"Put your glasses on and dive into another world" - Virtual Reality (VR) is often advertised in this or a similar way. And especially the therapeutic benefit and use arouses the interest of science and research - especially in combination with neurofeedback. Recently, a sensational case study was published. According to this study, a patient suffering from chronic pain showed a 40% improvement in her symptoms after only 20 sessions with ILF VR neurofeedback. More details and why VR can also be so interesting for neurofeedback are covered in this article.
What does “Virtual Reality” even mean?
Virtual reality usually refers to computer-generated environments. What makes them so special is their interactivity. The user can navigate through the virtual world with the movements he or she makes in the real world. Virtual reality is created through VR glasses with an integrated screen. Unlike 3D glasses, which only allow certain animations to be perceived more vividly through special filters, VR glasses allow the user to "enter" a virtual world that opens up right before his or her eyes and with which he or she can interact.
If you lift your head, for example, the image section changes, just as it would in the real world. With additional controllers and sensors that detect movements and transfer them to the virtual environment, it is also possible to walk through the virtual world, climb stairs and even solve more complex tasks. VR is therefore often compared to a video game, except that you are not sitting in front of a screen and controlling a character via controllers, rather you ARE this character. Application areas for VR therefore open up in all areas that concern the simulation of experiences in protected spaces. For example, VR is already used for flight simulation training for pilots, for visualizations in medicine or for virtual training. Therapeutic use is also the subject of numerous studies, mostly under the term "virtual rehabilitation".
Feedback animations in Neurofeedback - more than just video games
Feedback animations play a central role in neurofeedback. They visualize what is to be reflected back to the brain.
The first neurofeedback animations were very simple. Mostly they were bars that changed their height depending on the EEG frequency. And even today - more than 30 years later - very simple animations are still common in some procedures, where for example objects simply move up and down.
However, the technical possibilities are far greater. Feedback games such as InnerTube© or Tropical Heat© make it possible to experience animations similar to a video game. With ILF neurofeedback, up to 14 parameters are sometimes hidden in an animation - from color nuances that change subtly to the speed and movement of objects in the foreground and background to the brightness. In addition, the Cygnet neurofeedback software offers a particularly wide range of different animations, which allows an individual adaptation to the patient. This promotes motivation and anticipation of the neurofeedback sessions, the therapy is diverse and, last but not least, patients can actively participate in therapy decisions.
But not only the optics of the games and their graphic implementation have changed. Neurofeedback with images and sound has become established over time. By adding tactile feedback, for example the Brummi©, which passes on vibrations, the three senses of sight, hearing and touch, are already included in feedback processing. VR now goes beyond this and enables three-dimensional feedback.
VR in Neurofeedback research
Already at the beginning of the 2000s, first studies showed that three-dimensional neurofeedback animations can lead to an improved therapy result and also to a higher patient motivation. The following thesis applies: the more modalities are addressed by the feedback animation, the more effective the neurofeedback intervention can be (Othmer & Kaiser, 2000).
Thus, the type of feedback has an impact on the quality and outcomes of therapy. For example, studies have also shown that feedback animations in the form of a video game lead to more effective outcomes than audio-visual content alone (Hafeez et al., 2019). Studies using VR neurofeedback indicate greater learning success as well as greater success in improving inattention and impulsivity than two-dimensional neurofeedback procedures (Berger & Davelaar, 2018; Cho et al., 2004). Not only attention, but also relaxation was successfully trained with VR neurofeedback (Gu & Frasson, 2017).
VR neurofeedback can therefore increase patients' motivation, interest, and also their sense of control during therapy. Of course, this is only possible if patients have a confident and open-minded attitude towards this technology (Kober et al., 2016).
The use of virtual reality in a therapeutic setting can therefore be helpful, especially to facilitate the transfer of learned skills from the therapeutic situation to everyday life (Blume et al., 2017; Hudak et al., 2017). While this is not the focus of neurofeedback, as self-regulatory skills training strengthens personal resources across situations, it can be beneficial for patients' self-efficacy to try out acquired skills in virtual realities accompanied by therapy. This is especially true for patients with anxiety disorders and phobias. Here, for example, a step-by-step approach with the fear-inducing stimulus can take place in virtual reality; or also in post-traumatic stress disorders. It can also be useful for ADHD, for example, to be able to work specifically with situations from the problematic learning environment in therapy.
ILF VR Neurofeedback for chronic pain
A recently published case study in which a 55 year old female patient with chronic pain was treated with VR ILF neurofeedback is currently receiving special attention. After 20 sessions of ILF VR neurofeedback, she reported a 40% improvement in her pain. The patient's rating of subjective pain decreased even further over time during therapy and in follow-up surveys. One year after completion of therapy, the patient reported an 80% improvement in pain perception. Similarly, she reported improvements in general well-being and coping with activities of daily living. In addition, symptoms of depression and anxiety as well as sleep quality improved (Orakpo, Vieux & Castro-Nuñez, 2021) .
VR in Neurofeedback Practice
VR ILF neurofeedback is a very promising approach. Depending on the individual aspects of the patient, preferences, needs and of course therapy goals and symptom elevation, it can be a very interesting additional option for patients.
Many people still associate VR goggles as something that is only suitable for technical enthusiasts. But the application is simple. And with our neurofeedback systems one can easily get started with this exciting technology. The Cygnet Neurofeedback Software already has a VR module with great animations for VR. And also the use in exposure therapy or the transfer of learning into everyday life, where especially the combination with neurofeedback opens up opportunities, is spreading more and more.
Berger, A.M. & Davelaar, E.J. (2018). Frontal alpha oscillations and attentional control: A virtual reality neurofeedback study. Neuroscience,378, 189–197.
Blume, F., Hudak, J., Dresler, T., Ehlis, A.-C., Kühnhausen, J., Renner T. & Gawrilow C. (2017). NIRS-based neurofeedback training in a virtual reality classroom for children with attention-deficit/hyperactivity disorder: Study protocol for a randomized controlled trial. Trials,18 (1), 41.
Cho, B. H., Kim, S., Shin, D. I., Lee, J. H., Min Lee, S., Young Kim, I., & Kim, S. I. (2004). Neurofeedback training with virtual reality for inattention and impulsiveness. Cyberpsychology & Behavior, 7(5), 519-526.
Gu, G. & Frausson, C. (2017). Virtual sophrologist: a virtual reality neurofeedback relaxation training system. In International Conference on Brain Function Assessment in Learning (pp. 176-185). Springer.
Hafeez, Y., Ali, S. S. A., Mumtaz, W., Moinuddin, M., Adil, S. H., Al-Saggaf, U. M., ... & Malik, A. S. (2019). Investigating Neurofeedback Protocols for Stress Mitigation: A Comparative Analysis of Different Stimulus Contents. IEEE Access, 7, 141021-141035.
Kober, S. E., Reichert, J. L., Schweiger, D., Neuper, C., & Wood, G. (2016). Effects of a 3D virtual reality neurofeedback scenario on user experience and performance in stroke patients. In International Conference on Games and Learning Alliance (pp. 83-94). Springer.
Hudak, J., Blume, F., Dresler, T., Haeussinger, F. B., Renner, T. J., Fallgatter, A. J.,... & Ehlis, A. C. (2017). Near-infrared spectroscopy-based frontal lobe neurofeedback integrated in virtual reality modulates brain and behavior in highly impulsive adults. Frontiers in human neuroscience, 11, 425.
Orakpo, N., Vieux, U. & Castro-Nuñez, C. (2021). Case Report : Virtual Reality Neurofeedback Therapy as a Novel Modality for Sustained Analgesia in Centralized Pain Syndromes. Frontiers in Psychiatry, 12, 3-7.
Othmer, S. & Kaiser, D. (2000). Implementation of Virtual Reality in EEG Biofeedback. Cyberpsychology and Behaviour, 3 (3), 415-420.