Exercises using virtual reality to relieve shortness of breath from COVID


Patients recovering from severe coronavirus pneumonia 2019 (COVID-19) often experience intractable shortness of breath.

A recent study published on the Preprint Server medRxiv * conducted at the University Hospital of Geneva in Switzerland is evaluating a digital intervention based on immersive virtual reality (iVR) to relieve refractory shortness of breath in patients recovering from COVID-19 pneumonia.

Study: Virtual reality exercise to help COVID patients with refractory shortness of breath. Image Credit: Photographee.eu/Shutterstock.com

Refractory shortness of breath

Chronic shortness of breath syndrome causes a disabling sensation of difficult breathing. It even occurs when the patient is undergoing treatment optimized for the diagnosed medical condition.

Refractory shortness of breath is a stubborn and unmanageable condition that can be observed in acute illness. This condition often has a negative impact on the quality of life and autonomy of patients.

Since refractory shortness of breath accompanies acute conditions, identification of the underlying condition is essential for pathophysiological treatment. Currently, refractory shortness of breath is an underestimated respiratory condition; thus, there remains a need to develop evidence-based interventions to alleviate shortness of breath.

Digital therapy

Perception of shortness of breath occurs through neural pathways similar to pain processing and bodily self-awareness, as evidenced by neuroimaging. Digital products or digital iVR-based therapy (DTx) have been used as interventions to relieve chronic pain in patients with complex regional pain syndrome or spinal cord injury.

In patients with respiratory discomfort, based on visual and respiratory feedback, visuo-respiratory stimulation can provide an increased sensation of breathing control and changes in physiological measures of breathing. This approach is also associated with a reduced negative emotional state associated with experimentally induced shortness of breath.


Long COVID is a complex condition where symptoms occur beyond the period of infection and recovery from COVID-19. Long-lasting symptoms of COVID include general weakness, malaise, fatigue, trouble concentrating, and shortness of breath. About 25% of long-term COVID patients complain of shortness of breath.

Shortness of breath is poorly associated with lung function tests or lung imaging in long-term COVIDs. Therefore, current treatments focus on pulmonary rehabilitation; However, a neuro-rehabilitation approach could be tested to understand and alleviate shortness of breath.

COVID-19 Virtual Reality Clinical Study (COVVR)

The COVVR study is a controlled, randomized, single-blind, crossover clinical study that aims to determine the effects of iVR-based DTx on respiratory comfort in patients recovering from severe COVID-19 pneumonia. This is a single site study that was conducted at the Geneva University Hospital in Switzerland and is registered with ClinicalTrials.gov (NCT04844567).

Thirty-one patients were included, all of whom were recovering from severe COVID-19 pneumonia and presented with refractory shortness of breath with a self-rated intensity of five or more on a ten-point analogue visual dyspnea scale. All the patients who participated in this study gave their consent and spoke French or English.

Patient exclusion criteria included unstable respiratory, neurological, or cardiac disorders, or psychiatric illness and a score below 25 on the Montreal Cognitive Assessment (MoCA). Five patients were excluded due to a MoCA score below 25. Crossover groups were randomly assigned and hidden from the referring clinician.

Experimental setup

The patients were in a semi-seated position in their hospital beds and wore a breathing belt attached to the abdomen that recorded respiratory movements. They also wore a head-mounted display containing a VR-compatible smartphone.

The smartphone ran the VR simulation and was connected via Bluetooth® to the breathing belt. Scientists have developed software in collaboration with MindMaze to collect and filter respiratory data and render a computer-generated virtual environment in real time.

In the virtual reality environment, patients could see a same-sex virtual body lying on a bed in a position similar to their own. The virtual body gave a visual effect of the respiratory movements. This visual effect can be in synchrony (synchronous condition) or massive asynchronous (asynchronous condition) with the respiratory movements of the patient.

Participants received synchronous (intervention) or asynchronous (control) feedback of their breathing that was embodied via a gender-matched avatar in the iVR. Before the first exposure and after the two experimental conditions, the patients filled out questionnaires. Respiratory patterns were captured continuously. Scientists have also quantified the subjective benefit of such an intervention and the feasibility of using this new respiratory rehabilitation tool at home or in wards in long-term COVID patients.

Portable configuration and virtual reality feedback. (A) A breathing belt picks up the breathing movements of the chest and sends the signal to a smartphone via Bluetooth. Custom software generates the virtual environment. (B) A same-sex avatar is displayed and observed by patients with their heads slightly turned to the side. The virtual body is illuminated synchronously or asynchronously with respect to the patient’s chest movements. The top image shows the end of exhalation with low blinking intensity, while the bottom image shows the end of inspiration corresponding to maximum brightness in synchronous condition.

Visuo-respiratory stimulation improves respiratory comfort

A total of 26 patients (27% female; mean age = 57 years) were included in this study, of which 14 patients were randomized to the “synchronous / asynchronous” sequence and 12 to the “asynchronous / synchronous” sequence. Data were not available for two patients.

The mean rating for respiratory comfort was 0.1 at baseline, -0.8 ± 1.8 for asynchronous, and 1.3 ± 1.4 for synchronous feedback, where -3 indicates less respiratory comfort. and 3 indicates the highest breathing comfort. Of all patients, 91.2% were satisfied with the procedure and 66.7% perceived it to be beneficial for their breathing. No patient reported any adverse event.

Boxplots representing the subjects’ scores during the asynchronous condition versus the synchronous condition, regardless of the experimental sequence. The thick line inside a boxplot represents the median, the diamond represents the mean, the upper limit of the box indicates the 25th percentile, and the lower limit the 75th percentile. Whiskers above and below the box indicate minimum and maximum values, while points above or below the whiskers indicate outliers. Subjective scores were measured using a 7-point Likert scale with -3 = Strongly Disagree, -2 = Disagree; −1 = Somewhat disagree; 0 = Neither agree nor disagree; 1 = Tend to agree; 2 = agree; 3 = Strongly agree.


The present study demonstrates the benefit of IVR-based visual-respiratory intervention in patients recovering from COVID-19. Scientists therefore propose that this iVR-based immersive DTx with a good safety profile is an inexpensive neuro-rehabilitation tool that could be used to increase respiratory comfort in patients recovering from COVID-19.

*Important Notice

medRxiv publishes preliminary scientific reports which are not peer reviewed and, therefore, should not be considered conclusive, guide clinical practice / health-related behavior, or treated as established information.

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