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Virtual Reality as a support tool

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DOCUMENT 16 FOI 25/26-1343

Virtual Reality as a support tool

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The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

Research question: How can Virtual Reality (VR) be used to implement NDIS supports?

What considerations would go into determining if VR mediated supports are reasonable and necessary?

What are the benefits and risks of VR in different therapeutic / support contexts?

How much does virtual reality equipment cost and are there other associated costs?

Date: 26/04/2022 Requestor: Karen redacted: s22(1)(a)(ii) - irrelevant material

Endorsed by (EL1 or above): n/a Researcher: Aaron redacted: s22(1)(a)(ii) - irrelevant material Cleared by: Stephanie redacted: s22(1)(a)(ii) - irrelevant material

1. Contents

Virtual Reality as a support tool ……………………………………………………………………………………. 1

    1. Contents ……………………………………………………………………………………………………….. 1
    1. Summary ………………………………………………………………………………………………………. 2
    1. What is Virtual Reality? ……………………………………………………………………………………. 2
    1. VR Technology ………………………………………………………………………………………………. 4
    • 4.1 Accessibility of VR technology ……………………………………………………………………….. 5
    • 4.2 Cost of some VR devices ……………………………………………………………………………… 6
    1. Virtual Reality as therapy and skills development ………………………………………………… 6
    • 5.1 Autism Spectrum Disorder …………………………………………………………………………….. 8
    • 5.2 Cerebral Palsy …………………………………………………………………………………………….. 8
    • 5.3 Dementia ……………………………………………………………………………………………………. 9
    • 5.4 Down syndrome …………………………………………………………………………………………… 9
    • 5.5 Mental health and psychiatric conditions ……………………………………………………….. 10
    • 5.6 Multiple Sclerosis ……………………………………………………………………………………….. 11
    • 5.7 Parkinson’s disease ……………………………………………………………………………………. 12
    • 5.8 Spinal Cord Injury ……………………………………………………………………………………. 12
    • 5.9 Stroke ………………………………………………………………………………………………….. 12
    • 5.10 Traumatic brain injury ………………………………………………………………………………. 13
    1. Risks of virtual reality use ………………………………………………………………………………. 14
    1. Reasonable and necessary considerations ………………………………………………………. 14
    1. References ………………………………………………………………………………………………….. 15
    1. Version control ……………………………………………………………………………………………… 21

2. Summary

This paper gives an overview of virtual reality (VR), its use for people with disabilities and its potential for use by NDIS participants. VR is a wide-ranging technology that can supplement therapies and support patients in a variety of ways. The effectiveness of VR as a therapeutic medium varies with condition and symptoms targeted.

A frequent barrier cited by systematic reviewers is the difficulty of combining results due to the heterogeneous nature of the technology and ways of implementing the technology in clinical and research settings. Further research is required to say reliably whether and how much benefit is gained by the key features of VR such as immersion and interaction.

Considering the rapidly changing technology and the already expansive literature on the use of virtual reality for people with disabilities, further research focusing on specific cohorts may be beneficial.

3. What is Virtual Reality?

VR is a form of human-computer interaction which reproduces sensory information for a user in the absence of the real object typically associated with the information (Doerner et al, 2022). There is no universally acknowledged definition of VR (Doerner et al, 2022) and there may be

no list of necessary and sufficient criteria by which we can say conclusively that some piece of technology is or is not VR.

However, VR is often distinguished from other presentational or representational media (eg. film, animation, computer games etc.) by its multi-sensory content being three-dimensional and variable in real-time based on life-like bodily movements (Doerner et al, 2022). For example, whereas in a traditional computer game you might adjust the perspective on a two-dimensional display by using a mouse or controller, in a VR environment you would adjust the perspective on a three-dimensional display by turning your own body.

VR systems typically have the goal of maximising immersion and presence. Presence is the user’s feeling of actually being in the virtual environment (Doerner et al, 2022). Immersion refers to how well the technical features of the system promote presence. A system is more highly immersive when it:

  • limits information from outside the VR system
  • includes multiple sense modalities
  • has a panoramic rather than narrow or limited display
  • has vivid, high resolution, high fidelity displays (Doerner et al, 2022).

Bell et al describe an immersive VR system involving an HMD displaying three-dimensional images on a screen:

Images are continuously rendered relative to the position of the head and can capture movements of the body, allowing users to explore and interact with objects and avatars (digital agents) in the virtual space. These virtual environments are either programmed using specialist software to create computer-generated, photorealistic images, or filmed with specialized cameras to create 360-degree videos of real-world scenes that can be replayed within VR. Together, these capabilities make it possible for researchers and clinicians to observe and record individuals in highly controlled and near-natural environments, in real time (2020, p.169).

There is some disagreement in the literature about the meaning of immersion and presence. Doerner et al note that head-mounted devices/displays (HMDs) and multi-screen display systems are sometimes called immersive or fully immersive systems. Desktop displays and single screen displays are sometimes called non-immersive or semi-immersive systems (Doerner et al, 2022). Brassel et al. use the term slightly differently so that immersive refers only to HMDs, semi-immersive refers to only projection-based VR and non-immersive refers to screen-based or desktop VR (Brassel, 2021).

The lack of definitional certainty can lead to some borderline cases. For example, there is some ambiguity in the literature about whether exercise game consoles like the Nintendo Wii or XBOX Kinect should count as non-immersive VR or just a regular videogame (Iosa et al, 2022; Fandim et al, 2021; Halldorsson, 2021). While these systems do utilise some responsive bodily movements (e.g swinging your arm to swing a virtual tennis racket), they do not typically

have 3D displays and interaction or responsiveness is prioritised over immersion or presence. Immersion is a key feature of the definition of VR for a lot of researchers (Fandima et al, 2021; Khan et al, 2021; Jin et al, 2022), which makes the idea of non-immersive VR an oxymoron. Borderline cases and variable applications of VR may make synthesis of results difficult when different systems are in play. Iosa et al. argue that misuse of the term “virtual reality” is one limitation in the current literature on use of gaming in neurorehabilitation (Iosa et al, 2022). This problem is meliorated at least partially if researchers make their definition of VR explicit.

A related concept which is becoming quite common is augmented reality (AR). Instead of replacing the real world with a virtual world, AR supplements or integrates virtual elements into reality (Doerner et al, 2022). For example, a pair of AR glasses might integrate with a GPS system and use visual cues to point to user to their destination. Cieslik et al offer this taxonomy:

Depending on what real and virtual objects are presented in the image, there are four basic categories: (1) Reality, the real world; (2) Augmented Reality, where computer-generated data are merged into a real-world image; (3) Augmented Virtuality, where real-life data are merged into a computer-generated world; and (4) Virtual Reality, where the world has been created entirely by a computer. (2020, p.2)

4. VR Technology

Note: links are provided below to illustrate technologies or products. VR technology is developing quickly with new products entering the market and old products being discontinued. The examples may not be currently commercially available products or the best or most cost effective products.

VR systems can be recognised by typical technological features such as HMDs, stereo-glasses, motion or spatial tracking devices, data gloves or controllers (Bell et al, 2020, p.69; Doerner et al, 2022). Virtual reality can also be implemented by single or multi-screen systems including rooms or domes (Doerner et al, 2022).

Most commercially available VR kits include a headset, controllers, cords and base stations. Examples include Valve Index, HTC Vive Pro and HTC Vive Cosmos Elite. The headset contains the stereoscopic display screen and may also contain motion sensors. The controllers are handheld devices which track hand movements. The base stations are devices which are placed at appropriate points around the room to track movements of the body. Most VR kits require a computer to run. The Valve Index and HTC models recommend minimum specifications for the computer. The headset will be tethered to the computer with a long cord or via some cordless technology. The PlayStation VR has a separate headset which interacts with the PlayStation4 or PlayStation5 console, controllers and camera. The Oculus Quest 2 is a stand-alone system that does not require base stations or a separate computer to run (Greenwald, 2022, The Big Question: Which VR Headset Is the Best?).

Some commercially available VR kits make use of a person’s mobile device. The mobile device is fitted into an HMD and may be linked to a controller. For example, a Samsung phone can connect to the Samsung Gear SM-R325 providing some VR features including motion sensing (User Manual SMR325, 2017). This technology is often cheaper than stand-alone VR systems or systems that run using a computer. However, the industry may be moving away from this type of technology and so ongoing support could be a problem (Greenwald, 2022, What happened to phone-based VR?).

4.1 Accessibility of VR technology

VR technology may be able to improve functional capacity of people with disabilities in some settings (refer to 5. Virtual reality as therapy and skills development). It can also make experiences and situations more accessibility for people with disabilities. For example, Shaker et al (2020) have designed a VR tour program that allows people to become familiar with a place before attending it in person, thereby potentially reducing anxieties about novel situations.

However, the technology itself still has some accessibility issues. The content of VR programs are still primarily visual, even though they often include auditory and haptic inputs as well (Mott et al, 2019). This can limit involvement from people with visual impairments. Teofilo et al outline accessibility features that have been added to an example system. They include:

  • zoom – giving the user the ability to magnify content
  • inverted colours – can allow users to change the display colours to suit their need
  • auto-reading – audio information is provided when the user hovers over an element
  • captions – transcription of dialogue or description of content (Teofilo et al, 2018).

Microsoft is developing a ‘Canetroller’ that could render content haptically exactly how a cane user would experience it (Mott et al, 2019).

Other concerns include the way VR systems or software respond to the user’s body. VR allows users to do things they wouldn’t ordinarily be able to do (eg. fly) but developers also often strive to make the system or program mimic one’s own bodily movements as closely as possible. This can potentially duplicate physical barriers from the real to the virtual environment (Mott et al, 2019).

The physical features of the device can also pose barriers. The HMD can be difficult or impossible to wear for people with glasses, hearing aids, cochlear implants (Mott et al, 2019). Most commercially available VR systems depend on a controller, which requires a level of grip strength and manual dexterity to operate (Mott et al, 2019). This can be addressed with integration of other types of interaction device. Examples include voice commands, eye-gaze technology or the Leap Motion Controller, which tracks the movements of the hand and fingers via camera (Aguilera-Rubio, 2022; Mott et al, 2019).

4.2 Cost of some VR devices

System Equipment needed Cost
1 Valve Index Included: headset and controllers, base stations. Not included: PC with minimum dual-core CPU, Nvidia GeForce GTX 970 or AMD RX 480 GPU. $2,500 (not including PC)
2 Oculus Quest 2 Included: Headset and controllers Not included: nil $479
3 HTC Vive Pro full kit Included: headset Not included: controllers, base stations, PC with Intel Core i5-4590 or AMD FX 8350, equivalent or better and NVIDIA GeForce GTX1060 or AMD Radeon RX480, equivalent or better. $1899 (not including PC)
4 HTC Vive Cosmos Elite Included: headset, controllers and base stations Not included: PC with Intel Core i5-4590 or AMD FX 8350 equivalent or better, and NVIDIA GeForce GTX 970 4GB, AMD Radeon R9 290 4GB equivalent or better $1699 (not including PC)

5. Virtual Reality as therapy and skills development

VR is currently being used for rehabilitation, therapy and skills development targeting pain, physical and motor function, social and vocational skills, and capacity to complete daily activities.

There are several potential benefits of VR based therapies or skills building programs. Many researchers note that VR has the potential to improve user’s motivation to take part in therapy or stick to a skills development program (Brassel et al, 2021; Alashram 2019; Demers et al, 2021; Zhao et al, 2020; Cortes-Perez et al, 2021; Aguilera-Rubio et al, 2021; Jin et al, 2022). VR may be especially beneficial for people who live in rural or remote areas with limited

access to allied health services or who otherwise experience barriers to accessing conventional therapies.

VR programs are customisable in a way that might aid in a therapeutic or skills development context. Skills development programs can be specified to progressively adjust difficulty of tasks. Virtual scenarios can be designed to provide low-risk environments to talk with strangers, interview for a job, go shopping or confront fears or anxieties. However, there are mixed results about the transferability of skills gained in a virtual world to their real-world cognates.

This variability in VR programs as well as the multitude of available systems and rapid technological development has led to difficulties in drawing reliable conclusions in the literature. Most of the systematic reviews discussed above include multiple VR systems, with multiple or undisclosed therapy programs with potentially relevant clinical differences. For example, immersion has been shown in a few studies to mediate effect size of treatment, with more immersive systems showing larger effect sizes (Dellazizzio et al, 2020; Zhu et al, 2021; Aguilera-Rubio et al, 2022). However, many studies draw conclusions based on combined results for fully-, semi- and non-immersive VR.

Technological change causes an additional barrier to research and its applications as new VR systems are created and old systems are discontinued. For example, much of the research on low immersive VR exercise games utilises the Ninento Wii or XBOX Kinect. Both systems have been discontinued. It would need to be established that the results achieved for those systems are also achievable by or representative of other systems.

The literature relating to VR use in a medical or therapeutic context is growing rapidly. At the time of writing this research paper, a search of the PubMed database for the phrase “virtual reality” returns 15,926 results since 1991 with 8,120 results from the last 5 years. A search for “virtual reality” AND:

  • “disability” returns 633 results, with 326 from the last 5 years
  • “autism” returns 182 results with 115 from the last 5 years
  • “PTSD” returns 232 results with 96 from the last 5 years
  • “cerebral palsy” returns 198 results with 90 from the last 5 years
  • “stroke” returns 1,018 results with 501 from the last 5 years.

Due to the volume of available research I have restricted source material to systematic reviews into the use of a variety of VR tools for rehabilitation, therapy and skills development. Discussions of the use of VR for assessment, screening and staff training have been excluded as they are less relevant to the research question. Further targeted research into other clinical uses of VR or into specific conditions or impairments may be beneficial to get a more detailed picture of VR’s use and benefit.

5.1 Autism Spectrum Disorder

Use of VR based therapies for people with Autism Spectrum Disorder (ASD) has theoretical support due to the preference of many people with ASD for computer mediated ways of learning, communicating and relaxing (Valencia et al, 2019; Berenguer et al, 2020). However, the evidence for the effectiveness of VR in improving outcomes for people with ASD is still preliminary (Mesa-Gresa et al, 2018; Dellazizzio et al, 2020).

Two recent systematic reviews found preliminary and non-conclusive support for the effectiveness of VR type technologies in improving outcomes for children and adolescents with ASD (Mesa-Gresa, 2018; Berenguer, 2020). Studies reviewed targeted social interaction, pretended play, communication, emotion, recognition, daily living skills, attention, phobias, motor skills and physical activity (Berenguer, 2020; Mesa-Gresa, 2018). The majority of included studies found positive support for the effectiveness of therapies including VR or AR. Barriers to more reliable conclusions include: low levels of evidence (e.g large number of case studies or single subject designs), small sample sizes, disproportionate representation of boys in samples, lack of longitudinal studies, focus on high functioning ASD, lack of control groups or inappropriate control groups, (Mesa-Gresa, 2018; Berenguer, 2020).

The variety of VR technologies and implementations is of particular relevance as it prevents adequate synthesis of results. Studies used VR driving simulators, HMDs, smartphones, tablets, computers, consoles and smartglasses. Technologies were implemented in various ways as well, including mirror-type experiences where the user could see themselves with different facial expressions or performing different actions, augmented pop-up story books, 3D concept maps overlayed onto movies or games, daily living activity simulators (eg. driving, shopping) or avatar based virtual environments (Mesa-Gresa, 2018; Berenguer, 2020). Reviews did not draw conclusions about dosage or the relevance of immersion or presence.

5.2 Cerebral Palsy

A 2021 systematic review found VR is well-placed to integrate motor learning principles into therapy practice. For example, VR based therapies can be motivating, incorporate regular feedback and gradually increase in complexity or difficulty. However, the actual integration of these principles into current studies is mixed (Demers et al, 2021).

The authors also found generally lower study quality (Poor or Fair on the Downs and Black checklist) (p.4), which seems to be a feature of a body of evidence composed in large part of small pilot or proof-of-concept studies (Demers et al, 2021).

A handful of systematic reviews have returned mixed results. A review into VR motor function interventions for stroke, Parkinson’s disease and cerebral palsy found general endorsement of VR techniques, except in the case of cerebral palsy (Amirthalingam et al, 2021). Another found VR therapy improves balance and walking but results were limited by small sample sizes, lack of RCTs and variety of VR technology (Warnier, Lambregts, Van De Port, 2020). A review of

RCTs describing VR treatment for hand function in children with CP found mixed results with 4 studies reporting improvement and 2 studies reporting no improvement (Rathinam et al, 2019).

Fandim et al’s 2021 systematic review of VR interventions for children and young adults with CP found mixed results of generally low or very low quality of evidence. The authors found low or very low quality of evidence supporting VR plus conventional therapy in improvement of upper limb function and lower limb strength compared to conventional therapy alone. They also found low or very low quality of evidence showing no benefit to VR plus conventional therapy in improvement of postural control, postural stability, balance and gait (Fandim et al, 2021). Comparing VR with and without conventional therapy, the authors found very low quality evidence that VR improves postural control and balance immediately post intervention and low quality evidence that there is no benefit of VR on these outcomes after a short term follow up. The authors also found low or very low quality evidence showing no improvement with VR in upper limb function, gait speed or functional strength (Fandim et al, 2021).

5.3 Dementia

A 2021 review into use of digital technologies in intervention for people with dementia reviewed only 3 studies including the use of VR tools. One found a positive effect of VR tools in improvement of activities of daily living. One found a positive effect of VR tools for improvement in emotional regulation. One found no statistically significant effects. All studies were of fair study quality (using the NIH assessment tool) (Neal et al, 2021).

Zhu et al (2021) reviewed 11 RCTs of generally high quality targeting domains such as attention, executive function, memory, visuo-spatial ability, global cognition, gait and balance. Analysis showed a significant moderate positive effect on attention, memory, global cognition and balance. The authors found a small positive effect on motor function and no significant effect on visuo-spatial ability or gait (Zhu et al, 2021). The meta-analysis was also able to show that immersion mediates effect size such that fully immersive VR has a greater effect (Zhu et al, 2021). In contrast, a review of studies of exercise games found evidence of improvement to cognitive function for people with dementia (Zhao et al, 2020). Also of note, the authors found that all studies which tracked motivation showed the technology could increase motivation to engage in cognitive and physical exercise (Zhao et al, 2020). This is supported by Clay et al, who reviewed 4 studies using fully immersive VR tools. They found that while there was no reliable evidence of therapeutic benefit, the subjects were motivated to complete the tasks involved in treatment (Clay et al, 2020).

5.4 Down syndrome

Two systematic reviews have addressed the use of virtual reality tool for people with Down syndrome. Boato et al noted improvements in global motor skills, balance, postural control, body layout, spatial organization, visual-motor cognition skills and sensorimotor function after treatment with a non-immersive exercise game (Boato et al, 2022). They conclude that VR-type games have the potential to impact daily living, language, social and learning skills of

people with Down syndrome (Boato et al, 2022). However, the authors did not report the study designs or quality of the studies reviewed and so results are not reliable. More suggestive is the review from Stander et al, who included 6 studies of overall moderate levels of evidence and good study quality. They found use of non-immersive VR in combination with physiotherapy or occupational therapy did not improve motor proficiency though it could improve agility and strength in people with Down syndrome, and balance and coordination in children with Down syndrome (Stander et al, 2021).

5.5 Mental health and psychiatric conditions

Two meta-reviews give a good picture of the current state of evidence for use of VR in the treatment of mental health and psychiatric conditions. Cieslik et al (2020) reviewed 70 systematic reviews reporting on the use of VR in psychiatric disorders. The reviews covered pain perceptions, post-traumatic stress disorder, phobias, attention deficit hyperactivity disorder, psychosis and depression. The results were largely in favour of VR across all categories. 23 systematic reviews agreed that VR could be a useful non-pharmacological technique for the management of pain. 23 systematic reviews agreed that VR could be a good accompaniment to traditional treatments of anxiety and phobias. 17 reviews of various conditions including psychosis, depression, substance disorders, eating disorders, schizophrenia, spatial neglect cognitive impairment and dementia all confirmed the effectiveness of VR compared to conventional treatments. One review stated there was no good quality evidence for using VR for treatment compliance for people with schizophrenia (Cieslik et al, 2020; Dellazizzo et al, 2020).

Despite the overall positive results of the included reviews, Cieslik et al echo a common observation in the literature on VR, that is, the variety of hardware and software used in interventions is often not well reported, which is a barrier to reliable synthesis of results (Cieslik et al, 2020; Skurla et al, 2021). Further, while Cieslik et al claim the majority of included studies are of good methodological quality, they were not able to offer specific meta-analyses of results. When only papers that include meta-analysis were reviewed then assessment of quality is much lower. The meta-review from Dellazizzo et al (2020) into uses of VR in psychiatric disorders focussed on quantitatively evaluable meta-analyses. In general, the meta-analyses reviewed were found to be of very low to moderate quality.

The authors limited their investigation to 11 papers and were able to offer more specific results about effect sizes of VR based treatments. They found that VR therapy showed moderate to large effect sizes in the treatment of anxiety disorders or post-traumatic stress disorder but showed no significant difference with conventional therapy. VR has been shown to reduce symptoms of depression and may improve cognition and emotion in subjects with neurocognitive disorders (Dellazizzo et al, 2020).

Recent evidence into more specific populations or focussing on more specific interventions is mixed. Halldorsson et al. (2021) recommend VR therapies for mental health should not be offered to children and young people until further research is conducted. VR environments

may produce anxiety in children and there is only minimal evidence which focussed on children. In contrast, Kelson et al (2021) recommend VR therapies for reducing psychological distress in adolescents but base this assessment on only 4 RCTs. Jahn et al. (2021) looked specifically at fully immersive VR as a tool for cognitive rehabilitation in people with cognitive impairment, stroke, schizophrenia and ADHD. They found therapies could improve theory of mind, attention, visual working memory and executive function. The largest effect sizes were found in studies that involved training in activities of daily living like cooking or shopping. However, there is very little evidence of a transfer effect from VR training to real life activities. Larger studies are needed to establish conclusions (p.9). In contrast, Schroeder et al (2022) found evidence of transference of skills from virtual to real situations. They noted improvements in real-world social skills, community participation, managing housework, job performance as well as increased likelihood of receiving a job offer. However, they also acknowledge the small sample sizes which may affect the reliability of the results.

5.6 Multiple Sclerosis

A number of systematic reviews have focused on the use of VR tools to improve balance, gait and motor function for people with multiple sclerosis. Webster et al (2021) found conflicting evidence that VR tools could improve upper limb motor function with no consensus about which technology is best placed to achieve outcomes. Truijen et al (2022) found improvement in both treatment and control groups with no significant difference in outcome. They concluded that non-immersive VR type exercise games could be used to prolong physical therapy. Results from Truijen et al are consistent with an earlier review from Casuso-Holgado et al (2018) who found VR training is more effective than no treatment and as effective as conventional therapy in improving balance and gait.

Two 2021 reviews have obtained more positive results. Calafiori et al (2021) reviewed 9 RCTs with a total of 209 participants and concluded that balance can be improved with the use of non-immersive VR type exercise games. Nascimento et al (2021) found VR exercises were no better than conventional exercises in improving functional mobility but may offer greater benefit to fatigue, balance and quality of life.

Of particular interest is a 2021 review from Cortés-Pérez et al who found that VR based therapies can reduce the functional impact of MS. Specifically, VR based therapy can reduce the impact of MS and improve overall quality of life compared to no intervention, can reduce fatigue more than conventional therapy, and when combined with conventional therapy can improve the physical and mental dimensions of quality of life compared with conventional therapy alone (Cortés-Pérez et al, 2021). These results are limited by the number of studies, low sample sizes and medium level quality of the studies reviewed. Also noteworthy, the majority of studies investigated the use of non-immersive exercise games. Results may not generalise for more costly fully or semi-immersive VR tools (Cortés-Pérez et al, 2021).

5.7 Parkinson’s disease

An early review of VR tools to improve outcomes in patients with Parkinson’s disease found low quality evidence that VR and physiotherapy showed comparable improvements in gait, balance and quality of life and low quality evidence of an improvement in step and stride length in comparison to physiotherapy (Dockx, 2016).

The ambiguous findings from Truijen et al (2022), discussed in 4.6 Multiple Sclerosis also include patients with Parkinson’s disease. More positive results were found in Wu et al (2022). The authors found a significant improvement in balance compared to the control groups. In addition they were able to show that specially designed rehabilitation systems were more effective than commercially available systems. These results are consistent with Sevcenko and Lindgren (2022), who show that VR is at least as effective as conventional therapy in patients with Parkinson’s when considering balance, gait and function.

5.8 Spinal Cord Injury

Two systematic reviews of studies on pain in patients with spinal cord injury showed reduction in pain and disabling effect of pain. However, both reviews note limitations in the literature including small sample sizes, high risk of bias and general low quality (Ahern et al, 2020; Austin & Siddall, 2021).

Two systematic reviews from Miguel-Rubio et al found there is not enough evidence that VR interventions are more effective than conventional therapy for improving either upper limb motor function or functional performance in patients with spinal cord injury (Miguel-Rubio et al, 2020a; Miguel-Rubio et al, 2020b). However, due to conflicting results in other published studies, more research is required.

The same team did find beneficial effects of VR on balance when combined with conventional physiotherapy (Miguel-Rubio et al, 2020c). Preliminary evidence for effectiveness on balance is supported in the literature (Abou et al, 2020; Alashram et al, 2020). Abou et al found beneficial effects on both sitting and standing balance. However the levels of evidence of the studies that support these controls could be improved for more reliable results.

5.9 Stroke

In their meta-analysis of high quality studies looking at chronic stroke, Gao et al (2021) found significant and large effects of VR therapies on overall cognition, attention, executive function and depressive mood compared to conventional therapy. In addition, they found doses of larger than 20 hours and frequency of over 4 times per week showed larger effects. These findings are inconsistent with other recent reviews, however other reviews do not focus specifically on patients in the chronic phase of stroke. For example, Zhang et al. (2021) find that VR was similar to conventional therapy in improving cognition, but could improve upper and lower limb function, walking ability, balance, gait and completion of daily activities.

Aguilera-Rubio et al (2022) reviewed 6 studies that use the Leap Motion Controller, a hands-free device that enables interaction with a virtual interface without holding a controller or wearing a data-glove. Benefits to upper-limb function were reported in all studies. Jin et al reviewed 40 studies with a total 2018 participants and found an overall small benefit in arm function and completion in daily activities. However, a larger effect is produced for participants with moderately severe or severe arm muscle weakness (compared with low-moderate) and for fully immersive VR systems (compared with semi- or non-immersive systems). However, differences in study design, level of stroke, dosage and frequency, measurement tool and VR system used for treatment make generalising results difficult (Aguilera-Rubio, 2021; Jin et al, 2022). Khan et al (2021) also support the benefit of VR for motor function, finding a majority of studies reporting positive results. However the results of their meta-analysis shows no significant difference with conventional therapies. This indicates VR may be beneficial in contexts where conventional therapy is difficult to achieve.

5.10 Traumatic brain injury

Research into VR based rehabilitation treatments for traumatic brain injury (TBI) has focused on physical and cognitive symptoms of TBI including gait, balance, upper limb function, attention, memory and executive function. Treatments have involved virtual car simulators, virtual activities of daily living such as shopping, and general exercises in a virtual environment (Bassel et al, 2021; Ausilio, Han, Gleuck, 2020; Alashram et al, 2019).

There is mixed evidence for the benefit of virtual reality for rehabilitation after TBI. Three systematic reviews completed between 2019 and 2021 found overall positive results with limited explanatory power due to low levels of evidence, small sample size and risk of bias (Bassel et al, 2021; Ausilio, Han, Gleuck, 2020; Alashram et al, 2019). Meta-analyses in all reviews were not possible due to heterogeneity of studies (Bassel et al, 2021; Ausilio, Han, Gleuck, 2020; Alashram et al, 2019).

The 2019 review found mixed results for improvement in cognition. Two RCTs found positive results for memory and executive function. One RCT found comparable improvement in both treatment and control groups. (Alashram et al, 2019). This is supported by Ausilio, Han and Gleuck (2020) who also found mixed and unreliable support for benefit to cognition. However, they did find moderate support for improvements in balance and gait. Overall studies considered in this review were limited by low levels of evidence, small sample sizes (50% of studies with less than 10 participants) and risk of bias.

Brassel et al (2021) conclude the evidence base for the therapeutic benefit of VR for rehabilitation after TBI is too small to draw any reliable conclusions. This is due to overall low levels of evidence, overall low study quality and heterogeneity of the included studies marked by different measures, severity of TBI and types of VR. The authors were able to draw out some recommendations for future studies from a descriptive consideration of the literature on acquired brain injury (ABI) in general. These recommendations include the importance of co-design in developing the VR tool / intervention, describing barriers and potential safety risks

and ensuring tasks are progressively challenging and customisable. The evidence base for ABI is larger owing significantly to the number of studies looking at stroke. Refer to 5.9 Stroke for more information.

6. Risks of virtual reality use

There may be some risks of virtual reality to children. Many VR companies state that their products are not for children under 12 years old (Virtual Reality, eSafety.gov.au). Immersive VR aims to shut out stimulus outside the VR environment. This means that during play, the user will be less aware of hazards in the real world. Aubrey et al (2018) point out that while the immersive effects of VR can be more powerful for children than adults and the long-term effects of VR use on children is unknown, there is no evidence of harm associated with brief exposure (5-10 minutes) to appropriate content. Tychsen and Foeller (2020) found that after two 30 minute sessions in a fully immersive VR headset, there were no ill effects on visuomotor functions or the vestibule-ocular reflex. In their study, 2 out of 50 children experienced mild motion sickness.

Fully immersive VR may have a negative effect on static balance and cause eye strain or fatigue (Park & Lee, 2020). VR sickness, with symptoms similar to motion sickness, is a recognised problem for the industry (Saredakis et al, 2020). In their systematic review of studies reporting VR sickness, Saredakis et al reviewed 55 papers representing a total of 3016 participants. 15.6% of participants dropped out of the studies due to VR sickness. They find that content of the VR environment is a significant contributing factor to VR sickness which indicates that developers can adjust the content to reduce the likelihood or impact of VR sickness. This is supported by Park and Lee (2020) and Oh and Lee (2021) who argue that moving backgrounds can increase the likelihood of users experiencing VR sickness, so that static backgrounds should be preferred for VR in a rehabilitation or therapeutic setting.

7. Reasonable and necessary considerations

Participants may request funding for VR therapy or skills training or for the purchase or rental of a VR system itself. The following should be considered when determining if a request is reasonable and necessary:

  • In many settings, there is good evidence that VR can assist with improving capacity and skills development. However, this varies by population and targeted functional domain.
  • Despite the growing literature, researchers are still often tentative about recommending VR as a therapy tool due to limitations in the level and quality of evidence.
  • There is no standard or ‘best practice’ therapy program as conclusions about dosage and frequency are more difficult to reach than conclusions about VR’s general effectiveness.
  • Beyond a trend in some settings that immersive VR is more effective than semi- or non-immersive VR, there is very little research comparing different systems or evaluating cost-effectiveness of different systems.
  • Much of the existing research shows similar effectiveness of VR based therapy and conventional physiotherapy or occupational therapy. This raises questions of the duplication of supports if VR is being requested in addition to regular therapies.
  • Most VR systems require hardware beyond the VR kit itself. For example, gaming consoles like the PlayStation or XBOX or above standard PCs designed to accommodate game-play.
  • Commercially available VR systems are growing in popularity and may constitute an everyday entertainment device.
  • VR therapy may be particularly useful for people in rural or remote areas or who otherwise have difficulties accessing allied health services. However, some programs may require a reliable internet connection to use which could be problematic in some rural or remote settings.
  • Much of the existing research demonstrating the effectiveness of VR is in the context of rehabilitation after spinal injury, stroke or other brain injury, funding for which is not the role of NDIS.
  • In some cases VR systems may count as therapy tools, funding for which may not be the role of NDIS.
  • There are still accessibility issues with some VR systems.
  • VR systems are generally not recommended for children under 12.
  • While very few studies report adverse effects of VR, some people can succumb to VR sickness when exposed to fully immersive VR environments.

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9. Version control

Version Amended by Brief Description of Change Status Date
1.0 Aaron Harrison Report on uses, risks and features of VR in an NDIS context Cleared 26/04/2022