VR has attracted attention as a means of managing health and rehabilitation in a wide range of health fields in recent years, which is reflected within the literature. It is generally accepted that VR provides patients and service users with sensory stimulation, and a more immersive environment, with real-time feedback during specific task-orientated actions reflecting both motor learning and neuroplasticity. The benefits of VR in rehabilitation provide control over a particular stimulus and hence deliver consistency to service users; it has the ability to vary the stimuli from say a ‘simple’ to more ‘complex situations’, thus enabling professionals to ‘test’ users in a safe and controlled manner. The ability to quantifiably record (and perhaps reward) an individual’s progress remains key in the role of VR use amongst individuals. For instance, VR therapy for stroke survivors has an added benefit by providing instant feedback to individuals with the level of difficulty of the therapy modified when appropriate (Singh et al, 2013). Individuals recovering from a stroke have reported that the use of VR was more engaging and stimulating for them, when compared with conventional therapy (Levin et al, 2012). It is evident that VR has the ability to deliver ‘personalized care’ to individuals, reflecting their needs and abilities due to the extent of their condition, thus arguably falling into the personalized medicine realm of healthcare delivery. The example of such a personalized medical approach resonates with patients with stroke and brain-related injuries, whereby the scope of injury and/or recovery will vary, depending on the situation.

In short, VR applications have wide ranging applications and potential in terms of neuroplasticity for individuals (Cheung et al, 2014). VR remains a promising tool for treating and managing patient experiences, coincided with cognitive and physical recovery (Shin and Kim, 2015), upper limb function (Goncalves et al, 2018), whilst improving memory and retention, regardless of the level of immersion (Mendes et al, 2012). Thus, whilst a clear focus still remains in rehabilitation, there are other areas which lead the way with VR use, which this book examines.

VR has the capability of generating the physical world analogs via simulated settings, of which patients and/or service users interact (Pausch. 1993). There is an argument that the conventional one-to-one application of either training or rehabilitation (without the use of VR) is seen to be monotonous or even boring to patients and as such many struggle to integrate it into their daily lives (Feng et al, 2019). The counter argument favours VR technology, whereby favoured games encourage motivation, which lead to reward upon completion of a particular exercise. This interconnection with gamification via reward mechanisms aims to help improve patient outcomes, which can be supported with choice of music and exquisite pictures of family, friends or idyllic scenery in order to help instill motivation and engagement (Dias et al, 2019).

Other examples of VR use have been associated with The Virtual Reality Exposure Therapy (VRET) application, helping prospective radiotherapists position and treat cancer patients using high levels of ionising radiation. Further, we are witnessing VR use in psychology, as a treatment for phobias. For instance, a recent study by Gujjar et al (2018) identified how VR facilitated dental phobias, alleviating anxiety in patients. Here, we can see that positive stimuli may help foster a unique health and rehabilitation environment in order to help reduce phobias and is being considered in other health settings. For instance, a study by Brown et al (2019) examined the application of VR as a tool to desensitize claustrophobic patients prior to attending magnetic resonance imaging (MRI) examinations. The authors of this study prospectively aim to use a mobile phone application and headset in order to provide a glimpse of an MRI experience (from within the bore of the magnet). By providing the patient with an initial virtual experience, it is anticipated that both hospital cancellations and abandonment of MRI examinations during imaging may reduce, leading to a more cost-effective service.

Another interesting area of VR use is the notion of anaesthesia. Because VR is now able to combine visual, auditory, haptic and olfactory senses, it is arguably able to distract individuals from painful processes. A study by Hayashi et al (2019) demonstrated that exercised-induced pain in healthy subjects showed VR immersion significantly reduced pain intensity by the participants. Further, a meta-analysis by Mallari et al (2019) examined the effectiveness of VR in reducing both acute and chronic pain. A good example of the application of VR to limit pain has been demonstrated by Maani et al (2011), whereby the use of immersive VR reduced pain of patients with combat-related bring injuries during severe burn wound debridement. In other examples, VR has demonstrated pain reduction in intravenous placement (Gold et al, 2005), dental work (Gujjar et al, 2018), neck pain (Chen et al, 2017), spinal cord injuries (Chi et al, 2019) and cancer treatment (Mohammad and Ahmad, 2019).

Whilst the aforementioned offers a unique paradigm shift in terms of healthcare delivery, VR has the potential to cause discomfort, nausea, disorientation, dizziness, eyestrain and fatigue when used (Davis et al, 2014). This is generally described as cybersickness and there are two common theories that aim to describe its occurrence. First, the sensory conflict theory assigns the occurrence of symptoms to discrepancies between the perceived motion of the virtual optic flow and the motion of the participant detected by their vestibular, proprioceptive and somatosensory systems (Keshavarz et al, 2015). For instance, it has been reported that stroke survivors may experience issues processing information from the above-mentioned systems, thus making them susceptible to cybersickness (Massetti et al, 2018). Second, the postural instability theory identifies postural instability as the cause for symptoms and suggests that they are due to postural instability in unfamiliar situations in order to maintain balance (Lim et al, 2018). Again, stroke survivors might be more prone to develop cybersickness as they could already experience postural instability (Weech et al, 2019). Cybersickness symptoms might rapidly fade but could even persist for days afterwards (Lackner, 2014), increasing a potential risk for falls, which could preclude the use of immersive VR.

Whilst we are observing the unique application of VR within health and rehabilitation settings, it is important to remain mindful of other associated risks, such as cybersickness, which may cause additional stress and potentially lead to additional risks for patients.

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