How Virtual Reality Games Can Improve Lives

Virtual reality (VR) games allow for an unprecedented amount of immersion in a video game. Thanks to technological advances, your body’s movements can be reflected in-game and your vision can be completely submerged in countless virtual worlds.

These technological advances have not gone unnoticed in the world of medical research. Researchers are increasingly using VR games as a method of overcoming complex physical health problems, helping mental health problems, and improving physical and mental health medical training. This article aims to showcase and summarise dozens of research studies that have used VR games to improve the lives of others.

Please note that medical definitions of ‘virtual reality’ do not require a Head Mounted Display (HMD) such as the Oculus Rift (Trost & Parsons, 2014). Due to issues and complications surrounding HMDs for medical research (which will be discussed in ‘Critique’), this article will contain research using a mixture of HMDs and technology such as the Kinect that allows for users’ movements to translate to a virtual world on-screen.

As usual, there will be a summary at the end if you do not wish to read everything. Let’s begin!

Contents

1. 1. 1. VR and Stroke Recovery
      2. VR and Other Physical Health
      3. VR and Mental Health
      4. VR and Medical Training
      5. Critique
      6. Summary
      7. References

VR and Stroke Recovery

In medical research, one of the largest fields of study for VR games is how they can improve the quality of life of stroke survivors. Stroke is the world’s leading cause of disability, with approximately 33 million stroke survivors worldwide (Stroke Association, 2018; Feigin et al., 2014).

Up to 85% of stroke survivors report difficulties with their upper limbs, limiting their daily activities and their overall quality of life (Kwah et al., 2013; Morris et al., 2012; Chen et al., 2015; Lai et al., 2002). Despite the prevalence of upper limb limitations, the primary focus of stroke recovery appears to be the strengthening of the lower limbs (Warland et al., 2018). Reviews of stroke recovery sessions have shown that the average session spends only around ten minutes trying to improve upper limb functioning (Lang et al., 2007; Kaur et al., 2012).

The ability to deliver stroke rehabilitation treatment also suffers from a number of problems. A significant problem for stroke recovery is – to be blunt – how boring the treatment is. Intense sessions of repetitive motions are necessary to improve limb functioning, but they are so boring that stroke survivors stop attending sessions and stop adhering to their exercises (Gil-Gómez et al., 2011; Yates et al., 2016). Another key barrier for stroke recovery is hospital facilities. It is argued that 45 minutes of repetitive exercise five days a week is necessary for stroke recovery (Langhorne et al., 2009; NICE, 2013). However, the ability to deliver this level of intense exercise is challenged by budget cuts, employee availability, and initiatives to reduce hospital stays for stroke survivors (Barker & Brauer, 2005; McHugh & Swain, 2013).

VR games have been able to overcome every barrier that is listed above.

Technology such as modified Kinects allow for a safe, hands-free method of strengthening upper limbs in a population who may struggle to hold controllers and other exercise equipment (Warland et al.). When practicing exercises, the VR game can showcase the ideal motion and movement trajectory patients should be aiming for (Van Dokkum et al., 2012; Huang et al., 2018). VR games for stroke recovery provide patients with feedback on how close they are to meeting these ideal motions (Yates et al.). This feedback motivates and engages patients as they learn how close they are to reaching their goal (Imam & Jarus, 2014; Teo et al., 2016).

VR games and their feedback can be used to combat barriers such as medical budget cuts and lack of rehabilitation staff. The availability of VR hardware means that stroke patients can exercise and receive feedback from the safety and comfort of their own home. The game can then store their progress to date to be reviewed by a trained professional. Patients exercising from home are grateful for the ability to have their progress monitored by a professional to ensure they are making progress (Warland et al.).

A massive benefit of VR games is just how enjoyable they are. By turning repetitive exercise into fun and rewarding games with challenges, patients are encouraged to exercise more and view exercise as less of a boring burden (Peek et al., 2016; Kwakkel et al., 2004; Saposnik et al., 2011). This is supported by research from Warland et al., with participants finding VR gaming so enjoyable that they began playing outside of their allocated exercise time.

Participants in Warland et al.’s research said that they preferred VR games over traditional treatment as it was more enjoyable, focused more on upper limb improvements, and they could exercise almost instantly – they didn’t have to wait for their number to be called for an appointment. Participants even expressed the idea that “time was flying” during VR gaming sessions.

So research such as Warland et al.’s has demonstrated that VR games are an enjoyable method of improving upper limb functioning, but what about in comparison to traditional treatments? Stockley et al. (2017) compared the effectiveness of VR gaming and traditional guided gym training. After a 12 week research period, the group who played VR games showed similar improvements to those who travelled to the gym to use specialist equipment. However, as predicted, the VR gaming group were more motivated and engaged than the gym group due to how entertaining VR gaming was.

While VR gaming has been used to improve upper limb functioning post-stroke, it has also been used to improve other stroke-related disability. After six weeks of training with VR gaming, participants reported significant improvements in their overall levels of mobility (Malik & Masood, 2017). Another six-week study aimed to improve the balance of those who had suffered from a stroke (Park et al., 2017). It was hypothesised that VR gaming would help improve balance due to having to visually focus on their in-game avatar and maintain their balance on-screen (Walker et al., 2010; Yang et al., 2008). This hypothesis was supported as balance and motor functions did indeed improve after the six-week study period. A similar study was able to improve balance post-stroke with exercises completely conducted at home (Held et al., 2018). Participants were able to communicate online with a therapist and receive feedback on their progress, resulting in treatment that was safe and comfortable for them.

To summarise, VR gaming can be used to address a number of key barriers to stroke recovery. VR gaming can help improve upper limb functioning and more, can be used at home, and can transform exercise from boring to fun.

VR and Other Physical Health

Due to its immersive nature, VR has been used as a method of pain relief for medical procedures, acute pain, and chronic pain (Keefe et al., 2012). It was theorised that VR gaming would be effective pain relief due to its ability to distract from pain (Gold et al., 2007; Malloy & Milling, 2010). As patients would be fully immersed in completing tasks in virtual worlds, they would have fewer cognitive resources to focus on their pain (Law et al., 2011; Van Damme et al., 2012; Van Ryckeghem et al., 2013).

The focus on completing tasks in VR games seems to be an important mechanism in pain relief: VR displays that allow you to watch footage were less effective in distracting from pain than VR games with objectives (Jameson et al., 2011; Dahlquist et al., 2007; Wender et al., 2009). Research has found that VR games could help reduce pain in: burn care, medical procedures (e.g. port implantation), childbirth, fibromyalgia, arthritis, back pain, and treatment for traumatic injuries (Keefe et al.; Garrett et al., 2014; Schmitt et al., 2011; Hoffman et al., 2009; Botella et al., 2013; Lin et al., 2007; Kim et al., 2014; Cowles et al., 2019). VR gaming can also be used to offer pain relief for phantom limb syndrome. VR therapy for phantom limb syndrome involves showing participants an on-screen avatar with their limbs intact while practicing muscle relaxant techniques (Cole et al., 2009; Ortiz-Catalan et al., 2014; Murray et al., 2006). This helps to focus the phantom pain and teach strategies on how to manage the phantom pain when it is experienced.

As mentioned in stroke research, a benefit of VR gaming is its ability to showcase to participants the ideal motions they should be making for recovery. This benefit is being used in treatment for spinal cord injuries (SCI), an injury which sufferers can lack motivation to improve from due to how boring the treatment is (Lohse et al., 2013). In Dimbwadyo-Terrer et al.’s research (2016), participants had their own personalised in-game avatar which showed the motions necessary for their therapy. Not only were the physical benefits similar to traditional SCI therapy, but participants reported the game to be “more pleasant and attractive” than the traditional therapy.

VR games have been used to help young people suffering from cerebral palsy. Those with cerebral palsy can have difficulties controlling their balance and mobility (Campbell, 2000). Bryanton et al. (2006) aimed to use VR gaming in 7-17 year olds to improve their mobility, particularly in their ankles. Despite the VR gaming treatment being less intense than traditional treatment, VR gaming resulted in better ankle performance than traditional therapy. When interviewed about the therapy, the young people reported how much they enjoyed VR gaming, and parents stated that their child exercised more at home when they had access to VR gaming. It is also possible for VR gaming to increase those with cerebral palsy’s confidence and self-belief about their ability to exercise (Miller & Reid 2003; Harris & Reid, 2005).

While research in this section has focused on how VR games can help with health problems, VR games can also be used to detect health problems such as brain injuries in medical settings. By creating virtual environments to explore from the safety of a medical room (e.g. a virtual kitchen), doctors can observe whether participants can mentally conduct everyday tasks such as making a cup of tea. This safe, cheap and convenient method of assessing daily-life activity has already been used to detect traumatic brain injuries and concussions (Wright et al., 2017; Besnard et al., 2016; Teel et al., 2016).

VR and Mental Health

Alongside helping with physical health, VR gaming has been used to benefit and improve mental health. VR games have been used in research to minimise pre-operative anxiety. While we may take being nervous before an operation for granted, it is important to minimise pre-op anxiety as it can lead to heightened aggression and sleep problems (Kain et al., 1999).

Research by Ryu et al. (2018) used a novel approach to minimise pre-op anxiety. While other medical anxiety treatments focus on distracting the patient (Inan & Inal, 2019), Ryu et al.’s research confronts the surgery head-on. Young people who were scheduled for surgery played a VR game that acted as a tour of the operating theatre. In this game, they could interact with digital surgical tools and become familiarised with the procedure they would be going through. Not only did this game help the young people feel more calm about the procedure, but it also benefitted the surgical team: the participants were more cooperative when receiving anaesthetic. The researchers argue that this is a cheap, safe and educational method of minimising pre-op anxiety.

Virtual reality therapy (VRT) is currently being used in mental health treatment to treat anxiety disorders and addictions (Ling et al., 2014; Kothgassner et al., 2016). For example, if someone had a debilitating fear of spiders, VRT would allow them to get closer and closer to a digital spider with the support of a therapist. For treating addictions, VRT aims to break the association between the addiction and positive emotions such as relief from cravings (Son et al., 2015; Kim et al., 2014). For example, VRT for alcohol dependence would involve immersing participants in images of consequences such as damaged livers. Research into VRT has shown that it is helpful for treating nicotine and alcohol dependence, with VRT appearing to be more effective for alcohol dependence than traditional Cognitive Behavioural Therapy (CBT; Lee et al., 2009; Son et al.; Kim et al.).

If you’ve been following gaming coverage in the last few years, you may be familiar with the controversy surrounding Gaming Disorder. Part of its controversy is the lack of consensus for how gaming addiction should be treated, particularly as previous treatment methods have resulted in death (Wang, 2007). Emerging research suggests that VRT may be a safe and effective method of treating those who feel they are addicted to gaming. In Park et al.’s research (2016), participants were immersed in images of adverse effects of excessive gaming such as falling asleep face-down on a keyboard. The four week treatment programme appeared to be as effective as eight sessions of CBT, with sessions taking a quarter of the time as CBT sessions.

Finally, an experimental study is exploring how VR technology can improve the educational performance of those with Attention Deficit Hyperactivity Disorder (ADHD). Those with ADHD may be disadvantaged in a classroom environment due to its many distractions (students talking, chairs moving etc.; Rapport & Moffitt, 2002). By using VR technology, Rohani et al. (2014) were able to create a digital classroom full of the same distractions as a typical classroom. This digital classroom can be used in therapy to help students develop individual coping mechanisms to deal with distractions and increase their concentration in class.

VR and Medical Training

As many of us know, practice makes perfect. However, surgical residents may lack opportunities to practice their surgery skills due to its potential risk to life (Asch & Parker, 1988; Dawe et al., 2014). As you may predict from this article, a method of overcoming this limitation is VR gaming. By creating video games based on precise surgery motions and immersing residents in these games, medical students can practice conducting surgery in a safe environment that translates well to actual operating room scenarios (IJgosse et al., 2018; Jalink et al., 2014; Hamilton et al., 2002; Palter & Grantcharov, 2014; Sroka et al., 2010).

As many of us also know, video games can bring out our inner competitor and spark friendly rivalries. While VR surgery games are helpful for practicing surgery skills, an additional benefit was hypothesised: students would begin to compete for the top score on the leaderboard (Verdaasdonk et al., 2009). This is exactly what happened in El-Beheiry et al.’s research (2017). In this research, a leaderboard was added to a VR game aimed to help surgical residents practice their laparoscopy (‘keyhole surgery’) skills. The students who competed with one another practiced the game so much that they completed their course requirements significantly earlier than those who did not compete.

VR training games can not only be used for physical health training, but also mental health training. In research conducted by Verkuyl et al. (2018), a VR scenario was created where mental health nurses could practice engaging with clients and making critical decisions about their safety and wellbeing. Participants received feedback on their performance and guidance on how certain situations could be handled better.

All participants praised the VR training for its engaging and realistic experience. To quote one participant:

I actually felt I was in the room, my heart was racing…

 

– Research participant (Verkuyl et al.)

 

The VR training was also praised for addressing a gap in the curriculum: mental health nurses do not usually get to practice making home visits or assessing suicide risk in such a realistic setting. The use of VR training to address this gap not only improved their nursing skills, but could potentially save the lives of their future clients.

Critique

While VR gaming is helpful for improving physical health, mental health and medical training, the research base and VR gaming itself is not without its flaws. Before I address the main flaw of VR gaming itself, I will mention some brief issues found within VR gaming research.

VR gaming research suffers from issues that are commonly found across medical research. Due to the costly nature of medical trials, it is common for VR gaming research to contain small sample sizes, typically below 50. There is also a lack of follow-up across VR research. For example, it would be beneficial to know if physical health benefits identified at the end of a six-week programme were still found several months later. Having larger sample sizes followed up several months later would inform us of how effective VR treatments are long-term in a wider range of people. A further issue identified in Stockley et al.’s research involved the software freezing and needing assistance to fix. This could be a barrier for home treatment as technologically illiterate users may not know how to fix these problems by themselves.

The largest flaw of VR gaming itself may be something that readers can identify with. Crosbie et al. (2012) conducted a study with the aim of using Head Mounted Displays (HMDs) such as the Oculus Rift to improve arm functioning post-stroke. However, several participants reported feeling dizziness and nausea when using an HMD.

The dizziness and nausea felt by these participants, known as ‘VR Sickness’, is a problem that continues to burden creators of HMDs to this day (Shafer et al., 2019). VR Sickness is a form of what is known as kinetosis. To explain it simply, kinetosis occurs when our vision and movements are not in sync (Reason, 1978). For example, imagine you are using an HMD and playing a game in first-person mode. You use the controller to move your character and explore your surroundings, but your legs are not moving. This disconnect between the motion you are witnessing and your legs not moving results in nausea.

Content creators have explored how VR Sickness is being combatted for general consumers. In the world of medical research, VR Sickness is being tackled in other ways.

Meet the Virtual Reality Navigation Chair (VRNChair). VRNChair is the brainchild of Byagowi et al. (2013) and their attempt to combat kinetosis in VR gaming. VRNChair is a motorised wheelchair that moves when the in-game character moves, minimising the disconnect between motion viewed and motion felt.

In tests of HMD games without VRNChair, 30% of participants had to stop playing due to nausea. When playing the same game while using VRNChair, this number fell to zero. This research is promising as it indicates that vulnerable populations can enjoy the benefits of completely immersive virtual reality experiences without suffering from nausea.

Summary

• Stroke survivors face a number of barriers to their recovery, including: treatment that is boring, treatment that neglects their upper limbs, hospital staff shortages, and reduced stays in hospital. VR gaming can overcome these barriers by making stroke recovery exercises more entertaining, focused more on upper limbs, and by making treatment and exercise available at home. VR gaming has significantly improved the upper limb functioning, mobility and balance of stroke survivors.
• VR has a multitude of additional physical health benefits. VR can be a powerful pain relief tool for burn care, childbirth, phantom limb syndrome and more. VR gaming can help those with spinal cord injuries by showing avatars of the correct motions they should be making for recovery. VR gaming can also improve the muscle strength, balance, and exercise confidence of young people with cerebral palsy. VR can also be used to detect health conditions such as brain injuries in hospital by observing how they navigate around and function in virtual rooms.
• VR gaming can be used to benefit mental health. Pre-operative anxiety can be reduced by allowing young people to play a virtual tour game of an operating theatre. Virtual reality therapy is a powerful tool that is being used to treat phobias, drug and alcohol dependency, and even gaming addiction. Experimental research is exploring how VR can be used to simulate distracting environments (e.g. a noisy classroom) that can be integrated into treatment for Attention Deficit Hyperactivity Disorder (ADHD).
• VR gaming can be used to improve medical training for physical and mental health. Surgical residents may be unable to practice their surgery skills due to potential risk to life. However, VR surgery games allow surgical skills practice and leads to skill growth that is applicable to the operating theatre. The simple addition of a leaderboard for surgery game scores resulted in participants meeting their course requirements significantly earlier than other participants. Virtual scenarios allow mental health nurses to practice assessing the mental health needs and suicide risk of clients at home, something that is currently lacking in mental health nursing curriculums.
• While VR gaming research is extremely promising, it does have its own limitations. Sample sizes are often small and participants do not tend to be followed up afterwards to assess long-term health benefits. VR games may also freeze or crash, something which technologically illiterate people may struggle with. VR gaming may also not be for everyone due to VR Sickness. However, VR Sickness can be combatted in vulnerable populations by using VRNChair, a motorised wheelchair that has completely reduced VR Sickness in experimental research.

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References

I have cited a massive 83 sources in this article, making the reference section as long as the article itself. To avoid artificially inflating the scroll bar and scaring away potential readers, I have placed the reference list in a separate Google Document here.