Thoughts on Side Effects of Virtual Reality Therapy,
I have decided to share some of my thoughts on immersive therapy and related topics. In the literature, VR side effects go by a few names, including sim sickness and cybersickness.
( Disclaimer: I am not providing clinical advice for using VR therapy programs or managing VR side effects. Please talk with your doctor about VR therapy programs and any side effects you might be having related to it. Below I am just providing my opinion on some topics related to VR side effects.)
I have worked on two manuscripts that relate to this topic. The first discussed the importance of incorporating the reporting of VR side effects into various stages of clinical study. The second was with a team that reviewed several content specific factors and individual related factors for VR side effects. I’m not going to talk about those today, but if you have an interest in VR clinical trials and factors related to VR side effects, I highly recommend checking them out.
How often do VR side effects happen?
If you find a paper with the overall frequency in a large patient population send it my way. There is a large range in the frequency of VR side effects in non-medical publications, but the software made for clinical settings can be quite different than what has been tested in other areas. Many of the previous randomized clinical trials for VR pain reduction excluded patients with history of motion sickness and had rates lower than 5% of patients. The last RCT from our lab had none. When studies remove that exclusion, the incidence goes up. I don’t have a published RCT but here is a pilot study (VR1). It is not a bad thing for studies to remove this exclusion. Based on my experience dealing with these symptoms it is quite manageable.
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When does it happen?
VR side effects most often happen in the first session. A new symptom after several uses is rare, as long as they aren’t using the device for longer than recommended. In some cases, the symptoms start soon after they put on the headset and in others, they build up over the course of an 8–20 minute session. Most clinical VR programs for pain reduction are under 20 minutes and likely a good limit for a first-time patient. Once they take the headset off, symptoms most often resolve in a matter of minutes, unless again they use the device for longer than recommended. I haven’t yet had a patient that needed medication to treat VR side effects.
This rapid presentation allows providers to assess if a patient is a good candidate in the first session. Usually, I ask about symptoms in the first minute, then several minutes into it. After about 10 minutes, symptoms would likely have started. Even if a symptom comes up I’ve tested it out a few more times with short sessions as some patients can be desensitized. With that said, if the patient became rapidly uncomfortable after putting on the headset and doesn’t want to try it again, it is best to seek an alternative treatment.
Issues with VR side effect surveys
The main validated assessment is called the simulator sickness questionnaire (SSQ) and it’s not optimal for at-home VR clinical trials. With this new wave of decentralized therapy, we need a survey that has a longer recall period after the session with fewer questions. Also, the survey has a few symptoms that are outdated. I’ve used VR on close to 700 patients and I’ve yet to see a single patient come out of the headset burping. The SSQ was made with old flight simulators that might have made even an E-sport player nauseous. Attempts have been made to make the SSQ more relevant to modern VR (e.g. Virtual Reality Sickness Questionnaire (VRSQ)) but most are not widely used yet.
For our next at-home VR therapy clinical trial, we are collecting adverse events using a general questionnaire and the SSQ to quantify the impact VR side effects had in the first experience. We are also asking patients if they have a propensity for motion sickness as they can have a large impact on VR side effects. At the end of the study, we will have some additional evidence regarding VR side effects, including:
· When motion sickness is not excluded, how often do VR side effects happen?
· Which of the 16 symptoms in SSQ will actually be present in those with VR side effects?
· Are there any symptoms after using VR for 12 weeks? If not, how long should we be assessing for symptoms?
· We will also explore how motion sickness and SSQ scores affect the primary outcome of pain interference.
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Thoughts on Side Effects of Virtual Reality Therapy was originally published in AR/VR Journey: Augmented & Virtual Reality Magazine on Medium, where people are continuing the conversation by highlighting and responding to this story.
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Author: Brandon Birckhead MD