Innovations In Clinical Neuroscience

JAN-FEB 2017

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

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Innovations in CLINICAL NEUROSCIENCE [ 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 ] 18 thinking about pain (31%), and worst p ain experienced (27%) in VR conditions, but did not observe statistically significant improvements in range of motion (ROM) physical therapy, which consists of assisted exercises d esigned to help patients gain movement in affected body segments (e.g. hand, wrist, elbow, shoulder, knee, or ankle). A study by Patterson et al 21 assessed the analgesic efficacy of virtual reality hypnosis (VRH), a new procedure in which the hypnotist verbally expresses suggestions that focus the patient's attention away from pain. Based on scores obtained both immediately after the interventions and eight hours later, VRH patients reported less unpleasantness and less pain intensity than both control groups (VR without hypnosis, or standard analgesic treatment alone). Two studies of burn patients utilizing low-cost, easily accessible and affordable VR HMD systems (Z800 3DVisor, eMagin, New York, New York) and off-the-shelf software computer games did not report significant differences in self-reported pain measures or anxiety (see Table 2 for detailed descriptions of scales used). Morris et al 19 compared adult burn patient exposure to VR (video games plus analgesics) to a control condition (analgesics alone) and found a marginally significant difference in pain reduction between conditions (p=0.06), but no significant decreases in self- reported anxiety. In the Kipping et al study, 18 patients did not report decreases in pain during burn wound redressing, but nursing staff observed significant reductions. One study utilized wall projections and motion detection instead of HMDs to examine the effectiveness of therapeutic play for reducing depressive symptoms in pediatric oncology patients. 25 After a week of treatment, children in the experimental group reported significantly fewer depressive symptoms than those in the control group, but they did not report significant differences in state anxiety. Eating disorders (EDs) and obesity. Two recent studies investigating the efficacy of VR treatment in populations w ith EDs are presented in Table 1. Cesa et al 26 assessed the brief and long-term efficacy of VR plus cognitive-behavioral therapy in a group of 90 female patients with obesity at an inpatient rehabilitation c linic. In the VR treatment arm, participants wore HMDs and navigated through 14 different virtual environments. Patients were exposed to tempting situations (e.g., buying unhealthy food at the supermarket) to improve self-control and motivation, as well as situations that challenged negative body image (e.g., swimming pool). Although improvements in body satisfaction were reported in all study conditions, only patients in the VR condition reported improved body image perceptions at five-week follow-up. After one year, VR patients were significantly better (44.4%) at improving or maintaining weight loss than patients in control conditions (10.4%). Manzoni et al 2 7 demonstrated that both VR and imagination-based relaxation training conditions helped reduce emotional eating, anxiety, depressive symptoms, and self-efficacy (see Table 2 for scales used). However, at a three-month follow-up, the VR condition—wherein patients wandered in an idyllic mountain landscape— demonstrated greater efficacy in reducing emotional eating than control conditions. Cognitive and motor rehabilitation. In a study by Larson et al, 23 patients of all ages with traumatic brain injuries (TBI) completed 12 four-minute-long cancellation exercises using a system called Virtual Reality and Robotic Optical Operations Machine (VRROOM [developed by Patton et al 38 ]; See Table 2) over a period of two days. 23 The authors observed improvements in memory and attention across trials as measured by target acquisition times. Distractions involving both visual and haptic stimuli were especially effective. Also, in a study by Yin et al, 22 stroke patients utilized the Sixense VR system (Sixense, Los Gatos, California), a rehabilitation gaming software consisting of an avatar on a screen that is synchronized with the patient's movements. 22 In a virtual environment, users are instructed to pick fruit from a shelf and release it into a basket as many t imes as possible within a two-minute time frame. The authors observed improved sensorimotor function for both VR and non-VR (conventional physical therapy) conditions, as measured by the F ugl-Meyer Assessment (FMA; see Table 2), though no significant differences were found between conditions. Patient satisfaction and side effects. Patient satisfaction and side effects are displayed in the "Secondary Observations" column in Table 1. Participants often rated VR sessions as more fun, more immersive, more useful, and more enjoyable than non-VR conditions. 15,20,22 Despite previous findings that HMDs or peripheral devices often restrict movement, no such results were found in the present review. 2 8 A majority of studies did not report VR side effects, such as motion sickness or fatigue, as factors negatively influencing patient satisfaction or the efficacy of VR treatments. When asked, patients in the study by Kipping et al 17 did not report experiencing nausea, and 97 percent of patients in the sutdy by Carrougher et al 18 reported no to mild nausea after using HMDs. Yin et al 2 2 found no significant side effects, and deemed VR technology feasible and safe for participants. However, in the Larson et al 23 study of 18 patients with TBI, three participants dropped out due to fatigue and eye pain caused by the VRROOM system (Table 2). DISCUSSION In contrast to previous reviews of case reports and observational evidence, the present review focused on controlled studies that describe applications of VR technology in the treatment and rehabilitation of medical inpatients. 29,30 Data from 11 eligible studies provide insight into three current medical applications of VR technology: pain distraction, eating disorders, and cognitive/motor rehabilitation. Pain distraction. VR is particularly useful as a pain distraction that supplements or replaces traditional pharmacotherapies. According to Wiederhold, 7 pain perception is dependent on a patient's capacity to attend to a certain stimulus. Thus, pain

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