17 July 2017

How virtual reality may reshape healthcare – or not

Clinical Technology

Are VR technologies the crest of a revolutionary wave for therapies, or is the hype outrunning the reality?

A man walks into a virtual bar … but this is no joke, instead it just may be the future of mental-health treatment.

Just say you’re a patient with severe paranoia and persecutory beliefs. Being stuck in a bar with dozens of other people would be a highly stressful situation, where thoughts such as “People are talking about me”, “People can read my mind” or “Someone wants to kill me” come unbidden.

Of course, a natural reaction would be to put your head down and avoid eye contact, and to get out of there as soon as possible. Unfortunately, these safety-seeking behaviours help to support that original delusion – that people really were out to get you and the only reason they didn’t was because of the steps you took to prevent it.

This is where virtual reality (VR) steps in.

A key goal of treatment is to get patients with persecutory beliefs to experience these situations without taking those avoidant measures, so that they can see that their fears are unfounded. Unfortunately,  such exposure in real-life may be too overwhelming and stressful for some, or impractical if the feared situation is difficult to access.

So instead, Oxford University researchers decided to test whether spending time in an immersive, virtual version of a train or a lift would work instead.

They split a group of 30 patients with persecutory delusions, who were attending treatment services at Oxford Health NHS Foundation Trust, into two groups: one group was asked to spend time in the simulation using their normal defence tactics, and the other group were encouraged to drop their defences and, in fact, do the opposite.

The first group were told that they would enter the computer world and that more and more computer characters would be gradually added in as an exposure therapy. “It works a bit like getting into cold water. When you first get in it feels uncomfortable, but after a while you get used to it, as long as you stay in,” they were told.

The second group were encouraged to really challenge their intuitions, going as far as to stand toe-to-toe with the computer-simulated people and holding long eye contact.

The results were striking. At the end of the first day, half of all the patients who challenged their defences no longer met the criteria for severe paranoia. The benefits of VR exposure were even apparent for those who maintained their safety-seeking behaviours, with one in five of the first group also no longer meeting the criteria after the first day.

Patients who tested out their defence mechanisms also had much lower levels of  distress when they went out into the real world, compared with the group that only underwent exposure therapy.

This is just one example of the way VR is set to shake up patient care. And as the price of the technology drops, the number of proposed uses skyrockets.

Expanding role

As well as anxiety disorders, groups around the world are developing VR for the treatment of everything from stroke and rehabilitation, to eating disorders and chronic pain.

As a result, business is booming. In 2014, Facebook paid more than $US2 billion for one of the most well-known VR companies, Oculus. Worldwide spending on virtual and augmented reality is estimated to be $US14 billion this year, reaching more than $US140 billion by 2020.

Of course, this covers everything from gaming, to military training, to pornography, but there is real excitement in the medical space about what VR could do for patients.

Just like those with paranoid delusions, in the future, people with alcohol problems could also test out their triggers by spending time in a virtual bar. Right now, it’s time-consuming, difficult, and a little bit chaotic to take a patient to a place where their addiction cues might kick in.

Therapists can ask their patients to imagine they are in a bar or at a party to undertake psychotherapy, but early research into VR indicates that real cravings can be induced in a virtual environment, simultaneously developing skills and techniques to help combat them. All the while, the patient and therapist are sitting in the therapist’s office, ready to repeat the same experience, or slightly modifying some details, to try it again.

Dr Greg Wadley, lecturer in the department of computing and information systems at Melbourne University, says VR can better help clinicians communicate difficult concepts to their patients.

In his work with youth mental health group Orygen, they have been designing VR to help young people practise mindfulness to deal with their depression and anxiety.

For example, one of their planned apps has patients putting on a headset to find themselves standing at a train platform, with trains pulling into the station. Down the side of these trains, words representing recurrent and troublesome thoughts are written.

Dr Wadley says it’s quite a confronting and visceral experience to see the trains bearing down on you with a big, bold “hopeless” on it, and at the same time very memorable.

“But instead of getting on the train and being taken where the thought wants to take them, they become an observer seeing the thoughts come and thoughts go,” Dr Wadley explains. “They are being trained in how to use a mindfulness technique and experiencing it at the same time.”

VR, in itself, is far more appealing to young people than the idea of sitting down and talking with a therapist about an abstract concept like mindfulness for 45 minutes, Dr Wadley says.

“It’s challenging the way you interact with them,” he says. “You take difficult-to-convey, abstract concepts and present it in a memorable and actionable way.”

The falling cost of VR technology means that these apps and devices could feasibly be set up in a clinic, Dr Wadley says.

Using a HTC Vive VR system and a high-end computer may cost around $4000, but a less sophisticated VR system such as Oculus Rift could be half that price. Then at the lowest end of the spectrum, mobile phone-based VR, will leave a patient or clinician out of pocket only a few hundred dollars.

“It’s very, very affordable, and it’s only going to get more so,” Dr Wadley says.

One of the benefits of pharmacotherapy is that it’s a quick and relatively cheap intervention when compared with the weeks, months or even years of psychotherapy that certain mental illnesses might need. But it’s no secret that it comes at a price. No drug is without side effects.

So this is a space where VR might sit nicely, as a quick and cheap intervention in place of drug therapy, or as an adjunct, to assist with longer term psychotherapy.

Dr Brennan Spiegel, VR researcher and the director of health services research at Cedars-Sinai Medical Center in Los Angeles, foresees a new type of specialist in the future  – a “virtualist”.

“What this means is that if VR is a therapy, then we need a ‘VR pharmacy’ of evidence-based, well-characterised visualisations that clinicians can pull off the shelf and ‘prescribe’ to individual patients,” he writes on his website MyGiHealth.

The virtualist would be the medical expert trained to decide on what type, dosage, frequency and intensity the patient needs for their condition – and also how to evaluate the patient’s response.

“It would also help to have a formal way to match patient knowledge, attitudes, beliefs, and preferences with specific off-the-shelf visualisations.”

But before that, the VR world will need more high-quality, rigorous, properly powered, adequately controlled trials to understand what actually works, Dr Spiegel says.

Dr Spiegel and his colleagues have tried to nail down the facts and cut through the hype around VR by undertaking a systematic review of the randomised, controlled trials into VR for patients in hospitals and rehabilitation centres.

Published this year, the review found VR to overall be “efficacious, easy to use, safe and contributing to high patient satisfaction”, and accompanied by minimal side effects.

The ability of clinicians to tailor their treatment to patients of different ages, genders and medical disorders was a boon, and as the devices and programs get cheaper, VR would “undoubtedly shape the future of healthcare”, they concluded.

Researchers from the University of Oxford and University of Barcelona undertook a separate review into the evidence around VR for mental health disorders. The paper, published earlier this year, highlights the dramatic changes that have occurred in the last 20 years of development in this field.

“A technical revolution in mental health care is approaching,” write the authors, placing VR at the forefront of the new paradigm.

The benefits of VR are in its ability to create situations that are immersive, tightly controlled and designed specifically for their therapeutic benefit – unlike the unpredictable reality of trialling certain psychological interventions in the real word.

Historically, most good research into mental health and VR has been done on anxiety disorders such as phobias, social anxiety and PTSD.

While research into this area has been hampered by a lack of quality in the studies, and minimal RCTs, overall “VR treatments seem to perform comparably in efficacy to face-to-face equivalent interventions,” they say.

“When long-term follow-ups have been included, treatment effects for these short-term therapies have strikingly been shown to persist over a number of years.

“Revolutionary is an overused word; for VR and mental-health care, it may actually be justified over the coming years,” they conclude.

VR for pain

The most common application for VR Dr Spiegel and colleagues found was for pain management, and most of the research had been done using one of the earliest programs developed for this purpose, SnowWorld. Now a decade old, SnowWorld was developed by University of Washington researchers to help control pain in patients who had to undergo burn wound redressing.

During this extremely painful experience, patients are able to don a headset and play in the icy, winter world, where they can throw snowballs at snowmen, interact with penguins and hang out with woolly mammoths, all with a keyboard or mouse.

A 2008 study of this therapy found patients had a 41% reduction in pain when immersed in SnowWorld compared with when they had the debridement without the VR. Being in the VR also reduced the time thinking about pain from 76% to 22% and there was a strong correlation between feelings of being immersed in the world and their experience of pain.

Other big wins also appeared to be in patients who had the highest initial pain scores, indicating a promising alternative to pharmacotherapy for pain relief.

These self-reported experiences were supported by imaging studies on the brains of burns patients, which showed less activation in the pain centres of the brain, such as the thalamus, insula, primary and secondary somatosensory cortices, and the anterior cingulate cortex, the Cedars-Sinai researchers wrote. Similar findings have been seen in paediatric populations.

One of the reasons this might work for pain relief is what’s known as the “Gate Control Theory”, which suggests that the experience of pain is intensified depending on the level of attention paid to the pain, as well as the emotions and memories associated with it.

The theory is that we have a limited field of attention, and so being distracted means that less energy is able to be given to the pain.

Something like VR, which gives the patients input from their eyes, ears, and sometimes touch and smell, is highly stimulating.

Reductions in the intensity and unpleasantness of pain using VR is something backed up by a number of other small studies, however when the Cedars-Sinai investigators looked at two studies of cheap, personal VR machines and off-the-shelf software computer games, the outcomes were less than impressive. One found the VR was marginally effective in pain reduction but self-reported anxiety was unaffected, and a second showed no difference on self-reported pain – although nursing staff reported reductions that were statistically significant.

Rehabilitation uses 

In Australia, researchers at RMIT are trialling the technology in rehabilitation for patients with traumatic brain injury, with promising results.  To help improve the physical impairments that follow traumatic brain injury, Dr Jonathan Duckworth, director of Creative interventions, Art and Rehabilitative Technology (CiART) at the university, and his colleagues use augmented reality to reinforce better everyday motor skills.

“One of the main issues and challenges for therapists is a lot of the patients will lose motivation quite early on in the rehabilitation process,” Dr Duckworth says, which was a driving factor for the team to make their program motivating and engaging.

The best way to think about augmented reality is Pokémon Go, with the real world still there but gifted with some cool additional features.

“Some patients have a problem with perception cues, not able to feel the object their using in their hands or knowing whether their object touched the surface,” Dr Duckworth says.

In such cases, a patient may be asked to slide an object around a tabletop screen. On successfully sliding the object, a soft-glowing, water-like ripples trail the movement. Using secondary feedback, such as lights and sounds, helps patients know whether they have completed the task properly.

The augmented feedback of the trail shows them how well and smoothly they have done that, Dr Duckworth explains.

The patient sees if there is a lot of tremor or unnecessary movement and where to improve, and it’s a useful tool for the therapist, as well.

There are limited rehabilitation options for patients with brain injury and the traditional approaches can be very tedious, he says.

The hype cycle

With words such as “revolutionary” and “shaping the future of healthcare”, VR is certainly generating enthusiasm in the medical world.

But it’s worth being cautious. Dr Wadley points to a concept in technology studies known as the “hype cycle”, which describes the phases of emerging technologies. If you think of a graph of visibility against time, in the very early hype phase everybody is talking about the new technology and how it will revolutionise everything, he explains.

Then the wave breaks into a trough of disillusionment, and when technology comes through that trough of disillusionment to the other side then people have a more realistic expectation of what it can do.

“In VR we are most definitely in a hype phase right now,” Dr Wadley says.  “Hype usually leads to disappointment, and I’m sure in another year or two we will have collectively calmed down about our enthusiasm.”

There is another risk, and that is that people without medical expertise will capitalise on the hype and create systems without an evidence base, something already well under way with the medical phone app industry, Dr Wadley says.

It’s a problem already.

“You can get VR apps which claim to help with psychological problems, fear of this or that, or systems that are claiming to have emotional effects such as calming you down. [These are] really untested claims.”

For that reason, it will be critical to have trained clinicians involved in the development of these systems as we move into this VR future, and a strong evidence base behind touted therapies.