Virtual Worlds and Virtual Reality.
A virtual world exists inside a computer. Virtual reality involves the use of additional equipment, such as a headset or goggles, and possibly other items. However, especially in the early days of both technologies, the two terms were used somewhat interchangeably. (See for example Sullivan et al., 2013.)
Both work by giving the user a sense of immersion and embodiment. For some people, virtual reality provides a deeper sense of immersion and more complete sense of embodiment. Various factors in the virtual environment affect the user’s sense of presence as well as their response (Hoffman et al., 2004). Both virtual worlds and virtual reality differ significantly from other forms of computer-aided interactions, including chat rooms and forums.
Behm-Morawitz (2013) found that avatar immersion in a virtual world affects body perception and health. Some argue that the virtual is not separate from the “real,” but is a part of our reality, given the technologies now available.
Ghanbarzadeh et al (2014) created a taxonomy of uses of virtual worlds in healthcare after an extensive literature review. Their taxonomy includes: academic education, professional education, treatment, evaluation, lifestyle, and modeling.
The use of virtual treatments for pain is an area of intense research.
The National Institute on Drug Abuse (NIDA), National Institute of Health (NIH), is actively funding research on virtual reality treatments for pain (Thomas, 2014).
A meta-analysis (Garrett et al., 2014) showed that virtual reality can be a useful distraction for patients undergoing painful procedures. This has been shown for children with cancer (Gershon et al., 2004), children undergoing IV placement (Gold et al., 2006), patients with low back pain (Trost et al., 2015), a patient undergoing thermotherapy (Wright et al., 2005); individuals with phantom limb pain (Ortiz-Catalan et al., 2014), child and adult burn patients (Chan et al., 2007; Das et al., 2005; Hoffman, Doctor, et al., 2000; Hoffman, Patterson, et al., 2000, 2001, 2004, 2008; Maani et al., 2011a, 2011b; Mott et al., 2008; Sharar, 2007; Sil et al., 2013; van Twillert et al., 2007), chronic pain patients (Keefe et al., 2012; Wiederhold et al., 2014), persons with fibromyalgia (Garcia-Palacios et al., 2015; Herrero et al., 2014), and patients undergoing dental procedures (Hoffman, Garcia-Palacios, et al. 2001).
The effects of virtual reality pain control are additive to the effects of opiods (Hoffman et al., 2007). Some evidence exists that virtual reality can be used to enhance pain control (Loreto-Quijada et al., 2014). Virtual pain coaching has also been explored (McDonald et al., 2013). Hypnosis induced while in a virtual world, used as a distraction from pain of burn wound care, has been reported (Patterson et al. 2004, 2006).
Various theories exist about how virtual therapy induces analgesia (Gold et al., 2007; Li et al., 2011).
Communication can be enhanced by participation in a virtual environment.
Interacting with representations (avatars) of fellow humans in a metaphorical environment allows non-speaking people new ways to converse (Alm et al., 1998). The benefits of working in virtual reality for persons on the Autism Spectrum have been documented extensively (Biever, 2007). People with autism spectrum disorders often find virtual world communication more comfortable than in real life.
Communicating in a virtual environment slows social interactions down and gives people with autism better control. Many people with autism, who are unable to interact with others in real life, feel comfortable communicating through their avatar. Observing avatar gestures and experimenting with using them in in-world communication improves the ability of people with autism to interpret facial expressions and body language.
Communication with clinical psychologists could be facilitated in a virtual world setting, and group interaction and cohesiveness could also be positively influenced during therapy (Gorini et al, 2008). Lung cancer patents can be coached to use more assertive communication during virtual clinic visits (Brown-Johnson et al., 2015). Balandin (2011) discusses the use of virtual worlds to support persons with complex communication needs as they participate in communities.
Virtual therapy can aid in improvement of cognitive functioning.
The realistic scenes and personal interactions capture the interest and channel the attention of persons with ADHD (Alm, 1998). Virtual reality can assist people with cognitive impairments (Darrow, 1995). Exercising in a virtual reality environment can lead to significant gains in cognitive function during rehabilitation from traumatic brain injury (Grealy et al., 1999).
Virtual therapy can also help patients improve motor skills.
The realistic graphical interface allows mobility through the landscape with minimal physical effort. Navigating a three-dimensional Virtual Reality landscape improves spatial awareness. Warner’s research (1995) showed that eye/hand coordination and fine motor skills can be developed with the patient using very little strength.
Mao et al. (2014) report improved balance in patients given virtual reality training. Participation in a virtual reality balance exercise program improved balance confidence and function by adults with moderate or severe traumatic brain injury (Thornton et al., 2005). These adults and their caregivers also showed substantially greater enthusiasm and knowledge compared to a control group participating in an activity-based program.
Virtual reality therapy with monitoring of hand movements has been used with stroke patients (Burdea, 2002). Gatica-Rojas and Mendez-Rebolledo (2014) envision virtual reality devices used in physical rehabilitation therapy for patients with neurological disorders who need motor training.
Various types of psychotherapeutic interventions have been tried.
A pilot mind-body therapeutic intervention for stress control is described by Hoch et al. (2012). Yuen et al. (2013) report an effective virtual world treatment for social anxiety disorder. A case study of a psychotherapy intervention is provided by Quackenbush and Krasner (2014). Brahnam and Brooks (2014) developed a virtual world expressive therapy psychotherapy treatment. Phobia-inducing virtual environments have been prescribed for patients with cognitive deficits (Burdea, 2003).
Life skills can be learned virtually.
Some adults with intellectual disabilities can be trained to use virtual worlds (Balandin & Molka-Danielsen, 2015; Hall et al., 2011). People with developmental disabilities can learn life skills, such as grocery shopping, through the use of virtual reality (Standen & Cromby, 1995). Persons recovering from traumatic brain injury can learn meal preparation skills in virtual reality settings (Christiansen et al., 1998).
Virtual environments can offer social skills training
for people on the Autism Spectrum (Parsons & Mitchell, 2002). Participants can practice behaviors through role-play situations, in a safe environment for rule learning and task repetition. Practicing behaviors, both within and across contexts, may encourage people with autism to have a more flexible approach to social problem solving.
Patient education is another potential use of virtual worlds.
Knapfel et al (2014) used a virtual world to promote the use of Personal Health Records. Individuals with severe disabilities, who might not be able to participate in focus group research on healthcare topics, can offer their thoughts in a virtual world setting (Krueger, 2014).
Peer support and self-management support are possible in virtual world settings.
Generally, providing online resources and patient support has been seen as beneficial (Stevens, 2004; Williams & Nicolas, 2005). Managing chronic illness in isolated rural environments is challenging due to limited sources of social support and health information. Research on an Internet intervention targeting this population (Hill & Weinert, 2004) showed that highly interactive features of the project were rated as most important by the participants. Overall, the program was beneficial in assisting participants to better manage their chronic illness.
Self-management for diabetes has been facilitated through the use of virtual world communities (Johnson et al., 2013; Mitchell et al., 2014; Rosal et al., 2014; Ruggiero et al. 2015; Vorderstrasse et al., 2014; Watson, 2008).
Peer support delivered through a virtual world environment can benefit caregivers as well (O’Connor et al., 2014).
Additionally, virtual reality may be used in diagnosis of neurologic conditions (Llobera et al., 2013). Elderly patients can be monitored remotely through a combination of sensors and virtual world avatars (Pouke & Hakkila, 2013).
Virtual therapies can be highly motivating.
Virtual therapy fosters motivation to work at improving health and physical and mental functioning during rehabilitation because the person is having fun (Warner, 1995). Warner notes that a physiological reason is not the deterrent from improvement, “it’s the psychological capacity that blocks them. They don’t want to do it. They are depressed. They’ve lost function.”
Virtual therapeutic interventions have been shown to improve cognitive function and concentration for individuals who have suffered a traumatic brain injury through interaction with a pleasant activity. Researchers (Sveistrup et al., 2004) have shown that for this disability group, working in virtual therapy increases both self esteem and empowerment.
Individuals with a variety of disabling conditions showed improvements on six psychosocial measures after interacting in a virtual world without specific treatment (Gilbert et al., 2013). Individuals in the study showed lower trait anxiety, loneliness and depressive symptoms, and improved positive affect, self-esteem, and life satisfaction.
Virtual environments offer disabled users more and better control over their surroundings and their interactions with other individuals. This may be the main benefit of their being in this type of setting (Alm et al, 1998). Virtual environments do this by offering experiences that are both engaging and rewarding, that shift the user’s focus from completing a therapeutic task to interacting with the virtual environment.
What is the significance of virtual worlds and virtual reality in healthcare?
Beside improved motivation among users with various conditions, advantages to their participation in virtual reality settings include adaptability and variability based on baseline functioning, transparent data storage, online remote data access by caregivers, economy of scale, and reduced medical costs (Burdea, 2003). Because virtual worlds are internet-based, they can be used by people in different geographic areas synchronously (Gorini, 2008). Ethical and legal issues for therapy delivered in virtual environments are no different from those for therapy delivered in person (Yellowlees et al., 2012).
Sveistrup and colleagues (2004) believe that “simple applications of virtual reality have significant impacts on physical and psychosocial variables.”
Virtual reality use by people with disabilities shows that it is a tool, not a game.
McClintock, H. F., Kurichi, J. E., Barg, F. K., Krueger, A., Colletti, P. M., Wearing, K. A., et al. (2017). Health care access and quality for persons with disabilities: Patient and provider recommendations. Disability and Health Journal. (in press) View the abstract here.
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The Virtual Ability Research Group encourages, promotes, supports and disseminates sound research activities within disabilities communities in Second Life®. This includes providing researchers with access to disabled communities for legitimate research purposes when possible.
We seek to enable people within disability communities to give back to the research communities that try to improve lives. We assist in research, teaching and service promotion and tenure activities when appropriate. We promote sound and appropriate research agendas in disability research and seek to develop quantifiable and repeatable data to show the effects that Second Life® has for people with disabilities. We can provide consultation to researchers and funders on disability issues. We help sustain and perpetuate high-quality disability research and services in Second Life®.
The Research Pavilion on Healthinfo Island is a venue where many researchers explain their proposed projects, recruit subjects, and report their results. One pavilion contains posters with information about research projects in which persons with disabilities might wish to participate.
Membership in the Virtual Ability Research Group is open to professional researchers and their students from the corporate, governmental, non-governmental and academic sectors. To join, send an IM to Gentle Heron inworld.