Authors: Rishad Khan, Joanne Plahouras, Bradley C Johnston, Michael A Scaffidi, Samir C Grover


Endoscopy has traditionally been taught with novices practicing on real patients under the supervision of experienced endoscopists. Recently, the growing awareness of the need for patient safety has brought simulation training to the forefront. Simulation training can provide trainees with the chance to practice their skills in a learner‐centred, risk‐free environment. It is important to ensure that skills gained through simulation positively transfer to the clinical environment. This updated review was performed to evaluate the effectiveness of virtual reality (VR) simulation training in gastrointestinal endoscopy.


To determine whether virtual reality simulation training can supplement and/or replace early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy, and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience.

Search methods

We searched the following health professions, educational, and computer databases until 12 July 2017: the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase, Scopus, Web of Science, BIOSIS Previews, CINAHL, AMED, ERIC, Education Full Text, CBCA Education, ACM Digital Library, IEEE Xplore, Abstracts in New Technology and Engineering, Computer and Information Systems Abstracts, and ProQuest Dissertations and Theses Global. We also searched the grey literature until November 2017.

Selection criteria

We included randomised and quasi‐randomised clinical trials comparing VR endoscopy simulation training versus any other method of endoscopy training with outcomes measured on humans in the clinical setting, including conventional patient‐based training, training using another form of endoscopy simulation, or no training. We also included trials comparing two different methods of VR training.

Data collection and analysis

Two review authors independently assessed the eligibility and methodological quality of trials, and extracted data on the trial characteristics and outcomes. We pooled data for meta‐analysis where participant groups were similar, studies assessed the same intervention and comparator, and had similar definitions of outcome measures. We calculated risk ratio for dichotomous outcomes with 95% confidence intervals (CI). We calculated mean difference (MD) and standardised mean difference (SMD) with 95% CI for continuous outcomes when studies reported the same or different outcome measures, respectively. We used GRADE to rate the quality of the evidence.

Main results

We included 18 trials (421 participants; 3817 endoscopic procedures). We judged three trials as at low risk of bias. Ten trials compared VR training with no training, five trials with conventional endoscopy training, one trial with another form of endoscopy simulation training, and two trials compared two different methods of VR training. Due to substantial clinical and methodological heterogeneity across our four comparisons, we did not perform a meta‐analysis for several outcomes. We rated the quality of evidence as moderate, low, or very low due to risk of bias, imprecision, and heterogeneity.

Virtual reality endoscopy simulation training versus no training: There was insufficient evidence to determine the effect on composite score of competency (MD 3.10, 95% CI ‐0.16 to 6.36; 1 trial, 24 procedures; low‐quality evidence). Composite score of competency was based on 5‐point Likert scales assessing seven domains: atraumatic technique, colonoscope advancement, use of instrument controls, flow of procedure, use of assistants, knowledge of specific procedure, and overall performance. Scoring range was from 7 to 35, a higher score representing a higher level of competence. Virtual reality training compared to no training likely provides participants with some benefit, as measured by independent procedure completion (RR 1.62, 95% CI 1.15 to 2.26; 6 trials, 815 procedures; moderate‐quality evidence). We evaluated overall rating of performance (MD 0.45, 95% CI 0.15 to 0.75; 1 trial, 18 procedures), visualisation of mucosa (MD 0.60, 95% CI 0.20 to 1.00; 1 trial, 55 procedures), performance time (MD ‐0.20 minutes, 95% CI ‐0.71 to 0.30; 2 trials, 29 procedures), and patient discomfort (SMD ‐0.16, 95% CI ‐0.68 to 0.35; 2 trials, 145 procedures), all with very low‐quality evidence. No trials reported procedure‐related complications or critical flaws (e.g. bleeding, luminal perforation) (3 trials, 550 procedures; moderate‐quality evidence).

Virtual reality endoscopy simulation training versus conventional patient‐based training: One trial reported composite score of competency but did not provide sufficient data for quantitative analysis. Virtual reality training compared to conventional patient‐based training resulted in fewer independent procedure completions (RR 0.45, 95% CI 0.27 to 0.74; 2 trials, 174 procedures; low‐quality evidence). We evaluated performance time (SMD 0.12, 95% CI ‐0.55 to 0.80; 2 trials, 34 procedures), overall rating of performance (MD ‐0.90, 95% CI ‐4.40 to 2.60; 1 trial, 16 procedures), and visualisation of mucosa (MD 0.0, 95% CI ‐6.02 to 6.02; 1 trial, 18 procedures), all with very low‐quality evidence. Virtual reality training in combination with conventional training appears to be advantageous over VR training alone. No trials reported any procedure‐related complications or critical flaws (3 trials, 72 procedures; very low‐quality evidence).

Virtual reality endoscopy simulation training versus another form of endoscopy simulation: Based on one study, there were no differences between groups with respect to composite score of competency, performance time, and visualisation of mucosa. Virtual reality training in combination with another form of endoscopy simulation training did not appear to confer any benefit compared to VR training alone.

Two methods of virtual reality training: Based on one study, a structured VR simulation‐based training curriculum compared to self regulated learning on a VR simulator appears to provide benefit with respect to a composite score evaluating competency. Based on another study, a progressive‐learning curriculum that sequentially increases task difficulty provides benefit with respect to a composite score of competency over the structured VR training curriculum.

Authors’ conclusions

VR simulation‐based training can be used to supplement early conventional endoscopy training for health professions trainees with limited or no prior endoscopic experience. However, we found insufficient evidence to advise for or against the use of VR simulation‐based training as a replacement for early conventional endoscopy training. The quality of the current evidence was low due to inadequate randomisation, allocation concealment, and/or blinding of outcome assessment in several trials. Further trials are needed that are at low risk of bias, utilise outcome measures with strong evidence of validity and reliability, and examine the optimal nature and duration of training.


Magdalena Sylwia Kamińska, Agnieszka Miller, Iwona rotter, Aleksandra Szylińska, Elżbieta Grochans


Virtual reality (VR) training using modern game consoles is an innovative rehabilitation method for fall-prone elderly people. The aim of this study was to assess the effectiveness of VR training using the “Xbox 360 Kinect” in people over 60 years of age.


The aim of this study was to assess the effectiveness of VR training using the “Xbox 360 Kinect” in the context of reducing the risk of falls among elderly people.


The study involved 23 people, including 19 women and 4 men (mean age 75.74±8.09 years). The following functional tests were employed as research instruments: the 6-minute walking test (6MWT), the Dynamic Gait Index (DGI), the tandem stance test (TST), the tandem walk test (TWT), and the Beck Depression Inventory (BDI). A “spring hand dynamometer” was also used. The participants underwent 30-day VR training using an Xbox 360 Kinect. They trained 3 times a week, with each exercise lasting 30 minutes.


The 6MWT (P<0.001), the DGI (P=0.008), the TST (P<0.001), the TWT (P=0.002), and the BDI (P<0.001) outcomes were significantly improved. There were differences in the results for the strength of the “pressing muscles” in the right (P=0.106) and left (P=0.043) hands of the participants. Both participants under 80 years of age and those aged 80 years and over had visibly better results on the 6MWT (P<0.001 and P=0.008, respectively), the TST (P<0.001 and P=0.008, respectively), and the BDI (P=0.003 and P=0.012, respectively).


Training based on VR increases the possibilities of motor training and can help reduce the risk of falls by improving the static and dynamic balance.–peer-reviewed-article-CIA

Authors: Haylie L. Miller and Nicoleta L. Bugnariu


Different levels of immersion in Virtual environments (VEs) for delivering social skills interventions to individuals with autism spectrum disorder (ASD) and the influence of this levels of immersion on the efficacy of VEs as a tool for assessing and teaching social skills.


  • To critically evaluate the level of immersion used in previous studies (low, moderate, and high immersion);
  • To highlight unanswered questions about the generalizability of skills learned in the virtual world, the level of immersion required to successfully teach social skills, and the variability in treatment response across individuals with ASD with differing symptom profiles; and
  • To propose a possible theoretical framework for examining the level of immersion used in a study.


This research groups studies into low-, moderate-, and high-immersion categories and examins them from five aspects of immersion including identifying emotions or intentions, conversation, gesturing, socially appropriate behaviours and cooperation.


Low-immersion VEs are sufficient to detect some differences in social performance. Exceptions may be due to participant characteristics, including the tendency to be immersed, attention, and symptom severity. However, the literature on intervention studies is considerably less straightforward. In one instance, low-immersion VEs produced improvement in social skills. However, while some moderate-immersion VEs have produced improvements, others have not.


The current body of work suggests that VEs may offer an appropriate avenue for delivery of social skills therapies for some individuals with ASD. The potential advantage to using VEs in place of more traditional measures or intervention approaches lies in the ability to generate more ecologically valid tasks and to teach and assess skills under conditions that more closely mimic the real world. Additional research is needed to determine whether this approach is equivalent to traditional face-to-face intervention.

Authors: Brandon Birckhead, Carine Khalil, Xiaoyu Liu, Samuel Conovitz, Albert Rizzo, Itai Danovitch, Kim Bullock, and Brennan Spiegel


Therapeutic virtual reality (VR) is an innovative and efficacious treatment modality gaining considerable attention to manage a broad range of health conditions. However, in spite of encouraging outcomes from early stage research, a consensus is needed for how best to develop and evaluate VR treatments within a scientific framework.


This research sought to develop a methodological framework with input from an international working group to guide the design, implementation, analysis, interpretation, and communication of trials that develop and test VR treatments.


A group of 21 international experts was recruited based upon contributions to the VR literature. The resulting Virtual Reality Committee of Outcomes Research Experts (VR-CORE) held iterative meetings to seek consensus regarding best practices for development and testing of VR treatments.


The interactions were transcribed, and key themes were identified to support a scientific framework to support methodology best practices for clinical VR trials. A framework emerged to support three phases of VR clinical study designs, herein named VR1, VR2, and VR3.

VR1studies focus on content development by working with patients and providers through principles of human centered design. VR2trials conduct early testing with a focus on feasibility, acceptability, tolerability and initial clinical efficacy. VR3 trials are randomized, controlled studies to evaluate efficacy versus a control condition. Best practice recommendations for each trial are provided.


Patients, providers, payers and regulators may consider this best practice framework when assessing the validity of VR treatments.