Covidence software. The Google Scholar database was searched using the predefined search terms. The inclusion criteria of the articles were restricted to relevant primary studies published from 2017 to 2024. Furthermore, reviews, abstracts, viewpoints, opinion pieces, and low-quality studies were excluded. Additionally, data on publication statistics, topic, technology, cyber threats, and risk mitigation were extracted. These data were synthesized and analyzed using the STRIDE (spoofing, tampering, repudiation, information disclosure, denial of service, and elevation of privilege) framework, enterprise risk management framework, and National Institute of Standards and Technology Cybersecurity Framework, as well as developing threat taxonomies. Results: Google Scholar returned 482 articles that matched the search criteria. After title and abstract screening, 53 studies were extracted for a full-text review, of which 29 were included for analysis. Of these, the majority were published in the last 4 years and had a focus on VR. The greatest cyber threat identified to XR components was information disclosure followed by tampering when mapped against the STRIDE framework. The majority of risk mitigation strategies provide confidentiality and integrity and can potentially address these threats. Only 3 of 29 papers mention XR in the context of health care and none of the identified threats or mitigations have been studied in a clinical setting. Conclusions: This scoping review identified privacy threats where personal and health-related data may be inferred from VR usage data, potentially breaching confidentiality, as the most significant threat posited for health care VR systems. Additionally, immersive manipulation threats were highlighted, which could potentially risk user safety when launched from a compromised VR system. Many potential mitigations were identified for these threats, but these mitigations must first be assessed for their effectiveness and suitability for health care services. Furthermore, health care services should consider the usage and governance of XR for each individual application based on risk threshold and perceived benefits. Finally, it is also important to note that this scoping review was limited by the quality and scope of the studies returned by Google Scholar. %R 10.2196/59409 %U https://xr.jmir.org/2024/1/e59409 %U https://doi.org/10.2196/59409 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 11 %N %P e56278 %T Older Adults’ Acceptance of a Virtual Reality Group Intervention in Nursing Homes: Pre-Post Study Under Naturalistic Conditions %A Li,Yijun %A Shiyanov,Irina %A Muschalla,Beate %K virtual reality %K VR %K computer-generated simulation %K simulation %K technology acceptance %K nursing home %K nursing facility %K long-term care center %K long-term care facility %K older adult %K elder %K elderly %K older person %K older people %K senior %K understanding human behavior %K meaningful activity %K group intervention %K human behavior %D 2024 %7 4.10.2024 %9 %J JMIR Hum Factors %G English %X Background: Virtual reality (VR) group activities can act as interventions against inactivity and lack of meaningful activities in nursing homes. The acceptance of VR among older adults has been explored from different perspectives. However, research on the impact of older adults’ individual characteristics on the acceptance of VR group activities in nursing homes is necessary. Objective: This study investigates the impact of individual characteristics (eg, psychosocial capacities) on VR acceptance among older adults in nursing homes, as well as this group’s perceptions of VR after participating in a VR intervention. Methods: In this pre-post study conducted in nursing homes, we applied a VR group intervention with 113 older adult participants. These participants were categorized into two groups based on their naturalistic choice to join the intervention: a higher VR acceptance group (n=90) and a lower VR acceptance group (n=23). We compared the two groups with respect to their sociodemographic characteristics, psychosocial capacities, and attitudes toward new technologies. Additionally, we examined the participants’ perceptions of VR. Results: The results show that those with lower acceptance of VR initially reported higher capacities in organizing daily activities and stronger interpersonal relationships compared to older adults with higher VR acceptance. The VR group activity might hold limited significance for the latter group, but it offers the chance to activate older adults with lower proactivity. Openness to new technology was associated with a favorable perception of VR. After the VR intervention, the acceptance of VR remained high. Conclusions: This study investigates the acceptance of VR group events as meaningful activities for older adults in nursing homes under naturalistic conditions. The results indicate that the VR group intervention effectively addressed low proactivity and interpersonal relationship issues among older adults in nursing homes. Older adults should be encouraged to experience VR if the opportunity to participate is offered, potentially facilitated by caregivers or trusted individuals. %R 10.2196/56278 %U https://humanfactors.jmir.org/2024/1/e56278 %U https://doi.org/10.2196/56278 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e58089 %T Implementation of a Virtual Reality Intervention in Outpatient Physiotherapy for Chronic Pain: Protocol for a Pilot Implementation Study %A Elser,Alexander %A Kopkow,Christian %A Schäfer,Axel Georg %+ Faculty of Social Work and Health, HAWK University of Applied Sciences and Arts Hildesheim/Holzminden/Göttingen, Hohnsen 4, Hildesheim, 31134, Germany, 49 5121881 12, alexander.elser@hawk.de %K chronic pain %K implementation %K virtual reality %K VR %K physiotherapy %K virtual reality intervention %K pain %K outpatient %K chronic pain conditions %K evidence-based %D 2024 %7 23.9.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Chronic pain is a global health issue that causes physical, psychological, and social disabilities for patients, as well as high costs for societies. Virtual reality (VR) is a new treatment that provides an opportunity to narrow the gap between clinical practice and recommended care in the use of patient education and behavioral interventions in the outpatient physiotherapy setting. However, there is currently no implementation strategy to integrate VR treatments into this setting. Objective: This protocol outlines a pilot implementation study that aims to (1) identify barriers and facilitators for implementing a VR intervention in outpatient physiotherapy care for people with chronic pain and (2) develop and pilot test an implementation strategy in 5 practices in Germany. Methods: The study consists of 4 phases. The first phase involves adapting the treatment protocol of the VR intervention to the local context of outpatient physiotherapy practices in Germany. The second phase includes the collection of barriers and facilitators through semistructured interviews from physiotherapists and the development of a theory-driven implementation strategy based on the Theoretical Domains framework and the Behavior Change Wheel. This strategy will be applied in the third phase, which will also include a 6-month span of using VR interventions in practices, along with a process evaluation. The fourth phase consists of semistructured interviews to evaluate the developed implementation strategy. Results: The recruitment process and phase 1, including the adaptation of the treatment protocol, have already been completed. We recruited 5 physiotherapy practices in Lower Saxony, Germany, where the VR intervention will be implemented. The collection of barriers and facilitators through semistructured interviews is scheduled to begin in February 2024. Conclusions: This pilot implementation study aims to develop a theory-driven implementation strategy for integrating a VR intervention into outpatient physiotherapy care for people with chronic pain. The identified barriers and facilitators, along with the implementation strategy, will serve as a starting point for future randomized controlled implementation studies in different settings to refine the implementation process and integrate VR interventions into the outpatient care of people with chronic pain. Trial Registration: German Clinical Trials Register DRKS00030862; https://tinyurl.com/3zf7uujx International Registered Report Identifier (IRRID): DERR1-10.2196/58089 %M 39312768 %R 10.2196/58089 %U https://www.researchprotocols.org/2024/1/e58089 %U https://doi.org/10.2196/58089 %U http://www.ncbi.nlm.nih.gov/pubmed/39312768 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e55730 %T Toward Physiological Detection of a “Just-Right” Challenge Level for Motor Learning in Immersive Virtual Reality: Protocol for a Cross-Sectional Study %A Houzangbe,Samory %A Lemay,Martin %A Levac,Danielle E %+ School of Rehabilitation, Faculty of Medicine, University of Montreal, Centre de Réadaptation Marie Enfant, 5200 rue Bélanger, Montréal, QC, H1T 1E1, Canada, 1 5145523756, samory.houzangbe@umontreal.ca %K virtual reality %K pediatric rehabilitation %K physiological data %K engagement %K just-right challenge %D 2024 %7 23.9.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Motor learning, a primary goal of pediatric rehabilitation, is facilitated when tasks are presented at a “just-right” challenge level—at the edge of the child’s current abilities, yet attainable enough to motivate the child in persistent efforts for success. Immersive virtual reality (VR) may be ideally suited for “just-right” task challenges because it enables precise adjustments of task parameters in motivating environments. Rehabilitation-specific VR tasks often use dynamic difficulty algorithms based on task performance to personalize task difficulty. However, these approaches do not consider relevant cognitive processes that could also impact “just-right” challenges, such as attention and engagement. Objective physiological measurement of these cognitive processes using wearable sensors could support their integration within “just-right” challenge detection and prediction algorithms. As a first step, it is important to explore relationships between objectively and subjectively measured psychophysiological states at progressively challenging task difficulty levels. Objective: This study aims to (1) evaluate the performance of wearable sensors in a novel movement-based motor learning immersive VR task; (2) evaluate changes in physiological data at 3 task difficulty levels; and (3) explore the relationship between physiological data, task performance, and self-reported cognitive processes at each task difficulty level. Methods: This study uses the within-participant experimental design. Typically developing children and youth aged 8-16 years will be recruited to take part in a single 90-minute data collection session. Physiological sensors include electrodermal activity, heart rate, electroencephalography, and eye-tracking. After collecting physiological data at rest, participants will play a seated unimanual immersive VR task involving bouncing a virtual ball on a virtual racket. They will first play for 3 minutes at a predefined medium level of difficulty to determine their baseline ability level and then at a personalized choice of 3 progressive difficulty levels of 3 minutes each. Following each 3-minute session, participants will complete a short Likert-scale questionnaire evaluating engagement, attention, cognitive workload, physical effort, self-efficacy, and motivation. Data loss and data quality will be calculated for each sensor. Repeated-measures ANOVAs will evaluate changes in physiological response at each difficulty level. Correlation analyses will determine individual relationships between task performance, physiological data, and self-reported data at each difficulty level. Results: Research ethics board approval has been obtained, and data collection is underway. Data collection was conducted on December 12, 2023, and April 12, 2024, with a total of 15 typically developing children. Data analysis has been completed, and results are expected to be published in the fall of 2024. Conclusions: Wearable sensors may provide insights into the physiological effects of immersive VR task interaction at progressive difficulty levels in children and youth. Understanding the relationship between physiological and self-reported cognitive processes is a first step in better identifying and predicting “just-right” task challenges during immersive VR motor learning interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/55730 %M 39312763 %R 10.2196/55730 %U https://www.researchprotocols.org/2024/1/e55730 %U https://doi.org/10.2196/55730 %U http://www.ncbi.nlm.nih.gov/pubmed/39312763 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e57093 %T Exploring Adaptive Virtual Reality Systems Used in Interventions for Children With Autism Spectrum Disorder: Systematic Review %A Maddalon,Luna %A Minissi,Maria Eleonora %A Parsons,Thomas %A Hervas,Amaia %A Alcaniz,Mariano %+ Laboratory of Immersive Neurotechnologies, Institute Human-Tech, Universitat Politècnica de València, Camino de Vera s/n, Polytechnic City of Innovation: Access N – Building 8B – 3rd Floor, Valencia, 46022, Spain, 34 963877518 ext 67018, lmaddal@upv.edu.es %K adaptive system %K virtual reality %K autism spectrum disorder %K intervention %K training %K children %K machine learning %K biosignal %D 2024 %7 18.9.2024 %9 Review %J J Med Internet Res %G English %X Background: Adaptive systems serve to personalize interventions or training based on the user’s needs and performance. The adaptation techniques rely on an underlying engine responsible for processing incoming data and generating tailored responses. Adaptive virtual reality (VR) systems have proven to be efficient in data monitoring and manipulation, as well as in their ability to transfer learning outcomes to the real world. In recent years, there has been significant interest in applying these systems to improve deficits associated with autism spectrum disorder (ASD). This is driven by the heterogeneity of symptoms among the population affected, highlighting the need for early customized interventions that target each individual’s specific symptom configuration. Objective: Recognizing these technology-driven therapeutic tools as efficient solutions, this systematic review aims to explore the application of adaptive VR systems in interventions for young individuals with ASD. Methods: An extensive search was conducted across 3 different databases—PubMed Central, Scopus, and Web of Science—to identify relevant studies from approximately the past decade. Each author independently screened the included studies to assess the risk of bias. Studies satisfying the following inclusion criteria were selected: (1) the experimental tasks were delivered via a VR system, (2) system adaptation was automated, (3) the VR system was designed for intervention or training of ASD symptoms, (4) participants’ ages ranged from 6 to 19 years, (5) the sample included at least 1 group with ASD, and (6) the adaptation strategy was thoroughly explained. Relevant information extracted from the studies included the sample size and mean age, the study’s objectives, the skill trained, the implemented device, the adaptive strategy used, the engine techniques, and the signal used to adapt the systems. Results: Overall, a total of 10 articles were included, involving 129 participants, 76% of whom had ASD. The studies included level switching (7/10, 70%), adaptive feedback strategies (9/10, 90%), and weighing the choice between a machine learning (ML) adaptive engine (3/10, 30%) and a non-ML adaptive engine (8/10, 80%). Adaptation signals ranged from explicit behavioral indicators (6/10, 60%), such as task performance, to implicit biosignals, such as motor movements, eye gaze, speech, and peripheral physiological responses (7/10, 70%). Conclusions: The findings reveal promising trends in the field, suggesting that automated VR systems leveraging real-time progression level switching and verbal feedback driven by non-ML techniques using explicit or, better yet, implicit signal processing have the potential to enhance interventions for young individuals with ASD. The limitations discussed mainly stem from the fact that no technological or automated tools were used to handle data, potentially introducing bias due to human error. %M 39293060 %R 10.2196/57093 %U https://www.jmir.org/2024/1/e57093 %U https://doi.org/10.2196/57093 %U http://www.ncbi.nlm.nih.gov/pubmed/39293060 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52785 %T Is the Apple Vision Pro the Ultimate Display? A First Perspective and Survey on Entering the Wonderland of Precision Medicine %A Egger,Jan %A Gsaxner,Christina %A Luijten,Gijs %A Chen,Jianxu %A Chen,Xiaojun %A Bian,Jiang %A Kleesiek,Jens %A Puladi,Behrus %+ Department of Oral and Maxillofacial Surgery & Institute of Medical Informatics, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany, 49 241 80 88231, bpuladi@ukaachen.de %K Apple Vision Pro %K mixed reality %K augmented reality %K virtual reality %K health care %K mobile phone %D 2024 %7 18.9.2024 %9 Viewpoint %J JMIR Serious Games %G English %X At the Worldwide Developers Conference in June 2023, Apple introduced the Vision Pro. The Apple Vision Pro (AVP) is a mixed reality headset; more specifically, it is a virtual reality device with an additional video see-through capability. The video see-through capability turns the AVP into an augmented reality (AR) device. The AR feature is enabled by streaming the real world via cameras on the (virtual reality) screens in front of the user’s eyes. This is, of course, not unique and is similar to other devices, such as the Varjo XR-3 (Varjo Technologies Oy). Nevertheless, the AVP has some interesting features, such as an inside-out screen that can show the headset wearer’s eyes to “outsiders,” and a button on the top, called the “digital crown,” that allows a seamless blend of digital content with the user’s physical space by turning it. In addition, it is untethered, except for the cable to the battery, which makes the headset more agile, compared to the Varjo XR-3. This could actually come closer to “The Ultimate Display,” which Ivan Sutherland had already sketched in 1965. After a great response from the media and social networks to the release, we were able to test and review the new AVP ourselves in March 2024. Including an expert survey with 13 of our colleagues after testing the AVP in our institute, this Viewpoint explores whether the AVP can overcome clinical challenges that AR especially still faces in the medical domain; we also go beyond this and discuss whether the AVP could support clinicians in essential tasks to allow them to spend more time with their patients. %M 39292499 %R 10.2196/52785 %U https://games.jmir.org/2024/1/e52785 %U https://doi.org/10.2196/52785 %U http://www.ncbi.nlm.nih.gov/pubmed/39292499 %0 Journal Article %@ 2561-9128 %I JMIR Publications %V 7 %N %P e48959 %T Use of Biofeedback-Based Virtual Reality in Pediatric Perioperative and Postoperative Settings: Observational Study %A Orgil,Zandantsetseg %A Karthic,Anitra %A Bell,Nora F %A Heisterberg,Lisa M %A Williams,Sara E %A Ding,Lili %A Kashikar-Zuck,Susmita %A King,Christopher D %A Olbrecht,Vanessa A %+ Department of Anesthesiology and Perioperative Medicine, Nemours Children’s Health, Delaware Valley, 1600 Rockland Road, Wilmington, DE, 19803, United States, 1 3022987443, Vanessa.Olbrecht@nemours.org %K virtual reality %K biofeedback %K biofeedback-based virtual reality %K acute pain %K postoperative pain %K pediatrics %K postoperative %K pain %K anxiety %K children %K adolescents %K perioperative management %K acceptability %K feasibility %K pain reduction %D 2024 %7 16.9.2024 %9 Original Paper %J JMIR Perioper Med %G English %X Background: Biofeedback-based virtual reality (VR-BF) is a novel, nonpharmacologic method for teaching patients how to control their breathing, which in turn increases heart rate variability (HRV) and may reduce pain. Unlike traditional forms of biofeedback, VR-BF is delivered through a gamified virtual reality environment, increasing the accessibility of biofeedback. This is the first study to systematically integrate VR-BF use in the pediatric perioperative setting, with the ultimate goal of evaluating the efficacy of VR-BF to reduce pain, anxiety, and opioid consumption once feasibility and acceptability have been established. Objectives: The primary objective was to develop a clinical trial protocol for VR-BF use in the pediatric perioperative setting, including preoperative education and training, and postoperative application of VR-BF in children undergoing surgery. A secondary objective was to evaluate the patient and parent experience with VR-BF. Methods: A total of 23 patients (12-18 years of age) scheduled for surgery at Nationwide Children’s Hospital were recruited using purposive sampling. Following training, participants independently completed a daily, 10-minute VR-BF session for 7 days before surgery and during their inpatient stay. Participants could use VR-BF up to 2 weeks after hospital discharge. Patient- and session-level data of VR-BF usage and achievement of target HRV parameters were measured to identify the optimal frequency and duration of sessions before and after surgery for this population. Standardized questionnaires and semistructured interviews were conducted to obtain qualitative information about patients’ experiences with VR-BF. Results: Patient-level data indicated that the highest odds of achieving 1 session under target HRV parameters was after 4 sessions (odds ratio [OR] 5.1 for 4 vs 3 sessions, 95% CI 1.3-20.6; OR 16.6 for 3 vs 2 sessions, 95% CI 1.2-217.0). Session-level data showed that a session duration of 9 to 10 minutes provided the greatest odds of achieving 1 session under target HRV parameters (OR 1.3 for 9 vs 8 min, 95% CI 1.1-1.7; OR 1.4 for 8 vs 7 min, 95% CI 1.1-1.8; OR 1 for 10 vs 9 min, 95% CI 0.9-1.2). Qualitative data revealed patient satisfaction with the VR-BF technology, particularly in managing perioperative stress (17/20, 85%). Few patients reported VR-BF as beneficial for pain (8/20, 40%). Conclusions: Children and adolescents undergoing surgery successfully learned behavioral strategies with VR-BF with 10-minute sessions once daily for 5 days. To integrate VR-BF as a therapeutic intervention in a subsequent clinical trial, patients will be instructed to complete three 10-minute sessions a day for 7 days after surgery. Trial Registration: ClinicalTrials NCT04943874; https://clinicaltrials.gov/ct2/show/NCT04943874 %M 38742940 %R 10.2196/48959 %U https://periop.jmir.org/2024/1/e48959 %U https://doi.org/10.2196/48959 %U http://www.ncbi.nlm.nih.gov/pubmed/38742940 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e57809 %T Effects of Virtual Reality Motor-Cognitive Training for Older People With Cognitive Frailty: Multicentered Randomized Controlled Trial %A Kwan,Rick Yiu Cho %A Liu,Justina %A Sin,Olive Suk Kan %A Fong,Kenneth N K %A Qin,Jing %A Wong,Joe Chi Yin %A Lai,Claudia %+ School of Nursing, Tung Wah College, 31 Wylie Road, Homantin, Hong Kong, NA, China (Hong Kong), 852 34686813, rickkwan@twc.edu.hk %K virtual reality %K motor-cognitive training %K cognitive frailty %K gamification %D 2024 %7 11.9.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive frailty refers to a clinical syndrome in which physical frailty and mild cognitive impairment coexist. Motor-cognitive training and virtual reality (VR) have been used to launch various therapeutic modalities to promote health in older people. The literature advocates that motor-cognitive training and VR are effective in promoting the cognitive and physical function of older people. However, the effects on older people with cognitive frailty are unclear. Objective: This study examined the effects of VR motor-cognitive training (VRMCT) on global cognitive function, physical frailty, walking speed, visual short-term memory, inhibition of cognitive interference, and executive function in older people with cognitive frailty. Methods: This study used a multicentered, assessor-blinded, 2-parallel-group randomized controlled trial design. Participants were recruited face-to-face in 8 older adult community centers. Eligible participants were aged ≥60 years, were community dwelling, lived with cognitive frailty, had no dementia, and were not mobility restricted. In the intervention group, participants received VRMCT led by interventionists with 16 one-hour training sessions delivered twice per week for 8 weeks. In the control group, participants received the usual care provided by the older adult community centers that the investigators did not interfere with. The primary outcome was global cognitive function. The secondary outcomes included physical frailty, walking speed, verbal short-term memory, inhibition of cognitive interference, and executive function. Data were collected at baseline (T0) and the week after the intervention (T1). Generalized estimating equations were used to examine the group, time, and interaction (time × group) effects on the outcomes. Results: In total, 293 eligible participants enrolled in the study. The mean age of the participants was 74.5 (SD 6.8) years. Most participants were female (229/293, 78.2%), had completed primary education (152/293, 52.1%), were married (167/293, 57.2%), lived with friends (127/293, 43.3%), and had no VR experience (232/293, 79.5%). In the intervention group, 81.6% (119/146) of participants attended >80% (13/16, 81%) of the total number of sessions. A negligible number of participants experienced VR sickness symptoms (1/146, 0.7% to 5/146, 3%). VRMCT was effective in promoting global cognitive function (interaction effect: P=.03), marginally promoting executive function (interaction effect: P=.07), and reducing frailty (interaction effect: P=.03). The effects were not statistically significant on other outcomes. Conclusions: VRMCT is effective in promoting cognitive functions and reducing physical frailty and is well tolerated and accepted by older people with cognitive frailty, as evidenced by its high attendance rate and negligible VR sickness symptoms. Further studies should examine the efficacy of the intervention components (eg, VR vs non-VR or dual task vs single task) on health outcomes, the effect of using technology on intervention adherence, and the long-term effects of the intervention on older people with cognitive frailty at the level of daily living. Trial Registration: ClinicalTrials.gov NCT04730817; https://clinicaltrials.gov/study/NCT04730817 %M 39259959 %R 10.2196/57809 %U https://www.jmir.org/2024/1/e57809 %U https://doi.org/10.2196/57809 %U http://www.ncbi.nlm.nih.gov/pubmed/39259959 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e57588 %T Feasibility of At-Home Hand Arm Bimanual Intensive Training in Virtual Reality: Case Study %A Gehringer,James E %A Woodruff Jameson,Anne %A Boyer,Hailey %A Konieczny,Jennifer %A Thomas,Ryan %A Pierce III,James %A Cunha,Andrea B %A Willett,Sandra %+ Virtual Reality Laboratory, Munroe-Meyer Insitute, University of Nebraska Medical Center, 985450 Nebraska Medical Center, Omaha, NE, 68198, United States, 1 4025592562, james.gehringer@unmc.edu %K cerebral palsy %K HABIT %K home intervention %K virtual reality %K rehabilitation %K VR %K case study %K hand %K hands %K arm %K arms %K intensive training %K feasibility %K game %K games %K gaming %K hand arm bimanual intensive training %K motor %K movement %K home setting %K home-based %K child %K children %K male %K males %K men %K quasi-experimental %K parent %K parents %K intervention %K interventions %D 2024 %7 6.9.2024 %9 Case Report %J JMIR Form Res %G English %X This single-participant case study examines the feasibility of using custom virtual reality (VR) gaming software in the home environment for low-dose Hand Arm Bimanual Intensive Training (HABIT). A 10-year-old with right unilateral cerebral palsy participated in this trial. Fine and gross motor skills as well as personal goals for motor outcomes were assessed before and after the intervention using the Box and Blocks Test, Nine-Hole Peg Test, and Canadian Occupational Performance Measure. Movement intensities collected via the VR hardware accelerometers, VR game scores, and task accuracy were recorded via the HABIT-VR software as indices of motor performance. The child and family were instructed to use the HABIT-VR games twice daily for 30 minutes over a 14-day period and asked to record when they used the system. The child used the system and completed the 14-hour, low-dose HABIT-VR intervention across 22 days. There was no change in Box and Blocks Test and Nine-Hole Peg Test scores before and after the intervention. Canadian Occupational Performance Measure scores increased but did not reach the clinically relevant threshold, due to high scores at baseline. Changes in motor task intensities during the use of VR and mastery of the VR bimanual tasks suggested improved motor efficiency. This case study provides preliminary evidence that HABIT-VR is useful for promoting adherence to HABIT activities and for the maintenance of upper extremity motor skills in the home setting. %M 39241226 %R 10.2196/57588 %U https://formative.jmir.org/2024/1/e57588 %U https://doi.org/10.2196/57588 %U http://www.ncbi.nlm.nih.gov/pubmed/39241226 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e57990 %T Assessing Predictive Factors of Attitudes Toward Peer-Supported Mental Health Interventions in the Metaverse: Mixed Methods Study %A Ramos,Francisco Nicolas %A Bernstein,Rachel A %A Ezawa,Iony D %+ Department of Psychology, University of Southern California, 3620 S McClintock Ave, Los Angeles, CA, 90089, United States, 1 (213) 740 2203, ezawa@usc.edu %K metaverse %K mental health intervention %K consumer attitude %K digital mental health intervention %K virtual world %D 2024 %7 22.8.2024 %9 Original Paper %J JMIR XR Spatial Comput %G English %X Background: The metaverse is a promising avenue for accessible, effective digital mental health treatments. However, general attitudes toward peer-supported metaverse mental health interventions (MMHIs) remain largely unexplored. Objective: This study examined the relation of sociodemographic, mental health, and technology factors in predicting attitudes toward MMHIs. Methods: We used a mixed methods design with a self-report online survey (N=545 participants) to assess participant attitudes toward MMHIs and sociodemographic, mental health, and technology factors. Ordinal logistic regression was used to examine predictors of general interest in peer-supported MMHIs and binary logistic regression to examine predictors of preference for MMHIs versus face-to-face interventions. Inductive content analysis was performed on 483 open-ended responses regarding intervention preference. Results: Older age (odds ratio [OR] 1.03, 95% CI 1.02-1.05; P<.001), higher ethnic identity centrality (OR 1.44, 95% CI 1.25-1.66; P<.001), more positive mental help–seeking attitudes (OR 1.22, 95% CI 1.06-1.42; P=.007), more online video game use (OR 1.26, 95% CI 1.09-1.44; P=.001), and greater virtual reality experience (OR 1.55, 95% CI 1.28-1.90; P<.001) were associated with greater odds of reporting more interest in MMHIs. Internet access was associated with greater odds of reporting less interest in MMHIs (OR 0.50, 95% CI 0.30-0.84; P=.01). Hispanic ethnicity (OR 1.81, 95% CI 1.13-2.90; P=.01), older age (OR 1.04, 95% CI 1.02-1.05; P<.001), higher ethnic identity centrality (OR 1.28, 95% CI 1.09-1.51; P=.003), smartphone access (OR 10.46, 95% CI 2.87-50.71; P<.001), higher self-reported video game use (OR 1.25, 95% CI 1.05-1.48; P=.01), and more positive computer attitudes (OR 1.05, 95% CI 1.01-1.10; P=.02) predicted greater odds of preference for MMHIs (versus face-to-face interventions), whereas the male gender (OR 0.43, 95% CI 0.28-0.68; P<.001), internet access (OR 0.12, 95% CI 0.02-0.40; P=.002), more positive mental help–seeking attitudes (OR 0.76, 95% CI 0.62-0.92; P=.005), and moderately severe (OR 0.20, 95% CI 0.07-0.51; P=.001) and severe (OR 0.26, 95% CI 0.08-0.79; P=.02) levels of depression symptoms predicted lower odds of preference for MMHIs. Qualitative analysis revealed 14 themes describing reasons for intervention preference. Anonymity (133/483, 27.5%), social aversion (38/483, 7.9%), ease of use and accessibility (35/483, 7.2%), anxiety (28/483, 5.8%), and comfort (26/483, 5.4%) tended to be endorsed by those preferring MMHIs. Ecological validity of social interactions (99/483, 20.5%), ecological validity of interventions (75/483, 15.5%), aversion/distrust toward technology (42/483, 8.7%), impersonal quality (31/483, 6.4%), and immersion/engagement (11/483, 2.3%) tended to be endorsed by those who preferred face-to-face interventions. Mental health attitudes (28/483, 5.8%), privacy (19/483, 3.9%), and miscellaneous reasons (46/483, 9.5%) were endorsed equally between preferences. Novelty (21/483, 4.3%) was most cited by those who expressed no preference. Conclusions: This study identified several factors associated with attitudes toward peer-supported MMHIs, which may be leveraged to inform mental health outreach to interested populations. %R 10.2196/57990 %U https://xr.jmir.org/2024/1/e57990 %U https://doi.org/10.2196/57990 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e50066 %T The Rationale Behind the Design Decisions in an Augmented Reality Mobile eHealth Exergame to Increase Physical Activity for Inactive Older People With Heart Failure %A Berglund,Aseel %A Klompstra,Leonie %A Orädd,Helena %A Fallström,Johan %A Strömberg,Anna %A Jaarsma,Tiny %A Berglund,Erik %K sedentary %K exercise %K exertion %K exergames %K technology %K training %K inactivity %K eHealth application %K heart disease %K physical activity %D 2024 %7 21.8.2024 %9 %J JMIR Serious Games %G English %X Physical activity is important for everyone to maintain and improve health, especially for people with chronic diseases. Mobile exergaming has the potential to increase physical activity and to specifically reach people with poor activity levels. However, commercial mobile exergames are not specially designed for older people with chronic illnesses such as heart failure. The primary aim of this viewpoint is to describe the underlying reasoning guiding the design choices made in developing a mobile exergame, Heart Farming, tailored specifically for sedentary older people diagnosed with heart failure. The goal of the exergame is to increase physical activity levels by increasing the daily walking duration of patients with heart failure by at least 10 minutes. The rationale guiding the design decisions of the mobile exergame is grounded in the thoughtful integration of gamification strategies tailored for application in cardiovascular care. This integration is achieved through applying gamification components, gamification elements, and gamification principles. The Heart Farming mobile exergame is about helping a farmer take care of and expand a virtual farm, with these activities taking place while the patient walks in the real world. The exergame can be adapted to individual preferences and physical condition regarding where, how, when, and how much to play and walk. The exergame is developed using augmented reality so it can be played both indoors and outdoors. Augmented reality technology is used to track the patients’ movement in the real world and to interpret that movement into events in the exergame rather than to augment the mobile user interface. %R 10.2196/50066 %U https://games.jmir.org/2024/1/e50066 %U https://doi.org/10.2196/50066 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e54724 %T Use of Immersive Virtual Reality in Nursing Homes for People With Dementia: Feasibility Study to Assess Cognitive, Motor, and Emotional Responses %A Prinz,Alexander %A Buerger,Dan %A Krafft,Jelena %A Bergmann,Matteo %A Woll,Alexander %A Barisch-Fritz,Bettina %A Witte,Kerstin %+ Institute of Sports and Sports Science, Karlsruhe Institute of Technology, Engler-Bunte-Ring 15, Karlsruhe, 76131, Germany, 49 721 49049244, bettina.barisch-fritz@kit.edu %K persons with dementia %K virtual reality %K VR %K immersive virtual reality %K iVR %K head-mounted display %K HMD %K physical performance %K physical activity %K physical function %K motor performance %K Alzheimer’s disease %K Alzheimer’s %K Alzheimer’s treatment %K Alzheimer’s care %K Alzheimer’s symptom control %K dementia %K dementia therapy %K dementia care %K cognitive decline %K cognitive impairment %K cognitive impairments %K neurocognition %K neurology %K neurologist %K neurologists %K nursing home %K nursing homes %K nursing facility %K senior home %K long-term care center %K long-term care facility %D 2024 %7 21.8.2024 %9 Original Paper %J JMIR XR Spatial Comput %G English %X Background: Physical activity interventions for people with dementia have shown promising effects in improving cognition and physical function or slowing disease-related decline. Immersive virtual reality (iVR), using head-mounted displays, facilitates realistic experiences by blurring the boundaries between VR and the real world. The use of iVR for people with dementia offers the potential to increase active time and improve dementia therapy and care through exercise interventions. However, the feasibility of using VR use in people with dementia, considering changes in motor, cognitive, psychological, and physiological parameters, remains insufficiently investigated. Objective: This study aims to investigate the feasibility of using iVR in people with dementia or mild cognitive impairment in nursing homes. Specifically, we examined changes in motor performance (balance and mobility), cognitive performance (global cognition and executive functions), emotional responses, and fear of falling using iVR. Methods: Utilizing a pre-post design, this study recruited 35 participants with mild-to-moderate dementia, assessed by the Mini-Mental State Examination (MMSE). Participants underwent a single session involving iVR exposure, with pre- and postexposure assessments and a feedback form, to exclude negative effects on cognitive and motor functions, mood, anxiety levels, and balance performance. The use of iVR involved 4 scenes, with a total length of 8 minutes. These scenes depicted a park with short and rather passive impressions presented as a 360° video in a head-mounted display. Before and after using the iVR, cognitive parameters were assessed using the Trail-Making Test A (TMT-A), motor parameters were assessed using the FICSIT-4 (Frailty and Injuries: Cooperative Studies of Intervention Techniques-4) and Timed-Up-and-Go (TUG) tests, and psychological parameters were assessed using the Dementia Mood Picture Test, State-Trait Anxiety Inventory, and Short Falls Efficacy Scale-International (Short FES-I). The Emotion Rating Scale and the duration of use were recorded during use, and a feedback questionnaire was completed afterward in addition to the posttests. Paired t tests and Wilcoxon tests were used to examine pre-post differences. Results: Of the 35 initial participants, 33 completed the study, which corresponds to a dropout rate of 6%. All 33 participants, who had a mean of 83.71 (SD 5.01) years, had dementia. They showed no statistically significant difference in cognitive and motor performance before and after iVR use. Thus, no negative effects on cognitive and motor functions, mood, anxiety levels, and balance performance were observed. The emotion rating scale also showed that 72% (n=24) felt joy and fun during iVR use, 100% (n=33) showed no emotions such as fear, sadness, or anger, and 93% (n=31) were attentive during iVR use. Conclusions: The feasibility of using iVR for people with dementia can be rated positively. There were no changes in motor, cognitive, or emotional parameters that would increase the risk of falls or other negative emotional reactions during or after iVR use. Further studies are needed to investigate prolonged use in a more stimulating computer-generated environment and possible physical and cognitive tasks for people with dementia in nursing homes. Trial Registration: German Clinical Trials Register DRKS00030616; https://drks.de/search/de/trial/DRKS00030616 %R 10.2196/54724 %U https://xr.jmir.org/2024/1/e54724 %U https://doi.org/10.2196/54724 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e48787 %T Immersive and Nonimmersive Virtual Reality–Assisted Active Training in Chronic Musculoskeletal Pain: Systematic Review and Meta-Analysis %A Lo,Hermione Hin Man %A Zhu,Mengting %A Zou,Zihui %A Wong,Cho Lee %A Lo,Suzanne Hoi Shan %A Chung,Vincent Chi-Ho %A Wong,Samuel Yeung-Shan %A Sit,Regina Wing Shan %+ Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Room 209, Public Health Building, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong, China (Hong Kong), 852 2252 8452, reginasit@cuhk.edu.hk %K virtual reality %K VR %K physical therapy %K musculoskeletal %K pain %K physiotherapy %K chronic pain %K musculoskeletal pain %K low back pain %K neck pain %K osteoarthritis %K knee pain %K shoulder pain %K disability %K kinesiophobia %K arthritis %K systematic %K review methods %K review methodology %K immersive %K simulation %K simulations %D 2024 %7 19.8.2024 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) in different immersive conditions has been increasingly used as a nonpharmacological method for managing chronic musculoskeletal pain. Objective: We aimed to assess the effectiveness of VR-assisted active training versus conventional exercise or physiotherapy in chronic musculoskeletal pain and to analyze the effects of immersive versus nonimmersive VR on pain outcomes. Methods: This systematic review of randomized control trials (RCTs) searched PubMed, Scopus, and Web of Science databases from inception to June 9, 2024. RCTs comparing adults with chronic musculoskeletal pain receiving VR-assisted training were included. The primary outcome was pain intensity; secondary outcomes included functional disability and kinesiophobia. Available data were pooled in a meta-analysis. Studies were graded using the Cochrane Risk-of-Bias Tool version 2. Results: In total, 28 RCTs including 1114 participants with some concerns for a high risk of bias were identified, and 25 RCTs were included in the meta-analysis. In low back pain, short-term outcomes measured post intervention showed that nonimmersive VR is effective in reducing pain (standardized mean difference [SMD] –1.79, 95% CI –2.72 to –0.87; P<.001), improving disability (SMD –0.44, 95% CI –0.72 to –0.16; P=.002), and kinesiophobia (SMD –2.94, 95% CI –5.20 to –0.68; P=.01). Intermediate-term outcomes measured at 6 months also showed that nonimmersive VR is effective in reducing pain (SMD –8.15, 95% CI –15.29 to –1.01; P=.03), and kinesiophobia (SMD –4.28, 95% CI –8.12 to –0.44; P=.03) compared to conventional active training. For neck pain, immersive VR reduced pain intensity (SMD –0.55, 95% CI –1.02 to –0.08; P=.02) but not disability and kinesiophobia in the short term. No statistical significances were detected for knee pain or other pain regions at all time points. In addition, 2 (8%) studies had a high risk of bias. Conclusions: Both nonimmersive and immersive VR–assisted active training is effective in reducing back and neck pain symptoms. Our study findings suggest that VR is effective in alleviating chronic musculoskeletal pain. Trial Registration: PROSPERO CRD42022302912; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=302912 %M 39159449 %R 10.2196/48787 %U https://www.jmir.org/2024/1/e48787 %U https://doi.org/10.2196/48787 %U http://www.ncbi.nlm.nih.gov/pubmed/39159449 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e62842 %T Immersive Virtual Reality Use in Medical Intensive Care: Mixed Methods Feasibility Study %A Locke,Brian W %A Tsai,Te-yi %A Reategui-Rivera,C Mahony %A Gabriel,Aileen S %A Smiley,Aref %A Finkelstein,Joseph %+ Division of Respiratory, Critical Care, and Occupational Pulmonary Medicine, Department of Internal Medicine, University of Utah, 30 N Mario Capecchi Dr, Salt Lake City, UT, 84112, United States, 1 801 581 7606, brian.locke@imail.org %K immersive virtual reality %K intensive care unit %K distraction therapy %K virtual reality %K mixed methods %K feasibility study %K semistructured interview %K therapy %K therapist %K critical illness %K critically ill %K adult %K patient acceptance %K user experience %K games for health %K serious games %K gamification %D 2024 %7 9.8.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Immersive virtual reality (VR) is a promising therapy to improve the experience of patients with critical illness and may help avoid postdischarge functional impairments. However, the determinants of interest and usability may vary locally and reports of uptake in the literature are variable. Objective: The aim of this mixed methods feasibility study was to assess the acceptability and potential utility of immersive VR in critically ill patients at a single institution. Methods: Adults without delirium who were admitted to 1 of 2 intensive care units were offered the opportunity to participate in 5-15 minutes of immersive VR delivered by a VR headset. Patient vital signs, heart rate variability, mood, and pain were assessed before and after the VR experience. Pre-post comparisons were performed using paired 2-sided t tests. A semistructured interview was administered after the VR experience. Patient descriptions of the experience, issues, and potential uses were summarized with thematic analysis. Results: Of the 35 patients offered the chance to participate, 20 (57%) agreed to partake in the immersive VR experience, with no difference in participation rate by age. Improvements were observed in overall mood (mean difference 1.8 points, 95% CI 0.6-3.0; P=.002), anxiety (difference of 1.7 points, 95% CI 0.8-2.7; P=.001), and pain (difference of 1.3 points, 95% CI 0.5-2.1; P=.003) assessed on 1-10 scales. The heart rate changed by a mean of –1.1 (95% CI –0.3 to –1.9; P=.008) beats per minute (bpm) from a baseline of 86.1 (SD 11.8) bpm and heart rate variability, assessed by the stress index (SI), changed by a mean of –5.0 (95% CI –1.5 to –8.5; P=.004) seconds–2 from a baseline SI of 40.0 (SD 23) seconds–2. Patients commented on the potential for the therapy to address pain, lessen anxiety, and facilitate calmness. Technical challenges were minimal and there were no adverse effects observed. Conclusions: Patient acceptance of immersive VR was high in a mostly medical intensive care population with little prior VR experience. Patients commented on the potential of immersive VR to ameliorate cognitive and emotional symptoms. Investigators can consider integrating minimally modified commercial VR headsets into the existing intensive care unit workflow to further assess VR’s efficacy for a variety of endpoints. %M 39046869 %R 10.2196/62842 %U https://games.jmir.org/2024/1/e62842 %U https://doi.org/10.2196/62842 %U http://www.ncbi.nlm.nih.gov/pubmed/39046869 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e51512 %T Developing an Automated Virtual Reality Therapy for Improving Positive Self-Beliefs and Psychological Well-Being (Phoenix VR Self-Confidence Therapy): Tutorial %A Rosebrock,Laina %A Freeman,Jason %A Rovira,Aitor %A Miguel,Andre Lages %A Ward,Rupert %A Bousfield,Matthew %A Riffiod,Ludovic %A Kamvar,Roya %A Kabir,Thomas %A Waite,Felicity %A Freeman,Daniel %K virtual reality %K VR %K psychosis %K cognitive behavioural therapy %K psychological well-being %K design process %K self-beliefs %K psychological therapy %K real-world %K efficacy %K well-being %K mental health %K participant %K stakeholder %K user %K Phoenix VR Self-Confidence Therapy %D 2024 %7 7.8.2024 %9 %J JMIR Serious Games %G English %X Virtual reality (VR) is an immersive technology in which delivery of psychological therapy techniques can be automated. Techniques can be implemented similarly to real-world delivery or in ways that are not possible in the real world to enhance efficacy. The potential is for greater access for patients to effective therapy. Despite an increase in the use of VR for mental health, there are few descriptions of how to build and design automated VR therapies. We describe the development of Phoenix VR Self-Confidence Therapy, designed to increase positive self-beliefs in young patients diagnosed with psychosis in order to improve psychological well-being. A double-diamond, user-centered design process conducted over the course of 18 months was used, involving stakeholders from multiple areas: individuals with lived experience of psychosis, clinical psychologists, treatment designers, and VR software developers. Thirteen meetings were held with young patients diagnosed with psychosis to increase the understanding and improve the assessment of positive self-beliefs, help design the scenarios for implementing therapeutic techniques, and conduct user testing. The resulting Phoenix therapy is a class I United Kingdom Conformity Assessed (UKCA)–certified medical device designed to be used on the standalone Meta Quest 2 (Meta Platforms) headset. Phoenix aims to build up 3 types of positive self-beliefs that are connected to psychological well-being. In a community farm area, tasks are designed to increase a sense of mastery and achievement (“I can make a difference”); in a TV studio, users complete an activity with graded levels of difficulty to promote success in the face of a challenge (“I can do this”); and in a forest by a lake, activities are designed to encourage feelings of pleasure and enjoyment (“I can enjoy things”). Phoenix is delivered over the course of approximately 6 weekly sessions supported by a mental health provider. Patients can take the headsets home to use in between sessions. Usability testing with individuals with lived experience of psychosis, as well as patients in the National Health Service (aged 16‐26 years), demonstrated that Phoenix is engaging, easy to use, and has high levels of satisfaction. %R 10.2196/51512 %U https://games.jmir.org/2024/1/e51512 %U https://doi.org/10.2196/51512 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e58654 %T Comparing Learning Outcomes of Machine-Guided Virtual Reality–Based Training With Educator-Guided Training in a Metaverse Environment: Randomized Controlled Trial %A Kitapcioglu,Dilek %A Aksoy,Mehmet Emin %A Ozkan,Arun Ekin %A Usseli,Tuba %+ Department of Biomedical Device Technology, Acibadem Mehmet Ali Aydinlar University, Kayisdagi cad. No:32 Atasehir, Istanbul, 34752, Turkey, 90 05052685158, dreminaksoy@gmail.com %K metaverse %K serious gaming %K virtual reality %K educator guidance %K educator %K learning %K machine guided %K VR %K guided training %K randomized controlled trial %K mixed reality %K training %K training module %K module %K correlation %K gaming %K gaming module %K serious game %K game %K games %D 2024 %7 7.8.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) modules are commonly used for health care training, such as adult advanced cardiac life support (ACLS), due to immersion and engagement. The metaverse differs from current VR serious gaming by enabling shared social connections, while current VR modules focus on computer-based content without social interaction. Educators in the metaverse can foster communication and collaboration during training sessions. Objective: This study aimed to compare learning outcomes of VR-based, machine-guided training with educator-guided, VR-based training in the metaverse environment. Methods: A total of 62 volunteered students from Acibadem Mehmet Ali Aydinlar University Vocational School for Anesthesiology were randomly divided into 2 groups of 31 participants each: one group received VR-based training with machine guidance (MG), and the other received VR-based training with educator guidance (EG) in the metaverse. The members of both groups undertook VR-based basic training for ACLS. Afterward, the MG group was trained with a VR-based advanced training module, which provides training with full MG, whereas the EG group attended the VR-based, educator-guided training in the metaverse. The primary outcome of the study was determined by the exam score of the VR-based training module. Descriptive statistics defined continuous variables such as VR exam scores and time spent on machine- or educator-guided training. The correlation between training time and VR exam scores was assessed with the Spearman rank correlation, and nonnormally distributed variables were compared using the Mann-Whitney U test. Statistical significance was set at P<.05, with analyses executed by MedCalc Statistical Software (version 12.7.7). Results: Comparing the VR test scores between the MG and EG groups revealed no statistically significant difference. The VR test scores for the EG group had a median of 86 (range 11-100). In contrast, the MG group scores had a median of 66 (range 13-100; P=.08). Regarding the correlation between the duration of machine-guided or educator-guided training and VR-based exam scores, for the MG group, =0.569 and P=.005 were obtained. For the EG group, this correlation was found to be =0.298 and P=.10. While this correlation is statistically significant for the MG group, it is not significant for the EG group. The post hoc power analysis (80%), considering the correlation between the time spent on training and exam scores, supported this finding. Conclusions: The results of this study suggest that a well-designed, VR-based serious gaming module with MG could provide comparable learning outcomes to VR training in the metaverse with EG for adult ACLS training. Future research with a larger sample size could explore whether social interaction with educators in a metaverse environment offers added benefits for learners. Trial Registration: ClinicalTrials.gov NCT06288087; https://clinicaltrials.gov/study/NCT06288087 %M 39110497 %R 10.2196/58654 %U https://games.jmir.org/2024/1/e58654 %U https://doi.org/10.2196/58654 %U http://www.ncbi.nlm.nih.gov/pubmed/39110497 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e59005 %T The Second Life Metaverse and Its Usefulness in Medical Education After a Quarter of a Century %A Sendra-Portero,Francisco %A Lorenzo-Álvarez,Rocío %A Rudolphi-Solero,Teodoro %A Ruiz-Gómez,Miguel José %+ Department of Radiology and Physical Medicine, Facultad de Medicina, Universidad de Málaga, Bvd. Luis Pasteur, 32. 20071, Málaga, 29071, Spain, 34 952131653, sendra@uma.es %K medical education %K medical students %K postgraduate %K computer simulation %K virtual worlds %K metaverse %D 2024 %7 6.8.2024 %9 Viewpoint %J J Med Internet Res %G English %X The immersive virtual world platform Second Life (SL) was conceived 25 years ago, when Philip Rosedale founded Linden Lab in 1999 with the intention of developing computing hardware that would allow people to immerse themselves in a virtual world. This initial effort was transformed 4 years later into SL, a universally accessible virtual world centered on the user, with commercial transactions and even its own virtual currency, which fully connects with the concept of the metaverse, recently repopularized after the statements of the chief executive officer of Meta (formerly Facebook) in October 2021. SL is considered the best known virtual environment among higher education professionals. This paper aimed to review medical education in the SL metaverse; its evolution; and its possibilities, limitations, and future perspectives, focusing especially on medical education experiences during undergraduate, residency, and continuing medical education. The concept of the metaverse and virtual worlds was described, making special reference to SL and its conceptual philosophy, historical evolution, and technical aspects and capabilities for higher education. A narrative review of the existing literature was performed, including at the same time a point of view from our teaching team after an uninterrupted practical experience of undergraduate and postgraduate medical education in the last 13 years with >4000 users and >10 publications on the subject. From an educational point of view, SL has the advantages of being available 24/7 and creating in the student the important feeling of “being there” and of copresence. This, together with the reproduction of the 3D world, real-time interaction, and the quality of voice communication, makes the immersive experiences unique, generating engagement and a fluid interrelation of students with each other and with their teachers. Various groups of researchers in medical education have developed experiences during these years, which have shown that courses, seminars, workshops and conferences, problem-based learning experiences, evaluations, teamwork, gamification, medical simulation, and virtual objective structured clinical examinations can be successfully carried out. Acceptance from students and faculty is generally positive, recognizing its usefulness for undergraduate medical education and continuing medical education. In the 25 years since its conception, SL has proven to be a virtual platform that connects with the concept of the metaverse, an interconnected, open, and globally accessible system that all humans can access to socialize or share products for free or using a virtual currency. SL remains active and technologically improved since its creation. It is necessary to continue carrying out educational experiences, outlining the organization, objectives, and content and measuring the actual educational impact to make SL a tool of more universal use. %M 39106480 %R 10.2196/59005 %U https://www.jmir.org/2024/1/e59005 %U https://doi.org/10.2196/59005 %U http://www.ncbi.nlm.nih.gov/pubmed/39106480 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e46220 %T The Use of a Novel Virtual Reality Training Tool for Peritoneal Dialysis: Qualitative Assessment Among Health Care Professionals %A Lonati,Caterina %A Wellhausen,Marie %A Pennig,Stefan %A Röhrßen,Thomas %A Kircelli,Fatih %A Arendt,Svenja %A Tschulena,Ulrich %+ Fresenius Medical Care, Else-Kröner-Str. 1, Bad Homburg, 61352, Germany, 49 61722688932, Ulrich.Tschulena@freseniusmedicalcare.com %K peritoneal dialysis %K virtual reality %K patient education %K patient training %K chronic kidney disease %K nursing %K qualitative assessment %D 2024 %7 6.8.2024 %9 Original Paper %J JMIR Med Educ %G English %X Background: Effective peritoneal dialysis (PD) training is essential for performing dialysis at home and reducing the risk of peritonitis and other PD-related infections. Virtual reality (VR) is an innovative learning tool that is able to combine theoretical information, interactivity, and behavioral instructions while offering a playful learning environment. To improve patient training for PD, Fresenius Medical Care launched the stay•safe MyTraining VR, a novel educational program based on the use of a VR headset and a handheld controller. Objective: This qualitative assessment aims to investigate opinions toward the new tool among the health care professionals (HCPs) who were responsible for implementing the VR application. Methods: We recruited nursing staff and nephrologists who have gained practical experience with the stay•safe MyTraining VR within pilot dialysis centers. Predetermined open-ended questions were administered during individual and group video interviews. Results: We interviewed 7 HCPs who have 2 to 20 years of experience in PD training. The number of patients trained with the stay•safe MyTraining VR ranged from 2 to 5 for each professional. The stay•safe MyTraining VR was well accepted and perceived as a valuable supplementary tool for PD training. From the respondents’ perspective, the technology improved patients’ learning experience by facilitating the internalization of both medical information and procedural skills. HCPs highlighted that the opportunity offered by VR to reiterate training activities in a positive and safe learning environment, according to each patient’s needs, can facilitate error correction and implement a standardized training curriculum. However, VR had limited use in the final phase of the patient PD training program, where learners need to get familiar with the handling of the materials. Moreover, the traditional PD training was still considered essential to manage the emotional and motivational aspects and address any patient-specific application-oriented questions. In addition to its use within PD training, VR was perceived as a useful tool to support the decision-making process of patients and train other HCPs. Moreover, VR introduction was associated with increased efficiency and productivity of HCPs because it enabled them to perform other activities while the patient was practicing with the device. As for patients’ acceptance of the new tool, interviewees reported positive feedback, including that of older adults. Limited use with patients experiencing dementia or severe visual impairment or lacking sensomotoric competence was mentioned. Conclusions: The stay•safe MyTraining VR is suggested to improve training efficiency and efficacy and thus could have a positive impact in the PD training scenario. Our study offers a process proposal that can serve as a guide to the implementation of a VR-based PD training program within other dialysis centers. Dedicated research is needed to assess the operational benefits and the consequences on patient management. %M 39106093 %R 10.2196/46220 %U https://mededu.jmir.org/2024/1/e46220 %U https://doi.org/10.2196/46220 %U http://www.ncbi.nlm.nih.gov/pubmed/39106093 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e52893 %T Mobile Phone–Based Personalized and Interactive Augmented Reality Pictorial Health Warnings for Enhancing a Brief Advice Model for Smoking Cessation: Pilot Randomized Controlled Trial %A Guo,Ziqiu %A Wu,Yongda %A Wang,Man Ping %+ School of Nursing, The University of Hong Kong, 3 Sassoon Road, Pokfulam, Hong Kong, China (Hong Kong), 852 39176600, yongdang@connect.hku.hk %K augmented reality %K mobile-based %K smoking cessation %K brief advice %K pictorial health warning %K pilot randomized controlled trial %D 2024 %7 1.8.2024 %9 Original Paper %J JMIR XR Spatial Comput %G English %X Background: Augmented reality (AR) is a novel modality for promoting smoking cessation (SC). AR-visualized adverse consequences for education and smoking prevention have only been evaluated in nonsmokers in previous studies. Objective: To assess the feasibility and preliminary effectiveness for SC of AR pictorial health warnings (PHWs) on cigarette packs. Methods: We conducted a pilot randomized controlled trial in adult daily smokers in communities in Hong Kong. All participants received AWARD (ask, warn, advise, referral, do-it-again) model–guided SC advice, a warning leaflet, and referral to SC services at baseline. Interactive, chat-based SC support comprising regular messages and real-time support was provided to all participants via instant messaging apps (eg, WhatsApp) for 3 months after randomization. Participants in the intervention group additionally received 6 links to the AR PHWs showing the worsening health status of various organs caused by smoking. The level of the AR PHWs was adjustable to smoking behaviors (ie, smoking duration or daily cigarette consumption) to increase interaction. Participants could swipe, drag, or rotate the 3D PHWs to reinforce their impression of the health consequences of smoking. The primary outcome was self-reported past 7-day point-prevalence abstinence (PPA) at 3 months. The acceptability of the AR intervention was assessed by the proportion of participants who had viewed AR PHWs during the intervention. Participants who viewed AR PHWs further evaluated the perceived effect of the AR PHWs on a scale of 0 (not helpful at all) to 10 (very helpful). Intention to treat was used, and the risk ratio (RR) of the intervention effect was estimated by Poisson regression. Results: From April to November 2021, 80 participants were recruited and randomly assigned to intervention (n=40) and control (n=40) groups. Most participants were male (66/80, 83%) and planned to quit beyond 30 days or were undecided (65/80, 81%). The intervention group had a higher but nonsignificant 7-day PPA (7/40, 18% vs 5/40, 13%; RR 1.40, 95% CI 0.48-4.07) and quit attempts (15/40, 38% vs 11/40, 28%; RR 1.36, 95% CI 0.71-2.60) at 3 months than the control group. In the intervention group, 17 of 40 (43%) participants viewed the AR PHWs. The AR PHWs had modest effects on knowledge of the adverse consequences of smoking on personal health (mean score 3.94, SD 3.52), reducing the frequency of buying cigarettes (mean score 3.29, SD 3.08), increasing the perceived importance of quitting (mean score 3.88, SD 3.50), and making the PHWs more disgusting (mean score 3.41, SD 3.08) and horrible (mean score 3.38, SD 3.05). The 3-month self-reported 7-day PPA was higher in those who ever (vs never) viewed the AR PHWs (5/17, 29% vs 2/23, 9%). Conclusions: The mobile-based interactive AR PHWs were feasible, and the effectiveness on smoking abstinence warrants further testing. Trial Registration: ClinicalTrials.gov NCT04830072; https://clinicaltrials.gov/study/NCT04830072 %R 10.2196/52893 %U https://xr.jmir.org/2024/1/e52893 %U https://doi.org/10.2196/52893 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e57101 %T Effectiveness of a Virtual Reality Open-Air Bath Program in Reducing Loneliness and Improving Brain Function for Dementia Prevention in Older Adults: Protocol for a Prospective Randomized Crossover Study %A Imai,Ayu %A Matsuoka,Teruyuki %A Nakayama,Chikara %A Hashimoto,Nana %A Sano,Mutsuo %A Narumoto,Jin %+ Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan, 81 075 251 5612, tmms2004@koto.kpu-m.ac.jp %K loneliness %K virtual reality %K VR %K Alzheimer disease %K predementia %K intervention %K subjective cognitive decline %K mild cognitive impairment %K dementia %K older adult %K geriatric %K depression %K cognitive impairments %D 2024 %7 1.8.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Older adults often face loneliness due to chronic illness or loss of close ones, a situation worsened by the COVID-19 pandemic. Increased loneliness heightens the risk of diseases, especially dementia, necessitating urgent action. Objective: This study aims to assess the impact of a virtual reality (VR)–based open-air bath program on depression and loneliness in older individuals with subjective cognitive decline/mild cognitive impairment attending the Dementia Medical Center in Kyoto, Japan. We further aim to evaluate the feasibility of the program (participant recruitment and adherence) and to measure program enjoyment and satisfaction. Methods: The study design is a crossover trial with a 1:1 ratio, wherein 12 participants will be randomly assigned to groups 1 and 2, with group 2 serving as a waitlist control and group 1 receiving the VR program from the onset for 6 months; the VR program will be conducted 6 times (monthly). Program completion for group 1 will be followed by an observation period from months 7 to 12. Group 2 will participate in the VR program from months 7 to 12, with an observation period from months 1 to 6. Cognitive tests, psychiatric assessments, and the University of California, Los Angeles Loneliness Scale will be conducted before the study, at 6 months, and at 12 months. Results will be analyzed using repeated-measures ANOVA. Head magnetic resonance imaging and single-photon emission computed tomography scans will be performed before and after the VR program to evaluate changes and effects on brain regions. Results: Recruitment began in September 2023 and data collection is expected to be completed by March 2025. Complete study results will be published by September 2025. Conclusions: This study examines the preliminary effects of VR on loneliness in older adults with predementia through open-air bath simulations. VR experiences could benefit this population, particularly those with limited outdoor activities. Quantifying VR’s impact will aid in determining the size for a larger clinical trial. Qualitative results will inform participation mechanisms and guide the implementation and design of future trials. Trial Registration: University hospital Medical Information Network UMIN000052667; https://tinyurl.com/3yaccay5 International Registered Report Identifier (IRRID): DERR1-10.2196/57101 %M 39088243 %R 10.2196/57101 %U https://www.researchprotocols.org/2024/1/e57101 %U https://doi.org/10.2196/57101 %U http://www.ncbi.nlm.nih.gov/pubmed/39088243 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e56447 %T Enhancement of Immersive Technology Use in Pediatric Health Care With Accessible, Context-Specific Training: Descriptive Feasibility Study %A Li,Brian S K %A Fereday,Brendan %A Wang,Ellen %A Rodriguez,Samuel %A Forssell,Karin %A Bollaert,André N %A Menendez,Maria %A Caruso,Thomas J %+ Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 453 Quarry Rd, MC 5663, Palo Alto, CA, 94305, United States, 1 (650) 723 5728, tjcaruso@stanford.edu %K immersive technology %K implementation %K adult learning %K education %K pediatric %K accessibility %K training %K therapeutic %K pediatric care %K utilization %K virtual reality %K VR %K monitoring %K license %K development %K software %K monitoring software %D 2024 %7 30.7.2024 %9 Original Paper %J JMIR XR Spatial Comput %G English %X Background: Immersive technology provides adjuncts for pediatric care. However, accessibility and inadequate training limit implementation of this technology. Standardized instruction with no-cost software licensing may improve health care professionals’ facility with immersive technologies. Objective: This descriptive feasibility study aimed to examine the applications of immersive technologies in pediatric health care, including virtual reality (VR) and projectors. Methods: We developed immersive technology instructional guides for pediatric health care. The training guides were created for multiple software content and hardware types across several clinical scenarios. Content was available in print and digital versions. The primary outcome was technology use across sites with no-cost software agreements. The secondary outcome was the specific application types used at a single site, stratified by sessions and minutes. Data were analyzed using descriptive statistics. Results: Data were collected from 19 licensed sites from January through June 2022. Among the 19 sites, 32% (n=6) used 10 or more VR units. Among the 6 sites that had projectors, half used 5 or more units. The mean minutes of use per month of all sites combined was 2199 (IQR 51-1058). Three sites had more than 10,000 minutes of total use during the 6-month review period. Secondary results indicated that active VR (977 total sessions) and passive projector streaming (1261 total sessions) were the most popular application types by session, while active projector (66,849 total minutes) and passive projector streaming (32,711 total minutes) were the most popular types when stratified by minutes of use. The active VR application with the most minutes of use was an application often used in physical therapy. Conclusions: Context-specific technological instruction coupled to no-cost licenses may increase access to immersive technology in pediatric health care settings. %R 10.2196/56447 %U https://xr.jmir.org/2024/1/e56447 %U https://doi.org/10.2196/56447 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e64545 %T Discovering and Creating the Leading Edge of Extended Reality and Spatial Computing: A Message From the Editor-in-Chief %A Riedemann,Lars %+ Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg, 69120, Germany, 49 6221 56 6999, lars.riedemann@med.uni-heidelberg.de %K editorial %K extended reality %K XR %K spatial computing %D 2024 %7 26.7.2024 %9 Editorial %J JMIR XR Spatial Comput %G English %X We are pleased to introduce JMIR XR and Spatial Computing, a peer-reviewed journal dedicated to advancing the integration of extended reality and spatial computing technologies into routine clinical care. %R 10.2196/64545 %U https://xr.jmir.org/2024/1/e64545 %U https://doi.org/10.2196/64545 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e52878 %T Education in Laparoscopic Cholecystectomy: Design and Feasibility Study of the LapBot Safe Chole Mobile Game %A Noroozi,Mohammad %A St John,Ace %A Masino,Caterina %A Laplante,Simon %A Hunter,Jaryd %A Brudno,Michael %A Madani,Amin %A Kersten-Oertel,Marta %+ Applied Perception Lab, Department of Computer Science and Software Engineering, Concordia University, 2155 Guy Street ER923, Montreal, QC, H3G 1M8, Canada, 1 8482424 ext 5830, marta.kersten@concordia.ca %K gamification %K serious games %K surgery %K education %K laparoscopic cholecystectomy %K artificial intelligence %K AI %K laparoscope %K gallbladder %K cholecystectomy %K mobile game %K gamify %K educational game %K interactive %K decision-making %K mobile phone %D 2024 %7 25.7.2024 %9 Original Paper %J JMIR Form Res %G English %X Background:  Major bile duct injuries during laparoscopic cholecystectomy (LC), often stemming from errors in surgical judgment and visual misperception of critical anatomy, significantly impact morbidity, mortality, disability, and health care costs. Objective:  To enhance safe LC learning, we developed an educational mobile game, LapBot Safe Chole, which uses an artificial intelligence (AI) model to provide real-time coaching and feedback, improving intraoperative decision-making. Methods:  LapBot Safe Chole offers a free, accessible simulated learning experience with real-time AI feedback. Players engage with intraoperative LC scenarios (short video clips) and identify ideal dissection zones. After the response, users receive an accuracy score from a validated AI algorithm. The game consists of 5 levels of increasing difficulty based on the Parkland grading scale for cholecystitis. Results:  Beta testing (n=29) showed score improvements with each round, with attendings and senior trainees achieving top scores faster than junior residents. Learning curves and progression distinguished candidates, with a significant association between user level and scores (P=.003). Players found LapBot enjoyable and educational. Conclusions:  LapBot Safe Chole effectively integrates safe LC principles into a fun, accessible, and educational game using AI-generated feedback. Initial beta testing supports the validity of the assessment scores and suggests high adoption and engagement potential among surgical trainees. %M 39052314 %R 10.2196/52878 %U https://formative.jmir.org/2024/1/e52878 %U https://doi.org/10.2196/52878 %U http://www.ncbi.nlm.nih.gov/pubmed/39052314 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e38413 %T Extended Reality for Mental Health Evaluation: Scoping Review %A Omisore,Olatunji Mumini %A Odenigbo,Ifeanyi %A Orji,Joseph %A Beltran,Amelia Itzel Hernandez %A Meier,Sandra %A Baghaei,Nilufar %A Orji,Rita %+ Research Centre for Medical Robotics and Minimally Invasive Surgical Devices, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, 1068 XueYuan Avenue, Xili, NanShan District, Shenzhen, 518055, China, 86 13172482240, omisore@siat.ac.cn %K extended reality %K mental disorder %K depression %K anxiety %K exposure therapy %D 2024 %7 24.7.2024 %9 Review %J JMIR Serious Games %G English %X Background: Mental health disorders are the leading cause of health-related problems worldwide. It is projected that mental health disorders will be the leading cause of morbidity among adults as the incidence rates of anxiety and depression grow worldwide. Recently, “extended reality” (XR), a general term covering virtual reality (VR), augmented reality (AR), and mixed reality (MR), is paving the way for the delivery of mental health care. Objective: We aimed to investigate the adoption and implementation of XR technology used in interventions for mental disorders and to provide statistical analyses of the design, usage, and effectiveness of XR technology for mental health interventions with a worldwide demographic focus. Methods: In this paper, we conducted a scoping review of the development and application of XR in the area of mental disorders. We performed a database search to identify relevant studies indexed in Google Scholar, PubMed, and the ACM Digital Library. A search period between August 2016 and December 2023 was defined to select papers related to the usage of VR, AR, and MR in a mental health context. The database search was performed with predefined queries, and a total of 831 papers were identified. Ten papers were identified through professional recommendation. Inclusion and exclusion criteria were designed and applied to ensure that only relevant studies were included in the literature review. Results: We identified a total of 85 studies from 27 countries worldwide that used different types of VR, AR, and MR techniques for managing 14 types of mental disorders. By performing data analysis, we found that most of the studies focused on high-income countries, such as the United States (n=14, 16.47%) and Germany (n=12, 14.12%). None of the studies were for African countries. The majority of papers reported that XR techniques lead to a significant reduction in symptoms of anxiety or depression. The majority of studies were published in 2021 (n=26, 30.59%). This could indicate that mental disorder intervention received higher attention when COVID-19 emerged. Most studies (n=65, 76.47%) focused on a population in the age range of 18-65 years, while few studies (n=2, 3.35%) focused on teenagers (ie, subjects in the age range of 10-19 years). In addition, more studies were conducted experimentally (n=67, 78.82%) rather than by using analytical and modeling approaches (n=8, 9.41%). This shows that there is a rapid development of XR technology for mental health care. Furthermore, these studies showed that XR technology can effectively be used for evaluating mental disorders in a similar or better way that conventional approaches. Conclusions: In this scoping review, we studied the adoption and implementation of XR technology for mental disorder care. Our review shows that XR treatment yields high patient satisfaction, and follow-up assessments show significant improvement with large effect sizes. Moreover, the studies adopted unique designs that were set up to record and analyze the symptoms reported by their participants. This review may aid future research and development of various XR mechanisms for differentiated mental disorder procedures. %M 39047289 %R 10.2196/38413 %U https://games.jmir.org/2024/1/e38413 %U https://doi.org/10.2196/38413 %U http://www.ncbi.nlm.nih.gov/pubmed/39047289 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e57566 %T Effects of Immersive Technology–Based Education for Undergraduate Nursing Students: Systematic Review and Meta-Analysis Using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Approach %A Park,Subin %A Shin,Hui Ju %A Kwak,Hyoeun %A Lee,Hyun Joo %+ Mo-Im Kim Nursing Research Institute, College of Nursing, Seodaemun-gu, 50-1, Yonsei-ro, Seoul, 03722, Republic of Korea, 82 2 2228 3282, leehj1509@yuhs.ac %K nursing education %K nursing students %K immersive technology %K systematic review %K meta-analysis %K virtual reality %K augmented reality %K extended reality %K simulation-based learning %K medical education %D 2024 %7 24.7.2024 %9 Review %J J Med Internet Res %G English %X Background: The adoption of immersive technology in simulation-based nursing education has grown significantly, offering a solution to resource limitations and enabling safe access to clinical environments. Despite its advantages, there are still diverse reports regarding the effectiveness of immersive technology. It is crucial to verify the effectiveness of immersive technology in nursing education to inform future educational programs. Objective: This systematic review aimed to identify the contents of immersive technology–based education for undergraduate nursing students and evaluate the effectiveness of immersive technology compared to traditional teaching methods. Methods: A literature search was performed using 4 databases: PubMed, CINAHL, Embase, and Web of Science; the latest search was completed on January 19, 2023. The inclusion criteria were as follows: participants were undergraduate nursing students; studies were published in Korean or English; designs included randomized controlled trials (RCTs) or nonrandomized studies; and interventions involved virtual reality (VR), augmented reality (AR), mixed reality, or extended reality. Quality assessment was conducted using Cochrane Risk-of-Bias Tool version 2 for RCTs and the Risk-of-Bias Assessment Tool for Nonrandomized Studies. The main outcomes of the included studies were classified according to the New World Kirkpatrick Model (NWKM), ranging from level 1 (reaction) to level 4 (results). Meta-analysis was conducted using RevMan 5.4 software, and subgroup analysis was conducted due to heterogeneity of the results of the meta-analysis. The Grading of Recommendations, Assessment, Development, and Evaluation approach was adopted for assessing certainty and synthesizing results of the relevant literature. Results: A total of 23 studies were included, with participant numbers ranging from 33 to 289. Of these, 19 (82.6%) studies adopted VR to simulate various nursing scenarios, including disaster training, resuscitation, health assessments, and home health care; 4 (17.4%) studies used AR technologies; and 15 (65.2%) studies involved virtual patients in their scenarios. Based on the NWKM, the main outcome variables were classified as level 1 (usability and satisfaction), level 2 (knowledge, motivation, confidence, performance, attitude, and self-efficacy), and level 3 (clinical reasoning); level 4 outcomes were not found in the selected studies. Results of the subgroup analysis showed that immersive technology–based nursing education is more effective than traditional education in knowledge attainment (standard mean difference [SMD]=0.59, 95% CI 0.28-0.90, P<.001, I2=49%). Additionally, there were significant difference differences between the experimental and control group in confidence (SMD=0.70, 95% CI 0.05-1.35, P=.03, I2=82%) and self-efficacy (SMD=0.86, 95% CI 0.42-1.30, P<.001, I2=63%). Conclusions: These findings support the effectiveness of immersive technology–based education for undergraduate nursing students, despite heterogeneity in methods and interventions. We suggest that long-term cohort studies be conducted to evaluate the effects of immersive technology–based nursing education on NWKM level 4. %M 38978483 %R 10.2196/57566 %U https://www.jmir.org/2024/1/e57566 %U https://doi.org/10.2196/57566 %U http://www.ncbi.nlm.nih.gov/pubmed/38978483 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e54817 %T Adding Virtual Reality Mindful Exposure Therapy to a Cancer Center’s Tobacco Treatment Offerings: Feasibility and Acceptability Single-Group Pilot Study %A Jackson,Riley Walton %A Cao-Nasalga,Ann %A Chieng,Amy %A Pirkl,Amy %A Jagielo,Annemarie D %A Xu,Cindy %A Goldenhersch,Emilio %A Rosencovich,Nicolas %A Waitman,Cristian %A Prochaska,Judith J %+ Stanford Prevention Research Center, Department of Medicine, Stanford University, 3180 Porter Drive, Palo Alto, CA, 94304, United States, 1 650 724 3608, jpro@stanford.edu %K tobacco cessation %K virtual reality %K exposure therapy %K cancer care %K mobile phone %D 2024 %7 23.7.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Smoking contributes to 1 in 3 cancer deaths. At the Stanford Cancer Center, tobacco cessation medication management and counseling are provided as a covered benefit. Patients charted as using tobacco are contacted by a tobacco treatment specialist and offered cessation services. As a novel addition, this study examined the acceptability of a virtual reality (VR) mindful exposure therapy app for quitting smoking called MindCotine. Objective: The objective of this study was to determine the feasibility and acceptability of offering 6 weeks of MindCotine treatment as a part of Stanford’s Tobacco Treatment Services for patients seen for cancer care. Methods: As part of a single-group pilot study, the MindCotine VR program was offered to English- or Spanish-speaking patients interested in quitting smoking. Given the visual interface, epilepsy was a medical exclusion. Viewed from a smartphone with an attachable VR headset, MindCotine provides a digital environment with audiovisual content guiding mindfulness exercises (eg, breathing techniques, body awareness, and thought recognition), text-based coaching, and cognitive behavioral therapy-based self-reflections for quitting smoking. Interested patients providing informed consent were mailed a MindCotine headset and asked to use the app for 10+ minutes a day. At the end of 6 weeks, participants completed a feedback survey. Results: Of the 357 patients reached by the tobacco treatment specialist, 62 (17.3%) were ineligible, 190 (53.2%) were not interested in tobacco treatment services, and 78 (21.8%) preferred other tobacco treatment services. Among the 105 eligible and interested in assistance with quitting, 27 (25.7%) were interested in MindCotine, of whom 20 completed the informed consent, 9 used the program, and 8 completed their end-of-treatment survey. Participants using MindCotine completed, on average, 13 (SD 20.2) program activities, 19 (SD 26) journal records, and 11 (SD 12.3) coaching engagements. Of the 9 participants who used MindCotine, 4 (44%) reported some dizziness with app use that resolved and 7 (78%) would recommend MindCotine to a friend. In total, 2 participants quit tobacco (22.2% reporting, 10% overall), 2 others reduced their smoking by 50% or more, and 2 quit for 24 hours and then relapsed. Conclusions: In a feasibility and acceptability pilot study of a novel VR tobacco treatment app offered to patients at a cancer center, 4 of 9 (44%) reporting and 4 of 20 (20%) overall substantially reduced or quit using tobacco after 6 weeks and most would recommend the app to others. Further testing on a larger sample is warranted. Trial Registration: ClinicalTrials.gov NCT05220254; https://clinicaltrials.gov/study/NCT05220254 %M 39042439 %R 10.2196/54817 %U https://formative.jmir.org/2024/1/e54817 %U https://doi.org/10.2196/54817 %U http://www.ncbi.nlm.nih.gov/pubmed/39042439 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e52212 %T Desensitizing Anxiety Through Imperceptible Change: Feasibility Study on a Paradigm for Single-Session Exposure Therapy for Fear of Public Speaking %A Banakou,Domna %A Johnston,Tania %A Beacco,Alejandro %A Senel,Gizem %A Slater,Mel %+ Event Lab, Department of Clinical Psychology and Psychobiology, Institute of Neurosciences, University of Barcelona, Campus de Mundet Edifici CAVE, Passeig de la Vall d'Hebron 171, Barcelona, 08035, Spain, 34 93 403 ext 9618, melslater@ub.edu %K exposure therapy %K virtual reality %K gradual exposure %K fear of public speaking %K anxiety %K change blindness %K public speaking %K desensitization %K anxiety disorder %K feasibility study %D 2024 %7 22.7.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Exposure therapy (ET) for anxiety disorders involves introducing the participant to an anxiety-provoking situation over several treatment sessions. Each time, the participant is exposed to a higher anxiety-provoking stimulus; for example, in the case of fear of heights, the participant would successively experience being at a greater height. ET is effective, and its counterpart, virtual reality (VR) exposure therapy (VRET), where VR substitutes real-world exposure, is equally so. However, ET is time-consuming, requiring several sessions. Objective: This study aimed to compare the results of single-session exposure with those of traditional VRET with regard to reducing public speaking anxiety. Methods: We introduced a paradigm concerned with public speaking anxiety where the VR exposure occurred in a single session while the participant interacted with a virtual therapist. Over time, the therapist transformed into an entire audience with almost imperceptible changes. We carried out a feasibility study with 45 participants, comparing 3 conditions: single-session exposure (n=16, 36%); conventional multiple-session exposure (n=14, 31%), where the same content was delivered in successive segments over 5 sessions; and a control group (n=15, 33%), who interacted with a single virtual character to talk about everyday matters. A week later, the participants were required to speak on a stage in front of a large audience in VR. Results: Across most of the series of conventional public speaking anxiety measures, the single-session exposure was at least as effective in reducing anxiety as the multiple-session exposure, and both these conditions were better than the control condition. The 12-item Personal Report of Confidence as a Speaker was used to measure public speaking anxiety levels, where higher values indicated more anxiety. Using a Bayesian model, the posterior probabilities of improvement compared to a high baseline were at least 1.7 times greater for single- and multiple-session exposures compared to the control group. The State Perceived Index of Competence was used as a measure of anticipatory anxiety for speaking on a stage in front of a large audience, where lower values indicated higher anxiety. The probabilities of improvement were just over 4 times greater for single- and multiple-session exposures compared to the control group for a low baseline and 489 (single) and 53 (multiple) times greater for a middle baseline. Conclusions: Overall, the results of this feasibility study show that for moderate public speaking anxiety, the paradigm of gradual change in a single session is worth following up with further studies with more severe levels of anxiety and a larger sample size, first with a randomized controlled trial with nonpatients and subsequently, if the outcomes follow those that we have found, with a full clinical trial with patients. %M 39037760 %R 10.2196/52212 %U https://formative.jmir.org/2024/1/e52212 %U https://doi.org/10.2196/52212 %U http://www.ncbi.nlm.nih.gov/pubmed/39037760 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e59468 %T Assessing the Clinical Effectiveness of an Exergame-Based Exercise Training Program Using Ring Fit Adventure to Prevent and Postpone Frailty and Sarcopenia Among Older Adults in Rural Long-Term Care Facilities: Randomized Controlled Trial %A Tuan,Sheng-Hui %A Chang,Lin-Hui %A Sun,Shu-Fen %A Li,Chien-Hui %A Chen,Guan-Bo %A Tsai,Yi-Ju %+ Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, No 1, University Road, Tainan, 701, Taiwan, 886 6 235 3535 ext 5720, yjtsaincku2024@gmail.com %K exergame %K Ring Fit Adventure %K sarcopenia %K frailty %K long-term care %K multicomponent training %D 2024 %7 18.7.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Frailty and sarcopenia are geriatric syndromes of increasing concern and are associated with adverse health outcomes. They are more prevalent among long-term care facility (LTCF) users than among community dwellers. Exercise, especially multicomponent and progressive resistance training, is essential for managing these conditions. However, LTCFs, particularly in rural areas, face challenges in implementing structured exercise programs due to health care professional shortages. Moreover, older adults often become bored with repetitive exercise training and may lose interest over time. The Nintendo Switch Ring Fit Adventure (RFA) exergame is a novel exergame that combines resistance, aerobic, and balance exercises and offers a potential solution by boosting motivation in an immersive manner and reducing staff intervention needs. Objective: We aimed to evaluate the clinical effectiveness of an exergame-based exercise training program delivered via RFA (exergame-RFA) in improving muscle mass and functional performance among older adult LTCF users. Methods: This was a randomized controlled trial conducted from August 2022 to September 2023 and involved older adult LTCF users (aged ≥60 y) in rural southern Taiwan. Participants were randomized into an intervention group (exergame-RFA plus standard care) or a control group (standard care alone). The intervention, conducted seated with arm fit skills and trunk control exercises using the RFA, lasted 30 minutes twice weekly over 12 weeks. The primary outcomes measured were the Study of Osteoporotic Fractures index (serving as an indicator of frailty status) and the diagnostic criteria for sarcopenia (appendicular skeletal muscle mass index, handgrip strength, and gait speed). The secondary outcomes included functional performance (box and block test as well as maximum voluntary isometric contraction of the dominant upper extremity), muscle condition (muscle thickness measured using ultrasonography), activities of daily living (Kihon checklist), health-related quality of life (Short Form Health Survey-36), and cognitive function (brain health test). We used an intention-to-treat analysis, incorporating a simple imputation technique in statistical analysis. A mixed ANOVA, with time as a within-participant factor and intervention as a between-participant factor, was used to compare the training effects on outcomes. Results: We recruited 96 individuals, of whom 60 (62%) underwent randomization. Of these 60 participants, 55 (92%) completed the study. Significant group×time interactions were observed in the intervention group in all primary outcomes (all P<.001, except P=.01 for handgrip strength) and most secondary outcomes, including maximum voluntary isometric contraction of the biceps (P=.004) and triceps brachii (P<.001) muscles, biceps muscle thickness measured using ultrasonography (P<.001), box and block test (P<.001), Kihon checklist (physical function: P=.01, mood status: P=.003, and total: P=.003), and brain health test (P<.001). Conclusions: The exergame-RFA intervention significantly improved muscle mass, strength, and functional performance among older adult users of rural LTCFs, offering a novel approach to addressing frailty and sarcopenia. Trial Registration: ClinicalTrials.gov NCT05360667; https://clinicaltrials.gov/study/NCT05360667 International Registered Report Identifier (IRRID): RR2-10.3389/fmed.2022.1071409 %M 39024000 %R 10.2196/59468 %U https://www.jmir.org/2024/1/e59468 %U https://doi.org/10.2196/59468 %U http://www.ncbi.nlm.nih.gov/pubmed/39024000 %0 Journal Article %@ 2291-9279 %I %V 12 %N %P e58411 %T Effect of Elastic Resistance on Exercise Intensity and User Satisfaction While Playing the Active Video Game BoxVR in Immersive Virtual Reality: Empirical Study %A Polechoński,Jacek %A Przepiórzyński,Alan %A Polechoński,Piotr %A Tomik,Rajmund %K virtual reality %K VR %K game %K gaming %K immersive %K immersion %K health-related physical activity %K physical activity %K exercise %K active video games %K attractiveness %K enjoyment scale %K enjoyment %K serious games %K elastic resistance %K resistance %D 2024 %7 16.7.2024 %9 %J JMIR Serious Games %G English %X Background: One of the main contemporary forms of physical activity (PA) involves exercises and games in an immersive virtual reality (VR) environment, which allows the user to practice various forms of PA in a small space. Unfortunately, most of the currently available VR games and workout applications are mostly based on upper body movements, especially the arms, which do not guarantee sufficiently high exercise intensity and health benefits. Therefore, it is worth seeking solutions to help increase the exercise load during PA in VR. Objective: The main aim of this study was to evaluate the effect of elastic arm resistance in the form of latex resistance bands of different elasticity levels on the intensity of students’ PA while playing the BoxVR game. We further assessed the satisfaction of this form of exercise and its associations with PA intensity. Methods: A total of 21 healthy and physically fit men (mean age 22.5, SD 2.0 years) were included in the study. The tests consisted of 3 10-minute games. One game was run with no load and the other two were run with 1.5-meter latex resistance bands (low and high resistance). The order of the tests was randomized and the participants rested for 20 minutes after each exercise. Exercise intensity was estimated using objective (heart rate monitoring) and subjective (Borg scale) methods. The Physical Activity Enjoyment Scale was used to assess satisfaction with the PA. The effect of elastic resistance on exercise intensity and user enjoyment was estimated using ANOVA for repeated measures. Results: The ANOVA results indicated that incorporation of elastic resistance caused a significant change (F2,40=20.235, P<.001; η²p=0.503) in the intensity of PA in VR, which was low while playing without resistance and then increased to a moderate level with additional resistance. The use of elastic bands also changed participants’ perceptions of the enjoyment of exercise in VR (F2,40=9.259, P<.001; η²p=0.316). The students rated their satisfaction with PA in VR on a 7-point scale highly and similarly when exercising without an upper limb load (mean 6.19, SD 0.61) and with slight elastic resistance (mean 6.17, SD 0.66), whereas their satisfaction declined significantly (mean 5.66, SD 0.94) when incorporating a higher load. Conclusions: The intensity of PA among students playing the BoxVR game is at a relatively low level. With the added resistance of elastic bands attached to the upper limbs, the intensity of the exercise increased to a moderate level, as recommended for obtaining health benefits. Participants rated the enjoyment of PA in VR highly. The use of slight elastic resistance did not negatively affect satisfaction with the BoxVR game, although user satisfaction declined with a higher load. Further research should be undertaken to increase the effectiveness of exercise in VR so that regular users can enjoy the health benefits. %R 10.2196/58411 %U https://games.jmir.org/2024/1/e58411 %U https://doi.org/10.2196/58411 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e57762 %T Factors Associated With Continuous Use of a Cancer Education Metaverse Platform: Mixed Methods Study %A Kim,Sunghak %A Jung,Timothy %A Sohn,Dae Kyung %A Suh,Mina %A Chang,Yoon Jung %+ National Cancer Survivorship Center, National Cancer Control Institute, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, 10408, Republic of Korea, 82 10 8729 5835, eunice.ncc@gmail.com %K metaverse %K virtual reality %K cancer education %K cancer detection %K digital health %D 2024 %7 15.7.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Early detection of cancer and provision of appropriate treatment can increase the cancer cure rate and reduce cancer-related deaths. Early detection requires improving the cancer screening quality of each medical institution and enhancing the capabilities of health professionals through tailored education in each field. However, during the COVID-19 pandemic, regional disparities in educational infrastructure emerged, and educational accessibility was restricted. The demand for remote cancer education services to address these issues has increased, and in this study, we considered medical metaverses as a potential means of meeting these needs. In 2022, we used Metaverse Educational Center, developed for the virtual training of health professionals, to train radiologic technologists remotely in mammography positioning. Objective: This study aims to investigate the user experience of the Metaverse Educational Center subplatform and the factors associated with the intention for continuous use by focusing on cases of using the subplatform in a remote mammography positioning training project. Methods: We conducted a multicenter, cross-sectional survey between July and December 2022. We performed a descriptive analysis to examine the Metaverse Educational Center user experience and a logistic regression analysis to clarify factors closely related to the intention to use the subplatform continuously. In addition, a supplementary open-ended question was used to obtain feedback from users to improve Metaverse Educational Center. Results: Responses from 192 Korean participants (male participants: n=16, 8.3%; female participants: n=176, 91.7%) were analyzed. Most participants were satisfied with Metaverse Educational Center (178/192, 92.7%) and wanted to continue using the subplatform in the future (157/192, 81.8%). Less than half of the participants (85/192, 44.3%) had no difficulty in wearing the device. Logistic regression analysis results showed that intention for continuous use was associated with satisfaction (adjusted odds ratio 3.542, 95% CI 1.037-12.097; P=.04), immersion (adjusted odds ratio 2.803, 95% CI 1.201-6.539; P=.02), and no difficulty in wearing the device (adjusted odds ratio 2.020, 95% CI 1.004-4.062; P=.049). However, intention for continuous use was not associated with interest (adjusted odds ratio 0.736, 95% CI 0.303-1.789; P=.50) or perceived ease of use (adjusted odds ratio 1.284, 95% CI 0.614-2.685; P=.51). According to the qualitative feedback, Metaverse Educational Center was useful in cancer education, but the experience of wearing the device and the types and qualities of the content still need to be improved. Conclusions: Our results demonstrate the positive user experience of Metaverse Educational Center by focusing on cases of using the subplatform in a remote mammography positioning training project. Our results also suggest that improving users’ satisfaction and immersion and ensuring the lack of difficulty in wearing the device may enhance their intention for continuous use of the subplatform. %M 39008834 %R 10.2196/57762 %U https://www.jmir.org/2024/1/e57762 %U https://doi.org/10.2196/57762 %U http://www.ncbi.nlm.nih.gov/pubmed/39008834 %0 Journal Article %@ 2373-6658 %I JMIR Publications %V 8 %N %P e58818 %T The Use of Immersive Virtual Reality Training for Developing Nontechnical Skills Among Nursing Students: Multimethods Study %A Chan,Kitty %A Kor,Patrick Pui Kin %A Liu,Justina Yat Wa %A Cheung,Kin %A Lai,Timothy %A Kwan,Rick Yiu Cho %+ School of Nursing, The Hong Kong Polytechnic University, 11 Yuk Choi Road, Hung Hom, Kowloon, China (Hong Kong), 852 2766 6883, kitty.yy.chan@polyu.edu.hk %K education %K educational %K hospital %K hospitals %K nontechnical skills %K nurse %K nurses %K nursing education %K nursing %K satisfaction %K self-confidence %K simulation %K simulations %K virtual reality %K VR %K immersive %D 2024 %7 10.7.2024 %9 Original Paper %J Asian Pac Isl Nurs J %G English %X Background: Immersive virtual reality (IVR) is a niche technology rising in popularity in nursing education. Although there is an abundance of evidence to demonstrate the effect of virtual reality (VR) on desired learning outcomes, this evidence is limited to technical or procedural skills or managing a single patient with clinical problems. Nontechnical skills (NTS), such as communication, decision-making, teamwork, situation awareness, and managerial skills, have not been explored using IVR technology. Objective: This study aimed to (1) investigate the potential efficacy of the IVR system virtual reality hospital (VR-Hospital, or VR-Hosp), a single-user game we developed, on nursing students’ NTS, sense of presence in the virtual clinical environment, and satisfaction and self-confidence in learning; (2) identify variables that predict NTS; and (3) explore students’ experience in using VR-Hosp. Methods: A multimethods design with a quantitative and qualitative approach was adopted. Participants were provided with VR-Hosp with 3 scenarios in training. VR-Hosp adopted a multibed, multipatient, multitask approach and was embedded with various clinical situations. Learning outcomes were measured after the training, followed by group interviews. Results: In total, 202 students joined the study. Results revealed high levels of satisfaction and self-confidence in learning. Significant achievement in NTS was perceived by the students. The levels of satisfaction and self-confidence in learning and the involvement and sensory fidelity domains in the sense of presence were positive predictors of NTS. Conclusions: The promising results offer a basis for designing IVR activities for nursing education. Further investigations are imperative to determine the impact of IVR technology on learning outcomes in clinical practice. %M 38986130 %R 10.2196/58818 %U https://apinj.jmir.org/2024/1/e58818 %U https://doi.org/10.2196/58818 %U http://www.ncbi.nlm.nih.gov/pubmed/38986130 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e49344 %T The Influence of Billboard-Based Tobacco Prevention Posters on Memorization, Attitudes, and Craving: Immersive Virtual Reality Study %A Bonneterre,Solenne %A Zerhouni,Oulmann %A Boffo,Marilisa %+ Université Paris Nanterre, 200 Avenue de la République, Nanterre, 92000, France, 33 06161484588, solenne.bonneterre@gmail.com %K tobacco %K smoking %K health promotion %K health prevention campaigns %K immersive virtual reality %K incidental exposure %K advertising %D 2024 %7 9.7.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Health prevention campaigns often face challenges in reaching their target audience and achieving the desired impact on health behaviors. These campaigns, particularly those aimed at reducing tobacco use, require rigorous evaluation methods to assess their effectiveness. Objective: This study aims to use immersive virtual reality (iVR) to systematically evaluate recall, attitudinal, and craving responses to antitobacco prevention messages when presented in a realistic virtual environment, thereby exploring the potential of iVR as a novel tool to improve the effectiveness of public health campaigns. Methods: A total of 121 undergraduate students (mean age 19.6, SD 3.7 years), mostly female (n=99, 82.5%), were invited to take a guided walk in the virtual environment, where they were randomly exposed to a different ratio of prevention and general advertising posters (80/20 or 20/80) depending on the experimental condition. Participants’ gaze was tracked throughout the procedure, and outcomes were assessed after the iVR exposure. Results: Incidental exposure to antitobacco prevention and general advertising posters did not significantly alter attitudes toward tobacco. Memorization of prevention posters was unexpectedly better in the condition where advertising was more frequent (β=–6.15; P<.001), and high contrast between poster types led to a better memorization of the less frequent type. Despite a nonsignificant trend, directing attention to prevention posters slightly improved their memorization (β=.02; P=.07). In addition, the duration of exposure to prevention posters relative to advertisements negatively affected memorization of advertising posters (β=–2.30; P=.01). Conclusions: Although this study did not find significant changes in attitudes toward tobacco after exposure to prevention campaigns using iVR, the technology does show promise as an evaluation tool. To fully evaluate the use of iVR in public health prevention strategies, future research should examine different types of content, longer exposure durations, and different contexts. Trial Registration: Open Science Framework E3YK7; https://osf.io/e3yk7 %M 38980707 %R 10.2196/49344 %U https://www.jmir.org/2024/1/e49344 %U https://doi.org/10.2196/49344 %U http://www.ncbi.nlm.nih.gov/pubmed/38980707 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e53196 %T Exploring Relations Between Unique Patient Characteristics and Virtual Reality Immersion Level on Anxiety and Pain in Patients Undergoing Venipuncture: Secondary Analysis of a Randomized Control Trial %A Gold,Jeffrey I %A Akbar,Krystal M %A Avila,Sandra %A Ngo,Nhat H %A Klein,Margaret J %+ Department of Anesthesiology Critical Care Medicine, The Saban Research Institute, Children's Hospital Los Angeles, 4650 Sunset Boulevard MS#12, Los Angeles, CA, 90027, United States, 1 3233616341, jgold@chla.usc.edu %K pediatrics %K virtual reality %K VR %K immersion %K anxiety %K pain management %K routine medical procedures %K venipuncture %K secondary data analysis %K mediation %K moderation %K pain %K acute pain %K pediatric pain %K anxiety sensitivity %K pain management %D 2024 %7 1.7.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) is a well-researched digital intervention that has been used for managing acute pain and anxiety in pediatric patients undergoing various medical procedures. This study focuses on investigating the role of unique patient characteristics and VR immersion level on the effectiveness of VR for managing pediatric pain and anxiety during venipuncture. Objective: The purpose of this study is to determine how specific patient characteristics and level of immersion during a VR intervention impact anxiety and pain levels for pediatric patients undergoing venipuncture procedures. Methods: This study is a secondary data analysis of 2 combined, previously published randomized control trials on 252 pediatric patients aged 10-21 years observed at Children’s Hospital Los Angeles from April 12, 2017, to July 24, 2019. One randomized clinical trial was conducted in 3 clinical environments examining peripheral intravenous catheter placement (radiology and an infusion center) and blood draw (phlebotomy). Conditional process analysis was used to conduct moderation and mediation analyses to assess the impact of immersion level during the VR intervention. Results: Significant moderation was found between the level of immersion and anxiety sensitivity when predicting postprocedural anxiety (P=.01). Patients exhibiting the highest anxiety sensitivity within the standard of care yielded a 1.9 (95% CI 0.9-2.8; P<.001)-point elevation in postprocedural anxiety relative to individuals with high immersion levels. No other significant factors were found to mediate or moderate the effect of immersion on either postprocedural anxiety or pain. Conclusions: VR is most effective for patients with higher anxiety sensitivity who report feeling highly immersed. Age, location of the procedure, and gender of the patient were not found to significantly impact VR’s success in managing levels of postprocedural pain or anxiety, suggesting that immersive VR may be a beneficial intervention for a broad pediatric population. Trial Registration: ClinicalTrials.gov NCT04268901; https://clinicaltrials.gov/study/NCT04268901 %M 38949862 %R 10.2196/53196 %U https://www.jmir.org/2024/1/e53196 %U https://doi.org/10.2196/53196 %U http://www.ncbi.nlm.nih.gov/pubmed/38949862 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e59197 %T Experience of Youths and Older People With Virtual Reality Games for Cognitive Assessment: Inductive Thematic Analysis and Insights for Key Stakeholders %A Bhargava,Yesoda %A Baths,Veeky %+ Cognitive Neuroscience Lab, Department of Biological Sciences, Birla Institute of Technology and Science, Pilani - K. K. Birla Campus, NH 17B, Bypass, Road, Zuarinagar, Sankval, Goa, 403726, India, 91 9823764987, veeky@goa.bits-pilani.ac.in %K virtual reality %K cognitive assessment games %K inductive thematic analysis %K youth %K older adult %K cognitive %K cognitive assessment %K virtual reality games %K game %K games %K thematic analysis %K neurological %K utility %K cognitive assessment tools %K game based %K cognitive games %D 2024 %7 28.6.2024 %9 Original Paper %J JMIR XR Spatial Comput %G English %X Background: Virtual reality (VR)–based goal-oriented games for cognitive assessment are rapidly emerging and progressively being used in neuropsychological settings. These games have been validated quantitatively, but minimal qualitative insights from users currently exist. Such insights on user experience are essential to answering critical questions linked to the games’ large-scale usability, adoption in hospital settings, and game design refinement. Current qualitative studies on these games have used general questionnaires or web-based reviews to answer these questions, but direct observation from primary settings is missing. We believe that direct observation of participants playing these games and subsequent interaction with them is critical to developing a more objective, clear, and unbiased view of the games’ efficacy, usability, and acceptability. Objective: In this study, we aimed to extract constructive and relevant insights directly from the participants who played VR-based goal-oriented games. We used these insights to answer vital questions linked to the practical utility of VR-based cognitive assessment. On the basis of these results, we also aimed to provide actionable insights to key stakeholders in the field, such as researchers, game developers, business personnel, and neuropsychology and allied professionals. Methods: Interview data from 82 younger (aged 18-28 years) and 42 older adult (aged >60 years) participants were used. The interview data were obtained from the 2 pilot studies we conducted on VR games for cognitive assessment. Inductive thematic analysis was conducted on the interview data, and later, the findings were carefully interpreted to develop implications for the key stakeholders. Results: We identified 5 themes: ergonomic issues, learning and training, postgame effects, game feedback, and system purpose. Regarding hardware, headset weight, adjustment straps, and controllers need to be improved to promote easy use of the device. Regarding software, graphics quality, immersion experience, and game mechanics are the primary deciding factors for a positive user experience. The younger group prioritized purpose and utility for long-term use, whereas the older participants cherished the entertainment aspect. Researchers and game developers must conceptualize and develop games that can provide maximum insights into real-world abilities. Manufacturing businesses need to improve the headset and accessories to make them more user-friendly. Finally, neuropsychology and allied practitioners must identify strategies to engage and train the participants to try VR-based cognitive assessment games. Conclusions: VR-based games for cognitive assessment are promising tools to improve the current practices of neuropsychological evaluations; however, a few changes are required to make the overall user experience enjoyable, purposeful, and sustainable. In addition, all the key stakeholders need to focus on meaning and purpose over the hype of VR and are advised to work in synergy. %R 10.2196/59197 %U https://xr.jmir.org/2024/1/e59197 %U https://doi.org/10.2196/59197 %0 Journal Article %@ 2291-9279 %I %V 12 %N %P e54220 %T Attentional Bias, Pupillometry, and Spontaneous Blink Rate: Eye Characteristic Assessment Within a Translatable Nicotine Cue Virtual Reality Paradigm %A Courtney,Kelly Elizabeth %A Liu,Weichen %A Andrade,Gianna %A Schulze,Jurgen %A Doran,Neal %K nicotine %K craving %K cue exposure %K virtual reality %K attentional bias %K pupillometry %K spontaneous blink rate %K eye-tracking %K tobacco %K VR %K development %K addiction %K eye %K pupil %K craving %K biomarker %K biomarkers %K tobacco product %D 2024 %7 27.6.2024 %9 %J JMIR Serious Games %G English %X Background: Incentive salience processes are important for the development and maintenance of addiction. Eye characteristics such as gaze fixation time, pupil diameter, and spontaneous eyeblink rate (EBR) are theorized to reflect incentive salience and may serve as useful biomarkers. However, conventional cue exposure paradigms have limitations that may impede accurate assessment of these markers. Objective: This study sought to evaluate the validity of these eye-tracking metrics as indicators of incentive salience within a virtual reality (VR) environment replicating real-world situations of nicotine and tobacco product (NTP) use. Methods: NTP users from the community were recruited and grouped by NTP use patterns: nondaily (n=33) and daily (n=75) use. Participants underwent the NTP cue VR paradigm and completed measures of nicotine craving, NTP use history, and VR-related assessments. Eye-gaze fixation time (attentional bias) and pupillometry in response to NTP versus control cues and EBR during the active and neutral VR scenes were recorded and analyzed using ANOVA and analysis of covariance models. Results: Greater subjective craving, as measured by the Tobacco Craving Questionnaire–Short Form, following active versus neutral scenes was observed (F1,106=47.95; P<.001). Greater mean eye-gaze fixation time (F1,106=48.34; P<.001) and pupil diameter (F1,102=5.99; P=.02) in response to NTP versus control cues were also detected. Evidence of NTP use group effects was observed in fixation time and pupillometry analyses, as well as correlations between these metrics, NTP use history, and nicotine craving. No significant associations were observed with EBR. Conclusions: This study provides additional evidence for attentional bias, as measured via eye-gaze fixation time, and pupillometry as useful biomarkers of incentive salience, and partially supports theories suggesting that incentive salience diminishes as nicotine dependence severity increases. %R 10.2196/54220 %U https://games.jmir.org/2024/1/e54220 %U https://doi.org/10.2196/54220 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e58465 %T Visual Function and Driving Performance Under Different Lighting Conditions in Older Drivers: Preliminary Results From an Observational Study %A Yang,Jingzhen %A Alshaikh,Enas %A Yu,Deyue %A Kerwin,Thomas %A Rundus,Christopher %A Zhang,Fangda %A Wrabel,Cameron G %A Perry,Landon %A Lu,Zhong-Lin %+ Center for Injury Research and Policy at the Abigail Wexner Research Institute, Nationwide Children’s Hospital, 700 Children's Drive, Columbus, OH, 43205, United States, 1 6143555852, Ginger.Yang@nationwidechildrens.org %K nighttime driving %K functional vision %K driving simulation %K older drivers %K visual functions %K photopic %K mesopic %K glare %K driving simulator %D 2024 %7 26.6.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Age-related vision changes significantly contribute to fatal crashes at night among older drivers. However, the effects of lighting conditions on age-related vision changes and associated driving performance remain unclear. Objective: This pilot study examined the associations between visual function and driving performance assessed by a high-fidelity driving simulator among drivers 60 and older across 3 lighting conditions: daytime (photopic), nighttime (mesopic), and nighttime with glare. Methods: Active drivers aged 60 years or older participated in visual function assessments and simulated driving on a high-fidelity driving simulator. Visual acuity (VA), contrast sensitivity function (CSF), and visual field map (VFM) were measured using quantitative VA, quantitative CSF, and quantitative VFM procedures under photopic and mesopic conditions. VA and CSF were also obtained in the presence of glare in the mesopic condition. Two summary metrics, the area under the log CSF (AULCSF) and volume under the surface of VFM (VUSVFM), quantified CSF and VFM. Driving performance measures (average speed, SD of speed [SDspeed], SD of lane position (SDLP), and reaction time) were assessed under daytime, nighttime, and nighttime with glare conditions. Pearson correlations determined the associations between visual function and driving performance across the 3 lighting conditions. Results: Of the 20 drivers included, the average age was 70.3 years; 55% were male. Poor photopic VA was significantly correlated with greater SDspeed (r=0.26; P<.001) and greater SDLP (r=0.31; P<.001). Poor photopic AULCSF was correlated with greater SDLP (r=–0.22; P=.01). Poor mesopic VUSFVM was significantly correlated with slower average speed (r=–0.24; P=.007), larger SDspeed (r=–0.19; P=.04), greater SDLP (r=–0.22; P=.007), and longer reaction times (r=–0.22; P=.04) while driving at night. For functional vision in the mesopic condition with glare, poor VA was significantly correlated with longer reaction times (r=0.21; P=.046) while driving at night with glare; poor AULCSF was significantly correlated with slower speed (r=–0.32; P<.001), greater SDLP (r=–0.26; P=.001) and longer reaction times (r=–0.2; P=.04) while driving at night with glare. No other significant correlations were observed between visual function and driving performance under the same lighting conditions. Conclusions: Visual functions differentially affect driving performance in different lighting conditions among older drivers, with more substantial impacts on driving during nighttime, especially in glare. Additional research with larger sample sizes is needed to confirm these results. %M 38922681 %R 10.2196/58465 %U https://formative.jmir.org/2024/1/e58465 %U https://doi.org/10.2196/58465 %U http://www.ncbi.nlm.nih.gov/pubmed/38922681 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 11 %N %P e48129 %T The Value of a Virtual Assistant to Improve Engagement in Computerized Cognitive Training at Home: Exploratory Study %A Zsoldos,Isabella %A Trân,Eléonore %A Fournier,Hippolyte %A Tarpin-Bernard,Franck %A Fruitet,Joan %A Fouillen,Mélodie %A Bailly,Gérard %A Elisei,Frédéric %A Bouchot,Béatrice %A Constant,Patrick %A Ringeval,Fabien %A Koenig,Olivier %A Chainay,Hanna %+ Laboratoire d’Étude des Mécanismes Cognitifs, Université Lumière Lyon 2, 5 Avenue Pierre Mendès France, Lyon, 69500, France, 33 478774335, isabella.zsoldos@hotmail.fr %K cognitive training %K cognitive decline %K cognitive disorders %K mild cognitive impairment %K Alzheimer disease %K digital therapies %K virtual health assistant %K conversational agent %K artificial intelligence %K social interaction %K THERADIA %D 2024 %7 20.6.2024 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Impaired cognitive function is observed in many pathologies, including neurodegenerative diseases such as Alzheimer disease. At present, the pharmaceutical treatments available to counter cognitive decline have only modest effects, with significant side effects. A nonpharmacological treatment that has received considerable attention is computerized cognitive training (CCT), which aims to maintain or improve cognitive functioning through repeated practice in standardized exercises. CCT allows for more regular and thorough training of cognitive functions directly at home, which represents a significant opportunity to prevent and fight cognitive decline. However, the presence of assistance during training seems to be an important parameter to improve patients’ motivation and adherence to treatment. To compensate for the absence of a therapist during at-home CCT, a relevant option could be to include a virtual assistant to accompany patients throughout their training. Objective: The objective of this exploratory study was to evaluate the interest of including a virtual assistant to accompany patients during CCT. We investigated the relationship between various individual factors (eg, age, psycho-affective functioning, personality, personal motivations, and cognitive skills) and the appreciation and usefulness of a virtual assistant during CCT. This study is part of the THERADIA (Thérapies Digitales Augmentées par l’Intelligence Artificielle) project, which aims to develop an empathetic virtual assistant. Methods: A total of 104 participants were recruited, including 52 (50%) young adults (mean age 21.2, range 18 to 27, SD 2.9 years) and 52 (50%) older adults (mean age 67.9, range 60 to 79, SD 5.1 years). All participants were invited to the laboratory to answer several questionnaires and perform 1 CCT session, which consisted of 4 cognitive exercises supervised by a virtual assistant animated by a human pilot via the Wizard of Oz method. The participants evaluated the virtual assistant and CCT at the end of the session. Results: Analyses were performed using the Bayesian framework. The results suggest that the virtual assistant was appreciated and perceived as useful during CCT in both age groups. However, older adults rated the assistant and CCT more positively overall than young adults. Certain characteristics of users, especially their current affective state (ie, arousal, intrinsic relevance, goal conduciveness, and anxiety state), appeared to be related to their evaluation of the session. Conclusions: This study provides, for the first time, insight into how young and older adults perceive a virtual assistant during CCT. The results suggest that such an assistant could have a beneficial influence on users’ motivation, provided that it can handle different situations, particularly their emotional state. The next step of our project will be to evaluate our device with patients experiencing mild cognitive impairment and to test its effectiveness in long-term cognitive training. %M 38901017 %R 10.2196/48129 %U https://rehab.jmir.org/2024/1/e48129 %U https://doi.org/10.2196/48129 %U http://www.ncbi.nlm.nih.gov/pubmed/38901017 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e53261 %T The Effectiveness of Virtual Reality–Based Training on Cognitive, Social, and Physical Functioning in High-Functioning Older Adults (CoSoPhy FX): 2-Arm, Parallel-Group Randomized Controlled Trial %A Szczepocka,Ewa %A Mokros,Łukasz %A Kazmierski,Jakub %A Nowakowska,Karina %A Łucka,Anna %A Antoszczyk,Anna %A Oltra-Cucarella,Javier %A Werzowa,Walter %A Hellevik,Martin Moum %A Skouras,Stavros %A Bagger,Karsten %+ Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Czechosłowacka 8/10, Lodz, 92-216, Poland, 48 426757372, ewa.szczepocka@umed.lodz.pl %K cognitive functions %K head-mounted-display %K healthy seniors %K virtual reality %K well-being %K mobile phone %D 2024 %7 5.6.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Virtual reality (VR) has emerged as a promising technology for enhancing the health care of older individuals, particularly in the domains of cognition, physical activity, and social engagement. However, existing VR products and services have limited availability and affordability; hence, there is a need for a scientifically validated and personalized VR service to be used by older adults in their homes, which can improve their overall physical, cognitive, and social well-being. Objective: The main purpose of the CoSoPhy FX (Cognitive, Social, and Physical Effects) study was to analyze the effects of a VR-based digital therapeutics app on the cognitive, social, and physical performance abilities of healthy (high-functioning) older adults. This paper presents the study protocol and the results from the recruitment phase. Methods: A group of 188 healthy older adults aged 65-85 years, recruited at the Medical University of Lodz, Poland, were randomly allocated to the experimental group (VR dual-task training program) or to the control group (using a VR headset app showing nature videos). A total of 3 cognitive exercises were performed in various 360° nature environments delivered via a VR head-mounted display; the participants listened to their preferred music genre. Each patient received 3 sessions of 12 minutes per week for 12 weeks, totaling a minimum of 36 sessions per participant. Attention and working memory (Central Nervous System Vital Signs computerized cognitive battery) were used as primary outcomes, while other cognitive domains in the Central Nervous System Vital Signs battery, quality of life (World Health Organization–5 Well-Being Index), health-related quality of life (EQ-5D-5L), and anxiety (General Anxiety Disorder 7-item questionnaire) were the secondary outcomes. The group-by-time interaction was determined using linear mixed models with participants’ individual slopes. Results: In total, 122 (39%) of the initial 310 participants failed to meet the inclusion criteria, resulting in a recruitment rate of 61% (188/310). Among the participants, 68 successfully completed the intervention and 62 completed the control treatment. The data are currently being analyzed, and we plan to publish the results by the end of September 2024. Conclusions: VR interventions have significant potential among healthy older individuals. VR can address various aspects of well-being by stimulating cognitive functions, promoting physical activity, and facilitating social interaction. However, challenges such as physical discomfort, technology acceptance, safety concerns, and cost must be considered when implementing them for older adults. Further research is needed to determine the long-term effects of VR-based interventions, optimal intervention designs, and the specific populations that would benefit most. Trial Registration: ClinicalTrials.gov NCT05369897; https://clinicaltrials.gov/study/NCT05369897 International Registered Report Identifier (IRRID): DERR1-10.2196/53261 %M 38837194 %R 10.2196/53261 %U https://www.researchprotocols.org/2024/1/e53261 %U https://doi.org/10.2196/53261 %U http://www.ncbi.nlm.nih.gov/pubmed/38837194 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e53999 %T Examining and Comparing the Energy Expenditure of Two Modes of a Virtual Reality Fitness Game (Supernatural): Indirect Calorimetry Study %A Craig,Tabitha V %A Rhodes,Ryan E %A Sui,Wuyou %+ Behavioural Medicine Lab, Department of Exercise Science, Physical & Health Education, University of Victoria, 3800 Finnerty Rd, Victoria, BC, V8P 5C2, Canada, 1 250 472 5288, yoahsui@gmail.com %K energy expenditure %K exergaming %K indirect calorimetry %K virtual reality %K VR %K VR fitness %K VR gaming %D 2024 %7 4.6.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: The effectiveness of virtual reality (VR) fitness games as a form of moderate to vigorous physical activity has yet to be thoroughly quantified through gold standard energy expenditure measures. Objective: The purpose of this study was to examine the energy expenditure of 2 medium-intensity modes (“Flow and “Boxing”) of a VR fitness game, Supernatural, using indirect calorimetry. Methods: Indirect calorimetry was used to examine relative and objective maximal oxygen consumption (VO2 max), metabolic equivalents of task (METs), and calories burned during medium-intensity bouts of both Flow and Boxing gameplay modes in young (mean age 25.42, SD 3.25 years), active individuals (n=12 female and n=11 male). METs and calories were also compared using a triaxial waist-worn accelerometer, an Apple smartwatch, and a VR headset. Mood states were assessed pre- and postbout using the shortened Profile of Mood States Questionnaire. Paired 2-tailed t tests were used to examine differences in game modes, between sexes, and pre-post exercise sessions. Results: Objective and relative VO2 max averaged 1.93 (SD 0.44) L/min and 27.61 (SD 5.60) mL/kg/min, respectively, between modes. Flow (mean 8.2, SD 1.54 METs) and Boxing (mean 7.6, SD 1.66 METs) are both classified as high energy expenditure, vigorous activities. Calorie expenditure data of the accelerometer and VR headset differed significantly from the metabolic cart. Mood changes pre- to post exercise were consistent with expected values for moderate- to vigorous-intensity physical activity, with participants reporting that they felt more “active,” “full of pep,” “vigorous,” and “lively” (P<.05) following bouts. Male individuals reported higher objective oxygen consumption (VO2) for both Flow and Boxing modes; no other sex-specific differences were observed. Conclusions: Both Flow and Boxing gameplay modes of Supernatural classify as vigorous physical activity and demonstrate the potential to promote mental and physical health benefits. Supernatural may be an effective exercise modality in a VO2 training program. %M 38833285 %R 10.2196/53999 %U https://games.jmir.org/2024/1/e53999 %U https://doi.org/10.2196/53999 %U http://www.ncbi.nlm.nih.gov/pubmed/38833285 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e53642 %T Development of a Subjective Visual Vertical Test System Using a Smartphone With Virtual Reality Goggles for Screening of Otolithic Dysfunction: Observational Study %A Umibe,Akiko %A Fushiki,Hiroaki %A Tsunoda,Reiko %A Kuroda,Tatsuaki %A Kuroda,Kazuhiro %A Tanaka,Yasuhiro %+ Department of Otorhinolaryngology, Head and Neck Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50, Minami-Koshigaya, Koshigaya-shi, Saitama, 343-8555, Japan, 81 489651111, aumibe@dokkyomed.ac.jp %K vestibular function tests %K telemedicine %K smartphone %K virtual reality %K otolith dysfunction screening tool %K vestibular evoked myogenic potential %K iPhone %K mobile phone %D 2024 %7 4.6.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: The subjective visual vertical (SVV) test can evaluate otolith function and spatial awareness and is performed in dedicated vertigo centers using specialized equipment; however, it is not otherwise widely used because of the specific equipment and space requirements. An SVV test smartphone app was developed to easily perform assessments in outpatient facilities. Objective: This study aimed to verify whether the SVV test smartphone app with commercially available virtual reality goggles can be used in a clinical setting. Methods: The reference range was calculated for 15 healthy participants. We included 14 adult patients with unilateral vestibular neuritis, sudden sensorineural hearing loss with vertigo, and Meniere disease and investigated the correlation between the SVV test results and vestibular evoked myogenic potential (VEMP) results. Results: The SVV reference range of healthy participants for the sitting front-facing position was small, ranging from –2.6º to 2.3º. Among the 14 patients, 6 (43%) exceeded the reference range for healthy participants. The SVV of patients with vestibular neuritis and sudden sensorineural hearing loss tended to deviate to the affected side. A total of 9 (64%) had abnormal cervical VEMP (cVEMP) values and 6 (43%) had abnormal ocular VEMP (oVEMP) values. No significant difference was found between the presence or absence of abnormal SVV values and the presence or absence of abnormal cVEMP and oVEMP values; however, the odds ratios (ORs) suggested a higher likelihood of abnormal SVV values among those with abnormal cVEMP and oVEMP responses (OR 2.40, 95% CI 0.18-32.88; P>.99; and OR 2, 95% CI 0.90-4.45; P=.46, respectively). Conclusions: The SVV app can be used anywhere and in a short period while reducing directional bias by using virtual reality goggles, thus making it highly versatile and useful as a practical otolith dysfunction screening tool. %M 38833295 %R 10.2196/53642 %U https://formative.jmir.org/2024/1/e53642 %U https://doi.org/10.2196/53642 %U http://www.ncbi.nlm.nih.gov/pubmed/38833295 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e52309 %T Virtual Reality Applications for the Implementation of Domestic Respiratory Rehabilitation Programs for Patients With Long COVID and Post-COVID Condition: Scoping Review %A Dalko,Katharina %A Elsuson,Hlynur Andri %A Kalter,Ivonne %A Zilezinski,Max %A Hofstetter,Sebastian %A Stoevesandt,Dietrich %A Paulicke,Denny %A Jahn,Patrick %+ Dorothea Erxleben Lernzentrum, Medical Faculty Halle, Martin-Luther-University Halle-Wittenberg, Magdeburger Straße 12, Halle (Saale), 06112, Germany, 49 345 557 5493, katharina.dalko@medizin.uni-halle.de %K long COVID %K post-COVID %K rehabilitation %K virtual reality %K implementation %K respiratory %K respiratory rehabilitation %K scoping review %K development %K accessibility %K support %K physical %K psychological %K motivation %K compliance %K usability %K COVID-19 %K COVID %D 2024 %7 31.5.2024 %9 Review %J JMIR Serious Games %G English %X Background: Due to a high number of patients affected by long COVID or post-COVID condition, an essential step to address the long-term effects of COVID-19 lies in the development and implementation of flexible and accessible rehabilitation programs. Virtual reality (VR) technologies offer the potential to support traditional therapies with individualized at-home programs. Objective: This study aims to provide an overview of existing scientific evidence on the development and implementation of VR-assisted respiratory rehabilitation programs for patients with long COVID and post-COVID condition and to synthesize the results. Methods: We conducted a scoping review of studies from 6 databases. PubMed, CINAHL, Cochrane, ScienceDirect, Web of Science Social Sciences Citation Index, and PEDro were searched using an exploratory search strategy. The search, which was last updated in February 2024, included peer-reviewed studies on immersive VR applications providing respiratory rehabilitation programs for patients with chronic obstructive pulmonary disease and long COVID or post-COVID condition. Exclusion criteria were studies in clinical or inpatient settings, telemedicine, nonimmersive VR applications, and gray literature. Nine publications were included in this review. Findings were extracted and summarized from the studies according to the JBI (Joanna Briggs Institute) method and thematically categorized. Topics covered were study characteristics, physiotherapeutic concept, clinical parameters, as well as usability and acceptability. Results: The 9 publications included in the qualitative analysis were published in 2019-2023. Eight empirical studies were included: 4 followed a mixed methods design, 3 were qualitative studies, and 1 followed a quantitative method. One scoping review was included in the data analyses. Four of the included studies were on patients with chronic obstructive pulmonary disease. The 9 studies demonstrated that VR-supported respiratory rehabilitation programs result in positive initial outcomes in terms of physical as well as psychological parameters. Particularly noteworthy was the increased motivation and compliance of patients. However, adverse effects and lack of usability are the barriers to the implementation of this innovative approach. Conclusions: Overall, VR is a promising technology for the implementation of individualized and flexible respiratory rehabilitation programs for patients with long COVID and post-COVID condition. Nevertheless, corresponding approaches are still under development and need to be more closely adapted to the needs of users. Further, the evidence was limited to pilot studies or a small number of patients, and no randomized controlled trials or long-term studies were part of the study selection. The included studies were performed by 4 groups of researchers: 3 from Europe and 1 from the United States. %M 38819890 %R 10.2196/52309 %U https://games.jmir.org/2024/1/e52309 %U https://doi.org/10.2196/52309 %U http://www.ncbi.nlm.nih.gov/pubmed/38819890 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e53129 %T Barriers and Facilitators to the Implementation of Virtual Reality Interventions for People With Chronic Pain: Scoping Review %A Elser,Alexander %A Lange,Marina %A Kopkow,Christian %A Schäfer,Axel Georg %+ Faculty of Social Work and Health, HAWK Hildesheim/Holzminden/Göttingen University of Applied Sciences and Arts, Goschentor 1, Hildesheim, Germany, 49 5121881121, alexander.elser@hawk.de %K virtual reality %K VR %K chronic pain %K implementation science %K scoping review %K barriers %K facilitators %D 2024 %7 15.5.2024 %9 Review %J JMIR XR Spatial Comput %G English %X Background: Chronic pain is a growing health problem worldwide with a significant impact on individuals and societies. In regard to treatment, there is a gap between guideline recommendations and common practice in health care, especially concerning cognitive and psychological interventions. Virtual reality (VR) may provide a way to improve this situation. A growing body of evidence indicates that VR therapy has positive effects on pain and physical function. However, there is limited knowledge about barriers and facilitators to the implementation of VR interventions for people with chronic pain in health care settings. Objective: The aim of this study was to identify and analyze the barriers and facilitators involved in implementing VR interventions for people with chronic pain. Methods: We conducted a scoping review of the German and English literature using the MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, PEDro, LILACS, and Web of Science (inception to November 2023) databases, including quantitative, qualitative, and mixed methods studies reporting barriers and facilitators to the implementation of VR interventions for people with chronic pain, as reported by patients or health care professionals. Two reviewers systematically screened the abstracts and full texts of retrieved articles according to the inclusion criteria. All mentioned barriers and facilitators were extracted and categorized according to the Theoretical Domains Framework (TDF). Results: The database search resulted in 1864 records after removal of duplicates. From the 14 included studies, 30 barriers and 33 facilitators from the patient perspective and 2 facilitators from the health care professional perspective were extracted. Barriers reported by people with chronic pain were most frequently assigned to the TDF domains environmental context (60%) and skills (16.7%). Most facilitators were found in three domains for both the patients and health care professionals: beliefs about consequences (30.3%), emotions (18.2%), and environmental context (18.2%). Conclusions: The findings of this review can inform the development of strategies for future implementations of VR interventions for people with chronic pain. Additionally, further research should address knowledge gaps about the perspective of health care professionals regarding the implementation of VR interventions for people with chronic pain. %R 10.2196/53129 %U https://xr.jmir.org/2024/1/e53129 %U https://doi.org/10.2196/53129 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e55692 %T An Immersive Virtual Reality Intervention for Preoperative Anxiety and Distress Among Adults Undergoing Oncological Surgery: Protocol for a 3-Phase Development and Feasibility Trial %A El-Gabalawy,Renée %A Sommer,Jordana L %A Hebbard,Pamela %A Reynolds,Kristin %A Logan,Gabrielle S %A Smith,Michael S D %A Mutter,Thomas C %A Mutch,W Alan %A Mota,Natalie %A Proulx,Catherine %A Gagnon Shaigetz,Vincent %A Maples-Keller,Jessica L %A Arora,Rakesh C %A Perrin,David %A Benedictson,Jada %A Jacobsohn,Eric %+ Department of Clinical Health Psychology, University of Manitoba, PZ-339 771 Bannatyne Avenue, Winnipeg, MB, R3E 3N4, Canada, 1 (204) 787 4713, renee.el-gabalawy@umanitoba.ca %K virtual reality %K preoperative anxiety and distress %K perioperative mental health %K breast cancer %K oncological surgery %D 2024 %7 14.5.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Preoperative state anxiety (PSA) is distress and anxiety directly associated with perioperative events. PSA is associated with negative postoperative outcomes such as longer hospital length of stay, increased pain and opioid use, and higher rates of rehospitalization. Psychological prehabilitation, such as education, exposure to hospital environments, and relaxation strategies, has been shown to mitigate PSA; however, there are limited skilled personnel to deliver such interventions in clinical practice. Immersive virtual reality (VR) has the potential for greater accessibility and enhanced integration into an immersive and interactive experience. VR is rarely used in the preoperative setting, but similar forms of stress inoculation training involving exposure to stressful events have improved psychological preparation in contexts such as military deployment. Objective: This study seeks to develop and investigate a targeted PSA intervention in patients undergoing oncological surgery using a single preoperative VR exposure. The primary objectives are to (1) develop a novel VR program for patients undergoing oncological surgery with general anesthesia; (2) assess the feasibility, including acceptability, of a single exposure to this intervention; (3) assess the feasibility, including acceptability, of outcome measures of PSA; and (4) use these results to refine the VR content and outcome measures for a larger trial. A secondary objective is to preliminarily assess the clinical utility of the intervention for PSA. Methods: This study comprises 3 phases. Phase 1 (completed) involved the development of a VR prototype targeting PSA, using multidisciplinary iterative input. Phase 2 (data collection completed) involves examining the feasibility aspects of the VR intervention. This randomized feasibility trial involves assessing the novel VR preoperative intervention compared to a VR control (ie, nature trek) condition and a treatment-as-usual group among patients undergoing breast cancer surgery. Phase 3 will involve refining the prototype based on feasibility findings and input from people with lived experience for a future clinical trial, using focus groups with participants from phase 2. Results: This study was funded in March 2019. Phase 1 was completed in April 2020. Phase 2 data collection was completed in January 2024 and data analysis is ongoing. Focus groups were completed in February 2024. Both the feasibility study and focus groups will contribute to further refinement of the initial VR prototype (phase 3), with the final simulation to be completed by mid-2024. Conclusions: The findings from this work will contribute to the limited body of research examining feasible and broadly accessible interventions for PSA. Knowledge gained from this research will contribute to the final development of a novel VR intervention to be tested in a large population of patients with cancer before surgery in a randomized clinical trial. Trial Registration: ClinicalTrials.gov NCT04544618; https://www.clinicaltrials.gov/study/NCT04544618 International Registered Report Identifier (IRRID): DERR1-10.2196/55692 %M 38743939 %R 10.2196/55692 %U https://www.researchprotocols.org/2024/1/e55692 %U https://doi.org/10.2196/55692 %U http://www.ncbi.nlm.nih.gov/pubmed/38743939 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e47382 %T Exploring How Virtual Reality Could Be Used to Treat Eating Disorders: Qualitative Study of People With Eating Disorders and Clinicians Who Treat Them %A Bould,Helen %A Kennedy,Mari-Rose %A Penton-Voak,Ian %A Thomas,Lisa May %A Bird,Jon %A Biddle,Lucy %+ Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, United Kingdom, 44 (0)117 9289000, helen.bould@bristol.ac.uk %K eating disorders %K virtual reality %K anorexia nervosa %K bulimia nervosa %K EDNOS %K treatment %K immersive %K clinicians %K qualitative data %K psychoeducation %K therapeutic %K limitations %D 2024 %7 14.5.2024 %9 Original Paper %J JMIR XR Spatial Comput %G English %X Background: Immersive virtual reality (VR) interventions are being developed and trialed for use in the treatment of eating disorders. However, little work has explored the opinions of people with eating disorders, or the clinicians who treat them, on the possible use of VR in this context. Objective: This study aims to use qualitative methodology to explore the views of people with eating disorders, and clinicians who treat them, on the possible use of VR in the treatment of eating disorders. Methods: We conducted a series of focus groups and interviews with people with lived experience of eating disorders and clinicians on their views about VR and how it could potentially be used in the treatment of eating disorders. People with lived experience of eating disorders were recruited between October and December 2020, with focus groups held online between November 2020 and February 2021; clinicians were recruited in September 2021 and interviewed between September and October 2021. We took a thematic approach to analyzing the resulting qualitative data. Results: We conducted 3 focus groups with 10 individuals with a current or previous eating disorder, 2 focus groups with 4 participants, and 1 with 2 participants. We held individual interviews with 4 clinicians experienced in treating people with eating disorders. Clinicians were all interviewed one-to-one because of difficulties in scheduling mutually convenient groups. We describe themes around representing the body in VR, potential therapeutic uses for VR, the strengths and limitations of VR in this context, and the practicalities of delivering VR therapy. Suggested therapeutic uses were to practice challenging situations around food-related and weight/appearance-related scenarios and interactions, to retrain attention, the representation of the body, to represent the eating disorder, for psychoeducation, and to enable therapeutic conversations with oneself. There was a substantial agreement between the groups on these themes. Conclusions: People with lived experience of eating disorders and clinicians with experience in treating eating disorders generated many ideas as to how VR could be used as a part of eating disorders treatment. They were also aware of potential limitations and expressed the need for caution around how bodies are represented in a VR setting. %R 10.2196/47382 %U https://xr.jmir.org/2024/1/e47382 %U https://doi.org/10.2196/47382 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e52649 %T Effectiveness of Virtual Reality in Reducing Perceived Pain and Anxiety Among Patients Within a Hospital System: Protocol for a Mixed Methods Study %A Mittal,Ajay %A Wakim,Jonathan %A Huq,Suhaiba %A Wynn,Tung %+ College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32610, United States, 1 3526158883, ajaymittal2400@gmail.com %K virtual reality %K digital health %K feasibility %K acceptability %K pain %K anxiety %K hospital %K hospitalization %K in-patient %K observational study %K pharmacologic pain management %K pain management %K topical anesthetic creams %K topical cream %D 2024 %7 9.5.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Within hospital systems, diverse subsets of patients are subject to minimally invasive procedures that provide therapeutic relief and necessary health data that are often perceived as anxiogenic or painful. These feelings are particularly relevant to patients experiencing procedures where they are conscious and not sedated or placed under general anesthesia that renders them incapacitated. Pharmacologic pain management and topical anesthetic creams are used to manage these feelings; however, distraction-based methods can provide nonpharmacologic means to modify the painful experience and discomfort often associated with these procedures. Recent studies support distraction as a useful method for reducing anxiety and pain and as a result, improving patient experience. Virtual reality (VR) is an emerging technology that provides an immersive user experience and can operate through a distraction-based method to reduce the negative or painful experience often related to procedures where the patient is conscious. Given the possible short-term and long-term outcomes of poorly managed pain and enduring among patients, health care professionals are challenged to improve patient well-being during medically essential procedures. Objective: The purpose of this pilot project is to assess the efficacy of using VR as a distraction-based intervention for anxiety or pain management compared to other nonpharmacologic interventions in a variety of hospital settings, specifically in patients undergoing lumbar puncture procedures and bone marrow biopsies at the oncology ward, patients receiving nerve block for a broken bone at an anesthesia or surgical center, patients undergoing a cleaning at a dental clinic, patients conscious during an ablation procedure at a cardiology clinic, and patients awake during a kidney biopsy at a nephrology clinic. This will provide the framework for additional studies in other health care settings. Methods: In a single visit, patients eligible for the study will complete brief preprocedural and postprocedural questionnaires about their perceived fear, anxiety, and pain levels. During the procedure, research assistants will place a VR headset on the patient and the patient will undergo a VR experience to distract from any pain felt from the procedure. Participants’ vitals, including blood pressure, heart rate, and rate of respiration, will also be recorded before, during, and after the procedure. Results: The study is already underway, and results support a decrease in perceived pain by 1.00 and a decrease in perceived anxiety by 0.3 compared to the control group (on a 10-point Likert scale). Among the VR intervention group, the average rating for comfort was 4.35 out of 5. Conclusions: This study will provide greater insight into how patients’ perception of anxiety and pain could potentially be altered. Furthermore, metrics related to the operational efficiency of providing a VR intervention compared to a control will provide insight into the feasibility and integration of such technologies in routine practice. International Registered Report Identifier (IRRID): DERR1-10.2196/52649 %M 38722681 %R 10.2196/52649 %U https://www.researchprotocols.org/2024/1/e52649 %U https://doi.org/10.2196/52649 %U http://www.ncbi.nlm.nih.gov/pubmed/38722681 %0 Journal Article %@ 2369-3762 %I %V 10 %N %P e52953 %T The Scope of Virtual Reality Simulators in Radiology Education: Systematic Literature Review %A Shetty,Shishir %A Bhat,Supriya %A Al Bayatti,Saad %A Al Kawas,Sausan %A Talaat,Wael %A El-Kishawi,Mohamed %A Al Rawi,Natheer %A Narasimhan,Sangeetha %A Al-Daghestani,Hiba %A Madi,Medhini %A Shetty,Raghavendra %K virtual reality %K simulators %K radiology education %K medical imaging %K radiology %K education %K systematic review %K literature review %K imaging %K meta analysis %K student %K students %K VR %K PRISMA %K Preferred Reporting Items for Systematic Reviews and Meta-Analyses %D 2024 %7 8.5.2024 %9 %J JMIR Med Educ %G English %X Background: In recent years, virtual reality (VR) has gained significant importance in medical education. Radiology education also has seen the induction of VR technology. However, there is no comprehensive review in this specific area. This review aims to fill this knowledge gap. Objective: This systematic literature review aims to explore the scope of VR use in radiology education. Methods: A literature search was carried out using PubMed, Scopus, ScienceDirect, and Google Scholar for articles relating to the use of VR in radiology education, published from database inception to September 1, 2023. The identified articles were then subjected to a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)–defined study selection process. Results: The database search identified 2503 nonduplicate articles. After PRISMA screening, 17 were included in the review for analysis, of which 3 (18%) were randomized controlled trials, 7 (41%) were randomized experimental trials, and 7 (41%) were cross-sectional studies. Of the 10 randomized trials, 3 (30%) had a low risk of bias, 5 (50%) showed some concerns, and 2 (20%) had a high risk of bias. Among the 7 cross-sectional studies, 2 (29%) scored “good” in the overall quality and the remaining 5 (71%) scored “fair.” VR was found to be significantly more effective than traditional methods of teaching in improving the radiographic and radiologic skills of students. The use of VR systems was found to improve the students’ skills in overall proficiency, patient positioning, equipment knowledge, equipment handling, and radiographic techniques. Student feedback was also reported in the included studies. The students generally provided positive feedback about the utility, ease of use, and satisfaction of VR systems, as well as their perceived positive impact on skill and knowledge acquisition. Conclusions: The evidence from this review shows that the use of VR had significant benefit for students in various aspects of radiology education. However, the variable nature of the studies included in the review reduces the scope for a comprehensive recommendation of VR use in radiology education. %R 10.2196/52953 %U https://mededu.jmir.org/2024/1/e52953 %U https://doi.org/10.2196/52953 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e56188 %T Factors Associated With Risky Drinking Decisions in a Virtual Reality Alcohol Prevention Simulation: Structural Equation Model %A Hrynyschyn,Robert %A Guldager,Julie Dalgaard %A Schulze,Daniel %A Lyk,Patricia Bianca %A Majgaard,Gunver %A Stock,Christiane %+ Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Health and Nursing Science, Augustenburger Platz 1, Berlin, 13353, Germany, 49 30450529030, robert.hrynyschyn@charite.de %K alcohol %K prevention %K virtual reality %K risk behavior %K structural equation model %D 2024 %7 6.5.2024 %9 Original Paper %J JMIR XR Spatial Comput %G English %X Background: Risky alcohol consumption among adolescents is a significant public health concern in most Western countries. Various motives and factors (eg, sensation seeking, gender, reduced self-efficacy) known in the literature are associated with risky drinking decisions in real life. Efforts to tackle risky drinking decisions in real life through skills training to deal with social pressures have been successful. However, interventions of this nature require significant resources. Technological solutions, such as virtual reality (VR), offer advantages, as they enable immersive experiences that replicate real-life scenarios. However, a question persists pertaining to the fidelity of real-world behaviors within virtual environments. Objective: This study is exploratory and aims to ascertain if the established drinking motives and factors for risky drinking decisions are transferrable to the virtual environment in the simulation game VR FestLab and to uncover determinants linked to risky drinking decisions within the simulation. Methods: The study analyzed data from the intervention arm of a cluster-randomized study of 161 Danish students aged 14-18 years who tested the virtual alcohol prevention simulation VR FestLab. At baseline and before playing VR FestLab, independent variables such as age, gender, alcohol consumption, use of other drugs, sensation seeking, drinking refusal skills, knowledge of blood alcohol concentration, and refusal communication skills were recorded. The dependent variable, virtual risk decisions, was measured immediately after the gameplay. Confirmatory factor analysis and structural equation modeling were used to examine the latent variables in relation to virtual risk decisions. Moderation analyses for age and gender in relation to the latent characteristics and the primary outcome were also conducted. Results: The data indicate that 73.9% (119/161) of the participants engaged in binge drinking at least once in their lifetime. The confirmatory factor analysis demonstrated a good fit of the items for their respective constructs; therefore, they were adopted without modification in the structural equation model. The data suggest that individuals with prior alcohol experience are 4 times more likely to engage in virtual risk decisions within the simulated environment (odds ratio 4.31, 95% CI 1.70-10.84; P=.01). Knowledge and awareness of blood alcohol concentration were associated with a lower chance to engage in virtual risk decisions (odds ratio 0.32, 95% CI 0.11-0.93; P=.04). However, no significant associations were found between virtual risk decisions and other latent variables. Gender and age did not moderate the associations. Conclusions: The immersive and lifelike properties of VR partially reflected risk-related decisions. However, it remains unclear which factors favor the mapping of real-world behaviors in virtual simulations. Therefore, future research should address the mechanisms underlying behavioral dynamics in virtual simulations and explore the translation of virtual behaviors into real behaviors to gain a comprehensive understanding of the potential of virtual simulations for alcohol prevention. %R 10.2196/56188 %U https://xr.jmir.org/2024/1/e56188 %U https://doi.org/10.2196/56188 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e54180 %T Digital Interventions to Understand and Mitigate Stress Response: Protocol for Process and Content Evaluation of a Cohort Study %A Martin,Josh %A Rueda,Alice %A Lee,Gyu Hee %A Tassone,Vanessa K %A Park,Haley %A Ivanov,Martin %A Darnell,Benjamin C %A Beavers,Lindsay %A Campbell,Douglas M %A Nguyen,Binh %A Torres,Andrei %A Jung,Hyejung %A Lou,Wendy %A Nazarov,Anthony %A Ashbaugh,Andrea %A Kapralos,Bill %A Litz,Brett %A Jetly,Rakesh %A Dubrowski,Adam %A Strudwick,Gillian %A Krishnan,Sridhar %A Bhat,Venkat %+ Interventional Psychiatry Program, St Michael's Hospital, Unity Health Toronto, 193 Yonge Street, Suite 6-013, Toronto, ON, M5B 1M4, Canada, 1 416 360 4000 ext 76404, venkat.bhat@utoronto.ca %K web-based platform %K stress %K distress %K moral distress %K wearable %K oura ring %K virtual reality %K VR %K COVID-19 %K nursing %K digital health implementation %D 2024 %7 6.5.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Staffing and resource shortages, especially during the COVID-19 pandemic, have increased stress levels among health care workers. Many health care workers have reported feeling unable to maintain the quality of care expected within their profession, which, at times, may lead to moral distress and moral injury. Currently, interventions for moral distress and moral injury are limited. Objective: This study has the following aims: (1) to characterize and reduce stress and moral distress related to decision-making in morally complex situations using a virtual reality (VR) scenario and a didactic intervention; (2) to identify features contributing to mental health outcomes using wearable, physiological, and self-reported questionnaire data; and (3) to create a personal digital phenotype profile that characterizes stress and moral distress at the individual level. Methods: This will be a single cohort, pre- and posttest study of 100 nursing professionals in Ontario, Canada. Participants will undergo a VR simulation that requires them to make morally complex decisions related to patient care, which will be administered before and after an educational video on techniques to mitigate distress. During the VR session, participants will complete questionnaires measuring their distress and moral distress, and physiological data (electrocardiogram, electrodermal activity, plethysmography, and respiration) will be collected to assess their stress response. In a subsequent 12-week follow-up period, participants will complete regular assessments measuring clinical outcomes, including distress, moral distress, anxiety, depression, and loneliness. A wearable device will also be used to collect continuous data for 2 weeks before, throughout, and for 12 weeks after the VR session. A pre-post comparison will be conducted to analyze the effects of the VR intervention, and machine learning will be used to create a personal digital phenotype profile for each participant using the physiological, wearable, and self-reported data. Finally, thematic analysis of post-VR debriefing sessions and exit interviews will examine reoccurring codes and overarching themes expressed across participants’ experiences. Results: The study was funded in 2022 and received research ethics board approval in April 2023. The study is ongoing. Conclusions: It is expected that the VR scenario will elicit stress and moral distress. Additionally, the didactic intervention is anticipated to improve understanding of and decrease feelings of stress and moral distress. Models of digital phenotypes developed and integrated with wearables could allow for the prediction of risk and the assessment of treatment responses in individuals experiencing moral distress in real-time and naturalistic contexts. This paradigm could also be used in other populations prone to moral distress and injury, such as military and public safety personnel. Trial Registration: ClinicalTrials.gov NCT05923398; https://clinicaltrials.gov/study/NCT05923398 International Registered Report Identifier (IRRID): DERR1-10.2196/54180 %M 38709554 %R 10.2196/54180 %U https://www.researchprotocols.org/2024/1/e54180 %U https://doi.org/10.2196/54180 %U http://www.ncbi.nlm.nih.gov/pubmed/38709554 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e51508 %T Views of Specialist Clinicians and People With Multiple Sclerosis on Upper Limb Impairment and the Potential Role of Virtual Reality in the Rehabilitation of the Upper Limb in Multiple Sclerosis: Focus Group Study %A Webster,Amy %A Poyade,Matthieu %A Coulter,Elaine %A Forrest,Lisa %A Paul,Lorna %+ School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, United Kingdom, 44 141 273 1345, Amy.Webster@gcu.ac.uk %K virtual reality %K multiple sclerosis %K upper limb rehabilitation %K coproduction %K activities of daily living %K exercise games %K upper limb impairment %D 2024 %7 26.4.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Finding enjoyable and effective long-term approaches to rehabilitation for improving the upper limb (UL) function of people with multiple sclerosis (MS) is challenging. Using virtual reality (VR) could be a solution to this challenge; however, there is a lack of reporting on the views of people with MS and clinicians on VR-based approaches and recommendations for games for rehabilitation. Objective: This study aims to identify common UL problems and their related current therapeutic approaches for people with MS, and to explore the opinions of people with MS and specialist clinicians on VR and obtain suggestions for the development and design of VR games. Methods: Separate focus groups were conducted with people with MS, recruited through the MS Society UK’s research network, and clinicians, recruited through the MS Trust Therapists in MS network. A total of 10 people with MS (2 focus groups) and 8 clinicians (5 physiotherapists, 2 occupational therapists, and 1 MS nurse in 2 focus groups) were involved. The focus groups were recorded and transcriptions were analyzed using theme-based content analysis. Results: People with MS commonly reported that their UL problems interfered with activities of daily living and resulted in the loss of meaningful hobbies such as writing. Many people with MS neglected UL exercise and found strategies for adapting to the UL impairments. Similarly, clinicians stated UL rehabilitation was neglected within their service and that it was challenging to find interesting treatment strategies. VR was suggested by both participant groups as a solution, as it was convenient for people with MS to access and it could provide a more engaging and disguised approach to exercise. There were shared concerns with cybersickness and disengagement with using VR approaches. Both groups agreed games should be meaningful and adaptable for users but suggested different VR activities, with clinicians suggesting games directly reflecting activities of daily living and people with MS suggesting more abstract activities. Conclusions: VR was well received by both people with MS and clinicians for UL rehabilitation. Recommendations were made for the development of VR rehabilitation games which are personalized and customizable for the varying abilities of people with MS. %M 38669680 %R 10.2196/51508 %U https://games.jmir.org/2024/1/e51508 %U https://doi.org/10.2196/51508 %U http://www.ncbi.nlm.nih.gov/pubmed/38669680 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e56056 %T Immersive Technologies for Depression Care: Scoping Review %A Reategui-Rivera,C Mahony %A Villarreal-Zegarra,David %A De La Cruz-Torralva,Kelly %A Díaz-Sánchez,Paquita %A Finkelstein,Joseph %+ Department of Biomedical Informatics, University of Utah, 421 Wakara Way, Ste 140, Salt Lake City, UT, 84108, United States, 1 801 581 4080, mahony.reategui@utah.edu %K depression %K immersive technologies %K virtual reality %K augmented reality %K mobile phone %D 2024 %7 25.4.2024 %9 Review %J JMIR Ment Health %G English %X Background: Depression significantly impacts quality of life, affecting approximately 280 million people worldwide. However, only 16.5% of those affected receive treatment, indicating a substantial treatment gap. Immersive technologies (IMTs) such as virtual reality (VR) and augmented reality offer new avenues for treating depression by creating immersive environments for therapeutic interventions. Despite their potential, significant gaps exist in the current evidence regarding the design, implementation, and use of IMTs for depression care. Objective: We aim to map the available evidence on IMT interventions targeting depression treatment. Methods: This scoping review followed a methodological framework, and we systematically searched databases for studies on IMTs and depression. The focus was on randomized clinical trials involving adults and using IMTs. The selection and charting process involved multiple reviewers to minimize bias. Results: The search identified 16 peer-reviewed articles, predominantly from Europe (n=10, 63%), with a notable emphasis on Poland (n=9, 56%), which contributed to more than half of the articles. Most of the studies (9/16, 56%) were conducted between 2020 and 2021. Regarding participant demographics, of the 16 articles, 5 (31%) exclusively involved female participants, and 7 (44%) featured participants whose mean or median age was >60 years. Regarding technical aspects, all studies focused on VR, with most using stand-alone VR headsets (14/16, 88%), and interventions typically ranging from 2 to 8 weeks, predominantly in hospital settings (11/16, 69%). Only 2 (13%) of the 16 studies mentioned using a specific VR design framework in planning their interventions. The most frequently used therapeutic approach was Ericksonian psychotherapy, used in 56% (9/16) of the studies. Notably, none of the articles reported using an implementation framework or identified barriers and enablers to implementation. Conclusions: This scoping review highlights the growing interest in using IMTs, particularly VR, for depression treatment but emphasizes the need for more inclusive and comprehensive research. Future studies should explore varied therapeutic approaches and cost-effectiveness as well as the inclusion of augmented reality to fully realize the potential of IMTs in mental health care. %M 38663004 %R 10.2196/56056 %U https://mental.jmir.org/2024/1/e56056 %U https://doi.org/10.2196/56056 %U http://www.ncbi.nlm.nih.gov/pubmed/38663004 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e42829 %T Effects of Virtual Reality Therapy Combined With Conventional Rehabilitation on Pain, Kinematic Function, and Disability in Patients With Chronic Neck Pain: Randomized Controlled Trial %A Guo,Qifan %A Zhang,Liming %A Han,Leo Lianyi %A Gui,Chenfan %A Chen,Guanghui %A Ling,Chunyan %A Wang,Wei %A Gao,Qiang %+ West China Hospital, Sichuan University, No 37 Guoxuexiang, Chengdu, 610041, China, 86 18980605992, gaoqiang_hxkf@163.com %K virtual reality %K neck pain %K disability %K kinematic function %K rehabilitation %K physiotherapy %K neck %K pain %K chronic %K therapy %K kinematic %K efficacy %K patient %K effect %D 2024 %7 24.4.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Neck pain is a common condition that leads to neck motor dysfunction and subsequent disability, with a significant global health care burden. As a newly emerging tool, virtual reality (VR) technology has been employed to address pain and reduce disability among patients with neck pain. However, there is still a lack of high-quality studies evaluating the efficacy of VR therapy combined with conventional rehabilitation for patients with chronic neck pain, particularly in terms of kinematic function. Objective: This study aims to investigate the effect of VR therapy combined with conventional rehabilitation on pain, kinematic function, and disability in patients with chronic neck pain. Methods: We conducted an assessor-blinded, allocation-concealed randomized controlled trial. Sixty-four participants experiencing chronic neck pain were randomly allocated into the experimental group that underwent VR rehabilitation plus conventional rehabilitation or the control group receiving the same amount of conventional rehabilitation alone for 10 sessions over 4 weeks. Pain intensity, disability, kinematic function (cervical range of motion, proprioception, and mean and peak velocity), degree of satisfaction, and relief of symptoms were evaluated at 3 timepoints (baseline, postintervention, and at 3 months follow-up). A 2*3 mixed repeated measures analysis of variance was utilized for analyzing the difference across indicators, with a significant difference level of .05. Results: Both groups demonstrated significant improvements in pain, disability, and kinematic functions (P<.05) at postintervention and at 3-month follow-up. The experimental group showed superior therapeutic outcomes compared to the control group in pain reduction (mean difference from the baseline: 5.50 vs 1.81 at posttreatment; 5.21 vs 1.91 at the 3-month follow-up, respectively; P<.001), disability improvement (mean difference from baseline: 3.04 vs 0.50 at posttreatment; 3.20 vs 0.85 at the 3-month follow-up, respectively; P<.001), and enhanced kinematic functions (P<.05). Moreover, participants in the experimental group reported better satisfaction and relief of symptoms than the control group (P<.05), with better initiative for exercising during the follow-up period. However, there was no between-group difference of improvement in proprioception. No adverse events were reported or observed in our research. Conclusions: The findings of our study support the efficacy of combining VR therapy with conventional rehabilitation in alleviating pain, enhancing kinematic function, and reducing disability of patients with chronic neck pain. Future research should focus on refining the therapeutic protocols and dosages for VR therapy as well as on optimizing its application in clinical settings for improved convenience and effectiveness. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000040132; http://www.chictr.org.cn/showproj.aspx?proj=64346 %M 38656775 %R 10.2196/42829 %U https://games.jmir.org/2024/1/e42829 %U https://doi.org/10.2196/42829 %U http://www.ncbi.nlm.nih.gov/pubmed/38656775 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e49171 %T Using Virtual Reality to Reduce Stress in Adolescents: Mixed Methods Usability Study %A Björling,Elin A %A Sonney,Jennifer %A Zade,Himanshu %A Rodriguez,Sofia %A Pullmann,Michael D %A Moon,Soo Hyun %+ Human Centered Design and Engineering, University of Washington, 428 Sieg Hall, Campus Box 352315, Seattle, WA, 98195, United States, 1 206 606 2662, bjorling@uw.edu %K virtual reality %K adolescents %K perceived stress %K participatory design %K depression %D 2024 %7 22.4.2024 %9 Original Paper %J JMIR XR Spatial Comput %G English %X Background: Adolescent mental health is a national mental health emergency amid surging rates of anxiety and depression. Given the scarcity and lack of scalable mental health services, the use of self-administered, evidence-based technologies to support adolescent mental health is both timely and imperative. Objective: The goal of this study was 2-fold: (1) to determine the feasibility, usability, and engagement of a participatory designed, nature-based virtual reality (VR) environment and (2) to determine the preliminary outcomes of our self-administered VR environment on depression, mindfulness, perceived stress, and momentary stress and mood. Methods: We conducted a within-person, 3-week, in-home study with a community-based sample of 44 adolescents. Participants completed surveys of perceived stress, depression, cognitive fusion, and mindfulness at intake, postintervention, and a 3-week follow-up. Participants were invited to use a nature-based, VR environment that included 6 evidence-based activities 3 to 5 times per week. They completed momentary stress and mood surveys 5 times each day and before and after each VR session. Postintervention, participants completed surveys on system and intervention usability and their experiences with using the VR system. Quantitative data were analyzed using descriptive statistics and mixed effects modeling to explore the effect of the VR environment on stress. Qualitative data were analyzed using collaborative thematic analysis. Results: Participants’ use of the VR environment ranged from 1 session to 24 sessions (mean 6.27 sessions) at home over a 3-week period. The 44 participants completed all study protocols, indicating our protocol was feasible and the VR environment was engaging for most. Both the use of the VR system and novel VR intervention received strong usability ratings (mean 74.87 on the System Usability Scale). Most teens indicated that they found the tool to be easily administered, relaxing, and helpful with stress. For some, it offered space to process difficult emotions. The themes calm, regulating, and forget about everything resulted from open-ended exit interview data. Although the Relaxation Environment for Stress in Teens (RESeT) did not significantly affect repeated survey measurements of depression, mindfulness, nor cognitive fusion, it did positively affect momentary mood (pre-intervention: 10.8, post-intervention: 12.0, P=.001) and decrease momentary stress (pre-intervention: 37.9, post-intervention: 20.6, P=.001). We found a significant reduction in within-day momentary stress that strengthened with increased VR use over time during the study period (P=.03). Conclusions: These preliminary data inform our own VR environment design but also provide evidence of the potential for self-administered VR as a promising tool to support adolescent mental health. Self-administered VR for mental health may be an effective intervention for reducing adolescent stress. However, understanding barriers (including disengagement) to using VR, as well as further encouraging participatory design with teens, may be imperative to the success of future mental health interventions. %R 10.2196/49171 %U https://xr.jmir.org/2024/1/e49171 %U https://doi.org/10.2196/49171 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e54538 %T Integrating Biomarkers From Virtual Reality and Magnetic Resonance Imaging for the Early Detection of Mild Cognitive Impairment Using a Multimodal Learning Approach: Validation Study %A Park,Bogyeom %A Kim,Yuwon %A Park,Jinseok %A Choi,Hojin %A Kim,Seong-Eun %A Ryu,Hokyoung %A Seo,Kyoungwon %+ Department of Applied Artificial Intelligence, Seoul National University of Science and Technology, Sangsang Hall, 4th Fl, Gongneung-ro, Gongneung-dong, Nowon-gu, Seoul, 01811, Republic of Korea, 82 010 5668 8660, kwseo@seoultech.ac.kr %K magnetic resonance imaging %K MRI %K virtual reality %K VR %K early detection %K mild cognitive impairment %K multimodal learning %K hand movement %K eye movement %D 2024 %7 17.4.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Early detection of mild cognitive impairment (MCI), a transitional stage between normal aging and Alzheimer disease, is crucial for preventing the progression of dementia. Virtual reality (VR) biomarkers have proven to be effective in capturing behaviors associated with subtle deficits in instrumental activities of daily living, such as challenges in using a food-ordering kiosk, for early detection of MCI. On the other hand, magnetic resonance imaging (MRI) biomarkers have demonstrated their efficacy in quantifying observable structural brain changes that can aid in early MCI detection. Nevertheless, the relationship between VR-derived and MRI biomarkers remains an open question. In this context, we explored the integration of VR-derived and MRI biomarkers to enhance early MCI detection through a multimodal learning approach. Objective: We aimed to evaluate and compare the efficacy of VR-derived and MRI biomarkers in the classification of MCI while also examining the strengths and weaknesses of each approach. Furthermore, we focused on improving early MCI detection by leveraging multimodal learning to integrate VR-derived and MRI biomarkers. Methods: The study encompassed a total of 54 participants, comprising 22 (41%) healthy controls and 32 (59%) patients with MCI. Participants completed a virtual kiosk test to collect 4 VR-derived biomarkers (hand movement speed, scanpath length, time to completion, and the number of errors), and T1-weighted MRI scans were performed to collect 22 MRI biomarkers from both hemispheres. Analyses of covariance were used to compare these biomarkers between healthy controls and patients with MCI, with age considered as a covariate. Subsequently, the biomarkers that exhibited significant differences between the 2 groups were used to train and validate a multimodal learning model aimed at early screening for patients with MCI among healthy controls. Results: The support vector machine (SVM) using only VR-derived biomarkers achieved a sensitivity of 87.5% and specificity of 90%, whereas the MRI biomarkers showed a sensitivity of 90.9% and specificity of 71.4%. Moreover, a correlation analysis revealed a significant association between MRI-observed brain atrophy and impaired performance in instrumental activities of daily living in the VR environment. Notably, the integration of both VR-derived and MRI biomarkers into a multimodal SVM model yielded superior results compared to unimodal SVM models, achieving higher accuracy (94.4%), sensitivity (100%), specificity (90.9%), precision (87.5%), and F1-score (93.3%). Conclusions: The results indicate that VR-derived biomarkers, characterized by their high specificity, can be valuable as a robust, early screening tool for MCI in a broader older adult population. On the other hand, MRI biomarkers, known for their high sensitivity, excel at confirming the presence of MCI. Moreover, the multimodal learning approach introduced in our study provides valuable insights into the improvement of early MCI detection by integrating a diverse set of biomarkers. %M 38631021 %R 10.2196/54538 %U https://www.jmir.org/2024/1/e54538 %U https://doi.org/10.2196/54538 %U http://www.ncbi.nlm.nih.gov/pubmed/38631021 %0 Journal Article %@ 2291-9279 %I %V 12 %N %P e44025 %T Using Virtual Reality in a Rehabilitation Program for Patients With Breast Cancer: Phenomenological Study %A Wu,Shih-Chung %A Chuang,Chia-Wen %A Liao,Wen-Chun %A Li,Chung-Fang %A Shih,Hsin-Hsin %K breast cancer %K rehabilitation %K virtual reality %K VR %K virtual reality design process %K VR design process %K feasibility %K accessibility %D 2024 %7 16.4.2024 %9 %J JMIR Serious Games %G English %X Background: Surgery is an essential treatment for early-stage breast cancer. However, various side effects of breast cancer surgery, such as arm dysfunction and lymphedema, remain causes for concern. Rehabilitation exercises to prevent such side effects should be initiated within 24 hours after surgery. Virtual reality (VR) can assist the process of rehabilitation; however, the feasibility of applying VR for rehabilitation must be explored, in addition to experiences of this application. Objective: This study explored patients’ attitudes toward and experiences of using VR for their rehabilitation to determine the feasibility of such VR use and to identify potential barriers. Methods: A phenomenological qualitative study was conducted from September to December 2021. A total of 18 patients with breast cancer who had undergone surgical treatment were interviewed using open-ended questions. The Colaizzi 7-step procedure for phenomenological analysis was used for data analysis. To ensure high study reliability, this study followed previously reported quality criteria for trustworthiness. Results: Three themes were identified: (1) VR was powerful in facilitating rehabilitation, (2) early and repetitive upper limb movements were an advantage of VR rehabilitation, and (3) extensive VR use had challenges to be overcome. Most of the interviewed patients reported positive experiences of using VR for rehabilitation. Specifically, VR helped these patients identify appropriate motion and angle limits while exercising; in other words, knowledge gained through VR can play a key role in the rehabilitation process. In addition, the patients reported that the use of VR provided them company, similar to when a physiotherapist is present. Finally, the gamified nature of the VR system seemed to make VR-based rehabilitation more engaging than traditional rehabilitation, particularly with respect to early rehabilitation; however, the high cost of VR equipment made VR-based rehabilitation difficult to implement at home. Conclusions: The interviewed patients with breast cancer had positive experiences in using VR for rehabilitation. The high cost of both VR equipment and software development presents a challenge for applying VR-based rehabilitation. %R 10.2196/44025 %U https://games.jmir.org/2024/1/e44025 %U https://doi.org/10.2196/44025 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e53212 %T Virtual Reality for Basic Life Support Training in High School Students: Thematic Analysis of Focus Group Interviews %A Min,Hyojin Jennifer %A Andler,Caroline %A Barber,Rebecca Ortiz La Banca %A Chang,Todd P %A Abelairas-Gomez,Cristian %A Knowlin,Laquanda T %A Liu,Deborah R %A Fijačko,Nino %+ Children’s Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA, 90027, United States, 1 3233614606, hmin@chla.usc.edu %K virtual reality %K mixed reality %K technology %K basic life support %K cardiovascular pulmonary resuscitation %K near-peer mentoring %K education %K high school students %D 2024 %7 16.4.2024 %9 Original Paper %J JMIR XR Spatial Comput %G English %X Background: High-quality and engaging cardiopulmonary resuscitation (CPR) training of both health care professionals and members of the public is necessary to provide timely and effective CPR to maximize survival and minimize injuries. Virtual reality (VR) is a novel method to enhance CPR engagement and training. However, a near-peer mentoring framework has not been applied in such training to date. Objective: The purpose of this pilot qualitative study was to understand the acceptability and feasibility of using VR technology to introduce basic life support (BLS) to high school students reinforced by near-peer coaching. Methods: Dyads of high school students underwent BLS training in CPR using a VR experience reinforced by the near-peer mentoring model. Focus group interviews were performed following the intervention. The interview sessions were recorded, transcribed verbatim, and subjected to thematic analysis. VR software data were analyzed after five cycles of chest compressions between the two participants. Results: The overwhelming responses from the three dyads of high school students indicated positive acceptance of learning CPR using VR. Analysis of emerging themes revealed three main categories of barriers and facilitators: (1) motivation to learn CPR, (2) CPR learning modality, and (3) coaching CPR content. These themes supported the theoretical framework of an “intention-focused” paradigm leading to acquiring the skills needed to perform CPR and ultimately increasing the chances of a bystander performing CPR. Conclusions: This study highlights the potential for training a unique population to increase bystander effects using novel VR technology coupled with a near-peer mentoring method. Further research is warranted to measure the outcome of the knowledge attained and the intention to perform CPR by high school students who participate in CPR education using VR and a near-peer mentoring method. %R 10.2196/53212 %U https://xr.jmir.org/2024/1/e53212 %U https://doi.org/10.2196/53212 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e52326 %T Examining the Efficacy of Extended Reality–Enhanced Behavioral Activation for Adults With Major Depressive Disorder: Randomized Controlled Trial %A Paul,Margot %A Bullock,Kim %A Bailenson,Jeremy %A Burns,David %+ Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd, Stanford, CA, 94305, United States, 1 781 572 4136, mdpaul@stanford.edu %K virtual reality %K extended reality %K major depressive disorder %K behavioral activation %K depression %K Meta Quest 2 %D 2024 %7 15.4.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Major depressive disorder (MDD) is a global concern with increasing prevalence. While many evidence-based psychotherapies (EBPs) have been identified to treat MDD, there are numerous barriers to patients accessing them. Virtual reality (VR) has been used as a treatment enhancement for a variety of mental health disorders, but few studies have examined its clinical use in treating MDD. Behavioral activation (BA) is a simple yet effective and established first-line EBP for MDD that has the potential to be easily enhanced and adapted with VR technology. A previous report by our group explored the feasibility and acceptability of VR-enhanced BA in a small clinical proof-of-concept pilot. This study examines the clinical efficacy of a more immersive extended reality (XR)–enhanced BA (XR-BA) prototype. This is the first clinical efficacy test of an XR-BA protocol. Objective: This study examined whether XR-BA was feasible and efficacious in treating MDD in an ambulatory telemedicine clinic. Methods: A nonblinded between-subject randomized controlled trial compared XR-BA to traditional BA delivered via telehealth. The study used a previously established, brief 3-week, 4-session BA EBP intervention. The experimental XR-BA participants were directed to use a Meta Quest 2 (Reality Labs) VR headset to engage in simulated pleasant or mastery activities and were compared to a control arm, which used only real-life mastery or pleasant activities as between-session homework. The Patient Health Questionnaire (PHQ)–9 was the primary outcome measure. Independent-sample and paired-sample t tests (2-tailed) were used to determine statistical significance and confirmed using structural equation modeling. Results: Overall, 26 participants with MDD were randomized to receive either XR-BA (n=13, 50%) or traditional BA (n=13, 50%). The mean age of the 26 participants (n=6, 23% male; n=19, 73% female; n=1, 4% nonbinary or third gender) was 50.3 (SD 17.3) years. No adverse events were reported in either group, and no substantial differences in dropout rates or homework completion were observed. XR-BA was found to be statistically noninferior to traditional BA (t18.6=−0.28; P=.78). Both the XR-BA (t9=2.5; P=.04) and traditional BA (t10=2.3; P=.04) arms showed a statistically significant decrease in PHQ-9 and clinical severity from the beginning of session 1 to the beginning of session 4. There was a significant decrease in PHQ-8 to PHQ-9 scores between the phone intake and the beginning of session 1 for the XR-BA group (t11=2.6; P=.03) but not the traditional BA group (t11=1.4; P=.20). Conclusions: This study confirmed previous findings that XR-BA may be a feasible, non-inferior, and acceptable enhancement to traditional BA. Additionally, there was evidence that supports the potential of XR to enhance expectation or placebo effects. Further research is needed to examine the potential of XR to improve access, outcomes, and barriers to MDD care. Trial Registration: ClinicalTrials.gov NCT05525390; https://clinicaltrials.gov/study/NCT05525390 %M 38437873 %R 10.2196/52326 %U https://mental.jmir.org/2024/1/e52326 %U https://doi.org/10.2196/52326 %U http://www.ncbi.nlm.nih.gov/pubmed/38437873 %0 Journal Article %@ 2291-9279 %I JMIR Serious Games %V 12 %N %P e46789 %T Efficacy of a Virtual 3D Simulation–Based Digital Training Module for Building Dental Technology Students’ Long-Term Competency in Removable Partial Denture Design: Prospective Cohort Study %A Liu,KeXin %A Xu,YaQian %A Ma,ChaoYi %A Yu,Na %A Tan,FaBing %A Li,Yi %A Bai,YaXin %A Fu,XiaoMing %A Wan,JiaWu %A Fan,DongQi %A Yin,HuBin %A Chen,MeiXi %A Chen,HongJi %A Jiang,Lin %A Song,JinLin %A Ji,Ping %A Zhao,XiaoHan %A Pang,MengWei %K removable partial denture %K RPD %K virtual simulation %K dental technology %K computer-aided design %K CAD %K clinical practice %K efficacy %K cohort study %K digital training %K training %K dentistry %K treatment %K design %K virtual %K assessment %D 2024 %7 5.4.2024 %9 %J JMIR Serious Games %G English %X Background: Removable partial denture (RPD) design is crucial to long-term success in dental treatment, but shortcomings in RPD design training and competency acquisition among dental students have persisted for decades. Digital production is increasing in prevalence in stomatology, and a digital RPD (D-RPD) module, under the framework of the certified Objective Manipulative Skill Examination of Dental Technicians (OMEDT) system reported in our previous work, may improve on existing RPD training models for students. Objective: We aimed to determine the efficacy of a virtual 3D simulation–based progressive digital training module for RPD design compared to traditional training. Methods: We developed a prospective cohort study including dental technology students at the Stomatology College of Chongqing Medical University. Cohort 1 received traditional RPD design training (7 wk). Cohort 2 received D-RPD module training based on text and 2D sketches (7 wk). Cohort 3 received D-RPD module pilot training based on text and 2D sketches (4 wk) and continued to receive training based on 3D virtual casts of real patients (3 wk). RPD design tests based on virtual casts were conducted at 1 month and 1 year after training. We collected RPD design scores and the time spent to perform each assessment. Results: We collected the RPD design scores and the time spent to perform each assessment at 1 month and 1 year after training. The study recruited 109 students, including 58 (53.2%) female and 51 male (56.8%) students. Cohort 1 scored the lowest and cohort 3 scored the highest in both tests (cohorts 1-3 at 1 mo: mean score 65.8, SD 21.5; mean score 81.9, SD 6.88; and mean score 85.3, SD 8.55, respectively; P<.001; cohorts 1-3 at 1 y: mean score 60.3, SD 16.7; mean score 75.5, SD 3.90; and mean score 90.9, SD 4.3, respectively; P<.001). The difference between cohorts in the time spent was not statistically significant at 1 month (cohorts 1-3: mean 2407.8, SD 1370.3 s; mean 1835.0, SD 1329.2 s; and mean 1790.3, SD 1195.5 s, respectively; P=.06) but was statistically significant at 1 year (cohorts 1-3: mean 2049.16, SD 1099.0 s; mean 1857.33, SD 587.39 s; and mean 2524.3, SD 566.37 s, respectively; P<.001). Intracohort comparisons indicated that the differences in scores at 1 month and 1 year were not statistically significant for cohort 1 (95% CI –2.1 to 13.0; P=.16), while cohort 3 obtained significantly higher scores 1 year later (95% CI 2.5-8.7; P=.001), and cohort 2 obtained significantly lower scores 1 year later (95% CI –8.8 to –3.9; P<.001). Conclusions: Cohort 3 obtained the highest score at both time points with retention of competency at 1 year, indicating that progressive D-RPD training including virtual 3D simulation facilitated improved competency in RPD design. The adoption of D-RPD training may benefit learning outcomes. %R 10.2196/46789 %U https://games.jmir.org/2024/1/e46789 %U https://doi.org/10.2196/46789 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51558 %T Assessing the Clinical Efficacy of a Virtual Reality Tool for the Treatment of Obesity: Randomized Controlled Trial %A Anastasiadou,Dimitra %A Herrero,Pol %A Garcia-Royo,Paula %A Vázquez-De Sebastián,Julia %A Slater,Mel %A Spanlang,Bernhard %A Álvarez de la Campa,Elena %A Ciudin,Andreea %A Comas,Marta %A Ramos-Quiroga,Josep Antoni %A Lusilla-Palacios,Pilar %+ Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Barcelona, Bellaterra, Barcelona, 08193, Spain, 34 935813854, dimitra.anastasiadou@uab.cat %K obesity %K virtual reality %K psychological treatment %K embodiment %K motivational interviewing %K self-conversation %D 2024 %7 5.4.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) interventions, based on cognitive behavioral therapy principles, have been proven effective as complementary tools in managing obesity and have been associated with promoting healthy behaviors and addressing body image concerns. However, they have not fully addressed certain underlying causes of obesity, such as a lack of motivation to change, low self-efficacy, and the impact of weight stigma interiorization, which often impede treatment adherence and long-term lifestyle habit changes. To tackle these concerns, this study introduces the VR self-counseling paradigm, which incorporates embodiment and body-swapping techniques, along with motivational strategies, to help people living with obesity effectively address some of the root causes of their condition. Objective: This study aims to assess the clinical efficacy of ConVRself (Virtual Reality self-talk), a VR platform that allows participants to engage in motivational self-conversations. Methods: A randomized controlled trial was conducted with 68 participants from the bariatric surgery waiting list from the obesity unit of the Vall d’Hebron University Hospital in Barcelona, Spain. Participants were assigned to 1 of 3 groups: a control group (CG), which only received treatment as usual from the obesity unit; experimental group 1 (EG1), which, after intensive motivational interviewing training, engaged in 4 sessions of VR-based self-conversations with ConVRself, and underwent embodiment and body-swapping techniques; and experimental group 2 (EG2), which engaged in 4 VR-based sessions led by a virtual counselor with a prerecorded discourse, and only underwent the embodiment technique. In the case of both EG1 and EG2, the VR interventions were assisted by a clinical researcher. Readiness to change habits, eating habits, and psychological variables, as well as adherence and satisfaction with ConVRself were measured at baseline, after the intervention, 1 week after the intervention, and 4 weeks after the intervention. Results: Regarding the primary outcomes, EG1 (24/68, 35%) and EG2 (22/68, 32%) showed significant improvements in confidence to lose weight compared to the CG (22/68, 32%) at all assessment points (β=−.16; P=.02). Similarly, EG1 demonstrated a significant increase after the intervention in readiness to exercise more compared to the CG (β=−.17; P=.03). Regarding the secondary outcomes, EG1 participants showed a significant reduction in uncontrolled eating (β=.71; P=.01) and emotional eating (β=.29; P=.03) compared to the CG participants, as well as in their anxiety levels compared to EG2 and CG participants (β=.65; P=.01). In addition, participants from the experimental groups reported high adherence and satisfaction with the VR platform (EG1: mean 59.82, SD 4.00; EG2: mean 58.43, SD 5.22; d=0.30, 95% CI −0.30 to 0.89). Conclusions: This study revealed that using VR self-conversations, based on motivational interviewing principles, may have benefits in helping people with obesity to enhance their readiness to change habits and self-efficacy, as well as reduce dysfunctional eating behaviors and anxiety. Trial Registration: ClinicalTrials.gov NCT05094557; https://www.clinicaltrials.gov/study/NCT05094557 %M 38578667 %R 10.2196/51558 %U https://www.jmir.org/2024/1/e51558 %U https://doi.org/10.2196/51558 %U http://www.ncbi.nlm.nih.gov/pubmed/38578667 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e52186 %T Effectiveness of Virtual Reality–Based Well-Being Interventions for Stress Reduction in Young Adults: Systematic Review %A Xu,Joy %A Khanotia,Areej %A Juni,Shmuel %A Ku,Josephine %A Sami,Hana %A Lin,Vallen %A Walterson,Roberta %A Payne,Evelyn %A Jo,Helen %A Rahimpoor-Marnani,Parmin %+ David Geffen School of Medicine at UCLA, 417 Charles E Young Drive West, Los Angeles, CA, 90024, United States, 1 3109481476, joyjxu@gmail.com %K well-being %K well-being %K virtual reality %K VR %K stress, nature %K academic %K student %K intervention %K young adults %K teens %K adolescent %K stressors %K stress management %K systematic review %K accessible %K accessibility %K students %K affordable %D 2024 %7 29.3.2024 %9 Review %J JMIR Ment Health %G English %X Background: Adolescents can be especially vulnerable to various stressors as they are still in their formative years and transitioning into adulthood. Hence, it is important for them to have effective stress management strategies. Objective: This systematic review investigates current well-being interventions that are aimed at reducing stress among young adults. In particular, interventions using the medium of virtual reality (VR) are explored. Methods: This mixed methods systematic review follows the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) guidelines, and papers were gathered from databases such as PsycINFO, PubMed, Science Direct, Web of Science, OpenGrey, and Edutopia. Predetermined criteria and specific keywords were used to search for the papers. Search results were screened and extracted with all article screening or extraction delegated among all authors. Any disagreements after reconciliation were settled by a third author. The quality and risk of bias of included studies were assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) Tool for Quantitative Studies. Studies were analyzed qualitatively. Results: In total, 20 studies were included, and qualitative analysis was performed to evaluate the effectiveness of VR-based interventions in 3 domains: nature, stress, and academics. Conclusions: Studies using VR interventions, overall, promoted a reduction in stress and an increase in well-being. The findings suggest that VR may serve as an accessible and affordable medium of stress reduction for students and young adults. Larger sample sizes, and a greater number of included studies, may be required in future directions. %M 38551625 %R 10.2196/52186 %U https://mental.jmir.org/2024/1/e52186 %U https://doi.org/10.2196/52186 %U http://www.ncbi.nlm.nih.gov/pubmed/38551625 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e50796 %T Impact of Virtual Reality–Based Group Activities on Activity Level and Well-Being Among Older Adults in Nursing Homes: Longitudinal Exploratory Study %A Li,Yijun %A Wilke,Carlotta %A Shiyanov,Irina %A Muschalla,Beate %+ Department of Psychotherapy and Diagnostics, Technische Universität Braunschweig, Institute of Psychology, Humboldtstraße 33, Braunschweig, 38106, Germany, 49 0531 391 3603, yijun.li@tu-braunschweig.de %K virtual reality %K group activity %K aging care %K older adults %K meaningful activity %K mental health %K well-being %K social interaction %K psychosocial capacities %K activity of daily living %D 2024 %7 29.3.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: In addition to illness, inactivity is a risk factor for high mortality in nursing homes. Using innovative technology, such as virtual reality (VR), for meaningful group activities could provide new opportunities for solving this problem. VR interventions have already been approved as a promising method for enhancing the health of older adults. Objective: In this study, we examined whether VR-based group activities can have a positive impact on activity level and group interaction among older adults living in nursing homes. Methods: We conducted a longitudinal study and provided VR interventions as a group activity once a week for 4 consecutive weeks in nursing homes. Participants were recruited based on the experience of the nursing staff members and the natural decisions of the older adults. Within a virtual cottage, designed according to the needs of the target group, older adults were able to perform daily tasks that they were no longer able to do in real life, such as gardening and making pizza. Overall, 2 psychologists measured the psychosocial capacities, activities of daily life, and well-being before and after the interventions using standardized instruments. Results: The results focus on a total of 84 older adults from 14 nursing homes who completed at least 3 VR interventions. The results indicate that several psychosocial capacities among the older adults improved, including adherence to regulations (P<.001; η²=0.122), flexibility (P<.001; η²=0.109), and group integration (P<.001; η²=0.141). Problems related to competence also showed a slight decrease (P=.04; η²=0.039). In addition, the VR intervention promoted their proactivity (P<.001; η²=0.104) and mobility (P=.04; η²=0.039). During the VR group intervention, older adults’ well-being could be maintained at a high level. The results highlight the beneficial effects of VR intervention as a meaningful activity in nursing homes, showcasing the potential of VR applications in this setting. Conclusions: This study provides a novel and naturalistic perspective, offering new insights into the use of VR in nursing homes. The VR intervention was well accepted and fulfilled the aim of enhancing capacity and well-being. It could be a meaningful group activity in nursing homes to improve social group interaction. To provide stronger evidence, randomized controlled trials are necessary. %M 38551635 %R 10.2196/50796 %U https://games.jmir.org/2024/1/e50796 %U https://doi.org/10.2196/50796 %U http://www.ncbi.nlm.nih.gov/pubmed/38551635 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e49550 %T Comparing Walking-Related Everyday Life Tasks of Children with Gait Disorders in a Virtual Reality Setup With a Physical Setup: Cross-Sectional Noninferiority Study %A Rhiel,Sophia %A Kläy,Andrina %A Keller,Urs %A van Hedel,Hubertus J A %A Ammann-Reiffer,Corinne %+ Swiss Children’s Rehab, University Children's Hospital Zurich, University of Zurich, Mühlebergstrasse 104, Affoltern am Albis, 8910, Switzerland, 41 44 762 52 97, sophia.rhiel@kispi.uzh.ch %K adolescent %K child %K gait %K head-mounted display %K motion capture %K neurological rehabilitation %K noninferiority trial %K physical therapy %K virtual reality %K walking %D 2024 %7 18.3.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: A frequent rehabilitation goal for children with gait disorders is to practice daily-life walking activities. Unfortunately, these are often difficult to practice in a conventional therapeutic setting. Virtual reality (VR) with head-mounted displays (HMDs) could be a promising approach in neurorehabilitation to train such activities in a safe environment. First, however, we must know whether obstacles in VR are indeed mastered as obstacles. Objective: This study aimed to provide information on whether VR is feasible and motivating to induce and practice movements needed to master real obstacles in children and adolescents with gait disorders. Furthermore, this project aims to evaluate which kinds of everyday walking activities are appropriate to be practiced in VR. Methods: In this cross-sectional study, participants stepped over a bar, crossed a gap, balanced over a beam, and circumvented stationary obstructions arranged in a course under real physical and virtual conditions wearing a VR HMD. We recorded the respective primary outcomes (step height, step length, step width, and minimal shoulder-obstacle distance) with motion capture. We then calculated the mean differences and 95% CI of the spatiotemporal parameters between the VR and physical setup and later compared them using noninferiority analysis with margins defined a priori by a clinical expert panel. Additionally, the participants responded to a standardized questionnaire while the therapists observed and evaluated their movement performance. Results: We recruited 20 participants (mean age 12.0, range 6.6-17.8 years) with various diagnoses affecting their walking ability. At 3.77 (95% CI 1.28 to 6.26) cm, the mean difference in step height of the leading foot in the overstepping task did not exceed the predefined margin of –2 cm, thus signifying noninferiority of the VR condition compared to mastering the physical obstacles. The same was true for step length (–1.75, 95% CI –4.91 to 1.41 cm; margin –10 cm), step width (1.05, 95% CI 0.20 to –1.90 cm; margin 3 cm), and the minimal shoulder-obstacle distance (0.25, 95% CI –0.85 to 0.35 cm; margin –2 cm) in the other tasks. Only the trailing foot in the overstepping task yielded inconclusive results. Conclusions: Children with gait disorders perform everyday walking tasks like overstepping, crossing, balancing, or circumventing similarly in physical and VR environments, suggesting that VR could be a feasible therapeutic tool to practice everyday walking tasks. %M 38498048 %R 10.2196/49550 %U https://games.jmir.org/2024/1/e49550 %U https://doi.org/10.2196/49550 %U http://www.ncbi.nlm.nih.gov/pubmed/38498048 %0 Journal Article %@ 2817-092X %I JMIR Publications %V 3 %N %P e50538 %T Virtual Reality–Based Neurorehabilitation Support Tool for People With Cognitive Impairments Resulting From an Acquired Brain Injury: Usability and Feasibility Study %A Prats-Bisbe,Alba %A López-Carballo,Jaume %A García-Molina,Alberto %A Leno-Colorado,David %A García-Rudolph,Alejandro %A Opisso,Eloy %A Jané,Raimon %+ Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la Universitat Autònoma de Barcelona, Camí de Can Ruti, s/n, Badalona, 08916, Spain, 34 934 977 700, aprats@guttmann.com %K acquired brain injury %K virtual reality %K head-mounted display %K neurorehabilitation %K usability %K feasibility %K co-design %K multidisciplinary experiences %K immersive serious games %D 2024 %7 18.3.2024 %9 Original Paper %J JMIR Neurotech %G English %X Background: Acquired brain injury (ABI) is a prominent cause of disability globally, with virtual reality (VR) emerging as a promising aid in neurorehabilitation. Nonetheless, the diversity among VR interventions can result in inconsistent outcomes and pose challenges in determining efficacy. Recent reviews offer best practice recommendations for designing and implementing therapeutic VR interventions to evaluate the acceptance of fully immersive VR interventions. Objective: This study aims to evaluate the usability and feasibility of a co-designed VR-based neurorehabilitation support tool by conducting multiple proof-of-concept trials in a sample of patients with ABI within a hospital setting. Methods: A single session deploying custom immersive serious games to train cognitive functions using a new-generation head-mounted display was conducted among a sample of inpatients with ABI. Structured questionnaires were administered at the end of the session to evaluate the usability of the system and the intervention, participants’ familiarity with the technology, and any adverse effects related to cybersickness. Additionally, the training duration while wearing the headset and the demographic characteristics of the participants were considered. Results: A total of 20 patients with ABI participated in a 1-hour proof-of-concept trial. The mean usability score was 37 (SD 2.6) out of 40, the technology familiarity level was 9.2 (SD 2.9) out of 12, and the Simulator Sickness Questionnaire total score was 1.3 (SD 2). On average, participants wore the headset for approximately 25.6 (SD 4.7) minutes during the intervention. There were no substantial differences in usability and technology familiarity levels based on patients’ etiology or age, with no notable symptoms of cybersickness reported. Significantly strong correlations were noted between cybersickness symptoms and various usability categories, including exposure, motivation, interactivity, task specificity, and immersion aspects. Further, there was a significant association between the intervention time and the number of tasks performed (P<.001). Furthermore, patients who derived enjoyment from VR sessions expressed a heightened interest in incorporating VR into their daily neurorehabilitation practice (P<.001). Moreover, oculomotor issues were found to be highly sensitive to the onset of disorientation sickness symptoms (P<.001). Conclusions: Through a collaborative approach, this study showcases the usability and feasibility of a VR-based support tool for cognitive rehabilitation among inpatients with ABI. Key components of such interventions encompass a multidisciplinary array of immersive experiences integrating neurorehabilitation principles and serious games techniques. %R 10.2196/50538 %U https://neuro.jmir.org/2024/1/e50538 %U https://doi.org/10.2196/50538 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e49218 %T Using a Virtual Reality Tool to Provide Primary Prevention Training in the Construction Field Following a Periodic Medical Visit: Cross-Sectional Study %A Chamot,Sylvain %A Mahieu,Isabelle %A Delzard,Marion %A Leroy,Léa %A Marhic,Gwen %A Gignon,Maxime %+ Regional Center for Occupational and Environmental Pathologies of Hauts-de-France, Amiens University Hospital, 1 rond point du Pr Christian Cabrol, Amiens, 80000, France, 33 322087760, chamot.sylvain@chu-amiens.fr %K virtual reality %K virtual training tool %K prevention %K occupational medicine %K construction %D 2024 %7 15.3.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: The construction field is highly concerned with the risk of work-related accidents, and training employees is difficult due to their small numbers in most companies. Objective: This study aimed to study the impact of a virtual reality (VR) training tool following a periodic occupational health medical visit on the feeling of personal effectiveness in preventing occupational risks related to co-activity on a construction site. Methods: We conducted a cross-sectional study with employees who had a periodic medical visit between April 1, 2022, and October 13, 2022, in a French occupational health service specializing in the construction field (Services Médicaux Interentreprises Bâtiment Travaux Publics [SMIBTP]). The employees were divided into 2 groups according to the training received: a medical visit alone or coupled with a session with a VR tool. We compared the scores for a “feeling of self-efficacy in occupational risk prevention” using the Fisher exact test. Results: Of the 588 employees included, 210 had a medical visit alone, and 378 had a medical visit coupled with VR training. Training with the VR tool was associated with an increased “feeling of self-efficacy in occupational risk prevention.” The employees who benefited from the training reported a willingness to apply the advice given on prevention to a greater extent than those who did not, and they believed that risks on the worksite could be reduced using this tool. Conclusions: Using VR training as a complement to periodic medical visits in an occupational health service improves the feeling of personal effectiveness in occupational risk prevention at the end of the training. If this trend is confirmed over a longer period of time, it could be an easily accessible prevention lever for employees in the future. %M 38488851 %R 10.2196/49218 %U https://games.jmir.org/2024/1/e49218 %U https://doi.org/10.2196/49218 %U http://www.ncbi.nlm.nih.gov/pubmed/38488851 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e34535 %T A Smartphone-Gamified Virtual Reality Exposure Therapy Augmented With Biofeedback for Ailurophobia: Development and Evaluation Study %A Khaleghi,Ali %A Narimani,Abbas %A Aghaei,Zahra %A Khorrami Banaraki,Anahita %A Hassani-Abharian,Peyman %+ Iranian Light Source Facility, Institute for Research in Fundamental Sciences, Opposite the Araj, Artesh Highway, Aghdassieh, Tehran, 19395-5746, Iran, 98 9121003006, ali.khaleghi.ir@gmail.com %K animal phobia %K specific phobia %K ailurophobia %K cat phobia %K biofeedback %K smartphones %K virtual reality %K gamification %K mobile phone %D 2024 %7 6.3.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: To the best of our knowledge, no specialized research has been conducted to address ailurophobia (fear of cats) in Iran or globally. This has driven our project, along with the prevalence of ailurophobia and the absence of a gamified virtual reality exposure therapy (VRET) that incorporates affordable and easily accessible biofeedback (BF) tools. We hypothesize that a gamified VRET augmented with BF will yield more positive effects than a similar device lacking BF. Objective: This study primarily focuses on the development and preliminary evaluation of a smartphone-gamified VRET integrated with BF, targeting animal phobia, with a specific case study on ailurophobia. The secondary objectives are using affordable and readily available BF found in devices such as smart bands and smartwatches and creating a mobile virtual reality gamified app to improve patients’ adherence to treatments while simultaneously enhancing the app’s accessibility, scalability, and outreach. Methods: Evaluations encompassed 3 methods. First, we identified the tool’s potential positive effects on phobia interventions, exploring 4 effects: intrinsic motivation, simulation of fearful situations, management of stressful circumstances without therapists’ presence and mitigation of catastrophic thoughts, and preliminary effects on ailurophobia treatment. Participants were divided into BF and non-BF groups. Second, we gathered user preferences and opinions about the treatment. Third, we conducted heuristic evaluations using 44 heuristics from existing system usability scales assessing user interfaces, virtual reality platforms, and video games’ playability. To interpret the data, mean scores; ANOVA, single factor; and ANOVA, 2-factor with replication were used. A total of 29 individuals were identified, of which 10 met the eligibility criteria or were accessible. Results: The smartphone-gamified VRET augmented with BF exhibited better results on the identified effects compared with the non-BF version and contributed to normalizing encounters with cats. Moreover, 41 of the 44 heuristics achieved a percentage above 62%, indicating its potential as a therapeutic product and its ability to enhance patient adherence to treatments. Patient preferences on the treatment and its strengths and weaknesses were provided for further improvement. Conclusions: The tool has the potential to evolve into a comprehensive solution by incorporating various types of cats and their behaviors, simulating environments in which they are commonly found, and enhancing its appeal through an increased sense of adventure without inducing unrealistic fears. By adapting fear elements, the game can be tailored to treat various animal phobias. Phobia-focused games should avoid action and combat scenarios to prevent reinforcement of fear responses. After rigorous evaluation, further exploration is required to provide remote use beyond clinical settings. %M 38446522 %R 10.2196/34535 %U https://games.jmir.org/2024/1/e34535 %U https://doi.org/10.2196/34535 %U http://www.ncbi.nlm.nih.gov/pubmed/38446522 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e45406 %T Virtual Reality–Based Training in Chronic Low Back Pain: Systematic Review and Meta-Analysis of Randomized Controlled Trials %A Li,Ran %A Li,Yinghao %A Kong,Youli %A Li,Hanbin %A Hu,Danrong %A Fu,Chenying %A Wei,Quan %+ Rehabilitation Medicine Center and Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, No.37 Guo Xue Alley, Chengdu, 610041, China, 86 18980606730, weiquan@scu.edu.cn %K virtual reality %K low back pain %K chronic %K rehabilitation %K exercise %D 2024 %7 26.2.2024 %9 Review %J J Med Internet Res %G English %X Background: Low back pain is one of the most prevalent pain conditions worldwide. Virtual reality–based training has been used for low back pain as a new treatment strategy. Present evidence indicated that the effectiveness of virtual reality–based training for people with chronic low back pain is inconclusive. Objective: This study conducted a meta-analysis to evaluate the immediate- and short-term effects of virtual reality–based training on pain, pain-related fear, and disability in people with chronic low back pain. Methods: We searched the PubMed, Embase, Web of Science, PEDro, CENTRAL, and CINAHL databases from inception until January 2024. Only randomized controlled trials assessing the effects of virtual reality–based training on individuals with chronic low back pain were selected. The outcomes were focused on pain, pain-related fear measured by the Tampa Scale of Kinesiophobia, and disability measured by the Oswestry Disability Index. The immediate term was defined as the immediate period after intervention, and the short term was defined as 3 to 6 months after intervention. The Cochrane Risk of Bias tool and the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach were used to evaluate the quality of the methodology and evidence, respectively. Results: In total, 20 randomized controlled trials involving 1059 patients were eligible for analysis. Virtual reality–based training showed significant improvements in pain (mean difference [MD] –1.43; 95% CI –1.86 to –1.00; I2=95%; P<.001), pain-related fear using the Tampa Scale of Kinesiophobia (MD –5.46; 95% CI –9.40 to 1.52; I2=90%; P=.007), and disability using the Oswestry Disability Index (MD –11.50; 95% CI –20.00 to –3.01; I2=95%; P=.008) in individuals with chronic low back pain immediately after interventions. However, there were no significant differences observed in pain (P=.16), pain-related fear (P=.10), and disability (P=.43) in the short term. Conclusions: These findings indicated that virtual reality–based training can be used effectively for individuals with chronic low back pain in the immediate term, especially to reduce pain, alleviate pain-related fear, and improve disability. However, the short-term benefits need more high-quality trials to be demonstrated. Trial Registration: PROSPERO CRD42021292633; http://tinyurl.com/25mydxpz %M 38407948 %R 10.2196/45406 %U https://www.jmir.org/2024/1/e45406 %U https://doi.org/10.2196/45406 %U http://www.ncbi.nlm.nih.gov/pubmed/38407948 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e49312 %T Virtual Reality–Based Exercise Rehabilitation in Cancer-Related Dysfunctions: Scoping Review %A Su,Zhenzhen %A Zhang,Liyan %A Lian,Xuemin %A Guan,Miaomiao %+ Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, 52 Fucheng Road, Haidian District, Beijing, 100142, China, 86 18210187087, zhangliyand@126.com %K virtual reality %K cancer %K virtual reality–based exercise rehabilitation %K cancer-related dysfunction %K rehabilitation %K scoping review %D 2024 %7 26.2.2024 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality–based exercise rehabilitation (VRER) is a promising intervention for patients with cancer-related dysfunctions (CRDs). However, studies focusing on VRER for CRDs are lacking, and the results are inconsistent. Objective: We aimed to review the application of VRER in patients with CRDs. Methods: This scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist framework. Publications were included from the time of database establishment to October 14, 2023. The databases were PubMed, Embase, Scopus, Cochrane, Web of Science, ProQuest, arXiv, IEEE Xplore, MedRxiv, CNKI, Wanfang Data, VIP, and SinoMed. The population included patients with cancer. A virtual reality (VR) system or device was required to be provided in exercise rehabilitation as an intervention. Eligible studies focused on VRER used for CRDs. Study selection and data extraction were performed by 2 reviewers independently. Extracted data included authors, year, country, study type, groups, sample size, participant age, cancer type, existing or potential CRDs, VR models and devices, intervention programs and durations, effectiveness, compliance, satisfaction, and safety. Results: We identified 25 articles, and among these, 12 (48%) were randomized clinical trials, 11 (44%) were other experimental studies, and 2 (8%) were observational studies. The total sample size was 1174 (range 6-136). Among the 25 studies, 22 (88%), 2 (8%), and 1 (4%) included nonimmersive VR, immersive VR, and augmented reality, respectively, which are models of VRER. Commercial game programs (17/25, 68%) were the most popular interventions of VRER, and their duration ranged from 3 to 12 weeks. Using these models and devices, VRER was mostly applied in patients with breast cancer (14/25, 56%), leukemia (8/25, 32%), and lung cancer (3/25, 12%). Furthermore, 6 CRDs were intervened by VRER, and among these, postmastectomy syndromes were the most common (10/25, 40%). Overall, 74% (17/23) of studies reported positive results, including significant improvements in limb function, joint range of motion, edema rates, cognition, respiratory disturbance index, apnea, activities of daily living, and quality of life. The compliance rate ranged from 56% to 100%. Overall, 32% (8/25) of studies reported on patient satisfaction, and of these, 88% (7/8) reported satisfaction with VRER. Moreover, 13% (1/8) reported mild sickness as an adverse event. Conclusions: We found that around half of the studies reported using VRER in patients with breast cancer and postmastectomy dysfunctions through nonimmersive models and commercial game programs having durations of 3-12 weeks. In addition, most studies showed that VRER was effective owing to virtualization and interaction. Therefore, VRER may be an alternate intervention for patients with CRDs. However, as the conclusions were drawn from data with acknowledged inconsistencies and limited satisfaction reports, studies with larger sample sizes and more outcome indictors are required. %M 38407951 %R 10.2196/49312 %U https://www.jmir.org/2024/1/e49312 %U https://doi.org/10.2196/49312 %U http://www.ncbi.nlm.nih.gov/pubmed/38407951 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e50282 %T Immersive Virtual Reality–Based Methods for Assessing Executive Functioning: Systematic Review %A Kirkham,Rebecca %A Kooijman,Lars %A Albertella,Lucy %A Myles,Dan %A Yücel,Murat %A Rotaru,Kristian %+ Turner Institute for Brain and Mental Health, School of Psychological Sciences and Monash Biomedical Imaging Facility, Monash University, 770 Blackburn Road, Clayton, 3168, Australia, 61 (03) 9905 0100, rebecca.kirkham@monash.edu %K virtual reality %K executive functioning %K neuropsychological assessment %K systematic review %K psychometric properties %K cybersickness %K immersion %K cognition %D 2024 %7 26.2.2024 %9 Review %J JMIR Serious Games %G English %X Background: Neuropsychological assessments traditionally include tests of executive functioning (EF) because of its critical role in daily activities and link to mental disorders. Established traditional EF assessments, although robust, lack ecological validity and are limited to single cognitive processes. These methods, which are suitable for clinical populations, are less informative regarding EF in healthy individuals. With these limitations in mind, immersive virtual reality (VR)–based assessments of EF have garnered interest because of their potential to increase test sensitivity, ecological validity, and neuropsychological assessment accessibility. Objective: This systematic review aims to explore the literature on immersive VR assessments of EF focusing on (1) EF components being assessed, (2) how these assessments are validated, and (3) strategies for monitoring potential adverse (cybersickness) and beneficial (immersion) effects. Methods: EBSCOhost, Scopus, and Web of Science were searched in July 2022 using keywords that reflected the main themes of VR, neuropsychological tests, and EF. Articles had to be peer-reviewed manuscripts written in English and published after 2013 that detailed empirical, clinical, or proof-of-concept studies in which a virtual environment using a head-mounted display was used to assess EF in an adult population. A tabular synthesis method was used in which validation details from each study, including comparative assessments and scores, were systematically organized in a table. The results were summed and qualitatively analyzed to provide a comprehensive overview of the findings. Results: The search retrieved 555 unique articles, of which 19 (3.4%) met the inclusion criteria. The reviewed studies encompassed EF and associated higher-order cognitive functions such as inhibitory control, cognitive flexibility, working memory, planning, and attention. VR assessments commonly underwent validation against gold-standard traditional tasks. However, discrepancies were observed, with some studies lacking reported a priori planned correlations, omitting detailed descriptions of the EF constructs evaluated using the VR paradigms, and frequently reporting incomplete results. Notably, only 4 of the 19 (21%) studies evaluated cybersickness, and 5 of the 19 (26%) studies included user experience assessments. Conclusions: Although it acknowledges the potential of VR paradigms for assessing EF, the evidence has limitations. The methodological and psychometric properties of the included studies were inconsistently addressed, raising concerns about their validity and reliability. Infrequent monitoring of adverse effects such as cybersickness and considerable variability in sample sizes may limit interpretation and hinder psychometric evaluation. Several recommendations are proposed to improve the theory and practice of immersive VR assessments of EF. Future studies should explore the integration of biosensors with VR systems and the capabilities of VR in the context of spatial navigation assessments. Despite considerable promise, the systematic and validated implementation of VR assessments is essential for ensuring their practical utility in real-world applications. %M 38407958 %R 10.2196/50282 %U https://games.jmir.org/2024/1/e50282 %U https://doi.org/10.2196/50282 %U http://www.ncbi.nlm.nih.gov/pubmed/38407958 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e49906 %T Extended Reality–Based Mobile App Solutions for the Therapy of Children With Autism Spectrum Disorders: Systematic Literature Review %A Toma,Marian-Vladut %A Turcu,Cristina Elena %A Turcu,Corneliu Octavian %A Vlad,Sorin %A Tiliute,Doru Eugen %A Pascu,Paul %+ Faculty of Economics, Administration and Business, “Stefan cel Mare” University of Suceava, Universitatii Street nr.13, Suceava, 720229, Romania, 40 752425739, vlad.toma@usm.ro %K autism %K autistic %K autism spectrum disorder %K ASD %K virtual reality %K augmented reality %K extended reality %K mixed reality %K mobile app %K children %K preschool %K mobile phone %D 2024 %7 19.2.2024 %9 Review %J JMIR Serious Games %G English %X Background: The increasing prevalence of autism spectrum disorder (ASD) has driven research interest on the therapy of individuals with autism, especially children, as early diagnosis and appropriate treatment can lead to improvement in the condition. With the widespread availability of virtual reality, augmented reality (AR), and mixed reality technologies to the public and the increasing popularity of mobile devices, the interest in the use of applications and technologies to provide support for the therapy of children with autism is growing. Objective: This study aims to describe the literature on the potential of virtual reality, AR, and mixed reality technologies in the context of therapy for children with ASD. We propose to investigate and analyze the temporal distribution of relevant papers, identify the target audience for studies related to extended reality apps in ASD therapy, examine the technologies used in the development of these apps, assess the skills targeted for improvement in primary studies, explore the purposes of the proposed solutions, and summarize the results obtained from their application. Methods: For the systematic literature review, 6 research questions were defined in the first phase, after which 5 international databases (Web of Science, Scopus, ScienceDirect, IEEE Xplore Digital Library, and ACM Digital Library) were searched using specific search strings. Results were centralized, filtered, and processed applying eligibility criteria and using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The results were refined using a technical and IT-oriented approach. The quality criteria assessed whether the research addressed ASDs, focused on children’s therapy, involved targeted technologies, deployed solutions on mobile devices, and produced results relevant to our study. Results: In the first step, 179 publications were identified in Zotero reference manager software (Corporation for Digital Scholarship). After excluding articles that did not meet the eligibility or quality assessment criteria, 28 publications were finalized. The analysis revealed an increase in publications related to apps for children with autism starting in 2015 and peaking in 2019. Most studies (22/28, 79%) focused on mobile AR solutions for Android devices, which were developed using the Unity 3D platform and the Vuforia engine. Although 68% (19/28) of these apps were tested with children, 32% (9/28) were tested exclusively by developers. More than half (15/28, 54%) of the studies used interviews as an evaluation method, yielding mostly favorable although preliminary results, indicating the need for more extensive testing. Conclusions: The findings reported in the studies highlight the fact that these technologies are appropriate for the therapy of children with ASD. Several studies showed a distinct trend toward the use of AR technology as an educational tool for people with ASD. This trend entails multidisciplinary cooperation and an integrated research approach, with an emphasis on comprehensive empirical evaluations and technology ethics. %M 38373032 %R 10.2196/49906 %U https://games.jmir.org/2024/1/e49906 %U https://doi.org/10.2196/49906 %U http://www.ncbi.nlm.nih.gov/pubmed/38373032 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e34162 %T Effects of Embodiment in Virtual Reality for Treatment of Chronic Pain: Pilot Open-Label Study %A Saby,Adam %A Alvarez,Anthony %A Smolins,David %A Petros,James %A Nguyen,Lincoln %A Trujillo,Michael %A Aygün,Oytun %+ Karuna Labs, 185 Wythe Avenue Brooklyn, New York, NY, 11249, United States, 1 641824514, oytunsultanaygun@gmail.com %K centralized pain %K dicentralized pain %K digital therapeutics %K visual analog scale %K Fear-Avoidance Beliefs Questionnaire %K Oswestry %K Oswestry Low Back Pain Disability Questionnaire %K Pain Catastrophizing Scale %K Patient Health Questionnaire %K sensorimotor %K virtual reality %K chronic pain %K pain %K rehabilitation %D 2024 %7 16.2.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Chronic pain has long been a major health burden that has been addressed through numerous forms of pharmacological and nonpharmacological treatment. One of the tenets of modern medicine is to minimize risk while providing efficacy. Further, because of its noninvasive nature, virtual reality (VR) provides an attractive platform for potentially developing novel therapeutic modalities. Objective: The purpose of this study was to determine the feasibility of a novel VR-based digital therapy for the treatment of chronic pain. Methods: An open-label study assessed the feasibility of using virtual embodiment in VR to treat chronic pain. In total, 24 patients with chronic pain were recruited from local pain clinics and completed 8 sessions of a novel digital therapeutic that combines virtual embodiment with graded motor imagery to deliver functional rehabilitation exercises over the course of 4 weeks. Pain intensity as measured by a visual analog scale before and after each virtual embodiment training session was used as the primary outcome measure. Additionally, a battery of patient-reported pain questionnaires (Fear-Avoidance Beliefs Questionnaire, Oswestry Low Back Pain Disability Questionnaire, Pain Catastrophizing Scale, and Patient Health Questionnaire) were administered before and after 8 sessions of virtual embodiment training as exploratory outcome measures to assess if the measures are appropriate and warrant a larger randomized controlled trial. Results: A 2-way ANOVA on session × pre- versus postvirtual embodiment training revealed that individual virtual embodiment training sessions significantly reduced the intensity of pain as measured by the visual analog scale (P<.001). Perceived disability due to lower back pain as measured by the Oswestry Low Back Pain Disability Questionnaire significantly improved (P=.003) over the 4-week course of virtual embodiment regimen. Improvement was also observed on the helplessness subscale of the Pain Catastrophizing Scale (P=.02). Conclusions: This study provides evidence that functional rehabilitation exercises delivered in VR are safe and may have positive effects on alleviating the symptoms of chronic pain. Additionally, the virtual embodiment intervention may improve perceived disability and helplessness of patients with chronic pain after 8 sessions. The results support the justification for a larger randomized controlled trial to assess the extent to which virtual embodiment training can exert an effect on symptoms associated with chronic pain. Trial Registration: ClinicalTrials.gov NCT04060875; https://clinicaltrials.gov/ct2/show/NCT04060875 %M 38363591 %R 10.2196/34162 %U https://formative.jmir.org/2024/1/e34162 %U https://doi.org/10.2196/34162 %U http://www.ncbi.nlm.nih.gov/pubmed/38363591 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 10 %N %P e48566 %T The Effects of Immersive Virtual Reality–Assisted Experiential Learning on Enhancing Empathy in Undergraduate Health Care Students Toward Older Adults With Cognitive Impairment: Multiple-Methods Study %A Liu,Justina Yat Wa %A Mak,Pui Ying %A Chan,Kitty %A Cheung,Daphne Sze Ki %A Cheung,Kin %A Fong,Kenneth N K %A Kor,Patrick Pui Kin %A Lai,Timothy Kam Hung %A Maximo,Tulio %+ School of Nursing, The Hong Kong Polytechnic University, 11 Yuk Choi Rd, Hung Hom, Kowloon, Hong Kong, China (Hong Kong), 852 27664097, justina.liu@polyu.edu.hk %K immersive virtual reality %K undergraduate health care education %K empathy %K cognitive impairment %D 2024 %7 15.2.2024 %9 Original Paper %J JMIR Med Educ %G English %X Background: Immersive virtual reality (IVR)–assisted experiential learning has the potential to foster empathy among undergraduate health care students toward older adults with cognitive impairment by facilitating a sense of embodiment. However, the extent of its effectiveness, including enhancing students’ learning experiences and achieving intended learning outcomes, remains underexplored. Objective: This study aims to evaluate the impacts of IVR-assisted experiential learning on the empathy of undergraduate health care students toward older people with cognitive impairment as the primary outcome (objective 1) and on their learning experience (objective 2) and their attainment of learning outcomes as the secondary outcomes (objective 3). Methods: A multiple-methods design was used, which included surveys, focus groups, and a review of the students’ group assignments. Survey data were summarized using descriptive statistics, whereas paired 2-tailed t tests were used to evaluate differences in empathy scores before and after the 2-hour IVR tutorial (objective 1). Focus groups were conducted to evaluate the impacts of IVR-assisted experiential learning on the empathy of undergraduate health care students toward older people with cognitive impairment (objective 1). Descriptive statistics obtained from surveys and thematic analyses of focus groups were used to explore the students’ learning experiences (objective 2). Thematic analysis of group assignments was conducted to identify learning outcomes (objective 3). Results: A total of 367 undergraduate nursing and occupational therapy students were recruited via convenience sampling. There was a significant increase in the students’ empathy scores, measured using the Kiersma-Chen Empathy Scale, from 78.06 (SD 7.72) before to 81.17 (SD 8.93) after (P<.001). Students expressed high satisfaction with the IVR learning innovation, with a high satisfaction mean score of 20.68 (SD 2.55) and a high self-confidence mean score of 32.04 (SD 3.52) on the Student Satisfaction and Self-Confidence scale. Students exhibited a good sense of presence in the IVR learning environment, as reflected in the scores for adaptation (41.30, SD 6.03), interface quality (11.36, SD 3.70), involvement (62.00, SD 9.47), and sensory fidelity (31.47, SD 5.23) on the Presence Questionnaire version 2.0. In total, 3 major themes were identified from the focus groups, which involved 23 nursing students: enhanced sympathy toward older adults with cognitive impairment, improved engagement in IVR learning, and confidence in understanding the key concepts through the learning process. These themes supplement and align with the survey results. The analysis of the written assignments revealed that students attained the learning outcomes of understanding the challenges faced by older adults with cognitive impairment, the importance of providing person-centered care, and the need for an age-friendly society. Conclusions: IVR-assisted experiential learning enhances students’ knowledge and empathy in caring for older adults with cognitive impairment. These findings suggest that IVR can be a valuable tool in professional health care education. %M 38358800 %R 10.2196/48566 %U https://mededu.jmir.org/2024/1/e48566 %U https://doi.org/10.2196/48566 %U http://www.ncbi.nlm.nih.gov/pubmed/38358800 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e41670 %T Extended Reality—New Opportunity for People With Disability? Practical and Ethical Considerations %A Stendal,Karen %A Bernabe,Rosemarie D L C %+ Department of Business, Marketing and Law, University of South-Eastern Norway, Bredalsveien 14, Honefoss, 3502, Norway, 47 31009477, karen.stendal@usn.no %K extended reality %K virtual worlds %K virtual reality %K disability %K practical %K ethical %K technology %K virtual %K reality %K development %K research %K challenges %D 2024 %7 13.2.2024 %9 Viewpoint %J J Med Internet Res %G English %X Since the introduction of virtual environments in the 70s, technologies have moved through virtual reality, mixed reality, and augmented reality into extended reality (XR). This development is promising for various groups. Previous research has shown people with disability benefiting from using technology in social and professional settings. Technology has offered people with disability the opportunity to communicate, interact, participate, and build new relationships. However, we do not know what impact XR has or will have and whether it will offer new opportunities for people with disability. This paper aims to indicate potential opportunities and challenges afforded by XR to people with disability. We offer reflections on the opportunities as well as the ethical considerations needed when introducing immersive technologies to a marginalized group. %M 38349731 %R 10.2196/41670 %U https://www.jmir.org/2024/1/e41670 %U https://doi.org/10.2196/41670 %U http://www.ncbi.nlm.nih.gov/pubmed/38349731 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e50089 %T Virtual Reality Therapy for the Management of Chronic Spinal Pain: Systematic Review and Meta-Analysis %A Zhang,Tongtong %A Li,Xin %A Zhou,Xuan %A Zhan,Lixia %A Wu,Fan %A Huang,Zefan %A Sun,Yuxun %A Feng,Yufei %A Du,Qing %+ Department of Rehabilitation, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Road, Yangpu District, Shanghai, China, Shanghai, 200092, China, 86 021 25078600, duqing@xinhuamed.com.cn %K virtual reality %K chronic spinal pain %K inflammation-related pain %K systematic review %K meta-analysis %D 2024 %7 12.2.2024 %9 Review %J JMIR Serious Games %G English %X Background: The effectiveness of virtual reality (VR) therapy in adults with chronic spinal pain (CSP) is unclear. Objective: This study was conducted to compare the effectiveness of VR therapy and other therapies in adults with CSP, especially patients with inflammation-related pain. Methods: PubMed, Web of Science, Cochrane Library, Embase, and CINAHL databases were searched up to November 11, 2023. Randomized controlled trials (RCTs) comparing adults with CSP receiving VR therapy with those receiving other therapies were included. The trial registration platform as well as the reference lists of included studies and previous systematic reviews and meta-analyses were manually searched. Two independent reviewers performed study selection, data extraction, risk-of-bias assessment, and evaluation of the quality of the evidence. The weighted mean difference (WMD) was used as the effect size used to synthesize the outcome measure. Results: In total, 16 RCTs involving 800 participants were included in this meta-analysis. The pooled data from 15 (94%) RCTs including 776 (97%) participants showed that VR therapy was superior in improving pain intensity (WMD=–1.63, 95% CI –2.11 to –1.16, P<.001, I2=90%) and reducing inflammatory markers, including C-reactive protein (WMD=–0.89, 95% CI –1.07 to –0.70, P<.001, I2=0%), tumor necrosis factor-alpha (WMD=–6.60, 95% CI –8.56 to –4.64, P<.001, I2=98%), and interleukin-6 (WMD=–2.76, 95% CI –2.98 to –2.53, P<.001, I2=0%). However, no significant differences were found in terms of the spinal range of motion (ROM), disability level, or fear of movement. In addition, 10 (63%) of the included RCTs had a high risk of bias. Conclusions: VR therapy may be an effective and safe intervention for reducing symptoms in patients with CSP, as it is shown to exert significant analgesic effects and beneficial improvements in inflammatory factor levels. However, this approach may not have significant effects on the spinal ROM, disability level, or fear of movement. Notably, the quality of the evidence from the RCTs included in this study ranged from moderate to low. Therefore, we recommend that readers interpret the results of this study with caution. Trial Registration: PROSPERO CRD42022382331; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=382331 %M 38345832 %R 10.2196/50089 %U https://games.jmir.org/2024/1/e50089 %U https://doi.org/10.2196/50089 %U http://www.ncbi.nlm.nih.gov/pubmed/38345832 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e43574 %T Electronic Interactive Games for Glycemic Control in Individuals With Diabetes: Systematic Review and Meta-Analysis %A Yao,WenQi %A Han,YiBing %A Yang,Li %A Chen,Ying %A Yan,ShengZhe %A Cheng,YanZhen %+ Department of Endocrinology, Zhujiang Hospital of Southern Medical University, No.253 Gongye Avenue Central, Guangzhou, 510280, China, 86 0 206 278 2330, chengyzx@163.com %K electronic game %K physical activity %K diet %K diabetes mellitus %K glycemic control %D 2024 %7 12.2.2024 %9 Review %J JMIR Serious Games %G English %X Background: Several electronic interventions have been used to improve glycemic control in patients with diabetes. Electronic interactive games specific to physical activity are available, but it is unclear if these are effective at improving glycemic control in patients with diabetes. Objective: This study aimed to determine the effects of electronic game–based interventions on glycemic control in patients with diabetes. Methods: Relevant studies that were published before April 1, 2023, were searched from 5 databases: PubMed, Embase, Web of Science, Scopus, and Cochrane Library. Eligibility criteria included prospective studies examining the relationship between electronic games with physical activities or diet education and glycemic control as the outcome. The risk of bias was assessed using the Cochrane risk-of-bias tool. All analyses were conducted using RevMan5.4.1. Depending on the heterogeneity across studies, the pooled effects were calculated using fixed-effects or random-effects models. Results: Participants from 9 studies were included and assessed. Glycated hemoglobin (HbA1c) and fasting blood glucose improved in the intervention group, although the analysis revealed no significant reduction in HbA1c (−0.09%, 95% CI −0.29% to 0.10%) or fasting blood glucose (−0.94 mg/dL, 95% CI −9.34 to 7.46 mg/dL). However, the physical activity of individuals in the intervention group was significantly higher than that of those in the control group (standardized mean difference=0.84, 95% CI 0.30 to 1.38; P=.002). Other outcomes, such as weight and blood lipids, exhibited no significant improvement (all P>.05). Conclusions: Electronic games had a good impact on participants’ physical activity and offered an advantage in glycemic control without reaching statistical significance. Electronic games are convenient for reminders and education. Low-intensity exercise games may not be considered a better adjuvant intervention to improve diabetes self-management care. %M 38345856 %R 10.2196/43574 %U https://games.jmir.org/2024/1/e43574 %U https://doi.org/10.2196/43574 %U http://www.ncbi.nlm.nih.gov/pubmed/38345856 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e48916 %T Effectiveness and User Experience of Virtual Reality for Social Anxiety Disorder: Systematic Review %A Shahid,Simon %A Kelson,Joshua %A Saliba,Anthony %+ Faculty of Business, Justice, and Behavioural Sciences, Charles Sturt University, Panorama Ave, Bathurst, 2795, Australia, 61 2 6338 4570, jkelson@csu.edu.au %K social anxiety disorder %K social phobia %K virtual reality %K VR %K VR exposure therapy %K effectiveness %K user experience %K safety %K usability %K acceptability %K anxiety %K phobia %K exposure %K systematic %K review methods %K review methodology %K social %K psychiatric %K mental health %K mobile phone %D 2024 %7 8.2.2024 %9 Review %J JMIR Ment Health %G English %X Background: Social anxiety disorder (SAD) is a debilitating psychiatric disorder that affects occupational and social functioning. Virtual reality (VR) therapies can provide effective treatment for people with SAD. However, with rapid innovations in immersive VR technology, more contemporary research is required to examine the effectiveness and concomitant user experience outcomes (ie, safety, usability, acceptability, and attrition) of emerging VR interventions for SAD. Objective: The aim of this systematic review was to examine the effectiveness and user experience of contemporary VR interventions among people with SAD. Methods: The Cochrane Library, Emcare, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science databases were searched between January 1, 2012, and April 26, 2022. Deduplicated search results were screened based on title and abstract information. Full-text examination was conducted on 71 articles. Studies of all designs and comparator groups were included if they appraised the effectiveness and user experience outcomes of any immersive VR intervention among people with SAD. A standardized coding sheet was used to extract data on key participant, intervention, comparator, outcome, and study design items. Results: The findings were tabulated and discussed using a narrative synthesis. A total of 18 studies met the inclusion criteria. Conclusions: The findings showed that VR exposure therapy–based interventions can generally provide effective, safe, usable, and acceptable treatments for adults with SAD. The average attrition rate from VR treatment was low (11.36%) despite some reported user experience difficulties, including potential simulator sickness, exposure-based emotional distress, and problems with managing treatment delivered in a synchronous group setting. This review also revealed several research gaps, including a lack of VR treatment studies on children and adolescents with SAD as well as a paucity of standardized assessments of VR user experience interactions. More studies are required to address these issues. Trial Registration: PROSPERO CRD42022353891; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=353891 %M 38329804 %R 10.2196/48916 %U https://mental.jmir.org/2024/1/e48916 %U https://doi.org/10.2196/48916 %U http://www.ncbi.nlm.nih.gov/pubmed/38329804 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e52904 %T What is Diminished Virtuality? A Directional and Layer-Based Taxonomy for the Reality-Virtuality Continuum %A Egger,Jan %A Gsaxner,Christina %A Kleesiek,Jens %A Puladi,Behrus %+ Institute of Computer Graphics and Vision, Graz University of Technology, Inffeldgasse 16c/2, Graz, 8010, Austria, 43 316 873 5076, egger@icg.tugraz.at %K reality-virtuality continuum %K diminished virtuality %K Apple Vision Pro %K VR %K virtual reality %K reality-virtuality %K mixed reality %K augmented reality %K XR %K extended reality %K taxonomy %K classification %K classifications %K concept %K concepts %K conceptual %D 2024 %7 31.1.2024 %9 Viewpoint %J JMIR XR Spatial Comput %G English %X The concept of reality-virtuality (RV) continuum was introduced by Paul Milgram and Fumio Kishino in 1994. It describes a spectrum that ranges from a purely physical reality (the real world) to a purely virtual reality (a completely computer-generated environment), with various degrees of mixed reality in between. This continuum is “realized” by different types of displays to encompass different levels of immersion and interaction, allowing for the classification of different types of environments and experiences. What is often overlooked in this concept is the act of diminishing real objects (or persons, animals, etc) from the reality, that is, a diminution, rather than augmenting it, that is, an augmentation. Hence, we want to propose in this contribution an update or modification of the RV continuum where the diminished reality aspect is more prominent. We hope this will help users, especially those who are new to the field, to get a better understanding of the entire extended reality (XR) topic, as well as assist in the decision-making for hardware (devices) and software or algorithms that are needed for new diminished reality applications. However, we also propose another, more sophisticated directional and layer-based taxonomy for the RV continuum that we believe goes beyond the mediated and multimediated realities. Furthermore, we initiate the question of whether the RV continuum truly ends on one side with physical reality. %R 10.2196/52904 %U https://xr.jmir.org/2024/1/e52904 %U https://doi.org/10.2196/52904 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e51758 %T Evaluating the Impact of Virtual Reality on the Behavioral and Psychological Symptoms of Dementia and Quality of Life of Inpatients With Dementia in Acute Care: Randomized Controlled Trial (VRCT) %A Appel,Lora %A Appel,Eva %A Kisonas,Erika %A Lewis-Fung,Samantha %A Pardini,Susanna %A Rosenberg,Jarred %A Appel,Julian %A Smith,Christopher %+ School of Health Policy and Management, Faculty of Health, York Universtiy, 4700 Keele Street, 426 Health, Nursing and Environmental Studies Building, Toronto, ON, M3J 1P3, Canada, 1 416 736 2100 ext 22653, lora.appel@yorku.ca %K digital therapies %K nonpharmacological %K cognitive impairment %K behavioral and psychological symptoms of dementia %K BPSDs %K randomized controlled trial %K virtual reality %D 2024 %7 30.1.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) is increasingly considered a valuable therapeutic tool for people with dementia. However, rigorous studies are still needed to evaluate its impact on behavioral and psychological symptoms of dementia (BPSDs) and quality of life (QoL) across care settings. Objective: The primary aim of this study was to evaluate the impact of VR therapy on managing BPSDs, falls, length of stay, and QoL in inpatients with dementia admitted to an acute care hospital. The secondary aim was to evaluate the intervention’s feasibility in terms of acceptability, safety, and patient experience. Methods: A prospective, open-label, mixed methods, randomized controlled clinical trial was conducted between April 2019 and March 2020. A total of 69 participants (aged ≥65 years with a diagnosis of dementia and who did not meet the exclusion criteria) were randomly assigned to either the control (n=35, 51%) or VR (n=34, 49%) arm. Participants in the experimental (VR) arm were visited by a researcher and watched 360° VR films on a head-mounted display for up to 20 minutes every 1 to 3 days, whereas individuals in the control arm received standard of care. Instances of daily BPSDs and falls were collected from nurses’ daily notes. QoL was measured through semistructured interviews and the Quality of Life in Late-Stage Dementia scale. Structured observations and semistructured interviews were used to measure treatment feasibility. The primary outcomes were analyzed at a 95% significance level based on the intention-to-treat method. Results: VR therapy had a statistically significant effect on reducing aggressiveness (ie, physical aggression and loud vociferation; P=.01). Substantial impact of VR therapy was not found for other BPSDs (eg, apathy), falls, length of stay, or QoL as measured using the Quality of Life in Late-Stage Dementia scale. The average VR therapy session lasted 6.8 (SD 6.6; range 0-20) minutes, and the intervention was overall an acceptable and enjoyable experience for participants. No adverse events occurred as a result of VR therapy. Conclusions: Immersive VR therapy appears to have an effect on aggressive behaviors in patients with dementia in acute care. Although the randomized controlled trial was stopped before reaching the intended sample size owing to COVID-19 restrictions, trends in the results are promising. We suggest conducting future trials with larger samples and, in some cases, more sensitive data collection instruments. Trial Registration: ClinicalTrials.gov NCT03941119; https://clinicaltrials.gov/study/NCT03941119 International Registered Report Identifier (IRRID): RR2-10.2196/22406 %M 38289666 %R 10.2196/51758 %U https://www.jmir.org/2024/1/e51758 %U https://doi.org/10.2196/51758 %U http://www.ncbi.nlm.nih.gov/pubmed/38289666 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e48649 %T Personalized Virtual Reality Compared With Guided Imagery for Enhancing the Impact of Progressive Muscle Relaxation Training: Pilot Randomized Controlled Trial %A Pardini,Susanna %A Gabrielli,Silvia %A Olivetto,Silvia %A Fusina,Francesca %A Dianti,Marco %A Forti,Stefano %A Lancini,Cristina %A Novara,Caterina %+ Department of General Psychology, University of Padova, 8 Venezia St, Padova, Italy, 39 3335944315, susanna.pardini@phd.unipd.it %K digital health %K progressive muscular relaxation technique %K mental well-being %K virtual reality therapy %K anxiety %K relaxation %K e-therapy %K eHealth %K mobile phone %D 2024 %7 30.1.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Empirical evidence has shown that virtual reality (VR) scenarios can increase the effects of relaxation techniques, reducing anxiety by enabling people to experience emotional conditions in more vivid settings. Objective: This pilot randomized controlled study aims to investigate whether the progressive muscle relaxation technique (PMRT) associated with a personalized scenario in VR promotes psychological well-being and facilitates the recall of relaxing images more than the standard complementary intervention that involves the integration of PMRT and guided imagery (GI). Methods: On the basis of a longitudinal, between-subject design, 72 university students were randomly exposed to one of two experimental conditions: (1) standard complementary procedure (PMRT and GI exposure) and (2) experimental procedure (PMRT and personalized VR exposure). Individuals were assessed by a therapist before and after 7 training sessions based on measures investigating anxiety, depression, quality of life, coping strategies, sense of presence, engagement, and side effects related to VR exposure. Heart rate data were also collected. Results: Differences in changes between the 2 groups after the in vivo PMRT session conducted by the psychotherapist (T1) were statistically significant for state anxiety (F1,67=30.56; P<.001) and heart rate (F1,67=4.87; P=.01). Individuals in the VR group obtained lower scores both before (t67=−2.63; P=.01; Cohen d=0.91) and after (t67=−7.23; P<.001; Cohen d=2.45) the relaxation session when it was self-administered by participants (T2). A significant reduction in perceived state anxiety at T1 and T2 was observed for both groups (P<.001). After the VR experience, individuals reported feeling higher engagement in the experience than what was mentioned by participants in the GI group (F1,67=2.85; P=.03; ηp2=0.15), and they experienced the environment as more realistic (F1,67=4.38; P=.003; ηp2=0.21). No differences between groups regarding sense of presence were found (F1,67=1.99; P=.11; ηp2=0.11). Individuals exposed before to the VR scenario (T1) referred to perceiving the scenario recalled in-imagination at T2 as more realistic than what those in the GI group experienced (F1,67=3.21; P=.02; ηp2=0.12). The VR group had lower trait anxiety levels than the GI group after the relaxation session during session 7 (T2; t67=−2.43; P=.02). Conclusions: Personalized relaxing VR scenarios can contribute to improving relaxation and decreasing anxiety when integrated with PMRT as a complementary relaxation method. Trial Registration: ClinicalTrials.gov NCT05478941; https://classic.clinicaltrials.gov/ct2/show/NCT05478941 International Registered Report Identifier (IRRID): RR2-10.2196/44183 %M 38289673 %R 10.2196/48649 %U https://mental.jmir.org/2024/1/e48649 %U https://doi.org/10.2196/48649 %U http://www.ncbi.nlm.nih.gov/pubmed/38289673 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 7 %N %P e49415 %T Promoting Personalized Reminiscence Among Cognitively Intact Older Adults Through an AI-Driven Interactive Multimodal Photo Album: Development and Usability Study %A Wang,Xin %A Li,Juan %A Liang,Tianyi %A Hasan,Wordh Ul %A Zaman,Kimia Tuz %A Du,Yang %A Xie,Bo %A Tao,Cui %+ Department of Computer Science, North Dakota State University, Quentin Burdick Building Room 258, 1320 Albrecht Boulevard, Fargo, ND, 58105, United States, 1 7012318562, J.Li@ndsu.edu %K aging %K knowledge graph %K machine learning %K reminiscence %K voice assistant %D 2024 %7 23.1.2024 %9 Original Paper %J JMIR Aging %G English %X Background: Reminiscence, a therapy that uses stimulating materials such as old photos and videos to stimulate long-term memory, can improve the emotional well-being and life satisfaction of older adults, including those who are cognitively intact. However, providing personalized reminiscence therapy can be challenging for caregivers and family members. Objective: This study aimed to achieve three objectives: (1) design and develop the GoodTimes app, an interactive multimodal photo album that uses artificial intelligence (AI) to engage users in personalized conversations and storytelling about their pictures, encompassing family, friends, and special moments; (2) examine the app’s functionalities in various scenarios using use-case studies and assess the app’s usability and user experience through the user study; and (3) investigate the app’s potential as a supplementary tool for reminiscence therapy among cognitively intact older adults, aiming to enhance their psychological well-being by facilitating the recollection of past experiences. Methods: We used state-of-the-art AI technologies, including image recognition, natural language processing, knowledge graph, logic, and machine learning, to develop GoodTimes. First, we constructed a comprehensive knowledge graph that models the information required for effective communication, including photos, people, locations, time, and stories related to the photos. Next, we developed a voice assistant that interacts with users by leveraging the knowledge graph and machine learning techniques. Then, we created various use cases to examine the functions of the system in different scenarios. Finally, to evaluate GoodTimes’ usability, we conducted a study with older adults (N=13; age range 58-84, mean 65.8 years). The study period started from January to March 2023. Results: The use-case tests demonstrated the performance of GoodTimes in handling a variety of scenarios, highlighting its versatility and adaptability. For the user study, the feedback from our participants was highly positive, with 92% (12/13) reporting a positive experience conversing with GoodTimes. All participants mentioned that the app invoked pleasant memories and aided in recollecting loved ones, resulting in a sense of happiness for the majority (11/13, 85%). Additionally, a significant majority found GoodTimes to be helpful (11/13, 85%) and user-friendly (12/13, 92%). Most participants (9/13, 69%) expressed a desire to use the app frequently, although some (4/13, 31%) indicated a need for technical support to navigate the system effectively. Conclusions: Our AI-based interactive photo album, GoodTimes, was able to engage users in browsing their photos and conversing about them. Preliminary evidence supports GoodTimes’ usability and benefits cognitively intact older adults. Future work is needed to explore its potential positive effects among older adults with cognitive impairment. %M 38261365 %R 10.2196/49415 %U https://aging.jmir.org/2024/1/e49415 %U https://doi.org/10.2196/49415 %U http://www.ncbi.nlm.nih.gov/pubmed/38261365 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 13 %N %P e45946 %T Education of Patients With Atrial Fibrillation and Evaluation of the Efficacy of a Mobile Virtual Patient Environment: Protocol for a Multicenter Pseudorandomized Controlled Trial %A Antoniou,Panagiotis %A Dafli,Eleni %A Giannakoulas,George %A Igimbayeva,Gaukhar %A Visternichan,Olga %A Kyselov,Serhii %A Lykhasenko,Ivetta %A Lashkul,Dmytro %A Nadareishvili,Ilia %A Tabagari,Sergo %A Bamidis,Panagiotis D %+ Lab of Medical Physics and Digital Innovation, School of Medicine, Aristotle University of Thessaloniki, PO Box 376, Thessaloniki, 541 24, Greece, 30 6972008122, bamidis@auth.gr %K atrial fibrillation %K virtual patient %K scenario based learning %K technology enhanced learning %K mHealth %K mobile health %K patient engagement %K patient education %K cardiac arrhythmia %K mortality %K mobile application %K mobile app %K health education %K randomized control trial %K cardiology %K cardiac %K heart %K Greece %K Ukraine %K Kazakhstan %K clinical decision support systems %K CDSS %K virtual patient scenario %K myocardial infarction %K arrhythmia %K stroke %D 2024 %7 23.1.2024 %9 Protocol %J JMIR Res Protoc %G English %X Background: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is a leading cause of mortality and morbidity. Patient knowledge about AF and its management is paramount but often limited. Patients need to be appropriately informed about treatment options, medicinal adherence, and potential consequences of nonadherence, while also understanding treatment goals and expectations from it. Mobile health apps have experienced an explosion both in their availability and acceptance as “soft interventions” for patient engagement and education; however, the prolific nature of such solutions revealed a gap in the evidence base regarding their efficacy and impact. Virtual patients (VPs), interactive computer simulations, have been used as learning activities in modern health care education. VPs demonstrably improved cognitive and behavioral skills; hence, they have been effectively implemented across undergraduate and postgraduate curricula. However, their application in patient education has been rather limited so far. Objective: This work aims to implement and evaluate the efficacy of a mobile-deployed VP regimen for the education and engagement of patients with AF on crucial topics regarding their condition. A mobile VP app is being developed with the goal of each VP being a simple scenario with a set goal and very specific messages and will be subsequently attempted and evaluated. Methods: A mobile VP player app is being developed so as to be used for the design of 3 educational scenarios for AF management. A pseudorandomized controlled trial for the efficacy of VPs is planned to be executed at 3 sites in Greece, Ukraine, and Kazakhstan for patients with AF. The Welch t test will be used to demonstrate the performance of patients’ evaluation of the VP experience. Results: Our study is at the development stage. A preliminary study regarding the system’s development and feasibility was initiated in December 2022. The results of our study are expected to be available in 2024 or when the needed sample size is achieved. Conclusions: This study aims to evaluate and demonstrate the first significant evidence for the value of VP resources in outreach and training endeavors for empowering and patients with AF and fostering healthy habits among them. International Registered Report Identifier (IRRID): PRR1-10.2196/45946 %M 38261376 %R 10.2196/45946 %U https://www.researchprotocols.org/2024/1/e45946 %U https://doi.org/10.2196/45946 %U http://www.ncbi.nlm.nih.gov/pubmed/38261376 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e45637 %T Virtual Exercise in Medicine: A Proof of Concept in a Healthy Population %A Le Roy,Barbara %A Martin-Krumm,Charles %A Poupon,Charlotte %A Richieri,Raphaëlle %A Malbos,Eric %A Barthélémy,Fanny %A Guedj,Eric %A Trousselard,Marion %+ Unité neurophysiologie du stress, Institut de recherche biomédicale des armées, Place Général Valérie André, Brétigny-sur-Orge, 91220, France, 33 123456789, barbara.m.le.roy@gmail.com %K countermeasures %K mental health %K physical activity %K virtual reality %K user experience %D 2024 %7 22.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Science is beginning to establish the benefits of the use of virtual reality (VR) in health care. This therapeutic approach may be an appropriate complementary treatment for some mental illnesses. It could prevent high levels of morbidity and improve the physical health of patients. For many years, the literature has shown the health benefits of physical exercise. Physical exercise in a VR environment may improve the management of mild to moderate mental health conditions. In this context, we developed a virtual environment combined with an ergocycle (the augmented physical training for isolated and confined environments [APTICE] system). Objective: This study aims to investigate the impact of physical exercise in a VR environment. Methods: A total of 14 healthy participants (11 men and 3 women; mean age 43.28, SD 10.60 years) undertook 15 minutes of immersive physical exercise using the system. Measures included mindfulness and immersion disposition, subjective perceptions of sensory information, user experience, and VR experience (ie, psychological state, flow, and presence). Results: First, the APTICE system appears to be a useful tool because the user experience is positive (subscales in the AttrakDiff questionnaire: pragmatic quality=0.99; hedonic quality–stimulation=1.90; hedonic quality–identification=0.67; attractiveness=1.58). Second, the system can induce a positive psychological state (negative emotion, P=.06) and an experience of flow and presence (P values ranging from <.001 to .04). Third, individual immersive and mindful disposition plays a role in the VR experience (P values ranging from <.02 to .04). Finally, our findings suggest that there is a link between the subjective perception of sensory information and the VR experience (P values ranging from <.02 to .04). Conclusions: These results indicate that the device is well accepted with positive psychological and exteroceptive outcomes. Overall, the APTICE system could be a proof of concept to explore the benefits of virtual physical exercise in clinical medicine. %M 38252484 %R 10.2196/45637 %U https://formative.jmir.org/2024/1/e45637 %U https://doi.org/10.2196/45637 %U http://www.ncbi.nlm.nih.gov/pubmed/38252484 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 26 %N %P e45168 %T Exploring Discussions About Virtual Reality on Twitter to Inform Brain Injury Rehabilitation: Content and Network Analysis %A Brassel,Sophie %A Brunner,Melissa %A Campbell,Andrew %A Power,Emma %A Togher,Leanne %+ Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Western Avenue, Sydney, 2006, Australia, 61 286279541, sophie.brassel@sydney.edu.au %K virtual reality %K Twitter %K brain injury %K rehabilitation %K cognitive communication %K social networks %K social media %K brain injury rehabilitation %K engagement %K development %K clinical practice %K injury %K users %D 2024 %7 19.1.2024 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) use in brain injury rehabilitation is emerging. Recommendations for VR development in this field encourage end user engagement to determine the benefits and challenges of VR use; however, existing literature on this topic is limited. Data from social networking sites such as Twitter may further inform development and clinical practice related to the use of VR in brain injury rehabilitation. Objective: This study collected and analyzed VR-related tweets to (1) explore the VR tweeting community to determine topics of conversation and network connections, (2) understand user opinions and experiences of VR, and (3) identify tweets related to VR use in health care and brain injury rehabilitation. Methods: Publicly available tweets containing the hashtags #virtualreality and #VR were collected up to twice weekly during a 6-week period from July 2020 to August 2020 using NCapture (QSR International). The included tweets were analyzed using mixed methods. All tweets were coded using inductive content analysis. Relevant tweets (ie, coded as “VR in health care” or “talking about VR”) were further analyzed using Dann’s content coding. The biographies of users who sent relevant tweets were examined descriptively. Tweet data networks were visualized using Gephi computational analysis. Results: A total of 260,715 tweets were collected, and 70,051 (26.87%) were analyzed following eligibility screening. The sample comprised 33.68% (23,596/70,051) original tweets and 66.32% (46,455/70,051) retweets. Content analysis generated 10 main categories of original tweets related to VR (ie, advertising and promotion, VR content, talking about VR, VR news, general technology, VR industry, VR live streams, VR in health care, VR events, and VR community). Approximately 4.48% (1056/23,596) of original tweets were related to VR use in health care, whereas 0.19% (45/23,596) referred to VR in brain injury rehabilitation. In total, 14.86% (3506/23,596) of original tweets featured commentary on user opinions and experiences of VR applications, equipment, and software. The VR tweeting community comprised a large network of 26,001 unique Twitter users. Users that posted tweets related to “VR in health care” (2124/26,001, 8.17%) did not form an interconnected VR network, whereas many users “talking about VR” (3752/26,001, 14.43%) were connected within a central network. Conclusions: This study provides valuable data on community-based experiences and opinions related to VR. Tweets showcased various VR applications, including in health care, and identified important user-based considerations that can be used to inform VR use in brain injury rehabilitation (eg, technical design, accessibility, and VR sickness). Limited discussions and small user networks related to VR in brain injury rehabilitation reflect the paucity of literature on this topic and the potential underuse of this technology. These findings emphasize that further research is required to understand the specific needs and perspectives of people with brain injuries and clinicians regarding VR use in rehabilitation. %M 38241072 %R 10.2196/45168 %U https://www.jmir.org/2024/1/e45168 %U https://doi.org/10.2196/45168 %U http://www.ncbi.nlm.nih.gov/pubmed/38241072 %0 Journal Article %@ 2818-3045 %I JMIR Publications %V 1 %N %P e47468 %T Brain Activation During Virtual Reality Symptom Provocation in Obsessive-Compulsive Disorder: Proof-of-Concept Study %A van Bennekom,Martine J %A van Wingen,Guido %A Bruin,Willem Benjamin %A Luigjes,Judy %A Denys,Damiaan %+ Adult Psychiatry, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, Netherlands, 31 0208913656, m.j.vanbennekom@amsterdamumc.nl %K virtual reality %K obsessive-compulsive disorder %K VR %K symptom provocation %K MRI %K neuroimaging %K OCD %D 2024 %7 19.1.2024 %9 Original Paper %J JMIR XR Spatial Comput %G English %X Background: Obsessive-compulsive disorder (OCD) is a psychiatric disorder characterized by obsessions and compulsions. We previously showed that a virtual reality (VR) game can be used to provoke and measure anxiety and compulsions in patients with OCD. Here, we investigated whether this VR game activates brain regions associated with symptom provocation. Objective: In this study, we aim to investigate the neural regions that are activated in patients with OCD when they are interactively confronted with a symptom-provoking event and when they are performing compulsive actions in VR. Methods: In a proof-of-concept study, we investigated brain activation in response to the VR game in 9 patients with OCD and 9 healthy controls. Participants played the VR game while regional changes in blood oxygenation were measured using functional magnetic resonance imaging. We investigated brain activation in relation to OCD-related events and virtual compulsions in the VR game. Due to low statistical power because of the sample size, we also reported results at trend significance level with a threshold of P<.10. Additionally, we investigated correlations between OCD severity and brain activation. Results: We observed a trend for increased activation in the left amygdala (P=.07) upon confrontation with OCD-related events and for increased activation in the bilateral amygdala (P=.06 and P=.09) and right insula (P=.09) when performing virtual compulsive actions in patients with OCD compared to healthy controls, but this did not attain statistical significance. The amygdala and insula activation did not correlate with OCD severity. Conclusions: The findings of this proof-of-concept study indicate that VR elicits brain activation in line with previous provocation studies. Our findings need to be replicated in a study with a larger sample size. VR may be used as an innovative and unique method of interactive symptom provocation in future neuroimaging studies. Trial Registration: Netherlands Trial Register NTR6420; https://onderzoekmetmensen.nl/nl/trial/25755 %R 10.2196/47468 %U https://xr.jmir.org/2024/1/e47468 %U https://doi.org/10.2196/47468 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e46367 %T Preoperative Virtual Reality to Expose Patients With Breast Cancer to the Operating Room Environment: Feasibility and Pilot Case Series Study %A Sommer,Jordana L %A Reynolds,Kristin %A Hebbard,Pamela %A Smith,Michael S D %A Mota,Natalie %A Mutch,W Alan C %A Maples-Keller,Jessica %A Roos,Leslie %A El-Gabalawy,Renée %+ Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, AE207 Harry Medovy House, 671 William Avenue, Winnipeg, MB, R3E 0Z2, Canada, 1 204 787 4713, sommerj@myumanitoba.ca %K virtual reality %K preoperative anxiety and distress %K breast cancer surgery %K anesthesia %K feasibility %K pilot %D 2024 %7 17.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Clinically elevated preoperative distress and anxiety are common among patients undergoing cancer surgery. Preoperative interventions have been developed to mitigate this distress and anxiety but are inconsistent in efficacy and feasibility for broad implementation. Objective: This preliminary pilot study aims to assess the feasibility and utility of a newly developed virtual reality (VR) intervention to expose patients awaiting breast cancer surgery to the operating room environment and a simulation of anesthetic induction. Methods: Patients undergoing breast cancer surgery (N=7) were assigned to the VR intervention or control (treatment as usual) group and completed self-report measures of distress and anxiety before surgery, on the day of surgery, and after surgery (5 and 30 d postoperatively). Those in the intervention group trialed the VR simulation 1 to 2 weeks preoperatively and provided qualitative and quantitative feedback. We assessed the feasibility of recruitment capability and study design and evaluated participants’ impressions of the intervention using self-report rating scales and open-ended questions. We also descriptively examined distress and anxiety levels throughout the duration of the study. Results: Recruitment occurred between December 2021 and December 2022 and progressed slowly (rate: 1 participant/7 wk on average; some hesitancy because of stress and being overwhelmed). All participants who consented to participate completed the entire study. All participants were female and aged 56 (SD 10.56) years on average. In total, 57% (4/7) of the participants were assigned to the intervention group. On average, intervention participants spent 12 minutes engaged in the VR simulation. In general, the intervention was rated favorably (eg, clear information, enjoyable, and attractive presentation; mean% agreement 95.00-96.25, SD 4.79-10.00) and as helpful (mean% agreement 87.50, SD 25.00). Participants described the intervention as realistic (eg, “It was realistic to my past surgical experiences”), impacting their degree of preparedness and expectations for surgery (eg, “The sounds and sights and procedures give you a test run; they prepare you for the actual day”), and having a calming or relaxing effect (eg, “You feel more relaxed for the surgery”). Conclusions: This preoperative VR intervention demonstrated preliminary feasibility among a sample of patients undergoing breast cancer surgery. Results and participant feedback will inform modifications to the VR intervention and the study design of a large-scale randomized controlled trial to examine the efficacy of this intervention. Trial Registration: ClinicalTrials.gov NCT04544618; https://clinicaltrials.gov/study/NCT04544618 %M 38231570 %R 10.2196/46367 %U https://formative.jmir.org/2024/1/e46367 %U https://doi.org/10.2196/46367 %U http://www.ncbi.nlm.nih.gov/pubmed/38231570 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e44653 %T Virtual and Interprofessional Objective Structured Clinical Examination in Dentistry and Dental Technology: Development and User Evaluations %A Pang,MengWei %A Dong,YanLing %A Zhao,XiaoHan %A Wan,JiaWu %A Jiang,Li %A Song,JinLin %A Ji,Ping %A Jiang,Lin %+ Stomatological Hospital of Chongqing Medical University, 426# Songshibei Road, Yubei District, Chongqing, 401147, China, 86 15922650133, jianglin@hospital.cqmu.edu.cn %K dentist %K dental technician %K objective structured clinical examination %K OSCE %K interprofessional education %K interprofessional collaborative practice %D 2024 %7 17.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Interprofessional education (IPE) facilitates interprofessional collaborative practice (IPCP) to encourage teamwork among dental care professionals and is increasingly becoming a part of training programs for dental and dental technology students. However, the focus of previous IPE and IPCP studies has largely been on subjective student and instructor perceptions without including objective assessments of collaborative practice as an outcome measure. Objective: The purposes of this study were to develop the framework for a novel virtual and interprofessional objective structured clinical examination (viOSCE) applicable to dental and dental technology students, to assess the effectiveness of the framework as a tool for measuring the outcomes of IPE, and to promote IPCP among dental and dental technology students. Methods: The framework of the proposed novel viOSCE was developed using the modified Delphi method and then piloted. The lead researcher and a group of experts determined the content and scoring system. Subjective data were collected using the Readiness for Interprofessional Learning Scale and a self-made scale, and objective data were collected using examiner ratings. Data were analyzed using nonparametric tests. Results: We successfully developed a viOSCE framework applicable to dental and dental technology students. Of 50 students, 32 (64%) participated in the pilot study and completed the questionnaires. On the basis of the Readiness for Interprofessional Learning Scale, the subjective evaluation indicated that teamwork skills were improved, and the only statistically significant difference in participant motivation between the 2 professional groups was in the mutual evaluation scale (P=.004). For the viOSCE evaluation scale, the difference between the professional groups in removable prosthodontics was statistically significant, and a trend for negative correlation between subjective and objective scores was noted, but it was not statistically significant. Conclusions: The results confirm that viOSCE can be used as an objective evaluation tool to assess the outcomes of IPE and IPCP. This study also revealed an interesting relationship between mutual evaluation and IPCP results, further demonstrating that the IPE and IPCP results urgently need to be supplemented with objective evaluation tools. Therefore, the implementation of viOSCE as part of a large and more complete objective structured clinical examination to test the ability of students to meet undergraduate graduation requirements will be the focus of our future studies. %M 38231556 %R 10.2196/44653 %U https://formative.jmir.org/2024/1/e44653 %U https://doi.org/10.2196/44653 %U http://www.ncbi.nlm.nih.gov/pubmed/38231556 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 11 %N %P e48537 %T Understanding Public Perceptions of Virtual Reality Psychological Therapy Using the Attitudes Towards Virtual Reality Therapy (AVRT) Scale: Mixed Methods Development Study %A Gomez Bergin,Aislinn D %A Allison,Aoife M %A Hazell,Cassie M %+ National Institute of Health and Care Research MindTech MedTech Co-operative, Institute of Mental Health, University of Nottingham, Jubilee Campus, Triumph Rd, Nottingham, NG7 2TU, United Kingdom, 44 115 82 30431, aislinn.bergin@nottingham.ac.uk %K psychological interventions %K digital %K virtual reality %K virtual agent %K mental health %K presence %D 2024 %7 12.1.2024 %9 Original Paper %J JMIR Ment Health %G English %X Background: Virtual reality (VR) psychological therapy has the potential to increase access to evidence-based mental health interventions by automating their delivery while maintaining outcomes. However, it is unclear whether these more automated therapies are acceptable to potential users of mental health services. Objective: The main aim of this study was to develop a new, validated questionnaire to measure public perceptions of VR therapy (VRT) guided by a virtual coach. We also aimed to explore these perceptions in depth and test how aspects such as familiarity with VR and mental health are associated with these perceptions, using both quantitative and qualitative approaches. Methods: We used a cross-sectional mixed methods design and conducted an exploratory factor analysis of a questionnaire that we developed, the Attitudes Towards Virtual Reality Therapy (AVRT) Scale, and a qualitative content analysis of the data collected through free-text responses during completion of the questionnaire. Results: We received 295 responses and identified 4 factors within the AVRT Scale, including attitudes toward VRT, expectation of presence, preference for VRT, and cost-effectiveness. We found that being more familiar with VR was correlated with more positive attitudes toward VRT (factor 1), a higher expectation of presence (factor 2), a preference for VRT over face-to-face therapy (factor 3), and a belief that VRT is cost-effective (factor 4). Qualitative data supported the factors we identified and indicated that VRT is acceptable when delivered at home and guided by a virtual coach. Conclusions: This study is the first to validate a scale to explore attitudes toward VRT guided by a virtual coach. Our findings indicate that people are willing to try VRT, particularly because it offers increased access and choice, and that as VR becomes ubiquitous, they will also have positive attitudes toward VRT. Future research should further validate the AVRT Scale. %M 38214958 %R 10.2196/48537 %U https://mental.jmir.org/2024/1/e48537 %U https://doi.org/10.2196/48537 %U http://www.ncbi.nlm.nih.gov/pubmed/38214958 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 12 %N %P e48900 %T Design of Virtual Reality Exergames for Upper Limb Stroke Rehabilitation Following Iterative Design Methods: Usability Study %A Villada Castillo,Julian Felipe %A Montoya Vega,Maria Fernanda %A Muñoz Cardona,John Edison %A Lopez,David %A Quiñones,Leonardo %A Henao Gallo,Oscar Alberto %A Lopez,Jose Fernando %+ Faculty of Basic Sciences, Department of Physics, Universidad Tecnologica de Pereira, Carrera 27 #10-02 Álamos, Pereira, 660003, Colombia, 57 606 3137300, jfvillada@utp.edu.co %K stroke %K user-centered design %K exergame %K design %K virtual reality %K playtest %K upper limb rehabilitation %D 2024 %7 11.1.2024 %9 Original Paper %J JMIR Serious Games %G English %X Background: Since the early 2000s, there has been a growing interest in using exercise video games (exergames) and virtual reality (VR)–based interventions as innovative methods to enhance physical rehabilitation for individuals with multiple disabilities. Over the past decade, researchers and exercise professionals have focused on developing specialized immersive exercise video games for various populations, including those who have experienced a stroke, revealing tangible benefits for upper limb rehabilitation. However, it is necessary to develop highly engaging, personalized games that can facilitate the creation of experiences aligned with the preferences, motivations, and challenges communicated by people who have had an episode of stroke. Objective: This study seeks to explore the customization potential of an exergame for individuals who have undergone a stroke, concurrently evaluating its usability as a technological tool in the realm of physical therapy and rehabilitation. Methods: We introduce a playtest methodology to enhance the design of a VR exergame developed using a user-centered approach for upper limb rehabilitation in stroke survivors. Over 4 playtesting sessions, stroke survivors interacted with initial game versions using VR headsets, providing essential feedback for refining game content and mechanics. Additionally, a pilot study involving 10 stroke survivors collected data through VR-related questionnaires to assess game design aspects such as mechanics, assistance, experience, motion sickness, and immersion. Results: The playtest methodology was beneficial for improving the exergame to align with user needs, consistently incorporating their perspectives and achieving noteworthy results. The pilot study revealed that users had a positive response. In the first scenario, a carpenter presents a game based on the flexion-extension movement of the elbow; the second scenario includes a tejo game (a traditional Colombian throwing game) designed around game mechanics related to the flexion-extension movement of the shoulder; and in the third scenario, a farmer challenges the player to perform a movement combining elbow flexion and extension with internal and external rotation of the shoulder. These findings suggest the potential of the studied exergame as a tool for the upper limb rehabilitation of individuals who have experienced a stroke. Conclusions: The inclusion of exergames in rehabilitation for stroke-induced hemiparesis has significantly benefited the recovery process by focusing on essential shoulder and elbow movements. These interactive games play a crucial role in helping users regain mobility and restore practical use of affected limbs. They also serve as valuable data sources for researchers, improving the system’s responsiveness. This iterative approach enhances game design and markedly boosts user satisfaction, suggesting exergames have promising potential as adjunctive elements in traditional therapeutic approaches. %M 38206670 %R 10.2196/48900 %U https://games.jmir.org/2024/1/e48900 %U https://doi.org/10.2196/48900 %U http://www.ncbi.nlm.nih.gov/pubmed/38206670 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 8 %N %P e52157 %T Promoting Self-Efficacy of Individuals With Autism in Practicing Social Skills in the Workplace Using Virtual Reality and Physiological Sensors: Mixed Methods Study %A Kim,Sung-In %A Jang,So-youn %A Kim,Taewan %A Kim,Bogoan %A Jeong,Dayoung %A Noh,Taehyung %A Jeong,Mingon %A Hall,Kaely %A Kim,Meelim %A Yoo,Hee Jeong %A Han,Kyungsik %A Hong,Hwajung %A Kim,Jennifer G %+ Georgia Institute of Technology, 225 North Ave, Atlanta, GA, 30332, United States, 1 404 894 2000, jennifer.kim@cc.gatech.edu %K autism %K virtual reality %K workplace %K self-efficacy %K social skills %K data reflection %D 2024 %7 11.1.2024 %9 Original Paper %J JMIR Form Res %G English %X Background: Individuals with autism often experience heightened anxiety in workplace environments because of challenges in communication and sensory overload. As these experiences can result in negative self-image, promoting their self-efficacy in the workplace is crucial. Virtual reality (VR) systems have emerged as promising tools for enhancing the self-efficacy of individuals with autism in navigating social scenarios, aiding in the identification of anxiety-inducing situations, and preparing for real-world interactions. However, there is limited research exploring the potential of VR to enhance self-efficacy by facilitating an understanding of emotional and physiological states during social skills practice. Objective: This study aims to develop and evaluate a VR system that enabled users to experience simulated work-related social scenarios and reflect on their behavioral and physiological data through data visualizations. We intended to investigate how these data, combined with the simulations, can support individuals with autism in building their self-efficacy in social skills. Methods: We developed WorkplaceVR, a comprehensive VR system designed for engagement in simulated work-related social scenarios, supplemented with data-driven reflections of users’ behavioral and physiological responses. A within-subject deployment study was subsequently conducted with 14 young adults with autism to examine WorkplaceVR’s feasibility. A mixed methods approach was used, compassing pre- and postsystem use assessments of participants’ self-efficacy perceptions. Results: The study results revealed WorkplaceVR’s effectiveness in enhancing social skills and self-efficacy among individuals with autism. First, participants exhibited a statistically significant increase in perceived self-efficacy following their engagement with the VR system (P=.02). Second, thematic analysis of the interview data confirmed that the VR system and reflections on the data fostered increased self-awareness among participants about social situations that trigger their anxiety, as well as the behaviors they exhibit during anxious moments. This increased self-awareness prompted the participants to recollect their related experiences in the real world and articulate anxiety management strategies. Furthermore, the insights uncovered motivated participants to engage in self-advocacy, as they wanted to share the insights with others. Conclusions: This study highlights the potential of VR simulations enriched with physiological and behavioral sensing as a valuable tool for augmenting self-efficacy in workplace social interactions for individuals with autism. Data reflection facilitated by physiological sensors helped participants with autism become more self-aware of their emotions and behaviors, advocate for their characteristics, and develop positive self-beliefs. %M 38206652 %R 10.2196/52157 %U https://formative.jmir.org/2024/1/e52157 %U https://doi.org/10.2196/52157 %U http://www.ncbi.nlm.nih.gov/pubmed/38206652 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e34346 %T The Effects of Virtual Reality Telemedicine With Pediatric Patients Diagnosed With Posttraumatic Stress Disorder: Exploratory Research Method Case Report %A Bogdanski,Erin %+ TheraVR Inc, 5855 Horton Street, Emeryville, CA, 94608, United States, 1 707 394 6088, erinb@theravr.io %K virtual reality %K psychology %K neuroscience %K behavioral health %K telehealth %K eHealth %K telemedicine %K trauma %K traumatic %K PTSD %K posttraumatic stress disorder %K mental health %K mental condition %K mental illness %K cognitive behavioral therapy %K CBT %K avatar %K case study %K pediatric %K child %K youth %K psychiatric disorder %D 2023 %7 22.12.2023 %9 Case Report %J JMIR Form Res %G English %X Background: Trauma-focused cognitive behavioral therapy (TF-CBT) strategies are common interventions to treat child trauma and a posttraumatic stress disorder (PTSD) diagnosis in children with histories of sexual and physical abuse. With the advent of COVID-19, the disruption of child development combined with intense exposure to technology and screen time indicate a need for delivering other novel approaches to treat pediatric PTSD. Virtual reality (VR) has been used with evidence-based TF-CBT as an intervention in lab-based settings, but never as telehealth. Such technologies, including a VR head-mounted device (HMD) programmed with novel TheraVR software, for psychotherapy and treating trauma-related symptoms could redefine how pediatric populations respond to treatment. Objective: The aim of this exploratory single-case study was to reflect symptom improvement and patient engagement using VR as telehealth. Methods: The patient was a 10-year-old girl of Middle Eastern descent diagnosed with trauma and comorbid medical conditions. The patient was in divorced joint parental custody and a Child Protective Services report was made with referral for therapy. Night terrors, hallucinations, depression, anxiety, isolation, and encopresis symptoms were assessed at the beginning of treatment. Clinical analysis met the criteria for a diagnosis of early onset PTSD, which was treated over the course of 7 months using TF-CBT. A cross-analysis design was used to compare improved effectiveness in treatment and patient outcomes when moving from delivery of care with telehealth using desktop and tablet synchronous technology to 2D VR desktop telehealth with TheraVR software and subsequently HMD VR telehealth with TheraVR software. Sessions were conducted in private practice providing psychotherapy for remote patient care, collateral care with the family, and coordination of clinical care with the patient’s pediatrician. Safety and protocols for reducing triggers were clinically monitored by the provider. Results: Over the course of treatment, and moving from standard telehealth to 2D VR to TheraVR with a standalone HMD, there was a significant reduction in PTSD symptoms. The transfer from using the standard video conferencing with face-to-face video to using customizable avatar technology with an assigned scene environment presented an increase in patient retention and follow-through with the treatment goals. The continuous use of delivery of care using VR with the TheraVR software demonstrated breakthrough clinical observations where the patient devised her own interventions for coping with mood, emotional regulation, and negative cognitive processes using the 10 different VR environments. Conclusions: This study shows the potential efficacy in using VR specifically for younger populations as a better modality of pediatrics care, while improving engagement with the provider through telehealth. These findings suggest the value of further research through larger clinical trials including pediatric patients diagnosed with severe trauma or trauma-related symptoms to assess the effectiveness of TheraVR software. %M 38133920 %R 10.2196/34346 %U https://formative.jmir.org/2023/1/e34346 %U https://doi.org/10.2196/34346 %U http://www.ncbi.nlm.nih.gov/pubmed/38133920 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e51719 %T Co-Design of a Virtual Reality Multiplayer Adventure Game for Adolescents With Autism Spectrum Disorder: Mixed Methods Study %A Gabrielli,Silvia %A Cristofolini,Melanie %A Dianti,Marco %A Alvari,Gianpaolo %A Vallefuoco,Ersilia %A Bentenuto,Arianna %A Venuti,Paola %A Mayora Ibarra,Oscar %A Salvadori,Elio %+ Digital Health Research, Fondazione Bruno Kessler, Via Sommarive 18, Trento, 38123, Italy, 39 0461 312 477, sgabrielli@fbk.eu %K co-design %K virtual reality environments %K autism %K social skills interventions %K multiplayer game design %K serious games %D 2023 %7 8.12.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) adventure games can offer ideal technological solutions for training social skills in adolescents with autism spectrum disorder (ASD), leveraging their support for multisensory and multiplayer interactions over distance, which may lower barriers to training access and increase user motivation. However, the design of VR-based game environments for social skills training is still understudied and deserves the deployment of an inclusive design approach to ensure its acceptability by target users. Objective: We aimed to present the inclusive design process that we had followed to develop the Zentastic VR adventure game to foster social skills training in adolescents with ASD and to investigate its feasibility as a training environment for adolescents. Methods: The VR game supports multiplayer training sessions involving small groups of adolescents and their therapists, who act as facilitators. Adolescents with ASD and their therapists were involved in the design and in an explorative acceptability study of an initial prototype of the gaming environment, as well as in a later feasibility multisession evaluation of the VR game final release. Results: The feasibility study demonstrated good acceptability of the VR game by adolescents and an enhancement of their social skills from baseline to posttraining. Conclusions: The findings provide preliminary evidence of the benefits that VR-based games can bring to the training of adolescents with ASD and, potentially, other neurodevelopmental disorders. %M 38064258 %R 10.2196/51719 %U https://games.jmir.org/2023/1/e51719 %U https://doi.org/10.2196/51719 %U http://www.ncbi.nlm.nih.gov/pubmed/38064258 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e43416 %T TACTICS VR Stroke Telehealth Virtual Reality Training for Health Care Professionals Involved in Stroke Management at Telestroke Spoke Hospitals: Module Design and Implementation Study %A Maltby,Steven %A Garcia-Esperon,Carlos %A Jackson,Kate %A Butcher,Ken %A Evans,James W %A O'Brien,William %A Dixon,Courtney %A Russell,Skye %A Wilson,Natalie %A Kluge,Murielle G %A Ryan,Annika %A Paul,Christine L %A Spratt,Neil J %A Levi,Christopher R %A Walker,Frederick Rohan %+ Centre for Advanced Training Systems, The University of Newcastle, Medical Sciences Building - Room 317, University Drive, Newcastle, 2308, Australia, 61 249215012, rohan.walker@newcastle.edu.au %K virtual reality %K technology %K medical education %K telehealth %K stroke management %K stroke workflow %D 2023 %7 7.12.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Stroke management in rural areas is more variable and there is less access to reperfusion therapies, when compared with metropolitan areas. Delays in treatment contribute to worse patient outcomes. To improve stroke management in rural areas, health districts are implementing telestroke networks. The New South Wales Telestroke Service provides neurologist-led telehealth to 23 rural spoke hospitals aiming to improve treatment delivery and patient outcomes. The training of clinical staff was identified as a critical aspect for the successful implementation of this service. Virtual reality (VR) training has not previously been used in this context. Objective: We sought to develop an evidence-based VR training module specifically tailored for stroke telehealth. During implementation, we aimed to assess the feasibility of workplace deployment and collected feedback from spoke hospital staff involved in stroke management on training acceptability and usability as well as perceived training impact. Methods: The TACTICS VR Stroke Telehealth application was developed with subject matter experts. During implementation, both quantitative and qualitative data were documented, including VR use and survey feedback. VR hardware was deployed to 23 rural hospitals, and use data were captured via automated Wi-Fi transfer. At 7 hospitals in a single local health district, staff using TACTICS VR were invited to complete surveys before and after training. Results: TACTICS VR Stroke Telehealth was deployed to rural New South Wales hospitals starting on April 14, 2021. Through August 20, 2023, a total of 177 VR sessions were completed. Survey respondents (n=20) indicated a high level of acceptability, usability, and perceived training impact (eg, accuracy and knowledge transfer; mean scores 3.8-4.4; 5=strongly agree). Furthermore, respondents agreed that TACTICS VR increased confidence (13/18, 72%), improved understanding (16/18, 89%), and improved awareness (17/18, 94%) regarding stroke telehealth. A comparison of matched pre- and posttraining responses revealed that training improved the understanding of telehealth workflow practices (after training: mean 4.2, SD 0.6; before training: mean 3.2, SD 0.9; P<.001), knowledge on accessing stroke telehealth (mean 4.1, SD 0.6 vs mean 3.1, SD 1.0; P=.001), the awareness of stroke telehealth (mean 4.1, SD 0.6 vs mean 3.4, SD 0.9; P=.03), ability to optimally communicate with colleagues (mean 4.2, SD 0.6 vs mean 3.7, SD 0.9; P=.02), and ability to make improvements (mean 4.0, SD 0.6 vs mean 3.5, SD 0.9; P=.03). Remote training and deployment were feasible, and limited issues were identified, although uptake varied widely (0-66 sessions/site). Conclusions: TACTICS VR Stroke Telehealth is a new VR application specifically tailored for stroke telehealth workflow training at spoke hospitals. Training was considered acceptable, usable, and useful and had positive perceived training impacts in a real-world clinical implementation context. Additional work is required to optimize training uptake and integrate training into existing education pathways. %M 38060297 %R 10.2196/43416 %U https://games.jmir.org/2023/1/e43416 %U https://doi.org/10.2196/43416 %U http://www.ncbi.nlm.nih.gov/pubmed/38060297 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e47630 %T Improving Social Isolation and Loneliness Among Adolescents With Physical Disabilities Through Group-Based Virtual Reality Gaming: Feasibility Pre-Post Trial Study %A Lai,Byron %A Young,Raven %A Craig,Mary %A Chaviano,Kelli %A Swanson-Kimani,Erin %A Wozow,Cynthia %A Davis,Drew %A Rimmer,James H %+ Division of Pediatric Rehabilitation Medicine, Department of Pediatrics, University of Alabama at Birmingham, 1600 7th Avenue South, 5 Dearth, McWane 5601, Birmingham, AL, 35233, United States, 1 2056389790 ext 8 9725, blai@uabmc.edu %K therapy %K mindfulness %K play %K friend %K friends %K friendship %K lonely %K loneliness %K psychotherapy %K peer %K peers %K recreation %K disability %K adolescent %K adolescents %K disability %K disabled %K physical disability %K digital mental health intervention %K youth %K young adult %K virtual reality %K VR %K gaming %K depression %K depressive %K mental health %K social %K isolated %K isolation %K socialize %K socializing %K socialization %K interaction %K interactions %K acceptability %K game %K games %K gaming %K exergame %K exergames %K exergaming %D 2023 %7 6.12.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Adolescents with disabilities experience alarmingly higher rates of depression and isolation than peers without disabilities. There is a need to identify interventions that can improve mental health and isolation among this underserved population. Innovations in virtual reality (VR) gaming “standalone” headsets allow greater access to immersive high-quality digital experiences, due to their relatively low cost. Objective: This study had three purposes, which were to (1) examine the preliminary effects of a low-cost, home-based VR multiplayer recreation and socialization on depression, socialization, and loneliness; (2) quantify the acceptability of the program as measured by participant adherence, total play time, and exercise time; and (3) identify and describe behavioral mechanisms that affected participant engagement. Methods: This was a single-group, pre- to postdesign trial. The intervention was conducted at home. Participants were recruited from a children’s hospital. The intervention lasted 4 weeks and included 2×1-hour sessions per week of supervised peer-to-peer gaming. Participants used the Meta Quest 2 headset to meet peers and 2 coaches in a private party held digitally. Aim 1 was evaluated with the Children’s Depression Inventory 2 Short Form and the University of California, Los Angeles Loneliness Scale 20 items, which are measures of social isolation and loneliness, respectively. Aim 2 was evaluated through the following metrics: participant adherence, the types of games played, friendship building and playtime, and program satisfaction and enjoyment. Results: In total, 12 people enrolled (mean age 16.6, SD 1.8 years; male: n=9 and female: n=3), and 8 people completed the program. Mean attendance for the 8 participants was 77% (49 sessions of 64 total possible sessions; mean 6, SD 2 sessions). A trend was observed for improved Children’s Depression Inventory 2 Short Form scores (mean preintervention score 7.25, SD 4.2; mean postintervention score 5.38, SD 4.1; P=.06; effect size=0.45, 95% CI –0.15 to 3.9), but this was not statistically significant; no difference was observed for University of California, Los Angeles Loneliness Scale 20 items scores. Most participants (7/8, 88%) stated that they became friends with a peer in class; 50% (4/8) reported that they played with other people. Participants reported high levels of enjoyment and satisfaction with how the program was implemented. Qualitative analysis resulted in 4 qualitative themes that explained behavioral mechanisms that determined engagement in the program. Conclusions: The study findings demonstrated that a brief VR group program could be valuable for potentially improving mental health among adolescents with physical disabilities. Participants built friendships with peers and other players on the web, using low-cost consumer equipment that provided easy access and strong scale-up potential. Study findings identified factors that can be addressed to enhance the program within a larger clinical trial. Trial Registration: ClinicalTrials.gov NCT05259462; https://clinicaltrials.gov/study/NCT05259462 International Registered Report Identifier (IRRID): RR2-10.2196/42651 %M 38055309 %R 10.2196/47630 %U https://formative.jmir.org/2023/1/e47630 %U https://doi.org/10.2196/47630 %U http://www.ncbi.nlm.nih.gov/pubmed/38055309 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e49237 %T Ethical Challenges of Virtual Reality Technology Interventions for the Vulnerabilities of Patients With Chronic Pain: Exploration of Technician Responsibility %A Zhou,Siyu %A Gromala,Diane %A Wang,Leyu %+ Department of Philosophy, Central South University, South Campus of Central South University, 605 South Lu Shan Road, Yue Lu District, Changsha, 410017, China, 86 19198089919, 200201001@csu.edu.cn %K patients with chronic pain %K vulnerability %K virtual reality interventions %K ethics %K responsibility %K technical developers %D 2023 %7 4.12.2023 %9 Viewpoint %J J Med Internet Res %G English %X Chronic pain, a common disease, is a crucial global public health concern. Approximately 20% of the worldwide population is affected by chronic pain, which accounts for 15% to 20% of hospital visits. In Canada, approximately 7.6 million people—or 1 in 5 people—experience chronic pain. Among this population, 60% has either lost their employment or experienced a reduction in income as a result of their pain. The proportion of older people (aged ≥65 years) with chronic pain is high, comprising one-third of the total older population. In addition, the causes of chronic pain and its cures are unknown, and treatment is limited by these unknowns and the dangers of opioids. These essential factors make patients with chronic pain one of the most vulnerable populations. The use of emerging virtual reality (VR) technology as an intervention for chronic pain has consistently demonstrated early effectiveness and has been termed as a “nonpharmacological analgesic.” Nevertheless, we must remain vigilant about the potential ethical risks of VR interventions, as inappropriate VR interventions may exacerbate the vulnerabilities of patients. Currently, a central challenge for VR developers is the ambiguity of patient vulnerability and the unpredictability of ethical dilemmas. Therefore, our paper focused on the vulnerability and ethical dilemmas faced by patients with chronic pain in VR interventions. Through an experience-based, prospective ethical examination, we have identified both existing and potential new vulnerabilities and specific manifestations that patients with chronic pain may encounter in VR interventions. Our aim was to highlight the ethical risks that may be present in VR interventions. On one hand, this can help raise awareness among technology developers regarding the vulnerabilities of patients with chronic pain and mitigate technological ethical risks. In addition, it can assist technology developers in determining the priorities for VR technology interventions. These efforts collectively lay a solid foundation for the comprehensive realization of responsible VR technology interventions. %M 38048153 %R 10.2196/49237 %U https://www.jmir.org/2023/1/e49237 %U https://doi.org/10.2196/49237 %U http://www.ncbi.nlm.nih.gov/pubmed/38048153 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e51318 %T The Efficacy and Therapeutic Alliance of Augmented Reality Exposure Therapy in Treating Adults With Phobic Disorders: Systematic Review %A Hasan,Safa %A Alhaj,Hamid %A Hassoulas,Athanasios %+ University of Sharjah, College of Medicine, University of Shajah, Sharjah, United Arab Emirates, 971 65057239, halhaj@sharjah.ac.ae %K augmented reality %K virtual reality %K anxiety disorders %K phobic disorders %K exposure therapy %K augmented reality exposure %K phobia %K excessive fear %K prevalence %K technology %K cost-effectiveness %K fear %K phobia %K phobic %D 2023 %7 30.11.2023 %9 Review %J JMIR Ment Health %G English %X Background: Phobic disorders are characterized by excessive fear of a stimulus that can affect the quality of a patient’s life. The lifetime prevalence in adults is 7.7% to 12.5%. The current literature provides evidence-based inferences about the effectiveness of in-vivo exposure therapy (IVET) in treating phobia. However, this method can put the therapist and the client in danger, with high drop out and refusal rates. A newer approach for exposure therapy using augmented reality technology is under assessment. Objective: This systematic review investigated the novel technology’s efficacy, cost-efficacy, and therapeutic alliance in treating adults with phobia. Methods: An extensive search was conducted using 4 major databases (MEDLINE, PsycINFO, Embase, and Scopus) using a comprehensive list of synonyms for augmented reality exposure therapy (ARET) and phobic disorders. The search targeted any randomized control trial testing ARET in adults with phobic disorders up to August 8, 2022. Results: A total of 6 studies were included, with 208 participants providing results. Studies investigating the efficacy of ARET compared to no intervention showed significant results (P<.05) in the ARET group improvement. Head-to-head comparative studies comparing ARET to IVET showed no significant difference (P>.05) in the effectiveness and therapeutic alliance between both therapies. Further, the results demonstrated that the ARET group had a better long-term effect than IVET, with the ability to put the patients in more situations to face the feared object. Conclusions: The current data suggest clinically significant efficacy and a promising therapeutic alliance of ARET. However, no data are available investigating the cost-effectiveness of ARET. Further research is warranted to ascertain ARET’s cost-effectiveness and examine its efficacy in other populations and anxiety conditions. %M 38032710 %R 10.2196/51318 %U https://mental.jmir.org/2023/1/e51318 %U https://doi.org/10.2196/51318 %U http://www.ncbi.nlm.nih.gov/pubmed/38032710 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e46242 %T The Multidomain Metaverse Cancer Care Digital Platform: Development and Usability Study %A Kim,Sunghak %A Jung,Timothy %A Sohn,Dae Kyung %A Chae,Yoon %A Kim,Young Ae %A Kang,Seung Hyun %A Park,Yujin %A Chang,Yoon Jung %+ Division of Cancer Control and Policy, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang, 10408, Republic of Korea, 82 10 8729 5835, eunice.ncc@gmail.com %K metaverse %K virtual reality %K cancer education %K cancer care %K digital health %K cancer treatment %K patient care %K cross-sectional survey %K digital health intervention %D 2023 %7 30.11.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: As cancer treatment methods have diversified and the importance of self-management, which lowers the dependence rate on direct hospital visits, has increased, effective cancer care education and management for health professionals and patients have become necessary. The metaverse is in the spotlight as a means of digital health that allows users to engage in cancer care education and management beyond physical constraints. However, it is difficult to find a multipurpose medical metaverse that can not only be used in the field but also complements current cancer care. Objective: This study aimed to develop an integrated metaverse cancer care platform, Dr. Meta, and examine its usability. Methods: We conducted a multicenter, cross-sectional survey between November and December 2021. A descriptive analysis was performed to examine users’ experiences with Dr. Meta. In addition, a supplementary open-ended question was used to ask users for their suggestions and improvements regarding the platform. Results: Responses from 70 Korean participants (male: n=19, 27% and female: n=51, 73%) were analyzed. More than half (n=37, 54%) of the participants were satisfied with Dr. Meta; they responded that it was an interesting and immersive platform (n=50, 72%). Less than half perceived no discomfort when using Dr. Meta (n=34, 49%) and no difficulty in wearing and operating the device (n=30, 43%). Furthermore, more than half (n=50, 72%) of the participants reported that Dr. Meta would help provide non–face-to-face and noncontact services. More than half also wanted to continue using this platform in the future (n=41, 59%) and recommended it to others (n=42, 60%). Conclusions: We developed a multidomain metaverse cancer care platform that can support both health professionals and patients in non–face-to-face cancer care. The platform was uniquely disseminated and implemented in multiple regional hospitals and showed the potential to perform successful cancer care. %M 38032697 %R 10.2196/46242 %U https://games.jmir.org/2023/1/e46242 %U https://doi.org/10.2196/46242 %U http://www.ncbi.nlm.nih.gov/pubmed/38032697 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e46592 %T Treatment Responsivity in Adolescents With Disruptive Behavior Problems: Co-Creation of a Virtual Reality–Based Add-On Intervention %A Klein Schaarsberg,Renée E %A Ribberink,Amber Z %A Osinga,Babette %A van Dam,Levi %A Lindauer,Ramón J L %A Popma,Arne %+ Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam UMC location Vrije Universiteit Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, Netherlands, 31 0208901000, r.e.kleinschaarsberg@amsterdamumc.nl %K virtual reality %K role-playing %K cognitive behavioral therapy %K co-creation %K disruptive behavior %K mentalization %K adolescence %K mental health %K child %K youth %K clinical practice %K intervention %D 2023 %7 28.11.2023 %9 Early Report %J JMIR Form Res %G English %X Background: We developed Street Temptations (ST) as an add-on intervention to increase the treatment responsivity of adolescents with disruptive behavior problems. ST’s primary aim is to improve adolescents’ mentalizing abilities in order to help them engage in and benefit from psychotherapy. Additionally, virtual reality (VR) is used to work in a more visual, less verbal, fashion. Objective: By recapping the lessons learned while developing ST so far, we aim to design the following study on ST. Furthermore, we aim to enhance the development and study of new health care interventions in clinical practice, together with adolescents as their end users. Methods: We followed an iterative co-creation process to develop a prototype of ST, in collaboration with adolescents and professionals from a secured residential facility in Amsterdam, the Netherlands. The prototype was tested during a pilot phase, involving 2 test runs, in which 4 adolescents and 4 professionals participated. Qualitative data were collected through interviews with the adolescents and by conducting a group interview with the professionals, in order to gain first insights into ST’s usability, feasibility, and its added value to clinical practice. In between the first and second test runs, the prototype was enhanced. On the basis of the complete pilot phase, we reflected on the future development and implementation of ST to design a subsequent study. Results: Over the course of 6 months, ST’s first prototype was developed during multiple creative sessions. Included was the development of a short 360° VR video, to serve as a base for the mentalization exercises. The final version of ST consisted of 7 individual therapy sessions, incorporating both the VR video and a VR StreetView app. On the basis of the qualitative data collected during the pilot phase, we found preliminary signs of ST’s potential to support adolescents’ perspective-taking abilities specifically. Additionally, using VR to focus on real-life situations that adolescents encounter in their daily lives possibly helps to facilitate communication. However, several challenges and requests concerning the VR hardware and software and the implementation of ST emerged, pointing toward further development of ST as an add-on intervention. These challenges currently limit large-scale implementation, resulting in specific requirements regarding a subsequent study. Conclusions: In order to gather more extensive information to shape further development and study treatment effects, a small-scale and individually oriented research design seems currently more suitable than a more standard between-subjects design. Using the reflection on the lessons learned described in this report, a research protocol for a forthcoming study on ST has been developed. By presenting our co-creation journey thus far, we hope to be of inspiration for a more co-creative mindset and in that way contribute to the mutual reinforcement of science and clinical practice. %M 38015607 %R 10.2196/46592 %U https://formative.jmir.org/2023/1/e46592 %U https://doi.org/10.2196/46592 %U http://www.ncbi.nlm.nih.gov/pubmed/38015607 %0 Journal Article %@ 2291-9279 %I %V 11 %N %P e52022 %T Virtual Reality in Clinical Nursing Practice Over the Past 10 Years: Umbrella Review of Meta-Analyses %A Hu,Yanjie %A Yuan,Xingzhu %A Ye,Peiling %A Chang,Chengting %A Hu,Yue Han %A Zhang,Weihua %A Li,Ka %K virtual reality %K clinical nursing %K artificial intelligence %K AI-assisted medical rehabilitation %K health promotion %K umbrella review %D 2023 %7 23.11.2023 %9 %J JMIR Serious Games %G English %X Background: Virtual reality (VR) has shown promising levels of effectiveness in nursing education, pain management, and rehabilitation. However, meta-analyses have discussed the effects of VR usage in nursing unilaterally and inconsistently, and the evidence base is diffuse and varied. Objective: We aimed to synthesize the combined evidence from meta-analyses that assessed the effects of nurses using VR technology on nursing education or patient health outcomes. Methods: We conducted an umbrella review by searching for meta-analyses about VR intervention in clinical nursing practice on Web of Science, Embase, Cochrane, and PubMed, and in reference lists. Eligible studies were published in English between December 1, 2012, and September 20, 2023. Meta-analyses of ≤2 intervention studies and meta-analyses without 95% CI or heterogeneity data were excluded. Characteristic indicators, population information, VR intervention information, and 95% CIs were extracted. A descriptive analysis of research results was conducted to discern relationships between VR interventions and outcomes. I2 and P values were used to evaluate publication bias. AMSTAR (A Measurement Tool to Assess Systematic Reviews) 2 and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) checklist were used to appraise literature quality. Results: In total, 768 records were identified; 74 meta-analyses were included for review. The most reported VR study conditions were neuronursing (25/74, 34%), pediatric nursing (13/74, 18%), surgical and wound care (11/74, 15%), oncological nursing (11/74, 15%), and older adult nursing (10/74, 14%). Further, 30% (22/74) of meta-analyses reported publication bias, and 15% (11/74) and 8% (6/74) were rated as “high” based on AMSTAR 2 and the GRADE checklist, respectively. The main outcome indicators among all included meta-analyses were pain (37/214, 17.3%), anxiety (36/214, 16.8%), cognitive function (17/214, 7.9%), balance (16/214, 7.5%), depression (16/214, 7.5%), motor function (12/214, 5.6%), and participation in life (12/214, 5.6%). VR treatment for cognition, pain, anxiety, and depression was effective (all P values were <.05), while the utility of VR for improving motor function, balance, memory, and attention was controversial. Adverse effects included nausea, vomiting, and dizziness (incidence: range 4.76%-50%). The most common VR platforms were Pico VR glasses, head-mounted displays, the Nintendo Wii, and the Xbox Kinect. VR intervention duration ranged from 2 weeks to 12 months (typically ≥4 wk). VR session length and frequency ranged from 5 to 100 minutes and from 1 to 10 times per week, respectively. Conclusions: VR in nursing has positive effects—relieving patients’ pain, anxiety, and depression and improving cognitive function—despite the included studies’ limited quality. However, applying VR in nursing to improve patients’ motor function, balance, memory, and attention remains controversial. Nursing researchers need to further explore the effects and standard operation protocols of VR in clinical practice, and more high-quality research on VR in nursing is needed. Trial Registration: PROSPERO CRD42022381382; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=381382 %R 10.2196/52022 %U https://games.jmir.org/2023/1/e52022 %U https://doi.org/10.2196/52022 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45821 %T Medical Extended Reality Trials: Building Robust Comparators, Controls, and Sham %A Persky,Susan %A Colloca,Luana %+ Social and Behavioral Research Branch, National Human Genome Research Institute, 31 Center Drive, B1B36, Bethesda, MD, 20892, United States, 1 3014430098, perskys@mail.nih.gov %K augmented reality %K clinical trial design %K control conditions %K medical extended reality %K sham VR %K virtual reality %D 2023 %7 22.11.2023 %9 Viewpoint %J J Med Internet Res %G English %X The explosive pace of development and research in medical extended reality (MXR) is a testament to its promise for health care and medicine. In comparison with this growth, there is a relative sparsity of rigorous clinical trials that establish the efficacy and effectiveness of these interventions. Explicating mechanisms of action across clinical areas and MXR applications is another major area of need. A primary impediment to these goals is a lack of frameworks for trial design, more specifically, the selection of appropriate controls that effectively address unique elements of MXR. This paper delineates a framework for designing controls, sham conditions, and comparators, as well as proposed considerations for MXR trial designs. Special consideration is given to the design of sham conditions. Improved designs would enable more robust findings and the development of generalizable knowledge that could be adopted across MXR interventions. %M 37991836 %R 10.2196/45821 %U https://www.jmir.org/2023/1/e45821 %U https://doi.org/10.2196/45821 %U http://www.ncbi.nlm.nih.gov/pubmed/37991836 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 10 %N %P e47541 %T Use of Virtual Reality in Interdisciplinary Multimodal Pain Treatment With Insights From Health Care Professionals and Patients: Action Research Study %A Ummels,Darcy %A Cnockaert,Elise %A Timmers,Inge %A den Hollander,Marlies %A Smeets,Rob %+ Department of Rehabilitation Medicine, Care and Public Health Research Institute, Faculty of Health, Medicine & Life Sciences, Maastricht University, P.O. Box 616, Maastricht, 6200 MD, Netherlands, 31 43 388 2160, darcy.ummels@maastrichtuniversity.nl %K virtual reality %K interdisciplinary multimodal pain treatment %K chronic pain %K pain %K rehabilitation %K digital health %K physiotherapy %K occupational therapy %K physical therapy %D 2023 %7 10.11.2023 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Chronic pain is a widespread global health problem. Interdisciplinary multimodal pain treatment (IMPT) is a treatment option for people with chronic pain. Virtual reality (VR) could be used to broaden IMPT programs. However, despite the advantages of VR, it is rarely used in daily clinical practice. Objective: This research aimed to explore how, when, and with whom VR can be used meaningfully during IMPT, either as an addition or substitution as a component of IMPT. Methods: This research used an action research design to help health care professionals and patients learn how, when, and with whom they can use VR. Data were collected through reflection sessions with health care professionals and semistructured interviews with patients in 2 specialized centers that provide IMPT for chronic pain. Two researchers performed direct content analyses. Results: In total, 4 physiotherapists, 1 occupational therapist, 3 psychologists, and 22 patients participated in this research. Three iteration cycles, including 9 reflection sessions and 8 semistructured interviews, were performed. Both health care professionals and patients considered VR to be useful in therapy as an addition but not a substitution. VR was used as a diagnostic and intervention tool with all patients at the rehabilitation center or home. VR was used to gain insight into patients’ pain beliefs, cognitions, and irrational cognitions about additional damage and physical abilities. Considering VR as an intervention tool, the health care professionals had 3 goals: balancing relaxation and competition, grading activities, and exposure in vivo. Conclusions: VR could be a valuable addition to IMPT for both patients with chronic pain and health care professionals. More research should be performed to assess the additional effects of VR on patients’ participation in daily life. %M 37948109 %R 10.2196/47541 %U https://rehab.jmir.org/2023/1/e47541 %U https://doi.org/10.2196/47541 %U http://www.ncbi.nlm.nih.gov/pubmed/37948109 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e49956 %T Effects of a Virtual Reality Game on Children’s Anxiety During Dental Procedures (VR-TOOTH): Protocol for a Pilot Randomized Controlled Trial %A Wu,Wenjia %A Le May,Sylvie %A Hung,Nicole %A Fortin,Olivier %A Genest,Christine %A Francoeur,Maxime %A Guingo,Estelle %A St-Arneault,Kate %A Sylfra,Annie %A Vu,An Kateri %A Carmel,Janick %A Lessard,Laurence %A Cara-Slavich,Stephany %A De Koven,Katheryn %A Paquette,Julie %A Hoffman,Hunter %A Asselin,Marie-Eve %+ Research Center, Centre Hospitalier Universitaire Sainte-Justine, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada, 1 5143436384, sylvie.lemay@umontreal.ca %K virtual reality %K pediatrics %K children %K dentistry %K procedures %K fear %K anxiety %K child %K pediatric %K dentist %K dental %K tooth %K teeth %K oral %K anxious %K immersion %K immersive %K RCT %K randomized %K controlled trial %D 2023 %7 10.11.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Dental fear and anxiety (DFA) is a condition that affects approximately one-quarter of children and adolescents. It is a significant cause for pediatric patients to avoid dental care later in adulthood. Lack of patient cooperation due to DFA can create an environment of stress, often obligating dentists to end appointments prematurely and consider alternative pharmacological treatment options. Virtual reality (VR) use during dental care, providing an immersive experience through sensory stimuli, is potentially an additional nonpharmacologic tool to better manage DFA in children with special health care needs (SHCN) undergoing dental procedures. Objective: This pilot study aims to assess the feasibility and acceptability of VR immersion as a tool to reduce DFA in pediatric special needs patients undergoing dental procedures. The study also aims to gain insight on parent and health care provider perspectives on the use of VR during dental appointments. Methods: This pilot randomized controlled trial study will follow a parallel design including 2 groups: a control group (clinic’s standard care using a wall TV) and an experimental group (using a VR game). We will randomize 20 participants to either group. Recruitment will be carried out at the dental clinic of the Centre Hospitalier Universitaire Sainte-Justine, a tertiary-quaternary care center that mostly serves pediatric patients with SHCN. The primary outcome will be patient recruitment rates and completion rates of planned procedures. DFA in children will be assessed using both an observation-based proxy assessment with the Venham Anxiety and Behavior Rating Scale and physiological assessments using parameters such as change in heart rate and levels of salivary alpha-amylase as a stress biomarker before and 10 minutes after the procedure. Sociodemographic characteristics, measures of the levels of parent and health care professional satisfaction, occurrence of side effects, and any deviation from normal procedure length will also be collected. Descriptive statistics, nonparametric tests, and effect sizes will be used for demographic and clinical variables and to present parent and health care professional satisfaction levels as well as procedural time. Results: This study will be conducted from May 2023 to May 2024, with results expected to be available in December 2024. Conclusions: The pilot study will provide insight on the feasibility and acceptability of VR use in clinical dentistry to reduce DFA for pediatric patients with SHCN. This study will guide future research on VR use in pediatric dentistry and can serve as a framework for a larger randomized clinical trial. Trial Registration: ClinicalTrials.gov NCT05898100; https://classic.clinicaltrials.gov/ct2/show/NCT05898100 International Registered Report Identifier (IRRID): DERR1-10.2196/49956 %R 10.2196/49956 %U https://www.researchprotocols.org/2023/1/e49956/ %U https://doi.org/10.2196/49956 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e48761 %T Use of Immersive Virtual Reality Spaces to Engage Adolescent and Young Adult Patients With Cancer in Therapist-Guided Support Groups: Protocol for a Pre-Post Study %A Marks,Asher %A Garbatini,Amanda %A Hieftje,Kimberly %A Puthenpura,Vidya %A Weser,Veronica %A Fernandes,Claudia-Santi F %+ Section of Pediatric Hematology/Oncology, Department of Pediatrics, Yale School of Medicine, 333 York St., New Haven, CT, 06510, United States, 1 203 785 4640, asher.marks@yale.edu %K cancer %K virtual reality %K support groups %K peer support %K adolescent %K young adult %K resilience %K adolescents and young adults %K oncology %K therapist-guided support %K social isolation %K support system %K psychosocial support %K barrier %K quality of life %D 2023 %7 9.11.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: For adolescents and young adults, a cancer diagnoses can magnify feelings of social isolation at an inherently vulnerable developmental stage. Prior studies have highlighted the importance of peer groups during cancer treatment. Support groups help foster connection and resilience, but patients find in-person participation difficult due to a variety of factors. Additionally, physical changes brought on by cancer makes these patients hesitant to meet in person. The COVID-19 pandemic magnified these difficulties. Virtual reality (VR) allows for the creation of a therapist-curated, computer-generated social space that potentially enables support groups for this population. Objective: This protocol describes a pilot study examining the efficacy, feasibility, and acceptability of a social VR support group intervention for adolescent and young adult patients with cancer. Methods: We approached 20 participants aged 17-20 years, and 16 agreed to participate. Moreover, 1 participant dropped out due to hospitalization. Participants attended virtual, professionally facilitated support groups using Meta Quest VR headsets. The groups consisted of 4 participants and 1 facilitator, amounting to a total of 22 individual sessions. Each session lasted 45-60 minutes and took place weekly for 4-6 weeks. The primary aim of this study was to collect quantitative and qualitative data on the feasibility and acceptability of the intervention. Feasibility was measured through session participation rates and overall retention rates. The acceptability of the intervention was explored through brief in-person interviews with participants at the end of the final intervention session. The secondary aim of this study was to collect data on the preliminary efficacy of the intervention in decreasing symptoms of participant depression and anxiety and increasing positive affect and resiliency. Results: In total, 15 patients aged 17-20 years participated in 22 sessions between November 5, 2019, and July 8, 2021. The median age was 19 (IQR 17-20) years. Overall, 10 (62%) participants identified as male, 5 (31%) as female, and 1 (6%) as transgender female. Furthermore, 5 (31%) participants identified as Hispanic, 1 (6%) identified as non-Hispanic Asian, 3 (19%) identified as non-Hispanic Black, 6 (38%) identified as non-Hispanic White, and 1 (6%) identified as other race or ethnicity. Hematologic malignancies or bone marrow failure was the most common diagnosis (8/16, 50%). The mean attendance rate was 72.8% (SD 25.7%) and retention was 86.7% (SD 0.35%). Moreover, 45% (10/22) of sessions had to be postponed by a week or more due to unexpected participant scheduling issues. Conclusions: The use of VR to deliver psychosocial support for adolescents and young adults with cancer may reduce common barriers associated with attending in-person peer support groups while improving quality-of-life measures. The data from this study will inform future studies focused on conducting VR support groups in other rare disease populations, including older adults with cancer. International Registered Report Identifier (IRRID): DERR1-10.2196/48761 %M 37943596 %R 10.2196/48761 %U https://www.researchprotocols.org/2023/1/e48761 %U https://doi.org/10.2196/48761 %U http://www.ncbi.nlm.nih.gov/pubmed/37943596 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e42194 %T Effectiveness of Reducing Craving in Alcohol Use Disorder Using a Serious Game (SALIENCE): Randomized Controlled Trial %A Weber,Antonia %A Shevchenko,Yury %A Gerhardt,Sarah %A Hoffmann,Sabine %A Kiefer,Falk %A Vollstädt-Klein,Sabine %+ Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Square J5, Mannheim, 68159, Germany, 49 1792011684, sabine.vollstaedt-klein@zi-mannheim.de %K alcohol approach bias %K alcohol attentional bias %K alcohol use disorder %K alcohol %K attention %K cognitive bias modification therapy %K craving %K cue-exposure therapy %K decision-making training %K decision-making %K incentive salience %K serious games %K therapy %K training %D 2023 %7 7.11.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Alcohol use disorder (AUD) has become a major global health problem. Therapy for this condition is still a great challenge. Recently, it has become increasingly evident that computer-based training is a valuable addition to the treatment of addictive disorders. Objective: This study aims to evaluate the web-based serious game SALIENCE (Stop Alcohol in Everyday Life-New Choices and Evaluations) as an add-on therapy for AUD. It combines the cue-exposure therapy approach with elements of decision-making training, enhanced by interactive panoramic images. The effects of SALIENCE training on levels of craving, attention, and cognitive bias are investigated. Methods: In a randomized controlled trial, 62 participants with AUD undergoing 3 weeks of an extended alcohol detoxification program were randomly allocated to an intervention and a control group. A total of 49 individuals (mean age 44.04 y; 17/49, 35% female) completed all sessions and were included in the analysis. Only pretreatment data were available from the other 13 patients. Participants answered questionnaires related to alcohol consumption and craving and completed neuropsychological tasks at the beginning of the study and 2 weeks later to evaluate levels of attention and cognitive biases. During the 2-week period, 27 of the participants additionally performed the SALIENCE training for 30 minutes 3 times a week, for a total of 6 sessions. Results: We observed a significant decrease in craving in both groups: the control group (mean 15.59, SD 8.02 on the first examination day vs mean 13.18, SD 8.38 on the second examination day) and the intervention group (mean 15.19, SD 6.71 on the first examination day vs mean 13.30, SD 8.47 on the second examination day; F1,47=4.31; P=.04), whereas the interaction effect was not statistically significant (F1,47=0.06; P=.80). Results of the multiple linear regression controlling for individual differences between participants indicated a significantly greater decrease in craving (β=4.12; t36=2.34; P=.03) with the SALIENCE intervention. Participants with lower drinking in negative situations reduced their craving (β=.38; t36=3.01; P=.005) more than people with higher drinking in negative situations. Conclusions: The general effectiveness of SALIENCE training as an add-on therapy in reducing alcohol craving was not confirmed. Nevertheless, taking into account individual differences (gender, duration of dependence, stress, anxiety, and drinking behavior in different situations), it was shown that SALIENCE training resulted in a larger reduction in craving than without. Notably, individuals who rarely consume alcohol due to negative affect profited the most from SALIENCE training. In addition to the beneficial effect of SALIENCE training, these findings highlight the relevance of individualized therapy for AUD, adapted to personal circumstances such as drinking motivation. Trial Registration: ClinicalTrials.gov NCT03765476; https://clinicaltrials.gov/show/NCT03765476 %M 37934561 %R 10.2196/42194 %U https://formative.jmir.org/2023/1/e42194 %U https://doi.org/10.2196/42194 %U http://www.ncbi.nlm.nih.gov/pubmed/37934561 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e46368 %T Evaluation of a Virtual Reality Platform to Train Stress Management Skills for a Defense Workforce: Multisite, Mixed Methods Feasibility Study %A Kluge,Murielle G %A Maltby,Steven %A Kuhne,Caroline %A Walker,Nicole %A Bennett,Neanne %A Aidman,Eugene %A Nalivaiko,Eugene %A Walker,Frederick Rohan %+ Centre for Advanced Training Systems, Faculty of Health, Medicine & Wellbeing, The University of Newcastle, University Drive, Callaghan, 2300, Australia, 61 024921 5012, rohan.walker@newcastle.edu.au %K virtual reality %K workplace training %K stress management %K defense %D 2023 %7 6.11.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Psychological stress-related injuries within first-responder organizations have created a need for the implementation of effective stress management training. Most stress management training solutions have limitations associated with scaled adoption within the workforce. For instance, those that are effective in civilian populations often do not align with the human performance culture embedded within first-responder organizations. Programs involving expert-led instructions that are high in quality are often expensive. Objective: This study sought to evaluate a tailored stress management training platform within the existing training schedule of the Australian Defense Force (ADF). The platform, known as Performance Edge (PE), is a novel virtual reality (VR) and biofeedback-enabled stress management skills training platform. Focusing on practical training of well-established skills and strategies, the platform was designed to take advantage of VR technology to generate an immersive and private training environment. This study aimed to assess the feasibility of delivering the VR platform within the existing group-based training context and intended training population. In this setting, the study further aimed to collect data on critical predictors of user acceptance and technology adoption in education, including perceived usability, usefulness, and engagement, while also assessing training impacts. Methods: This study used a mixed methods, multisite approach to collect observational, self-reported, and biometric data from both training staff and trainers within a real-world “on-base” training context in the ADF. Validated scales include the Presence Questionnaire and User Engagement Scale for perceived usefulness, usability, and engagement, as well as the State Mindfulness Scale and Relaxation Inventory, to gain insights into immediate training impacts for specific training modules. Additional surveys were specifically developed to assess implementation feedback, intention to use skills, and perceived training impact and value. Results: PE training was delivered to 189 ADF trainees over 372 training sessions. The platform was easy to use at an individual level and was feasible to deliver in a classroom setting. Trainee feedback consistently showed high levels of engagement and a sense of presence with the training content and environment. PE is overall perceived as an effective and useful training tool. Self-report and objective indices confirmed knowledge improvement, increased skill confidence, and increased competency after training. Specific training elements resulted in increased state mindfulness, increased physical relaxation, and reduced breathing rate. The ability to practice cognitive strategies in a diverse, private, and immersive training environment while in a group setting was highlighted as particularly valuable. Conclusions: This study found the VR-based platform (PE) to be a feasible stress management training solution for group-based training delivery in a defense population. Furthermore, the intended end users, both trainers and trainees, perceive the platform to be usable, useful, engaging, and effective for training, suggesting end-user acceptance and potential for technology adoption. %M 37930751 %R 10.2196/46368 %U https://www.jmir.org/2023/1/e46368 %U https://doi.org/10.2196/46368 %U http://www.ncbi.nlm.nih.gov/pubmed/37930751 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 10 %N %P e46959 %T Rehabilitation Supported by Immersive Virtual Reality for Adults With Communication Disorders: Semistructured Interviews and Usability Survey Study %A Vaezipour,Atiyeh %A Aldridge,Danielle %A Koenig,Sebastian %A Burns,Clare %A Baghaei,Nilufar %A Theodoros,Deborah %A Russell,Trevor %+ RECOVER Injury Research Centre, Faculty of Health and Behavioural Sciences, The University of Queensland, Surgical, Treatment and Rehabilitation Service, 296 Herston Road, Brisbane, 4029, Australia, 61 733655560, atiyeh.vaezipour@gmail.com %K communication disorders %K speech and language therapy %K rehabilitation %K virtual reality %K human-computer interaction %K technology acceptance %K acceptance %K communication %K therapy %K usefulness %K usability %K survey %K barrier %K mobile phone %D 2023 %7 31.10.2023 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Individuals who have acquired communication disorders often struggle to transfer the skills they learn during therapy sessions to real-life situations. Immersive virtual reality (VR) technology has the potential to create realistic communication environments that can be used both in clinical settings and for practice at home by individuals with communication disorders. Objective: This research aims to enhance our understanding of the acceptance, usefulness, and usability of a VR application (SIM:Kitchen), designed for communication rehabilitation. Additionally, this research aims to identify the perceived barriers and benefits of using VR technology from the perspective of individuals with acquired communication disorders. Methods: Semistructured interviews and usability surveys were conducted with 10 individuals with acquired neurogenic communication disorders aged 46-81 (mean 58, SD 9.57) years after trialing an immersive VR application. The audio-recorded interviews were transcribed and analyzed to identify themes. Results: The quantitative data regarding the usability of the system associated with participants’ immersion experience in the VR application were promising. Findings from semistructured interviews are discussed across five key thematic areas including (1) participant’s attitude toward VR, (2) perceived usefulness of the VR system, (3) perceived ease of use of the VR system, (4) their willingness to continue using VR, and (5) the factors they perceived as challenges or facilitators to adopting this VR technology. Conclusions: Overall, participants in this study found the VR experience to be enjoyable and were impressed by the realism of the VR application designed for communication rehabilitation. This study highlighted personally relevant, immersive VR interventions with different levels of task difficulty that could enhance technology uptake in the context of communication rehabilitation. However, it is essential that VR hand controller technology is refined to be more naturalistic in movement and able to accommodate user capabilities. %M 37906228 %R 10.2196/46959 %U https://rehab.jmir.org/2023/1/e46959 %U https://doi.org/10.2196/46959 %U http://www.ncbi.nlm.nih.gov/pubmed/37906228 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e48912 %T Effect of Individual Virtual Reality Cognitive Training Programs on Cognitive Function and Depression in Middle-Aged Women: Randomized Controlled Trial %A Kim,Du-Ri %A Moon,EunSoo %A Shin,Myung-Jun %A Yang,Yeong-Ae %A Park,Jong-Hwan %+ Health Convergence Medicine Laboratory, Biomedical Research Institute, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan, 49241, Republic of Korea, 82 0512407071, parkj@pusan.ac.kr %K cognitive function %K depression %K middle aged %K virtual reality %K women %D 2023 %7 25.10.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Given the increasing incidence of early-onset Alzheimer disease, strategies for early diagnosis and swift treatment interventions are crucial for mitigating cognitive problems in women and middle-aged individuals who face a high risk of cognitive impairment. Objective: This study aimed to assess the effectiveness of individual cognitive training programs based on virtual reality (VR), a nonpharmacological intervention, on cognitive function and depression in middle-aged women at risk of cognitive impairment. It used VR technology, which has recently been recognized as a promising tool. Methods: We administered a VR-based cognitive training program for 30 minutes daily, twice a week, for 12 weeks (24 sessions). This study included middle-aged women residing in older adults’ welfare facilities in G-gu, Busan, from May to August 2021. A total of 60 participants were randomly divided into the training (n=30) and control (n=30) groups. Cognitive and depressive functions were assessed using the Korean versions of the Montreal Cognitive Assessment (K-MoCA), Digit Span Test (DST), Korean-Color Word Stroop Test (K-CWST), and Short Form of the Geriatric Depression Scale (SGDS-K) before the intervention. The training group underwent a VR-based cognitive training program, whereas the control group was educated to maintain regular daily activities. The same assessments were performed 12 weeks after treatment. Results: A comparison of the mean scores before and after K-MoCA in the training group revealed a significant increase from 24.87 (SD 2.62) to 27.50 (SD 1.70; P<.01), indicating substantial cognitive improvement. Similarly, the mean DST forward scores increased significantly from 6.97 (SD 1.10) to 7.90 (SD 1.18; P<.01), suggesting enhanced short-term auditory memory and attention. The mean DST backward scores also showed a significant improvement from 4.10 (SD 0.71) to 4.77 (SD 1.2; P=.01). Notably, the mean SGDS-K scores decreased significantly from 3.97 (SD 2.51) to 2.13 (SD 1.87; P<.01), indicating a reduction in depression within the training group. Conclusions: The VR-based cognitive training programs significantly enhanced cognitive function and reduced depression in middle-aged women. Consequently, these programs are considered beneficial nonpharmacological cognitive training interventions for middle-aged women at high risk of cognitive impairment. Trial Registration: UMIN Clinical Trials Registry UMIN000049752; https://tinyurl.com/z5du989z %M 37878378 %R 10.2196/48912 %U https://mental.jmir.org/2023/1/e48912 %U https://doi.org/10.2196/48912 %U http://www.ncbi.nlm.nih.gov/pubmed/37878378 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e46243 %T Social Presence, Negative Emotions, and Self-Protective Behavioral Intentions of Nonsmokers in Response to Secondhand Smoking in Virtual Reality: Quasi-Experimental Design %A Liu,Miao %A Zhu,Yicheng %A Xu,Zihan %A Meng,Sitong %+ School of Journalism and Communication, Beijing Normal University, 19 Xinjiekou Outer St. Beijing Normal University, Haidian Dist., Beijing, 100875, China, 86 13436952270, yichengresearch@gmail.com %K virtual reality %K VR %K social presence %K emotions %K secondhand smoking %D 2023 %7 25.10.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: The application of virtual reality (VR) in health care has grown rapidly in China, where approximately half of the population is directly exposed to secondhand smoke (SHS). As VR headsets have become increasingly popular and short video platforms have incorporated 360° videos in China, new formats and opportunities for health campaigns about SHS have emerged. Objective: In a simulated environment of exposure to SHS, this study aims to explore the emotional and behavioral responses to enhanced social presence brought about by VR in contrast to flat-screen videos. It also aims to examine whether and to what extent video modality (360° video vs flat-screen video) and contextual cues (high threat vs low threat) influence psychometric and intentional variables among viewers. Methods: A total of 245 undergraduate and graduate students who were nonsmokers and from a large university in China participated in this study between October 2020 and January 2021. This study created 4 different versions of a SHS experience in a café with a 2 (360° video on a head-mounted display vs flat-screen display) × 2 (high threat vs low threat) experimental design. It developed and tested a path model examining the effects of experience modality and threat levels on social presence, emotions (anger and disgust), and eventually behavioral intentions (staying away and asking for help). Results: We found that both video modality (P<.001) and threat level (P=.005) significantly influenced social presence, whereas the interaction of video modality and threat level did not have a statistically significant effect on social presence (P=.55). Negative emotions mediated the relationships between social presence and SHS-related self-protective behaviors. Specifically, anger positively predicted the intention to ask smokers to stop smoking through the waitress (P<.001). Disgust and fear both positively predicted the intention to stay away from the SHS environment (P<.001 for disgust; P=.002 for fear). Conclusions: This study explored the potential mediating mechanisms that influence individuals’ responses to the risks of SHS in public areas. The results demonstrated that social presence and negative emotions are 2 important mediators that underlie the relationship between video modality and behavioral intention regarding SHS in a VR setting. These findings suggest that an immersive environment could be a better stimulator of anti-SHS emotions and behaviors than flat-screen videos. %M 37878358 %R 10.2196/46243 %U https://games.jmir.org/2023/1/e46243 %U https://doi.org/10.2196/46243 %U http://www.ncbi.nlm.nih.gov/pubmed/37878358 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e48093 %T Digital Marker for Early Screening of Mild Cognitive Impairment Through Hand and Eye Movement Analysis in Virtual Reality Using Machine Learning: First Validation Study %A Kim,Se Young %A Park,Jinseok %A Choi,Hojin %A Loeser,Martin %A Ryu,Hokyoung %A Seo,Kyoungwon %+ Department of Applied Artificial Intelligence, Seoul National University of Science and Technology, Sangsang hall, 4th Fl., Gongneung-ro, Gongneung-dong, Nowon-gu, Seoul, 01811, Republic of Korea, 82 010 5668 8660, kwseo@seoultech.ac.kr %K Alzheimer disease %K biomarkers %K dementia %K digital markers %K eye movement %K hand movement %K machine learning %K mild cognitive impairment %K screening %K virtual reality %D 2023 %7 20.10.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: With the global rise in Alzheimer disease (AD), early screening for mild cognitive impairment (MCI), which is a preclinical stage of AD, is of paramount importance. Although biomarkers such as cerebrospinal fluid amyloid level and magnetic resonance imaging have been studied, they have limitations, such as high cost and invasiveness. Digital markers to assess cognitive impairment by analyzing behavioral data collected from digital devices in daily life can be a new alternative. In this context, we developed a “virtual kiosk test” for early screening of MCI by analyzing behavioral data collected when using a kiosk in a virtual environment. Objective: We aimed to investigate key behavioral features collected from a virtual kiosk test that could distinguish patients with MCI from healthy controls with high statistical significance. Also, we focused on developing a machine learning model capable of early screening of MCI based on these behavioral features. Methods: A total of 51 participants comprising 20 healthy controls and 31 patients with MCI were recruited by 2 neurologists from a university hospital. The participants performed a virtual kiosk test—developed by our group—where we recorded various behavioral data such as hand and eye movements. Based on these time series data, we computed the following 4 behavioral features: hand movement speed, proportion of fixation duration, time to completion, and the number of errors. To compare these behavioral features between healthy controls and patients with MCI, independent-samples 2-tailed t tests were used. Additionally, we used these behavioral features to train and validate a machine learning model for early screening of patients with MCI from healthy controls. Results: In the virtual kiosk test, all 4 behavioral features showed statistically significant differences between patients with MCI and healthy controls. Compared with healthy controls, patients with MCI had slower hand movement speed (t49=3.45; P=.004), lower proportion of fixation duration (t49=2.69; P=.04), longer time to completion (t49=–3.44; P=.004), and a greater number of errors (t49=–3.77; P=.001). All 4 features were then used to train a support vector machine to distinguish between healthy controls and patients with MCI. Our machine learning model achieved 93.3% accuracy, 100% sensitivity, 83.3% specificity, 90% precision, and 94.7% F1-score. Conclusions: Our research preliminarily suggests that analyzing hand and eye movements in the virtual kiosk test holds potential as a digital marker for early screening of MCI. In contrast to conventional biomarkers, this digital marker in virtual reality is advantageous as it can collect ecologically valid data at an affordable cost and in a short period (5-15 minutes), making it a suitable means for early screening of MCI. We call for further studies to confirm the reliability and validity of this approach. %M 37862101 %R 10.2196/48093 %U https://www.jmir.org/2023/1/e48093 %U https://doi.org/10.2196/48093 %U http://www.ncbi.nlm.nih.gov/pubmed/37862101 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45044 %T Remote Perimetry in a Virtual Reality Metaverse Environment for Out-of-Hospital Functional Eye Screening Compared Against the Gold Standard Humphrey Visual Fields Perimeter: Proof-of-Concept Pilot Study %A Wong,Kang-An %A Ang,Bryan Chin Hou %A Gunasekeran,Dinesh Visva %A Husain,Rahat %A Boon,Joewee %A Vikneson,Krishna %A Tan,Zyna Pei Qi %A Tan,Gavin Siew Wei %A Wong,Tien Yin %A Agrawal,Rupesh %+ National University of Singapore, 10 Medical Drive, Singapore, 117597, Singapore, 65 67723737, dineshvg@hotmail.sg %K eye %K screening %K glaucoma %K virtual reality %K metaverse %K digital health %K virtual reality %K visual impairment %K visually impaired %K functional testing %K ophthalmologic %K ophthalmology %K remote care %K visual field %K HVF %K perimetry test %D 2023 %7 19.10.2023 %9 Research Letter %J J Med Internet Res %G English %X Background: The growing global burden of visual impairment necessitates better population eye screening for early detection of eye diseases. However, accessibility to testing is often limited and centralized at in-hospital settings. Furthermore, many eye screening programs were disrupted by the COVID-19 pandemic, presenting an urgent need for out-of-hospital solutions. Objective: This study investigates the performance of a novel remote perimetry application designed in a virtual reality metaverse environment to enable functional testing in community-based and primary care settings. Methods: This was a prospective observational study investigating the performance of a novel remote perimetry solution in comparison with the gold standard Humphrey visual field (HVF) perimeter. Subjects received a comprehensive ophthalmologic assessment, HVF perimetry, and remote perimetry testing. The primary outcome measure was the agreement in the classification of overall perimetry result normality by the HVF (Swedish interactive threshold algorithm–fast) and testing with the novel algorithm. Secondary outcome measures included concordance of individual testing points and perimetry topographic maps. Results: We recruited 10 subjects with an average age of 59.6 (range 28-81) years. Of these, 7 (70%) were male and 3 (30%) were female. The agreement in the classification of overall perimetry results was high (9/10, 90%). The pointwise concordance in the automated classification of individual test points was 83.3% (8.2%; range 75%-100%). In addition, there was good perimetry topographic concordance with the HVF in all subjects. Conclusions: Remote perimetry in a metaverse environment had good concordance with gold standard perimetry using the HVF and could potentially avail functional eye screening in out-of-hospital settings. %M 37856179 %R 10.2196/45044 %U https://www.jmir.org/2023/1/e45044 %U https://doi.org/10.2196/45044 %U http://www.ncbi.nlm.nih.gov/pubmed/37856179 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e49080 %T Effects of Virtual Reality Pilates Training on Duration of Posture Maintenance and Flow in Young, Healthy Individuals: Randomized Crossover Trial %A Park,Sung Je %A Lee,Jea Woog %+ Intelligence Information Processing Lab, Chung-Ang University, 84, Heukseok-ro, Dongjak-gu, Seoul, 06974, Republic of Korea, 82 010 5426 7318, yyizeuks@cau.ac.kr %K virtual reality %K Pilates %K exercise program %K flow %K duration of posture maintenance %K sport video data analytics %K video %K data analytics %K sport %K sports %K exercise %K physical activity %K posture %K VR %K balance %K movement %K self-reported %K patient reported %D 2023 %7 19.10.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: This study explored the use of virtual reality (VR) technology to enhance the effectiveness and duration of low-intensity movements and postures in Pilates-derived exercises. We postulate that by leveraging the flow state in VR, individuals can engage in these exercises for longer periods while maintaining a high level of flow. Objective: The purpose of this study was to compare differences in posture maintenance and flow between VR Pilates training and conventional Pilates training, and the correlation between the 2 factors. Methods: The 18 participants in each group received either VR training or conventional training and were switched to the other training type after a 2-day wash-out period. Each group performed Pilates movements in a VR environment and a conventional environment, divided into 4 types. After training sessions, participants were evaluated for flow using a self-report questionnaire. In addition, a sports video analysis program was used to measure the duration of posture maintenance in 2 video-recorded sessions. Repeated-measures ANOVA and correlation analysis were performed on the measured duration of posture maintenance and flow scores. In all cases, the statistical significance level was set at P<.05. Results: Results for the duration of posture maintenance verification by type showed that simple behavior (F1,16=17.631; P<.001), upper body–arm coordination behavior (F1,16=6.083; P=.04), upper body–leg coordination behavior (F1,16=8.359; P<.001), and whole-body coordination behavior (F1,16=8.426; P<.001) all showed an interaction effect at P<.05. Flow (F1,16=15.250; P<.001) also showed an interaction effect. In addition, significant correlations were determined between duration of all types of posture maintenance and flow in the VR training group at P<.05. Conclusions: Our results indicate that VR Pilates training may be more useful than conventional Pilates training in improving the duration of posture maintenance and that it promotes a significantly higher degree of flow when compared with conventional Pilates training. %M 37856178 %R 10.2196/49080 %U https://games.jmir.org/2023/1/e49080 %U https://doi.org/10.2196/49080 %U http://www.ncbi.nlm.nih.gov/pubmed/37856178 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e46209 %T Virtual Reality Meditation for Fatigue in Persons With Rheumatoid Arthritis: Mixed Methods Pilot Study %A Dreesmann,Nathan J %A Buchanan,Diana %A Tang,Hsin-Yi Jean %A Furness III,Thomas %A Thompson,Hilaire %+ Virtual Therapeutics, 13905 NE 128th St, Suite 200, Kirkland, WA, 98034, United States, 1 (425) 821 8001, nathan.dreesmann@vthera.com %K anxiety %K chronic pain %K depression %K fatigue %K feasibility study %K feasibility %K head-mounted display %K meditation %K mixed method %K mood %K pain %K rheumatoid arthritis %K symptom %K virtual reality %K VR %D 2023 %7 17.10.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Effective symptom management is crucial to enhancing the quality of life for individuals with chronic diseases. Health care has changed markedly over the past decade as immersive, stand-alone, and wearable technologies including virtual reality have become available. One chronic pain population that could benefit from such an intervention is individuals with rheumatoid arthritis (RA). Recent pharmacologic advances in the management of RA have led to a decrease in inflammatory symptoms (eg, chronic pain) or even disease remission, yet up to 70% of patients with RA still suffer from fatigue. While VR-delivered behavior, meditation, and biofeedback programs show promise for pain and anxiety management, there is little information on the use of virtual reality meditation (VRM) for fatigue management among individuals with RA. Objective: This study aims to (1) examine the feasibility of implementing a study protocol that uses VRM, (2) determine the acceptability of using VRM for fatigue management in an outpatient population, and (3) identify barriers and contextual factors that might impact VRM use for fatigue management in outpatients with RA. Methods: We used a convergent, mixed methods design and enrolled adults aged 18 years or older with a clinical diagnosis of RA. Patient-Reported Outcome Measure Information System (PROMIS) measures of fatigue, depression, anxiety, pain behavior, and physical function were assessed alongside the brief mood introspection scale at baseline and weekly for 4 weeks. VRM use across the 4-week study period was automatically stored on headsets and later extracted for analysis. Semistructured interview questions focused on feedback regarding the participant’s experience with RA, previous experience of fatigue, strategies participants use for fatigue management, and the participant’s experience using VRM and recommendations for future use. Results: A total of 13 participants completed this study. Most participants completed all study surveys and measures (11/13, 84% and 13/13, 100%, respectively) and were active participants in interviews at the beginning and end of the program. Participants used VRM an average of 8.9 (SD 8.5) times over the course of the 4-week program. Most participants enjoyed VRM, found it relaxing, or recommended its use (12/13, 92%), but 8 (62%) noted barriers and conceptual factors that impacted VRM use. On average, participants saw decreases in PROMIS fatigue (–6.4, SD 5.1), depression (–5.6, SD 5.7), anxiety (–4.5, SD 6), and pain behavior (–3.9, SD 5.3), and improvements in PROMIS physical function (1.5, SD 2.7) and Brief Mood Introspection Scale mood (5.3, SD 6.7) over the course of this 4-week study. Conclusions: While this study’s implementation was feasible, VRM’s acceptability as an adjunctive modality for symptom management in RA is contingent on effectively overcoming barriers to use and thoughtfully addressing the contextual factors of those with RA to ensure successful intervention deployment. Trial Registration: ClinicalTrials.gov NCT04804462; https://classic.clinicaltrials.gov/ct2/show/NCT04804462 %M 37847542 %R 10.2196/46209 %U https://formative.jmir.org/2023/1/e46209 %U https://doi.org/10.2196/46209 %U http://www.ncbi.nlm.nih.gov/pubmed/37847542 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e42025 %T An Exposure-Based Video Game (Dr. Zoo) to Reduce Needle Phobia in Children Aged 3 to 6 Years: Development and Mixed Methods Pilot Study %A Healy,Pat %A Lu,Celine %A Silk,Jennifer S %A Lindhiem,Oliver %A Harper,Reagan %A Viswanathan,Abhishek %A Babichenko,Dmitriy %+ University of Pittsburgh, School of Computing and Information, 135 N. Bellefield Avenue, Pittsburgh, PA, 15213, United States, 1 (412) 624 5015, pat.healy@pitt.edu %K needle phobia %K serious games %K children %K exposure therapy %K cognitive behavioral therapy %K anxiety %K mobile phone %D 2023 %7 16.10.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Needle phobia, which affects 19% of children aged 4 to 6 years, prevents many children from receiving necessary or preventive medical treatments. Digital interventions have been made to target needle phobia but currently rely on distraction rather than evidence-based exposure. Objective: We designed and evaluated a serious exposure-based mobile game called Dr. Zoo to reduce the fear of needles in children aged 3 to 6 years, where players administered shots to cartoon animals. Methods: We conducted a mixed methods study with 30 parents (mean age 35.87, SD 4.39 years) and their 36 children (mean age 4.44, SD 1.11 years) who played the game for 5 days leading to a scheduled appointment that included an injection (eg, influenza vaccination). After the study, parents completed exit surveys and participated in semistructured interviews to evaluate ease of use, acceptability, and preliminary effectiveness of the game and to provide insights on their experience with the game to inform future developments. Interview transcripts were analyzed by 3 independent coders following an open coding process and subsequently coded and discussed to reach consensus. Results: Parents rated their child’s difficulty in completing the game as very low on average (scale 1-5; mean 1.76, SD 0.82) and were highly likely to recommend Dr. Zoo to other parents (scale 1-5; mean 4.41, SD 0.87), suggesting Dr. Zoo’s strong ease of use and high acceptability. In the exit survey, parents rated their child’s fear as significantly lower after participating in the study (scale 1-5; mean 3.09, SD 1.17) compared with that before participating (scale 1-5; mean 4.37, SD 0.81; z score=−4.638; P<.001). Furthermore, 74% (26/35) of the parents reported that the game had a positive impact on their child’s fear or perception of needles (only 2 parents reported a negative impact). Qualitative analysis of the interview transcripts revealed potentially important features of the game in this positive impact, such as the game’s interactive design, as observed in 69% (24/35) of our participants. Conclusions: The results suggest that an evidence-based serious mobile game can be an easy-to-use, acceptable, and potentially effective intervention for changing young children’s fear and perceptions of needles. Leveraging digital interventions may be a potential solution to needle anxiety as a public health concern. %M 37843885 %R 10.2196/42025 %U https://games.jmir.org/2023/1/e42025 %U https://doi.org/10.2196/42025 %U http://www.ncbi.nlm.nih.gov/pubmed/37843885 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e47443 %T Patient Perceptions of In Vivo Versus Virtual Reality Exposures for the Treatment of Anxiety Disorders: Cross-Sectional Survey Study %A Levy,Amanda N %A Nittas,Vasileios %A Wray,Tyler B %+ Department of Computer Science, Brown University, 115 Waterman St, Providence, RI, 02906, United States, 1 401 863 7600, amanda_levy@brown.edu %K counseling treatment %K phobias %K PTSD %K patient perspective %K in vivo exposures %K virtual reality %K exposure therapy %K anxiety %K psychotherapy %K effectiveness %K digital therapy %K affective disorders %D 2023 %7 16.10.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Psychotherapy, and particularly exposure therapy, has been proven to be an effective treatment for many anxiety disorders, including social and specific phobias, as well as posttraumatic stress disorders. Currently, exposures are underused and mostly delivered in vivo. Virtual reality exposure therapy (VRET) offers a more flexible delivery mechanism that has the potential to address some of the implementation barriers of in vivo exposures while retaining effectiveness. Yet, there is little evidence on how patients perceive different exposure therapy methods. Objective: This study aims to explore the perceptions of individuals with anxiety disorders toward in vivo and VRET. Our findings can inform therapists about the degree of patient interest in both methods while exploring the demand for VRET as an alternative and novel treatment approach. Methods: Web-based survey assessing the (1) interest in, (2) willingness to use, (3) comfort with, (4) enthusiasm toward, and (5) perceived effectiveness of exposure therapy when delivered in vivo and through VR. Participants included individuals with specific phobia, social phobia, posttraumatic stress disorder, or acute stress disorder or reaction. Participants were presented with educational videos about in vivo and VRET and asked to provide their perceptions quantitatively and qualitatively through a rated scale and free-text responses. Results: In total, 184 surveys were completed and analyzed, in which 82% (n=151) of participants reported being willing to receive in vivo exposures and 90.2% (n=166) reported willingness to receive VRET. Participants reported higher interest in, comfort with, enthusiasm toward, and perceived effectiveness of VRET compared to in vivo. Most reported in vivo concerns were linked to (1) increased anxiety, (2) feelings of embarrassment or shame, and (3) exacerbation of current condition. Most reported VRET concerns were linked to (1) risk of side effects including increased anxiety, (2) efficacy uncertainty, and (3) health insurance coverage. The most frequently mentioned VRET benefits include (1) privacy, (2) safety, (3) the ability to control exposures, (4) comfort, (5) the absence of real-life consequences, (6) effectiveness, and (7) customizability to a wider variety of exposures. Conclusions: On average, our participants expressed positive perceptions toward exposure therapy, with slightly more positive perceptions of VRET over in vivo exposures. Despite valid personal concerns and some misconceptions, our findings emphasize that VRET provides an opportunity to get much-needed therapy to patients in ways that are more acceptable and less concerning. %M 37843884 %R 10.2196/47443 %U https://formative.jmir.org/2023/1/e47443 %U https://doi.org/10.2196/47443 %U http://www.ncbi.nlm.nih.gov/pubmed/37843884 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e45539 %T The Application of Fully Immersive Virtual Reality on Reminiscence Interventions for Older Adults: Scoping Review %A Lu,Zhipeng %A Wang,Wenjin %A Yan,Wei %A Kew,Chung Lin %A Seo,Jinsil Hwaryoung %A Ory,Marcia %+ Department of Architecture, Texas A&M University, 3137 TAMU, College Station, TX, 77845, United States, 1 9798456183, luzhipeng@live.com %K older adults %K fully immersive virtual reality %K reminiscence %K Alzheimer %K cognitive function %K mental health %K psychological well-being %K memory care %K dementia %K scoping review %D 2023 %7 6.10.2023 %9 Review %J JMIR Serious Games %G English %X Background: The increasing number of older adults with mental, behavioral, and memory challenges presents significant public health concerns. Reminiscence is one type of nonpharmacological intervention that can effectively evoke memories, stimulate mental activities, and improve psychological well-being in older adults through a series of discussions on previous experiences. Fully immersive virtual reality (FIVR) may be a useful tool for reminiscence interventions because it uses realistic virtual environments connected to a person’s significant past stories. Objective: This review aims to examine empirical evidence regarding the application of FIVR in reminiscence interventions, its usability and acceptability, and its effectiveness in assisting the intervention to achieve optimal outcomes. Methods: We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach for scoping reviews. The PubMed, PsycINFO, Embase, CINAHL, Web of Science, ACM, and IEEE Xplore electronic databases were used for the search. We included peer-reviewed studies that used FIVR as an assistive tool for reminiscence interventions; were published between January 1, 2000, and August 1, 2022; reported empirical research; involved older adults as participants; and addressed health- and behavior-related outcomes or the feasibility and usability of FIVR. We used Endnote X9 to organize the search results and Microsoft Excel for data extraction and synthesis. Results: Of the 806 articles collected from the databases and other resources, 11 were identified. Most of the studies involved participants aged between 70 and 90 years. Only 1 study did not involve those with cognitive impairments, whereas 3 specifically targeted people living with dementia. The results indicated that FIVR reminiscence interventions enhanced engagement and reduced fatigue. Although some studies have observed positive effects on anxiety, apathy, depression, cognitive functions, and caregiver burden reduction, these findings were inconsistent across other research. In addition, FIVR showed overall usability and acceptability with manageable side effects among older adults across various health conditions during reminiscence sessions. However, 1 study reported adverse feelings among participants, triggered by unpleasant memories evoked by the virtual reality content. Conclusions: The role of FIVR in reminiscence interventions remains nascent, with limited studies evaluating its impacts on older adults. Many of the reviewed studies had notable limitations: small sample sizes, absence of rigorous research design, limited assessment of long-term effects, lack of measures for health and behavior outcomes, and quality of life. Beyond these limitations, this review identified a list of future research directions in 6 categories. On the basis of the review findings, we provide practical recommendations to enhance FIVR reminiscence interventions, covering topics such as virtual reality content, device choice, intervention types, and the role and responsibility of facilitators. %M 37801360 %R 10.2196/45539 %U https://games.jmir.org/2023/1/e45539 %U https://doi.org/10.2196/45539 %U http://www.ncbi.nlm.nih.gov/pubmed/37801360 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e50492 %T Serious Game for Fine Motor Control Rehabilitation for Children With Epileptic Encephalopathy: Development and Usability Study %A Vidal,Elizabeth %A Castro-Gutierrez,Eveling %A Arisaca,Robert %A Paz-Valderrama,Alfredo %A Albiol-Pérez,Sergio %+ Universidad Nacional de San Agustín de Arequipa, Av. Venezuela s/n, Arequipa, 54, Peru, 51 986451412, evidald@unsa.edu.pe %K serious game %K virtual motor rehabilitation %K ecologic virtual system %K fine motor rehabilitation %K virtual reality %K rare diseases %K children with epileptic encephalopathy %D 2023 %7 3.10.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Epileptic encephalopathy (EE) is defined as the presence of frequent epileptiform activity that adversely impacts development, typically causing the slowing or regression of developmental skills, and is usually associated with frequent seizures. One of the main disturbances in EE is in the coordination of the upper extremities and hands. Traditional rehabilitation for this type of pathology focuses on the alleviation of gross or fine motor disability. In the last few years, the use of low-cost devices together with customized serious games has shown improvements in motor disorders and enrichments in activities of daily living. Objective: This study aims to explore the feasibility of a new serious game for improving fine motor control in children with EE. Methods: The participants were 4 children with EE (male: n=2, 50%; female: n=2, 50%) who were classified as belonging to level 1 in the Gross Motor Classification System. The children were tested over 10 sessions during the intervention period (before and after treatment). The clinical tests performed were the Bruininks-Oseretsky Test of Motor Proficiency, 2nd edition and Pittsburgh Rehabilitation Participation Scale. The subscales of the Bruininks-Oseretsky Test of Motor Proficiency, 2nd edition were fine motor precision, fine motor integration, manual dexterity, and upper-limb coordination. At the end of the first session, we used the User Satisfaction Evaluation Questionnaire to analyze user satisfaction. Results: The significance outcomes for a Student t test (1-tailed) were as follows: P=.009 for fine motor precision, P=.002 for fine motor integration, P=.56 for manual dexterity, and P=.99 for upper-limb coordination. The participation rate as measured using the Pittsburgh Rehabilitation Participation Scale was between good and very good, which means that, based on the therapist’s evaluation, interest, independence, and motivation were achieved by each participant. The mean User Satisfaction Evaluation Questionnaire score was close to 30, which is the maximum value. Conclusions: The results support the use of the proposed serious game as a complement in therapeutic sessions during the rehabilitation processes for children with EE. Significant improvements in fine motor control and activities of daily living revealed that the proposed serious game is beneficial for fine motor disorders of this pathology. %M 37788071 %R 10.2196/50492 %U https://formative.jmir.org/2023/1/e50492 %U https://doi.org/10.2196/50492 %U http://www.ncbi.nlm.nih.gov/pubmed/37788071 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e47617 %T Individualized Virtual Reality for Increasing Self-Compassion: Evaluation Study %A Halim,Ilona %A Stemmet,Lehan %A Hach,Sylvia %A Porter,Richard %A Liang,Hai-Ning %A Vaezipour,Atiyeh %A Henry,Julie D %A Baghaei,Nilufar %+ School of Electrical Engineering and Computer Science, The University of Queensland, Staff House Road, St Lucia, 4072, Australia, 61 450150234, n.baghaei@uq.edu.au %K individualized virtual reality %K mental health %K self-compassion %K depression %K depressive symptoms %K mobile phone %D 2023 %7 2.10.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depression and anxiety are common and debilitating mental disorders with severe negative repercussions at both individual and societal levels. Although virtual reality (VR) has emerged as a safe and effective tool for the treatment of anxiety disorders, studies of the therapeutic application of VR to treat depression are more limited. Objective: The purpose of this study was to test whether a novel type of individualized VR (iVR) can be used to improve self-compassion and decrease depressive symptoms and to evaluate the usability and acceptability of this approach, as rated by participants. The iVR system was designed and developed based on the feedback obtained from a previous study, with improved appearance and feel of the avatar and enhanced graphical quality. Methods: A total of 36 young adult participants were recruited from a university community social media site. Participants were aware that the study was investigating a treatment for depression but were not recruited based on depression diagnosis. Participants were asked to complete 2 iVR sessions, spaced 2 weeks apart. At baseline and upon completion of each iVR session, participants were asked to complete validated measures of self-compassion and depression. Upon completion of both iVR sessions, additional measures were administered to assess participants’ perceptions about the perceived usability and system acceptability of the iVR approach. Results: Self-compassion was assessed at the beginning of session 1 (preintervention baseline) and at the end of session 1 (postintervention assessment). Owing to COVID-19 constraints, 36% (13/36) of the participants were unable to complete the follow-up iVR session. Self-compassion was assessed again for the remaining 64% (23/36) of the participants at the end of session 2 (postintervention assessment). Within-group analyses revealed that self-compassion was significantly increased at the end of both session 1 (P=.01) and session 2 (P=.03) relative to baseline. There was also a nonsignificant trend for depressive symptoms to be low at the end of session 2 relative to baseline. Both quantitative and qualitative participant data supported the iVR approach as being acceptable and usable. Conclusions: Although these data must be treated as preliminary owing to the small sample size and potential selection bias, the data provide encouraging initial evidence that iVR might be a useful tool to enhance self-compassion and reduce depressive symptoms, highlighting the need for randomized controlled trials in the future. %M 37782537 %R 10.2196/47617 %U https://mental.jmir.org/2023/1/e47617 %U https://doi.org/10.2196/47617 %U http://www.ncbi.nlm.nih.gov/pubmed/37782537 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e47228 %T Usability of Augmented Reality Technology in Situational Telementorship for Managing Clinical Scenarios: Quasi-Experimental Study %A Bui,Dung T %A Barnett,Tony %A Hoang,Ha %A Chinthammit,Winyu %+ Centre for Rural Health, School of Health Sciences, College of Health and Medicine, University of Tasmania, E Block, Newnham Campus, Launceston, 7248, Australia, 61 363243318, dungtrung.bui@utas.edu.au %K augmented reality %K mentorship %K patient simulation %K patient care management %K quasi-experimental study %K telehealth %D 2023 %7 2.10.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Telementorship provides a way to maintain the professional skills of isolated rural health care workers. The incorporation of augmented reality (AR) technology into telementoring systems could be used to mentor health care professionals remotely under different clinical situations. Objective: This study aims to evaluate the usability of AR technology in telementorship for managing clinical scenarios in a simulation laboratory. Methods: This study used a quasi-experimental design. Experienced health professionals and novice health practitioners were recruited for the roles of mentors and mentees, respectively, and then trained in the use of the AR setup. In the experiment, each mentee wearing an AR headset was asked to respond to 4 different clinical scenarios: acute coronary syndrome (ACS), acute myocardial infarction (AMI), pneumonia severe reaction to antibiotics (PSRA), and hypoglycemic emergency (HE). Their mentor used a laptop to provide remote guidance, following the treatment protocols developed for each scenario. Rating scales were used to measure the AR’s usability, mentorship effectiveness, and mentees’ self-confidence and skill performance. Results: A total of 4 mentors and 15 mentees participated in this study. Mentors and mentees were positive about using the AR technology, despite some technical issues and the time required to become familiar with the technology. The positive experience of telementorship was highlighted (mean 4.8, SD 0.414 for mentees and mean of 4.25, SD 0.5 for mentors on the 5-point Likert scale). Mentees’ confidence in managing each of the 4 scenarios improved after telementoring (P=.001 for the ACS, AMI, and PSRA scenarios and P=.002 for the HE scenario). Mentees’ individual skill performance rates ranged from 98% in the ACS scenario to 97% in the AMI, PSRA, and HE scenarios. Conclusions: This study provides evidence about the usability of AR technology in telementorship for managing clinical scenarios. The findings suggest the potential for this technology to be used to support health workers in real-world clinical environments and point to new directions of research. %M 37782533 %R 10.2196/47228 %U https://mededu.jmir.org/2023/1/e47228 %U https://doi.org/10.2196/47228 %U http://www.ncbi.nlm.nih.gov/pubmed/37782533 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 10 %N %P e47114 %T Virtual Reality for Pulmonary Rehabilitation: Comprehensive Review %A Pittara,Melpo %A Matsangidou,Maria %A Pattichis,Constantinos S %+ Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, Nijenborgh 4 9747 AG Groningen, Groningen, , Netherlands, 31 050 363 9111, melpopittara@gmail.com %K breathing exercise %K breathing exercise gaming %K pulmonary rehabilitation %K respiratory biofeedback %K virtual reality %D 2023 %7 2.10.2023 %9 Review %J JMIR Rehabil Assist Technol %G English %X Background: Pulmonary rehabilitation is a vital component of comprehensive care for patients with respiratory conditions, such as lung cancer, chronic obstructive pulmonary disease, and asthma, and those recovering from respiratory diseases like COVID-19. It aims to enhance patients’ functional ability and quality of life, and reduce symptoms, such as stress, anxiety, and chronic pain. Virtual reality is a novel technology that offers new opportunities for customized implementation and self-control of pulmonary rehabilitation through patient engagement. Objective: This review focused on all types of virtual reality technologies (nonimmersive, semi-immersive, and fully immersive) that witnessed significant development and were released in the field of pulmonary rehabilitation, including breathing exercises, biofeedback systems, virtual environments for exercise, and educational models. Methods: The review screened 7 electronic libraries from 2010 to 2023. The libraries were ACM Digital Library, Google Scholar, IEEE Xplore, MEDLINE, PubMed, Sage, and ScienceDirect. Thematic analysis was used as an additional methodology to classify our findings based on themes. The themes were virtual reality training, interaction, types of virtual environments, effectiveness, feasibility, design strategies, limitations, and future directions. Results: A total of 2319 articles were identified, and after a detailed screening process, 32 studies were reviewed. Based on the findings of all the studies that were reviewed (29 with a positive label and 3 with a neutral label), virtual reality can be an effective solution for pulmonary rehabilitation in patients with lung cancer, chronic obstructive pulmonary disease, and asthma, and in individuals and children who are dealing with mental health–related disorders, such as anxiety. The outcomes indicated that virtual reality is a reliable and feasible solution for pulmonary rehabilitation. Interventions can provide immersive experiences to patients and offer tailored and engaging rehabilitation that promotes improved functional outcomes of pulmonary rehabilitation, breathing body awareness, and relaxation breathing techniques. Conclusions: The identified studies on virtual reality in pulmonary rehabilitation showed that virtual reality holds great promise for improving the outcomes and experiences of patients. The immersive and interactive nature of virtual reality interventions offers a new dimension to traditional rehabilitation approaches, providing personalized exercises and addressing psychological well-being. However, additional research is needed to establish standardized protocols, identify the most effective strategies, and evaluate long-term benefits. As virtual reality technology continues to advance, it has the potential to revolutionize pulmonary rehabilitation and significantly improve the lives of patients with chronic lung diseases. %M 37782529 %R 10.2196/47114 %U https://rehab.jmir.org/2023/1/e47114 %U https://doi.org/10.2196/47114 %U http://www.ncbi.nlm.nih.gov/pubmed/37782529 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e46964 %T Comparing the Outcomes of Virtual Reality–Based Serious Gaming and Lecture-Based Training for Advanced Life Support Training: Randomized Controlled Trial %A Aksoy,Mehmet Emin %A Özkan,Arun Ekin %A Kitapcioglu,Dilek %A Usseli,Tuba %+ Department of Biomedical Device Technology, Center of Advanced Simulation and Education, Acibadem Mehmet Ali Aydinlar University, Kayisdagi cad No: 32, Istanbul, 34752, Turkey, 90 5052685158, dreminaksoy@gmail.com %K Advanced Cardiac Life Support %K virtual reality %K serious game %K randomized controlled trial %K Advanced Life Support %D 2023 %7 28.9.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Simulation-based Advanced Cardiac Life Support (ACLS) or Advanced Life Support (ALS) training for health care professionals is important worldwide for saving lives. Virtual reality (VR)–based serious gaming can be an alternative modality to be used as a part of simulation-based ALS training. Objective: The aim of this study is to investigate whether a VR-based ALS serious game module can replace classroom-based ALS lectures, the latter being part of existing conventional ALS training protocols in addition to skills training. Methods: Participants were students from Acibadem Mehmet Ali Aydinlar University’s Vocational School for Anesthesiology (N=29) randomly divided into 2 groups with 15 (conventional training group) and 14 (VR-based training group) participants each. Participants in the conventional training group had to complete the pretest consisting of multiple-choice questions at the beginning of the study. Afterward, they took part in an interactive classroom-based ALS lecture. The next step involved skills training with task trainers to teach them compression skills. Following this, the conventional training group was divided into Code Blue teams, each consisting of 5 participants for the simulation session. Two independent instructors evaluated video recordings in terms of technical and nontechnical skills. The score acquired from the manikin-based simulation session was considered the main performance indicator in this study to measure the learning outcome. A similar workflow was used for the VR-based training group, but this group was trained with the VR-based ALS serious game module instead of the theoretical lecture. The final stage of the study involved completing the posttest consisting of multiple-choice questions. A preference survey was conducted among the study participants. Mann-Whitney U and Wilcoxon signed-rank tests were used to analyze the 2 groups’ performances in this study. Results: The improvement in posttest results compared with pretest results was significant in the conventional training group (P=.002). Hands-on technical scores of the conventional training group were higher than those of the VR-based training group during manikin-based simulation, but total scores, including those for technical and crisis resource management skills, acquired from the manikin-based simulation session did not reveal any significant difference between the 2 groups. The results of the VR preference survey revealed that the majority of the participants prefer VR-based serious game–based training instead of classroom lectures. Conclusions: Although hands-on technical scores of the conventional training group during the manikin-based simulation session were higher than those of the VR-based training group, both groups’ total performance scores, including those for technical and crisis resource management skills, did not differ significantly. The preference survey reveals that the majority of the participants would prefer a VR-based ALS serious gaming module instead of lecture-based training. Further studies are required to reveal the learning outcome of VR-based ALS serious gaming. Trial Registration: ClinicalTrials.gov NCT05798910; https://clinicaltrials.gov/study/NCT05798910 %M 37768719 %R 10.2196/46964 %U https://games.jmir.org/2023/1/e46964 %U https://doi.org/10.2196/46964 %U http://www.ncbi.nlm.nih.gov/pubmed/37768719 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 12 %N %P e45433 %T Development of a Core Set of Quality Criteria for Virtual Reality Applications Designed for Older Adults: Multistep Qualitative Study %A Napetschnig,Alina %A Brixius,Klara %A Deiters,Wolfgang %+ Department of Community Health, Hochschule für Gesundheit Bochum, Gesundheitscampus 6-8, Bochum, 44801, Germany, 49 234 77727 764, alina.napetschnig@gmail.com %K virtual reality %K older adults %K quality criteria %K user-centered %D 2023 %7 27.9.2023 %9 Original Paper %J Interact J Med Res %G English %X Background: Virtual reality (VR) applications are gaining growing significance, particularly among older adults. These applications can provide valuable support to older adults by offering immersive VR content that positively influences various aspects of their daily lives, including activities of daily living. Furthermore, VR applications can contribute to the enhancement of cognitive and motor skills, ultimately leading to an improved quality of life for older individuals. Nevertheless, to ensure a positive impact, it is crucial to develop VR experiences that are tailored to the needs and preferences of the users. Objective: This study aims to develop a core set of quality criteria and guidelines for the development of user-centered VR applications specifically designed for older adults (target group). Methods: The multistep qualitative study design comprised several key stages, beginning with a systematic literature search. This was followed by a framework analysis aimed at identifying a core set of criteria. Subsequently, these criteria underwent validation through expert workshops. The outcomes achieved through this iterative process were organized and categorized into criteria, accompanied by explanations detailing the underlying categories or codes. Results: The quality criteria core set for older adults–friendly VR applications has been developed through an iterative process. It is divided into 2 distinct parts, each containing criteria categorized into specific areas. The first part includes the following categories: (1) quality assurance of medical/health content, (2) data protection provisions, (3) quality requirements, (4) consumer protection, and (5) interoperability. The second part includes the following categories: (1) graphic/quality, (2) 3D character/avatar, (3) providing in-game instructions and prompts, (4) interaction, (5) navigation, and (6) promotion of user motivation and loyalty to use. The results imply a differentiated scope as well as a differentiated granularity of the criteria. Conclusions: Considering the ongoing advancement of VR technology and the diverse needs within the older adult demographic, it is essential to assess the quality criteria core set results on an individual basis. %M 37756112 %R 10.2196/45433 %U https://www.i-jmr.org/2023/1/e45433 %U https://doi.org/10.2196/45433 %U http://www.ncbi.nlm.nih.gov/pubmed/37756112 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e42117 %T Using Augmented Reality Toward Improving Social Skills: Scoping Review %A Mittmann,Gloria %A Zehetner,Vanessa %A Hoehl,Stefanie %A Schrank,Beate %A Barnard,Adam %A Woodcock,Kate %+ School of Psychology, University of Birmingham, 52 Pritchatts Road, Birmingham, B15 2SA, United Kingdom, 44 121 414 6036, papers@katewoodcock.com %K virtual reality %K serious games %K autism spectrum disorder %K social learning %K communication %K cooperation %K mobile phone %D 2023 %7 20.9.2023 %9 Review %J JMIR Serious Games %G English %X Background: Augmented reality (AR) has emerged as a promising technology in educational settings owing to its engaging nature. However, apart from applications aimed at the autism spectrum disorder population, the potential of AR in social-emotional learning has received less attention. Objective: This scoping review aims to map the range of AR applications that improve social skills and map the characteristics of such applications. Methods: In total, 2 independent researchers screened 2748 records derived from 3 databases in December 2021—PubMed, IEEE Xplore, and ACM Guide to Computing Literature. In addition, the reference lists of all the included records and existing reviews were screened. Records that had developed a prototype with the main outcome of improving social skills were included in the scoping review. Included records were narratively described for their content regarding AR and social skills, their target populations, and their outcomes. Evaluation studies were assessed for methodological quality. Results: A total of 17 records met the inclusion criteria for this study. Overall, 10 records describe applications for children with autism, primarily teaching about reading emotions in facial expressions; 7 records describe applications for a general population, targeting both children and adults, with a diverse range of outcome goals. The methodological quality of evaluation studies was found to be weak. Conclusions: Most applications are designed to be used alone, although AR is well suited to facilitating real-world interactions during a digital experience, including interactions with other people. Therefore, future AR applications could endorse social skills in a general population in more complex group settings. %M 37728971 %R 10.2196/42117 %U https://games.jmir.org/2023/1/e42117 %U https://doi.org/10.2196/42117 %U http://www.ncbi.nlm.nih.gov/pubmed/37728971 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e48208 %T Effectiveness of Social Virtual Reality Training in Enhancing Social Interaction Skills in Children With Attention-Deficit/Hyperactivity Disorder: Protocol for a Three-Arm Pilot Randomized Controlled Trial %A Wong,Ka Po %A Qin,Jing %+ Department of Applied Social Sciences, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China (Hong Kong), 852 64860214, wongkapoportia@gmail.com %K attention-deficit/hyperactivity disorder %K social interaction skills %K executive functioning %K emotional control %K 3-arm randomized controlled trial %K ADHD %K attention deficit %K hyperactive %K hyperactivity %K randomized %K RCT %K social interaction %K social interactions %K social skills %K child %K children %K youth %K pediatric %K pediatrics %K VR %K virtual reality %K childhood %K neurodevelopmental %D 2023 %7 18.9.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Children with ADHD have challenges in understanding social cues and behavioral problems when entering a social setting. Virtual reality (VR) has been applied to improve cognitive behaviors in children with ADHD. Previous studies have not adopted VR to improve social interaction competence and appropriateness in children with ADHD. VR offers a more effective alternative to therapeutic strategies for children with ADHD. Objective: This study aims to examine the feasibility and effectiveness of social VR training in enhancing social interaction skills compared to traditional social skills training in children with ADHD. We hypothesize that participants in the social VR training group are likely to perform better on social interaction skills than those in the traditional social skills training group. Methods: In this nonblinded, 3-arm randomized controlled trial (RCT), 90 participants with ADHD recruited from the community will be randomized 1:1:1 to the social VR intervention group, traditional social skills training group, or waitlist control group. The child psychiatrist will conduct assessments for each participant at baseline and after the intervention. The Social Skills Rating Scale–Parent will be used to assess the social interaction skills of the participants before and after the intervention. Participants in the social VR intervention group and traditional social skills training group will receive twelve 20-minute training sessions for 3 weeks. The participants in the waitlist control group will receive no training. The primary outcome measure is training acceptability and compliance. The secondary outcome measures are the child psychiatrist's assessment and the Social Skills Rating Scale–Parent before and after the intervention. Another outcome measure is the Behavior Rating Inventory of Executive Function and Attention. Differences in the scale scores will be examined using a t test and an F test. Results: This study is set to commence in the fourth quarter of 2023. It is anticipated that participants in the social VR intervention group will exhibit superior social interaction skills than those in the traditional social skills training group. Conclusions: To our knowledge, this RCT is the first study examining the feasibility and effectiveness of a social VR-based intervention for enhancing the social interaction skills of children with ADHD in Hong Kong. The VR-based social skills training is expected to provide a safer and more effective environment for children with ADHD to learn than the traditional approach. This study can lead to a full-scale RCT. Trial Registration: ClinicalTrials.gov NCT05778526; https://clinicaltrials.gov/study/NCT05778526 International Registered Report Identifier (IRRID): PRR1-10.2196/48208 %M 37721790 %R 10.2196/48208 %U https://www.researchprotocols.org/2023/1/e48208 %U https://doi.org/10.2196/48208 %U http://www.ncbi.nlm.nih.gov/pubmed/37721790 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e42154 %T Creating Custom Immersive 360-Degree Videos for Use in Clinical and Nonclinical Settings: Tutorial %A Naef,Aileen C %A Jeitziner,Marie-Madlen %A Jakob,Stephan M %A Müri,René M %A Nef,Tobias %+ Gerontechnology and Rehabilitation Group, ARTORG Center for Biomedical Engineering Research, University of Bern, Freiburgstrasse 3, Bern, 3010, Switzerland, 41 031 632 75 79, tobias.nef@unibe.ch %K 360-degree video %K head-mounted display %K healthcare %K relaxing content %K technology %K video content %K video production %K virtual reality %K VR %D 2023 %7 14.9.2023 %9 Tutorial %J JMIR Med Educ %G English %X The use of virtual reality (VR) stimulation in clinical settings has increased in recent years. In particular, there has been increasing interest in the use of VR stimulation for a variety of purposes, including medical training, pain therapy, and relaxation. Unfortunately, there is still a limited amount of real-world 360-degree content that is both available and suitable for these applications. Therefore, this tutorial paper describes a pipeline for the creation of custom VR content. It covers the planning and designing of content; the selection of appropriate equipment; the creation and processing of footage; and the deployment, visualization, and evaluation of the VR experience. This paper aims to provide a set of guidelines, based on first-hand experience, that readers can use to help create their own 360-degree videos. By discussing and elaborating upon the challenges associated with making 360-degree content, this tutorial can help researchers and health care professionals anticipate and avoid common pitfalls during their own content creation process. %M 37707883 %R 10.2196/42154 %U https://mededu.jmir.org/2023/1/e42154 %U https://doi.org/10.2196/42154 %U http://www.ncbi.nlm.nih.gov/pubmed/37707883 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e42067 %T Short- to Long-Term Effects of Virtual Reality on Motor Skill Learning in Children With Cerebral Palsy: Systematic Review and Meta-Analysis %A Kilcioglu,Seyma %A Schiltz,Benoît %A Araneda,Rodrigo %A Bleyenheuft,Yannick %+ Institute of Neuroscience, Université Catholique de Louvain (UCLouvain), Avenue E. Mounier 53, 1200, Brussels, Belgium, 32 27645446, rodrigo.araneda@uclouvain.be %K cerebral palsy %K virtual reality %K motor skill learning %K long-term effect %K daily life activities %K motor functions %D 2023 %7 12.9.2023 %9 Review %J JMIR Serious Games %G English %X Background: Many studies have started integrating virtual reality (VR) into neurorehabilitation for children with cerebral palsy (CP). The results of the effects of VR on motor skill learning, including the short- to long-term results of relevant studies, must be pooled in a generic framework. Objective: This systematic review and meta-analysis aimed to investigate the short- to long-term effects of therapies including VR on motor skill learning in children with CP. Methods: Two examiners followed the inclusion and exclusion criteria of the “Participant, Intervention, Control, and Outcome” framework. Randomized controlled trials (RCTs) and non-RCTs were considered if they compared VR-included interventions with control groups on motor functions and daily life activities in children with CP. PubMed, ScienceDirect, Embase, and IEEE Xplore databases were searched. The modified Downs and Black assessment was used to assess the methodological quality of the included studies. Meta-analyses and subgroup analyses for RCTs were conducted whenever possible. Results: A total of 7 RCTs, 2 non-RCTs, and 258 children with CP were included. The priority focus of 78% (7/9) of the studies was upper limb functions. There was a significant short-term effect of adding VR to conventional therapies on upper limb functions when compared with conventional therapies (P=.04; standardized mean difference [SMD]=0.39, 95% CI 0.01-0.76). The overall medium- to long-term effects showed a trend toward favoring the VR group, although the difference was not statistically significant (P=.06; SMD=0.37, 95% CI −0.02 to 0.77). For balance (P=.06; SMD=1.04, 95% CI −0.04 to 2.12), gross motor functions (P=.30; SMD=2.85, 95% CI −2.57 to 8.28), and daily life activities outcomes (P=.21; SMD=0.29, 95% CI −0.16 to 0.74), the overall effect in the short term also showed a trend toward favoring the VR group, but these results were not statistically significant. Conclusions: VR seems to have additional benefits for motor skill learning in children with CP. Studies with follow-up outcomes of VR training focusing on balance and gross motor functions in patients with CP were quite limited. Future research on balance and gross motor function outcomes should target particularly long-term results of therapies including VR on motor skill learning. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021227734; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021227734 %M 37698895 %R 10.2196/42067 %U https://games.jmir.org/2023/1/e42067 %U https://doi.org/10.2196/42067 %U http://www.ncbi.nlm.nih.gov/pubmed/37698895 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e46398 %T Design and Evaluation of Using Head-Mounted Virtual Reality for Learning Clinical Procedures: Mixed Methods Study %A Lau,Siew Tiang %A Siah,Rosalind Chiew Jiat %A Dzakirin Bin Rusli,Khairul %A Loh,Wen Liang %A Yap,John Yin Gwee %A Ang,Emily %A Lim,Fui Ping %A Liaw,Sok Ying %+ Alice Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD 11, 10 Medical Drive, Singapore, 117597, Singapore, 65 66011299, nurlst@nus.edu.sg %K user experience %K acceptability %K usability %K virtual patient %K clinical procedure %K immersive %K nursing student %K virtual reality %K education %K performance %D 2023 %7 30.8.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: The capacity of health care professionals to perform clinical procedures safely and competently is crucial as it will directly impact patients’ outcomes. Given the ability of head-mounted virtual reality to simulate the authentic clinical environment, this platform should be suitable for nurses to refine their clinical skills for knowledge and skills acquisition. However, research on head-mounted virtual reality in learning clinical procedures is limited. Objective: The objectives of this study were (1) to describe the design of a head-mounted virtual reality system and evaluate it for education on clinical procedures for nursing students and (2) to explore the experience of nursing students using head-mounted virtual reality for learning clinical procedures and the usability of the system. Methods: This usability study used a mixed method approach. The stages included developing 3D models of the necessary instruments and materials used in intravenous therapy and subcutaneous injection procedures performed by nurses, followed by developing the procedures using the Unreal Engine (Epic Games). Questionnaires on the perception of continuance intention and the System Usability Scale were used along with open-ended questions. Results: Twenty-nine nursing students took part in this questionnaire study after experiencing the immersive virtual reality (IVR) intervention. Participants reported largely favorable game perception and learning experience. Mean perception scores ranged from 3.21 to 4.38 of a maximum score of 5, while the mean system usability score was 53.53 of 100. The majority found that the IVR experience was engaging, and they were immersed in the game. The challenges encountered included unfamiliarity with the new learning format; technological constraints, such as using hand controllers; and physical discomfort. Conclusions: The conception of IVR for learning clinical procedures through deliberate practice to enhance nurses’ knowledge and skills is promising. However, refinement of the prototypes is required to improve user experience and learning. Future research can explore other ways to use IVR for better education and health care purposes. %M 37647108 %R 10.2196/46398 %U https://games.jmir.org/2023/1/e46398 %U https://doi.org/10.2196/46398 %U http://www.ncbi.nlm.nih.gov/pubmed/37647108 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e48586 %T The Impact of Web-Based Continuing Medical Education Using Patient Simulation on Real-World Treatment Selection in Type 2 Diabetes: Retrospective Case-Control Analysis %A Lucero,Katie Stringer %A Larkin,Amy %A Zakharkin,Stanislav %A Wysham,Carol %A Anderson,John %+ Medscape, LLC, 395 Hudson St, New York, NY, 10014, United States, 1 212 301 6782, klucero@webmd.net %K continuing medical education %K virtual patient simulation %K real-world evidence %K evaluation %K outcomes %K diabetes education %K medical education %K type 2 diabetes %K web-based learning %K web-based education %D 2023 %7 29.8.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Despite guidelines recommending the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in certain patients with type 2 diabetes (T2D), they are not being prescribed for many of these patients. Web-based continuing medical education (CME) patient simulations have been used to identify clinicians’ practice gaps and improve clinical decision-making as measured within a simulation, but the impact of this format on real-world treatment has not been researched. Objective: This study aimed to evaluate the effect of a simulation-based CME intervention on real-world use of GLP-1 RAs by endocrinologists and primary care physicians. Methods: Two evaluation phases of the CME simulation were conducted: phase I, the CME simulation phase, was a paired, pre-post study of 435 physician learners in the United States; and phase II, the real-world phase, was a retrospective, matched case-control study of 157 of the 435 physicians who had claims data available for the study period. Results: Phase I CME results showed a 29 percentage point increase in correct decisions from pre- to postfeedback (178/435, 40.9% to 304/435, 69.9%; P<.001) in selecting treatment that addresses both glycemic control and cardiovascular event protection. Phase II results showed that 39 of 157 (24.8%) physicians in the intervention group increased use of GLP-1 RAs, compared to 20 of 157 (12.7%) in the comparison group. Being in the intervention group predicted GLP-1 RA use after education (odds ratio 4.49; 95% CI 1.45-13.97; P=.001). Conclusions: A web-based CME simulation focused on secondary prevention of cardiovascular events in a patient with T2D was associated with increased use of evidence-based treatment selection in the real world. %M 37642994 %R 10.2196/48586 %U https://mededu.jmir.org/2023/1/e48586 %U https://doi.org/10.2196/48586 %U http://www.ncbi.nlm.nih.gov/pubmed/37642994 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e42862 %T Virtual Worlds Technology to Enhance Training for Primary Care Providers in Assessment and Management of Posttraumatic Stress Disorder Using Motivational Interviewing: Pilot Randomized Controlled Trial %A Manuel,Jennifer K %A Purcell,Natalie %A Abadjian,Linda %A Cardoos,Stephanie %A Yalch,Matthew %A Hill,Coleen %A McCarthy,Brittan %A Bertenthal,Daniel %A McGrath,Sarah %A Seal,Karen %+ San Francisco Veterans Affairs Health Care System, 4150 Clement St, San Francisco, CA, 94121, United States, 1 415 221 4810 ext 25206, jennifer.manuel@va.gov %K primary care %K posttraumatic stress disorder %K PTSD %K motivational interviewing %K virtual training %K training %K virtual %K stress %K disorder %K treatment %K patient %K assessment %K communication %K feasibility %K acceptability %K efficacy %D 2023 %7 28.8.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Many individuals with posttraumatic stress disorder (PTSD) first present to primary care rather than specialty mental health care. Primary care providers often lack the training required to assess and treat patients with PTSD. Virtual trainings have emerged as a convenient and effective way of training primary care providers in PTSD assessment and communication methods (ie, motivational interviewing [MI]). Objective: The aim of this study was to conduct a pilot randomized controlled trial of a synchronous Virtual Worlds (VW; a virtual world where learners were immersed as avatars) training versus an asynchronous web-based training on PTSD and MI, comparing the feasibility, acceptability, usability, and preliminary efficacy of 2 different training platforms among primary care providers. Methods: Participating primary care providers were randomized to a VW and a web-based PTSD training. Outcomes were collected at baseline, posttraining, and 90-days follow-up. Standardized patient interviews measured participants’ communication skills in assessing and managing patients with PTSD symptoms. Results: Compared to the web-based training, the VW training platform achieved larger learning gains in MI (ie, partnership and empathy) and in discussing pharmacotherapy and psychotherapy for PTSD. Both VW and web-based trainings led to increases in PTSD knowledge and primary care providers’ self-confidence. Conclusions: The asynchronous web-based PTSD training improved PTSD-related knowledge and self-confidence but was not as effective as the VW immersive experience in teaching MI or clinical management. Because VW training is synchronous and new for many learners, it required more time, facilitation, and technical support. As computer technology improves, VW educational interventions may become more feasible, particularly in teaching clinical skills. Trial Registration: ClinicalTrials.gov NCT03898271; https://tinyurl.com/mu479es5 %M 37639299 %R 10.2196/42862 %U https://mededu.jmir.org/2023/1/e42862 %U https://doi.org/10.2196/42862 %U http://www.ncbi.nlm.nih.gov/pubmed/37639299 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45458 %T Benefits of Telerehabilitation for Patients With Severe Acquired Brain Injury: Promising Results From a Multicenter Randomized Controlled Trial Using Nonimmersive Virtual Reality %A Calabrò,Rocco Salvatore %A Bonanno,Mirjam %A Torregrossa,William %A Cacciante,Luisa %A Celesti,Antonio %A Rifici,Carmela %A Tonin,Paolo %A De Luca,Rosaria %A Quartarone,Angelo %+ Istituto di Ricovero e Cura a Carattere Scientifico Centro Neurolesi Bonino Pulejo, Cda Casazza, SS 113, Messina, 98123, Italy, 39 09060128391, mirjam.bonanno@irccsme.it %K telerehabilitation %K teleneuro-VRRS %K virtual reality rehabilitation system %K SABI %K severe acquired brain injury %K acquired brain injury %K virtual reality %K rehabilitation %K neurorehabilitation %K brain injury %K neurology %D 2023 %7 21.8.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: In neurorehabilitation, the use of innovative technologies offers many opportunities to monitor and improve the health status of patients with severe acquired brain injury (SABI). Telerehabilitation allows for continuity of service through the entire rehabilitation cycle, including assessment, intervention, consultation, and education, affording early reintegration and positively enhancing the quality of life (QoL). Objective: The main purpose of this multicenter randomized controlled trial was to test the effectiveness of advanced training provided using a nonimmersive virtual reality rehabilitation system (ie, the VRRS HomeKit device) in improving functional outcomes in patients with SABI. Methods: In total, 40 patients with SABI and their 40 caregivers visiting 2 Italian rehabilitation centers were enrolled in the study protocol and randomized into 2 groups. Of the 40 patients, 20 (50%) underwent the experimental training using the VRRS HomeKit (teleneuro-VRRS group), whereas the other 20 (50%) were administered usual territorial rehabilitative treatments (UTRTs; control group). To investigate motor and neuropsychological functioning, patients with SABI were evaluated before (T0) and at the end of (T1) each training session by a multispecialist team through a complete clinical and psychometric battery: the Barthel Index (BI), the Tinetti Scale (TS), the Modified Ashworth Scale (MAS), the Montreal Cognitive Assessment (MoCa), the Frontal Assessment Battery (FAB), the Beck Depression Inventory II (BDI-II), the Short Form Health Survey 36 (SF-36), and the Psychological General Well-Being Index (PGWBI). In addition, the Caregiver Burden Inventory (CBI) was administered to each caregiver to investigate the emotional burden status. Results: The teleneuro-VRRS group achieved a statistically significant improvement in both general and motor outcomes, as well as psychological well-being and QoL, compared to the control group. In particular, the BI (P<.001), FAB (P<.001), and BDI-II (P<.001) were the outcome scales with the best improvement. The burden of caregivers also significantly improved in the teleneuro-VRRS group (CBI; P<.004). Between-group analysis showed statistical differences in the anxiety (effect size [ES]=0.85, P<.02) and self-control (ES=0.40, P<.03) subtests of the PGWBI and in the social role functioning (ES=0.85, P<.02) subtest of the SF-36, confirmed by quite medium and large ESs. Conclusions: Our results suggest that the VRRS is a suitable alternative tool or complementary tool or both to improve motor (level of functional independence) and cognitive (frontal/executive abilities) outcomes, reducing behavioral alterations (anxiety and depression symptoms) in patients with SABI, with a beneficial impact also on the caregivers’ burden distress management, mitigating distress and promoting positive aspects of caring. Trial Registration: ClinicalTrials.gov NCT03709875; https://classic.clinicaltrials.gov/ct2/show/NCT03709875 %M 37490017 %R 10.2196/45458 %U https://www.jmir.org/2023/1/e45458 %U https://doi.org/10.2196/45458 %U http://www.ncbi.nlm.nih.gov/pubmed/37490017 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e44766 %T Virtual Reality Technology in Nursing Professional Skills Training: Bibliometric Analysis %A Hong,Chengang %A Wang,Liping %+ School of Nursing, Hangzhou Normal University, 2318 Yuhang Tang Road, Yuhang District, Hangzhou, 311100, China, 86 15356641080, wangliping111@126.com %K virtual reality %K VR %K nursing professional skills %K bibliometric analysis %K visual content analysis %K extended reality %K XR %K augmented reality %K AR %K mixed reality %D 2023 %7 21.8.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Nursing professional skills training has undergone significant transformation due to the exponential growth of computer and medical technology. The innovative use of virtual reality (VR) in nursing education has emerged as a cutting-edge technical support technique that has gained attention as a highly effective method for improving nurse training quality. Objective: This study aims to review the current status of VR technology in nursing professional skills training, research hotspots, and emerging trends in the last 15 years. Methods: The Web of Science Core Collection database was used to search for literature on VR technology in nursing professional skills training covering the period from 2006 to 2022. Biblioshiny (K-Synth Srl) was used to import and convert the records to Bibliometrix (K-Synth Srl) for analysis, and R (R Core Team) was used for descriptive bibliometric analysis. VOSviewer (Leiden University) was used to cluster co-occurring keywords, and Scimago Graphica (version 1.0.16; Scimago Lab) was used to generate a geographical visualization of published countries and regions. Results: A total of 1073 papers were analyzed, indicating a surge in research on the application of VR in nursing professional skills training in recent years, as evidenced by a positive trend in annual publication of relevant literature. The majority of studies were from the United States (n=340) and Canada (n=107), and Margaret Verkuyl was the most prolific author, leading the way with 9 publications. Furthermore, “Computerized Virtual Patients in Health Professions Education: a Systematic Review and Meta-Analysis” was the most frequently cited reference. Keywords such as education, simulation, skills, students, and care were most commonly used by researchers. Conclusions: The bibliometric analysis provides a comprehensive overview of the use of VR in nursing professional skills training, indicating that VR-based training is an effective means of improving the skills and competencies of nursing students and professionals alike. The COVID-19 pandemic has reinforced the importance of developing VR-based distance education, despite challenges such as integrating virtual and real-world training and mitigating safety risks. %M 37603389 %R 10.2196/44766 %U https://games.jmir.org/2023/1/e44766 %U https://doi.org/10.2196/44766 %U http://www.ncbi.nlm.nih.gov/pubmed/37603389 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e43710 %T Teaching Palliative Care to Emergency Medicine Residents Using Gamified Deliberate Practice-Based Simulation: Palliative Gaming Simulation Study %A Stanich,Jessica %A Sunga,Kharmene %A Loprinzi-Brauer,Caitlin %A Ginsburg,Alexander %A Ingram,Cory %A Bellolio,Fernanda %A Cabrera,Daniel %+ Department of Emergency Medicine, Mayo Clinic, 200 First Steet SW, Rochester, MN, 55905, United States, 1 5072554137, jstans44@gmail.com %K palliative care %K emergency medicine %K gaming simulation %K resident education %K medical education %K residency %K end of life %K palliative %K dying %K death %K interpersonal skill %D 2023 %7 16.8.2023 %9 Original Paper %J JMIR Med Educ %G English %X Background: Emergency departments (EDs) care for many patients nearing the end of life with advanced serious illnesses. Simulation training offers an opportunity to teach physicians the interpersonal skills required to manage end-of-life care. Objective: We hypothesized a gaming simulation of an imminently dying patient using the LIVE. DIE. REPEAT (LDR) format, would be perceived as an effective method to teach end-of-life communication and palliative care management skills. Methods: This was a gaming simulation replicating the experience of caring for a dying patient with advanced serious illness in the ED. The scenario involved a patient with pancreatic cancer presenting with sepsis and respiratory distress, with a previously established goal of comfort care. The gaming simulation game was divided into 4 stages, and at each level, learners were tasked with completing 1 critical action. The gaming simulation was designed using the LDR serious game scheme in which learners are allowed infinite opportunities to progress through defined stages depicting a single patient scenario. If learners successfully complete the predetermined critical actions of each stage, the game is paused, and there is a debriefing to reinforce knowledge or skills before progressing to the next stage of the gaming simulation. Conversely, if learners do not achieve the critical actions, the game is over, and learners undergo debriefing before repeating the failed stage with an immediate transition into the next. We used the Simulation Effectiveness Tool–Modified survey to evaluate perceived effectiveness in teaching end-of-life management. Results: Eighty percent (16/20) of residents completed the Simulation Effectiveness Tool–Modified survey, and nearly 100% (20/20) either strongly or somewhat agreed that the gaming simulation improved their skills and confidence at the end of life in the following dimensions: (1) better prepared to respond to changes in condition, (2) more confident in assessment skills, (3) teaching patients, (4) reporting to the health care team, (5) empowered to make clinical decisions, and (6) able to prioritize care and interventions. All residents felt the debriefing contributed to learning and provided opportunities to self-reflect. All strongly or somewhat agree that they felt better prepared to respond to changes in the patient’s condition, had a better understanding of pathophysiology, were more confident on their assessment skills, and had a better understanding of the medications and therapies after the gaming simulation. A total of 88% (14/16) of them feel more empowered to make clinical decisions. After completing the gaming simulation, 88% (14/16) of residents strongly agreed that they would feel more confident communicating with a patient and prioritizing care interventions in this context. Conclusions: This palliative gaming simulation using the LDR format was perceived by resident physicians to improve confidence in end-of-life communication and palliative care management. %M 37585258 %R 10.2196/43710 %U https://mededu.jmir.org/2023/1/e43710 %U https://doi.org/10.2196/43710 %U http://www.ncbi.nlm.nih.gov/pubmed/37585258 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44479 %T The Influence of Anthropomorphic Cues on Patients’ Perceived Anthropomorphism, Social Presence, Trust Building, and Acceptance of Health Care Conversational Agents: Within-Subject Web-Based Experiment %A Li,Qingchuan %A Luximon,Yan %A Zhang,Jiaxin %+ School of System Design and Intelligent Manufacturing, Southern University of Science and Technology, 1088 Xueyuan Avenue, Shenzhen, 518055, China, 86 755 88011701, zhangjx@sustech.edu.cn %K anthropomorphic cues %K intelligent guidance conversational agents %K social presence %K trust %K technology acceptance %K mindful and mindless anthropomorphism %D 2023 %7 10.8.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: The last decade has witnessed the rapid development of health care conversational agents (CAs); however, there are still great challenges in making health care CAs trustworthy and acceptable to patients. Objective: Focusing on intelligent guidance CAs, a type of health care CA for web-based patient triage, this study aims to investigate how anthropomorphic cues influence patients’ perceived anthropomorphism and social presence of such CAs and evaluate how these perceptions facilitate their trust-building process and acceptance behavior. Methods: To test the research hypotheses, the video vignette methodology was used to evaluate patients’ perceptions and acceptance of various intelligent guidance CAs. The anthropomorphic cues of CAs were manipulated in a 3×2 within-subject factorial experiment with 103 participants, with the factors of agent appearance (high, medium, and low anthropomorphic levels) and verbal cues (humanlike and machine-like verbal cues) as the within-subject variables. Results: The 2-way repeated measures ANOVA analysis indicated that the higher anthropomorphic level of agent appearance significantly increased mindful anthropomorphism (high level>medium level: 4.57 vs 4.27; P=.01; high level>low level: 4.57 vs 4.04; P<.001; medium level>low level: 4.27 vs 4.04; P=.04), mindless anthropomorphism (high level>medium level: 5.39 vs 5.01; P<.001; high level>low level: 5.39 vs 4.85; P<.001), and social presence (high level>medium level: 5.19 vs 4.83; P<.001; high level>low level: 5.19 vs 4.72; P<.001), and the higher anthropomorphic level of verbal cues significantly increased mindful anthropomorphism (4.83 vs 3.76; P<.001), mindless anthropomorphism (5.60 vs 4.57; P<.001), and social presence (5.41 vs 4.41; P<.001). Meanwhile, a significant interaction between agent appearance and verbal cues (.004) was revealed. Second, the partial least squares results indicated that privacy concerns were negatively influenced by social presence (β=−.375; t312=4.494) and mindful anthropomorphism (β=−.112; t312=1.970). Privacy concerns (β=−.273; t312=9.558), social presence (β=.265; t312=4.314), and mindless anthropomorphism (β=.405; t312=7.145) predicted the trust in CAs, which further promoted the intention to disclose information (β=.675; t312=21.163), the intention to continuously use CAs (β=.190; t312=4.874), and satisfaction (β=.818; t312=46.783). Conclusions: The findings show that a high anthropomorphic level of agent appearance and verbal cues could improve the perceptions of mindful anthropomorphism and mindless anthropomorphism as well as social presence. Furthermore, mindless anthropomorphism and social presence significantly promoted patients’ trust in CAs, and mindful anthropomorphism and social presence decreased privacy concerns. It is also worth noting that trust was an important antecedent and determinant of patients’ acceptance of CAs, including their satisfaction, intention to disclose information, and intention to continuously use CAs. %M 37561567 %R 10.2196/44479 %U https://www.jmir.org/2023/1/e44479 %U https://doi.org/10.2196/44479 %U http://www.ncbi.nlm.nih.gov/pubmed/37561567 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e44348 %T Eating Behavior and Satiety With Virtual Reality Meals Compared With Real Meals: Randomized Crossover Study %A Glympi,Alkyoni %A Odegi,Dorothy %A Zandian,Modjtaba %A Södersten,Per %A Bergh,Cecilia %A Langlet,Billy %+ Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels allé 23, Huddinge, Stockholm, 141 52, Sweden, 46 086905826, billy.langlet@ki.se %K exposure therapy %K eating behavior %K anorexia nervosa %K bulimia nervosa %K binge eating disorder %K overweight %K obesity %K immersive virtual reality %K VR %K virtual reality %D 2023 %7 10.8.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Eating disorders and obesity are serious health problems with poor treatment outcomes and high relapse rates despite well-established treatments. Several studies have suggested that virtual reality technology could enhance the current treatment outcomes and could be used as an adjunctive tool in their treatment. Objective: This study aims to investigate the differences between eating virtual and real-life meals and test the hypothesis that eating a virtual meal can reduce hunger among healthy women. Methods: The study included 20 healthy women and used a randomized crossover design. The participants were asked to eat 1 introduction meal, 2 real meals, and 2 virtual meals, all containing real or virtual meatballs and potatoes. The real meals were eaten on a plate that had been placed on a scale that communicated with analytical software on a computer. The virtual meals were eaten in a room where participants were seated on a real chair in front of a real table and fitted with the virtual reality equipment. The eating behavior for both the real and virtual meals was filmed. Hunger was measured before and after the meals using questionnaires. Results: There was a significant difference in hunger from baseline to after the real meal (mean difference=61.8, P<.001) but no significant change in hunger from before to after the virtual meal (mean difference=6.9, P=.10). There was no significant difference in food intake between the virtual and real meals (mean difference=36.8, P=.07). Meal duration was significantly shorter in the virtual meal (mean difference=–5.4, P<.001), which led to a higher eating rate (mean difference=82.9, P<.001). Some participants took bites and chewed during the virtual meal, but the number of bites and chews was lower than in the real meal. The meal duration was reduced from the first virtual meal to the second virtual meal, but no significant difference was observed between the 2 real meals. Conclusions: Eating a virtual meal does not appear to significantly reduce hunger in healthy individuals. Also, this methodology does not significantly result in eating behaviors identical to real-life conditions but does evoke chewing and bite behavior in certain individuals. Trial Registration: ClinicalTrials.gov NCT05734209, https://clinicaltrials.gov/ct2/show/NCT05734209 %M 37561558 %R 10.2196/44348 %U https://games.jmir.org/2023/1/e44348 %U https://doi.org/10.2196/44348 %U http://www.ncbi.nlm.nih.gov/pubmed/37561558 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 10 %N %P e41993 %T The Usability of a Touchpad Active Video Game Controller for Individuals With Impaired Mobility: Observational Study %A Mendonca,Christen J %A Malone,Laurie A %A Mohanraj,Sangeetha %A Thirumalai,Mohanraj %+ School of Health Professions, The University of Alabama at Birmingham, SHPB 331, 1720 2nd Ave S, Birmingham, AL, 35294-3361, United States, 1 205 975 6415, christenjm@uab.edu %K active video games %K exergames %K usability %K enjoyment %K disability %K mobility limitation %K mobility impairment %D 2023 %7 3.8.2023 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Video games are a popular sedentary activity among people with impaired mobility; however, active video game hardware typically lacks accessibility and customization options for individuals with mobility impairments. A touchpad video game system can elicit moderate physical activity in healthy adults; however, it is unclear if this system is usable by adults with impaired mobility. Objective: The purpose of this study was to assess the usability of a touchpad video game controller system adapted for adults with impaired mobility. Additional outcomes explored were enjoyment, perceived exertion, self-efficacy, participant feedback, and researcher observations of gameplay. Methods: Participants played several video game titles for 20 minutes with a touchpad video game controller as they stood or sat in a chair or their wheelchair. Usability was assessed with the System Usability Scale (SUS) and the Health Information Technology Usability Evaluation Scale (Health-ITUES) surveys after gameplay. After each video game, participants reported enjoyment using a visual analog scale (0 to 100 mm) and a rating of perceived exertion using the OMNI 0 to 10 scale. Self-efficacy was measured before and after gameplay. Participants provided feedback at the end of their session. Results: In total, 21 adults (6 females and 15 males) with a mean age of 48.8 (SD 13.8) years with various mobility impairments participated in this study. The touchpads received mean usability scores on the SUS 80.1 (SD 18.5) and Health-ITUES 4.23 (SD 0.67). Conclusions: The SUS scores reported suggest the touchpad system is “usable”; however, the Health-ITUES scores were slightly below a suggested benchmark. Participants reported moderate to high enjoyment but perceived the exertion as “somewhat easy.” Self-efficacy was moderate to high and did not differ pre- to postgame play. The participants regarded the touchpads as novel, fun, and entertaining. The generalizability of our results is limited due to the heterogenous sample; however, our participants identified several areas of improvement for future iteration. %M 37535411 %R 10.2196/41993 %U https://rehab.jmir.org/2023/1/e41993 %U https://doi.org/10.2196/41993 %U http://www.ncbi.nlm.nih.gov/pubmed/37535411 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e38282 %T Transfer Validity of Pediatric Supracondylar Humeral Fracture Pin Placement Practice on In-Theater Performance by Orthopedic Trainees Using an Augmented Reality Simulator: Protocol for a Pilot Interventional Cohort Study With a Retrospective Comparator Cohort %A Guo,Joyce %A Blyth,Phil %A Clifford,Kari %A Hooper,Nikki %A Crawford,Haemish %+ Department of the Dean, Otago Medical School, University of Otago, 201 Great King Street, Central Dunedin, Dunedin, 9016, New Zealand, 64 273635352, joyce.guo@postgrad.otago.ac.nz %K pediatric orthopedics %K augmented reality simulator %K supracondylar humeral fractures %K closed reduction and percutaneous pinning %K transfer validity %K fracture %K surgeons %K education %K practice %K trainees %K pediatric %K orthopedic %K training %K surgical procedure %D 2023 %7 2.8.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Supracondylar humeral fractures (SCHF) are a common cause of orthopedic morbidity in pediatric populations across the world. The treatment of this fracture is likely one of the first procedures involving x-ray–guided wire insertion that trainee orthopedic surgeons will encounter in their career. Traditional surgical training methods of “see one, do one, teach one” are reliant on the presence of real-world cases and must be conducted within an operative environment. We have developed an augmented reality simulator that allows trainees to practice this procedure in a radiation-free environment at no extra risk to patients. Objective: This study aims to examine whether training on a simulator in addition to traditional surgical training improves the in-theater performance of trainees. Methods: This multicenter, interventional cohort study will involve orthopedic trainees from New Zealand in their first year of advanced training between 2019 and 2023. Advanced trainees with no simulator exposure who were in their first year in 2019-2021 will form the comparator cohort, while those in the years 2022-2023 will receive additional regular simulator training as the intervention cohort. The comparator cohort’s performance in pediatric SCHF surgery will be retrospectively audited using routinely collected operative outcomes and parameters over a 6-month period. Data on the performance of the intervention cohorts will be collected in the same way over a comparable period. The data collected for both groups will be used to determine whether additional training with an augmented reality training shows improved real-world surgical outcomes compared to traditional surgical training. Results: As of February 2022, a total of 8 retrospective comparator trainees have been recruited by email. The study is financially supported through an external grant from the Wishbone Orthopaedic Research Foundation of New Zealand (September 2021) and an internal research grant from the University of Otago (July 2021). Conclusions: This protocol has been approved by the University of Otago Health Ethics committee (reference HD21/087), and the study is due for completion in 2024. This protocol may assist other researchers conducting similar studies in the field. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12623000816651; https://tinyurl.com/mtdkecwb International Registered Report Identifier (IRRID): DERR1-10.2196/38282 %M 37531159 %R 10.2196/38282 %U https://www.researchprotocols.org/2023/1/e38282 %U https://doi.org/10.2196/38282 %U http://www.ncbi.nlm.nih.gov/pubmed/37531159 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e38369 %T V-CarE—A Conceptual Design Model for Providing COVID-19 Pandemic Awareness: Proposal for a Virtual Reality Design Approach to Facilitate People With Persistent Postural-Perceptual Dizziness %A Zaidi,Syed Fawad M %A Shafiabady,Niusha %A Afifi,Shereen %A Beilby,Justin %+ Department of Business Information Systems, Torrens University Australia, 17/51 Foveaux St, Surry Hills, Sydney, 2010, Australia, 61 1300 575 803, fawad.zaidi@torrens.edu.au %K COVID-19 %K immersion %K pandemic %K Persistent Postural–Perceptual Dizziness %K PPPD %K virtual reality %D 2023 %7 27.7.2023 %9 Proposal %J JMIR Res Protoc %G English %X Background: Virtual reality (VR) technology has been solidifying its ground since its existence, where engagement and a sense of presence are key. The contemporary field of development has captured the attention of researchers due to its flexibility and compatibility attributes. During the COVID-19 pandemic, several research outputs have shown promising prospects of continuing research in the field of VR design and development—in health sciences including learning and training. Objective: In this paper, we aim to propose a conceptual development model named V-CarE (Virtual Care Experience) that can facilitate the understanding of pandemics when it comes to a crisis, taking precautionary measures where needed, and getting used to certain actions for preventing pandemic spread through habituation. Moreover, this conceptual model is useful to expand the development strategy to incorporate different types of users and technological aid as per need and requirement. Methods: For a detailed understanding of the proposed model, we have developed a novel design strategy to bring awareness to the user about the current COVID-19 pandemic. VR research in health sciences has shown that with appropriate management and development, VR technology can efficiently support people with health issues and special needs, which motivated our attempts to explore the possibility of employing our proposed model to treat Persistent Postural-Perceptual Dizziness (PPPD)—a persistent nonvertiginous dizziness that could last for 3 months or more. The purpose of including patients with PPPD is to get them engaged in the learning experience and to make them comfortable with VR. We believe this confidence and habituation would help them get engaged with VR for treatment (dizziness alleviation) while practicing the preventive measures during the pandemic in an interactive environment without actually facing any pandemic directly. Subsequently, for advanced development using the V-CarE model, we have briefly discussed that even contemporary technology like internet of things (IoT) for handling devices, can be incorporated without disrupting the complete 3D-immersive experience. Results: In our discussion, we have shown that the proposed model represents a significant step toward the accessibility of VR technology by creating a pathway toward awareness of pandemics and, also, an effective care strategy for PPPD people. Moreover, by introducing advanced technology, we will only further enhance the development for wider accessibility of VR technology while keeping the core purpose of the development intact. Conclusions: V-CarE–based developed VR projects are designed with all the core elements of health sciences, technology, and training making it accessible and engaging for the users and improving their lifestyle by safely experiencing the unknown. We suggest that with further design-based research, the proposed V-CarE model has the potential to be a valuable tool connecting different fields to wider communities. %M 37224279 %R 10.2196/38369 %U https://www.researchprotocols.org/2023/1/e38369 %U https://doi.org/10.2196/38369 %U http://www.ncbi.nlm.nih.gov/pubmed/37224279 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e47748 %T Artificial Intelligence Versus Human-Controlled Doctor in Virtual Reality Simulation for Sepsis Team Training: Randomized Controlled Study %A Liaw,Sok Ying %A Tan,Jian Zhi %A Bin Rusli,Khairul Dzakirin %A Ratan,Rabindra %A Zhou,Wentao %A Lim,Siriwan %A Lau,Tang Ching %A Seah,Betsy %A Chua,Wei Ling %+ Alice Lee Centre for Nursing Studies, National University of Singapore, Block MD11, Level 2, 10 Medical Drive, Singapore, 117597, Singapore, 65 65167451, nurliaw@nus.edu.sg %K artificial intelligence %K interprofessional education %K interprofessional communication %K sepsis care %K team training %K virtual reality %K simulation %K AI %K health care education %K nursing student %K nursing education %K medical education %D 2023 %7 26.7.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Interprofessional communication is needed to enhance the early recognition and management of patients with sepsis. Preparing medical and nursing students using virtual reality simulation has been shown to be an effective learning approach for sepsis team training. However, its scalability is constrained by unequal cohort sizes between medical and nursing students. An artificial intelligence (AI) medical team member can be implemented in a virtual reality simulation to engage nursing students in sepsis team training. Objective: This study aimed to evaluate the effectiveness of an AI-powered doctor versus a human-controlled doctor in training nursing students for sepsis care and interprofessional communication. Methods: A randomized controlled trial study was conducted with 64 nursing students who were randomly assigned to undertake sepsis team training with an AI-powered doctor (AI-powered group) or with medical students using virtual reality simulation (human-controlled group). Participants from both groups were tested on their sepsis and communication performance through simulation-based assessments (posttest). Participants’ sepsis knowledge and self-efficacy in interprofessional communication were also evaluated before and after the study interventions. Results: A total of 32 nursing students from each group completed the simulation-based assessment, sepsis and communication knowledge test, and self-efficacy questionnaire. Compared with the baseline scores, both the AI-powered and human-controlled groups demonstrated significant improvements in communication knowledge (P=.001) and self-efficacy in interprofessional communication (P<.001) in posttest scores. For sepsis care knowledge, a significant improvement in sepsis care knowledge from the baseline was observed in the AI-powered group (P<.001) but not in the human-controlled group (P=.16). Although no significant differences were found in sepsis care performance between the groups (AI-powered group: mean 13.63, SD 4.23, vs human-controlled group: mean 12.75, SD 3.85, P=.39), the AI-powered group (mean 9.06, SD 1.78) had statistically significantly higher sepsis posttest knowledge scores (P=.009) than the human-controlled group (mean 7.75, SD 2.08). No significant differences were found in interprofessional communication performance between the 2 groups (AI-powered group: mean 29.34, SD 8.37, vs human-controlled group: mean 27.06, SD 5.69, P=.21). However, the human-controlled group (mean 69.6, SD 14.4) reported a significantly higher level of self-efficacy in interprofessional communication (P=.008) than the AI-powered group (mean 60.1, SD 13.3). Conclusions: Our study suggested that AI-powered doctors are not inferior to human-controlled virtual reality simulations with respect to sepsis care and interprofessional communication performance, which supports the viability of implementing AI-powered doctors to achieve scalability in sepsis team training. Our findings also suggested that future innovations should focus on the sociability of AI-powered doctors to enhance users’ interprofessional communication training. Perhaps in the nearer term, future studies should examine how to best blend AI-powered training with human-controlled virtual reality simulation to optimize clinical performance in sepsis care and interprofessional communication. Trial Registration: ClinicalTrials.gov NCT05953441; https://clinicaltrials.gov/study/NCT05953441 %M 37494112 %R 10.2196/47748 %U https://www.jmir.org/2023/1/e47748 %U https://doi.org/10.2196/47748 %U http://www.ncbi.nlm.nih.gov/pubmed/37494112 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 10 %N %P e34629 %T Mixed Reality Technology to Deliver Psychological Interventions to Adolescents With Asthma: Qualitative Study Using the Theoretical Framework of Acceptability %A Sharrad,Kelsey %A Martini,Caitlin %A Tai,Andrew %A Spurrier,Nicola %A Smith,Ross %A Esterman,Adrian %A Gwilt,Ian %A Sandford,Debra %A Carson-Chahhoud,Kristin %+ Translational Medicine and Technology Group, Australian Centre for Precision Health, University of South Australia, GPO Box 2471, Adelaide, 5001, Australia, 61 08 8302 2734, Kelsey.hibberd@live.com.au %K asthma %K augmented reality %K virtual reality %K mixed reality %K psychological distress %K adolescent %K cognitive behavioral therapies %K mental health %D 2023 %7 26.7.2023 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Interactive, mixed reality technologies such as augmented reality, virtual reality, and holographic technology may provide a novel solution to fast-track the translation of evidence into practice. They may also help overcome barriers to both mental health and asthma management service uptake, such as cost, availability of appointments, fear of judgment, and quality of care. Objective: This study aimed to investigate if mixed reality technology is an acceptable mechanism for the delivery of a component of cognitive and behavioral therapies for the management of elevated psychological distress among young people with asthma. Methods: To explore the perceived acceptability of these technologies, mixed reality tools were evaluated via qualitative, 1-on-1 interviews with young people with asthma and symptoms of psychological distress, parents/caregivers of young people with asthma and symptoms of psychological distress, and relevant health professionals. The Theoretical Framework of Acceptability was used for the deductive coding of the recorded interview transcripts. Results: This study enrolled the following participants: (1) 3 adolescents with asthma and symptoms of psychological distress with a mean age of 14 (SD 1.7) years; (2) 4 parents/caregivers of adolescents with asthma with a mean age of 55 (SD 14.6) years; and (3) 6 health professionals with a mean age of 40.8 (SD 4.3) years. A total of 4 constructs—experienced affective attitude, experienced effectiveness, self-efficacy, and intervention coherence—were coded in all participant transcripts. The most frequently coded constructs were experienced affective attitude and intervention coherence, which were reported a total of 96 times. The least frequently coded construct was anticipated opportunity cost, which was reported a total of 5 times. Participants were mostly positive about the mixed reality resources. However, some concerns were raised regarding ethicality, particularly regarding privacy, accessibility, and messaging. Participants noted the need for technology to be used in conjunction with face-to-face engagement with health professionals and that some patients would respond to this type of delivery mechanism better than others. Conclusions: These results suggest that mixed reality technology to deliver psychological interventions may be an acceptable addition to current health care practices for young people with asthma and symptoms of psychological distress. Trial Registration: Australia and New Zealand Clinical Trials Registry ACTRN12620001109998; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380427 %M 37494096 %R 10.2196/34629 %U https://humanfactors.jmir.org/2023/1/e34629 %U https://doi.org/10.2196/34629 %U http://www.ncbi.nlm.nih.gov/pubmed/37494096 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e45816 %T Cognitive Training With Head-Mounted Display Virtual Reality in Neurorehabilitation: Pilot Randomized Controlled Trial %A Specht,Julian %A Stegmann,Barbara %A Gross,Hanna %A Krakow,Karsten %+ SRH University of Applied Sciences Heidelberg, Department of Applied Psychology, Ludwig-Guttmann-Straße 6, Heidelberg, 69123, Germany, 49 01737808422, julian.specht@livingbrain.de %K cognitive rehabilitation %K virtual reality %K neurorehabilitation %K psychology %K stroke %D 2023 %7 21.7.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Neurological rehabilitation is technologically evolving rapidly, resulting in new treatments for patients. Stroke, one of the most prevalent conditions in neurorehabilitation, has been a particular focus in recent years. However, patients often need help with physical and cognitive constraints, whereby the cognitive domain in neurorehabilitation does not technologically exploit existing potential. Usually, cognitive rehabilitation is performed with pen and paper or on a computer, which leads to limitations in preparation for activities of daily living. Technologies such as virtual reality (VR) can bridge this gap. Objective: This pilot study investigated the use of immersive VR in cognitive rehabilitation for patients undergoing inpatient neurorehabilitation. The goal was to determine the difference in rehabilitation effectiveness between a VR serious game that combines everyday activities with cognitive paradigms and conventional computerized cognitive training. We hypothesized the superiority of the VR serious game regarding cognitive abilities and patient-reported outcomes as well as transfer to daily life. Methods: We recruited 42 patients with acute brain affection from a German neurorehabilitation clinic in inpatient care with a Mini Mental Status Test score >20 to participate in this randomized controlled trial. Participants were randomly assigned to 2 groups, with 1 receiving the experimental VR treatment (n=21). VR training consisted of daily life scenarios, for example, in a kitchen, focusing on treating executive functions such as planning and problem-solving. The control group (n=21) received conventional computerized cognitive training. Each participant received a minimum of 18 treatment sessions in their respective group. Patients were tested for cognitive status, subjective health, and quality of life before and after the intervention (Alters-Konzentrations-Test, Wechsler Memory Scale—Revised, Trail Making Test A and B, Tower of London—German version, Short Form 36, European Quality of Life 5 Dimensions visual analog scale, and Fragebogen zur Erfassung der Performance in VR). Results: Repeated-measures ANOVA revealed several significant main effects in the cognitive tests: Tower of London—German version (P=.046), Trail Making Test A (P=.01), and Wechsler Memory Scale—Revised (P=.006). However, post hoc tests revealed that the VR group showed significant improvement in the planning, executive control, and problem-solving domains (P=.046, Bonferroni P=.02). In contrast, no significant improvement in the control group between t0 and t1 was detected (all P>.05). Furthermore, a nonsignificant trend was observed in visual speed in the VR group (P=.09, Bonferroni P=.02). Conclusions: The results of this pilot randomized controlled trial showed that immersive VR training in cognitive rehabilitation had greater effectiveness than the standard of care in treating patients experiencing stroke in some cognitive domains . These findings support the further use and study of VR training incorporating activities of daily living in other neurological disorders involving cognitive dysfunction. Trial Registration: Federal Registry of Clinical Trials of Germany (DRKS) DRKS00023605; https://drks.de/search/de/trial/DRKS00023605 %M 37477957 %R 10.2196/45816 %U https://games.jmir.org/2023/1/e45816 %U https://doi.org/10.2196/45816 %U http://www.ncbi.nlm.nih.gov/pubmed/37477957 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e42377 %T Examining Predictors of Depression and Anxiety Symptom Change in Cognitive Behavioral Immersion: Observational Study %A Ezawa,Iony D %A Hollon,Steven D %A Robinson,Noah %+ Department of Psychology, University of Southern California, 3620 McClintock Ave, Los Angeles, CA, 90089, United States, 1 213 740 2203, ezawa@usc.edu %K Cognitive Behavioral Immersion %K virtual reality %K metaverse %K alliance %K social support %K cognitive behavioral %K depression %K anxiety %K mood %K mental health %K mobile phone %D 2023 %7 14.7.2023 %9 Original Paper %J JMIR Ment Health %G English %X Background: Depressive and anxiety disorders are the most common mental disorders, and there is a critical need for effective, affordable, and accessible interventions. Cognitive Behavioral Immersion (CBI) is a novel group-based cognitive behavioral skills training program delivered by lay coaches in the metaverse that can be accessed through various modalities including virtual reality (VR) head-mounted displays or flat-screen devices. Combining its ability to offer empirically supported therapy skills in a digital setting that can still facilitate interpersonal variables (eg, working alliance and sense of social support) with the aid of lay coaches, CBI has the potential to help fill this critical need. Objective: This study had 2 primary aims. First, we aimed to examine changes in depression and anxiety symptoms in a sample of individuals who participated in CBI. Second, we aimed to examine 2 interpersonal process variables (working alliance and web-based social support) as predictors of symptom changes. We predicted CBI participants would experience depression and anxiety symptom improvements and that such improvements would be associated with an increase in both interpersonal process variables. Methods: The study sample consists of 127 participants who endorsed clinical levels of depression or anxiety symptoms during their first CBI session and attended at least 2 sessions. Participants were asked to complete self-report measures of depression symptoms, anxiety symptoms, alliance, and web-based social support throughout their participation in CBI. Results: Repeated measures ANOVAs determined that depression and anxiety symptom scores differed significantly across sessions (Ps<.01). We also found participants’ web-based social support predicted improvement in depression symptoms (P=.01), but neither the alliance nor web-based social support predicted change in anxiety symptoms (Ps>.05). We also observed a significant difference in anxiety symptoms between participants who used a VR head-mounted display to access CBI and those who did not, such that participants who used VR head-mounted displays endorsed lower anxiety symptoms than those who did not at nearly every session (P=.04). Conclusions: Participation in CBI is associated with both depression and anxiety symptom improvement. Web-based social support may play an important role in fostering changes in depression symptoms. Future studies are encouraged to continue examining the process of change in CBI with special attention paid to methods that can elucidate causal mechanisms of change. %M 37450322 %R 10.2196/42377 %U https://mental.jmir.org/2023/1/e42377 %U https://doi.org/10.2196/42377 %U http://www.ncbi.nlm.nih.gov/pubmed/37450322 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e44998 %T The Use of Virtual Reality Interventions to Promote Positive Mental Health: Systematic Literature Review %A Li Pira,Giorgio %A Aquilini,Beatrice %A Davoli,Alessandro %A Grandi,Silvana %A Ruini,Chiara %+ Department for Life Quality Studies, University of Bologna, Corso d’Augusto 237, Rimini, 47921, Italy, 39 0547 338533, chiara.ruini@unibo.it %K positive mental health %K well-being %K virtual reality %K interventions %K psychopathology %K mobile phone %D 2023 %7 6.7.2023 %9 Review %J JMIR Ment Health %G English %X Background: A large body of research has documented the efficacy of psychological interventions integrated with virtual reality (VR) therapies in treating psychiatric disorders. However, the concept of positive mental health calls for a 2-fold approach in which both symptoms and positive functioning should be addressed by modern interventions. Objective: This review aimed to summarize studies that applied VR therapies by embracing the positive mental health perspective. Methods: A literature search was conducted by entering the following keywords—“virtual reality” AND “intervention” OR “treatment” OR “therapy” AND “mental health” NOT “systematic review or meta-analysis”—and limiting it to “journal article” and the English language. To be included in this review, articles had to present at least one quantitative measure of positive functioning and one quantitative measure of symptoms or distress and had to investigate adult populations, including populations with psychiatric disorders. Results: A total of 20 articles were included. They described various VR protocols that were applied for the treatment of anxiety disorders (5/20, 25%), depression (2/20, 10%), posttraumatic stress disorder (3/20, 15%), psychosis (3/20, 15%), and stress (7/20, 35%). Most of the studies (13/20, 65%) showed the beneficial effects of VR therapies in improving stress and negative symptoms. However, 35% (7/20) of the studies showed no or a small effect on the various dimensions of positivity, particularly in clinical samples. Conclusions: VR interventions might be cost-effective and largely scalable, but further research is needed to develop existing VR software and treatments according to the modern positive mental health approach. %M 37410520 %R 10.2196/44998 %U https://mental.jmir.org/2023/1/e44998 %U https://doi.org/10.2196/44998 %U http://www.ncbi.nlm.nih.gov/pubmed/37410520 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e47391 %T Virtual Reality for Upper Limb Rehabilitation in Patients With Obstetric Brachial Palsy: Systematic Review and Meta-Analysis of Randomized Controlled Trials %A De Miguel-Rubio,Amaranta %A Alba-Rueda,Alvaro %A Millán-Salguero,Elena María %A De Miguel-Rubio,M Dolores %A Moral-Munoz,Jose A %A Lucena-Anton,David %+ Departamento de Enfermería y Fisioterapia, Instituto de Investigación e Innovación Biomédica de Cádiz (INiBICA), Facultad de Enfermería y Fisioterapia, Universidad de Cádiz, Avda. Ana de Viya, 52, Cádiz, 11009, Spain, 34 956015699, joseantonio.moral@uca.es %K neonatal brachial plexus palsy %K virtual reality %K rehabilitation %K upper extremity %K review %K meta-analysis %D 2023 %7 30.6.2023 %9 Review %J J Med Internet Res %G English %X Background: Obstetric brachial palsy (OBP) is a pathology caused by complications during childbirth because of cervical spine elongation, affecting the motor and sensory innervation of the upper limbs. The most common lesion occurs on the C5 and C6 nerve branches, known as Erb-Duchenne palsy. The least common lesion is when all nerve roots are affected (C5-T1), which has the worst prognosis. Virtual reality (VR) is commonly used in neurological rehabilitation for the evaluation and treatment of physical deficits. Objective: This systematic review aims to assess the efficacy of VR in the rehabilitation of upper limb function in patients with OBP. Methods: A search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines in several scientific databases—PubMed, Web of Science, PEDro, Cochrane, MEDLINE, Scopus, and CINAHL—without language or date restrictions and including articles published up to April 2023. The inclusion criteria were established according to the population, intervention, comparison, outcome, and study (PICOS) design framework: children aged <18 years diagnosed with OBP, VR therapy used in addition to conventional therapy or isolated, VR therapy compared with conventional therapy, outcomes related to OBP rehabilitation therapy, and randomized controlled trials (RCTs). The PEDro scale was used to assess the methodological quality of the RCTs, and the Cochrane Collaboration tool was used to assess the risk of bias. The Review Manager statistical software (version 5.4; The Cochrane Collaboration) was used to conduct the meta-analysis. The results were synthesized through information extraction and presented in tables and forest plots. Results: In total, 5 RCTs were included in this systematic review, with 3 (60%) providing information for the meta-analysis. A total of 138 participants were analyzed. All the studies used semi-immersive or nonimmersive VR systems. The statistical analysis showed no favorable results for all outcomes except for the hand-to-mouth subtest of the Mallet scoring system (functional activity; standardized mean difference −0.97, 95% CI −1.67 to −0.27; P=.007). Conclusions: The evidence for the use of VR therapy for upper limb rehabilitation outcomes in patients with OBP was insufficient to support its efficacy and strongly recommend its use. Nevertheless, scientific literature supports the use of VR technologies for rehabilitation as it provides several advantages, such as enhancing the patient’s motivation, providing direct feedback, and focusing the patient’s attention during the intervention. Thus, the use of VR for upper limb rehabilitation in patients with OBP is still in its first stages. Small sample sizes; limited long-term analysis; lack of testing of different doses; and absence of International Classification of Functioning, Disability, and Health–related outcomes were present in the included RCTs, so further research is needed to fully understand the potential of VR technologies as a therapeutic approach for patients with OBP. Trial Registration: PROSPERO CRD42022314264; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=314264 %M 37389922 %R 10.2196/47391 %U https://www.jmir.org/2023/1/e47391 %U https://doi.org/10.2196/47391 %U http://www.ncbi.nlm.nih.gov/pubmed/37389922 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e48927 %T Intergenerational Reminiscence Approach in Improving Emotional Well-Being of Older Asian Americans in Early-Stage Dementia Using Virtual Reality: Protocol for an Explanatory Sequential Mixed Methods Study %A Xu,Ling %A Hagedorn,Aaron %A Chi,Iris %+ School of Social Work, University of Texas at Arlington, 501 W Mitchell Street, Arlington, TX, 76019, United States, 1 817 272 3181, lingxu@uta.edu %K intergenerational reminiscence %K grandparent-grandchild %K dyad %K emotional %K well-being %K Asian American %K older adults %K dementia %K virtual reality %K VR %D 2023 %7 26.6.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: After a dementia diagnosis, Asian Americans experience anxiety, feelings of shame, and other negative effects. Emotional well-being is not only an important aspect of mental health, but also a quality of resilience that helps people bounce back faster from difficulties. However, few studies have addressed issues in developing, implementing, and testing intervention strategies to promote emotional well-being among older adults. Intergenerational solidarity between grandparents and grandchildren has been emphasized in Asian families and is beneficial for the health of persons with dementia. Reminiscence and life review have been identified as potentially effective intervention strategies for helping depression and emotional well-being for older adults. Objective: This proposed study aims to develop and implement an intergenerational reminiscence approach and evaluate its potential feasibility and effectiveness in improving the emotional well-being of older Asian American adults who have a recent dementia diagnosis. Methods: An explanatory sequential mixed methods design will be used in which quantitative data will first be collected and analyzed to identify subsamples of participants who report the greatest and least change in emotional well-being; then, these subsamples will be interviewed to further understand why or why not this intervention works for them. Older adults will receive 6 sessions of life review with grandchildren in virtual reality (VR; 1-1.5 hours each week for 6 weeks), aided by pictures and virtually traveling to important places in their life using Google Earth to look around at those places and remember important times. Quantitative survey data will be collected pre- and postintervention and at a 3-month follow-up. Qualitative interviews with selected participants will also be integrated into the study design. The quantitative data from the surveys will be entered into SPSS (IBM Corp) and analyzed using descriptive analyses, Pearson chi-square tests, nonparametric Friedman tests, or nonparametric Wilcox signed-rank tests (2-tailed). The qualitative data will be transcribed by research assistants, coded by the investigators independently, and analyzed with guidance from content analysis software (Atlas.ti; Atlas.ti Scientific Software Development GmbH). Results: The project was delayed due to the COVID-19 pandemic. Data collection started in late 2021, and 26 participants were recruited as of December 2022. While we are still cleaning and analyzing the quantitative data, the qualitative interviews showed promising results of this intergenerational reminiscence approach in improving emotional well-being among older Asian American adults who have cognitive impairment. Conclusions: Intergenerational reminiscence provided by grandchildren is promising in improving the emotional well-being of grandparents. VR technology is likely to be accepted by older adults. Future research may consider scaling up this pilot into a trackable, replicable model that includes more participants and develops a more rigorous study design with control groups to test the effectiveness of this intervention for older adults with dementia. International Registered Report Identifier (IRRID): DERR1-10.2196/48927 %M 37358895 %R 10.2196/48927 %U https://www.researchprotocols.org/2023/1/e48927 %U https://doi.org/10.2196/48927 %U http://www.ncbi.nlm.nih.gov/pubmed/37358895 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44538 %T Novel Software for High-level Virological Testing: Self-Designed Immersive Virtual Reality Training Approach %A Tsai,Huey-Pin %A Lin,Che-Wei %A Lin,Ying-Jun %A Yeh,Chun-Sheng %A Shan,Yan-Shen %+ Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Road, Tainan, 70428, Taiwan, 886 62353535 ext 2616, tsaihp@mail.ncku.edu.tw %K design %K immersive %K virtual reality %K VR %K high-level clinical virology %K skill training %K testing %K virology %K virological %K medical education %K clinical practice %K simulation %K biotechnology %K molecular %K detection %K pathogen %K development %K software %K teaching %D 2023 %7 21.6.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: To ensure the timely diagnosis of emerging infectious diseases, high-tech molecular biotechnology is often used to detect pathogens and has gradually become the gold standard for virological testing. However, beginners and students are often unable to practice their skills due to the higher costs associated with high-level virological testing, the increasing complexity of the equipment, and the limited number of specimens from patients. Therefore, a new training program is necessary to increase training and reduce the risk of test failure. Objective: The aim of the study is to (1) develop and implement a virtual reality (VR) software for simulated and interactive high-level virological testing that can be applied in clinical practice and skills building or training settings and (2) evaluate the VR simulation’s effectiveness on reaction, learning, and behavior of the students (trainees). Methods: Viral nucleic acid tests on a BD MAX instrument were selected for our VR project because it is a high-tech automatic detection system. There was cooperation between teachers of medical technology and biomedical engineering. Medical technology teachers were responsible for designing the lesson plan, and the biomedical engineering personnel developed the VR software. We designed a novel VR teaching software to simulate cognitive learning via various procedure scenarios and interactive models. The VR software contains 2D VR “cognitive test and learning” lessons and 3D VR “practical skills training” lessons. We evaluated students’ learning effectiveness pre- and posttraining and then recorded their behavior patterns when answering questions, performing repeated exercises, and engaging in clinical practice. Results: The results showed that the use of the VR software met participants’ needs and enhanced their interest in learning. The average posttraining scores of participants exposed to 2D and 3D VR training were significantly higher than participants who were exposed solely to traditional demonstration teaching (P<.001). Behavioral assessments of students pre- and posttraining showed that students exposed to VR-based training to acquire relevant knowledge of advanced virological testing exhibited significantly improved knowledge of specific items posttraining (P<.01). A higher participant score led to fewer attempts when responding to each item in a matching task. Thus, VR can enhance students’ understanding of difficult topics. Conclusions: The VR program designed for this study can reduce the costs associated with virological testing training, thus, increasing their accessibility for students and beginners. It can also reduce the risk of viral infections particularly during disease outbreaks (eg, the COVID-19 pandemic) and also enhance students’ learning motivation to strengthen their practical skills. %M 37342081 %R 10.2196/44538 %U https://www.jmir.org/2023/1/e44538 %U https://doi.org/10.2196/44538 %U http://www.ncbi.nlm.nih.gov/pubmed/37342081 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e45100 %T Positive Psychological Intervention Delivered Using Virtual Reality in Patients on Hemodialysis With Comorbid Depression: Protocol and Design for the Joviality Randomized Controlled Trial %A Hernandez,Rosalba %A Wilund,Ken %A Solai,Killivalavan %A Tamayo,David %A Fast,Drew %A Venkatesan,Prasakthi %A Lash,James P %A Lora,Claudia M %A Martinez,Lizet %A Martin Alemañy,Geovana %A Martinez,Angela %A Kwon,Soonhyung %A Romero,Dana %A Browning,Matthew H E M %A Moskowitz,Judith T %+ Department of Population Health Nursing Science, College of Nursing, University of Illinois Chicago, 845 S Damen Ave, MC 802, Chicago, IL, 60612, United States, 1 3129965706, rherna17@uic.edu %K virtual reality %K hemodialysis %K positive psychology %K emotional well-being %K mindfulness %K depression %K comorbid depression %D 2023 %7 16.6.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is highly prevalent in individuals on hemodialysis, but it is infrequently identified and remains undertreated. In this paper, we present details of the methodology of a randomized controlled trial (RCT) aimed at testing the feasibility and preliminary efficacy of a 5-week positive psychological intervention in individuals on hemodialysis with comorbid depression delivered using immersive virtual reality (VR) technology. Objective: We aim to describe the protocol and design of the Joviality trial whose main objectives are 2-fold: determine the feasibility of the Joviality VR software through metrics capturing rates of recruitment, refusal, retention, noncompliance, and adherence, as well as end-user feedback; and assess preliminary efficacy for outcomes measures of depressive symptoms, psychological well-being and distress, quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalizations. Methods: This 2-arm RCT is scheduled to enroll 84 individuals on hemodialysis with comorbid depression from multiple outpatient centers in Chicago, Illinois, United States. Enrollees will be randomized to the following groups: VR-based Joviality positive psychological intervention or sham VR (2D wildlife footage and nature-based settings with inert music presented using a head-mounted display). To be eligible, individuals must be on hemodialysis for at least 3 months, have Beck Depression Inventory-II scores of ≥11 (ie, indicative of mild-to-severe depressive symptoms), be aged ≥21 years, and be fluent in English or Spanish. The Joviality VR software was built using agile design principles and incorporates fully immersive content, digital avatars, and multiplex features of interactability. Targeted skills of the intervention include noticing positive events, positive reappraisal, gratitude, acts of kindness, and mindful or nonjudgmental awareness. The primary outcomes include metrics of feasibility and acceptability, along with preliminary efficacy focused on decreasing symptoms of depression. The secondary and tertiary outcomes include quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalization rates. There are 4 assessment time points: baseline, immediately after the intervention, 3 months after the intervention, and 6 months after the intervention. We hypothesize that depressive symptoms and hemodialysis-related markers of disease will substantially improve in participants randomized to the VR-based Joviality positive psychology treatment arm compared with those in the attention control condition. Results: This RCT is funded by the National Institute of Diabetes and Digestive and Kidney Diseases and is scheduled to commence participant recruitment in June 2023. Conclusions: This trial will be the first to test custom-built VR software to deliver a positive psychological intervention, chairside, in individuals on hemodialysis to reduce symptoms of depression. Within the context of an RCT using an active control arm, if proven effective, VR technology may become a potent tool to deliver mental health programming in clinical populations during their outpatient treatment sessions. Trial Registration: ClinicalTrials.gov NCT05642364; https://clinicaltrials.gov/ct2/show/NCT05642364 International Registered Report Identifier (IRRID): PRR1-10.2196/45100 %M 37327026 %R 10.2196/45100 %U https://www.researchprotocols.org/2023/1/e45100 %U https://doi.org/10.2196/45100 %U http://www.ncbi.nlm.nih.gov/pubmed/37327026 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45210 %T Using Virtual Reality Head-Mounted Displays to Assess Skills in Emergency Medicine: Validity Study %A Knudsen,Marie Høxbro %A Breindahl,Niklas %A Dalsgaard,Tor-Salve %A Isbye,Dan %A Mølbak,Anne Grethe %A Tiwald,Gerhard %A Svendsen,Morten Bo Søndergaard %A Konge,Lars %A Bergström,Joanna %A Todsen,Tobias %+ Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Entrance 7, 4th floor, section 7046, Inge Lehmann's vej 8, Copenhagen, 2100, Denmark, 45 26708011, mariehoexbroknudsen@gmail.com %K virtual reality %K simulation-based education %K undergraduate medical education %K emergency medicine %K assessment, acute medicine %K Messick framework %K medical education %K head-mounted display %K medical student %K emergency %D 2023 %7 6.6.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Many junior doctors must prepare to manage acutely ill patients in the emergency department. The setting is often stressful, and urgent treatment decisions are needed. Overlooking symptoms and making wrong choices may lead to substantial patient morbidity or death, and it is essential to ensure that junior doctors are competent. Virtual reality (VR) software can provide standardized and unbiased assessment, but solid validity evidence is necessary before implementation. Objective: This study aimed to gather validity evidence for using 360-degree VR videos with integrated multiple-choice questions (MCQs) to assess emergency medicine skills. Methods: Five full-scale emergency medicine scenarios were recorded with a 360-degree video camera, and MCQs were integrated into the scenarios to be played in a head-mounted display. We invited 3 groups of medical students with different experience levels to participate: first- to third-year medical students (novice group), last-year medical students without emergency medicine training (intermediate group), and last-year medical students with completed emergency medicine training (experienced group). Each participant’s total test score was calculated based on the number of correct MCQ answers (maximum score of 28), and the groups’ mean scores were compared. The participants rated their experienced presence in emergency scenarios using the Igroup Presence Questionnaire (IPQ) and their cognitive workload with the National Aeronautics and Space Administration Task Load Index (NASA-TLX). Results: We included 61 medical students from December 2020 to December 2021. The experienced group had significantly higher mean scores than the intermediate group (23 vs 20; P=.04), and the intermediate group had significantly higher scores than the novice group (20 vs 14; P<.001). The contrasting groups’ standard-setting method established a pass-or-fail score of 19 points (68% of the maximum possible score of 28). Interscenario reliability was high, with a Cronbach α of 0.82. The participants experienced the VR scenarios with a high degree of presence with an IPQ score of 5.83 (on a scale from 1-7), and the task was shown to be mentally demanding with a NASA-TLX score of 13.30 (on a scale from 1-21). Conclusions: This study provides validity evidence to support using 360-degree VR scenarios to assess emergency medicine skills. The students evaluated the VR experience as mentally demanding with a high degree of presence, suggesting that VR is a promising new technology for emergency medicine skills assessment. %M 37279049 %R 10.2196/45210 %U https://www.jmir.org/2023/1/e45210 %U https://doi.org/10.2196/45210 %U http://www.ncbi.nlm.nih.gov/pubmed/37279049 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e40044 %T Virtual Reality for Chronic Pain Management Among Historically Marginalized Populations: Systematic Review of Usability Studies %A Dy,Marika %A Olazo,Kristan %A Lisker,Sarah %A Brown,Ellenor %A Saha,Anindita %A Weinberg,Jessica %A Sarkar,Urmimala %+ Department of Medicine, Division of General Internal Medicine, University of California San Francisco, 1001 Potrero Avenue, UCSF DGIM, BLDG 10, Ward 13, San Francisco, CA, 94143, United States, 1 628 206 4273, urmimala.sarkar@ucsf.edu %K virtual reality %K chronic pain management %K systematic review %K historically marginalized populations %K VR %K usability %K pain management %K pain %K chronic pain %D 2023 %7 6.6.2023 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) has potential to improve chronic pain management outcomes. However, the majority of studies assessing VR are conducted in predominantly White populations in well-resourced settings, thus leaving a gap in knowledge of VR use among diverse populations who experience a significant chronic pain burden. Objective: This review aims to examine the extent to which usability of VR for chronic pain management has been studied within historically marginalized patient groups. Methods: We conducted a systematic search to identify studies with usability outcomes located in high-income countries that included a historically marginalized population, defined by a mean age greater than or equal to 65 years, lower educational attainment (greater than or equal to 60% having attained high school education or less), and being a racial or ethnic minority (less than or equal to 50% non-Hispanic White people for studies based in the United States). Results: Our analysis included 5 papers, which we used to conduct a narrative analysis. Three studies examined VR usability as a primary outcome. All studies assessed VR usability using different measures, of which 4 found VR to be usable by their respective study population. Only 1 study found a significant improvement in pain levels post–VR intervention. Conclusions: The use of VR shows promise for chronic pain management, but few studies include populations that are older, have limited educational attainment, or have racial or ethnic diversity. Additional studies with these populations are needed to further develop VR systems that work best for diverse patients with chronic pain. %M 37279039 %R 10.2196/40044 %U https://www.jmir.org/2023/1/e40044 %U https://doi.org/10.2196/40044 %U http://www.ncbi.nlm.nih.gov/pubmed/37279039 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e43015 %T A Virtual Reality App Intervention to Improve Concussion Recognition and Reporting in Athletes Aged 9 to 12 Years: Development and Pilot Testing %A Sullivan,Lindsay %A McKenzie,Lara B %A Roberts,Kristin %A Recker,Robyn %A Schwebel,David C %A Pommering,Thomas %A Yang,Jingzhen %+ Center for Injury Research and Policy, Abigail Wexner Research Institute, Nationwide Children's Hospital, RBIII-WB5403, 700 Children's Drive, Columbus, OH, 43205, United States, 1 614 355 5852, ginger.yang@nationwidechildrens.org %K concussion %K education %K sports %K athlete %K athletic %K virtual reality %K youth %K child %K pediatric %K head injury %K symptom reporting %K symptom recognition %K patient education %K brain injury %K user experience %K user centered design %D 2023 %7 26.5.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Existing concussion education programs for preteen athletes typically do not result in sustained improvements in concussion symptom recognition or reporting behaviors. Virtual reality (VR) technology offers an innovative tool that may improve concussion symptom recognition and reporting behaviors among preteen athletes. Objective: We aimed to describe the design and development of a VR concussion education app, Make Play Safe (MPS), and present findings on the usability and preliminary efficacy of MPS in improving concussion recognition and reporting intentions among soccer athletes aged 9-12 years. Methods: A collaborative user-centered design process was implemented to develop and evaluate MPS, a semi-immersive VR concussion education app designed to address two behavioral outcomes in preteen athletes aged 9-12 years: (1) recognizing concussion and (2) reporting concussion. The development of MPS occurred in three phases: (1) design and development, (2) usability testing, and (3) preliminary efficacy testing. During phase 1, consultations were completed with 6 experts. Additionally, 5 interviews with children who had a history of concussion were conducted to collect feedback about the proof of concept of MPS. During phase 2, a participatory workshop with 11 preteen athletes and a small group discussion with 6 parents and 2 coaches were conducted to explore the usefulness and acceptability of MPS from the perspective of end users. Finally, phase 3 included preliminary efficacy testing with 33 soccer athletes aged 9-12 years to examine changes in concussion-related knowledge, attitudes, and reporting intentions from pre- to postintervention. The data generated from each phase of this study informed the development of the final version of the proof of concept of the VR concussion education app, MPS. Results: Experts positively rated the features of MPS and noted that the design and content were innovative and age-appropriate. Preteens with a history of concussion indicated the scenarios and symptoms portrayed in the app represented well what they experienced while concussed. Further, they stated that the app would be an engaging way for children to learn about concussions. The 11 healthy children in the workshop perceived the app positively, noting that the scenarios were informative and engaging. Results from preliminary efficacy testing revealed increases in many athletes’ knowledge and reporting intentions from pre- to postintervention. Others demonstrated no significant changes or a decrease in knowledge, attitudes, or reporting intentions from pre- to postintervention. Group-level changes in concussion knowledge and intention to report concussions were statistically significant (P<.05), while changes in attitudes toward reporting concussions were not (P=.08). Conclusions: Results suggest VR technology may be an effective and efficient tool to equip preteen athletes with the requisite knowledge and skills to recognize and report future concussions. Further research is recommended to examine the use of VR as an effective strategy to improve concussion-reporting behaviors in preteen athletes. %M 37234027 %R 10.2196/43015 %U https://formative.jmir.org/2023/1/e43015 %U https://doi.org/10.2196/43015 %U http://www.ncbi.nlm.nih.gov/pubmed/37234027 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e44484 %T Technology-Assisted Cognitive Motor Dual-Task Rehabilitation in Chronic Age-Related Conditions: Systematic Review %A Tuena,Cosimo %A Borghesi,Francesca %A Bruni,Francesca %A Cavedoni,Silvia %A Maestri,Sara %A Riva,Giuseppe %A Tettamanti,Mauro %A Liperoti,Rosa %A Rossi,Lorena %A Ferrarin,Maurizio %A Stramba-Badiale,Marco %+ Applied Technology for Neuro-Psychology Lab, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico, Via Alessandro Magnasco 2, Milan, 20145, Italy, 39 02619112726, c.tuena@auxologico.it %K dementia %K Parkinson disease %K falls %K virtual reality %K dual-task %K aging %K rehabilitation %D 2023 %7 22.5.2023 %9 Review %J J Med Internet Res %G English %X Background: Cognitive-motor dual-task (CMDT) is defined as the parallel processing of motor (eg, gait) and cognitive (eg, executive functions) activities and is an essential ability in daily life. Older adults living with frailty, chronic conditions (eg, neurodegenerative diseases), or multimorbidity pay high costs during CMDT. This can have serious consequences on the health and safety of older adults with chronic age-related conditions. However, CMDT rehabilitation can provide useful and effective therapies for these patients, particularly if delivered through technological devices. Objective: This review aims to describe the current technological applications, CMDT rehabilitative procedures, target populations, condition assessment, and efficacy and effectiveness of technology-assisted CMDT rehabilitation in chronic age-related conditions. Methods: We performed this systematic review, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, on 3 databases (Web of Science, Embase, and PubMed). Original articles that were published in English; involved older adults (>65 years) with ≥1 chronic condition and/or frailty; and tested, with a clinical trial, a technology-assisted CMDT rehabilitation against a control condition were included. Risk of bias (Cochrane tool) and the RITES (Rating of Included Trials on the Efficacy-Effectiveness Spectrum) tool were used to evaluate the included studies. Results: A total of 1097 papers were screened, and 8 (0.73%) studies met the predefined inclusion criteria for this review. The target conditions for technology-assisted CMDT rehabilitation included Parkinson disease and dementia. However, little information regarding multimorbidity, chronicity, or frailty status is available. The primary outcomes included falls, balance, gait parameters, dual-task performance, and executive functions and attention. CMDT technology mainly consists of a motion-tracking system combined with virtual reality. CMDT rehabilitation involves different types of tasks (eg, obstacle negotiation and CMDT exercises). Compared with control conditions, CMDT training was found to be pleasant, safe, and effective particularly for dual-task performances, falls, gait, and cognition, and the effects were maintained at midterm follow-up. Conclusions: Despite further research being mandatory, technology-assisted CMDT rehabilitation is a promising method to enhance motor-cognitive functions in older adults with chronic conditions. %M 37213200 %R 10.2196/44484 %U https://www.jmir.org/2023/1/e44484 %U https://doi.org/10.2196/44484 %U http://www.ncbi.nlm.nih.gov/pubmed/37213200 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e42365 %T Physical Versus Virtual Reality–Based Calm Rooms for Psychiatric Inpatients: Quasi-Randomized Trial %A Ilioudi,Maria %A Lindner,Philip %A Ali,Lilas %A Wallström,Sara %A Thunström,Almira Osmanovic %A Ioannou,Michael %A Anving,Nicole %A Johansson,Viktor %A Hamilton,William %A Falk,Örjan %A Steingrimsson,Steinn %+ Psychiatric Department, Sahlgrenska University Hospital, Region Västra Götaland, Journalvägen 5, Gothenburg, 41650, Sweden, 46 722448372, steinn.steingrimsson@vgregion.se %K psychiatry %K psychiatric inpatient care %K relaxation %K sensory room %K virtual reality %D 2023 %7 19.5.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Interest in sensory rooms or so-called “calm rooms” in psychiatric inpatient care has increased significantly. In a hospital setting, their purpose is to introduce a relaxing environment to increase well-being as well as to decrease anxiety and aggressive behaviors. Calm rooms can also be used as a tool to provide self-help through a convenient environment for the patients and, at the same time, strengthen the therapeutic relationship between the patient and the professional. Recent developments in virtual reality (VR) have made virtual calm rooms possible, but these have not yet been evaluated in psychiatric inpatient care. Objective: This study aimed to compare the effects of VR and physical calm rooms on self-reported well-being and physiological markers of arousal. Methods: The study was conducted in 2 inpatient psychiatric wards specializing in bipolar disorder from March 2019 to February 2021. Patients who were already admitted were asked if they were interested in using a calm room and willing to provide ratings. This study relied on the quasi-randomized allocation of patients to the wards, which either had a physical or VR calm room. Self-assessment scales (Montgomery-Åsberg Depression Rating Scale-Self Assessment [MADRS-S], Beck Anxiety Scale, and Clinical Global Impression) were used to determine the participants' baseline level of depressive and anxiety symptoms before their use of the physical or VR calm room. The study determined the state of well-being measured using an 11-point visual analog scale (VAS) as well as arousal measured by blood pressure (systolic and diastolic) and heart rate before and after the use of the calm rooms. The primary end point was self-reported well-being using the VAS. Results: A total of 60 participants were included—40 used the VR calm room and 20 used the physical calm room. The mean age of participants was 39 years and the majority were women (35/60, 58%). Analysis of VAS measurement showed improved well-being at the group level from before to after the intervention (P<.05), with no statistically significant difference in effects between the 2 different interventions. Effects were not moderated by baseline depression levels (dichotomized as MADRS-S >20 or ≤20) despite an overall difference in reported well-being between subgroups. Conclusions: Although the power in this study was low, the findings of this first study indicate comparable effects with respect to well-being and arousal of a VR calm room and a physical calm room. This suggests that a VR calm room can be a viable alternative when the use of a physical calm room is not an option for logistic or other reasons. Trial Registration: ClinicalTrials.gov NCT03918954; https://clinicaltrials.gov/ct2/show/NCT03918954 %M 37204858 %R 10.2196/42365 %U https://www.jmir.org/2023/1/e42365 %U https://doi.org/10.2196/42365 %U http://www.ncbi.nlm.nih.gov/pubmed/37204858 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e44632 %T Evaluating the Feasibility of Emotion Expressions in Avatars Created From Real Person Photos: Pilot Web-Based Survey of Virtual Reality Software %A Dechsling,Anders %A Cogo-Moreira,Hugo %A Gangestad,Jonathan Spydevold %A Johannessen,Sandra Nettum %A Nordahl-Hansen,Anders %+ Department of Education, ICT and Learning, Faculty of Teacher Education and Languages, Østfold University College, B R A veien 4, Halden, NO-1757, Norway, 47 69608000, anders.dechsling@hiof.no %K avatar %K emotion recognition %K emotion %K face %K facial expression %K facial %K images %K real images %K software %K virtual reality %D 2023 %7 11.5.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: The availability and potential of virtual reality (VR) has led to an increase of its application. VR is suggested to be helpful in training elements of social competence but with an emphasis on interventions being tailored. Recognizing facial expressions is an important social skill and thus a target for training. Using VR in training these skills could have advantages over desktop alternatives. Children with autism, for instance, appear to prefer avatars over real images when assessing facial expressions. Available software provides the opportunity to transform profile pictures into avatars, thereby giving the possibility of tailoring according to an individual’s own environment. However, the emotions provided by such software should be validated before application. Objective: Our aim was to investigate whether available software is a quick, easy, and viable way of providing emotion expressions in avatars transformed from real images. Methods: A total of 401 participants from a general population completed a survey on the web containing 27 different images of avatars transformed, using a software, from real images. We calculated the reliability of each image and their level of difficulty using a structural equation modeling approach. We used Bayesian confirmatory factor analysis testing under a multidimensional first-order correlated factor structure where faces showing the same emotions represented a latent variable. Results: Few emotions were correctly perceived and rated as higher than other emotions. The factor loadings indicating the discrimination of the image were around 0.7, which means 49% shared variance with the latent factor that the face is linked with. The standardized thresholds indicating the difficulty level of the images are mostly around average, and the highest correlation is between faces showing happiness and anger. Conclusions: Only using a software to transform profile pictures to avatars is not sufficient to provide valid emotion expressions. Adjustments are needed to increase faces’ discrimination (eg, increasing reliabilities). The faces showed average levels of difficulty, meaning that they are neither very difficult nor very easy to perceive, which fits a general population. Adjustments should be made for specific populations and when applying this technology in clinical practice. %M 37166970 %R 10.2196/44632 %U https://formative.jmir.org/2023/1/e44632 %U https://doi.org/10.2196/44632 %U http://www.ncbi.nlm.nih.gov/pubmed/37166970 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 10 %N %P e43240 %T Adverse Effects of Virtual and Augmented Reality Interventions in Psychiatry: Systematic Review %A Lundin,Robert M %A Yeap,Yuhern %A Menkes,David B %+ Change to Improve Mental Health, Mental Health Drugs and Alcohol Services, Barwon Health, Level 1/126 Little Malop St, Geelong, 3220, Australia, 61 34215000, robert@lundin.no %K virtual reality %K augmented reality %K mental health %K side effects %K adverse events %K hardware %K VR %K software %K AR %K cybersickness %K reporting standards %D 2023 %7 5.5.2023 %9 Review %J JMIR Ment Health %G English %X Background: Virtual reality (VR) and augmented reality (AR) are emerging treatment modalities in psychiatry, which are capable of producing clinical outcomes broadly comparable to those achieved with standard psychotherapies. Objective: Because the side effect profile associated with the clinical use of VR and AR remains largely unknown, we systematically reviewed available evidence of their adverse effects. Methods: A systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework across 3 mental health databases (PubMed, PsycINFO, and Embase) to identify VR and AR interventions targeting mental health diagnoses. Results: Of 73 studies meeting the inclusion criteria, 7 reported worsening clinical symptoms or an increased fall risk. Another 21 studies reported “no adverse effects” but failed to identify obvious adverse effects, mainly cybersickness, documented in their results. More concerningly, 45 of the 73 studies made no mention of adverse effects whatsoever. Conclusions: An appropriate screening tool would help ensure that VR adverse effects are correctly identified and reported. %M 37145841 %R 10.2196/43240 %U https://mental.jmir.org/2023/1/e43240 %U https://doi.org/10.2196/43240 %U http://www.ncbi.nlm.nih.gov/pubmed/37145841 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e45297 %T Acceptance and Privacy Perceptions Toward Video-based Active and Assisted Living Technologies: Scoping Review %A Mujirishvili,Tamara %A Maidhof,Caterina %A Florez-Revuelta,Francisco %A Ziefle,Martina %A Richart-Martinez,Miguel %A Cabrero-García,Julio %+ Department of Nursing, University of Alicante, Carrer San Vicente del Raspeig, Alicante, 03690, Spain, 34 965903400 ext 2581, julio.cabrero@ua.es %K video-based active assisted living technologies %K video monitoring %K life logging %K user acceptance %K privacy %K older adults %K disability %K eHealth %K virtual assistance %K technology %K assistive technology %K virtual assistant %K virtual reality %D 2023 %7 1.5.2023 %9 Review %J J Med Internet Res %G English %X Background: The aging society posits new socioeconomic challenges to which a potential solution is active and assisted living (AAL) technologies. Visual-based sensing systems are technologically among the most advantageous forms of AAL technologies in providing health and social care; however, they come at the risk of violating rights to privacy. With the immersion of video-based technologies, privacy-preserving smart solutions are being developed; however, the user acceptance research about these developments is not yet being systematized. Objective: With this scoping review, we aimed to gain an overview of existing studies examining the viewpoints of older adults and/or their caregivers on technology acceptance and privacy perceptions, specifically toward video-based AAL technology. Methods: A total of 22 studies were identified with a primary focus on user acceptance and privacy attitudes during a literature search of major databases. Methodological quality assessment and thematic analysis of the selected studies were executed and principal findings are summarized. The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines were followed at every step of this scoping review. Results: Acceptance attitudes toward video-based AAL technologies are rather conditional, and are summarized into five main themes seen from the two end-user perspectives: caregiver and care receiver. With privacy being a major barrier to video-based AAL technologies, security and medical safety were identified as the major benefits across the studies. Conclusions: This review reveals a very low methodological quality of the empirical studies assessing user acceptance of video-based AAL technologies. We propose that more specific and more end user– and real life–targeting research is needed to assess the acceptance of proposed solutions. %M 37126390 %R 10.2196/45297 %U https://www.jmir.org/2023/1/e45297 %U https://doi.org/10.2196/45297 %U http://www.ncbi.nlm.nih.gov/pubmed/37126390 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e46136 %T Promoting Social Participation and Recovery Using Virtual Reality–Based Interventions Among People With Mental Health and Substance Use Disorders: Qualitative Study %A Aasen,Jan %A Galaaen,Kari %A Nilsson,Fredrik %A Sørensen,Torgeir %A Lien,Lars %A Leonhardt,Marja %+ Norwegian National Advisory Unit on Concurrent Substance Use and Mental Health Disorders, Innlandet Hospital Trust, Post Box 104, Brummundal, 2381, Norway, 47 99428096, jan.aasen@sykehuset-innlandet.no %K mental health disorders and substance use disorders %K MHD %K SUD %K recovery %K social participation %K social functioning impairments %K virtual reality–based interventions %K VRI %K reflexive thematic analysis %K qualitative study %D 2023 %7 27.4.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: People with mental health disorders (MHDs) and substance use disorders (SUDs) are a highly vulnerable group, particularly affected by social exclusion, marginalization, and disconnectedness. Virtual reality technology holds a potential for simulating social environments and interactions to mitigate the social barriers and marginalization faced by people recovering from MHDs and SUDs. However, it is still unclear how we can harness the greater ecological validity of virtual reality–based interventions targeting social and functional impairments in individuals with MHDs and SUDs. Objective: The aim of this paper was to explore how service providers in community-based MHD and SUD health care services perceive the barriers to social participation among adults recovering from MHDs and SUDs to provide a broader understanding of how learning experiences can be modeled to promote social participation in virtual reality environments. Methods: Two semistructured, open-ended, and dual-moderator focus group interviews were conducted with participants representing different community-based MHD and SUD health care services. Service providers were recruited from their MHD and SUD services in our collaborating municipality in Eastern Norway. We recruited the first participant group at a municipal MHD and SUD assisted living facility for service users with ongoing excessive substance use and severe social dysfunctionality. We recruited the second participant group at a community-based follow-up care service aimed at clients with a broad range of MHDs and SUDs and various levels of social functioning. The qualitative data extracted in the interviews were analyzed, using reflexive thematic analysis. Results: The analysis of the service providers’ perceptions of the barriers to social participation among clients with MHDs and SUDs revealed the following five main themes: challenging or lacking social connections, impaired cognitive functions, negative self-perception, impaired personal functioning, and insufficient social security. The barriers identified are interrelated in a cluster of cognitive, socioemotional, and functional impairments, leading to a severe and diverse complex of barriers to social participation. Conclusions: Social participation relies on people’s capability to use their present social opportunities. Promoting basic human functioning is key to promoting social participation among people with MHDs and SUDs. The findings in this study indicate a need to address cognitive functioning, socioemotional learning, instrumental skills, and complex social functions to meet the complexity and diversity of the identified barriers to social functioning in our target group. Virtual reality–based interventions for promoting social participation should be sequenced into distinct scenarios dedicated to specific learning goals to build complex learning in a step-by-step process based on successively more complex levels of human and social functioning. %M 37104000 %R 10.2196/46136 %U https://formative.jmir.org/2023/1/e46136 %U https://doi.org/10.2196/46136 %U http://www.ncbi.nlm.nih.gov/pubmed/37104000 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e42523 %T Development of an Alcohol Refusal Training in Immersive Virtual Reality for Patients With Mild to Borderline Intellectual Disability and Alcohol Use Disorder: Cocreation With Experts in Addiction Care %A Langener,Simon %A Kolkmeier,Jan %A VanDerNagel,Joanne %A Klaassen,Randy %A van Manen,Jeannette %A Heylen,Dirk %+ Department of Human Media Interaction, University of Twente, Hallenweg 15, Enschede, 7522NH, Netherlands, 31 534898771, s.langener@utwente.nl %K virtual reality %K conversational agent %K embodied agent %K persuasion %K peer pressure %K addiction %K alcohol %K intellectual disability %D 2023 %7 26.4.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: People with mild to borderline intellectual disability (MBID; IQ=50-85) are at risk for developing an alcohol use disorder (AUD). One factor contributing to this risk is sensitivity to peer pressure. Hence, tailored trainings are needed to practice alcohol refusal in impacted patients. Immersive virtual reality (IVR) appears promising to engage patients in dialogs with virtual humans, allowing to practice alcohol refusal realistically. However, requirements for such an IVR have not been studied for MBID/AUD. Objective: This study aims to develop an IVR alcohol refusal training for patients with MBID and AUD. In this work, we cocreated our peer pressure simulation with experienced experts in addiction care. Methods: We followed the Persuasive System Design (PSD) model to develop our IVR alcohol refusal training. With 5 experts from a Dutch addiction clinic for patients with MBID, we held 3 focus groups to design the virtual environment, persuasive virtual human(s), and persuasive dialog. Subsequently, we developed our initial IVR prototype and conducted another focus group to evaluate IVR and procedures for clinical usage, resulting in our final peer pressure simulation. Results: Our experts described visiting a friend at home with multiple friends as the most relevant peer pressure situation in the clinical setting. Based on the identified requirements, we developed a social-housing apartment with multiple virtual friends present. Moreover, we embedded a virtual man with generic appearance to exert peer pressure using a persuasive dialog. Patients can respond to persuasive attempts by selecting (refusal) responses with varying degrees of risk for relapse in alcohol use. Our evaluation showed that experts value a realistic and interactable IVR. However, experts identified lacking persuasive design elements, such as paralanguage, for our virtual human. For clinical usage, a user-centered customization is needed to prevent adverse effects. Further, interventions should be therapist delivered to avoid try-and-error in patients with MBID. Lastly, we identified factors for immersion, as well as facilitators and barriers for IVR accessibility. Conclusions: Our work establishes an initial PSD for IVR for alcohol refusal trainings in patients with MBID and AUD. With this, scholars can create comparable simulations by performing an analogous cocreation, replicate findings, and identify active PSD elements. For peer pressure, conveying emotional information in a virtual human’s voice (eg, paralanguage) seems vital. However, previous rapport building may be needed to ensure that virtual humans are perceived as cognitively capable entities. Future work should validate our PSD with patients and start developing IVR treatment protocols using interdisciplinary teams. %M 37099362 %R 10.2196/42523 %U https://formative.jmir.org/2023/1/e42523 %U https://doi.org/10.2196/42523 %U http://www.ncbi.nlm.nih.gov/pubmed/37099362 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e42944 %T Effects of Exergaming on Musculoskeletal Pain in Older Adults: Systematic Review and Meta-analysis %A Mo,Nan %A Feng,Jin yu %A Liu,Hai xia %A Chen,Xiao yu %A Zhang,Hui %A Zeng,Hui %+ Xiangya Nursing School, Central South University, Xiangya School of Medicine, Number 172, Tong zipo Road, Changsha, 410013, China, 86 1 378 615 5688, zenghui@csu.edu.cn %K aged %K exergaming %K pain %K review %K video game %K virtual reality %D 2023 %7 25.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Exercise is effective for musculoskeletal pain. However, physical, social, and environmental factors make it difficult for older adults to persist in exercising. Exergaming is a new pathway that combines exercise with gameplay and may be helpful for older adults to overcome these difficulties and engage in regular exercise. Objective: This systematic review aimed to determine the efficacy of exergaming to improve musculoskeletal pain in older adults. Methods: The search was performed in 5 databases (PubMed, Embase, CINAHL, Web of Science, and Cochrane Library). The risk of bias for randomized controlled studies was assessed using the revised Cochrane Risk of Bias tool in randomized trials (RoB 2), and the methodological quality was assessed using the Physiotherapy Evidence-Based Database scale. Standardized mean difference and 95% CI were calculated using fixed-effects model meta-analyses in the Review Manager version 5.3 (RevMan 5.3). Results: Seven randomized controlled studies were included, which contained 264 older adults. Three of the 7 studies reported significant improvements in pain after the exergaming intervention, but only 1 reported a significant difference between groups after adjustment for baseline (P<.05), and another reported a significant improvement in thermal pain between the 2 groups (P<.001). The results of the meta-analysis of the 7 studies showed no statistically significant improvement in pain compared to the control group (standardized mean difference –0.22; 95% CI –0.47 to 0.02; P=.07). Conclusions: Although the effects of exergames on musculoskeletal pain in older adults are unknown, exergame training is generally safe, fun, and appealing to older adults. Unsupervised exercise at home is feasible and cost-effective. However, most of the current studies have used commercial exergames, and it is recommended that there should be more cooperation between industries in the future to develop professional rehabilitation exergames that are more suitable for older adults. The sample sizes of the studies included are small, the risk of bias is high, and the results should be interpreted with caution. Further randomized controlled studies with large sample sizes, high quality, and rigor are needed in the future. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42022342325; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=342325 %M 37097717 %R 10.2196/42944 %U https://games.jmir.org/2023/1/e42944 %U https://doi.org/10.2196/42944 %U http://www.ncbi.nlm.nih.gov/pubmed/37097717 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e44183 %T Personalized, Naturalistic Virtual Reality Scenarios Coupled With Web-Based Progressive Muscle Relaxation Training for the General Population: Protocol for a Proof-of-Principle Randomized Controlled Trial %A Pardini,Susanna %A Gabrielli,Silvia %A Olivetto,Silvia %A Fusina,Francesca %A Dianti,Marco %A Forti,Stefano %A Lancini,Cristina %A Novara,Caterina %+ Department of General Psychology, University of Padova, via Venezia 14, Padova, 35131, Italy, 39 3335944315, susanna.pardini@phd.unipd.it %K digital health %K progressive muscular relaxation technique %K mental well-being %K virtual reality therapy %K anxiety %K relaxation %K e-therapy %K e-Health %K virtual reality %K tool %K symptoms %K depression %K quality of life %K coping %D 2023 %7 17.4.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Virtual reality (VR) is an innovative tool that can facilitate exposure to either stressful or relaxing stimuli and enables individuals who have difficulties visualizing scenes to be involved in a more realistic sensorimotor experience. It also facilitates multisensory stimulation, a sense of presence, and achievement of relaxation. VR scenarios representing visual and auditory elements of natural relaxing environments can facilitate the learning of relaxation techniques such as the progressive muscle relaxation technique (PMRT). A complementary standardized technique deployed to reduce anxiety symptoms is the integration of PMRT and guided imagery (GI). Exposure to a pleasant imaginary environment helps the establishment of an association between a relaxing scenario and the relaxation technique, consequently promoting relaxation. Empirical evidence has shown that VR scenarios can increase the effects of relaxation techniques by enabling people to experience emotional conditions in more vivid settings. Objective: The main aim of this pilot study protocol is to investigate the impact on state anxiety of PMRT, associated with a personalized relaxing scenario in VR, and the role of VR scenarios in facilitating the recall of relaxing images and a sense of presence. A secondary aim is to understand if relaxing sessions administered via Zoom are more effective for managing anxiety and stress than a procedural setting based on audio-track guidance. Methods: Based on a longitudinal, between-subject design, 108 university students will be randomly exposed to one of three experimental conditions: (1) PMRT via Zoom and GI exposure, (2) PMRT via Zoom and personalized VR exposure, and (3) PMRT based on audio-track guidance and personalized VR exposure. Individuals are assessed before and after 7 training sessions based on self-report questionnaires investigating anxiety, depression, quality of life, coping strategies, sense of presence, engagement, and side effects related to VR exposure. Heart rate data are also detected by an Mi Band 2 sensor. Results: The experimental procedure is ongoing. In this paper, preliminary data from a sample of 40 participants will be illustrated. The experimental phase is expected to conclude in May 2023, and the final results of the research will be presented in June 2023. Conclusions: The results of this study will help shape the experimental design to apply it on a subsequent randomized controlled trial, also considering clinical samples. This work is expected to measure whether VR is a more engaging and helpful technique in promoting relaxation and decreasing anxiety levels than GI, by making the visualization process easier and by helping people to face more realistic sensory experiences. Assessing the efficacy of the PMRT in alternative delivery modes may extend its applications, especially in situations where the standard procedure is more challenging to be administered. To our knowledge, no equivalent study has been published so far on this matter. Trial Registration: ClinicalTrials.gov NCT05478941; https://clinicaltrials.gov/ct2/show/NCT05478941 International Registered Report Identifier (IRRID): DERR1-10.2196/44183 %M 37067881 %R 10.2196/44183 %U https://www.researchprotocols.org/2023/1/e44183 %U https://doi.org/10.2196/44183 %U http://www.ncbi.nlm.nih.gov/pubmed/37067881 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e41807 %T Characterizing Consumer Smartphone Apps for Virtual Reality–Based Exposure Therapy: Content Analysis %A Sunkara,Charvi %A Thakkar,Rajvi %A Ong,Triton %A Bunnell,Brian E %+ Doxy.me Research, Doxy.me Inc, 3445 Winton Place, Suite #114, Rochester, NY, 14623, United States, 1 8444369963, triton.ong@doxy.me %K virtual reality %K exposure therapy %K phobia %K apps %K smartphones %K VR %K smartphone apps %K mobile phone apps %K content analysis %K treatment %K clinical evaluation %K phobia %K consumer apps %K mHealth apps %D 2023 %7 14.4.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: In vivo exposure therapy is the most effective treatment for phobias but is often impractical. Virtual reality exposure therapy (VRET) can help overcome critical barriers to in vivo exposure therapy. However, accessible mobile software related to VRET is not well understood. Objective: The purpose of our study is to describe the landscape of accessible smartphone apps with potential utility for clinical VRET. Methods: We conducted a content analysis of publicly available smartphone apps related to virtual reality on the Google Play Store and the Apple App Store as of March 2020. Results: The initial search yielded 525 apps, with 84 apps (52 on the Google Play Store and 32 on the Apple App Store) included for analysis. The most common phobic stimulus depicted was bodies of water or weather events (25/84, 29.8%), followed by heights (24/84, 28.6%), and animals (23/84, 27.4%). More than half of the apps were visually abstract (39/84, 53.5%). Most apps were free to use (48/84, 57.1%), while the rest were free to try (22/84, 26.2%) or required payment for use (14/84, 16.7%), with the highest cost for use being US $6. The average overall app rating was 2.9 stars out of 5, but the number of ratings ranged from 0 to 49,233. None of the 84 apps advertised compliance with the Health Insurance Portability and Accountability Act, offered the ability to monitor data, provided clinician control over variables in the app experiences, or explicitly stated use by or development with clinicians. Conclusions: None of the smartphone apps reviewed were explicitly developed for phobia therapy. However, 16 of the 84 included apps were considered ideal candidates to investigate further as part of treatment due to their accessibility, depiction of phobia-relevant stimuli, low or no cost, and high user scores. Most of these apps were visually abstract and free to use, making them accessible and potentially flexible as part of clinical exposure hierarchies. However, none of the apps were designed for clinical use, nor did they provide tools for clinician workflows. Formal evaluation of these accessible smartphone apps is needed to understand the clinical potential of accessible VRET solutions. %M 37058343 %R 10.2196/41807 %U https://www.jmir.org/2023/1/e41807 %U https://doi.org/10.2196/41807 %U http://www.ncbi.nlm.nih.gov/pubmed/37058343 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e40806 %T Appropriate Image Selection With Virtual Reality in Vestibular Rehabilitation: Cross-sectional Study %A Ersin,Kerem %A Gürlek,Emre %A Güler,Hakan %A Kalaycık Ertugay,Çiğdem %A Şerbetçioğlu,Mustafa Bülent %+ Graduate School of Health Sciences, Istanbul Medipol University, Göztepe Mahallesi Atatürk Caddesi No. 40 Beykoz, Istanbul, 34820, Turkey, 90 507 934 71 16, emregurlek1622@gmail.com %K balance %K computerized dynamic posturography %K stress %K vestibular rehabilitation %K vestibular system %K virtual reality %D 2023 %7 13.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: While vestibular rehabilitation with virtual reality (VR) is becoming more popular every day, the disadvantages of this method are not yet clear. Objective: The aim of this study is to examine the effect of the image to be used in vestibular rehabilitation with VR on the systems that provide body posture. Methods: The study was carried out with 36 participants (18 women and 18 men) aged 18 to 30 years. To assess balance control components separately, a sensory organization test was administered to the participants in the presence of stressful and relaxing environment images with VR technology. The State-Trait Anxiety Inventory survey was also used to measure the stress values in the created environments. Results: The State-Trait Anxiety Inventory survey revealed that while stressful videos significantly increased stress, relaxing videos reduced stress. Among measurements obtained in the presence of VR, significant decreases were observed mostly in the visual system data. A significant increase in vestibular system data (P=.01) was observed with a decrease in visual system data (P<.001) when the relaxing image was presented. Additionally, there was a significant difference in the somatosensory (P=.001), composite (P=.002), and visual system (P<.001) data in the presence of stressful videos. Conclusions: Although the use of a VR system for vestibular rehabilitation is relatively new, no extant studies have examined how the image type used in VR can affect the integration of visual system data. Therefore, this study is unique in terms of showing the effects of the stress created by the change in the type of the image used in VR. When VR technology is used for therapeutic vestibular rehabilitation for patients whose balance disorder is due to the vestibular system, stress-free videos should be used. However, the use of stressful videos in VR technology will be beneficial in the rehabilitation of those with balance disorders due to the somatosensory system. %M 37052976 %R 10.2196/40806 %U https://games.jmir.org/2023/1/e40806 %U https://doi.org/10.2196/40806 %U http://www.ncbi.nlm.nih.gov/pubmed/37052976 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e43904 %T Co-design of a Virtual Reality Cognitive Remediation Program for Depression (bWell-D) With Patient End Users and Clinicians: Qualitative Interview Study Among Patients and Clinicians %A Hernandez Hernandez,Maria Elena %A Michalak,Erin %A Choudhury,Nusrat %A Hewko,Mark %A Torres,Ivan %A Menon,Mahesh %A Lam,Raymond W %A Chakrabarty,Trisha %+ University of British Columbia, Faculty of Medicine, Department of Psychiatry, 2255 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada, 1 604 822 7314, elena.hernandez@ntnu.no %K depression %K cognitive remediation %K cognitive dysfunction %K thematic analysis %K virtual reality %K VR %K qualitative study %K user-centered design %K immersive %K co-design %K depressive %K mental health %K mental illness %D 2023 %7 7.4.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Major depressive disorder (MDD) is the leading cause of global disability; however, the existing treatments do not always address cognitive dysfunction—a core feature of MDD. Immersive virtual reality (VR) has emerged as a promising modality to enhance the real-world effectiveness of cognitive remediation. Objective: This study aimed to develop the first prototype VR cognitive remediation program for MDD (“bWell-D”). This study gathered qualitative data from end users early in the design process to enhance its efficacy and feasibility in clinical settings. Methods: Semistructured end-user interviews were conducted remotely (n=15 patients and n=12 clinicians), assessing the participants’ perceptions and goals for a VR cognitive remediation program. Video samples of bWell-D were also shared to obtain feedback regarding the program. The interviews were transcribed, coded, and analyzed via thematic analysis. Results: End users showed an optimistic outlook toward VR as a treatment modality, and perceived it as a novel approach with the potential of having multiple applications. The participants expressed a need for an engaging VR treatment that included realistic and multisensorial settings and activities, as well as customizable features. Some skepticism regarding its effectiveness was also reported, especially when the real-world applications of the practiced skills were not made explicit, as well as some concerns regarding equipment accessibility. A home-based or hybrid (ie, home and clinic) treatment modality was preferred. Conclusions: Patients and clinicians considered bWell-D interesting, acceptable, and potentially feasible, and provided suggestions to enhance its real-world applicability. The inclusion of end-user feedback is encouraged when developing future VR programs for clinical purposes. %M 37027183 %R 10.2196/43904 %U https://games.jmir.org/2023/1/e43904 %U https://doi.org/10.2196/43904 %U http://www.ncbi.nlm.nih.gov/pubmed/37027183 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 10 %N %P e40932 %T Designing Virtual Natural Environments for Older Adults: Think-Aloud Study %A Lundstedt,Rikard %A Persson,Johanna %A Håkansson,Carita %A Frennert,Susanne %A Wallergård,Mattias %+ Ergonomics & Aerosol Technology, Department of Design Sciences, Lund University, Box 118, Lund, 221 00, Sweden, 46 46 222 79 16, rikard.lundstedt@design.lth.se %K virtual natural environments %K user-centered design %K qualitative method %K real-time 3D graphics %K older adults %D 2023 %7 7.4.2023 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Spending time in natural environments is beneficial for human health, but many older adults have limited or no access to natural environments. Virtual reality technology may be a means to facilitate nature experiences, and so, there is a need for knowledge on how to design virtual restorative natural environments for older adults. Objective: The aim of this study was to identify, implement, and test older adults’ preferences and ideas regarding virtual natural environments. Methods: A total of 14 older adults (mean age 75, SD 5.9 years) participated in an iterative process to design such an environment. We used think-aloud protocols and qualitative content analysis and established questionnaires that targeted usability, affective aspects, and side effects. These data guided the design decisions for incremental implementations of a prototype. Results: The participants’ preferences included trueness to reality in terms of rendition and behavior; traces of human activity and natural processes that trigger the imagination and provide believability; the ability to roam, explore, and interact with the environment; and a familiar, relatable environment that evokes memories. The iterative design process resulted in a prototype featuring many of the participants’ ideas and preferences, including a seated locomotion technique, animals, a boat ride, the discovery of a boat wreck, and apple picking. The questionnaire results indicated high perceived usability, interest, and enjoyment; low pressure and tension; moderate value and usefulness; and negligible side effects. Conclusions: We suggested 3 principles for virtual natural environments for older adults: realness, interactivity, and relatedness. Virtual natural environments should also provide a diversity of content and activities to accommodate the heterogeneity in older adults’ preferences. These results can contribute to a framework for designing virtual natural environments for older adults. However, these findings need to be tested and potentially revised in future studies. %M 37027206 %R 10.2196/40932 %U https://humanfactors.jmir.org/2023/1/e40932 %U https://doi.org/10.2196/40932 %U http://www.ncbi.nlm.nih.gov/pubmed/37027206 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e38256 %T Virtual Reality Intervention for Patients With Neck Pain: Systematic Review and Meta-analysis of Randomized Controlled Trials %A Guo,Qifan %A Zhang,LIMing %A Gui,Chenfan %A Chen,Guanghui %A Chen,Yi %A Tan,Huixin %A Su,Wei %A Zhang,Ruishi %A Gao,Qiang %+ Department of Rehabilitation Medicine, West China Hospital, Sichuan University, No. 37 Guoxuexiang, Sichuan Province, Chengdu, 610041, China, 86 18980605992, gaoqiang_hxkf@163.com %K meta-analysis %K virtual reality %K neck pain %K disability %K systematic review %D 2023 %7 3.4.2023 %9 Review %J J Med Internet Res %G English %X Background: Neck pain is a prevalent condition that causes an enormous health care burden due to the lack of efficient therapies. As a promising technology, virtual reality (VR) has shown advantages in orthopedic rehabilitation. However, there is no meta-analysis evaluating the effectiveness of VR in neck pain management. Objective: This study aims to review original randomized controlled trials (RCTs) evaluating the effectiveness of VR for neck pain and to provide evidence for the clinical application of a new alternative approach for pain management. Methods: A total of 9 electronic databases were systematically searched for relevant articles published from inception to October 2022. RCTs in English or Chinese that investigated VR therapy for participants with neck pain were included. The methodological quality and the evidence level were assessed using the Cochrane Back and Neck Risk of Bias tool and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guideline, respectively. Results: A total of 8 studies with 382 participants were included for the final analysis. For the pain intensity, the overall pooled effect size was 0.51, with a standardized mean difference (SMD) of −0.51 (95% CI −0.91 to −0.11; GRADE: moderate), favoring VR therapy compared with controls. Subgroups analyses revealed that significant differences in pain intensity were found in the multimodal intervention (VR in combination with other therapies) than in other interventions (SMD −0.45, 95% CI −0.78 to −0.13; GRADE: moderate), and better analgesic effects were also observed in patients with chronic neck pain receiving VR intervention (SMD −0.70, 95% CI −1.08 to −0.32; GRADE: moderate) and patients treated in the clinic or research unit (SMD −0.52, 95% CI −0.99 to −0.05; GRADE: moderate) than controls. Regarding other health outcomes, the VR experienced less disability, lower kinesiophobia, and greater kinematic function (cervical range of motion, mean and peak velocity). Nevertheless, the follow-up effects of VR therapy on pain intensity and disability were not found. Conclusions: Existing moderate evidence support VR as a beneficial nonpharmacological approach to improve pain intensity in patients with neck pain, with advantages to multimodal intervention, people with chronic neck pain, and clinic or research unit–based VR therapy. However, the limited quantity and high heterogeneity of the articles limit our findings. Trial Registration: PROSPERO CRD42020188635; https://tinyurl.com/2839jh8w %M 37010891 %R 10.2196/38256 %U https://www.jmir.org/2023/1/e38256 %U https://doi.org/10.2196/38256 %U http://www.ncbi.nlm.nih.gov/pubmed/37010891 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e45211 %T Perceptions About Augmented Reality in Remote Medical Care: Interview Study of Emergency Telemedicine Providers %A Dinh,Alana %A Tseng,Emily %A Yin,Andrew Lukas %A Estrin,Deborah %A Greenwald,Peter %A Fortenko,Alexander %+ Medical College, Weill Cornell Medicine, 1300 York Avenue, New York, NY, 10021, United States, 1 212 746 1067, ald4006@med.cornell.edu %K augmented reality %K telemedicine %K telehealth %K emergency medicine %K education %K mobile phone %D 2023 %7 28.3.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: Augmented reality (AR) and virtual reality (VR) have increasingly appeared in the medical literature in the past decade, with AR recently being studied for its potential role in remote health care delivery and communication. Recent literature describes AR’s implementation in real-time telemedicine contexts across multiple specialties and settings, with remote emergency services in particular using AR to enhance disaster support and simulation education. Despite the introduction of AR in the medical literature and its potential to shape the future of remote medical services, studies have yet to investigate the perspectives of telemedicine providers regarding this novel technology. Objective: This study aimed to understand the applications and challenges of AR in telemedicine anticipated by emergency medicine providers with a range of experiences in using telemedicine and AR or VR technology. Methods: Across 10 academic medical institutions, 21 emergency medicine providers with variable exposures to telemedicine and AR or VR technology were recruited for semistructured interviews via snowball sampling. The interview questions focused on various potential uses of AR, anticipated obstacles that prevent its implementation in the telemedicine area, and how providers and patients might respond to its introduction. We included video demonstrations of a prototype using AR during the interviews to elicit more informed and complete insights regarding AR’s potential in remote health care. Interviews were transcribed and analyzed via thematic coding. Results: Our study identified 2 major areas of use for AR in telemedicine. First, AR is perceived to facilitate information gathering by enhancing observational tasks such as visual examination and granting simultaneous access to data and remote experts. Second, AR is anticipated to supplement distance learning of both minor and major procedures and nonprocedural skills such as cue recognition and empathy for patients and trainees. AR may also supplement long-distance education programs and thereby support less specialized medical facilities. However, the addition of AR may exacerbate the preexisting financial, structural, and literacy barriers to telemedicine. Providers seek value demonstrated by extensive research on the clinical outcome, satisfaction, and financial benefits of AR. They also seek institutional support and early training before adopting novel tools such as AR. Although an overall mixed reception is anticipated, consumer adoption and awareness are key components in AR’s adoption. Conclusions: AR has the potential to enhance the ability to gather observational and medical information, which would serve a diverse set of applications in remote health care delivery and education. However, AR faces obstacles similar to those faced by the current telemedicine technology, such as lack of access, infrastructure, and familiarity. This paper discusses the potential areas of investigation that would inform future studies and approaches to implementing AR in telemedicine. %M 36976628 %R 10.2196/45211 %U https://formative.jmir.org/2023/1/e45211 %U https://doi.org/10.2196/45211 %U http://www.ncbi.nlm.nih.gov/pubmed/36976628 %0 Journal Article %@ 2561-3278 %I JMIR Publications %V 8 %N %P e42709 %T Mixed Reality Platforms in Telehealth Delivery: Scoping Review %A Worlikar,Hemendra %A Coleman,Sean %A Kelly,Jack %A O’Connor,Sadhbh %A Murray,Aoife %A McVeigh,Terri %A Doran,Jennifer %A McCabe,Ian %A O'Keeffe,Derek %+ Health Innovation Via Engineering Laboratory, Cúram Science Foundation Ireland Research Centre for Medical Devices, University of Galway, Lambe Institute, Galway, H91 TK33, Ireland, 353 899413431, worlikarhemendra09@gmail.com %K augmented reality %K virtual reality %K mixed realities %K telemedicine %K eHealth %K mobile health %K mHealth %D 2023 %7 24.3.2023 %9 Review %J JMIR Biomed Eng %G English %X Background: The distinctive features of the digital reality platforms, namely augmented reality (AR), virtual reality (VR), and mixed reality (MR) have extended to medical education, training, simulation, and patient care. Furthermore, this digital reality technology seamlessly merges with information and communication technology creating an enriched telehealth ecosystem. This review provides a composite overview of the prospects of telehealth delivered using the MR platform in clinical settings. Objective: This review identifies various clinical applications of high-fidelity digital display technology, namely AR, VR, and MR, delivered using telehealth capabilities. Next, the review focuses on the technical characteristics, hardware, and software technologies used in the composition of AR, VR, and MR in telehealth. Methods: We conducted a scoping review using the methodological framework and reporting design using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. Full-length articles in English were obtained from the Embase, PubMed, and Web of Science databases. The search protocol was based on the following keywords and Medical Subject Headings to obtain relevant results: “augmented reality,” “virtual reality,” “mixed-reality,” “telemedicine,” “telehealth,” and “digital health.” A predefined inclusion-exclusion criterion was developed in filtering the obtained results and the final selection of the articles, followed by data extraction and construction of the review. Results: We identified 4407 articles, of which 320 were eligible for full-text screening. A total of 134 full-text articles were included in the review. Telerehabilitation, telementoring, teleconsultation, telemonitoring, telepsychiatry, telesurgery, and telediagnosis were the segments of the telehealth division that explored the use of AR, VR, and MR platforms. Telerehabilitation using VR was the most commonly recurring segment in the included studies. AR and MR has been mainly used for telementoring and teleconsultation. The most important technical features of digital reality technology to emerge with telehealth were virtual environment, exergaming, 3D avatars, telepresence, anchoring annotations, and first-person viewpoint. Different arrangements of technology—3D modeling and viewing tools, communication and streaming platforms, file transfer and sharing platforms, sensors, high-fidelity displays, and controllers—formed the basis of most systems. Conclusions: This review constitutes a recent overview of the evolving digital AR and VR in various clinical applications using the telehealth setup. This combination of telehealth with AR, VR, and MR allows for remote facilitation of clinical expertise and further development of home-based treatment. This review explores the rapidly growing suite of technologies available to users within the digital health sector and examines the opportunities and challenges they present. %M 38875694 %R 10.2196/42709 %U https://biomedeng.jmir.org/2023/1/e42709 %U https://doi.org/10.2196/42709 %U http://www.ncbi.nlm.nih.gov/pubmed/38875694 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 7 %N %P e41829 %T Developing a Virtual Reality Educational Tool to Stimulate Emotions for Learning: Focus Group Study %A Lie,Silje Stangeland %A Røykenes,Kari %A Sæheim,Aleksandra %A Groven,Karen Synne %+ Faculty of Health Studies, VID Specialized University, Misjonsmarka 12, Stavanger, 4024, Norway, 47 990 90 005, silje.lie@vid.no %K virtual reality %K 360° video %K learning %K experiences %K emotions %K health care and social work higher education %D 2023 %7 20.3.2023 %9 Original Paper %J JMIR Form Res %G English %X Background: By watching 360° videos in virtual reality headsets, students may experience being immersed in the portrayed situation. There is a paucity of empirical studies on the application of immersive 360° videos watched in virtual reality headsets for students in health care and social work education and the pedagogical theory guiding the development of such educational tools. This led to our interest in exploring how a virtual reality educational tool involving 360° videos can stimulate emotions and how this can be used as a pedagogical tool in these educational programs. Objective: The aim of this study was to explore the experiences of faculty members and students regarding a prototype 360° video watched in virtual reality headsets during the development phase of an educational project. We addressed the following research questions: How does the virtual reality prototype stimulate emotions? How can virtual reality be used in higher education for health care and social work students? Methods: We used a qualitative design and collected data through focus group interviews with project participants. The data were analyzed using qualitative content analysis. Results: Our analysis identified 2 main themes in participants’ experiences with the virtual reality prototype. The first theme highlights that when participants experienced watching the 360° video in a virtual reality headset, it stimulated their emotions as an authentic professional experience would. The second theme, contextualization of virtual reality, highlights participants’ perceptions of how the virtual reality experience should be incorporated into a safe educational context. Conclusions: Our findings suggest that 360° videos with human actors who use eye contact with the camera can trigger emotions in the viewer and therefore serve as a pedagogic tool that can create authentic professional experiences for students. The participants expressed the view that the virtual reality educational tool could be used to prepare students for real-life practice in health care and social work. However, they underlined that 360° videos in virtual reality need to be contextualized in educational programs to create a safe environment for learning and to ensure follow-up on the emotions such experiences can trigger in students. Our results highlight the perceived importance of allowing students to reflect on the virtual reality experience in a safe setting and of follow-up by faculty members. In-person follow-up with students can be resource intensive for programs with large numbers of students and makes it challenging to offer repeated training, something that has been identified as one of the benefits of virtual reality. %M 36939819 %R 10.2196/41829 %U https://formative.jmir.org/2023/1/e41829 %U https://doi.org/10.2196/41829 %U http://www.ncbi.nlm.nih.gov/pubmed/36939819 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e37599 %T Application of Virtual and Augmented Reality Technology in Hip Surgery: Systematic Review %A Sun,Peng %A Zhao,Yao %A Men,Jie %A Ma,Zhe-Ru %A Jiang,Hao-Zhuo %A Liu,Cheng-Yan %A Feng,Wei %+ Department of Bone and Joint Surgery, Orthopaedic Center, The First Hospital of Jilin University, 1 Xinmin Street, Chang chun, 130000, China, 86 0431 81875596, feng_wei@jlu.edu.cn %K virtual reality %K augmented reality %K hip %K pelvis %K arthroplasty %K mobile phone %D 2023 %7 10.3.2023 %9 Review %J J Med Internet Res %G English %X Background: Virtual and augmented reality (VAR) represents a combination of current state-of-the-art computer and imaging technologies and has the potential to be a revolutionary technology in many surgical fields. An increasing number of investigators have developed and applied VAR in hip-related surgery with the aim of using this technology to reduce hip surgery–related complications, improve surgical success rates, and reduce surgical risks. These technologies are beginning to be widely used in hip-related preoperative operation simulation and training, intraoperative navigation tools in the operating room, and postoperative rehabilitation. Objective: With the aim of reviewing the current status of virtual reality (VR) and augmented reality (AR) in hip-related surgery and summarizing its benefits, we discussed and briefly described the applicability, advantages, limitations, and future perspectives of VR and AR techniques in hip-related surgery, such as preoperative operation simulation and training; explored the possible future applications of AR in the operating room; and discussed the bright prospects of VR and AR technologies in postoperative rehabilitation after hip surgery. Methods: We searched the PubMed and Web of Science databases using the following key search terms: (“virtual reality” OR “augmented reality”) AND (“pelvis” OR “hip”). The literature on basic and clinical research related to the aforementioned key search terms, that is, studies evaluating the key factors, challenges, or problems of using of VAR technology in hip-related surgery, was collected. Results: A total of 40 studies and reports were included and classified into the following categories: total hip arthroplasty, hip resurfacing, femoral neck fracture, pelvic fracture, acetabular fracture, tumor, arthroscopy, and postoperative rehabilitation. Quality assessment could be performed in 30 studies. Among the clinical studies, there were 16 case series with an average score of 89 out of 100 points (89%) and 1 case report that scored 81 (SD 10.11) out of 100 points (81%) according to the Joanna Briggs Institute Critical Appraisal Checklist. Two cadaveric studies scored 85 of 100 points (85%) and 92 of 100 points (92%) according to the Quality Appraisal for Cadaveric Studies scale. Conclusions: VR and AR technologies hold great promise for hip-related surgeries, especially for preoperative operation simulation and training, feasibility applications in the operating room, and postoperative rehabilitation, and have the potential to assist orthopedic surgeons in operating more accurately and safely. More comparative studies are necessary, including studies focusing on clinical outcomes and cost-effectiveness. %M 36651587 %R 10.2196/37599 %U https://www.jmir.org/2023/1/e37599 %U https://doi.org/10.2196/37599 %U http://www.ncbi.nlm.nih.gov/pubmed/36651587 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e39989 %T The Effects of Immersive Virtual Reality Applications on Enhancing the Learning Outcomes of Undergraduate Health Care Students: Systematic Review With Meta-synthesis %A Liu,Justina Yat Wa %A Yin,Yue-Heng %A Kor,Patrick Pui Kin %A Cheung,Daphne Sze Ki %A Zhao,Ivy Yan %A Wang,Shanshan %A Su,Jing Jing %A Christensen,Martin %A Tyrovolas,Stefanos %A Leung,Angela Y M %+ School of Nursing, The Hong Kong Polytechnic University, No 11 Yuk Choi Road, Hong Kong, Hong Kong, 852 2766 4097, justina.liu@polyu.edu.hk %K immersive virtual reality %K virtual reality %K effects %K undergraduate health care education %K systematic review %K meta-synthesis %D 2023 %7 6.3.2023 %9 Review %J J Med Internet Res %G English %X Background: Immersive virtual reality (IVR) applications are gaining popularity in health care education. They provide an uninterrupted, scaled environment capable of simulating the full magnitude of sensory stimuli present in busy health care settings and increase students’ competence and confidence by providing them with accessible and repeatable learning opportunities in a fail-safe environment. Objective: This systematic review aimed to evaluate the effects of IVR teaching on the learning outcomes and experiences of undergraduate health care students compared with other teaching methods. Methods: MEDLINE, Embase, PubMed, and Scopus were searched (last search on May 2022) for randomized controlled trials (RCTs) or quasi-experimental studies published in English between January 2000 and March 2022. The inclusion criteria were studies involving undergraduate students majoring in health care, IVR teaching, and evaluations of students’ learning outcomes and experiences. The methodological validity of the studies was examined using the Joanna Briggs Institute standard critical appraisal instruments for RCTs or quasi-experimental studies. The findings were synthesized without a meta-analysis using vote counting as the synthesis metric. A binomial test with P<.05 was used to test for statistical significance using SPSS (version 28; IBM Corp). The overall quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation tool. Results: A total of 17 articles from 16 studies totaling 1787 participants conducted between 2007 and 2021 were included. The undergraduate students in the studies majored in medicine, nursing, rehabilitation, pharmacy, biomedicine, radiography, audiology, or stomatology. The IVR teaching domains included procedural training (13/16, 81%), anatomical knowledge (2/16, 12%), and orientation to the operating room setting (1/16, 6%). The quality of the 75% (12/16) of RCT studies was poor, with unclear descriptions of randomization, allocation concealment, and outcome assessor blinding procedures. The overall risk of bias was relatively low in the 25% (4/16) of quasi-experimental studies. A vote count showed that 60% (9/15; 95% CI 16.3%-67.7%; P=.61) of the studies identified similar learning outcomes between IVR teaching and other teaching approaches regardless of teaching domains. The vote count showed that 62% (8/13) of the studies favored using IVR as a teaching medium. The results of the binomial test (95% CI 34.9%-90%; P=.59) did not show a statistically significant difference. Low-level evidence was identified based on the Grading of Recommendations Assessment, Development, and Evaluation tool. Conclusions: This review found that undergraduate students had positive learning outcomes and experiences after engaging with IVR teaching, although the effects may be similar to those of other forms of virtual reality or conventional teaching methods. Given the identification of risk of bias and low level of the overall evidence, more studies with a larger sample size and robust study design are required to evaluate the effects of IVR teaching. Trial Registration: International prospective register of systematic reviews (PROSPERO) CRD42022313706; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=313706 %M 36877550 %R 10.2196/39989 %U https://www.jmir.org/2023/1/e39989 %U https://doi.org/10.2196/39989 %U http://www.ncbi.nlm.nih.gov/pubmed/36877550 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e41091 %T Research Status and Emerging Trends in Virtual Reality Rehabilitation: Bibliometric and Knowledge Graph Study %A Fan,Ting %A Wang,Xiaobei %A Song,Xiaoxi %A Zhao,Gang %A Zhang,Zhichang %+ Department of Computer, School of Intelligent Medicine, China Medical University, No 77 Puhe Road, Shenyang North New Area, Shenyang, 110122, China, 86 18900910770, zczhang@cmu.edu.cn %K mobility %K rehabilitation %K virtual reality %K bibliometric %K technology %K training %K interactive %K research %K exercise %K resources %K cerebral palsy %K adult %K video games %D 2023 %7 6.3.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) technology has been widely used in rehabilitation training because of its immersive, interactive, and imaginative features. A comprehensive bibliometric review is required to help researchers focus on future directions based on the new definitions of VR technologies in rehabilitation, which reveal new situations and requirements. Objective: Herein, we aimed to summarize effective research methods for and potential innovative approaches to VR rehabilitation by evaluating publications from various countries to encourage research on efficient strategies to improve VR rehabilitation. Methods: The SCIE (Science Citation Index Expanded) database was searched on January 20, 2022, for publications related to the application of VR technology in rehabilitation research. We found 1617 papers, and we created a clustered network, using the 46,116 references cited in the papers. CiteSpace V (Drexel University) and VOSviewer (Leiden University) were used to identify countries, institutions, journals, keywords, cocited references, and research hot spots. Results: A total of 63 countries and 1921 institutes have contributed publications. The United States of America has taken the leading position in this field; it has the highest number of publications; the highest h-index; and the largest collaborative network, which includes other countries. The reference clusters of SCIE papers were divided into the following nine categories: kinematics, neurorehabilitation, brain injury, exergames, aging, motor rehabilitation, mobility, cerebral palsy, and exercise intensity. The research frontiers were represented by the following keywords: video games (2017-2021), and young adults (2018-2021). Conclusions: Our study comprehensively assesses the current research state of VR rehabilitation and analyzes the current research hot spots and future trends in the field, with the aims of providing resources for more intensive investigation and encouraging more researchers to further develop VR rehabilitation. %M 36877556 %R 10.2196/41091 %U https://games.jmir.org/2023/1/e41091 %U https://doi.org/10.2196/41091 %U http://www.ncbi.nlm.nih.gov/pubmed/36877556 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43649 %T Virtual Reality for Emergency Medicine Training in Medical School: Prospective, Large-Cohort Implementation Study %A Mahling,Moritz %A Wunderlich,Robert %A Steiner,Daniel %A Gorgati,Eleonora %A Festl-Wietek,Teresa %A Herrmann-Werner,Anne %+ University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Eberhard Karls University, Hoppe-Seyler-Str.3, Tübingen, 72076, Germany, 49 70712968039, Robert.Wunderlich@med.uni-tuebingen.de %K emergency medicine %K resuscitation %K virtual reality %K simulation %K undergraduate medical education %K Germany %K medical education %K virtual training %K digital learning %K medical student %D 2023 %7 3.3.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR)–based simulation is being increasingly used to train medical students in emergency medicine. However, because the usefulness of VR may depend on various factors, the best practices for implementing this technology in the medical school curriculum are yet to be determined. Objective: The overall objective of our study was to assess the perceptions of a large cohort of students toward VR-based training and to identify the associations between these attitudes and individual factors, such as gender and age. Methods: The authors implemented a voluntary, VR-based teaching session in the emergency medicine course at the Medical Faculty in Tübingen, Germany. Fourth-year medical students were invited to participate on a voluntary basis. Afterward, we asked the students about their perceptions, collected data on individual factors, and assessed the test scores achieved by them in the VR-based assessment scenarios. We used ordinal regression analysis and linear mixed-effects analysis to detect the impact of individual factors on the questionnaire answers. Results: A total of 129 students participated in our study (mean age 24.7, SD 2.9 years; n=51, 39.8% male; n=77, 60.2% female). No student had previously used VR for learning, and only 4.7% (n=6) of the students had prior experience with VR. Most of the students agreed that VR can convey complex issues quickly (n=117, 91%), that VR is a useful addition to mannequin-based courses (n=114, 88%) or could even replace them (n=93, 72%), and that VR simulations should also be used for examinations (n=103, 80%). However, female students showed significantly less agreement with these statements. Most students perceived the VR scenario as realistic (n=69, 53%) and intuitive (n=62, 48%), with a relatively lower agreement for the latter among female respondents. We found high agreement among all participants (n=88, 69%) for immersion but strong disagreement (n=69, 54%) for empathy with the virtual patient. Only 3% (n=4) of the students felt confident regarding the medical content. Responses for the linguistic aspects of the scenario were largely mixed; however, most of the students were confident with the English language (not native) scenarios and disagreed that the scenario should be offered in their native language (female students agreed more strongly than male students). Most of the students would not have felt confident with the scenarios in a real-world context (n=69, 53%). Although physical symptoms during VR sessions were reported by 16% (n=21) of the respondents, this did not lead to the termination of the simulation. The regression analysis revealed that the final test scores were not influenced by gender, age, or prior experience in emergency medicine or with virtual reality. Conclusions: In this study, we observed a strong positive attitude in medical students toward VR-based teaching and assessment. However, this positivity was comparatively lower among female students, potentially indicating that gender differences need to be addressed when VR is implemented in the curriculum. Interestingly, gender, age, or prior experience did not influence the final test scores. Furthermore, confidence regarding the medical content was low, which suggests that the students may need further training in emergency medicine. %M 36867440 %R 10.2196/43649 %U https://www.jmir.org/2023/1/e43649 %U https://doi.org/10.2196/43649 %U http://www.ncbi.nlm.nih.gov/pubmed/36867440 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43634 %T Effects of Fetal Images Produced in Virtual Reality on Maternal-Fetal Attachment: Randomized Controlled Trial %A Lee,Kyong-No %A Kim,Hyeon Ji %A Choe,Kiroong %A Cho,Aeri %A Kim,Bohyoung %A Seo,Jinwook %A Myung,Woojae %A Park,Jee Yoon %A Oh,Kyung Joon %+ Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro, 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea, 82 31 787 7266, jyparkmd08@snu.ac.kr %K maternal-fetal attachment %K virtual reality %K ultrasound %K pregnancy %K fetus %K postpartum depression %K pediatric %K mobile app %K mental well-being %K mobile health app %K maternal health %K women's health %D 2023 %7 24.2.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Maternal-fetal attachment (MFA) has been reported to be associated with the postpartum mother-infant relationship. Seeing the fetus through ultrasound might influence MFA, and the effect could be increased by more realistic images, such as those generated in virtual reality (VR). Objective: The aim was to determine the effect of fetal images generated in VR on MFA and depressive symptoms through a prenatal-coaching mobile app. Methods: This 2-arm parallel randomized controlled trial involved a total of 80 pregnant women. Eligible women were randomly assigned to either a mobile app–only group (n=40) or an app plus VR group (n=40). The VR group experienced their own baby’s images generated in VR based on images obtained from fetal ultrasonography. The prenatal-coaching mobile app recommended health behavior for the pregnant women according to gestational age, provided feedback on entered data for maternal weight, blood pressure, and glucose levels, and included a private diary service for fetal ultrasound images. Both groups received the same app, but the VR group also viewed fetal images produced in VR; these images were stored in the app. All participants filled out questionnaires to assess MFA, depressive symptoms, and other basic medical information. The questionnaires were filled out again after the interventions. Results: Basic demographic data were comparable between the 2 groups. Most of the assessments showed comparable results for the 2 groups, but the mean score to assess interaction with the fetus was significantly higher for the VR group than the control group (0.4 vs 0.1, P=.004). The proportion of participants with an increased score for this category after the intervention was significantly higher in the VR group than the control group (43% vs 13%, P=.005). The feedback questionnaire revealed that scores for the degree of perception of fetal appearance all increased after the intervention in the VR group. Conclusions: The use of a mobile app with fetal images in VR significantly increased maternal interaction with the fetus. Trial Registration: ClinicalTrials.gov NCT04942197; https://clinicaltrials.gov/ct2/show/NCT04942197 %M 36826976 %R 10.2196/43634 %U https://www.jmir.org/2023/1/e43634 %U https://doi.org/10.2196/43634 %U http://www.ncbi.nlm.nih.gov/pubmed/36826976 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e38619 %T A New Option for Pain Prevention Using a Therapeutic Virtual Reality Solution for Bone Marrow Biopsy (REVEH Trial): Open-Label, Randomized, Multicenter, Phase 3 Study %A Le Du,Katell %A Septans,Anne-Lise %A Maloisel,Frédéric %A Vanquaethem,Hélène %A Schmitt,Anna %A Le Goff,Marielle %A Clavert,Aline %A Zinger,Marie %A Bourgeois,Hugues %A Dupuis,Olivier %A Denis,Fabrice %A Bouchard,Stéphane %+ Department of Hematology, Confluent Private Hospital, 2 rue Eric Tabarly, Nantes, 44200, France, 33 615246067, katell.ledu@gmail.com %K virtual reality %K VR %K bone marrow %K biopsy %K pain %K digital therapeutics %K digital health %K eHealth %K RCT %K randomized controlled trial %K clinical trial %K distraction %K imagery %K imagination %K imaginary %K immersive environment %K interactive environment %K head-mounted display %K medical procedure %K satisfaction %K safety %K efficacy %K effectiveness %D 2023 %7 15.2.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Evidence regarding the analgesic effect of distraction through immersion in virtual reality (VR) for care-induced pain has been documented in several phase 2 trials, but comparison with standard treatments in large, randomized studies is needed. Objective: In this open-label, multicenter, randomized, phase 3 trial, we evaluated the safety and efficacy of a novel VR therapy solution for distraction in the context of bone marrow biopsy. Methods: Bliss is a VR software with 4 imaginary interactive environments in 3 dimensions with binaural sound (head-mounted display). Efficacy regarding pain intensity was evaluated using a visual analog scale (VAS; score from 0 to 10) immediately after the biopsy. Secondary end points were anxiety and tolerance. Modified intention-to-treat analysis was performed. Results: Overall, 126 patients with previously documented untreated or suspected malignant hemopathy between September 6, 2018, and May 18, 2020, were randomly assigned in a 1:1 ratio to receive pain prevention with a mixture of nitrous oxide/oxygen (MEOPA; n=63) or VR (n=63) before and during the bone marrow biopsy. We excluded 8 patients from the final analysis (3 in the MEOPA group and 5 in the VR group). All patients received local anesthesia (lidocaine) before biopsy. Follow-up was limited to 1 month after the biopsy. Participants’ median age was 65.5 (range 18-87) years, and 54.2% (64/118) of patients were male. The average pain intensity was 3.5 (SD 2.6, 95% CI –1.6 to 8.6) for the MEOPA group and 3.0 (SD 2.4, 95% CI –1.7 to 7.7) for the VR group, without any significant differences in age, sex, center, and hemopathy (P=.26). Concerning anxiety, 67.5% (79/117; fear of pain questionnaire) of the patients were afraid before the biopsy, and anxiety scores were moderate to very high in 26.3% (30/114; revised Spielberger State-Trait Anxiety Inventory questionnaire) of the patients before the biopsy and 9.0% (10/114) after the biopsy for all patients, without a significant difference between the 2 groups (P=.83). Immersion in VR was well tolerated by the majority (54/57, 95%) of patients in the VR group. Conclusions: The intensity of pain did not significantly differ between both arms. VR was well tolerated, and the satisfaction of patients, nurses, and physicians was very high. VR could be an alternative treatment in case of contraindication or intolerance to MEOPA. Trial Registration: ClinicalTrials.gov NCT03483194; https://clinicaltrials.gov/ct2/show/NCT03483194 %M 36790852 %R 10.2196/38619 %U https://www.jmir.org/2023/1/e38619 %U https://doi.org/10.2196/38619 %U http://www.ncbi.nlm.nih.gov/pubmed/36790852 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e41090 %T Creating a Successful Virtual Reality–Based Medical Simulation Environment: Tutorial %A Gupta,Sanchit %A Wilcocks,Kyle %A Matava,Clyde %A Wiegelmann,Julian %A Kaustov,Lilia %A Alam,Fahad %+ Department of Anesthesia, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada, 1 4164804864, fahad.alam@sunnybrook.ca %K virtual reality %K innovation %K digital health %K simulation %K medical education %K medical training %K tutorial %K how-to %K curriculum %D 2023 %7 14.2.2023 %9 Tutorial %J JMIR Med Educ %G English %X Innovation in medical education is not only inevitable but a requirement. Manikin-based simulation is currently the gold standard for supplemental clinical training; however, this modality requires significant equipment and personnel to operate. Virtual reality (VR) is emerging as a new method of delivering medical simulation sessions that requires less infrastructure but also allows for greater accessibility and flexibility. VR has slowly been integrated into the medical curriculum in some hospitals; however, more widespread adoption would transform the delivery of medical education for future clinicians. This tutorial introduces educators to the BUILD REALITY (begin, use, identify, leverage, define, recreate, educate, adapt, look, identify, test, amplify) framework, a series of practical tips for designing and implementing a VR-based medical simulation environment in their curriculum. The suggestions are based on the relevant literature and the authors’ personal experience in creating and implementing VR environments for medical trainees. Altogether, this paper provides guidance on conducting a needs assessment, setting objectives, designing a VR environment, and incorporating the session into the broader medical curriculum. %M 36787169 %R 10.2196/41090 %U https://mededu.jmir.org/2023/1/e41090 %U https://doi.org/10.2196/41090 %U http://www.ncbi.nlm.nih.gov/pubmed/36787169 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e43549 %T The Metaverse, the Built Environment, and Public Health: Opportunities and Uncertainties %A Koohsari,Mohammad Javad %A McCormack,Gavin R %A Nakaya,Tomoki %A Yasunaga,Akitomo %A Fuller,Daniel %A Nagai,Yukari %A Oka,Koichiro %+ School of Knowledge Science, Japan Advanced Institute of Science and Technology, 1-1 Asahidai, Nomi, 923-1292, Japan, 81 76151 ext 1705, koohsari@jaist.ac.jp %K virtual reality %K technology %K neighborhood %K urban design %K health %K epidemiology %K artificial intelligence %K sport sciences %K augmented reality %K health care %D 2023 %7 13.2.2023 %9 Viewpoint %J J Med Internet Res %G English %X There has been a growing interest in the “metaverse,” and discourse about how this platform may contribute to different fields of science is already beginning to emerge. In this paper, we discuss key opportunities and uncertainties about how a metaverse might contribute to advancing knowledge in the interdisciplinary field of the built environment and public health aimed at reducing noncommunicable diseases. %M 36780208 %R 10.2196/43549 %U https://www.jmir.org/2023/1/e43549 %U https://doi.org/10.2196/43549 %U http://www.ncbi.nlm.nih.gov/pubmed/36780208 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e43388 %T Time to Think “Meta”: A Critical Viewpoint on the Risks and Benefits of Virtual Worlds for Mental Health %A Paquin,Vincent %A Ferrari,Manuela %A Sekhon,Harmehr %A Rej,Soham %+ Department of Psychiatry, McGill University, 1033 Avenue des Pins, Montreal, QC, H3A 1A1, Canada, 1 514 398 4909, vincent.paquin2@mail.mcgill.ca %K metaverse %K digital media %K virtual reality %K mental health %K addiction %K social functioning %K virtual %K technology %K augmented reality %K gaming %K social media %K cognitive %K physical activity %K behavior %K psychological %K development %K patient %K policy %D 2023 %7 7.2.2023 %9 Viewpoint %J JMIR Serious Games %G English %X The metaverse is gaining traction in the general population and has become a priority of the technological industry. Defined as persistent virtual worlds that exist in virtual or augmented reality, the metaverse proposes to afford a range of activities of daily life, from socializing and relaxing to gaming, shopping, and working. Because of its scope, its projected popularity, and its immersivity, the metaverse may pose unique opportunities and risks for mental health. In this viewpoint article, we integrate existing evidence on the mental health impacts of video games, social media, and virtual reality to anticipate how the metaverse could influence mental health. We outline 2 categories of mechanisms related to mental health: experiences or behaviors afforded by the metaverse and experiences or behaviors displaced by it. The metaverse may benefit mental health by affording control (over an avatar and its virtual environment), cognitive activation, physical activity, social connections, and a sense of autonomy and competence. However, repetitive rewarding experiences may lead to addiction-like behaviors, and high engagement in virtual worlds may facilitate and perpetuate the avoidance of challenges in the offline environment. Further, time spent in virtual worlds may displace (reduce) other determinants of mental health, such as sleep rhythms and offline social capital. Importantly, individuals will differ in their uses of and psychological responses to the metaverse, resulting in heterogeneous impacts on their mental health. Their technological motivations, developmental stage, sociodemographic context, and prior mental health problems are some of the factors that may modify and frame the positive and negative effects of the metaverse on their mental health. In conclusion, as the metaverse is being scaffolded by the industry and by its users, there is a window of opportunity for researchers, clinicians, and people with lived experience to coproduce knowledge on its possible impacts on mental health and illness, with the hope of influencing policy-making, technological development, and counseling of patients. %M 36661284 %R 10.2196/43388 %U https://games.jmir.org/2023/1/e43388 %U https://doi.org/10.2196/43388 %U http://www.ncbi.nlm.nih.gov/pubmed/36661284 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 9 %N %P e41589 %T Implementation of Virtual Reality in Health Professions Education: Scoping Review %A Lie,Silje Stangeland %A Helle,Nikolina %A Sletteland,Nina Vahl %A Vikman,Miriam Dubland %A Bonsaksen,Tore %+ Department of Health, Faculty of Health Studies, VID Specialized University, Misjonsmarka 12, Stavanger, 4024, Norway, siljes.lie@vid.no %K implementation %K virtual reality %K higher education %K medical education %K health professions education %K continuing education %K scoping review %K health professional %K technology %D 2023 %7 24.1.2023 %9 Review %J JMIR Med Educ %G English %X Background: Virtual reality has been gaining ground in health professions education and may offer students a platform to experience and master situations without endangering patients or themselves. When implemented effectively, virtual reality technologies may enable highly engaging learning activities and interactive simulations. However, implementation processes present challenges, and the key to successful implementation is identifying barriers and facilitators as well as finding strategies to address them. Objective: This scoping review aimed to identify the literature on virtual reality implementation in health professions education, identify barriers to and facilitators of implementation, and highlight gaps in the literature in this area. Methods: The scoping review was conducted based on the Joanna Briggs Institute Evidence Synthesis methodologies. Electronic searches were conducted in the Academic Search Elite, Education Source, and CINAHL databases on January 5, 2022, in Google Scholar on February 2 and November 18, 2022, and in PubMed database on November 18, 2022. We conducted hand searches of key items, reference tracking, and citation tracking and searches on government webpages on February 2, 2022. At least 2 reviewers screened the identified literature. Eligible studies were considered based on predefined inclusion criteria. The results of the identified items were analyzed and synthesized using qualitative content analysis. Results: We included 7 papers and identified 7 categories related to facilitators of and barriers to implementation—collaborative participation, availability, expenses, guidelines, technology, careful design and evaluation, and training—and developed a model that links the categories to the 4 constructs from Carl May’s general theory of implementation. All the included reports provided recommendations for implementation, including recommendations for careful design and evaluation, training of faculty and students, and faculty presence during use. Conclusions: Virtual reality implementation in health professions education appears to be a new and underexplored research field. This scoping review has several limitations, including definitions and search words, language, and that we did not assess the included papers’ quality. Important implications from our findings are that ensuring faculty’s and students’ competence in using virtual reality technology is necessary for the implementation processes. Collaborative participation by including end users in the development process is another factor that may ensure successful implementation in higher education contexts. To ensure stakeholders’ motivation and potential to use virtual reality, faculty and students could be invited to participate in the development process to ensure that the educational content is valued. Moreover, technological challenges and usability issues should be resolved before implementation to ensure that pedagogical content is the focus. This accentuates the importance of piloting, sufficient time resources, basic testing, and sharing of experiences before implementation. International Registered Report Identifier (IRRID): RR2-10.2196/37222 %M 36692934 %R 10.2196/41589 %U https://mededu.jmir.org/2023/1/e41589 %U https://doi.org/10.2196/41589 %U http://www.ncbi.nlm.nih.gov/pubmed/36692934 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e41523 %T Virtual Reality Therapy for People With Epilepsy and Related Anxiety: Protocol for a 3-Phase Pilot Clinical Trial %A Gray,Hannah Gabrielle %A Tchao,Danielle %A Lewis-Fung,Samantha %A Pardini,Susanna %A Harris,Laurence R %A Appel,Lora %+ School of Health Policy & Management, York University, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada, 1 6475046537, lappel16@yorku.ca %K epilepsy %K anxiety %K virtual reality %K exposure therapy %K eHealth %K digital health %K virtual reality exposure therapy %K cognitive behavioral therapy %K CBT %K nonpharmacological intervention %K biomedical technology %D 2023 %7 24.1.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: Anxiety is one of the most common psychiatric comorbidities in people with epilepsy and often involves fears specifically related to the condition, such as anxiety related to the fear of having another seizure. These epilepsy- or seizure-related fears have been reported as being more disabling than the seizures themselves and significantly impact quality of life. Although research has suggested that exposure therapy (ET) is helpful in decreasing anxiety in people with epilepsy, no research to our knowledge has been conducted on ET in people with epilepsy using virtual reality (VR). The use of novel technologies such as an immersive VR head-mounted display for ET in this population offers several benefits. Indeed, using VR can increase accessibility for people with epilepsy with transportation barriers (eg, those who live outside urban centers or who have a suspended driver’s license owing to their condition), among other advantages. In the present research protocol, we describe the design of an innovative VR-ET program administered in the home that focuses on decreasing anxiety in people with epilepsy, specifically anxiety related to their epilepsy or seizures. Objective: Our primary objective is to examine the feasibility of the study protocol and proposed treatment as well as identify suggestions for improvement when designing subsequent larger clinical trials. Our secondary objective is to evaluate whether VR-ET is effective in decreasing anxiety in a pilot study. We hypothesize that levels of anxiety in people with epilepsy will decrease from using VR-ET. Methods: This mixed methods study comprises 3 phases. Phase 1 involves engaging with those with lived experience through a web-based questionnaire to validate assumptions about anxiety in people with epilepsy. Phase 2 involves filming videos using a 360° camera for the VR-ET intervention (likely consisting of 3 sets of scenes, each with 3 intensity levels) based on the epilepsy- and seizure-related fears most commonly reported in the phase 1 questionnaire. Finally, phase 3 involves evaluating the at-home VR-ET intervention and study methods using a series of validated scales, as well as semistructured interviews. Results: This pilot study was funded in November 2021. Data collection for phase 1 was completed as of August 7, 2022, and had a final sample of 18 participants. Conclusions: Our findings will add to the limited body of knowledge on anxiety in people with epilepsy and the use of VR in this population. We anticipate that the insights gained from this study will lay the foundation for a novel and accessible VR intervention for this underrecognized and undertreated comorbidity in people with epilepsy. Trial Registration: ClinicalTrials.gov NCT05296057; https://clinicaltrials.gov/ct2/show/NCT05296057 International Registered Report Identifier (IRRID): DERR1-10.2196/41523 %M 36692939 %R 10.2196/41523 %U https://www.researchprotocols.org/2023/1/e41523 %U https://doi.org/10.2196/41523 %U http://www.ncbi.nlm.nih.gov/pubmed/36692939 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 12 %N %P e41080 %T Comparing Smartphone Virtual Reality Exposure Preparation to Care as Usual in Children Aged 6 to 14 Years Undergoing Magnetic Resonance Imaging: Protocol for a Multicenter, Observer-Blinded, Randomized Controlled Trial %A van Spaendonck,Zita %A Leeuwenburgh,Koen Pieter %A Dremmen,Marjolein %A van Schuppen,Joost %A Starreveld,Daniëlle %A Dierckx,Bram %A Legerstee,Jeroen S %+ Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center Sophia Children’s Hospital, Doctor Molewaterplein 40, Rotterdam, 3015 GD, Netherlands, 31 010 7040704, j.s.legerstee@erasmusmc.nl %K virtual reality %K VR %K children %K anxiety %K magnetic resonance imaging %K MRI %K MRI scans %K imaging %K randomized controlled trial %K MRI preparation %K smartphone virtual reality %K smartphone intervention %K procedural anxiety %K psychosocial intervention %D 2023 %7 24.1.2023 %9 Protocol %J JMIR Res Protoc %G English %X Background: A magnetic resonance imaging (MRI) procedure can cause preprocedural and periprocedural anxiety in children. Psychosocial interventions are used to prepare children for the procedure to alleviate anxiety, but these interventions are time-consuming and costly, limiting their clinical use. Virtual reality (VR) is a promising way to overcome these limitations in the preparation of children before an MRI scan. Objective: The objective of this study is (1) to develop a VR smartphone intervention to prepare children at home for an MRI procedure; and (2) to examine the effect of the VR intervention in a randomized controlled trial, in which the VR intervention will be compared to care as usual (CAU). CAU involves an information letter about an MRI examination. The primary outcome is the child’s procedural anxiety during the MRI procedure. Secondary outcomes include preprocedural anxiety and parental anxiety. We hypothesize that the VR preparation will result in a higher reduction of the periprocedural anxiety of both parents and children as compared to CAU. Methods: The VR intervention provides a highly realistic and child-friendly representation of an MRI environment. In this randomized controlled trial, 128 children (aged 6 to 14 years) undergoing an MRI scan will be randomly allocated to the VR intervention or CAU. Children in the VR intervention will receive a log-in code for the VR app and are sent cardboard VR glasses. Results: The VR smartphone preparation app was developed in 2020. The recruitment of participants is expected to be completed in December 2022. Data will be analyzed, and scientific papers will be submitted for publication in 2023. Conclusions: The VR smartphone app is expected to significantly reduce pre- and periprocedural anxiety in pediatric patients undergoing an MRI scan. The VR app offers a realistic and child-friendly experience that can contribute to modern care. A smartphone version of the VR app has the advantage that children, and potentially their parents, can get habituated to the VR environment and noises in their own home environment and can do this VR MRI preparation as often and as long as needed. Trial Registration: ISRCTN Registry ISRCTN20976625; https://www.isrctn.com/ISRCTN20976625 International Registered Report Identifier (IRRID): DERR1-10.2196/41080 %M 36692931 %R 10.2196/41080 %U https://www.researchprotocols.org/2023/1/e41080 %U https://doi.org/10.2196/41080 %U http://www.ncbi.nlm.nih.gov/pubmed/36692931 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 6 %N %P e40582 %T Pioneering the Metaverse: The Role of the Metaverse in an Aging Population %A Shu,Sara %A Woo,Benjamin K P %+ Department of Family Medicine, Mayo Clinic, 200 First Street SW, Rochester, CA, 59905, United States, 1 858 761 7863, shus@g.ucla.edu %K metaverse %K older adult %K aging in place %K dementia %K gerontology %K geriatric %K digital health %K digital technology %K computer generated %K artificial intelligence %K virtual reality %K mixed reality %K augmented reality %K aging %K mental health %D 2023 %7 20.1.2023 %9 Viewpoint %J JMIR Aging %G English %X Amid a worldwide pandemic in the setting of an era of rapidly developing technologies, we turn now to the novel and exciting endeavor of pioneering the metaverse. Described as the conglomeration of augmented reality, virtual reality, and artificial intelligence, the metaverse has widespread applications in multiple settings, including revolutionizing health care. It also holds the potential to transform geriatric medicine, introducing new dimensions through which we can prevent social isolation, encourage health and well-being, and offer a new dimension through which we manage chronic disease. Although it is still a futuristic and novel technology, the metaverse’s realization may indeed be closer than we think. %M 36662547 %R 10.2196/40582 %U https://aging.jmir.org/2023/1/e40582 %U https://doi.org/10.2196/40582 %U http://www.ncbi.nlm.nih.gov/pubmed/36662547 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e40541 %T Advantages of a Training Course for Surgical Planning in Virtual Reality for Oral and Maxillofacial Surgery: Crossover Study %A Ulbrich,Max %A Van den Bosch,Vincent %A Bönsch,Andrea %A Gruber,Lennart Johannes %A Ooms,Mark %A Melchior,Claire %A Motmaen,Ila %A Wilpert,Caroline %A Rashad,Ashkan %A Kuhlen,Torsten Wolfgang %A Hölzle,Frank %A Puladi,Behrus %+ Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany, 49 241 80 88231, bpuladi@ukaachen.de %K virtual surgical planning %K virtual reality %K Elucis %K 3D Slicer %K oral and maxillofacial surgery %D 2023 %7 19.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: As an integral part of computer-assisted surgery, virtual surgical planning (VSP) leads to significantly better surgery results, such as for oral and maxillofacial reconstruction with microvascular grafts of the fibula or iliac crest. It is performed on a 2D computer desktop screen (DS) based on preoperative medical imaging. However, in this environment, VSP is associated with shortcomings, such as a time-consuming planning process and the requirement of a learning process. Therefore, a virtual reality (VR)–based VSP application has great potential to reduce or even overcome these shortcomings due to the benefits of visuospatial vision, bimanual interaction, and full immersion. However, the efficacy of such a VR environment has not yet been investigated. Objective: This study aimed to demonstrate the possible advantages of a VR environment through a substep of VSP, specifically the segmentation of the fibula (calf bone) and os coxae (hip bone), by conducting a training course in both DS and VR environments and comparing the results. Methods: During the training course, 6 novices were taught how to use a software application in a DS environment (3D Slicer) and in a VR environment (Elucis) for the segmentation of the fibula and os coxae, and they were asked to carry out the maneuvers as accurately and quickly as possible. Overall, 13 fibula and 13 os coxae were segmented for each participant in both methods (VR and DS), resulting in 156 different models (78 fibula and 78 os coxae) per method (VR and DS) and 312 models in total. The individual learning processes in both environments were compared using objective criteria (time and segmentation performance) and self-reported questionnaires. The models resulting from the segmentation were compared mathematically (Hausdorff distance and Dice coefficient) and evaluated by 2 experienced radiologists in a blinded manner. Results: A much faster learning curve was observed for the VR environment than the DS environment (β=.86 vs β=.25). This nearly doubled the segmentation speed (cm3/min) by the end of training, leading to a shorter time (P<.001) to reach a qualitative result. However, there was no qualitative difference between the models for VR and DS (P=.99). The VR environment was perceived by participants as more intuitive and less exhausting, and was favored over the DS environment. Conclusions: The more rapid learning process and the ability to work faster in the VR environment could save time and reduce the VSP workload, providing certain advantages over the DS environment. %M 36656632 %R 10.2196/40541 %U https://games.jmir.org/2023/1/e40541 %U https://doi.org/10.2196/40541 %U http://www.ncbi.nlm.nih.gov/pubmed/36656632 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e38065 %T A Safe Place to Learn: Peer Research Qualitative Investigation of gameChange Virtual Reality Therapy %A Bond,Jessica %A Kenny,Alexandra %A Pinfold,Vanessa %A Couperthwaite,Lisa %A , %A Kabir,Thomas %A Larkin,Michael %A Beckley,Ariane %A Rosebrock,Laina %A Lambe,Sinéad %A Freeman,Daniel %A Waite,Felicity %A Robotham,Dan %+ McPin Foundation, 7-14 Great Dover Street, London, SE1 4YR, United Kingdom, 44 207 922 7877, contact@mcpin.org %K peer research %K lived experience %K qualitative methods %K interpretative phenomenological analysis %K IPA %K anxiety %K psychosis %K virtual reality %K VR %K cognitive therapy %K automated %K implementation %D 2023 %7 16.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Automated virtual reality (VR) therapy has the potential to substantially increase access to evidence-based psychological treatments. The results of a multicenter randomized controlled trial showed that gameChange VR cognitive therapy reduces the agoraphobic avoidance of people diagnosed with psychosis, especially for those with severe avoidance. Objective: We set out to use a peer research approach to explore participants’ experiences with gameChange VR therapy. This in-depth experiential exploration of user experience may inform the implementation in clinical services and future VR therapy development. Methods: Peer-led semistructured remote interviews were conducted with 20 people with a diagnosis of psychosis who had received gameChange as part of the clinical trial (ISRCTN17308399). Data were analyzed using interpretative phenomenological analysis and template analyses. A multiperspectival approach was taken to explore subgroups. Credibility checks were conducted with the study Lived Experience Advisory Panel. Results: Participants reported the substantial impact of anxious avoidance on their lives before the VR intervention, leaving some of them housebound and isolated. Those who were struggling the most with agoraphobic avoidance expressed the most appreciation for, and gains from, the gameChange therapy. The VR scenarios provided “a place to practise.” Immersion within the VR scenarios triggered anxiety, yet participants were able to observe this and respond in different ways than usual. The “security of knowing the VR scenarios are not real” created a safe place to learn about fears. The “balance of safety and anxiety” could be calibrated to the individual. The new learning made in VR was “taken into the real world” through practice and distilling key messages with support from the delivery staff member. Conclusions: Automated VR can provide a therapeutic simulation that allows people diagnosed with psychosis to learn and embed new ways of responding to the situations that challenge them. An important process in anxiety reduction is enabling the presentation of stimuli that induce the original anxious fears yet allow for learning of safety. In gameChange, the interaction of anxiety and safety could be calibrated to provide a safe place to learn about fears and build confidence. This navigation of therapeutic learning can be successfully managed by patients themselves in an automated therapy, with staff support, that provides users with personalized control. The clinical improvements for people with severe anxious avoidance, the positive experience of VR, and the maintenance of a sense of control are likely to facilitate implementation. %M 36645707 %R 10.2196/38065 %U https://games.jmir.org/2023/1/e38065 %U https://doi.org/10.2196/38065 %U http://www.ncbi.nlm.nih.gov/pubmed/36645707 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e34586 %T Preference of Virtual Reality Games in Psychological Pressure and Depression Treatment: Discrete Choice Experiment %A Jin,Shan %A Tan,Zijian %A Liu,Taoran %A Chan,Sze Ngai %A Sheng,Jie %A Wong,Tak-hap %A Huang,Jian %A Zhang,Casper J P %A Ming,Wai-Kit %+ Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Room 1A-503, 5/F, Block 1, To Yuen Building, 31 To Yuen Street, Hong Kong, China (Hong Kong), 852 34426956, wkming2@cityu.edu.hk %K virtual reality %K discrete choice experiment %K college student %K depression therapy %D 2023 %7 16.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) can be used to build many different scenes aimed at reducing study-related stress. However, only few academic experiments on university students for preference testing have been performed. Objective: This study aims to assess the preference of VR games for stress and depression treatment using a discrete choice experiment (DCE). Methods: A total of 5 different attributes were selected based on the depression therapy parameters and attributes related to VR: (1) treatment modality; (2) therapy duration; (3) perceived remission rate; (4) probability of adverse events; and the (5) monthly cost of adding treatment to a discrete choice experiment. By comparing different attributes and levels, we could draw some conclusions about the depression therapy testing preference for university students; 1 university student was responsible for VR scene development and 1 for participant recruitment. Results: The utility value of different attributes for “0% Probability of adverse events” was higher than others (99.22), and the utility value of VR treatment as the most popular treatment method compared with counseling and medicine treatment was 80.95. Three parameter aspects (different treatments for depression) were statistically significant (P<.001), including “0%” and “50%” of “Probability of adverse events” and “¥500” (a currency exchange rate of ¥1 [Chinese yuan]=US $0.15 is applicable) of “The monthly cost of treatment.” Most individuals preferred 12 months as the therapy duration, and the odds ratio of “12 months” was 1.095 (95% CI 0.945-1.270) when compared with the reference level (6 months). Meanwhile, the cheapest price (¥500) of depression therapy was the optimum choice for most students. Conclusions: People placed great preference on VR technology psychological intervention methods, which indicates that VR may have a potential market in the treatment of psychological problems. However, adverse events and treatment costs need to be considered. This study can be used to guide policies that are relevant to the development of the application of VR technology in the field of psychological pressure and depression treatment. %M 36645698 %R 10.2196/34586 %U https://games.jmir.org/2023/1/e34586 %U https://doi.org/10.2196/34586 %U http://www.ncbi.nlm.nih.gov/pubmed/36645698 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 25 %N %P e40267 %T Characteristics and Health Care Use of Patients Attending Virtual Walk-in Clinics in Ontario, Canada: Cross-sectional Analysis %A Lapointe-Shaw,Lauren %A Salahub,Christine %A Bird,Cherryl %A Bhatia,R Sacha %A Desveaux,Laura %A Glazier,Richard H %A Hedden,Lindsay %A Ivers,Noah M %A Martin,Danielle %A Na,Yingbo %A Spithoff,Sheryl %A Tadrous,Mina %A Kiran,Tara %+ Division of General Internal Medicine and Geriatrics, University Health Network and Sinai Health System, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada, 1 416 340 4800 ext 7136, lauren.lapointe.shaw@utoronto.ca %K virtual walk-in clinic %K telemedicine %K virtual care %K primary health care %K family practice %K family physicians %K Canada %K health care use %K emergency department %K walk-in clinic %K use %K engagement %K virtual health care %K integration %D 2023 %7 12.1.2023 %9 Original Paper %J J Med Internet Res %G English %X Background: Funding changes in response to the COVID-19 pandemic supported the growth of direct-to-consumer virtual walk-in clinics in several countries. Little is known about patients who attend virtual walk-in clinics or how these clinics contribute to care continuity and subsequent health care use. Objective: The objective of the present study was to describe the characteristics and measure the health care use of patients who attended virtual walk-in clinics compared to the general population and a subset that received any virtual family physician visit. Methods: This was a retrospective, cross-sectional study in Ontario, Canada. Patients who had received a family physician visit at 1 of 13 selected virtual walk-in clinics from April 1 to December 31, 2020, were compared to Ontario residents who had any virtual family physician visit. The main outcome was postvisit health care use. Results: Virtual walk-in patients (n=132,168) had fewer comorbidities and lower previous health care use than Ontarians with any virtual family physician visit. Virtual walk-in patients were also less likely to have a subsequent in-person visit with the same physician (309/132,168, 0.2% vs 704,759/6,412,304, 11%; standardized mean difference [SMD] 0.48), more likely to have a subsequent virtual visit (40,030/132,168, 30.3% vs 1,403,778/6,412,304, 21.9%; SMD 0.19), and twice as likely to have an emergency department visit within 30 days (11,003/132,168, 8.3% vs 262,509/6,412,304, 4.1%; SMD 0.18), an effect that persisted after adjustment and across urban/rural resident groups. Conclusions: Compared to Ontarians attending any family physician virtual visit, virtual walk-in patients were less likely to have a subsequent in-person physician visit and were more likely to visit the emergency department. These findings will inform policy makers aiming to ensure the integration of virtual visits with longitudinal primary care. %M 36633894 %R 10.2196/40267 %U https://www.jmir.org/2023/1/e40267 %U https://doi.org/10.2196/40267 %U http://www.ncbi.nlm.nih.gov/pubmed/36633894 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 6 %N %P e36325 %T A Perspective on Using Virtual Reality to Incorporate the Affective Context of Everyday Falls Into Fall Prevention %A Raffegeau,Tiphanie E %A Young,William R %A Fino,Peter C %A Williams,A Mark %+ School of Kinesiology, George Mason University, 10890 George Mason Circle, 201G Katherine G Johnson Hall, Manassas, VA, 20110, United States, 1 7039937000, traffege@gmu.edu %K aging %K balance %K perturbation %K locomotion %K cognition %K exergame %K anxiety %D 2023 %7 11.1.2023 %9 Viewpoint %J JMIR Aging %G English %X Virtual reality (VR) is a promising and cost-effective tool that has the potential to reduce the prevalence of falls and locomotor impairments in older adults. However, we believe that existing VR-based approaches to prevent falls do not mimic the full breadth of perceptual, cognitive, and motor demands that older adults encounter in daily life. Researchers have not yet fully leveraged VR to address affective factors related to fall risk, and how stressors such as anxiety influence older adult balance and real-world falls. In this perspective paper, we propose developing VR-based tools that replicate the affective demands of real-world falls (eg, crossing the street) to enhance fall prevention diagnostics and interventions by capturing the underlying processes that influence everyday mobility. An effort to replicate realistic scenarios that precipitate falls in VR environments will inform evidence-based diagnostics and individualize interventions in a way that could reduce falls in older adults in daily life. %M 36630173 %R 10.2196/36325 %U https://aging.jmir.org/2023/1/e36325 %U https://doi.org/10.2196/36325 %U http://www.ncbi.nlm.nih.gov/pubmed/36630173 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e41297 %T Mixed Reality in Modern Surgical and Interventional Practice: Narrative Review of the Literature %A Vervoorn,Mats T %A Wulfse,Maaike %A Van Doormaal,Tristan P C %A Ruurda,Jelle P %A Van der Kaaij,Niels P %A De Heer,Linda M %+ University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3508 GA, Netherlands, 31 88 7556179, m.t.vervoorn-4@umcutrecht.nl %K mixed reality %K extended reality %K surgery %K intervention %K education %D 2023 %7 6.1.2023 %9 Review %J JMIR Serious Games %G English %X Background: Mixed reality (MR) and its potential applications have gained increasing interest within the medical community over the recent years. The ability to integrate virtual objects into a real-world environment within a single video-see-through display is a topic that sparks imagination. Given these characteristics, MR could facilitate preoperative and preinterventional planning, provide intraoperative and intrainterventional guidance, and aid in education and training, thereby improving the skills and merits of surgeons and residents alike. Objective: In this narrative review, we provide a broad overview of the different applications of MR within the entire spectrum of surgical and interventional practice and elucidate on potential future directions. Methods: A targeted literature search within the PubMed, Embase, and Cochrane databases was performed regarding the application of MR within surgical and interventional practice. Studies were included if they met the criteria for technological readiness level 5, and as such, had to be validated in a relevant environment. Results: A total of 57 studies were included and divided into studies regarding preoperative and interventional planning, intraoperative and interventional guidance, as well as training and education. Conclusions: The overall experience with MR is positive. The main benefits of MR seem to be related to improved efficiency. Limitations primarily seem to be related to constraints associated with head-mounted display. Future directions should be aimed at improving head-mounted display technology as well as incorporation of MR within surgical microscopes, robots, and design of trials to prove superiority. %M 36607711 %R 10.2196/41297 %U https://games.jmir.org/2023/1/e41297 %U https://doi.org/10.2196/41297 %U http://www.ncbi.nlm.nih.gov/pubmed/36607711 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e40421 %T Differences in Brain Activity and Body Movements Between Virtual Reality and Offline Exercise: Randomized Crossover Trial %A Kim,Hee Jin %A Lee,Jea Woog %A Choi,Gangta %A Huh,Junghoon %A Han,Doug Hyun %+ Department of Psychiatry, College of Medicine, Chung-Ang University, Heuk Seok Ro 84, Seoul, 06974, Republic of Korea, 82 2 6299 3132, hduk70@gmail.com %K virtual reality exercise %K near-infrared spectroscopy %K spectroscopy %K hemodynamic %K blood flow %K hemoglobin %K brain %K prefrontal cortex %K orbitofrontal cortex %K immersion %K virtual reality %K VR %K exercise %K range of motion %K physical activity %K fitness %K motion %K movement %K randomized %K calorie %D 2023 %7 5.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) has been suggested to be effective at enhancing physical exercises because of its immersive characteristics. However, few studies have quantitatively assessed the range of motion and brain activity during VR exercises. Objective: We hypothesized that 3D immersive VR could stimulate body movement and brain activity more effectively than standard exercises and that the increased range of motions during 3D immersive VR exercises would be associated with orbitofrontal activation. Methods: A randomized crossover trial was conducted to compare exercises with and without VR. A total of 24 healthy males performed the same motions when exercising with and without 3D immersive VR, and the recorded videos were used for motion analysis. Hemodynamic changes in the prefrontal cortex were assessed using functional near-infrared spectroscopy. Results: There were significant differences in the total angle (z=−2.31; P=.02), length (z=−2.78; P=.005), calorie consumption (z=−3.04; P=.002), and change in accumulated oxygenated hemoglobin within the right orbitofrontal cortex (F1,94=9.36; P=.003) between the VR and offline trials. Hemodynamic changes in the right orbitofrontal cortex were positively correlated with the total angle (r=0.45; P=.001) and length (r=0.38; P=.007) in the VR exercise; however, there was no significant correlation in the offline trial. Conclusions: The results of this study suggest that 3D immersive VR exercise effectively increases the range of motion in healthy individuals in relation to orbitofrontal activation. Trial Registration: Clinical Research Information Service KCT0008021; https://cris.nih.go.kr/cris/search/detailSearch.do/23671 %M 36602842 %R 10.2196/40421 %U https://games.jmir.org/2023/1/e40421 %U https://doi.org/10.2196/40421 %U http://www.ncbi.nlm.nih.gov/pubmed/36602842 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 11 %N %P e43203 %T Exploring Key Factors Influencing Nursing Students’ Cognitive Load and Willingness to Serve Older Adults: Cross-sectional Descriptive Correlational Study %A Hsieh,Pei-Lun %A Wang,Yu-Rung %A Huang,Tien-Chi %+ Department of Nursing, National Taichung University of Science and Technology, No. 193, Sec. 1, San-Min Rd, Taichung, ​40343, Taiwan, 886 422196854, peilun@nutc.edu.tw %K immersive virtual reality learning %K VR learning %K mental effort %K mental load %K service willingness %K older adult %K virtual reality %K nursing student %K professional education %K digital learning %K older adult population %D 2023 %7 4.1.2023 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual learning environments (VLEs) use a virtual environment to support learning activities. VLEs are commonly used to overcome the temporal and spatial restrictions of learning activities held in conventional face-to-face classrooms. In VLEs, students can participate in learning activities using the internet, and teachers can provide assistive learning tools during the process. Objective: The purpose of this study was to investigate the relationships among nursing students’ mental load, cognitive load, and affective learning outcomes in terms of their willingness to serve older adults in an interaction-based educational virtual reality (VR) learning environment. Methods: This study used a cross-sectional method. A total of 130 students participated in interaction-based VR learning and completed related questionnaires. Descriptive and inferential statistics and stepwise regression for data analysis were used. Results: The research results revealed that in the dimension of willingness to use VR learning materials, perceived usefulness received the highest score (mean 4.42, SD 0.45). In the dimension of nursing ability, students scored the highest in information management and application ability to care for case patients (mean 4.35, SD 0.54). Correlation analysis revealed that cognitive load during learning and willingness to serve older adults were negatively correlated, whereas willingness to use VR learning materials was positively correlated with nursing ability and willingness to serve older adults. Analyzing the regression coefficients of predictor variables revealed that willingness to use VR learning materials (β=.23; t2=2.89, P=.005) and cognitive load during learning (β=–.35; t2=–.4.30, P<.001) were predictive factors of nursing students’ willingness to serve older adults. Conclusions: This study demonstrated that students’ willingness to use VR learning materials and their cognitive load during learning affected their willingness to care for older adults. Therefore, the components of mental or cognitive load generate inconsistent predictive effects on affective variables and willingness to serve older adults. %M 36333104 %R 10.2196/43203 %U https://games.jmir.org/2023/1/e43203 %U https://doi.org/10.2196/43203 %U http://www.ncbi.nlm.nih.gov/pubmed/36333104 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 9 %N 4 %P e40400 %T Usability Evaluation of the Preoperative ISBAR (Identification, Situation, Background, Assessment, and Recommendation) Desktop Virtual Reality Application: Qualitative Observational Study %A Andreasen,Eva Mari %A Høigaard,Rune %A Berg,Helen %A Steinsbekk,Aslak %A Haraldstad,Kristin %+ Department of Health and Nursing Sciences, University of Agder, P.O. Box 422, Kristiansand, 4604, Norway, 47 90642121, eva.mari.andreasen@uia.no %K desktop virtual reality %K handover %K ISBAR %K preoperative %K undergraduate nursing students %K usability evaluation %K usability %K nursing %K health care education %K student %K medical education %K medical training %K VR %K virtual reality %K surgery %K surgical %K System Usability Scale %K communication %K self-instruction %K self-guided %K nurse %K training %K undergraduate %K health care professional %K health care provider %D 2022 %7 29.12.2022 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Systematic communication, such as the ISBAR (identification, situation, background, assessment, recommendation) approach, comprises a generic, transferable nontechnical skill. It can be used during the handover of patients set to undergo surgery and can be practiced in various ways, including virtual reality (VR). VR increasingly has been implemented and valued in nursing education as a positive contribution to teach students about pre- and postoperative nursing. A new nonimmersive 3D learning activity called the Preoperative ISBAR Desktop VR Application has been developed for undergraduate nursing students to learn preoperative handover using the ISBAR approach. However, the usability of this learning activity has not been studied. Objective: This study aimed to investigate how second-year undergraduate nursing students evaluated the usability of the Preoperative ISBAR Desktop VR Application. Methods: This was a qualitative study with observation and interviews. The inclusion criteria were undergraduate second-year nursing students of varying ages, gender, and anticipated technological competence. The System Usability Scale (SUS) questionnaire was used to get a score on overall usability. Results: A total of 9 second-year nursing students aged 22-29 years participated in the study. The average score on the SUS was 83 (range 0-100), which equals a “B” on the graded scale and is excellent for an adjective-grade rating. The students expressed increased motivation to learn while working in self-instructed desktop VR. Still, a few technical difficulties occurred, and some students reported that they experienced some problems comprehending the instructions provided in the application. Long written instructions and a lack of self-pacing built into the application were considered limitations. Conclusions: The nursing students found the application to be usable overall, giving it an excellent usability score and noting that the application provided opportunities for active participation, which was motivational and facilitated their perceived learning outcomes. The next version of the application, to be used in a randomized controlled trial, will be upgraded to address technological and comprehension issues. %M 36580357 %R 10.2196/40400 %U https://humanfactors.jmir.org/2022/4/e40400 %U https://doi.org/10.2196/40400 %U http://www.ncbi.nlm.nih.gov/pubmed/36580357 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e37228 %T Key Stakeholders’ Experiences and Perceptions of Virtual Reality for Older Adults Living With Dementia: Systematic Review and Thematic Synthesis %A Flynn,Aisling %A Healy,David %A Barry,Marguerite %A Brennan,Attracta %A Redfern,Sam %A Houghton,Catherine %A Casey,Dympna %+ School of Nursing and Midwifery, Aras Moyola, University of Galway, Galway, H91 TK33, Ireland, 353 91493973, a.flynn15@universityofgalway.ie %K virtual reality %K VR %K dementia %K experience %K perception %K qualitative evidence synthesis (QES) %K thematic synthesis %D 2022 %7 23.12.2022 %9 Review %J JMIR Serious Games %G English %X Background: Technology is increasingly being used and evolving in the dementia care landscape. One such technology that has gained traction over the last decade is virtual reality (VR). VR is being applied in many areas of dementia care, including cognitive assessment and training, reminiscence therapy, music therapy, and other recreational VR applications. Despite the plethora of applications, they are often not shaped by the experiences and perceptions of older adults living with dementia. Currently, there is no qualitative evidence synthesis (QES) to explore this area. This review aimed to provide qualitative evidence supporting existing systematic reviews in this area. Objective: The aim of this QES was to explore key stakeholders’ experiences and perceptions of VR for older adults living with dementia. It aimed to explore the barriers and facilitators to VR use and provide recommendations for future design and implementation. Methods: QES was used, which involved a systematic search of 6 databases to identify studies that qualitatively explored key stakeholders’ experiences and perceptions of VR for older adults living with dementia. Thematic synthesis was used to integrate the findings of 14 studies (from 15 reports). The Critical Appraisal Skills Programme tool was used to assess the methodological quality of the included studies. The confidence placed in the review findings was assessed using the GRADE-CERQUAL (Confidence in the Evidence from Reviews of Qualitative research). Results: A total of 15 reports from 14 studies were included in the review, consisting of a range of levels of VR immersion, stages of dementia, and care contexts. Three analytical themes were generated: stepping into virtuality, a virtual world, and returning to reality. The results indicate the importance of sensitively designing and introducing VR to this population, as older adults living with dementia often have no prior experience of using this technology. VR can be a positive experience for older adults living with dementia and can provide meaningful interactions, positive expressions, and long-term impacts on everyday functioning. However, it should be acknowledged that some negative associations must be accounted for before, during, and after use. Conclusions: This review highlights the positive implications as well as negative associations of VR use. It emphasizes the need for VR design and implementation driven by the needs and views of older adults living with dementia as well as with other key stakeholders. Future research needs to explore the vital role that older adults living with dementia can play in the design process and how they can be empowered to meaningfully design and use this technology. %M 36563042 %R 10.2196/37228 %U https://games.jmir.org/2022/4/e37228 %U https://doi.org/10.2196/37228 %U http://www.ncbi.nlm.nih.gov/pubmed/36563042 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e41097 %T An Automated Virtual Reality Training System for Teacher-Student Interaction: A Randomized Controlled Trial %A King,Seth %A Boyer,Joseph %A Bell,Tyler %A Estapa,Anne %+ Department of Teaching and Learning, College of Education, University of Iowa, 240 S. Madison St., Iowa City, IA, 52242, United States, 1 828 448 0950, sakng@uiowa.edu %K virtual reality %K artificial intelligence %K behavioral skills training %K education %K professional development %K staff training %K mathematics %D 2022 %7 8.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Shortages in qualified supervision and other resources prevent education personnel from rehearsing effective practices. Interactive simulations, although increasingly used in education, frequently require instructor management. Automated simulations rarely engage trainees in skills related to practice (eg, speech). Objective: We evaluated the capability of delivering behavioral skills training through an automated virtual reality (VR) simulation using artificial intelligence to improve the implementation of a nondirective mathematical questioning strategy. Methods: We recruited and randomly assigned 30 college-aged participants to equivalent treatment (ie, lecture, modeling, and VR; 15/30, 50%) and control groups (ie, lecture and modeling only; 15/30, 50%). The participants were blind to treatment conditions. Sessions and assessments were conducted face to face and involved the use of VR for assessment regardless of the condition. Lessons concerned the use of a nondirective mathematical questioning strategy in instances where a simulated student provided correct or incorrect answers to word problems. The measures included observed and automated assessments of participant performance and subjective assessments of participant confidence. The participants completed the pretest, posttest, and maintenance probes each week over the course of 3 weeks. Results: A mixed ANOVA revealed significant main effects of time (F2,27=124.154; P<.001; ηp2=0.816) and treatment (F1,28=19.281; P<.001; ηp2=0.408) as well as an interaction effect (F2,28=8.429; P<.001; ηp2=0.231) for the average percentage of steps in the questioning procedure. Posttest scores for the intervention group (mean 88%, SD 22.62%) exceeded those of the control group (mean 63.33%, SD 22.64%), with t28=3.653, P<.001, and Cohen d=1.334. Maintenance scores indicated a positive effect of the intervention (mean 83.33%, SD 24.40%) relative to the control (mean 54.67%, SD 15.98%), t28=3.807, P<.001, Cohen d=1.39. A Mann-Whitney U test indicated that the treatment groups’ self-ratings of confidence (mean 2.41, SD 0.51) were higher than those of the control group (mean 2.04, SD 0.52), U=64, P=.04, r=0.137. Conclusions: The results demonstrate the potential of artificial intelligence-augmented VR to deliver effective, evidence-based training with limited instructor management. Additional work is needed to demonstrate the cascading effect of training on authentic practice and to encompass a wider range of skills. %M 36480248 %R 10.2196/41097 %U https://games.jmir.org/2022/4/e41097 %U https://doi.org/10.2196/41097 %U http://www.ncbi.nlm.nih.gov/pubmed/36480248 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 12 %P e42342 %T Mobile Health–Supported Virtual Reality and Group Problem Management Plus: Protocol for a Cluster Randomized Trial Among Urban Refugee and Displaced Youth in Kampala, Uganda (Tushirikiane4MH, Supporting Each Other for Mental Health) %A Logie,Carmen H %A Okumu,Moses %A Kortenaar,Jean-Luc %A Gittings,Lesley %A Khan,Naimul %A Hakiza,Robert %A Kibuuka Musoke,Daniel %A Nakitende,Aidah %A Katisi,Brenda %A Kyambadde,Peter %A Khan,Torsum %A Lester,Richard %A Mbuagbaw,Lawrence %+ Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M6N 4N3, Canada, 1 416 340 4800 ext 4765, carmen.logie@utoronto.ca %K adolescents and youth %K mental health %K refugee %K implementation research %K virtual reality %K mobile health %K Uganda %K urban %D 2022 %7 8.12.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Although mental health challenges disproportionately affect people in humanitarian contexts, most refugee youth do not receive the mental health support needed. Uganda is the largest refugee-hosting nation in Africa, hosting over 1.58 million refugees in 2022, with more than 111,000 living in the city of Kampala. There is limited information about effective and feasible interventions to improve mental health outcomes and mental health literacy, and to reduce mental health stigma among urban refugee adolescents and youth in low- and middle-income countries (LMICs). Virtual reality (VR) is a promising approach to reduce stigma and improve mental health and coping, yet such interventions have not yet been tested in LMICs where most forcibly displaced people reside. Group Problem Management Plus (GPM+) is a scalable brief psychological transdiagnostic intervention for people experiencing a range of adversities, but has not been tested with adolescents and youth to date. Further, mobile health (mHealth) strategies have demonstrated promise in promoting mental health literacy. Objective: The aim of this study is to evaluate the feasibility and effectiveness of two youth-tailored mental health interventions (VR alone and VR combined with GMP+) in comparison with the standard of care in improving mental health outcomes among refugee and displaced youth aged 16-24 years in Kampala, Uganda. Methods: A three-arm cluster randomized controlled trial will be implemented across five informal settlements grouped into three sites, based on proximity, and randomized in a 1:1:1 design. Approximately 330 adolescents (110 per cluster) are enrolled and will be followed for approximately 16 weeks. Data will be collected at three time points: baseline enrollment, 8 weeks following enrollment, and 16 weeks after enrollment. Primary (depression) and secondary outcomes (mental health literacy, attitudes toward mental help–seeking, adaptive coping, mental health stigma, mental well-being, level of functioning) will be evaluated. Results: The study will be conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. The study has received ethical approval from the University of Toronto (#40965; May 12, 2021), Mildmay Uganda Research Ethics Committee (MUREC-2021-41; June 24, 2021), and Uganda National Council for Science & Technology (SS1021ES; January 1, 2022). A qualitative formative phase was conducted using focus groups and in-depth, semistructured key informant interviews to understand contextual factors influencing mental well-being among urban refugee and displaced youth. Qualitative findings will inform the VR intervention, SMS text check-in messages, and the adaptation of GPM+. Intervention development was conducted in collaboration with refugee youth peer navigators. The trial launched in June 2022 and the final follow-up survey will be conducted in November 2022. Conclusions: This study will contribute to the knowledge of youth-tailored mental health intervention strategies for urban refugee and displaced youth living in informal settlements in LMIC contexts. Findings will be shared in peer-reviewed publications, conference presentations, and with community dissemination. Trial Registration: ClinicalTrials.gov NCT05187689; https://clinicaltrials.gov/ct2/show/NCT05187689 International Registered Report Identifier (IRRID): DERR1-10.2196/42342 %M 36480274 %R 10.2196/42342 %U https://www.researchprotocols.org/2022/12/e42342 %U https://doi.org/10.2196/42342 %U http://www.ncbi.nlm.nih.gov/pubmed/36480274 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e39966 %T Immersive Virtual Reality Avatars for Embodiment Illusions in People With Mild to Borderline Intellectual Disability: User-Centered Development and Feasibility Study %A Langener,Simon %A Klaassen,Randy %A VanDerNagel,Joanne %A Heylen,Dirk %+ Department of Human Media Interaction, University of Twente, PO Box 217, Enschede, 7500 AE, Netherlands, 31 534898771, s.langener@utwente.nl %K virtual reality %K VR %K embodiment %K avatar %K embodied learning %K body-centered %K intellectual disability %K addiction %K user-centered design %D 2022 %7 7.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Immersive virtual reality (IVR) has been investigated as a tool for treating psychiatric conditions. In particular, the practical nature of IVR, by offering a doing instead of talking approach, could support people who do not benefit from existing treatments. Hence, people with mild to borderline intellectual disability (MBID; IQ=50-85) might profit particularly from IVR therapies, for instance, to circumvent issues in understanding relevant concepts and interrelations. In this context, immersing the user into a virtual body (ie, avatar) appears promising for enhancing learning (eg, by changing perspectives) and usability (eg, natural interactions). However, design requirements, immersion procedures, and proof of concept of such embodiment illusion (ie, substituting the real body with a virtual one) have not been explored in this group. Objective: Our study aimed to establish design guidelines for IVR embodiment illusions in people with MBID. We explored 3 factors to induce the illusion, by testing the avatar’s appearance, locomotion using IVR controllers, and virtual object manipulation. Furthermore, we report on the feasibility to induce the embodiment illusion and provide procedural guidance. Methods: We conducted a user-centered study with 29 end users in care facilities, to investigate the avatar’s appearance, controller-based locomotion (ie, teleport, joystick, or hybrid), and object manipulation. Overall, 3 iterations were conducted using semistructured interviews to explore design factors to induce embodiment illusions in our group. To further understand the influence of interactions on the illusion, we measured the sense of embodiment (SoE) during 5 interaction tasks. Results: IVR embodiment illusions can be induced in adults with MBID. To induce the illusion, having a high degree of control over the body outweighed avatar customization, despite the participants’ desire to replicate their own body image. Similarly, the highest SoE was measured during object manipulation tasks, which required a combination of (virtual) locomotion and object manipulation behavior. Notably, interactions that are implausible (eg, teleport and occlusions when grabbing) showed a negative influence on SoE. In contrast, implementing artificial interaction aids into the IVR avatar’s hands (ie, for user interfaces) did not diminish the illusion, presuming that the control was unimpaired. Nonetheless, embodiment illusions showed a tedious and complex need for (control) habituation (eg, motion sickness), possibly hindering uptake in practice. Conclusions: Balancing the embodiment immersion by focusing on interaction habituation (eg, controller-based locomotion) and lowering customization effort seems crucial to achieve both high SoE and usability for people with MBID. Hence, future studies should investigate the requirements for natural IVR avatar interactions by using multisensory integrations for the virtual body (eg, animations, physics-based collision, and touch) and other interaction techniques (eg, hand tracking and redirected walking). In addition, procedures and use for learning should be explored for tailored mental health therapies in people with MBID. %M 36476721 %R 10.2196/39966 %U https://games.jmir.org/2022/4/e39966 %U https://doi.org/10.2196/39966 %U http://www.ncbi.nlm.nih.gov/pubmed/36476721 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e40727 %T A Novel Scenario-Based, Mixed-Reality Platform for Training Nontechnical Skills of Battlefield First Aid: Prospective Interventional Study %A Du,Wenqiong %A Zhong,Xin %A Jia,Yijun %A Jiang,Renqing %A Yang,Haoyang %A Ye,Zhao %A Zong,Zhaowen %+ State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, 30 Gaotanyan St, Shapingba District, Chongqing, 400038, China, 86 138 8350 6677, zongzhaowen@163.com %K mixed reality %K decision-making %K team work %K battlefield first aid %K nontechnical skills %K training %K next-generation modeling %K virtual reality %K medical education %D 2022 %7 6.12.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although battlefield first aid (BFA) training shares many common features with civilian training, such as the need to address technical skills and nontechnical skills (NTSs), it is more highly scenario-dependent. Studies into extended reality show clear benefits in medical training; however, the training effects of extended reality on NTSs, including teamwork and decision-making in BFA, have not been fully proven. Objective: The current study aimed to create and test a scenario-based, mixed-reality platform suitable for training NTSs in BFA. Methods: First, using next-generation modeling technology and an animation synchronization system, a 10-person offensive battle drill was established. Decision-making training software addressing basic principles of tactical combat casualty care was constructed and integrated into the scenarios with Unreal Engine 4 (Epic Games). Large-space teamwork and virtual interaction systems that made sense in the proposed platform were developed. Unreal Engine 4 and software engineering technology were used to combine modules to establish a mixed-reality BFA training platform. A total of 20 Grade 4 medical students were recruited to accept BFA training with the platform. Pretraining and posttraining tests were carried out in 2 forms to evaluate the training effectiveness: one was knowledge acquisition regarding the NTS and the other was a real-world, scenario-based test. In addition, the students were asked to rate their agreement with a series of survey items on a 5-point Likert scale. Results: A battlefield geographic environment, tactical scenarios, scenario-based decision software, large-space teamwork, and virtual interaction system modules were successfully developed and combined to establish the mixed-reality training platform for BFA. The posttraining score of the students’ knowledge acquisition was significantly higher than that of pretraining (t=−12.114; P≤.001). Furthermore, the NTS score and the total score that the students obtained in the real-world test were significantly higher than those before training (t=−17.756 and t=−21.354, respectively; P≤.001). However, there was no significant difference between the scores of technical skills that the students obtained before and after training. A posttraining survey revealed that the students found the platform helpful in improving NTSs for BFA, and they were confident in applying BFA skills after training. However, most trainees thought that the platform was not helpful for improving the technical skills of BFA, and 45% (9/20) of the trainees were not satisfied with the simulation effect. Conclusions: A scenario-based, mixed-reality platform was constructed in this study. In this platform, interaction of the movement of multiple players in a large space and the interaction of decision-making by the trainees between the real world and the virtual world were accomplished. The platform could improve the NTSs of BFA. Future works, including improvement of the simulation effects and development of a training platform that could effectively improve both the technical skills and NTSs of BFA, will be carried out. %M 36472903 %R 10.2196/40727 %U https://games.jmir.org/2022/4/e40727 %U https://doi.org/10.2196/40727 %U http://www.ncbi.nlm.nih.gov/pubmed/36472903 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e35802 %T Older Adults’ Experiences and Perceptions of Immersive Virtual Reality: Systematic Review and Thematic Synthesis %A Healy,David %A Flynn,Aisling %A Conlan,Owen %A McSharry,Jenny %A Walsh,Jane %+ School of Psychology, University of Galway, University Rd, Galway, H91 TK33, Ireland, 353 863014265, d.healy24@nuigalway.ie %K older adults %K virtual reality %K immersive virtual reality %K aging %K systematic review %K qualitative evidence synthesis %K thematic synthesis %D 2022 %7 6.12.2022 %9 Review %J JMIR Serious Games %G English %X Background: Immersive virtual reality (IVR) can be defined as a fully computer-generated environment shown on a head-mounted display. Existing research suggests that key features of IVR can assist older adults in their everyday lives, providing opportunities for health promotion and tackling social isolation and loneliness. There has been a surge in qualitative studies exploring older adults’ experiences and perceptions of IVR. However, there has been no systematic synthesis of these studies to inform the design of new, more accessible IVR technologies. Objective: This study aimed to systematically review and synthesize qualitative studies exploring older adults’ experiences and perceptions of IVR. Methods: A systematic review and thematic synthesis were conducted following the ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) guidelines. In total, 2 reviewers completed title and abstract screening, full-text screening, data extraction, and quality appraisal. Thematic synthesis is derived from the qualitative method, thematic analysis. It involves 3 key steps: initial coding and grouping of these codes, the formation of descriptive themes from these codes, and going beyond these data to form analytical themes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation-Confidence in the Evidence from Reviews of Qualitative Research approach. Results: Overall, 13 studies were included in the final synthesis, including 224 participants across 9 countries and 5 continents. Confidence in the evidence ranged from high to moderate. Three descriptive themes were generated: practical aspects of IVR use, experiencing unique features of IVR, and perceptions of IVR. The findings from the descriptive themes suggested that there are several improvements that need to be made to existing IVR devices to facilitate older adults’ use of this technology. However, older adults’ responses to IVR were generally positive. Three analytical themes were generated: tolerating the bad to experience the good, buying in to IVR (don’t judge a book by its cover), and “it proves to me I can do it.” The analytical themes illustrated that older adults were willing to tolerate discomforts that accompany existing IVR technologies to experience features such as immersive social networking. There was a discrepancy between older adults’ perceptions of IVR before use—which were generally negative—and after use—which were generally positive—and IVR provided a platform for older adults to access certain activities and environments more easily than in the real world because of limitations caused by aging. Conclusions: This review offers insights into older adults’ experiences and perceptions of IVR and suggests how a few improvements to its existing hardware and software as well as how it is first presented could offer new opportunities for older adults to take part in meaningful activities tailored to their needs and preferences. Trial Registration: PROSPERO CRD42020200774; https://tinyurl.com/8f48w2vt International Registered Report Identifier (IRRID): RR2-10.1177/16094069211009682 %M 36472894 %R 10.2196/35802 %U https://games.jmir.org/2022/4/e35802 %U https://doi.org/10.2196/35802 %U http://www.ncbi.nlm.nih.gov/pubmed/36472894 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 12 %P e40056 %T Experiences of Patients and Therapists Testing a Virtual Reality Exposure App for Symptoms of Claustrophobia: Mixed Methods Study %A Mayer,Gwendolyn %A Gronewold,Nadine %A Polte,Kirsten %A Hummel,Svenja %A Barniske,Joshua %A Korbel,Jakob J %A Zarnekow,Rüdiger %A Schultz,Jobst-Hendrik %+ Department of General Internal Medicine and Psychosomatics, Heidelberg University Hospital, Im Neuenheimer Feld, 130.3, Heidelberg, 69120, Germany, 49 62215635685, gwendolyn.mayer@med.uni-heidelberg.de %K virtual reality %K exposure therapy %K anxiety disorders %K claustrophobia %K think-aloud %K mixed methods %K virtual reality exposure therapy %K VR %K anxiety %K therapy %K mental health %K user experience %K perspective %D 2022 %7 5.12.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: The effectiveness of virtual reality exposure (VRE) in the treatment of anxiety disorders is well established. Several psychological mechanisms of VRE have been identified, whereby both emotional processing and the sense of presence play a key role. However, there are only few studies that contribute to our knowledge of examples of implementation in the case of VRE for claustrophobia based on patients' experiences and the perspective of therapists. Objective: This study asks for key elements of a VRE app that are necessary for effective exposure for people with claustrophobic symptoms. Methods: A mixed methods design was applied in which patients (n=15) and therapeutic experts (n=15) tested a VRE intervention of an elevator ride at 5 intensity levels. Intensity was varied by elevator size, duration of the elevator ride, and presence of virtual humans. Quantitative measures examined self-reported presence with the Igroup Presence Questionnaire (IPQ) ranging from 0 to 6 and 15 Likert-scaled evaluation items that had been developed for the purpose of this study, ranging from 1 to 5. In both measures, higher scores indicate higher levels of presence or agreement. Think-aloud protocols of the patients and semistructured interviews posttreatment of all participants were conducted to gain in-depth perspectives on emotional processes. Results: The intervention induced a feeling of presence in patients and experts, posttreatment scores showed a high IPQ presence score (mean 3.84, SD 0.88), with its subscores IPQ spatial presence (mean 4.53, SD 1.06), IPQ involvement (mean 3.83, SD 1.22), and IPQ experienced realism (mean 2.75, SD 1.02). Patients preferred a setting in the presence of a therapist (mean 4.13, SD 0.83) more than the experts did (mean 3.33, SD 1.54). Think-aloud protocols of the patients revealed that presence and anxiety both were achieved. Qualitative interviews of patients and experts uncovered 8 topics: feelings and emotions, personal story, telepresence, potential therapeutic effects, barriers, conditions and requirements, future prospects, and realization. The intensity levels were felt to appropriately increase in challenge, with ambivalent results regarding the final level. Virtual humans contributed to feelings of fear. Conclusions: Key elements of a VRE app for claustrophobic symptoms should include variation of intensity by adding challenging cues in order to evoke presence and anxiety. Virtual humans are a suitable possibility to make the intervention realistic and to provide a sense of closeness; however, some of the fears might then be related to symptoms of social phobia or agoraphobia. Patients may need the physical presence of a therapist, though not all of them share this view. A higher degree of sophistication in the intensity levels is needed to deliver targeted help for specific symptoms of anxiety. %M 36469413 %R 10.2196/40056 %U https://mental.jmir.org/2022/12/e40056 %U https://doi.org/10.2196/40056 %U http://www.ncbi.nlm.nih.gov/pubmed/36469413 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 12 %P e42332 %T Disinfection of Virtual Reality Devices in Health Care Settings: In Vitro Assessment and Survey Study %A Roberts,Scott C %A Havill,Nancy L %A Flores,Rosa M %A Hendrix II,Curtis Anthony %A Williams,Maximillian J %A Feinn,Richard S %A Choi,Steven J %A Martinello,Richard A %A Marks,Asher M %A Murray,Thomas S %+ Section of Infectious Diseases, Department of Internal Medicine, Yale School of Medicine, 20 York Street, Hunter 527, New Haven, CT, 06510, United States, 1 240 328 9031, scott.c.roberts@yale.edu %K disinfection %K healthcare-acquired infection %K healthcare worker %K virtual reality %K disinfect %K occupational health %K occupational safety %K infection control %K infection spread %D 2022 %7 1.12.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) devices are increasingly used in health care settings. The use among patients has the potential to unintentionally transmit pathogens between patients and hospital staff. No standard operating procedure for disinfection exists to ensure safe use between patients. Objective: This study aims to determine the efficacy of disinfectants on VR devices in order to ensure safe use in health care settings. Methods: Three types of bacteria were inoculated onto porous and nonporous surfaces of 2 VR devices: the Meta Oculus Quest and Meta Oculus Quest 2. Disinfection was performed using either isopropyl alcohol or alcohol-free quaternary ammonium wipes. A quantitative culture was used to assess the adequacy of disinfection. A survey was separately sent out to VR device technicians at other pediatric health care institutes to compare the methods of disinfection and how they were established. Results: Both products achieved adequate disinfection of the treated surfaces; however, a greater log-kill was achieved on nonporous surfaces than on the porous surfaces. Alcohol performed better than quaternary ammonium on porous surfaces. The survey respondents reported a wide variability in disinfection processes with only 1 person reporting an established standard operating procedure. Conclusions: Disinfection can be achieved through the use of either isopropyl alcohol or quaternary ammonium products. Porous surfaces showed lesser log-kill rates than the nonporous surfaces, indicating that the use of an added barrier may be of benefit and should be a point of future research. Given the variability in the disinfection process across health care systems, a standard operating procedure is proposed. %M 36269222 %R 10.2196/42332 %U https://www.jmir.org/2022/12/e42332 %U https://doi.org/10.2196/42332 %U http://www.ncbi.nlm.nih.gov/pubmed/36269222 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e41234 %T Effects of a Modern Virtual Reality 3D Head-Mounted Display Exergame on Simulator Sickness and Immersion Under Specific Conditions in Young Women and Men: Experimental Study %A Ciążyńska,Julia %A Janowski,Michał %A Maciaszek,Janusz %+ Department of Physical Activity and Health Promotion Science, Poznan University of Physical Education, 61-871 Poznan, Królowej Jadwigi 27/39, Poznan, 61-871, Poland, 48 (61) 835 52 14, ciazynska@awf.poznan.pl %K virtual reality %K HMD %K simulator sickness %K immersion %K physical activity %K exergame %K Zephyr %K gender differences %K WHO recommendation %K young adult %K digital health %K energy expenditure %K exercise game %D 2022 %7 29.11.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Many young adults do not reach the World Health Organization’s minimum recommendations for the amount of weekly physical activity. The virtual reality 3D head-mounted display (VR 3D HMD) exergame is a technology that is more immersive than a typical exercise session. Our study considers gender differences in the experience of using VR games for increasing physical activity. Objective: The aim of this study was to examine the differences in the effects of VR 3D HMD gaming in terms of immersion, simulator sickness, heart rate, breathing rate, and energy expenditure during two 30-minute sessions of playing an exergame of increasing intensity on males and females. Methods: To examine the effects of the VR 3D HMD exergame, we experimented with 45 participants (23 males and 22 females) exercising with VR 3D HMD Oculus Quest 1, hand controllers, and Zephyr BioHarness 3.0. Players exercised according to the Audio Trip exergame. We evaluated the immersion levels and monitored the average heart rate, maximum heart rate, average breathing rate, maximum breathing rate, and energy expenditure in addition to simulator sickness during two 30-minute exergame sessions of increasing intensity. Results: Audio Trip was well-tolerated, as there were no dropouts due to simulator sickness. Significant differences between genders were observed in the simulator sickness questionnaire for nausea (F2,86=0.80; P=.046), oculomotor disorders (F2,86=2.37; P=.010), disorientation (F2,86=0.92; P=.040), and total of all these symptoms (F2,86=3.33; P=.04). The measurements after the first 30-minute VR 3D HMD exergame session for all the participants showed no significant change compared to the measurements before the first 30-minute exergame session according to the total score. There were no gender differences in the immersion (F1,43=0.02; P=.90), but the measurements after the second 30-minute exergame session showed an increase in the average points for immersion in women and men. The increase in the level of immersion in the female group was higher than that in the male group. A significant difference between genders was observed in the average breathing rate (F2,86=1.44; P=.04), maximum breathing rate (F2,86=1.15; P=.047), and energy expenditure (F2,86=10.51; P=.001) measurements. No gender differences were observed in the average heart rate and maximum heart rate measurements in the two 30-minute sessions. Conclusions: Our 30-minute VR 3D HMD exergame session does not cause simulator sickness and is a very immersive type of exercise for men and women users. This exergame allows reaching the minimum recommendations for the amount of weekly physical activity for adults. The second exergame session resulted in simulator sickness in both groups, more noticeably in women, as reflected in the responses in the simulator sickness questionnaire. The gender differences observed in the breathing rates and energy expenditure measurements can be helpful when programming VR exergame intensity in future research. %M 36445744 %R 10.2196/41234 %U https://games.jmir.org/2022/4/e41234 %U https://doi.org/10.2196/41234 %U http://www.ncbi.nlm.nih.gov/pubmed/36445744 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 11 %P e38536 %T A Digital Health Intervention for Stress and Anxiety Relief in Perioperative Care: Protocol for a Feasibility Randomized Controlled Trial %A Kondylakis,Haridimos %A Chicchi Giglioli,Irene Alice %A Katehakis,Dimitrios G %A Aldemir,Hatice %A Zikas,Paul %A Papagiannakis,George %A Hors-Fraile,Santiago %A González-Sanz,Pedro L %A Apostolakis,Konstantinos C %A Stephanidis,Constantine %A Núñez-Benjumea,Francisco J %A Baños-Rivera,Rosa M %A Fernandez-Luque,Luis %A Kouroubali,Angelina %+ Adhera Health, Inc, 1001 Page Mill Rd Building One, Suite 200, Palo Alto, CA, 94304, United States, 1 656930901, luis@adherahealth.com %K CARINAE %K digital health %K perioperative process %K patient empowerment %K stress and anxiety management %K mobile health %K mHealth %K virtual reality %K VR %K health recommender system %K HRS %D 2022 %7 29.11.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Stress and anxiety are psychophysiological responses commonly experienced by patients during the perioperative process that can increase presurgical and postsurgical complications to a comprehensive and positive recovery. Preventing and intervening in stress and anxiety can help patients achieve positive health and well-being outcomes. Similarly, the provision of education about surgery can be a crucial component and is inversely correlated with preoperative anxiety levels. However, few patients receive stress and anxiety relief support before surgery, and resource constraints make face-to-face education sessions untenable. Digital health interventions can be helpful in empowering patients and enhancing a more positive experience. Digital health interventions have been shown to help patients feel informed about the possible benefits and risks of available treatment options. However, they currently focus only on providing informative content, neglecting the importance of personalization and patient empowerment. Objective: This study aimed to explore the feasibility of a digital health intervention called the Adhera CARINAE Digital Health Program, designed to provide evidence-based, personalized stress- and anxiety-management methods enabled by a comprehensive digital ecosystem that incorporates wearable, mobile, and virtual reality technologies. The intervention program includes the use of advanced data-driven techniques for tailored patient education and lifestyle support. Methods: The trial will include 5 hospitals across 3 European countries and will use a randomized controlled design including 30 intervention participants and 30 control group participants. The involved surgeries are cardiopulmonary and coronary artery bypass surgeries, cardiac valve replacement, prostate or bladder cancer surgeries, hip and knee replacement, maxillofacial surgery, or scoliosis. The control group will receive standard care, and the intervention group will additionally be exposed to the digital health intervention program. Results: The recruitment process started in January 2022 and has been completed. The primary impact analysis is currently ongoing. The expected results will be published in early 2023. Conclusions: This manuscript details a comprehensive protocol for a study that will provide valuable information about the intervention program, such as the measurement of comparative intervention effects on stress; anxiety and pain management; and usability by patients, caregivers, and health care professionals. This will contribute to the evidence planning process for the future adoption of diverse digital health solutions in the field of surgery. Trial Registration: ClinicalTrials.gov NCT05184725; https://www.clinicaltrials.gov/ct2/show/NCT05184725 International Registered Report Identifier (IRRID): DERR1-10.2196/38536 %M 36445734 %R 10.2196/38536 %U https://www.researchprotocols.org/2022/11/e38536 %U https://doi.org/10.2196/38536 %U http://www.ncbi.nlm.nih.gov/pubmed/36445734 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e38988 %T An Analysis of Priorities in Developing Virtual Reality Programs for Core Nursing Skills: Cross-sectional Descriptive Study Using the Borich Needs Assessment Model and Locus for Focus Model %A Jeong,EunYoung %A Lim,JunSeo %+ Research Institute of Nursing Science, College of Nursing, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea, 82 1091100844, junseo@snu.ac.kr %K core nursing skills %K virtual reality %K Borich priority formula %K Locus for Focus Model %K need assessment %K nursing education %D 2022 %7 24.11.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: There are limitations to conducting face-to-face classes following the recent COVID-19 pandemic. Web-based education is no longer a temporary form of teaching and learning during unusual events, such as pandemics, but has proven to be necessary to uphold in parallel with offline education in the future. Therefore, it is necessary to scientifically organize the priorities of a learner needs analysis by systematically and rationally investigating and analyzing the needs of learners for the development of virtual reality (VR) programs for core nursing skills (CNS). Objective: This study aimed to identify the priorities of learners’ needs for the development of VR programs for CNS using the Locus for Focus Model and Borich need assessment model. Methods: The participants included nursing students in South Korea who were in their second year or higher and had taken courses in fundamental nursing or CNS-related classes. The survey took place from May 20 to June 25, 2021. A total of 337 completed questionnaires were collected. Of these, 222 were used to conduct the final analysis. The self-report questionnaire consisted of 3 parts: perception of VR programs, demand for developing VR programs, and general characteristics. The general characteristics of the participants were analyzed using descriptive statistics. To determine the priority of the demand for developing VR programs for CNS, the Locus for Focus Model and the Borich priority formula were used. Results: In all, 7 skills were identified as being of the top priority for development, including intramuscular injection, intradermal injection, tube feeding, enema, postoperative care, supplying oxygen via nasal cannula, and endotracheal suction. Conclusions: The analysis showed that nursing students generally needed and prioritized the development of VR programs for the nursing skills involving invasive procedures. The results of this study are intended to help in various practical education classes using VR programs in nursing departments, which are currently facing difficulties in teaching CNS on the web owing to COVID-19. %M 36422882 %R 10.2196/38988 %U https://games.jmir.org/2022/4/e38988 %U https://doi.org/10.2196/38988 %U http://www.ncbi.nlm.nih.gov/pubmed/36422882 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e39932 %T Handheld Weights as an Effective and Comfortable Way To Increase Exercise Intensity of Physical Activity in Virtual Reality: Empirical Study %A Polechoński,Jacek %A Zwierzchowska,Anna %A Makioła,Łukasz %A Groffik,Dorota %A Kostorz,Karolina %+ Institute of Sport Sciences, The Jerzy Kukuczka Academy of Physical Education in Katowice, 72A, Mikołowska St, Katowice, 40-065, Poland, 48 32 207 51 93, j.polechonski@awf.katowice.pl %K immersive virtual reality %K virtual reality %K health-related physical activity %K intensity of physical activity %K active video games %K serious games %D 2022 %7 23.11.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: In recent years, there has been a growing interest in active virtual reality games (AVRGs) that provide entertainment and encourage more physical activity (PA). Since playing AVRGs involves primarily arm movements, the intensity of this form of PA may not be sufficient for health benefits. Therefore, it is worth looking for virtual entertainment solutions that are comfortable for users and at the same time increase physical exercise. Objective: The main objective of this study was to evaluate the effect of external loading of the arms in the form of handheld weights (HHWs) on exercise intensity in users playing a popular AVRG. The results obtained in the study were compared with the PA recommendations for health. The study also assessed the perceptions of the users about the attractiveness and usefulness of this type of exercise and discomfort caused by additional load on the arms. Methods: The study covered 17 young adults aged 18 to 25 years playing an AVRG (Beat Saber) with no arm load and with HHWs (0.5 kg). A PlayStation 4 PRO console (Sony) with accessories including a head-mounted display and controllers was used in the study. PA intensity was evaluated using a heart rate monitor based on the percentage of maximal heart rate (% HRmax). The usability, attractiveness, and comfort perceived during exercise by users were evaluated using a survey questionnaire. Results: The measurements showed that the mean % HRmax in participants playing Beat Saber without HHWs was significantly lower (P<.001; Cohen d=1.07) than that observed when playing with HHWs. It should be emphasized that with no additional load, the intensity of PA was low (mean 63.7% HRmax, SD 9.3% HRmax), while with the upper limb load, it increased to a moderate level (mean 67.1% HRmax, SD 10.3% HRmax), which is recommended for health benefits. The survey conducted in the study showed that HHWs (0.5 kg) attached to the wrists did not disturb Beat Saber players. Conclusions: Since PA in most of the modern AVRGs primarily involves upper limb movements, the use of HHW seems to be a simple and effective way to increase exercise intensity, especially because, as reported by the study participants, such a procedure does not cause discomfort while using the application. %M 36416873 %R 10.2196/39932 %U https://games.jmir.org/2022/4/e39932 %U https://doi.org/10.2196/39932 %U http://www.ncbi.nlm.nih.gov/pubmed/36416873 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e36695 %T The Effects of Virtual Reality in Maternal Delivery: Systematic Review and Meta-analysis %A Xu,Nuo %A Chen,Sijing %A Liu,Yan %A Jing,Yuewen %A Gu,Ping %+ School of Nursing, Nanjing Medical University, 101 Longmian Avenue, Jiangning District, Nanjing, 211166, China, 86 1 358 520 5899, gpapple83@163.com %K virtual reality technology %K delivery %K labor pain %K anxiety %K meta-analysis %K systematic review %K pain %K pregnancy %K virtual reality %K maternity %K labor %K technology %K pregnant women %K review %K childbirth %K mental health %D 2022 %7 23.11.2022 %9 Review %J JMIR Serious Games %G English %X Background: Extreme labor pain has negative effects; pharmacologic analgesic modalities are effective but are accompanied by adverse effects. Virtual reality (VR) works as a distracting nonpharmacologic intervention for pain and anxiety relief; however, the effects of VR use in laboring women is unknown. Objective: Our study aimed to determine the safety and effectiveness of VR technology during labor and delivery and investigate whether it impacts labor and patient satisfaction. Methods: In all, 7 databases (PubMed, Embase, Web of Science, the Cochrane Library, CINAHL, China National Knowledge Infrastructure, and Wan-Fang Database) were systematically searched for randomized controlled trials of VR use in pregnancy and childbirth from the time of database construction until November 24, 2021. Two researchers extracted data and evaluated study quality using the Cochrane Risk of Bias tool 2.0. Outcome measures were labor pain, anxiety, duration, satisfaction, and adverse events. Meta-analyses were performed where possible. Results: A total of 12 studies with 1095 participants were included, of which 1 and 11 studies were rated as “Low risk” and “Some concerns” for risk of bias, respectively. Of the 12 studies, 11 reported labor pain, 7 reported labor anxiety, and 4 reported labor duration. Meta-analysis revealed that VR use could relieve pain during labor (mean difference –1.81, 95% CI –2.04 to –1.57; P<.001) and the active period (standardized mean difference [SMD] –0.41, 95% CI –0.68 to –0.14; P=.003); reduce anxiety (SMD –1.39, 95% CI –1.99 to –0.78; P<.001); and improve satisfaction with delivery (relative risk 1.32, 95% CI 1.10-1.59; P=.003). The effects of VR on the duration of the first (SMD –1.12, 95% CI –2.38 to 0.13; P=.08) and second (SMD –0.22, 95% CI –0.67 to 0.24; P=.35) stages of labor were not statistically significant. Conclusions: VR is safe and effective in relieving maternal labor pain and anxiety; however, due to the heterogeneity among studies conducted to date, more rigorous, large-scale, and standardized randomized controlled trials are required to provide a higher-quality evidence base for the use of VR technology in maternal labor, with the aim of improving experience and outcomes. Trial Registration: PROSPERO CRD42021295410; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=295410 %M 36416881 %R 10.2196/36695 %U https://games.jmir.org/2022/4/e36695 %U https://doi.org/10.2196/36695 %U http://www.ncbi.nlm.nih.gov/pubmed/36416881 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 11 %P e39248 %T Estimating the Economic Value of Automated Virtual Reality Cognitive Therapy for Treating Agoraphobic Avoidance in Patients With Psychosis: Findings From the gameChange Randomized Controlled Clinical Trial %A Altunkaya,James %A Craven,Michael %A Lambe,Sinéad %A Beckley,Ariane %A Rosebrock,Laina %A Dudley,Robert %A Chapman,Kate %A Morrison,Anthony %A O'Regan,Eileen %A Grabey,Jenna %A Bergin,Aislinn %A Kabir,Thomas %A Waite,Felicity %A Freeman,Daniel %A Leal,José %+ Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, United Kingdom, 44 1865 289263, jose.leal@dph.ox.ac.uk %K gameChange %K virtual reality %K National Health Service %K NHS %K cost-effectiveness %K economic evaluation %K maximum price %D 2022 %7 18.11.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: An automated virtual reality cognitive therapy (gameChange) has demonstrated its effectiveness to treat agoraphobia in patients with psychosis, especially for high or severe anxious avoidance. Its economic value to the health care system is not yet established. Objective: In this study, we aimed to estimate the potential economic value of gameChange for the UK National Health Service (NHS) and establish the maximum cost-effective price per patient. Methods: Using data from a randomized controlled trial with 346 patients with psychosis (ISRCTN17308399), we estimated differences in health-related quality of life, health and social care costs, and wider societal costs for patients receiving virtual reality therapy in addition to treatment as usual compared with treatment as usual alone. The maximum cost-effective prices of gameChange were calculated based on UK cost-effectiveness thresholds. The sensitivity of the results to analytical assumptions was tested. Results: Patients allocated to gameChange reported higher quality-adjusted life years (0.008 QALYs, 95% CI –0.010 to 0.026) and lower NHS and social care costs (–£105, 95% CI –£1135 to £924) compared with treatment as usual (£1=US $1.28); however, these differences were not statistically significant. gameChange was estimated to be worth up to £341 per patient from an NHS and social care (NHS and personal social services) perspective or £1967 per patient from a wider societal perspective. In patients with high or severe anxious avoidance, maximum cost-effective prices rose to £877 and £3073 per patient from an NHS and personal social services perspective and societal perspective, respectively. Conclusions: gameChange is a promising, cost-effective intervention for the UK NHS and is particularly valuable for patients with high or severe anxious avoidance. This presents an opportunity to expand cost-effective psychological treatment coverage for a population with significant health needs. Trial Registration: ISRCTN Registry ISRCTN17308399; https://www.isrctn.com/ISRCTN17308399 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2019-031606 %M 36399379 %R 10.2196/39248 %U https://www.jmir.org/2022/11/e39248 %U https://doi.org/10.2196/39248 %U http://www.ncbi.nlm.nih.gov/pubmed/36399379 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e38972 %T The Effects of Virtual Reality Training on Balance, Gross Motor Function, and Daily Living Ability in Children With Cerebral Palsy: Systematic Review and Meta-analysis %A Liu,Cong %A Wang,Xing %A Chen,Rao %A Zhang,Jie %+ Department of Physical Education, Donghua University, 2999 Renmin North Road, Songjiang District, Shanghai, 201620, China, 86 15221857691, j202166@163.com %K virtual reality %K cerebral palsy %K balance %K gross motor activities %K activities of daily living %K meta %K motor %K children %K pediatrics %D 2022 %7 9.11.2022 %9 Review %J JMIR Serious Games %G English %X Background: The increasing number of children with cerebral palsy (CP) has a serious impact on individuals, families, and society. As a new technology, virtual reality (VR) has been used in the rehabilitation of children with CP. Objective: This study aimed to systematically evaluate the effect of VR training on balance, gross motor function, and daily living ability in children with CP. Methods: PubMed, Embase, The Cochrane Library, Web of Science, and China National Knowledge Infrastructure databases were searched by computer, with the search period being from the establishment of each database to December 25, 2021, to collect randomized controlled trials (RCTs) on the effects of VR training on balance, gross motor function, and daily living ability in children with CP. The Cochrane risk of bias assessment tool was used to conduct quality assessment on the included literature, and RevMan software (version 5.3) was used to analyze data. Results: A total of 16 articles were included, involving 513 children with CP. VR training can improve the balance function (Pediatric Balance Scale: mean difference 2.06, 95% CI 1.15-2.97; P<.001; Berg Balance Scale: mean difference 3.66, 95% CI 0.29-7.02; P=.03) and gross motor function (standardized mean difference [SMD] 0.60, 95% CI 0.34-0.87; P<.001) of children with CP. However, there is still certain disagreement on the impact on daily living ability (SMD 0.37, 95% CI –0.04 to 0.78; P=.08); after removing the source literature with heterogeneity, VR training can improve the daily living ability of children with CP (SMD 0.55, 95% CI 0.30-0.81; P<.001). Conclusions: VR training can significantly improve the balance function and gross motor function of children with CP, but the effect on the daily living ability of children with CP remains controversial. %M 36350683 %R 10.2196/38972 %U https://games.jmir.org/2022/4/e38972 %U https://doi.org/10.2196/38972 %U http://www.ncbi.nlm.nih.gov/pubmed/36350683 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e40119 %T Impact of Personalized Avatars and Motion Synchrony on Embodiment and Users’ Subjective Experience: Empirical Study %A Jung,Myeongul %A Sim,Sangyong %A Kim,Jejoong %A Kim,Kwanguk %+ Department of Computer Science, Hanyang University, 222, Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea, 82 222202319, kenny@hanyang.ac.kr %K embodiment %K virtual reality %K virtual avatar %K personalization %K personalized %K body motion %K presence %K simulator sickness %K simulator %K simulation %K avatar %K motion %K body ownership %K self location %K agency %K experience %K virtual world %K immersive %D 2022 %7 8.11.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Embodiment through a virtual avatar is a key element for people to feel that they are in the virtual world. Objective: This study aimed to elucidate the interaction between 2 methods of eliciting embodiment through a virtual avatar: motion synchronization and appearance similarity between a human and avatar, to understand embodiment (agency, body ownership, and self-location) and subjective experience (presence, simulator sickness, and emotion) in virtual reality. Methods: Using a full-body motion capture system, 24 participants experienced their virtual avatars with a 3D-scanned face and size-matched body from a first-person perspective. This study used a 2 (motion; sync and async) × 2 (appearance; personalized and generic) within-subject design. Results: The results indicated that agency and body ownership increased when motion and appearance were matched, whereas self-location, presence, and emotion were affected by motion only. Interestingly, if the avatar’s appearance was similar to the participants (personalized avatar), they formed an agency toward the avatar’s motion that was not performed by themselves. Conclusions: Our findings would be applicable in the field of behavioral therapy, rehabilitation, and entertainment applications, by eliciting higher agency with a personalized avatar. %M 36346658 %R 10.2196/40119 %U https://games.jmir.org/2022/4/e40119 %U https://doi.org/10.2196/40119 %U http://www.ncbi.nlm.nih.gov/pubmed/36346658 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e35000 %T Virtual Reality Applications in Medicine During the COVID-19 Pandemic: Systematic Review %A Pallavicini,Federica %A Pepe,Alessandro %A Clerici,Massimo %A Mantovani,Fabrizia %+ Department of Human Sciences for Education, Università degli Studi di Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, Milano, 20126, Italy, 39 0264484931, federica.pallavicini@unimib.it %K virtual reality %K medicine %K mental health %K physical health %K education %K training %K COVID-19 %D 2022 %7 25.10.2022 %9 Review %J JMIR Serious Games %G English %X Background: Virtual reality can play an important role during the COVID-19 pandemic in the health care sector. This technology has the potential to supplement the traditional in-hospital medical training and treatment, and may increase access to training and therapies in various health care settings. Objective: This systematic review aimed to describe the literature on health care–targeted virtual reality applications during the COVID-19 crisis. Methods: We conducted a systematic search of the literature on the PsycINFO, Web of Science, and MEDLINE databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The search string was as follows: “[(virtual reality)] AND [(COVID-19) OR (coronavirus) OR (SARS-CoV-2) OR (healthcare)].” Papers published in English after December 2019 in peer-reviewed journals were selected and subjected to the inclusion and exclusion criteria. We used the Mixed Methods Appraisal Tool to assess the quality of studies and the risk of bias. Results: Thirty-nine studies met the inclusion criteria. Seventeen studies showed the usefulness of virtual reality during the COVID-19 crisis for reducing stress, anxiety, depression, and pain, and promoting physical activity. Twenty-two studies revealed that virtual reality was a helpful learning and training tool during the COVID-19 crisis in several areas, including emergency medicine, nursing, and pediatrics. This technology was also used as an educational tool for increasing public understanding of the COVID-19 pandemic. Different levels of immersion (ie, immersive and desktop virtual reality), types of head-mounted displays (ie, PC-based, mobile, and standalone), and content (ie, 360° videos and photos, virtual environments, virtual reality video games, and embodied virtual agents) have been successfully used. Virtual reality was helpful in both face-to-face and remote trials. Conclusions: Virtual reality has been applied frequently in medicine during the COVID-19 pandemic, with positive effects for treating several health conditions and for medical education and training. Some barriers need to be overcome for the broader adoption of virtual reality in the health care panorama. Trial Registration: International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) INPLASY202190108; https://inplasy.com/inplasy-2021-9-0108/ %M 36282554 %R 10.2196/35000 %U https://games.jmir.org/2022/4/e35000 %U https://doi.org/10.2196/35000 %U http://www.ncbi.nlm.nih.gov/pubmed/36282554 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e38315 %T Virtual Reality Technology in Cognitive Rehabilitation Application: Bibliometric Analysis %A He,Danni %A Cao,Shihua %A Le,Yuchao %A Wang,Mengxin %A Chen,Yanfei %A Qian,Beiying %+ Nursing Department, Hangzhou Normal University Qianjiang College, No.16 Xuelin St, Jianggan District, Hangzhou City, Zhejiang Province, Hangzhou, 310036, China, 86 13777861361, csh@hznu.edu.cn %K virtual reality %K cognitive rehabilitation %K bibliometric analysis %K CiteSpace %K gCLUTO %K rehabilitation %K cognitive disorder %K visual content analysis %D 2022 %7 19.10.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: In recent years, with the development of computer science and medical science, virtual reality (VR) technology has become a promising tool for improving cognitive function. Research on VR-based cognitive training has garnered increasing attention. Objective: This study aimed to investigate the application status, research hot spots, and emerging trends of VR in cognitive rehabilitation over the past 20 years. Methods: Articles on VR-based cognitive rehabilitation from 2001 to 2021 were retrieved from the Web of Science Core Collection. CiteSpace software was used for the visual analysis of authors and countries or regions, and Scimago Graphica software was used for the geographic visualization of published countries or regions. Keywords were clustered using the gCLUTO software. Results: A total of 1259 papers were included. In recent years, research on the application of VR in cognitive rehabilitation has been widely conducted, and the annual publication of relevant literature has shown a positive trend. The main research areas include neuroscience and neurology, psychology, computer science, and rehabilitation. The United States ranked first with 328 papers, and Italy ranked second with 140 papers. Giuseppe Riva, an Italian academic, was the most prolific author with 29 publications. The most frequently cited reference was “Using Reality to Characterize Episodic Memory Profiles in Amnestic Mild Cognitive Impairment and Alzheimer’s Disease: Influence of Active and Passive Encoding.” The most common keywords used by researchers include “virtual reality,” “cognition,” “rehabilitation,” “performance,” and “older adult.” The largest source of research funding is from the public sector in the United States. Conclusions: The bibliometric analysis provided an overview of the application of VR in cognitive rehabilitation. VR-based cognitive rehabilitation can be integrated into multiple disciplines. We conclude that, in the context of the COVID-19 pandemic, the development of VR-based telerehabilitation is crucial, and there are still many problems that need to be addressed, such as the lack of consensus on treatment methods and the existence of safety hazards. %M 36260388 %R 10.2196/38315 %U https://games.jmir.org/2022/4/e38315 %U https://doi.org/10.2196/38315 %U http://www.ncbi.nlm.nih.gov/pubmed/36260388 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e37938 %T Effects of Cybersickness Caused by Head-Mounted Display–Based Virtual Reality on Physiological Responses: Cross-sectional Study %A Kim,Yoon Sang %A Won,JuHye %A Jang,Seong-Wook %A Ko,Junho %+ BioComputing Lab, Institute for Bio-engineering Application Technology, Department of Computer Science and Engineering, Korea University of Technology and Education, 1600, Chungjeol-ro, Byeongcheon-myeon, Dongnam-gu, Cheonan-si, 31253, Republic of Korea, 82 0415601496, yoonsang@koreatech.ac.kr %K cybersickness %K physiological responses %K virtual reality %K VR %K head-mounted displays %K heart rate %K cortisol %D 2022 %7 17.10.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although more people are experiencing cybersickness due to the popularization of virtual reality (VR), no official standard for the cause and reduction of cybersickness exists to date. One of the main reasons is that an objective method to assess cybersickness has not been established. To resolve this, research on evaluating cybersickness with physiological responses that can be measured in real time is required. Since research on deriving physiological responses that can assess cybersickness is at an early stage, further studies examining various physiological responses are needed. Objective: This study analyzed the effects of cybersickness caused by head-mounted display–based VR on physiological responses. Methods: We developed content that provided users with a first-person view of an aircraft that moved (with translation and combined rotation) over a city via a predetermined trajectory. In the experiment, cybersickness and the physiological responses of participants were measured. Cybersickness was assessed by the Simulator Sickness Questionnaire (SSQ). The measured physiological responses were heart rate, blood pressure, body temperature, and cortisol level. Results: Our measurement confirmed that all SSQ scores increased significantly (all Ps<.05) when participants experienced cybersickness. Heart rate and cortisol level increased significantly (P=.01 and P=.001, respectively). Body temperature also increased, but there was no statistically significant difference (P=.02). Systolic blood pressure and diastolic blood pressure decreased significantly (P=.001). Conclusions: Based on the results of our analysis, the following conclusions were drawn: (1) cybersickness causes significant disorientation, and research on this topic should focus on factors that affect disorientation; and (2) the physiological responses that are suitable for measuring cybersickness are heart rate and cortisol level. %M 36251360 %R 10.2196/37938 %U https://games.jmir.org/2022/4/e37938 %U https://doi.org/10.2196/37938 %U http://www.ncbi.nlm.nih.gov/pubmed/36251360 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 10 %P e42651 %T Group Telegaming Through Immersive Virtual Reality to Improve Mental Health Among Adolescents With Physical Disabilities: Pre- and Posttrial Protocol %A Lai,Byron %A Davis,Drew %A Young,Raven %A Swanson-Kimani,Erin %A Wozow,Cynthia %A Chaviano,Kelli %A Rimmer,James H %+ Division of Pediatric Rehabilitation Medicine, Department of Pediatrics, University of Alabama at Birmingham, 1720 University Blvd, Birmingham, AL, 35233, United States, 1 205 638 9790 ext 8 9725, blai@uabmc.edu %K disability %K physical activity %K active video gaming %K mindfulness %D 2022 %7 13.10.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Adolescents with physical disabilities have higher rates of mental health conditions and issues than adolescents without disabilities, and this disparity was exacerbated by the onset of the COVID-19 pandemic. They also have limited access to on-site programs and nearby peers. Objective: This pilot aims to investigate the potential effects of a low-dose multiplayer virtual reality telegaming program on depression, socialization, and loneliness among a cohort of children with physical disabilities. A secondary aim is to describe feasibility metrics, namely, recruitment and adherence rates and perceived program enjoyment and satisfaction. The tertiary aim is to describe behavioral mechanisms that affect participant adherence and social participation in the classes. Methods: This study is a single-group pre- and posttest–designed trial. A single cohort of 12 children with physical disabilities will pilot a 1-month program that includes 2 supervised 1-hour sessions per week of group-based exergaming. Participants will complete questionnaires before and after the program. The primary aim measures will include the Children’s Depression Inventory 2 Short Form, a measure of feelings of depression, and the UCLA Loneliness Scale, a measure of both loneliness and social isolation. Secondary aim measures will include three posttest Likert scale questionnaires: perceived program enjoyment, program satisfaction, and satisfaction with multiplayer experiences. At postintervention or dropout, participants will undergo semistructured interviews to identify behavioral mechanisms that underlie participation. Data will be reported descriptively and be supported by t tests as appropriate. Results: Recruitment procedures started in July 2022. All data are expected to be collected by January 2023. Full trial results are expected to be published by March 2023. Secondary analyses of data will be subsequently published. Conclusions: This trial tests a peer-to-peer virtual reality telegaming program that includes a completely remote enrollment, assessment, and intervention protocol. This program is accessible and short in duration and frequency, allowing it to be integrated into other interventions. Knowledge obtained from this study will inform the development of a larger trial for improving the mental health and well-being of adolescents with physical disabilities. Trial Registration: ClinicalTrials.gov NCT05259462; https://clinicaltrials.gov/ct2/show/NCT05259462 International Registered Report Identifier (IRRID): PRR1-10.2196/42651 %M 36194864 %R 10.2196/42651 %U https://www.researchprotocols.org/2022/10/e42651 %U https://doi.org/10.2196/42651 %U http://www.ncbi.nlm.nih.gov/pubmed/36194864 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 4 %P e33221 %T Pain Assessment Using Virtual Reality Facemask During Bone Marrow Aspiration: Prospective Study Including Propensity-Matched Analysis %A Soret,Lou %A Gendron,Nicolas %A Rivet,Nadia %A Chocron,Richard %A Macraigne,Laure %A Clausse,Darless %A Cholley,Bernard %A Gaussem,Pascale %A Smadja,David M %A Darnige,Luc %+ Innovative Therapies in Haemostasis, INSERM, Université Paris Cité, 20 rue Leblanc, Paris, 75015, France, 33 015609 39 38, nicolas.gendron@aphp.fr %K bone marrow aspiration %K pain assessment %K virtual reality facemask %K anxiety %K hematology %K virtual reality %K VR %K haematology %K haematological %K hematological %K hematological disorder %K pain %K pain scale %K medical procedure %K bone marrow %K facemask %K diagnosis %K monitoring %K anxiety %D 2022 %7 12.10.2022 %9 Short Paper %J JMIR Serious Games %G English %X Background: Bone marrow aspiration (BMA) is a medical procedure necessary to the diagnosis and monitoring of patients with hematological or nonhematological disorders. This procedure is considered painful, and patients are generally anxious before and during BMA. Objective: This study assesses the effect of immersive virtual reality on pain during BMA. Methods: This observational prospective and monocentric study enrolled 105 consecutive patients who underwent sternal BMA with lidocaine anesthesia. The study was carried on during 2 periods. First, virtual reality facemask (VRF) was proposed to all patients in the absence of exclusion criteria. During the second period, BMA was performed without the VRF. For all patients, pain intensity after the procedure was assessed using a 10-point numerical pain rating scale (NPRS). All analyses were performed on propensity score–matched cohort (with or without VRF) to evaluate efficacy on NRPS levels. Results: The final matched cohort included 12 patients in the VRF group and 24 in the control group. No difference in anxiety level before BMA evaluated by the patient and by the operator was observed between groups (P=.71 and .42 respectively). No difference of NPRS was observed using VRF when compared to control group (median NPRS 3.8, IQR 2.0-6.3 vs 3.0, IQR 1.9-3.0, respectively; P=.09). Conclusions: Our study did not prove the efficacy of VRF to reduce pain during BMA. %M 36222814 %R 10.2196/33221 %U https://games.jmir.org/2022/4/e33221 %U https://doi.org/10.2196/33221 %U http://www.ncbi.nlm.nih.gov/pubmed/36222814 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 10 %P e39140 %T Developing an Immersive Virtual Reality Training System for Novel Pediatric Power Wheelchair Users: Protocol for a Feasibility Study %A Drisdelle,Sara %A Power,Liam %A Thieu,Scott %A Sheriko,Jordan %+ Department of Pediatrics, Izaak Walton Killam Health Centre, 5850/5980 University Avenue, Halifax, NS, B3K 6R8, Canada, 1 902 470 8719, Sara.Drisdelle@iwk.nshealth.ca %K immersive virtual reality %K power wheelchair %K training %K pediatric rehabilitation %K feasibility %D 2022 %7 6.10.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Power wheelchairs can empower children with physical limitations to gain independence in their everyday lives; however, traditional methods of power wheelchair training are often limited by poor accessibility and safety concerns. Immersive virtual reality technology (IVRT) uses advanced display technology to place users in a fully immersive web-based environment that can support real-time skills training, often requiring less resources and fewer safety concerns than real-world methods. IVRT interventions have shown to be a feasible training option among adult power wheelchair users; however, there is still a need to understand the technical and clinical feasibility of developing an IVRT power wheelchair training tool for the pediatric population. Objective: This proposed study aims to use expert feedback and an iterative design process to develop an IVRT training intervention for pediatric power wheelchair skill development. Methods: This 3-phase feasibility study will be conducted within the assistive technology unit of a public pediatric hospital. Separate participant groups will be recruited for each phase, consisting of approximately 10 to 15 clinicians (phase 1), 10 pediatric power wheelchair users (phase 2), and 15 to 20 additional pediatric power wheelchair users (phase 3). Phase 1 will be conducted to gather feedback on the baseline IVRT training intervention. Clinicians will test the intervention and assess its usability and acceptability using qualitative and quantitative methods. Phase 1 participants will also be invited back for a subsequent session to reassess a revised version of the training intervention that has been updated based on their previous feedback. Phase 2 and phase 3 will also use mixed methods to gather feedback on the usability, acceptability, and user experience of the IVRT training intervention from current pediatric power wheelchair users. In addition, phase 3 participants will perform a skills transfer assessment to compare power mobility skill performance between the virtual reality and real-life environments. Data gathered in phase 2 will be used to further refine the IVRT intervention, whereas phase 3 data will be used to statistically evaluate the final version. Results: This study was approved by the Izaak Walton Killam Health Centre research ethics board in August 2021. Phase 1 testing began in February 2022. The entire study is expected to be completed by 2023. Conclusions: The results of this study will be used to create an IVRT training intervention for pediatric power wheelchair skill development through an iterative and collaborative design process. Results may also assist in directing future studies in this area. International Registered Report Identifier (IRRID): DERR1-10.2196/39140 %M 36201405 %R 10.2196/39140 %U https://www.researchprotocols.org/2022/10/e39140 %U https://doi.org/10.2196/39140 %U http://www.ncbi.nlm.nih.gov/pubmed/36201405 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e38200 %T The Effects of Acute Virtual Reality Exergaming on Mood and Executive Function: Exploratory Crossover Trial %A Ochi,Genta %A Kuwamizu,Ryuta %A Fujimoto,Tomomi %A Ikarashi,Koyuki %A Yamashiro,Koya %A Sato,Daisuke %+ Department of Health and Sports, Niigata University of Health and Welfare, Kita-ku, Shimami-cho, 1398, Niigata, 950-3198, Japan, 81 025 257 4595, ochi@nuhw.ac.jp %K virtual reality %K exergaming %K exercise %K executive function %K physical activity %K mental health %D 2022 %7 28.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) exergaming is a new intervention strategy to help humans engage in physical activity to enhance mood. VR exergaming may improve both mood and executive function by acting on the prefrontal cortex, expanding the potential benefits. However, the impact of VR exergaming on executive function has not been fully investigated, and associated intervention strategies have not yet been established. Objective: This study aims to investigate the effects of 10 minutes of VR exergaming on mood and executive function. Methods: A total of 12 participants played the exergame “FitXR” under 3 conditions: (1) a VR exergame condition (ie, exercise with a head-mounted display condition [VR-EX]) in which they played using a head-mounted display, (2) playing the exergame in front of a flat display (2D-EX), and (3) a resting condition in which they sat in a chair. The color-word Stroop task (CWST), which assesses executive function; the short form of the Profile of Mood States second edition (POMS2); and the short form of the Two-Dimensional Mood Scale (TDMS), which assess mood, were administered before and after the exercise or rest conditions. Results: The VR-EX condition increased the POMS2 vigor activity score (rest and VR-EX: t11=3.69, P=.003) as well as the TDMS arousal (rest vs 2D-EX: t11=5.34, P<.001; rest vs VR-EX: t11=5.99, P<.001; 2D-EX vs VR-EX: t11=3.02, P=.01) and vitality scores (rest vs 2D-EX: t11=3.74, P=.007; rest vs VR-EX: t11=4.84, P=.002; 2D-EX vs VR-EX: t11=3.53, P=.006), suggesting that VR exergaming enhanced mood. Conversely, there was no effect on CWST performance in either the 2D-EX or VR-EX conditions. Interestingly, the VR-EX condition showed a significant positive correlation between changes in CWST arousal and reaction time (r=0.58, P=.046). This suggests that the effect of exergaming on improving executive function may disappear under an excessively increased arousal level in VR exergaming. Conclusions: Our findings showed that 10 minutes of VR exergaming enhanced mood but did not affect executive function. This suggests that some VR content may increase cognitive demands, leading to psychological fatigue and cognitive decline as an individual approaches the limits of available attentional capacity. Future research must examine the combination of exercise and VR that enhances both brain function and mood. %M 36169992 %R 10.2196/38200 %U https://games.jmir.org/2022/3/e38200 %U https://doi.org/10.2196/38200 %U http://www.ncbi.nlm.nih.gov/pubmed/36169992 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e37506 %T Virtual Reality–Based Rehabilitation as a Feasible and Engaging Tool for the Management of Chronic Poststroke Upper-Extremity Function Recovery: Randomized Controlled Trial %A Hernandez,Alejandro %A Bubyr,Liudmila %A Archambault,Philippe S %A Higgins,Johanne %A Levin,Mindy F %A Kairy,Dahlia %+ Centre for Interdisciplinary Research in Rehabilitation, 6363 Hudson Road, Office 061, Lindsay Pavilion of the Institut universitaire sur la réadaptation en déficience physique de Montréal, Montreal, QC, H3S 1M9, Canada, 1 514 737 0592 ext 4778, alejandro.hernandez@mail.mcgill.ca %K rehabilitation %K serious game %K stroke %K telerehabilitation %K upper extremity %K virtual reality–based rehabilitation %K virtual reality %K virtual care %D 2022 %7 27.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: A growing number of stroke survivors are left with little to no rehabilitation services upon discharge from stroke rehabilitation, although arm deficits may persist or develop from disuse once rehabilitation services have ceased. Virtual reality (VR)–based rehabilitation, combined with new technologies such as telerehabilitation, including serious games using VR environments that encourage users to practice functional movements from home with minimal supervision, may have an important role to play in optimizing and maintaining upper extremity (UE) function. Objective: The primary objective of this study is to determine the extent to which a 1-month intervention using a VR-based serious game is effective in improving UE function compared with an evidence-based home exercise program. A secondary objective is to assess the feasibility of implementing the intervention for chronic stroke rehabilitation in participants’ homes. Methods: A total of 51 chronic stroke participants were randomized to treatment (n=26, 51%; Jintronix system) or standard care (n=25, 49%; standardized Graded Repetitive Arm Supplementary Program kit home program) groups. The participants were evaluated at baseline (before), immediately after the intervention (after), and at follow-up (4 weeks). The primary outcome measure was the Fugl-Meyer Assessment for UE (FMA-UE). Secondary outcome measures included the Stroke Impact Scale and an abridged version of the Motor Activity Log-14. Self-reported number of sessions was logged for the standard care group. Results: No statistically significant differences between groups were found across measures. Overall time effects were found for the FMA-UE (P=.045), specifically between preintervention and postintervention time points for both groups (P=.03). A total of 9 participants in the treatment group reached or surpassed the minimal clinically important difference in scores for the FMA-UE, with 7 (78%) of them having baseline low or moderate arm function, compared with 3 (33%) participants in the standard care group. Furthermore, 56% (9/16) of the participants in the treatment group who actively engaged with the system reached the minimal clinically important difference for the FMA-UE, compared with none for the 0% (0/10) less-active participants. Conclusions: These findings suggest that UE training for chronic stroke survivors using virtual rehabilitation in their home may be as effective as a gold standard home exercise program and that those who used the system the most achieved the greatest improvement in UE function, indicating its relevance to being included as part of ongoing rehabilitation services. Trial Registration: ClinicalTrials.gov NCT02491203; https://clinicaltrials.gov/ct2/show/NCT02491203 International Registered Report Identifier (IRRID): RR2-10.1016/j.cct.2015.12.006 %M 36166289 %R 10.2196/37506 %U https://games.jmir.org/2022/3/e37506 %U https://doi.org/10.2196/37506 %U http://www.ncbi.nlm.nih.gov/pubmed/36166289 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36397 %T A New Approach for Reducing Virtual Reality Sickness in Real Time: Design and Validation Study %A Won,JuHye %A Kim,Yoon Sang %+ BioComputing Lab, Institute for Bio-engineering Application Technology, Department of Computer Science and Engineering, Korea University of Technology and Education, 1600, Chungjeol-ro, Byeongcheon-myeon, Dongnam-gu, Cheonan-si, 31253, Republic of Korea, 82 0415601496, yoonsang@koreatech.ac.kr %K virtual reality %K VR %K VR sickness %K VR sickness reduction method %K simulator sickness questionnaire %K SSQ, visual guide %K field of view %K serious game %K VR sickness reduction %K VR content %K technology %K digital health %D 2022 %7 27.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Recently, technology that provides virtual reality (VR) content based on streaming services has been rapidly developed. However, there have been few studies to reduce VR sickness that occurs while the user watches VR content while wearing a head-mounted display (HMD) in real time. Objective: Based on this background, we propose a new approach to measure and reduce VR sickness that occurs while the user watches VR content while wearing an HMD in real time. Methods: The proposed approach is to apply VR sickness reduction methods in accordance with the user’s real-time VR sickness level. Three methods that are known to be effective in reducing VR sickness and a single type of VR content were used to examine the effectiveness of the proposed approach, which was confirmed by the experimental results. Results: Our results show that VR sickness significantly decreased when a new approach was applied to VR content (in all cases, P<.05). Conclusions: From our results, it was confirmed that VR sickness could be measured without wearing additional equipment, and its reduction method could be applied in real time in accordance with the user’s condition by the proposed approach in this paper. %M 36166294 %R 10.2196/36397 %U https://games.jmir.org/2022/3/e36397 %U https://doi.org/10.2196/36397 %U http://www.ncbi.nlm.nih.gov/pubmed/36166294 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e38284 %T Prediction of Specific Anxiety Symptoms and Virtual Reality Sickness Using In Situ Autonomic Physiological Signals During Virtual Reality Treatment in Patients With Social Anxiety Disorder: Mixed Methods Study %A Chun,Joo Young %A Kim,Hyun-Jin %A Hur,Ji-Won %A Jung,Dooyoung %A Lee,Heon-Jeong %A Pack,Seung Pil %A Lee,Sungkil %A Kim,Gerard %A Cho,Chung-Yean %A Lee,Seung-Moo %A Lee,Hyeri %A Choi,Seungmoon %A Cheong,Taesu %A Cho,Chul-Hyun %+ Department of Psychiatry, Korea University College of Medicine, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea, 82 029205505, david0203@gmail.com %K social anxiety %K virtual reality %K autonomic physiological signals %K machine learning %K virtual reality sickness %D 2022 %7 16.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Social anxiety disorder (SAD) is the fear of social situations where a person anticipates being evaluated negatively. Changes in autonomic response patterns are related to the expression of anxiety symptoms. Virtual reality (VR) sickness can inhibit VR experiences. Objective: This study aimed to predict the severity of specific anxiety symptoms and VR sickness in patients with SAD, using machine learning based on in situ autonomic physiological signals (heart rate and galvanic skin response) during VR treatment sessions. Methods: This study included 32 participants with SAD taking part in 6 VR sessions. During each VR session, the heart rate and galvanic skin response of all participants were measured in real time. We assessed specific anxiety symptoms using the Internalized Shame Scale (ISS) and the Post-Event Rumination Scale (PERS), and VR sickness using the Simulator Sickness Questionnaire (SSQ) during 4 VR sessions (#1, #2, #4, and #6). Logistic regression, random forest, and naïve Bayes classification classified and predicted the severity groups in the ISS, PERS, and SSQ subdomains based on in situ autonomic physiological signal data. Results: The severity of SAD was predicted with 3 machine learning models. According to the F1 score, the highest prediction performance among each domain for severity was determined. The F1 score of the ISS mistake anxiety subdomain was 0.8421 using the logistic regression model, that of the PERS positive subdomain was 0.7619 using the naïve Bayes classifier, and that of total VR sickness was 0.7059 using the random forest model. Conclusions: This study could predict specific anxiety symptoms and VR sickness during VR intervention by autonomic physiological signals alone in real time. Machine learning models can predict the severe and nonsevere psychological states of individuals based on in situ physiological signal data during VR interventions for real-time interactive services. These models can support the diagnosis of specific anxiety symptoms and VR sickness with minimal participant bias. Trial Registration: Clinical Research Information Service KCT0003854; https://cris.nih.go.kr/cris/search/detailSearch.do/13508 %M 36112407 %R 10.2196/38284 %U https://games.jmir.org/2022/3/e38284 %U https://doi.org/10.2196/38284 %U http://www.ncbi.nlm.nih.gov/pubmed/36112407 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 9 %N 3 %P e31305 %T Lessons Learned From Clinicians and Stroke Survivors About Using Telerehabilitation Combined With Exergames: Multiple Case Study %A Allegue,Dorra Rakia %A Sweet,Shane Norman %A Higgins,Johanne %A Archambault,Philippe S %A Michaud,Francois %A Miller,William C %A Tousignant,Michel %A Kairy,Dahlia %+ The Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Institut universitaire sur la réadaptation en déficience physique de Montréal, 6363 Chemin Hudson, Montreal, QC, H3S1M9, Canada, 1 438 990 1309, dorra.rakia.allegue@umontreal.ca %K stroke %K rehabilitation %K virtual reality %K video games %K telerehabilitation %K upper extremity %K motivation %D 2022 %7 15.9.2022 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: In Canada, stroke survivors have difficulty accessing community-based rehabilitation services because of a lack of resources. VirTele, a personalized remote rehabilitation program combining virtual reality exergames and telerehabilitation, was developed to provide stroke survivors an opportunity to pursue rehabilitation of their chronic upper extremity (UE) deficits at home while receiving ongoing follow-up from a clinician. Objective: We aimed to identify the behavioral and motivational techniques used by clinicians during the VirTele intervention, explore the indicators of empowerment among stroke survivors, and investigate the determinants of VirTele use among stroke survivors and clinicians. Methods: This multiple case study involved 3 stroke survivors with chronic UE deficits and their respective clinicians (physiotherapists) who participated in the VirTele intervention, a 2-month remote rehabilitation intervention that uses nonimmersive virtual reality exergames and telerehabilitation aimed at improving UE deficits in stroke survivors. Study participants had autonomous access to Jintronix exergames and were asked to use them for 30 minutes, 5 times a week. The VirTele intervention included 1-hour videoconference sessions with a clinician 1 to 3 times a week, during which the clinician engaged in motivational interviewing, supervised the stroke survivors’ use of the exergames, and monitored their use of the affected UE through activities of daily living. Semidirected interviews were conducted with the clinicians and stroke survivors 4 to 5 weeks after the end of the VirTele intervention. All interviews were audiorecorded and transcribed verbatim. An abductive thematic analysis was conducted to generate new ideas through a dynamic interaction between data and theory. Results: Three stroke survivors (n=2, 67%, women and n=1, 33%, man), with a mean age of 58.8 (SD 19.4) years, and 2 physiotherapists participated in the study. Five major determinants of VirTele use emerged from the qualitative analyses, namely technology performance (usefulness and perception of exergames), effort (ease of use), family support (encouragement), facilitators (considerations of the stroke survivors’ safety as well as trust and understanding of instructions), and challenges (miscommunication and exergame limits). During the VirTele intervention, both clinicians used motivational and behavioral techniques to support autonomy, competence, and connectivity. All these attributes were reflected as empowerment indicators in the stroke survivors. Lessons learned from using telerehabilitation combined with exergames are provided, which will be relevant to other researchers and contexts. Conclusions: This multiple case study provides a first glimpse into the impact that motivational interviewing can have on adherence to exergames and changes in behavior in the use of the affected UE in stroke survivors. Lessons learned regarding the supportive role caregivers play and the new responsibilities clinicians have when using the VirTele intervention may inform the use of exergames via telerehabilitation. These lessons will also serve as a model to guide the implementation of similar interventions. International Registered Report Identifier (IRRID): RR2-10.2196/14629 %M 36107484 %R 10.2196/31305 %U https://rehab.jmir.org/2022/3/e31305 %U https://doi.org/10.2196/31305 %U http://www.ncbi.nlm.nih.gov/pubmed/36107484 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36288 %T The Design, Development, and Testing of a Virtual Reality Device for Upper Limb Training in People With Multiple Sclerosis: Single-Center Feasibility Study %A Kalron,Alon %A Frid,Lior %A Fonkatz,Iliya %A Menascu,Shay %A Dolev,Mark %A Magalashvili,David %A Achiron,Anat %+ Department of Physical Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Tel-Aviv, 39040, Israel, 972 036405430, alonkalr@post.tau.ac.il %K virtual reality %K rehabilitation %K feasibility %K upper limb %K multiple sclerosis %D 2022 %7 12.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Multiple sclerosis (MS) is a common nontraumatic, neurological, disabling disease that often presents with upper limb dysfunction. Exercise training has resulted in improvement for patients; however, there can be a lack of compliance due to access because of location and lack of MS experts. Virtual reality (VR) is a promising technology that can offer exercise therapy/rehabilitation at a distance. This type of remote training can be motivational and effective for patients with MS and can improve range of motion and muscle strength for those with upper limb dysfunction. Objective: The aim of this study is to evaluate the safety and feasibility of the XRHealth software and the Oculus Rift Station for patients with MS with upper limb motor dysfunction. Methods: A single-center, prospective, feasibility study was conducted with patients with MS who had upper limb motor dysfunction. Patients participated in a single 45-minute digital environment session with VR and completed a questionnaire about the quality of the training and fatigability. The clinician also completed a questionnaire to evaluate the suitability and safety of the training. Results: Overall, 30 patients were enrolled between the ages of 20 and 81 years. Patients reported that the training sessions within the digital environment were helpful, challenging, fun, and simple to understand, and that they would be willing to repeat the sessions again. The physical therapist that oversaw the patients reported that the training was suitable for 87% (n=26) of the patients. Anticipated adverse events were fatigue, temporary dizziness, and temporary nausea. The operator complications included that the cable of the head-mounted display interrupted the training (n=2, 7%) and fatigue that caused cessation of the VR training session (n=2, 7%). No serious adverse events were reported. Conclusions: These preliminary results demonstrated that the use of the XRHealth software and Oculus Rift Station platform is feasible, safe, and engaging for patients, and has the potential to improve the functionality of the upper limbs in patients with MS. This study provides support for future studies of implementing a series of training sessions with virtual reality in a home-based environment. %M 36094809 %R 10.2196/36288 %U https://games.jmir.org/2022/3/e36288 %U https://doi.org/10.2196/36288 %U http://www.ncbi.nlm.nih.gov/pubmed/36094809 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36079 %T Preliminary User Evaluation of a New Dental Technology Virtual Simulation System: Development and Validation Study %A Pang,Mengwei %A Zhao,Xiaohan %A Lu,Daiyu %A Dong,Yihan %A Jiang,Lin %A Li,Jie %A Ji,Ping %+ College of Stomatology, Chongqing Medical University, 426# Songshibei Road, Yubei District, Chongqing, 401147, China, 86 023 8886 0026, jiping@hospital.cqmu.edu.cn %K virtual simulation %K dental technology %K OSCE %K virtual reality %K dentistry %K dental technician %K framework %K certified dental technician %K development %K validation %K serious game %K dental technology %K dental %K technology %D 2022 %7 12.9.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: With the advancements in the dental health care industry, the demand for dental technicians has increased. Dental technicians should be thoroughly assessed and trained in practical skills and pass professional certification examinations to ensure that they are competent to work closely with dentists. Unfortunately, such training courses and tests are in short supply worldwide. The use of virtual simulation technology can help solve these problems. Objective: This study presents a new strategic framework design for a certified dental technician practical examination called as the certified Objective Manipulative Skill Examination of Dental Technicians (OMEDT), which is based on the Objective Structured Clinical Examination (OSCE). We present the development and validation of the OMEDT system, a new virtual simulated training system, to meet the demands of the OMEDT framework. The combination of OMEDT and the OMEDT system can solve the complex problems encountered in the certified dental technician practical examination with excellent efficiency, high quality, and low cost. Methods: The OMEDT framework design was constructed according to the OSCE guide and the Chinese vocational skill standards for dental technicians. To develop the OMEDT system, we organized a new framework based on the virtual learning network platform, the haptic feedback system, and the real-time dental training and evaluation system. The effectiveness evaluation of the OMEDT system was divided into 2 phases: in the first phase, 36 students were recruited to use the test module to finish the task and their performance data were collected and analyzed; and in the second phase, a questionnaire was administered to 30 students who used the system for their studies and graduation exams. Results: The OMEDT and the corresponding skill training virtual simulation OMEDT system were developed, and preliminary user evaluation was performed to assess their effectiveness and usefulness. The OMEDT system was found to improve students’ practical skills by training with the evaluation results. In addition, several key research topics were explored, including the effects of positive feedback of the knowledge of results on the improvement of the students’ skill level and the common sense transformation of educators in the virtual simulation technology environment. Conclusions: The development of OMEDT and the OMEDT system has been completed and their effectiveness has been verified. %M 36094803 %R 10.2196/36079 %U https://games.jmir.org/2022/3/e36079 %U https://doi.org/10.2196/36079 %U http://www.ncbi.nlm.nih.gov/pubmed/36094803 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 8 %N 3 %P e37297 %T Using Mobile Virtual Reality Simulation to Prepare for In-Person Helping Babies Breathe Training: Secondary Analysis of a Randomized Controlled Trial (the eHBB/mHBS Trial) %A Ezenwa,Beatrice Nkolika %A Umoren,Rachel %A Fajolu,Iretiola Bamikeolu %A Hippe,Daniel S %A Bucher,Sherri %A Purkayastha,Saptarshi %A Okwako,Felicitas %A Esamai,Fabian %A Feltner,John B %A Olawuyi,Olubukola %A Mmboga,Annet %A Nafula,Mary Concepta %A Paton,Chris %A Ezeaka,Veronica Chinyere %+ Department of Paediatrics, College of Medicine, University of Lagos, Ishaga Road, Idi-Araba, Lagos, 100254, Nigeria, 234 8051403189, beatriceezenwa@yahoo.com %K virtual reality %K mobile learning %K Helping Babies Breathe %K neonatal resuscitation %K mobile Helping Babies Survive powered by District Health Information Software 2 %K neonatal mortality %K digital education %K health care education %K health care worker %K medical education %K digital intervention %D 2022 %7 12.9.2022 %9 Original Paper %J JMIR Med Educ %G English %X Background: Neonatal mortality accounts for approximately 46% of global under-5 child mortality. The widespread access to mobile devices in low- and middle-income countries has enabled innovations, such as mobile virtual reality (VR), to be leveraged in simulation education for health care workers. Objective: This study explores the feasibility and educational efficacy of using mobile VR for the precourse preparation of health care professionals in neonatal resuscitation training. Methods: Health care professionals in obstetrics and newborn care units at 20 secondary and tertiary health care facilities in Lagos, Nigeria, and Busia, Western Kenya, who had not received training in Helping Babies Breathe (HBB) within the past 1 year were randomized to access the electronic HBB VR simulation and digitized HBB Provider’s Guide (VR group) or the digitized HBB Provider’s Guide only (control group). A sample size of 91 participants per group was calculated based on the main study protocol that was previously published. Participants were directed to use the electronic HBB VR simulation and digitized HBB Provider’s Guide or the digitized HBB Provider’s Guide alone for a minimum of 20 minutes. HBB knowledge and skills assessments were then conducted, which were immediately followed by a standard, in-person HBB training course that was led by study staff and used standard HBB evaluation tools and the Neonatalie Live manikin (Laerdal Medical). Results: A total of 179 nurses and midwives participated (VR group: n=91; control group: n=88). The overall performance scores on the knowledge check (P=.29), bag and mask ventilation skills check (P=.34), and Objective Structured Clinical Examination A checklist (P=.43) were similar between groups, with low overall pass rates (6/178, 3.4% of participants). During the Objective Structured Clinical Examination A test, participants in the VR group performed better on the critical step of positioning the head and clearing the airway (VR group: 77/90, 86%; control group: 57/88, 65%; P=.002). The median percentage of ventilations that were performed via head tilt, as recorded by the Neonatalie Live manikin, was also numerically higher in the VR group (75%, IQR 9%-98%) than in the control group (62%, IQR 13%-97%), though not statistically significantly different (P=.35). Participants in the control group performed better on the identifying a helper and reviewing the emergency plan step (VR group: 7/90, 8%; control group: 16/88, 18%; P=.045) and the washing hands step (VR group: 20/90, 22%; control group: 32/88, 36%; P=.048). Conclusions: The use of digital interventions, such as mobile VR simulations, may be a viable approach to precourse preparation in neonatal resuscitation training for health care professionals in low- and middle-income countries. %M 36094807 %R 10.2196/37297 %U https://mededu.jmir.org/2022/3/e37297 %U https://doi.org/10.2196/37297 %U http://www.ncbi.nlm.nih.gov/pubmed/36094807 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 9 %P e38354 %T Tough Talks Virtual Simulation HIV Disclosure Intervention for Young Men Who Have Sex With Men: Development and Usability Testing %A Hightow-Weidman,Lisa B %A Muessig,Kathryn %A Soberano,Zach %A Rosso,Matthew T %A Currie,Andrew %A Adams Larsen,Margo %A Knudtson,Kelly %A Vecchio,Alyssa %+ Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, 130 Mason Farm Rd, Chapel Hill, NC, 27599, United States, 1 919 843 0033, lisa_hightow@med.unc.edu %K HIV %K virtual reality %K status disclosure %K prevention %K young men who have sex with men %K artificial intelligence %K medication adherence %K transmission %K viral load %K men %K sex %K development %K usability %K testing %K virtual simulation %K young men %K United States %K behavior %K social determinants %D 2022 %7 8.9.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: HIV status disclosure is an important decision with barriers specific to young men who have sex with men (YMSM), who have the highest rates of new HIV infections in the United States. Behavioral and social determinants of the difficulty to disclose can include fear of rejection, stigma, loss of financial stability, and lack of communication skills. Once able to disclose, a person may have increased access to social support and improved informed risk reduction conversations and medication adherence. Despite the known challenges and advantages of disclosure, there are few effective tools supporting this behavior. Objective: To address this gap in disclosure interventions, the Tough Talks (TT) app, an mHealth intervention using artificial intelligence (AI)–facilitated role-playing scenarios, was developed for YMSM. This paper reports stages of development of the integrated app and results of the usability testing. Methods: Building on the successful development and testing of a stand-alone interactive dialogue feature in phases 1-3, we conducted additional formative research to further refine and enhance the disclosure scenarios and develop and situate them within the context of a comprehensive intervention app to support disclosure. We assessed the new iteration for acceptability and relevance in a usability study with 8 YMSM with HIV. Participants completed a presurvey, app modules, and a semistructured qualitative interview. Results: TT content and activities were based on social cognitive theory and disclosure process model framework and expanded to a 4-module curriculum. The AI-facilitated scenarios used dialogue from an utterance database developed using language crowdsourced through a comic book contest. In usability testing, YMSM reported high satisfaction with TT, with 98% (31/33) of activities receiving positive ratings. Participants found the AI-facilitated scenarios and activities to be representative and relevant to their lived experiences, although they noted difficulty having nuanced disclosure conversations with the AI. Conclusions: TT was an engaging and practical intervention for self-disclosure among YMSM with HIV. Facilitating informed disclosure decisions has the potential to impact engagement in sexual risk behaviors and HIV care. More information is needed about the ideal environment, technical assistance, and clinical support for an mHealth disclosure intervention. TT is being tested as a scalable intervention in a multisite randomized controlled trial to address outstanding questions on accessibility and effect on viral suppression. Trial Registration: ClinicalTrials.gov NCT03414372; https://clinicaltrials.gov/ct2/show/NCT03414372 %M 36074551 %R 10.2196/38354 %U https://formative.jmir.org/2022/9/e38354 %U https://doi.org/10.2196/38354 %U http://www.ncbi.nlm.nih.gov/pubmed/36074551 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 8 %P e40445 %T A Novel Theory-Based Virtual Reality Training to Improve Patient Safety Culture in the Department of Surgery of a Large Academic Medical Center: Protocol for a Mixed Methods Study %A Mazur,Lukasz M %A Khasawneh,Amro %A Fenison,Christi %A Buchanan,Shawna %A Kratzke,Ian M %A Adapa,Karthik %A An,Selena J %A Butler,Logan %A Zebrowski,Ashlyn %A Chakravarthula,Praneeth %A Ra,Jin H %+ Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina, 101 Manning Drive, Chapel Hill, NC, 27713, United States, 1 9196169702, lmazur@med.unc.edu %K virtual reality training %K patient safety culture %K patient safety events %K sensemaking %K high reliability organizations %D 2022 %7 24.8.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Preventable surgical errors of varying degrees of physical, emotional, and financial harm account for a significant number of adverse events. These errors are frequently tied to systemic problems within a health care system, including the absence of necessary policies/procedures, obstructive cultural hierarchy, and communication breakdown between staff. We developed an innovative, theory-based virtual reality (VR) training to promote understanding and sensemaking toward the holistic view of the culture of patient safety and high reliability. Objective: We aim to assess the effect of VR training on health care workers’ (HCWs’) understanding of contributing factors to patient safety events, sensemaking of patient safety culture, and high reliability organization principles in the laboratory environment. Further, we aim to assess the effect of VR training on patient safety culture, TeamSTEPPS behavior scores, and reporting of patient safety events in the surgery department of an academic medical center in the clinical environment. Methods: This mixed methods study uses a pre-VR versus post-VR training study design involving attending faculty, residents, nurses, technicians of the department of surgery, and frontline HCWs in the operation rooms at an academic medical center. HCWs’ understanding of contributing factors to patient safety events will be assessed using a scale based on the Human Factors Analysis and Classification System. We will use the data frame theory framework, supported by a semistructured interview guide to capture the sensemaking process of patient safety culture and principles of high reliability organizations. Changes in the culture of patient safety will be quantified using the Agency for Healthcare Research and Quality surveys on patient safety culture. TeamSTEPPS behavior scores based on observation will be measured using the Teamwork Evaluation of Non-Technical Skills tool. Patient safety events reported in the voluntary institutional reporting system will be compared before the training versus those after the training. We will compare the Agency for Healthcare Research and Quality patient safety culture scores and patient safety events reporting before the training versus those after the training by using descriptive statistics and a within-subject 2-tailed, 2-sample t test with the significance level set at .05. Results: Ethics approval was obtained in May 2021 from the institutional review board of the University of North Carolina at Chapel Hill (22-1150). The enrollment of participants for this study will start in fall 2022 and is expected to be completed by early spring 2023. The data analysis is expected to be completed by July 2023. Conclusions: Our findings will help assess the effectiveness of VR training in improving HCWs’ understanding of contributing factors of patient safety events, sensemaking of patient safety culture, and principles and behaviors of high reliability organizations. These findings will contribute to developing VR training to improve patient safety culture in other specialties. %M 36001370 %R 10.2196/40445 %U https://www.researchprotocols.org/2022/8/e40445 %U https://doi.org/10.2196/40445 %U http://www.ncbi.nlm.nih.gov/pubmed/36001370 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e31456 %T Digital Interventions for Emotion Regulation in Children and Early Adolescents: Systematic Review and Meta-analysis %A Reynard,Sally %A Dias,Joao %A Mitic,Marija %A Schrank,Beate %A Woodcock,Kate Anne %+ Centre for Applied Psychology, University of Birmingham, 52 Pritchatts Road, Birmingham, B15 2SA, United Kingdom, 44 0121 414 6036, sallyreynard1@gmail.com %K emotion regulation %K digital interventions %K youth %K systematic review %K meta-analysis %K children %K early adolescents %K serious games %K training %K biofeedback %K mobile phone %D 2022 %7 19.8.2022 %9 Review %J JMIR Serious Games %G English %X Background: Difficulties in emotion regulation are common in adolescence and are associated with poor social and mental health outcomes. However, psychological therapies that promote adaptive emotion regulation may be inaccessible and unattractive to youth. Digital interventions may help address this need. Objective: The aim of this systematic review and meta-analysis was to synthesize evidence on the efficacy, feasibility, and acceptability of emotion regulation digital interventions in children and early adolescents aged 8 to 14 years. Methods: Systematic searches of Web of Science, MEDLINE, PsycINFO, EMBASE, Education Resources Information Centre, ACM Digital Library, and IEEE Xplore up to July 2020 identified 39 studies, of which 11 (28%) were included in the meta-analyses (n=2476 participants). A bespoke tool was used to assess risk of bias. Results: The studies evaluated digital games (27/39, 69%), biofeedback (4/39, 10%), virtual or augmented reality (4/39, 10%), and program or multimedia (4/39, 10%) digital interventions in samples classified as diagnosed, at risk, healthy, and universal. The most consistent evidence came from digital games, which reduced negative emotional experience with a small significant effect, largely in youth at risk of anxiety (Hedges g=–0.19, 95% CI –0.34 to –0.04). In general, digital interventions tended to improve emotion regulation, but this effect was not significant (Hedges g=0.19, 95% CI –0.16 to 0.54). Conclusions: Most feasibility issues were identified in diagnosed youth, and acceptability was generally high across intervention types and samples. Although there is cause to be optimistic about digital interventions supporting the difficulties that youth experience in emotion regulation, the predominance of early-stage development studies highlights the need for more work in this area. %M 35984681 %R 10.2196/31456 %U https://games.jmir.org/2022/3/e31456 %U https://doi.org/10.2196/31456 %U http://www.ncbi.nlm.nih.gov/pubmed/35984681 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 8 %P e40708 %T The Effects of Virtual Reality Tele-exergaming on Cardiometabolic Indicators of Health Among Youth With Cerebral Palsy: Protocol for a Pilot Randomized Controlled Trial %A Lai,Byron %A Davis,Drew %A Young,Raven %A Kimani-Swanson,Erin %A Wozow,Cynthia %A Wen,Huacong %A Kim,Yumi %A Wilroy,Jereme %A Rimmer,James %+ Division of Pediatric Rehabilitation Medicine, Department of Pediatrics, University of Alabama at Birmingham, 1720 University Blvd, Birmingham, AL, 35294, United States, 1 205 638 9790 ext 8 9725, blai@uabmc.edu %K disability %K physical therapy %K adapted physical activity %K physical activity %K active video gaming %D 2022 %7 17.8.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Youth with cerebral palsy do not have enjoyable, accessible, and scalable exercise options that can empower them to independently maintain their cardiometabolic health. Objective: The primary aim is to examine the preliminary efficacy of a 12-week home-based virtual reality tele-exergaming intervention on several indicators of cardiometabolic health in youth with cerebral palsy compared to the wait list control. A secondary aim is to describe feasibility metrics, namely, recruitment, retention, and adherence rates; perceived enjoyment; intervention safety; and management issues. The tertiary aim is to generate a theory that reveals critical behavioral mechanisms of adherence to tele-exergaming. Methods: In this parallel group design randomized controlled trial, 34 inactive youths with cerebral palsy are randomly allocated to one of two groups: a group that immediately receives 12 weeks of virtual reality exergaming with tele–physical education or a wait list control group that undergoes their habitual activity for 12 weeks. Participants are recruited from a Children’s Hospital and community network. At baseline (week 0), week 6, and week 12, high sensitivity C-reactive protein and blood insulin, hemoglobin A1c, triglycerides, cholesterol, and pressure are measured by the youth and a caregiver at home using a blood spot test kit and blood pressure cuff. They will also self-measure their lung function and body weight using a peak flow meter and bathroom scale, respectively. Collections are supervised by research staff via videoconference. Changes in outcomes are compared between and within groups using exploratory statistical analyses and descriptive statistics. At postintervention or dropout, participants will undergo semistructured interviews to identify behavioral mechanisms that underly participation. Results: Recruitment procedures started in June 2022. All data are expected to be collected by October 2023. Full trial results are expected to be published by February 2024. Secondary analyses of data will be subsequently published. Conclusions: This trial tests an innovative serious exergaming virtual reality program that includes a completely remote enrollment, assessment, and intervention tele-protocol. The knowledge obtained will inform the development of a larger effectiveness trial for improving the health and well-being of youth with cerebral palsy. Trial Registration: ClinicalTrials.gov NCT05336227; https://clinicaltrials.gov/ct2/show/NCT05336227 International Registered Report Identifier (IRRID): PRR1-10.2196/40708 %M 35976192 %R 10.2196/40708 %U https://www.researchprotocols.org/2022/8/e40708 %U https://doi.org/10.2196/40708 %U http://www.ncbi.nlm.nih.gov/pubmed/35976192 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 9 %N 3 %P e36836 %T Feasibility of Virtual Reality Exercises at Home for Post–COVID-19 Condition: Cohort Study %A Groenveld,Tjitske %A Achttien,Retze %A Smits,Merlijn %A de Vries,Marjan %A van Heerde,Ron %A Staal,Bart %A van Goor,Harry %A , %+ Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, 6525GA, Netherlands, 31 243667331, tjitske.groenveld@radboudumc.nl %K virtual reality %K rehabilitation %K COVID-19 %K long COVID %K feasibility %K physical function %K quality of life %K pandemic %K multimodal virtual reality %K outpatient care %K physiotherapy %K digital health %K patient care %D 2022 %7 15.8.2022 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Between 30% to 76% of COVID-19 patients have persistent physical and mental symptoms, sometimes up to 9 months after acute COVID-19. Current rehabilitation is mostly focused on the physical symptoms, whereas experts have agreed on the need for a biopsychosocial approach. A novel approach such as virtual reality (VR) rehabilitation at home might benefit patients and therapists, especially considering the expected rush of patients with post–COVID-19 condition needing rehabilitation. Objective: The aim of this study was to investigate the feasibility of self-administered VR exercises at home for post–COVID-19 condition. Methods: This was a single-arm feasibility study in an outpatient care setting. Patients who needed physiotherapy because of post–COVID-19 condition were included as determined by the treating physiotherapist. Participants performed VR physical exercises at home for a period of 6 weeks and were allowed to perform VR mental exercise through applications available on the VR platform to reduce stress and anxiety and promote cognitive functioning. The main outcomes were related to feasibility (ie, duration and frequency of VR use), safety (ie, adverse events), patient satisfaction, and reasons to withdraw. Physical performance, daily activities, cognitive functioning, anxiety and depression, and the quality of life were measured before and after. Results: In total, 48 patients were included; 1 (2%) patient did not start VR, and 7 (15%) patients withdrew, mostly due to dizziness. Almost 70% (33/47) of participants reported experiencing any adverse event during VR exercising. However, only 25% (9/36) recalled these events at the end of the intervention period. The majority (27/36, 75%) of the patients described VR as having a positive influence on their recovery, and the global satisfaction score was 67%. The average VR use was 30 minutes per session, 3-4 times a week for 3-6 weeks. The overall use of VR applications was almost equally distributed over the 3 sets of VR exercises (physical, relaxing, and cognitive). However, the use frequency of physical exercises seemed to decrease over time, whereas the use of cognitive and relaxation exercises remained stable. Physical performance and quality of life outcomes were significantly improved after 6 weeks. Conclusions: VR physical exercises at home is feasible and safe with good acceptance in a significant percentage of patient with post–COVID-19 condition. Trial Registration: ClinicalTrials.gov NCT04505761; https://clinicaltrials.gov/ct2/show/NCT04505761 %M 35858254 %R 10.2196/36836 %U https://rehab.jmir.org/2022/3/e36836 %U https://doi.org/10.2196/36836 %U http://www.ncbi.nlm.nih.gov/pubmed/35858254 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e35008 %T Effect of Virtual Reality on Pediatric Pain and Fear During Procedures Involving Needles: Systematic Review and Meta-analysis %A Lluesma-Vidal,Marta %A Carcelén González,Raquel %A García-Garcés,Laura %A Sánchez-López,María I %A Peyro,Loreto %A Ruiz-Zaldibar,Cayetana %+ Department of Medicine and Surgery, Faculty of Health of Science, Universidad Cardenal Herrera-CEU, CEU Universities, C/Ramon y Cajal s/n, Alfara del Patriarca, Valencia, 64115, Spain, 34 96136900 ext 64335, raquel.carcelen@uchceu.es %K virtual reality %K pain %K fear %K pediatric %K needle %K child %K injection %K VR %K systematic review %K meta-analysis %K paediatric %D 2022 %7 9.8.2022 %9 Review %J JMIR Serious Games %G English %X Background: Virtual reality (VR) is used as a distraction measure during painful clinical procedures associated with the use of needles. These procedures include vaccinations, blood draws, or the administration of medications, which can cause children to feel increased levels of pain and fear. Objective: The objective of this study was to collect and analyze the current evidence regarding the effectiveness of VR as a tool to distract children from pain and fear during needle procedures as compared to that of standard techniques. Methods: A systematic review and meta-analysis was performed. We included randomized clinical trials (RCTs) or quasi-RCTs with participants younger than 21 years who underwent needle procedures in which the main distraction measure used was VR and where the main outcome measure was pain. The databases searched included the PubMed, Web of Science, Scopus, PsycINFO, CINAHL, and Cochrane libraries. In this systematic review, the studies were analyzed by applying the Critical Appraisal Skills Program guide in Spanish and the Jadad scale. In the meta-analysis, the effect size of the studies was analyzed based on the results for pain and fear in children. Results: From 665 unique search results, 21 studies were included in this systematic review, most of which reported low methodological quality. The study sample cohorts ranged from a minimum of 15 participants to a maximum of 220 participants. Ten studies were included in the meta-analysis. The global effect of using VR as a distraction measure was a significant reduction in pain (inverse variance [IV] –2.37, 95% CI –3.20 to –1.54; Z=5.58; P<.001) and fear (IV –1.26, 95% CI –1.89 to –0.63; Z=3.92; P<.001) in children in the experimental groups. Conclusions: The quality of the studies was mostly low. The main limitations were the impossibility of blinding the participants and health care personnel to the VR intervention. Nonetheless, the use of VR as a distraction measure was effective in reducing pain and fear in children during procedures involving needles. %M 35943776 %R 10.2196/35008 %U https://games.jmir.org/2022/3/e35008 %U https://doi.org/10.2196/35008 %U http://www.ncbi.nlm.nih.gov/pubmed/35943776 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36850 %T Social Media Users’ Perceptions of a Wearable Mixed Reality Headset During the COVID-19 Pandemic: Aspect-Based Sentiment Analysis %A Jeong,Heejin %A Bayro,Allison %A Umesh,Sai Patipati %A Mamgain,Kaushal %A Lee,Moontae %+ Department of Mechanical and Industrial Engineering, University of Illinois Chicago, 842 W Taylor St, Chicago, IL, 60607, United States, 1 312 355 5558, heejinj@uic.edu %K HoloLens 2 %K sentiment analysis %K natural language processing, Twitter %K COVID-19 %K usability evaluation %D 2022 %7 4.8.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Mixed reality (MR) devices provide real-time environments for physical-digital interactions across many domains. Owing to the unprecedented COVID-19 pandemic, MR technologies have supported many new use cases in the health care industry, enabling social distancing practices to minimize the risk of contact and transmission. Despite their novelty and increasing popularity, public evaluations are sparse and often rely on social interactions among users, developers, researchers, and potential buyers. Objective: The purpose of this study is to use aspect-based sentiment analysis to explore changes in sentiment during the onset of the COVID-19 pandemic as new use cases emerged in the health care industry; to characterize net insights for MR developers, researchers, and users; and to analyze the features of HoloLens 2 (Microsoft Corporation) that are helpful for certain fields and purposes. Methods: To investigate the user sentiment, we collected 8492 tweets on a wearable MR headset, HoloLens 2, during the initial 10 months since its release in late 2019, coinciding with the onset of the pandemic. Human annotators rated the individual tweets as positive, negative, neutral, or inconclusive. Furthermore, by hiring an interannotator to ensure agreements between the annotators, we used various word vector representations to measure the impact of specific words on sentiment ratings. Following the sentiment classification for each tweet, we trained a model for sentiment analysis via supervised learning. Results: The results of our sentiment analysis showed that the bag-of-words tokenizing method using a random forest supervised learning approach produced the highest accuracy of the test set at 81.29%. Furthermore, the results showed an apparent change in sentiment during the COVID-19 pandemic period. During the onset of the pandemic, consumer goods were severely affected, which aligns with a drop in both positive and negative sentiment. Following this, there is a sudden spike in positive sentiment, hypothesized to be caused by the new use cases of the device in health care education and training. This pandemic also aligns with drastic changes in the increased number of practical insights for MR developers, researchers, and users and positive net sentiments toward the HoloLens 2 characteristics. Conclusions: Our approach suggests a simple yet effective way to survey public opinion about new hardware devices quickly. The findings of this study contribute to a holistic understanding of public perception and acceptance of MR technologies during the COVID-19 pandemic and highlight several new implementations of HoloLens 2 in health care. We hope that these findings will inspire new use cases and technological features. %M 35708916 %R 10.2196/36850 %U https://games.jmir.org/2022/3/e36850 %U https://doi.org/10.2196/36850 %U http://www.ncbi.nlm.nih.gov/pubmed/35708916 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 7 %P e33255 %T Effect of Virtual Reality Hypnosis on Pain Threshold and Neurophysiological and Autonomic Biomarkers in Healthy Volunteers: Prospective Randomized Crossover Study %A Terzulli,Claire %A Melchior,Meggane %A Goffin,Laurent %A Faisan,Sylvain %A Gianesini,Coralie %A Graff,Denis %A Dufour,André %A Laroche,Edouard %A Chauvin,Chloé %A Poisbeau,Pierrick %+ Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, University of Strasbourg, 8 Allée du Général Rouvillois, Strasbourg, 67000, France, 33 662710070, poisbeau@inci-cnrs.unistra.fr %K virtual reality %K hypnosis %K pain %K analgesia %K autonomic changes %K thermal pain %K physiological %K nervous system %K heat pain %D 2022 %7 29.7.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality hypnosis (VRH) is a promising tool to reduce pain. However, the benefits of VRH on pain perception and on the physiological expression of pain require further investigation. Objective: In this study, we characterized the effects of VRH on the heat pain threshold among adult healthy volunteers while monitoring several physiological and autonomic functions. Methods: Sixty healthy volunteers were prospectively included to receive nociceptive stimulations. The first set of thermal stimuli consisted of 20 stimulations at 60°C (duration 500 milliseconds) to trigger contact heat evoked potentials (CHEPs). The second set of thermal stimuli consisted of ramps (1°C/second) to determine the heat pain threshold of the participants. Electrocardiogram, skin conductance responses, respiration rate, as well as the analgesia nociception index were also recorded throughout the experiment. Results: Data from 58 participants were analyzed. There was a small but significant increase in pain threshold in VRH (50.19°C, SD 1.98°C) compared to that in the control condition (mean 49.45°C, SD 1.87; P<.001, Wilcoxon matched-pairs signed-rank test; Cohen d=0.38). No significant effect of VRH on CHEPs and heart rate variability parameters was observed (all P>0.5; n=22 and n=52, respectively). During VRH, participants exhibited a clear reduction in their autonomic sympathetic tone, as shown by the lower number of nonspecific skin conductance peak responses (P<.001, two-way analysis of variance; n=39) and by an increase in the analgesia nociception index (P<.001, paired t-test; n=40). Conclusions: The results obtained in this study support the idea that VRH administration is effective at increasing heat pain thresholds and impacts autonomic functions among healthy volunteers. As a nonpharmacological intervention, VRH has beneficial action on acute experimental heat pain. This beneficial action will need to be evaluated for the treatment of other types of pain, including chronic pain. %M 35904872 %R 10.2196/33255 %U https://www.jmir.org/2022/7/e33255 %U https://doi.org/10.2196/33255 %U http://www.ncbi.nlm.nih.gov/pubmed/35904872 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 7 %P e37169 %T Changes in Resilience Following Engagement With a Virtual Mental Health System: Real-world Observational Study %A Graziani,Grant %A Aylward,Brandon S %A Kunkle,Sarah %A Shih,Emily %+ Ginger, 116 New Montgomery St. Suite 500, San Francisco, CA, 94105, United States, 1 855 446 4374, ggraziani@ginger.io %K behavioral coaching %K psychological resilience %K mental health %K telehealth %D 2022 %7 29.7.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Digital health services can serve as scalable solutions to address the growing demand for mental health care. However, more research is needed to better understand the association between engagement with care and improvements in subclinical outcomes. Objective: This study aims to fill this research gap by examining the relationship between members’ engagement with the Ginger platform and changes in their psychological resilience. Methods: We conducted a retrospective observational study of 3272 members who accessed Ginger, an on-demand mental health service, between January 2021 and November 2021. Each member completed the 10-item Connor-Davidson Resilience Scale questionnaire, a measure of psychological resilience, at baseline and again during a 6- to 16-week follow-up window. Depression and anxiety symptoms (9-item Patient Health Questionnaire and 7-item Generalized Anxiety Disorder) were also measured. Linear regression was used to identify the association between engagement with Ginger’s multiple care modalities and changes in resilience. Moderator analysis was conducted to test whether clinical depression or anxiety at baseline moderated the relationship between engagement level and changes in resilience. Results: Of the 3272 members, 2683 (82%) reported low resilience at baseline. The mean change in resilience was 0.77 (SD 5.50) points. Linear regression models showed that age and census region did not predict changes in resilience; however, male members showed larger improvements (coefficient=0.58; P=.04). Baseline mental health outcomes, including resilience and depression and anxiety symptoms, were strong predictors of changes in resilience. Every point decrease in baseline resilience is associated with a 0.28-point increase in change in resilience (P<.001), and members with no or mild depression and anxiety at baseline saw changes in resilience that were 1.44 points (P<.001) larger than their clinical counterparts. Engagement with the Ginger system predicted changes in resilience. Members who engaged with Ginger coaching, clinical services, or both improved their resilience by 1.82, 1.55, and 1.40 points, respectively (P<.001), more than those who only engaged with Ginger content. Screening negative for moderate to severe depression and anxiety at baseline was associated with larger improvements in resilience (coefficient=1.30; P<.001); however, subclinical status was not shown to be a moderator for the association between level of engagement and changes in resilience. Conclusions: Engagement with Ginger services was associated with improvements in resilience. Members who engaged in coaching or clinical care had significantly larger improvements compared with those who only engaged in self-guided content, regardless of whether a member screened positive for clinical depression or anxiety at baseline. %M 35904875 %R 10.2196/37169 %U https://formative.jmir.org/2022/7/e37169 %U https://doi.org/10.2196/37169 %U http://www.ncbi.nlm.nih.gov/pubmed/35904875 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 8 %N 3 %P e24306 %T Implementing Remote Collaboration in a Virtual Patient Platform: Usability Study %A Kiesewetter,Jan %A Hege,Inga %A Sailer,Michael %A Bauer,Elisabeth %A Schulz,Claudia %A Platz,Manfred %A Adler,Martin %+ Institut für Didaktik und Ausbildungsforschung in der Medizin am Klinikum der Ludwig-Maximilians-Universität München, Pettenkoferstr. 8a, Munich, 80336, Germany, 49 89440057213, jan.kiesewetter@med.lmu.de %K collaborative learning %K clinical reasoning %K webRTC %K collaboration %K collaborative %K decision making %D 2022 %7 28.7.2022 %9 Original Paper %J JMIR Med Educ %G English %X Background: Learning with virtual patients is highly popular for fostering clinical reasoning in medical education. However, little learning with virtual patients is done collaboratively, despite the potential learning benefits of collaborative versus individual learning. Objective: This paper describes the implementation of student collaboration in a virtual patient platform. Our aim was to allow pairs of students to communicate remotely with each other during virtual patient learning sessions. We hypothesized that we could provide a collaborative tool that did not impair the usability of the system compared to individual learning and that this would lead to better diagnostic accuracy for the pairs of students. Methods: Implementing the collaboration tool had five steps: (1) searching for a suitable software library, (2) implementing the application programming interface, (3) performing technical adaptations to ensure high-quality connections for the users, (4) designing and developing the user interface, and (5) testing the usability of the tool in 270 virtual patient sessions. We compared dyad to individual diagnostic accuracy and usability with the 10-item System Usability Scale. Results: We recruited 137 students who worked on 6 virtual patients. Out of 270 virtual patient sessions per group (45 dyads times 6 virtual patients, and 47 students working individually times 6 virtual patients minus 2 randomly selected deleted sessions) the students made successful diagnoses in 143/270 sessions (53%, SD 26%) when working alone and 192/270 sessions (71%, SD 20%) when collaborating (P=.04, η2=0.12). A usability questionnaire given to the students who used the collaboration tool showed a usability score of 82.16 (SD 1.31), representing a B+ grade. Conclusions: The collaboration tool provides a generic approach for collaboration that can be used with most virtual patient systems. The collaboration tool helped students diagnose virtual patients and had good overall usability. More broadly, the collaboration tool will provide an array of new possibilities for researchers and medical educators alike to design courses for collaborative learning with virtual patients. %M 35900827 %R 10.2196/24306 %U https://mededu.jmir.org/2022/3/e24306 %U https://doi.org/10.2196/24306 %U http://www.ncbi.nlm.nih.gov/pubmed/35900827 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e36720 %T The Long-term Effects of Immersive Virtual Reality Reminiscence in People With Dementia: Longitudinal Observational Study %A Huang,Ling-Chun %A Yang,Yuan-Han %+ Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, 68 Jhonghua 3rd Road, Cianjin District, Kaohsiung, 80145, Taiwan, 886 7 2911101 ext 8913, endlessyhy@gmail.com %K virtual reality %K reminiscence %K dementia %K long-term care %D 2022 %7 25.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Novel nonpharmacological therapies are being developed to prevent cognitive decline and reduce behavioral and psychological symptoms in patients with dementia. Virtual reality (VR) reminiscence was reported to improve anxiety, apathy, and cognitive function immediately after intervention in individuals at residential aged care facilities. However, its effect on elderly patients with dementia and how long this effect could last remain unknown. Objective: The aim of this paper is to investigate the effect of immersive VR reminiscence in people with dementia both immediately after and 3-6 months after intervention. Methods: A pilot study was conducted in 2 dementia care units. VR reminiscence therapy sessions were conducted twice per week for a 3-month period. Cognitive function, global status, depressive symptoms, and caregiver burden were assessed before and immediately after VR intervention in 20 participants. Subsequently, 7 participants were reassessed 3-6 months after the VR intervention. Wilcoxon sign-rank test was used for statistical comparisons of the changes. Results: There were no significant changes in cognitive function, global status, and caregiver burden immediately after the VR intervention, but there was a significant reduction in depressive symptoms (P=.008). Moreover, compared with the cognitive function immediately after VR, it kept declining 3-6 months after. Conclusions: Immersive VR reminiscence can improve mood and preserve cognitive function in elderly patients with dementia during the period of the intervention. Studies using a control group and comparing the use of VR with traditional forms of reminiscence should be conducted in the future to confirm and expand on these findings. %M 35877169 %R 10.2196/36720 %U https://games.jmir.org/2022/3/e36720 %U https://doi.org/10.2196/36720 %U http://www.ncbi.nlm.nih.gov/pubmed/35877169 %0 Journal Article %@ 2369-1999 %I JMIR Publications %V 8 %N 3 %P e38300 %T An Investigation of Virtual Reality Nature Experiences in Patients With Metastatic Breast Cancer: Secondary Analysis of a Randomized Controlled Trial %A Chin,Stanley %A Cavadino,Alana %A Akroyd,Amelia %A Tennant,Geraldine %A Dobson,Rosie %A Gautier,Adele %A Reynolds,Lisa %+ Department of Psychological Medicine, The University of Auckland, Private Bag 92019, Victoria Street West, Auckland, 1142, New Zealand, 64 9234938, l.reynolds@auckland.ac.nz %K metastatic breast cancer %K virtual reality %K nature connectedness %K intervention %K quality of life %D 2022 %7 22.7.2022 %9 Original Paper %J JMIR Cancer %G English %X Background: Connection with nature has well-established physical and psychological benefits. However, women with metastatic breast cancer (MBC) are often unable to access nature because of physical limitations, psychological barriers, and treatment demands. Virtual reality (VR) nature experiences offer an alternative means of connecting with nature and may be of particular benefit to patients with cancer who are house- or hospital-bound. Objective: This study aims to explore whether VR nature experiences are associated with physical and psychological benefits for women with MBC who are disconnected with nature. Methods: This secondary analysis of a previous randomized controlled crossover trial recruited participants from the emailing lists of breast cancer support organizations. Participants were provided VR headsets for daily use in their homes for over 3 weeks. In the first week, participants used 1 of 2 VR nature experiences (Ripple or Happy Place) daily, followed by a 1-week washout period, before using the other VR experience every day for the final week. Outcomes assessed changes between baseline and postintervention scores in quality of life (EQ-5D-5L), pain (Brief Pain Inventory Short Form), fatigue (Functional Assessment of Chronic Illness Therapy-fatigue), depression (Depression, Anxiety, and Stress Scale-depression), anxiety (Depression, Anxiety, and Stress Scale-anxiety), and spiritual well-being (Functional Assessment of Chronic Illness Therapy- Spiritual Well-being) and investigated whether benefits were greater in participants who were not strongly connected with nature at baseline. Results: A total of 38 women with MBC completed the VR interventions and were included in the analyses. Participants reported significantly less fatigue (P=.001), less depression (P<.001), and greater quality of life (P=.02) following the interventions than at baseline. Women with a weaker connection to nature reported greater fatigue (P=.03), depression (P=.006), and anxiety (P=.001), and poorer spirituality (P=.004) than their strongly connected counterparts. Only those with a weaker baseline connection with nature showed improvements in depression following the intervention (P=.03), with similar trends observed in fatigue (P=.07) and quality of life (P=.10). Conclusions: This study provides preliminary evidence that feeling connected with nature is associated with better physical and psychological status in patients with MBC and that VR nature interventions might be beneficial for this clinical population. Future studies should focus on activities that encourage connection with nature (rather than simply exposure to nature) and investigate the aspects of VR nature interventions that have the greatest therapeutic potential. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12619001480178; https://tinyurl.com/et6z3vac %M 35867398 %R 10.2196/38300 %U https://cancer.jmir.org/2022/3/e38300 %U https://doi.org/10.2196/38300 %U http://www.ncbi.nlm.nih.gov/pubmed/35867398 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e38509 %T Virtual Reality as a Therapy Tool for Walking Activities in Pediatric Neurorehabilitation: Usability and User Experience Evaluation %A Ammann-Reiffer,Corinne %A Kläy,Andrina %A Keller,Urs %+ Research Department, Swiss Children's Rehab, University Children's Hospital Zurich - Eleonore Foundation, Mühlebergstrasse 104, Affoltern am Albis, 8910, Switzerland, 41 447625297, corinne.ammann@kispi.uzh.ch %K rehabilitation %K pediatric %K child %K adolescent %K walking %K feasibility study %K virtual reality %K head-mounted display %K therapy %K tool %K user %K usability %K walking %K visual %K auditory %K feedback %K youth %D 2022 %7 14.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Many essential walking activities in daily life, such as crossing a street, are challenging to practice in conventional therapeutic settings. Virtual environments (VEs) delivered through a virtual reality (VR) head-mounted display (HMD) would allow training such activities in a safe and attractive environment. Furthermore, the game-like character and high degree of immersion in these applications might help maintain or increase children’s motivation and active participation during the rehabilitation process. Objective: This study aimed to investigate the usability, user experience, and acceptability of an immersive VE experienced through a VR HMD to train everyday life walking activities in pediatric neurorehabilitation. Methods: In a cross-sectional study, 21 youths (median age 12.1 years; range 6.8-17.7 years) with a neuromotor impairment undergoing inpatient or outpatient neurorehabilitation tested a VE experienced through the VR HMD Oculus Quest. The participants, accompanied by their physiotherapists, moved freely around a 4.4 by 10-meter VE, displaying a magical forest and featuring various gamified everyday activities in different game designs. Using their hands, represented in the VE, the participants could interact with the virtual objects placed throughout the VE and trigger visual and auditory feedback. Symptoms of cybersickness were checked, and usability, user experience, and acceptability were evaluated using customized questionnaires with a visual analog scale for youths and a 5-point Likert scale for their therapists. Results: None of the participants reported any signs of cybersickness after 20 minutes of VR HMD exposure time. They rated comfort (median 10/10) and movement ability (median 10/10) with the VR HMD as high. The VE was perceived as being really there by the majority (median 8/10), and the participants had a strong feeling of spatial presence in the VE (median 9.5/10). They enjoyed exploring the virtual world (median 10/10) and liked this new therapy approach (median 10/10). Therapists’ acceptance of the VR HMD was high (4/5). There were 5 patients that needed more support than usual, mainly for supervision, when moving around with the VR HMD. Otherwise, therapists felt that the VR HMD hardly affected their patients’ movement behavior (median 4.75/5), whereas it seemed to increase their level of therapy engagement (median 4/5) compared to conventional physiotherapy sessions. Conclusions: This study demonstrates the usability of an immersive VE delivered through a VR HMD to engage youths in the training of everyday walking activities. The participants’ and therapists’ positive ratings on user experience and acceptance further support the promising application of this technology as a future therapeutic tool in pediatric neurorehabilitation. %M 35834316 %R 10.2196/38509 %U https://games.jmir.org/2022/3/e38509 %U https://doi.org/10.2196/38509 %U http://www.ncbi.nlm.nih.gov/pubmed/35834316 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 7 %P e38366 %T Active Virtual Reality for Chronic Primary Pain: Mixed Methods Randomized Pilot Study %A Tuck,Natalie %A Pollard,Catherine %A Good,Clinton %A Williams,Caitlin %A Lewis,Gwyn %A Hames,Murray %A Aamir,Tipu %A Bean,Debbie %+ The Health and Rehabilitation Research Institute, Auckland University of Technology, 90 Akoranga Drive, Northcote, Auckland, 0627, New Zealand, 64 21 2669363, natalie.tuck@aut.ac.nz %K chronic pain %K virtual reality %K VR %K rehabilitation %K serious games %K physiotherapy %K pain management %K acceptability %K intervention %K feasibility %D 2022 %7 13.7.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: The modern management of chronic pain is largely focused on improving functional capacity (often despite ongoing pain) by using graded activation and exposure paradigms. However, many people with chronic pain find functional activation programs aversive, and dropout rates are high. Modern technologies such as virtual reality (VR) could provide a more enjoyable and less threatening way for people with chronic pain to engage in physical activity. Although VR has been successfully used for pain relief in acute and chronic pain settings, as well as to facilitate rehabilitation in conditions such as stroke and cerebral palsy, it is not known whether VR can also be used to improve functional outcomes in people with chronic pain. Objective: This study aimed to assess the feasibility of conducting an adequately powered randomized controlled trial (RCT) to test the efficacy of VR in a chronic pain treatment center and assess the acceptability of an active VR treatment program for patients in this setting. Methods: For this mixed methods pilot study, which was designed to test the feasibility and acceptability of the proposed study methods, 29 people seeking treatment for chronic pain were randomized to an active VR intervention or physiotherapy treatment as usual (TAU). The TAU group completed a 6-week waitlist before receiving standard treatment to act as a no-treatment control group. The VR intervention comprised twice-weekly immersive and embodied VR sessions using commercially available gaming software, which was selected to encourage movement. A total of 7 VR participants completed semistructured interviews to assess their perception of the intervention. Results: Of the 99 patients referred to physiotherapy, 53 (54%) were eligible, 29 (29%) enrolled, and 17 (17%) completed the trial, indicating that running an adequately powered RCT in this setting would not be feasible. Despite this, those in the VR group showed greater improvements in activity levels, pain intensity, and pain interference and reported greater treatment satisfaction and perceived improvement than both the waitlist and TAU groups. Relative effect sizes were larger when VR was compared with the waitlist (range small to very large) and smaller when VR was compared with TAU (range none to medium). The qualitative analysis produced the following three themes: VR is an enjoyable alternative to traditional physiotherapy, VR has functional and psychological benefits despite continued pain, and a well-designed VR setup is important. Conclusions: The active VR intervention in this study was highly acceptable to participants, produced favorable effects when compared with the waitlist, and showed similar outcomes as those of TAU. These findings suggest that a confirmatory RCT is warranted; however, substantial barriers to recruitment indicate that incentivizing participation and using a different treatment setting or running a multicenter trial are needed. %M 35830224 %R 10.2196/38366 %U https://formative.jmir.org/2022/7/e38366 %U https://doi.org/10.2196/38366 %U http://www.ncbi.nlm.nih.gov/pubmed/35830224 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e33755 %T The Impact of Cognitive Function on Virtual Reality Intervention for Upper Extremity Rehabilitation of Patients With Subacute Stroke: Prospective Randomized Controlled Trial With 6-Month Follow-up %A Leng,Yan %A Lo,Wai Leung Ambrose %A Mao,Yu Rong %A Bian,Ruihao %A Zhao,Jiang Li %A Xu,Zhiqin %A Li,Le %A Huang,Dong Feng %+ Guangdong Engineering and Technology Research Center for Rehabilitation Medicine and Translation, Sun Yat-sen University, 58 Zhongshan Er Lu Road, Guangzhou, 510080, China, 86 13922318919, huangdf@mail.sysu.edu.cn %K stroke %K motor function of upper extremity %K virtual reality %K cognitive function %D 2022 %7 8.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Stroke is among the leading causes of long-term disability worldwide. Motor impairments after stroke not only impact the individuals quality of life but also lay substantial burdens on the society. Motor planning is a key component of cognitive function that impacts motor control. Hand movements such as grasping or reaching to grasp require the application of correct force and the coordination of multiple limb segments. Successful completion of hand motor task requires a certain degree of cognitive function to anticipate the requirement of the task. Cognitive function may thus be a confounding factor to rehabilitation outcomes. Objective: This study aims to explore the impact of cognitive function on functional outcomes in people with subacute stroke after VR intervention. Methods: Patients with stroke were first stratified into cognitively normal (CN) and cognitively impaired (CI), followed by allocation to the VR or control group (CG). Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Barthel Index (BI), and Instrumental Activities of Daily Living (IADL) were recorded at baseline, 3 weeks after the intervention, and 3 and 6 months after the intervention. The between-group and within-group differences were assessed by repeated-measures analysis of variance (ANOVA). Results: The between-group comparison indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) scores improved significantly in both groups after the intervention. Repeated-measures ANOVA indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) were significantly different in each subgroup after the intervention. For BI score, the ANOVA results showed obvious interaction effects (treatment × time × cognitive effect, P=.04). Conclusions: VR intervention was as effective as traditional conventional therapy in improving upper limb function regardless of the cognitive functional level. Patients with stroke with impaired cognitive function may gain more improvement in upper limb function and independency in performing activities of daily living after a VR-based intervention. Trial Registration: Chinese Clinical Trial Registry ChiCTR-IOC-15006064; https://tinyurl.com/4c9vkrrn %M 35802415 %R 10.2196/33755 %U https://games.jmir.org/2022/3/e33755 %U https://doi.org/10.2196/33755 %U http://www.ncbi.nlm.nih.gov/pubmed/35802415 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 3 %P e38669 %T Designing Virtual Reality–Based Conversational Agents to Train Clinicians in Verbal De-escalation Skills: Exploratory Usability Study %A Moore,Nathan %A Ahmadpour,Naseem %A Brown,Martin %A Poronnik,Philip %A Davids,Jennifer %+ Digital Health Solutions, Western Sydney Local Health District, Cumberland Hospital East Campus, Building 106, North Parramatta, 2151, Australia, 61 0427850889, nathan.moore@health.nsw.gov.au %K virtual reality %K code black %K verbal de-escalation %K violence and aggression %K education %K clinical training %K conversational agent %D 2022 %7 6.7.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Violence and aggression are significant workplace challenges faced by clinicians worldwide. Traditional methods of training consist of “on-the-job learning” and role-play simulations. Although both approaches can result in improved skill levels, they are not without limitation. Interactive simulations using virtual reality (VR) can complement traditional training processes as a cost-effective, engaging, easily accessible, and flexible training tool. Objective: In this exploratory study, we aimed to determine the feasibility of and barriers to verbal engagement with a virtual agent in the context of the Code Black VR application. Code Black VR is a new interactive VR-based verbal de-escalation trainer that we developed based on the Clinical Training Through VR Design Framework. Methods: In total, 28 participants with varying clinical expertise from 4 local hospitals enrolled in the Western Sydney Local Health District Clinical Initiative Nurse program and Transition to Emergency Nursing Programs and participated in 1 of 5 workshops. They completed multiple playthroughs of the Code Black VR verbal de-escalation trainer application and verbally interacted with a virtual agent. We documented observations and poststudy reflection notes. After the playthroughs, the users completed the System Usability Scale and provided written comments on their experience. A thematic analysis was conducted on the results. Data were also obtained through the application itself, which also recorded the total interactions and successfully completed interactions. Results: The Code Black VR verbal de-escalation training application was well received. The findings reinforced the factors in the existing design framework and identified 3 new factors—motion sickness, perceived value, and privacy—to be considered for future application development. Conclusions: Verbal interaction with a virtual agent is feasible for training staff in verbal de-escalation skills. It is an effective medium to supplement clinician training in verbal de-escalation skills. We provide broader design considerations to guide further developments in this area. %M 35793129 %R 10.2196/38669 %U https://games.jmir.org/2022/3/e38669 %U https://doi.org/10.2196/38669 %U http://www.ncbi.nlm.nih.gov/pubmed/35793129 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 7 %P e37567 %T Participant Experiences of a COVID-19 Virtual Clinical Study Using the Current Health Remote Monitoring Platform: Case Study and Qualitative Analysis %A Pugmire,Juliana %A Lever Taylor,Jessie %A Wilkes,Matt %A Wolfberg,Adam %A Zahradka,Nicole %+ Current Health Ltd, Suite 2, Ground Floor, Orchard Brae House, 30 Queensferry Road, Edinburgh, EH4 2HS, United Kingdom, 44 131 285 8101, juliana.pugmire@currenthealth.com %K virtual trial designs %K virtual enrollment %K digitalized health %K theoretical domains framework %K thematic analysis %K remote patient monitoring %D 2022 %7 5.7.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: During the COVID-19 pandemic, individuals with a positive viral test were enrolled in a study, within 48 hours, to remotely monitor their vital signs to characterize disease progression and recovery. A virtual trial design was adopted to reduce risks to participants and the research community in a study titled Risk Stratification and Early Alerting Regarding COVID-19 Hospitalization (RiskSEARCH). The Food and Drug Administration–cleared Current Health platform with a wearable device is a continuous remote patient monitoring technology that supports hospital-at-home care and is used as a data collection tool. Enrolled participants wore the Current Health wearable device continuously for up to 30 days and took a daily symptom survey via a tablet that was provided. A qualitative substudy was conducted in parallel to better understand virtual trial implementation, including barriers and facilitators for participants. Objective: This study aimed to understand the barriers and facilitators of the user experience of interacting with a virtual care platform and research team, while participating in a fully virtual study using qualitative and quantitative data. Methods: Semistructured interviews were conducted to understand participants’ experience of participating in a virtual study during a global pandemic. The schedule included their experience of enrollment and their interactions with equipment and study staff. A total of 3 RiskSEARCH participants were interviewed over telephone, and transcriptions were inductively coded and analyzed using thematic analysis. Themes were mapped onto the Theoretical Domains Framework (TDF) to identify and describe the factors that influenced study adherence. Quantitative metrics, including adherence to wearable and scheduled tasks collected as part of the RiskSEARCH main study, were paired with the interviews to present an overall picture of participation. Results: All participants exceeded our definition of a fully adherent participant and reported that participation was feasible and had a low burden. The symptoms progressively resolved during the trial. Inductive thematic analysis identified 13 main themes from the interview data, which were deductively mapped onto 11 of the 14 TDF domains, highlighting barriers and facilitators for each. Conclusions: Participants in the RiskSEARCH substudy showed high levels of adherence and engagement throughout participation. Although participants experienced some challenges in setting up and maintaining the Current Health kit (eg, charging devices), they reported feeling that the requirements of participation were both reasonable and realistic. We demonstrated that the TDF can be used for inductive thematic analysis. We anticipate expanding this work in future virtual studies and trials to identify barriers and enabling factors for implementation. %M 35671408 %R 10.2196/37567 %U https://formative.jmir.org/2022/7/e37567 %U https://doi.org/10.2196/37567 %U http://www.ncbi.nlm.nih.gov/pubmed/35671408 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 7 %P e37222 %T Implementation of Virtual Reality in Health Professional Higher Education: Protocol for a Scoping Review %A Lie,Silje Stangeland %A Helle,Nikolina %A Sletteland,Nina Vahl %A Vikman,Miriam Dubland %A Bonsaksen,Tore %+ Faculty of Health Studies, VID Specialized University, Misjonsmarka 12, Stavanger, 4024, Norway, 47 97506752, silje.lie@vid.no %K virtual reality %K higher education %K medical education %K health care professional education %K continuing education %K implementation %K technology %K scoping review %K Google Scholar %K health professional %D 2022 %7 5.7.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: The use of virtual reality in higher education show great potential to promote novel and innovative learning experiences. Until recently, virtual reality has mostly been used in technical higher education, but lately medical education programs have begun using virtual reality. Virtual reality for health professional education improves the knowledge and skills of health professionals compared with traditional or other digital education initiatives. However, the implementation of technology in higher education is slow because of barriers to technology use and innovative and successful practices are not shared. It is, therefore, of great interest to explore how virtual reality is implemented in higher health professional and continuing education. Objective: The aim of this scoping review is to identify studies that reported implementation of virtual reality in higher health professional education, to identify barriers and facilitators for implementation, and to highlight research gaps in this area. Methods: The scoping review will be conducted according to JBI Evidence Synthesis methodologies. CINAHL, the Academic Search Elite and Education Source electronic databases, and Google Scholar will be searched for studies published between 2017 and 2022. In addition, manual searching of key items, reference tracking, and citation tracking will be performed. Searches for white papers will also be manually conducted. All authors will independently extract data from full-text papers. We will use qualitative content analysis to abstract the findings. Results: The literature searches were conducted in January and February 2022. The review is expected to be completed by fall 2022, after which time it will be submitted for publication. Conclusions: We anticipate that, from the review, we will be able to coordinate recommendations for and present the challenges of virtual reality initiatives in health professional education programs. We will present recommendations for future research. International Registered Report Identifier (IRRID): DERR1-10.2196/37222 %M 35787531 %R 10.2196/37222 %U https://www.researchprotocols.org/2022/7/e37222 %U https://doi.org/10.2196/37222 %U http://www.ncbi.nlm.nih.gov/pubmed/35787531 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e38952 %T Instructor Development Workshops for Advanced Life Support Training Courses Held in a Fully Virtual Space: Observational Study %A Kiyozumi,Tetsuro %A Ishigami,Norio %A Tatsushima,Daisuke %A Araki,Yoshiyuki %A Yoshimura,Yuya %A Saitoh,Daizoh %+ Department of Defense Medicine, National Defense Medical College, Namiki 3-2, Tokorozawa, 3598513, Japan, 81 429951211, kiyosan@ka2.so-net.ne.jp %K virtual reality %K virtual space %K instructor development workshop %K resuscitation training course %K advanced life support %K resuscitation training %K digital training %K virtual learning %K digital education %K medical education %D 2022 %7 29.6.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Various face-to-face training opportunities have been lost due to the COVID-19 pandemic. Instructor development workshops for advanced resuscitation (ie, advanced life support) training courses are no exception. Virtual reality (VR) is an attractive strategy for remote training. However, to our knowledge, there are no reports of resuscitation instructor training programs being held in a virtual space. Objective: This study aimed to investigate the learning effects of an instructor development workshop that was conducted in a virtual space. Methods: In this observational study, we created a virtual workshop space by using NEUTRANS (Synamon Inc)—a commercial VR collaboration service. The instructor development workshop for the advanced life support training course was held in a virtual space (ie, termed the VR course) as a certified workshop by the Japanese Association of Acute Medicine. We asked 13 instructor candidates (students) who participated in the VR course to provide a workshop report (VR group). Reports from a previously held face-to-face workshop (ie, the face-to-face course and group) were likewise prepared for comparison. A total of 5 certified instructor trainers viewed and scored the reports on a 5-point Likert scale. Results: All students completed the VR course without any problems and received certificates of completion. The scores for the VR group and the face-to-face group did not differ at the level of statistical significance (median 3.8, IQR 3.8-4.0 and median 4.2, IQR 3.9-4.2, respectively; P=.41). Conclusions: We successfully conducted an instructor development workshop in a virtual space. The degree of learning in the virtual workshop was the same as that in the face-to-face workshop. %M 35767318 %R 10.2196/38952 %U https://games.jmir.org/2022/2/e38952 %U https://doi.org/10.2196/38952 %U http://www.ncbi.nlm.nih.gov/pubmed/35767318 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 10 %N 6 %P e37196 %T Virtual Specialist Care During the COVID-19 Pandemic: Multimethod Patient Experience Study %A Dainty,Katie N %A Seaton,M Bianca %A Estacio,Antonio %A Hicks,Lisa K %A Jamieson,Trevor %A Ward,Sarah %A Yu,Catherine H %A Mosko,Jeffrey D %A Kassardjian,Charles D %+ North York General Hospital, 4001 Leslie Street, LE-140, Toronto, ON, M2K 1E1, Canada, 1 16474482485, katie.dainty@utoronto.ca %K virtual care %K specialist care %K patient experience %K COVID-19 %K medical care %K virtual health %K care data %K decision support %K telehealth %K video consultation %D 2022 %7 28.6.2022 %9 Original Paper %J JMIR Med Inform %G English %X Background: Transitioning nonemergency, ambulatory medical care to virtual visits in light of the COVID-19 global pandemic has been a massive shift in philosophy and practice that naturally came with a steep learning curve for patients, physicians, and clinic administrators. Objective: We undertook a multimethod study to understand the key factors associated with successful and less successful experiences of virtual specialist care, particularly as they relate to the patient experience of care. Methods: This study was designed as a multimethod patient experience study using survey methods, descriptive qualitative interview methodology, and administrative virtual care data collected by the hospital decision support team. Six specialty departments participated in the study (endoscopy, orthopedics, neurology, hematology, rheumatology, and gastroenterology). All patients who could speak and read English and attended a virtual specialist appointment in a participating clinic at St. Michael’s Hospital (Toronto, Ontario, Canada) between October 1, 2020, and January 30, 2021, were eligible to participate. Results: During the study period, 51,702 virtual specialist visits were conducted in the departments that participated in the study. Of those, 96% were conducted by telephone and 4% by video. In both the survey and interview data, there was an overall consensus that virtual care is a satisfying alternative to in-person care, with benefits such as reduced travel, cost, time, and SARS-CoV-2 exposure, and increased convenience. Our analysis further revealed that the specific reason for the visit and the nature and status of the medical condition are important considerations in terms of guidance on where virtual care is most effective. Technology issues were not reported as a major challenge in our data, given that the majority of “virtual” visits reported by our participants were conducted by telephone, which is an important distinction. Despite the positive value of virtual care discussed by the majority of interview participants, 50% of the survey respondents still indicated they would prefer to see their physician in person. Conclusions: Patient experience data collected in this study indicate a high level of satisfaction with virtual specialty care, but also signal that there are nuances to be considered to ensure it is an appropriate and sustainable part of the standard of care. %M 35482950 %R 10.2196/37196 %U https://medinform.jmir.org/2022/6/e37196 %U https://doi.org/10.2196/37196 %U http://www.ncbi.nlm.nih.gov/pubmed/35482950 %0 Journal Article %@ 2561-1011 %I JMIR Publications %V 6 %N 1 %P e35488 %T Virtual Reality Cardiac Surgical Planning Software (CorFix) for Designing Patient-Specific Vascular Grafts: Development and Pilot Usability Study %A Kim,Byeol %A Nguyen,Phong %A Loke,Yue-Hin %A Cleveland,Vincent %A Liu,Xiaolong %A Mass,Paige %A Hibino,Narutoshi %A Olivieri,Laura %A Krieger,Axel %+ Department of Mechanical Engineering, Johns Hopkins University, 200 Hackerman Hall, 3400 N. Charles St, Baltimore, MD, 21218, United States, 1 410 516 8000, axel@jhu.edu %K virtual reality %K congenital heart disease %K surgical planning %K usability study %K heart %K surgery %D 2022 %7 17.6.2022 %9 Original Paper %J JMIR Cardio %G English %X Background: Patients with single ventricle heart defects receive 3 stages of operations culminating in the Fontan procedure. During the Fontan procedure, a vascular graft is sutured between the inferior vena cava and pulmonary artery to divert deoxygenated blood flow to the lungs via passive flow. Customizing the graft configuration can maximize the long-term benefits. However, planning patient-specific procedures has several challenges, including the ability for physicians to customize grafts and evaluate their hemodynamic performance. Objective: The aim of this study was to develop a virtual reality (VR) Fontan graft modeling and evaluation software for physicians. A user study was performed to achieve 2 additional goals: (1) to evaluate the software when used by medical doctors and engineers, and (2) to explore the impact of viewing hemodynamic simulation results in numerical and graphical formats. Methods: A total of 5 medical professionals including 4 physicians (1 fourth-year resident, 1 third-year cardiac fellow, 1 pediatric intensivist, and 1 pediatric cardiac surgeon) and 1 biomedical engineer voluntarily participated in the study. The study was pre-scripted to minimize the variability of the interactions between the experimenter and the participants. All participants were trained to use the VR gear and our software, CorFix. Each participant designed 1 bifurcated and 1 tube-shaped Fontan graft for a single patient. A hemodynamic performance evaluation was then completed, allowing the participants to further modify their tube-shaped design. The design time and hemodynamic performance for each graft design were recorded. At the end of the study, all participants were provided surveys to evaluate the usability and learnability of the software and rate the intensity of VR sickness. Results: The average times for creating 1 bifurcated and 1 tube-shaped graft after a single 10-minute training session were 13.40 and 5.49 minutes, respectively, with 3 out 5 bifurcated and 1 out of 5 tube-shaped graft designs being in the benchmark range of hepatic flow distribution. Reviewing hemodynamic performance results and modifying the tube-shaped design took an average time of 2.92 minutes. Participants who modified their tube-shaped graft designs were able to improve the nonphysiologic wall shear stress (WSS) percentage by 7.02%. All tube-shaped graft designs improved the WSS percentage compared to the native surgical case of the patient. None of the designs met the benchmark indexed power loss. Conclusions: VR graft design software can quickly be taught to physicians with no engineering background or VR experience. Improving the CorFix system could improve performance of the users in customizing and optimizing grafts for patients. With graphical visualization, physicians were able to improve WSS percentage of a tube-shaped graft, lowering the chance of thrombosis. Bifurcated graft designs showed potential strength in better flow split to the lungs, reducing the risk for pulmonary arteriovenous malformations. %M 35713940 %R 10.2196/35488 %U https://cardio.jmir.org/2022/1/e35488 %U https://doi.org/10.2196/35488 %U http://www.ncbi.nlm.nih.gov/pubmed/35713940 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e29830 %T Virtual Reality Training Using Nintendo Wii Games for Patients With Stroke: Randomized Controlled Trial %A Anwar,Naveed %A Karimi,Hossein %A Ahmad,Ashfaq %A Gilani,Syed Amir %A Khalid,Kehkshan %A Aslam,Ahmed Sohaib %A Hanif,Asif %+ University Institute of Physical Therapy, University of Lahore, 1-Km, Defence Road, Bhupatian Chowk, Off Raiwind Road, Lahore, Pakistan, 92 3336140916, dr.hossein.karimi@gmail.com %K stroke %K virtual reality %K Fugl-Meyer score %K rehabilitation %K training %K physical therapy %K therapy %K balance %K function %K randomized controlled trial %D 2022 %7 13.6.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Stroke is a leading cause of disability. It is difficult to devise an optimal rehabilitation plan once stroke survivors are back home. Conventional rehabilitative therapies are extensively used in patients with stroke to recover motor functioning and disability, but these are arduous and expensive. Virtual reality (VR) video games inspire patients to get involved in their therapeutic exercise routine in a fun way. VR in the form of games provides a fruitful, secure, and challenging learning environment for motor control and neural plasticity development in rehabilitation. The effects of upper limb sensorimotor functioning and balance are the main focus of this trial. Objective: The aim of this study is to compare the effects of VR training and routine physical therapy on balance and upper extremity sensorimotor function in patients with stroke. Methods: It was a single assessor-blinded randomized clinical trial. A total of 74 participants with their first chronic stroke were included and rehabilitated in a clinical setting. The lottery method was used to randomly assign patients to either the VR group (n=37) or the routine physical therapy group (n=37). The VR group received a 1-hour session of VR training for 3 weekdays over 6 weeks, and the routine physical therapy group received different stretching and strengthening exercises. The outcome measuring tools were the Berg Balance Scale for balance and the Fugl-Meyer Assessment (upper extremity) scale for sensorimotor, joint pain, and range assessment. The assessment was done at the start of treatment and after the 6 weeks of intervention. Data analysis was done using SPSS 22. Results: The trial was completed by 68 patients. A significant difference between the two groups was found in the Berg Balance Scale score (P<.001), Fugl-Meyer Assessment for motor function (P=.03), and Fugl-Meyer Assessment for joint pain and joint range (P<.001); however, no significant difference (P=.19) in the Fugl-Meyer Assessment for upper extremity sensation was noted. Conclusions: VR training is helpful for improving balance and function of the upper extremities in the routine life of patients with stroke; although, it was not found to be better than conventional training in improving upper limb sensation. VR training can be a better option in a rehabilitation plan designed to increase functional capability. Trial Registration: Iranian Registry of Clinical Trials RCT20190715044216N1; https://www.irct.ir/user/trial/40898/view %M 35699989 %R 10.2196/29830 %U https://games.jmir.org/2022/2/e29830 %U https://doi.org/10.2196/29830 %U http://www.ncbi.nlm.nih.gov/pubmed/35699989 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 6 %P e32955 %T Immersive Virtual Reality Exergames to Promote the Well-being of Community-Dwelling Older Adults: Protocol for a Mixed Methods Pilot Study %A Mehrabi,Samira %A Muñoz,John E %A Basharat,Aysha %A Boger,Jennifer %A Cao,Shi %A Barnett-Cowan,Michael %A Middleton,Laura E %+ Department of Kinesiology, University of Waterloo, 200 University Ave W, Waterloo, ON, N2L 3G1, Canada, 1 (519) 888 4567, samira.mehrabi@uwaterloo.ca %K virtual reality %K exergames %K community-dwelling older adults %K pilot protocol %K feasibility %K well-being %K physical activity %K cognition %K perception %K mood %K COVID-19 %D 2022 %7 13.6.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Despite the proven benefits of exercise in older adults, challenges such as access and motivation can deter their engagement. Interactive virtual reality (VR) games combined with exercise (exergames) are a plausible strategy to encourage physical activity among this population. However, there has been little research on the feasibility, acceptability, and potential benefits of deploying at-home VR exergames among community-dwelling older adults. Objective: The objectives of this study are to estimate the feasibility, usability, and acceptability of a co-designed VR exergame in community-dwelling older adults; examine intervention feasibility and assessment protocols for a future large-scale trial; and provide pilot data on outcomes of interest (physical activity, exercise self-efficacy, mood, cognition, perception, and gameplay metrics). Methods: The study will be a remote, 6-week intervention comprising an experimental and a control group. A sample of at least 12 community-dwelling older adults (with no or mild cognitive impairment) will be recruited for each group. Both groups will follow the same study procedures and assessment methods. However, the experimental group will engage with a co-designed VR exergame (Seas The Day) thrice weekly for approximately 20 minutes using the Oculus Quest 2 (Facebook Reality Labs) VR headset. The control group will read (instead of playing Seas The Day) thrice weekly for approximately 20 minutes over the 6-week period. A mixed methods evaluation will be used. Changes in physical activity, exercise self-efficacy, mood, cognition, and perception will be compared before and after acute data as well as before and after the 6 weeks between the experimental (exergaming) and control (reading) groups. Qualitative data from postintervention focus groups or interviews and informal notes and reports from all participants will be analyzed to assess the feasibility of the study protocol. Qualitative data from the experimental group will also be analyzed to assess the feasibility, usability, and acceptability of at-home VR exergames and explore perceived facilitators of and barriers to uptaking VR systems among community-dwelling older adults. Results: The screening and recruitment process for the experimental group started in May 2021, and the data collection process will be completed by September 2021. The timeline of the recruitment process for the control group is September 2021 to December 2021. We anticipate an estimated adherence rate of ≥80%. Challenges associated with VR technology and the complexity of remote assessments are expected. Conclusions: This pilot study will provide important information on the feasibility, acceptability, and usability of a custom-made VR exergaming intervention to promote older adults’ well-being. Findings from this study will be useful to inform the methodology, design, study procedures, and assessment protocol for future large-scale trials of VR exergames with older adults as well as deepen the understanding of remote deployment and at-home use of VR for exercise in older adults. International Registered Report Identifier (IRRID): DERR1-10.2196/32955 %M 35700014 %R 10.2196/32955 %U https://www.researchprotocols.org/2022/6/e32955 %U https://doi.org/10.2196/32955 %U http://www.ncbi.nlm.nih.gov/pubmed/35700014 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 6 %P e30616 %T The Efficacy of Virtual Reality Game Preparation for Children Scheduled for Magnetic Resonance Imaging Procedures (IMAGINE): Protocol for a Randomized Controlled Trial %A Le May,Sylvie %A Genest,Christine %A Hung,Nicole %A Francoeur,Maxime %A Guingo,Estelle %A Paquette,Julie %A Fortin,Olivier %A Guay,Stéphane %+ Research Center, Centre Hospitalier Universitaire Sainte-Justine, 3175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada, 1 514 345 4931, sylvie.lemay@umontreal.ca %K virtual reality %K children %K video games %K magnetic resonance imaging %K anxiety %K pediatrics %K patient collaboration %K patient preparation %K biofeedback %D 2022 %7 13.6.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: It is known that magnetic resonance imaging (MRI) procedures generate fear and anxiety. Children may become restless during scanning, which results in movement artifacts requiring the MRI procedure to be repeated with sedation. Few studies seem to have looked at the effect of immersive virtual reality (IVR) on anxiety in children scheduled for MRI scans and how to identify which children are more responsive. Objective: The aims of this study are 3-fold: develop an algorithm of predictability based on biofeedback, address feasibility and acceptability of preprocedural IVR game preparation for anxiety management during MRI procedures, and examine the efficacy of IVR game preparation compared with usual care for the management of procedural anxiety during MRI scans. Methods: This study will have 2 phases. We will first conduct a field test with 10 participants aged 7 to 17 years to develop a predictive algorithm for biofeedback solution and to address the feasibility and acceptability of the research. After the field test, a randomized controlled trial will be completed using a parallel design with 2 groups: an experimental group (preprocedural IVR game preparation) and a usual care group (standard care as per the radiology department’s protocol) in an equal ratio of 49 participants per group for 98 participants. Recruitment will be carried out at a hospital in Quebec, Canada. The experimental group will receive a preprocedural IVR game preparation (IMAGINE) that offers an immersive simulation of the MRI scan. Participants will complete a questionnaire to assess the acceptability, feasibility, and incidence of side effects related to the intervention and the biofeedback device. Data collected will include sociodemographic and clinical characteristics as well as measures of procedure-related anxiety with the French-Canadian version of the State-Trait Anxiety Inventory for Children (score 1-3) and the Children’s Fear Scale (score 0-4). Physiological signs will be noted and include heart rate, skin conductance, hand temperature, and muscle tension. Measures of the level of satisfaction of health care professionals, parents, and participants will also be collected. Analyses will be carried out according to the intention-to-treat principle, with a Cronbach α significance level of .05. Results: As of May 10, 2022, no participant was enrolled in the clinical trial. The data collection time frame is projected to be between April 1, 2022, and March 31, 2023. Findings will be disseminated through peer-reviewed publications. Conclusions: Our study provides an alternative method for anxiety management to better prepare patients for an awake MRI procedure. The biofeedback will help predict which children are more responsive to this type of intervention. This study will guide future medical practice by providing evidence-based knowledge on a nonpharmacological therapeutic modality for anxiety management in children scheduled for an MRI scan. Trial Registration: ClinicalTrials.gov NCT04988516; https://clinicaltrials.gov/ct2/show/NCT04988516 International Registered Report Identifier (IRRID): PRR1-10.2196/30616 %M 35700000 %R 10.2196/30616 %U https://www.researchprotocols.org/2022/6/e30616 %U https://doi.org/10.2196/30616 %U http://www.ncbi.nlm.nih.gov/pubmed/35700000 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 6 %P e36843 %T Cybersickness Variability by Race: Findings From 6 Studies and a Mini Meta-analysis %A Martingano,Alison Jane %A Brown,Ellenor %A Telaak,Sydney H %A Dolwick,Alexander P %A Persky,Susan %+ Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, 31 Center Drive, B1B36, Bethesda, MD, 20892, United States, 1 3014430098, perskys@mail.nih.gov %K cybersickness %K racial differences %K virtual reality %K head-mounted displays %K simulator sickness %D 2022 %7 1.6.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: With the influx of medical virtual reality (VR) technologies, cybersickness has transitioned from a nuisance experienced during leisure activities to a potential safety and efficacy concern for patients and clinicians. To improve health equity, it is important to understand any potential differences in cybersickness propensity among demographic groups, including racial groups. Objective: This study aims to explore whether cybersickness propensity differs across racial groups. Methods: We collected self-reported cybersickness ratings from 6 racially diverse independent samples within 1 laboratory group (N=931). In these studies, the participants were asked to perform tasks in VR such as traversing environments, pointing at and selecting objects, and interacting with virtual humans. Results: Significant racial differences in cybersickness were found in 50% (3/6) of studies. A mini meta-analysis revealed that, on average, Black participants reported approximately one-third of SD less cybersickness than White participants (Cohen d=−0.31; P<.001), regardless of the nature of the VR experience. There was no overall difference in reported cybersickness between the Asian and White participants (Cohen d=−0.11; P=.51). Conclusions: Racial differences in cybersickness indicate that researchers, practitioners, and regulators should consider patient demographics when evaluating VR health intervention outcomes. These findings lay the groundwork for future studies that may explore racial differences in cybersickness directly. %M 35648477 %R 10.2196/36843 %U https://www.jmir.org/2022/6/e36843 %U https://doi.org/10.2196/36843 %U http://www.ncbi.nlm.nih.gov/pubmed/35648477 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e35099 %T Innovative Technology–Based Interventions to Reduce Stigma Toward People With Mental Illness: Systematic Review and Meta-analysis %A Rodríguez-Rivas,Matías E %A Cangas,Adolfo J %A Cariola,Laura A %A Varela,Jorge J %A Valdebenito,Sara %+ Facultad de Psicología, Universidad del Desarrollo, Avenida Plaza 680, Santiago, Chile, 56 223279110, matrodriguezr@udd.cl %K stigma %K mental illness %K technology-based %K serious games %K virtual reality %K e-contact %K simulation intervention %K internet intervention %K meta-analysis %D 2022 %7 30.5.2022 %9 Review %J JMIR Serious Games %G English %X Background: Stigma toward people with mental illness presents serious consequences for the impacted individuals, such as social exclusion and increased difficulties in the recovery process. Recently, several interventions have been developed to mitigate public stigma, based on the use of innovative technologies, such as virtual reality and video games. Objective: This review aims to systematically review, synthesize, measure, and critically discuss experimental studies that measure the effect of technological interventions on stigmatization levels. Methods: This systematic review and meta-analysis was based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and included studies in English and Spanish published between 2016 and 2021. Searches were run in 5 different databases (ie, PubMed, PsycInfo, Scopus, Cochrane Library, and ScienceDirect). Only randomized controlled trials were included. Two independent reviewers determined the eligibility, extracted data, and rated methodological quality of the studies. Meta-analyses were performed using the Comprehensive Meta-Analysis software. Results: Based on the 1158 articles screened, 72 articles were evaluated as full text, of which 9 were included in the qualitative and quantitative syntheses. A diversity of interventions was observed, including video games, audiovisual simulation of hallucinations, virtual reality, and electronic contact with mental health services users. The meta-analysis (n=1832 participants) demonstrated that these interventions had a consistent medium effect on reducing the level of public stigma (d=–0.64; 95% CI 0.31-0.96; P<.001). Conclusions: Innovative interventions involving the use of technologies are an effective tool in stigma reduction, therefore new challenges are proposed and discussed for the demonstration of their adaptability to different contexts and countries, thus leading to their massification. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021261935; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021261935 %M 35635744 %R 10.2196/35099 %U https://games.jmir.org/2022/2/e35099 %U https://doi.org/10.2196/35099 %U http://www.ncbi.nlm.nih.gov/pubmed/35635744 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 5 %P e37480 %T Durability of the Treatment Effects of an 8-Week Self-administered Home-Based Virtual Reality Program for Chronic Low Back Pain: 6-Month Follow-up Study of a Randomized Clinical Trial %A Garcia,Laura %A Birckhead,Brandon %A Krishnamurthy,Parthasarathy %A Mackey,Ian %A Sackman,Josh %A Salmasi,Vafi %A Louis,Robert %A Castro,Carina %A Maddox,Roselani %A Maddox,Todd %A Darnall,Beth D %+ AppliedVR, 16760 Stagg St, Suite 216, Van Nuys, CA, 91406, United States, 1 5129478494, tmaddox@appliedvr.io %K behavioral health %K chronic low back pain %K treatment %K virtual reality %D 2022 %7 25.5.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: We previously reported the efficacy of an 8-week home-based therapeutic immersive virtual reality (VR) program in a double-blind randomized placebo-controlled study. Community-based adults with self-reported chronic low back pain were randomized 1:1 to receive either (1) a 56-day immersive therapeutic pain relief skills VR program (EaseVRx) or (2) a 56-day sham VR program. Immediate posttreatment results revealed the superiority of therapeutic VR over sham VR for reducing pain intensity; pain-related interference with activity, mood, and stress (but not sleep); physical function; and sleep disturbance. At 3 months posttreatment, therapeutic VR maintained superiority for reducing pain intensity and pain-related interference with activity, stress, and sleep (new finding). Objective: This study assessed between-group and within-group treatment effects 6 months posttreatment to determine the extended efficacy, magnitude of efficacy, and clinical importance of home-based therapeutic VR. Methods: E-surveys were deployed at pretreatment, end-of-treatment, and posttreatment months 1, 2, 3, and 6. Self-reported data for 188 participants were analyzed in a mixed-model framework using a marginal model to allow for correlated responses across the repeated measures. Primary outcomes were pain intensity and pain-related interference with activity, mood, stress, and sleep at 6 months posttreatment. Secondary outcomes were Patient-Reported Outcome Measurement Information System (PROMIS) sleep disturbance and physical function. Results: Therapeutic VR maintained significant and clinically meaningful effects 6 months posttreatment and remained superior to sham VR for reducing pain intensity and pain-related interference with activity, stress, and sleep (ds=0.44-0.54; P<.003). Between-group comparisons for physical function and sleep disturbance showed superiority of EaseVRx over sham VR (ds=0.34; P=.02 and ds=0.46; P<.001, respectively). Participants were encouraged to contact study staff with any problems experienced during treatment; however, no participants contacted study staff to report adverse events of any type, including nausea and motion sickness. Conclusions: Our 8-week home-based VR pain management program caused important reductions in pain intensity and interference up to 6 months after treatment. Additional studies are needed in diverse samples. Trial Registration: ClinicalTrials.gov NCT04415177; https://clinicaltrials.gov/ct2/show/NCT04415177 International Registered Report Identifier (IRRID): RR2-10.2196/25291 %M 35612905 %R 10.2196/37480 %U https://www.jmir.org/2022/5/e37480 %U https://doi.org/10.2196/37480 %U http://www.ncbi.nlm.nih.gov/pubmed/35612905 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e34884 %T Effects of Virtual Reality–Based Multimodal Audio-Tactile Cueing in Patients With Spatial Attention Deficits: Pilot Usability Study %A Knobel,Samuel Elia Johannes %A Kaufmann,Brigitte Charlotte %A Geiser,Nora %A Gerber,Stephan Moreno %A Müri,René M %A Nef,Tobias %A Nyffeler,Thomas %A Cazzoli,Dario %+ Neurocenter, Luzerner Kantonsspital, Spitalstrasse, Luzern, 6004, Switzerland, 41 205 56 86, dario.cazzoli@luks.ch %K virtual reality %K search task %K stroke %K neglect, multimodal cueing %K bird search task %D 2022 %7 25.5.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) devices are increasingly being used in medicine and other areas for a broad spectrum of applications. One of the possible applications of VR involves the creation of an environment manipulated in a way that helps patients with disturbances in the spatial allocation of visual attention (so-called hemispatial neglect). One approach to ameliorate neglect is to apply cross-modal cues (ie, cues in sensory modalities other than the visual one, eg, auditory and tactile) to guide visual attention toward the neglected space. So far, no study has investigated the effects of audio-tactile cues in VR on the spatial deployment of visual attention in neglect patients. Objective: This pilot study aimed to investigate the feasibility and usability of multimodal (audio-tactile) cueing, as implemented in a 3D VR setting, in patients with neglect, and obtain preliminary results concerning the effects of different types of cues on visual attention allocation compared with noncued conditions. Methods: Patients were placed in a virtual environment using a head-mounted display (HMD). The inlay of the HMD was equipped to deliver tactile feedback to the forehead. The task was to find and flag appearing birds. The birds could appear at 4 different presentation angles (lateral and paracentral on the left and right sides), and with (auditory, tactile, or audio-tactile cue) or without (no cue) a spatially meaningful cue. The task usability and feasibility, and 2 simple in-task measures (performance and early orientation) were assessed in 12 right-hemispheric stroke patients with neglect (5 with and 7 without additional somatosensory impairment). Results: The new VR setup showed high usability (mean score 10.2, SD 1.85; maximum score 12) and no relevant side effects (mean score 0.833, SD 0.834; maximum score 21). A repeated measures ANOVA on task performance data, with presentation angle, cue type, and group as factors, revealed a significant main effect of cue type (F30,3=9.863; P<.001) and a significant 3-way interaction (F90,9=2.057; P=.04). Post-hoc analyses revealed that among patients without somatosensory impairment, any cue led to better performance compared with no cue, for targets on the left side, and audio-tactile cues did not seem to have additive effects. Among patients with somatosensory impairment, performance was better with both auditory and audio-tactile cueing than with no cue, at every presentation angle; conversely, tactile cueing alone had no significant effect at any presentation angle. Analysis of early orientation data showed that any type of cue triggered better orientation in both groups for lateral presentation angles, possibly reflecting an early alerting effect. Conclusions: Overall, audio-tactile cueing seems to be a promising method to guide patient attention. For instance, in the future, it could be used as an add-on method that supports attentional orientation during established therapeutic approaches. %M 35612894 %R 10.2196/34884 %U https://games.jmir.org/2022/2/e34884 %U https://doi.org/10.2196/34884 %U http://www.ncbi.nlm.nih.gov/pubmed/35612894 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 5 %P e34120 %T Implementation of Virtual Reality to Parent-Child Interaction Therapy for Enhancement of Positive Parenting Skills: Study Protocol for Single-Case Experimental Design With Multiple Baselines %A Scherpbier,Iza C A %A Abrahamse,Mariëlle E %A Belleman,Robert G %A Popma,Arne %A Lindauer,Ramón J L %+ Amsterdam UMC Location University of Amsterdam, Child and Adolescent Psychiatry, Meibergdreef 9, Amsterdam, 1105 AZ, Netherlands, 31 020 890 1000, i.c.a.scherpbier@amsterdamumc.nl %K PCIT %K virtual reality %K single-case experimental design %K positive parenting skills %K disruptive behavioral problems %K parenting %K child %K disruptive behavior %K behavioral %K mental health %K mobile phone %D 2022 %7 20.5.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Disruptive behavior is a common reason for young children to be referred to mental health care services worldwide. Research indicates that treatments for child disruptive behavior where parents are the primary agents of change are most impactful. Parent-Child Interaction Therapy (PCIT) is an effective parent management training program currently implemented in therapeutic settings within the Netherlands. Ongoing research into improving the effectiveness of PCIT is being done within these settings. To further promote the key elements of PCIT, this study focuses on creating the opportunity for parents to practice positive parenting skills more outside of the clinical setting by adding virtual reality (VR) as an additional homework element. PCIT has shown to make impactful long-term improvements in parental warmth, responsiveness, and the parent-child relationship. Through VR, parents practice the taught parenting skills out loud in the comfort of their own homes in VR scenarios. We expect that VR addition will innovatively increase the effectiveness of PCIT. Objective: This study aimed to evaluate the added value of VR to PCIT by using a multiple baseline single-case experimental design (SCED). We expect to find that PCIT-VR will ameliorate positive parenting skills. By implementing the VR element, we secondarily expected that meeting the skill criteria will be achieved sooner, treatment completion rates will increase, and the parent-child relationship will be better, whereas parental stress and child disruptive behavior will decrease. Methods: A total of 15 children (aged 2-7 years) with disruptive behavior and their parents will be followed throughout the PCIT-VR treatment. Using a multiple baseline SCED with 3 phases, 15 families will fill out questionnaires weekly, in addition to having pre- and posttreatment and follow-up measurements to monitor their positive parenting skills, child disruptive behavior, parenting stress, and VR progress. Moreover, quantitative information and qualitative interviews will be analyzed visually and statistically and summarized to provide a complete picture of experiences. Results: As of February 2021, 6 families have been enrolled in the study at the moment of submission. Data collection is projected to be completed in 2023. Quantitative and qualitative results are planned to be published in peer-reviewed journals, as well as being presented at national and international conferences. Conclusions: The SCED—with its phased design, randomization, and the opportunity to replicate and assess both individual and group treatment effects—and adaptability of the VR technology are the strengths of the study. The risks of increased type I errors, maturation effects, or technological failure will be mitigated with the right statistical support. This study aims to magnify the scope of the treatment through additional skill training, ultimately in support of routinely implementing VR within PCIT. International Registered Report Identifier (IRRID): DERR1-10.2196/34120 %M 35594138 %R 10.2196/34120 %U https://www.researchprotocols.org/2022/5/e34120 %U https://doi.org/10.2196/34120 %U http://www.ncbi.nlm.nih.gov/pubmed/35594138 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 5 %P e33555 %T The Effects of a Virtual Reality–Based Training Program for Adolescents With Disruptive Behavior Problems on Cognitive Distortions and Treatment Motivation: Protocol for a Multiple Baseline Single-Case Experimental Design %A Klein Schaarsberg,Renée E %A Popma,Arne %A Lindauer,Ramón J L %A van Dam,Levi %+ Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam UMC location Vrije Universiteit Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, Netherlands, 31 0208901000, r.e.kleinschaarsberg@amsterdamumc.nl %K treatment motivation %K cognitive distortions %K reflective functioning %K disruptive behavior problems %K adolescence %K virtual reality %K single-case experimental design %D 2022 %7 20.5.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Serious disruptive behavior among adolescents is a prevalent and often persistent problem. This highlights the importance of adequate and effective treatment to help adolescents with disruptive behavior problems react less hostile and aggressive. In order to create a treatment environment in which behavioral change can be enhanced, treatment motivation plays an essential role. Regarding treatment itself, a focus on challenging self-serving cognitive distortions in order to achieve behavioral change is important. Street Temptations (ST) is a new training program that was developed to address both treatment motivation and cognitive distortions in adolescents with disruptive behavior problems. One of the innovative aspects of ST is the use of virtual reality (VR) techniques to provide adolescents during treatment with visually presented daily social scenarios to activate emotional engagement and dysfunctional cognitions. By using the VR scenarios as an integral starting point of ST’s sessions and transferring the power of the VR experience into playful and dynamic exercises to practice social perspective–taking, adolescents are encouraged to reflect on both their own behavior and that of others. This focus on reflection is grounded in ST’s main treatment mechanism to influence treatment motivation and cognitive distortions, namely, mentalizing (ie, reflective functioning). Objective: The aim of this study is to describe the research protocol to evaluate the effects of ST on treatment motivation and cognitive distortions. We take a closer look at the use of ST and the methodology used, namely, the repeated single-case experimental design (SCED). Methods: The effects of ST are studied through a multiple baseline SCED, using both quantitative and qualitative data. In total, 18 adolescents from secure residential youth care facilities and secondary special education schools are randomly assigned to 1 of the 3 different baseline conditions. Throughout the baseline phase (1, 2, or 3 weeks), intervention phase (4 weeks), and follow-up phase (1, 2, or 3 weeks), daily measurements on treatment motivation and cognitive distortions are conducted. Secondary study parameters are assessed before baseline, after intervention, and after follow-up. Qualitative data are collected after intervention, as well as at 3 months and 6 months after the intervention. Results: Data collection for this study started in November 2021 and is planned to be completed by August 2023. The results will be published in peer-reviewed journals and presented at national and international conferences. Conclusions: ST aims to improve the disruptive behavior problems of adolescents. This study will be the first to gain insights into the effectiveness of ST. The strengths of this study include its thorough and individually focused design (SCED), the focus on a residential as well as a secondary special education setting, and the ecological validity. The implications for practice are discussed. Trial Registration: Central Committee on Research Involving Human Subjects NL75545.029.20. Netherlands Trial Register NL9639; https://www.trialregister.nl/trial/9639 International Registered Report Identifier (IRRID): PRR1-10.2196/33555 %M 35594071 %R 10.2196/33555 %U https://www.researchprotocols.org/2022/5/e33555 %U https://doi.org/10.2196/33555 %U http://www.ncbi.nlm.nih.gov/pubmed/35594071 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 5 %P e38348 %T Cardiovascular Disease Prevention Education Using a Virtual Environment in Sexual-Minority Men of Color With HIV: Protocol for a Sequential, Mixed Method, Waitlist Randomized Controlled Trial %A Ramos,S Raquel %A Johnson,Constance %A Melkus,Gail %A Kershaw,Trace %A Gwadz,Marya %A Reynolds,Harmony %A Vorderstrasse,Allison %+ School of Nursing, Yale University, 400 West Campus Drive, Orange, CT, 06477, United States, 1 203 737 2339, raquel.ramos@yale.edu %K virtual environment %K behavioral intervention %K consumer health informatics %K HIV %K cardiovascular disease %K sexual minority men %K prevention education %K gamification %K health communication %D 2022 %7 17.5.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: It is estimated that 70% of all deaths each year in the United States are due to chronic conditions. Cardiovascular disease (CVD), a chronic condition, is the leading cause of death in ethnic and racial minority males. It has been identified as the second most common cause of death in persons with HIV. By the year 2030, it is estimated that 78% of persons with HIV will be diagnosed with CVD. Objective: We propose the first technology-based virtual environment intervention to address behavioral, modifiable risk factors associated with cardiovascular and metabolic comorbidities in sexual-minority men of color with HIV. Methods: This study will be guided using social cognitive theory and the Technology Acceptance Model. A sequential, mixed method, waitlist controlled randomized control feasibility trial will be conducted. Aim 1 is to qualitatively explore perceptions of cardiovascular risk in 15 participants. Aim 2 is to conduct a waitlist controlled comparison to test if a virtual environment is feasible and acceptable for CVD prevention, based on web-based, self-assessed, behavioral, and psychosocial outcomes in 80 sexual-minority men of color with HIV. Results: The study was approved by the New York University Institutional Review Board in 2019, University of Texas Health Science Center at Houston in 2020, and by the Yale University Institutional Review Board in February 2022. As of April 2022, aim 1 data collection is 87% completed. We expect to complete data collection for aim 1 by April 30, 2022. Recruitment for aim 2 will begin mid-May 2022. Conclusions: This study will be the first online virtual environment intervention for CVD prevention in sexual-minority men of color with HIV. We anticipate that the intervention will be beneficial for CVD prevention education and building peer social supports, resulting in change or modification over time in risk behaviors for CVD. Trial Registration: ClinicalTrials.gov NCT05242952; https://clinicaltrials.gov/ct2/show/NCT05242952 International Registered Report Identifier (IRRID): PRR1-10.2196/38348 %M 35579928 %R 10.2196/38348 %U https://www.researchprotocols.org/2022/5/e38348 %U https://doi.org/10.2196/38348 %U http://www.ncbi.nlm.nih.gov/pubmed/35579928 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e35159 %T Digital Health Interventions for Delivery of Mental Health Care: Systematic and Comprehensive Meta-Review %A Philippe,Tristan J %A Sikder,Naureen %A Jackson,Anna %A Koblanski,Maya E %A Liow,Eric %A Pilarinos,Andreas %A Vasarhelyi,Krisztina %+ Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada, 1 604 875 4111 ext 64710, Krisztina.Vasarhelyi@vch.ca %K digital health %K telepsychology %K computer-assisted therapy %K online therapy %K mobile applications %K mobile apps %K telemedicine %K telepsychiatry %K virtual reality exposure therapy %K mental health %K COVID-19 %D 2022 %7 12.5.2022 %9 Review %J JMIR Ment Health %G English %X Background: The COVID-19 pandemic has shifted mental health care delivery to digital platforms, videoconferencing, and other mobile communications. However, existing reviews of digital health interventions are narrow in scope and focus on a limited number of mental health conditions. Objective: To address this gap, we conducted a comprehensive systematic meta-review of the literature to assess the state of digital health interventions for the treatment of mental health conditions. Methods: We searched MEDLINE for secondary literature published between 2010 and 2021 on the use, efficacy, and appropriateness of digital health interventions for the delivery of mental health care. Results: Of the 3022 records identified, 466 proceeded to full-text review and 304 met the criteria for inclusion in this study. A majority (52%) of research involved the treatment of substance use disorders, 29% focused on mood, anxiety, and traumatic stress disorders, and >5% for each remaining mental health conditions. Synchronous and asynchronous communication, computerized therapy, and cognitive training appear to be effective but require further examination in understudied mental health conditions. Similarly, virtual reality, mobile apps, social media platforms, and web-based forums are novel technologies that have the potential to improve mental health but require higher quality evidence. Conclusions: Digital health interventions offer promise in the treatment of mental health conditions. In the context of the COVID-19 pandemic, digital health interventions provide a safer alternative to face-to-face treatment. However, further research on the applications of digital interventions in understudied mental health conditions is needed. Additionally, evidence is needed on the effectiveness and appropriateness of digital health tools for patients who are marginalized and may lack access to digital health interventions. %M 35551058 %R 10.2196/35159 %U https://mental.jmir.org/2022/5/e35159 %U https://doi.org/10.2196/35159 %U http://www.ncbi.nlm.nih.gov/pubmed/35551058 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 5 %N 2 %P e35224 %T Virtual Reality Intervention for Managing Apathy in People With Cognitive Impairment: Systematic Review %A Ho,Ka Ying %A Cheung,Po Mang %A Cheng,Tap Wing %A Suen,Wing Yin %A Ho,Hiu Ying %A Cheung,Daphne Sze Ki %+ School of Nursing, The Hong Kong Polytechinc University, Room GH526, Hung Hom, Kowloon, Hong Kong, Hong Kong, 852 27664534, daphne.cheung@polyu.edu.hk %K virtual reality %K apathy %K cognitive impairment %K dementia %K systematic review %D 2022 %7 11.5.2022 %9 Review %J JMIR Aging %G English %X Background: Apathy is common in people with cognitive impairment. It leads to different consequences, such as more severe cognitive deficits, rapid functional decline, and decreased quality of life. Virtual reality (VR) interventions are increasingly being used to manage apathy in individuals with cognitive impairment. However, reports of VR interventions are scattered across studies, which has hindered the development and use of the interventions. Objective: This study aimed to systematically review existing evidence on the use of VR interventions for managing apathy in people with cognitive impairment with regard to the effectiveness, contents, and implementation of the interventions. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. The PubMed, Embase, CINAHL, and PsycINFO databases were systematically searched for experimental studies published up to March 13, 2022, that reported the effects of VR interventions on apathy in older adults with cognitive impairment. Hand searching and citation chasing were conducted. The results of the included studies were synthesized by using a narrative synthesis. Their quality was appraised by using the Effective Public Health Practice Project quality assessment tool. However, because the VR interventions varied in duration, content, and implementation across studies, a meta-analysis was not conducted. Results: A total of 22 studies were identified from the databases, of which 6 (27%) met the inclusion criteria. Of these 6 studies, 2 (33%) were randomized controlled trials, 1 (17%) was a controlled clinical trial, and 3 (50%) were quasi-experimental studies. Individual studies showed significant improvement in apathy and yielded within-group medium to large effect sizes. The level of immersion ranged from low to high. Minor adverse effects were reported. The VR content mostly included natural scenes, followed by city views and game-based activities. A background soundtrack was often used with natural scenes. Most (5/6, 83%) of the studies were conducted in a residential care setting and were implemented by health care professionals or researchers. Safety precautions were taken in most (5/6, 83%) of the studies. Conclusions: Although preliminary evidence shows that VR interventions may be effective and feasible for alleviating apathy in people with cognitive impairment, the methodological limitations in the included studies make it difficult to reach a firm conclusion on these points. The implementation of the interventions was highlighted and discussed. More rigorous studies are encouraged. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021268289; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021268289 %M 35544317 %R 10.2196/35224 %U https://aging.jmir.org/2022/2/e35224 %U https://doi.org/10.2196/35224 %U http://www.ncbi.nlm.nih.gov/pubmed/35544317 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e34402 %T Virtual Reality Applications in Chronic Pain Management: Systematic Review and Meta-analysis %A Goudman,Lisa %A Jansen,Julie %A Billot,Maxime %A Vets,Nieke %A De Smedt,Ann %A Roulaud,Manuel %A Rigoard,Philippe %A Moens,Maarten %+ STIMULUS, Vrije Universiteit Brussel, Laarbeeklaan 103, Jette, 1090, Belgium, 32 2477 5514, lisa.goudman@gmail.com %K virtual reality %K chronic pain %K systematic review %K multilevel meta-analysis %K immersive technologies %K clinical outcomes %K mobile phone %D 2022 %7 10.5.2022 %9 Review %J JMIR Serious Games %G English %X Background: Virtual reality (VR) is a computer technology that immerses a user in a completely different reality. The application of VR in acute pain settings is well established. However, in chronic pain, the applications and outcome parameters influenced by VR are less clear. Objective: This review aimed to systematically identify all outcome parameters that are reported in relation to VR in patients with chronic pain. Methods: A total of 4 electronic databases (PubMed, Scopus, Web of Science, and Embase) were searched for relevant studies. Multilevel random-effect meta-analyses were performed, whereby the standardized mean difference was chosen as the effect size to denote the difference between measurements before and after a VR intervention. Results: The initial database search identified 1430 studies, of which 41 (2.87%) were eventually included in the systematic review. Evidence has been found for the effects of VR on pain, functioning, mobility, functional capacity, psychological outcomes, quality of life, neuropsychological outcomes, and physical sensations. The overall effect size (a total of 194 effect sizes from 25 studies) based on a three level meta-analysis was estimated at 1.22 (95% CI 0.55-1.89; z=3.56; P<.001), in favor of improvements after a VR intervention. When categorizing effect sizes, the overall effect sizes were reported as follows: 1.60 (95% CI 0.83-2.36; z=4.09; P<.001) for the effect of VR on pain (n=31), 1.40 (95% CI 0.13-2.67; z=2.17; P=.03) for functioning (n=60), 0.49 (95% CI −0.71 to 1.68; z=0.80; P=.42) for mobility (n=24), and 0.34 (95% CI −1.52 to 2.20; z=0.36; P=.72) for functional capacity (n=21). Conclusions: This systematic review revealed a broad range of outcome variables influenced by an intervention of VR technology, with statistically significant pain relief and improvements in functioning. These findings indicate that VR not only has applications in acute pain management but also in chronic pain settings, whereby VR might be able to become a promising first-line intervention as complementary therapy for patients with chronic pain. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021227016; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=227016 %M 35536641 %R 10.2196/34402 %U https://games.jmir.org/2022/2/e34402 %U https://doi.org/10.2196/34402 %U http://www.ncbi.nlm.nih.gov/pubmed/35536641 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 5 %P e35526 %T Virtual Reality Behavioral Activation for Adults With Major Depressive Disorder: Feasibility Randomized Controlled Trial %A Paul,Margot %A Bullock,Kim %A Bailenson,Jeremy %+ PGSP-Stanford PsyD Consortium, Palo Alto University, 1791 Arastradero Rd, Palo Alto, CA, 94304, United States, 1 800 818 6136, mdpaul@stanford.edu %K virtual reality %K major depressive disorder %K behavioral activation %K depression %D 2022 %7 6.5.2022 %9 Original Paper %J JMIR Ment Health %G English %X Background: Major depressive disorder (MDD) is a global crisis with increasing incidence and prevalence. There are many established evidence-based psychotherapies (EBPs) for depression, but numerous barriers still exist; most notably, access and dissemination. Virtual reality (VR) may offer some solutions to existing constraints of EBPs for MDD. Objective: We aimed to examine the feasibility, acceptability, and tolerability of using VR as a method of delivering behavioral activation (BA) for adults diagnosed with MDD during a global pandemic and to explore for signs of clinical efficacy by comparing VR-enhanced BA (VR BA) to a standard BA treatment and a treatment as usual control group for individuals diagnosed with MDD. Methods: A feasibility trial using a 3-armed, unblinded, randomized controlled pilot design was conducted. The study took place remotely via Zoom telehealth visits between April 8, 2020, and January 15, 2021. This study used a 3-week, 4-session protocol in which VR BA participants used a VR headset to complete their BA homework. Feasibility was measured using dropout rates, serious adverse events, completion of homework, an adapted telepresence scale, the Simulator Sickness Questionnaire, the Brief Agitation Measure, and an adapted Technology Acceptance Model. Efficacy was assessed using the Patient Health Questionnaire–9. Results: Of the 35 participants assessed for eligibility, 13 (37%) were randomized into VR BA (n=5, 38%), traditional BA (n=4, 31%), or a treatment as usual control (n=4, 31%). The mean age of the 13 participants (5/13, 38% male; 7/13, 54% female; and 1/13, 8% nonbinary or third gender) was 35.4 (SD 12.3) years. This study demonstrated VR BA feasibility in participants with MDD through documented high levels of acceptability and tolerability while engaging in VR-induced pleasurable activities in conjunction with a brief BA protocol. No adverse events were reported. This study also illustrated that VR BA may have potential clinical utility for treating MDD, as the average VR BA participant’s clinical severity decreased by 5.67 points, signifying a clinically meaningful change in severity from a moderate to a mild level of depression as per the Patient Health Questionnaire–9 score. Conclusions: The findings of this study demonstrate that VR BA is safe and feasible to explore for the treatment of MDD. This study documented evidence that VR BA may be efficacious and justifies further examination in an adequately powered randomized controlled trial. This pilot study highlights the potential utility that VR technology may offer patients with MDD, especially those who have difficulty accessing real-world pleasant activities. In addition, for those having difficulty accessing care, VR BA could be adapted as a first step to help people improve their mood and increase their motivation while waiting to connect with a health care professional for other EBPs. Trial Registration: ClinicalTrials.gov NCT04268316; https://clinicaltrials.gov/ct2/show/NCT04268316 International Registered Report Identifier (IRRID): RR2-10.2196/24331 %M 35404830 %R 10.2196/35526 %U https://mental.jmir.org/2022/5/e35526 %U https://doi.org/10.2196/35526 %U http://www.ncbi.nlm.nih.gov/pubmed/35404830 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 8 %N 2 %P e32657 %T Perspectives of 360-Degree Cinematic Virtual Reality: Interview Study Among Health Care Professionals %A Beverly,Elizabeth %A Rigot,Brooke %A Love,Carrie %A Love,Matt %+ Ohio University Heritage College of Osteopathic Medicine, 1 Ohio University, Irvine Hall 307, Athens, OH, 45701, United States, 1 740 593 4616, beverle1@ohio.edu %K virtual reality %K qualitative %K medical education %K health care %K digital learning %K learning platform %K health care providers %D 2022 %7 29.4.2022 %9 Original Paper %J JMIR Med Educ %G English %X Background: The global market for medical education is projected to increase exponentially over the next 5 years. A mode of delivery expected to drive the growth of this market is virtual reality (VR). VR simulates real-world objects, events, locations, and interactions in 3D multimedia sensory environments. It has been used successfully in medical education for surgical training, learning anatomy, and advancing drug discovery. New VR research has been used to simulate role-playing and clinical encounters; however, most of this research has been conducted with health professions students and not current health care professionals. Thus, more research is needed to explore how health care professionals experience VR with role-playing and clinical encounters. Objective: The aim of this study was to explore health care professionals’ experiences with a cinematic VR (cine-VR) training program focused on role-playing and clinical encounters addressing social determinants of health, Appalachian culture, and diabetes. Cine-VR leverages 360-degree video with the narrative storytelling of cinema to create an engaging educational experience. Methods: We conducted in-depth telephone interviews with health care professionals who participated in the cine-VR training. The interviews were audio recorded and transcribed verbatim. A multidisciplinary team coded and analyzed the data using content and thematic analyses with NVivo software. Results: We conducted 24 in-depth interviews with health care professionals (age=45.3, SD 11.3, years; n=16, 67%, women; n=22, 92%, White; and n=4, 17%, physicians) to explore their experiences with the cine-VR training. Qualitative analysis revealed five themes: immersed in the virtual world: seeing a 360-degree sphere allowed participants to immerse themselves in the virtual world; facilitated knowledge acquisition: all the participants accurately recalled the culture of Appalachia and listed the social determinants of health presented in the training; empathized with multiple perspectives: the cine-VR provided a glimpse into the real life of the main character, and participants described thinking about, feeling, and empathizing with the character’s frustrations and disappointments; perceived ease of use of cine-VR: 96% (23/24) of the participants described the cine-VR as easy to use, and they liked the 360-degree movement, image resolution, and sound quality but noted limitations with the buttons on the headsets and risk for motion sickness; and perceived utility of cine-VR as a teaching tool: participants described cine-VR as an effective teaching tool because it activated visual and affective learning for them. Conclusions: Participants emphasized the realism of the cine-VR training program. They attributed the utility of the cine-VR to visual learning in conjunction with the emotional connection to the VR characters. Furthermore, participants reported that the cine-VR increased their empathy for people. More research is needed to confirm an association between the level of immersion and empathy in cine-VR training for health care professionals. %M 35486427 %R 10.2196/32657 %U https://mededu.jmir.org/2022/2/e32657 %U https://doi.org/10.2196/32657 %U http://www.ncbi.nlm.nih.gov/pubmed/35486427 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e35295 %T Impact of Visual Game-Like Features on Cognitive Performance in a Virtual Reality Working Memory Task: Within-Subjects Experiment %A Redlinger,Eric %A Glas,Bernhard %A Rong,Yang %+ Tokyo Institute of Technology, Institute of Innovative Research / Koike & Yoshimura Lab, 2-12-1-I3-20 Ookayama Campus, Tokyo, 152-8552, Japan, 81 3 5734 362, redlinger.e.aa@m.titech.ac.jp %K HMD %K working memory %K gamification %K cognitive training %K serious game %K game %K cognitive activity %K user performance %K visual memory %K cognitive %K user performance %K mobile phone %D 2022 %7 28.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although the pursuit of improved cognitive function through working memory training has been the subject of decades of research, the recent growth in commercial adaptations of classic working memory tasks in the form of gamified apps warrants additional scrutiny. In particular, the emergence of virtual reality as a platform for cognitive training presents opportunities for the use of novel visual features. Objective: This study aimed to add to the body of knowledge regarding the use of game-like visual design elements by specifically examining the application of two particular visual features common to virtual reality environments: immersive, colorful backgrounds and the use of 3D depth. In addition, electroencephalography (EEG) data were collected to identify potential neural correlates of any observed changes in performance. Methods: A simple visual working memory task was presented to participants in several game-like adaptations, including the use of colorful, immersive backgrounds and 3D depth. The impact of each adaptation was separately assessed using both EEG and performance assessment outcomes and compared with an unmodified version of the task. Results: Results suggest that although accuracy and reaction time may be slightly affected by the introduction of such game elements, the effects were small and not statistically significant. Changes in EEG power, particularly in the beta and theta rhythms, were significant but failed to correlate with any corresponding changes in performance. Therefore, they may only reflect cognitive changes at the perceptual level. Conclusions: Overall, the data suggest that the addition of these specific visual features to simple cognitive tasks does not appear to significantly affect performance or task-dependent cognitive load. %M 35482373 %R 10.2196/35295 %U https://games.jmir.org/2022/2/e35295 %U https://doi.org/10.2196/35295 %U http://www.ncbi.nlm.nih.gov/pubmed/35482373 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e34781 %T Augmented Reality-Based Surgery on the Human Cadaver Using a New Generation of Optical Head-Mounted Displays: Development and Feasibility Study %A Puladi,Behrus %A Ooms,Mark %A Bellgardt,Martin %A Cesov,Mark %A Lipprandt,Myriam %A Raith,Stefan %A Peters,Florian %A Möhlhenrich,Stephan Christian %A Prescher,Andreas %A Hölzle,Frank %A Kuhlen,Torsten Wolfgang %A Modabber,Ali %+ Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen, 52074, Germany, 49 241 80 88231, bpuladi@ukaachen.de %K digital health in surgery %K surgical technique %K surgical training %K computer-assisted surgery %K optical see-through head-mounted display %K HoloLens %K surgical navigation %K medical regulation %K open-source %K AR %K augmented reality %K surgery %K surgeon %K cadaver %K serious game %K head-mounted display %D 2022 %7 25.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although nearly one-third of the world’s disease burden requires surgical care, only a small proportion of digital health applications are directly used in the surgical field. In the coming decades, the application of augmented reality (AR) with a new generation of optical-see-through head-mounted displays (OST-HMDs) like the HoloLens (Microsoft Corp) has the potential to bring digital health into the surgical field. However, for the application to be performed on a living person, proof of performance must first be provided due to regulatory requirements. In this regard, cadaver studies could provide initial evidence. Objective: The goal of the research was to develop an open-source system for AR-based surgery on human cadavers using freely available technologies. Methods: We tested our system using an easy-to-understand scenario in which fractured zygomatic arches of the face had to be repositioned with visual and auditory feedback to the investigators using a HoloLens. Results were verified with postoperative imaging and assessed in a blinded fashion by 2 investigators. The developed system and scenario were qualitatively evaluated by consensus interview and individual questionnaires. Results: The development and implementation of our system was feasible and could be realized in the course of a cadaver study. The AR system was found helpful by the investigators for spatial perception in addition to the combination of visual as well as auditory feedback. The surgical end point could be determined metrically as well as by assessment. Conclusions: The development and application of an AR-based surgical system using freely available technologies to perform OST-HMD–guided surgical procedures in cadavers is feasible. Cadaver studies are suitable for OST-HMD–guided interventions to measure a surgical end point and provide an initial data foundation for future clinical trials. The availability of free systems for researchers could be helpful for a possible translation process from digital health to AR-based surgery using OST-HMDs in the operating theater via cadaver studies. %M 35468090 %R 10.2196/34781 %U https://games.jmir.org/2022/2/e34781 %U https://doi.org/10.2196/34781 %U http://www.ncbi.nlm.nih.gov/pubmed/35468090 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 5 %N 2 %P e32473 %T Voice-Enabled Intelligent Virtual Agents for People With Amnesia: Systematic Review %A Boumans,Roel %A van de Sande,Yana %A Thill,Serge %A Bosse,Tibor %+ Behavioural Science Institute, Radboud University, Thomas van Aquinostraat 4, Nijmegen, 6525 GD, Netherlands, 31 0622372708, roel.boumans@ru.nl %K intelligent virtual agent %K amnesia %K dementia %K Alzheimer %K systematic review %K mobile phone %D 2022 %7 25.4.2022 %9 Review %J JMIR Aging %G English %X Background: Older adults often have increasing memory problems (amnesia), and approximately 50 million people worldwide have dementia. This syndrome gradually affects a patient over a period of 10-20 years. Intelligent virtual agents may support people with amnesia. Objective: This study aims to identify state-of-the-art experimental studies with virtual agents on a screen capable of verbal dialogues with a target group of older adults with amnesia. Methods: We conducted a systematic search of PubMed, SCOPUS, Microsoft Academic, Google Scholar, Web of Science, and CrossRef on virtual agent and amnesia on papers that describe such experiments. Search criteria were (Virtual Agent OR Virtual Assistant OR Virtual Human OR Conversational Agent OR Virtual Coach OR Chatbot) AND (Amnesia OR Dementia OR Alzheimer OR Mild Cognitive Impairment). Risk of bias was evaluated using the QualSyst tool (University of Alberta), which scores 14 study quality items. Eligible studies are reported in a table including country, study design type, target sample size, controls, study aims, experiment population, intervention details, results, and an image of the agent. Results: A total of 8 studies was included in this meta-analysis. The average number of participants in the studies was 20 (SD 12). The verbal interactions were generally short. The usability was generally reported to be positive. The human utterance was seen in 7 (88%) out of 8 studies based on short words or phrases that were predefined in the agent’s speech recognition algorithm. The average study quality score was 0.69 (SD 0.08) on a scale of 0 to 1. Conclusions: The number of experimental studies on talking about virtual agents that support people with memory problems is still small. The details on the verbal interaction are limited, which makes it difficult to assess the quality of the interaction and the possible effects of confounding parameters. In addition, the derivation of the aggregated data was difficult. Further research with extended and prolonged dialogues is required. %M 35468084 %R 10.2196/32473 %U https://aging.jmir.org/2022/2/e32473 %U https://doi.org/10.2196/32473 %U http://www.ncbi.nlm.nih.gov/pubmed/35468084 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 6 %N 4 %P e33681 %T Technology Acceptance and Usability of a Virtual Reality Intervention for Military Members and Veterans With Posttraumatic Stress Disorder: Mixed Methods Unified Theory of Acceptance and Use of Technology Study %A Jones,Chelsea %A Miguel Cruz,Antonio %A Smith-MacDonald,Lorraine %A Brown,Matthew R G %A Vermetten,Eric %A Brémault-Phillips,Suzette %+ Heroes in Mind, Advocacy and Research Consortum, Faculty of Rehabilitation Medicine, University of Alberta, 1-94 Corbett Hall, 8205 - 114 Street, Edmonton, AB, T6G 2G4, Canada, 1 7804920404, cweiman@ualberta.ca %K PTSD %K UTAUT %K technology acceptance model %K trauma %K mental health %K therapy %K rehabilitation %K digital health %K psychotherapy %K military %K veteran %K psychotherapy %K 3MDR %K technology acceptability %K technology acceptance %K Canadian Armed Forces %K virtual reality %D 2022 %7 21.4.2022 %9 Original Paper %J JMIR Form Res %G English %X Background: Military members and veterans exhibit higher rates of injuries and illnesses such as posttraumatic stress disorder (PTSD) because of their increased exposure to combat and other traumatic scenarios. Novel treatments for PTSD are beginning to emerge and increasingly leverage advances in gaming and other technologies, such as virtual reality. Without assessing the degree of technology acceptance and perception of usability to the end users, including the military members, veterans, and their attending therapists and staff, it is difficult to determine whether a technology-based treatment will be used successfully in wider clinical practice. The Unified Theory of Acceptance and Use of Technology model is commonly used to address the technology acceptance and usability of applications in 5 domains. Objective: Using the Unified Theory of Acceptance and Use of Technology model, the purpose of this study was to determine the technology acceptance and usability of multimodal motion-assisted memory desensitization and reconsolidation (3MDR) on a virtual reality system in the primary user group (military members and veterans with treatment-resistant PTSD, 3MDR therapists, and virtual reality environment operators). Methods: This mixed methods embedded pilot study included military members (n=3) and veterans (n=8) with a diagnosis of combat-related PTSD, as well as their therapists (n=13) and operators (n=5) who completed pre-post questionnaires before and on completion of 6 weekly sessions of 3MDR. A partial least squares structural equation model was used to analyze the questionnaire results. Qualitative data from the interviews were assessed using thematic analysis. Results: Effort expectancy, which was the most notable predictor of behavioral intention, increased after a course of 3MDR with the virtual reality system, whereas all other constructs demonstrated no significant change. Participants’ expectations of the technology were met, as demonstrated by the nonsignificant differences in the pre-post scores. The key qualitative themes included feasibility and function, technical support, and tailored immersion. Conclusions: 3MDR via a virtual reality environment appears to be a feasible, usable, and accepted technology for delivering 3MDR to military members and veterans who experience PTSD and 3MDR therapists and operators who facilitate their treatment. %M 35451971 %R 10.2196/33681 %U https://formative.jmir.org/2022/4/e33681 %U https://doi.org/10.2196/33681 %U http://www.ncbi.nlm.nih.gov/pubmed/35451971 %0 Journal Article %@ 2563-6316 %I JMIR Publications %V 3 %N 2 %P e33502 %T Toward Human Digital Twins for Cybersecurity Simulations on the Metaverse: Ontological and Network Science Approach %A Nguyen,Tam N %+ Department of Management Information Systems, University of Arizona, 1130 E Helen St, PO Box 210108, Tucson, AZ, 85721-0108, United States, 1 970 404 1232, tamn@email.arizona.edu %K human behavior modeling %K cognitive twins %K human digital twins %K cybersecurity %K cognitive systems %K digital twins %K Metaverse %K artificial intelligence %D 2022 %7 20.4.2022 %9 Original Paper %J JMIRx Med %G English %X Background: Cyber defense is reactive and slow. On average, the time-to-remedy is hundreds of times larger than the time-to-compromise. In response, Human Digital Twins (HDTs) offer the capability of running massive simulations across multiple domains on the Metaverse. Simulated results may predict adversaries' behaviors and tactics, leading to more proactive cyber defense strategies. However, current HDTs’ cognitive architectures are underdeveloped for such use. Objective: This paper aims to make a case for extending the current digital cognitive architectures as the first step toward more robust HDTs that are suitable for realistic Metaverse cybersecurity simulations. Methods: This study formally documented 108 psychology constructs and thousands of related paths based on 20 time-tested psychology theories, all of which were packaged as Cybonto—a novel ontology. Then, this study applied 20 network science centrality algorithms in ranking the Cybonto psychology constructs by their influences. Results: Out of 108 psychology constructs, the top 10 are Behavior, Arousal, Goals, Perception, Self-efficacy, Circumstances, Evaluating, Behavior-Controllability, Knowledge, and Intentional Modality. In this list, only Behaviors, Goals, Perception, Evaluating, and Knowledge are parts of existing digital cognitive architectures. Notably, some of the constructs are not explicitly implemented. Early usability tests demonstrate that Cybonto can also be useful for immediate uses such as manual analysis of hackers’ behaviors and automatic analysis of behavioral cybersecurity knowledge texts. Conclusions: The results call for specific extensions of current digital cognitive architectures such as explicitly implementing more refined structures of Long-term Memory and Perception, placing a stronger focus on noncognitive yet influential constructs such as Arousal, and creating new capabilities for simulating, reasoning about, and selecting circumstances. %M 27666280 %R 10.2196/33502 %U https://med.jmirx.org/2022/2/e33502 %U https://doi.org/10.2196/33502 %U http://www.ncbi.nlm.nih.gov/pubmed/27666280 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 4 %P e30260 %T Distracting Through Procedural Pain and Distress Using Virtual Reality and Guided Imagery in Pediatric, Adolescent, and Young Adult Patients: Randomized Controlled Trial %A Hoag,Jennifer A %A Karst,Jeffrey %A Bingen,Kristin %A Palou-Torres,Akasha %A Yan,Ke %+ Division of Pediatric Psychology and Developmental Medicine, Department of Pediatrics, Medical College of Wisconsin, 8701 W Watertown Plank Road, MFRC 3018, Milwaukee, WI, 53226, United States, 1 414 955 5738, jhoag@mcw.edu %K virtual reality %K procedural %K pain %K anxiety %K pediatric %K guided imagery %D 2022 %7 18.4.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Children with acute and chronic illness undergo frequent, painful, and distressing procedures. Objective: This randomized controlled trial was used to evaluate the effectiveness of guided imagery (GI) versus virtual reality (VR) on the procedural pain and state anxiety of children and young adults undergoing unsedated procedures. We explored the role of trait anxiety and pain catastrophizing in intervention response. Methods: Children and young adults were recruited from the hematology, oncology, and blood and marrow transplant clinics at a children’s hospital. Each study participant completed the GI and VR intervention during separate but consecutive unsedated procedures. Self-report measures of pain and anxiety were completed before and after the procedures. Results: A total of 50 participants (median age 13 years) completed both interventions. GI and VR performed similarly in the management of procedural pain. Those with high pain catastrophizing reported experiencing less nervousness about pain during procedures that used VR than those using GI. State anxiety declined pre- to postprocedure in both interventions; however, the decrease reached the level of significance during the VR intervention only. Those with high trait anxiety had less pain during GI. Conclusions: In our sample, VR worked as well as GI to manage the pain and distress associated with common procedures experienced by children with acute or chronic illnesses. Children who are primed for pain based on beliefs about pain or because of their history of chronic pain had a better response to VR. GI was a better intervention for those with high trait anxiety. Trial Registration: ClinicalTrials.gov NCT04892160; https://clinicaltrials.gov/ct2/show/NCT04892160 %M 35436209 %R 10.2196/30260 %U https://www.jmir.org/2022/4/e30260 %U https://doi.org/10.2196/30260 %U http://www.ncbi.nlm.nih.gov/pubmed/35436209 %0 Journal Article %@ 2561-9128 %I JMIR Publications %V 5 %N 1 %P e35415 %T Assessing the Different Levels of Virtual Reality That Influence Anxiety, Behavior, and Oral Health Status in Preschool Children: Randomized Controlled Clinical Trial %A Aminabadi,Naser Asl %A Golsanamlou,Ozra %A Halimi,Zohreh %A Jamali,Zahra %+ Faculty of Dentistry, Tabriz University of Medical Sciences, Golgasht St, Tabriz, 5166746911, Iran, 98 9144157200, aslaminabadi@gmail.com %K virtual reality %K anxiety %K behavior %K oral health training %D 2022 %7 18.4.2022 %9 Original Paper %J JMIR Perioper Med %G English %X Background: Compared with a traditional behavior management strategy and oral health training, virtual reality (VR) integrated with multisensory feedback possesses potential advantages in dentistry. Objective: This study aimed to assess the impact of different levels of VR on anxiety, behavior, and oral health status. Methods: This study was carried out in the Department of Pediatric Dentistry at the Tabriz University of Medical Sciences from December 2020 to June 2021. We randomly assigned 60 healthy children aged 4 years to 6 years to 4 groups, each consisting of 15 children. The study consisted of 2 consecutive sessions. During the first visit, the plaque index was calculated, and oral health education was carried out in all groups using Immersive VR (group I), Semi-immersive VR (group II), Nonimmersive VR (group III), and tell-show-do (TSD; group IV). In the second session, an amalgam restoration was performed in all groups. Participants’ anxiety and behavior were recorded using the face version of the Modified Child Dental Anxiety Scale (MCDAS[f]) and Frankl scale. The plaque index was recorded in 2 follow-up sessions. Results: The greatest prevalence of positive behavior (P=.004) and the lowest anxiety (P<.001) were recorded in group I, followed by group II, group III, and group IV. The plaque index scores showed a reduced trend between the first session and follow-up sessions (P<.001), but the values did not differ significantly between the 4 groups during the 3 sessions (P=.28, P=.54, P=.18). Conclusions: The most positive behavior was observed in the Immersive VR group, followed by the Semi-immersive VR, Nonimmersive VR, and TSD groups. Moreover, oral health education using VR resources can improve oral health status in children. Trial Registration: Iranian Registry of Clinical Trials 20210103049926N1; https://www.irct.ir/trial/53475 %M 35436233 %R 10.2196/35415 %U https://periop.jmir.org/2022/1/e35415 %U https://doi.org/10.2196/35415 %U http://www.ncbi.nlm.nih.gov/pubmed/35436233 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e29594 %T Outcomes, Measurement Instruments, and Their Validity Evidence in Randomized Controlled Trials on Virtual, Augmented, and Mixed Reality in Undergraduate Medical Education: Systematic Mapping Review %A Tudor Car,Lorainne %A Kyaw,Bhone Myint %A Teo,Andrew %A Fox,Tatiana Erlikh %A Vimalesvaran,Sunitha %A Apfelbacher,Christian %A Kemp,Sandra %A Chavannes,Niels %+ Lee Kong Chian School of Medicine, Nanyang Technological University, Clinical Sciences Building, 11 Mandalay Road, Singapore, 308232, Singapore, 65 69041258, lorainne.tudor.car@ntu.edu.sg %K virtual reality %K augmented reality %K mixed reality %K outcomes %K extended reality %K digital education %K randomized controlled trials %K medical education %K measurement instruments %D 2022 %7 13.4.2022 %9 Review %J JMIR Serious Games %G English %X Background: Extended reality, which encompasses virtual reality (VR), augmented reality (AR), and mixed reality (MR), is increasingly used in medical education. Studies assessing the effectiveness of these new educational modalities should measure relevant outcomes using outcome measurement tools with validity evidence. Objective: Our aim is to determine the choice of outcomes, measurement instruments, and the use of measurement instruments with validity evidence in randomized controlled trials (RCTs) on the effectiveness of VR, AR, and MR in medical student education. Methods: We conducted a systematic mapping review. We searched 7 major bibliographic databases from January 1990 to April 2020, and 2 reviewers screened the citations and extracted data independently from the included studies. We report our findings in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Of the 126 retrieved RCTs, 115 (91.3%) were on VR and 11 (8.7%) were on AR. No RCT on MR in medical student education was found. Of the 115 studies on VR, 64 (55.6%) were on VR simulators, 30 (26.1%) on screen-based VR, 9 (7.8%) on VR patient simulations, and 12 (10.4%) on VR serious games. Most studies reported only a single outcome and immediate postintervention assessment data. Skills outcome was the most common outcome reported in studies on VR simulators (97%), VR patient simulations (100%), and AR (73%). Knowledge was the most common outcome reported in studies on screen-based VR (80%) and VR serious games (58%). Less common outcomes included participants’ attitudes, satisfaction, cognitive or mental load, learning efficacy, engagement or self-efficacy beliefs, emotional state, competency developed, and patient outcomes. At least one form of validity evidence was found in approximately half of the studies on VR simulators (55%), VR patient simulations (56%), VR serious games (58%), and AR (55%) and in a quarter of the studies on screen-based VR (27%). Most studies used assessment methods that were implemented in a nondigital format, such as paper-based written exercises or in-person assessments where examiners observed performance (72%). Conclusions: RCTs on VR and AR in medical education report a restricted range of outcomes, mostly skills and knowledge. The studies largely report immediate postintervention outcome data and use assessment methods that are in a nondigital format. Future RCTs should include a broader set of outcomes, report on the validity evidence of the measurement instruments used, and explore the use of assessments that are implemented digitally. %M 35416789 %R 10.2196/29594 %U https://games.jmir.org/2022/2/e29594 %U https://doi.org/10.2196/29594 %U http://www.ncbi.nlm.nih.gov/pubmed/35416789 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 5 %N 2 %P e31162 %T Technology-Mediated Enrichment in Aged Care: Survey and Interview Study %A Waycott,Jenny %A Zhao,Wei %A Kelly,Ryan M %A Robertson,Elena %+ School of Computing and Information Systems, The University of Melbourne, 700 Swanston Street, Melbourne, 3010, Australia, 61 383448964, jwaycott@unimelb.edu.au %K aged care %K older adults %K technology %K social enrichment %K virtual reality %K robots %K videoconferencing %K care providers %D 2022 %7 12.4.2022 %9 Original Paper %J JMIR Aging %G English %X Background: Digital technologies such as virtual reality (VR), humanoid robots, and digital companion pets have the potential to provide social and emotional enrichment for people living in aged care. However, there is currently limited knowledge about how technologies are being used to provide enrichment, what benefits they provide, and what challenges arise when deploying these technologies in aged care settings. Objective: This study aims to investigate how digital technologies are being used for social and emotional enrichment in the Australian aged care industry and identify the benefits and challenges of using technology for enrichment in aged care. Methods: A web-based survey (N=20) was distributed among people working in the Australian aged care sector. The survey collected information about the types of technologies being deployed and their perceived value. The survey was followed by semistructured interviews (N=12) with aged care workers and technology developers to investigate their experiences of deploying technologies with older adults living in aged care. Survey data were analyzed using summary descriptive statistics and categorizing open-ended text responses. Interview data were analyzed using reflexive thematic analysis. Results: The survey revealed that a range of commercial technologies, such as VR, tablet devices, and mobile phones, are being used in aged care to support social activities and provide entertainment. Respondents had differing views about the value of emerging technologies, such as VR, social robots, and robot pets, but were more united in their views about the value of videoconferencing. Interviews revealed 4 types of technology-mediated enrichment experiences: enhancing social engagement, virtually leaving the care home, reconnecting with personal interests, and providing entertainment and distraction. Our analysis identified 5 barriers: resource constraints, the need to select appropriate devices and apps, client challenges, limited staff and organizational support, and family resistance. Conclusions: This study demonstrates that technologies can be used in aged care to create personally meaningful enrichment experiences for aged care clients. To maximize the effectiveness of technology-mediated enrichment, we argue that a person-centered care approach is crucial. Although enrichment experiences can be created using available technologies, they must be carefully selected and co-deployed with aged care clients. However, significant changes may be required within organizations to allow caregivers to facilitate individual technology-based activities for enrichment. %M 34975014 %R 10.2196/31162 %U https://aging.jmir.org/2022/2/e31162 %U https://doi.org/10.2196/31162 %U http://www.ncbi.nlm.nih.gov/pubmed/34975014 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e34373 %T Using Virtual Reality to Improve Classroom Behavior in People With Down Syndrome: Within-Subjects Experimental Design %A Michalski,Stefan Carlo %A Szpak,Ancret %A Ellison,Caroline %A Cornish,Rowena %A Loetscher,Tobias %+ UniSA Justice and Society, University of South Australia, Magill Campus, GPO Box 2471, Adelaide, 5001, Australia, 61 088302 ext 2611, stefan.michalski@mymail.unisa.edu.au %K virtual reality %K Down syndrome %K intellectual disability %K drawing %K art %K behavior %K mood %K attention %K classroom %K self-report %D 2022 %7 7.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: People with Down syndrome face various learning challenges. Introducing new and enjoyable experiences in learning settings may improve learning outcomes. Immersive and interactive technologies such as virtual reality can be used to deliver rich visual experiences in classrooms. Objective: The aim of this study was to investigate the feasibility and benefits of virtual reality exposure for people with Down syndrome in learning settings. Methods: To address this aim, we used a within-subjects design to assess the effect of a brief virtual reality drawing experience and conventional drawing experience on subsequent behavior in 16 participants. Results: Large positive effects were found for virtual reality drawing (t15=5.020, P<.001) and conventional drawing (t15=3.720, P=.002) in improving subsequent behavior in a learning setting. Irrespective of the intervention, the participant’s mood, attention, and overall behavior significantly improved. No significant differences were found between the interventions (t15=–0.648; P=.53). Conclusions: This study’s results are encouraging for researchers and educators interested in using virtual reality for people with Down syndrome, as virtual reality was found to be highly feasible. Recommendations are made for researchers and educators interested in providing virtual reality experiences for people with Down syndrome. %M 35124567 %R 10.2196/34373 %U https://games.jmir.org/2022/2/e34373 %U https://doi.org/10.2196/34373 %U http://www.ncbi.nlm.nih.gov/pubmed/35124567 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 2 %P e30196 %T A Mobile-based Virtual Reality Speech Rehabilitation App for Patients With Aphasia After Stroke: Development and Pilot Usability Study %A Bu,Xiaofan %A Ng,Peter HF %A Tong,Ying %A Chen,Peter Q %A Fan,Rongrong %A Tang,Qingping %A Cheng,Qinqin %A Li,Shuangshuang %A Cheng,Andy SK %A Liu,Xiangyu %+ Department of Health Service Center, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, No.283, Tongzipo Road, Yuelu District, Changsha, 410013, China, 86 18674869736, 979596459@qq.com %K virtual reality %K speech rehabilitation %K stroke %K app %K Delphi %D 2022 %7 7.4.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Stroke has the highest disability-adjusted life-years lost in any disease, and approximately one-third of the patients get aphasia. Computers and tablets are innovative and aid in intensive treatments in speech rehabilitation for patients with aphasia. However, mechanical training limits the help to patients. Objective: This study aims to provide a framework for an integrated virtual reality (VR) app to provide speech rehabilitation for patients with aphasia. Methods: The content was generated through an in-depth literature review and discussion with experienced rehabilitation physicians and occupational therapists. We then conducted a 2-round Delphi study with 15 experts from hospitals and universities to rate the content using a 5-point Likert scale. The app was developed by an interdisciplinary team involving VR, medical science of rehabilitation, and therapeutic rehabilitation. Pilot usability testing of this novel app was conducted among 5 patients with aphasia, 5 healthy volunteers, 5 medical staff, and 2 VR experts. Results: We designed 4 modules of speech rehabilitation: oral expression, auditory comprehension, cognition, and comprehensive application. Our VR-based interactive and intelligent app was developed to provide an alternative option for patients with aphasia. Pilot usability testing revealed user satisfaction with the app. Conclusions: This study designed and tested a novel VR-based app for speech rehabilitation specifically adapted to patients with aphasia. This will guide other studies to develop a similar program or intelligent system in a clinical setting. %M 35389349 %R 10.2196/30196 %U https://games.jmir.org/2022/2/e30196 %U https://doi.org/10.2196/30196 %U http://www.ncbi.nlm.nih.gov/pubmed/35389349 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 11 %N 4 %P e35910 %T Use of Virtual Reality in the Reduction of Pain After the Administration of Vaccines Among Children in Primary Care Centers: Protocol for a Randomized Clinical Trial %A de la Cruz Herrera,Mercedes %A Fuster-Casanovas,Aïna %A Miró Catalina,Queralt %A Cigarrán Mensa,Mireia %A Alcántara Pinillos,Pablo %A Vilanova Guitart,Isabel %A Grau Carrión,Sergi %A Vidal-Alaball,Josep %+ Gerència Territorial de la Catalunya Central, Institut Català de la Salut, C/Pica d'Estats 13-15, Sant Fruitós de Bages, 08272, Spain, 34 936930040, afuster.cc.ics@gencat.cat %K children %K virtual reality %K pain %K pain perception %K anxiety %K vaccination %K immunization schedule %D 2022 %7 7.4.2022 %9 Protocol %J JMIR Res Protoc %G English %X Background: Pain and anxiety caused by vaccination and other medical procedures in childhood can result in discomfort for both patients and their parents. Virtual reality (VR) is a technology that is capable of entertaining and distracting the user. Among its many applications, we find the improvement of pain management and the reduction of anxiety in patients undergoing medical interventions. Objective: We aim to publish the protocol of a clinical trial for the reduction of pain and anxiety after the administration of 2 vaccines in children aged 3 to 6 years. Methods: We will conduct a randomized, parallel, controlled clinical trial with 2 assigned groups. The intervention group will wear VR goggles during the administration of 2 vaccines, while the control group will receive standard care from a primary care center for the procedure. Randomization will be carried out by using the RandomizedR computer system—a randomization tool of the R Studio program. This trial will be an open or unblinded trial; both the subjects and the investigators will know the assigned treatment groups. Due to the nature of the VR intervention, it will be impossible to blind the patients, caregivers, or observers. However, a blind third-party assessment will be carried out. The study population will include children aged 3 to 6 years who are included in the patient registry and cared for in a primary care center of the region of Central Catalonia. They will receive the following vaccines during the Well-Child checkup: the triple viral+varicella vaccine at 3 years of age and the hepatitis A+diphtheria-tetanus-pertussis vaccine at 6 years of age. Results: The study is scheduled to begin in January 2022 and is scheduled to end in January 2023, which is when the statistical analysis will begin. As of March 2022, a total of 23 children have been recruited, of which 13 have used VR during the vaccination process. In addition, all of the guardians have found that VR helps to reduce pain during vaccination. Conclusions: VR can be a useful tool in pediatric procedures that generate pain and anxiety. International Registered Report Identifier (IRRID): PRR1-10.2196/35910 %M 35388793 %R 10.2196/35910 %U https://www.researchprotocols.org/2022/4/e35910 %U https://doi.org/10.2196/35910 %U http://www.ncbi.nlm.nih.gov/pubmed/35388793 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 5 %N 1 %P e29164 %T Immersive Reality Experience Technology for Reducing Social Isolation and Improving Social Connectedness and Well-being of Children and Young People Who Are Hospitalized: Open Trial %A Thabrew,Hiran %A Chubb,Laura A %A Kumar,Harshali %A Fouché,Christa %+ The Werry Centre, Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, 20-22 Park Road, Grafton, Auckland, 1142, New Zealand, 64 21 402 055, h.thabrew@auckland.ac.nz %K immersive reality experiences %K social isolation %K hospitalized children %K well-being %K social connectedness %K immersive reality %K virtual reality %K serious games %K pediatrics %K mental health %K isolation %K hospitalized patients %K adolescents %D 2022 %7 25.3.2022 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Children and young people who are hospitalized can feel disconnected from their peers and families, which can, in turn, predispose them to psychological problems, including anxiety and depression. Immersive reality experience technology, recently developed by the New Zealand Patience Project Charitable Trust, may help to overcome these issues. Immersive reality experience technology uses immersive 360° live streaming and a virtual reality headset to enable children and young people who are hospitalized to connect through cameras located in either their school or home environment and via SMS text messaging with a designated buddy. Objective: This trial aims to expand qualitative findings from a previous smaller proof of concept trial to ascertain the views of New Zealand children and young people who are hospitalized, their caregivers, and teachers regarding immersive reality experience technology and quantitatively evaluate the effectiveness of immersive reality experience technology in reducing social isolation and improving social connectedness and well-being using validated outcome measures. Methods: An open trial of immersive reality experience technology was conducted between December 2019 and December 2020 for which 19 New Zealand children and young people aged 13 to 18 years who had been hospitalized at Starship Hospital—a specialist pediatric hospital in Auckland—for at least 2 weeks were recruited. All young people completed the Short Warwick–Edinburgh Mental Well-Being Scale, an abbreviated version of the Social Connectedness Scale, and the Social Inclusion Scale at baseline. Of the 19 participants, 10 (53%) used immersive reality experience technology as often as they wished over a 6-week period and completed postintervention measures. Semistructured interviews with a subset of the 10 young people, 4 caregivers, and 6 teachers were conducted immediately after the intervention. Results: Participants reported improvements in social inclusion (mean change 3.9, SD 2.8; P=.06), social connectedness (mean change 14.2, SD 10.0; P=.002), and well-being (mean change 5.7, SD 4.0; P=.001). Key themes from interviews with participants, caregivers, and teachers were the importance of support for using immersive reality experience technology, connecting versus connectedness, choice and connection, and the value of setting it up and getting it right. Recommendations for improving connectedness via immersive reality experience and related technologies were also provided. Conclusions: Immersive reality experience technology can improve the social inclusion, social connectedness, and well-being of New Zealand children and young people who are hospitalized. With some technological modifications and simplified implementation, immersive reality experience and related technology could become part of standard care and support children and young people who are hospitalized in New Zealand and elsewhere to sustain family and peer cohesion, experience fewer psychological problems, and more easily return to normal life following the completion of treatment. Trial Registration: Australian New Zealand Clinical Trials Network Registry ACTRN12619000252112; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376837&isReview=true %M 35333184 %R 10.2196/29164 %U https://pediatrics.jmir.org/2022/1/e29164 %U https://doi.org/10.2196/29164 %U http://www.ncbi.nlm.nih.gov/pubmed/35333184 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e28595 %T Viewpoint: Virtual and Augmented Reality in Basic and Advanced Life Support Training %A Ricci,Serena %A Calandrino,Andrea %A Borgonovo,Giacomo %A Chirico,Marco %A Casadio,Maura %+ Simulation and Advanced Education Center, University of Genova, Via Pastore 3, Genova, 16132, Italy, 39 01033550188, serena.ricci@edu.unige.it %K basic and advanced life support %K first aid %K cardiopulmonary resuscitation %K emergency %K training %K simulation training %K medical simulation %K healthcare simulation %K virtual reality %K augmented reality %D 2022 %7 23.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X The use of augmented reality (AR) and virtual reality (VR) for life support training is increasing. These technologies provide an immersive experience that supports learning in a safe and controlled environment. This review focuses on the use of AR and VR for emergency care training for health care providers, medical students, and nonprofessionals. In particular, we analyzed (1) serious games, nonimmersive games, both single-player and multiplayer; (2) VR tools ranging from semi-immersive to immersive virtual and mixed reality; and (3) AR applications. All the toolkits have been investigated in terms of application goals (training, assessment, or both), simulated procedures, and skills. The main goal of this work is to summarize and organize the findings of studies coming from multiple research areas in order to make them accessible to all the professionals involved in medical simulation. The analysis of the state-of-the-art technologies reveals that tools and studies related to the multiplayer experience, haptic feedback, and evaluation of user’s manual skills in the foregoing health care-related environments are still limited and require further investigation. Also, there is an additional need to conduct studies aimed at assessing whether AR/VR-based systems are superior or, at the minimum, comparable to traditional training methods. %M 35319477 %R 10.2196/28595 %U https://games.jmir.org/2022/1/e28595 %U https://doi.org/10.2196/28595 %U http://www.ncbi.nlm.nih.gov/pubmed/35319477 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e32027 %T A Virtual Reality Game Suite for Graded Rehabilitation in Patients With Low Back Pain and a High Fear of Movement: Within-Subject Comparative Study %A Peebles,Alexander T %A van der Veen,Susanne %A Stamenkovic,Alexander %A France,Christopher R %A Pidcoe,Peter E %A Thomas,James S %+ Department of Physical Therapy, Virginia Commonwealth University, 900 E. Leigh St, 4th Floor, Richmond, VA, 23298, United States, 1 740 541 6324, jthomas32@vcu.edu %K virtual reality %K reaching %K intervention %K rehabilitation %K exergaming %K biomechanics %K serious games %K gamification %K movement %K physiotherapy %K lumbar %D 2022 %7 23.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Complex movement pathologies that are biopsychosocial in nature (eg, back pain) require a multidimensional approach for effective treatment. Virtual reality is a promising tool for rehabilitation, where therapeutic interventions can be gamified to promote and train specific movement behaviors while increasing enjoyment, engagement, and retention. We have previously created virtual reality–based tools to assess and promote lumbar excursion during reaching and functional gameplay tasks by manipulating the position of static and dynamic contact targets. Based on the framework of graded exposure rehabilitation, we have created a new virtual reality therapy aimed to alter movement speed while retaining the movement-promoting features of our other developments. Objective: This study aims to compare lumbar flexion excursion and velocity across our previous and newly developed virtual reality tools in a healthy control cohort. Methods: A total of 31 healthy participants (16 males, 15 females) took part in 3 gamified virtual reality therapies (ie, Reachality, Fishality, and Dodgeality), while whole-body 3D kinematics were collected at 100 Hz using a 14-camera motion capture system. Lumbar excursion, lumbar flexion velocity, and actual target impact location in the anterior and vertical direction were compared across each virtual reality task and between the 4 anthropometrically defined intended target impact locations using separate 2-way repeated measures analysis of variance models. Results: There was an interaction between game and impact height for each outcome (all P<.001). Post-hoc simple effects models revealed that lumbar excursion was reduced during Reachality and Fishality relative to that during Dodgeality for the 2 higher impact heights but was greater during Reachality than during Fishality and Dodgeality for the lowest impact height. Peak lumbar flexion velocity was greater during Dodgeality than during Fishality and Reachality across heights. Actual target impact locations during Dodgeality and Fishality were lower relative to those during Reachality at higher intended impact locations but higher at lower intended impact locations. Finally, actual target impact location was further in the anterior direction for Reachality compared to that for Fishality and for Fishality relative to that for Dodgeality. Conclusions: Lumbar flexion velocity was reduced during Fishality relative to that during Dodgeality and resembled velocity demands more similar to those for a self-paced reaching task (ie, Reachality). Additionally, lumbar motion and target impact location during Fishality were more similar to those during Reachality than to those during Dodgeality, which suggests that this new virtual reality game is an effective tool for shaping movement. These findings are encouraging for future research aimed at developing an individualized and graded virtual reality intervention for patients with low back pain and a high fear of movement. %M 35319471 %R 10.2196/32027 %U https://games.jmir.org/2022/1/e32027 %U https://doi.org/10.2196/32027 %U http://www.ncbi.nlm.nih.gov/pubmed/35319471 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e30366 %T Determining the Optimal Virtual Reality Exergame Approach for Balance Therapy in Persons With Neurological Disorders Using a Rasch Analysis: Longitudinal Observational Study %A Wiskerke,Evelyne %A Kool,Jan %A Hilfiker,Roger %A Sattelmayer,Karl Martin %A Verheyden,Geert %+ Rehazentrum Valens, Kliniken Valens, Taminaplatz 1, Valens, 7317, Switzerland, 41 813031403, evelien.wiskerke@kuleuven.be %K digital therapeutics %K virtual reality %K exergaming %K balance %K stroke %K multiple sclerosis %K neurorehabilitation %K Rasch analysis %D 2022 %7 22.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) exergames have gained popularity in the rehabilitation of persons with neurological disorders as an add-on therapy to increase intensity of training. Intensity is strongly dependent on the motivation of the patient. Motivation can be increased by delivering variation within training and challenging exercises. However, patients are often underchallenged, as exergame difficulty often does not match the patient’s ability. A Rasch analysis can establish hierarchy of exergame items in order to assist the delivery of patient-centered therapy. Objective: The aim of this study was to apply the Rasch model to create a hierarchical order of existing VR balance exergames and to relate these exergames to the abilities of persons with neurological disorders, in order to deliver challenge and variation. Methods: A total of 30 persons with stroke and 51 persons with multiple sclerosis (MS) were included in the study. All participants performed a training program, lasting 3 weeks for persons with MS and 4 weeks for persons with stroke, in which they performed VR balance exergames with a movement recognition–based system (MindMotion GO; MindMaze SA). VR exercise scores, Berg Balance Scale scores, and clinical descriptive data were collected. Berg Balance Scale and device scores were analyzed with the Rasch model using a repeated-measures approach to examine whether the distribution of exercise scores fitted the Rasch model. Secondly, a person-item map was created to show the hierarchy of exercise difficulty and person ability. Results: Participants completed a selection of 56 balance exercises (ie, items), which consisted of a combination of various balance tasks and levels (ie, exercises). Using repeated measures, this resulted in a count of 785 observations. Analysis showed strong evidence for unidimensionality of the data. A total of 47 exercises (ie, items) had a sufficiently good fit to the Rasch model. Six items showed underfit, with outfit mean square values above 1.5. One item showed underfit but was kept in the analysis. Three items had negative point-biserial correlations. The final model consisted of 47 exercises, which were provided for persons with low to moderate balance ability. Conclusions: The VR exercises sufficiently fitted the Rasch model and resulted in a hierarchical order of VR balance exercises for persons with stroke and MS with low to moderate balance ability. In combination with the Berg Balance Scale, the results can guide clinical decision-making in the selection of patient-focused VR balance exercises. Trial Registration: ClinicalTrials.gov NCT03993275; https://clinicaltrials.gov/ct2/show/NCT03993275 %M 35315785 %R 10.2196/30366 %U https://games.jmir.org/2022/1/e30366 %U https://doi.org/10.2196/30366 %U http://www.ncbi.nlm.nih.gov/pubmed/35315785 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e35642 %T Visual Attention of Anesthesia Providers in Simulated Anesthesia Emergencies Using Conventional Number-Based and Avatar-Based Patient Monitoring: Prospective Eye-Tracking Study %A Ljubenovic,Arsène %A Said,Sadiq %A Braun,Julia %A Grande,Bastian %A Kolbe,Michaela %A Spahn,Donat R %A Nöthiger,Christoph B %A Tscholl,David W %A Roche,Tadzio R %+ Institute of Anesthesiology, University of Zurich, University Hospital Zurich, Rämistrasse 100, Zurich, 8091, Switzerland, 41 432530255, tadzioraoul.roche@usz.ch %K Anesthesia %K eye-tracking technology %K patient monitoring %K patient simulation %K situation awareness %K task performance %K visual attention %K avatar based model %K simulated anesthesia %K perioperative %D 2022 %7 22.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Inadequate situational awareness accounts for two-thirds of preventable complications in anesthesia. An essential tool for situational awareness in the perioperative setting is the patient monitor. However, the conventional monitor has several weaknesses. Avatar-based patient monitoring may address these shortcomings and promote situation awareness, a prerequisite for good decision making. Objective: The spatial distribution of visual attention is a fundamental process for achieving adequate situation awareness and thus a potential quantifiable surrogate for situation awareness. Moreover, measuring visual attention with a head-mounted eye-tracker may provide insights into usage and acceptance of the new avatar-based patient monitoring modality. Methods: This prospective eye-tracking study compared anesthesia providers' visual attention on conventional and avatar-based patient monitors during simulated critical anesthesia events. We defined visual attention, measured as fixation count and dwell time, as our primary outcome. We correlated visual attention with the potential confounders: performance in managing simulated critical anesthesia events (task performance), work experience, and profession. We used mixed linear models to analyze the results. Results: Fifty-two teams performed 156 simulations. After a manual quality check of the eye-tracking footage, we excluded 57 simulations due to technical problems and quality issues. Participants had a median of 198 (IQR 92.5-317.5) fixations on the patient monitor with a median dwell time of 30.2 (IQR 14.9-51.3) seconds. We found no significant difference in participants' visual attention when using avatar-based patient monitoring or conventional patient monitoring. However, we found that with each percentage point of better task performance, the number of fixations decreased by about 1.39 (coefficient –1.39; 95% CI –2.44 to –0.34; P=.02), and the dwell time diminished by 0.23 seconds (coefficient –0.23; 95% CI: –0.4 to –0.06; P=.01). Conclusions: Using eye tracking, we found no significant difference in visual attention when anesthesia providers used avatar-based monitoring or conventional patient monitoring in simulated critical anesthesia events. However, we identified visual attention in conjunction with task performance as a surrogate for situational awareness. %M 35172958 %R 10.2196/35642 %U https://games.jmir.org/2022/1/e35642 %U https://doi.org/10.2196/35642 %U http://www.ncbi.nlm.nih.gov/pubmed/35172958 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 7 %N 1 %P e26013 %T Mobile Virtual Reality Versus Mobile 360° Video to Promote Enrollment in the Diabetes Prevention Program Among Hispanic Adults: Pilot Study %A Gibson,Bryan %A Simonsen,Sara %A Jensen,Jakob D %A Yingling,Leah %A Schaefer,Julia %A Sundaresh,Vishnu %A Zhang,Yue %A Altizer,Roger %+ Department of Biomedical Informatics, School of Medicine, University of Utah, 421 Wakara Way, Salt Lake City, UT, 84108, United States, 1 801 585 0929, Bryan.Gibson@utah.edu %K diabetes prevention %K virtual reality %K risk %K perception %K diabetes %K type 2 diabetes %K mobile phone %K prediabetes %K prevention %K VR %K enrollment %K pilot study %K video %D 2022 %7 17.3.2022 %9 Original Paper %J JMIR Diabetes %G English %X Background: Hispanic adults are at increased risk of developing type 2 diabetes. The Diabetes Prevention Program (DPP) reduces the risk of developing type 2 diabetes; however, the rate of enrollment is very low. Objective: The goal of this pilot project was to determine whether presenting brief motivational mobile videos in virtual reality vs 360° video has differential effects on risk perceptions and enrollment in the DPP. Methods: Adults with prediabetes were recruited at a clinic serving a low-income Hispanic community. After consenting, the participants completed a baseline survey that collected information about demographics and risk perceptions. All participants then viewed 2 videos. Per random assignment, the videos were presented either using the participant’s smartphone alone (360° video) or were viewed with their smartphone in a virtual reality (VR) cardboard headset. Two weeks later, a follow-up survey collected measures of enrollment in the DPP, risk perceptions, health literacy, the importance of contextual factors related to the decision of whether to enroll in the DPP (eg, distance to the class), and qualitative feedback on the interventions. We used logistic regression to determine whether enrollment in the DPP differed by intervention mode, while accounting for health literacy and contextual factors related to the DPP. We used unpaired t tests to examine differences in change in risk perceptions between groups. Paired t tests were used to examine within-subject changes in risk perceptions. Results: A total of 116 participants provided complete data. Most participants were middle-aged (mean age 44.6 years; SD 11.9) Hispanic (114/116), female (79/116), with low health literacy (mean score 12.3/20; SD 3.4). Enrollment in the DPP was 44/116 (37.9%) overall but did not differ by group (odds ratio for enrolling in VR group 1.78, 95% CI 0.75-4.3; P=.19). Individuals who rated the distance needed to travel to attend the DPP as more important were less likely to enroll in the DPP (odds ratio 0.56, 95% CI 0.33-0.92; P=.03). Risk perceptions did not differ by group (mean change in 360° video group -0.07, mean change in VR group 0.03, t=0.6, P=.54) and did not change within subjects (mean 0.02, t=0.21, P=.83). Participant feedback suggested that the videos are emotionally engaging and educational. Conclusions: The videos presented in 360° video and mobile VR had equal efficacy in promoting enrollment in the DPP. Future work to rigorously evaluate this intervention, its mechanism of action, and potential moderators of the efficacy are discussed. %M 35297771 %R 10.2196/26013 %U https://diabetes.jmir.org/2022/1/e26013 %U https://doi.org/10.2196/26013 %U http://www.ncbi.nlm.nih.gov/pubmed/35297771 %0 Journal Article %@ 2562-7600 %I JMIR Publications %V 5 %N 1 %P e34036 %T Virtual Reality in Clinical Practice and Research: Viewpoint on Novel Applications for Nursing %A Son,Hyojin %A Ross,Alyson %A Mendoza-Tirado,Elizabeth %A Lee,Lena Jumin %+ Translational Biobehavioral and Health Disparities Branch, National Institutes of Health Clinical Center, 10 Center Drive, Bethesda, MD, 20892, United States, 1 667 701 5768, hyojin.son@nih.gov %K virtual reality %K health care %K application %K nursing %D 2022 %7 16.3.2022 %9 Viewpoint %J JMIR Nursing %G English %X Virtual reality is a novel technology that provides users with an immersive experience in 3D virtual environments. The use of virtual reality is expanding in the medical and nursing settings to support treatment and promote wellness. Nursing has primarily used virtual reality for nursing education, but nurses might incorporate this technology into clinical practice to enhance treatment experience of patients and caregivers. Thus, it is important for nurses to understand what virtual reality and its features are, how this technology has been used in the health care field, and what future efforts are needed in practice and research for this technology to benefit nursing. In this article, we provide a brief orientation to virtual reality, describe the current application of this technology in multiple clinical scenarios, and present implications for future clinical practice and research in nursing. %M 35293870 %R 10.2196/34036 %U https://nursing.jmir.org/2022/1/e34036 %U https://doi.org/10.2196/34036 %U http://www.ncbi.nlm.nih.gov/pubmed/35293870 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e30653 %T Mixed Reality and Haptic–Based Dental Simulator for Tooth Preparation: Research, Development, and Preliminary Evaluation %A Li,Yaning %A Ye,Hongqiang %A Wu,Siyu %A Zhao,Xiaohan %A Liu,Yunsong %A Lv,Longwei %A Zhang,Ping %A Zhang,Xiao %A Zhou,Yongsheng %+ Department of Prosthodontics, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Avenue, Haidian District, Beijing, 100081, China, 86 10 82195070, kqzhouysh@hsc.pku.edu.cn %K dental education %K simulator %K mixed reality %K tooth preparation %D 2022 %7 9.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) dental simulators are currently used in preclinical skills training. However, with the development of extended reality technologies, the use of mixed reality (MR) has shown significant advantages over VR. Objective: This study aimed to describe the research and development of a newly developed MR and haptic–based dental simulator for tooth preparation and to conduct a preliminary evaluation of its face validity. Methods: A prototype of the MR dental simulator for tooth preparation was developed by integrating a head-mounted display (HMD), special force feedback handles, a foot pedal, computer hardware, and software program. We recruited 34 participants and divided them into the Novice group (n=17) and Skilled group (n=17) based on their clinical experience. All participants prepared a maxillary right central incisor for an all-ceramic crown in the dental simulator, completed a questionnaire afterward about their simulation experience, and evaluated hardware and software aspects of the dental simulator. Results: Of the participants, 74% (25/34) were satisfied with the overall experience of using the Unidental MR Simulator. Approximately 90% (31/34, 91%) agreed that it could stimulate their interest in learning, and 82% (28/34) were willing to use it for skills training in the future. Differences between the 2 study groups in their experience with the HMD (resolution: P=.95; wearing comfort: P=.10), dental instruments (P=.95), force feedback of the tooth (P=.08), simulation of the tooth preparation process (P=.79), overall experience with the simulation (P=.47), and attitude toward the simulator (improves skills: P=.47; suitable for learning: P=.36; willing to use: P=.89; inspiring for learning: P=.63) were not significant. The Novice group was more satisfied with the simulator’s ease of use (P=.04). There were significant positive correlations between the overall experience with the simulation and the HMD’s resolution (P=.03) and simulation of the preparation process (P=.001). Conclusions: The newly developed Unidental MR Simulator for tooth preparation has good face validity. It can achieve a higher degree of resemblance to the real clinical treatment environment by improving the positional adjustment of the simulated patients, for a better training experience in dental skills. %M 35262501 %R 10.2196/30653 %U https://games.jmir.org/2022/1/e30653 %U https://doi.org/10.2196/30653 %U http://www.ncbi.nlm.nih.gov/pubmed/35262501 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e30456 %T Virtual Reality Simulation Training for Cardiopulmonary Resuscitation After Cardiac Surgery: Face and Content Validity Study %A Sadeghi,Amir H %A Peek,Jette J %A Max,Samuel A %A Smit,Liselot L %A Martina,Bryan G %A Rosalia,Rodney A %A Bakhuis,Wouter %A Bogers,Ad JJC %A Mahtab,Edris AF %+ Department of Cardiothoracic Surgery, Erasmus University Medical Center, Doctor Molewaterplein 40, Rotterdam, 3015 GD, Netherlands, 31 10 704 0704, h.sadeghi@erasmusmc.nl %K cardiac surgery %K cardiopulmonary resuscitation %K emergency resternotomy %K virtual reality %K simulation training %K serious games %K virtual reality simulation %K digital health %K medical training %K virtual training %D 2022 %7 2.3.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cardiac arrest after cardiac surgery commonly has a reversible cause, where emergency resternotomy is often required for treatment, as recommended by international guidelines. We have developed a virtual reality (VR) simulation for training of cardiopulmonary resuscitation (CPR) and emergency resternotomy procedures after cardiac surgery, the Cardiopulmonary Resuscitation Virtual Reality Simulator (CPVR-sim). Two fictive clinical scenarios were used: one case of pulseless electrical activity (PEA) and a combined case of PEA and ventricular fibrillation. In this prospective study, we researched the face validity and content validity of the CPVR-sim. Objective: We designed a prospective study to assess the feasibility and to establish the face and content validity of two clinical scenarios (shockable and nonshockable cardiac arrest) of the CPVR-sim partly divided into a group of novices and experts in performing CPR and emergency resternotomies in patients after cardiac surgery. Methods: Clinicians (staff cardiothoracic surgeons, physicians, surgical residents, nurse practitioners, and medical students) participated in this study and performed two different scenarios, either PEA or combined PEA and ventricular fibrillation. All participants (N=41) performed a simulation and completed the questionnaire rating the simulator’s usefulness, satisfaction, ease of use, effectiveness, and immersiveness to assess face validity and content validity. Results: Responses toward face validity and content validity were predominantly positive in both groups. Most participants in the PEA scenario (n=26, 87%) felt actively involved in the simulation, and 23 (77%) participants felt in charge of the situation. The participants thought it was easy to learn how to interact with the software (n=24, 80%) and thought that the software responded adequately (n=21, 70%). All 15 (100%) expert participants preferred VR training as an addition to conventional training. Moreover, 13 (87%) of the expert participants would recommend VR training to other colleagues, and 14 (93%) of the expert participants thought the CPVR-sim was a useful method to train for infrequent post–cardiac surgery emergencies requiring CPR. Additionally, 10 (91%) of the participants thought it was easy to move in the VR environment, and that the CPVR-sim responded adequately in this scenario. Conclusions: We developed a proof-of-concept VR simulation for CPR training with two scenarios of a patient after cardiac surgery, which participants found was immersive and useful. By proving the face validity and content validity of the CPVR-sim, we present the first step toward a cardiothoracic surgery VR training platform. %M 35234652 %R 10.2196/30456 %U https://games.jmir.org/2022/1/e30456 %U https://doi.org/10.2196/30456 %U http://www.ncbi.nlm.nih.gov/pubmed/35234652 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e30882 %T Benefits of Virtual Reality Balance Training for Patients With Parkinson Disease: Systematic Review, Meta-analysis, and Meta-Regression of a Randomized Controlled Trial %A Wu,Jinlong %A Zhang,Hui %A Chen,Ziyan %A Fu,Ruijia %A Yang,Hao %A Zeng,Hongfa %A Ren,Zhanbing %+ Department of Physical Education, Shenzhen University, No 3588 Nanhai Road, Shenzhen, 518060, China, 86 13318881919, rzb@szu.edu.cn %K virtual reality %K Parkinson disease %K balance %K systematic review %K meta-analysis %K meta-regression %K serious games %K VR %K rehabilitation %K VR training %D 2022 %7 1.3.2022 %9 Review %J JMIR Serious Games %G English %X Background: Virtual reality (VR) balance training is increasingly being pursued in biomedical research, specifically with respect to investigating balance ability with VR. However, existing systematic reviews have found inconsistent conclusions about the efficacy of VR in improving balance in Parkinson disease (PD) patients. Objective: The goal of the research was to evaluate the impact of VR balance training on the balance ability of patients with PD. Methods: All major databases, including Web of Science, PubMed, Scopus, China National Knowledge Infrastructure, and Wanfang, were searched to identify all relevant studies published in English or Chinese since September 15, 2010. Two researchers independently conducted document retrieval, study selection, data extraction, and methodological quality evaluation. Results: A total of 16 randomized controlled trials were analyzed (n=583 patients with PD), with the methodological quality evaluation score ranging from 5 to 8 points. A random effects model was selected to combine effect sizes. Meta-analysis showed that the balance ability of PD was significantly improved after VR training compared with the control group (standardized mean difference [SMD] 2.127, 95% CI 1.202 to 3.052, P<.001, I2=95.1, df=15). It is worth noting that the intervention platform may be the main reason for heterogeneity. Meta regression analysis showed that no training program could predict the impact of VR training (P=.57 to .94) on PD balance ability. Subgroup result showed that a single training time of 0 to 20 minutes (SMD 6.446), 4 to 6 times per week (SMD 4.067), training for 3 to 5 weeks (SMD 62.478), training course reached more than 30 times (SMD 4.405), and 201 to 300 minutes per week (SMD 4.059) maybe have more benefit. Conclusions: A systematic review and meta-analysis confirmed that VR balance training is a highly effective means to improve balance performance with large effects in PD. In addition, we preliminarily extracted dose-effect relationships for training volume, informing clinicians and practitioners to design effective VR balance training for balance ability. Further research is needed to reveal optimal dose-response relationships following VR balance training. %M 35230242 %R 10.2196/30882 %U https://games.jmir.org/2022/1/e30882 %U https://doi.org/10.2196/30882 %U http://www.ncbi.nlm.nih.gov/pubmed/35230242 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31395 %T The Effectiveness of Virtual Reality–Based Interventions in Rehabilitation Management of Breast Cancer Survivors: Systematic Review and Meta-analysis %A Bu,Xiaofan %A Ng,Peter H F %A Xu,Wenjing %A Cheng,Qinqin %A Chen,Peter Q %A Cheng,Andy S K %A Liu,Xiangyu %+ Department of Health Service Center, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Number 283, Tongzi Road, Changsha, 410013, China, 86 18674869736, 979596459@qq.com %K virtual reality %K rehabilitation management %K symptom %K motor function %K systematic review %K meta-analysis %D 2022 %7 28.2.2022 %9 Review %J JMIR Serious Games %G English %X Background: Breast cancer survivors (BCSs) can present with various physical and psychological symptoms and functional deficits that impact their quality of life. Virtual reality (VR) technology is being used in breast cancer rehabilitation management to improve the emotional, cognitive, and physical well-being of BCSs. Objective: This systematic review aimed to examine the effectiveness of VR-based interventions on health-related outcomes in BCSs. A meta-analysis was conducted to evaluate the effectiveness of VR-based interventions in the rehabilitation management of BCSs. Methods: A systematic search was conducted on PubMed, Web of Science, EMBASE, CINAHL with Full Text, the Cochrane Central Register of Controlled Trials, CNKI, WanFang, VIP, and CBM, from inception to May 25, 2021. The inclusion criteria of the selected studies were as follows: (1) adults diagnosed with breast cancer; (2) any type of VR-based interventions (immersive and nonimmersive virtual environment); (3) comparison of traditional rehabilitation methods; (4) outcomes including pain, depression, anxiety, fatigue, cognitive function, shoulder range of motion (ROM), hand grip strength, lymphedema, cybersickness symptoms, fear of movement, bleeding, effusion, and flap necrosis, both during and after treatment; and (5) randomized controlled trials (RCTs), case-controlled trials, and quasi-experimental studies. The Cochrane Collaboration Tool was used to evaluate the risk of bias. Review Manager version 5.3 (Cochrane Collaboration) was used to conduct the meta-analysis. The mean difference (MD) and SDs with 95% CIs were used to calculate continuous variables. Results: Twelve articles were included in this systematic review, of which 10 contributed information to the meta-analysis. A total of 604 participants were analyzed. The statistical analysis showed significant results for flexion (standard mean difference [SMD] 1.79; 95% CI 0.55 to 3.03; P=.005), extension (SMD 1.54; 95% CI 0.83 to 2.25; P<.001), abduction (MD 17.53; 95% CI 14.33 to 20.72; P<.001), adduction (MD 15.98; 95% CI 14.02 to 17.94; P<.001), internal rotation (MD 7.12; 95% CI 5.54 to 8.70; P<.001), external rotation (SMD 0.96; 95% CI 0.62 to 1.29; P<.001), anxiety (MD −6.47; 95% CI −7.21 to −5.73; P<.001), depression (MD −4.27; 95% CI −4.64 to −3.91; P<.001), pain (MD −1.32; 95% CI −2.56 to −0.09; P=.04), and cognitive function (MD 8.80; 95% CI 8.24 to 9.36; P<.001). The meta-analysis indicated little to no difference in hand grip strength (MD 1.96; 95% CI –0.93 to 4.85; P=.18). Conclusions: Findings of this review noted a weak but consistent positive association between VR-based interventions and outcomes. However, these results must be interpreted with caution due to the limited number of controlled trials analyzed, small sample sizes, and poor methodological quality. Well‐designed, large, high‐quality trials may have a significant impact on our confidence in the results. Future studies should identify specific aspects that improve the clinical impact of VR-based interventions on major outcomes in BCSs in the clinical setting. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021250727; https://tinyurl.com/2p89rmnk %M 35225817 %R 10.2196/31395 %U https://games.jmir.org/2022/1/e31395 %U https://doi.org/10.2196/31395 %U http://www.ncbi.nlm.nih.gov/pubmed/35225817 %0 Journal Article %@ 2561-1011 %I JMIR Publications %V 6 %N 1 %P e29473 %T A Preoperative Virtual Reality App for Patients Scheduled for Cardiac Catheterization: Pre–Post Questionnaire Study Examining Feasibility, Usability, and Acceptability %A Aardoom,Jiska J %A Hilt,Alexander D %A Woudenberg,Tamar %A Chavannes,Niels H %A Atsma,Douwe E %+ Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, Leiden, 2300 RC, Netherlands, 31 7152668605, j.j.aardoom@lumc.nl %K virtual reality %K cardiac catheterization %K stress inoculation training %K preoperative anxiety %K acceptability %K feasibility %K presence %K immersive tendencies %K presence %K patient education %K mobile phone %D 2022 %7 22.2.2022 %9 Original Paper %J JMIR Cardio %G English %X Background: Pre- and postoperative anxiety is a common phenomenon associated with negative postoperative outcomes. Symptoms of posttraumatic stress disorder, such as fear, nightmares, and sleep deprivation, are prevalent in approximately 30% to 50% of patients following discharge from intensive care units after cardiac surgery. Preliminary evidence suggests a promising role of virtual reality (VR) in preventing stress-related reactions using stress inoculation training. Such training enables cognitive preparation of individuals for stressful situations, thereby becoming more tolerant and resistant to stress, subsequently reducing the risk of potential negative psychological consequences. This study investigated a preoperative VR app—Pre-View—aimed at better informing and preparing patients for cardiac catheterization. Objective: This study aims to assess the feasibility, usability, and acceptability of Pre-View in patients undergoing cardiac catheterization. Methods: Eligible participants were adults scheduled for elective cardiac catheterization. Pre-View comprised an interactive virtual representation of the whole care process related to cardiac catheterization, from entering the hospital for admission to postprocedural stay and discharge. These processes were represented through 360° videos and interactive photos. Self-report questionnaires were completed at baseline (ie, before catheterization and after undergoing the VR experience) and after cardiac catheterization. Outcome measures included user experience and satisfaction, VR presence and immersive tendencies, and user friendliness. The perceived effectiveness was assessed exploratively. Results: A total of 8 individuals, with a mean age of 67 (SD 7.5) years, participated in this study. Half of them underwent the VR experience at the hospital and the other half at home. Participants reported high levels of presence in the virtual environment (Presence Questionnaire score: mean 129.1, SD 13.4). The usability of Pre-View was well evaluated (System Usability Scale score: mean 89.1, SD 12.0), and patient satisfaction was high (Client Satisfaction Questionnaire score: mean 27.1, SD 3.2). Usability and satisfaction scores were higher for participants who underwent Pre-View at home versus those who underwent Pre-View at the hospital, although the latter group was significantly older; 72.8 versus 61.3, respectively. All participants reported Pre-View to be effective in terms of feeling better informed about the care process of cardiac catheterization. Most participants (7/8, 88%) reported Pre-View to be effective in terms of feeling better prepared for cardiac catheterization, acknowledging the potential of Pre-View in reducing negative psychological consequences after catheterization. Conclusions: The results provide initial support for the feasibility and acceptability of a preoperative VR app, creating a virtual environment that supports patient education and preparation for upcoming cardiac catheterization. More studies are needed to further investigate the effects of VR as a tool to better prepare patients for medical procedures, its effectiveness in reducing negative patient outcomes (eg, anxiety, stress, and postoperative recovery outcomes), and the generalizability of effects across different settings and patient populations. %M 35191839 %R 10.2196/29473 %U https://cardio.jmir.org/2022/1/e29473 %U https://doi.org/10.2196/29473 %U http://www.ncbi.nlm.nih.gov/pubmed/35191839 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e29579 %T Experiences of Patients Undergoing Chemotherapy With Virtual Reality: Mixed Methods Feasibility Study %A Janssen,Anna %A Fletcher,Jennifer %A Keep,Melanie %A Ahmadpour,Naseem %A Rouf,Anika %A Marthick,Michael %A Booth,Rebecca %+ Research in Implementation Science and eHealth Group, Faculty of Medicine and Health, The University of Sydney, Level 2, Charles Perkins Centre D17, Sydney, 2006, Australia, 61 9036 9406, anna.janssen@sydney.edu.au %K eHealth %K digital health %K virtual reality %K cancer %K chemotherapy %K mixed methods research %K virtual health %K serious games %K treatment %D 2022 %7 21.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Current research into virtual reality (VR) use during chemotherapy shows that it can be an effective distraction intervention. However, there is limited research in adult patients and to investigate how VR can be sustainably implemented in health care organizations. Objective: The aim of this study was to explore the feasibility and acceptability of using VR for adult patients undergoing chemotherapy, and to identify the factors that would enable the sustained use of VR during chemotherapy in health care organizations. Methods: Patients undergoing chemotherapy were recruited to participate in a VR intervention during chemotherapy infusion. Participants were observed during the session and completed a postintervention survey. Each participant was invited to participate in a semistructured interview about their experience. Results: A total of 18 patients participated in the study, 5 of whom participated in semistructured interviews. Findings indicated that the use of VR was acceptable for patients undergoing chemotherapy and the intervention was also feasible. Some participants felt that the VR was an effective distraction during chemotherapy infusion, although most still seemed to be aware of how long their treatment was taking. Although VR was acceptable and feasible to patients, interviews identified several barriers to sustained implementation, including access to a reliable app library and impact on staff workloads. Conclusions: VR was acceptable to patients with a diagnosis of cancer undergoing chemotherapy treatment. Patients found VR beneficial for breaking up the monotony of treatment, to provide an additional choice of activity in addition to other recreation, and in some instances as a distraction from the treatment itself. However, there are challenges to address if VR is to be implemented in practice for this patient group. %M 35188474 %R 10.2196/29579 %U https://games.jmir.org/2022/1/e29579 %U https://doi.org/10.2196/29579 %U http://www.ncbi.nlm.nih.gov/pubmed/35188474 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 9 %N 2 %P e28502 %T Feasibility and Efficacy of Virtual Reality Interventions to Improve Psychosocial Functioning in Psychosis: Systematic Review %A Schroeder,Alexandra H %A Bogie,Bryce J M %A Rahman,Tabassum T %A Thérond,Alexandra %A Matheson,Hannah %A Guimond,Synthia %+ The Royal’s Institute of Mental Health Research, University of Ottawa, 1145 Carling Avenue, Ottawa, ON, K1Z 7K4, Canada, 1 (613) 722 6521 ext 6586, synthia.guimond@uqo.ca %K auditory verbal hallucinations %K cognitive remediation %K functional outcomes %K neurocognition %K paranoia %K psychosis %K schizophrenia %K social skills %K virtual reality (VR) %K vocational skills %D 2022 %7 18.2.2022 %9 Review %J JMIR Ment Health %G English %X Background: Functional recovery in psychosis remains a challenge despite current evidence-based treatment approaches. To address this problem, innovative interventions using virtual reality (VR) have recently been developed. VR technologies have enabled the development of realistic environments in which individuals with psychosis can receive psychosocial treatment interventions in more ecological settings than traditional clinics. These interventions may therefore increase the transfer of learned psychosocial skills to real-world environments, thereby promoting long-term functional recovery. However, the overall feasibility and efficacy of such interventions within the psychosis population remain unclear. Objective: This systematic review aims to investigate whether VR-based psychosocial interventions are feasible and enjoyable for individuals with psychosis, synthesize current evidence on the efficacy of VR-based psychosocial interventions for psychosis, and identify the limitations in the current literature to guide future research. Methods: This research followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Literature searches were conducted in PubMed and PsycINFO in May 2021. We searched for peer-reviewed English articles that used a psychosocial intervention with a VR component. Participants in the included studies were diagnosed with schizophrenia, schizoaffective disorder, or another psychotic disorder. The included studies were divided into four categories as follows: cognitive remediation interventions, social skills interventions, vocational skills interventions, and auditory verbal hallucinations and paranoia interventions. The risk of bias assessment was performed for each study. Results: A total of 18 studies were included in this systematic review. Of these 18 studies, 4 (22%) studies used a cognitive remediation intervention, 4 (22%) studies used a social skills intervention, 3 (17%) studies used a vocational skills intervention, and 7 (39%) studies implemented an intervention aimed at improving auditory verbal hallucinations or paranoia. A total of 745 individuals with psychosis were included in the study. All the studies that evaluated feasibility showed that VR-based psychosocial interventions were feasible and enjoyable for individuals with psychosis. The preliminary evidence on efficacy included in this review suggests that VR-based psychosocial interventions can improve cognitive, social, and vocational skills in individuals with psychosis. VR-based interventions may also improve the symptoms of auditory verbal hallucinations and paranoia. The skills that participants learned through these interventions were durable, transferred into real-world environments, and led to improved functional outcomes, such as autonomy, managing housework, and work performance. Conclusions: VR-based interventions may represent a novel and efficacious approach for improving psychosocial functioning in psychosis. Therefore, VR-based psychosocial interventions represent a promising adjunctive therapy for the treatment of psychosis, which may be used to improve psychosocial skills, community functioning, and quality of life. %M 35179501 %R 10.2196/28502 %U https://mental.jmir.org/2022/2/e28502 %U https://doi.org/10.2196/28502 %U http://www.ncbi.nlm.nih.gov/pubmed/35179501 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31020 %T Immersive Virtual Reality and Vestibular Rehabilitation in Multiple Sclerosis: Case Report %A García-Muñoz,Cristina %A Cortés-Vega,María-Dolores %A Hernández-Rodríguez,Juan-Carlos %A Fernández-Seguín,Lourdes M %A Escobio-Prieto,Isabel %A Casuso-Holgado,María Jesús %+ Department of Physiotherapy, Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, C/ Avicena S/N, Seville, 41009, Spain, 34 954486528, mdcortes@us.es %K immersive virtual reality %K vestibular rehabilitation %K multiple sclerosis %K exergames %D 2022 %7 16.2.2022 %9 Case Report %J JMIR Serious Games %G English %X Background: Dizziness and imbalance are common and disabling symptoms in patients with multiple sclerosis (MS) and are caused by a central, peripheral, or mixed vestibulopathy. Central vestibular disorder is the most frequently reported vestibular problem in the MS population due to demyelination. Vestibular rehabilitation ameliorates these symptoms and their repercussions and improves quality of life. Immersive virtual reality (VRi) is an emerging tool in this field; however, no previous research has been performed studying its effects in MS. Objective: The aim of this study was to apply a VRi vestibular training protocol to a patient with MS and assess the effects induced by the experimental intervention. Methods: This case study included a 54-year-old woman with relapsing-remitting MS. We developed a standardized VRi exercise protocol for vestibular rehabilitation based on the gold-standard Cawthorne-Cooksey vestibular training protocol. The 20-session intervention was made up of 10 initial sessions and 10 advanced sessions. Each 50-minute session was performed two to three times per week for 7 weeks. Four evaluations were carried out over the study period: at baseline (T0), between initial and advances phases (T1), postintervention (T2), and 1 month after the experimental procedure (T3). The research outcomes were dizziness, balance, gait, impact of fatigue, quality of life, repercussions in muscular tone, and usability of the head-mounted display device. Results: After implementing the VRi vestibular protocol, improvements were seen in the following patient parameters: Dizziness Handicap Inventory score (62 points at T0; 4 points at T2); Berg Balance Scale score (47 points at T0; 54 points at T2); instrumented Timed Up and Go time (8.35 seconds at T0; 5.57 seconds at T2); muscular tone of the erector spinae, rectus femoris, and soleus; Modified Fatigue Impact Scale score (61 points at T0; 37 points at T2); and Multiple Sclerosis Quality of Life-54 values (67.16% in the physical health area at T2; 33.56% in the mental health area at T2). The patient rated the usability of the system as 90%, based on the System Usability Scale, and gave the system a grade of A. Conclusions: Although further research is needed, this study provided initial evidence that the first VRi vestibular protocol for the MS population can improve dizziness, balance, gait, impact of fatigue, quality of life, and muscular tone through an exergame intervention. This study may help establish a standardized VRi protocol for vestibular rehabilitation. %M 34766551 %R 10.2196/31020 %U https://games.jmir.org/2022/1/e31020 %U https://doi.org/10.2196/31020 %U http://www.ncbi.nlm.nih.gov/pubmed/34766551 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e32243 %T Using Virtual Reality to Induce and Assess Objective Correlates of Nicotine Craving: Paradigm Development Study %A Liu,Weichen %A Andrade,Gianna %A Schulze,Jurgen %A Doran,Neal %A Courtney,Kelly E %+ Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, United States, 1 858 534 5157, kecourtney@health.ucsd.edu %K nicotine %K craving %K cue-exposure %K virtual reality %K attentional bias %K pupillometry %K development %K smoking %K addiction %K eye-tracking %D 2022 %7 15.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Craving is a clinically important phenotype for the development and maintenance of nicotine addiction. Virtual reality (VR) paradigms are successful in eliciting cue-induced subjective craving and may even elicit stronger craving than traditional picture-cue methods. However, few studies have leveraged the advances of this technology to improve the assessment of craving. Objective: This report details the development of a novel, translatable VR paradigm designed to both elicit nicotine craving and assess multiple eye-related characteristics as potential objective correlates of craving. Methods: A VR paradigm was developed, which includes three Active scenes with nicotine and tobacco product (NTP) cues present, and three Neutral scenes devoid of NTP cues. A pilot sample (N=31) of NTP users underwent the paradigm and completed subjective measures of nicotine craving, sense of presence in the VR paradigm, and VR-related sickness. Eye-gaze fixation time (“attentional bias”) and pupil diameter toward Active versus Neutral cues, as well as spontaneous blink rate during the Active and Neutral scenes, were recorded. Results: The NTP Cue VR paradigm was found to elicit a moderate sense of presence (mean Igroup Presence Questionnaire score 60.05, SD 9.66) and low VR-related sickness (mean Virtual Reality Sickness Questionnaire score 16.25, SD 13.94). Scene-specific effects on attentional bias and pupil diameter were observed, with two of the three Active scenes eliciting greater NTP versus control cue attentional bias and pupil diameter (Cohen d=0.30-0.92). The spontaneous blink rate metrics did not differ across Active and Neutral scenes. Conclusions: This report outlines the development of the NTP Cue VR paradigm. Our results support the potential of this paradigm as an effective laboratory-based cue-exposure task and provide early evidence of the utility of attentional bias and pupillometry, as measured during VR, as useful markers for nicotine addiction. %M 35166685 %R 10.2196/32243 %U https://games.jmir.org/2022/1/e32243 %U https://doi.org/10.2196/32243 %U http://www.ncbi.nlm.nih.gov/pubmed/35166685 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31644 %T How, for Whom, and in Which Contexts or Conditions Augmented and Virtual Reality Training Works in Upskilling Health Care Workers: Realist Synthesis %A Gasteiger,Norina %A van der Veer,Sabine N %A Wilson,Paul %A Dowding,Dawn %+ Division of Nursing, Midwifery and Social Work, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, United Kingdom, 44 01613067798, norina.gasteiger@postgrad.manchester.ac.uk %K realist synthesis %K realist review %K review %K virtual reality %K augmented reality %K simulation %K training %K health %K health personnel %K education %K mobile phone %D 2022 %7 14.2.2022 %9 Review %J JMIR Serious Games %G English %X Background: Using traditional simulators (eg, cadavers, animals, or actors) to upskill health workers is becoming less common because of ethical issues, commitment to patient safety, and cost and resource restrictions. Virtual reality (VR) and augmented reality (AR) may help to overcome these barriers. However, their effectiveness is often contested and poorly understood and warrants further investigation. Objective: The aim of this review is to develop, test, and refine an evidence-informed program theory on how, for whom, and to what extent training using AR or VR works for upskilling health care workers and to understand what facilitates or constrains their implementation and maintenance. Methods: We conducted a realist synthesis using the following 3-step process: theory elicitation, theory testing, and theory refinement. We first searched 7 databases and 11 practitioner journals for literature on AR or VR used to train health care staff. In total, 80 papers were identified, and information regarding context-mechanism-outcome (CMO) was extracted. We conducted a narrative synthesis to form an initial program theory comprising of CMO configurations. To refine and test this theory, we identified empirical studies through a second search of the same databases used in the first search. We used the Mixed Methods Appraisal Tool to assess the quality of the studies and to determine our confidence in each CMO configuration. Results: Of the 41 CMO configurations identified, we had moderate to high confidence in 9 (22%) based on 46 empirical studies reporting on VR, AR, or mixed simulation training programs. These stated that realistic (high-fidelity) simulations trigger perceptions of realism, easier visualization of patient anatomy, and an interactive experience, which result in increased learner satisfaction and more effective learning. Immersive VR or AR engages learners in deep immersion and improves learning and skill performance. When transferable skills and knowledge are taught using VR or AR, skills are enhanced and practiced in a safe environment, leading to knowledge and skill transfer to clinical practice. Finally, for novices, VR or AR enables repeated practice, resulting in technical proficiency, skill acquisition, and improved performance. The most common barriers to implementation were up-front costs, negative attitudes and experiences (ie, cybersickness), developmental and logistical considerations, and the complexity of creating a curriculum. Facilitating factors included decreasing costs through commercialization, increasing the cost-effectiveness of training, a cultural shift toward acceptance, access to training, and leadership and collaboration. Conclusions: Technical and nontechnical skills training programs using AR or VR for health care staff may trigger perceptions of realism and deep immersion and enable easier visualization, interactivity, enhanced skills, and repeated practice in a safe environment. This may improve skills and increase learning, knowledge, and learner satisfaction. The future testing of these mechanisms using hypothesis-driven approaches is required. Research is also required to explore implementation considerations. %M 35156931 %R 10.2196/31644 %U https://games.jmir.org/2022/1/e31644 %U https://doi.org/10.2196/31644 %U http://www.ncbi.nlm.nih.gov/pubmed/35156931 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 2 %P e26736 %T The Effectiveness of Virtual Reality Exposure–Based Cognitive Behavioral Therapy for Severe Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder: Meta-analysis %A van Loenen,Inge %A Scholten,Willemijn %A Muntingh,Anna %A Smit,Johannes %A Batelaan,Neeltje %+ GGZ inGeest Specialized Mental Health Care, Oldenaller 1, Amsterdam, 1081HJ, Netherlands, 31 207884666, w.scholten@ggzingeest.nl %K anxiety disorders %K virtual reality %K virtual reality exposure therapy %K cognitive behavioral therapy %K meta-analysis %K mobile phone %D 2022 %7 10.2.2022 %9 Review %J J Med Internet Res %G English %X Background: In recent years, virtual reality exposure–based cognitive behavioral therapy (VRE-CBT) has shown good treatment results in (subclinical) anxiety disorders and seems to be a good alternative to exposure in vivo in regular cognitive behavioral therapy (CBT). However, previous meta-analyses on the efficacy of VRE-CBT on anxiety disorders have included studies on specific phobias and subthreshold anxiety; therefore, these results may not be generalizable to patients with more severe and disabling anxiety disorders. Objective: The objective of our study is to determine the efficacy of VRE-CBT on more severe anxiety disorders, excluding specific phobias and subthreshold anxiety disorders. Meta-analyses will be conducted to examine the efficacy of VRE-CBT versus waitlist and regular CBT. Our secondary objectives are to examine whether the efficacy differs according to the type of anxiety disorder, type of recruitment, and type of VRE-CBT (virtual reality exposure either with or without regular CBT). Furthermore, attrition in VRE-CBT and CBT will be compared. Methods: Studies published until August 20, 2020, were retrieved through systematic literature searches in PubMed, PsycINFO, and Embase. We calculated the effect sizes (Hedges g) for the difference between the conditions and their 95% CIs for posttest and follow-up measurements in a random effects model. A separate meta-analysis was performed to compare attrition between the VRE-CBT and CBT conditions. Results: A total of 16 trials with 817 participants were included. We identified 10 comparisons between VRE-CBT and a waitlist condition and 13 comparisons between VRE-CBT and a CBT condition. With regard to risk of bias, information on random sequence generation, allocation concealment, and risk of bias for selective outcome reporting was often absent or unclear. The mean effect size of VRE-CBT compared with waitlist (nco=10) was medium and significant, favoring VRE-CBT (Hedges g=−0.490, 95% CI −0.82 to −0.16; P=.003). The mean effect size of VRE-CBT compared with CBT (nco=13) was small and nonsignificant, favoring CBT (Hedges g=0.083, 95% CI −0.13 to 0.30; P=.45). The dropout rates between VRE-CBT and CBT (nco=10) showed no significant difference (odds ratio 0.79, 95% CI 0.49-1.27; P=.32). There were no indications of small study effects or publication bias. Conclusions: The results of our study show that VRE-CBT is more effective than waitlist and as effective as CBT in the treatment of more severe anxiety disorders. Therefore, VRE-CBT may be considered a promising alternative to CBT for patients with more severe anxiety disorders. Higher-quality randomized controlled trials are needed to verify the robustness of these findings. %M 35142632 %R 10.2196/26736 %U https://www.jmir.org/2022/2/e26736 %U https://doi.org/10.2196/26736 %U http://www.ncbi.nlm.nih.gov/pubmed/35142632 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e27597 %T Data-Driven Classification of Human Movements in Virtual Reality–Based Serious Games: Preclinical Rehabilitation Study in Citizen Science %A Barak Ventura,Roni %A Stewart Hughes,Kora %A Nov,Oded %A Raghavan,Preeti %A Ruiz Marín,Manuel %A Porfiri,Maurizio %+ Center for Urban Science and Progress, New York University, 370 Jay Street, Brooklyn, NY, 11201, United States, 1 646 997 3681, mporfiri@nyu.edu %K motion analysis %K principal component analysis %K telerehabilitation %K virtual reality %D 2022 %7 10.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Sustained engagement is essential for the success of telerehabilitation programs. However, patients’ lack of motivation and adherence could undermine these goals. To overcome this challenge, physical exercises have often been gamified. Building on the advantages of serious games, we propose a citizen science–based approach in which patients perform scientific tasks by using interactive interfaces and help advance scientific causes of their choice. This approach capitalizes on human intellect and benevolence while promoting learning. To further enhance engagement, we propose performing citizen science activities in immersive media, such as virtual reality (VR). Objective: This study aims to present a novel methodology to facilitate the remote identification and classification of human movements for the automatic assessment of motor performance in telerehabilitation. The data-driven approach is presented in the context of a citizen science software dedicated to bimanual training in VR. Specifically, users interact with the interface and make contributions to an environmental citizen science project while moving both arms in concert. Methods: In all, 9 healthy individuals interacted with the citizen science software by using a commercial VR gaming device. The software included a calibration phase to evaluate the users’ range of motion along the 3 anatomical planes of motion and to adapt the sensitivity of the software’s response to their movements. During calibration, the time series of the users’ movements were recorded by the sensors embedded in the device. We performed principal component analysis to identify salient features of movements and then applied a bagged trees ensemble classifier to classify the movements. Results: The classification achieved high performance, reaching 99.9% accuracy. Among the movements, elbow flexion was the most accurately classified movement (99.2%), and horizontal shoulder abduction to the right side of the body was the most misclassified movement (98.8%). Conclusions: Coordinated bimanual movements in VR can be classified with high accuracy. Our findings lay the foundation for the development of motion analysis algorithms in VR-mediated telerehabilitation. %M 35142629 %R 10.2196/27597 %U https://games.jmir.org/2022/1/e27597 %U https://doi.org/10.2196/27597 %U http://www.ncbi.nlm.nih.gov/pubmed/35142629 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31747 %T Development and Evaluation of a Virtual Reality Puzzle Game to Decrease Food Intake: Randomized Controlled Trial %A Liu,Yunxin %A Stamos,Angelos %A Dewitte,Siegfried %A van Berlo,Zeph M C %A van der Laan,Laura N %+ Department of Communication and Cognition, Tilburg University, PO Box 90153, Tilburg, 5000 LE, Netherlands, 31 (0)134664811, L.N.vdLaan@tilburguniversity.edu %K virtual reality %K pre-exposure %K self-control %K hedonic consumption %K food cravings %D 2022 %7 3.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) has gained popularity in daily life, and VR food cues seem to elicit food cravings, similar to real food cues. However, little is known about the impact of VR food cues on actual food intake. Objective: In real life (RL), exposure to food cues in a situation in which the desire to eat food interferes with the completion of a food-related task reduces the subsequent food intake (ie, the pre-exposure effect). In this study, we examine, on the one hand, whether the pre-exposure effect could be replicated in RL and, on the other hand, whether this effect could be extended to VR contexts. Methods: The study used a 2 (stimulus type: food vs nonfood) × 2 (mode: VR vs RL) between-subject design (n=175). Participants were randomly assigned to 1 of the 4 conditions. Results: We found the main effect of mode on food intake, with a higher food intake after both VR conditions than after RL conditions (P=.02). In addition, among female participants, we found that exposure to both food cues (ie, VR and RL) resulted in lower food intake than exposure to both nonfood cues (P=.05). In contrast, this effect was not observed among male participants (P=.34). Additionally, VR and RL cues generated similar emotional and behavioral responses (eg, arousal and game difficulty). Conclusions: We were unable to replicate the exposure effect in our complete sample. Subgroup analyses, however, showed that for women, exposure to food cues (either in VR or in RL) reduces food intake, indicating that a VR pre-exposure procedure may effectively be applied exclusively for women. Trial Registration: ClinicalTrials.gov NCT05169996; https://clinicaltrials.gov/ct2/show/NCT05169996 %M 35113028 %R 10.2196/31747 %U https://games.jmir.org/2022/1/e31747 %U https://doi.org/10.2196/31747 %U http://www.ncbi.nlm.nih.gov/pubmed/35113028 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 8 %N 1 %P e34860 %T Virtual Reality in Medical Students’ Education: Scoping Review %A Jiang,Haowen %A Vimalesvaran,Sunitha %A Wang,Jeremy King %A Lim,Kee Boon %A Mogali,Sreenivasulu Reddy %A Car,Lorainne Tudor %+ Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road Singapore, Singapore, 308232, Singapore, 65 69041258, lorainne.tudor.car@ntu.edu.sg %K virtual reality %K medical education %K medical students %K virtual worlds %K digital health education %D 2022 %7 2.2.2022 %9 Original Paper %J JMIR Med Educ %G English %X Background: Virtual reality (VR) produces a virtual manifestation of the real world and has been shown to be useful as a digital education modality. As VR encompasses different modalities, tools, and applications, there is a need to explore how VR has been used in medical education. Objective: The objective of this scoping review is to map existing research on the use of VR in undergraduate medical education and to identify areas of future research. Methods: We performed a search of 4 bibliographic databases in December 2020. Data were extracted using a standardized data extraction form. The study was conducted according to the Joanna Briggs Institute methodology for scoping reviews and reported in line with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Results: Of the 114 included studies, 69 (60.5%) reported the use of commercially available surgical VR simulators. Other VR modalities included 3D models (15/114, 13.2%) and virtual worlds (20/114, 17.5%), which were mainly used for anatomy education. Most of the VR modalities included were semi-immersive (68/114, 59.6%) and were of high interactivity (79/114, 69.3%). There is limited evidence on the use of more novel VR modalities, such as mobile VR and virtual dissection tables (8/114, 7%), as well as the use of VR for nonsurgical and nonpsychomotor skills training (20/114, 17.5%) or in a group setting (16/114, 14%). Only 2.6% (3/114) of the studies reported the use of conceptual frameworks or theories in the design of VR. Conclusions: Despite the extensive research available on VR in medical education, there continue to be important gaps in the evidence. Future studies should explore the use of VR for the development of nonpsychomotor skills and in areas other than surgery and anatomy. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2020-046986 %M 35107421 %R 10.2196/34860 %U https://mededu.jmir.org/2022/1/e34860 %U https://doi.org/10.2196/34860 %U http://www.ncbi.nlm.nih.gov/pubmed/35107421 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e31404 %T A Serious Game for Performing Task-Oriented Cervical Exercises Among Older Adult Patients With Chronic Neck Pain: Development, Suitability, and Crossover Pilot Study %A Beltran-Alacreu,Hector %A Navarro-Fernández,Gonzalo %A Godia-Lledó,Daniela %A Graell-Pasarón,Lucas %A Ramos-González,Álvaro %A Raya,Rafael %A Martin-Pintado Zugasti,Aitor %A Fernandez-Carnero,Josue %+ Departamento de Fisioterapia, Facultad de Medicina, Universidad San Pablo-CEU, CEU Universities, Avenida de Monteprincipe s/n Boadilla del Monte, Madrid, 28668, Spain, 34 91 3724700 ext 14635, martinpintado.a@gmail.com %K video games %K neck pain %K aged %K virtual reality %K exercise therapy %K physical therapy modalities %K technology %D 2022 %7 1.2.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: There is sparse research on the effectiveness of therapeutic exercise for the treatment of neck pain in older adult populations. Moreover, there is a lack of research on the use of serious games or virtual reality for the treatment of neck pain in this population. Objective: The primary aim of this study was to develop and assess the suitability of a serious game for performing task-oriented cervical exercises in patients with neck pain. Methods: A serious game was designed based on the key features identified by previous studies that designed serious video games for physical and cognitive rehabilitation or exercise. The game in this study was designed to provide an interactive scenario, with the main functionality of the software solution to control a virtual airplane to reach targets using head motions. At the end of the exercise, the application stores the targets reached and missed and the airplane’s trajectory. A crossover pilot study was carried out for preliminary evaluation of the suitability of the technology in the older adult population. Men and women over 65 years of age with chronic neck pain were included. Subjects were randomly assigned to two study arms; each arm consisted of a sequence of two 4-week treatments with an intermediate washout period of 4 weeks. The total study duration was 16 weeks due to a final follow-up measure 4 weeks after the end of all treatments. Treatment A consisted of the use of the serious game developed in this study, and treatment B consisted of conventional exercises. Subjects allocated to the A-B study arm received treatment A first, followed by treatment B, and vice versa in the B-A arm. The following variables were assessed: Suitability Evaluation Questionnaire (SEQ) scores, Visual Analog Scale scores, and the number of targets reached in the serious game. Results: A total of 18 subjects were assessed for eligibility. A total of 13 subjects, aged between 71 and 92 years (mean 81.85, SD 6.82), were finally included and completed the study protocol. The global mean SEQ score was 50.38 (SD 5.35) out of 65 points, showing good suitability of the serious game. Most patients considered the experience very enjoyable and “real” in terms of the virtual environment and found the information provided to be clear. Also, they believed that the game could be very helpful for their rehabilitation. None of the patients felt any neck pain or discomfort when playing the game, and only 2 patients out of 13 (15%) reported some degree of dizziness, eye discomfort, or disorientation, which did not limit their capacity to finish the session. Conclusions: The serious game developed in this study showed good suitability for use in adults over 70 years of age with chronic neck pain. The game was a safe method for performing task-oriented cervical exercises, and patients reported very high levels of satisfaction and acceptance after the use of this technology. %M 35103608 %R 10.2196/31404 %U https://games.jmir.org/2022/1/e31404 %U https://doi.org/10.2196/31404 %U http://www.ncbi.nlm.nih.gov/pubmed/35103608 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 1 %P e32368 %T Intensive Care Unit–Specific Virtual Reality for Critically Ill Patients With COVID-19: Multicenter Randomized Controlled Trial %A Vlake,Johan H %A van Bommel,Jasper %A Wils,Evert-Jan %A Bienvenu,Joe %A Hellemons,Merel E %A Korevaar,Tim IM %A Schut,Anna FC %A Labout,Joost AM %A Schreuder,Lois LH %A van Bavel,Marten P %A Gommers,Diederik %A van Genderen,Michel E %+ Department of Intensive Care, Erasmus MC, Dr Molewaterplein 40, Rotterdam, 3015 GD, Netherlands, 31 107039881, m.vangenderen@erasmusmc.nl %K SARS-CoV-2 %K intensive care %K post-intensive care syndrome %K virtual reality %K quality of life %K satisfaction %K COVID-19 %D 2022 %7 31.1.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Although psychological sequelae after intensive care unit (ICU) treatment are considered quite intrusive, robustly effective interventions to treat or prevent these long-term sequelae are lacking. Recently, it was demonstrated that ICU-specific virtual reality (ICU-VR) is a feasible and acceptable intervention with potential mental health benefits. However, its effect on mental health and ICU aftercare in COVID-19 ICU survivors is unknown. Objective: This study aimed to explore the effects of ICU-VR on mental health and on patients’ perceived quality of, satisfaction with, and rating of ICU aftercare among COVID-19 ICU survivors. Methods: This was a multicenter randomized controlled trial. Patients were randomized to either the ICU-VR (intervention) or the control group. All patients were invited to an COVID-19 post-ICU follow-up clinic 3 months after hospital discharge, during which patients in the intervention group received ICU-VR. One month and 3 months later (4 and 6 months after hospital discharge), mental health, quality of life, perceived quality, satisfaction with, and rating of ICU aftercare were scored using questionnaires. Results: Eighty-nine patients (median age 58 years; 63 males, 70%) were included. The prevalence and severity of psychological distress were limited throughout follow-up, and no differences in psychological distress or quality of life were observed between the groups. ICU-VR improved satisfaction with (mean score 8.7, SD 1.6 vs 7.6, SD 1.6 [ICU-VR vs control]; t64=–2.82, P=.006) and overall rating of ICU aftercare (mean overall rating of aftercare 8.9, SD 0.9 vs 7.8, SD 1.7 [ICU-VR vs control]; t64=–3.25; P=.002) compared to controls. ICU-VR added to the quality of ICU aftercare according to 81% of the patients, and all patients would recommend ICU-VR to other ICU survivors. Conclusions: ICU-VR is a feasible and acceptable innovative method to improve satisfaction with and rating of ICU aftercare and adds to its perceived quality. We observed a low prevalence of psychological distress after ICU treatment for COVID-19, and ICU-VR did not improve psychological recovery or quality of life. Future research is needed to confirm our results in other critical illness survivors to potentially facilitate ICU-VR’s widespread availability and application during follow-up. Trial Registration: Netherlands Trial Register NL8835; https://www.trialregister.nl/trial/8835 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-021-05271-z %M 34978530 %R 10.2196/32368 %U https://www.jmir.org/2022/1/e32368 %U https://doi.org/10.2196/32368 %U http://www.ncbi.nlm.nih.gov/pubmed/34978530 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 1 %P e30600 %T Virtual Reality Simulation for Disaster Preparedness Training in Hospitals: Integrated Review %A Jung,Younhyun %+ School of Computing, Gachon University, 1332, Seongnam-daero, Sujeong-gu, Seongnam-si, 13120, Republic of Korea, 82 317504771, younhyun.jung@gachon.ac.kr %K virtual reality %K in-hospital disaster preparedness training %K mass casualty incidents %K hospitals %D 2022 %7 28.1.2022 %9 Review %J J Med Internet Res %G English %X Background: A critical component of disaster preparedness in hospitals is experiential education and training of health care professionals. A live drill is a well-established, effective training approach, but cost restraints and logistic constraints make clinical implementation challenging, and training opportunities with live drills may be severely limited. Virtual reality simulation (VRS) technology may offer a viable training alternative with its inherent features of reproducibility, just-in-time training, and repeatability. Objective: This integrated review examines the scientific evidence pertaining to the effectiveness of VRS and its practical usefulness in training health care professionals for in-hospital disaster preparedness. Methods: A well-known 4-stage methodology was used for the integrated review process. It consisted of problem identification, a literature search and inclusion criteria determination, 2-stage validation and analysis of searched studies, and presentation of findings. A search of diverse publication repositories was performed. They included Web of Science (WOS), PubMed (PMD), and Embase (EMB). Results: The integrated review process resulted in 12 studies being included. Principle findings identified 3 major capabilities of VRS: (1) to realistically simulate the clinical environment and medical practices related to different disaster scenarios, (2) to develop learning effects on increased confidence and enhanced knowledge acquisition, and (3) to enable cost-effective implementation of training programs. Conclusions: The findings from the integrated review suggested that VRS could be a competitive, cost-effective adjunct to existing training approaches. Although the findings demonstrated the applicability of VRS to different training scenarios, these do not entirely cover all disaster scenarios that could happen in hospitals. This integrated review expects that the recent advances of VR technologies can be 1 of the catalysts to enable the wider adoption of VRS training on challenging clinical scenarios that require sophisticated modeling and environment depiction. %M 35089144 %R 10.2196/30600 %U https://www.jmir.org/2022/1/e30600 %U https://doi.org/10.2196/30600 %U http://www.ncbi.nlm.nih.gov/pubmed/35089144 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 24 %N 1 %P e27641 %T A Novel Virtual Reality Assessment of Functional Cognition: Validation Study %A Porffy,Lilla Alexandra %A Mehta,Mitul A %A Patchitt,Joel %A Boussebaa,Celia %A Brett,Jack %A D’Oliveira,Teresa %A Mouchlianitis,Elias %A Shergill,Sukhi S %+ Institute of Psychiatry, Psychology & Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AF, United Kingdom, 44 07738244217, lilla.a.porffy@kcl.ac.uk %K virtual reality %K virtual reality assessment %K cognition %K functional cognition %K functional capacity %K neuropsychological testing %D 2022 %7 26.1.2022 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive deficits are present in several neuropsychiatric disorders, including Alzheimer disease, schizophrenia, and depression. Assessments used to measure cognition in these disorders are time-consuming, burdensome, and have low ecological validity. To address these limitations, we developed a novel virtual reality shopping task—VStore. Objective: This study aims to establish the construct validity of VStore in relation to the established computerized cognitive battery, Cogstate, and explore its sensitivity to age-related cognitive decline. Methods: A total of 142 healthy volunteers aged 20-79 years participated in the study. The main VStore outcomes included verbal recall of 12 grocery items, time to collect items, time to select items on a self-checkout machine, time to make the payment, time to order coffee, and total completion time. Construct validity was examined through a series of backward elimination regression models to establish which Cogstate tasks, measuring attention, processing speed, verbal and visual learning, working memory, executive function, and paired associate learning, in addition to age and technological familiarity, best predicted VStore performance. In addition, 2 ridge regression and 2 logistic regression models supplemented with receiver operating characteristic curves were built, with VStore outcomes in the first model and Cogstate outcomes in the second model entered as predictors of age and age cohorts, respectively. Results: Overall VStore performance, as indexed by the total time spent completing the task, was best explained by Cogstate tasks measuring attention, working memory, paired associate learning, and age and technological familiarity, accounting for 47% of the variance. In addition, with λ=5.16, the ridge regression model selected 5 parameters for VStore when predicting age (mean squared error 185.80, SE 19.34), and with λ=9.49 for Cogstate, the model selected all 8 tasks (mean squared error 226.80, SE 23.48). Finally, VStore was found to be highly sensitive (87%) and specific (91.7%) to age cohorts, with 94.6% of the area under the receiver operating characteristic curve. Conclusions: Our findings suggest that VStore is a promising assessment that engages standard cognitive domains and is sensitive to age-related cognitive decline. %M 35080501 %R 10.2196/27641 %U https://www.jmir.org/2022/1/e27641 %U https://doi.org/10.2196/27641 %U http://www.ncbi.nlm.nih.gov/pubmed/35080501 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 10 %N 1 %P e29987 %T Immersive Virtual Reality Exergames for Persons Living With Dementia: User-Centered Design Study as a Multistakeholder Team During the COVID-19 Pandemic %A Muñoz,John %A Mehrabi,Samira %A Li,Yirou %A Basharat,Aysha %A Middleton,Laura E %A Cao,Shi %A Barnett-Cowan,Michael %A Boger,Jennifer %+ Department of Systems Design Engineering, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada, 1 (519) 888 4567, john.munoz.hci@uwaterloo.ca %K virtual reality %K exergames %K persons living with dementia %K physical activity %K head mounted displays %K participatory design %K co-development %K gaming %K older adults %K elderly %K design %K dementia %K VR %K user-centered %K physical activity %K exercise %K COVID-19 %D 2022 %7 19.1.2022 %9 Original Paper %J JMIR Serious Games %G English %X Background: Advancements in supporting personalized health care and well-being using virtual reality (VR) have created opportunities to use immersive games to support a healthy lifestyle for persons living with dementia and mild cognitive impairment (MCI). Collaboratively designing exercise video games (exergames) as a multistakeholder team is fundamental to creating games that are attractive, effective, and accessible. Objective: This research extensively explores the use of human-centered design methods that involve persons living with dementia in long-term care facilitates, exercise professionals, content developers, game designers, and researchers in the creation of VR exergames targeting physical activity promotion for persons living with dementia/MCI. Methods: Conceptualization, collaborative design, and playtesting activities were carried out to design VR exergames to engage persons living with dementia in exercises to promote upper limb flexibility, strength, and aerobic endurance. We involved a total of 7 persons living with dementia/MCI, 5 exercise professionals, 5 community-dwelling older adults, a VR company for content creation, and a multidisciplinary research team with game designers, engineers, and kinesiology experts. Results: An immersive VR exergame called Seas the Day was jointly designed and developed and it is freely available to be played in state-of-the-art VR headsets (Oculus Quest 1, 2). A model for the triadic interaction (health care institution, industry partner, academia) is also presented to illustrate how different stakeholders contribute to the design of VR exergames that consider/complement complex needs, preferences, and motivators of an underrepresented group of end users. Conclusions: This study provides evidence that a collaborative multistakeholder design results in more tailored and context-aware VR games for persons living with dementia. The insights and lessons learned from this research can be used by others to co-design games, including remote engagement techniques that were used during the COVID-19 pandemic. %M 35044320 %R 10.2196/29987 %U https://games.jmir.org/2022/1/e29987 %U https://doi.org/10.2196/29987 %U http://www.ncbi.nlm.nih.gov/pubmed/35044320 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 12 %P e31844 %T The Effects of Virtual Reality Treatment on Prefrontal Cortex Activity in Patients With Social Anxiety Disorder: Participatory and Interactive Virtual Reality Treatment Study %A Lee,Hojun %A Choi,JongKwan %A Jung,Dooyoung %A Hur,Ji-Won %A Cho,Chul-Hyun %+ Department of Psychiatry, College of Medicine, Chungnam National University, 82 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea, 82 044 995 4775, david0203@gmail.com %K anxiety %K social anxiety disorder %K virtual reality %K fNIRS %K brain activity %K prefrontal cortex %K effectiveness %D 2021 %7 17.12.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Attempts to use virtual reality (VR) as a treatment for various psychiatric disorders have been made recently, and many researchers have identified the effects of VR in psychiatric disorders. Studies have reported that VR therapy is effective in social anxiety disorder (SAD). However, there is no prior study on the neural correlates of VR therapy in patients with SAD. Objective: The aim of this study is to find the neural correlates of VR therapy by evaluating the treatment effectiveness of VR in patients with SAD using portable functional near-infrared spectroscopy (fNIRS). Methods: Patients with SAD (n=28) were provided with 6 sessions of VR treatment that was developed for exposure to social situations with a recording system of each participant’s self-introduction in VR. After each VR treatment session, the first-person view (video 1) and third-person view (video 2) clips of the participant’s self-introduction were automatically generated. The functional activities of prefrontal regions were measured by fNIRS while watching videos 1 and 2 with a cognitive task, before and after whole VR treatment sessions, and after the first session of VR treatment. We compared the data of fNIRS between patients with SAD and healthy controls (HCs; n=27). Results: We found that reduction in activities of the right frontopolar prefrontal cortex (FPPFC) in HCs was greater than in the SAD group at baseline (t=–2.01, P=.049). Comparing the frontal cortex activation before and after VR treatment sessions in the SAD group showed significant differences in activities of the FPPFC (right: t=–2.93, P<.001; left: t=–2.25, P=.03) and the orbitofrontal cortex (OFC) (right: t=–2.10, P=.045; left: t=–2.21, P=.04) while watching video 2. Conclusions: Activities of the FPPFC and OFC were associated with symptom reduction after VR treatment for SAD. Our study findings might provide a clue to understanding the mechanisms underlying VR treatment for SAD. Trial Registration: Clinical Research Information Service (CRIS) KCT0003854; https://tinyurl.com/559jp2kp %M 34801979 %R 10.2196/31844 %U https://www.jmir.org/2021/12/e31844 %U https://doi.org/10.2196/31844 %U http://www.ncbi.nlm.nih.gov/pubmed/34801979 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e30482 %T Awareness, Prevention, Detection, and Therapy Applications for Depression and Anxiety in Serious Games for Children and Adolescents: Systematic Review %A Martinez,Kim %A Menéndez-Menéndez,Maria Isabel %A Bustillo,Andres %+ Department of History, Geography and Communication, University of Burgos, Don Juan de Austria, Burgos, 09001, Spain, 34 947 49 91 12, kmartinez@ubu.es %K serious games %K depression %K anxiety %K children %K adolescents %K virtual reality %K mental health %K detection %K awareness %K prevention %K therapy %D 2021 %7 16.12.2021 %9 Review %J JMIR Serious Games %G English %X Background: Depression and anxiety in children and adolescents are major health problems worldwide. In recent years, serious games research has advanced in the development of tools to address these mental health conditions. However, there has not been an extensive analysis of these games, their tendencies, and capacities. Objective: This review aims to gather the most current serious games, published from 2015 to 2020, with a new approach focusing on their applications: awareness, prevention, detection, and therapy. The purpose is also to analyze the implementation, development, and evaluation of these tools to obtain trends, strengths, and weaknesses for future research lines. Methods: The identification of the serious games through a literature search was conducted on the databases PubMed, Scopus, Wiley, Taylor and Francis, Springer, PsycINFO, PsycArticles, Web of Science, and Science Direct. The identified records were screened to include only the manuscripts meeting these criteria: a serious game for PC, smartphone, or virtual reality; developed by research teams; targeting only depression or anxiety or both; aiming specifically at children or adolescents. Results: A total of 34 studies have been found that developed serious games for PC, smartphone, and virtual reality devices and tested them in children and adolescents. Most of the games address both conditions and are applied in prevention and therapy. Nevertheless, there is a trend that anxiety is targeted more in childhood and depression targeted more in adolescence. Regarding design, the game genres arcade minigames, adventure worlds, and social simulations are used, in this order. For implementation, these serious games usually require sessions of 1 hour and are most often played using a PC. Moreover, the common evaluation tools are normalized questionnaires that measure acquisition of skills or reduction of symptoms. Most studies collect and compare these data before and after the participants play. Conclusions: The results show that more awareness and detection games are needed, as well as games that mix the awareness, prevention, detection, and therapy applications. In addition, games for depression and anxiety should equally target all age ranges. For future research, the development and evaluation of serious games should be standardized, so the implementation of serious games as tools would advance. The games should always offer support while playing, in addition to collecting data on participant behavior during the game to better analyze their learning. Furthermore, there is an open line regarding the use of virtual reality for these games due to the capabilities offered by this technology. %M 34927589 %R 10.2196/30482 %U https://games.jmir.org/2021/4/e30482 %U https://doi.org/10.2196/30482 %U http://www.ncbi.nlm.nih.gov/pubmed/34927589 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e30985 %T Augmented Reality in Physical Therapy: Systematic Review and Meta-analysis %A Vinolo Gil,Maria Jesus %A Gonzalez-Medina,Gloria %A Lucena-Anton,David %A Perez-Cabezas,Veronica %A Ruiz-Molinero,María Del Carmen %A Martín-Valero,Rocío %+ Department of Nursing and Physical Therapy, University of Cadiz, Avda Ana de Viya 52, Cadiz, 11009, Spain, 34 670609656, gloriagonzalez.medina@uca.es %K augmented reality %K physical therapy %K rehabilitation %K functionality %D 2021 %7 15.12.2021 %9 Review %J JMIR Serious Games %G English %X Background: Augmented reality (AR) is a rapidly expanding technology; it comprises the generation of new images from digital information in the real physical environment of a person, which simulates an environment where the artificial and real are mixed. The use of AR in physiotherapy has shown benefits in certain areas of patient health. However, these benefits have not been studied as a whole. Objective: This study aims to ascertain the current scientific evidence on AR therapy as a complement to physiotherapy and to determine the areas in which it has been used the most and which variables and methods have been most effective. Methods: A systematic review registered in PROSPERO (International Prospective Register of Systematic Reviews) was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) recommendations. The search was conducted from July to August 2021 in the PubMed, PEDro, Web of Science, Scopus, and Cochrane Library scientific databases using the keywords augmented reality, physiotherapy, physical therapy, exercise therapy, rehabilitation, physical medicine, fitness, and occupational therapy. The methodological quality was evaluated using the PEDro scale and the Scottish Intercollegiate Guidelines Network scale to determine the degree of recommendation. The Cochrane Collaboration tool was used to evaluate the risk of bias. Results: In total, 11 articles were included in the systematic review. Of the 11 articles, 4 (36%) contributed information to the meta-analysis. Overall, 64% (7/11) obtained a good level of evidence, and most had a B degree of recommendation of evidence. A total of 308 participants were analyzed. Favorable results were found for the Berg Balance Scale (standardized mean change 0.473, 95% CI −0.0877 to 1.0338; z=1.65; P=.10) and the Timed Up and Go test (standardized mean change −1.211, 95% CI −3.2005 to 0.7768; z=−1.194; P=.23). Conclusions: AR, in combination with conventional therapy, has been used for the treatment of balance and fall prevention in geriatrics, lower and upper limb functionality in stroke, pain in phantom pain syndrome, and turning in place in patients with Parkinson disease with freezing of gait. AR is effective for the improvement of balance; however, given the small size of the samples and the high heterogeneity of the studies, the results were not conclusive. Future studies using larger sample sizes and with greater homogeneity in terms of the devices used and the frequency and intensity of the interventions are needed. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020180766; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=180766 %M 34914611 %R 10.2196/30985 %U https://games.jmir.org/2021/4/e30985 %U https://doi.org/10.2196/30985 %U http://www.ncbi.nlm.nih.gov/pubmed/34914611 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e29956 %T Design of a Virtual Reality Interactive Training System for Public Health Emergency Preparedness for Major Emerging Infectious Diseases: Theory and Framework %A Luo,Yue %A Li,Mei %A Tang,Jian %A Ren,JianLan %A Zheng,Yu %A Yu,XingLi %A Jiang,LinRui %A Fan,DingLin %A Chen,YanHua %+ Department of Nursing, The Affiliated Hospital of Southwest Medical University, 25, Taiping Road, Luzhou City, 646000, China, 86 18982765016, Chen_yanhua25@163.com %K virtual reality %K major emerging infectious diseases %K emergency preparedness %K interactive narrative theory %K situated learning theory %K human-computer interaction theory %K emergency simulation %K public health %K training %K VR %K epidemic %K medical education %K education %D 2021 %7 14.12.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Sufficient public health emergency preparedness (PHEP) is the key factor in effectively responding to and recovering from major emerging infectious diseases (MEIDs). However, in the face of MEIDs, PHEP is insufficient, so it is necessary to improve PHEP. The rapid development of virtual reality and human-computer interaction provides unprecedented opportunities for innovative educational methods. Objective: This study designed a virtual reality interactive training system (VRITS) to provide an effective path for improving PHEP in the context of MEIDs so that the public can effectively respond to and recover from MEIDs. Methods: This study used interactive narrative, situated learning and human-computer interaction theories as a theoretical framework to guide the design of the system. We used the literature research method and the Delphi method; consulted multidisciplinary experts, such as infectious diseases, disease control, psychology, and public health personnel, to determine the educational content framework; and set up an interdisciplinary team to construct an operating system framework for the VRITS. Results: We named the VRITS “People’s War Against Pandemic.” The educational content framework includes 20 knowledge, emotion, and behavior skills in 5 aspects (cooperating with prevention and control work, improving emergency response ability, guaranteeing supplies and equipment, preparing economic resources, and maintaining physical and mental health). The operating system framework includes virtual interactive training, knowledge corner, intelligent evaluation, and community forum modules, and the core module is the virtual interactive training module. In this module, users control virtual characters to move in various scenes, and then identify and analyze the controllability and harmfulness of the evolving pandemic and select the correct prevention and control strategy to avoid infecting themselves and others. Conclusions: The development and sharing of the multidisciplinary theoretical framework adopted by People’s War Against Pandemic can help us clarify the design ideas and assumptions of the VRITS; predict training results; understand the ability of training to change emergency knowledge, emergency emotion, and behavioral responses to MEIDs; and promote the development of more effective training systems based on virtual reality. %M 34904951 %R 10.2196/29956 %U https://games.jmir.org/2021/4/e29956 %U https://doi.org/10.2196/29956 %U http://www.ncbi.nlm.nih.gov/pubmed/34904951 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e30919 %T A Virtual Supermarket Program for the Screening of Mild Cognitive Impairment in Older Adults: Diagnostic Accuracy Study %A Yan,Mingli %A Yin,Huiru %A Meng,Qiuyan %A Wang,Shuo %A Ding,Yiwen %A Li,Guichen %A Wang,Chunyan %A Chen,Li %+ School of Nursing, Jilin University, 965 Xinjiang Street, Changchun, 130021, China, 86 043185619366, chen_care@126.com %K virtual reality %K mild cognitive impairment %K dementia %K ambient intelligence %K digital health %K elderly population %K aging %D 2021 %7 3.12.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Mild cognitive impairment (MCI) is often a precursor of dementia, and patients with MCI develop dementia at a higher rate than healthy older adults. Early detection of cognitive decline at the MCI stage supports better planning of care and interventions. At present, the use of virtual reality (VR) in screening for MCI in older adults is promising, but there is little evidence regarding the use of virtual supermarkets to screen for MCI. Objective: The objectives of this study are to validate a VR game–based test, namely, the Virtual Supermarket Program (VSP), for differentiating patients with MCI and healthy controls and to identify cutoff scores for different age levels. Methods: Subjects were recruited from several nursing homes and communities in Changchun, China. They were divided into a healthy control group (n=64) and an MCI group (n=62). All subjects were administered the VSP and a series of neuropsychological examinations. The study determined the optimal cutoff, discriminating validity, concurrent validity, and retest reliability of the VSP. We used the area under the receiver operating characteristic curve (AUC) to evaluate the discriminating validity and obtain the optimal cutoff values. Pearson correlation analysis and the intraclass correlation coefficient were used to evaluate the concurrent validity and retest reliability, respectively. Results: A cutoff score of 46.4 was optimal for the entire sample, yielding a sensitivity of 85.9% and specificity of 79.0% for differentiating individuals with MCI and healthy controls, and the AUC was 0.870 (95% CI 0.799-0.924). The median index of VSP score was 51.1 (range 42.6-60.0). There was a moderate positive correlation between the VSP total score and Mini-Mental State Examination score (r=0.429, P<.001). There was a strong positive correlation between VSP total score and Montreal Cognitive Assessment score (r=0.645, P<.001). The retest reliability of the VSP was feasible (r=0.588, P=.048). Conclusions: The VSP is interesting and feasible for subjects. It shows high sensitivity and specificity for the identification of MCI in older adults, which makes it a promising screening method. The VSP may be generalized to older adults in other countries, although some cultural adaptation may be necessary. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000040074; https://www.chictr.org.cn/showprojen.aspx?proj=64639 %M 34870610 %R 10.2196/30919 %U https://games.jmir.org/2021/4/e30919 %U https://doi.org/10.2196/30919 %U http://www.ncbi.nlm.nih.gov/pubmed/34870610 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e32721 %T Virtual Reality in Health Care: Bibliometric Analysis %A Pawassar,Christian Matthias %A Tiberius,Victor %+ Faculty of Economics and Social Sciences, University of Potsdam, August-Bebel-Str 89, Potsdam, 14482, Germany, 49 3319773593, tiberius@uni-potsdam.de %K virtual reality %K healthcare %K bibliometric analysis %K literature review %K citation analysis %K VR %K usability %K review %K health care %D 2021 %7 1.12.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Research into the application of virtual reality technology in the health care sector has rapidly increased, resulting in a large body of research that is difficult to keep up with. Objective: We will provide an overview of the annual publication numbers in this field and the most productive and influential countries, journals, and authors, as well as the most used, most co-occurring, and most recent keywords. Methods: Based on a data set of 356 publications and 20,363 citations derived from Web of Science, we conducted a bibliometric analysis using BibExcel, HistCite, and VOSviewer. Results: The strongest growth in publications occurred in 2020, accounting for 29.49% of all publications so far. The most productive countries are the United States, the United Kingdom, and Spain; the most influential countries are the United States, Canada, and the United Kingdom. The most productive journals are the Journal of Medical Internet Research (JMIR), JMIR Serious Games, and the Games for Health Journal; the most influential journals are Patient Education and Counselling, Medical Education, and Quality of Life Research. The most productive authors are Riva, del Piccolo, and Schwebel; the most influential authors are Finset, del Piccolo, and Eide. The most frequently occurring keywords other than “virtual” and “reality” are “training,” “trial,” and “patients.” The most relevant research themes are communication, education, and novel treatments; the most recent research trends are fitness and exergames. Conclusions: The analysis shows that the field has left its infant state and its specialization is advancing, with a clear focus on patient usability. %M 34855606 %R 10.2196/32721 %U https://games.jmir.org/2021/4/e32721 %U https://doi.org/10.2196/32721 %U http://www.ncbi.nlm.nih.gov/pubmed/34855606 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e30249 %T Examining the Academic Trends in Neuropsychological Tests for Executive Functions Using Virtual Reality: Systematic Literature Review %A Kim,Euisung %A Han,Jieun %A Choi,Hojin %A Prié,Yannick %A Vigier,Toinon %A Bulteau,Samuel %A Kwon,Gyu Hyun %+ Graduate School of Technology and Innovation Management, Hanyang University, Wangsimni-ro 222, Multidisciplinary Lecture Hall 703, Seoul, 04763, Republic of Korea, 82 222202414, ghkwon@hanyang.ac.kr %K virtual reality %K neuropsychological test %K executive function %K cognitive ability %K brain disorder %K immersive %K digital health %K cognition %K academic trends %K neurology %D 2021 %7 24.11.2021 %9 Review %J JMIR Serious Games %G English %X Background: In neuropsychology, fully immersive virtual reality (VR) has been spotlighted as a promising tool. It is considered that VR not only overcomes the existing limitation of neuropsychological tests but is also appropriate for treating executive functions (EFs) within activities of daily living (ADL) due to its high ecological validity. While fully immersive VR offers new possibilities of neuropsychological tests, there are few studies that overview the intellectual landscape and academic trends in the research related to mainly targeted EFs with fully immersive VR. Objective: The objective of this study is to get an overview of the research trends that use VR in neuropsychological tests and to analyze the research trends using fully immersive VR neuropsychological tests with experimental articles. Methods: This review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were searched in three web databases using keywords related to VR, EFs, and cognitive abilities. The study was conducted in two steps, keyword analysis and in-depth systematic review. In the web database search from 2000 to 2019, 1167 articles were initially collected, of which 234 articles in the eligibility phase were used to conduct keyword analysis and a total of 47 articles were included for systematic review. Results: In keyword analysis, the number of articles focused on dementia including the keywords “MCI,” “SCD,” and “dementia” were highlighted over the period, rather than other symptoms. In addition, we identified that the use of behavioral and physiological data in virtual environments (VEs) has dramatically increased in recent studies. In the systematic review, we focused on the purpose of study, assessment, treatment, and validation of usability and structure. We found that treatment studies and uncategorized studies including presence and cybersickness issues have emerged in the recent period. In addition, the target symptoms and range of participants were diversified. Conclusions: There has been a continuously increasing interest in dealing with neuropsychology by using fully immersive VR. Target cognitive abilities have been diversified, as well as target symptoms. Moreover, the concept of embodied cognition was transplanted in this research area. %M 34822341 %R 10.2196/30249 %U https://games.jmir.org/2021/4/e30249 %U https://doi.org/10.2196/30249 %U http://www.ncbi.nlm.nih.gov/pubmed/34822341 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 11 %P e30590 %T Effectiveness of Self-Guided Virtual Reality–Based Cognitive Behavioral Therapy for Panic Disorder: Randomized Controlled Trial %A Shin,Bokyoung %A Oh,Jooyoung %A Kim,Byung-Hoon %A Kim,Hesun Erin %A Kim,Hyunji %A Kim,Suji %A Kim,Jae-Jin %+ Department of Psychiatry, Yonsei University College of Medicine, Gangnam Severance Hospital, Yonsei University Health System, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea, 82 2 2019 3342, ojuojuoju@yuhs.ac %K virtual reality %K panic disorder %K cognitive behavioral therapy %K exposure therapy %K intervention %D 2021 %7 22.11.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Virtual reality (VR) is as effective a technique as traditional cognitive behavioral therapy (CBT) and a promising tool for treating panic disorder symptoms because VR exposure can be safer and has better acceptability than in vivo exposure and is more immersive than exposure through imagination. CBT techniques can be delivered more effectively using VR as well. So far, VR has required high-quality devices, but the development of mobile VR technology has improved user availability. At the same time, a well-structured form of VR can be reproduced and used anywhere. This means that VR can be used to provide a self-guided form of treatment and address the high treatment costs of evidence-based therapy and the lack of professional therapists. This study aimed to investigate the potential of self-guided VR as an alternative to high-cost treatment. Objective: The main goal of this study was to offer data about the efficacy of a mobile app-based self-led VR CBT in the treatment of panic disorder. Methods: A total of 54 subjects with panic disorder were enrolled in this study and randomly assigned to either the VR treatment group or waitlist group. The VR treatment was designed to be total 12 sessions for 4 weeks. The VR treatment consists of 4 steps in which patients are gradually exposed to phobic stimuli while learning to cope with panic symptoms in each stage. The effectiveness of treatment was assessed through the Panic Disorder Severity Scale, Hamilton Rating Scale for Depression, Body Sensations Questionnaire, Albany Panic and Phobia Questionnaire, Anxiety Sensitivity Index, State-Trait Anxiety Inventory, Hospital Anxiety and Depression Scale, Korean Inventory of Social Avoidance and Distress Scale, Korean Inventory of Depressive Symptomatology, and Perceived Stress Scale. In addition, physiological changes using heart rate variability were evaluated. Results: In within-group analyses, the VR treatment group exhibited improvements in panic disorder symptoms, anxiety, and depression after 4 weeks, while the waitlist group did not show any significant improvement. Compared to the waitlist group, the VR treatment group showed significantly greater improvements in the Panic Disorder Severity Scale in both completer analysis and intention-to-treat analysis. Heart rate variability in the VR treatment group showed improvement in normalized high frequency from baseline to postassessment with no significant differences in any outcome measure between groups. Conclusions: The self-guided, mobile app-based VR intervention was effective in the treatment of panic symptoms and restoring the autonomic nervous system demonstrating the validity of the use of VR for self-guided treatment. VR treatment can be a cost-effective therapeutic approach. Trial Registration: ClinicalTrials.gov NCT04985019; https://clinicaltrials.gov/ct2/show/NCT04985019 %M 34813486 %R 10.2196/30590 %U https://mental.jmir.org/2021/11/e30590 %U https://doi.org/10.2196/30590 %U http://www.ncbi.nlm.nih.gov/pubmed/34813486 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e13124 %T Using a 360° Virtual Reality or 2D Video to Learn History Taking and Physical Examination Skills for Undergraduate Medical Students: Pilot Randomized Controlled Trial %A Chao,Yi-Ping %A Chuang,Hai-Hua %A Hsin,Li-Jen %A Kang,Chung-Jan %A Fang,Tuan-Jen %A Li,Hsueh-Yu %A Huang,Chung-Guei %A Kuo,Terry B J %A Yang,Cheryl C H %A Shyu,Hsin-Yih %A Wang,Shu-Ling %A Shyu,Liang-Yu %A Lee,Li-Ang %+ Department of Otorhinolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Linkou Main Branch, No 5, Fu-Hsing Street, Guishan District, Taoyuan, 33305, Taiwan, 886 3 328 1200 ext 3972, 5738@cgmh.org.tw %K cognitive load %K heart rate variability %K video learning %K learning outcome %K secondary-task reaction time %K virtual reality %D 2021 %7 22.11.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Learning through a 360° virtual reality (VR) or 2D video represents an alternative way to learn a complex medical education task. However, there is currently no consensus on how best to assess the effects of different learning materials on cognitive load estimates, heart rate variability (HRV), outcomes, and experience in learning history taking and physical examination (H&P) skills. Objective: The aim of this study was to investigate how learning materials (ie, VR or 2D video) impact learning outcomes and experience through changes in cognitive load estimates and HRV for learning H&P skills. Methods: This pilot system–design study included 32 undergraduate medical students at an academic teaching hospital. The students were randomly assigned, with a 1:1 allocation, to a 360° VR video group or a 2D video group, matched by age, sex, and cognitive style. The contents of both videos were different with regard to visual angle and self-determination. Learning outcomes were evaluated using the Milestone reporting form. Subjective and objective cognitive loads were estimated using the Paas Cognitive Load Scale, the National Aeronautics and Space Administration Task Load Index, and secondary-task reaction time. Cardiac autonomic function was assessed using HRV measurements. Learning experience was assessed using the AttrakDiff2 questionnaire and qualitative feedback. Statistical significance was accepted at a two-sided P value of <.01. Results: All 32 participants received the intended intervention. The sample consisted of 20 (63%) males and 12 (38%) females, with a median age of 24 (IQR 23-25) years. The 360° VR video group seemed to have a higher Milestone level than the 2D video group (P=.04). The reaction time at the 10th minute in the 360° VR video group was significantly higher than that in the 2D video group (P<.001). Multiple logistic regression models of the overall cohort showed that the 360° VR video module was independently and positively associated with a reaction time at the 10th minute of ≥3.6 seconds (exp B=18.8, 95% CI 3.2-110.8; P=.001) and a Milestone level of ≥3 (exp B=15.0, 95% CI 2.3-99.6; P=.005). However, a reaction time at the 10th minute of ≥3.6 seconds was not related to a Milestone level of ≥3. A low-frequency to high-frequency ratio between the 5th and 10th minute of ≥1.43 seemed to be inversely associated with a hedonic stimulation score of ≥2.0 (exp B=0.14, 95% CI 0.03-0.68; P=.015) after adjusting for video module. The main qualitative feedback indicated that the 360° VR video module was fun but caused mild dizziness, whereas the 2D video module was easy to follow but tedious. Conclusions: Our preliminary results showed that 360° VR video learning may be associated with a better Milestone level than 2D video learning, and that this did not seem to be related to cognitive load estimates or HRV indexes in the novice learners. Of note, an increase in sympathovagal balance may have been associated with a lower hedonic stimulation score, which may have met the learners’ needs and prompted learning through the different video modules. Trial Registration: ClinicalTrials.gov NCT03501641; https://clinicaltrials.gov/ct2/show/NCT03501641 %M 34813485 %R 10.2196/13124 %U https://games.jmir.org/2021/4/e13124 %U https://doi.org/10.2196/13124 %U http://www.ncbi.nlm.nih.gov/pubmed/34813485 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e29330 %T Effects of an Immersive Virtual Reality Exergame on University Students’ Anxiety, Depression, and Perceived Stress: Pilot Feasibility and Usability Study %A Xu,Wenge %A Liang,Hai-Ning %A Baghaei,Nilufar %A Ma,Xiaoyue %A Yu,Kangyou %A Meng,Xuanru %A Wen,Shaoyue %+ Department of Computing, School of Advanced Technology, Xi'an Jiaotong-Liverpool University, 111 Renai Road, Suzhou Industrial Park, Suzhou, 215123, China, 86 51288161516, haining.liang@xjtlu.edu.cn %K university students %K depression %K anxiety %K stress %K immersive virtual reality %K exergame %D 2021 %7 22.11.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: In recent years, there has been an increase in the number of students with depression, anxiety, and perceived stress. A solution that has been increasingly used for improving health and well-being is exergaming. The effects and acceptability of exergames have been studied widely but mostly with older adults. The feasibility and usability of exergames among university students, especially those of immersive virtual reality (iVR) exergames, remain unexplored. Objective: This study aimed to explore the feasibility of a 6-week iVR exergame–based intervention in reducing anxiety, depression, and perceived stress among university students and to examine the usability and acceptability of such games. Methods: A total of 31 university students were recruited to participate in a 6-week study in which they needed to play a boxing-style iVR exergame called FitXR (FitXR Limited) twice per week (30 minutes per session). Their anxiety (Beck Anxiety Inventory), depression (Beck Depression Inventory-II), and perceived stress (Perceived Stress Scale) levels were measured before and after intervention. Results: A total of 15 participants completed the 6-week study. Our results suggested that participants’ mean depression scores decreased significantly from 8.33 (SD 5.98) to 5.40 (SD 5.14) after the intervention (P=.01). In addition, most participants (14/15, 93%) believed that the iVR exergame has good usability. Furthermore, most participants (14/15, 93%) were satisfied with the iVR gameplay experience and would play the iVR exergame again in the future. Of the 15 participants, 11 (73%) would recommend the iVR exergame to their friends. Conclusions: The results gained from this study show that the iVR exergame has good usability, is highly acceptable, and has the potential to reduce depression levels among university students. %M 34813487 %R 10.2196/29330 %U https://games.jmir.org/2021/4/e29330 %U https://doi.org/10.2196/29330 %U http://www.ncbi.nlm.nih.gov/pubmed/34813487 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e31007 %T Impact of Virtual Reality-Based Therapies on Cognition and Mental Health of Stroke Patients: Systematic Review and Meta-analysis %A Zhang,Qi %A Fu,Yu %A Lu,Yanhui %A Zhang,Yating %A Huang,Qifang %A Yang,Yajie %A Zhang,Ke %A Li,Mingzi %+ School of Nursing, Peking University, 38 Xueyuan Road, Beijing, 100191, China, 86 010 82805230, limingzi2000@163.com %K virtual reality %K stroke %K cognition %K depression %K mental health %D 2021 %7 17.11.2021 %9 Review %J J Med Internet Res %G English %X Background: Stroke remains one of the major chronic illnesses worldwide that health care organizations will need to address for the next several decades. Individuals poststroke are subject to levels of cognitive impairment and mental health problems. Virtual reality (VR)-based therapies are new technologies used for cognitive rehabilitation and the management of psychological outcomes. Objective: This study performed a meta-analysis to evaluate the effects of VR-based therapies on cognitive function and mental health in patients with stroke. Methods: A comprehensive database search was performed using PubMed, MEDLINE (Ovid), Embase, Cochrane Library, and APA PsycINFO databases for randomized controlled trials (RCTs) that studied the effects of VR on patients with stroke. We included trials published up to April 15, 2021, that fulfilled our inclusion and exclusion criteria. The literature was screened, data were extracted, and the methodological quality of the included trials was assessed. Meta-analysis was performed using RevMan 5.3 software. Results: A total of 894 patients from 23 RCTs were included in our meta-analysis. Compared to traditional rehabilitation therapies, the executive function (standard mean difference [SMD]=0.88, 95% confidence interval [CI]=0.06-1.70, P=.03), memory (SMD=1.44, 95% CI=0.21-2.68, P=.02), and visuospatial function (SMD=0.78, 95% CI=0.23-1.33, P=.006) significantly improved among patients after VR intervention. However, there were no significant differences observed in global cognitive function, attention, verbal fluency, depression, and the quality of life (QoL). Conclusions: The findings of our meta-analysis showed that VR-based therapies are efficacious in improving executive function, memory, and visuospatial function in patients with stroke. For global cognitive function, attention, verbal fluency, depression, and the QoL, further research is required. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021252788; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=252788 %M 34787571 %R 10.2196/31007 %U https://www.jmir.org/2021/11/e31007 %U https://doi.org/10.2196/31007 %U http://www.ncbi.nlm.nih.gov/pubmed/34787571 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 8 %N 4 %P e24950 %T Investigating the Use of Virtual Reality Headsets for Postural Control Assessment: Instrument Validation Study %A Sylcott,Brian %A Lin,Chia-Cheng %A Williams,Keith %A Hinderaker,Mark %+ Department of Engineering, East Carolina University, 1000 East 5th Street, Greenville, NC, 27858, United States, 1 2527374652, sylcottb15@ecu.edu %K postural sway %K virtual reality %K force plate %K center of pressure %D 2021 %7 15.11.2021 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Accurately measuring postural sway is an important part of balance assessment and rehabilitation. Although force plates give accurate measurements, their costs and space requirements make their use impractical in many situations. Objective: The work presented in this paper aimed to address this issue by validating a virtual reality (VR) headset as a relatively low-cost alternative to force plates for postural sway measurement. The HTC Vive (HTC Corporation) VR headset has built-in sensors that allow for position and orientation tracking, making it a potentially effective tool for balance assessments. Methods: Participants in this study were asked to stand upright on a force plate (NeuroCom; Natus Medical Incorporated) while wearing the HTC Vive. Position data were collected from the headset and force plate simultaneously as participants experienced a custom-built VR environment that covered their entire field of view. The intraclass correlation coefficient (ICC) was used to examine the test-retest reliability of the postural control variables, which included the normalized path length, root mean square (RMS), and peak-to-peak (P2P) value. These were computed from the VR position output data and the center of pressure (COP) data from the force plate. Linear regression was used to investigate the correlations between the VR and force plate measurements. Results: Our results showed that the test-retest reliability of the RMS and P2P value of VR headset outputs (ICC: range 0.285-0.636) was similar to that of the RMS and P2P value of COP outputs (ICC: range 0.228-0.759). The linear regression between VR and COP measures showed significant correlations in RMSs and P2P values. Conclusions: Based on our results, the VR headset has the potential to be used for postural control measurements. However, the further development of software and testing protocols for balance assessments is needed. %M 34779789 %R 10.2196/24950 %U https://rehab.jmir.org/2021/4/e24950 %U https://doi.org/10.2196/24950 %U http://www.ncbi.nlm.nih.gov/pubmed/34779789 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 8 %N 4 %P e26629 %T An Immersive and Interactive Platform for Cognitive Assessment and Rehabilitation (bWell): Design and Iterative Development Process %A Gagnon Shaigetz,Vincent %A Proulx,Catherine %A Cabral,Anne %A Choudhury,Nusrat %A Hewko,Mark %A Kohlenberg,Elicia %A Segado,Melanie %A Smith,Michael S D %A Debergue,Patricia %+ Simulation and Digital Health, Medical Devices Research Centre, National Research Council Canada, 75 Boulevard de Mortagne, Boucherville, QC, J4B 6Y4, Canada, 1 4506415208, nusrat.choudhury@nrc.ca %K virtual reality %K clinical psychology %K cognitive assessment %K neuropsychology %K mental health %K cognitive rehabilitation %K digital therapeutics %K mobile phone %K cognitive training %D 2021 %7 3.11.2021 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Immersive technologies like virtual reality can enable clinical care that meaningfully aligns with real-world deficits in cognitive functioning. However, options in immersive 3D environments are limited, partly because of the unique challenges presented by the development of a clinical care platform. These challenges include selecting clinically relevant features, enabling tasks that capture the full breadth of deficits, ensuring longevity in a rapidly changing technology landscape, and performing the extensive technical and clinical validation required for digital interventions. Complicating development, is the need to integrate recommendations from domain experts at all stages. Objective: The Cognitive Health Technologies team at the National Research Council Canada aims to overcome these challenges with an iterative process for the development of bWell, a cognitive care platform providing multisensory cognitive tasks for adoption by treatment providers. Methods: The team harnessed the affordances of immersive technologies while taking an interdisciplinary research and developmental approach, obtaining active input from domain experts with iterative deliveries of the platform. The process made use of technology readiness levels, agile software development, and human-centered design to advance four main activities: identification of basic requirements and key differentiators, prototype design and foundational research to implement components, testing and validation in lab settings, and recruitment of external clinical partners. Results: bWell was implemented according to the findings from the design process. The main features of bWell include multimodal (fully, semi, or nonimmersive) and multiplatform (extended reality, mobile, and PC) implementation, configurable exercises that pair standardized assessment with adaptive and gamified variants for therapy, a therapist-facing user interface for task administration and dosing, and automated activity data logging. bWell has been designed to serve as a broadly applicable toolkit, targeting general aspects of cognition that are commonly impacted across many disorders, rather than focusing on 1 disorder or a specific cognitive domain. It comprises 8 exercises targeting different domains: states of attention (Egg), visual working memory (Theater), relaxation (Tent), inhibition and cognitive control (Mole), multitasking (Lab), self-regulation (Butterfly), sustained attention (Stroll), and visual search (Cloud). The prototype was tested and validated with healthy adults in a laboratory environment. In addition, a cognitive care network (5 sites across Canada and 1 in Japan) was established, enabling access to domain expertise and providing iterative input throughout the development process. Conclusions: Implementing an interdisciplinary and iterative approach considering technology maturity brought important considerations for the development of bWell. Altogether, this harnesses the affordances of immersive technology and design for a broad range of applications, and for use in both cognitive assessment and rehabilitation. The technology has attained a maturity level of prototype implementation with preliminary validation carried out in laboratory settings, with next steps to perform the validation required for its eventual adoption as a clinical tool. %M 34730536 %R 10.2196/26629 %U https://rehab.jmir.org/2021/4/e26629 %U https://doi.org/10.2196/26629 %U http://www.ncbi.nlm.nih.gov/pubmed/34730536 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 11 %P e28315 %T A Video Self-Modeling Intervention Using Virtual Reality Plus Physical Practice for Freezing of Gait in Parkinson Disease: Feasibility and Acceptability Study %A Goh,Lina %A Allen,Natalie E %A Ahmadpour,Naseem %A Ehgoetz Martens,Kaylena A %A Song,Jooeun %A Clemson,Lindy %A Lewis,Simon J G %A MacDougall,Hamish G %A Canning,Colleen G %+ Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Level 7 Susan Wakil Health Building D18, Camperdown, 2006, Australia, 61 9351 9016, natalie.allen@sydney.edu.au %K Parkinson disease %K freezing of gait %K action observation %K video self-modelling %K virtual reality %D 2021 %7 3.11.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Despite optimal medical and surgical intervention, freezing of gait commonly occurs in people with Parkinson disease. Action observation via video self-modeling, combined with physical practice, has potential as a noninvasive intervention to reduce freezing of gait. Objective: The aim of this study is to determine the feasibility and acceptability of a home-based, personalized video self-modeling intervention delivered via a virtual reality head-mounted display (HMD) to reduce freezing of gait in people with Parkinson disease. The secondary aim is to investigate the potential effect of this intervention on freezing of gait, mobility, and anxiety. Methods: The study was a single-group pre-post mixed methods pilot trial for which 10 participants with Parkinson disease and freezing of gait were recruited. A physiotherapist assessed the participants in their homes to identify person-specific triggers of freezing and developed individualized movement strategies to overcome freezing of gait. 180° videos of the participants successfully performing their movement strategies were created. Participants watched their videos using a virtual reality HMD, followed by physical practice of their strategies in their own homes over a 6-week intervention period. The primary outcome measures included the feasibility and acceptability of the intervention. Secondary outcome measures included freezing of gait physical tests and questionnaires, including the Timed Up and Go Test, 10-meter walk test, Goal Attainment Scale, and Parkinson Anxiety Scale. Results: The recruitment rate was 24% (10/42), and the retention rate was 90% (9/10). Adherence to the intervention was high, with participants completing a mean of 84% (SD 49%) for the prescribed video viewing and a mean of 100% (SD 56%) for the prescribed physical practice. One participant used the virtual reality HMD for 1 week and completed the rest of the intervention using a flat-screen device because of a gradual worsening of his motion sickness. No other adverse events occurred during the intervention or assessment. Most of the participants found using the HMD to view their videos interesting and enjoyable and would choose to use this intervention to manage their freezing of gait in the future. Five themes were constructed from the interview data: reflections when seeing myself, my experience of using the virtual reality system, the role of the virtual reality system in supporting my learning, developing a deeper understanding of how to manage my freezing of gait, and the impact of the intervention on my daily activities. Overall, there were minimal changes to the freezing of gait, mobility, or anxiety measures from baseline to postintervention, although there was substantial variability between participants. The intervention showed potential in reducing anxiety in participants with high levels of anxiety. Conclusions: Video self-modeling using an immersive virtual reality HMD plus physical practice of personalized movement strategies is a feasible and acceptable method of addressing freezing of gait in people with Parkinson disease. %M 34730537 %R 10.2196/28315 %U https://formative.jmir.org/2021/11/e28315 %U https://doi.org/10.2196/28315 %U http://www.ncbi.nlm.nih.gov/pubmed/34730537 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 11 %P e29862 %T Examining the Effectiveness of 3D Virtual Reality Training on Problem-solving, Self-efficacy, and Teamwork Among Inexperienced Volunteers Helping With Drug Use Prevention: Randomized Controlled Trial %A Chiang,Chih-Huei %A Huang,Chiu-Mieh %A Sheu,Jiunn-Jye %A Liao,Jung-Yu %A Hsu,Hsiao-Pei %A Wang,Shih-Wen %A Guo,Jong-Long %+ Department of Health Promotion and Health Education, College of Education, National Taiwan Normal University, No.162, Sec. 1, He-ping East Road, Taipei, 10610, Taiwan, 886 77493715, jonglong@ntnu.edu.tw %K 3D virtual reality %K volunteers %K problem-solving %K self-efficacy %K teamwork %D 2021 %7 2.11.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Illegal drug usage among adolescents is a critical health problem. The Taiwanese government provides an accompanying volunteer program to prevent students who experiment with drugs from reusing them. An appropriate training program can improve volunteers’ abilities to assist students using drugs. Problem-solving, self-efficacy, and teamwork are critical abilities for inexperienced volunteers who help with drug use prevention. By interacting with the animation or 3D virtual reality (VR) in the virtual scene, learners can immerse themselves in the virtual environment to learn, and 3D VR can increase learning opportunities and reduce the cost of human and material resources. Objective: The aim of this study was to examine the effectiveness of spherical video-based virtual reality (SVVR) training in improving problem-solving, self-efficacy, and teamwork among volunteers who helped prevent adolescents from using illegal drugs. Methods: This study used a randomized controlled design with a total of 68 participants in the experimental (n=35) and control (n=33) groups. The participants in the experimental group received the SVVR training program and their counterparts in the control group did not receive any training. Results: Generalized estimating equation analyses indicated that the experimental group showed significant posttraining improvements in problem-solving and self-efficacy but not teamwork when compared with the control group. Conclusions: The results of this study revealed that SVVR could improve participants’ problem-solving skills and self-efficacy for assisting students in not using illegal drugs. However, future studies are suggested to develop effective SVVR to assist inexperienced volunteers in enhancing their teamwork abilities. We believed that introducing the training program to more sites can enhance volunteer training so that volunteers can have a better companionship effect when helping students quit drugs. Trial Registration: ClinicalTrials.gov NCT05072431; https://clinicaltrials.gov/ct2/show/NCT05072431 %M 34726606 %R 10.2196/29862 %U https://www.jmir.org/2021/11/e29862 %U https://doi.org/10.2196/29862 %U http://www.ncbi.nlm.nih.gov/pubmed/34726606 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 10 %P e31742 %T Automated Virtual Reality Cognitive Therapy for People With Psychosis: Protocol for a Qualitative Investigation Using Peer Research Methods %A Bond,Jessica %A Robotham,Dan %A Kenny,Alexandra %A Pinfold,Vanessa %A Kabir,Thomas %A Andleeb,Humma %A Larkin,Michael %A Martin,Jennifer L %A Brown,Susan %A Bergin,Aislinn D %A Petit,Ariane %A Rosebrock,Laina %A Lambe,Sinéad %A Freeman,Daniel %A Waite,Felicity %+ McPin Foundation, 7-14 Great Dover Street, London, SE1 4YR, United Kingdom, 44 20 7922 7871, JessicaBond@mcpin.org %K virtual reality %K therapy %K schizophrenia %K agoraphobia %K peer research %K qualitative methods %K implementation %K mental health %K psychosis %K cognitive therapy %D 2021 %7 25.10.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Many people with psychosis experience difficulties in everyday social situations. Anxiety can make life challenging, leading to withdrawal. Cognitive therapy, using active in vivo learning, enables people to overcome fears. These treatments are not readily available to people with psychosis. Automated virtual reality (VR) therapy is a potential route to increase accessibility. The gameChange automated VR cognitive therapy is designed to help people overcome anxious avoidance and build confidence in everyday social situations. A virtual coach guides the person through the treatment. Understanding user experience is key to facilitating future implementation. Peer research methods, in which people with lived experience of the issues being studied are involved in collecting and analyzing data, may be useful in developing this understanding. This encourages researchers to draw on their lived experience to explore participant perspectives and co-create knowledge. Objective: The primary objective is to use a peer research approach to explore the participant experience of a novel automated VR therapy for anxious social avoidance. This includes understanding (1) the experience of anxious social avoidance in people with psychosis, (2) the experience of the gameChange automated VR cognitive therapy, and (3) any potential impact of the therapy in people’s lives. This will inform future implementation strategies. The secondary objective is to explore how peer research can be used to co-create knowledge. Methods: Semistructured interviews will be conducted with approximately 25 people with psychosis participating in the gameChange trial (ISRCTN17308399). Participants will be recruited from the five trial centers based in National Health Service mental health trusts across England. Interviews will be conducted by two researchers. One is a peer researcher with similar lived experience to the trial participants. The other has lived experiences of mental health issues that do not directly overlap with those of the trial participants. Interview questions will focus on an individual’s experience of anxious social avoidance, experiences of participating in the gameChange VR therapy, and any changes or impact following therapy. The interview schedule was developed in collaboration with the gameChange Lived Experience Advisory Panel (LEAP), comprising 10 project advisors with lived experience of psychosis. Interpretative phenomenological analysis and template analysis will be used to explore individual accounts. The LEAP will contribute to the analysis. Results: Data collection will be conducted from April to September 2021, and analysis will be conducted from June to October 2021. As of September 28, 2021, 20 participants had been interviewed, and coding is underway. Conclusions: The study, employing a peer research approach, may provide a unique insight into the experiences of anxious social avoidance in people with psychosis and its treatment using automated VR therapy. This will inform potential future implementation of VR automated therapies in mental health services. International Registered Report Identifier (IRRID): DERR1-10.2196/31742 %M 34694236 %R 10.2196/31742 %U https://www.researchprotocols.org/2021/10/e31742 %U https://doi.org/10.2196/31742 %U http://www.ncbi.nlm.nih.gov/pubmed/34694236 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 10 %P e17472 %T Augmented Reality for Guideline Presentation in Medicine: Randomized Crossover Simulation Trial for Technically Assisted Decision-making %A Follmann,Andreas %A Ruhl,Alexander %A Gösch,Michael %A Felzen,Marc %A Rossaint,Rolf %A Czaplik,Michael %+ Department of Anesthesiology, Faculty of Medicine, Rheinisch-Westfälische Technische Hochschule Aachen University, Pauwelsstraße 30, Aachen, 52074, Germany, 49 241 80 36219, afollmann@ukaachen.de %K augmented reality %K smart glasses %K wearables %K guideline presentation %K decision support %K triage %D 2021 %7 18.10.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Guidelines provide instructions for diagnostics and therapy in modern medicine. Various mobile devices are used to represent the potential complex decision trees. An example of time-critical decisions is triage in case of a mass casualty incident. Objective: In this randomized controlled crossover study, the potential of augmented reality for guideline presentation was evaluated and compared with the guideline presentation provided in a tablet PC as a conventional device. Methods: A specific Android app was designed for use with smart glasses and a tablet PC for the presentation of a triage algorithm as an example for a complex guideline. Forty volunteers simulated a triage based on 30 fictional patient descriptions, each with technical support from smart glasses and a tablet PC in a crossover trial design. The time to come to a decision and the accuracy were recorded and compared between both devices. Results: A total of 2400 assessments were performed by the 40 volunteers. A significantly faster time to triage was achieved in total with the tablet PC (median 12.8 seconds, IQR 9.4-17.7; 95% CI 14.1-14.9) compared to that to triage with smart glasses (median 17.5 seconds, IQR 13.2-22.8, 95% CI 18.4-19.2; P=.001). Considering the difference in the triage time between both devices, the additional time needed with the smart glasses could be reduced significantly in the course of assessments (21.5 seconds, IQR 16.5-27.3, 95% CI 21.6-23.2) in the first run, 17.4 seconds (IQR 13-22.4, 95% CI 17.6-18.9) in the second run, and 14.9 seconds (IQR 11.7-18.6, 95% CI 15.2-16.3) in the third run (P=.001). With regard to the accuracy of the guideline decisions, there was no significant difference between both the devices. Conclusions: The presentation of a guideline on a tablet PC as well as through augmented reality achieved good results. The implementation with smart glasses took more time owing to their more complex operating concept but could be accelerated in the course of the study after adaptation. Especially in a non–time-critical working area where hands-free interfaces are useful, a guideline presentation with augmented reality can be of great use during clinical management. %M 34661548 %R 10.2196/17472 %U https://mhealth.jmir.org/2021/10/e17472 %U https://doi.org/10.2196/17472 %U http://www.ncbi.nlm.nih.gov/pubmed/34661548 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 10 %P e31051 %T Effects of Virtual Reality Training on Upper Limb Function and Balance in Stroke Patients: Systematic Review and Meta-Meta-Analysis %A Wu,Jinlong %A Zeng,Aihua %A Chen,Ziyan %A Wei,Ye %A Huang,Kunlun %A Chen,Jiafeng %A Ren,Zhanbing %+ Department of Physical Education, Shenzhen University, No 3588 Nanhai Road, Shenzhen, 518061, China, 86 13318881919, rzb@szu.edu.cn %K virtual reality %K stroke %K motor function %K review %K meta-meta-analysis %K mental health %K motor skills %K rehabilitation %K digital intervention %K health care %K stroke patients %D 2021 %7 12.10.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) training is a promising intervention strategy that has been utilized in health care fields like stroke rehabilitation and psychotherapy. Current studies suggest that VR training is effective in improving the locomotor ability of stroke patients. Objective: This is the first meta-meta-analysis of the effects of VR on motor function in stroke patients. This study aimed to systematically summarize and quantify the present meta-analyses results of VR training and produce high-quality meta-meta-analysis results to obtain a more accurate prediction. Methods: We searched 4 online databases (Web of Science, Scopus, PubMed, and Chinese National Knowledge Infrastructure) for meta-analysis studies. After accounting for overlap, 10 studies (accounting for almost 550 stroke patients) were obtained. Based on the meta-meta-analysis of these patients, this study quantified the impact of VR training on stroke patients’ motor performance, mainly including upper limb function, balance, and walking ability. We combined the effects under the random effect model and pooled the estimates as standardized mean differences (SMD). Results: The results of the meta-meta-analysis showed that VR training effectively improves upper limb function (SMD 4.606, 95% CI 2.733-6.479, P<.05) and balance (SMD 2.101, 95% CI 0.202-4.000, P<.05) of stroke patients. However, the results showed considerable heterogeneity and thus, may need to be treated with caution. Due to the limited research, a meta-meta-analysis of walking ability was not performed. Conclusions: These findings represent a comprehensive body of high-quality evidence that VR training is more effective at improving upper limb function and balance of stroke patients. %M 34636735 %R 10.2196/31051 %U https://www.jmir.org/2021/10/e31051 %U https://doi.org/10.2196/31051 %U http://www.ncbi.nlm.nih.gov/pubmed/34636735 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 10 %P e27298 %T Brain Mechanisms of Virtual Reality Breathing Versus Traditional Mindful Breathing in Pain Modulation: Observational Functional Near-infrared Spectroscopy Study %A Hu,Xiao-Su %A Beard,Katherine %A Sherbel,Mary Catherine %A Nascimento,Thiago D %A Petty,Sean %A Pantzlaff,Eddie %A Schwitzer,David %A Kaciroti,Niko %A Maslowski,Eric %A Ashman,Lawrence M %A Feinberg,Stephen E %A DaSilva,Alexandre F %+ Headache & Orofacial Pain Effort Lab, Biologic and Materials Sciences & Prosthodontics Department, University of Michigan School of Dentistry, 205 Zina Pitcher Pl, room 1021, Ann Arbor, MI, 48109-5720, United States, 1 734 615 3807, adasilva@umich.edu %K virtual reality breathing %K traditional mindful breathing %K pain %K functional near-infrared spectroscopy %K mobile phone %D 2021 %7 12.10.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Pain is a complex experience that involves sensory-discriminative and cognitive-emotional neuronal processes. It has long been known across cultures that pain can be relieved by mindful breathing (MB). There is a common assumption that MB exerts its analgesic effect through interoception. Interoception refers to consciously refocusing the mind’s attention to the physical sensation of internal organ function. Objective: In this study, we dissect the cortical analgesic processes by imaging the brains of healthy subjects exposed to traditional MB (TMB) and compare them with another group for which we augmented MB to an outside sensory experience via virtual reality breathing (VRB). Methods: The VRB protocol involved in-house–developed virtual reality 3D lungs that synchronized with the participants’ breathing cycles in real time, providing them with an immersive visual-auditory exteroception of their breathing. Results: We found that both breathing interventions led to a significant increase in pain thresholds after week-long practices, as measured by a thermal quantitative sensory test. However, the underlying analgesic brain mechanisms were opposite, as revealed by functional near-infrared spectroscopy data. In the TMB practice, the anterior prefrontal cortex uniquely modulated the premotor cortex. This increased its functional connection with the primary somatosensory cortex (S1), thereby facilitating the S1-based sensory-interoceptive processing of breathing but inhibiting its other role in sensory-discriminative pain processing. In contrast, virtual reality induced an immersive 3D exteroception with augmented visual-auditory cortical activations, which diminished the functional connection with the S1 and consequently weakened the pain processing function of the S1. Conclusions: In summary, our study suggested two analgesic neuromechanisms of VRB and TMB practices—exteroception and interoception—that distinctively modulated the S1 processing of the ascending noxious inputs. This is in line with the concept of dualism (Yin and Yang). %M 34636731 %R 10.2196/27298 %U https://www.jmir.org/2021/10/e27298 %U https://doi.org/10.2196/27298 %U http://www.ncbi.nlm.nih.gov/pubmed/34636731 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 4 %P e29586 %T Effectiveness and Utility of Virtual Reality Simulation as an Educational Tool for Safe Performance of COVID-19 Diagnostics: Prospective, Randomized Pilot Trial %A Birrenbach,Tanja %A Zbinden,Josua %A Papagiannakis,George %A Exadaktylos,Aristomenis K %A Müller,Martin %A Hautz,Wolf E %A Sauter,Thomas Christian %+ Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, Bern, 3010, Switzerland, 41 31 6322111, tanja.birrenbach@insel.ch %K virtual reality %K VR %K simulation %K medical education %K hand hygiene %K COVID-19 %K PPE %K nasopharyngeal swab %K protection %K effectiveness %K utility %K diagnostic %K testing %K pilot study %D 2021 %7 8.10.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although the proper use of hygiene and personal protective equipment (PPE) is paramount for preventing the spread of diseases such as COVID-19, health care personnel have been shown to use incorrect techniques for donning/doffing of PPE and hand hygiene, leading to a large number of infections among health professionals. Education and training are difficult owing to the social distancing restrictions in place, shortages of PPE and testing material, and lack of evidence on optimal training. Virtual reality (VR) simulation can offer a multisensory, 3-D, fully immersive, and safe training opportunity that addresses these obstacles. Objective: The aim of this study is to explore the short- and long-term effectiveness of a fully immersive VR simulation versus a traditional learning method regarding a COVID-19–related skill set and media-specific variables influencing training outcomes. Methods: This was a prospective, randomized controlled pilot study on medical students (N=29; intervention VR training, n=15, vs control video-based instruction, n=14) to compare the performance of hand disinfection, nasopharyngeal swab taking, and donning/doffing of PPE before and after training and 1 month later as well as variables of media use. Results: Both groups performed significantly better after training, with the effect sustained over one month. After training, the VR group performed significantly better in taking a nasopharyngeal swab, scoring a median of 14 out of 17 points (IQR 13-15) versus 12 out of 17 points (IQR 11-14) in the control group, P=.03. With good immersion and tolerability of the VR simulation, satisfaction was significantly higher in the VR group compared to the control group (median score of User Satisfaction Evaluation Questionnaire 27/30, IQR 23-28, vs 22/30, IQR 20-24, in the control group; P=.01). Conclusions: VR simulation was at least as effective as traditional learning methods in training medical students while providing benefits regarding user satisfaction. These results add to the growing body of evidence that VR is a useful tool for acquiring simple and complex clinical skills. %M 34623315 %R 10.2196/29586 %U https://games.jmir.org/2021/4/e29586 %U https://doi.org/10.2196/29586 %U http://www.ncbi.nlm.nih.gov/pubmed/34623315 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 8 %N 4 %P e29763 %T A Virtual Smash Room for Venting Frustration or Just Having Fun: Participatory Design of Virtual Environments in Digitally Reinforced Cancer Rehabilitation %A Persson,Johanna %A Clifford,Douglas %A Wallergård,Mattias %A Sandén,Ulrika %+ Department of Design Sciences, Lund University, Box 118, Lund, 22100, Sweden, 46 462224358, johanna.persson@design.lth.se %K virtual reality %K virtual environment %K cancer rehabilitation %K emotions %K participatory design %K virtual smash room %K human factors %D 2021 %7 7.10.2021 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Cancer rehabilitation is central for helping patients and relatives create a functional everyday life based on the changes in life conditions. The needs are highly individual and include physical, mental, and social challenges. Cancer rehabilitation programs offer coping strategies, including guidelines on how to handle emotions. Objective: This paper presents a participatory design activity where patients in cancer rehabilitation use a virtual smash room, which is a virtual environment where the user can break things, mainly porcelain or glass items such as vases or plates. The objective is to understand attitudes to, and some effects of, using this application, as well as eliciting ideas of other virtual environments that would be desired. Methods: The virtual environment presented here, the virtual smash room, was designed at the request of a patient with cancer who wanted a tool for venting frustration. In this virtual environment, the user can break porcelain, vases, and plates. Patients participating in a week-long cancer rehabilitation program tested the virtual smash room and reported their experiences through a questionnaire. The questionnaire comprised three sections: (1) a subset of the Intrinsic Motivation Inventory (IMI), (2) a subset of the Virtual Reality Symptoms Questionnaire (VRSQ), and (3) a free-text response section. Results: A total of 101 responses were gathered. The results from the IMI questions showed that the participants found the virtual experience enjoyable (mean 4.52, maximum 5, SD 0.73), and it helped them retain their focus (mean 4.44, maximum 5, SD 0.74). The VRSQ revealed that there were only minor symptoms related to general discomfort (5.9%, n=6), fatigue (5.9%, n=6), nausea (3.0%, n=3), and tired eyes (8.9%, n=9), while several participants experienced dizziness (22.8%, n=23). Since only postmeasurements were gathered, nothing could be concluded about the prevalence of these symptoms before testing. The free-text responses indicated that the user group had many ideas for other virtual environments to use in cancer rehabilitation. Conclusions: This study presents a concept of using virtual reality in the cancer rehabilitation process and exemplifies activities of patient participation in the design process. Virtual reality has potential in being both distracting and enjoyable, while certain aspects of cybersickness might be especially important to consider for a user group already experiencing physical and mental issues. The results will act as input in the process of further designing virtual applications in digitally reinforced cancer rehabilitation. %M 34617913 %R 10.2196/29763 %U https://rehab.jmir.org/2021/4/e29763 %U https://doi.org/10.2196/29763 %U http://www.ncbi.nlm.nih.gov/pubmed/34617913 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e25837 %T Development, Feasibility, Acceptability, and Utility of an Expressive Speech-Enabled Digital Health Agent to Deliver Online, Brief Motivational Interviewing for Alcohol Misuse: Descriptive Study %A Boustani,Maya %A Lunn,Stephanie %A Visser,Ubbo %A Lisetti,Christine %+ Department of Psychology, Loma Linda University, 11130 Anderson St, Suite 117, Loma Linda, CA, 92350, United States, 1 909 558 7680, mboustani@llu.edu %K digital health agent %K virtual health assistant %K online intervention %K alcohol abuse %K brief intervention %K motivational interviewing %K intelligent virtual agent %K embodied conversational agent %D 2021 %7 29.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Digital health agents — embodied conversational agents designed specifically for health interventions — provide a promising alternative or supplement to behavioral health services by reducing barriers to access to care. Objective: Our goals were to (1) develop an expressive, speech-enabled digital health agent operating in a 3-dimensional virtual environment to deliver a brief behavioral health intervention over the internet to reduce alcohol use and to (2) understand its acceptability, feasibility, and utility with its end users. Methods: We developed an expressive, speech-enabled digital health agent with facial expressions and body gestures operating in a 3-dimensional virtual office and able to deliver a brief behavioral health intervention over the internet to reduce alcohol use. We then asked 51 alcohol users to report on the digital health agent acceptability, feasibility, and utility. Results: The developed digital health agent uses speech recognition and a model of empathetic verbal and nonverbal behaviors to engage the user, and its performance enabled it to successfully deliver a brief behavioral health intervention over the internet to reduce alcohol use. Descriptive statistics indicated that participants had overwhelmingly positive experiences with the digital health agent, including engagement with the technology, acceptance, perceived utility, and intent to use the technology. Illustrative qualitative quotes provided further insight about the potential reach and impact of digital health agents in behavioral health care. Conclusions: Web-delivered interventions delivered by expressive, speech-enabled digital health agents may provide an exciting complement or alternative to traditional one-on-one treatment. They may be especially helpful for hard-to-reach communities with behavioral workforce shortages. %M 34586074 %R 10.2196/25837 %U https://www.jmir.org/2021/9/e25837 %U https://doi.org/10.2196/25837 %U http://www.ncbi.nlm.nih.gov/pubmed/34586074 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e28037 %T Acceptability Evaluation of the Use of Virtual Reality Games in Smoking-Prevention Education for High School Students: Prospective Observational Study %A Guo,Jong-Long %A Hsu,Hsiao-Pei %A Lai,Tzu-Ming %A Lin,Mei-Ling %A Chung,Chih-Ming %A Huang,Chiu-Mieh %+ Institute of Clinical Nursing, College of Nursing, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan, 886 2 28267362, cmhuang2021@nycu.edu.tw %K behavioral intention %K ARCS motivation model %K persuasiveness %K smoking prevention %K educational games %D 2021 %7 28.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Alternative forms of cigarettes, such as electronic cigarettes (e-cigarettes), are becoming increasingly common among adolescents. Many high schools now provide smoking-prevention education in an attempt to minimize the potential negative health effects and illness burdens e-cigarettes may induce in adolescents. However, it is often difficult to motivate young students to engage with traditional education regarding the harmful effects of tobacco; thus, the development of alternative approaches may be required. Objective: In this study, we aimed to conduct an acceptability evaluation of educational virtual reality games designed to support smoking-prevention measures. We based the acceptability evaluation on the following two experience types: game-playing and content-learning experiences. The paths by which these experience types affect the intention to abstain from smoking were also examined. Methods: We applied a prospective observational study design. We developed educational games based on three-dimensional virtual reality technology, in which participants operated joysticks to complete challenge tasks. To increase the possibility of the games fostering motivation to abstain from smoking, the ARCS motivational model (comprising attention, relevance, confidence, and satisfaction) was used as a framework during the games’ design. We measured the participants’ game-playing experiences by inquiring about the strength of the ARCS elements; content-learning experiences were measured using overall knowledge improvement and the perceived persuasiveness of the content. A total of 130 students participated in the program. Study hypotheses for this evaluation were derived from a literature review. We used partial least squares structural equation modeling to examine the proposed hypotheses. Results: Based on the responses of the students to questionnaire items concerning attention, relevance, confidence, and satisfaction in the context of the games, most students agreed or strongly agreed that the educational games were motivational, and that their game-playing experiences were positive. Regarding content-learning experiences, there was a significant improvement in knowledge (t129=25.67, P<.001), and most students perceived themselves as being persuaded to abstain from smoking. Attention, relevance, and satisfaction significantly influenced perceived persuasiveness (t=3.19, P<.001; t=4.28, P<.001; and t=3.49, P<.001, respectively); however, confidence did not (t=0.42, P=.67). Perceived persuasiveness, relevance, and satisfaction significantly influenced the intention to abstain from smoking (t=3.57, P<.001). In addition to directly affecting the intention to abstain from smoking, indirect effects were observed from both relevance and satisfaction to intention via perceived persuasiveness (t=2.87, P=.004 and t=2.11, P=.04, respectively). However, intention was not significantly influenced by knowledge improvement. Conclusions: Our findings revealed that the educational games were positively accepted by the participating students. This indicates that the integration of the ARCS framework and persuasive strategies is applicable for smoking-prevention education. We recommend that the games be included as teaching materials for smoking-prevention education. %M 34581679 %R 10.2196/28037 %U https://www.jmir.org/2021/9/e28037 %U https://doi.org/10.2196/28037 %U http://www.ncbi.nlm.nih.gov/pubmed/34581679 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 9 %P e29681 %T Virtual Reality for Supporting the Treatment of Depression and Anxiety: Scoping Review %A Baghaei,Nilufar %A Chitale,Vibhav %A Hlasnik,Andrej %A Stemmet,Lehan %A Liang,Hai-Ning %A Porter,Richard %+ Department of Natural and Computational Sciences, Massey University, Oteha Rohe Albany Highway, Albany, Auckland, 0632, New Zealand, 64 800 627 739, n.baghaei@massey.ac.nz %K virtual reality %K mental health %K depression %K anxiety %K CBT %D 2021 %7 23.9.2021 %9 Review %J JMIR Ment Health %G English %X Background: Mental health conditions pose a major challenge to health care providers and society at large. The World Health Organization predicts that by 2030, mental health conditions will be the leading cause of disease burden worldwide. The current need for mental health care is overwhelming. In New Zealand, 1 in 6 adults has been diagnosed with common mental disorders, such as depression and anxiety disorders, according to a national survey. Cognitive behavioral therapy (CBT) has been shown to effectively help patients overcome a wide variety of mental health conditions. Virtual reality exposure therapy (VRET) might be one of the most exciting technologies emerging in the clinical setting for the treatment of anxiety and depression. Objective: This study aims to investigate the virtual reality (VR) technologies currently being used to help support the treatment of depression and anxiety. We also aim to investigate whether and how CBT is included as part of VRET and look at the VR technologies and interventions that have been used in recent studies on depression and anxiety. Methods: We performed a scoping review. To identify significant studies, we decided to use already aggregated sources from the Google Scholar database. Overall, the goal of our search strategy was to limit the number of initial results related to VR in mental health to only a relevant minimum. Results: Using our defined keywords, Google Scholar identified >17,300 articles. After applying all the inclusion and exclusion criteria, we identified a total of 369 articles for further processing. After manual evaluation, 34 articles were shortlisted; of the 34 articles, 9 (26%) reported the use of CBT with VR. All of the articles were published between 2017 and 2021. Out of the 9 studies, CBT was conducted within a VR environment in 5 (56%) studies, whereas in the remaining 4 (44%) studies, CBT was used as an addition to VRET. All 9 studies reported the use of CBT either in vivo or in a virtual environment to be effective in supporting the treatment of anxiety or depression. Conclusions: Most studies demonstrated the use of VR to be effective for supporting the treatment of anxiety or depression in a range of settings and recommended its potential as a tool for use in a clinical environment. Even though standalone headsets are much easier to work with and more suitable for home use, the shift from tethered VR headsets to standalone headsets in the mental health environment was not observed. All studies that looked at the use of CBT either in vivo or in a virtual environment found it to be effective in supporting the treatment of anxiety or depression. %M 34554097 %R 10.2196/29681 %U https://mental.jmir.org/2021/9/e29681 %U https://doi.org/10.2196/29681 %U http://www.ncbi.nlm.nih.gov/pubmed/34554097 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e26623 %T Barriers and Facilitators to the Implementation of Virtual Reality as a Pain Management Modality in Academic, Community, and Safety-Net Settings: Qualitative Analysis %A Sarkar,Urmimala %A Lee,Jane E %A Nguyen,Kim H %A Lisker,Sarah %A Lyles,Courtney R %+ Department of Medicine, University of California San Francisco, 1001 Potrero Avenue, Box 1364, San Francisco, CA, 94143, United States, 1 6282064273, urmimala.sarkar@ucsf.edu %K virtual reality %K medical informatics %K information technology %K implementation science %K qualitative research %D 2021 %7 22.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Prior studies have shown that virtual reality (VR) is an efficacious treatment modality for opioid-sparing pain management. However, the majority of these studies were conducted among primarily White, relatively advantaged populations and in well-resourced settings. Objective: We conducted a qualitative, theory-informed implementation science study to assess the readiness for VR in safety-net settings. Methods: Using the theoretical lens of the Consolidated Framework for Implementation Research (CFIR) framework, we conducted semistructured interviews with current VR users and nonusers based in safety-net health systems (n=15). We investigated barriers and facilitators to a commercially available, previously validated VR technology platform AppliedVR (Los Angeles, CA, USA). We used deductive qualitative analysis using the overarching domains of the CFIR framework and performed open, inductive coding to identify specific themes within each domain. Results: Interviewees deemed the VR intervention to be useful, scalable, and an appealing alternative to existing pain management approaches. Both users and nonusers identified a lack of reimbursement for VR as a significant challenge for adoption. Current users cited positive patient feedback, but safety-net stakeholders voiced concern that existing VR content may not be relevant or appealing to diverse patients. All respondents acknowledged the challenge of integrating and maintaining VR in current pain management workflows across a range of clinical settings, and this adoption challenge was particularly acute, given resource and staffing constraints in safety-net settings. Conclusions: VR for pain management holds interest for frontline pain management clinicians and leadership in safety-net health settings but will require significant tailoring and adaption to address the needs of diverse populations. Integration into complex workflows for pain management is a significant barrier to adoption, and participants cited structural cost and reimbursement concerns as impediments to initial implementation and scaling of VR use. %M 34550074 %R 10.2196/26623 %U https://www.jmir.org/2021/9/e26623 %U https://doi.org/10.2196/26623 %U http://www.ncbi.nlm.nih.gov/pubmed/34550074 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e22942 %T Comparing a Virtual Reality–Based Simulation App (VR-MRI) With a Standard Preparatory Manual and Child Life Program for Improving Success and Reducing Anxiety During Pediatric Medical Imaging: Randomized Clinical Trial %A Stunden,Chelsea %A Stratton,Kirsten %A Zakani,Sima %A Jacob,John %+ Department of Pediatrics, Faculty of Medicine, University of British Columbia, Rm 2D19, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada, 1 604 875 2345 ext 2393, john.jacob@cw.bc.ca %K virtual reality %K magnetic resonance imaging simulation %K certified child life specialists %K pediatrics %K magnetic resonance imaging procedures %K alternatives to sedation %K preparing children for MRI %D 2021 %7 22.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The experience of undergoing magnetic resonance imaging (MRI) can be anxiety provoking, particularly for pediatric patients and their families. Alternative methods to improve success and experiences without the use of sedation are needed. Objective: This study aims to compare the effectiveness of a virtual reality (VR)—based simulation app (VR-MRI) with a standard preparatory manual (SPM) and a hospital-based Child Life Program (CLP) on success and anxiety during a simulated pediatric MRI scan. Our secondary aim is to compare caregivers’ reported anxiety, procedural data, caregiver usability, child satisfaction, and fun. Methods: This unblinded, randomized, triple-arm clinical trial involved 92 children aged 4-13 years and their caregivers. Recruitment was conducted through posters, public libraries, community centers, and social media. At a 2-hour session, participants were instructed to prepare for a simulated MRI head scan using one of three randomly assigned preparation materials: the VR-MRI app, SPM, or the CLP. Data were collected before preparation, during a simulated MRI head scan, and after the simulated scan. The primary outcomes were the success of the simulated MRI scan (MoTrak head motion tracking system), and child-reported anxiety (Venham picture test). We secondarily measured caregivers’ reported anxiety (short State-Trait Anxiety Inventory), procedural data (minutes), usability (Usefulness, Satisfaction, and Ease of Use Questionnaire), and child-reported satisfaction and fun (visual analog scales). Results: A total of 84 participants were included in the final analysis (VR-MRI: 30/84, 36%; SPM: 24/84, 29%; and CLP: 30/84, 36%). There were no clinically significant differences between the groups in terms of success during the MRI simulation (P=.27) or the children’s reported anxiety at any timepoint (timepoint 1, P=.99; timepoint 2, P=.008; timepoint 3, P=.10). Caregivers reported being significantly more anxious after preparing with the manual than caregivers in the other 2 groups (P<.001). Child and caregiver anxiety had a significant relationship, increasing together with moderate effect (r84=0.421; P<.001). Participants using VR-MRI took the most time to prepare (P<.001) and participants using the manual took the least time (P<.001). No statistically significant relationships were found between time preparing and time completing the simulated assessment (P=.13). There were no differences found in ease of use (P=.99), ease of learning (P=.48), and usefulness (P=.11) between the groups; however, caregivers reported being significantly more satisfied with the VR-MRI app and CLP than SPM (P<.001). Children reported the most satisfaction with the CLP (P<.001). There were no differences in how much fun the preparation materials were perceived to be (P=.37). Conclusions: Digital preparation experiences using VR-based media could be a viable solution to improve the success of nonsedated MRI scans, with outcomes comparable with hospital-based in-person preparatory programs. Future research should focus on validating the results in a real MRI setting. Trial Registration: Clinicaltrials.gov NCT03931382; https://clinicaltrials.gov/ct2/show/NCT03931382 %M 34550072 %R 10.2196/22942 %U https://www.jmir.org/2021/9/e22942 %U https://doi.org/10.2196/22942 %U http://www.ncbi.nlm.nih.gov/pubmed/34550072 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e29210 %T The Effect of Reminiscence Therapy Using Virtual Reality on Apathy in Residential Aged Care: Multisite Nonrandomized Controlled Trial %A Saredakis,Dimitrios %A Keage,Hannah AD %A Corlis,Megan %A Ghezzi,Erica S %A Loffler,Helen %A Loetscher,Tobias %+ UniSA Justice & Society, University of South Australia, St Bernards Road, Magill, Adelaide, South Australia, 5072, Australia, 61 8 8302 4083, dimitrios.saredakis@mymail.unisa.edu.au %K reminiscence %K head-mounted display %K apathy %K cognitive aging %K dementia %K residential facilities %K virtual reality %D 2021 %7 20.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Apathy is a frequent and underrecognized neurological disorder symptom. Reduced goal-directed behavior caused by apathy is associated with poor outcomes for older adults in residential aged care. Recommended nonpharmacological treatments include person-centered therapy using information and communication technology. Virtual reality (VR) in the form of head-mounted displays (HMDs) is a fully immersive technology that provides access to a wide range of freely available content. The use of VR as a therapy tool has demonstrated promise in the treatment of posttraumatic stress disorder and anxiety. In addition, VR has been used to improve conditions including depression, anxiety, cognitive function, and balance in older adults with memory deficits, Alzheimer disease, and Parkinson disease. Research using VR for the symptoms of apathy in older adults living in residential aged care facilities is limited. Objective: This study aims to examine whether using HMDs as a tool for reminiscence therapy improves the symptoms of apathy compared with using a laptop computer and physical items with older adults living in residential aged care. Methods: In this multisite trial, 43 participants were allocated to one of three groups: reminiscence therapy intervention using VR in the form of HMDs, reminiscence therapy using a laptop computer supplemented by physical items if required (active control), and a usual care (passive control) group. The primary outcome was apathy, and the secondary outcomes included cognition and depression. The side effects of using HMDs were also measured in the VR group. Results: Mixed model analyses revealed no significant group interaction over time in outcomes between the VR and laptop groups (estimate=−2.24, SE 1.89; t40=−1.18; P=.24). Pooled apathy scores in the two intervention groups compared with the passive control group also revealed no significant group interaction over time (estimate=−0.26, SE 1.66; t40=−0.16; P=.88). There were no significant secondary outcomes. Most participants in the VR group stated that they would prefer to watch content in VR than on a flat screen (Χ22=11.2; P=.004), side effects from HMD use were negligible to minimal according to the Simulator Sickness Questionnaire cutoff scores. Conclusions: Although there were no significant results in outcome measures, this study found that participants engaged in the research and enjoyed the process of reminiscing using both forms of technology. It was found that VR can be implemented in an aged care setting with correct protocols in place. Providing residents in aged care with a choice of technology may assist in increasing participation in activities. We cannot dismiss the importance of immediate effects while the therapy was in progress, and this is an avenue for future research. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12619001510134; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378564. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2020-046030 %M 34542418 %R 10.2196/29210 %U https://www.jmir.org/2021/9/e29210 %U https://doi.org/10.2196/29210 %U http://www.ncbi.nlm.nih.gov/pubmed/34542418 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e24307 %T Virtual Reality Technology Use in Cigarette Craving and Smoking Interventions (I “Virtually” Quit): Systematic Review %A Keijsers,Merel %A Vega-Corredor,Maria Cecilia %A Tomintz,Melanie %A Hoermann,Simon %+ School of Product Design, College of Engineering, University of Canterbury, 9 Engineering Road, Christchurch, 8041, New Zealand, 64 3 369 2457, simon.hoermann@canterbury.ac.nz %K virtual reality technology %K nicotine dependency %K nicotine addiction %K smoking addiction %K smoking intervention %K smoking therapy %K Electronic Nicotine Delivery Systems %D 2021 %7 17.9.2021 %9 Review %J J Med Internet Res %G English %X Background: Over the last 2 decades, virtual reality technologies (VRTs) have been proposed as a way to enhance and improve smoking cessation therapy. Objective: This systematic review aims to evaluate and summarize the current knowledge on the application of VRT in various smoking cessation therapies, as well as to explore potential directions for future research and intervention development. Methods: A literature review of smoking interventions using VRT was conducted. Results: Not all intervention studies included an alternative therapy or a placebo condition against which the effectiveness of the intervention could be benchmarked, or a follow-up measure to ensure that the effects were lasting. Virtual reality (VR) cue exposure therapy was the most extensively studied intervention, but its effect on long-term smoking behavior was inconsistent. Behavioral therapies such as a VR approach-avoidance task or gamified interventions were less common but reported positive results. Notably, only 1 study combined Electronic Nicotine Delivery Devices with VRT. Conclusions: The inclusion of a behavioral component, as is done in the VR approach-avoidance task and gamified interventions, may be an interesting avenue for future research on smoking interventions. As Electronic Nicotine Delivery Devices are still the subject of much controversy, their potential to support smoking cessation remains unclear. For future research, behavioral or multicomponent interventions are promising avenues of exploration. Future studies should improve their validity by comparing their intervention group with at least 1 alternative or placebo control group, as well as incorporating follow-up measures. %M 34533471 %R 10.2196/24307 %U https://www.jmir.org/2021/9/e24307 %U https://doi.org/10.2196/24307 %U http://www.ncbi.nlm.nih.gov/pubmed/34533471 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 9 %P e31637 %T Psychological Effects of Heart Rate and Physical Vibration on the Operation of Construction Machines: Experimental Study %A Hashiguchi,Nobuki %A Cao,Jianfei %A Lim,Yeongjoo %A Kuroishi,Shinichi %A Miyazaki,Yasuhiro %A Kitahara,Shigeo %A Sengoku,Shintaro %A Matsubayashi,Katsushi %A Kodama,Kota %+ Graduate School of Technology Management, Ritsumeikan University, 2-150, Iwakuracho, Ibaraki, 5678570, Japan, 81 0726652448, kkodama@fc.ritsumei.ac.jp %K heart rate variability %K complexity %K vital signs %K vibration at work %K stress %K wearable technology %K remote operation %K monitoring %D 2021 %7 15.9.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: A construction method has emerged in which a camera is installed around a construction machine, and the operator remotely controls the machine while synchronizing the vibration of the machine with the images seen from the operator's seat using virtual reality (VR) technology. Indices related to changes in heart rate (HR) and physical vibration, such as heart rate variability (HRV) and multiscale entropy (MSE), can then be measured among the operators. As these indices are quantitative measures of autonomic regulation in the cardiovascular system, they can provide a useful means of assessing operational stress. Objective: In this study, we aimed to evaluate changes in HR and body vibration of machine operators and investigate appropriate methods of machine operation while considering the psychological load. Methods: We enrolled 9 remote operators (18-50 years old) in the experiment, which involved 42 measurements. A construction machine was driven on a test course simulating a construction site, and three patterns of operation—riding operation, remote operation using monitor images, and VR operation combining monitor images and machine vibration—were compared. The heartbeat, body vibration, and driving time of the participants were measured using sensing wear made of a woven film-like conductive material and a three-axis acceleration measurement device (WHS-2). We used HRV analysis in the time and frequency domains, MSE analysis as a measure of the complexity of heart rate changes, and the ISO (International Standards Organization) 2631 vibration index. Multiple regression analysis was conducted to model the relationship among the low frequency (LF)/high frequency (HF) HRV, MSE, vibration index, and driving time of construction equipment. Efficiency in driving time was investigated with a focus on stress reduction. Results: Multiple comparisons conducted via the Bonferroni test and Kruskal-Wallis test showed statistically significant differences (P=.05) in HRV-LF/HF, the vibration index, weighted acceleration, motion sickness dose value (MSDVz), and the driving time among the three operation patterns. The riding operation was found to reduce the driving time of the machine, but the operation stress was the highest in this case; operation based on the monitor image was found to have the lowest operation stress but the longest operation time. Multiple regression analysis showed that the explanatory variables (LH/HF), RR interval, and vibration index (MSDVz by vertical oscillation at 0.5-5 Hz) had a negative effect on the driving time (adjusted coefficient of determination R2=0.449). Conclusions: A new method was developed to calculate the appropriate operating time by considering operational stress and suppressing the physical vibration within an acceptable range. By focusing on the relationship between psychological load and physical vibration, which has not been explored in previous studies, the relationship of these variables with the driving time of construction machines was clarified. %M 34524105 %R 10.2196/31637 %U https://mhealth.jmir.org/2021/9/e31637 %U https://doi.org/10.2196/31637 %U http://www.ncbi.nlm.nih.gov/pubmed/34524105 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e24081 %T A 3D Hologram With Mixed Reality Techniques to Improve Understanding of Pulmonary Lesions Caused by COVID-19: Randomized Controlled Trial %A Liu,Songxiang %A Xie,Mao %A Zhang,Zhicai %A Wu,Xinghuo %A Gao,Fei %A Lu,Lin %A Zhang,Jiayao %A Xie,Yi %A Yang,Fan %A Ye,Zhewei %+ Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430019, China, 86 13971213880, yezhewei@hust.edu.cn %K COVID-19 %K mixed reality %K hologram %K pulmonary %K lesion %K diagnostic %K imaging %D 2021 %7 10.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: The COVID-19 outbreak has now become a pandemic and has had a serious adverse impact on global public health. The effect of COVID-19 on the lungs can be determined through 2D computed tomography (CT) imaging, which requires a high level of spatial imagination on the part of the medical provider. Objective: The purpose of this study is to determine whether viewing a 3D hologram with mixed reality techniques can improve medical professionals’ understanding of the pulmonary lesions caused by COVID-19. Methods: The study involved 60 participants, including 20 radiologists, 20 surgeons, and 20 medical students. Each of the three groups was randomly divided into two groups, either the 2D CT group (n=30; mean age 29 years [range 19-38 years]; males=20) or the 3D holographic group (n=30; mean age 30 years [range 20=38 years]; males=20). The two groups completed the same task, which involved identifying lung lesions caused by COVID-19 for 6 cases using a 2D CT or 3D hologram. Finally, an independent radiology professor rated the participants' performance (out of 100). All participants in two groups completed a Likert scale questionnaire regarding the educational utility and efficiency of 3D holograms. The National Aeronautics and Space Administration Task Load Index (NASA-TLX) was completed by all participants. Results: The mean task score of the 3D hologram group (mean 91.98, SD 2.45) was significantly higher than that of the 2D CT group (mean 74.09, SD 7.59; P<.001). With the help of 3D holograms, surgeons and medical students achieved the same score as radiologists and made obvious progress in identifying pulmonary lesions caused by COVID-19. The Likert scale questionnaire results showed that the 3D hologram group had superior results compared to the 2D CT group (teaching: 2D CT group median 2, IQR 1-2 versus 3D group median 5, IQR 5-5; P<.001; understanding and communicating: 2D CT group median 1, IQR 1-1 versus 3D group median 5, IQR 5-5; P<.001; increasing interest: 2D CT group median 2, IQR 2-2 versus 3D group median 5, IQR 5-5; P<.001; lowering the learning curve: 2D CT group median 2, IQR 1-2 versus 3D group median 4, IQR 4-5; P<.001; spatial awareness: 2D CT group median 2, IQR 1-2 versus 3D group median 5, IQR 5-5; P<.001; learning: 2D CT group median 3, IQR 2-3 versus 3D group median 5, IQR 5-5; P<.001). The 3D group scored significantly lower than the 2D CT group for the “mental,” “temporal,” “performance,” and “frustration” subscales on the NASA-TLX. Conclusions: A 3D hologram with mixed reality techniques can be used to help medical professionals, especially medical students and newly hired doctors, better identify pulmonary lesions caused by COVID-19. It can be used in medical education to improve spatial awareness, increase interest, improve understandability, and lower the learning curve. Trial Registration: Chinese Clinical Trial Registry ChiCTR2100045845; http://www.chictr.org.cn/showprojen.aspx?proj=125761 %M 34061760 %R 10.2196/24081 %U https://www.jmir.org/2021/9/e24081 %U https://doi.org/10.2196/24081 %U http://www.ncbi.nlm.nih.gov/pubmed/34061760 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 9 %N 9 %P e29498 %T Nursing Interns’ Attitudes Toward, Preferences for, and Use of Diabetes Virtual Simulation Teaching Applications in China: National Web-Based Survey %A Liu,Fang %A Weng,Huiting %A Xu,Rong %A Li,Xia %A Zhang,Zhe %A Zhao,Kuaile %A Zhou,Zhiguang %A Wang,Qin %+ Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, 139 Middle Renmin Road, Changsha, 410011, China, 86 18774806226, wangqin3421@csu.edu.cn %K nursing interns %K virtual simulation %K China %K nursing education %K diabetes %D 2021 %7 9.9.2021 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Diabetes has placed heavy social and economic burdens on society and families worldwide. Insufficient knowledge and training of frontline medical staff, such as nurses, interns, and residents, may lead to an increase in acute and chronic complications among patients with diabetes. However, interns have insufficient knowledge about diabetes management. The factors that affect interns’ current level of diabetes-related knowledge are still unclear. Therefore, understanding the behavioral intentions of interns is essential to supporting the development and promotion of the use of virtual simulation teaching applications. Objective: This study aimed to identify the determinants of nursing interns’ intentions to use simulation-based education applications. Methods: From December 1, 2020, to February 28, 2021, the web-based survey tool Sojump (Changsha Xingxin Information Technology Co) was used to survey nursing interns in hospitals across China. Two survey links were sent to 37 partner schools in 23 major cities in China, and they were disseminated through participants’ WeChat networks. Multiple regression analysis was used to determine the association between demographic information and basic disease information and the use of the application for treating adult patients. Results: Overall, 883 nursing interns from 23 provinces in China responded to the survey. Among them, the virtual simulation utilization rate was 35.6% (314/883) and the awareness rate was 10.2% (90/883). In addition, among the interns, only 10.2% (90/883) correctly understood the concept of virtual simulation, and most of them (793/883, 89.8%) believed that scenario-simulation training or the use of models for teaching are all the same. Multiple regression analysis showed that the educational level, independent learning ability, and professional identity of the interns were related to use of the application (P<.05). Skills and knowledge that the interns most wanted to acquire included the treatment of hypoglycemia (626/883, 70.9%), functional test simulation (610/883, 69.1%), and blood glucose monitoring technology (485/883, 54.9%). A total of 60.5% (534/883) of the interns wanted to acquire clinical thinking skills, while 16.0% (141/883) wanted to acquire operational skills. Nursing trainees believed that the greatest obstacles to virtual simulation included limited time (280/883, 31.7%), the degree of simulation (129/883, 14.6%), the demand for satisfaction (108/883, 12.2%), and test scores (66/883, 7.5%). Conclusions: The understanding and usage rate of diabetes virtual simulation teaching applications by Chinese nursing interns is very low. However, they have high requirements regarding this teaching method. Conducting high-quality randomized controlled trials and designing applications that are suitable for the needs of different nurse trainees will increase students’ interest in learning and help improve diabetes knowledge among nursing interns. %M 34499047 %R 10.2196/29498 %U https://mhealth.jmir.org/2021/9/e29498 %U https://doi.org/10.2196/29498 %U http://www.ncbi.nlm.nih.gov/pubmed/34499047 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 9 %P e28018 %T Virtual Reality Tour to Reduce Perioperative Anxiety in an Operating Setting Before Anesthesia: Randomized Clinical Trial %A Vogt,Lina %A Klasen,Martin %A Rossaint,Rolf %A Goeretz,Ute %A Ebus,Peter %A Sopka,Sasa %+ AIXTRA Competence Center for Training and Patient Safety, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, Aachen, 52074, Germany, 49 2418089974, lvogt@ukaachen.de %K anesthesia %K anxiety %K exposure %K operating theater %K patient empowerment %K periperative trait anxiety %K STOA %K STAI %K virtual reality %K VR %D 2021 %7 1.9.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Perioperative anxiety is a major burden to patients undergoing surgeries with general anesthesia. Objective: This study investigated whether a virtual operating room tour (VORT) before surgery can be used to ameliorate perioperative anxiety. Methods: We employed a randomized parallel-group design with 2 study arms to compare VORT to the standard operation preparation procedure. The study included 84 patients. A validated inventory (state-trait operation anxiety-state) was used to assess perioperative state anxiety before (T1) and after (T2) surgery. In addition, trait operation anxiety was evaluated with an additional validated inventory (state-trait operation anxiety-trait). Moreover, user ratings on the usefulness of VORT were assessed with an evaluation questionnaire. Study arms were compared for perioperative state anxiety with two-tailed independent samples t tests. Subjective ratings were correlated with STOA-Trait values to investigate possible associations between perioperative anxiety with perceived usefulness. Results: There were no significant differences in perioperative state anxiety between VORT and standard operation preparation procedures before and after the surgery. Nonetheless, patients’ ratings of VORT overall were positive. The tour was perceived as useful and, therefore, showed acceptance for VR use. These ratings were unrelated to the degree of perioperative anxiety. Conclusions: The subjective benefit of VORT could not be explained by a reduction of perioperative anxiety. Instead, VORT appears to serve the need for information and reduce uncertainty. In addition, VORT is perceived as beneficial regardless of the age of the patients. Considering this effect and the manageable organizational and financial effort toward implementation, the general use of VORT can be recommended. Trial Registration: ClinicalTrials.gov NCT04579354; https://clinicaltrials.gov/ct2/show/NCT04579354 %M 34252034 %R 10.2196/28018 %U https://www.jmir.org/2021/9/e28018 %U https://doi.org/10.2196/28018 %U http://www.ncbi.nlm.nih.gov/pubmed/34252034 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26976 %T Feasibility of Virtual Reality Audiological Testing: Prospective Study %A Seol,Hye Yoon %A Kang,Soojin %A Lim,Jihyun %A Hong,Sung Hwa %A Moon,Il Joon %+ Department of Otolaryngology-Head & Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea, 82 2 3410 3579, moonij@skku.edu %K hearing loss %K virtual reality %K speech performance %K real-world performance %K hearing %K audiology %D 2021 %7 31.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: It has been noted in the literature that there is a gap between clinical assessment and real-world performance. Real-world conversations entail visual and audio information, yet there are not any audiological assessment tools that include visual information. Virtual reality (VR) technology has been applied to various areas, including audiology. However, the use of VR in speech-in-noise perception has not yet been investigated. Objective: The purpose of this study was to investigate the impact of virtual space (VS) on speech performance and its feasibility to be used as a speech test instrument. We hypothesized that individuals’ ability to recognize speech would improve when visual cues were provided. Methods: A total of 30 individuals with normal hearing and 25 individuals with hearing loss completed pure-tone audiometry and the Korean version of the Hearing in Noise Test (K-HINT) under three conditions—conventional K-HINT (cK-HINT), VS on PC (VSPC), and VS head-mounted display (VSHMD)—at –10 dB, –5 dB, 0 dB, and +5 dB signal-to-noise ratios (SNRs). Participants listened to target speech and repeated it back to the tester for all conditions. Hearing aid users in the hearing loss group completed testing under unaided and aided conditions. A questionnaire was administered after testing to gather subjective opinions on the headset, the VSHMD condition, and test preference. Results: Provision of visual information had a significant impact on speech performance between the normal hearing and hearing impaired groups. The Mann-Whitney U test showed statistical significance (P<.05) between the two groups under all test conditions. Hearing aid use led to better integration of audio and visual cues. Statistical significance through the Mann-Whitney U test was observed for –5 dB (P=.04) and 0 dB (P=.02) SNRs under the cK-HINT condition, as well as for –10 dB (P=.007) and 0 dB (P=.04) SNRs under the VSPC condition, between hearing aid and non–hearing aid users. Participants reported positive responses across almost all items on the questionnaire except for the weight of the headset. Participants preferred a test method with visual imagery, but found the headset to be heavy. Conclusions: Findings are in line with previous literature that showed that visual cues were beneficial for communication. This is the first study to include hearing aid users with a more naturalistic stimulus and a relatively simple test environment, suggesting the feasibility of VR audiological testing in clinical practice. %M 34463624 %R 10.2196/26976 %U https://games.jmir.org/2021/3/e26976 %U https://doi.org/10.2196/26976 %U http://www.ncbi.nlm.nih.gov/pubmed/34463624 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26153 %T A Personalized Home-Based Rehabilitation Program Using Exergames Combined With a Telerehabilitation App in a Chronic Stroke Survivor: Mixed Methods Case Study %A Allegue,Dorra Rakia %A Kairy,Dahlia %A Higgins,Johanne %A Archambault,Philippe S %A Michaud,Francois %A Miller,William C %A Sweet,Shane N %A Tousignant,Michel %+ The Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Institut universitaire sur la réadaptation en déficience physique de Montréal, 6363 Chemin Hudson (fifth floor), Montreal, QC, H3S1M9, Canada, 1 4389901309, dorra.rakia.allegue@umontreal.ca %K stroke %K rehabilitation %K virtual reality %K video games %K telerehabilitation %K upper extremity %K motivation %D 2021 %7 31.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: In Canada, only 11% of stroke survivors have access to outpatient and community-based rehabilitation after discharge from inpatient rehabilitation. Hence, innovative community-based strategies are needed to provide adequate postrehabilitation services. The VirTele program, which combines virtual reality exergames and a telerehabilitation app, was developed to provide stroke survivors with residual upper extremity deficits, the opportunity to participate in a personalized home rehabilitation program. Objective: This study aims to determine the feasibility of VirTele for remote upper extremity rehabilitation in a chronic stroke survivor; explore the preliminary efficacy of VirTele on upper extremity motor function, the amount and quality of upper extremity use, and impact on quality of life and motivation; and explore the determinants of behavioral intention and use behavior of VirTele along with indicators of empowerment. Methods: A 63-year-old male stroke survivor (3 years) with moderate upper extremity impairment participated in a 2-month VirTele intervention. He was instructed to use exergames (5 games for upper extremity) for 30 minutes, 5 times per week, and conduct videoconference sessions with a clinician at least once per week. Motivational interviewing was incorporated into VirTele to empower the participant to continue exercising and use his upper extremities in everyday activities. Upper extremity motor function (Fugl-Meyer Assessment–upper extremity), amount and quality of upper extremity use (Motor Activity Log-30), and impact on quality of life (Stroke Impact Scale-16) and motivation (Treatment Self-Regulation Questionnaire-15) were measured before (T1), after (T2) VirTele intervention, and during a 1- (T3) and 2-month (T4) follow-up period. Qualitative data were collected through logs and semistructured interviews. Feasibility data (eg, number and duration of videoconference sessions and adherence) were documented at the end of each week. Results: The participant completed 48 exergame sessions (33 hours) and 8 videoconference sessions. Results suggest that the VirTele intervention and the study protocol could be feasible for stroke survivors. The participant exhibited clinically meaningful improvements at T2 on the Fugl-Meyer and Stroke Impact Scale-16 and maintained these gains at T3 and T4. During the follow-up periods, the amount and quality of upper extremity use showed meaningful changes, suggesting more involvement of the affected upper extremity in daily activities. The participant demonstrated a high level of autonomous motivation, which may explain his adherence. Performance, effort, and social influence have meaningful weights in the behavioral intention of using VirTele. However, the lack of control of technical and organizational infrastructures may influence the long-term use of technology. At the end of the intervention, the participant demonstrated considerable empowerment at both the behavioral and capacity levels. Conclusions: VirTele was shown to be feasible for use in chronic stroke survivors for remote upper extremity rehabilitation. Meaningful determinants of behavioral intention and use behavior of VirTele were identified, and preliminary efficacy results are promising. International Registered Report Identifier (IRRID): RR2-10.2196/14629 %M 34132649 %R 10.2196/26153 %U https://games.jmir.org/2021/3/e26153 %U https://doi.org/10.2196/26153 %U http://www.ncbi.nlm.nih.gov/pubmed/34132649 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 8 %P e24152 %T Applications of Extended Reality in Ophthalmology: Systematic Review %A Ong,Chee Wui %A Tan,Marcus Chun Jin %A Lam,Michael %A Koh,Victor Teck Chang %+ Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road NUHS Tower Block, Level 7, Singapore, 119228, Singapore, 65 90230056, victor_koh@nuhs.edu.sg %K extended reality %K virtual reality %K augmented reality %K mixed reality %K ophthalmology %K ophthalmic %D 2021 %7 19.8.2021 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality, augmented reality, and mixed reality make use of a variety of different software and hardware, but they share three main characteristics: immersion, presence, and interaction. The umbrella term for technologies with these characteristics is extended reality. The ability of extended reality to create environments that are otherwise impossible in the real world has practical implications in the medical discipline. In ophthalmology, virtual reality simulators have become increasingly popular as tools for surgical education. Recent developments have also explored diagnostic and therapeutic uses in ophthalmology. Objective: This systematic review aims to identify and investigate the utility of extended reality in ophthalmic education, diagnostics, and therapeutics. Methods: A literature search was conducted using PubMed, Embase, and Cochrane Register of Controlled Trials. Publications from January 1, 1956 to April 15, 2020 were included. Inclusion criteria were studies evaluating the use of extended reality in ophthalmic education, diagnostics, and therapeutics. Eligible studies were evaluated using the Oxford Centre for Evidence-Based Medicine levels of evidence. Relevant studies were also evaluated using a validity framework. Findings and relevant data from the studies were extracted, evaluated, and compared to determine the utility of extended reality in ophthalmology. Results: We identified 12,490 unique records in our literature search; 87 met final eligibility criteria, comprising studies that evaluated the use of extended reality in education (n=54), diagnostics (n=5), and therapeutics (n=28). Of these, 79 studies (91%) achieved evidence levels in the range 2b to 4, indicating poor quality. Only 2 (9%) out of 22 relevant studies addressed all 5 sources of validity evidence. In education, we found that ophthalmic surgical simulators demonstrated efficacy and validity in improving surgical performance and reducing complication rates. Ophthalmoscopy simulators demonstrated efficacy and validity evidence in improving ophthalmoscopy skills in the clinical setting. In diagnostics, studies demonstrated proof-of-concept in presenting ocular imaging data on extended reality platforms and validity in assessing the function of patients with ophthalmic diseases. In therapeutics, heads-up surgical systems had similar complication rates, procedural success rates, and outcomes in comparison with conventional ophthalmic surgery. Conclusions: Extended reality has promising areas of application in ophthalmology, but additional high-quality comparative studies are needed to assess their roles among incumbent methods of ophthalmic education, diagnostics, and therapeutics. %M 34420929 %R 10.2196/24152 %U https://www.jmir.org/2021/8/e24152 %U https://doi.org/10.2196/24152 %U http://www.ncbi.nlm.nih.gov/pubmed/34420929 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e28400 %T Feasibility and Effects of Virtual Reality Motor-Cognitive Training in Community-Dwelling Older People With Cognitive Frailty: Pilot Randomized Controlled Trial %A Kwan,Rick Yiu Cho %A Liu,Justina Yat Wa %A Fong,Kenneth Nai Kuen %A Qin,Jing %A Leung,Philip Kwok-Yuen %A Sin,Olive Suk Kan %A Hon,Pik Yuen %A Suen,Lydia W %A Tse,Man-Kei %A Lai,Claudia KY %+ Centre for Gerontological Nursing, School of Nursing, The Hong Kong Polytechnic University, GH502, Hung Hom, Kowloon, Hong Kong, , China (Hong Kong), 852 2766 6546, rick.kwan@polyu.edu.hk %K virtual reality %K motor-cognitive training %K cognitive frailty %K game %K feasibility %K VR %K training %K older adults %K frail %K pilot study %K randomized controlled trial %D 2021 %7 6.8.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Cognitive frailty refers to the coexistence of physical frailty and cognitive impairment, and is associated with many adverse health outcomes. Although cognitive frailty is prevalent in older people, motor-cognitive training is effective at enhancing cognitive and physical function. We proposed a virtual reality (VR) simultaneous motor-cognitive training program, which allowed older people to perform daily activities in a virtual space mimicking real environments. Objective: We aimed to (1) explore the feasibility of offering VR simultaneous motor-cognitive training to older people with cognitive frailty and (2) compare its effects with an existing motor-cognitive training program in the community on the cognitive function and physical function of older people with cognitive frailty. Methods: A two-arm (1:1), assessor-blinded, parallel design, randomized controlled trial was employed. The eligibility criteria for participants were: (1) aged ≥60 years, (2) community dwelling, and (3) with cognitive frailty. Those in the intervention group received cognitive training (ie, cognitive games) and motor training (ie, cycling on an ergometer) simultaneously on a VR platform, mimicking the daily living activities of older people. Those in the control group received cognitive training (ie, cognitive games) on tablet computers and motor training (ie, cycling on the ergometer) sequentially on a non-VR platform. Both groups received a 30-minute session twice a week for 8 weeks. Feasibility was measured by adherence, adverse outcomes, and successful learning. The outcomes were cognitive function, physical frailty level, and walking speed. Results: Seventeen participants were recruited and randomized to either the control group (n=8) or intervention group (n=9). At baseline, the median age was 74.0 years (IQR 9.5) and the median Montreal Cognitive Assessment score was 20.0 (IQR 4.0). No significant between-group differences were found in baseline characteristics except in the number of chronic illnesses (P=.04). At postintervention, the intervention group (Z=–2.67, P=.01) showed a significantly larger improvement in cognitive function than the control group (Z=–1.19, P=.24). The reduction in physical frailty in the intervention group (Z=–1.73, P=.08) was similar to that in the control group (Z=–1.89, P=.06). Improvement in walking speed based on the Timed Up-and-Go test was moderate in the intervention group (Z=–0.16, P=.11) and greater in the control group (Z=–2.52, P=.01). The recruitment rate was acceptable (17/33, 52%). Both groups had a 100% attendance rate. The intervention group had a higher completion rate than the control group. Training was terminated for one participant (1/9, 11%) due to minimal VR sickness (Virtual Reality Sickness Questionnaire score=18.3/100). Two participants (2/8, 25%) in the control group withdrew due to moderate leg pain. No injuries were observed in either group. Conclusions: This study provides preliminary evidence that the VR simultaneous motor-cognitive training is effective at enhancing the cognitive function of older people with cognitive frailty. The effect size on frailty was close to reaching a level of significance and was similar to that observed in the control group. VR training is feasible and safe for older people with cognitive frailty. Trial Registration: ClinicalTrials.gov NCT04467216; https://clinicaltrials.gov/ct2/show/NCT04467216 %M 34383662 %R 10.2196/28400 %U https://games.jmir.org/2021/3/e28400 %U https://doi.org/10.2196/28400 %U http://www.ncbi.nlm.nih.gov/pubmed/34383662 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 8 %P e28073 %T Usability and Effectiveness of Immersive Virtual Grocery Shopping for Assessing Cognitive Fatigue in Healthy Controls: Protocol for a Randomized Controlled Trial %A Holdnack,James A %A Brennan,Patricia Flatley %+ National Institute of Nursing Research, National Institutes of Health, BG 10 RM 2N110A, 10 Center Drive, Bethesda, MD, United States, 1 301 402 8056, jim.holdnack@nih.gov %K cognitive fatigue %K immersive VR %K user experience %K virtual grocery shopping %K instrumental activity of daily living %D 2021 %7 4.8.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Cognitive fatigue (CF) is a human response to stimulation and stress and is a common comorbidity in many medical conditions that can result in serious consequences; however, studying CF under controlled conditions is difficult. Immersive virtual reality provides an experimental environment that enables the precise measurement of the response of an individual to complex stimuli in a controlled environment. Objective: We aim to examine the development of an immersive virtual shopping experience to measure subjective and objective indicators of CF induced by instrumental activities of daily living. Methods: We will recruit 84 healthy participants (aged 18-75 years) for a 2-phase study. Phase 1 is a user experience study for testing the software functionality, user interface, and realism of the virtual shopping environment. Phase 2 uses a 3-arm randomized controlled trial to determine the effect that the immersive environment has on fatigue. Participants will be randomized into 1 of 3 conditions exploring fatigue response during a typical human activity (grocery shopping). The level of cognitive and emotional challenges will change during each activity. The primary outcome of phase 1 is the experience of user interface difficulties. The primary outcome of phase 2 is self-reported CF. The core secondary phase 2 outcomes include subjective cognitive load, change in task performance behavior, and eye tracking. Phase 2 uses within-subject repeated measures analysis of variance to compare pre- and postfatigue measures under 3 conditions (control, cognitive challenge, and emotional challenge). Results: This study was approved by the scientific review committee of the National Institute of Nursing Research and was identified as an exempt study by the institutional review board of the National Institutes of Health. Data collection will begin in spring 2021. Conclusions: Immersive virtual reality may be a useful research platform for simulating the induction of CF associated with the cognitive and emotional challenges of instrumental activities of daily living. Trial Registration: ClinicalTrials.gov NCT04883359; http://clinicaltrials.gov/ct2/show/NCT04883359 International Registered Report Identifier (IRRID): PRR1-10.2196/28073 %M 34346898 %R 10.2196/28073 %U https://www.researchprotocols.org/2021/8/e28073 %U https://doi.org/10.2196/28073 %U http://www.ncbi.nlm.nih.gov/pubmed/34346898 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e26344 %T Recommendations for the Design and Implementation of Virtual Reality for Acquired Brain Injury Rehabilitation: Systematic Review %A Brassel,Sophie %A Power,Emma %A Campbell,Andrew %A Brunner,Melissa %A Togher,Leanne %+ Discipline of Speech Pathology, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Susan Wakil Health Building D18, Western Avenue, The University of Sydney, Sydney, 2006, Australia, 61 2 8627 9541, sophie.brassel@sydney.edu.au %K virtual reality %K acquired brain injury %K traumatic brain injury %K rehabilitation %K systematic review %K recommendations %K cognitive communication %K mobile phone %D 2021 %7 30.7.2021 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) is increasingly being used for the assessment and treatment of impairments arising from acquired brain injuries (ABIs) due to perceived benefits over traditional methods. However, no tailored options exist for the design and implementation of VR for ABI rehabilitation and, more specifically, traumatic brain injury (TBI) rehabilitation. In addition, the evidence base lacks systematic reviews of immersive VR use for TBI rehabilitation. Recommendations for this population are important because of the many complex and diverse impairments that individuals can experience. Objective: This study aims to conduct a two-part systematic review to identify and synthesize existing recommendations for designing and implementing therapeutic VR for ABI rehabilitation, including TBI, and to identify current evidence for using immersive VR for TBI assessment and treatment and to map the degree to which this literature includes recommendations for VR design and implementation. Methods: This review was guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). A comprehensive search of 11 databases and gray literature was conducted in August 2019 and repeated in June 2020. Studies were included if they met relevant search terms, were peer-reviewed, were written in English, and were published between 2009 and 2020. Studies were reviewed to determine the level of evidence and methodological quality. For the first part, qualitative data were synthesized and categorized via meta-synthesis. For the second part, findings were analyzed and synthesized descriptively owing to the heterogeneity of data extracted from the included studies. Results: In the first part, a total of 14 papers met the inclusion criteria. Recommendations for VR design and implementation were not specific to TBI but rather to stroke or ABI rehabilitation more broadly. The synthesis and analysis of data resulted in three key phases and nine categories of recommendations for designing and implementing VR for ABI rehabilitation. In the second part, 5 studies met the inclusion criteria. A total of 2 studies reported on VR for assessment and three for treatment. Studies were varied in terms of therapeutic targets, VR tasks, and outcome measures. VR was used to assess or treat impairments in cognition, balance, and anxiety, with positive outcomes. However, the levels of evidence, methodological quality, and inclusion of recommendations for VR design and implementation were poor. Conclusions: There is limited research on the use of immersive VR for TBI rehabilitation. Few studies have been conducted, and there is limited inclusion of recommendations for therapeutic VR design and implementation. Future research in ABI rehabilitation should consider a stepwise approach to VR development, from early co-design studies with end users to larger controlled trials. A list of recommendations is offered to provide guidance and a more consistent model to advance clinical research in this area. %M 34328434 %R 10.2196/26344 %U https://www.jmir.org/2021/7/e26344 %U https://doi.org/10.2196/26344 %U http://www.ncbi.nlm.nih.gov/pubmed/34328434 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e22920 %T Resuscitating Cardiopulmonary Resuscitation Training in a Virtual Reality: Prospective Interventional Study %A Perron,Janaya Elizabeth %A Coffey,Michael Jonathon %A Lovell-Simons,Andrew %A Dominguez,Luis %A King,Mark E %A Ooi,Chee Y %+ Discipline of Paediatrics, School of Women's and Children's Health, University of New South Wales, Centre for Child Health Research & Innovation, Level 8, Bright Alliance Building, Corner of Avoca & High Streets, Randwick, Australia, 61 2 9382 5500, j.perron@unswalumni.com %K pediatrics %K cardiopulmonary resuscitation %K virtual reality %K medical education %D 2021 %7 29.7.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Simulation-based technologies are emerging to enhance medical education in the digital era. However, there is limited data for the use of virtual reality simulation in pediatric medical education. We developed Virtual Doc as a highly immersive virtual reality simulation to teach pediatric cardiopulmonary resuscitation skills to medical students. Objective: The primary objectives of this study were to evaluate participant satisfaction and perceived educational efficacy of Virtual Doc. The secondary aim of this study was to assess the game play features of Virtual Doc. Methods: We conducted a prospective closed beta-testing study at the University of New South Wales (Sydney, Australia) in 2018. All medical students from the 6-year undergraduate program were eligible to participate and were recruited through voluntary convenience sampling. Participants attended a 1-hour testing session and attempted at least one full resuscitation case using the virtual reality simulator. Following this, participants were asked to complete an anonymous postsession questionnaire. Responses were analyzed using descriptive statistics. Results: A total of 26 participants were recruited, consented to participate in this study, and attended a 1-hour in-person closed beta-testing session, and 88% (23/26) of participants completed the anonymous questionnaire and were included in this study. Regarding participant satisfaction, Virtual Doc was enjoyed by 91% (21/23) of participants, with 74% (17/23) intending to recommend the simulation to a colleague and 66% (15/23) intending to recommend the simulation to a friend. In assessment of the perceived educational value of Virtual Doc, 70% (16/23) of participants agreed they had an improved understanding of cardiopulmonary resuscitation, and 78% (18/23) agreed that Virtual Doc will help prepare for and deal with real-life clinical scenarios. Furthermore, 91% (21/23) of participants agreed with the development of additional Virtual Doc cases as beneficial for learning. An evaluation of the game play features as our secondary objective revealed that 70% (16/23) of participants agreed with ease in understanding how to use Virtual Doc, and 74% (17/23) found the game play elements useful in understanding cardiopulmonary resuscitation. One-third (7/23, 30%) found it easy to work with the interactive elements. In addition, 74% (17/23) were interested in interacting with other students within the simulation. Conclusions: Our study demonstrates a positive response regarding trainee satisfaction and perceived educational efficacy of Virtual Doc. The simulation was widely accepted by the majority of users and may have the potential to improve educational learning objectives. %M 34326040 %R 10.2196/22920 %U https://www.jmir.org/2021/7/e22920 %U https://doi.org/10.2196/22920 %U http://www.ncbi.nlm.nih.gov/pubmed/34326040 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 4 %N 3 %P e26040 %T Pediatric Coping During Venipuncture With Virtual Reality: Pilot Randomized Controlled Trial %A Canares,Therese %A Parrish,Carisa %A Santos,Christine %A Badawi,Alia %A Stewart,Alyssa %A Kleinman,Keith %A Psoter,Kevin %A McGuire,Joseph %+ Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, 1800 Orleans Street Suite G1509, Baltimore, MD, 21287-0010, United States, 1 4439964711, tcanare1@jhmi.edu %K pediatrics %K psychological distress %K virtual reality %K procedural pain %K anxiety %K phlebotomy %D 2021 %7 28.7.2021 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Virtual reality (VR) has shown promise in reducing children’s pain and anxiety during venipuncture, but studies on VR lack objective observations of pediatric coping. Notably, the process of capturing objective behavioral coping data can be labor- and personnel-intensive. Objective: The primary aims of this pilot trial were to assess the feasibility of conducting a trial of VR in a pediatric emergency department and the feasibility of documenting observed coping behaviors during pediatric procedures. Secondarily, this study examined whether VR affects child and caregiver coping and distress during venipuncture in the pediatric emergency department. Methods: This stratified, randomized, controlled pilot trial compared coping and distress between child life–supported VR engagement and child life specialist support without VR during painful procedures in children aged 7-22 years in the pediatric emergency department. An external control (reference group) received no standardized support. Primary feasibility outcomes included rates of recruitment, rates of withdrawal from VR, and rates of completed Child Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF) observations. Secondary clinical outcomes were applied to venipuncture procedures and included CAMPIS-SF coping and distress (range 0-1.0), pain and anxiety on a visual analog scale (range 0-10), and cybersickness symptoms. Results: Overall recruitment was 93% (66/71), VR withdrawal rate was 27% (4/15), and of the completed procedures, 100% (63/63) CAMPIS-SF observations were completed. A total of 55 patients undergoing venipuncture in the pediatric emergency department were included in the analyses of clinical outcomes: 15 patients (15 caregivers) randomized to VR, 20 patients (15 caregivers) randomized to child life specialist support, and 20 patients (17 caregivers) in the reference group. Patient coping differed across groups with higher coping in the VR group and child life specialist group than in the reference group (P=.046). There were no significant differences in the distress and pain ratings for patients and caregivers between the groups. Caregivers rated the lowest perceived anxiety in the child life specialist group (P=.03). There was no apparent change in cybersickness symptoms before and after VR use (P=.37). Conclusions: Real-time documentation of observed behaviors in patients and caregivers was feasible during medical procedures in which VR was utilized, particularly with the availability of research staff. VR and child life specialists improved coping in children during venipuncture procedures. Given the high participation rate, future studies to evaluate the efficacy of VR are recommended to determine whether an off-the-shelf VR headset can be a low-cost and low-risk tool to improve children’s coping during venipuncture or other related procedures. Trial Registration: ClinicalTrials.gov NCT03686176; https://clinicaltrials.gov/ct2/show/NCT03686176 %M 34319249 %R 10.2196/26040 %U https://pediatrics.jmir.org/2021/3/e26040 %U https://doi.org/10.2196/26040 %U http://www.ncbi.nlm.nih.gov/pubmed/34319249 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e26520 %T Extended Reality for Enhanced Telehealth During and Beyond COVID-19: Viewpoint %A Ong,Triton %A Wilczewski,Hattie %A Paige,Samantha R %A Soni,Hiral %A Welch,Brandon M %A Bunnell,Brian E %+ Doxy.me, LLC, 3445 Winton Place, Suite #114, Rochester, NY, 14623, United States, 1 1844436996, triton.ong@doxy.me %K extended reality %K virtual reality %K augmented reality %K mixed reality %K telehealth %K telemedicine %K COVID-19 %K telepresence %D 2021 %7 26.7.2021 %9 Viewpoint %J JMIR Serious Games %G English %X The COVID-19 pandemic caused widespread challenges and revealed vulnerabilities across global health care systems. In response, many health care providers turned to telehealth solutions, which have been widely embraced and are likely to become standard for modern care. Immersive extended reality (XR) technologies have the potential to enhance telehealth with greater acceptability, engagement, and presence. However, numerous technical, logistic, and clinical barriers remain to the incorporation of XR technology into telehealth practice. COVID-19 may accelerate the union of XR and telehealth as researchers explore novel solutions to close social distances. In this viewpoint, we highlight research demonstrations of XR telehealth during the COVID-19 pandemic and discuss future directions to make XR the next evolution of remote health care. %M 34227992 %R 10.2196/26520 %U https://games.jmir.org/2021/3/e26520 %U https://doi.org/10.2196/26520 %U http://www.ncbi.nlm.nih.gov/pubmed/34227992 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 7 %P e28671 %T Virtual Interactive Surgical Skills Classroom: Protocol for a Parallel-Group, Noninferiority, Adjudicator-Blinded, Randomized Controlled Trial (VIRTUAL) %A Nathan,Arjun %A Fricker,Monty %A Patel,Sonam %A Georgi,Maria %A Hang,Man Kien %A Asif,Aqua %A Sinha,Amil %A Mullins,William %A Shea,Jessie %A Hanna,Nancy %A Lamb,Benjamin %A Kelly,John %A Sridhar,Ashwin %A Collins,Justin %+ University College London, Gower Street, London, WC1E 6BT, United Kingdom, 44 7595189982, arjun.nathan.11@ucl.ac.uk %K digital education %K digital health %K education %K surgery %K surgical skills %K surgical training %K surgical %K suturing %K telemedicine %K virtual classroom %K virtual training %D 2021 %7 22.7.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Traditional face-to-face training (FFT) for basic surgical skills is inaccessible and resource-intensive. Noninteractive computer-based learning is more economical but less educationally beneficial. Virtual classroom training (VCT) is a novel method that permits distanced interactive expert instruction. VCT may optimize resources and increase accessibility. Objective: We aim to investigate whether VCT is superior to computer-based learning and noninferior to FFT in improving proficiency in basic surgical skills. Methods: This is a protocol for a parallel-group, noninferiority, randomized controlled trial. A sample of 72 undergraduates will be recruited from 5 medical schools in London. Participants will be stratified by subjective and objective suturing experience level and allocated to 3 intervention groups at a 1:1:1 ratio. VCT will be delivered using the BARCO weConnect software, and FFT will be provided by expert instructors. Optimal student-to-teacher ratios of 12:1 for VCT and 4:1 for FFT will be maintained. The assessed task will be interrupted suturing with hand-tied knots. Results: The primary outcome will be the postintervention Objective Structured Assessment of Technical Skills score, adjudicated by 2 experts blinded to the study and adjusted for baseline proficiency. The noninferiority margin (δ) will be defined using historical data. Conclusions: This study will serve as a comprehensive appraisal of the suitability of virtual basic surgical skills classroom training as an alternative to FFT. Our findings will assist the development and implementation of further resource-efficient, accessible, virtual basic surgical skills training programs during the COVID-19 pandemic and in the future. Trial Registration: International Standard Randomized Controlled Trial Number ISRCTN12448098; https://www.isrctn.com/ISRCTN12448098 International Registered Report Identifier (IRRID): PRR1-10.2196/28671 %M 34292162 %R 10.2196/28671 %U https://www.researchprotocols.org/2021/7/e28671 %U https://doi.org/10.2196/28671 %U http://www.ncbi.nlm.nih.gov/pubmed/34292162 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e18020 %T Using Visual Guides to Reduce Virtual Reality Sickness in First-Person Shooter Games: Correlation Analysis %A Seok,Kwang-Ho %A Kim,YeolHo %A Son,Wookho %A Kim,Yoon Sang %+ BioComputing Lab, Institute for Bio-engineering Application Technology, School of Computer Science and Engineering, Korea University of Technology and Education, 1600, Chungjeol-ro, Byeongcheon-myeon, Dongnam-gu, Cheonan-si, 31253, Republic of Korea, 82 0415601496, yoonsang@koreatech.ac.kr %K virtual reality %K motion sickness %K VR sickness %K visual guide %K VR fidelity %D 2021 %7 15.7.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The virtual reality (VR) content market is rapidly growing due to an increased supply of VR devices such as head-mounted displays (HMDs), whereas VR sickness (reported to occur while experiencing VR) remains an unsolved problem. The most widely used method of reducing VR sickness is the use of a rest frame that stabilizes the user's viewpoint by providing fixed visual stimuli in VR content (including video). However, the earth-fixed grid and natural independent visual background that are widely used as rest frames cannot maintain VR fidelity, as they reduce the immersion and the presence of the user. A visual guide is a visual element (eg, a crosshair of first-person shooter [FPS]) that induces a user's gaze movement within the VR content while maintaining VR fidelity, whereas there are no studies on the correlation of visual guide with VR sickness. Objective: This study aimed to analyze the correlation between VR sickness and crosshair, which is widely used as a visual guide in FPS games. Methods: Eight experimental scenarios were designed and evaluated, including having the visual guide on/off, the game controller on/off, and varying the size and position of the visual guide to determine the effect of visual guide on VR sickness. Results: The results showed that VR sickness significantly decreased when visual guide was applied in an FPS game. In addition, VR sickness was lower when the visual guide was adjusted to 30% of the aspect ratio and positioned in the head-tracking direction. Conclusions: The experimental results of this study indicate that the visual guide can achieve VR sickness reduction while maintaining user presence and immersion in the virtual environment. In other words, the use of a visual guide is expected to solve the existing limitation of distributing various types of content due to VR sickness. %M 34264196 %R 10.2196/18020 %U https://games.jmir.org/2021/3/e18020 %U https://doi.org/10.2196/18020 %U http://www.ncbi.nlm.nih.gov/pubmed/34264196 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e23683 %T The Effects of Immersive Virtual Reality in Reducing Public Stigma of Mental Illness in the University Population of Hong Kong: Randomized Controlled Trial %A Yuen,Anna S Y %A Mak,Winnie W S %+ Department of Psychology, The Chinese University of Hong Kong, Room 354, Sino Building, Hong Kong, Hong Kong, 852 3943 6577, wwsmak@cuhk.edu.hk %K immersive virtual reality %K narrative persuasion %K public stigma %K mental health stigma %K sense of embodiment %K story transportation %K stigma intervention %D 2021 %7 14.7.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Public stigma in mental health often brings various adverse effects on people with mental illness. Researchers have been developing different interventions in combating public stigma. Objective: This study investigates the effects of immersive virtual reality (IVR) in reducing the public stigma of mental illness using a single-blinded randomized control trial. Methods: A pre-post experimental design with a 1-week follow-up was conducted. Participants (N=206) were recruited through the mass mail system of The Chinese University of Hong Kong and randomized into 3 conditions: immersive animation, text, and control. In the immersive animation condition (n=72), participants experienced the simulation of daily life and the stigma experienced as an animated story protagonist with mixed anxiety and depressive disorder with IVR. In the text condition (n=65), participants experienced an identical story to the immersive animation condition with first-person audio narration using the same virtual reality headset. In the control condition (n=69), participants watched a video about planets with IVR. All participants received interventions with a researcher-assisted Oculus Go virtual reality headset. Participants’ public stigma was measured through self-administered online questionnaires and compared across conditions and at different time points using repeated measures analysis of variance. Simple and sequential mediation analyses on the relationship of condition (immersive animation vs text) and follow-up public stigma with possible mediators, including sense of embodiment and story transportation, were conducted using PROCESS. Results: Public stigma did not differ significantly across conditions at pre-experiment (P>.99). In the immersive animation and text conditions, public stigma was significantly reduced at postexperiment and at the 1-week follow-up compared to pre-experiment (all with P<.001). Public stigma in the control condition at postexperiment and follow-up remained unchanged compared with pre-experiment (P=.69). Immersive animation had significantly lower public stigma than the control at postexperiment (P=.003) and follow-up (P=.02). Text also had lower public stigma than the control at postexperiment (P=.007) and follow-up (P=.03). However, immersive animation did not significantly differ from text in public stigma at postexperiment and follow-up (both P>.99). In simple mediation models, both sense of embodiment (95% CI –0.22 to 0.46) and story transportation (95% CI –0.18 to 0.00) were not significant mediators. In the sequential mediation model, both sense of embodiment and story transportation were significant sequential mediators. Sense of embodiment was positively associated with story transportation (P<.001), while story transportation was negatively associated with public stigma (P<.001). The indirect effect of the sequential mediation model was significant (95% CI –0.38 to –0.11). Conclusions: This study provides novel findings and a rigorous comparison in understanding the effects of IVR on public stigma. The findings showed that IVR and text with audio narration performed similarly and significantly in stigma reduction. Sense of embodiment and story transportation were found to be sequentially associated with public stigma reduction. Trial Registration: Centre for Clinical Research and Biostatistics Clinical Trial Registry CUHK_Ccrb00638; https://www2.ccrb.cuhk.edu.hk/registry/public/632 %M 34259636 %R 10.2196/23683 %U https://www.jmir.org/2021/7/e23683 %U https://doi.org/10.2196/23683 %U http://www.ncbi.nlm.nih.gov/pubmed/34259636 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 7 %P e26328 %T Guided Relaxation–Based Virtual Reality for Acute Postoperative Pain and Anxiety in a Pediatric Population: Pilot Observational Study %A Olbrecht,Vanessa A %A O'Conor,Keith T %A Williams,Sara E %A Boehmer,Chloe O %A Marchant,Gilbert W %A Glynn,Susan M %A Geisler,Kristie J %A Ding,Lili %A Yang,Gang %A King,Christopher D %+ Center for Understanding Pediatric Pain, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH, 45229, United States, 1 513 636 4408, vanessa.olbrecht@cchmc.org %K virtual reality %K guided relaxation–based virtual reality %K pain %K anxiety %K acute pain %K postoperative pain %K pediatrics %D 2021 %7 12.7.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Distraction-based therapies, such as virtual reality (VR), have been used to reduce pain during acutely painful procedures. However, distraction alone cannot produce prolonged pain reduction to manage sustained postoperative pain. Therefore, the integration of VR with other pain-reducing therapies, like guided relaxation, may enhance its clinical impact. Objective: The goal of this pilot study was to assess the impact of a single guided relaxation–based VR (VR-GR) session on postoperative pain and anxiety reduction in children. We also explored the influence of pain catastrophizing and anxiety sensitivity on this association. Methods: A total of 51 children and adolescents (7-21 years) with postoperative pain and followed by the Acute Pain Service at Cincinnati Children’s Hospital were recruited over an 8-month period to undergo a single VR-GR session. Prior to VR, the patients completed 2 questionnaires: Pain Catastrophizing Scale for Children (PCS-C) and the Child Anxiety Sensitivity Index (CASI). The primary outcome was a change in pain intensity following the VR-GR session (immediately, 15 minutes, and 30 minutes). The secondary outcomes included changes in pain unpleasantness and anxiety. Results: The VR-GR decreased pain intensity immediately (P<.001) and at 30 minutes (P=.04) after the VR session, but not at 15 minutes (P=.16) postsession. Reductions in pain unpleasantness were observed at all time intervals (P<.001 at all intervals). Anxiety was reduced immediately (P=.02) but not at 15 minutes (P=.08) or 30 minutes (P=.30) following VR-GR. Patients with higher CASI scores reported greater reductions in pain intensity (P=.04) and unpleasantness (P=.01) following VR-GR. Pain catastrophizing was not associated with changes in pain and anxiety. Conclusions: A single, short VR-GR session showed transient reductions in pain intensity, pain unpleasantness, and anxiety in children and adolescents with acute postoperative pain. The results call for a future randomized controlled trial to assess the efficacy of VR-GR. Trial Registration: ClinicalTrials.gov NCT04556747; https://clinicaltrials.gov/ct2/show/NCT04556747 %M 34048358 %R 10.2196/26328 %U https://www.jmir.org/2021/7/e26328 %U https://doi.org/10.2196/26328 %U http://www.ncbi.nlm.nih.gov/pubmed/34048358 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e27544 %T Use of a Virtual Reality Simulator for Tendon Repair Training: Randomized Controlled Trial %A Mok,Tsz-Ngai %A Chen,Junyuan %A Pan,Jinghua %A Ming,Wai-Kit %A He,Qiyu %A Sin,Tat-Hang %A Deng,Jialin %A Li,Jieruo %A Zha,Zhengang %+ Institute of Orthopedics Diseases and Center for Joint Surgery and Sports Medicine, The First Affiliated Hospital of Jinan University, 613 West Huangpu Avenue, Tianhe District, Guangzhou, China, 86 2038688563, ilorugaie@163.com %K virtual reality simulators %K tendon suture %K medical education %D 2021 %7 12.7.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) simulators have become widespread tools for training medical students and residents in medical schools. Students using VR simulators are provided with a 3D human model to observe the details by using multiple senses and they can participate in an environment that is similar to reality. Objective: The aim of this study was to promote a new approach consisting of a shared and independent study platform for medical orthopedic students, to compare traditional tendon repair training with VR simulation of tendon repair, and to evaluate future applications of VR simulation in the academic medical field. Methods: In this study, 121 participants were randomly allocated to VR or control groups. The participants in the VR group studied the tendon repair technique via the VR simulator, while the control group followed traditional tendon repair teaching methods. The final assessment for the medical students involved performing tendon repair with the “Kessler tendon repair with 2 interrupted tendon repair knots” (KS) method and the “Bunnell tendon repair with figure 8 tendon repair” (BS) method on a synthetic model. The operative performance was evaluated using the global rating scale. Results: Of the 121 participants, 117 participants finished the assessment and 4 participants were lost to follow-up. The overall performance (a total score of 35) of the VR group using the KS method and the BS method was significantly higher (P<.001) than that of the control group. Thus, participants who received VR simulator training had a significantly higher score on the global rating scale than those who received traditional tendon repair training (P<.001). Conclusions: Our study shows that compared with the traditional tendon repair method, the VR simulator for learning tendon suturing resulted in a significant improvement of the medical students in the time in motion, flow of operation, and knowledge of the procedure. Therefore, VR simulator development in the future would most likely be beneficial for medical education and clinical practice. Trial Registration: Chinese Clinical Trial Registry ChiCTR2100046648; http://www.chictr.org.cn/hvshowproject.aspx?id=90180 %M 34255649 %R 10.2196/27544 %U https://games.jmir.org/2021/3/e27544 %U https://doi.org/10.2196/27544 %U http://www.ncbi.nlm.nih.gov/pubmed/34255649 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e29080 %T Augmented, Mixed, and Virtual Reality-Based Head-Mounted Devices for Medical Education: Systematic Review %A Barteit,Sandra %A Lanfermann,Lucia %A Bärnighausen,Till %A Neuhann,Florian %A Beiersmann,Claudia %+ Heidelberg Institute of Global Health, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany, 49 62215634030, barteit@uni-heidelberg.de %K virtual reality %K augmented reality %K global health %K income-limited countries %K medical education %D 2021 %7 8.7.2021 %9 Review %J JMIR Serious Games %G English %X Background: Augmented reality (AR), mixed reality (MR), and virtual reality (VR), realized as head-mounted devices (HMDs), may open up new ways of teaching medical content for low-resource settings. The advantages are that HMDs enable repeated practice without adverse effects on the patient in various medical disciplines; may introduce new ways to learn complex medical content; and may alleviate financial, ethical, and supervisory constraints on the use of traditional medical learning materials, like cadavers and other skills lab equipment. Objective: We examine the effectiveness of AR, MR, and VR HMDs for medical education, whereby we aim to incorporate a global health perspective comprising low- and middle-income countries (LMICs). Methods: We conducted a systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) and Cochrane guidelines. Seven medical databases (PubMed, Cochrane Library, Web of Science, Science Direct, PsycINFO, Education Resources Information Centre, and Google Scholar) were searched for peer-reviewed publications from January 1, 2014, to May 31, 2019. An extensive search was carried out to examine relevant literature guided by three concepts of extended reality (XR), which comprises the concepts of AR, MR, and VR, and the concepts of medicine and education. It included health professionals who took part in an HMD intervention that was compared to another teaching or learning method and evaluated with regard to its effectiveness. Quality and risk of bias were assessed with the Medical Education Research Study Quality Instrument, the Newcastle-Ottawa Scale-Education, and A Cochrane Risk of Bias Assessment Tool for Non-Randomized Studies of Interventions. We extracted relevant data and aggregated the data according to the main outcomes of this review (knowledge, skills, and XR HMD). Results: A total of 27 studies comprising 956 study participants were included. The participants included all types of health care professionals, especially medical students (n=573, 59.9%) and residents (n=289, 30.2%). AR and VR implemented with HMDs were most often used for training in the fields of surgery (n=13, 48%) and anatomy (n=4, 15%). A range of study designs were used, and quantitative methods were clearly dominant (n=21, 78%). Training with AR- and VR-based HMDs was perceived as salient, motivating, and engaging. In the majority of studies (n=17, 63%), HMD-based interventions were found to be effective. A small number of included studies (n=4, 15%) indicated that HMDs were effective for certain aspects of medical skills and knowledge learning and training, while other studies suggested that HMDs were only viable as an additional teaching tool (n=4, 15%). Only 2 (7%) studies found no effectiveness in the use of HMDs. Conclusions: The majority of included studies suggested that XR-based HMDs have beneficial effects for medical education, whereby only a minority of studies were from LMICs. Nevertheless, as most studies showed at least noninferior results when compared to conventional teaching and training, the results of this review suggest applicability and potential effectiveness in LMICs. Overall, users demonstrated greater enthusiasm and enjoyment in learning with XR-based HMDs. It has to be noted that many HMD-based interventions were small-scale and conducted as short-term pilots. To generate relevant evidence in the future, it is key to rigorously evaluate XR-based HMDs with AR and VR implementations, particularly in LMICs, to better understand the strengths and shortcomings of HMDs for medical education. %M 34255668 %R 10.2196/29080 %U https://games.jmir.org/2021/3/e29080 %U https://doi.org/10.2196/29080 %U http://www.ncbi.nlm.nih.gov/pubmed/34255668 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 3 %P e29182 %T Development of a Search Task Using Immersive Virtual Reality: Proof-of-Concept Study %A Knobel,Samuel Elia Johannes %A Kaufmann,Brigitte Charlotte %A Gerber,Stephan Moreno %A Urwyler,Prabitha %A Cazzoli,Dario %A Müri,René M %A Nef,Tobias %A Nyffeler,Thomas %+ Neurocenter, Luzerner Kantonsspital, Spitalstrasse, Lucerne, 6004, Switzerland, 41 205 56 86, thomas.nyffeler@luks.ch %K virtual reality %K serious game %K search task %K stroke %K neglect %K usability %K development %K immersion %K concept %K gaming %D 2021 %7 2.7.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games are gaining increasing importance in neurorehabilitation since they increase motivation and adherence to therapy, thereby potentially improving its outcome. The benefits of serious games, such as the possibility to implement adaptive feedback and the calculation of comparable performance measures, can be even further improved by using immersive virtual reality (iVR), allowing a more intuitive interaction with training devices and higher ecological validity. Objective: This study aimed to develop a visual search task embedded in a serious game setting for iVR, including self-adapting difficulty scaling, thus being able to adjust to the needs and ability levels of different groups of individuals. Methods: In a two-step process, a serious game in iVR (bird search task) was developed and tested in healthy young (n=21) and elderly (n=23) participants and in a group of patients with impaired visual exploration behavior (ie, patients with hemispatial neglect after right-hemispheric stroke; n=11). Usability, side effects, game experience, immersion, and presence of the iVR serious game were assessed by validated questionnaires. Moreover, in the group of stroke patients, the performance in the iVR serious game was also considered with respect to hemispatial neglect severity, as assessed by established objective hemispatial neglect measures. Results: In all 3 groups, reported usability of the iVR serious game was above 4.5 (on a Likert scale with scores ranging from 1 to 5) and reported side effects were infrequent and of low intensity (below 1.5 on a Likert scale with scores ranging from 1 to 4). All 3 groups equally judged the iVR serious game as highly motivating and entertaining. Performance in the game (in terms of mean search time) showed a lateralized increase in search time in patients with hemispatial neglect that varied strongly as a function of objective hemispatial neglect severity. Conclusions: The developed iVR serious game, “bird search task,” was a motivating, entertaining, and immersive task, which can, due to its adaptive difficulty scaling, adjust and be played by different populations with different levels of skills, including individuals with cognitive impairments. As a complementary finding, it seems that performance in the game is able to capture typical patterns of impaired visual exploration behavior in hemispatial neglect, as there is a high correlation between performance and neglect severity as assessed with a cancellation task. %M 34255653 %R 10.2196/29182 %U https://games.jmir.org/2021/3/e29182 %U https://doi.org/10.2196/29182 %U http://www.ncbi.nlm.nih.gov/pubmed/34255653 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 4 %N 2 %P e27972 %T The Effect of Mixed Reality Technologies for Falls Prevention Among Older Adults: Systematic Review and Meta-analysis %A Nishchyk,Anna %A Chen,Weiqin %A Pripp,Are Hugo %A Bergland,Astrid %+ Department of Computer Science, Faculty of Technology, Art and Design, Oslo Metropolitan University, PO Box 4, St Olavs plass, Oslo, 0130, Norway, 47 45128733, annani@oslomet.no %K falls %K fall prevention %K mixed reality %K augmented reality %K virtual reality %K physical exercise %D 2021 %7 30.6.2021 %9 Review %J JMIR Aging %G English %X Background: Falling is one of the most common and serious age-related issues, and falls can significantly impair the quality of life of older adults. Approximately one-third of people over 65 experience a fall annually. Previous research has shown that physical exercise could help reduce falls among older adults and improve their health. However, older adults often find it challenging to follow and adhere to physical exercise programs. Interventions using mixed reality (MR) technology could help address these issues. MR combines artificial augmented computer-generated elements with the real world. It has frequently been used for training and rehabilitation purposes. Objective: The aim of this systematic literature review and meta-analysis was to investigate the use of the full spectrum of MR technologies for fall prevention intervention and summarize evidence of the effectiveness of this approach. Methods: In our qualitative synthesis, we analyzed a number of features of the selected studies, including aim, type of exercise, technology used for intervention, study sample size, participant demographics and history of falls, study design, involvement of health professionals or caregivers, duration and frequency of the intervention, study outcome measures, and results of the study. To systematically assess the results of the selected studies and identify the common effect of MR interventions, a meta-analysis was performed. Results: Seven databases were searched, and the initial search yielded 5838 results. With the considered inclusion and exclusion criteria, 21 studies were included in the qualitative synthesis and 12 were included in meta-analysis. The majority of studies demonstrated a positive effect of an MR intervention on fall risk factors among older participants. The meta-analysis demonstrated a statistically significant difference in Berg Balance Scale score between the intervention and control groups (ES: 0.564; 95% CI 0.246-0.882; P<.001) with heterogeneity statistics of I2=54.9% and Q=17.74 (P=.02), and a statistical difference in Timed Up and Go test scores between the intervention and control groups (ES: 0.318; 95% CI 0.025-0.662; P<.001) with heterogeneity statistics of I2=77.6% and Q=44.63 (P<.001). The corresponding funnel plot and the Egger test for small-study effects (P=.76 and P=.11 for Berg Balance Scale and Timed Up and Go, respectively) indicate that a minor publication bias in the studies might be present in the Berg Balance Scale results. Conclusions: The literature review and meta-analysis demonstrate that the use of MR interventions can have a positive effect on physical functions in the elderly. MR has the potential to help older users perform physical exercises that could improve their health conditions. However, more research on the effect of MR fall prevention interventions should be conducted with special focus given to MR usability issues. %M 34255643 %R 10.2196/27972 %U https://aging.jmir.org/2021/2/e27972 %U https://doi.org/10.2196/27972 %U http://www.ncbi.nlm.nih.gov/pubmed/34255643 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e26963 %T Effects of Self-focused Augmented Reality on Health Perceptions During the COVID-19 Pandemic: A Web-Based Between-Subject Experiment %A Seals,Ayanna %A Olaosebikan,Monsurat %A Otiono,Jennifer %A Shaer,Orit %A Nov,Oded %+ New York University, 5 Metrotech Center, 4th Fl, Brooklyn, NY, 11201, United States, 1 646 997 3760, ayannaseals@nyu.edu %K COVID-19 %K health behavior %K augmented reality %K self-focused attention %K vicarious reinforcement %K human-computer interactions %K hand hygiene %K perception %D 2021 %7 29.6.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Self-focused augmented reality (AR) technologies are growing in popularity and present an opportunity to address health communication and behavior change challenges. Objective: We aimed to examine the impact of self-focused AR and vicarious reinforcement on psychological predictors of behavior change during the COVID-19 pandemic. In addition, our study included measures of fear and message minimization to assess potential adverse reactions to the design interventions. Methods: A between-subjects web-based experiment was conducted to compare the health perceptions of participants in self-focused AR and vicarious reinforcement design conditions to those in a control condition. Participants were randomly assigned to the control group or to an intervention condition (ie, self-focused AR, reinforcement, self-focus AR × reinforcement, and avatar). Results: A total of 335 participants were included in the analysis. We found that participants who experienced self-focused AR and vicarious reinforcement scored higher in perceived threat severity (P=.03) and susceptibility (P=.01) when compared to the control. A significant indirect effect of self-focused AR and vicarious reinforcement on intention was found with perceived threat severity as a mediator (b=.06, 95% CI 0.02-0.12, SE .02). Self-focused AR and vicarious reinforcement did not result in higher levels of fear (P=.32) or message minimization (P=.42) when compared to the control. Conclusions: Augmenting one’s reflection with vicarious reinforcement may be an effective strategy for health communication designers. While our study’s results did not show adverse effects in regard to fear and message minimization, utilization of self-focused AR as a health communication strategy should be done with care due to the possible adverse effects of heightened levels of fear. %M 33878017 %R 10.2196/26963 %U https://www.jmir.org/2021/6/e26963 %U https://doi.org/10.2196/26963 %U http://www.ncbi.nlm.nih.gov/pubmed/33878017 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 4 %N 2 %P e29518 %T A Virtual Reality Resident Training Curriculum on Behavioral Health Anticipatory Guidance: Development and Usability Study %A Herbst,Rachel %A Rybak,Tiffany %A Meisman,Andrea %A Whitehead,Monica %A Rosen,Brittany %A Crosby,Lori E %A Klein,Melissa D %A Real,Francis J %+ Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 3015, Cincinnati, OH, United States, 1 513 517 1092, rachel.herbst@cchmc.org %K resident education %K virtual reality %K behavioral health promotion %K COVID-19 %D 2021 %7 29.6.2021 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Behavioral health disorders have steadily increased and been exacerbated by the COVID-19 pandemic. Though behavioral health disorders can be successfully mitigated with early implementation of evidence-based parent management strategies, education for pediatric residents on behavioral health anticipatory guidance has been limited to date, with training challenges compounded by the physical distancing requirements of the COVID-19 pandemic. Virtual reality (VR) simulations provide an opportunity to train residents on this complex competency by allowing deliberate practice of necessary skills while adhering to current social distancing guidelines. Objective: This study explored the usability of a VR-based behavioral health anticipatory guidance curriculum for pediatric residents. Methods: This mixed methods study included 14 postgraduate third-year pediatric residents who completed the behavioral health anticipatory guidance VR curriculum. Residents completed the MEC Spatial Presence Questionnaire to assess immersion in the virtual environment. Semistructured interviews were used to elucidate residents’ perspectives on the curriculum’s content and format. The interviews were analyzed using conventional content analysis. Results: Quantitatively, residents reported a high degree of immersion, spatial presence, and cognitive involvement. Most residents (11/14, 79%) agreed or strongly agreed that it seemed as though they took part in the action of the simulation. Qualitatively, two themes emerged from the data: (1) the curriculum expands behavioral health anticipatory guidance and motivational interviewing knowledge and skills and (2) VR technology is uniquely positioned to develop competence. These themes revealed that the curriculum expanded their current level of knowledge and skill, addressed training gaps, and was applicable to all residents. Additionally, residents experienced VR as immersive, feasible, realistic to the clinic setting, and a safe space to practice and learn new skills. Conclusions: Pilot data indicates that VR may be an effective tool to teach pediatric residents behavioral health anticipatory guidance, meeting a current gap in medical education training. This VR curriculum is particularly relevant in the context of the COVID-19 pandemic given the increased behavioral health concerns of families. %M 34081601 %R 10.2196/29518 %U https://pediatrics.jmir.org/2021/2/e29518 %U https://doi.org/10.2196/29518 %U http://www.ncbi.nlm.nih.gov/pubmed/34081601 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 6 %P e24967 %T Effectiveness of Virtual Reality Interventions for Adolescent Patients in Hospital Settings: Systematic Review %A Ridout,Brad %A Kelson,Joshua %A Campbell,Andrew %A Steinbeck,Kate %+ Cyberpsychology Research Group, Faculty of Medicine and Health, The University of Sydney, City Road, Sydney, 2006, Australia, 61 2 8627 1444, brad.ridout@sydney.edu.au %K virtual reality %K hospital %K pain %K anxiety %K adolescents %D 2021 %7 28.6.2021 %9 Review %J J Med Internet Res %G English %X Background: Given the high level of interest and increasing familiarity with virtual reality among adolescents, there is great potential to use virtual reality to address adolescents’ unique health care delivery needs while in hospital. While there have been reviews on the use of virtual reality for specific health conditions and procedures, none to date have reviewed the full scope of virtual reality hospital interventions for adolescents who are often combined with children as a homogenous group, despite the fact that adolescents experience virtual environments different from children. Objective: The aim of this review was to systematically identify available evidence regarding the use of virtual reality interventions for adolescent patients in hospital settings to evaluate effectiveness, suitability, and safety and identify opportunities for future research. Methods: PubMed, PsycINFO, Medline, and Scopus databases were searched using keywords and phrases. Retrieved abstracts (n=1525) were double screened, yielding 276 articles for full-text screening. Of these, 8 articles met inclusion criteria. Data were extracted to a standardized coding sheet, and a narrative synthesis was performed due to the heterogeneity of the studies. Results: Four RCTs and 4 single-case reports were identified for inclusion, all of which aimed to reduce pain or anxiety. The scenarios targeted were burn pain, venipuncture, chemotherapy, preoperative anxiety, and palliative care. Three out of 4 RCTs found significant reductions in pain or anxiety outcomes measures when using virtual reality compared to standard care or other distraction techniques; however, only 1 study combined self-reported experiences of pain or anxiety with any physiological measures. Single-case reports relied primarily upon qualitative feedback, with patients reporting reduced pain or anxiety and a preference for virtual reality to no virtual reality. Conclusions: Virtual reality can provide a safe and engaging way to reduce pain and anxiety in adolescents while in hospital, particularly when virtual reality software is highly immersive and specifically designed for therapeutic purposes. As VR becomes more accessible and affordable for use in hospitals, larger and more diverse studies that capitalize on adolescents’ interest in and aptitude for virtual reality, and on the full range of capabilities of this emerging technology, are needed to build on these promising results. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020198760; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020198760 %M 34185015 %R 10.2196/24967 %U https://www.jmir.org/2021/6/e24967 %U https://doi.org/10.2196/24967 %U http://www.ncbi.nlm.nih.gov/pubmed/34185015 %0 Journal Article %@ 2561-3278 %I JMIR Publications %V 6 %N 2 %P e26332 %T Virtual Reality–Guided Meditation for Chronic Pain in Patients With Cancer: Exploratory Analysis of Electroencephalograph Activity %A Fu,Henry %A Garrett,Bernie %A Tao,Gordon %A Cordingley,Elliott %A Ofoghi,Zahra %A Taverner,Tarnia %A Sun,Crystal %A Cheung,Teresa %+ School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada, 1 604 822 7443, bernie.garrett@nursing.ubc.ca %K virtual reality %K guided meditation %K neurophysiology %K electroencephalograph %K EEG %D 2021 %7 24.6.2021 %9 Original Paper %J JMIR Biomed Eng %G English %X Background: Mindfulness-based stress reduction has demonstrated some efficacy for chronic pain management. More recently, virtual reality (VR)–guided meditation has been used to assist mindfulness-based stress reduction. Although studies have also found electroencephalograph (EEG) changes in the brain during mindfulness meditation practices, such changes have not been demonstrated during VR-guided meditation. Objective: This exploratory study is designed to explore the potential for recording and analyzing EEG during VR experiences in terms of the power of EEG waveforms, topographic mapping, and coherence. We examine how these measures changed during a VR-guided meditation experience in participants with cancer-related chronic pain. Methods: A total of 10 adult patients with chronic cancer pain underwent a VR-guided meditation experience while EEG signals were recorded during the session using a BioSemi ActiveTwo system (64 channels, standard 10-20 configuration). The EEG recording session consisted of an 8-minute resting condition (pre), a 30-minute sequence of 3 VR-guided meditation conditions (med), and a final rest condition (post). Power spectral density (PSD) was compared between each condition using a cluster-based permutation test and across conditions using multivariate analysis of variance. A topographic analysis, including coherence exploration, was performed. In addition, an exploratory repeated measures correlation was used to examine possible associations between pain scores and EEG signal power. Results: The predominant pattern was for increased β and γ bandwidth power in the meditation condition (P<.025), compared with both the baseline and postexperience conditions. Increased power in the δ bandwidth was evident, although not statistically significant. The pre versus post comparison also showed changes in the θ and α bands (P=.02) located around the frontal, central, and parietal cortices. Across conditions, multivariate analysis of variance tests identified 4 clusters with significant (P<.05) PSD differences in the δ, θ, β, and γ bands located around the frontal, central, and parietal cortices. Topographically, 5 peak channels were identified: AF7, FP2, FC1, CP5, and P5, and verified the changes in power in the different brain regions. Coherence changes were observed primarily between the frontal, parietal, and occipital regions in the θ, α, and γ bands (P<.0025). No significant associations were observed between pain scores and EEG PSD. Conclusions: This study demonstrates the feasibility of EEG recording in exploring neurophysiological changes in brain activity during VR-guided meditation and its effect on pain reduction. These findings suggest that distinct altered neurophysiological brain signals are detectable during VR-guided meditation. However, these changes were not necessarily associated with pain. These exploratory findings may guide further studies to investigate the highlighted regions and EEG bands with respect to VR-guided meditation. Trial Registration: ClinicalTrials.gov NCT00102401; http://clinicaltrials.gov/ct2/show/NCT00102401 %M 38907380 %R 10.2196/26332 %U https://biomedeng.jmir.org/2021/2/e26332/ %U https://doi.org/10.2196/26332 %U http://www.ncbi.nlm.nih.gov/pubmed/38907380 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 6 %P e24353 %T Virtual Engagement in a Social Media Community of Mothers With Substance Use Disorders: Content Analysis %A Mazel,Shayna %A Zisman-Ilani,Yaara %A Hennig,Shannon %A Garnick,Deborah %A Nicholson,Joanne %+ Heller School for Social Policy and Management, Brandeis University, 415 South Street, Mailstop 035, Waltham, MA, 02454-9110, United States, 1 (781) 736 3820, mazel@brandeis.edu %K virtual engagement %K virtual community participation %K social media %K mental health %K opioids %K substance use %D 2021 %7 24.6.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Co-occurring substance use disorder is common among pregnant and parenting women with mental illness, but their engagement with and utilization of relevant services and treatment is low. Social media has the potential to convey benefits and facilitate engagement among this target group. Objective: This study aimed to explore the reach and engagement of specific social media posts among pregnant women and mothers with substance use disorders. Methods: Eighteen posts providing content related to substance use (cannabis, opioids, or alcohol), varying in type of content (informational or experiential) and target (policy-, practice-, or perception-related), were posted in a closed Facebook community page comprising over 33,000 pregnant women and mothers between May 2019 and October 2019. Results: The overall level of reach of these Facebook posts ranged from 453 to 3045 community members. Engagement levels, measured via the number of likes, comments, or posts shared, varied based on the type of post content (ie, informational or experiential). Conclusions: Participation in a virtual community via social media platforms can facilitate engagement among pregnant women and mothers with mental illness by communicating relevant information about substance use, as well as potentially promoting awareness of, access to, and engagement with treatment services. %M 34184993 %R 10.2196/24353 %U https://formative.jmir.org/2021/6/e24353/ %U https://doi.org/10.2196/24353 %U http://www.ncbi.nlm.nih.gov/pubmed/34184993 %0 Journal Article %@ 2561-3278 %I JMIR Publications %V 6 %N 2 %P e26942 %T Using Medical Device Standards for Design and Risk Management of Immersive Virtual Reality for At-Home Therapy and Remote Patient Monitoring %A Salisbury,Joseph Peter %+ Playhab R&D, Cognivive, Inc., 2003 Baywood Ln, Davis, CA, 95618, United States, 1 530 361 6006, joey@cognivive.com %K virtual reality %K telerehabilitation %K remote patient monitoring %K medical device design %K safety %K medical device regulation %K risk assessment %K failure modes and effects analysis %D 2021 %7 3.6.2021 %9 Viewpoint %J JMIR Biomed Eng %G English %X Numerous virtual reality (VR) systems have received regulatory clearance as therapeutic medical devices for in-clinic and at-home use. These systems enable remote patient monitoring of clinician-prescribed rehabilitation exercises, although most of these systems are nonimmersive. With the expanding availability of affordable and easy-to-use head-mounted display (HMD)-based VR, there is growing interest in immersive VR therapies. However, HMD-based VR presents unique risks. Following standards for medical device development, the objective of this paper is to demonstrate a risk management process for a generic immersive VR system for remote patient monitoring of at-home therapy. Regulations, standards, and guidance documents applicable to therapeutic VR design are reviewed to provide necessary background. Generic requirements for an immersive VR system for home use and remote patient monitoring are identified using predicate analysis and specified for both patients and clinicians using user stories. To analyze risk, failure modes and effects analysis, adapted for medical device risk management, is performed on the generic user stories and a set of risk control measures is proposed. Many therapeutic applications of VR would be regulated as a medical device if they were to be commercially marketed. Understanding relevant standards for design and risk management early in the development process can help expedite the availability of innovative VR therapies that are safe and effective. %M 38907371 %R 10.2196/26942 %U https://biomedeng.jmir.org/2021/2/e26942 %U https://doi.org/10.2196/26942 %U http://www.ncbi.nlm.nih.gov/pubmed/38907371 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e26820 %T Virtual Reality Human–Human Interface to Deliver Psychotherapy to People Experiencing Auditory Verbal Hallucinations: Development and Usability Study %A Brander,Mischa %A Egger,Stephan T %A Hürlimann,Noa %A Seifritz,Erich %A Sumner,Robert W %A Vetter,Stefan %A Magnenat,Stéphane %+ Psychotherapy and Psychosomatics, Department of Psychiatry, Psychiatric University Hospital of Zurich, University of Zürich, Lenggstrasse 31, Zurich, 8032, Switzerland, 41 523049340, stephan.egger@pukzh.ch %K system usability %K virtual reality psychotherapy %K verbal auditory hallucinations %D 2021 %7 1.6.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Digital technologies have expanded the options for delivering psychotherapy, permitting for example, the treatment of schizophrenia using Avatar Therapy. Despite its considerable potential, this treatment method has not been widely disseminated. As a result, its operability and functionality remain largely unknown. Objective: We aimed to study the usability of a therapeutic virtual reality human–human interface, created in a game engine. Methods: Participants were psychiatric hospital staff who were introduced to the therapeutic platform in a hands-on session. The System Usability Scale (SUS) was employed for evaluation purposes. Statistical evaluation was conducted using descriptive statistics, the chi-square test, analysis of variance, and multilevel factor analysis. Results: In total, 109 staff members were introduced to the therapeutic tool and completed the SUS. The mean SUS global score was 81.49 (SD 11.1). Psychotherapists (mean 86.44, SD 8.79) scored significantly higher (F2,106=6.136; P=.003) than nursing staff (mean 79.01, SD 13.30) and administrative personnel (mean 77.98, SD 10.72). A multilevel factor analysis demonstrates a different factor structure for each profession. Conclusions: In all professional groups in this study, the usability of a digital psychotherapeutic tool developed using a game engine achieved the benchmark for an excellent system, scoring highest among the professional target group (psychotherapists). The usability of the system seems, to some extent, to be dependent on the professional background of the user. It is possible to create and customize novel psychotherapeutic approaches with gaming technologies and platforms. Trial Registration: Clinicaltrials.gov NCT04099940; http://clinicaltrials.gov/ct2/show/NCT04099940 %M 33769295 %R 10.2196/26820 %U https://games.jmir.org/2021/2/e26820 %U https://doi.org/10.2196/26820 %U http://www.ncbi.nlm.nih.gov/pubmed/33769295 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e26349 %T Virtual Reality for Sedation During Atrial Fibrillation Ablation in Clinical Practice: Observational Study %A Roxburgh,Thomas %A Li,Anthony %A Guenancia,Charles %A Pernollet,Patrice %A Bouleti,Claire %A Alos,Benjamin %A Gras,Matthieu %A Kerforne,Thomas %A Frasca,Denis %A Le Gal,François %A Christiaens,Luc %A Degand,Bruno %A Garcia,Rodrigue %+ Department of Anesthesia and Critical Care, University Hospital of Poitiers, 2 Rue de la Milétrie, Poitiers, 86021, France, 33 549443729, rodrigue.garcia@chu-poitiers.fr %K connected devices %K virtual reality %K atrial fibrillation %K pain management %D 2021 %7 27.5.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Connected devices are dramatically changing many aspects in health care. One such device, the virtual reality (VR) headset, has recently been shown to improve analgesia in a small sample of patients undergoing transcatheter aortic valve implantation. Objective: We aimed to investigate the feasibility and effectiveness of VR in patients undergoing atrial fibrillation (AF) ablation under conscious sedation. Methods: All patients who underwent an AF ablation with VR from March to May 2020 were included. Patients were compared to a consecutive cohort of patients who underwent AF ablation in the 3 months prior to the study. Primary efficacy was assessed by using a visual analog scale, summarizing the overall pain experienced during the ablation. Results: The AF cryoablation procedure with VR was performed for 48 patients (mean age 63.0, SD 10.9 years; n=16, 33.3% females). No patient refused to use the device, although 14.6% (n=7) terminated the VR session prematurely. Preparation of the VR headset took on average 78 (SD 13) seconds. Compared to the control group, the mean perceived pain, assessed with the visual analog scale, was lower in the VR group (3.5 [SD 1.5] vs 4.3 [SD 1.6]; P=.004), and comfort was higher in the VR group (7.5 [SD 1.6] vs 6.8 [SD 1.7]; P=.03). On the other hand, morphine consumption was not different between the groups. Lastly, complications, as well as procedure and fluoroscopy duration, were not different between the two groups. Conclusions: We found that VR was associated with a reduction in the perception of pain in patients undergoing AF ablation under conscious sedation. Our findings demonstrate that VR can be easily incorporated into the standard ablation workflow. %M 34042589 %R 10.2196/26349 %U https://www.jmir.org/2021/5/e26349 %U https://doi.org/10.2196/26349 %U http://www.ncbi.nlm.nih.gov/pubmed/34042589 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 8 %N 2 %P e28210 %T Examining the Feasibility of Early Mobilization With Virtual Reality Gaming Using Head-Mounted Display and Adaptive Software With Adolescents in the Pediatric Intensive Care Unit: Case Report %A Lai,Byron %A Powell,Maegen %A Clement,Anne Grace %A Davis,Drew %A Swanson-Kimani,Erin %A Hayes,Leslie %+ Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, 1720 University Blvd, Birmingham, AL, 35294, United States, 1 2056389790 ext 8 9725, byronlai@uab.edu %K physical activity %K active video gaming %K exergaming %K early mobility %K rehabilitation %D 2021 %7 27.5.2021 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Early rehabilitative mobilization for adolescents is safe and feasible. However, there is a lack of published rehabilitation strategies and treatments that can maximize engagement and outcomes among adolescents in the pediatric intensive care unit (PICU). Virtual reality (VR) gaming using a head-mounted display (HMD) and adaptive software can allow active and nonactive gameplay at the bedside for people with limited arm mobility, making it a potentially inclusive and enjoyable treatment modality for adolescents in the PICU. Objective: The purpose of this brief case study is to report on the preliminary feasibility of incorporating adaptive VR gaming using an HMD with 2 adolescents who received early mobility treatment within the PICU. Methods: This study was a mini-ethnographic investigation of 2 adolescents (a 15-year-old male and a 13-year old male) in the PICU who underwent VR gaming sessions as part of their early mobilization care, using an Oculus Rift HMD and adaptive software (WalkinVR) that promoted full gameplay in bed. The Rift was plugged into a gaming laptop that was set up on a table within the patient’s room before each session. The intervention was delivered by an adapted exercise professional and supervised by a physical therapist. Patients had access to a variety of active games (eg, boxing, rhythmic movement to music, and exploratory adventure) and nonactive games (eg, racing and narrative adventure). Gaming sessions were scheduled between usual care, when tolerable and requested by the participant. The interventionist and therapists took audio-recorded and written notes after completing each gaming session. These data were analyzed and presented in a narrative format from the perspective of the research team. Results: Case 1 participated in 4 gaming sessions, with an average of 18 minutes (SD 11) per session. Case 2 participated in 2 sessions, with an average of 35 minutes (SD 7) per session. Both cases were capable of performing active gaming at a moderate level of exercise intensity, as indicated by their heart rate. However, their health and symptoms fluctuated on a daily basis, which prompted the gameplay of adventure or nonactive games. Gameplay appeared to improve participants’ affect and alertness and motivate them to be more engaged in early mobilization therapy. Gameplay without the WalkinVR software caused several usability issues. There were no serious adverse events, but both cases experienced symptoms based on their condition. Conclusions: The findings of this study suggest that VR gaming with HMDs and adaptive software is likely a feasible supplement to usual care for adolescents within the PICU, and these findings warrant further investigation. Recommendations for future studies aimed at incorporating VR gaming during early mobilization are presented herein. %M 34042602 %R 10.2196/28210 %U https://rehab.jmir.org/2021/2/e28210 %U https://doi.org/10.2196/28210 %U http://www.ncbi.nlm.nih.gov/pubmed/34042602 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e16536 %T Assessing the Feasibility of an Open-Source Virtual Reality Mirror Visual Feedback Module for Complex Regional Pain Syndrome: Pilot Usability Study %A Won,Andrea Stevenson %A Barreau,Ariana C %A Gaertner,Mark %A Stone,Tristan %A Zhu,Joshua %A Wang,Cheng Yao %A Mackey,Sean %+ Department of Communication, Cornell University, 471 Mann Library Building, Ithaca, NY, 14853, United States, 1 919 906 0287, asw248@cornell.edu %K virtual reality %K pain %K complex regional pain syndrome %K CRPS %K open source %K mirror visual feedback %D 2021 %7 26.5.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Complex regional pain syndrome (CRPS) is a rare and severe chronic pain condition, with effective treatment options not established for many patients. The underlying pathophysiology remains unclear, but there is a growing appreciation for the role of central mechanisms which have formed the basis for brain-based therapies such as transcranial magnetic stimulation and mirror visual feedback (MVF). MVF has been deployed in the treatment of CRPS using both conventional mirrors and virtual reality (VR). Objective: The aim of this study was to further investigate the use of VR in the treatment of patients with unilateral upper limb CRPS. VR has the potential advantage of more flexible and more motivating tasks, as well as the option of tracking patient improvement through the use of movement data. Methods: We describe the development, acceptability, feasibility, and usability of an open-source VR program MVF module designed to be used with consumer VR systems for the treatment of CRPS. The development team was an interdisciplinary group of physical therapists, pain researchers, and VR researchers. Patients recruited from a pain clinic completed 3-5 visits each to trial the system and assessed their experiences in pre- and post-treatment questionnaires. Results: All 9 (100%) participants were able to use the system for 3, 4, or 5 trials each. None of the participants quit any trial due to cybersickness. All 9 (100%) participants reported interest in using the module in the future. Participants’ reported average pain scores in the affected limb were not significantly different from baseline during treatment or after treatment (P=.16). We did not find a statistically significant effect on participants’ self-reported average pain scores. Conclusions: We propose that this module could be a useful starting point for modification and testing for other researchers. We share modifications to make this module usable with standalone headsets and finger tracking. Next steps include adapting this module for at-home use, or for use with participants with lower limb pain. %M 34037530 %R 10.2196/16536 %U https://www.jmir.org/2021/5/e16536 %U https://doi.org/10.2196/16536 %U http://www.ncbi.nlm.nih.gov/pubmed/34037530 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 5 %P e24446 %T Reporting of Differences in Taste Between Branded and Unbranded Cigarettes by Smokers Blinded to Cigarette Branding: Within-Person, Randomized Crossover Study %A BinDhim,Nasser F %A Althumiri,Nora A %A Basyouni,Mada H %A Almubark,Rasha A %A Alkhamaali,Zaied %A Banjar,Weam %A Zamakhshary,Mohammed %A AlKattan,Khaled M %+ Sharik Association for Health Research, 4 Anas ibn Malik, Riyadh, 11778, Saudi Arabia, 966 505435544, nora@althumiri.net %K smoking %K plain packaging %K sensory %K Saudi Arabia %K tobacco %K virtual reality %K cigarettes %D 2021 %7 14.5.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Saudi Arabia implemented a plain tobacco packaging regulation, one of the World Health Organization’s recommended initiatives to help reduce smoking rates, in August 2019. A few weeks after implementation, a large number of smokers complained via various media channels, especially social media (eg, Twitter), that an extreme change in cigarette taste had occurred, frequency of coughing had increased, and for some, shortness of breath had led to hospitalization. Objective: The main objective is to determine whether smokers blinded to cigarette branding report differences in taste between branded and unbranded cigarettes. The secondary objective is to observe the frequency of immediate cough or shortness of breath. Methods: This study employed a within-person, randomized crossover design that recruited current smokers 18 years and older who were cleared upon physical assessment before the experiment. Participants received 6 sequences of different random exposures (3 puffs) to 3 plain-packaged cigarettes (2 from their favorite brand and 1 from another brand as a control) and 3 branded cigarettes (2 from the favorite brand and 1 from another brand as a control). Participants wore virtual reality goggles accompanied by special software to alter visual reality and gloves to alter the touch sensation. Results: This study recruited 18 participants, measured at 6 time points, to produce 108 experiments. Participants were not able to identify the correct type of cigarettes (plain or branded, estimate of fixed effect=−0.01, P=.79). Moreover, there were no differences in the ability of the participants to identify their favorite brand (t107=−0.63, mean 0.47, P=.53). In terms of immediate coughing, out of the 108 experiments, 1 episode of short coughing was observed, which was attributed to the branded cigarette, not the plain-packaged cigarette. Conclusions: After controlling the visual and touch sensations, participants were not able to differentiate between branded and plain-packaged cigarettes in terms of taste or inducing immediate shortness of breath or cough. Interestingly, participants were not able to identify their favorite brand. %M 33988511 %R 10.2196/24446 %U https://formative.jmir.org/2021/5/e24446 %U https://doi.org/10.2196/24446 %U http://www.ncbi.nlm.nih.gov/pubmed/33988511 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e23835 %T A Virtual Reality–Based App to Educate Health Care Professionals and Medical Students About Inflammatory Arthritis: Feasibility Study %A Klemm,Philipp %A Kleyer,Arnd %A Tascilar,Koray %A Schuster,Louis %A Meinderink,Timo %A Steiger,Florian %A Lange,Uwe %A Müller-Ladner,Ulf %A Knitza,Johannes %A Sewerin,Philipp %A Mucke,Johanna %A Pfeil,Alexander %A Schett,Georg %A Hartmann,Fabian %A Hueber,Axel J %A Simon,David %+ Department of Internal Medicine 3, Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Ulmenweg 18, Erlangen, 91054, Germany, 49 091318543253, david.simon@uk-erlangen.de %K feasibility %K virtual reality %K inflammatory arthritis %K psoriatic arthritis %K rheumatoid arthritis %D 2021 %7 11.5.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Inflammatory arthritides (IA) such as rheumatoid arthritis or psoriatic arthritis are disorders that can be difficult to comprehend for health professionals and students in terms of the heterogeneity of clinical symptoms and pathologies. New didactic approaches using innovative technologies such as virtual reality (VR) apps could be helpful to demonstrate disease manifestations as well as joint pathologies in a more comprehensive manner. However, the potential of using a VR education concept in IA has not yet been evaluated. Objective: We evaluated the feasibility of a VR app to educate health care professionals and medical students about IA. Methods: We developed a VR app using data from IA patients as well as 2D and 3D-visualized pathological joints from X-ray and computed tomography–generated images. This VR app (Rheumality) allows the user to interact with representative arthritic joint and bone pathologies of patients with IA. In a consensus meeting, an online questionnaire was designed to collect basic demographic data (age, sex); profession of the participants; and their feedback on the general impression, knowledge gain, and potential areas of application of the VR app. The VR app was subsequently tested and evaluated by health care professionals (physicians, researchers, and other professionals) and medical students at predefined events (two annual rheumatology conferences and academic teaching seminars at two sites in Germany). To explore associations between categorical variables, the χ2 or Fisher test was used as appropriate. Two-sided P values ≤.05 were regarded as significant. Results: A total of 125 individuals participated in this study. Among them, 56% of the participants identified as female, 43% identified as male, and 1% identified as nonbinary; 59% of the participants were 18-30 years of age, 18% were 31-40 years old, 10% were 41-50 years old, 8% were 51-60 years old, and 5% were 61-70 years old. The participants (N=125) rated the VR app as excellent, with a mean rating of 9.0 (SD 1.2) out of 10, and many participants would recommend use of the app, with a mean recommendation score of 3.2 (SD 1.1) out of 4. A large majority (120/125, 96.0%) stated that the presentation of pathological bone formation improves understanding of the disease. We did not find any association between participant characteristics and evaluation of the VR experience or recommendation scores. Conclusions: The data show that IA-targeting innovative teaching approaches based on VR technology are feasible. %M 33973858 %R 10.2196/23835 %U https://games.jmir.org/2021/2/e23835 %U https://doi.org/10.2196/23835 %U http://www.ncbi.nlm.nih.gov/pubmed/33973858 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 5 %P e26133 %T Immersive Virtual Reality to Improve Outcomes in Veterans With Stroke: Protocol for a Single-Arm Pilot Study %A Tran,Johanna E %A Fowler,Christopher A %A Delikat,Jemy %A Kaplan,Howard %A Merzier,Marie M %A Schlesinger,Michelle R %A Litzenberger,Stefan %A Marszalek,Jacob M %A Scott,Steven %A Winkler,Sandra L %+ Physical Medicine and Rehabilitation Service, James A Haley Veterans' Hospital, 13000 Bruce B Downs Blvd, Tampa, FL, 33612, United States, 1 (813) 972 2000 ext 5421, Johanna.Tran@va.gov %K stroke %K immersive virtual reality %K feasibility %K veterans affairs %K veterans %K pilot %K recovery %K upper extremity %D 2021 %7 10.5.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Over the last decade, virtual reality (VR) has emerged as a cutting-edge technology in stroke rehabilitation. VR is defined as a type of computer-user interface that implements real-time simulation of an activity or environment allowing user interaction via multiple sensory modalities. In a stroke population, VR interventions have been shown to enhance motor, cognitive, and psychological recovery when utilized as a rehabilitation adjunct. VR has also demonstrated noninferiority to usual care therapies for stroke rehabilitation. Objective: The proposed pilot study aims to (1) determine the feasibility and tolerability of using a therapeutic VR platform in an inpatient comprehensive stroke rehabilitation program and (2) estimate the initial clinical efficacy (effect size) associated with the VR platform using apps for pain distraction and upper extremity exercise for poststroke neurologic recovery. Methods: This study will be conducted in the Comprehensive Integrated Inpatient Rehabilitation Program at the James A Haley Veterans’ Hospital. Qualitative interviews will be conducted with 10 clinical staff members to assess the feasibility of the VR platform from the clinician perspective. A prospective within-subject pretest-posttest pilot design will be used to examine the tolerability of the VR platform and the clinical outcomes (ie, upper extremity neurologic recovery, hand dexterity, pain severity) in 10 veteran inpatients. A VR platform consisting of commercially available pain distraction and upper extremity apps will be available at the participants’ bedside for daily use during their inpatient stay (approximately 4-6 weeks). Clinician interviews will be analyzed using qualitative descriptive analysis. Cohen d effect sizes with corresponding 95% CIs will be calculated for upper extremity neurologic recovery, hand dexterity, and pain. The proportion of participants who achieve minimal clinically important difference after using the VR platform will be calculated for each clinical outcome. Results: This study was selected for funding in August 2020. Institutional review board approval was received in October 2020. The project start date was December 2020. The United States Department has issued a moratorium on in-person research activities secondary to COVID-19. Data collection will commence once this moratorium is lifted. Conclusions: Our next step is to conduct a large multi-site clinical trial that will incorporate the lessons learned from this pilot feasibility study to test the efficacy of a VR intervention in inpatient rehabilitation and transition to home environments. When VR is used in patients’ rooms, it serves to provide additional therapy and may reduce clinician burden. VR also presents an opportunity similar to home-based practice exercises. VR can be implemented in both clinical settings and people’s own homes, where engagement in ongoing self-management approaches is often most challenging. This unique experience offers the potential for seamless transition from inpatient rehabilitation to the home. International Registered Report Identifier (IRRID): PRR1-10.2196/26133 %M 33970110 %R 10.2196/26133 %U https://www.researchprotocols.org/2021/5/e26133 %U https://doi.org/10.2196/26133 %U http://www.ncbi.nlm.nih.gov/pubmed/33970110 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e24526 %T Effect of Cognitive Training in Fully Immersive Virtual Reality on Visuospatial Function and Frontal-Occipital Functional Connectivity in Predementia: Randomized Controlled Trial %A Kang,Jae Myeong %A Kim,Nambeom %A Lee,Sook Young %A Woo,Soo Kyun %A Park,Geumjin %A Yeon,Byeong Kil %A Park,Jung Woon %A Youn,Jung-Hae %A Ryu,Seung-Ho %A Lee,Jun-Young %A Cho,Seong-Jin %+ Department of Psychiatry, Gil Medical Center, Gachon University College of Medicine, 21, 774-gil, Namdong-daero, Namdong-gu, Incheon, 21565, Republic of Korea, 82 32 460 8420, sjcho@gilhospital.com %K virtual reality %K cognitive training %K visuospatial function %K fMRI %K visual network %K mild cognitive impairment %D 2021 %7 6.5.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Cognitive training can potentially prevent cognitive decline. However, the results of recent studies using semi-immersive virtual reality (VR)-assisted cognitive training are inconsistent. Objective: We aimed to examine the hypothesis that cognitive training using fully immersive VR, which may facilitate visuospatial processes, could improve visuospatial functioning, comprehensive neuropsychological functioning, psychiatric symptoms, and functional connectivity in the visual brain network in predementia. Methods: Participants over 60 years old with subjective cognitive decline or mild cognitive impairment from a memory clinic were randomly allocated to the VR (n=23) or the control (n=18) group. The VR group participants received multidomain and neuropsychologist-assisted cognitive training in a fully immersive VR environment twice a week for 1 month. The control group participants did not undergo any additional intervention except for their usual therapy such as pharmacotherapy. Participants of both groups were evaluated for cognitive function using face-to-face comprehensive neuropsychological tests, including the Rey-Osterrieth Complex Figure Test (RCFT) copy task; for psychiatric symptoms such as depression, apathy, affect, and quality of life; as well as resting-state functional magnetic resonance imaging (rsfMRI) at baseline and after training. Repeated-measures analysis of variance was used to compare the effect of cognitive training between groups. Seed-to-voxel–based analyses were used to identify the cognitive improvement–related functional connectivity in the visual network of the brain. Results: After VR cognitive training, significant improvement was found in the total score (F1,39=14.69, P=.001) and basic components score of the RCFT copy task (F1,39=9.27, P=.005) compared with those of the control group. The VR group also showed improvements, albeit not significant, in naming ability (F1,39=3.55, P=.07), verbal memory delayed recall (F1,39=3.03, P=.09), and phonemic fluency (F1,39=3.08, P=.09). Improvements in psychiatric symptoms such as apathy (F1,39=7.02, P=.01), affect (F1,39=14.40, P=.001 for positive affect; F1,39=4.23, P=.047 for negative affect), and quality of life (F1,39=4.49, P=.04) were found in the VR group compared to the control group. Improvement in the RCFT copy task was associated with a frontal-occipital functional connectivity increase revealed by rsfMRI in the VR group compared to the control group. Conclusions: Fully immersive VR cognitive training had positive effects on the visuospatial function, apathy, affect, quality of life, and increased frontal-occipital functional connectivity in older people in a predementia state. Future trials using VR cognitive training with larger sample sizes and more sophisticated designs over a longer duration may reveal greater improvements in cognition, psychiatric symptoms, and brain functional connectivity. Trial Registration: Clinical Research Information Service KCT0005243; https://tinyurl.com/2a4kfasa %M 33955835 %R 10.2196/24526 %U https://www.jmir.org/2021/5/e24526 %U https://doi.org/10.2196/24526 %U http://www.ncbi.nlm.nih.gov/pubmed/33955835 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 5 %P e27640 %T Feasibility, Acceptability, and Efficacy of Virtual Reality Training for Older Adults and People With Disabilities: Single-Arm Pre-Post Study %A Chau,Pui Hing %A Kwok,Yan Yan Jojo %A Chan,Mee Kie Maggie %A Kwan,Ka Yu Daniel %A Wong,Kam Lun %A Tang,Ying Ho %A Chau,Kan Lung Peter %A Lau,Sheung Wa Matthew %A Yiu,Yan Yan Yannex %A Kwong,Mei Yan Fanny %A Lai,Wai Ting Thomas %A Leung,Mun Kit %+ School of Nursing, The University of Hong Kong, 4/F, William MW Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong, China, 852 3917 6626, phchau@graduate.hku.hk %K virtual reality %K rehabilitation %K older adults, people with disabilities %K evaluation %D 2021 %7 4.5.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Unlike most virtual reality (VR) training programs that are targeted at homogenous populations, a set of VR games for rehabilitation purposes targeted at a heterogeneous group of users was developed. The VR games covered physical training, cognitive training (classification and reality orientation), community-living skills training, and relaxing scenery experiences. Special considerations for local older adults and people with disabilities were made in terms of hardware choice and software design. Objective: This study aimed to evaluate the feasibility, acceptance, and efficacy of VR training among users with varying abilities. Methods: A single-arm pretest-posttest evaluation study was conducted. The participants of the evaluation study were encouraged to undergo 30-minute VR training three times a week for 6 weeks. The 30-minute session consisted of 10 minutes of upper-limb motion games, 10 minutes of lower-limb motion games, and 10 minutes of cognitive games/community-living skills training/relaxing scenery experiences, as appropriate. On completion of each session, usage statistics were documented via the built-in VR software, whereas feedback on the experience of the VR games and adverse events was collected via self-reports and staff observations. Feasibility was reflected by usage statistics, and acceptance was reflected by positive feedback. In addition, health outcomes, including upper-limb dexterity, functional mobility, cognitive function, and happiness, were assessed at baseline, as well as 6 weeks and 3 months after baseline. The primary outcomes were upper-limb dexterity and acceptance of playing VR games. Results: A total of 135 participants with a mean age of 62.7 years (SD 21.5) were recruited from May 2019 to January 2020, and 124 (91.9%) completed at least one follow-up. Additionally, 76.3% (103/135) of the participants could attend at least 70% of the proposed 18 sessions, and 72.5% (1382/1906) of the sessions had a training time of at least 20 minutes. Linear mixed effect models showed statistically significant effects in terms of upper-limb dexterity (small effect) and cognitive function (moderate effect). Among the 135 participants, 88 provided positive comments. Additionally, 10.4% (14/135) reported mild discomfort, such as dizziness, and none reported severe discomfort. Conclusions: A set of VR training games for rehabilitation could be applied to users with heterogeneous abilities. Our VR games were acceptable to local older adults and those with different disabilities. Benefits in upper-limb dexterity and cognitive function were observed despite partial compliance to the training protocol. Service providers could refer to our experiences when developing VR training systems for their clients. %M 33944795 %R 10.2196/27640 %U https://www.jmir.org/2021/5/e27640 %U https://doi.org/10.2196/27640 %U http://www.ncbi.nlm.nih.gov/pubmed/33944795 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 4 %P e27164 %T Innovative Virtual Role Play Simulations for Managing Substance Use Conversations: Pilot Study Results and Relevance During and After COVID-19 %A Albright,Glenn %A Khalid,Nikita %A Shockley,Kristen %A Robinson,Kelsey %A Hughes,Kevin %A Pace-Danley,Bethany %+ Peer Assistance Services, Inc, 2170 South Parker Road, Suite 229, Denver, CO, 80231, United States, 1 303 369 0039 ext 245, bpace-danley@peerassist.org %K simulations %K behavior change %K motivational interviewing %K virtual humans %K role play %K substance use %K prevention %K alcohol %K public awareness %K innovation %K interview %K COVID-19 %K pilot study %K simulation %K communication %K problem solving %D 2021 %7 29.4.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Substance use places a substantial burden on our communities, both economically and socially. In light of COVID-19, it is predicted that as many as 75,000 more people will die from alcohol and other substance use and suicide as a result of isolation, new mental health concerns, and various other stressors related to the pandemic. Public awareness campaigns that aim to destigmatize substance use and help individuals have meaningful conversations with friends, coworkers, or family members to address substance use concerns are a timely and cost-effective means of augmenting existing behavioral health efforts related to substance use. These types of interventions can supplement the work being done by existing public health initiatives. Objective: This pilot study examines the impact of the One Degree: Shift the Influence role play simulation, designed to teach family, friends, and coworkers to effectively manage problem-solving conversations with individuals that they are concerned about regarding substance use. Methods: Participants recruited for this mixed methods study completed a presurvey, the simulation, and a postsurvey, and were sent a 6-week follow-up survey. The simulation involves practicing a role play conversation with a virtual human coded with emotions, a memory, and a personality. A virtual coach provides feedback in using evidence-based communication strategies such as motivational interviewing. Results: A matched sample analysis of variance revealed significant increases at follow-up in composite attitudinal constructs of preparedness (P<.001) and self-efficacy (P=.01), including starting a conversation with someone regarding substance use, avoiding upsetting someone while bringing up concerns, focusing on observable facts, and problem solving. Qualitative data provided further evidence of the simulation’s positive impact on the ability to have meaningful conversations about substance use. Conclusions: This study provides preliminary evidence that conversation-based simulations like One Degree: Shift the Influence that use role play practice can teach individuals to use evidence-based communication strategies and can cost-effectively reach geographically dispersed populations to support public health initiatives for primary prevention. %M 33848972 %R 10.2196/27164 %U https://formative.jmir.org/2021/4/e27164 %U https://doi.org/10.2196/27164 %U http://www.ncbi.nlm.nih.gov/pubmed/33848972 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e25916 %T Leveraging Virtual Reality and Augmented Reality to Combat Chronic Pain in Youth: Position Paper From the Interdisciplinary Network on Virtual and Augmented Technologies for Pain Management %A Logan,Deirdre E %A Simons,Laura E %A Caruso,Thomas J %A Gold,Jeffrey I %A Greenleaf,Walter %A Griffin,Anya %A King,Christopher D %A Menendez,Maria %A Olbrecht,Vanessa A %A Rodriguez,Samuel %A Silvia,Megan %A Stinson,Jennifer N %A Wang,Ellen %A Williams,Sara E %A Wilson,Luke %+ Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Suite 300, 1070 Arastradero Road, Palo Alto, CA, 94304, United States, 1 650 736 0838, lesimons@stanford.edu %K virtual reality %K pediatric %K chronic pain %D 2021 %7 26.4.2021 %9 Viewpoint %J J Med Internet Res %G English %X Background: Virtual reality (VR) and augmented reality (AR) interventions are emerging as promising tools in the treatment of pediatric chronic pain conditions. However, in this young field, there is little consensus to guide the process of engaging in the development and evaluation of targeted VR-based interventions. Objective: The INOVATE-Pain (Interdisciplinary Network on Virtual and Augmented Technologies for Pain management) consortium aims to advance the field of VR for pediatric chronic pain rehabilitation by providing guidance for best practices in the design, evaluation, and dissemination of VR-based interventions targeting this population. Methods: An interdisciplinary meeting of 16 academics, clinicians, industry partners, and philanthropy partners was held in January 2020. Results: Reviewing the state of the field, the consortium identified important directions for research-driven innovation in VR and AR clinical care, highlighted key opportunities and challenges facing the field, and established a consensus on best methodological practices to adopt in future efforts to advance the research and practice of VR and AR in pediatric pain. The consortium also identified important next steps to undertake to continue to advance the work in this promising new area of digital health pain interventions. Conclusions: To realize the promise of this realm of innovation, key ingredients for success include productive partnerships among industry, academic, and clinical stakeholders; a uniform set of outcome domains and measures for standardized evaluation; and widespread access to the latest opportunities, tools, and resources. The INOVATE-Pain collaborative hopes to promote the creation, rigorous yet efficient evaluation, and dissemination of innovative VR-based interventions to reduce pain and improve quality of life for children. %M 33667177 %R 10.2196/25916 %U https://www.jmir.org/2021/4/e25916 %U https://doi.org/10.2196/25916 %U http://www.ncbi.nlm.nih.gov/pubmed/33667177 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e25504 %T “Doc McStuffins: Doctor for a Day” Virtual Reality (DocVR) for Pediatric Preoperative Anxiety and Satisfaction: Pediatric Medical Technology Feasibility Study %A Gold,Jeffrey I %A Annick,Erin T %A Lane,Arianna S %A Ho,Katherine %A Marty,Ryan T %A Espinoza,Juan C %+ Department of Anesthesiology Critical Care Medicine, The Saban Research Institute, Children’s Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA, 90027, United States, 1 13233616341, JGold@chla.usc.edu %K virtual reality (VR) %K pediatric %K anxiety %K preoperative %K satisfaction %K Doc McStuffins %D 2021 %7 19.4.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Preoperative anxiety is a common occurrence among children and is associated with a host of maladaptive postoperative behaviors. Consequently, increased attention has been placed on interventions to reduce preoperative anxiety and its associated outcomes. Child Life preparation prior to surgery includes evidence-based practices such as age-appropriate distraction and therapeutic play. Virtual reality (VR) is a promising addition to the Child Life toolbox to address anxiety prior to surgery. The current study evaluates the implementation and feasibility of a VR experience, “Doc McStuffins: Doctor for a Day Virtual Reality Experience” (DocVR), developed by Disney Junior in collaboration with Children’s Hospital Los Angeles, to target pediatric preoperative anxiety. Objective: The primary aim of this study was to examine the feasibility and efficacy of DocVR for preoperative anxiety. A secondary aim was to improve patient, caregiver, and health care provider satisfaction with the preoperative experience. Methods: In this study, 51 patients (age 6-14 years) scheduled for surgery in the ambulatory surgery center and the main operating room at Children’s Hospital Los Angeles were approached to participate in Disney’s DocVR experience. The patients played the DocVR experience for an average of 18 minutes (3-55 minutes). Irrespective of surgical procedure, patients and their families were eligible, as long as they had no known marked cognitive or visual impairments that would interfere with completing the survey and engaging in the DocVR experience. Results: Patients who tried the DocVR experience (n=51) responded overwhelmingly positively to both the VR technology and to the game itself. Patients experienced a statistically significant decrease in anxiety following DocVR game play (Z=–3.26, P=.001). On the Facial Affective Scale, the percentage of patients who chose the face with the most positive facial expression to represent their affect increased from 23% (12/51) pre-VR to 49% (25/47) post-VR. Furthermore, 97% (38/39) of patients reported feeling more comfortable at the hospital, and 74% (28/38) reported feeling less scared at the hospital after playing the game. The game was enjoyed by 94% (46/49) of patients, and 88% (30/34) of patients reported feeling both “Interested” and “Involved” in the game. Conclusions: DocVR is a feasible and beneficial VR experience to relieve pediatric preoperative anxiety and improve satisfaction in the preoperative area. The VR experience resulted in a decrease in overall anxiety and an increase in overall positive affect during the preoperative time. Patients also responded positively to the game, confirming their interest in the content and affirming the quality of the DocVR experience. The positive response to the game indicates that DocVR has the potential to make the overall preoperative experience less anxiety-producing and more comfortable, which leads to improved patient satisfaction. Naturally, improved patient outcomes lead to improved caregiver and health care provider satisfaction. %M 33730687 %R 10.2196/25504 %U https://www.jmir.org/2021/4/e25504 %U https://doi.org/10.2196/25504 %U http://www.ncbi.nlm.nih.gov/pubmed/33730687 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e23882 %T Effect of a Virtual Reality–Enhanced Exercise and Education Intervention on Patient Engagement and Learning in Cardiac Rehabilitation: Randomized Controlled Trial %A Gulick,Victoria %A Graves,Daniel %A Ames,Shannon %A Krishnamani,Pavitra Parimala %+ Information Services & Technologies, Jefferson Health, 833 Chestnut St, Suite 1000, Philadelphia, PA, 19107, United States, 1 215 503 3224, victoria.gulick@jefferson.edu %K virtual reality %K VR %K cardiac rehabilitation %K patient experience %K patient education %K outpatient therapy %K exercise %D 2021 %7 15.4.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Cardiac rehabilitation (CR) is clinically proven to reduce morbidity and mortality; however, many eligible patients do not enroll in treatment. Furthermore, many enrolled patients do not complete their full course of treatment. This is greatly influenced by socioeconomic factors but is also because of patients’ lack of understanding of the importance of their care and a lack of motivation to maintain attendance. Objective: This study aims to explore the potential benefits of virtual reality (VR) walking trails within CR treatment, specifically with regard to patient knowledge retention, satisfaction with treatment, and the overall attendance of treatment sessions. Methods: New CR patients were enrolled and randomized on a rolling basis to either the control group or intervention group. Intervention patients completed their time on the treadmill with VR walking trails, which included audio-recorded education, whereas control patients completed the standard of care therapy. Both groups were assisted by nursing staff for all treatment sessions. Primary outcomes were determined by assessing 6-minute walk test improvement. In addition, secondary outcomes of patients’ cardiac knowledge and satisfaction were assessed via a computer-based questionnaire; patient adherence to the recommended number of sessions was also monitored. Cardiac knowledge assessment included a prerehabilitation education quiz, and the same quiz was repeated at patients’ final visit and again at the 2-month follow-up. The satisfaction questionnaire was completed at the final visit. Results: Between January 2018 and May 2019, 72 patients were enrolled—41 in the intervention group and 31 in the control group. On the basis of the results of the prerehabilitation and postrehabilitation 6-minute walk test, no significant differences were observed between the intervention and control groups (P=.64). No statistical differences were observed between groups in terms of education (P=.86) or satisfaction (P=.32) at any time point. The control group had statistically more favorable rates of attendance, as determined by the risk group comparison (P=.02) and the comparison of the rates for completing the minimum number of sessions (P=.046), but no correlation was observed between the study group and reasons for ending treatment. Conclusions: Although no improvements were seen in the VR intervention group over the control group, it is worth noting that limitations in the study design may have influenced these outcomes, not the medium itself. Furthermore, the qualitative information suggests that patients may have indeed enjoyed their experience with VR, even though quantitative satisfaction data did not capture this. Further considerations for how and when VR should be applied to CR are suggested in this paper. Trial Registration: ClinicalTrials.gov NCT03945201; https://clinicaltrials.gov/ct2/show/NCT03945201 %M 33856355 %R 10.2196/23882 %U https://www.jmir.org/2021/4/e23882 %U https://doi.org/10.2196/23882 %U http://www.ncbi.nlm.nih.gov/pubmed/33856355 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 8 %N 4 %P e25731 %T Virtual Reality–Based Psychotherapy in Social Anxiety Disorder: fMRI Study Using a Self-Referential Task %A Hur,Ji-Won %A Shin,Hyemin %A Jung,Dooyoung %A Lee,Heon-Jeong %A Lee,Sungkil %A Kim,Gerard J %A Cho,Chung-Yean %A Choi,Seungmoon %A Lee,Seung-Moo %A Cho,Chul-Hyun %+ Department of Psychiatry, College of Medicine, Chungnam National University, 82 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea, 82 44 995 4775, david0203@gmail.com %K virtual reality %K VR %K social anxiety %K social phobia %K exposure therapy %K fMRI %K unctional magnetic resonance imaging %D 2021 %7 14.4.2021 %9 Original Paper %J JMIR Ment Health %G English %X Background: Although it has been well demonstrated that the efficacy of virtual reality therapy for social anxiety disorder is comparable to that of traditional cognitive behavioral therapy, little is known about the effect of virtual reality on pathological self-referential processes in individuals with social anxiety disorder. Objective: We aimed to determine changes in self-referential processing and their neural mechanisms following virtual reality treatment. Methods: We recruited participants with and without a primary diagnosis of social anxiety disorder to undergo clinical assessments (Social Phobia Scale and Post-Event Rumination Scale) and functional magnetic resonance imaging (fMRI) scans. Participants with social anxiety disorder received virtual reality–based exposure treatment for 6 sessions starting immediately after baseline testing. After the sixth session, participants with social anxiety disorder completed follow-up scans during which they were asked to judge whether a series of words (positive, negative, neutral) was relevant to them. Results: Of 25 individuals with social anxiety disorder who participated in the study, 21 completed the sessions and follow-up; 22 control individuals also participated. There were no significant differences in age (P=.36), sex (P=.71), or handedness (P=.51) between the groups. Whole-brain analysis revealed that participants in the social anxiety disorder group had increased neural responses during positive self-referential processing in the medial temporal and frontal cortexes compared with those in the control group. Participants in the social anxiety disorder group also showed increased left insular activation and decreased right middle frontal gyrus activation during negative self-referential processing. After undergoing virtual reality–based therapy, overall symptoms of the participants with social anxiety disorder were reduced, and these participants exhibited greater activity in a brain regions responsible for self-referential and autobiographical memory processes while viewing positive words during postintervention fMRI scans. Interestingly, the greater the blood oxygen level dependent changes related to positive self-referential processing, the lower the tendency to ruminate on the negative events and the lower the social anxiety following the virtual reality session. Compared with that at baseline, higher activation was also found within broad somatosensory areas in individuals with social anxiety disorder during negative self-referential processing following virtual reality therapy. Conclusions: These fMRI findings might reflect the enhanced physiological and cognitive processing in individuals with social anxiety disorder in response to self-referential information. They also provide neural evidence of the effect of virtual reality exposure therapy on social anxiety and self-derogation. %M 33851931 %R 10.2196/25731 %U https://mental.jmir.org/2021/4/e25731 %U https://doi.org/10.2196/25731 %U http://www.ncbi.nlm.nih.gov/pubmed/33851931 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e24998 %T Virtual Reality App for Treating Eating Behavior in Eating Disorders: Development and Usability Study %A Langlet,Billy Sundström %A Odegi,Dorothy %A Zandian,Modjtaba %A Nolstam,Jenny %A Södersten,Per %A Bergh,Cecilia %+ Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Hälsovägen 7, 3rd floor, Stockholm, 141 52, Sweden, 46 852488034, billy.langlet@ki.se %K feeding and eating disorders %K anorexia nervosa %K bulimia nervosa %K binge eating disorder %K immersive virtual reality %K eating disorders %K virtual reality %D 2021 %7 13.4.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Anorexia nervosa is one of the more severe eating disorders, which is characterized by reduced food intake, leading to emaciation and psychological maladjustment. Treatment outcomes are often discouraging, with most interventions displaying a recovery rate below 50%, a dropout rate from 20% to 50%, and a high risk of relapse. Patients with anorexia nervosa often display anxiety and aversive behaviors toward food. Virtual reality has been successful in treating vertigo, anxiety disorder, and posttraumatic stress syndrome, and could potentially be used as an aid in treating eating disorders. Objective: The aim of this study was to evaluate the feasibility and usability of an immersive virtual reality technology administered through an app for use by patients with eating disorders. Methods: Twenty-six participants, including 19 eating disorder clinic personnel and 5 information technology personnel, were recruited through emails and personal invitations. Participants handled virtual food and utensils on an app using immersive virtual reality technology comprising a headset and two hand controllers. In the app, the participants learned about the available actions through a tutorial and they were introduced to a food challenge. The challenge consisted of a meal type (meatballs, potatoes, sauce, and lingonberries) that is typically difficult for patients with anorexia nervosa to eat in real life. Participants were instructed, via visual feedback from the app, to eat at a healthy rate, which is also a challenge for patients. Participants rated the feasibility and usability of the app by responding to the mHealth Evidence Reporting and Assessment checklist, the 10-item System Usability Scale, and the 20-point heuristic evaluation questionnaire. A cognitive walkthrough was performed using video recordings of participant interactions in the virtual environment. Results: The mean age of participants was 37.9 (SD 9.7) years. Half of the participants had previous experience with virtual reality. Answers to the mHealth Evidence Reporting and Assessment checklist suggested that implementation of the app would face minor infrastructural, technological, interoperability, financial, and adoption problems. There was some disagreement on intervention delivery, specifically regarding frequency of use; however, most of the participants agreed that the app should be used at least once per week. The app received a mean score of 73.4 (range 55-90), earning an overall “good” rating. The mean score of single items of the heuristic evaluation questionnaire was 3.6 out of 5. The lowest score (2.6) was given to the “accuracy” item. During the cognitive walkthrough, 32% of the participants displayed difficulty in understanding what to do at the initial selection screen. However, after passing the selection screen, all participants understood how to progress through the tasks. Conclusions: Participants found the app to be usable and eating disorder personnel were positive regarding its fit with current treatment methods. Along with the food item challenges in the current app, participants considered that the app requires improvement to offer environmental and social (eg, crowded room vs eating alone) challenges. %M 33847593 %R 10.2196/24998 %U https://games.jmir.org/2021/2/e24998 %U https://doi.org/10.2196/24998 %U http://www.ncbi.nlm.nih.gov/pubmed/33847593 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 4 %P e22008 %T Virtual Reality Self-help Treatment for Aviophobia: Protocol for a Randomized Controlled Trial %A Fehribach,Jamie Rhiannon %A Toffolo,Marieke Bianca Jolien %A Cornelisz,Ilja %A van Klaveren,Chris %A van Straten,Annemieke %A van Gelder,Jean-Louis %A Donker,Tara %+ Clinical Psychology, Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands, 31 641313555, t.donker@vu.nl %K aviophobia %K specific phobia %K virtual reality %K cognitive behavioral therapy %K exposure therapy %D 2021 %7 12.4.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Aviophobia (the fear of flying) can greatly impact the daily life functioning of people with the condition. Traditional exposure-based treatment is hampered by the limited availability of airplane practice situations, which is a result of economical and practical concerns. Easily accessible and low-cost virtual reality exposure therapy may address these challenges. Objective: The purpose of our study is to investigate the effectiveness of ZeroPhobia: Aviophobia (a self-help mobile app–based treatment) in reducing flight anxiety symptoms and depressive and anxiety symptoms. We will also investigate the effects of usage intensity, the sense of immersion, inherent absorption ability, and perceived user-friendliness on the treatment effect. Methods: Participants (N=114) who are aged 18-64 years and experience at least mild symptoms of aviophobia will be recruited from the general Dutch population and randomized into a treatment group or waitlist control group. By using their own phones and rudimentary mobile virtual reality headsets, participants will receive six modules of psychoeducation and cognitive behavioral therapy, which will include six levels of virtual reality exposure therapy over a period of 6 weeks. Assessments will be conducted at baseline, posttest (ie, after 6 weeks), and 3- and 12-month follow-ups. The primary outcome measure of our study is the Flight Anxiety Situations Questionnaire. The secondary outcome measures include anxiety and depression measures and additional covariates (including usage intensity, the degree of immersion, etc). We will test treatment effectiveness by conducting an intention-to-treat analysis and estimating average treatment effects on the treated. The mechanisms of treatment effect will also be explored. Results: The study was funded on September 25, 2018. Ethical approval was received on October 11, 2019. Recruitment closed on May 7, 2020. Conclusions: Our study will further the scientific understanding and clinical implications of technology’s current ability to aid in providing effective, accessible treatment for the fear of flying. Trial Registration: Netherlands Trial Registry NL70238.029.19; https://www.trialregister.nl/trial/8257. International Registered Report Identifier (IRRID): DERR1-10.2196/22008 %M 33843605 %R 10.2196/22008 %U https://www.researchprotocols.org/2021/4/e22008 %U https://doi.org/10.2196/22008 %U http://www.ncbi.nlm.nih.gov/pubmed/33843605 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 4 %P e23635 %T The Current Situation and Future Prospects of Simulators in Dental Education %A Li,Yaning %A Ye,Hongqiang %A Ye,Fan %A Liu,Yunsong %A Lv,Longwei %A Zhang,Ping %A Zhang,Xiao %A Zhou,Yongsheng %+ Department of Prosthodontics, Peking University School and Hospital of Stomatology, 22 Zhongguancun South Avenue, Haidian District, Beijing, 100081, China, 86 010 82195070, kqzhouysh@hsc.pku.edu.cn %K dental simulator %K dental education %K virtual reality %D 2021 %7 8.4.2021 %9 Viewpoint %J J Med Internet Res %G English %X The application of virtual reality has become increasingly extensive as this technology has developed. In dental education, virtual reality is mainly used to assist or replace traditional methods of teaching clinical skills in preclinical training for several subjects, such as endodontics, prosthodontics, periodontics, implantology, and dental surgery. The application of dental simulators in teaching can make up for the deficiency of traditional teaching methods and reduce the teaching burden, improving convenience for both teachers and students. However, because of the technology limitations of virtual reality and force feedback, dental simulators still have many hardware and software disadvantages that have prevented them from being an alternative to traditional dental simulators as a primary skill training method. In the future, when combined with big data, cloud computing, 5G, and deep learning technology, dental simulators will be able to give students individualized learning assistance, and their functions will be more diverse and suitable for preclinical training. The purpose of this review is to provide an overview of current dental simulators on related technologies, advantages and disadvantages, methods of evaluating effectiveness, and future directions for development. %M 33830059 %R 10.2196/23635 %U https://www.jmir.org/2021/4/e23635 %U https://doi.org/10.2196/23635 %U http://www.ncbi.nlm.nih.gov/pubmed/33830059 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 2 %P e23822 %T Integration of Motor Learning Principles Into Virtual Reality Interventions for Individuals With Cerebral Palsy: Systematic Review %A Demers,Marika %A Fung,Karen %A Subramanian,Sandeep K %A Lemay,Martin %A Robert,Maxime T %+ Centre for Interdisciplinary Research in Rehabilitation and Social Integration, Department of Rehabilitation, Faculty of Medicine, Université Laval, 525 boul Hamel, Quebec, QC, G1M 2S8, Canada, 1 418 529 9141 ext 6121, maxime.robert@fmed.ulaval.ca %K virtual rehabilitation %K upper limb %K brain damage %K feedback %K active video games %K learning %D 2021 %7 7.4.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Increasing evidence supports the use of virtual reality systems to improve upper limb motor functions in individuals with cerebral palsy. While virtual reality offers the possibility to include key components to promote motor learning, it remains unclear if and how motor learning principles are incorporated into the development of rehabilitation interventions using virtual reality. Objective: The objective of this study was to determine the extent to which motor learning principles are integrated into virtual reality interventions targeting upper limb function in individuals with cerebral palsy. Methods: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search was performed in 10 databases using a combination of keywords related to cerebral palsy, virtual reality, video games, and rehabilitation. Studies were divided into 2 categories: commercial video game platforms and devices and custom virtual reality systems. Study quality was assessed using the modified Downs and Black checklist. Results: The initial search yielded 1497 publications. A total of 26 studies from 30 publications were included, with most studies classified as “fair” according to the modified Downs and Black checklist. The majority of studies provided enhanced feedback and variable practice and used functionally relevant and motivating virtual tasks. The dosage varied greatly (total training time ranged from 300 to 3360 minutes), with only 6 studies reporting the number of movement repetitions per session. The difficulty progression and the assessment of skills retention and transfer were poorly incorporated, especially for the commercial video games. Conclusions: Motor learning principles should be better integrated into the development of future virtual reality systems for optimal upper limb motor recovery in individuals with cerebral palsy. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020151982; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020151982 %M 33825690 %R 10.2196/23822 %U https://games.jmir.org/2021/2/e23822 %U https://doi.org/10.2196/23822 %U http://www.ncbi.nlm.nih.gov/pubmed/33825690 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e24652 %T A Virtual Reality Game to Change Sun Protection Behavior and Prevent Cancer: User-Centered Design Approach %A Horsham,Caitlin %A Dutton-Regester,Ken %A Antrobus,Jodie %A Goldston,Andrew %A Price,Harley %A Ford,Helen %A Hacker,Elke %+ School of Public Health and Social Work, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Brisbane, 4059, Australia, 61 731389674, elke.hacker@qut.edu.au %K virtual reality %K gamification %K primary prevention %K health promotion %K skin cancer %K mobile phone %D 2021 %7 25.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Public health sun safety campaigns introduced during the 1980s have successfully reduced skin cancer rates in Australia. Despite this success, high rates of sunburn continue to be reported by youth and young adults. As such, new strategies to reinforce sun protection approaches in this demographic are needed. Objective: This study aims to develop a virtual reality (VR) game containing preventive skin cancer messaging and to assess the safety and satisfaction of the design based on end user feedback. Methods: Using a two-phase design approach, we created a prototype VR game that immersed the player inside the human body while being confronted with growing cancer cells. The first design phase involved defining the problem, identifying stakeholders, choosing the technology platform, brainstorming, and designing esthetic elements. In the second design phase, we tested the prototype VR experience with stakeholders and end users in focus groups and interviews, with feedback incorporated into refining and improving the design. Results: The focus groups and interviews were conducted with 18 participants. Qualitative feedback indicated high levels of satisfaction, with all participants reporting the VR game as engaging. A total of 11% (2/8) of participants reported a side effect of feeling nauseous during the experience. The end user feedback identified game improvements, suggesting an extended multistage experience with visual transitions to other environments and interactions involving cancer causation. The implementation of the VR game identified challenges in sharing VR equipment and hygiene issues. Conclusions: This study presents key findings highlighting the design and implementation approaches for a VR health intervention primarily aimed at improving sun protection behaviors. This design approach can be applied to other health prevention programs in the future. %M 33764308 %R 10.2196/24652 %U https://games.jmir.org/2021/1/e24652 %U https://doi.org/10.2196/24652 %U http://www.ncbi.nlm.nih.gov/pubmed/33764308 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 3 %P e24373 %T Immersive Virtual Reality and Ocular Tracking for Brain Mapping During Awake Surgery: Prospective Evaluation Study %A Casanova,Morgane %A Clavreul,Anne %A Soulard,Gwénaëlle %A Delion,Matthieu %A Aubin,Ghislaine %A Ter Minassian,Aram %A Seguier,Renaud %A Menei,Philippe %+ Département de Neurochirurgie, CHU d'Angers, 4 rue Larrey, Angers , France, 33 241 354822, phmenei@chu-angers.fr %K virtual reality %K eye tracking %K brain mapping %K awake surgery %K visuospatial cognition %K nonverbal language %K mobile phone %D 2021 %7 24.3.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Language mapping during awake brain surgery is currently a standard procedure. However, mapping is rarely performed for other cognitive functions that are important for social interaction, such as visuospatial cognition and nonverbal language, including facial expressions and eye gaze. The main reason for this omission is the lack of tasks that are fully compatible with the restrictive environment of an operating room and awake brain surgery procedures. Objective: This study aims to evaluate the feasibility and safety of a virtual reality headset equipped with an eye-tracking device that is able to promote an immersive visuospatial and social virtual reality (VR) experience for patients undergoing awake craniotomy. Methods: We recruited 15 patients with brain tumors near language and/or motor areas. Language mapping was performed with a naming task, DO 80, presented on a computer tablet and then in 2D and 3D via the VRH. Patients were also immersed in a visuospatial and social VR experience. Results: None of the patients experienced VR sickness, whereas 2 patients had an intraoperative focal seizure without consequence; there was no reason to attribute these seizures to virtual reality headset use. The patients were able to perform the VR tasks. Eye tracking was functional, enabling the medical team to analyze the patients’ attention and exploration of the visual field of the virtual reality headset directly. Conclusions: We found that it is possible and safe to immerse the patient in an interactive virtual environment during awake brain surgery, paving the way for new VR-based brain mapping procedures. Trial Registration: ClinicalTrials.gov NCT03010943; https://clinicaltrials.gov/ct2/show/NCT03010943. %M 33759794 %R 10.2196/24373 %U https://www.jmir.org/2021/3/e24373 %U https://doi.org/10.2196/24373 %U http://www.ncbi.nlm.nih.gov/pubmed/33759794 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e24170 %T Α Virtual Reality App for Physical and Cognitive Training of Older People With Mild Cognitive Impairment: Mixed Methods Feasibility Study %A Hassandra,Mary %A Galanis,Evangelos %A Hatzigeorgiadis,Antonis %A Goudas,Marios %A Mouzakidis,Christos %A Karathanasi,Eleni Maria %A Petridou,Niki %A Tsolaki,Magda %A Zikas,Paul %A Evangelou,Giannis %A Papagiannakis,George %A Bellis,George %A Kokkotis,Christos %A Panagiotopoulos,Spyridon Rafail %A Giakas,Giannis %A Theodorakis,Yannis %+ School of Physical Education, Sport Science and Dietetics, Department of Physical Education and Sport Science, University of Thessaly, Karies, Trikala, 42100, Greece, 30 24310 4700, mxasad@uth.gr %K virtual reality %K elderly %K mild cognitive impairment %K combined physical and cognitive function %K dual task %D 2021 %7 24.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: Therapeutic virtual reality (VR) has emerged as an effective treatment modality for cognitive and physical training in people with mild cognitive impairment (MCI). However, to replace existing nonpharmaceutical treatment training protocols, VR platforms need significant improvement if they are to appeal to older people with symptoms of cognitive decline and meet their specific needs. Objective: This study aims to design and test the acceptability, usability, and tolerability of an immersive VR platform that allows older people with MCI symptoms to simultaneously practice physical and cognitive skills on a dual task. Methods: On the basis of interviews with 20 older people with MCI symptoms (15 females; mean age 76.25, SD 5.03 years) and inputs from their health care providers (formative study VR1), an interdisciplinary group of experts developed a VR system called VRADA (VR Exercise App for Dementia and Alzheimer’s Patients). Using an identical training protocol, the VRADA system was first tested with a group of 30 university students (16 females; mean age 20.86, SD 1.17 years) and then with 27 older people (19 females; mean age 73.22, SD 9.26 years) who had been diagnosed with MCI (feasibility studies VR2a and VR2b). Those in the latter group attended two Hellenic Association Day Care Centers for Alzheimer’s Disease and Related Disorders. Participants in both groups were asked to perform a dual task training protocol that combined physical and cognitive exercises in two different training conditions. In condition A, participants performed a cycling task in a lab environment while being asked by the researcher to perform oral math calculations (single-digit additions and subtractions). In condition B, participants performed a cycling task in the virtual environment while performing calculations that appeared within the VR app. Participants in both groups were assessed in the same way; this included questionnaires and semistructured interviews immediately after the experiment to capture perceptions of acceptability, usability, and tolerability, and to determine which of the two training conditions each participant preferred. Results: Participants in both groups showed a significant preference for the VR condition (students: mean 0.66, SD 0.41, t29=8.74, P<.001; patients with MCI: mean 0.72, SD 0.51, t26=7.36, P<.001), as well as high acceptance scores for intended future use, attitude toward VR training, and enjoyment. System usability scale scores (82.66 for the students and 77.96 for the older group) were well above the acceptability threshold (75/100). The perceived adverse effects were minimal, indicating a satisfactory tolerability. Conclusions: The findings suggest that VRADA is an acceptable, usable, and tolerable system for physical and cognitive training of older people with MCI and university students. Randomized controlled trial studies are needed to assess the efficacy of VRADA as a tool to promote physical and cognitive health in patients with MCI. %M 33759797 %R 10.2196/24170 %U https://games.jmir.org/2021/1/e24170 %U https://doi.org/10.2196/24170 %U http://www.ncbi.nlm.nih.gov/pubmed/33759797 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 9 %N 1 %P e20916 %T A Depth Camera–Based, Task-Specific Virtual Reality Rehabilitation Game for Patients With Stroke: Pilot Usability Study %A Xu,Yangfan %A Tong,Meiqinzi %A Ming,Wai-Kit %A Lin,Yangyang %A Mai,Wangxiang %A Huang,Weixin %A Chen,Zhuoming %+ The First Affiliated Hospital of Jinan University, No 613 Huangpu Road West, Tianhe District, Guangzhou, China, 86 13392692183, 1090029753@qq.com %K virtual reality %K rehabilitation %K stroke %K lower extremity %K rehabilitation game %D 2021 %7 24.3.2021 %9 Original Paper %J JMIR Serious Games %G English %X Background: The use of virtual reality is popular in clinical rehabilitation, but the effects of using commercial virtual reality games in patients with stroke have been mixed. Objective: We developed a depth camera–based, task-specific virtual reality game, Stomp Joy, for poststroke rehabilitation of the lower extremities. This study aims to assess its feasibility and clinical efficacy. Methods: We carried out a feasibility test for Stomp Joy within representative user groups. Then, a clinical efficacy experiment was performed with a randomized controlled trial, in which 22 patients with stroke received 10 sessions (2 weeks) of conventional physical therapy only (control group) or conventional physical therapy plus 30 minutes of the Stomp Joy intervention (experimental group) in the clinic. The Fugl-Meyer Assessment for Lower Extremity (FMA-LE), Modified Barthel Index (MBI), Berg Balance Scale (BBS) score, single-leg stance (SLS) time, dropout rate, and adverse effects were recorded. Results: This feasibility test showed that Stomp Joy improved interest, pressure, perceived competence, value, and effort using the Intrinsic Motivation Inventory. The clinical efficacy trial showed a significant time-group interaction effect for the FMA-LE (P=.006), MBI (P=.001), BBS (P=.004), and SLS time (P=.001). A significant time effect was found for the FMA-LE (P=.001), MBI (P<.001), BBS (P<.001), and SLS time (P=.03). These indicated an improvement in lower extremity motor ability, basic activities of daily living, balance ability, and single-leg stance time in both groups after 2 weeks of the intervention. However, no significant group effects were found for the FMA-LE (P=.06), MBI (P=.76), and BBS (P=.38), while a significant group interaction was detected for SLS time (P<.001). These results indicated that the experimental group significantly improved more in SLS time than did the control group. During the study, 2 dropouts, including 1 participant who fell, were reported. Conclusions: Stomp Joy is an effective depth camera–based virtual reality game for replacing part of conventional physiotherapy, achieving equally effective improvement in lower extremity function among stroke survivors. High-powered randomized controlled studies are now needed before recommending the routine use of Stomp Joy in order to confirm these findings by recruiting a large sample size. %M 33759795 %R 10.2196/20916 %U https://games.jmir.org/2021/1/e20916 %U https://doi.org/10.2196/20916 %U http://www.ncbi.nlm.nih.gov/pubmed/33759795 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e26292 %T An 8-Week Self-Administered At-Home Behavioral Skills-Based Virtual Reality Program for Chronic Low Back Pain: Double-Blind, Randomized, Placebo-Controlled Trial Conducted During COVID-19 %A Garcia,Laura M %A Birckhead,Brandon J %A Krishnamurthy,Parthasarathy %A Sackman,Josh %A Mackey,Ian G %A Louis,Robert G %A Salmasi,Vafi %A Maddox,Todd %A Darnall,Beth D %+ Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Ste 200, MC5596, Palo Alto, CA, 94304, United States, 1 15035778377, bdarnall@stanford.edu %K virtual reality %K low back pain %K opioids %K chronic pain %K behavioral health %K pain treatment, randomized controlled trial %K COVID-19 %D 2021 %7 22.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Chronic low back pain is the most prevalent chronic pain condition worldwide and access to behavioral pain treatment is limited. Virtual reality (VR) is an immersive technology that may provide effective behavioral therapeutics for chronic pain. Objective: We aimed to conduct a double-blind, parallel-arm, single-cohort, remote, randomized placebo-controlled trial for a self-administered behavioral skills-based VR program in community-based individuals with self-reported chronic low back pain during the COVID-19 pandemic. Methods: A national online convenience sample of individuals with self-reported nonmalignant low back pain with duration of 6 months or more and with average pain intensity of 4 or more/10 was enrolled and randomized 1:1 to 1 of 2 daily (56-day) VR programs: (1) EaseVRx (immersive pain relief skills VR program); or (2) Sham VR (2D nature content delivered in a VR headset). Objective device use data and self-reported data were collected. The primary outcomes were the between-group effect of EaseVRx versus Sham VR across time points, and the between–within interaction effect representing the change in average pain intensity and pain-related interference with activity, stress, mood, and sleep over time (baseline to end-of-treatment at day 56). Secondary outcomes were global impression of change and change in physical function, sleep disturbance, pain self-efficacy, pain catastrophizing, pain acceptance, pain medication use, and user satisfaction. Analytic methods included intention-to-treat and a mixed-model framework. Results: The study sample was 179 adults (female: 76.5%, 137/179; Caucasian: 90.5%, 162/179; at least some college education: 91.1%, 163/179; mean age: 51.5 years [SD 13.1]; average pain intensity: 5/10 [SD 1.2]; back pain duration ≥5 years: 67%, 120/179). No group differences were found for any baseline variable or treatment engagement. User satisfaction ratings were higher for EaseVRx versus Sham VR (P<.001). For the between-groups factor, EaseVRx was superior to Sham VR for all primary outcomes (highest P value=.009), and between-groups Cohen d effect sizes ranged from 0.40 to 0.49, indicating superiority was moderately clinically meaningful. For EaseVRx, large pre–post effect sizes ranged from 1.17 to 1.3 and met moderate to substantial clinical importance for reduced pain intensity and pain-related interference with activity, mood, and stress. Between-group comparisons for Physical Function and Sleep Disturbance showed superiority for the EaseVRx group versus the Sham VR group (P=.022 and .013, respectively). Pain catastrophizing, pain self-efficacy, pain acceptance, prescription opioid use (morphine milligram equivalent) did not reach statistical significance for either group. Use of over-the-counter analgesic use was reduced for EaseVRx (P<.01) but not for Sham VR. Conclusions: EaseVRx had high user satisfaction and superior and clinically meaningful symptom reduction for average pain intensity and pain-related interference with activity, mood, and stress compared to sham VR. Additional research is needed to determine durability of treatment effects and to characterize mechanisms of treatment effects. Home-based VR may expand access to effective and on-demand nonpharmacologic treatment for chronic low back pain. Trial Registration: ClinicalTrials.gov NCT04415177; https://clinicaltrials.gov/ct2/show/NCT04415177 International Registered Report Identifier (IRRID): RR2-10.2196/25291 %M 33484240 %R 10.2196/26292 %U https://www.jmir.org/2021/2/e26292 %U https://doi.org/10.2196/26292 %U http://www.ncbi.nlm.nih.gov/pubmed/33484240 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e25322 %T Virtual Reality or Augmented Reality as a Tool for Studying Bystander Behaviors in Interpersonal Violence: Scoping Review %A Xue,Jia %A Hu,Ran %A Zhang,Wenzhao %A Zhao,Yaxi %A Zhang,Bolun %A Liu,Nian %A Li,Sam-Chin %A Logan,Judith %+ Factor Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street West, Toronto, ON, M5S 1V4, Canada, 1 4169465429, jia.xue@utoronto.ca %K virtual reality %K augmented reality %K bystander behaviors %K interpersonal violence %K violent incidents %K people’s responses %K dating violence %K sexual violence %D 2021 %7 15.2.2021 %9 Review %J J Med Internet Res %G English %X Background: To provide participants with a more real and immersive intervening experience, virtual reality (VR) and/or augmented reality (AR) technologies have been integrated into some bystander intervention training programs and studies measuring bystander behaviors. Objective: We focused on whether VR or AR can be used as a tool to enhance training bystanders. We reviewed the evidence from empirical studies that used VR and/or AR as a tool for examining bystander behaviors in the domain of interpersonal violence research. Methods: Two librarians searched for articles in databases, including APA PsycInfo (Ovid), Criminal Justice Abstracts (EBSCO), Medline (Ovid), Applied Social Sciences Index & Abstracts (ProQuest), Sociological Abstracts (ProQuest), and Scopus till April 15, 2020. Studies focusing on bystander behaviors in conflict situations were included. All study types (except reviews) written in English in any discipline were included. Results: The search resulted in 12,972 articles from six databases, and the articles were imported into Covidence. Eleven studies met the inclusion and exclusion criteria. All 11 articles examined the use of VR as a tool for studying bystander behaviors. Most of the studies were conducted in US young adults. The types of interpersonal violence were school bullying, dating violence, sexual violence/assault, and soccer-associated violence. VR technology was used as an observational measure and bystander intervention program. We evaluated the different uses of VR for bystander behaviors and noted a lack of empirical evidence for AR as a tool. We also discuss the empirical evidence regarding the design, effectiveness, and limitations of implementing VR as a tool in the reviewed studies. Conclusions: The reviewed results have implications and recommendations for future research in designing and implementing VR/AR technology in the area of interpersonal violence. Future studies in this area may further contribute to the use of VR as an observational measure and explore the potential use of AR to study bystander behaviors. %M 33587044 %R 10.2196/25322 %U http://www.jmir.org/2021/2/e25322/ %U https://doi.org/10.2196/25322 %U http://www.ncbi.nlm.nih.gov/pubmed/33587044 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e25499 %T Virtual and Augmented Reality Applications in Medicine: Analysis of the Scientific Literature %A Yeung,Andy Wai Kan %A Tosevska,Anela %A Klager,Elisabeth %A Eibensteiner,Fabian %A Laxar,Daniel %A Stoyanov,Jivko %A Glisic,Marija %A Zeiner,Sebastian %A Kulnik,Stefan Tino %A Crutzen,Rik %A Kimberger,Oliver %A Kletecka-Pulker,Maria %A Atanasov,Atanas G %A Willschke,Harald %+ Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Spitalgasse 23, Vienna, , Austria, 43 664 1929 852, atanas.atanasov@univie.ac.at %K virtual reality %K augmented reality %K mixed reality %K bibliometric %K surgical procedures %K rehabilitation %K neurodegenerative disorder %K pain %K stroke %K medicine %D 2021 %7 10.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) and augmented reality (AR) have recently become popular research themes. However, there are no published bibliometric reports that have analyzed the corresponding scientific literature in relation to the application of these technologies in medicine. Objective: We used a bibliometric approach to identify and analyze the scientific literature on VR and AR research in medicine, revealing the popular research topics, key authors, scientific institutions, countries, and journals. We further aimed to capture and describe the themes and medical conditions most commonly investigated by VR and AR research. Methods: The Web of Science electronic database was searched to identify relevant papers on VR research in medicine. Basic publication and citation data were acquired using the “Analyze” and “Create Citation Report” functions of the database. Complete bibliographic data were exported to VOSviewer and Bibliometrix, dedicated bibliometric software packages, for further analyses. Visualization maps were generated to illustrate the recurring keywords and words mentioned in the titles and abstracts. Results: The analysis was based on data from 8399 papers. Major research themes were diagnostic and surgical procedures, as well as rehabilitation. Commonly studied medical conditions were pain, stroke, anxiety, depression, fear, cancer, and neurodegenerative disorders. Overall, contributions to the literature were globally distributed with heaviest contributions from the United States and United Kingdom. Studies from more clinically related research areas such as surgery, psychology, neurosciences, and rehabilitation had higher average numbers of citations than studies from computer sciences and engineering. Conclusions: The conducted bibliometric analysis unequivocally reveals the versatile emerging applications of VR and AR in medicine. With the further maturation of the technology and improved accessibility in countries where VR and AR research is strong, we expect it to have a marked impact on clinical practice and in the life of patients. %M 33565986 %R 10.2196/25499 %U http://www.jmir.org/2021/2/e25499/ %U https://doi.org/10.2196/25499 %U http://www.ncbi.nlm.nih.gov/pubmed/33565986 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e18161 %T A Virtual Reality Exergame to Engage Adolescents in Physical Activity: Mixed Methods Study Describing the Formative Intervention Development Process %A Farič,Nuša %A Smith,Lee %A Hon,Adrian %A Potts,Henry W W %A Newby,Katie %A Steptoe,Andrew %A Fisher,Abi %+ Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, United Kingdom, 44 207 7679 4466 ext 419, nusa.faric.11@ucl.ac.uk %K adolescent %K adult %K exercise %K leisure activities %K obesity %K sports %K video games %K mobile phone %K virtual reality %K motivation %D 2021 %7 4.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Early adolescence (13-17 years) is a critical developmental stage for physical activity promotion. Virtual reality (VR) exergaming is a promising intervention strategy to engage adolescents in physical activity. Objective: The vEngage project aims to develop a physical activity intervention for adolescents using VR exergaming. Here, we describe the formative intervention development work and process of academic-industry collaboration. Methods: The formative development was guided by the Medical Research Council framework and included recruiting an adolescent user group to provide iterative feedback, a literature review, a quantitative survey of adolescents, qualitative interviews with adolescents and parents, inductive thematic analysis of public reviews of VR exergames, a quantitative survey and qualitative interviews with users of the augmented reality running app Zombies, Run!, and building and testing a prototype with our adolescent user group. Results: VR exergaming was appealing to adolescents and acceptable to parents. We identified behavior change techniques that users would engage with and features that should be incorporated into a VR exergame, including realistic body movements, accurate graphics, stepped levels of gameplay difficulty, new challenges, in-game rewards, multiplayer options, and the potential to link with real-world aspects such as physical activity trackers. We also identified some potential barriers to use, such as cost, perceived discomfort of VR headsets, and motion sickness concerns. A prototype game was developed and user-tested with generally positive feedback. Conclusions: This is the first attempt to develop a VR exergame designed to engage adolescents in physical activity that has been developed within a public health intervention development framework. Our formative work suggests that this is a very promising avenue. The benefit of the design process was the collaborative parallel work between academics and game designers and the involvement of the target population in the game (intervention) design from the outset. Developing the game within an intervention framework allowed us to consider factors, such as parental support, that would be important for future implementation. This study also serves as a call to action for potential collaborators who may wish to join this endeavor for future phases and an example of how academic-industry collaboration can be successful and beneficial. %M 33538697 %R 10.2196/18161 %U http://www.jmir.org/2021/2/e18161/ %U https://doi.org/10.2196/18161 %U http://www.ncbi.nlm.nih.gov/pubmed/33538697 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 2 %P e22406 %T Administering Virtual Reality Therapy to Manage Behavioral and Psychological Symptoms in Patients With Dementia Admitted to an Acute Care Hospital: Results of a Pilot Study %A Appel,Lora %A Kisonas,Erika %A Appel,Eva %A Klein,Jennifer %A Bartlett,Deanna %A Rosenberg,Jarred %A Smith,Christopher NC %+ Faculty of Health, School of Health Policy and Management, York University, 426 Health, Nursing and Environmental Studies Building, 4700 Keele Street, Toronto, ON, M3J 1P3, Canada, 1 6475046537, lora.appel@uhn.ca %K virtual reality %K wearable electronic devices %K sensory art therapies %K hospitalization %K hospitals, community %K hospitals, general %K aged %K humans %K dementia %K behavioral symptoms %K nature %K mobile phone %D 2021 %7 3.2.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: As virtual reality (VR) technologies become increasingly accessible and affordable, clinicians are eager to try VR therapy as a novel means to manage behavioral and psychological symptoms of dementia, which are exacerbated during acute care hospitalization, with the goal of reducing the use of antipsychotics, sedatives, and physical restraints associated with negative adverse effects, increased length of stay, and caregiver burden. To date, no evaluations of immersive VR therapy have been reported for patients with dementia in acute care hospitals. Objective: This study aimed to determine the feasibility (acceptance, comfort, and safety) of using immersive VR therapy for people living with dementia (mild, moderate, and advanced) during acute care hospitalization and explore its potential to manage behavioral and psychological symptoms of dementia. Methods: A prospective, longitudinal pilot study was conducted at a community teaching hospital in Toronto. The study was nonrandomized and unblinded. A total of 10 patients aged >65 years (mean 86.5, SD 5.7) diagnosed with dementia participated in one or more research coordinator–facilitated sessions of viewing immersive 360° VR footage of nature scenes displayed on a Samsung Gear VR head-mounted display. This mixed-methods study included review of patient charts, standardized observations during the intervention, and pre- and postintervention semistructured interviews about the VR experience. Results: All recruited participants (N=10) completed the study. Of the 10 participants, 7 (70%) displayed enjoyment or relaxation during the VR session, which averaged 6 minutes per view, and 1 (10%) experienced dizziness. No interference between the VR equipment and hearing aids or medical devices was reported. Conclusions: It is feasible to expose older people with dementia of various degrees admitted to an acute care hospital to immersive VR therapy. VR therapy was found to be acceptable to and comfortable by most participants. This pilot study provides the basis for conducting the first randomized controlled trial to evaluate the impact of VR therapy on managing behavioral and psychological symptoms of dementia in acute care hospitals. %M 33533720 %R 10.2196/22406 %U https://formative.jmir.org/2021/2/e22406 %U https://doi.org/10.2196/22406 %U http://www.ncbi.nlm.nih.gov/pubmed/33533720 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e18482 %T Virtual Reality Cognitive Training Among Individuals With Alcohol Use Disorder Undergoing Residential Treatment: Pilot Randomized Controlled Trial %A Gamito,Pedro %A Oliveira,Jorge %A Matias,Marcelo %A Cunha,Elsa %A Brito,Rodrigo %A Lopes,Paulo Ferreira %A Deus,Alberto %+ School of Psychology and Life Sciences, Lusófona University, Campo Grande, 376, Lisboa, 1749-024, Portugal, 351 217515500, jorge.oliveira@ulusofona.pt %K alcohol use disorder %K cognitive training %K virtual reality %D 2021 %7 29.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Alcohol use disorder (AUD) has been associated with diverse physical and mental morbidities. Among the main consequences of chronic and excessive alcohol use are cognitive and executive deficits. Some of these deficits may be reversed in specific cognitive and executive domains with behavioral approaches consisting of cognitive training. The advent of computer-based interventions may leverage these improvements, but randomized controlled trials (RCTs) of digital interactive-based interventions are still scarce. Objective: The aim of this study is to explore whether a cognitive training approach using VR exercises based on activities of daily living is feasible for improving the cognitive function of patients with AUD undergoing residential treatment, as well as to estimate the effect size for this intervention to power future definitive RCTs. Methods: This study consisted of a two-arm pilot RCT with a sample of 36 individuals recovering from AUD in a therapeutic community; experimental group participants received a therapist-guided, VR-based cognitive training intervention combined with treatment as usual, and control group participants received treatment as usual without cognitive training. A comprehensive neuropsychological battery of tests was used both at pre- and postassessments, including measurement of global cognition, executive functions, attention, visual memory, and cognitive flexibility. Results: In order to control for potential effects of global cognition and executive functions at baseline, these domains were controlled for in the statistical analysis for each individual outcome. Results indicate intervention effects on attention in two out of five outcomes and on cognitive flexibility in two out of six outcomes, with effect sizes in significant comparisons being larger for attention than for cognitive flexibility. Patient retention in cognitive training was high, in line with previous studies. Conclusions: Overall, the data suggest that VR-based cognitive training results in specific contributions to improving attention ability and cognitive flexibility of patients recovering from AUD. Trial Registration: ClinicalTrials.gov NCT04505345; https://clinicaltrials.gov/show/NCT04505345 %M 33512329 %R 10.2196/18482 %U http://www.jmir.org/2021/1/e18482/ %U https://doi.org/10.2196/18482 %U http://www.ncbi.nlm.nih.gov/pubmed/33512329 %0 Journal Article %@ 2371-4379 %I JMIR Publications %V 6 %N 1 %P e23708 %T Using Virtual Reality to Improve Health Care Providers’ Cultural Self-Efficacy and Diabetes Attitudes: Pilot Questionnaire Study %A Beverly,Elizabeth Ann %A Love,Carrie %A Love,Matthew %A Williams,Eric %A Bowditch,John %+ Department of Primary Care, Heritage College of Osteopathic Medicine, Ohio University, 1 Ohio University, Grosvenor Hall 357, Athens, OH, 45701, United States, 1 17405934616, beverle1@ohio.edu %K virtual reality %K diabetes attitudes %K cultural self-efficacy %K health care providers %K VR %K diabetes %K training %D 2021 %7 27.1.2021 %9 Original Paper %J JMIR Diabetes %G English %X Background: In southeastern Appalachian Ohio, the prevalence of diabetes is 19.9%, nearly double that of the national average of 10.5%. Here, people with diabetes are more likely to have a delayed diagnosis, limited access to health care, and lower health literacy. Despite the high rates of diabetes in the region, the availability of endocrinologists and certified diabetes care and education specialists is limited. Therefore, innovative strategies to address the growing diabetes care demands are needed. One approach is to train the primary care workforce in new and emerging therapies for type 2 diabetes to meet the increasing demands and complexity of diabetes care. Objective: The aim of this study was to assess the effectiveness of a virtual reality training program designed to improve cultural self-efficacy and diabetes attitudes. Methods: Health care providers and administrators were recruited from large health care systems, private practices, university-owned hospitals or clinics, Federally Qualified Health Centers, local health departments, and AmeriCorps. Providers and administrators participated in a 3-hour virtual reality training program consisting of 360-degree videos produced in a professional, cinematic manner; this technique is called virtual reality cinema (cine-VR). Questionnaires measuring cultural self-efficacy, diabetes attitudes, and presence in cine-VR were administered to providers and administrators before and after the program. Results: A total of 69 participants completed the study. The mean age of the sample was 42.2 years (SD 13.7), 86% (59/69) identified as female, 83% (57/69) identified as White, 86% (59/69) identified as providers, and 25% (17/69) identified as nurses. Following the training program, we observed positive improvements in all three of the cultural self-efficacy subscales: Cognitive (mean change –1.29; t65=–9.309; P<.001), Practical (mean change –1.85; t65=–9.319; P<.001), and Affective (mean change –0.75; t65=–7.067; P<.001). We observed the largest magnitude of change with the subscale, with a Cohen d of 1.16 indicating a very large effect. In addition, we observed positive improvements in all five of the diabetes attitude subscales: Need for special training (mean change –0.21; t67=–6.154; P<.001), Seriousness of type 2 diabetes (mean change –0.34; t67=–8.114; P<.001), Value of tight glucose control (mean change –0.13; t67=–3.029; P=.001), Psychosocial impact of diabetes (mean change –0.33; t67=–6.610; P<.001), and Attitude toward patient autonomy (mean change –0.17; t67=–3.889; P<.001). We observed the largest magnitude of change with the Psychosocial impact of diabetes subscale, with a Cohen d of 0.87 indicating a large effect. We observed only one significant correlation between presence in cine-VR (ie, Interface Quality) and a positive change score (ie, Affective self-efficacy) (r=.285; P=.03). Conclusions: Our findings support the notion that cine-VR education is an innovative approach to improve cultural self-efficacy and diabetes attitudes among health care providers and administrators. The long-term impact of cine-VR education on cultural self-efficacy and diabetes attitudes needs to be determined. %M 33502335 %R 10.2196/23708 %U http://diabetes.jmir.org/2021/1/e23708/ %U https://doi.org/10.2196/23708 %U http://www.ncbi.nlm.nih.gov/pubmed/33502335 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e25291 %T Self-Administered Behavioral Skills–Based At-Home Virtual Reality Therapy for Chronic Low Back Pain: Protocol for a Randomized Controlled Trial %A Garcia,Laura M %A Darnall,Beth D %A Krishnamurthy,Parthasarathy %A Mackey,Ian G %A Sackman,Josh %A Louis,Robert G %A Maddox,Todd %A Birckhead,Brandon J %+ Division of Health Services Research, Department of Medicine, Cedars-Sinai Health System, Pacific Theaters Building, Suite 800 116 N. Robertson Blvd., Los Angeles, CA, 90048, United States, 1 818 850 0814, bbirckhead@appliedvr.io %K chronic pain %K virtual reality %K behavioral medicine %K behavioral health %K pain treatment %K randomized controlled trial %D 2021 %7 19.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Chronic pain is one of the most common and debilitating health conditions. Treatments for chronic low back pain typically focus on biomedical treatment approaches. While psychosocial treatments exist, multiple barriers prevent broad access. There is a significant unmet need for integrative, easily accessible, non-opioid solutions for chronic pain. Virtual reality (VR) is an immersive technology allowing innovation in the delivery of behavioral pain treatments. Behavioral skills-based VR is effective at facilitating pain management and reducing pain-related concerns. Continued research on these emerging approaches is needed. Objective: In this randomized controlled trial, we seek to test the efficacy of a self-administered behavioral skills-based VR program as a nonpharmacological home-based pain management treatment for people with chronic low back pain (cLBP). Methods: We will randomize 180 individuals with cLBP to 1 of 2 VR programs: (1) EaseVRx (8-week skills-based VR program); or (2) Sham VR (control condition). All participants will receive a VR headset to minimize any biases related to the technology’s novelty. The Sham VR group had 2D neutral content in a 3D theater-like environment. Our primary outcome is average pain intensity and pain-related interference with activity, stress, mood, and sleep. Our secondary outcomes include patient-reported physical function, sleep disturbance, pain self-efficacy, pain catastrophizing, pain acceptance, health utilization, medication use, and user satisfaction. We hypothesize superiority for the skills-based VR program in all of these measures compared to the control condition. Team statisticians blinded to treatment assignment will assess outcomes up to 6 months posttreatment using an approach suitable for the longitudinal nature of the data. Results: The study was approved by the Western Institutional Review Board on July 2, 2020. The protocol (NCT04415177) was registered on May 27, 2020. Recruitment for this study was completed in July 2020, and data collection will remain active until March 2021. In total, 186 participants were recruited. Multiple manuscripts will be generated from this study. The primary manuscript will be submitted for publication in the winter of 2020. Conclusions: Effectively delivering behavioral treatments in VR could overcome barriers to care and provide scalable solutions to chronic pain’s societal burden. Our study could help shape future research and development of these innovative approaches. Trial Registration: ClinicalTrials.gov NCT04415177; https://clinicaltrials.gov/ct2/show/NCT04415177 International Registered Report Identifier (IRRID): RR1-10.2196/25291 %M 33464215 %R 10.2196/25291 %U https://www.researchprotocols.org/2021/1/e25291 %U https://doi.org/10.2196/25291 %U http://www.ncbi.nlm.nih.gov/pubmed/33464215 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 1 %P e17233 %T Virtual Reality Relaxation for Patients With a Psychiatric Disorder: Crossover Randomized Controlled Trial %A Veling,Wim %A Lestestuiver,Bart %A Jongma,Marieke %A Hoenders,H J Rogier %A van Driel,Catheleine %+ Department of Psychiatry, University Medical Center Groningen, University of Groningen, PO Box 30.001, Groningen, 9700 RB, Netherlands, 31 503612367, w.veling@umcg.nl %K virtual reality %K stress %K relaxation %K negative affect %K positive affect %K depression %K anxiety %K randomized controlled trial %D 2021 %7 15.1.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) relaxation is a promising mental health intervention that may be an effective tool for stress reduction but has hardly been tested in clinical trials with psychiatric patients. We developed an easy-to-use VR self-management relaxation tool (VRelax) with immersive 360° nature videos and interactive animated elements. Objective: To investigate the immediate effects of VR relaxation on negative and positive affective states and short-term effects on perceived stress and symptoms in patients with a psychiatric disorder, compared to standard relaxation exercises. Methods: A randomized crossover trial was conducted in 50 patients receiving ambulatory treatment for anxiety, psychotic, depressive, or bipolar disorder. Participants were randomly assigned to start with VRelax or standard relaxation and used both interventions for 10 days at home. They completed 8 visual analog scales of momentary negative and positive affective states before and after each session. Global perceived stress and psychiatric symptoms were measured before and after both intervention periods. Treatment effects were analyzed with multilevel mixed model regression analyses and 2-way analysis of variance. Results: Both VRelax and standard relaxation exercises led to a statistically significant immediate improvement of all negative and positive affective states. Compared to standard relaxation, VRelax resulted in a significantly greater reduction of total negative affective state (change 16.2% versus 21.2%; t1684=−2.02, 95% CI −18.70 to −0.28; P=.04). Specifically, VRelax had a stronger beneficial effect on momentary anxiety (t1684=−3.24, 95% CI −6.86 to −1.69), sadness (t1684=−2.32, 95% CI −6.51 to −0.55), and cheerfulness (t1684=2.35, 95% CI 0.51 to 5.75). There were no significant differences between short-term effects of the two treatments on global perceived stress and symptoms. Conclusions: If the results of this trial are replicated and extended, VRelax may provide a much-needed, effective, easy-to-use self-management relaxation intervention to enhance psychiatric treatments. Trial Registration: Netherlands Trial Register NTR7294; https://www.trialregister.nl/trial/7096 %M 33448933 %R 10.2196/17233 %U http://www.jmir.org/2021/1/e17233/ %U https://doi.org/10.2196/17233 %U http://www.ncbi.nlm.nih.gov/pubmed/33448933 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e19580 %T Use of Virtual Reality to Assess Dynamic Posturography and Sensory Organization: Instrument Validation Study %A Wittstein,Matthew William %A Crider,Anthony %A Mastrocola,Samantha %A Guerena Gonzalez,Mariana %+ Department of Exercise Science, Elon University, 2525 Campus Box, Elon, NC, 27244, United States, 1 336 278 6693, mwittstein@elon.edu %K postural control %K virtual reality %K sensory organization test %K intraclass correlations %D 2020 %7 16.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The Equitest system (Neurocom) is a computerized dynamic posturography device used by health care providers and clinical researchers to safely test an individual’s postural control. While the Equitest system has evaluative and rehabilitative value, it may be limited owing to its cost, lack of portability, and reliance on only sagittal plane movements. Virtual reality (VR) provides an opportunity to reduce these limitations by providing more mobile and cost-effective tools while also observing a wider array of postural characteristics. Objective: This study aimed to test the plausibility of using VR as a feasible alternative to the Equitest system for conducting a sensory organization test. Methods: A convenience sample of 20 college-aged healthy individuals participated in the study. Participants completed the sensory organization test using the Equitest system as well as using a VR environment while standing atop a force plate (Bertec Inc). The Equitest system measures the equilibrium index. During VR trials, the estimated equilibrium index, 95% ellipse area, path length, and anterior-posterior detrended fluctuation analysis scaling exponent alpha were calculated from center of pressure data. Pearson correlation coefficients were used to assess the relationship between the equilibrium index and center of pressure–derived balance measures. Intraclass correlations for absolute agreement and consistency were calculated to compare the equilibrium index and estimated equilibrium index. Results: Intraclass correlations demonstrated moderate consistency and absolute agreement (0.5 < intraclass correlation coefficient < 0.75) between the equilibrium index and estimated equilibrium index from the Equitest and VR sensory organization test (SOT), respectively, in four of six tested conditions. Additionally, weak to moderate correlations between force plate measurements and the equilibrium index were noted in several of the conditions. Conclusions: This research demonstrated the plausibility of using VR as an alternative method to conduct the SOT. Ongoing development and testing of virtual environments are necessary before employing the technology as a replacement to current clinical tests. %M 33325830 %R 10.2196/19580 %U http://games.jmir.org/2020/4/e19580/ %U https://doi.org/10.2196/19580 %U http://www.ncbi.nlm.nih.gov/pubmed/33325830 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e20691 %T Acceptance of a Virtual Reality Headset Designed for Fall Prevention in Older Adults: Questionnaire Study %A Mascret,Nicolas %A Delbes,Lisa %A Voron,Amélie %A Temprado,Jean-Jacques %A Montagne,Gilles %+ Aix Marseille Univ, CNRS, ISM, 163 avenue de Luminy, case 910, Marseille, 13288 cedex 9, France, 33 618022983, nicolas.mascret@univ-amu.fr %K technology acceptance model %K acceptability %K acceptance %K virtual reality %K elderly %K fall %K eHealth %K self-efficacy %K achievement goals %D 2020 %7 14.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Falls are a common phenomenon among people aged 65 and older and affect older adults’ health, quality of life, and autonomy. Technology-based intervention programs are designed to prevent the occurrence of falls and their effectiveness often surpasses that of more conventional programs. However, to be effective, these programs must first be accepted by seniors. Objective: Based on the technology acceptance model, this study aimed to examine the acceptance among older adults before a first use of a virtual reality headset (VRH) used in an intervention program designed to prevent falls. Methods: A sample of 271 French older adults (mean age 73.69 years, SD 6.37 years) voluntarily and anonymously filled out a questionnaire containing the focal constructs (perceived usefulness, perceived enjoyment, perceived ease of use, intention to use, fall-related self-efficacy, and self-avoidance goals) adapted to the VRH, which was designed to prevent falls. Results: The results of the structural equation modeling analysis showed that intention to use the VRH was positively predicted by perceived usefulness, perceived enjoyment, and perceived ease of use. Perceived usefulness of the VRH was also negatively predicted by fall-related self-efficacy (ie, the perceived level of confidence of an individual when performing daily activities without falling) and positively predicted by self-avoidance goals (ie, participating in a physical activity to avoid physical regression). Conclusions: A better understanding of the initial acceptance among older adults of this VRH is the first step to involving older adults in intervention programs designed to prevent falls using this kind of device. %M 33315019 %R 10.2196/20691 %U http://www.jmir.org/2020/12/e20691/ %U https://doi.org/10.2196/20691 %U http://www.ncbi.nlm.nih.gov/pubmed/33315019 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e18473 %T Choice of Leisure Activities by Adolescents and Adults With Internet Gaming Disorder: Development and Feasibility Study of a Virtual Reality Program %A Lee,Narae %A Kim,Jae-Jin %A Shin,Yu-Bin %A Eom,Hyojung %A Kim,Min-Kyeong %A Kyeong,Sunghyon %A Jung,Young Hoon %A Min,Sarang %A Kwon,Joon Hee %A Kim,Eunjoo %+ Department of Psychiatry, Yonsei University Gangnam Severance Hospital, Eonju-ro 211, Gangnam-gu, Seoul, 06273, Republic of Korea, 82 2 2019 3345, ejkim96@yuhs.ac %K virtual reality %K VR %K internet game disorder %K IGD %K cognitive behavioral therapy %K CBT %K motivation %D 2020 %7 11.12.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Excessive internet game use frequently leads to various physical, psychological, and social problems, and internet gaming disorder (IGD) has become a serious public health issue worldwide. Recently, virtual reality (VR) therapy has emerged as a promising method to increase psychological treatment motivation and accessibility. However, few studies have examined the potential of VR technology for the management of IGD, and VR content tailored to IGD characteristics remains scarce. Objective: This preliminary study aimed to examine the potential of a VR-based program that was designed to help users identify their leisure time use patterns, especially those related to gaming, and to modify their gaming overuse by alternative activities provided in the VR content. Moreover, to investigate whether users’ VR activities reflect various clinical variables of IGD in youth, we examined the relationships among the leisure time activity selection pattern, built-in response, and speech data obtained from the VR program, as well as symptom severity of internet gaming, psychiatric comorbidities, and motivation of participants reported through relevant questionnaire data. Methods: Three types of VR content (understanding my daily activities at home, finding an alternative activity to internet gaming at home, expressing contradictory opinions toward a friend’s gaming beliefs) were developed by simulating the daily situations in which patients with IGD can select alternative free-time leisure activities. We examined internet addiction, mental health problems, and motivation for 23 IGD and 29 control participants. Behavioral and self-rated responses from VR, such as alternative activity selection data and speech patterns (speech time, speech satisfaction, and speech accordance), and results from various questionnaires were compared between groups. The correlations between IGD behaviors in VR and real-life behaviors assessed by questionnaire measures were analyzed. Results: Significant correlations were found between internet gaming behavior and user activity data, such as speech and activity selection pattern, in our VR program. Our results showed that the IGD group had fewer leisure activities and preferred game or digital activities to other types of activities compared to controls, even in VR. There was a positive relationship between the viability of alternative leisure activities the participants selected in VR and the amount of perceived satisfaction from that activity (r=.748, P<.001). Speech accordance in the IGD group was lower than in the control group and was correlated negatively with Internet Addiction Test and Internet Addiction Test–gaming scores (r=.300, P=.03) but positively with users’ motivation (r=.312, P=.02). Conclusions: The results from our VR program can provide information about daily activity patterns of youths with IGD and the relationship between user VR activities and IGD symptoms, which can be useful in applying VR technology to IGD management. %M 33306033 %R 10.2196/18473 %U http://games.jmir.org/2020/4/e18473/ %U https://doi.org/10.2196/18473 %U http://www.ncbi.nlm.nih.gov/pubmed/33306033 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 12 %P e21576 %T The Use of Virtual Reality Technologies in the Treatment of Duchenne Muscular Dystrophy: Systematic Review %A Baeza-Barragán,Maria Rosa %A Labajos Manzanares,Maria Teresa %A Ruiz Vergara,Carmen %A Casuso-Holgado,María Jesús %A Martín-Valero,Rocío %+ Department of Physiotherapy, Faculty of Health Sciences, University of Malaga, Arquitecto Francisco Peñalosa 3, Ampliación de Campus de Teatinos, Malaga, 29071, Spain, 34 951 95 28 58, rovalemas@gmail.com %K Duchenne muscular dystrophy %K virtual reality %K upper limb %K physical therapy %K muscular dystrophy %K mutation %K muscle %K degeneration %D 2020 %7 8.12.2020 %9 Review %J JMIR Mhealth Uhealth %G English %X Background: Duchenne muscular dystrophy is a serious and progressive disease affecting one in 3500-6000 live male births. The use of new virtual reality technologies has revolutionized the world of youth rehabilitation. Objective: We performed a systematic review to study the effectiveness of the use of virtual reality systems applied in the rehabilitation of the upper limbs of individuals with Duchenne muscular dystrophy. Methods: Between June 2018 and September 2019, we carried out a series of searches in 5 scientific databases: (1) PubMed, (2) Web of Science, (3) Scopus, (4) The Cochrane Library, and (5) MEDLINE via EBSCO. Two evaluators independently conducted the searches following the PRISMA recommendations for systematic reviews for articles. Two independent evaluators collated the results. Article quality was determined using the PEDro scale. Results: A total of 7 clinical trials were included in the final review. These studies used new technologies as tools for physiotherapeutic rehabilitation of the upper limbs of patients with Duchenne muscular dystrophy. Collectively, the studies showed improvement in functionality, quality of life, and motivation with the use of virtual reality technologies in the rehabilitation of upper limbs of individuals with Duchenne muscular dystrophy. Conclusions: The treatment of neuromuscular diseases has changed in recent years, from palliative symptom management to preventive methods for capacity building. The use of virtual reality is beginning to be necessary in the treatment of progressive diseases involving movement difficulties, as it provides freedom and facilitates the improvement of results in capacity training. Given that new technologies are increasingly accessible, rehabilitation and physiotherapy programs can use these technologies more frequently, and virtual reality environments can be used to improve task performance, which is essential for people with disabilities. Ultimately, virtual reality can be a great tool for physiotherapy and can be used for Duchenne muscular dystrophy rehabilitation programs to improve patient performance during training. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42018102548; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=102548 %M 33289679 %R 10.2196/21576 %U http://mhealth.jmir.org/2020/12/e21576/ %U https://doi.org/10.2196/21576 %U http://www.ncbi.nlm.nih.gov/pubmed/33289679 %0 Journal Article %@ 2561-1011 %I JMIR Publications %V 4 %N 1 %P e20633 %T A Novel Virtual Reality Medical Image Display System for Group Discussions of Congenital Heart Disease: Development and Usability Testing %A Kim,Byeol %A Loke,Yue-Hin %A Mass,Paige %A Irwin,Matthew R %A Capeland,Conrad %A Olivieri,Laura %A Krieger,Axel %+ University of Maryland, 2181 Glenn L Martin Hall, University of Maryland, College Park, MD, 20742, United States, 1 516 428 3217, star@umd.edu %K virtual reality %K cardiac diagnostics %K usability study %K congenital heart disease %K group collaboration %D 2020 %7 8.12.2020 %9 Original Paper %J JMIR Cardio %G English %X Background: The complex 3-dimensional (3D) nature of anatomical abnormalities in congenital heart disease (CHD) necessitates multidisciplinary group discussions centered around the review of medical images such as magnetic resonance imaging. Currently, group viewings of medical images are constrained to 2-dimensional (2D) cross-sectional displays of 3D scans. However, 2D display methods could introduce additional challenges since they require physicians to accurately reconstruct the images mentally into 3D anatomies for diagnosis, staging, and planning of surgery or other therapies. Virtual reality (VR) software may enhance diagnosis and care of CHD via 3D visualization of medical images. Yet, present-day VR developments for medicine lack the emphasis on multiuser collaborative environments, and the effect of displays and level of immersion for diagnosing CHDs have not been studied. Objective: The objective of the study was to evaluate and compare the diagnostic accuracies and preferences of various display systems, including the conventional 2D display and a novel group VR software, in group discussions of CHD. Methods: A total of 22 medical trainees consisting of 1 first-year, 10 second-year, 4 third-year, and 1 fourth-year residents and 6 medical students, who volunteered for the study, were formed into groups of 4 to 5 participants. Each group discussed three diagnostic cases of CHD with varying structural complexity using conventional 2D display and group VR software. A group VR software, Cardiac Review 3D, was developed by our team using the Unity engine. By using different display hardware, VR was classified into nonimmersive and full-immersive settings. The discussion time, diagnostic accuracy score, and peer assessment were collected to capture the group and individual diagnostic performances. The diagnostic accuracies for each participant were scored by two experienced cardiologists following a predetermined answer rubric. At the end of the study, all participants were provided a survey to rank their preferences of the display systems for performing group medical discussions. Results: Diagnostic accuracies were highest when groups used the full-immersive VR compared with the conventional and nonimmersive VR (χ22=9.0, P=.01) displays. Differences between the display systems were more prominent with increasing case complexity (χ22=14.1, P<.001) where full-immersive VR had accuracy scores that were 54.49% and 146.82% higher than conventional and nonimmersive VR, respectively. The diagnostic accuracies provided by the two cardiologists for each participant did not statistically differ from each other (t=–1.01, P=.31). The full-immersive VR was ranked as the most preferred display for performing group CHD discussions by 68% of the participants. Conclusions: The most preferred display system among medical trainees for visualizing medical images during group diagnostic discussions is full-immersive VR, with a trend toward improved diagnostic accuracy in complex anatomical abnormalities. Immersion is a crucial feature of displays of medical images for diagnostic accuracy in collaborative discussions. %M 33289675 %R 10.2196/20633 %U http://cardio.jmir.org/2020/1/e20633/ %U https://doi.org/10.2196/20633 %U http://www.ncbi.nlm.nih.gov/pubmed/33289675 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 7 %N 2 %P e22620 %T Virtual Reality in Pain Rehabilitation for Youth With Chronic Pain: Pilot Feasibility Study %A Griffin,Anya %A Wilson,Luke %A Feinstein,Amanda B %A Bortz,Adeline %A Heirich,Marissa S %A Gilkerson,Rachel %A Wagner,Jenny FM %A Menendez,Maria %A Caruso,Thomas J %A Rodriguez,Samuel %A Naidu,Srinivas %A Golianu,Brenda %A Simons,Laura E %+ Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, 300 N Pasteur Dr, Stanford, CA, 94305, United States, 1 650 736 3656, anyag@stanford.edu %K digital health care %K virtual reality %K immersive technology %K chronic pain management %K adolescents %D 2020 %7 23.11.2020 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: In the field of pain, virtual reality (VR) technology has been increasingly common in the context of procedural pain management. As an interactive technology tool, VR has the potential to be extended beyond acute pain management to chronic pain rehabilitation with a focus on increasing engagement with painful or avoided movements. Objective: We outline the development and initial implementation of a VR program in pain rehabilitation intervention to enhance function in youth with chronic pain. Methods: We present the development, acceptability, feasibility, and utility of an innovative VR program (Fruity Feet) for pediatric pain rehabilitation to facilitate increased upper and lower extremity engagement. The development team was an interdisciplinary group of pediatric experts, including physical therapists, occupational therapists, pain psychologists, anesthesiologists, pain researchers, and a VR software developer. We used a 4-phase iterative development process that engaged clinicians, parents, and patients via interviews and standardized questionnaires. Results: This study included 17 pediatric patients (13 female, 4 male) enrolled in an intensive interdisciplinary pain treatment (IIPT) program, with mean age of 13.24 (range 7-17) years, completing a total of 63 VR sessions. Overall reports of presence were high (mean 28.98; max 40; SD 4.02), suggestive of a high level of immersion. Among those with multisession data (n=8), reports of pain (P<.001), fear (P=.003), avoidance (P=.004), and functional limitations (P=.01) significantly decreased. Qualitative analysis revealed (1) a positive experience with VR (eg, enjoyed VR, would like to utilize the VR program again, felt VR was a helpful tool); (2) feeling distracted from pain while engaged in VR; (3) greater perceived mobility; and (4) fewer clinician-observed pain behaviors during VR. Movement data support the targeted impact of the Fruity Feet compared to other available VR programs. Conclusions: The iterative development process yielded a highly engaging and feasible VR program based on qualitative feedback, questionnaires, and movement data. We discuss next steps for the refinement, implementation, and assessment of impact of VR on chronic pain rehabilitation. VR holds great promise as a tool to facilitate therapeutic gains in chronic pain rehabilitation in a manner that is highly reinforcing and fun. %M 33226346 %R 10.2196/22620 %U http://rehab.jmir.org/2020/2/e22620/ %U https://doi.org/10.2196/22620 %U http://www.ncbi.nlm.nih.gov/pubmed/33226346 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 11 %P e24331 %T Virtual Reality Behavioral Activation as an Intervention for Major Depressive Disorder: Case Report %A Paul,Margot %A Bullock,Kim %A Bailenson,Jeremy %+ PGSP-Stanford PsyD Consortium, 1791 Arastradero Rd, Palo Alto, CA, 94304, United States, 1 781 572 4136, mdpaul@stanford.edu %K virtual reality %K case report %K major depressive disorder %K behavioral activation %K VR %K depression %K COVID-19 %K behavior %K intervention %K feasibility %K acceptability %K telehealth %K pilot study %D 2020 %7 3.11.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Major depressive disorder (MDD) is a global problem with an increasing incidence and prevalence. There has additionally been an increase in depression due to the COVID-19 pandemic. Behavioral activation is considered an evidence-based treatment for MDD. However, there are many barriers that could hinder one’s ability to engage in behavioral activation, with COVID-19 “shelter-in-place” and social distancing orders being current and large impediments. Virtual reality (VR) has been successfully used to help treat a variety of mental health conditions, but it has not yet been used as a method of administering behavioral activation to a clinical population. Using VR to engage in behavioral activation could eliminate barriers that pandemic precautions place and help decrease symptoms of depression that are especially exacerbated in these times. Objective: The following case report examines the feasibility, acceptability, and tolerability of VR behavioral activation for an adult with MDD during a global pandemic. This participant was part of a larger pilot study, and the case serves as a description of the VR intervention. Methods: The participant engaged in a weekly 50-minute psychotherapy Zoom session for 4 weeks, in which a modified behavioral activation protocol was administered using a VR headset to simulate activities. Data on mood ratings, homework compliance, and headset use were obtained from the headset. Acceptability, tolerability, and depression symptoms were obtained using self-report rating scales. Results: The intervention was feasible, acceptable, and tolerable, as reported by this participant. The participant’s depressive symptoms decreased by five-points on the Patient Health Questionnaire-9 over a month, with a beginning score of 10 (moderate depression) and a final score of 5 (mild depression). Conclusions: The implications of these findings for future research are discussed. Trial Registration: ClinicalTrials.gov NCT04268316; http://clinicaltrials.gov/ct2/show/NCT04268316 %M 33031046 %R 10.2196/24331 %U https://mental.jmir.org/2020/11/e24331 %U https://doi.org/10.2196/24331 %U http://www.ncbi.nlm.nih.gov/pubmed/33031046 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e17980 %T The Effectiveness of Virtual Reality in Managing Acute Pain and Anxiety for Medical Inpatients: Systematic Review %A Smith,Vinayak %A Warty,Ritesh Rikain %A Sursas,Joel Arun %A Payne,Olivia %A Nair,Amrish %A Krishnan,Sathya %A da Silva Costa,Fabricio %A Wallace,Euan Morrison %A Vollenhoven,Beverley %+ Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Road, Clayton, Australia, 61 431330754, vinayak.smith@monash.edu %K virtual reality %K VR %K pain management %K anxiety %K procedural pain %K wound management %K acute pain %K analgesia %K pain %D 2020 %7 2.11.2020 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality is increasingly being utilized by clinicians to facilitate analgesia and anxiolysis within an inpatient setting. There is however, a lack of a clinically relevant review to guide its use for this purpose. Objective: To systematically review the current evidence for the efficacy of virtual reality as an analgesic in the management of acute pain and anxiolysis in an inpatient setting. Methods: A comprehensive search was conducted up to and including January 2019 on PubMed, Ovid Medline, EMBASE, and Cochrane Database of Systematic reviews according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search terms included virtual reality, vr, and pain. Primary articles with a focus on acute pain in the clinical setting were considered for the review. Primary outcome measures included degree of analgesia afforded by virtual reality therapy, degree of anxiolysis afforded by virtual reality therapy, effect of virtual reality on physiological parameters, side effects precipitated by virtual reality, virtual reality content type, and type of equipment utilized. Results: Eighteen studies were deemed eligible for inclusion in this systematic review; 67% (12/18) of studies demonstrated significant reductions in pain with the utilization of virtual reality; 44% (8/18) of studies assessed the effects of virtual reality on procedural anxiety, with 50% (4/8) of these demonstrating significant reductions; 28% (5/18) of studies screened for side effects with incidence rates of 0.5% to 8%; 39% (7/18) of studies evaluated the effects of virtual reality on autonomic arousal as a biomarker of pain, with 29% (2/7) demonstrating significant changes; 100% (18/18) of studies utilized a head mounted display to deliver virtual reality therapy, with 50% being in active form (participants interacting with the environment) and 50% being in passive form (participants observing the content only). Conclusions: Available evidence suggests that virtual reality therapy can be applied to facilitate analgesia for acute pain in a variety of inpatient settings. Its effects, however, are likely to vary by patient population and indication. This highlights the need for individualized pilot testing of virtual reality therapy’s effects for each specific clinical use case rather than generalizing its use for the broad indication of facilitating analgesia. In addition, virtual reality therapy has the added potential of concurrently providing procedural anxiolysis, thereby improving patient experience and cooperation, while being associated with a low incidence of side effects (nausea, vomiting, eye strain, and dizziness). Furthermore, findings indicated a head mounted display should be utilized to deliver virtual reality therapy in a clinical setting with a slight preference for active over passive virtual reality for analgesia. There, however, appears to be insufficient evidence to substantiate the effect of virtual reality on autonomic arousal, and this should be considered at best to be for investigational uses, at present. %M 33136055 %R 10.2196/17980 %U https://www.jmir.org/2020/11/e17980 %U https://doi.org/10.2196/17980 %U http://www.ncbi.nlm.nih.gov/pubmed/33136055 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 11 %P e19002 %T Effects of a Combination of Three-Dimensional Virtual Reality and Hands-on Horticultural Therapy on Institutionalized Older Adults’ Physical and Mental Health: Quasi-Experimental Design %A Lin,Tsung-Yi %A Huang,Chiu-Mieh %A Hsu,Hsiao-Pei %A Liao,Jung-Yu %A Cheng,Vivian Ya-Wen %A Wang,Shih-Wen %A Guo,Jong-Long %+ Department of Health Promotion and Health Education, College of Education, National Taiwan Normal University, No.162, Sec. 1, He-ping East Road, Taipei, 10610, Taiwan, 886 77493705, jonglong@ntnu.edu.tw %K horticultural therapy %K 3D VR %K older adults %K long-term care facility %K mental health %D 2020 %7 2.11.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Institutionalized older adults have limited ability to engage in horticultural activities that can improve their physical and mental health. Objective: This study explored the effects of a combination of 3D virtual reality and horticultural therapy on institutionalized older adults’ physical and mental health. Methods: The study used a quasi-experimental design. A total of 106 older adults from 2 long-term care facilities were recruited and assigned to the experimental (n=59) or control (n=47) group. The experimental participants received a 9-week intervention. Both groups completed 3 assessments: at baseline, after the intervention, and 2 months later. The outcome variables included health status, meaning in life, perceived mattering, loneliness, and depression. Results: The experimental group demonstrated significantly improved health status (P<.001), meaning in life (P<.001), and perceived mattering (P<.001) as well as significantly reduced depression (P<.001) and loneliness (P<.001) compared to the control group immediately after the intervention; these effects persisted for up to 2 months. Conclusions: This study verified the beneficial effects of a combination of 3D virtual reality and hands-on horticultural therapy on older adults’ health. These results could support the future successful implementation of similar programs for institutionalized older adults on a larger scale. %M 33135666 %R 10.2196/19002 %U https://www.jmir.org/2020/11/e19002 %U https://doi.org/10.2196/19002 %U http://www.ncbi.nlm.nih.gov/pubmed/33135666 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 10 %P e20620 %T Virtual Reality–Based Treatment for Military Members and Veterans With Combat-Related Posttraumatic Stress Disorder: Protocol for a Multimodular Motion-Assisted Memory Desensitization and Reconsolidation Randomized Controlled Trial %A Jones,Chelsea %A Smith-MacDonald,Lorraine %A Miguel-Cruz,Antonio %A Pike,Ashley %A van Gelderen,Marieke %A Lentz,Liana %A Shiu,Maria Y %A Tang,Emily %A Sawalha,Jeffrey %A Greenshaw,Andrew %A Rhind,Shawn G %A Fang,Xin %A Norbash,Adrian %A Jetly,Rakesh %A Vermetten,Eric %A Brémault-Phillips,Suzette %+ Heroes in Mind, Advocacy and Research Consortium, Faculty of Rehabilitation, University of Alberta, 1-94 Corbett Hall, 8205-114 Street, Edmonton, AB, T6G 2G4, Canada, 1 780 492 0404, cweiman@ualberta.ca %K 3MDR %K posttraumatic stress disorder %K military %K veteran %K psychotherapy %K virtual reality %D 2020 %7 29.10.2020 %9 Protocol %J JMIR Res Protoc %G English %X Background: Military members are at elevated risk of operational stress injuries, including posttraumatic stress disorder (PTSD) and moral injury. Although psychotherapy can reduce symptoms, some military members may experience treatment-resistant PTSD. Multimodular motion-assisted memory desensitization and reconsolidation (3MDR) has been introduced as a virtual reality (VR) intervention for military members with PTSD related to military service. The 3MDR intervention incorporates exposure therapy, psychotherapy, eye movement desensitization and reconsolidation, VR, supportive counselling, and treadmill walking. Objective: The objective of this study is to investigate whether 3MDR reduces PTSD symptoms among military members with combat-related treatment-resistant PTSD (TR-PTSD); examine the technology acceptance and usability of the Computer Assisted Rehabilitation ENvironment (CAREN) and 3MDR interventions by Canadian Armed Forces service members (CAF-SMs), veterans, 3MDR clinicians, and operators; and evaluate the impact on clinicians and operators of delivering 3MDR. Methods: This is a mixed-methods waitlist controlled crossover design randomized controlled trial. Participants include both CAF-SMs and veterans (N=40) aged 18-60 years with combat-related TR-PTSD (unsuccessful experience of at least 2 evidence-based trauma treatments). Participants will also include clinicians and operators (N=12) who have been trained in 3MDR and subsequently utilized this intervention with patients. CAF-SMs and veterans will receive 6 weekly 90-minute 3MDR sessions. Quantitative and qualitative data will be collected at baseline and at 1, 3, and 6 months postintervention. Quantitative data collection will include multiomic biomarkers (ie, blood and salivary proteomic and genomic profiles of neuroendocrine, immune-inflammatory mediators, and microRNA), eye tracking, electroencephalography, and physiological data. Data from outcome measures will capture self-reported symptoms of PTSD, moral injury, resilience, and technology acceptance and usability. Qualitative data will be collected from audiovisual recordings of 3MDR sessions and semistructured interviews. Data analysis will include univariate and multivariate approaches, and thematic analysis of treatment sessions and interviews. Machine learning analysis will be included to develop models for the prediction of diagnosis, symptom severity, and treatment outcomes. Results: This study commenced in April 2019 and is planned to conclude in April 2021. Study results will guide the further evolution and utilization of 3MDR for military members with TR-PTSD and will have utility in treating other trauma-affected populations. Conclusions: The goal of this study is to utilize qualitative and quantitative primary and secondary outcomes to provide evidence for the effectiveness and feasibility of 3MDR for treating CAF-SMs and veterans with combat-related TR-PTSD. The results will inform a full-scale clinical trial and stimulate development and adaptation of the protocol to mobile VR apps in supervised clinical settings. This study will add to knowledge of the clinical effectiveness of 3MDR, and provide the first comprehensive analysis of biomarkers, technology acceptance and usability, moral injury, resilience, and the experience of clinicians and operators delivering 3MDR. Trial Registration: ISRCTN Registry 11264368; http://www.isrctn.com/ISRCTN11264368. International Registered Report Identifier (IRRID): DERR1-10.2196/20620 %M 33118957 %R 10.2196/20620 %U http://www.researchprotocols.org/2020/10/e20620/ %U https://doi.org/10.2196/20620 %U http://www.ncbi.nlm.nih.gov/pubmed/33118957 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e18153 %T A Primer on Usability Assessment Approaches for Health-Related Applications of Virtual Reality %A Zhang,Timothy %A Booth,Richard %A Jean-Louis,Royce %A Chan,Ryan %A Yeung,Anthony %A Gratzer,David %A Strudwick,Gillian %+ Centre for Addiction and Mental Health, Bell Gateway Building, Room 7343, 1001 Queen St W, Toronto, ON, M6J 1H4, Canada, 1 4165358501 ext 39333, gillian.strudwick@camh.ca %K virtual reality %K simulated environment %K usability %K evaluation %K assessment methods %K medical informatics %K nursing informatics %D 2020 %7 28.10.2020 %9 Viewpoint %J JMIR Serious Games %G English %X Health-related virtual reality (VR) applications for patient treatment, rehabilitation, and medical professional training are on the rise. However, there is little guidance on how to select and perform usability evaluations for VR health interventions compared to the supports that exist for other digital health technologies. The purpose of this viewpoint paper is to present an introductory summary of various usability testing approaches or methods that can be used for VR applications. Along with an overview of each, a list of resources is provided for readers to obtain additionally relevant information. Six categories of VR usability evaluations are described using a previously developed classification taxonomy specific to VR environments: (1) cognitive or task walkthrough, (2) graphical evaluation, (3) post hoc questionnaires or interviews, (4) physical performance evaluation, (5) user interface evaluation, and (6) heuristic evaluation. Given the growth of VR in health care, rigorous evaluation and usability testing is crucial in the development and implementation of novel VR interventions. The approaches outlined in this paper provide a starting point for conducting usability assessments for health-related VR applications; however, there is a need to also move beyond these to adopt those from the gaming industry, where assessments for both usability and user experience are routinely conducted. %M 33112243 %R 10.2196/18153 %U http://games.jmir.org/2020/4/e18153/ %U https://doi.org/10.2196/18153 %U http://www.ncbi.nlm.nih.gov/pubmed/33112243 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e16693 %T Effects of Virtual Reality and Non–Virtual Reality Exercises on the Exercise Capacity and Concentration of Users in a Ski Exergame: Comparative Study %A Ko,Junho %A Jang,Seong-Wook %A Lee,Hyo Taek %A Yun,Han-Kyung %A Kim,Yoon Sang %+ BioComputing Lab, Institute for Bio-engineering Application Technology, School of Computer Science and Engineering, Korea University of Technology and Education, 1600, Chungjeol-ro, Byeongcheon-myeon, Dongnam-gu, Cheonan-si, 31253, Republic of Korea, 82 24273295, yoonsang@koreatech.ac.kr %K exergame %K virtual reality %K VR content %K ski simulation %D 2020 %7 28.10.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Recently, ski exergames have been gaining popularity due to the growing interest in health improvement. Conventional studies evaluating the effects of ski exergames only considered exercise capacity and overlooked concentration. Ski exergames consist of a motion platform for exercise and virtual reality (VR) content in the game. The VR content enhances the exercise capacity and concentration of the user by providing a challenging goal. Objective: The aim of this study is to evaluate the effects of VR and non-VR exercises on the exercise capacity and concentration of users in a ski exergame. Methods: To examine the effects of the VR content in ski exergames, we performed 2 experiments, non-VR exercise and VR exercise, where participants exercised on the motion platform. If a user performs an exercise without using any VR content, it is a non-VR exercise. Contrastingly, in the case of VR exercise, a user exercises according to the VR content (a downhill scenario). In addition to the range of motion (ROM) of the ankle and rated perceived exertion (RPE) to assess exercise capacity, we used electroencephalography (EEG) to assess users’ concentration. Results: We evaluated the effects of the VR content by comparing the results obtained from VR and non-VR exercises. The ROM of the ankle with VR exercise was wider than that with non-VR exercise. Specifically, ROM of the ankle was 115.71° (SD 17.71°) and 78.50° (SD 20.43°) in VR exercise and non-VR exercise, respectively. The RPE difference between the 2 exercises was not statistically significant. The result of the sensorimotor rhythm waves (which are concentration-related EEG signals) was more favorable for VR exercise than non-VR exercise. The ratios of sensorimotor rhythm wave in EEG were 3.08% and 2.70% in the VR exercise and non-VR exercise, respectively. Conclusions: According to the results of this experiment, higher exercise capability and concentration were achieved with the VR exercise compared with non-VR exercise. The observations confirm that VR content can enhance both exercise capability and concentration of the user. Thus, the ski exergames can be used effectively by those who, in general, do not like exercise but enjoy games. %M 33112240 %R 10.2196/16693 %U https://games.jmir.org/2020/4/e16693 %U https://doi.org/10.2196/16693 %U http://www.ncbi.nlm.nih.gov/pubmed/33112240 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e19840 %T Exergaming With Beat Saber: An Investigation of Virtual Reality Aftereffects %A Szpak,Ancret %A Michalski,Stefan Carlo %A Loetscher,Tobias %+ University of South Australia, St Bernards Road, Magill, South Australia, Adelaide, 5072, Australia, 61 08 8302 ext 4336, ancret.szpak@unisa.edu.au %K virtual reality %K motion sickness %K exercise %K sedentary behavior %K depth perception %D 2020 %7 23.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) exergaming has the potential to target sedentary behavior. Immersive environments can distract users from the physical exertion of exercise and can motivate them to continue exergaming. Despite the recent surge in VR popularity, numerous users still experience VR sickness from using head-mounted displays (HMDs). Apart from the commonly assessed self-reported symptoms, depth perception and cognition may also be affected. Considering the potential benefits of VR exergaming, it is crucial to identify the adverse effects limiting its potential and continued uptake. Objective: This study aims to investigate the consequences of playing one of the most popular VR exergames for 10 and 50 min on aspects of vision, cognition, and self-reported VR sickness. Methods: A total of 36 participants played an exergame, called Beat Saber, using an HMD. A repeated measures within-subject design was conducted to assess changes in vision, cognition, and well-being after short (10 min) and long (50 min) durations of VR exposure. We measured accommodation, convergence, decision speed, movement speed, and self-reported sickness at 3 test periods—before VR, immediately after VR, and 40 min after VR (late). Results: Beat Saber was well tolerated, as there were no dropouts due to sickness. For most participants, any immediate aftereffects were short-lived and returned to baseline levels after 40 min of exiting VR. For both short and long exposures, there were changes in accommodation (F1,35=8.424; P=.006) and convergence (F1,35=7.826; P=.008); however, in the late test period, participants returned to baseline levels. Measures on cognition revealed no concern. The total simulator sickness questionnaire (SSQ) scores increased immediately after VR (F1,35=26.515; P<.001) and were significantly higher for long compared with short exposures (t35=2.807; P=.03), but there were no differences in exposure duration in the late test period, with scores returning to baseline levels. Although at a group level, participants’ sickness levels returned to baseline 40 min after VR exposure, approximately 14% of the participants still reported high levels of sickness in the late test period after playing 50 min of Beat Saber. We also showed that the participants who experienced a high level of sickness after a short exposure were almost certain to experience a high level of symptoms after a longer exposure. Conclusions: Irrespective of the duration of exposure, this study found no strong evidence for adverse symptoms 40 min after exiting VR; however, some individuals still reported high levels of VR sickness at this stage. We recommend that users commit to a waiting period after exiting VR to ensure that any aftereffects have deteriorated. Exergames in HMDs have the potential to encourage people to exercise but are understudied, and the aftereffects of exergaming need to be closely monitored to ensure that VR exergames can reach their full potential. %M 33095182 %R 10.2196/19840 %U http://www.jmir.org/2020/10/e19840/ %U https://doi.org/10.2196/19840 %U http://www.ncbi.nlm.nih.gov/pubmed/33095182 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 4 %P e18455 %T Effect of Spatial Disorientation in a Virtual Environment on Gait and Vital Features in Patients with Dementia: Pilot Single-Blind Randomized Control Trial %A Amaefule,Chimezie O %A Lüdtke,Stefan %A Kirste,Thomas %A Teipel,Stefan J %+ German Center for Neurodegenerative Diseases (DZNE), Gehlsheimer Strasse 20, Rostock, 18147, Germany, 49 381 494 9478, chimezie.amaefule@dzne.de %K spatial disorientation %K activity recognition %K wayfinding %K wearable sensors %K dementia %K virtual reality %K older adults %D 2020 %7 8.10.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Orientation deficits are among the most devastating consequences of early dementia. Digital navigation devices could overcome these deficits if adaptable to the user’s needs (ie, provide situation-aware, proactive navigation assistance). To fulfill this task, systems need to automatically detect spatial disorientation from sensors in real time. Ideally, this would require field studies consisting of real-world navigation. However, such field studies can be challenging and are not guaranteed to cover sufficient instances of disorientation due to the large variability of real-world settings and a lack of control over the environment. Objective: Extending a foregoing field study, we aim to evaluate the feasibility of using a sophisticated virtual reality (VR) setup, which allows a more controlled observation of disorientation states and accompanying behavioral and physiological parameters in cognitively healthy older people and people with dementia. Methods: In this feasibility study, we described the experimental design and pilot outcomes of an ongoing study aimed at investigating the effect of disorientation on gait and selected physiological features in a virtual laboratory. We transferred a real-world navigation task to a treadmill-based virtual system for gait analysis. Disorientation was induced by deliberately manipulating landmarks in the VR projection. Associated responses in motion behavior and physiological parameters were recorded by sensors. Primary outcomes were variations in motion and physiological parameters, frequency of disorientation, and questionnaire-derived usability estimates (immersion and perceived control of the gait system) for our population of interest. At this time, the included participants were 9 cognitively healthy older participants [5/9 women, 4/9 men; mean age 70 years, SD 4.40; Mini–Mental State Examination (MMSE) mean 29, SD 0.70) and 4 participants with dementia (2/4 women, 2/4 men; mean age 78 years, SD 2.30 years; MMSE mean 20.50, SD 7.54). Recruitment is ongoing, with the aim of including 30 cognitively healthy older participants and 20 participants with dementia. Results: All 13 participants completed the experiment. Patients’ route was adapted by shortening it relative to the original route. Average instances of disorientation were 21.40, 36.50, and 37.50 for the cognitively healthy older control, cognitively healthy older experimental participants, and participants with dementia, respectively. Questionnaire outcomes indicated that participants experienced adequate usability and immersion; 4.30 for presence, 3.73 for involvement, and 3.85 for realism of 7 possible points, indicating a good overall ability to cope with the experiment. Variations were also observed in motion and physiological parameters during instances of disorientation. Conclusions: This study presents the first feasibility outcomes of a study investigating the viability of using a sophisticated VR setup, based on an earlier real-world navigation study, to study spatial disorientation among cognitively healthy older people and people with dementia. Preliminary outcomes give confidence to the notion that our setup can be used to assess motion and physiological markers of disorientation, even in people with cognitive decline. Trial Registration: ClinicalTrials.gov; https://clinicaltrials.gov/ct2/show/NCT04134806 %M 33030436 %R 10.2196/18455 %U https://games.jmir.org/2020/4/e18455 %U https://doi.org/10.2196/18455 %U http://www.ncbi.nlm.nih.gov/pubmed/33030436 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 10 %P e23024 %T Effectiveness of a Participatory and Interactive Virtual Reality Intervention in Patients With Social Anxiety Disorder: Longitudinal Questionnaire Study %A Kim,Hyun-Jin %A Lee,Seulki %A Jung,Dooyoung %A Hur,Ji-Won %A Lee,Heon-Jeong %A Lee,Sungkil %A Kim,Gerard J %A Cho,Chung-Yean %A Choi,Seungmoon %A Lee,Seung-Moo %A Cho,Chul-Hyun %+ Department of Psychiatry, College of Medicine, Chungnam National University, 82 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea, 82 449954775, david0203@gmail.com %K anxiety %K social anxiety disorder %K virtual reality %K intervention %K effectiveness %K questionnaires %D 2020 %7 6.10.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Social anxiety disorder (SAD) is characterized by excessive fear of negative evaluation and humiliation in social interactions and situations. Virtual reality (VR) treatment is a promising intervention option for SAD. Objective: The purpose of this study was to create a participatory and interactive VR intervention for SAD. Treatment progress, including the severity of symptoms and the cognitive and emotional aspects of SAD, was analyzed to evaluate the effectiveness of the intervention. Methods: In total, 32 individuals with SAD and 34 healthy control participants were enrolled in the study through advertisements for online bulletin boards at universities. A VR intervention was designed consisting of three stages (introduction, core, and finishing) and three difficulty levels (easy, medium, and hard) that could be selected by the participants. The core stage was the exposure intervention in which participants engaged in social situations. The effectiveness of treatment was assessed through Beck Anxiety inventory (BAI), State‐Trait Anxiety Inventory (STAI), Internalized Shame Scale (ISS), Post-Event Rumination Scale (PERS), Social Phobia Scale (SPS), Social Interaction Anxiety Scale (SIAS), Brief-Fear of Negative Evaluation Scale (BFNE), and Liebowitz Social Anxiety Scale (LSAS). Results: In the SAD group, scores on the BAI (F=4.616, P=.009), STAI-Trait (F=4.670, P=.004), ISS (F=6.924, P=.001), PERS-negative (F=1.008, P<.001), SPS (F=8.456, P<.001), BFNE (F=6.117, P=.004), KSAD (F=13.259, P<.001), and LSAS (F=4.103, P=.009) significantly improved over the treatment process. Compared with the healthy control group before treatment, the SAD group showed significantly higher scores on all scales (P<.001), and these significant differences persisted even after treatment (P<.001). In the comparison between the VR treatment responder and nonresponder subgroups, there was no significant difference across the course of the VR session. Conclusions: These findings indicated that a participatory and interactive VR intervention had a significant effect on alleviation of the clinical symptoms of SAD, confirming the usefulness of VR for the treatment of SAD. VR treatment is expected to be one of various beneficial therapeutic approaches in the future. Trial Registration: Clinical Research Information Service (CRIS) KCT0003854; https://cris.nih.go.kr/cris/search/search_result_st01.jsp?seq=13508 %M 33021481 %R 10.2196/23024 %U http://www.jmir.org/2020/10/e23024/ %U https://doi.org/10.2196/23024 %U http://www.ncbi.nlm.nih.gov/pubmed/33021481 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 9 %P e18244 %T Virtual Reality Meditation Among Youth Experiencing Homelessness: Pilot Randomized Controlled Trial of Feasibility %A Chavez,Laura Johnson %A Kelleher,Kelly %A Slesnick,Natasha %A Holowacz,Eugene %A Luthy,Ellison %A Moore,Laura %A Ford,Jodi %+ Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, United States, 1 614 355 0342, laura.chavez@nationwidechildrens.org %K virtual reality %K meditation %K homelessness %K stress %D 2020 %7 24.9.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Homelessness among youth is devastating, with high rates of substance use disorders and mental health comorbidity. Mindfulness-based interventions that include meditation and mindfulness skills training reduce stress and symptoms of anxiety or depression. However, engaging high-risk youth in interventions is challenging. Virtual reality is a more flexible platform for delivering meditation and may be appealing to youth. Objective: The study objectives were to evaluate the feasibility of delivering virtual reality meditation and of collecting outcome measures, including anxiety and physiologic stress. Methods: A sample of 30 youth experiencing homelessness was enrolled in the study. Youth were randomized to receive 10 minutes of one of three interventions: (1) virtual reality meditation, (2) audio meditation (through a web-based platform), or (3) virtual reality imagery of historical pictures and text. Subjects who consented to the study attended two research visits. The first visit collected survey measures of demographics, mental health, and substance use, and oriented subjects to the intervention platforms. The second visit (1-3 days later) delivered the intervention and collected pre and post outcome measures of anxiety and physiologic stress (salivary cortisol). Changes in anxiety and cortisol at the second visit were compared across groups using a linear regression model in which the primary analysis compared virtual reality meditation to audio meditation and secondary analyses compared virtual reality meditation to virtual reality imagery. Results: Anxiety scores decreased in all groups, with a larger reduction among the virtual reality meditation group (difference=10.8) compared to the web-based meditation or virtual reality images groups (difference=5.8 and 5.0, respectively). After controlling for baseline values, there were no significant group differences in changes in anxiety scores or cortisol levels. In comparing virtual reality meditation and audio meditation, the effect size for anxiety was moderate (Cohen d=0.58) while the effect size for cortisol was small (Cohen d=0.08). Conclusions: Preliminary results suggest that virtual reality meditation has a moderate benefit for anxiety but not physiologic stress. Future research is needed to confirm these results in a larger sample and to investigate whether the effects are sustained or increase with repeated use of virtual reality mediation. Virtual reality meditation appears feasible to deliver among homeless youth and merits further study. Trial Registration: ClinicalTrials.gov NCT04004520; https://clinicaltrials.gov/ct2/show/NCT04004520 %M 32969834 %R 10.2196/18244 %U http://mental.jmir.org/2020/9/e18244/ %U https://doi.org/10.2196/18244 %U http://www.ncbi.nlm.nih.gov/pubmed/32969834 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e21879 %T Controlling the Sense of Embodiment for Virtual Avatar Applications: Methods and Empirical Study %A Kim,Chang-Seop %A Jung,Myeongul %A Kim,So-Yeon %A Kim,Kwanguk %+ Department of Computer Science, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul, 04763, Republic of Korea, 82 2 2220 2319, kenny@hanyang.ac.kr %K embodiment %K virtual avatar %K full-body illusion %K motion capture %K virtual reality %D 2020 %7 22.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The sense of embodiment (SoE) is the feeling of one’s own body, and research on the SoE extends from the rubber hand illusion to the full-body ownership illusion with a virtual avatar. Objective: The key to utilizing a virtual avatar is understanding and controlling the SoE, and it can be extended to several medical applications. In this study, we aimed to clarify these aspects by considering the following three subcomponents of SoE: sense of agency, ownership, and self-location. Methods: We defined a human avatar (HA), point light avatar (PLA), and out-of-body point light avatar (OBPLA) and compared them in three user studies. In study 1, 28 participants were recruited and the three avatar conditions (HA, PLA, and OBPLA) were compared. In study 2, 29 new participants were recruited, and there were two avatar conditions (HA ad PLA) and two motion synchrony conditions (synchrony and asynchrony). In study 3, 29 other participants were recruited, and there were two avatar conditions (PLA and OBPLA) and two motion synchrony conditions (synchrony and asynchrony). Dependent measures included sense of agency, ownership, and self-location; emotional response; presence; and simulator sickness. Results: The findings of study 1 showed that the three avatar generation methodologies can control the sense of ownership and self-location in a stepwise manner while maintaining a high sense of agency. In studies 2 and 3, we found dependencies among the three subcomponents of SoE and observed that they affected users’ subjective experiences. Conclusions: Our findings may have implications for boosting the effects of virtual avatar applications in medical areas, by understanding and controlling the SoE with a full-body illusion. %M 32960174 %R 10.2196/21879 %U http://games.jmir.org/2020/3/e21879/ %U https://doi.org/10.2196/21879 %U http://www.ncbi.nlm.nih.gov/pubmed/32960174 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e18290 %T Effectiveness of Virtual Reality in Nursing Education: Meta-Analysis %A Chen,Feng-Qin %A Leng,Yu-Fei %A Ge,Jian-Feng %A Wang,Dan-Wen %A Li,Cheng %A Chen,Bin %A Sun,Zhi-Ling %+ School of Nursing, Nanjing University of Chinese Medicine, 138 Xian Lin Road, Nanjing, China, 86 13813892093, szl@njucm.edu.cn %K virtual reality %K nursing education %K meta-analysis %D 2020 %7 15.9.2020 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) is the use of computer technology to create an interactive three-dimensional (3D) world, which gives users a sense of spatial presence. In nursing education, VR has been used to help optimize teaching and learning processes. Objective: The purpose of this study was to evaluate the effectiveness of VR in nursing education in the areas of knowledge, skills, satisfaction, confidence, and performance time. Methods: We conducted a meta-analysis of the effectiveness of VR in nursing education based on the Cochrane methodology. An electronic literature search using the Cochrane Library, Web of Science, PubMed, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature), up to December 2019 was conducted to identify studies that reported the effectiveness of VR on knowledge, skills, satisfaction, confidence, and performance time. The study selection and data extraction were carried out by two independent reviewers. The methodological quality of the selected studies was determined using the Cochrane criteria for risk-of-bias assessment. Results: A total of 12 studies, including 821 participants, were selected for the final analysis. We found that VR was more effective than the control conditions in improving knowledge (standard mean difference [SMD]=0.58, 95% CI 0.41-0.75, P<.001, I2=47%). However, there was no difference between VR and the control conditions in skills (SMD=0.01, 95% CI –0.24 to 0.26, P=.93, I2=37%), satisfaction (SMD=0.01, 95% CI –0.79 to 0.80, P=.99, I2=86%), confidence (SMD=0.00, 95% CI –0.28 to 0.27, P=.99, I2=0%), and performance time (SMD=–0.55, 95% CI –2.04 to 0.94, P=.47, I2=97%). Conclusions: The results of this study suggest that VR can effectively improve knowledge in nursing education, but it was not more effective than other education methods in areas of skills, satisfaction, confidence, and performance time. Further rigorous studies with a larger sample size are warranted to confirm these results. %M 32930664 %R 10.2196/18290 %U http://www.jmir.org/2020/9/e18290/ %U https://doi.org/10.2196/18290 %U http://www.ncbi.nlm.nih.gov/pubmed/32930664 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e17576 %T Usability of Individualized Head-Related Transfer Functions in Virtual Reality: Empirical Study With Perceptual Attributes in Sagittal Plane Sound Localization %A Jenny,Claudia %A Reuter,Christoph %+ Musicological Department, University of Vienna, Spitalgasse 2, Hof 9, Vienna, 1090, Austria, 43 1 4277 44280, christoph.reuter@univie.ac.at %K head-related transfer function %K sound localization %K immersive virtual reality %K binaural virtual acoustics %K 3D audio perception %D 2020 %7 8.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: In order to present virtual sound sources via headphones spatially, head-related transfer functions (HRTFs) can be applied to audio signals. In this so-called binaural virtual acoustics, the spatial perception may be degraded if the HRTFs deviate from the true HRTFs of the listener. Objective: In this study, participants wearing virtual reality (VR) headsets performed a listening test on the 3D audio perception of virtual audiovisual scenes, thus enabling us to investigate the necessity and influence of the individualization of HRTFs. Two hypotheses were investigated: first, general HRTFs lead to limitations of 3D audio perception in VR and second, the localization model for stationary localization errors is transferable to nonindividualized HRTFs in more complex environments such as VR. Methods: For the evaluation, 39 subjects rated individualized and nonindividualized HRTFs in an audiovisual virtual scene on the basis of 5 perceptual qualities: localizability, front-back position, externalization, tone color, and realism. The VR listening experiment consisted of 2 tests: in the first test, subjects evaluated their own and the general HRTF from the Massachusetts Institute of Technology Knowles Electronics Manikin for Acoustic Research database and in the second test, their own and 2 other nonindividualized HRTFs from the Acoustics Research Institute HRTF database. For the experiment, 2 subject-specific, nonindividualized HRTFs with a minimal and maximal localization error deviation were selected according to the localization model in sagittal planes. Results: With the Wilcoxon signed-rank test for the first test, analysis of variance for the second test, and a sample size of 78, the results were significant in all perceptual qualities, except for the front-back position between own and minimal deviant nonindividualized HRTF (P=.06). Conclusions: Both hypotheses have been accepted. Sounds filtered by individualized HRTFs are considered easier to localize, easier to externalize, more natural in timbre, and thus more realistic compared to sounds filtered by nonindividualized HRTFs. %M 32897232 %R 10.2196/17576 %U http://games.jmir.org/2020/3/e17576/ %U https://doi.org/10.2196/17576 %U http://www.ncbi.nlm.nih.gov/pubmed/32897232 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e20667 %T Feasibility of a Commercially Available Virtual Reality System to Achieve Exercise Guidelines in Youth With Spina Bifida: Mixed Methods Case Study %A Lai,Byron %A Davis,Drew %A Narasaki-Jara,Mai %A Hopson,Betsy %A Powell,Danielle %A Gowey,Marissa %A Rocque,Brandon G %A Rimmer,James H %+ Division of Pediatric Rehabilitation Medicine, School of Medicine, University of Alabama at Birmingham, 1720 University Blvd, Birmingham, AL, 35294, United States, 1 2052001724, byronlai@uab.edu %K physical activity %K active video gaming %K exergaming %K disability %K Oculus Quest %D 2020 %7 3.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Access to physical activity among youth with spina bifida (SB) is much lower than it is for children without disability. Enjoyable home-based exercise programs are greatly needed. Objective: Our objective is to examine the feasibility of a virtual reality (VR) active video gaming system (ie, bundle of consumer-available equipment) to meet US physical activity guidelines in two youth with SB. Methods: Two youth with SB—a 12-year-old female and a 13-year-old male; both full-time wheelchair users—participated in a brief, 4-week exercise program using a popular VR head-mounted display: Oculus Quest (Facebook Technologies). The system included a Polar H10 (Polar Canada) Bluetooth heart rate monitor, a no-cost mobile phone app (VR Health Exercise Tracker [Virtual Reality Institute of Health and Exercise]), and 13 games. The intervention protocol was conducted entirely in the homes of the participants due to the coronavirus disease 2019 (COVID-19) pandemic. The VR system was shipped to participants and they were instructed to do their best to complete 60 minutes of moderate-intensity VR exercise per day. Exercise duration, intensity, and calories expended were objectively monitored and recorded during exercise using the heart rate monitor and a mobile app. Fatigue and depression were measured via self-report questionnaires at pre- and postintervention. Participants underwent a semistructured interview with research staff at postintervention. Results: Across the intervention period, the total average minutes of all exercise performed each week for participants 1 and 2 were 281 (SD 93) and 262 (SD 55) minutes, respectively. The total average minutes of moderate-intensity exercise performed per week for participants 1 and 2 were 184 (SD 103) (184/281, 65.4%) and 215 (SD 90) (215/262, 82.1%) minutes, respectively. One participant had a reduction in their depression score, using the Quality of Life in Neurological Disorders (Neuro-QoL) test, from baseline to postintervention, but no other changes were observed for fatigue and depression scores. Participants reported that the amount of exercise they completed was far higher than what was objectively recorded, due to usability issues with the chest-worn heart rate monitor. Participants noted that they were motivated to exercise due to the enjoyment of the games and VR headset as well as support from a caregiver. Conclusions: This study demonstrated that two youth with SB who used wheelchairs could use a VR system to independently and safely achieve exercise guidelines at home. Study findings identified a promising protocol for promoting exercise in this population and this warrants further examination in future studies with larger samples. %M 32880577 %R 10.2196/20667 %U http://games.jmir.org/2020/3/e20667/ %U https://doi.org/10.2196/20667 %U http://www.ncbi.nlm.nih.gov/pubmed/32880577 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e17823 %T Biosensor Real-Time Affective Analytics in Virtual and Mixed Reality Medical Education Serious Games: Cohort Study %A Antoniou,Panagiotis E %A Arfaras,George %A Pandria,Niki %A Athanasiou,Alkinoos %A Ntakakis,George %A Babatsikos,Emmanouil %A Nigdelis,Vasilis %A Bamidis,Panagiotis %+ Lab of Medical Physics, The Medical School, Aristotle University of Thessaloniki, PO Box 376, Thessaloniki, 54124, Greece, 30 2310 999310, bamidis@auth.gr %K virtual patients %K affective learning %K electroencephalography %K medical education %K virtual reality %K wearable sensors %K serious medical games %D 2020 %7 2.9.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: The role of emotion is crucial to the learning process, as it is linked to motivation, interest, and attention. Affective states are expressed in the brain and in overall biological activity. Biosignals, like heart rate (HR), electrodermal activity (EDA), and electroencephalography (EEG) are physiological expressions affected by emotional state. Analyzing these biosignal recordings can point to a person’s emotional state. Contemporary medical education has progressed extensively towards diverse learning resources using virtual reality (VR) and mixed reality (MR) applications. Objective: This paper aims to study the efficacy of wearable biosensors for affect detection in a learning process involving a serious game in the Microsoft HoloLens VR/MR platform. Methods: A wearable array of sensors recording HR, EDA, and EEG signals was deployed during 2 educational activities conducted by 11 participants of diverse educational level (undergraduate, postgraduate, and specialist neurosurgeon doctors). The first scenario was a conventional virtual patient case used for establishing the personal biosignal baselines for the participant. The second was a case in a VR/MR environment regarding neuroanatomy. The affective measures that we recorded were EEG (theta/beta ratio and alpha rhythm), HR, and EDA. Results: Results were recorded and aggregated across all 3 groups. Average EEG ratios of the virtual patient (VP) versus the MR serious game cases were recorded at 3.49 (SD 0.82) versus 3.23 (SD 0.94) for students, 2.59 (SD 0.96) versus 2.90 (SD 1.78) for neurosurgeons, and 2.33 (SD 0.26) versus 2.56 (SD 0.62) for postgraduate medical students. Average alpha rhythm of the VP versus the MR serious game cases were recorded at 7.77 (SD 1.62) μV versus 8.42 (SD 2.56) μV for students, 7.03 (SD 2.19) μV versus 7.15 (SD 1.86) μV for neurosurgeons, and 11.84 (SD 6.15) μV versus 9.55 (SD 3.12) μV for postgraduate medical students. Average HR of the VP versus the MR serious game cases were recorded at 87 (SD 13) versus 86 (SD 12) bpm for students, 81 (SD 7) versus 83 (SD 7) bpm for neurosurgeons, and 81 (SD 7) versus 77 (SD 6) bpm for postgraduate medical students. Average EDA of the VP versus the MR serious game cases were recorded at 1.198 (SD 1.467) μS versus 4.097 (SD 2.79) μS for students, 1.890 (SD 2.269) μS versus 5.407 (SD 5.391) μS for neurosurgeons, and 0.739 (SD 0.509) μS versus 2.498 (SD 1.72) μS for postgraduate medical students. The variations of these metrics have been correlated with existing theoretical interpretations regarding educationally relevant affective analytics, such as engagement and educational focus. Conclusions: These results demonstrate that this novel sensor configuration can lead to credible affective state detection and can be used in platforms like intelligent tutoring systems for providing real-time, evidence-based, affective learning analytics using VR/MR-deployed medical education resources. %M 32876575 %R 10.2196/17823 %U http://games.jmir.org/2020/3/e17823/ %U https://doi.org/10.2196/17823 %U http://www.ncbi.nlm.nih.gov/pubmed/32876575 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 7 %N 2 %P e17822 %T Acceptability of a Mobile Phone–Based Augmented Reality Game for Rehabilitation of Patients With Upper Limb Deficits from Stroke: Case Study %A LaPiana,Nina %A Duong,Alvin %A Lee,Alex %A Alschitz,Leon %A Silva,Rafael M L %A Early,Jody %A Bunnell,Aaron %A Mourad,Pierre %+ Department of Neurological Surgery, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, United States, 1 206 221 8967, lapiana@uw.edu %K augmented reality %K stroke %K upper limb rehabilitation %K gamification %K motor rehabilitation %K motivation %K participation %D 2020 %7 2.9.2020 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Upper limb functional deficits are common after stroke and result from motor weakness, ataxia, spasticity, spatial neglect, and poor stamina. Past studies employing a range of commercial gaming systems to deliver rehabilitation to stroke patients provided short-term efficacy but have not yet demonstrated whether or not those games are acceptable, that is, motivational, comfortable, and engaging, which are all necessary for potential adoption and use by patients. Objective: The goal of the study was to assess the acceptability of a smartphone-based augmented reality game as a means of delivering stroke rehabilitation for patients with upper limb motor function loss. Methods: Patients aged 50 to 70 years, all of whom experienced motor deficits after acute ischemic stroke, participated in 3 optional therapy sessions using augmented reality therapeutic gaming over the course of 1 week, targeting deficits in upper extremity strength and range of motion. After completion of the game, we administered a 16-item questionnaire to the patients to assess the game’s acceptability; 8 questions were answered by rating on a scale from 1 (very negative experience) to 5 (very positive experience); 8 questions were qualitative. Results: Patients (n=5) completed a total of 23 out of 45 scheduled augmented reality game sessions, with patient fatigue as the primary factor for uncompleted sessions. Each patient consented to 9 potential game sessions and completed a mean of 4.6 (SE 1.3) games. Of the 5 patients, 4 (80%) completed the questionnaire at the end of their final gaming session. Of note, patients were motivated to continue to the end of a given gaming session (mean 4.25, 95% CI 3.31-5.19), to try other game-based therapies (mean 3.75, 95% CI 2.81-4.69), to do another session (mean 3.50, 95% CI 2.93-4.07), and to perform other daily rehabilitation exercises (mean 3.25, 95% CI 2.76-3.74). In addition, participants gave mean scores of 4.00 (95% CI 2.87-5.13) for overall experience; 4.25 (95% CI 3.31-5.19) for comfort; 3.25 (95% CI 2.31-4.19) for finding the study fun, enjoyable, and engaging; and 3.50 (95% CI 2.52-4.48) for believing the technology could help them reach their rehabilitation goals. For each of the 4 patients, their reported scores were statistically significantly higher than those generated by a random sampling of values (patient 1: P=.04; patient 2: P=.04; patient 4: P=.004; patient 5: P=.04). Conclusions: Based on the questionnaire scores, the patients with upper limb motor deficits following stroke who participated in our case study found our augmented reality game motivating, comfortable, engaging, and tolerable. Improvements in augmented reality technology motivated by this case study may one day allow patients to work with improved versions of this therapy independently in their own home. We therefore anticipate that smartphone-based augmented reality gaming systems may eventually provide useful postdischarge self-treatment as a supplement to professional therapy for patients with upper limb deficiencies from stroke. %M 32876580 %R 10.2196/17822 %U http://rehab.jmir.org/2020/2/e17822/ %U https://doi.org/10.2196/17822 %U http://www.ncbi.nlm.nih.gov/pubmed/32876580 %0 Journal Article %@ 2562-7600 %I JMIR Publications %V 3 %N 1 %P e20249 %T Learning With Virtual Reality in Nursing Education: Qualitative Interview Study Among Nursing Students Using the Unified Theory of Acceptance and Use of Technology Model %A Lange,Ann-Kathrin %A Koch,Jana %A Beck,Anastasia %A Neugebauer,Till %A Watzema,Frauke %A Wrona,Kamil J %A Dockweiler,Christoph %+ University of Bielefeld, Universitätsstr 25, Bielefeld, 33615, Germany, 49 521106 ext 5160, ann-kathrin.lange@uni-bielefeld.de %K virtual reality %K edutainment %K serious games %K education %K health care %K gamification %K anatomy %K digital game–based learning %K nursing %K nursing informatics %D 2020 %7 1.9.2020 %9 Original Paper %J JMIR Nursing %G English %X Background: Digital games–based learning is a method of using digital games to impart knowledge. Virtual reality (VR) programs are a practical application of this method. Due to demographic changes, the nursing profession will become increasingly important. These VR applications can be of use in training nurses for future professional challenges they may encounter. The continuous development of VR applications enables trainees to encounter simulated real life effectively and to experience increasingly concrete situations. This can be of great importance in nursing education, since 3-dimensionality enables a better visualization of many fields of activity and can prevent potential future errors. In addition to this learning effect, VR applications also bring an element of fun to learning. Objective: The aim of this qualitative research effort is to observe the degree of acceptance of VR applications by nursing students in Germany. Various factors, including social influences, performance expectations, and effort expectations, are taken into consideration. Methods: With a qualitative cohort study, the acceptance of nursing students towards VR applications in anatomy teaching was determined. The 12 participants were first asked to fill out a quantitative questionnaire on their sociodemographic characteristics and the extent to which they valued and liked using technology. The participants were then allowed to test the VR application themselves and were finally asked about their experience in a qualitative interview. For the collection of data and the analysis of results, the unified theory of acceptance and use of technology was used in this study. Results: Overall, the study shows that the interviewed persons rated the VR application quite positively. The greatest influence in this was the personal attitude towards technology; the higher this affinity is, the more useful the VR application appears. Social influences can also increase the participant’s own acceptance if peers have a positive attitude towards such applications. The study shows that the trainees' motivation to learn was increased by using VR. We believe this is because each trainee could learn individually and the VR application was perceived as an enjoyable activity. Nevertheless, the cost factor of implementing VR applications in nursing training is currently still an obstacle, as not every institution has such financial capacities. Conclusions: The extent to which the use of VR applications in the training of nursing staff is justified depends on the degree of personal acceptance. The collected results give good practice-oriented insight into the attitude of trainees towards VR. Many of the interviewed persons saw benefits in the use of VR technologies. As VR applications are constantly developing, it is necessary to conduct further studies on VR applications in nursing education and to include other possible disciplines in which these applications can be helpful. %M 34345791 %R 10.2196/20249 %U https://nursing.jmir.org/2020/1/e20249/ %U https://doi.org/10.2196/20249 %U http://www.ncbi.nlm.nih.gov/pubmed/34345791 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 8 %P e19495 %T Motion-Based Technology for People With Dementia Training at Home: Three-Phase Pilot Study Assessing Feasibility and Efficacy %A Petersen,Jindong Ding %A Larsen,Eva Ladekjær %A la Cour,Karen %A von Bülow,Cecilie %A Skouboe,Malene %A Christensen,Jeanette Reffstrup %A Waldorff,Frans Boch %+ Research Unit for General Practice, Department of Public Health, University of Southern Denmark, J B Winsløws Vej 9, Odense, Denmark, 45 29367599, jindong@health.sdu.dk %K dementia %K motion-based technology %K virtual reality %K telerehabilitation %K physical training %K physical and mental function %D 2020 %7 26.8.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Persons with dementia tend to be vulnerable to mobility challenges and hence face a greater risk of fall and subsequent fractures, morbidity, and mortality. Motion-based technologies (MBTs), also called sensor-based technologies or virtual reality, have the potential for assisting physical exercise and training as a part of a disease management and rehabilitation program, but little is known about its' use for people with dementia. Objective: The purpose of this pilot study was to investigate the feasibility and efficacy of MBT physical training at home for people with dementia. Methods: A 3-phase pilot study: (1) baseline start-up, (2) 15 weeks of group training at a local care center twice a week, and (3) 12 weeks of group training reduced to once a week, supplemented with individual MBT training twice a week at home. A total of 26 people with dementia from a municipality in Southern Denmark were eligible and agreed to participate in this study. Three withdrew from the study, leaving 23 participants for the final analysis. Feasibility was measured by the percentage of participants who trained with MBT at home, and their completion rate of total scheduled MBT sessions. Efficacy was evaluated by physical function, measured by Sit-to-Stand (STS), Timed-Up-and-Go (TUG), 6-minute Walk Test (6MW), and 10-meter Dual-task Walking Test (10MDW); cognitive function was measured by Mini-Mental State Examination (MMSE) and Neuropsychiatric Inventory-Questionnaire (NPI-Q); and European Quality of Life 5 dimensions questionnaire (EQOL5) was used for measuring quality of life. Descriptive statistics were applied accordingly. Wilcoxon signed-rank and rank-sum tests were applied to explore significant differences within and between the groups. Results: As much as 12 of 23 participants (52%) used the supplemental MBT training at home. Among them, 6 (50%) completed 75% or more scheduled sessions, 3 completed 25% or less, and 3 completed between 25% and 75% of scheduled sessions. For physical and cognitive function tests, supplementing with MBT training at home showed a tendency of overall stabilization of scores among the group of participants who actively trained with MBT; especially, the 10MDW test even showed a significant improvement from 9.2 to 7.1 seconds (P=.03). We found no positive effect on EQOL5 tests. Conclusions: More than half of the study population with dementia used MBT training at home, and among them, half had an overall high adherence to the home training activity. Physical function tended to remain stable or even improved among high-adherence MBT individuals. We conclude that MBT training at home may be feasible for some individuals with dementia. Further research is warranted. %M 32845243 %R 10.2196/19495 %U http://mental.jmir.org/2020/8/e19495/ %U https://doi.org/10.2196/19495 %U http://www.ncbi.nlm.nih.gov/pubmed/32845243 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e16947 %T Virtual Reality–Based Executive Function Rehabilitation System for Children With Traumatic Brain Injury: Design and Usability Study %A Shen,Jiabin %A Xiang,Henry %A Luna,John %A Grishchenko,Alice %A Patterson,Jeremy %A Strouse,Robert V %A Roland,Maxwell %A Lundine,Jennifer P %A Koterba,Christine H %A Lever,Kimberly %A Groner,Jonathan I %A Huang,Yungui %A Lin,En-Ju Deborah %+ Research Information Solutions and Innovation, Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, United States, 1 6143553071, deborah.lin@nationwidechildrens.org %K traumatic brain injury %K virtual reality %K neurological rehabilitation %K executive function %K cognitive rehabilitation %D 2020 %7 25.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Traumatic brain injury (TBI) poses a significant threat to children’s health. Cognitive rehabilitation for pediatric TBI has the potential to improve the quality of life following the injury. Virtual reality (VR) can provide enriched cognitive training in a life-like but safe environment. However, existing VR applications for pediatric TBIs have primarily focused on physical rehabilitation. Objective: This study aims to design and develop an integrative hardware and software VR system to provide rehabilitation of executive functions (EF) for children with TBI, particularly in 3 core EF: inhibitory control, working memory, and cognitive flexibility. Methods: The VR training system was developed by an interdisciplinary team with expertise in best practices of VR design, developmental psychology, and pediatric TBI rehabilitation. Pilot usability testing of this novel system was conducted among 10 healthy children and 4 children with TBIs. Results: Our VR-based interactive cognitive training system was developed to provide assistive training on core EF following pediatric TBI. Pilot usability testing showed adequate user satisfaction ratings for both the hardware and software components of the VR system. Conclusions: This project designed and tested a novel VR-based system for executive function rehabilitation that is specifically adapted to children following TBI. %M 32447275 %R 10.2196/16947 %U http://games.jmir.org/2020/3/e16947/ %U https://doi.org/10.2196/16947 %U http://www.ncbi.nlm.nih.gov/pubmed/32447275 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 9 %N 8 %P e20300 %T Virtual Reality Cognitive Therapy in Inpatient Psychiatric Wards: Protocol for a Qualitative Investigation of Staff and Patient Views Across Multiple National Health Service Sites %A Brown,Poppy %A Waite,Felicity %A Lambe,Sinéad %A Rosebrock,Laina %A Freeman,Daniel %+ Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, OX3 7JX, United Kingdom, 44 (0)1865 618262, poppy.brown@psych.ox.ac.uk %K virtual reality %K therapy %K inpatient psychiatric care %K implementation %D 2020 %7 20.8.2020 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Patients in psychiatric wards typically have very limited access to individual psychological therapy. Inpatients often have significant time available, and an important transition back to everyday life to prepare for—but historically, there have been few trained therapists available on wards for the delivery of evidence-based therapy. Automated virtual reality (VR) therapy may be one route to increase the provision of powerful psychological treatments in psychiatric hospitals. The gameChange automated VR cognitive therapy is targeted at helping patients overcome anxious avoidance and re-engage in everyday situations (such as walking down the street, taking a bus, or going to a shop). This treatment target may fit well for many patients preparing for discharge. However, little is known about how VR therapy may be viewed in this setting. Objective: The objectives of the study are to explore psychiatric hospital staff and patients’ initial expectations of VR therapy, to gather patient and staff views of an automated VR cognitive therapy (gameChange) after briefly experiencing it, and to identify potential differences across National Health Service (NHS) mental health trusts for implementation. Guided by an implementation framework, the knowledge gained from this study will be used to assess the feasibility of VR treatment adoption into psychiatric hospitals. Methods: Focus groups will be conducted with NHS staff and patients in acute psychiatric wards at 5 NHS mental health trusts across England. Staff and patients will be interviewed in separate groups. Individual interviews will also be conducted when preferred by a participant. Within each of the 5 trusts, 1 to 2 wards will be visited. A total of 8-15 staff and patients per ward will be recruited, with a minimum total of 50 staff and patients recruited across all sites. Focus group questions have been derived from the nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability (NASSS) framework. Focus groups will discuss expectations of VR therapy before participants are given the opportunity to briefly try the gameChange VR therapy. Questions will then focus on opinions about the therapy and investigate feasibility of adoption, with particular consideration given to site specific issues. A thematic analysis will be conducted. Results: As of May 15, 2020, 1 patient focus group has been conducted. Conclusions: The study will provide unique insight from patients and staff into the potential for implementing automated VR therapy in psychiatric wards. Perspectives will be captured both on the use of immersive technology hardware and therapy-specific issues in such settings. International Registered Report Identifier (IRRID): DERR1-10.2196/20300 %M 32667897 %R 10.2196/20300 %U http://www.researchprotocols.org/2020/8/e20300/ %U https://doi.org/10.2196/20300 %U http://www.ncbi.nlm.nih.gov/pubmed/32667897 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e20889 %T Evidence on Virtual Reality–Based Therapies for Psychiatric Disorders: Meta-Review of Meta-Analyses %A Dellazizzo,Laura %A Potvin,Stéphane %A Luigi,Mimosa %A Dumais,Alexandre %+ Research Center of the Institut Universitaire en Santé Mentale de Montréal, 7331 Hochelaga, Montreal, QC, H1N 3V2, Canada, 1 514 251 4000 ext 3925, alexandre.dumais@umontreal.ca %K systematic review %K virtual reality %K therapy %K mental disorders %K meta-analysis %D 2020 %7 19.8.2020 %9 Review %J J Med Internet Res %G English %X Background: Among all diseases globally, mental illnesses are one of the major causes of burden. As many people are resistant to conventional evidence-based treatments, there is an unmet need for the implementation of novel mental health treatments. Efforts to increase the effectiveness and benefits of evidence-based psychotherapy in psychiatry have led to the emergence of virtual reality (VR)–based interventions. These interventions have shown a wide range of advantages over conventional psychotherapies. Currently, VR-based interventions have been developed mainly for anxiety-related disorders; however, they are also used for developmental disorders, severe mental disorders, and neurocognitive disorders. Objective: This meta-review aims to summarize the current state of evidence on the efficacy of VR-based interventions for various psychiatric disorders by evaluating the quality of evidence provided by meta-analytical studies. Methods: A systematic search was performed using the following electronic databases: PubMed, PsycINFO, Web of Science, and Google Scholar (any time until February 2020). Meta-analyses were included as long as they quantitatively examined the efficacy of VR-based interventions for symptoms of a psychiatric disorder. To avoid overlap among meta-analyses, for each subanalysis included within this meta-review, only one analysis provided from one meta-analysis was selected based on the best quality of evidence. Results: The search retrieved 11 eligible meta-analyses. The quality of evidence varied from very low to moderate quality. Several reasons account for the lower quality evidence, such as a limited number of randomized controlled trials, lack of follow-up analysis or control group, and the presence of heterogeneity and publication bias. Nonetheless, evidence has shown that VR-based interventions for anxiety-related disorders display overall medium-to-large effects when compared with inactive controls but no significant difference when compared with standard evidence-based approaches. Preliminary data have highlighted that such effects appear to be sustained in time, and subjects may fare better than active controls. Neurocognitive disorders also appear to improve with VR-based approaches, with small effects being found for various clinical outcomes (eg, cognition, emotion). Finally, there are insufficient data to classify VR-based interventions as an evidence-based practice for social skills training in neurodevelopmental disorders and compliance among patients with schizophrenia. Conclusions: VR provides unlimited opportunities by tailoring approaches to specific complex problems and individualizing the intervention. However, VR-based interventions have not shown superiority compared with usual evidence-based treatments. Future VR-based interventions should focus on developing innovative approaches for complex and treatment-resistant symptoms that are difficult to address with traditional treatments. Future research should also aim to gain a better understanding of the potential factors that may mediate VR outcomes to improve treatment. %M 32812889 %R 10.2196/20889 %U http://www.jmir.org/2020/8/e20889/ %U https://doi.org/10.2196/20889 %U http://www.ncbi.nlm.nih.gov/pubmed/32812889 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18888 %T Effects of Avatar Perspective on Joint Excursions Used to Play Virtual Dodgeball: Within-Subject Comparative Study %A van der Veen,Susanne M %A Stamenkovic,Alexander %A Applegate,Megan E %A Leitkam,Samuel T %A France,Christopher R %A Thomas,James S %+ Virginia Commonwealth University, 900 E Leigh St, 4th Floor, Richmond, VA, 23298, United States, 1 7405416324, smvanderveen@vcu.edu %K virtual reality %K avatar perspective %K reaching %K joint excursion %K exergaming %K exercise rehabilitation %K head mounted display %D 2020 %7 19.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Visual representation of oneself is likely to affect movement patterns. Prior work in virtual dodgeball showed greater excursion of the ankles, knees, hips, spine, and shoulder occurs when presented in the first-person perspective compared to the third-person perspective. However, the mode of presentation differed between the two conditions such that a head-mounted display was used to present the avatar in the first-person perspective, but a 3D television (3DTV) display was used to present the avatar in the third-person. Thus, it is unknown whether changes in joint excursions are driven by the visual display (head-mounted display versus 3DTV) or avatar perspective during virtual gameplay. Objective: This study aimed to determine the influence of avatar perspective on joint excursion in healthy individuals playing virtual dodgeball using a head-mounted display. Methods: Participants (n=29, 15 male, 14 female) performed full-body movements to intercept launched virtual targets presented in a game of virtual dodgeball using a head-mounted display. Two avatar perspectives were compared during each session of gameplay. A first-person perspective was created by placing the center of the displayed content at the bridge of the participant’s nose, while a third-person perspective was created by placing the camera view at the participant’s eye level but set 1 m behind the participant avatar. During gameplay, virtual dodgeballs were launched at a consistent velocity of 30 m/s to one of nine locations determined by a combination of three different intended impact heights and three different directions (left, center, or right) based on subject anthropometrics. Joint kinematics and angular excursions of the ankles, knees, hips, lumbar spine, elbows, and shoulders were assessed. Results: The change in joint excursions from initial posture to the interception of the virtual dodgeball were averaged across trials. Separate repeated-measures ANOVAs revealed greater excursions of the ankle (P=.010), knee (P=.001), hip (P=.0014), spine (P=.001), and shoulder (P=.001) joints while playing virtual dodgeball in the first versus third-person perspective. Aligning with the expectations, there was a significant effect of impact height on joint excursions. Conclusions: As clinicians develop treatment strategies in virtual reality to shape motion in orthopedic populations, it is important to be aware that changes in avatar perspective can significantly influence motor behavior. These data are important for the development of virtual reality assessment and treatment tools that are becoming increasingly practical for home and clinic-based rehabilitation. %M 32812885 %R 10.2196/18888 %U http://games.jmir.org/2020/3/e18888/ %U https://doi.org/10.2196/18888 %U http://www.ncbi.nlm.nih.gov/pubmed/32812885 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e21486 %T Use of the HoloLens2 Mixed Reality Headset for Protecting Health Care Workers During the COVID-19 Pandemic: Prospective, Observational Evaluation %A Martin,Guy %A Koizia,Louis %A Kooner,Angad %A Cafferkey,John %A Ross,Clare %A Purkayastha,Sanjay %A Sivananthan,Arun %A Tanna,Anisha %A Pratt,Philip %A Kinross,James %A , %+ Department of Surgery and Cancer, Imperial College London, 10th Floor, QEQM Building, St Mary’s Hospital, London, W2 1NY, United Kingdom, 44 0203 312 6072, guy.martin@imperial.ac.uk %K COVID-19 %K mixed reality %K telemedicine %K protection %K acceptability %K feasibility %K impact %K headset %K virtual reality %K augmented reality %K pilot %D 2020 %7 14.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The coronavirus disease (COVID-19) pandemic has led to rapid acceleration in the deployment of new digital technologies to improve both accessibility to and quality of care, and to protect staff. Mixed-reality (MR) technology is the latest iteration of telemedicine innovation; it is a logical next step in the move toward the provision of digitally supported clinical care and medical education. This technology has the potential to revolutionize care both during and after the COVID-19 pandemic. Objective: This pilot project sought to deploy the HoloLens2 MR device to support the delivery of remote care in COVID-19 hospital environments. Methods: A prospective, observational, nested cohort evaluation of the HoloLens2 was undertaken across three distinct clinical clusters in a teaching hospital in the United Kingdom. Data pertaining to staff exposure to high-risk COVID-19 environments and personal protective equipment (PPE) use by clinical staff (N=28) were collected, and assessments of acceptability and feasibility were conducted. Results: The deployment of the HoloLens2 led to a 51.5% reduction in time exposed to harm for staff looking after COVID-19 patients (3.32 vs 1.63 hours/day/staff member; P=.002), and an 83.1% reduction in the amount of PPE used (178 vs 30 items/round/day; P=.02). This represents 222.98 hours of reduced staff exposure to COVID-19, and 3100 fewer PPE items used each week across the three clusters evaluated. The majority of staff using the device agreed it was easy to set up and comfortable to wear, improved the quality of care and decision making, and led to better teamwork and communication. In total, 89.3% (25/28) of users felt that their clinical team was safer when using the HoloLens2. Conclusions: New technologies have a role in minimizing exposure to nosocomial infection, optimizing the use of PPE, and enhancing aspects of care. Deploying such technologies at pace requires context-specific information security, infection control, user experience, and workflow integration to be addressed at the outset and led by clinical end-users. The deployment of new telemedicine technology must be supported with objective evidence for its safety and effectiveness to ensure maximum impact. %M 32730222 %R 10.2196/21486 %U http://www.jmir.org/2020/8/e21486/ %U https://doi.org/10.2196/21486 %U http://www.ncbi.nlm.nih.gov/pubmed/32730222 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 8 %P e17367 %T The Acceptability and Impact of the Xploro Digital Therapeutic Platform to Inform and Prepare Children for Planned Procedures in a Hospital: Before and After Evaluation Study %A Bray,Lucy %A Sharpe,Ashley %A Gichuru,Phillip %A Fortune,Peter-Marc %A Blake,Lucy %A Appleton,Victoria %+ Faculty of Health, Social Care and Medicine, Edge Hill University, St Helens Road, Ormskirk, L39 4QP, United Kingdom, 44 01695 657231, brayl@edgehill.ac.uk %K health literacy %K augmented reality %K children %K procedure %K health %K artificial intelligence %D 2020 %7 11.8.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: There is increasing interest in finding novel approaches to improve the preparation of children for hospital procedures such as surgery, x-rays, and blood tests. Well-prepared and informed children have better outcomes (less procedural anxiety and higher satisfaction). A digital therapeutic (DTx) platform (Xploro) was developed with children to provide health information through gamification, serious games, a chatbot, and an augmented reality avatar. Objective: This before and after evaluation study aims to assess the acceptability of the Xploro DTx and examine its impact on children and their parent’s procedural knowledge, procedural anxiety, and reported experiences when attending a hospital for a planned procedure. Methods: We used a mixed methods design with quantitative measures and qualitative data collected sequentially from a group of children who received standard hospital information (before group) and a group of children who received the DTx intervention (after group). Participants were children aged between 8 and 14 years and their parents who attended a hospital for a planned clinical procedure at a children’s hospital in North West England. Children and their parents completed self-report measures (perceived knowledge, procedural anxiety, procedural satisfaction, and procedural involvement) at baseline, preprocedure, and postprocedure. Results: A total of 80 children (n=40 standard care group and n=40 intervention group) and their parents participated in the study; the children were aged between 8 and 14 years (average 10.4, SD 2.27 years) and were attending a hospital for a range of procedures. The children in the intervention group reported significantly lower levels of procedural anxiety before the procedure than those in the standard group (two-tailed t63.64=2.740; P=.008). The children in the intervention group also felt more involved in their procedure than those in the standard group (t75=−2.238; P=.03). The children in the intervention group also reported significantly higher levels of perceived procedural knowledge preprocedure (t59.98=−4.892; P=.001) than those in the standard group. As for parents, those with access to the Xploro intervention reported significantly lower levels of procedural anxiety preprocedure than those who did not (t68.51=1.985; P=.05). During the semistructured write and tell interviews, children stated that they enjoyed using the intervention, it was fun and easy to use, and they felt that it had positively influenced their experiences of coming to the hospital for a procedure. Conclusions: This study has shown that the DTx platform, Xploro, has a positive impact on children attending a hospital for a procedure by reducing levels of procedural anxiety. The children and parents in the intervention group described Xploro as improving their experiences and being easy and fun to use. %M 32780025 %R 10.2196/17367 %U http://www.jmir.org/2020/8/e17367/ %U https://doi.org/10.2196/17367 %U http://www.ncbi.nlm.nih.gov/pubmed/32780025 %0 Journal Article %@ 2561-7605 %I JMIR Publications %V 3 %N 2 %P e17286 %T Emerging Technologies With Potential Care and Support Applications for Older People: Review of Gray Literature %A Abdi,Sarah %A de Witte,Luc %A Hawley,Mark %+ Centre for Assistive Technology and Connected Healthcare, School of Health and Related Research, The University of Sheffield, The Innovation Centre, 217 Portobello, Sheffield, S1 4DP, United Kingdom, 44 114 222 0682, mark.hawley@sheffield.ac.uk %K artificial intelligence %K internet of things %K mobile phone %K robotics %K emerging technologies %K older people %K care and support %D 2020 %7 11.8.2020 %9 Review %J JMIR Aging %G English %X Background: The number of older people with unmet care and support needs is increasing substantially due to the challenges facing the formal and informal care systems. Emerging technological developments have the potential to address some of the care and support challenges of older people. However, limited work has been done to identify emerging technological developments with the potential to meet the care and support needs of the aging population. Objective: This review aimed to gain an overview of emerging technologies with potential care and support applications for older people, particularly for those living at home. Methods: A scoping gray literature review was carried out by using the databases of 13 key organizations, hand searching reference lists of included documents, using funding data, and consulting technology experts. A narrative synthesis approach was used to analyze and summarize the findings of the literature review. Results: A total of 39 documents were included in the final analysis. From the analysis, 8 emerging technologies were identified that could potentially be used to meet older people’s needs in various care and support domains. These emerging technologies were (1) assistive autonomous robots; (2) self-driving vehicles; (3) artificial intelligence–enabled health smart apps and wearables; (4) new drug release mechanisms; (5) portable diagnostics; (6) voice-activated devices; (7) virtual, augmented, and mixed reality; and (8) intelligent homes. These emerging technologies were at different levels of development, with some being trialed for care applications, whereas others being in the early phases of development. However, only a few documents mentioned including older people during the process of designing and developing these technologies. Conclusions: This review has identified key emerging technologies with the potential to contribute to the support and care needs of older people. However, to increase the adoption of these technologies by older people, there is a need to involve them and other stakeholders, such as formal and informal carers, in the process of designing and developing these technologies. %M 32780020 %R 10.2196/17286 %U http://aging.jmir.org/2020/2/e17286/ %U https://doi.org/10.2196/17286 %U http://www.ncbi.nlm.nih.gov/pubmed/32780020 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e17799 %T A Graded Exposure, Locomotion-Enabled Virtual Reality App During Walking and Reaching for Individuals With Chronic Low Back Pain: Cohort Gaming Design %A Hennessy,Rebecca White %A Rumble,Deanna %A Christian,Mike %A Brown,David A %A Trost,Zina %+ PhD Program in Rehabilitation Science, School of Health Professions, University of Alabama at Birmingham, 1716 9th Avenue South, Birmingham, AL, United States, 1 205 975 3592, rwhite31@uab.edu %K virtual reality %K chronic low back pain %K walking %K rehabilitation %K virtual reality exposure therapy %D 2020 %7 10.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Chronic low back pain (cLBP) can interfere with daily activities, and individuals with elevated pain-related fear (also known as kinesiophobia or the fear of injury due to movement) can develop worse long-term disability. Graded exposure (GEXP) protocols use successive participation in avoided activities to help individuals overcome fearful movement appraisals and encourage activity. We sought to develop a series of GEXP virtual reality (VR) walking and reaching scenarios to increase the exposure and engagement of people with high kinesiophobia and cLBP. Objective: This study aims to (1) determine GEXP content validity of the VR application and (2) determine the feasibility of individuals with cLBP performing locomotion-enabled physical activities. Methods: We recruited 13 individuals with cLBP and high pain-related fear to experience six VR modules, which provide progressive movement exposure over three sessions in a 1 week period. At session 1, participants ranked each module by likelihood to avoid and assigned an expected pain and concern for harming their back rating to each module. Participants provided a rating of perceived exertion (RPE) after experiencing each module. To test feasibility, we administered the system usability scale (SUS) and treatment evaluation inventory (TEI) following the final session. In addition, we measured pain and pain-related fear at baseline and follow-up. Results: The 12 participants who completed the study period assigned higher avoidance (P=.002), expected pain (P=.002), and expected concern (P=.002) for session 3 modules compared with session 1 modules. RPE significantly increased from session 1 (mean 14.8, SD 2.3) to session 3 (mean 16.8, SD 2.2; P=.009). The VR application showed positive feasibility for individuals with cLBP through acceptable SUS (mean 76.7, SD 13.0) and TEI (mean 32.5, SD 4.9) scores. Neither pain (P=.20) nor pain-related fear (P=.58) changed significantly across sessions. Conclusions: The GEXP VR modules provided progressive exposure to physical challenges, and participants found the VR application acceptable and usable as a potential treatment option. Furthermore, the lack of significant change for pain and pain-related fear reflects that participants were able to complete the modules safely. %M 32773381 %R 10.2196/17799 %U http://games.jmir.org/2020/3/e17799/ %U https://doi.org/10.2196/17799 %U http://www.ncbi.nlm.nih.gov/pubmed/32773381 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e17354 %T Designing a Virtual Reality Game for Promoting Empathy Toward Patients With Chronic Pain: Feasibility and Usability Study %A Tong,Xin %A Gromala,Diane %A Kiaei Ziabari,Seyedeh Pegah %A Shaw,Christopher D %+ Simon Fraser University, 250-13450 102 Ave, Surrey, BC, V3T 0A3, Canada, 1 7788911232, tongxint@sfu.ca %K virtual reality %K serious games %K empathy %K chronic pain %K game design %D 2020 %7 7.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Many researchers have been evaluating how digital media may impact the emotional and perspective taking aspects of empathy in both clinical and nonclinical settings. Despite the growing interest in using virtual reality (VR) and VR games to motivate empathy, few studies have focused on empathy for people who live with chronic pain. Objective: Chronic pain affects, by conservative estimates, 1 in 5 people in industrialized countries. Despite this prevalence, public awareness of chronic pain was remarkably low until the recent opioid crisis; as a result, stigma remains a problem frequently faced by people who live with this condition. To address this, the VR game AS IF was developed to increase nonpatients’ empathy toward the growing number of people who live with long-term chronic pain. On the basis of our prior work, we overhauled our approach, designed and built a VR prototype and evaluated it, and offered design suggestions for future research. Methods: We introduced the design features of the VR game AS IF and described the study we devised to evaluate its effectiveness. We adopted a mixed methods approach and compared the empathy-related outcomes in both pre- and posttesting. A total of 19 participants were recruited. Results: The findings of this study suggest that the VR game was effective in improving implicit and explicit empathy as well as its emotional and perspective taking aspects. More specifically, for the Empathy Scale, the total pretest scores (mean 47.33, SD 4.24) and posttest scores (mean 59.22, SD 4.33) did not reach statistical significance (P=.08). However, we did find differences in the subscales. The kindness subscale showed a statistically significant increase in the posttest score (mean 15.61, SD 2.85) compared with the pretest score (mean 17.06, SD 2.65;P=.001). For the Willingness to Help Scale, a significant increase was observed from a t test analysis (P<.001) of scores before (mean 7.17, SD 2.28) and after (mean 8.33, SD 2.03) the gameplay. The effect size for this analysis was large (d=−1.063). Conclusions: The contributions of this research are as follows: AS IF provides a promising approach for designing VR games to motivate people’s empathy toward patients with chronic pain, the study evaluates the potential effectiveness of such a VR approach, and the general design suggestions devised from this study could shed light on future VR game systems. %M 32763883 %R 10.2196/17354 %U http://games.jmir.org/2020/3/e17354/ %U https://doi.org/10.2196/17354 %U http://www.ncbi.nlm.nih.gov/pubmed/32763883 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e17565 %T User Experience of Interactive Technologies for People With Dementia: Comparative Observational Study %A Andrade Ferreira,Luis Duarte %A Ferreira,Henrique %A Cavaco,Sofia %A Cameirão,Mónica %A i Badia,Sergi Bermúdez %+ NOVA LINCS, Dep de Informática, Faculdade de Ciências e Tecnologia, Universidade Nova de Lisboa, Campus de Caparica, Caparica, Lisboa, 2829-516, Portugal, 351 21 294 8300, luis.d.ferreira@m-iti.org %K dementia %K technology %K interaction %K psychomotor performance %K equipment safety %K costs and cost analysis %K user-computer interface %D 2020 %7 5.8.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games (SGs) are used as complementary approaches to stimulate patients with dementia. However, many of the SGs use out-of-the-shelf technologies that may not always be suitable for such populations, as they can lead to negative behaviors, such as anxiety, fatigue, and even cybersickness. Objective: This study aims to evaluate how patients with dementia interact and accept 5 out-of-the-shelf technologies while completing 10 virtual reality tasks. Methods: A total of 12 participants diagnosed with dementia (mean age 75.08 [SD 8.07] years, mean Mini-Mental State Examination score 17.33 [SD 5.79], and mean schooling 5.55 [SD 3.30]) at a health care center in Portugal were invited to participate in this study. A within-subject experimental design was used to allow all participants to interact with all technologies, such as HTC VIVE, head-mounted display (HMD), tablet, mouse, augmented reality (AR), leap motion (LM), and a combination of HMD with LM. Participants’ performance was quantified through behavioral and verbal responses, which were captured through video recordings and written notes. Results: The findings of this study revealed that the user experience using technology was dependent on the patient profile; the patients had a better user experience when they use technologies with direct interaction configuration as opposed to indirect interaction configuration in terms of assistance required (P=.01) and comprehension (P=.01); the participants did not trigger any emotional responses when using any of the technologies; the participants’ performance was task-dependent; the most cost-effective technology was the mouse, whereas the least cost-effective was AR; and all the technologies, except for one (HMD with LM), were not exposed to external hazards. Conclusions: Most participants were able to perform tasks using out-of-the-shelf technologies. However, there is no perfect technology, as they are not explicitly designed to address the needs and skills of people with dementia. Here, we propose a set of guidelines that aim to help health professionals and engineers maximize user experience when using such technologies for the population with dementia. %M 32755894 %R 10.2196/17565 %U http://games.jmir.org/2020/3/e17565/ %U https://doi.org/10.2196/17565 %U http://www.ncbi.nlm.nih.gov/pubmed/32755894 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18822 %T An Immersive Multi-User Virtual Reality for Emergency Simulation Training: Usability Study %A Lerner,Dieter %A Mohr,Stefan %A Schild,Jonas %A Göring,Martin %A Luiz,Thomas %+ Fraunhofer Institute for Experimental Software Engineering, Research Program Digital Healthcare, Fraunhofer-Platz 1, Kaiserslautern, 67663, Germany, 49 631 6800 2148, Thomas.Luiz@iese.fraunhofer.de %K virtual reality %K educational virtual realities %K virtual patient simulation %K virtual emergency scenario %K simulation training %K head-mounted display %K immersive media %K training effectiveness %K presence experience %K anaphylaxis %K emergency medicine %D 2020 %7 31.7.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) is increasingly used as simulation technology in emergency medicine education and training, in particular for training nontechnical skills. Experimental studies comparing teaching and learning in VR with traditional training media often demonstrate the equivalence or even superiority regarding particular variables of learning or training effectiveness. Objective: In the EPICSAVE (Enhanced Paramedic Vocational Training with Serious Games and Virtual Environments) project, a highly immersive room-scaled multi-user 3-dimensional VR simulation environment was developed. In this feasibility study, we wanted to gain initial insights into the training effectiveness and media use factors influencing learning and training in VR. Methods: The virtual emergency scenario was anaphylaxis grade III with shock, swelling of the upper and lower respiratory tract, as well as skin symptoms in a 5-year-old girl (virtual patient) visiting an indoor family amusement park with her grandfather (virtual agent). A cross-sectional, one-group pretest and posttest design was used to evaluate the training effectiveness and quality of the training execution. The sample included 18 active emergency physicians. Results: The 18 participants rated the VR simulation training positive in terms of training effectiveness and quality of the training execution. A strong, significant correlation (r=.53, P=.01) between experiencing presence and assessing training effectiveness was observed. Perceived limitations in usability and a relatively high extraneous cognitive load reduced this positive effect. Conclusions: The training within the virtual simulation environment was rated as an effective educational approach. Specific media use factors appear to modulate training effectiveness (ie, improvement through “experience of presence” or reduction through perceived limitations in usability). These factors should be specific targets in the further development of this VR simulation training. %M 32735548 %R 10.2196/18822 %U https://games.jmir.org/2020/3/e18822 %U https://doi.org/10.2196/18822 %U http://www.ncbi.nlm.nih.gov/pubmed/32735548 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17571 %T Virtual Reality Smartphone-Based Intervention for Smoking Cessation: Pilot Randomized Controlled Trial on Initial Clinical Efficacy and Adherence %A Goldenhersch,Emilio %A Thrul,Johannes %A Ungaretti,Joaquín %A Rosencovich,Nicolas %A Waitman,Cristian %A Ceberio,Marcelo Rodriguez %+ Laboratorio de Investigación en Neurociencia y Ciencias Sociales, Universidad de Flores, Avenida Rivadavia 5741, Ciudad Autónoma de Buenos Aires, CP 1414, Argentina, 1 4808860102, emiliogolden@gmail.com %K smoking cessation %K nicotine dependence %K craving %K virtual reality %K mindfulness %K digital therapy %K mHealth %K mobile phone %D 2020 %7 29.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Obstacles to current tobacco cessation programs include limited access and adherence to effective interventions. Digital interventions offer a great opportunity to overcome these difficulties, yet virtual reality has not been used as a remote and self-administered tool to help increase adherence and effectiveness of digital interventions for tobacco cessation. Objective: This study aimed to evaluate participant adherence and smoking cessation outcomes in a pilot randomized controlled trial of the digital intervention Mindcotine (MindCotine Inc) using a self-administered treatment of virtual reality combined with mindfulness. Methods: A sample of 120 participants was recruited in the city of Buenos Aires, Argentina (mean age 43.20 years, SD 9.50; 57/120, 47.5% female). Participants were randomly assigned to a treatment group (TG), which received a self-assisted 21-day program based on virtual reality mindful exposure therapy (VR-MET) sessions, daily surveys, and online peer-to-peer support moderated by psychologists, or a control group (CG), which received the online version of the smoking cessation manual from the Argentine Ministry of Health. Follow-up assessments were conducted by online surveys at postintervention and 90-day follow-up. The primary outcome was self-reported abstinence at postintervention, with missing data assumed as still smoking. Secondary outcomes included sustained abstinence at 90-day follow-up, adherence to the program, and readiness to quit. Results: Follow-up rates at day 1 were 93% (56/60) for the TG and 100% (60/60) for the CG. At postintervention, the TG reported 23% (14/60) abstinence on that day compared with 5% (3/60) in the CG. This difference was statistically significant (χ21=8.3; P=.004). The TG reported sustained abstinence of 33% (20/60) at 90 days. Since only 20% (12/60) of participants in the CG completed the 90-day follow-up, we did not conduct a statistical comparison between groups at this follow-up time point. Among participants still smoking at postintervention, the TG was significantly more ready to quit compared to the CG (TG: mean 7.71, SD 0.13; CG: mean 7.16, SD 0.13; P=.005). A total of 41% (23/56) of participants completed the treatment in the time frame recommended by the program. Conclusions: Results provide initial support for participant adherence to and efficacy of Mindcotine and warrant testing the intervention in a fully powered randomized trial. However, feasibility of trial follow-up assessment procedures for control group participants needs to be improved. Further research is needed on the impact of VR-MET on long-term outcomes. Trial Registration: ISRCTN Registry ISRCTN50586181; http://www.isrctn.com/ISRCTN50586181 %M 32723722 %R 10.2196/17571 %U http://www.jmir.org/2020/7/e17571/ %U https://doi.org/10.2196/17571 %U http://www.ncbi.nlm.nih.gov/pubmed/32723722 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e17972 %T Results and Guidelines From a Repeated-Measures Design Experiment Comparing Standing and Seated Full-Body Gesture-Based Immersive Virtual Reality Exergames: Within-Subjects Evaluation %A Xu,Wenge %A Liang,Hai-Ning %A He,Qiuyu %A Li,Xiang %A Yu,Kangyou %A Chen,Yuzheng %+ Xi'an Jiaotong-Liverpool University, 111 Ren'ai Road, Suzhou, China, 86 51288161516, haining.liang@xjtlu.edu.cn %K exergames %K immersive virtual reality %K standing exergame %K seated exergame %K exercising %D 2020 %7 27.7.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Although full-body seated exercises have been studied in a wide range of settings (ie, homes, hospitals, and daycare centers), they have rarely been converted to seated exergames. In addition, there is an increasing number of studies on immersive virtual reality (iVR) full-body gesture-based standing exergames, but the suitability and usefulness of seated exergames remain largely unexplored. Objective: This study aimed to evaluate the difference between playing a full-body gesture-based iVR standing exergame and seated exergame in terms of gameplay performance, intrinsic motivation, and motion sickness. Methods: A total of 52 participants completed the experiment. The order of the game mode (standing and sitting) was counterbalanced. Gameplay performance was evaluated by action or gesture completion time and the number of missed gestures. Exertion was measured by the average heart rate (HR) percentage (AvgHR%), increased HR%, calories burned, and the Borg 6-20 questionnaire. Intrinsic motivation was assessed with the Intrinsic Motivation Inventory (IMI), whereas motion sickness was assessed via the Motion Sickness Assessment Questionnaire (MSAQ). In addition, we measured the fear of falling using a 10-point Likert scale questionnaire. Results: Players missed more gestures in the seated exergame than in the standing exergame, but the overall miss rate was low (2.3/120, 1.9%). The analysis yielded significantly higher AvgHR%, increased HR%, calories burned, and Borg 6-20 rating of perceived exertion values for the seated exergame (all P<.001). The seated exergame was rated significantly higher on peripheral sickness (P=.02) and sopite-related sickness (MSAQ) (P=.004) than the standing exergame. The score of the subscale “value/usefulness” from IMI was reported to be higher for the seated exergame than the standing exergame. There was no significant difference between the seated exergame and standing exergame in terms of intrinsic motivation (interest/enjoyment, P=.96; perceived competence, P=.26; pressure/tension, P=.42) and the fear of falling (P=.25). Conclusions: Seated iVR full-body gesture-based exergames can be valuable complements to standing exergames. Seated exergames have the potential to lead to higher exertion, provide higher value to players, and be more applicable in small spaces compared with standing exergames. However, gestures for seated exergames need to be designed carefully to minimize motion sickness, and more time should be given to users to perform gestures in seated exergames compared with standing exergames. %M 32716004 %R 10.2196/17972 %U http://games.jmir.org/2020/3/e17972/ %U https://doi.org/10.2196/17972 %U http://www.ncbi.nlm.nih.gov/pubmed/32716004 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e17096 %T Combination of 3-Dimensional Virtual Reality and Hands-On Aromatherapy in Improving Institutionalized Older Adults’ Psychological Health: Quasi-Experimental Study %A Cheng,Vivian Ya-Wen %A Huang,Chiu-Mieh %A Liao,Jung-Yu %A Hsu,Hsiao-Pei %A Wang,Shih-Wen %A Huang,Su-Fei %A Guo,Jong-Long %+ Department of Health Promotion and Health Education, College of Education, National Taiwan Normal University, 162, Section 1, He-ping East Road, Taipei, 10610, Taiwan, 886 277493705, jonglong@ntnu.edu.tw %K three-dimensional %K virtual reality %K aromatherapy %K older adult %K happiness %K stress %K sleep quality %K meditation %K life satisfaction %D 2020 %7 23.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: In Taiwan, which has one of the most rapidly aging populations in the world, it is becoming increasingly critical to promote successful aging strategies that are effective, easily usable, and acceptable to institutionalized older adults. Although many practitioners and professionals have explored aromatherapy and identified its psychological benefits, the effectiveness of combining 3-dimensional (3D) virtual reality and hands-on aromatherapy remains unknown. Objective: A quasi-experimental trial was designed to evaluate the effectiveness of this combination in lowering perceived stress and promoting happiness, sleep quality, meditation experience, and life satisfaction among institutionalized older adults in Taiwan. Methods: A total of 60 institutionalized elderly participants either received the combined intervention or were in a control group. Weekly 2-hour sessions were implemented over 9 weeks. The outcome variables were happiness, perceived stress, sleep quality, meditation experience, and life satisfaction, which were assessed at baseline and after the intervention. Results: Generalized estimating equation (GEE) analyses indicated that the experimental group showed significant post-intervention improvements in terms of scores for happiness, perceived stress, sleep quality, meditation experience, and life satisfaction (n=48; all P<.001). Another GEE analysis showed that the significant improvements in the 5 outcome variables persisted in participants aged 80 years and older (n=35; all P<.001). Conclusions: This is the first trial to explore the effectiveness of a combination of 3D virtual reality and hands-on aromatherapy in improving older adults’ psychological health. The results are promising for the promotion of psychological health in institutionalized older adults. Trial Registration: ClinicalTrials.gov NCT04324216; https://clinicaltrials.gov/ct2/show/NCT04324216. %M 32706660 %R 10.2196/17096 %U http://www.jmir.org/2020/7/e17096/ %U https://doi.org/10.2196/17096 %U http://www.ncbi.nlm.nih.gov/pubmed/32706660 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19752 %T Synthesizing Multiple Stakeholder Perspectives on Using Virtual Reality to Improve the Periprocedural Experience in Children and Adolescents: Survey Study %A Ahmadpour,Naseem %A Weatherall,Andrew David %A Menezes,Minal %A Yoo,Soojeong %A Hong,Hanyang %A Wong,Gail %+ Design Lab, School of Architecture, Design and Planning, The University of Sydney, 148 City Road, Darlington, NSW, 2006, Australia, 61 286275649, naseem.ahmadpour@sydney.edu.au %K virtual reality %K periprocedural anxiety %K children %K adolescents %K stakeholder perspective %K design %K VR %K pediatrics %K patient experience %K app %K eHealth %D 2020 %7 17.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) technology is a powerful tool for augmenting patient experience in pediatric settings. Incorporating the needs and values of stakeholders in the design of VR apps in health care can contribute to better outcomes and meaningful experiences for patients. Objective: We used a multiperspective approach to investigate how VR apps can be designed to improve the periprocedural experiences of children and adolescents, particularly those with severe anxiety. Methods: This study included a focus group (n=4) and a survey (n=56) of clinicians. Semistructured interviews were conducted with children and adolescents in an immunization clinic (n=3) and perioperative setting (n=65) and with parents and carers in an immunization clinic (n=3) and perioperative setting (n=35). Results: Qualitative data were examined to determine the experience and psychological needs and intervention and design strategies that may contribute to better experiences for children in three age groups (4-7, 8-11, and 12-17 years). Quantitative data were used to identify areas of priority for future VR interventions. Conclusions: We propose a set of ten design considerations for the creation of future VR experiences for pediatric patients. Enhancing patient experience may be achieved by combining multiple VR solutions through a holistic approach considering the roles of clinicians and carers and the temporality of the patient’s experience. These situations require personalized solutions to fulfill the needs of pediatric patients before and during the medical procedure. In particular, communication should be placed at the center of preprocedure solutions, while emotional goals can be embedded into a procedure-focused VR app to help patients shift their focus in a meaningful way to build skills to manage their anxiety. %M 32706671 %R 10.2196/19752 %U http://www.jmir.org/2020/7/e19752/ %U https://doi.org/10.2196/19752 %U http://www.ncbi.nlm.nih.gov/pubmed/32706671 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 3 %P e18313 %T Immersive Virtual Reality for the Reduction of State Anxiety in Clinical Interview Exams: Prospective Cohort Study %A Concannon,Brendan Joseph %A Esmail,Shaniff %A Roduta Roberts,Mary %+ Department of Occupational Therapy, University of Alberta, 8205 - 114 St 2-64 Corbett Hall, Edmonton, AB, T6G 2G4, Canada, 1 780 492 2499, mroberts@ualberta.ca %K virtual reality %K VR %K head-mounted display %K HMD %K immersive technology %K occupational therapy %K OSCE %K simulation %K psychology %K anxiety %D 2020 %7 9.7.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Immersive virtual reality (VR) with head-mounted display was used to determine if clinical interview simulation could reduce the anxiety levels of first-year occupational therapy (OT) students as they prepared for upcoming Objective Structured Clinical Examinations (OSCEs). Anxiety among health science students is a potential problem that may diminish their performance during OSCEs. This investigation aimed to fill the gap in the literature regarding the effectiveness of VR to reduce anxiety in OT students. Objective: This investigation aimed to uncover the effectiveness of immersive VR in reducing state anxiety in OT students who were preparing for OSCEs. Methods: A prospective, experimental, nonrandomized controlled trial compared levels of state anxiety, test anxiety, and academic self-efficacy in two groups of first-year OT students; these levels were measured at four different time points by self-reported psychometric scales, analyzed with a mixed factorial analysis of variance (ANOVA). Members of Phase 1 (NoVR) were not exposed to the VR simulation and acted as a control group for members of Phase 2 (YesVR), who were exposed to the VR simulation. VR simulation featured a virtual clinic and a standardized patient who students could interview in natural language. Measures of student study strategies and previous experience with VR were also recorded. Results: A total of 49 participants—29 in the NoVR group and 20 in the YesVR group—showed that state anxiety had a rise-then-fall trend, peaking at the time point just before the OSCE. At that point, the YesVR students showed significantly less state anxiety than did the NoVR students (t46.19=2.34, P=.02, Cohen d=0.65, ηp2=0.105). The mean difference was 6.78 units (95% CI 0.96-12.61). In similar trends for both groups, student test anxiety remained relatively static across the time points, while academic self-efficacy continually increased. A moderate positive correlation was found for total time spent studying and peak state anxiety (NoVR r=.46, n=28, P=.01; YesVR r=.52, n=19, P=.02). Conclusions: This investigation shows evidence of immersive VR’s capability to reduce state anxiety in OT students preparing for clinical practical exams. Immersive VR simulation, used for the reduction of anxiety in health science students, can potentially lead to a future of positive mental health change from the virtual to the real world. %M 32673223 %R 10.2196/18313 %U http://games.jmir.org/2020/3/e18313/ %U https://doi.org/10.2196/18313 %U http://www.ncbi.nlm.nih.gov/pubmed/32673223 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e14178 %T A Virtual Reality–Supported Intervention for Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease: Mixed Methods Study %A Jung,Timothy %A Moorhouse,Natasha %A Shi,Xin %A Amin,Muhammad Farhan %+ Manchester Metropolitan University, Business School, Oxford Road, Manchester, M15 6BH, United Kingdom, 44 7527423967, x.shi@mmu.ac.uk %K virtual reality %K COPD %K rehabilitation %D 2020 %7 7.7.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The uptake of traditional pulmonary rehabilitation classes by patients with chronic obstructive pulmonary disease (COPD) is poor because of personal factors that prevent accessibility to the venue. Therefore, there is a need for innovative methods of pulmonary rehabilitation, and virtual reality (VR) could be a promising technology for patients with COPD to access services remotely. Objective: This study aimed to investigate whether VR improves compliance with pulmonary rehabilitation among patients with COPD, a particularly vulnerable patient group (Medical Research Council [MRC] 4 or 5), and whether VR provides a credible alternative to traditional pulmonary rehabilitation programs. Methods: This was an 8-week patient trial using an innovative VR pulmonary rehabilitation program. A purposive sample of 10 patients with COPD graded MRC 4 or 5 and registered at a selected health care center and a hospital in Cumbria, United Kingdom, were included. Qualitative (focus groups and interviews) data were collected, and to further support the qualitative findings, quantitative data (self-report patient surveys) were gathered before and after the 8-week trial. The 5 self-reported surveys included the Patient Activation Measure, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, Short Physical Performance Battery, and the Edmonton Frail Scale. Results: In a thematic analysis of the qualitative data, 11 themes emerged specific to delivering pulmonary rehabilitation using VR. The quantitative data further support the qualitative findings by revealing significant improvements in all physical measures. Conclusions: Overall, this study demonstrates how remotely supervised VR-based pulmonary rehabilitation could help to overcome current issues and limitations associated with providing this service to patients with COPD at scale. %M 32673224 %R 10.2196/14178 %U https://www.jmir.org/2020/7/e14178 %U https://doi.org/10.2196/14178 %U http://www.ncbi.nlm.nih.gov/pubmed/32673224 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e17293 %T Self-Administered Skills-Based Virtual Reality Intervention for Chronic Pain: Randomized Controlled Pilot Study %A Darnall,Beth D %A Krishnamurthy,Parthasarathy %A Tsuei,Jeannette %A Minor,Jorge D %+ Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, MC 5596, Palo Alto, CA, 94304, United States, 1 (650) 725 9642, bdarnall@stanford.edu %K chronic pain %K virtual reality %K behavioral medicine %K self-management %K mobile phone %K randomized controlled trial %D 2020 %7 7.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Patients with chronic pain often have limited access to comprehensive care that includes behavioral pain management strategies. Virtual reality (VR) is an immersive technology and emerging digital behavioral pain therapy with analgesic efficacy for acute pain. We found no scientific literature on skills-based VR behavioral programs for chronic pain populations. Objective: The primary aim of this study is to evaluate the feasibility of a self-administered VR program that included content and skills informed by evidence-based behavioral treatment for chronic pain. The secondary aim is to determine the preliminary efficacy of the VR program in terms of average pain intensity and pain-related interference with activity, stress, mood, and sleep, and its impact on pain-related cognition and self-efficacy. The tertiary aim was to conduct a randomized controlled trial (RCT) and compare the VR treatment with an audio-only treatment. This comparison isolated the immersive effects of the VR program, thereby informing potential mechanisms of effect. Methods: We conducted an RCT involving a web-based convenience sample of adults (N=97) aged 18-75 years with self-reported chronic nonmalignant low back pain or fibromyalgia, with an average pain intensity >4 over the past month and chronic pain duration >6 months. Enrolled participants were randomly assigned to 1 of 2 unblinded treatments: (1) VR: a 21-day, skills-based VR program for chronic pain; and (2) audio: an audio-only version of the 21-day VR program. The analytic data set included participants who completed at least 1 of 8 surveys administered during the intervention period: VR (n=39) and audio (n=35). Results: The VR and audio groups launched a total of 1067 and 1048 sessions, respectively. The majority of VR participants (n=19/25, 76%) reported no nausea or motion sickness. High satisfaction ratings were reported for VR (n=24/29, 83%) and audio (n=26/33, 72%). For VR efficacy, symptom improvement over time was found for each pain variable (all P<.001), with results strengthening after 2 weeks. Importantly, significant time×group effects were found in favor of the VR group for average pain intensity (P=.04), pain-related inference with activity (P=.005), sleep (P<.001), mood (P<.001), and stress (P=.003). For pain catastrophizing and pain self-efficacy, we found a significant declining trend for both treatment groups. Conclusions: High engagement and satisfaction combined with low levels of adverse effects support the feasibility and acceptability of at-home skills-based VR for chronic pain. A significant reduction in pain outcomes over the course of the 21-day treatment both within the VR group and compared with an audio-only version suggests that VR has the potential to provide enhanced treatment and greater improvement across a range of pain outcomes. These findings provide a foundation for future research on VR behavioral interventions for chronic pain. %M 32374272 %R 10.2196/17293 %U https://formative.jmir.org/2020/7/e17293 %U https://doi.org/10.2196/17293 %U http://www.ncbi.nlm.nih.gov/pubmed/32374272 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17632 %T Using Virtual Reality to Improve Apathy in Residential Aged Care: Mixed Methods Study %A Saredakis,Dimitrios %A Keage,Hannah AD %A Corlis,Megan %A Loetscher,Tobias %+ University of South Australia, St Bernards Road, Magill, South Australia, Adelaide, 5072, Australia, 61 08 8302 4083, dimitrios.saredakis@mymail.unisa.edu.au %K reminiscence %K head-mounted display %K apathy %K cognitive aging %K dementia %K residential facilities %K virtual reality %D 2020 %7 26.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Apathy is a common symptom in neurological disorders, including dementia, and is associated with a faster rate of cognitive decline, reduced quality of life, and high caregiver burden. There is a lack of effective pharmacological treatments for apathy, and nonpharmacological interventions are a preferred first-line approach to treatment. Virtual reality (VR) using head-mounted displays (HMDs) is being successfully used in exposure- and distraction-based therapies; however, there is limited research on using HMDs for symptoms of neurological disorders. Objective: This feasibility study aimed to assess whether VR using HMDs could be used to deliver tailored reminiscence therapy and examine the willingness to participate, response rates to measures, time taken to create tailored content, and technical problems. In addition, this study aimed to explore the immediate effects between verbal fluency and apathy after exposure to VR. Methods: A mixed methods study was conducted in a sample of older adults residing in aged care, and 17 participants were recruited. Apathy was measured using the Apathy Evaluation Scale (AES), and verbal fluency was used as a proxy measure of improvements in apathy and debriefing interviews to assess feedback from participants. Side effects that can occur from using HMDs were also measured. Results: We recruited participants from a high socioeconomic status setting with a high education level, and the participation rate was 85% (17/20); most responses to measures were positive. Access to a wide range of freely available content and the absence of technical difficulties made the delivery of a VR reminiscence intervention highly feasible. Participants had improved semantic scores (t14=−3.27; P=.006) but not phonemic fluency scores (t14=0.55; P=.59) immediately after the intervention. Those with higher levels of apathy demonstrated the greatest cognitive improvements after a VR reminiscence experience, which was indicated by a strong positive relationship between the AES and semantic verbal fluency change scores postminus pre-VR (r=0.719; 95% CI 0.327 to 0.900; P=.003). All participants enjoyed the experience despite 35% (6/17) of participants experiencing temporary side effects. Conclusions: This study provides initial evidence that it is feasible to use VR with HMDs for therapy to treat symptoms of apathy in older adults in residential aged care. However, there is a need to closely monitor the side effects of HMD use in older adults. Further research is needed using an active control group to compare the use of VR with traditional forms of reminiscence therapy. %M 32469314 %R 10.2196/17632 %U http://www.jmir.org/2020/6/e17632/ %U https://doi.org/10.2196/17632 %U http://www.ncbi.nlm.nih.gov/pubmed/32469314 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e13995 %T Simulator Pre-Screening of Underprepared Drivers Prior to Licensing On-Road Examination: Clustering of Virtual Driving Test Time Series Data %A Grethlein,David %A Winston,Flaura Koplin %A Walshe,Elizabeth %A Tanner,Sean %A Kandadai,Venk %A Ontañón,Santiago %+ Diagnostic Driving, Inc, 705 S 50th Street, Philadelphia, PA, 19143, United States, 1 215 315 3204, david@diagnosticdriving.com %K simulated driving assessment %K on-road exam %K machine learning %K adolescent %K child %K support vector machines %K humans %K accidents, traffic %K cause of death %K licensure %K automobile driving %K motor vehicle %K motor vehicles %D 2020 %7 18.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: A large Midwestern state commissioned a virtual driving test (VDT) to assess driving skills preparedness before the on-road examination (ORE). Since July 2017, a pilot deployment of the VDT in state licensing centers (VDT pilot) has collected both VDT and ORE data from new license applicants with the aim of creating a scoring algorithm that could predict those who were underprepared. Objective: Leveraging data collected from the VDT pilot, this study aimed to develop and conduct an initial evaluation of a novel machine learning (ML)–based classifier using limited domain knowledge and minimal feature engineering to reliably predict applicant pass/fail on the ORE. Such methods, if proven useful, could be applicable to the classification of other time series data collected within medical and other settings. Methods: We analyzed an initial dataset that comprised 4308 drivers who completed both the VDT and the ORE, in which 1096 (25.4%) drivers went on to fail the ORE. We studied 2 different approaches to constructing feature sets to use as input to ML algorithms: the standard method of reducing the time series data to a set of manually defined variables that summarize driving behavior and a novel approach using time series clustering. We then fed these representations into different ML algorithms to compare their ability to predict a driver’s ORE outcome (pass/fail). Results: The new method using time series clustering performed similarly compared with the standard method in terms of overall accuracy for predicting pass or fail outcome (76.1% vs 76.2%) and area under the curve (0.656 vs 0.682). However, the time series clustering slightly outperformed the standard method in differentially predicting failure on the ORE. The novel clustering method yielded a risk ratio for failure of 3.07 (95% CI 2.75-3.43), whereas the standard variables method yielded a risk ratio for failure of 2.68 (95% CI 2.41-2.99). In addition, the time series clustering method with logistic regression produced the lowest ratio of false alarms (those who were predicted to fail but went on to pass the ORE; 27.2%). Conclusions: Our results provide initial evidence that the clustering method is useful for feature construction in classification tasks involving time series data when resources are limited to create multiple, domain-relevant variables. %M 32554384 %R 10.2196/13995 %U https://www.jmir.org/2020/6/e13995 %U https://doi.org/10.2196/13995 %U http://www.ncbi.nlm.nih.gov/pubmed/32554384 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e15635 %T Virtual Reality Games and the Role of Body Involvement in Enhancing Positive Emotions and Decreasing Anxiety: Within-Subjects Pilot Study %A Pallavicini,Federica %A Pepe,Alessandro %+ Department of Human Sciences for Education, University of Milano-Bicocca, Piazza dell'Ateneo Nuovo 1, Milan, 20100, Italy, 39 0264484903, federica.pallavicini@gmail.com %K virtual reality %K virtual reality gaming %K video games %K emotions %K positive emotions %K anxiety %K state anxiety %D 2020 %7 17.6.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: In the last few years, the introduction of immersive technologies, especially virtual reality, into the gaming market has dramatically altered the traditional concept of video games. Given the unique features of virtual reality in terms of interaction and its ability to completely immerse the individual into the game, this technology should increase the propensity for video games to effectively elicit positive emotions and decrease negative emotions and anxiety in the players. However, to date, few studies have investigated the ability of virtual reality games to induce positive emotions, and the possible effect of this new type of video game in diminishing negative emotions and anxiety has not yet been tested. Furthermore, given the critical role of body movement in individuals’ well-being and in emotional responses to video games, it seems critical to investigate how body involvement can be exploited to modulate the psychological benefits of virtual reality games in terms of enhancing players’ positive emotions and decreasing negative emotions and anxiety. Objective: This within-subjects study aimed to explore the ability of commercial virtual reality games to induce positive emotions and diminish negative emotions and state anxiety of the players, investigating the effects of the level of body involvement requested by the game (ie, high vs low). Methods: A total of 36 young adults played a low body-involvement (ie, Fruit Ninja VR) and a high body-involvement (ie, Audioshield) video game in virtual reality. The Visual Analogue Scale (VAS) and the State-Trait Anxiety Inventory, Form-Y1 (STAI-Y1) were used to assess positive and negative emotions and state anxiety. Results: Results of the generalized linear model (GLM) for repeated-measures multivariate analysis of variance (MANOVA) revealed a statistically significant increase in the intensity of happiness (P<.001) and surprise (P=.003) and, in parallel, a significant decrease in fear (P=.01) and sadness (P<.001) reported by the users. Regarding the ability to improve anxiety in the players, the results showed a significant decrease in perceived state anxiety after game play, assessed with both the STAI-Y1 (P=.003) and the VAS-anxiety (P=.002). Finally, the results of the GLM MANOVA showed a greater efficacy of the high body-involvement game (ie, Audioshield) compared to the low body-involvement game (ie, Fruit Ninja VR), both for eliciting positive emotions (happiness, P<.001; and surprise, P=.01) and in reducing negative emotions (fear, P=.05; and sadness, P=.05) and state anxiety, as measured by the STAI-Y1 (P=.05). Conclusions: The two main principal findings of this study are as follows: (1) virtual reality video games appear to be effective tools to elicit positive emotions and to decrease negative emotions and state anxiety in individuals and (2) the level of body involvement of the virtual video game has an important effect in determining the ability of the game to improve positive emotions and decrease negative emotions and state anxiety of the players. %M 32554371 %R 10.2196/15635 %U http://games.jmir.org/2020/2/e15635/ %U https://doi.org/10.2196/15635 %U http://www.ncbi.nlm.nih.gov/pubmed/32554371 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17945 %T Physiological State and Learning Ability of Students in Normal and Virtual Reality Conditions: Complexity-Based Analysis %A Babini,Mohammad H %A Kulish,Vladimir V %A Namazi,Hamidreza %+ School of Engineering, Monash University, Jalan Lagoon Selatan, Subang Jaya, 47500, Malaysia, 60 172757619, hamidreza.namazi@monash.edu %K virtual reality %K learning ability %K brain %K facial muscle %K fractal theory %D 2020 %7 1.6.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Education and learning are the most important goals of all universities. For this purpose, lecturers use various tools to grab the attention of students and improve their learning ability. Virtual reality refers to the subjective sensory experience of being immersed in a computer-mediated world, and has recently been implemented in learning environments. Objective: The aim of this study was to analyze the effect of a virtual reality condition on students’ learning ability and physiological state. Methods: Students were shown 6 sets of videos (3 videos in a two-dimensional condition and 3 videos in a three-dimensional condition), and their learning ability was analyzed based on a subsequent questionnaire. In addition, we analyzed the reaction of the brain and facial muscles of the students during both the two-dimensional and three-dimensional viewing conditions and used fractal theory to investigate their attention to the videos. Results: The learning ability of students was increased in the three-dimensional condition compared to that in the two-dimensional condition. In addition, analysis of physiological signals showed that students paid more attention to the three-dimensional videos. Conclusions: A virtual reality condition has a greater effect on enhancing the learning ability of students. The analytical approach of this study can be further extended to evaluate other physiological signals of subjects in a virtual reality condition. %M 32478661 %R 10.2196/17945 %U https://www.jmir.org/2020/6/e17945 %U https://doi.org/10.2196/17945 %U http://www.ncbi.nlm.nih.gov/pubmed/32478661 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 6 %P e17331 %T The Role of Virtual Reality in Improving Health Outcomes for Community-Dwelling Older Adults: Systematic Review %A Dermody,Gordana %A Whitehead,Lisa %A Wilson,Graham %A Glass,Courtney %+ School of Nursing and Midwifery, Edith Cowan University, 270 Joondalup Drive, Joondalup, 6027, Australia, 61 8 6304 3470, g.dermody@ecu.edu.au %K virtual reality %K aged %K aged, 80 and over %K outcome assessment, health care %K independent living %K systematic review %D 2020 %7 1.6.2020 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) delivered through immersive headsets creates an opportunity to deliver interventions to improve physical, mental, and psychosocial health outcomes. VR app studies with older adults have primarily focused on rehabilitation and physical function including gait, balance, fall prevention, pain management, and cognition. Several systematic reviews have previously been conducted, but much of the extant literature is focused on rehabilitation or other institutional settings, and little is known about the effectiveness of VR apps using immersive headsets to target health outcomes among community-dwelling older adults. Objective: The objective of this review was to evaluate the effectiveness of VR apps delivered using commercially available immersive headsets to improve physical, mental, or psychosocial health outcomes in community-dwelling older adults. Methods: Peer-reviewed publications that included community-dwelling older adults aged ≥60 years residing in residential aged care settings and nursing homes were included. This systematic review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews of effectiveness evidence. The title of this review was registered with JBI, and the systematic review protocol was registered with the International Prospective Register of Systematic Reviews. Results: In total, 7 studies that specifically included community-dwelling older adults were included in this review. VR apps using a head-mounted display led to improvements in a number of health outcomes, including pain management, posture, cognitive functioning specifically related to Alzheimer disease, and a decreased risk of falls. A total of 6 studies reported a statistically significant difference post VR intervention, and 1 study reported an improvement in cognitive function to reduce navigational errors. Only one study reported on the usability and acceptability of the interventions delivered through VR. While one study used a distraction mechanism for pain management, none of the studies used gaming technology to promote enjoyment. Conclusions: Interventions to improve health outcomes through VR have demonstrated potential; however, the ability to synthesize findings by primary outcome for the older adult population is not possible. A number of factors, especially related to frailty, usability, and acceptability, also need to be explored before more substantial recommendations on the effectiveness of VR interventions for older adults can be made. Trial Registration: PROSPERO CRD42019143504; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=143504 %M 32478662 %R 10.2196/17331 %U https://www.jmir.org/2020/6/e17331 %U https://doi.org/10.2196/17331 %U http://www.ncbi.nlm.nih.gov/pubmed/32478662 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e14910 %T Augmented Reality Learning Environment for Basic Life Support and Defibrillation Training: Usability Study %A Ingrassia,Pier Luigi %A Mormando,Giulia %A Giudici,Eleonora %A Strada,Francesco %A Carfagna,Fabio %A Lamberti,Fabrizio %A Bottino,Andrea %+ SIMNOVA - Centro di Simulazione in Medicina e Professioni Sanitarie, Università del Piemonte Orientale, Via Lanino 1, Novara, 28100, Italy, 39 3294212083, pierluigi.ingrassia@med.uniupo.it %K augmented reality %K cardiopulmonary resuscitation %K automated external defibrillators %D 2020 %7 12.5.2020 %9 Short Paper %J J Med Internet Res %G English %X Background: Basic life support (BLS) is crucial in the emergency response system, as sudden cardiac arrest is still a major cause of death worldwide. Unfortunately, only a minority of victims receive cardiopulmonary resuscitation (CPR) from bystanders. In this context, training could be helpful to save more lives, and technology-enhanced BLS simulation is one possible solution. Objective: The aim of this study is to assess the feasibility and acceptability of our augmented reality (AR) prototype as a tool for BLS training. Methods: Holo-BLSD is an AR self-instruction training system, in which a standard CPR manikin is “augmented” with an interactive virtual environment that reproduces realistic scenarios. Learners can use natural gestures, body movements, and spoken commands to perform their tasks, with virtual 3D objects anchored to the manikin and the environment. During the experience, users were trained to use the device while being guided through an emergency simulation and, at the end, were asked to complete a survey to assess the feasibility and acceptability of the proposed tool (5-point Likert scale; 1=Strongly Disagree, 5=Strongly Agree). Results: The system was rated easy to use (mean 4.00, SD 0.94), and the trainees stated that most people would learn to use it very quickly (mean 4.00, SD 0.89). Voice (mean 4.48, SD 0.87), gaze (mean 4.12, SD 0.97), and gesture interaction (mean 3.84, SD 1.14) were judged positively, although some hand gesture recognition errors reduced the feeling of having the right level of control over the system (mean 3.40, SD 1.04). Conclusions: We found the Holo-BLSD system to be a feasible and acceptable tool for AR BLS training. %M 32396128 %R 10.2196/14910 %U https://www.jmir.org/2020/5/e14910 %U https://doi.org/10.2196/14910 %U http://www.ncbi.nlm.nih.gov/pubmed/32396128 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e14369 %T Can Social Communication Skills for Children Diagnosed With Autism Spectrum Disorder Rehearsed Inside the Video Game Environment of Minecraft Generalize to the Real World? %A Cadieux,Lee %A Keenan,Mickey %+ School of Arts and Humanities, Ulster University, MA205 Magee Campus, Northland Road, Londonderry, BT48 7JL, United Kingdom, 44 2871675025, l.cadieux@ulster.ac.uk %K autism %K behavior analysis %K serious games %K social skills %K gamification %K Lego %K neurodiversity %K Minecraft %K virtual worlds %K virtual reality %D 2020 %7 12.5.2020 %9 Viewpoint %J JMIR Serious Games %G English %X In this paper, we outline opportunities within the video game environment for building skills applicable to real-world issues faced by some children. The game Minecraft is extremely popular and of particular interest to children diagnosed with autism spectrum disorder. Although the game has been used by support communities to facilitate the social interaction of children and peer support for their parents, little has been done to examine how social skills developed within the game environment generalize to the real world. Social Craft aims to establish a framework in which key social communication skills would be rehearsed in-game with a view to facilitating their replication in a similarly contained real-world environment. Central to this approach is an understanding of the basic principles of behavior and the engagement of a sound methodology for the collection of data inside and outside the respective environments. %M 32396129 %R 10.2196/14369 %U http://games.jmir.org/2020/2/e14369/ %U https://doi.org/10.2196/14369 %U http://www.ncbi.nlm.nih.gov/pubmed/32396129 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e17098 %T Cost-Effectiveness of Virtual Reality Cognitive Behavioral Therapy for Psychosis: Health-Economic Evaluation Within a Randomized Controlled Trial %A Pot-Kolder,Roos %A Veling,Wim %A Geraets,Chris %A Lokkerbol,Joran %A Smit,Filip %A Jongeneel,Alyssa %A Ising,Helga %A van der Gaag,Mark %+ Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Van der Boechorststraat 7, Amsterdam, 1081 BT, Netherlands, 31 641034764, roos.potkolder@gmail.com %K psychosis %K virtual reality %K cognitive behavioral therapy %K cost-effectiveness %D 2020 %7 5.5.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Evidence was found for the effectiveness of virtual reality-based cognitive behavioral therapy (VR-CBT) for treating paranoia in psychosis, but health-economic evaluations are lacking. Objective: This study aimed to determine the short-term cost-effectiveness of VR-CBT. Methods: The health-economic evaluation was embedded in a randomized controlled trial evaluating VR-CBT in 116 patients with a psychotic disorder suffering from paranoid ideation. The control group (n=58) received treatment as usual (TAU) for psychotic disorders in accordance with the clinical guidelines. The experimental group (n=58) received TAU complemented with add-on VR-CBT to reduce paranoid ideation and social avoidance. Data were collected at baseline and at 3 and 6 months postbaseline. Treatment response was defined as a pre-post improvement of symptoms of at least 20% in social participation measures. Change in quality-adjusted life years (QALYs) was estimated by using Sanderson et al’s conversion factor to map a change in the standardized mean difference of Green’s Paranoid Thoughts Scale score on a corresponding change in utility. The incremental cost-effectiveness ratios were calculated using 5000 bootstraps of seemingly unrelated regression equations of costs and effects. The cost-effectiveness acceptability curves were graphed for the costs per treatment responder gained and per QALY gained. Results: The average mean incremental costs for a treatment responder on social participation ranged between €8079 and €19,525, with 90.74%-99.74% showing improvement. The average incremental cost per QALY was €48,868 over the 6 months of follow-up, with 99.98% showing improved QALYs. Sensitivity analyses show costs to be lower when relevant baseline differences were included in the analysis. Average costs per treatment responder now ranged between €6800 and €16,597, while the average cost per QALY gained was €42,030. Conclusions: This study demonstrates that offering VR-CBT to patients with paranoid delusions is an economically viable approach toward improving patients’ health in a cost-effective manner. Long-term effects need further research. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 12929657; http://www.isrctn.com/ISRCTN12929657 %M 32369036 %R 10.2196/17098 %U https://www.jmir.org/2020/5/e17098 %U https://doi.org/10.2196/17098 %U http://www.ncbi.nlm.nih.gov/pubmed/32369036 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 2 %P e17807 %T Experiences of Gamified and Automated Virtual Reality Exposure Therapy for Spider Phobia: Qualitative Study %A Lindner,Philip %A Rozental,Alexander %A Jurell,Alice %A Reuterskiöld,Lena %A Andersson,Gerhard %A Hamilton,William %A Miloff,Alexander %A Carlbring,Per %+ Department of Psychology, Stockholm University, Frescati hagväg 8, 104 05, Stockholm, , Sweden, 46 704522587, philip.lindner@ki.se %K virtual reality %K gamification %K serious game %K exposure therapy %K phobia %K user experience %D 2020 %7 29.4.2020 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality exposure therapy is an efficacious treatment of anxiety disorders, and recent research suggests that such treatments can be automated, relying on gamification elements instead of a real-life therapist directing treatment. Such automated, gamified treatments could be disseminated without restrictions, helping to close the treatment gap for anxiety disorders. Despite initial findings suggesting high efficacy, very is little is known about how users experience this type of intervention. Objective: The aim of this study was to examine user experiences of automated, gamified virtual reality exposure therapy using in-depth qualitative methods. Methods: Seven participants were recruited from a parallel clinical trial comparing automated, gamified virtual reality exposure therapy for spider phobia against an in vivo exposure equivalent. Participants received the same virtual reality treatment as in the trial and completed a semistructured interview afterward. The transcribed material was analyzed using thematic analysis. Results: Many of the uncovered themes pertained directly or indirectly to a sense of presence in the virtual environment, both positive and negative. The automated format was perceived as natural and the gamification elements appear to have been successful in framing the experience not as psychotherapy devoid of a therapist but rather as a serious game with a psychotherapeutic goal. Conclusions: Automated, gamified virtual reality exposure therapy appears to be an appealing treatment modality and to work by the intended mechanisms. Findings from the current study may guide the next generation of interventions and inform dissemination efforts and future qualitative research into user experiences. %M 32347803 %R 10.2196/17807 %U http://games.jmir.org/2020/2/e17807/ %U https://doi.org/10.2196/17807 %U http://www.ncbi.nlm.nih.gov/pubmed/32347803 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e16724 %T Multidimensional Evaluation of Virtual Reality Paradigms in Clinical Neuropsychology: Application of the VR-Check Framework %A Krohn,Stephan %A Tromp,Johanne %A Quinque,Eva M %A Belger,Julia %A Klotzsche,Felix %A Rekers,Sophia %A Chojecki,Paul %A de Mooij,Jeroen %A Akbal,Mert %A McCall,Cade %A Villringer,Arno %A Gaebler,Michael %A Finke,Carsten %A Thöne-Otto,Angelika %+ Department of Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany, 49 30 45050, stephan.krohn@charite.de %K virtual reality %K neuropsychology %K cognition %K research design %D 2020 %7 27.4.2020 %9 Viewpoint %J J Med Internet Res %G English %X Virtual reality (VR) represents a key technology of the 21st century, attracting substantial interest from a wide range of scientific disciplines. With regard to clinical neuropsychology, a multitude of new VR applications are being developed to overcome the limitations of classical paradigms. Consequently, researchers increasingly face the challenge of systematically evaluating the characteristics and quality of VR applications to design the optimal paradigm for their specific research question and study population. However, the multifaceted character of contemporary VR is not adequately captured by the traditional quality criteria (ie, objectivity, reliability, validity), highlighting the need for an extended paradigm evaluation framework. To address this gap, we propose a multidimensional evaluation framework for VR applications in clinical neuropsychology, summarized as an easy-to-use checklist (VR-Check). This framework rests on 10 main evaluation dimensions encompassing cognitive domain specificity, ecological relevance, technical feasibility, user feasibility, user motivation, task adaptability, performance quantification, immersive capacities, training feasibility, and predictable pitfalls. We show how VR-Check enables systematic and comparative paradigm optimization by illustrating its application in an exemplary research project on the assessment of spatial cognition and executive functions with immersive VR. This application furthermore demonstrates how the framework allows researchers to identify across-domain trade-offs, makes deliberate design decisions explicit, and optimizes the allocation of study resources. Complementing recent approaches to standardize clinical VR studies, the VR-Check framework enables systematic and project-specific paradigm optimization for behavioral and cognitive research in neuropsychology. %M 32338614 %R 10.2196/16724 %U https://www.jmir.org/2020/4/e16724 %U https://doi.org/10.2196/16724 %U http://www.ncbi.nlm.nih.gov/pubmed/32338614 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e16386 %T Bringing Virtual Reality From Clinical Trials to Clinical Practice for the Treatment of Eating Disorders: An Example Using Virtual Reality Cue Exposure Therapy %A Brown,Theresa %A Nauman Vogel,Emily %A Adler,Sarah %A Bohon,Cara %A Bullock,Kim %A Nameth,Katherine %A Riva,Giuseppe %A Safer,Debra L %A Runfola,Cristin D %+ Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Rd, Stanford, CA, 94304, United States, 1 650 498 9111, dlsafer@stanford.edu %K virtual reality %K exposure therapy %K eating disorders %K translational research %K technological innovation %D 2020 %7 23.4.2020 %9 Viewpoint %J J Med Internet Res %G English %X Novel treatment options for eating disorders (EDs) are critically needed to enhance treatment outcomes and reduce the rates of treatment dropouts. On average, only 50% of individuals receiving evidence-based care remit, whereas 24% drop out before treatment completion. One particularly promising direction involves integrating virtual reality (VR) with existing evidence-based treatments (EBTs) such as cue exposure therapy (CET). Across psychiatric disorders, VR-based interventions are demonstrating at least preliminary efficacy and noninferiority to traditional treatments. Furthermore, VR technology has become increasingly portable, resulting in improved acceptance, increased access, and reductions in cost. However, more efficient research processes may be needed to uncover the potential benefits of these rapid technological advances. This viewpoint paper reviews existing empirical support for integrating VR with EBTs (with a focus on its use with EDs) and proposes key next steps to more rapidly bring this innovative technology-based intervention into real-world clinic settings, as warranted. VR-CET for EDs is used to illustrate a suggested process for developing such treatment enhancements. We recommend following a deployment-focused model of intervention development and testing to enable rapid implementation of robust, practice-ready treatments. In addition, our review highlights the need for a comprehensive clinical protocol that supports clinicians and researchers in the implementation and testing of VR-CET and identifies key missing protocol components with rationale for their inclusion. Ultimately, this work may lead to a more complete understanding of the full potential of the applications and integrations of VR into mental health care globally. %M 32324145 %R 10.2196/16386 %U http://www.jmir.org/2020/4/e16386/ %U https://doi.org/10.2196/16386 %U http://www.ncbi.nlm.nih.gov/pubmed/32324145 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e17279 %T Nurse-Physician Communication Team Training in Virtual Reality Versus Live Simulations: Randomized Controlled Trial on Team Communication and Teamwork Attitudes %A Liaw,Sok Ying %A Ooi,Sim Win %A Rusli,Khairul Dzakirin Bin %A Lau,Tang Ching %A Tam,Wilson Wai San %A Chua,Wei Ling %+ Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore, Singapore, 65 65167451, nurliaw@nus.edu.sg %K interprofessional education %K team training %K nurse-physician communication %K virtual reality %K simulation %D 2020 %7 8.4.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Interprofessional team training is needed to improve nurse-physician communication skills that are lacking in clinical practice. Using simulations has proven to be an effective learning approach for team training. Yet, it has logistical constraints that call for the exploration of virtual environments in delivering team training. Objective: This study aimed to evaluate a team training program using virtual reality vs conventional live simulations on medical and nursing students’ communication skill performances and teamwork attitudes. Methods: In June 2018, the authors implemented nurse-physician communication team training using communication tools. A randomized controlled trial study was conducted with 120 undergraduate medical and nursing students who were randomly assigned to undertake team training using virtual reality or live simulations. The participants from both groups were tested on their communication performances through team-based simulation assessments. Their teamwork attitudes were evaluated using interprofessional attitude surveys that were administered before, immediately after, and 2 months after the study interventions. Results: The team-based simulation assessment revealed no significant differences in the communication performance posttest scores (P=.29) between the virtual and simulation groups. Both groups reported significant increases in the interprofessional attitudes posttest scores from the baseline scores, with no significant differences found between the groups over the 3 time points. Conclusions: Our study outcomes did not show an inferiority of team training using virtual reality when compared with live simulations, which supports the potential use of virtual reality to substitute conventional simulations for communication team training. Future studies can leverage the use of artificial intelligence technology in virtual reality to replace costly human-controlled facilitators to achieve better scalability and sustainability of team-based training in interprofessional education. Trial Registration: ClinicalTrials.gov NCT04330924; https://clinicaltrials.gov/ct2/show/NCT04330924 %M 32267235 %R 10.2196/17279 %U https://www.jmir.org/2020/4/e17279 %U https://doi.org/10.2196/17279 %U http://www.ncbi.nlm.nih.gov/pubmed/32267235 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e16660 %T Measuring Alliance Toward Embodied Virtual Therapists in the Era of Automated Treatments With the Virtual Therapist Alliance Scale (VTAS): Development and Psychometric Evaluation %A Miloff,Alexander %A Carlbring,Per %A Hamilton,William %A Andersson,Gerhard %A Reuterskiöld,Lena %A Lindner,Philip %+ Department of Psychology, Stockholm University, Frescati Hagväg 8, C402, Stockholm, SE-106 91, Sweden, 46 08 163680, alexander.miloff@psychology.su.se %K alliance %K virtual reality %K exposure therapy %K automated treatment %K psychometric %K embodiment %K virtual therapist %K virtual coach %K avatar %K usability %K presence %K empathy %D 2020 %7 24.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Automated virtual reality exposure therapies (VRETs) are self-help treatments conducted by oneself and supported by a virtual therapist embodied visually and/or with audio feedback. This simulates many of the nonspecific relational elements and common factors present in face-to-face therapy and may be a means of improving adherence to and efficacy of self-guided treatments. However, little is known about alliance toward the virtual therapist, despite alliance being an important predictor of treatment outcome. Objective: In this study, we aimed to evaluate the first alliance instrument developed for use with embodied virtual therapists in an automated treatment format—the Virtual Therapist Alliance Scale (VTAS)—by (1) assessing its psychometric properties, (2) verifying the dimensionality of the scale, and (3) determining the predictive ability of the scale with treatment outcome. Methods: A psychometric evaluation and exploratory factor analysis of the VTAS was conducted using data from two samples of spider-fearful patients treated with VRET and the help of an embodied, voice-based virtual therapist (n=70). Multiple regression models and bivariate correlations were used to assess the VTAS relationship with treatment outcome, according to self-reported fear and convergence with presence and user-friendliness process measures. Results: The VTAS showed a sound two-factor solution composed of a primary factor covering task, goal, and copresence; adequate internal consistency; and good convergent validity, including moderate correlation (r=.310, P=.01) with outcomes over follow-up. Conclusions: These preliminary results suggest that alliance toward a virtual therapist is a significant predictor of treatment outcome, favors the importance of a task-goal over bond-factor, and should be explored in studies with larger sample sizes and in additional forms of embodiment. %M 32207690 %R 10.2196/16660 %U https://www.jmir.org/2020/3/e16660 %U https://doi.org/10.2196/16660 %U http://www.ncbi.nlm.nih.gov/pubmed/32207690 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 7 %N 3 %P e16066 %T Efficacy of a Virtual Reality Biofeedback Game (DEEP) to Reduce Anxiety and Disruptive Classroom Behavior: Single-Case Study %A Bossenbroek,Rineke %A Wols,Aniek %A Weerdmeester,Joanneke %A Lichtwarck-Aschoff,Anna %A Granic,Isabela %A van Rooij,Marieke M J W %+ Behavioural Science Institute, Radboud University, PO Box 9104, Nijmegen, 6500 HE, Netherlands, 31 243612638, r.bossenbroek@pwo.ru.nl %K anxiety %K disruptive behavior %K single-case study %K applied game %K serious games %K special education %K attention-deficit/hyperactivity disorder (ADHD) %K autism spectrum disorder (ASD) %K adolescents %D 2020 %7 24.3.2020 %9 Original Paper %J JMIR Ment Health %G English %X Background: Many adolescents in special education are affected by anxiety in addition to their behavioral problems. Anxiety leads to substantial long-term problems and may underlie disruptive behaviors in the classroom as a result of the individual’s inability to tolerate anxiety-provoking situations. Thus, interventions in special needs schools that help adolescents cope with anxiety and, in turn, diminish disruptive classroom behaviors are needed. Objective: This study aimed to evaluate the effect of a virtual reality biofeedback game, DEEP, on daily levels of state-anxiety and disruptive classroom behavior in a clinical sample. In addition, the study also aimed to examine the duration of the calm or relaxed state after playing DEEP. Methods: A total of 8 adolescents attending a special secondary school for students with behavioral and psychiatric problems participated in a single-case experimental ABAB study. Over a 4-week period, participants completed 6 DEEP sessions. In addition, momentary assessments (ie, 3 times a day) of self-reported state-anxiety and teacher-reported classroom behavior were collected throughout all A and B phases. Results: From analyzing the individual profiles, it was found that 6 participants showed reductions in anxiety, and 5 participants showed reductions in disruptive classroom behaviors after the introduction of DEEP. On a group level, results showed a small but significant reduction of anxiety (d=–0.29) and a small, nonsignificant reduction of disruptive classroom behavior (d=−0.16) on days when participants played DEEP. Moreover, it was found that the calm or relaxed state of participants after playing DEEP lasted for about 2 hours on average. Conclusions: This study demonstrates the potential of the game, DEEP, as an intervention for anxiety and disruptive classroom behavior in a special school setting. Future research is needed to fully optimize and personalize DEEP as an intervention for the heterogeneous special school population. %M 32207697 %R 10.2196/16066 %U http://mental.jmir.org/2020/3/e16066/ %U https://doi.org/10.2196/16066 %U http://www.ncbi.nlm.nih.gov/pubmed/32207697 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e16106 %T Understanding How Virtual Reality Can Support Mindfulness Practice: Mixed Methods Study %A Seabrook,Elizabeth %A Kelly,Ryan %A Foley,Fiona %A Theiler,Stephen %A Thomas,Neil %A Wadley,Greg %A Nedeljkovic,Maja %+ Centre for Mental Health, Swinburne University of Technology, 1 John Street, Hawthorn, Melbourne, 3122, Australia, 61 392145266, eseabrook@swin.edu.au %K virtual reality %K mindfulness %K emotion %K pilot projects %K acceptability %K evaluation %D 2020 %7 18.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Regular mindfulness practice has been demonstrated to be beneficial for mental health, but mindfulness can be challenging to adopt, with environmental and personal distractors often cited as challenges. Virtual reality (VR) may address these challenges by providing an immersive environment for practicing mindfulness and by supporting the user to orient attention to the present moment within a tailored virtual setting. However, there is currently a limited understanding of the ways in which VR can support or hinder mindfulness practice. Such an understanding is required to design effective VR apps while ensuring that VR-supported mindfulness is acceptable to end users. Objective: This study aimed to explore how VR can support mindfulness practice and to understand user experience issues that may affect the acceptability and efficacy of VR mindfulness for users in the general population. Methods: A sample of 37 participants from the general population trialed a VR mindfulness app in a controlled laboratory setting. The VR app presented users with an omnidirectional video of a peaceful forest environment with a guided mindfulness voiceover that was delivered by a male narrator. Scores on the State Mindfulness Scale, Simulator Sickness Questionnaire, and single-item measures of positive and negative emotion and arousal were measured pre- and post-VR for all participants. Qualitative feedback was collected through interviews with a subset of 19 participants. The interviews sought to understand the user experience of mindfulness practice in VR. Results: State mindfulness (P<.001; Cohen d=1.80) and positive affect (P=.006; r=.45) significantly increased after using the VR mindfulness app. No notable changes in negative emotion, subjective arousal, or symptoms of simulator sickness were observed across the sample. Participants described the user experience as relaxing, calming, and peaceful. Participants suggested that the use of VR helped them to focus on the present moment by using visual and auditory elements of VR as attentional anchors. The sense of presence in the virtual environment (VE) was identified by participants as being helpful to practicing mindfulness. Interruptions to presence acted as distractors. Some uncomfortable experiences were discussed, primarily in relation to video fidelity and the weight of the VR headset, although these were infrequent and minor. Conclusions: This study suggests that an appropriately designed VR app can support mindfulness practice by enhancing state mindfulness and inducing positive affect. VR may help address the challenges of practicing mindfulness by creating a sense of presence in a tailored VE; by allowing users to attend to visual and auditory anchors of their choice; and by reducing the scope of the content in users’ mind-wandering. VR has the unique capability to combine guided mindfulness practice with tailored VEs that lend themselves to support individuals to focus attention on the present moment. %M 32186519 %R 10.2196/16106 %U http://www.jmir.org/2020/3/e16106/ %U https://doi.org/10.2196/16106 %U http://www.ncbi.nlm.nih.gov/pubmed/32186519 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e17425 %T Utilization of a Voice-Based Virtual Reality Advanced Cardiac Life Support Team Leader Refresher: Prospective Observational Study %A Katz,Daniel %A Shah,Ronak %A Kim,Elizabeth %A Park,Chang %A Shah,Anjan %A Levine,Adam %A Burnett,Garrett %+ Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, , New York, NY, United States, 1 7323226675, dkatz621@gmail.com %K video game %K experimental game %K virtual reality %K advanced cardiac life support %D 2020 %7 12.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The incidence of cardiac arrests per year in the United States continues to increase, yet in-hospital cardiac arrest survival rates significantly vary between hospitals. Current methods of training are expensive, time consuming, and difficult to scale, which necessitates improvements in advanced cardiac life support (ACLS) training. Virtual reality (VR) has been proposed as an alternative or adjunct to high-fidelity simulation (HFS) in several environments. No evaluations to date have explored the ability of a VR program to examine both technical and behavioral skills and demonstrate a cost comparison. Objective: This study aimed to explore the utility of a voice-based VR ACLS team leader refresher as compared with HFS. Methods: This prospective observational study performed at an academic institution consisted of 25 postgraduate year 2 residents. Participants were randomized to HFS or VR training and then crossed groups after a 2-week washout. Participants were graded on technical and nontechnical skills. Participants also completed self-assessments about the modules. Proctors were assessed for fatigue and task saturation, and cost analysis based on local economic data was performed. Results: A total of 23 of 25 participants were included in the scoring analysis. Fewer participants were familiar with VR compared with HFS (9/25, 36% vs 25/25, 100%; P<.001). Self-reported satisfaction and utilization scores were similar; however, significantly more participants felt HFS provided better feedback: 99 (IQR 89-100) vs 79 (IQR 71-88); P<.001. Technical scores were higher in the HFS group; however, nontechnical scores for decision making and communication were not significantly different between modalities. VR sessions were 21 (IQR 19-24) min shorter than HFS sessions, the National Aeronautics and Space Administration task load index scores for proctors were lower in each category, and VR sessions were estimated to be US $103.68 less expensive in a single-learner, single-session model. Conclusions: Utilization of a VR-based team leader refresher for ACLS skills is comparable with HFS in several areas, including learner satisfaction. The VR module was more cost-effective and was easier to proctor; however, HFS was better at delivering feedback to participants. Optimal education strategies likely contain elements of both modalities. Further studies are needed to examine the utility of VR-based environments at scale. %M 32163038 %R 10.2196/17425 %U http://www.jmir.org/2020/3/e17425/ %U https://doi.org/10.2196/17425 %U http://www.ncbi.nlm.nih.gov/pubmed/32163038 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 1 %P e14565 %T Design Strategies for Virtual Reality Interventions for Managing Pain and Anxiety in Children and Adolescents: Scoping Review %A Ahmadpour,Naseem %A Keep,Melanie %A Janssen,Anna %A Rouf,Anika Saiyara %A Marthick,Michael %+ Design Lab, Sydney School of Architecture, Design and Planning, The University of Sydney, Rm 280 Wilkinson Building G04, 148 City Road, Sydney, NSW 2006, Australia, 61 286275649, naseem.ahmadpour@sydney.edu.au %K virtual reality %K distraction %K pain %K anxiety %K children %K adolescents %K design %D 2020 %7 31.1.2020 %9 Review %J JMIR Serious Games %G English %X Background: Virtual reality (VR) technology has been explored in the health sector as a novel tool for supporting treatment side effects, including managing pain and anxiety. VR has recently become more available with the launch of low-cost devices and apps. Objective: This study aimed to provide an updated review of the research into VR use for pain and anxiety in pediatric patients undergoing medical procedures. Specifically, we wanted to gain an understanding of the techniques and goals used in selecting or designing VR apps in this context. Methods: We performed a scoping review. To identify relevant studies, we searched three electronic databases. Two authors screened the titles and abstracts for relevance and eligibility criteria. Results: Overall, 1386 articles published between 2013 and 2018 were identified. In total 18 articles were included in the review, with 7 reporting significant reduction in pediatric pain or anxiety, 3 testing but finding no significant impact of the VR apps employed, and the rest not conducting any test of significance. We identified 9 articles that were based on VR apps specifically designed and tailored for pediatric patients. The findings were analyzed to develop a holistic model and describe the product, experience, and intervention aspects that need to be considered in designing such medical VR apps. Conclusions: VR has been demonstrated to be a viable choice for managing pain and anxiety in a range of medical treatments. However, commercial products lack diversity and meaningful design strategies are limited beyond distraction techniques. We propose future VR interventions to explore skill-building goals in apps characterized by dynamic feedback to the patient and experiential and product qualities that enable them to be an active participant in managing their own care. To achieve this, design must be part of the development. %M 32012042 %R 10.2196/14565 %U http://games.jmir.org/2020/1/e14565/ %U https://doi.org/10.2196/14565 %U http://www.ncbi.nlm.nih.gov/pubmed/32012042 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 8 %N 1 %P e15422 %T Using 360-Degree Video as a Research Stimulus in Digital Health Studies: Lessons Learned %A Zulkiewicz,Brittany A %A Boudewyns,Vanessa %A Gupta,Catherine %A Kirschenbaum,Ari %A Lewis,Megan A %+ Center for Communication Science, RTI International, 3040 East Cornwallis Rd, Research Triangle Park, NC, , United States, 1 206 268 3613, melewis@rti.org %K virtual reality %K 360-degree video %K empathy %K migraine disorders %K health personnel %K medical education %D 2020 %7 6.1.2020 %9 Viewpoint %J JMIR Serious Games %G English %X Due to the accessibility of omnidirectional cameras to record 360-degree videos and the technology to view the videos via mobile phones and other devices, 360-degree videos are being used more frequently to place people in different contexts and convey health-related information. Increasingly, 360-degree videos are being employed in health marketing because they have the potential to enhance health-related attitudes and behaviors. As a case study on how this technology may be used for health-related information and its effect on health care providers, we created a 360-degree video that portrays the experience of a migraine sufferer to be used as a stimulus in an online study. We describe the challenges and lessons learned in designing and implementing a 360-degree video as part of an online experiment focused on inducing empathy among clinicians for understanding patient experience. Given the rapid change in digital technology, future research can use this knowledge to design and implement 360-degree video studies more effectively. %M 31904577 %R 10.2196/15422 %U https://games.jmir.org/2020/1/e15422 %U https://doi.org/10.2196/15422 %U http://www.ncbi.nlm.nih.gov/pubmed/31904577 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 1 %P e15582 %T A Virtual Home for the Virtual Clinical Trial %A Persky,Susan %+ Social and Behavioral Research Branch, National Human Genome Research Institute, 31 Center Dr Bldg 31 Rm B1B36, Bethesda, MD, 20892, United States, 1 301 443 0098, perskys@mail.nih.gov %K virtual reality %K virtual clinical trials %K eHealth %D 2020 %7 3.1.2020 %9 Viewpoint %J J Med Internet Res %G English %X Virtual clinical trials (VCTs) can satisfy the need for rigorous clinical trials by using distributed technological solutions that eliminate the need for a physical trial site. This report explores potential benefits of using virtual reality (VR) to provide a “virtual site” for VCTs, a shared immersive hub in which VCT participants could experience elements of the trial and interact with the trial team. VR is a communication technology that has been emerging alongside the development of VCTs, although they have never been merged in a substantial way. Many of the gaps within the VCT paradigm are areas in which VR excels. VR environments are standardized and precisely uniform, the technology allows introduction of an almost endless set of stimuli to participants’ visual and auditory systems, and VR systems are adept at capturing precise movement and behavioral data. Although VR has not yet found its way into VCTs, much of the groundwork for such integration has been laid through research and technological development achieved in the past few years. Future implementation of VR within VCTs could move us from site-less trials to those with a virtual site serving as a hub for trial information provision, interaction with trial representatives, administration of evaluations and assessments, and more. %M 31899455 %R 10.2196/15582 %U https://www.jmir.org/2020/1/e15582 %U https://doi.org/10.2196/15582 %U http://www.ncbi.nlm.nih.gov/pubmed/31899455 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 12 %P e11643 %T How New Technologies Can Improve Prediction, Assessment, and Intervention in Obsessive-Compulsive Disorder (e-OCD): Review %A Ferreri,Florian %A Bourla,Alexis %A Peretti,Charles-Siegfried %A Segawa,Tomoyuki %A Jaafari,Nemat %A Mouchabac,Stéphane %+ Sorbonne Université, Department of Adult Psychiatry and Medical Psychology, APHP, Saint-Antoine Hospital, 184 rue du Faubourg Saint-Antoine, Paris, 75012, France, 33 149282635, alexis.bourla@aphp.fr %K obsessive-compulsive disorder %K ecological momentary assessment %K biofeedback %K digital biomarkers %K digital phenotyping %K mobile health %K virtual reality %K machine learning %D 2019 %7 10.12.2019 %9 Review %J JMIR Ment Health %G English %X Background: New technologies are set to profoundly change the way we understand and manage psychiatric disorders, including obsessive-compulsive disorder (OCD). Developments in imaging and biomarkers, along with medical informatics, may well allow for better assessments and interventions in the future. Recent advances in the concept of digital phenotype, which involves using computerized measurement tools to capture the characteristics of a given psychiatric disorder, is one paradigmatic example. Objective: The impact of new technologies on health professionals’ practice in OCD care remains to be determined. Recent developments could disrupt not just their clinical practices, but also their beliefs, ethics, and representations, even going so far as to question their professional culture. This study aimed to conduct an extensive review of new technologies in OCD. Methods: We conducted the review by looking for titles in the PubMed database up to December 2017 that contained the following terms: [Obsessive] AND [Smartphone] OR [phone] OR [Internet] OR [Device] OR [Wearable] OR [Mobile] OR [Machine learning] OR [Artificial] OR [Biofeedback] OR [Neurofeedback] OR [Momentary] OR [Computerized] OR [Heart rate variability] OR [actigraphy] OR [actimetry] OR [digital] OR [virtual reality] OR [Tele] OR [video]. Results: We analyzed 364 articles, of which 62 were included. Our review was divided into 3 parts: prediction, assessment (including diagnosis, screening, and monitoring), and intervention. Conclusions: The review showed that the place of connected objects, machine learning, and remote monitoring has yet to be defined in OCD. Smartphone assessment apps and the Web Screening Questionnaire demonstrated good sensitivity and adequate specificity for detecting OCD symptoms when compared with a full-length structured clinical interview. The ecological momentary assessment procedure may also represent a worthy addition to the current suite of assessment tools. In the field of intervention, CBT supported by smartphone, internet, or computer may not be more effective than that delivered by a qualified practitioner, but it is easy to use, well accepted by patients, reproducible, and cost-effective. Finally, new technologies are enabling the development of new therapies, including biofeedback and virtual reality, which focus on the learning of coping skills. For them to be used, these tools must be properly explained and tailored to individual physician and patient profiles. %M 31821153 %R 10.2196/11643 %U https://mental.jmir.org/2019/12/e11643 %U https://doi.org/10.2196/11643 %U http://www.ncbi.nlm.nih.gov/pubmed/31821153 %0 Journal Article %@ 2561-9128 %I JMIR Publications %V 2 %N 2 %P e15579 %T Comparing the Relaxing Effects of Different Virtual Reality Environments in the Intensive Care Unit: Observational Study %A Gerber,Stephan M %A Jeitziner,Marie-Madlen %A Sänger,Simon D %A Knobel,Samuel E J %A Marchal-Crespo,Laura %A Müri,René M %A Schefold,Joerg C %A Jakob,Stephan M %A Nef,Tobias %+ Gerontechnology & Rehabilitation Group, University of Bern, Murtenstrasse 50, Bern, 3008, Switzerland, 41 316327579, tobias.nef@artorg.unibe.ch %K virtual reality %K critical illness %K intensive care unit %K neurocognitive late effects %K nature %K urban %K stimulation %D 2019 %7 15.11.2019 %9 Original Paper %J JMIR Perioper Med %G English %X Background: After a prolonged intensive care unit (ICU) stay, approximately 50%-75% of all critically ill patients suffer from neurocognitive late effects and a reduction of health-related quality of life. It is assumed that the noisy and stressful ICU environment leads to sensory overload and deprivation and potentially to long-term cognitive impairment. Objective: In this study, we investigated three different virtual reality environments and their potentially restorative and relaxing effects for reducing sensory overload and deprivation in the ICU. Methods: A total of 45 healthy subjects were exposed to three different environments, each 10 minutes in length (dynamic, virtual, natural, and urban environments presented inside the head-mounted display, and a neutral video on an ICU TV screen). During the study, data was collected by validated questionnaires (ie, restoration and sickness) and sensors to record physiological parameters (240 hertz). Results: The results showed that the natural environment had the highest positive and restorative effect on the physiological and psychological state of healthy subjects, followed by the urban environment and the ICU TV screen. Conclusions: Overall, virtual reality stimulation with head-mounted display using a dynamic, virtual and natural environment has the potential, if directly used in the ICU, to reduce sensory overload and deprivation in critically ill patients and thus to prevent neurocognitive late effects. %M 33393906 %R 10.2196/15579 %U http://periop.jmir.org/2019/2/e15579/ %U https://doi.org/10.2196/15579 %U http://www.ncbi.nlm.nih.gov/pubmed/33393906 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 4 %P e11266 %T Virtual Reality as a Therapy Adjunct for Fear of Movement in Veterans With Chronic Pain: Single-Arm Feasibility Study %A Fowler,Christopher A %A Ballistrea,Lisa M %A Mazzone,Kerry E %A Martin,Aaron M %A Kaplan,Howard %A Kip,Kevin E %A Ralston,Katherine %A Murphy,Jennifer L %A Winkler,Sandra L %+ Research and Development Service, James A Haley Veterans Hospital, 8900 Grand Oak Circle, Tampa, FL, 33705, United States, 1 813 558 3904, christopher.fowler3@va.gov %K chronic pain %K virtual reality %K Veterans %K pain management %K rehabilitation %K fear of movement %K kinesiophobia %K exposure therapy %K distraction therapy %D 2019 %7 30.10.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Virtual reality (VR) has demonstrated efficacy for distraction from pain-related thoughts and exposure to feared movements. Little empirical VR research has focused on chronic pain management. Objective: The purpose of this study was to examine the feasibility of VR as an adjunctive intervention for Veterans with chronic pain. We designed a hierarchy ranging from low-intensity pain distraction to high-intensity movement-based exposure for this purpose. VR apps were mapped onto the hierarchy. Methods: Sixteen Veterans receiving inpatient chronic pain rehabilitation participated in daily VR sessions over a 3-week period. Trajectories across the distraction-to-exposure hierarchy and Veteran-reported intensity ratings were described and evaluated over time. Minimum clinically important differences (MCIDs), pre-post effect sizes, and 95% confidence intervals were examined for fear of movement using the Fear of Daily Activities Questionnaire (FDAQ) and Pain Outcomes Questionnaire-VA (POQ-VA; fear scale). This approach was applied to secondary outcomes: POQ-VA (pain intensity, interference, negative affect), Pain Catastrophizing Scale, and Patient-Specific Functioning Scale (PSFS). Session attendance, completion, and VR experiences were described. Results: Ten of 14 Veterans (71%) who participated in three or more VR sessions completed the distraction-to-exposure hierarchy. Only three trajectories emerged more than once. Due to high completion rates, Veterans that completed the hierarchy could self-select nonhierarchy apps. Veterans rated all hierarchy levels (low, medium, high) near medium intensity. Self-selected activities were rated as high intensity. For kinesiophobia, six Veterans (38%) exceeded the MCID on the FDAQ and a small effect size improvement was observed (Cohen d=−0.35). The confidence interval (95% CI −0.71 to 0.01) indicated the possibility of a null effect. The POQ-VA fear scale yielded no effect (Cohen d=0.06, 95% CI −0.43 to 0.54). For secondary outcomes, Veterans exceeding MCID were calculated with complete data: pain intensity (1/15, 7%), pain catastrophizing (5/14, 36%), and patient-specific functioning (10/15, 67%). Effect sizes were large for patient-specific functioning (Cohen d=1.14, 95% CI 0.50-1.78), medium for mobility interference (Cohen d=−0.56, 95% CI −0.96 to −0.16), and small for pain intensity (Cohen d=−0.40, 95% CI −0.69 to −0.12) and catastrophizing (Cohen d=−0.41, 95% CI −0.79 to −0.02). No effects were observed for interference in daily activities (Cohen d=0.10, 95% CI −0.27 to 0.47) and negative affect (Cohen d=0.07, 95% CI −0.26 to 0.40). Veterans attended 85.2% (98/108) of VR sessions and completed 95% (93/96) of sessions attended. Twenty-minute sessions were rated as too short. No significant adverse events were reported. Conclusions: Findings support the feasibility of VR as an adjunct for Veterans with chronic pain. However, the hierarchy will require modification, as evidenced by homogeneous intensity ratings. Veteran-selected activities presented the highest intensity ratings, largest outcome effect size (PSFS), and MCID. This highlights the important role of utilizing Veteran stakeholders in hierarchy modification, design of VR interventions, and outcome selection. %M 31670696 %R 10.2196/11266 %U http://formative.jmir.org/2019/4/e11266/ %U https://doi.org/10.2196/11266 %U http://www.ncbi.nlm.nih.gov/pubmed/31670696 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e14658 %T A Virtual Counseling Application Using Artificial Intelligence for Communication Skills Training in Nursing Education: Development Study %A Shorey,Shefaly %A Ang,Emily %A Yap,John %A Ng,Esperanza Debby %A Lau,Siew Tiang %A Chui,Chee Kong %+ Alice Lee Centre for Nursing Studies, National University of Singapore, Clinical Research Centre 10 Medical Drive, Singapore, 117597, Singapore, 65 66011294, nurssh@nus.edu.sg %K artificial intelligence %K communication %K learning %K nursing education %K patients %K technology %K virtual reality %D 2019 %7 29.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The ability of nursing undergraduates to communicate effectively with health care providers, patients, and their family members is crucial to their nursing professions as these can affect patient outcomes. However, the traditional use of didactic lectures for communication skills training is ineffective, and the use of standardized patients is not time- or cost-effective. Given the abilities of virtual patients (VPs) to simulate interactive and authentic clinical scenarios in secured environments with unlimited training attempts, a virtual counseling application is an ideal platform for nursing students to hone their communication skills before their clinical postings. Objective: The aim of this study was to develop and test the use of VPs to better prepare nursing undergraduates for communicating with real-life patients, their family members, and other health care professionals during their clinical postings. Methods: The stages of the creation of VPs included preparation, design, and development, followed by a testing phase before the official implementation. An initial voice chatbot was trained using a natural language processing engine, Google Cloud’s Dialogflow, and was later visualized into a three-dimensional (3D) avatar form using Unity 3D. Results: The VPs included four case scenarios that were congruent with the nursing undergraduates’ semesters’ learning objectives: (1) assessing the pain experienced by a pregnant woman, (2) taking the history of a depressed patient, (3) escalating a bleeding episode of a postoperative patient to a physician, and (4) showing empathy to a stressed-out fellow final-year nursing student. Challenges arose in terms of content development, technological limitations, and expectations management, which can be resolved by contingency planning, open communication, constant program updates, refinement, and training. Conclusions: The creation of VPs to assist in nursing students’ communication skills training may provide authentic learning environments that enhance students’ perceived self-efficacy and confidence in effective communication skills. However, given the infancy stage of this project, further refinement and constant enhancements are needed to train the VPs to simulate real-life conversations before the official implementation. %M 31663857 %R 10.2196/14658 %U https://www.jmir.org/2019/10/e14658 %U https://doi.org/10.2196/14658 %U http://www.ncbi.nlm.nih.gov/pubmed/31663857 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 10 %P e14143 %T Antismoking Advertisements and Price Promotions and Their Association With the Urge to Smoke and Purchases in a Virtual Convenience Store: Randomized Experiment %A Dutra,Lauren McCarl %A Nonnemaker,James %A Bradfield,Brian %A Taylor,Nathaniel %A Guillory,Jamie %A Feld,Ashley %A Kim,Annice %+ Center for Health Policy Science and Tobacco Research, RTI International, 2150 Shattuck Avenue, Suite 1200, Berkeley, CA, 94704, United States, 1 5106658297, ldutra@rti.org %K cigarette smoking %K advertisement %K craving %K tobacco products %K commerce %K consumer behavior %D 2019 %7 23.10.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Point of sale (POS) advertising is associated with smoking initiation, current smoking, and relapse among former smokers. Price promotion bans and antismoking advertisements (ads) are 2 possible interventions for combating POS advertising. Objective: The purpose of this analysis was to determine the influence of antismoking ads and promotions on urges to smoke and tobacco purchases. Methods: This analysis examined exposure to graphic (graphic images depicting physical consequences of tobacco use) and supportive (pictures of and supportive messages from former smokers) antismoking ads and promotions in a virtual convenience store as predictors of urge to smoke and buying tobacco products among 1200 current cigarette smokers and 800 recent quitters recruited via a Web-based panel (analytical n=1970). We constructed linear regression models for urge to smoke and logistic regression models for the odds of purchasing tobacco products, stratified by smoking status. Results: The only significant finding was a significant negative relationship between exposure to supportive antismoking ads and urge to smoke among current smokers (beta coefficient=−5.04, 95% CI −9.85 to −0.22; P=.04). There was no significant relationship between graphic antismoking ads and urge to smoke among current smokers (coefficient=−3.77, 95% CI −8.56 to 1.02; P=.12). Neither relationship was significant for recent quitters (graphic: coefficient=−3.42, 95% CI −8.65 to 1.81; P=.15 or supportive: coefficient=−3.82, 95% CI −8.99 to 1.36; P=.20). There were no significant differences in urge to smoke by exposure to promotions for current smokers (coefficient=−1.06, 95% CI −4.53 to 2.41; P=.55) or recent quitters (coefficient=1.76, 95% CI −2.07 to 5.59; P=.37). There were also no differences in tobacco purchases by exposure to graphic (current smokers: coefficient=0.93, 95% CI 0.67 to 1.29; P=.66 and recent quitters: coefficient=0.73, 95% CI 0.44 to 1.19; P=.20) or supportive (current smokers: coefficient=1.05, 95% CI 0.75 to 1.46; P=.78 and recent quitters: coefficient=0.73, 95% CI 0.45 to 1.18; P=.20) antismoking ads or price promotions (current smokers: coefficient=1.09, 95% CI 0.86 to 1.38; P=.49 and recent quitters: coefficient=0.90, 95% CI 0.62 to 1.31; P=.60). Conclusions: The results of this analysis support future research on the ability of supportive antismoking ads to reduce urges to smoke among current cigarette smokers. Research on urges to smoke has important tobacco control implications, given the relationship between urge to smoke and smoking cigarettes, time to next smoke, and amount smoked. %M 31647468 %R 10.2196/14143 %U https://www.jmir.org/2019/10/e14143 %U https://doi.org/10.2196/14143 %U http://www.ncbi.nlm.nih.gov/pubmed/31647468 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 2 %N 2 %P e14429 %T Virtual Reality Support for Joint Attention Using the Floreo Joint Attention Module: Usability and Feasibility Pilot Study %A Ravindran,Vijay %A Osgood,Monica %A Sazawal,Vibha %A Solorzano,Rita %A Turnacioglu,Sinan %+ Floreo Inc, 1875 Connecticut Ave NW, Washington, DC, 20009-6046, United States, 1 2402449473, sinan@floreotech.com %K autism spectrum disorder %K interpersonal skills %K virtual reality, instructional %D 2019 %7 30.9.2019 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Advances in virtual reality (VR) technology offer new opportunities to design supports for the core behaviors associated with autism spectrum disorder (ASD) that promote progress toward optimal outcomes. Floreo has developed a novel mobile VR platform that pairs a user receiving instruction on target skills with an adult monitor. Objective: The primary objective of this pilot study was to explore the feasibility of using Floreo’s Joint Attention Module in school-aged children with autism in a special education setting. A secondary objective was to explore a novel joint attention measure designed for use with school-aged children and to observe whether there was a suggestion of change in joint attention skills from preintervention to postintervention. Methods: A total of 12 participants (age range: 9 to 16 years) received training with the Joint Attention Module for 14 sessions over 5 weeks. Results: No serious side effects were reported, and no participants dropped out of the study because of undesirable side effects. On the basis of monitor data, 95.4% (126/132) of the time participants tolerated the headset, 95.4% (126/132) of the time participants seemed to enjoy using Floreo’s platform, and 95.5% (128/134) of the time the VR experience was reported as valuable. In addition, scoring of the joint attention measure suggested a positive change in participant skills related to the total number of interactions, use of eye contact, and initiation of interactions. Conclusions: The study results suggest that Floreo’s Joint Attention Module is safe and well tolerated by students with ASD, and preliminary data also suggest that its use is related to improvements in fundamental joint attention skills. %M 31573921 %R 10.2196/14429 %U http://pediatrics.jmir.org/2019/2/e14429/ %U https://doi.org/10.2196/14429 %U http://www.ncbi.nlm.nih.gov/pubmed/31573921 %0 Journal Article %@ 2561-3278 %I JMIR Publications %V 4 %N 1 %P e15025 %T Immersive Virtual Reality in Health Care: Systematic Review of Technology and Disease States %A Snoswell,Aaron J %A Snoswell,Centaine L %+ School of Information Technology and Electrical Engineering, The University of Queensland, Level 4 / General Purpose South Building (Building 78), Brisbane, 4072, Australia, 61 422424060, a.snoswell@uq.edu.au %K virtual reality %K health care %K telemedicine %K systematic review %K mHealth %D 2019 %7 26.9.2019 %9 Review %J JMIR Biomed Eng %G English %X Background: Immersive virtual reality (IVR) presents new possibilities for application in health care. Health care professionals can now immerse their patients in environments to achieve exposure to a specific scene or experience, evoke targeted emotional responses, inspire, or distract from an experience occurring in reality. Objective: This review aimed to identify patient-focused applications for head-mounted IVR for acute treatment of health conditions and determine the technical specifications of the systems used. Methods: A systematic review was conducted by searching medical and engineering peer-reviewed literature databases in 2018. The databases included PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Association for Computing Machinery, Institute of Electrical and Electronics Engineers, Scopus, and Web of Science. Search terms relating to health and IVR were used. To be included, studies had to investigate the effectiveness of IVR for acute treatment of a specific health condition. IVR was defined as a head-mounted platform that provides virtual and auditory immersion for the participant and includes a minimum of 3 degrees of orientation tracking. Once identified, data were extracted from articles and aggregated in a narrative review format. Results: A total of 58 studies were conducted in 19 countries. The studies reported IVR use for 5 main clinical areas: neurological and development (n=10), pain reduction through distraction (n=20), exposure therapy for phobias (n=9), psychological applications (n=14), and others (n=5). Studies were primarily feasibility studies exploring systems and general user acceptance (n=29) and efficacy studies testing clinical effect (n=28). Conclusions: IVR has a promising future in health care, both in research and commercial realms. As many of the studies examined are still exploring the feasibility of IVR for acute treatment of health conditions, evidence for the effectiveness of IVR is still developing. %R 10.2196/15025 %U https://biomedeng.jmir.org/2019/1/e15025 %U https://doi.org/10.2196/15025 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 9 %P e13833 %T What Players of Virtual Reality Exercise Games Want: Thematic Analysis of Web-Based Reviews %A Faric,Nuša %A Potts,Henry W W %A Hon,Adrian %A Smith,Lee %A Newby,Katie %A Steptoe,Andrew %A Fisher,Abi %+ Behavioural Science and Health, University College London, 1-19 Torrington Place, London, WC1E 6BT, United Kingdom, 44 020776794466, nfaric@gmail.com %K virtual reality %K exercise %K video games %K sedentary lifestyle %K weight loss %K behavior %K obesity %K sports %D 2019 %7 16.09.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Physical activity (PA) is associated with a variety of physical and psychosocial health benefits, but levels of moderate-to-vigorous intensity PA remain low worldwide. Virtual reality (VR) gaming systems involving movement (VR exergames) could be used to engage people in more PA. Objective: This study aimed to synthesize public reviews of popular VR exergames to identify common features that players liked or disliked to inform future VR exergame design. Methods: We conducted a thematic analysis of 498 reviews of the 29 most popular exergames sold in the top 3 VR marketplaces: Steam (Valve Corporation), Viveport (Valve Corporation), and Oculus (Oculus VR). We categorized reviews as positive and negative as they appeared in the marketplaces and identified the most common themes using an inductive thematic analysis. Results: The reviews were often mixed, reporting a wide variety of expectations, preferences, and gaming experiences. Players preferred highly realistic games (eg, closely simulated real-world sport), games that were intuitive (in terms of body movement and controls), and games that provided gradual increases in skill acquisition. Players reported feeling that they reached a high level of exertion when playing and that the immersion distracted them from the intensity of the exercise. Some preferred features included music and social aspects of the games, with multiplayer options to include friends or receive help from experienced players. There were 3 main themes in negative reviews. The first concerned bugs that rendered games frustrating. Second, the quality of graphics had a particularly strong impact on perceived enjoyment. Finally, reviewers disliked when games had overly complex controls and display functions that evoked motion sickness. Conclusions: Exergames prove to be a stimulating avenue for players to engage in PA and distract themselves from the negative perceptions of performing exercise. The common negative aspects of VR exergames should be addressed for increased uptake and continued engagement. %M 31538951 %R 10.2196/13833 %U https://www.jmir.org/2019/9/e13833/ %U https://doi.org/10.2196/13833 %U http://www.ncbi.nlm.nih.gov/pubmed/31538951 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 9 %P e14096 %T The Use of Virtual and Immersive Technology in Creating Personalized Multisensory Spaces for People Living With Dementia (SENSE-GARDEN): Protocol for a Multisite Before-After Trial %A Goodall,Gemma %A Ciobanu,Ileana %A Taraldsen,Kristin %A Sørgaard,Jon %A Marin,Andreea %A Draghici,Rozeta %A Zamfir,Mihai-Viorel %A Berteanu,Mihai %A Maetzler,Walter %A Serrano,J Artur %+ Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, , Trondheim,, Norway, 47 40554367, gemma.goodall@ntnu.no %K dementia %K emotions %K technology %K multimedia %K eHealth %D 2019 %7 19.8.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: The number of people living with dementia is rapidly increasing. With dementia’s impact on memory, communication, and self-identity, it is important to identify ways of meeting individual needs of diagnosed individuals and their caregivers. This study will test a new intervention, SENSE-GARDEN, that integrates autobiographical music, films, pictures, and scents with innovative technology to create an immersive environment tailored specifically for the individual. Objective: The SENSE-GARDEN study is an Active Assisted Living Program–funded multicenter project. The primary objective of the study is to assess whether a personalized, innovative technology-based intervention can improve the well-being of older adults living with moderate to severe dementia. The study will also assess whether the intervention can improve coping and reduce burden in caregivers. Methods: A controlled before-after study design will be used. There will be 3 sites in 3 trial countries: Belgium, Norway, and Portugal. A total of 55 people with dementia (PWDs) will be recruited. All eligible participants for the study will be randomized into the intervention or control group. For the first three months of the study, all participants will receive the SENSE-GARDEN intervention. For the final month of the study, the intervention group will continue visits to the SENSE-GARDEN, and the control group will discontinue visits. A mixed-methods approach will be used, including the use of standardized outcome measures, quantitative physiological data, and qualitative interview data. Results: The trials commenced recruitment in August 2019, and all data are expected to be collected by the end of May 2020. A user-centered design process is underway, with results from the first phase of user interviews indicating that people with mild cognitive impairment, family caregivers, and professional caregivers consider the SENSE-GARDEN to be a potentially valuable tool in providing numerous benefits to dementia care. Feasibility testing of the SENSE-GARDEN has been completed and results are expected to be published in October 2019. Conclusions: Findings from the SENSE-GARDEN trials will provide insights into the use of technology for personalizing interventions to the PWD. This will have potential implications on not only dementia research, but it may also have influences on care practice. International Registered Report Identifier (IRRID): DERR1-10.2196/14096 %M 31538942 %R 10.2196/14096 %U https://www.researchprotocols.org/2019/9/e14096 %U https://doi.org/10.2196/14096 %U http://www.ncbi.nlm.nih.gov/pubmed/31538942 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 9 %P e13887 %T An Immersive Virtual Reality Platform for Assessing Spatial Navigation Memory in Predementia Screening: Feasibility and Usability Study %A Ijaz,Kiran %A Ahmadpour,Naseem %A Naismith,Sharon L %A Calvo,Rafael A %+ Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road, Macquarie University, North Ryde,, Sydney, 2109, Australia, 61 298502494, kiran.ijaz@mq.edu.au %K virtual reality %K healthy aging %K memory %K cognition %K dementia %D 2019 %7 03.09.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Traditional methods for assessing memory are expensive and have high administrative costs. Memory assessment is important for establishing cognitive impairment in cases such as detecting dementia in older adults. Virtual reality (VR) technology can assist in establishing better quality outcome in such crucial screening by supporting the well-being of individuals and offering them an engaging, cognitively challenging task that is not stressful. However, unmet user needs can compromise the validity of the outcome. Therefore, screening technology for older adults must address their specific design and usability requirements. Objective: This study aimed to design and evaluate the feasibility of an immersive VR platform to assess spatial navigation memory in older adults and establish its compatibility by comparing the outcome to a standard screening platform on a personal computer (PC). Methods: VR-CogAssess is a platform integrating an Oculus Rift head-mounted display and immersive photorealistic imagery. In a pilot study with healthy older adults (N=42; mean age 73.22 years, SD 9.26), a landmark recall test was conducted, and assessment on the VR-CogAssess was compared against a standard PC (SPC) setup. Results: Results showed that participants in VR were significantly more engaged (P=.003), achieved higher landmark recall scores (P=.004), made less navigational mistakes (P=.04), and reported a higher level of presence (P=.002) than those in SPC setup. In addition, participants in VR indicated no significantly higher stress than SPC setup (P=.87). Conclusions: The study findings suggest immersive VR is feasible and compatible with SPC counterpart for spatial navigation memory assessment. The study provides a set of design guidelines for creating similar platforms in the future. %M 31482851 %R 10.2196/13887 %U https://mental.jmir.org/2019/9/e13887/ %U https://doi.org/10.2196/13887 %U http://www.ncbi.nlm.nih.gov/pubmed/31482851 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e12972 %T The Importance of Systematically Reporting and Reflecting on eHealth Development: Participatory Development Process of a Virtual Reality Application for Forensic Mental Health Care %A Kip,Hanneke %A Kelders,Saskia M %A Bouman,Yvonne H A %A van Gemert-Pijnen,Lisette J E W C %+ Centre for eHealth and Wellbeing Research, Department of Psychology, Health and Technology, University of Twente, Drienerlolaan 5, Enschede, 7522 NB, Netherlands, 31 534896536, h.kip@utwente.nl %K eHealth %K technology development %K virtual reality %K forensic psychiatry %K community-based participatory research %K human-centered design %K case study %D 2019 %7 19.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The use of electronic health (eHealth) technologies in practice often is lower than expected, mostly because there is no optimal fit among a technology, the characteristics of prospective users, and their context. To improve this fit, a thorough systematic development process is recommended. However, more knowledge about suitable development methods is necessary to create a tool kit that guides researchers in choosing development methods that are appropriate for their context and users. In addition, there is a need for reflection on the existing frameworks for eHealth development to be able to constantly improve them. Objective: The two main objectives of this case study were to present and reflect on the (1) methods used in the development process of a virtual reality application for forensic mental health care and (2) development model that was used: the CeHRes Roadmap (the Centre for eHealth Research Roadmap). Methods: In the development process, multiple methods were used to operationalize the first 2 phases of the CeHRes Roadmap: the contextual inquiry and value specification. To summarize the most relevant information for the goals of this study, the following information was extracted per method: (1) research goal, (2) explanation of the method used, (3) main results, (4) main conclusions, and (5) lessons learned about the method. Results: Information on 10 methods used is presented in a structured manner. These 10 methods were stakeholder identification, project team composition, focus groups, literature study, semistructured interviews, idea generation with scenarios, Web-based questionnaire, value specification, idea generation with prototyping, and a second round of interviews. The lessons learned showed that although each method added new insights to the development process, not every method appeared to be the most appropriate for each research goal. Conclusions: Reflection on the methods used pointed out that brief methods with concrete examples or scenarios fit the forensic psychiatric patients the best, among other things, because of difficulties with abstract reasoning and low motivation to invest much time in participating in research. Formulating clear research questions based on a model’s underlying principles and composing a multidisciplinary project team with prospective end users appeared to be important in this study. The research questions supported the project team in keeping the complex development processes structured and prevented tunnel vision. With regard to the CeHRes Roadmap, continuous stakeholder involvement and formative evaluations were evaluated as strong points. A suggestion to further improve the Roadmap is to explicitly integrate the use of domain-specific theories and models. To create a tool kit with a broad range of methods for eHealth development and further improve development models, studies that report and reflect on development processes in a consistent and structured manner are needed. %M 31429415 %R 10.2196/12972 %U http://www.jmir.org/2019/8/e12972/ %U https://doi.org/10.2196/12972 %U http://www.ncbi.nlm.nih.gov/pubmed/31429415 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 3 %P e13993 %T Development and Evaluation of a Virtual Research Environment to Improve Quality of Care in Overcrowded Emergency Departments: Observational Study %A Houze-Cerfon,Charles-Henri %A Vaissié,Christine %A Gout,Laurent %A Bastiani,Bruno %A Charpentier,Sandrine %A Lauque,Dominique %+ Institut Toulousain de Simulation en Santé, ITSIMS - pavillon U2000, Place du Dr Baylac, Toulouse,, France, 33 561772147, houze-cerfon.ch@chu-toulouse.fr %K virtual reality %K interprofessional relations %K emergency medicine %D 2019 %7 08.08.2019 %9 Original Paper %J JMIR Serious Games %G English %X Background: Despite a wide range of literature on emergency department (ED) overcrowding, scientific knowledge on emergency physicians’ cognitive processes coping with overcrowding is limited. Objective: This study aimed to develop and evaluate a virtual research environment that will allow us to study the effect of physicians’ strategies and behaviors on quality of care in the context of ED overcrowding. Methods: A simulation-based observational study was conducted over two stages: the development of a simulation model and its evaluation. A research environment in emergency medicine combining virtual reality and simulated patients was designed and developed. Afterwards, 12 emergency physicians took part in simulation scenarios and had to manage 13 patients during a 2-hour period. The study outcome was the authenticity of the environment through realism, consistency, and mastering. The realism was the resemblance perceived by the participants between virtual and real ED. The consistency of the scenario and the participants’ mastering of the environment was expected for 90% (12/13) of the participants. Results: The virtual ED was considered realistic with no significant difference from the real world with respect to facilities and resources, except for the length of time of procedures that was perceived to be shorter. A total of 100% (13/13) of participants deemed that patient information, decision making, and managing patient flow were similar to real clinical practice. The virtual environment was well-mastered by all participants over the course of the scenarios. Conclusions: The new simulation tool, Virtual Research Environment in Emergency Medicine, has been successfully designed and developed. It has been assessed as perfectly authentic by emergency physicians compared with real EDs and thus offers another way to study human factors, quality of care, and patient safety in the context of ED overcrowding. %M 31397292 %R 10.2196/13993 %U http://games.jmir.org/2019/3/e13993/ %U https://doi.org/10.2196/13993 %U http://www.ncbi.nlm.nih.gov/pubmed/31397292 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e14821 %T Virtual Reality for Screening of Cognitive Function in Older Persons: Comparative Study %A Chua,Sean Ing Loon %A Tan,Ngiap Chuan %A Wong,Wei Teen %A Allen Jr,John Carson %A Quah,Joanne Hui Min %A Malhotra,Rahul %A Østbye,Truls %+ SingHealth Polyclinics, 167 Jalan Bukit Merah, Connection One Tower 5 #15-10, Singapore, 150167, Singapore, 65 63777136, tan.ngiap.chuan@singhealth.com.sg %K virtual reality %K feasibility studies %K mental status and dementia tests %K technology %K video games %K dementia %K cognitive dysfunction %D 2019 %7 01.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The prevalence of dementia, which presents as cognitive decline in one or more cognitive domains affecting function, is increasing worldwide. Traditional cognitive screening tools for dementia have their limitations, with emphasis on memory and, to a lesser extent, on the cognitive domain of executive function. The use of virtual reality (VR) in screening for cognitive function in older persons is promising, but evidence for its use is sparse. Objective: The primary aim was to examine the feasibility and acceptability of using VR to screen for cognitive impairment in older persons in a primary care setting. The secondary aim was to assess the module’s ability to discriminate between cognitively intact and cognitively impaired participants. Methods: A comparative study was conducted at a public primary care clinic in Singapore, where persons aged 65-85 years were recruited based on a cut-off score of 26 on the Montreal Cognitive Assessment (MoCA) scale. They participated in a VR module for assessment of their learning and memory, perceptual-motor function, and executive function. Each participant was evaluated by the total performance score (range: 0-700) upon completion of the study. A questionnaire was also administered to assess their perception of and attitude toward VR. Results: A total of 37 participants in Group 1 (cognitively intact; MoCA score≥26) and 23 participants in Group 2 (cognitively impaired; MoCA score<26) were assessed. The mean time to completion of the study was 19.1 (SD 3.6) minutes in Group 1 and 20.4 (3.4) minutes in Group 2. Mean feedback scores ranged from 3.80 to 4.48 (max=5) in favor of VR. The total performance score in Group 1 (552.0, SD 57.2) was higher than that in Group 2 (476.1, SD 61.9; P<.001) and exhibited a moderate positive correlation with scores from other cognitive screening tools: Abbreviated Mental Test (0.312), Mini-Mental State Examination (0.373), and MoCA (0.427). A receiver operating characteristic curve analysis for the relationship between the total performance score and the presence of cognitive impairment showed an area under curve of 0.821 (95% CI 0.714-0.928). Conclusions: We demonstrated the feasibility of using a VR-based screening tool for cognitive function in older persons in primary care, who were largely in favor of this tool. %M 31373274 %R 10.2196/14821 %U https://www.jmir.org/2019/8/e14821/ %U https://doi.org/10.2196/14821 %U http://www.ncbi.nlm.nih.gov/pubmed/31373274 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e11086 %T An Evaluation of the Effectiveness of the Modalities Used to Deliver Electronic Health Interventions for Chronic Pain: Systematic Review With Network Meta-Analysis %A Slattery,Brian W %A Haugh,Stephanie %A O'Connor,Laura %A Francis,Kady %A Dwyer,Christopher P %A O'Higgins,Siobhán %A Egan,Jonathan %A McGuire,Brian E %+ School of Nursing and Human Sciences, Dublin City University, Glasnevin, Dublin, 9, Ireland, 353 017008034, brian.slattery@dcu.ie %K eHealth %K mHealth %K digital health %K Virtual Reality %K chronic pain %K systematic review %K network meta-analysis %D 2019 %7 17.07.2019 %9 Review %J J Med Internet Res %G English %X Background: Electronic health (eHealth) is the use of information and communication technology in the context of health care and health research. Recently, there has been a rise in the number of eHealth modalities and the frequency with which they are used to deliver technology-assisted self-management interventions for people living with chronic pain. However, there has been little or no research directly comparing these eHealth modalities. Objective: The aim of this systematic review with a network meta-analysis (NMA) is to compare the effectiveness of eHealth modalities in the context of chronic pain. Methods: Randomized controlled trials (N>20 per arm) that investigated interventions for adults with chronic pain, delivered via an eHealth modality, were included. Included studies were categorized into their primary node of delivery. Data were extracted on the primary outcome, pain interference, and secondary outcomes, pain severity, psychological distress, and health-related quality of life. Pairwise meta-analyses were undertaken where possible, and an NMA was conducted to generate indirect comparisons and rankings of modalities for reducing pain interference. Results: The search returned 18,470 studies with 18,349 being excluded (duplicates=2310; title and abstract=16,039). Of the remaining papers, 30 studies with 5394 randomized participants were included in the review. Rankings tentatively indicated that modern eHealth modalities are the most effective, with a 43% chance that mobile apps delivered the most effective interventions, followed by a 34% chance that interventions delivered via virtual reality were the most effective. Conclusions: This systematic review with an NMA generated comparisons between eHealth modalities previously not compared to determine which delivered the most effective interventions for the reduction of pain interference in chronic pain patients. There are limitations with this review, in particular, the underrepresented nature of some eHealth modalities included in the analysis. However, in the event that the review is regularly updated, a clear ranking of eHealth modalities for the reduction of pain interference will emerge. %M 31317869 %R 10.2196/11086 %U https://www.jmir.org/2019/7/e11086/ %U https://doi.org/10.2196/11086 %U http://www.ncbi.nlm.nih.gov/pubmed/31317869 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 7 %P e13368 %T Virtual Reality and Web-Based Growth Mindset Interventions for Adolescent Depression: Protocol for a Three-Arm Randomized Trial %A Schleider,Jessica Lee %A Mullarkey,Michael C %A Weisz,John R %+ Department of Psychology, Stony Brook University, Psychology B 340, Stony Brook, NY,, United States, 1 631 632 4131, jessica.schleider@stonybrook.edu %K mental health %K depression %K virtual reality %K adolescence %K ehealth %D 2019 %7 09.07.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression is the leading cause of disability in youth, with a global economic burden of US >$210 billion annually. However, up to 70% of youth with depression do not receive services. Even among those who do access treatment, 30% to 65% fail to respond and many dropout prematurely, demonstrating a need for more potent, accessible interventions. In a previous trial, a single-session Web-based growth mindset (GM) intervention significantly reduced depressive symptoms in high-symptom adolescents; however, this intervention did not benefit adolescents uniformly. For instance, the intervention reduced depression in adolescents who reported post intervention increases in perceived control, but it did not lead to significant depression reductions in adolescents who reported no significant post intervention increases in perceived control. Objective: The goal of this project is to test the acceptability and efficacy of a novel, single-session, virtual reality (VR) depression intervention—the VR Personality Project—teaching GM, the belief that personal attributes are malleable rather than fixed. The VR Personality Project was designed to systematically target and increase adolescents’ perceived control by offering a more immersive, engaging, user-directed intervention experience than the Web-based intervention can provide. By targeting an identified predictor of intervention response, the VR Personality Project may lead to larger reductions in depressive symptoms than existing Web-based mindset interventions. Methods: Adolescents with elevated depressive symptoms or a recent history of depression (N=159; ages 12 to 16 years) will be randomized to one of 3 intervention conditions: the VR Personality Project; the Web-based GM intervention tested previously; or an active, Web-based control. Adolescents and their parents will report on the adolescents’ depression symptoms, perceived control, and related domains of functioning at preintervention, postintervention, and at 3- and 9-month follow-up assessments. Results: We predict that the VR and Web-based mindset interventions will both lead to larger reductions in adolescent symptoms than the control intervention. Additionally, we predict that the VR-based single session intervention will lead to larger reductions in depression than the online mindset intervention and that these symptom reductions will be mediated by increases in adolescents’ perceived control from pre- to postintervention. Conclusions: The results may suggest an efficient strategy for reducing adolescent depressive symptoms: One that is mechanism-targeted, relatively affordable (less than US $200 for a commercially available VR headset, a fraction of the cost of long-term psychotherapy) and potentially engaging to adolescents experiencing mood-related distress. Trial Registration: ClinicalTrials.gov NCT0385881; https://clinicaltrials.gov/ct2/show/NCT03858881 (Archived by WebCite at http://www.webcitation.org/78C3roDgA). International Registered Report Identifier (IRRID): DERR1-10.2196/13368 %M 31290406 %R 10.2196/13368 %U https://www.researchprotocols.org/2019/7/e13368/ %U https://doi.org/10.2196/13368 %U http://www.ncbi.nlm.nih.gov/pubmed/31290406 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 6 %P e13594 %T Feasibility of a Real-Time Clinical Augmented Reality and Artificial Intelligence Framework for Pain Detection and Localization From the Brain %A Hu,Xiao-Su %A Nascimento,Thiago D %A Bender,Mary C %A Hall,Theodore %A Petty,Sean %A O’Malley,Stephanie %A Ellwood,Roger P %A Kaciroti,Niko %A Maslowski,Eric %A DaSilva,Alexandre F %+ Headache & Orofacial Pain Effort Lab, Biologic & Materials Sciences Department, School of Dentistry, University of Michigan, 1011 N University Ave, Ann Arbor, MI, 48109-1078, United States, 1 734 615 3807, adasilva@umich.edu %K pain %K spectroscopy, near-infrared %K virtual reality %K artificial intelligence %D 2019 %7 28.06.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: For many years, clinicians have been seeking for objective pain assessment solutions via neuroimaging techniques, focusing on the brain to detect human pain. Unfortunately, most of those techniques are not applicable in the clinical environment or lack accuracy. Objective: This study aimed to test the feasibility of a mobile neuroimaging-based clinical augmented reality (AR) and artificial intelligence (AI) framework, CLARAi, for objective pain detection and also localization direct from the patient’s brain in real time. Methods: Clinical dental pain was triggered in 21 patients by hypersensitive tooth stimulation with 20 consecutive descending cold stimulations (32°C-0°C). We used a portable optical neuroimaging technology, functional near-infrared spectroscopy, to gauge their cortical activity during evoked acute clinical pain. The data were decoded using a neural network (NN)–based AI algorithm to classify hemodynamic response data into pain and no-pain brain states in real time. We tested the performance of several networks (NN with 7 layers, 6 layers, 5 layers, 3 layers, recurrent NN, and long short-term memory network) upon reorganized data features on pain diction and localization in a simulated real-time environment. In addition, we also tested the feasibility of transmitting the neuroimaging data to an AR device, HoloLens, in the same simulated environment, allowing visualization of the ongoing cortical activity on a 3-dimensional brain template virtually plotted on the patients’ head during clinical consult. Results: The artificial neutral network (3-layer NN) achieved an optimal classification accuracy at 80.37% (126,000/156,680) for pain and no pain discrimination, with positive likelihood ratio (PLR) at 2.35. We further explored a 3-class localization task of left/right side pain and no-pain states, and convolutional NN-6 (6-layer NN) achieved highest classification accuracy at 74.23% (1040/1401) with PLR at 2.02. Conclusions: Additional studies are needed to optimize and validate our prototype CLARAi framework for other pains and neurologic disorders. However, we presented an innovative and feasible neuroimaging-based AR/AI concept that can potentially transform the human brain into an objective target to visualize and precisely measure and localize pain in real time where it is most needed: in the doctor’s office. International Registered Report Identifier (IRRID): RR1-10.2196/13594 %M 31254336 %R 10.2196/13594 %U https://www.jmir.org/2019/6/e13594/ %U https://doi.org/10.2196/13594 %U http://www.ncbi.nlm.nih.gov/pubmed/31254336 %0 Journal Article %@ 1929-073X %I JMIR Publications %V 8 %N 2 %P e13698 %T Using Virtual Reality to Improve Antiretroviral Therapy Adherence in the Treatment of HIV: Open-Label Repeated Measure Study %A Liran,Omer %A Dasher,Robert %A Kaeochinda,Kevin %+ Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California - Los Angeles, 10833 Le Conte Ave, Los Angeles, CA, 91604, United States, 1 (310) 825 6373, oliran@ucla.edu %K HAART %K technology %K virtual reality %K medication adherence %K viral load %K education %D 2019 %7 20.06.2019 %9 Original Paper %J Interact J Med Res %G English %X Background: Nonadherence to HIV medications is a serious unsolved problem and is a major cause of morbidity and mortality in the HIV-positive population. Although treatment efficacy is high if compliance is greater than 90%, about 40% of people with HIV do not meet this threshold. Objective: This study aimed to test a novel approach to improve medication adherence by using a low-cost virtual reality (VR) experience to educate people with HIV about their illness. We hypothesized that people with HIV would be more likely to be compliant with the treatment following the 7-minute experience and, therefore, should have decreasing viral load (VL), increasing cluster of differentiation 4+ (CD4+) cell counts, and improved self-reported adherence. Methods: We showed the VR experience to 107 participants with HIV at a county hospital in Los Angeles, California. Participants were asked to self-report how often they take their medications on a Likert-scale. The self-reported question (SRQ) was given before and at least 2 weeks after the VR experience. We also compared VL and CD4+ cell counts before and on average 101 days after the experience. VL and CD4+ were obtained per the clinic’s standard care protocol. Two-tailed paired t tests were performed on the initial and follow-up SRQ scores, VL, and CD4+. We restricted the CD4+ analysis to participants who had a pre-CD4+ below normal (defined as 500 cells/mm3). To reduce the possibility that VL were trending down and CD4+ were trending up regardless of the VR experience, 2 serial VL and CD4+ obtained before the experience were also compared and analyzed. Immediately following the VR experience, participants were given a 4-question Likert-type postexperience questionnaire (PEQ) that assessed their opinions about the experience. Results: SRQ scores improved from pre to post experience with high significance (P<.001). VL decreased from pre to post experience by 0.38 log10 copies/mL (95% CI 0.06-0.70; P=.02). In contrast, the 2 serial VL obtained before the experience showed no statistically significant changes. There was also a statistically significant increase in CD4+ (95% CI –3.4 to –54.3 cells/mm3; P=.03). Analysis of the PEQ revealed that VR was comfortable for almost all of the participants and that most participants believed the experience to be educational and that it would improve their medication adherence. Conclusions: The findings suggest that the low-cost VR experience caused an increased rate of antiretroviral therapy adherence that resulted in a decrease of VL and an increase of CD4+. Further studies are required to explore the duration of this effect and whether these results are generalizable to other treatment settings and populations. %M 31223117 %R 10.2196/13698 %U http://www.i-jmr.org/2019/2/e13698/ %U https://doi.org/10.2196/13698 %U http://www.ncbi.nlm.nih.gov/pubmed/31223117 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 2 %P e11960 %T Younger Adolescents’ Perceptions of Physical Activity, Exergaming, and Virtual Reality: Qualitative Intervention Development Study %A Faric,Nuša %A Yorke,Eleanor %A Varnes,Laura %A Newby,Katie %A Potts,Henry WW %A Smith,Lee %A Hon,Adrian %A Steptoe,Andrew %A Fisher,Abigail %+ Department of Behavioural Science & Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, United Kingdom, 44 02067694466 ext 41914, nfaric@gmail.com %K exercise %K obesity %K video games %K adolescent %K adolescence %K sports %K health %K leisure activities %K virtual reality %D 2019 %7 17.06.2019 %9 Original Paper %J JMIR Serious Games %G English %X Background: Novel strategies to promote physical activity (PA) in adolescence are required. The vEngage study aims to test whether a virtual reality (VR) exergaming intervention can engage younger adolescents (aged 13 to 15 years) with PA. Objective: This study aimed to gather adolescents’ views of using VR to encourage PA and identify the key features they would like to see in a VR exergaming intervention via interviews. Methods: Participants were recruited through 2 schools in London, United Kingdom. Semistructured interviews were conducted with adolescents about their views on PA and what might work to increase PA, technology, knowledge and experience of VR, and desired features in a VR exergaming intervention. Data were analyzed using Framework Analysis. Results: A total of 31 participants aged between 13 and 15 years (58% female, 62% from nonwhite ethnicities) participated in this interview study. The vast majority had no awareness of government PA recommendations but felt they should be more thoroughly informed. All participants were positive about the use of VR in PA promotion. Rewards, increasing challenges, and a social or multiplayer aspect were identified by participants as crucial aspects to include in a VR exercise game. Barriers were related to cost of high-end systems. Being able to exercise at home was very appealing. VR exergaming was viewed as a way to overcome multiple perceived social and cultural barriers to PA, particularly for girls. Conclusions: Key elements that should be incorporated into a VR game for health intervention were identified and described. These also included the use of rewards, novelty and enjoyment in immersive game play, multiplayer options, and real-world elements, as well as continual updates and new challenge levels. The use of VR to promote PA in adolescents is promising, but some barriers were raised. %M 31210135 %R 10.2196/11960 %U http://games.jmir.org/2019/2/e11960/ %U https://doi.org/10.2196/11960 %U http://www.ncbi.nlm.nih.gov/pubmed/31210135 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 2 %P e13633 %T Exploring the Potential for Use of Virtual Reality Technology in the Treatment of Severe Mental Illness Among Adults in Mid-Norway: Collaborative Research Between Clinicians and Researchers %A Ose,Solveig Osborg %A Færevik,Hilde %A Kaasbøll,Jannike %A Lindgren,Martin %A Thaulow,Kristin %A Antonsen,Stig %A Burkeland,Olav %+ SINTEF AS Digital, Klaebuveien 153, Trondheim,, Norway, 47 90728684, solveig.ose@sintef.no %K virtual reality %K severe mental illness %K collaborative research %K technology %K social work %D 2019 %7 10.6.2019 %9 Original Paper %J JMIR Form Res %G English %X Background: Virtual reality (VR) technology is not currently used in the treatment of severe mental health illness in Norway. Objective: We aimed to explore the potential of VR as a treatment for severe mental health illness in Norway, through collaborative research between clinicians and researchers. Methods: A collaborative research team was established, comprising researchers, the manager at a district psychiatric center, and the manager of the local municipal mental health service. An all-day workshop with eight clinicians—four from specialist mental health services and four from municipal mental health services—was conducted. The clinicians watched three different VR movies and after each one, they answered predefined questions designed to reflect their immediate thoughts about VR’s potential use in clinical practice. At the end of the workshop, two focus group interviews, each with four clinicians from each service level, were conducted. Results: VR technology in specialist services might be a new tool for the treatment of severe mental health illness. In municipal mental health services, VR might particularly be useful in systematic social training that would otherwise take a very long time to complete. Conclusions: We found substantial potential for the use of VR in the treatment of severe mental health illness in specialist and municipal mental health services. One of the uses of VR technology with the greatest potential was helping individuals who had isolated themselves and needed training in social skills and everyday activity to enable them to have more active social lives. VR could also be used to simulate severe mental illness to provide a better understanding of how the person with severe mental illness experiences their situation. %M 31199315 %R 10.2196/13633 %U http://formative.jmir.org/2019/2/e13633/ %U https://doi.org/10.2196/13633 %U http://www.ncbi.nlm.nih.gov/pubmed/31199315 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 2 %N 1 %P e11684 %T A Free Virtual Reality Experience to Prepare Pediatric Patients for Magnetic Resonance Imaging: Cross-Sectional Questionnaire Study %A Ashmore,Jonathan %A Di Pietro,Jerome %A Williams,Kelly %A Stokes,Euan %A Symons,Anna %A Smith,Martina %A Clegg,Louise %A McGrath,Cormac %+ Department of Medical Physics and Bioengineering, NHS Highland, Old Perth Road, Inverness,, United Kingdom, 44 07760712289, jonathan.ashmore@nhs.net %K virtual reality %K MRI %K anxiety %D 2019 %7 18.04.2019 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: A magnetic resonance image (MRI) is a diagnostic test that requires patients to lie still for prolonged periods within a claustrophobic and noisy environment. This can be difficult for children to tolerate, and often general anesthetic (GA) is required at considerable cost and detriment to patient safety. Virtual reality (VR) is a newly emerging technology that can be implemented at low cost within a health care setting. It has been shown to reduce fear associated with a number of high-anxiety situations and medical procedures. Objective: The goal of the research was to develop a VR resource to prepare pediatric patients for MRI, helping to reduce anxieties in children undergoing the procedure. Methods: A freely accessible VR preparation resource was developed to prepare pediatric patients for their upcoming MRI. The resource consists of an app and supporting preparation book and used a series of panoramic 360 degree videos of the entire MRI journey, including footage from within the bore of the scanner. The app, deployed via the Android Play Store and iOS App Store, can be viewed on most mobile phones, allowing a child to experience an MRI in VR using an inexpensive Google Cardboard headset. The app contains 360 degree videos within an animated, interactive VR interface designed for 4 to 12-year-olds. The resource was evaluated as part of a clinical audit on 23 patients (aged 4 to 12 years), and feedback was obtained from 10 staff members. In 5 patients, the resource was evaluated as a tool to prepare patients for an awake MRI who otherwise were booked to have an MRI under GA. Results: The VR preparation resource has been successfully implemented at 3 UK institutions. Of the 23 patients surveyed, on a scale of 1 to 10, the VR resource was rated with a median score of 8.5 for enjoyment, 8 for helpfulness, and 10 for ease of use. All patients agreed that it made them feel more positive about their MRI, and all suggested they would recommend the resource to other children. When considering their experiences using the resource with pediatric patients, on a scale of 1 to 10, the staff members rated the VR resource a median score of 8.5 for enjoyment, 9 for helpfulness, and 9 for ease of use. All staff believed it could help prepare children for an awake MRI, thus avoiding GA. A successful awake MRI was achieved in 4 of the 5 children for whom routine care would have resulted in an MRI under GA. Conclusions: Our VR resource has the potential to relieve anxieties and better prepare patients for an awake MRI. The resource has potential to avoid GA through educating the child about the MRI process. %M 31518319 %R 10.2196/11684 %U http://pediatrics.jmir.org/2019/1/e11684/ %U https://doi.org/10.2196/11684 %U http://www.ncbi.nlm.nih.gov/pubmed/31518319 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 3 %P e11529 %T Clinical Virtual Simulation in Nursing Education: Randomized Controlled Trial %A Padilha,José Miguel %A Machado,Paulo Puga %A Ribeiro,Ana %A Ramos,José %A Costa,Patrício %+ Nursing School of Porto; CINTESIS – Tech4edusim, Street Dr António Bernardino de Almeida, Porto, 4200-072, Portugal, 351 225 073 500, miguelpadilha@esenf.pt %K clinical virtual simulation %K nursing education %K virtual patient %K user-computer interface %D 2019 %7 18.03.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: In the field of health care, knowledge and clinical reasoning are key with regard to quality and confidence in decision making. The development of knowledge and clinical reasoning is influenced not only by students’ intrinsic factors but also by extrinsic factors such as satisfaction with taught content, pedagogic resources and pedagogic methods, and the nature of the objectives and challenges proposed. Nowadays, professors play the role of learning facilitators rather than simple “lecturers” and face students as active learners who are capable of attributing individual meanings to their personal goals, challenges, and experiences to build their own knowledge over time. Innovations in health simulation technologies have led to clinical virtual simulation. Clinical virtual simulation is the recreation of reality depicted on a computer screen and involves real people operating simulated systems. It is a type of simulation that places people in a central role through their exercising of motor control skills, decision skills, and communication skills using virtual patients in a variety of clinical settings. Clinical virtual simulation can provide a pedagogical strategy and can act as a facilitator of knowledge retention, clinical reasoning, improved satisfaction with learning, and finally, improved self-efficacy. However, little is known about its effectiveness with regard to satisfaction, self-efficacy, knowledge retention, and clinical reasoning. Objective: This study aimed to evaluate the effect of clinical virtual simulation with regard to knowledge retention, clinical reasoning, self-efficacy, and satisfaction with the learning experience among nursing students. Methods: A randomized controlled trial with a pretest and 2 posttests was carried out with Portuguese nursing students (N=42). The participants, split into 2 groups, had a lesson with the same objectives and timing. The experimental group (n=21) used a case-based learning approach, with clinical virtual simulator as a resource, whereas the control group (n=21) used the same case-based learning approach, with recourse to a low-fidelity simulator and a realistic environment. The classes were conducted by the usual course lecturers. We assessed knowledge and clinical reasoning before the intervention, after the intervention, and 2 months later, with a true or false and multiple-choice knowledge test. The students’ levels of learning satisfaction and self-efficacy were assessed with a Likert scale after the intervention. Results: The experimental group made more significant improvements in knowledge after the intervention (P=.001; d=1.13) and 2 months later (P=.02; d=0.75), and it also showed higher levels of learning satisfaction (P<.001; d=1.33). We did not find statistical differences in self-efficacy perceptions (P=.9; d=0.054). Conclusions: The introduction of clinical virtual simulation in nursing education has the potential to improve knowledge retention and clinical reasoning in an initial stage and over time, and it increases the satisfaction with the learning experience among nursing students. %M 30882355 %R 10.2196/11529 %U http://www.jmir.org/2019/3/e11529/ %U https://doi.org/10.2196/11529 %U http://www.ncbi.nlm.nih.gov/pubmed/30882355 %0 Journal Article %@ 2561-9128 %I JMIR Publications %V 2 %N 1 %P e11259 %T An Interactive Virtual Reality Tour for Adolescents Receiving Proton Radiation Therapy: Proof-of-Concept Study %A Galvez,Jorge %A Eisenhower,Melanie %A England,William %A Wartman,Elicia %A Simpao,Allan %A Rehman,Mohamed %A Lustig,Robert %A Hribar,Michelle %+ Section of Biomedical Informatics, Department of Anesthesiology & Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Suite 9329, Philadelphia, PA, 19104, United States, 1 2155901858, galvezj@email.chop.edu %K child guidance %K patient simulation %K proton therapy %K radiotherapy %K virtual reality exposure therapy %D 2019 %7 05.03.2019 %9 Original Paper %J JMIR Perioper Med %G English %X Background: Child life therapists provide patient education for children undergoing radiation therapy to assist in coping with and understanding their treatment. Objective: This proof-of-concept study aimed to determine the feasibility of incorporating a 360-degree video tour via a virtual reality system for children scheduled to receive radiation therapy. The secondary objective was to qualitatively describe each subject’s virtual reality experience. Methods: Children aged ≥13 years scheduled to receive proton radiation therapy were included in the study. Subjects watched the 360-degree video of the radiation therapy facility in an immersive virtual reality environment with a child life therapist experienced in coaching children receiving radiation therapy and completed a survey after the tour. Results: Eight subjects consented to participate in the study, and six subjects completed the 360-degree video tour and survey. All the enrolled patients completed the tour successfully. Two subjects did not complete the survey. Two subjects requested to pause the tour to ask questions about the facility. Five subjects said the tour was helpful preparation before undergoing proton radiation therapy. Subjects stated that the tour was helpful because “it showed [them] what’s to come” and was helpful to see “what it’s like to lay in the machine.” One subject said, “it made me feel less nervous.” Six subjects stated that they would like to see this type of tour available for other areas of the hospital, such as diagnostic imaging rooms. None of the subjects experienced nausea or vomiting. Conclusions: The 360-degree video tour allowed patients to explore the treatment facility in a comfortable environment. Participants felt that the tour was beneficial and would appreciate seeing other parts of the hospital in this manner. %M 33393932 %R 10.2196/11259 %U http://periop.jmir.org/2019/1/e11259/ %U https://doi.org/10.2196/11259 %U http://www.ncbi.nlm.nih.gov/pubmed/33393932 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 1 %P e13028 %T Serious Games in Surgical Medical Education: A Virtual Emergency Department as a Tool for Teaching Clinical Reasoning to Medical Students %A Chon,Seung-Hun %A Timmermann,Ferdinand %A Dratsch,Thomas %A Schuelper,Nikolai %A Plum,Patrick %A Berlth,Felix %A Datta,Rabi Raj %A Schramm,Christoph %A Haneder,Stefan %A Späth,Martin Richard %A Dübbers,Martin %A Kleinert,Julia %A Raupach,Tobias %A Bruns,Christiane %A Kleinert,Robert %+ Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Strasse 62, Cologne, 50937, Germany, 49 221 478 4864, seung-hun.chon@uk-koeln.de %K serious game %K surgical education %K clinical reasoning %K virtual emergency department %K medical education %D 2019 %7 05.03.2019 %9 Original Paper %J JMIR Serious Games %G English %X Background: Serious games enable the simulation of daily working practices and constitute a potential tool for teaching both declarative and procedural knowledge. The availability of educational serious games offering a high-fidelity, three-dimensional environment in combination with profound medical background is limited, and most published studies have assessed student satisfaction rather than learning outcome as a function of game use. Objective: This study aimed to test the effect of a serious game simulating an emergency department (“EMERGE”) on students’ declarative and procedural knowledge, as well as their satisfaction with the serious game. Methods: This nonrandomized trial was performed at the Department of General, Visceral and Cancer Surgery at University Hospital Cologne, Germany. A total of 140 medical students in the clinical part of their training (5th to 12th semester) self-selected to participate in this experimental study. Declarative knowledge (measured with 20 multiple choice questions) and procedural knowledge (measured with written questions derived from an Objective Structured Clinical Examination station) were assessed before and after working with EMERGE. Students’ impression of the effectiveness and applicability of EMERGE were measured on a 6-point Likert scale. Results: A pretest-posttest comparison yielded a significant increase in declarative knowledge. The percentage of correct answers to multiple choice questions increased from before (mean 60.4, SD 16.6) to after (mean 76.0, SD 11.6) playing EMERGE (P<.001). The effect on declarative knowledge was larger in students in lower semesters than in students in higher semesters (P<.001). Additionally, students’ overall impression of EMERGE was positive. Conclusions: Students self-selecting to use a serious game in addition to formal teaching gain declarative and procedural knowledge. %M 30835239 %R 10.2196/13028 %U http://games.jmir.org/2019/1/e13028/ %U https://doi.org/10.2196/13028 %U http://www.ncbi.nlm.nih.gov/pubmed/30835239 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 2 %P e11517 %T Believing Is Seeing: A Proof-of-Concept Semiexperimental Study on Using Mobile Virtual Reality to Boost the Effects of Interpretation Bias Modification for Anxiety %A Otkhmezuri,Boris %A Boffo,Marilisa %A Siriaraya,Panote %A Matsangidou,Maria %A Wiers,Reinout W %A Mackintosh,Bundy %A Ang,Chee Siang %A Salemink,Elske %+ Faculty of Sciences, School of Engineering and Digital Arts, University of Kent, Jennison Building, University of Kent, Canterbury, CT2 7NT, United Kingdom, 44 1227 823, bo201@kent.ac.uk %K anxiety %K emotional reactivity %K interpretation bias %K cognitive bias modification %K virtual reality %K head mounted display %K immersion %K presence %D 2019 %7 21.02.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Cognitive Bias Modification of Interpretations (CBM-I) is a computerized intervention designed to change negatively biased interpretations of ambiguous information, which underlie and reinforce anxiety. The repetitive and monotonous features of CBM-I can negatively impact training adherence and learning processes. Objective: This proof-of-concept study aimed to examine whether performing a CBM-I training using mobile virtual reality technology (virtual reality Cognitive Bias Modification of Interpretations [VR-CBM-I]) improves training experience and effectiveness. Methods: A total of 42 students high in trait anxiety completed 1 session of either VR-CBM-I or standard CBM-I training for performance anxiety. Participants’ feelings of immersion and presence, emotional reactivity to a stressor, and changes in interpretation bias and state anxiety, were assessed. Results: The VR-CBM-I resulted in greater feelings of presence (P<.001, d=1.47) and immersion (P<.001, ηp2=0.74) in the training scenarios and outperformed the standard training in effects on state anxiety (P<.001, ηp2=0.3) and emotional reactivity to a stressor (P=.03, ηp2=0.12). Both training varieties successfully increased the endorsement of positive interpretations (P<.001, drepeated measures [drm]=0.79) and decreased negative ones. (P<.001, drm=0.72). In addition, changes in the emotional outcomes were correlated with greater feelings of immersion and presence. Conclusions: This study provided first evidence that (1) the putative working principles underlying CBM-I trainings can be translated into a virtual environment and (2) virtual reality holds promise as a tool to boost the effects of CMB-I training for highly anxious individuals while increasing users’ experience with the training application. %M 30789353 %R 10.2196/11517 %U http://mental.jmir.org/2019/2/e11517/ %U https://doi.org/10.2196/11517 %U http://www.ncbi.nlm.nih.gov/pubmed/30789353 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 1 %P e11973 %T Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an International Working Group: Iterative Study %A Birckhead,Brandon %A Khalil,Carine %A Liu,Xiaoyu %A Conovitz,Samuel %A Rizzo,Albert %A Danovitch,Itai %A Bullock,Kim %A Spiegel,Brennan %+ Division of Health Services Research, Department of Medicine, Cedars-Sinai Health System, Pacific Theaters Building, Suite 800, 116 North Robertson Boulevard, Los Angeles, CA, 90048, United States, 1 310 423 6784, Brennan.Spiegel@cshs.org %K clinical trials %K consensus %K virtual reality %D 2019 %7 31.01.2019 %9 Viewpoint %J JMIR Ment Health %G English %X Background: Therapeutic virtual reality (VR) has emerged as an efficacious treatment modality for a wide range of health conditions. However, despite encouraging outcomes from early stage research, a consensus for the best way to develop and evaluate VR treatments within a scientific framework is needed. Objective: We aimed to develop a methodological framework with input from an international working group in order to guide the design, implementation, analysis, interpretation, and communication of trials that develop and test VR treatments. Methods: A group of 21 international experts was recruited based on their contributions to the VR literature. The resulting Virtual Reality Clinical Outcomes Research Experts held iterative meetings to seek consensus on best practices for the development and testing of VR treatments. Results: The interactions were transcribed, and key themes were identified to develop a scientific framework in order to support best practices in methodology of clinical VR trials. Using the Food and Drug Administration Phase I-III pharmacotherapy model as guidance, a framework emerged to support three phases of VR clinical study designs—VR1, VR2, and VR3. VR1 studies focus on content development by working with patients and providers through the principles of human-centered design. VR2 trials conduct early testing with a focus on feasibility, acceptability, tolerability, and initial clinical efficacy. VR3 trials are randomized, controlled studies that evaluate efficacy against a control condition. Best practice recommendations for each trial were provided. Conclusions: Patients, providers, payers, and regulators should consider this best practice framework when assessing the validity of VR treatments. %M 30702436 %R 10.2196/11973 %U https://mental.jmir.org/2019/1/e11973/ %U https://doi.org/10.2196/11973 %U http://www.ncbi.nlm.nih.gov/pubmed/30702436 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e10885 %T Expertise Modulates Students’ Perception of Pain From a Self-Perspective: Quasi-Experimental Study %A Said Yekta-Michael,Sareh %A Schüppen,André %A Gaebler,Arnim Johannes %A Ellrich,Jens %A Koten,Jan Willem %+ Department of Conservative Dentistry, Periodontology and Preventive Dentistry, RWTH Aachen University, Pauwelsstrasse 30, Aachen, 52074, Germany, 49 02418088118, samichael@ukaachen.de %K medical education %K virtual reality %K questionnaires %K physician %D 2019 %7 23.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Perception of stimuli presented in a virtual dentistry environment affects regions of the brain that are related to pain perception. Objective: We investigated whether neural correlates of virtual pain perception are affected by education in dentistry. Methods: In this functional magnetic resonance imaging study, a sample of 20 dental students and 20 age-matched controls viewed and listened to video clips presenting a dental treatment from the first‐person perspective. An anxiety questionnaire was used to assess the level of dental anxiety. Neural correlates of pain perception were investigated through classic general linear model analysis and in-house classification methods. Results: Dental students and naïve controls exhibited similar anxiety levels for invasive stimuli. Invasive dentistry scenes evoked a less affective component of pain in dental students compared with naïve controls (P<.001). Reduced affective pain perception went along with suppressed brain activity in pain matrix regions including the insula, anterior cingulate cortex, and basal ganglia. Furthermore, a substantial reduction of brain activity was observed in motor-related regions, particularly the supplementary motor area, premotor cortex, and basal ganglia. Within this context, a classifier analysis based on neural activity in the nucleus lentiformis could identify dental students and controls on the individual subject level in 85% of the cases (34 out of 40 participants, sensitivity=90%, specificity=80%). Conclusions: Virtual dental treatment activates pain-related brain regions in controls. By contrast, dental students suppress affective and motor-related aspects of pain. We speculate that dental students learn to control motoric aspects of pain perception during their education because it is a prerequisite for the professional manual treatment of patients. We discuss that a specific set of learning mechanisms might affect perceived self-efficacy of dental students, which in turn might reduce their affective component of pain perception. %M 30674449 %R 10.2196/10885 %U http://www.jmir.org/2019/1/e10885/ %U https://doi.org/10.2196/10885 %U http://www.ncbi.nlm.nih.gov/pubmed/30674449 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e12959 %T Virtual Reality for Health Professions Education: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration %A Kyaw,Bhone Myint %A Saxena,Nakul %A Posadzki,Pawel %A Vseteckova,Jitka %A Nikolaou,Charoula Konstantia %A George,Pradeep Paul %A Divakar,Ushashree %A Masiello,Italo %A Kononowicz,Andrzej A %A Zary,Nabil %A Tudor Car,Lorainne %+ Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Singapore,, Singapore, 65 69041258, lorainne.tudor.car@ntu.edu.sg %K virtual reality %K health professions education %K randomized controlled trials %K systematic review %K meta-analysis %D 2019 %7 22.01.2019 %9 Review %J J Med Internet Res %G English %X Background: Virtual reality (VR) is a technology that allows the user to explore and manipulate computer-generated real or artificial three-dimensional multimedia sensory environments in real time to gain practical knowledge that can be used in clinical practice. Objective: The aim of this systematic review was to evaluate the effectiveness of VR for educating health professionals and improving their knowledge, cognitive skills, attitudes, and satisfaction. Methods: We performed a systematic review of the effectiveness of VR in pre- and postregistration health professions education following the gold standard Cochrane methodology. We searched 7 databases from the year 1990 to August 2017. No language restrictions were applied. We included randomized controlled trials and cluster-randomized trials. We independently selected studies, extracted data, and assessed risk of bias, and then, we compared the information in pairs. We contacted authors of the studies for additional information if necessary. All pooled analyses were based on random-effects models. We used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach to rate the quality of the body of evidence. Results: A total of 31 studies (2407 participants) were included. Meta-analysis of 8 studies found that VR slightly improves postintervention knowledge scores when compared with traditional learning (standardized mean difference [SMD]=0.44; 95% CI 0.18-0.69; I2=49%; 603 participants; moderate certainty evidence) or other types of digital education such as online or offline digital education (SMD=0.43; 95% CI 0.07-0.79; I2=78%; 608 participants [8 studies]; low certainty evidence). Another meta-analysis of 4 studies found that VR improves health professionals’ cognitive skills when compared with traditional learning (SMD=1.12; 95% CI 0.81-1.43; I2=0%; 235 participants; large effect size; moderate certainty evidence). Two studies compared the effect of VR with other forms of digital education on skills, favoring the VR group (SMD=0.5; 95% CI 0.32-0.69; I2=0%; 467 participants; moderate effect size; low certainty evidence). The findings for attitudes and satisfaction were mixed and inconclusive. None of the studies reported any patient-related outcomes, behavior change, as well as unintended or adverse effects of VR. Overall, the certainty of evidence according to the GRADE criteria ranged from low to moderate. We downgraded our certainty of evidence primarily because of the risk of bias and/or inconsistency. Conclusions: We found evidence suggesting that VR improves postintervention knowledge and skills outcomes of health professionals when compared with traditional education or other types of digital education such as online or offline digital education. The findings on other outcomes are limited. Future research should evaluate the effectiveness of immersive and interactive forms of VR and evaluate other outcomes such as attitude, satisfaction, cost-effectiveness, and clinical practice or behavior change. %M 30668519 %R 10.2196/12959 %U http://www.jmir.org/2019/1/e12959/ %U https://doi.org/10.2196/12959 %U http://www.ncbi.nlm.nih.gov/pubmed/30668519 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 6 %N 1 %P e12008 %T Advancing Cardiac Surgery Case Planning and Case Review Conferences Using Virtual Reality in Medical Libraries: Evaluation of the Usability of Two Virtual Reality Apps %A Napa,Sandeep %A Moore,Michael %A Bardyn,Tania %+ Department of Biomedical Informatics and Medical Education, School of Medicine, University of Washington, T334 Health Sciences Building, 1959 NE Pacific Street, Seattle, WA, 98195, United States, 1 2062219010, sandeepnapa@me.com %K virtual reality %K cardiac surgery %K usability study %K system usability score %K NASA-Task Load Index %K medical libraries %K case planning %K presurgical planning %D 2019 %7 16.01.2019 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Care providers and surgeons prepare for cardiac surgery using case conferences to review, discuss, and run through the surgical procedure. Surgeons visualize a patient’s anatomy to decide the right surgical approach using magnetic resonance imaging and echocardiograms in a presurgical case planning session. Previous studies have shown that surgical errors can be reduced through the effective use of immersive virtual reality (VR) to visualize patient anatomy. However, inconsistent user interfaces, delegation of view control, and insufficient depth information cause user disorientation and interaction difficulties in using VR apps for case planning. Objective: The objective of the study was to evaluate and compare the usability of 2 commercially available VR apps—Bosc (Pyrus Medical systems) and Medical Holodeck (Nooon Web & IT GmbH)—using the Vive VR headset (HTC Corporation) to evaluate ease of use, physician attitudes toward VR technology, and viability for presurgical case planning. The role of medical libraries in advancing case planning is also explored. Methods: After screening a convenience sample of surgeons, fellows, and residents, ethnographic interviews were conducted to understand physician attitudes and experience with VR. Gaps in current case planning methods were also examined. We ran a usability study, employing a concurrent think-aloud protocol. To evaluate user satisfaction, we used the system usability scale (SUS) and the National Aeronautics and Space Administration-Task Load Index (NASA-TLX). A poststudy questionnaire was used to evaluate the VR experience and explore the role of medical libraries in advancing presurgical case planning. Semistructured interview data were analyzed using content analysis with feedback categorization. Results: Participants were residents, fellows, and surgeons from the University of Washington with a mean age of 41.5 (SD 11.67) years. A total of 8 surgeons participated in the usability study, 3 of whom had prior exposure to VR. Users found Medical Holodeck easier to use than Bosc. Mean adjusted NASA-TLX score for Medical Holodeck was 62.71 (SD 18.25) versus Bosc’s 40.87 (SD 13.90). Neither app passed the mean SUS score of 68 for an app to be considered usable, though Medical Holodeck (66.25 [SD 12.87]) scored a higher mean SUS than Bosc (37.19 [SD 22.41]). One user rated the Bosc usable, whereas 3 users rated Medical Holodeck usable. Conclusions: Interviews highlighted the importance of precise anatomical conceptualization in presurgical case planning and teaching, identifying it as the top reason for modifying a surgical procedure. The importance of standardized user interaction features such as labeling is justified. The study also sheds light on the new roles medical librarians can play in curating VR content and promoting interdisciplinary collaboration. %M 30664469 %R 10.2196/12008 %U http://humanfactors.jmir.org/2019/1/e12008/ %U https://doi.org/10.2196/12008 %U http://www.ncbi.nlm.nih.gov/pubmed/30664469 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 5 %N 1 %P e11921 %T Use of Smartphone-Based Head-Mounted Display Devices to View a Three-Dimensional Dissection Model in a Virtual Reality Environment: Pilot Questionnaire Study %A Masuoka,Yoshihito %A Morikawa,Hiroyuki %A Kawai,Takashi %A Nakagohri,Toshio %+ Department of Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan, 81 463 93 1121, y-masu@is.icc.u-tokai.ac.jp %K medical education %K smartphone %K virtual reality %D 2019 %7 14.01.2019 %9 Original Paper %J JMIR Med Educ %G English %X Background: Virtual reality (VR) technology has started to gain attention as a form of surgical support in medical settings. Likewise, the widespread use of smartphones has resulted in the development of various medical applications; for example, Google Cardboard, which can be used to build simple head-mounted displays (HMDs). However, because of the absence of observed and reported outcomes of the use of three-dimensional (3D) organ models in relevant environments, we have yet to determine the effects of or issues with the use of such VR technology. Objective: The aim of this paper was to study the issues that arise while observing a 3D model of an organ that is created based on an actual surgical case through the use of a smartphone-based simple HMD. Upon completion, we evaluated and gathered feedback on the performance and usability of the simple observation environment we had created. Methods: We downloaded our data to a smartphone (Galaxy S6; Samsung, Seoul, Korea) and created a simple HMD system using Google Cardboard (Google). A total of 17 medical students performed 2 experiments: an observation conducted by a single observer and another one carried out by multiple observers using a simple HMD. Afterward, they assessed the results by responding to a questionnaire survey. Results: We received a largely favorable response in the evaluation of the dissection model, but also a low score because of visually induced motion sickness and eye fatigue. In an introspective report on simultaneous observations made by multiple observers, positive opinions indicated clear image quality and shared understanding, but displeasure caused by visually induced motion sickness, eye fatigue, and hardware problems was also expressed. Conclusions: We established a simple system that enables multiple persons to observe a 3D model. Although the observation conducted by multiple observers was successful, problems likely arose because of poor smartphone performance. Therefore, smartphone performance improvement may be a key factor in establishing a low-cost and user-friendly 3D observation environment. %M 31344673 %R 10.2196/11921 %U http://mededu.jmir.org/2019/1/e11921/ %U https://doi.org/10.2196/11921 %U http://www.ncbi.nlm.nih.gov/pubmed/31344673 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 1 %P e11470 %T Rehabilitation for Children With Dystonic Cerebral Palsy Using Haptic Feedback in Virtual Reality: Protocol for a Randomized Controlled Trial %A McNish,Reika Nicole %A Chembrammel,Pramod %A Speidel,Nathaniel Christopher %A Lin,Julian Jwchun %A López-Ortiz,Citlali %+ Department of Kinesiology and Community Health, Department of Dance, Neuroscience Program, Illinois Informatics Institute, Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, 906 South Goodwin Avenue, Urbana, IL, 61801, United States, 1 2173001022, lopezort@illinois.edu %K cerebral palsy %K child %K dystonia %K motor skills %K muscle spasticity %K randomized controlled trial %K rehabilitation %K robotics %K sensory feedback %K virtual reality %D 2019 %7 14.01.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Cerebral palsy (CP) is the most common developmental motor disorder in children. Individuals with CP demonstrate abnormal muscle tone and motor control. Within the population of children with CP, between 4% and 17% present dystonic symptoms that may manifest as large errors in movement tasks, high variability in movement trajectories, and undesired movements at rest. These symptoms of dystonia typically worsen with physical intervention exercises. Objective: The aim of this study is to establish the effect of haptic feedback in a virtual reality (VR) game intervention on movement outcomes of children with dystonic CP. Methods: The protocol describes a randomized controlled trial that uses a VR game-based intervention incorporating fully automated robotic haptic feedback. The study consists of face-to-face assessments of movement before, after, and 1 month following the completion of the 6-session game-based intervention. Children with dystonic CP, aged between 7 and 17 years, will be recruited for this study through posted fliers and laboratory websites along with a group of typically developing (TD) children in the same age range. We anticipate to recruit a total of 68 participants, 34 each with CP and TD. Both groups of children will be randomly allocated into an intervention or control group using a blocked randomization method. The primary outcome measure will be the smoothness index of the interaction force with the robot and of the accelerometry signals of sensors placed on the upper limb segments. Secondary outcomes include a battery of clinical tests and a quantitative measure of spasticity. Assessors administering clinical measures will be blinded. All sessions will be administered on-site by research personnel. Results: The trial has not started and is pending local institutional review board approval. Conclusions: Movement outcomes will be examined for changes in muscle activation and clinical measures in children with dystonic CP and TD children. Paired t tests will be conducted on movement outcomes for both groups of children independently. Positive and negative results will be reported and addressed. Trial Registration: ClinicalTrials.gov NCT03744884; https://clinicaltrials.gov/ct2/show/NCT03744884 (Archived by WebCite at http://www.webcitation.org/74RSvmbZP) International Registered Report Identifier (IRRID): PRR1-10.2196/11470 %M 31344678 %R 10.2196/11470 %U https://www.researchprotocols.org/2019/1/e11470/ %U https://doi.org/10.2196/11470 %U http://www.ncbi.nlm.nih.gov/pubmed/31344678 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 7 %N 1 %P e10902 %T A Novel Clinician-Orchestrated Virtual Reality Platform for Distraction During Pediatric Intravenous Procedures in Children With Hemophilia: Randomized Controlled Trial %A Dunn,Amy %A Patterson,Jeremy %A Biega,Charmaine F %A Grishchenko,Alice %A Luna,John %A Stanek,Joseph R %A Strouse,Robert %+ Nationwide Children's Hospital, Division of Hematology, Oncology and BMT, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, United States, 1 614 722 3564, amy.dunn@nationwidechildrens.org %K anxiety %K distraction %K hemophilia %K intravenous %K mobile phone %K needle %K pediatric %K virtual reality %D 2019 %7 09.01.2019 %9 Original Paper %J JMIR Serious Games %G English %X Background: Needles are frequently required for routine medical procedures. Children with severe hemophilia require intensive intravenous (IV) therapy to treat and prevent life-threatening bleeding and undergo hundreds of IV procedures. Fear of needle-related procedures may lead to avoidance of future health care and poor clinical outcomes. Virtual reality (VR) is a promising distraction technique during procedures, but barriers to commercially available VR platforms for pediatric health care purposes have prevented widespread use. Objective: We hypothesized that we could create a VR platform that would be used for pediatric hemophilia care, allow clinician orchestration, and be safe and feasible to use for distraction during IV procedures performed as part of complex health care. Methods: We created a VR platform comprising wireless, adjustable, disposable headsets and a suite of remotely orchestrated VR games. The platform was customized for a pediatric hemophilia population that required hands-free navigation to allow access to a child’s hands or arms for procedures. A hemophilia nurse observing the procedure performed orchestration. The primary endpoint of the trial was safety. Preliminary feasibility and usability of the platform were assessed in a single-center, randomized clinical trial from June to December 2016. Participants were children with hemophilia aged 6-18 years. After obtaining informed consent, 25 patients were enrolled and randomized. Each subject, 1 caregiver, and 1 hemophilia nurse orchestrator assessed the degree of preprocedural nervousness or anxiety with an anchored, combined modified visual analog (VAS)/FACES scale. Each participant then underwent a timed IV procedure with either VR or standard of care (SOC) distraction. Each rater assessed the distraction methods using the VAS/FACES scale at the completion of the IV procedure, with questions targeting usability, engagement, impact on procedural anxiety, impact on procedural pain, and likability of the distraction technique. Participants, caregivers, and nurses also rated how much they would like to use VR for future procedures. To compare the length of procedure time between the groups, Mann-Whitney test was used. Results: Of the 25 enrolled children, 24 were included in the primary analysis. No safety concerns or VR sickness occurred. The median procedure time was 10 (range 1-31) minutes in the VR group and was comparable to 9 (range 3-20) minutes in the SOC group (P=.76). Patients in both the groups reported a positive influence of distraction on procedural anxiety and pain. Overall, in 80% (34/45) of the VR evaluations, children, caregivers, and nurses reported that they would like to use VR for future procedures. Conclusions: We demonstrated that an orchestrated, VR environment could be developed and safely used during pediatric hemophilia care for distraction during IV interventions. This platform has the potential to improve patient experience during medical procedures. Trial Registration: Clinical Trials.gov NCT03507582; https://clinicaltrials.gov/ct2/show/NCT03507582 (Archived by WebCite at http://www.webcitation.org/73G75upA3) %M 30626567 %R 10.2196/10902 %U https://games.jmir.org/2019/1/e10902/ %U https://doi.org/10.2196/10902 %U http://www.ncbi.nlm.nih.gov/pubmed/30626567 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 3 %N 1 %P e12456 %T A Virtual Reality Food Court to Study Meal Choices in Youth: Design and Assessment of Usability %A Allman-Farinelli,Margaret %A Ijaz,Kiran %A Tran,Helen %A Pallotta,Hermes %A Ramos,Sidney %A Liu,Junya %A Wellard-Cole,Lyndal %A Calvo,Rafael A %+ Charles Perkins Centre, School of Life and Environmental Sciences, University of Sydney, Building D17, NSW, 2006, Australia, 61 0290367045, margaret.allmanfarinelli@sydney.edu.au %K virtual reality %K nutrition promotion %K food policy %K take-out food %K obesity %K young adults %D 2019 %7 09.01.2019 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Regular consumption of take-out and fast foods with sugary drinks is associated with poor quality diets and higher prevalence of obesity. Among the settings where such food is consumed is the food court typically found in shopping malls prominent in many countries. Objective: The objective of this research was to develop a virtual reality food court that could be used to test food environmental interventions, such as taxation, and ultimately to facilitate the selection of healthier food choices. Methods: Fourteen food courts in Sydney, Australia were selected to include those in the city center and suburbs of high and low socioeconomic status. Researchers visited the courts to collect information on number and type of food outlets, all menu items for sale, cost of foods and beverages and sales promotions. This information was used to assemble 14 food outlets typically found in food courts, and representative menus were compiled. The UNITY gaming platform was used to design a virtual reality food court that could be used with HTC VIVE goggles. Participants navigated the virtual reality food court using the head-mounted display, keyboard, and mouse and selected a lunch meal, including food and beverage. A validated questionnaire on presence within the virtual reality food court and system usability was completed at the end of the session. The constructs for presence included a sense of control, sensory fidelity, realism, distraction, and involvement. Questions were rated on a scale from 1 (worst) through 7 (best) for each of 28 questions giving a maximum total score of 196. The systems usability scale (SUS) that gives a final score out of 100 was also assessed. Results: One hundred and sixty-two participants with a mean age of 22.5 (SD 3.1) years completed the survey. The mean score for total presence was 144 (SE 1.4) consisting of control: 62.1 (SE 0.8), realism: 17.5 (SE 0.2), involvement: 9.6 (SE 0.2), sensory fidelity: 34.9 (SE 0.4), and distraction: 24.0 (SE 0.3). The mean SUS was 69 (SE 1.1). Conclusions: Virtual reality shows promise as a tool to study food choice for test interventions to inform practice and policy. %M 30684440 %R 10.2196/12456 %U http://formative.jmir.org/2019/1/e12456/ %U https://doi.org/10.2196/12456 %U http://www.ncbi.nlm.nih.gov/pubmed/30684440 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 1 %N 2 %P e10 %T Home to Hospital Live Streaming With Virtual Reality Goggles: A Qualitative Study Exploring the Experiences of Hospitalized Children %A Bakker,Aafke %A Janssen,Lindy %A Noordam,Cees %+ Amalia Children's Hospital, Department of Pediatrics, Radboud University Medical Center, Route 804, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, Netherlands, 31 243614433, aafke.bakker@solcon.nl %K experiences %K hospitalization %K mobile phone %K livestream %K pediatrics %K qualitative analysis %K videoconferencing %K virtual reality %D 2018 %7 13.12.2018 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Being separated from home and relatives is a major stressor for children and adolescents when hospitalized. Children long for a manner to be distracted, pleasured, and socially connected during hospitalization. Different technological devices have been applied in health care to answer those needs. Both virtual reality (VR) and videoconferencing have proven their value in hospital wards and pediatrics. VisitU combines these 2 technologies innovatively. VisitU is a recently launched VR product enabling users to be virtually at home during hospitalization. Objective: This study aims to explore the experiences of hospitalized patients with the VR intervention of VisitU in addition to standard care. Methods: Over a 3-month period, a purposive sample of 10 patients hospitalized in the Radboudumc Amalia Children’s Hospital was included in this qualitative study. Semistructured interviews were performed, one before and one after the use of the VR device. Patients were asked open-ended questions concerning their experiences with VisitU on practical, cognitive, emotional, and social domains. The interviews were audiorecorded and transcribed verbatim. Atlas.ti was used to support the qualitative analysis. Furthermore, the inductive thematic analysis was done according to the 6-step procedure described by Braun and Clarke. Results: The following 6 main themes were the result of the qualitative analysis: “Being hospitalized,” “Expectations of VisitU,” “VisitU in use,” “VisitU, the benefits,” “The impact of VisitU,” and “Barriers when using VisitU.” The way VisitU was used by patients varied. The main benefits of VisitU were being somewhere else, being at home, and facilitating social connection. Limitations were experienced on the technical abilities, physical side effects, and complexity of use. Despite that, patients were positive about VisitU and unanimous in the view that they would like to use it again and advise other patients to use it. Conclusions: This study shows the positive experiences of pediatric patients with VR live streaming. VisitU brings together the needs of patients and possibilities of VR and videoconferencing; it offers patients a way out of the hospital. Nevertheless, practical and technical obstacles must be overcome and side effects are an area of further research. %M 31518293 %R 10.2196/pediatrics.9576 %U http://pediatrics.jmir.org/2018/2/e10/ %U https://doi.org/10.2196/pediatrics.9576 %U http://www.ncbi.nlm.nih.gov/pubmed/31518293 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 11 %P e11152 %T Involuntary Attention Restoration During Exposure to Mobile-Based 360° Virtual Nature in Healthy Adults With Different Levels of Restorative Experience: Event-Related Potential Study %A Chung,Kyungmi %A Lee,Daeho %A Park,Jin Young %+ Department of Psychiatry, Yonsei University College of Medicine, Gangnam Severance Hospital, 611, Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea, 82 2 2019 3342, empathy@yuhs.ac %K smartphone %K virtual reality %K attention %K surveys and questionnaires %K electroencephalography %K evoked potentials %D 2018 %7 30.11.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: With the global trend of urbanization, there are increasing reports of a possible association between decreased exposure to nature and increased occurrence of mental disorders. New 360° virtual reality (VR) technology using smartphones and portable VR glasses can overcome spatial and temporal limitations to help people deal with mental fatigue in everyday life. Objective: On the basis of attention restoration theory (ART), this study aimed to investigate whether the amplitude of the mismatch negativity (MMN)/P3a complex could act as an event-related potential (ERP) biomarker of involuntary attention restoration during exposure to 360° virtual nature in healthy young adults with different levels of restorative VR experience. Methods: A total of 40 healthy adults completed prequestionnaires on demographics and simulator sickness and postquestionnaires on simulator sickness and perceived restorativeness before and after exposure to virtual nature, respectively. During the VR exposure, brain activity was measured by electroencephalography as participants were asked to conduct a 2-tone passive auditory oddball task. Results: The amplitude and latency of the MMN/P3a complex were compared between individuals reporting a highly restorative experience and those reporting a less restorative experience. Although viewing a virtual nature environment, the high restorative group (N=19) exhibited significantly reduced P3a amplitudes compared with the low restorative group (N=20; t38=2.57; P=.02; d=0.59). Particularly, a moderate but significant negative correlation was found between the self-reported restorativeness scores and the P3a amplitudes at the fronto-central region (r=−.38; P=.02). However, the latency of the MMN/P3a complex did not significantly differ between the 2 groups (auditory mismatch negativity: t38=−1.47; P=.15 and P3a: t38=−0.31; P=.76). Conclusions: Considering individuals’ restorative experience, the amplitude of the fronto-central MMN/P3a complex can potentially be employed as a distinct ERP component of interest in involuntary attention restoration during virtual nature experience in healthy young adults. The findings for the 360° virtual nature experience seem to be consistent with those of previous ERP studies on the effects of meditation practice. This study extends the findings of previous ART and ERP studies of real-world meditation, restoration, and mental fatigue management into the virtual world created by mobile phone–based VR glasses and 360° video content. %M 30504121 %R 10.2196/11152 %U http://www.jmir.org/2018/11/e11152/ %U https://doi.org/10.2196/11152 %U http://www.ncbi.nlm.nih.gov/pubmed/30504121 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e10965 %T Implementations of Virtual Reality for Anxiety-Related Disorders: Systematic Review %A Oing,Theodore %A Prescott,Julie %+ School of Education and Psychology, University of Bolton, Deane Road, Bolton, BL3 5AB, United Kingdom, 44 0120490 ext 3676, j.prescott@bolton.ac.uk %K virtual reality %K virtual reality exposure therapy %K phobic disorders %K anxiety disorders %D 2018 %7 07.11.2018 %9 Review %J JMIR Serious Games %G English %X Background: Although traditional forms of therapy for anxiety-related disorders (eg, cognitive behavioral therapy, CBT) have been effective, there have been long-standing issues with these therapies that largely center around the costs and risks associated with the components comprising the therapeutic process. To treat certain types of specific phobias, sessions may need to be held in public, therefore risking patient confidentiality and the occurrence of uncontrollable circumstances (eg, weather and bystander behavior) or additional expenses such as travel to reach a destination. To address these issues, past studies have implemented virtual reality (VR) technologies for virtual reality exposure therapy (VRET) to provide an immersive, interactive experience that can be conducted privately and inexpensively. The versatility of VR allows various environments and scenarios to be generated while giving therapists control over variables that would otherwise be impossible in a natural setting. Although the outcomes from these studies have been generally positive despite the limitations of legacy VR systems, it is necessary to review these studies to identify how modern VR systems can and should improve to treat disorders in which anxiety is a key symptom, including specific phobias, posttraumatic stress disorder and acute stress disorder, generalized anxiety disorder, and paranoid ideations. Objective: The aim of this review was to establish the efficacy of VR-based treatment for anxiety-related disorders as well as to outline how modern VR systems need to address the shortcomings of legacy VR systems. Methods: A systematic search was conducted for any VR-related, peer-reviewed articles focused on the treatment or assessment of anxiety-based disorders published before August 31, 2017, within the ProQuest Central, PsycINFO, and PsycARTICLES databases. References from these articles were also evaluated. Results: A total of 49 studies met the inclusion criteria from an initial pool of 2419 studies. These studies were a mix of case studies focused solely on VRET, experimental studies comparing the efficacy of VRET with various forms of CBT (eg, in vivo exposure, imaginal exposure, and exposure group therapy), and studies evaluating the usefulness of VR technology as a diagnostic tool for paranoid ideations. The majority of studies reported positive findings in favor of VRET despite the VR technology’s limitations. Conclusions: Although past studies have demonstrated promising and emerging efficacy for the use of VR as a treatment and diagnostic tool for anxiety-related disorders, it is clear that VR technology as a whole needs to improve to provide a completely immersive and interactive experience that is capable of blurring the lines between the real and virtual world. %M 30404770 %R 10.2196/10965 %U http://games.jmir.org/2018/4/e10965/ %U https://doi.org/10.2196/10965 %U http://www.ncbi.nlm.nih.gov/pubmed/30404770 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 4 %N 2 %P e10088 %T Improving Shared Decision Making Between Patients and Clinicians: Design and Development of a Virtual Patient Simulation Tool %A Jacklin,Simon %A Maskrey,Neal %A Chapman,Stephen %+ School of Pharmacy, Keele University, Hornbeam Building, School of Pharmacy, Keele, ST55BG, United Kingdom, 44 07597935501, s.jacklin@keele.ac.uk %K clinical decision making %K education %K medical education %K mobile phone %K pharmacy education %K virtual patient %K virtual reality %D 2018 %7 06.11.2018 %9 Original Paper %J JMIR Med Educ %G English %X Background: Shared decision making (SDM) involves the formation of a collaborative partnership between the patient and clinician combining both of their expertise in order to benefit decision making. In order for clinicians to be able to carry out this skilled task, they require practice. Virtual reality, in the form of a virtual patient, could offer a potential method of facilitating this. Objective: The objective of this study was to create a virtual patient that simulated a primary care consultation, affording the opportunity to practice SDM. A second aim was to involve patients in the design of a virtual patient simulation and report the process of the design. Methods: We employed a multistep design process drawing on patient and expert involvement. Results: A virtual patient, following a narrative style, was built, which allows a user to practice and receive feedback; both clinical and communication skills are required for the simulation. The patient group provided multiple insights, which the academic team had overlooked. They pertained mostly to issues concerning the patient experience. Conclusions: It is possible to design a virtual patient that allows a learner to practice their ability to conduct SDM. Patient input into the design of virtual patient simulations can be a worthwhile activity. %M 30401667 %R 10.2196/10088 %U http://mededu.jmir.org/2018/2/e10088/ %U https://doi.org/10.2196/10088 %U http://www.ncbi.nlm.nih.gov/pubmed/30401667 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 4 %P e10839 %T Virtual Reality Clinical Research: Promises and Challenges %A Garrett,Bernie %A Taverner,Tarnia %A Gromala,Diane %A Tao,Gordon %A Cordingley,Elliott %A Sun,Crystal %+ School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada, 1 16047538942, bernie.garrett@ubc.ca %K virtual reality %K clinical research %K VR standards %K VR theory %K VR immersion %K VR presence %D 2018 %7 17.10.2018 %9 Viewpoint %J JMIR Serious Games %G English %X Background: Virtual reality (VR) therapy has been explored as a novel therapeutic approach for numerous health applications, in which three-dimensional virtual environments can be explored in real time. Studies have found positive outcomes for patients using VR for clinical conditions such as anxiety disorders, addictions, phobias, posttraumatic stress disorder, eating disorders, stroke rehabilitation, and for pain management. Objective: This work aims to highlight key issues in the implementation of clinical research for VR technologies. Methods: A discussion paper was developed from a narrative review of recent clinical research in the field, and the researchers’ own experiences in conducting VR clinical research with chronic pain patients. Results: Some of the key issues in implementing clinical VR research include theoretical immaturity, a lack of technical standards, the problems of separating effects of media versus medium, practical in vivo issues, and costs. Conclusions: Over the last decade, some significant successes have been claimed for the use of VR. Nevertheless, the implementation of clinical VR research outside of the laboratory presents substantial clinical challenges. It is argued that careful attention to addressing these issues in research design and pilot studies are needed in order to make clinical VR research more rigorous and improve the clinical significance of findings. %M 30333096 %R 10.2196/10839 %U http://games.jmir.org/2018/4/e10839/ %U https://doi.org/10.2196/10839 %U http://www.ncbi.nlm.nih.gov/pubmed/30333096 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e10522 %T Determining Physiological and Psychological Predictors of Time to Task Failure on a Virtual Reality Sørensen Test in Participants With and Without Recurrent Low Back Pain: Exploratory Study %A Applegate,Megan E %A France,Christopher R %A Russ,David W %A Leitkam,Samuel T %A Thomas,James S %+ Wyss Institute for Biologically Inspired Engineering, 60 Oxford Street, Cambridge, MA, 02138, United States, 1 815 474 6743, applegate@seas.harvard.edu %K fatigue %K low back pain %K Sørensen test %K trunk mass %K virtual reality %D 2018 %7 10.09.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Sørensen trunk extension endurance test performance predicts the development of low back pain and is a strong discriminator of those with and without low back pain. Performance may greatly depend on psychological factors, such as kinesiophobia, self-efficacy, and motivation. Virtual reality video games have been used in people with low back pain to encourage physical activity that would otherwise be avoided out of fear of pain or harm. Accordingly, we developed a virtual reality video game to assess the influence of immersive gaming on the Sørensen test performance. Objective: The objective of our study was to determine the physiological and psychological predictors of time to task failure (TTF) on a virtual reality Sørensen test in participants with and without a history of recurrent low back pain. Methods: We recruited 24 individuals with a history of recurrent low back pain and 24 sex-, age-, and body mass index–matched individuals without a history of low back pain. Participants completed a series of psychological measures, including the Center for Epidemiological Studies-Depression Scale, Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and a self-efficacy measure. The maximal isometric strength of trunk and hip extensors and TTF on a virtual reality Sørensen test were measured. Electromyography of the erector spinae, gluteus maximus, and biceps femoris was recorded during the strength and endurance trials. Results: A two-way analysis of variance revealed no significant difference in TTF between groups (P=.99), but there was a trend for longer TTF in females on the virtual reality Sørensen test (P=.06). Linear regression analyses were performed to determine predictors of TTF in each group. In healthy participants, the normalized median power frequency slope of erector spinae (beta=.450, P=.01), biceps femoris (beta=.400, P=.01), and trunk mass (beta=−.32, P=.02) predicted TTF. In participants with recurrent low back pain, trunk mass (beta=−.67, P<.001), Tampa Scale for Kinesiophobia (beta=−.43, P=.01), and self-efficacy (beta=.35, P=.03) predicted TTF. Conclusions: Trunk mass appears to be a consistent predictor of performance. Kinesiophobia appears to negatively influence TTF for those with a history of recurrent low back pain, but does not influence healthy individuals. Self-efficacy is associated with better performance in individuals with a history of recurrent low back pain, whereas a less steep median power frequency slope of the trunk and hip extensors is associated with better performance in individuals without a history of low back pain. %M 30201604 %R 10.2196/10522 %U http://games.jmir.org/2018/3/e10522/ %U https://doi.org/10.2196/10522 %U http://www.ncbi.nlm.nih.gov/pubmed/30201604 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 7 %P e239 %T Creating Low-Cost 360-Degree Virtual Reality Videos for Hospitals: A Technical Paper on the Dos and Don’ts %A O’Sullivan,Benjamin %A Alam,Fahad %A Matava,Clyde %+ Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, 555 University Ave, Toronto, ON,, Canada, 1 8137445, clyde.matava@sickkids.ca %K 360-degree video %K VR %K virtual reality %K video production %K anesthetic preparation %K preoperative anxiety %K preoperative preparation %D 2018 %7 16.07.2018 %9 Tutorial %J J Med Internet Res %G English %X This article will provide a framework for producing immersive 360-degree videos for pediatric and adult patients in hospitals. This information may be useful to hospitals across the globe who may wish to produce similar videos for their patients. Advancements in immersive 360-degree technologies have allowed us to produce our own “virtual experience” where our children can prepare for anesthesia by “experiencing” all the sights and sounds of receiving and recovering from an anesthetic. We have shown that health care professionals, children, and their parents find this form of preparation valid, acceptable and fun. Perhaps more importantly, children and parents have self-reported that undertaking our virtual experience has led to a reduction in their anxiety when they go to the operating room. We provide definitions, and technical aspects to assist other health care professionals in the development of low-cost 360-degree videos. %M 30012545 %R 10.2196/jmir.9596 %U http://www.jmir.org/2018/7/e239/ %U https://doi.org/10.2196/jmir.9596 %U http://www.ncbi.nlm.nih.gov/pubmed/30012545 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e14 %T Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research %A Jerdan,Shaun W %A Grindle,Mark %A van Woerden,Hugo C %A Kamel Boulos,Maged N %+ Department of Digital Health, Centre for Health Science, University of the Highlands and Islands, Old Perth Road, Inverness, IV2 3JH, United Kingdom, 44 734 298 7169, shaun.jerdan@uhi.ac.uk %K virtual reality %K well-being %K behavior change %D 2018 %7 06.07.2018 %9 Review %J JMIR Serious Games %G English %X Background: eHealth interventions are becoming increasingly used in public health, with virtual reality (VR) being one of the most exciting recent developments. VR consists of a three-dimensional, computer-generated environment viewed through a head-mounted display. This medium has provided new possibilities to adapt problematic behaviors that affect mental health. VR is no longer unaffordable for individuals, and with mobile phone technology being able to track movements and project images through mobile head-mounted devices, VR is now a mobile tool that can be used at work, home, or on the move. Objective: In line with recent advances in technology, in this review, we aimed to critically assess the current state of research surrounding mental health. Methods: We compiled a table of 82 studies that made use of head-mounted devices in their interventions. Results: Our review demonstrated that VR is effective in provoking realistic reactions to feared stimuli, particularly for anxiety; moreover, it proved that the immersive nature of VR is an ideal fit for the management of pain. However, the lack of studies surrounding depression and stress highlight the literature gaps that still exist. Conclusions: Virtual environments that promote positive stimuli combined with health knowledge could prove to be a valuable tool for public health and mental health. The current state of research highlights the importance of the nature and content of VR interventions for improved mental health. While future research should look to incorporate more mobile forms of VR, a more rigorous reporting of VR and computer hardware and software may help us understand the relationship (if any) between increased specifications and the efficacy of treatment. %M 29980500 %R 10.2196/games.9226 %U http://games.jmir.org/2018/3/e14/ %U https://doi.org/10.2196/games.9226 %U http://www.ncbi.nlm.nih.gov/pubmed/29980500 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e13 %T Indigenous Adolescents’ Perception of an eMental Health Program (SPARX): Exploratory Qualitative Assessment %A Shepherd,Matthew %A Merry,Sally %A Lambie,Ian %A Thompson,Andrew %+ School of Counselling, Human Services and Social Work, Faculty of Education, The University of Auckland, Gate 4, 60 Epsom Ave, Epsom, Auckland,, New Zealand, 64 9 623 8899 ext 46368, m.shepherd@auckland.ac.nz %K Māori youth %K indigenous %K depression %K computerized CBT %K consumer views %K serious games %K virtual worlds %D 2018 %7 05.07.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Depression is a major health issue for indigenous adolescents, yet there is little research conducted about the efficacy and development of psychological interventions for these populations. In New Zealand there is little known about taitamariki (Māori adolescent) opinions regarding the development and effectiveness of psychological interventions, let alone computerized cognitive behavioral therapy. SPARX (Smart, Positive, Active, Realistic, X-factor thoughts) is a computerized intervention developed in New Zealand to treat mild-to-moderate depression in young people. Users are engaged in a virtual 3D environment where they must complete missions to progress to the next level. In each level there are challenges and puzzles to completeIt was designed to appeal to all young people in New Zealand and incorporates several images and concepts that are specifically Māori. Objective: The aim was to conduct an exploratory qualitative study of Māori adolescents’ opinions about the SPARX program. This is a follow-up to an earlier study where taitamariki opinions were gathered to inform the design of a computerized cognitive behavior therapy program. Methods: Taitamariki were interviewed using a semistructured interview once they had completed work with the SPARX resource. Six participants agreed to complete the interview; the interviews ranged from 10 to 30 minutes. Results: Taitamariki participating in the interviews found SPARX to be helpful. The Māori designs from the SPARX game were appropriate and useful, and the ability to customize the SPARX characters with Māori designs was beneficial and appeared to enhance cultural identity. These helped young people to feel engaged with SPARX which, in turn, assisted with the acquisition of relaxation and cognitive restructuring skills. Overall, using SPARX led to improved mood and increased levels of hope for the participants. In some instances, SPARX was used by wider whānau (Māori word for family) members with reported beneficial effect. Conclusions: Overall, this small group of Māori adolescents reported that cultural designs made it easier for them to engage with SPARX, which, in turn, led to an improvement in their mood and gave them hope. Further research is needed about how SPARX could be best used to support the families of these young people. %M 29980495 %R 10.2196/games.8752 %U http://games.jmir.org/2018/3/e13/ %U https://doi.org/10.2196/games.8752 %U http://www.ncbi.nlm.nih.gov/pubmed/29980495 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 3 %P e10693 %T Web-Based Immersive Patient Simulator as a Curricular Tool for Objective Structured Clinical Examination Preparation in Surgery: Development and Evaluation %A Chon,Seung-Hun %A Hilgers,Sabrina %A Timmermann,Ferdinand %A Dratsch,Thomas %A Plum,Patrick Sven %A Berlth,Felix %A Datta,Rabi %A Alakus,Hakan %A Schlößer,Hans Anton %A Schramm,Christoph %A Pinto dos Santos,Daniel %A Bruns,Christiane %A Kleinert,Robert %+ Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50937, Germany, 49 2214786254, robert.kleinert@uk-koeln.de %K immersive patient simulator %K simulator-based curriculum %K Objective Structured Clinical Examination %K artificial learning interface %D 2018 %7 04.07.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Objective Structured Clinical Examination is a standard method of testing declarative and process knowledge in clinical core competencies. It is desirable that students undergo Objective Structured Clinical Examination training before participating in the exam. However, establishing Objective Structured Clinical Examination training is resource intensive and therefore there is often limited practice time. Web-based immersive patient simulators such as ALICE (Artificial Learning Interface of Clinical Education) can possibly fill this gap as they allow for the training of complex medical procedures at the user’s individual pace and with an adaptable number of repetitions at home. ALICE has previously been shown to positively influence knowledge gain and motivation. Objective: Therefore, the aim of this study was to develop a Web-based curriculum that teaches declarative and process knowledge and prepares students for a real Objective Structured Clinical Examination station. Furthermore, we wanted to test the influence of ALICE on knowledge gain and student motivation. Methods: A specific curriculum was developed in order to implement the relevant medical content of 2 surgical Objective Structured Clinical Examination stations into the ALICE simulator framework. A total of 160 medical students were included in the study, where 100 students had access to ALICE and their performance was compared to 60 students in a control group. The simulator performance was validated on different levels and students’ knowledge gain and motivation were tested at different points during the study. Results: The curriculum was developed according to the Kern cycle. Four virtual clinical cases were implemented with different teaching methods (structured feedback, keynote speech, group discussion, and debriefing by a real instructor) in order to consolidate declarative and process knowledge. Working with ALICE had significant impact on declarative knowledge gain and Objective Structured Clinical Examination performance. Simulator validation was positive for face, content, construct, and predictive validity. Students showed high levels of motivation and enjoyed working with ALICE. Conclusions: ALICE offers Web-based training for Objective Structured Clinical Examination preparation and can be used as a selective didactic intervention as it has positive effect on knowledge gain and student motivation. %M 29973333 %R 10.2196/10693 %U http://games.jmir.org/2018/3/e10693/ %U https://doi.org/10.2196/10693 %U http://www.ncbi.nlm.nih.gov/pubmed/29973333 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 6 %P e10332 %T Using a Virtual Reality Social Network During Awake Craniotomy to Map Social Cognition: Prospective Trial %A Bernard,Florian %A Lemée,Jean-Michel %A Aubin,Ghislaine %A Ter Minassian,Aram %A Menei,Philippe %+ Neurosurgery, CHU Angers, , Angers,, France, 33 680353917, phmenei@chu-angers.fr %K virtual reality %K neurosurgery %K social cognition %K awake surgery %D 2018 %7 26.06.2018 %9 Short Paper %J J Med Internet Res %G English %X Background: In awake craniotomy, it is possible to temporarily inactivate regions of the brain using direct electrical stimulation, while the patient performs neuropsychological tasks. If the patient shows decreased performance in a given task, the neurosurgeon will not remove these regions, so as to maintain all brain functions. Objective: The objective of our study was to describe our experience of using a virtual reality (VR) social network during awake craniotomy and discuss its future applications for perioperative mapping of nonverbal language, empathy, and theory of mind. Methods: This was a single-center, prospective, unblinded trial. During wound closure, different VR experiences with a VR headset were proposed to the patient. This project sought to explore interactions with the neuropsychologist’s avatar in virtual locations using a VR social network as an available experience. Results: Three patients experienced VR. Despite some limitations due to patient positioning during the operation and the limitation of nonverbal cues inherent to the app, the neuropsychologist, as an avatar, could communicate with the patient and explore gesture communication while wearing a VR headset. Conclusions: With some improvements, VR social networks can be used in the near future to map social cognition during awake craniotomy. Trial Registration: ClinicalTrials.gov NCT03010943; https://clinicaltrials.gov/ct2/show/NCT03010943 (Archived at WebCite at http://www.webcitation.org/70CYDil0P) %M 29945859 %R 10.2196/10332 %U http://www.jmir.org/2018/6/e10332/ %U https://doi.org/10.2196/10332 %U http://www.ncbi.nlm.nih.gov/pubmed/29945859 %0 Journal Article %@ 2369-2529 %I JMIR Publications %V 5 %N 1 %P e11 %T Person-Generated Health Data in Simulated Rehabilitation Using Kinect for Stroke: Literature Review %A Dimaguila,Gerardo Luis %A Gray,Kathleen %A Merolli,Mark %+ Health and Biomedical Informatics Centre, University of Melbourne, Level 1, 202 Berkeley Street, Melbourne,, Australia, 61 3 9035 8703, dgl@student.unimelb.edu.au %K health care information systems %K Kinect %K patient-generated health data %K person-generated health data %K review %K simulated rehabilitation %K stroke %K stroke rehabilitation %K video games %K virtual rehabilitation %D 2018 %7 08.05.2018 %9 Review %J JMIR Rehabil Assist Technol %G English %X Background: Person- or patient-generated health data (PGHD) are health, wellness, and clinical data that people generate, record, and analyze for themselves. There is potential for PGHD to improve the efficiency and effectiveness of simulated rehabilitation technologies for stroke. Simulated rehabilitation is a type of telerehabilitation that uses computer technologies and interfaces to allow the real-time simulation of rehabilitation activities or a rehabilitation environment. A leading technology for simulated rehabilitation is Microsoft’s Kinect, a video-based technology that uses infrared to track a user’s body movements. Objective: This review attempts to understand to what extent Kinect-based stroke rehabilitation systems (K-SRS) have used PGHD and to what benefit. Methods: The review is conducted in two parts. In part 1, aspects of relevance for PGHD were searched for in existing systematic reviews on K-SRS. The following databases were searched: IEEE Xplore, Association of Computing Machinery Digital Library, PubMed, Biomed Central, Cochrane Library, and Campbell Collaboration. In part 2, original research papers that presented or used K-SRS were reviewed in terms of (1) types of PGHD, (2) patient access to PGHD, (3) PGHD use, and (4) effects of PGHD use. The search was conducted in the same databases as part 1 except Cochrane and Campbell Collaboration. Reference lists on K-SRS of the reviews found in part 1 were also included in the search for part 2. There was no date restriction. The search was closed in June 2017. The quality of the papers was not assessed, as it was not deemed critical to understanding PGHD access and use in studies that used K-SRS. Results: In part 1, 192 papers were identified, and after assessment only 3 papers were included. Part 1 showed that previous reviews focused on technical effectiveness of K-SRS with some attention on clinical effectiveness. None of those reviews reported on home-based implementation or PGHD use. In part 2, 163 papers were identified and after assessment, 41 papers were included. Part 2 showed that there is a gap in understanding how PGHD use may affect patients using K-SRS and a lack of patient participation in the design of such systems. Conclusions: This paper calls specifically for further studies of K-SRS—and for studies of technologies that allow patients to generate their own health data in general—to pay more attention to how patients’ own use of their data may influence their care processes and outcomes. Future studies that trial the effectiveness of K-SRS outside the clinic should also explore how patients and carers use PGHD in home rehabilitation programs. %M 29739739 %R 10.2196/rehab.9123 %U http://rehab.jmir.org/2018/1/e11/ %U https://doi.org/10.2196/rehab.9123 %U http://www.ncbi.nlm.nih.gov/pubmed/29739739 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 4 %P e157 %T The Use of Virtual Reality in Patients with Eating Disorders: Systematic Review %A Clus,Damien %A Larsen,Mark Erik %A Lemey,Christophe %A Berrouiguet,Sofian %+ UMR CNRS 6285 Lab-STICC, Institut Mines Télécom Atlantique, Université Bretagne Loire F-29238 Brest, Brest Medical University Hospital at Bohars, Adult Psychiatry, Route de Ploudalmezeau, Brest, 29200, France, 33 668204178, sofian.berrouiguet@gmail.com %K virtual reality exposure therapy %K feeding and eating disorders %K binge-eating disorder %K anorexia nervosa %K bulimia nervosa %D 2018 %7 27.04.2018 %9 Review %J J Med Internet Res %G English %X Background: Patients with eating disorders are characterized by pathological eating habits and a tendency to overestimate their weight and body shape. Virtual reality shows promise for the evaluation and management of patients with eating disorders. This technology, when accepted by this population, allows immersion in virtual environments, assessment, and therapeutic approaches, by exposing users to high-calorie foods or changes in body shape. Objective: To better understand the value of virtual reality, we conducted a review of the literature, including clinical studies proposing the use of virtual reality for the evaluation and management of patients with eating disorders. Methods: We searched PubMed, PsycINFO, ScienceDirect, the Cochrane Library, Scopus, and Web of Science up to April 2017. We created the list of keywords based on two domains: virtual reality and eating disorders. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses to identify, select, and critically appraise relevant research while minimizing bias. Results: The initial database searches identified 311 articles, 149 of which we removed as duplicates. We analyzed the resulting set of 26 unique studies that met the inclusion criteria. Of these, 8 studies were randomized controlled trials, 13 were nonrandomized studies, and 5 were clinical trials with only 1 participant. Most articles focused on clinical populations (19/26, 73%), with the remainder reporting case-control studies (7/26, 27%). Most of the studies used visual immersive equipment (16/26, 62%) with a head-mounted display (15/16, 94%). Two main areas of interest emerged from these studies: virtual work on patients’ body image (7/26, 27%) and exposure to virtual food stimuli (10/26, 38%). Conclusions: We conducted a broad analysis of studies on the use of virtual reality in patients with eating disorders. This review of the literature showed that virtual reality is an acceptable and promising therapeutic tool for patients with eating disorders. %M 29703715 %R 10.2196/jmir.7898 %U http://www.jmir.org/2018/4/e157/ %U https://doi.org/10.2196/jmir.7898 %U http://www.ncbi.nlm.nih.gov/pubmed/29703715 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 2 %P e7 %T Virtual Reality Cue Refusal Video Game for Alcohol and Cigarette Recovery Support: Summative Study %A Metcalf,Mary %A Rossie,Karen %A Stokes,Katie %A Tallman,Christina %A Tanner,Bradley %+ Clinical Tools, Inc, 101 Market Street, Suite A, Chapel Hill, NC,, United States, 1 919 960 8118, metcalf@clinicaltools.com %K addiction treatment %K Kinect %K serious games %K motion control games %K virtual reality %D 2018 %7 16.04.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: New technologies such as virtual reality, augmented reality, and video games hold promise to support and enhance individuals in addiction treatment and recovery. Quitting or decreasing cigarette or alcohol use can lead to significant health improvements for individuals, decreasing heart disease risk and cancer risks (for both nicotine and alcohol use), among others. However, remaining in recovery from use is a significant challenge for most individuals. Objective: We developed and assessed the Take Control game, a partially immersive Kinect for Windows platform game that allows users to counter substance cues through active movements (hitting, kicking, etc). Methods: Formative analysis during phase I and phase II guided development. We conducted a small wait-list control trial using a quasi-random sampling technique (systematic) with 61 participants in recovery from addiction to alcohol or tobacco. Participants used the game 3 times and reported on substance use, cravings, satisfaction with the game experience, self-efficacy related to recovery, and side effects from exposure to a virtual reality intervention and substance cues. Results: Participants found the game engaging and fun and felt playing the game would support recovery efforts. On average, reported substance use decreased for participants during the intervention period. Participants in recovery for alcohol use saw more benefit than those in recovery for tobacco use, with a statistically significant increase in self-efficacy, attitude, and behavior during the intervention. Side effects from the use of a virtual reality intervention were minor and decreased over time; cravings and side effects also decreased during the study. Conclusions: The preliminary results suggest the intervention holds promise as an adjunct to standard treatment for those in recovery, particularly from alcohol use. %M 29661748 %R 10.2196/games.9231 %U http://games.jmir.org/2018/2/e7/ %U https://doi.org/10.2196/games.9231 %U http://www.ncbi.nlm.nih.gov/pubmed/29661748 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 6 %N 1 %P e5 %T Virtual Travel Training for Autism Spectrum Disorder: Proof-of-Concept Interventional Study %A Simões,Marco %A Bernardes,Miguel %A Barros,Fernando %A Castelo-Branco,Miguel %+ Faculty of Medicine, University of Coimbra, Azinhaga Santa Comba, Celas, Coimbra, 3000-548, Portugal, 351 239480029, mcbranco@fmed.uc.pt %K Autism Spectrum Disorder %K serious games %K virtual reality %K virtual reality therapy %K travel train %K bus. %D 2018 %7 20.03.2018 %9 Original Paper %J JMIR Serious Games %G English %X Background: Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by impairments in social interaction and repetitive patterns of behavior, which can lead to deficits in adaptive behavior. In this study, a serious game was developed to train individuals with ASD for an important type of outdoor activity, which is the use of buses as a means of transportation. Objective: The aim of this study was to develop a serious game that defines a “safe environment” where the players became familiar with the process of taking a bus and to validate if it could be used effectively to teach bus-taking routines and adaptive procedures to individuals with ASD. Methods: In the game, players were placed in a three-dimensional city and were submitted to a set of tasks that involved taking buses to reach specific destinations. Participants with ASD (n=10) underwent between 1 to 3 training sessions. Participants with typical development (n=10) were also included in this study for comparison purposes and received 1 control session. Results: We found a statistically significant increase in the measures of knowledge of the process of riding a bus, a reduction in the electrodermal activity (a metric of anxiety) measured inside the bus environments, and a high success rate of their application within the game (93.8%). Conclusions: The developed game proved to be potentially useful in the context of emerging immersive virtual reality technologies, of which use in therapies and serious games is still in its infancy. Our findings suggest that serious games, using these technologies, can be used effectively in helping people with ASD become more independent in outdoor activities, specifically regarding the use of buses for transportation. %M 29559425 %R 10.2196/games.8428 %U http://games.jmir.org/2018/1/e5/ %U https://doi.org/10.2196/games.8428 %U http://www.ncbi.nlm.nih.gov/pubmed/29559425 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 20 %N 2 %P e61 %T Type 2 Diabetes Education and Support in a Virtual Environment: A Secondary Analysis of Synchronously Exchanged Social Interaction and Support %A Lewinski,Allison A %A Anderson,Ruth A %A Vorderstrasse,Allison A %A Fisher,Edwin B %A Pan,Wei %A Johnson,Constance M %+ Durham Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, 508 Fulton St., Attn: 558/152, Durham, NC, 27705, United States, 1 9192860411 ext 4048, allison.lewinski@duke.edu %K type 2 diabetes %K social interaction %K self-management %K virtual reality %K social support %D 2018 %7 21.02.2018 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual environments (VEs) facilitate interaction and support among individuals with chronic illness, yet the characteristics of these VE interactions remain unknown. Objective: The objective of this study was to describe social interaction and support among individuals with type 2 diabetes (T2D) who interacted in a VE. Methods: Data included VE-mediated synchronous conversations and text-chat and asynchronous emails and discussion board posts from a study that facilitated interaction among individuals with T2D and diabetes educators (N=24) in 2 types of sessions: education and support. Results: VE interactions consisted of communication techniques (how individuals interact in the VE), expressions of self-management (T2D-related topics), depth (personalization of topics), and breadth (number of topics discussed). Individuals exchanged support more often in the education (723/1170, 61.79%) than in the support (406/1170, 34.70%) sessions or outside session time (41/1170, 3.50%). Of all support exchanges, 535/1170 (45.73%) were informational, 377/1170 (32.22%) were emotional, 217/1170 (18.55%) were appraisal, and 41/1170 (3.50%) were instrumental. When comparing session types, education sessions predominately provided informational support (357/723, 49.4%), and the support sessions predominately provided emotional (159/406, 39.2%) and informational (159/406, 39.2%) support. Conclusions: VE-mediated interactions resemble those in face-to-face environments, as individuals in VEs engage in bidirectional exchanges with others to obtain self-management education and support. Similar to face-to-face environments, individuals in the VE revealed personal information, sought information, and exchanged support during the moderated education sessions and unstructured support sessions. With this versatility, VEs are able to contribute substantially to support for those with diabetes and, very likely, other chronic diseases. %M 29467118 %R 10.2196/jmir.9390 %U http://www.jmir.org/2018/2/e61/ %U https://doi.org/10.2196/jmir.9390 %U http://www.ncbi.nlm.nih.gov/pubmed/29467118 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 1 %P e15 %T Concussion Assessment With Smartglasses: Validation Study of Balance Measurement Toward a Lightweight, Multimodal, Field-Ready Platform %A Salisbury,Joseph P %A Keshav,Neha U %A Sossong,Anthony D %A Sahin,Ned T %+ Empowerment Lab, Brain Power, LLC, 1 Broadway 14th Fl, Cambridge, MA, 02142, United States, 1 617 758 4100, sahin@post.harvard.edu %K postural balance %K wearable technology %K accelerometry %K mild traumatic brain injury %D 2018 %7 23.01.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Lightweight and portable devices that objectively measure concussion-related impairments could improve injury detection and critical decision-making in contact sports and the military, where brain injuries commonly occur but remain underreported. Current standard assessments often rely heavily on subjective methods such as symptom self-reporting. Head-mounted wearables, such as smartglasses, provide an emerging platform for consideration that could deliver the range of assessments necessary to develop a rapid and objective screen for brain injury. Standing balance assessment, one parameter that may inform a concussion diagnosis, could theoretically be performed quantitatively using current off-the-shelf smartglasses with an internal accelerometer. However, the validity of balance measurement using smartglasses has not been investigated. Objective: This study aimed to perform preliminary validation of a smartglasses-based balance accelerometer measure (BAM) compared with the well-described and characterized waist-based BAM. Methods: Forty-two healthy individuals (26 male, 16 female; mean age 23.8 [SD 5.2] years) participated in the study. Following the BAM protocol, each subject performed 2 trials of 6 balance stances while accelerometer and gyroscope data were recorded from smartglasses (Glass Explorer Edition). Test-retest reliability and correlation were determined relative to waist-based BAM as used in the National Institutes of Health’s Standing Balance Toolbox. Results: Balance measurements obtained using a head-mounted wearable were highly correlated with those obtained through a waist-mounted accelerometer (Spearman rho, ρ=.85). Test-retest reliability was high (intraclass correlation coefficient, ICC2,1=0.85, 95% CI 0.81-0.88) and in good agreement with waist balance measurements (ICC2,1=0.84, 95% CI 0.80-0.88). Considering the normalized path length magnitude across all 3 axes improved interdevice correlation (ρ=.90) while maintaining test-retest reliability (ICC2,1=0.87, 95% CI 0.83-0.90). All subjects successfully completed the study, demonstrating the feasibility of using a head-mounted wearable to assess balance in a healthy population. Conclusions: Balance measurements derived from the smartglasses-based accelerometer were consistent with those obtained using a waist-mounted accelerometer. Additional research is necessary to determine to what extent smartglasses-based accelerometry measures can detect balance dysfunction associated with concussion. However, given the potential for smartglasses to perform additional concussion-related assessments in an integrated, wearable platform, continued development and validation of a smartglasses-based balance assessment is warranted. This approach could lead to a wearable platform for real-time assessment of concussion-related impairments that could be further augmented with telemedicine capabilities to integrate professional clinical guidance. Smartglasses may be superior to fully immersive virtual reality headsets for this application, given their lighter weight and reduced likelihood of potential safety concerns. %M 29362210 %R 10.2196/mhealth.8478 %U http://mhealth.jmir.org/2018/1/e15/ %U https://doi.org/10.2196/mhealth.8478 %U http://www.ncbi.nlm.nih.gov/pubmed/29362210 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 12 %P e419 %T Public Perceptions Regarding Use of Virtual Reality in Health Care: A Social Media Content Analysis Using Facebook %A Keller,Michelle Sophie %A Park,Hannah J %A Cunningham,Maria Elena %A Fouladian,Joshua Eleazar %A Chen,Michelle %A Spiegel,Brennan Mason Ross %+ Cedars-Sinai Center for Outcomes Research and Education, Cedars-Sinai Medical Center, 116 N Robertson Blvd, Suite 800, Los Angeles, CA, 90048, United States, 1 310 248 8011, michelle.keller@cshs.org %K social media %K virtual reality %K qualitative research %D 2017 %7 19.12.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Virtual reality (VR) technology provides an immersive environment that enables users to have modified experiences of reality. VR is increasingly used to manage patients with pain, disability, obesity, neurologic dysfunction, anxiety, and depression. However, public opinion regarding the use of VR in health care has not been explored. Understanding public opinion of VR is critical to ensuring effective implementation of this emerging technology. Objective: This study aimed to examine public opinion about health care VR using social listening, a method that allows for the exploration of unfiltered views of topics discussed on social media and online forums. Methods: In March 2016, NBC News produced a video depicting the use of VR for patient care. The video was repackaged by NowThis, a social media news website, and distributed on Facebook by Upworthy, a news aggregator, yielding 4.3 million views and 2401 comments. We used Microsoft Excel Power Query and ATLAS.ti software (version 7.5, Scientific Software Development) to analyze the comments using content analysis and categorized the comments around first-, second-, and third-order concepts. We determined self-identified gender from the user’s Facebook page and performed sentiment analysis of the language to analyze whether the perception of VR differed by gender using a Pearson’s chi-square test. Results: Out of the 1614 analyzable comments, 1021 (63.26%) were attributed to female Facebook users, 572 (35.44%) to male users, and 21 (1.30%) to users of unknown gender. There were 1197 comments coded as expressing a positive perception about VR (74.16%), 251 coded as expressing a negative perception and/or concern (15.56%), and 560 coded as neutral (34.70%). Informants identified 20 use cases for VR in health care, including the use of VR for pain and stress reduction; bed-bound individuals; women during labor; and patients undergoing chemotherapy, dialysis, radiation, or imaging procedures. Negative comments expressed concerns about radiation, infection risk, motion sickness, and the ubiquity of and overall dependence on technology. There was a statistically significant association between the language valence of the Facebook post and the gender of the Facebook user; men were more likely to post negative perceptions about the use of VR for health care, whereas women were more likely to post positive perceptions (P<.001). Conclusions: Most informants expressed positive perceptions about the use of VR in a wide range of health care settings. However, many expressed concerns that should be acknowledged and addressed as health care VR continues to evolve. Our results provide guidance in determining where further research on the use of VR in patient care is needed, and offer a formal opportunity for public opinion to shape the VR research agenda. %M 29258975 %R 10.2196/jmir.7467 %U http://www.jmir.org/2017/12/e419/ %U https://doi.org/10.2196/jmir.7467 %U http://www.ncbi.nlm.nih.gov/pubmed/29258975 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 12 %P e371 %T Getting to the Root of Fine Motor Skill Performance in Dentistry: Brain Activity During Dental Tasks in a Virtual Reality Haptic Simulation %A Perry,Suzanne %A Bridges,Susan M %A Zhu,Frank %A Leung,W Keung %A Burrow,Michael F %A Poolton,Jamie %A Masters,Rich SW %+ Faculty of Education, The University of Hong Kong, Pokfulam road, Hong Kong SAR,, China, 86 63171105, subygee@yahoo.co.uk %K simulation %K fNIRS %K functional near-infrared spectroscopy %K spectroscopy, near-infrared %K virtual reality %K psychomotor skills training %K dentistry %K education, medical %D 2017 %7 12.12.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: There is little evidence considering the relationship between movement-specific reinvestment (a dimension of personality which refers to the propensity for individuals to consciously monitor and control their movements) and working memory during motor skill performance. Functional near-infrared spectroscopy (fNIRS) measuring oxyhemoglobin demands in the frontal cortex during performance of virtual reality (VR) psychomotor tasks can be used to examine this research gap. Objective: The aim of this study was to determine the potential relationship between the propensity to reinvest and blood flow to the dorsolateral prefrontal cortices of the brain. A secondary aim was to determine the propensity to reinvest and performance during 2 dental tasks carried out using haptic VR simulators. Methods: We used fNIRS to assess oxygen demands in 24 undergraduate dental students during 2 dental tasks (clinical, nonclinical) on a VR haptic simulator. We used the Movement-Specific Reinvestment Scale questionnaire to assess the students’ propensity to reinvest. Results: Students with a high propensity for movement-specific reinvestment displayed significantly greater oxyhemoglobin demands in an area associated with working memory during the nonclinical task (Spearman correlation, rs=.49, P=.03). Conclusions: This small-scale study suggests that neurophysiological differences are evident between high and low reinvesters during a dental VR task in terms of oxyhemoglobin demands in an area associated with working memory. %M 29233801 %R 10.2196/jmir.8046 %U http://www.jmir.org/2017/12/e371/ %U https://doi.org/10.2196/jmir.8046 %U http://www.ncbi.nlm.nih.gov/pubmed/29233801 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 12 %P e365 %T The Use of Avatar Counseling for HIV/AIDS Health Education: The Examination of Self-Identity in Avatar Preferences %A Canidate,Shantrel %A Hart,Mark %+ Social and Behavioral Sciences Program, College of Public Health and Health Professions, University of Florida, 1225 Center Drive, PO Box 100182 HSC, Gainesville, FL, 32610-0182, United States, 1 3862147771, ssc1987@phhp.ufl.edu %K technology %K distance education %K learning %K avatars %D 2017 %7 01.12.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: The number of adults using the Internet to obtain health information is on the rise. An estimated 66% of the adults reportedly use the Internet to obtain health information related to a specific disease (ie, human immunodeficiency virus and acquired immunodeficiency syndrome, HIV/AIDS). Previous research has demonstrated that health information seekers use the Internet to seek answers to stigma-laden questions from health avatars. Objective: The objective of this study was to identify patterns in the choice of avatar among health information seekers (patients or public health workers) using the Internet to obtain HIV/AIDS information and to describe the demographic characteristics (age, gender, and ethnicity) of health information seekers to determine whether they preferred an avatar that was similar to their own gender and ethnicity. Methods: The Rural South Public Health Training Center (RSPHTC) partnered with the New York State Department of Health to create the HIV/AIDS Avatar project. The avatar project was created to serve as an educational resource for public health workers by providing relevant and accurate information about HIV/AIDS. First, the user was instructed to choose one of the 8 avatars that voiced responses to 100 common questions and answers about HIV/AIDS. Next, the website gave users the option to complete a brief 3-question demographic survey. Finally, the demographic characteristics of each user were compared with the chosen avatar to determine whether they preferred an avatar that was similar to their own gender and ethnicity. Results: The avatar project website was loaded with 800 videos that included the answers to the top 100 questions about HIV/AIDS voiced by 8 avatars. A total of 1119 Web-based health information seekers completed the demographic survey upon accessing the website. Of these, 55.14% (617/1119) users were female. A total of 49.96% (559/1119) users were aged between 30 and 49 years. The ethnicity of the user and the avatar was found to have the strongest connection. All the users choose the female avatar matching their own ethnicity, followed by the male avatar. Additionally, the white female avatar was chosen the most by all users regardless of the age group or gender. Conclusions: Web-based health information seekers using the Internet to access medical research information may feel more comfortable receiving the answers to HIV stigma-laden questions from avatars, rather than receiving information directly from a health care provider. Additionally, providers seeking to utilize avatars to deliver interventions in health care settings may benefit from offering individuals choices in how they receive health information. Having the ability to choose whom you seek information from may lead to an increase in knowledge and awareness and could motivate HIV-positive individuals to seek care. %M 29196281 %R 10.2196/jmir.6740 %U http://www.jmir.org/2017/12/e365/ %U https://doi.org/10.2196/jmir.6740 %U http://www.ncbi.nlm.nih.gov/pubmed/29196281 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 11 %P e369 %T Preventing Depression in Final Year Secondary Students: School-Based Randomized Controlled Trial %A Perry,Yael %A Werner-Seidler,Aliza %A Calear,Alison %A Mackinnon,Andrew %A King,Catherine %A Scott,Jan %A Merry,Sally %A Fleming,Theresa %A Stasiak,Karolina %A Christensen,Helen %A Batterham,Philip J %+ Black Dog Institute, University of New South Wales, Hospital Road, Randwick,, Australia, 61 2 9382 8208, h.christensen@blackdog.org.au %K prevention %K depression %K adolescent %K digital cognitive behavior therapy %D 2017 %7 02.11.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression often emerges for the first time during adolescence. There is accumulating evidence that universal depression prevention programs may have the capacity to reduce the impact of depression when delivered in the school environment. Objective: This trial investigated the effectiveness of SPARX-R, a gamified online cognitive behavior therapy intervention for the prevention of depression relative to an attention-matched control intervention delivered to students prior to facing a significant stressor—final secondary school exams. It was hypothesized that delivering a prevention intervention in advance of a stressor would reduce depressive symptoms relative to the control group. Methods: A cluster randomized controlled trial was conducted in 10 government schools in Sydney, Australia. Participants were 540 final year secondary students (mean 16.7 [SD 0.51] years), and clusters at the school level were randomly allocated to SPARX-R or the control intervention. Interventions were delivered weekly in 7 modules, each taking approximately 20 to 30 minutes to complete. The primary outcome was symptoms of depression as measured by the Major Depression Inventory. Intention-to-treat analyses were performed. Results: Compared to controls, participants in the SPARX-R condition (n=242) showed significantly reduced depression symptoms relative to the control (n=298) at post-intervention (Cohen d=0.29) and 6 months post-baseline (d=0.21) but not at 18 months post-baseline (d=0.33). Conclusions: This is the first trial to demonstrate a preventive effect on depressive symptoms prior to a significant and universal stressor in adolescents. It demonstrates that an online intervention delivered in advance of a stressful experience can reduce the impact of such an event on the potential development or exacerbation of depression. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12614000316606; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365986 (Archived by WebCite at http://www.webcitation.org/ 6u7ou1aI9) %M 29097357 %R 10.2196/jmir.8241 %U http://www.jmir.org/2017/11/e369/ %U https://doi.org/10.2196/jmir.8241 %U http://www.ncbi.nlm.nih.gov/pubmed/29097357 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 10 %P e343 %T Using a UK Virtual Supermarket to Examine Purchasing Behavior Across Different Income Groups in the United Kingdom: Development and Feasibility Study %A Mizdrak,Anja %A Waterlander,Wilma Elzeline %A Rayner,Mike %A Scarborough,Peter %+ Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme (BODE3), Department of Public Health, University of Otago, Wellington, 23 Mein Street, Newtown, Wellington, 6021, New Zealand, 64 49186192, anja.mizdrak@otago.ac.nz %K food %K diet %K public health %K United Kingdom %K socioeconomic status %D 2017 %7 09.10.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: The majority of food in the United Kingdom is purchased in supermarkets, and therefore, supermarket interventions provide an opportunity to improve diets. Randomized controlled trials are costly, time-consuming, and difficult to conduct in real stores. Alternative approaches of assessing the impact of supermarket interventions on food purchases are needed, especially with respect to assessing differential impacts on population subgroups. Objective: The aim of this study was to assess the feasibility of using the United Kingdom Virtual Supermarket (UKVS), a three-dimensional (3D) computer simulation of a supermarket, to measure food purchasing behavior across income groups. Methods: Participants (primary household shoppers in the United Kingdom with computer access) were asked to conduct two shopping tasks using the UKVS and complete questionnaires on demographics, food purchasing habits, and feedback on the UKVS software. Data on recruitment method and rate, completion of study procedure, purchases, and feedback on usability were collected to inform future trial protocols. Results: A total of 98 participants were recruited, and 46 (47%) fully completed the study procedure. Low-income participants were less likely to complete the study (P=.02). Most participants found the UKVS easy to use (38/46, 83%) and reported that UKVS purchases resembled their usual purchases (41/46, 89%). Conclusions: The UKVS is likely to be a useful tool to examine the effects of nutrition interventions using randomized controlled designs. Feedback was positive from participants who completed the study and did not differ by income group. However, retention was low and needs to be addressed in future studies. This study provides purchasing data to establish sample size requirements for full trials using the UKVS. %M 28993301 %R 10.2196/jmir.7982 %U http://www.jmir.org/2017/10/e343/ %U https://doi.org/10.2196/jmir.7982 %U http://www.ncbi.nlm.nih.gov/pubmed/28993301 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 9 %P e174 %T Development of a Virtual Reality Exposure Tool as Psychological Preparation for Elective Pediatric Day Care Surgery: Methodological Approach for a Randomized Controlled Trial %A Eijlers,Robin %A Legerstee,Jeroen S %A Dierckx,Bram %A Staals,Lonneke M %A Berghmans,Johan %A van der Schroeff,Marc P %A Wijnen,Rene MH %A Utens,Elisabeth MWJ %+ Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Center (Erasmus MC) Sophia Children’s Hospital, Wytemaweg 8, Rotterdam, 3015 CN, Netherlands, 31 107036155, e.utens@erasmusmc.nl %K virtual reality %K pediatric %K anxiety %K surgery %K anesthesia %K intervention %K exposure %K randomized controlled trial %D 2017 %7 11.09.2017 %9 Protocol %J JMIR Res Protoc %G English %X Background: Preoperative anxiety in children is highly prevalent and is associated with adverse outcomes. Existing psychosocial interventions to reduce preoperative anxiety are often aimed at distraction and are of limited efficacy. Gradual exposure is a far more effective way to reduce anxiety. Virtual reality (VR) provides a unique opportunity to gradually expose children to all aspects of the operating theater. Objective: The aims of our study are (1) to develop a virtual reality exposure (VRE) tool to prepare children psychologically for surgery; and (2) to examine the efficacy of the VRE tool in a randomized controlled trial (RCT), in which VRE will be compared to care as usual (CAU). Methods: The VRE tool is highly realistic and resembles the operating room environment accurately. With this tool, children will not only be able to explore the operating room environment, but also get accustomed to general anesthesia procedures. The PREoperative Virtual reality Intervention to Enhance Wellbeing (PREVIEW) study will be conducted. In this single-blinded RCT, 200 consecutive patients (aged 4 to 12 years) undergoing elective day care surgery for dental, oral, or ear-nose-throat problems, will be randomly allocated to the preoperative VRE intervention or CAU. The primary outcome is change in child state anxiety level between baseline and induction of anesthesia. Secondary outcome measures include child’s postoperative anxiety, emergence delirium, postoperative pain, use of analgesics, health care use, and pre- and postoperative parental anxiety. Results: The VRE tool has been developed. Participant recruitment began March 2017 and is expected to be completed by September 2018. Conclusions: To our knowledge, this is the first RCT evaluating the effect of a VRE tool to prepare children for surgery. The VRE intervention is expected to significantly diminish preoperative anxiety, postoperative pain, and the use of postoperative analgesics in pediatric patients. The tool could create a less stressful experience for both children and their parents, in line with the modern emphasis on patient- and family-centered care. Trial Registration: Netherlands Trial Registry: NTR6116; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6116 (Archived by WebCite at http://www.webcitation.org/6ryke7aep) %M 28893727 %R 10.2196/resprot.7617 %U http://www.researchprotocols.org/2017/9/e174/ %U https://doi.org/10.2196/resprot.7617 %U http://www.ncbi.nlm.nih.gov/pubmed/28893727 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 5 %N 3 %P e15 %T Domiciliary VR-Based Therapy for Functional Recovery and Cortical Reorganization: Randomized Controlled Trial in Participants at the Chronic Stage Post Stroke %A Ballester,Belén Rubio %A Nirme,Jens %A Camacho,Irene %A Duarte,Esther %A Rodríguez,Susana %A Cuxart,Ampar %A Duff,Armin %A Verschure,Paul F.M.J %+ Laboratory of Synthetic Perceptive, Emotive and Cognitive Systems, Center of Autonomous Systems and Neurorobotics, Department of Information and Communication Technologies, Pompeu Fabra, Roc Boronat, 138, Barcelona, 08018, Spain, 34 +34652969755, paul.verschure@upf.edu %K stroke %K movement disorder %K recovery of function, neuroplasticity %K transcranial magnetic stimulation %K physical therapy %K hemiparesis %K computer applications software %D 2017 %7 07.08.2017 %9 Original Paper %J JMIR Serious Games %G English %X Background: Most stroke survivors continue to experience motor impairments even after hospital discharge. Virtual reality-based techniques have shown potential for rehabilitative training of these motor impairments. Here we assess the impact of at-home VR-based motor training on functional motor recovery, corticospinal excitability and cortical reorganization. Objective: The aim of this study was to identify the effects of home-based VR-based motor rehabilitation on (1) cortical reorganization, (2) corticospinal tract, and (3) functional recovery after stroke in comparison to home-based occupational therapy. Methods: We conducted a parallel-group, controlled trial to compare the effectiveness of domiciliary VR-based therapy with occupational therapy in inducing motor recovery of the upper extremities. A total of 35 participants with chronic stroke underwent 3 weeks of home-based treatment. A group of subjects was trained using a VR-based system for motor rehabilitation, while the control group followed a conventional therapy. Motor function was evaluated at baseline, after the intervention, and at 12-weeks follow-up. In a subgroup of subjects, we used Navigated Brain Stimulation (NBS) procedures to measure the effect of the interventions on corticospinal excitability and cortical reorganization. Results: Results from the system’s recordings and clinical evaluation showed significantly greater functional recovery for the experimental group when compared with the control group (1.53, SD 2.4 in Chedoke Arm and Hand Activity Inventory). However, functional improvements did not reach clinical significance. After the therapy, physiological measures obtained from a subgroup of subjects revealed an increased corticospinal excitability for distal muscles driven by the pathological hemisphere, that is, abductor pollicis brevis. We also observed a displacement of the centroid of the cortical map for each tested muscle in the damaged hemisphere, which strongly correlated with improvements in clinical scales. Conclusions: These findings suggest that, in chronic stages, remote delivery of customized VR-based motor training promotes functional gains that are accompanied by neuroplastic changes. Trial Registration: International Standard Randomized Controlled Trial Number NCT02699398 (Archived by ClinicalTrials.gov at https://clinicaltrials.gov/ct2/show/NCT02699398?term=NCT02699398&rank=1) %M 28784593 %R 10.2196/games.6773 %U http://games.jmir.org/2017/3/e15/ %U https://doi.org/10.2196/games.6773 %U http://www.ncbi.nlm.nih.gov/pubmed/28784593 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 6 %P e108 %T A Cloud-Based Virtual Reality App for a Novel Telemindfulness Service: Rationale, Design and Feasibility Evaluation %A Cikajlo,Imre %A Cizman Staba,Ursa %A Vrhovac,Suzana %A Larkin,Frances %A Roddy,Mark %+ University Rehabilitation Institute, Republic of Slovenia, Linhartova c 51, Ljubljana, 1000, Slovenia, 386 14758158, imre.cikajlo@ir-rs.si %K Virtual reality %K headset %K Samsung %K psychology %K mindfulness %K telepsychology %K telehealth technology %K telemedicine %D 2017 %7 05.06.2017 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Worldwide, there has been a marked increase in stress and anxiety, also among patients with traumatic brain injury (TBI). Access to psychology services is limited, with some estimates suggesting that over 50% of sufferers are not accessing the existing services available to them for reasons such as inconvenience, embarrassment, or stigmatization concerns around mental health. Health service providers have increasingly been turning to drug-free therapies, such as mindfulness programs, as complementary treatments. Objective: Virtual reality (VR) as a new delivery method for meditation-based stress and anxiety reduction therapy offers configurable environments and privacy protection. Our objective was to design a serious learning-meditation environment and to test the feasibility of the developed telemindfulness approach based on cloud technologies. Methods: We developed a cloud-based system, which consisted of a Web interface for the mindfulness instructor and remote clients, who had 3D VR headsets. The mindfulness instructor could communicate over the Web interface with the participants using the headset. Additionally, the Web app enabled group sessions in virtual rooms, 360-degree videos, and real interactions or standalone meditation. The mindfulness program was designed as an 8-week Mindfulness-Based Stress Reduction course specifically for the developed virtual environments. The program was tested with four employees and four patients with TBI. The effects were measured with psychometric tests, the Mindful Attention Awareness Scale (MAAS) and the Satisfaction With Life Scale (SWLS). Patients also carried out the Mini-Mental State Examination (MMSE). An additional objective evaluation has also been carried out by tracking head motion. Additionally, the power spectrum analyses of similar tasks between sessions were tested. Results: The patients achieved a higher level of life satisfaction during the study (SWLS: mean 23.0, SD 1.8 vs mean 18.3, SD 3.9) and a slight increase of the MAAS score (mean 3.4, SD 0.6 vs mean 3.3, SD 0.4). Particular insight into the MAAS items revealed that one patient had a lower MAAS score (mean 2.3). Employees showed high MAAS scores (mean 4.3, SD 0.7) and although their SWLS dropped to mean 26, their SWLS was still high (mean 27.3, SD 2.8). The power spectrum showed that the employees had a considerable reduction in high-frequency movements less than 0.34 Hz, particularly with the 360-degree video. As expected, the patients demonstrated a gradual decrease of high-frequency movements while sitting during the mindfulness practices in the virtual environment. Conclusions: With such a small sample size, it is too early to make any specific conclusions, but the presented results may accelerate the use of innovative technologies and challenge new ideas in research and development in the field of mindfulness/telemindfulness. %M 28583904 %R 10.2196/resprot.6849 %U http://www.researchprotocols.org/2017/6/e108/ %U https://doi.org/10.2196/resprot.6849 %U http://www.ncbi.nlm.nih.gov/pubmed/28583904 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e183 %T Adherence to AHA Guidelines When Adapted for Augmented Reality Glasses for Assisted Pediatric Cardiopulmonary Resuscitation: A Randomized Controlled Trial %A Siebert,Johan N %A Ehrler,Frederic %A Gervaix,Alain %A Haddad,Kevin %A Lacroix,Laurence %A Schrurs,Philippe %A Sahin,Ayhan %A Lovis,Christian %A Manzano,Sergio %+ Geneva Children’s Hospital, Department of Pediatric Emergency Medicine, University Hospitals of Geneva, Avenue de la Roseraie, 47, Geneva, 1205, Switzerland, 41 795534072, Johan.Siebert@hcuge.ch %K resuscitation %K emergency medicine %K pediatrics %K biomedical technologies %K equipment and supplies %K eyeglasses %D 2017 %7 29.05.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: The American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world’s most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36%, whereas it falls below 10% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses. Objective: The study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards. Methods: We conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario—pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines. Results: Twenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53% (21/40, P<.001) and cumulative defibrillation dose by 37% (5.14/14, P=.001) with AR glasses. Conclusions: AR glasses did not decrease time to first defibrillation attempt and other critical resuscitation endpoints when compared with PALS pocket cards. However, they improved adherence and performance among residents in terms of administering the defibrillation doses set by AHA. %M 28554878 %R 10.2196/jmir.7379 %U http://www.jmir.org/2017/5/e183/ %U https://doi.org/10.2196/jmir.7379 %U http://www.ncbi.nlm.nih.gov/pubmed/28554878 %0 Journal Article %@ 2291-9694 %I JMIR Publications %V 5 %N 2 %P e11 %T Virtual Reality as an Adjunct Home Therapy in Chronic Pain Management: An Exploratory Study %A Garrett,Bernie %A Taverner,Tarnia %A McDade,Paul %+ School of Nursing, University of British Columbia, T 201 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada, 1 604 753 8942, bernie.garrett@nursing.ubc.ca %K pain management %K chronic illness %K therapeutics %K medical informatics %D 2017 %7 11.05.2017 %9 Original Paper %J JMIR Med Inform %G English %X Background: Virtual reality (VR) therapy has been successfully used as an adjunct therapy for the management of acute pain in adults and children, and evidence of potential efficacy in other health applications is growing. However, minimal research exists on the value of VR as an intervention for chronic pain. Objective: This case series examined the value of VR to be used as an adjunctive therapy for chronic pain patients in their own homes. Methods: An exploratory approach using a case series and personal interviews was used. Ten chronic pain patients received VR therapy for 30 min on alternate days for 1 month. Pre- and postexposure (immediately afterwards, 3 h, and at 24 h) pain assessment was recorded using the Numerical Rating Scale (NRS), and weekly using the Brief Pain Inventory (BPI) and Self-completed Leeds Assessment of Neuropathic Symptoms and Signs pain scale (S-LANSS). Terminal semistructured personal interviews with the patients were also undertaken. Results: Of the 8 patients who completed the study, 5 of them reported that pain was reduced during the VR experience but no overall treatment difference in pain scores postexposure was observed. VR was not associated with any serious adverse events, although 60% of patients reported some cybersickness during some of the experiences. Conclusions: Of note is that the majority of these study participants reported a reduction in pain while using the VR but with highly individualized responses. One patient also reported some short-term improved mobility following VR use. Some evidence was found for the short-term efficacy of VR in chronic pain but no evidence for persistent benefits. %M 28495661 %R 10.2196/medinform.7271 %U http://medinform.jmir.org/2017/2/e11/ %U https://doi.org/10.2196/medinform.7271 %U http://www.ncbi.nlm.nih.gov/pubmed/28495661 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 19 %N 5 %P e151 %T Embodied Conversational Agents in Clinical Psychology: A Scoping Review %A Provoost,Simon %A Lau,Ho Ming %A Ruwaard,Jeroen %A Riper,Heleen %+ Department of Clinical, Neuro & Developmental Psychology, Section Clinical Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 1, Amsterdam, 1081 BT, Netherlands, 31 205985059, s.j.provoost@vu.nl %K eHealth %K review %K embodied conversational agent %K human computer interaction %K clinical psychology %K mental disorders %K intelligent agent %K health behavior %D 2017 %7 09.05.2017 %9 Original Paper %J J Med Internet Res %G English %X Background: Embodied conversational agents (ECAs) are computer-generated characters that simulate key properties of human face-to-face conversation, such as verbal and nonverbal behavior. In Internet-based eHealth interventions, ECAs may be used for the delivery of automated human support factors. Objective: We aim to provide an overview of the technological and clinical possibilities, as well as the evidence base for ECA applications in clinical psychology, to inform health professionals about the activity in this field of research. Methods: Given the large variety of applied methodologies, types of applications, and scientific disciplines involved in ECA research, we conducted a systematic scoping review. Scoping reviews aim to map key concepts and types of evidence underlying an area of research, and answer less-specific questions than traditional systematic reviews. Systematic searches for ECA applications in the treatment of mood, anxiety, psychotic, autism spectrum, and substance use disorders were conducted in databases in the fields of psychology and computer science, as well as in interdisciplinary databases. Studies were included if they conveyed primary research findings on an ECA application that targeted one of the disorders. We mapped each study’s background information, how the different disorders were addressed, how ECAs and users could interact with one another, methodological aspects, and the study’s aims and outcomes. Results: This study included N=54 publications (N=49 studies). More than half of the studies (n=26) focused on autism treatment, and ECAs were used most often for social skills training (n=23). Applications ranged from simple reinforcement of social behaviors through emotional expressions to sophisticated multimodal conversational systems. Most applications (n=43) were still in the development and piloting phase, that is, not yet ready for routine practice evaluation or application. Few studies conducted controlled research into clinical effects of ECAs, such as a reduction in symptom severity. Conclusions: ECAs for mental disorders are emerging. State-of-the-art techniques, involving, for example, communication through natural language or nonverbal behavior, are increasingly being considered and adopted for psychotherapeutic interventions in ECA research with promising results. However, evidence on their clinical application remains scarce. At present, their value to clinical practice lies mostly in the experimental determination of critical human support factors. In the context of using ECAs as an adjunct to existing interventions with the aim of supporting users, important questions remain with regard to the personalization of ECAs’ interaction with users, and the optimal timing and manner of providing support. To increase the evidence base with regard to Internet interventions, we propose an additional focus on low-tech ECA solutions that can be rapidly developed, tested, and applied in routine practice. %M 28487267 %R 10.2196/jmir.6553 %U http://www.jmir.org/2017/5/e151/ %U https://doi.org/10.2196/jmir.6553 %U http://www.ncbi.nlm.nih.gov/pubmed/28487267 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 6 %N 4 %P e65 %T Analyzing Unstructured Communication in a Computer-Mediated Environment for Adults With Type 2 Diabetes: A Research Protocol %A Lewinski,Allison A %A Anderson,Ruth A %A Vorderstrasse,Allison A %A Fisher,Edwin B %A Pan,Wei %A Johnson,Constance M %+ Duke University School of Nursing, 307 Trent Drive, DUMC 3322, Durham, NC, 27710, United States, 1 919 684 9198, allison.lewinski@duke.edu %K diabetes type 2 %K social support %K adults %K Internet %K peer support %K self-management %K mixed methods %K social interaction %K secondary analysis %D 2017 %7 24.04.2017 %9 Proposal %J JMIR Res Protoc %G English %X Background: Individuals with type 2 diabetes have an increased risk for comorbidities such as heart disease, lower limb amputations, stroke, and renal failure. Multiple factors influence development of complications in a person living with type 2 diabetes; however, an individual’s self-management behaviors may delay the onset of, or lessen the severity of, these complications. Social support provides personal, informal advice and knowledge that helps individuals initiate and sustain self-management and adherence. Objective: Our aim was to gain an understanding of type 2 diabetes social interaction in a virtual environment, one type of computer-mediated environment (CME), and the social support characteristics that increase and sustain self-management in adults living with chronic illness. Methods: This study is a secondary analysis of longitudinal data collected in a CME study, Second Life Impacts Diabetes Education & Self-Management (1R21-LM010727-01). This virtual environment replicated a real-life community where 6 months of naturalistic synchronous voice conversations, emails, and text chats were recorded among participants and providers. This analysis uses a mixed-methods approach to explore and compare qualitative and quantitative findings. This analysis is guided by two theories: Strong/Weak Ties Theory and Social Penetration Theory. Qualitative data will be analyzed using content analysis, and we will complete descriptive statistics on the quantified variables (eg, average number of ties). Institutional review board approval was obtained in June 2016. Results: This study is in progress. Conclusions: Interventions provided through virtual environments are a promising solution to increasing self-management practices. However, little is known of the depth, breadth, and quality of social support that is exchanged and how interaction supports self-management and relates to health outcomes. This study will provide knowledge that will help guide clinical practice and policy to enhance social support for chronic illness via the Internet. %M 28438726 %R 10.2196/resprot.7442 %U http://www.researchprotocols.org/2017/4/e65/ %U https://doi.org/10.2196/resprot.7442 %U http://www.ncbi.nlm.nih.gov/pubmed/28438726 %0 Journal Article %@ 2369-3762 %I JMIR Publications %V 3 %N 1 %P e7 %T Simulated Conversations With Virtual Humans to Improve Patient-Provider Communication and Reduce Unnecessary Prescriptions for Antibiotics: A Repeated Measure Pilot Study %A Schoenthaler,Antoinette %A Albright,Glenn %A Hibbard,Judith %A Goldman,Ron %+ Center for Healthful Behavior Change, Department of Population Health, NYU School of Medicine, 227 East 30th street, New York, NY, 10016, United States, 1 212 263 4205, antoinette.schoenthaler@nyumc.org %K simulation training %K health communication %K patient activation %K motivational interviewing %K decision making %D 2017 %7 19.04.2017 %9 Original Paper %J JMIR Med Educ %G English %X Background: Despite clear evidence that antibiotics do not cure viral infections, the problem of unnecessary prescribing of antibiotics in ambulatory care persists, and in some cases, prescribing patterns have increased. The overuse of antibiotics for treating viral infections has created numerous economic and clinical consequences including increased medical costs due to unnecessary hospitalizations, antibiotic resistance, disruption of gut bacteria, and obesity. Recent research has underscored the importance of collaborative patient-provider communication as a means to reduce the high rates of unnecessary prescriptions for antibiotics. However, most patients and providers do not feel prepared to engage in such challenging conversations. Objectives: The aim of this pilot study was to assess the ability of a brief 15-min simulated role-play conversation with virtual humans to serve as a preliminary step to help health care providers and patients practice, and learn how to engage in effective conversations about antibiotics overuse. Methods: A total of 69 participants (35 providers and 34 patients) completed the simulation once in one sitting. A pre-post repeated measures design was used to assess changes in patients’ and providers’ self-reported communication behaviors, activation, and preparedness, intention, and confidence to effectively communicate in the patient-provider encounter. Changes in patients’ knowledge and beliefs regarding antibiotic use were also evaluated. Results: Patients experienced a short-term positive improvement in beliefs about appropriate antibiotic use for infection (F1,30=14.10, P=.001). Knowledge scores regarding the correct uses of antibiotics improved immediately postsimulation, but decreased at the 1-month follow-up (F1,30=31.16, P<.001). There was no change in patient activation and shared decision-making (SDM) scores in the total sample of patients (P>.10) Patients with lower levels of activation exhibited positive, short-term benefits in increased intent and confidence to discuss their needs and ask questions in the clinic visit, positive attitudes regarding participation in SDM with their provider, and accurate beliefs about the use of antibiotics (P<.10). The results also suggest small immediate gains in providers’ attitudes about SDM (mean change 0.20; F1,33= 8.03, P=.01). Conclusions: This pilot study provided preliminary evidence on the efficacy of the use of simulated conversations with virtual humans as a tool to improve patient-provider communication (ie, through increasing patient confidence to actively participate in the visit and physician attitudes about SDM) for engaging in conversations about antibiotic use. Future research should explore if repeated opportunities to use the 15-min simulation as well as providing users with several different conversations to practice with would result in sustained improvements in antibiotics beliefs and knowledge and communication behaviors over time. The results of this pilot study offered several opportunities to improve on the simulation in order to bolster communication skills and knowledge retention. %M 28428160 %R 10.2196/mededu.6305 %U http://mededu.jmir.org/2017/1/e7/ %U https://doi.org/10.2196/mededu.6305 %U http://www.ncbi.nlm.nih.gov/pubmed/28428160 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 1 %P e9 %T Virtual Reality for Management of Pain in Hospitalized Patients: Results of a Controlled Trial %A Tashjian,Vartan C %A Mosadeghi,Sasan %A Howard,Amber R %A Lopez,Mayra %A Dupuy,Taylor %A Reid,Mark %A Martinez,Bibiana %A Ahmed,Shahzad %A Dailey,Francis %A Robbins,Karen %A Rosen,Bradley %A Fuller,Garth %A Danovitch,Itai %A IsHak,Waguih %A Spiegel,Brennan %+ Cedars-Sinai Medical Center, Health Services Research, 8700 Beverly Blvd, Los Angeles,CA, CA, 90048, United States, 1 310 423 6239, brennan.spiegel@cshs.org %K pain %K virtual reality %K inpatients %K hospitalization %D 2017 %7 29.03.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Improvements in software and design and reduction in cost have made virtual reality (VR) a practical tool for immersive, three-dimensional (3D), multisensory experiences that distract patients from painful stimuli. Objective: The objective of the study was to measure the impact of a onetime 3D VR intervention versus a two-dimensional (2D) distraction video for pain in hospitalized patients. Methods: We conducted a comparative cohort study in a large, urban teaching hospital in medical inpatients with an average pain score of ≥3/10 from any cause. Patients with nausea, vomiting, dementia, motion sickness, stroke, seizure, and epilepsy and those placed in isolation were excluded. Patients in the intervention cohort viewed a 3D VR experience designed to reduce pain using the Samsung Gear Oculus VR headset; control patients viewed a high-definition, 2D nature video on a 14-inch bedside screen. Pre- and postintervention pain scores were recorded. Difference-in-difference scores and the proportion achieving a half standard deviation pain response were compared between groups. Results: There were 50 subjects per cohort (N=100). The mean pain reduction in the VR cohort was greater than in controls (−1.3 vs −0.6 points, respectively; P=.008). A total of 35 (65%) patients in the VR cohort achieved a pain response versus 40% of controls (P=.01; number needed to treat=4). No adverse events were reported from VR. Conclusions: Use of VR in hospitalized patients significantly reduces pain versus a control distraction condition. These results indicate that VR is an effective and safe adjunctive therapy for pain management in the acute inpatient setting; future randomized trials should confirm benefit with different visualizations and exposure periods. Trial Registration: Clinicaltrials.gov NCT02456987; https://clinicaltrials.gov/ct2/show/NCT02456987 (Archived by WebCite at http://www.webcitation.org/6pJ1P644S) %M 28356241 %R 10.2196/mental.7387 %U http://mental.jmir.org/2017/1/e9/ %U https://doi.org/10.2196/mental.7387 %U http://www.ncbi.nlm.nih.gov/pubmed/28356241 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e22 %T Cardiopulmonary Resuscitation Training by Avatars: A Qualitative Study of Medical Students’ Experiences Using a Multiplayer Virtual World %A Creutzfeldt,Johan %A Hedman,Leif %A Felländer-Tsai,Li %+ Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, K32, Karolinska University Hospital, Stockholm, 14186, Sweden, 46 8 585 82102, johan.creutzfeldt@ki.se %K avatars %K cardiopulmonary resuscitation %K educational technology %K medical students %K experiences %K multiplayer virtual worlds %K patient simulation %K virtual learning environments %D 2016 %7 16.12.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Emergency medical practices are often team efforts. Training for various tasks and collaborations may be carried out in virtual environments. Although promising results exist from studies of serious games, little is known about the subjective reactions of learners when using multiplayer virtual world (MVW) training in medicine. Objective: The objective of this study was to reach a better understanding of the learners’ reactions and experiences when using an MVW for team training of cardiopulmonary resuscitation (CPR). Methods: Twelve Swedish medical students participated in semistructured focus group discussions after CPR training in an MVW with partially preset options. The students’ perceptions and feelings related to use of this educational tool were investigated. Using qualitative methodology, discussions were analyzed by a phenomenological data-driven approach. Quality measures included negotiations, back-and-forth reading, triangulation, and validation with the informants. Results: Four categories characterizing the students’ experiences could be defined: (1) Focused Mental Training, (2) Interface Diverting Focus From Training, (3) Benefits of Practicing in a Group, and (4) Easy Loss of Focus When Passive. We interpreted the results, compared them to findings of others, and propose advantages and risks of using virtual worlds for learning. Conclusions: Beneficial aspects of learning CPR in a virtual world were confirmed. To achieve high participant engagement and create good conditions for training, well-established procedures should be practiced. Furthermore, students should be kept in an active mode and frequent feedback should be utilized. It cannot be completely ruled out that the use of virtual training may contribute to erroneous self-beliefs that can affect later clinical performance. %M 27986645 %R 10.2196/games.6448 %U http://games.jmir.org/2016/2/e22/ %U https://doi.org/10.2196/games.6448 %U http://www.ncbi.nlm.nih.gov/pubmed/27986645 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 12 %P e315 %T Influence of Pokémon Go on Physical Activity: Study and Implications %A Althoff,Tim %A White,Ryen W %A Horvitz,Eric %+ Computer Science Department, Stanford University, 94 Thoburn Ct., Apt 108, Stanford, CA, 94305, United States, 1 6504850758, althoff@cs.stanford.edu %K physical activity %K Pokémon Go %K mobile health %K mHealth %K wearable devices %K mobile applications %K games %K exergames %K public health %D 2016 %7 06.12.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Physical activity helps people maintain a healthy weight and reduces the risk for several chronic diseases. Although this knowledge is widely recognized, adults and children in many countries around the world do not get recommended amounts of physical activity. Although many interventions are found to be ineffective at increasing physical activity or reaching inactive populations, there have been anecdotal reports of increased physical activity due to novel mobile games that embed game play in the physical world. The most recent and salient example of such a game is Pokémon Go, which has reportedly reached tens of millions of users in the United States and worldwide. Objective: The objective of this study was to quantify the impact of Pokémon Go on physical activity. Methods: We study the effect of Pokémon Go on physical activity through a combination of signals from large-scale corpora of wearable sensor data and search engine logs for 32,000 Microsoft Band users over a period of 3 months. Pokémon Go players are identified through search engine queries and physical activity is measured through accelerometers. Results: We find that Pokémon Go leads to significant increases in physical activity over a period of 30 days, with particularly engaged users (ie, those making multiple search queries for details about game usage) increasing their activity by 1473 steps a day on average, a more than 25% increase compared with their prior activity level (P<.001). In the short time span of the study, we estimate that Pokémon Go has added a total of 144 billion steps to US physical activity. Furthermore, Pokémon Go has been able to increase physical activity across men and women of all ages, weight status, and prior activity levels showing this form of game leads to increases in physical activity with significant implications for public health. In particular, we find that Pokémon Go is able to reach low activity populations, whereas all 4 leading mobile health apps studied in this work largely draw from an already very active population. Conclusions: Mobile apps combining game play with physical activity lead to substantial short-term activity increases and, in contrast to many existing interventions and mobile health apps, have the potential to reach activity-poor populations. Future studies are needed to investigate potential long-term effects of these applications. %M 27923778 %R 10.2196/jmir.6759 %U http://www.jmir.org/2016/12/e315/ %U https://doi.org/10.2196/jmir.6759 %U http://www.ncbi.nlm.nih.gov/pubmed/27923778 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 10 %P e259 %T The Effectiveness of Lower-Limb Wearable Technology for Improving Activity and Participation in Adult Stroke Survivors: A Systematic Review %A Powell,Lauren %A Parker,Jack %A Martyn St-James,Marrissa %A Mawson,Susan %+ School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S14DA, United Kingdom, 44 1142228275, l.a.powell@sheffield.ac.uk %K wearable technology %K stroke %K gait %K rehabilitation %D 2016 %7 07.10.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: With advances in technology, the adoption of wearable devices has become a viable adjunct in poststroke rehabilitation. Regaining ambulation is a top priority for an increasing number of stroke survivors. However, despite an increase in research exploring these devices for lower limb rehabilitation, little is known of the effectiveness. Objective: This review aims to assess the effectiveness of lower limb wearable technology for improving activity and participation in adult stroke survivors. Methods: Randomized controlled trials (RCTs) of lower limb wearable technology for poststroke rehabilitation were included. Primary outcome measures were validated measures of activity and participation as defined by the International Classification of Functioning, Disability and Health. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the RCTs. Results: In the review, we included 11 RCTs with collectively 550 participants at baseline and 474 participants at final follow-up including control groups and participants post stroke. Participants' stroke type and severity varied. Only one study found significant between-group differences for systems functioning and activity. Across the included RCTs, the lowest number of participants was 12 and the highest was 151 with a mean of 49 participants. The lowest number of participants to drop out of an RCT was zero in two of the studies and 19 in one study. Significant between-group differences were found across three of the 11 included trials. Out of the activity and participation measures alone, P values ranged from P=.87 to P ≤.001. Conclusions: This review has highlighted a number of reasons for insignificant findings in this area including low sample sizes, appropriateness of the RCT methodology for complex interventions, a lack of appropriate analysis of outcome data, and participant stroke severity. %M 27717920 %R 10.2196/jmir.5891 %U http://www.jmir.org/2016/10/e259/ %U https://doi.org/10.2196/jmir.5891 %U http://www.ncbi.nlm.nih.gov/pubmed/27717920 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 2 %P e16 %T Effects of Visual Display on Joint Excursions Used to Play Virtual Dodgeball %A Thomas,James S %A France,Christopher R %A Applegate,Megan E %A Leitkam,Samuel T %A Pidcoe,Peter E %A Walkowski,Stevan %+ School of Rehabilitation and Communication Sciences, Ohio University, W281 Grover Center, Athens, OH, 45701, United States, 1 740 593 4178, thomasj5@ohio.edu %K virtual reality %K avatar presentation %K joint kinematics %D 2016 %7 15.09.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality (VR) interventions hold great potential for rehabilitation as commercial systems are becoming more affordable and can be easily applied to both clinical and home settings. Objective: In this study, we sought to determine how differences in the VR display type can influence motor behavior, cognitive load, and participant engagement. Methods: Movement patterns of 17 healthy young adults (8 female, 9 male) were examined during games of Virtual Dodgeball presented on a three-dimensional television (3DTV) and a head-mounted display (HMD). The participant’s avatar was presented from a third-person perspective on a 3DTV and from a first-person perspective on an HMD. Results: Examination of motor behavior revealed significantly greater excursions of the knee (P=.003), hip (P<.001), spine (P<.001), shoulder (P=.001), and elbow (P=.026) during HMD versus 3DTV gameplay, resulting in significant differences in forward (P=.003) and downward (P<.001) displacement of the whole-body center of mass. Analyses of cognitive load and engagement revealed that relative to 3DTV, participants indicated that HMD gameplay resulted in greater satisfaction with overall performance and was less frustrating (P<.001). There were no significant differences noted for mental demand. Conclusions: Differences in visual display type and participant perspective influence how participants perform in Virtual Dodgeball. Because VR use within rehabilitation settings is often designed to help restore movement following orthopedic or neurologic injury, these findings provide an important caveat regarding the need to consider the potential influence of presentation format and perspective on motor behavior. %M 27634561 %R 10.2196/games.6476 %U http://games.jmir.org/2016/2/e16/ %U https://doi.org/10.2196/games.6476 %U http://www.ncbi.nlm.nih.gov/pubmed/27634561 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 3 %N 2 %P e28 %T Feasibility of an Immersive Virtual Reality Intervention for Hospitalized Patients: An Observational Cohort Study %A Mosadeghi,Sasan %A Reid,Mark William %A Martinez,Bibiana %A Rosen,Bradley Todd %A Spiegel,Brennan Mason Ross %+ Cedars-Sinai Health System, Health Services Research, 116 N Robertson Boulevard, Suite 400, Los Angeles, CA, 90048, United States, 1 310 423 6467, Brennan.Spiegel@cshs.org %K virtual reality therapy %K hospitalization %K feasibility studies %D 2016 %7 27.06.2016 %9 Original Paper %J JMIR Ment Health %G English %X Background: Virtual reality (VR) offers immersive, realistic, three-dimensional experiences that “transport” users to novel environments. Because VR is effective for acute pain and anxiety, it may have benefits for hospitalized patients; however, there are few reports using VR in this setting. Objective: The aim was to evaluate the acceptability and feasibility of VR in a diverse cohort of hospitalized patients. Methods: We assessed the acceptability and feasibility of VR in a cohort of patients admitted to an inpatient hospitalist service over a 4-month period. We excluded patients with motion sickness, stroke, seizure, dementia, nausea, and in isolation. Eligible patients viewed VR experiences (eg, ocean exploration; Cirque du Soleil; tour of Iceland) with Samsung Gear VR goggles. We then conducted semistructured patient interview and performed statistical testing to compare patients willing versus unwilling to use VR. Results: We evaluated 510 patients; 423 were excluded and 57 refused to participate, leaving 30 participants. Patients willing versus unwilling to use VR were younger (mean 49.1, SD 17.4 years vs mean 60.2, SD 17.7 years; P=.01); there were no differences by sex, race, or ethnicity. Among users, most reported a positive experience and indicated that VR could improve pain and anxiety, although many felt the goggles were uncomfortable. Conclusions: Most inpatient users of VR described the experience as pleasant and capable of reducing pain and anxiety. However, few hospitalized patients in this “real-world” series were both eligible and willing to use VR. Consistent with the “digital divide” for emerging technologies, younger patients were more willing to participate. Future research should evaluate the impact of VR on clinical and resource outcomes. ClinicalTrial: Clinicaltrials.gov NCT02456987; https://clinicaltrials.gov/ct2/show/NCT02456987 (Archived by WebCite at http://www.webcitation.org/6iFIMRNh3) %M 27349654 %R 10.2196/mental.5801 %U http://mental.jmir.org/2016/2/e28/ %U https://doi.org/10.2196/mental.5801 %U http://www.ncbi.nlm.nih.gov/pubmed/27349654 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 5 %N 2 %P e81 %T Acceptance, Usability and Health Applications of Virtual Worlds by Older Adults: A Feasibility Study %A Cook,Nicole %A Winkler,Sandra L %+ Master of Public Health program, College of Osteopathic Medicine, Nova Southeastern University, 3200 South University Drive, Fort Lauderdale, FL, 33314, United States, 1 9542621505, nc570@nova.edu %K Second Life %K virtual worlds %K older adults %K seniors %K health care %K training %D 2016 %7 02.06.2016 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Virtual worlds allow users to communicate and interact across various environments, scenarios, and platforms. Virtual worlds present opportunities in health care to reduce the burden of illness and disability by supporting education, rehabilitation, self-management, and social networking. The application of virtual worlds to older adults who bear the burden and cost of health conditions associated with age has not been evaluated. Objective: The aim of this study is to explore the usability, ease of use, and enjoyment of a virtual world by older adults, the types of virtual world activities that older adults may engage in, and the perceptions of older adults regarding the application of virtual worlds in health care. Methods: This quasi-experimental pre-post design research was guided by the Technology Acceptance Model (TAM). Participants were recruited from a Lifelong Learning Institute (LLI) program at Nova Southeastern University. Participants attended four training sessions over a 5-week period in the Second Life (SL) virtual world. Subjects were surveyed before and after the training on perceived ease of use, attitudes towards technology, behavioral intention to use the system, facilitating conditions, effort expectancy, and self-efficacy. Results: Older adults (N=19) completed the informed consent and attended the first training session, and 11 participants (58%, 11/19) completed the full training and the post survey. Completers (82%, 9/11) were more likely than non-completers (37%, 3/8) to consider themselves technologically savvy (P=.048), and to express confidence in being able to use the virtual world (100%, 11/11 vs 37%, 3/8; P=.002). All completers (100%, 11/11) perceived that SL has application in health behaviors and disease and reducing social isolation among people who are homebound. Of the completers, 10 (91%, 10/11) responded that they enjoyed learning how to use SL. Completers suggested that future trainings include more assistants and smaller groups. Conclusions: This pilot study suggests that virtual worlds can be both a feasible and an applicable method to promote health among some seniors. Future research on virtual worlds with older populations should consider using state-of-the art technology including large monitors, providing a minimum of one trainer for every two to three participants, and distributing a comprehensive training manual at the start of the training to support organization and recall. %M 27256457 %R 10.2196/resprot.5423 %U http://www.researchprotocols.org/2016/2/e81/ %U https://doi.org/10.2196/resprot.5423 %U http://www.ncbi.nlm.nih.gov/pubmed/27256457 %0 Journal Article %@ 2291-9279 %I JMIR Publications %V 4 %N 1 %P e9 %T Development and Reliability Evaluation of the Movement Rating Instrument for Virtual Reality Video Game Play %A Levac,Danielle %A Nawrotek,Joanna %A Deschenes,Emilie %A Giguere,Tia %A Serafin,Julie %A Bilodeau,Martin %A Sveistrup,Heidi %+ Northeastern University, Department of Physical Therapy, Movement and Rehabilitation Sciences, 407c Robinson Hall, 360 Huntington Avenue, Boston, MA, 02115, United States, 1 6173735198, d.levac@neu.edu %K active video games, virtual reality, physical therapy, movement, reliability %D 2016 %7 01.06.2016 %9 Original Paper %J JMIR Serious Games %G English %X Background: Virtual reality active video games are increasingly popular physical therapy interventions for children with cerebral palsy. However, physical therapists require educational resources to support decision making about game selection to match individual patient goals. Quantifying the movements elicited during virtual reality active video game play can inform individualized game selection in pediatric rehabilitation. Objective: The objectives of this study were to develop and evaluate the feasibility and reliability of the Movement Rating Instrument for Virtual Reality Game Play (MRI-VRGP). Methods: Item generation occurred through an iterative process of literature review and sample videotape viewing. The MRI-VRGP includes 25 items quantifying upper extremity, lower extremity, and total body movements. A total of 176 videotaped 90-second game play sessions involving 7 typically developing children and 4 children with cerebral palsy were rated by 3 raters trained in MRI-VRGP use. Children played 8 games on 2 virtual reality and active video game systems. Intraclass correlation coefficients (ICCs) determined intra-rater and interrater reliability. Results: Excellent intrarater reliability was evidenced by ICCs of >0.75 for 17 of the 25 items across the 3 raters. Interrater reliability estimates were less precise. Excellent interrater reliability was achieved for far reach upper extremity movements (ICC=0.92 [for right and ICC=0.90 for left) and for squat (ICC=0.80) and jump items (ICC=0.99), with 9 items achieving ICCs of >0.70, 12 items achieving ICCs of between 0.40 and 0.70, and 4 items achieving poor reliability (close-reach upper extremity-ICC=0.14 for right and ICC=0.07 for left) and single-leg stance (ICC=0.55 for right and ICC=0.27 for left). Conclusions: Poor video quality, differing item interpretations between raters, and difficulty quantifying the high-speed movements involved in game play affected reliability. With item definition clarification and further psychometric property evaluation, the MRI-VRGP could inform the content of educational resources for therapists by ranking games according to frequency and type of elicited body movements. %M 27251029 %R 10.2196/games.5528 %U http://games.jmir.org/2016/1/e9/ %U https://doi.org/10.2196/games.5528 %U http://www.ncbi.nlm.nih.gov/pubmed/27251029 %0 Journal Article %@ 2369-2529 %I JMIR Publications Inc. %V 3 %N 1 %P e5 %T Systemic Lisbon Battery: Normative Data for Memory and Attention Assessments %A Gamito,Pedro %A Morais,Diogo %A Oliveira,Jorge %A Ferreira Lopes,Paulo %A Picareli,Luís Felipe %A Matias,Marcelo %A Correia,Sara %A Brito,Rodrigo %+ Cognition and People-centric Computing Laboratories– COPELABS. Lusophone University of Humanities and Technologies, Campo Grande, 376, Lisbon, 1749 - 02, Portugal, 351 217505020 ext 7003, pedro.gamito@ulusofona.pt %K Systemic Lisbon Battery %K attention %K memory %K cognitive assessment %K virtual reality %D 2016 %7 04.05.2016 %9 Original Paper %J JMIR Rehabil Assist Technol %G English %X Background: Memory and attention are two cognitive domains pivotal for the performance of instrumental activities of daily living (IADLs). The assessment of these functions is still widely carried out with pencil-and-paper tests, which lack ecological validity. The evaluation of cognitive and memory functions while the patients are performing IADLs should contribute to the ecological validity of the evaluation process. Objective: The objective of this study is to establish normative data from virtual reality (VR) IADLs designed to activate memory and attention functions. Methods: A total of 243 non-clinical participants carried out a paper-and-pencil Mini-Mental State Examination (MMSE) and performed 3 VR activities: art gallery visual matching task, supermarket shopping task, and memory fruit matching game. The data (execution time and errors, and money spent in the case of the supermarket activity) was automatically generated from the app. Results: Outcomes were computed using non-parametric statistics, due to non-normality of distributions. Age, academic qualifications, and computer experience all had significant effects on most measures. Normative values for different levels of these measures were defined. Conclusions: Age, academic qualifications, and computer experience should be taken into account while using our VR-based platform for cognitive assessment purposes. %M 28582246 %R 10.2196/rehab.4155 %U http://rehab.jmir.org/2016/1/e5/ %U https://doi.org/10.2196/rehab.4155 %U http://www.ncbi.nlm.nih.gov/pubmed/28582246 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 10 %P e229 %T Medical Content Searching, Retrieving, and Sharing Over the Internet: Lessons Learned From the mEducator Through a Scenario-Based Evaluation %A Antoniades,Athos %A Nicolaidou,Iolie %A Spachos,Dimitris %A Mylläri,Jarkko %A Giordano,Daniela %A Dafli,Eleni %A Mitsopoulou,Evangelia %A Schizas,Christos N %A Pattichis,Constantinos %A Nikolaidou,Maria %A Bamidis,Panagiotis %+ Lab of Medical Physics, Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, PO Box 376, Thessaloniki, 54124, Greece, 30 2310 999310, bamidis@med.auth.gr %K searching and sharing of medical educational content %K repurposing %K metadata %K evaluation %D 2015 %7 09.10.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: The mEducator Best Practice Network (BPN) implemented and extended standards and reference models in e-learning to develop innovative frameworks as well as solutions that enable specialized state-of-the-art medical educational content to be discovered, retrieved, shared, and re-purposed across European Institutions, targeting medical students, doctors, educators and health care professionals. Scenario-based evaluation for usability testing, complemented with data from online questionnaires and field notes of users’ performance, was designed and utilized for the evaluation of these solutions. Objective: The objective of this work is twofold: (1) to describe one instantiation of the mEducator BPN solutions (mEducator3.0 - “MEdical Education LINnked Arena” MELINA+) with a focus on the metadata schema used, as well as on other aspects of the system that pertain to usability and acceptance, and (2) to present evaluation results on the suitability of the proposed metadata schema for searching, retrieving, and sharing of medical content and with respect to the overall usability and acceptance of the system from the target users. Methods: A comprehensive evaluation methodology framework was developed and applied to four case studies, which were conducted in four different countries (ie, Greece, Cyprus, Bulgaria and Romania), with a total of 126 participants. In these case studies, scenarios referring to creating, sharing, and retrieving medical educational content using mEducator3.0 were used. The data were collected through two online questionnaires, consisting of 36 closed-ended questions and two open-ended questions that referred to mEducator 3.0 and through the use of field notes during scenario-based evaluations. Results: The main findings of the study showed that even though the informational needs of the mEducator target groups were addressed to a satisfactory extent and the metadata schema supported content creation, sharing, and retrieval from an end-user perspective, users faced difficulties in achieving a shared understanding of the meaning of some metadata fields and in correctly managing the intellectual property rights of repurposed content. Conclusions: The results of this evaluation impact researchers, medical professionals, and designers interested in using similar systems for educational content sharing in medical and other domains. Recommendations on how to improve the search, retrieval, identification, and obtaining of medical resources are provided, by addressing issues of content description metadata, content description procedures, and intellectual property rights for re-purposed content. %M 26453250 %R 10.2196/jmir.3650 %U http://www.jmir.org/2015/10/e229/ %U https://doi.org/10.2196/jmir.3650 %U http://www.ncbi.nlm.nih.gov/pubmed/26453250 %0 Journal Article %@ 2369-3762 %I JMIR Publications Inc. %V 1 %N 2 %P e10 %T Design of Mobile Augmented Reality in Health Care Education: A Theory-Driven Framework %A Zhu,Egui %A Lilienthal,Anneliese %A Shluzas,Lauren Aquino %A Masiello,Italo %A Zary,Nabil %+ Centre for Learning and Knowledge, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, 3th Floor, Tomtebodavägen 18a, Stockholm, 171 77, Sweden, 46 8 524 83711, egui.zhu@ki.se %K augmented reality %K health care education %K antibiotics %K general practitioners %K learning environment %K learning theory %K mobile technology %D 2015 %7 18.09.2015 %9 Original Paper %J JMIR Medical Education %G English %X Background: Augmented reality (AR) is increasingly used across a range of subject areas in health care education as health care settings partner to bridge the gap between knowledge and practice. As the first contact with patients, general practitioners (GPs) are important in the battle against a global health threat, the spread of antibiotic resistance. AR has potential as a practical tool for GPs to combine learning and practice in the rational use of antibiotics. Objective: This paper was driven by learning theory to develop a mobile augmented reality education (MARE) design framework. The primary goal of the framework is to guide the development of AR educational apps. This study focuses on (1) identifying suitable learning theories for guiding the design of AR education apps, (2) integrating learning outcomes and learning theories to support health care education through AR, and (3) applying the design framework in the context of improving GPs’ rational use of antibiotics. Methods: The design framework was first constructed with the conceptual framework analysis method. Data were collected from multidisciplinary publications and reference materials and were analyzed with directed content analysis to identify key concepts and their relationships. Then the design framework was applied to a health care educational challenge. Results: The proposed MARE framework consists of three hierarchical layers: the foundation, function, and outcome layers. Three learning theories—situated, experiential, and transformative learning—provide foundational support based on differing views of the relationships among learning, practice, and the environment. The function layer depends upon the learners’ personal paradigms and indicates how health care learning could be achieved with MARE. The outcome layer analyzes different learning abilities, from knowledge to the practice level, to clarify learning objectives and expectations and to avoid teaching pitched at the wrong level. Suggestions for learning activities and the requirements of the learning environment form the foundation for AR to fill the gap between learning outcomes and medical learners’ personal paradigms. With the design framework, the expected rational use of antibiotics by GPs is described and is easy to execute and evaluate. The comparison of specific expected abilities with the GP personal paradigm helps solidify the GP practical learning objectives and helps design the learning environment and activities. The learning environment and activities were supported by learning theories. Conclusions: This paper describes a framework for guiding the design, development, and application of mobile AR for medical education in the health care setting. The framework is theory driven with an understanding of the characteristics of AR and specific medical disciplines toward helping medical education improve professional development from knowledge to practice. Future research will use the framework as a guide for developing AR apps in practice to validate and improve the design framework. %M 27731839 %R 10.2196/mededu.4443 %U http://mededu.jmir.org/2015/2/e10/ %U https://doi.org/10.2196/mededu.4443 %U http://www.ncbi.nlm.nih.gov/pubmed/27731839 %0 Journal Article %@ 2291-9279 %I JMIR Publications Inc. %V 3 %N 2 %P e5 %T Using a Virtual Environment to Deliver Evidence-Based Interventions: The Facilitator's Experience %A Aebersold,Michelle %A Villarruel,Antonia %A Tschannen,Dana %A Valladares,Angel %A Yaksich,Joseph %A Yeagley,Emily %A Hawes,Armani %+ University of Michigan, School of Nursing, 400 North Ingalls, Ann Arbor, MI, , United States, 1 734 615 8498, mabersol@umich.edu %K Second Life %K multi-user virtual environments %K evidence-based interventions %K community-based organizations %D 2015 %7 21.07.2015 %9 Original Paper %J JMIR Serious Games %G English %X Background: Evidence-based interventions (EBIs) have the potential to maximize positive impact on communities. However, despite the quantity and quality of EBIs for prevention, the need for formalized training and associated training-related expenses, such as travel costs, program materials, and input of personnel hours, pose implementation challenges for many community-based organizations. In this study, the community of inquiry (CoI) framework was used to develop the virtual learning environment to support the adaptation of the ¡Cuídate! (Take Care of Yourself!) Training of Facilitators curriculum (an EBI) to train facilitators from community-based organizations. Objective: The purpose of this study was to examine the feasibility of adapting a traditional face-to-face facilitator training program for ¡Cuídate!, a sexual risk reduction EBI for Latino youth, for use in a multi-user virtual environment (MUVE). Additionally, two aims of the study were explored: the acceptability of the facilitator training and the level of the facilitators’ knowledge and self-efficacy to implement the training. Methods: A total of 35 facilitators were trained in the virtual environment. We evaluated the facilitators' experience in the virtual training environment and determined if the learning environment was acceptable and supported the acquisition of learning outcomes. To this end, the facilitators were surveyed using a modified community of inquiry survey, with questions specific to the Second Life environment and an open-ended questionnaire. In addition, a comparison to face-to-face training was conducted using survey methods. Results: Results of the community of inquiry survey demonstrated a subscale mean of 23.11 (SD 4.12) out of a possible 30 on social presence, a subscale mean of 8.74 (SD 1.01) out of a possible 10 on teaching presence, and a subscale mean of 16.69 (SD 1.97) out of a possible 20 on cognitive presence. The comparison to face-to-face training showed no significant differences in participants' ability to respond to challenging or sensitive questions (P=.50) or their ability to help participants recognize how Latino culture supports safer sex (P=.32). There was a significant difference in their knowledge of core elements and modules (P<.001). A total of 74% (26/35) of the Second Life participants did agree/strongly agree that they had the skills to deliver the ¡Cuídate! program. Conclusions: The results showed that participants found the Second Life environment to be acceptable to the learners and supported an experience in which learners were able to acquire the knowledge and skills needed to deliver the curriculum. %M 26199045 %R 10.2196/games.4293 %U http://games.jmir.org/2015/2/e5/ %U https://doi.org/10.2196/games.4293 %U http://www.ncbi.nlm.nih.gov/pubmed/26199045 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 4 %P e107 %T Using a 3D Virtual Supermarket to Measure Food Purchase Behavior: A Validation Study %A Waterlander,Wilma Elzeline %A Jiang,Yannan %A Steenhuis,Ingrid Hendrika Margaretha %A Ni Mhurchu,Cliona %+ National Institute for Health Innovation, School of Population Health, University of Auckland, Tamaki Campus, 261 Morrin Road, Auckland, 1072, New Zealand, 64 09 9234612, w.waterlander@auckland.ac.nz %K virtual reality %K user-computer interface %K software validation %K nutrition policy %K food %K behavior %K public health %D 2015 %7 28.04.2015 %9 Original Paper %J J Med Internet Res %G English %X Background: There is increasing recognition that supermarkets are an important environment for health-promoting interventions such as fiscal food policies or front-of-pack nutrition labeling. However, due to the complexities of undertaking such research in the real world, well-designed randomized controlled trials on these kinds of interventions are lacking. The Virtual Supermarket is a 3-dimensional computerized research environment designed to enable experimental studies in a supermarket setting without the complexity or costs normally associated with undertaking such research. Objective: The primary objective was to validate the Virtual Supermarket by comparing virtual and real-life food purchasing behavior. A secondary objective was to obtain participant feedback on perceived sense of “presence” (the subjective experience of being in one place or environment even if physically located in another) in the Virtual Supermarket. Methods: Eligible main household shoppers (New Zealand adults aged ≥18 years) were asked to conduct 3 shopping occasions in the Virtual Supermarket over 3 consecutive weeks, complete the validated Presence Questionnaire Items Stems, and collect their real supermarket grocery till receipts for that same period. Proportional expenditure (NZ$) and the proportion of products purchased over 18 major food groups were compared between the virtual and real supermarkets. Data were analyzed using repeated measures mixed models. Results: A total of 123 participants consented to take part in the study. In total, 69.9% (86/123) completed 1 shop in the Virtual Supermarket, 64.2% (79/123) completed 2 shops, 60.2% (74/123) completed 3 shops, and 48.8% (60/123) returned their real supermarket till receipts. The 4 food groups with the highest relative expenditures were the same for the virtual and real supermarkets: fresh fruit and vegetables (virtual estimate: 14.3%; real: 17.4%), bread and bakery (virtual: 10.0%; real: 8.2%), dairy (virtual: 19.1%; real: 12.6%), and meat and fish (virtual: 16.5%; real: 16.8%). Significant differences in proportional expenditures were observed for 6 food groups, with largest differences (virtual – real) for dairy (in expenditure 6.5%, P<.001; in items 2.2%, P=.04) and fresh fruit and vegetables (in expenditure: –3.1%, P=.04; in items: 5.9%, P=.002). There was no trend of overspending in the Virtual Supermarket and participants experienced a medium-to-high presence (88%, 73/83 scored medium; 8%, 7/83 scored high). Conclusions: Shopping patterns in the Virtual Supermarket were comparable to those in real life. Overall, the Virtual Supermarket is a valid tool to measure food purchasing behavior. Nevertheless, it is important to improve the functionality of some food categories, in particular fruit and vegetables and dairy. The results of this validation will assist in making further improvements to the software and with optimization of the internal and external validity of this innovative methodology. %M 25921185 %R 10.2196/jmir.3774 %U http://www.jmir.org/2015/4/e107/ %U https://doi.org/10.2196/jmir.3774 %U http://www.ncbi.nlm.nih.gov/pubmed/25921185 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 17 %N 4 %P e91 %T 3D Immersive Patient Simulators and Their Impact on Learning Success: A Thematic Review %A Kleinert,Robert %A Wahba,Roger %A Chang,De-Hua %A Plum,Patrick %A Hölscher,Arnulf H %A Stippel,Dirk L %+ Department of General, Visceral and Cancer Surgery, University of Cologne, Kerpener 62, Cologne, 50937, Germany, 49 1774445859, robert.kleinert@uk-koeln.de %K immersive patient simulators %K Web-based learning %K validity %K immersion %K procedural knowledge %D 2015 %7 08.04.2015 %9 Review %J J Med Internet Res %G English %X Background: Immersive patient simulators (IPSs) combine the simulation of virtual patients with a three-dimensional (3D) environment and, thus, allow an illusionary immersion into a synthetic world, similar to computer games. Playful learning in a 3D environment is motivating and allows repetitive training and internalization of medical workflows (ie, procedural knowledge) without compromising real patients. The impact of this innovative educational concept on learning success requires review of feasibility and validity. Objective: It was the aim of this paper to conduct a survey of all immersive patient simulators currently available. In addition, we address the question of whether the use of these simulators has an impact on knowledge gain by summarizing the existing validation studies. Methods: A systematic literature search via PubMed was performed using predefined inclusion criteria (ie, virtual worlds, focus on education of medical students, validation testing) to identify all available simulators. Validation testing was defined as the primary end point. Results: There are currently 13 immersive patient simulators available. Of these, 9 are Web-based simulators and represent feasibility studies. None of these simulators are used routinely for student education. The workstation-based simulators are commercially driven and show a higher quality in terms of graphical quality and/or data content. Out of the studies, 1 showed a positive correlation between simulated content and real content (ie, content validity). There was a positive correlation between the outcome of simulator training and alternative training methods (ie, concordance validity), and a positive coherence between measured outcome and future professional attitude and performance (ie, predictive validity). Conclusions: IPSs can promote learning and consolidation of procedural knowledge. The use of immersive patient simulators is still marginal, and technical and educational approaches are heterogeneous. Academic-driven IPSs could possibly enhance the content quality, improve the validity level, and make this educational concept accessible to all medical students. %M 25858862 %R 10.2196/jmir.3492 %U http://www.jmir.org/2015/4/e91/ %U https://doi.org/10.2196/jmir.3492 %U http://www.ncbi.nlm.nih.gov/pubmed/25858862 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 2 %P e39 %T The Use of Virtual World-Based Cardiac Rehabilitation to Encourage Healthy Lifestyle Choices Among Cardiac Patients: Intervention Development and Pilot Study Protocol %A Brewer,LaPrincess C %A Kaihoi,Brian %A Zarling,Kathleen K %A Squires,Ray W %A Thomas,Randal %A Kopecky,Stephen %+ Mayo Clinic College of Medicine, Department of Medicine, 200 First Street SW, Rochester, MN, 55905, United States, 1 507 284 9601, kopecky.stephen@mayo.edu %K cardiac rehabilitation %K cardiovascular diseases %K eHealth %K telemedicine %K Internet %K health behavior %D 2015 %7 08.04.2015 %9 Protocol %J JMIR Res Protoc %G English %X Background: Despite proven benefits through the secondary prevention of cardiovascular disease (CVD) and reduction of mortality, cardiac rehabilitation (CR) remains underutilized in cardiac patients. Underserved populations most affected by CVD including rural residents, low socioeconomic status patients, and racial/ethnic minorities have the lowest participation rates due to access barriers. Internet-and mobile-based lifestyle interventions have emerged as potential modalities to complement and increase accessibility to CR. An outpatient CR program using virtual world technology may provide an effective alternative to conventional CR by overcoming patient access limitations such as geographics, work schedule constraints, and transportation. Objective: The objective of this paper is to describe the research protocol of a two-phased, pilot study that will assess the feasibility (Phase 1) and comparative effectiveness (Phase 2) of a virtual world-based (Second Life) CR program as an extension of a conventional CR program in achieving healthy behavioral change among post-acute coronary syndrome (ACS) and post-percutaneous coronary intervention (PCI) patients. We hypothesize that virtual world CR users will improve behaviors (physical activity, diet, and smoking) to a greater degree than conventional CR participants. Methods: In Phase 1, we will recruit at least 10 patients enrolled in outpatient CR who were recently hospitalized for an ACS (unstable angina, ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction) or who recently underwent elective PCI at Mayo Clinic Hospital, Rochester Campus in Rochester, MN with at least one modifiable, lifestyle risk factor target (sedentary lifestyle, unhealthy diet, and current smoking). Recruited patients will participate in a 12-week, virtual world health education program which will provide feedback on the feasibility, usability, and design of the intervention. During Phase 2, we will conduct a 2-arm, parallel group, single-center, randomized controlled trial (RCT). Patients will be randomized at a 1:1 ratio to adjunct virtual world-based CR with conventional CR or conventional CR only. The primary outcome is a composite including at least one of the following (1) at least 150 minutes of physical activity per week, (2) daily consumption of five or more fruits and vegetables, and (3) smoking cessation. Patients will be assessed at 3, 6, and 12 months. Results: The Phase 1 feasibility study is currently open for recruitment which will be followed by the Phase 2 RCT. The anticipated completion date for the study is May 2016. Conclusions: While research on the use of virtual world technology in health programs is in its infancy, it offers unique advantages over current Web-based health interventions including social interactivity and active learning. It also increases accessibility to vulnerable populations who have higher burdens of CVD. This study will yield results on the effectiveness of a virtual world-based CR program as an innovative platform to influence healthy lifestyle behavior and self-efficacy. %M 25857331 %R 10.2196/resprot.4285 %U http://www.researchprotocols.org/2015/2/e39/ %U https://doi.org/10.2196/resprot.4285 %U http://www.ncbi.nlm.nih.gov/pubmed/25857331 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 16 %N 12 %P e283 %T Occupational Therapists’ Views on Using a Virtual Reality Interior Design Application Within the Pre-Discharge Home Visit Process %A Atwal,Anita %A Money,Arthur %A Harvey,Michele %+ Brunel University, Department of Computer Science, Brunel University, St Johns, London, UB8 3PH, United Kingdom, 44 1895266758, arthur.money@brunel.ac.uk %K occupational therapy %K pre-discharge home visits %K virtual reality %K 3D %K patient collaboration %K patient engagement %K empowerment %K technology assisted care %K patient perceptions %D 2014 %7 18.12.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: A key role of Occupational Therapists (OTs) is to carry out pre-discharge home visits (PHV) and propose appropriate adaptations to the home environment in order to enable patients to function independently after hospital discharge. However, research shows that more than 50% of specialist equipment installed as part of home adaptations is not used by patients. A key reason for this is that decisions about home adaptations are often made without adequate collaboration and consultation with the patient. Consequently, there is an urgent need to seek out new and innovative uses of technology to facilitate patient/practitioner collaboration, engagement, and shared decision making in the PHV process. Virtual reality interior design applications (VRIDAs) primarily allow users to simulate the home environment and visualize changes prior to implementing them. Customized VRIDAs, which also model specialist occupational therapy equipment, could become a valuable tool to facilitate improved patient/practitioner collaboration, if developed effectively and integrated into the PHV process. Objective: The intent of the study was to explore the perceptions of OTs with regard to using VRIDAs as an assistive tool within the PHV process. Methods: Task-oriented interactive usability sessions, utilizing the think-aloud protocol and subsequent semi-structured interviews were carried out with seven OTs who possessed significant experience across a range of clinical settings. Template analysis was carried out on the think-aloud and interview data. Analysis was both inductive and driven by theory, centering around the parameters that impact upon the acceptance, adoption, and use of this technology in practice as indicated by the Technology Acceptance Model (TAM). Results: OTs’ perceptions were identified relating to three core themes: (1) perceived usefulness (PU), (2) perceived ease of use (PEoU), and (3) actual use (AU). Regarding PU, OTs believed VRIDAs had promising potential to increase understanding, enrich communication and patient involvement, and improve patient/practitioner shared understanding. However, it was unlikely that VRIDAs would be suitable for use with cognitively impaired patients. For PEoU, all OTs were able to use the software and complete the tasks successfully; however, participants noted numerous specialist equipment items that could be added to the furniture library. AU perceptions were positive regarding use of the application across a range of clinical settings including children/young adults, long-term conditions, neurology, older adults, and social services. However, some “fine tuning” may be necessary if the application is to be optimally used in practice. Conclusions: Participants perceived the use of VRIDAs in practice would enhance levels of patient/practitioner collaboration and provide a much needed mechanism via which patients are empowered to become more equal partners in decisions made about their care. Further research is needed to explore patient perceptions of VRIDAs, to make necessary customizations accordingly, and to explore deployment of the application in a collaborative patient/practitioner-based context. %M 25526615 %R 10.2196/jmir.3723 %U http://www.jmir.org/2014/12/e283/ %U https://doi.org/10.2196/jmir.3723 %U http://www.ncbi.nlm.nih.gov/pubmed/25526615 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 3 %N 4 %P e54 %T A Virtual World Versus Face-to-Face Intervention Format to Promote Diabetes Self-Management Among African American Women: A Pilot Randomized Clinical Trial %A Rosal,Milagros C %A Heyden,Robin %A Mejilla,Roanne %A Capelson,Roberta %A Chalmers,Karen A %A Rizzo DePaoli,Maria %A Veerappa,Chetty %A Wiecha,John M %+ University of Massachusetts Medical School, Division of Preventive and Behavioral Medicine, 55 Lake Avenue North, Worcester, MA, 01655, United States, 1 508 856 3173, milagros.rosal@umassmed.edu %K African Americans %K clinical trials %K feasibility %K health behavior %K health disparities %K minority health %K technology %K type 2 diabetes %K virtual systems %K randomized clinical trial %D 2014 %7 24.10.2014 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Virtual world environments have the potential to increase access to diabetes self-management interventions and may lower cost. Objective: We tested the feasibility and comparative effectiveness of a virtual world versus a face-to-face diabetes self-management group intervention. Methods: We recruited African American women with type 2 diabetes to participate in an 8-week diabetes self-management program adapted from Power to Prevent, a behavior-change in-person group program for African Americans with diabetes or pre-diabetes. The program is social cognitive theory–guided, evidence-based, and culturally tailored. Participants were randomized to participate in the program via virtual world (Second Life) or face-to-face, both delivered by a single intervention team. Blinded assessors conducted in-person clinical (HbA1c), behavioral, and psychosocial measurements at baseline and 4-month follow-up. Pre-post differences within and between intervention groups were assessed using t tests and chi-square tests (two-sided and intention-to-treat analyses for all comparisons). Results: Participants (N=89) were an average of 52 years old (SD 10), 60% had ≤high school, 82% had household incomes 40) female patients with BED upon referral to an obesity rehabilitation center were randomly assigned to conditions (31 to ECT, 30 to CBT, and 29 to IP). Before treatment completion, 24 patients discharged themselves from hospital (4 in ECT, 10 in CBT, and 10 in IP). The remaining 66 inpatients received either 15 sessions of ECT, 15 sessions of CBT, or no additional treatment over a 5-week usual care inpatient regimen (IP). ECT and CBT treatments were administered by 3 licensed psychotherapists, and patients were blinded to conditions. At start, upon completion of the inpatient treatment, and at 1-year follow-up, patients' weight, number of binge eating episodes during the previous month, and body satisfaction were assessed by self-report questionnaires and compared across conditions. 22 patients who received all sessions did not provide follow-up data (9 in ECT, 6 in CBT, and 7 in IP). Results: Only ECT was effective at improving weight loss at 1-year follow-up. Conversely, control participants regained on average most of the weight they had lost during the inpatient program. Binge eating episodes decreased to zero during the inpatient program but were reported again in all the three groups at 1-year follow-up. However, a substantial regain was observed only in the group who received the inpatient program alone, while both ECT and CBT were successful in maintaining a low rate of monthly binge eating episodes. Conclusions: Despite study limitations, findings support the hypothesis that the integration of a VR-based treatment, aimed at both unlocking the negative memory of the body and at modifying its behavioral and emotional correlates, may improve the long-term outcome of a treatment for obese BED patients. As expected, the VR-based treatment, in comparison with the standard CBT approach, was able to better prevent weight regain but not to better manage binge eating episodes. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 59019572; http://www.controlled-trials.com/ISRCTN59019572 (Archived by WebCite at http://www.webcitation.org/6GxHxAR2G) %M 23759286 %R 10.2196/jmir.2441 %U http://www.jmir.org/2013/6/e113/ %U https://doi.org/10.2196/jmir.2441 %U http://www.ncbi.nlm.nih.gov/pubmed/23759286 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 5 %P e103 %T Social Media and the Empowering of Opponents of Medical Technologies: The Case of Anti-Vaccinationism %A Wilson,Kumanan %A Keelan,Jennifer %+ Ottawa Hospital Research Institute, University of Ottawa, Department of Medicine, The Ottawa Hospital, Civic Campus, Box 684, Administrative Services Building, Room 1009, 1053 Carling Avenue,, Ottawa, ON, K1Y4E9, Canada, 1 613 798 5555 ext 17921, kwilson@ohri.ca %K social media %K immunization %D 2013 %7 28.05.2013 %9 Viewpoint %J J Med Internet Res %G English %X Social media has contributed positively to the interaction between proponents of medical products and technologies and the public by permitting more direct interaction between these two groups. However, it has also provided opponents of these products a new mechanism to organize opposition. Using the example of anti-vaccinationism, we provide recommendations for how proponents of medical products and technologies should address this new challenge. %M 23715762 %R 10.2196/jmir.2409 %U http://www.jmir.org/2013/5/e103/ %U https://doi.org/10.2196/jmir.2409 %U http://www.ncbi.nlm.nih.gov/pubmed/23715762 %0 Journal Article %@ 1438-8871 %I Gunther Eysenbach %V 15 %N 1 %P e9 %T Cardiopulmonary Resuscitation Training in High School Using Avatars in Virtual Worlds: An International Feasibility Study %A Creutzfeldt,Johan %A Hedman,Leif %A Heinrichs,LeRoy %A Youngblood,Patricia %A Felländer-Tsai,Li %+ Department of Clinical Science, Intervention and Technology, Karolinska Institutet, K32, Stockholm, 14186, Sweden, 46 858580000 ext 86334, johan.creutzfeldt@ki.se %K Serious games %K virtual learning environments %K MMVW %K avatars %K students %K cardiopulmonary resuscitation %K patient simulation %K self-efficacy %K concentration %D 2013 %7 14.01.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Approximately 300,000 people suffer sudden cardiac arrest (SCA) annually in the United States. Less than 30% of out-of-hospital victims receive cardiopulmonary resuscitation (CPR) despite the American Heart Association training over 12 million laypersons annually to conduct CPR. New engaging learning methods are needed for CPR education, especially in schools. Massively multiplayer virtual worlds (MMVW) offer platforms for serious games that are promising learning methods that take advantage of the computer capabilities of today’s youth (ie, the digital native generation). Objective: Our main aim was to assess the feasibility of cardiopulmonary resuscitation training in high school students by using avatars in MMVM. We also analyzed experiences, self-efficacy, and concentration in response to training. Methods: In this prospective international collaborative study, an e-learning method was used with high school students in Sweden and the United States. A software game platform was modified for use as a serious game to train in emergency medical situations. Using MMVW technology, participants in teams of 3 were engaged in virtual-world scenarios to learn how to treat victims suffering cardiac arrest. Short debriefings were carried out after each scenario. A total of 36 high school students (Sweden, n=12; United States, n=24) participated. Their self-efficacy and concentration (task motivation) were assessed. An exit questionnaire was used to solicit experiences and attitudes toward this type of training. Among the Swedish students, a follow-up was carried out after 6 months. Depending on the distributions, t tests or Mann-Whitney tests were used. Correlation between variables was assessed by using Spearman rank correlation. Regression analyses were used for time-dependent variables. Results: The participants enjoyed the training and reported a self-perceived benefit as a consequence of training. The mean rating for self-efficacy increased from 5.8/7 (SD 0.72) to 6.5/7 (SD 0.57, P<.001). In the Swedish follow-up, it subsequently increased from 5.7/7 (SD 0.56) to 6.3/7 (SD 0.38, P=.006). In the Swedish group, the mean concentration value increased from 52.4/100 (SD 9.8) to 62.7/100 (SD 8.9, P=.05); in the US group, the concentration value increased from 70.8/100 (SD 7.9) to 82.5/100 (SD 4.7, P<.001). We found a significant positive correlation (P<.001) between self-efficacy and concentration scores. Overall, the participants were moderately or highly immersed and the software was easy to use. Conclusions: By using online MMVWs, team training in CPR is feasible and reliable for this international group of high school students (Sweden and United States). A high level of appreciation was reported among these adolescents and their self-efficacy increased significantly. The described training is a novel and interesting way to learn CPR teamwork, and in the future could be combined with psychomotor skills training. %M 23318253 %R 10.2196/jmir.1715 %U http://www.jmir.org/2013/1/e9/ %U https://doi.org/10.2196/jmir.1715 %U http://www.ncbi.nlm.nih.gov/pubmed/23318253 %0 Journal Article %@ 1438-8871 %I Gunther Eysenbach %V 14 %N 5 %P e120 %T Innovation in Weight Loss Programs: A 3-Dimensional Virtual-World Approach %A Johnston,Jeanne D %A Massey,Anne P %A DeVaneaux,Celeste A %+ Department of Kinesiology, Indiana University, 1025 East 7th Street, HPER 112, Bloomington, IN, 47405, United States, 1 812 855 5073, jdjohnst@indiana.edu %K Virtual world %K obesity %K weight loss programs %K Internet technology %K behavior change %D 2012 %7 20.09.2012 %9 Original Paper %J J Med Internet Res %G English %X Background: The rising trend in obesity calls for innovative weight loss programs. While behavioral-based face-to-face programs have proven to be the most effective, they are expensive and often inaccessible. Internet or Web-based weight loss programs have expanded reach but may lack qualities critical to weight loss and maintenance such as human interaction, social support, and engagement. In contrast to Web technologies, virtual reality technologies offer unique affordances as a behavioral intervention by directly supporting engagement and active learning. Objective: To explore the effectiveness of a virtual-world weight loss program relative to weight loss and behavior change. Methods: We collected data from overweight people (N = 54) participating in a face-to-face or a virtual-world weight loss program. Weight, body mass index (BMI), percentage weight change, and health behaviors (ie, weight loss self-efficacy, physical activity self-efficacy, self-reported physical activity, and fruit and vegetable consumption) were assessed before and after the 12-week program. Repeated measures analysis was used to detect differences between groups and across time. Results: A total of 54 participants with a BMI of 32 (SD 6.05) kg/m2 enrolled in the study, with a 13% dropout rate for each group (virtual world group: 5/38; face-to-face group: 3/24). Both groups lost a significant amount of weight (virtual world: 3.9 kg, P < .001; face-to-face: 2.8 kg, P = .002); however, no significant differences between groups were detected (P = .29). Compared with baseline, the virtual-world group lost an average of 4.2%, with 33% (11/33) of the participants losing a clinically significant (≥5%) amount of baseline weight. The face-to-face group lost an average of 3.0% of their baseline weight, with 29% (6/21) losing a clinically significant amount. We detected a significant group × time interaction for moderate (P = .006) and vigorous physical activity (P = .008), physical activity self-efficacy (P = .04), fruit and vegetable consumption (P = .007), and weight loss self-efficacy (P < .001). Post hoc paired t tests indicated significant improvements across all of the variables for the virtual-world group. Conclusions: Overall, these results offer positive early evidence that a virtual-world-based weight loss program can be as effective as a face-to-face one relative to biometric changes. In addition, our results suggest that a virtual world may be a more effective platform to influence meaningful behavioral changes and improve self-efficacy. %M 22995535 %R 10.2196/jmir.2254 %U http://www.jmir.org/2012/5/e120/ %U https://doi.org/10.2196/jmir.2254 %U http://www.ncbi.nlm.nih.gov/pubmed/22995535 %0 Journal Article %@ 1438-8871 %I Gunther Eysenbach %V 13 %N 4 %P e91 %T Using Virtual Reality to Provide Health Care Information to People With Intellectual Disabilities: Acceptability, Usability, and Potential Utility %A Hall,Valerie %A Conboy-Hill,Suzanne %A Taylor,Dave %+ Centre for Health Research, University of Brighton, 265 Mayfield House, Falmer, Brighton, BN1 9PH, United Kingdom, 44 1273 644015, v.hall@brighton.ac.uk %K Learning disabilities %K intellectual disabilities %K virtual reality %K health information %K participatory research %K capacity to consent %K presence %D 2011 %7 14.11.2011 %9 Original Paper %J J Med Internet Res %G English %X Background: People with intellectual disabilities have poor access to health care, which may be further compromised by a lack of accessible health information. To be effective, health information must be easily understood and remembered. People with intellectual disabilities learn better from multimodal information sources, and virtual reality offers a 3-dimensional (3D) computer-generated environment that can be used for providing information and learning. To date, research into virtual reality experiences for people with intellectual disabilities has been limited to skill-based training and leisure opportunities within the young to mid age ranges. Objective: This study assessed the acceptability, usability, and potential utility of a virtual reality experience as a means of providing health care-related information to people with intellectual disabilities. We designed a prototype multimodal experience based on a hospital scenario and situated on an island in the Second Life 3D virtual world. We wanted to know how people of different ages and with varying levels of cognitive function would participate in the customized virtual environment, what they understood from being there, and what they remembered a week later. Methods: The study drew on qualitative data. We used a participatory research approach that involved working alongside people with intellectual disabilities and their supporters in a community setting. Cognitive function was assessed, using the Matrix Analogies Test and the British Picture Vocabulary Scale, to describe the sample. Participants, supported by facilitators, were video recorded accessing and engaging with the virtual environment. We assessed recall 1 week later, using a specialized interview technique. Data were downloaded into NVivo 8 and analyzed using the framework analysis technique. Results: Study participants were 20 people aged between 20 and 80 years with mild to severe intellectual disabilities. All participants were able to access the environment and voluntarily stayed there for between 23 and 57 minutes. With facilitator support, all participants moved the avatar themselves. Participants engaged with the scenario as if they were actually there, indicating cognitive presence. Some referred back to previous medical experiences, indicating the potential for experiential knowledge to become the foundation of new learning and retention of knowledge. When interviewed, all participants remembered some aspects of the environment. Conclusions: A sample of adults with intellectual disabilities of all ages, and with varying levels of cognitive function, accessed and enjoyed a virtual-world environment that drew on a health care-related scenario, and remembered aspects of it a week later. The small sample size limits generalizability of findings, but the potential shown for experiential learning to aid retention of knowledge on which consent is based appears promising. Successfully delivering health care-related information in a non-National Health Service setting indicates potential for delivery in institutional, community, or home settings, thereby widening access to the information. %M 22082765 %R 10.2196/jmir.1917 %U http://www.jmir.org/2011/4/e91/ %U https://doi.org/10.2196/jmir.1917 %U http://www.ncbi.nlm.nih.gov/pubmed/22082765 %0 Journal Article %@ 1438-8871 %I Gunther Eysenbach %V 13 %N 3 %P e77 %T A Pilot Study of Motivational Interviewing Training in a Virtual World %A Mitchell,Suzanne %A Heyden,Robin %A Heyden,Neil %A Schroy,Paul %A Andrew,Stephen %A Sadikova,Ekaterina %A Wiecha,John %+ Boston University School of Medicine, Department of Family Medicine, Dowling 5 South, 771 Albany Street, Boston, MA, 02118, United States, 1 617 414 4465, suzanne.mitchell@bmc.org %K Medical education %K continuing medical education %K computer-assisted instruction %K computer-aided instruction %K distance education %K computer simulation %K patient simulation %K motivational interviewing %K virtual world %D 2011 %7 26.09.2011 %9 Original Paper %J J Med Internet Res %G English %X Background: Motivational interviewing (MI) is an evidence-based, patient-centered counseling strategy proven to support patients seeking health behavior change. Yet the time and travel commitment for MI training is often a barrier to the adoption of MI by health care professionals. Virtual worlds such as Second Life (SL) are rapidly becoming part of the educational technology landscape and offer not only the potential to improve access to MI training but also to deepen the MI training experience through the use of immersive online environments. Despite SL’s potential for medical education applications, little work is published studying its use for this purpose and still less is known of educational outcomes for physician training in MI using a virtual-world platform. Objective: Our aims were to (1) explore the feasibility, acceptability, and effectiveness of a virtual-world platform for delivering MI training designed for physicians and (2) pilot test instructional designs using SL for MI training. Methods: We designed and pilot tested an MI training program in the SL virtual world. We trained and enrolled 13 primary care physicians in a two-session, interactive program in SL on the use of MI for counseling patients about colorectal cancer screening. We measured self-reported changes in confidence and clinical practice patterns for counseling on colorectal cancer screening, and acceptability of the virtual-world learning environment and the MI instructional design. Effectiveness of the MI training was assessed by coding and scoring tape-recorded interviews with a blinded mock patient conducted pre- and post-training. Results: A total of 13 physicians completed the training. Acceptability ratings for the MI training ranged from 4.1 to 4.7 on a 5-point scale. The SL learning environment was also highly rated, with 77% (n = 10) of the doctors reporting SL to be an effective educational medium. Learners’ confidence and clinical practice patterns for colorectal cancer screening improved after training. Pre- to post-training mean confidence scores for the ability to elicit and address barriers to colorectal cancer screening (4.5 to 6.2, P = .004) and knowledge of decision-making psychology (4.5 to 5.7, P = .02) and behavior change psychology (4.9 to 6.2, P = .02) increased significantly. Global MI skills scores increased significantly and component scores for the MI skills also increased, with statistically significant improvements in 4 of the 5 component skills: empathy (3.12 to 3.85, P = .001), autonomy (3.07 to 3.85, P < .001), collaboration (2.88 to 3.46, P = .02), and evocative response (2.80 to 3.61, P = .008). Conclusions: The results of this pilot study suggest that virtual worlds offer the potential for a new medical education pedagogy that will enhance learning outcomes for patient-centered communication skills training. %M 21946183 %R 10.2196/jmir.1825 %U http://www.jmir.org/2011/3/e77/ %U https://doi.org/10.2196/jmir.1825 %U http://www.ncbi.nlm.nih.gov/pubmed/21946183