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Olfactory Virtual Reality (OVR) for Wellbeing and Reduction of Stress, Anxiety and Pain

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  • Community College of Vermont - Nortades Psychotherapy - Vermont Academy of Arts and Sciences

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Background: As part of a consistent effort to examine and provide integrative medical approaches to the therapeutic offering for psy-chophysical health, this study investigates the utilization of Olfactory Virtual Reality (OVR) in an inpatient psychiatry unit, more specifically in the Shepardson 3 Objectives: The purpose of this protocol is to explore the therapeutic value of olfactory virtual reality (OVR) in the above described population , and to collect statistically significant data to determine the feasibility of potential future OVR studies. Method: Direct subject observation and monitoring in the context of Olfactory Virtual Reality (OVR) sessions and Qualitative data collection via the administration of subject surveys, subdivided in: a) Pre-OVR experience, b) Immediate post-OVR experience, and c) 1-to-3-hour post-OVR experience questionnaires. Results: The research yielded positive outcomes in all areas investigated , despite challenges related to the utilization of the device itself, issues in individual olfactory threshold, and COVID-19 restrictions and limitations. Conclusion: The outcome of this study indicates that the utilization of olfactory virtual reality technologies is a safe and effective integrative approach to target several aspects of psychological and physical health such as anxiety, stress, and pain, in combination with the psychothera-peutic and pharmacological standards of care in inpatient psychiatry.
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Journal of Medical Research and Health Sciences
Received 20 Nov 2020 | Revised 20 Jan 2021 | Accepted 4 Mar 2021 | Published Online 17 Mar 2021
DOI: https://doi.org/10.15520/jmrhs.v4i3.322
JMRHS 4 (3), 12121221 (2021) ISSN (O) 2589-9031 | (P) 2589-9023
ORIGINAL ARTICLE
Olfactory Virtual Reality (OVR) for Wellbeing and Reduction of Stress,
Anxiety and Pain
David Tomasi , PhD,EdD-PhD,MMed,MA,MCS,AAT,GT1* | Hannah Ferris, MS 2 | Priscilla Booraem,
MS, GT 3 | Lindsay Enman, MSW,GT4 | Sheri Gates, MA, GT5 | Emily Reyns, MA, R-DMT, MHC, GT6
1University of Vermont Integrative
2University of Vermont Larner
College of Medicine, Department
of Pharmacology; University of
Vermont; University of Vermont
Medical Center
3,4,5University of Vermont Medical
Center, Inpatient Psychiatry
Abstract
Background: As part of a consistent effort to examine and provide
integrative medical approaches to the therapeutic offering for psy-
chophysical health, this study investigates the utilization of Olfactory
Virtual Reality (OVR) in an inpatient psychiatry unit, more specifically
in the Shepardson 3 Inpatient Psychiatry Unit at the University of
Vermont Medical Center, in Burlington, VT, USA.
Objectives: The purpose of this protocol is to explore the therapeutic
value of olfactory virtual reality (OVR) in the above described pop-
ulation, and to collect statistically significant data to determine the
feasibility of potential future OVR studies.
Method: Direct subject observation and monitoring in the context of
Olfactory Virtual Reality (OVR) sessions and Qualitative data collec-
tion via the administration of subject surveys, subdivided in: a) Pre-
OVR experience, b) Immediate post-OVR experience, and c) 1-to-3-
hour post-OVR experience questionnaires.
Results: The research yielded positive outcomes in all areas investi-
gated, despite challenges related to the utilization of the device itself,
issues in individual olfactory threshold, and COVID-19 restrictions and
limitations.
Conclusion: The outcome of this study indicates that the utilization of
olfactory virtual reality technologies is a safe and effective integrative
approach to target several aspects of psychological and physical health
such as anxiety, stress, and pain, in combination with the psychothera-
peutic and pharmacological standards of care in inpatient psychiatry.
Keywords: Medicine, Neuroscience, Virtual Reality, Olfactory System,
Stress, Anxiety, Pain, Psychiatry, Psychology
Copyright : © 2021 The Authors. Published by MRER Publisher
Ltd. This is an open access article under the CC BY-NC-ND license
(https://creativecommons.org/licenses/by-nc-nd/4.0/).
JMRHS 4 (3), 12121221MEERP LTD 1211
Health, College of Nursing and
Health Sciences, Department of
Rehabilitation and Movement
Science; University of Vermont
Continuing and Distance
Education, UVM Healthcare
Programs ; University of Vermont
Human Development and Family
Studies Program, Department of
Leadership & Developmental
Sciences; University of Vermont
Medical Center, Inpatient
Psychiatry; Community College of
Vermont
6University of Vermont Integrative
Health, College of Nursing and
Health Sciences; University of
Vermont Medical Center,
Inpatient Psychiatry;
1 INTRODUCTION
The goal of this study is to use an OVR-
Technology-developed Virtual and Altered
Reality (VAR) device ( Image 1) that includes
an olfactory stimulation (scent) component in
addition to the traditional visual component of
virtual reality. (1),(2),(3) The OVR sessions enginee
-red for this research protocol were focused on
creating a more immersive, realistic, evocative,
meaningful, and emotional VAR experience, and by
allowing for the subjects enrolled therein to enter a
calming and realistic environment, in order to
decrease the amount of anxiety, stress, and pain
experienced by study subjects. In multiple studies,
the utilization of Virtual reality-based technologies
has proven to be a useful tool in a range of medical
issues connected with psycho-physical challenges
including, but not limited to, distraction for pain and
medical procedures, relaxation and calming, and im-
mersion therapy for trauma, PTSD and phobias. (4),
(5),(6),(7),(8),(9),(10),(11) Certainly, there are sign-
ificant challenges and potential dan-gers in the
utilization of digital-virtual technolo-gies (with
significant differences among the specific types of
technology examined), often associated with
decrease in cognitive and emotional capacity and
understanding, focus vs. attention, as well as
possible addictive properties of this type of
intervention. (12),(13),(14),(15),(16) These aspects
are particularly relevant in a vulnerable population
such as the one examined in this particular study,
i.e. inpatient psy-chiatry patients.
However, due to the documented relationships be-
tween scent, memory, and emotion (17),(18),(19),
(20),(21),(22) the authors of this study wanted to
verify the possible benefits of adding an olfactory
stimulation component, following the current scien-
tific evidence on emotion, cognition, attention, and
memory in general, and more in detail on specific
neural areas such as the olfactory-related afferents
and efferents of the mediodorsal thalamic nucleus
(MDT), (23),(24),(25) to the virtual reality com-
ponent of the experience, thereby monitoring the
potential to increase the immersion and presence
of such virtual environments, and to create a more
therapeutically appropriate and nurturing emotional
connection, in the broader context of wellbeing and
health.
2 | INTERVENTION
General Description
The OVR environment is an immersive, 3-
dimensional, 6 DoF (Six Degrees of Freedom)
environment in which the subject can freely move
and interact with the virtual items presented therein
(e.g. campfire, marshmallows, sticks/logs wood),
flowers, citronella candles, bacon, tree bark, soda-
cola, with ambient scent of forest, as well as natural
environment sounds such as leaves, etc.), to re-
create a reality-like environment (Image 3). The
”safety range” of approximately 10ft x 10ft in the
selected study room has been cleared of any objects
or furniture, so that subjects may move through the
environment safely. These borders are defined by
invisible walls in the OVR software, when the
patient gets close to the edge of this safety range.
More specifically, the environment is designed to
simulate a relaxing camping experience including a
tranquil campsite, tent, picnic table and fire pit
cluster at the edge of rocks and trees overlooking
the sunset. There are many objects in the OVR
environment that the subject can interact with using
two hand-held wands (virtual hands). These wands
are tracked through HMD (head-mounted display)-
mounted sensors to correspond with their
movements and have buttons and grips that allow
the user to interact with items (Image 2 ). As the
subject moves about and interacts with the
environment, corresponding odors connected to the
general environment as well as specific items and
interactions are precisely released to give the
environment an enhanced perception vs.
proprioception of presence. Each subject spent on
average 10 minutes in the OVR environment before
the Inpatient psychiatry Group therapist (GT)
Supplementary information The online version of
this article (https://doi.org/10.15520/jmrhs.v4i3.322)
contains supplementary material, which is avail-
able to authorized users.
Corresponding Author: David Tomasi
JMRHS 4 (3), 12121221MEERP LTD 1211
OLFACTORY VIRTUAL REALITY (OVR) FOR WELLBEING AND REDUCTION OF STRESS,
ANXIETY AND PAIN
assisted the patient in removing the Head-Mounted
Display (HMD).
Primary Workflow and Timeline
This research study has been conducted over a
4-month period with Inpatient Psychiatry subjects
(N= 60). Each patient participated in 2 sessions
per week for a minimum of 2 weeks (with data
being considered admissible after 2 sessions). Data
have been recorded from each patient before, during,
and after each session though Pre-, Immediate Post-
and 1-to-3 hours Post- Questionnaires. After initial
brief explanation, the clinician (Psychotherapist /
Group Therapist) assisted the subject in securing the
OVR/HMD device. More specifically, the HMD in
this test was a Samsung Odyssey. This is a display
device, worn on the head that covers both eyes and
is secured via straps. The OVR device is mounted
to the bottom of the mask and sits near the nose
without making any skin contact to the user. As
soon as the HMD is secured the clinician handed
the subject the wands and ensured that they are
comfortable. After this procedure has been com-
pleted, the OVR experience/session began through
activation on a connected computer. Subjects have
been monitored as they experienced the environment
to ensure the absence of technical and/or clinical-
medical issues and had the ability to turn off the
environment from the connected computer at any
time. After 8 to 12 minutes, at the conclusion of the
OVR experience/session, the GT helped each subject
individually remove the HMD and secure the device
nearby, and turn off the environment via the attached
computer. Following each session/single patient use,
the device has been sanitized and examined for any
loose connections or issues. The environment has
then been rebooted in preparation of the next session
with a new subject.
3 METHODS
Population and Eligibility
The subjects examined in this study were adult pa-
tients (18 and above, N=60) on the inpatient psy-
chiatry unit Shepardson 3, University of Vermont
Medical Center (UVMMC), over a 4-month study
period (September-December 2020). More specif-
ically, UVMMC Shepardson 3 presents a patient
population with DSM-5 psychiatric diagnoses rang-
ing from PTSD and other traumas, MDD, Bipolar
Affective Disorder(s) (BPAD I vs II), Cluster A, B,
and C Personality Disorders, other mood disorders,
as well as Adjustment- and Generalized Anxiety
Disorders, often in combination with other speci-
fied/unspecified psychiatric vs. general medical is-
sues and comorbidities.
Qualitative and Quantitative Analysis
The pre-, immediate post-, and 1-to-3-hour post-
session surveys addressed anxiety and stress levels,
emotional and physical pain, psychological state,
overall mood, level of enjoyment during the ses-
sion, using a combination of binary (Yes/No) re-
sponses and Likert scales, with reported percentages
and p-value from McNemar test and p-value from
Wilcoxon Signed-Rank, in combination with open-
ended question about the overall experience as sub-
jectively perceived by the subject. The complete list
of questions in the surveys administered to patients,
with relative percentages and statistically relevant
annotations, is reported in Section C - Question-
naires (1,2 and 3) respectively.
Inclusion Criteria
At the beginning of each OVR session, the Group
Therapist read the informed consent information and
procedure to the patients. Following informed con-
sent documentation, every patient had the option to
decline to take part in the exercise and nutrition
education group.
Withdrawal Procedures
Following informed consent documentation, every
patient had the option to decline session attendance,
and to fill out the research survey.
Subjects had been allowed to withdraw from the
study at any time, knowing that withdrawing from
the study will have no impact on their clinical care. PI
and multidisciplinary treatment team members (PhD,
PsyD, MA, MD, MS, and MSW) assessed subjects to
determine whether to withdraw subjects when clini-
cally/medically inappropriate circumstances arise.
JMRHS 4 (3), 12121221 (2021) MEERP LTD 1212
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DAVID TOMASI ET AL.
All the information has been collected without any
identifiers and used only for statistical purposes,
and it will not be connected or linkable to clini-
cal/medical records of single patients and/or groups
/ categories / diagnosis in the future. The hardcopy
data has been archived in the locked group Therapist
Office on Shepardson 529, separated from both Inpa-
tient Psychiatry Units Shepardson 3 and Shepardson
6. Each GT documented on paper the number of
subjects participating in the session and the number
of subjects absent or subjects who declined to take
part in the group.
4 RESULTS
Positive Aspects
Examining the data obtained by analyzing subjects’
responses in the administered pre-, immediate post-,
and 1-to-3-hour post-session surveys, the researchers
have been able to identify multiple positive outcomes
as direct results of the implementation of Olfactory
Virtual Reality in Inpatient Psychiatry. Of note, as
the study-related OVR sessions have been offered in
combination with the pre-existing integrative ther-
apeutic offerings conducted by the UVMMC psy-
chotherapists / group therapists as part of the weekly
schedule, (26) , (27) all the subjects/patients involved
in this research had the opportunity to further discuss
their experiences in a nurturing, supportive and clin-
ically appropriate environment for the whole dura-
tion of their admission, thereby providing them with
constant opportunities for processing and cognitive,
emotional improvement and overall well-being.
More specifically, the data yielded positive results
across the spectrum of psycho-physical areas inves-
tigated. Utilizing a 1-10 scale (1-lowest, 10-highest
value), Anxiety levels of 9 (16.2 %) or 10 (29.4
%) in the Before session, reported 1.8 % and 0 %
respectively in the Immediately After session, and
0 % and 0% in the 1-to-3 hours After session, with
a Relative Difference of -1.0 in both cases (Figure
1a) . Similarly significant values were observed in
the Stress area, with levels of 9 (16.4 %) and 10
(36.1 %) in the Before Session, 3.6 % and 0 %
respectively in the Immediately After Session, and
5.0 % and 0% in the 1-to-3 hours After session with
a Relative Difference of -0.7 for value 9 and -1.0
for value 10 (Figure 2b). For the Pain–related
responses, the values were 6.6 % in both 9 and 10 in
the Before Session, 0 % and 0 % respectively in the
Immediately After Session, and 0 % and 0% in the 1-
to-3 hours After session, with a Relative Difference
of -1.0 in both cases (Figure 3a ).
As observed in figures (Figure 1b, Figure 2b and
Figure 3b) the overall improvement (i.e.
significant decrease) in these three areas was
observed through-out the response provided.
Subjects answering the quefstion “Is there
anything bothering you today (mental or
physical)” also selected their response on the same
1-10 scale (1-lowest, 10-highest value) in the case
of a positive (“yes”) answer (Questionnaires 1, 2,
and 3). The results yielded were 23 % for level
9 and 23 % for level 10 in the Before Session, with
a significant decrease in the Immediately After
Session, with 7.0 % for both value 9 and 10, and
0.0 % for both value 9 and 10 in the 1-to-3 hours
After session (Figure 4b). The Relative Difference
to the same question in the comparison between
Before, Immediately After, and 1-to-3 hours After
Session yielded a 0.2 for “Yes” and 10.5 for
“No” (Table 1). For the question “Did you enjoy
the virtual reality experience?” the values observed
were 0.02 for “Yes” and -1.0 for “No” (Table 2) .
While these results are very significant, it is also
important to note the impact of the decrease in the
psychological factors in the context of complex di-
agnostic medical-psychiatric presentations, particu-
larly in inpatient psychiatry. In this sense, multiple
studies have also indicated that an overall amelio-
ration of psychological wellbeing has resulted in an
improvement of physical factors. (28),(29),(30),
(31) This is evidenced by the results presented in
(Figure 5, Figure 6, Figure 7) with an overall
significant decrease in the levels of anxiety and
stress and the broader, bio-psycho-social model-
based area investigated by the question “Is there
anything bothering you today (mental or physical).”
The aforementioned data thus indicated that Olfac-
tory Virtual Reality, in conjunction with standard-of-
care psychotherapeutic and pharmacological inter-
ventions, significantly resulted in a reduction of the
subject-reported values for anxiety, stress and pain.
MEERP LTD JMRHS 4 (3), 12121221 (2021) 1213
Safety, Privacy and Consent
OLFACTORY VIRTUAL REALITY (OVR) FOR WELLBEING AND REDUCTION OF STRESS,
ANXIETY AND PAIN
Negative Aspects
Some of the challenges encountered during the study
were related to technical glitches and/or to the uti-
lization of the VAR device itself, which proved to
be somewhat difficult to utilize by the elder subjects
in the study population examined. As an example
of the above, once the subject already started the
OVR process, if they had pressed on any other button
on the “joystick/virtual hand” and they inadvertently
exited the program, the software would open a new
sub-menu, thus requiring, at times, the process to be
started anew. Some more specific challenges were
related to the medical presentation of the subject
undergoing the OVR experience, for instance in
regard to the need to re-adjust the virtual perime-
ter/boundaries and height for subjects who were ex-
periencing the VAR scenario on a wheelchair (the
VR cable often got stuck either under the wheels
or the oxygen cylinder). Another potential issue lied
in the very nature of the study presented, i.e. some
decreased scores in olfactory threshold experienced
by subjects affected by depressive disorders, as ev-
idenced in multiple studies. (32),(33),(34) Of
note, while similar clinical presentations regarding
olfaction have been observed in COVID-19-positive
individuals, all subjects who undertook this research
study have been testing negative for SARS-Cov-2
Test prior to their admission to the Inpatient Psy-
chiatry Unit Shepardson 3, where the study was
conducted.
The current COVID-19 pandemic had of course
added challenges, particularly in terms of the allotted
number of subjects allowed in the OVR session room
at any given time (N=1 + GT) and the required im-
plementation of safety & hygiene restrictions, which
contributed to the slowing down of the examination
process in general.
5 CONCLUSIONS
Mounting evidence from current scientific research
warrants the need for incorporating integrative meth-
ods to improve clinical outcomes across a wide
range of physical and mental health disorders. (35),
(36),(37),(38),(39),(40),(41),(42),(43) Certainly, an
attentive investigation of the specific approaches
within integrative therapeutic modali-ties is
warranted, especially in the context of the
complexity of psycho-physical clinical presentations
of individuals in an inpatient psychiatry unit. The
results of this study indicates that the utilization of
an integrative approach focused on olfactory vir-
tual reality technologies in addition to the evidence-
based standards of care within psychotherapy and
pharmacology is a safe and effective strategy to
target several aspects of psychological and physical
health such as anxiety, stress, and pain.
Beside the observed decrease in self-reported levels
of anxiety, stress, and pain, an important factor at the
center of the application of olfactory virtual reality
in inpatient psychiatry is its ability to provide an
immersive psychological, physical, and (albeit to a
lesser extent given the added restrictions of both
technology and safety measures) social experience
to those patients who are otherwise unable to en-
gage in other integrative approaches to care, such
as physical exercise, gentle movement or stretching,
Yoga and T’ai Chi Chuan, Music Therapy or Dance
Movement Therapy, due to physical problems or
other medical comorbidities. This is especially true
in the context of the current COVID-19 the pan-
demic which contributes to further self-isolation, a
significant problem affecting, and in turn, affected,
by a vast range of psychological issues, particularly
depressive states and traumas. In other words, where
physical proximity is not possible and or allowed,
this type of technology allows the individual to expe-
rience a re-created environment in a safe, monitored,
and measurable way.
Furthermore, the ability of the olfactory-visual stim-
ulation provided by OVR to positively affect emo-
tion and memory can be an important aide and sup-
port in the complex process of mitigating the nega-
tive effects of the aforementioned psychological and
social issues (e.g. MDD, PTSD, as well as Addiction
disorders, etc.) affecting such vulnerable popula-
tions and could promote a better understanding of
the psychological functioning in the general public
during a times of epidemiological challenges and
increased risks for further medical and psychological
problems.
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DAVID TOMASI ET AL.
6 LIMITATIONS AND FUTURE STUDIES
The primary limitations of this study are the specific
population investigated, the total number of par-
ticipants, the limited technical glitches encountered
during the setting up portion of the OVR session, the
specific challenges linked to the diagnostic presen-
tation of the subjects examined, and the limitations
in terms of clinical safety and exposure parameters
for clinical research subjects, following COVID-19
taskforce recommendations. Future EBM double-
blind RCTs and biostatistical-epidemiological analy-
sis are recommended to verify the empirical validity
of the results and outcomes discussed herein.
Declaration of Conflicting Interests
The authors declared no potential conflicts of inter-
est with respect to the research, authorship, and/or
publication of this article.
Funding
The authors received no financial support for author-
ship, and/or publication of this article.
Acknowledgments
Gratitude extended to all staff, students, faculty at
the University of Vermont Medical Center and the
University of Vermont.
Images
A) General Results
The Wilcoxon Signed Rank test was completed be-
tween the Before and Immediately After time points,
z = -6.528, p < 0.001 and the Before and 1-3h After
time points, z = -5.550, p < 0.001.
Figure 1b. Time point comparison in percent of
responses per level of Anxiety subdivided into
Before, Immediately After, and 1-to-3 hours-After
Figure 2a.
The Wilcoxon Signed Rank test was completed be-
tween the Before and Immediately After time points,
z = -6.437, p < 0.001, and the Before and 1-3h After
time points, z = -5.415, p < 0.001.
Figure 2b.: Time point comparison in percent of
responses per level of Stress subdivided into
Before, Immediately Aer, and 1-to-3 hours-Aer
MEERP LTD JMRHS 4 (3), 12121221 (2021) 1215
Figure 1a.
OLFACTORY VIRTUAL REALITY (OVR) FOR WELLBEING AND REDUCTION OF STRESS,
ANXIETY AND PAIN
Figure 3b : Time point comparison in percent of
responses per level of Pain subdivided into
Before, Immediately Aer, and 1-to-3 hours-Aer
Figure 4b: Time point comparison in percent of
responses per level of Anything bothering [you]
subdivided intoBefore, Immediately Aer, and 1-
to-3 hours-Aer
Figure 5: Pie Charts of responses Before OVR
session, per level of Anxiety, Stress, Pain, and
Anything bothering [you] in Percent (%).
Figure 6: Pie Charts of responses Immediately
Aer OVR session, per level of Anxiety, Stress, Pain,
and Anything bothering [you] in Percent (%).
JMRHS 4 (3), 12121221 (2021) MEERP LTD 1216
The Wilcoxon Signed Rank test was completed
between the Before and Immediately After time
points,z = -1.534, p = 0.125, and the Before and
1-3h After time points, z = -4.439, p < 0.001.
Figure 3a
Figure 4a
The Wilcoxon Signed Rank test was completed be-
tween the Before and Immediately After time
points, z = -5.452, p < 0.001, and the Before and
1-3h After time points, z = -3.759, p < 0.001. Missing levels have values = 0.
Figure 3b
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DAVID TOMASI ET AL.
Figure 7: Pie Charts of responses 1-to-3 Hours
Aer OVR session, per level of Anxiety, Stress,
Pain, and Anything bothering [you] in Percent
(%).
Table 2.
Percent (%) of responses to “Did you enjoy the
vir-tual reality experience?” Before, Immediately
After, 1-to-3 hours After, and relative difference
The McNemar test was completed between the Im-
mediately after and 1-3 hours after responses, N =
38, p = 1.000.
MEERP LTD JMRHS 4 (3), 12121221 (2021) 1217
Missing levels have values = 0.
B) Comparative Tables
Table 1.
Percent (%) of responses to “Is anything bothering
you today?” Before, Immediately After, 1-to-3
hours After, and relative difference
The McNemar test was completed between the Be-
fore and Immediately After responses, N = 56, p =
0.002, and the Before and 1-3h After responses, N
= 41, p = 0.008.
C) Questionnaires
Questionnaire 1. The pre-session survey
Questionnaire 2. The immediate post-session
survey.
OLFACTORY VIRTUAL REALITY (OVR) FOR WELLBEING AND REDUCTION OF STRESS,
ANXIETY AND PAIN
Questionnaire 3. The 1-to-3-hour post-session
survey
JMRHS 4 (3), 12121221 (2021) MEERP LTD 1218
Table 4. Subjects’ Narratives (Abstracts)
Image 1: The HMD-mounted ION on-mask, wifi /
USB scent Device, Headset, Cartridges
(foreground) and scent extracts (background)
developed by OVR Technology. The Architecture
of Scent® framework translates VR movements
and inputs into real-time scent output, allowing
for .1 millisecond bursts of scent and change
between scents in 20 milliseconds.
D) Patients’ Narratives
E) Software and Hardware
Image 2: Frontal view of the installed version of
the HMD-mounted ION on-mask, wifi / USB
scent Device, Headset, and Cartridges utilized in
this study.
Image 3: A Virtual reality scenario / 3D
rendering developed by OVR Technology
utilized in this study.
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How to cite this article: David Tomasi, Hannah
Ferris, Priscilla Booraem, Lindsay Enman, Sheri
Gates, Emily Reyns. Olfactory Virtual Reality
(OVR) for Wellbeing and Reduction of Stress,
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