Access to Nature via Virtual Reality: A Mini-Review

Virtual Reality Interventions and Chronic Pain: Scoping Review

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.

Designing a Smartphone-Based Virtual Reality App for Relaxation: Qualitative Crossover Study

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.

Harnessing the therapeutic effects of nature for chronic Pain: A role for immersive virtual reality? A narrative review

BACKGROUND AND OBJECTIVE

There is a growing interest in the relationship between nature and pain relief. Evidence from environmental psychology, neuroscience and physiology-based studies point towards analgesic effects of nature being mediated through various cognitive, affective and/or autonomic factors. Being able to harness these therapeutic effects using immersive virtual reality (VR) could help to optimize and improve accessibility of nature-based environments as part of chronic pain management plans. In this narrative review, we present evidence supporting a new theoretical framework for nature-based analgesia and suggest ways for applying this through immersive VR.

DATABASES AND DATA TREATMENT

We provide an overview of the evidence on (1) the therapeutic effects of nature on pain, (2) environmental psychology theory that underpins the health benefits of nature, (3) key mechanistic evidence from nature neuroimaging and physiology-based studies, (4) previous studies that have used VR-based nature in pain research and (5) how to design effective VR interventions that can be used to integrate nature into immersive 360 environments.

RESULTS

We have demonstrated how environmental psychology, neuroscience and physiology-based research can be used to form a novel theoretical framework for nature-based analgesia. Using this framework, we identify how key aspects of nature can act as analgesic and how this can be harnessed using immersive VR.

CONCLUSIONS

Through developing this theoretical framework, we have provided a foundation on which to guide future experimental and clinical studies as well as helping to improve the accessibility of nature for chronic pain patients through immersive VR technologies.

SIGNIFICANCE

This review article summarizes key multidisciplinary evidence to help understand how nature exerts beneficial effects on pain processing. The use of this theoretical framework alongside advances in immersive VR technologies provides a springboard for future research and can be used to help develop new nature-based therapeutics using VR.

Virtual Reality to Improve the Psychological and Physical Well-Being in Cancer Patients: An Umbrella Review

BACKGROUND/OBJECTIVES

Cancer patients often experience psychological and physical symptoms that can significantly impact their quality of life and treatment outcomes. Virtual reality (VR) has emerged as a promising complementary approach to standard cancer care. Due to the rapidly evolving nature of VR research in oncology, it seems essential to provide an overview of the current state of knowledge in this field. Therefore, this umbrella review aimed to synthesize evidence from all relevant systematic reviews and meta-analyses on VR-based interventions for improving psychological and physical well-being among cancer patients.

METHODS

A comprehensive search was conducted in four databases (Cochrane Database of Systematic Reviews, Medline, Web of Science, PsycInfo) from inception to August 2023. We included systematic reviews with or without meta-analyses that evaluated the effects of VR-based interventions on any health-related outcomes in cancer patients. The methodological quality of included reviews was assessed using the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews) tool.

RESULTS

Eighteen individual systematic reviews including ten performed meta-analyses were included, with sample sizes ranging from 225 to 842 participants. VR-based interventions were categorized into three main types: distraction, rehabilitation, and education. The interventions varied significantly in terms of content, equipment, setting, and duration. The most frequent use of VR is one-off exposure in hospital settings to distract patients from anticancer treatment and painful procedures, with natural or game-based content. The mechanism most commonly proposed to explain the effectiveness of VR involves attentional redirection.

CONCLUSIONS

This umbrella review suggests that VR-based interventions may be effective in improving psychological outcomes in cancer patients, particularly anxiety, pain, and depression. However, high heterogeneity across studies and mixed results for some outcomes indicate a need for further high-quality research. Moreover, a more refined analysis of VR-based interventions is essential to explore the specific mechanisms of action associated with each type. This approach would enable us to establish the optimal characteristics of each intervention and their long-term effects.

Effect of Relaxation-Based Virtual Reality on Psychological and Physiological Stress of Substance Abusers Under Detoxification: A Randomized Controlled Trial

INTRODUCTION

Substance abuse is a widespread problem, with high rates of treatment dropout. Stress plays a crucial role in this problem, so innovative interventions with stressed patients can assist them in completing treatment.

METHODS

This study is a randomized controlled trial with 60 participants who have substance abuse disorder undergoing detoxification at a residency facility in Tehran, Iran. Participants were randomly assigned to one of three groups: watching a 360° video of nature, a 360° video of a city environment, or no virtual experience. The intervention was performed only for one session. Psychological stress was measured using the Positive and Negative Affect Schedule and Perceived Stress Scale before and after the intervention. Physiological stress was assessed through respiratory rate, skin conductance, and heart rate recordings during the virtual reality (VR) experience. Data analysis was performed using R software (version 4.2).

RESULTS

Paired t-test results indicated significant psychological differences before and after virtual nature experiences, but not in the control and city groups. The repeated measure ANOVA showed a significant reduction in skin conductance (p < 0.01) and respiratory rate (p < 0.01) scores in the nature group.

CONCLUSION

The findings suggest that VR relaxation could be a potentially beneficial intervention for reducing stress in patients during detoxification.

The effects of combining visual-auditory stimuli with exercise on short-term affect improvement: a randomized controlled trial

ABSTRAC T

Prior research has explored the effects of engaging with real or virtual natural landscapes and listening to music during aerobic exercise on short-term affect, however, the specific differences in the improvement of short-term affect by different combinations of Virtual Reality (VR) and music rhythm require further investigation. The objective of this study is to investigate the effects of various combinations of VR and music on short-term mood, thereby providing a reference for future research on public fitness. This study recruited 132 valid participants (mean age 24.0 ± 0.9 years), with a gender distribution of 68 males and 64 females. Participants were randomly assigned to one of four groups: Visual-Music (V-M), Music-Visual (M-V), Visual-only (V), and Music-only (M). The exercise mode was 15 min of aerobic power cycling with 2 min of low-intensity power cycling intervals in the middle. After the exercise, the participants were asked to sit and then performed either a VR intervention or a music intervention for 15 min. The collected indicators included blood pressure, positive/negative affect, and heart rate variability indicators (RMSSD, SDNN, LF/HF). Data analysis included descriptive statistics, repeated measures ANOVA, and multifactor ANOVA. The effect of different VR and Music combined with exercise interventions on the improvement of short-term affect was analyzed based on the effect size (ɳp2) and combined with the significance p-value. Intra-group results showed that DBP, positive and negative affect, SDNN, RMSSD indicators in V-M group were significant differences (p < 0.05), while SBP, positive affect, negative affect, SDNN, RMSSD, LF/HF indicators in M-V group were significant differences (p < 0.05). Only SDNN and RMSSD indicators in M group had significant differences (p < 0.05), and only SBP and RMSSD indicators in V group had significant differences (p < 0.05). The results between groups showed that only SDNN and LH/HF groups had a significant difference (p < 0.05), other indicators had a trend of improvement or positive promotion to a certain extent, but the statistical difference was not significant (p > 0.05). Aerobic exercise with consistent intensity and the combined visual-auditory interventions (M-V and V-M) significantly improved blood pressure, and the short-term affect of physiological responses (LF/HF, SDNN, RMSSD), along with subjective affect measures, compared to other groups. These findings suggest that incorporating VR and music with exercise can effectively enhance short-term affect, recommending an integrated approach to aerobic exercise and relaxation through music and visual exposure to natural environments.

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

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.

SafeVRwards: Designing a complementary virtual reality module to the Safewards framework intended to relax and manage conflict in mental health wards

BACKGROUND

Aggression and negative activation in mental health inpatient units pose significant challenges for both patients and staff with severe physical and psychological ramifications. The Safewards model is an evidence-based conflict-containment framework including 10 strategies, such as 'Calm Down Methods'. As virtual reality (VR) scenarios have successfully enhanced anxiolytic and deactivating effects of therapeutic interventions, they are increasingly considered a means to enhance current models, like Safewards.

OBJECTIVES

The present participatory design investigates the feasibility and user experience of integrating VR therapy as an add-on strategy to the Safewards model, gathering preliminary data and qualitative feedback from bedside staff in an adult inpatient mental health unit.

METHODS

An exploratory within-subjects design combining qualitative observations, self-report questionnaires and semistructured interviews is employed with four nurse champions from the mental health unit at Michael Garron Hospital (Toronto, Canada).

RESULTS

A chronological overview of the design process, adaptations and description of the user experience is reported.

CONCLUSION

'SafeVRwards' introduces VR as a promising conflic-containment strategy complementary to the Safewards model, which can be optimised for deployment through user-oriented refinements and enhanced customisation capacity driven by clinical staff input.

"It Helps Make the Fuzzy Go Away": Autistic Adults' Perspectives on Nature's Relationship with Well-being Through the Life Course

Background

While previous work highlights the links between nature and various positive well-being-related outcomes, the experiences of autistic people in nature have received limited empirical research. Our study aimed at gathering autistic adults' perspectives on the relationship between nature and well-being in both childhood and adulthood.

Methods

We used an online survey to capture the views of 127 autistic adults across the United Kingdom. Using reflexive thematic analysis, we analyzed responses to three questions focused on nature experiences in childhood and adulthood and how the participants felt that nature was (or was not) related to well-being. Guided by self-determination theory, we used both inductive and deductive analysis.

Results

We developed three main themes to reflect the nature experiences of autistic adults: choosing to escape into nature, supporting relatedness through connecting in (and to) nature, and nature doesn't judge, but other people do. Compared with many other contexts, nature provides a non-judgmental space through which (in both childhood and adulthood) many, but not all, autistic individuals can meet individual needs and experience autonomy, relatedness, and competence.

Conclusion

This analysis of how autistic adults in the United Kingdom utilize nature to support well-being has implications for how nature can be used in social prescribing as well as in ensuring that existing outdoor spaces, organizations, and activities are supportive of autistic people.

Virtual reality-based training may improve visual memory and some aspects of sustained attention among healthy older adults - preliminary results of a randomized controlled study

BACKGROUND/AIMS

Older age and cognitive inactivity have been associated with cognitive impairment, which in turn is linked to economic and societal burdens due to the high costs of care, especially for care homes and informal care. Emerging non-pharmacological interventions using new technologies, such as virtual reality (VR) delivered on a head-mounted display (HMD), might offer an alternative to maintain or improve cognition. The study aimed to evaluate the efficacy and safety of a VR-based Digital Therapeutics application for improving cognitive functions among healthy older adults.

METHODS

Seventy-two healthy seniors (experimental group N = 35, control group N = 37), aged 65-85 years, were recruited by the Medical University of Lodz (Poland). Participants were randomly allocated to the experimental group (a VR-based cognitive training which consists of a warm-up module and three tasks, including one-back and dual-N-back) or to the control group (a regular VR headset app only showing nature videos). The exercises are performed in different 360-degree natural environments while listening to a preferred music genre and delivered on a head-mounted display (HMD). The 12-week intervention of 12 min was delivered at least three times per week (36 sessions). Compliance and performance were followed through a web-based application. Primary outcomes included attention and working memory (CNS-Vital Signs computerized cognitive battery). Secondary outcomes comprised other cognitive domains. Mixed linear models were constructed to elucidate the difference in pre- and post-intervention measures between the experimental and control groups.

RESULTS

The users performed, on average, 39.8 sessions (range 1-100), and 60% performed more than 36 sessions. The experimental group achieved higher scores in the visual memory module (B = 7.767, p = 0.011) and in the one-back continuous performance test (in terms of correct responses: B = 2.057, p = 0.003 and omission errors: B = -1.950, p = 0.007) than the control group in the post-test assessment. The results were independent of participants' sex, age, and years of education. The differences in CNS Vital Signs' global score, working memory, executive function, reaction time, processing speed, simple and complex attention, verbal memory, cognitive flexibility, motor speed, and psychomotor speed were not statistically significant.

CONCLUSIONS

VR-based cognitive training may prove to be a valuable, efficacious, and well-received tool in terms of improving visual memory and some aspect of sustainability of attention among healthy older adults. This is a preliminary analysis based on part of the obtained results to that point. Final conclusions will be drawn after the analysis of the target sample size.

TRIAL REGISTRATION

Clinicaltrials.gov ID NCT05369897.

The application of virtual reality meditation and mind-body exercises among older adults

Virtual reality (VR)-based mindfulness is a promising method to improve the health of older adults. Therefore, many attempts have been made to explore the application of VR-based mindfulness, such as VR meditation and mind-body exercises, in older adults. Generally, current studies indicate the heavy reliance on apparatus for implementing VR-based mindfulness interventions. In VR meditation, the crucial apparatus is VR headsets. In VR mind-body exercises, three essential components are required: motion capture sensors, main consoles, and display screens. In the aspect of health promotion, VR meditation is an effective method for improving mental health, pain, and quality of life in older adults. VR mind-body exercises contribute to increasing the mental health and physical function of older adults. Furthermore, VR mind-body exercises may be combined with other forms of exercise as a mixed method to promote the health of older adults. VR-based mindfulness interventions enhance the meditation and mind-body exercises experience for older adults while improving accessibility. However, their implementation still encounters a series of challenges, such as cost, technical anxiety, and apparatus-related issues. Additionally, we recommend future research to examine the optimal exercise dose for VR mind-body exercises to maximize their health benefits.

Nature-based virtual reality intervention to manage stress in family caregivers of allogeneic hematopoietic stem cell transplant recipients: a two-phase pilot study protocol

Millions of family members and/or friends in the U.S. serve as unpaid caregivers for individuals with chronic conditions, such as cancer. Caregiving for someone undergoing an intense allogeneic hematopoietic stem cell transplant (HSCT) is particularly demanding, with accompanying physical and psychological stress. Increased stress and stress-related symptoms could make it difficult for caregivers to fulfill their roles and could negatively impact the health status and quality of life of themselves and the recipients. Virtual reality (VR) is a promising technology increasingly used for treatment and wellness in various medical settings. There is growing evidence that studies have reported the positive effects of the VR intervention in managing and reducing stress among diverse populations in various clinical scenarios; however, no published studies have focused on family caregivers of patients with cancer. The study aims to assess the feasibility and acceptability of a four-week nature-based VR intervention and to examine the effectiveness of the VR intervention on stress in HSCT caregivers. This study comprises two phases. Phase I of the study will be a single-arm pre-post design focused on assessing the feasibility and acceptability of the VR intervention. Phase II of the study will be a prospective randomized controlled group design to examine the effectiveness of the VR intervention on perceived stress. Adults (≥ 18 years) who serve as primary caregivers for a person who will undergo an allogeneic HSCT will be recruited. Fifteen participants will be enrolled for Phase I and 94 participants for Phase II (Active VR arm N=47; Sham VR arm N=47). The nature-based immersive VR program contains 360° high-definition videos of nature scenes along with nature sounds through a head-mounted display (HMD) for 20 minutes every day for four weeks. Primary outcome is perceived stress measured by the Perceived Stress Scale. Secondary/exploratory outcomes are stress-related symptoms (e.g., fatigue, sleep disturbance) and physiological biomarkers (e.g., cortisol, alpha-amylase). The importance and innovativeness of this study consist of using a first-of-its-kind, immersive VR technology to target stress and investigating the health outcomes assessed by validated objective biomarkers as well as self-report measures of the nature-based intervention in the caregiver population.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05909202.

How can plant-enriched natural environments benefit human health: a narrative review of relevant theories

Plant-enriched environments, the most common terrestrial landscapes, are usually coded as "green space" in urban studies. To understand how these natural environments can benefit human health, many theories have been developed, such as the well-known Attention Restoration Theory. Nowadays, more theories are emerging with regard to various and complex health dimensions. In this context, we searched online databases (from 2000 to 2022) and conducted a narrative review aiming to introduce relevant theories concerning psychological (e.g. Perceptual Fluency Account and Conditioned Restoration Theory), physiological (e.g. volatile organic compounds and environmental microbiomes), and behavioural (e.g. physical activity and social contact) perspectives. We also slightly mentioned some limitations and directions to be considered when using these theories. These results may offer general readers insights into the value of nature exposure and also help relevant researchers with study design and result interpretation.

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.

The effect of nature exposure on pain experience and quality of life in patients with chronic pain: A systematic review and meta-analysis protocol

BACKGROUND

Chronic pain is a complex condition with short and long-term effects on physical and psychosocial health. Nature exposure therapy has been investigated as a potential non-pharmacological intervention to improve physical and emotional health of individuals with chronic pain. This proposed systematic review aims to examine the effects of nature exposure therapy on pain experience and quality of life in patients with chronic pain.

METHODS

Studies will be identified by searching the MEDLINE, Embase and Cumulative Index for Nursing and Allied Health Literature (CINAHL) databases. All included studies will be required to be interventional controlled trials comparing nature exposure therapy to placebo or standard care in patients with chronic pain. Primary outcomes for this review will be pain intensity and quality of life scores. Secondary outcomes will include self-efficacy, depression and pain-related anxiety scores. If 2 or more studies are included, results will be pooled for meta-analysis. If meta-analysis is not possible, the results will be presented in a narrative form.

DISCUSSION

Given the adverse effects of opioid use, non-pharmacological interventions are a necessary alternative to treat patients with chronic pain. Nature exposure therapy is an intriguing example of such an intervention. We hope that this systematic review will guide future clinical decision-making for patients with chronic pain and provide evidence for or against the need for natural spaces and improved urban planning.

TRIAL REGISTRATION

PROSPERO registration number: CRD42021226949.

Creating Custom Immersive 360-Degree Videos for Use in Clinical and Nonclinical Settings: Tutorial

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.

Using Virtual Reality to Bring Restorative Environments to Employees: An Online Pilot Study

Employees face many demands throughout the workday. Participating in activities can help employees recover from the pressures of work, and physical activity and time spent in nature are among the most beneficial. Simulations of nature offer some of the benefits of actual contact with nature and can address some of the barriers to exercising outdoors that some employees may face. In this pilot study, we examine the influence of physical activity and virtual or actual nature contact on affect, boredom, and satisfaction when experienced during a break from a demanding work task. Twenty-five employed adults participated in an online study in which they completed a problem-solving task, completed a twenty-minute break, and then completed another session of the problem-solving task. During the break, participants were randomized to either a control condition, a physical activity and low-fidelity virtual nature contact condition, a physical activity and high-fidelity virtual nature contact condition, or a physical activity and actual nature contact condition. An examination of the means of affect, boredom, and satisfaction before, during, and after the break revealed that those in high-fidelity virtual nature and actual nature contact conditions seemed to report more positive well-being during the break. The results highlight that to help employees recover from work demands, it could be important to take breaks, be physically active, and have contact with nature, which should be simulated in high fidelity if actual nature contact cannot be achieved.

Immersive virtual reality as support for the mental health of elderly women: a randomized controlled trial

Several forms of virtual reality (VR) have shown promise in treating mental disorders. However, there is a lack of research investigating the use of multicomponent immersive VR. Therefore, this study aimed to evaluate the effectiveness of an immersive virtual reality (IVR) intervention that incorporated Japanese garden aesthetics, relaxation, and elements of Erickson's psychotherapy in alleviating depression and anxiety symptoms among elderly women. Sixty women with depressive symptoms were randomly assigned to one of two treatment groups. Both groups received eight (twice a week for four weeks) low-intensity general fitness training sessions. The IVR group (n = 30) received eight additional VR-based relaxation sessions, whereas the control group (n = 30) received eight group relaxation. As outcome measures, the geriatric depression scale (GDS; primary) and Hospital Anxiety and Depression Scale (HADS; secondary) were administered before and after the interventions. The protocol was registered in the ClinicalTrials.gov PRS database (Registration number: NCT05285501). Patients receiving IVR therapy exhibited a greater significant reduction in the GDS (adjusted mean post-difference of 4.10; 95% CI = 2.27-5.93) and HADS (2.95; 95% CI = 0.98-4.92) scores than those receiving the control intervention. In conclusion, IVR with elements of psychotherapy, relaxation, and garden aesthetics may alleviate the severity of depression and anxiety symptoms in elderly women.

Impact of Virtual Reality Cognitive and Motor Exercises on Brain Health

Innovative technologies of the 21st century have an extremely significant impact on all activities of modern humans. Among them, virtual reality (VR) offers great opportunities for scientific research and public health. The results of research to date both demonstrate the beneficial effects of using virtual worlds, and indicate undesirable effects on bodily functions. This review presents interesting recent findings related to training/exercise in virtual environments and its impact on cognitive and motor functions. It also highlights the importance of VR as an effective tool for assessing and diagnosing these functions both in research and modern medical practice. The findings point to the enormous future potential of these rapidly developing innovative technologies. Of particular importance are applications of virtual reality in basic and clinical neuroscience.

The effect of different combinations of physical activity and natural environment videos on children's attention levels between class breaks

BACKGROUND

Physical activity intervention and watching natural environment videos have been proven to improve young children's attention levels. However, evidence comparing the improvement effects of different combinations of the two activities has rarely been reported. By comparing the differences in the improvement effects of four combinations of physical activities and watching natural environment videos on young children's attention levels, this study can enrich the evidence in this research field and also provide a reference for arranging effective intervention methods for children's attention recovery between classes.

METHOD

A total of 152 children aged 4 to 6 years were recruited and randomly divided into four intervention groups: (1) physical activity intervention first and thereafter watching a natural environment video group (activity + video group), (2) watching a natural environment video first and thereafter the physical activity intervention group (video + activity group), (3) physical activity-based group, and (4) natural environment video-based group. Physical activity involved 4 min of moderate-intensity basic physical fitness combination training. The subjects wore the Pico Neo pioneer version of the VR glasses all-in-one machine to watch a natural environment video. Thereafter, population sociological variables and daily physical activity levels were investigated. Auditory and visual sustained attention tests were performed before and after intervention in each group.

RESULT

The auditory attention post-test scores of the four groups showed an improvement trend compared with the pretest scores. In particular, the activity + video group (F = 10.828; ɳp2 = 0.226; p = 0.002) and natural environment video-based group (F = 9.452; ɳp2 = 0.203; p = 0.004) have the best improvement effect. For visual attention, only the activity + video group showed a significant improvement trend (F = 4.287; ɳp2 = 0.104; p = 0.045), while the other three groups showed a downward trend in scores.

CONCLUSIONS

Among the different intervention combinations, the physical activity intervention first and watching natural environment videos thereafter group has the best effect on improving children's attention during recess. Physical activity interventions at the end of recess adversely affect young children's visual attention levels at the beginning of the class. Therefore, this study recommends that children should not engage in physical activity interventions in the second half of the class break. Lastly, the current research recommends presenting the content of physical activity interventions first and further improving their attention thereafter by watching natural environment videos.

An eye-tracking study on visual perception of vegetation permeability in virtual reality forest exposure

Previous studies have confirmed the significant effects of single forest stand attributes, such as forest type (FT), understory vegetation cover (UVC), and understory vegetation height (UVH) on visitors' visual perception. However, rarely study has yet clearly determined the relationship between vegetation permeability and visual perception, while the former is formed by the interaction of multiple forest stand attributes (i.e., FT, UVC, UVH). Based on a mixed factor matrix of FT (i.e., coniferous forests and broadleaf), UVC level (i.e., 10, 60, and 100%), and UVH level (0.1, 1, and 3 m), the study creates 18 immersive virtual forest videos with different stand attributes. Virtual reality eye-tracking technology and questionnaires are used to collect visual perception data from viewing virtual forest videos. The study finds that vegetation permeability which is formed by the interaction effect of canopy density (i.e., FT) and understory density (i.e., UVC, UVH), significantly affects participant's visual perception: in terms of visual physiology characteristics, pupil size is significantly negatively correlated with vegetation permeability when participants are viewing virtual reality forest; in terms of visual psychological characteristics, the understory density formed by the interaction of UVC and UVH has a significant impact on visual attractiveness and perceived safety and the impact in which understory density is significantly negatively correlated with perceived safety. Apart from these, the study finds a significant negative correlation between average pupil diameter and perceived safety when participants are viewing virtual reality forests. The findings may be beneficial for the maintenance and management of forest parks, as well as provide insights into similar studies to explore urban public green spaces.

Effects of virtual reality natural experiences on factory workers' psychological and physiological stress

Introduction

Manufacturing facilities and factories are stressful work environments. Interventions to improve factory workers' stress is necessary to promote occupational health. This study aimed to examine the effects of virtual reality natural experiences on furniture factory employees' psychological and physiological stress.

Methods

A single-blinded, non-randomised quasi-experimental study was conducted between July and December 2021. Factory workers were recruited from two factories, and all participants at a given factory were assigned to either an experimental group or a comparison group. The intervention was conducted in a clean conference room once a week for 12 weeks during the worker's break time. The experimental group received virtual reality natural experiences consisting of 30-minute nature-based 360° videos which were played in a headset. The generalised estimating equations were performed for the statistical analyses.

Results

In total, 35 participants completed the intervention. As to psychological stress, the experimental group showed improvements in distress, depression, and anxiety, and a positive affect after the intervention compared to the comparison group. As to physiological stress, the experimental group showed improvements in indicators of heart rate variability compared to the comparison group, including standard deviations of all normal-to-normal intervals, low-frequency power, and high-frequency power.

Discussion

Virtual reality is an innovative platform to bring the natural environment into an indoor environment to create similar health effects.

Investigating the role of auditory and visual sensory inputs for inducing relaxation during virtual reality stimulation

Stress is a part of everyday life which can be counteracted by evoking the relaxation response via nature scenes presented using immersive virtual reality (VR). The aim of this study was to determine which sensory aspect of immersive VR intervention is responsible for the greatest relaxation response. We compared four conditions: auditory and visual combined (audiovisual), auditory only, visual only, and no artificial sensory input. Physiological changes in heart rate, respiration rate, and blood pressure were recorded, while participants reported their preferred condition and awareness of people, noise, and light in the real-world. Over the duration of the stimulation, participants had the lowest heart rate during the audiovisual and visual only conditions. They had the steadiest decrease in respiration rate and the lowest blood pressure during the audiovisual condition, compared to the other conditions, indicating the greatest relaxation. Moreover, ratings of awareness indicated that participants reported being less aware of their surroundings (i.e., people, noise, light, real environment) during the audiovisual condition versus the other conditions (p < 0.001), with a preference for audiovisual inputs. Overall, the use of audiovisual VR stimulation is more effective at inducing a relaxation response compared to no artificial sensory inputs, or the independent inputs.

Green Space for Mental Health in the COVID-19 Era: A Pathway Analysis in Residential Green Space Users

Residential green space is among the most accessible types of urban green spaces and may help maintain mental health during the COVID-19 pandemic. However, it is insufficiently understood how residents use residential green space for exercise during the epidemic. The pathways between residential green space and mental health also merit further exploration. Therefore, we conducted an online study among Chinese residents in December 2021 to capture data on engagement with urban green space for green exercise, the frequency of green exercise, perceived pollution in green space, perceptions of residential green space, social cohesion, depression, and anxiety. Among the 1208 respondents who engaged in green exercise last month, 967 (80%) reported that green exercise primarily occurred in residential neighborhoods. The rest (20%) reported that green exercise occurred in more distant urban green spaces. The most common reasons that respondents sought green exercise in urban green spaces were better air and environmental qualities. Structural equation modeling (SEM) was then employed to explore the pathways between the perceived greenness of residential neighborhoods and mental health among respondents who used residential green space for exercise. The final model suggested that residential green space was negatively associated with anxiety (β = −0.30, p = 0.001) and depression (β = −0.33, p < 0.001), mainly through indirect pathways. Perceived pollution and social cohesion were the two mediators that contributed to most of the indirect effects. Perceived pollution was also indirectly associated with green exercise through less social cohesion (β = −0.04, p = 0.010). These findings suggest a potential framework to understand the mental health benefits of residential green space and its accompanying pathways during the COVID-19 era.

The Role of Personalization in the User Experience, Preferences and Engagement with Virtual Reality Environments for Relaxation

Virtual Reality Environments (VREs) are widely deployed in mental health treatments, often associated with relaxation techniques. The personalization of natural VR-based scenarios is a key element that can further facilitate users’ sense of presence and relaxation. This study explored the role of VREs’ personalization in the user experience with an environment supporting relaxation, by deploying mixed methods. Methods: A non-clinical sample of 20 individuals participated in exposure to a supportive body-scan-guided relaxation VRE. In the personalized conditions, the participants had the option of choosing the context (e.g., sea, mountain, or countryside) and including in the scenario different types of sounds, visual elements, and changing the time of day and weather. In the standard conditions, individuals were exposed to a relaxing VRE, but they could choose neither the context nor the auditory and visual elements. The order of presentation of the personalized vs non-personalized environments was randomized. Measures regarding relaxation, state-anxiety perceived levels, VRE-related symptoms, the usability of the Virtual Reality (VR) setting, sense of presence, pleasure, activation, engagement, and level of immersion experienced were collected before and after exposure to the VR environments. Results: Findings showed that personalized VREs were preferred by users. Participants generally preferred to experience a greater immersivity, pleasure, engagement, and relaxation in the personalized virtual settings. Conclusion: The study further confirms the role of personalization as a component positively contributing to relaxation and engagement. Future research may further assess this effect in the context of large-scale controlled studies involving clinical and non-clinical populations.

Lifestyle Prescription for Depression with a Focus on Nature Exposure and Screen Time: A Narrative Review

Recent lifestyles changes have favored increased time in contact with screens and a parallel reduction in contact with natural environments. There is growing awareness that nature exposure and screen time are related to depression. So far, the roles of how these environmental lifestyles affect depressive symptoms and disorders have not been reviewed simultaneously. The aim of this review was to gather the literature regarding the role of nature exposure and screen time in depression. An emphasis was made on clinical samples of patients with well-defined depression and the different methodological approaches used in the field. A second goal was to suggest an agenda for clinical practice and research. Studies were included if they assessed depressive symptoms in patients with a clinical diagnosis of depression. An overview of the published literature was conducted using three scientific databases up to December 2021. Several interventions involving nature exposure have shown positive effects on depressive symptoms and mood-related measures. The most consistent finding suggests that walks in natural environments may decrease depressive symptoms in patients with clinical depression. Less researched interventions, such as psychotherapy delivered in a forest or access to natural environments via virtual reality, may also be effective. In contrast, fewer observational studies and no experimental research on screen time have been conducted in patients with clinical depression. Thus, recommendations for practice and research are also discussed. Scarce research, diverse interventions, and several methodological shortcomings prevent us from drawing conclusions in this area. More high-quality experimental research is needed to establish interventions with proven efficacy in clinical depression. At this stage, it is too early to formulate practice guidelines and advise the prescription of these lifestyles to individuals with depression. The present findings may serve as a basis to develop strategies based on nature exposure and screen time targeting clinical depression.