Anatomy of a fall in virtual reality: a major breakthrough against the fear of falling in the elderly
- KineQuantum
- 6 days ago
- 7 min read
Balance disorders, amplified by the fear of falling, represent a psychological challenge for seniors, with a prevalence of 3% to 92% (Schoene et al., 2019).
This fear can induce avoidance behavior, in which individuals limit their physical activity due to kinesiophobia, or fear of falling. This can unfortunately lead to reduced mobility and a loss of independence (Tinetti & Powell, 1993; Lachman et al., 1998; Gaxatte et al., 2011).
This vicious cycle of deconditioning and increased risk of falls constitutes a real public health issue.
Dr. Hajer Rmadi explores these complex dynamics in her thesis, "A Postural-Behavioral Approach to Fear of Falling in Virtual Reality: Acceptance and Perspectives for Management in the Elderly" (2023). She highlights the mechanisms explaining the links between the emotion of "fear of falling" and posture, as well as the potential of virtual reality for rehabilitation as an innovative therapeutic intervention.
In his doctoral work, Dr. Rmadi conducted 3 studies: the first on the acceptance of virtual reality by the elderly, then two studies on reactions related to the fear of falling when exposing elderly subjects and then young subjects under 30 years of age to virtual reality.
Innovation in geriatrics: the potential of virtual reality (VR)
Virtual reality presents itself as a promising solution for addressing the fear of falling, allowing the creation of controlled environments where fall scenarios can be simulated without risk. This approach would promote a gradual habituation to the sensation of imbalance (Grenier et al., 2015).
However, this requires prior acceptance of virtual reality and its integration into care protocols for elderly subjects.
In his doctoral work, Dr. Rmadi demonstrates a positive adherence to virtual reality among 33 people, with an average age of 89.3 years, living in 8 different nursing homes.
Immersive virtual reality is not only well tolerated, but also well accepted by a senior audience, paving the way for broader therapeutic applications.
Facing the fear of falling: deciphering emotions and postural reactions
Dr. Rmadi goes on to examine the influence of fear on postural reactions in virtual environments and the effect of repeated exposure through two studies with elderly and young subjects, in collaboration with KineQuantum.
The experiment with older adults was conducted as a two-center randomized crossover trial. The 27 participants were over 65 years old and able to maintain a bipedal stance for at least 5 minutes. They were exposed to two types of virtual scenarios: a forward Tilt (B) scene simulating a previous fall, and a Translation (T) scene reproducing forward movement without a fall.
The participants were then exposed to these scenes repeatedly, to assess the evolution of the participants' reactions.
When virtual reality simulates fear: a virtual fall, but a phobic reality
The scene of the seesaw (falling forward) generates more fear than the translation in young and old people.
Analysis of emotional responses reveals a significant increase in fear during the first exposure to the Tipping Point scenario.
This translates to an average of 4.57 out of 10 on the Numerical Fear Scale (NFS), compared to only 0.90 for the Translation Scale.
Several key factors explain why the Seesaw scene is perceived as more fearful by older people than by younger people. These factors include their understanding of falling, their history of falls, and a perceived feeling of helplessness in the face of such a fall. This combination of factors has thus allowed researchers to attribute the phobic nature of falling in virtual reality .
Psychological fear in virtual reality: very real postural reactions
Both younger and older participants also developed more postural reactions in the Seesaw scene. In older subjects, postural attitudes (center of pressure length and phase diagram area) resulted from a decrease in the attentional resources needed to mobilize them both towards falling and towards postural control.
Indeed, attentional reserves diminish with age, and maintaining posture becomes particularly cognitively demanding for older adults. Thus, the attentional bias directed at the threat of falling would lead to excessive postural alterations in seniors when exposed to virtual falls.
The crucial role of sight in managing fear of falling: the impact of visual stimuli on posture
The high changes in subjects' postural reactions can be attributed to the intense visual stimulation and sensation of movement induced by the virtual reality headset, which amplify the impression of imbalance and, consequently, the fear of falling.
Indeed, an increased level of postural anxiety influences the sensory reweighting process involved in posture control by increasing visual anchoring in the face of perceived threat (Bolmont et al. 2002; Hainaut et al. 2011).
The participants therefore developed a dependence on visual information and this altered their perception of spatial reference points and subjective verticality (Barra et al., 2010).
This observation is validated by Viaud-Delmon et al. (2001) who explain that, in threatening situations, states of anxiety are accompanied by a visual dependence and a difficulty in constructing a coherent perception of the body's position in space.
Given the link between subjective verticality and postural disorders (particularly retropulsion) (Manckoundia et al., 2007), individuals' postural and behavioral reactions upon threat perception are a consequence of a bias in the perception of physical verticality. The impact of visual stimulation induced by virtual reality on muscle reactivity must also be considered.
Technology at the service of physiotherapists: overcoming the fear of falling with virtual reality
The gradual reduction of fear: the effect of emotional habituation
A gradual decrease in fear was measured over the course of exposures to the Seesaw scene. This translates into a decrease in the ENP from 4.57 initially to 1.52 after several occurrences, highlighting a significant phenomenon of emotional habituation.
Indeed, repeated exposure to an object initially perceived as phobic and threatening can gradually modify the cognitive pattern of fear associated with that situation (Lambrey et al., 2010).
Through this process, participants perceive the previous void and fall as less and less worrisome, thus reducing their feelings of fear and imbalance. This finding has also been observed in other studies in which emotional and cognitive changes were noted following repeated exposure to the threat (Zaback et al., 2019b).
Postural and behavioral transformation through virtual reality
Beyond the habituation of emotional reactions, repeated exposure to the virtual fall scene also allowed for a reduction in postural-behavioral responses .
A cognitive release of attentional resources, initially allocated to the threat, partly explains this decrease. Postural adjustments gradually became more automatic, and postural control became less costly during subsequent exposures. This adaptation resulted in a reduction in the area of the phase diagram from the second exposure onward , and this reduction continued during the 11 subsequent exposures.
The participants quickly acclimated to the threat of falling, adopting a more effective balancing strategy.
In addition to this neurological mechanism, a sensory process also facilitates postural adaptation. As the fall was no longer perceived as threatening, the visual anchoring initially attributed to the threat diminished with repeated exposures, reducing visual dependence and improving the patient's postural attitude.
These results refer back to Cognitive Behavioral Theories (CBT), in which the approach is based on repeated exposure to the source of the phobia in order to mitigate emotional reactions and adapt behavior.
Virtual reality: a powerful tool for cognitive-behavioral therapy
Behavioral desensitization techniques systematically expose individuals to a threatening stimulus in order to reduce or normalize the emotional and behavioral response to that threat (Lang & Craske, 2000).
However, to guarantee the validity and effectiveness of Cognitive Behavioral Therapy (CBT), certain conditions must be met: accurate reproduction of the phobic object and the possibility of reducing, following multiple exposures, the associated subjective fear as well as an improvement in related reactions (Hofmann et al., 2012). This is what this doctoral work has demonstrated.
Breakthrough in the fight against PMSD: The winning alliance of virtual reality and CBT
Psychomotor Disadaptation Syndrome (PMDS) is one of the most serious and frequent complications of falls for the elderly, sometimes affecting up to 75% of patients hospitalized following a fall (Manckoundia et al., 2014).
Individuals with PDMS evaluate certain situations as more threatening than they actually are and respond accordingly with an exaggerated defensive posture.
Dr. Rmadi observed that, during an initial exposure to a fall, participants experienced fear and postural-behavioral reactions similar to those described in the SDPM. She demonstrated that by repeatedly exposing participants to a scene simulating a fall, the range of emotional and postural-behavioral responses can be reduced .
The virtual reality scenario thus meets the necessary conditions for the application of CBT to re-educate the psychological and postural-behavioral components of PDMS.
Virtual reality, a very promising tool for seniors
Dr. Rmadi's work has demonstrated that:
Virtual reality can be used safely with elderly subjects .
A virtual reality scene simulating a fall is a phobic component of the fear of falling.
The positive effect of repeated exposure to the phobic element on the attenuation of the psychological and postural components of the fear of falling .
Therapeutic virtual reality could be an effective tool for managing PMSD.
Applied progressively and adapted to the abilities of older people, it could reduce both the psychological and postural components of PDMS.
Exposure with this equipment would be gradual , depending on the patient's tolerance, with adjustable speed and rotation amplitude . This would complement rehabilitation therapy, which would confront the individual with their own fear in the real world. This transposition would allow the transfer of learning acquired through virtual reality exposure to the real environment. Motor rehabilitation through physiotherapy could then consolidate and put these gains into practice, particularly with functional exercises.
The usefulness of virtual reality rehabilitation therapy combined with a physiotherapy program for seniors with postural control disorder (PCD) is therefore validated. Modernizing the management of psychological, psychomotor, and postural disorders in PCD through the use of virtual reality exposure therapy equipment proves to be interesting and very promising.
Dr. Rmadi's work confirms the importance and effectiveness of virtual reality as a therapeutic tool in addressing the fear of falling in older adults . The acceptance of virtual reality by seniors in nursing homes and its effectiveness in simulating phobic events opens up truly promising prospects for the treatment of postural anxiety disorder and, more generally, falls in older adults.
The increased use of virtual reality, particularly through VR rehabilitation devices such as KineQuantum, represents a significant advancement in geriatric care. We thank Dr. Rmadi for his work.
His innovative approach provides a solid foundation for the future development of individualized therapeutic methods, with exercises tailored to the specific needs of the aging population.
To learn more, also discover by clicking here the work carried out by Mathilde Mangin at the Geneva Institute for Home Care on falls.
Comments