Development and usability testing of a fully immersive VR simulation for REBOA training

BackgroundIt appears that active video games (AVGs) and training apps that allow for physical activity (PA) in immersive virtual reality (VR) may be useful for sports, health-enhancing PA, and physical education (PE). Therefore, research is needed to identify their potential.ObjectiveThe study aimed to evaluate the intensity and attractiveness of exercise during table tennis (TT) training in VR in arcade and simulation modes and to assess the potential for using such exercises in health-enhancing PA, sport, and PE.MethodsThe research used the Racket Fury: Table Tennis VR. Exercise intensity during TT training in VR was evaluated by heart rate (HR) monitoring and rating of perceived exertion (RPE 6–20). The effectiveness of short-term TT training in VR was estimated based on the user’s performance in playing against an opponent with artificial intelligence (AI), satisfaction with playing TT was measured using the Physical Activity Enjoyment Scale (PACES), and the potential usefulness of the tested app in PA, sport, and PE was assessed based on a questionnaire for participating PE teachers (30 participants).ResultsPA intensity during TT training in VR expressed as a percentage of maximum heart rate (HRmax) was moderate but was significantly (p < 0.001; d=-0.830) higher in the easier arcade mode (69.50 ± 12.58%HRmax) than in the simulation mode (64.10 ± 9.67%HRmax). Despite the greater fatigue of respondents, user satisfaction was significantly higher in arcade mode. Users’ performance when playing with AI was significantly better after 20 min of training in VR than before training. PE teachers recognize the great potential of the app.ConclusionsThe application tested is characterized by a beneficial PA intensity, with its level depending on the game mode. Facilitating strokes during a game of virtual TT promotes increased intensity of exercise and increased enjoyment of the PA. Short-term TT training in VR improves playing skills in a virtual environment. PE teachers spoke highly of the app and recognized the potential for using VR technology in PA, sports, and school PE.

Immersive virtual reality can expose humans to novel training and sensory environments, but motor training with virtual reality has not been able to improve motor performance as much as motor training in real-world conditions. An advantage of immersive virtual reality that has not been fully leveraged is that it can introduce transient visual perturbations on top of the visual environment being displayed. The goal of this study was to determine whether transient visual perturbations introduced in immersive virtual reality modify electrocortical activity and behavioral outcomes in human subjects practicing a novel balancing task during walking. We studied three groups of healthy young adults (5 male and 5 female for each) while they learned a balance beam walking task for 30 min under different conditions. Two groups trained while wearing a virtual reality headset, and one of those groups also had half-second visual rotation perturbations lasting ~10% of the training time. The third group trained without virtual reality. We recorded high-density electroencephalography (EEG) and movement kinematics. We hypothesized that virtual reality training with perturbations would increase electrocortical activity and improve balance performance compared with virtual reality training without perturbations. Our results confirmed the hypothesis. Brief visual perturbations induced increased theta spectral power and decreased alpha spectral power in parietal and occipital regions and improved balance performance in posttesting. Our findings indicate that transient visual perturbations during immersive virtual reality training can boost short-term motor learning by inducing a cognitive change, minimizing the negative effects of virtual reality on motor training. NEW & NOTEWORTHY We found that transient visual perturbations in virtual reality during balance training can boost short-term motor learning by inducing a cognitive change, overcoming the negative effects of immersive virtual reality. As a result, subjects training in immersive virtual reality with visual perturbations have equivalent performance improvement as training in real-world conditions. Visual perturbations elicited cortical responses in occipital and parietal regions and may have improved the brain's ability to adapt to variations in sensory input.

To determine the impact of clinical and anamnestic data of stroke patients on the rehabilitation process's outcome in virtual reality (VR). To study parameters of postural stability, gait, daily activity and affective functions during motor training in the immersive high-tech polymodal VR system. We examined 34 patients (16 women, 18 men, mean age 51.9±12.5) who had a stroke at least 2 weeks ago and had a degree of disability no more than 3 points on the Rankin scale, mainly due to movement disorders. The patients underwent training in the VR system (Grail, Motekforce) for 10 sessions. Before and after the end of the training, the patient's condition was diagnosed, including indicators of motor and daily activities, affective functions, as well as an instrumental assessment of balance and gait in VR. After training up to 62% of patients showed improvements in physical activity, up to 41% - in daily living activities, up to 73% - in the affective sphere. The results of multiple linear regression analysis showed that gender, the type of stroke and the side of the brain lesion are significant predictors for the rehabilitation of postural stability, while the type of stroke and the period of recovery after stroke predict the restoration of the affective sphere. Groups of patients stratified by gender, the type of stroke, the side of the brain lesion and recovery period, for whom training in the VR system was most effective, are identified. Based on the results of the study, the authors suggest the criteria of inclusion of VR in the individual rehabilitation program of patients with stroke.

Introduction: Previous studies evaluating the effect of virtual reality (VR) training on operating room performance have only analyzed the latter portion of the laparoscopic cholecystectomy (LC), while including many residents beyond their second year of training. The aim of this study was to better understand the impact of VR training on subjects with limited laparoscopic surgical experience during completion of an entire laparoscopic cholecystectomy. Methods: Twelve surgical residents (PGY 1 & 2) were randomized to either standard training (n = 6) or VR training (n = 6). In the VR training group subjects were required to reach expert established performance criterion levels on the manipulation diathermy task of the Minimally Invasive Surgical Trainer (MIST-VR). All subjects then performed a video-recorded LC under the supervision of a surgeon blinded to training status. Recordings were assessed by two blinded surgeon investigators using scores based on expert-defined errors with inter-rater reliability >0.9. Results: VR trained subjects completed the full LC 20% faster than controls (39 min. vs. 31 min.), made half as many errors while exposing cystic structures (5.3 vs 10), and one-third fewer errors in dissecting the gallbladder (5.5 vs. 8.2). Overall, controls made 40% more errors (11.7 vs 19.7, p Conclusions: Criterion based VR training to expert performance levels for junior surgical residents results in fewer intra-operative errors and greater performance consistency during the entire laparoscopic cholecystectomy procedure.

There is limited data assessing simulation and virtual reality training as a standardized tool in medical education. This feasibility study aimed to evaluate the effectiveness of virtual reality training and a student-led simulation module in preparing medical students to perform a lumbar puncture. Twenty-five medical students completed a pre-intervention survey, and a baseline video recorded lumbar puncture procedure on a task trainer. Students were randomly distributed into the virtual reality group, or the curriculum's standard student-led procedural instruction group. Participants were then given 45min to practice the lumbar puncture procedure. After the intervention, all participants were video recorded again as they performed a post-intervention lumbar puncture and completed a post-intervention survey. Pre- and post-intervention videos were scored using a critical action checklist in conjunction with time needed to complete the procedure to evaluate proficiency. At baseline, there were no major statistically significant differences between groups. Assessing overall post-intervention performance, both groups showed improvement in aggregate score (p < 0.001) and time required to complete (p = 0.002) the lumbar puncture. Following interventions, the student-led group improved over the virtual reality group in a variety of metrics. The student-led group increased their aggregate score by 3.49 and decreased their time to completion by 34s over the VR group when controlling for baseline measures. Both virtual reality and student-led simulation training were useful training modalities, with hands-on simulation showing better results versus virtual reality training in this setting. The online version contains supplementary material available at 10.1007/s40670-020-01141-6.

Finding enjoyable and effective long-term approaches to rehabilitation for improving the upper limb (UL) function of people with multiple sclerosis (MS) is challenging. Virtual reality (VR) with its engagement, interaction, and real time feedback could be a solution, with immersive VR systems having preliminary evidence in stroke to be more effective in improving UL outcomes in comparison to non-immersive VR. However, immersive VR research is limited within the realm of MS rehabilitation. Therefore, the main aim of the PhD was to explore immersive VR as an approach for UL rehabilitation for people with MS (pwMS). This was achieved in four stages: 1) a systematic review of the current evidence for VR in UL rehabilitation in MS; 2) predevelopment focus groups to determine requirements for the development of bespoke immersive VR games; 3) software development of bespoke VR games to potentially improve UL function for pwMS; and 4) a feasibility study of the games and immersive VR for pwMS’ UL rehabilitation. The systematic review initially yielded ten articles with varying study design, VR intervention and UL outcome measures used. There were some statistically significant improvements after VR interventions in outcomes such as in nine-hole peg test (NHPT), hand grip strength and active range of motion. There were however conflicting results regarding if VR was more effective than conventional approaches. Whilst the review demonstrated there were positive results for VR improving UL function, most of the studies had small sample sizes and were inadequately powered, and the level of immersion on effectiveness in MS remains unknown. The predevelopment focus groups recruited ten pwMS and eight specialist clinicians to explore their views on immersive VR as an approach to UL rehabilitation and determine requirements to develop VR games for this purpose. PwMS commonly reported that their UL problems interfered with activities of daily living and resulted in the loss of meaningful hobbies such as writing. Many pwMS neglected UL exercise and found strategies for adapting to their UL impairments. Similarly, clinicians stated UL rehabilitation was neglected within their service and that it was challenging to find interesting treatment strategies. VR was suggested by both participant groups as a potential solution, as it was convenient for pwMS to access and could provide a more engaging and disguised approach to exercise. Although, there were shared concerns about cybersickness and disengagement while using VR approaches. Finally, both groups agreed games should be meaningful and adaptable for users but suggested different VR activities, with clinicians suggesting games directly reflecting activities of daily living and pwMS suggesting more abstract activities. Recommendations were made for the development of VR rehabilitation games which could be personalised and customisable for the varying abilities of pwMS. Using theme-based content analysis and requirement analysis, requirements for the software development of immersive VR games were created and developed using Unity game engine. Three games, “Piano”; “Catch-a-falling-star” and “VR Whack-a-mole” which targeted dexterity and strength for pwMS were developed, with different difficulty levels implemented to adapt to varying ability of pwMS. The final stage of this PhD was a randomised, controlled feasibility study to investigate an intervention of immersive VR involving the three co-produced games for pwMS’ UL rehabilitation. Participants were randomised to either an intervention group consisting of 30 minutes of VR co-produced games, twice/week, for eight weeks, or to a control group of usual care. Participants were recruited from the NHS and third sector organisations. Nineteen pwMS were recruited (intervention n=11, control n=8), with a recruitment rate of 3.2 participants/month. Only minor adverse events were reported (n=9), such as fatigue and UL pain. Adherence was good with 87% (±12%) session completed, and two dropouts were reported in the control group. There were positive trends for improving NHPT and hand grip strength, but there was an observed ceiling effect in the Action Research Arm Test. Participants reported high levels of satisfaction and good usability of the co-produced VR games, as measured by the USE questionnaire. Thematic analysis revealed participants enjoyed the distraction and atmospheres that immersive VR provided, and believed the games were fit for purpose with the majority of participants reporting improvements in their UL function. Participants suggested more variety and progression of exercises for future development. Overall, these studies show that immersive VR has the potential to be beneficial for UL rehabilitation and is feasible and safe for pwMS. Therefore, future work should refine VR games for long-term application and explore the clinical and cost effectiveness of this approach.

Objectives This study is aimed at exploring the effects of virtual reality (VR) training on postural control, measured by anticipatory and compensatory postural adjustments (APAs and CPAs, respectively), in patients with chronic nonspecific low back pain (CNLBP) and the potential neuromuscular mechanism of VR training. Methods Thirty-four patients were recruited and randomly assigned to the VR group (n = 11), the motor control exercise group (MCE, n = 12) and the control group (CG, n = 11). The VR group received VR training using Kinect Xbox 360 systems and magnetic therapy. Besides magnetic therapy, the participants in the MCE group performed real-time ultrasound-guided abdominal drawing-in maneuver (ADIM) and four-point kneeling exercise. The CG only received magnetic therapy. Surface muscle electromyography (sEMG) was used to record the muscle activities of transverse abdominis (TrA), multifidus (MF), lateral gastrocnemius (LG), and tibialis anterior (TA) during ball-hitting tasks. The muscle activation time and integrals of the electromyography activities (IEMGs) during the APA and CPA stages were calculated and used in the data analysis. The visual analogue scale (VAS) and Oswestry dysfunction index (ODI) scores were also recorded. Results A significant interaction effect of time × group was observed on the activation time of TrA (p = 0.018) and MF (p = 0.037). The post-intervention activation time of the TrA was earlier in the VR group (p = 0.029). In contrast, the post-intervention activation time of the MF was significantly delayed in the VR group (p = 0.001). The IEMGs of TrA (p = 0.002) and TA (p = 0.007) during CPA1 significantly decreased only in the VR group after the intervention. The VAS scores of three group participants showed significant decreases after intervention (p < 0.001). Conclusions Patients with CNLBP showed reciprocal muscle activation patterns of the TrA and MF muscles after VR training. VR training may be a potential intervention for enhancing the APAs of the patients with CNLBP.

Standard surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time-consuming, costly, and of variable effectiveness. Training using a virtual reality simulator is an option to supplement standard training. Virtual reality training improves the technical skills of surgical trainees such as decreased time for suturing and improved accuracy. The clinical impact of virtual reality training is not known. To assess the benefits (increased surgical proficiency and improved patient outcomes) and harms (potentially worse patient outcomes) of supplementary virtual reality training of surgical trainees with limited laparoscopic experience. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE and Science Citation Index Expanded until July 2012. We included all randomised clinical trials comparing virtual reality training versus other forms of training including box-trainer training, no training, or standard laparoscopic training in surgical trainees with little laparoscopic experience. We also planned to include trials comparing different methods of virtual reality training. We included only trials that assessed the outcomes in people undergoing laparoscopic surgery. Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5 analysis. For each outcome we calculated the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals based on intention-to-treat analysis. We included eight trials covering 109 surgical trainees with limited laparoscopic experience. Of the eight trials, six compared virtual reality versus no supplementary training. One trial compared virtual reality training versus box-trainer training and versus no supplementary training, and one trial compared virtual reality training versus box-trainer training. There were no trials that compared different forms of virtual reality training. All the trials were at high risk of bias. Operating time and operative performance were the only outcomes reported in the trials. The remaining outcomes such as mortality, morbidity, quality of life (the primary outcomes of this review) and hospital stay (a secondary outcome) were not reported. Virtual reality training versus no supplementary training: The operating time was significantly shorter in the virtual reality group than in the no supplementary training group (3 trials; 49 participants; MD -11.76 minutes; 95% CI -15.23 to -8.30). Two trials that could not be included in the meta-analysis also showed a reduction in operating time (statistically significant in one trial). The numerical values for operating time were not reported in these two trials. The operative performance was significantly better in the virtual reality group than the no supplementary training group using the fixed-effect model (2 trials; 33 participants; SMD 1.65; 95% CI 0.72 to 2.58). The results became non-significant when the random-effects model was used (2 trials; 33 participants; SMD 2.14; 95% CI -1.29 to 5.57). One trial could not be included in the meta-analysis as it did not report the numerical values. The authors stated that the operative performance of virtual reality group was significantly better than the control group. Virtual reality training versus box-trainer training: The only trial that reported operating time did not report the numerical values. In this trial, the operating time in the virtual reality group was significantly shorter than in the box-trainer group. Of the two trials that reported operative performance, only one trial reported the numerical values. The operative performance was significantly better in the virtual reality group than in the box-trainer group (1 trial; 19 participants; SMD 1.46; 95% CI 0.42 to 2.50). In the other trial that did not report the numerical values, the authors stated that the operative performance in the virtual reality group was significantly better than the box-trainer group. Virtual reality training appears to decrease the operating time and improve the operative performance of surgical trainees with limited laparoscopic experience when compared with no training or with box-trainer training. However, the impact of this decreased operating time and improvement in operative performance on patients and healthcare funders in terms of improved outcomes or decreased costs is not known. Further well-designed trials at low risk of bias and random errors are necessary. Such trials should assess the impact of virtual reality training on clinical outcomes.

In recent years, bicycle-related accidents have increased in Japan; and Virtual Reality (VR) training has shown its effectiveness across various domains. This study aims to examine the effectiveness of VR safety training for bicyclists. A safety training program was developed using both VR and video formats with identical content. A randomized controlled experiment involved 30 subjects receiving VR training (VR group) and another 30 receiving video training (control group). The effectiveness was measured in terms of knowledge acquisition, risk prediction ability and enhancement of safety awareness. Although there was no significant difference between the two groups in terms of traffic rule knowledge acquisition, the VR group showed significantly greater enhancement in risk prediction ability for complex scenarios and in safety awareness. In terms of the training method, VR training was rated higher for ease of understanding, immersion and novelty; though it also led to higher eye strain and mental burden. Accordingly, to maximize VR training’s strength and minimize its negative effects, we recommend that VR safety training be designed for complex content, within an appropriate duration and could be served as a supplement or review to video training.

BackgroundBehavioral and psychological symptoms are a common challenge for healthcare professionals when managing patients with dementia, and effective verbal and nonverbal communication skills are crucial in caring for such patients.ObjectivesThis article describes a research study protocol for investigating the effectiveness of a virtual reality (VR) training program for healthcare professionals in managing disruptive behavioral and psychological symptoms of dementia (BPSD), such as aggressiveness, agitation, and care refusal.MethodsThe training scenarios were co-designed with ten healthcare professionals and implemented using an immersive 3D VR platform. Forty geriatric healthcare professionals will participate in a 2-hour training session using VR movies and a Moodle-based theoretical reinforcement. Before and after the training, participants will complete self-assessment questionnaires and knowledge-based quizzes designed to evaluate their perceived competence and understanding of appropriate communication strategies with patients displaying BPSD. The primary outcome will be the change in quiz scores between the pre- and post-training evaluations. Secondary outcomes include training satisfaction, perceived competence, and system usability.HypothesesTrial registrationThis study is registered in the French General Data Protection Regulation (GDPR) registry of Assistance Publique – Hôpitaux de Paris (N° 2022 0518135339–18 May 2022). As the trial targets health-providers and measures effects only on them (and not on providers’ patients), clinical trial registration is not required (see ICMJE guidelines: https://www.icmje.org/about-icmje/faqs/clinical-trials-registration/).

Cortical excitability of motor anticipatory in subacute stroke patients after virtual reality training: A preliminary movement-related potential study

Cybersickness (CS) is a serious usability problem in virtual reality (VR). Postural instability theory has emerged as one major hypothesis for the cause of CS. Based on such a hypothesis, we present two experiments to observe the trends in users’ trained balance ability with respect to their susceptibilities to CS. The first experiment (as a preliminary study) evaluated the effects of 2-week balance training under three different operational conditions: training in VR (VRT), training in non-immersive media with a 2D projection display (2DT), and VR exposure without any training (VRO; Baseline). The effect toward CS was tested not only in the training space but also in a different VR content to observe for any transfer effect. As results clearly indicated that the non-VR 2DT was ineffective in gaining any significant tolerance to CS, we conducted a follow-up second experiment with 1-week balance training, focusing on comparing only the VRT and VRO conditions. Overall, the experimental findings have shown, aside from the obvious improvement in balance performance itself, that accompanying balance training had the stronger effect of increasing tolerance to CS than mere exposure to VR. Furthermore, the tolerance to CS developed through VR balance training exhibited a transfer effect, that is, with reduced levels of CS in another VR content (not used during the training sessions).

To explore the impact of an immersive virtual reality (VR) training module on infection prevention and control (IPC) knowledge and attitudes of healthcare personnel (HCP) and to demonstrate the use of VR for performance assessment in cleaning and disinfection of portable medical equipment (PME). Quasi-experimental study. Two academic medical centers and three long-term care facilities. HCP in clinical roles were recruited. Pilot sites trained participants on an immersive VR training module on PME cleaning and disinfection. Participants completed the VR module and pre- and post-knowledge and attitude assessment surveys, including a post-survey on the user experience of the VR module. Performance data were collected from the head-mounted displays (HMD) on the duration of the VR session, and participant performance including in-module task completion, hand hygiene compliance, PME disinfection percentage, and in-module quiz performance. Statistical significance and effect size were calculated using paired sample t-tests and Cohen's D for pre- and post-survey results. HMD data were analyzed using descriptive statistics. A total of 60 participants were recruited; 54 were included for analysis, with improvements in knowledge and attitudes post-training. Participant user experience was rated 50.19/55. HMD data demonstrated: 22-minute mean module duration, mean of 2.15/28 tasks not completed, mean of 2.56 missed hand hygiene opportunities, and 54% PME mean disinfection percentage, and varied performance on in-module quizzes. Immersive VR training may be effective in improving HCP knowledge and attitudes in IPC concepts. Performance data collected through VR training can evaluate learner performance and be used to target training for improvement.

IntroductionLayperson cardiopulmonary resuscitation (CPR) is a key aspect in the chain of survival after cardiac arrest. New, low-cost, easily accessible training methods such as virtual reality (VR) training with a...

Due to limited space and resources, it can be difficult to train students on audiological procedures adequately. In the present study, we compared audiology training outcomes between a traditional approach and a recently developed immersive virtual reality (VR) approach in audiology students. Twenty-nine first-year audiology students participated in the study; 14 received traditional training (“TT group”), and 15 received the VR training (“VRT group”). Pre- and post-training evaluation included a 20-item test developed by an audiology educator. Post-training satisfaction and self-confidence were evaluated using Likert scales. Mean post-training test scores improved by 6.9±9.8 percentage points in the TT group and by 21.1±7.8 points in the VRT group; the improvement in scores was significant for both groups. After completing the traditional training, the TT group was subsequently trained with the VR system, after which mean scores further improved by 7.5 points; there was no significant difference in post-VR training scores between the TT and VRT groups. After training, the TT and VRT groups completed satisfaction and self-confidence questionnaires. Satisfaction and self-confidence ratings were significantly higher for the VR training group, compared to the traditional training group. Satisfaction ratings were “good” (4 on Likert scale) for 74% of the TT group and 100% of the VRT group. Self-confidence ratings were “good” for 71% of the TT group and 92% of the VRT group. These results suggest that a VR training approach may be an effective alternative or supplement to traditional training for audiology students.