a number of disorders. some factors to consider when virtual rehabilitation include cultural sensitivity, accessibility, and ability to finance the virtual therapy. advantages virtual rehabilitation offers a number of advantages compared to conventional therapeutic methods: it is entertaining, thus motivating the patient; potential for involvement of the patients' stimulus modalities for more realistic environments for treatment. it provides objective outcome measures of therapy efficacy (limb velocity, range of movement, error rates, game scores, etc.); these data are transparently stored by the computer running the simulation and can be made available on the internet. virtual rehabilitation can be performed in the patient's home and monitored at a distance (becoming telerehabilitation) the patient feels more actively involved in the desensitization the patient may "forget" they are in treatment or undergoing observation resulting in more authentic expressions. effective for hospitals to reduce their costs because of lowered cost of medicine and equipment. great impact of virtual reality on pain relief disadvantages despite all the merits of vr therapy as listed in the sections above, there are pitfalls and obstacles in the development of widespread vr solutions. cost effectiveness: vret may show promising returns on investment but the fact remains that the true development cost of vret environments depends heavily on the choice of hardware and software chosen. treatment effectiveness: for the treatment to take effect, a patient should be able to successfully project and experience their anxiety in a virtual environment. unfortunately, this projection is highly subjective and personalised per patient; and outside the control of the therapists. this limitation might adversely impact the therapy. migrating back to reality from virtual reality: another skepticism is the correlation between virtual reality and actual reality. if a patient successfully combats their phobia in a virtual environment, does that guarantee success in real life too? further, when treating more complicated ailments such as schizophrenia, there is inadequate projection on how delusions and hallucinations may translate from the real world to the virtual one. vr sickness: movement in a virtual environment is said to cause visual discomfort. prolonged periods of exposure to vr may lead to side effects like dry eyes, headaches, nausea and sweating; symptoms similar to motion sickness. ethical and legal considerations: since vr is a relatively new technology, its ethical implications are not as comprehensive as other forms of treatment. there is a need to formalize the limits, side effects, disclaimers, privacy regulations as we increase the breadth of impact of vr therapy; especially in matters related to forensic cases. acceptance by the medical community: as vr-based therapy increases, it might pose a challenge to licensed therapists and medical professionals who may perceive vr as a threat. afterall, vr deviates from the pre-established norm of "talking cure" . therapeutical targets depression in february 2006 the uk's national institute of health and clinical excellence (nice) recommended that vrt be made available for use within the nhs across england and wales, for patients presenting with mild/moderate depression, rather than immediately opting for antidepressant medication. some areas have developed, or are trialing. at auckland university in new zealand, a team led by dr. sally merry have been developing a computerized cbt fantasy "serious" game to help tackle depression amongst adolescents. the game, sparx, has a number of features to help combat depression, where the user takes on a role of a character who travels through a fantasy world, combating "literal" negative thoughts and learning techniques to manage their depression. eating disorders and body dysmorphia virtual reality therapy has also been used to attempt to treat eating disorders and body dysmorphia. one study in 2013 had participants complete various tasks in virtual reality environments which could not have been easily replicated without the technology. tasks included showing patients the implications of reaching their desired weight, comparing their actual body shape to an avatar created using their perceived body size, and altering a virtual reflection to match their actual body size. gender dysphoria early research suggests that virtual reality experiences may offer therapeutic benefits to transgender individuals experiencing gender dysphoria. more experimentation and professional examination is needed before virtual reality could be prescribed as a treatment in practice. however, some transgender individuals have engaged in what can be characterized as an anecdotally alleviating form of self-administered, virtual sex reassignment therapy. digital spaces offer a form of anonymous self-expression that trans individuals, due to exposure of discrimination and violence, are not fully granted to them in real life or irl. the sophistication of virtual reality expands on these newfound liberties by providing an avenue for those with gender dysphoria to embody their gender identity, if it not accessible for them to do so in their real life. through use of available vr videogames and chat rooms, those with gender dysphoria can create avatars of themselves, interact anonymously, and work towards therapeutic goals. acrophobia a study published in the lancent psychiatry proved that virtual reality therapy can help treat acrophobia. over the course of the study, participants were introduced to intimidating heights in a virtual reality environment then asked to complete various activities at those heights while under the supervision and support of a coach. this study, although insufficient in terms of scope and scrutiny for direct adoption into remedial practices, surrounds future research and treatment modeling with promise, as a majority of the participants considered themselves no longer afraid of heights. stroke research suggests that patients who had a stroke found virtual reality (vr) rehab techniques in their physical therapy treatment plans very beneficial. throughout a rehabilitation program aimed to restore and/or retain balance and walking skills, patients who have had a stroke often must relearn how to control certain muscles. in most physical therapy settings, this is done through high intensity, repetitive, and task-specific practice. programs of this type can prove to be physically demanding, are expensive, and require several days of training per week. additionally, regimens may seem redundant, and produce only modest and/or delayed effects in patient recovery. a physical therapy regimen using vr provides an opportunity to individualize training to fit the specific needs of the patient. while the exercises and movements required for proper motor learning can seem repetitive, using vr adds a level of intrigue and engagement for the patient. training with vr enhances motor learning by giving the patient opportunities to practice their movements/exercise protocol in different vr environments. this ensures that patients are always challenged and may be better prepared to perform in their environments. feedback is an important element of physical therapy for patients recovering from stroke and/or other neuromuscular disorders. within the scope of motor learning, receiving feedback during performance of a task improves the learning rate. according to a cochrane review, visual feedback, specifically, has been shown to aid in balance recovery for patients who have had a stroke. vr can provide continuous visual feedback that a physical therapist may not be able to during their sessions. results have also suggested that in addition to improvements in balance, positive effects are also seen in walking ability. in one study, patients with vr training coupled with their physical therapy program had better improvements in walking speed than others not using vr training. the most recent review about the effect of vr training on balance and gait ability showed significant benefits of vr training on gait speed, berg balance scale (bbs) scores, and timed "up & go" test scores when vr was time dose matched to conventional therapy. parkinson's disease many studies (cochrane review) have shown that using vr technology during physical therapy treatments for patients with parkinson's disease had positive outcomes. for patients with pd the vr therapy: increased gait and balance. improved functions of activities of daily living (adl's). improved quality of life. improved cognitive function. it is speculated that these improvements occurred because the vr gave increased feedback to the patient regarding their performance during the vr sessions. vr stimulates a patient's motor and cognitive processes, both of which may be impaired as a result of the disease. another benefit of vr is that it replicates real life scenarios, allowing patients to practice functional activities. wound care additionally, vr provides beneficial outcomes when it is implemented for patients who are receiving wound care rehabilitation. studies have speculated that the more immersive the vr, the greater the experience and concentration the patient will have on the virtual environment. equally important, vr has shown to reduce pain, anxiety and depressive symptoms, as well as an increasing their treatment adherence. in other studies, the results point to the benefits of vr in relation to increased distraction, and patients reported less time thinking about pain, less intense pain and immersion, which facilitates care such as dressing changes and physiotherapy. wound dressing often generates a pain-provoking experience. therefore, use of vr was related to more efficient dressings, increased distraction from the pain during procedures (e.g. dressing and physical rehabilitation) which reduced the patients' stress and anxiety. cardiovascular the use of vr and video games could be considered as complementary tools for physical training in patients with cardiovascular diseases. certain games designed for exercise have been shown to promote increases in heart rate, fatigue perception, and physical activity. in addition, it has been shown to reduce pain and increase adherence to physical therapy programs in patients with cardiovascular diseases. finally, virtual reality and video games enhance motivation and adherence in cardiac rehabilitation programs. autism virtual reality has been shown to improve the social skills of young adults with autism. in one study, participants controlled a virtual avatar in different virtual environments and maneuvered through various social tasks such as interviewing, meeting new people, and dealing with arguments. researchers found that participants improved in the areas of emotional recognition in voices and faces and in considering the thoughts of other people. participants were also surveyed months after the study for how effective they thought the treatments were, and the responses were overwhelmingly positive. many other studies have also explored this occupational therapy option. attention deficit hyperactivity disorder a clinical trial published in the journal of attention disorders found that school age children with adhd who underwent a virtual classroom cognitive treatment series were able to achieve the same management of symptoms of impulsivity and distractibility as children who were medicated with a stimulant. post-traumatic stress disorder it may also be possible to use virtual reality to assist those with ptsd. the virtual reality allows the patients to relive their combat situations at different extremes as a therapist can be there with them guiding them through the process. some scholars believe that this is an effective way to treat ptsd patients as it allows for the recreation of exactly what they experienced. "it allows for greater engagement by the patient and, consequently, greater activation of the traumatic memory, which is necessary for the extinction of the conditioned fear." stroke virtual reality also has applications in the physical side of occupational therapy. for stroke patients, various virtual reality technologies can help bring fine control back to different muscle groups. therapy often includes games controlled with haptic-feedback controllers that require fine movements, such as playing piano with a virtual hand. the wii gaming system has also been used in conjunction with virtual reality as a treatment method. the impact of virtual reality on chronic pain. chronic and acute pain virtual reality (vr) has been shown to be effective in immediately decreasing procedural or acute pain. to date there have been few studies on its efficacy in chronic pain. such chronic pain patients can tolerate the vr session without the side effects that sometimes come with vr such as headaches, dizziness or nausea. rehab virtual reality is also helping patients overcome balance and mobility problems resulting from stroke or head injury. in the study of vr, the modest advantage of vr over conventional training supports further investigation of the effect of video-capture vr or vr combined with conventional therapy in larger-scale randomized, more intense controlled studies. it shows the vr-assisted patients had better mobility when the doctors checked in two months later. other research has shown similarly successful outcomes for patients with cerebral palsy undergoing rehab for balance problems. surgery vr smoothly blurs the demarcation between the physical world and the computer simulation as surgeons can use latest versions of virtual reality glasses to interact in a