Although it hasn’t yet established its place as a mainstream treatment modality, virtual reality has grown from an interesting diversion into a frequent topic of conversation within digital health. As researchers continue to dig their teeth into the immersive technology, it’s becoming clear that this new tool, often associated with video gaming and entertainment, could play a role in addressing some of the long-standing issues of the healthcare industry.
“If we make things better for the patient, easier, more convenient, we may be able to create a system that is truly patient-centric or consumer-centric and allow us to be able to address some of those key issues,” Dr. David Rhew, chief medical officer and VP and general manager of enterprise healthcare at Samsung Electronics America, said during a keynote presentation at the Virtual Medicine symposium hosted by Cedars-Sinai Medical Center in late March. “That’s what we’re trying to accomplish: we’re understanding how technology can be used to improve the health and wellbeing for the healthy, the sick, the aged.”
VR certainly looks to be making itself comfortable within the healthcare industry so far. One recent market forecast, for example, predicts that the technologies will enjoy a 54.5 percent compound annual growth rate in healthcare until 2023, and already there are a number of players — such as Samsung, appliedVR, Rendever, and One Caring Team — specifically developing their VR products for use in care.
As of now, the most established of these VR offerings often fall under a few major use cases, including education and training for physicians, and distraction therapy for inpatients and seniors. Still, ever-advancing technology and growing acceptance by physicians and patients alike has many digital health researchers excited to investigate more novel clinical use cases and tackle the various hurdles that remain for VR.
“Some of these topics are not sexy, like how do we connect these to EHRs, how do we get someone to pay for it. Some of them are real exciting, like getting music to work [in VR], or getting the right prescriptions available, and so on,” Dr. Brennan Spiegel, director of health services research at Cedars-Sinai Health System, told MobiHealthNews. “Really, it’s going to require a lot of resources and a lot of people.”
[[For a list of 15 clinical VR use cases, click here.]]
Treating the brain virtually
Researchers have become more confident that VR is not only capable of distracting a patient from their acute pain, but of blocking their brain's pain receptors in much the same way a prescription opioid would.
“If you were to do a functional MRI of individuals who have pain, their brain will light up like a Christmas tree. … We’re just focused on that pain,” Rhew said. “But when you have virtual reality in these treatments, and even after you’ve taken the headset off — which is the remarkable part, it’s not just being distracted in the moment, but it’s this persistence of the pain relief — we can still see a quieting down, and that’s seen visually on the functional MRIs.”
Studies of VR pain management are gaining steam (as evidenced by a recently announced collaboration between Samsung, Travelers Insurance, Bayer, AppliedVR, and Cedars-Sinai), but nowadays they aren’t the only investigations of VR’s impact on the brain. For Dr. Brandon Birckhead, a resident physician in radiation oncology at Medical College of Wisconsin and VR researcher, some of the most exciting of these are deep dives into the the role of virtual embodiment within embodied cognition — or, in other words, how an avatar in VR can potentially rewrite the relationship between a patient’s brain and their motor system.
“Say, if a patient isn’t using one arm. Whenever a person uses the other arm, [the VR application] mirrors that motion to the other part of their virtual avatar, and over time the brain has a very hard time not attaching itself to that virtual avatar and to some degree seeing that avatar move is having some effect,” Birckhead explained. “It’s a really interesting finding — taking what’s been done in mirror therapy and really taking it to a new level with this embodiment with a virtual avatar.”
A 30-participant study exploring the feasibility of this therapy headed by Dr. Kim Bullock, a clinical associate professor of psychiatry and behavioral sciences at Stanford, is currently underway and is expected to conclude by the end of this year.
Meanwhile, another recently announced study, to be conducted by Kessler Foundation and Virtualware, will use a somewhat similar concept. To tackle stroke patients’ spatial neglect, a condition in which a patient has difficulty paying attention to the side of space opposite to an injured cerebral hemisphere, this study looks to build a game-like training scenario on an HTC Vive headset that helps users remap and realign their visual and motor abilities.
“Currently there are several tools that facilitate rehabilitation tasks in this type of patient. Many of them, very effective, are based on expensive robotic technology,” Julio Alvarez, eHealth business unit manager at Virtualware, wrote in an email to MobiHealthNews. “Virtual reality comes to fill a gap within the therapies and tools for rehabilitation, which aims, in an affordable and universal way, to provide new systems that motivate users to perform their rehabilitation sessions, both in the medical office and at home.”
While these and other efforts — such as Duke University’s ongoing Walk Again Neurorehabilitation program, in which a combination VR-exoskeleton physical rehabilitation was reported in 2016 to improve locomotive function in eight chronic spinal cord injury paraplegics — primarily focus on recuperation, some are tapping VR as an answer to psychiatric disorders. In this area, Birckhead highlighted a pilot trial published this year by Dr. Alexandre Dumais and colleagues at the Université de Montréal that found success employing VR for schizophrenia patients experiencing persistent auditory hallucinations.
“Patients will have auditory hallucinations many times, and [Dumais] actually was looking at personifying those auditory hallucinations as a visual avatar so the patient is able to visualize the hallucination and actually talk down to it — you know, giving it a face and being able to more visually take control,” Birckhead explained.
VR could soon be a resource in treating a different kind of recurring fear as well. Digital health therapeutic company Pear Therapeutics’ pipeline includes reCALL for PTSD, an immersive, experimental VR treatment that would be prescribed in conjunction with pharmaceuticals to reduce patients’ psychological trauma. So far, pilot studies have shown a “marked improvement” in PTSD scores among patients using the VR therapy compared to standard care alone.
Placing veterans or others with the condition back into a simulated version of a traumatic event might sound counterintuitive, but according to USC Davis School of Gerontology professor Albert “Skip” Rizzo, experiencing a version of the events in which they have greater control can provide a sense of resolution.
“Exposure therapy is an ideal match with VR,” Rizzo said during an NBC interview on the subject. “You can place people in provocative environments and systematically control the stimulus presentation. In some sense it’s the perfect application because we can take evidence-based treatments and use it as a tool to amplify the effect of the treatment.”
Refining the tool
One growing area of VR research is not necessarily tied to any specific intervention. Rather, it’s the growing exploration of how VR, as a platform, can best be deployed to meet the individual needs of a patient and their situation.
“Virtual reality is a lot like a syringe,” Spiegel said. “A syringe is just a platform; what matters is what medicine goes through the syringe, not the syringe itself. We speak of VR like it’s some kind of singular thing, but it’s just a headset, a head-mounted device. What matters is the visualizations, what goes through the headset, what people see and hear and feel. That’s really where we get to this idea of personalizing VR treatment — we need a VR pharmacy, and we need to be able to conduct psychometric assessments of individual patients and use that to draw from a library of VR content to tailor the experience.”
In another session at the Virtual Medicine Symposium, Josh Sackman, president of appliedVR, expanded on Spiegel's point by stressing the heterogeneity of patients that will encounter a healthcare provider on any given day. Instead of working to develop a one-size-fits-all VR therapy, he argued for the development of a wide range of VR content and the use of complementary technologies so that providers can offer experiences fine-tuned for each individual patient.
“With digital health, it’s never really about one thing. It’s about arming a toolkit,” he said during the session. “The virtual reality goggles deliver these immersive experiences … but then combine it with biosensors, where we can actually optimize the VR experience for the patient in that moment, using sensors that uniquely measure a patient’s reaction and can change the stimuli based on what’s working and what’s not, and allow objective measures as the patient progresses over time to know if the patient’s actually improving or not.”
This kind of reimagining for how VR should be formed and deployed was something of a recurring theme throughout Cedars-Sinai’s event, and often it came from avenues well outside of traditional healthcare.
Jeremy Soule, a prolific composer of video game soundtracks whose resume ranges from “The Elder Scrolls” to “Star Wars,” is one such example. His presentation during the event explored how different harmonic intervals can intuitively communicate specific emotions or ideas, a topic that he said he hopes could help “start a conversation [among healthcare VR researchers] around where we are in understanding the fundamentals of sound and the brain and the cognitive process."
“Therapeutically we know music therapy makes a difference,” Spiegel said. “We really need to think about how to take best practices in sound and acoustics and music, and then layer them over the three-dimensional acoustics so there are soundscapes that track with the visual cues to really supercharge the experience of therapeutic VR.”
Another outside perspective came from the Rev. Kelvin Sauls of the Holman United Methodist Church in Los Angeles. Sauls, along with Bernice Coleman, associate director for nursing research at Cedars-Sinai, spearheaded a community program designed to improve church members’ fitness and health. After engaging the program’s participants and providing health education, a later phase in the partnership brought in a behavioral VR intervention that showed participants first-hand the impact that salty foods would have on their cardiovascular health. The intervention resulted in a significant drop in participants’ blood pressures and behaviors, researchers reported.
Sauls gave VR its due credit, but stressed that there was much more going on than just the technology's impact alone. Rather, VR was effective and well-received because it was part of a holistic approach, he said. In the future, he said, VR researchers should bear in mind the myriad additional influences on a patient’s health when designing a tech-driven intervention.
“It was an integrative approach. I have much respect for VR, but [if] you want to take over the world you can’t do it by yourself,” he said during a presentation. “You see, we had to lay the groundwork with preventative health education into active health education, experiential health education. By the time we brought VR in, seeds had been planted, soil had been tilled, and they were ready to go.”
VR faces familiar digital health challenges
Across the board, the experts agreed that therapeutic VR will be most effective if researchers and providers can find ways to support the technology within wider health initiatives.
“[VR has] been shown in many different ways to be beneficial, but it is just one tool, and if we want to build a house we need more than just one tool. We need to put this together in the structure of a program,” Rhew said. “How can this be put together as a program to holistically treat patients? Combining other modalities together, looking to see how we can implement this as a program or a pathway, figuring out … whether clinical decision support can be used — that is how we make this operational. We’ve got great tools that [have] to be put into the context of a program.”
Such a goal is easier said than done, however, as VR and its growing body of clinical evidence still has a few more hurdles to clear before it can begin making an impact at scale.
“We still struggle with some of the boxy headsets that are available today. They probably will remind us of the big brick cellphones when we look back," Spiegel said. "We need lighter, less obtrusive, easier to use headsets because our patients are not gamers ...We still feel a lot of resistance among patients.”
While technological limitations are the first to come to mind, Spiegel noted that many of the latest devices, like Facebook’s recently announced Oculus VR headset, are beginning to chip away at longstanding hardware concerns like weight, size, and cost (although Spiegel did lament Oculus and other manufacturers’ use of felt padding, a logistical nightmare when it comes to hospital sterilization protocols).
Instead, VR’s primary challenges are shifting toward other issues that should be familiar to anyone in digital health.
“The elephant in the room is the payer, and [whether] insurance companies are going to pay for this,” Spiegel said. “That’s as much of a pressing issue to solve as any technical or therapeutic objective.”
“What will insurance companies do with VR therapeutics — Will they want to incorporate this into a reimbursement plan?” he asked. “I’ve heard some talk that they may want to do this in some type of preventative plan. It’s completely unknown to me what they’ll want to do to incorporate, even with more robust randomized data that’ll be coming out in a year or two.”
Another issue is exactly how VR will be viewed within hospital workflows, and in particular how it will be incorporated into notoriously inflexible EHR systems.
“The EHR is really the digital backbone of modern western medicine, and we need to have a way for VR, which is a digital therapeutic, to be interconnected to that backbone,” Spiegel said. “What that would allow is really more efficient implementation, tracking, usage, and prescribing. Really, I should be able to prescribe VR through the computer just as I would prescribe a medication. I shouldn’t have to have any other way of doing it or require special calls or emails or whatever in an informal way.”
Of course, there is always the human element to consider when it comes to anything new or out of the ordinary. Most practicing doctors are still unfamiliar with VR or may only have a passing idea of why it could make a difference, Spiegel explained. For VR to take off, healthcare needs “VR clinicians” who are able to speak authoritatively on how and why to use VR for specific scenarios, or “VR clinics” where a patient interested in the technology could be directed to receive their treatments, he said.
Rhew shared the sentiment, but noted that the healthcare industry of 2018 is far more open to technologic advances than that of the past.
“The challenge is that we have, within the medical community, found only a certain number of individuals who use this, so what we need to do is we need to start thinking about how do we get this to the point where everyone knows about it and everyone is aware of it, including physicians,” he said. “It’s really remarkable how it takes about 10 to15 years for cutting-edge medical evidence to be brought to real life practice. But nowadays we have the ability for us to ...share this and hopefully accelerate the pace of adoption so that we might be able to get this to the point where people are using it regularly and [it’s] widespread.”
As VR looks to gain credibility and support, so too do its most ardent supporters. Earlier this year, Birckhead and Spiegel announced the formation of VR-CORE (The Virtual Reality Committee of Outcomes Research Experts), a cooperative group of international academics and clinicians focused on therapeutic VR research.
“This is sort of an academic thing, but it’s really important because it’s sort of the Wild West out there right now in terms of validation and evidence for the so-called treatments in VR that are being promulgated and promoted,” Spiegel explained. “Some of these treatments have excellent evidence, but most have no evidence or bad evidence, so what VR-Core is trying to do is create a centralized thinking about how best to create and validate interventions in [this] emerging field.”
The pair said that they first reached out to prospective members of the group last summer, and held their first meeting in the fall to develop a set of clinical guidelines, which have since been submitted for publication. Birckhead went on to stress the importance of being able to efficiently collaborate on large-scale research efforts, especially in a new field of research where grants and other sources of research funding may be infrequent.
“Whenever you see large studies done in any medical field, they’re done through some kind of cooperative group. Medical oncologists, radiation oncologists, surgeons, you name it, they all have their acronym group that they collaborate with, that they pool ideas and resources through, and they talk about studies,” he said. “In my mind, that’s what I want for VR-Core long term. Initially, we just want it to talk about how we come up with consensus on clinical trial guidelines, or how we come up with consensus on ethics. When you [don’t have] much data because your field is so young, that’s where you have to start.”Alphabounce SD M