Background: Suicide is a leading cause of preventable death worldwide. Nurses play a critical role in suicide prevention; yet, they face significant obstacles. Improving the evaluation and management of patients at risk of suicide requires innovative training techniques that safely and effectively enhance nursing students' skills, knowledge, and confidence. Virtual simulation (VS) based training can be particularly effective because it allows interaction with patients without the risk of causing harm.
Objective: The purpose of this study was to evaluate the pedagogical effectiveness of a novel VS tool featuring a fully automated and emotionally reactive virtual patient by assessing its ability to assist nursing students in learning suicide risk assessment. VS also included an online group debriefing, co-run by a nurse and a medical teacher.
Methods: A randomized controlled investigation was conducted with 68 first-year nursing students recruited from nursing schools offline and online. They were divided into a control group receiving teaching as usual (TAU) and an intervention group receiving TAU plus VS. The intervention was purely web-based and unblinded. Outcomes were self-assessed through questionnaires using Kirkpatrick Training Evaluation Model, which focuses on knowledge, skills, confidence, empathy, and satisfaction among students.
Results: The VS group exhibited significantly higher confidence (3 points of increase after TAU vs 10.6 points of increase after VS, B=7.2; SE 2.5; t111.5=2.8; P=.006) and a marginally enhanced ability to respond appropriately to suicidal thoughts (1.6 points of improvement after TAU vs 6.4 points of improvement after VS, B=-4.5; SE 2.5; t119.5=-1.8; P=.08) compared with the control group. However, there were no significant differences in knowledge acquisition or the general level of empathy. Satisfaction with VS was high, particularly regarding the authenticity of the virtual patient. Authenticity was perceived as greater when emotional prosody was included with facial emotions.
Conclusions: The use of VS demonstrated promising results in enhancing nursing students' confidence in detecting suicide risk and their skills in counseling individuals experiencing a suicide crisis, suggesting its incorporation into routine teaching methods. Further research is needed to explore its long-term benefits for students and its impact on patient outcomes.
Background: Specific learning disorder in reading (SLD reading), commonly named dyslexia, is a neurodevelopmental condition affecting reading. Current best practice recommendations for SLD reading emphasize the necessity of including graphophonological interventions. The serious game Mila-Learn, which is based on rhythm training, showed promising results in a prior randomized trial. However, it lacked a component of graphophonological training.
Objective: This study aimed to evaluate the effectiveness of Poppins, a new digital medical device that combines rhythm-based and graphophonological training for improving reading and phonological skills in children with SLD reading. We also explored its performance against Mila-Learn, the earlier version based on rhythm training only.
Methods: A single-arm study without an active control group was conducted with 38 children (aged 7-11 years) diagnosed with SLD reading. The participants completed an 8-week training program with Poppins (five 20-minute sessions per week). Pre- and posttraining assessments measured reading accuracy and speed, phoneme deletion, and phonological discrimination. Statistical analysis included pre- and postcomparisons (primary analysis) and comparisons with children's improvement from a previous randomized controlled trial of Mila-Learn, an earlier version of the device (exploratory analysis).
Results: The participants demonstrated significant improvements in reading accuracy (+11.46 words correctly read; P<.001), reading speed (+10.26 words read; P<.001), and phoneme deletion (+2.87 points; P<.001). No significant change was observed in reading comprehension for younger participants (grades 2-3; P=.09), although improvements were noted in older children (grades 4-5, P=.03). Exploratory analysis comparing children's improvements with Mila-Learn and Poppins revealed similar gains in reading accuracy and speed but revealed superior improvement in phonological skills for the Poppins group, with a moderate effect size according to the benchmarks by Cohen (Cohen d=0.48, P=.02).
Conclusions: Poppins is an effective and safe tool for enhancing reading and phonological skills in children with SLD reading. By integrating rhythm-based and graphophonological exercises, the device aligns with best practice recommendations for curative intervention. Future research should explore its long-term effects and medicoeconomic impact and compare outcomes with those of conventional therapy, as serious games provide an engaging, scalable method for delivering such interventions.
Trial registration: ClinicalTrials.gov NCT06596980; https://clinicaltrials.gov/study/NCT06596980.
Background: Young people feel increasingly anxious and sad nowadays. Engaging with works of art and entertainment, such as playing open-world games or watching Studio Ghibli films, can be more than just a pastime. However, the extent to which, if at all, open-world games and feelings of nostalgia affect overall happiness in life remains unclear.
Objective: This study aimed to examine the extent to which open-world games, such as The Legend of Zelda: Breath of the Wild, and nostalgia evoked by Studio Ghibli films, such as Hayao Miyazaki's My Neighbor Totoro or Kiki's Delivery Service, affect postgraduate students' sense of exploration, calm, mastery and skill, purpose and meaning, and, ultimately, happiness in life.
Methods: A controlled laboratory experiment was conducted using a 2 (playing an open-world game vs no open-world game) × 2 (nostalgia vs no nostalgia) between-subject design. Study participants (N=518) were randomly assigned to the study's 4 conditions and answered a brief questionnaire, examining their sense of exploration, calm, mastery and skill, purpose and meaning, and, ultimately, happiness in life. As part of the study, we conducted univariate analysis and bootstrapping-based moderated mediation analysis with 5000 resamples.
Results: The results showed a significant and positive impact of playing an open-world game on overall life happiness (mean [M]playedgame 4.563, SD 0.072, vs Mnotplayedgame 3.170, SD 0.072; F(1, 517)=117.246, P<.001). Furthermore, the positive impact of open-world games on overall life happiness was significantly enhanced by nostalgia evoked by watching Studio Ghibli films (Mnostalgia 5.45, SD 0.102, vs Mnonostalgia 3.58, SD 0.102; SE 0.144, 95% CI 1.332-1.900; P<.001). Moreover, exploratory moderated mediation with bootstrapped-based analyses and 5000 resamples demonstrated that the effect of playing open-world games on happiness is mediated by a sense of exploration (effect=0.11; SE 0.05, 95% CI 0.04-0.21), sense of calm (effect=0.32; SE 0.09, 95% CI 0.15-0.51), sense of skill and mastery (effect=0.08; SE 0.05, 95% CI 0.01-0.18), and sense of purpose and meaning (effect=0.32; SE 0.14, 95% CI 0.06-0.60).
Conclusions: This study shows that playing an open-world game, such as The The Legend of Zelda: Breath of the Wild, and nostalgia evoked by Studio Ghibli films significantly foster a sense of exploration and calm in life, as well as a feeling of mastery and skill, and purpose and meaning, hence ultimately contributing positively to one's overall happiness in life.
Trial registration: ISRCTN ISRCTN14757739; https://www.isrctn.com/ISRCTN14757739.
Background: Sarcopenia in older adults is associated with reduced muscle mass and function, leading to frailty, increased fall risk, and decreased quality of life (QOL). Mixed reality (MR)-based interventions have emerged as promising tools to enhance physical therapy engagement and effectiveness through immersive, interactive environments.
Objective: This study aimed to investigate the effects of a Mixed Reality-Based Physical Therapy (Mr.PT) platform on quadricep muscle thickness, balance confidence, activities of daily living, and QOL in older adults with sarcopenia.
Methods: A preliminary randomized controlled trial was conducted involving 30 older women (mean age 75.3, SD 9.9 y) diagnosed with sarcopenia based on the Asian Working Group for Sarcopenia criteria. Participants were randomly assigned to either the Mr.PT group or a conventional physical activity (CPA) group. Both groups participated in 30-minute exercise sessions, 3 times per week, over 4 weeks. The Mr.PT program used head-mounted MR devices with gamified, interactive training, while the CPA group received standard therapist-led exercises using resistance bands. Outcome measures included ultrasound imaging of quadricep muscle thickness, the Korean version of the Activities of Daily Living scale (Katz Index of Independence in Activities of Daily Living), the Activities-Specific Balance Confidence (ABC) scale, and the 12-Item Short-Form Health Survey. Statistical analysis was performed using repeated-measures ANOVA and Tukey post hoc tests.
Results: The Mr.PT group showed significantly greater improvement in quadricep muscle thickness than the CPA group (P=.001). Within-group improvements in balance confidence (ABC scale) and daily functioning (Katz Index of Independence in Activities of Daily Living) were observed in both groups (P<.05), though between-group differences were not statistically significant. However, the Mr.PT group demonstrated significantly greater gains in QOL as measured by 12-Item Short-Form Health Survey (P=.02). All participants completed the intervention without dropouts or adverse events.
Conclusions: MR-based exercise using the Mr.PT platform appears effective in increasing muscle mass and enhancing QOL among older adults with sarcopenia. Its interactive and adaptive features may improve engagement and motivation, suggesting potential advantages over traditional programs. Further research with larger cohorts and longer follow-up is recommended to confirm these preliminary findings and explore long-term outcomes.
Background: Frailty is a geriatric syndrome associated with increased risk of falls, hospitalization, and reduced quality of life. Traditional exercises may be unsuitable for older adults with frailty due to mobility issues and accessibility barriers. Virtual reality (VR) offers an engaging, home-based alternative by providing interactive training with real-time feedback. VR interventions have shown potential benefits for improving balance, strength, and mobility.
Objective: This systematic review and meta-analysis aimed to evaluate the effectiveness of VR-based home training programs in improving balance, strength, and mobility among older adults with frailty and prefrailty.
Methods: A systematic search was conducted in PubMed, Scopus, and Web of Science from inception to November 1, 2023, using terms related to older adults, frailty, virtual reality, balance, mobility, and strength. Eligible studies included randomized and nonrandomized trials involving adults with frailty or prefrailty aged ≥65 years who received home-based VR interventions aimed at improving balance, strength, or functional mobility. Comparator groups included no intervention, traditional exercise, or standard care. Studies involving participants with neurological or cognitive disorders were excluded. Study quality was assessed using the Physiotherapy Evidence Database scale. A random-effects meta-analysis was performed to calculate pooled mean differences (MD) and 95% CIs for 3 primary outcomes: Berg Balance Scale, Timed Up and Go, and Chair Stand.
Results: A total of 1063 records were identified, with 1023 screened after duplicate removal. Six studies met the inclusion criteria, involving 407 participants (mean age 75.2, SD 6.4 y), of whom 198 were allocated to VR interventions and 159 to control groups. VR interventions lasted a mean of 13.3 (SD 7.7) weeks, with an average of 39.6 (SD 5.2) sessions lasting 25.3 (SD 5) minutes. Methodological quality was high in 5 studies (mean Physiotherapy Evidence Database score=5.6, SD 1.3). Four studies were included in the meta-analysis. Significant improvements were observed in balance, as measured by the Berg Balance Scale (MD=3.62; 95% CI 2.29-4.95; P<.001; I²=0%). No significant effects were found for mobility (Timed Up and Go: MD=-0.37; 95% CI -1.16 to 0.41; P=.35; I²=0%) or strength (Chair Stand: MD=-0.20; 95% CI -1.70 to 1.29; P=.79; I²=21%).
Conclusions: VR-based home exercise interventions show promise in improving balance among older adults with frailty and prefrailty. However, their effects on strength and functional mobility remain unclear. Variability in study designs and outcome measures limits the generalizability of current findings. Further high-quality research is needed to determine optimal VR training protocols and assess long-term adherence and clinical effectiveness.
Background: Virtual reality (VR) interventions are emerging as promising nonpharmacological strategies for people with dementia, aiming to prevent cognitive decline, reduce behavioral and psychological symptoms of dementia (BPSD), and alleviate caregiver burden. Although some studies have reported beneficial effects, findings remain inconsistent, and little is known about the duration and sustainability of these effects, particularly in real-world care settings.
Objective: This study aimed to examine both the immediate and long-term effects of an immersive VR reminiscence intervention on BPSD and caregiver burden in people with dementia attending day care centers.
Methods: This longitudinal observational study was conducted in 10 dementia day care centers in Kaohsiung, Taiwan. A total of 82 participants with dementia were enrolled. The VR intervention consisted of twice-weekly sessions over one month, featuring culturally familiar live-action 360° scenes filmed in well-known Taiwanese locations. Each session lasted approximately 10-12 minutes and included interactive elements. Neuropsychiatric symptoms were assessed using the Neuropsychiatric Inventory Questionnaire, and caregiver burden was assessed using the Zarit Caregiver Burden Interview. Measurements were taken at 3 time points: preintervention, immediately postintervention, and 2 months after the intervention ended. The Wilcoxon signed-rank test was used for statistical comparisons, and rank-biserial correlation was calculated as the effect size.
Results: Significant improvements were observed after 1 month of VR intervention in both caregiver burden (Z=-3.095, P=.002, r=0.34) and neuropsychiatric symptoms (Z=-2.929, P=.003, r=0.32). At the two-month follow-up, neuropsychiatric symptoms remained significantly improved (Z=-4.327, P<.001, r=0.48), although caregiver burden returned to preintervention levels. Regarding specific neuropsychiatric symptoms, significant improvements were observed immediately after the intervention in dysphoria or depression, anxiety, and sleep or nighttime behaviors. These effects were sustained over time, with additional long-term improvements noted in euphoria or elation, apathy or indifference, irritability or lability, aberrant motor behavior, and appetite or eating behaviors.
Conclusions: A 1-month immersive VR reminiscence intervention appears to improve neuropsychiatric symptoms and temporarily reduce caregiver burden in people with dementia, with some symptom improvements lasting up to 2 months. These findings suggest that VR may offer a meaningful therapeutic option in day care settings. Future studies with control groups, including nonimmersive 2D conditions, and comparisons to traditional reminiscence therapy are needed to validate and expand upon these findings.
Background: Aging can bring upon several effects that can hinder one's quality of life. One of the effects is the decline in one's ability to perform activities of daily living, which is caused by the loss of hand function due to aging. To mitigate this, several virtual reality (VR)-based training or rehabilitation systems that use hand tracking were developed. Although these systems are effective, immersive, and can promote motivation, they are mostly limited to providing range of motion exercises. The addition of a force control component to the hand tracking of these systems could make them even more effective at improving or restoring hand function, as the majority of activities of daily living require a degree of force control.
Objective: This study aimed to compare the effects of 2 VR input systems: regular hand tracking and the novel VR input system in this study, which incorporate force control to regular hand tracking on the brain activity of younger and older adults. The degree of cortical activity during a training or rehabilitation task is linked to better functional outcomes and improvements of neuroplasticity.
Methods: Twelve younger adults (mean age 25.00, SD 4.50 years) and 12 older adults (mean age 73.00, SD 3.6 years) were recruited to play a game specifically developed for this study using 2 VR input systems. Brain activity during gameplay was recorded using functional near-infrared spectroscopy over the following cortical regions: prefrontal cortex (PFC), premotor cortex (PMC), supplementary motor area (SMA), and primary motor cortex (M1).
Results: Compared with the regular hand-tracking system, adding a force control component increased average oxygenated hemoglobin (HbO) concentrations and decreased deoxygenated hemoglobin (HbR) concentrations in key brain regions. In young adults, these changes were observed in the right PMC and right M1. In older adults, higher HbO and lower HbR concentrations appeared in the right PFC, bilateral M1, and right SMA (HbR only). The force control component also led to more widespread activity across all ROIs.
Conclusions: The novel input system in this study can be used for improving or restoring hand function. The results of this study can be used as a reference for the development of better VR-based training or rehabilitation systems.
Background: Accumulating evidence and medical guidelines recommend high-dose neurorehabilitation for recovery after stroke. The reality, however, is that most patients receive a fraction of this dose, with therapist availability and costs of delivery being major implementational barriers.
Objective: This study aimed to explore a potential solution by conducting a retrospective analysis of a real-world enhanced clinical service that used gamified self-training technologies at home under remote therapist supervision.
Methods: Data from 17 patients who completed a 12-18 week full-body, high-dose neurorehabilitation program entirely at home were analyzed. Program delivery relied primarily on patients training independently (asynchronously) with the MindMotion GO (MindMaze) gamified-therapy solution. Accompanying telerehabilitation training sessions with a therapist occurred weekly while therapists used a web application to continuously monitor and manage the program remotely. Effectiveness of the program was assessed through measured active training time, a measure that more closely reflects delivered dosage as opposed to scheduled dose. Patient recovery was evaluated with standardized impairment and functional clinical measures and patient self-reported outcome measures. Finally, a cost model was computed to evaluate the resource efficiency of the program.
Results: Patients maintained high training adherence throughout the program and reached an average total active training time of 39.7 (SD 21.4) hours, with the majority delivered asynchronously (mean 82.2%, SD 10.8%). Patients improved in both upper-limb (Fugl-Meyer Upper Extremity, mean 6.4, SD 5.1; P<.001) and gait and balance measures (Functional Gait Assessment, mean 3.1, SD 2.6; P<.001; Berg Balance Scale, mean 6.1, SD 4.4; P<.001). Overall, the program was viewed very favorably among patients who completed a post-program survey, with 73.7% (14/19) of respondents being satisfied or very satisfied, while 63.2% (12/19) of respondents reported subjective improvements in physical abilities. Per-patient therapist costs approximated US $338, representing a resource-efficient alternative to delivering the same dose via one-on-one in-person training sessions (US $1903).
Conclusions: This work demonstrates effective high-dose neurorehabilitation delivery via gamified therapy technologies at home. The approach shows that training time can be successfully decoupled from therapist-presence without compromising adherence, outcomes, or patient satisfaction over an extended program period. Given growing concerns over therapist availability and increasing health care costs, this resource-efficient approach can help achieve medical guidelines and complement existing clinic-based approaches.
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