The Soothing Sea: A Virtual Coastal Walk Can Reduce Experienced and Recollected Pain

The impact of an immersive digital therapeutic tool on experimental pain: a pilot randomized within-subject experiment with an active control condition

Background

Pain is a complex and multifaced sensory and emotional experience. Virtual reality (VR) has shown promise in reducing experimental pain and chronic pain. This study examines an immersive VR environment initially designed for endometriosis patients, which demonstrated short-term analgesic effects. The research aims to determine the impact of the VR environment on experimental pain intensity and unpleasantness both during and after VR exposure (3D with binaural beats), while using an active control condition (2D with no binaural beats). Additionally, a secondary objective of the study was to identify the psychological and psychophysical factors that predict the analgesic effects of the immersive digital therapeutic tool.

Methods

The study involved twenty-one healthy individuals and used a within-subject design, comparing a VR treatment with an active control condition. Continuous heat stimulation was applied to the left forearm with a Peltier thermode. Pain ratings were collected for immediate and short-term effects.

Results

In both the VR and Control conditions, there were no significant differences in pain intensity before, during, and after exposure. However, during VR exposure, there was a significant decrease in pain unpleasantness as compared to before exposure (p < 0.001), with a 27.2% pain reduction. In the Control condition, there were no significant differences in pain unpleasantness during and after exposure. Furthermore, no psychological and psychophysical factors predicted the analgesic effects.

Discussion

The study investigated how a VR environment affected experimentally induced pain in healthy volunteers. It showed that VR reduced pain unpleasantness during exposure but had no lasting impact. The VR environment mainly influenced the emotional aspect of pain, possibly due to its inclusion of binaural beats and natural stimuli. The study suggests that the VR environment should be tested in chronic pain population with high distress levels.

Registration number clinicaltrialsgov

NCT06130267.

Improving immersive experiences in virtual natural setting for public health and environmental design: A systematic review and meta-analysis of randomized controlled trials

In recent years, virtual reality (VR) technology has emerged as a powerful tool in the field of therapeutic landscapes. For hospitalized patients or individuals with limited mobility, VR provides highly personalized therapy by simulating authentic natural environments within a safe, convenient, and engaging setting. This study investigated the effectiveness of immersing patients in virtual natural environments for health recovery and compared the varying impacts of different types of landscapes on patients' recovery levels. The aim was to complement traditional medical approaches and enhance environmental design in the field of public health. Researchers systematically reviewed databases (January 2018 to August 2, 2023) to identify randomized controlled trials comparing the efficacy of virtual nature immersion with other treatments. The inclusion/exclusion criteria were established based on the population, intervention, comparison, outcomes, study design, and other aspects (expanded PICO) framework. The Cochrane tool was employed to assess the risk of bias. Meta-analysis was conducted by pooling the mean differences with a 95% confidence interval. Among 30 trials, a total of 2123 patients met the inclusion criteria, with 15 studies included in the meta-analysis. 30 trials met the criteria. Results show significant improvements in pain, anxiety, fear, and some physiological indicators with virtual nature-based treatments. On the other hand, natural scenes incorporating blue and green elements have been applied more extensively and have shown more significant effects. In comparison to conventional methods, this study strongly advocates that virtual reality environments are a crucial tool in bridging the gap between patients and nature, demonstrating their potential to reshape medical interventions and improve environmental design in the field of public health.

Greater usage and positive mood change for users of a dynamic VR app before and after the COVID-19 pandemic onset

Americans reported an increase in stress during the novel coronavirus disease 2019 (COVID-19). Virtual reality (VR) apps have been shown to distract users from stressors in the environment, but little is known about the efficacy of specific content features to reduce stress or improve mood for consumer users during a pandemic. The present study investigated secondary archival data to explore how mood and usage behavior changed before and after the onset of COVID-19 for consumer users of a VR app with dynamic, interactive content. Study findings indicate that the COVID-19 pandemic had significant effects on user behavior and mood. Users created more accounts and used app content more often during the pandemic, while reporting increased negative mood states. This suggests that users were motivated to use the content to cope with pandemic stressors. Users also experienced a greater positive mood change after using the content during the pandemic than before, which implies that elements related to the VR app content met users' psychological needs. Passive content with less interactivity resulted in a greater positive mood state after the COVID-19 onset, likely related to its capacity to reduce stress, facilitate restoration, and improve persistent affective states in stressful environments. This study offers a vital window into how consumer users respond to psychosocial pandemic stressors outside of a controlled environment as well as the prospective for VR app content to serve as a valuable mental health intervention during similar stressful events.

The effect of virtual reality on reducing patients' anxiety and pain during dental implant surgery

BACKGROUND

Dental anxiety and pain pose serious problems for both patients and dentists. One of the most stressful and frightening dental procedures for patients is dental implant surgery; that even hearing its name causes them stress. Virtual reality (VR) distraction is an effective intervention used by healthcare professionals to help patients cope with unpleasant procedures. Our aim is to evaluate the use of high-quality VR and natural environments on dental implant patients to determine the effect on reducing pain and anxiety.

METHODS

Seventy-three patients having two dental implant surgeries participated in a randomized controlled trial. One surgery was with VR, and one was without. Anxiety was measured with the the State-Trait Anxiety Inventory and the Modified Dental Anxiety Scale tests. The pain was measured with the Numerical Rating Scales. Patient satisfaction, surgeon distress, memory vividness, and time perception were evaluated. Physiological data were collected with biofeedback and neurofeedback device.

RESULTS

VR effectively reduced anxiety and pain compared to no VR. Physiological data validated the questionnaire results. Patient satisfaction increased, with 90.4% willing to reuse VR. VR reduced time perception and memory vividness.

CONCLUSION

Psychometric and psychophysiological assessments showed that VR successfully reduced patient pain and anxiety. More dental clinicians should use VR technology to manage patient anxiety and pain.

The impact of virtual reality natural and built environments on affective responses: a systematic review and meta-analysis

This study aims to evaluate the extent to which virtual reality (VR) natural and built settings affect emotional states. Web of Science, SCOPUS, and PubMed were searched for relevant articles prior to February 2022. Of 15 articles identified for systematic review, 6 met the inclusion criteria for meta-analysis (studies with only pre- and post-condition measures of the Positive and Negative Affect Schedule (PANAS) were included). Both positive affect (g = 0.20, p = 0.001) and negative affect (g = - 0.30, p = 0.001) change scores for the VR natural environment were statistically significant. On the other hand, change scores for VR built environment were not significant in both positive affect (g = - 0.08, p = 0.355) and negative affect (g = - 0.08, p = 0.058). The findings revealed that, in addition to a VR natural environment, a VR built environment is capable of providing restorative experiences against negative mood in some circumstances.

Acceptability, feasibility, and user satisfaction of a virtual reality relaxation intervention in a psychiatric outpatient setting during the COVID-19 pandemic

Background

The COVID-19 pandemic was particularly difficult for individuals with mental disorders. Due to governmental restrictions, face-to-face offers for psychiatric outpatients like therapies, psychoeducational groups or relaxation courses were limited. Virtual reality (VR) might be a new possibility to support these patients by providing them with a home-based relaxation tool.

Objective

The aim of this study was to evaluate the acceptability, feasibility, and user satisfaction of a supportive therapy-accompanying, relaxation VR intervention in psychiatric outpatients during the COVID-19 pandemic in Germany.

Methods

The four-weeks VR intervention consisted of regular watching of relaxing videos in the participants' home environment. Sociodemographics, feasibility (frequency of use, user-friendliness), satisfaction (Client Satisfaction Questionnaire-8), depressive symptoms (Patient Health Questionnaire-9), quality of life (abbreviated World Health Organization Quality of Life assessment), and credibility and expectancy (Credibility Expectancy Questionnaire-8) were measured in an intention-to-treat (ITT) analysis and a per-protocol (PP) analysis of completers.

Results

In total, N = 40 patients participated in the study. Most of the participants in the ITT analysis (n = 30, 75.0%) used the VR device three or 4 weeks. A majority of the N = 29 completers (PP: n = 18, 62.1%) used it all 4 weeks. Most participants used the device two or more times a week (ITT: n = 30, 83.3%; PP: n = 26, 89.7%) and described the user-friendliness as rather or very easy (ITT: n = 33, 91.7%; PP: n = 26, 89.7%). User satisfaction was high (ITT: 19.42, SD = 4.08; PP: M = 20.00, SD = 4.19) and did not correlate with participants' sex or age (all p < 0.05). Depressive symptoms and psychological quality of life improved significantly from pre-to post-intervention (ITT and PP, all p < 0.05). Higher pre-intervention credibility significantly correlated with a better outcome of satisfaction (ITT and PP), depressive symptoms, physical, psychological, and social quality of life (PP; all p < 0.05).

Conclusion

A supportive therapy-accompanying VR relaxation intervention is feasible and acceptable in a psychiatric outpatient setting. Due to the high satisfaction and user-friendliness, VR can be an easy to implement relaxation tool to support psychiatric outpatients.

Clinical trial registration

https://clinicaltrials.gov/, DRKS00027911.

Physiotherapy and ecosystem services: improving the health of our patients, the population, and the environment

INTRODUCTION

The relevance of ecosystems to physiotherapy has traditionally been overlooked, despite its potential for health impacts relevant to conditions often managed by physiotherapists.

PURPOSE

The purpose of this article is to introduce the concept of ecosystem services to physiotherapists, and to discuss how understanding ecosystem services may improve patient care, and population and planetary health.

DISCUSSION AND CONCLUSION

Physiotherapists with an understanding of ecosystem services may improve patient care by value-adding to management through patient education, empathy, advocacy, and broader population health approaches. Physiotherapists are also well placed to promote the conservation and restoration of ecosystem through participation, advocacy, and the development of public health measures, to the benefit of global sustainability and population health. Further research is required into how physiotherapists currently use nature-based interventions, and the barriers and enablers to their use. To be adequately prepared to meet the challenges that climate change and environmental degradation pose to patient care, population health and health systems, both current and future physiotherapists need to take a broader view of their practice. By including consideration of the potential role of the environment and green space exposure in particular on their patient's health, physiotherapists can ultimately contribute more to population and planetary health.

Effects of exposure to immersive computer-generated virtual nature and control environments on affect and cognition

Previous research has shown that exposure to immersive virtual nature environments is able to induce positive affective and physiological effects. However, research on the effects on cognitive performance is scarce. Additionally, the effects of virtual nature exposure compared to a virtual control environment with a comparable amount of virtual objects have not been examined so far. Therefore, we conducted an experiment with 27 participants to study the psychological effects of such exposure. The virtual nature consisted of a 3D model of a typical forest environment, whereas the control environment was an abstract replication of the virtual forest environment. In both environments, a virtual wooden cart was used to transport the users from the start to the end of the virtual road. The typical background noise of moving such a cart was integrated into both environments as well. In addition, the virtual nature environment included typical forest sounds in the background, whereas the control condition did not have such background sounds. Both environments were compared with regard to their effects on cognitive performance (using trail making tests (TMTA, TMTB, and TMTB-A) as well as digit span forward and digit span backward tests), perceived restorativeness, mood, stress, sense of presence, and simulator sickness. The results showed that in comparison to the control environment, exposure to the virtual nature resulted in significantly higher cognitive performance, higher perceived restorativeness, higher positive affect, higher sense of presence, lower perceived stress, and lower simulator sickness.

Key Stakeholders' Experiences and Perceptions of Virtual Reality for Older Adults Living With Dementia: Systematic Review and Thematic Synthesis

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.

Perioperative Outcomes of Immersive Virtual Reality as Adjunct Anesthesia in Primary Total Hip and Knee Arthroplasty

Background

Immersive virtual reality (IVR) is utilized as an adjunct to anesthesia to distract patients from their intraoperative environment, thereby potentially reducing sedative and narcotic medication usage. This study evaluated intraoperative and acute postoperative results of patients undergoing primary total hip (THA) and total knee arthroplasty (TKA) with and without IVR.

Methods

Utilizing IVR as an adjunct to spinal anesthesia, 18 primary THAs (n = 8) and TKAs (n = 10) were performed. These cases were 1:2 matched based on procedure type, age, sex, and body mass index to those performed without IVR. Intraoperative and postanesthesia care unit sedative/narcotic usage, vital signs, and pain scores were compared. Acute perioperative outcomes, including 24-hour oral morphine equivalent (OME), first ambulation distance, length of stay, and 30-day complications, were also analyzed. Pearson Chi-square and Wilcoxon-Mann-Whitney tests evaluated categorical and continuous variables, respectively.

Results

When compared to non-IVR primary THAs and TKAs, those performed with IVR utilized significantly less intraoperative sedation (48 mg vs 708 mg of propofol; P < .001) and trended toward less narcotic usage (13 mcg vs 39 mcg of fentanyl; P = .07). In the postanesthesia care unit, IVR and non-IVR patients showed no significant differences (P > .3) in vital signs, pain scores, or OME received. Additionally, similar (P > .3) postoperative outcomes were noted in both cohorts’ 24-hour OME use, distance at first ambulation, length of stay, and 30-day complications.

Conclusions

The use of spinal anesthesia with the IVR adjunct to perform primary THAs and TKAs appears to be well-tolerated and associated with less intraoperative sedative medication usage than spinal anesthesia alone.

An Analysis of Theoretical Perspectives in Research on Nature-Based Interventions and Pain

Chronic pain results from a complex series of biomechanical, inflammatory, neurological, psychological, social, and environmental mechanisms. Pain and pain-related diseases are the leading causes of disability and disease burden globally. Employing nature-based interventions for the treatment of pain is an emerging field. Current theory driving the suggested mechanism(s) linking the pain reducing effects of nature-based interventions is lacking. A two-step approach was taken to complete a theoretical review and analysis. First, a literature review was completed to gather a substantive amount of research related to theoretical frameworks on the topic of nature-based interventions and pain. Secondly, a theoretical analysis as proposed by Walker and Avant was completed to explore current theoretical frameworks accepted in the literature on nature-based interventions and pain. Stress reduction theory and attention restoration theory were the most common theoretical frameworks identified. Neither theoretical framework explicitly identifies, describes, or intends to adequately measure the concept of pain, revealing a limitation for their application in research with nature-based interventions and pain. Theoretical development is needed, as it pertains to nature-based interventions and pain. Without this development, research on nature-based interventions and pain will continue to use proxy concepts for measurement and may result in misrepresented findings.

A Systematic Review of Virtual Reality Therapeutics for Acute Pain Management

OBJECTIVES

The purpose of this systematic review is to examine the delivery and clinical efficacy of virtual reality (VR) therapeutics for acute pain management in adults and identify practical considerations of VR deployment, as well as current gaps in the literature.

DESIGN

A systematic review.

DATA SOURCES

A search of PubMed, CINAHL, PsychINFO, Embase, Compendex, and Inspec was completed using Medical Subject Headings (MeSH) and keyword search terms related to acute pain and VR.

REVIEW/ANALYSIS METHODS

A systematic review of all pertinent articles published between January 1, 2000, and August 1, 2020, was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines.

RESULTS

Twenty-three articles met final inclusion criteria and were included in this review. Studies utilized VR in a variety of settings for wound care, procedure-induced pain, physical or occupational therapy, dental treatment or generalized acute pain. A likely mechanism by which VR promoted analgesia in these studies is distraction. Of the reviewed studies, 19 (83%) reported decreases in pain intensity while using VR compared with no VR use or with a non-VR group.

CONCLUSIONS

This systematic review found VR to be an effective tool for acute pain management. Findings from this review also underscore the importance of addressing the patient's sense of presence and levels of immersion, interaction, and interest when deploying VR. Future VR studies should consider incorporation of anxiety, presence, and VR side effect measures in addition to acute pain metrics.

Non-Pharmacological Interventions for Reducing Fear and Anxiety in Patients Undergoing Third Molar Extraction under Local Anesthesia: Systematic Review and Meta-Analysis

This report investigated the effectiveness of non-pharmacological interventions for reducing dental fear and anxiety in patients undergoing third molar extraction under local anesthesia. In November 2020, multiple electronic databases (Cochrane, EMBASE, MEDLINE, PsycInfo, PsycArticles, PubMed, and Web of Science) were searched for articles published in English. Inclusion criteria were randomized-controlled trials reporting the effectiveness of any non-pharmacological interventions in reducing fear or anxiety levels in patients with third molar extraction. A total of 3015 studies by electronic search and 2 studies by hand search were identified. After screening, 21 studies were eligible for systematic review. Seven studies were included in the meta-analysis. Study selection, data extraction, and quality assessment of the included studies were performed by two independent investigators. The anxiety levels after intervention in each study were pooled and meta-analyzed by the random-effect model. A significant reduction in anxiety level was observed in non-pharmacological intervention groups (SMD = -0.32; 95% CI -0.57 to -0.07; p = 0.01). Subgroup analyses showed that a significant anxiety reduction by non-pharmacological interventions could be demonstrated by pooled data from studies using psychometric assessments, but not from studies using physiological assessments. Non-pharmacological interventions appear to reduce fear and anxiety levels in patients undergoing third molar extraction under local anesthesia.

The State of Science in the Use of Virtual Reality in the Treatment of Acute and Chronic Pain: A Systematic Scoping Review

Previous reviews have reported virtual reality (VR) to be an effective method to treat pain. This scoping review examines the state of the science for VR and pain both generally and by pain type (acute and chronic) related to types of mechanisms, dosage, effectiveness, and adverse events (AEs). We searched online databases PubMed, Web of Science, PsychInfo, and CINAHL from 2010 to 2020 and included studies from peer reviewed journals that examined people with pain, (excluding pain-free participants) with a primary outcome measuring pain. We assessed studies for risk of bias using PEDro criteria. We described data through counts and percentages. Significant results were determined through P-values. We found 70 studies representing 4105 people; 46 acute pain studies (65.7%), 22 chronic pain studies (31.4%), and 2 (2.9%) "both." The most common VR mechanism was distraction (78.6%) then embodiment (17.1%). However, distraction was the mechanism for 97.8% acute pain studies while embodiment was more common for chronic pain (54.5%). Dosage of VR was inconsistently reported and varied considerably. VR treatment groups showed significant improvements in pain, particularly for intensity of pain (72.1%) and quality of pain (75.0%). Few studies examined AEs. Limitations of this review include only examining last 10 years of articles and that many studies were missing data. VR appears to be an effective intervention to address both acute and chronic pain. Research evaluating VR mechanisms, dosage, and AEs is warranted, as is further work in under-served populations (children for chronic pain and older adults) as the current evidence is largely limited to adult populations with pain.

Simulated Forest Immersion Therapy: Methods Development

Shinrin-yoku, forest bathing, may provide relief from chronic and breakthrough pain in patients with axial spondyloarthritis and improve immune function through increasing NK cell numbers and activity and their downstream effectors, perforin and granulysin, after chemo- or radiation therapy in breast and prostate cancer patients. The aim of this paper is to describe the study protocol for a simulated forest immersion therapy using virtual reality and atomized phytoncides, volatile organic compounds found in forested areas designed to effect positive change for these two patient populations. The setting, including the room set up and samples with inclusion/exclusion specific to this type of intervention, is outlined. Measures and calibration procedures pertinent to determining the feasibility of simulated forest immersion therapy are presented and include: ambient and surface room temperatures and relative humidity in real time, ambient ultrafine particulate matter, ambient droplet measurement that coincides with volatile organic compounds, specific phytoncides, and virtual reality and atomization of phytoncide set up. Particular lessons learned while training and setting up the equipment are presented. Simulated forest immersion therapy is possible with attention to detail during this early phase when development of methods, equipment testing, and feasibility in deploying the intervention become operational. The expected outcome of the development of the methods for this study is the creation of a standardized approach to simulating forest therapy in a controlled laboratory space.

Understanding the Role of Nature Engagement in Supporting Health and Wellbeing during COVID-19

The importance of natural environments in supporting health and wellbeing has been well evidenced in supporting positive mental and physical health outcomes, including during periods of crisis and stress. Given the disproportionate impacts of the COVID-19 pandemic have been greatest for those who are most vulnerable, understanding the role of natural environment and alternative forms of nature engagement in supporting health and wellbeing for vulnerable groups is important. This study explored how nature engagement supported health and wellbeing in those with a pre-existing health condition during the first UK lockdown. Semi-structured interviews were conducted with 17 adults with a pre-existing health condition and analysed using Interpretative Phenomenological Analysis (IPA). Four themes were identified: COVID-19 versus nature; Nature as an extension and replacement; Nature connectedness; and Therapeutic nature. The findings show the importance of nature in supporting health and wellbeing in those with a pre-existing health condition through engagement with private and public natural environments, micro-restorative opportunities, nature connection as an important pathway, and the therapeutic benefits of nature engagement. The present research extends the evidence-base beyond patterns of nature engagement to a deeper understanding of how those with existing health conditions perceived and interacted with nature in relation to their health and wellbeing during the first UK lockdown. Findings are discussed in relation to health supporting environments, micro-restorative opportunities, and policy implications.

Access to Nature via Virtual Reality: A Mini-Review

Nature exposure is known to promote physical and mental health. However, actual nature exposure may be difficult to achieve for the population of people with physical disabilities or chronic conditions. Therefore, many attempts have been made to duplicate nature exposure via media devices, and virtual reality (VR) is deemed as a promising technology due to its advantage in creating a sense of immersion. Generally, current studies suggest that being exposed to virtual nature may contribute to psychological and physiological relaxation. Besides, some pieces of evidence indicate that virtual nature may improve attentional resources, cognitive performance, and pain experience. Although VR is deemed as an advanced media, insufficient evidence was found concerning the advantages of VR over traditional two-dimensional media when it comes to simulated nature exposure. On the other hand, computer-generated (CG) scenarios were found to be more beneficial than 360° videos, and mini-games may be useful in creating an interactive VR format for simulated nature exposure. Further research is needed because of the limited relevant studies.

Viewing Nature Lets Your Mind Run Free: Three Experiments about the Influence of Viewing a Nature Video on Cognitive Coping with Psychological Distress

Viewing nature has restorative qualities that might help people cope with their personal struggles. Three lab experiments (N = 506) studied whether environment (nature vs. built) influences cognitive coping with psychological distress. Psychological distress was induced with an autobiographical recall task about serious regret, whereafter participants were randomly assigned to view a nature or built video. Cognitive coping (i) Quantity, (ii) Content, and (iii) Quality were hereafter assessed as well as extent and vividness of the regretful memory during the video. Results showed a higher cognitive coping Quantity (Study 1 and 3) and a higher cognitive coping Quality (All studies) for the nature (vs. built) condition. Regarding cognitive coping Content, results varied across the studies. Additionally, participants reported to have thought about the experienced psychological distress to a greater extent while viewing the nature (vs. built) video. Yet they did rate viewing nature as more relaxing. We propose a two-step pathway as an underlying mechanism of restoration. In the first step the capacity for directed attention replenishes. Secondly, this renewed capacity is directed towards internal processes, creating the optimal setting for reflection. Hence, viewing nature allows people to truly process whatever is occupying their minds, which is ultimately relieving and beneficial for mental health.

Immersive Virtual Reality Used as Adjunct Anesthesia for Conversion Total Hip Arthroplasty in a 100-Year-Old Patient

Immersive virtual reality (IVR) is an adjunctive form of anesthesia intended to distract patients from their intraoperative environment and reduce other side effects of sedating or narcotic agents. While this technology has been applied sparingly in various orthopedic procedural environments, its clinical utility has not been widely evaluated in major, nonelective surgical settings. The use of IVR in the geriatric hip fracture population represents a novel indication with potential benefit to reduced cognitive dysfunction and delirium. We report a case of a 100-year-old patient who received IVR adjunctive to neuraxial anesthesia during conversion total hip arthroplasty via posterolateral approach for treatment of failed peritrochanteric hip fracture fixation.

Effect of virtual reality distraction on pain and anxiety during infiltration anesthesia in pediatric patients: a randomized clinical trial

Background

Different distraction techniques have been used in dentistry and have shown great results in managing anxious pediatric patients specially during local anesthesia administration. One of the recently invented techniques is virtual reality. The purpose of the study was to evaluate the effect of virtual reality distraction on anxiety and pain during buccal infiltration anesthesia in pediatric patients.

Methods

Healthy, cooperative 6- to 12-year-old children requiring buccal infiltration anesthesia were randomly assigned to a test or control group. In the test group, local anesthesia was administered while the subjects were watching a cartoon video using virtual reality goggles. Subjects in the control group watched a cartoon video on a screen during the administration of local anesthesia. To assess anxiety in both groups, heart rate was recorded using a pulse oximeter at five time points: (1) once the subject sets on the dental chair as a baseline; (2) when video is on; (3) at topical anesthesia application; (4) during needle insertion; (5) after the administration of local anesthesia. The face, legs, activity, cry, consolability (FLACC) behavioral pain assessment scale and the Wong–Baker FACES pain rating scale were used to assess pain.

Results

A total of 50 subjects were included with a mean age of 8.4 ± 1.46 years. Twenty-nine (58.0%) of the subjects were females. The mean heart rate at all time points except baseline was significantly higher among the test group compared to the control group. Multiple regression analysis showed that younger subjects and females had higher mean FLACC behavioral pain assessment scale scores (P = 0.034 and P = 0.004, respectively) regardless of the distraction technique used. Younger subjects and subjects with higher baseline heart rate reported higher mean Wong–Baker FACES pain rating scale score (P = 0.031 and P = 0.010, respectively), controlling for all other variables.

Conclusion

Female subjects and the younger age group were more likely to report higher pain scores during local anesthesia administration regardless of the type of distraction used.

Trial registration

The study was retrospectively registered in ClinicalTrials.gov with the identifier: NCT04483336 on 23/07/2020.

Application of Virtual Environments for Biophilic Design: A Critical Review

Biophilic design as a new design approach promotes the integration of natural elements into the built environment, leading to a significant impact on human health, well-being, and productivity. On the other hand, scholars have explored Virtual Environment (VE) to create virtual nature and provide a complex experience of exposure to natural elements virtually. However, there is a lack of understanding about such studies in general, which use VE as a reliable tool to support biophilic design. Thus, the authors conducted a literature review on the applications, capabilities, and limitations of VE for biophilic design. The literature review shows that VE is capable of supporting critical features of biophilic design studies such as representing combinations of biophilic patterns, providing multimodal sensory inputs, simulating stress induction tasks, supporting required exposure time to observe biophilic patterns, and measuring human’s biological responses to natural environment. However, factors affecting user’s experience of a virtual biophilic environment exist, such as VE experience dimensions, user-related factors, cybersickness, navigational issues, and possible limitations of VE sensory input. Overall, biophilic design studies in VEs are still limited. Nevertheless, there are many opportunities for further research in this field.

Restore or Get Restored: The Effect of Control on Stress Reduction and Restoration in Virtual Nature Settings

Virtual nature experiences can improve physiological and psychological well-being. Although there is ample research on the positive effects of nature, both in virtual and physical settings, we know little about potential moderators of restoration effects in virtual reality settings. According to theories of needs and control beliefs, it is plausible to assume that control over one’s actions affects how people respond to nature experiences. In this virtual reality (VR) experiment, 64 participants either actively navigated through a VR landscape or they were navigated by the experimenter. We measured their perceived stress, mood, and vitality before and after the VR experience as well as the subjective restoration outcome and the perceived restorativeness of the landscape afterwards. Results revealed that participants’ positive affective states increased after the VR experience, regardless of control. There was a main effect such that participants reported lower stress after the VR experience; however, this was qualified by an interaction showing that this result was only the case in the no control condition. These results unexpectedly suggest that active VR experiences may be more stressful than passive ones, opening pathways for future research on how handling of and navigating in VR can attenuate the effects of virtual nature.

What is the best way of delivering virtual nature for improving mood? An experimental comparison of high definition TV, 360° video, and computer generated virtual reality

Exposure to 'real' nature can increase positive affect and decrease negative affect, but direct access is not always possible, e.g. for people in health/care settings who often experience chronic boredom. In these settings 'virtual' forms of nature may also have mood-related benefits (e.g. reducing boredom) but it has been difficult to separate effects of nature content from those of delivery mode. The present laboratory-based study explored whether exposure to three different delivery modes of virtual nature could reduce negative affect (including boredom) and/or increase positive affect. Adult volunteer participants (n = 96) took part in a boredom induction task (to simulate the emotional state of many people in health/care settings) before being randomly assigned to view/interact with a virtual underwater coral reef in one of three experimental conditions: (a) 2D video viewed on a high-definition TV screen; (b) 360⁰ video VR (360-VR) viewed via a head mounted display (HMD); or (c) interactive computer-generated VR (CG-VR), also viewed via a HMD and interacted with using a hand-held controller. Visual and auditory content was closely matched across conditions with help from the BBC's Blue Planet II series team. Supporting predictions, virtual exposure to a coral reef reduced boredom and negative affect and increased positive affect and nature connectedness. Although reductions in boredom and negative affect were similar across all three conditions, CG-VR was associated with significantly greater improvements in positive affect than TV, which were mediated by greater experienced presence and increases in nature connectedness. Results improve our understanding of the importance of virtual nature delivery mode and will inform studies in real care settings.

Blue space, health and well-being: A narrative overview and synthesis of potential benefits

Research into the potential health and well-being benefits from exposure to green spaces such as parks and woodlands has led to the development of several frameworks linking the different strands of evidence. The current paper builds on these to provide a model of how exposure to aquatic environments, or blue spaces such as rivers, lakes and the coast, in particular, may benefit health and well-being. Although green and blue spaces share many commonalities, there are also important differences. Given the breadth of the research, spanning multiple disciplines and research methodologies, a narrative review approach was adopted which aimed to highlight key issues and processes rather than provide a definitive balance of evidence summary. Novel aspects of our framework included the inclusion of outcomes that are only indirectly good for health through being good for the environment, the addition of nature connectedness as both a trait and state, and feedback loops where actions/interventions to increase exposure are implemented. Limitations of the review and areas for future work, including the need to integrate potential benefits with potential risks, are discussed.

Effects of virtual reality on relieving postoperative pain in surgical patients: A systematic review and meta-analysis

BACKGROUND

Postoperative pain is a prevalent problem leading to many adverse outcomes in surgical patients. Virtual reality (VR) is an emerging non-pharmacological method of postoperative pain relief, but the effects of it are not clear. This review aimed to explore the effects of VR on relieving postoperative pain.

METHODS

Studies published up to November 2019 were identified by searching the PubMed (Medline), Embase, Web of Science, and other databases. Meta-analyses were conducted to compare VR and usual care for relieving postoperative pain. Subgroup analyses and sensitivity analyses were performed to explain the heterogeneity.

RESULTS

Overall, 8 randomized control trials (RCTs) enrolling 723 participants were included. Our results demonstrated that the patients receiving the VR intervention had lower postoperative pain scores than those receiving the usual care (mean difference [MD] -0.64; 95% CI -1.05 to -0.22; P = 0.002). One subgroup analysis revealed that VR could relieve postoperative pain both in minor surgery (MD -1.48; 95% CI -2.02 to -0.95; P < 0.0001) and major surgery (MD -0.32; 95% CI -0.53 to -0.11; P < 0.03). Another subgroup analysis demonstrated a significant reduction in postoperative pain among patients receiving VR during the intraoperative (MD -1.51; 95% CI -2.04 to -0.97; P < 0.00001) and the postoperative periods (MD -0.50; 95% CI -0.76 to -0.24; P = 0.002). However, there was no significant postoperative pain relief when receiving VR during the preoperative period. Additionally, significant improvements in postoperative satisfaction were reported in two studies. However, another two studies included found that VR could not affect physiological parameters related to pain.

CONCLUSIONS

Applying VR can relieve postoperative pain effectively. The type of surgery and timing of using VR are the main sources of heterogeneity. More rigorous studies about the relationship between VR and postoperative pain relief will be needed.

Effects of immersive virtual reality therapy on intravenous patient-controlled sedation during orthopaedic surgery under regional anesthesia: A randomized controlled trial

Background

Immersive virtual reality (IVR) is a form of distraction therapy that has shown potential as an analgesia and sedation sparing agent. This study assessed the effect of IVR on the self-administered sedation requirements of patients undergoing joint replacement surgery under regional anesthesia in a single center.

Methods and findings

This study was a single-center, randomized control trial at St Vincent’s Hospital in Melbourne, Australia. Fifty patients undergoing elective total knee and total hip arthroplasty were randomized to IVR and Propofol patient-controlled sedation (PCS) or propofol PCS alone. The primary outcome measure was intra-operative propofol use. Secondary outcomes included pattern of propofol use over time, use of adjunct analgesia, unmet propofol demand, and patient satisfaction survey scores. Of 50 total patients, 25 received IVR in conjunction with PCS, and 25 received PCS alone. All patients received adjunct analgesia from the treating Anesthesiologist. Median propofol use/hour over the entire procedure in the control group was 40 (11.1, 93.9) mg/hour compared with 45 (0, 94.7) mg/hour in the IVR group (p = 0.90). There were no differences in patterns of propofol use over the course of each procedure. Adjusting for various baseline characteristics did not change the results. Postoperative satisfaction scores were equivalent in both groups. The VR intervention was well tolerated by all patients, with no report of major side effects. Key limitations were relatively small sample size, the non-blinded nature of the study, and use of adjunct analgesia.

Conclusions

In patients receiving joint replacement surgery under regional anesthesia with PCS, IVR was well tolerated but did not decrease the overall sedation requirement.

Can Simulated Nature Support Mental Health? Comparing Short, Single-Doses of 360-Degree Nature Videos in Virtual Reality With the Outdoors

Nature exposure in virtual reality (VR) can provide emotional well-being benefits for people who cannot access the outdoors. Little is known about how these simulated experiences compare with real outdoor experiences. We conduct an experiment with healthy undergraduate students that tests the effects of 6 min of outdoor nature exposure with 6 min of exposure to a 360-degree VR nature video, which is recorded at the outdoor nature exposure location. Skin conductivity, restorativeness, and mood before and after exposure are measured. We find that both types of nature exposure increase physiological arousal, benefit positive mood levels, and are restorative compared to an indoor setting without nature; however, for outdoor exposure, positive mood levels increase and for virtual nature, they stay the same. The nature-based experience shows benefits above and beyond the variance explained by participants’ preferences, nature and VR experiences, and demographic characteristics. Settings where people have limited access to nature might consider using VR nature experiences to promote mental health.

Head-Mounted Virtual Reality and Mental Health: Critical Review of Current Research

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.

Nearby Nature 'Buffers' the Effect of Low Social Connectedness on Adult Subjective Wellbeing over the Last 7 Days

Subjective wellbeing (SWB) is positively associated with both social connectedness and contact with natural environments. However, few studies have explored how these two predictors of SWB might interact. The current work hypothesised that high levels of nature exposure might mitigate (or buffer) any negative effects of a lack of recent social connectedness on wellbeing, by offering an alternative way for individuals to connect with the world around them. Results are based on data from 359 individuals who responded to an online survey in the UK. Measures of SWB, social connectedness and nature visit frequency all focused on the last seven days, and nearby nature was assessed in terms of the view from home and surrounding area. Regression models predicting SWB used interaction terms to test the buffering hypothesis, and controlled for sociodemographic and personality variables. Supporting predictions, social connectedness, nearby nature, and nature visit frequency were all positively associated with SWB. Partially supporting our buffering hypothesis, nearby nature, but not nature visit frequency, moderated the relationship between social connectedness and SWB. People with poor social connectedness still showed high levels of wellbeing if they reported high levels of nearby nature, and there was a lower likelihood of levels of wellbeing associated with depression among those with poor social connectedness if they had high nearby nature. Results confirmed the importance of nature exposure for wellbeing in itself, and highlighted its potential role in offering socially isolated individuals a way of satisfying the need to feel connected.

A prescription for "nature" - the potential of using virtual nature in therapeutics

Many studies suggest that increased exposure to urban greenness is associated with better population health. Accessing nature can in some circumstances, however, be difficult, especially for individuals with mobility constraints. Therefore, a growing body of work is investigating the ways to replace the in vivo experience with forms of "virtual" contact, in order to provide these individuals with at least some benefits of the natural environment. The aim of this paper is to provide a review of previous use of virtual reality (VR) nature in health and care settings and contemplate the potential use of this technology in future. Our central question is whether engaging with virtual nature can contribute to enhanced physical and emotional well-being in housebound or mobility-constrained individuals. We conclude that while contact with real-world nature is preferred, VR use can be an alternative in cases when in vivo contact with nature is not possible. There are many possibilities for the use of VR technology in psychiatric and medical care; however, the risks, benefits, and cost efficiency of these attempts should be carefully assessed and the outcomes should be measured in a scientifically valid manner. The current review has nonetheless demonstrated that VR nature could play a role in each of the proposed mediating mechanisms linking natural environments and health.