Case Studies

Virtual reality and health tech: what’s happening?

The advancement of virtual reality (VR) technology has led to many exciting developments with vast applications to the field of healthcare and beyond. Currently, studies are ongoing into the potential uses for this technology, including in pain management, surgical training, mental health therapy, physical rehabilitation, and more. As the technology continues to develop, the possibilities for VR are only likely to continue to grow.

With this in mind, let’s take a look at some of the most innovative and exciting research on VR in healthcare to have emerged to date.

Surgical Training

Surgery and surgical training is one of the areas which has benefitted from the most scholarly research about the impact of VR, revealing some great successes and some exciting prospects for the future.

VR for jaw surgery

In the field of orthognathic surgical education, a study entitled ‘Validity of an immersive virtual reality training system for orthognathic surgical education‘ tested an immersive VR (iVR) training system for double jaw orthognathic surgery. Seven senior surgeons and seven fifth-year medical students were given the opportunity to complete a training mode and an assessment mode in bimaxillary orthognathic surgical procedure, before being asked to complete a questionnaire based on the Likert scale.

Immersed in a virtual operating room, and using virtual models of surgical instruments, participants worked on a patient model designed using computed tomography (CT) and dental casts of a real patient with skeletal class III malocclusion. The training mode included VR guidance on next steps and correct instrument positions, accompanied by voice prompts of the surgical procedure. In the assessment mode, participants needed to select the appropriate instruments from the virtual instrument table, before correctly initiating the next surgical step without guidance.

Results demonstrated that all participants strongly agreed that they hoped more surgical procedures could be simulated in the VR system; that the VR application could increase their interest in learning surgical methods; that it was very helpful in learning different types of surgery; and that they found the system interesting. All participants agreed that this application could be used as a supplementary method to traditional surgical training.

“iVR technology has the potential to revolutionize surgical training and education by providing standardized and cost-effective training, objective assessment, and multi-user capabilities. As the technology continues to develop and improve, it may become an increasingly valuable tool in surgical training and education.”

VR for clipping intracranial aneurysms 

In a study entitled ‘Immersive VR training system for clipping intracranial aneurysms‘, researchers attempted to use VR to overcome issues relating to ethics surrounding cadaver training and consumption of resources in 3D printed models, in the clipping of intracranial aneurysms.

The study states: “By proposing an immersive virtual reality training system, we make use of increased motivation, engagement and realism when using a virtual operating room.”

In the study, one senior and one novice neurosurgeon were tasked with performing the procedure using VR, before being asked a series of questions about their experience. Whilst the lack of haptic feedback and the absence of a stable surface (usually the physical skull of the patient being operated on) were drawbacks identified by the senior neurosurgeon, both participants were able to give feedback on how they felt the design of the system could be improved.

Regarding clipping, both participants liked the deformation and rated it as realistic enough. They also emphasised that it is a crucial part of a training system. However, it would be good to have the possibility to modulate the speed of the clip application.”

“Regarding clip assessment, different possibilities were discussed. The first possibility would be to include visual exploration of the clipped aneurysm. Both rated this approach as very useful, as this would be similar to an angiography with which one can check whether the aneurysm is sealed off completely. Furthermore, they would appreciate an additional numeric output indicating how much (e.g. percentage) of the aneurysm ostium is closed.”

VR and learning

Another study worth noting explored ‘The Effectiveness of Learning to Use HMD-Based VR Technologies on Nursing Students: Chemoport Insertion Surgery‘. Using a head-mounted display VR nursing education programme, 30 nursing students were given paper handouts and tasked with self-learning for 30 minutes, whilst 30 nursing students were given training using the VR model. Results showed that the experimental group utilising the HMD-based VR showed “significantly improved post-intervention knowledge on operating nursing, learning attitude, and satisfaction compared to the control group.”

Patient education, preoperative anxiety reduction and pain management

Another exciting application of VR to have emerged is in the field of patient education and anxiety reduction.

VR for reducing pain and stress 

A feasibility study published last year entitled ‘The effect of Virtual Reality (VR) on anxiety and pain in patients undergoing port implantation‘, explored the effect of VR on pain, stress and anxiety in patients undergoing elective surgeries such as implantation of a centralvenous port catheter. 

20 patients with an indication for port implantation were split into two equal groups of 10, before being assigned ‘VR’ or ‘no VR’ group status. As with standard practice, local anaesthesia was used for both. The primary endpoint for the study was the reduction of intraoperative pain sensation, as well as patient levels of anxiety and stress, measured using the Short Form McGill Pain Questionnaire. Secondary endpoints were identified as ‘the recording of preoperative pain and anxiety levels (baseline assessment) using the Pain Catastrophizing Scale (PCS) Questionnaire.’

Patients in the VR group selected from a range of relaxing scenarios including an underwater world, beach, winter landscape and forest walk; then selected jazz, lounge or classical background music.

Using the McGill Questionnaire, both total normative estimated pain intensity and present pain intensity were measured as being slightly lower in the VR group. Although not reaching significance levels, these findings support a growing body of evidence which suggests that VR may be beneficial to the reduction of pain and stress in patients undergoing minor surgeries under local anaesthesia.

VR as a component of patient education and preoperative anxiety reduction

A larger study conducted at the Department of Cardiac Surgery at LMU University Hospital, Munich, entitled ‘New perspectives in patient education for cardiac surgery using 3D-printing and virtual reality‘ found much more significant outcomes of VR on patient anxiety.

Using a sample of 99 participants who were scheduled to undergo coronary artery bypass graft surgery, surgical aortic valve replacement or thoracic aortic aneurysm repair, three study groups were created. One group was the control group, with participants educated using standardised paper-based models; one group was educated using 3D-printed models; and the final group was educated using VR models.

Three questionnaires were used at different time points in patient journeys: the first to gain insight into patient characteristics including age, gender, procedural understanding before patient education and basic anxiety using visual analog scale (VAS) and the state anxiety inventory. The second questionnaire was given to participants immediately following their patient education, again asking questions about procedural understanding, anxiety and patient satisfaction with the method of patient education in accordance with their group. Finally, the third questionnaire was given to patients at least one week following their surgery, or at discharge, and measured trait anxiety in each of the participants.

Results revealed a “significant decrease in VAS anxiety for patients educated using VR models”. As for understanding of surgical procedure, better results were found for both understanding and visualisation in the VR group than the control or 3D-printed groups.

Stroke Recovery, physical rehabilitation and physiotherapy

Physiotherapy in adults over 75

A study entitled ‘Physiotherapy Programmes Aided by VR Solutions Applied to the Seniors Affected by Functional Capacity Impairment: Randomised Controlled Trial‘ used 60 community-dwelling older adults aged 75 and over as participants in a trial of a virtual reality comprehensive rehabilitation rooms (VRCRR) software. The authors describe how the “physiotherapy programme introduces a comprehensively structured procedure aimed at maintaining or enhancing individual balance and cognitive abilities within a fully immersive VR environment”.

Participants were split randomly into four groups, including the classic programme group. The classic group completed traditional exercises; another group wore VR goggles to ‘relocate’ them to a VR environment; a third group completed dual tasks in combination with VR; and one group made use of VR ‘comprehensive rehabilitation rooms’ as an additional component to be integrated with the physiotherapy programme.

The groups had 30-minute physiotherapy sessions in their own homes three times per week, for three weeks. Their progress was tested with a preliminary assessment designed to allow researchers to measure improvements over the course of the study.

The participants were tested to establish their general health status, and then in the second the groups undertook a variety of activities to evaluate overall individual mobility and exposure to overall fall risk owing to stability issues when walking, with added complications such as timed assessments wherein they had to carry out the tasks whilst counting backwards and walking.

Results indicated that the group using the VR comprehensive rehabilitation rooms showed significantly higher score in balance when compared to the other groups, and also scored higher on the ‘timed up and go’ test which is designed to assess individual mobility and exposure to overall fall risk. However, the classic group scored higher in evaluation of gait.

The authors conclude: “Making use of VR environments in the physiotherapeutic management of community-dwelling older adults appreciably enhanced individual functional performance, especially in terms of static balance. Physiotherapy management aided by VR technology solutions offers a viable alternative to conventional physiotherapeutic regimens in enhancing individual functional performance.”

VR and chronic stroke patients

The study ‘Effects of a Brain-Computer Interface With Virtual Reality (VR) Neurofeedback: A Pilot Study in Chronic Stroke Patients‘, explores the potential effects of VR and brain-computer interfaces (BCI) in strengthening key motor pathways in stroke patients.

Using a platform combining both VR and BCI, four chronic stroke patients with different levels of motor impairment were assessed using EEG signals to detect attempts to move a virtual avatar arm. The platform could be tailored to meet the specific requirements and capabilities of stroke patients, offering differing degrees of freedom for patients. EEG was used in direct brain-to-VR interfacing in patients with no active movement; EMG in muscle-to-VR interfacing was used in those with weak muscle activation; and hand tracking was used for those who had substantial active movement.

During pre- and post-intervention assessment, motor impairment was measured in participants using a set of clinical tests, as well as through functional and structural scans with MRI, and with neurophysiological measurements with transcranial magnetic stimulation (TMS). The intervention itself consisted of eight training sessions of one-and-a-half hours, whereby participants were immersed in a virtual environment in which they had a virtual pair of hands that they could see from a first-person perspective. They were then tasked with performing a wrist and elbow extension toward a pre-defined target, with the virtual arm moving toward the target when an increase in sensorimotor brain activity was detected.

In terms of neurofeedback performance, only one of the participants demonstrated an increased score of 7.3 percent between the first and last training sessions, whilst all other participants demonstrated a significantly decreased score of 5.4 percent – 37.1 percent. During TMS sessions, the motor hotspot in the undamaged hemisphere around M1 was localised, and resting motor threshold (RMT) was acquired at the same intensity at this location in both pre- and post-intervention sessions. Only one patient had a reachable RMT during the first session (71 percent). A different participant demonstrated a reachable RMT by the final session.

The Fugl-Meyer Assessment for upper extremity scores increased in all participants from pre- to post-intervention, with one participant in particular demonstrating a six-point increase, meeting the minimal clinically important difference threshold. Self-reported scores on the Stroke Impact Scale (SIS) increased in three of the four participants. The patient with the most significant motor impairments was the only participant to have significant changes in cortical physiology, and also had large improvements in SIS.

“One potential hypothesis to explain this finding is that in individuals with worse motor impairment, there are fewer inputs to and outputs from the damaged motor cortex, hence poorer motor ability. Given this, these brain areas may be more flexible to neuromodulation and may be more easily trained because these regions are not being actively engaged for other tasks. On the other hand, in individuals with volitional movement, these brain regions may already be actively recruited through more naturalistic processes (e.g., trying to move one’s arm on a regular basis) and may be less flexible to learn new patterns imposed by the neurofeedback training.”

Future Directions

As VR technology develops, there are likely to be a host of unexplored applications of VR to the field of healthcare. Below are some of the most interesting proposals for research projects that we found, which could potentially have a positive impact in the future.

ADHD diagnosis

The study ‘A Four-Step Method for the Development of an ADHD-VR Digital Game Diagnostic Tool Prototype for Children Using a DL Model‘ proposes a four-step method for the development of an ADHD-VR digital game diagnostic tool for children.

It states: “ADHD is one of the prevalent neurodevelopmental disorders in a clinical setting. VR and machine learning, such as DL technologies, hold great promise for application in human health diagnostic tools in the near future, especially in areas with low health and mental health resources, such as general practitioners, child psychiatrists, general psychiatrists, psychologists, and behavior pediatricians. Therefore, by utilizing an ADHD-VR digital game diagnostic tool prototype for children with a DL model in standard health services or tele-psychiatry consultation, ADHD can be diagnosed and early management can be delivered, thereby reducing the impact of the illness.”

Exploring VR interventions following COVID

In the study ‘Effect of an intensive care unit-specific virtual reality (ICU-VR) to improve psychological well-being and quality of life in COVID-19 ICU survivors: a study protocol for a multi centre, randomized controlled trial‘, we hear about the protocol to test the possibility for an ICU-specific virtual reality intervention to have a positive impact on psychological well-being and quality of life after COVID-19 ICU treatment.

“The SARS-CoV-2 outbreak has resulted in a tremendous increase in hospital and intensive care unit (ICU) admissions all over the world. Patients with severe coronavirus disease 2019 (COVID-19) warranting ICU treatment usually have prolonged mechanical ventilation and are expected to be prone to develop psychological impairments, such as post-traumatic stress disorder (PTSD), anxiety and depression, which negatively impact quality of life. To date, no effective treatment strategy is available. In the current trial, we aim to assess the effect of an ICU-specific virtual reality (ICU-VR) intervention on psychological well-being and quality of life after COVID-19 ICU treatment.”

VR to reduce sedentary lifestyles 

Exploring the content of the STAND-VR intervention: A qualitative interview study‘ is an exploratory study of the perspectives of older adults on the STAND-VR intervention, intended to inform future work that are more accessible to retired and non-working adults, with the goal of reducing sedentary behaviour and improving associated health outcomes.

The study highlights how six or more hours spent sedentary each day has been associated with the development of a number of chronic conditions as well as mortality. “Immersive virtual reality, a relatively new digital technology, offers new ways to be less sedentary which retired and non-working adults can potentially ascribe more meaning to, such as taking part in physical activities they enjoy as well as facilitating social connection.”

It continues: “IVR is a computer technology that makes a person feel like they are somewhere else. The findings from this study describe how retired and non-working adults perceived IVR before and after use, how they would like to learn how to use IVR, the content and people they would like to interact with and finally, their beliefs about their sedentary activity and using IVR. These findings will inform the design of future virtual experiences that are tailored to retired and non-working adults’ needs and preferences.”