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Extinction is an important mechanism to inhibit initially acquired fear responses. There is growing evidence that the ventromedial prefrontal cortex (vmPFC) inhibits the amygdala and therefore plays an important role in the extinction of delay fear conditioning. To our knowledge, there is no evidence on the role of the prefrontal cortex in the extinction of trace conditioning up to now. Thus, we compared brain structures involved in the extinction of human delay and trace fear conditioning in a between-subjects-design in an fMRI study. Participants were passively guided through a virtual environment during learning and extinction of conditioned fear. Two different lights served as conditioned stimuli (CS); as unconditioned stimulus (US) a mildly painful electric stimulus was delivered. In the delay conditioning group (DCG) the US was administered with offset of one light (CS+), whereas in the trace conditioning group (TCG) the US was presented 4s after CS+ offset. Both groups showed insular and striatal activation during early extinction, but differed in their prefrontal activation. The vmPFC was mainly activated in the DCG, whereas the TCG showed activation of the dorsolateral prefrontal cortex (dlPFC) during extinction. These results point to different extinction processes in delay and trace conditioning. VmPFC activation during extinction of delay conditioning might reflect the inhibition of the fear response. In contrast, dlPFC activation during extinction of trace conditioning may reflect modulation of working memory processes which are involved in bridging the trace interval and hold information in short term memory.
Virtual reality (VR) has made its way into mainstream psychological research in the last two decades. This technology, with its unique ability to simulate complex, real situations and contexts, offers researchers unprecedented opportunities to investigate human behavior in well controlled designs in the laboratory. One important application of VR is the investigation of pathological processes in mental disorders, especially anxiety disorders. Research on the processes underlying threat perception, fear, and exposure therapy has shed light on more general aspects of the relation between perception and emotion. Being by its nature virtual, i.e., simulation of reality, VR strongly relies on the adequate selection of specific perceptual cues to activate emotions. Emotional experiences in turn are related to presence, another important concept in VR, which describes the user's sense of being in a VR environment. This paper summarizes current research into perception of fear cues, emotion, and presence, aiming at the identification of the most relevant aspects of emotional experience in VR and their mutual relations. A special focus lies on a series of recent experiments designed to test the relative contribution of perception and conceptual information on fear in VR. This strand of research capitalizes on the dissociation between perception (bottom up input) and conceptual information (top-down input) that is possible in VR. Further, we review the factors that have so far been recognized to influence presence, with emotions (e.g., fear) being the most relevant in the context of clinical psychology. Recent research has highlighted the mutual influence of presence and fear in VR, but has also traced the limits of our current understanding of this relationship. In this paper, the crucial role of perception on eliciting emotional reactions is highlighted, and the role of arousal as a basic dimension of emotional experience is discussed. An interoceptive attribution model of presence is suggested as a first step toward an integrative framework for emotion research in VR. Gaps in the current literature and future directions are outlined.
Embodiment (i.e., the involvement of a bodily representation) is thought to be relevant in emotional experiences. Virtual reality (VR) is a capable means of activating phobic fear in patients. The representation of the patient’s body (e.g., the right hand) in VR enhances immersion and increases presence, but its effect on phobic fear is still unknown. We analyzed the influence of the presentation of the participant’s hand in VR on presence and fear responses in 32 women with spider phobia and 32 matched controls. Participants sat in front of a table with an acrylic glass container within reaching distance. During the experiment this setup was concealed by a head-mounted display (HMD). The VR scenario presented via HMD showed the same setup, i.e., a table with an acrylic glass container. Participants were randomly assigned to one of two experimental groups. In one group, fear responses were triggered by fear-relevant visual input in VR (virtual spider in the virtual acrylic glass container), while information about a real but unseen neutral control animal (living snake in the acrylic glass container) was given. The second group received fear-relevant information of the real but unseen situation (living spider in the acrylic glass container), but visual input was kept neutral VR (virtual snake in the virtual acrylic glass container). Participants were instructed to touch the acrylic glass container with their right hand in 20 consecutive trials. Visibility of the hand was varied randomly in a within-subjects design. We found for all participants that visibility of the participant’s hand increased presence independently of the fear trigger. However, in patients, the influence of the virtual hand on fear depended on the fear trigger. When fear was triggered perceptually, i.e., by a virtual spider, the virtual hand increased fear. When fear was triggered by information about a real spider, the virtual hand had no effect on fear. Our results shed light on the significance of different fear triggers (visual, conceptual) in interaction with body representations.
In this article, we present approaches to interactive simulations of biohybrid systems. These simulations are comprised of two major computational components: (1) agent-based developmental models that retrace organismal growth and unfolding of technical scaffoldings and (2) interfaces to explore these models interactively. Simulations of biohybrid systems allow us to fast forward and experience their evolution over time based on our design decisions involving the choice, configuration and initial states of the deployed biological and robotic actors as well as their interplay with the environment. We briefly introduce the concept of swarm grammars, an agent-based extension of L-systems for retracing growth processes and structural artifacts. Next, we review an early augmented reality prototype for designing and projecting biohybrid system simulations into real space. In addition to models that retrace plant behaviors, we specify swarm grammar agents to braid structures in a self-organizing manner. Based on this model, both robotic and plant-driven braiding processes can be experienced and explored in virtual worlds. We present an according user interface for use in virtual reality. As we present interactive models concerning rather diverse description levels, we only ensured their principal capacity for interaction but did not consider efficiency analyzes beyond prototypic operation. We conclude this article with an outlook on future works on melding reality and virtuality to drive the design and deployment of biohybrid systems.
Acrophobia is characterized by intense fear in height situations. Virtual reality (VR) can be used to trigger such phobic fear, and VR exposure therapy (VRET) has proven effective for treatment of phobias, although it remains important to further elucidate factors that modulate and mediate the fear responses triggered in VR. The present study assessed verbal and behavioral fear responses triggered by a height simulation in a 5-sided cave automatic virtual environment (CAVE) with visual and acoustic simulation and further investigated how fear responses are modulated by immersion, i.e., an additional wind simulation, and presence, i.e., the feeling to be present in the VE. Results revealed a high validity for the CAVE and VE in provoking height related self-reported fear and avoidance behavior in accordance with a trait measure of acrophobic fear. Increasing immersion significantly increased fear responses in high height anxious (HHA) participants, but did not affect presence. Nevertheless, presence was found to be an important predictor of fear responses. We conclude that a CAVE system can be used to elicit valid fear responses, which might be further enhanced by immersion manipulations independent from presence. These results may help to improve VRET efficacy and its transfer to real situations.
Context conditioning is characterized by unpredictable threat and its generalization may constitute risk factors for panic disorder (PD). Therefore, we examined differences between individuals with panic attacks (PA; N = 21) and healthy controls (HC, N = 22) in contextual learning and context generalization using a virtual reality (VR) paradigm. Successful context conditioning was indicated in both groups by higher arousal, anxiety and contingency ratings, and increased startle responses and skin conductance levels (SCLs) in an anxiety context (CTX+) where an aversive unconditioned stimulus (US) occurred unpredictably vs. a safety context (CTX−). PA compared to HC exhibited increased differential responding to CTX+ vs. CTX− and overgeneralization of contextual anxiety on an evaluative verbal level, but not on a physiological level. We conclude that increased contextual conditioning and contextual generalization may constitute risk factors for PD or agoraphobia contributing to the characteristic avoidance of anxiety contexts and withdrawal to safety contexts and that evaluative cognitive process may play a major role.
Investigating approach-avoidance behavior regarding affective stimuli is important in broadening the understanding of one of the most common psychiatric disorders, social anxiety disorder. Many studies in this field rely on approach-avoidance tasks, which mainly assess hand movements, or interpersonal distance measures, which return inconsistent results and lack ecological validity. Therefore, the present study introduces a virtual reality task, looking at avoidance parameters (movement time and speed, distance to social stimulus, gaze behavior) during whole-body movements. These complex movements represent the most ecologically valid form of approach and avoidance behavior. These are at the core of complex and natural social behavior. With this newly developed task, the present study examined whether high socially anxious individuals differ in avoidance behavior when bypassing another person, here virtual humans with neutral and angry facial expressions. Results showed that virtual bystanders displaying angry facial expressions were generally avoided by all participants. In addition, high socially anxious participants generally displayed enhanced avoidance behavior towards virtual people, but no specifically exaggerated avoidance behavior towards virtual people with a negative facial expression. The newly developed virtual reality task proved to be an ecological valid tool for research on complex approach-avoidance behavior in social situations. The first results revealed that whole body approach-avoidance behavior relative to passive bystanders is modulated by their emotional facial expressions and that social anxiety generally amplifies such avoidance.
Virtual reality plays an increasingly important role in research and therapy of pathological fear. However, the mechanisms how virtual environments elicit and modify fear responses are not yet fully understood. Presence, a psychological construct referring to the ‘sense of being there’ in a virtual environment, is widely assumed to crucially influence the strength of the elicited fear responses, however, causality is still under debate. The present study is the first that experimentally manipulated both variables to unravel the causal link between presence and fear responses. Height-fearful participants (N = 49) were immersed into a virtual height situation and a neutral control situation (fear manipulation) with either high versus low sensory realism (presence manipulation). Ratings of presence and verbal and physiological (skin conductance, heart rate) fear responses were recorded. Results revealed an effect of the fear manipulation on presence, i.e., higher presence ratings in the height situation compared to the neutral control situation, but no effect of the presence manipulation on fear responses. However, the presence ratings during the first exposure to the high quality neutral environment were predictive of later fear responses in the height situation. Our findings support the hypothesis that experiencing emotional responses in a virtual environment leads to a stronger feeling of being there, i.e., increase presence. In contrast, the effects of presence on fear seem to be more complex: on the one hand, increased presence due to the quality of the virtual environment did not influence fear; on the other hand, presence variability that likely stemmed from differences in user characteristics did predict later fear responses. These findings underscore the importance of user characteristics in the emergence of presence.
Latency is a key characteristic inherent to any computer system. Motion-to-Photon (MTP) latency describes the time between the movement of a tracked object and its corresponding movement rendered and depicted by computer-generated images on a graphical output screen. High MTP latency can cause a loss of performance in interactive graphics applications and, even worse, can provoke cybersickness in Virtual Reality (VR) applications. Here, cybersickness can degrade VR experiences or may render the experiences completely unusable. It can confound research findings of an otherwise sound experiment. Latency as a contributing factor to cybersickness needs to be properly understood. Its effects need to be analyzed, its sources need to be identified, good measurement methods need to be developed, and proper counter measures need to be developed in order to reduce potentially harmful impacts of latency on the usability and safety of VR systems. Research shows that latency can exhibit intricate timing patterns with various spiking and periodic behavior. These timing behaviors may vary, yet most are found to provoke cybersickness. Overall, latency can differ drastically between different systems interfering with generalization of measurement results. This review article describes the causes and effects of latency with regard to cybersickness. We report on different existing approaches to measure and report latency. Hence, the article provides readers with the knowledge to understand and report latency for their own applications, evaluations, and experiments. It should also help to measure, identify, and finally control and counteract latency and hence gain confidence into the soundness of empirical data collected by VR exposures. Low latency increases the usability and safety of VR systems.
Measurements of physiological parameters provide an objective, often non-intrusive, and (at least semi-)automatic evaluation and utilization of user behavior. In addition, specific hardware devices of Virtual Reality (VR) often ship with built-in sensors, i.e. eye-tracking and movements sensors. Hence, the combination of physiological measurements and VR applications seems promising. Several approaches have investigated the applicability and benefits of this combination for various fields of applications. However, the range of possible application fields, coupled with potentially useful and beneficial physiological parameters, types of sensor, target variables and factors, and analysis approaches and techniques is manifold. This article provides a systematic overview and an extensive state-of-the-art review of the usage of physiological measurements in VR. We identified 1,119 works that make use of physiological measurements in VR. Within these, we identified 32 approaches that focus on the classification of characteristics of experience, common in VR applications. The first part of this review categorizes the 1,119 works by field of application, i.e. therapy, training, entertainment, and communication and interaction, as well as by the specific target factors and variables measured by the physiological parameters. An additional category summarizes general VR approaches applicable to all specific fields of application since they target typical VR qualities. In the second part of this review, we analyze the target factors and variables regarding the respective methods used for an automatic analysis and, potentially, classification. For example, we highlight which measurement setups have been proven to be sensitive enough to distinguish different levels of arousal, valence, anxiety, stress, or cognitive workload in the virtual realm. This work may prove useful for all researchers wanting to use physiological data in VR and who want to have a good overview of prior approaches taken, their benefits and potential drawbacks.
Mindfulness is considered an important factor of an individual's subjective well-being. Consequently, Human-Computer Interaction (HCI) has investigated approaches that strengthen mindfulness, i.e., by inventing multimedia technologies to support mindfulness meditation. These approaches often use smartphones, tablets, or consumer-grade desktop systems to allow everyday usage in users' private lives or in the scope of organized therapies. Virtual, Augmented, and Mixed Reality (VR, AR, MR; in short: XR) significantly extend the design space for such approaches. XR covers a wide range of potential sensory stimulation, perceptive and cognitive manipulations, content presentation, interaction, and agency. These facilities are linked to typical XR-specific perceptions that are conceptually closely related to mindfulness research, such as (virtual) presence and (virtual) embodiment. However, a successful exploitation of XR that strengthens mindfulness requires a systematic analysis of the potential interrelation and influencing mechanisms between XR technology, its properties, factors, and phenomena and existing models and theories of the construct of mindfulness. This article reports such a systematic analysis of XR-related research from HCI and life sciences to determine the extent to which existing research frameworks on HCI and mindfulness can be applied to XR technologies, the potential of XR technologies to support mindfulness, and open research gaps. Fifty papers of ACM Digital Library and National Institutes of Health's National Library of Medicine (PubMed) with and without empirical efficacy evaluation were included in our analysis. The results reveal that at the current time, empirical research on XR-based mindfulness support mainly focuses on therapy and therapeutic outcomes. Furthermore, most of the currently investigated XR-supported mindfulness interactions are limited to vocally guided meditations within nature-inspired virtual environments. While an analysis of empirical research on those systems did not reveal differences in mindfulness compared to non-mediated mindfulness practices, various design proposals illustrate that XR has the potential to provide interactive and body-based innovations for mindfulness practice. We propose a structured approach for future work to specify and further explore the potential of XR as mindfulness-support. The resulting framework provides design guidelines for XR-based mindfulness support based on the elements and psychological mechanisms of XR interactions.
Psycho-pathological conditions, such as depression or schizophrenia, are often accompanied by a distorted perception of time. People suffering from this conditions often report that the passage of time slows down considerably and that they are “stuck in time.” Virtual Reality (VR) could potentially help to diagnose and maybe treat such mental conditions. However, the conditions in which a VR simulation could correctly diagnose a time perception deviation are still unknown. In this paper, we present an experiment investigating the difference in time experience with and without a virtual body in VR, also known as avatar. The process of substituting a person’s body with a virtual body is called avatar embodiment. Numerous studies demonstrated interesting perceptual, emotional, behavioral, and psychological effects caused by avatar embodiment. However, the relations between time perception and avatar embodiment are still unclear. Whether or not the presence or absence of an avatar is already influencing time perception is still open to question. Therefore, we conducted a between-subjects design with and without avatar embodiment as well as a real condition (avatar vs. no-avatar vs. real). A group of 105 healthy subjects had to wait for seven and a half minutes in a room without any distractors (e.g., no window, magazine, people, decoration) or time indicators (e.g., clocks, sunlight). The virtual environment replicates the real physical environment. Participants were unaware that they will be asked to estimate their waiting time duration as well as describing their experience of the passage of time at a later stage. Our main finding shows that the presence of an avatar is leading to a significantly faster perceived passage of time. It seems to be promising to integrate avatar embodiment in future VR time-based therapy applications as they potentially could modulate a user’s perception of the passage of time. We also found no significant difference in time perception between the real and the VR conditions (avatar, no-avatar), but further research is needed to better understand this outcome.
The successful development and classroom integration of Virtual (VR) and Augmented Reality (AR) learning environments requires competencies and content knowledge with respect to media didactics and the respective technologies. The paper discusses a pedagogical concept specifically aiming at the interdisciplinary education of pre-service teachers in collaboration with human-computer interaction students. The students’ overarching goal is the interdisciplinary realization and integration of VR/AR learning environments in teaching and learning concepts. To assist this approach, we developed a specific tutorial guiding the developmental process. We evaluate and validate the effectiveness of the overall pedagogical concept by analyzing the change in attitudes regarding 1) the use of VR/AR for educational purposes and in competencies and content knowledge regarding 2) media didactics and 3) technology. Our results indicate a significant improvement in the knowledge of media didactics and technology. We further report on four STEM learning environments that have been developed during the seminar.
This article introduces the Off-The-Shelf Stylus (OTSS), a framework for 2D interaction (in 3D) as well as for handwriting and sketching with digital pen, ink, and paper on physically aligned virtual surfaces in Virtual, Augmented, and Mixed Reality (VR, AR, MR: XR for short). OTSS supports self-made XR styluses based on consumer-grade six-degrees-of-freedom XR controllers and commercially available styluses. The framework provides separate modules for three basic but vital features: 1) The stylus module provides stylus construction and calibration features. 2) The surface module provides surface calibration and visual feedback features for virtual-physical 2D surface alignment using our so-called 3ViSuAl procedure, and surface interaction features. 3) The evaluation suite provides a comprehensive test bed combining technical measurements for precision, accuracy, and latency with extensive usability evaluations including handwriting and sketching tasks based on established visuomotor, graphomotor, and handwriting research. The framework’s development is accompanied by an extensive open source reference implementation targeting the Unity game engine using an Oculus Rift S headset and Oculus Touch controllers. The development compares three low-cost and low-tech options to equip controllers with a tip and includes a web browser-based surface providing support for interacting, handwriting, and sketching. The evaluation of the reference implementation based on the OTSS framework identified an average stylus precision of 0.98 mm (SD = 0.54 mm) and an average surface accuracy of 0.60 mm (SD = 0.32 mm) in a seated VR environment. The time for displaying the stylus movement as digital ink on the web browser surface in VR was 79.40 ms on average (SD = 23.26 ms), including the physical controller’s motion-to-photon latency visualized by its virtual representation (M = 42.57 ms, SD = 15.70 ms). The usability evaluation (N = 10) revealed a low task load, high usability, and high user experience. Participants successfully reproduced given shapes and created legible handwriting, indicating that the OTSS and it’s reference implementation is ready for everyday use. We provide source code access to our implementation, including stylus and surface calibration and surface interaction features, making it easy to reuse, extend, adapt and/or replicate previous results (https://go.uniwue.de/hci-otss).
In this paper, we present a virtual audience simulation system for Virtual Reality (VR). The system implements an audience perception model controlling the nonverbal behaviors of virtual spectators, such as facial expressions or postures. Groups of virtual spectators are animated by a set of nonverbal behavior rules representing a particular audience attitude (e.g., indifferent or enthusiastic). Each rule specifies a nonverbal behavior category: posture, head movement, facial expression and gaze direction as well as three parameters: type, frequency and proportion. In a first user-study, we asked participants to pretend to be a speaker in VR and then create sets of nonverbal behaviour parameters to simulate different attitudes. Participants manipulated the nonverbal behaviours of single virtual spectator to match a specific levels of engagement and opinion toward them. In a second user-study, we used these parameters to design different types of virtual audiences with our nonverbal behavior rules and evaluated their perceptions. Our results demonstrate our system’s ability to create virtual audiences with three types of different perceived attitudes: indifferent, critical, enthusiastic. The analysis of the results also lead to a set of recommendations and guidelines regarding attitudes and expressions for future design of audiences for VR therapy and training applications.
Effects of Acrophobic Fear and Trait Anxiety on Human Behavior in a Virtual Elevated Plus-Maze
(2021)
The Elevated Plus-Maze (EPM) is a well-established apparatus to measure anxiety in rodents, i.e., animals exhibiting an increased relative time spent in the closed vs. the open arms are considered anxious. To examine whether such anxiety-modulated behaviors are conserved in humans, we re-translated this paradigm to a human setting using virtual reality in a Cave Automatic Virtual Environment (CAVE) system. In two studies, we examined whether the EPM exploration behavior of humans is modulated by their trait anxiety and also assessed the individuals’ levels of acrophobia (fear of height), claustrophobia (fear of confined spaces), sensation seeking, and the reported anxiety when on the maze. First, we constructed an exact virtual copy of the animal EPM adjusted to human proportions. In analogy to animal EPM studies, participants (N = 30) freely explored the EPM for 5 min. In the second study (N = 61), we redesigned the EPM to make it more human-adapted and to differentiate influences of trait anxiety and acrophobia by introducing various floor textures and lower walls of closed arms to the height of standard handrails. In the first experiment, hierarchical regression analyses of exploration behavior revealed the expected association between open arm avoidance and Trait Anxiety, an even stronger association with acrophobic fear. In the second study, results revealed that acrophobia was associated with avoidance of open arms with mesh-floor texture, whereas for trait anxiety, claustrophobia, and sensation seeking, no effect was detected. Also, subjects’ fear rating was moderated by all psychometrics but trait anxiety. In sum, both studies consistently indicate that humans show no general open arm avoidance analogous to rodents and that human EPM behavior is modulated strongest by acrophobic fear, whereas trait anxiety plays a subordinate role. Thus, we conclude that the criteria for cross-species validity are met insufficiently in this case. Despite the exploratory nature, our studies provide in-depth insights into human exploration behavior on the virtual EPM.
The design and evaluation of assisting technologies to support behavior change processes have become an essential topic within the field of human-computer interaction research in general and the field of immersive intervention technologies in particular. The mechanisms and success of behavior change techniques and interventions are broadly investigated in the field of psychology. However, it is not always easy to adapt these psychological findings to the context of immersive technologies. The lack of theoretical foundation also leads to a lack of explanation as to why and how immersive interventions support behavior change processes. The Behavioral Framework for immersive Technologies (BehaveFIT) addresses this lack by 1) presenting an intelligible categorization and condensation of psychological barriers and immersive features, by 2) suggesting a mapping that shows why and how immersive technologies can help to overcome barriers and finally by 3) proposing a generic prediction path that enables a structured, theory-based approach to the development and evaluation of immersive interventions. These three steps explain how BehaveFIT can be used, and include guiding questions for each step. Further, two use cases illustrate the usage of BehaveFIT. Thus, the present paper contributes to guidance for immersive intervention design and evaluation, showing that immersive interventions support behavior change processes and explain and predict 'why' and 'how' immersive interventions can bridge the intention-behavior-gap.
Impaired decision-making leads to the inability to distinguish between advantageous and disadvantageous choices. The impairment of a person’s decision-making is a common goal of gambling games. Given the recent trend of gambling using immersive Virtual Reality it is crucial to investigate the effects of both immersion and the virtual environment (VE) on decision-making. In a novel user study, we measured decision-making using three virtual versions of the Iowa Gambling Task (IGT). The versions differed with regard to the degree of immersion and design of the virtual environment. While emotions affect decision-making, we further measured the positive and negative affect of participants. A higher visual angle on a stimulus leads to an increased emotional response. Thus, we kept the visual angle on the Iowa Gambling Task the same between our conditions. Our results revealed no significant impact of immersion or the VE on the IGT. We further found no significant difference between the conditions with regard to positive and negative affect. This suggests that neither the medium used nor the design of the VE causes an impairment of decision-making. However, in combination with a recent study, we provide first evidence that a higher visual angle on the IGT leads to an effect of impairment.
Background: The rehabilitation of gait disorders in patients with multiple sclerosis (MS) and stroke is often based on conventional treadmill training. Virtual reality (VR)-based treadmill training can increase motivation and improve therapy outcomes. The present study evaluated an immersive virtual reality application (using a head-mounted display, HMD) for gait rehabilitation with patients to (1) demonstrate its feasibility and acceptance and to (2) compare its short-term effects to a semi-immersive presentation (using a monitor) and a conventional treadmill training without VR to assess the usability of both systems and estimate the effects on walking speed and motivation. Methods: In a within-subjects study design, 36 healthy participants and 14 persons with MS or stroke participated in each of the three experimental conditions (VR via HMD, VR via monitor, treadmill training without VR). Results: For both groups, the walking speed in the HMD condition was higher than in treadmill training without VR and in the monitor condition. Healthy participants reported a higher motivation after the HMD condition as compared with the other conditions. Importantly, no side effects in the sense of simulator sickness occurred and usability ratings were high. No increases in heart rate were observed following the VR conditions. Presence ratings were higher for the HMD condition compared with the monitor condition for both user groups. Most of the healthy study participants (89%) and patients (71%) preferred the HMD-based training among the three conditions and most patients could imagine using it more frequently. Conclusions For the first time, the present study evaluated the usability of an immersive VR system for gait rehabilitation in a direct comparison with a semi-immersive system and a conventional training without VR with healthy participants and patients. The study demonstrated the feasibility of combining a treadmill training with immersive VR. Due to its high usability and low side effects, it might be particularly suited for patients to improve training motivation and training outcome e. g. the walking speed compared with treadmill training using no or only semi-immersive VR. Immersive VR systems still require specific technical setup procedures. This should be taken into account for specific clinical use-cases during a cost-benefit assessment.