latest research on virtual reality

Along with Stanford news and stories, show me:

• Student information
• Faculty/Staff information

We want to provide announcements, events, leadership messages and resources that are relevant to you. Your selection is stored in a browser cookie which you can remove at any time using “Clear all personalization” below.

In the realm of virtual reality (VR), users can completely transform the appearances of themselves as avatars and of their digital environments, all at the mere click of a button. In a pioneering new study, Stanford University researchers have examined how this unique and profound ability significantly impacts social interactions in the metaverse – the term for immersive virtual worlds, experienced through VR headsets, where people are increasingly gathering to play and work.

Go to the web site to view the video.

When participants were in “outdoor” VR environments surrounded by “nature” they reported the experience was more restorative and provided greater enjoyment than when they were in “indoor” VR environments.

“In the metaverse, you can be anyone or anywhere,” says study lead author Eugy Han , a PhD student in communication who is advised by Jeremy Bailenson , the Thomas More Storke Professor in the School of Humanities and Sciences at Stanford University. “Our ongoing work reported in this study is showing who you are and where you are matters tremendously for learning, collaborating, socializing, and other metaverse activities.”

The study, published in the Journal of Computer-Mediated Communication , is the latest to come out of Stanford University’s innovative Virtual People course. Taught by Bailenson and colleagues, the course is among the first and largest ever conducted mostly in VR.

For the study, 272 students used VR headsets to meet in virtual environments for 30 minutes once a week over eight weeks. During those sessions, the students participated in two experiments, accumulating hundreds of thousands of minutes of interactions for researchers to analyze.

Real benefits from virtual environments

One experiment assessed the effects of where the students were, across a range of digital surroundings. The other experiment assessed the effects of who the students were, via how they presented themselves as avatars.

In the experiment focused on virtual settings, students interacted in constrained or spacious virtual environments, both indoors and outdoors. The researchers created 192 unique environments with these varying attributes, from tight train cars to vast enclosed arenas and from walled gardens to endless fields.

When in wide open virtual spaces, whether in- or outdoors, the students exhibited greater non-verbal synchrony and reported increases in many positive measures such as group cohesion, pleasure, arousal, presence, and enjoyment, versus when the students interacted in constrained surroundings. The study also showed that outdoor environments with elements of nature generated more positive feelings independent of the apparent size of the virtual space. “Where you are in the metaverse can have a major impact on your experience and the shared experience of a group,” says Han. “Large, open, panoramic spaces for people to move around in really helped with group behavior.”

The findings accordingly suggest that people can take advantage of the available grandness of VR by opting for big, outdoor environments instead of recreating cramped meeting rooms or lecture halls.

“At the very core of collaboration is people attending and reacting to one another in a productive manner,” says Bailenson, “and our data show that all these great downstream things happen when you make your virtual rooms huge compared to a traditional office space.”

Sense of self in VR

In the other experiment, students virtually interacted with each other either as self-avatars, which resembled the students’ actual, physical-world appearances, or as generic avatars that all looked and dressed alike. The researchers observed the students’ VR behaviors and the students reported on their feelings of measures such as group cohesion, presence, enjoyment, and realism.

The study found that when represented by avatars that looked like themselves, the students displayed more non-verbal synchrony, meaning they gestured and postured similarly to one another. Dovetailing with these observations, the students reported feeling more “in sync” with themselves and each other when congregating as self-avatars. When represented as generic avatars and thus “not themselves” virtually, the students reported the experience to be entertainingly freeing. “People enjoyed being in generic avatars stripped of all identity,” says Han. “On the other hand, when represented by self-avatars, the students reported feeling more active and engaged.”

Real impacts, virtual locations, and avatars

A key takeaway from these results is that for more productive and collaborative interactions – for instance for workplace or professional purposes – self-avatars are the preferred option. “When you’re getting serious in the metaverse, you want to look like you,” says Bailenson, the founding director of Stanford’s Virtual Human Interaction Lab (VHIL) and also a study co-author.

Importantly, the two experiments found that the reported benefits of interacting virtually as certain avatars and in certain environments grew over time. Bailenson says those findings suggest the effects are enduring and not just isolated, positive VR experiences.

The study also demonstrates the potential for VR as a novel and insightful medium for conducting psychological studies, given its unlimited digital possibilities and low costs compared to physical-world alternatives.

“In the history of social science, there are very few studies on the psychological effect of huge indoor spaces, for the obvious reason that it is, for example, very expensive to rent out Madison Square Garden to run a four-person meeting,” says Bailenson. “But in VR, the cost goes away, and one of the more compelling findings from our study is that huge indoor spaces have much of the same redeeming psychological value of being outdoors.”

Additional Stanford co-authors of this research include graduate students Cyan DeVeaux, Hanseul Jun, and Mark Miller;  Jeffrey Hancock , the Harry and Norman Chandler Professor of Communication; and Nilam Ram , Professor of Communication and Psychology.

Co-author Kristine Nowak, is from the University of Connecticut.

Bailenson is also a senior fellow at  Stanford Woods Institute for the Environment , member of  Stanford Bio-X , member of the  Wu Tsai Human Performance Alliance , senior fellow of  Stanford Woods Institute for the Environment , and member of the  Wu Tsai Neurosciences Institute . Hancock is also a member of  Stanford Bio-X and a faculty affiliate of the Institute for Human-Centered Artificial Intelligence (HAI).

To read all stories about Stanford science, subscribe to the biweekly Stanford Science Digest .

Media Contacts

Holly Alyssa MacCormick, Stanford School of Humanities and Sciences:  [email protected]

artificial intelligence

human-machine interaction

learning + teaching

architecture

human-computer interaction

consumer electronics

wearable computing

bioengineering

machine learning

environment

entertainment

social science

computer science

storytelling

engineering

prosthetics

civic technology

developing countries

social robotics

augmented reality

social media

neurobiology

computer vision

virtual reality

communications

public health

urban planning

synthetic biology

biotechnology

affective computing

social networks

transportation

climate change

biomechanics

data visualization

behavioral science

social change

fabrication

zero gravity

data science

cognitive science

sustainability

manufacturing

agriculture

prosthetic design

human augmentation

neural interfacing and control

racial justice

3d printing

electrical engineering

banking and finance

cryptocurrency

civic action

construction

performance

microfabrication

language learning

mental health

open source

interactive

visualization

natural language processing

marginalized communities

autonomous vehicles

microbiology

internet of things

social justice

collective intelligence

mechanical engineering

member company

clinical science

nanoscience

nonverbal behavior

assistive technology

biomedical imaging

long-term interaction

sports and fitness

orthotic design

gender studies

womens health

pharmaceuticals

autism research

mechatronics

soft-tissue biomechanics

open access

digital currency

real estate

decision-making

misinformation

Startup’s displays engineer light to create immersive experiences without the headsets

“We are adding a new layer of control between the world of computers and what your eyes see,” says Barmak Heshmat, co-founder of Brelyon

Designing Systems for Cognitive Support

Invent new tangible and embodied interactions that inspire and engage people

Extending expression, learning, and health through innovations in musical composition, performance, and participation

Augmenting and mediating human experience, interaction, and perception with sensor networks

Designing, prototyping, and building the artifacts of our sci-fi space future

Paul Liang joins MIT Media Lab Media Arts + Science Program + EECS/Schwarzman College of Computing as Asst. Professor, AI + Human Experience

Paul Liang joins the MIT Media Lab's Program in Media Arts and Sciences (MAS) and MIT Schwarzman College of Computing with a shar…

Handheld Mapping of Specular Surfaces using Consumer-grade Flash Lidar.

Tsung-Han Lin, Connor Henley, Siddharth Somasundaram, Akshat Dave, Moshe Laifenfeld, and Ramesh Raskar. Handheld mapping of specular surfaces using consumer-grade flash lidar. In IEEE International Conference on Computational Photography (ICCP), 2024.

Development and user study of the Operational Geology in a Virtual Environment (OGIVE) platform

C. Paige, D.D. Haddad, Trent Piercy, J. Todd, F. Ward, A. Ekblaw, D. Newman. "Development and user study of the Operational Geology in a Virtual Environment (OGIVE) platform." Acta Astronautica, Volume 224, 2024, Pages 17-36, ISSN 0094-5765. https://doi.org/10.1016/j.actaastro.2024.07.043.

Capturing the Moon: Assessing virtual reality for remote Lunar geological fieldwork

Cody Paige, MIT AeroAstro Contributors: Ferrous Ward, MIT AeroAstro; Don Derek Haddad, ResEnv; Jess Todd, MIT…

People and intelligent machines in a creative, symbiotic loop

Earth Mission Control (EMC)

Advanced Data Visualizations for Climate IntelligenceMarked by heightened awareness and global concern over the climate crisis, the MI…

Microgravity Research Flights with the Space Exploration Intiative

The Space Exploration Initiative charters an annual ZERO-G parabolic flight for 10-15 projects and 25 researchers across MIT Media Lab, sev…

To Lunar Gravity and Back: What reduced gravity flights can teach us about our future in space

The Space Exploration Initiative’s 2022 microgravity flight features lunar-specific payloads in advance of an upcoming moon mission

Building intelligent personified technologies that collaborate with people to help them learn, thrive, and flourish.

Stochastic Self-Assembly via Magnetically Programmed Materials

By Martin NisserThe ability to deploy large space structures is key to enabling long-duration and long-distance space missions, supporting …

Life with AI | Designing the future of smart systems to improve the human experience

Co-creating climate futures with real-time data and spatial storytelling

WORLDING workshop organizers collaborated with research scientist Dr. Rachel Connolly to co-design their first-ever in-person event.

Connected Mind + Body | Revolutionizing the future of mental and physical wellbeing

Humanizing Agent-Based Models (h - ABM)

Humanizing Agent-Based Models (h-ABM) emerges as a pioneering technique to simulate real-world behaviors, aiming to seamlessly bridge …

Future Worlds | Design and action for the future we want to live in

The Gravity Loading Countermeasure Skinsuit

By Rachel BellisleOverview:The Gravity Loading Countermeasure Skinsuit (GLCS or “Skinsuit”) is an intravehicular activity suit for astronau…

Essence Wearables: Biometric Olfactory Interfaces for Day and Night

Human-computer interaction (HCI) has traditionally focused on designing and investigating interfaces that provide explicit visual, auditory…

KnitworkVR is an immersive virtual experience designed to simulate the Living Knitwork Pavilion showcased at Burning Man, through the use o…

Personalized Performance-Optimization Platform (AttentivU - P-POP)

​The environmental conditions of prolonged spaceflight pose significant psychological risks for astronauts. In particular, crews of future …

Cultivating Creativity | Catalyzing a global movement enabling everyone to unlock and unleash their individual and collective creativity

MIT Time Travel VR Installation

A virtual, outdoor time-travel experience.

Making the invisible visible–inside our bodies, around us, and beyond–for health, work, and connection

Inventing, building, and deploying wireless sensor technologies to address complex problems in society, industry, and ecology

Curiosity Unbounded Episode 4: Build your own superpower, then share it with the world

On Curiosity Unbounded, Professor Fadel Adib, head of the Signal Kinetics group, talks to MIT President Sally Kornbluth about his work.

How x-ray vision is becoming a reality

Tara Boroushaki, a PhD student in the Signal Kinetics group, explains how she's combined AR and wireless signals to find hidden objects.

Dr. Mary Lou Jepsen: Curing cancer and human telepathy

Media Lab alum and former professor Mary Lou Jepsen talks to Danielle Newnham about her journey and inspirations.

Detecting and Mapping Transparent or Mirror-like Surfaces with Lidar

Although lidar is widely used for mapping the 3D geometry of surfaces, the technology has historically been challenged by specular, or mirr…

Interplanetary Gastronomy

The  Interplanetary Gastronomy research  aims to address the unique challenges and opportunities associated with eating in s…

Tasting Menu in Zero G

 A multi-course tasting menu was flown on a zero gravity flight in August 2019.  Five specially crafted dishes were consumed…

Molecular Gastronomy in Zero G

A molecular gastronomy experiment was flown on a zero gravity flight in August 2019, using spherification techniques to create recipes in z…

Mental Machine: Labour in the Self Economy

​Mental Machine: Labour in the Self Economy, 2022, is a live performance by Kawita Vatanajyankur made in collaboration with Pat Patara…

Battery-free wireless underwater camera

More than 95% of the ocean has never been observed by humans, even though the ocean plays the largest role in the world's climate system, h…

Augmented Reality with X-Ray Vision

X-AR is an augmented reality (AR) system that gives humans "X-Ray Vision" X-AR is a new AR headset that enables users to see things th…

Deep Reinforcement Learning for Autonomous UAVs (AUAVs)

Many tasks are not easily defined and/or too complex for supervised machine learning approaches. For these reasons, a technique known as&nb…

Domain Randomization & Synthetic Data Generation for AUAVs - Reducing Perceptual Uncertainty of Sim2Real Navigation

Navigation for autonomous UAVS (unmanned aerial vehicles) is a complex problem and physical field testing of associated tasks introduces a …

Fiducial Marker-Based Navigation for Autonomous UAVs (AUAVs)

Depending on the operational environment of an autonomous system, a great deal of perceptual uncertainty may be introduced to an object det…

Unmanned Aerial Vehicle (UAV) Pilot Simulator

With the advent of real-time photorealism (RTPR), virtual environments are now able to achieve higher degrees of engagement than ever befor…

Oceans Internet of Things

Our Oceans IoT technologies enable new applications in climate and ecological monitoring, aquaculture, energy, and robotic navigation. …

Virtual reality system lets you stop and smell the roses

Media Lab alum Judith Amores talks to Scientific American about a lightweight, wireless interface to deliver scents to VR users.

New research from the Signal Kinetics research group is featured on "Science Without the Gobbledygook"

Physicist Sabine Hossenfelder discusses X-AR, the new research from the Media Lab’s Signal Kinetics group.

MIT researchers develop augmented reality headset to help users see hidden objects

Using augmented reality, the X-AR system developed by the Signal Kinetics research group can guide users to find hidden objects.

Towards a Congruent Hybrid Reality without Experiential Artifacts

​Situated VR: Towards a Congruent Hybrid RealityThe vision of Extended Reality (XR) systems is living in a hybrid reality or "Metaverse" wh…

Adaptive Virtual Neuroarchitecture

Jain, A., Maes, P., Sra, M. (2023). Adaptive Virtual Neuroarchitecture. In: Simeone, A., Weyers, B., Bialkova, S., Lindeman, R.W. (eds) Everyday Virtual and Augmented Reality. Human–Computer Interaction Series. Springer, Cham. https://doi.org/10.1007/978-3-031-05804-2_9

Augmented reality headset enables users to see hidden objects

The device could help workers locate objects for fulfilling e-commerce orders or identify parts for assembling products.

Transforming data into knowledge

The One Earth Model: Geographic interoperability in the real-world metaverse

Michael Naimark considers the potential of the "real-world metaverse," which combines virtual experiences with specific physical places.

Unveiling the Invisible

Tamiko Thiel, an innovator in VR/AR who studied computer graphics and visual imaging, talks about her work and her career.

Brelyon secures $15 million for Ultra Reality immersive technology

Media Lab spinoff Brelyon has raised $15 million in Series A financing to accelerate development of headset-free immersive displays.

ML Learning

Changing storytelling, communication, and everyday life through sensing, understanding, and new interface technologies

Bird: a 3D Cursor for 3D Interaction in Virtual Reality

Bird is a hand-controlled pointing system that translates a user's finger movements and positions into the motion of a 3D pointer in a virt…

Virtual and augmented reality headsets are unique as they have access to our facial area, an area that presents an excellent opportunity fo…

EmotionalBeasts

With advances in virtual reality (VR) and physiological sensing technology, even more immersive computer-mediated communication through lif…

Body-Borne Reality: Risky Disembodiment in VR

Ai-generated characters are here, they’re just not evenly distributed.

The Fluid Interfaces group + NTT DATA hosted Virtual Beings + Being Virtual, a workshop exploring positive uses of AI-generated characters

Hacking Reality

XR technology is becoming increasingly important in a world where the need to know intersects with the need to experience.

Living Observatory: Sensor networks for documenting and experiencing ecology

Living Observatory is an initiative for documenting and interpreting ecological change that will allow people, individually and collectivel…

E-maki: XR-enabled Scroll for Interactive Museum Artifacts

E-maki is a collection of ancient, painted scrolls accompanied by a cross-reality app that give contextual information and interactive expe…

The Interplanetary Cookbook

The Interplanetary Cookbook, developed by Maggie Coblentz, presents thought-provoking recipes and zero-g kitchenware for the future of life…

Increasing Embodiment for Desktop-Based Participants in Mixed Desktop and Immersive Collaborative Virtual Environments

Simonson, Aubrey and Pattie Maes. “Increasing Embodiment for Desktop-Based Participants in Mixed Desktop and Immersive Collaborative Virtual Environments.” (May 7, 2020).

What’s it like to design a meal that floats?

Taking a taste of the sensory research of Space Exploration Initiative’s Maggie Coblentz

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Open access
• Published: 31 July 2024

Advances in olfactory augmented virtual reality towards future metaverse applications

• Zixuan Zhang 1 , 2 ,
• Xinge Guo 1 , 2 &
• Chengkuo Lee   ORCID: orcid.org/0000-0002-8886-3649 1 , 2 , 3  

Nature Communications volume  15 , Article number:  6465 ( 2024 ) Cite this article

2028 Accesses

1 Citations

35 Altmetric

Metrics details

• Biomedical engineering
• Electrical and electronic engineering

Recent advances in virtual reality technologies accelerate the immersive interaction between human and augmented 3D virtual worlds. Here, the authors discuss olfactory feedback technologies that facilitate interaction with real and virtual objects and the evolution of wearable devices for immersive VR/AR applications.

Virtual reality (VR) technology typically employs visual and auditory devices, such as head-mounted displays and VR goggles, but further immersion in virtual spaces can be achieved through wearable devices including gloves, exoskeletons, shoes, etc., and electronic skins (e-skin) 1 . These wearable devices enable the realization of full-body sensory perception or sensation, requiring the capability to perceive human movements, simulate sensations, and being flexible and comfortable for users (Fig.  1 ). Recently, sensors for detecting physical signals, e.g., stretch, pressure, temperature, etc., have been flourishing. They can be utilized for biosensing and detecting human motion signals 2 . In addition, wearable systems integrating multiple types of flexible actuators, such as tendon actuators, pneumatic actuators, and electrostatic actuators, can achieve kinesthetic, electro-tactile, vibrotactile, and thermal-tactile feedback, respectively. Such systems provide tactile stimulation to the skin’s sensory receptors 3 . Multimodal haptic feedback enables users a better immersive sensory experience by enhancing interaction between humans and virtual environments. For example, an augmented tactile-perception and haptic feedback ring, equipped with multimodal sensing encompassing tactile, temperature sensing, and feedback encompassing vibratory and thermal haptic stimuli, demonstrates the potential beyond the commercial rings 4 . A skin-integrated wireless haptic interface using actuator arrays offers multimodal mechanisms for complex feedback. Within this interface, various feedback modes including mechanical, electrotactile, and thermal, are utilized to target distinct cutaneous receptors selectively, offering users diverse haptic sensations 5 . The fusion of VR display technology with such multimodal somatosensory sensation for full-body perception and feedback is essential for future metaverse applications. An augmented 3D virtual society, i.e., a 4D VR world, could facilitate intelligent and interactive experiences across various domains such as social interactions, education, entertainment, healthcare, etc.

The development trends of physical sensing and physical feedback devices 2 , 3 , 4 , 5 , olfactory sensing devices 6 , 7 , 8 , 9 , 10 , and olfactory feedback devices 11 , 12 , 13 , 14 . Figure adapted with permission from: (‘Skin-interfaced biosensor’), ref. 2 , Springer Nature Ltd; (‘Stretchable thermos-haptic device’), ref. 3 , Wiley; (‘Augmented tactile-perception and haptic feedback ring’), ref. 4 , Springer Nature Ltd; (‘Skin-interfaced multimodal haptic interface’), ref. 5 , Springer Nature Ltd; (‘Transcutaneous blood VOC imaging system’), ref. 6 , American Chemical Society; (‘Tactile-olfactory bionic sensing array’), ref. 7 , Springer Nature Ltd; (‘Surface acoustic wave device based sensor’), ref. 8 , American Chemical Society; (‘Machine learning-enhanced mid-infrared gas sensing’, top), ref. 9 , Springer Nature Ltd; (‘Machine learning-enhanced mid-infrared gas sensing’, bottom), ref. 10 , Wiley; (‘Surface acoustic wave device based atomizer’), ref. 11 , IEEE; (‘Bionic fibrous membrane’), ref., Wiley; (‘Physical phase change of odorous paraffin wax’), ref. 13 , Springer Nature Ltd; (‘Multi-element solenoid value array’), ref. 14 , Springer Nature Ltd.

Equally important to traditional visual, auditory, and tactile sensations, olfaction exerts both physiological and psychological influences on humans. The pivotal role of olfaction in shaping human experiences is undeniable, given that many aspects of daily life that are influenced by scent emanate from industrial processes, transportation, household products, etc. With significant advancements in chemistry, biology, and neuroscience, odor sensors (gas/ liquid sensors) are witnessing the rapid development of decoding complex odor mixtures facilitated by conventional rigid and innovative flexible sensing electronics. They provide non-invasive methods for detecting biomarkers and informing about metabolic processes and disease progression for humans and plants, thus greatly appealing for real-time health monitoring and point-of-care diagnostics. A highly sensitive bio-fluorometric gas sensor “bio-sniffer” based on an enzymatic reaction is developed to measure the concentration of transcutaneous ethanol (EtOH) after drinking 6 . Concurrently, the emergence of artificial intelligence (AI)-based data analytics introduces the potential to enhance sensor functionalities towards intelligent sensing. Leveraging the robust feature extraction capabilities of machine learning, previously subtle valuable features within complex signal outputs can be discerned and harnessed, which can be used to achieve advanced sensory perceptions. A tactile-olfactory sensing array is developed to permit the real-time acquisition of the local topography, stiffness, and odor of various objects without visual input 7 , by leveraging the bioinspired olfactory-tactile associated AI algorithm. Moreover, a single piezoelectric cantilever is used to detect temperature and CO 2 concentration with the interference of humidity and temperature for noncontact sensation and monitoring human breath and plant ecosystem 8 . Photonics noses/tongues are the emerging vital tools that utilize optical technology to mimic human olfactory systems. The mid-infrared photonics nose/ tongue distinguishes different olfactory by analyzing the absorption spectra of liquid gas samples 9 , 10 . They offer advantages such as high sensitivity, rapid response, and noncontact detection, making them valuable in medical, food industry, and environmental monitoring applications. The development and application of artificial noses and tongues with better-than-human capability in AI-enhanced optical sensing technology are crucial for enhancing the sensitivity and accuracy of odor and taste detection.

Unlike the visual, auditory, and tactile sensory channels, olfaction is a nonlinear chemical sense, which makes it challenging to develop a technically comprehensive olfactory feedback system for precise control of odor generation and delivery. The olfactory feedback technologies reported so far still face huge challenges. Current olfaction-generating technologies are struggled with bulky dimensions, limited scent variety, and slow response times. Such olfaction-generating technologies are mainly associated with either large instruments designed to generate smell in a closed area/ room or an in-built bulky VR set. Consequently, these olfaction feedback approaches are far behind the advancement of visual/ auditory-based VR devices, thereby severely constraining their potential applications. For example, an olfactory display for blending many ingredients in any recipe was developed based on solenoid valves and surface acoustic wave atomizers 11 . However, the bulky circuits and systems make it difficult for them to become wearable solutions. In addition, a bionic fibrous membrane (BFM) integrated with the function of electrostatic field accelerated evaporation is applied to realize the virtual olfactory generation system 12 . Although it realizes the functionality of wearable and 4-odor generation, the response time of this system still needs to be improved. Therefore, Liu et al. reported a skin-interfaced olfactory feedback system with wirelessly programmable capabilities based on an array of flexible and miniaturized odor generators (OGs) for olfactory VR applications 13 , which demonstrates outstanding performance including rapid response rates to odor concentration, prolonged continuous operation, robust mechanical/ electrical stability, and minimal power consumption. Furthermore, they developed an OGs array with advanced artificial intelligence (AI) algorithms 14 , which exhibit milestone advances in various features of performance, including millisecond-level response time (70 ms), milliwatt-scale power consumption (84.8 mW), miniaturized size (11 mm × 10 mm × 1.8 mm), and high stability (12-hr continuous operation). Miniaturized olfactory generators with millisecond-level response times, milliwatt-scale power consumption, compact size, stability, and a high number of odor supplies establish a bridge between electronics and users for broad applications ranging from entertainment to education, medical treatment, and human-machine interfaces. Compared with traditional olfactory feedback technologies, the odor generators reported by Liu et al. based on the physical phase change of odorous paraffin wax by controlling the heating temperature exhibit advances in the realization of 32 odor with adjustable concentrations and long operation duration to support long-term utilization without frequent replacement. In addition, the whole system is the first to be built on a skin-integrated soft substrate and equipped with a paired intelligent electronic control panel, allowing remote operation of various selective odor types according to users’ requirements.

By leveraging the advanced olfactory feedback integrated with wearable/flexible technologies 13 , 14 , the high-channel odor generation arrays of a miniaturized, lightweight, and flexible format expand the interactive potential of VR applications, facilitating experiential learning and emotional modulation (Fig.  2 ). Users control the odor generation in the virtual world through event-triggering in the real world, which can be better used to help beginners recognize the smell of different types of flowers and plants, and to serve as a teaching function. It can also be used as important feedback in VR games, such as picking different fruits in a virtual orchard and simulating flower arrangements. Moreover, the importance of olfactory generation technology lies in its capacity to enhance immersion and realism by simulating various scents that evoke emotional responses and deepen cognitive engagement. While VR primarily caters to visual and auditory senses, adding olfactory stimuli enriches the sensory experience, fostering a more profound sense of presence within the virtual environment. Olfactory cues have been shown to trigger vivid memories and emotional reactions, thus contributing to heightened cognitive and emotional engagement. Olfactory feedback can also realize olfactory training to ameliorate the disorders resulting from various causes, such as upper respiratory tract infections, trauma, idiopathic factors, and neurological diseases 14 . Furthermore, research suggests that incorporating a greater variety of odor in the training regimen can enhance the rate of improvement in olfactory function. The future of olfactory feedback is advancing towards olfactory encoding 15 , by leveraging neuroscientific analysis to achieve the mapping from chemical structures to olfactory perception and microelectronics technology to realize quantified feedback for complex mixed odor. Developing bidirectional AI algorithms for enhanced odor recognition and odor generation in a system aiming at advanced metaverse applications is the next milestone technology. By combining olfactory cues with visual, auditory, and tactile feedback, virtual environments can be made more comprehensive and lifelike, expanding the application field across various domains, including entertainment, education, and healthcare, offering users a more diverse and immersive sensory experience. For example, in a fire escape practice, the fidelity and effectiveness of training can be achieved by providing the smell of smoke based on the odor generator technology from Liu et al. 13 , 14 and high-temperature sensation based on thermal-tactile feedback 3 , 5 . In the future, the advanced micro/nano-scale technology may help to create new olfactory generators and required electronic control devices for metaverse applications.

The implementation of different odor releases from odor generators bridges the gap between reality and virtual worlds, applied in mixed reality for education and entertainment 13 , 14 . Various odor releases in virtual spaces can serve clinical therapy, emotion regulation, and olfactory training for olfactory disorders.

Sun, Z., Zhang, Z. & Lee, C. A skin-like multimodal haptic interface. Nat. Electron. 6 , 941–942 (2023).

Article   Google Scholar  

Chung, H. U. et al. Skin-interfaced biosensors for advanced wireless physiological monitoring in neonatal and pediatric intensive-care units. Nat. Med. 26 , 418–429 (2020).

Article   CAS   PubMed   PubMed Central   Google Scholar  

Lee, J. et al. Stretchable skin‐like cooling/heating device for reconstruction of artificial thermal sensation in virtual reality. Adv. Funct. Mater. 30 , 1–11 (2020).

ADS   CAS   Google Scholar  

Sun, Z., Zhu, M., Shan, X. & Lee, C. Augmented tactile-perception and haptic-feedback rings as human-machine interfaces aiming for immersive interactions. Nat. Commun. 13 , 5224 (2022).

Article   ADS   CAS   PubMed   PubMed Central   Google Scholar  

Huang, Y. et al. A skin-integrated multimodal haptic interface for immersive tactile feedback. Nat. Electron. 6 , 1020–1031 (2023).

Iitani, K., Toma, K., Arakawa, T. & Mitsubayashi, K. Transcutaneous blood VOC imaging system (skin-gas cam) with real-time bio-fluorometric device on rounded skin surface. ACS Sens. 5 , 338–345 (2020).

Article   CAS   PubMed   Google Scholar  

Liu, M. et al. A star-nose-like tactile-olfactory bionic sensing array for robust object recognition in non-visual environments. Nat. Commun. 13 , 79 (2022).

Li, D. et al. Machine learning-assisted multifunctional environmental sensing based on a piezoelectric cantilever. ACS Sens. 7 , 2767–2777 (2022).

Ren, Z., Zhang, Z., Wei, J., Dong, B. & Lee, C. Wavelength-multiplexed hook nanoantennas for machine learning enabled mid-infrared spectroscopy. Nat. Commun. 13 , 3859 (2022).

Liu, X. et al. Artificial intelligence-enhanced waveguide “photonic nose”- augmented sensing platform for VOC gases in mid-infrared. Small 2400035 , 1–12 (2024).

ADS   Google Scholar  

Nakamoto, T., Ito, S., Kato, S. & Qi, G. P. Multicomponent olfactory display using solenoid valves and SAW atomizer and its blending-capability evaluation. IEEE Sens. J. 18 , 5213–5218 (2018).

Article   ADS   CAS   Google Scholar  

Yang, P. et al. Self-powered virtual olfactory generation system based on bionic fibrous membrane and electrostatic field accelerated evaporation. EcoMat 5 , 1–15 (2023).

Liu, Y. et al. Soft, miniaturized, wireless olfactory interface for virtual reality. Nat. Commun. 14 , 2297 (2023).

Liu, Y. et al. Intelligent wearable olfactory interface for latency-free mixed reality and fast olfactory enhancement. Nat. Commun. 15 , 4474 (2024).

Lee, B. K. et al. A principal odor map unifies diverse tasks in olfactory perception. Science. 381 , 999–1006 (2023).

Article   ADS   CAS   PubMed   Google Scholar  

Download references

Acknowledgements

This work was supported by the NRF Competitive Research Programme (CRP-28th) under the research grant of CRP28-2022-0038 (awarded to C.L.); RIE-2025, Piezo Specialty Lab-in-Fab 2.0 (RIE2025 IAF-ICP (I2301E0027), awarded to C.L.); Ministry of Education (MOE) under the research grant of A-0009520-01-00 (awarded to C.L.) at National University of Singapore.

Author information

Authors and affiliations.

Department of Electrical and Computer Engineering, National University of Singapore, 4 Engineering Drive 3, Singapore, 117576, Singapore

Zixuan Zhang, Xinge Guo & Chengkuo Lee

Center for Intelligent Sensors and MEMS (CISM), National University of Singapore, 4 Engineering Drive 3, Singapore, 117576, Singapore

NUS Graduate School - Integrative Sciences and Engineering Programme (ISEP), National University of Singapore, 21 Lower Kent Ridge Road, Singapore, 119077, Singapore

Chengkuo Lee

You can also search for this author in PubMed   Google Scholar

Contributions

C.L. conceived the article. Z.Z. and X.G. wrote the first version of the manuscript with constructive input from C.L. All authors approved the submitted version of the article.

Corresponding author

Correspondence to Chengkuo Lee .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

Zhang, Z., Guo, X. & Lee, C. Advances in olfactory augmented virtual reality towards future metaverse applications. Nat Commun 15 , 6465 (2024). https://doi.org/10.1038/s41467-024-50261-9

Download citation

Received : 13 May 2024

Accepted : 01 July 2024

Published : 31 July 2024

DOI : https://doi.org/10.1038/s41467-024-50261-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

We apologize for the inconvenience...

To ensure we keep this website safe, please can you confirm you are a human by ticking the box below.

If you are unable to complete the above request please contact us using the below link, providing a screenshot of your experience.

https://ioppublishing.org/contacts/

Articles on Virtual reality

Displaying 1 - 20 of 196 articles.

What are ‘metacrimes’ – and how can we stop them?

Ausma Bernot , Griffith University ; Kai Lin , University of Technology Sydney ; Milind Tiwari , Charles Sturt University , and You Zhou , Monash University

Virtual reality ‘embodiment illusions’ may help the skewed perceptions behind body image disturbances

Jade Portingale , The University of Melbourne

Hearing voices is common and can be distressing. Virtual reality might help us meet and ‘treat’ them

Leila Jameel , Swinburne University of Technology ; Imogen Bell , The University of Melbourne ; Neil Thomas , Swinburne University of Technology , and Rachel Brand , University of the Sunshine Coast

An eerie ‘digital afterlife’ is no longer science fiction. So how do we navigate the risks?

Arif Perdana , Monash University

The metaverse could change our religious experiences, and create new ones

Marco Adria , University of Alberta

We created a VR tool to test brain function. It could one day help diagnose dementia

Joyce Siette , Western Sydney University and Paul Strutt , Western Sydney University

Our brains take rhythmic snapshots of the world as we walk – and we never knew

Matthew Davidson , University of Sydney

We gave palliative care patients VR therapy. More than 50% said it helped reduce pain and depression symptoms

Tobias Loetscher , University of South Australia and Gregory Crawford , University of Adelaide

Virtual reality grooming is an increasing danger. How can parents keep children safe?

Marika Guggisberg , CQUniversity Australia

Editing memories, spying on our bodies, normalising weird goggles: Apple’s new Vision Pro has big ambitions

Luke Heemsbergen , Deakin University

Four ways AI will impact music, from Elvis holograms to interactive soundscapes

Somdip Dey , University of Essex

A 360 camera, 1°C weather and an ambitious VR documentary: what I learnt as cinematographer on Sorella’s Story

Gilberto Roque , University of Southern Queensland

Virtual reality can help emergency services navigate the complexities of real-life  crises

Brandon May , University of Winchester and Selina Robinson , University of Winchester

Virtual reality has negative side effects – new research shows that can be a problem in the workplace

Alexis Souchet , University of Southern California

The Apple Vision Pro hasn’t really impressed consumers, but that isn’t the goal – for now

Martie-Louise Verreynne , The University of Queensland and Margarietha de Villiers Scheepers , University of the Sunshine Coast

Apple’s new Vision Pro mixed-reality headset could bring the metaverse back to life

Omar H. Fares , Toronto Metropolitan University

Apple Vision Pro headset: what does it do and will it deliver?

Panagiotis Ritsos , Bangor University and Peter Butcher , Bangor University

Technology is radically changing sleep as we know it

Catherine Coveney , Loughborough University and Eric L Hsu , University of South Australia

We’re using VR to help find the next generation of basketball stars

Pooya Soltani , Staffordshire University

The latest trends in video games from the 2023 global Game Developers Conference

Gavin Wade , University of Portsmouth

Related Topics

• Artificial intelligence (AI)
• Augmented reality
• Oculus Rift

Top contributors

Researcher in Virtual Reality, Auckland University of Technology

Senior Lecturer in Digital Cultures, SOAR Fellow., University of Sydney

Lecturer in Digital Cultures, University of Sydney

Senior Lecturer in Applied Ethics & CyberSecurity, Griffith University

Professor of Creative and Cultural Industries, University of Nottingham

Senior Lecturer in Digital Marketing, University of the West of Scotland

Professor of Screen Media, King's College London

Chair in Interactive Multimedia Systems, University of Birmingham

Professor of Management, University of North Carolina – Greensboro

Senior Lecturer in Media Studies, University of Portsmouth

Senior Lecturer, Digital, Political, Media, Deakin University

Associate Professor – Information & Communication Technology (ICT), CQUniversity Australia

Professor of Anthropology, University of California, Irvine

Assistant Professor, Northumbria University, Newcastle

Enterprise Fellow, University of South Australia

• X (Twitter)
• Unfollow topic Follow topic

Find anything you save across the site in your account

Where Will Virtual Reality Take Us?

Because we in Silicon Valley are newness junkies, it can feel like an act of sabotage to have memories, but, for better or worse, I have them. It’s been more than forty years since I co-founded the first company to make headsets and software for simulated experiences, and came up with familiar terms like virtual and mixed reality. Since then, virtual reality has flooded the public imagination in waves; back in the nineteen-eighties, for instance, it had quite a presence in movies, cartoons, TV shows, the occasional arcade game, and a few early consumer products, like the Nintendo Power Glove. I still love V.R. But, these days, I sense that what I experience of it, what I enjoy in it, is different from what it has come to mean to many enthusiasts.

Back then, at the beginning, did I talk about V.R. like the people I disagree with now? Sometimes I did! I did occasionally promote V.R. as an alternate cosmos that might swallow us all to good effect. I don’t agree with that sort of talk now, but at the time the joy of being edgy and extreme was too great to resist. Every young technical person wants to see around the corners that others cannot, to be the harbinger of great change. To explain to someone in the early eighties what V.R. was—to give them a demo—was an ego rush, because they often couldn’t grasp what was being said or what had just happened to them. It was a primal validation, a power trip, and I wish I had done it with more humility. But here we are, after almost a half century of products, movies, and startups, and V.R. people still seek that rush. Apple’s promotional videos for its new headset—the Vision Pro, a metal-and-glass, ski-goggle-like apparatus that costs around thirty-five hundred dollars—show people experiencing V.R. for the first time. The producers either had to search hard for those people or ask actors to pretend.

Apple’s entrance into V.R. has symbolic weight, because the company has had so much influence on computers and phones. Back in 1984, when the Macintosh was introduced, a few members of the Mac team left Apple to join my startup, V.P.L., and help us create the first generation of commercial V.R. products. At the time, we guessed that Apple itself would enter the market in 2010. We knew that the consumer adoption of the technology was a long way off. We were selling tools for millions of dollars to customers like NASA . But despite the conservative clients, our early V.R. software was radically strange. You could program while in our virtual world, and see all the variables not as textual symbols but as virtual objects; there was no source code. I used to wax on about how virtual reality would lead to a new style of “post-symbolic” communication, in which we would make experiences for one another, sharing them directly instead of just describing them.

The hope was to make V.R. a place for spontaneous invention. Virtual reality would allow groups of people to “play the world into existence” on virtual devices that resembled musical instruments. (Instead, we now talk about “speaking the world into existence” using A.I.) It would be like a social lucid dream.

In the intervening decades, V.R. has thrived at two extremes in the quest for “killer apps.” It has long been an established industrial technology: if you’ve flown, ridden, or sailed in a factory-built vehicle in the last thirty years, virtual reality may have played a central role. It’s been used to design surgical procedures and train surgeons ever since our first simulated gallbladder, at Stanford Med, some three decades ago; Boeing, Ford, and many other companies started using VR for design in the early days as well. And then there are the visionary, mystical, and philosophical applications. V.R. can be a way of exploring the nature of consciousness, relationships, bodies, and, perception. In other words, it can be art. V.R. is most fun when approached that way.

In between the two extremes lies a mystery: What role might V.R. play in everyday life? The question has lingered for generations, and is still open. Gaming seems likely—but, for most gamers, not so much. There are many reasons why V.R. and gaming don’t quite work, and I suspect that one is that gamers like to be bigger than the game, not engulfed by it. You want to feel big, not small, when you play. (“Star Wars” might have got this right with holographic chess.) Apple’s initial round of Vision Pro apps, like those from its competitors, aren’t entirely compelling, either, and can even have a lonely, dystopian flavor. (Watching a simulated big-screen movie, by yourself?) But my belief is that the quotidian killer apps will come. Maybe you’ll use V.R. to learn quickly about the Airbnb at which you’ve just arrived. Maybe V.R. will help you assemble IKEA furniture. Maybe!

Virtual-reality headsets come in various forms. A major divide has to do with how they acknowledge the real world. Some headsets obscure the surrounding environment completely; this is typical in gaming headsets. But there is another option, which I used to call “mixed” reality, and which came to be known as “augmented” reality in the nineteen-nineties. Some mixed or augmented headsets, such as the Microsoft HoloLens or the system created by Magic Leap, allow you to see the real world through the headset glass so that it can be combined with virtual content using challenging optical techniques. Others, like Apple’s Vision Pro and the recent offerings from Meta , capture the real world with cameras, then render it as part of the virtual environment so that it can be combined with fabulated content.

Camera-based mixed reality is vastly easier to accomplish than the optical version, but it is concerning. Early research by a Stanford-led team has found evidence of cognitive challenges. Your hands are never quite in the right relationship with your eyes, for instance. Given what is going on with deepfakes out on the 2-D Internet, we also need to start worrying about deception and abuse, because reality can be so easily altered as it’s virtualized.

The attention-maximizing business model that drives current social media naturally gravitates toward alarming content that activates primal fight-or-flight responses. Fortunately, Apple is one of the companies that doesn’t rely on that model. Nonetheless, experiences will come from all kinds of companies, and V.R. could agitate and depress people even more than the little screens on smartphones.

Today, in much of the online world, algorithms calculate “feeds”—a term suggesting that people are cattle, and not free-range ones. This is a good reason for wanting virtual reality to be an environment in which users actively create their own content, rather than passively experiencing what big companies have built for them. For most of the technology’s history, however, virtual experiences have been hard to build and maintain. This has been one of V.R.’s biggest problems. I saw the first V.R. teaching demonstration of general relativity at least as early as 1992, and have seen dozens more since then; they’re often wonderful, and help users grasp the concept in new ways. But they only run for a year or so because there are too many variables in a V.R. system for creators to keep experiences available. Graphics chips change, and with them the layers of mediating software. That’s true for other programs, too, but with V.R., when the properties of a headset (like field of view) or an input device shift, the whole experience and interaction method must often be rejiggered. It’s too much ongoing effort, so it usually doesn’t happen; developers move on to other projects. The exceptions have been locked-down V.R. experiences that assume a minimal level of interaction, which limits the magic.

Still, the first generation of V.R. entrepreneurs thought of it as a fundamentally active experience. In fact, the illusion at the heart of virtual reality requires activity on your part: the virtual world only starts to feel real when you move your head; it’s when your surroundings compensate for that motion that they appear to exist outside of you. And yet we often see V.R. depicted as a funnel that dumps spectacular experiences into the brain of the user.

Today, the V.R. community seems to want to make headsets smaller and smaller, until they disappear. But in the old days I’d build one-of-a-kind V.R. headsets into big masks from different cultures, sometimes adding lightning bolts and feathers. I wanted the headsets to be vibrant, exciting objects that enriched the real world, too. Apple’s device shows the eyes of the wearer, by means of screens on the front, and this creates the illusion that the headset is transparent. But in past decades we used similar screens to show those in the real world the face of the virtual avatar that the wearer was inhabiting: a viking, an octopus, an abstract geometric construction. You wouldn’t want to disguise a motorcycle as a bicycle. If you’re going to wear a headset, you should be proud of that weird thing on your head!

Apple is marketing the Vision Pro as a device you might wear for everyday purposes—to write e-mails or code, to make video calls, to watch football games. But I’ve always thought that V.R. sessions make the most sense either when they accomplish something specific and practical that doesn’t take very long, or when they are as weird as possible.

The practical side of V.R. is a scattering of wonderful niches: in addition to surgical simulation and vehicle design, the technology is used by oil companies to simulate geological structures, by drug companies to envision molecules, and by planners working on city centers. The new frontier, which might apply more to everyday life, is the spontaneous creation of practical apps that you might not even bother to save. My research group, for instance, has presented a prototype system—the “mixed-reality copilot”—that allowed us to recreate, with a single voice request, a program that allows you to use your hands to paint and sculpt with virtual stuff. A decade ago, it took months to make that kind of program. Hopefully, in the near future, one will be able to ask for a V.R. relativity simulation tailored for a student who has color blindness and A.D.H.D., and it will simply appear. More prosaically, you might walk through a facility in augmented reality, asking an A.I. for instant advice about potential safety hazards and fixes. These ideas might even work already: one of the curious features of this accelerated period of A.I. development is that there aren’t enough minutes in the day to try everything.

On the weird edge, it turns out you can change your body plan in V.R. You can become different animals. You can map your body to that of a lobster or an octopus, and experience, to a significant extent, the control of that other body. The brain has had to adapt to many body plans over the course of its evolution, and it’s pre-adapted to work with more. When you change your body, you can also play with the flow of time. By shifting the rhythm of the natural sway of your limbs, and also how the objects around you move and change in response, you alter the reference points that your brain uses to mark the flow of time. You can speed it up or slow it down. In V.R., you can change the rules of the world. You can exist in strange geometries that are too hard to describe in words. You can become an archipelago of parts instead of a continuous animal. You can blend and share bodies with others, to a surprising degree.

All this can happen, and yet there’s a little nub that remains unchanged. There’s still a you floating in the middle of it all. This makes virtual reality a consciousness-noticing machine. Lately, people in A.I. have colonized the word “consciousness”; they sometimes suggest that their models have it. This can make us wonder if it’s even real. But V.R. reminds us that experience really exists. It’s at the core of V.R. It exists even when the world around it is an illusion.

There are fresh, urgent reasons to reaffirm the value of experience. It is impossible to judge technology without a sense of its purpose—and its only plausible purpose is to benefit people, or perhaps animals, or the over-all ecosystem of the planet. In any case, if we pursue technologies that make it hard to delineate the beneficiaries—for instance, by blending brains into robotics not to cure a disease but just because it seems cool—then we make the very idea of technology absurd. The central question of the technological future is how to identify the people who are supposed to benefit from technology, especially if they seem to have melted into it. If people aren’t special, how can we act in a way that benefits people? We can’t. The principles of ethics, design, and even technology itself become nonsense. What can that specialness be? It must be something that is not technologically accessible, since technology expands unpredictably. It’s a little mystical. The definition of people must be one of apartness. We must now put people on pedestals, or they will drown.

When I put on a V.R. headset, I still notice that I am floating there, that I exist independently of the information I experience. But then there’s the moment I take off the headset, which is the very best. In the nineteen-eighties, we used to try to sneak flowers or pretty crystals in front of people before they would take off their headsets; it was a great joy to see their expressions as they experienced awe. In a sense, this was like the awe someone might experience when appreciating a flower while on a psychedelic drug. But it was actually the opposite of that. They were perceiving the authentic ecstasy of the ordinary, anew.

This is the kind of experience you can have only if you use V.R. fleetingly, not constantly. Here we come to one of the greatest differences between what I love about virtual reality and how it is often promoted today. Venture capitalists and company-runners talk about how people will spend most of their time in V.R., the same way they spend lots of time on their phones. The motivation for imagining this future is clear; who wouldn’t want to own the next iPhone-like platform? If people live their lives with headsets on, then whoever runs the V.R. platforms will control a gigantic, hyper-profitable empire.

But I don’t think customers want that future. People can sense the looming absurdity of it, and see how it will lead them to lose their groundedness and meaning. In the early days of V.R., I actually tried living in it all the time; on a number of occasions, I stayed in virtual reality for several days. In fact, back at the start, some of my young colleagues and I made a vow: if we ever became parents—a possibility as remote for us at that time as a visit to Alpha Centauri—we would slip baby V.R. googles onto our kids at birth, then swap in bigger ones as the kids grew. That way, our kids could grow up in four dimensions, and become the greatest mathematicians ever. When I told my daughter about this, at around age eight, she was angry that I’d denied her this chance.

Maybe someone will actually do it one day. I wonder if it will be legal. But the truth is that living in V.R. makes no sense. Life within a construction is life without a frontier. It is closed, calculated, and pointless. Reality, real reality, the mysterious physical stuff, is open, unknown, and beyond us; we must not lose it.

Just because owning a major tech platform is desirable, that doesn’t suggest there is no other way to succeed in the technology business. There are water companies and soda companies, and then there is fine wine. All are viable businesses. The metaphor isn’t perfect, but I suspect that V.R. entrepreneurs will find their sweet spot by emulating Napa Valley.

This perspective might make business sense, but it violates what might be called the religion of infinity in tech culture. Infinity is a fake drug, but a powerful one. No one wants to die; everyone wants to fly everywhere in the universe. Young men, especially, get high on infinity; their version of tech culture is the most influential culture of our time. It is the only remaining cultural force that can defy market forces, technological limitations, and the law—at least for a while. The crypto world is an example: it’s a disastrous junk yard of fraud and failure, funding some of the world’s worst actors, and any normal investor community would have soured on it by now. But the dream of infinity propels people forward without bounds.

The dream has many faces. A.I. is often portrayed as a godlike, transcendent project that will take over the fabric of our physical reality, leading to a singularity, meaning nothing that matters now is likely to matter after. But singularities, like the ones we hypothesize in black holes, are the very definition of ignorance. There is no learning that bridges the before and after of a singularity. It is the absolute rejection of intelligence. Virtual reality is sometimes stirred into this mix. But our best understanding of how reality works is entirely bound to finitude. Physics is all about conservation principles. There are no infinities, only S curves. There is no free lunch. Technical culture often longs for freedom from finitude. A profound truth, however, is that the greatest mysteries are found in conserved systems, which can become rich and complex, not in infinite ones, which stretch out like blank white sheets to the edge of the cosmos.

And so another urgent question is whether people can enjoy the storied reality of finitude after coming down from the high of fake infinity. Can being merely human suffice? Can the everyday miracle of the real world be appreciated enough? Or will the future of culture only be viral? Will all markets become Ponzi-like fantasies? Will people reject physics forever, the moment we have technology that’s good enough to allow us to pretend it’s gone?

Virtual reality can take us either way. I still experience V.R. as a beacon of humanism. Maybe others will, too. ♦

More Science and Technology

Can we stop runaway A.I. ?

Saving the climate will depend on blue-collar workers. Can we train enough of them before time runs out ?

There are ways of controlling A.I.—but first we need to stop mythologizing it .

A security camera for the entire planet .

What’s the point of reading writing by humans ?

A heat shield for the most important ice on Earth .

The climate solutions we can’t live without .

Support The New Yorker’s award-winning journalism. Subscribe today .

Advertisement

Better, Virtually: the Past, Present, and Future of Virtual Reality Cognitive Behavior Therapy

• Open access
• Published: 20 October 2020
• Volume 14 , pages 23–46, ( 2021 )

Cite this article

You have full access to this open access article

• Philip Lindner   ORCID: orcid.org/0000-0002-3061-501X 1  

20k Accesses

49 Citations

3 Altmetric

Explore all metrics

Virtual reality (VR) is an immersive technology capable of creating a powerful, perceptual illusion of being present in a virtual environment. VR technology has been used in cognitive behavior therapy since the 1990s and accumulated an impressive evidence base, yet with the recent release of consumer VR platforms came a true paradigm shift in the capabilities and scalability of VR for mental health. This narrative review summarizes the past, present, and future of the field, including milestone studies and discussions on the clinical potential of alternative embodiment, gamification, avatar therapists, virtual gatherings, immersive storytelling, and more. Although the future is hard to predict, clinical VR has and will continue to be inherently intertwined with what are now rapid developments in technology, presenting both challenges and exciting opportunities to do what is not possible in the real world.

Similar content being viewed by others

Advances in the use of virtual reality to treat mental health conditions

Theory-Guided Virtual Reality Psychotherapies: Going beyond CBT-Based Approaches

Virtual reality: a powerful technology to provide novel insight into treatment mechanisms of addiction

Explore related subjects.

• Artificial Intelligence
• Medical Ethics

Avoid common mistakes on your manuscript.

Introduction

Since its merging into a coherent therapeutic tradition in the 1980s, cognitive behavior therapy (CBT) has proven a remarkable success in treating a wide range of mental disorders, psychosomatic conditions, and many non-medical issues for which sufferers need help with. A distinguishing feature of CBT, common to and prominent in both its behavioral and cognitive roots, is the emphasis on carrying out exercises designed to change behavior and/or cognitions related to some problem area (Mennin et al. 2013 ). This is often explicitly framed as a multi-stage process, including first providing a psychotherapeutic rationale for the exercise, and then detailed and concrete planning, controlled execution, reporting of specific outcomes, drawing lessons learned, and progressing to the next exercise. Since exercises are so central in CBT—congruent with its historical emphasis on specific as opposed to common factors (Buchholz and Abramowitz 2020 )—this therapeutic tradition is inherently well suited for technology-mediated delivery formats that do not rely on there being a traditional client-therapist relationship. The rapid, paradigm shifting and often unpredictable development and dissemination in the last decades of different consumer information technologies (everything from personal computers to portable media players, smartphones, and wearables) have allowed researchers and clinicians to explore new avenues for treatment design and delivery. A prominent success story of the merger of technology and psychotherapy is Internet-administered CBT (iCBT), which enjoys a robust evidence base with demonstrated efficacy equivalent to face-to-face treatments for mental disorders and psychosomatic conditions (Carlbring et al. 2018 ), and is now implemented in routine care in many countries (Titov et al. 2018 ). iCBT, as it is typically packaged, is in essence a digital form of bibliotherapy: a virtual self-help book where modules replace chapters, delivered not on paper but via an online platform, with or without support from an online therapist (often through asynchronous messaging). These modules convey in writing what would otherwise be conveyed orally in the face-to-face format, covering both psychoeducation and exercises. The bibliotherapeutic roots of iCBT are apparent in that many trials adapted existing self-help books (Andersson et al. 2016 ) or have afterwards been published as such (Carlbring et al. 2001 ).

Without any doubt, iCBT was certainly revolutionary at the time of the first appearance, challenging entrenched preconceptions of what psychotherapy is, offering unlimited dissemination of evidence-based treatment, and raising the scientific standard of psychotherapy research to that of the medical field (Andersson 2016 ). The novelty of iCBT however lied in the format of delivery, not the therapeutic content. With immersive technology like virtual reality (VR), it is possible to revolutionize not only how treatment is delivered but also how change-promoting experiences are designed and evaluated, by making the unrealistic a reality. This narrative review will introduce readers to VR technology and how it can be put to clinical use, and discuss the past, present, and future of VR-CBT for mental disorders. The aim is not to provide a systematic review (Freeman et al. 2017 ) or a meta-analysis of the field (Botella et al. 2017 ; Carl et al. 2018 ; Wechsler et al. 2019 ) but rather to give a historical overview and context, showing how developments in technology have fueled clinical progress. Perspectives on the future of the field will also be provided. The focus will be on VR-CBT treatments for anxiety disorders since this application dominates the extant literature, although other clinical applications will also be discussed. In addition to being a treatment tool, VR is also seeing increasing use as an experimental platform for studying psychopathology (Juvrud et al. 2018 ) and treatment mechanisms (Scheveneels et al. 2019 ); coverage of this exciting application is however beyond the scope of this review.

What Is Virtual Reality?

In essence, VR refers to any technology that creates a simulated experience of being present in a virtual environment that replaces the physical world (Riva et al. 2016 ). This sense of (virtual) presence is a key concept in VR and is what distinguishes this technology from others along the so-called mixed reality spectrum: someone playing a traditional video game, for example, or even reading a captivating book, may very well become immersed in it but is unlikely to feel physically transported to the locale depicted on their computer screen. Experiencing presence in VR is a powerful perceptual illusion, yet an illusion nonetheless: the environment may indeed prompt overt cognitions like “I know this is not real”—as individuals undergoing VR exposure therapy often think and say aloud as a safety behavior—yet this is done after the same user has already acted congruent with the environment, thereby demonstrating that it is nonetheless perceived as real (Slater 2018 ).

To create this perceptual illusion, special hardware is required. As will be discussed in the coming sections, until only a few years ago, such hardware was inaccessible, expensive, and required trained professionals to both develop software for and use. While it is possible to transform a (restricted) physical environment into a virtual one by projecting interactive images onto the walls—a so-called CAVE setup (Bouchard et al. 2013 )—developments in head-mounted display (HMD) technology has made this latter VR approach the dominant one, especially with the release of consumer VR platforms that are all of the HMD kind. Modern VR HMDs come in two versions: mobile devices, either freestanding or smartphone-based, and tethered devices. Mobile devices offer simplicity of use and do not physically constrain the user, yet are computationally limited and must also be recharged. Tethered devices require a high-end computer or gaming console to run, connected via cable. It should be noted that wireless tethering is being developed and will likely be released in the years to come and that VR devices like the Oculus Quest can now run in both mobile and tethered modes, offering more computational power in the latter.

Since VR HMDs first appeared in the 1960s, these have relied on the same core principles to create a sense of presence in a virtual world: by including two 2D displays (one covering each eye, thereby also withholding the real world) showing views with offset angles corresponding to an average (or custom) interocular distance, binocular depth perception can be simulated, termed stereoscopy. In addition, the HMD continuously measures head rotation in all directions (pitch, yaw, and roll, so-called three degrees of freedom or 3DOF) using gyroscopes and adapts the visual presentation accordingly, giving the user the perceptual illusion of being able to look around the virtual environment (Scarfe and Glennerster 2019 ). Immersion and presence are both mediated by interactivity with the virtual world, and since vision is the dominant sense in humans (Posner et al. 1976 ), stereoscopy coupled with 3DOF is a simple but powerful setup to create VR. Modern VR platforms typically also include adaptive stereo sound, as well as wireless handheld controllers that can be used both for mouse-type pointing and to control virtual hands. In addition, there are now both tethered and mobile VR platforms that have 6DOF functionality: alongside rotation tracking, these devices also continuously measure movement in X, Y, and Z (positional tracking) using either cameras placed in the physical room (outside-in tracking) or integrated into the HMD (inside-out tracking) and then use this data to update the visual presentation, giving the user the ability to also physically walk around the virtual environment.

Not unexpectedly, the history of clinical VR is intertwined with the history of VR technology. The sections that follow provide a brief historical overview of these parallel tracks of development, divided into the past (roughly 1968–2013), present (2014–2020), and future.

Recognizable VR technology has existed since the 1960s, emerging from and taking root in the bourgeoning computer science scene (Sutherland 1968 ) and aerospace industry (Furness 1986 ), developing alongside advances in computational power and display technology. By the 1990s, a series of failed attempts to mass-commercialize what was still unripe VR technology into gaming products struck a hard blow to the VR field, pushing it back to the peripheries and the niche applications found there (e.g., flight simulation) for which this technology had always been valuable. It would take almost 20 years before anyone made a serious attempt at consumer VR again (see below), yet by the mid-1990s, the inherent capabilities of VR had become apparent to clinical research psychologists around the world. Remarkably, the capabilities and advantages of VR in treating anxiety disorders that were raised already in 1996 (Glantz et al. 1996 ) are still echoed today (Lindner et al. 2017 ). Since the virtual environment is built from scratch, it can be made fully controllable, flexible, adaptive, and interactive in ways not practically feasible or even possible in the real world. In treating spider phobia, for example, the therapist or patient could conveniently choose the specific type of spider to be used in exposure, linearly increase how frightening the virtual spider looks, and make its behavior adaptive to how the user behaves. Further, VR exposure will always be safer than in vivo equivalent exposure and additionally solves practical issues in providing exposure therapy: there is no need to leave the therapy room, either to perform exposure exercises or prepare stimuli material in advance.

While the mid-to-late 1990s was not an exciting period in terms of VR technology development, the period marks the beginning of using VR for mental health purposes. Early published case reports and trials from well-funded laboratories revealed the feasibility and promise of VR exposure therapy for acrophobia (Rothbaum et al. 1995a , 1995b ), aviophobia (Rothbaum et al. 1996 ), claustrophobia (Botella et al. 1998 ), spider phobia (Carlin et al. 1997 ), and PTSD (Rothbaum et al. 1999 ). In all cases, VR was used to generate virtual equivalents of phobic stimuli to perform otherwise rather traditional exposure therapy, resulting in impressive symptom reductions considering the hardware limitations of the period. However, the unique clinical advantages of VR were put to use already at this early stage: in the claustrophobia exposure paradigm, for example, the user had the ability to move a wall of a virtual room, making it bigger or smaller (Botella et al. 1998 ). In addition to enabling a convenient, linear version of the fear hierarchy, such features also provide the user with an important sense of control over the exposure scenario (Lindner et al. 2017 ). Another early example of innovative and unique applications was a small feasibility study on using VR to treat body image disturbances (Perpiñá et al. 1999 ), an important component of eating disorders that—at least at the time—was a neglected topic in CBT protocols (Rosen 1996 ). This first VR study included several pioneering clinical components, including the possibility to change the size of different body sections of a human avatar body, with the patient’s actual body overlaid to highlight discrepancies that could then also be highlighted and discussed in traditional Socratic dialogue. This example thereby illustrates how well VR experiences can be integrated into a CBT framework, in which mapping and resolving discrepancies are an important generic component.

These first studies used VR hardware like the Division dVisor, a bulky and heavy HMD by today’s standard that included an aft counterweight just to balance the weight of the dual LCDs capable of generating around 146,000 pixels at 10 frames per second (about 1/80th of the pixels per second that a modern tethered HMD is capable of). The system additionally required a high-end computer and several peripherals to run and costs up to a hundred thousand euros depending on the setup. Not surprisingly, the heavy and bulky HMDs of the time, with their low resolutions and framerates, were prone to induce so-called cybersickness (Rebenitsch and Owen 2016 ): symptoms resembling motion sickness believed to be caused primarily by sensory conflict between the visual and vestibular/proprioceptor systems, although display properties in themselves also play a role (Saredakis et al. 2020 ). Cybersickness was a well-recognized phenomenon already in the 1990s (McCauley and Sharkey 1992 ) yet was much less an issue in clinical VR than in, e.g., the aerospace industry where VR was typically (and still is) used to simulate flight, i.e., virtual movement (as per the visual system) without physical movement (as per the vestibular/proprioceptor systems). Many of the common principles for the design of VR exposure paradigms emerged at this early stage, including minimizing first-person movement to avoid inducing cybersickness—letting the feared stimuli come to the user and not the other way around, which may even have therapeutic benefits in some cases (Lindner et al. 2017 ).

The decade or so that followed saw an exponential growth of research on clinical applications of VR, as shown in the graph below on published and accumulated papers on VR and anxiety over time (Fig.  1 ) and as evident by several meta-analytic studies being published around this time (Parsons and Rizzo 2008 ; Powers and Emmelkamp 2008 ). By 2012, there were k  = 21 randomized controlled trials of VR exposure therapy for anxiety disorders available for meta-analysis, showing, e.g., that VR exposure therapy outperformed waitlist control conditions, had similar outcomes to other evidence-based interventions, and had stable long-term effects (Opriş et al. 2012 ). Regarding the latter, it should be noted that only three studies at the time had follow-up periods of 1 year or more; studies with longer follow-up periods have since been published (Anderson et al. 2016 ). A landmark meta-analysis was published in 2015 showing that previously reported within- and between-group effect sizes remained when only considering trials with in vivo behavioral outcomes, revealing that fear reductions in VR does indeed translate to reduced fear also in vivo (Morina et al. 2015 ).

VR research published up until release of consumer VR technology

In addition to establishing VR as an efficacious treatment of many anxiety disorders, the early 2000s also saw a growing research interest in the mechanisms of VR-CBT, in particular on the role of presence: does increased presence drive increased distress during VR exposure (and indirectly treatment outcomes), vice versa, or is this association bidirectional? A 2014 meta-analysis reported an overall significant correlation of r  = .28 (95% CI: 0.18–0.38) between self-reported distress and presence during exposure, albeit with significant differences across sample clinical characteristics and type of VR equipment used (Ling et al. 2014 ). Two of the covered studies deserve special mention: a 2004 study on acrophobia exposure experimentally assigned participants to experiencing VR exposure with either a low-presence HMD or a high-presence CAVE, and despite finding the expected difference in presence scores, the groups did not differ on outcomes (although it should be noted that this contrast was low powered) (Krijn et al. 2004 ). A 2007 study on VR exposure for aviophobia found that while presence partially mediated the association between pre-existing anxiety and distress during exposure, presence did not moderate outcomes, suggesting that presence is a necessary but insufficient requirement for symptom reduction (Price and Anderson 2007 ), congruent with the 2004 study. Unfortunately, the complex associations between presence, distress, and outcomes have not cleared much since then, although recent experimental research has begun to shed more light on this important aspect (Gromer et al. 2019 ). It is not unlikely that measurement error from the self-reported presence ratings contribute to this confusion: using behavioral measures of presence—e.g., a behavioral response consistent with the virtual environment as per the very definition of presence (Slater 2018 )—was in fact proposed and showed promise already in the early 2000s (Freeman et al. 2000 ) yet did not become popular in clinical paradigms due to the more elaborate procedure and data analysis required compared to self-report ratings. With the release of consumer VR platforms, developing appropriate paradigms and analyzing data has become much more convenient, hopefully paving the way for a renaissance of behavioral measures of presence.

Finally, the first extended decade of the new millennium was also a period when researchers first began examining the contextual factors of importance to field, including views on VR held by both patients and clinicians. One early study reported that nine out of ten spider-fearful individuals would prefer VR exposure over in vivo exposure (Garcia-Palacios et al. 2001 ); to what degree such a preference serves as a proxy measure for greater baseline severity and functions as a safety behavior remains unknown and has been the subject of surprisingly little research since. Two later survey studies found that clinicians have a generally favorable view of using VR clinically, although they also reported fears about required training, handling the equipment and, financial costs, and reported an overall low degree of acquaintance with the technology (Schwartzman et al. 2012 ; Segal et al. 2011 ). Recent survey research, conducted after the advent of consumer VR, indicates that these fears have now decreased, although both professional and even recreational experiences of using VR were still rare, and knowledge of VR exposure therapy still low (Lindner et al. 2019d ). Together, the first three studies provided early evidence that there were no substantial human barriers to implementing VR interventions in regular clinical settings—a quest that endured into the period of modern VR.

The Present

The history of modern VR really begins in 2012, when a start-up company named Oculus (later purchased by Facebook) revived the VR field by launching a crowdfunding campaign to finance the development and release of a modern VR HMD, primarily for gaming. This happened at a critical point in time when the maturation of two related technologies converged: the rapid development of smartphones, which had begun only a few years prior, meant that high-quality flat screen technology was now readily available along with miniaturized peripheral hardware (e.g., gyroscopes). In parallel, consumer gaming computers had now grown powerful enough to render impressive graphical quality, even with the increased resolution, field of view, and refresh rate required by VR HMDs. A working prototype of the tethered Oculus Rift HMD (Development Kit 2) was shipped in 2014 and was quickly adapted for use in clinical research (Anderson et al. 2017 ; Peterson et al. 2018 ). At around the same time, the Samsung Gear VR platform was announced and soon released, making it the first mobile VR device to see widespread consumer adoption. It too quickly saw use in clinical research (Lindner et al. 2019c ; Miloff et al. 2016 ; Spiegel et al. 2019 ; Tashjian et al. 2017 ). The Gear VR platform featured a unique, since abandoned design wherein a compatible smartphone from the same brand snapped into place at the front of a simpler HMD containing only optics, a touchpad, and rotation trackers. The smartphone then served as the display and ran the VR applications. This solution was meant to lower the threshold for mass adoption by offering VR at a lower price to users that already had a powerful smartphone that could be put to use. Google used the same solution for both their simpler Cardboard VR platform (for use with nearly any smartphone) and their Gear-equivalent Daydream platform (for use with only a few compatible smartphone models). Although both the Gear and Cardboard platforms became relatively popular among consumers—the extremely low-cost Cardboard solution also finding some unique clinical applications in that it allowed for unprecedented, low-cost distribution of VR for at-home use (Donker et al. 2019 ; Lindner et al. 2019b )—these platforms have since been abandoned by both Samsung and Google without replacements. The required hardware matching was simply not cost-effective, and requiring a compatible smartphone was ultimately deemed to exclude more potential adopters than those brought on by the lowered threshold for adoption. The release and ensuing popularity of the affordably priced, mobile Oculus Go device convinced the industry that freestanding mobile VR was the future—that high-quality freestanding HMDs could be developed and released to a cost only negligibly higher than smartphone-dependent solutions. Other influential hardware releases in the last few years include the tethered HTC Vive (a competitor to the Rift platform), the tethered Playstation VR platform, and the recent release of the mobile Oculus Quest which provides 6DOF through inside-out tracking, allows interaction through hand gesture mapping (making hand controllers optional in many applications), and can also be run in tethered mode for increased performance.

The section below on the present state of clinical VR will not be told chronologically and is not exhaustive but rather touches upon a selection of topics of current interest in the field.

Automated Treatments

Arguably the most exciting recent development in the field of clinical VR is the rise of automated VR exposure therapy applications. Three high-quality randomized trials have been published recently, featuring three different applications: two on acrophobia with comparison against waiting-list (Donker et al. 2019 ; Freeman et al. 2018 ) and one on spider phobia examining non-inferiority against gold-standard in vivo exposure (Miloff et al. 2019 ). Findings from the later spider phobia trial have since been replicated in a single-subject trial with simulated real-world conditions (Lindner et al. 2020b ) and valuable usage data from one of the acrophobia trials has also been reported (Donker et al. 2020 ). A qualitative study on the experience of undergoing automated VR exposure therapy for spider phobia has also been published (Lindner et al. 2020c ). All three trials report impressive symptom reductions, revealing the public health and clinical potential of this innovative approach to treatment. Recent advances in this field include a large, ongoing randomized controlled trial of automated VR-CBT for anxious avoidance of social situations among patients with psychosis (Freeman et al. 2019 ; Lambe et al. 2020 ).

Automation in this context means that no human therapist took part in immediate treatment delivery. Instead, these applications are designed to be freestanding and offer a complete therapeutic experience, including onboarding and psychoeducation, instructions, gamified cognitive-behavioral exercises, a virtual therapist (see below), and more—all packaged in a user-friendly interface, sometimes with an explicit, overarching narrative. The term gamification refers to the application of traditional game components, originally designed for enjoyment, to a non-gaming setting (Koivisto and Hamari 2019 ). Such components typically include simple game mechanics, earning points by completion of tasks, and overt reinforcement of progress through, e.g., unlockables and collecting badges. When combined with onboarding and a cohesive, progressive, and possibly interactive narrative, and with an explicit goal other than pure enjoyment, the experience may be considered a so called serious game (Fleming et al. 2017 ; Laamarti et al. 2014 ). Findings from the first qualitative study on automated VR exposure therapy showed that even aversive experiences like exposure therapy can indeed be framed and viewed by users as a serious game with a psychotherapeutic goal (Lindner et al. 2020c ). Being a high-immersion technology, the VR modality is inherently well suited for gamification, with gaming remaining the unique selling point of VR, driving consumer adoption. Gamification has long been assumed to increase compliance and thereby treatment effects by increasing both short- and long-term engagements and making aversive experiences less so. Congruently, qualitative research has shown gamification elements are indeed perceived as attractive features by users (Faric et al. 2019a , 2019b ; Lindner et al. 2020c ; Tobler-Ammann et al. 2017 ). Empirical evidence for the presumed effects is however surprisingly scarce (Fleming et al. 2017 ; Johnson et al. 2016 ). Automated VR interventions distributed as applications on ordinary digital marketplaces have the potential to reach tens or hundreds of thousands of users (Lindner et al. 2019c ), providing not only a vector for substantial public health impact but also the necessary sample sizes to use factorial designs (Chakraborty et al. 2009 ) and randomized A-B testing to disentangle the causal impact of each gamification component.

Virtual Therapists

Interestingly enough, all three automated VR exposure applications mentioned above opted to include a virtual therapist of some sort (Donker et al. 2019 ; Freeman et al. 2018 ; Miloff et al. 2019 ), either voiceover or as an embodied agent. Such a feature serves many purposes: it reminds users of the therapeutic context, is a convenient and familiar way of conveying information (psychoeducation) and reinforcing progress, and adds a pleasant human touch. Little is known however about this novel addition to the VR arsenal. Early research examined working alliance towards the virtual environment itself, finding psychometric properties that suggest that the alliance concept can indeed be applied in this way (Miragall et al. 2015 ). Recently, a novel instrument has been developed specifically to measure working alliance with an embodied virtual therapist, using data from automated VR exposure therapy for spider phobia (Lindner et al. 2020b ; Miloff et al. 2019 ), showing that a relationship similar to a working alliance does seem to form with the virtual therapist and that the quality of this relationship predicted long-term improvements (Miloff et al. 2020 ). Qualitative interview research on the same VR intervention for spider phobia showed that the virtual therapist was an appreciated feature (Lindner et al. 2020c ). These findings are consistent with research on unguided iCBT and bibliotherapy, for example, showing that a relationship similar to a working alliance (but obviously not exactly the same) can develop with the therapeutic material itself (Heim et al. 2018 ). How best to make therapeutic use of virtual therapists remains an important topic for future research.

Virtual embodiment entails creating a perceptual illusion of being present in a body other than one’s own physical. In VR, this is typically achieved by having the user see a virtual body positioned below the camera position (an impression which can be amplified by placing virtual mirrors in the environment) and promoting body ownership by allowing the user to move this body using hand controllers and/or 6DOF positional tracking. Building on early research (Perpina et al. 2003 ; Perpiñá et al. 1999 ), a VR full-body illusion has been shown to decrease body image disturbance in anorexia nervosa (Keizer et al. 2016 ). More recently, a VR body swap illusion has been used to increase self-compassion (Cebolla et al. 2019 ). In another recent study, participants practiced delivering compassion in one virtual body and then experienced a recorded version of this act embodied as the receiving party, leading to reduced depression and self-criticism and increased self-compassion (Falconer et al. 2016 ). Another innovative approach involves allowing a single user to alternate between two virtual bodies (one being Sigmund Freud) engaged in a conversation, essentially a form of semi-externalized self-dialogue. Compared to a scripted control condition, participants engaged in embodied self-dialogue reported being helped and changed to a greater degree (Slater et al. 2019 ). In addition to inspiring a new line of research, this type of paradigm presents a fine example of how a generic CBT technique like perspective-changing can be empowered and amplified using VR (Lindner et al. 2019a ).

VR for Other Disorders

A 2017 systematic review found that at the time, most clinical VR research had been conducted on anxiety disorders (including PTSD and OCD), schizophrenia, substance use disorders, and eating disorders, with only two studies on depression (Freeman et al. 2017 ). Notably, VR interventions for autism (Didehbani et al. 2016 ; Maskey et al. 2019 ) were not covered by the systematic search, nor were gambling disorder (Bouchard et al. 2017 ), stress (Anderson et al. 2017 ; Serrano et al. 2016 ), or ADHD (Neguț et al. 2017 ). A recent survey study on attitudes towards VR among practicing CBT clinicians found that those who worked clinically with neuropsychiatric disorders, personality disorders, and psychosomatic disorders were more inclined to report that VR could be used with the respective disorder (Lindner et al. 2019d ), suggesting that novel clinical applications of VR are indeed possible. The VR field is currently expanding rapidly, including new research on innovative VR treatments for disorders that have previously received little attention like depression (Migoya-Borja et al. 2020 ; Schleider et al. 2019 ), sleep problems (Lee and Kang 2020 ), and worry (Guitard et al. 2019 ). Recent work has also studied how VR can be used for modifying cognitions (Silviu Matu 2019 ) and feared self-perceptions (Wong 2019 ), in approach-avoidance training for obesity (Kakoschke 2019 ), and to treat aggressive behavior in children (Alsem 2019 ), revealing how VR has matured into a flexible, innovative treatment tool.

The future of VR-CBT will continue to be inherently intertwined with the development of VR technology, yet the latter now develops at a pace so rapid that clinical researchers are struggling to keep up and make full use of the new capabilities offered by new technologies. It has proven notoriously difficult to predict advances in technology that could in turn drive novel therapeutic applications: progress is both linear (as with, e.g., display properties like resolution and refresh rate), discrete and unexpected (as with, e.g., the development of inside-out tracking enabling 6DOF also on mobile VR HMDs), and a complex combination thereof. Nonetheless, some predictions on the future of clinical VR for mental health can be made based on obvious gaps in the extant research literature, trends in consumer VR, and recent technological advances.

Beyond Efficacy: Demonstrating Effectiveness

Clinical research can be placed along a continuum ranging from basic science, to efficacy and effectiveness trials (Wieland et al. 2017 ). The efficacy-effectiveness continuum is noteworthy since it emphasizes that study design and study aims need to be adapted to the context of the extant literature. In building an evidence base for a new intervention, one would first examine efficacy (“Does the intervention work under optimal conditions?”), and then proceed to examining effectiveness (“Does the intervention work under real-world conditions?”). In the case of VR exposure therapy for anxiety disorders, more than a dozen efficacy trials conducted over 20 years have convincingly shown that this intervention is efficacious (Carl et al. 2019 ; Fodor et al. 2018 ; Wechsler et al. 2019 ) and associated with low rates of deterioration (Fernández-Álvarez et al. 2019 ). To the author’s knowledge, only a single effectiveness trial of VR exposure therapy has been published to date: although it demonstrated feasibility and replicated the effect size from the preceding efficacy trial, the sample size was relatively small and for ethical and practical reasons, a single-case design was chosen instead of comparison with treatment-as-usual (Lindner et al. 2020a ). The lack of large, multi-arm effectiveness trials presents a substantial gap in the extant literature and should be considered a research priority in the years to come, if VR is ever to become a part of routine clinical care.

Still Awaiting Mass Adoption by Consumers

Despite VR now being an accessible and affordable consumer product (Lindner et al. 2017 ), mass adoption has yet to occur and growth remains linear rather than exponential, hindering the full public health and clinical potential of VR. The exact number of sold VR devices and active users is difficult to estimate for many reasons, yet publically released hardware statistics from the Steam gaming platform in spring 2020 revealed that around 2% of the platform’s active user base has access to VR, equivalent to roughly 2 million users. At the end of 2019, Sony confirmed having sold more than five million units of their Playstation VR device. If one includes simpler Cardboard-based VR HMDs that require a smartphone to run and offers only a rudimentary VR experience, there are at least twenty million VR units distributed worldwide, possibly twice that. Usage patterns among device owners will likely vary considerably, from daily to one-time use. By comparison, approximately half of the world’s population is now estimated to have access to a smartphone. Releasing mental health interventions, packaged as applications, on ordinary VR content marketplaces would allow dissemination on an almost unprecedented scale. Even in the early days of consumer VR, a first-generation VR relaxation application reached 40,000 unique users in 2 years (Lindner et al. 2019c ), a number that would likely be surpassed rapidly at time of writing. Still, until VR mass adoption by consumers, the dissemination potential is limited by the overlap of early adopters, those experiencing mental health problems, and those that view this medium as appropriate for help-seeking.

The comparably low adoption rate also hinders some promising clinical applications, e.g., having a patient perform VR exposure tasks in-between in-vivo exposure sessions or completely by themselves using an automated intervention. Today, this would likely require the clinic to lend or rent out the specific VR equipment (sending it by mail if necessary). While this approach does indeed offer an innovative solution to a clear clinical need, the lack of interest thus far among ordinary clinics demonstrates that it also comes with potent barriers. Costs in acquiring and maintaining the equipment, as well as those relating to the logistics of distributing it, may simply outweigh the benefits it brings. Until consumer mass adoption, this approach is unlikely to be successful unless applicable health insurance models begin to incorporate and reimburse it. In the first effectiveness trial of VR exposure therapy in routine care, the clinic was reimbursed either through existing occupational healthcare contracts or the patients payed out-of-pocket (Lindner et al. 2020a ), in no case with any additional cost included to cover the clinics investment in VR. Whether such models are financially sustainable at scale remains to be evaluated.

Novel Uses of Virtual Embodiment

Arguably, clinical researchers have only begun to scratch the surface of the clinical potential of virtual embodiment, especially with regard to how such experiences can be merged with traditional, evidence-based CBT techniques. With regard to exposure therapy, for example, one could imagine allowing patients to experience the very thing they fear by embodying them, e.g., as a feared conversation partner in a virtual social scenario, allowing them to truly experience it from both perspectives. Such an experience should not be less tolerable than standard exposure and has the potential to promote rapid fear reduction since one need not fear themselves. Virtual embodiment could also, for example, be used to allow individuals with substance use disorders to interact with their influenced self through embodiment of a concerned significant other, providing a potentially powerful transformative experience of the negative effects of substance misuse, the full extent of which may not otherwise be perceived by the person affected.

Full Immersion Through Innovative User Interfaces and Making Use of This Data

While research has begun to collect and analyze user engagement metrics and self-reported data from self-guided VR interventions (Donker et al. 2020 ), there has been surprisingly little research on data that offers deeper insight. The entire concept of (HMD) VR relies on continuous head rotation tracking, making rotation a suitable user interface through the use of a crosshair that fixates eye gaze and synchronizes it (at least to same degree) with head rotation. In fact, human-computer interaction research has shown that head rotation provides an adequate proxy measure of eye gaze: gaze tends to focus around a rotation-controlled crosshair, and gaze shifts above 25° are typically accompanied by subsequent head movement with a lag of 30–150 ms (Sidenmark and Gellersen 2020 ). In general, head rotation data has seen very few published clinical applications beyond its immediate role in graphical presentation, either as a way of adapting the virtual environment (e.g., prompting a “Look up!” message during public speaking exposure when the user stares at the floor as a safety behavior) or as a non-invasive, continuous measure that can be used for further analysis. A rare 2016 study demonstrated the value of this data by showing that horizontal rotation during VR exposure for public speaking anxiety correlated with distress in female participants (Won et al. 2016 ). Until the average consumer VR HMDs includes proper eye tracking technology—already available in some high-grade consumer HMDs—head rotation appears to be a valuable proxy measure that can be put to greater use. This includes the possibility of using VR head rotation data as a proxy measure of other physiological variables like heart rate that indicate emotional distress, proof-of-concept of which has already been demonstrated (Noori et al. 2019 ) and is possible with related methods (Lomaliza and Park 2019 ).

The future of VR-CBT will likely also see greater use of other user interfaces that are already available technology-wise yet have seen limited use thus far in clinical applications. Embodied conversational agents, capable of instantaneous natural language processing (Provoost et al. 2017 ), may, for example, be used to include interactive, virtual therapists that the user can speak with freely without preselected options. HMDs like the Oculus Quest can now use its 6DOF cameras to track hand movements directly, bypassing the need for hand controllers to map hand movement and enabling the user to interact with the virtual environment with individual fingers. This could be used clinically for simulating touching phobic stimuli, for example (Hoffman et al. 2003 ; Tardif et al. 2019 ). 6DOF technology, although not new but now much more user-friendly, remains underutilized in clinical VR, in particular as core clinical components. VR exergames, for example, could provide a form of behavioral activation for depression (Lindner et al. 2019a ). All these discussed user interfaces rely on continuous, non-invasive measurement that provide large amounts of data. Research on how this data can be used with machine learning (Pfeiffer et al. 2020 ) to, e.g., predict clinical outcomes will likely be another topic of interest in the years to come. Collecting vast amounts of data on (proxy) gaze, motor actions and in-virtuo behaviors from VR usage—in addition to the camera mapping of physical surroundings required by inside-out tracking 6DOF—is however not without ethical aspects; privacy concerns have already been raised (Slater et al. 2020 ; Spiegel 2018 ) and must continue to be discussed within clinical research, especially since this issue will likely grow more prominent among VR users in general.

The Importance of (and Need for) Tailoring and Adaptation

Many previously studied VR paradigms have included features that allowed the user to customize the environment to fit their therapeutic needs, including the “Virtual Iraq/Afghanistan” paradigm developed for PTSD treatment that allowed users to recreate specific traumatic scenarios (Rizzo et al. 2010 ). To what degree virtual environments need to be tailored to the specific user remains an open question of great importance to the field since so-called sandbox-type paradigms require additional developmental resources, which may not be cost-effective in relation to efficacy. This question has however received surprisingly little research attention thus far. One recent study compared exposure to standardized catastrophic scenarios in VR, to imaginal exposure with personalized scenarios, and found no difference in evoked anxiety (Guitard et al. 2019 ), suggesting that perfect tailoring is at least not necessary. A study on (360° video) VR relaxation found a strong correlation between averages preference rating of different virtual nature environments and average improvement in positive mood (Gao et al. 2019 ). A related research question concerns the benefits of including adaptive virtual environments. Research on VR biofeedback paradigm (Fominykh et al. 2017 ) have demonstrated the feasibility of including such adaptive components, which could easily be combined with other CBT techniques like exposure. Having, e.g., already created a series of spider models with increasingly frightening appearances and behaviors (Miloff et al. 2019 ), it would certainly be possible with today’s technology to create an exposure task wherein the spider stimuli morphs automatically depending on the heart rate or some other continuous measure of emotional distress acquired using off-the-shelf, wearable technology integrated through an API. Whether adaptive and/or tailored virtual scenarios show additional clinical benefits that warrant the extra developmental and practical resources required remains to be examined. Relating to the issue of what works for whom, more individual patient data meta-analytic research (Fernández-Álvarez et al. 2019 ) with high-resolution variables is needed to establish predictors of treatment response, non-response and negative effects (see below).

Social VR is growing increasingly popular and refers to any application allowing two or more people to meet and directly interact in a virtual environment, typically through embodied avatars. Many VR games already feature or are explicitly built around multiplayer functionality, including virtual tennis and realistic shooter games. More generic virtual meetup applications have also begun to appear, and it is likely only a matter of time before a VR equivalent of Second Life becomes ubiquitous (Sonia Huang 2011 )—hence (presumably) Facebook’s interest in the technology. In terms of research, studies on social presence experienced with both avatars and agents (Fox et al. 2015 ) have a long and extensive history, with a recent systematic review identifying k  = 152 studies investigating different factors of importance (Oh et al. 2018 ). However, clinical applications of social VR have thus far been scarce. There are a number of possible uses of social VR in CBT: social VR could be used as an immersive type of videoconferencing psychotherapy (Tarp et al. 2017 ), virtual gatherings could be used as a form of behavioral activation in depression (Lindner et al. 2019a ), a patient in non-automated VR exposure therapy would likely benefit from observing an embodied avatar therapist modeling non-phobic responses (Olsson and Phelps 2007 ; Öst 1989 ), VR could also make it convenient to perform VR exposure therapy for public speaking anxiety (Kahlon et al. 2019 ) in front of avatars instead of agents, and more.

Therapeutic Storytelling

The fact that modern consumer VR is primarily marketed, and used, as an entertainment platform hints at the potential of using this immersive technology to distribute powerful storytelling experiences that are designed to be therapeutic in themselves, i.e., going beyond the simple overarching narratives that may be included as gamification elements. Using techniques, principles, and lessons learned from the field of VR entertainment, it may be possible to develop interactive or even passive VR experiences that tell stories that have a significant and stable impact on how individuals view themselves and others, e.g., by allowing individuals to experience emotionally charged events and scenarios from different perspectives, conceptually akin to traditional cognitive rescripting exercises for early traumatic memories (Wild and Clark 2011 ). Although there is some preliminary, indirect research in support of this approach (Shin 2018 ), therapeutic effects on psychopathology have yet to be demonstrated. Of note, the idea of using storytelling therapeutically is not new to the field of clinical psychology: so-called creative bibliotherapy—patient reading selected works of fiction, as opposed to self-help material—has a long history yet has received very little research attention (Troscianko 2018 ) and can therefore not currently be considered an evidence-based treatment. Whether VR equivalents can make clinical use of storytelling remains to be evaluated, yet this approach shows prima facie potential as a low-threshold, single-session intervention that could be distributed at scale and would likely be viewed as attractive by users.

Raising Research Quality

Concerns have been raised about research quality of trials examining VR exposure therapy for anxiety disorders, primarily the reliance on small samples, and no or questionable control conditions (Page and Coxon 2016 ). It should however be noted that meta-analytic research has found no correlation between study quality and observed effect size (McCann et al. 2014 ). The small sample sizes that characterized early (and to a lesser degree, also current) research is not unexpected given the added practical requirements in providing VR treatment, at least with the previous generation of technology: in addition to all the regular logistics required of any psychotherapy trial, such trials also required acquiring expensive hardware, developing special software and training therapists in the use of equipment that was often far from user-friendly. However, since the expected effect sizes in these studies were large (as with in vivo exposure therapy), even smaller trials may nonetheless have been well powered; further, the fact that VR allows for a greater, even full degree of standardization should decrease outcome variance and thereby sample size requirement (Lindner et al. 2020b ).

The advent of modern consumer VR has resolved most of the logistic barriers to running larger clinical trials (but see below), as reflected in the larger sample sizes found in recent studies (Donker et al. 2019 ; Freeman et al. 2018 ; Miloff et al. 2019 ). Hopefully, with technological progress now having made greater sample sizes feasible, future VR research will also address the critique of suboptimal control conditions. The choice of control condition is a long-standing debate and multifaceted issue in psychotherapy research, with placebo interventions remaining the gold-standard despite being hard to implement in research on traditional psychotherapy (Gold et al. 2017 ). VR however is inherently well suited for the use of placebo interventions: therapeutic techniques may be packaged in non-traditional ways (e.g., as serious games) and the occurrence and precise extent of each component can easily be modified. Patients, in turn, are also likely to have markedly fewer preconceptions of what constitutes a VR psychological treatment, offering good grounds for (double) blinding. Future research contrasting active VR interventions against VR placebos is of special importance in VR applications for mental health problems where the immersion itself may have an effect. This includes VR pain management (Kenney and Milling 2016 ) where (sensory) distraction is often explicitly framed as the mediating mechanism (Gupta et al. 2018 ), as well as VR relaxation (Anderson et al. 2017 ) which is believed to work by evoking a strong sense of presence in a calming virtual environment (Seabrook et al. 2020 ). Research contrasting VR interventions with active components to VR placebos without active components, would be able to disentangle the specific effect of the presumed therapeutic mechanism from the nonspecific effect of using immersive technology, and would also raise the research quality of the field.

Finally, as the field of clinical VR grows and expands, research must continue to be vigilant to negative effects and aspects. VR has a long history of studying negative effects in the form of cybersickness (Rebenitsch and Owen 2016 ), meta-analytic research has revealed low rates of deterioration in VR exposure therapy (Fernández-Álvarez et al. 2019 ), and trials have already begun (Miloff et al. 2019 ) to include and report results from broader measures of negative effects used elsewhere in psychotherapy research (Rozental et al. 2016 ). New patient groups, treatment forms and delivery modalities nonetheless continue to raise new challenges. Recent survey research suggests that ordinary clinicians do continue to see certain risks in using VR in therapy, although positive views outweigh negative (Lindner et al. 2019d ). Widespread reports of difficulties in implementing exposure therapy for PTSD in clinical settings (Waller and Turner 2016 ), for example, stress the importance of considering therapist views in efforts to disseminate new treatments. In disseminating automated VR treatments for, e.g., depression (Lindner et al. 2019a ) and phobias (Garcia-Palacios et al. 2007 ), care must also be taken to avoid that engaging with such interventions serve as avoidance behaviors to seeking more comprehensive help. One could however certainly imagine automated VR treatments as part of a stepped-care model, and in most cases, any treatment will be preferable to none. Research on consumer smartphone applications for mental health (Larsen et al. 2019 ; Shen et al. 2015 ) suggests that few future consumer VR applications that will be released on ordinary digital marketplaces can be expected to be evidence-based and effective.

Conclusions

It has now been 25 years since the first mental health applications of VR technology appeared and much has happened since, both in terms of scientific progression and technological advances. The recent release of consumer VR platforms constitutes a true paradigm shift in the development and dissemination of clinical VR, which has inspired and continues to inspire a new generation of interventions grounded in a CBT framework. How the field will develop is as difficult to predict now as in the field’s infancy. A review article from 1996 on “VR psychotherapy” made a number of interesting predictions on the future of the field: while some predictions did turn out true, most ultimately did not (Glantz et al. 1996 ). At the turn of the millennium, few people would have predicted that less than 20 years later, half of the world’s population would own a device that not only lets you speak to nearly anyone on the globe, but also features instant, fast access to the Internet, more computational power than high-end computers of the day, several high-definition digital cameras and a display good enough to view movies on—all packaged in a device weighing less than 200 g, less than a centimeter thick and affordable enough that many people switch models every year. VR and other mixed reality technologies are still awaiting mass adoption, but when this does happen, there will already be a firm evidence base to inform the next generation of VR interventions for mental health. The field of VR-CBT is expanding rapidly with new publications every week, but the same constraints on time and funding prevalent elsewhere in academic research apply also here. Thus, while the field at large will hopefully continue to house an impressive width of research interests, individual research groups and researchers will likely find themselves at a crossroads of sort, whether they like it or not. Do we continue exploring the efficacy of innovative clinical applications of new VR technology under optimal conditions, or is the time ripe to focus on public health dissemination and implementation in routine care? Should we focus on developing automated treatments or user-friendly VR tools for clinicians to solve practical issues and do things not possible in real life? Do we expand to include new interventions for previously neglected mental disorders, or should we aim to improve on existing intervention for disorders that VR has been shown to work with? Should we continue to create virtual equivalents of what we otherwise do in the therapy room, or is it time to leave the constraints of the real world behind and truly think outside the (real world) box? As in the mid-1990s, such decisions will shape the future of VR-CBT. Given the momentum that consumer VR has already picked up this time around, it certainly looks like consumer VR is now here to stay—and if so, so is VR-CBT.

Alsem, S. (2019). Using interactive virtual reality to treat aggressive behavior problems in children. in 9th World Congress of Behavioural and Cognitive Therapies .

Google Scholar  

Anderson, P. L., Edwards, S. M., & Goodnight, J. R. (2016). Virtual reality and exposure group therapy for social anxiety disorder: results from a 4–6 year follow-up. Cognitive Therapy and Research . https://doi.org/10.1007/s10608-016-9820-y .

Anderson, A. P., Mayer, M. D., Fellows, A. M., Cowan, D. R., Hegel, M. T., & Buckey, J. C. (2017). Relaxation with immersive natural scenes presented using virtual reality.  Aerospace Medicine and Human Performance, 88 , 520–526. https://doi.org/10.3357/AMHP.4747.2017 .

Article   PubMed   Google Scholar  

Andersson, G. (2016). Internet-delivered psychological treatments. Annual Review of Clinical Psychology, 12 , 157–179. https://doi.org/10.1146/annurev-clinpsy-021815-093006 .

Andersson, E., Hedman, E., Wadström, O., Boberg, J., Andersson, E. Y., Axelsson, E., et al. (2016). Internet-based extinction therapy for Worry: A Randomized Controlled Trial. Behav. Ther. doi: https://doi.org/10.1016/j.beth.2016.07.003 .

Botella, C., Baños, R. M., Perpiñá, C., Villa, H., Alcañiz, M., & Rey, A. (1998). Virtual reality treatment of claustrophobia: a case report. Behaviour Research and Therapy, 36 , 239–246. https://doi.org/10.1016/S0005-7967(97)10006-7 .

Botella, C., Fernández-Álvarez, J., Guillén, V., García-Palacios, A., & Baños, R. (2017). Recent Progress in virtual reality exposure therapy for phobias: a systematic review. Current Psychiatry Reports, 19 , 42. https://doi.org/10.1007/s11920-017-0788-4 .

Bouchard, S., Bernier, F., Boivin, É., Dumoulin, S., Laforest, M., Guitard, T., et al. (2013). Empathy toward virtual humans depicting a known or unknown person expressing pain. Cyberpsychology, Behavior and Social Networking, 16 , 61–71. https://doi.org/10.1089/cyber.2012.1571 .

Bouchard, S., Robillard, G., Giroux, I., Jacques, C., Loranger, C., St-pierre, M., et al. (2017). Using virtual reality in the treatment of gambling disorder : the development of a new tool for cognitive behaviour therapy. Frontiers in Psychology, 8 , 1–10. https://doi.org/10.3389/fpsyt.2017.00027 .

Article   Google Scholar  

Buchholz, J. L., & Abramowitz, J. S. (2020). The therapeutic alliance in exposure therapy for anxiety-related disorders: a critical review. Journal of Anxiety Disorders, 70 , 102194. https://doi.org/10.1016/j.janxdis.2020.102194 .

Carl, E., Stein, T., A., Levihn-Coon, A., Pogue, J. R., Rothbaum, B., Emmelkamp, P., et al. (2018). Virtual reality exposure therapy for anxiety and related disorders: a meta-analysis of randomized controlled trials. Journal of Anxiety Disorders . https://doi.org/10.1016/j.janxdis.2018.08.003 .

Carl, E., Stein, A. T., Levihn-Coon, A., Pogue, J. R., Rothbaum, B., Emmelkamp, P., et al. (2019). Virtual reality exposure therapy for anxiety and related disorders: a meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 61 , 27–36. https://doi.org/10.1016/j.janxdis.2018.08.003 .

Carlbring, P., Westling, B. E., Ljungstrand, P., Ekselius, L., & Andersson, G. (2001). Treatment of panic disorder via the internet: a randomized trial of a self-help program. Behavior Therapy, 32 , 751–764. https://doi.org/10.1016/S0005-7894(01)80019-8 .

Carlbring, P., Andersson, G., Cuijpers, P., Riper, H., & Hedman-Lagerlöf, E. (2018). Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. Cognitive Behaviour Therapy, 47 , 1–18. https://doi.org/10.1080/16506073.2017.1401115 .

Carlin, A. S., Hoffman, H. G., & Weghorst, S. (1997). Virtual reality and tactile augmentation in the treatment of spider phobia: a case report. Behaviour Research and Therapy, 35 , 153–158. https://doi.org/10.1016/S0005-7967(96)00085-X .

Cebolla, A., Herrero, R., Ventura, S., Miragall, M., Bellosta-Batalla, M., Llorens, R., et al. (2019). Putting oneself in the body of others: a pilot study on the efficacy of an embodied virtual reality system to generate self-compassion. Frontiers in Psychology, 10 . https://doi.org/10.3389/fpsyg.2019.01521 .

Chakraborty, B., Collins, L. M., Strecher, V. J., & Murphy, S. A. (2009). Developing multicomponent interventions using fractional factorial designs. Statistics in Medicine, 28 , 2687–2708. https://doi.org/10.1002/sim.3643 .

Article   PubMed   PubMed Central   Google Scholar  

Didehbani, N., Allen, T., Kandalaft, M., Krawczyk, D., & Chapman, S. (2016). Virtual reality social cognition training for children with high functioning autism. Computers in Human Behavior, 62 , 703–711. https://doi.org/10.1016/j.chb.2016.04.033 .

Donker, T., Cornelisz, I., van Klaveren, C., van Straten, A., Carlbring, P., Cuijpers, P., et al. (2019). Effectiveness of self-guided app-based virtual reality cognitive behavior therapy for acrophobia: a randomized clinical trial. JAMA Psychiatry, 76 , 682. https://doi.org/10.1001/jamapsychiatry.2019.0219 .

Donker, T., Klaveren, C. Van, Cornelisz, I., Kok, R. N., and van Gelder, J.-L. van (2020). Analysis of usage data from a self-guided app-based virtual reality cognitive behavior therapy for acrophobia: a randomized controlled trial. Journal of Clinical Medicine 9, 1614. doi: https://doi.org/10.3390/jcm9061614 .

Falconer, C. J., Rovira, A., King, J. A., Gilbert, P., Antley, A., Fearon, P., et al. (2016). Embodying self-compassion within virtual reality and its effects on patients with depression. BJPsych Open, 2 , 74–80. https://doi.org/10.1192/bjpo.bp.115.002147 .

Faric, N., Potts, H. W. W., Hon, A., Smith, L., Newby, K., Steptoe, A., et al. (2019a). What players of virtual reality exercise games want: thematic analysis of web-based reviews. Journal of Medical Internet Research, 21 , 1–13. https://doi.org/10.2196/13833 .

Faric, N., Yorke, E., Varnes, L., Newby, K., Potts, H. W., Smith, L., et al. (2019b). Younger adolescents’ perceptions of physical activity, Exergaming, and virtual reality: qualitative intervention development study. JMIR Serious Games, 7 , e11960. https://doi.org/10.2196/11960 .

Fernández-Álvarez, J., Rozental, A., Carlbring, P., Colombo, D., Riva, G., Anderson, P. L., et al. (2019). Deterioration rates in virtual reality therapy: an individual patient data level meta-analysis. Journal of Anxiety Disorders, 61 , 3–17. https://doi.org/10.1016/j.janxdis.2018.06.005 .

Fleming, T. M., Bavin, L., Stasiak, K., Hermansson-Webb, E., Merry, S. N., Cheek, C., et al. (2017). Serious games and gamification for mental health: current status and promising directions. Frontiers in Psychiatry, 7 . https://doi.org/10.3389/fpsyt.2016.00215 .

Fodor, L. A., Coteț, C. D., Cuijpers, P., Szamoskozi, Ș., David, D., & Cristea, I. A. (2018). The effectiveness of virtual reality based interventions for symptoms of anxiety and depression: a meta-analysis. Scientific Reports, 8 , 10323. https://doi.org/10.1038/s41598-018-28113-6 .

Fominykh, M., Prasolova-Førland, E., Stiles, T. C., Krogh, A. B., & Linde, M. (2017). Conceptual framework for therapeutic training with biofeedback in virtual reality: first evaluation of a relaxation simulator. Journal of Interactive Learning Research, 29 (1), 51–75.

Fox, J., Ahn, S. J. (. G.)., Janssen, J. H., Yeykelis, L., Segovia, K. Y., & Bailenson, J. N. (2015). Avatars versus agents: a meta-analysis quantifying the effect of agency on social influence. Human Computer Interaction, 30 , 401–432. https://doi.org/10.1080/07370024.2014.921494 .

Freeman, J., Avons, S. E., Meddis, R., Pearson, D. E., & IJsselsteijn, W. (2000). Using behavioral realism to estimate presence: a study of the utility of postural responses to motion stimuli. Presence Teleoperators and Virtual Environments, 9 , 149–164. https://doi.org/10.1162/105474600566691 .

Freeman, D., Reeve, S., Robinson, A., Ehlers, A., Clark, D., Spanlang, B., et al. (2017). Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychological Medicine, 47 , 2393–2400. https://doi.org/10.1017/S003329171700040X .

Freeman, D., Haselton, P., Freeman, J., Spanlang, B., Kishore, S., Albery, E., et al. (2018). Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial. Lancet Psychiatry, 5 , 625–632. https://doi.org/10.1016/S2215-0366(18)30226-8 .

Freeman, D., Yu, L. M., Kabir, T., Martin, J., Craven, M., Leal, J., et al. (2019). Automated virtual reality (VR) cognitive therapy for patients with psychosis: study protocol for a single-blind parallel group randomised controlled trial (gameChange). BMJ Open, 9 , 1–8. https://doi.org/10.1136/bmjopen-2019-031606 .

Furness, T. A. (1986). The super cockpit and its human factors challenges.  Proceedings of the Human Factors Society Annual Meeting, 30 , 48–52. https://doi.org/10.1177/154193128603000112 .

Gao, T., Zhang, T., Zhu, L., Gao, Y., & Qiu, L. (2019). Exploring psychophysiological restoration and individual preference in the different environments based on virtual reality. International Journal of Environmental Research and Public Health, 16 , 1–14. https://doi.org/10.3390/ijerph16173102 .

Garcia-Palacios, A., Hoffman, H. G., See, S. K., Tsai, A., & Botella, C. (2001). Redefining therapeutic success with virtual reality exposure therapy. Cyberpsychology & Behavior, 4 , 341–348. https://doi.org/10.1089/109493101300210231 .

Garcia-Palacios, A., Botella, C., Hoffman, H., & Fabregat, S. (2007). Comparing acceptance and refusal rates of virtual reality exposure vs. in vivo exposure by patients with specific phobias. CyberPsychology and Behaviour, 10 , 722–724. https://doi.org/10.1089/cpb.2007.9962 .

Glantz, K., Durlach, N. I., Barnett, R. C., & Aviles, W. A. (1996). Virtual reality (VR) for psychotherapy: From the physical to the social environment. Psychotherapy: Theory, Research, Practice, Training, 33 , 464–473. https://doi.org/10.1037/0033-3204.33.3.464 .

Gold, S. M., Enck, P., Hasselmann, H., Friede, T., Hegerl, U., Mohr, D. C., et al. (2017). Control conditions for randomised trials of behavioural interventions in psychiatry: a decision framework. Lancet Psychiatry, 4 , 725–732. https://doi.org/10.1016/S2215-0366(17)30153-0 .

Gromer, D., Reinke, M., Christner, I., & Pauli, P. (2019). Causal interactive links between presence and fear in virtual reality height exposure. Frontiers in Psychology, 10 , 1–11. https://doi.org/10.3389/fpsyg.2019.00141 .

Guitard, T., Bouchard, S., Bélanger, C., & Berthiaume, M. (2019). Exposure to a standardized catastrophic scenario in virtual reality or a personalized scenario in imagination for generalized anxiety disorder. Journal of Clinical Medicine, 8 , 309. https://doi.org/10.3390/jcm8030309 .

Article   PubMed Central   Google Scholar  

Gupta, A., Scott, K., & Dukewich, M. (2018). Innovative technology using virtual reality in the treatment of pain: does it reduce pain via distraction, or is there more to it? Pain Medicine (United States), 19 , 151–159. https://doi.org/10.1093/pm/pnx109 .

Heim, E., Rötger, A., Lorenz, N., & Maercker, A. (2018). Working alliance with an avatar: how far can we go with internet interventions? Internet Interventions, 11 , 41–46. https://doi.org/10.1016/j.invent.2018.01.005 .

Hoffman, H. G., Garcia-Palacios, A., Carlin, A., Furness III, T. A., & Botella-Arbona, C. (2003). Interfaces that heal: Coupling real and virtual objects to treat spider phobia. International Journal of Human Computer Interaction, 16 , 283–300. https://doi.org/10.1207/S15327590IJHC1602_08 .

Johnson, D., Deterding, S., Kuhn, K.-A., Staneva, A., Stoyanov, S., & Hides, L. (2016). Gamification for health and wellbeing: a systematic review of the literature. Internet Interventions, 6 , 89–106. https://doi.org/10.1016/j.invent.2016.10.002 .

Juvrud, J., Gredebäck, G., Åhs, F., Lerin, N., Nyström, P., Kastrati, G., et al. (2018). The immersive virtual reality lab: possibilities for remote experimental manipulations of autonomic activity on a large scale. Frontiers in Neuroscience, 12 . https://doi.org/10.3389/fnins.2018.00305 .

Kahlon, S., Lindner, P., & Nordgreen, T. (2019). Virtual reality exposure therapy for adolescents with fear of public speaking: a non-randomized feasibility and pilot study. Child and Adolescent Psychiatry and Mental Health, 13 , 47. https://doi.org/10.1186/s13034-019-0307-y .

Kakoschke, N. (2019). Participatory design of a virtual reality approach-avoidance training intervention for obesity. in 9th World Congress of Behavioural and Cognitive Therapies.

Keizer, A., Van Elburg, A., Helms, R., & Dijkerman, H. C. (2016). A virtual reality full body illusion improves body image disturbance in anorexia nervosa. PLoS One, 11 , 1–21. https://doi.org/10.1371/journal.pone.0163921 .

Kenney, M. P., & Milling, L. S. (2016). The effectiveness of virtual reality distraction for reducing pain: a meta-analysis. Psychology of Consciousness: Theory, Research and Practice, 3 , 199–210. https://doi.org/10.1037/cns0000084 .

Koivisto, J., & Hamari, J. (2019). The rise of motivational information systems: a review of gamification research. International Journal of Information Management, 45 , 191–210. https://doi.org/10.1016/j.ijinfomgt.2018.10.013 .

Krijn, M., Emmelkamp, P. M. G., Biemond, R., De Wilde De Ligny, C., Schuemie, M. J., & Van Der Mast, C. A. P. G. (2004). Treatment of acrophobia in virtual reality: the role of immersion and presence. Behaviour Research and Therapy, 42 , 229–239. https://doi.org/10.1016/S0005-7967(03)00139-6 .

Laamarti, F., Eid, M., & El Saddik, A. (2014). An overview of serious games. Internatiol Journal Computer Games Technology, 2014 . https://doi.org/10.1155/2014/358152 .

Lambe, S., Knight, I., Kabir, T., West, J., Patel, R., Lister, R., et al. (2020). Developing an automated VR cognitive treatment for psychosis: gameChange VR therapy.  Journal of Behavioral and Cognitive Therapy, 30 , 33–40. https://doi.org/10.1016/j.jbct.2019.12.001 .

Larsen, M. E., Huckvale, K., Nicholas, J., Torous, J., Birrell, L., Li, E., et al. (2019). Using science to sell apps: evaluation of mental health app store quality claims. npj Digit Med 2. https://doi.org/10.1038/s41746-019-0093-1 .

Lee, S. Y., & Kang, J. (2020). Effect of virtual reality meditation on sleep quality of intensive care unit patients: a randomised controlled trial. Intensive & Critical Care Nursing, 59 , 102849. https://doi.org/10.1016/j.iccn.2020.102849 .

Lindner, P., Miloff, A., Hamilton, W., Reuterskiöld, L., Andersson, G., Powers, M. B., et al. (2017). Creating state of the art, next-generation virtual reality exposure therapies for anxiety disorders using consumer hardware platforms: design considerations and future directions. Cognitive Behaviour Therapy, 46 , 404–420. https://doi.org/10.1080/16506073.2017.1280843 .

Lindner, P., Hamilton, W., Miloff, A., & Carlbring, P. (2019a). How to treat depression with low-intensity virtual reality interventions: perspectives on translating cognitive behavioral techniques into the virtual reality modality and how to make anti-depressive use of virtual reality–unique experiences. Frontiers in Psychiatry, 10 , 1–6. https://doi.org/10.3389/fpsyt.2019.00792 .

Lindner, P., Miloff, A., Fagernäs, S., Andersen, J., Sigeman, M., Andersson, G., et al. (2019b). Therapist-led and self-led one-session virtual reality exposure therapy for public speaking anxiety with consumer hardware and software: a randomized controlled trial. Journal of Anxiety Disorders, 61 , 45–54. https://doi.org/10.1016/j.janxdis.2018.07.003 .

Lindner, P., Miloff, A., Hamilton, W., & Carlbring, P. (2019c). The potential of consumer-targeted virtual reality relaxation applications: descriptive usage, uptake and application performance statistics for a first-generation application. Frontiers in Psychology, 10 , 1–6. https://doi.org/10.3389/fpsyg.2019.00132 .

Lindner, P., Miloff, A., Zetterlund, E., Reuterskiöld, L., Andersson, G., & Carlbring, P. (2019d). Attitudes toward and familiarity with virtual reality therapy among practicing cognitive behavior therapists: a cross-sectional survey study in the era of consumer VR platforms. Frontiers in Psychology, 10 , 1–10. https://doi.org/10.3389/fpsyg.2019.00176 .

Lindner, P., Dagöö, J., Hamilton, W., Miloff, A., Andersson, G., Schill, A., et al. (2020a). Virtual reality exposure therapy for public speaking anxiety in routine care: a single-subject effectiveness trial. Cognitive Behaviour Therapy, 1–21 . https://doi.org/10.1080/16506073.2020.1795240 .

Lindner, P., Miloff, A., Bergman, C., Andersson, G., Hamilton, W., & Carlbring, P. (2020b). Gamified, automated virtual reality exposure therapy for fear of spiders: a single-subject trial under simulated real-world conditions. Frontiers in Psychiatry . https://doi.org/10.3389/fpsyt.2020.00116 .

Lindner, P., Rozental, A., Jurell, A., Reuterskiöld, L., Andersson, G., Hamilton, W., et al. (2020c). Experiences of gamified and automated virtual reality exposure therapy for spider phobia: a qualitative study. JMIR Serious Games . https://doi.org/10.2196/17807 .

Ling, Y., Nefs, H. T., Morina, N., Heynderickx, I., & Brinkman, W. P. (2014). A meta-analysis on the relationship between self-reported presence and anxiety in virtual reality exposure therapy for anxiety disorders. PLoS One, 9 , 1–12. https://doi.org/10.1371/journal.pone.0096144 .

Lomaliza, J. P., and Park, H. (2019). Improved heart-rate measurement from mobile face videos. Electronics 8. https://doi.org/10.3390/electronics8060663 .

Maskey, M., Rodgers, J., Grahame, V., Glod, M., Honey, E., Kinnear, J., et al. (2019). A randomised controlled feasibility trial of immersive virtual reality treatment with cognitive behaviour therapy for specific phobias in young people with autism spectrum disorder. Journal of Autism and Developmental Disorders, 49 , 1912–1927. https://doi.org/10.1007/s10803-018-3861-x .

McCann, R. A., Armstrong, C. M., Skopp, N. A., Edwards-Stewart, A., Smolenski, D. J., June, J. D., et al. (2014). Virtual reality exposure therapy for the treatment of anxiety disorders: an evaluation of research quality. Journal of Anxiety Disorders, 28 , 625–631. https://doi.org/10.1016/j.janxdis.2014.05.010 .

McCauley, M. E., & Sharkey, T. J. (1992). Cybersickness: perception of self-motion in virtual environments. Presence Teleoperators and Virtual Environments, 1 , 311–318. https://doi.org/10.1162/pres.1992.1.3.311 .

Mennin, D. S., Ellard, K. K., Fresco, D. M., & Gross, J. J. (2013). United we stand: emphasizing commonalities across cognitive-behavioral therapies. Behavior Therapy, 44 , 234–248. https://doi.org/10.1016/j.beth.2013.02.004 .

Migoya-Borja, M., Delgado-Gómez, D., Carmona-Camacho, R., Porras-Segovia, A., López-Moriñigo, J.-D., Sánchez-Alonso, M., et al. (2020). Feasibility of a virtual reality-based psychoeducational tool (VRight) for depressive patients. Cyberpsychology, Behavior and Social Networking, 23 , 246–252. https://doi.org/10.1089/cyber.2019.0497 .

Miloff, A., Lindner, P., Hamilton, W., Reuterskiöld, L., Andersson, G., & Carlbring, P. (2016). Single-session gamified virtual reality exposure therapy for spider phobia vs. traditional exposure therapy: study protocol for a randomized controlled non-inferiority trial. Trials, 17 , 60. https://doi.org/10.1186/s13063-016-1171-1 .

Miloff, A., Lindner, P., Dafgård, P., Deak, S., Garke, M., Hamilton, W., et al. (2019). Automated virtual reality exposure therapy for spider phobia vs. in-vivo one-session treatment: a randomized non-inferiority trial. Behaviour Research and Therapy, 118 , 130–140. https://doi.org/10.1016/j.brat.2019.04.004 .

Miloff, A., Carlbring, P., Hamilton, W., Andersson, G., Reuterskiöld, L., & Lindner, P. (2020). Measuring alliance toward embodied virtual therapists in the era of automated treatments with the virtual therapist alliance scale (VTAS): development and psychometric evaluation. Journal of Medical Internet Research, 22 , e16660. https://doi.org/10.2196/16660 .

Miragall, M., Baños, R. M., Cebolla, A., & Botella, C. (2015). Working alliance inventory applied to virtual and augmented reality (WAI-VAR): psychometrics and therapeutic outcomes. Frontiers in Psychology, 6 . https://doi.org/10.3389/fpsyg.2015.01531 .

Morina, N., Ijntema, H., Meyerbröker, K., & Emmelkamp, P. M. G. (2015). Can virtual reality exposure therapy gains be generalized to real-life? A meta-analysis of studies applying behavioral assessments. Behaviour Research and Therapy, 74 , 18–24. https://doi.org/10.1016/j.brat.2015.08.010 .

Neguț, A., Jurma, A. M., & David, D. (2017). Virtual-reality-based attention assessment of ADHD: ClinicaVR: classroom-CPT versus a traditional continuous performance test. Child Neuropsychology, 23 , 692–712. https://doi.org/10.1080/09297049.2016.1186617 .

Noori, F. M., Kahlon, S., Lindner, P., Nordgreen, T., Torresen, J., & Riegler, M. (2019). Heart rate prediction from head movement during virtual reality treatment for social anxiety. In In 2019 International Conference on Content-Based Multimedia Indexing (CBMI) (IEEE) (pp. 1–5). https://doi.org/10.1109/CBMI.2019.8877454 .

Chapter   Google Scholar  

Oh, C. S., Bailenson, J. N., & Welch, G. F. (2018). A systematic review of social presence: definition, antecedents, and implications.  Frontiers in Robotics and AI, 5 , 472–475. https://doi.org/10.3389/frobt.2018.00114 .

Olsson, A., & Phelps, E. A. (2007). Social learning of fear. Nature Neuroscience, 10 , 1095–1102. https://doi.org/10.1038/nn1968 .

Opriş, D., Pintea, S., García-Palacios, A., Botella, C., Szamosközi, Ş., & David, D. (2012). Virtual reality exposure therapy in anxiety disorders: a quantitative meta-analysis. Depression and Anxiety, 29 , 85–93. https://doi.org/10.1002/da.20910 .

Öst, L. G. (1989). One-session treatment for specific phobias. Behaviour Research and Therapy, 27 , 1–7.

Page, S., & Coxon, M. (2016). Virtual reality exposure therapy for anxiety disorders: small samples and no controls? Frontiers in Psychology, 7 , 1–4. https://doi.org/10.3389/fpsyg.2016.00326 .

Parsons, T. D., & Rizzo, A. a. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: a meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry, 39 , 250–261. https://doi.org/10.1016/j.jbtep.2007.07.007 .

Perpiñá, C., Botella, C., Baños, R., Marco, H., Alcañiz, M., & Quero, S. (1999). Body image and virtual reality in eating disorders: is exposure to virtual reality more effective than the classical body image treatment? Cyberpsychology & Behavior, 2 , 149–155. https://doi.org/10.1089/cpb.1999.2.149 .

Perpina, C., Botella, C., & Ban, R. M. (2003). Virtual reality in eating disorders. European Eating Disorders Review, 278 , 261–278. https://doi.org/10.1002/erv.520 .

Peterson, S. M., Furuichi, E., & Ferris, D. P. (2018). Effects of virtual reality high heights exposure during beam-walking on physiological stress and cognitive loading. PLoS One, 13 , 1–17. https://doi.org/10.1371/journal.pone.0200306 .

Pfeiffer, J., Pfeiffer, T., Meißner, M., and Weiß, E. (2020). Eye-tracking-based classification of information search behavior using machine learning: evidence from experiments in physical shops and virtual reality shopping environments. Inf. Syst. Res., isre.2019.0907. doi: https://doi.org/10.1287/isre.2019.0907 .

Posner, M. I., Nissen, M. J., & Klein, R. M. (1976). Visual dominance: an information-processing account of its origins and significance. Psychological Review, 83 , 157–171. https://doi.org/10.1037/0033-295X.83.2.157 .

Powers, M. B., & Emmelkamp, P. M. G. (2008). Virtual reality exposure therapy for anxiety disorders: a meta-analysis. Journal of Anxiety Disorders, 22 , 561–569. https://doi.org/10.1016/j.janxdis.2007.04.006 .

Price, M., & Anderson, P. (2007). The role of presence in virtual reality exposure therapy. Journal of Anxiety Disorders, 21 , 742–751. https://doi.org/10.1016/j.janxdis.2006.11.002 .

Provoost, S., Lau, H. M., Ruwaard, J., and Riper, H. (2017). Embodied conversational agents in clinical psychology: a scoping review. J Med Internet Res 19. doi: https://doi.org/10.2196/jmir.6553 .

Rebenitsch, L., & Owen, C. (2016). Review on cybersickness in applications and visual displays. Virtual Reality, 20 , 101–125. https://doi.org/10.1007/s10055-016-0285-9 .

Riva, G., Baños, R. M., Botella, C., Mantovani, F., & Gaggioli, A. (2016). Transforming experience: the potential of augmented reality and virtual reality for enhancing personal and clinical change. Frontiers in Psychiatry, 7 , 1–14. https://doi.org/10.3389/fpsyt.2016.00164 .

Rizzo, A., Difede, J., Rothbaum, B. O., Reger, G., Spitalnick, J., Cukor, J., et al. (2010). Development and early evaluation of the virtual Iraq/Afghanistan exposure therapy system for combat-related PTSD. Annals of the New York Academy of Sciences, 1208 , 114–125. https://doi.org/10.1111/j.1749-6632.2010.05755.x .

Rosen, J. C. (1996). Body image assessment and treatment in controlled studies of eating disorders. The International Journal of Eating Disorders, 20 , 331–343. https://doi.org/10.1002/(SICI)1098-108X(199612)20:4<331::AID-EAT1>3.0.CO;2-O .

Rothbaum, B. O., Hodges, L. F., Kooper, R., Opdyke, D., Williford, J. S., & North, M. (1995a). Effectiveness of computer-generated (virtual reality) graded exposure in the treatment of acrophobia. The American Journal of Psychiatry, 152 , 626–628. https://doi.org/10.1176/ajp.152.4.626 .

Rothbaum, B. O., Hodges, L. F., Kooper, R., Opdyke, D., Williford, J. S., & North, M. (1995b). Virtual reality graded exposure in the treatment of acrophobia: a case report. Behavior Therapy, 26 , 547–554. https://doi.org/10.1016/S0005-7894(05)80100-5 .

Rothbaum, B. O., Hodges, L., Watson, B. A., Kessler, G. D., & Opdyke, D. (1996). Virtual reality exposure therapy in the treatment of fear of flying: a case report. Behaviour Research and Therapy, 34 , 477–481. https://doi.org/10.1016/0005-7967(96)00007-1 .

Rothbaum, B. O., Hodges, L., Alarcon, R., Ready, D., Shahar, F., Graap, K., et al. (1999). Virtual reality exposure therapy for PSTD Vietnam veterans: a case study. Journal of Traumatic Stress, 12 , 263–271. https://doi.org/10.1023/A:1024772308758 .

Rozental, A., Kottorp, A., Boettcher, J., Andersson, G., & Carlbring, P. (2016). Negative effects of psychological treatments: an exploratory factor analysis of the negative effects questionnaire for monitoring and reporting adverse and unwanted events. PLoS One, 11 , e0157503. https://doi.org/10.1371/journal.pone.0157503 .

Saredakis, D., Szpak, A., Birckhead, B., Keage, H. A. D., Rizzo, A., & Loetscher, T. (2020). Factors associated with virtual reality sickness in head-mounted displays: a systematic review and meta-analysis. Frontiers in Human Neuroscience, 14 . https://doi.org/10.3389/fnhum.2020.00096 .

Scarfe, P., & Glennerster, A. (2019). The science behind virtual reality displays. Annu Rev Vis Sci, 5 , 529–547. https://doi.org/10.1146/annurev-vision-091718-014942 .

Scheveneels, S., Boddez, Y., Van Daele, T., & Hermans, D. (2019). Virtually unexpected: no role for expectancy violation in virtual reality exposure for public speaking anxiety. Frontiers in Psychology, 10 , 1–10. https://doi.org/10.3389/fpsyg.2019.02849 .

Schleider, J. L., Mullarkey, M. C., & Weisz, J. R. (2019). Virtual reality and web-based growth mindset interventions for adolescent depression: protocol for a three-arm randomized trial. Journal of Medical Internet Research, 21 , 1–14. https://doi.org/10.2196/13368 .

Schwartzman, D., Segal, R., & Drapeau, M. (2012). Perceptions of virtual reality among therapists who do not apply this technology in clinical practice. Psychological Services, 9 , 310–315. https://doi.org/10.1037/a0026801 .

Seabrook, E., Kelly, R., Foley, F., Theiler, S., Thomas, N., Wadley, G., et al. (2020). Understanding how virtual reality can support mindfulness practice: mixed methods study. Journal of Medical Internet Research, 22 , e16106. https://doi.org/10.2196/16106 .

Segal, R., Bhatia, M., and Drapeau, M. (2011). Therapists’ perception of benefits and costs of using virtual reality treatments. Cyberpsychology , Behavior and Social Networking 14, 29–34. doi: https://doi.org/10.1089/cyber.2009.0398 .

Serrano, B., Baños, R. M., & Botella, C. (2016). Virtual reality and stimulation of touch and smell for inducing relaxation: a randomized controlled trial. Computers in Human Behavior, 55 , 1–8. https://doi.org/10.1016/j.chb.2015.08.007 .

Shen, N., Levitan, M.-J., Johnson, A., Bender, J. L., Hamilton-Page, M., & Jadad, A. (Alex) R., et al. (2015). Finding a depression app: a review and content analysis of the depression app marketplace. JMIR mHealth and uHealth, 3 , e16. https://doi.org/10.2196/mhealth.3713 .

Shin, D. (2018). Empathy and embodied experience in virtual environment: to what extent can virtual reality stimulate empathy and embodied experience? Computers in Human Behavior, 78 , 64–73. https://doi.org/10.1016/j.chb.2017.09.012 .

Sidenmark, L., & Gellersen, H. (2020). Eye, head and torso coordination during gaze shifts in virtual reality.  ACM Transactions on Computer-Human Interaction, 27 , 1–40. https://doi.org/10.1145/3361218 .

Silviu Matu, D. (2019). Using virtual reality to study and modify cognitions in cognitive-behavior therapy: theoretical rationales and experimental results. in 9th World Congress of Behavioural and Cognitive Therapies.

Slater, M. (2018). Immersion and the illusion of presence in virtual reality. British Journal of Psychology, 109 , 431–433. https://doi.org/10.1111/bjop.12305 .

Slater, M., Neyret, S., Johnston, T., Iruretagoyena, G., & Crespo, M. Á. de la C., Alabèrnia-Segura, M., et al. (2019). An experimental study of a virtual reality counselling paradigm using embodied self-dialogue. Scientific Reports, 9 , 10903. https://doi.org/10.1038/s41598-019-46877-3 .

Slater, M., Gonzalez-Liencres, C., Haggard, P., Vinkers, C., Gregory-Clarke, R., Jelley, S., et al. (2020). The ethics of realism in virtual and augmented reality.  Frontiers in Virtual Reality, 1 , 1–13. https://doi.org/10.3389/frvir.2020.00001 .

Sonia Huang, J. (2011). An examination of the business strategies in the second life virtual market. Journal of Media Business Studies, 8 , 1–17. https://doi.org/10.1080/16522354.2011.11073520 .

Spiegel, J. S. (2018). The ethics of virtual reality technology: social hazards and public policy recommendations. Science and Engineering Ethics, 24 , 1537–1550. https://doi.org/10.1007/s11948-017-9979-y .

Spiegel, B., Fuller, G., Lopez, M., Dupuy, T., Noah, B., Howard, A., et al. (2019). Virtual reality for management of pain in hospitalized patients: a randomized comparative effectiveness trial. PLoS One, 14 , e0219115. https://doi.org/10.1371/journal.pone.0219115 .

Sutherland, I. E. (1968). A head-mounted three dimensional display. In Proceedings of the December 9-11, 1968, fall joint computer conference, part I on - AFIPS ‘68 (Fall, part I) (New York, New York, USA: ACM press), 757. doi: https://doi.org/10.1145/1476589.1476686 .

Tardif, N., Therrien, C.-É., and Bouchard, S. (2019). Re-examining psychological mechanisms underlying virtual reality-based exposure for spider phobia. Cyberpsychology, Behavior and Social Networking 22, 39–45. doi: https://doi.org/10.1089/cyber.2017.0711 .

Tarp, K., Bojesen, A. B., Mejldal, A., & Nielsen, A. S. (2017). Effectiveness of optional videoconferencing-based treatment of alcohol use disorders: randomized controlled trial. JMIR Mental Health, 4 , e38. https://doi.org/10.2196/mental.6713 .

Tashjian, V. C., Mosadeghi, S., Howard, A. R., Lopez, M., Dupuy, T., Reid, M., et al. (2017). Virtual reality for management of pain in hospitalized patients: results of a controlled trial. JMIR Mental Health, 4 , e9. https://doi.org/10.2196/mental.7387 .

Titov, N., Dear, B., Nielssen, O., Staples, L., Hadjistavropoulos, H., Nugent, M., et al. (2018). ICBT in routine care: a descriptive analysis of successful clinics in five countries. Internet Interventions, 13 , 108–115. https://doi.org/10.1016/j.invent.2018.07.006 .

Tobler-Ammann, B. C., Surer, E., Knols, R. H., Borghese, N. A., & de Bruin, E. D. (2017). User perspectives on Exergames designed to explore the hemineglected space for stroke patients with visuospatial neglect: usability study. JMIR Serious Games, 5 , e18. https://doi.org/10.2196/games.8013 .

Troscianko, E. T. (2018). Fiction-reading for good or ill: eating disorders, interpretation and the case for creative bibliotherapy research. Medical Humanities, 44 , 201–211. https://doi.org/10.1136/medhum-2017-011375 .

Waller, G., & Turner, H. (2016). Therapist drift redux: why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track. Behaviour Research and Therapy, 77 , 129–137. https://doi.org/10.1016/j.brat.2015.12.005 .

Wechsler, T. F., Kümpers, F., & Mühlberger, A. (2019). Inferiority or even superiority of virtual reality exposure therapy in phobias?—A systematic review and quantitative meta-analysis on randomized controlled trials specifically comparing the efficacy of virtual reality exposure to gold standard in vivo Exp. Frontiers in Psychology, 10 . https://doi.org/10.3389/fpsyg.2019.01758 .

Wieland, L. S., Berman, B. M., Altman, D. G., Barth, J., Bouter, L. M., D’Adamo, C. R., et al. (2017). Rating of included trials on the efficacy–effectiveness spectrum: development of a new tool for systematic reviews. Journal of Clinical Epidemiology, 84 , 95–104. https://doi.org/10.1016/j.jclinepi.2017.01.010 .

Wild, J., & Clark, D. M. (2011). Imagery rescripting of early traumatic memories in social phobia. Cognitive and Behavioral Practice, 18 , 433–443. https://doi.org/10.1016/j.cbpra.2011.03.002 .

Won, A. S., Perone, B., Friend, M., and Bailenson, J. N. (2016). Identifying anxiety through tracked head movements in a virtual classroom. Cyberpsychology , Behavior and Social Networking 19, 380–387. doi: https://doi.org/10.1089/cyber.2015.0326 .

Wong, S. (2019). Feared self and obsessive-compulsive symptoms: an experimental manipulation using virtual reality. in 9th World Congress of Behavioural and Cognitive Therapies.

Download references

Acknowledgments

Open access funding provided by Karolinska Institute. The author wishes to thank Dr. Alexander Miloff and William Hamilton for many fruitful discussions on the topics discussed above. The author is funded by an internal grant from the Centre for Psychiatry Research, Region Stockholm and Karolinska Institutet.

Author information

Authors and affiliations.

Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Katrinebergsbacken 35A, 117 61, Stockholm, Sweden

Philip Lindner

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Philip Lindner .

Ethics declarations

Conflict of interest.

The author reports involvement in several academia-industry collaborations related to the work described, including direct financial reimbursement for consulting work for one private company (Mimerse), but holds no financial stake in any such company.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Lindner, P. Better, Virtually: the Past, Present, and Future of Virtual Reality Cognitive Behavior Therapy. J Cogn Ther 14 , 23–46 (2021). https://doi.org/10.1007/s41811-020-00090-7

Download citation

Accepted : 05 October 2020

Published : 20 October 2020

Issue Date : March 2021

DOI : https://doi.org/10.1007/s41811-020-00090-7

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Virtual reality
• Gamification
• Serious game
• Find a journal
• Publish with us
• Track your research

IEEE Account

• Change Username/Password
• Update Address

Purchase Details

• Payment Options
• Order History
• View Purchased Documents

Profile Information

• Communications Preferences
• Profession and Education
• Technical Interests
• US & Canada: +1 800 678 4333
• Worldwide: +1 732 981 0060
• Contact & Support
• About IEEE Xplore
• Accessibility
• Terms of Use
• Nondiscrimination Policy
• Privacy & Opting Out of Cookies

A not-for-profit organization, IEEE is the world's largest technical professional organization dedicated to advancing technology for the benefit of humanity. © Copyright 2024 IEEE - All rights reserved. Use of this web site signifies your agreement to the terms and conditions.

New Research Finds Virtual Reality Can Help Treat Anxiety

Several studies support the use of virtual reality for anxiety treatment..

Posted September 26, 2021 | Reviewed by Kaja Perina

• What Is Anxiety?
• Take our Generalized Anxiety Disorder Test
• Find a therapist to overcome anxiety

New research published in JMIR Mental Health has found that virtual reality (VR) can be useful in the treatment of anxiety and depression . Virtual reality can be used effectively to augment and enhance traditional treatment methods, such as cognitive behavioral therapy and exposure therapy.

The recent study reviewed articles published between 2017 to 2021 related to virtual reality in the treatment of mental health issues and found 369 articles in this subject area, which were narrowed down to 34 clinical studies. Most of these studies combined cognitive behavioral therapy, a standard method of treating anxiety, with virtual reality immersive environments and simulations. Based on this recent review of research, VR research has primarily focused on anxiety, and there is less research on the effectiveness and use of VR in depression.

Virtual reality uses computer modeling and simulation so that people can interact with realistic 3D visual environments as well as other senses through interfaces like sensory gloves. Virtual reality in health care entered the scene in the early 2000s with the use of a VR gaming system SnowWorld which was found to be able to reduce pain levels in burn wound care.

Virtual reality combined with cognitive behavioral therapy has been effective in the treatment of social anxiety disorder, generalized anxiety disorder, as well as treatment for specific fears such as public speaking anxiety, exam anxiety, and driving-related anxiety. However, most research in this area has small participant sample sizes, ranging from 2 to 115. All the studies used head-mounted displays, as opposed to projection -based displays, to provide simulated environments.

The most common VR intervention was VR exposure therapy (VRET). Virtual reality exposure therapy is a behavioral method in which participants are deliberately shown a feared object or anxiety-provoking experience in a simulated environment. VRET has been useful to treat social anxiety and public speaking anxiety . The theory is that gradual and repeated exposure to this triggering simulated environment can reduce anxiety over time. Virtual reality provides a useful way for participants to experience safely and confidentially a simulated environment and gives people a chance to work directly with therapists in real time. For example, people with social anxiety were placed in a virtual workplace or job interview or people with a fear of public speaking were placed in a virtual classroom or conference room.

Virtual reality technology can also enhance the possibilities of music therapy . One study placed participants in a virtual performance hall where they could sing and perform. Another study used VR to enhance art therapy by using a virtual painting program. VR has also been used to conduct healthy games and exercises and as a way to provide neurofeedback and biofeedback .

As virtual reality technology continues to expand and develop, it will hopefully become more accessible to everyone. Virtual reality is a useful and novel way to enhance and make more efficient traditional forms of treatment for of anxiety and depression.

Marlynn Wei, MD, PLLC © Copyright 2021

Baghaei N, Chitale V, Hlasnik A, Stemmet L, Liang H, Porter R. Virtual Reality for Supporting the Treatment of Depression and Anxiety: Scoping Review. JMIR Ment Health 2021;8(9):e29681

Marlynn Wei, M.D., J.D., is a board-certified Harvard and Yale-trained psychiatrist and therapist in New York City.

• Find a Therapist
• Find a Treatment Center
• Find a Psychiatrist
• Find a Support Group
• Find Online Therapy
• United States
• Brooklyn, NY
• Chicago, IL
• Houston, TX
• Los Angeles, CA
• New York, NY
• Portland, OR
• San Diego, CA
• San Francisco, CA
• Seattle, WA
• Washington, DC
• Asperger's
• Bipolar Disorder
• Chronic Pain
• Eating Disorders
• Passive Aggression
• Personality
• Goal Setting
• Positive Psychology
• Stopping Smoking
• Low Sexual Desire
• Relationships
• Child Development
• Self Tests NEW
• Therapy Center
• Diagnosis Dictionary
• Types of Therapy

It’s increasingly common for someone to be diagnosed with a condition such as ADHD or autism as an adult. A diagnosis often brings relief, but it can also come with as many questions as answers.

• Emotional Intelligence
• Gaslighting
• Affective Forecasting
• Neuroscience

Numbers, Facts and Trends Shaping Your World

Read our research on:

Full Topic List

Regions & Countries

• Publications
• Our Methods
• Short Reads
• Tools & Resources

Read Our Research On:

• Visions of the Internet in 2035
• 6. Altering “reality”

Table of Contents

• 1. A sampling of overarching views
• 2. Building better spaces
• 3. Constructing effective communities
• 4. Empowering individuals
• 5. Changing economic life and work
• 7. Tackling wicked problems
• 8. Closing thoughts
• About this canvassing of experts
• Acknowledgments

A considerable number of these experts focused their answers on the transformative potential of artificial intelligence (AI), virtual reality (VR) and augmented reality (AR). They say these digital enhancements or alternatives will have growing impact on everything online and in the physical world. This, they believe, is the real “metaverse” that indisputably lies ahead. They salute the possibilities inherent in the advancement of these assistive and immersive technologies, but also worry they can be abused – often in ways yet to be discovered. A number of respondents also predict that yet-to-be envisioned realms will arise.

Andrew Tutt, an expert in law expert and author of “ An FDA for Algorithms ,” predicted, “Digital spaces in the future will be so widely varied that there will not be any canonical digital space, just as there is no canonical physical space. A multitude of new digital spaces using augmented reality and virtual reality to create new ways for people to interact online in ways that feel more personal, intimate and like the physical world will likely arise. These spaces will provide opportunities to experience the world and society in new and exciting ways. One imagines, for example, that in the future, digital classrooms could involve students sitting at virtual desks with a virtual teacher giving a lesson at the front of the room.

“There will be future digital concerts with virtually limitless capacity that allow people to watch their favorite bands in venues. And through AR and VR, people will take future ‘trips’ to museums that can only be visited today by buying plane tickets to fly half a world away. Unlike the experiences of today, which are tightly constrained by limitations of physical distance and space, these offer an opportunity to create a more engaged and interactive civil, political and artistic discourse. People are no longer prevented from meaningfully taking advantage of opportunities for education, entertainment and civic and political discourse. These opportunities will not eliminate the problems that digital spaces today confront.

A fundamental reorientation around these new types of [digital] spaces … will be necessary, but the multiplication of opportunities to interact with friends, neighbors and strangers across the world may have the salutary effect of helping us to be better citizens of these digital spaces and thereby improve them without necessarily changing the fundamental technologies and structures on which they rely. Andrew Tutt, an expert in law expert and author of “ An FDA for Algorithms”

“A fundamental reorientation around these new types of spaces – one in which we impose shared values for these types of shared spaces – will be necessary, but the multiplication of opportunities to interact with friends, neighbors and strangers across the world may have the salutary effect of helping us to be better citizens of these digital spaces and thereby improve them without necessarily changing the fundamental technologies and structures on which they rely.”

Mark Lemley, professor of law and director of the Stanford University program in Law, Science and Technology, said, “We will live more of our lives in more – and more realistic – virtual spaces.”

Mark Deuze, professor of media studies at the University of Amsterdam, the Netherlands, wrote, “The foundation of digital life in 2035 will be lived in a mixed or cross-reality in which the ‘real’ is intersected with and interdependent with multiple forms of augmented and virtual realities. This will make our experience of the world and ourselves in it much more malleable than it already is, with one significant difference: By that time, almost all users will have grown up with this experience of plasticity, and we will be much more likely to commit to making it work together.”

Shel Israel, author of seven books on disruptive technologies and communications strategist to tech CEOs, responded, “By 2035 AR and VR are likely to fit into fashionable headsets that look like everyday eyeglasses and will be the center of our digital lives. Nearly all digital activities will occur through them rather than desktop computers or mobile devices. We will use them for shopping and to virtually visit destinations before we book travel. They will scan our eyes for warnings of biologic anomalies and health concerns. We will see the news and attend classes and communicate through them. By 2045, these glasses will be contact lenses and by 2050, they will be nanotech implants. This will be mostly good, but there will be considerable problems and social issues caused by them. They will likely destroy our privacy, they will be vulnerable to hacking and, by then, they could possibly be used for mind control attempts.

“Positives for 2035:

• Medical technology will prolong and improve human life.
• Immersive technology will allow us to communicate with each other through holograms that we can touch and feel, beyond simple Zoom chatting or phoning.
• Most transportation will be emissions-free.
• Robots will do most of our unpleasant work, including the fighting of wars.
• Tech will improve the experience of learning.

“On the dark side of 2035:

• Personal privacy will be eradicated.
• The cost of cybercrime will be many times worse than it is today.
• Global warming will be worse.
• The computing experience will bombard us with an increasing barrage of unwanted messages.”

Jamais Cascio, distinguished fellow at the Institute for the Future, shared this first-person 2035 scenario: “Today, I felt like a frog so I became one. Well, virtually, of course. I adjusted my presentation avatar (my ‘toon’) to give me recognizably ranidaean features. Anyone who saw me through mixed-reality lenses – that is, pretty much everybody at this point – would see this froggy version of me. I got a few laughs at the taqueria I went to for lunch. It felt good, man. My partner, conversely, had a meeting in which she had to deal with a major problem and (worse) she had to attend physically. To fit her mood, she pulled on the flaming ballgown I had purchased for her a few years ago. The designer went all-out for that one, adding in ray-tracing and color sampling to make sure the flames that composed the dress properly illuminated the world around her from both her point of view and the perspective of observers. She said that she felt as terrifying as she looked. When mixed reality glasses took off late in the 2020s, most pundits paid attention to the opportunity they would give people to remix and recreate the world around them. Would people block out things they didn’t want to see? Would they create imaginary environments and ignore the climate chaos around them? Turned out that what people really wanted to do was wear elaborate only-possible-in-the-virtual-world fashion. Think about it: what was the big draw for real money transactions in online games? Skins – that is, alternative looks for your characters. It’s not hard to see how that could translate into the non-game world. You want to be a frog? Here are five dozen different designs under Creative Commons and another several hundred for prices ranging from a dollar to a thousand dollars. You want to look serious and professional? This outfit includes a new virtual hairstyle, too. We sometimes get so busy trying to deal with the chaos of reality that we sometimes forget that the best way to handle chaos is to play.”

The founder and director of a digital consultancy predicted, “AR and VR technologies will do more to bring us together, teach us about distant places, cultures and experiences and help us become healthier through virtual diagnostics and digital wellness tools. I suppose what I’m really envisioning is a future where the entities that provide digital social services are reoriented to serve users rather than shareholders; a new class of not-for-profit digital utilities regulated by an international network of civic-minded experts. I would like to envision a digital future where we assemble around communities – geographical or interest-based – that provide real support and a plethora of viewpoints. This is really more of a return to the days before Facebook took over the social web and development from there.”

A leading professor of legal studies and business ethics responded, “The expectation that persistent metaverse experiences will be more widespread by 2035 isn’t a prediction, it is a certainty given current development and investment trends. I have wonderful experiences in the digital space of World of Warcraft, which started in 2004. With the huge investment in metaverse platforms, I expect that more people will have that kind of social experience, extending beyond it simply being used for gaming. But that doesn’t mean that digital life will be better or worse on average for 8 billion people in the world.”

A distinguished scientist and data management expert who works at Microsoft said, “In 2035 there will be more ‘face-to-face’ (‘virtual,’ but with a real feel) discussion in digital spaces that opens people’s minds to alternative viewpoints.”

Sam Punnett, retired owner of FAD Research, said, “A better world online would involve authenticated participants. It isn’t too far-fetched to imagine that 15 years from now we will have seen a broad adoption of VR interfaces with a combination of gesture and voice control. After many years of two-dimensional video representation and its interfaces, technology and bandwidth will advance to a point where the VR gesture/voice interface will represent ‘new and improved.’ Watch the gaming environments for more such advances in interface and interaction, as gaming most always leads invention and adoption.”

Seth Finkelstein, principal at Finkelstein Consulting and Electronic Frontier Foundation Pioneer Award winner, commented, “If virtual reality improves akin to the way that video conferencing has improved, VR gaming will be awesome. We have the ‘Star Trek’ communicator now (with mobile phones). If better sensing of body movement was combined with additional advances in head-mounted display and audio, we’d have something like a primitive ‘Star Trek’ holodeck.”

A professor of computer science and entrepreneur wrote a hopeful, homey vignette: “Wearing augmented-reality hardware, a child is learning by doing while moving – launching a rocket, planting a tree, solving an animal-enclosure puzzle in a virtual zoo. In the next room, a sitting parent is teaming with colleagues across the globe to design the next version of a flying car. Grandpa downstairs is baking cookies from the porch Adirondack chair by controlling – via a tablet and instrumented gloves – a couple of chef-robots in the kitchen. While Grandma, from an adjacent chair, is interacting with a granddaughter who lives across the country via virtual-reality goggles.”

Victor Dupuis, managing partner at the UFinancial Group, shared a shopping scenario, writing, “You are buying a new car. You browse cars by using a personal Zoom-type video tech, then switch into a VR mode to take a test drive. After testing several EV cars from different manufacturers, you simultaneously negotiate the best possible price from many of them. You settle on a choice, handle a much more briefly-structured financial transaction, your car is delivered to your front door by drone truck and your trade-in vehicle leaves in the same way.

“Between now and 2035, digital spaces will continue to improve the methods and efficiencies of how we transact life. Financial decision making, information interpretation, major personal and home purchases, all will be handled more efficiently, resulting in reduced unit costs for consumers and the need for companies to plan on higher sales volume to thrive. On the negative side, we are eroding relationally because of an increased dependence on digital space for building relationships and fostering long-term connections. This will continue to erode the relationship aspect of human nature, resulting in more divorces and fractured relationships, and fewer deep and abiding relationships among us.”

Advances in AI can be crucial to achieving human goals

Alexa Raad , chief purpose and policy officer at Human Security and host of the TechSequences podcast, said, “In 2035 AI will increase access to a basic level of medical diagnostic care, mental health counseling, training and education for the average user. Advances in augmented and virtual reality will make access to anything from entertainment to ‘hands-on’ medical training on innovative procedures possible without restrictions imposed by our physical environment (i.e., geography). Advances in the Internet of Things and robotics will enable the average user to control many aspects of their physical lives online by directing robots (routine living tasks like cleaning, shopping, cooking, etc.). Advances in biometrics will help us manage and secure our digital identities.”

A foresight strategist based in Washington, D.C., predicted, “Probably the most significant change in ‘digital life’ in the next 14 years will be the geometric expansion of the power and ubiquity of artificial intelligence. I consider it likely that bots (writ large) will be responsible for generating an increasing portion of our cultural and social information, from entertainment media to news media to autonomous agents that attend our medical and psychosocial needs. Obviously, a lot can go right or wrong in this scenario, and it’s incumbent upon those of us who work in and with digital tech to anticipate these challenges and to help center human dignity and agency as AI becomes more pervasive and powerful.”

Peter B. Reiner, professor and co-founder of the National Core for Neuroethics at the University of British Columbia, proposed the creation of “Loyal AI,” writing, “As artificial intelligence comes to encroach upon more and more aspects of our lives, we need to ensure that our interests as humans are being well-served. The best way for this to happen would be the advent of ‘Loyal AI’ – artificially intelligent agents that put the interests of users first rather than those of the corporations that are developing the technology. This will require wholesale reinvention of the current rapacious business model of surveillance capitalism that pervades our digital lives, whether through innovation or government regulation or both. Such trustworthy AI might foster increased trust in institutions, paving the way for a society in which we can all flourish.”

Digital spaces will live in us. Direct connectivity with the digital world and thus with each other will drive us to new dimensions of discovery of ourselves, our species and life in general (thus not only digital life). Paul Epping, chairman and co-founder of XponentialEQ

Paul Epping, chairman and co-founder of XponentialEQ, predicted, “The way we think and communicate will change. Politics, as we know it today, will disappear because we will all be hyperconnected in a hybrid fashion: physically and virtually. Governments and politics have, in essence, been all about control. That will be different. Things will most likely be ‘governed’ by AI. Therefore, our focus should be on developing ‘good’ AI. The way we solve things today will not be possible in that new society. It has been said that first we create technology and then technology creates us. At that point, tech will operate on a direct cognitive level. Radical ‘neuroconnectivity’ has exponentially more possibilities than we can imagine today; our old brains will not be able to solve new problems anymore. Technology will create the science that we need to evolve.

“Digital spaces will live in us. Direct connectivity with the digital world and thus with each other will drive us to new dimensions of discovery of ourselves, our species and life in general (thus not only digital life). And it will be needed to survive as a species. Since I think that the technologies being used for that purpose are cheaper, faster, smaller and safer, everyone can benefit from it. A lot of the problems along the way will be solved and will have been solved, although new unknowns will brace us for unexpected challenges. E.g.: how will we filter information and what defines the ownership of data/information in that new digital space? Such things must be solved with the future capabilities of thinking in the framework of that time; we can’t solve them with our current way of thinking.”

Heather D. Benoit, a senior managing director of strategic foresight, wrote, “I imagine a world in which information is more useful, more accessible and more relevant. By 2035, AIs should be able to vet information against other sources to verify its accuracy. They should also be able to provide this information to consumers at the times that make the most sense based on time of day, activity and location. Furthermore, some information would be restricted and presented to each individual based on their preferences and communication style. I imagine we’ll all have our own personal AIs that carry out these functions for us, that we trust and that we consider companions of a sort.”

Sam Lehman-Wilzig, professor and former chair of communications at Bar-Ilan University, Israel, said, “I envision greater use of artificial intelligence by social media in ‘censoring’ out particularly egregious speech. Another possibility: Social media that divides itself into ‘modules’ in which some disallow patently political speech or other types of subject matter, i.e., social media modules that are subject-specific.”

An expert on the future of software engineering presented the following scenario: “A political operative writes a misleading story and attempts to circulate it via social media. By means of a carefully engineered network topology, it reaches trusted community members representing diverse views, and – with the assistance of sophisticated AI that helps to find and evaluate the provenance of the story and related information – the network determines that the story is likely a fabrication and damps its tendency to spread. The process and technology are very reliable and trusted across the political spectrum.”

Jerome Glenn, co-founder and CEO of The Millennium Project, predicted, “Personal AI/avatars will search the internet while we are asleep and later wake us up in the morning with all kinds of interesting things to do. They will have filtered out information pollution, distilling just the best for our own unique self-actualization by using blockchain and smart contracts.”

Dweep Chand Singh , professor and director/head of clinical psychology at Aibhas Amity University in India, said, “Communication via digital mode is here to stay, with an eventual addition of brain-to-brain transmission and exchange of information. Biological chips will be prepared and inserted in brains of human beings to facilitate communication without external devices. In addition, artificial neurotransmitters will be developed in neuroscience labs for an alternative mode of brain-to-brain communication.”

An ICANN and IEEE leader based in India proposed a potential future in which everything is connected to everything, writing, “Our lives, the lives of other humans linked to us and the lives of non-human entities (pets, garden plants, homes, devices and household appliances) will all be connected in ways that enhance the sharing of information in order for people to have more meaningful lives. We will be able to upload our thoughts directly to the internet and others will be able to download and experience them. The ‘thoughts’ (experiences, sensory information, states of mind) of other non-human entities will also be uploaded. Among these online thought-objects, there will also be ‘bots’ (AI thought entities), and the internet will become a bus for thoughts and awareness. This will lead to stunning emergent properties that could transform the human experience.”

A futures strategist and consultant warned, “Within the next 15 years, the AI singularity could happen. Humanity can only hope that the optimistic beliefs of Isaac Asimov will hold true. Even in the present day, some AI platforms that were developed in research settings have evolved into somewhat psychopathic personalities, for lack of a better description. We might, in the future, see AI forecasting events based on accumulated information and making decisions that could limit humanity in some facets of life. Many more jobs than present will be run and controlled by this AI, and major companies will literally jump at the nearly free workforce that AI will provide, but at what cost for humanity? We can only hope as we wait and see how this technology will play out. AI lacks the human element that makes us who we are: the ability to dream, to be illogical, to make decisions based on a ‘gut feeling.’ Society could become logic-based, as this is the perception that AI will base its decisions on. Humanity could lose its ability for compassion and, with that, for understanding.”

Sign up for our weekly newsletter

Fresh data delivery Saturday mornings

Sign up for The Briefing

Weekly updates on the world of news & information

• Artificial Intelligence
• Emerging Technology
• Future of the Internet (Project)
• Gig & Sharing Economies
• Misinformation Online
• Online Privacy & Security
• Platforms & Services
• Social Media
• Social Relations & Tech
• Tech Companies

A quarter of U.S. teachers say AI tools do more harm than good in K-12 education

Many americans think generative ai programs should credit the sources they rely on, americans’ use of chatgpt is ticking up, but few trust its election information, q&a: how we used large language models to identify guests on popular podcasts, striking findings from 2023, most popular, report materials.

901 E St. NW, Suite 300 Washington, DC 20004 USA (+1) 202-419-4300 | Main (+1) 202-857-8562 | Fax (+1) 202-419-4372 |  Media Inquiries

Research Topics

• Email Newsletters

ABOUT PEW RESEARCH CENTER  Pew Research Center is a nonpartisan, nonadvocacy fact tank that informs the public about the issues, attitudes and trends shaping the world. It does not take policy positions. The Center conducts public opinion polling, demographic research, computational social science research and other data-driven research. Pew Research Center is a subsidiary of The Pew Charitable Trusts , its primary funder.

© 2024 Pew Research Center

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int J Environ Res Public Health

How Virtual Reality Technology Has Changed Our Lives: An Overview of the Current and Potential Applications and Limitations

Associated data.

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Despite virtual reality (VR) being initially marketed toward gaming, there are many potential and existing VR applications in various sectors and fields, including education, training, simulations, and even in exercise and healthcare. Unfortunately, there is still a lack of general understanding of the strengths and limitations of VR as a technology in various application domains. Therefore, the aim of this literature review is to contribute to the library of literature concerning VR technology, its applications in everyday use, and some of its existing drawbacks. Key VR applications were discussed in terms of how they are currently utilized or can be utilized in the future, spanning fields such as medicine, engineering, education, and entertainment. The main benefits of VR are expressed through the text, followed by a discussion of some of the main limitations of current VR technologies and how they can be mitigated or improved. Overall, this literature review shows how virtual reality technology has the potential to be a greatly beneficial tool in a multitude of applications and a wide variety of fields. VR as a technology is still in its early stages, but more people are becoming interested in it and are optimistic about seeing what kind of changes VR can make in their everyday lives. With how rapidly modern society has adapted to personal computers and smartphones, VR has the opportunity to become the next big technological turning point that will eventually become commonplace in most households.

1. Introduction

This literature review aims to contribute to the library of literature on the applications of virtual reality (VR), how they are currently used and can be used in the future, and some of the strengths and difficulties that come with using VR.

Virtual reality (VR) refers to a computer-generated, three-dimensional virtual environment that users can interact with, typically accessed via a computer that is capable of projecting 3D information via a display, which can be isolated screens or a wearable display, e.g., a head-mounted display (HMD), along with user identification sensors [ 1 ]. VR can mainly be divided into two categories: non-immersive, and immersive [ 2 ]. Non-immersive VR utilizes a combination of screens surrounding the user to present virtual information [ 3 ]. A typical example of this is driving or flight simulations in which the user sits in a chair with multiple screens around them, giving them the feeling of being in the cockpit or driver’s seat without being fully immersed. Immersive VR refers to using a wearable display, e.g., HMD, to track a user’s movement and present the VR information based on the position of users [ 4 ], which allows them to experience 360 degrees of the virtual environment. This immersive experience is what most people think of when it comes to VR and is one of the most marketable aspects of VR technology. In between immersive and non-immersive VR, there is also augmented reality (AR). AR makes use of computer-generated imagery that is overlayed on physical elements in the real world, which can be found in many applications, such as stores providing a virtual fitting application for people to “try on” clothes. Mixed reality (XR) represents the spectrum between the physical and digital worlds, combining AR and VR to allow users to both immerse themselves in a virtual world while also being somewhat grounded in reality.

The concept of VR was first introduced in the 1960s, with Morton’s creation of the Telesphere Mask and the Sensorama [ 5 ]. The original technologies served the purpose of immersing the user in the video display around them, making them feel like they are a part of the video. The Ultimate display was an idea developed by Ivan Sutherland [ 6 ], operating on a similar concept of allowing the user to feel immersed in a computer-generated environment using multiple input and output devices [ 7 , 8 ]. Following the creation of the Sensorama and the idea of the Ultimate display in the 1960s, the next large boom in VR technology development occurred in the early 2010s. During this period of time, VR was still considered a gimmick—it was expensive and was not considered a technology that would ever become popular with the general public. This, however, started to shift in 2012, when Palmer Luckey debuted his prototype for the first Oculus [ 9 ]. In 2014, Facebook acquired Oculus after seeing the interest it garnered, leading to a significant increase in the popularity of VR devices for home use. Since then, VR has grown to become more popular and accessible to the everyday consumer, with more VR headsets available on the market, such as the HTC Vive, Samsung VR, Oculus, Google Cardboard, and more.

Despite VR being initially marketed toward gaming, there are many potential and existing VR applications in various sectors and fields, including education, training, simulations, and even in exercise and healthcare. Unfortunately, there is still a lack of general understanding of the strengths and limitations of VR as a technology in various application domains. Some of the largest issues with current VR technology are hard to overcome and can span from technical to financial and health issues. Technological limitations regarding users feeling uncomfortable or ill while using a VR headset, the inaccessibility of this technology to most people due to the high price of the associated hardware, and the lack of technical standardization are all current issues that the tech industry is hoping to overcome with research and future improvements.

Overall, this literature review serves the purpose of covering how different types of VR applications can be utilized, as well as providing information on the advantages and drawbacks of using VR technology in various application domains.

In order to present a reliable literature review, an extensive search was performed using common journal search engines/websites, e.g., Google Scholar, JSTOR, MDPI, ResearchGate, PubMed, and Science Direct, which includes peer-reviewed studies and articles. Keywords and phrases used in searching for sources include a combination of “VR” or “virtual reality” with “Education”, “Simulation,” “Games”, “Virtual”, “Immersive”, “Non-immersive”, “Training”, “Application”, “Manufacturing”, “Industrial”, “Medical”, “Healthcare”, and “Entertainment”. The variety in keywords helped yield different results for VR not only as a technology but also in major use cases where it has already been utilized for different industries and fields. The gathered papers and articles were then reviewed to further select representative and up-to-date evidence.

Papers were selected with the goal of providing sufficient coverage of the topic by presenting an overarching summary rather than an exhaustive review of every type of application within VR. Having a large variety of papers does not guarantee that every particular use case of VR is covered, but it does provide a wide breadth of use cases of VR that are currently applied, as well as opportunity spaces for VR applications in the future. As shown in Figure 1 , 145 papers were initially collected, but only 77 were thoroughly reviewed to provide enough coverage without unnecessary advanced technical details. Five additional papers and articles were added after review to accommodate additional information, resulting in a total of 82 sources used for the final literature review.

General structure of the paper selection and literature review.

Included papers were those that clearly presented a specific VR application, those that showed clear negative or positive outcomes of VR usage, or papers that provided relevant background information on a specific VR technology. Exclusion criteria included disregarding papers that had an overt focus on VR hardware components, excluding studies that may have mentioned VR without it being the focus, and rejecting papers that became repetitive after utilizing other papers on similar topics. The following sections provide detailed reviews based on various VR applications and domains.

3. Reviews of VR Technology Applications

The technological applications of VR have advanced to a point where they can be applied to an extensive range of fields and industries outside of just gaming or entertainment. Many have started to take advantage of VR in performing tasks that are hard to practice due to limited resources or the inherent risks and dangers associated with said tasks that can sometimes lead to catastrophic consequences. The greatest strength of VR is that it opens up opportunities for people to practice these tasks in a safe capacity while also being immersed enough for it to feel realistic and transferable to the real world and depict almost any situation accurately [ 10 ]. This section covers some of the main categories of VR applications and provides examples of how these applications are applied or can be applied to different use cases across various fields.

One of the most widely used and largely applicable applications of VR is the simulation aspect, which can be uniquely created and customized to suit users’ needs. There are two main types of simulations: immersive and non-immersive. As mentioned above, non-immersive VR simulations usually include multiple screens and some type of platform or apparatus that mimics the activities or tasks in reality [ 3 ]. Immersive VR simulations differ in terms of using HMDs in place of screens and can either utilize a control platform or apparatus such as the ones used in non-immersive simulations [ 11 ] or can instead be fully contained within a virtual setup and require no external setups or platforms. Whether users opt for immersive or non-immersive VR simulations, there is no significant difference in the performance, and the results appear to be very similar in fulfilling the simulation’s purpose [ 12 ]. There is, however, a slight advantage to using immersive VR simulations with HMDs, as they are capable of fully immersing the user in the simulated environment and giving them a more thorough experience [ 13 ].

3.1. Industrial Simulation Applications

VR simulations have many applications that can span from training simulation to prototyping, designing, and testing tools and objects. Some commonly used VR simulations in the industrial domain include driving simulators, flight simulators for pilots, and combat simulators for military personnel, all of which provide training to users in highly dangerous circumstances without putting them at risk during the training process [ 14 ]. Among the many use cases, two typical simulation applications are further discussed in the following sections.

3.1.1. Driving Simulations

One major use of VR simulations is driving simulations for both driving training and within the automotive industry; VR provides the ability to create driving simulations in which users can be placed in risky driving scenarios without real danger [ 15 ]. Driving simulators can be useful in multiple capacities, such as observing driving behavior to collect data or training inexperienced drivers in a low-stress environment.

VR driving simulations can be used to train young or novice drivers and help them understand their mistakes or point out some bad driving habits they need to adjust. Within a simulation, drivers can be placed in a virtual vehicle within an environment resembling a cityscape, with their behaviors and actions observed and recorded to later analyze for any issues or mistakes or to see if the drivers made the correct decisions in a given scenario [ 16 ]. After conducting the simulation, drivers can be informed of their mistakes and receive feedback about how to improve their behaviors in an actual driving situation. These driving simulations can also be beneficial in training young drivers with neurodevelopmental disorders such as autism spectrum disorder (ASD) [ 17 ], who may otherwise have difficulties learning in an uncontrolled environment.

Another application of VR driving simulations is the ability to collect real-time data on how users react to different scenarios as drivers on the road in a simulated environment. This data can be used in multiple capacities, such as designing better safety features in a vehicle, providing a better user experience for drivers, developing training modules for drivers, and for use in autonomous vehicle (AV) research and development. AVs have been an emerging field of technology that will continue to develop and advance, with VR simulations continuously providing opportunities for safe and efficient data collection and user testing [ 18 ]. One common issue in the field is developing trust between users and autonomous vehicles and understanding how to mitigate the distrust most people have in this technology [ 19 ]. It is important to ensure users have a certain level of trust in an AV so as to ensure drivers take over when appropriate. Accordingly, putting users in a VR driving simulation in which they interact with an autonomous vehicle virtually can yield substantial amounts of data on how users behave within that environment while also ensuring that users feel safe in the process and can become accustomed to being in an AV [ 20 ].

3.1.2. Product Design and Prototyping

One application of VR that can be useful is the ability to look at 3D models in a virtual space in a way that is difficult to visualize via a screen. Prototypes or preliminary designs for products can be modeled and shown in a virtual environment for test and evaluation purposes [ 21 ]. One significant advantage of showing these models in VR is presenting a virtual prototype or part without spending a lot of time, money, effort, or material on building the prototype in real life. Through simulations, VR can also show how the product would react under different conditions. Simulations can be run in VR to show the effect of different interactions between the prototype and surrounding subjects [ 22 ]. This can help the prototype designers determine if any areas of the prototype need to be improved based on the simulated interaction results. The ability to see the product in a virtual environment can also provide the ability to make changes to VR design for a quick turnaround and faster results, which could increase the speed of prototyping, reduce prototype production waste, and increase the understanding of the functions of the prototype.

3.2. Education

Educational applications of VR have not been utilized much yet, but there are many promising examples and studies of how beneficial VR can be in an educational environment. Using VR can help increase student attention by keeping them engaged with what is happening inside the VR environment [ 23 , 24 ]. Most teenage students find it challenging to pay attention in class, especially when they feel that the discussed topics are not relevant to them. When students use exciting technologies such as VR, they are more interested and engaged with what they are learning while immersed in a virtual environment [ 25 , 26 ]. VR headsets are also useful in blocking out visual and auditory distractions, creating an opportunity for the student to focus on teaching materials better. Such VR approaches open up more opportunities for teachers to interact one-on-one with students and have more useful and beneficial teacher–student interactions [ 27 ].

VR also provides the opportunity for students to construct and practice their own knowledge by being able to engage in meaningful experiences. Students are able to immersively engage in educational activities and gain a better understanding of the topic at hand [ 28 ]. VR also has the capability of transporting students to different environments, allowing them to learn and explore various concepts safely and efficiently. This can be especially useful to demonstrate environments that are impossible to visit in reality, such as underwater or space [ 29 , 30 ].

Mixed reality can be considered an extended VR application, which can be applied to real learning environments, such as exploring laboratory experiments [ 31 ]. Students can wear an HMD that shows information and instructions about the laboratory they will experience and can interact with items in reality to recreate what is simulated to them in VR. Essentially, students are still fully aware of their surroundings while also having a better visual understanding and representation of their task, which can help reduce mistakes, allow students to be more independent, and keep students interested and engaged.

With the start of the COVID-19 pandemic, there has been a sudden increase in virtual learning, with many classes being held via online meeting platforms and others being fully asynchronous. VR offers a new, unique approach to asynchronous learning; VR can create a learning environment in which a student can participate in lectures and ask questions to virtual instructors with pre-generated answers [ 32 ]. It is particularly important for students to feel immersed in the virtual environment in order to keep them engaged [ 33 ]. Virtual environments can be created to look just like real-life classrooms where students can walk around and work with other students on assignments [ 34 ]. The issue with asynchronous classroom experiences is that not all of a student’s questions will necessarily be answered; information will be limited to what is currently updated within the virtual experience. Thus, VR-based virtual education does provide a better experience to students than watching videos online, but it cannot replace the experience of being in a classroom with teachers who can directly engage with students.

With VR technology further advancing, VR could also be used for live, synchronous classes where students can engage with classmates and teachers from the comfort of their homes in real time. This would have been especially beneficial when schools were closed due to the pandemic, but it can also provide a way for students to attend classes while experiencing health difficulties, traveling, or living in other countries, etc. Even though live classes have not yet really been held using VR, such applications can be developed in the future, especially with some of the current development being made in both asynchronous learning and social interaction.

3.3. Public Health

Another domain in which VR has been utilized is within public health and wellness. Due to the immersive nature of VR, it can be used to simulate experiences that can directly impact people’s health. Some examples include providing immersive training simulations to medical personnel, offering a new method of exercise or meditation, and presenting therapists with opportunities to better help and understand their patients.

3.3.1. Medical Training

VR simulations provide the opportunity for medical professionals to practice procedures before operating on a patient, which has proven to help provide patients with better outcomes more consistently and reduce the incidence of mistakes. Preparation and practice in VR help improve patient outcomes because medical personnel are better prepared for each patient’s unique circumstances before operating [ 35 , 36 ].

In terms of learning how to perform procedures, medical students can train in an interactive virtual environment that can be programmed with different scenarios, which allows a student to experience real-life scenarios with virtual patients [ 37 ]. The virtual environment can be programmed in a multitude of diverse ways so the student can be prepared and better accustomed to different types of scenarios they may face with future patients. The simulation can be programmed so that a video can be played, showing how to effectively use a tool or object when the user looks at it [ 38 ]. The simulation can also provide hints or step-by-step instructions to students so they know how to perform the surgery properly. All these practices are much more hands-on than reading a textbook and more realistic than practicing on mannequins with minimal risks to a real patient, which makes VR a perfect tool to assist student learning.

Medical students are not the only ones who can benefit from VR simulations; seasoned medical professionals and surgeons can also benefit from this technology. Patient-specific virtual reality simulations (PSVR) are a technology that allows doctors to practice actual upcoming operations in VR [ 39 ]. This technology allows surgeons to practice customized procedures to match their patients’ specific needs and circumstances. A patient’s medical history and physical attributes can be created in the simulation and programmed with the most likely outcomes. When a surgeon performs a task or action in the simulation, the appropriate or most likely reaction can be programmed to simulate what would occur in real life under the same circumstance. This provides an opportunity for surgeons to plan out their surgery beforehand in a virtual environment, allowing them to be better prepared and more confident in their plan for the surgery ahead [ 40 ].

3.3.2. Exergaming, Fitness and Sports

With the initial focus of VR being on gaming, developers saw an opportunity for the emergence of a genre of games called exergames, in which users participate in physical activities to achieve the goals of the game. “The core concept of exergaming rests on the idea of using vigorous body activity as the input for interacting with engaging digital game content with the hope of supplanting the sedentary activity that typifies traditional game interaction that relies on keyboards, gamepads, and joysticks” [ 41 ]. VR games tend to fall under the category of exergames by requiring the user to stand up and move around in order to interact with the environment. Games such as Beat Saber (Beat Games, Prague, Czech Republic) make the user move around frequently to fulfill the game’s requirements.

Using VR as a workout tool helps gamify exercise, which can greatly assist users in staying motivated and engaged by providing them with goals to achieve during their workout. A study performed by Segura-Orti on dialysis patients shows that patients that used VR exercises instead of conventional physical activities had an increased level of physical activity compared to those who worked out using conventional methods [ 42 , 43 ]. This is probably due to the more enjoyable experience of getting exercise in game form that real life has failed to achieve with exercise apps and challenges. Some current examples include the implementation of treadmills and stationary bicycles with VR applications that allow users to physically run/cycle in place while virtually traveling through a virtual environment. These types of immersive experiences can make users’ workouts more enjoyable and can help encourage those new to fitness to start exercising from home in a new and exciting fashion.

VR technology is also being utilized in sports, where it is used to train athletes to improve their skills and can help provide them with physical therapy and rehabilitation. In terms of athletic training, VR presents a great method of perceptual-cognitive skills training [ 44 ], where users are able to experience and learn from video-based playback in an immersive environment rather than on a screen. This can be especially useful in customizing training for players in large team sports, such as football, basketball, or soccer [ 45 ]. VR allows individuals to repeatedly practice skills with lower risks of harm, which helps reduce injury. When injuries do occur in the real world, VR can be used in the rehabilitation process by allowing athletes to train from anywhere and at any time, even in the absence of a trainer or facility.

3.3.3. Therapy and Meditation

Another use of VR is in mental health therapy and meditation. The immersive nature of VR provides the flexibility to create various types of environments or experiences. Accordingly, VR can be used to experience situations that are hard to come by in real life, or that can be dangerous to go through in real life. For example, for those who suffer from post-traumatic stress disorder (PTSD), VR can be a way to experience situations that can trigger traumatic events within a safe, controlled capacity. Specific scenarios can be recreated in a virtual environment, and the patient can experience them in the presence of a therapist in order to receive help dealing with their trauma [ 46 ]. This type of therapy is similar to exposure therapy, in which patients confront what triggers them in order to slowly heal from their trauma [ 47 ].

For people who have certain disorders that may be hard to explain with words, VR can be a safe way to put people in scenarios that may trigger their disorders and observe their behaviors. Allowing a therapist to observe the situation can give them a better insight into why their patient is reacting in a certain way, which will allow them to better treat their patient [ 48 ].

Another application of VR is to use the immersive nature of the technology for meditation purposes. With the ability to experience a calm virtual environment that fully blocks distractions, VR presents a unique form of meditation that may be otherwise difficult to achieve at home. Studies on the use of VR in meditation have shown a slight increase in positive effects and a state of mindfulness in users after the meditation experience [ 49 ]. One study showed that VR meditation was more successful in reducing pre-exam anxiety in college students than watching a meditation video, where 71% of those using VR reported lower anxiety levels compared to 47% of the control group [ 50 ]. VR mediation has been shown to be useful in calming healthcare workers, especially during the COVID-19 pandemic. Virtual reality plus neurofeedback (VR + NF) meditation was shown to decrease the user’s anger, tension, depression, vigor, fatigue, and confusion [ 51 ]. Navarro-Haro et al. experienced an immersive VR mediation simulation and reported an increase in mindfulness and a reduction in negative emotional stress [ 52 ]. They were also less sad and less angry after the simulation. Mediation experts acknowledge that meditation with VR can be an immensely helpful and unique experience that is not yet fully utilized, and studies such as the one discussed here show promising results for this use of VR.

3.4. Social Interaction

VR provides the ability to transport users to a virtual environment in which they can interact with other users. This provides an opportunity to create social connections that may otherwise be hard to create or maintain. Social interaction via VR can be especially helpful for those with autism, as it provides a way for them to practice their communication skills. Users are able to participate in virtual cognition training to better improve their social skills, such as emotion recognition, social attribution, and analogical reasoning [ 53 ]. There are even programs in which young adults with high-functioning autism can participate that are designed with the purpose of increasing their social skills. These programs train users to better recognize facial expressions, body language, and emotions from a person’s voice [ 54 ]. These programs have lasting effects on the users, as they gain the ability to recognize other people’s emotions within the training that they can carry forward in their lives.

Social virtual reality also provides a new way for people to connect over long distances. Virtual spaces can be created in a VR environment and allow users to interact with each other in a realistic setting; users can have realistic avatars and talk to each other as if they were face-to-face [ 55 ]. This method of communication can be as effective as talking to another person in real life as long as the users feel immersed in the environment. When the users are immersed in the virtual environment, they have a better sense of presence, and their responses are more genuine [ 56 ]. This was especially popular during the COVID-19 pandemic when social distancing and travel restrictions made it much harder for people to see and speak with their loved ones [ 57 ]. Being able to attend events and experience activities with others via VR has provided a substitute for real-life interactions that is more realistic than merely speaking over the phone or via video chat [ 58 ].

3.5. Entertainment

The most prominent application of VR among the general public is within the sphere of entertainment, with VR offering new ways for users to experience several types of media in an immersive capacity.

One such form of media consumption within VR is watching movies, shows, or videos. VR offers new ways for users to experience visual media due to its ability to immerse users in a virtual world. VR displays are able to play 360° videos and allow the users to move around in the virtual environment, which provides the user with a more immersive experience and allows them to interact with the world as they see fit [ 59 ]. Users now have more control over what they want to pay attention to in a video and can experience videos in a whole new way.

Another application is virtual travel and tourism. Virtual tourism allows users to experience immersive tourism in simulated environments based on real landscapes or locations. This can make travel attainable to many people that would otherwise not be able to afford the time or money needed to physically visit faraway destinations. Examples of VR tourism include virtual museum visits, navigating areas using applications such as Google Street View, and virtual tours of popular destinations such as the Grand Canyon or the Great Wall of China. The concept of virtually visiting other countries or worlds has existed since the 90s [ 60 ], but there was a boost in interest recently due to travel constraints during the COVID-19 pandemic [ 61 ], with more people seeking travel experiences from the confines of their homes.

Live music is another form of entertainment that seems to be gaining traction as another large application of VR. Virtual reality has the ability to change the way people experience concerts, offering users the ability to attend and enjoy concerts from anywhere in the world. Prerecorded concerts are already available as a VR experience, with videos of the concerts filmed in 360 using omnidirectional cameras, allowing users to move their heads around and feel like they are physically present at the concert [ 62 ]. This can be an opportunity for users who do not have the ability to travel or could not get tickets to still enjoy the show. This will also allow users to see parts of the concert they could not see even if they were there due to cameras either being positioned on stage or close to the stage. The livestreaming of concerts in VR is still not technologically applicable, but it seems like the music industry is aiming to make it a reality at some point in the future with further VR development. As part of the most significant applications of VR, gaming has gained huge popularity recently, with headsets becoming more accessible and game developers investing more in the VR landscape. Many users have purchased VR headsets to play popular games such as Beat Saber , Super-Hot , and Job Simulator (Menlo Park, Prague, Czech Republic), some of the top-selling VR games. Besides designated VR games, many other games that were not initially made for VR are also being developed to include this capability and expand the options gamers have concerning their in-game experience. The rise of VR gaming popularity in recent years owes to the immersive capabilities of HMDs to immerse the users in the game environment, blocking out all external distractions [ 63 ] and giving the users a better sense of presence [ 64 ]. Players can experience the game from their point of view, which allows users to experience games in a whole new way [ 65 ].

4. Limitations and Side Effects of VR

Despite VR being a powerful and versatile tool, current VR technology has some evident limitations and drawbacks. These limitations include technological limits on what VR can do, how accessible VR is to the general public, and some of the side effects of using VR devices.

4.1. Technological Limitations

As a technology still in the earlier stages of development on a grand scale, VR has made significant leaps in evolution. Still, more substantial progress must occur before VR can be fully utilized in all possible applications and purposes.

Right now, the standardization of VR technology and presentation is still limited [ 66 ]; every developer may have their own interface specifications and functionality associated with their technology, and applications are not easily transferable between devices. The only standardization that can be observed as of now tends to be with popular games that are developed to be used across different VR platforms. It is also hard to troubleshoot bugs and receive proper support for any issues due to the lack of standardization. Hopefully, with time and progress in VR development, the technology can become more streamlined and provide better usability for users and transferability between devices. There are currently efforts to standardize VR, but these efforts are new, and the process is still in its infancy [ 67 ].

Other issues include hardware and software requirements for professional VR development, as most VR development software tends to take up a lot of data space on computers and have high-power consumption [ 68 ]. VR headsets also tend to be very heavy and can cause physical strain on users, causing headaches and pain, especially around the neck and shoulders [ 69 ]. As of now, it is not yet known what kind of detrimental effects VR use will have on users’ eyesight, but it is known that it can cause strain, especially with prolonged usage [ 70 ].

Another common issue is the lag between the user’s movements and the visual display within a VR headset [ 71 ]. A lot of the time, the headset’s tracking does not keep up properly with the user’s movements, which not only decreases their immersion but can also cause dizziness or “cybersickness,” which is explained in more detail below [ 71 , 72 ].

Cybersickness

One of the crucial issues with VR usage is VR-induced motion sickness, or “cybersickness” [ 73 , 74 ]. Cybersickness is a phenomenon where users will feel symptoms similar to motion sickness (i.e., nausea, dizziness, lightheadedness) as a result of using a VR device [ 71 ]. It is not yet known exactly why this occurs, but there are a few theories to explain this phenomenon. The most likely theory is known as the “sensory conflict theory,” which states that the excessive mismatch between the motion a user perceives visually and the lack of the corresponding movement in their body causes a conflict [ 71 , 72 , 75 ]. This happens when there is a disparity between the user’s visual system and vestibular system, which is the sensory system responsible for providing the brain with information about motion, head position, and spatial orientation [ 76 ]. Another explanation for cybersickness is the “ecological hypothesis”, which states that when people are not able to perceive or react to new dynamic situations, postural instability occurs [ 77 ].

Cybersickness does not always come with virtual experiences, but the issue can be exacerbated by several factors. Some individual factors include prolonged VR exposure; the user’s predisposition to motion sickness, fatigue, or nausea; and how adapted a user is to VR applications [ 71 , 78 ]. Cybersickness symptoms also seem to be less frequent when users are sitting instead of standing. Symptoms tend to worsen when a user is experiencing a high-speed simulation or game. Being a passive participant makes users more susceptible to symptoms than when they are in control of the simulation [ 71 , 79 , 80 ].

There are also some technical factors that can increase the likelihood of cybersickness occurring. These issues include noticeable lags (delays in the visual display can cause symptoms), position tracking errors (better head tracking reduces symptoms), and flicker in the visual display [ 71 , 72 ].

Cybersickness is one of the most uncomfortable issues that comes with VR usage, and if users continue to experience these uncomfortable symptoms, this can present a huge hindrance to the widespread development and utilization of VR applications [ 72 , 77 ].

4.2. Accessibility

As VR technology evolves, it is becoming more accessible, especially compared to its earlier stages. The cost of VR headsets on the market is still higher than most people can afford, but their current pricing is on par with most gaming consoles. Headsets such as Oculus Quest 2 cost about $300 for the base model and can be fully operated without the need for a computer, making it one of the more accessible headsets on the market. Most other headsets require using a computer that is “VR-ready”, meaning a high-end computer with a powerful graphics card that can manage VR applications. VR-ready computers tend to be more expensive than most computers, making this type of VR headset more expensive overall and out of reach for most people. This makes cost one of the larger barriers for people to get into VR as regular consumers, which is a hindrance to the growth of VR as a household technology.

VR as a field also includes augmented reality (AR) and mixed reality (XR), which are less immersive forms of virtual experiences where users still operate in the real world with a virtual overlay. AR and XR applications are more accessible to people due to their development for use on mobile devices, which are much more common with most people owning or having access to one. A common example of this type of application is AR games such as the popular Pokémon Go , which combines using a smartphone with a physical exploration of the real world [ 81 ] in search of “Pokémon” around them that can only be observed via their phones. Distances are tracked based on a user’s steps, and users can connect fitness apps to the game in order to increase rewards gained from crossing long distances. These types of games and applications can encourage people to be more physically active by gamifying the walking experience [ 82 ]. Similar smartphone games and applications can be a more accessible entry point for people interested in VR but who lack the funds to invest in an immersive headset and computer setup.

5. Conclusions

This literature review has shown how virtual reality technology has the potential to be a greatly beneficial tool in a multitude of applications and a wide variety of fields. Current applications span different domains such as engineering, education, medicine, and entertainment. With VR technology gaining popularity and traction, more VR applications can be further utilized in the future, both in improving current use cases as well as expanding to more domains. The hope is that with more VR technological breakthroughs and development, the current limitations and issues can be overcome, making long-term VR usage more realistic and accessible to more people.

Overall, VR as a technology is still in its early stages, but more people are becoming interested in it and are optimistic about seeing what kind of changes VR can make in their everyday lives. However, more and more application scenarios are under development by experts from different fields, which allows for more specific applications and development. With how rapidly modern society has adapted to personal computers and smartphones, VR has the opportunity to become the next big technological turning point that will eventually become commonplace in most households.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, A.H. and B.J. methodology, A.H. and B.J. validation, B.J.; formal analysis, A.H.; investigation, A.H.; resources, A.H.; data curation, A.H.; writing—original draft preparation, A.H.; writing—review and editing, B.J.; visualization, A.H.; supervision, B.J. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Open access
• Published: 09 September 2024

Theoretical foundations and implications of augmented reality, virtual reality, and mixed reality for immersive learning in health professions education

• Maryam Asoodar   ORCID: orcid.org/0000-0001-6044-6790 1 ,
• Fatemeh Janesarvatan   ORCID: orcid.org/0000-0001-7152-386X 1 , 3 ,
• Hao Yu   ORCID: orcid.org/0000-0003-0473-2914 1 &
• Nynke de Jong   ORCID: orcid.org/0000-0002-0821-8018 1 , 2  

Advances in Simulation volume  9 , Article number:  36 ( 2024 ) Cite this article

114 Accesses

1 Altmetric

Metrics details

Augmented Reality (AR), Virtual Reality (VR) and Mixed Reality (MR) are emerging technologies that can create immersive learning environments for health professions education. However, there is a lack of systematic reviews on how these technologies are used, what benefits they offer, and what instructional design models or theories guide their use.

This scoping review aims to provide a global overview of the usage and potential benefits of AR/VR/MR tools for education and training of students and professionals in the healthcare domain, and to investigate whether any instructional design models or theories have been applied when using these tools.

Methodology

A systematic search was conducted in several electronic databases to identify peer-reviewed studies published between and including 2015 and 2020 that reported on the use of AR/VR/MR in health professions education. The selected studies were coded and analyzed according to various criteria, such as domains of healthcare, types of participants, types of study design and methodologies, rationales behind the use of AR/VR/MR, types of learning and behavioral outcomes, and findings of the studies. The (Morrison et al. John Wiley & Sons, 2010) model was used as a reference to map the instructional design aspects of the studies.

A total of 184 studies were included in the review. The majority of studies focused on the use of VR, followed by AR and MR. The predominant domains of healthcare using these technologies were surgery and anatomy, and the most common types of participants were medical and nursing students. The most frequent types of study design and methodologies were usability studies and randomized controlled trials. The most typical rationales behind the use of AR/VR/MR were to overcome limitations of traditional methods, to provide immersive and realistic training, and to improve students’ motivations and engagements. The most standard types of learning and behavioral outcomes were cognitive and psychomotor skills. The majority of studies reported positive or partially positive effects of AR/VR/MR on learning outcomes. Only a few studies explicitly mentioned the use of instructional design models or theories to guide the design and implementation of AR/VR/MR interventions.

Discussion and conclusion

The review revealed that AR/VR/MR are promising tools for enhancing health professions education, especially for training surgical and anatomical skills. However, there is a need for more rigorous and theory-based research to investigate the optimal design and integration of these technologies in the curriculum, and to explore their impact on other domains of healthcare and other types of learning outcomes, such as affective and collaborative skills. The review also suggested that the (Morrison et al. John Wiley & Sons, 2010) model can be a useful framework to inform the instructional design of AR/VR/MR interventions, as it covers various elements and factors that need to be considered in the design process.

Introduction

Health professions education is a dynamic and complex field that requires constant adaptation to the changing needs of society and the health care system [ 20 , 71 ]. One of the emerging trends in this field is the use of virtual technologies, such as augmented reality (AR), virtual reality (VR), and mixed reality (MR), to enhance the teaching and learning of various skills and competencies. These technologies offer the potential to create immersive, interactive, and realistic environments that can facilitate learning through feedback, reflection, and practice, while reducing the risks and costs associated with real-life scenarios. However, the effective integration of these technologies into health professions education depends on the sound application of instructional design principles and theories, as well as the evaluation of learning outcomes and impacts. This scoping review aims to provide a comprehensive overview of the current state of the art of using AR/VR/MR in health professions education, with a focus on the instructional design aspects and the learning and behavioral outcomes reported in the literature.

Current educational methods in health professions training encompass various approaches. These include problem-based learning [ 70 ], team-based learning [ 1 ], eLearning (Van Nuland et al. [ 19 ]), and simulation-based medical education (SBME) [ 19 ]. Recently, virtual technologies have emerged in alignment with educational trends. Augmented Reality (AR, Virtual Reality (VR, and Mixed Reality (MR are increasingly utilized not only in general education but also specifically in health professions education (Van Nuland et al. [ 19 ],). These technologies offer a range of potential strategies for comprehensive and practical training, contributing to safer patient care [ 19 ].

In the field of healthcare, diverse AR/VR/MR applications are already in use to train healthcare professionals, primarily assisting in surgical procedures for enhanced navigation and visualization [ 9 , 62 ]. These applications aim to facilitate learning through immersion, reflection, feedback, and practice, all while mitigating the inherent risks of real-life experiences. Simulators play a pivotal role in introducing novel teaching methods for complex medical content [ 16 , 21 , 27 , 29 , 35 ]. They allow repeated practice across a wide spectrum of medical disciplines [ 39 , 59 ], Peterson et al. [ 61 ] and may address challenges encountered in traditional health training programs.

VR creates an artificial environment where users interact with computer-generated sights and sounds. It immerses them in a simulated world using devices like headsets and motion sensors [ 69 ]. AR is an interactive overlay onto a real environment, where it offers an extra layer on top of the environment and the user experiences an immersive, interactive setting [ 13 , 27 ]. In MR, elements of VR and AR are combined, and computer graphics interact with elements of the real world, allowing users to interact with both virtual and physical elements simultaneous [ 29 ]. Extended Reality (XR) serves as an umbrella term that unifies Augmented Reality (AR), Virtual Reality (VR), and Mixed Reality (MR) into a single category, reducing public confusion [ 6 ].

In short, AR/VR/MR technologies create digital environments that closely resemble real-world features. These environments enable trainees to learn tasks safely, whether within the bounds of realism or in entirely new experiences beyond traditional constraints [ 41 ]. Notably, in healthcare, the use of computer-enhanced learning has led to positive outcomes such as improved patient safety, enhanced training experiences, and cost reduction [ 34 ].

Investigating prior research in the field of AR/VR/MR in healthcare is important, as this reveals the current state of the field and offers guidance to researchers who are seeking suitable topics to explore and educationists who want to improve the teaching and learning at their institutes [ 34 ]. Currently, there is a lack of insight on the effective application of AR/VR/MR particularly in health professions education and their added value based on instructional design models or theories as most reviews have focused on the technological aspects on AR/VR/MR for medical education, or on comparison with other methods.

This review takes a global perspective to identify the usage and potential benefits of including AR/VR/MR tools for education and training of students and professionals in the health domain. Technologies are constantly evolving and there is a need for obtaining an overview of current trends in an educational context. No review, however, was found that had considered to study whether and how instructional design theories or models guided the use of AR/VR/MR for teaching in health professions education to optimize complex learning within a recent time frame. An important aspect in this regard is the theoretical grounding on which the use of methods, technological or otherwise, is based. Already four decades ago, Reigeluth [ 65 ] argued for the grounding of instructional design in sound theoretical models, stating that instruction is often ineffective and knowledge about instructional design needs to be taken into account in order to remedy this problem. In other words, in addition to focusing on what is taught, how it is taught is also of critical importance [ 65 ]. Unfortunately, interventions are often insufficiently or inconsistently grounded in such theoretical models [ 38 ], Reigeluth & Carr-Chellman [ 66 ].

By now, numerous instructional design models exist that can serve as the basis for determining how content should be taught [ 32 ]. The model that is of particular interest to the topic of this review is the model proposed by Morrison et al. [ 55 ]. This model provides instructional designers with flexibility in determining the design steps to be taken and places significant emphasis on selecting the delivery mode, including considering technology’s potential role Obizoba et al. [ 58 ].

Starting from essential elements to be taken into account when planning instructional design (learners, objectives, methods and evaluation), the Morrison et al. [ 55 ] stipulates a circular design process consisting of nine elements: instructional problems, learner characteristics, task analysis, instructional objectives, content sequencing, instructional strategies, designing the message, instructional delivery, and evaluation instruments (Fig.  1 ).

Instructional Design by Morrison et al. [ 55 ]

In Table  1 , the elements of this models have been set alongside the ADDIE model showing analyze, design, develop, implement and evaluate. The design of the Morrison et al. [ 55 ] model is purposefully circular, signaling flexibility in terms of the order of elements on which to work on rather than prescribing a rigid linear process. Furthermore, the nine elements are considered to be interdependent Obizoba et al. [ 58 ] [ 3 ]F. Placed around these nine elements are formative evaluation and revision, as well as planning, project management, summative evaluation and support services [ 55 ].

The purpose of the study

There are a number of review studies that explore the application of AR/VR/MR in healthcare education and training. These studies primarily concentrate on evaluating the effectiveness of these technologies in learning [ 10 ], comparing their effectiveness with conventional or other teaching methods (as studied by [ 45 ]), and examining the prevailing trends in this field (as reviewed by [ 31 ]). Currently, there is lack of insight on the application of an instructional design model or instructional theories for the design of education with the integration of AR/VR/MR into education, particularly in health professions education. The first objective of this scoping review is to identify the usage and the potential benefits of including AR/VR/MR tools for education and training of students and professionals in the health domain. Therefore, we will provide a global overview of how AR/VR/MR tools are applied in health professions education and training with regard to the distribution over time, domains, methodologies, rational, outcomes, and findings. The second objective is to investigate whether any instructional design models or instructional theories have been applied when using these tools in designing education. We mapped the results based on the Morrison et al. [ 55 ] model. No other review was found that had considered instructional design theories or models guiding the use of AR/VR/MR for teaching in health professions education considering the recent time frame. To fill that gap in the literature, in this study we located and then analyzed all of the peer-reviewed studies in the mentioned databases in the methods section. The purpose is to present a review of the literature on how AR/VR/MR are used in healthcare educational settings from 2015 until 2020. Therefore, with regard to the use of AR/VR/MR in healthcare education and training, the following research questions (RQ) are addressed:

RQ1: What is the distribution over time of the selected studies?

RQ2: Which domains of healthcare and what types of participants are addressed?

RQ3: What type of (instructional) design/methodologies are used? ( Instructional design aspects + educational theories), how do they map on the Morrison et al. [ 55 ] model?

RQ4: What is the rationale behind the exposure to AR/VR/MR?

RQ5: What types of learning and behavioral outcomes (based on Blooms taxonomy) are encouraged?

RQ6: What are the findings of the selected studies?

In this study, we have conducted a scoping review following the framework proposed by Arksey and O’Malley [ 7 ] . The purpose of this scoping review is to map the existing literature on the topic, identify key concepts, sources of evidence, and gaps in the research. The process began with identifying the research question, followed by identifying relevant studies through a comprehensive search of databases such as PubMed, Web of Science, and other publishers. An iterative selection process was used to determine the inclusion and exclusion criteria, and the selected studies were charted based on their key characteristics and findings. The results were then gathered, summarized, and reported.

This scoping review specifically aims to explore the benefits of using AR/VR/MR tools in health education and training. It will also investigates the application of instructional design models or theories in designing education with these tools.

Databases searched

The electronic databases searched in this review were a set of databases accessible through Libsearch, which is the search engine available through our University library. The databases available through this search engine are: WorldCat.org, Web of science, MEDLINE, SpringerLink, ScienceDirect, Wiley Online Library, Taylor and Francis Journals, ERIC, BMJ Journals, and Sage journals.

Our research focused on papers published from 2015 through the end of 2020. We selected only peer-reviewed papers written in English.

Our data collection was completed before the COVID-19 outbreak, and due to the significant impact of the pandemic on the nature of studies conducted, we deliberately excluded papers published in 2021 and beyond. A preliminary review revealed that the methodologies of studies during this period underwent significant changes. This would have necessitated substantial modifications to our research questions. Consequently, we made the decision to confine our research to the year 2020.

Search terms

The databases were searched using key terms related to virtual, augmented and mixed-reality as well as terms for possible usage of these devices in medicine, health and bio-medical education. The following search string was used:

[("virtual reality" OR "augment* reality" OR "mixed reality") AND (health OR health science* OR medicine OR "medical science*" OR biomed* OR "biomed* science" OR “life science*”)].

Search for education and training in medical, biomedical and health sciences

The search returned a large number of papers n  = 5629 (Fig.  2 ). This set was further screened by manually going through all titles and abstracts for relevant terminology like “AR, VR or MR,” “training,” “education,” “medical,” “biomedical,” and “health sciences”. Papers selected on this basis were collated and duplicates removed ( n  = 414).

Flow chart showing the screening process

Selection of papers for inclusion in the review

To select the appropriate studies for inclusion in the review, the full papers ( n  = 414) and the additional papers ( n  = 20) retrieved via cross referencing were screened and a number of further criteria were applied. Selected papers had to (a) include empirical evidence related to the use of AR/VR/MR in education and training, (b) the training had to be in the field of medicine, biomedical sciences or health sciences. The PICOS (population, intervention, comparison, outcome, study design) framework [ 54 ] guided the inclusion and exclusion criteria of this study (Table  2 ).

Coding of selected papers

The papers selected on the basis of the inclusion criteria were coded. To summarize, papers were coded with respect to:

the publication year;

the type of participants addressed in the study;

which one of the AR/VR/MR was used for teaching/learning;

the country and continent where the first author of the paper was based;

behavioral outcomes based on Bloom’s taxonomy: cognitive, affective or psychomotor skills;

the domain of healthcare that AR/VR/MR has been used: neurosurgery, endoscopic surgery, etc.;

what type of (instructional) design/methodologies are used? (Instructional design aspects + educational theories);

the rationale behind using AR/VR/MR for training: whether the AR/VR/MR could offer an environment that could overcome the current limitation. For examples, overcoming limitations on teaching surgical steps, or teaching and practicing psychomotor and cognitive skills, etc.;

variables related to the study: the research design used in the study, categorized as a randomized control trial (RCT); quasi-experimental; survey; correlational or qualitative design; and

the findings of the selected studies.

Quality of the studies

Papers were assessed according to the following criteria: (1) quality of research design: RCT; quasi-experimental controlled study, pre-test/post-test design (an explicit research design had to be present, not just reports on a tool); (2) relevance of the aim of the study for using AR/VR/MR and (3) findings of the study (did the findings of the paper really relate to education/some sort of learning? Were the participants really doing something to learn, rather than for example only testing the tool? Was it used to teach someone to do something?

Consistency and reliability of coding

All authors took part in the identification, coding and quality coding of papers but, for consistency, one of the researchers (MA) oversaw all the coding. A first sample of articles was taken to discuss and align the coding. Subsequently, regular meetings were scheduled between the authors to discuss the papers and their coding.

The systematic search identified a total of 5629 articles (Fig.  3 ). After removing duplicates, 4999 articles were screened for relevance based on title and abstract. As a result, 4585 articles were excluded, leaving 414 articles for full-text review. Cross-reference search identified 20 more articles to be eligible. After full-text review, a total of 184 articles remained relevant for inclusion.

Distribution of the studies from 2015 till end of 2020

Distribution of studies over time

Overall, the number of studies including AR/VR/MR in health education, seems to be increasing. A total of 17 (9%) of the 184 articles included in our review were published in 2015; 24 (13%) of the articles were published in 2016, and 23 (12%) in 2017. In 2018, 35 (19%) articles were published, in 2019, 34 (18%) and in 2020 there were 51 (27%) articles. Figure  3 , depicts a rise in the number of studies per year from 2015 till end of 2020.

Domains of healthcare and types of participants

Most research studies primarily explored the application of AR/VR/MR technology in the medical field, specifically for training medical and nursing students in surgical procedures and anatomy courses. However, a limited number of studies investigated other healthcare domains. For instance, twelve studies specifically examined dentistry, while seven studies included biomedical and health sciences students alongside medical students. For the studies focusing on medicine, the majority of uses for AR/VR/MR in teaching was for training surgical skills (Fig.  4 ). Most the surgeries were mainly related to minimally invasive surgeries, like endoscopy, laparoscopy, etc. When counting all the research related to AR/VR/MR in surgery, which also included the research in fields like endoscopy, laparoscopy, etc. we ended up with 69 papers (Fig.  4 ). A second common use for AR/VR/MR in medical education was to teach anatomy, n  = 31 papers (Fig.  4 ). The focus of these studies were on neuroanatomy, 3D learning structures, and improving visual ability on anatomical understandings.

Domains of healthcare—categories mentioned here are not mutually exclusive, they can overlap and intersect with one another

In the comprehensive analysis of the studies included, a diverse spectrum of student levels is addressed. This encompasses bachelor students, master’s students, residents, and specialized continuous education. Notably, certain studies also delve into student training programs and multi-level training sessions, which involve a combination of students, residents, and expert specialists (Table  3 ).

The bubble chart in Fig.  5 links study domains and population. As evident, most studies are related to training residents’ surgery skills ( n  = 32) and to teaching anatomy to bachelor students ( n  = 24). The coded number of papers based on the domain and population can be found in Appendix 1, Table A. The reference to the codes can be found in Appendix 2.

A visual representation of the study domains and population

Types of Study design/methodologies

For consistency, we took the terms AR, VR or MR used by the authors of the original papers to make our classification. As shown in Fig.  6 , the large majority of studies ( n  = 149; 81%) focused in VR, followed by AR ( N3  = 25; 14%) and MR ( n  = 10; 5%).

Distribution of research focus across VR, AR, and MR

We divided the articles and distinguished between studies with qualitative, quantitative or mixed designs. Large majority of studies used a quantitative methodology ( n  = 152; 83%), followed by mixed-methods designs ( n  = 22; 12%), and there were only a very small number of qualitative studies ( n  = 10; 5%) (Fig.  7 ).

Distribution of research methodologies: quantitative, mixed-methods, and qualitative

In Fig.  8 , you see that most studies focused on usability aspects of AR/VR/MR ( n  = 53, 29%). Their purpose was typically to see if these tools could be used for a particular purpose, and mostly to check all the functions of the tool. The second most common study methodology is Randomized Controlled Trial (RCT) ( n  = 41, 22%).

Types of study methodologies in percentages

To plot the study design against the mode of technology used, Table B in Appendix1, was prepared. The reference to the coded papers can be found in Appendix 2. Figure  9 , clearly shows that 123 papers used VR in quantitative study designs. Eighteen papers used AR in quantitative study designs and 17 studies used VR in mixed method research designs.

Distribution of study designs by technology mode

To plot the study methodology against the mode of technology used, Table C in Appendix 1 was prepared. Coded papers in Table C can be found in appendix 2. Figure  10 clearly shows that 40 studies used VR in usability studies, 34 studies used VR in RCT research methodologies and there were 30 experimental studies with VR.

Plotting distribution of study methodologies by technology mode

Instructional design aspects and educational theories used in these studies

Looking at instructional design and educational theories in combination with AR/VR/MR, we see that only 44 studies out of the total of 184 had something mentioned about theories or instructional designs that they used for designing their teaching and learning. Interestingly, some studies specifically investigated usability aspects of AR, VR, or MR in medical education but did not incorporate any explicit educational design theory. This underscores the need for intentional integration of instructional design principles and educational theories when implementing these immersive technologies in educational settings. Table 4 displays the different theories that some studies applied for their educational design. These theories have literally been mentioned in the studies by the authors (Table 4 ). Among them, self-directed, competency-based and PBL, and evidence-based learning were most commonly used.

In Table  5 , we tried to link the already existing theories to the underlying elements in an instructional design theory. Here the Morrison et al. [ 55 ] was a good match. The purpose was to show how an instructional design model and, in this case, the different elements of the Morrison et al. [ 55 ] model, could be used as guidelines in designing courses with AR/VR/MR in medical education. We especially looked at the design element in the Morrison et al. [ 55 ] model. We hope to reveal some guidelines for including instructional design aspects when planning to use AR/VR/MR in medical education. While Table  5 clearly indicates that only a limited number of studies have taken instructional design elements into account, it’s worth noting that a small subset of studies did indeed consider these aspects. For example, code 141 is a study by Chheang, et al. [ 15 ], they are relying on instructional strategies like problem-based learning, hoping that these strategies would open new directions for operating room training during surgery. We also see, in the study by Liaw, et al. [ 47 ], (code 113), that VR has been used as an instructional strategy for collaborative learning across different healthcare courses and institutions in preparing for future collaborative-ready workforces. Another example can be the way VR is used in course design and in relation to cognitive load. Vera, et al. [ 75 ], (code 127), show that a certain VR operating tool can be integrated in the residency program which is sensitive to residents' task load, and it could be used as a new index to easily and rapidly assess task (over)load in healthcare scenarios. In another research, (code 24), Küçük, et al. [ 44 ] designed a study to determine the effects of learning anatomy via mobile AR on medical students' academic achievement and cognitive load.

Rationale behind using AR/VR/MR in healthcare education

The predominant motivation behind incorporating AR/VR/MR (Augmented Reality, Virtual Reality, and Mixed Reality) in healthcare education was to address specific limitations. These common limitations included factors such as the absence of realism, the financial burden associated with maintaining real-life props, time constraints, the need to simulate complex scenarios, ensuring a safe and controlled practice environment, managing cognitive load, and facilitating repetitive training opportunities (Table  6 ). For example, VR was used as an alternative to plastic or cadaver models, which were mentioned as being subject to a lack of realism and pertaining high maintenance costs, respectively [ 1 , 8 ]. Furthermore, learners in the wider healthcare field, often needed many hours of practice to master a skill, AR/VR/MR were good examples to provide an efficient field for practice. In some specialties, VR was specifically used because it provided the possibility to set up highly complex scenarios at a low cost. Through the use of VR, these limitations could be overcome and practice could be provided in a safe, controlled setting [ 29 ]. In a similar vein, some studies mentioned that they would use VR to reduce students’ cognitive load [ 16 , 44 ], by manipulating some aspects of the task over others. The ability to manipulate aspects of the task can be useful for both training and assessment.

Another rationale was to improve students’ motivation [ 39 , 50 ] and/or self-directed learning [ 27 , 46 ]. As students are used to using digital technologies in almost all aspects of their lives, using these technologies in education was thought to have a positive impact on their perceptions. This rationale was often mentioned for teaching anatomy, which is a course that students often tend to find uninteresting [ 27 , 44 ].

Moreover, in the context of Augmented Reality (AR), technologies have been employed to enhance student engagement and observation beyond what is achievable under typical circumstances.. For example, AR technologies would be used to overlay information from other modalities (e.g., MRI) on to-be-diagnosed images, making it easier to combine the information in order to locate abnormalities [ 12 ].

We plotted instructional design aspects against the rationale for using AR/VR/MR tools that each research considered for their study design or simulation design (Table  7 ). Since rationale behind using a specific method or tool comes at the analysis part of instructional design, we took the analysis section of the Morrison et al. [ 55 ]. The purpose is to see how relying on the analysis section of an instructional design model can help with logically designing the rationale behind using a tool operated by AR/VR/MR in health education.

The available data shows that some studies considered the learner characteristics by having two groups with different knowledge levels (novice/expert) and compared their performance [ 22 ],code 19). Some provided immersive training as an instructional objective to improve face and content validity [ 24 ],code 20). Some others utilized simulation in order to improve student’s motivation [ 27 ],code 21). Some considered task analysis by providing tasks at different simulations [ 28 , 39 ],codes 22, 23). In other studies, simulation was used for personalized and self-directed learning [ 50 ],codes 26) and some attempted to resolve the issues, difficulties and disadvantages of current methods [ 53 ],code 28).

Types of learning and behavioral outcomes

The AR/VR/MR articles were divided into the different learning and behavioral domains. According to Bloom’s revised taxonomy [ 5 ], three domains can be distinguished: the cognitive, affective and the psychomotor domain. The cognitive domain refers to the mental processes needed to engage in (higher-order) thinking. The affective domain refers to development of students’ values and attitudes, while the psychomotor domain has to do with developing the physical skills required to execute a (professional) task [ 5 ]. Of the included studies, seventy-five used AR/VR/MR for teaching cognitive skills (41%, Fig.  11 . Psychomotor skills were targeted in 53 studies (29%, and 5 studies (3% focused on affective outcomes aiming at improving learners’ confidence in surgery; especially, training in neurosurgery, laparoscopy, orthopaedic, endoscopy, sinus surgery, bone surgery, electro-surgery, and eobotic surgery. It is also interesting to know that fifty-one studies (27%) utilized a mixed skills training.

Outcomes of the studies that used AR/VR/MR in healthcare education

The included studies in this review generally categorized an intervention as effective if the majority of the participants achieved significantly higher scores in tests (experiment/control, pre-posttest, exercises) compared to traditional instructional approaches, such as analogue surgery or ultrasound procedures (Table  8 ). Up to 56% of the studies were experimental studies (Fig.  12 ).

Effectiveness of included studies

Some studies were considered as partly effective (Table  8 ), when there were no significant differences in all participants scores (19%, Fig.  12 ) (e.g. [ 17 , 35 ],Van Nuland et al., 2016; [ 76 ]). Here, differences among the participating groups in the studies could be attributed to the level of the training or expertise of the learners (e.g., [ 33 ]). Although in some of these studies, students using the more traditional approaches were performing at the same level as the students in the AR/VR/MR group, there were partial differences reported that learning with AR/VR/MR improved aspects like time efficiency, or precision sensitivity (e.g., [ 52 , 64 , 73 , 74 ]).

Some studies did not report any effectiveness (3%, Fig.  12 ). Study by Llena et al. [ 49 ] showed that although students experienced the AR technology as favorable, no significant differences in learning were found between group learning with AR compared to the group learning with traditional teaching methods. In the study by Huang et al. [ 40 ], no differences were found between students learning with a VR model versus a traditional physical model.

There were also studies showing mixed results, with some but not all outcomes improving in the AR/VR/MR conditions (e.g., [ 68 ]). Other studies reported the positive effects of applying AR/VR/MR as usable (e.g., [ 41 , 51 ],Van Nuland et al., 2016), feasible (e.g. [ 67 ]) tool for healthcare training (e.g. [ 47 , 72 , 75 , 76 ]). Few studies considered contextual factors like face/content validity (e.g. [ 30 , 63 ]), construct validity (e.g. [ 1 , 21 , 22 , 56 ]), study protocols [ 4 ], and accuracy (e.g. [ 12 , 43 , 60 ]).

Several studies reported on variables that impact the effectiveness of AR/VR/MR technologies. One commonly mentioned variable was level of expertise: learners/practitioners with more experiences and/or years of training outperformed novices (e.g., [ 37 ]), and experience had a positive effect on skills acquisition when using these technologies (e.g., [ 44 ]). An exception to this was the study of Hudson et al. [ 42 ], in which nurses with more years of practice found it more difficult to use the technology. Furthermore, Lin et al. [ 48 ] reports an effect of gender, in which men tended to reach proficiency sooner than women when using a laparoscopic surgery simulator. Nickel et al. [ 57 ] further indicated that experiencing fun was also relevant for the student’s learning. In the study by Huber et al., [ 41 ] were they investigated the use of VR to improve residents’ surgery confidence, a correlation was found between confidence improvement and students’ perceived utility of rehearsal. In the same study, the authors showed that the effect of the rehearsal on learner’s confidence was further dependent on trainees’ level of experience and on task difficulty. Finally, Chalhoub et al. [ 14 ] found that gamers had an advantage over non-gamers when using a ‘smartphone game’ to learn laparoscopic skills in the first learning session, although all participants improved in a similar manner.

In this comprehensive review of literature, we explored the application of AR/VR/MR technologies in the instruction of various stages of medical and health professions education. We identified six key research questions to guide our investigation: 1) the trend of studies over time, 2) the healthcare domains and participant types included in these studies, 3) the design methodologies and instructional design aspects/educational theories employed in these studies, 4) the benefits and underlying reasons for using AR/VR/MR in medical and health professions education, 5) the kinds of learning and behavioral outcomes promoted by the use of AR/VR/MR in this field, and 6) the results regarding these learning outcomes in studies that examine the use of these technologies in medical and health professions education.

In general, we observed a rising trend in the number of studies focusing on the application of AR/VR/MR in medical and health professions education. This suggests a consistent and growing interest in leveraging these technologies to enhance student learning across various healthcare disciplines. The primary use of these tools was found to be in teaching surgical skills to residents and anatomy skills to undergraduate students.

When examining the research methodologies employed to study the integration of AR/VR/MR, a notable finding was the predominant focus on quantitative methodology. However, given the limited number of participants in programs such as residency or professional training, qualitative methods could offer researchers the opportunity for a more comprehensive analysis of these tools’ usage and provide detailed insights into these complex learning situations [ 2 , 18 ].

It is interesting to note that the study of affective outcomes is often overlooked when integrating AR/VR/MR into health professions education. While studies are typically categorized based on cognitive, psychomotor, and affective outcomes, the majority focus on cognitive aspects, followed by psychomotor outcomes. Only a small number of studies explore the use of AR/VR/MR for teaching affective outcomes.

Usually, when AR/VR/MR is used in contexts related to emotions and affections, it serves more psychological purposes for patients rather than instructional ones [ 26 ]. However, there is potential value in using these technologies for specific situations, such as targeting affective outcomes like empathy (e.g., [ 25 ]).

In the context of 21st-century multidisciplinary healthcare, prioritizing patient needs and addressing their concerns is crucial. Compassionate and appropriate communication within healthcare teams can build patient trust [ 23 ]. To foster interpersonal skills among healthcare providers, it’s important for health professions education programs to emphasize student competencies in the affective domain of learning [ 20 ]. Interestingly, despite its importance, this aspect is less explored compared to other applications of AR/VR/MR in health professions education.

In this review, we not only examined outcomes but also scrutinized the findings from the included studies. These findings were grouped into three categories: experimental design, usability studies, and contextual factors (Table  8 ). Interestingly, not all experimental studies demonstrated effective outcomes for the application of AR/VR/MR in medical and health profession education. Some studies argued that display technologies did not significantly enhance learning across all or most outcome measures (e.g., [ 14 , 17 , 21 , 35 , 40 , 49 , 69 , 76 ]).

This review also uncovered that only a handful of studies built their AR/VR/MR applications based on specific instructional design models or theories, and there is little description on how these applications can be incorporated into the teaching curriculum. As mentioned in the introduction, instructional design should be rooted in robust theoretical models. Instruction is often ineffective, and knowledge about instructional design needs to be considered to address this issue and optimize complex learning. In other words, the focus should not only be on what is taught but also on how it is taught, which is of paramount importance [ 38 ], Reigeluth & Carr-Chellman [ 66 ].

We suggest that several factors should be considered when creating educational materials based on AR/VR/MR. In this review, we recommend using the instructional design model by Morrison et al. [ 55 ]. When focusing on this model, it is crucial to consider the unique value that a virtual environment can add to enhance students’ learning process when addressing instructional problems and strategies. For instance, AR/VR/MR can offer distinct advantages to learning by providing scenarios where patient privacy is crucial Pan, et al. [ 59 ] or where standardization is key [ 43 , 67 , 74 ].

Regarding learner characteristics, it is important for learners to be at ease with the general use of technology and specifically for learning. VR can provide a safe environment for both patients and students to practice essential skills (e.g., [ 8 , 29 , 33 , 57 , 60 , 63 ]).

When considering task analysis , it’s crucial to understand that all students will be performing the same task, leading to the point of standardization. All participants can practice the same task, allowing teachers to manage what everyone is learning. The tasks can be whole-task problems (e.g., students demonstrating they can conduct a full consultation) [ 56 ], or part-tasks (e.g., surgical procedures) [ 43 , 51 , 67 , 76 ]. Similar to the instructional problem mentioned earlier, it’s important to consider the objectives of the task before designing the teaching/learning methodologies and applications.

In terms of instructional objectives , it is a widely accepted practice in education to clearly define intended learning outcomes (ILOs) prior to designing learning and assessment tasks [ 11 ]. This principle holds true for the use of AR/VR/MR in health professions education. As previously mentioned, the application of these technologies should have a specific purpose, rather than being used merely for their “cool” factor or “motivating” qualities (e.g., [ 17 , 27 , 39 , 49 , 50 , 69 ]). The most common justifications found in the studies included in this review were to overcome certain limitations (such as lack of realism, high maintenance costs for real-life props, time constraints, practicing complex scenarios, providing a safe/controlled setting for practice, cognitive load, and the opportunity for repetitive training), to boost students’ motivation, or to enhance students’ observation skills and attentiveness beyond their usual capabilities.

Beyond integration, it’s also crucial to consider where in the curriculum the technology will be most effective, which relates to the aspect of content sequencing . This will depend on the course and curriculum content, as well as the intended learning outcomes (ILOs). In terms of assessment tools, these technologies can also be utilized for evaluation purposes . Particularly in formative assessment, they can offer learning opportunities coupled with feedback for the users [ 36 ].

When discussing all the elements of the Morrison et al. [ 55 ] model, it is equally important to consider instructional delivery , particularly in terms of the necessary resources and support. For instance, teacher training is crucial, as it can not be assumed that teachers are inherently capable of utilizing the technology. This pertains not only to the technological aspects of the application (how does it operate?), but also to the pedagogical aspects (how should it be implemented in class, and how should students be guided?). With the insights from this research and the recommendations based on the Morrison et al. [ 55 ] model, the understanding of new training and practice methods will enable practitioners to choose from a wider range of training options.

Limitations

This review has several limitations. Firstly, we exclusively examined studies that incorporated an intervention and utilized AR/VR/MR to teach knowledge or skills to the healthcare professions population. We ignored all theoretical papers. There might be more discussions in theoretical papers on the use of different educational models and theories. Future work might need to include all sorts of studies to cover a broader picture.

Secondly, we limited ourselves to publications between 2015 and 2020, assuming that this would be the timeline when AR/VR/MR gained more popularity in the health education domain.

Thirdly, our study did not thoroughly investigate the limitations and barriers associated with utilizing AR/VR/MR technologies for educational purposes.. When using these technologies in the classroom, it is necessary to acquire the required equipment and to be able to store it safely, both in terms of physical storage of devices as well as cloud storage of data. Batteries may need to be charged and the equipment must be kept clean. Updates may sometimes be required, and it is possible that these will happen at an inconvenient time (e.g., mid-session). Special requirements may be present for the software to run. For example, it might be necessary to make an account in order to be able to use the software, which must then be arranged while also taking into account data protection rules. The space in which instruction takes place should also be considered. For example, is it necessary that students can walk around? If so, this should also be facilitated. Finally, it is worthy of mentioning that none of the named limitations impairs the value of this work, in fact it provides opportunities to more research and further strengthening this topic.

Conclusion and recommendations for future research

The most important points that stand out when looking at the results of this review are general lack of instructional design theories or models guiding the use of these technologies for teaching and learning, and the abundant use of these tools for teaching courses like anatomy or for designing part-task practice routines in surgery, especially things like offering the possibility of scalability and repeated practice. For the lack of models and theories in course design with AR/VR/MR, we have tried looking at the instructional design model by Morrison et al. [ 55 ] and plotting our findings against this model to help guide further studies on how they can use an instructional design model in designing courses that include AR/VR/MR tools.

In general, when looking at the quality of the existing studies and applications including the educational benefits of these technologies, further studies need to be conducted to gain better insight into the added value of including these expensive and sophisticated tools into our education [ 31 ]. The most common rationales that were found in the included studies referred to overcoming some sort of limitation (lack of realism, high maintenance costs for real life props, time limitations, practicing high complex scenarios, providing safe/controlled setting for practice, cognitive load and, providing the possibility of repetitive training), enhancing students’ motivation or improving students’ observation and attentiveness beyond their normal capabilities.

Availability of data and materials

All relevant data are available in the form of appendices.

Abbreviations

Augmented Reality

Virtual Reality

Mixed Reality

Maastricht University

Public Medical Literature

Educational Research Information Center

Institute Electrical Engineers

Scientific Content on Public Access

Electronic Book Service Company

Research Question

Analysis Design Development Implementation Evaluation

Population, intervention, comparison, outcome, study design

Medical Literature Analysis and Retrieval System Online

Medical Journal

Randomized control trial

Magnetic Resonance Imaging

Abelson JS, Silverman E, Banfelder J, Naides A, Costa R, Dakin G. Virtual operating room for team training in surgery. The American Journal of Surgery. 2015;210(3):585–90. https://doi.org/10.1016/j.amjsurg.2015.01.024 .

Article   PubMed   Google Scholar  

Adams, A., & Cox, A. L. (2008). Questionnaires, in-depth interviews and focus groups (pp. 17–34). Cambridge University Press. http://oro.open.ac.uk/11909/

Akbulut, Y. Implications of two well-known models for instructional designers in distance education: Dick-Carey versus Morrison-Ross-Kemp. Turkish Online Journal of Distance Education. 2007;8(2), 62–68. https://doi.org/10.1.1.501.3625

Alismail, A., Thomas, J., Daher, N. S., Cohen, A., Almutairi, W., Terry, M. H.,  Tan, L. D. Augmented reality glasses improve adherence to evidence-based intubation practice. Adv Med Educ Pract. 2019;10, 279–286. https://doi.org/10.2147/AMEP.S201640

Anderson, L.W. (Ed.), Krathwohl, D. R. (Ed.), Airasian, P.W., Cruikshank, K.A., Mayer, R.E., Pintrich, P.R., Raths, J., & Wittrock, M.C. A taxonomy for learning, teaching, and assessing: A revision of Bloom's Taxonomy of Educational Objectives. Allyn & Bacon. 2001.  http://eduq.info/xmlui/handle/11515/18345

Andrews C, Southworth MK, Silva JN, Silva JR. Extended reality in medical practice. Curr Treat Options Cardiovasc Med. 2019;21:1–12.

Article   Google Scholar  

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.

Azarnoush, H., Alzhrani, G., Winkler-Schwartz, A., Alotaibi, F., Gelinas-Phaneuf, N., Pazos, V., ... & Del Maestro, R. F. Neurosurgical virtual reality simulation metrics to assess psychomotor skills during brain tumor resection. International journal of computer assisted radiology and surgery. 2015;10(5)603–618. https://doi.org/10.1007/s11548-014-1091-z

Barsom EZ, Graafland M, Schijven MP. Systematic review on the effectiveness of augmented reality applications in medical training. Surg Endosc. 2016;30(10):4174–83. https://doi.org/10.1007/s00464-016-4800-6 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Barteit S, Lanfermann L, Bärnighausen T, Neuhann F, Beiersmann C. Augmented, mixed, and virtual reality-based head-mounted devices for medical education: systematic review. JMIR serious games. 2021;9(3): e29080.

Article   PubMed   PubMed Central   Google Scholar  

Biggs J, Tang C. Teaching for Quality Learning at University: What the Student Does. 4th ed. McGraw-Hill Education; 2011.

Bourdel N, Collins T, Pizarro D, Bartoli A, Da Ines D, Perreira B, Canis M. Augmented reality in gynecologic surgery: evaluation of potential benefits for myomectomy in an experimental uterine model. Surg Endosc. 2017;31(1):456–61. https://doi.org/10.1007/s00464-016-4932-8 .

Carmigniani J, Furht B, Anisetti M, Ceravolo P, Damiani E, Ivkovic M. Augmented reality technologies, systems and applications. Multimedia Tools and Applications. 2011;51(1):341–77. https://doi.org/10.1007/s11042-010-0660-6 .

Chalhoub M, Khazzaka A, Sarkis R, Sleiman Z. The role of smartphone game applications in improving laparoscopic skills. Adv Med Educ Pract. 2018;9:541. https://doi.org/10.2147/AMEP.S162619 .

Chheang V, Fischer V, Buggenhagen H, Huber T, Huettl F, Kneist W, Hansen C. Toward interprofessional team training for surgeons and anesthesiologists using virtual reality. Int J Comput Assist Radiol Surg. 2020;15(12):2109–18. https://doi.org/10.1007/s11548-020-02276-y .

Chowriappa, A., Raza, S. J., Fazili, A., Field, E., Malito, C., Samarasekera, D.,  Eun, D. D. Augmented‐reality‐based skills training for robot‐assisted urethrovesical anastomosis: a multi‐institutional randomised controlled trial. BJU international. 2015;115(2)336–345. https://doi.org/10.1111/bju.12704

Courteille, O., Fahlstedt, M., Ho, J., Hedman, L., Fors, U., Von Holst, H., Möller, H.  Learning through a virtual patient vs. recorded lecture: a comparison of knowledge retention in a trauma case. International journal of medical education. 2018;9:86. https://doi.org/10.5116/ijme.5aa3.ccf2

Creswell, J. W., & Creswell, J. D. Research design: Qualitative, quantitative, and mixed methods approaches. Sage publications. 2017.  http://e-pedagogium.upol.cz/pdfs/epd/2016/04/08.pdf

Datta R, Upadhyay KK, Jaideep CN. Simulation and its role in medical education. Medical Journal Armed Forces India. 2012;68(2):167–72.

Delany C, Watkin D. A study of critical reflection in health professional education: ‘learning where others are coming from.’ Adv Health Sci Educ. 2009;14(3):411–29. https://doi.org/10.1007/s10459-008-9128-0 .

Dharmawardana, N., Ruthenbeck, G., Woods, C., Elmiyeh, B., Diment, L., Ooi, E. H., ... & Carney, A. S. Validation of virtual‐reality‐based simulations for endoscopic sinus surgery. Clinical Otolaryngology. 2015;40(6):569–579. https://doi.org/10.1111/coa.12414

Diment LE, Ruthenbeck GS, Dharmawardana N, Carney AS, Woods CM, Ooi EH, Reynolds KJ. Comparing surgical experience with performance on a sinus surgery simulator. ANZ J Surg. 2016;86(12):990–5. https://doi.org/10.1111/ans.13418 .

Donlan P. Developing affective domain learning in health professions education. J Allied Health. 2018;47(4):289–95.

PubMed   Google Scholar  

Dorozhkin, D., Nemani, A., Roberts, K., Ahn, W., Halic, T., Dargar, S., . De, S. Face and content validation of a Virtual Translumenal Endoscopic Surgery Trainer (VTEST™). Surgical endoscopy. 2016;30(12):5529–5536. https://doi.org/10.1007/s00464-016-4917-7

Dyer E, Swartzlander BJ, Gugliucci MR. Using virtual reality in medical education to teach empathy. Journal of the Medical Library Association: JMLA. 2018;106(4):498.

Emmelkamp PM, Meyerbröker K. Virtual reality therapy in mental health. Annu Rev Clin Psychol. 2021;17:495–519.

Ferrer-Torregrosa J, Jiménez-Rodríguez MÁ, Torralba-Estelles J, Garzón-Farinós F, Pérez-Bermejo M, Fernández-Ehrling N. Distance learning ects and flipped classroom in the anatomy learning: comparative study of the use of augmented reality, video and notes. BMC Med Educ. 2016;16(1):230. https://doi.org/10.1186/s12909-016-0757-3 .

Fischer, M., Fuerst, B., Lee, S. C., Fotouhi, J., Habert, S., Weidert, S., Navab, N. Preclinical usability study of multiple augmented reality concepts for K-wire placement. International journal of computer assisted radiology and surgery. 2016;11(6)1007–1014. https://doi.org/10.1007/s11548-016-1363-x

Freschi C, Parrini S, Dinelli N, Ferrari M, Ferrari V. Hybrid simulation using mixed reality for interventional ultrasound imaging training. Int J Comput Assist Radiol Surg. 2015;10(7):1109–15. https://doi.org/10.1007/s11548-014-1113-x .

Article   CAS   PubMed   Google Scholar  

Fucentese SF, Rahm S, Wieser K, Spillmann J, Harders M, Koch PP. Evaluation of a virtual-reality-based simulator using passive haptic feedback for knee arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2015;23(4):1077–85. https://doi.org/10.1007/s00167-014-2888-6 .

Gerup J, Soerensen CB, Dieckmann P. Augmented reality and mixed reality for healthcare education beyond surgery: an integrative review. Int J Med Educ. 2020;11:1.

Göksu I, Özcan KV, Cakir R, Göktas Y. Content analysis of research trends in instructional design models: 1999–2014. J Learn Des. 2017;10(2):85–109.

Google Scholar  

Gomez PP, Willis RE, Van Sickle KR. Development of a virtual reality robotic surgical curriculum using the da Vinci Si surgical system. Surg Endosc. 2015;29(8):2171–9. https://doi.org/10.1007/s00464-014-3914-y .

Graafland M, Schraagen JMC, Schijven MP. Systematic review of validity of serious games for medical education and surgical skills training. Br J Surg. 2012;99(10):1322–30. https://doi.org/10.1002/bjs.8819 .

Grover, S. C., Garg, A., Scaffidi, M. A., Jeffrey, J. Y., Plener, I. S., Yong, E., Walsh, C. M. Impact of a simulation training curriculum on technical and nontechnical skills in colonoscopy: a randomized trial. Gastrointestinal endoscopy. 2015;82(6);1072–1079. https://doi.org/10.1016/j.gie.2015.04.008

Heeneman S, et al. The Impact of Programmatic Assessment on Student Learning: Theory Versus Practice. Med Educ. 2015;49(5):487–98. https://doi.org/10.1111/medu.12645 .

Holloway, T., Lorsch, Z. S., Chary, M. A., Sobotka, S., Moore, M. M., Costa, A. B., ... & Bederson, J. Operator experience determines performance in a simulated computer-based brain tumor resection task. International journal of computer assisted radiology and surgery. 2015;10(11):1853–1862. https://doi.org/10.1007/s11548-015-1160-y

Honebein, P. C., & Reigeluth, C. M. (2021). Making good design judgments via the instructional theory framework. Design for Learning . Edtechbooks. https://open.byu.edu/id/making_good_design?book_nav=true

Hu A, Shewokis PA, Ting K, Fung K. Motivation in computer-assisted instruction. Laryngoscope. 2016;126:S5–13. https://doi.org/10.1002/lary.26040 .

Huang, C. Y., Thomas, J. B., Alismail, A., Cohen, A., Almutairi, W., Daher, N. S., ... & Tan, L. D. The use of augmented reality glasses in central line simulation:“see one, simulate many, do one competently, and teach everyone”. Advances in medical education and practice. 2018;9:357. https://doi.org/10.2147/AMEP.S160704

Huber T, Paschold M, Hansen C, Wunderling T, Lang H, Kneist W. New dimensions in surgical training: immersive virtual reality laparoscopic simulation exhilarates surgical staff. Surg Endosc. 2017;31(11):4472–7. https://doi.org/10.1007/s00464-017-5500-6 .

Hudson K, Taylor LA, Kozachik SL, Shaefer SJ, Wilson ML. Second Life simulation as a strategy to enhance decision-making in diabetes care: a case study. J Clin Nurs. 2015;24(5–6):797–804. https://doi.org/10.1111/jocn.12709 .

Korzeniowski P, White RJ, Bello F. VCSim3: a VR simulator for cardiovascular interventions. Int J Comput Assist Radiol Surg. 2018;13(1):135–49. https://doi.org/10.1007/s11548-017-1679-1 .

Küçük S, Kapakin S, Göktaş Y. Learning anatomy via mobile augmented reality: effects on achievement and cognitive load. Anat Sci Educ. 2016;9(5):411–21. https://doi.org/10.1002/ase.1603 .

Kyaw, B. M., Saxena, N., Posadzki, P., Vseteckova, J., Nikolaou, C. K., George, PP, .Car, L. T. Virtual reality for health professions education: systematic review and meta-analysis by the digital health education collaboration. Journal of medical Internet research. 2019;21(1):e12959.

Levac D, Espy D, Fox E, Pradhan S, Deutsch JE. “Kinect-ing” with clinicians: A knowledge translation resource to support decision making about video game use in rehabilitation. Phys Ther. 2015;95(3):426–40. https://doi.org/10.2522/ptj.20130618 .

Liaw SY, Soh SL, Tan KK, Wu LT, Yap J, Chow YL, Wong LF. Design and evaluation of a 3D virtual environment for collaborative learning in interprofessional team care delivery. Nurse Educ Today. 2019;81:64–71. https://doi.org/10.1016/j.nedt.2019.06.012 .

Lin, D., Pena, G., Field, J., Altree, M., Marlow, N., Babidge, W., ... & Maddern, G. What are the demographic predictors in laparoscopic simulator performance?. ANZ journal of surgery. 2016;86(12):983–989. https://doi.org/10.1111/ans.12992

Llena C, Folguera S, Forner L, Rodríguez-Lozano FJ. Implementation of augmented reality in operative dentistry learning. Eur J Dent Educ. 2018;22(1):122–30. https://doi.org/10.1111/eje.12269 .

Ma M, Fallavollita P, Seelbach I, Von Der Heide AM, Euler E, Waschke J, Navab N. Personalized augmented reality for anatomy education. Clin Anat. 2016;29(4):446–53. https://doi.org/10.1002/ca.22675 .

Mathews, S., Brodman, M., D'Angelo, D., Chudnoff, S., McGovern, P., Kolev, T., ... & Kischak, P. Predictors of laparoscopic simulation performance among practicing obstetrician gynecologists. American journal of obstetrics and gynecology. 2017;217(5)596-e1. https://doi.org/10.1016/j.ajog.2017.07.002

Mathiowetz V, Yu CH, Quake-Rapp C. Comparison of a gross anatomy laboratory to online anatomy software for teaching anatomy. Anat Sci Educ. 2016;9(1):52–9. https://doi.org/10.1002/ase.1528 .

Medellín-Castillo HI, Govea-Valladares EH, Pérez-Guerrero CN, Gil-Valladares J, Lim T, Ritchie JM. The evaluation of a novel haptic-enabled virtual reality approach for computer-aided cephalometry. Comput Methods Programs Biomed. 2016;130:46–53. https://doi.org/10.1016/j.cmpb.2016.03.014 .

Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res. 2014;14(1):1–10.

Morrison GR, Ross SM, Kemp JE, Kalman H. Designing effective instruction. 6th ed. New York: John Wiley & Sons; 2010.

Nayar, S. K., Musto, L., Fernandes, R., & Bharathan, R. (2018). Validation of a virtual reality laparoscopic appendicectomy simulator: a novel process using cognitive task analysis. Irish Journal of Medical Science (1971-). 2019:1–9. https://doi.org/10.1007/s11845-018-1931-x

Nickel F, Hendrie JD, Bruckner T, Kowalewski KF, Kenngott HG, Müller-Stich BP, Fischer L. Successful learning of surgical liver anatomy in a computer-based teaching module. Int J Comput Assist Radiol Surg. 2016;11(12):2295–301. https://doi.org/10.1007/s11548-016-1354-y .

Obizoba C. Instructional Design Models—Framework for Innovative Teaching and Learning Methodologies. Int J High Educ Manag. 2015;2(1):40–51. https://doi.org/10.24052/IJHEM/2015/v2/i1/3 .

Pan, X., Slater, M., Beacco, A., Navarro, X., Rivas, A. I. B., Swapp, D., ... & Delacroix, S. The responses of medical general practitioners to unreasonable patient demand for antibiotics-a study of medical ethics using immersive virtual reality. PloS one. 2019;11(2)e0146837. https://doi.org/10.1371/journal.pone.0146837

Perin, A., Galbiati, T. F., Gambatesa, E., Ayadi, R., Orena, E. F., Cuomo, V., … Group, E. N. S. S. Filling the gap between the OR and virtual simulation: a European study on a basic neurosurgical procedure. Acta Neurochir. 2018;160(11):2087–97. https://doi.org/10.1007/s00701-018-3676-8 .

Peterson DC, Mlynarczyk GS. Analysis of traditional versus three-dimensional augmented curriculum on anatomical learning outcome measures. Anat Sci Educ. 2016;9(6):529–36. https://doi.org/10.1002/ase.1612 .

Pottle J. Virtual reality and the transformation of medical education. Future Healthcare Journal. 2019;6(3):181. https://doi.org/10.7861/fhj.2019-0036 .

Rahm S, Germann M, Hingsammer A, Wieser K, Gerber C. Validation of a virtual reality-based simulator for shoulder arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2016;24(5):1730–7. https://doi.org/10.1007/s00167-016-4022-4 .

Rasmussen SR, Konge L, Mikkelsen PT, Sørensen MS, Andersen SA. Notes from the field: Secondary task precision for cognitive load estimation during virtual reality surgical simulation training. Eval Health Prof. 2016;39(1):114–20. https://doi.org/10.1177/0163278715597962 .

Reigeluth CM. Instructional design theories and models: An overview of their current status. Routledge. 1983. https://doi.org/10.4324/9780203824283 .

Reigeluth, C. M., & Carr-Chellman, A. A. (Eds.). Instructional-design theories and models, volume III: Building a common knowledge base 2009, (Vol. 3). Routledge.

Sampogna G, Pugliese R, Elli M, Vanzulli A, Forgione A. Routine clinical application of virtual reality in abdominal surgery. Minim Invasive Ther Allied Technol. 2017;26(3):135–43. https://doi.org/10.1080/13645706.2016.1275016 .

Siebert, J. N., Ehrler, F., Gervaix, A., Haddad, K., Lacroix, L., Schrurs, P., ... & Manzano, S. Adherence to AHA guidelines when adapted for augmented reality glasses for assisted pediatric cardiopulmonary resuscitation: A randomized controlled trial. Journal of medical Internet research. 2017;19(5), e183. https://doi.org/10.2196/jmir.7379

Stepan, K., Zeiger, J., Hanchuk, S., Del Signore, A., Shrivastava, R., Govindaraj, S., & Iloreta, A. (2017, October). Immersive virtual reality as a teaching tool for neuroanatomy. In International forum of allergy & rhinology (Vol. 7, No. 10, pp. 1006–1013). https://doi.org/10.1002/alr.21986

Telang A. Problem-based learning in health professions education: an overview. Arch Med Health Sci. 2014;2(2):243.

Thibault GE. The future of health professions education: Emerging trends in the United States. FASEB BioAdvances. 2020;2(12):685–94. https://doi.org/10.1096/fba.2020-00061 .

Tran C, Toth-Pal E, Ekblad S, Fors U, Salminen H. A virtual patient model for students’ interprofessional learning in primary healthcare. PLoS ONE. 2020;15(9): e0238797. https://doi.org/10.1371/journal.pone.0238797 .

Valdis M, Chu MW, Schlachta C, Kiaii B. Evaluation of robotic cardiac surgery simulation training: a randomized controlled trial. J Thorac Cardiovasc Surg. 2016;151(6):1498–505. https://doi.org/10.1016/j.jtcvs.2016.02.016 .

Våpenstad, C., Hofstad, E. F., Bø, L. E., Kuhry, E., Johnsen, G., Mårvik, R., ... & Hernes, T. N. Lack of transfer of skills after virtual reality simulator training with haptic feedback. Minimally Invasive Therapy & Allied Technologies. 2017;26(6):346–354. https://doi.org/10.1080/13645706.2017.1319866

Vera J, Diaz-Piedra C, Jimenez R, Sanchez-Carrion JM, Di Stasi LL. Intraocular pressure increases after complex simulated surgical procedures in residents: an experimental study. Surg Endosc. 2019;33(1):216–24. https://doi.org/10.1007/s00464-018-6297-7 .

Wang, S., Parsons, M., Stone-McLean, J., Rogers, P., Boyd, S., Hoover, K., ... & Smith, A. Augmented reality as a telemedicine platform for remote procedural training. Sensors. 2017;17(10):2294. https://doi.org/10.3390/s17102294

Download references

Acknowledgements

Special thanks to Sanne Rovers for contributing in some meetings for brainstorming ideas.

There was no funding allocated to this research.

Author information

Authors and affiliations.

School of Health Professions Education, Department of Educational Development and Research, Faculty of Health, Medicine and Life sciences, Maastricht University, Universiteitssingel 60, Maastricht, 6229 MD, The Netherlands

Maryam Asoodar, Fatemeh Janesarvatan, Hao Yu & Nynke de Jong

Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

Nynke de Jong

School of Business and Economics, Educational Research and Development Maastricht University, Maastricht, The Netherlands

Fatemeh Janesarvatan

You can also search for this author in PubMed   Google Scholar

Contributions

MA took the lead in sketching the outline for this research through several meetings with NdJ. MA, NdJ, HY, and FJ contributed in analyzing the papers and narrowing down the search. MA and FJ wrote the paper. MA and HY designed the figures and the tables.

Corresponding author

Correspondence to Maryam Asoodar .

Ethics declarations

Ethics approval and consent to participate.

This is a literature review. We had no participants in this paper.

Consent for publication

This is a literature review. There were no participants.

Competing interests

No conflict of interest.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Asoodar, M., Janesarvatan, F., Yu, H. et al. Theoretical foundations and implications of augmented reality, virtual reality, and mixed reality for immersive learning in health professions education. Adv Simul 9 , 36 (2024). https://doi.org/10.1186/s41077-024-00311-5

Download citation

Received : 07 September 2023

Accepted : 29 August 2024

Published : 09 September 2024

DOI : https://doi.org/10.1186/s41077-024-00311-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Immersive learning
• Instructional design models or theories
• Health professions education

Advances in Simulation

ISSN: 2059-0628

• General enquiries: [email protected]

A Bibliometric Analysis of Virtual Reality Research on Critical Thinking Skills and Student Responses using PLS-SEM

New citation alert added.

This alert has been successfully added and will be sent to:

You will be notified whenever a record that you have chosen has been cited.

To manage your alert preferences, click on the button below.

New Citation Alert!

Please log in to your account

Information & Contributors

Bibliometrics & citations, index terms.

Applied computing

Interactive learning environments

Recommendations

Personal space in virtual reality.

Improving the sense of “presence” is a common goal of three-dimensional (3D) display technology for film, television, and virtual reality. However, there are instances in which 3D presentations may elicit unanticipated negative responses. For example, ...

Bibliometric analysis of bioeconomy research in South Africa

This document provides an analysis of bioeconomy research in South Africa and it discusses sources of growth in the country’s bioeconomy literature in general. We performed bibliometric analysis as indexed in the Web of Science (WoS) for number of ...

Extending Virtual Reality Display Wall Environments Using Augmented Reality

Two major form factors for virtual reality are head-mounted displays and large display environments such as CAVE®and the LCD-based successor CAVE2®. Each of these has distinct advantages and limitations based on how they’re used. This work explores ...

Information

Published in.

Association for Computing Machinery

New York, NY, United States

Publication History

Permissions, check for updates, author tags.

• Bibliometric
• Critical Thinkings Skills
• Student Response’
• and Virtual Reality
• Research-article
• Refereed limited

Funding Sources

• DAPT-EQUITY Program, Indonesia Endowment Fund for Education, Ministry of Finance, the Republic of Indonesia

Contributors

Other metrics, bibliometrics, article metrics.

• 0 Total Citations
• 0 Total Downloads
• Downloads (Last 12 months) 0
• Downloads (Last 6 weeks) 0

View Options

Login options.

Check if you have access through your login credentials or your institution to get full access on this article.

Full Access

View options.

View or Download as a PDF file.

View online with eReader .

HTML Format

View this article in HTML Format.

Share this Publication link

Copying failed.

Share on social media

Affiliations, export citations.

• Please download or close your previous search result export first before starting a new bulk export. Preview is not available. By clicking download, a status dialog will open to start the export process. The process may take a few minutes but once it finishes a file will be downloadable from your browser. You may continue to browse the DL while the export process is in progress. Download
• Download citation
• Copy citation

We are preparing your search results for download ...

We will inform you here when the file is ready.

Your file of search results citations is now ready.

Your search export query has expired. Please try again.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Perception and control of a virtual body in immersive virtual reality for rehabilitation

Affiliations.

• 1 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS).
• 2 Institució Catalana de Investigación y Estudios Avanzados (ICREA), Passeig de Lluís Companys, Barcelona, Spain.
• PMID: 39253749
• DOI: 10.1097/WCO.0000000000001321

Purpose of review: This review explores recent advances in using immersive virtual reality to improve bodily perception and motor control in rehabilitation across musculoskeletal and neurological conditions, examining how virtual reality's unique capabilities can address the challenges of traditional approaches. The potential in this area of the emerging metaverse and the integration of artificial intelligence in virtual reality are discussed.

Recent findings: In musculoskeletal rehabilitation, virtual reality shows promise in enhancing motivation, adherence, improving range of motion, and reducing kinesiophobia, particularly postsurgery. For neurological conditions like stroke and spinal cord injury, virtual reality's ability to manipulate bodily perceptions offers significant therapeutic potential, with reported improvements in upper limb function and gait performance. Balance and gait rehabilitation, especially in older adults, have also seen positive outcomes. The integration of virtual reality with brain-computer interfaces presents exciting possibilities for severe speech and motor impairments.

Summary: Current research is limited by small sample sizes, short intervention durations, and variability in virtual reality systems. Future studies should focus on larger, long-term trials to confirm findings and explore underlying mechanisms. As virtual reality technology advances, its integration into rehabilitation programs could revolutionize treatment approaches, personalizing treatments, facilitating home training, and potentially improving patient outcomes across a wide variety of conditions.

Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.

PubMed Disclaimer

• Lephart SM, Henry TJ. Functional rehabilitation for the upper and lower extremity. Orthop Clin North Am 1995; 26:579–592.
• Röijezon U, Clark NC, Treleaven J. Proprioception in musculoskeletal rehabilitation. Part 1: Basic science and principles of assessment and clinical interventions. Man Ther 2015; 20:368–377.
• Gallagher S, Cole J. Body schema and body image in a deafferented subject. J Mind Behav 1995; 16:369–390.
• Kessner SS, Bingel U, Thomalla G. Somatosensory deficits after stroke: a scoping review. Top Stroke Rehabil 2016; 23:136–146.
• Slater M, Sanchez-Vives MV. From presence to consciousness through virtual reality. Nat Rev Neurosci 2005; 6:332–339.

LinkOut - more resources

Full text sources.

• Wolters Kluwer

Research Materials

• NCI CPTC Antibody Characterization Program

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.