By Dr. Liji Thomas, MD Feb 1 2024 Reviewed by Danielle Ellis, B.Sc.

Palliative care is necessary to ensure comfort and an improved quality of life towards the end of one’s life when enduring chronic or fatal diseases. With the graying of the population in many developed countries, the importance of this segment of healthcare is growing rapidly. Study: Flourishing-Life-Of-Wish Virtual Reality Relaxation Therapy (FLOW-VRT-Relaxation) outperforms traditional relaxation therapy in palliative care: results from a randomized controlled trial. Image Credit: Chinnapong/Shutterstock.com

In this context, a new study published in Frontiers in Virtual Reality explored the effectiveness of a psychological strategy called Flourishing-Life-Of-Wish Virtual Reality Therapy (FLOW-VRT)® in helping people cope with their symptoms and achieve relaxation at the end of life. Background

While earlier studies that compared the use of virtual reality (VR) in palliative therapy have been reported, none have been randomized controlled trials (RCTs), driving the current experimental study.

It is known from prior research that palliative care leaves multiple areas of need unsatisfied, including pain relief, psychological distress over loss of autonomy, and limited opportunity for social interactions. This impacts the quality of life and promotes the progression of the illness.

Both pharmacological and non-pharmacological interventions are used in palliative care. Psychotherapy and other psychological tools are extensively used as they do not have the potential for adverse effects that medications have. Moreover, these are inexpensive and practical, especially when focused on helping the patient relax.

Most studies on relaxation in the field of palliative medicine look only at traditional techniques, largely ignoring the potential for VR to ease pain and facilitate relaxation. However, VR creates an immersive experience that makes patients feel they are present in another environment.

VR thus prevents the consciousness of the present, miserable surroundings while promoting a sense of being in a virtual environment that is controlled. This leads to distraction, a known cognitive-behavioral tool for pain relief. Moreover, this is improved by the chance for the patient to choose the preferred environment, even using this platform to fulfill deeply cherished longings.

This ability to virtually fulfill their wishes to travel to a relaxing destination or environment could bring happiness and relieve the discomfort and sadness of the terminal condition.

Building on earlier feasibilty and pilot studies, the current study seeks to document the impact of VR on patient symptoms in palliative care by simulating activities that are meaningful for the patient. The researchers built a structured psychological program for palliative care patients.

Called FLOW-VRT Relaxation, this is built upon various psychological theories, including flow theory (“completely absorbed in activity without reflective self-consciousness but with a deep sense of control”), self-determination theory (autonomy and a sense of control), stress coping theory, and the attention restoration theory that attributes renewed cognitive ability and greater wellbeing to exposures to natural environments. It is one form of the broader FLOW-VRT intervention, modified for relaxation, allowing patients to choose their relaxing experience. What did the study show?

The study included 128 patients recruited from a palliative care unit over ten months. About 93% completed the study, the mean age being 67 years, and 70% being female. The participants were administered the Chinese version of the Edmonton Symptom Assessment System (CESAS), consisting of a questionnaire exploring nine typically encountered symptoms among cancer patients. This was first done at baseline, followed by randomization and post-test assessment. Related StoriesUK Biobank research reveals significant impact of type 2 diabetes on COVID-19 outcomesNew research highlights regional variations in COPD prevalence according to diagnostic criteriaStudy shows how social media fuels unhappiness and materialism

At baseline, total, physical, and emotional subscale scores on the CESAS were comparable for test and control groups. After the Flow-VRT Relaxation intervention, total, physical, and emotional scores changed in both groups, those exposed to the FLOW-VRT –Relaxation therapy and those who underwent traditional relaxation therapy.

However, the scale of reduction in all three subscale scores was significantly greater with FLOW-VRT Relaxation, indicating that this intervention produced superior symptom improvement compared to traditional measures. This may be due to the individual’s freedom to choose meaningful content for the VR experience, promoting self-determination by supporting the person’s autonomy rather than forcing the individual to embrace an experience chosen by someone else.

The use of immersive VR technology could be another reason for the improved symptom control, as this induces flow, which is linked to physical and mental wellbeing. In addition, it may allow patients to explore and learn to use stress management strategies when going through stressful physical and emotional symptoms. Such emotion-focused coping is more easily managed for many patients undergoing the trauma of end-of-life after a terminal illness and are unable to exercise problem-focused coping strategies. What are the implications?

“Our results showed that following a FLOW-VRT-Relaxation session, the symptoms of distress that patients in palliative care have to endure significantly reduced.” Both physically and emotionally, patients reported that they did not feel the same level of distress. These promising results could point to the extending potential of this approach for elderly patients in long-term care homes and rehabilitation centers.

This sheds light on the scope for the use of this intervention in this area, considering its relatively low cost, scalability, and personalization potential. The use of this approach is especially suitable for those with terminal illnesses who are often bedridden or confined to hospital wards, unable to find pain relief, or suffering from the adverse effects of required medical therapy. Moreover, they are emotionally vulnerable as they have unfulfilled wishes of traveling or escaping their pain.

Further studies are required to follow up on the effects of FLOW-VRT Relaxation over time. However, this is not an essential feature in palliative care, where patient survival is typically expected to be short. In fact, against a background of unfulfilled wishes and a short lifespan, FLOW-VRT Relaxation provides a meaningful impact on the patient’s wellbeing as it can virtually satisfy some of these longings and provide a sense of control.

At the same time, the study brought out some potential risks of such technology, which may engender a greater sense of loss of past abilities or skills in contrast to the patient’s current situation. Further research should look at how VR content may be made still more personalized to have meaning for each individual and design training protocols to make sure the intervention is delivered as intended. Journal reference: Woo, O. K. L. et al. (2024). Flourishing-Life-Of-Wish Virtual Reality Relaxation Therapy (FLOW-VRT-Relaxation) outperforms traditional relaxation therapy in palliative care: results from a randomized controlled trial. Frontiers in Virtual Reality. doi: https://doi.org/10.3389/frvir.2023.1304155. https://www.frontiersin.org/articles/10.3389/frvir.2023.1304155/full.