Virtual Natural Environments for Restoration and Rehabilitation in Healthcare

  • Robert StoneEmail author
  • Charlotte Small
  • James Knight
  • Cheng Qian
  • Vishant Shingari
Part of the Intelligent Systems Reference Library book series (ISRL, volume 68)


For over two decades, research and clinical projects have exploited Virtual Reality technologies in the treatment of numerous human conditions, from desensitisation régimes combating phobias to the use of distraction and exposure therapies for burns victims and those suffering from post-traumatic stress disorders. In contrast to previous “high-tech” interface and combat-oriented approaches to using VR in the psychological rehabilitation process, the present chapter advocates the use of virtual restorative environments (VREs)—the recreation of locations and scenes that, by virtue of their natural beauty and peacefulness, can significantly help to reduce the body’s reactivity to stress and restore cognitive or attentional capacities. The chapter also argues that VREs, suitably enhanced with more interactive and dynamic features, could offer significant benefits to patients in physical rehabilitation programmes. This is especially the case for amputees, for example, who, whilst awaiting the fitting of prosthetic limbs, could undertake competitive and motivational “virtual exercises”, thereby avoiding muscle atrophy and related reductions in residual limb capabilities. The report concludes that the exploitation of simulation technologies in psychological therapies is worthy of continued investigation, especially in the pursuit of enhancing patients’ recovery profiles following surgical procedures, from intensive care to the hospital recovery ward. VREs possess a range of important qualities, not least significant of which is real-time interaction and ease-of-editing, supporting the cost-effective generation of engaging and distributable scenarios that can be tailored relatively easily to meet the needs of individual patients.


Virtual reality Rehabilitation Restoration Healthcare Human factors 


  1. 1.
    Abkar, M., Kamal, M.M.S., Maulan, S., Mariapan, M.: Influences of viewing nature through windows. Aust. J. Basic Appl. Sci. 4(10), 5346–5351 (2009)Google Scholar
  2. 2.
    Bangor, A., Kortum, P.T., Miller, J.T.: An empirical evaluation of the system usability scale. Int. J. Hum. Comput. Interact. 24(6), 574–594 (2008)CrossRefGoogle Scholar
  3. 3.
    Berman, M.G., Jonides, J., Kaplan, S.: The cognitive benefits of interacting with nature. Psychol. Sci. 19, 1207–1212 (2008)CrossRefGoogle Scholar
  4. 4.
    Berto, R.: Exposure to restorative environments helps restore attentional capacity. J. Environ. Psychol. 25, 249–259 (2005)CrossRefGoogle Scholar
  5. 5.
    Botella, C., Baños, R.M., Villa, H., Perpiñá, C.: Virtual Reality in the treatment of claustrophobic fear: a controlled, multiple-baseline design. Behav. Ther. 31(3), 583–595 (2000)CrossRefGoogle Scholar
  6. 6.
    Bringslimark, T., Hartig, T., Patil, G.G.: Adaptation to windowlessness: do office workers compensate for a lack of visual access to the outdoors? Environ. Behav. 43(4), 469–487 (2011)CrossRefGoogle Scholar
  7. 7.
    Brooke, J.: SUS: a quick and dirty usability scale. In: Jordan, P.W., Thomas, B., Weerdmeester, B.A., McClelland, I.L. (eds.) Usability Evaluation in Industry, pp. 189–194. Taylor & Francis, London (1996)Google Scholar
  8. 8.
    Carlin, A.S., Hoffman, H.G., Weghorst, S.: Virtual reality and tactile augmentation in the treatment of spider phobia: a case report. Behav. Res. Ther. 35(2), 153–158 (1997)CrossRefGoogle Scholar
  9. 9.
    Collimore, K.C., McCabe, R.E., Carleton, R.N., Asmundsen, G.J.G.: Media exposure and dimensions of anxiety sensitivity: differential associations with PTSD symptom clusters. J. Anxiety Disord. 22(6), 1021–1028 (2008)CrossRefGoogle Scholar
  10. 10.
    de Kort, Y.A.W., Ijsselsteijn, W.A.: Reality check: the role of realism in stress reduction using media technology. Cyber Psychol. Behav. 9(2), 230–233 (2006)CrossRefGoogle Scholar
  11. 11.
    Depledge, M.H., Bird, W.J.: The blue gym: health and well-being from our coasts. Mar. Pollut. Bull. 58, 947–948 (2009)CrossRefGoogle Scholar
  12. 12.
    Depledge, M.H., Stone, R.J., Bird, W.J.: Can natural and virtual environments be used to promote improved human health and wellbeing? Environ. Sci. Technol. 45(11), 4659–5064 (2011)CrossRefGoogle Scholar
  13. 13.
    Diette, G.B., Lechtzin, N., Haponik, E., Devrotes, A., Rubin, H.R.: Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy: a complementary approach to routine analgesia. Chest 123(3), 941–948 (2003)CrossRefGoogle Scholar
  14. 14.
    Difede, J., Cukor, J., Jayasinghe, N., Patt, I., Jedel, S., Spielman, L., Giosan, C., Hoffman, H.G.: Virtual reality exposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001. J. Clin. Psychiatry 68, 1639–1647 (2007)CrossRefGoogle Scholar
  15. 15.
    Difede, J., Hoffman, H.G.: Virtual reality exposure therapy for world trade center post-traumatic stress disorder: a case report. Cyber Psychol. Behav. 5(6), 529–535 (2002)CrossRefGoogle Scholar
  16. 16.
    Evans, G.W., McCoy, J.: When buildings don’t work: the role of architecture in human health. J. Environ. Psychol. 18(1), 85–94 (1998)CrossRefGoogle Scholar
  17. 17.
    Friedman, B., Freier, N.G., Kahn Jr, P.H.: Office windows of the future? Two case studies of an augmented window. In: Poster Presentation: Conference on Human Factors in Computing Systems, CHI 2004, Vienna, Austria (2004)Google Scholar
  18. 18.
    Friedman, B., Freier, N.G., Kahn Jr, P.H., Lin, P., Sodeman, R.: Office window of the future? Field-based analyses of a new use of a large display. Int. J. Hum. Comput. Stud. 66, 452–465 (2008)CrossRefGoogle Scholar
  19. 19.
    Galea, S., Nandi, A., Vla, D.: The epidemiology of post-traumatic stress disorder after disasters. Epidemiol. Rev. 27(1), 78–91 (2005)CrossRefGoogle Scholar
  20. 20.
    Gallagher, A.G., Ritter, E.M., Champion, H., Higgins, G., Fried, M.P., Moses, G., Smith, C.D., Satava, R.M.: Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Ann. Surg. 241(2), 364–372 (2005)Google Scholar
  21. 21.
    Garcia-Palacios, A., Hoffman, H., Carlin, A., Furness, T.A., Botella, C.: Virtual reality in the treatment of spider phobia: a controlled study. Behav. Res. Ther. 40, 983–993 (2002)CrossRefGoogle Scholar
  22. 22.
    Garcia-Palacios, A., Hoffman, H.G., Kwong See, S.K., Tsai, A., Botella, C.: Redefining therapeutic success with VR exposure therapy. Cyber Psychol. Behav. 4, 341–348 (2001)CrossRefGoogle Scholar
  23. 23.
    Hartig, T., Catalono, R., Ong, M.: Cold summer weather, constrained restoration and the use of antidepressants in Sweden. J. Environ. Psychol. 27(2), 107–116 (2007)CrossRefGoogle Scholar
  24. 24.
    Hartig, T., Evans, G.W., Jammer, L.D., Davis, D., Garling, T.: Tracking restoration in natural and urban field settings. J. Exp. Psychol. 23, 109–123 (2003)Google Scholar
  25. 25.
    Hoffman, H.G., Doctor, J.N., Patterson, D.R., Carrougher, G.J., Furness, T.A.: Use of virtual reality for adjunctive treatment of adolescent burn pain during wound care: a case report. Pain 85(1–2), 305–309 (2000)CrossRefGoogle Scholar
  26. 26.
    Hoffman, H.G., Garcia-Palacios, A., Carlin, C., Furness, T.A., Botella-Arbona, C.: Interfaces that heal: coupling real and virtual objects to cure spider phobia. Int. J. Hum. Comput. Inter. 16(2), 283–300 (2003)CrossRefGoogle Scholar
  27. 27.
    Hoffman, H.G., Hollander, A., Schroder, K., Rousseau, S., Furness, T.A.: Physically touching and tasting virtual objects enhances the realism of virtual experiences. Virtual Reality: Res. Dev. Appl. 3, 226–234 (1998)CrossRefGoogle Scholar
  28. 28.
    Hoffman, H.G., Richards, T.L., Coda, B., Bills, A.R., Blough, D., Richards, A.L., Sharar, S.R.: Modulation of thermal pain-related brain activity with virtual reality: evidence from fMRI. NeuroReport 15(8), 1245–1248 (2004)CrossRefGoogle Scholar
  29. 29.
    Jaycox, L.H., Foa, E.B., Morral, A.R.: Influence of emotional engagement and habituation on exposure therapy for PTSD. J. Consult. Clin. Psychol. 66, 186–192 (1998)CrossRefGoogle Scholar
  30. 30.
    Kahn, P.H., Severson, R.L., Ruckert, J.H.: Technological nature—and the problem when good enough becomes good. In: Drenthen, M., Keulartz, J., Proctor, J. (eds.) New Visions of Nature: Complexity and Authenticity, Chapter 2, pp. 21–40. Springer, The Netherlands (2009)CrossRefGoogle Scholar
  31. 31.
    Kaplan, R.: The nature of the view from home: psychological benefits. Environ. Behav. 33(4), 507–542 (2001)CrossRefGoogle Scholar
  32. 32.
    Kaplan, R., Kaplan, S.: The Experience of Nature: A Psychological Perspective. Cambridge University Press, Cambridge (1989)Google Scholar
  33. 33.
    Kaplan, S.: The restorative environment: nature and human experience. In: Relf, D. (ed.) The Role of Horticulture in Human Well-Being and Social Development. A National Symposium (Proceedings of a Conference held 19–21 April 1990, Arlington, Virginia, USA), pp. 134–142. Timber Press, Portland, OR (1992)Google Scholar
  34. 34.
    Kaplan, S.: The restorative benefits of nature: toward an integrative framework. J. Environ. Psychol. 15, 169–182 (1995)CrossRefGoogle Scholar
  35. 35.
    Krijn, M., Emmelkamp, P.M.G., Ólafsson, R.P., Bouwman, M., van Gerwen, L.J., Spinhoven, P., Schuemie, M.J., van der Mast, C.A.P.G.: Fear of flying treatment methods: virtual reality exposure vs. cognitive behavioral therapy. Aviat. Space Environ. Med. 78(2), 121–128 (2007)Google Scholar
  36. 36.
    Lawson, B., Phiri, M., Wells-Thorpe, J.: The architectural healthcare environment and its effects on patient health outcomes, a report on an NHS Estates-funded research project. The Stationery Office (2004)Google Scholar
  37. 37.
    Levi, D., Kocher, S.: Virtual nature experiences as emotional benefits in green product consumption: the moderating role of environmental attitudes. Environ. Behav. 40, 818–842 (2008)CrossRefGoogle Scholar
  38. 38.
    Li, Q., Morimoto, K., Kobayashi, M., Inagaki, H., Katsumata, M., Hirata, Y., Hirata, K., Suzuki, H., Li, Y.J., Wakayama, Y., Kawada, T., Park, B-J., Ohira, T., Matsui, N., Kagawa, T., Miyazaki, Y., Krensky, A.M.: Visiting a forest, but not a city, increases human natural killer activity and expression of anti-cancer proteins. Int. J. Immunopathol. Pharmacol. 21(1), 117–127 (2008)Google Scholar
  39. 39.
    Mazer, S.E.: Music and nature at the bedside: part II of a two-part series. Res. Des. Connections, Issue 1 (2010). Last retrieved 01 July 2013. From:
  40. 40.
    Nanda, U., Gaydos, H.L.B., Hathon, K., Watkins, N.: Art and posttraumatic stress: a review of the empirical literature on the therapeutic implications of artwork for war veterans with posttraumatic stress disorder. Environ. Behav. 42(3), 376–390 (2010)Google Scholar
  41. 41.
    North, M.M., North, S.M., Coble, J.R.: Effectiveness of VRT for acrophobia. In: North, M.M. (ed.) Virtual Reality Therapy. An Innovative Paradigm. IPI Press, Colorado Springs, pp. 68–70 (1996a)Google Scholar
  42. 42.
    North, M.M., North, S.M., Coble, J.R.: Effectiveness of virtual environment desensitization in the treatment of agoraphobia. Presence: Teleoperators Virtual Environ. 5, 346–352 (1996b)Google Scholar
  43. 43.
    North, M.M., North, S.M., Coble, J.R.: VRT in the treatment of agoraphobia. In: North, M.M. (ed.) Virtual Reality Therapy. An Innovative paradigm. IPI Press, Colorado Springs, p. 46 (1996c)Google Scholar
  44. 44.
    North, M.M., North, S.M., Coble, J.R.: Virtual reality therapy for fear of flying. Am. J. Psychiatry 154, 130 (1997)Google Scholar
  45. 45.
    North, M.M., North, S.M., Coble, J.R.: Virtual reality therapy: an effective treatment for the fear of public speaking. Int. J. Virtual Reality 3(3), 1–6 (1998)Google Scholar
  46. 46.
    Park, B.-J., Tsunetsugu, Y., Kasetani, T., Hirano, H., Kagawa, T., Sato, M., Miyazaki, Y.: Physiological effects of Shinrin-Yoku (taking in the atmosphere of the forest) using salivary cortisol and cerebral activity as indicators. J. Physiol. Anthropol. 26(2), 123–128 (2007)CrossRefGoogle Scholar
  47. 47.
    Pertaub, D.P., Slater, M., Barker, C.: An experiment on public speaking anxiety in response to three different types of virtual audience. Presence: Teleoperators Virtual Environ. 11, 68–78 (2002)CrossRefGoogle Scholar
  48. 48.
    Peters, M.I., Godaert, G.I., Ballieux, R.E., van Vliet, M., Willemsen, J.J., Sweep, F.C., et al.: Cardiovascular and endocrine responses to experimental stress: effects of mental effort and controllability. Psychoneuroendocrinology 23(1), 1–17 (1998)CrossRefGoogle Scholar
  49. 49.
    Rego, P., Moreira, P.M., Reis, L.P.: Serious games for rehabilitation: a survey and a classification towards a taxonomy. In: Proceedings of Information Systems and Technologies (CISTI: 5th Iberian Conference), pp. 1–6, 16–19 June 2010Google Scholar
  50. 50.
    Riva, G., Waterworth, J.A., Waterworth, E.L.: The layers of presence: a bio-cultural approach to understanding presence in natural and mediated environments. Cyber Psychol. Behav. 7(4), 402–416 (2004)CrossRefGoogle Scholar
  51. 51.
    Rizzo, A.R., Difede, J., Rothbaum, O., Johnston, S., McLay, R.N., Reger, G., Gahm, G., Parsons, T., Graap, K., Pair, J.: VR PTSD exposure therapy results with active duty OIF/OEF combatants. In: Westwood, J.D., et al. (eds.) Proceedings of Medicine Meets Virtual Reality 17, IOS Press, pp. 277–282 (2009a)Google Scholar
  52. 52.
    Rizzo, A., Newman, B., Parsons, T., Difede, J., Reger, G., Holloway, K., Gahm, G., McLay, R., Johnston, S., Rothbaum, B., Graap, K., Spitalnick, J., Bordnick, P.: Development and clinical results from the virtual Iraq exposure therapy application for PTSD. In: Proceedings of the Virtual Rehabilitation International Conference, Haifa, pp. 8–15, 29 June–02 July 2009bGoogle Scholar
  53. 53.
    Rothbaum, B.O., Hodges, L.F., Kooper, R., Opdyke, D., Williford, J.S., North, M.: Virtual reality graded exposure in the treatment of acrophobia: a case report. Behav. Ther. 26(3), 547–554 (1995)CrossRefGoogle Scholar
  54. 54.
    Rothbaum, B.O., Meadows, E.A., Resick, P., Foy, D.W.: Cognitive-behavioral therapy. In: Foa, E.B., Keane, T.M., Friedman, M.J. (eds.) Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies, pp. 320–325. Guilford Press, New York (2000)Google Scholar
  55. 55.
    Satava, R.M.: Virtual reality, telesurgery, and the new world order of medicine. J. Image Guided Surg. 1(1), 12–16 (1995)CrossRefGoogle Scholar
  56. 56.
    Sharar, S.R., Carrougher, G.J., Nakamura, D., Hoffman, H.G., Blough, D.K., Patterson, D.R.: Factors influencing the efficacy of virtual reality distraction analgesia during postburn physical therapy: preliminary results from 3 ongoing studies. Arch. Phys. Med. Rehabil. 88(12), Supplement 2, S43–S49 (2007)Google Scholar
  57. 57.
    Simonic, T.: Urban landscape as a restorative environment: preferences and design considerations. Acta Agriculturae Slov. 87(2), 325–332 (2006)Google Scholar
  58. 58.
    Stone, R.J.: Serious games: virtual reality’s second coming? Virtual Reality 8, 129–130 (2005)CrossRefGoogle Scholar
  59. 59.
    Stone, R.J.: Human Factors Guidelines for Interactive 3D and Games-Based Training Systems Design, Edn 1. Human Factors Integration Defence Technology Centre publication. Available at: (2008)
  60. 60.
    Stone, R.J.: The (human) science of medical virtual learning environments. Philos. Trans. Royal Soc. B 366(1562), 276–285 (2011)CrossRefGoogle Scholar
  61. 61.
    Stone, R.J.: Human Factors Guidance for Interactive 3D and Games-Based Training Systems Design, Edn 2. Human Factors Integration Defence Technology Centre Publication. Available at:, (2012)
  62. 62.
    Stone, R.J., Barker, P.: Serious gaming: a new generation of virtual simulation technologies for defence medicine and surgery. Int. Rev. Armed Forces Med. Serv., pp. 120–128 (2006)Google Scholar
  63. 63.
    Tsunetsugu, Y., Park, B.-J., Ishii, H., Hirano, H., Kagawa, T., Miyazaki, Y.: Physiological effects of Shinrin-Yoku (taking in the atmosphere of the forest) in an old-growth broadleaf forest in Yamagata Prefecture. Jpn. J. Physiol. Anthropol. 26(2), 135–142 (2007)CrossRefGoogle Scholar
  64. 64.
    Ulrich, R.S.: Natural versus urban scenes: some psychophysiological effects. Environ. Behav. 13, 523–556 (1981)CrossRefGoogle Scholar
  65. 65.
    Ulrich, R.S.: View through a window may influence recovery from surgery. Science 224(4647), 420–421 (1984)CrossRefGoogle Scholar
  66. 66.
    Ulrich, R.S., Gilpin, L.: Healing arts: nutrition for the soul. In: Frampton, S.B., Gilpin, L., Charmel, P. (eds.) Putting Patients First: Designing and Practicing Patient-Centered Care, pp. 117–146. Wiley, San Francisco (2003)Google Scholar
  67. 67.
    Ulrich, R.S., Simons, R.F., Miles, M.A.: Effects of environmental simulations and television on blood donor stress. J. Architect. Plan. Res. 20(1), 38–48 (2003)Google Scholar
  68. 68.
    Valtchanov, D., Barton, K.R., Ellard, C.: Restorative effects of virtual nature settings. Cyberpsychol. Behav. Soc. Network. 13(5), 503–512 (2010)CrossRefGoogle Scholar
  69. 69.
    van den Berg, A.E.: Restorative effects of nature: towards a neurobiological approach. In: Louts, T., Reitenbach, M., Molenbroek, J. (eds.) Human Diversity, Design for Life. Proceedings of 9th Congress of Physiological Anthropology, pp. 132–138 (2009)Google Scholar
  70. 70.
    Vincelli, F.: From imagination to virtual reality: the future of clinical psychology. Cyber Psychol. Behav. 2, 241–248 (1999)CrossRefGoogle Scholar
  71. 71.
    Waterworth, J.A., Waterworth, E.L.: Relaxation Island: a virtual tropical paradise. Interactive experience provided at British Computer Society HCI Conference 2004: Designing for Life. Last retrieved 01 July 2013, from:
  72. 72.
    White, M., Smith, A., Humphryes, K., Pahl, S., Snelling, D., Depledge, M.: The importance of water in judgments of natural and built scenes. J. Environ. Psychol. 30(4), 482–493 (2010)CrossRefGoogle Scholar
  73. 73.
    Williams, M.B., Poijula, S.: The PTSD workbook: simple, effective techniques for overcoming traumatic stress symptoms. New Harbinger, Oakland, CA (2002)Google Scholar
  74. 74.
    Wohlwill, J.F.: The concept of nature: a psychologist’s view. In: Altman, I., Wohlwill, J.F. (eds.) Behaviour and the Natural Environment, Advances in Theory and Research, vol. 6, pp. 5–38. Plenum Press, New York (1983)Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Robert Stone
    • 1
    Email author
  • Charlotte Small
    • 1
  • James Knight
    • 1
  • Cheng Qian
    • 1
  • Vishant Shingari
    • 1
  1. 1.Human Interface Technologies TeamUniversity of BirminghamBirminghamUK

Personalised recommendations