Hello, welcome to my presentation about the effect of VR Games on perceived exertion, exercise, adherence and health. My name is Katie Houlahan and start with a quick introduction about myself. So I have a background in applied sport and exercise science.And I did my masters in biomedical engineering where I focused my dissertation on using VR Games for helping with chronic pain. When I left university, I co-founded virtually healthy to be able to use VR Games within health and fitness for both mental and physical health. So we all know that it, we need to exercise regularly to stay healthy and it's recommended for 30 minutes of exercise per day with 100 and 50 minutes of moderate exercise or f 75 minutes of vigorous aerobic exercise per week and strengthening exercises two times per week. But unfortunately, only about 27% of UK citizens and 23% of us citizens actually meet this recommendation. And we have a similar low adherence to exercise programs for managing health conditions and recovering from injuries, which is a major problem within the healthcare industry and costs healthcare industries around the world. Billions of dollars and pounds and because of this, so why, I guess, uh, you might ask that there are a lot of it barriers that people perceive to exercise and the biggest one being lack of time when somebody says that they don't have enough time to exercise.

What they usually mean is that exercise is a lower priority on their list. For example, you might get home from a hard day at work and you'd rather sit on the sofa and watch some TV for half an hour than get on the exercise bike or go for a run. Yeah, that just means that, that relaxation after a long day is a higher priority to exercise. Or perhaps you've got kids that you need to cook dinner for and that's a higher priority than exercising for half an hour. A lot of people say that they don't have the, the motivation to get started to exercise and perhaps that might be because of a mental health condition or depression. Um, a lot of people are very self conscious about their body image so they might not want to go to the gym and exercise in front of people or they might just not like looking at themselves exercising others might be in pain. Uh, whether that's for a chronic pain condition. And do you feel pain because of that, or if it's just because you don't like the feeling of your lungs burning after a hard run? Yeah, everybody's been there a lot of people just don't enjoy exercise.

If you don't enjoy it, then you're less likely to engage in it. And then we have the problem of lack of access to facilities and the cost of exercise, which can be uh quite expensive for some sports and some types of exercise. So this is where virtual reality can come in. We have seen the research show VR has been able to distract from mental and physical pain, providing a reduction in pain whilst exercising and also helping with anxiety and depression so can help relieve that stress and that anxiety and depression when you're engaging with VR.

So according to the gate theory of attention, VR absorbs and diverts attention away from pain, reducing perception of this pain. And it could even change the way that the brain physically registers that pain. And a lot of this research stresses the importance of gaming and play elements in VR interventions that are aimed at reducing pain. So this is how VR may actually help to overcome many of the barriers to exercise. And it provides a platform for fun and motivational exercise rather than just standard exercise programs that you get given uh for health and fitness. Generally, we can use Gamification along with VR. So Gamification is basically game like experiences which promote flow mastery achievement and intrinsic motivation encourages participation, positively influences attitude and behavior towards exercise and it allows for easy goal setting and progression. So there are three main aspects of Gamification for exercise.

We have these motivational affordances, things like feedback that give context to progress and ability points that measure achievement in relation to others. Badges that visually reward achievements levels that encourage progress to unlock new rewards scoreboards which create competition between players goal setting that provides a mo motivation to reach a long term goal and challenges which engage players with specific tasks to complete.

And these motivational affordances lead to psychological outcomes such as increased self efficacy. So your belief to uh your belief in your own ability to succeed, it can reduce perception of pain whilst exercise and it can improve your attitude towards exercise. So these psychological outcomes then lead to this further behavioral outcome of increased participation in exercise, which overall leads to a better quality of life. So if we can combine these two into gamified virtual reality, we can provide a much needed solution to low engagement in exercise for health, which can help holistically with both mental and physical health together mental and physical health. Go hand in hand. They are very often dealt with separately within our healthcare systems. So that brings us to the research that we've been doing at virtually healthy. We carried out an 18 week VR study to investigate the use of VR Games for health and fitness. We used 36 different VR Games that were already out there on the market with 20 participants and we used heart rate monitoring motion capture like at scale questionnaires including using the rate of perceived exertion for each game. So we used a borg scale of R pr pe scale rate of perceived exertion scale, which goes from six, which is basically no exertion as if you're lying down or sitting down doing nothing to a 20 which is maximal exertion like the maximum you can give.

And finally, we recorded attendance. So what do we find? We found that VR was effective at inducing exercise. So obviously, this was dependent on the game itself. On average, we found one game induced very low intensity exercise. So less than 50% of the maximum heart rate. But 14 games induced low intensity exercise of 50 to 63% of maximum heart rate. 13 games induced moderate intensity of exercise. So 64 to 76% of maximum heart rate, seven games induced a high intensity of exercise. So 77 to 93% maximum heart rate and one game induced a very high intensity exercise of 94 to 99% of maximum heart rate. We took people's R pe rate of perceived exertion and we converted it to heart rate to be able to compare the two. So we can we compared perceived exertion to actual exertion and we found that perceived exertion was actually lower than the actual exertion with a statistically significant result, which may be one of the reasons why we had such great adherence rates, we had 90% adherence to our program with only a 10% dropout rate, which is an amazing statistic because for similar research with standard exercise programs, 67% adherence is considered successful with general adherence of around 45 to 60%.

And dropout rates ranged from 25% to 80% in the majority of the literature um that we were looking at beforehand. So here is some of the average questionnaire results for all the games. So this is all of the games uh put together and all the participants to put together just to give an overview of how our participants felt whilst playing these games. So obviously, it would differed depending on the game. Again. Uh Overall, we found that um participants didn't find this boring. Yeah, they found it quite exciting and fun and many of them weren't relaxing because of course, we're trying to induce exercise. Uh Not many of them were uncomfortable to play. We had a couple of games that did induce some motion sickness and these were the games uh that were moving the participant through the level and that sort of game is known to cause motion sickness. Uh Many of the games were thought to be very comfortable to play though and did not use any sort of motion sickness. Uh Many of the games challenged our participants to solve problems and some were a little bit difficult which is uh not necessarily a bad thing trying to engage people in this challenge, motivational avoidance as we were talking about before, with uh Gamification, uh we had many of the games and people were mentally refreshed after playing it.

And most of the games we had people would choose to play again and spend money on. And then the big ones is that we had a lot of our participants putting effort into these games and they felt motivated to get a high score and ultimately were very immersed in the game. And overall, we had a very satisfactory rating of the games. We also found in some cases that heart rate was actually observed to be lower than the initial heart rate, uh resting heart rate, sorry it whilst in virtual reality, this was usually whilst in the menus, not whilst playing the exercise type games. Uh This can show how VR can lower people's anxiety and help with that mental health and, and have that most relaxing element and distracting element from, from your mental pain. In some ways, we had two participants that had slight limitations to their upper limb movement. And without prompting, they noted how they felt that they could do things in VR that they couldn't do in real life. They had that extra movement, extra range of motion, which is has been noted in some other research and is being researched further. Uh by other people, we had mental health benefits that were noted by 12 of our participants, including two who suffer from depression, they've been diagnosed with depression um through their GP.

And here are a couple of the quotes that they had in response to the question, did playing RRVR regularly have any effect on your mental health. So one said I have found it beneficial for my mental health. It has been good for me to have the weekly activity just for myself, which I really enjoy. And I found the immersive nature of VR helps me to just switch off for a period of time, particularly when I'm feeling anxious. And the other said, definitely it has been a highlight of my week and has always lifted my mood when I was feeling low otherwise. So we ha currently have a journal paper that is being peer reviewed about this study to publish later this year. But in the meantime, you can read an overview of all of our research on our blog at virtually healthy.co.uk/blog and we are releasing detailed information about the specific games that were included through our blog as well. So we have currently released details about racket NX Synth RTI until you fall via regatta and Creed. Rise to glory. So, Creed, we also did a, we did a small study that looked into the differences between their new endurance mode and their normal fighting mode, the c the boxing game. And we also have details on spark which are going to be released next week.

And I'm excited to announce our new virtually healthy certification. Games that are proven to have benefits for health and fitness. Through our research can now be awarded a virtually healthy certification and be considered a virtually healthy game. All virtually healthy games will be given a digital certificate detailing the categories in which they are proven to be beneficial. So, we currently have two categories, cardiovascular exercise and range of motion. We have plans for more categories in the future as our research progresses and develops further.

So keep an eye out for games with a certificate or logo on their steam in Oculus pages. And once we release our app and our VR programs later this year, which I'll talk about in a moment, you'll be able to access a list of all of the virtually healthy games and which categories they fall into. So what's next for us at virtually healthy? We are using all of this data to develop via health and fitness programs. We are beginning beta testing on our first programs later this month and these are our first programs of many. So we are first releasing general health and fitness programs for um keeping up exer exercise, regular exercise. And in the future, we want to develop more specific exercise programs for more specific health conditions, whether that's mental or physical health or combination of the two, we will be conducting more in depth movement analysis to develop more specific programs for our fitness and rehabilitation.

And we want to provide data, allowing health and fitness professionals to be able to create custom programs. So you might have data about which muscles these games use. What type of range of motion, what uh forces and accelerations of the joints um are being induced in each of these games. We will be continuing our research. Uh So we'll have more individual research projects that are planned uh for other games. So we can continue to add games to our VR programs and we will be conducting research into the effectiveness of each of our VR programs to show that they are effective for our intended purposes. We will be releasing our VR programs on a website app to start with and once we've released our first programs, we'll be beginning our first funding round to grow our app to be able to continue our research and progress further in the future. We are looking to organize a VR headset learning system which will be released both online and through private health and fitness services. So you might be able to go to your local local physiotherapist or your local gym and be able to rent out a VR headset to be able to participate in our programs which will have all of the games necessary to use on there.

We also have several partnerships planned with the arcade companies, with private health and fitness professionals and organizations and with game developers themselves who have all seemed very enthusiastic about what we're doing at virtually healthy and want to help us in any way they can to push forward this use of virtual reality gains within health and fitness.

So here are some of the references uh that I've used throughout talking through this presentation. And thank you very much for listening and I would be more than happy to take any questions or comments in the Q and A. You can contact me at Katie at Virtually healthy.co do UK or on linkedin or Facebook. You can sign up for updates on our website, Virtually healthy.co.uk. And please join our Facebook community, virtually healthy community where we have regular discussions and content that gets shown there about VR in health and fitness. So first question, how much do you think the low dropout rate was due to the novelty of VR? And do you think the results would be affected by VR becoming more common in society that may be, may be part of it? But we also have participants that owned VR headsets themselves and have used VR for the past year, two years, three years. So the fact that they didn't drop out either does show something to the fact that it's not quite just a novelty. And if you look at the VR communities, so Facebook and things like that, we have uh people that have been using VR since the very beginning that it was released for 54 or five years ago and are still just as enthusiastic about using VR for health and fitness for games and personally anecdotally, of course, um I've been using VR for the last five years and I still use it very regularly for, for exercise and health.

So there are worries about the novelty, but I feel like there is a lot of difference between this and say the Nintendo Wii and the Xbox connect, which def definitely did stop um being used so much because of the novelty of that. And there is more to VR with the, the level of immersion that you, you get from the VR. Um definitely there is a novelty and the wow factor when you, when you first go into VR, but I don't think that really wears off and has, has an impact on um on participation and engagement with it. Do we have any other questions? All right. Well, uh thank you very much for listening. This has been uh lovely to present to you. Please get in touch if you have any questions or would like to, to talk more. Um I'm always open to, to having a conversation with anybody that uh that is interested in, in this technology and its uses within mental and physical health. Have a great rest of the event. Thank you very much.