Virtual Reality in Healthcare: An Amazing Clinical and Technological Tool

Are you aware that virtual reality (VR) has been used as a clinical tool in healthcare since the early 1990s, or are you like me – thinking VR was a new, emerging technology that had just recently been developed?  Do you consider it an entertainment/gaming device or an educational and clinical tool used in a large variety of clinical situations?

In reviewing the trends for 2018, I began to realize that VR is being used as a very effective, credible educational and clinical tool. I have to admit I was surprised at the depth and breadth of its use in healthcare over the past 25 years and its expected expansion in scope for the future, given the fact that the technology has become more advanced, less costly, and easier to mass produce.

So it looks like virtual reality is here to stay! But what exactly is VR?  

Definition
According to the Merriam-Webster Dictionary, virtual reality is "an artificial environment that is experienced through sensory stimuli (such as sights and sounds) provided by a computer and in which one's actions partially determine what happens in the environment." With the use of a head-mounted display, the user sees only the computer-generated image; the rest of the physical world is blocked from view. This creates a simulated real-life environment that the user is totally immersed in and able to interact with. In addition to sight and hearing, VR can also include the use of touch, smell, and taste. With VR, users can swim with dolphins, travel to far-off lands, play with their favorite pet, participate in an art class, listen and watch their favorite concert or relax on a beautiful beach.  

VR, also referred to as "virtual environment, computer-simulated life, or immersive multimedia," is a totally immersive experience that provides a real-world feel to the experience. This total immersion experience makes it different than other types of semi-immersive virtual environments:

• Augmented reality (AR) is a system that overlays computer images onto the physical world, providing a mix of real and virtual worlds visible to the user. An example would be seeing a realistic 3-D version of internal organs or bones, ligaments, and tendons as they appear in the body. Another example would be using a scanner device to see where veins and arteries are located in a patient’s arm before injecting a medication or drawing blood. AR and VR are often closely linked or spoken of as the same technology, but they are different. (Note: AR will also tend to grow significantly in the healthcare area over the next few years, but this article will focus specifically on VR technologies.)
  

• "Fish Tank" reality projects stereo images on a monitor in front of the user.

• Projection-based reality projects images on a screen, wall(s), and/or floor around the user.    

History
As noted earlier, virtual reality is not a new technology. The history of VR shows that it is built upon ideas that date back to the 1800s, almost to the very beginning of practical photography.

• 1838: The first stereoscope was invented, which used two mirrors to create a single image.

• 1939: The View-Master, which gave a photograph a 3-dimensional look, was developed. Many of us remember using this toy when we were children.
  

• 1956: The Sensorama was developed to demonstrate what it was like to be "in" a movie. It provided a simulated ride on a motorcycle, in which the user was able to see the road, hear and feel the engine and road vibrations, and smell the exhaust fumes.

• 1960: The Telesphere Mask, a head-mounted display device, was developed.

• 1970s: Optical advances allowed a user to feel as if they were actually moving around in a virtual space.

The term "virtual reality" was first used in the mid-1980s, when goggles and gloves were used to provide the experience referred to as "virtual reality."

• 1980s: The Virtual Interface Environment Workstation (VIEW) system, developed by NASA’s Ames Research Center, combined a head-mounted device and gloves to include the perception of touch.

• 1990s: VR simulations were used to treat patients with:
  
  • Phobias and fears related to: flying, heights, driving, confined spaces, bugs or animals, crowds, needles, public speaking, etc.
  • Anxiety and depression
    
  • Severe pain in burn victims and chronic uncontrolled pain
    

• 1996: VR studies were begun in the UK to treat Autism.

• 1997: Treatment for post-traumatic stress disorder (PTSD) was developed.

• 2000s The interest in using VR in other conditions continued through the 2000s. Examples include: stroke, attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), physical therapy, rehabilitation and various other conditions

• Current: Incredible interest in VR due to mass production of low-cost VR devices, games, and head-mounted display products.
  

VR Use in Educational Programs and Training Sessions
VR is used in a variety of healthcare settings. One of the key areas is in educational programs and training sessions for:

• Providers: Virtual organ models and surgery simulators are being used to help surgeons prepare for delicate or complicated procedures they may have little experience with or have not performed previously. The simulators allow them to "practice" the surgery on a life-like mannequin (for safety purposes) to increase their precision, avoid complications and improve clinical outcomes. A good example of this is the preparation for a surgery to separate co-joined twins. This is a rare surgery, and every one is a little different. This process allows the surgeon to review diagnostic studies to determine and practice exactly how the surgery will be performed.
  
  Another example of this remote surgery occurred in 2016 when a physician performed the first worldwide VR livestream of a surgery with about 50,000 people watching it on their desktops, phones, and VR head-mounted displays. Future livestreams plan to have the camera attached to the head of one of the surgeons, rather than on a table as with the first surgery, in order to provide an even more realistic view.  
  

• Residents and Medical Students: Videotaped surgeries and other procedures are being done on mannequins and provided to residents and students as hands-on training. The students use endoscopic cameras and other tools to diagnose and treat the "patient." They experience realistic sights and sounds and are able to see the same results, as if they were really performing a live procedure. Emergency scenarios can also be introduced to simulate how they would act in crisis situations.
  
  Another interesting VR training approach being used is to place the resident or student "in the patient’s body" to experience the patient’s perspective. This allows them to see what it is like to have macular degeneration, glaucoma, a stroke, hearing problems, general aging problems associated with the elderly, or any other type of condition. VR helps the young provider foster empathy for the patient because they know how the patient feels.  
  

• Healthcare Team Members, Patients, and Families: VR is providing in-depth educational programs on conditions, treatments, symptoms, condition management, procedures, diagnostic tests, and surgeries, as well as how to perform CPR and the Heimlich maneuver.
  
  Another VR training experience is designed to teach young or new team members how to talk with a patient or family. These scenarios use fully animated, virtual humans with whom the trainee talks about substance abuse, a threat of suicide, non-compliance with medications or the treatment plan or other controversial subject. This practice session allows the trainee to learn how to handle such situations in a non-threatening environment and develop the skills and confidence to use them in real-life situations.
  

• Patients and Families: There are also interactive, preventive medicine programs to educate patients and families on the effects of poor lifestyle choices, including smoking, overeating and consuming unhealthy foods.

VR Use in Clinical and Treatment Programs
The other main area in healthcare where VR is used is clinical and treatment programs. These are just a few examples of the more popular types of VR clinical and treatment programs being used:

• Mental Health:
  
  • Phobias and fears related to: flying, heights, driving, confined spaces, bugs or animals, crowds, needles, public speaking, etc.
  • Anxiety, depression, PTSD, attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD), and obsessive compulsive disorder (OCD)
    
  • Dementia and Alzheimer’s
    

• Autism: to help patients develop eye contact and improve social skills.

• Pain Control: Severe pain in burn victims, chronic uncontrolled pain, and phantom limb pain (feeling of pain, burning, itching, or tingling in the missing limb). These programs use biofeedback to help patients relax, control their breathing and reinforce a positive attitude to lessen pain. They typically provide a relaxing environment for the patient, such as being on a beach or traveling to a serene place.

• Other conditions: Stroke, head injury, Parkinson’s, multiple sclerosis and other neurological conditions, etc.

• Cancer and Chemotherapy: VR is used to help patients with chemotherapy and its side effects. The program helps distract them during and after chemotherapy and the game aspect provides more fun than just lying in bed thinking about their condition.  

• Ophthalmic Conditions: VR programs have been developed to treat eye conditions, such as strabismus, amblyopia and convergence disorders.

• Rehabilitation for Brain Injury and Stroke: Therapy programs have been developed to help with balance and how to learn to walk again. VR can also help patients who struggle with daily tasks, such as shopping, by having them practice these tasks with increasing complexity. This results in quicker recovery and a higher level of cognitive function.
  
  Physicians also use these as assessment tools to help identify memory loss, reduced attention or difficulty in making decisions.

• Physical Therapy for Stroke, Injury, Surgery, Back Pain, Walking Disorders, Orthopedic and Neurological Issues: For patients with difficulty walking, VR can make it look as if they are walking slower than they actually are, which makes the patient increase their pace without realizing it and without increasing their pain or anxiety.
  
  Regaining loss of function quickly is essential for stroke and traumatic brain injury patients, but they are not physically or mentally capable of actually lifting their arms or moving their fingers. However, the VR therapy program allows them to "practice" these movements by having them raise their arms to catch a ball. This improves movement, visual and auditory feedback, and patient motivation and engagement. The repetitive movement in a VR program is also more fun than going to a gym and results in faster recovery.
  

• Socialization and Connectedness: Patients who are hospitalized for a long period or who are a long way from their family can have live contact with them for a birthday party or football game by using a smartphone and virtual glasses or head-mounted device and a 360-degree camera at the patient’s home or family event.  

• Homebound and disabled individuals can use VR to provide social interaction and safety programs to prevent falls.

Evidence of Effectiveness
VR programs are often more interesting and enjoyable than traditional therapy tasks, but are they effective? Research studies have been conducted on a variety of VR programs. These are a few studies that show the effectiveness of these programs.

• Mental Health Conditions: A growing body of evidence suggests that virtual reality (VR) technology can be an effective part of treatment for mental health conditions such as phobias, post-traumatic stress disorder, panic disorders, schizophrenia, acute, addictions (including smoking) and eating disorders. Positive results in these areas have been consistent since the 1990s. Patients also cite their satisfaction with these programs because it allows them to be treated in private, eliminating any embarrassment or loss of confidentiality.

• Autism: A study conducted by Duke University on the use of VR to improve social skills in autistic patients showed it was effective and reduced overall costs because the amount of time spent with therapists and the number of visits were reduced.   

• Stroke: A study was done to compare the effectiveness of VR and interactive video gaming with alternative interventions in the treatment of stroke. It found that there was significant improvement in arm function and activities of daily living. However, there was no statistical significance on gait speed. They also identified low participation rates, possibly attributed to lack of desire or interest in using technology.

• Pain Control: VR programs for pain programs have proved successful over the years, especially those related to severe pain from burns, chronic uncontrolled pain, and phantom pain after the loss of a limb. Clinical trials and studies conducted by companies developing VR programs have reported 24 percent and 60 percent pain reduction from patients using VR relaxation programs.
  
  A physician in Chicago started a VR treatment program for her impoverished patients suffering with anxiety, depression, brain trauma, and chronic pain. The program used a guided meditation and relaxation VR application that used psychedelic nature-inspired tours to quiet, serene places. After a few months, the results showed a reduction in blood pressures and a reduction in self-reported pain, which some patients noticed within 10 minutes of the beginning of a session. None of these patients had received benefit from traditional therapies. No negative symptoms or side effects were reported. This program showed a potential for cost reduction as well, because the program was less costly than other traditional therapies and it taught the participants to be proactive about their wellness.

• Immersion Increases Results: There is evidence that shows that the results of transferring learning skills from the virtual training environment to the real-world environment are better if the learner is immersed in the training environment. Perhaps the most important factor for VR is the sense of presence in the environment. Variables that help create this type of positive environment include real-time performance feedback; independent, repetitive practice; graduated exposure to stimuli; ability to modify situations based on physical abilities; ability to distract the patient’s attention when needed; patient motivation; and provision of a safe testing and training environment.

VR programs are not appropriate for everyone. People with serious medical problems, epilepsy, major psychiatric or psychological problems or those with a potential for panic attacks are not good candidates for these programs.

In general, the studies conducted and the anecdotal information from healthcare personnel seems to show that VR reduces the number and intensity of healthcare resources, thereby reducing overall costs. Yet it provides a safe, effective alternative to conventional therapy that improves patient engagement, satisfaction and quality of life.  

As in all areas of healthcare, innovators in this field will be increasingly scrutinized regarding evidence for clinical efficacy through properly designed and controlled human trials.

The Future of VR
It is likely that VR applications will continue to proliferate due to the fact that the cost of head-mounted displays keep getting less costly, smaller and less bulky. While use of a VR program used to mean a patient needed to go to a hospital or clinic area, the use of mobile devices attached to smartphones now allow patients to use these programs at home. This should reduce costs because patients will not need to go to a hospital or healthcare facility to use the programs.

There is a definite increase in the number of companies who are investing in VR, as they see this as a growing sector of the healthcare market. According to the The Statistics Portal from Statistica, the VR healthcare market in the U.S., which was valued at $525 Million in 2012, increased to $976 million in 2017. Looking into the future, Global Industry Analysts, Inc. predicts the global healthcare segment will reach $3.8 billion by 2020.

Research shows the expected increase in use of VRs in healthcare will be in the areas of surgical simulation and training, innovative diagnostic tools, non-invasive and endoscopic procedures, neurological disorders and robotic systems. They also cite the following trends that will drive continued growth: the aging population will drive the development of rehabilitation and assisted living VR programs; cancer and chronic pain programs will continue to be a major emphasis for treatment options; and surgical robotics and medical visualization will see major innovative programs.

Additional opportunities abound with remote program possibilities in the telemedicine/telehealth area, enabling remote mental health visits and technology-based intervention programs for substance abuse and other similar programs. With the success VR has had in helping to reduce pain (and the number of narcotic prescriptions being written for pain control), perhaps programs can be developed to help reduce the addiction to opioids, which is a major issue in the U.S.

As with all computerized programs, there will be a focus on seamlessly integrating all VR programs with other new innovations, big data, artificial intelligence (AI), and the patient’s record. This should provide even more awe-inspiring programs.

Conclusion
"It's a question of when, not if, the VR ‘revolution’ will occur in health care," says Bruce Y. Lee, Associate Professor of International Health at Johns Hopkins Bloomberg School of Public Health. Dr. Lee notes that the "biggest obstacles preventing VR from becoming more of a presence in healthcare are the three A’s: Awareness, Acceptance and Aw, come on, why aren’t more people investing in this? Not everyone in healthcare is aware of the great potential of VR."

However, Dr. Lee feels certain that VR will become a common reality in healthcare. In the meantime, he suggests we work on the following areas:

• Smaller, more convenient, less expensive headsets or glasses

• A smoother, more graphic presentation

• Reducing costs

• More innovation in handling remote training

• More recognition of the potential positive impact of VR

"VR is moving into the leading edge in healthcare. Still, inflated expectations abound for its use in the industry, says Mutaz Shegewi, research director for provider IT transformation strategies at IDC Health Insights. His advice is to "Gain an accurate understanding of how VR is playing out in healthcare and align it with your concerns and goals."

Even though VR has been around for almost 30 years, it is still in its infancy. With new innovations – who knows how far it will go and what kind of programs we can look forward to in the future? Aren’t you glad you are here to witness this? Don’t you want to try some of these programs?  I know I do!   

Pat Stricker, RN, MEd, is senior vice president of Clinical Services at TCS Healthcare Technologies. She can be reached at pstricker@tcshealthcare.com.