Virtual reality exposure therapy for anxiety disorders: A meta-analysis

Ask the Expert: Anxiety Disorders Virtual Reality Therapy

Virtual reality (VR) as a digital technology has developed rapidly, becoming more realistic, portable, sensory and easier to navigate. Although studies have found VR to be effective for many clinical applications, patients and clinicians have described several barriers to the successful implementation of this technology. To remove barriers for implementation of VR in health care, a greater understanding is needed of how VR can integrate into clinical environments, particularly complex settings such as an intensive care unit. This study aimed to explore the perceived barriers and facilitators for the implementation of VR exposure therapy for intensive care patients and clinical staff. A qualitative study using an Interpretative Description approach was undertaken. Semi-structured focus groups were conducted with 13 participants: nine patients and four health care professionals. Focus groups explored barriers and facilitators of using virtual reality (VR) exposure therapy in intensive care. Thematic analysis was employed to produce codes and themes. In total, eight themes describing the perceived barriers and facilitators to implementing VR exposure therapy were identified. Four themes related to the perceived barriers of implementing VR exposure therapy in intensive care were identified: psychological, sensory, environmental and staff competency and confidence. There were a further four themes related to the perceived facilitators to the implementation of VR exposure therapy: staff training, patient capacity, orientation to technology and support during the intervention. This study identified novel barriers and facilitators that could be expected when implementing VR exposure therapy for patients' post-intensive care unit stay. The findings suggest that psychological barriers of fear and apprehension were expected to provoke patient avoidance of exposure therapy. Perceived barriers for staff focused on preparedness to deliver the VR exposure therapy and a lack of technological competence. Both patients and staff stated that a comprehensive induction, orientation and training could facilitate VR exposure therapy, improving engagement. This study has identified that with appropriate staff training, resources, and integration into current patient care pathways, VR exposure therapy may be a valuable intervention to support patient recovery following critical illness. Prior to undertaking VR exposure therapy, patients often need reassurance that side-effects can be managed, and that they can easily control their virtual exposure experience.

In virtual reality exposure therapy (VRET) for anxiety disorders, sense of presence in the virtual environment is considered the principal mechanism that enables anxiety to be felt. Existing studies on the relation between sense of presence and level of anxiety, however, have yielded mixed results on the correlation between the two. In this meta-analysis, we reviewed publications on VRET for anxiety that included self-reported presence and anxiety. The comprehensive search of the literature identified 33 publications with a total of 1196 participants. The correlation between self-reported sense of presence and anxiety was extracted and meta-analyzed. Potential moderators such as technology characteristics, sample characteristics including age, gender and clinical status, disorder characteristics and study design characteristics such as measurements were also examined. The random effects analysis showed a medium effect size for the correlation between sense of presence and anxiety (r = .28; 95% CI: 0.18–0.38). Moderation analyses revealed that the effect size of the correlation differed across different anxiety disorders, with a large effect size for fear of animals (r = .50; 95% CI: 0.30–0.66) and a no to small effect size for social anxiety disorder (r = .001; 95% CI: −0.19–0.19). Further, the correlation between anxiety and presence was stronger in studies with participants who met criteria for an anxiety disorder than in studies with a non-clinical population. Trackers with six degrees of freedom and displays with a larger field of view resulted in higher effect sizes, compared to trackers with three degrees of freedom and displays with a smaller field of view. In addition, no difference in effect size was found for the type of presence measurement and the type of anxiety measurement. This meta-analysis confirms the positive relation between sense of presence and anxiety and demonstrates that this relation can be affected by various moderating factors.

Computer-Based Social Anxiety Regulation in Virtual Reality Exposure Therapy

Virtual reality (VR) has been investigated as amedium for exposure therapy of anxiety disorders for 20years. Various meta-analyses have provided convincing evidence of the therapeutic efficacy of exposure therapy in VR. In recent years VR technology and its applications have considerably improved. Therefore, the current state of the art of VR exposure therapy is presented. This article provides anarrative review of current research on VR exposure therapy for anxiety disorders and major directions of development in this area. After an almost exclusive focus on specific phobias in the early days, research on more complex anxiety disorders (particularly on social anxiety disorder) is increasing. In addition, VR has become established as an experimental method to probe psychopathological processes and to elucidate the mechanism of action of (VR) exposure therapy. There is still aneed for more research into VR exposure therapy, especially in complex anxiety disorders (e. g. panic disorder, agoraphobia and social anxiety disorder) and trauma-related disorders. Furthermore, VR has become established as aresearch tool. The rapid technological development gives reason to expect acontinuing increase in VR research, in clinical as well as basic research.

Maximizing the impact of virtual reality exposure therapy for anxiety disorders

Objectives. To identify the virtual reality (VR) interventions used for the lower extremity rehabilitation in stroke population and to explain their underlying training mechanisms using Social Cognitive (SCT) and Motor Learning (MLT) theoretical frameworks. Methods. Medline, Embase, Cinahl, and Cochrane databases were searched up to July 11, 2013. Randomized controlled trials that included a VR intervention for lower extremity rehabilitation in stroke population were included. The Physiotherapy Evidence Database (PEDro) scale was used to assess the quality of the included studies. The underlying training mechanisms involved in each VR intervention were explained according to the principles of SCT (vicarious learning, performance accomplishment, and verbal persuasion) and MLT (focus of attention, order and predictability of practice, augmented feedback, and feedback fading). Results. Eleven studies were included. PEDro scores varied from 3 to 7/10. All studies but one showed significant improvement in outcomes in favour of the VR group (P < 0.05). Ten VR interventions followed the principle of performance accomplishment. All the eleven VR interventions directed subject's attention externally, whereas nine provided training in an unpredictable and variable fashion. Conclusions. The results of this review suggest that VR applications used for lower extremity rehabilitation in stroke population predominantly mediate learning through providing a task-oriented and graduated learning under a variable and unpredictable practice.

Virtual reality (VR) therapy has gained attention as a promising intervention in stroke rehabilitation, particularly for its potential to enhance motor function and promote neuroplasticity. However, its specific effects on balance, mobility, and gait remain underexplored. This review aims to provide a comprehensive evaluation of the effectiveness of VR therapy on the recovery of lower limb function in stroke survivors. Randomized controlled trials comparing VR therapy with conventional therapy were eligible for inclusion. All studies were identified through databases, such as MEDLINE, Embase, PubMed, Cochrane Library, Web of Science, and PsycINFO (up to July 2024). The primary outcomes included balance, assessed using the Berg Balance Scale (BBS), and mobility, measured with the Timed Up and Go Test (TUG) and 10-Meter Walk Test (10-MWT). Secondary outcomes included gait parameters (stride length and step length), the Functional Reach Test (FRT), the Dynamic Gait Index (DGI), and the Falls Efficacy Scale-International (FES-I). RevMan version 5.4 (The Cochrane Collaboration) software was used for the meta-analysis. A total of 2145 studies were screened, and 24 randomized controlled trials that met the inclusion criteria were included, involving 768 participants. Meta-analysis results showed that VR therapy, compared to conventional therapy, significantly improved BBS (mean difference [MD] 3.29, 95% CI 0.52-6.06; P=.02), TUG (MD -1.67, 95% CI -2.89 to -0.46; P=.007), and step length (MD 3.59, 95% CI 0.50-6.69; P=.02). However, no significant difference was observed between the 2 groups in 10-MWT (MD -0.91, 95% CI -3.33 to 1.50; P=.46), stride length (MD 5.63, 95% CI -0.73 to 11.99; P=.08), FRT (MD 2.68, 95% CI -0.30 to 5.67; P=.08), DGI (MD 1.08, 95% CI -0.41 to 2.58; P=.16), and FES-I (MD 0.16, 95% CI -2.92 to 3.24; P=.92). In the subgroup analyses, significant improvements in balance and mobility were observed in patients receiving greater than or equal to 20 sessions, with BBS improved by 5.14 points (95% CI 0.43-9.85; P=.03) and TUG reduced by 1.98 seconds (95% CI -3.33 to -0.63; P=.004). In addition, patients who received VR therapy more than 6 months after stroke showed greater improvements in BBS (MD 1.64, 95% CI 0.14-3.14; P=.03), compared to those who received VR therapy between 7 days and 6 months after stroke. Long-term VR-based therapies are more effective in improving functional ability after stroke. VR therapy has demonstrated significant potential for enhancing lower limb recovery, especially when applied with frequencies of ≥20 sessions.

The use of virtual reality (VR) technology to improve health among older adults has been receiving increased attention. VR technology has many applications and can produce benefits for people with various medical conditions such as symptom reduction or improving the diagnostic process. Despite the increase in the number of research studies of VR technology, little is known about how it has been used to improve health-related outcomes among people with dementia. This systematic review aimed to synthesize research evidence regarding the scope and impact of VR based interventions among people with dementia. Five databases, CINAHL, Embase, PsychINFO, PudMed, and Web of Science were searched to identify studies leveraging VR to facilitate interventions designed for people with dementia. Multiple keywords were used in combination including: dementia, Alzheimer’s, VR, virtual reality, and Virtual Reality Exposure Therapy. Articles were screened if they were published between 2000 through 2020. Fifteen studies met the criteria, with ten utilizing a randomized controlled trial. The VR based interventions in those studies included virtual physical exercises, virtual forests or natural landscapes, and virtual basic living activities. The results of these studies show that VR as a display medium can greatly improve decision-making, hearing, vision, motor ability, and memory in people with dementia residing either in the community or in long term care settings. Our review demonstrated that VR showed positive benefits through various applications for people with dementia. Future research is needed to make VR interventions more customized toward effectively meeting the needs of people with dementia.

Among military personnel who participated in combat, the prevalence of post-traumatic stress disorder ranges from 3 % to 11 %. Up to 40 % of patients with post-traumatic stress disorder may not respond to classical treatments such as pharmacotherapy or psychotherapy. Therefore, it is extremely important to develop neurobiological non-drug rehabilitation methods that will more accurately target the neural mechanisms of sensorimotor integration. In this regard, we consider it advisable to analyze whether exposure therapy in virtual reality will effectively address a wide range of symptoms in post-traumatic stress disorder. We conducted a search for articles on the Medline (PubMed) website up to and including March 3, 2025. The search bar was a query for (VR OR virtual reality) AND (PTSD OR post-traumatic stress disorder). We found 25 articles. After deleting the articles that did not meet the criteria, 7 articles remained. Patients with post-traumatic stress disorder report a high degree of immersion when using exposure therapy in virtual reality, and studies show that increased emotional engagement can improve treatment outcomes. Exposure therapy in virtual reality may be particularly useful in the treatment of resistant post-traumatic stress disorder, as it allows the patient to activate traumatic memory more intensively, which is necessary for the extinction of conditioned fear. Exposure therapy in virtual reality had a positive effect on a range of post-traumatic stress disorder symptoms in combat veterans, and all treatment outcomes persisted for 3, 6, and 12 months, although the clear cost advantage and clinical benefits of exposure therapy in virtual reality compared to traditional exposure therapy have not yet been demonstrated.

BackgroundHemiplegia resulting from a stroke frequently causes considerable difficulties in hand function. Virtual reality (VR) therapy has evolved as an innovative and engaging method to facilitate sensorimotor rehabilitation.ObjectiveThis meta-analysis assessed the efficacy of VR-based therapies on hand function in post-stroke hemiplegic patients. The study evaluated the impact of treatment duration, type of VR (immersive, semi-immersive, non-immersive), and stroke stage (subacute versus chronic) on outcomes.MethodsA comprehensive search of six databases until September 2024 identified randomized controlled trials (RCTs) that compared VR therapy with conventional rehabilitation or sham control. The primary outcomes consisted of validated, hand-specific performance metrics, including the Fugl-Meyer upper extremity subscale, Action Research Arm Test, Box and Block Test, Jebsen-Taylor Hand Function Test and Box and Block Test.ResultsTwenty-five RCTs involving 844 participants were evaluated. VR therapy significantly enhanced hand function (SMD = 0.68; 95% CI: 0.41-0.95; p < 0.00001), while there was considerable heterogeneity (I2 = 71%). Subgroup analysis indicated that semi-immersive VR had the most significant benefit (SMD = 1.03), whereas interventions with a cumulative training duration beyond 12 h, along with those administered to subacute patients, demonstrated greater effect size in hand function relative to shorter interventions (pooled SMD for >12 h = 0.94; 95% CI: 0.66-1.23).ConclusionThis meta-analysis suggests that semi-immersive VR therapy improves hand function in post-stroke patients, especially when the total cumulative treatment duration exceeds 12 h. Future research should determine the principal treatment elements, establish uniform dosing methods, and evaluate long-term results, including activities of daily living and quality of life.

Many older adults desire to age in place, a term used to describe living independently versus transitioning to a residential care facility. Virtual reality (VR) has the potential to positively impact the functioning of older adults as an assessment or intervention to help compensate for lost or declining functions. VR captures a wide variety of technologies ranging from non-immersive to fully immersive, designed to give the user a feeling of presence. To date, VR interventions have been used with older adults including improving health outcomes, improving functional abilities, and for neuropsychological purposes. A handful of meta-analyses (M-As) attempt to summarize the overall effectiveness of VR interventions with older adults, but many contain methodological issues and cover the gamut of VR technology. The present M-A fills a gap in the literature by assessing the literature on immersive VR interventions for older adults. Sixteen articles met inclusion for meta-analysis, and 41 effect sizes (ES) were calculated. ES were grouped by category, neuropsychological, health/mental health, functional, and eight meta-analyses were performed with one exploratory analysis. Results revealed small, significant ES for VR interventions on measures of global cognition, simple attention tasks, executive functioning tasks, anxiety ratings, and pain ratings. Nonsignificant ES were found for stress ratings, gait speed, depression ratings, and TUG task (exploratory M-A). Continuing to develop affordable, safe interventions to assist with aging in place is important as the number of older adults continues to increase. Immersive VR is a promising avenue to continue exploring to better assist the aging population.

Tinnitus is the sensation of hearing a "ringing" or "buzzing" in the ears without any external stimuli. Possible causes of tinnitus include hyperactivity in central auditory nuclei, 1 tonotopic reorganization in the auditory cortex, 2 noise exposure, 3 underlying conditions, 4 and use of certain medications. 5 Between 5% and 30% of adults suffer from tinnitus, 6 with about 50% having idiopathic tinnitus. 7www.Shutterstock.com, virtual reality, artificial intelligence, tinnitus.Patients' emotional well-being is affected by tinnitus, 8 including increased anxiety levels. 9 The amygdala and other nonauditory structures in the brain may be involved in tinnitus maintenance by mediating the emotional response in tinnitus patients. 10,11 Novel techniques like the use of vagus nerve implants have been explored for tinnitus mitigation. 12 Although there is no cure for tinnitus yet, effective management techniques include relaxation/mindfulness training, 13 amplification, 14 and sound therapy for both hearing aid users 15 as well as cochlear implant recipients. 16 Sweetow and Sabes 17 evaluated the effects of combining amplification and sound therapy for tinnitus management. The sound therapy included white noise and fractal tones from Widex Zen Therapy. 18 Participants reported a significant reduction in tinnitus annoyance after listening to both sounds but reported feeling more relaxed when hearing the fractal tones. Stress reduction is a significant component in managing chronic health conditions. Distressed patients may turn to social media or mobile applications to explore solutions. 19–22 Techniques for reducing stress can decrease the impact of tinnitus. 23 A randomized controlled trial (RCT) discovered that 16 hours of therapy over two months led to significant reductions in tinnitus measures and reactions to tinnitus. 13 Therapy techniques using virtual reality (VR) have been shown to reduce anxiety in patients with chronic conditions. 24 VR uses specialized equipment that presents visual and auditory information to create specific simulated environments. The use of VR has proven to aid in acute pain management of patients receiving routine and invasive medical procedures. 25 VR also has proven to have significant effects on all affective domains mediated by the limbic system, 26 which is also involved in the perpetuation of tinnitus. 27 Therefore, VR therapy may lessen the engagement of the limbic system in tinnitus perception by delivering relaxation and sound therapy components. The aim of the present study 28 was to explore whether the use of VR combined with conventional sound therapy helped in mitigating tinnitus and reactions to tinnitus as compared to conventional sound therapy alone. STUDY PARTICIPANTS Adults with continuous, chronic, subjective tinnitus were sought as study participants. Adults with hearing aids were recruited if they did not have tinnitus management features programmed into their hearing aids. Twenty adults with both unilateral and bilateral tinnitus (11 males, nine females) between the ages of 18 and 76 years were enrolled in the study. PROCEDURES This study was an RCT with a crossover design. Each participant received two sessions, one week apart. The control intervention provided sound therapy alone, while the experimental intervention provided sound therapy with VR. The sound therapy component used the Zen Aqua program from Widex. The sounds were played for 15 minutes through a computer loudspeaker at a comfortable volume level. The experimental intervention included 15-minute viewings of natural scenes, including flowing streams, lakes, and gorges, presented via VR goggles, while listening to the Zen sounds. Ten participants received the control intervention followed by the experimental intervention and 10 received the experimental intervention followed by the control intervention. Participants' tinnitus loudness, tinnitus functional index (TFI), 29 and minimum masking level (MML) scores were recorded before and after each intervention. RESULTS A multilevel mixed-effects linear regression model accounting for confounding variables revealed that the mean tinnitus loudness and TFI scores reduced significantly (p=0.015 and p=0.043, respectively) after the experimental intervention compared to the control intervention. The MML differences were not statistically significant, but mean values were reduced after the experimental intervention than after the control intervention (p=0.090). DISCUSSION Tinnitus loudness, MMLs, and TFI scores have been used to portray the effectiveness of tinnitus management strategies. 30–32 In the present study, since tinnitus loudness levels and TFI scores improved significantly after receiving the experimental intervention, it can be concluded that these factors are positively affected by combining VR with sound therapy in a controlled setting. While there was no significant improvement in MMLs after the experimental intervention, this could be due to the study procedures causing participants' attention to be focused on their tinnitus. Many tinnitus therapy techniques recommend having an active lifestyle to redirect attention from tinnitus. 33 Previous research has demonstrated that sound therapy, especially fractal tones, can be used to induce relaxation and manage tinnitus. 34,35 In the Sweetow and Sabes study, 17 86% of participants reported feeling relaxed after listening to the wind-chime-like fractal tones. Simonetti et al. 36 discovered a significant reduction in tinnitus handicap inventory (THI) 37 scores after studying the effects of fractal tones on patients with chronic tinnitus. In the present study, participants listened to fractal tones either standalone or with a VR video. Following these interventions, reductions in tinnitus loudness, MMLs, and TFI were present. The emotional and auditory effects of sound therapy can partially explain this trend. For more than two decades, VR has been used to treat conditions such as phobias, 38 anxiety disorders, 24 eating disorders, 39 and intractable pain. 40 A systematic review of 20 studies found VR to be an effective treatment for decreasing acute pain. In 2010, a theoretical framework for the use of VR to manage chronic subjective tinnitus was proposed. 41 Malinvaud et al.42 applied this framework to assess the differences in tinnitus attributes between those receiving VR and those receiving cognitive behavioral therapy (CBT). Without significant differences found between interventions, both interventions showed improvement on THI scores, subjective tinnitus severity scale, and the hospital anxiety and depression scale. 43 The Malinvaud 44 study concluded that VR can be at least as effective as CBT when managing tinnitus. The present study showed significant reductions in tinnitus loudness and TFI for the experimental intervention as compared to the control intervention, supporting these results. LIMITATIONS AND FUTURE DIRECTIONS The present study was conducted in a laboratory setting. Future studies could explore the effects of VR on tinnitus in more natural settings, such as at home. Stimuli can also be presented for a longer duration with more sessions. A longitudinal study would be able to analyze the long-term effects of VR on tinnitus. Future studies could also use a larger participant group. Genetic risk modeling can be used to investigate the biological mechanisms underlying tinnitus. In the present study, participants benefitted from using VR combined with sound therapy for 15 minutes in a laboratory setting. After this intervention, tinnitus loudness levels, MMLs, and TFI scores were reduced when compared to receiving sound therapy alone. Therefore, VR combined with sound therapy is a promising potential technique for managing tinnitus. Future studies could alter the stimuli, mode of delivery, number of sessions, total therapy duration, and number of participants. More trials will be needed before confirming the use of VR and sound therapy to manage tinnitus in a clinical setting.

Background and Purpose. The use of virtual reality (VR) therapy among individuals with spinal cord injury (SCI) is a relatively new rehabilitation approach replicating real-life scenarios. The aim of this study was to evaluate the effectiveness of VR therapy for improving gait and balance in individuals with SCI. Methods. Databases of PubMed, Web of Science, Scopus, SportDiscuss, and CINHAL were searched from inception until September 2019. Two independent reviewers screened articles for inclusion, extracted data, and evaluated methodological quality of the trials. Results. Ten trials, including 3 randomized clinical trials (RCTs) and 7 pre-post trials, with a total of 149 participants were analyzed. Meta-analysis of RCTs demonstrated significant improvement in sitting balance (standardized mean difference [SMD] = 1.65; 95% CI 1.21-2.09; P < .01) after VR therapy with conventional rehabilitation compared with only conventional rehabilitation. Also, pre-post studies using VR therapy without a control group showed improvement in standing balance (Berg Balance Scale, MD = 4.22; 95% CI 1.78-6.66; P < .01 and Activities-specific Balance Confidence scale, MD = 8.53; 95% CI 2.52-14.53; P = .01) and a trend for improvement in gait (SMD = 0.34; 95% CI 0.02-0.66; P = .04). Conclusion. This study demonstrated the beneficial effects of VR therapy to enhance sitting and standing balance and showed a trend of gait improvement in individuals with SCI. This conclusion is based on mainly preliminary data and therefore, more RCTs are needed to confirm the effects of the use of VR in individuals with SCI.

A number of carefully controlled studies have documented the effectiveness of traditional imaginal exposure for the treatment of post-traumatic stress disorder (PTSD). Virtual reality (VR) exposure therapy is based on a similar logic but rather than self-generating imagery, patients wear a VR helmet and go into a three-dimensional (3-D) computer generated virtual world to help them gain access to their memory of the traumatic event. Recent preliminary research has shown that some patients who fail to respond to traditional therapy benefit from virtual reality exposure therapy, presumably because VR helps the patient become emotionally engaged while recollecting/recounting/re-interpreting/emotionally processing what happened during the traumatic event. The present paper presents a brief overview of a new VR World we developed to provide virtual reality therapy for terrorist bus bombing victims in Israel, and a brief description of our research protocol and measures (for details, see www.vrpain.com).