Virtual reality biofeedback interventions for treating anxiety : A systematic review, meta-analysis and future perspective

Abstract

Background: Virtual reality (VR)-based biofeedback is a relatively new intervention and is increasingly being used for the treatment of anxiety disorders. This is the first research synthesis regarding effects and efficacy of this novel mode of treatment.

Method: We conducted a systematic review and meta-analysis of the VR biofeedback literature on treating anxiety symptoms. The MEDLINE/PubMed, Scopus and Web of Science databases were searched for eligible pre-post comparisons and randomized controlled trials (RCTs). We used self-reported anxiety, heart rate (HR), and heart rate variability (HRV) as primary outcome measures.

Results: A total of 7 studies with 191 participants reported VR biofeedback interventions. Of these studies 5 were RCTs, with 103 participants receiving VR biofeedback and 99 control participants (either 2D biofeedback or waiting list controls). We found that VR biofeedback significantly lowers self-reported anxiety (g = -0.28) and HR (g = -0.45), but not HRV. Furthermore, there were no significant differences in outcomes between VR biofeedback and 2D biofeedback but a significant reduction in HR in the VR biofeedback group compared with the waiting list (g = -0.52).

Conclusion: While the first findings are optimistic, more controlled studies with a wider variety of samples are needed to bring this field forward. Particularly, children and adolescents may profit from the combination of gamification elements, VR, and biofeedback.

Keywords: Anxiety; Complementary therapies; Heart rate variability; Psychological treatment; Virtual environment.

Fig. 1

PRISMA chart of screening, exclusion and inclusion criteria

Fig. 2

Forest plots of the standardized mean difference (Hedges’ g) of the effect of VR biofeedback on a self-reported anxiety, b heart rate and c RMSSD (pre-post changes)

Fig. 3

Forest plots of the standardized mean difference (Hedges’ g) of the efficacy of VR biofeedback on a, b self-reported anxiety, c, d heart rate and e, f RMSSD grouped by type of control groups. a Self-reported anxiety—Waiting list controls, b Self-reported anxiety—Active controls, c Heart rate—Waiting list controls, d Heart rate—Active controls, e RMSSD—Waiting list controls, f RMSSD—Active controls

Fig. 4

Assessment of quality for low (green), moderate (orange) or high (red) risk of bias based on the AHRQ method guide for comparative effectiveness reviews [52]

Fig. 5

Game-based virtual reality biofeedback for children and adolescents Relaxation scenario (environment translates during induced relaxation: images following from low to high relaxation level) in a game-based virtual reality biofeedback of children and adolescents with anxiety disorders (Conquer Catharsis) [33]. (Copyright and with permission by Andreas Lenz & Helmut Hlavacs)