Innovations In Clinical Neuroscience

JAN-FEB 2017

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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[ V O L U M E 1 4 , N U M B E R 1 – 2 , J A N U A R Y – F E B R U A R Y 2 0 1 7 ] Innovations in CLINICAL NEUROSCIENCE 17 Kappa statistic. 16 Because of the apparent heterogeneity of studies and inconsistency of reported results, we opted not to conduct a meta-analysis. RESULTS Overview. We identified 11 controlled studies of medical inpatients for the current review, but only eight studies randomized patients to VR conditions, or randomized the order of delivery of VR or standard interventions using crossover designs. We observed that studies were heterogeneous with regard to targeted disease state, VR equipment and intervention materials, and outcomes assessed. Thus, we categorized results within each application of VR to medical inpatients. Study quality. Studies varied in terms of quality (average quality score=0.87; standard deviation [SD]=0.06; range=0.78–0.96). 13 The raters were in strong agreement on most study quality domains assessed (Cohen's κ=0.84). No studies defined the magnitude of the outcome to be evaluated (e.g., a 20% drop in pain GRS scores) or explicitly discussed cost-effectiveness, although four studies did consider VR device cost. 15,17–19 Five of the 11 studies used small samples (i.e., n<30), as expected in a novel technology efficacy trial. 19–23 Notably, the lowest rated study (Patterson et al 21 ) and the highest rated study (Schmitt et al 15 ) were authored by members of the same study team. 15,21 Lower quality studies utilized smaller samples, did not randomize participants, and did not consider all factors associated with treatment (e.g., cost, adherence, side effects). Higher quality studies conformed to the expected structure of an RCT, justified and utilized larger samples, and considered patient side effects. We observed no temporal patterns in study quality, and found no associations between targeted disease state and quality score. Pain distraction. As shown in Table 1, VR is used for pain management in inpatient populations more commonly than for other applications. Most researchers utilized the SnowWorld VR system (University of Washington HITLab and Harborview Burn Center, Seattle Washington)—the first VR software created for pain control during burn wound redressing—consisting of an HMD through which patients view and interact with snow-themed characters and throw virtual snowballs at approaching snowmen via a computer mouse or keyboard. 20,24 In a first-of-its- kind study of burn victims using SnowWorld, Hoffman et al 20 observed a 41-percent reduction in pain in the VR condition versus a control group, as well a strong negative correlation between self-reported "immersion" in the VR environment and pain ratings. Schmitt et al 15 observed significant reductions in cognitive pain (time spent thinking about pain, reduced 44%), affective pain (emotional unpleasantness, reduced 32%), and sensory pain (reduced 27%), as well as highly positive feelings toward the VR intervention (which many labelled as "fun"). Carrougher et al 17 also observed reductions in pain unpleasantness (31%), time spent T ABLE 1 cont. Studies using virtual reality (VR) as a tool for improving medical conditions A PPLICATION F IRST AUTHOR (YEAR) E QUIPMENT P ARTICIPANTS S TUDY DESIGN OUTCOME/ E FFECTIVENESS ( PRIMARY RESULT) S ECONDARY OBSERVATIONS AVERAGE Q UALITY S CORE Eating disorders/ o besity Cesa et al 26 ( 2013) N euroVR 2 software; HMD showing virtual e nvironments +2 b ody image comparisons. n=90 women with binge eating d isorder (BED) at r ehab center Random assignment: (n=31 CBT+VR, n=30 C BT, n=29 usual care i npatient regimen [IP]); 15 weekly g roup sessions over 5 weeks Body image concerns (BIAQ) improvement and w eight loss aid in CBT+VR o nly; overall improvements in body s atisfaction (BSS and C DRS) in all 3 conditions 34.6% of patients d ropped out after 1- y ear follow-up; increased weight gain i n all 3 after 1 year 0 .85 E ating disorders/ o besity M anzoni et al 2 7 ( 2009) H MD: VE called G reen Valley showed mountain landscape with relaxing lake s cenes; participants a sked to walk around, observe nature, then sit down o n a bench and r elax. Imaginative condition: psychologists asked p articipants to imagine similar e nvironments. n=60; adult female i npatients at a w eight reduction facility in Italy 12 relaxation training sessions (4 per week) over 3 weeks either w ith VR, traditional i magination treatments, or standard hospital care ( control) At 3-month follow-up: VR condition—reduced e motional eating; both r elaxation training conditions (VR and Imaginative) helped reduce e motional eating (WELSQ; E OQ), anxiety (STAI), depressive symptoms (BDI); improvements in s elf-efficacy (WELSQ) Not applicable 0.87 C ognitive and motor rehabilitation L arson et al 2 3 (2011) VRROOM: a 3-D s ystem through w hich patients view virtual objects super-imposed onto real world n =18; patients with traumatic brain i njury (TBI) aged 1 9–73 years receiving acute inpatient rehabilitation; not randomized W ithin-subjects d esign; 2-day treatment (with 12 four-minute trials) Improvements in memory i mpairments and attention; t reatment with haptic cues helped improve performance vs. when cues were not present 3 participants dropped out due to fatigue and eye pain 0.85

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