“Your Digital Doctor Will Now See You”: A Narrative Review of VR and AI Technology in Chronic Illness Management

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Please see attached wordfile.

Comments for author File: Comments.pdf

Comments on the Quality of English Language

The Title is also a bit of a quandary to me as it says Gigital rather than Digital. If this were the true intention, a clear explanation is needed

There are unusual hyphenations throughout the article with inconsistent and irregular compound words.  I am not sure if this is due to the use of chatgpt for english translation but the article will require serious editing and proofreading for this.

Several paragraphs may also be improved to be more concise and streamlined.

Author Response

Comment 1: Title: Did you really mean “Gigital” or Digital? Does it hold a special meaning? If so, please define/expound.

 

Response 1: We corrected the typo (“gitial” instead of “digital”) in the title and clarified the type of review that was conducted. Now the title is “Your digital doctor will now see you”: A narrative review of VR and AI technology in chronic illness management.”

 

Comment 2: Abstract: Could be improved by stating the research methodology and results clearly

 

Response 2: We revised the abstract to clearly convey the motivation behind our narrative review, including the methodology and results.

 

Comment 3: It is unclear to me whether this review article is a narrative review, a mini-scoping review, or an opinion/commentary. What search method was used to gather articles for review? What were the choices for inclusion/ exclusion? Did you follow a system? If yes, do you have a PRISMA diagram or decision flowchart? If no search strategy was used, it may help to define your goals and methods clearly early on in the paper. 

 

Response 3: 

To address this issue, we included the “Methods” in which we:

• stated the motivation for conducting the literature review,
• described the process of literature search by providing search engines, keyword combination, exclusion criteria, and the final number of obtained queries

Comment 4: In addition, since the topic is quite broad, as it encompasses VR-MR-AI, it may help to divide it into 2 papers: one for VR-MR and another for AI.

 

Response 4: We appreciate the reviewer's constructive suggestion. We acknowledge that VR/MR and AI are each substantial fields that could warrant separate reviews. However, the intent of this manuscript is to focus specifically on their intersection in the context of chronic illness management, rather than to provide exhaustive, standalone reviews of each technology. In this paper, our goal was to highlight how immersive environments and AI-driven agents together can support engagement, personalization, and long-term self-management. By doing that, we sought to identify shared challenges, risks, and implementation considerations that emerge primarily when these technologies are combined in clinical settings. We have clarified this intersectional focus in the manuscript and note that separate, technology-specific reviews represent a valuable direction for future work. We also made some significant changes to the article, which make it more coherent in its main point without covering too many topics.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Author(s),

Thank you for submitting this timely and comprehensive narrative review exploring the role of immersive VR/MR systems and AI-driven virtual agents in chronic illness management. I recommend a revision at the level between minor and major, mostly related to structural clarity, balance between sections, and strengthening the methodological justification for a narrative review. These enhancements will significantly improve the manuscript’s readability and scholarly impact. Below are detailed suggestions, with optional page/line references aligned with the PDF version provided.

1. Clarify the Review Methodology (Recommended)

Since the manuscript presents an extensive literature synthesis, readers would benefit from a brief description of how sources were identified. Even a short statement indicating that this is a narrative review (non-systematic search, prioritizing 2020–2025 systematic reviews and meta-analyses) would strengthen transparency and methodological rigor.

2. Improve Structural Symmetry Between the VR and AI Sections

Pages 3–7 (VR section) vs. Pages 8–12 (AI section)
The VR section is rich in examples and clinical applications but becomes lengthy and somewhat fragmented due to frequent condition-based subsections. The AI section, on the other hand, is more compact and technical, but less consistently structured. To enhance readability, you might consider aligning the substructure across both major sections. This would help readers compare the two domains more intuitively.

3. Figures 1 and 4: Consider Strengthening Their Explanatory Role

Both schematic diagrams list opportunities and challenges but are currently descriptive. Including a brief explanation in the main text about how these visual summaries integrate with your narrative (e.g., highlighting which challenges are most prevalent in chronic illness management) could make them more analytically valuable.

4. Minor Clarifications and Text Improvements

• Page 3, Line 118: The phrase “ike as initial discomfort” appears to be a typo (“like”).
• Page 6, Lines 247-257: The paragraph on session duration and cybersickness is informative but long; consider splitting into two paragraphs for clarity.
• Page 12-13 (parasocial attachment risks): Excellent discussion, but you may add 1–2 lines clarifying mitigation strategies (e.g., boundary-setting rules, clinician oversight).

5. Add a Short Paragraph on Practical Safeguards in AI-Driven Therapy

The discussion of AI-induced psychological risks is excellent and detailed. However, readers would benefit from a short concluding note describing practical safeguards for clinical deployment (e.g., scripted boundaries, alert thresholds, explainable AI protocols). This also aligns with your discussion section where you highlight safety and patient-centered design.

6. Strengthen the Conclusion With Future Research Directions

The conclusion is well-written but could be enhanced with a brief forward-looking perspective—for example:

• The need for long-term, real-world trials,
• Standardization of AI–VR integration reporting,
• Challenges in pediatric and multimorbidity populations,

This would emphasize the manuscript’s value for guiding future work.

Author Response

Comment 1: Since the manuscript presents an extensive literature synthesis, readers would benefit from a brief description of how sources were identified. Even a short statement indicating that this is a narrative review (non-systematic search, prioritizing 2020–2025 systematic reviews and meta-analyses) would strengthen transparency and methodological rigor.

 

Response 1: 

To address this issue, we included the “Methods” in which we:

• stated the motivation for conducting the literature review,
• described the process of literature search by providing search engines, keyword combination, exclusion criteria, and the final number of obtained queries

 

Comment 2: Pages 3–7 (VR section) vs. Pages 8–12 (AI section)

The VR section is rich in examples and clinical applications, but it becomes lengthy and somewhat fragmented due to the frequent inclusion of condition-based subsections. The AI section, on the other hand, is more compact and technical, but less consistently structured. To enhance readability, you might consider aligning the substructure across both major sections. This would help readers compare the two domains more intuitively.

 

Response 2: We addressed this issue by combining the two sections into the same subsections - one describing the opportunities for using particular technology and the other describing the challenges and guidelines for implementing technology in healthcare. 

 

Comment 3: Both schematic diagrams list opportunities and challenges but are currently descriptive. Including a brief explanation in the main text about how these visual summaries integrate with your narrative (e.g., highlighting which challenges are most prevalent in chronic illness management) could make them more analytically valuable.

 

Response 3: We provided a brief introduction and explanation in the main text of what is depicted on both of the graphs

 

Comment 4: Page 3, Line 118: The phrase “ike as initial discomfort” appears to be a typo (“like”).

• Page 6, Lines 247-257: The paragraph on session duration and cybersickness is informative but long; consider splitting it into two paragraphs for clarity.
• Page 12-13 (parasocial attachment risks): Excellent discussion, but you may add 1–2 lines clarifying mitigation strategies (e.g., boundary-setting rules, clinician oversight).

Response 4: 

We fixed the typo, replacing “ike” with “like.”

 

To address the comment about parasocial attachment risks, we added the following fragment: "Clinician responsible for applying such AI-powered solutions should clearly inform the patient about the possibilities and limitations of virtual therapists, maintaining the AI explainability ."

 

We split and extended the paragraphs on cybersickness and session duration protocols, also providing additional citations.

 

Comment 5: The discussion of AI-induced psychological risks is excellent and detailed. However, readers would benefit from a brief concluding note outlining practical safeguards for clinical deployment (e.g., scripted boundaries, alert thresholds, and explainable AI protocols). This also aligns with your discussion section, where you highlight the importance of safety and patient-centered design.

 

Response 5: 

We added the following fragment on page 12: Ultimately,  safeguarding patient autonomy and data integrity must remain central to AI-driven healthcare innovation; without robust trust frameworks,  even the most advanced LLM-powered systems risk undermining the very patient-centered care they aim to deliver. We also added a new, short section right before the “Discussion” that focuses on the safe implementation of AI/VR technology in tackling chronic illness

 

Comment 6:

The conclusion is well-written but could be enhanced with a brief forward-looking perspective—for example:

• The need for long-term, real-world trials,
• Standardization of AI–VR integration reporting,
• Challenges in pediatric and multimorbidity populations,

This would emphasize the manuscript’s value for guiding future work.

Response 6: We added the future research directions paragraph to the "Conclusion" section.

Reviewer 3 Report

Comments and Suggestions for Authors

Title: “Your gitital doctor will now see you” – the review of VR and

AI technology in chronic illness management, I assume is DIGITAL? there is a need of BIG proofreading and also alignment problem. - not well organised.

The paper is a state-of-the-art review showing how VR/MR and AI virtual agents can improve chronic illness management while also highlighting the technical, ethical, and psychosocial challenges that must be addressed for safe implementation. however, the contribution is not strong enough. I suggest, if there is any meta analysis to be included, or providing strong evidence synthesis or systematic methodology to enhance it.

As for now the analysis is mostly narrative and thematic and not quantitative. besides, the norm term clinical effectiveness is not evaluated. 

Try describing search strategy, inclusion/exclusion criteria, quality appraisal, or database selection. I am concern about the selection bias and whether the evidence of review given is a complete set or not.

In several sections, claims about the effectiveness of VR or AI are stated without sufficient empirical support, and some conclusions appear over-generalized beyond the cited evidence. The integration of VR, MR, and AI is conceptually discussed, but no framework or analytic method is used to synthesize findings systematically. As a result, some interpretations risk being anecdotal rather than evidence-driven. The paper draws conclusions without presenting how the literature was selected or analyzed, making the scientific basis unclear.

The contributions of authors' section could be improved also.

The statement "Contemporary research clearly indicates that VR can serve as a supportive tool that enhances the effectiveness of therapy." - this is with no specific studies or evidence levels are provided.

Lines 105–116 present VR/MR benefits and risks, but do not differentiate between findings from clinical trials vs. general observations.

AI-based systems are discussed in broad terms without grounding in specific studies.

Conclusion: For example, the paper claims AI can “optimize clinical decision-making and resource allocation” yet provides no empirical evidence. This is a large claim that would require clinical evidence or systematic reviews. 

Although some psychosocial risks are mentioned (e.g., over-attachment), the paper does not provide Safety thresholds, Recommended session durations, Contraindications for VR usage and Clinical risk frameworks.

Again there is no methodology, tables of comparison? Flowchart of evidence? and thematic synthesis in the review.

 

Author Response

Comment 1: Title: “Your gitital doctor will now see you” – the review of VR and

AI technology in chronic illness management, I assume, is DIGITAL? There is a need of BIG proofreading and also an alignment problem. - not well organised.

Response 1: We corrected the typo (“gitial” instead of “digital”) in the title and clarified the type of review that was conducted. Now the title is “Your digital doctor will now see you”: A narrative review of VR and AI technology in chronic illness management.”

 

Comment 2: The paper presents a state-of-the-art review, demonstrating how VR/MR and AI virtual agents can enhance chronic illness management while also highlighting the technical, ethical, and psychosocial challenges that must be addressed for safe implementation. However, the contribution is not strong enough. I suggest, if there is any meta-analysis to be included, or providing strong evidence synthesis or systematic methodology to enhance it.

As for now the analysis is mostly narrative and thematic and not quantitative. Besides, the norm term clinical effectiveness is not evaluated. 

Try describing the search strategy, including/excluding criteria, quality appraisal, or database selection. I am concerned about the potential selection bias and whether the evidence provided in the review is a complete set or not. In several sections, claims about the effectiveness of VR or AI are made without sufficient empirical support, and some conclusions appear overly generalized beyond the cited evidence. The integration of VR, MR, and AI is conceptually discussed, but no framework or analytic method is employed to systematically synthesize the findings. As a result, some interpretations risk being anecdotal rather than evidence-driven. The paper draws conclusions without presenting how the literature was selected or analyzed, making the scientific basis unclear.

Again there is no methodology, tables of comparison? Flowchart of evidence? and thematic synthesis in the review.

Response 2: To address this issue, we included the “Methods” in which we:

• stated the motivation for conducting the literature review,
• described the process of literature search by providing search engines, keyword combination, exclusion criteria, and the final number of obtained queries

We added new citations in the fragments that stated important claims, referring to relevant review and meta-analysis articles obtained during our review. 

 

Comment 3: The contributions of the authors' section could also be improved.

 

Response 3: We adjusted the "Author Contributions" so it better fits the journal template

 

Comment 4: The statement "Contemporary research clearly indicates that VR can serve as a supportive tool that enhances the effectiveness of therapy." - This is with no specific studies or evidence levels are provided.

 

Response 4: We addressed this issue by providing examples of phobia and anxiety treatment, along with relevant citations from the literature. 

 

Comment 5: Lines 105–116 present VR/MR benefits and risks, but do not differentiate between findings from clinical trials vs. general observations. For example, the paper claims AI can “optimize clinical decision-making and resource allocation,” yet provides no empirical evidence. This is a large claim that would require clinical evidence or systematic reviews. 

 

Response 5: 

We adjusted the bullet point list that describes how VR and AI can improve clinical workflow by adding relevant citations to back the claims regarding the optimization of clinical decision-making, personalization of behavior-change support, and reduction of treatment burden. We also provided some examples to better explain the outcomes of particular studies.

 

Comment 6: 

AI-based systems are discussed in broad terms without grounding in specific studies.

Response 6: 

We gave additional examples of how AI is used in particular clinical settings by also providing relevant citations

 

Comment 7: Although some psychosocial risks are mentioned (e.g., over-attachment), the paper does not provide Safety thresholds, recommended session durations, Contraindications for VR usage, and Clinical risk frameworks.

 

Response 7: We added the “Safe implementation of AI/VR technology in tackling chronic illnesses” section to address this issue

 

Comment 8: Besides, the norm term clinical effectiveness is not evaluated

 

Response 8: We replaced this term with “effective in supporting clinicians’ work.”

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

The authors have highlighted and made necessary changes and improvements.

Author Response

We would like to thank all of the reviewers for insightful comments and suggestions. Below, we describe the changes applied to another version of our manuscript.

1. We added the flowchart in the “Methods” section to visualize the process of literature review
2. We deleted the number before the “Introduction” title to keep the names of the sections consistent
3. Regarding “The main findings and implications at the beginning of this paper should appear somewhere in the discussion or conclusions instead,” we decided not to include any changes. Our explanation for that decision is the following:
1. First point of the main finding: we show the positive effects of VR/AI implementation within patients with chronic illness in the following fragment of the Discussion: “Engagement and short-term outcomes are consistently positive. CAs and chatbots supporting mental health and self-management generally show small-to-moderate short-term benefits across depressive and anxiety symptoms, distress, well-being, and condition-specific complaints; effects tend to be larger when systems personalize content and respond empathically, and with longer interaction time (...).”
2. Second point of the main findings: we also highlight the negative consequences of implementing such technology. Here are some examples: “According to current research, humans and the 'uncanny' feeling accord an important role in the acceptance of technology. Social presence helps patients feel more heard by agents that personalize motivational messages to their situation, but human-like avatars, mismatched prosody, and latency can induce discomfort or erode trust, especially in emotionally vulnerable users. “Evidence-based scripts and safety rules should be of the highest priority when it comes to using CAs and virtual coaches in healthcare settings.”
3. First point of implications: in the “Conclusions” section, we address that combining both technologies (VR and AI) requires oversight from the clinicians, for example, “Clinician adoption will hinge on healthcare workflows, training in ethical/technical limits, and the routine use of UX research and co-design to align systems with patient abilities and preferences.”
4. Second point of implications: we also pointed out that with the proper handling, this technology can be used as a good supplement to traditional methods:  “If these preconditions are met, the technologies reviewed here are well-positioned to meaningfully support prevention and quality of life across the chronic care continuum.

However, we are still open to adding any necessary changes if reviewers require so. 

1. We deleted figures 1, 2, 3, and 4 because they didn’t add any insights beyond what was already stated in the paper. We also deleted the references to these figures.
2. We fixed the highlighted typos.