To assess the feasibility of delivering a definitive trial around the use of relaxation VR for inpatients undergoing neurorehabilitation in the NHS, we studied the following.

I. Feasibility of recruitment

Ethical approval was given by East of England–Essex Research Ethics Committee (ref: 23/EE/0209) on 2 October 2023. The study was sponsored by the University of Nottingham.

This open-label feasibility study was conducted in an inpatient neurorehabilitation unit located in a community hospital in the East Midlands of the United Kingdom.

Participants were eligible for inclusion if they met the following criteria.

• Admission to King’s Lodge Neurorehabilitation Unit for a period of inpatient neurorehabilitation

Informed consent was taken from all participants.

Dr. VR is a VR distraction-therapy product and comprises a PICO VR headset with optional noise-cancelling headphones, operated by a closed system which includes a Samsung tablet and internet router.

Participants were offered VR sessions depending on the availability of staff to deliver and supervise the sessions and participant choice.

Participants chose from a list of 28 VR experiences, classified as “escape” (visiting beautiful, distracting, or interesting locations including swimming underwater in the ocean, hiking through beaches and forests, and viewing wildlife or dinosaurs), “relax” (guided meditations in a range of environments), and “play” (interactive games). Most experiences lasted for 7–8 min.

A clinician supervised participants throughout the VR session, including helping with donning and doffing the headset and completing outcome measures if necessary.

Participants scored their pain and anxiety severity using a face-based Likert scale before and after each VR intervention, scoring from 0 (no pain/anxiety) to 10 (extreme pain/anxiety). Supervising clinicians recorded comments made by participants during or immediately after the sessions and any relevant behaviours or movements from participants during the session. Acceptability for patients was based on willingness to use the VR headset; acceptability to staff was based on staff feedback.

Pain and anxiety scores were exported to an Excel spreadsheet and analysed using GraphPad Prism 10.

Comments made by participants and observations made by staff were handwritten at the time of or immediately following the session, transcribed into a Word document, and analyzed using simple thematic analysis.

Forty potential participants were excluded. Among the common reasons for exclusion were the following:

• 10—not sufficiently oriented

1 participant used the device only once and then declined further use as they reported visual difficulties which had not previously been identified.

The fatigue and visual disturbances were not directly related to the use of the VR.

Of the 23 sessions delivered, 18 were delivered by a neurorehabilitation doctor, two by a physiotherapist, two by a speech and language therapist, and one by an occupational therapist. No differences were noted in outcomes depending on who delivered the session.

Several other members of staff were trained to deliver the intervention but, due to time and staffing pressures, could not.

No problems with delivering the intervention were reported in 9/23 sessions.

The most commonly reported problems were around optimizing volume (usually helped by use of noise-cancelling headphones) or headset positioning, particularly where participants had limited manual dexterity and so often relied on the investigator to place the headset on the participant’s head.

No problems were identified.

No problems were identified. Outcome measures were recorded pre- and post-intervention for all participants and all sessions.

Statistically significant improvements were seen in both pain and anxiety scores comparing pre- and post-VR intervention (Figure 1). Comparing all pre- and post-scores, Wilcoxon matched-pair signed-rank test scores were p = 0.0039 for both analyses; effect size r = 0.423 for pain and r = 0.416 for anxiety. Excluding those participants whose starting and finishing scores were 0, median scores of pain were 4.0 pre- and 2.5 post-intervention, with anxiety 3.0 and 0.5, respectively.

Feedback provided by participants and observations by staff members were nearly all positive (Table 1). One participant felt that the dinosaur park tour was “a bit childish,” and another commented that the dinosaurs “weren’t like you see on tv.” Staff reported that the VR sessions encouraged participants to move their head around to experience the 360° environment and that participants seemed relaxed and keen to discuss their experiences with staff and other patients.

One participant noted on two occasions that, immediately following the removal of the VR headset, they experienced increased sensitivity to ambient lighting, but this self-terminated within a few minutes. No other adverse events were noted.

The study was limited by low participant numbers (primarily due to strict inclusion criteria) and limited staff availability to deliver VR sessions as frequently as might have been preferred. At times, participants did not wish to use the VR, most commonly due to pre-existing fatigue, which is very common for patients undergoing neurorehabilitation. Future research could explore gradual exposure to VR or re-introducing the concept at a later stage of recovery when fatigue is less disabling. Despite this, the positive feedback and improvements in pain and anxiety scores suggest that this type of VR intervention could be useful for selected patients and could be considered in addition to standard neurorehabilitation care.