Applications of Virtual Reality in Modern Medicine

Current methods of evaluating and treating patients are vastly different from the methods used just a few decades ago. Today’s patients have different expectations than patients of the past. They expect the use of technology to evaluate and treat common medical problems. Technological game changers in the 20th century included Thomas Edison and the light bulb, as well as Henry Ford, with the automobile and the introduction of mass production. So far, the technological advances in the 21st century that have changed the world include Steve Jobs’ Apple products, Mark Zuckerberg’s Facebook, and other social media platforms. These new technologies have inserted themselves into healthcare along with other advances that we take for granted in the clinical care of patients, such as magnetic resonance imaging and stem cell transplants.

What is Virtual Reality?

The term virtual reality (VR) generally refers to a medium that uses the elements of a virtual world—immersion, sensory feedback, and interactivity. VR consists of interactive computer simulations that sense the participant’s position in time, space, and actions, and replace or augment feedback to one or more senses (e.g., sight, hearing, smell, and touch), giving the user the feeling of actually being immersed or present in the simulation.(1)

History of Virtual Reality Technology

The main feature of VR is immersion by artificial stimulation of the senses, a human practice that can be traced back to before 40,000 BC to the earliest known forms of visual art and the consumption of plants that induce psychedelic experiences. Other manmade immersive experiences—storytelling, theatre, photography, moving pictures, and even architecture—are argued to be the predecessors of VR due to their ability to artificially stimulate the senses.(2)

Throughout the 1900s, the development of VR technology was driven primarily by practical and conceptual purposes. The first major development in VR technology occurred in 1956 when Morton Heilig created Sensorama, a single-person multimodal display system that integrated prerecorded sounds, vibrations, smells, wind, and visuals to create a multisensory experience.(3) In 1960, Heilig patented the stereoscopic-television apparatus for individual use, which was the first of the head-mounted display (HMD) devices to combine olfactory, aural, and visual sensations.(1) Computer scientist, composer, visual artist, and author Jaron Lanier coined the term “virtual reality” in 1980. He also codeveloped the first glove device that allowed tactile interaction with the virtual world and virtual objects.(3 )In 1984, Lanier founded Virtual Programming Languages Research, Inc., which developed the first commercial VR devices. The commercialization of VR exploded, with several companies developing new VR systems. In addition, there was a sharp increase in public knowledge of the technology.(1) The most widely known development of VR technology was the creation of the Oculus Rift, a virtual reality headset created in 2012 by Oculus. Since then, VR has been used extensively for entertainment, primarily gaming, and for advertising by major companies such as Nissan and Wrigley.(4)

Nonclinical Applications of Virtual Reality

With the rise of widespread VR, the technology is becoming ubiquitous in gaming and entertainment. The increasing popularity of VR as a form of entertainment is due to the user’s ability to experience a virtual environment just as the person would a real environment. VR has been shown to offer a more immersive experience than traditional two-dimensional entertainment media.(5)

VR technology may be used as a hands-on immersive learning tool for educational purposes in the classroom to combat issues of student disengagement and difficulty in grasping abstract concepts.(6) VR may improve student enjoyment by using inexpensive and readily available VR devices such as Google Cardboard in the classroom.(7) The use of VR technology also may improve student understanding of science concepts when compared with two-dimensional learning.(8) As a result, students who are already comfortable with gaming and use of computers are more engaged with the learning process.

How Does Virtual Reality Work?

Technology of Virtual Reality

VR technology can simulate three-dimensional (3D) interactive environments and provide real-time feedback to the user, producing a lifelike scenario that feels as if it is a real environment. The perception of 3D space is produced by displaying separate right- and left-eye images, which are calibrated so that the two-dimensional images together create the illusion of a 3D scene, much like how the brain combines images from the right eye and the left eye to interpret the environment in which we live and work in a 3D fashion.

A VR device consists of five basic hardware components: a computer workstation; sensory displays; process acceleration cards; a tracking system; and input devices An HMD is most commonly used to display the screens and to track head movement, to which the computer responds to alter the environment being displayed. Input devices such as joysticks, instrumented gloves, keyboards, and voice recognition also contribute to the information used by the computer to alter the environment, and haptic feedback, which applies tactile sensation to the user, can provide an extra layer of immersion. For example, a surgeon using instruments on virtually simulated organs would be able to feel the instruments touching the virtual organs by the computer sending information to haptic feedback devices inside his or her glove.(1)

Types of Virtual Reality

The two basic types of VR are nonimmersive and immersive.

Nonimmersive VR is comparable to playing a modern video game. A virtual world is presented on a flat screen, such as a television screen or handheld gaming console. The user navigates through the virtual world using controls such as joysticks, specialized interface devices, or a mouse and keyboard. Although this experience is not fully immersive, nonimmersive VR may provide the feeling of being present in the virtual situation.

Immersive VR integrates computers, HMDs, body-tracking sensors, specialized interface devices, and 3D graphics so that the user’s body is able to participate actively in the virtual world as it would participate in the real world. The illusion of being inside the virtual world is created along with added artificial sounds and physical sensory information that contribute to further the sensation of immersion. Less common than HMDs are cave automatic virtual environments (CAVE) systems, which are rooms with projections on all six walls. These are costly and impractical for most applications.(9)

Medical Applications

Although VR first became popular in the gaming industry, several other industries have adopted VR and related technologies. VR has recently developed into a technology that is practical for use in healthcare. Its medical applications have become widespread as it has become more accessible due to the advances in the technology.

Posttraumatic Stress Disorder

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the overall lifetime risk of developing posttraumatic stress disorder (PTSD) is 8.7%. It is most commonly developed, however, by those who have lived through extremely traumatic events, such as military veterans and rape survivors.(10) PTSD involves a characteristic development of an array of behavioral and psychological symptoms following exposure to one or more traumatic events. Therapeutic treatment of PTSD commonly involves Pavlovian fear reconditioning through exposure therapy. The patient is exposed to the traumatic event in therapy, where he or she is able to learn that the feared result of the traumatic event that has caused the PTSD will not happen again. The fear responses—such as avoidance and negative mood symptoms—associated with PTSD can, therefore, be eliminated with exposure therapy in a safe and secure environment using VR technology.(11)

VR can be used as an effective method of exposure therapy because of its ability to portray real-life situations in a believable and engaging way, evoking a sense of immersion and the actual presence of the patient in the situation. During VR exposure therapy, the clinician is able to control the patient’s virtual environment and contribute to the patient’s experience while the patient is experiencing the simulation through a VR–clinician interface.(12) It is a valuable solution for patients who are resistant to other forms of exposure therapy, such as guided imaginal exposure, which involves only recalling a traumatic incident with the assistance of a therapist. With VR exposure therapy, patients are in control and experience a lifelike recreation that engages them emotionally while avoiding the trauma of actually reliving the event.(13) A patient’s physiological response to VR exposure therapy suggests the ability to predict treatment response according to a study on the outcomes of VR exposure therapy in the treatment of PTSD. Heart rate and skin conductance have been found to increase with VR exposure therapy, likely signaling higher physiological engagement with the stimuli.(14)

VR can recreate any event or convey any circumstance to a patient with a high level of realism.

Another study shows promise that VR exposure therapy may be able to assist in assessing and treating subthreshold PTSD symptoms or PTSD symptoms that do not include the necessary DSM-V criteria. The VR therapy is presented early, before progression into full-blown PTSD. Patients with subthreshold PTSD symptoms have shown increased heart rate and skin conductance with VR exposure therapy, providing advance warning of developing PTSD that can be treated with early intervention.(15)

PTSD in military members and veterans who have experienced combat is a significant problem in the mental health world. It is noteworthy that the number of military suicides has exceeded the number of combat deaths in Afghanistan.(16) VR is able to accurately recreate a combat environment in which patients can navigate during exposure therapy to confront traumatic experiences incurred in the military. Sounds and haptic feedback can be used, along with a navigable visual environment during therapy to simulate the actual traumatic experience and maximize the accuracy of the traumatic incident. In a study of participants with combat-related PTSD who served in Iraq and Afghanistan, VR exposure therapy was shown to significantly improve their symptoms, and the improvement was maintained after three months.(17)

Although several studies concerning VR treatment of PTSD involve participants with military-related PTSD, VR exposure therapy is not limited to combat scenarios. VR can recreate any event or convey any circumstance to a patient with a high level of realism. For example, VR exposure therapy can be used to treat patients who experienced the 9/11 attack on the World Trade Center( )and for those who have PTSD as a result of more common traumatic events, such as car accidents.(13,18) A six-wall VR system also has been shown to be effective in inducing emotions in sexual assault victims in a safe virtual bar environment and could be developed further into a treatment form for PTSD resulting from sexual assault.(19)

Pain Management

Pain management is a main concern for patients and medical providers, in conditions ranging from diseases resulting in chronic pain to painful medical procedures. Patients are concerned about the implications of pain for their daily lives and their experiences with pain in clinical settings.(20) Traditional treatment of pain with opioids has resulted in an opioid addiction epidemic, which has created a need for nonopioid pain management alternatives.(21) Long-term use of opioids increases the likelihood of disease and even death, and often results in substance abuse and psychiatric conditions that adversely affect the patient’s pain.(22) Opioids have additional dangerous side effects, such as cognitive impairment, and respiratory depression in pediatric patients.(23) The development of new pain management techniques is of great importance, and VR promises to be an effective modality to combat pain in a variety of situations.

The immersive properties of VR make it an improved distraction technique.

Painful medical procedures such as vaccinations, wound dressing, and surgeries can cause anxiety in pediatric patients, resulting in difficulty performing the procedure as well as future procedures. Medical professionals currently use distraction to ease the patient’s pain during pediatric procedures. The immersive properties of VR make it an improved distraction technique that should outperform traditional distraction techniques such as television and games. Pediatric patients can interact actively with virtual worlds when using VR, resulting in a high level of distraction and even enjoyment, which counters pain during medical procedures.(23)

Acute pain as a result of minor medical procedures can induce anxiety in children and can create a concern for their caregivers. A trip to the outpatient clinic for a child’s bloodwork can become a daunting task for the caregiver and child if the child suffers from anxiety triggered by medical procedures, needles, or blood. Use of VR is an effective and enjoyable way to manage pain in routine pediatric blood draws. VR distracts the patient from the minimally painful procedure, which can assist in making blood draws easier experiences for pediatric patients, their caregivers, and phlebotomists.(24)

Lengthy hospitalization and recovery are characteristic of burn care. The treatment of burns includes debridement, dressing changes, and other procedures that result in pain, along with physical and psychological stress.(25) Opioids are the primary oral pharmaceutical analgesic technique for treating acute pain, including the treatment of burns, but they should not be used alone to manage pain. Favorable outcomes result from using a variety of treatments, such as physical therapy, psychological counseling, and alternative therapies, along with opioids and other pharmaceutical treatments.(26) Adding VR treatment to this mix has been extensively studied and has been shown to assist in reducing pain. Low-cost VR technology can be feasibly implemented into the burn care regimen, and patient satisfaction with VR treatment indicates that it should be a more readily available option for burn care.(27) VR has been shown to drastically reduce pain in wound debridement of combat-related burns. Patients experiencing the most pain without VR have the most significant pain reduction with the use of VR.(28) Brain scans show less pain-related brain activity when VR is used during painful burn-related procedures.(29)

Other uses of VR in pain management include pain reduction in hospital reception areas and at home. When a VR sea view is displayed to migraine patients in hospital reception areas, pain reduction is seen as a result of the simulated non-hospital setting.(30) Another study involving a home-based VR treatment for chronic pain also showed a reduction in pain among the majority of participants. This study demonstrates the ability to use VR technology for pain management at home or in other nonclinical settings.(31)

Conclusion

Healthcare is changing at an unprecedented pace. We are moving from hospital care to ambulatory treatment care, and now providing much more care, including surgical procedures, in the office setting. We have moved from paper charts to electronic medical records, to the consternation of some middle-aged and older physicians. We have cracked the human genome and can now consider replacing defective genes. We are providing care for patients via computers or telemedicine and have found that we can provide excellent care even when we are not in the same room as the patient. Very importantly, physicians have changed their focus from illness to wellness, as many patients are now interested in staying healthy and avoiding visits to doctors’ offices.

The time has arrived where VR will be used in the management of several conditions, including pain management and PTSD, to name just a few. This technology already has demonstrated its effectiveness in several medical conditions. We are at the point where VR has been recognized by insurance companies as a cost-effective treatment option for several medical conditions involving hundreds of thousands of patients. VR will soon have its own ICD-10 code, and practices will be reimbursed for prescribing VR. The take-home message is that VR has truly become a reality!

References

1. Sherman WR, Craig AB. Understanding Virtual Reality: Interface, Application, and Design. Cambridge, MA: Elsevier; 2003.

2. Stankovic´ S. Virtual Reality and Virtual Environments in 10 Lectures. San Rafael, CA: Morgan & Claypool; 2016.

3. Peddie J. The History of Visual Magic in Computers: How Beautiful Images Are Made in CAD, 3D, VR and AR. London: Springer; 2013.

4. Williams E. Altered states. Creative Review. 2014;34(11):28-32.

5. Foreman N, Korallo L. Past and future applications of 3-D (virtual reality) technology. Sci Tech J Inf Technol Mech Opt. 2014;14(6):1-8

6. Hu-Au E, Lee J. Virtual reality in education: a tool for learning in the experience age. Int J Innov Educ. 2017;4(4): 215.

7. Lee SH, Sergueeva K, Catangui M, Kandaurova M. Assessing Google Cardboard virtual reality as a content delivery system in business classrooms. J Educ Bus. 2017;92(4):153-160.

8. Lamb RL. Examination of the effects of dimensionality of cognitive processing in science: a computational modeling experiment comparing online laboratory simulations and serious educational games. J Sci Educ Technol. 2015;25(1):1-15.

9. Rizzo AS. Is clinical virtual reality ready for primetime? Neuropsychology. 2017;31(8):877-899.

10. Kessler RC, Berglund P, Delmer O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiat. 2005;62:593-602.

11. Maples-Keller JL, Yasinski C, Manjin N, Rothbaum BO. Virtual reality-enhanced extinction of phobias and post-traumatic stress. Neurotherapeutics. 2017;14:554-563.

12. Rizzo AS, Difede J, Rothbaum BO, et al. Development and early evaluation of the Virtual Iraq/Afghanistan exposure therapy system for combat-related PTSD. Ann NY Acad Sci. 2010;1208(1):114-125.

13. Difede J, Hoffman HG. Virtual reality exposure therapy for World Trade Center post-traumatic stress disorder: a case report. Cyberpsychol Behav. 2002;5:529-535.

14. Norrholm SD, Jovanovic T, Gerardi M, et al. Baseline psychophysiological and cortisol reactivity as a predictor of PTSD treatment outcome in virtual reality exposure therapy. Behav Res Ther. 2016;82:28-37.

15. Costanzo ME, Leaman S, Jovanovic T, et al. Psychophysiological response to virtual reality and subthreshold posttraumatic stress disorder symptoms in recently deployed military. Psychosom Med. 2014;76:670-677.

16. Stern J. PTSD: policy issues. Psychoanal Psychol. 2014;31:255-261.

17. Mclay RN, Graap K, Spira J, et al. Development and testing of virtual reality exposure therapy for post-traumatic stress disorder in active duty service members who served in Iraq and Afghanistan. Mil Med. 2012;177:635-642.

18. Beck JG, Palyo SA, Winer EH, Schwagler BE, Ang EJ. Virtual reality exposure therapy for ptsd symptoms after a road accident: an uncontrolled case series. Behav Ther. 2007;38(1):39-48.

19. Loranger C, Bouchard S. Validating a virtual environment for sexual assault victims. J Trauma Stress. 2017;30(2):157-165.

20. Franklin ZC, Smith NC, Fowler NE. A qualitative investigation of factors that matter to individuals in the pain management process. Disabil Rehabil. 2016;38(19):1934-1942.

21. Pourmand A, Davis S, Marchak A, Whiteside T, Sikka N. Virtual reality as a clinical tool for pain management. Curr Pain Headache R. 2018;22(8):1-6.

22. Krashin D, Murinova N, Sullivan M. Challenges to treatment of chronic pain and addiction during the “opioid crisis”. Curr Pain and Headache R. 2016;20(12):65.

23. Arane K, Behboudi A, Goldman RD. Virtual reality for pain and anxiety management in children. Can Fam Physician. 2017;63(12):932-934.

24. Gold JI, Mahrer NE. Is virtual reality ready for prime time in the medical space? A randomized control trial of pediatric virtual reality for acute procedural pain management. J Pediatr Psychol. 2018;43(3):266-275.

25. Scapin S, Echevarría-Guanilo ME, Boeira Fuculo Junior PR, et al. Virtual reality in the treatment of burn patients: a systematic review. Burns. 2018;44(6):1403-1416.

26. James DL, Jowza M. Principles of burn pain management. Clin Plast Surg. 2017;44(4):737-747.

27. Ford CG, Manegold EM, Randall CL, Aballay AM, Duncan CL. Assessing the feasibility of implementing low-cost virtual reality therapy during routine burn care. Burns. 2018;44(4):886-895.

28. Maani CV, Hoffman HG, Morrow M, et al. Virtual reality pain control during burn wound debridement of combat-related burn injuries using robot-like arm mounted VR goggles. J Trauma. 2011;71(1):S125-S130.

29. Hoffman H, Meyer WJ 3rd, Ramirez M, et al. Feasibility of articulated arm mounted Oculus Rift virtual reality goggles for adjunctive pain control during occupational therapy in pediatric burn patients. Cyberpsychol Behav Soc Netw. 2014;17(6):397-401.

30. De Tommaso M, Ricci K, Laneve L, et al. Virtual visual effect of hospital waiting room on pain modulation in healthy subjects and patients with chronic migraine. Pain Res Treat. 2013;2013:1-8.

31. Garrett B, Taverner T, Mcdade P. Virtual reality as an adjunct home therapy in chronic pain management: an exploratory study. JMIR Med Inform. 2017;5(2).