Cybersickness in People with Multiple Sclerosis Exposed to Immersive Virtual Reality

Together with the wide range of possible benefits for the rehabilitation/training of people with multiple sclerosis (pwMS) and other neurologic conditions, exposure to immersive virtual reality (VR) has often been associated with unpleasant symptoms, such as transient dizziness, headache, nausea, disorientation and impaired postural control (i.e., cybersickness). Since these symptoms can significantly impact the safety and tolerability of the treatment, it appears important to correctly estimate their presence and magnitude. Given the existing data scarcity, this study aims to assess the existence and severity of possible adverse effects associated with exposure to immersive VR in a cohort of pwMS using both objective measurements of postural control effectiveness and subjective evaluations of perceived symptoms. To this aim, postural sway under upright quiet posture (in the presence and absence of visual input) of 56 pwMS with an Expanded Disability Status Scale score (EDSS) in the range of 0–6.5 (mean EDSS 2.3) and 33 unaffected individuals was measured before and after a 10-min immersive VR session and at 10 min follow-up on the basis of center of pressure (COP) trajectories. The severity of cybersickness symptoms associated with VR exposure was also self-rated by the participants using the Italian version of the Simulator Sickness Questionnaire (SSQ). Temporary impairments of postural control in terms of significantly increased sway area were observed after the VR session only in pwMS with mild–moderate disability (i.e., EDSS in the range of 2.5–6.5) in the presence of visual input. No changes were observed in pwMS with low disability (EDSS 0–2) and unaffected individuals. In contrast, when the visual input was removed, there was a decrease in sway area (pwMS with mild–moderate disability) and COP path length relating to the use of VR (pwMS with mild–moderate disability and unaffected individuals), thus suggesting a sort of “balance training effect”. Even in this case, the baseline values were restored at follow-up. All participants, regardless of their status, experienced significant post-VR side effects, especially in terms of blurred vision and nausea. Taken together, the findings of the present study suggest that a short immersive VR session negatively (eyes open) and positively (eyes closed) impacts the postural control of pwMS and causes significant disorientation. However, such effects are of limited duration. While it is reasonable to state that immersive VR is sufficiently safe and tolerable to not be contraindicated in the rehabilitation/training of pwMS, in order to reduce possible negative effects and maximize the efficacy, safety and comfort of the treatment, it appears necessary to develop specific guidelines that consider important factors like individual susceptibility, maximum exposure time according to the specific features of the simulation, posture to adopt and protocols to assess objective and perceived effects on participants

Feasibility and safety of an immersive virtual reality-based vestibular rehabilitation programme in people with multiple sclerosis experiencing vestibular impairment: a protocol for a pilot randomised controlled trial

Introduction: Vestibular system damage in patients with multiple sclerosis (MS) may have a central and/or peripheral origin. Subsequent vestibular impairments may contribute to dizziness, balance disorders and fatigue in this population. Vestibular rehabilitation targeting vestibular impairments may improve these symptoms. Furthermore, as a successful tool in neurological rehabilitation, immersive virtual reality (VRi) could also be implemented within a vestibular rehabilitation intervention. Methods and analysis: This protocol describes a parallel-arm, pilot randomised controlled trial, with blinded assessments, in 30 patients with MS with vestibular impairment (Dizziness Handicap Inventory ≥16). The experimental group will receive a VRi vestibular rehabilitation intervention based on the conventional Cawthorne-Cooksey protocol; the control group will perform the conventional protocol. The duration of the intervention in both groups will be 7 weeks (20 sessions, 3 sessions/week). The primary outcomes are the feasibility and safety of the vestibular VRi intervention in patients with MS. Secondary outcome measures are dizziness symptoms, balance performance, fatigue and quality of life. Quantitative assessment will be carried out at baseline (T0), immediately after intervention (T1), and after a follow-up period of 3 and 6 months (T2 and T3). Additionally, in order to further examine the feasibility of the intervention, a qualitative assessment will be performed at T1. Ethics and dissemination: The study was approved by the Andalusian Review Board and Ethics Committee, Virgen Macarena-Virgen del Rocio Hospitals (ID 2148-N-19, 25 March 2020). Informed consent will be collected from participants who wish to participate in the research. The results of this research will be disseminated by publication in peer-reviewed scientific journals

Development of a new immersive virtual reality (VR) headset-based dexterity training for patients with multiple sclerosis: Clinical and technical aspects.

BACKGROUND Impaired manual dexterity is frequent and disabling in patients with multiple sclerosis (MS), affecting activities of daily living and quality of life. OBJECTIVE To develop a new immersive virtual-reality (VR) headset-based dexterity training to improve impaired manual dexterity in persons with MS (pwMS) while being feasible and usable in a home-based setting. METHODS The training intervention was tailored to the specific group of pwMS by implementing a simple and intuitive application with regard to hardware and software. To be efficacious, the training intervention covers the main functions of the hands and arm relevant for use in everyday life. RESULTS Taking clinical, feasibility, usability as well as technical aspects with regard to hardware and software into account, six different training exercises using hand tracking technology were developed on the Meta quest 2 using Unity. CONCLUSION We report the developmental process of a new immersive virtual VR headset-based dexterity training for pwMS implementing clinical and technical aspects. Good feasibility, usability, and patient satisfaction was already shown in a feasibility study qualifying this training intervention for further efficacy trials

How immersive virtual reality methods may meet the criteria of the National Academy of Neuropsychology and American Academy of Clinical Neuropsychology:A software review of the Virtual Reality Everyday Assessment Lab (VR-EAL)

International audienceClinical tools involving immersive virtual reality (VR) may bring several advantages to cognitive neuroscience and neuropsychology. However, there are some technical and methodological pitfalls. The American Academy of Clinical Neuropsychology (AACN) and the National Academy of Neuropsychology (NAN) raised 8 key issues pertaining to Computerized Neuropsychological Assessment Devices. These issues pertain to: (1) the safety and effectivity; (2) the identity of the end-user; (3) the technical hardware and software features; (4) privacy and data security; (5) the psychometric properties; (6) examinee issues; (7) the use of reporting services; and (8) the reliability of the responses and results. The VR Everyday Assessment Lab (VR-EAL) is the first immersive VR neuropsychological battery with enhanced ecological validity for the assessment of everyday cognitive functions by offering a pleasant testing experience without inducing cybersickness. The VR-EAL meets the criteria of the NAN and AACN, addresses the methodological pitfalls, and brings advantages for neuropsychological testing. However, there are still shortcomings of the VR-EAL, which should be addressed. Future iterations should strive to improve the embodiment illusion in VR-EAL and the creation of an open access VR software library should be attempted. The discussed studies demonstrate the utility of VR methods in cognitive neuroscience and neuropsychology

Immersive virtual reality to improve functional capacities in people with multiple sclerosis: study protocol

Multiple sclerosis is an autoimmune, inflammatory, and chronic neurodegenerative disease caused by myelin loss in the central nervous system. One strategy that shows evidence of numerous benefits is therapeutic exercise, but these therapies, based on repetitive physical actions, can sometimes be unmotivating for patients. Our proposal suggests that an exergame programme with immersive virtual reality (IVR) is feasible for people with multiple sclerosis (pwMS) and will improve their physical function through more motivational sessions. We present a protocol for a single-blind randomised controlled trial to assess the feasibility and impact on functional capacities of an 8-week IVR programme (ExeRVIEM protocol) in pwMS. Balance, gait, risk of falling, functional mobility and lower limb strength, fatigue, handgrip strength, and reaction times will be evaluated. The control group will maintain the usual activities scheduled in the centre, and the experimental group will add the ExeRVIEM protocol (two sessions per week). Therapies based on the combination of exercise and IVR explored in this study may offer new treatment approaches and open new lines of research in this field by improving the functionality of pwMS, as well as motivating patients and encouraging their adherence to treatment

The potential of using virtual reality-based self-paced treadmill to assess road-crossing safety and self-evaluation with traumatic brain injuries: a series case study

Impaired self-awareness (ISA) is common following traumatic brain injury (TBI) and can significantly impact safe road-crossing. Road-crossing interventions are variable and involve high-risk real-world situations. Virtual reality (VR)-based road-crossing can elicit changes in real-world functioning but has not been trialled in the TBI population. The primary objective of this research was to explore whether VR-based self-paced treadmill technology offers a safe road-crossing assessment mechanism for people with TBI. Three participants with TBI completed two road-crossing pilot-trials using a VR-based self-paced treadmill. Avatar feedback and verbal feedback were provided between trials. Participants were provided with a safe road-crossing strategy for the second pilot-trial. The Researcher and Participant evaluated road-crossing following each trial using the Mayo-Portland Adaptability Inventory and the number of safe road-crossings to assess changes in self-evaluation and performance between trials. One of the participants perceived improvements in self-evaluation and performance in the second pilot-trial. All participants attempted to apply the safe road-crossing strategy advised. No safety issues were identified using the VR-based self-paced treadmill within this study’s protocol thereby supporting the primary objective of the work. Future research is warranted to strengthen the evidence-base for using VR to elicit improvements in ISA in road-crossing and in generalising findings to the wider TBI population

The Effects of Primary and Secondary Task Workloads on Cybersickness in Immersive Virtual Active Exploration Experiences

Virtual reality (VR) technology promises to transform humanity. The technology enables users to explore and interact with computer-generated environments that can be simulated to approximate or deviate from reality. This creates an endless number of ways to propitiously apply the technology in our lives. It follows that large technological conglomerates are pushing for the widespread adoption of VR, financing the creation of the Metaverse - a hypothetical representation of the next iteration of the internet. Even with VR technology\u27s continuous growth, its widespread adoption remains long overdue. This can largely be attributed to an affliction called cybersickness, an analog to motion sickness, which often manifests in users as an undesirable side-effect of VR experiences, inhibiting its sustained usage. This makes it highly important to study factors related to the malady. The tasks performed in a simulated environment provide context, purpose, and meaning to the experience. Active exploration experiences afford users control over their motion, primarily allowing them to navigate through an environment. While navigating, users may also have to engage in secondary tasks that can be distracting. These navigation and distraction tasks differ in terms of the source and magnitude of attentional demands involved, potentially influencing how cyber-sickening a simulation can be. Given the sparse literature in this area, this dissertation sets out to investigate how the interplay between these factors impacts the onset and severity of sickness, thereby contributing to the knowledge base on how the attentional demands associated with the tasks performed during navigation affect cybersickness in virtual reality

Validation of the Virtual Reality Neuroscience Questionnaire:Maximum duration of immersive virtual reality sessions without the presence of pertinent adverse symptomatology

International audienceThere are major concerns about the suitability of immersive virtual reality (VR) systems (i.e., head-mounted display; HMD) to be implemented in research and clinical settings, because of the presence of nausea, dizziness, disorientation, fatigue, and instability (i.e., VR induced symptoms and effects; VRISE). Research suggests that the duration of a VR session modulates the presence and intensity of VRISE, but there are no suggestions regarding the appropriate maximum duration of VR sessions. The implementation of high-end VR HMDs in conjunction with ergonomic VR software seems to mitigate the presence of VRISE substantially. However, a brief tool does not currently exist to appraise and report both the quality of software features and VRISE intensity quantitatively. The Virtual Reality Neuroscience Questionnaire (VRNQ) was developed to assess the quality of VR software in terms of user experience, game mechanics, in-game assistance, and VRISE. Forty participants aged between 28 and 43 years were recruited (18 gamers and 22 non-gamers) for the study. They participated in 3 different VR sessions until they felt weary or discomfort and subsequently filled in the VRNQ. Our results demonstrated that VRNQ is a valid tool for assessing VR software as it has good convergent, discriminant, and construct validity. The maximum duration of VR sessions should be between 55 and 70 min when the VR software meets or exceeds the parsimonious cut-offs of the VRNQ and the users are familiarized with the VR system. Also, the gaming experience does not seem to affect how long VR sessions should last. Also, while the quality of VR software substantially modulates the maximum duration of VR sessions, age and education do not. Finally, deeper immersion, better quality of graphics and sound, and more helpful in-game instructions and prompts were found to reduce VRISE intensity. The VRNQ facilitates the brief assessment and reporting of the quality of VR software features and/or the intensity of VRISE, while its minimum and parsimonious cut-offs may appraise the suitability of VR software for implementation in research and clinical settings. The findings of this study contribute to the establishment of rigorous VR methods that are crucial for the viability of immersive VR as a research and clinical tool in cognitive neuroscience and neuropsychology